Every finding on record at Pines Rehab & Health Center

Based on interview and policy review, the facility failed to prevent contamination of laundry by leaving wet clean laundry in the washing machine overnight. This has the potential to affect all residents in the facility. Findings include: Per interview on 2/11/2026 at 9:25 AM, while observing the laundry room a member of the laundry staff stated that the night shift person usually places laundry in the washing machine when they leave at 8:00 PM and that the morning shift places the wet laundry in the dryer upon arrival at 5:30-6:00 AM the following day.Per interview on 2/11/2026 at 9:32 AM, a second laundry staff member confirmed that wet clean laundry is left in the washing machine overnight on a regular basis.Per interview on 2/11/2026 at 10:20 AM, the Infection Preventionist confirmed that wet laundry should not be left in the washer overnight.Per policy review, Do not leave damp linen in washing machines overnight is written into facility's Laundry and Linen policy [last revised October 2022].Leaving wet clean laundry in the washing machine overnight can lead to the growth of mildew (a fungus that grows in warm, damp environments). Some symptoms that exposure to mildew can cause are wheezing, coughing, skin rash, itchy eyes, and runny nose. People with asthma, respiratory illness, immune disorders as well as the elderly are at an increased risk. work cited: Cleveland Clinichttps://health.clevelandclinic.org/mold-what-you-need-to-know-to-cut-your-riskUpdated May 26, 2025, Retrieved February 20, 2026 Guidelines for Environmental Infection Control in Health-Care Facilities (2003), G.II. Laundry Facilities and EquipmentPart II. Recommendations for Environmental Infection Control in Health-Care Facilities | Infection Control | CDCLast updated January 11, 2024, Retrieved February 20, 2026

Based on staff interviews and observations, the facility failed to consistently store food in accordance with professional standards for food service. There is a potential to affect all residents. Findings include:Per observation and interview on 2/9/2026 at 10:25 AM, during an initial tour of the kitchen, the Kitchen Manager confirmed there were three loaves of bread on the counter that did not have discard by dates on them. She confirmed that all perishable foods removed from the freezer and stored in the refrigerator, or on the countertop for imminent use, are supposed to be labeled with a discard by date. She confirmed that all leftovers of food prepared in the kitchen are also supposed to be labeled with a discard by date. The discard by date indicates that the food has been in the refrigerator for three days and needs to be discarded. The Kitchen Manager confirmed at 10:36 AM that there was a large box of hard-boiled eggs in the refrigerator with a discard by date of 11/20/25. She confirmed that there was a bag of pancakes in the refrigerator without a discard by date on the bag. Per interview with a cook on 2/9/2026 at approximately 11:30 AM, he confirmed that the bag of cheese he was going to use in his preparation of lunch, had a discard by date of 2/4/26.

Based on observation, record review, and interview, the facility failed to ensure that dinnerware was sanitized and failed to maintain a clean kitchen environment, which has the potential to impact all residents in the facility. Findings include: On 02/24/25, at 10:41 AM, it was observed that the shelf under steam table was covered in a greasy residue with crumbs and dust adhering to it. This shelf contained the clean steam table trays, which were stacked, opening side down, on the soiled shelf. Crumbs were observed on the counter near and under the toaster, and there were brown stains on the counter at the window used to pass food and beverages to the dining room. The facility uses a high temperature dishwasher (which uses heat for sanitization rather than chemicals). Per regulatory requirements, the dishwasher must have a wash cycle temperature of 150 to 165 degrees Fahrenheit. A record review of the 12/2024 Dishwasher Temperature Log showed the following insufficient temperatures were recorded on the log by staff: 12/4/2024 148 degrees Fahrenheit (F), 12/5/2024 120 degrees F, 12/7/2024 140 degrees F, 12/8/2024 110 degrees F, 12/15/2024 125 degrees F, 12/16/2024 140 degrees F, 12/17/2024, 140 degrees F, and 12/21/2024 130 degrees F. During an interview, on 2/24/25 at 10:50 AM, the Certified Dietary Manager confirmed that the shelf under the steam table was not clean and that the counters were not clean. During an interview, on 2/26/25 at 10:16 AM, the Certified Dietary Manager confirmed wash cycle temperatures for the dishwasher were insufficient for sanitization on 12/4/2024, 12/5/2024, 12/7/2024, 12/8/2024, 12/15/2024, 12/16/2024, 12/17/2024, and 12/21/2024.

