Every finding on record at Oak Pointe Nursing & Rehabilitation

Based on observation, medical record review, review of the pre-admission screening and resident review (PASARR) assessment, and staff interview, the facility failed to implement specialized services as indicated in the PASARR level II outcome determination letter. This affected one (#50) of three residents reviewed for PASARR. The facility census was 82. Findings include: Medical record review revealed Resident #50 was admitted on [DATE] with diagnoses including schizoaffective bipolar type disorder, delusional disorder, panic disorder, auditory hallucinations, psychosis, suicidal ideations, depression, generalized anxiety, and insomnia. Review of the care plan: PASARR recommendations due to significant change dated 01/11/24 revealed interventions for interdisciplinary team to review the PASARR recommendations and follow recommendations as able or applicable. There was no evidence the other recommended services were added to the care plan after the PASARR determination letter was received approving Specialized Services on 02/03/25. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50's PASARR level II conditions indicated there resident had a serious mental illness and had been discharged to an inpatient psychiatric facility. Review of the PASARR level II outcome report dated 02/03/25 revealed it was determined Resident #50 was appropriate for nursing facility services with approved Specialized Services. The following behavioral health services were required to be provided by the nursing facility including: a crisis intervention plan, a behavior management safety plan to decrease inappropriate behaviors and ensure safety, ongoing evaluation of the effectiveness of current psychotropic medication on target symptoms, ongoing medication review by a psychiatrist or similarly credentialed professional, mental health counseling, and a behaviorally based treatment plan. The reason for those services was to reduce mental health symptoms and provide supports. Other recommended services the resident would need to be provided by the certified nursing facility included but were not limited to : self-health care management training, activities of daily living (ADL) training, therapy evaluations, skills training, adaptive equipment evaluation, and structured therapeutic activities. The reason for the above supports was to promote health, wellness and independence. There was no evidence in Resident #50's medical record of a crisis intervention plan or behavior management safety plan as required or other recommendations as indicated in the PASARR determination letter dated 02/03/25. On 05/27/25 at 12:17 P.M., observation and interview revealed Resident #50 was laying in bed and refused to acknowledge Registered Nurse (RN) #215 or speak to the surveyor. RN #215 stated Resident #50 has not been receptive to staff and stated Resident #50 might need her medications adjusted. RN #215 stated Resident #50 was seen by the psychiatrist but did not know if the resident had a crisis plan. On 05/28/25 at 3:03 P.M., interview with Clinical Coordinator/Licensed Practical Nurse #271 verified there was no evidence the required PASARR services had been implemented after Resident #50 was approved for Specialized Services on 02/03/25. On 05/29/25 at 8:07 A.M., interview with Social Service Designee (SSD) #273 verified Resident #50's PASARR was approved with specialized services and these had not been addressed to date. On 05/29/25 at 9:40 A.M., interview with SSD #273 stated when he receives the PASARR Level II outcomes, he reviews the determination and then he was to update the care plan. SSD #273 notifies the clinical coordinator and physician to see if they want to order any of those services on the determination letter. SSD #273 stated he did not realize the behavioral health services and Specialized Services were required to be provided per the determination letter by the admitting nursing facility.

Based on observation, record review, and resident and staff interview, the facility failed to ensure the residents were treated with respect and dignity. This affected one (Resident #54) of one resident reviewed for respect and dignity. The facility census was 82. Findings include: Review of the medical record revealed Resident #54 was admitted on [DATE] with diagnoses including schizoaffective disorder, alcohol dependence with alcohol-induced persisting dementia, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had cognitive impairment and behaviors which included hallucinations and delusions. Observation and interview on 05/27/25 at 12:29 P.M. revealed Certified Nursing Assistant (CNA) #276 standing at the doorway to the smoking room calling residents by name to enter the smoking room. Resident #54 was walking down the hall towards the smoking room. CNA #276 told Resident #54 to stop. Resident #54 kept walking and got close to CNA #276. CNA #276 leaned towards Resident #54 and in a raised voice told Resident #54 to go sit down until it was her turn. Resident #54 continued past CNA #276 and entered the smoking room. At 12:31 P.M., CNA #276 verified she had raised her voice and told Resident #54 to go sit down. CNA #276 stated Resident #54 raised her voice first and Resident #54 would push past other residents and had almost made several other residents fall before. That was why she told Resident #54 to sit down and wait her turn. At 12:32 P.M., Resident #54 was sitting in the smoke room and when asked if it bothered her that CNA #276 raised her voice and told Resident #54 to sit down, Resident #54 said it did. At 12:34 P.M., another resident (Resident #24) stated CNA #276 was not out of line because Resident #54 would just push her way through and would run into other people. Resident #24 stated CNA #276 was not abusive or disrespectful to any of the residents.

Based on observation, medical record review, policy review, review of manufacturer guidelines and Medscape guidance, and staff interview, the facility failed to ensure their medication error rate did not exceed five percent (%). Nine errors occurred within 26 opportunities for an error rate of 34.6%. This affected three (#17, #62, and #72) of five residents observed for medication administration. The facility census was 82. Findings include: 1. Medical record review revealed Resident #17 was admitted on [DATE] with diagnoses including schizophrenia, paraplegia, congestive heart failure, and anxiety disorder. Review of Resident #17's physician orders dated May 2025 revealed to administer medications upon rising which included Aripiprazole (antipsychotic) 7.5 milligrams (mg). Review of the pharmacy pre-packaged pouch labeled At Rise for Resident #17 dated 05/27/25 revealed the pouch included Aripiprazole 7.5 mg with instructions 'Do Not Crush'. On 05/27/25 between 9:26 A.M. and 9:35 A.M., observation revealed Licensed Practical Nurse (LPN) #255 prepared Resident #17's medications including Aripiprazole and eight other medications. LPN #22 placed the nine medications into a plastic sleeve including the Aripiprazole and crushed the medications. LPN #255 put the crushed tablets in pudding and administered the medications to Resident #17. On 05/27/25 at 9:57 A.M., interview with LPN #255 verified she crushed Resident #17's Aripiprazole and the pharmacy instructions on the pre-packaged pouch indicated do not crush Aripiprazole. Review of Medscape guidance found at https://reference.medscape.com/drug/Abilify-maintena-aristada-aripiprazole-342983#11 revealed to swallow tablet whole; do not divide, crush, or chew. 2. Medical record review revealed Resident #72 was admitted on [DATE] with diagnoses including anxiety, Alzheimer's disease, hypertension and psychosis. Review of the physician orders dated May 2025 revealed to administer medications including tramadol (opioid), ativan (anxiety), benazepril (blood pressure), Colace (stool softener), famotidine (gastroesophageal reflex disease), Meloxicam (nonsteroidal anti-inflammatory), Miralax (stool softener), and lactulose liquid (stool softener). On 05/27/25 between 9:38 A.M. and 9:55 A.M., observation revealed Licensed Practical Nurse (LPN) #255 prepared Resident #72's At Rise medications including tramadol, ativan, benazepril, colace, famotidine and Meloxicam into a plastic sleeve, crushed the medications and put the crushed tablets in pudding. LPN #255 prepared Resident #72's Miralax in six ounces of water, lactulose liquid dose was poured into a glass of nutritional supplement and the above medications were taken to the lounge area where Resident #72 was seated in a specialty wheelchair. LPN #255 was observed scooping the crushed medications from the medication cup with a plastic spoon into Resident #72's mouth. The resident was observed to take the crushed medications in pudding that was heaping above the rim of the spoon; however, the bowl of the plastic spoon remained full of crushed medications and pudding. LPN #255 poured the liquid lactulose into the nutritional supplement and Resident #72 drank approximately five ounces of the nutritional supplement. The remaining doses of the crushed medications and liquid medications were all discarded in the trash. On 05/27/25 at 9:57 A.M., interview with LPN #255 verified the entire dose of crushed medications and liquid medication were not administered to Resident #72 and had been discarded in the trash. LPN #255 was unable to state which medications and how much of the medication was left in the pudding or nutritional supplement due to the medications were mixed together. 3. Medical record review revealed Resident #62 was admitted on [DATE] with diagnoses including congestive heart failure. Review of the physician orders dated May 2025 revealed to administer medications including Eliquis (anticoagulant), Lasix (diuretic), and Sacubitril-Valsartan (treats heart failure; also known as Entresto). On 05/28/25 at 3:30 P.M., observation of Resident #62's medication administration revealed Registered Nurse (RN) #281 placed Eliquis, Lasix and Sacubitril-Valsartan into a plastic sleeve, crushed the medication, put the crushed tablets in chocolate pudding and administered the medications to Resident #62. On 05/28/25 at 3:57 P.M., interview with RN #281 verified the above observation and stated the medications including Sacubitril-Valsartan were crushed because Resident #62 would chew the medications if not crushed. Review of the Novartis: Entresto manufacturer guidelines dated April 2024 does not recommend the splitting or crushing of Entresto. If you cannot swallow tablets, or if tablets are not available in the prescribed strength, you may take Entresto tablets prepared as a liquid (oral) suspension or may take Entresto sprinkle. Review of the policy titled Medication Administration dated 06/21/17 revealed medications were to be administered by legally-authorized and trained persons in accordance to applicable state, local and federal lows and consistent with accepted standards of practice.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of nursing schedules, employee time punch review and interviews, the facility failed to ensure a registered nurse was scheduled for eight consecutive hours every day. This had the potential to affect all 81 residents. Findings include: Review of nursing schedules and time punches for the days dated 04/08/23, 04/09/23, 04/22/23, 05/06/23, 05/07/23, 05/20/23 and 06/17/23 revealed there was no registered nurse (RN) coverage for eight consecutive hours. During an interview on 01/30/24 at 1:43 P.M. with the Administrator verified the facility had no RN coverage for eight consecutive hours on the following dates 04/08/23, 04/09/23, 04/22/23, 05/06/23, 05/07/23, 05/20/23, and 06/17/23. The deficient practice was corrected on 10/15/23 when the facility implemented the following corrective actions: - Actively recruited RN hires for both day and night shift positions. - Audited third quarter nurse schedules to ensure minimum qualifications were met. - Educated clinical staff on the need for eight hours of continually RN coverage seven days a week. - Continual monitoring of nurse schedules to ensure RN staffing levels are meeting at least the minimum requirements.

