Every finding on record at Medical Hill Healthcare Center

Based on observation, interview and record review, the facility failed to ensure, for Residents 2-4, the scheduled (controlled medication, narcotic) medication record system was complete (all documents available) and accurate (numbers match). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility did not have complete records. The facility did not have accurate records. These failures resulted in the potential for undetected loss and diversion. In addition, these failures resulted in the potential for avoidable medication errors. Findings: During a concurrent observation and interview, on 8/4/25 at 10:30 a.m., at Nursing Station 1, Licensed Vocational Nurse (LVN 1) identified a medication cart. LVN 1 was asked to describe the scheduled medication accountability procedure. LVN 1's description included the pharmacy courier delivered the scheduled medication and the Shipping Manifest to the nurse. The nurse and the courier signed the Shipping Manifest. The nurse placed the medication in the medication cart. The nurse filed the CDR at the cart. LVN 1 stated that for each dose of scheduled medication administered or removed, it was signed out on the CDR. When the scheduled medication was discontinued the remaining medication and the CDR were transferred to Director of Nursing (DON). The nurse and DON signed a record for the transfer of the scheduled medication. DON removed the scheduled medication from the medication cart. During an interview, on 8/4/25 at 11:00 a.m., at Nursing Station 4, Licensed Vocational Nurse (LVN 2) was asked to describe the scheduled medication accountability procedure. LVN 2 stated that the nurse and DON signed the CDR to document the transfer of medication from the cart. In addition, she described that DON and the pharmacist signed the CDR at the time of medication destruction. Durning an interview, on 8/4/25 at 12:15 p.m., Medical Record Director (MRD) was requested to provide pharmacy Shipping Manifests from 2/2023 through 5/2023. Durning an interview, on 8/4/25 at 2:45 p.m., Medical Records (MR) was asked to describe the CDR accountability process. MR's description included that the CDRs were filed in the resident's medical records. During a concurrent interview and record review, on 8/5/25 at 9:15 a.m., MR was requested to provide the medical records for Residents 1-10. Resident 3 CDR 531382 4/10/23 Oxycodone (narcotic pain reliever) 5 mg tablet was not provided before the end of the survey. During an interview, on 8/5/25 at 1:45 p.m., DON was asked to describe the scheduled medication accountably process. DON's description included using the Destruction Log to document accountability through destruction. The destruction of scheduled medications was documented on the log. Destruction was verified by signatures of the DON and the pharmacist. During an interview, on 8/6/25, at 10:30 a.m., Administrator (ADM) was requested to provide the Consultant Pharmacist reports from 1/23 through 12/23. During a concurrent interview and record review, on 8/6/25 at 11:15 a.m., DON identified Resident 2 MAR and CDR 5218571 3/20/23 for Hydrocodone (narcotic pain reliever)/APAP (acetaminophen, pain reliever) 5/325 tablets #30. DON reviewed the CDR and the MAR. DON stated that the CDR showed medication removed from the cart on 3/23/23 0600 and 3/24/23 0700. DON stated the MAR did not show the medication was administered at the corresponding times. During a concurrent interview and record review on 8/6/25 at 2:30 p.m., DON acknowledged the medical records, including the CDRs for Resident 3 (4/10/23) and Resident 4 5305945 4/7/23 Oxycodone 5 mg tablet could not be located. Continuing the interview, DON stated that it was the facilities' expectation that scheduled medication records were complete and accurate. Continuing the interview, DON identified the Consultant Pharmacist reports 1/23 through 12/23. DON acknowledged the reports did not document recommendations addressing the accuracy of the scheduled medication records. DON stated that it was the facilities' expectation the Consultant Pharmacist ensured schedule medication records were accurate. During an administrative record review, of the policy for Controlled Substances (undated) showed, Dispensing and Reconciling Controlled Substances, 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records (MAR); c. Declining inventory records (CDR); and d. Destruction (logs), waste and return to pharmacy records.

Based on observation, interviews, and record review, the facility failed to provide pharmaceutical services and procedures to six of six sampled residents (Residents 58, 93, 24, 121, 29, and 69) that ensured acquiring, dispensing, administration, and maintaining accurate controlled drug records when:Resident 93 and Resident 58's routine medications were not available during medication administration.The Controlled Drug Records (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) for four out of four sampled residents (Residents 29, 121, 69, and 24) did not reconcile with the Medication Administration Records (MAR). This failure had the potential to result in inaccurate accountability and the potential for abuse and diversion (when medication is taken for use by someone other than whom it is prescribed) of controlled medications and Resident 93 and Resident 58 not receiving appropriate treatments as per physician orders.1.During a record review of Resident 58's admission Record, the admission Record indicated Resident 58 was admitted to the facility in September 2023 with multiple medical diagnosis including schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms).During a record review of Resident 58's MAR, dated 8/1/25 to 8/30/25, the MAR indicated Resident 58 had a physician order dated 12/10/24 for chlorpromazine hydrochloride (medication used to manage and treat mental conditions) tablet 25 mg, give two tablets by mouth one time a day for schizoaffective disorder manifested by delusions. The MAR also indicated Resident 58 did not receive chlorpromazine on 8/6/25.During a medication pass observation on 8/6/25 at 8:49 p.m. with Registered Nurse (RN) 1, RN 1 prepared Resident 58's morning routine medications. RN 1 stated Resident 58's chlorpromazine tablets were not available for administration. RN 1 proceeded to administer Resident 58's routine morning medication without the chlorpromazine.During a record review of Resident 93's admission Record, the admission Record indicated Resident 93 was admitted to the facility in June 2023 with multiple medical diagnosis including hypertension (High blood pressure). During a record review of Resident 93's MAR, dated 8/1/25 to 8/30/25, the MAR indicated Resident 93 had a physician order dated 8/2/24 for Eliquis (an anticoagulant or blood thinner to reduce risk of stroke and blood clots) oral tablet 2.5 mg, give 2.5 mg by mouth two times a day for atrial fibrillation (an irregular and often very rapid heart rhythm) The MAR also indicated Resident 93 did not receive Eliquis on the following dates and times:- 8/5/25 at 9:00 a.m.- 8/5/25 at 6:00 p.m.- 8/6/25 at 9:00 a.m.During a record review of Resident 93's Progress Notes, dated 8/5/25, the Progress Notes indicated the Eliquis was on order at 9:13 a.m. and medication unavailable. at 6:49 p.m.During a record review of Resident 93's Progress Notes, dated 8/6/25, the Progress Notes indicated the Eliquis was on order at 10:00 a.m.During a record review of Resident 93's Progress Notes, dated 8/6/25 at 3:26 p.m., the Progress Notes indicated Eliquis medication not administered because ran out.During medication pass observation on 8/6/25 at 9:42 a.m. with RN 1, RN 1 stated Resident 93's Eliquis was not available. RN 1 informed the Assistant Director of Nursing (ADON) about the missing Eliquis. ADON was observed searching for the Eliquis in the medication but did not find it. RN 1 then proceeded to administer the rest of Resident 98's routine morning medications without the Eliquis.During an interview on 8/6/25 at 10:04 a.m. with RN 1, RN 1 stated he was new to the medication cart and was not sure why there were some medications that were unavailable for residents to use. RN 1 stated if a medication was not available, they should have checked the emergency kit (or e-kit, a limited supply of medication for urgent use) if the medication was available, inform the physician, and call the pharmacy to reorder the medication. RN 1 stated Resident 58 had the risk of mental instability if the chlorpromazine was not given as ordered by the physician. RN 1 further stated without the Eliquis, Resident 93 could have had complications of atrial fibrillation such as stroke.During a phone interview on 8/7/25 at 1:22 p.m. with Consultant Pharmacist (CP), CP stated the facility should have reordered from the pharmacy if the medications were running low. CP stated the medications in the bubble packs (a card that packaged doses of medication within plastic bubbles or blisters) contained a reminder label indicating the date to place a reorder. CP stated the facility had eight days to refill before the medications ran out. CP further stated Eliquis should have been available in e-kit for Resident 93 to use. CP stated it was important for residents to receive their routine medications in a timely manner because missed doses could have caused consequences. 2.During a record review of Resident 24's Medication Administration Record (MAR), dated 7/1/25 to 8/31/25, the MAR indicated Resident 24 had a physician order, dated 7/4/25, 7/18/25, and 7/21/25 for lorazepam (a controlled substance used for anti-anxiety) 2 milligrams (mg, unit of volume), give one tablet by mouth every four hours as needed for anxiety manifested by over concern with anything for 14 days.During a record review of Resident 24's CDR, dated between 7/15/25 to 8/2/25, the CDR indicated licensed nursing staff signed out one tablet on the following dates and times but did not document the medication administration on the July and August 2025 MAR (total of seven doses):- 7/18/25 at 10:30 a.m.- 7/19/25 at 6:00 a.m.- 7/19/25 at 10:10 a.m.- 7/21/25 at 6:00 a.m.- 7/21/25 at 9:30 p.m.- 8/2/25 at 5:30 a.m.- 8/2/25 at 5:00 a.m.During a record review of Resident 121's MAR, dated 7/1/25 to 7/31/25, the MAR indicated Resident 121 had a physician order, dated 7/23/25 for lorazepam 2mg, give one tablet by mouth every four hours as needed for anxiety manifested by over concern with anything for 14 days, hold for sedation.During a record review of Resident 121's CDR, dated between 7/24/25 to 8/4/25, the CDR indicated licensed nursing staff signed out one tablet on the following dates and times but did not document the medication administration on the July 2025 MAR (total of three doses):- 7/27/25 at 6:00 p.m.- 7/28/25 at 8:00 a.m.- 8/1/25 at 10:13 a.m.During a record review of Resident 29's MAR, dated 8/1/25 to 8/30/25, the MAR indicated Resident 29 had a physician order, dated 6/18/25, for oxycodone hydrochloride (a controlled substance used to relieve severe pain)) oral capsule 5 mg, give one capsule by mouth every four hours as needed for moderate to severe pain.During a record review of Resident 29's CDR, dated between 8/2/25 to 8/5/25, the CDR indicated licensed nursing staff signed out one capsule on the following dates and times but did not document the medication administration on the August 2025 MAR (total of two doses):- 8/3/25 at 4:30 a.m.- 8/3/25 at 5:05 p.m.During a record review of Resident 69's MAR, dated 8/1/25 to 8/30/25, the MAR indicated Resident 69 had a physician order, dated 7/29/25, for Roxicodone (an opioid analgesic used to treat moderate to severe pain) oral tablet 5mg, give two tablets by mouth every four hours as needed for severe pain.During a record review of Resident 69's CDR, dated between 8/1/25 to 8/5/25, the CDR indicated licensed nursing staff signed out two tablets on the following dates and times but did not document the medication administration on the August 2025 MAR (total of two doses):- 8/1/25 at 5:00 a.m.- 8/2/25 at 3:00 a.m.During a phone interview on 8/7/25 at 1:07 p.m. with the CP, CP stated when pulling out a controlled substance, licensed nursing staff were expected to document on both the CDR and MAR. CP stated MAR was an assurance that the controlled substance medications were received by residents. CP stated if CDR did not match the MAR, it would have been considered a discrepancy. CP stated not documenting accurately on the MAR, it would have been difficult to identify if the controlled substances were actually given to the residents.During an interview on 8/8/25 at 9:22 a.m. with Medical Record Director (MRD) 1, MRD 1 stated the CDR should have reflected the MAR for accurate recording of controlled drugs. MRD 1 stated she did not know how to answer when asked how they verified that the controlled medications were given to Residents 24, 121, 29, and 69 when licensed nursing staff did not document the controlled drugs given on CDR and MAR concurrently. MRD 1 stated not accurately documenting the administration of the controlled drugs had the risk for drug diversion where nurses could have used the controlled drugs for their own use. During a record review of the facility's policy and procedures (P&P), titled, Medication Administration, dated January 2023, the P&P indicated, The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. During a record review of the facility's P&P, titled, Controlled Substances, dated November 2022, the P&P indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of Comprehensive Drug Abuse Prevention and Control Act of 1976).The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following.a. Records of personnel access and usage.b. Medication administration records.During a record review of the facility's P&P, titled, Pharmacy Services Overview, dated April 2024, the P&P indicated, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist.1. Pharmaceutical services consist of.a. process of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling.dispensing.distributing, administering.c. the process of identifying evaluating and addressing medication-related issues including prevention and reporting of medication errors.3. Pharmacy services are available to residents 24 hours a day, seven days a week.8. The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to).a. acquisition and availability of medications.reconciliations of medications.f. documentation of processes, as applicable.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices with census of 119 when: 1) A box of Resident 59's discontinued and unlabeled oral prescribed medication was stored in an active storage area in medication cart #3.2) Resident 65's discontinued as needed prescription medication was stored in medication cart #2.3) Multiple medications with different routes of administration (a way by which a drug is taken into the body) were stored together in medication carts #2 and #3.4) An unopened insulin vial with pharmacy label of refrigerate until opened was stored at room temperature in medication cart #2.These failed practices could contribute to unsafe use of medications and potential for medication error. Findings:During a record review of Resident 59's Order Summary Report dated 8/7/25, the Orders Summary Report indicated Resident 59 had a physician order of cholestyramine light oral packet 4 grams - give 1 packet by mouth two times a day. that was discontinued since 8/30/24.During a concurrent observation and interview on 8/4/25 at 12:54 p.m. with Director of Staff Development (DSD) and Licensed Vocational Nurse (LVN) 3, in the medication cart #3, a box of medication with multiple cholestyramine light oral packet 4 grams (a prescription-only medication used to treat high cholesterol) did not have a label and the top lid of the container was missing. LVN 3 and DSD stated they did not know who the medication belonged to. After checking the electronic health records (EHR), LVN 3 stated the medication belonged to Resident 59. LVN 3 stated he was not sure if Resident 59's cholestyramine was discontinued or not. DSD stated all prescription medications should have had labels to prevent mistakes or errors. DSD stated medications without labels had potential to be given to other residents.During a concurrent observation and interview on 8/4/25 at 1:05 p.m. with DSD, two inhalers called Advair and Albuterol (handheld device used to deliver medication that helps breathing directly into the lungs), one haloperidol (antipsychotic medication that treats schizophrenia, a chronic mental disorder that affects how a person thinks) oral solution, one box nicotine lozenge (helps quit smoking), and one Proventil nebulizer solution (a liquid solution that is transformed into a fine mist by a nebulizer device and inhaled to lungs to help with breathing) were stored in one compartment in an active storage area of medication cart #3. DSD stated the medications should have been separated by route of administration to prevent contamination between the medications.During a record review of Resident 65's Order Summary Report dated 8/5/25, the Order Summary Report indicated Resident 65 had a physician order of hydroxyzine (medication used to treat anxiety) hydrochloride oral tablet 25 milligrams (mg, unit of volume) - give one tablet by mouth every 6 hours as needed for anxiety manifested by overconcern with anything for 14 days that was completed since 4/9/25. During an observation and interview, on 8/5/25 at 11:48 a.m. with LVN 4, the medication cart #4 contained Resident 65's discontinued hydroxyzine oral tablet 25 mg was stored in medication cart #4. LVN 4 stated Resident 65's hydroxyzine should have been discarded and destroyed by two licensed nurses because it had the risk of being given to the wrong residents.During an observation and interview on 8/5/25 at 12:10 p.m. with Assistant Director of Nursing (ADON), Resident 70's eyedrops called cyclosporine ophthalmic emulsion 0.05% (a prescription medication used to treat chronic dry eye disease) was stored together with Resident 29's diclofenac sodium 1% gel (a topical gel medication that treats arthritis of the knee). ADON stated she needed to verify what their policy was for storing medications.During an observation and interview on 8/5/25 at 12:29 p.m. with LVN 1, Resident 86's unopened insulin vial with a pharmacy label of refrigerate until opened was stored at room temperature inside the medication cart #2. LVN 1 stated Resident 86's unopened insulin should have been refrigerated and not stored at room temperature. LVN 1 stated storing unopened insulin incorrectly could have decreased its effectiveness.During an interview on 8/7/25 at 1:07 p.m. with Consultant Pharmacist (CP), CP stated discontinued medications should have been pulled out and discarded from the medication carts. CP stated storing discontinued medications could have caused confusion from the nurses that could potentially have caused medications errors. CP stated all residents' medications should have had proper labeling. CP further stated without proper labeling, nurses could have had a hard time identifying the difference between a prescription and over the counter medications. CP further stated without a label; the medication had a risk of being given to the wrong resident. CP stated nurses had a risk of giving the medications continually to the residents. CP stated the medications should have been stored by route of administration to prevent medication errors. CP stated it was best practice to keep unopened insulin vials in the refrigerator if not ready for use. CP stated once the unopened insulin vial was stored at room temperature, then the 28-day count for the expiration date should have been started even without opening the vial.During a record review of the facility's policy and procedure (P&P), titled, Medication Storage dated January 2023, the P&P indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support a safe effective drug administration.1. The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements.This may include such containers as medication carts medication rooms.4. Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, suppositories.6. Eye medications are stored separately from ear medications and inhalers, etc.12. Insulin products should be stored in the refrigerator until opened.14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy.

