Every finding on record at Norwalk Nursing and Rehabilitation Center

Based on clinical record review, staff interview, Nurse Practitioner (NP) interview and facility policy the facility failed to ensure insulin orders transcribed for staff awareness, failed to verify the order accuracy before signing, failed to administer insulin for diabetes management, Resident #5 (R#5). The facility reported a census of 42.The Minimum Data Set (MDS) quarterly assessment for R#5 dated 10/10/26 for R#5 revealed diagnosis of diabetes was coded as receiving insulin during last 7 days. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognitive impairment. The Care Plan initiated 12/20/23 documented R#5 has diagnosis of diabetes, is at risk for frequent infections, alteration of skin, visual impairment, hyper/hypoglycemia, renal failure andcognitive/ physical impairments.The lab report dated 6/23/25 documented resident hemoglobin A1C (a blood test measuring your average blood sugar over the last 60 to 90 days) was 6.8 indicated high on the lab order. The Medication Administration Record for R#5 dated December 2025 documented the following orders for #5's diabetes. a. Lantus insulin, inject 5 unit subcutaneously in the morning related to type 2 diabetes. Start 3/20/25b. Lantus insulin, inject 20 unit subcutaneously at bedtime related to type 2 diabetes. Start 3/20/2025 c. Blood sugar checks two times a day (BID) related to type 2 diabetes, start 10/30/25.d. Novolog insulin Injection solution 100 unit/millimeter, inject as per sliding scale (reflecting the blood sugar results) subcutaneously every 8 hours as needed for high blood sugars due to holidays related to type 2 diabetes, start 11/24/25. If blood sugar is 0 - 150 = 0 units no call needed;151 -200 = 2 units no call needed;201 - 250 = 4 units no call needed;251 - 300 = 6 units no call needed;301 - 350 = 8 units no call needed;351 - 400 = 10 units no call needed unless symptomatic;401 - 600 = 12 units and call the nurse practitioner. The Medication Administration Record (MAR) for December 2025 revealed the following blood sugar results that required insulin per the sliding scale order by Nurse Practitioner, (NP) Staff A, the insulin was not administered as follows. On 12/2/25 the AM blood sugar was 156, the 2 units of insulin ordered was not given On 12/2/25 the PM blood sugar was 189, the 2 units of insulin ordered was not givenOn 12/3/25 the AM blood sugar was181, the 2 units of insulin ordered was not givenOn 12/4/25 the PM blood sugar was 236, the 4 units of insulin ordered was not givenOn 12/5/25 the PM blood sugar was 155, the 2 units of insulin ordered was not givenOn 12/6/25 the PM blood sugar was 217, the 4 units of insulin ordered was not givenOn 12/7/25 the PM blood sugar was 295, the 6 units of insulin ordered was not givenOn 12/8/25 the AM blood sugar was 201, the 4 units of insulin ordered was not givenOn 12/8/25 the PM blood sugar was 177, the 2 units of insulin ordered was not givenOn 12/9/25 the AM blood sugar was 199, the 2 units of insulin ordered was not givenOn 12/10/25 the AM blood sugar was 215, the 4 units of insulin ordered was not givenOn 12/10/25 the PM blood sugar was 165, the 2 units of insulin ordered was not givenOn 12/11/25 the PM blood sugar was 253, the 6 units of insulin ordered was not givenOn 12/12/25 the PM blood sugar was 180, the 4 units of insulin ordered was not givenOn 12/13/25 the PM blood sugar was 243, the 4 units of insulin ordered was not givenOn 12/14/25 the PM blood sugar was 173, the 2 units of insulin ordered was not givenOn 12/15/25 the AM blood sugar was 331, the 8 units of insulin ordered was not givenOn 12/16/25 the AM blood sugar was 153, the 2 units of insulin ordered was not givenOn 12/17/25 the PM blood sugar was 206, the 4 units of insulin ordered was not givenOn 12/18/25 the PM blood sugar was 269, the 6 units of insulin ordered was not givenOn 12/19/25 the PM blood sugar was 165, the 2 units of insulin ordered was not givenOn 12/20/25 the PM blood sugar was 200, the 4 units of insulin ordered was not givenOn 12/21/25 the PM blood sugar was 165, the 2 units of insulin ordered was not givenOn 12/23/25 the PM blood sugar was 165, the 2 units of insulin ordered was not givenOn 12/24/25 the AM blood sugar was 159, the 2 units of insulin ordered was not givenOn 12/24/25 the PM blood sugar was 186, the 2 units of insulin ordered was not givenOn 12/26/25 the PM blood sugar was 167, the 2 units of insulin ordered was not givenOn 12/27/25 the AM blood sugar was 197, the 2 units of insulin ordered was not givenOn 12/27/25 the PM blood sugar was 197, the 2 units of insulin ordered was not given0n 12/28/25 the AM blood sugar was 180, the 2 units of insulin ordered was not givenOn 12/28/25 the PM blood sugar was 208, the 4 units of insulin ordered was not givenOn 12/30/25 at 4:20 PM, Staff A, Nurse Practitioner (NP) relayed, did not know why the sliding scale order was transcribed to include every eight-hour parameter and felt that was an error by the ADON who transcribed the verbal order. Staff A (NP) relayed the insulin should be given as needed any time the blood sugar is high as directed per the sliding scale. Staff A (NP) Relayed R#5 blood sugars were fluctuating and he resisted having blood sugar checks four times a day, was changed to twice a day followed by the sliding scale order to manage hyperglycemic episodes. The additional insulin was intended to be given when the blood sugar was checked routinely, twice a day and as needed in such instances for example when R#5 overate. Staff A (NP) acknowledged understanding that the insulin was not given as intended and also acknowledged, had signed the written transcribed order that documented the timeframe every 8 hours, and reiterated that was incorrectly noted. The NP relayed had many residents to oversee and missed verifying the accuracy of the sliding scare order prior to approving. On 12/30/25 at 4:30 PM Registered Nurse, Staff B relayed the ADON had transcribed the order and she was on vacation and could not get clarification of how the order should be shown on the MAR. RN Staff B relayed since the sliding scale was on PRN (pro-re-nata refers to as needed) medication list, was easily missed. Staff B relayed had just consulted with NP, Staff A and would be correcting the medication record. On 12/30/25 at 5:00 PM the Administrator relayed was working with the nurses to ensure the insulin order was corrected so R#5 would receive additional insulin as he needed for his diabetes. The Administrator acknowledged the sliding scale order was missed by nurses since the order had no time frames and only transcribed as PRN (as needed) on the MAR. The policy titled, titled Verbal orders , revision date 2025 documented, physician orders may be received by telephone, by a licensed nurse or other licensed or registered health, to repeat any prescribed orders back to the physician or health care provider, to use clarification questions to avoid misunderstandings, to enter the order into the medical record, the physician should sign the order on the next visit to the facility or within the time frame

Based on clinical record review, observation, and staff interview, the facility failed to ensure staff appropriately and safely transferred a resident for 2 of 5 residents observed during transfers (Resident #5 & #6). The facility reported a census of 40 residents. Findings include: 1. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had diagnoses of Parkinson's Disease, anxiety disorder, muscle weakness, and a history of falls. The MDS documented the resident had a Brief Interview for Mental Status score of 6, indicating severely impaired cognition. The MDS indicated the resident used a wheelchair, required substantial to maximum assistance for transfers and had dependence on staff for wheeling her in a wheelchair 50 feet and 150 feet. The Care Plan updated on 1/27/25 revealed Resident #5 had a risk for falls and limited mobility related to impaired balance, poor safety awareness, and use of medications that increased her risk for falls. The Care Plan revealed the resident utilized a wheelchair that staff propelled for her. During observation on 4/15/25 at 12:20 PM, Staff A, Certified Nursing Assistant (CNA) pushed Resident #5 in a high back wheelchair without foot pedals from the resident's room to the dining room approximately 60 feet. The resident's feet were near the floor as the CNA pushed her in the wheelchair. 2. The Quarterly MDS assessment dated [DATE] revealed Resident #6 had diagnoses of Alzheimer's Disease, dementia, muscle weakness, and low back pain. The MDS recorded the resident had a BIMS score of 6, indicating severely impaired cognition. The MDS indicated the resident required partial to moderate assistance for transfers and used a wheelchair. The Care Plan revised 3/26/25 revealed Resident #6 had a risk for falls related to impaired safety awareness and required assistance with Activities of Daily Living (ADL's). The Care Plan revealed the resident used a wheelchair. The Care Plan directed staff to propel the resident in the wheelchair as needed. During observation on 4/15/25 at 12:15 PM, Staff A, CNA, pushed Resident# 6 in a wheelchair without foot pedals from the resident's room to the dining room approximately 50 feet. The bottom of the resident's feet brushed the floor as the resident sat in the wheelchair and Staff A pushed the wheelchair. During an interview 4/16/25 3:40 PM, the Director of Nursing reported foot pedals needed to be on the wheelchair and utilized whenever staff transported a resident in a wheelchair. On 4/16/25 at 3:40 PM, the Administrator reported the facility did not have a policy for transporting or pushing a resident in a wheelchair.

Based on observations, clinical record review, facility policy review and staff interviews the facility failed to provide a dependent resident a dignified eating experience during a noon meal service for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) of Resident #3, dated 11/27/24, identified a Brief Interview of Mental Status (BIMS) score of 2 which indicated severe cognitive impairment. The MDS coded the resident as dependent for eating. The Care Plan revised 11/13/24, included a Focus area to address [Name redacted] has a self-care deficit as evidenced by requires assistance with ADLs (activities of daily living), impaired balance during transitions requires assistance and/or walking. Interventions included, in part; Eating: 1 (one) assist. The Care Plan revised on 11/27/24, included a Focus area to address [Name redacted] has potential nutritional problem r/t (related to) obesity, need for mechanically altered diet, CVA (cerebrovascular accident, or stroke); advanced age. Interventions included, in part; Dependent assist at all meals also encourage intake of additional fluids. A continuous observations of the noon meal on 12/3/24 starting at 11:36 am revealed the following: a. At 11:36 am, Resident #3 assisted to dining room. Her wheelchair placed at a dining table with other residents present. b. At 12:11 pm, staff started to service food and beverages. c. At 12:21 pm, the residents sitting at the table with Resident #3 began to get their meals, and receive assistance to eat and drink. d. At 12:27 pm, Staff A, Certified Nurse Aide/Housekeeping Supervisor brought food to Resident #3 and began to assist her to eat. e. At 12:32 pm, Staff A, CNA offered Resident #3 a drink and then began conversing with another staff member at the table. Without looking at Resident #3, he gave the resident a small sip of her milk. f. At 12:35 pm, Staff B, CNA entered the dining room and Staff A asked him to take over assisting Resident #3. Staff B sat with Resident #3. g. At 12:37 pm, Staff B left the table and assisted Staff C, CNA to reposition another resident in the dining room. h. At 12:38 pm, Staff B returned to the table to sit with Resident #3. i. At 12:41 pm, Staff B left the dining area. j. At 12:42 pm, Staff G, Licensed Practical Nurse (LPN) came to the table with medications for Resident #3. After administering the medications, she encouraged the resident to take some drinks. k. At 12:43 pm, Staff B returned and sat at the table and assisted another resident. l. At 12:44 pm, Staff C, CNA while sitting at table next to Resident #3, cued her to take a drink of milk. Staff D, CNA then sat at the table next to Resident #3. m. At 12:47 pm, Staff B and Staff D left the table. One staff member remained present at the table but was not assisting Resident #3. n. At 12:48 pm, Staff E, Activities Director and CNA arrived to the table and assisted Resident #3 to eat. She then moved to another resident at the table and also assisted that resident. Staff E stayed with Resident #3, alternating helping her as well as another resident until 12:56 pm. o. At 12:57 pm, Staff F, CNA sat with Resident #3 and encouraged fluids. p. At 1:00 pm, Staff F left, while Resident #3 remained at the table. q. At 1:02 pm, Staff Staff C stood at Resident #3's table, assisting another resident. She verbalized to Resident #3 to drink her fluids. r. At 1:03 pm, Staff E returned and assisted Resident #3. s. At 1:05 pm, Staff E left the table. t. At 1:07 pm, Staff F returned and sat with Resident #3 again. u. At 1:09 pm, Reident #3 continued to chew food while the dietary staff started clearing tables. The remainder of the food on Resident #3 plate was removed from the table and dumped into a refuse barrel. v. At 1:11 pm, observation ended with no food or drink remained on the table. During an interview on 12/3/24 at 1:44 pm, the Assistant Director of Nursing stated Resident #3 will sometimes get agitated and at times does better to have a switch in staff members. She stated that it was excessive to switch that many times and usually is two people per meal. During an interview on 12/3/24 at 1:46 pm, the Director of Nursing stated Resident #3 sometimes pushes her food away and prefers to feed herself rather than have staff feed her. He stated staff needs to just get her going to eat and give her a chance to feed herself. He stated sometimes a different face being there will spur her to eat. He stated she has had multiple hospitalization s but has maintained her weight. During an interview on 12/5/24 at 8:02 am, Staff F, CNA stated the normal routine for Resident #3 is for staff to assist her with food and drinks and to always have a staff member at the table. She stated she is currently on light duty and she helps wherever she is able. She stated Resident #3 will push her food away when she is done eating. She stated she asked Resident #3 if she was done on 12/3/24 and Resident #3 stated yes. During an interview on 12/5/24 at 10:46 am, Staff G, LPN stated usually a couple of staff members assist Resident #3 with each meal. She said they have tried to have a single person assist, but it usually does not happen. She stated that was not a normal day and a lot was happening that day. She stated it was a lot to have State Surveyors in the building. She was unable to give any other details but just said it was a lot that day. During an interview on 12/5/24 at 10:51 am, Staff B, CNA stated staff just kind of does that when asked why people came and went so much during lunch service. He stated staff likes to take turns answering call lights or helping residents toilet and alternate between who is sitting with residents and who is on the floor doing other things. During an interview on 12/5/24 at 11:05 am, Staff A, CNA and Housekeeping Supervisor stated if he sees a resident is sitting and needs fed, he will jump in and help. He stated he did not know why so many people came and went on 12/3/24. He stated she often doesn't like to directly be fed but will take cues to eat. During an interview on 12/5/24 at 11:08 am, Staff E, Activities Director/CNA stated there is supposed to be a staff member sitting with Resident #3 at all times during her meal. She stated she normally does not assist to feed residents but she saw other people get up and leave so she came when there was nobody else there with her. The facility policy Dignity, Revision Date February 2021 documented the following: 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. 3. Individual needs and preferences of the resident are identified through the assessment process.

