Every finding on record at Life Care Center of Paradise Valley

Based on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure a comprehensive care plan was implemented for one of three sampled residents (#25) to ensure safe mobility during a functional transfer. The deficient practice could result in injury to a resident, or failure to honor a resident's preference.-Findings include:Resident #25 was admitted [DATE], with diagnoses of schizophrenia, anxiety, depression, emotional lability, chronic obstructive pulmonary disease, gangrene and necrosis of lung, and sarcopenia. A care plan focus initiated October 23, 2024, revealed Resident #25 had an activities of daily living (ADL) performance deficit due to weakness.Additionally, a care plan focus initiated September 26, 2025, revealed the resident had episodes of paranoia as evidence by making statements about other residents and staff that were unfounded.A revision to the resident's ADL care plan focus dated March 11, 2026, revealed two additional interventions for transfers: the resident required a mechanical hoyer lift with two staff assistance, and the resident was totally dependent on two staff for transfers.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #25 had a Brief Interview for Mental Status (BIMS) assessment score of 12, indicating moderate cognitive impairment. Section E-Behavior revealed that Resident #25 had no hallucinations or delusions, and no behavioral symptoms. Section GG-Functional Abilities revealed the resident required substantial / maximal assistance to perform lying to sitting on the side of the bed. Additionally, the resident required dependent assistance for transfers to and from the bed to a chair or a wheelchair. The assessment revealed the resident did not walk, and that she used a wheelchair for mobility.An Incident Report dated June 22, 2026, revealed a certified nursing assistant (CNA) notified the nurse (Staff #31) that Resident #25 was upset and in pain after a bed to wheelchair transfer. The documentation revealed the nurse went to the resident's room and asked the resident what was wrong, and the resident stated she was transferred manually by a CNA onto her wheelchair, causing pain in her abdominal area and lower left leg during the transfer. The report revealed the nurse reported the incident to the nurse manager, the CNA was asked to leave the area, the wound nurse performed a skin assessment, and x-rays were ordered to the resident's lower back and left lower extremity.A Behavior Note dated June 22, 2026, revealed the nurse was called to the resident's room regarding a care concern on June 22, 2026, and an intervention was added for frequent psychosocial visits to ensure the resident feels safe in her environment.A physician's order dated June 22, 2026, indicated for stat (immediate) x-rays to the resident's left upper and lower leg, ankle, and back due to pain.A facility self-report submitted to the State Agency dated June 22, 2026, revealed that at 4:45 p.m., Resident #25 stated that the CNA put her roughly in the chair and grabbed her breast. The report revealed that another CNA was present during that time, and stated this did not occur. The documentation included that the accused CNA was removed from care areas and sent home pending investigation.A written staff interview/statement dated June 22, 2026, by a CNA (Staff #56) revealed Staff #56 went to check on Resident #25 to see if she needed changing, and the resident requested to get up in her wheelchair. The statement revealed that Staff #56 and the witness assisted the resident by changing her, and then Staff #56 proceeded to transfer the resident to her wheelchair from the bed. The documentation revealed that the resident stated she did not like the way that Staff #56 transferred her, and that Staff #56 had strangled her. Staff #56 immediately notified the nurse and supervisor of the situation.A written staff interview/statement dated June 22, 2026, by a CNA (Staff #20) revealed that Staff #20 and Staff #56 went to Resident #25's room to change the resident, who then demanded to get up in her wheelchair. The documentation revealed that Staff #20 and Staff #56 changed the resident, and then Staff #56 proceeded to transfer Resident #25. During the transfer, the resident became upset and verbalized care concerns, and then Staff #20 and Staff #56 went and reported the incident to the nurse immediately.Another written staff statement/interview dated June 22, 2026, by a licensed practical nurse (LPN / Staff #31) revealed that a CNA (Staff #56) came and informed Staff #31 that he had transferred Resident #25 manually, and the resident reported pain in the abdomen and left lower leg during the transfer. The documentation revealed the nurse asked Staff #56 why he did not use a hoyer lift, and Staff #56 stated that the resident appeared in a rush and asked to be transferred quickly. The nurse went to the resident's room and Resident #25 advised the nurse that she was in pain after the manual transfer. The resident also stated that another CNA (Staff #20) was in the room at the time of the transfer. The nurse then asked Staff #20 what happened, and Staff #20 informed the nurse that Staff #56 had transferred the resident manually, causing pain in the abdomen and left lower leg, and that he had transferred the resident to the wheelchair by lifting under the resident's arms. The document revealed that Staff #20 also informed the nurse that Staff #56 had not touched the resident's neck or strangled her. The document also revealed that the nurse manager was informed of the incident and that the wound nurse performed a skin assessment of Resident #25.A weekly skin assessment dated [DATE], revealed a skin impairment on the resident's right outer ankle, 1.0 x 1.0 centimeters, and that the skin integrity was disrupted involving the epidermis only, and included a slight pink color, and that the surrounding skin was intact.A physician's order dated June 23, 2026, included change in condition monitoring due to care concerns, every shift for 3 days.A revision to the care plan focus for the resident's episodes of paranoia dated June 23, 2026, revealed a care concern on June 22, 2026, and an added intervention for frequent psychosocial visits to ensure the resident feels safe in her environment.An observation was conducted on June 24, 2026, at 9:08 a.m. of Resident #25 laying in her bed in her room. An Adult Protective Services (APS) investigator was in the room beside the resident and was conducting an interview with the resident.An interview was conducted on June 24, 2026, at 9:17 a.m. with the APS investigator, who stated that she interviewed the resident regarding the incident on June 22, 2026. The APS investigator stated that Resident #25 stated that a few days ago, she was in her bed and had asked a male staff member to help her get up in her wheelchair so that she could go downstairs. The APS investigator stated that the male staff did not give her any prompts, and picked her up with his hands under her armpit area, and flung her around like a rag doll to the wheelchair, and that he did not sit her straight in the wheelchair. The APS investigator stated that the resident said that then a female staff who was in the room corrected the male staff and told him to straighten Resident #25 in the wheelchair, and then the male staff straightened her in the wheelchair. The APS investigator stated that Resident #25 informed her that during the transfer, the male staff's hand had touched above her breast, and that Resident #25 stated that it was likely an accident, and that the male staff probably did not intend to touch above her breast.A telephonic interview was conducted on June 24, 2026, at 10:57 a.m. with a CNA (Staff #20) who stated that staff normally provide care in pairs, with two staff present, for Resident #25 due to her past behaviors of allegations against staff. The CNA stated that on June 22, 2026, Staff #56 and she went into Resident #25's room before dinner to change the resident. The CNA stated that they changed the resident, and the resident was demanding to get up out of bed into her wheelchair. The CNA stated that then Staff #56 moved Resident #25 from lying to sitting on the edge of the bed, and then performed a one-person transfer for Resident #25 to the wheelchair. The CNA stated that Resident #25 was saying that Staff #56 was squeezing her tightly and that she was uncomfortable, and that after the transfer, the resident was crying and saying she was hurt. The CNA stated the resident's leg may have been bumped on the wheelchair footrest during the transfer, but she was not sure, and after that, she left the resident's room. The CNA stated that she normally transferred Resident #25 using a hoyer lift with two staff assistance.A telephonic interview was conducted with a CNA (Staff #56) on June 24, 2026, at 11:05 a.m. The CNA stated that staff provide care in pairs for Resident #25. The CNA stated on June 22, 2026, around dinnertime, that he and another staff had entered the resident's room, assisted the resident by changing her, and then the resident wanted to get up into her wheelchair. The CNA stated that he helped the resident to sit up on the edge of the bed, and then lifted the resident under her arms to transfer her to the wheelchair. The CNA stated that the resident then started accusing him that he had strangled her and hurt her, and the CNA then left the room and reported the situation immediately to the nurse (Staff #31). The CNA stated that if he could do the situation over again, he would have used the hoyer lift to transfer the resident.A telephonic interview was conducted with an LPN (Staff #31) on June 24, 2026, at 11:23 a.m. The LPN stated that on June 22, 2026, a CNA (Staff #56) came to her and told her that Resident #25 was being changed, and wanted to get up into her wheelchair as soon as possible, and that Staff #56 had transferred the resident quickly to the wheelchair by picking her up under her arms. The nurse stated that she went to the resident's room and the resident was crying and stated the CNA had hurt her. The nurse stated that she asked the resident what happened, and the resident stated that Staff #56 had squeezed her and strangled her, and that her stomach and leg hurt. The nurse stated that she asked the other CNA (Staff #20) who was present in the room at the time what had happened, and the CNA stated that Staff #56 had transferred the resident, but had not strangled her. The nurse stated that the resident was a heavy patient, and a hoyer lift should have been used for the transfer.An interview was conducted with an LPN / staff development manager (Staff #85) on June 24, 2026, at 12:01 p.m. who stated nursing staff would follow the care plan to safely assist a resident with functional transfers. Staff #85 stated that she was familiar with Resident #25, and that the resident had high anxiety, hallucinations, and accusatory behaviors, and required care in pairs for staff to have a witness present. Staff #85 stated that Resident #25 required a hoyer lift to transfer to the wheelchair, and that it was not safe for a single staff to attempt to manually transfer the resident, and it would not matter how big or strong that staff member was. Staff #85 stated on June 22, 2026, staff called her to inform her of the incident with Resident #25, and that Staff #85 was informed that Staff #56 had transferred the resident manually, with his hands under her arms, to the wheelchair. Staff #85 stated that when she arrived to the resident's room, the resident stated that she had pain in her left leg, and that there was a very light red mark on her left leg that may have resulted from the transfer, however it was hard to say for certain. Staff #85 stated that if a staff were performing that type of manual transfer, a gait belt should be used to lift the resident, instead of lifting a resident under their arms. Additionally, Staff #85 stated that for Resident #25, Staff #56 should not have transferred her manually and should have used the hoyer lift, per the care plan.An interview was conducted with the interim Director of Nursing (DON / Staff #66) on June 24, 2026, at 2:33 p.m. who stated that the process for ensuring residents were safely assisted with mobility was that staff were trained extensively as part of onboarding, that nursing staff have monthly meetings, and that CNAs share pertinent information through verbal report each shift. The DON stated that information regarding safe transfer technique should be in the resident's care plan. Regarding Resident #25's incident, Staff #66 stated that she was not familiar with the details of the incident, but that she had learned the resident was on change of condition monitoring after the incident. The clinical record was reviewed, and the DON stated that Resident #25 had a care plan focus for ADLs and it included that for transfers, the resident was totally dependent with two staff, and required a mechanical hoyer lift. The DON stated that regarding the incident, a CNA notified the nurse that the resident was upset after she was transferred manually to her wheelchair, and that she could not tell exactly what occurred or if the care plan was followed because the investigation was still ongoing. The DON stated that there could be risk to a resident if the care plan was not followed, and could result in an unsafe situation or the resident having a fall.An interview was conducted with the Administrator (Staff #4) on June 24, 2026, at 3:09 p.m. who stated that the process for ensuring residents are safe when staff are assisting with their mobility was for staff to follow the care plan or care profile, and that residents were assessed upon admission and routinely to determine what level of assistance was needed. Staff #4 stated that if the care plan was not followed for assisting a resident with a transfer, then the resident could get injured. Staff #4 stated the steps for assisting with a safe transfer included ensuring staff are following proper body mechanics, ensuring the resident had appropriate footwear, and for staff to explain the procedure and ensure the resident understands before proceeding with the transfer. Additionally, Staff #4 stated that staff should use a gait belt when lifting a resident for a transfer, unless there was a contraindication such as the resident having a fractured rib. Staff #4 stated if staff did not use a gait belt to lift a resident, then the resident could be at risk for injury. Regarding Resident #25, Staff #4 stated that the resident required a hoyer lift to transfer. Staff #4 stated that she was first notified of the incident when Staff #85 had called her to inform her that Resident #25 stated that Staff #56 threw her in the chair, touched her breast, and strangled her. Staff #4 stated that Staff #56 was suspended pending the investigation of the incident, and that the resident was assessed for injury and did not have any. Staff #4 stated that through the course of the investigation, she learned that the resident's allegations regarding the CNA touching the resident's breast and strangling her were not substantiated; however, Staff #4 stated she did learn that Staff #56 had manually transferred the resident, and that it did not meet her expectation of following the care plan. After the incident, Staff #4 stated that one-on-one education was provided to Staff #56, as well as in-services for all the staff regarding safe hoyer transfers and following the plan of care.Review of the facility policy titled Area of Focus: Care Planning- Baseline, Comprehensive, and Routine Updates, revised November 25, 2024, revealed the comprehensive care plan is developed after the MDS Assessment is completed to address the resident's goals and preferences, contain measurable objectives and timeframe, interventions to assist the resident meets their goals, additional follow-up and clarification, items needing additional assessment, testing, and review with the practitioner, items that may require additional monitoring but do not require other interventions, and the resident's preference and potential for future discharge and discharge plan. The policy additionally revealed that Federal Regulation S483.21(b) requires the facility to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical nursing, and mental and psychosocial needs that are identified in the comprehensive assessment (MDS).