Based on interview and record review the facility failed to ensure accuracy of medical record for four of four sampled residents (Residents 24, 121, 29, and 69) when:1. Resident 24 had a physician's order to give an as needed lorazepam (a controlled substance used by calming the nervous system and reducing feelings of anxiety, fear, and worry) was created on 8/5/25 with a start date of 8/1/25, resulting in a four-day backdate (put an earlier date to a document than the actual one) without verification.2. Residents 24, 121, 29, and 69's controlled drug records (CDR) and medication administration record (MAR) did not match, and licensed nursing staff subsequently created late entry and back dated notes.This failure resulted in inaccurate reflection of physician orders for Resident 24, as well as inaccurate accountability for Resident 24, 121, 29, and 69''s controlled medications that had the potential for abuse and drug diversion (when medication is taken for use by someone other than whom it is prescribed). 1. During a record review of Resident 24's admission Record (AR), dated 8/5/25, the AR indicated Resident 24 was admitted in the facility in August 2025 with diagnosis of schizoaffective disorder (a mental health condition characterized by a combination of schizophrenia symptoms like hallucinations and delusions and mood disorder symptoms like depression or mania) and anxiety disorders (a group of mental health conditions characterized by excessive worry, fear, or unease that can interfere with daily life. During a record review of Resident 24's Physician Order, dated 8/1/25, the Physician Order indicated an order for Lorazepam oral tablet two milligrams (mg, unit of volume) .Controlled drug.Give one tablet by mouth every four hours as needed for anxiety manifested by over concern with anything for 14 days. The Physician Order also indicated the order for lorazepam was created on 8/5/25, resulting in a four-day backdate.During a concurrent interview and record review on 8/6/25 at 11:26 a.m. with Assistant Director of Nursing (ADON), Resident 24's order for lorazepam was reviewed. ADON stated on 8/1/25, she received a verbal order from the physician authorizing the administration of lorazepam to Resident 24. ADON stated she could not recall why she did not enter the physician's order right away into Resident 24's record. ADON further stated they have 30 days to correct documentation including medication administration. ADON stated she informed the charge nurse on 8/1/25 that it was okay to administer lorazepam to Resident 24. During a follow up interview and record review on 8/7/25 at 12:08 p.m. with ADON, Resident 24's medical records were reviewed. ADON stated she could not recall if she created a physician order sheet after she received the verbal order from the physician as part of their policy and procedure. ADON stated she did not find any documentation from the physician that indicated the rationale for Resident 24 to continue the as needed lorazepam. ADON stated late entry of physician's order had a risk of administering the wrong medication and may have had prevented the medications from being given on time.During a phone interview on 8/7/25 at 1:07 p.m. with Consultant Pharmacist (CP), CP stated any psychotropic (a class of drugs that affect the brain and influence mental processes and behaviors) medication including lorazepam could not be renewed or reordered verbally unless it was written and signed by the physician. CP stated only a pharmacist may receive verbal orders for controlled drugs from the physician, and only in emergency situations.2. During a record review of Resident 24's Medication Administration Record (MAR), dated 7/1/25 to 8/31/25, the MAR indicated Resident 24 had a physician order, dated 7/4/25, 7/18/25, and 7/21/25 for lorazepam (a controlled substance used for anti-anxiety) 2 milligrams (mg, unit of volume), give one tablet by mouth every four hours as needed for anxiety manifested by over concern with anything for 14 days.During a record review of Resident 24's CDR, dated between 7/15/25 to 8/2/25, the CDR indicated licensed nursing staff signed out one tablet on the following dates and times but did not document the medication administration on the July and August 2025 MAR (total of eight doses):- 7/18/25 at 10:30 a.m.- 7/18/25 at 6:12 p.m.- 7/19/25 at 6:00 a.m.- 7/19/25 at 10:10 a.m.- 7/21/25 at 6:00 a.m.- 7/21/25 at 9:30 p.m.- 8/2/25 at 5:30 a.m.- 8/2/25 at 5:00 a.m.During record review of Resident 24's Progress Notes with an effective date on 7/18/25 at 10:30 a.m., was created on 8/5/25 at 5:51 p.m., resulting in an 18-day backdate. The Progress Notes indicated the lorazepam was administered.During record review of Resident 24's Progress Notes with an effective date on 7/18/25 at 6:12 p.m. was created on 8/5/25 at 6:11 p.m., resulting in an 18-day backdate. The Progress Notes indicated the lorazepam was administered.During record review of Resident 24's Progress Notes with an effective date on 7/19/25 at 6:00 a.m. was created on 8/5/25 at 5:58 p.m., resulting in a 17-day backdate. The Progress Notes indicated the lorazepam was administered.During record review of Resident 24's Progress Notes with an effective date on 7/19/25 at 10:00 a.m. was created on 8/5/25 at 5:52 p.m., resulting in a 17-day backdate. The Progress Notes indicated the lorazepam was administered.During record review of Resident 24's Progress Notes with an effective date on 7/21/25 at 6:00 a.m. was created on 8/5/25 at 6:06 p.m., resulting in a 14-day backdate. The Progress Notes indicated the lorazepam was administered.During record review of Resident 24's Progress Notes with an effective date on 7/21/25 at 9:14 p.m. was created on 8/5/25 at 6:15 p.m., resulting in a 14-day backdate. The Progress Notes indicated the lorazepam was administered.During record review of Resident 24's Progress Notes with an effective date on 8/2/25 at 5:30 a.m. was created on 8/5/25 at 4:43 p.m., resulting in a 4-day backdate. The Progress Notes indicated the lorazepam was administered.During a record review of Resident 121's admission Record (AR), dated 8/5/25, the AR indicated Resident 121 was admitted in the facility in April 2025 with diagnosis of schizoaffective disorder.During a record review of Resident 121's MAR, dated 7/1/25 to 7/31/25, the MAR indicated Resident 121 had a physician order, dated 7/23/25 for lorazepam 2mg, give one tablet by mouth every four hours as needed for anxiety manifested by over concern with anything for 14 days, hold for sedation.During a record review of Resident 121's CDR, dated between 7/24/25 to 8/4/25, the CDR indicated licensed nursing staff signed out one tablet on the following dates and times but did not document the medication administration on the July 2025 MAR (total of three doses):- 7/27/25 at 6:00 p.m.- 7/28/25 at 8:00 a.m.- 8/1/25 at 10:13 a.m.During record review of Resident 121's Progress Notes with an effective date on 7/27/25 at 6:00 p.m. was created on 8/5/25 at 4:42 p.m., resulting in a 9-day backdate. The Progress Notes indicated the lorazepam was administered.During record review of Resident 121's Progress Notes with an effective date on 7/28/25 at 8:00 a.m. was created on 8/5/25 at 5:17 p.m., resulting in an 8-day backdate. The Progress Notes indicated the lorazepam was administered.During record review of Resident 121's Progress Notes with an effective date on 8/1/25 at 10:13 a.m. was created on 8/5/25 at 5:27 p.m., resulting in a 4-day backdate. The Progress Notes indicated the lorazepam was administered.During a record review of Resident 29's admission Record (AR), dated 8/5/25, the AR indicated Resident 29 was admitted in the facility in May 2024 with diagnoses of polyneuropathy (happens when the nerves that are located outside of the brain and spinal cord are damaged) and chronic pain (persistent or recurrent pain lasting longer than three to six months).During a record review of Resident 29's MAR, dated 8/1/25 to 8/30/25, the MAR indicated Resident 29 had a physician order, dated 6/18/25, for oxycodone hydrochloride (a controlled substance used to relieve severe pain)) oral capsule 5 mg, give one capsule by mouth every four hours as needed for moderate to severe pain.During a record review of Resident 29's CDR, dated between 8/2/25 to 8/5/25, the CDR indicated licensed nursing staff signed out one capsule on the following dates and times but did not document the medication administration on the August 2025 MAR (total of two doses):- 8/3/25 at 4:30 a.m.- 8/3/25 at 5:05 p.m.During record review of Resident 29's Progress Notes with an effective date on 8/3/25 at 4:30 a.m. was created on 8/5/25 at 5:02 p.m., resulting in a 2-day backdate. The Progress Notes indicated the oxycodone was administered.During record review of Resident 29's Progress Notes with an effective date on 8/3/25 at 5:05 p.m. was created on 8/5/25 at 5:41 p.m., resulting in a 2-day backdate. The Progress Notes indicated the oxycodone was administered.During a record review of Resident 69's admission Record (AR), dated 8/5/25, the AR indicated Resident 69 was admitted in the facility in May 2025 with diagnosis of right clavicle fracture (broken collarbone). During a record review of Resident 69's MAR, dated 8/1/25 to 8/30/25, the MAR indicated Resident 69 had a physician order, dated 7/29/25, for Roxicodone (an opioid analgesic used to treat moderate to severe pain) oral tablet 5mg, give two tablets by mouth every four hours as needed for severe pain.During a record review of Resident 69's CDR, dated between 8/1/25 to 8/5/25, the CDR indicated licensed nursing staff signed out two tablets on the following dates and times but did not document the medication administration on the August 2025 MAR (total of two doses):- 8/1/25 at 5:00 a.m.- 8/2/25 at 3:00 a.m.During record review of Resident 69's Progress Notes with an effective date on 8/1/25 at 5:00 a.m. was created on 8/5/25 at 5:11 p.m., resulting in a 4-day backdate. The Progress Notes indicated the Roxicodone was administered.During record review of Resident 69's Progress Notes with an effective date on 8/2/25 at 3:00 a.m. was created on 8/5/25 at 5:24 p.m., resulting in a 3-day backdate. The Progress Notes indicated the Roxicodone was administered.During a phone interview on 8/7/25 at 1:07 p.m. with the CP, CP stated when pulling out a controlled substance, licensed nursing staff were expected to document on both the CDR and MAR. CP stated MAR was an assurance that the controlled substance medications were received by residents. CP stated if CDR did not match the MAR, it would have been considered a discrepancy. CP stated not documenting accurately on the MAR, it would have been difficult to identify if the controlled substances were actually given to the residents and it had the risk for drug diversion. MDR 1 stated inaccurate recording of the controlled substance had the potential for abuse and nurses using the controlled substances for their own good.During an interview on 8/8/25 at 9:22 a.m. with Medical Record Director (MRD) 1, MRD 1 stated the CDR should have reflected the MAR for accurate recording of controlled drugs. MRD 1 stated she did not know how to answer when asked how they verified that the controlled medications were given to Residents 24, 121, 29, and 69 when licensed nursing staff did not document the controlled drugs given on CDR and MAR concurrently. MRD 1 stated not accurately documenting the administration of the controlled drugs had the risk for drug diversion where nurses could have used the controlled drugs for their own use.During an interview on 8/8/25 at 9:30 a.m. with MRD 2, MRD 2 stated residents' charts and records should have been done in a timely manner to make sure they were compliant. MRD 2 stated documenting a medication administration should have been done as soon as the medication was given. MRD 2 stated a resident's chart should have had complete and accurate documentation, including progress notes and MAR because they were all part of a resident's records. During a record review of the facility's policy and procedures (P&P), titled, Controlled Substance Medication Orders, dated January 2023, the P&P indicated, Before a controlled substance medication can be dispensed, the pharmacy must be in receipt of a clear, complete, valid prescription from a person lawfully authorized to prescribe them.The pharmacy can dispense a Schedule III-V (Schedules I-V are classification of controlled drugs based on their potential for abuse including lorazepam) controlled substance medication after a receipt of practitioner signed a valid Schedule III-V prescription (original, fax, or electronically prescribed).or the practitioner (or his agent) speaks directly to the pharmacist providing verbal authorized controlled substance prescription.Incomplete prescriptions and verbal order for controlled substances may not be edited or changed by the facility nursing staff.During a record review of the facility's P&P, titled, Controlled Substances, dated November 2022, the P&P indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of Comprehensive Drug Abuse Prevention and Control Act of 1976).The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following.a. Records of personnel access and usage.b. Medication administration records.During a record review of the facility's P&P, titled, Medication Administration, dated January 2023, the P&P indicated, The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.During a record review of the facility's P&P, titled, Charting and Documentation, dated July 2017, the P&P indicated, All services provided to the resident.shall be documented in the resident 's medical record.Documentation in the medical record will be objective.complete, and accurate.