Based on clinical record review, facility policy review and staff interviews the facility failed to ensure accurate code status for 1 of 16 resident reviewed for advanced directives (Resident #28). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 medical diagnoses included Parkinson's disease, peripheral vascular disease and respiratory disease. The Brief Interview for Mental Status exam scored 15 out of 15 which indicated intact cognition. The MDS reflected resident elected hospice care. The Clinical Resident Profile in the electronic health record for Resident #28 indicated Code Status: (Advance Directives) FULL CODE. Special Instructions: [Name redacted] Hospice. The Care Plan initiated [DATE] revealed a focus area for code status, Do not Resuscitate (DNR), code status will be honored. Interventions included, signed Do Not Resuscitate (DNR) orders, maintain copy of IPOST in chart. The Iowa Physician Orders for Scope of Treatment (IPOST) document signed by the resident on [DATE] directed DNR/Do Not Attempt Resuscitation. The provider signed the form on [DATE]. The IPOST found in a code status binder located at the nurses station. During an interview on [DATE] at 5:00 pm, the Director of Nursing (DON) stated Resident #28 wanted CPR. The DON reported there was a recent change from DNR to CPR. The DON reported the updated form signed by Resident #28 was not updated in the code status book and the new form should of been in the code book. The Administrator, also present during the interview, agreed the electronic record should be the same as the IPOST form. During an interview on [DATE] at 9:30 am, Staff G, Licensed Practical Nurse (LPN) stated she would check for code status in wherever was handy at the time, either the electronic record or the code book kept at the nurses desk. Staff G stated she knew from staff updates, Resident #28 changed to a full code and was still approved to be under hospice. On [DATE] at 9:49 am, Staff H, Registered Nurse stated she would look at the electronic record for code status or the code status binder for the IPOST paper copy. The facility policy, revised [DATE], Policy Interpretation and Implementation section directed, in part: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatments and to formulate an advance directive if he or she chooses to do so. 19. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment MDS and care plan.

Based on personnel file reviews, staff interviews and facility policy review, the facility failed to assure all employees had a child abuse background check completed prior to working in the facility as a Certified Nursing Assistant (CNA) for 1 of 5 current employees sampled. The facility reported a census of 42 residents. Findings include: A review of the personnel file for Staff I, CNA revealed a hire date of 2/28/24. The file failed to contain an abuse registry check prior to hire date. Review of the background check titled Singe Contact License & Background Check (SING), completed on 2/27/24 at 11:02 AM, revealed Child Abuse results required initiating record check evaluation by contacting the Department of Human Services (DHS). During an interview on 12/05/24 at 11:04 am, the Administrator confirmed there was no documentation in the Staff I, CNA personnel file with the results of DHS child abuse evaluation record check. She stated the facility had removed Staff I, CNA from the schedule until they complete the required abuse evaluation through the DHS. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated 7.8.2024 documented The facility shall screen all potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of Residents. It further described the facility will not engage or employ those applicants found on abuse registry and will maintain documentation with such results.

Based on clinical record review, facility policy review and staff interview the facility failed to update the care plan to reflect a residents change in their choice of advance directives for 1 of 16 residents reviewed for advanced directives (Resident #28). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 medical diagnoses, included Parkinson's disease, peripheral vascular disease and respiratory disease. The Brief Interview for Mental Status (BIMS) exam scored 15 out of 15 which indicated intact cognition. The MDS reflected resident elected hospice care. On [DATE] a review of the Clinical Resident Profile in the electronic health record for Resident #28 revealed Code Status: (Advance Directives) FULL CODE. Special Instructions: [Name redacted] Hospice. The Care Plan revealed a focus initiated [DATE] for Resident #28 documented Do not Resuscitate (DNR), code status will be honored, included signed Do Not Resuscitate (DNR) orders, maintain copy of IPOST (The Iowa Physician Orders for Scope of Treatment) in chart. During an interview on [DATE] at 5:00 PM Interview with the Director of Nursing (DON) relayed there was a recent change with Resident #28 code status choice, had signed an updated form wanted CPR. On [DATE] at 10:30 AM the Director of Nursing (DON) and the Administrator acknowledged Resident #28 care plan should have been updated to reflect resident wanted CPR. The facility policy, revised [DATE], titled Care Plans, Comprehensive Person-Centered, Policy Interpretation and Implementation directed, in part: 13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' condition changes.

Based on observations, clinical record review, facility policy review and staff interview the facility failed to utilize infection control techniques during incontinence cares for a resident with a history of multiple urinary tract infections in an attempt to minimize the potential for reoccurrence of an infection for 1 of 2 residents reviewed (Resident #3). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) of Resident #3 dated 11/27/24, identified a Brief Interview of Mental Status (BIMS) score of 2 which indicated severe cognitive impairment. The MDS coded the resident as dependent for toileting hygiene. The MDS reflected the resident always continent with urine and bowel. The Care Plan, initiated date of 10/26/24, revised on 11/25/25 included a Focus area to address [Name redacted[ has BLE (bilateral lower extremities, or legs) and UTI (urinary tract infection) and is at risk for increased temperature dehydration, pain/discomfort. The Care Plan, initiated date of 1/5/24, revised on 10/10/02/24 included a Focus area to address [Name redacted] has the potential for infection related to a history of UTI. A review of a General Progress Note dated 11/24/24, revealed Resident #3 returned from the emergency room with an order for Keflex Oral Capsule 500 mg 1 capsule by mouth four times a day for Cellulite /UTI for 10 days. A review of an Admission Assessment note dated 11/1/24, revealed Resident #3 returned to the facility after a hospitalization . The note documented currently on antibiotic therapy due to an active infection .Levofloxacin (an antibiotic) for UT (urinary tract). A review of a ED (Emergency Department) to Hosp-Admission (discharged ) note revealed patient admitted on [DATE] with septic shock (a life-threatening condition that occurs when a severe infection causes dangerously low blood pressure) found to be from urinary source and started on cefepime (antibiotic). A review of a General Progress Note dated 10/27/24, revealed an order for Bactrim DS (an antibiotic) Oral Tablet 800-160 MG (milligrams). Give 1 tablet by mouth two times a day for UTI for 5 days. A review of an Order Note dated 9/13/24, revealed an order for Amoxicillin-Pot Clavulanate (an antibiotic combination) Oral Tablet 875-125 MG. Give 1 tablet by mouth two times a day for UTI for 7 days. A review of a General Progress Note dated 8/29/24, revealed an order for Cephalexin (antibiotic) Oral Tablet 500 mg. Give 500 mg by mouth two times a day for UTI until 9/4/24. During an observation on 12/3/24 started at 11:16 am the following revealed: Staff C and Staff D, Certified Nurse Aides (CNA) took Resident #3 into her room for cares. The Director of Nursing (DON) was present in the room for the observation. After transferring the resident from her wheelchair onto her bed, Staff C, CNA washed her hands and donned gloves. Staff D, CNA remained next to the bed. Staff C reminded Staff D she needed to also wash her hands. Staff D washed her hands and donned gloves. She then opened the closed bathroom door to gather supplies for cares from the bathroom and also from the sink area outside the bathroom. Staff D returned to the resident's bedside, and both Staff C and Staff D assisted to turn the resident to her left side, then side to side to lower her pants. Staff D opened the resident's incontinence brief. Without changing gloves or washing hands, Staff D then performed peri care on Resident #3. The resident was incontinent of bowel and bladder. Staff D performed peri cares as Staff C provided supplies. After completing cares on Resident #3's front side, Staff D removed her gloves, performed hand hygiene and placed new gloves on her hands. Both staff then turned the resident to her side. Staff D gathered the dirty brief and placed the brief in the garbage and then began to cleanse the resident's buttocks. Staff C then placed a clean incontinence brief under the resident. Both staff removed their gloves, performed hand hygiene and placed new gloves. Staff then repositioned resident side to side to replace her clothing and secure the brief. Staff D removed her gloves and took the soiled trash out of the trash can and placed a clean bag in the can and placed the trash bag on the floor near the door. After using hand sanitizer, staff transferred the resident back to her wheelchair. During an interview on 12/3/24 at 1:39 pm, the DON stated staff did not wash their hands as frequently as they should have during the observation earlier in the day. He stated after hands were washed and gloves were placed, staff should not have then went into the bathroom for supplies or an additional hand hygiene and gloving should have been done prior to performing peri cares. The facility policy, revised February 2018, titled Purpose statement declared The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.

Based on clinical record reviews, observations, staff interviews, and facility policy review, facility staff failed to ensure restorative nursing services and to consistently implement interventions to prevent the development or worsening of contractures for 2 of 2 residents (Residents #6 and #14) reviewed for limited range of motion, positioning, and mobility. The facility reported a census of 37 residents at the time of the survey. Findings include: 1. Resident #6's annual MDS (Minimum Data Set) assessment dated [DATE] documented her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #6 experienced severely impaired cognitive skills for daily decision-making. The resident showed total dependence on staff for ADLs (activities of daily living), had impaired range of motion on all upper and lower extremities, and used a wheelchair as mobility device. The MDS further indicated that Resident #6 did not receive restorative nursing services in the 7 days of the assessment's look-back period. Resident #6's care plan identified a focus area regarding ADL self-performance deficit related to residual effects of [CONDITION(S)] (stroke) as evidenced by need for total staff assistance with ADLs. The care plan described Resident # 6 as non-ambulatory and unable to bear weight on bilateral (both) lower extremities, she utilized bilateral 1/2 side rails as a mobility aid for attempts to assist with repositioning related to difficulty due to stroke and [CONDITION(S)] disorders diagnoses. The care plan directed staff to encourage Resident #6 to work with Restorative Therapy CNA [certified nurse aide] as outlined in restorative care plan. The care plan also directed PT/OT (physical therapy/occupational therapy) evaluation and treatment according to doctor's orders. The resident's Order Summary Sheet documented an order dated 1/28/22 directing PT/OT/ST (physical therapy/occupational therapy/speech therapy) to evaluate and treat Resident # 6. During observation on 10/05/22 at 8:12 AM, Resident #6 sat in the dining room area in a geriatric chair, with clenched fists on her chest area. At times she'd raise her right hand and touch her mouth area with stiff fingers. A throw blanket covered Resident # 6's lap and lower extremities except for the left foot, which was raised and not resting on the leg support board. During observation on 10/10/22 at 8:05 AM, Resident #6 sat in a geriatric chair at the dining room with a throw blanket covering on lap area and lower extremities. Resident #6's hands were visible on her chest area with contracted fingers. On 10/10/22 at 8:10 AM, the DOR (Director of Rehabilitation) stated that Resident #6 has ongoing restorative nursing therapy, however, the DOR reported that the only restorative nursing documentation she could find for Resident # 6 were from 2018. The DOR also stated that Therapy recommends a restorative nursing program and then nursing staff adjusts it as they see fit. The DOR reported that Resident #6 received therapy services on 1/13/22 to 1/18/22 because of her contractures but was discharged due to change in payor source. The DOR further reported that Resident #6 resumed skilled therapy on 2/1/22 and discharged on [DATE]. The resident's PT Discharge Summary dated 2/24/22 recommended that Resident #6 discharge to an ICF (Intermediate Care Facility) level of care with restorative nursing in place. The discharge recommendations also documented, Recommend RA [Restorative Aide] program to maintain gains made in therapy and prevent functional decline and for contracture management. During interview on 10/10/22 at 9:29 AM, the RA (Restorative Aide) stated that Resident # 6 was not receiving restorative nursing services and had not been on them for a long time. The RA also reported a lack of any restorative nursing documentation because Resident # 6 was not on it. During interview on 10/10/22 at 11:03 AM, the Administrator verified the lack of implementation and follow through regarding Resident # 6's restorative nursing care. The Administrator acknowledged the importance of following treatment recommendations after the ordered PT/OT evaluations. The Administrator stated expectations for staff to follow orders and recommendations. The facility's policy titled, Restorative Nursing Services, dated July 2017, provided that restorative nursing may be started during the course of stay or upon discharge from rehabilitative care. The policy provided that restorative goals and objectives are individualized and resident-centered and are outlined in the residents' plan of care. The policy further provided that restorative goals may include developing, maintaining, and strengthening physiological and psychological resources. 2. The MDS assessment for Resident #14 dated 4/15/22 recorded a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 points, indicating a severe cognitive deficit. The assessment documented the resident required a 2-person staff assist for bed mobility, transfers, dressing, toilet use and 1-person staff assist for wheelchair locomotion and eating. The MDS listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #14's MDS of 12/14/21 documented she entered the facility on 12/10/21 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of documentation titled Occupational Therapy evaluation, dated 12/12/21 revealed in the section labeled musculoskelatal system assessment that the resident had no contractures on this date. The resident's Occupational Therapy Treatment Encounter Note dated 3/25/22 documented the therapist provided gentle passive range of motion to the resident's left upper extremity and increased tightness of the resident's wrist/fingers. The resident was not wearing her hand splint and the Occupational Therapist Assistant placed the hand splint on the resident after performing range of motion. Additional notes with encounter dates of 4/4/22 and 4/13/22 revealed documentation of increased tone (inflexibility) in left upper extremity and stiffness in the wrist and fingers. In review of the comprehensive care plan for the resident with a focus area of self care deficit, an intervention dated 2/11/22 directed that Resident #14 has a contracture of the left hand and directed staff to provide skin care to keep the skin clean and prevent skin breakdown. An intervention dated 3/20/22 directed staff to apply a resting hand splint to the resident's left hand every day and remove the splint at bedtime. During an interview on 10/6/22 at 9:00 am, Staff E, Occupational Therapist stated she had worked with Resident #14 multiple times from her initial admission in 12/21 through several months of the resident receiving occupational therapy. She stated the resident's left arm was completely flaccid (soft and hanging limp) and she had no contracture upon admission. Staff E additionally stated she was the person who initiated getting the hand splint for the resident as a means of reducing the chances of developing a contracture. Staff E stated contractures are common in residents who have [CONDITION(S)] and the splint was intended to be a preventative for the development of a contracture. Observations of the resident on multiple occasions revealed her to be seen not wearing the ordered soft hand splint: a. On 10/4/22 at 3:20 pm the resident rested in her bed. She had a geri sleeve on her left arm and did not wear a left hand splint. b. On 10/5/22 at 7:50 am the resident was observed in her room with a staff member completing morning cares. The resident wore TED (antiembolism) hose and a left geri sleeve. The resident did not wear a left hand splint. c. On 10/5/22 at 8:25 am the resident ate breakfast in the dining room. The resident fed herself with her dominant right hand and had no hand splint on. d. On 10/6/22 at 8:05 am the resident was again observed in the dining room waiting for breakfast. She did not wear a hand splint during the observation. Review of the resident's Treatment Administration Record (TAR) for 10/22 revealed an order directing staff to apply a resting hand splint every day shift to Resident #14's left hand with a start date of 2/13/22. The TAR documented placement of the resident's hand splint on 10/4, 10/5 and 10/6/22 contradictory to observations. During an interview on 10/6/22 at 9:25 am in Resident #14's, Staff G, Registered Nurse (RN) confirmed the resident was not wearing her ordered hand splint. Staff G acknowledged the resident is supposed to be wearing it and she started looking around the room to locate the splint. After opening drawers in the nightstand and looking in other places around the room, Staff G located the splint in the sink area. Staff G then placed the splint on the resident's left hand. Staff G stated the normal routine is for the CNA who gets the resident dressed to place the splint as part of the morning cares. During an interview on 10/6/22 at 9:50 am, Staff D, CNA stated she had been taught the procedure for how to place the hand splint on Resident #14 but she was not aware of who was responsible for placing it on the resident daily. Staff D believed therapy staff normally put it on the resident. During an interview on 10/6/22 at 10:55 am, Staff F, Occupational Therapist confirmed she authored a document titled Occupational Therapy Evaluation and Plan of Treatment dated 1/19/22 for Resident #14. This document recorded Short Term Goal #2 as ' Patient will tolerate range of motion techniques to bilateral upper extremities for contracture management and improved upper body activities of daily living performance ' . Staff F stated the language contracture management listed in this goal meant that the resident did not have a contracture at that time and the goal was to manage the prevention of a contracture developing. The evaluation also documented in the section labeled Musculoskelatal system assessment (page 3) a question if there currently were functional limitations present due to contracture which the answer was no. Staff F stated this meant the resident did not have any contractures at the time of the evaluation.