Based on clinical record review, staff interviews, facility documentation, and policies and procedures, the facility failed to protect the rights of one resident (#51) to be free from physical abuse from facility staff. The deficient practice could result in appropriate action not taken and further abuse of residents. Findings include:Resident #51 (alleged victim) was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, adjustment disorder with mixed anxiety and depressed mood, hyperlipidemia, morbid (severe) obesity due to excess calories, neuralgia and neuritis, and abnormalities of gait and mobility.The annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating that the resident is cognitively intact. In a progress note dated June 2, 2026 At 5:46 pm the documentation revealed that at approximately 2:15 pm, LPN (Licensed Practical Nurse/ staff #82) was summoned by CNA (Certified Nursing Assistant/ staff #38) to assist with resident (#51) shower because the resident was exhibiting behaviors of yelling and throwing a hairbrush. Staff #82 had CNA, staff #38, leave the shower room and the LPN took over providing the shower. The resident reported care concerns.In a progress note dated June 3, 2026 At 8:37 pm the documentation revealed DON met with resident. She (resident) stated she is doing well and appeared to be in good spirits. She was smiling when the DON spoke with her. She stated she feels safe in the facility.A telephone interview was conducted with Staff #82 on June 4, 2026 at approximately 12:31 pm. Staff #82 revealed that there was a situation and the CNA (staff #38) asked for assistance with the resident (#51). She (the LPN) went into the shower room and the CNA had told her that the resident had thrown a brush at her. The CNA's clothes and hair were wet. The LPN stated that she stepped behind the privacy curtain with the resident. The resident was yelling and she (LPN) could not understand her. The LPN stated that she asked the resident to calm down a bit so she could be understood. Staff #82 reported that the resident stated that she had asked the CNA (staff #38) if she was just going to stand there and the CNA responded negatively at which time the resident stated to the LPN that she threw the hairbrush. The resident said she threw it in the opposite direction of the CNA The resident had then reported to the LPN that she was hit by the CNA twice. Staff #82 then asked Certified Nursing Assistant (CNA/Staff #38/Alleged Perpetrator) to leave and that she (LPN) would take over. Staff #82 , continued providing care, and looking the resident over. The LPN then called the unit supervisor and the DON with a request to see them in the shower room. Staff #82 noted that Resident #51 had a red area on her right shoulder. Staff #82 then described the red mark as looking like fingers from a slap. Staff #82 stated that abuse allegations should be reported immediately and the residents should be made safe and kept safe. We separate the resident from whoever, resident and staff, make sure they are safe and report it immediately.An interview was conducted with Resident #51 on June 4, 2026 at 1:46 pm. Resident #51 revealed that she was in the shower room trying to brush her hair before her shower and Staff #38 was watching her struggle. Resident #51 then reports that she asked Staff #38 if she was going to help, and Staff #38 said some smart-ass remark. Resident #51 then reported that she threw the brush at the wall and told Staff #38 that she needs to get a job she likes. Resident #51 then stated that Staff #38 smacked me in the shoulder and smacked me in the back of the head. A telephone interview was conducted Staff #38 on June 4, 2026 at approximately 2:41 pm. Staff #38 revealed that she had gone into the shower room with Resident #51 and handed Resident #51 her hairbrush. Staff #38 then reported that Resident #51 had told her that the staff don't do anything and that they don't do anything to help her, to which Staff #38 said that she asked Resident #51 what was wrong with her. Staff # 38 stated that she told the resident and that if she didn't like it there, then she could go somewhere else. Staff #38 reported that Resident #51 then threw her brush on the floor and it broke. During an interview with the Director of Nursing (DON/staff #112) conducted on June 05, 2026 at 11:45am, she stated that Resident #51 had alleged she had been hit on the arm and that Staff #82 observed what was a red outline that was possibly a hand. Additionally, Staff #112 revealed that it was Staff #82 who told her about the red mark and that Resident #51 had told her that Staff #38 had struck her in the arm and in the back of the head. The DON identified that there was no documentation of the red mark in the resident's record.During an interview with the Administrator (Staff #160) on June 05, 2026 at 12:00 pm she stated that immediately on notification of the allegation, the staff(#38) was removed from care and then was removed from the building. Interviews were conducted to see if other residents are at risk and if staff had concerns. Psychosocial monitoring was conducted for Resident #51 as well as in-service training for staff. Follow-up with the resident is scheduled with the psychiatric provider inhouse.Review of the facility's follow up investigation report received June 08, 2026 revealed that an interview was conducted on June 02, 2026 at approximately 2:30pm with the LPN Staff #82. During the interview, Staff #82 revealed that she was at the nurse's station when Certified Nursing Assistant (CNA/Staff #38/Alleged Perpetrator) came out of the shower room and asked for assistance with a resident who was exhibiting increased behaviors in the shower room. She entered the shower room and saw that Resident #51 was sitting in a shower chair behind the privacy curtain and a broken hairbrush was on the floor. Staff #82 asked Resident #51 what was wrong, however, Staff #82 could hardly understand Resident #51 because she was upset and crying. Staff #82 provided therapeutic communication to calm Resident #51, who then reported to Staff #82 that Staff #38 hit her twice; on the right arm and on the back of her head. Staff #82 assessed Resident #51's arm and noticed a red area. She assessed the back of her head and did not observe any redness or injury. Additionally, Staff #82 revealed that Staff #38 had told her that Resident #51 had thrown a hairbrush at her.Further review of the facility's follow up investigation report revealed that an interview was conducted with Staff #38, in which Staff #38 revealed that Resident #51 had thrown the hairbrush on the floor.In the facility follow up investigation it identified that the CNA told LPN that the resident had thrown the hairbrush at the CNA and then this CNA (staff#38) repeated the details and told ADMIN and DON that the hairbrush was thrown on the floor.Further review of the facility's follow up investigation report revealed a timeline of events, which revealed that Staff #82 had assessed Resident #51's shoulder and head for injury and observed what looked like a red mark with fingers. Further review of the facility's follow up investigation report revealed that based on the a comprehensive review of the resident's medical record, the information gathered and analyzed during the investigation, staff and resident interviews, the facility found the allegation of abuse was verified based on the nurse observation of redness on the residents arm that appeared to be a silhouette of fingers.The facility identified the deficient practice after the incident on June 2, 2026. The facility completed an event check list and held an ad hoc QAPI meeting. The facility began a plan of correction that included an inservice directed at all staff to define abuse and reporting. The facility also initiated de-escalation training with return demonstration. Interviews with random staff members verified consistent knowledge. Review of the facility policy titled Abuse - Identification Types, reviewed date April 01, 2026, revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, and that this includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The policy also defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Further, the policy also states that instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on facility observations, resident and staff interviews, and review of the clinical record and facility policy, the facility failed to ensure that medications were stored securely and were not left unattended at residents' bedsides for two of 28 sampled residents (#53 and #40) or on top of the medication cart. The deficient practice could result in unauthorized access to medications, medication errors, misuse, allergic reactions, adverse drug effects or other harm.Findings Include: -Regarding Resident #53: Resident #53 was admitted to the facility on [DATE], with a diagnosis including: chronic obstructive pulmonary disease with (acute) exacerbation, atrial fibrillation, and pneumonia. A Care Plan initiated on January 12, 2026, revealed a focus for a physician's order for unsupervised self-administration of the following medications: Ventolin HFA 2 puffs every(Q) 4hrs (hours) prn (as needed). The care plan was revised on February 17, 2026, to include a physician's order for Voltaren gel 2 grams TID (three times a day), and Breztri inhaler 2 puffs BID (two times a day), date initiated on January 27, 2026, and revised on February 17, 2026. A Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating resident #53 had moderate cognitive impairment. Further review of the MDS revealed no indicators for mood or behaviors, debility, cardiorespiratory conditions, or oxygen therapy. Review of the Order Summary Report revealed a physician's order for self-administration with a start date of February 17, 2026, for Voltaren Arthritis Pain External Gel 1 % (Diclofenac Sodium (Topical) and Budeson-Glycopyrrol-Formoterol Inhalation Aerosol160-9-4.8 MCG/ACT (Budesonide-Glycopyrrolate-Formoterol Fumarate). A medication self-administration review dated February 17, 2026, revealed an assessment for self-administration for two medications: medication #1 was for Breztri 2 puffs BID and medication #2 was for Voltaren Gel, apply 2 grams TID to the shoulder and left knee. However, this review was completed after the surveyor brought medications left unattended at the resident's bedside to the facility's attention. On February 17, 2026, at 12:32 PM, an observation and concurrent interview were conducted with the Resident (#53). Upon entering the resident's room, one prescribed Breztri inhaler 160mcg 28 inhalations, and one tube of Voltaren gel 100 gm, was observed on the resident's vanity sink area, and one albuterol inhaler at the bedside. Resident #53 stated the nurse must have forgotten to take the Breztri inhaler and Voltaren gel medications with her, and that the inhaler stays on his bedside table in case he needs it. On February 17, 2026, at 12:32 PM, Registered Nurse (RN/Staff/#125) was called to the room and verified the above findings. The RN stated that Resident #53 had an order for self-administration for the Ventolin rescue inhaler, but did not have a current physician's order for self-administration for the Breztri inhaler or the Voltaren gel. The RN stated medications should not be left at the resident's bedside, and the risks of having medications left in the resident's room place other residents at risk who may take them, or the resident can use the medications without authorization. -Regarding Resident #40: Resident #40 was admitted to the facility on [DATE], with Chronic Obstructive Pulmonary Disease, Abdominal Aortic Aneurysm, without rupture, unsteadiness on feet, difficulty in walking, not elsewhere classified, muscle weakness (generalized). A review of the provider orders revealed no evidence of prescribed Lidocaine roll-ons to be administered. A care plan, initiated February 5, 2026, revealed no evidence of a focus or interventions for Lidocaine roll-ons. Further review of the care plan revealed a focus for left hip pain. Interventions included pain meds as ordered. There were no interventions for Lidocaine roll-ons. The MDS assessment dated [DATE], revealed resident's #40 BIMS score of 15, indicating cognition intact. Further review of the MDS revealed no indicators for mood or behaviors. On February 17, 2026, at 1:52 PM, an observation and concurrent interview were conducted with the resident (#40). Upon entering the resident's room, two 2.5 Lidocaine roll-on bottles were observed on resident #40's vanity sink area. The resident stated he had brought them with him on admission, and he keeps the Lidocaine roll-ons at the sink area and has used them since admission to the facility, and that no staff have said anything about them. The resident stated he had asked staff to roll the Lidocaine on his hip for pain, but could not recall who administered the Lidocaine roll-ons. On February 17, 2026, at approximately 1:58 PM, RN (Staff #125) was called to the resident's room and verified the above findings. The RN stated that the medications were not prescribed, informing the resident she would be removing them from the resident's room and placing them in the medication cart. She further stated she would return the medications to the resident's spouse. An interview was conducted on February 19, 2026, at 11:22 AM with an RN (Staff#53). The RN stated that the facility's process for resident self-administration is making sure that the resident can do it safely, can follow directions, check with the doctor, and determine if there is any resident decline. The RN stated that resident #53 had a decline in the last 24 hours and will be evaluated by hospice. The RN further stated that in the last 24 hours, resident #53 is no longer a candidate for self-administration as of today. The RN stated the process for determining that a resident can no longer self-administer their medications is to notify the unit manager, case management, and the provider, and inform them of a difference in the resident's cognition. The RN stated to ensure compliance with medication administration policies and procedures for self-administration, the resident would call the nurse before using their medication, and steps are taken to monitor a patient after they take their medication by checking that the resident does rinse his mouth following administration. The RN stated the process for documenting medication self-administration to ensure accuracy is documenting on the MAR for self-administration and will assist with their medication schedules by leaving a piece of paper at the bedside with the times for use. The RN stated the facility had safety measures to ensure other residents do not have access to medications in residents' rooms, such as keeping a close eye on the resident's medications, especially with a rescue inhaler on the bedside table. The RN also stated the risks of leaving medication at the bedside could result in the resident taking too much of the medication, and with inhalers, their breathing could worsen even further and increase their anxiety. An interview was conducted on February 19, 2026, at 11:22 AM with RN (Staff #53). The RN stated that a medication is anything that can alter the mind and can either help the resident or not, depending on the medication. She stated route of medications can be administered by mouth, intramuscular, subcutaneously, intravenously, rectally or topically, and that this would also include over-the-counter medications such as Tylenol, stool softeners, and that Lidocaine roll-ons would also be considered as medications. The RN stated the risks of having medications at a resident's bedside could result in the potential for a resident to take or use too much, another resident can gain access to the medications, and if they have any allergies, there could be allergies. An interview and concurrent record review were conducted on February 19, 2026, at 1:22 PM with the Director of Nursing (DON/Staff #85). The DON stated the facility's process for resident self-administration is an assessment that is completed for self-administration, and from that assessment, it is determined if it is safe for the resident. The DON stated that the criteria for a resident to administer medications depends on the medication, and if the resident is cognitively aware to administer and to make sure that the resident understands when to administer. The DON stated the facility has safety measures to ensure other residents do not have access to medications in residents' rooms by ensuring the medications are put away and that each resident has their own nightstand to put away their medications for self-administration. The DON reviewed the physician orders for resident #53 and confirmed that self-administration assessment for the Voltaren gel 2 grams 3 times a day and Breztri 2 puffs twice a day was not completed until February 17, 2026, at 12:40 PM. The DON stated that the risks of leaving access to medications in a resident's room can place the resident at risk for not knowing how to administer the medication properly, and the risk of another resident gaining access to the medication when the resident's door is open. - Regarding medications being left unattended on top of a medication cart: On February 19, 2026, at 1:23 PM, during a medication administration observation, a licensed practical nurse (staff #196) removed metronidazole (an antimicrobial) 500 milligrams from the medication cart, placed the medication in a medication cup, and left the cup unattended on top of the medication cart. The nurse then walked away from the medication cart down the hall toward a resident's room, with her back to the cart. No residents were observed passing the cart at that time. An interview was conducted on February 19, 2026, at 1:39 PM with staff #196 who stated that leaving the medications unattended created a risk that someone could access medications that were not theirs. She further stated identified additional risks, including a resident experiencing an allergic reaction or physical adverse reactions such as drop in blood pressure. An interview was conducted on February 20, 2026, at 11:41 AM with the Director of Nursing (DON/ Staff #85), who stated the facility's expectation is that no medications should be left unattended. When a nurse needs to step away, the medication should be stored in a safe place or taken with the nurse. She confirmed that leaving medications on top of a medication cart unattended is not a safe practice. The DON further stated that possible risks would vary depending on medication ingested and there would be a risk of side effects. Review of the facility policy titled Administration of Medications, Reviewed September 9, 2025, states, The facility will ensure medications are administered safely and appropriately per physician order to address the resident's diagnosis and signs and symptoms. Review of the facility policy titled Self-Administration of Medication, Reviewed September 15, 2025, states, The facility will ensure that each resident who requests to self-administer medications is assessed by the interdisciplinary team (IDT) to determine if the resident is safe to self-administer medications.

Based on clinical record review, observation, and staff interviews, the facility failed to ensure appropriate infection control practices were implemented for 1 of 5 sampled residents (#136) regarding following contact precautions. The universe was 28 residents. The deficient practice could result in a spread of preventable illness to residents and staff. Findings include: -Resident #136 was admitted to the facility on [DATE], with diagnoses that included prosthesis, subsequent encounter, aftercare following joint replacement surgery, systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction.The physician order dated February 11, 2026 included usage of contact isolation precautions over and above standard precautions, related to ESBL- E. coli hip wound infection every shift.The care plan initiated on February 12, 2026 revealed a focus that the resident was on intravenous medications related to ESBL-E. coli (Escherichia coli producing extended-spectrum beta-lactamase) hip wound infection. Interventions in place for this focus included the use of Contact Isolation.The admission Minimum Data Set (MDS), dated [DATE], revealed that Resident #136 had an active diagnosis for infection/inflammatory reaction due to internal hip prosthesis, subsequent encounter.An observation of the room tray pass was conducted on February 17, 2026, at 12:41 PM for Resident #136's lunch tray. Observation revealed a certified nursing assistant (CNA/Staff# 60) entered a contact precaution room belonging to resident #136 without sanitizing hands or donning personal protective equipment (PPE) that was located at the entrance of the resident's room, as well as the signage on the wall indicating the room had contact precautions before entering the resident's room. The CNA was observed taking the room tray off the cart, entering the resident's room, and placing the resident's room tray on the bedside table. Further observation revealed that the CNA leaned to place the tray on the bedside table, his clothing came into contact with the resident's bed linen. The CNA exited the resident's room and was in the process of reaching for another tray when he was questioned regarding the observation.An interview was immediately conducted on February 17, 2026, at 12:44 PM with Staff#60 who stated that PPE for contact isolation should have been used when he entered Resident #136's room. The CNA stated that he got confused and he usually worked the other hall. He stated that he was helping pass out the room trays and he wasn't thinking when he went into the room. The CNA also stated he had received infection control training, and the risks of not donning PPE when entering a room with contact precautions is that he can transfer the germs to other residents. An interview was conducted on February 19, 2026, at 11:32 AM with CNA (Staff#69) who stated that staff are made aware of residents with precautions from the nursing report and signage on the residents' doors. The CNA also stated the process when entering a resident's room with contact precautions is to clean your hands, gown up before entering, and remove the PPE before leaving the room, then immediately wash your hands. The CNA further stated that staff are provided with infection control meetings and online training twice per month. The CNA stated that the risk of not using proper infection control precautions can cause the spread of infection and the risk of the resident's infection not getting better. An interview was conducted on February 19, 2026, at 2:43 PM with Infection Control Preventionist (IP/Staff #61) who stated that all staff are provided with training regarding infection control prevention through the Healthcare Academy, new hire orientation that discusses trends, and residents. The IP stated all staff are made aware of resident's on precautions when signage is placed, and their nurse will keep them informed. The IP also stated it is expected that all staff utilize infection control precautions when providing care and passing their room trays and to cleanse their hands, don the PPE outside of the room, doff the PPE before exiting the room, and sanitize or handwash their hands when they have exited the room. The IP stated that the risks of not following contact isolation precautions are spreading the infection to other residents or staff. The IP further stated We want to make sure it is contained. The IP also stated that she was aware of the incident and provided an immediate in-service to all staff working that floor, and also provided CNA #69 with individual training, and also discussed the concerns with not following infection control precautions. An interview was conducted on February 19, 2026, at 3:29 PM with the Director of Nursing (DON/Staff #85), who stated that staff should don PPE any time they are in residents' rooms or providing direct care for residents with orders for contact precaution. The DON identified the purpose of contact precautions as to decrease the risk for infection, especially for residents and staff.Review of the facility policy titled Contact Precautions revised December 30, 2025 states Contact precautions should be used when a resident develops signs and symptoms of a transmissible infection or has a laboratory confirmed infections that requires the use of contact precautions to prevent transmission of pathogens that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment (e.g., MRSA, scabies), and requires the use of appropriate PPE, including a gown and gloves.

Based on observations, interviews, facility documentation and policy, the facility failed to ensure that a mechanical lift for resident transfer, was cleaned and disinfected according to professional standards. The deficient practice could result in the spread of infection and resident illness. Findings include: At the conclusion of a mechanical lift observation conducted on June 19, 2025 at 12:45 p.m., the Certified Nursing Assistant (CNA/Staff #20) rolled the mechanical lift to the end of the hallway. Cleaning and disinfection of the lift was not performed after resident use. A second mechanical lift transfer observation was conducted. The mechanical lift was not cleaned or disinfected prior to resident use at approximately 12:50 p.m. At the conclusion of the second mechanical lift observation, CNA/Staff#7 was observed rolling the mechanical lift with the sling to the end of the hall without cleaning or disinfecting the equipment. At approximately June 19, 2025 at 1:10 p.m., CNA # 20 was observed picking up the unwiped sling from the parked mechanical lift with bare hands and proceeded to walk down the hall with it open to air. An interview was conducted on June 19, 2025 at 1:13 p.m. with CNA # 7, who confirmed that the mechanical lift was not wiped down after its use. The CNA stated that it was important making sure resident equipment is cleaned properly after every use to decrease the chance of spreading infection. During an interview on June 19, 2025 at 1:20 p.m., with the Unit Manager (Staff # 54), she stated that after a resident lift is completed the lift should be cleaned and disinfected before storage and before use on another resident in order to decrease spread of illness, and to keep the machine clean and in working condition. An interview was conducted with the Director of Nursing (DON/Staff # 1) on June 19, 2025 at approximately 1:25 p.m., who stated that the facility expectation are to make sure resident equipment is cleaned and disinfected according to facility policy after resident use. The Mechanical Lift User Instruction Manual, instructs the user to clean the equipment before use. The manual further specifies that the lift is to be cleaned with ordinary soap and water and/or any hard surface disinfectant. The facility's Cleaning and Disinfection of Non-Critical Patient Care Equipment, revised August 22, 2022 revealed equipment will be cleaned and disinfected prior to storage. The facility's Transfer with a mechanical lift, long-term care policy, revised August 9, 2023, instructs the staff to clean and disinfect the mechanical lift accessory equipment after use according to the manufacturer's instructions to prevent the spread of infection.