Based on interview and record review, for one of three sampled residents for closed record review (Resident 132), the facility failed to ensure an effective discharge process when caregiver training and discharge notice were not provided in a timely manner. This failure had the potential to result in avoidable accidents and unsafe discharge. During a review of Resident 132's admission Record (AR), the AR indicated Resident 132 was admitted to the facility on [DATE] with diagnoses that included dislocation of the left knee, difficulty walking, dislocation of left hip prosthesis and the need for assistance with personal care. During a review of Resident 132's Order Summary Report (OSR) as of 8/7/25, the OSR indicated a physician's order dated 7/8/25 to discharge Resident 132 to home with hospital bed and Hoyer lift (also known as a patient lift or hydraulic lift, is a medical device designed to assist in the transfer of patients with limited mobility. It is commonly used in hospitals, nursing homes, and private residences to move patients safely from one location to another, such as from a bed to a wheelchair or from a wheelchair to a toilet). During a review of Resident 132's care plans, dated 5/19/25, the care plans indicated the following: - Discharge/Transfer Referral, interventions included to arrange for necessary home modifications as indicated, and to coordinate in-home support services. - Discharge/Transfer Planning Preference interventions included addressing availability, capability, and training needs of caregiver/support person as needed and to coordinate in-home support services. - The resident wishes to return home. interventions included to make arrangement with required community resources to support independence after discharge. During an interview on 8/7/25 at 12:37 p.m. with Director of Nursing (DON), DON stated that Resident 132 was scheduled for discharge on [DATE]. DON stated, on the day of discharge, Resident 132 complained of stroke-like symptoms and was sent to the hospital. DON stated, discharge plans had already begun while Resident 132 was at the facility. During discharge planning, Resident 132 mentioned having a caregiver, a friend, to assist. DON stated she did not know if the caregiver received training and would check with the Rehabilitation Department. During an interview on 8/7/25 at 1:30 p.m. with Assistant Director of Rehabilitation (ADOR), ADOR stated Resident 132 would not improve with activities of daily living despite treatments. ADOR stated the facility's social services indicated Resident 132 would be discharged home. ADOR stated Resident 132 would need assistance will all ADLS at home, if a caregiver was present, the caregiver would need training for care transfers and Hoyer lift transfers. ADOR stated no caregiver training was provided for Resident 132. During a telephone interview on 8/7/25 at 2:15 p.m. with Ombudsman (OMB), OMB stated Resident 132 was wheelchair-bound and appeared absent-minded during a visit. OMB stated Resident 132 did not have a caregiver, had no power in the apartment, and that property manager had left it unlocked. OMB stated the hospital case manager communicated that Resident 132's insurance and approved an additional week at the facility to complete discharge arrangements. During an interview on 8/7/25 at 2:54 p.m. with Case Manager (CM) 1, CM 1 stated that on 7/1/25, she and DON asked Resident 132 if she wanted to be discharged , and Resident 132 agreed. CM 1 stated discharge planning began, and the necessary Durable Medical Equipment (hospital bed and Hoyer lift) was delivered before the 7/9/25 discharge date . CM 1 stated that Resident 132 had a Community Case Manager (CCM) who arranged for a caregiver but did not verify this herself with CCM. CM 1 stated although Resident 132 had a brother and a sister, they were not involved in the discharge planning. CM 1 stated, on 7/9/25, the day Resident 132 was to be discharged home, CM 1 missed several calls from CCM and could not return them. During a telephone interview on 8/7/25 at 3:48 p.m. with CCM, CCM stated, on 7/1/25, Resident 132 had called to say the facility planned to discharge her on 7/9/25. CCM stated she called CM 1 regarding Resident 132's discharge plan, but CM 1 indicated no knowledge of the discharge plan or date. CCM stated, on 7/9/25, Resident 132 called again to inform CCM that she was being discharged that day. CCM 1 stated she attempted multiple times to reach CM 1 to prevent the discharge, but none of her calls were answered or returned. CCM stated the facility did not contact her to coordinate Resident 132's discharge, had they called her, CCM stated she would have informed them that Resident 132 did not have a caregiver and did not have resources at home. CCM stated only becoming aware that Resident 132 had been taken to the hospital when Resident 132 called CCM the following day, distressed, stating that she had been left on the couch by the transport service and had not moved because Resident 132 was wheelchair-bound. CCM stated the office called 911 to have Resident 132 transported back to the hospital. During a review of Resident 132's ED (Emergency Department) Notes dated 7/9/25, the ED notes indicated, Was being discharged today from the facility and upon being given. papers [Resident 132] started to complain of abdominal pain.also states left shoulder was painful.anxious about her living situation as she has nowhere to go. During a follow-up interview on 8/8/25 at 9:28 a.m. with CM 1, CM 1 stated, discharge notice for Resident 132 was to be given on the day of discharge. CM 1 stated she did not keep a copy of the discharge notice or document it in the clinical record. CM 1 added being unsure of the discharge process due to the sudden departure of the social services staff responsible. During an interview on 8/8/25 at 9:51 a.m. with Director of Staff Development (DSD), DSD stated that residents receive a notice of discharge on e week prior to the actual discharge date . During a joint interview on 8/8/25 at 9:53 a.m. with CM 2 and DON, CM 2 stated the notice of discharge is signed by the resident on the day of discharge, the same copy would be sent to the Ombudsman's office the same day. DON stated Resident 132 stayed at the facility for over 30 days. During a review of the facility's policy and procedure (P&P) titled Discharge Summary and Plan last revised March 2025, the P&P indicated every resident has an individualized discharge plan, developed by the interdisciplinary team (a group composed of individuals from different departments of the facility) to meet the resident's discharge needs. A resident's discharge needs must be addressed before the resident can be safely discharged (e.g. caregiver support and education, rehabilitation, etc.).

Based on observation, interview, and record review the skilled nursing facility's licensed nursing staff did not perform a complete assessment of 2 of 17 sampled residents (Residents 81 and 129) when:Assigned nursing staff were unable to explain why Resident 81 was grinding her teeth. Assigned nursing staff could not explain the necessity for a 1:1 sitter (aide with a resident around-the-clock) for Resident 129. This deficient practice had the potential to result in residents receiving inappropriate care or being unable to achieve established health care goals. Record review of the document admission Record showed the facility admitted Resident 81 on 12/8/2010. Diagnoses included Major Depressive Disorder.Record review of the document MDS 3.0 Section C-Cognitive Patterns (Resident Assessment) dated 5/8/2025 indicated Resident 81 could not identify the correct day of week, current month or year. On 8/4/2025 at 11:3 0 a.m. Resident 81 was observed sitting in a wheelchair in the hallway. She was moving her jaw side to side which produced an audible grinding/clicking sound. In a concurrent interview, Licensed Vocational Nurse 6 (LVN 6) stated he did not know why Resident 81 was producing the noise and asked, Maybe it's her behavior? LVN 6 stated he was Unsure how having that information would impact the care he provided for Resident 81.During an interview on 8/5/2025 at 9:15 a.m. Registered Nurse 1 (RN 1) stated he was not sure why Resident 81 was making the oral grinding/clicking sounds. RN 1 stated he should have that information as More knowledge means better care.Record review of the document NBU Behavioral & Psychiatric Interdisciplinary Rounds dated 7/30/2025 indicated Resident 81 had Bruxism (teeth grinding) which she had reported to staff was due to her getting food out of her teeth. Plan was to increase Lorazepam (anti-anxiety medication)During a record review of the document PACS-Medication Administration Record dated 7/1/2025 - 7/31/2025 showed Resident 81 was to be administered Lorazepam 1 mg 2 times per day for anxiety, increase muscle mouth rigidity, sweatiness, bruxism, muscle tension, racing heart. During an interview on 8/6/2025 at 10 a.m. the facility's Director of Nursing (DON) was asked why Resident 81 was grinding her teeth. The DON stated she not sure and would need to Investigate. Record review of the document admission Record showed the facility admitted Resident 129 on 5/23/2025. Diagnoses included schizophrenia. (mental health condition with symptoms that include hallucinations, delusions, depression, mania)Record review of the document MDS 3.0 Section C - Cognitive Patterns dated 5/30/2025 indicated Resident 81 could not identify the correct current day, year or month.Record review of the document Care Plan Report dated 5/23/2025 indicated Resident 81 had a history of a suicide attempt and interventions included 1:1 supervision.During an observation on on 8/4/2025 at 11:13 a.m. Resident 129 was observed in his room with a 1:1 sitter.During an interview on 8/4/2025 at 11:13 a.m. LVN 6 stated he did not know why Resident 129 had a 1:1 sitter. LVN 6 stated it would be good for him to know so he could Care for him appropriately.During an interview on 8/6/2025 at 10:20 a.m., the DON stated she would expect staff to understand why a resident was with a 1:1 sitter or why someone may be grinding their teeth as knowing this information Is helpful in caring for the resident. Record review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered dated 2001 indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to ensure an environment free of accident hazards when one of three (Resident 67) sampled residents, Resident 67, who was on pureed diet, did not receive adequate supervision during meals. Resident 67 received and ate regular consistency food. This failure had the potential to result in choking and aspiration. During a review of Resident 67's admission Record (AR), the AR indicated Resident 67 was admitted to the facility in March 2025 with diagnoses that included dementia (decline in cognitive function, impaired memory, thinking and decision-making abilities severe enough to interfere with daily life) and dysphagia (difficulty swallowing). During a review of Resident 67's Order Summary Report (OSR) as of 8/7/25, the OSR indicated an order dated 6/3/25 for Resident 67 to have pureed texture with honey thick liquid, 1:1 assist with meals as needed.During an observation on 8/4/25 at 1:36 p.m. in the front dining room, Resident 67 was seated at a dining table with Resident 2 and Resident 72. Resident 67 pointed towards the tray of noodles and orange chicken brought by Resident 2's family for lunch. The family offered some noodles and three pieces of cut-up chicken, which Resident 67 eagerly accepted. Resident 67 proceeded to eat the noodles with a fork, though some fell from her mouth. Resident 2's family expressed uncertainty about whether Resident 67 was allowed to consume noodles and chicken, and apologized by saying, I'm sorry. There were no staff members present in the dining room at that time. During an interview on 8/4/25 at 1:39 p.m., Registered Nurse (RN) 1 was asked about Resident 67's diet. RN 1 responded that Resident 67 was not his patient and did not go to the dining room to check on Resident 67. During an interview on 8/4/25 from 1:41 p.m. to 1:43 p.m. with Director of Staff Development (DSD), DSD stated Certified Nursing Assistant (CNA) 1 was assigned to monitor the dining room. However, DSD later found CNA 1 in another resident's room and instructed CNA 1 to check on Resident 67. CNA 1 went to the dining room to attend to Resident 67. DSD stated Resident 67 was on pureed diet. During an interview on 8/4/25 at 1:43 p.m. with CNA 1, CNA 1 stated being in the dining room but had to step out of the dining room to give the food to another resident who was not in the resident's room. CNA 1 stated because Resident 67's tray was pureed, was the last tray to come out as all the other regular trays have all been served. CNA 1 stated Resident 67 needed assistance with meals. During an interview on 8/4/25 at 2:49 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 67's nurse, LVN 1 stated Resident 67 was on pureed diet and honey thick liquids. LVN 1 stated, during mealtimes, it was very important for staff to supervise Resident 67 to prevent aspiration or choking accidents. During a joint interview on 8/4/25 at 3:05 p.m. neither LVN 1 nor Assistant Director of Nursing (ADON) knew the number of staff assigned to monitor the dining room during mealtimes or could explain the facility's dining protocol. During a review of the facility's policy and procedure (P&P) titled Dining Room last revised October 2024, the P&P indicated the dietician, and/or the dietary supervisor will make scheduled daily meal rounds to every dining room at all mealtimes to assess whether adequate staff are available to assist with passing trays, meal set-up and feeding.