Based on clinical record reviews, observations, interviews, and facility policy review, the facility failed to ensure development of a comprehensive care plan with focus on restorative nursing services for 1 of 2 residents (Resident # 6) sampled for limited range of motion. In addition the facility did not develop a care plan for the prevention of falls for 1 of 4 residents (Resident # 14) in the sample reviewed for accidents. The facility reported a census of 37 residents at the time of the survey. Findings include: 1. Resident #6's annual MDS (Minimum Data Set) assessment dated [DATE] documented her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #6 experienced severely impaired cognitive skills for daily decision-making. The resident showed total dependence on staff for ADLs (activities of daily living), had impaired range of motion on all upper and lower extremities, and used a wheelchair as mobility device. The MDS further indicated that Resident #6 did not receive restorative nursing services in the 7 days of the assessment's look-back period. Observations on 10/05/22 at 8:12 AM and on 10/10/22 at 8:05 AM, showed Resident #6 in the dining room, with contractures in her fingers and hands, and with stiff lower extremities. The resident's Order Summary Sheet documented an order dated 1/28/22 directing PT/OT/ST (physical therapy/occupational therapy/speech therapy) to evaluate and treat Resident # 6. The resident's PT Discharge Summary dated 2/24/22 recommended that Resident # 6 discharge to an ICF (Intermediate Care Facility) level of care with restorative nursing in place. The discharge recommendations also documented, Recommend RA [Restorative Aide] program to maintain gains made in therapy and prevent functional decline and for contracture management. However, the resident's undated care plan lacked development of a restorative nursing care program for Resident # 6. Interviews that revealed lack of directions regarding restorative nursing care for Resident # 6 were as follows: a. During interview on 10/10/22 at 8:10 AM, the DOR (Director of Rehabilitation) reported that Resident #6 received therapy services on 1/13/22 to 1/18/22 because of her contractures, and then discharged because of a change in payor source. The DOR said Resident #6 resumed skilled therapy from 2/1/22 to 2/18/22, and then discharged on [DATE]. b. During interview on 10/10/22 at 9:29 AM, the RA (Restorative Aide) said that Resident #6 was not receiving restorative nursing services and that Resident #6 had not been on restorative nursing for a long time. The RA also verified lack of any restorative nursing documentation, saying that Resident #6 was not on it. c. On 10/10/22 at 11:03 AM, the Administrator verified the lack of implementation and follow through regarding a restorative nursing plan. The Administrator acknowledged the importance of following treatment recommendations after the ordered PT/OT evaluations. The Administrator stated expectations for staff to follow orders and recommendations. The facility's policy titled, Restorative Nursing Services, dated July 2017, provided that restorative goals and objectives are individualized and resident-centered and are outlined in the residents' plan of care. The policy also provided that restorative goals may include developing, maintaining, and strengthening physiological and psychological resources. 2. The MDS assessment for Resident #14 dated 4/15/22 recorded the resident scored 6 out of a possible 15 points on a Brief Interview of Mental Status (BIMS), indicating severely impaired memory and cognition. The assessment documented the resident required 2-person staff assistance for bed mobility, transfers, dressing, toilet use and personal hygiene and 1-person staff assist for wheelchair locomotion and eating. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's admission MDS assessment dated [DATE] revealed in Section V, Care Area Assessment (CAA) Summary, that she triggered for the section of Falls. Further review showed the reason the resident assessment triggered this area as she was unstable during surface to surface transfers and only able to stabilize with staff assistance. The CAA worksheet recorded this was an actual (vs potential) finding and indicated further risk of falls based on use of antipsychotic medication as well as having circulatory, neuromuscular and cognitive risk factors. Under the heading of care plan considerations, staff documented a focus area of falls would be addressed on the care plan with the statement the care plan will be initiated/reviewed to improve/maintain current physical function as it relates to ADLs, gait stability, strength and endurance, mobility, decrease fall risk and minimize injury related to falls. The CAA was dated 12/23/21. Review of the State Operations Manual reveals the comprehensive care plan must be developed within 7 day after completion of the comprehensive assessment. Review of an incident report for Resident #14 dated 2/7/22 revealed the resident fell which resulted in multiple injuries. Her comprehensive care plan showed staff initiated a focus area of falls on 3/20/22. Incident reports revealed that Resident #14 had further falls on 6/8/22, 6/24/22 and 8/8/22. An intervention dated 6/9/22 on the care plan directed staff to to put the resident's bed in low position and to have a fall mat on both sides of bed. An intervention dated 8/9/22 revealed a medication review was completed. No intervention could be found for the fall on 6/24/22.

Based on clinical record review, observation, resident and staff interviews, and facility policy review, the facility failed to follow the individual plan of care and provide at least one to two baths per week for 2 of 5 residents (#16 and #18) reviewed who required assistance to maintain their personal hygiene. The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #16 dated 9/26/22 recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented a Brief Interview Mental Status (BIMS) score of 13 out of 15, which indicated intact memory and cognition. Resident #16 required the assistance of one staff member for physical help during bathing. The assessment did not document the presence of behavioral symptoms or that Resident #16 rejected care. The comprehensive care plan instructed that Resident #16 has a self-care deficit and she required assistance with Activities of Daily Living (ADLs). Resident #16 is to bathe twice weekly and required extensive assistance with personal hygiene care. During an interview on 10/4/22 at 2:17 p.m. with Resident #16, stated she had not received a a bath for one month and could smell herself. She stated she has never refused to shower when offered. During an interview on 10/5/22 at 4:00 p.m. with Resident #16 stated she received a bath on 10/4/22. She appeared clean, with combed hair and clean clothing. Bathing sheets recorded that Resident #16 received one bath per week from 9/1/22 to 9/30/22 and had a 17-day gap without a bath from 9/13/22 to 9/30/22. The The Shower List for 9/1 - 9/30/22 recorded that Resident #16 received showers on 9/2, 9/6, 9/13, and 9/30/22. 2. The MDS assessment for Resident #18 dated 7/27/22 recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 00 out of 15, indicating severely impaired memory and cognition. The MDS documented she required extensive assistance with bed mobility, transfers, and toilet use and as totally dependent on staff for bathing. The comprehensive care plan instructed that Resident #18 has a self-care deficit related to Alzheimer's disease and the use of psychoactive medications and dementia. She is totally dependent on staff assistance for ADLs and bathing, with direction to bathe once weekly and as needed per her preference. Observation on 10/5/22 at 11:45 a.m. revealed Resident #18 laid in bed; her hair appeared stringy and greasy. Observation on 10/5/22 at 4:02 p.m. revealed Resident #18 sat at the dining table waiting for dinner. The resident's hair appeared unkept and greasy. Observation on 10/6/22 at 8:26 a.m. revealed Resident #18 sat at the dining table with her hair pulled back in a pony tail; her hair appeared greasy. An interview on 10/5/22 at 1:47 p.m. with the Director of Nursing (DON) revealed that Staff A, Shower Aide, did not work 10/5/22 and residents would not receive a shower. The DON verified that certain residents only receive showers on Wednesdays. The DON did not have a plan for residents who would not receive a shower on 10/5/22. During an interview on 10/6/22 at 8:27 a.m. Staff A stated that Resident #18 got a shower a week ago on Wednesday, and she is to receive one shower per week on Wednesday. Staff A stated that Resident #18 did not receive a shower the Wednesday prior on 10/5/22. During an interview on 10/6/22 at 8:45 a.m. the Administrator stated that all residents should be offered a shower or bed bath twice per week. During an interview on 10/6/22 at 9:00 a.m. Staff A stated she has not been able to give 2 showers per week and bathes residents one time per week. Staff A did not know that staff directives for resident baths were on the care plan. On 10/6/22 at 10:33 a.m. the DON stated she was unaware residents received one bath per week and that Staff A did not know she was expected to document showers in the electronic health record (EMR). The Bathing documented recorded that Resident #18 received a shower 9/7/22 and 9/14/22 only during September. Facility documentation demonstrated Resident #18 a 14-day gap without a bath between 9/14/22 - 9/28/22. The facility's policy titled Activities of Daily Living, Supporting, dated March 2018 instructed that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination, dining, and communication.

Based on clinical record review, observations, staff and resident interviews, and facility policy review, facility staff failed to ensure resident safety and did not implement its policy to immediately remove an alleged abuse perpetrator from further work pending results of investigation and to report abuse allegations immediately to the facility administrator for 1 of 2 residents (Resident # 29) in the sample reviewed for abuse. The facility reported a census of 37 residents at the time of the survey. Findings include: Resident # 29's annual MDS (Minimum Data Set) assessment dated [DATE], showed a BIMS (Brief Interview for Mental Status) score of 14 that indicated intact memory and cognition. His most recent MDS assessment dated [DATE] documented a BIMS score of 15, also indicating intact memory and cognition. # 29's MDS assessments identified active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan identified Resident # 29's risk for alteration in mood/behavior related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan noted that Resident # 29 can become verbally aggressive when his routine is disrupted or he was not anticipating the interaction. The care plan directed staff to implement interventions that include assessment of Resident # 29's understanding of the situation, allowing time for him to express self and feelings toward the situation; and monitoring and documenting observed behaviors and attempted interventions The care plan also identified Resident # 29's impaired cognitive function with impaired thought processes related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan directed staff to to communicate with Resident # 29 regarding capabilities and needs; to identify yourself at each interaction; face Resident # 29 when speaking and make eye contact; provide consistent, simple, directive sentences and necessary cues, and then to stop and return if agitated; monitor/document/report any changes in cognitive function; and monitor/document occurrence of behavioral symptoms inappropriate response to verbal communication, violence/aggression towards staff/others, and document per facility protocol. On 6/21/22, the facility reported an incident to the Department of Inspections and Appeals (DIA) regarding Resident #29. The report documented that an agency certified nursing assistant called Resident #29 a 'son of a b****' as overheard by Staff I, Housekeeper. On 10/04/22 at 1:36 PM, Resident # 29 sat in a wheelchair in his room and watched a program being played in his computer. Resident # 29 responded to the knock and greeting but stated that he did not want to answer questions. On 10/06/22 at 12:55 PM, Resident # 29's call light was on, Staff H LPN (Licensed Practical Nurse) responded and entered Resident # 29's room at 12:56 PM. Staff H described Resident # 29 as someone who did not really want talking with staff and wanted staff to go in and out. During observation and interview on 10/06/22 at 1:20 PM, Resident # 29 remained in his room, quietly sitting in wheelchair, with attention to his computer on top of the bedside table. Resident # 29 waved in response to a knock, but when asked about interviewing to follow-up on incident at the facility, Resident # 29 verbalized that he was not interested in any of those and repeated, no thank you. During interview on 10/10/22 at 10:21 AM, Staff I stated she worked the weekend of 6/19/22, and while in the 300 hallway at about 7:30 AM delivering laundry, there were 2 agency staff in Resident # 29's room doing cares. One of the agency staff called Resident # 29 an a**-hole to which Resident # 29 answered back, watch your mouth!. Staff I further said that the upset agency Staff J CNA (Certified Nurse Aide) uttered, Son of a b****! while walking out from Resident # 29's room and into the hallway. Staff I said she reported what she heard to Staff K CNA (former regular staff). Staff K then approached Staff J saying that what she (Staff J) said was not nice and she should no longer be caring for Resident # 29. Staff I said she also reported the same to Staff L LPN who was the nurse on duty at that time. Staff I stated that Staff J should not have been allowed to continue working her shift. During interview on 10/10/22 at 10:32 AM, Staff L acknowledged that she was the nurse on duty the weekend of 6/19/22 during an incident involving Staff J and Resident # 29. Staff L stated she learned about the incident from Staff K (former regular staff) and not from Staff I. Staff L said she pulled Staff J aside and told Staff J that was not nice to say/treat to Resident # 29 and that she (Staff J) would no longer be allowed in Resident # 29's room. Staff L said she went to check on Resident # 29, who said he was fine, and that he was not sure if what Staff J said under her breath was directed at him. Staff L stated she did not report the incident immediately to administrator saying, as she felt like she protected the resident even though all was hearsay, there was confusion, it was so busy but that residents were protected. Staff L further said Staff J no longer went to Resident # 29's room but finished the shift caring for other residents. The facility's staffing schedule for 6/19/22 recorded that Staff J worked from 6 AM to 2 PM. The incident happened at approximately 7:30 AM on 6/19/22, per Staff I interview. The facility's investigation report showed that the incident was reported to the Administrator on 6/21/22 at 7:30 AM or 2 days after the occurrence. During interview on 10/10/22 at 2:20 PM, the Administrator stated there was some confusion on what the staff did to handle the incident involving Resident # 29 on 6/19/22. The staff members did not know about abuse incident reporting. The Administrator also said it is their understanding that the policy provision written as immediate removal of alleged perpetrator from center pending results of investigation meant for as long as the facility removed the alleged perpetrator from caring for the resident involved. The facility's policy titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, updated on 3/3/22, provided that all residents have the right to be free from abuse, to include prohibiting nursing facility staff from taking acts that result in personal degradation (*statement intended to shame, degrade, humiliate, or otherwise harm the personal dignity of the dependent adult). The policy directed facility to implement written procedures that prohibit abuse, protection of residents and prevention, identification, investigation, and timely reporting of abuse. The policy noted, Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. The policy also directed staff to separate employee accused of abuse from all residents by moving the employee where there will be no contact with any residents of the facility. The further provided that all allegations of resident abuse/mistreatment should be reported immediately to the Administrator.