Based on clinical record review, staff interviews, observation of current practice, and review of the facility's policies, the facility failed to ensure one resident #77, was free from verbal and/or physical abuse from a family member. The deficient practice could result in residents experiencing emotional and mental trauma from the abuse. Findings include: Resident #77 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing, chronic kidney disease, stage 2 (mild) and rheumatoid arthritis, unspecified. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #77 BIMS (Brief Interview of Mental Status) score was 14 which indicated intact cognition. The care plan revised on January 13, 2024 included resident #77 had limited mobility and pain from severe rheumatoid arthritis, contractures and deformity of the back, neck, bilateral hands, feet and ankles. The Care Plan revealed that resident required extensive assist by 1-2 staff for toileting and personal hygiene. A review of resident's progress notes revealed an entry dated August 17, 2024 at 6:34 PM. The note revealed assigned Certified Nursing Assistant (CNA/Staff #202) reported that patients' family was yelling at her and left the building immediately after. Furthermore, progress notes revealed resident reporting to staff that the family member had slapped her. An interview was conducted on August 26, 2024 at 3:11p.m. with the CNA (Staff #202). Staff #202 stated she was working in the unit where resident #77 resides and heard yelling and screaming. She stated it was coming from resident #77's room. She stated as she approached the room she observed that the door was opened and heard, you're an OCD Bitch. I also heard resident #77 yelling Help, Help!. Staff stated as she was entering the room, resident's #77 family member (Resident #77's sister) was exiting the room. She stated when she entered the resident's room, the resident had head down and was crying- and stated she hit me, she hit me very hard on my mouth. Staff #202 stated she immediately told the assigned licensed practical nurse, (LPN/Staff#180). Staff #202 stated she went back to the resident's room and she was visibly shaking and asked to call her mother. She further stated she did not observe any redness or bruising. Staff #202 stated she has observed that the family member does not have patience with the resident and will often make faces and raise her voice when talking to the resident, but, stated she had not heard them like this before. She stated the family member help with the residents laundry and brings her snacks and always appeared happy to see her family member and is excited for her visit. An interview as conducted August 26, 2024 at 3:02p.m. with the LPN (Staff #180). He stated the family member visited 1-2 times per week and brought supplies. He stated Staff#202 had reported to him that she had heard arguing in resident #77's room and then had observed the family member leaving. He stated he went to check on the resident and was told by the resident, regarding her family member, she beat me up and called me an OCD bitch and slapped me on the face. Staff #180 stated he completed an assessment and did not observe any bruising or redness. Staff #180 stated that he was aware of prior arguments between the resident and the family member that included elevated voices and yelling. He stated he did not report this to anyone or document the prior incidents, nor could he recall when the incidents happened. Staff #180 stated he has received abuse training and that there is now a picture of the family member at the front lobby desk and that family member is not allowed to enter or visit at this time. An interview was conducted on August 26, 2024 at 3:37p.m. with resident #77 at 3:37p.m. the resident reported that family member gets all riled up and had become upset when the resident had stated she wanted to keep an empty tissue box that her family member wanted to toss away. The resident stated a disagreement ensued, and that family member went ballistic. Resident #77 stated the family member hit her in the face with the tissue box, hitting her in the mouth. The resident stated the family member always gets mad at her and raises her voice at her. She stated that the family member complained about having to come to the facility to see her. She stated the family member cursed at her all the time calling her a selfish bitch OCD bitch- and other names. The resident stated she has told her nurse, staff#180 about the name calling and how her sister made her feel. The resident stated she became depressed following the incident and did not get up or go out. An interview was conducted on August 26, 2024 at 4:17p.m. with Social Services Director (SSD/Staff#205). Staff # 205 stated the incident happened during the weekend and was informed to follow-up with the resident to address and discuss how to move forward with the situation. Staff #205 stated the family member is not allowed to interact with the resident at this time. Staff #205 stated the resident is stressed out due to the situation between her and her family member and concern was now going to provide the additional support. She stated that the follow-up visit was for socio-emotional assessment and did not discuss the relationship between the resident and the family member. An interview was conducted on August 26, 2024 at 4:28 p.m. with Administrator (Staff#15) who stated her expectations are that staff report what they see or hear, stop it and report it to their supervisor on duty or if unavailable to any supervisor. Staff #15 stated verbal abuse are any derogatory remarks or mocking, mean statements directed toward a resident and the expectations are that staff would report any abuse and staff are not to decide what is reportable, that they are to report any incidents. Review of the facility policy titled Abuse-Prevention states it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on review of clinical record review, resident/staff interviews the facility documentation and policy review, failed to ensure a discharge planning based on the assessed needs and goals was in place for one resident (#49). The deficient practice could result in the delay of the resident transfer/discharge to the facility of choice. Findings include: Resident #49 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure (CRF) with hypoxia, dependence of supplemental oxygen, and heart failure. The care plan dated December 21, 2023 included a discharge plan that the resident wished to return home. The communication note dated May 23, 2024 included that the social services director (SSD/staff #50) had a conversation with the resident's family related to a request to transfer to an assisted living (AL). Per the documentation, the family wanted the transfer. An email correspondence dated May 23, 2024 between the SSD (staff #50) and the Director of Marketing (DoM of the assisted living facility (ALF) the resident was going to) revealed that the planned discharged to the ALF was the choice of the resident and her family. A late entry nurse practitioner (NP) progress note dated May 28, 2024 included that the resident had an advanced COPD, CRF with hypoxia, was O2 (oxygen) dependent at 2 LPM (liters per minute), and used a CPAP (continuous positive airway pressure) at night. The follow-up email from the DoM on June 4 and 5, 2024 addressed to the SSD revealed another request for the physician to sign the documents necessary to discharge the resident to the ALF. The follow-up psych evaluation note dated June 10, 2024 included that the resident was alert and oriented to person, place and time. An email correspondence from the insurance case manager addressed to the SSD (staff #50) and dated June 20, 2024 revealed a request to have TB test completed timely as the resident was very anxious to be discharged . The social service note dated June 21, 2024 included that the SSD followed up with the ALF regarding the resident's transfer to ALF on June 26, 2024. An email correspondence from the DoM to the SSD dated June 21, 2024 revealed that the resident was scheduled for discharge on June 25, 2024. The email from the DoM addressed to the SSD dated June 24, 2024 revealed a request from the resident's family for confirmation that transportation had been set up for June 25, 2024. The SSD replied to this email on June 25, 2025 (the day of the planned discharge) that it was the role of the accepting facility to set up transportation and not the discharging facility. An email from the DoM addressed to the SSD and dated June 25, 2024 included that per the resident's LTC (long term care) insurance that it should be the discharging facility that sets up transportation. The SSD replied to this email on June 25, 2024 that the resident had a manual wheelchair, had several boxes of personal belongings, and needed home oxygen equipment. However, there was no evidence found in the clinical record that the SSD sent the DME referral for the home oxygen equipment and supplies to the approved DME vendor. Another email from the DoM addressed to the SSD and the LTC case manager and dated June 25, 2025 revealed that the DoM was inquiring whether the home oxygen and DME had been set up for discharge for resident #49. A communication note dated June 25, 2024 included that the concerns with transfer of the resident to the ALF was discussed with the ALF. The order administration note dated June 25, 2024 included that the portable oxygen tank was switched to an oxygen concentrator at bedtime. An email correspondence from the ED (Executive Director of the ALF the resident was going to be transferred) addressed to the facility and dated June 25, 2024 revealed the ED informed the SSD and the DON that it was the role of the discharging facility to set up the DME orders through an approved DME provider for the discharging resident. It also included a request that the facility send the orders including any DME orders, and a discharge summary to assist in the setting-up of the DME referral for Resident #49 for discharge. The ED of the facility (staff #140) replied to this email on June 25, 2025 that the facility does not set up DME orders and will not be arranging transport. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. A late entry mood note dated June 26, 2024 revealed that the resident was in the process of transferring to another facility per the resident and family request. Despite the documentation that the resident will be transferred to the ALF on June 26, 2024, there was no evidence found in the clinical record that discharge plan was developed to assess and address the resident's discharge needs to include oxygen and DME (durable medical equipment) needs. A fax cover sheet with transmission date of June 27, 2024 addressed to the DME provider from the social services revealed a hand written note that the resident was transferring to the ALF; and, to drop off equipment at the ALF and to confirm the delivery date and time. It also included a Respiratory and Durable Medical Equipment Referral form with a blank RX date and included that an oxygen test was done on June 26, 2024. However, this form was signed by the physician on February 6, 2024. The care management note dated June 28, 2024 included that the SSD informed that the DME and transportation for resident #49 were not confirmed. The communication note dated June 30, 2024 included that the resident family was requesting for an update on the resident's DME; and that, the SSD informed the family that a referral was sent and follow-up emails had been provided. Despite the documentation that the DME were not confirmed, there was no evidence found in the clinical record that the DME referral was re-sent to the DME provider; or, that facility asked the DME provider for any clarification as to why the DME referral was not processed or confirmed until July 8, 2024. A fax cover sheet with transmission date of July 8, 2024 addressed to the DME provider from the facility social services included a hand written note that the request was resident #49; and to follow up with the ALF staff. It also included a Respiratory and Durable Medical Equipment Referral form with a blank RX date and included that an oxygen test was done on July 8, 2024. However, this form was signed by the physician but did not have a date as to when it was signed. In an email from the LTC case manager addressed to the SSD, DON, the ED of the ALF and the DoM dated July 08, 2024 included that an oxygen test had be completed and results had to be faxed to the approved DME provider; and, if DME provider receives the DME order and the requested oxygen test, it can be delivered on the same date. It also included that the LTC case manager requested that once the receiving facility confirmed the delivery of the DME, the SSD would schedule transportation for the following date of July 09, 2024. An email correspondence from the DoM addressed to the SSD and dated July 11, 2024 included that the DoM was asking the facility to check the status of the DME equipment referral. Per the documentation, once the DME equipment was delivered, Resident #49 can move in to the ALF. However, the documentation included that the DME equipment had not been delivered to the ALF. In an email from the ED of the ALF addressed to the facility and dated July 12, 2024, the ED of the ALF informed that after reserving the apartment reserved for resident #49 for over a month, the ALF had to released it from being held for Resident #49. Additionally, The ED of the ALF expressed concerns and was feeling uncomfortable with Resident #49 not having a coordinated, safe discharge plan as protected in her resident rights to transition to their community. A communication note dated July 15, 2024 revealed that the SSD informed the resident that the ALF was not holding apartment that was reserved for her when she transfers; and that, things were not completed on time regarding the oxygen. Per the documentation, the SSD that she can continue to find placement that the resident wanted. In an interview conducted with resident #49 on July, 16, 2024 at 2:47 p.m., the resident stated that she was still awaiting discharge from the facility. During the interview, the resident became tearful when she described her strong desire to discharge from the facility; and, verbalized her frustration with how the discharge process was taking an extend time to complete. An interview with the SSD (Staff #50) was conducted on July 17, 2024 at 11:01 a.m. The SSD stated that delayed discharge for resident #49 was due to multiple factors and failing to realize the current barrier to discharge was that the DME provider would not accept the oxygen test on the form that she had faxed twice. During the interview, a review of the clinical record was conducted with the SSD who stated that there was no evidence of any emails or documented phone calls made by the SSD or any staff of the facility to the DME provider for clarification on how to correctly submit an oxygen test for DME orders. During an interview with the DON conducted on July 17, 2024 at 3:09 p.m., the DON stated that the IDT team was involved with discharges and the facility had discharge meeting every week to discuss nursing, case management and the goals for discharge. Regarding the discharge of resident #49, the DON stated that she was not involved with the discharge process for resident #49 until issues came up related to the DME. She stated that she was aware that the family wanted to go to an ALF. Review of the facility's policy titled, Transfers and Discharges (revised June 2024) revealed, for resident-initiated discharges, the medical record should contain documentation or evidence of documented discussions with the resident or, if appropriate, his/her representative.

Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure one resident (#25) was treated with dignity and respect by a visitor. The deficient practice has the potential for additional residents to be treated with a lack of dignity and respect. The facility census was 89, and the resident sample was 18. Findings include: Resident #25 was admitted on [DATE] with diagnoses that included, dementia, type 2 diabetes mellitus with hyperglycemia, hemiplegia/hemiparesis related to cerebral infarction. The care plan, initiated on November 18, 2019 revealed the following areas of focus: -Cognitive deficits related to diagnosis of dementia, and history of CVA -Communication: may have barriers to communication related to expressive aphasia Review the June 2024 Medication Administration Record (MAR) revealed change of condition monitoring for mental well-being from June 12, 2024 through June 15, 2024. The progress note dated June 12, 2024 through June 15, 2024, revealed no documentation of behavioral changes or signs of distress. The facility 5-day investigation report dated June 18, 2024 revealed on June 12, 2024, resident #25 was in the 400-station day room reading near the window and another resident (#392) was seated in a wheelchair in front of the television. A staff member heard a visitor of resident #392 state you mother f**ker, I'm going to throw you out the window; and that, the visitor requested that staff come into the day room. The investigation included interviews with the staff who reported that the visitor yelled and cursed at resident #25; and that, the visitor was concerned the other resident's (#392) breasts were exposed and her pants were pulled down. The report indicated that Resident #25 was placed on change of condition monitoring for three days after the incident. Further, the report also included a type written interview with resident #25 conducted during the facility investigation on June 13, 2024. Resident #25 denied putting his hands on the other resident (#392); and stated that he was holding onto his reading material, and that he left the room when the yelling began. Review of a quarterly Minimum Data Set (MDS) dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment also included that the resident had no behaviors identified. An interview was conducted on July 16, 2024 at 10:42 AM, with the Director of Nursing (DON/Staff #12), who stated that staff reported that on June 12, 2024, a visitor was seen walking past the 400-unit nursing station, entered the day room, and immediately returned to the nursing station asking for a nurse. The DON stated that the visitor returned to the day room with the nurse and then yelled and cursed at resident #25. The DON stated that the resident (#392) the visitor was visiting had pants that did not fit well and would often fall down; and that, staff would cover the resident with a blanket, but the resident would remove it. The DON stated that the visitor was immediately removed from the day room and his behavior was discussed with management. The DON stated that the visitor later told the facility that he really did not think that resident #25 did anything to the resident (#392) he was visiting; but, but he was concerned that the resident was not covered appropriately. The DON further stated that there had been no other complaints/concerns regarding resident #25 being inappropriate with other residents. An interview was conducted on July 17, 2024 at 11:12 AM with a Registered Nurse (RN/staff #13) who stated that on June 12, 2024 on the 400-unit, a visitor who seemed angry stated I need someone in this room (referring to the day room at the station) now. The RN stated when she entered the day room, resident #25 was sitting a few feet away from the door reading, and resident (#392) was visiting was sitting in front of the TV with her blanket on the floor. The RN stated that the visitor pointed that the other resident (#392) nipples were exposed. The RN stated that she immediately pulled the other resident's (#392) shirt down and apologized to the visitor. The RN further stated that the visitor reported that resident #25 was touching the other resident (#392); and that, he would throw resident #25 out of the window. The RN stated she asked the visitor not to talk to the residents like that and the visitor told her to get out of his face. The RN stated that a CNA took resident #25 out of the room, and called the supervisor. The RN said that she assessed resident #25 after the incident; and that, she asked resident #25 if he had touched the other resident (#392). The RN said that resident #25 reported that he did not know what happened. The RN further stated that later in the day a CNA reported that resident #25 was very upset about the situation. An interview was conducted on July 17, 2024 at 11:30 AM with a Licensed Practical Nurse (LPN/staff #75) who stated that a visitor of another resident (#392) entered the 400-unit day room, and less than a minute later went back to the nursing station and asked the nurse to get in the room immediately. The LPN stated that the visitor thought that resident #25 had moved the other resident's (#392) clothing. The LPN stated that when she and the RN (staff #12) entered the day room, resident #25 was on the other side of the room day room reading. The LPN stated that when the visitor saw the other resident (#392) exposed, the visitor thought that resident #25 had done it. The LPN stated that the other resident (#392) would play with her clothes and would pull her shirt up and her pants down; and, this was a normal behavior for the other resident (#392) that staff would keep her covered and faced toward the TV. The LPN also stated that resident #25 did not comprehend what was going on, and he was removed from the day room immediately. The LPN stated that the nurses were standing between resident #25 and the visitor. Further, the LPN stated that the next day resident #25 was kind of sad, but did not know why he was sad. The LPN stated that resident #25 did not have the capacity to comprehend but was aware of time/place. However, the LPN said that resident #25 had to be guided. The LPN stated that she had not observed this type of behavior from the visitor previously, and he had always been a really nice guy. In an interview with another LPN (staff #68) conducted on 07/17/2024 at 12:19 PM, the LPN stated that she was the acting nurse supervisor on June 12, 2024, and she spoke with an RN (staff #13) and the visitor regarding the incident that occurred that day. The LPN stated that the RN (staff #13) came to her office with the visitor and reported that the visitor had yelled at, threatened to punch and throw resident #25 out the window. The LPN stated that the visitor told her he was angry because the other resident's (#392) clothes were askew and resident #25 was next to her reading; and that, as soon as resident #25 saw him, resident #25 backed up. The LPN stated that she discussed the incident with the visitor and she thought that he became upset that the other resident (#392) was exposed, but educated the visitor that he cannot threaten patients or staff. The LPN stated that after the incident, the visitor was only allowed to visit with the other resident (#392) in the lobby and not in the unit. The LPN also stated that her previous interactions with the visitor had always been civil, and she would never have thought that he would do that sort of thing. An interview with Social Services (Staff #50) was conducted on July 17, 2024 at 12:26 PM. Staff #50 stated that she met/interviewed resident #25 on June 12, 2024, after the incident; and, the resident told her that he did not feel safe, and that being yelled at felt like s**t. Staff #50 stated that she could not find her documentation in the medical record, but it was included in the 5-day incident report. During an interview with a Certified Nursing Assistant (CNA/staff #71) conducted on July 17, 2024 at 11:04 AM, the CNA stated that he remembered the incident that occurred on June 12 2024 and that the incident was pretty scary. The CNA stated that he was passing meal trays, and saw the visitor of resident #392 flailing his arms around and yelling at resident #25; and that, the visitor was telling resident #25 that he would throw resident #25 out the window. The CNA stated that the other resident (#392) that the visitor was visiting had her breasts and brief exposed. However, the CNA stated that resident #25 was not anywhere near the other resident (#392). The CNA stated that he covered the other resident (#392) to make sure she was not exposed, and removed her from the area. The CNA stated that resident #25 looked confused and scared, his eyes were all big, and he was sitting a good distance from the other resident (#392); and, was not close enough to touch her. The CNA stated that the visitor was removed from the area as soon as possible, and resident #25 was taken to the dining room. The CNA also stated that he never saw resident #25 acted inappropriately with other residents. Further, the CNA stated that there had been previous times when the visitor would speak loudly, and was not nice to staff and the visitor's approach was mean. A facility policy titled, Dignity, revealed that each resident has the right to be treated with dignity and respect. The facility must protect and promote the rights of the resident. A facility policy titled, Resident Rights, revealed that the facility must protect and promote the rights of the resident. The resident has the right to be treated with respect and dignity. A facility policy titled, Abuse Prevention, revealed that it is the policy of the facility to prevent and prohibit all types of abuse and neglect. Ensure the health and safety of each resident with regard to visitor's subject to the resident's rights.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure one resident's (#3) choice regarding advance directives and orders were accurately reflected in the medical record. The deficient practice could result in resident's choices noted being followed. The resident census was 89 and the sample was 18. Findings include: Resident #3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including acute kidney failure, pneumonitis, anxiety, and depression. The advance directive statement form dated [DATE] revealed the resident wanted CPR (cardiopulmonary resuscitation) in the event that he experiences cardiac arrest. The care plan dated [DATE] revealed the resident had an Advance Directives of CPR and was a full code. Goal was that the resident's advance directives will be honored. Interventions included that code status will be reviewed quarterly and as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The advance directive statement form signed by the resident and dated [DATE] included that the resident wanted CPR (cardiopulmonary resuscitation) in the event that he experiences cardiac arrest. In another advanced directive statement form signed by the resident and dated on [DATE], it included that the resident did not want CPR in the event that he experiences cardiac arrest. However, review of provider order recap revealed that the resident had a full code status. Further, the care plan was not revised to reflect the resident's change in advance directives. On [DATE], the resident signed another advance directive statement form indicating that he wanted CPR in the event that he experiences cardiac arrest. An interview was conducted on [DATE] at 11:20 AM with a Licensed Practical Nurse (LPN / Staff #63) who reviewed the medical record and stated that Resident #3 was a Full Code. The LPN said that the resident signed a revised advanced directive choosing DNR on [DATE]. She stated that staff should base code status on the resident's most recent advance directive which was a DNR (Do Not Resuscitate). However, the LPN was no able to find any orders for a DNR or any paper versions of the resident advance directive. The LPN further stated that this situation could result in staff not following a residents' advance directive choice. During an interview with the Director of Nursing (DON/ Staff #12) conducted on [DATE] at 1:42 PM, the DON stated that resident #3 should have been a full code; and, the inconsistencies in the advance directives of the resident had corrected after the issue brought to their attention. Review of a facility policy on Advance Directives and Advance Care Planning, included that residents may revise an advance directive either orally or in writing. With an oral reversal, charting is due immediately, the physician is notified immediately, and immediate notation is made on the care plan, and an immediate entry is made in the medical record. With written reversals, the physician is notified, and the plan is permanently adjusted. The physician must give an order for any changes in the advance directives.

Based on clinical record review, observations, staff interviews, and policy, the facility failed to ensure that a care plan intervention for monitoring medication side effects related to use of an antianxiety medication was implemented for one resident (#60). The deficient practice could result in the resident not receiving the care and services to meet their needs. Findings include: Resident #60 was admitted on [DATE] with diagnoses of dementia, Alzheimer's disease, cerebral infarction, mild neurocognitive disorder, and altered mental status. The active physician order summary included an order to monitor for side effects related to anti-anxiety medications. The care plan revealed dated December 28, 2023 included that the resident used anti-anxiety medication related to anxiety disorder as evidenced by restlessness. The physician order dated December 28, 2023 included to monitor behaviors of restlessness every shift for 14 days; and, to code whether behavior improved, worsened or unchanged. The care plan was revised on January 18, 2024 to include interventions to observe for the occurrence of target behavior, to report as needed any adverse reactions to the medication and to administer the medications as ordered. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status with a score of 00 indicating the resident had severe cognitive impairment. A physician order dated June 12, 2024 included for Ativan (antianxiety) 1 mg tablet administered via G-Tube every 8 hours as needed (PRN) for Anxiety as evidenced be (AEB) restlessness for 14 days, starting on June 12, 2024. The orders for Ativan, monitoring for side effects related to its use were transcribed onto the MAR (medication administration review) for June 2024. Review of the MAR for June 2024 revealed that Ativan was administered to the resident on 10 occasions between June 13 and June 24, 2024. However, the MAR revealed that the monitoring for side effects were not documented as completed from June 13 to 24, 2024. The clinical record revealed no evidence that the monitoring for side effects related to the use of Ativan was discontinued or put on hold. An interview was conducted on July 17, 2024 at 1:17 p.m. with the Director of Nursing (DON/staff# 12) who stated that residents should be monitored for behaviors and side effects while taking psychoactive medication such as Ativan. During the interview, the DON reviewed the clinical record and stated that there was an active order for Ativan for resident #60 and the medication was administered to the resident on 10 occasions between Jun 13 and 24, 2024. The DON also stated that the side effect monitoring was not implemented by staff as care planned between June 13, 2024 and June 24, 2024. The DON stated the risk for not following the care planned interventions could result in lack of identifying side effects and effectiveness of the medication and could affect the overall care of the resident. Review of the facility policy titled, Comprehensive Care Plans and Revisions, revealed that the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan and to ensure that the comprehensive care plans reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update and quarterly review assessments.

