Every finding on record at Myrtle Point Rehabilitation & Care

Based on observation, interview and record review, it was determined the facility failed to ensure residents were provided activities of choice for 4 of 4 sampled residents (#s 5, 8, 13, and 19) reviewed for choices and activities. This placed residents at risk of diminished psychosocial well-being. Findings include: The 1/2/26 Resident Council notes revealed resident concerns regarding not having enough social events and a lack of outings. Residents requested opportunities for bus rides, coffee outings, shopping, attendance at community events, and trips such as countryside drives and beach visits. The facility response indicated, we're working on getting more employees covered by company insurance so that we can take more residents on outings. The 2/27/26 Resident Council notes revealed residents expressed confusion about outings and concerns they are no longer able to go on outings. Residents requested clarification regarding the facility's plan to facilitate outings, including availability of a driver, and concerns the facility van was too small to accommodate multiple residents. The 3/26/26 Resident Council notes revealed residents expressed dissatisfaction with activities and they wanted to go off the property to do activities. Residents indicated activities are dead. 1. Resident 5 was admitted to the facility in 2/2024 with diagnoses including Parkinson's disease. The 2/28/26 Annual MDS indicated Resident 5 had a BIMS of 14 and was cognitively intact. Resident 5 indicated going outside was very important to her/him. The 9/13/25 revised Care Plan indicated Resident 5 had a variety of activity interests and liked to participate in group activities. Staff were to assist with arranging community activities and transportation. On 4/9/26 at 11:50 AM, Staff 13 (CNA) stated she was aware Resident 5 requested more outings but it's been a while since they had outings.On 4/10/26 at 9:06 AM and 4/10/26 at 10:38 AM, Staff 8 (Social Service Director/Activity Director) stated multiple residents had been asking to go on outings for the past couple months and it had not happened despite resident request. On 4/10/26 10:12 AM, Resident 5 stated she/he would like to go on outings, but it's been too long since they last had any outings. Resident 5 further stated she/he would really like to go on outings. On 4/10/26 at 10:50 AM, Staff 3 (Corporate Nurse Manager) and Staff 20 (Regional Director) reviewed the resident council documentation and confirmed residents had requested outings and acknowledged delays addressing the residents' requests. On 4/10/26 at 11:50 AM, Staff 2 (DNS) stated she was aware residents had requested to go on outings for the past three months and confirmed a solution had not been implemented.2. Resident 8 was admitted to the facility in 8/2024 with diagnoses including heart failure. The 8/16/24 admission MDS indicated Resident 8 had a BIMS of 15 and was cognitively intact. Resident 8 indicated going outside was very important to her/him.On 4/6/26 at 12:45 PM, Resident 8 stated the bus had not been used. Resident 8 stated she/he wanted to go outside to go fishing at the ponds.On 4/9/26 at 11:50 AM, Staff 13 (CNA) stated she was aware of Resident 8 requesting more outings, but it's been a while since they had outings.On 4/10/26 at 9:06 AM and 4/10/26 at 10:38 AM, Staff 8 (Social Service Director/Activity Director) stated multiple residents had been asking to go on outings for the past couple months and it had not happened despite resident requests. On 4/10/26 10:12 AM, Resident 8 stated she/he would really like to go on outings. Resident 8 further stated she/he would like to go on outings but its been too long since they last had any outings.On 4/10/26 at 10:50 AM, Staff 3 (Corporate Nurse Manager) and Staff 20 (Regional Director) reviewed the resident council meeting documentation and confirmed residents had requested outings and acknowledged delays addressing the request. On 4/10/26 at 11:50 AM, Staff 2 (DNS) stated she was aware of residents had requested to go on outings for the past three months and confirmed a solution had not been implemented.3. Resident 13 admitted to the facility in 10/2024 with diagnoses including heart failure and diabetes.The 10/30/24 admission MDS indicated Resident 13 had a BIMS of 15 and was cognitively intact. Resident 13 indicated going outside was very important to her/him. On 4/9/2026 at 1:59 PM, Resident 13 stated she/he was the Resident Council President. Resident 13 reported residents were not been informed why they were unable to go on outings. Resident 13 stated multiple residents voiced concerns about not going on outings. Resident 13 reported she/he could understand not going on outings during poor weather; however, the weather had been mild, and residents had repeatedly asked about outings. Resident 13 described the activities as boring. Resident 13 further stated the activity bus was available and could hold up to six residents.On 4/10/26 at 9:06 AM and 4/10/26 at 10:38 AM, Staff 8 (Social Service Director/Activity Director) stated multiple residents requested to go on outings over the past several months; however, outings had not occurred due to lack of approved staff to drive the bus. Staff 8 stated she requested to be added to the facility insurance without resolution. Staff 8 confirmed residents requests for outings had not been resolved. On 4/10/2026 at 9:14 AM, Staff 19 (Maintenance Director) confirmed he was the only staff approved to drive the bus and stated the last outing occurred in approximately August or September 2025.On 4/10/26 at 10:50 AM, Staff 3 (Corporate Nurse Manager) and Staff 20 (Regional Director) reviewed the resident council meeting documentation and confirmed residents requested outings and acknowledged delays addressing the request.On 4/10/26 at 11:50 AM, Staff 2 (DNS) confirmed awareness of residents' requests for outings for approximately three months and stated a resolution had not been implemented.4. Resident 19 was admitted to the facility in 11/2025 with diagnoses including anxiety and depression. The 11/18/25 admission MDS indicated Resident 19 had a BIMS of 15 and was cognitively intact. Resident 19 indicated going outside was very important to her/him. The 2/7/25 revised Care Plan indicated Resident 19 enjoyed going outside. On 4/10/26 at 9:06 AM and 4/10/26 at 10:38 AM, Staff 8 (Social Service Director/Activity Director) stated multiple residents had been asking to go on outings for the past couple months and it has not happened despite resident requests. On 4/10/26 at 10:20 AM, Resident 19 stated she/he would love to go on outings. Resident 19 stated she/he would like to go anywhere just to get out of the facility. Resident 19 further stated she/he was told they have a bus but no one has talked to her about going on outings and she/he would like to go on drives and to the park.On 4/10/26 at 11:50 AM, Staff 2 (DNS) confirmed awareness of residents' requests for outings for approximately three months and stated a resolution had not been implemented.On 4/10/26 at 10:50 AM, Staff 3 (Corporate Nurse Manager) and Staff 20 (Regional Director) reviewed the resident council meeting documentation and confirmed residents had requested outings and acknowledged delays addressing the request.

Based on observation, interview, and record review it was determined the facility failed to provide education to residents and monitor personal food safety for 1 of 3 sampled residents (#13) reviewed for food. This placed residents at risk for food borne illnesses. Resident 13 was admitted to the facility in 10/2024 with diagnoses including diabetes and heart failure. A 3/2022 Foods Brought by Family/Visitors policy indicated the following:-Safe food handling practices were to be explained to family and visitors in a language and format they understand.-Food left with the resident to consume later was to include a label of the item, the use by date, and stored in the refrigerator.-The nursing staff was to discard perishable foods on or before the use by date. A 11/6/25 Annual MDS revealed a BIMS assessment score of 14 (cognitively intact) for Resident 13. On 4/7/26 at 9:00 AM, Resident 13 stated her/his private refrigerator in her/his room was not monitored. The temperatures was observed at 42 degrees. Inside the bottom of the refrigerator black debris was observed with drops of liquid on the inside wall of the refrigerator. The contents of the refrigerator included: undated and opened hotdogs, unmarked bowls of fruit with contents exposed, and jam with an expiration date of 11/2024. Resident 13 stated she/he was not opposed to eating the food in her/his refrigerator. On 4/8/26 at 11:27 AM, Staff 4 (Dietary Manager) stated kitchen staff did not monitor the food in resident refrigerators and was unaware who provided residents with the Food Brought by Family/Visitors policy. On 4/8/26 at 5:03 PM, Staff 7 (LPN) did not know of any available policy related to food brought from outside the facility for residents. Staff 7 stated nursing was to check the temperatures of refrigerators in resident rooms. She did not know she was to look for expired food. Staff 7 stated she knew Resident 13 had a refrigerator in her/his room and confirmed the refrigerator was not routinely monitored because the task to monitor was not on a list. On 4/8/26 at 5:12 PM, Staff 5 (Business Office Manager) stated the information in the Resident Handbook Nursing Facility covered rules and rights of residents that were discussed with each resident at admission. Staff 5 stated she was not aware of a policy on Food Brought by Family/Visitors or of food in resident rooms. On 4/8/26 at 5:19 PM, Staff 3 (Regional Nurse Consultant) confirmed the facility did have a policy related to food brought in by family and expected a review of the policy with residents during the admission process. On 4/9/26 at 1:12 PM, Staff 4 stated the last time she checked on resident refrigerators was in 10/2025 when she provided temperature log sheets for nursing. Staff 4 stated it was understood that each resident was responsible for their own refrigerator and contents. Staff 4 acknowledged resident food was to be dated and discarded timely and the task was not getting done. On 4/10/26 at 9:21 AM, Staff 3 acknowledged the facility did not follow their own policy related to resident food safety and food brought in by family and visitors. Staff 3 expected education for all staff on the Food Brought by Family/Visitors policy and food safety expectations. On 4/10/26 at 1:48 PM, Staff 21 (Activities Assistance) was observed to deliver food to a resident's room. Staff 21 stated she was not aware of any policy related to food safety in resident's rooms or food brought in by family or visitors.

Based on observation, interview, and record review it was determined the facility failed to ensure meal preferences were honored during posted mealtimes for 1 of 1 kitchen and 2 of 4 sampled residents (#s 13 and 21) reviewed for food, choices, and kitchen. This placed residents at risk for lack of meal satisfaction. Findings include:The Undated Mealtimes postings located near the nurse station and kitchen indicated the following: -Breakfast was served from 7:30 AM to 8:30 AM.-Lunch was served from 12:00 PM to 1:00 PM.-Dinner was served from 5:30 PM to 6:30 PM.1. Resident 13 was admitted to the facility in 10/2024 with diagnoses including diabetes and heart failure.A 11/6/25 Annual MDS revealed a BIMS assessment score of 14 (cognitively intact) for Resident 13. On 4/6/26 at 12:23 PM, Resident 13 stated she/he received less food than normal during mealtimes. Resident 13 stated she/he received one pancake and wanted more and requested two bowls of cereal on another day but they ran out. On 4/9/26 at 9:56 AM, Staff 11 (Dietary Aide) stated staff were aware CNAs had complaints from residents who requested additional food during meal service. Staff 11 stated sufficient food supplies were sometimes not pulled from the freezer to thaw and prepare for the meal.On 4/10/26 at 10:27 AM, Staff 10 (Cook) stated she held breakfast for 30 minutes after meals were served and was verbally instructed to prepare two to three additional servings which were utilized for pureed foods and left no additional servings after food trays were served. Staff 10 stated there were no guidelines in writing and confirmed she was unsure if additional food for residents was to be offered if requested. On 4/10/26 at 11:17 AM, Staff 4 (Dietary Manager) acknowledged the expectation was to provide residents the food on the menu for one hour once food trays were delivered. Staff 4 stated the expectations were not communicated to residents and staff in writing and ample food was not always available. 2. Resident 21 was admitted to the facility in 10/2025 with diagnoses including spinal stenosis (narrowing of spaces in the spine causing pain). The 3/3/26 Quarterly MDS revealed a BIMS assessment score of 15 (cognitively intact) for Resident 21.On 4/9/26 at 9:56 AM, Staff 11 (Dietary Aide) stated staff were aware CNAs had complaints from residents who requested additional food during meal service. Staff 11 stated sufficient food supplies were sometimes not pulled from the freezer to thaw and prepare for the meal.On 4/10/26 at 10:11 AM, Resident 21 stated, on 4/10/26, she/he received one pancake and two sausage links and was still hungry. Resident 21 stated Staff 18 (CNA) contacted the kitchen a few minutes after meals were served and was informed there were no additional pancakes or sausage. On 4/10/26 at 10:27 AM, Staff 10 (Cook) stated she held the breakfast for 30 minutes after the meal was served and was verbally instructed to prepare two to three additional servings which were utilized for pureed foods and left no additional servings. Staff 10 stated there were no guidelines in writing and confirmed she was unsure if additional food for residents was to be offered if requested. On 4/10/26 at 10:52 AM, Staff 18 acknowledged, on 4/10/26 during breakfast, kitchen staff stated there was no additional food from the menu and the request for additional food was made within the one hour window. Staff 18 stated she trained new CNAs and the expectation was food was available from the kitchen for one hour once the food trays arrived to resident rooms. Staff 18 stated on 4/9/26 breakfast was served at 8:45 AM and the mealtime was not sufficient to allow residents a one hour window for service and food requests. On 4/10/26 at 11:17 AM, Staff 4 (Dietary Manager) acknowledged the expectation was to provide residents the food on the menu for one hour once food trays were delivered. Staff 4 stated the expectations were not communicated to residents and staff in writing and ample food was not always available. 3. On 4/6/26 at 11:45 AM, Staff 10 (Cook) was observed to serve food with a team of staff to the residents on the second floor. After the meal service was completed and before 1:00 PM, staff requested lunch from the remaining food.On 4/8/26 at 11:27 AM, Staff 4 (Dietary Manager) stated staff were to request food two hours before meal service to ensure sufficient food was prepared. Staff 4 stated if food ran out before the end of meal service, she expected staff to find out what food was requested and prepare more food. Staff 4 stated alternative food options were verbally made known to residents when needed and the expectation was to prepare two to three extra servings each meal to ensure sufficient food for residents. On 4/8/26 at 12:20 PM lunch meal service began. A sample tray was requested to include a hamburger patty with gravy. On 4/8/26 at 1:02 PM, the sample tray was assembled and did not include a hamburger patty with gravy. Staff 4 stated she did not serve the last hamburger patty because it was dry and not edible and acknowledged it was the last serving. Staff 4 stated a substitute should be offered. On 4/9/26 at 9:56 AM, Staff 11 (Dietary Aide) stated staff were aware CNAs had complaints from residents who requested additional food during meal service. Staff 11 stated sufficient food supplies were sometimes not pulled from the freezer to thaw and prepare for the meal.On 4/10/26 at 11:17 AM, Staff 4 (Dietary Manager) acknowledged the expectation was to provide residents the food on the menu for one hour once food trays were delivered. Staff 4 stated the expectations were not communicated to residents and staff in writing and ample food for residents was not always available. On 4/10/26 at 2:42 PM, Staff 2 (DNS) expected alternative food options to be available when there was not enough food from the menu or when requested by residents.

Based on interview and record review it was determined the facility failed to ensure residents were free of significant medication errors for 1 of 1 sampled Resident (#32) reviewed for medication errors. This placed residents at risk for adverse medication side effects. Findings include: Resident 32 was admitted to the facility in 10/2025 with diagnoses including chronic pain and fibromyalgia (widespread pain and stiffness).The 4/2019 Administering Medication Policy Statement indicated: The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. The 11/6/24 admission MDS indicated Resident 32 was cognitively intact.A review of the 1/2/25 Facility Investigation Summary revealed on 1/2/25 Staff 22 (Former CMA) administered Resident 32 her/his morning dose of Lyrica at 6:00 AM and then again at 11:00 AM. The second dose of Lyrica was to be administered 12 hours after the first dose.A physician order revealed Resident 32 had hydrocodone (narcotic pain medication) for pain. Staff 22 administered the second dose of Lyrica instead of the hydrocodone. Resident 32 developed adverse medication side effects and was sent to the ER for physician evaluation. On 1/6/25 the investigation concluded Resident 32's dosing schedule was every 12 hours for Lyrica. Resident 32 received a 6:00 AM dose of Lyrica and the second dose was given approximately five hours later. Resident 32 was transported to the ER for evaluation due to possible adverse side effects from the medication. Poison control was called by the ER and stated the Lyrica was not a high enough dose to cause adverse side effects. Resident 32 returned to the facility and was placed on alert charting. The medication error should have been prevented. Education and coaching provided to Staff 22.On 4/7/26 at 1:38 PM Witness 4 (Family Member) stated Resident 32 was given her/his pain medications too close together and was sent to the ER with adverse medication side effects.On 4/7/26 at 2:02 PM Staff 22 indicated she did not remember the incident and no longer worked in the facility.On 4/10/26 at 2:42 PM Staff 13 (Corporate Nurse Consultant) stated Resident 32's Lyrica order was one dose in the AM and one dose in the PM. Staff 13 acknowledged Staff 22 did not follow the five rights of administering medications and Resident 32 received the wrong medication. The deficient practice was identified as Past Noncompliance based on the following:On 1/3/25 the deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the incident and determined there was a medication error. The plan of correction included: retraining of staff for medication administration including the five rights of administering medications properly, review of the Medication Administration Policy and Procedure, and audits showing compliance. The facility identified the issue, implemented a systemic plan of correction, and verified its effectiveness before the start of the survey, this tag is cited as past non-compliance. Corrective actions were completed on 1/6/25.