Based on observation, record review and interview the facility failed to ensure all residents had clean linen and furniture in good repair. This affected five residents (#12, #23, #33, #45 and #76) of 80 residents residing in the facility. Findings include: The following environmental concerns were identified during the annual recertification survey: a. On 02/14/22 at 1:43 P.M. interview with Resident #76 revealed concerns her bedspread and bed sheets were dirty. She said her sheets had only been changed three times since she arrived to the facility. The resident said she had spilled pop on her bedspread. On 02/14/22 at 1:45 P.M. observation of the resident's bed revealed there were approximately seven brown areas on the bedspread covering an approximate three foot by three foot area of the white bedspread. There were also brown areas on the fitted mattress sheet and pillow case. On 02/16/22 at 11:16 A.M. observation of the resident's bed revealed her pillow case had red/brown marks on it as well as the fitted sheet. The bedspread had six to seven brown areas as observed 02/14/22. On 02/16/22 at 11:13 A.M. interview with State tested Nursing Assistant (STNA) #815 revealed the residents were to get their sheets changed on shower days. She indicated Resident #76 was a night shift shower. On 02/16/22 at 11:27 A.M. interview with STNA #815 revealed Resident #76 gets a shower every Tuesday, Thursday and Saturday. STNA #815 indicated the resident had a shower the night prior. STNA #815 stated the resident should of had her sheets changed the night prior when she received her shower. STNA #815 verified the sheets were soiled and not changed. On 02/16/22 at 12:25 P.M. observation and interview with the administrator verified the resident's bed sheets and bedspread were soiled. On 02/16/22 at 3:53 P.M. interview with the Administrator revealed the facility did not have a policy to change sheets. b. On 02/14/22 between 9:20 A.M. and 5:57 P.M. observations on the Behavior Unit revealed the following: Resident #12's over bed table was delaminating on three of the four sides. Resident #23's over bed table was in disrepair delaminating. Resident #33 did not have an over bed table. Resident #45 did not have a bedside table in his room. Resident #76's over bed table was delaminating on the top left corner and damaged in about a six inch area. On 02/16/22 at 12:19 P.M. interview with Maintenance #900 revealed the facility did not have any extra furniture for the resident rooms. On 02/16/22 at 12:25 P.M. observation and interview with the Administrator verified the above residents had damaged over bed tables on the Behavior Unit. The Administrator verified not all residents had bedside and over bed tables. The Administrator revealed she had orders a few over bed tables for no certain residents. The facility presented an invoice dated 02/04/22 where they ordered seven new over bed tables that had not been delivered as of this date.

Based on observation, record review and interview the facility failed to ensure the correct serving size was used during the preparation of the pureed protein (beef) on 02/15/22. This had the potential to affect 17 residents (#9, #42, #13, #52, #41, #7, #55, #22, #43, #63, #2, #44, #18, #72, #3, #38 and #34) of 17 residents who were ordered a pureed diet. The facility census was 80. Findings include: Review of the facility provided menu spreadsheet, dated 11/17/21 revealed for the dinner meal on 02/15/22 residents on a pureed diet were to receive two #10 scoops (six ounces (oz)) of beef. On 02/15/22 beginning at 3:32 P.M. interview with Cook #850 revealed there were 17 residents (Resident #9, #42, #13, #52, #41, #7, #55, #22, #43, #63, #2, #44, #18, #72, #3, #38 and #34) who were on a pureed diet and one of those 17 residents received double portions. The cook was observed to remove the beef stir fry to puree and indicated she was using a number six (#6) scoop to measure out 20 servings of beef stir fry to puree. Cook #850 indicated the number six scoop was equivalent to six ounces (oz). On 02/15/22 at 4:25 P.M. observation of the dinner meal tray line revealed Cook #850 was serving each resident on a pureed diet one scoop of protein (beef) using a number six scoop. On 02/15/22 at 4:26 P.M. interview with Cook #850 confirmed she was using a #6 scoop (which was 5.33 oz) to portion out the meal tray for each resident on a pureed diet. Review of a facility provided measurement conversion document revealed a #6 scoop equaled 2/3 of a cup or 5.33 ounces. Further review of the measurement conversion revealed a number ten (#10) scoop was 3/4 of a cup (three ounces) and two scoops were equal to six-ounce servings. On 02/15/22 at approximately 4:30 P.M. interview with Cook #850 and Dietary Manager #818 confirmed the residents were receiving 0.67 ounces less than the planned menu when the cook used the #6 scoop instead of two of the #10 scoops. The cook incorrectly identified the #6 scoop as a six ounce serving when it was actually 5.33 oz. On 02/15/22 at 4:51 P.M. during an interview with Dietary Manager (DM) #818, the DM did not dispute the pureed beef was not served with the correct serving scoop, resulting in the residents receiving less protein than the menu called for.