Based on clinical record review, observations, staff interviews, and policy, the facility failed to ensure that a care plan was revised to include resident-specific nutritional goals for one resident (#76). The deficient practice could result the resident not being involved and not able to make decisions about their care and needs. Findings include: Resident #76 was admitted on [DATE] with diagnoses of acute metabolic acidosis, type 2 diabetes mellitus, unspecified protein-calorie malnutrition, anemia, dysphagia, and chronic kidney disease. The weight on May 03, 2024 was 130 lbs. (pounds) Review of the nutrition care plan initiated on May 03, 2024 revealed the resident had nutritional problems due her medical diagnoses of dysphagia, esophageal stenosis, and cerebrovascular accident; and, had nutritional risks due to suboptimal meal intakes related to decreased appetite, and potential for weight fluctuations/fluid deficit due to fluid shifts due to diuretic medication. Interventions included to report results to physician and follow up as indicated on any signs and symptoms of dysphagia, to provide and serve diet as ordered, monitor intake and record every meal, registered dietician to evaluate and make diet change recommendations as needed, and to weigh and monitor per orders. The goal was that the resident will have no signs and symptoms of aspiration. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment. The skilled note dated May 6, 2024 included the resident was alert and oriented x 2-3 and was non-compliant with physician orders. A Nutrition Admission Assessment progress note dated on May 6, 2024 revealed the resident was alert and oriented, had swallowing difficulties related to dysphagia, had a weight of 130 pounds; and, was consuming an average of 50% of meals. Per the documentation, interventions included medication pass supplement 4 ounces three times per day and to monitor weight and oral intakes. The weight record on May 9, 2024 was 121.4 lbs. The Nutrition/Dietary Note dated May 9, 2024 revealed that the weight was 121.4 lbs. and the resident had a weight loss of 8.6 lbs. in 1 week. The documentation included that the resident was refusing the medication pass supplement 6 times due to terrible taste; and that, the resident agreed to have supplemental cereal at breakfast and supplemental pudding at lunch and dinner. The care plan was revised on May 9, 2024 to include an intervention to provide and serve supplements as ordered. The care plan did not include any resident-specific goals and desired outcomes related to her nutrition and weight loss. The physician note dated May 10, 2024 included that the resident did not have the capacity to make her own decision. The skilled nursing note dated May 13, 2024 included that the resident complaint of nausea and vomiting post breakfast and was administered with an antiemetic medication. The skilled note dated May 20, 2024 included that the resident refused her breakfast, ate her lunch and was compliant with most of her medications. The weight record on May 20, 2024 was 115.8 pounds, which was a 14.2 pound weight loss in 17 days. The order administration note dated May 20, 2024 included that the resident was alert and oriented x 4 and refused SNP pudding (supplement). A Nutrition/Dietary Note dated May 22, 2024 revealed the resident had a weight of 115.8 lbs.; and that, the resident had a 14.2% weight loss in 3 weeks. The documentation included that the resident consumed an average of 35% of meals; 55% average of the SNP pudding and 35% of the SNP cereals. Recommendations included to add the house shakes three times a day for additional 600 kcal (kilo calories/18 g (grams) protein; and to continue to monitor weights and oral intakes. The care plan was revised on May 22, 2024 to include that the weekly weight loss continued and the supplements were increased. However, the care plan did not include resident's goals and desired outcomes related to her nutrition and weight loss. The weight record on June 1, 2024 was 115 lbs. The Nutrition/Dietary note dated June 12, 2024 revealed the resident was on palliative care, had a weight of 115 lbs. and had a significant unplanned weight loss of 15 lbs. in a month. Per the documentation, the resident had an inadequate intake consuming on the average 40% of her meals, had a decreased appetite and refused supplements. Plan included fortified food house shakes three times daily. Further the documentation included that there were no new recommendations at this time. Despite documentation of resident refusal of supplements in the clinical record, the care plan was not revised to include interventions to address this issue; and, the care plan was not revised to include any new or revised resident-specific goals. An interview was conducted on July 18, 2024 at 9:45 a.m. with the Registered Dietician (RD/staff #77), who stated that she was not following resident #76 for any weight loss; and that, a referral for an evaluation would have been appropriate for the resident due to her significant unplanned weight loss. In an interview with the Director of Nursing (DON/staff #12) conducted on July 18, 2024 at 10:51 a.m., the DON stated that the facility monitors the effectiveness of interventions through IDT (interdisciplinary team) reviews; and, the care plan was discussed weekly in the IDT meeting or daily, and revised if needed. During the interview, a review of the clinical record was conducted with the DON who stated that there was no evidence found in the clinical record that the care plan did not have any resident-specific goals related to the resident's continued weight loss since the resident's admission on May 3, 2024. The DON further stated that the care plan should have been revised to address the weight loss with resident-specific goals. Review of the facility's policy titled, Comprehensive Care Plans and Revisions, dated [DATE], revealed that the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. According to the procedure section of this policy, the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery, this can include; additional interventions on existing problems, updating goal or problem statements, and adding a short-term problem, goal, and interventions to address a time limited condition.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure one oxygen-dependent resident (#49) did not have an empty oxygen tank while in use. The deficient practice could result in scaling down of services, provided by the facility, that do not align with the highest practicability of care. Findings include: Resident #49 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure (CRF) with hypoxia, dependence of supplemental oxygen, and heart failure. The care-plan initiated on January 11, 2024 revealed that the resident had oxygen therapy related to COPD. Interventions included O2 (oxygen) via nasal cannula continuous per medical doctor orders. A physician order dated July 18, 2024 revealed an order for oxygen at 2 liters per minute continuously via nasal cannula; may titrate to 4 liters to maintain 88% saturation. An observation conducted on July 18, 2024 at 2:03 p.m. revealed Resident #49 was in the activity room playing bingo with nasal cannula on. The oxygen tank gauge displayed an empty oxygen tank. An interview was conducted on July 18, 2024 with Certified Nursing Assistant (CNA/Staff # 42) who stated that in order to prevent the oxygen tank for Resident #49 from being empty was to monitor the gauge when it was nearing empty. However, the CNA stated that there were instances in the past where the oxygen tank had been empty and it happens. In another observation conducted on July 18, 2024 at 2:03 p.m., the CNA (staff #42) told the resident that she needed a replacement for her oxygen tank. An interview was conducted on July 18, 2024 with Director of Nursing (DON/Staff # 12) who stated that a resident with continuous oxygen orders and utilizing an empty oxygen would not meet the facility's expectations. The DON further stated that if there was an oxygen order for a resident, staff were expected to be checking the resident's oxygen throughout the shift. Review of the facility's policy titled, Administration of Medications (reviewed August 2023) revealed, the facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. It also included that staff must adhere to right of medication administration including: Right Time and Frequency, check the order for when it would be given and when was the last time it was given; Right Assessment, note the resident's history and any parameters around drug administration; Right Evaluation, ensure the medication is working the way it should, ensure medications are reviewed regularly, ongoing observations if required.

Based on personnel file review, staff interviews, facility policy review and Center for Medicare and Medicaid Services (CMS) guideline, the facility failed to ensure that the occupational therapist (OT/staff #88) had a valid Cardiopulmonary Resuscitation (CPR) and first aid certifications. The deficient practice could result in staff not being knowledgeable of how to prvide emergency care to residents. Findings include: Review of the personnel file for an occupational therapist (OT/staff #88) revealed a hire date of [DATE]. Continued review of the personnel file included that the CPR or First Aid certification had an expiration date of February 28, 2012. During an interview conducted on [DATE] at 11:00 a.m, a review of the personnel file of the OT was conducted with the Payroll Coordinator (staff #55) who stated that there was no evidence found of any valid CPR or First Aid certifications for the OT (staff #88). The payroll coordinator stated that she thought that CPR or First Aid certifications were only required for only nurses and nurse aids, and, not required for Physical Therapy (PT)/OT staff. An interview was conducted on [DATE] at 1:42 p.m. with the Director of Nursing (DON, Staff #12) who stated she was told by the Director of Rehabilitaion that CPR and First Aid were longer required of PT or OT staff. Review of Centers for Medicare & Medicaid Services (CMS) guideline on Cardiopulmonary Resuscitation (CPR) in Nursing Homes dated [DATE] included that staff must maintain current CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessment. The facility policy titled, Specialized Rehabilitative Services, included that care provided by facility associates should be coordinated and consistent with the specialized rehabilitative services provided by qualified personnel. The facility policy titled, Competent Staff, included that the facility will have staff with the appropriate competencies and skills needed to provide nursing and related services to assure resident safety and maintain the highest level of care.

Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure there was adequate monitoring for side effects related to the use of a psychotropic medication for one resident (#60). The census was 89. The deficient practice could result in residents being at risk for unidentified adverse reactions related to the use of the medication. Findings include: Resident #60 was admitted on [DATE] with diagnoses of dementia, Alzheimer's disease, cerebral infarction, mild neurocognitive disorder, and altered mental status. The active physician order summary included an order to monitor for side effects related to anti-anxiety medications. The care plan revealed dated December 28, 2023 included that the resident used anti-anxiety medication related to anxiety disorder as evidenced by restlessness. The care plan was revised on January 18, 2024 to include interventions to observe for the occurrence of target behavior, to report as needed any adverse reactions to the medication every shift and to administer the medications as ordered. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status with a score of 00 indicating the resident had severe cognitive impairment. A physician order dated June 12, 2024 included for Ativan (antianxiety) 1 mg tablet administered via G-Tube every 8 hours as needed (PRN) for Anxiety as evidenced be (AEB) restlessness for 14 days, starting on June 12, 2024. The follow-up psych evaluation note dated June 17, 2024 included the resident continued to have intermittent episodes of yelling out along with severe restlessness and agitation. Per the documentation, Ativan helped with the symptoms; and that, the resident continued to receive Ativan at least once daily. Plan was to continue Ativan as needed for anxiety as evidenced by restlessness. A follow-up psych evaluation note dated June 24, 2024 revealed that the resident continued to have intermittent episodes of restlessness and agitation along with episodes of yelling out. The documentation included that staff reported the resident responded well to Ativan when he exhibited these behaviors; and that, the record showed that the resident received Ativan at least twice daily for his symptoms of restlessness. The plan was to change Ativan to a scheduled medication twice daily. The orders for Ativan, monitoring for side effects related to its use were transcribed onto the MAR (medication administration review) for June 2024. Review of the MAR for June 2024 revealed that Ativan was administered to the resident on 10 occasions between June 13 and June 24, 2024. However, the MAR revealed that the monitoring for side effects were not documented as completed from June 13 to 24, 2024. The clinical record revealed no evidence that the monitoring for side effects related to the use of Ativan was discontinued or put on hold. An interview was conducted on July 17, 2024 at 10:04 a.m. with a Licensed Practical Nurse (LPN/staff #112), who stated that the resident should be monitored for behaviors and side effects while taking Ativan, regardless of the medication being scheduled or given as needed. The LPN stated that behaviors and side effects monitoring should be documented in the MAR; and, whenever a psychoactive medication such as Ativan was ordered there should be an additional order to monitor for behaviors and side effects related to its use. During the interview, the LPN reviewed the clinical record and stated that there was an active order for Ativan which was administered to the resident. However, the LPN stated that there was no documentation of that the side effects related to the use of Ativan was monitored on June 13 through June 24, 2024. The LPN further stated that the risk could result in staff not being able to monitor the actual effects of the medication on the resident. An interview was conducted on July 17, 2024 at 1:17 p.m. with the Director of Nursing (DON/staff# 12) who stated that residents should be monitored for behaviors and side effects while taking psychoactive medication such as Ativan. During the interview, the DON reviewed the clinical record and stated that there was an active order for Ativan for resident #60 and the medication was administered to the resident on 10 occasions between Jun 13 and 24, 2024. The DON also stated that there was no documentation of side effects monitoring completed during that time period; and that, this could result in staff not identifying the side effects should it happen and could affect the overall care of the resident. Review of the facility policy titled, Psychotropic Medication Use, revealed that psychotropic drugs include but are not limited to antipsychotics, anti-anxiety, and sedative-hypnotics that affect brain activities associated with mental processes and behavior. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medial or psychiatric causes of behavioral symptoms. All medications used to treat behaviors should be monitored for: efficacy, risks, benefits, and harm or adverse consequences.

Based on clinical record reviews, facility and hospital documentation, staff interviews and policy review, the facility failed to ensure that two residents (#17, 10) was free from verbal abuse. Findings include: -Resident #10 was admitted on [DATE] with diagnoses of Major Depressive Disorder, Adjustment Disorder with disturbance of conduct. Review of a care plan initiated 12/19/2023 included that this resident displays comments towards other residents and visitors at times as noted aggressive like behaviors. This care plan included 2 incidents: Family visiting and resident verbalized you need to control your kids and stated fat people are ugly, continued comments related to residents' appearances and body size. 12/19/2023 interaction with another resident and 3/27/24 confrontational language. This care plan included an intervention of observe interaction around others and intervene if noted concerns. However, an abusive incident was noted on 3/27/2024. A progress note dated 3/27/2024 included that at approximately 1530, nurse observed resident #17 shouting at resident #10 in T-Hall walk way area near the nurse's station. Nurse stood between the 2 residents to prevent any incidents from occurring. The note stated resident #17 was redirected to the nurse station, and calmed down and resident #10 was assisted by wheelchair to the other end of the hall. Another progress note dated 03/27/2024 included that Social Services (SS) and the Assistant Director of Nursing spoke with resident#10 regarding a verbal exchange that took place between her and resident #17. The note stated that resident#10 stated she did not like the way another resident was dressed and stated that Her fat was hanging out. It was disgusting. Resident #10 stated this upset resident #17. Resident #10 then called resident #17 fatso and resident #17 began yelling. The note further stated SS asked what resident #17 yelled at her and she said she was unable to hear exactly what was said. SS asked resident if she felt safe, she stated yes. SS reminded resident#10 that language can be hurtful and encouraged her to refrain from saying things to others that may be perceived as such. The note stated resident#10 verbalized understanding. -Resident #17 was admitted on [DATE] with diagnoses of schizoaffective disorder, bipolar disorder current episode manic severe with psychotic features and attention-deficit hyperactivity disorder. Review of a care plan initiated 5/19/2023, resident #17 has a behavior problem yelling, verbal aggression, throws items, plays in feces & accusatory related to delusions/psychosis and included that the resident has expressed thoughts of self-harm and thoughts of harming others. This care plan included an 3/27/2024 verbal aggression, and thoughts of harming self. This care plan included interventions of intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, and to remove from situation and take to alternate location as needed. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] included that this resident experienced delusion, and had verbal behavioral symptoms directed at others and had other behavioral symptoms not directed at others. A progress note dated 3/27/2024 included that at approximately 1530, the nurse observed resident #10 shouting at resident #17 in T-Hall walk way area near the nurse's station. This note includes the nurse stood between the 2 residents to prevent any incidents from occurring. This note included that the resident was redirected to the nurse station, and calmed down and that the other resident #17 was assisted by wheelchair to the other end of the hall. Another progress note dated 3/27/2024 included that at approximately 1533, a nurse transported resident to the office and the writer asked the resident what they could help her with and she stated I'm going to kick her ass. This note included that when the writer asked resident who she was referring to and she named a resident #10. This note included that the writer asked her what transpired and she stated she called my friend fat and I don't appreciate that. (another resident) is not fat and I'm not going to let her talk about my friend like that, then the writer asked her did she mean what she had just said and this resident repeated again I'm going to kick her ass. This note included that the writer asked this resident if she have a plan on how she was going to accomplish that and she stated yes I'm going to strangle her in her sleep and then the writer asked the resident did she want to harm herself as well? and she stated yes and that she did not have a plan. This note included that a medical doctor was consulted and that the doctor said to send the resident out to the hospital for a psychiatric evaluation and that the residents were kept separated until that happened. An interview was conducted on 06/14/2024 at 1:31 P.M. with resident #10 who said that resident #17 is a very disturbed person and that she would go around half naked. This resident said she should cover herself. This resident said that resident #17 came after her multiple times, that she swung at her and called her bitch but they were in wheelchairs passing and she could not hit me. She said that the staff knew and that they restrained her from going after me. An interview was conducted on 6/14/2024 at 1:07 P.M. with a Certified Nursing Assistant (CNA/staff #32) who said that resident #17 was kind of aggressive but denied witnessing incidents between residents. She said that abuse could be verbal and that it should be reported to the nurse right away. An interview was conducted on 6/14/24 at 12:46 P.M. with a Licensed Practical Nurse (LPN/staff #55) who said that abuse can be sexual, financial, neglect, seclusion, physical, verbal or mental. She said that if a resident is cussing or threatening another resident it's verbal abuse. She said that if she encountered that situation, that she would make sure that the two residents are never together. This nurse said that she would change floors or change destinations, have social services involved, and care plan that. She said that she would have to make the change occur so it would no longer happen. An interview was conducted on 6/14/24 at 1:45 P.M. with the Director of Nursing (DON/staff #27) who said that if a resident to resident occurs that immediately staff separate them and report right away to management. This DON included that resident #17 was here when she came back in august, and that she had quite a few behaviors, diagnoses, manipulative when they had to set boundaries. This DON said that they had to speak to her about activities, and that she would make statements to other residents, she was very involved in psych services and that they had to monitor her behavior because some days she was manic, some days not. This DON said that resident #17 would get the idea that someone did not like her and she would take things upon herself to resolve it. She said that her understanding of what happened in that instance, that resident #17 said that resident #10 had made a comment about her appearance. This DON stated that resident #10 was also verbally abusive and that incidents were going to happen but that they would take steps to prevent them. A policy reviewed 7/18/2023 revealed that it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (# 8) was free from verbal abuse. The deficient practice may result in psychosocial harm as a result of un-averting or intervening communication that may lead to verbal abuse. Findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic neuropathy, and recurrent severe major depressive disorder with psychotic symptoms. The Annual MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 15, which indicated the resident was cognitively intact. A review of medical record documentation revealed that on August 17, 2023 at 10:30 a.m. Resident #8 reported to the facility's administrator that she had felt threatened a day prior by a night shift staff. Resident # 8 disclosed the interaction which made her feel threated involved Certified Nursing Assistant (CNA/Staff # 30). Resident # 8 admitted she should not have played a part of, nonetheless antagonized Staff # 30 by saying her name in a 'sing-[NAME] voice'. Staff # 30 responded by telling Resident # 8 please don't talk to me. Resident # 8 then replied to Staff # 30 that they were both adults and had to move on adding that Staff # 30 should be careful because she was a resident. Staff # 30 then replied, no you need to watch yourself. During the facility's investigation of the incident on August 21, 2023 at 03:30 PM, review of documentation revealed that during an interview conducted by Administrator (ED/Staff # 1) and Director of Nursing (DON/Staff # 6), Staff # 30 stated she had felt antagonized by Resident # 8 for a few months, however had intensified in the recent weeks. Staff # 30 stated that in response to Resident # 8 telling her to watch herself, she responded with, you need to watch yourself because you make me feel uncomfortable. Investigation revealed that Staff # 30 was terminated and reminded that even if she feels threatened, she is a healthcare professional and cannot engage in threatening behavior. Moreover, investigation revealed she should have removed herself from the situation immediately and called either Staff # 1 or Staff # 6. Staff # 30 was reported to the board of nursing as a result of the facility's investigation. The care plan was updated on August 23, 2023 and revealed the resident had a behavior problem and that, the resident tend to antagonize staff at times. The interventions and tasks that were implemented included: -If reasonable, discuss the resident's behavior; explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. -Observe for behaviors antagonizing; document behavior and attempted interventions. -Observe for behavior episodes and attempt to determine underlying cause; consider location, time of day, persons involved, and situations. An interview was conducted with Director of Nursing (Staff # 6) on May 16, 2024 who confirmed that staff are terminated if found guilty of verbal abuse if the allegation were found accurate. Staff # 6 confirmed that Staff # 30 was terminated in lieu of verbally abusing Resident # 8. Staff # 6 stated that any type of abuse including verbal abuse does not meet the facility's expectations. Furthermore, Staff # 6 stated that the response by Staff # 30 which made Resident # 8 feel threatened did not meet facility's expectations. Review of the facility's Policy titled, Abuse, Neglect, and Exploitation (reviewed July 18, 2023) revealed, it is the policy of this facility to identify abuse; this includes but is not limited to identifying and understanding the different types of abuse and possible indicators; the resident has the right to be free from abuse; the facility must not use verbal; mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure transmission-based precautions, particularly enhanced barrier precautions, signage and personal protective equipment were in-place to help prevent development or transmission of infections. The deficient practice could result in development or transmission of infections within the facility. Findings include: Resident #408 was admitted on [DATE] with diagnoses of surgical aftercare following surgery on the skin, sepsis (unspecified organism), and encounter for attention to gastrostomy. The most recent Admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. Review of medical records for Resident #408 revealed the presence of a feeding tube, wound, and a catheter. However, during an observation of care for Resident #408 February 13, 2024 at 10:05 AM, in room [ROOM NUMBER] revealed no transmission-based precaution Centers for Disease Control (CDC) Prevention signage or personal protective equipment (PPE) outside or near the room entrance. An interview was conducted on February 13, 2024 at 11:10 AM with Assistant Director of Nursing/Infection Preventionist (ADON/IP/Staff # 43), who stated that the facility does not use enhanced barrier precautions in the facility, and therefore no enhanced barrier precautions signage is outside any room. Staff # 43 stated it was a decision made by everyone because sometimes it is confusing for the staff. Staff # 43 stated the isolation precaution signage that the facility utilizes are only droplet and airborne. Staff # 43 stated the risks of not using appropriate PPE, or displaying transmission-based precaution signage recommended by the CDC, including for enhanced barrier precautions when it is initiated, may result in widespread infection for resident and staff. An interview was conducted on February 13, 2024 at 11:22 AM with the Director of Nursing (DON/Staff # 94), who confirmed that enhanced barrier signage was not used in the facility. Staff # 94 stated that the facility follows CDC recommendations in regards to infection control as well as their facility policy, however due to verbiage regarding enhanced barrier by CDC it is up to the discretion of the facility whether to be implemented as well as recommendations made by advisors. Staff # 94 stated the risks of transmission-based precaution signage not being followed is possibly carrying infections to other residents. On February 14, 2024 at 8:30 AM a list of resident names with G-tube, J-Tube, wounds, colostomy, nephrostomy, catheters, multi-drug-resistant organisms (MDRO) was requested which revealed the following number of residents in the facility within each category: G Tubes/J Tubes: 5 residents; Wounds: 8 residents; Colostomy, Nephrostomy, Catheter: 11 residents; MDRO: 2 residents. On February 14, 2024 at 9:00-9:30 AM an observation of entire facility consisting of the 1st and 2nd floor hallway rooms revealed no PPE or enhanced barrier signage present at any resident room with G Tubes/J Tubes, Wounds, Colostomy, Nephrostomy, Catheter, or MDRO. An interview was conducted on February 15, 2024 at 11:45 AM with the Executive Administrator (EA/Staff # 450), who confirmed that the entire management team have access to facility policies. Staff # 450 stated she expects policies to be followed and it would not meet facility expectations if staff did not follow enhanced barrier precaution facility policy. The facility's policy and procedure document titled, Transmission-based Precautions and Isolation Procedures (revised September 15, 2023), revealed: Standard and transmission-based precautions to be followed to prevent spread of infections. Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Enhanced Barrier Precautions can be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Wound care: any skin opening requiring a dressing When a resident is placed on transmission-based precautions, the staff should implement the following: Place type precaution signage to be initiated on the outside of the resident room in a conspicuous place such as door or on the wall next to the doorway identifying the CDC category or categories of transmission-based precautions (e.g. contact, droplet, airborne, or enhanced), instructions for use of PPE, and/or instructions to see the nurse before entering. Make PPE readily available near the entrance to the resident's room.