Based on observation, interview, and record review it was determined the facility failed to update a care plan to reflect changes in care needs for 1 of 1 sampled resident (#22) reviewed for bowel and bladder. This placed residents at risk for skin breakdown. Findings include:Resident 22 was admitted to the facility in 4/2025 with diagnoses including cerebral palsy (impaired muscle coordination) and chronic kidney disease. The 2/14/25 physician signed Skin Protocols for the facility indicated barrier cream (protection for the skin from urine or feces) was to be applied as needed per facility protocol. The 2/5/26 Quarterly MDS revealed Resident 22 was always incontinent of bowel and bladder and had a BIMS assessment score of 10 (moderately cognitively impaired).A 3/25/26 Skin Integrity report revealed a CNA reported skin discoloration and abrasions on both of Resident 22's upper inner thighs. The area was cleaned, barrier cream was applied and the resident's physician was notified. The 4/2026 TAR and physician orders revealed nystatin powder (antifungal medication) was topically applied to Resident 22's upper inner thighs three times a day for redness at the resident's groin area for ten days. A 4/5/26 revised Care Plan indicated Resident 22 had bowel and bladder incontinence and to clean the area around her/his groin after each incontinence episode. On 4/7/26 at 10:34 AM, Resident 22 stated she/he urinated without knowing and was not aware of ongoing treatments to her/his groin area. On 4/9/26 at 1:37 PM, Staff 13 (CNA) stated she cared for Resident 22 and only applied nystatin powder to her/his groin area. On 4/9/26 5:36 PM, Staff 15 (CNA) stated she only applied powder to Resident 22's groin area and no barrier cream. On 4/9/26 at 8:44 PM, Staff 9 (LPN) stated she contacted Resident 22's physician for the nystatin powder order on 3/25/26. She stated the skin abrasions to the resident's groin area were not open at the time.On 4/10/26 at 12:16 PM, Resident 22's groin area was observed with skin areas that were slightly open and red. Staff 2 (DNS) stated Resident 22's skin abrasions to the groin area had improved and the area was no longer fungal. The 4/2026 TAR revealed nystatin powder was topically applied to Resident 22's upper inner thighs three times a day for redness at the resident's groin area for ten days. There was no order found for the application of barrier cream in the resident's clinical record. On 4/10/26 at 12:17 PM, Staff 7 (LPN) stated she only applied nystatin powder to Resident 22's groin area because that was what was ordered and did not apply barrier cream. In an interview on 4/10/26 at 8:47 AM, Staff 2 (DNS) stated she expected the application of barrier cream as an intervention for all incontinent residents and acknowledged Resident 22's care plan did not include interventions to apply barrier cream.

Based on interview and record review it was determined the facility failed to ensure dignity was maintained for 1 of 1 sampled resident (#1) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include:Resident 1 was admitted to the facility in 4/2024 with diagnoses including stroke and a fractured femur (thigh bone). A 1/12/26 Significant Change MDS and associated CAAS indicated Resident 1 had a BIMS assessment score of 10 (moderately impaired cognition), exhibited poor safety awareness, and required assistance by one staff for toileting transfers.A 4/4/26 Alleged Abuse indicated Staff 9 (LPN) directed Staff 6 (CNA) to assist Resident 1 with her/his urinal in bed. The report indicated Staff instructed Resident 1 to urinate in her/his brief because she/he continued to try and stand.A 4/5/26 statement by Staff 6 indicated she was only able to yell at Resident 1 because she/he was hard of hearing. Staff 6 acknowledged she told Resident 1 to urinate in her/his brief.On 4/9/26 at 7:30 PM, Staff 17 (CNA) stated she worked with Staff 6 on 4/4/26 and heard Resident 1 yell for help to use the bathroom. Staff 17 stated she reported to Staff 9 about Staff 6's anger towards Resident 1 during the shift.On 4/9/26 at 8:00 PM, Staff 6 stated she believed Resident 1 was not medicated properly and required one on one care due to her/his impulsiveness. Staff 6 stated she did not identify any issues between herself and Resident 1.On 4/10/26 at 8:44 PM, Staff 9 stated she told Staff 6 to be patient with Resident 1 due to Staff 6's frustration and confirmed the care for Resident 1 was manageable with one staff.On 4/10/26 at 9:01 AM, Resident 1 was interviewed about the incident on 4/4/26, and did not recall the event.On 4/10/26 at 4:04 PM, Staff 2 (DNS) stated Staff 6 provided her own statement of admission to inappropriate actions. Staff 2 acknowledged it was unacceptable to instruct a resident to use her/his brief than provide assistance with toileting. Staff 2 stated she expected resident concerns to be addressed immediately.

Based on interview and record review it was determined the facility failed to provide residents a private environment for physical intimacy for 2 of 4 sample residents (#s 1 and 2) reviewed for abuse. This placed residents at risk for lack of privacy. Findings include: Resident 1 was admitted to the facility in 6/2023 with a diagnosis of chronic lung disease. Resident 1's 9/15/25's Quarterly MDS indicated she/he was moderately cognitively impaired. Resident 2 was admitted to the facility in 10/2025 with a diagnosis of heart disease. Resident 2's 10/6/25's admission MDS revealed she/he was cognitively intact. Resident 1's 10/6/25 Progress Notes revealed on 10/5/25 staff spoke to Resident 1 about an incident when there was heavy petting outside the building and once inside the building where a resident of the opposite gender had her/his hands inside Resident 1's shirt. Resident 1 reported to staff the incident was consensual. Resident 1's 10/10/25 Sexual Consent Capacity Evaluation revealed she/he had the capacity to consent and had the desire to be sexually active. Resident 2's 10/10/25 Sexual Consent Capacity Evaluation revealed she/he had the capacity to consent and had the desire to be sexually active. Resident 2's 10/11/25 Progress Note revealed a CNA reported she observed Resident 2 and Resident 1 with their hands down each other's pants while outside. The residents were separated and informed private time could be provided but public displays were inappropriate.On 10/13/25 at 3:52 PM Resident 2 stated Resident 1 did not do anything physical with him/her that she/he did not want. Resident 2 denied an ongoing relationship with Resident 1. On 10/14/2025 10:38 AM Resident 1 stated the facility never provided a private place for her/him to meet for intimacy. Resident 1 stated she/he was allowed to meet Resident 2, but it was chaperoned. On 10/14/2025 11:20 AM Staff 2 (DNS) stated there was no location in the facility designated for residents to meet privately if they chose to have a sexual or intimate relationship.

Based on interview and record review it was determined the facility failed to ensure an allegation of abuse was reported within two hours for 1 of 4 sampled residents (#1) reviewed for abuse. This placed residents at risk for ongoing abuse. Findings include: Resident 1 was admitted to the facility in 6/2023 with a diagnosis of chronic lung disease. Resident 1's 9/15/25's Quarterly MDS indicated she/he was moderately cognitively impaired. Resident 2 was admitted to the facility in 10/2025 with a diagnosis of heart disease. Resident 2's 10/6/25's admission MDs indicated she/he was cognitively intact. A FRI dated 10/6/25 indicated on 10/5/25 at 8:30 PM Resident 2 was observed to have her/his hands up Resident 1's shirt. The incident was not reported to the administrator until 10/6/25 at 9:30 AM and was reported to the State agency on 10/6/25 at 11:08 AM. This was over 12 hours after the initial incident of potential abuse.On 10/14/2025 at 6:14 AM Staff 4 (Charge Nurse) stated he was not aware he needed to report potential abuse within two hours. On 10/14/25 11:59 AM Staff 1 (administrator) stated allegations of abuse were to be reported within two hours. The deficient practice was identified as Past Noncompliance based on the following: On 10/6/25 administration identified the deficient practice and immediately provided training on the following:-types of abuse-timeframes for reporting abuse-evaluating incidents-investigating events and reporting incidents as abuse until ruled out

Based on interview and record review it was determined the facility failed to ensure a resident was assessed for sexual consent for 1 of 4 sampled residents (#1) reviewed for abuse. This placed residents at risk for trauma. Findings include:Resident 1 was admitted to the facility in 6/2023 with a diagnosis of chronic lung disease. Resident 1's 9/15/25's Quarterly MDS indicated she/he was moderately cognitively impaired. Resident 2 was admitted to the facility in 10/2025 with a diagnosis of heart disease. Resident 2's 10/6/25's admission MDs indicated she/he was cognitively intact. Resident 1's 10/6/25 Progress Notes revealed on 10/5/25 staff spoke to Resident 1 about an incident when there was heavy petting outside the building and once inside the building when a resident of the opposite gender had her/his hands inside Resident 1's shirt. Resident 1 reported to staff the incident was consensual. On 10/13/25 at 4:17 PM Staff 3 (CNA) stated on 10/5/25 he went outside to bring the residents in from a smoke break and observed Resident 2 to have her/his hands up Resident 1's shirt. Staff 3 assisted Resident 1 back to the facility and notified the nurse. Staff 3 stated the rest of the evening shift both residents were in the sunroom watching a movie. Staff 3 also stated he monitored both residents until the shift ended at 10:00 PM and then he provided report to the oncoming CNA. Staff 3 stated Staff 4 (Charge Nurse) was the same nurse for the night shift. On 10/13/25 at 4:32 PM Staff 11 (CNA) stated she worked the night shift on 10/5/25 to 10/6/25. She was told Resident 1 and Resident 2 could be together, but they needed to be in a private area if they wanted to be intimate. On 10/14/25 at 6:14 AM Staff 4 stated on 10/5/25 on the evening shift there were two incidents with Resident 1 and Resident 2. The first incident occurred outside when Resident 2 had her/his hands up Resident 1's shirt. The residents were separated, then they both sat in the sunroom, and watched a movie. Initially, when both residents were brought back from the smoking area, they did not want to go to their separate rooms. Staff 4 stated he did not have the opportunity to talk to either resident separately to ensure the interaction was consensual until after the second event. Initially Resident 2 denied the incident but then indicated it was consensual. Resident 1 reported the interactions were consensual. Staff 4 stated after the first interaction between Resident 1 and Resident 2 he should have ensured both residents were able to consent, and the interaction was consensual. 10/14/2025 11:59 AM Staff 1 (Administrator) stated staff were to ensure residents were assessed after an incident to ensure resident safety.

Based on interview and record review it was determined the facility failed to submit Payroll Based Journal staffing data and other verifiable and auditable data as required for 1 of 1 facility reviewed. This placed residents at risk for inaccurate staffing data reporting. Findings include: Review of the Payroll Based Journal Staffing Data for fiscal year 2024, quarter three (4/1/24 through 6/30/24), revealed the facility failed to submit required data for the quarter. On 11/6/24 at 12:22 PM Staff 1 (Administrator) stated she was unaware the data was not submitted until the survey team alerted her to the omission.

Based on interview and record review it was determined the facility failed to employ a director of food and nutrition services with the required certification for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: On 11/7/24 at 3:12 PM Staff 23 (Dietary Manager) stated she would be certified in 2/2025 as a dietary manager. No documentation was provided for Staff 23's certification as a dietary manager. On 11/8/24 at 11:17 AM and 12:14 PM Staff 1 (Administrator) was informed Staff 23 currently lacked the required certification, and also did not have the required certification in 2023 which was identified during the annual recertification survey that year. Staff 1 stated Staff 23 was coming in on Sundays and working on the classes. Staff 1 stated since Staff 23's preceptor passed away, she did not complete the training. Staff 1 stated she was not aware the facility was cited previously for the same issue. Review of 2022 and 2023 recertification surveys revealed the facility was cited because Staff 23 did not possess the required certification.

Based on observation and interview it was determined the facility failed to ensure food was stored appropriately and was discarded in a timely manner for 1 of 1 resident refrigerator reviewed for food storage and handling. This placed residents at risk for food-borne illness and cross-contamination. Findings include: On [DATE] at 11:34 AM the resident refrigerator located in the sunroom contained the following food items that were labeled with expired dates: - Applesauce was dated [DATE] (expired for 7 days). - A sandwich was dated [DATE] (expired for 5 days). - A dish of pineapple was dated [DATE] (expired for 5 days). - A plastic bag of carrots was dated [DATE] (expired for 4 days). On [DATE] at 11:46 AM Staff 23 (Dietary Manager) confirmed the food items should have been discarded by the expiration dates.

Based on interview and record review the facility failed to protect residents' right to be free from verbal abuse by staff and neglect related to failure to provide residents needed supplies for 4 of 5 sampled residents (#3, 14, 18, and 20) reviewed for supplies and abuse. Findings include: 1. Resident 14 admitted to the facility in 5/2023 with diagnoses including arthritis and intervertebral disc degeneration (one or more discs in the spine deteriorate). A 5/30/24 MDS revealed Resident 14's BIMS score was 15 which indicated she/he was cognitively intact. A 7/14/24 Social Service Note written by Staff 20 (Former Administrator) indicated on 7/11/24 Resident 14 verbalized she/he would inform family members of her/his positive COVID-19 test results in the facility. Review of a Complex Medical Add On note revealed on 7/14/24 Resident 14 tested positive for COVID-19 and refused to stay inside her/his room. On 11/5/24 at 9:15 AM Staff 4 (CNA) stated in 7/2024 when the elevator did not work Staff 20 was yelling and screaming. On 11/5/24 at 11:58 AM Staff 25 (CNA) stated Staff 20 yelled at Resident 14 and there were other residents who also heard the yelling. On 11/6/24 at 9:42 AM Resident 14 stated in 7/2024 she/he tested positive for COVID-19. Staff paused the elevator operation so other residents did not come up the elevator while Resident 14 sat by the elevator, and staff went to get her/him a mask so she/he could go downstairs. Staff 20 came up the stairs and saw Resident 14 and told her/him to go to her/his room. Resident 14 stated she/he was not by any staff or residents and attempted to inform Staff 20 she/he wanted to go outside. Staff 20 became angry and kept telling her/him to go back to her/his room. Resident 14 stated Staff 20 was bullying her/him and she/he felt it was emotional and psychological abuse from Staff 20. Resident 14 stated after that she/he did not want to speak to Staff 20 alone. At a later time she/he was outside and asked Staff 20 to go away as she/he wanted someone else to witness the interaction. Resident 14 stated Staff 20 did not go away and Resident 14 became upset and was calling out for someone to come as Staff 20 would not leave her/him alone. Resident 14 started crying multiple times during the interview. On 11/7/24 at 9:05 AM Staff 13 (CNA) stated Staff 20 did a lot of loud talking, Staff 20 felt she was the judge and jury and was not pleasant. Staff 13 observed Staff 20 direct Resident 14 to go back to her/his room multiple times in an authoritative voice when Resident 14 was at the nurses' station by the elevator. On 11/7/24 and 11/8/24 attempts to contact Staff 20 were unsuccessful. On 11/7/24 at 7:09 AM Witness 7 (Former Staff) stated Resident 14 did not file any grievances regarding Staff 20 as she/he was concerned she/he would get punished for it, and would not get her/his needs met. Witness 7 stated she observed Staff 20 going down the hallway yelling and cussing before Staff 20 entered a resident room. On 11/8/24 at 7:25 AM Staff 18 (CNA) stated Resident 14 was uncomfortable talking alone with Staff 20. On 11/8/24 at 8:54 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated it was expected to interview Resident 14 and the staff who witnessed the interaction regarding Staff 20's level and tone of voice during the interaction noted above. 2. Resident 3 admitted to the facility in 1/2023 with diagnoses including irritable bowel syndrome and diarrhea. A 11/22/23 care plan revealed Resident 3 was incontinent of bowel and staff were to provide peri-care after each incontinent episode. A 5/13/24 MDS indicated Resident 3's BIMS score was 15 which indicated she/he was cognitively intact. Resident 3 was always incontinent of bowel and was dependent on staff for toileting hygiene. On 7/25/24 the State Survey Agency received a public complaint which indicated the facility lacked supplies incontinent including briefs and wipes. On 8/1/24 the State Survey Agency received a public complaint which indicated the facility was short on supplies for incontinent briefs and wipes. Staff were provided six packages of incontinent wipes to use on all residents for all shifts. When incontinent wipes were requested the staff member was informed the wipes were behind locked doors. Resident 3 had redness in her/his groin area from low-quality briefs. On 11/5/24 at 9:15 AM Witness 8 (Complainant) stated in 7/2024 and 8/2024 the facility did not provide enough briefs for residents and the briefs were not the right size. Some of the residents had redness from the briefs not being the right size. On 11/6/24 at 10:08 AM Staff 15 (Central Supply) stated in 8/2024 there were some delayed supply orders and Staff 20 (Former Administrator) was ordering supplies in 8/2024. The facility had many donations of incontinent briefs during 8/2024 because they were in short supply by the facility. On 11/6/at 10:12 AM Resident 3 stated in 7/2024 and 8/2024 incontinent briefs were not the right size, staff had to cinch the wrong size brief, and they were too tight. In 8/2024 the skin in her/his groin area became red due to the wrong-sized briefs. On 11/8/24 at 11:21 AM Staff 13 (CNA) stated around 7/2024 and 8/2024 the facility could not get the correct size incontinent briefs for bariatric residents, and there were not enough incontinent wipes. The briefs the facility had deteriorated. On 11/8/24 at 8:34 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) confirmed staff should have the correct size incontinent briefs available for residents. 3. Resident 18 admitted to the facility in 4/2023 with diagnoses including anxiety and skin rash. A review of a 5/4/24 MDS assessment revealed Resident 18's BIMS score was seven, which indicated severe cognitive deficits. Resident 18 was dependent on staff for toileting hygiene, was frequently incontinent of bladder, and always incontinent of bowel. On 7/25/24 the State Survey Agency received a public complaint which indicated the facility lacked supplies including incontinent briefs and wipes, and pillow cases. Resident 18 required XXXL size briefs. Around 7/11/24 there was only one size brief available in the facility for residents which was not size XXXL, staff attempted to keep her/him continent which was difficult, and they had to use liners with the one available size brief. Additionally staff had to use washcloths since no incontinent wipes were available. On 11/5/24 at 9:35 AM Staff 4 (CNA) stated in 7/2024 Resident 18 required extra-large incontinent briefs, the facility only provided large size briefs, and staff had to leave the brief open because it did not fit her/him. On 11/6/24 at 10:08 AM Staff 15 (Central Supply) stated in 8/2024 there were some delayed orders and Staff 20 (Former Administrator) was ordering supplies at that time. The facility had many donations of briefs during 8/2024 because they were in short supply by the facility. On 11/8/24 at 11:21 AM Staff 13 (CNA) stated around 7/2024 and 8/2024 the facility could not get the correct size incontinent briefs for bariatric residents, and there were not enough incontinent wipes. The briefs the facility had deteriorated. On 11/8/24 at 9:10 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) confirmed staff should have the correct size incontinent briefs available for residents. 4. Resident 20 admitted to the facility in 6/2024 with diagnoses including kidney disease and dementia. A 6/10/24 MDS indicated Resident 20's BIMS score was five indicating she/he had severe cognitive impairment. Resident 20 was always incontinent of bowel and bladder, and required substantial to maximal assistance with toileting hygiene. On 7/25/24 the State Survey Agency received a public complaint which indicated the facility lacked incontinent supplies including briefs and wipes. On 8/1/24 the State Survey Agency received a public complaint which indicated the facility was short on supplies for incontinent briefs and wipes. Staff were provided six packages of incontinent wipes to use on all residents for all shifts. When incontinent wipes were requested the staff member was informed the wipes were behind locked doors. Resident 3 had redness in her/his groin area from low-quality briefs An 8/1/24 Skin Integrity Issue investigation revealed Resident 20 had a red abrasion to the right hip. Resident 20 believed it was from the incontinent brief rubbing on her/his skin. On 11/5/24 at 9:15 AM Witness 8 (Complainant) stated in 7/2024 and 8/2024 the facility did not provide enough incontinent briefs for residents and the briefs were not the right size. Some of the residents had redness from the briefs not being the right size. On 11/6/24 at 10:08 AM Staff 15 (Central Supply) stated in 8/2024 there were some delayed orders and Staff 20 (Former Administrator) was ordering supplies at that time. The facility had many donations of briefs during 8/2024 because they were in short supply by the facility. On 11/8/24 at 11:21 AM Staff 13 (CNA) stated around 7/2024 and 8/2024 the facility could not get the correct size incontinent briefs for bariatric residents, and there were not enough incontinent wipes. The briefs the facility had deteriorated. On 11/8/24 at 9:10 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) confirmed staff should have the correct size incontinent briefs available for residents.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing activity program to meet the needs of residents for 1 of 1 sampled resident (#6) and 1 of 1 facility reviewed for activities. This placed residents at risk for decrease in quality of life. Findings include: 1. Resident 6 admitted to the facility in 2024 with diagnoses including chronic kidney disease and depression. On [DATE] at 1:40 PM Resident 6 stated she/he wanted to go fishing more often and the facility could not take residents on outings because the facility van was not road legal. On [DATE] at 12:26 PM Staff 3 (Social Services/Activities) stated the facility van's registration was not up-to-date, and she could not take residents on outings. Observation of the facility van's registration stickers on [DATE] at 2:43 PM revealed the registration was out of date. On [DATE] at 10:04 AM multiple residents at the resident council meeting stated they were unhappy the van was not available, and they wanted to go on outings. On [DATE] at 12:32 PM Staff 12 (Maintenance Director) verified the facility van's registration was expired, and he was not able to get them renewed because the title to the van was in the previous owner's name. He stated the regional representative for the facility was working on getting the title transferred to the facility, but he did not know when it would be completed. Staff 12 stated he would contact the regional representative for more information. No further information was provided. 35855 2. On [DATE] the State Survey agency received a public complaint which indicated the Social Services and Activity Directors' employment was around the first part of ,d+[DATE], and the positions remained vacant. There were no activities available for the residents. A review of Resident 16's Documentation Survey Report for ,d+[DATE] indicated she/he had one personal visit on [DATE], but no other activities were documented in ,d+[DATE]. A review of Resident 3's Documentation Survey Report for ,d+[DATE] revealed Resident 3 exercised on [DATE] and [DATE], but no other activites were documented for the month. A review of Resident 20's Documentation Survey Report for ,d+[DATE] revealed Resident 20 did not participate in any activities from [DATE] through [DATE]. A review of Resident 18's Documentation Survey Report for ,d+[DATE] revealed no documented activities for ,d+[DATE]. On [DATE] at 9:05 AM Staff 13 (CNA) stated in ,d+[DATE] Staff 20 (Former Administrator) fired the Activity Director and there were no activities for the residents. The activity calendar was posted on the wall, but no activities were occurring. On [DATE] at 10:02 AM Staff 3 (Activity Director and Social Services) stated she started as the Activity Director in ,d+[DATE]. Staff 3 stated she worked as a CNA on Sundays before she was hired as the Activity Director and there were no activities on Sundays when she worked as a CNA.