Based on observation, record review and interview the facility failed to ensure milk served during the dinner meal on 02/15/22 to residents on the secured unit was served at a proper and palatable temperature. This had the potential to affect 11 residents (#18, #72, #31, #5, #69, #5, #45, #23, #71, #60 and #3) of 41 residing on the secured unit who received milk with their evening meal. The facility census was 80. Findings include: On 02/15/22 at 4:40 P.M. a half gallon of milk was observed sitting on a paper towel on the counter of the small dining room on the secured unit. On 02/15/22 at 4:41 P.M. interview with State tested Nursing Assistant (STNA) #826 revealed the half gallon of milk had been removed from the hot beverage cart, before it was removed from the dining room by kitchen staff, to provide the residents with milk when their meals were served. The STNA revealed it was the procedure to remove the milk from the beverage cart prior to the cart being taken back to the kitchen. She confirmed the milk remained on the counter while waiting for the residents meals and then indicated a glass was poured for the residents who wanted milk once their meal tray arrived. STNA #826 confirmed the milk sat out on the counter until all the meal trays were passed and the last resident was served. The milk was then returned to the kitchen. On 02/15/22 at 4:41 P.M. a glass of milk from the half gallon sitting out on the counter was poured and the temperature was taken by Dietary Manager (DM) #818. The milk temperature was 46 degrees Fahrenheit. The findings were confirmed with Dietary Manager #818 who indicated the milk should have been stored in the provided bucket of ice. DM #818 then obtained a new half gallon of milk to provide the residents. On 02/15/22 at 4:49 P.M. the last resident meal was provided and a glass of milk was poured from the half gallon of milk that remained sitting on the counter. The temperature of the milk was taken and it was 47.6 degrees. The findings were confirmed with Dietary Manager #818 at the time of the observation. On 02/15/22 at 5:20 P.M. interview with STNA #826 revealed 11 residents, Resident #18, #72, #31, #5, #69, #5, #45, #23, #71, #60 and #3 would have received the milk from this container (which was not the proper temperature) with their evening meal. On 02/16/22 at 12:51 P.M. interview with Dietician #829 revealed the facility did not have a cold food storage policy and indicated they follow the federal guidelines. Review of the Ohio Department of Health website (https://odh.ohio.gov/know-our-programs/food-safety-program/fact-sheets-for-consumers) titled Food Safety Fact Sheets for Consumer revealed cold foods needed to be kept below 41° F. A cooler with ice or gel packs should be used to keep the foods cold.

Based on observation, facility policy and procedure review and interview the facility failed to ensure pureed protein (beef) was prepared at the correct consistency and prepared in a form to meet each residents needs. This had the potential to affect 17 residents (#9, #42, #13, #52, #41, #7, #55, #22, #43, #63, #2, #44, #18, #72, #3, #38 and #34) of 17 residents who were ordered a pureed diet. The facility census was 80. Findings include: Review of the facility provided menu spreadsheet, dated 11/17/21 revealed for the dinner meal on 02/15/22 residents on a pureed diet were to receive two #10 scoops (six ounces (oz)) of beef. On 02/15/22 beginning at 3:32 P.M. interview with Cook #850 revealed there were 17 residents (Resident #9, #42, #13, #52, #41, #7, #55, #22, #43, #63, #2, #44, #18, #72, #3, #38 and #34) who were on a pureed diet and one of those 17 residents received double portions. Observation of the pureed process with Cook #850 revealed the cook used a number six (#6) scoop, (5.33 ounce (oz)) to remove servings of the beef stir fry to puree. The cook placed ten #6 scoops of beef in the food processor and turned it on, allowing it to puree. The beef was removed from the food processor and the process repeated for 10 additional servings. During the observation, there was no evidence the cook was following a recipe or that she had referred to a recipe to detail the steps involved in the process to puree the beef stir fry. Upon completion of the pureed process, the surveyor requested to taste the food. Observation and tasting of the beef stir fry, with Cook #805 and Dietary Manager (DM) #818 present revealed the food contained a piece of broccoli that was still intact and that had not been properly pureed. On 02/15/22 at 3:38 P.M. Cook #850 (after seeing of the broccoli that was not pureed) placed the food into a second smaller food processor and continued to process the stir fry. At 3:41 P.M. Cook #850 was observed filling the food processor with the partially pureed beef covering the entire blade shaft. On 02/15/22 at 3:45 P.M. Cook #850 and Dietary Manager #818 tasted the beef for the second time and stated the consistency was now correct for pureed food item. On 02/15/22 at 3:46 P.M. the pureed stir fry was tasted by three surveyors. The stir fry had fibers that made the texture stringy and a chunk of food had to be chewed by one of the surveyors. On 02/15/22 at 3:47 P.M. interview with Cook #850 revealed beef was difficult to puree and took some time. She also indicated the food processor was overfilled, stating she was trying to make the process quick. The cook then removed several scoops of the beef and pureed the beef for the third time. There was no evidence the cook obtained or followed a recipe to puree the beef. On 02/15/22 at 4:51 P.M. during an interview with Dietary Manager (DM) #818, the DM did not dispute the pureed beef would have been served after the first pureed attempt even though the consistency was not smooth, chunks were present and the texture was stringy. Review of the facility policy titled Pureed Casserole (Protein), dated 03/24/16 revealed the protein (beef) should have been pureed with a little stock/cooking liquid to reach a smooth consistency. Further review of the policy revealed the puree consistency should have been smooth and similar to pudding or mashed potato consistency. There was no evidence the policy detailed the amount of stock/cooking liquid that should be used or the included the type of stock/cooking liquid to use to puree beef stir fry.

Based on observation, record review, staff interview and facility policy review the facility failed to ensure Resident #36, who required staff assistance for activities of daily living was provided adequate and timely nail care. This affected one resident (#36) of six residents reviewed for activities of daily living (ADL) care. The facility census was 80. Findings include: Review of the medical record for Resident #36 revealed an initial admitted [DATE] and a readmitted [DATE]. Resident #36 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/21 revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 99 (indicating the resident was unable to complete the interview). Behaviors included inattention, disorganized thinking, hallucinations, delusions, verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. The assessment revealed the resident required extensive assistance of one to two or more staff for all activities of daily living (ADL) care. Review of the care plan, dated 12/14/21 revealed the resident required assistance with ADL's and may be at risk for developing complications associated with decreased ADL self-performance. Interventions included diabetic nail care and grooming (nails/shave/hair) assistance as needed. Observation on 02/14/22 at 11:59 A.M. of Resident #36 revealed he had dirt under his fingernails on his left hand. Observation on 02/14/22 at 2:57 P.M. of Resident #36 revealed his left-hand nails were dirty, uneven, and jagged. Interview on 02/15/22 at 10:56 A.M. with Resident #36 revealed staff did not clean or trim his fingernails. The resident confirmed he would like to have nail care. Observation on 02/15/22 at 10:56 A.M. of Resident #36's nails revealed black debris under his left-hand nails and his right-hand nails were jagged and uneven. Interview on 02/15/22 at 10:58 A.M. with State tested Nursing Assistant (STNA) #844 confirmed the resident's nails had dirt under them and they were long, uneven and jagged. The STNA revealed nail care was to be completed with every shower/bath. She revealed nail care included cleaning under the fingernails with an orange stick, then cutting and filing the nails. She revealed residents' showers/baths were completed on a resident to resident basis, but most residents were showered at least three times per week. Review of the facility policy titled, Care of Fingernails/Toenails dated 07/2006 revealed nail care included daily cleaning and regular trimming. Further review of the policy revealed fingernails were to be trimmed in an oval shape then smoothed with a nail file or emery board. The policy revealed trimmed and smooth nails prevent the resident from accidentally scratching and injuring his skin.