Based on clinical record review, staff interviews and contract review, the facility failed to ensure one resident (#369) received treatment and care in accordance with professional standards of practice. The facility failed to ensure communication was provided to the family when the resident had a change of condition. This failure has the potential for confusion between resident's family and the facility. Findings: Resident (#369) was admitted to the facility on [DATE] with diagnosis that included, cardiac arrhythmia, unspecified; Parkinson's disease; bradycardia, unspecified; unspecified dementia with behavioral disturbance; anorexia; major depressive disorder, single episode unspecified. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) record revealed resident score was 03, indicating severe cognitive impairment. Further review of the MDS revealed resident was dependent or required extensive assist with activities of daily living. Review of the physician's orders revealed orders for COVID-19 Nasopharyngeal Swab Test one time only for potential COVID exposure for 3 Days. Resident was diagnosed with COVID on July 2, 2020. A review of the Care Plan dated September 2, 2020 revealed the following, resident (#369) has a behavior problem psychosis related to diagnoses of dementia, anxiety, bipolar disorder, has impaired cognitive ability/impaired thought processes related to) Dementia. There was no evidence in the facility documentation and clinical record that the family or responsible party was notified of a change in the resident's condition. On February 14, 2024 at 12:05 PM, an interview was conducted with Social Services Director Staff (#87) and Social Services Assistant Staff (#110). Staff #87 stated during COVID nursing was responsible for notifying families if a resident contracted COVID and it would be as soon as possible. She stated the physician makes the decision to have a conversation with the family if a resident's decision-making capabilities are compromised due to their cognitive status and will also utilize the Ombudsman. She further stated It was oversight on the facility's end that the spouse was not notified of the residents change of condition. An interview was conducted with the Director of Nursing (DON/Staff #94) on February 15, 2024 at 2:08PM. She stated nursing is responsible for notifying families for change of condition and the expected timeframe for notification is dependent on the change of condition, but that it is completed within their shift if the nurse is initiating the change of condition. She stated evaluations for decision making abilities are based on the residents BIM score and will, if needed get the physician involved and the Psych provider. She further added if it is documented that the resident is confused, alert to self only they would not be considered as able to make informed decisions for self. The facility would also look at the history of the patient and type of family dynamics with responsible party. Review of the facility policy titled Changes in Residents Condition or Status states this facility will notify the resident, his, her primary care provider, and resident's/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law.

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#520) was free from abuse of another. The deficient practice could result in other residents being abused. Findings include: 1.) Resident #520 (alleged victim) was admitted on [DATE] with diagnoses that included Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) was not conducted, however the resident was assessed as being severely cognitively impaired. The MDS also indicated that the resident had not exhibited psychosis, behavioral symptoms, or wandering during the assessment period. A cognition care plan initiated on October 4, 2022 revealed that the resident has impaired cognitive ability and impaired thought process related to Alzheimer's disease and dementia. Interventions included to allow extra time for resident to respond to question and instructions. A communication care plan initiated on October 18, 2022 indicated that the resident has difficulty communicating his needs since he only spoke Spanish. Interventions included to observe for physical/non-verbal indicators of discomfort or distress, and follow-up as needed. A progress note dated February 10, 2023 documented that a Certified Nursing Assistant (CNA) found resident #525 (roommate/alleged perpetrator) hitting resident #520 multiple times. Resident #520 was found in his bed curled up. The note indicated that resident #520 stated that I go him by him, I got him by him. The note also documented that resident #520 verbalized pain to his back, head, and right shoulder. Resident #520 was given pain medication. A skin assessment was completed and no visual injuries were noted at the time. The note indicated that the roommate/alleged perpetrator (resident #525) was removed from the room to ensure the residents' safety. 2.) Resident #525 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance, and anxiety, and major depressive disorder. Review of the cognition care plan initiated on November 18, 2019 revealed that the resident has cognitive deficits related to dementia and cerebral vascular accident (CVA). Interventions included to administer medications as ordered, allow time for resident to respond to questions and instructions. A communication care plan initiated on November 18, 2019 indicated that the resident may have barriers to communication related to expressive aphasia secondary to CVA. Interventions included to anticipate and meet needs, allow adequate time to respond, repeat as necessary, do not rush, and request clarification to ensure understanding. Review of the quarterly MDS assessment dated [DATE] revealed that a BIMS score was not assessed. The MDS also indicated that the resident was negative for psychosis, behavior symptoms, rejection of care, and wandering. A nursing note dated February 10, 2023 documented that a Certified Nursing Assistant (CNA) called a nurse to the resident's room after the CNA saw the resident punching his roommate multiple times on the body. The note stated that resident #525 said I fucking him up because he pissed on the floor again. The note indicated that skin assessments were completed on both residents. Resident was removed from the room. Review of the clinical record reveals no documentation of the resident having physical altercations with staff or other residents. There were two entries for verbal altercations, one on June 6, 2021 with his roomate, a room change was made and the other was on November 15, 2022 with a staff member. A nurse practitioner (NP) note dated February 10, 2023 documented that resident #525 stated that he became frustrated/agitated when his roommate urinated on the floor. The NP note indicated that resident struck his roommate and the NP was notified by nursing staff. The NP note documented that resident stated that he had aggressive behaviors in the past. NP indicated that psych will follow-up. Review of the Event Report completed on February 10, 2023 indicated that nurse was notified by a CNA that resident #525 punched his roommate, resident #520 multiple times on the body. The report indicated that no injuries were observed at the time of the incident. The immediate action taken was the resident was removed from the room and placed in the dayroom and skin assessments were completed. Review of the facility investigation report submitted February 15, 2023 indicated that a resident to resident altercation between residents #520 and #525 occurred on February 10, 2023 at approximately 5:10 AM. The report noted that a CNA saw resident #525 punching his roommate on the body multiple times. According to the report, resident #520 had urinated on the floor on February 9, 2023 which upset his roommate, resident #525 and resulted in the incident. An interview was conducted with a Certified Nursing Assistant (CNA/staff #25) on February 25, 2024 at 12:58 PM. Staff #25 stated that incidents/allegations of abuse are reported immediately. The CNA said that they make sure the resident(s) are safe, then it is reported to the charge nurse and ED (Executive Director). Staff #25 stated that in instances of resident to resident altercation, the staff separates the residents from each other and then talk to them. She noted that incidents are investigated. The investigation entails interview of staff working that day or was working with the residents, and any witnesses. In an interview with a Licensed Practical Nurse (LPN/staff #22) conducted on February 25, 2024 at 1:17 PM, Staff #22 stated that in incidents or allegations of abuse, staff makes sure that the resident(s) are safe. Then the administrator is notified immediately. In cases of resident to resident altercation, residents are separated then the administrator is notified. Staff #22 indicated that she was familiar with both residents #520 and #525. She said that she heard there was an incident between them but was not sure of the details since it did not occur during her shift. Staff #22 said that given that one of them is confused and the other was a wanderer, they were not a good fit to be roommates. During an interview with the Director of Nursing (DON/staff #94) conducted on February 15, 2024 at 2:08 PM, the DON stated that the expectation is that allegations of abuse is reported timely within guidelines and that staff know who to report it to, and what to report. Staff #94 said that the reporting process is initiated when staff reports it to their supervisor. In instances of resident to resident altercation the expectation is that they are separated and the incident reported immediately. Abuse investigations should have information from the individual who reported, interview of everyone directly involved or had the potential to be involved, interview of staff and residents, and review of documentation, care plan, and notification of parties involved. Review of the facility policy titled Abuse-Protection of Residents issued October 4, 2022 stated that the facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation. The policy noted that if the accused abuser is another resident, the residents must be separated while investigating the incident. Interventions must be implemented to assure the safety of all residents. The facility policy titled Abuse-Prevention issued October 4, 2022 stated that it is the policy of the facility to prevent and prohibit all types of abuse. It noted that they identify, assess, care plan for appropriate interventions, and monitor resident with needs and behaviors which might lead to conflict.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure that two resident's (#525, #535) care plans were updated and revised as needed. Findings include: 1.) Regarding resident #525 Resident #525 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance, and anxiety, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed that a BIMS score was not assessed. The MDS also indicated that the resident was negative for psychosis, behavior symptoms, rejection of care, and wandering. A nursing note dated February 10, 2023 documented that a Certified Nursing Assistant (CNA) called a nurse to the resident's room after the CNA saw the resident punching his roommate multiple times on the body. The note stated that resident #525 said I fucking him up because he pissed on the floor again. The note indicated that skin assessments were completed on both residents. Resident was removed from the room. Review of the clinical record did not reveal any documentation of physical aggression against staff or residents. There was documentation of a verbal altercation between the resident and his then roomater on June 6, 2020 resulting in a change of rooms and a second verbal altercation with a staff member on November 18, 2022 about moving his wheel chair from a doorway which was blocking access. A nurse practitioner (NP) note dated February 10, 2023 documented that resident #525 stated that he became frustrated/agitated when his roommate urinated on the floor. The NP note indicated that resident struck his roommate and the NP was notified by nursing staff. The NP note documented that resident stated that he had aggressive behaviors in the past. NP indicated that psych will follow-up. However, review of the care plan post incident revealed that the careplan was not updated to address the resident's behavior and risk for resident to resident altercation. No interventions were put in place to mitigate further resident to resident incidents. 2.) Regarding resident #535 Resident # 535 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, and bipolar disorder, with current episode manic severe with psychotic features. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident is cognitively intact. The MDS also indicated that the resident had exhibited verbal behavior symptoms directed towards others which occurred 1-3 days during the assessment period. A nursing note dated May 16, 2023 for resident #530, documented that resident #530 stated that her roommate, (resident #535) had threatened to kill her. Resident ##530 denied making any threats to harm her roomate. A nursing note for resident #535 documented that resident #530 stated that resident #535 told her I want to smother you with a pillow, and save a knife from the dinner tray and stab you. The note indicated that resident #535 was interviewed and denied threatening her roommate. A nurse practitioner (NP) note dated May 24, 2023 indicated that resident #535's chief complaint was that she wanted her own room. Note indicated that resident was moved due to behaviors that resulted in conflict. The note stated that per staff, resident manipulates and make false accusations when she does not get her way. Review of the care plan for residnet #535 revealed that it was not updated to address the resident's behavior and risk for resident to resident altercation. No interventions were in place to mitigate potential resident to resident incidents. During an interview with the Director of Nursing (DON/staff #94) conducted on February 15, 2024 at 2:08 PM, she stated that her expectation is that following a resident to resident altercation, resident should be put on change on condition to monitor for psychosocial needs, discuss interventions such as move rooms and ensure that staff are aware of how to intervene and provide psych services. Staff #94 said that there should be an update of interventions on the care plan following a resident to resident altercation. The facility policy titled Comprehensive Care Plans and Revisions issued March 2, 2022 stated that the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occurs, the facility should review and update the plan of care to reflect the changes to care delivery to include additional interventions on existing problems. Review of facility policy titled Abuse-Prevention issued October 4, 2022 stated that it is the policy of the facility to prevent and prohibit all types of abuse. It noted that they identify, assess, care plan for appropriate interventions, and monitor resident with needs and behaviors which might lead to conflict.