Based on observation, interview, and record review it was determined the facility failed to have adequate staff available to meet the needs of residents for 2 of 4 residents (#s 14 and 18) reviewed for ADLs, and 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 18 admitted to the facility in 2023 with diagnoses including dementia and cognitive impairment. A 5/4/24 annual MDS revealed Resident 18 had moderate cognitive impairment. A 7/19/24 provider note stated Resident 18 had dementia and arrived at her/his appointment without their required facility staff escort. The note stated the provider called the facility and was told no escort was available due to short staffing. On 11/8/24 at 11:35 AM Staff 1 (Administrator) stated she expectated staff to accompany residents to their appointments as required. She acknowledged the provider note stating no facility staff escort was provided due to short staffing. 35855 2. On 7/25/24 the State Survey Agency received a public complaint which indicated the facility was short staffed, and when there were not enough staff the facility did not address the issue. On the 7/24/24 to 7/25/24 night shifts the facility only had one nurse and one CNA for 27 residents. On 8/1/24 the State Survey Agency received a public complaint which indicated Staff 20 (Former Administrator) terminated the employment of multiple staff, and half of the CNAs and CMAs voluntarily ended their employment before it was terminated. All shifts were short-staffed, and the administration brought in agency nurses but no agency CNAs. On 8/1/24 the State Survey Agency received a public complaint which indicated Staff 20 terminated the employment of a lot of the staff. The facility did not have enough staff to adequately care for the residents and the resident acuity was high. On 11/5/24 at 9:26 AM Witness 8 (Complainant) confirmed in 7/2024 the facility was short-staffed, and the facility did not meet minimum required staffing levels for all the shifts. Review of the Direct Care Staff Daily Reports for the months of 4/2024 through 7/2024, 10/2024, and 11/2024 revealed the following days when one or more shifts did not meet the state minimum CNA staffing requirements: - 4/10/24 - 4/26/24 through 4/29/24 - 5/3/24 through 5/6/24 - 5/8/24 - 5/11/24 - 5/13/24 - 5/15/24 - 5/18/24 - 5/20/24 through 5/23/24 - 5/26/24 - 5/29/24 - 5/31/24 - 6/1/24 through 6/7/24 - 6/10/24 - 6/22/24 through 6/23/24 - 6/26/24 - 6/29/24 through 6/30/24 - 7/1/24 - 7/24/24 through 7/26/24 - 10/18/24 Noc shift On 11/5/24 at 11:46 AM Witness 9 (Complainant) stated in 7/2024 lack of staff was horrible. Witness 9 stated one night there was only one CNA and one nurse. Witness 9 stated she was deathly concerned about residents falling on the night shift when there were only two staff in the facility. On 11/6/24 at 12:11 PM Resident 14's call light was activated, and Staff 8 (CMA) went into Resident 14's room and requested Resident 14 turn off her/his call light. At 12:51 PM Resident 14 stated she/he requested batteries for her/his television remote at 7:30 AM, then again at 12:11 PM, and had not yet received the batteries. At 1:11 PM Resident 14's lunch tray was delivered, and Staff 10 (RN) stated she would go check about the batteries. On 11/7/24 at 7:09 AM Witness 7 (Former Staff) stated in 7/2024 Staff 20 hindered staff in completing their work. At times she cut the scheduled staff hours and the CNAS were always running and doing their best to provide care to the residents. On 11/7/24 at 10:04 AM Resident 3 stated staff needed to answer call lights more quickly. At times she/he waited 30 to 45 minutes which usually occured on evening shift. On 11/7/24 at 10:50 AM Resident 22 stated in 7/2024 the facility was a nasty place. Resident 22 stated he went multiple hours without her/his antibiotic and pain medications. The Administrator made her/him make phone calls to try and find her/his own housing for when she/he discharged . On 11/7/24 at 9:05 AM Staff 13 (CNA) stated in 7/2024 there was a shortage of staff because of all the changes in the facility. Staff 13 stated CNA staff assisted the residents as quickly as possible. On 11/8/24 at 7:25 AM Staff 18 (CNA) stated in 6/2024 and 7/2024 it was hit or miss on the evening shift and there were times evening shift was short of staff. On 11/8/24 at 8:44 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated they expected staff to address an issue if a call light was turned on in a resident room.

Based on interview and record review it was determined the facility failed to ensure nursing staff were able to demonstrate competency in skills and techniques necessary to care for residents for 3 of 5 staff (#s 18, 26, and 27) reviewed for competencies. This placed residents at risk for poor quality of care and lack of competent staff. Findings include: On 11/5/24 Staff 1 (Administrator) was asked to provide documentation of a completed competency checklist for Staff 17 (CNA), Staff 18 (CNA), Staff 26 (CNA), Staff 27 (CNA), and Staff 28 (CNA). On 11/6/24 at 10:00 AM Staff 1 provided completed competency checklists for Staff 17 and Staff 28. Staff 1 stated she did not have the requested completed competency checklists for Staff 18, Staff 26, and Staff 27.

Based on interview and record review it was determined the facility failed to ensure the required annual CNA training and annual performance reviews were completed for 2 of 5 sampled CNA staff (#s 26 and 28) reviewed for staffing. This placed residents at risk for unmet needs and lack of competent staff. Findings include: On 11/5/24 at 1:00 PM Staff 1 (Administrator) was asked to provide annual performance reviews and documentation of annual in-service training for Staff 26 and Staff 28. No annual performance reviews or in-service training documentation were provided for the identified staff members. On 11/6/24 at 10:00 AM Staff 1 (Administrator) stated in-service training was completed for CNA staff during staff meetings and via internet-based services. She stated she was recently hired and was not sure when or how evaluations were completed for staff. She acknowledged the identified CNA staff records did not show 12 hours of annual in-service training and did not include annual performance reviews. She stated the facility was not able to access the previous internet-based training service records, and the facility had not started the new internet-based training service.

Based on observation, interview, and record review it was determined the facility failed to provide a clean and homelike environment, and failed to ensure residents' belongings were safe for 2 of 7 sampled residents (#s 18 and 19) and 1 of 1 sunroom reviewed for environment and personal property. This placed residents at risk for an unclean, un-homelike environment, and missing belongings. Findings include: 1. Resident 18 admitted to the facility in 4/2023 with a diagnosis of a stroke. A care plan updated 5/21/24 revealed Resident 18 had hearing aids, but chose not to wear them. On 11/4/24 at 1:21 PM Witness 1 (Complainant) stated Resident 18 had hearing aids, but they were not in her/his room. Witness 1 stated this was reported to staff. On 11/6/24 at 11:42 AM Staff 4 (CNA) stated Resident 18 had hearing aids, but she was not aware where the hearing aids were located. On 11/5/24 at 1:25 PM Staff 3 (Social Services) stated she did not have a grievance for Resident 18's hearing aids. On 11/7/24 at 11:56 AM Staff 2 (Interim DNS) stated Resident 18 had hearing aids, but staff were not able to locate them. Staff 2 stated she would communicate with Resident 18's family to determine if family took the hearing aids home due to non-use. No additional information was provided. 35855 2. Resident 19 admitted to the facility in 3/2024 with diagnoses including depression and respiratory failure. On 8/1/24 the State Survey Agency received a public complaint which indicated the window in Resident 19's room was in disrepair. The glass fell out of the window but was not reinstalled correctly, and yellow and black caution tape was across the window. On 11/5/24 at 9:35 AM Staff 4 (CNA) stated the window in Resident 19's room was fastened with screws because without them the window would fall out. On 11/4/24 at 11:23 AM black and yellow caution tape in an 'X' pattern was observed around Resident 19's window in her/his room. Resident 19 stated the tape was there since she/he admitted to the room. Resident 19 stated she/he was not sure why the window was covered by the tape. On 11/7/24 at 9:54 AM Staff 12 (Maintenance) stated the facility received a bid to have the window fixed. Staff 12 stated if the window was opened the window would slide off its hinges. On 11/8/24 at 8:34 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated it was expected the window be fixed more quickly. 49676 3. On 11/4/24 at 12:11 PM the sunroom was observed with residents sitting in wheelchairs looking outside through the window. Cobwebs accumulated on the windows prevented a clear view for the residents. On 11/7/24 at 10:46 AM Resident 18 stated, The windows are awfully dirty. I sit here every day and look at filthy windows. They have been dirty for quite awhile. I just go with the flow and look out the filthy windows with all the black spiders. On 11/7/24 at 10:48 AM Resident 12 stated The windows have been dirty for awhile. On 11/7/24 at 10:43 AM Staff 12 (Maintenance) acknowledged the sunroom windows were not clean and needed pressure washed.

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 7 sampled residents (#27) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: Resident 27 admitted to the facility in 2/2024 with a diagnosis of a fracture to the right hip. A 5/20/24 Nursing Note indicated Resident 27 discharged from the facility to the hospital because she/he had copious amounts of pus drainage from her/his surgical site. A 6/6/24 hospital transfer orders indicated Resident 27 had active infection of Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterium which can cause serious infections in humans, is multi-drug resistant, and carriers could spread the infection even if they are not sick themselves). A 6/11/24 Nursing Note indicated Resident 27 had IV antibiotic treatment for an infected wound. No documentation was found in Resident 27's clinical record she/he was placed on precautions after readmitting to the facility on [DATE]. On 7/25/24 the State Survey Agency received a public complaint which indicated multiple residents admitted with MRSA and the biohazard receptacles were removed and Resident 27 developed a MRSA infection. On 11/5/24 at 11:58 AM Witness 9 (Complainant) confirmed the allegation Resident 27 developed MRSA in the facility due to lack of infection control. On 11/8/24 at 7:25 AM Staff 18 (CNA) stated Resident 27 readmitted from the hospital with MRSA. Staff 18 stated staff did not know Resident 27 had MRSA and she/he was not on any type of infection control precautions. On 11/8/24 at 9:16 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated they would review the information. Staff 2 provided a 7/3/24 care plan which indicated Resident 27 was placed on precautions 27 days after she/he readmitted to the facility. No further information or documentation was provided.

Based on observation, interview, and record review it was determined the facility failed to accommodate resident needs for 2 of 7 sampled residents (#s 8 and 14) reviewed for environment. This placed residents at risk for lack of independence. Findings include: 1. Resident 8 admitted to the facility on [DATE] with diagnoses including hemiplegia (weakness on one side of the body) and depression. On 11/5/24 at 2:38 PM Resident 8 complained she/he was moved to a different room because of a ceiling leak. She/he wanted to move back to the original room because that was where her/his adaptive equipment (trapeze and side rails) were installed to assist Resident 8 with bed mobility. When asked if there was adaptive equipment in her/his current room she/he replied, no it's in my old room. When asked how long she/he was without her/his adaptive equipment, she/he stated it was a few months. On 11/6/24 at 9:06 AM observation of Resident 8's previous room revealed the installed adaptive equipment. Observation of Resident 8's current room revealed no adaptive equipment. On 11/7/24 at 3:08 PM an interview with Staff 12 (Maintenance) revealed Resident 8 was moved from her/his room over two months ago because of a ceiling leak. Staff 12 confirmed he did not move Resident 8's adaptive equipment to the new room, and Resident 8 was without her/his adaptive equipment for over two months. 35855 2. Resident 14 admitted to the facility in 5/2023 with diagnoses including arthritis and intervertebral disc degeneration (one or more discs in the spine deteriorate). a. A 11/6/23 care plan indicated Resident 14 had an ADL self-care performance deficit with interventions including the use of an electric wheelchair for mobility. A 5/30/24 MDS revealed Resident 14's BIMS was 15 which indicated she/he was cognitively intact. On 7/24/24 the State Survey Agency received a public complaint which indicated Resident 14 requested a new power wheelchair since her/his admission as she/he was borrowing a power wheelchair which was too large for her/him. Resident 14's feet could not touch the floor. The physician completed the paperwork for the new power wheelchair a few months ago, but there was follow-up by staff. An 8/9/24 Communication form to Resident 14's provider indicated Resident 14 needed a prescription for a power mobility wheelchair. The provider's response on 8/13/24 was for a physical therapy evaluation to be completed and to schedule an MRI. No documents were found in clinical records a power wheelchair assessment was completed for Resident 14. A review of a Provider Note dated 8/12/24 revealed Resident 14 needed a prescription for a power mobility wheelchair. Resident 14 required a power wheelchair to interact in the community and attend medical appointments. An 8/29/24 Nursing Note revealed a request to the provider for Resident 14 for new wheelchair prescription. A 9/2/24 Provider Note indicated Resident 14 required access to a power wheelchair because of her/his inability to manually utilize a non-powered wheelchair. The power wheelchair she/he was currently using did not fit appropriately, and exacerbated many of her/his physical issues with pain. Resident 14 stated the frustration around the difficulties accessing care exacerbated her/his underlying anxiety and depression. A 9/5/24 Nursing Note stated a new prescription for a power wheelchair was received and sent to the wheelchair and mobility equipment company. An 10/19/24 physician order instructed staff to complete a referral for an electric wheelchair for Resident 14. On 11/6/24 at 9:42 AM Resident 14 stated she/he heard the wheelchair mobility equipment company declined her/his new wheelchair. Resident 14 stated the one she/he was using was too large and her/his feet did not touch the floor. On 11/7/24 at 9:24 AM Witness 7 (Complainant) stated Resident 14's wheelchair did not fit through her/his bathroom door, and she/he had to go to the bathroom in her/his incontinent brief. On 11/8/24 at 9:01 AM in interview with Staff 1 (Administrator) and Staff 2 (Interim DNS), Staff 2 stated she was working with the wheelchair and mobility equipment company because Resdient 14's insurance provider denied coverage for a new power wheelchair. Resident 14 provided incorrect information to the insurance compant and Staff 2 stated she was working to provide the correct information. b. On 3/6/24 the State Survey Agency received a public complaint which indicated Resident 14 could not access personal belongings because staff did not unpack them for her/him. Resident 14 could not reach her/his clothing as the clothing was located too high up in her/his closet for her/him to reach. A 11/6/23 care plan indicated Resident 14 had an ADL self-care performance deficit and required one staff assistance with most ADLs. On 11/6/24 Resident 14's room was observed with a shelf next to the window which was full of boxes. There were boxes in her/his closet which came out into the room approximately two feet. The clothes hanger bar in Resident 14's closet was too high for her/him to reach, and additionally the boxes prevented her/his access to the closet. A table located along the wall had multiple items stacked on it. Resident 14 stated staff informed her/him previously they would assist with unpacking the boxes when she/he moved into her/his current room. Review of Resident 14's room census revealed she/he moved into her/his room in 11/2023. On 11/7/24 at 9:24 AM Witness 7 (Complainant) stated staff did not lower Resident 14's clothes hanger bar in her/his closet and did not unpack her/his personal items in her/his room. On 11/8/24 at 7:25 AM Staff 18 (CNA) stated Resident 14 had boxes in her/his room which she/he wanted to go through. Staff 18 stated it was the responsibility of the CNA staff to assist residents to move and unpack their personal belongings and to take inventory. On 11/8/24 at 7:52 AM Staff 19 (CNA) stated it was the responsibility of the CNA staff to assist residents with putting away their personal belongings. On 11/8/24 at 8:44 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated they were unaware Resident 14 wanted her/his belongings unpacked and put away rather than left in boxes.