Based on record review, review of a facility self-reported incident (SRI) and interview the facility failed to develop and implement a comprehensive and individualized behavioral management plan for Resident #44 to effectively and timely identify and manage resident behaviors to prevent an altercation and assist the resident in maintaining her highest level of total well-being. This affected one resident (#44) of three residents reviewed for abuse. Findings include: Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's admission Minimum Data Set (MDS) 3.0 assessment, dated 03/03/21 revealed the resident had memory impairment. Review of the dementia care plan for Resident #44 revealed the resident had altered cognitive function related to dementia, anxiety and a mood disorder. Interventions included to be patient with the resident, ensure resident's physiological needs were met, provide medication as ordered, monitor for signs or symptoms of frustration and take measures to remove these, offer verbal reminders and cues as necessary, provide a calm and relaxing environment, and use a calm and relaxed tone during conversations. Review of a facility self-reported incident (SRI), tracking number 4, dated 05/15/21 revealed the facility reported an allegation of physical abuse involving Resident #44. A brief description of allegation/suspicion revealed an allegation of staff to resident altercation. The SRI included a narrative summary of the incident indicating during resident care with Resident #44, who was combative, a staff member made contact to posterior head of the resident with her hand. During the shift the resident was noted to have extreme agitation, verbal and physical aggression, delusions and exhibiting response to internal stimuli. The resident had previously been transferring and ambulating independently throughout lounge and dining room area, which was directly across from the nurse's station. During the period of restlessness and agitation staff were noted to be seated at nurse's station providing direct supervision to ensure safety and close monitoring of the resident. During the time period, the resident had pushed a dining room chair close to nurse's station and sat down, which placed the resident out of direct view of staff. Per a staff interview with the alleged wrongdoer, the staff member indicated she had come from behind the nurse's station and placed herself directly behind the resident, who was seated in a chair in front of the nurse's station to provide one on one to the resident. Upon staff attempt to provide one to one monitoring for safety the resident was noted to become increasingly more agitated towards staff and began flailing her arms and attempting to strike out at staff. The alleged wrongdoer attempted to provide verbal cues and reassurance with no effect resulting in staff attempting to calm the resident and gain attention of the resident, with staff reporting at that time that the alleged wrongdoer made contact to the posterior head of Resident #44 with an open hand. The resident was then assisted to a standing position and assisted to ambulate to her room where she was toileted and offered a change in environment to decrease stimuli and attempt to calm the resident. The SRI revealed once toileting and care were provided, Resident #44 was assisted to bed with a decrease in physical aggression and combative behaviors noted. The facility investigation included a witness statement from State tested Nursing Assistant (STNA) #801, dated 05/15/21 that indicated STNA #802 punched Resident #44 in the back of her head with a closed fist. The statement revealed the resident was not hit with a full force but enough to startle the resident. The resident was yelling and saying she is hurting me. A statement from STNA #802, dated 05/15/21 revealed the STNA tried to get the resident's attention by tapping her on her head. On 02/16/22 at 6:10 A.M. interview with STNA #801 regarding the incident that had occurred on 05/15/21 revealed Resident #44 was really confused, combative and verbally calling the staff names while sitting in a chair at the nursing desk. During the interview, STNA #801 reported STNA #802 was behind the resident and used a closed fist to hit the resident in the back of her head. STNA #801 denied the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] On 02/16/22 at 6:16 A.M. interview with STNA #802 revealed she tapped the resident on the back of her head using an open palm to get the resident's attention. During the interview, the STNA confirmed she did not preserve the resident's dignity at all times while attempting to manage the resident's behaviors on this date. On 02/16/22 at 6:19 A.M. interview with the Administrator revealed she interviewed both STNA #801 and STNA #802 involved in the incident with Resident #44 and she was aware of the conflicting statements of the two staff members. She stated after completion of the investigation, she felt the incident resulted in Resident #44 not being treated with dignity. As a result of the incident, the Administrator revealed STNA #802 was counseled and educated on managing resident behaviors.

Based on observation, record review, interview and facility policy review the facility failed to ensure Resident #36 was provided adequate and timely dental services. This affected one resident (#36) of four residents reviewed for dental care. The facility census was 80. Findings include: Review of the medical record for Resident #36 revealed an initial admitted [DATE] and a readmitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/21 revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 99 (indicating the resident was unable to complete the interview). The assessment revealed the resident had behaviors including inattention, disorganized thinking, hallucinations, delusions, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed towards others. The assessment revealed the resident required extensive assistance from one to two or more staff for all activities of daily living (ADL) care. Review of the care plan, dated 12/14/21 revealed Resident #36 had impaired dentition and was at risk for problems related to wearing dentures (uppers and lowers). Interventions included if dentures were ill fitting to contact social services to make arrangements to get dentures adjusted, consult the dentist as needed, dentures to be worn for meals and monitor for ill-fitting dentures. Review of the quarterly oral examination dated 12/20/21 confirmed the resident was edentulous, had no broken teeth and revealed the resident wore dentures (uppers and lowers) most of the time. On 02/14/22 at 2:45 P.M. Resident #36 revealed he had upper and lower dentures that he believed were at his home. The resident denied seeing a dentist recently and stated his lower denture needed an adjustment. On 02/16/22 at 11:25 A.M. interview with State tested Nursing Assistant (STNA) #844 revealed Resident #36 had a top denture but no bottom denture. The STNA was unable to recall ever seeing the resident with a bottom denture. On 02/16/22 at 2:55 P.M. during an interview with the Director of Nursing (DON), the DON was asked for additional information for the resident related to dental care/services. On 02/16/22 at 3:05 P.M. interview with the Administrator revealed the resident had upper and lower dentures up until approximately two weeks ago according to the completed oral assessment and the last time the dietician observed the resident's dentures. The Administrator revealed the resident was going to be scheduled with the dentist since he reported to her that his bottom dentures were ill fitting. She also revealed the resident told her he put the lower dentures in a shoe box at home, so the administrator assumed the resident had thrown them out. On 02/16/21 at 3:18 P.M. interview with Social Worker (SW) #814 revealed the resident was not seen by the dentist because the VA dictates when he would be seen by the dentist. She stated the resident was not seen by the in-house dentist because it was her belief the resident's family wanted him to only be seen by the VA. SW #814 was unsure when the resident had last been seen by the dentist. She stated she would contact the VA and obtain dental records. On 02/16/22 at 3:28 P.M. interview with Resident #36's wife revealed the resident had upper and lower dentures and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's wife revealed the resident had dentures in the facility although they were not in his mouth when she last visited in November 2021. The resident's wife revealed the resident usually goes to the VA to see the dentist and denied being offered in house dental services since the resident's admission. On 02/17/22 at 10:45 A.M. Resident #36 was observed sitting in a wheelchair in the dining room. The resident did not have any dentures in. Interview with the resident at the time of the interview revealed he had put his upper dentures in yesterday after speaking to the surveyor, but could not find his lower denture. On 02/17/22 at 10:57 A.M. interview with STNA #843 verified the resident only had an upper denture at this time and no lower denture. On 02/17/22 at 11:34 A.M. interview with Social Worker (SW) #814 revealed she was unable to obtain the resident's dental records since the resident was transferred from an out of state VA to a local VA and the entities do not communicate with each other and the records did not flow over. She stated she scheduled the resident for a dentist appointment for his lower denture. She stated she would not have scheduled the dentist appointment prior due to it being the VA's responsibility unless there was a specific reason for a dentist appointment and she stated she did not know there had been any dental need prior to this date. SW #814 confirmed the resident did not have a dental consent on file stating she asked him verbally on admission about it. She also confirmed the resident's dental service needs should have been care planned. Review of the facility policy titled Dental Services, dated 11/14/17 revealed the facility would refer the resident for dental services within three days or as soon as practicable for residents with lost or damaged dentures. Further review of the policy revealed the facility would assist the resident with making dental appointments and arranging transportation to and from the dental service location. The policy continued by revealing the facility would review and update the plan of care for residents or resident representatives who did not wish to be referred for dental services.