Based on interview, and record review, the facility failed to implement an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections related to Legionella prevention. Findings include: Per record review of the facility's water management program, there was no risk assessment to identify areas in the building that could grow and spread Legionella in the facility water system. Per the facility's Water Management for Legionella policy [effective date: 1/1/23] states, [NAME] kare locations will utilize water management practices to reduce the risk of growth of Legionella and other opportunities pathogens in building water systems .Core elements of the water management plan are: .describe the facilities water system using text and flow diagram, risk assessment with control methods and corrective actions, monitoring control measures . The facility's water management system policy did not include any testing protocols. An interview was conducted with the Infection Preventionist and Director of Maintenance on 2/26/25 at 10:50 AM. The Director of Maintenance and Infection Preventionist confirmed that the facility did not complete a risk assessment, including identifying areas in the building where Legionella could grow or reside.

Based on interview and record review, the facility failed to ensure residents remained free of accident hazards related to falls and care plan interventions for 2 residents [Residents #55 & #3] of 25 sampled residents. Findings include: 1.) Per record review Resident #55 was admitted to the facility with diagnoses that include a history of falls, alcohol-induced dementia, lack of coordination, and muscle wasting. The resident's Care Plan identified the resident at risk for falls due to a primary medical history of falls, alcohol abuse, and increased weakness. Review of progress notes for the resident dated 2/1/25 reveal At 2:10 PM: Nurse was summoned to resident's room after [s/he] was found on the floor beside [h/her] bathroom door . Root cause of fall: Alone and unassisted- resident lacks safety awareness. Further review of progress notes reveal the next day, 2/2/25 at 04:45 AM: Resident was found on the floor, beside [h/her] bed in a sitting position. Resident was awake and alert. The following day, 2/3/25, Progress notes record at 12:00 AM Resident was found on the floor, in a sitting position beside [h/her] bed while this nurse was making rounds. When resident was asked what had happened, resident was speaking in word salad [unintelligible, extremely disorganized speech]. Resident is confused at baseline. Review of the facility's 'Resident Centered Approaches to Managing Falls and Falls Risk' policy [revised March 2018] records the staff will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The policy continues If falling occurs despite initial interventions, staff will implement additional or different interventions .if underlying causes cannot be readily identified or corrected, staff will try various interventions .until falling is reduced or stopped. Review of Resident #55's Care Plan reveals no new interventions added to prevent further falls after falls on consecutive days 2/1/25 and 2/2/25. A third fall in 3 days [2/3/24] then resulted in interventions being added. 2.) Per record review Resident #3 was admitted to the facility with diagnoses that included paranoid schizophrenia, bipolar disorder, and borderline personality disorder. The resident's Care Plan identified the resident at risk for falls due to a history of falls and muscle weakness. Review of progress notes for the resident dated 12/7/24 reveal At 3:10 this morning this nurse was called into room by this resident's roommate via call light. On arrival [Resident #3] is seen laying on floor on the side of [h/her] bed. [Resident #3] stated had pain in chest area when asked why stated 'I fell on my chest facing down' . Resident skin assessment completed and noted redness on mid chest area,. During the end of skin assessment noted tenderness tor right side of chest wall under axillary area. Area is tender to touch and has a slight skin color change. Resident states this area hurts. MD suggested resident to go to Hospital. When asked resident if [s/he] would like to go to hospital to get x-ray and seen by MD there [s/he] declined. Review of Resident #3's Care Plan reveals no new interventions added to prevent further falls after the fall on 12/7/24. An interview was conducted with the Director of Nursing [DON] on 2/26/25 at 10:33 AM. The DON stated the expectation is that after a fall interventions are added to a resident's the care plan immediately to prevent any additional falls. The DON confirmed Resident #55 fell on ,d+[DATE], 2/2, & 2/3/25 before new interventions were added into the care plan on 2/4, after resident had fallen twice with no new actions taken. The DON also confirmed no new interventions were added to Resident #3's care plan interventions to prevent future falls after a fall on 12/7/24.