Based on observation, interview and record review it was determined the facility failed to provide essential services related to dialysis for 1 of 1 sampled resident (#26) reviewed for dialysis. An immediate jeopardy situation was identified. The facility failed to provide essential dialysis-related assessment, care planning and monitoring to Resident 26 resulting in pain, extensive bruising, and the likelihood of severe medical complications such as infection, bleeding, fluid overload, and adverse side effects including death. Findings include: Resident 26 was admitted to the facility in 2023 with diagnoses including acute kidney failure. A 5/19/23 Quarterly MDS revealed Resident 26's BIMS score was 15 which indicated she/he was cognitively intact. A 7/19/23 5:43 PM Nursing Progress Note revealed Resident 26 went out of the facility to obtain a dialysis port. No documentation was found in the clinical record for Resident 26's dialysis, monitoring of the dialysis port, schedule for dialysis or any additional information related to dialysis including emergency procedures. A 7/20/23 Physician Progress Note for a psychiatric telemedicine (use of technology to support physician services) visit revealed Resident 26 reported having pain to her/his dialysis port site. According to the 7/2023 MAR, on 7/20/23 at 11:16 AM staff administered acetaminophen (medication to treat mild to moderate pain) to Resident 26 for pain. Resident 26's pain level was not assessed. No other acetaminophen was documented as administered. Nursing Progress Notes on 7/19/23 at 9:28 PM, 7/21/23 at 2:20 AM and 7/22/23 at 2:19 AM by Staff 26 (LPN) repeated the exact words to document Resident 26 returned from surgery at approximately 6:30 PM, was resting quietly with eyes closed, and no complaints of pain to the surgical site. Resident 26's dressing was clean, dry and intact. Nursing Progress Notes on 7/21/23 at 3:20 PM by Staff 5 (LPN) were repeated word for word at 9:19 PM by Staff 25 (RN) to document Resident 26 had a recent placement of dialysis port to left chest wall with no redness, warmth, or signs or symptoms of infection and Resident 26 was medicated for pain PRN. Nursing Progress Notes on 7/23/23 at 11:15 PM by Staff 23 (LPN) were repeated word for word on 7/25/23 at 1:21 PM and 7/26/23 at 1:21 PM by Staff 25 to document Resident 26 was resting quietly with eyes closed with no complaints of pain to the surgical site, dressing was clean, dry and intact with no distress noted. No Nursing Progress Notes were found for 7/24/23. A review of Vitals Results for Pain from 7/5/23 through 7/31/23 revealed no pain level documented for Resident 26's pain. On 7/24/23 at 1:43 PM Resident 26 stated she/he had one dialysis port which was not taken out and was not working. Resident 26 reported she/he went to dialysis one time. Resident 26 stated she/he was in pain and had bruising from the procedure. Physicians' orders signed on 7/25/23 had no orders for dialysis services, monitoring of the central line dialysis port site or monitoring or treatment to the right failed port sites. On 7/25/26 6:54 AM Staff 8 (CNA) stated Resident 26 went to dialysis and was not in the facility that day. On 7/26/23 at 2:45 PM Staff 1 (Administrator) stated the facility did not have a contract for dialysis services. A 7/26/23 at 3:34 PM Nursing Progress Note revealed Resident 26 had recent placement of a dialysis port to the left chest wall with no redness, warmth or signs of infection noted. On 7/27/23 the comprehensive care plan was reviewed and revealed no information related to Resident 26's dialysis services. On 7/27/23 at 8:12 AM Staff 20 (CNA) stated Resident 26 was scheduled for dialysis transportation at 4:45 AM every Tuesday, Thursday and Saturday. Staff 20 stated Resident 26 had extreme bruising because attempts were madeto place two dialysis access ports, one on each side of her/his chest. Staff 20 stated after dialysis Resident 26 was tired, wanted to sleep and felt sick. On 7/27/23 at 8:24 AM a sticky note was observed on a CNA clipboard at the nurses' station which indicated Resident 26 had dialysis transport between 4:45 AM and 5:45 AM. On 7/27/23 at 12:37 PM Staff 3 (Clinical Operations Education Director) reported 7/27/23 was the first day Resident 26 went to dialysis. A 7/27/23 at 1:01 PM Nursing Progress Note revealed Resident 26 was assessed for pain to the right side of the chest around the failed dialysis port. The area was purple from the chest extending to the mid back. Across the front of the chest was yellowish from previous bruising. The new dialysis dressing was assessed and was clean, dry and intact. The port site was assessed for bruit (a murmur sound heard with a stethoscope over the carotid artery), which was positive. Nursing staff were to monitor each shift. On 7/27/23 at 1:56 PM Resident 26 was observed in her/his bed after dialysis by a nurse surveyor, and her/his chest had four square dressings approximately 1.5 by 1.5 inches. One was on her/his neck and then went down the right side of the chest to just above her/his nipple. Resident 26 was observed to have one square dressing of the same size on the left side of the chest and a white dressing below it which was approximately 4 inches long and 2 inches wide. Resident 26 had bruising the width of her/his chest from the neck to her/his nipples. The bruising was yellow with purple and redness throughout. Resident 26 stated that day was her/his third time she/he went to dialysis. On 7/28/23 at 11:07 AM Staff 5 stated Resident 26 was on dialysis and she could only monitor her/him and make sure the site for dialysis was not warm or anything like that, and that was all she could do. On 7/28/23 at 2:04 PM Witness 6 (Dialysis Administrative Assistant) stated they were using the central line on Resident 26's left side of her/his chest and did not provide treatment to any other area. Witness 6 stated Resident 26 started dialysis on 7/22/23, and received dialysis services on 7/25/23 and 7/27/23. Witness 6 stated a dialysis contract was sent to the facility but it was not returned. On 7/28/23 at 2:46 PM Staff 3 stated a dialysis central line should not be checked for bruit. On 7/28/23 at 5:39 PM Staff 26 stated Resident 26 complained of soreness and stiffness. Staff 26 did not believe Resident 26 had any bruising, thought Resident 26 had one dialysis access site and did not remember if it was on the right or left side of the chest. Staff 26 stated Resident 26 went to dialysis every Tuesday, Thursday and Saturday and thought she/he went to dialysis approximately four times. Staff 26 stated a dialysis communication sheet went with Resident 26 when she/he attended dialysis and it was then placed in a binder. No information was found in the clinical record Resident 26 had communication sheets for her/his attendance at dialysis. On 7/28/23 at 5:57 PM Staff 1 (Administrator), Staff 2 (DNS) , Staff 3 and Staff 17 (Regional Director of Operations) were notified of the immediate jeopardy (IJ) situation regarding the facility's failure to provide essential services related to dialysis including assessment, care planning, treatment and monitoring. This placed Resident 26, and any resident receiving dialysis services, at signifigant risk for infection, bleeding, fluid overload, and adverse side effects including death. As a result of the deficient practice, Resident 26 experienced pain and extensive bruising. On 7/28/23 at 8:00 PM Resident 26 was observed in her/his bed with Staff 2 and Staff 19 (RNCM) leaving the resident's room. Resident 26's chest continued to have bruising the entire width of her/his chest. On the left side of Resident 26's chest was a 4 inch by 2 inch dressing covering the dialysis access site. The smaller dressing previously observed on 7/27/23 after dialysis by the nurse surveyor was removed. On the right side of Resident 26's chest was a 4 inch by 4 inch dressing near her/his neck. All other dressings to the right side were removed as previously observed on 7/27/23 after dialysis. Three inches above the right nipple a square shaped discolored purple and red area was visible on Resident 26's skin with a pea sized round wound in the center. Staff 2 stated Resident 26 received the dressing change at dialysis the same day 7/28/23, and the remaining ports were removed at dialysis. There was no evidence in the clinical record Resident 26 had a port removal and dressing change on 7/28/23. On 7/28/23 at 9:29 PM an acceptable facility plan removing the immediate risk to resident health and welfare was accepted from and implemented by the facility. The plan indicated the following facility actions: -The facility would add and follow the Medical Director's order for dialysis written on 7/19/23 which was not in the medical record. -The facility conducted a facility wide physical resident audit of all residents on dialysis for dialysis access sites, infections, fluid overload and bleeding. -The facility would audit all dialysis care plans and update interventions and emergency intervention protocols in resident care plans. -The Clinical Manager would assess Resident 26's access ports to review neck, chest and mid-back for bruises. -The DNS or designee would audit for compliance two times a week for four weeks and monthly thereafter. -The facility would assess all residents currently on dialysis for bruising, bleeding, fluid overload, pain and evaluate bruits and thrills on appropriate dialysis residents by the end of day 7/28/23. -The care plans would be reviewed for all dialysis residents to ensure all emergency interventions were included in the plan of care. -The care plan for Resident 26 would be updated by end of day 7/28/23. -In-service of all staff would be completed starting 7/28/23 including reading and entering physician orders for dialysis, access care, dialysis schedule and monitoring for fluid restrictions. -Weights, vital signs, nutrition, abnormal lab results and pain would be assessed every shift. -The DNS would present relevant information to QAPI to ensure compliance. -Emergency kits and instructions for staff would be placed above dialysis residents' beds. On 7/31/23 at 9:10 AM Staff 3 stated Staff 5 completed wound treatment to Resident 26's right chest wounds on 7/28/23 without a physician order. Staff 3 reported the facility requested the physician orders for Resident 26's dialysis care.

Based on interview and record review it was determined the facility failed to timely respond to changes in condition and follow physician orders for 4 of 10 sampled residents (#s 2, 18, 26 and 129) reviewed for change of condition, position and mobility, UTIs and medications. This deficient practice was determined to be an immediate jeopardy situation as a result of a delay in treatment for Resident 129's sepsis (infection of the blood stream), UTI, lactic acidosis (buildup of lactic acid in blood stream), acute kidney failure, acute low blood pressure and GI bleed (bleeding in the intestinal tract). Resident 129 required hopsitalization, and died on [DATE]. Findings include: 1. Resident 129 was admitted to the facility in 2022 with diagnoses including heart attack, insomnia and muscle weakness. a. An [DATE] Quarterly MDS revealed Resident 129's BIMS score was an eight indicating severe cognitive impairment. Resident 129 received anticoagulant medications and required extensive assistence or was totally dependent with most ADLs. An [DATE] care plan indicated the following for Resident 129: -Impaired decision-making. -At risk for elevated blood pressure with interventions to assess weight as ordered, monitor for headache, lightheadedness and chest pain, provide diet and medications as ordered. -Impaired cardiovascular status with interventions including assess breath sounds as necessary, observe and report nausea, flushing, nosebleeds, shortness of breath, chest pain, edema, restlessness and fatigue. Monitor weight and report significant changes. On [DATE] Resident 129's blood pressure was checked which indicated her/his blood pressure was ,d+[DATE] and out of normal range. On [DATE] a SLP order was obtained and an evaluation was pending. A review of the Direct Care Staff Daily Reports [DATE] through [DATE] revealed there was no RN coverage on any shift for all days reviewed. A [DATE] Physician Progress Note indicated Resident 129 was seen for a follow-up for recent insomnia. Resident 129 reported she/he was sleeping better. The visit was completed via telemedicine (remote diagnosis and treatment using means of telecommunications technology). The Advanced Registered Nurse Practitioner ordered Resident 129's blood pressure to be checked daily. No documentation was found in Resident 129's clinical record her/his blood pressure was checked daily. The ,d+[DATE] MAR instructed staff to monitor sleep hours twice a day with a start date of [DATE]. From [DATE] through [DATE] documentation on the MAR revealed Resident 129 slept 10 to 12 hours a night. The ,d+[DATE] MAR instructed staff to administer Eliquis (a blood thinner) twice a day. No documentation was found in Resident 129's clinical record to indicate she/he was monitored for adverse side effects of the blood thinner. A [DATE] Monthly Summary revealed no vitals were checked for Resident 129, revealed her/his memory was per baseline, lungs were clear, bowel sounds were active, she/he had poor appetite and ate in her/his room. No progress notes were found in the clinical record from [DATE] at 2:44 PM through [DATE] at 12:52 AM. A Search Vitals Results for Fluids revealed the following total daily intake: -[DATE] 240 ml -[DATE] 220 ml -[DATE]: day shift 980 ml and no documentation fluids were offered after 6:29 PM -[DATE] no documentation of fluids offered until 9:34 AM, and the fluid were not accepted. On [DATE] Resident 129's oxygen saturation level was 73 percent which was out of the normal range. A [DATE] at 12:52 AM Nursing Progress Note indicated Resident 129 had two episodes of vomiting. Resident 129 was administered PRN nausea medication and Resident 129's temperature was 97.1 degrees. A [DATE] at 9:56 AM Nursing Progress Note indicated Resident 129 was unresponsive at 6:50 AM and vitals were documented: -temperature 97.2 -oxygen saturation 73 percent -blood pressure could not be read. A [DATE] emergency department Physician Note revealed Resident 129 admitted on [DATE] at 7:45 AM and was unresponsive. Resident 129 vomited during the night and when checked on in the morning she/he was unresponsive and the facility called emergency medical services. The resident's vital sign records revealed Resident 129's beats-per-minute heart rate was in the 40's. Emergency medical services noted a dark residue in her/his mouth. Witness 8 (Family Member) stated Resident 129 was on stomach acid reducing medication in the past but was not sure it was administered at the facility. During the physical exam of Resident 129's mouth she/he had dry mucous membranes and dark residue. When a catheter was placed her/his urine was cloudy yellow. At 6:16 PM it was noted she/he had a large volume of pus in the urinary catheter. Resident 129 was diagnosed with sepsis, UTI, lactic acidosis, acute kidney failure, acute low blood pressure and a GI bleed. Resident 129 died on [DATE] at 4:15 AM. A public complaint was received on [DATE] which indicated in mid-,d+[DATE] Resident 129 started vomiting and she/he was administered anti-nausea medication. Resident 129 was not eating or drinking enough. Resident 129 could barely whisper when she/he spoke. The week of [DATE] Resident 129 was still periodically vomiting and staff reported she/he had a virus. One evening around [DATE] Resident 129 was very sleepy and the CNA had a difficult time getting her/him to sit up to eat dinner. Resident 129 did not acknowledge the CNA and stared off into space. One side of her/his mouth was drooping. The CNA asked her/him questions and Resident 129 did not acknowledge her/him for an hour and it appeared Resident 129 was having a seizure. The CNA ran to get a nurse and Resident 129 vomited. Staff stated Resident 129 was fine and she/he was just getting sick. A CNA requested to have her/him evaluated and staff stated there was not much more they could do for her/him. The next morning concerns were reported to the administrative staff and a video conference was conducted. On [DATE] at 9:51 AM Witness 8 stated Resident 129 was non-responsive and would not make eye contact. On or around [DATE] Witness 8 spoke with the administrator and expressed concerns of a 12-hour delay for an assessment by a physician after the alleged seizure incident. Resident 129 had incidents of vomiting for almost a month and there was no follow up on her/his speech evaluation. Witness 8 confirmed the information in the [DATE] public complaint. On [DATE] at 10:58 AM Staff 34 (Social Services Director) stated Witness 8 had concerns about Resident 129's care. Staff 34 stated Resident 129 started sleeping more in ,d+[DATE] or ,d+[DATE]. On [DATE] at 11:18 AM Staff 32 (CNA) stated she worked the night Resident 129 vomited and reported it to Staff 33 (Former LPN). Staff 33 came in, observed Resident 129 and she/he vomited a huge amount. Staff 32 stated the week before Resident 129 went to the hospital, she/he slept more than usual, had increased confusion and her/his urine had an odor. Staff 32 stated Resident 129 took only little sips of fluids. Staff 32 stated prior to her/his transfer to the hospital Resident 129 did not recognize her and appeared to be afraid of Staff 32, which was not normal. On [DATE] at 5:30 PM Staff 26 (LPN) stated on [DATE] she administered Resident 129's mediations in the morning and later a CNA came in and stated Resident 129 was unresponsive. Staff 26 stated she had Resident 129 transferred to the hospital. On [DATE] at 10:27 AM, [DATE] at 11:35 AM, [DATE] at 11:22 AM and 11:35 AM and [DATE] at 11:08 AM Staff 3 (Clinical Operations Education Director) stated an order for a speech evaluation was requested but no one was available to complete the evaluation, so the request was sent to a third party and Resident 129 passed away before the evaluation could be completed. Staff 3 confirmed Resident 129 was not included in meetings held to discuss residents at high-risk relative to her/his weight loss. Staff 3 confirmed there was no monitoring for Eliquis, or blood pressure. Staff 3 confirmed physician orders for blood pressure monitoring daily were not followed. Staff 3 also confirmed no RN coverage in ,d+[DATE]. On [DATE] at 5:50 PM the facility administrative staff, including Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Clinical Operations Education Director) and Staff 17 (Regional Director of Operations) were notified of the immediate jeopardy (IJ) situation related to the facility's failure to document assessments and monitoring, follow physician orders, and identify and respond timely to significant changes of condition. On [DATE] at 10:20 PM an acceptable facility plan removing the immediate risk to residents' health and welfare was accepted from and implemented by the facility. The plan indicated the following facility actions: -Care plans would be updated by the end of day [DATE]. -The facility would in-service all staff on recognizing changes of conditions and interventions including: bowel care interventions, nausea, vomiting, vital signs, sepsis, UTI, acute kidney failure, low blood pressure, and GI bleeding. -Regional Nursing Consultant (RNC) would reeducate the DNS on the importance of recognizing resident change of condition by the end of day [DATE]. -DNS would present information to the QAPI committee to ensure compliance. -Education material included for DNS/Staff training: PowerPoint on change of condition and the facility's bowel protocol policy. -RN coverage for assessment and review: RNC would remotely assess once a week and be onsite once a month for two days, the MDS Coordinator would remotely assess once a week and speak with corporate recruiting on a plan of action to get a RN in house as soon as possible with corporate resources or agency. -Continue to monitor bowel care interventions, nausea, vomiting, vital signs, sepsis, UTI, acute kidney failure, low blood pressure, GI bleeding through correct progress notes, RNCM audits, quarterly QAPI meetings and care plan reviews. Refer to F656, F692 and F727 b. A [DATE] admission order revealed Resident 129 was to be administered 30 mg of lisinopril (blood pressure medication) daily. An [DATE] Physician Progress Note instructed staff to decrease lisinopril to 20 mg daily and hold the medication if the upper blood pressure reading was less than 110. An [DATE] Physician Progress Note indicated unfortunately Resident 129's lisinopril did not get decreased as previously ordered on [DATE]. An ,d+[DATE] MAR indicated Resident 129 received lisinopril as follows: -From [DATE] through [DATE] Resident 129 received 30 mg daily. -No documentation was found on the MAR Resident 129's blood pressure was monitored before administration of lisinopril, or lisinopril was reduced as ordered on [DATE]. A ,d+[DATE] MAR indicated on [DATE] Resident 129 was administered lisinopril 20 mg two times in one day. On [DATE] at 11:35 AM Staff 3 (Clinical Operations Education Director) confirmed Resident 129 was administered lisinopril two times on [DATE] and confirmed lisinopril physician orders were not followed. 2. Resident 26 was admitted to the facility in 2023 with a diagnoses including stroke, diabetes and depression. a. A ,d+[DATE] MAR instructed staff to weigh Resident 26 daily with frequency once a day on Monday. No weights were obtained from [DATE] through [DATE]. Resident 26 was weighed on [DATE] and weighed 212 pounds. The order was discontinued on [DATE]. A ,d+[DATE] MAR instructed staff to weigh Resident 26 weekly on Monday. The [DATE] and [DATE] weights were not obtained. On [DATE] Resident 26 weighed 187 pounds. On [DATE] at 1:40 PM Resident 26 stated she/he lost weight because she/he did not like the taste of the food and she/he only received fresh fruit once in a while. A [DATE] recapitulation signed physician order instructed staff to weigh Resident 26 daily with a start date of [DATE]. On [DATE] at 10:18 AM Staff 3 (Clinical Operations Education Director) confirmed Resident 26's weights were not completed as physician ordered. b. A [DATE] physician order instructed staff to administer sertraline (antidepressant) 150 mg once a day in the evenings. A ,d+[DATE] MAR revealed on [DATE] Resident 26 was administered sertraline twice. On [DATE] at 12:24 PM Staff 19 (RNCM) confirmed Resident 26 received two administrations of sertraline as dialysis ordered it to be given at night. Resident 26 received one dosage during the day and one at night. 3. Resident 2 admitted to the facility in 2022 with diagnoses including arthritis and dementia. A signed [DATE] PT Evaluation and Plan of Treatment instructed staff to use a PRAFO (Pressure relief ankle foot orthosis) brace to the left foot. A [DATE] Nursing Progress Note revealed an email was received from PT, Staff 2 (DNS) was aware and a copy was provided to Staff 1 (Administrator) to order the PRAFO boot. Review of the ,d+[DATE], ,d+[DATE] and ,d+[DATE] MAR/TAR and clinical records revealed no documentation, staff instructions, administration or refusals of the PRAFO boot to the left foot. On [DATE] at 10:20 AM Staff 3 (Clinical Operations Education Director) stated the PRAFO boot order should be documented on the MAR and staff should document refusals. 41455 4. Resident 18 was admitted to the facility in 2023 with diagnoses including depression and stroke. The [DATE] through [DATE] MAR indicated Resident 18 was administered Lopressor (heart medication) twice daily. The [DATE] signed Physician Order Report directed staff to administer Lopressor to Resident 18 twice daily with special instructions to hold the medication for systolic (upper blood pressure reading) less than 100 or diastolic (lower blood pressure reading) less than 60. A [DATE] through [DATE] Search Vitals Results revealed the following blood pressure readings for Resident 18: -On [DATE]: ,d+[DATE] -On [DATE]: ,d+[DATE] -On [DATE]: ,d+[DATE] -On [DATE]: ,d+[DATE] On [DATE] at 1:54 PM Staff 2 (DNS) stated Resident 18's physician's order for Lopressor was not followed. 34703