Based on observation, record review and interview the facility failed to ensure the accurate documentation for thromboembolic deterrent (TED) hose and an ankle-foot orthosis (AFO) device for Resident #20. This affected one resident (#20) of one resident reviewed for [CONDITION(S)]. Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 11/19/21 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, hallucinated and had delusions. The resident had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) one to three days of the assessment period and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) four to six days of the review review period. The assessment revealed the resident did not reject care, required extensive assistance from one staff for bed mobility and extensive assist from two staff for transfers. The resident did not receive scheduled pain medication but received as needed pain medication. The resident's pain was assessed to be almost constant and made it hard to sleep at night but did not limit activities. She said her pain was rated a ten on a scale of 0-10 with ten being the worst. Review of the resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the AFO may be taken off for personal care and hygiene and remove at bedtime (HS). Check skin integrity daily to bilateral lower extremities (BLE) two times a day for brace (AFO) on in A.M. and off at HS and an order (initiated 08/17/20) for bilateral compression hose on in A.M. and off at bedtime (HS) two times a day for [CONDITION(S)]. On 02/14/22 at 11:56 A.M. and 1:27 P.M. and on 02/15/22 at 10:08 A.M. observation of Resident #20 revealed the resident had bilateral lower leg [CONDITION(S)], had slipper socks on with swelling bulging over the top of the socks. The resident did not have on TED hose or an AFO. On 02/15/22 at 10:08 A.M. interview with Resident #20 revealed she had them but doesn't wear the TED hose because they leave lines on her legs. She said she doesn't like the AFO device. On 02/15/22 at 10:32 A.M. interview with State tested Nursing Assistant (STNA) #815 revealed Resident #20 did not wear TED hose. The STNA revealed the resident's legs were usually still swollen in the morning even after being in bed at night. On 02/15/22 at 10:38 A.M. interview with Licensed Practical Nurse (LPN) #829 revealed Resident #20 refused to wear TED hose. On 02/16/22 at 11:13 A.M. Resident #20 was observed in the dining room getting ready for lunch. The resident was observed to have bilateral lower leg [CONDITION(S)] with slipper socks half off. She did not have on TED hose or an AFO in place. Review of the Treatment Administration Record (TAR) revealed Resident #20 had TED hose and the AFO documented as being in place every day from 02/01/22 through 02/14/22. However, based on the above observations and interview, neither device was in place on 02/14/22 even though staff documented they were. Review of the January 2022 TAR reflected the application of the AFO and TED hose everyday with the exception of 01/31/22. The December 2021 TAR revealed the application of the AFO was documented as ordered with the exception of 12/16/21 and 12/29/21 which noted the resident had refused on those dates. The application of the TED hose was documented as being applied as ordered with the exception of 12/15/21, 12/16/21 and 12/29/21 when the resident refused. The November 2021 TAR revealed the AFO and TED hose were applied as ordered except for on 11/05/21 when the resident refused. On 02/16/22 at 2:22 P.M. interview with Licensed Practical Nurse (LPN) #80 revealed the resident cycled. There were times she would wear the TED hose and AFO as ordered. LPN #80 revealed the last time she saw the resident with TED hose on was one day last week. LPN #80 revealed after medications were administered she completed resident documentation. The LPN revealed she documented yes, the TED hose and AFO device were in place out of habit and without actually verifying the application of the devices which resulted in the resident's medical record being inaccurate.

Based on observation, record review and interview the facility failed to promote the dignity of cognitively impaired residents when incontinence products were visibly placed in chairs in common areas for residents on the unit to sit on. This affected two residents (Resident #7 and #128) and had the potential to affect 13 additional residents (Resident #26, #27, #31, #32, #49, #56, #62, #64, #66, #68, #69, #74 and #178) who resided on the facility secured dementia unit. The facility census was 80. Findings include: On 05/28/19 at 11:17 A.M. and 12:02 P.M. and on 05/29/19 at 4:05 P.M. and 5:43 P.M., observations on the secured dementia unit revealed there were six recliner chairs in the television/lobby (TV) area that were observed to have white incontinence pads covering the seats of the recliners. On 05/29/19 at 4:05 P.M., observation revealed Resident #7 and #128 were sitting on white, cloth incontinence pads that were placed in recliner chairs in the TV area of the dementia unit. There was no evidence either resident was incontinent of bowel or bladder. On 05/29/19 at 4:59 P.M., interview with Licensed Practical Nurse (LPN) #81 verified the recliner chairs in the TV area were all covered with white cloth incontinence pads to protect the furniture from possible incontinence episodes. Upon further interview, LPN #81 verified the first thought when you saw the white incontinence pads on the chairs was that whoever sat in the chair was going to be incontinent of urine and verified this was not dignified for the resident. The facility identified 15 residents, Resident #7, #26, #27, #31, #32, #49, #56, #62, #64, #66, #68, #69, #74, #128 and #178 who resided on the facility secured dementia unit On 05/29/19 at 6:18 P.M., interview with Registered Nurse #98 revealed the facility did not have a dignity policy and staff were to follow resident rights. Review of the undated Resident Rights revealed the facility was to maintain a residents' dignity.

Based on record review and staff interview the facility failed to ensure medical records were maintained in a complete and accurate manner. This affected one resident (Resident #56) of five residents reviewed for unnecessary medication use and one resident (Resident #129) of one resident reviewed for pressure ulcers. Findings include: 1. Medical record review revealed Resident #56 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #56's physician's orders [REDACTED]. The provider was to be notified if the fasting blood glucose was less than 60 mg/dL or more than 400 mg/dL. The order was discontinued on 04/11/19. Review of the Blood Sugar Summary revealed on 11/24/18 the resident's blood glucose was 111 mg/dL. Review of the record revealed no evidence a fasting blood glucose level was documented for (MONTH) (YEAR), (MONTH) 2019 or (MONTH) 2019. On 05/30/19 at 1:48 P.M., interview with the Director of Nursing (DON) verified Resident #56 had a monthly order for a fasting glucose level, the medical record indicated the glucose level was obtained but the actual glucose reading was not documented. The DON stated there was some documentation on the nurse practitioner board but it had multiple resident information on it and it was not part of the medical record. 2. Medical record review revealed Resident #129 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan, dated 05/16/19 revealed alteration in skin integrity as evidenced by a pressure ulcer, present at the sacral coccygeal area, with interventions including to assess the area for size, color, drainage weekly and as needed, and to notify the physician of changes as needed. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/21/19, revealed the presence of a Stage III pressure ulcer on admission. Review of the Skin Grid Assessment, dated 05/20/19, revealed a Stage III pressure ulcer, located on the coccyx area, measuring 1.5 centimeters (cm) length (l) by (x) 1.4 cm width (w) x 0.5 cm depth (d). Review of the Skin Grid Assessment, dated 05/27/19, revealed a Stage III pressure ulcer, located on the coccyx area, measuring 3.0 cm l x 2.0 cm w x 0.2 cm d with tunneling noted. The assessment incorrectly revealed the area was unchanged. During interview on 05/30/19 at 2:14 P.M., the Assistant Director of Nursing (ADON) verified the Skid Grid Assessment, dated 05/27/19, revealed the wound measurements reflected a decline from the previous weekly assessment, dated 05/20/19, and the documentation of the wound being unchanged was incorrect. Review of the facility's policy, titled Skin Assessment, dated (MONTH) (YEAR) revealed for areas of skin alteration, the resident's response to preventative efforts and treatment interventions was monitored and approaches were revised as appropriate.