Based on observation, interview and record review, the facility failed to revise a care plan for 1 of 21 sampled residents (Resident #20) related to past trauma. Findings include: During an interview, on 2/24/25 at 12:55 PM, Resident #20 and his/her roommate stated that more than one wandering resident had entered their room in the middle of the night via a shared bathroom several times over the course of a few months. Resident #20 and his/her roommate requested that a lock be put on the bathroom door to prevent anyone from accessing their room via the shared bathroom, which was done. Resident #20 became visibly upset, with noticeable anxiety and agitation. His/her voice became louder and s/he was clutching the arms of his/her wheel chair during the interview, stating The staff always forget to lock it! Resident #20 is hearing impaired, and said I wouldn't hear someone come in if my back was to the bathroom door. During this interview, this surveyor observed Resident #20 check the bathroom door, which was unlocked at the time. Per record review, Resident #20 has a Care Plan for Actual Psychosocial Well-being problem related to sexual abuse at a young age dated 10/19/2023. There are no updates in the Care Plan regarding wandering residents entering his/her room, or regarding the need for the bathroom door to always locked from inside the resident's room. During an interview, on 2/26/25 at 1:20 PM, the Director of Nursing and the Clinical Lead both confirmed that Resident #20 should have interventions in his/her Care Plan relating to wandering residents and the need for the bathroom door to be locked at all times, and both confirmed that s/he does not have these interventions in place.

Based on interview and record review, the facility failed to ensure each resident's drug regimen is free from unnecessary [CONDITION(S)] drugs for one of 12 residents (Resident #6) as evidenced by the resident being administered [CONDITION(S)] drugs without adequate monitoring. Findings include: 1. Per record review, orders were placed for two [CONDITION(S)] drugs for Resident #6 on 4/29/21. There is an order for [MEDICATION(S)] (an antidepressant) 30 milligrams a day for anxiety and depression and an order for [MEDICATION(S)] (an antipsychotic medication) 5 milligrams a day for anxiety and depression. The record shows that the [MEDICATION(S)] was increased to 7.5 milligrams on 10/21/21 per resident request. Per review of Resident #6's care plan, there is a care plan focus for depression initiated on 8/11/21 that includes interventions for medications as ordered and AIMS (Abnormal Involuntary Movement Scale) testing per protocol. AIMS testing is used to monitor for side effects of antipsychotics. Per review of assessments in the record, Resident #6 has only received AIMS assessments on 10/12/21 and 10/26/21 since their admission in April of 2021 and the subsequent ordering of [MEDICATION(S)]. There is no evidence in the record of monitoring side effects of antidepressants. There is also no evidence in the record of regular behavior monitoring to help assess for effectiveness of either medication. Per interview on 11/3/21 at approximately 1:30 PM, the Director of Clinical Services confirmed that there is no evidence in the record of monitoring for the [CONDITION(S)] medications, outside of the AIMS assessments.