Based on clinical review, staff interviews, facility policy and procedures and owner's manual for Hoyer lifts, the facility failed to ensure care and services related to pressure ulcer was provided for one resident (#39 and #24). The deficient practice could result in worsening and development of new pressure ulcers Findings include: -Resident #39 was admitted on [DATE] with diagnoses that included paraplegia, stage 4 pressure ulcer of left buttock, stage 4 pressure ulcer other site, gangrene not elsewhere classified and neuromuscular dysfunction of the bladder. The care plan dated March 29, 2023 revealed resident had self care deficit due to paraplegia, chronic pain syndrome, and anemia. Intervention included extensive assistance with 1 to 2 persons with transfers, bed mobility, dressing, and toileting. The skin integrity care plan dated March 29, 2023 revealed the resident was at risk for break in skin integrity to buttock and left foot heel. Interventions included following current treatment as ordered, pressure reducing mattress, and weekly skin checks. The Braden scale dated March 29, 2023 included a score of 17 indicating the resident was a mild risk for pressure ulcer. A wound care note dated March 29, 2023 included stage III pressure ulcer to the sacrum measuring 1 cm (centimeter) x 1 cm x 0.1 cm. The provider note dated March 31, 2023 included the resident had a chronic history of pressure ulcer to sacral and right buttock. The minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief mental status (BIMS) score of 13 indicating the resident was cognitively intact. The assessment also included that the resident was always incontinent of bowel and bladder and required a two-person extensive assistance with bed mobility, transfers, and toileting. Review of the clinical record revealed that on April 6, 2023, the resident had a stage III pressure ulcer to the sacrum which resolved on April 14, 2023. A wound note dated May 16, 2023 revealed the resident had an unstageable wound to the sacrum with 75% slough and serosanguineous drainage. Per the documentation, wound care and measurements were performed by the wound care nurse; and that, the true depth of the wound was unable to determined due to slough tissue to wound bed. The documentation also included that the wound care nurse practitioner was notified on May 16, 2023 of new areas to sacrum and bilateral buttocks; and that, new orders for SSD (silver sulfadiazine) daily and as needed (PRN). The documentation included that treatment to the sacrum and bilateral buttocks included to cleanse with NS (normal saline), pat dry and apply SSD impregnated gauze to wound bed secure with dry dressing daily and PRN. The wound care assessment dated [DATE] revealed the following pressure ulcer as facility acquired: -Sacral pressure ulcer (stage not included) that measured 1 cm (centimeter) x 2 cm x 0.1 cm; -Stage II pressure ulcer to right buttock that measured 2 cm x 1 cm x 0.1 cm, and unable to determine depth due to slough; -Stage II pressure ulcer to the left buttock with measurement of 2 cm x 2 cm x 0.1 cm. Per the documentation, the resident was educated on frequent repositioning, two hours or less in the wheelchair. The wound assessment dated [DATE] included: -Unstageable pressure ulcer to the sacrum, with 75% slough, serous drainage, measuring 1 cm x 2 cm x 0.1 cm, depth unable to be determined becaus of slough tissue with granutaiol tissue present; -Stage II pressure ulcer to the right buttocks, with epithelial tissue, serous drainage and measured 2 cm x 3 cm x 0.1 cm. -Stage II pressure ulcer to the left buttocks with epithelial tissue present, serous drainage and measures 3 cm x 2 cm x 0.1 cm. The wound assessment dated [DATE] included worsening unstageable pressure ulcer to the sacrum with measurement of 3 cm x 3 cm x 0.1 cm; and, worsening unstageable pressure ulcer to the right buttocks with 75% necrotic tissue. A screening dated July 13, 2023 was completed by the Director of Rehabilitation to determine the bed and wheelchair repositioning. The screening revealed that with use of the bed rails the resident was able to independently roll to both right an left sides; but when bed rails are let go, the resident was unable to sustain a side laying position. Per the documentation, the resident would require bed wedges or pillows to support her to maintain side laying position without holding onto the side rails. The resident was educated to use the tilt lift function every two hours for repositioning purposes. The resident was able to independently use both elbows to shift weight of both hips from front of chair to back. However, the documentation included that the resident performed these task as more of a shimmy motion as her buttocks does not rise off of the wheelchair seat. During an interview with a certified nursing assistant (CNA/staff #8) conducted on July 12, 2023 at 3:50 p.m., the resident was sleeping in a supine position. The CNA stated that the resident can reposition herself. An interview with resident #39 was conducted on July 13, 2023 at approximately 8:10 a.m. Resident #39 stated that staff say she can reposition herself in bed, turn to the side, hold herself by grasping onto the side bar while staff is changing her chuck. However, the resident stated that she cannot hold the position and she needed help with repositioning. She stated the wound nurse told her that she can be in her wheelchair only for 2 hours per day; however, there was not a CNA available to help her transition out of her wheelchair within two hours. Resident #39 stated that she needed two staff to transfer her from the wheelchair with the Hoyer lift; and that, she was put in a wrong position in the wheelchair when only one CNA transfers her. She stated that a certified nursing assistant (CNA/staff #57) tells her that she was picky. She stated that her sling went missing and staff were using the shower sling when transfering her into the wheelchair and staff were leaving the shower chair under her. The resident stated she was not supposed to use the shower sling for transfer because she has pressure ulcers on her bottom. Resident #39 stated that the shower sling had a hole in the middle and she was sitting on the edge of the hole where the material was thicker and this created additional pressure on her bottom. She stated that she was a paraplegic and cannot feel if she was sitting on the thicker yellow trim around the hole area. During the interview, an observation was conducted and revealed there was a sling made of blue netting with a thicker yellow trim around the hole in the middle of the sling placed on the resident's wheelchair. At 8:21 a.m. a CNA (staff #57) entered the room and the resident told the CNA that she wanted to get up. Staff #57 and staff #8 assisted the resident with transfers into the wheelchair. At 8:37 a.m., the resident's door opened and the resident told staff that she was probably going to be back for lunch. At approximately 8:39 a.m., the resident exited her room; and, the resident was sitting on the shower sling which was on her wheelchair. An observation with the CNA (staff #57) was conducted on July 13, 2023 at 8:44 a.m. Resident #39 was sitting in her wheelchair and staff #57 stated that the resident was sitting on the shower sling; and that, the sling was made of netting to dry fast and it has a hole in it. When asked if it was the correct sling to use with a wheelchair, staff #57 stated that it was the only sling available; and that, she did not know if the shower sling was supposed to be used with the wheelchair.The CNA stated that she knew resident #39 had pressure ulcers. After the resident left the room, the CNA looked at another shower sling and stated that the thicker yellow trim around the hole could create additional pressure and create a risk of additional skin damage to skin, pressure ulcers.She stated there were no other slings available for resident #39; and that, there were no slings in the building that could be used. She stated that the resident can reposition herself in the wheelchair and in bed. The CNA said that she does not check on the resident when the resident was outside, by the gazebo, by the fountain, or nearby and all the residents are allowed in these areas. She stated that she was supposed to check on the resident every two hours for continence care; and that, the resident had never stayed outside for more than two hours. In an interview with the Director of Rehabilitation (DOH/staff #51) conducted on July 13, 2023 at 10:34 a.m., the DOH stated resident #39 was evaluated by therapy on March 30, 2023 and was discharge from therapy on April 26, 2023. A review of the clinical record was conducted with the DOH who stated that resident #39 would need assistance to help fully reposition; and that, per the treatment notes dated April 21, 2023 the resident cannot reposition independently in wheelchair. The DOH said that she stated that therapy would not make a recommendation regarding the type of sling to be used; however, in theory and at other facilities, they have two different types of slings: a shower sling and a mobility sling. On July 13, 2023 at 11:08 a.m. an interview was conducted with (CNA/staff #8) who stated that the mobility slings do not have holes in it and the are shower slings. She went to a resident's room to get a green sling without the hole and stated that the green mobility slings are located throughout the facility; however, she does not know how many there were or where they were all located. The CNA stated that she tries to remove the mobility sling once the resident was in the wheelchair because she needed to wash it before another resident can use it. Regarding resident #39, the CNA stated that the resident had sores on her bottom; but, the resident does not want the shower sling removed from the wheelchair. She said that she tries to pull the shower sling up, so the hole on the sling was by the resident's back to try to prevent marks in the skin. An interview with a registered nurse (RN/staff #42) was conducted on July 13, 2023 at 11:27 a.m The RN stated stated the facility has two slings: the shower sling and the mobility sling. She stated the shower sling has a hole in it; and that, she had concerns if the staff were leaving the shower sling under the resident's bottom in the wheelchair because the stitching around the hole area would bother the resident. She stated that there was a risk of friction when using the shower sling with the wheelchair and she was not aware of CNAs leaving the shower sling in any of the resident's wheelchairs. She also stated that therapy would assess for type and size of sling and the resident's preference. During an interview with the Assistant Director of Nursing (ADON/staff #12) conducted on July 13, 2023 at 1:43 p.m., the ADON stated that as far as she knows, resident #39 would not be able to use the grab bar to turn herself and maintain the turn without assistance. The ADON stated that based on the clinical record, resident #39 was able to assist with repositioning and can grab the bar and assist which means that she needs assistance. The ADON said that there were two different types of slings: shower slings and the mobility slings which has no holes in it. She stated that when transfering the resident to a wheelchair, staff should be using the mobility sling and not the shower sling. The ADON also said that the mobility sling is left under the resident in the wheelchair, so staff can get the resident out of the wheelchair. She stated that if the shower sling was left under the resident, it creates the risk of skin breakdown because of the netting and the thickness of the stitching around the hole in the shower sling. The ADON further stated that if the resident was sitting in her wheelchair on the shower sling, this could be a contributing factor to pressure ulcers not healing for resident #39. On July 14, 2023 at 2:36 p.m., an interview was conducted with the Director of Nursing (DON/staff #73) who stated the CNAs check on residents approximately every two hours to reposition and provide continence care as needed. The DON said that it was her expectation that the CNAs offer to transfer the resident at least twice a day and if the resident refuses, it should be documented in the progress notes or under tasks. She stated that there was a risk of wounds developing when a resident was not repositioned. The facility's owner's manual and instructions for Hoyer lifts revealed that to use a sling that is recommended by the individual's doctor, nurse, or medical attendant for the comfort and safety of the individual being lifted. The facility's policy on Limited Lift Program (Safe Patient Handling) revised August 11, 2022 included the facility will establish protocols that will provide the safest possible methods to lift, transfer or reposition patients. The facility will assess residents for the need for assistance with transfer activities, mobility or repositioning utilizing a validated mobility assessment by either nursing or therapy. Associates will be responsible for utilizing mechanical lifting devices, transferring devices, proper body mechanics to lift, transfer, and/or pivot non-ambulatory patients as indicated. -Resident #24 was admitted on [DATE] with diagnoses of stage IV pressure ulcer to the right hip, stage III pressure ulcer right ankle and Alzheimer's Disease. The care plan dated June 27, 2022 included the resident had an activities of daily living (ADL)self-care deficit related to Alzheimer's Disease. Interventions included for staff to give total assistance with bed mobility, dressing, transfers with the Hoyer lift, and set up assist with meals. The skin care plan dated June 27, 2022 included the resident was at risk for break in skin integrity. Interventions included pressure reducing mattress and treatment as ordered. Review of the bed mobility task documentation revealed assistance with bed mobility was only provided during one shift on May 3, 7, 8, 12, 13, 15, and 20, 2023. Review of the order summary report revealed an order dated May 20, 2023 for treatment to right buttock, cleanse with NS or wound, cleanser, pat dry then apply manuka honey ointment and leave open to air daily and prn (as needed) for right buttock. The skin/wound note dated June 6, 2023 revealed that the resident was tolerating treatment and the right hip wound was stable. The documentation included right hip surgical wound, with a narrow tunneling, moderate amount of serous exudate, surrounding tissue within normal limits; and that, the resident had moisture associated skin damage (MASD). The documentation did not include pressure ulcer to the right buttocks. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status score of 2 indicating a severe cognitive impairment. It also included that the resident required extensive two-person assistance with bed mobility, two-person assist with transfers, total dependence with toileting and bathing. The MDS also included that the resident was at risk of developing pressure ulcers/injuries; and that, the resident did not have unhealed pressure ulcers. The order for treatment to the right buttocks were transcribed onto the treatment administration records (TARs) for June and July 2023. Review of the TARs for June and July 2023 revealed treatment to the right buttocks were documented as not administered on June 7, 14, 25, July 7 and 10, 2023. There was no documentation in the clinical record that the treatment was administered as ordered on dates not marked as administered in the TAR. The clinical record revealed no documentation of reason why treatment was not administered and that, the physician was notified. An interview was conducted on July 14, 2023 at 1:54 p.m. with a certified nurse assistant (CNA/staff #111) who stated that she checks on each resident a minimum of every 2 hours and as needed, repositions residents and documents that it was done on the task sheet in the clinical record. Regarding resident #24, the CNA stated the resident was not able to reposition independently in bed. In an interview with a registered (RN/staff #42) conducted on July 14, 2023 at 2:04 p.m., the RN stated that the CNAs were supposed to document on the task sheet when they reposition the resident; and that, if it was not documented, reposition was not done. The RN also stated that if the TAR was not initialed by the nurse, this means the treatment was not done. On July 14, 2023 at 2:36 p.m., an interview was conducted with (DON/staff #73) who stated that the CNAs need to be reposition the resident every two hours and document that it was done on the task sheet. She stated that if there was no documentation on the task sheet, the resident was not repositioned. A review of the clinical record was conducted during the interview. The DON stated that she did not see anything in the progress notes that the resident was refusing to reposition. She stated that there is risk of developing wounds if the resident is not being repositioned. The DON also stated that if the nurse did not document that the treatment was done on the TAR, she would assume that the treatment did not occur and was not administered. The facility's policy on Skin Integrity & Pressure Ulcer/Injury Prevention and Management reviewed March 31, 2023 states that based on the comprehensive assessment of a resident, the facility must ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Based on clinical record review, staff interviews, observations, and review of policy and procedure, the facility failed to provide services to one resident (#9) that were necessary to avoid physical harm or pain. The deficient practice resulted in major injury to the resident. Findings Include: Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] after a hospitalization , with diagnoses that included a fracture of the left femur, rheumatoid arthritis, neuropathy, and chronic kidney disease. Active Physicians orders included acetaminophen for pain dated 6/8/23 and gabapentin for neuropathy. She also had an order for bed rails to help with bed mobility and positioning. An occupational therapy evaluation and plan of treatment dated 2/22/22 identified that resident #9 level of function was wheelchair bound and transferred with a mechanical lift. According the Minimum Data Set (MDS) assessment from 05/16/23, Resident #9 was an extensive assist for transfers from two+ persons. Review of her comprehensive care plan initiated on 11/07/2019 revealed that Resident #9 required extensive assist with most of her Activity of Daily Living (ADL) tasks related to her limited mobility and pain from severe rheumatoid arthritis, contracture/deformity of back, neck, bilateral hands, feet, and ankles. She requires the use of a mechanical lift ([NAME]-sit to stand) for transfers. A review of progress notes from 06/03/23 at 03:15am reveals that Resident #9 was being transferred to bed, and was complaining of pain to her left hip, left knee and left ankle. Nursing staff follow up with the Nurse Practitioner (NP) who ordered x-rays of her hip, knee, and ankle. Resident # 9 also spoke with the activity director who notified the Executive Director by phone. An interact change in condition evaluation dated 6/3/23 identified marked localized bruising and swelling and an increase in pain. A radiology report dated 6/03/23 revealed a femoral fracture. On 6/3/23 at 5:46pm, the on call nurse practitioner reviewed results of the x-ray and ordered Resident #9 be sent to the emergency room . When the resident returned on 6/8/23, she had a soft brace in place and a diagnosis of fracture to distal end of left femur. During an interview on 6/30/23 at 12:25p with Resident #9 regarding the incident on 6/2/23, she stated that she was in her wheelchair, which she had used the [NAME] Lift to get into earlier in the day. She stated Staff #7 picked her up, then pivoted and put her to bed. According to Resident #9, she stated Staff #7 pulled her up to stand and said Hold on to me. Resident #9 stated she is unable to put her arms around her to hold on due to her arthritis and surgery on knees, hips, and hands, and during the pivot was when her leg broke. Resident #9 said she pushes herself in the wheelchair, and typically in the mornings and evening, staff will bring in a Sara lift and one staff will help her go from her wheelchair to bed and vice versa. She said Staff #9 is not allowed in her section or in room since incident. During interviews with 3 other residents on the same hall that also use mechanical lifts, they all stated they had no concerns with their lifts, and felt safe in the facility. During an interview conducted on 6/30/23 at 12:40, CNA Staff #33, stated she is made aware that a resident uses a mechanical lift, [NAME] or Hoyer, by other nurses and CNAs verbally communicating the information at shift change or checking the care plan. If a resident was ordered to use a Sara lift, it would have to be used all the time. She has never seen a worker not use an ordered lift when transferring a patient and would never do so herself. It is important to use the lift because the patient cannot stand by themselves and otherwise it might cause them damage/injury. If during a transfer a resident says they cannot stand, she stated she would get another coworker, and see if a Hoyer lift is more appropriate or reassess. She stated she did receive training on abuse and neglect, but cannot recall a recent training on using lifts. In an interview on 6/30/23 at 1:45p with another CNA, Staff #44, she also stated a resident who is ordered to be a Hoyer or Sara lift cannot be manually transferred. If a lift is not available due to no battery or being broken, they would not be able to transfer the patient. When asked if the battery ever dies, she said she could go get a charged battery from the storage room and there is a charger for the lifts. During an interview with LPN Staff #55, at 1:49p, she stated a resident who is ordered for mechanical lift cannot ever be manually transferred unless therapy has evaluated, and upgraded the order. If a lift is not available, they will need to locate another lift and update the patient. The next step would be to call the fire department. It is very seldom that there is not one available. They could go to the other station and/or bring it to them. Maintenance department is responsible for maintaining the lifts and they will reach out to manufacturer if there is services that need to be done. She stated she has not seen anyone ignoring the mechanical lifts, and if she ever did she would intervene. An interview was conducted over the phone with Staff #7 on 6/30/23 at 1pm. Staff #7 stated that on June 2nd between midnight to 2am, Resident #9 was in her wheelchair and her light was on the whole time. After she finished rounding early, she went to help out the other CNAs and offered to help Resident #9 go to bed. Staff #7 went to find the Sara lift, but stated the batteries were all dead. While Resident #9 was not her patient, she had helped before and had transferred manually before. She explained the situation to Resident #9 and asked if she would be okay being transferred manually. She explained her technique and that she made sure both of Resident #9s legs were between hers. She stated she talked to Resident #9 the whole time so that she did not become afraid or uncomfortable. She could recall they discussed Resident #9's husband and she did not make any sounds of distress or pain. She said the next day a nurse had called and said Resident #9 was complaining of pain all over her body, and asked how she had transferred her the night before. Stated she had to come in and demonstrate how she did the transfer for management. She was reiterated she was dismayed because at the time, Resident #9 thanked her afterwards. She had told her about the batteries being dead and Resident #9 said she had been waiting so long, and just wanted to manually transfer then to go to bed. She recalled she was suspended for a week, and when she returned she was placed on a different hall. A review of the staff schedule for 6/3/23 shows that Certified Nursing Assistant (CNA) #7 was scheduled to work on 6/2/23 and 6/3/23, but her punch details show she did not clock in on 6/3/23. 11:50a A review of abuse training and inservices showed Staff #7 took abuse prevention, mental health, and psychosocial needs and person-centered care in long term care on 6/14/23. She also took lift technique/ [NAME] procedures on 6/22/23. During an interview on 6/30/23 at 1:15p with the Director of Nursing (DON) Staff #5, she stated when determining if a self report for abuse is necessary, that would only be done if it was very obvious based on the information originally received that the incident can immediately be identified as not suspicious. Regarding the incident with Resident #9 on 6/2/23, she stated Resident #9 was being transferred and when put to bed, a CNA not her own put her to bed. She told her CNA that she was hurting. They followed up with the patient in the morning who stated she still had pain and ended up being sent to the ER. She had a fracture. The CNA was suspended. Resident #9 stayed at the hospital. An internal investigation was completed to determine what happened. It was determined not to be neglect/abuse, but if there was something deliberate done they would have reported it. The patient was at high risk for such injuries due to her osteoarthritis, rheumatoid arthritis, and therefore the injury was not suspicious. When interviewed other residents around them were able to say they were fine and had no problems and the staff was not a concern. When a staff member is implicated in any incidents, policy is to suspend the staff and send them home immediately. When asked whether a resident who requires a mechanical lift can ever be manually lift, DON stated it depends on if they can safely pivot, or do a 2 person lift. Hoyer lifts don't get up at all, if it isn't available. Eligible individuals would be those who can sit on edge of bed or move themselves in bed. They have a inservice/ training coming up in July for this exact thing. This is policy in order to keep residents safe. The following observations were made on 6/30/23 at the facility: At 1:48p viewed storage room [ROOM NUMBER] on station 2 which housed the lifts. The hoyer lift had a note on it that noted it was out of order and could not steer straight. The CNA, Staff #44 said it was not in use, and said she was very particular about lift protocol and for example would never use a hoyer without 2 people. At 2:50 pm- 3:00 pm on 6/30/23 a walk through was conducted with Restorative Nursing Assistant (RNA) Staff #66, of Station 4 and the on unit gym to look at 5 lifts (3 hoyers and 2 [NAME]). Of the 3 hoyers lifts, 1 had a dead battery. 1 [NAME] lift had a dead battery, and the other [NAME] lift had no battery in it. Review of Facility Abuse policy- Protection of Residents: Reducing the Threat of Abuse & Neglect last revised 8/10/32- stated that it was the facility's policy that to minimize the threat of abuse and/or neglect, nursing homes must incorporate clear cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. Residents must not be subjected to abuse by anyone including staff. For resident protect from abuse there is employee screening, training, and policies for prevention, identification, investigation, protection, reporting and response. There will be training on what is considered abuse and neglect so that staff can identify it. If the events that cause the allegation involve abuse or result in serious bodily injury, the report must be made in two hours.