Based on interview and record review, the facility failed to ensure one of one sample resident (Resident 24) was free from significant medication error when Resident 24 was given a psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication called lorazepam (drugs that helps calm the brain and reduce symptoms of anxiety) without a physician's order. This failure had the potential to result in unnecessary use of psychotropic medication, placing Resident 24 at risk for adverse consequences such as impairment or decline in Resident 24's mental or physical condition. During a record review of Resident 24's admission Record (AR), dated 8/5/25, the AR indicated Resident 24 was admitted in the facility in August 2025 with diagnosis of schizoaffective disorder (a mental health condition characterized by a combination of schizophrenia symptoms like hallucinations and delusions and mood disorder symptoms like depression or mania) and anxiety disorders (a group of mental health conditions characterized by excessive worry, fear, or unease that can interfere with daily life. During a record review of Resident 24's Physician Order, dated 8/1/25, the Physician Order indicated an order for Lorazepam oral tablet two milligrams (mg, unit of volume) .Controlled drug.Give one tablet by mouth every four hours as needed for anxiety manifested by over concern with anything for 14 days. The Physician Order also indicated the order for lorazepam was created on 8/5/25, resulting in a four-day backdate (writing a date on document or record that is earlier than the actual date it was completed or signed).During a record review of Resident 24's Medication Administration Record (MAR) dated 8/1/25 to 8/30/25, the MAR indicated Resident 24 received the lorazepam on 8/2/25 at 5:30 a.m. and 8/3/25 at 5:00 a.m.During record review of Resident 24's Progress Notes with an effective date on 8/2/25 at 5:30 a.m. was created on 8/5/25 at 4:43 p.m., resulting in a 4-day backdate. The Progress Notes indicated the lorazepam was administered.During a concurrent interview and record review on 8/6/25 at 11:26 a.m. with Assistant Director of Nursing (ADON), Resident 24's order for lorazepam was reviewed. ADON stated on 8/1/25 around past 10:00 p.m., she received a verbal order from the physician authorizing the administration of lorazepam to Resident 24. ADON stated she could not recall why she did not enter the physician's order right away into Resident 24's record. ADON further stated they have 30 days to correct documentation including medication administration. ADON stated she informed the charge nurse on 8/1/25 that it was okay to administer lorazepam to Resident 24. ADON stated she believed the informed consent was also obtained by the physician prior to administering the lorazepam to Resident 24.During a phone interview on 8/6/25 at 3:44 p.m. with Resident 24's Responsible Party (RP) 3, RP 3 stated the facility did not contact him on 8/1/25 to obtain informed consent for the use of lorazepam for Resident 24. During a follow up interview and record review on 8/7/25 at 12:08 p.m. with ADON, Resident 24's medical records were reviewed. ADON stated she could not recall if she created a physician order sheet after she received the verbal order from the physician as part of their policy and procedure. ADON stated she did not find any documentation from the physician that indicated the rationale for Resident 24 to continue the as needed lorazepam. ADON stated there was also no documentation explaining why the lorazepam was given and what behaviors Resident 24 exhibited on 8/2/25 and 8/3/25. ADON stated late entry of physician's order had a risk of administering the wrong medication and may have had prevented the medications from being given on time.During a phone interview on 8/7/25 at 1:07 p.m. with Consultant Pharmacist (CP), CP stated any psychotropic medication including lorazepam could not be renewed or reordered verbally unless it was written and signed by the physician. CP stated only a pharmacist may receive verbal orders for controlled drugs from the physician, and only in emergency situations. CP stated psychotropic medications could not be renewed unless the physician had re-evaluated a resident to determine the need to continued use. CP further stated administering psychotropic medication to a resident without a physician's order could be considered a medication error and could have affected a resident's mental stability.During a phone interview on 8/7/25 at 1:58 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 Resident 24 was readmitted on [DATE] and she noticed that the lorazepam was not included in Resident 24's medication order from the hospital. LVN 5 stated she informed ADON about it and both of them called the physician to obtain an order for lorazepam. LVN 5 stated she could not recall if lorazepam order was listed on the MAR when she administered it to Resident 24 on 8/2/25 and 8/3/25. LVN 5 stated based on the verbal order she received from ADON, she gave the lorazepam to Resident 24 even though the order did not reflect on the MAR. LVN 5 stated Resident 24 had ongoing behaviors of anxiety. LVN 5 stated she could not remember if she documented the reasons why she administered lorazepam to Resident 24 on 8/2/25 and 8/3/25.During a record review of the facility's policy and procedures (P&P), titled, Medication Administration, dated January 2023, the P&P indicated, Medications are administered as prescribed.Prior to administration, review and confirm medication orders for each individual resident on the MAR.Medications are administered in accordance with written orders from prescriber.During a record review of the facility's P&P, titled, Controlled Substance Medication Orders, dated January 2023, the P&P indicated, Before a controlled substance medication can be dispensed, the pharmacy must be in receipt of a clear, complete, valid prescription from a person lawfully authorized to prescribe them.The pharmacy can dispense a Schedule III-V (Schedules I-V are classification of controlled drugs based on their potential for abuse including lorazepam) controlled substance medication after a receipt of practitioner signed a valid Schedule III-V prescription (original, fax, or electronically prescribed).or the practitioner (or his agent) speaks directly to the pharmacist providing verbal authorized controlled substance prescription.Incomplete prescriptions and verbal order for controlled substances may not be edited or changed by the facility nursing staff.

Based on observation, interview and record review, for two of 27 sampled residents (Resident 40 and Resident 94), the facility failed to ensure their call lights were within reach.This failure had the potential to result in their inability to call for help.During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was admitted to the facility in September 2003 with diagnoses that included paraplegia (paralysis of the lower half of the body) and epilepsy (characterized by unprovoked seizures, loss of consciousness and sensory disturbances). During a review of Resident 40's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/9/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine a resident's cognitive status regarding attention, orientation, and inability to register and recall information) score of 5. A BIMS score of 0-7 indicates severe cognitive impairment). The MDS also indicated Resident 40 required staff assistance with turning and repositioning in bed.During a review of Resident 94's AR, the AR indicated Resident 94 was admitted to the facility in October 2019 with diagnoses that included anxiety disorder (mental health condition characterized by excessive and persistent worry and fear about everyday situations), major depressive disorder (persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in daily activities) and morbid obesity (extreme obesity).During a review of Resident 94's MDS dated [DATE], the MDS indicated Resident 94 had a BIMS score of 12. A BIMS score of 12 indicates moderate cognitive impairment. The MDS also indicated Resident 94 required staff assistance with turning and repositioning while in bed.During a concurrent observation and interview on 8/4/25 at 12:47 p.m. with Resident 94, Resident 94 stated not feeling well and had no way to call the nurse. Resident 94 stated she could not find the call light or knew its location. Resident 94 and Resident 40 were roommates.During a concurrent observation and interview on 8/4/25 at 12:56 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 entered the room and found Resident 94's call light tucked away in the nightstand drawer. Resident 94 stated being unable to see it due to limited neck movement. LVN 1 went over to Resident 40's bedside and found Resident 40's call light wrapped around the bed's left side rails. LVN 1 stated Resident 40 had limited range of motion on upper extremities and would not be able to unwrap the call light from the side rails.During a review of the facility's policy and procedure (P&P) titled Answering the Call Light last revised September 2022, the P&P indicated that to ensure timely response to the resident's needs and requests, staff must Ensure that the call light is nearby to the resident.

Based on observation, interview and record review, the facility failed to follow infection control and prevention measures when Certified Nursing Assistant (CNA) 1 provided direct resident care inside an Enhanced Barrier Precaution room without adequate Personal Protective Equipment (PPE). This failure had the potential to spread infections. Definitions: Enhanced Barrier Precaution (EBP, refers to the use of gown and gloves during high-contact care activities that provide opportunities for transfer of Multi-Drug-Resistant Organisms/ MDRO.) MDROs are microorganisms, usually bacteria, that have developed resistance to one or more classes of antimicrobial agents (antibiotics and antifungals) to staff hands and clothing. Personal Protective Equipment (PPE, refers to various types of protective clothing, gloves, face shields, goggles, face masks and other equipment designed to protect the wearer from injury or infection. During a review of Resident 67's admission Record (AR), the AR indicated Resident 67 was admitted to the facility in March 2025 with diagnoses that included urinary retention and sepsis. During a concurrent observation and interview on 8/5/25 at 10:25 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 67's room was an Enhanced Barrier Precaution (employs targeted gown and glove use during high contact resident care activities) room. There was a sign Contact Precaution (require the use of gown and gloves on every entry into a resident's room) posted on the door. LVN 2 stated she would go ask Director of Nursing DON why the posted sign indicated Contact Precaution instead of Enhanced Barrier Precaution. CNA 1 was inside the room, at Resident 67's bedside, providing care.During an interview on 8/5/25 at 10:27 a.m. with DON, DON stated the sign should indicate Enhanced Barrier Precaution, DON removed the sign Contact Precaution and posted Enhanced Barrier Precaution sign. During a concurrent observation and interview on 8/5/25 at 10:31 a.m. with CNA 1, CNA 1 came out of the room with a plastic bag of used disposable brief. CNA 1 stated she was in the room and changed Resident 67's briefs. CNA 1 did not wear any PPE except facemask and gloves. CNA 1 stated she did not wear a gown because Resident 67 had the tendency to grab CNA 1 during care.During a review of Resident 67's Order Summary Report (OSR) as of date 8/7/25, the OSR indicated a physician's order dated 3/19/25 for Contact Precaution (may cohort) related to ESBL. The OSR indicated Resident 67 had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine).During a review of the facility's policy and procedure (P&P) titled Enhanced Barrier Precaution last revised December 2024, the P&P indicated that contact precautions apply when: A resident is infected or colonized with any MDRO, has a wound or indwelling medical device. The P&P indicated other references such as the CDC Implementation of Personal Protective Equipment in Nursing Homes to Prevent Spread of MDRO.

Based on interview and record review, the facility failed to ensure an allegation of abuse were reported to officials that included the State Survey Agency, Office of the Long-Term Care Ombudsman and law enforcement officials within the required timeframe for one of one sampled resident (Resident 1). This failure had the potential to result in the lack of protection for residents alleging abuse. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was admitted to the facility in February 2025 with cerebral infarction (stroke) affecting left non-dominant side and need for assistance for personal care. During a record review of the Social Service Director ' s Progress Notes dated 3/7/25, the Progress Notes indicated Resident 1 ' s Responsible Party (RP) informed the facility that a female Certified Nurse Assistant (CNA) was very rough and rude during the care of Resident 1. The Progress Notes also indicated, Resident 1 said . a female CNA came to change her but just removed her blanket and told her to turn to her left side. According to the resident, the CNA was very rough .she got hurt and expressed ' ouch ' .and the CNA said, 'I'm just cleaning you, you want to stay on your shit?' .She also said that the same CNA is always rude to her and her roommate . During an interview on 5/30/25 at 11:40 a.m. with SSD, SSD stated she interviewed Resident 1 with the RP present on 3/7/25. SSD stated during her visit to Resident 1, Resident 1 was not able to recall the details of the incident involving a CNA. SSD stated because Resident 1 was very confused, and could not recall the details of the incident, the complaint was only filed as a grievance and not as an allegation of abuse. SSD stated the incident was reported to the Abuse Coordinator and it was decided that the incident was unfounded because Resdient 1 was confused. SSD stated she knew she was a mandated reporter and she should have considered Resident 1 ' s allegation as a suspected abuse. SSD stated she also did not interview the roommate to verify Resident 1's allegation of abuse. SSD further stated there was no follow up monitoring done for any psychosocial behavior changes on Resident 1. During a concurrent record review and interview on 5/30/25 at 12:02 p.m. with the Director of Staff Development (DSD), SSD ' s Progress Notes dated 3/7/25 was reviewed. DSD stated she considered Resident 1 ' s allegation as a suspected abuse and should have been reported and investigated appropriately. DSD stated it was very important to take the allegation of abuse seriously so that a thorough investigation could be conducted. DSD also stated when a staff was involved in an allegation of abuse, the staff should have been suspended while the investigation was ongoing. During an interview on 5/30/25 at 12:29 p.m. with the Director of Nursing (DON), the DON stated a suspected abuse should have included a thorough investigation, identification of the staff involved, staff suspension, and reporting to state and local agencies should be done immediately or within 23 hours. The DON further stated SSD did not consider the complaint as a suspected abuse because Resident 1 was confused. During a review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Mistreatment- Reporting and Investigating, copyrighted 2001, the P&P indicated, The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing certification agency responsible for surveying/licensing the facility; b. The local/stated ombudsman; .e. Law enforcement officials .'Immediately' is defined as a. within two hours of an allegation involving abuse or result in serious bodily injury .

Based on interview and record review, the facility failed to ensure an allegation of sexual assault was reported to officials that included the State Survey Agency, Office of the Long-Term Care Ombudsman and law enforcement officials within the required timeframe for one of two sampled residents (Resident 1). This failure had the potential to result in the lack of protection for residents alleging abuse. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was admitted to the facility in August 2023 with anxiety disorder and schizophrenic disorder. During an interview on 2/6/25 at 11:01 a.m. with Neurobehavioral Unit Director(NBUD), NBUD stated receiving the report of sexual assault on 2/3/25 from Resident 1's Conservator (RC). NBUD stated an investigation was conducted immediately and after interviews with Registered Nurse (RN) and Certified Nursing Assistant (CNA), the sexual assault could not be substantiated. NBUD also stated the allegation was not reported to the proper authorities because the facility could not establish an accusation from Resident 1. During a review of Resident 1's Behavior Note dated 2/3/25, the Behavior Note indicated Social Services Director (SSD), Director of Staff Development (DSD) and NBUD all went to Resident 1 to discuss Resident 1's allegation of being raped by a staff member. The sexual assault could not be substantiated because Resident 1 could not focus and was randomly talking about other topics and was not able to recall the incident. During an interview on 2/6/25 at 11:25 a.m. with Administrator (Adm), Adm stated Resident 1's sexual allegation against CNA should have been reported to the proper authorities but it was not reported in this case. During a review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Mistreatment- Reporting and Investigating, copyrighted 2001, the P&P indicated, The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing certification agency responsible for surveying/licensing the facility; b. The local/stated ombudsman; .e. Law enforcement officials .'Immediately' is defined as a. within two hours of an allegation involving abuse or result in serious bodily injury .

Based on interviews and record review, the facility failed to provide account statement of residents ' spending, including transaction receipts, timely information on account access and available account balances for 4 out of 4 residents when facility did not notify residents or their conservators of the amount of funds in their personal accounts, track spending or submit quarterly report statements on time. This failure undermined Residents ' Rights to have informed and easy access to their funds for personal purchases they wish to make. Findings: During a review of Resident 1 ' s, Admission Record, printed 10/15/24, the record indicated Resident 1 was admitted to the facility in July 2023 with multiple diagnosis including Malignant neoplasm (cancer) of bladder neck. A review of the Resident 1 ' s Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) MDS, reveals Resident had a BIMS score of 7 which indicated moderately impaired cognitive status. Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). During an interview on 10/22/24 at 10:17 a.m. with Resident 1 ' s Conservator 1, Conservator 1 stated that they send the facility $50.00 every month for Resident 1 to use for personal item expenses. Conservator 1 did not know how much money Resident 1 has in her account or what the funds have been used for. Conservator 1 also stated they have not received the quarterly statement or any itemized receipts from the facility. During a review of Resident 2 ' s, Admission Record, printed 10/15/24, the record indicated Resident 2 was admitted to the facility in September 2021 with multiple diagnosis including Schizophrenia (A mental illness that is characterized by disturbances in thought). A review of Resident 2 ' s MDS section C indicated Resident 2 had a BIMS score of 14 indicating Resident 2 was cognitively intact. During an interview on 10/15/24 at 11:50 a.m. with Resident 2, Resident 2 stated they did know they have money available to them in their personal account to purchase items and they have no knowledge of quarterly reports of fund. During a review of Resident 3 ' s, Admission Record, printed 10/15/24, the record indicated Resident 3 was admitted to the facility in June 2021 with multiple diagnosis including Multiple Sclerosis, MS (A chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). A review of Resident 3 ' s MDS revealed Resident 3 had a BIMS score of 15 indicating Resident 3 was cognitively intact. During an interview on 10/15/24 at 12:00 p.m. with Resident 3, Resident 3 stated they last made purchases around nine months ago when resident requested clothing and received 2 pantsuits. Resident 3 stated that they did not know how much the pantsuits cost and were not given an itemized receipt after the purchase. Resident 3 also stated they have not received a quarterly report of the balance in their personal account and is unaware of how much money they have. During an interview on 10/21/24 at 4:05 p.m. with Resident 3 ' s Conservator (3), Conservator 3 stated she does not receive itemized receipts of Resident ' s purchases and has not received a quarterly report for Resident 3. During a review of Resident 4 ' s, Admission Record, printed 10/15/24, the record indicated Resident 4 was admitted to the facility in November 2021 with multiple diagnosis including Schizoaffective Disorder (A mental illness that can affect thoughts, mood and behavior,) and Parkinson ' s Disease (A progressive disease of the nervous system, marked by tremor, muscular rigidity, and slow, and precise movements).A concurrent review of Resident 4 ' s MDS revealed, Resident 4 had a BIMS score of 6 indicating severe cognitive impairment. During an interview on 10/15/24 at 12:10 p.m. with resident 4, Resident 4 stated they are unaware how much money is in their personal account and they have no recollection of receiving a quarterly report of the spending and subsequent balance in their account. During an interview on 10/16/24 at 12:20 p.m. with Resident 4 ' s Conservator (4), Conservator 4 stated the facility had not sent her a quarterly report in a long time and cannot recall when the last quarterly report was received. Conservator stated that Resident 4 has money to purchase items but does not know or has receipt of what has been purchased. During an interview on 10/15/24 at 12:05 p.m. with Social Worker (SW), SW stated when Resident ' s request an item, the SW will check with the Business Office Manager (BOM) of how much money Resident has in their account and purchases the item. SW stated typically, this is done without Resident ' s feedback and in some cases, for Residents who want designer items, they will get Resident ' s permission before purchasing. Once purchase is completed, the SW will give item purchased to Resident and receipt of purchase to Business Office Manager (BOM). During an interview on 10/15/24 at 1:15 p.m. with Director of Nursing (DON), DON stated some residents have a conservator who manages Residents personal finances. DON stated they provided an itemized list of resident ' s balance of funds for the conserved residents to the conservator. During an interview on 10/15/24 at 1:45 p.m. with Administrator (ADM), ADM stated the Business Office Manager (BOM) handles accounting of Resident ' s personal financial accounts and trusts. Administrators had no knowledge of quarterly reports being issued out to Residents or Resident ' s Conservator. During an interview on 10/21/24 at 3:00 p.m. with BOM, BOM stated that the SW will provide a receipt of purchase and that it will be itemized in resident ' s account. BOM does not provide the receipt to Resident or Conservator. BOM stated that they are behind in sending out the quarterly reports to Conservators and sends the reports by postal mail and not email. BOM was unable to provide receipt of when the Conservator receives quarterly reports and stated the facility does not give the reports or receipts of items purchased to the residents. BOM stated the SW will show them weekly how much they have in their account digitally. A review of the Policy & Procedure titled Management of Resident ' s Funds indicated . Policy Interpretation and Implementation .3. Should the facility manage the resident ' s funds, the facility acts a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the Resident . 3. Should our facility be appointed the resident's representative payee, and directly receive monthly benefits to which the Resident is entitled, such funds are managed in accordance with established policies and Federal/State requirements .5. Copies of financial transactions are managed by the business office.