Based on clinical record reviews, resident interview, review of the Resident Assessment Instrument (RAI) manual v1.17.1_October 2019, and staff interviews, facility staff failed to assure each resident received an accurate Minimum Data Set (MDS) assessment, reflective of the residents' status at the time of the assessment for 2 of 2 residents (Residents #14 and #19) reviewed for Accuracy of Assessments. The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident 14 dated 4/15/22 recorded a score of 6 out of a possible 15 points on a Brief Interview of Mental Status (BIMS), indicating a severe cognitive deficit. Additionally, the MDS documented the resident required a 2-person staff assist for bed mobility, transfers, dressing, toilet use and personal hygiene and a 1-person staff assist for wheelchair locomotion and eating. The assessment listed she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the RAI, Section G of the MDS is to assess the functional status of the resident in regard to the need for assistance with the activities of daily living (ADLs). a. The MDS for Resident 14 dated 4/15/22 shows transfer status as extensive, 2-person assist. Review of admission note for Resident 14 revealed she required a Hoyer (mechanical) lift for transfers on admission. Review of Resident #14's care plan revealed she maintained the status of Hoyer lift transfers during her entire stay at the facility. Per the coding instruction of the RAI, transfers via lifts that require the resident to bear weight during the transfer, such as a stand-up lift, should be coded as Extensive Assistance, as the resident participated in the transfer lift and provided weight bearing support. A Hoyer lift is a lift in which the resident is in a sling in a sitting or lying position and fully lifted to transfer from on surface to another with no weight bearing and is considered Dependent assistance for coding on the MDS. During an interview on 10/6/22 at 9:50 am, Staff D, Certified Nurse Aide (CNA) stated that Resident #14 is always transferred using a Hoyer lift and has always been a Hoyer transfer for all of the time she had been a facility employee. b. The review of the MDS for Resident 14 dated 7/13/22, Section G0300A, recorded she was unsteady and only able to stabilize with staff assistance when moving from a seated position to a standing position. Further review revealed Section G0300D documented the resident was unsteady and only able to stabilize with staff assistance to move on and off the toilet. The resident could not stand and required the use of a Hoyer lift. Per comprehensive care plan with a focus area of self care deficit, an intervention dated 5/22/22 directed the resident does not use a toilet, bedpan or bedside commode. c. Review of multiple MDS assessments for Resident #14, with dates of 12/14/21, 1/10/22, 1/21/22, 4/15/22 and 7/13/22 all reveal in Section I8000 an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 14 has a documented height of 65 inches, with weights documented as 12/14/21 MDS admission MDS 154 pounds; 1/10/22 MDS discharge MDS 158 pounds; 1/21/22 MDS quarterly MDS 156 pounds; 4/15/22 MDS quarterly MDS 164 pounds; 7/13/22 MDS quarterly MDS 148 pounds. At the highest weight of 164 pounds, this is a Body Mass Index (BMI) of 27. Per the Centers for Disease Control and Prevention (CDC) [CONDITION(S)] is defined as a BMI of 40 or higher. d. Chapter 3 of the RAI instructed the definition of active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes from the medical director and nurse practitioner's visits for the resident since her admission to the facility reveal no documentation of an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent visit notes dated 7/26/22, 8/9/22 and 10/4/22 recorded a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . e. Review of an Incident Report for Resident #14, dated 2/7/22 revealed the resident was heard hollering and observed lying on the floor on the side of the bed near the window. Her bed was in high position. The resident was observed lying on her left side complaining of left hip and shoulder pain. She had blood noted from a mouth wound, a right elbow wound and left arm wound and wound to right hairline. Staff documented concern for a broken hip and the resident transferred to the hospital for x rays. Review of the MDS dated [DATE] revealed documentation that the resident had experienced zero falls in the time period since the most prior MDS dated [DATE]. 2. The MDS assessment for Resident #19 dated 7/27/22 indicated the resident scored a 15 on a BIMS assessment, indicating intact memory and cognition. The MDS documented the resident required a 1-person staff assist for bed mobility, transfers, wheelchair locomotion, dressing, toilet use and personal hygiene and bathing as well as set-up assistance for eating. The MDS listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The MDS assessment for Resident #19 dated 7/27/22, Sections G0110C and G0110D, recorded the resident walked both in his room and in the corridor with 1-person assistance. Section G0300B of the same MDS revealed documentation of walking as Did Not Occur. Review of the comprehensive care plan with a focus area of self care deficit dated 6/14/22 revealed lack of documentation of the resident being ambulatory. An intervention dated 6/17/20 directed staff he was independent in his use of an electric wheelchair for locomotion. During an interview with Resident #19 on 10/5/22 at 10:00 am, the resident stated he has used an electric wheelchair for over [AGE] years and has not walked due to multiple [CONDITION(S)]. b. Observation on 10/5/22 10:00 am, revealed Resident #19 had one-half side rails on both sides of his bed. During the resident interview on 10/5/22 at 10:00 am, the resident stated he requested these rails and uses them for assistance in bed mobility. The side rails assist him to turn side to side and he is able to transfer from the bed to his wheelchair without the side rails hindering his transfer. Resident #19 further staff staff had offered other alternatives to side rails and he did not wish for the side rails to be removed. The resident's comprehensive care plan had a focus area of utilizing half side rails, dated 8/25/22. The care plan directed that the use of side rails is to promote independence with bed mobility and positioning. Review of assessment titled Adaptive Equipment Restraint Use, dated 4/21/2021, revealed the definition of restraint as any manual method, physical/mechanical device or material/equipment attached/adjacent to the body that a resident can't easily remove, which restricts freedom of movement or normal access to one's body. Further review of the assessment revealed the use of half side rails for the resident does not meet the definition of a physical restraint. Review of the RAI revealed that any method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition. Additionally the RAI stated that any item that met the definition of restraint must have physician documentation of a medical symptom that supports the use of the restraint, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment for Resident #19 dated 5/5/21, Section P0100A, revealed documentation of daily use of bed rails as a restraint.

Based on clinical record review, staff and resident interviews, observation, and facility document review, facility staff failed to treat a resident in a respectful manner for one of seven residents reviewed (Resident #1). The facility identified a census of 39 current residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 possessed severe cognitive and memory impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of 0. The MDS documented she experienced signs of [CONDITION(S)] and displayed verbal behavioral symptoms directed toward others on 1 - 3 days of the assessment period. Resident #1 required the assistance of one staff to transfer, walk, dress, and use the toilet and displayed routine urinary incontinence and frequent bowel incontinence. Resident #1 received Hospice care while residing at the facility. Resident #1's Care Plan, revised on 12/9/21, instructed staff that she needed the assistance of 1 to use the toilet and that she entered Hospice care on 1/22/22. On 3/4/22 at 11:52 a.m., the facility reported an incident to the state agency which involved Resident #1. The facility reported that Staff A, CNA (Certified Nursing Assistant) cursed in the presence of the resident and told her to stop crying, she was faking it. Review of the facility's Incident Summary for Resident #1 dated 3/4/22 revealed on 3/4/22 at 11:20 a.m., Staff B, CNA reported she witnessed Staff A verbally abuse Resident #1. Staff B stated that Staff A and Staff C, NA (Nursing Assistant) brought the resident into the shower room while Staff B gave a shower to another resident. Staff B stated that Staff A said 'She is covered in sh*t. You need to give her a shower' and also told the resident she needed to quit crying as she was faking it. Facility staff immediately suspended Staff A, gathered statements and reported the incident. During an interview on 3/21/22 at 2:15 p.m., Staff C stated that on 3/4/22 about 10:30 to 11 a.m., she and Staff A worked in Resident #1's room. Resident #1 had been incontinent of stool in her brief. Staff A told Staff C that she really needed a cigarette, but they were told that Resident #1 needed to use the bathroom and Staff A wanted to make it quick. Staff A and Staff C transferred the resident to the toilet. After the resident sat a bit, the staff asked if she was done. The resident said yes so they assisted her to stand and noted the resident had incontinence of stool again. When they assisted her up a second time, the resident had a third bowel movement (BM). Staff C stated that Staff A told her to take the resident to the shower, but the resident said she did not want a shower. Staff C took the resident to the shower and Staff A followed down the hall. Staff A entered the shower room, then pulled off the resident's shirt; Resident #1 repeated that she didn't want a shower. Staff A told the resident she had to have a shower because she had 'sh*t all over her'. Resident #1 wanted to keep her undershirt on, but Staff A told her 'no, there's sh*t all over it'. Staff C stated she did not know what to do as she was a non-certified aide and had never had been in that situation. Staff B reported it to the nurse, who came and talked to Staff C later. Staff C recalled that Staff B went ahead with Resident #1's shower, thinking that Staff A would be away from the resident. Staff C also remembered that Staff A said she didn't care whether or not she got fired over the incident. Staff C could not tell if Resident #1 felt upset following the incident because it was hard to get a handle on her. Staff C stated she'd worked with Staff A and she had never been like that before: it came it from nowhere and she was not sure what triggered it. She added Staff A seemed to be in a bad mood before Resident #1 had even been incontinent. During an interview with Staff B on 3/21/22 at 11:55 a.m., she stated on 3/4/22, she worked providing showers for residents from 8 a.m. to 4 p.m. Staff B stated that about 11 a.m., she heard Staff A and Staff C call over the walkie (talkie) that Resident #1 was coming down for a shower. Staff B helped another resident to take a shower at the time, so she asked the aides to leave Resident #1 in the hallway. Staff B said Staff C brought Resident #1 into the shower while the other resident was still getting dressed, so they pulled the curtain and she asked them to wait. Staff A entered the shower room, agitated and mad, and said that Resident #1 was covered in[OBSCENITY] Resident #1 was crying and Staff A was forceful with the resident, telling her she had to take a shower. Staff A told the resident to 'stop crying, I know you're faking, you have to take a shower'. During the episode, Staff A said she didn't care if call lights were going off and she needed a f***ing cigarette all in the presence of 2 aides and 2 residents. Staff C stated that Staff A tried to move Resident #1, but she needed the assistance of 2 staff, so Staff C and Staff B also helped the resident into a shower chair. Staff B stated the resident stopped crying by the time the shower started and she acted in a very polite and gentle manner with the resident and she seemed calmer afterwards. Staff B manned Resident #7 as the other resident in the shower at the time of Staff A's outburst. Afterwards, Staff B talked with the resident's Hospice Aide (Staff E), who then spoke with Staff D, the nurse on duty. On 3/21/22 at 2:47 p.m. Resident #7 remembered staff asking her about an incident in the shower room on 3/4/22. Resident #7 reported she could could not tell them anything about it though, because staff were drying her hair at the time and a curtain was pulled in the shower room. During observation and interview on 3/22/22 at 9:20 a.m., Resident #1 lay supine in bed and agreed to talk. Resident #1 could not state her current location or the month and showed orientation only to her name. Resident #1 stated staff were fine to her and she could not remember anyone being unkind. During interview on 3/22/22 at 11:04 a.m., Staff E, Hospice CNA stated she arrived to the facility on [DATE] about 11 a.m. to work with Resident #1. Staff E did not witness the earlier incident, but sat down with the resident afterwards. Staff E stated Resident #1 appeared worried and upset and didn't say much. Staff E stated she asked Resident #1 if she took a shower and the resident told her it went really bad and it was her fault. Staff E stated she arrived to the facility on [DATE] about 11 a.m. to work with Resident #1. Staff E said she did not witness the earlier incident, but sat down with the resident afterwards and noted Resident #1 appeared worried and upset and didn't say much. Staff E stated she asked Resident #1 if she took a shower and the resident told her it went really bad and it was her fault. Staff E described this as a red flag, so she approached Staff B and asked about the resident's shower. Staff B informed her of the incident detailed above and Staff E reported what she learned to Staff D, the nurse on duty. Staff B joined her during the report and finished telling the nurse what happened. On 3/22/22 at 11:30 a.m. Staff D, LPN (Licensed Practical Nurse) stated that on 3/4/22 about 10:30 a.m., she worked at the nursing station. Staff B and Staff E reported that Staff A brought Resident #1 into the shower and Staff B reported another resident was in there already. Staff A told Staff B that Resident #1 was covered in sh*t, with the resident right there, and that she needed a shower. Staff then argued back and forth and Staff A left the resident in the shower. When reported, Resident #1 had already been showered and sat at the DR table. Resident #1 kept saying 'don't touch me, don't touch me.' She seemed upset and not her normal self. Staff D talked it over with the Human Resources, called the Administrator, got staff statements and separated Staff A from the residents. Staff D talked to the resident, who did not want to be touched so the nurse could not conduct a physical assessment. Staff D stated she saw the resident's arms, face, neck and chest and noted no injuries. Resident #1 finally told Staff D 'that girl was kind of nippy I thought.' Staff D attempted more specific questions, but that's all the resident would say. During interview on 3/22/22 at 11:48 a.m., the HRC (Human Resources Coordinator) stated on 3/4/22 near lunchtime, Staff D told her of the report about Staff A and Resident #1 in the shower. Because the Administrator was out that day, Staff D and the HRC obtained staff statements and sent Staff A home. Staff A informed them she did not say sh*t, but said poop instead. Staff A admitted saying she needed an f***ing cigarette and that she didn't care if she got fired. Interview with Staff A on 3/21/22 at 4:45 p.m. revealed she helped care for Resident #1 twice during the day shift on 3/4/22. Before lunch, Staff C helped her get the resident into the bathroom and they transferred Resident #1 to the toilet because she had been incontinent of BM. In the process of getting her to toilet, the resident started going BM again. Resident #1 got upset. With the incontinence, Staff A stated that Staff C just stood there and did not help her to cleanse the resident. Staff A stated she tried to cleanse her alone and stated 'f**k, there's[OBSCENITY]everywhere', but she did not think the resident heard her. When asked what happened in the shower, Staff A stated she was in the shower with the resident and Staff C and another staff member and resident were behind the curtain. Staff A stated she helped put Resident #1 on the shower chair and took her pants off, but that's it. She left before the resident had her shower. Staff A denied cursing in the shower room and had no memory of Resident #1 wanting to keep her undershirt on. Staff A also denied telling the resident she had sh*t on her undershirt and reported she would never say that to anybody. Review of Staff A's personnel file revealed an Employee Warning Notice dated 3/8/22. The description of the violation documented Staff A's inappropriate use of language toward a resident and staff. A required improvement instructed that Staff A would not use inappropriate language when speaking with any residents and/or staff members. The facility did not condone this type of behavior.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to immediately separate alleged abuse perpetrator from their alleged victim for one of five residents reviewed (Resident #1). The facility identified a census of 35 current residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 3/22/21, Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented she had severe cognitive and memory impairment, as evidenced by a Brief Interview for Mental Status test score of 6. The MDS revealed Resident #1 experienced fluctuating inattention, disorganized thinking, and an altered level of consciousness although she did not resist or refuse care during the assessment period. The MDS documented Resident #1 required the assistance of two staff for surface-to-surface transfers. A General Progress Note dated 3/18/21 at 6:12 pm documented Resident #1 required a Hoyer (total lift) and the assistance of two staff with transfers. On 3/24/21 at 10:20 am, the facility submitted an allegation of abuse to the Department of Inspections and Appeals. The report detailed a staff member forcefully grabbed Resident #1 during a Hoyer transfer, pinned both hands in her lap, and yelled in her face. The facility report documented the alleged abuse occurred on 3/23/21. A Progress Note dated 3/24/21 at noon and authored by the Assistant Director of Nursing (ADON) recorded the ADON received an incident report around 8:30 am by a CNA (Certified Nursing Assistant) that documented the alleged abuse occurred on 3/23/21 approximately 7:15 to 7:45 pm during a transfer. When Resident #1 returned from a doctor's appointment, the ADON assessed her and noted a light purple bruise to the right metacarpal (wrist) area measuring 1.8 by 2.5 centimeters (cm) as well as two dark purple bruises to the right arm measuring 3.4 by 3.0 cm and 1 by 2 cm. The resident had no complaints of pain at the time and the resident did not recall the incident. During an interview at the facility on 6/24/21 at 12:05 pm, Staff A, CNA stated she worked at the facility on 3/23/21 from 6 am to 2 pm as the shower aide and was asked to stay late to help get residents into bed. She worked until 8 pm on 3/23/21. Staff B, RN (Registered Nurse) offered to help get Resident #1 into bed. Staff A reported Staff B seemed irritated in Resident #1's room as the resident kept grabbing the Hoyer lift bars. Staff A explained that Resident #1 was not fully 'with it' and could not speak well. Staff A reported Staff B forcefully grabbed the resident's right wrist and pinned her hand down to her stomach, telling the resident 'no, you can't do that' in an angry and irritated tone of voice. Once Staff A and Staff B completed the transfer to bed, Staff A asked Staff B to leave the room, stating she felt uncomfortable having her help. Staff A did not report what she witnessed to other staff in the facility at the time and she left for the day. On 3/24/21 at 8 a.m., Staff A stated she reported the allegation to the ADON. When asked why the delay in reporting, Staff A stated she thought she had 24 hours to report an allegation of abuse, that personal issues clouded reporting and she wanted to report the allegation face to face. Staff A stated with later training, she learned she should report abuse allegations immediately. Review of the March 2021 schedule revealed Staff B as scheduled to work as the North nurse on 3/23/21 from 6 pm until 3/24/21 6 am. Review of Staff B's pay period records revealed she worked on 3/23/21 from 5:45 pm until 6 am on 3/24/21. During interview on 6/24/21 at 1:35 pm, the ADON stated she learned of the allegation on 3/24/21 when Staff A told the ADON wanted to make a report as what she saw made her sick. The ADON stated the facility's abuse prevention policy and procedure required immediate reporting of allegations and therefore Staff A should have called the ADON or Administrator right away. She added if Staff A would have called that night, Staff B would have been placed on leave on 3/23/21 pending investigation. The ADON said on 3/24/21, the ADON talked with Staff B, who was then suspended pending investigation. The facility's Abuse Policy/Procedure dated 9/17/19 instructed that residents will be protected from the alleged offender. Upon receiving a report of alleged abuse .ensuring safety and well-being for the vulnerable individual is of utmost priority. The alleged perpetrator will immediately be removed from the center and will remain removed pending the results of a thorough investigation.