Based on observation, record review and staff interview the facility failed to complete a physician ordered treatment to Resident #70's face. This affected one resident (Resident #70) of one resident reviewed for non-pressure skin conditions. Findings include: Review of Resident #70's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of Resident #70's care plan, dated 12/10/18 revealed the resident had the potential for altered health maintenance related to [MEDICAL CONDITION] with interventions to follow up with the dermatologist as ordered, skin dressing/treatment as ordered, monitor for new [MEDICAL CONDITION], pain, drainage, or a change in a lesion, and notify the physician of changes. The Minimum Data Set (MDS) 3.0 assessment, dated 04/24/19, revealed a Brief Interview of Mental Status (BIMS) score of 03 indicating the resident had impaired cognition. The assessment also revealed the resident required supervision from staff for transfers and locomotion. Record review revealed Resident #70 had physician orders [REDACTED]. Review of the treatment administration record (TAR) for (MONTH) 2019 revealed no evidence this treatment was completed as ordered. An observation on 05/30/19 at 11:00 A.M. revealed Resident #70 with no dressing to his face/chin area. The area was observed approximately dime sized and beefy red. An interview on 05/30/19 at 12:05 P.M. with Licensed Practical Nurse (LPN) #95 confirmed the absence of Resident #70's dressing to his chin. The LPN further confirmed the absence of the treatment order or evidence of treatment completion documented on the TAR.

Based on observation, record review and interview the facility failed to provide timely and appropriate treatment for [REDACTED]. This affected one resident (Resident #67) of one resident reviewed for limited range of motion. Findings include: Record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #67's care plan, dated 11/08/18 revealed the resident had a self care deficit and an activities of daily living decline may be expected related to [MEDICAL CONDITION] disease process. Interventions included maintain and prevent a decline in range of motion, provide necessary adaptive equipment to meet daily needs, and notify therapy for a decline in condition. A Minimum Data Set (MDS) 3.0 assessment, dated 04/17/19 revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. The assessment revealed the resident required supervision of one staff for transfers and limited assistance of one staff for locomotion via wheelchair, the resident was noted to have upper and lower extremity impairment on one side. Review of the plan of care revealed there was no documented evidence of the right hand contractures identified in Resident #67's care plan or specific interventions in place at the time the plan of care was developed to prevent additional decline or to maintain the resident's current level of function related to the right hand contracture. Record review revealed Resident #67 was receiving occupational therapy (OT) services three times a week for four weeks, which started on 05/08/19, for contracture management, gentle stretching to reduce the contracture, and orthotic/positioning device management. An observation on 05/28/19 at 1:08 P.M. revealed Resident #67 had a right hand contraction. No contraction prevention splint or device was observed to the resident's right hand at the time of the observation. An observation and interview on 05/30/19 at 11:13 A.M. with Resident #67 revealed he had a carrot he was supposed to wear for the right hand contraction, but he didn't wear it all the time. It was not in place at the time of the observation. An interview on 05/30/19 at 12:05 P.M. with Licensed Practical Nurse (LPN) #95 revealed she didn't think Resident #67 had a carrot he wore for his contraction. An interview on 05/30/19 at 12:13 P.M. with LPN #1 revealed Resident #67 had a carrot for his right hand contracture. An interview on 05/30/19 at 12:13 P.M. with State tested Nursing Assistant (STNA) #32 revealed Resident #67 sometimes refused the carrot, she thought therapy had ordered it, and the STNA staff were to help him apply it. An interview on 05/30/19 at 2:45 P.M. with the Director of Nursing (DON) confirmed the absence of the right hand contracture on Resident #67's care plan. An interview on 05/30/19 at 3:01 P.M. with the Physical Therapy Assistant/Rehab Director #96 revealed Resident #67's hands had been that way (indicating contraction) for a long time and occupational therapy (OT) was currently working with a carrot to see how he did with it. He further revealed Resident #67 started with OT on 05/08/19 because it was brought to their attention by the Certified Nurse Practitioner after she stated she wanted to try [MEDICATION NAME] (an injection to help manage contractures) therapy for the contractures. Physical Therapy Assistant/Rehab Director #96 revealed there was no formal education to the staff of the use of the carrot for the hand contracture as of this time.