Based on observations, interviews, and facility policy review, the facility failed to ensure staff prepared and served foods for residents in a sanitary manner. Specifically, staff failed to implement proper hand hygiene practices during meal service to prevent potential cross-contamination. This failure had the potential to affect 115 of 115 residents who received meals from the dietary department. Findings included: Review of a facility policy titled, Food Preparation, dated 2023 (no month specified), revealed, Employees will prepare food in a clean and safe manner to protect residents and staff from foodborne illness. The policy specified, 1. Hands should be properly washed prior to food preparation. Plastic gloves should be worn to avoid direct contact with food, i.e. [id est, Latin for that is] handling ground beef, mixing salads, ready-to-eat foods, etc. [et cetera, and so forth]. Hands must be washed prior to putting on gloves and any glove changes. The policy also indicated, 7. Proper utensils should be used when preparing and serving food. On 03/12/2024 beginning at 12:15 PM, meal service was observed. [NAME] #4 was observed on the meal service line serving foods. She was handling plates and serving utensils with gloved hands. At 12:24 PM, [NAME] #4 left the meal service line and opened the oven door to retrieve a foil package of a grilled cheese sandwich. Without changing gloves or washing hands, [NAME] #4 returned to the meal service line and continued serving food. At 12:25 PM, [NAME] #4 retrieved another foil package of a grilled cheese sandwich from the oven, then returned to the meal service line without washing hands or changing gloves. [NAME] #4 opened the grilled cheese and used her gloved hands to place the sandwich on a plate. [NAME] #4 was then observed plating pasta, and each time she placed a serving on a plate, she touched the pasta with her gloved hands. [NAME] #4 also served meatballs using a serving utensil but then used her gloved hands to place the meatballs more precisely on the plate. [NAME] #4 had not washed hands or changed gloves, despite leaving the meal service line more than once. At 12:59 PM, after retrieving another grilled cheese sandwich, [NAME] #4 performed hand hygiene for the first time and applied new gloves, and continued meal service. At 1:07 PM, [NAME] #4 again left the meal service line to cook a vegetable burger in the microwave. She returned to the meal service line and continued serving food without washing hands or changing gloves. During an interview on 03/13/2024 at 1:36 PM, with translation provided by Dietary Aide #5, [NAME] #4 said she did not recall touching the pasta with her hands during meal service, but she confirmed that she should not touch food items while on the serving line. [NAME] #4 did recall touching the sandwiches after pulling them from the oven and indicated she should have washed her hands and changed her gloves since she handled non-food items. During an interview on 03/13/2024 at 1:44 PM, the Dietary Director stated that staff should use a utensil rather than their hands while plating foods on the meal service line.

Based on observations, interviews, record review, and facility policy review, the facility failed to monitor the implementation of physician prescribed fluid restrictions for 1 (Resident #178) of 3 sampled residents reviewed for nutrition. Specifically, Resident #178, who received renal dialysis, had a physician's order for a 1200 milliliter (mL) fluid restriction each day, and the facility failed to ensure the resident did not routinely exceed 1200 mL of fluids per day. Findings included: Review of a facility policy titled, Encouraging and Restricting Fluids, revised in October 2010, revealed, The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan and/or daily assignment sheet to assess for any special needs of the resident. The policy further specified, Follow specific instructions concerning fluid intake or restrictions. Review of an Admission Record revealed the facility admitted Resident #178 on 12/26/2023 with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/31/2023, revealed Resident #178 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. According to the MDS, the resident required setup or clean-up assistance from staff with eating. Review of Resident #178's comprehensive care plan revealed a Focus area, initiated on 12/27/2023, that indicated the resident needed dialysis related to renal failure. An intervention dated 12/27/2023 directed staff to monitor intake and output. Another Focus area, initiated on 02/01/2024, indicated the resident was at risk for malnutrition. Interventions dated 02/01/2024 directed staff to assist with meals/fluid as needed and to provide the resident's diet as ordered, including an order for fluid restriction of 1200 mL per day. Review of Resident #178's Order Summary Report revealed an active order dated 01/24/2024 for a consistent carbohydrate renal diet, regular texture, with a fluid restriction of 1200 mL. Another active order, dated 03/13/2024, indicated of the 1200 mL fluids each day, dietary was to provide 600 mL and nursing was to provide 600 mL. Review of Resident #178's FLUID INTAKE documentation for the timeframe from 02/12/2024 through 03/11/2024 revealed 15 days during which the resident consumed over 1200 mL of fluids: - 02/12/2024 - 650 mL, 360 mL, and 240 mL, for a daily total of 1250 mL; - 02/13/2024 - 720 mL, 500 mL, and 240 mL, for a daily total of 1460 mL; - 02/14/2024 - 980 mL and 588 mL, for a daily total of 1568 mL; - 02/19/2024 - 360 mL, 980 mL, and 240 mL, for a daily total of 1580 mL; - 02/20/2024 - 980 mL and 580 mL, for a daily total of 1560 mL; - 02/21/2024 - 360 mL, 840 mL, and 120 mL, for a daily total of 1320 mL; - 02/25/2024 - 480 mL and 1280 mL, for a daily total of 1760 mL; - 02/26/2024 - 240 mL, 980 mL, and 480 mL, for a daily total of 1700 mL; - 02/28/2024 - 120 mL, 840 mL, and 480 mL, for a daily total of 1440 mL; - 03/03/2024 - 360 mL, 280 mL, and 590 mL, for a daily total of 1230 mL; - 03/04/2024 - 240 mL, 1000 mL, and 360 mL, for a daily total of 1600 mL; - 03/05/2024 - 240 mL, 860 mL, and 240 mL, for a daily total of 1340 mL; - 03/09/2024 - 480 mL, 680 mL, and 580 mL, for a daily total of 1740 mL; - 03/10/2024 - 300 mL, 980 mL, and 300 mL, for a daily total of 1580 mL; and - 03/11/2024 - 200 mL, 960 mL, and 480 mL, for a daily total of 1640 mL. During an observation on 03/13/2024 at 9:32 AM, Resident #178 had a pitcher of water at their bedside. During an interview on 03/13/2024 at 11:21 AM, Resident #178 said no one had spoken to them regarding the amount of fluid they were allowed to drink each day. Resident #178 said they kept a thermal pitcher in their room full of water to drink at their leisure. During an interview on 03/13/2024 at 11:11 AM, Certified Nursing Aide (CNA) #9 stated she was not aware of any of her assigned residents having fluid restrictions. CNA #9 revealed each resident's fluid intake was documented in their electronic health record daily. Later in the interview, CNA #9 stated she was aware that Resident #178 was on a fluid restriction. However, she did not know the amount of the resident's fluid restriction. During an interview on 03/13/2024 at 1:10 PM, Registered Nurse (RN) #7 stated she asked Resident #178 how many cups of water they drank and documented the amount Resident #178 told her. RN #7 did not know who provided the thermal pitcher of water to Resident #178, but stated the resident did not always drink the entire pitcher of water. RN #7 said Resident #178 was allowed to have up to 1200 mL of fluids per day. After reviewing fluid intake documentation for Resident #178, RN #7 could not explain why the resident exceeded the ordered fluid restriction of 1200 mL per day. During an interview on 03/13/2024 at 1:22 PM the Director of Nursing (DON) stated the Dietary Director had provided Resident #178 with the thermal water pitcher. The DON stated the water pitcher was provided to the resident each day. During an interview on 03/14/2024 at 10:09 AM, the Dietary Director stated Resident #178's fluid restriction was not reflected on their meal tickets until the surveyor inquired about fluids. The Dietary Director said Resident #178 was provided a 1.8 liter (1800 mL) thermal water pitcher upon the resident's request. The Dietary Director stated Resident #178 was drinking less than half of the pitcher, but they were not monitoring the amount that was consumed by the resident. During an interview on 03/14/2024 at 10:26 AM, the DON stated she expected orders for fluid restrictions to be carried out, monitored, and communicated with different departments. During an interview on 03/14/2024 at 11:38 AM, the Administrator stated his expectation was for orders for fluid restrictions to be followed and documented in the resident's electronic health record.

Based on interviews, record review, and facility document and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for 1 (Resident #45) of 5 sampled residents reviewed for PASRR requirements. Specifically, the facility failed to ensure a Level I PASRR Screening was resubmitted when Resident #45 remained in the facility longer than 30 days. Findings included: A review of a facility policy titled, Admission Criteria, revised in March 2023, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The acute hospital performs a Level I PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for a MD, ID, or RD. The policy further indicated, 11. The state may choose not to apply the preadmission screening requirement if: a. the individual is admitted directly to the facility from a hospital where he or she received acute inpatient care; b. the individual requires facility services for the condition for which he or she received care in the hospital; and c. the attending physician has certified (prior to admission) that the individual will likely need less than 30 days of care at the facility. A review of Resident #45's Admission Record revealed the facility admitted the resident from a hospital on 11/21/2023 with diagnoses that included schizophrenia, bipolar disorder, and anxiety disorder. A review of Resident #45's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 11/21/2023, revealed Resident #45 was exempt due to a 30-day Exempted Hospital Discharge. A review of an associated letter from the Department of Health Care Services regarding the results of the resident's Level I PASRR, dated 11/21/2023, revealed, If the individual remains in the NF [nursing facility] longer than 30 days, the facility should resubmit a Level I Screening as a Resident Review on the 31st day. There was no documented evidence the facility submitted another Level I PASRR for Resident #45 when the resident's stay at the facility exceeded 30 days. A review of Resident #45's Care Plan revealed a Focus area, initiated on 11/22/2023, that indicated the resident was at risk for decreased psychosocial wellbeing, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, and adverse effects on function. The Focus area also indicated Resident #45 was at risk for mental, physical, social, and spiritual wellbeing related to feeling down, depressed, or hopeless due to a diagnosis of schizophrenia. A review of Resident #45's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/22/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) of 7, indicating the resident had severe cognitive impairment. According to the MDS, at the time of the assessment, Resident #45 had active diagnoses of anxiety disorder, bipolar disorder, and schizophrenia and received antipsychotic and antianxiety medications. During an interview on 03/13/2024 at 12:26 PM, the MDS Nurse confirmed Resident #45's PASRR should have been resubmitted. During an interview on 03/14/2024 at 9:56 AM, the Director of Nursing (DON) stated Resident #45's PASRR should have been resubmitted. During an interview on 03/14/2024 at 10:22 AM, the Administrator stated that if the facility was instructed to resubmit a Level I PASRR Screening, the PASRR should have been resubmitted within the timeframe specified.