Based on observation, record review, and staff interview the facility failed to administer the enteral feeding at the appropriate rate for 1 of 1 residents reviewed (Resident #32) with a feeding tube. The facility reported a census of 33 residents. Findings Include: 1.A Minimum Data Set (MDS) assessment for Resident #32 with a completion date of 03/03/20, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident had short term memory impairment, with moderately impaired decision making ability. The MDS documented the resident as being dependent on staff for eating. The resident was coded on the MDS as having a feeding tube for nutrition, provided 51% or more of total calories. Review of the Care Plan revealed problem area with date of initiation 03/09/21, identified Resident #32 required tube feeding related to dysphagia following cerebral infarction (stroke). Intervention dated 03/09/21, [MEDICATION(S)] 1.2 at 55 cubic centimeter (cc) per hour continuous feeding with 35cc/hr water flush two times a day for nutrition. During observation of Resident #32 on 03/08/21 at 3:30 p.m., found resident resting in bed with head of bed elevated and enteral feeding ([MEDICATION(S)] 1.2) running at 50 cc per hour. Observation on 03/09/21 at 1:04 PM, found Resident #32 resting in bed with head of bed elevated and [MEDICATION(S)] 1.2 running at 50cc/hour. Patient Discharge and Transfer form dated 02/25/21, ordered [MEDICATION(S)] 1.2 at 50cc/hour continuous feeding. Review of Physician orders: - 02/27/21 - [MEDICATION(S)] 1.2 at 50cc/hour, continuous feeding two times a day for nutrition - 03/03/21 - [MEDICATION(S)] 1.2 at 55cc/hour, continuous feeding with 35cc/hour flush two times a day for nutrition Interview on 03/09/21 at 2:40 PM the Assistant Director of Nursing (ADON) confirmed the resident's [MEDICATION(S)] feeding was running at 50cc/hour. The ADON stated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON corrected the feeding rate to 55cc/hour during interview. -

Based on document review and staff interview the facility failed to ensure staff certified in Cardiopulmonary Resuscitation (CPR) was scheduled 24 hours per day. The facility reported a census of 33 residents. Review of document titled, [NAME] - Norwalk Nursing Schedule for [DATE] - [DATE], with a printed date of [DATE], no staff certified in CPR was scheduled on the following days: - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 10:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. - [DATE] - 6:00 p.m. - 6:00 a.m. Document titled Cardiopulmonary Resuscitation; undated, stated every resident admitted to the facility would receive total life support, including resuscitation, unless a decision not to resuscitate had been previously made. The document stated that CPR certified staff would be available to all residents at all times including on facility sponsored activities and facility provided transportation. Interview on [DATE] at 9:30 a.m., the Administrator confirmed there were no CPR certified staff on duty for the overnight shifts on the dates retrieved from document titled, [NAME] - Norwalk. Interview on [DATE] at 8:20 a.m., the Assistant Director of Nursing (ADON) stated she would expect all nursing staff to be CPR certified. The ADON stated it was an error on her part that staff was not up to date on CPR certifications. -

Based on observation, record review, policy review, and staff interview the facility failed to utilize infection control techniques for 2 of 3 residents reviewed (Residents #6 and #17). The facility reported a census of 33 residents. Findings Include: 1. Review of Minimum Data Set (MDS) assessment for Resident #6, with a completion date of 03/12/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS scored the resident 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS documented the resident required extensive assist of 2 staff for toileting and personal hygiene. The MDS identified the resident had an indwelling catheter. During observation on 03/08/21 at 12:44 p.m., found Resident #6 sitting in her wheelchair in the dining room. The resident's catheter drainage bag was in a dignity bag underneath the wheelchair, with the drainage tubing on the floor. Later in the day at 3:57 p.m., observed resident in her wheelchair in the dining room with catheter drainage tubing on the floor. During observation on 03/09/21 at 7:47 a.m., the resident was in the dining room with catheter drainage tubing on the floor. Later in day at 1:43 p.m., the Administrator assisted the resident in her wheelchair to the recliner, with catheter drainage tubing dragging on the floor. During observation on 03/10/21 at 7:50 a.m., the resident was propelling herself down the hall in her wheelchair, with catheter drainage tubing dragging on the floor. During observation on 03/16/21 at 8:15 a.m., the resident was in the dining room, in her wheelchair with the catheter drainage tubing on the floor. Interview on 03/16/21 at 8:20 a.m., the Assistant Director of Nursing (ADON) stated staff should be using the clip on the catheter tubing to keep the catheter tubing off the floor. Interview on 03/16/21 at 11:19 a.m., the ADON stated she would expect the resident's catheter tubing not to be on the floor while the resident was in her wheelchair. 2. Review of MDS for Resident #17, with a completion date of 03/10/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS scored the resident 4 out of 15 on the BIMS, indicating severe cognitive impairment. The MDS documented the resident as requiring extensive assist of two staff for bed mobility, dressing, toileting, and personal hygiene. The MDS coded the resident being dependent on 2 staff for transfers. The MDS revealed the resident was frequently incontinent of bowel and bladder. Observation on 03/09/21 at 8:05 a.m., Staff C Certified Nurse's Aide (CNA) entered Resident #17s room, washed her hands and donned gloves. The CNA assisted the resident by removing the bedpan and providing personal cares. The CNA then proceeded to place a new brief on resident, pull up the resident's pants, and then placed the Hoyer lift pad underneath the resident for transfer. The CNA then moved the Hoyer lift to the bed before she removed her gloves and washed her hands prior to transferring the resident to her wheelchair. The CNA failed to change her gloves &/or sanitize her hands between dirty and clean while providing cares for the resident. Document titled, Perineal Care Protocol, undated, instructed staff to: - Wash hands and don gloves - Remove soiled brief - Remove gloves, wash hands, and don clean gloves - Provide cares - Place a dry brief - Remove gloves and wash hands or use alcohol-based sanitizer - Do not touch anything with soiled gloves after procedure Interview on 03/16/21 at 8:20 a.m., the ADON stated the facility had a Skills Fair in November of 2020; personal care had been a skill that required a competency check off. The ADON stated the facility had several new CNA's and would benefit from re-education of personal care. -

Based on record review and staff interview the facility failed to administer a pneumococcal vaccine for one (Resident #1) of five residents reviewed. The facility reported a census of 33. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 02/26/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. The MDS documented the resident required limited assistance of 1 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of resident's progress note dated 06/01/2020, documented, staff had spoken with resident in regards to pneumococcal vaccine, and resident had given verbal consent to receive the vaccine. Staff faxed request to obtain order for vaccine and documented awaiting response. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (pneumonia vaccine) 1 dose intramuscular (IM) Review of resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . -

Based on employee file review, policy review, and staff interview, the facility failed to ensure 2 of 5 staff reviewed completed the Dependent Adult Abuse Training within 6 months of hire. The facility reported a census of 33 residents. Findings include: Review of Staff A Temporary Nurse's Aide with a hire date of 04/13/20 employee file lacked documentation of a completed Dependent Adult Abuse Mandatory Reporter Training. Review of Staff B Temporary Nurse's Aide with a hire date of 08/20/20 employee file lacked documentation of a completed Dependent Adult Abuse Mandatory Reporter Training. Document titled, Abuse Prevention Program, with a revised date of 12/2016, documented requirement of staff training/orientation programs that include topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally and physically aggressive resident behavior. Interview on 03/11/21 at 11:23 a.m., the Administrator confirmed Staff A & Staff B Temporary Nurse's Aides did not have the Dependent Adult Abuse training completed. Interview on 03/16/21 at 2:10 p.m., the Administrator stated she would expect all staff to have completed the Dependent Adult Abuse Mandatory training upon hire. -

Based on record review, resident and staff interviews, the facility failed to check the blood pressure and pulse of prior to giving a cardiac medication as prescribed one of three residents reviewed (Resident #1). The facility reported a census of 38 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 3/16/19 , Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident displayed intact cognition and required either extensive assistance of 1 to 2 staff or total assistance for most activities of daily living (ADLs). The 8/31/16 Care Plan documented Resident #1 experienced a self-care deficit and directed staff to administer medication as ordered. A document titled Special Requirements for Psych Meds directed to check blood pressure and pulse when administering beta blockers (cardiac medication that reduces heart rate and blood pressure). A document titled Administering Medications Using Electronic Medication Administration Record documented the facility's policy which directed staff to administer all medication to every resident as ordered by a physician in a safe and sanitary manner. The document also noted that all staff administering medication will be responsible for having knowledge of the drugs, usual doses, actions, potential side effects and nursing interventions prior to administering medication. The policy added staff should also verify the correct resident, medication, dose, time, route and technique prior to administering medication. According to their policy, staff should conduct any pre-administration assessment, such as checking the pulse or blood pressure, prior to administration whenever required. The (MONTH) 2019 physician's orders [REDACTED]. The (MONTH) 2019 Medication Administration Record (MAR) noted Resident #1 received one half of a 5 mg [MEDICATION NAME] tablet at 8:00 a.m. on 4/2/19 through 4/9/19 and a 2nd dose at 8:00 p.m. on 4/5/19 and 4/9/19; despite the fact they were only ordered once a day. According to the MAR and the physician's orders [REDACTED].#1's systolic blood pressure measured less than 100 or his pulse measured less than 55 beats per minute. Other documents revealed between 4/2/19 - 4/9/19 staff checked the resident 's blood pressure and pulse on 4/7/19 and the systolic blood pressure at that time measured 80. Further review of the resident's clinical record revealed despite the order, staff administered the medication at the time instead of holding it as prescribed. An interview on 10/28/19 at 11:05 a.m. with the Director of Nursing (DON) revealed staff should obtain a blood pressure and pulse assessment prior to every administration of a beta blocker. According to the DON, staff should consult the physician any time a resident that a resident taking beta blockers is admitted without hold parameters (unacceptable range of blood pressure and pulse measurements). A subsequent interview on 10/28/19 at 1:45 p.m. with the DON revealed that she expected staff to complete and document blood pressure and pulse assessments prior to giving beta blockers. The DON said staff either did not complete and/or not document many of the (MONTH) pre-administration assessments.