Based on observation, interview and record review it was determined the facility failed to provide adequate supervision to prevent accidents and failed to implement fall risk interventions and thoroughly investigate falls for 2 of 4 sampled residents (#s 20 and 25) reviewed for accidents. Resident 20 experienced a fall resulting in a leg fracture. Findings include: 1. Resident 20 was admitted to the facility in 2023 with diagnoses including weakness and a history of falls. A 2/21/23 Hospital PT note indicated Resident 20 was a two-person maximum assist to sit on the edge of the bed and a two-person moderate assist to stand. A 3/1/23 through 3/31/23 Point of Care document indicated Resident 20 was provided extensive assistance with physical help for transfers and toilet use. Resident 20's MDS dated [DATE] indicated Resident 20 was a two-person transfer. The 3/9/23 care plan indicated the resident would be free from falls and did not include transfer interventions. On 3/14/23 at 4:29 PM a Nursing Progress Note indicated Resident 20 incurred a ground level fall from the commode during a failed one-person transfer by Staff 38 (Former CNA). Resident 20 complained of knee pain. A Nursing Facility Fall Report dated 3/15/23 at 8:50 PM indicated the resident fell on [DATE] around 6:30 PM in the evening and the report was not complete. On 7/25/23 at 8:13 AM Resident 20 stated she/he turned on her/his call light to use the commode. Resident 20 stated staff entered her/his room and began to transfer her/him, but Resident 20 became dizzy and fell on her/his knees. Resident 20 stated it hurt bad. Resident 20 stated her/his pain was worse that night in her/his right knee and the knee became swollen. On 7/28/23 at 12:03 PM Staff 2 (DNS) stated Resident 20 fell on [DATE] in the evening. Staff 2 stated there was no documentation Staff 27 assessed the resident all night. Staff 2 stated when he arrived to the facility the morning of 3/15/23 he checked on Resident 20 with Staff 39 (Former RNCM) and found Resident 20 in pain and her/his right knee was swollen. Staff 2 sent the resident to the hospital and she/he returned after treatement for a fractured leg resulting from the 3/14/23 fall. On 7/31/23 at 1:19 PM Staff 27 stated she checked on the resident twice, once while she/he was sleeping, and the second time Resident 20 stated her/his knee hurt. Staff 27 acknowledged she did not document the two assessments. 41455 2. Resident 25 was admitted to the facility in 2023 with diagnoses including depression and dementia. A 5/4/23 Admission MDS indicated Resident 25 required two staff for transfers. A 6/28/23 Event Report indicated Resident 25 fell from her/his wheelchair on 6/28/23 while in her/his room and no injuries were noted. Resident 25 stated she/he attempted to transfer herself/himself into bed. Staff 37 (LPN) documented she and another nurse heard a scream for help coming from Resident 25's room and observed Resident 25 sitting on the floor leaning against her/his wheelchair. Resident 25 was educated to use her/his call light. No follow-up notes related to Resident 25's fall were indicated. A 6/29/23 revised care plan indicated to check Resident 25 regularly when in her/his chair to ensure safety and her/his bed was to be in the lowest position. A 6/29/23 progress note revealed Resident 25 had a bruise on her/his left thigh. On 7/26/23 at 4:55 PM Staff 18 (CNA) was observed exiting Resident 25's room without lowering her/his bed and stated she was not aware Resident 25 was a fall risk. On 7/27/23 at 12:25 PM Staff 5 (LPN) stated she was a nurse who was present when Resident 25 fell on [DATE] and no witness statement was requested. Staff 5 explained Resident 25 slid out of her/his wheelchair because of a loose cushion on the chair and a pillow placed behind her/his back that made Resident 25 lean forward. On 7/27/23 at 12:26 PM Resident 25's empty wheelchair was observed to contain a large pillow and loose wheelchair cushion covered with a loose blanket. Staff 5 confirmed the cushion and pillow observed were the same that were present on the day of Resident 25's fall. On 7/31/23 at 4:38 PM Staff 2 (DNS) stated witness statements and the note of Resident 25's bruising should have been obtained as part of the investigation of Resident 25's fall. Staff 2 stated he did not follow up on Resident 25's fall after he read the incomplete initial report. Staff 2 also stated all staff should read care plans and be aware of Resident 25's fall interventions to prevent futher falls and this was not done.

Based on observation, interview and record review it was determined the facility failed to ensure a PRN order for an antipsychotic was not in place for more than 14 days, failed to to identify or monitor targeted behaviors for the use of an antipsychotic and failed to have a system in place to determine the efficacy of an antipsychotic and communicate such to the physician for 3 of 3 sampled residents (#s 16, 18 and 19) reviewed for unnecessary medications. This failure resulted in new and prolonged significant change in alertness for Resident 16. Findings include: 1. Resident 16 admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The resident was severely cognitively impaired. Resident 16's Cognitive Loss and Behavioral Symptoms CAA completed on 8/10/20 assessed the resident's behaviors as wandering into other resident's rooms, swearing and striking at staff, especially out of anger when staff attempted to redirect her/him, and digging in the garbage. Resident 16's current care plan indicated multiple care areas related to behaviors and revealed behaviors were not new: 6/13/17 - Behavioral Symptoms: refusing care and yelling at staff at times. Interventions: approach resident in unhurried and calm manner; resident responds well to smiles; resident enjoys social activities and visiting with friends; reassure resident; when refuses care, re-approach later or offer a different time; 7/18/18 - Behavioral Symptoms: resident to resident verbal and physical altercations. Interventions: allow resident to have control over situations; convey an attitude of acceptance toward resident; support appropriate moods and behaviors; 12/3/18 - Behavioral Symptoms: cursing at staff; inappropriate hand gestures when redirected; striking out at staff; wandering; rummaging through garbage. Interventions: resident's strength was she/he can often be redirected with food; allow resident to have control over situations; avoid over-stimulation; do not engage resident in sensitive conversation when resident uses foul language or body gestures; offer food or fluids; check for other areas of discomfort which may contribute to behaviors 10/2/20 - Behavioral Symptoms: wandering; entering other resident's rooms; exit seeking; removing [MEDICAL CONDITION] bag and disposing of it in inappropriate areas; opening doors to the stairwells. Interventions: allow resident to have control over situations; when resident enters other rooms redirect to her/his room and offer food, fluids and activity; convey an attitude of acceptance; maintain a calm environment and a calm, slow approach; if available have a staff member take resident outside; seat resident where constant or near constant observation is possible; when resident is exit seeking, redirect to her/his room. 10/6/20 - Behavioral Symptoms: refused to wear a mask. Interventions: provide a mask and give reminders; social services and activities will spend 1:1 time each day. A 10/6/20 fax to the resident's physician from Staff 9 (RN) revealed the resident was an elopement risk and had behaviors which included going into other residents' rooms, touching personal protective equipment (PPE) with unclean hands, combative towards staff and cursed at staff when redirection was attempted. The physician responded with an order for [REDACTED]. A review of Resident 16's MAR from 10/1/20 through 1/31/21 revealed the order for PRN [MEDICATION NAME] remained continuous throughout that time period. The MAR indicated [REDACTED]. According to the MAR, the resident received the PRN [MEDICATION NAME] for the following reasons: *increased agitation - 14 times *going into other residents' rooms - 17 times *eloping - 4 times *removing [MEDICAL CONDITION] bag - 1 time *wandering - 1 time *throwing feces - 1 time *attempted to get on elevator - 1 time *getting into PPE - 1 time *inappropriate behavior, refused to wear a mask - 1 time. Follow up documentation of the PRN administration of [MEDICATION NAME] indicated 15 out of the 41 times the medication was either not effective or no follow up was done. A review of Resident 16's clinical record did not reveal any documentation the resident's physician directly examined the resident, evaluated her/his use of PRN [MEDICATION NAME] or wrote a new order every 14 days. A 12/18/20 physician order [REDACTED]. On 12/22/20, just four days after the resident started the scheduled [MEDICATION NAME], a fax to the resident's physician from Staff 2 (DNS) indicated Resident 16 currently received 1 mg of [MEDICATION NAME] every night and 0.5 mg of [MEDICATION NAME] every two hours PRN yet the resident continued to wander into other residents' rooms, strike out at staff and exit seek. She requested an additional scheduled dose of [MEDICATION NAME] for the resident. The physician agreed with the request for an additional 0.5 mg of [MEDICATION NAME] scheduled at 2:00 PM. A review of Resident 16's clinical record revealed no documentation related to the specific behaviors manifested by agitation the [MEDICATION NAME] was meant to address. A review of Resident 16's progress notes from 5/1/20 through 1/31/21 revealed the resident exhibited the same behaviors throughout that time period. A 1/13/21 progress note for the resident indicated same behaviors continue [MEDICATION NAME] ineffective. No evidence was found to indicate a behavior monitoring system was in place to determine if the antipsychotic was effective in treating the resident's behaviors. The FDA Black Box Warning for [MEDICATION NAME] indicated the medication was not approved for use by elderly patients with dementia-related [MEDICAL CONDITION] (behaviors that can include agitation or aggressive behavior) and those patients were at an increased risk of death from the use of the medication. The FDA label also revealed adverse side effects including [MEDICAL CONDITION] events such as stroke, somnolence (sleepiness or drowsiness), abdominal pain, dizziness, agitation and akathisia (a movement disorder). A review of Resident 16's current care plan did not reveal any documentation related to the resident's use of [MEDICATION NAME]. A review of the resident's clinical record did not reveal documentation related to the possible side effects of [MEDICATION NAME] or what and how the staff should monitor the resident. A 1/7/21 Pharmacy Consultant Recommendation requested Resident 16's physician to consider a trial reduction of [MEDICATION NAME] to 0.5 mg at 2:00 PM and 0.5 mg at bedtime and noted the [MEDICAL CONDITION] committee reported the resident was overly somnolent in the mornings. Staff 3 documented on the nursing assessment portion of the recommendation that the resident did not exhibit behaviors aside from wandering. A fax dated 1/25/21 from the resident's physician in response to the Staff 3's assessment on the pharmacy recommendation indicated the physicians response was I don't know who you are talking to because I am being told otherwise. I have multiple faxes that patient is verbally abusive and have assaulted fell ow residents/staff. Do not change! A fax communication from Resident 16's physician dated 1/25/21 in response to the pharmacy consultant's notification that [MEDICATION NAME] was prescribed for the resident without an adequate indication for use revealed patient has been assaulting staff and residents and with [MEDICATION NAME] those behaviors have been controlled. A review of Resident 16's clinical chart did not reveal incident reports related to any assaults indicated in the physician's documentation. Observations of Resident 16 from 1/20/21 through 1/26/21 revealed the following: - 1/20/21 1:18 PM the resident was asleep in bed with her/his lunch tray on the bedside table untouched. - 1/20/21 3:10 PM the resident sat on the edge of her/his bed, rocked back and forth slightly and appeared extremely drowsy. - 1/25/21 2:03 PM the resident laid in bed on her/his right side and gently rocked back and forth. The resident's eyes were open and stared straight ahead with glazed eyes. She/he did not react to movement in the doorway. - 1/25/21 3:12 PM the resident remained awake in the same position in her/his bed, with her/his eyes open in a glazed stare. - 1/25/21 4:27 PM the resident was in her/his wheelchair in her/his room staring at the blank wall with glazed eyes. - 1/26/21 12:09 PM the resident propelled her/himself up and down the hall bent forward in the wheelchair. She/he appeared withdrawn and did not interact with staff who said hello or stopped to talk to the resident. - 1/26/21 12:30 PM the resident was unable to hold the telephone while she/he talked with family on the phone in the hall. Her/his words were mumbled and incomprehensible. Staff 3 informed Staff 4 the behavior was a side effect of the [MEDICATION NAME]. On 1/20/21 at 1:21 PM Staff 7 (LPN) reported Resident 16 was more tired and slept most of the day since she/he started the [MEDICATION NAME]. On 1/26/21 at 11:41 AM Staff 11 (CMA) reported the resident seemed overmedicated. She explained the resident was zoned out which was not baseline for the resident. Staff 11 stated Resident 16 was usually up and she/he frequently requested food in between meals but now the resident slept all day and ate very little. On 1/26/21 at 12:02 PM Staff 7 reported she and Staff 3 both faxed Resident 16's physician and requested a decrease in the [MEDICATION NAME] due to the resident's decline and the physician would not decrease it. On 1/26/21 at 12:24 PM Staff 20 (CNA) reported Resident 16 slept more during the last couple of weeks. She stated the resident was like a zombie. On 1/26/21 at 1:15 PM 16 (CNA) stated the resident declined and slept more. On 1/27/21 at 12:37 PM Staff 4 (Social Services) stated she led the monthly [MEDICAL CONDITION] medication meetings and was not aware of the regulation related to the 14 day limit for PRN anti-psychotic medication orders. She confirmed the resident was not examined by her/his physician related to the use of the PRN [MEDICATION NAME]. Staff 4 stated there was not a system to monitor the resident's behaviors or the efficacy of the medication. She further stated she was not aware of specific monitoring for side effects of [MEDICATION NAME]. Staff 4 reported the resident was more groggy and slept more since she/he started the medication. On 1/27/21 at 1:20 PM Staff 7 (LPN) reported Resident 16 continued to exhibit the same behaviors as before the [MEDICATION NAME] was started. She explained the resident tried to get into things but staff would just try to redirect. She reported she usually kept the resident near her or another staff member and that intervention was effective. Staff 7 stated she did not agree with the [MEDICATION NAME] because she did not believe the resident needed it. She further reported the PRN [MEDICATION NAME] was never administered during her shift because they did not have the need to use it. She said only certain staff reported issues with behaviors from Resident 16. On 1/27/21 at 1:23 PM Staff 18 (CNA) reported she noticed a big difference in Resident 16 since Christmas. She explained the resident was now sleeping more and not her/himself. A review of Resident 16's hospital discharge date d 1/30/21 revealed the [MEDICATION NAME] was discontinued by the hospital physician per Witness 7's request. On 2/1/21 at 9:45 AM Staff 5 (Activity Director) stated in the last month the resident did not seem like her/himself. She reported Resident 16 was really tired and her/his eyes were glossed over. On 2/1/21 at 2:10 PM Witness 3 (Complainant) reported she was told the resident was started on the medication because she/he went into other residents' rooms. She stated the resident was likely bored and she did not agree with the use of the medication for that purpose. Witness 3 reported she believed the facility overmedicated the resident and used the medication instead of caring for her/him. She further reported when she visited the resident in 12/2020, the resident just stared and did not look at her. She explained the resident's behavior was odd and much different than when she visited the resident in 8/2020. She stated she was not aware the resident was on the [MEDICATION NAME] at that time. Witness 3 reported she was concerned with the withdrawn behavior of Resident 16 so the next day she called and asked staff why she/he seemed so different. She stated staff informed her at that time the resident started taking the antipsychotic which likely explained the changes. Witness 3 reported the resident recently went to the hospital and was found to have a UTI. She further reported the hospital physician informed her the side effects from the [MEDICATION NAME] masked the symptoms of the UTI which resulted in the severity of the UTI. On 2/1/21 at 4:16 PM Witness 7 (Pharmacy Consultant) reported Staff 2 contacted her in December because she wanted to increase Resident 16's scheduled [MEDICATION NAME]. She stated her recommendation to Staff 2 at the time was to eliminate the PRN [MEDICATION NAME] if she wanted to increase the scheduled dose. She further stated PRN psychoactive medications were meant to stabilize a patient on a short term basis only. Witness 7 stated during the January medication review, she recommended the physician discontinue the PRN as well as decrease the scheduled dose because the resident was overly somnolent. During observations of the resident on 2/2/21 and 2/3/21 she/he appeared noticeably more alert and bright eyed. The change in the resident was much like she/he was a different person. She/he was observed to look up at and interact with staff verbally. On 2/2/21 at 1:24 PM Staff 3 (RNCM) reported she was not aware of the regulation related to PRN antipsychotic medication orders. She stated the physician did not assess the resident related to the use of the [MEDICATION NAME] and the PRN order was continuous rather than renewed every 14 days. Staff 3 confirmed the clinical record did not provide documentation of the specific behaviors the PRN [MEDICATION NAME] was targeted to manage. She further confirmed there was no behavior monitoring in place. Staff 3 confirmed the care plan was not updated to include antipsychotic medication use or monitoring. Staff 3 reported she did not witness any behaviors which would warrant the use of an antipsychotic. She confirmed the resident's behaviors documented in the progress notes remained unchanged since the [MEDICATION NAME] started and indicated the medication was not effective to manage the resident's behaviors. Staff 3 further stated Resident 16's [MEDICATION NAME] order was unnecessary and was used as a convenience for staff more than anything else. She stated the resident became obtunded (lessened interest in environment, slowed response to stimulus and increased drowsiness). She further stated when Resident 16 went to the hospital and a UTI was diagnosed , the [MEDICATION NAME] was discontinued altogether and as a result the resident was more like her/himself again. Staff 3 reported she faxed the resident's physician to request the [MEDICATION NAME] be reduced or discontinued and informed the physician of the resident's somnolence since she/he started the medication. She stated the physician indicated other nurses in the facility reported otherwise and declined to decrease or discontinue the [MEDICATION NAME]. Staff 3 stated the staff who faxed the physician were not involved in the [MEDICAL CONDITION] meetings and did not understand the regulations related to the medications and should not have interfered with the physician communication related to the medication. 2. Resident 18 admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. The 12/20/20 Quarterly MDS Assessment revealed the resident had a BIMS score of 13 which indicated she/he was alert and oriented. The assessment revealed the resident received antipsychotic, antianxiety and antidepressant medications daily. A review of Resident 18's 1/2021 MAR indicated [REDACTED] *[MEDICATION NAME] (an antipsychotic) daily for behaviors of hitting/kicking *[MEDICATION NAME] (an antidepressant) daily for [MEDICAL CONDITION] *[MEDICATION NAME] (an antianxiety) daily for anxiety A review of the resident's clinical record did not indicate any monitoring was done for behaviors, including hitting, kicking or behavioral manifestations of depression and anxiety to determine the effectiveness of the medications. On 2/21/21 at 1:24 PM Staff 3 (RNCM) confirmed there was no behavior monitoring in place. 3. Resident 19 admitted to the facility in 6/2019 with [DIAGNOSES REDACTED]. The 11/15/20 Quarterly MDS Assessment indicated the resident was fully alert and oriented and exhibited verbal behaviors and rejection of care one to three days per week. The assessment revealed the resident received an antipsychotic daily. A 10/27/20 fax sent to the resident's physician by Staff 9 (RN) indicated the prescribed [MEDICATION NAME] (an antipsychotic) was no longer effective and the resident was still combative, actually hitting and kicking the staff. Staff 9 requested an order for [REDACTED]. A review of Resident 19's 1/2021 MAR indicated [REDACTED]. A review of the resident's clinical record revealed no monitoring of the resident's behaviors to determine the effectiveness of the medications. On 2/21/21 at 1:24 PM Staff 3 (RNCM) confirmed there was no behavior monitoring in place.