Based on clinical record review, staff interviews, personnel files, hospital documentation and policy review, the facility failed to ensure one resident (#71) was free from neglect. Findings include: Resident #71 was admitted to the facility on (MONTH) 11, 2008, with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 22, (YEAR) included a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS assessed the resident to require extensive assistance with bed mobility, transfers and hygiene. Review of a care plan for at risk for respiratory distress due to [MEDICAL CONDITION] revealed to maintain a patent airway and have minimal episodes of shortness of breath and no respiratory distress. Approaches included to encourage/assist resident to an upright position when short of breath, observe and report signs and symptoms of respiratory distress (i.e., confusion, rapid breathing, blue lips, sweating, and reports that he cannot breathe) notify physician with changes in lung sounds or increased episodes of shortness of breath, administer oxygen as ordered, and monitor for signs and symptoms of respiratory distress. A handwritten nursing note dated (MONTH) 24, (YEAR) at 1:30 p.m. by a licensed practical nurse (staff #29) included the following: Resident awake, disoriented, unable to verbalize, mumbles words slurred speech. Breathing labored. Pulse ox @ 80% RA (room air). Put resident on 10 liters of oxygen via mask and head of bed up. Skin cold and clammy. Blood pressure was 160/100, heart rate at 110, respirations at 26, and temperature was 99.5 (axillary). Resident is full code and 911 was called. Physician was notified and in agreement with sending resident out to the emergency room . Pulse ox went up to 93% on 10 liters of oxygen. Review of a change in condition nursing progress note dated (MONTH) 24, (YEAR) and entered at 3:06 p.m. by staff #205 (registered nurse) revealed the following: Resident started getting lethargic and disoriented this morning. Around 12:30 p.m. as two Certified Nursing Assistants (CNAs) were cleaning him he started to go unresponsive. Only awakened with sternal rub. Pulse ox started getting lower into the 80's and put 2 Liters of oxygen on him and the pulse ox went back up into the 90's. Temperature was 100. Blood pressure was 92/50. Reported to physician and Emergency Medical Services (EMS) was called and intravenous fluids were started. Resident did not awaken easily even with a sternal rub. Other nurses were assisting with assessing the resident until 911 was called and he was transferred to the hospital. He was last seen normal and baseline last night. An addendum nursing note dated 6/24/18 and signed by staff #205 at 5:35 p.m. included the following: Resident was slightly altered around 6 am to 11 am and then progressively got worse at 12:30 p.m. where his condition was significantly noticed. According to the hospital records dated (MONTH) 24, (YEAR), the resident was brought to the emergency room due to acute onset of altered mental status. Upon arrival the patient was in obvious acute [MEDICAL CONDITION] and was intubated accordingly. The resident was then admitted and sent to the intensive care unit for acute [MEDICAL CONDITION] and the need for mechanical ventilation. An interview was conducted with the Administrator (staff #209) on (MONTH) 1, (YEAR) at 11:30 a.m. She stated that she had no knowledge of an allegation of neglect between resident #71 and staff #205, therefore she did not complete an investigation. She stated that all allegations of neglect need to be investigated immediately. An interview was conducted on (MONTH) 2, (YEAR) at 8:50 a.m. with the Assistant Director of Nursing (staff #37). She stated that she was a witness when the prior Director of Nursing (DON) interviewed staff #205 regarding the incident with resident #71. She stated the DON told staff #205 that resident #71 had a change of condition and when a CNA (staff #39) told her (staff #205) to check on the resident right away, she did not respond to the request. She stated that staff #39 had to go to the first floor and get another nurse to assess the resident, and the resident was then sent out to the emergency room via 911. A phone call was placed to staff #205 on (MONTH) 2, (YEAR) at 9:14 a.m. She stated that she could not remember if she had been involved with this incident and had been terminated. Although she agreed to discuss the issue later in the day, she did not answer the telephone during multiple attempts. A review of the personnel file for staff #205 revealed she resigned effective (MONTH) 3, (YEAR) and was not eligible for rehire. Staff #205 had a license that was active and in good standing and there was evidence that she had been provided education and training on abuse and neglect. In addition, staff #205 had been provided a RN job description which was signed by her. The job description contained the following: 2) The nurse must possess the ability to make independent decisions when circumstances warrant such action. 3) The nurse must be able to evaluate resident needs through ongoing assessment based on changes in the resident's condition. An interview was conducted with CNA (staff #39) on (MONTH) 2, (YEAR) at 9:45 a.m. She stated that she knew the resident very well, as he had been in the facility for many years. She stated on the day of the incident with resident #71, she was not assigned to provide direct care to him, however, she made the time to check on the resident. Staff #39 said that at approximately 1:00 p.m. on (MONTH) 24, (YEAR), she checked on the resident and he was not right. She said that when she tried to talk to him he did not respond. She said she shook him but he did not respond. She stated she quickly found the nurse (staff #205) and told her she needed to come to the resident's room right away to check him, as he was not doing well. Staff #39 stated that staff #205 told her that maybe the resident had too much medicine and it just made him sleepy. Staff #39 said that she asked staff #205 if she was going to do anything about the situation and staff #205 told her No. Staff #39 stated she then quickly ran to the first floor of the facility and found a Licensed Practical Nurse (LPN/staff #29), who came right away and called 911. Staff #39 stated that when staff #205 refused to come and look at the resident it was not right. She stated that she told the Assistant Director of Nursing (ADON/staff #37) about the incident. An interview was conducted with staff #37 on (MONTH) 2, (YEAR) at 1:52 p.m. She stated that staff #205 did not go to the resident's room, even though staff #39 asked her to check on the resident right away. She said that staff #29 came from the first floor to help. An interview was conducted with staff #29 on (MONTH) 2, (YEAR) at 2:39 p.m. She stated that she recalled the incident with resident #71, who resided on the second floor of the facility. Staff #29 stated she was working on the first floor on the day of the incident. She said that staff #39 came to her and asked her to come right away to check on resident #71. Staff #29 stated that the CNA said that she told staff #205 to check on the resident and staff #205 told her that she was not going to go to the resident's room. Staff #29 stated the resident had slurred speech, was mumbling and made no sense. She stated she immediately called the physician, 911 was called and the resident was sent out to the emergency room . Staff #29 stated she tried to talk with staff #205, because staff #205 had not done anything for the resident. She stated that this would be neglect. Staff #29 stated that she notified the prior DON of the incident. An interview was conducted with the current DON (staff #95) on (MONTH) 2, (YEAR) at 3:15 p.m. She stated that a nurse not providing care to a resident in distress would be considered neglect and did not meet the standards of nursing practice. Review of a facility policy regarding Neglect revealed the following: Neglect is failure to provide goods and services necessary to avoid physical harm. All residents have the right to be free from neglect. It is the policy and practice of this facility that all residents be free of neglect.

Based on staff interview, closed record review, facility documentation and policy review, the facility failed to ensure that one resident (#2) on tube feeding received sufficient fluid intake to prevent dehydration. Findings include: Resident #2 was admitted at the facility on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on (MONTH) 9, (YEAR). The interim care plan dated (MONTH) 22, (YEAR) included that resident had nutrition/hydration needs related to resident requiring some or total assistance to eat/drink. Interventions included enteral feeding at 60 cc (cubic centimeter)/ hour and NPO (nothing per os). The feeding tube care plan dated (MONTH) 22, (YEAR) included the resident had a need for use of feeding tube related to insufficient caloric intake and failure/refusal to eat. Goal included nutritional status will be maintained with daily tube feeding. Interventions included administration of tube feeding formula and flushes as ordered and for dietician to monitor adequacy of tube feeding formula and free water flushes at least quarterly and PRN (as needed) with any change of status. The nutritional care plan dated (MONTH) 22, (YEAR) included the resident was at nutritional risk as evidenced by 10% below usual body weight related to disease process/condition. Interventions included provide/observe intake of diet and fluids. A diet order and communication dated (MONTH) 22, (YEAR) included and order for an NPO diet and [MEDICATION NAME] (tube feeding formula) 1.2 60 ml (milliliter)/hour A physician order [REDACTED]. The dietary assessment dated (MONTH) 24, (YEAR) included caloric needs of 1728 fluid needs of 1296 ml/day. [DIAGNOSES REDACTED]. Per the documentation, the resident had history of poor intake related to difficulty of swallowing and was dependent on tube feeding. It also included that tube feeding provided 1500 ml formula with 1215 ml of free water. The nutrition prescription included [MEDICATION NAME] 1.2 at 75 ml/hour for 20 hours and water flushes of 100 ml every 4 hours. Review of the MAR (medication administration record) for (MONTH) (YEAR) revealed that tube feeding orders were not marked as administered on multiple dates on different shifts. Review of the narrative notes from (MONTH) 24 through 31, (YEAR) revealed no evidence of any documentation that tube feedings were administered on multiple dates on different shifts not marked in the MAR. A dietary note dated (MONTH) 6, (YEAR) included that resident had continuous tube feeding [MEDICATION NAME] 1.2 at 75 ml/hour for 20 hours every day with 100 ml water flushes every 4 hours. Recommendation included to continue care plan and to monitoring of nutritional status. The physician order [REDACTED]. -[MEDICATION NAME] 1.2 formula via pump at 75 ml per hour for 20 hours via [DEVICE] daily -Routine flush of 100 ml water every 4 hours -Document tube feeding intake every shift These orders were transcribed in the MAR for (MONTH) (YEAR). The dietary note dated (MONTH) 21, (YEAR) included recommendation of slightly increasing tube feeding to [MEDICATION NAME] 1.2 at 80 ml/hours for 20 hours and water flushes of 100 ml every 4 hours. Per the documentation, this will provide 1296 ml of free water. It was also recommended that 30 ml flushes before and after medication administration will be added to the plan. Despite the dietary recommendation of adding 30 ml of water flushes before and after medication administration, there was no evidence found in the clinical record that this recommendation was followed. The nursing progress note dated (MONTH) 25, (YEAR) included that the resident has [MEDICATION NAME] 1.2 at 75 ml/hour for 10 hours. There was no evidence found in the clinical record that the resident's tube feeding order was changed on (MONTH) 25, (YEAR). A physician order [REDACTED]. This order and the dietary recommendation for medication flushes before and after medication administration were not transcribed in the MAR for (MONTH) (YEAR). The MAR for (MONTH) (YEAR) revealed that [MEDICATION NAME] 1.2 formula via pump at 75 cc/hour for 20 hours was transcribed. Per the documentation, this formula was administered as ordered from (MONTH) 1 through 9, (YEAR). Also, the MAR revealed a line from (MONTH) 10 through 30, (YEAR) with a handwritten note duplicate. There was no evidence of another MAR sheet for (MONTH) (YEAR) that included [MEDICATION NAME] 1.2 formula via pump at 75 cc/hour for 20 hours was transcribed and administered as ordered. However, further review of the MAR from (MONTH) 1, through 30, (YEAR) revealed tube feeding orders for routine flushes and tube feeding intake were not marked as administered on multiple dates. Review of the narrative notes for (MONTH) 1 through 30, (YEAR) revealed no evidence of any documentation that these orders were administered on multiple dates not marked as administered in the MAR. Per the documentation in the MAR and the clinical record, there was no evidence that tube feeding order for [MEDICATION NAME] was administered on the following dates: (MONTH) 11, 12, 14, 15, 17, 18, 21, 24, 28, and 30, (YEAR). The physician order [REDACTED]. -[MEDICATION NAME] 1.2 formula via pump at 80 ml per hour for 20 hours via [DEVICE] twice daily -Routine flush of 100 ml water every 4 hours -Document tube feeding intake every shift Despite dietary recommendation of water flushes before and after medication administration, there was no order for this transcribed in the recap. These orders were transcribed in the MAR for (MONTH) (YEAR). However, per documentation in the clinical record and the MAR, there was no evidence found related to tube feeding intake was administered and documented in the multiple dates on different shifts as ordered. The dietary note dated (MONTH) 19, (YEAR) included that tube feeding order was [MEDICATION NAME] 1.2 formula at 80 ml/hour for 20 hours. Per the documentation, water flushes of 100 ml every 4 hours gives a total of 600 ml water. Recommendation include [MEDICATION NAME] 1.2 formula at 85 ml/hour for 20 hours that results in 1377 of free water and to continue water flushes as ordered. A physician order [REDACTED]. This order was transcribed in the MAR and was administered as ordered. A nursing note dated (MONTH) 25, (YEAR) included that a new order for [MEDICATION NAME] bolus three times a day was received. A physician order [REDACTED]. It also included an order for [REDACTED]. Review of the MAR revealed that the order for 1 can of [MEDICATION NAME] 1.2 was not marked as administered at 2:00 p.m. and 6:00 p.m. on (MONTH) 29, (YEAR). There was no evidence found in the clinical record that the order for one can of [MEDICATION NAME] 1.2 was administered as ordered on (MONTH) 29, (YEAR). The dietary note dated (MONTH) 13, (YEAR) included tube feeding order of [MEDICATION NAME] 1.2 at 85 ml/hour x 12 hours nocturnal and 240 ml bolus three times a day during day. Per the documentation, total tube feeding provision included 1409 ml of free water. It also included total fluid of 1409 ml plus 600 ml (from routine flushes of 100 ml every 4 hours) equaled to 2009 ml plus medication flushes. Recommendation was to continue tube feeding and water flushes as ordered. The quarterly nutrition documentation dated (MONTH) 2, (YEAR) included that resident's had 18 lbs weight gain which was beneficial. However, per the documentation the resident still was underweight with a BMI of 14.9. Intervention included to continue to follow as needed. The hydration status and needs of the resident were not included in the documentation. The physician order [REDACTED]. -One can of [MEDICATION NAME] 1.2 three times a day per [DEVICE] -[MEDICATION NAME] 1.2 formula via pump at 85 ml per hour for 12 hours via [DEVICE] twice daily -Routine flush of 100 ml water every 4 hours -Document tube feeding intake every shift Review of the MAR for (MONTH) and (MONTH) (YEAR) revealed that routine flushes, tube feeding intake and [MEDICATION NAME] 1.2 one can three times a day were not marked as administered on multiple dates. Review of the narrative notes from (MONTH) 1 through (MONTH) 31, (YEAR) revealed no evidence that these orders were administered as ordered on dates not marked on the MAR. There was also no documentation found in the clinical record related as to why these orders were not administered. The physician order [REDACTED]. -Routine flush of 100 ml water every 4 hours -Document tube feeding intake every shift -Flush tube with 30 ml before and after medication administration (order date: (MONTH) 28, (YEAR)) These orders were transcribed in the MAR for (MONTH) (YEAR) and review of the MAR revealed the following: - Flushing the tube with 30 ml before and after medication administration was not marked as administered from (MONTH) 1 through 8 -Tube feeding intake every shift was not marked as administered in the morning shift from (MONTH) 3 through (MONTH) 6 There was no evidence found in the clinical record that these were administered as ordered The fall indicator report dated (MONTH) 8, (YEAR) included mental assessment of lethargy and circulatory assessment of fatigue. Despite the assessment of lethargy and fatigue, there was no evidence found in the clinical record that the resident was monitored on this day. A Change in Condition note dated (MONTH) 9, (YEAR) included that on (MONTH) 8, (YEAR) at 8:30 p.m., the resident had shortness of breath, breathing through his mouth and was lethargic. Per the documentation, on (MONTH) 9, (YEAR) at 5:00 a.m., the resident was found unresponsive with increased respiratory distress. The documentation revealed that at 5:40 a.m., the resident was sent to the hospital. The hospital records showed that on (MONTH) 9, (YEAR) at 6:00 a.m., the resident was seen at the emergency room . Physical examination include severely dry mucosa, tachypneic (increased respirations). Vital signs revealed heart rate (HR) of 127 bpm (beats per minute) which was indicated as high and a respiratory rate (RR) of 26 breaths/ minutes which was also indicated as high. Laboratory results done on (MONTH) 9, (YEAR) at 6:17 a.m., revealed a BUN (blood urea nitrogen) level of 43 mg/dl (deciliter) indicating high and osmolality calculation of 361 mOsm (milliosmole) per kilogram. [DIAGNOSES REDACTED]. In an interview with a licensed practical nurse (LPN/staff #44) conducted on (MONTH) 29, (YEAR) at 12:15 p.m., she stated that water flushes between medication is usually about 20-30 cc before and after medication and are administered depending on what the physician orders. She said that all documentation related to tube feeding will either be in the MAR or the progress notes in the clinical record. She further stated that when an order for [REDACTED]. In a later interview with staff #44 conducted on (MONTH) 29, (YEAR) at 2:21 p.m., she stated that the water flushes ordered by the physician are to ensure that resident gets hydrated because tube feeding does not provide enough water to hydrate the resident. During an interview with a registered nurse (RN/staff #2) conducted on (MONTH) 29, (YEAR) at 2:45 p.m., she stated resident on tube feeding have orders for routine flushes throughout the day and the amount and frequency of the flushes are dependent on what the physician orders. She said that routine labs which are mostly weekly or as ordered by the physician are also conducted to monitor or check resident's BMP (Basic metabolic panel) and sodium/electrolyte levels. Further she stated that tube feeding provides nutrition and flushes are to ensure that resident is hydrated. She said that dietary staff determines how much routine flushes will be administered based on resident's laboratory results and weights. She also said 30 cc water flushes will be administered before and after each medication administration. Further, she stated that tube feeding is purely to replace resident's food or nutrition needs and flushes keeps the resident hydrated. She said that administration of the tube feeding and flushes are documented as initialed by the nurse in the MAR. In an interview with the registered dietary consultant (staff #214) conducted on (MONTH) 30, (YEAR) at 8:46 a.m., she stated that the 30 ml medication flushes are to ensure patency of the tube and ease of flushing medications. She said administration of this should be documented and nurses had to sign off on this because this is a physician order. She further stated that medication flushes also add approximately an average of 240 ml (milliliter) of the fluid that the resident receive in a day on top of tube feeding and routine flushes. She also said routine flushes are for hydration and is based on the resident's fluid need. She also said when she reviews clinical records, she reviews nutrition laboratories done or completed which include BMP (basic metabolic panel), urinalysis and sodium levels. She said administration tube feeding including routine and medication flushes should also be documented and signed off in the MAR and the reason why it was not given must also be documented. She said resident's #2 tube feeding orders were changed from continuous feeding to bolus feeding because of and improvement in status. However, she stated that the resident was still underweight at that time. She further said there were no laboratory follow-ups conducted for this resident since (MONTH) (YEAR). An interview the Director of Nursing (DON/staff #1) was conducted on (MONTH) 30, (YEAR) at 12;58 p.m. She stated that tube feeding is like a medication and nurses are expected to administer TF, medication flushes and the total tube feeding intake as ordered by the physician and signed off in the MAR/TAR. Review of the MAR/TAR for (MONTH) (YEAR) was conducted with staff #1 during the interview. Staff #1 said she did not not know why the tube feeding intake from (MONTH) 3 through 6, (YEAR) was not initialed. She further stated that if the boxes in the MAR are blank or not marked, it's an omission. Further she stated that the standard of practice is if it not documented, it never happened. She stated that if these orders are not administered, the reason should be documented in the electronic record or the progress notes. She said resident #2 was very malnourished when he was admitted at the facility but had a significant weight gain so his tube feeding orders were changed from continuous to bolus tube feeding. Further, she said that she reviewed the clinical record and there were no laboratory ordered or completed between (MONTH) (YEAR) and (MONTH) (YEAR) to show that resident's hydration status was monitored. However, she said hydration status of the resident is ensured by following the dietary recommendation for resident's water needs and nursing observation of signs and symptoms for dehydration. She said laboratory orders to check hydration status of the resident is dependent on the physician but she or the nursing staff can make recommendations also. She said she was not aware that resident had problems of or had signs and symptoms of dehydration prior to his transfer to the hospital. The facility policy on Hydration for Residents stated Each resident receives a sufficient amount fluids to maintain proper hydration and health