Based on clinical record review, and resident, family, and staff interviews, the facility failed to provide necessary respiratory services and equipment for one of 12 residents reviewed (Resident #7). The facility reported a census of 37 residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] documented Resident #7 had [DIAGNOSES REDACTED]. The MDS documented the resident scored a 14 out of 15 on the Brief Interview for Mental Status indicating intact cognition. The MDS documented the resident required extensive assistance for bed mobility, transfers, toilet use and did not walk. The MDS documented the resident had shortness of breath while at rest, upon exertion, and lying flat. The MDS documented the resident required oxygen therapy. The initial care plan dated 11/18/16 failed to address the resident's respiratory needs and lacked interventions instructing staff on the medications and oxygen needs. The Hospital Medication Discharge Report dated 11/18/16 lacked an order for [REDACTED]. The Hospital Patient Discharge and Transfer Form dated 11/18/16 documented the resident required 5 liters of oxygen and breathing treatments. On 11/18/16 at 5:21 p.m. the facility received 2 facsimiles with orders for nebulizer treatments 4 times a day, 5 liters oxygen at rest and 8 liters oxygen with activity. The clinical record dated 11/18/16 at 3:56 p.m. documented the resident's admission to the facility. The Departmental Notes documented the resident had shortness of breath with activity, a dry cough with exertion, and labored breathing after transfer. The Departmental Notes documented the resident received 5 liters of oxygen per nasal cannula. The Departmental Notes dated 11/19/16 at 1:10 a.m. documented the resident had labored breathing, wheezing in lung bases and was on 5 liters of oxygen. The Departmental Notes dated 11/19/16 at 4:18 p.m. documented the resident had shortness of breath with activity. The Departmental Notes dated at 11:52 p.m. documented the resident had labored breathing with wheezing in the lung bases and on 5 liters oxygen. The Departmental Notes dated 11/20/16 at 4:44 p.m. documented the resident remained on bed rest. The Departmental Notes dated 11/21/16 at 1:12 a.m. documented the resident had oxygen at 5 liters and had labored breathing with wheezes in the lung bases when exhaling. The Departmental Notes dated 11/21/16 at 12:41 p.m. documented a new order for nebulizer inhalations four times a day. The Medication Administration Record [REDACTED]. The resident received 5 liters of oxygen beginning the 18th. The Medication Administration Record [REDACTED]. During an interview on 11/30/16 at 12:30 p.m. the resident stated he/she admitted to the facility on [DATE] and felt he/she could not move with only 5 liters of oxygen without becoming short of breath. The resident stated he/she frequently asked for nebulizer treatments and told staff he/she needed 8 liters of oxygen so he/she could get out of bed even to use the bathroom Staff stated they did not have an order for [REDACTED]. Observation revealed the resident received 5 liters of oxygen at the time of the interview and became short of breath while talking. During an interview on 12/6/16 at 10:30 a.m., the resident ' s family member reported he/she came to the facility shortly after the resident ' s admission. The family member recalled Resident #7 had required 8 liters of oxygen in the hospital to walk without becoming short of breath. The resident told his/her family member staff had told him/her to stay in bed because the facility did not have an oxygen concentrator that supplied 8 liters of oxygen. Also, the staff told Resident #7 they did not have nebulizer equipment. The family member stated he/she went to the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator. They all agreed to get the equipment needed for the resident. The facility obtained the equipment on the 21st. The resident's daughter feels the resident suffered all weekend. During an interview on 12/1/16 at 9:38 a.m., the Admission Coordinator stated she received information regarding Resident #7 on 11/17/16. Staff G stated she took the information to the admission team that included the Administrator, Social Worker, ADON, former DON, and therapy. She stated she could not remember if she visited the resident in the hospital, or what equipment the resident had required at the time. She reported the purpose of the team meeting was to decide whether or not to admit the resident. During an interview on 12/7/16 at 9:47 a.m., the former DON stated she had agreed to admit Resident #7 and confirmed her last day of work was 11/17/18. Information from the hospital dated 11/17/16 at 11:34 a.m. documented the resident received breathing treatments every four hours and required oxygen. The therapy note from the hospital documented the resident used 8 liters oxygen with increased endurance. A final report dated 11/16/16 documented the resident had non-small cell [MEDICAL CONDITION], pneumonia, [MEDICAL CONDITION], and hypoxic [MEDICAL CONDITION]. The report listed breathing treatments and 5 liters oxygen, 8 liters for activity. During an interview on 12/1/16 at 10:17 a.m., Staff A, LPN stated she usually worked nights but wanted to learn the admission process and helped with the admission. She recalled the orders sent from the hospital did not include orders for breathing treatments frequency or oxygen requirements. Staff A stated she, the ADON, Staff F and another staff member worked on the admission and Staff F received orders for oxygen and nebulizer treatments. Staff A recalled when the resident got into bed at admission his/her oxygen saturation levels dropped and he/she became short of breath. During an interview on 12/1/16 at 2:40 a.m., the current DON reported she began employment at the facility on 11/18/16 and confirmed she also helped with the admission. She stated Resident #7 was very anxious and Staff F obtained the orders for breathing treatments and oxygen. The DON stated she received no calls over the weekend (12/19/16 or 12/20/16) to inform her the resident did not receive his/her her medications; it was just missed. During an interview on 12/6/16 at 11:22 a.m., Staff F, RN stated she worked at the facility for 7 years and resigned on 11/18/16. She reported she worked 4 hours that day and the part of the admission she assisted with was texting the ARNP for orders. During an interview on 12/8/16 at 4:14 p.m., the resident's physician for respiratory care stated he sent a facsimile to the facility for 5 liters of oxygen at rest, 8 liters oxygen with activity, and nebulizer treatments 4 times a day. The physician expected these orders to be followed immediately. The physician stated he had no further contact with the facility. The physician stated the resident required these medications and without them, the resident would have respiratory distress and have to limit activity. During an interview on 12/12/16 at 1:02 a.m., the corporate account specialist with the supply company the facility utilized for oxygen concentrators stated they had no record of supplying an oxygen concentrator to that resident. During an interview on 12/12/16 at 3:19 p.m. the pharmacist from the pharmacy utilized by the facility stated the order for the [MEDICATION NAME] breathing treatments came on 11/19/16 and the pharmacy sent the medication to the facility the same day.

Based on clinical record review, staff interview, and facility record review, the facility failed to provide adequate supervision and implementation of safety measures to prevent injuries for 2 of 6 residents reviewed (Resident #6 & #11). The facility reported a census of 37 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 7/12/16, Resident #6 had [DIAGNOSES REDACTED]. The MDS documented the resident displayed severely impaired cognitive skills with signs of inattention and disorganized thinking. The assessment revealed the resident required limited physical assist of 1 staff for bed mobility and transfers. The care plan identified a problem onset dated 7/27/15 of a risk for injury related to falls evidenced by a personal history of falls. The care plan identified an additional risk related to generalized weakness, COPD with increased shortness of breath (SOB) with minimal activity, impaired mobility, use of diuretics, and B&B (bowel and bladder) incontinence. The care plan documented a history of self-transfers due to impaired cognition and documented staff found the resident on the floor next to the bed on 5/24/16. Staff updated the care plan at that time to reflect a fall mat placed next to the resident's bed. The care plan documented the resident fell from the side of the bed without injury on 9/24/16, and directed staff to have SR (side rails) up at all times with the bed in the low position. The care plan documented the resident fell again on 9/24/16 at 5:00 a.m., which resulted in a laceration and sutures. The care plan again directed staff to place a fall mat on the floor. The Incident Investigation dated 5/24/16 at 12:30 a.m. documented an unobserved fall. Staff found the resident on the floor next to his/her bed lying in the fetal position. The investigation documented staff notified maintenance placed a fall mat placed next to the bed on 5/25/16. The Incident Investigation dated 9/24/16 at 12:15 a.m. documented an unobserved fall; staff found the resident on the floor next to his/her bed. The investigation documented upon reviewing the incident, it appeared the resident did not have the bed in the low position and side rails up. The narrative documented the resident had a significant history of falls and should have side rails up and the bed in the low (position) at all times while in bed. The Resident Incident Report dated 9/24/16 at 5:00 a.m. documented the resident fell a second time at 5:00 a.m. The narrative recorded the resident sustained [REDACTED]. The narrative documented steri-strips (a type of bandage strip used to pull the skin together) attempted, but unable to control the bleeding and the on-call physician granted the order to transfer the resident. The Resident Incident Follow-up dated 9/24/16 at 5:00 a.m. documented a 24 hour condition and injury appearance which revealed a flap laceration with 8 stitches above the left eyebrow. The Incident Investigation dated 9/24/16 at 5:00 a.m. documented a work order put in for the resident to have a fall mat placed on the resident's floor with a plan to continue with the intervention of having the bed in the low (position) and side rails up while the resident resting in bed. The Departmental Notes dated 9/24/16 at 7:09 a.m. documented the resident found on floor again that morning and incurred a head laceration. The notes recorded originally pressure held and steri-strips on. The notes documented the day shift re-evaluated and said the resident should go in to the ER (emergency room ) for evaluation and treatment. The notes included documentation the resident complained of a headache with a laceration 3x3x1 cm in V shape flap laceration. The undated Summary of Evaluation and treatment for [REDACTED]. The summary discharge instructions ordered bed alarm/fall prevention and removal of 8 sutures in 8 to 10 days. The Departmental Notes dated 9/24/16 at 11:49 a.m. documented the resident returned to the facility at 10:30 a.m. and revealed ER staff placed 8 stitches to the left area above the eyebrow. The notes also documented the resident rested comfortably with a gauze dressing wrapped around his/her head. In an interview on 12/5/16 at 4:02 p.m., Staff N, CNA, stated she was familiar with Resident #6's care, and she remembered checking on the resident every hour the night in September when he/she had 2 falls. Staff N commented the resident was fine after the 1st fall but the resident fell harder the 2nd time. Staff N thought the 2nd fall was harder because of the bleeding on the head and blood on the floor. Staff N recalled no floor mat present in the room at the time of the resident's fall. Staff N reported the resident no longer got out of bed or ate as much since the fall. Staff N stated at the time of the fall the resident was a fall risk. Staff kept the wheelchair by the bed and the resident would transfer him/herself a lot, so Staff N always kept a close eye on the resident. In an interview on 12/6/16 at 3:17 p.m., Staff O, RN stated she was familiar with Resident #6's care. Staff O said the resident was always one to get up on his/her own and into the wheelchair, usually a couple dozen times a night. Staff O commented the facility changed the resident's room a lot because he she easily got along with residents that had behavior problems. Staff O reported the resident had 2 falls the night of 9/24/16 and recalled the resident got up and slipped beside the bed, the other fall was due to the resident up walking without a walker. Staff O stated the resident must have fallen hard based on the laceration injury to the head. Staff O reported she applied pressure and steri-strips to the laceration, but she ended up transferring the resident to the ER. Staff O stated the intervention for the 2nd fall was to order a floor mat. Staff O recalled no floor mat in the resident's room prior to the fall and speculated no floor mat available due to the resident changing rooms a lot. The MDS assessment dated [DATE] identified Resident #6 required supervision by 1 staff for locomotion on/off the unit via wheelchair. The care plan identified a problem onset dated 7/27/15 of a self-care deficit evidenced by limited to extensive level of assist with ADL's (activities of daily living) with additional risk for decline. The problem area documented the self-care deficit related to generalized weakness, COPD with increased SOB with minimal activity and oxygen dependency, incontinency, impaired cognition, and chronic kidney disease. The care plan directed staff to provide extensive 2 person assist with transfers. The Resident Incident Report dated 11/27/16 at 12:00 p.m. documented the resident incurred a fall with head injury, abrasion, and skin tear. The narrative recorded Staff C, Licensed Practical Nurse (LPN), summoned to the hallway outside the resident's room per Staff M, CNA, and another LPN. The narrative documented the resident lay supine on the floor in front of the wheelchair. The report documented Staff M stated she was pushing the resident in the wheelchair to the dining room when the resident fell forward from the wheelchair onto the floor. The report recorded the resident hit his/her head during the fall and complained of a headache. The report documented the resident sustained [REDACTED]. to the outer aspect of the left hand. Staff applied steri-strips to the skin tears. The report documented staff applied wheelchair pedals applied to the wheelchair. The Post-Incident Actions dated 11/27/16 at 12:00 p.m. documented an immediate post-incident action to assure foot pedals in place on the wheelchair if propelling the resident in the wheelchair. The Departmental Notes dated 11/27/16 at 3:05 p.m. documented the resident's fall that occurred at 12:00 p.m. The CNA stated she was propelling the resident in the wheelchair when the resident fell forward from the wheelchair onto the floor hitting his/her head. The notes recorded the resident given PRN (as needed) Tylenol for a complaint of a headache. In an interview on 12/1/16 at 11:15 a.m., the Director of Nursing (DON) stated Staff M pushed the resident without wheelchair pedals on 11/27/16 in the early a.m. and the resident fell forward out of the wheelchair. The DON stated she expected staff to not push a resident in a wheelchair if there were no wheelchair pedals present. In an interview on 12/1/16 at 12:09 p.m., Staff M stated the most accurate account of the events was documented in the nurse ' s notes. Staff M confirmed there were times she pushed residents without wheelchair pedals from the shower room on the 200 hall to the dining room. In an interview on 12/1/16 at 12:50 p.m., both Staff C and Staff A, LPN, reported working 11/27/16. Staff A stated she was first to the resident's room and Staff M in the room with the resident on the floor. Staff C stated she came to assist Staff A. Staff C and Staff A stated the nurse ' s notes documented the most accurate account of what happened. Staff C and Staff A verified the nurses notes documented Staff M pushed the resident without wheelchair pedals and the resident fell out of the chair. The 12/1/16 Wheelchair Pedal In-service conducted by the DON documented wheelchair pedals are to be on all wheelchairs, at all times, if propelling the resident. The in-service directed if the resident capable of propelling themselves, the foot pedals should be off and residents not to be pushed if pedals not on. 2. According to the MDS dated [DATE], Resident #11 had [DIAGNOSES REDACTED]. The MDS documented the resident as totally dependent on one staff for transfers and revealed the resident utilized a wheelchair. The MDS also documented Resident #11 required extensive assistance of one staff for locomotion on and off the unit. The care plan dated 5/20/16 directed staff the resident required assist of 1-2 staff with transfers, required use of Hoyer lift if combative with completion of cares, and used a wheelchair for locomotion. Observation on 11/30/16 at 12:54 p.m. revealed Staff B, (RN) pushed resident #11 from the dining room to the resident's room (#203) with foot pedals on the wheelchair, but the pedals were turned upward. The resident's feet dangled and a Hoyer sling dragged on the floor. At 12:55 p.m., Staff A, (LPN) instructed Staff B foot pedals needed to be down. Staff B then put the foot pedals down and placed the resident's feet on the pedals. Staff B then pushed the resident back to the dining area. Observation revealed approximately 38 steps from the dining room to the resident's room