Based on observation, staff interview, and record review the facility failed to provide adequate supervision of one resident in the applicable sample (Resident # 20). Finding include: Per record review Resident #20 has diagnoses that include intracranial injury, [CONDITION(S)], major depressive disorder, and sexual dysfunction. Progress notes and resident care plans reflect that Resident #20 has a history of frequently exhibiting hypersexual behaviors toward staff and other residents. These behaviors include groping, biting, and soliciting sex from staff, exposing her/himself to others, and following residents around and entering their rooms. Per review of Resident #20's care plan a focused Problem was implemented on 6/13/2018 (prior to the incident) and last reviewed on 9/15/2021 [Resident #20] is at risk of becoming sexually reactive in common areas with a goal listed as [Resident #20] will not display sexual behaviors or inappropriately expose self towards staff or others. Interventions include Staff will redirect [Resident #20] to a private area when acting out sexually in appropriate and [Resident] requires supervision when out of [her/his] room. On 1/8/2020 a care plan was implemented that states [Resident] has exhibited inappropriate behavior and yelling out during group activities and is distracting others. Interventions include [Resident] will have direct supervision while in the dining room. On 10/8/2020 during the lunch meal Resident #20 was left unsupervised. When staff returned a resident who is of the opposite sex reported that Resident #20 had touched her/his breast. A Nurse's Progress Note written on 10/8/2020 at 12:59 PM states Resident (#20) was moaning and pointing during the morning and at meals and was reported to have had inappropriate touching of [another] resident at about 12:20. Just prior to incident, two LNAs [Licensed Nursing Assistants] were in the dining room assisting with feeding and watching the room, then one resident began to vomit and was escorted to [her/his] room. Once [s/he] was [feeling] better, I asked the second LNA to help transfer the resident while I watched the dining room. While I watched the dining room, nothing happened, but the [other resident] sitting next to [Resident #20] seemed uncomfortable and repeatedly looked at [her/him] out of the corner of [her/his] eye. The PCA (patient care attendant) in the room came over to the [other resident] and asked if [s/he] was ok and [s/he] reported that [her/his] breast had been touched by [Resident #20]. They were both done eating at this point and were assisted to their rooms. It seems the touching occurred during a transition of supervision. Incident reported to supervisor. During direct observation on 11/1/2021 at approximately 2:15 PM, Resident #20 was sitting in the living room watching a movie with another resident. There were no staff members providing supervision to Resident #20. During observation on 11/02/21 at 8:52 AM Resident #20 was seen self-propelling her/his wheelchair throughout A wing unsupervised. Staff were observed walking by and entering other residents' rooms. On 11/03/21 at 11:16 AM Resident #20 was observed self-propelling down B-wing hall unsupervised by staff. Per interview with the Director of Nursing and the Director of Clinical Services on 11/3/2021 at 11:42 AM Resident #20 is seen by psych services and has modified clothing to prevent exposure. S/he does tool around and goes to visit other residents. When s/he has socially inappropriate behaviors staff offer trivia and other activities. During interview on 11/3/2021 at approximately 2:00 PM the Director of Clinical Services confirmed that Resident #20's care plan does reflect the need for supervision however, S/he is not always supervised when out of her/his room.

Based on interview and record review, the facility failed to ensure residents who require [CONDITION(S)] receive services, consistent with professional standards of practice, and the comprehensive, person-centered care plan for one of 12 residents (Resident #6). Findings include: 1. Per record review, Resident #6 receives [CONDITION(S)] treatment three days a week on Tuesdays, Thursdays, and Saturdays. Resident #6 has a fistula (an access point for [CONDITION(S)] treatment on the arm in which a vein and an artery are connected) in their left arm. Per review of Resident #6's care plan, there is a care plan focus for [CONDITION(S)]: Resident receives [CONDITION(S)] for [CONDITION(S)] ([CONDITION(S)]) that was initiated on 1/4/21. One of the interventions under this care plan focus is the intervention, Monitor AV shunt (fistula) in left arm every shift for bruit (a rumbling sound you can hear through a stethoscope) and thrill (a vibration that can be felt through the skin). Assessing a fistula for a bruit and thrill ensures that the fistula is working properly. Per review of Resident #6's TAR (treatment administration record), there is no documented evidence that Resident #6's fistula is assessed every shift by staff. A search of the rest of Resident #6's record does not show any documentation of a fistula assessment done every shift. Per interview on 11/3/21 at approximately 9:00 AM, the nurse caring for Resident #6 confirmed that there was nowhere in the record that they could find for documenting a fistula assessment. They also stated that they were not aware that they should be assessing Resident #6's fistula. Per interview on 11/3/21 at approximately 10:00 AM, the Director of Clinical Services confirmed that there is no documented evidence of facility staff assessing Resident #6's fistula every shift.

Based on staff interview and record review, the facility failed to provide regular in-service education to 2 of 5 sampled Licensed Nursing Assistants (LNA). (# 1,3) Findings include: Review of facility education and inservice documents showed that 2 LNAs did not receive the 12 hours of annual inservice education as required by regulation. LNA # 1 received 10.25 hours and LNA #3 received 8.0 hours. At 1:16 PM on 11/3/21, the Director of Clinical Services confirmed that there is no evidence that staff # 1 and #3 had received the required 12 hours of annual training.