Based on observation, record review and interview the facility failed to provide adequate supervision and ensure fall interventions were implemented for Resident #7 and Resident #128 to prevent falls. This affected two residents (Resident #7 and #128) of four residents reviewed for accidents. Findings include: 1. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan titled At risk for Falls, initiated 12/21/18 revealed Resident #128 had impaired cognition, an unsteady gait, had a history of [REDACTED]. Interventions included to provide staff one-on-one with the resident when restless, Dycem to the wheelchair, a chair alarm when in the recliner, knee pads and hipsters as tolerated. Resolved interventions included a pull tab alarm to the wheelchair to alert staff of the resident's attempts to transfer self unassisted. The wheelchair pull tab alarm was discontinued on 03/01/19. Review of the Discharge Return Anticipated Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #128 was moderately impaired for daily decision-making and required extensive assistance with transfers and walking. The resident had one fall since the previous assessment. Review of the monthly Physician order [REDACTED]. There was no current order for an alarm to Resident #128's wheelchair. Review of the admission Fall Risk assessment dated [DATE] revealed resident had three or more falls in the last 90 days, was unable or unwilling to follow directions, was cognitively impaired, ambulated with problems, was not steady moving from a seated to standing position, was not steady walking and was only able to stabilize with staff assistance. On 05/28/19 at 4:13 P.M., observation revealed Resident #128 was seated in a wheelchair with a chair alarm attached. The resident's right eye had dark red/black bruising nearest the nose and fading light yellow/green/black bruising below the eye, down the cheek and extending toward her ear. The resident was observed to raise up while holding herself up with one hand on the table and a chair alarm attached to the back of the wheelchair was sounding. No knee pads or hipsters were observed on the resident. On 05/29/19 at 4:05 P.M., observation revealed Resident #128 was seated in a lazy-boy recliner in the television area with no chair alarm observed. The resident was observed trying to sit up and leaning towards the left. On 05/29/19 at 4:37 P.M., observation revealed Resident #128 was sitting in a wheelchair with no Dycem and her feet did not touch the floor. The resident's non-skid socks were too big/loose and half the non-skid sock extended beyond the residents toes yet the top of the non skid sock was still loose and sagging at the resident's ankles. State tested nursing assistant (STNA) #84 verified the observation and stated she had taken care of Resident #128 for the last two days and her only fall intervention was a two staff assist for transfers and ambulation. STNA #84 pulled up the resident's sock but did not change or apply a pair of non skid socks that fit the resident. STNA #84 stated the resident was at risk for falls and was unable to follow simple commands due to cognitive deficits. On 05/29/19 between 4:39 P.M. and 4:59 P.M., Resident #128 was observed to stand and maneuver around the edge of the table taking three to four steps wearing the ill-fitting non-skid socks. STNA #84 had her back to Resident #128 and no other staff was in the vicinity of the resident. The surveyor alerted staff the resident had stood up and was starting to take steps away from the table. STNA #84 ran to the table and placed her arm under the resident's arm. The resident's non-skid socks continued to slide down her ankle and extend past her toes. On 05/29/19 at 6:17 P.M., interview with the Director of Nursing (DON) verified it was her expectation that nursing staff was to be aware of resident fall interventions and fall interventions were to be in place as ordered. The DON verified the resident did not have an order for [REDACTED]. On 05/30/19 between 7:11 A.M. and 7:30 A.M., observation revealed Resident #128 was attempting to stand from her wheelchair and STNA #42 stood next to the resident until she sat back down. The resident was wearing non-slip socks; however, the left sock was twisted around with the non-skid surface positioned on the top portion of the resident's foot. At 7:24 A.M., Resident #128 was observed to stand and Resident #48 told STNA #42 that Resident #128 was trying to stand and reached for her wheelchair. STNA #42 told Resident #48 she is ok and continued to wash her hands at the sink. The other two staff members in the dining room, Licensed Practical Nurse (LPN) #58 and STNA #72 were assisting other residents with their meals. Resident #128 was then observed to stand and fall to the floor landing on her buttock. The resident's feet were out stretched revealing no non-skid material on the bottom of the left sock and a skin tear was observed to the resident's left elbow. Review of the Progress Notes dated 05/30/19 revealed Resident #128 was seated in a wheelchair at the dining room table awaiting breakfast. The resident was noted to attempt to stand and transfer unassisted, lost her balance and fell . The resident was noted to have grippy socks and hipsters on. On 05/30/19 at 5:30 P.M., interview with the Director of Nursing (DON) verified Resident #128's progress note did not indicate the resident's left gripper sock was twisted with the non-slip surface on the top of the foot and not the bottom at the time of the above noted fall. Review of the Fall Management Policy dated 10/17/16 revealed it was the intention to promote programs geared to improving mobility, stamina, and reduce the risk of falls through a comprehensive process of assessment, care plan development and implementation with ongoing monitoring and review. A plan was to be identified and implemented as necessary to protect the resident and or others from recurrence. 2. Review of Resident #7's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the at risk for falls with potential for injury related to fall history, falls with injury, multiple falls risk factors including impaired balance, impaired cognition, poor decision making skills, psychoactive medications,, wanders and unsteady gait, unaware of safety needs and impaired cognition initiated 10/13/17 revealed interventions including a soft helmet to be worn as tolerated while up dated 02/25/19. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with bed mobility, transfers and toilet use. Further review revealed the resident required extensive assistance of one staff member with dressing and personal hygiene. Review of the physician's orders [REDACTED]. On 05/28/19 at 10:46 A.M., Resident #7 was observed seated in a recliner on the secured unit. The resident had bruising to his right eye. The resident was not wearing a helmet. On 05/28/19 at 2:00 P.M., the resident was observed seated in a recliner on the secured unit, watching sports. The resident was observed not to be wearing a helmet and the helmet was not observed in the area. On 05/29/19 at 3:00 P.M., Resident #7 was observed on the secured unit wearing the soft helmet. On 05/30/19 at 7:54 A.M., Resident #7 was observed seated in the dining room at a table eating breakfast. The resident was not wearing his soft helmet. At the time of the observation, interview with STNA #72 verified the resident was not wearing his helmet and the helmet was to be worn because of the resident's falls. The STNA did not state the resident refused his helmet earlier in her shift which started before breakfast. On 05/30/19 at 3:00 P.M., interview with the Director of Nursing (DON) verified the resident was to wear a soft helmet as tolerated for a safety intervention related to falls. The DON verified the medical record did not indicate the resident refused to wear his helmet on 05/28/19 and staff are to offer the helmet later if the resident refused to wear it. Further interview verified the resident declined to wear his helmet on 05/30/19 however the entry was not documented until after the surveyor asked the staff about the helmet being in place.

Based on record review and interview the facility failed to implement interventions to restore or maintain bladder function to prevent further decline in urinary status for Resident #56. This affected one resident (Resident #56) of one resident reviewed for bladder continence. Findings include: Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Bowel/Bladder Assessments 3.0 dated 08/04/18, 09/22/18, 10/08/18, 01/08/19 and 01/22/19 revealed Resident #56 was always continent of urine. Review of the Bladder Elimination records dated (MONTH) 2019 revealed Resident #56 had one incontinent episode. During (MONTH) 2019, the resident was incontinent of bladder 34 times. Review of the care plan titled Alteration in Elimination, dated 04/02/19 revealed Resident #56 was frequently incontinent of bladder. Interventions included to monitor for infection, monitor labs as ordered, provide hydration and provide incontinence care as needed. There was no evidence of a toileting program or schedule to restore bladder function. Review of the Progress Note dated 04/10/19 revealed the resident was found on the floor and complained of right hip pain. An X-ray revealed an acute non-displaced intertrochanter [MEDICAL CONDITION]. The resident was sent to the hospital for evaluation and treatment. Review of the Discharge-Return Anticipated Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #56 was moderately impaired for daily decision-making, required extensive assistance for toilet use and was always continent of urine. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #56 was severely impaired for daily decision-making and frequently incontinent of urine with no toileting program. Review of the Task: Bladder Elimination dated 05/01/19 to 05/30/19 revealed the resident was incontinent of urine on 20 of the 30 days. Review of the record revealed no documented evidence the resident was on a toileting program to restore bladder function. On 05/30/19 at 2:45 P.M., interview with Assistant Director of Nursing (ADON) #19 verified the resident had declined in continence since she fell and broke her hip without an individualized program or interventions implemented to restore normal bladder function. ADON #19 stated the resident was continent and toileted herself prior to fracturing her hip. Now the resident was dependent on staff to take her to the bathroom to void. She stated staff try to take her every two hours but this was not documented. ADON #19 stated the resident's incontinence was due to her now using a fracture pan and increased pain from the fracture repair. On 05/20/19 at 2:08 P.M., interview with ADON #19 verified there was no documentation or interventions implemented to restore or maintain bladder function since the resident's [MEDICAL CONDITION]. ADON #19 stated once Resident #56 was able to walk again and her pain was controlled a bladder restorative program would be initiated. On 05/30/19 at 3:09 P.M., interview with ADON #19 revealed the facility did not have a policy or procedure regarding restoring bladder function.

Based on record review and interview, the facility failed to ensure comprehensive Minimum Data Set (MDS) 3.0 assessments were accurately completed. This affected one resident (Resident #39) of two residents reviewed for Hospice, one resident (Resident #56) of five residents reviewed for unnecessary medication use and two residents (Resident #56 and Resident #128) of four residents reviewed for accidents. Findings include: 1. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Review of the Progress Note dated 04/10/19 revealed the resident was found on the floor and complained of right hip pain. An X-ray revealed an acute non-displaced intertrochanter [MEDICAL CONDITION]. The resident was sent to the hospital for evaluation and treatment. Review of the Discharge-Return Anticipated Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #56 had no falls since the last assessment. b. Review of Resident #56's Medication Administration Record [REDACTED] the resident received [MEDICATION NAME] (opioid) 5/325 milligrams (mg) for moderate pain on 05/4/19, 05/06/19, 05/07/19, 05/08/19, 05/09/19, and 05/10/19. Further review of the MAR indicated [REDACTED]. Review of the 30-day MDS assessment dated [DATE] revealed Resident #56 received no antidepressant or opioid medications. On 05/30/19 at 10:18 A.M., interview with MDS Registered Nurse #55 verified the above MDS assessments were inaccurate for Resident #56. 2. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Note dated 04/17/19 revealed Resident #128 was noted on the floor beside her bed, the left side of her head and eyebrow was discolored and raised. Review of the Discharge-Return Anticipated MDS assessment dated [DATE] revealed Resident #128 had one fall with no injury. On 05/30/19 at 9:32 A.M., interview with Assistant Director of Nursing #19 verified Resident #128 the MDS was inaccurate for a fall with an injury. 3. Review of Resident #39's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment. Further review revealed the resident did not have a life expectancy of less than six months but the resident was receiving Hospice services. Review of the physician's orders [REDACTED]. On 05/29/19 at 1:00 P.M. interview with Registered Nurse #55 verified the MDS was inaccurate and the resident did not receive Hospice services during the assessment period.