Based on record review, physician and staff interviews, the facility failed to plan for and direct nursing provisions with adequate assessment and timely intervention for one nine residents with a change in condition. Interviews and record review showed Resident #6 displayed lethargy, decreased fluid intakes, low urine outputs, intermittent elevated temperature and decreased mental status change until he/she became unresponsive. The hospital nurse reported Resident #6's suprapubic catheter site as red and oozing. The resident required hospitalization and transferred to hospice care. The facility reported a census of 39 residents. Findings include: According to the Minimum Data Set (MDS) assessment, dated [DATE] Resident #6 demonstrated long and short term memory problems and severely impaired cognitive skills for daily decision making. The MDS indicated Resident #6 demonstrated no acute change in mental status and had been re-admitted to the facility on [DATE]. Resident #6 could rarely or never make him/herself understood. The MDS documented Resident #6 required extensive assistance with activities of daily living including eating and personal hygiene. The MDS documented Resident #6 had an indwelling urinary catheter. The assessment identified Resident #6 with [DIAGNOSES REDACTED]. The assessment revealed Resident #6 did not have a UTI or [MEDICAL CONDITION] within the last 30 days. A Dehydration Status dated [DATE] scored Resident #6 at 4, with a score of 9 or greater indicating a moderate-high risk. The assessment indicated a low score did not always indicate low risk. The assessment identified signs of dehydration included: dry mucous membranes, poor skin turgor, dry sunken eyes, confusion, and a low grade temperature. A Care Area Assessment (CAA) regarding nutritional status dated [DATE] documented Resident #6 had a history of [REDACTED]. The CAA noted other considerations: Encourage extra fluids to promote adequate hydration. A letter addressed to Resident #6's family member dated [DATE] summarized Resident #6's care plan meeting. The nursing section included due to the use of the suprapubic catheter Resident #6 was at risk for infection and had a history of [REDACTED]. Fluids were encouraged in attempts to reduce the risk of infection. An Interdisciplinary Care Plan dated [DATE] identified a concern with nutrition. One of the goals read Resident #6 would not exhibit dehydration through the next review. The approaches included: a. Encourage liberal intake of fluids between meals. b. Monitor for signs and symptoms of dehydration. The care plan identified the use of a suprapubic catheter resulting in a significant history of UTI's, with a goal to remain free of signs and symptoms of UTI. The approaches included: a. Encourage adequate fluid intakes. b. Monitor for signs and symptoms of UTI and report to the physician if noted. The care plan identified a history of frequent UTI's. The approaches included: a. Observe urine color, odor, clarity, elevated temperature and report abnormal to the doctor. b. Encourage fluid intake with all interactions. A Nutrition assessment dated [DATE] documented Resident #6's estimated fluid needs at 1680 milliliters (ml =cc's) per day. A facility Intake and Output report showed Resident #6's fluid intakes: a. On [DATE], 810 cc's. b. On [DATE], 1586 cc's. c. On [DATE], 1260 cc's. d. On [DATE], 853 cc's. e. On [DATE], 730 cc's. f. On [DATE], 240 cc's. The [DATE] and [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] a. On [DATE], 480 cc's. b. On [DATE], 480 cc's. c. On [DATE], 480 cc's. d. On [DATE], 480 cc's. e. On [DATE], 480 cc's. f. On [DATE], 360 cc's A facility Intake and Output record showed Resident #6's urinary outputs: a. On [DATE], 1150 cc's. b. On [DATE], 550 cc's. c. On [DATE], 950 cc's. d. On [DATE], 316 cc's. e. On [DATE], 275 cc's. f. On [DATE], 150 cc's (at 4:45 a.m.) with no additional catheter output. A Weekly Skin and Hydration assessment dated [DATE] documented Resident #6 had moist mucous membranes, and non odiferous or concentrated urine. A Medication Record dated ,[DATE] directed the following for Resident #6: a. Ensure the suprapubic catheter drained in the down drain bag every shift (6 AM and 6PM). Monitor output and encourage fluids. b. Monitor for signs and symptoms of infection around the suprapubic site a.m. and HS (hour of sleep). c. Triple antibiotic to the suprapubic site and cover with a drain sponge every day. d. [MEDICATION NAME] to the left knuckle every day until healed. e. [MEDICATION NAME] to the left arm skin tear every day until healed. Circles around initials on [DATE] for all of the above indicated they were not done. During an interview on [DATE] at 2:00 p.m. the Director of Nursing (DON) confirmed that circles around initials on the medication or treatment sheet indicated not done. A Skin Conditions report dated [DATE] documented a skin tear to Resident #6's left knuckle. The area remained without signs and symptoms of infection, and no drainage. The report also identified a skin tear to Resident #6's left arm. The area did not have drainage, but did have purple discoloration around it. The physician's orders [REDACTED]. A Physician's Progress Note dated [DATE] at 3:20 p.m. Resident #6 went in for a checkup. Resident #6 sat quietly in a chair, and had skin tears of the knuckles of his/her left hand. The physician's impression included Parkinsonism, weight loss, protein calorie [MEDICAL CONDITION], and contracture of the left arm. The Nurse's Notes dated [DATE] at 10:30 a.m. documented staff called the physician regarding Resident #6's behaviors and agitation. Resident #6 had also been climbing out of bed. He/she had been rubbing his/her arms causing skin tears... Staff received a new order to start [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg every bedtime for 1 week, then increase to 15 mg every bedtime. The Nurse's Notes dated [DATE] at 2:00 a.m. documented the suprapubic catheter leaked a large amount of urine around the insertion site with no output in the bag. Staff attempted to flush the catheter without success. Staff changed the catheter with the return of a urine with a large amount of sediment in it. When staff entered the room Resident #6 had his/her geri sleeves and brief pulled off and agitated. The Nurse's Notes dated [DATE] at 2:45 p.m. a CNA reported Resident #6 agitated during cares. Upon entering the room Resident #6 had his/her suprapubic catheter in his/her hand and had pulled the catheter out. Resident #6 was incontinent of bowel and grabbed at the CNA, kicking and yelling. Attempted to reassure the resident without success. The nurse also noted Resident #6 hitting a CNA at the lunch table while attempting to feed the resident. After reinsertion of the catheter Resident #6 pulled the catheter and unhooked the drain bag. While attempting to remove the catheter from Resident #6's hand, he/she kicked the staff member in the abdomen, and grabbed the staff member's wrist. Attending physician made aware of Resident #6's behavior, and stated to wait until the [MEDICATION NAME] took effect. The Nurse's Notes dated [DATE] at 10:30 a.m. documented Resident #6 yelled for "help". A Certified Medication Aide (CMA) went to his/her room with the nurse. Resident #6 had taken off his/her brief...the CMA and the nurse performed peri-care while Resident #6 hit and kicked them and pulling on suprapubic catheter. The nurse put a catheter strap on Resident #6. The CMA asked Resident #6 if he/she had pain, and he/she replied "Yes, pain pill". Tylenol given. The Nurse's Notes dated [DATE] at 11:00 a.m. documented Resident #6 constantly removed geri sleeves causing skin tears to self. Staff made the physician aware of the behavior... The Nurse's notes dated [DATE] at 11:00 a.m. documented Resident #6's suprapubic catheter in place and patent. Resident #6 combative while trying to wrap arms...pinching and punching the nurse. A PRN Medication sheet dated [DATE] documented Resident #6 Received APAP (Tylenol) 500 milligrams (mg) 2 tablets at 6:50 p.m. for an elevated temperature. The medication sheet lacked a response, and the clinical record lacked any documentation of the resident's elevated temperature or assessment. During an interview on [DATE] the DON checked report sheets because Resident #6 received Tylenol on [DATE] for an elevated temperature with no charting regarding the temperature. The DON stated on [DATE] Resident #6 had an elevated temperature of 100.9 degrees using the tympanic thermometer. The Nurse's Notes dated [DATE] at 10:00 a.m. documented staff flushed the suprapubic catheter due to leaking, flushed with return. Resident #6 slightly agitated... At 11:10 a.m. Resident #6's vital signs: temperature at 96 degrees, pulse 88, respirations at 16, and blood pressure of ,[DATE]. Lung sounds with crackles on the left side. The physician ordered a chest x-ray, psychiatric evaluation, and call if pulse oximetry less than 90%... The nurse and the Director of Nursing unable to get a pulse oximetry after multiple attempts made with Resident #6 agitated and combative. At 12:00 p.m. staff placed Resident #6 in a wheelchair and he/she tried/attempted to throw him/herself out of the wheelchair... New orders obtained for Occupational Therapy to evaluate and treat for geri chair positioning for safety. At 12:30 p.m. Resident #6 positioned in geri chair safely and assisted with lunch in a safe position. Resident #6 did accept assistance from a CNA with the meal then attempted to hit the CNA with his/her hands. At 1:00 p.m. no new orders from the portable chest x-ray completed. The Nurse's Notes dated [DATE] at 2:00 a.m. documented Resident #6 without an elevated temperature the past evening. His/her temperature at 8:30 p.m. registered at 98.6 degrees, with a current temperature of 100.6 degrees. The resident ' s lungs sounded coarse and diminished without any noted respiratory distress and a pulse oximetry of 93%. Staff administered Tylenol to Resident #6l. The suprapubic catheter patent with amber urine in the down drain bag. At 3:00 a.m. Resident #6's temperature registered at 98.9 degrees. Resident #6 appeared to rest quietly, and did attempt to hit and pull away with cares or vitals, and the pulse oximetry read of 91%. At 3:15 p.m. Resident #6 had temperature of 96.3 degrees... The suprapubic catheter was patent with a small amount of urine noted in the drain bag. Resident #6 rested quietly... The Nurse's Notes dated [DATE] at 1:00 a.m. documented Resident #6's temperature registered at 98.5 degrees and pulse oximetry of 91% on room air. Resident #6 rested quietly without any signs and symptoms of respiratory distress. His/her lungs sounded coarse and diminished. The suprapubic catheter patent with amber urine in the down drain bag. At 12:00 p.m. Resident #6 demonstrated increased lethargy, and they were unable to give his/her scheduled medication. Staff assisted Resident #6 back to bed. Resident #6's vital signs taken were temperature 96.4 degrees, pulse 86, respirations 24, blood pressure ,[DATE], and pulse oximetry 91%. At 2:15 p.m. a CNA called the nurse to Resident #6's room due to increased shortness of breath. Resident #6's vital signs were temperature 96.7 degrees, pulse 81, respirations 30, blood pressure ,[DATE], and pulse oximetry 87%. His/her respirations appeared shallow, and lung sounds course. Resident #6's pupils did not react to light. Resident #6 responded little to a sternal rub. He/she exhibited yellow nasal drainage.... Staff notified the physician with new orders to transfer to the hospital emergency room . A Resident Transfer Form dated [DATE] documented the reason for Resident #6's transfer: Increased lethargy and a change in mental status. An Ambulance Pre-Hospital Care Report narrative dated [DATE] documented the ambulance dispatched to the nursing facility at 2:30 p.m. for a resident with unresponsiveness, with reports of altered mental status since the a.m. The report documented after multiple attempts an intravenous (IV) was established in the right foot with 1000 ml of normal saline set to infuse wide open. An Ambulance Pre-Hospital Care Report dated [DATE] documented the chief complaint: Unresponsiveness and [MEDICAL CONDITION] (low blood pressure). Resident #6's initial temperature registered at 100.6 degrees, blood pressure ,[DATE], and pulse oximetry of 78%. The resident received oxygen and 500 ml of intravenous fluid during transport. An ED Transferring Patient Form dated [DATE] documented Resident #6 demonstrated a few days altered mental status, with unresponsiveness today, a possible fever, and decreased urine output/dark urine. A hospital Nursing Note dated [DATE] at 4:02 p.m. documented Resident #6 appeared unkempt and smelled of urine. The dressing around the suprapubic catheter was wet, smelled of urine and had green pus on it. The urine in the catheter bag appeared very dark. At 5:15 p.m. the lab called with report of a critically high sodium level at 162 ([MEDICAL CONDITION]). An ED Transferring Patient Form dated [DATE] documented Resident #6 demonstrated a few days altered mental status, with unresponsiveness today, a possible fever, and decreased urine output/dark urine. A Braden Skin Scale dated [DATE] at 4:45 p.m. documented Resident #6 had numerous wounds/discolorations of various types all over his/her body. Some injuries scabbed, some general wounds that were partial thickness and oozing, including knees and knuckles. Redness noted to pressure points on the right side that blanched. Redness and oozing also noted around the suprapubic catheter. A prior General Chemistry report documented Resident #6's lab results on [DATE] as : a. Sodium of 144 (reference range ,[DATE]). b. BUN 29 (reference range ,[DATE]). c. Creatinine 1.1 (reference range 0XXX,[DATE].2). An ED Course/Workup dated [DATE] documented Resident #6's metabolic profile: a. Sodium 162. b. BUN of 143. c Creatinine 4.08. The workup showed a left sided infiltrate on chest x-ray and a urinary tract infection. The workup documented the clinical impression/Diagnoses: [REDACTED]. b. Dehydration.c. [MEDICAL CONDITION]. d. Urinary tract infection. A Discharge Summary dated [DATE] documented Resident #6's serum sodium diminished with replacement of free water intravenously. Resident #6 became more responsive. Resident #6 had a urine culture done, which grew [MEDICAL CONDITION] (MRSA) and [DIAGNOSES REDACTED]. a. Pneumonia. b.[MEDICAL CONDITIONS] (infection of the blood). c. Dehydration. d. [MEDICAL CONDITION]. e. Prerenal azotemia (abnormally high levels of nitrogen type wastes in the blood). f. [MEDICAL CONDITION] (failure). g. Parkinsonism. h. Contractures (muscle tightening) of upper and lower extremities. i. Multiple skin tears. j. Cachexia (loss of body mass). A History and Physical dated [DATE] documented the history obtained from review of records. The note documented for the past several weeks the physician received calls regarding how agitated and over active Resident #6 was. He/she struck out against staff. Resident #6 started on [MEDICATION NAME] and this p.m. was found poorly responsive with rapid respirations. The physical exam documented Resident #6 laying on the right side with excoriation of the left hip, with several skin tears of the arms and legs. Resident #6 demonstrated contractions of the arms and legs, laying in the fetal position, with neuros obtunded (dulled, altered). The note indicated Resident #6's urine showed pyuria (pus in the urine) and hematuria (blood in the urine). The Resident also exhibited hypoxemia (low blood oxygen). During an interview on [DATE] at 12:34 p.m. a Paramedic involved in Resident #6's transfer to the hospital stated they did not routinely start an IV when transporting a patient to the hospital. The Paramedic stated Resident #6 needed immediate intervention, he/she had a low blood pressure. The Paramedic stated when the facility called they said Resident #6 had altered mental status that got progressively worse. The paramedic stated Resident #6 demonstrated very poor skin turgor, noting tenting on his/her torso, and a visibly dry mouth and mucous membranes. During an interview on [DATE] at 12:14 p.m. the emergency room nurse stated she had been concern about Resident #6's condition when he/she came to the emergency room . The ER nurse stated Resident #6 had discolored areas, open wounds, scrapes, etc. all over his/her body. When she talked to the family they stated the areas were from falling out of bed. The ER nurse stated Resident #6 smelled strongly of urine. The dressing around Resident #6's suprapubic catheter site was wet and had pus on it. The ER nurse stated Resident #6 received 500 cc's of intravenous fluid in the ambulance and that bag finished for 1000 cc's plus another 750 cc's infused wide open before they dropped the rate down. The ER nurse stated Resident #6 had a critically high sodium level due to the dehydration. The ER nurse stated outputs below 30 cc's an hour (720 cc's in a 24 hour period) would be a concern and important information. Low urine outputs could be a sign of dehydration or [MEDICAL CONDITION]. The ER nurse stated Resident #6's urine appeared very dark. During an interview on [DATE] at 2:35 p.m. Staff B Certified Nursing Assistant (CNA) stated she worked the day Resident #6 transferred to the hospital. Staff B stated she worked the previous Thursday when Resident #6 had a fever. Staff B stated when she came to work Sunday ([DATE]) Resident #6 did not act his/her normal self. Staff B stated Resident #6 laid in the fetal position most of the day. Staff B stated Resident #6 never slept completely straight, but this was much more pronounced, he/she curled up more in a ball. Staff B stated she dressed Resident #6. He/she did not resist or assist, and he/she usually did one or the other. Resident #6 did not assist with transferring which was unusual for him/her. Staff B stated when she went to get Resident #6 up for lunch he/she did not respond. Resident #6 would not sit up straight in the chair or take anything orally for her at lunch or between meals. Staff B stated she did not assist Resident #6 at breakfast. Staff B did not remember emptying the catheter, but stated if it leaked she would have notified the nurse. During an interview on [DATE] at 9:42 a.m. Staff C Licensed Practical Nurse (LPN) stated she worked the day Resident #6 transferred to the hospital([DATE]). Staff C stated staff got Resident #6 up that morning and she gave him/her his medications while he/she sat in his/her chair in the room. Staff C stated Resident #6 took 2 ounces of 2-cal supplement, and she thought a cup of water. Staff C stated noting Resident #6 appeared a little more lethargic, but thought he/she had increased lethargy since Thursday ([DATE]), and thought it could be due to starting [MEDICATION NAME]. Staff C stated Resident #6 did not eat real well at noon (records indicate ate nothing), and staff reported Resident #6 just let food run out of his/her mouth, so she told them to lay him/her down. A CNA came later and reported something wrong with Resident #6. Staff C assessed Resident #6 and called the physician. Staff C stated the physician did not really think Resident #6 should be transferred, but she pressed the issue. Staff C stated she reported Resident #6's mental status change. Staff C stated she did not know Resident #6 had low outputs recorded, and no one reported that to her (outputs available in accunurse). Staff C stated she did not know Resident #6 did not take any food/fluids at breakfast until after she assessed him/her. Staff C stated if she had known Resident #6 did not take anything all day other than what she gave him/her and that he/she had low urine outputs she would have assessed him/her sooner and she would have assessed for dehydration. Staff C stated she went by his/her mental status change. Staff C stated Resident #6's suprapubic site appeared red and irritated because he/she pulled the catheter out with the balloon intact a few days before. Staff C stated she did not recall pus on the dressing or leakage that day (the med sheet showed the dressing change and check of the site not completed [DATE]). Staff C stated she wondered why they did not do a urine analysis with the elevated temperature, but thought probably because they did a chest x-ray [DATE]. Staff C stated Resident #6's urine always smelled strong ([DATE] hydration assessment indicated urine not odiferous). During an interview on [DATE] at 9:07 a.m. Staff A LPN stated if a resident acted different, or intakes were down she would check vital signs and do a hydration assessment. Staff A stated if outputs were low she would encourage fluids and notify the physician. Staff A agreed an elevated temperature indicated the need for additional fluids. Staff A stated she last did assessments on Resident #6's skin the Wednesday prior to his/her hospitalization . Staff A stated Resident #6 had 2 skin tears to the left elbow which had healed. Resident #6 had a skin tear on a left knuckle and a skin tear on his/her left arm with a bruise surrounding the area. Resident #6 had multiple reddish discolored areas on his/her skin. During an interview on [DATE] at 9:25 a.m. the facility Dietician stated Resident #6 had been at risk for inadequate intakes for some time. Resident #6 needed frequent offering of fluids to maintain hydration. The Dietician stated low intakes and outputs would indicate a concern for dehydration and an elevated temperatures would increase fluid needs. During an interview on [DATE] at 9:30 a.m. Resident #6's physician stated he had received calls from the facility about the resident fighting and hitting staff. He started Resident #6 on [MEDICATION NAME]. He stated the [MEDICATION NAME] may have contributed to Resident #6's decreased mental status, but felt if it did cause a decreased mental status the facility would notify him. He stated Resident #6 had a history of [REDACTED]. When discussing Resident #6's urine outputs the 2 days prior to the hospitalization , he stated outputs that low would have been a concern. He did not receive notification of the outputs. He stated the facility called him the afternoon Resident #6 transferred to the hospital. The facility did not notify him of decreased mental status prior to that. He stated the prerenal azotemia, [MEDICAL CONDITION], and [MEDICAL CONDITION] were all related to the dehydration. During an interview on [DATE] at 3:47 p.m. Resident #6's family member stated when they went to the ER that day the hospital stated concern with Resident #6's condition. The family member stated Resident #6 had lost weight over time, but looked really bad that day. The family member stated when the facility called they said Resident #6's blood pressure was dropping. The family member stated they told them at the hospital that Resident #6 had dehydration, pneumonia, and a urinary tract infection. The family member stated Resident #6's knees were pretty banged up. The family member stated he/she was sure one was open and getting infected. It looked pretty rough. The family member did not know when it occurred. He/she knew Resident #6 had some areas on his/her hands and arms. He/she figured the knee happened when falling out of bed. The family member described it as about the size of a half dollar with surrounding redness. The family member stated Resident #6 did come around after they got some fluids in him/her and could talk to him/her about what he/she wanted. The family member felt good about that. The family member stated they gave Resident #6 a lot of fluid in the ER because of the dehydration. The family member stated Resident #6 transferred to a hospice and died . The death certificate dated [DATE] for Resident #6 identified he/she expired at the hospice home on [DATE] with the primary cause of death as Parkinson ' s and the secondary cause of death as recurrent urinary tract infection [MEDICAL CONDITION]. The facility policy Perineal Care Procedure directed if the resident had an indwelling catheter in place, after emptying the drain bag, measure and document the urine and note the appearance of the urine. Notify the charge nurse of any unusual findings. The facility policy Urinary Bag Drainage directed to document urinary output in accunurse. A Care Path document for the potential for Dehydration indicated if staff noted a change in a resident at risk for dehydration including decreased oral intake over 24 hours due to altered mental status, take vital signs. If the vital sign criteria not met perform further nursing assessment: a. Mental status. b. Functional status. c. Respiratory. d. Gastrointestinal. e. [MEDICAL CONDITION]. f. Skin. The options for managing in the facility included: a. Monitor vital signs and urine output every ,[DATE] hours. b. Offer frequent small fluids. Evaluation of the signs and symptoms, including an acute mental status change, or not eating or drinking, indicated the need to notify the physician. A document titled " A Plan for Resolution" dated [DATE] identified the facility's failure to put intervention in place for low urine output and dehydration.