Based upon interview and record review, the facility failed to ensure 1 resident [Res. #29] of 2 residents with indwelling catheters received the appropriate care and services as ordered by the Physician regarding catheter care and treatment. Findings include: A review of Res. #29's medical record reveals the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of Suprapubic Catheter: A Quick Guide to Care of, Removal, and Changing :[https://suprapubiccatheter.org/suprapubic-catheter-a-quick-guide-to-care-of-removal-and-changing/] Without proper treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . It's important that procedures for suprapubic catheter care be followed and that care occurs in a timely manner. Care includes the daily changing of dressing . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record [TAR] for December 2020 reveals that the Supra Pubic site was not documented as being done twice a day per Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [12/3, 12/11, 12/13, 12/14, 12/15, 12/19, 12/23, 12/26, 12/28, 12/30, 12/31/20] Review of the TAR for January 2021 reveals that the cleansing of the Supra Pubic site was not documented as being done twice a day per Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [1/4, 1/6, 1/7, 1/9, 1/11, 1/13, 1/14, 1/18, 1/19, 1/20, 1/24, 1/27, 1/28, 1/29, 1/30, 1/31] Review of the TAR for February 2021 reveals that the cleansing of the Supra Pubic site was not documented as being done twice a day per Physician on 21 of 28 days: [2/2, 2/4, 2/5, 2/6, 2/8, 2/10, 2/12, 2/14, 2/15, 2/16, 2/17, and 2/19 through the end of the month]. Review of the TAR for March 2021 reveals that the cleansing of the Supra Pubic site was not documented as being done twice a day per Physician on 14 of 31 days: [3/1, 3/2, 3/3, 3/4, 3/6, 3/7, 3/12, 3/13, 3/16, 3/18, 3/19, 3/23, 3/25, 3/30]. Further record review reveals no documentation as to why the Supra Pubic site was not cleansed and a dressing applied as ordered on the above dates, or that the Physician was notified of the missed treatments. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR reveals dates left blank as the order not being completed on 15 of 31 days [1/4, 1/5, 1/6, 1/13, 1/14, 1/18, 1/19, 1/20, 1/24, 1/25, 1/27, 1/28, 1/29, 1/30, 1/31/21]. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review reveals no documentation as to why the Supra Pubic catheter was not flushed every shift as ordered on the above dates, or that the Physician was notified of the missed treatments. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of the Treatment Administration Record [TAR] for Res. #29 for December 2020, the Supra Pubic Catheter is documented as being changed on 12/17/20, making the due date for the next change 1/17/21. Review of the TAR for January 2021 reveals an order to Change Indwelling Supra Pubic Catheter every 4 weeks- Due 1/17/21. Review of the TAR records that area to initial the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per record review of Nursing Notes and Nurse Practitioner Notes for January 2021, there is no documentation that the Supra Pubic Catheter was changed on that date as ordered. Review of the Treatment Administration Record [TAR] for February 2021 records the date to change the Supra Pubic Catheter as due on 2/17/21. Review of the TAR records that area to initial the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per record review of Nursing Notes and Nurse Practitioner Notes for February 2021, there is no documentation that the Supra Pubic Catheter was changed on that date as ordered. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record [TAR] for April 2021 reveals an order to Change Indwelling Supra Pubic Catheter every 4 weeks- Due 4/2/21. Review of the TAR records that area to initial the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of the TAR for Res. #29 for April 2021, the Supra Pubic Catheter is documented as being changed on 4/6/21. Nursing Progress Notes dated 4/6/21 record Suprapubic catheter changed, as was due to be changed 4/2 but not done. An interview and record review were conducted with the Director of Nursing [DON] on 4/21/21 at 11:50 AM. The DON was able to demonstrate through Nurse Practitioner documentation that the Supra Pubic Catheter was changed sometime during January 2021. The DON confirmed that the Nurse Practitioner notes, electronically signed on 1/23/21, did not record the date the catheter was changed, and did not demonstrate that the catheter was changed on the due date of 1/17/21, 4 weeks after the last change as ordered by the Physician. The DON also confirmed there was no documentation that the Supra Pubic Catheter was changed at all during February 2021, and that per Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also confirmed that Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based upon interview and record review, the facility failed to ensure Care Plan interventions were implemented for 1 resident [Res. #29] of 2 residents with indwelling catheters regarding catheter care and treatment. Findings include: A review of Res. #29's medical record reveals the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Res. #29's Care Plan includes the resident identified as requires the use of a Suprapubic Catheter secondary to retention due to Bladder Outlet Obstruction, history of [CONDITION(S)] and End Stage Renal Disease requiring [CONDITION(S)]. Care Plan interventions for the resident include: Medications as ordered, Irrigation per MD orders, and Care/changing of urinary catheter per facility policy. 