Based on interview and record review it was determined the facility failed to develop and implement written policies related to required abuse training and reporting of abuse for 2 of 2 sampled residents (#s 16 and 21) reviewed for abuse. This failure resulted in psychosocial harm as evidenced by Resident #16's depressed mood and expression of fear and anxiety. Findings include: The facility's 4/2010 Reporting Abuse to Facility Management policy revealed the following: - It was the responsibility of employees to promptly report incidents or suspected incidents of resident abuse to facility management. - To assist with recognition of incidents, abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; and mental abuse was defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. - All personnel were encouraged to report incidents of resident abuse or suspected incidents of abuse and reports could be made without fear of retaliation from the facility or it's staff. The facility's 7/2017 Abuse Investigation and Reporting Policy indicated All reports of resident abuse .mistreatment .shall be promptly reported to local, state and federal agencies .and thoroughly investigated by facility management. Review of the facility's written policies and procedures related to abuse did not reveal any documentation related to required employee abuse training. A review of the documentation of staff abuse and behavioral management training indicated only 4 out of 23 direct care staff completed the required annual training. 1. Resident 16 admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The resident had a BIMS of 2 which indicated severe cognitive impairment. A complaint intake dated 5/1/20 indicated Staff 6 (LPN) tipped Resident 16's wheelchair backwards with the resident in it and aggressively told the resident to stay in her/his room. Additionally the complaint intake revealed Staff 6 instructed Witness 1 (Complainant) to withhold juice the resident requested without a medical reason. Witness 1 indicated in the complaint they did not report the concerns to management due to fear of retaliation. A complaint intake dated 9/29/20 indicated Staff 6 shoved Resident 16 in her/his wheelchair through the door and into her/his room forcefully. The complaint further indicated the behavior had gone on for some time but staff were afraid to report due to fear of retaliation. One investigation was found related to abuse towards Resident 16. It was completed on 9/26/20 and indicated Staff 6 allegedly transported the resident in an unsafe manner. A review of the investigation revealed: * There were no descriptions to explain how the wheelchair transport was unsafe. * Resident 16 had dementia, was alert to her/his name, recognized family and reported God spoke to her/him; yet the resident was able to deny psychological harm from the incident. * The resident was asked a series of yes or no questions, none of which were related to the incident cited in the allegation. * Staff statements documented in the investigation revealed the following: - Staff 11 (CMA) reported Staff 6 pushed the resident in her/his wheelchair in a manner that she felt was unsafe. - Staff 6 denied pushing the resident in the wheelchair in a manner that would place the resident at risk for injury. - Of the four additional interviews with staff, only one of them was interviewed related to the allegation of the unsafe wheelchair transport. The one staff reported she did not witness staff push the resident forcefully in the wheelchair. On 1/20/21 at 1:21 PM Staff 7 (LPN) stated some staff were agitated towards Resident 16 but did not think the staff's behavior was abuse. On 1/25/21 at 2:18 PM Staff 14 (CNA) reported she had abuse training in school but did not receive training from the facility. On 1/25/21 at 4:44 PM Staff 2 (DNS) reported she completed an investigation related to unsafe wheelchair transport in 9/2020 and did not find abuse. She stated the staff person who reported the alleged abuse was upset with Staff 6 which was why she reported the incident. Staff 2 denied any additional allegations of mistreatment towards Resident 16. On 1/26/21 at 12:24 PM Staff 20 (CNA) stated she reported concerns about evening shift staff yelling at Resident 16 and treating her/him roughly to management. She stated other staff would not report because they were worried about retaliation. On 1/26/21 at 1:15 PM Staff 16 (CNA) described the way Staff 6 and Staff 12 treated Resident 16 as both abuse and a dignity issue. She stated she reported her concerns to Staff 1 (Administrator). She further stated she probably should have made more of an official statement however she was used to things being swept under the rug by management. Staff 16 stated most of the staff were hesitant to speak up because the staff they reported would make our worlds tougher. On 1/26/21 at 1:55 PM Staff 15 (CNA) stated she reported concerns of verbal abuse towards Resident 16 by Staff 10 to management but nothing usually happened when concerns were brought to management. She reported when she advocated for resident's she was disciplined for minor infractions or punished with schedule changes. On 1/27/21 at 12:26 PM Staff 1 reported the first time he heard of any concerns related to mistreatment towards Resident 16 by Staff 6 was on 9/24/20. He stated at the time Staff 2 (DNS) investigated the incident and she determined abuse did not occur. He reported Staff 2 did not share anything related to the investigation with him besides abuse was ruled out. Staff 1 stated there were no other abuse allegations or investigations related to Resident 16. On 1/27/21 at 12:37 PM Staff 4 (Social Services) reported she witnessed what she thought was abuse towards Resident 16 and she informed Staff 1 of the incident on 9/1/20. She stated Staff 1 thanked her for letting him know but she did not hear anything more. On 1/27/21 at 1:23 PM Staff 18 (CNA) stated she reported concerns of mistreatment by Staff 6 towards Resident 16 to management, including Staff 1, and as a result became the target of hostile staff. On 2/1/21 at 9:31 AM Staff 23 (Confidential Staff) reported one day during the week of 1/18/21 at approximately 3:30 PM Resident 16 told her she/he was scared of the mean people. She stated the resident told her they're mean; they're scary and it's bad out there. Staff 23 stated the evening shift staff were not as patient with Resident 16 and tended to get upset with her/him. She reported Staff 6 and Staff 12 yelled at the resident and treated the resident like a dog when they pointed down the hallway and told her/him to go to her/his room. Staff 23 said Staff 6 and Staff 12 did not treat the resident like a human being. She reported concerns related to staff mistreatment of [REDACTED]. On 2/1/21 at 9:45 AM Staff 5 (Activity Director) reported there was no real abuse training. She stated there were two in-services done related to abuse but the training was not comprehensive. On 2/2/21 at 12:02 PM Staff 8 (Housekeeping) stated she informed Staff 1 of concerns which she described as verbal and mental abuse towards Resident 16 by Staff 6 and Staff 12 and he told her it would be investigated. She said the same concerns were brought up many times in morning huddle by other staff. On 2/2/21 at 1:24 PM Staff 3 (RNCM) confirmed concerns related to staff's mistreatment of [REDACTED]. On 2/3/21 at 2:52 PM Staff 1 (Administrator) confirmed he was aware of the concerns related to the staff mistreatment of [REDACTED]. He confirmed he did not investigate or report the concerns as abuse. Refer to F600 and F603. 2. Resident 21 admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. On 2/2/21 at 12:52 PM Resident 21 reported Staff 2 went into her/his room on 2/1/21 and started in on me. The resident stated she/he told Staff 2 she/he felt picked on and motioned for her to leave the room. Resident 21 reported Staff 2 would not leave her/his room. The resident further stated Staff 2 has it in for me because I talk back to her. On 2/2/21 at 5:39 PM Staff 19 (CNA) reported when Staff 2 went into Resident 21's room, she remained near to witness the interaction because Staff 2 frequently kind of picks on the resident. She reported on the evening of 2/1/21 the resident became really upset and asked Staff 2 to get out of her/his room twice but Staff 2 would not leave. Staff 19 reported she asked Staff 2 to respect the resident's wishes and leave the room. She said Staff 2 immediately retaliated against her and told her they would have a meeting the following day with Staff 1 (Administrator) due to her insubordination. She stated Staff 2 frequently used threats of discipline against staff who advocated for residents. On 2/3/21 at 2:20 PM Staff 3 (RNCM) said Resident 21 informed her she/he felt like Staff 2 repeatedly targeted and punished her/him. Staff 3 reported most of the staff witnessed how Staff 2 riles up Resident 21. She reported Staff 2 intended to fire Staff 19 because she stepped in during the incident on 2/1/21. On 2/3/21 at 2:52 PM Staff 1 (Administrator) reported he talked with Resident 21 following the interaction and she/he was really upset about the way she/he was treated by Staff 2. On 2/4/21 at 1:26 PM Staff 14 (CNA) reported when Staff 2 went into Resident 21's room on the night of 2/1/21 she remained nearby to listen to the interaction because she knew the resident would be upset. She reported after the resident asked Staff 2 to leave her/his room twice with no result, Staff 19 spoke up and told Staff 2 she needed to do as the resident asked. She reported Staff 2 then told Staff 19 she would be disciplined for intervening. Staff 14 reported Staff 19 was in trouble only because she advocated for the resident when Staff 2 was abusive. On 2/8/21 at 8:54 AM Staff 6 (LPN) reported when Staff 2 approached Resident 21's room on the evening of 2/1/21 she chose to stay in the med room two doors away so she could hear the interaction. She reported Staff 2 was inside the resident's room just harping on the resident with a raised voice and when the resident yelled at Staff 2 to leave her/his room she would not leave. Staff 6 reported Staff 19 stepped in and calmly told Staff 2 to leave the resident's room because the resident was visibly upset. She reported Staff 1 frequently wrote staff up for insubordination when they advocated for a resident. Staff 6 reported the facility provided vague training related to abuse and behaviors and it was only provided when the facility received a citation. Refer to F600.