Based on record review and interview the facility failed to ensure a comprehensive facility assessment was completed to determine the necessary staff and resources to provide services to the resident population to ensure all residents maintained their highest level of physical, social, mental and psycho-social well-being. This had the potential to affect all 80 residents residing in the facility. Findings include: Review of the facility assessment dated [DATE] to 05/29/19 revealed the assessment did not contain information regarding the number of staff necessary to provide care to the population in the facility. The assessment indicated the staffing levels were sufficient to provide services including activities of daily living, medications, treatments, mobility and rehabilitation services. However, it could not be determined how this conclusion was made or what sufficient staffing levels detailed. Further review revealed the assessment did not indicate the competencies or staff training necessary to provide services to the facility population or equipment needs to care for the resident population. On 05/29/19 at 5:28 P.M. interview with the Administrator revealed the Facility Assessment provided to the survey team was the entire assessment, no additional information was available or provided and the Administrator indicated he was responsible for completing the assessment. An additional interview on 05/30/19 at 4:00 P.M. verified the assessment did not contain information regarding the staff, training or equipment necessary for daily operation of the facility. No additional information was provided to the survey team related to the Facility Assessment.

Based on resident interview, staff interview, review of abuse policy, and review of Self-Reported Incidents (SRIs), the facility failed to ensure one of 20 Stage II sampled residents was not physically restrained for the purpose of convenience secondary to a medication refusal (Resident #98). Harm occurred when Resident #98 was physically restrained during a medical treatment resulting in an abraised area to his back which required administration of a pain medication. Findings include: Review of Resident #98's medical record revealed admission to the facility occurred on 09/24/10 with medical [DIAGNOSES REDACTED]. On 11/16/10 at 2:06 P.M., interview with Resident #98 revealed that when the resident was asked if he had ever been treated roughly by staff, he replied "yes." Resident #98 stated a male nurse had been rough with him during a [MEDICAL CONDITION] (TB) test administration. Resident #98 further revealed he reported the incident to a different male nurse identified as Licensed Practical Nurse (LPN) #300. Review of the medical record for Resident #98 revealed Progress Notes dated 10/06/10 at 12:05 A.M. revealed Resident #98 stated "this past Sunday, I was held against my will when they gave me a shot of Mantoux." The notes further revealed the resident stated the nurse held his arm and roughed him up while trying to give him a shot he did not want. Resident #98 complained of pain to the upper left back and was given two Tylenol for voicing discomfort at a level of "7" on a scale of 10. The notes revealed LPN #300 assessed Resident #98's back area, and the resident was noted to have an abraised area approximately 6.5 centimeters (cm) in diameter, pink in color, and green/yellow border to upper left back. The notes revealed a transparent dressing was applied to the area at the time. The note revealed LPN #300 reported the allegation to the director of nursing (DON) and assistant director of nursing (ADON). Further review of the Progress Notes dated 10/03/10 at 4:29 P.M. revealed "Resident in the dining room, refusing Mantoux; 1:1 with resident ineffective, and the resident making delusional statements and became physically aggressive with staff, personal space given. Mantoux given in LFA." The notation was written by LPN #310. On 11/17/10 at 2:15 P.M., further Interview with Resident #98 revealed LPN #320 "made me take the shot even though I did not want to take it." Resident #98 revealed he told LPN #300 about the incident and stated there were other nurses and residents in the area when it occurred. On 11/17/10 at 3:17 P.M., Resident #98 was directly asked if he felt as if he was abused? Resident #98 stated "Yes, I was abused by the nurses. They held me down and gave me that shot. All I was trying to do was refuse to take it." On 11/18/10 at 8:05 A.M., interview with Resident #98 revealed he did not usually refuse medications and confirmed he felt he needed them. When asked if he felt like he could refuse medications and or treatments now without issues, Resident #98 stated "I would hope so, but I am not sure." On 11/17/10 at 2:30 P.M., interview with the DON regarding the incident with Resident #98 revealed Resident #98 had refused to take a TB test shot when LPN #310 went into the resident's room. The DON identified that Registered Nurse (RN) #330 stated LPN #310 had come to her to get her to assist with Resident #98. When RN #330 returned with LPN #310, Resident #98 was located in the dining room/common area. Resident #98 stated he did not want to take the shot and was talking about West Virginia. RN #330 revealed Resident #98 was becoming physical; so a male nurse (LPN #320) was called over. Resident #98 sat in a chair in the common area and LPN #320 stood on Resident #98 left side and held down the resident's left arm and leaned across his body to keep him safe. LPN #320 held onto the resident's right arm for the nurse to give the injection. The interview further revealed Resident #98 did bite LPN #300 during the administration of the injection. On 11/17/10 at 2:56 P.M., interview with LPN #310 revealed Resident #98 had refused to take his TB test when she entered his room, so she left Resident #98 and returned with RN #330. LPN #310 revealed at that time she went into the common area and Resident #98 stated "no." The nurse revealed RN #330 and LPN #320 came over to Resident #98 with her. LPN #310 revealed RN #330 and LPN #320 "held Resident #98 down in the chair. LPN #320 was on the left and laid across Resident #98 and held both arms down so I could give Resident #98 the injection." LPN #310 confirmed she should not have administered an injection to Resident #98, because he was trying to refuse the test. Review of the facility SRI dated 10/06/10 revealed on 10/03/10 at 4:30 P.M. in the dining room during administration of a second step of TB administration, Resident #98 became delusional and both verbally and physically aggressive with staff members. Staff stabilized Resident #98 in the chair to ensure safety during administration of injection. The SRI was investigated by RN #330 who was involved with the incident. On 11/18/10 at 2:36 P.M., telephone interview of LPN #300 revealed Resident #98 had notified him of an abrasion on his back. Resident #98 further reported that during administration of a TB injection, he was held against his will by LPN #320. Resident #98 reported RN #330 and LPN #310 were also present at the time. LPN #300 revealed he reported the incident to the DON at the time, which was RN #330. On 11/17/10 at 4:17 P.M., interview of State-tested Nurse Aide (STNA) #400 revealed LPN #320 told Resident #98 it was facility policy that he had to take the injection. The interview confirmed Resident #98 was refusing to take the injection. STNA #400 revealed Resident #98 was always quiet since arrival to the facility and she had never seen him that "bent out of shape before." STNA #400 revealed that following the incident, Resident #98 calmed down when the staff nurse gave him a pop. On 11/17/10 at 4:50 P.M., interview with the facility's current DON #550 and the administrator confirmed that he (the administrator) was aware of the allegation. The administrator verified the DON at the time of the incident was named in the SRI and had also completed the investigation. The DON confirmed each of the involved nurses (RN #330, LPN #310 and LPN #320) were all given verbal counseling for inappropriately holding the resident down and not allowing Resident #98 to refuse treatment.