1. Review of Physician MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Per record review of Res. #29's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] & 12/30/20. Per review of Res. #29's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of Res. #29's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of Res. #29's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review reveals no documentation as to why the medication was not administered per the Care Plan intervention Medications as ordered on the above dates, or that the Physician was notified of the missed doses. 2. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR reveals dates left blank as the order not being completed on 15 of 31 days [1/4, 1/5, 1/6, 1/13, 1/14, 1/18, 1/19, 1/20, 1/24, 1/25, 1/27, 1/28, 1/29, 1/30, 1/31/21]. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review reveals no documentation as to why the Supra Pubic site was not flushed/irrigated as ordered per the Care Plan intervention Irrigation per MD orderson the above dates, or that the Physician was notified of the missed treatments. 3. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record [TAR] for December 2020 reveals that the Supra Pubic site was not documented as being done twice a day per Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [12/3, 12/11, 12/13, 12/14, 12/15, 12/19, 12/23, 12/26, 12/28, 12/30, 12/31/20] Review of the TAR for January 2021 reveals that the cleansing of the Supra Pubic site was not documented as being done twice a day per Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [1/4, 1/6, 1/7, 1/9, 1/11, 1/13, 1/14, 1/18, 1/19, 1/20, 1/24, 1/27, 1/28, 1/29, 1/30, 1/31] Review of the TAR for February 2021 reveals that the cleansing of the Supra Pubic site was not documented as being done twice a day per Physician on 21 of 28 days: [2/2, 2/4, 2/5, 2/6, 2/8, 2/10, 2/12, 2/14, 2/15, 2/16, 2/17, and 2/19 through the end of the month]. Review of the TAR for March 2021 reveals that the cleansing of the Supra Pubic site was not documented as being done twice a day per Physician on 14 of 31 days: [3/1, 3/2, 3/3, 3/4, 3/6, 3/7, 3/12, 3/13, 3/16, 3/18, 3/19, 3/23, 3/25, 3/30]. 4. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of the Treatment Administration Record [TAR] for Res. #29 for December 2020, the Supra Pubic Catheter is documented as being changed on 12/17/20, making the due date for the next change 1/17/21. Review of the TAR for January 2021 reveals an order to Change Indwelling Supra Pubic Catheter every 4 weeks- Due 1/17/21. Review of the TAR records that area to initial the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per record review of Nursing Notes and Nurse Practitioner Notes for January 2021, there is no documentation that the Supra Pubic Catheter was changed on that date as ordered. Review of the Treatment Administration Record [TAR] for February 2021 records the date to change the Supra Pubic Catheter as due on 2/17/21. Review of the TAR records that area to initial the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per record review of Nursing Notes and Nurse Practitioner Notes for February 2021, there is no documentation that the Supra Pubic Catheter was changed on that date as ordered. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record [TAR] for April 2021 reveals an order to Change Indwelling Supra Pubic Catheter every 4 weeks- Due 4/2/21. Review of the TAR records that area to initial the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of the TAR for Res. #29 for April 2021, the Supra Pubic Catheter is documented as being changed on 4/6/21. Nursing Progress Notes dated 4/6/21 record Suprapubic catheter changed, as was due to be changed 4/2 but not done. An interview and record review were conducted with the Director of Nursing [DON] on 4/21/21 at 11:50 AM. The DON was able to demonstrate through Nurse Practitioner documentation that the Supra Pubic Catheter was changed sometime during January 2021. The DON confirmed that the Nurse Practitioner notes, electronically signed on 1/23/21, did not record the date the catheter was changed, and did not demonstrate that the catheter was changed on the due date of 1/17/21, 4 weeks after the last change as ordered by the Physician. The DON also confirmed there was no documentation that the Supra Pubic Catheter was changed at all during February 2021, and that per Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed that interventions were not implemented per Res. #29's Care Plan regarding Care/changing of urinary catheter per facility policy. An interview and record review were conducted with the Director of Nursing [DON] on 4/21/21 at 11:50 AM. The DON confirmed that interventions were not implemented per Res. #29's Care Plan regarding Medications as ordered, Irrigation per MD orders, and Care/changing of urinary catheter per facility policy.