Based on observation, interview and record review it was determined the facility failed to protect residents from verbal and mental abuse for 2 of 2 sampled residents (#s 16 and 21) reviewed for abuse and dignity. This failure resulted in psychosocial harm as evidenced by Resident #16's depressed mood and expression of fear and anxiety. Findings include: The facility's 4/2010 Reporting Abuse to Facility Management policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy further defined mental abuse as, but not limited to, humiliation, harassment, threats of punishment or withholding of treatment and services. 1. Resident 16 admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The resident was severely cognitively impaired. A complaint intake dated 5/1/20 indicated Staff 6 (LPN) tipped Resident 16's wheelchair backwards with the resident in it and aggressively told the resident to stay in her/his room. Additionally the complaint intake revealed Staff 6 instructed Witness 1 (Complainant) to withhold juice the resident requested without a medical reason to withhold the juice. A review of the resident's clinical record did not indicate the resident was on fluid restrictions. The resident's care plan indicated the resident was at risk for dehydration and fluids, including juices, were to be encouraged throughout the day and night A 5/31/20 progress note revealed the resident made comments that she/he was so lonely. An 8/16/20 progress note indicated the resident reported being lonely and asked staff to check on her/him often. On 9/29/20 a public complaint was received that alleged Staff 6 shoved Resident 16 in her/his wheelchair into her/his room from the doorway. On 1/20/21 at 1:47 PM Staff 13 (CNA) reported she witnessed verbal abuse by Staff 12 (CMA) towards Resident 16. She further stated she also witnessed Staff 9 (RN) frequently be unkind to Resident 16. She reported the resident was not able to report if someone mistreated her/him. On 1/20/21 at 1:21 PM Staff 7 (LPN) stated some staff were more agitated with Resident 16 than others. On 1/20/21 at 3:15 PM Resident 16 was observed to propel her/his wheelchair in the hall as Staff 19 (CNA) exited another resident's room carrying a trash bag. Without saying anything to the resident, Staff 19 immediately used her one free hand to turn Resident 16's wheelchair around and pointed it towards her/his room. The resident wheeled her/himself back to her/his room. On 1/20/21 at 3:25 PM Resident 16 was observed at the entrance to the open med room door and Staff 12 (CMA) stated loudly and in an agitated manner no! not in here! to the resident. The resident wheeled her/himself back to her/his room. On 1/20/21 at 2:07 PM Resident 16 was observed to propel her/his wheelchair to the nurse's station and turned out of sight where day and evening staff were all huddled. From down the hall Staff 12 (CMA) was heard to say in an agitated and loud voice Oh no, I am not dealing with this today. Immediately following the her statement, Resident 16 exited the area and returned to her/his room. Observations made of Resident 16 on 1/26/21 between 10:00 AM and 2:00 PM revealed the resident propelled her/his wheelchair through the hall. The resident frequently appeared content to look around and be near staff. The unit was noticeably less restrictive during the day shift than it was during previous evening shift observations. Staff did not restrict Resident 16's movements and the resident was allowed to wander the hall freely and was not instructed to return to her/his room. No observations were made of inappropriate behavior, entering other resident's rooms or attempts to board the elevator. On 1/26/21 at 11:41 AM Staff 11 (CMA) stated she witnessed Staff 10 (RN) stand at the nurse's station and yell at Resident 16 repeatedly Get your mask on. Get your mask on but she never offered to assist her/him to put one on. Staff 11 further reported on 1/22/21 Staff 6 (LPN) pushed Resident 16 to her/his room and once she reached the entrance to her/his room, Staff 6 pushed the resident into the room and let go of the wheelchair after she pushed. She stated Staff 6 did the same thing many times previously and it stopped for a short period of time when she was talked to by management. Staff 11 reported Staff 9 and Staff 12 also frequently yelled at Resident 16 to go to her/his room. She further reported she heard Staff 12 say I ain't dealing with this today as soon as she saw Resident 16. On 1/26/21 at 12:24 PM Staff 20 (CNA) reported concerns related to staff on evening shift who wheeled Resident 16 back to her/his room every time she/he came out. She reported they did it pretty fast or rough. She further reported the staff on evening shift frequently yelled at the resident to return to her/his room and put her/his mask on. On 1/26/21 at 1:06 PM Resident 20, who was alert and oriented, stated Resident 16 liked to go around the facility in her/his wheelchair and Staff 6 always yelled at her/him to get back to her/his room. She/he reported Staff 6 talked real ornery to Resident 16. Resident 20 further stated she/he witnessed Staff 6 shove the resident into to her/his room really hard. She/he demonstrated a quick forward motion with her/his hands. Resident 20 further stated that's just not right. On 1/26/21 at 1:15 PM Staff 16 (CNA) stated during evening shift every time Resident 16 came out of her room Staff 6 and Staff 12 pushed her/him right back into her/his room. She explained they appeared a little over the top at times when they pushed the resident in her/his wheelchair and demonstrated with her arms a forceful forward pushing motion. She stated they were not nice to Resident 16 and they yelled at the resident to go to her/his room and constantly pushed them towards her/his room. Staff 16 described the treatment of [REDACTED]. Staff 16 reported the resident seemed more depressed. On 1/26/21 at 1:55 PM Staff 15 (CNA) reported she witnessed verbal abuse towards Resident 16 from Staff 10. On 1/27/21 at 12:37 PM Staff 4 (Social Services) reported she witnessed a complete lack of patience or [MEDICATION NAME] from Staff 6 towards the resident. She reported on 8/31/20 Resident 16 was in her/his wheelchair near the nurse's station where she/he liked to sit. She stated Staff 6 walked up to the resident and stood over her/him in a position of power and in a very gruff tone told the resident she/he needed to be down there and pointed towards the residents room. Staff 4 reported she then grabbed the wheelchair and pushed the resident towards her/his room. She stated what she observed appeared to be abuse and did not sit right with her. On 1/27/21 at 1:23 PM Staff 18 (CNA) reported Staff 6 repeatedly took Resident 16 back to her/his room and pushed her/him in a hateful way. She demonstrated a hard forward pushing motion with her arms and hands. Staff 18 stated during one incident Staff 6 leaned down and whispered to the resident and the resident began to cry. She reported several times Resident 16 described Staff 6 to her and told her she was mean. Staff 18 said the resident exhibited different behaviors on Friday and Saturday when Staff 6 worked than on other days. On 2/1/21 at 9:31 AM Staff 23 (Confidential Staff) reported during the week of 1/18/21 at approximately 3:30 PM Resident 16 told her she/he was scared of the mean people. She stated the resident told her they're mean; they're scary and it's bad out there. Staff 23 reported the resident held onto her hand and asked her not to leave. She stated the resident appeared scared and it was difficult to leave. Staff 23 reported the evening shift staff were not as patient with Resident 16 and tended to get upset with her/him. She reported Staff 6 and Staff 12 yelled at the resident and pointed down the hallway like a dog when they told her/him to go to her/his room. Staff 23 further stated they did not treat the resident like a human being. On 2/2/21 at 12:02 PM Staff 8 (Housekeeping) recalled an incident when Staff 12 wheeled Resident 16 to her/his room and the resident had her/his feet down on the ground pushing against the movement the whole time Staff 12 pushed the wheelchair. She described another incident when the resident asked Staff 6 for pain medication and Staff 6 yelled at the resident that she/he already had something for pain and told her/him to go back to her/his room. Staff 8 reported approximately two months earlier Staff 6 pushed Resident 16 really hard in her/his wheelchair. She reported another time Staff 6 pushed the resident through the door of her/his room and she put her foot on the back of the wheelchair and held her hands on the door frame to prevent the resident from pushing her/himself back out of the room. On 2/2/21 at 12:29 PM Staff 24 (Housekeeping) reported staff told her not to allow Resident 16 to touch her because the resident was really gross. She further stated she witnessed Staff 12 yell at and push the resident roughly in her/his wheelchair. On 2/2/21 at 1:24 PM Staff 3 (RNCM) stated staff did not report anything to her related to mistreatment of [REDACTED]. Staff 3 stated some staff treated the resident with disrespect and there were some staff on evening shift who repeatedly told Resident 16 to go to her/his room. She explained she did not think the staff intended to be mean when they were short with the resident. She reported she reminded the staff to not talk to the resident the way they did. On 2/2/21 at 2:23 PM a tray table was observed in the doorway of Resident 16's room, placed like a gate. The resident pushed the table out of the way and exited her/his room in her/his wheelchair. Once the resident arrived at the nurse's station, Staff 12 immediately instructed the resident to go back down the hall in an agitated tone. On 2/3/21 at 2:52 PM Staff 1 (Administrator) reported he was aware of concerns related to staff mistreatment of [REDACTED]. He reported he believed staff now treated the resident with respect. 2. Resident 21 admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. A review of Resident 21's progress notes revealed the following: *2/1/21 at 11:26 PM - The resident was upset after Staff 2 (DNS) spoke with her/him and the CNA had to tell the DNS that the resident wanted some privacy twice before the DNS finally stopped. It took the staff some time to calm down the resident. *2/2/21 at 6:13 PM - The resident reported she/he felt like she/he was targeted. The resident was very angry at the DNS and didn't want her in her/his room. On 2/2/21 at 12:52 PM Resident 21 reported Staff 2 went into her/his room on 2/1/21 and started in on me regarding the amount of visitors she/he had outside. The resident stated she/he told Staff 2 she/he felt like she was being picked on, told Staff 2 she/he had enough and motioned for her to leave her/his room. Resident 21 reported Staff 2 would not leave her/his room. The resident further stated she has it in for me because I talk back to her. On 2/2/21 at 1:24 PM Staff 3 (RNCM) reported Resident 21 told her she/he felt as if Staff 2 repeatedly targeted and punished her/him. On 2/2/21 at 5:39 PM Staff 19 (CNA) reported at approximately 8:15 PM on 2/1/21 Staff 2 went into Resident 21's room. Staff 19 stated she stood at the door to the medication room, two doors away from the resident's room with the intent to over hear what was about to occur because she was kind of ready for it. Staff 19 explained Staff 2 frequently does this with the resident. She stated Staff 2 kind of picks on Resident 21 so staff were always ready to interject and advocate for the resident. She reported Staff 2 informed the resident she spoke with the resident's daughter and whether the resident liked it or not staff would wear all personal protective equipment (PPE) when they entered her/his room. She further stated Staff 2 also told the resident she/he could not have anymore outside visits. Staff 19 stated the resident became upset and asked Staff 2 to get out of her/his room twice but Staff 2 would not leave. Staff 19 reported she stepped in and told Staff 2 to respect the resident's wishes and leave her/his room. On 2/3/21 at 12:38 PM Staff 9 (LPN) reported Resident 21 was upset the day following the interaction with Staff 2. She stated the resident told her if she/he could punch somebody in the nose she/he would have done it. On 2/3/21 at 2:52 PM Staff 1 (Administrator) reported he talked with Resident 21 following the interaction and she/he was upset about the way Staff 2 treated her/him. On 2/4/21 at 1:26 PM Staff 14 (CNA) reported when Staff 2 went to Resident 21's room on the night of 2/1/21 after 8:00 PM she stood nearby to listen to the interaction. She explained she did so because whenever Staff 2 went into Resident 21's room, she knew she would upset the resident and most staff stood nearby and looked out for the resident. Staff 14 reported during the interaction Staff 2 informed the resident staff would wear all PPE when they entered her/his room although she clarified the resident was not quarantined to her/his room. She stated the resident became upset, told Staff 2 she/he wanted privacy and told her to leave. She further stated Staff 2 did not leave the resident's room after she/he requested and Resident 21 again asked Staff 2 to leave. Staff 14 reported at that point, Staff 19 spoke up and told Staff 2 the resident asked her to leave and she needed to do so. Staff 14 stated it was not out of the ordinary for Staff 2 to treat Resident 21 differently than other residents and frequently spoke to the resident in a mean and controlling tone. She further stated the way Staff 2 treated the resident was mental abuse. On 2/4/21 at 2:06 PM Witness 6 (Family Member) reported Resident 21 informed her of the interaction with Staff 2 on the evening of 2/1/21 and she/he was very upset about it. She stated the resident stated on previous occasions she/he thought Staff 2 deliberately picked on her/him. She confirmed the resident was fully cognitively intact. On 2/8/21 at 8:54 AM Staff 6 (LPN) reported Staff 2 approached Resident 21's room on the evening of 2/1/21. She stated she was in the med room two doors away from the resident's room at the time and she chose to stay there so she could hear the interaction. Staff 6 reported other staff also froze and stood nearby because Staff 2 frequently targeted Resident 21 and they had to be ready to advocate for the resident. She stated Staff 2 was inside of the resident's room just harping on her/him regarding the resident being placed on enhanced precautions following her/his visit with family. Staff 6 reported Staff 2's voice was raised at Resident 21. She further reported the resident started to yell at Staff 2 to get out of her/his room. According to Staff 6, the resident repeatedly told Staff 2 to get out until Staff 19 intervened and calmly told Staff 2 to leave the resident's room. She stated even after staff intervened, it took a couple of minutes before Staff 2 finally backed off. Staff 6 reported the resident was visibly upset.

Based on observation, interview and record review it was determined the facility failed to prevent the worsening of a pressure ulcer and/or identify the presence of a partial ulcer timely for 1 of 3 (# 2) sampled residents. Resident 2's pressure ulcer worsened from a Stage 2 pressure ulcer (partial thickness skin loss) to a Stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss). This placed residents at an increased risk for skin integrity complications. Findings include: Resident 2 was admitted to the facility in September, 2015 with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident 2 did not have a pressure ulcer and the resident was incontinent of bowel and bladder. The facility's Admit Skin Audit form dated 10/12/15 indicated the resident's coccyx and buttocks were excoriated and a protective cream was to be applied twice a day. The Resident In-Room Care Plan dated 10/12/15 indicated the skin on the resident's buttocks was excoriated and staff needed to provide frequent repositioning and incontinence care. The Nursing Notes dated 10/14/15 revealed the resident sat in a wheelchair most of the shift. The Skin Integrity Flow Sheet dated 10/15/15 described an open area on the resident's coccyx as 4 cm x 6 cm with a shallow depth, yellow wound bed. No odor. No drainage. The physician's orders [REDACTED]. On 10/19/15 at 9:40 am Staff 2 (DNS) indicated she was not aware of any residents who currently had a pressure ulcer and Resident 2's buttocks were excoriated. She stated the LPNs did the residents' wound care and a facility RN assessed wounds and staged a pressure ulcer. On 10/19/15 at 9:45 am Staff 3 (RN) removed a foul-smelling, blood-tinged foam dressing from the resident's coccyx and 90% of the coccyx wound bed which was covered with yellow-colored slough (stringy tissue). She measured the wound size as 5.5 cm x 2.8 cm x 0.1 cm and stated the coccyx wound was a Stage 3 pressure ulcer. She measured the reddened area surrounding the pressure ulcer and its size was 12.2 cm x 8.4 cm x 0.1 cm. A fax dated 10/19/15 indicated the facility informed the physician about the resident's Stage 3 pressure ulcer on the coccyx. On 10/19/15 at 10:00 am the resident was observed while seated in a wheelchair which did not have a cushion. On 10/19/15 at 12:00 pm Staff 5 (LPN) indicated on 10/15/15 she wrote in the nursing notes and the skin integrity flow sheet information about the resident's coccyx having a shallow, yellow-colored wound and the physician was notified. On 10/19/15 at 12:20 pm the resident was observed in a wheelchair without a cushion. Staff 2 (DNS) was asked about a cushion for the resident and indicated the therapy department might have one. On 10/19/15 at 12:25 pm Staff 11 (PT) stated he was unaware the resident had a pressure ulcer and he would provide a wheelchair cushion for the resident. On 10/19/15 at 12:30 pm Staff 4 (Nurse Aide, NA) indicated staff were getting ready to transfer the resident back to bed for repositioning and incontinence care and they tried to do so every two hours. The Nursing Notes dated 10/19/15 revealed at 1:45 pm the resident had a low-grade fever, lung congestion, was sent to the emergency room and the resident was hospitalized . On 10/20/15 at 1:15 pm Staff 7 (LPN) indicated an open area developed on Resident 2's coccyx, a foam dressing was applied every few days and the resident often sat for long periods of time. On 11/9/15 at 10:33 am Staff 2 (DNS) indicated she was unaware Resident 2 had a pressure ulcer until after the Stage 3 pressure ulcer was identified by the RN on 10/19/15. On 11/9/15 at 2:00 pm Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 2 did not have a wheelchair cushion provided timely and the coccyx wound worsened into a Stage 3 pressure ulcer.