Based on clinical record reviews, staff interviews, CMS (Centers for Medicare and Medicaid Services) guidelines and review of policies and procedures, the facility failed to provide care and treatment to promote healing for three residents (#359, #390 and #426) with pressure sores. The sample size was 4. Findings include: -Resident #390 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Braden Scale for predicting pressure sore risk dated February 5, 2015, revealed a score of 18, which indicated the resident was at risk for a pressure sores. A review of the Initial Data Collection Tool dated February 5, 2015, included a section titled General Skin Condition, which revealed there were no pressure ulcers or open areas to the sacrum and/or buttocks area on admission. However; per the Pressure Ulcer Status form dated February 5, 2015, the resident had a pressure ulcer to the sacrum which measured 0.3 x 0.3 centimeters (cm), with a depth of 0.2 cm. The wound was described as a stage II pressure ulcer with no granulation and no necrotic tissue. This note also included that the physician was notified by the nurse. A review of the closed clinical record revealed a physician's orders [REDACTED]. Per the web site for [MEDICATION NAME], it acts as a barrier to protect the skin from moisture and irritating's substances. The ingredients help to draw moisture away from moist or inflamed areas. The information further included that [MEDICATION NAME] was formulated for use on intact or mildly damaged skin. A Pressure Ulcer/Wound Care Plan dated February 6, 2015, included that the resident had a sacral pressure ulcer and the goal was to promote healing of the ulcer. One of the interventions was to provide wound care as ordered by the physician. A Pressure Ulcer Status Form dated of February 10, 2015, included that the stage II pressure ulcer, measured 0.3 cm x 0.3 cm, with a depth of 0.2 cm., had scant drainage, was red in color, and that the resident was now experiencing pain. According to the admission Minimum Data Set (MDS) assessment dated [DATE], the resident had no cognitive impairment, and required extensive assistance of two with bed mobility and transfers. The MDS also included that the resident had a stage II pressure ulcer upon admission. A Pressure Ulcer Status form dated February 16, 2015, included the wound was now a suspected deep tissue injury and measured 4.0 cm x 1.0 cm with unknown depth, had a small amount of drainage, and was maroon in color. Despite the documentation that the wound had some drainage, the note also included that the wound was 30% maroon and intact. Per the documentation, the wound had deteriorated and the physician was notified. A physician's progress note dated February 16, 2015, included the decubitus was worse with urinary incontinence and for a Foley until wounds healed. The note also documented the resident had barrier cream applied, air mattress, and was to be turned frequently. Despite the wound deteriorating and tripling in size, there was no change in the wound treatment. The physician's progress note dated February 18, 2015, included that the resident's wound was seen with the wound nurse and had improved. However, according to the Pressure Ulcer Status Record dated February 23, 2015, the wound was now unstageable, measured 4.0 cm x 1.0 cm, with depth unknown. The wound also had a small amount of drainage, and the wound bed was covered with 40% slough/necrotic tissue. Review of the physician's orders [REDACTED]. Further review of the clinical record revealed there was no documentation the physician had been informed that the wound had deteriorated and now contained slough. Review of the physician progress notes [REDACTED]. Further review of the physicians/NP progress notes dated February 25, and 27, 2015, revealed documentation that the resident had pressure ulcers, but they did not include any additional information regarding the condition of the pressure ulcers. In addition, the Treatment Administration record for February 2015 showed that the [MEDICATION NAME] cream was not provided 4 times during the month. During an interview with the registered nurse (RN) unit manager on Station 100 conducted on March 26, 2015 at 1:00 p.m., she stated that they usually use [MEDICATION NAME] cream to treat wounds up to a Stage II pressure ulcer, as it is a zinc multipurpose cream. In a subsequent interview on March 27, 2015, the RN further stated that the wound on the resident's sacrum was so bad that no dressing or cream would have helped. In an interview with the licensed practical nurse (LPN/wound nurse), she stated that the physician was not notified of the slough, because the resident had so many other wounds and she did not believe the presence of slough was a deterioration in the wound. Regarding pressure ulcers to the left and right buttocks area: Continued review of the clinical record revealed, a skin assessment dated [DATE], which included the resident had a left buttock stage II pressure ulcer that measured 0.5 cm x 1.0 cm with a depth of 0.1 cm. The wound was dark red in color and had a scant amount of drainage. The assessment also included the resident had a stage II pressure ulcer on the right buttocks which measured 0.7 cm x 2.0 cm with a depth of 0.1 cm. The wound had a scant amount of drainage and was dark red. Both skin assessments documented that the resident's physician had been notified. A physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) for February 2015, revealed no documentation that the physician's orders [REDACTED]. The buttocks pressure ulcers were next assessed on February 23, 2015, with no change in the wounds. Review of the Pressure Ulcer Care plan revealed it had not been updated to include the two new pressure ulcers on the resident's buttocks. An interview with the LPN wound nurse was conducted on March 26, 2015 at 3:30 p.m. The LPN stated the nurse who obtains the order from the physician is the one who transcribes it to the treatment administration record and should also update the care plan. During an interview conducted on March 27, 2015 at 9:45 a.m., the RN unit manager stated she could not find documentation that the wound treatment had been provided as ordered. This RN also stated if she saw any open sores a resident she would just go ahead and put some of the [MEDICATION NAME] cream on the wounds. -Resident #426 was admitted for a hospice respite stay on January 24, 2014, with [DIAGNOSES REDACTED]. A Braden Scale for Predicting Pressure Sore Risk dated January 24, 2014, documented that the resident was considered very high risk due to very limited sensory perception, constantly having moist skin, bedfast, completely immobile, having probably inadequate nutritional intake, and a problem with repositioning that could cause skin friction and shearing. A review of the resident's clinical record revealed an Initial Data Collection Tool dated January 24, 2014, that documented the resident had an open spot on the coccyx/sacrum area. The documentation did not include a description of the wound bed, nor any measurements. An interim care plan dated January 24, 2014, included the resident was at risk for a skin breakdown. Interventions included to educate the family on skin integrity, provide a pressure reduction mattress/overlay/specialty bed/seat cushion, and complete a weekly skin check. The care plan did not address that the resident had actual skin breakdown. Further review of the clinical record revealed there was no documentation that the physician was notified of the open area to the coccyx upon admission, nor any treatment orders that were obtained. A Weekly Skin Integrity Data Collection sheet dated January 27, 2014, documented that the resident had an open pink area on the coccyx/sacrum area. A physician's orders [REDACTED]. A nurse's note dated January 29, 2014, documented the resident has friction and shearing to the buttocks and is red and moist. Review of the Treatment Administration Record for January 2014, revealed the above order. However, the treatment was only provided two times on January 29. The clinical record documented that the resident was discharged back home on January 29, 2014, with barrier cream to the buttocks. An interview was conducted on March 25, 2015, with the DON who stated that when a resident is admitted with an open area on the skin, the admission nurse should document the wound and notify the physician and obtain wound treatment orders. The wound nurse would be notified to assess the wound and if the resident was admitted on a Friday or during the weekend, the wound nurse may not see the resident until the following Monday. The DON stated the wound nurse would assess the wound for the type of wound, measure the wound, describe the wound bed, and notify the physician for new orders or clarification of existing orders. The DON stated that the resident was being followed by hospice, but that the facility was still responsible for the resident's care and treatment. An interview was conducted with the facility's wound nurse on March 25, 2015. The wound nurse stated she was unaware of the resident having any open areas, per the pre-admission documentation she had reviewed. The wound nurse stated she had not reviewed the admission assessment dated [DATE], which documented the open area on the resident's sacrum/coccyx area, nor did she see the January 27, skin sheet that also documented the open area on the resident's coccyx area. The wound nurse stated that she saw the resident on January 27 or 28, 2014, but did not document any assessment because she didn't observe a pressure ulcer. However, she stated that an order was obtained on January 28, 2014, for barrier cream for shearing. -Resident #359 was admitted to the facility on [DATE], and readmitted from the hospital on March 13, 2015, with [DIAGNOSES REDACTED]. Per the hospital transfer information dated March 13, 2015, the resident had excoriation to the buttocks area. The facility nursing initial data collection tool dated March 13, 2015, also documented that the resident had excoriation to the buttocks. There was no further documentation regarding the condition of the buttocks. Review of the physician's orders [REDACTED]. In addition, the clinical record documentation did not include that a thorough assessment of the buttocks area was completed upon admission, which included measurements of the area, a description of the wound bed, and if any drainage was present. A physician's orders [REDACTED]. An interview was conducted on March 25, 2015, with the LPN who was also the facility wound nurse. She stated that the excoriation on the buttocks area noted on March 13, 2015, was actually an unstageable pressure ulcer. She further stated that the physician should have been notified on the day of admission for orders. An interview was conducted with the DON on March 25, 2015. She stated that physician orders [REDACTED]. A review of the facility's Evaluations, Screening and Assessment policy regarding pressure ulcers revealed that at the time of admission, each resident is evaluated for special needs related to skin care and that skin should be checked daily. The policy included that an in-depth assessment is performed on a weekly basis. Review of the Assessment and Monitoring of Healing for pressure ulcers revealed that the purpose was to gather data for planning and implementing wound care treatment and to evaluate outcomes, rational and frequency. All disciplines are alerted immediately if the resident has skin breakdown with medically directed treatment for [REDACTED]. Pressure ulcers are assessed and monitored once a week to determine if the treatment plan is working or should be re-evaluated. The policy also noted that with each dressing change, the pressure ulcer is observed for developments that may indicate the need for a change in treatment such as wound deterioration or improvement, more or less exudate, and signs of infection. The physician is kept informed of the progress or lack of progress toward healing. Per the CMS guidelines for pressure ulcers revealed that shearing is the interaction of both gravity and friction against the surface of the skin.skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage. The guidelines also included that although friction and shearing are not primary causes of pressure ulcers, friction and shearing are important contributing factors to the development of a pressure ulcer.

Based on observations, clinical record reviews, hospital and facility documentation, staff interviews, and policy review, the facility failed to consistently assess one resident (#375) who was experiencing neurological symptoms and failed to notify the physician in a timely manner of a lack of neurological improvement, failed to consistently monitor one resident's (#204) blood pressure per physician's orders, and failed to administer [MEDICATION NAME] to one resident (#368) per pharmacy instructions. The sample size was 42. Findings include: -Resident #375 was admitted to the facility on [DATE] at 6 p.m., and discharged to the hospital on May 28, 2013. The resident's medical [DIAGNOSES REDACTED]. A review of the clinical record revealed the resident was alert and oriented and required one person assistance with transfers. Physician orders dated May 26, 2013 at 4:00 p.m., documented for neuro checks to be done for right arm weakness, per protocol. According to the Neurological Assessment Flow Sheet, the neuro checks were to be done every 2 hrs for 8 hrs, then every 4 hrs for 16 hrs, then every 8 hrs for 48 hrs. The neuro checks were started on May 26 at 5 p.m. The assessment documentation included the resident experienced weakness to the right arm and leg. A nurse's progress note dated May 26, 2013 at 10:00 p.m., documented the resident had complained of right arm weakness, the physician was notified, neurological checks were in order and will monitor closely for changes. Documentation further revealed that there was no facial drooping, the resident's legs were mobile and moved spontaneously and that the right arm grip was weak. Continued review of the Neurological Assessment Flow Sheet revealed that the neuro checks were completed throughout the evening of May 26, and through the early morning hours on May 27. The documentation showed that the resident had weakness to the right arm and leg and that the left arm and leg movement were strong. At 3:00 a.m., the documentation continued to include the resident had weakness to the right arm and leg. However, a nurse's note dated May 27, 2013 at 3:23 a.m., documented "have not noted any symptoms, which would indicate a stroke at this time, vitals have continued to be normal limits as well as neurological checks..." and will continue to monitor for any symptoms indicating a change in neuro status. The note also had conflicting documentation as it included the resident continued on 2 hr neuro checks "due to c/o (complaints of) LUE (left upper extremity) weakness" instead of right sided weakness per the Neurological Assessment Flow Sheet. According to the Neurological Assessment Flow Sheet neuro checks continued to be done on May 27 at 5:00 a.m., 7:00 a.m., 9:00 a.m., and 11:00 a.m. The documentation included the resident continued with weakness to the right arm and leg and that the left arm and leg movement were strong. There were no further neuro checks documented after 11:00 a.m. The neurological assessments stopped after 18 hours, even though the documentation showed that the resident was experiencing ongoing weakness to the right arm and leg. A nurse's note dated May 27, 2013 at 9:40 p.m., included "Continued Neuro checks without a change in status." However, there was no clinical record documentation of any continued neuro checks that were done. In addition, there was no documentation the physician was notified timely of the resident's ongoing right sided weakness or the lack of improvement in symptoms and there was no documentation the resident was assessed timely by a physician/NP, despite these symptoms. A physician progress notes [REDACTED]. She states the symptoms began Friday evening. She describes the weakness has waxing and wanning throughout the day but today she is having significant difficulty with right upper extremity and lower extremity weakness. The patient's motor exam was normal upon admission. She denies any problems with chest pain. She has not had any further [MEDICAL CONDITION] episodes. She denies any paresthesias on the right or left side. She has not had any visual changes. She is not having any difficulty swallowing. A 10 point review of systems was otherwise negative." The note further included under neuro; right upper and lower extremity weakness, diminished sensation on the right to light touch, left upper extremity and lower extremity strength is normal. Under assessment and medical decision making it stated "1. [MEDICAL CONDITION](cardiovascular accident); arrange stat non-contrast head scan, continue aspirin and monitor..." A physician's order dated May 28, 2013, included for a STAT (immediately) non-contrast head scan evaluation for right sided weakness. Another order that same day included to transfer the resident to the hospital for an acute [MEDICAL CONDITION]. A nurse's progress note dated May 28, 2013, revealed conflicting documentation regarding which side the weakness was on as follows: Late entry for 12:30 p.m., resident complained of right sided weakness and was seen by physician. The physician stated for the resident to be sent to the hospital for "left sided weakness and a possible stroke." A review of the hospital records dated May 28, 2013 at 6:30 p.m., revealed the resident was alert and oriented to person, place, time, and situation. The documentation further included the following: "Resident was completely flaccid on the right at this time. Non-hemorrhagic [MEDICAL CONDITION]. Resident stated that she had not been evaluated for the past two days, that she awoke on Sunday morning May 26, 2013, and was unable to move her right side. She reportedly notified her caregivers, who chose to await a doctors evaluation on May 28, 2013. Patient is a poor historian..." An interview with staff development conducted on January 8, 2014, revealed that she stated that the neurological assessment is to be conducted per facility protocol which is written on the flow sheet. Review of the facility policy regarding neurological assessment revealed, "...Neurological assessments shall be performed at least every four hours for the first 24 hours and then at least every eight hours, unless ordered more or less frequently by the physician or when the resident is determined to be at risk for neurological decompensation." -Resident #204 was readmitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. According to the physician's order from May 9, 2013, the resident was to have her blood pressure monitored daily and it was to be documented. Review of the resident's Medication Administration Records (MAR) and the computerized vital sign record from May 2013 to September 2013, revealed there was no blood pressure documentation for seven days in May, 16 days in June, eight days in July, 14 days in August, and 29 days in September. During an interview conducted on January 13, 2014 at 11:00 am, a Licensed Practical Nurse (LPN) reported that blood pressures need to be documented on the MAR if a resident has an order for [REDACTED]. An interview was conducted with a Unit Manager on January 13, 2014 at 2:20 pm. At that time she reported that blood pressures should be documented on the MAR for residents who have a physician's order for blood pressure monitoring. She stated that there were also blood pressures documented on the Certified Nursing Assistant (CNA) vital sign sheets. The Unit Manager started looking through the CNA vital sign sheets for September 2013, and reported that it looked like they were not being consistent with taking the resident's blood pressure. She was asked if all residents had their vital signs checked every day to which she replied "no, it depends on if there is a physician's order." The Unit Manager confirmed that there are three different places that the blood pressures could be documented, which included: on the MAR, in the computer, and on the CNA vital sign sheets. She was only able to find three days in September that the resident's blood pressure was documented on the CNA vital sign sheets, making it 26 days in September that the resident's blood pressure was not documented. During an interview conducted on January 14, 2013 at 7:45 am, a Nurse Consultant reported that they did not have any more CNA vital sign sheets to provide at that time. At 7:55am she stated that she did not know if they had more sheets since the CNA documentation is not part of the resident's permanent medical record. Review of the facility's policy on blood pressure documents that the nurse assistant is to report the blood pressure measurement to the staff/charge nurse. It further documents that once the blood pressure has been measured, the staff/charge nurse must record the blood pressure in the resident's medical record. -Resident #368 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A physician's order was written on January 2, 2014, for the use of [MEDICATION NAME] one gram orally three times per day for GERD. During a medication administration observation on January 8, 2014, the [MEDICATION NAME] was administered to this resident after she had eaten her breakfast. Review of the medication card for the [MEDICATION NAME] revealed a sticker placed on the card by pharmacy to give this medication on an empty stomach, before meals. An interview was conducted with a registered nurse (RN) immediately following the observation on January 8, 2014. The RN stated that this medication is always given to the resident after meals because of the way it is scheduled. She also stated that she did not know that the [MEDICATION NAME] was to be given on an empty stomach. Review of the facility's policy on Medication Administration revealed "...All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnosis...Read and follow any special instructions written on labels..."