Based on clinical record review, staff interviews, and resident interview, the facility failed to treat Resident #7 with consideration, respect and full recognition of dignity and individuality for a planned discharge which caused the resident to feel fearful and saddened when transferred from the facility. The facility reported a census of 41 residents and the sample consisted of 3 residents reviewed. Findings include: Resident #7 was admitted [DATE] and required extensive assistance from staff for activities of daily living needs. The resident weighed 606 pounds. Contracts signed by the resident, Administrator, Director of Nursing and Dietician proceeded with interventions in the hope for a goal of weight loss. A psychologist evaluated the resident and advised for additional visits, however, no other visits were identified in the clinical record. The facility advised the resident to find an alternative care facility to live in; however, the record clearly demonstrated the resident had shown improvement in weight, behaviors, etc.at the time of the transfer. The resident was admitted into the hospital for evaluation and treatment of [REDACTED]. On 9/30/2010 the resident weighed 593.3 pounds. On 10/25/2010, the resident weighed 534.2 pounds which the dietitian questioned as an accurate weight. 1. Resident #7 had an admission Minimum Data Set (MDS) assessment, with a reference date of 10/19/2009, which indicated the resident had no memory problems and required extensive assistance from staff for activities of daily living. Resident #7 did not walk and required the use of a mechanical lift for transfers. The resident displayed mood and behavior patterns of persistent anger with self or others. The assessment reflected the resident weighed 606 pounds and 61 inches in height (5 feet and 1 inch) The MDS with a reference date of 10/10/10 documented Resident #7 required extensive assistance of one person for transfers, dressing, personal hygiene, and toilet needs. The MDS documented the resident required set up help only for ambulation in the room and set up help with supervision for ambulation in the hallway. The MDS documented [DIAGNOSES REDACTED]. The nutrition risk assessment dated [DATE] documented the resident weighed 602.7 pounds. The assessment documented the resident had good oral intake but did not drink milk. The dietitian recommended adding calcium with vitamin D and obtaining a vitamin D blood level. The social service notes dated 10/27/09 documented the resident adjusted well to the new environment and scored well on the anxiety, depression, and cognitive screens. The dietary progress notes dated 11/1/09 documented the resident weighed 605.9 pounds. The dietitian had no recommendations. The dietary progress notes dated 11/5/09 documented the resident weighed 603.3 pounds. The dietitian noted the resident received vitamin D and vitamin B12 as well as started on an antidepressant. The social service progress notes dated 11/5/09 documented a visit with the social worker. The progress note described the resident's overall attitude and mood. The progress note did not document any behaviors or noncompliance with diet. The dietary progress notes dated 12/11/09 documented a meeting with the resident to discuss weight loss goals. The resident agreed to eat smaller portions and decrease snacks in the afternoon. The nutrition review dated 12/23/09 documented the resident showed adequate nutritional intake with calcium with vitamin D supplementation. The social service progress note dated 1/14/10 documented the resident had no significant changes. The dietary progress notes dated 1/16/10 documented the resident weighed 610.4 pounds and had no recommendations. The nutrition review dated 4/15/10 documented the resident exhibited good nutritional intakes as evidenced by laboratory values and well managed diabetes. The social service progress note dated 4/15/10 documented the staff complained that the resident was rude to them. The progress note documented the resident scored well on all the assessments. The dietary progress notes dated 5/23/10 documented the dietitian met with the resident regarding weight management and the resident did not want small portions. The progress notes failed to document any behaviors or noncompliance with diet. The dietary progress note dated 7/8/10 documented the interdisciplinary team met with the resident. The resident agreed to working more with therapy, keeping a food diary, and to try 100 calorie snacks. The facility wrote a contract for the resident to sign and the dietitian would re-evaluate in one to two months. The nurse's notes dated 7/8/10 documented the resident had a care plan. The nurse's notes dated 7/12/10 documented the resident signed a contract written by the social worker, Director of Nursing, Assistant Director of Nursing, Administrator, and Dietitian. The contract directed the resident to ? Regulate own snack intake by documentation of the amount of calories taken in per day and per meal. ? Therapy services would also be working with resident to aid with strength and weight loss goals set in place by the resident. ? If the course of care became ineffective after 45 days, then the resident would turn the calorie regulation over to the dietician, nurses and other medical professionals. ? If the resident refused aid or services from the professions then the resident would be found alternate placement. The nurse's notes dated 7/16/10 documented the resident had a confrontation with a certified nurse aide. An investigation was performed and it was determined the resident had called a nursing assistant " such an idiot " . The nursing assistant did not react to the statement and the behavior repeated when the nursing assistant entered the room again. The investigation form indicated the resident had exhibited these behaviors in the past. The Administrator documented communication with the resident properly seems to decrease the agitation. The nutrition review dated 7/17/10 documented the resident tried to eat regular portions and limit snacks. The dietitian supplied the resident with learning material. The dietitian stated the resident was receptive. The nurse's notes dated 7/19/10 documented the resident worked things out the certified nurse aide over the weekend. The resident received a psychological evaluation on 7/19/2010 to address depression and eating concerns. The assessment document indicated the resident continued to need to be assessed with [REDACTED]. The psychologist would monitor factors with personality and mood but felt the resident did not need medication intervention at that time, however, if the depression worsened the resident would be referred to the attending physician. The nurse's notes dated 7/21/10 documented the social worker followed up with the dietitian on the contract. The dietitian gave the resident materials to aide in weight loss. The dietary progress note dated 8/5/10 documented the resident weighed 605.4 pounds and a facsimile was sent to the physician to request a pre-[MEDICATION NAME] blood level be checked. The progress notes did not document any behaviors or noncompliance with diet and therapy. The nurse's notes dated 8/31/10 documented the resident voiced no concerns. The dietary progress notes dated 9/23/10 documented the administrator and the Director of Nursing required the resident to lose weight to continue residency. The resident agreed to a small portion diet. The nutritional progress notes dated 9/30/10 documented the resident weighed 593.3 pounds and resident expressed pleasure with the recent weight loss. The nutritional progress notes had no further documentation of the resident's noncompliance with diet. The nurse's note dated 9/23/10 documented the social worker, director of nursing, administrator, and restorative aide met with the resident to discuss resident's noncompliance with the diet. The resident agreed to work with the dietitian, to discuss options with Hospice, and for the facility to find alternate placement for a bariatric resident. The nurse's notes dated 9/23/10 documented the facility made a hospice referral. The referral was declined due to did not qualify for the need. The nurse ' s notes dated 9/30/2010 indicated the resident does well with current pain management regimen. The recent weight was 593 pounds with reflected a 3 pound loss from the weight of 9/29/2010. The nurse encouraged the resident to continue with the lower caloric intake and increase the activity. The note identified the resident as optimistic toward future weight loss goals and getting home to her family. The contract signed on 10/1/2010 by the resident, Director of Nursing and the Administrator directed the resident to: ? Resident would follow diet menu and must speak with dietary for any substitutions prior to the serving of that meal, ? Resident requests 1 snack each day at bedtime in which would be provided by the dietary department, ? Resident agreed to continue to work with therapy program established by the therapists, ? Resident needed to limit phone calls to the dietary department unless emergent situation, ? Noncompliance of the diet would be reported to the nursing and/or dietary manager, ? Failure to abide by these guidelines could pose a safety and health risk and the resident may need to be relocated to a facility more able to meet the resident ' s needs, ? Resident would not ask staff and or family members to purchase food items. All food items must come from dietary. The social service progress note dated 10/11/10 documented the administrator spoke to the resident while the resident was in the hospital ( the nurse ' s notes dated 10/10/2010 at 8:00 p.m., the facility notified the resident ' s brother-POA which hospital the resident should be transferred to). The administrator discussed the long-standing noncompliance with diet and care needs. The administrator told the resident the facility could not safely provide for the resident's needs and required alternate placement at a sister facility. The resident agreed for the sister facility to evaluate. The office manager documented on 10/25/2010, the Administrator had visited with the resident per telephone on 10/11/2010 regarding a transfer to another facility. The social service progress notes dated 10/12/10 documented the administrator spoke with the resident and the resident agreed to move to a sister facility. The progress note indicated the resident understood the need to transfer to another facility. The nutritional risk assessment dated [DATE] documented the resident weighed 534.2 pounds. The dietitian questioned the accuracy of the weight. The assessment did not document any resident behaviors. Further review of the clinical record revealed no further documentation of the resident's noncompliance with dietary restrictions or lack of activity. Further review of the clinical record revealed no further documentation of the resident's noncompliance with diet restrictions or lack of activity until 10/11/10 when the administrator told the resident he/she had to relocate to another facility. During an interview on 10/20/10 at 12:35 p.m., the Administrator stated the facility had multiple meetings discussing the resident's diet and behaviors. The Administrator stated the resident agreed to diet restrictions and agreed to work with therapy. The Administrator stated it took multiple staff to assist the resident to transfer and if there was an emergency, staff could not get the resident out of the room. The Administrator stated the facility had a psychologist review the resident and she would not return because the resident displayed hostility. The administrator stated the resident agreed to transfer to a sister facility. The clinical record contained no further documentation of psychological therapy. Since the initial assessment on 7/19/2010. The clinical record did not contain information which documented the resident displayed hostility toward the psychologist. The restorative notes dated August 2010 and September 2010 identified the goals had been achieved. During an interview on 10/21/10 at 4:39 p.m. Resident #7 stated the facility forced her/him to sign the contracts. The resident feared the facility would kick her/him out of the facility. The resident stated he/she was following the diet and had lost 20 pounds. The resident stated when she/he went to the hospital she/he wanted to sign a bed hold so the facility could not kick her/him out. The resident stated the administrator called the next day after the resident admitted to the hospital and told the resident he/she was being transferred. The administrator stated the resident was an emergency risk because the resident could not get out of the room. The resident stated he/she could transfer to the wheelchair to leave the room if an emergency occurred. The resident stated she/he had family close by but had no family close to the sister facility. The resident had feelings of sadness because he/she did not get to say good-bye to the roommate or staff that had become close to the resident. The clinical record revealed the resident had signed a bed hold document on 10/10/10. The resident went to the hospital for evaluation and treatment of [REDACTED]. The social service notes indicated on 10/11/2010, the social worker had visited with the resident via telephone regarding the hospitalization and transferring to an alternate facility. The social worker discussed the long standing non-compliance related to diet and care needs as well as the facility ' s inability to safely meet the resident ' s needs.