Based on record review and interviews, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 2 (Resident #2 and Resident #86) of 24 sampled residents. Specifically, the facility failed to ensure Resident #2's visual status and Resident #86's nutritional status was accurately reflected on each resident's MDS assessment. Findings included: On 03/14/2024 at 12:18 PM, the MDS Nurse stated the facility followed the Centers for Medicare and Medicaid Services Resident Assessment Instrument (RAI) Manual for MDS assessments and did not have an MDS policy. 1. Review Resident #2's Admission Record revealed the facility admitted Resident #2 on 09/12/2005 with diagnoses that included legal blindness. Review of Resident #2's Care Plan revealed a Focus area, last revised on 02/08/2018, that indicated the resident had impaired visual function related to being legally blind. The care plan indicated the resident was able to see large print in a well-lit room and required large print books as a visual aid. Interventions instructed staff to ensure appropriate visual aids were available to support the resident's participation in activities and to identify and record factors affecting visual function, including physiological and environmental factors and the resident's choices. Review of a quarterly MDS, with an Assessment Reference Date (ARD) of 01/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #2's vision was adequate (saw fine detail, such as regular print in newspapers/books). During an interview on 03/13/2024 at 12:27 PM, the MDS Nurse stated the information for the MDS came from the resident's electronic health record, their chart, and hospital records. She stated the MDS was completed by the interdisciplinary team member responsible for their section, and each person was accountable for their section. After reviewing Resident #2's record, she stated the resident had a diagnosis of being legally blind and confirmed that the resident's visual status was not captured correctly on the MDS. She stated a nurse and the social worker completed the hearing, speech, vision section of the MDS and was unsure why the resident's impaired vision was not captured. During an interview on 03/14/2024 at 9:12 AM, the Director of Nursing (DON) stated the information for the MDS should come from the residents' assessments and hospital records. She stated each department was responsible for their section of the MDS and its accuracy, and the MDS Nurse was responsible for ensuring the MDS was accurate. The DON stated if a resident was blind it should be captured on the MDS. She confirmed that Resident #2 was blind and that the resident's MDS was inaccurately coded. During an interview on 03/14/2024 at 12:07 PM, the Administrator stated the MDS should be accurate and reflect the resident's true condition. He stated the MDS Nurse was responsible for the overall accuracy of the MDS. 2. A review of Resident #86's Admission Record revealed the facility admitted the resident on 06/03/2022 with diagnoses that included dysphagia (difficulty swallowing). Review of a quarterly MDS, with an Assessment Reference Date (ARD) of 11/21/2023, revealed Resident #86 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #86 received parenteral (method of administering medication or nutrients that bypasses the digestive system)/intravenous feeding and had a feeding tube while a resident at the facility. Review of Resident #86's Order Summary Report, listing active orders as of 03/14/2024, revealed an order started on 07/24/2023 for a mechanical soft, ground texture diet and thin consistency liquids. The Order Summary Report did not reflect any orders for parenteral/intravenous feedings or a feeding tube. During an interview on 03/13/2024 at 12:27 PM, the MDS Nurse stated the information for the MDS came from the resident's electronic health record, their chart, and hospital records. She stated the MDS was completed by the interdisciplinary team member responsible for their section, and each person was accountable for their section. She stated Resident #86 did not have a feeding tube and the person that completed that section of the MDS clicked on the wrong button when completing the form. During an interview on 03/13/2024 at 8:52 AM, the Dietary Director stated she was responsible for completing the dietary section of the MDS and that the Director of Nursing (DON) brought the incorrect MDS coding to her attention. She stated she did not realize she had been coding that section of the MDS incorrectly. During an interview on 03/14/2024 at 9:12 AM, the DON stated the information for the MDS should come from the residents' assessments and hospital records. She stated each department was responsible for their section of the MDS and its accuracy, and the MDS Nurse was responsible for ensuring the MDS was accurate. During an interview on 03/14/2024 at 12:07 PM, the Administrator stated the MDS should be accurate and reflect the resident's true condition. He stated the MDS Nurse was responsible for the overall accuracy of the MDS.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure an order for oxygen use was transcribed into the electronic health record (EHR) for 1 (Resident #178) of 1 sampled resident reviewed for respiratory care. Findings included: A review of a facility policy titled Telephone Orders, revised in February 2014, revealed Verbal telephone orders may be accepted from each resident's Attending Physician. The policy specified, Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. A review of an Admission Record revealed the facility admitted Resident #178 on 12/26/2023. According to the Admission Record, the resident had a medical history that included diagnoses of end stage renal disease, malignant neoplasm of the rectum, anemia, and pneumonia. A review of Resident #178's comprehensive care plan revealed a Focus area, initiated on 01/08/2024, that indicated the resident required the use of intermittent oxygen related to shortness of breath. A review of a handwritten Comprehensive Physician's Order Sheet For: Telephone/Standing/Clarified Orders, dated 01/24/2024, revealed an order for Resident #178 to receive oxygen. However, review of Resident #178's Order Summary Report, generated from the resident's EHR, revealed the order for oxygen use was not transcribed until 03/12/2024, during the survey. A review of Resident #178's Treatment Administration Record and Medication Administration Record for February 2024 and March 2024 revealed no documentation related to the administration of oxygen. An observation of Resident #178 on 03/11/2024 at 10:55 AM revealed the resident's oxygen concentrator was infusing oxygen at a rate of 5 liters per minute (LPM). An observation on 03/11/2024 at 1:51 PM revealed Resident #178's oxygen concentrator was infusing oxygen at a rate of 4.5 LPM. An observation on 03/12/2024 at 8:15 AM revealed Resident #178's oxygen concentrator was infusing oxygen at a rate of 4.5 LPM. During an interview on 03/12/2024 at 9:31 AM, Registered Nurse (RN) #7 reviewed Resident #178's EHR and stated there was no current order for oxygen for the resident. She stated there was a telephone order dated 01/24/2024 for the resident to receive oxygen; however, the order was not transcribed to Resident #178's active physician's orders. During an interview on 03/14/2024 at 10:34 AM, the Director of Nursing (DON) said Resident #178 was previously transferred out of the facility and after their return, the order for oxygen use was not transcribed into the system as an active order.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to maintain a complete skin assessment that is accurately documented. This failure had the potential to result in lack of coordination of care among healthcare practitioners and delayed management of skin issues. Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (blood sugar levels are too high) and congestive heart failure (heart is unable to pump oxygen-rich blood to meet the body's needs). Resident 1 was discharged from the facility on 4/5/23. [Reference:https://medical-dictionary. com]. During review of Resident 1's Nursing -Admission/Readmission Assessment, dated 2/27/23, the assessment indicated, under Body Assessment, Resident 1 had a left anterior foot sore that measured 7 centimeters (cm) x 5 cm. Resident 1 had other skin conditions that included, the front side of the right and left lower leg had scars and scattered sores and there was yellowish mild pus noted on the right anterior sore. During review of the IDT(Interdisciplinary Team, a group composed of individuals representing different departments of the facility) Conference Notes dated 2/28/23, the notes indicated, Resident 1 had a bilateral lower leg abrasion and wound care will be provided to the bilateral lower extremities abrasion. During review of Progress Notes dated 2/8/23, the notes indicated another skin assessment on 2/7/23, to clarify that it was Resident 1's right dorsal foot (top part of the foot) that had an abrasion instead of the left foot as indicated in the Nursing Admission Assessment. The assessment further clarified there were no open areas on the left lower extremity as indicated in the IDT Conference Notes and Nursing-Admission/Readmission Assessment. During an interview and concurrent review of the clinical record, on 4/12/23 at 10:39 a.m., with Assistant Director of Nursing (ADON), ADON stated, Resident 1 had scars and scattered sores on the right and left lower leg. The clinical record did not indicate a skin assessment during Resident 1's discharge on 4/5/23. A review of Resident 1's discharge notes was requested. During review of Resident 1's clinical record, on 4/12/23 at 11: 20 a.m., while waiting for ADON to show documentation of Resident 1's skin status during discharge, a late entry was entered in Resident 1's Progress Notes electronic record. During an interview and concurrent review of Resident 1's clinical record with Treatment Nurse (TN), on 4/12/23 at 11:22 a.m., TN stated she had just entered a late entry dated 4/5/23 to indicate Resident 1's skin during discharge and stated the documentation was not previously in the progress notes. TN also stated she had to clarify the site of the open areas because the admitting nurse made a mistake. TN also stated skin sheets for open areas/abrasions were not in the medical record as skin assessments were only done if there were any changes noted and were not done routinely. Review of the Medical Practitioner Narrative Note dated 3/20/23 indicated a physical examination was done by the practitioner on Resident 1. Under Exam, lower extremities were observed for any swelling, under Skin, the notes indicated to see Skin Sheet. During an interview with ADON , on 4/12/23 at 11:57 a.m., ADON stated there were no skin sheets in Resident 1's medical record. ADON also stated, weekly wound rounds log (skin sheets) were completed only for pressure ulcers but not for abrasions like Resident 1 had. ADON also stated daily skilled charting by the charge nurses did not have skin assessments in them because it was the wound nurse (treatment nurse) that did skin assessments. During a telephone interview, on 5/11/23 at 1:55 p.m., with Registered Nurse (RN) 1, RN 1 stated, when Resident 1 was discharged on [DATE], RN 1 performed a quick assessment and noted there was a 4 x 4 dressing on Resident 1's foot. RN 1 stated she thought Resident 1 might have a wound or maybe a little skin tear on the foot . RN 1 further stated she did not remove the dressing to do a thorough assessment, and did not know what Resident 1 had on the lower extremities because the facility had a treatment nurse who was expected to do this task. Review of Resident 1's Discharge Summary written by RN 1 did not indicate an assessment of Resident 1's skin status during discharge.

Based on observation, record review and interview, the facility failed to post nurse staffing data. This deficient practice prevented residents and visitors from receiving information about the number of nursing personnel available to provide direct care to residents. Findings: During a concurrent observation and interview on 5/17/21 at 11:55 a.m., with the Infection Preventionist (IP), the IP stated the current daily staffing numbers were not posted as she had not completed the calculations for day shift yet. The facility document titled, Posting Direct Care Daily Staffing Numbers, revised 7/16, indicated For each shift, the number of licensed Nurses (RNs [registered nurses], LPNs [licensed practical nurses]. And LVNs [licensed vocational nurses]) and the number of unlicensed nursing personnel (CNAs [certified nurse assistants]) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observation, interview, and record review, the facility failed to protect one (Resident 1) of four sampled residents from physical abuse when Certified Nursing Assistant 2 (CNA 2) used Resident 1's reacher (a metal rod with a handle at one end and prongs that open to grab objects at the other end) to hit her. This deficient practice resulted in Resident 1 obtaining bruises on her body and feeling scared in her living environment. Findings: According to Resident 1's Face Sheet, dated 9/19/18, Resident 1 was admitted to the facility on [DATE]. Review of the Minimal Data Set (MDS - an assessment tool), dated 11/21/17, Section B indicated Resident 1 had clear speech, was able to make herself understood, and had the ability to understand others. During an interview with Resident 1 on 9/19/18, at 11:13 a.m., Resident 1 stated she was in bed when CNA 2 came into her room and took cookies from her bedside table, even though Resident 1 told her not to take them. Resident 1 stated she grabbed her reacher and hit CNA 2's arm. Resident 1 stated CNA 2 grabbed the reacher from Resident 1 and hit her two-to-three times on her right leg and left arm. Resident 1 stated she felt pain. Resident 1 further stated she felt scared and nervous being in the facility after CNA 2 hit her because something might happen to her. During an interview with Certified Nursing Assistant 3 (CNA 3) on 9/19/18, at 12:45 p.m., CNA 3 stated that on 9/11/18 she went into Resident 1's room to ask for some cookies to give to her own resident since the kitchen was closed. CNA 3 stated that Resident 1 said no to the request to share her cookies with the other resident. CNA 3 then stated that CNA 2 came into Resident 1's room and said, No, you're gonna give her some crackers (cookies). CNA 3 stated CNA 2 reached over and grabbed some cookies off of Resident 1's bedside table. CNA 3 stated Resident 1 told CNA 2 no as CNA 2 approached her. CNA 3 stated Resident 1 then picked up her reacher and started hitting CNA 2. CNA 3 stated CNA 2 snatched the reacher out of Resident 1's hand and hit Resident 1 three-to-four times. During a telephone interview with CNA 2 on 9/19/18, at 1:10 p.m., CNA 2 stated she was not assigned to Resident 1 the evening of the incident (9/11/18), but had taken care of Resident 1 in the past. CNA 2 stated while she was trying to take the reacher away from Resident 1, the reacher itself may have come into contact with Resident 1. CNA 2 stated she did not intentionally try to hit or hurt Resident 1. During a telephone interview with the Unit Manager (UM) on 9/21/18, at 2:21 p.m., the UM stated CNA 2 told her she accidentally hit Resident 1 with the reacher. The UM stated CNA 3 had witnessed the incident, and CNA 3 said CNA 2 deliberately hit Resident 1. The UM stated when she evaluated Resident 1 after the incident, she noted a red mark on her right upper leg, her shoulder, and left upper arm. The UM stated a few days after the incident, Resident 1 told her I'm scared. Somebody might hit me. During an observation and concurrent interview with Licensed Vocation Nurse 1 (LVN 1), on 9/19/18, at 1:55 p.m., Resident 1's right upper thigh was deep purple in color, and tender to touch. When asked, LVN 1 measured the bruise on Resident 1's right upper thigh which measured 6 centimeters (cm) in length and 0.5 cm in width. Resident 1's left upper arm showed no redness, swelling, or tenderness to touch. Review of a form titled, .Nursing - Body Assessment, dated 9/11/18, at 11:38 p.m., indicated Resident 1 had redness to right thigh measuring 10 cm in length and 0.3 cm in width. During an interview with the Social Services Director (SSD) on 9/19/18, at 1:17 p.m., the SSD stated he interviewed Resident 1 on 9/12/18 between 11 a.m. and 1 p.m. and he had followed up with Resident 1 twice since the incident. The SSD stated Resident 1 had trouble sleeping since the incident, and was fearful about CNA 2 coming back to facility. Review of the facility's Policies and Procedures (P&P) titled, Abuse Prevention, dated 12/31/15, indicated .Each resident has the right to be free from verbal, sexual, physical, and mental abuse .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff

Based on interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent an accident when Certified Nurse Assistant (CNA) 1 and CNA 2 transferred one of five sampled residents (Resident 1) without using an E-Z stand lift or a Hoyer lift (mechanical devices used to lift people). This deficient practice resulted in Resident 1 sustaining a painful fractured (broken bone) right tibia (anklebone), a fractured right fibula (anklebone). Findings: Review of the Resident Face Sheet, dated 8/30/17, indicated Resident 1 was initially admitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS - an assessment tool used to guide care), dated 4/24/17, indicated Resident 1's decision making ability was severely impaired. The MDS also indicated Resident 1 required extensive assistance of two plus persons when transferring to and from bed to wheelchair. Further review of the MDS indicated Resident 1's active [DIAGNOSES REDACTED]. During an interview with CNA 1 on 8/30/17 at 12:22 p.m., CNA 1 stated she and CNA 2 transferred Resident 1 from the wheelchair to the bed on 8/20/17 manually (without a mechanical lift). CNA 1 stated she was on the left side of Resident 1 and CNA 2 was on the right side of Resident 1. CNA 1 stated she and CNA 2 each placed one hand under the armpits of Resident 1, placed their other hands on the back of Resident 1's pants and lifted her from the wheelchair to a standing position. CNA 1 stated she and CNA 2 then guided Resident 1 to the bed. CNA 1 stated after Resident 1 was in bed, CNA 1 removed Resident 1's pants, changed her wet undergarment, and then Resident 1 stated cut my leg off, it hurts. CNA 1 stated she received training on how to use the lifts before the incident, and she was aware Resident 1 required a mechanical lift for transferring. During an interview with CNA 2 on 8/30/17, at 12:44 p.m., CNA 2 stated on 8/20/17 CNA 1 asked her to assist with transferring Resident 1 from wheelchair to bed. CNA 2 stated she and CNA 1 did not use a Hoyer lift or an E-Z stand lift to transfer Resident 1. CNA 2 stated she and CNA 1 put their hands under Resident 1's armpits, their other hands held the back of Resident 1's pants and lifted her from the wheelchair to a standing position. CNA 2 stated she kicked Resident 1's wheelchair out of the way and she and CNA 1 turned Resident 1 until the back of her legs touched the bed. CNA 2 stated she and CNA 1 assisted Resident 1 to a sitting position. CNA 2 stated she was not sure if Resident 1's feet moved when she was turned. CNA 2 stated Resident 1 complained of leg pain after she sat on the bed. Review of Resident 1's care plan Risk for falls, initiated on 1/5/15 and revised on 7/20/17, indicated Resident 1 was Only transfer(ed) with a Hoyer or EZ lift. Review of the facility's Transfer Levels For All Residents document, dated 8/14/17, indicated Resident 1's Level of assistance/mode of transfer was Hoyer, EZ stand. Review of the facility's investigation summary, dated 8/24/17, indicated CNA 1 and CNA 2 did not use an E-Z stand lift to transfer Resident 1, and this resulted in Resident 1 receiving a fracture on her ankle. During an interview with Registered Nurse (RN) 1 on 8/30/17, at 2:09 p.m., RN 1 stated on 8/20/17, stated CNA 1 informed her Resident 1 was yelling cut off my legs. RN 1 stated Resident 1 was grabbing her legs and complaining of pain when she entered the room. RN 1 stated she assessed Resident 1's feet and legs. RN 1 stated she noticed Resident 1 had a skin tear on her right shin (front part of lower leg). RN 1 also stated Resident 1 complained of pain when RN 1 touched Resident 1's right ankle. RN 1 further stated she notified the physician. Review of Resident 1's Progress Notes (Notes), dated 8/21/17, at 7:37 a.m., indicated Resident 1's right foot was twisted to an outward position from the ankle. The notes also indicated Resident 1 had swelling at the ankle and foot. The Notes further indicated Resident 1 was transferred to the acute care hospital for the evaluation and treatment of [REDACTED]. Review of the acute care hospital X-Ray report, dated 8/21/17, indicated Resident 1 sustained a fracture of her right tibia and fibula bones. Review of the facility's policy and procedure titled Full Body Transfer, dated 8/3/11, indicated .The full body transfer is a multi-person procedure usually used in emergencies under the supervision of a licensed nurse. (The facility) discourages the practice of manual body lifts for the safety of the staff and patients and only should be done in extreme circumstances. Use of mechanically lifts are preferred

Based on observation, interview, and record review, the facility failed to provide supervision to prevent accidents when Certified Nursing Assistant (CNA) 1 attempted to transfer Resident 1 twice in the same day without the assistance of a second staff person. This failure resulted in Resident 1 falling in the morning (and falling a second time 30 minutes later) and sustain a fracture to the fibula (the long, thin and lateral bone of the lower leg) and tibia (also known as the shin bone, runs parallel to the fibula, and plays a significant role in stabilizing the ankle and supporting the muscles of the lower leg). Findings: Review of Resident 1's Admission Record, dated 3/27/17, indicated Resident 1 was readmitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set, (MDS - an assessment tool used to guide care) dated 1/31/17, indicated Resident 1 required extensive physical assistance of two persons to use the toilet. The MDS also indicated Resident 1 required extensive physical assistance of one person to transfer from bed to wheelchair. Review of Resident 1's Care Plan, initiated on 5/9/17 (and last revised 3/7/17), indicated Resident 1 had the potential for falls due to poor communication/comprehension, poor safety awareness, and impulsivity (doing things suddenly and without careful thought). The Care Plan also indicated Resident 1 had history of multiple falls. Review of Resident 1's Fall Risk Assessment Tool, dated 3/19/17, indicated Resident 1 had a fall risk score of 9 (4 or more is considered at risk for falling) and was a fall risk. During an interview with Resident 1 on 4/13/17, at 1:54 p.m., Resident 1 stated she grabbed the rail, as CNA 1 pulled her pants up, but Resident 1's knee buckled. Resident 1 also stated she went down on her left leg, which was her weak side. During an interview with Registered Nurse (RN) 1 on 5/19/17, at 1:20 p.m., RN 1 stated that on March 2017 (during change of shifts between 7-7:30 a.m.), CNA 1 rushed to the nursing station and stated Resident 1 was assisted to the floor. According to RN 1, CNA 1 stated she tried to help the resident to the commode, but Resident 1 became weak and was assisted down to the floor. RN 1 stated Resident 1 had left-sided weakness and questioned why CNA 1 transferred Resident 1 without help. RN 1 further stated they (he and CNA 1) put Resident 1 back onto the commode and instructed CNA 1 not to leave resident alone while Resident 1 was in the toilet. RN 1 stated at 7:30 a.m., CNA 1 returned to the nursing station and told him Resident 1 had fallen the second time in the bathroom. RN 1 went inside the room to the toilet and found Resident 1 lying flat on the floor. According to RN 1, CNA 1 told him that Resident 1 grabbed on to the rail while she helped the resident put her pants back on, Resident 1 turned around, let go of the metal rail, and fell . RN 1 stated he and three other staff assisted Resident 1 back to the wheelchair, transferred the resident to bed, and that was when RN 1 stated he noted Resident 1's left leg was not aligned. RN 1 further stated Resident 1 was sent via 911 to the hospital for evaluation. Review of Resident 1's hospital Emergency Department (ED) visit, dated 3/25/17, indicated Resident 1 had discharge [DIAGNOSES REDACTED]. Resident 1 was discharged with a cast on the left lower leg. Review of the facility's policy titled NCD Accidents and Supervision to Prevent Accidents Definitions, dated 8/31/12 indicated, .Avoidable Accident means that a resident had an accident and the facility failed to: .3. Implement interventions, including adequate supervision, consistent with resident needs, goals, plan of care, and recognized standards of practice in order to reduce the risk of an accident

Based on observation, interview, and record review the facility failed to provide one of three sampled residents (Resident 1) with an assistance device to prevent accidents when Certified Nursing Assistant (CNA) 1 served Resident 1 hot tea in a lightweight foam cup. This failure resulted in Resident 1 spilling the hot tea and sustaining a second degree burn (involves the first two layers of skin and may appear as deep, reddening, and blistering of the skin) on the inside of her elbow. Findings: Review of the Face Sheet, (a document that gives a resident's information at a quick glance) dated 3/1/17, indicated Resident 1 was a [AGE] year old admitted to the facility with multiple [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool which guides care), dated 12/29/16, indicated that Resident 1 had severe mental cognition (did not have the ability to reason or remember clearly). Review of the Care Plan, dated 1/1/17, indicated Resident 1 was .at risk for injury (related to) getting hot water in the kitchen or sink for her tea. Resident is non-compliant with it. Resident only wants only xyloform (a type of Styrofoam) cups .staff (were) to assist resident in getting warm water instead of hot water During an interview with CNA 1, on 3/3/17 at 1:20 p.m., CNA 1 stated Resident 1 liked her water really hot and will throw the cup of water at us if it is not hot enough. CNA 1 stated she brought Resident 1 tea on 3/1/17, but the resident said the water was too cool. During a telephone interview with CNA 2, on 3/6/17, at 2 p.m., CNA 2 stated Resident .does not like it (tea) warm, she wants is very hot or she will throw it at me. I use a big Styrofoam cup and put it on her tray with breakfast .she (Resident 1) throws something every day During an interview with the Director of Nursing (DON) on 3/3/17, at 12:50 p.m., the DON stated Resident 1 had a long history of aggressive behavior and throwing her meal trays. The DON stated Resident 1 would only use a large foam cup and requested the water to be very hot for her tea. The DON stated Resident 1 would throw the cup with water at the CNAs if the water was not hot enough. During an interview with the DON, on 3/3/17, at 12:50 p.m., the DON stated that Resident 1 had a two centimeter (cm) by two cm burn blister on her arm. Review of the Health Status Note, dated 3/1/17, at 9:45 a.m. indicated Resident 1 .spill hot water on herself and burn her right forearm . Review of the Weekly Skin Alteration Report, dated 3/1/17, at 11:43 a.m. indicated .D. Assessment/Careplan Summary 1a. Summary of Care and treatment of [REDACTED]. She was given hot water this morning by CNA and assisted to make the tea with lemon before CNA left the room. After a few minutes staff heard yelling in her room and rushed into room. Charge nurse notice the cup on the floor and resident was complaining of discomfort in her right antecubital. First degree burn noted Review of the Treatment Administration Record, dated March 2017, indicated Resident 1 had physician's orders [REDACTED].

Based on observation of the Neurological Behavioral Unit (NBU), interview of the staff and review of records and the policy titled, "Accident / Hazard Risk Assessment", the facility failed to follow its own policy and procedure for securing sharp objects for 1 of 24 sampled residents and one randomly sampled residents (27) by allowing Resident 18 to handle and have in his possession a screwdriver without supervision in presence of Resident 27 who has history of violent behaviors. 1. For one sampled resident (18) and one random resident (27), the facility failed to ensure that personal items brought into the facility would not endanger the safety of the residents, by failing to remove a screwdriver from Resident 18's possession. 2. The sliding door on Station 4 was missing and replaced with plywood. 3. Loose metal drain with ragged edges and a broken plastic soap box with sharp edges in Shower Room 4 4. A metal butter knife and two soda cans with sharp openings were found in an unlocked cabinet in the (NBU) These failures placed all residents on the unit at risk for harm and was determined to constitute an Immediate Jeopardy. After consultation with HFEN supervisor, the Executive Director was notified of the IJ on August 22, 2013, at 11:55 a.m. by the survey team. The surveyors confirmed by interview, observation, and record review that the screwdriver was removed and a plan of correction detailing a room by room search for sharp objects was initiated by the management team. The AA was immediately in-serviced on prevention of accidents and hazards, and in-services were scheduled for all unit staff regarding accidents hazard prevention. In the presence of the team and the Executive Director, the IJ was abated on August 22, 2013 at 3:50 p.m. Findings: 1. During an observation tour of the NBU (a unit for residents with neurologically based behavioral disturbances) on 8/19/13 at 9 a.m.,a code was required to open the locked doors to enter. The doors could be pushed open to exit and were not locked from that direction. However, an alarm would sound if the doors were opened without entering the code. It was further observed that Resident 18 resided in a room, approximately 12 feet from the unit entrance door. Review of the clinical record, on 8/22/13, showed that Resident 18 was admitted with multiple [DIAGNOSES REDACTED]. A Psychology Progress Note, dated 7/8/13, indicating that "When emotionally aroused (the resident) can become easily angry and frustrated seemingly without an awareness about what he is currently feeling. In the past irritability has prompted physically aggressive behavior." A behavior monitoring flow sheet for July 2013 showed Resident 18 had eight episodes of being verbally abusive behavior. For the period of August 1 through 21, 2013, Resident 18 had two episodes of irritability. During an interview, on 8/22/13 at 11:30 a.m., Licensed Vocational Nurse (LVN) 2 stated when Resident 18 became irritable; he became loud and came out of his room pacing the hallway. LVN 2 stated that the staff was concerned for Resident 18 striking out at anything in his way. Resident 18's Care Plans (a document with measurable objectives and timeframes to meet residents' physical, mental, and psychosocial needs) included the following problems/concerns that were being monitored through 8/13: 1) Risk for violence towards peers and staff related to history of assaultive behavior, Psychiatric Diagnosis, inability to cope, impulsivity, and territorial 2) Cognitive Patterns/Communication: alteration in thought process; unable to anticipate consequences of behavior 3) Behavior with identified behaviors which included assaultive, threatening behavior, easily annoyed aggression and [DIAGNOSES REDACTED]." The clinical record for Resident 18's roommate (Resident 27) was reviewed on 8/22/13. He was admitted with multiple [DIAGNOSES REDACTED]. His Care Plans showed among others, the following problems/concerns for mood and behavior: Mood swings, Bi-polar Disorder (a brain disorder that causes unusual shifts in mood, energy, and activity levels), poor impulse control, delusions, hallucinations and plans to stop physical and verbal abuse toward others. The August 2013 behavior monitoring flow sheet for Resident 27 showed 40 episodes of hallucinations during day shift, 25 on evening shift and 19 on night shift. There were 35 delusional episodes on day shift, 34 on evening shift and 31 on the night shift. Nurses' notes, dated 8/20/13, showed Resident 27 had previously hit nurses at another facility. During an interview, and concurrent observation, on 8/22/13 at 9:35 a.m., with the Activities Assistant and Resident 18, Resident 18 was sitting on the side of his bed and stated that he was trying to fix his model car. He displayed an approximately 3 inch long screw driver. He stated that the Activities Assistant (AA) had assisted him in repairing the model car. Resident 27, who was Resident 18's roommate, was reclining in his bed and appeared to be sleeping at the time. During an interview, on 8/22/13 at 9:40 a.m., The AA confirmed that he had assisted Resident 18 to unscrew the battery pack door with the screwdriver, and that the screwdriver was included in the model car kit. When asked if it was okay for the resident to have the screw driver, the AA responded that the kit had been brought in by Resident 18's mother. The AA was again asked if it was okay for the resident to have the screw driver and responded, "I guess we should take it from him." During a follow-up interview, on 8/22/13 at 11:00 a.m., the AA stated that he had been aware of Resident 18 having the battery operated car for 2 months. He further stated the residents were not allowed to have scissors or sharp objects without being supervised, during activities that involved use of scissors or glue, each resident involved with the activity was monitored individually by an activities assistant. A Record review, on 9/9/13, of the AA's employee file included a Performance Improvement Form dated 8/23/13 indicating that the AA had been given a written warning for "Not confiscating (an) unsafe sharp item from (a) resident at time of discovery." During an interview, on 8/22/13 at 9:50 a.m., the Charge Nurse (LVN 1) stated that he was not aware that Resident 18 was in possession of a screw driver or a model car kit. He went on to say that as a rule, whenever a resident's family brought in anything for the resident, the Charge Nurse was to be notified and the items checked to make sure nothing inappropriate was brought in for the resident. During an interview, on 8/22/13 at 9:55 a.m., the Director of Nursing (DON) stated that she was not aware that Resident 18 had a screw driver. The DON stated that residents on the NBU should not have screw drivers. During an interview, on 9/9/13 at 2:35 p.m., LVN 6 stated she had oriented new staff to the NBU in the past. She further stated that her orientation included the process for visitors bringing in food or other items to the residents. According to LVN 6, visitors were to check in at the receptionist desk at the facility's front entrance. Any visitor bringing bags or new items would have them checked at the door as they entered the unit or be directed to a nurse at the nurses' station to have them checked. In an interview with LVN 5, on 9/9/13 at 2:40 p.m., she stated that she had oriented staff to the NBU in the past. LVN 5 validated the information that LVN 6 gave about visitors and items brought into the NBU. LVN 5 added that any new items brought in for the residents should be added to the resident's inventory sheet. The facility's policy titled, "Resident Personal Belongings" dated 9/1/10, showed that a personal belongings inventory sheet for each resident should be completed upon admission and updated as needed with personal belongings added and/or removed throughout the residents stay. A review of Resident 18s personal inventory sheet on 8/22/13 did not show that a model car kit added to his belongings. During an interview, on 9/9/13 at 2:50 p.m., the Unit Manager (UM) for the NBU stated that staff was given an in-service on how to work with residents with behavior issues as a part of the general orientation for new employees. The UM confirmed that staff that were new to the NBU were oriented by the licensed staff working on the NBU, as well as herself. A condition of Immediate Jeopardy (IJ) was identified by the survey team for the facility's failure to keep residents safe from accidents or hazards when they failed to confiscate the screw driver from Resident 18. The screw driver could have been used by Resident 18 or 27 (both men having a history of behavioral issues that led to physical abuse) to cause harm to themselves, other residents, staff or visitors. The IJ was called on August 22, 2013 at 11:55 a.m. In an interview on 8/22/13 at 11:00 a.m., Social Service Director (SSD) 2 stated that when residents were admitted to the NBU, staff went through their belongings to remove dangerous items. She stated that visitors were not given a list of prohibited items not to bring to the facility. In an interview on 8/22/13 at 11:15 a.m., the Activity Director (AD) stated that when activity staff used sharp object with residents, they were expected to keep direct eye contact with those sharp objects and count them before and after each activity. She stated that scissors were kept locked in the activity office. The AD stated that as far as she knew, there were no screwdrivers present in the NBU, but if there were, her expectation would be that activity staff would maintain one on one supervision of the resident. She stated that sharp objects should not be used in resident rooms. In an interview on 8/22/13 at 11:25 a.m., Licensed Vocational Nurse (LVN) 6 stated that she would consider a screwdriver a dangerous item that she would not permit in the NBU. She stated that when visitors came to the NBU, a licensed nurse was supposed to check their belongings to make sure they were not bringing any prohibited items. In an interview on 8/22/13 at 10:40 a.m., CNA 4 stated that if a package was brought in to the NBU, for logistical and safety reasons, she would tell the charge nurse about the package. "All things have to be passed by the charge nurse" In an interview on 8/22/13 at 10:40 a.m., and at 11:20 a.m., LVN 5 stated that per facility policy, it is the responsibility of the staff to make sure no sharp objects are available to the NBU residents and that screwdrivers are not allowed. She went on to say that the screw driver in possession of Resident 18 must have been packaged in a way where the staff did not notice it or else Resident 18 would not have been in possession of it at all. A review of the facility Policy and procedure titled "Accident / Hazard Risk Assessment", last revised on 4/28/10, stated that the SEOC committee members were to, "Conduct a 'walk-through' survey of each department, nursing unit and, accessible areas throughout the center" and to, "Observe the environment for the presence of potential hazards including but not limited to: accesses to sharp utensils/ tools". The policy further indicated that the committee members are to interview the staff in order to determine, "If the staff reported potential risks or environmental hazards to the supervisor or others according to the center's practice" and, "If the staff took action to correct and immediate hazard", and if the staff received in-service education regarding the centers practices to remove or reduce hazards. Lastly, the policy and procedure required documentation, analysis and staff education regarding the identified issues. On 9/9/13 at 4p.m., the Executive Director (ED) stated that the Safety Committee met monthly and consisted of the ED, and the maintenance, housekeeping, nursing, dietary, and activity supervisors. When asked about the procedures outlined in the accident / hazard risk assessment policy she stated that, "No we don't walk around as a team and I don't write things down when I do walk around. But the bottom line is that we identify safety issues and we have improvements." 2. In an observation and concurrent interview, on 8/19/13 at 9:30 a.m., the sliding door, located next to the activities area for Station 4, was missing and replaced with a plywood panel. There was a note taped to the plywood panel on the side facing outside that read, "Caution Not Secure Danger." The Director of Staff Development (DSD) stated the sliding door had been broken for one week. In an interview on 8/20/13 at 11:55 a.m., the Maintenance Assistant (MA) stated the frame and door broke one week ago when somebody slammed a wheel chair into the door and the door shattered. The MA stated that the Maintenance Supervisor (MS) ordered a new door. In an interview on 8/20/13 at 12 p.m., the Executive Director (ED) stated that the door shattered last week when it was taken off the tracks for cleaning. The ED stated that a new frame and door had been ordered on [DATE] and should be arriving this week. According to the ED, the vendor was to deliver the door on the previous Friday but the vendor did not show up. The ED stated that she had concerns for the safety of the residents with the temporary placement of the plywood panel. 3. When on tour of the facility's Neuro Behavioral Unit, (NBU) on 8/21/13, with facility's ED, Housekeeping, Maintenance Supervisor and Regional Housekeeping/Maintenance Director the following were observed: A loose and not fitting metal drain, with ragged edges in shower Room 4. Also, there was a broken plastic soap box with sharp edges. The shower room was open to any resident who cared to enter it.