Based on observation, interview and record review it was determined the facility failed to prevent the development of pressure ulcers related to the use of a medical device for 1 of 3 sampled residents (# 1) or assess and consistently monitor pressure ulcers for 2 of 3 sampled residents (#s 1 and 39) for whom pressure ulcers were reviewed. Resident 1 developed a Stage 3 pressure ulcer (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.) This placed residents at increased risk for complications associated with impaired skin integrity such as infection and pain. Findings include: A medical device-related pressure ulcer (MDRPU) is defined as a localized injury to the skin or underlying tissue resulting from sustained pressure caused by a medical device, such as a brace; splint, cast; respiratory mask or tubing. Many pressure ulcers result not from the device itself but from poor device positioning, securement or simple failure to check under the device. Preventive practices include frequently evaluating device positioning and securement and loosening the device at least once per shift to check for skin problems. (Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Editor-in-Chief Wound Care Advisor). 1. Resident 1 was readmitted to the facility in February 2015 after hospitalization for a [MEDICAL CONDITION]. The hip was not surgically repaired and the resident was discharged with orders for an abduction brace (a brace designed to limit the amount of hip movement to allow for healing). A physician's orders [REDACTED]." The order did not specify a wearing schedule or instruction for time out of the brace. The brace had a band above the hips across the low back connected to an adjustable metal brace that was secured at the thigh. The admission MDS dated [DATE] identified the resident required extensive assistance from one to two persons for bed mobility and transfers and extensive assistance from one person for dressing. According to the MDS the resident was identified at risk for pressure ulcers and was not admitted with pressure ulcers. Review of the record revealed no temporary care plan related to use of the abductor brace. The Comprehensive Care Plan was not updated after the readmission and did not include information about the brace. The In Room Care Plan (IRCP) dated 2/23/15 identified Resident 1 had a fracture to the right hip and "must wear the abductor brace." The IRCP indicated the resident was working with PT and OT for ambulation and aides were to follow their recommendations. The IRCP did not include an intervention to check skin beneath the brace each shift. Nursing Notes dated 3/12/15 described the discovery of a "10 cm x 5 cm purple area with 2 cm x 1 cm opened area" on the resident's spine. The area was cleansed and a protective Allevyn foam dressing was applied. The resident was given [MEDICATION NAME] (a narcotic pain medication) for complaint of pain to the area. A fax was sent to the physician on 3/12/15 informing him of the wound on the resident's spine with a request for an order for [REDACTED]. A Skin Integrity Flow Sheet was initiated on 3/12/15. The treatment order was not written on the Flow Sheet. It was written on the March 2015 Treatments Flowsheet kept in the same binder as the Medications Flowsheet. There was no documentation on the Treatment Flowsheet by the nursing staff to indicate when or if the dressing changes were done. A 3/19/15 nursing note mentioned the use of a synthetic sheep skin was in place to pad the brace. On 3/25/15 a fax was sent to Resident 1's physician to report the wound from the back brace was "now a Stage 3" and a treatment change was requested to include calcium alginate under [MEDICATION NAME] foam covered by Allevyn. The physician responded the same day with an order for [REDACTED]. According to the Skin Integrity Flow Sheet the pressure ulcer on the resident's spine improved between 4/9 and 4/21/15 and the treatment was changed. There was no corresponding physician order [REDACTED]. Review of Nursing Notes for Resident 1 revealed the dressing was changed on evening shift and was next due on 5/15/15. On 5/13/15 at 10:14 am Staff 6 (LPN) who worked day shift stated Resident 1's brace "seemed uncomfortable and would be on when we got here in the morning. It was not removed during the day." Staff 6 did not indicate she routinely examined the resident's skin under the brace during her shift. On 5/13/15 at 10:30 am Staff 7 (OT) stated the brace was worn "24/7" until nursing staff noticed skin breakdown from the brace. Therapy staff only needed to remove it to change the resident's pants. The resident could be toileted without removing the brace. Staff 7 recalled the sheepskin padding to the inside of the brace. She did not know if it was there before or after the skin breakdown was noted. On 5/13/15 at 11:40 am Staff 8 (CNA) transferred Resident 1 to an arm chair. The resident did not appear uncomfortable. The brace was lying on the floor in the resident's room. On 5/13/15 at 12:40 pm Staff 8 (CNA) stated the aides did not remove the brace when Resident 1 was wearing it. The resident required assistance of two staff during that time for transfers and bed mobility. The aides gave Resident 1 bed baths without removing the brace. On 5/13/15 at 1:05 pm Staff 9 (CNA) stated at first the brace had to stay on at all times. Nursing staff didn't take it off during care and the brace was in place over the resident's clothing. The sheepskin padding was not on at first but was added to the brace later. On 5/13/15 at 2:22 pm Staff 5 (LPN) stated she found the open area on the resident's back when helping a CNA provide care. She saw it when she attempted to pull the resident's shirt down under the brace. Staff 5 recalled the sheep skin was added later by therapy to pad the brace. The brace was not routinely removed and was on "24/7." Staff 5 stated she "tried to remember to check the (resident's) skin under the brace" on her shift but there was nothing on the treatment record directing nursing staff to do so. On 5/13/15 at 2:40 pm Staff 10 (CNA) stated he would report any skin redness to a nurse. He did not recall if he noticed redness before the open area was found on Resident 1. The brace was worn over the resident's clothing. "At first it was worn all the time then later could be off when (the resident) was in bed but on if she was up." On 5/14/15 at 7:00 am Staff 3 (RN) stated Resident 1 wore the brace at all times except for showers. There wasn't anything on the treatment sheet to direct nurses to check for skin breakdown under the brace every shift. "Nurses rely to some degree on CNAs to identify and report if areas are becoming red." On 5/14/15 at 9:54 am Staff 2 (DNS/RNCM) confirmed the brace order stated to wear at all times and PT was asked to change the resident's clothing instead of CNAs to ensure the brace was reapplied correctly. Therapists did this once a day. Staff 2 confirmed there was no documented evidence the resident's skin was visualized under the brace every shift and the wound was documented as a Stage 3 on 3/25/15 by the nurse assigned to do wound rounds (regular measurements and assessment). Staff 2 stated when a wound was first found, orders for treatment should be written in both the treatment record and "skin book" (where the Skin Integrity Flow Sheets were kept). Wound care should be documented as done according to physician orders [REDACTED]. Staff 2 confirmed the treatment to Resident 1's spine wound changed between 4/9 and 4/21/15 but no orders were obtained for the new treatment. 2. Resident 39 was admitted to the facility in December 2014 with [DIAGNOSES REDACTED]. The resident's Admit Skin Audit dated 12/16/14 documented scratch marks on each buttock and indicated there were no blisters, excoriated areas or open ulcers. A Preliminary Nursing assessment dated [DATE] documented a dark red area to Resident 39's left heel and red areas to the resident's coccyx. There were no measurements documented. A Nursing Note dated 12/17/14 for admit documented the resident's left heel had an unopened red area measuring .7 cm x .3 cm x .1 cm. The physician orders [REDACTED]. A Nursing Transfer Summary from the hospital dated 12/29/14 indicated Resident 39's left and right buttocks required cleansing and dressing changes and indicated the resident had an intact but small deep bruise/pressure wound to the left heel. There were no measurements or staging documented. Resident 39's MARs and TARs for December 2014 and January 2015 did not include skin treatments for the buttocks and heels. There was no documentation in the resident's medical record to determine when and if skin treatments occurred The Admit Skin Audit dated 12/29/14 described Stage 2 open ulcers on Resident 39's buttocks. The left buttock measured 1 cm x 2 cm and right buttock measured 1.8 cm x 1.4 cm. There were no depths documented and no mention of the resident's left heel. A Nursing Note for the 12/29/14 admission described a treatment for [REDACTED]. The note indicated Resident 39 had an unstageable left heel bruise but did not include measurements. The resident's Bi-Monthly Skin Audit dated 1/5/15 did not include measurements but noted the treatment for [REDACTED]. A Nursing Note dated 1/13/15 noted a 2.5 cm 1.5 cm "discolored" area to left heel. A Nursing Note dated 1/14/15 documented a 3 cm x 2.5 cm excoriated area to the resident's coccyx resulting from diarrhea. There was no indication of a weekly skin audit being completed for the week of 1/12/15. On 5/15/15 at 9:55 am Staff 2 (DNS/RNCM) confirmed the status and treatments of Resident 39's pressure ulcers and skin conditions were not consistently monitored and documented.

Based on interview and record review it was determined the facility failed to ensure professional standards of practice were followed related to care planned transfer instructions for 1 of 1 sampled residents (#1) who had a fall while being improperly transferred. Resident 1 sustained a fractured leg. Findings include: Resident 1 was admitted to the facility in 2011. [DIAGNOSES REDACTED]. The In Room Care Plan dated 6/12/12, used by the CNAs to provide resident care, indicated the resident should be transferred by a sit-to-stand lift (mechanical lift). Safety Concerns indicated the resident was at risk for falls due to pain, stroke, medications, amputated leg and Resident 1's fear of falling. The comprehensive Resident Care Plan last updated on 9/25/11, indicated the resident was at risk for falls due to BKA, stroke, pain, weakness, history of falls and use of pain medication. Approaches included to use a hoyer lift or a sit-to-stand lift for transfers. The resident required assistance from staff with ADLs due to BKA, pain, weakness and obesity. The In Room Care Plan updated on 9/25/12 indicated the resident could be transferred by the hoyer lift or the sit-to-stand mechanical lift. The MDS dated [DATE] indicated the resident was alert and oriented with some short term memory deficit. The resident required extensive assistance from staff for most ADLs. Resident 1 was able to make her/his needs known and was dependent for transfers. The 10/19/12 Nursing Notes at 5:00 am, indicated the resident was transferred by "pivot transfers to toilet/bed with two assist without incident." On 10/19/12 at 1:30 pm, the Nursing Notes indicated the resident was "doing well with stand and pivot to transfer, need to encourage (her/him) to continue to strengthen (her/his) leg." The Nurses Notes dated 10/19/12 indicated at 9:35 pm, the resident was being transferred to the hospital due to a knee injury received during a transfer. The CNA (Staff 5) stated he felt the resident's knee crack and saw instant swelling and pain. The facility Incident Report dated 10/19/12 indicated the resident was being transferred using a stand and pivot method, the resident's left knee became tangled in the CNA's (Staff 5) legs, the resident let go of the CNA's neck and the resident's knee twisted and made a popping sound. The narrative portion of the form indicated the sit-to-stand mechanical lift was not working and the resident requested the CNA transfer her/him without waiting for assistance or using the hoyer. The Incident Analysis and Recommendation portion of the report by the DNS (Staff 2) indicated the resident had a fear of falling especially when suspended in hoyer sling. The resident had requested not to use the hoyer lift when the sit-to-stand "was out of commission." The resident stated she/he wanted to be transferred using the stand/pivot method. The statement indicated the resident was sometimes transferred using the stand/pivot method "if the CNA felt comfortable with it, they complied." The resident was sent to the hospital and a fractured proximal tibia was confirmed, the resident returned to the facility with a straight leg splint. The hospital History and Physical dated 10/20/12 indicated the resident's knee was caught during a transfer at the facility. When she/he twisted on the weight-bearing leg a crunch sound was heard and immediate pain was felt. The resident was diagnosed with [REDACTED]." On 11/1/12 at 11:45 am, Staff 1 (Administrator) stated the facility's investigation revealed Resident 1 asked Staff 5 (CNA) to transfer her/him without help because she/he wanted to get to bed. Staff 1 stated the resident was care planned for a sit-to-stand mechanical lift for transfers but their lift had not been working for about five days. A new battery for the lift was obtained however, the problem was in the wiring. A new lift was being ordered when funding was approved. Staff 1 stated the CNA should have waited for another CNA to assist him with the transfer. Staff 1 stated the resident, who had a fear of falling, let go of the CNA's neck, they lost their balance and when the CNA turned quickly to complete the pivot the resident's knee popped and instant pain was felt by Resident 1. On 11/1/12 at 12:30 pm, Staff 2 (DNS) stated Staff 5 (CNA) felt terrible after the accident, he went to the hospital with the resident and stayed with her/him. Staff 2 stated the CNA was counseled about not following the resident's care plan and the need for another CNA to assist during a stand and pivot transfer. Staff 2 stated the CNA immediately reported his error and was cooperative during the investigation. On 11/1/12 at 1:20 pm, Staff 3 (CNA) was asked how she transferred Resident 1. Staff 3 stated she always used a mechanical lift. Staff 3 stated the resident would try and talk her into a stand and pivot transfer but she always used a hoyer because the resident was large and unsteady. Staff 3 confirmed the sit-to-stand lift did not consistently work for about a week. On 11/1/12 at 1:30 pm, Staff 4 (RNCM) stated before the resident was hospitalized with the broken leg she/he was able to be transferred with the sit-to-stand lift and now was a hoyer lift only. Staff 4 stated it was a poor decision on the CNA's part to do a stand/pivot transfer by himself but the resident talked him into it when another staff member was not available. Staff 4 stated the resident was alert and oriented, made her/his own decisions but sometimes not always the best decisions. Staff 4 stated the resident returned the same night of the accident with a splint and a wrap on her/his leg. On 11/1/12 at 1:45 pm, Staff 5 (CNA) stated he transferred Resident 1. Staff 5 stated the sit-to-stand lift was broken, he went to put the resident to bed and since no other help was available he made the decision to do a stand/pivot transfer at the resident's request. Staff 5 stated the resident did not want to wait for help and the resident "said (she/he) would be ok." Staff 5 stated he stood the resident up, had the resident's one leg between his legs, the resident's hands were around his neck and they went to turn. Staff 5 stated for some reason the resident panicked and let go of his neck, when that happened they both lost their balance and it was either a fast pivot to bed or down on the floor. Staff 5 stated as the pivot was made the resident's left knee made a "pop," he got the resident into bed and left to immediately get the nurse. On 11/1/12 at 2:15 pm, Resident 1 was observed up in a wheelchair with her/his leg in a straight leg splint. Resident 1 stated she/he was usually transferred from bed or wheelchair by the sit-to-stand lift but knew it was broken. Resident 1 stated the CNA (Staff 5) listened for another CNA to come help with a pivot transfer to bed, no one was available to help at that moment. Resident 1 stated some of the staff transferred her/him using a stand/pivot transfer, if they were strong enough. Resident 1 stated the CNA had not transferred her/him before using the stand/pivot method. Resident 1 stated she/he "did not ask the CNA to transfer (her/him) in that method." Resident 1 stated she/he felt it was her/his fault because she/he was used to doing more for her/himself. On 11/1/12 at 3:00 pm, Staff 6 (CNA) stated, before the accident, she always used the sit-to-stand mechanical lift to transfer Resident 1 due to the resident's anxiety and size. Staff 6 stated she thought the resident was a good historian.

Based on observations, interviews and record review the facility failed to provide a safe environment for 1 of 1 sampled residents (# 1) while being transferred. Resident 1 sustained a fractured left leg. Findings include: Resident 1 was admitted to the facility in 2011. [DIAGNOSES REDACTED]. The In Room Care Plan dated 6/12/12, used by the CNAs to provide resident care, indicated the resident should be transferred by a sit-to-stand lift (mechanical lift). Safety Concerns indicated the resident was at risk for falls due to pain, stroke, medications, amputated leg and Resident 1's fear of falling. The comprehensive Resident Care Plan last updated on 9/25/11, indicated the resident was at risk for falls due to BKA, stroke, pain, weakness, history of falls and use of pain medication. Approaches included to use a hoyer lift or a sit-to-stand lift for transfers. The resident required assistance from staff with ADLs due to BKA, pain, weakness and obesity. The In Room Care Plan updated on 9/25/12 indicated the resident could be transferred by the hoyer lift or the sit-to-stand mechanical lift. The MDS dated [DATE] indicated the resident was alert and oriented with some short term memory deficit. The resident required extensive assistance from staff for most ADLs. Resident 1 was able to make her/his needs known and was dependent for transfers. The 10/19/12 Nursing Notes at 5:00 am, indicated the resident was transferred by "pivot transfers to toilet/bed with two assist without incident." On 10/19/12 at 1:30 pm, the Nursing Notes indicated the resident was "doing well with stand and pivot to transfer, need to encourage (her/him) to continue to strengthen (her/his) leg." The Nurses Notes dated 10/19/12 indicated at 9:35 pm, the resident was being transferred to the hospital due to a knee injury received during a transfer. The CNA (Staff 5) stated he felt the resident's knee crack and saw instant swelling and pain. The facility Incident Report dated 10/19/12 indicated the resident was being transferred using a stand and pivot method, the resident's left knee became tangled in the CNA's (Staff 5) legs, the resident let go of the CNA's neck and the resident's knee twisted and made a popping sound. The narrative portion of the form indicated the sit-to-stand mechanical lift was not working and the resident requested the CNA transfer her/him without waiting for assistance or using the hoyer. The Incident Analysis and Recommendation portion of the report by the DNS (Staff 2) indicated the resident had a fear of falling especially when suspended in hoyer sling. The resident had requested not to use the hoyer lift when the sit-to-stand "was out of commission." The resident stated she/he wanted to be transferred using the stand/pivot method. The statement indicated the resident was sometimes transferred using the stand/pivot method "if the CNA felt comfortable with it, they complied." The resident was sent to the hospital and a fractured proximal tibia was confirmed, the resident returned to the facility with a straight leg splint. The hospital History and Physical dated 10/20/12 indicated the resident's knee was caught during a transfer at the facility. When she/he twisted on the weight-bearing leg a crunch sound was heard and immediate pain was felt. The resident was diagnosed with [REDACTED]." On 11/1/12 at 11:45 am, Staff 1 (Administrator) stated the facility's investigation revealed Resident 1 asked Staff 5 (CNA) to transfer her/him without help because she/he wanted to get to bed. Staff 1 stated the resident was care planned for a sit-to-stand mechanical lift for transfers but their lift had not been working for about five days. A new battery for the lift was obtained however, the problem was in the wiring and a the defective part was ordered. A new bariatric lift was being ordered when funding was approved. Staff 1 stated the CNA should have waited for another CNA to assist him with the transfer. Staff 1 stated the resident, who had a fear of falling, let go of the CNA's neck, they lost their balance and when the CNA turned quickly to complete the pivot the resident's knee popped and instant pain was felt by Resident 1. On 11/1/12 at 12:30 pm, Staff 2 (DNS) stated Staff 5 (CNA) felt terrible after the accident, he went to the hospital with the resident and stayed with her/him. Staff 2 stated the CNA was counseled about not following the resident's care plan and the need for another CNA to assist during a stand and pivot transfer. Staff 2 stated the CNA immediately reported his error and was cooperative during the investigation. On 11/1/12 at 1:20 pm, Staff 3 (CNA) was asked how she transferred Resident 1. Staff 3 stated she always used a mechanical lift. Staff 3 stated the resident would try and talk her into a stand and pivot transfer but she always used a hoyer because the resident was large and unsteady. Staff 3 confirmed the sit-to-stand lift did not consistently work for about a week. On 11/1/12 at 1:30 pm, Staff 4 (RNCM) stated before the resident was hospitalized with the broken leg she/he was able to be transferred with the sit-to-stand lift and now was a hoyer lift only. Staff 4 stated it was a poor decision on the CNA's part to do a stand/pivot transfer by himself but the resident talked him into it when another staff member was not available. Staff 4 stated the resident was alert and oriented, made her/his own decisions but sometimes not always the best decisions. Staff 4 stated the resident returned the same night of the accident with a splint and a wrap on her/his leg. On 11/1/12 at 1:45 pm, Staff 5 (CNA) stated he transferred Resident 1. Staff 5 stated the sit-to-stand lift was broken, he went to put the resident to bed and since no other help was available he made the decision to do a stand/pivot transfer at the resident's request. Staff 5 stated the resident did not want to wait for help and the resident "said (she/he) would be ok." Staff 5 stated he stood the resident up, had the resident's one leg between his legs, the resident's hands were around his neck and they went to turn. Staff 5 stated for some reason the resident panicked and let go of his neck, when that happened they both lost their balance and it was either a fast pivot to bed or down on the floor. Staff 5 stated as the pivot was made the resident's left knee made a "pop," he got the resident into bed and left to immediately get the nurse. On 11/1/12 at 2:15 pm, Resident 1 was observed up in a wheelchair with her/his leg in a straight leg splint. Resident 1 stated she/he was usually transferred from bed or wheelchair by the sit-to-stand lift but knew it was broken. Resident 1 stated the CNA (Staff 5) listened for another CNA to come help with a pivot transfer to bed, no one was around to help. Resident 1 stated some of the staff transferred her/him using a stand/pivot transfer, if they were strong enough. Resident 1 stated the CNA had not transferred her/him before using the stand/pivot method. Resident 1 stated she/he "did not ask the CNA to transfer (her/him) in that method." Resident 1 stated she/he felt it was her/his fault because she/he was used to doing more for her/himself. On 11/1/12 at 3:00 pm, Staff 6 (CNA) stated, before the accident, she always used the sit-to-stand mechanical lift to transfer Resident 1 due to the resident's anxiety and size. Staff 6 stated she thought the resident was a good historian.