Based on staff interview and record review, the facility failed to ensure individual financial records are available to 27 of 27 applicable residents through quarterly statements and upon request. Findings include: During interview on 4/21/21, the Business Office Manager (BOM) stated that the facility does not provide quarterly statements for residents with cash accounts at the facility. On 04/20/21 at 03:13 PM, the BOM and the facility Administrator confirmed that 27 residents are not provided quarterly statements as required by regulation.

Based on observation, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Findings include: Per observations on 03/10/21, facility staff failed to utilize proper signage for infection control practices. Per observations at 10:45 AM, there were no signs visible before entering A-Wing that indicated the unit had COVID-19 positive residents. The unit Licensed Practical Nurse (LPN) identified that there were three confirmed COVID-19 positive residents on the unit: Resident #1 (room [ROOM NUMBER]), #2 (room [ROOM NUMBER]), and #3 (room [ROOM NUMBER]). At 10:55 AM, rooms [ROOM NUMBER] had no signage indicators on the door identifying that they were COVID-19 positive residents and on precautions. Two residents were observed in the hallway without masks; one of the residents, the Director of Nursing Services (DNS) identified as a wanderer. (please change wanderer to person who wanders - to use person-first language) At 11:00 AM on 03/10/21, the DNS stated that it is his/her expectation that droplet/aerosol precaution signs should be visible on confirmed or suspected COVID-19 positive residents' doors. S/he confirmed that Resident #1, #2, and #3's doors had no signage indicating that they were on precautions. At 11:25 AM, the DNS confirmed that the facility Standard/Transmission Based Policy and Procedures stated that a precaution sign will be placed on a resident's door to alert staff and visitors to see the nurse before entering room of individuals on precautions. S/he confirmed that signs were not present on A-wing per policy. S/he stated that all residents on A-wing are on droplet precautions and s/he confirmed that there is no signage indicating this to staff before entering the A-wing unit.

Based on record review and staff interviews, the facility failed to assure that 1 of 4 residents in the applicable sample (Resident #4) remained free from physical abuse. Findings include: Per record review, Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Per record review the resident is known to have multiple behaviors that include but are not limited to putting herself onto the floor at will. Per review of the facility's internal investigation along with written witness, alleged perpetrator statements, and employee interviews, Resident #4 was the victim of a physically abusive event on (MONTH) 24, 2019. The Licensed Practical Nurse (LPN) who was contracted by the facility from a Travel Nurse Agency, was observed being visibly upset when dealing with the resident who was being disruptive and the LPN told staff to not baby the resident. The resident had been lowered to the floor by staff and was sitting on the floor in the hallway of the dementia unit. The LPN was then observed going behind the resident and lifting Resident #4 up from the floor and carrying them to their room. Upon exam, Resident #4 was observed to have bruises under both arms and both sides of their rib cage, consistent with where the LPN's hands would have carried the resident. The regulation interpretive guidelines clearly indicate that the facility assumes the responsibility of ensuring the safety and well-being of the resident. It is the facility's responsibility to ensure that all staff are trained and knowledgeable in how to react and respond appropriately to resident behavior. All staff are expected to be in control of their own behavior, are to behave professionally, and should understand how to work with the nursing home population.