Based on observation, interview and record review, the facility failed prevent one of 3 sampled residents from being sexually assaulted by one certified nursing assistant (CNA 1) during care. Resident 1 was found crying in her bed around 7 a.m. on 10/31/12 and said CNA 1 sexually assaulted her. The police were called and Resident 1 was sent to the emergency room where she was found to have physical signs of vaginal trauma commonly seen with forcible entry. The resident was tearful and upset two weeks later when talking about the incident on 11/13/12 . Findings: On 11/13/12 at 2 p.m. a review of Resident 1's medical record showed she was admitted on [DATE]. According to her admission minimum data set (MDS) assessment dated [DATE], she had the [DIAGNOSES REDACTED]. Her most recent quarterly MDS assessment dated [DATE] revealed the her active [DIAGNOSES REDACTED]. The quarterly MDS showed that Resident 1 was totally dependent for all her activities of daily living such as turning in bed, transferring between surfaces, such as bed to wheelchair, dressing, toileting, personal hygiene and bathing. She required the assistance of one person to physically assist with these activities. She had functional limitation in range of motion with impairment on one side, of both upper and lower extremity. She was incontinent of both bowel and bladder. She received more than 51% of her daily total of calories through a feeding tube. The MDS revealed that the resident did not have any problems with her mood or behavior. Her speech pattern was described as unclear speech - slurred or mumbled words, and her ability to make concrete requests was sometimes understood and she was able to understand and respond adequately to simple direct communication sometimes. Her short- term memory or ability to recall after 5 minutes appeared to be a problem, but her memory was "OK" to recall long past. The quarterly MDS dated [DATE] revealed that Resident 1 had no cognitive deficits and she scored 15 out of 15 right answers on the "Brief Interview of Mental Status (BIMS)" which evaluated orientation of year, month and day, and memory recall. During an interview on 11/13/12 at 2:20 p.m. Resident 1, who was sitting up in her wheelchair with her left arm resting on a supportive device on the arm of the chair, stated that she was hard of hearing in her right ear. Her speech was difficult to understand and she made some effort to articulate her words. When asked about what happened on 10/31/12, Resident 1 tearfully said "he" came in her room and "raped me." She pointed to her lap and pubic area and started crying. She then described how he put his finger to her nose and pursed his lips at her. She said "I'll call the police." and he grinned at her (she demonstrated his facial expression) and said to her, "Go ahead, call the police." She repeated that statement three or four times. She was crying off and on during the interview. Resident 2, Resident 1's only roommate, stated in an interview on 11/13/12 at 2:50 p.m., that CNA 1 came in their room at about 4:30 a.m., which she said was too early because he usually came in at 5 a.m. She stated that she was a retired Licensed Vocational Nurse (LVN) and a "clock watcher" and that was why she knew what time it was. She went on to describe what she saw that early morning. She got up to go to the bathroom and noticed that the privacy curtain was pulled all the way around Resident 1's bed. She was surprised because she had never seen the nurses pull the curtain all the way around the foot of the bed, just between the two beds. She heard Resident 1 make noise but stated, "she always makes a fuss, she tells the girls 'you don't know what you're doing'." She denied hearing any noises behind the curtain, and when asked if she thought her roommate was "raped," she said "yes." When asked why she thought that, she replied, "Because she hasn't been the same since. She's altered." A nurses note titled "Condition Change Form" dated 11/1/12 revealed that at approximately 7:15 a.m. the CNA (CNA 2) told the charge nurse to come to Resident 1's room. The note revealed, "Went immediately to Resident (1) asked her 'what happened last night?' She stated, 'the dark short man had sex with me in this room last night', "& repeated the word 'sex'..." Another nurses note dated 11/1/12 written at 1:40 p.m. revealed, "Approx. 7:20 a.m. CNA (unidentified) came to nsg. (nursing) station 1 with charge nurse on duty. Reported that resident claims that she was "[***] ed" by short bald blk (black) man last night ...Aprox. 8 a.m. called Oakland PD (police department)...Received instruction from police not to touch resident or clean/bathe until police comes ... " CNA 2 stated in an interview on 11/14/12 at 12:10 that she came to work on 11/1/12 at 7 a.m. She walked by Resident 1's room and stuck her head in to say good morning to Resident 2. Resident 2 then pointed to Resident 1 and CNA 2 said she could see Resident 2 with the covers over her face. She stated that she had never seen that behavior from Resident 1 before. Resident 1 was crying and the CNA went to her and asked why she was crying, what was wrong? Resident 1 told her, "That Black baldheaded man [***] ed me." CNA 2 asked her, "What did you just say?" So the resident repeated it, and CNA 2 asked her where? Resident 1 pointed to her genital area over the covers and the CNA asked, "with what?" The resident said with his penis. CNA 2 said that she took her hands away from her and went to the charge nurse (LVN 1) right away. She said the police came and interviewed her and used her to interpret for the resident because she was able to understand the resident and was her regular caregiver. A copy of the police report obtained by the evaluator on 11/28/12 revealed that the Oakland Police Officer (OPO) "received a call from an elderly nursing care facility that a patient had been assaulted by a staff member..." OPO requested transport for the resident to the acute care hospital emergency room . OPO requested a technician to the scene to process the scene for evidence, and at the emergency room OPO signed the authorization for the assault exam. OPO interviewed CNA 2 and took the following statement on 11/1/12 at 8:45 a.m., "My name is (CNA 2) and I work at ...(facility) ...Today on 1 [DATE] at about 7:10 a.m. I checked on a patient of mine (Resident 1) ...was in her bed ...she had the covers pulled over her body and face and was crying. I asked her what was wrong. She said, 'That Black bald headed man [***] ed me last night.' asked her again and she said that same thing. I said where and she pointed at her vagina. (Resident 1) demonstrating to me that she was trying to push the man away. She also stated that she was saying 'no' to the man. (Resident 1) also told me that the guy closed the curtain between her bed and the patient next to her. I then left the room and told my supervisor ...Resident 1 has a hard time with her speech and I'm able to understand what she is saying. This is a true statement ... " OPO's summary revealed that "Based on the information provided by the victim... and the witness, it appears that the suspect entered the victim's room and while providing her care he took advantage of (Resident 1) and sexually assaulted her. (Resident 1) cannot walk on her own and has limited movement. The suspect assaulted her by forcing his penis into her vagina against her will. The victim told the suspect not to come back to her room, as expressed by the witness (Resident 2). It is during the suspect's return visit that Resident 1 alleges that she was assaulted...I spoke with the physician assistant (P.A.) and he advised me that there were some signs of vaginal trauma, but he could not offer a specific opinion on what the source for the injury was ... " On 11/27/12, during a telephone interview the OPO stated that CNA 1 was arrested on 11/21/12. The surveyor made a request for a copy of the police record which was received on 11/28/12. According to the record the suspect, CNA 1, was described as a Black Male who's "Characteristics" were "Hair length bald/shaved," was charged with "Rape by force/fear/etc. statute severity: Felony," and "Cruelty to elder/dependent adult statute severity: Misdemeanor." A review of the emergency room report dated 11/1/12 revealed that Resident 1 was brought to the emergency room by ambulance and alleged that she was sexually assaulted at her SNF (skilled nursing facility) early that morning. The resident was able to answer yes and no questions but her speech was difficult to understand when she spoke a complete sentence, because of her history of stroke and its effects on her speech. The record revealed, "Pelvic: Multiple curvilinear tears from the posterior forchette (a tense band of mucous membranes at the back angle of the vagina that connects to the back ends of the inner labia) into the perineum (skin between the vagina and anus) and ending just before the anus. These are visible on inspection, confirmed with TB (Toluidine blue - a dye used to test for identification of trauma). No active bleeding. Pt. unable to tolerate speculum (instrument inserted in to the vagina) exam due to the tenderness of these tears. BRB (bright red blood) visible at the urethral meatus (area around the opening where the urine exits the body via a tube connected to the bladder). Pt. c/o' s (Patient complains) of pain with single cotton swabs placed individually into the vaginal vault ... " The record also revealed that the resident had a straight catheter (rubber tube) inserted into her bladder to obtain a urine sample. In a telephone interview on 11/29/12 at 9:02 a.m. the physician assistant (PA) stated that he remembered examining Resident 1 and pulled up her record to review during the interview. He stated that the multiple curvilinear tears were visible and that the Toluidine Blue was a dye that was applied to the skin to highlight skin tears when a light is shown on the skin. Although, he said, that he could see the curvilinear tears without the TB dye. When asked about the bright red blood at the urethral meatus, and about the collection of a urine sample, the PA explained that the results indicated a negligible amount of red blood cells in the urine, which indicated that the bright red blood seen at the urethral meatus probably did not come from the bladder. He said that as part of the exam he used two to four cotton swabs inserted into her vagina to collect evidence of semen. He gently inserted the swabs one at a time due to her cries of pain. He said he also used the assistance of two nurses to support her legs. He said that the curvilinear tears that she had at the posterior fourchette are commonly seen in "forcible entry," but would not answer the question if he thought in his experience that Resident 1 had been raped. He stated that he is usually called as an expert witness in these cases and wanted to be careful about making such a statement. He stated that the exam showed she had some trauma but did not know the cause. He stated the swabs and other physical evidence was turned over to the police and was not kept at the hospital.