Based on staff interviews and record review, the facility failed to protect and promote the rights of 1 of 4 residents in the applicable sample (Resident #4). The facility failed to treat Resident #4 with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing the resident's individuality. Findings include: Per review of written witness and alleged perpetrator statements, on (MONTH) 24, 2019, Resident #4 was observed having behaviors and being disruptive. The resident has a written care plan in place addressing these behaviors. However, the Licensed Practical Nurse (LPN) became visibly upset and stated to a Licensed Nurse Aide (LNA) stop babying the resident and came around behind Resident #4 and picked the resident up off the floor and carried them to their room. A subsequent exam showed Resident #4 had bruises under both arms and both sides of their rib cage, consistent with where the LPN's hands would have carried the resident. The LPN in question was subsequently suspended and eventually their agency contract was terminated citing unprofessional behavior. The regulation interpretive guidelines clearly indicate that all staff need to take into account that all interactions should be to assist the resident in maintaining and enhancing resident self-esteem and self-worth. That residents should be treated with dignity and respect. That staff must respect each resident's individuality. See also F600.

Based on record review and confirmed by staff interview the facility failed to ensure that 1 of 2 sampled residents were free from unnecessary medications related to excessive duration (Resident #2). This is a repeat citation from 3/27/19. The findings include the following: Per record review on 10/21/19, Resident #2 had a physician's orders [REDACTED]. (milligrams) by mouth daily. [MEDICATION NAME] is a medication used for high cholesterol levels. The physician discontinued the medication on 10/14/19. Per review of the Medication Administration Record [REDACTED]. Confirmation was made by the Director of Nurses on 10/21/19 at approximately 3:30 PM, that the medication has been administrated for past 6 evenings despite the order to discontinue.

Based on record review and staff interview, the facility failed to ensure that all the required members of the interdisciplinary team (IDT) were involved in preparing the comprehensive care plan for 11 of 19 residents sampled (Residents # 4, 5, 6, 14, 19, 23, 27, 30, 34, 43, and 45). In addition, 3 of 19 residents sampled did not have care plans revised to reflect their current status, (Resident #4, 27, and 30). Findings include: 1. Resident #5 had a care plan meeting held on 7/9/19. The Social Service care plan meeting documentation lists the disciplines attending, and there was no LNA, Dietary staff, or MD/NP input documented. 2. Resident #6 had a care plan meeting held on 5/14/19. The Social Services note indicated that the dietary staff and MD/NP were not present at the meeting. There was no documentation to indicate that the absent members of the team had provided input into the care plan meeting 3. Resident # 14 had a care plan meeting held on 9/30/19. The Social Services note documenting attendance does not show that activities staff, dietary staff, or an LNA were at the meeting. There was no documentation provided by social services to indicate that the absent members of the team had provided input to the care plan meeting. 4. Resident #45 had a care plan meeting on 7/3/19. Social Services note indicated that there was no LNA, MD/NP, or dietary staff who attended the care plan meeting, or documentation that indicated they had any input in development of the care plan. 5. Resident #23 had a care plan meeting on 8/1/19. Social Services documentation did not include the presence of NP/MD, dietary staff, or LNA input at this meeting,or documentation that indicated they had any input in development of the care plan. Per interview on 10/1/19 at 3:50 PM, the Director of Social Services confirmed that not all the interdisciplinary team members were present at the care plan meetings, or that the facility had a process for documenting the input of team members who did not attend. 6. Per review of the of the social service notes for Resident #30, who had a care plan meeting dated 08/28/19 at approximately 1 PM, does not identify the presence of all members of the Interdisciplinary Team (IDT). The members who were not present are the attending physician/nurse practitioner, a nurse's aide with the responsibility for the resident and a member of the food and nutrition services. The Director of Nurse (DNS) confirmed during interview on 10/1/19 and 10/2/19 that the full IDT has not consistently attended the care plan meetings, nor does the facility have a process for documenting the input of team members who did not attend. Also, per review of the person-centered care plan, last updated on 03/04/19, identifies that Resident #30 receives [MEDICATION NAME] 12.5 mg (milligrams) by mouth twice a day and 25 mg at bedtime. The medication was discontinued by the physician on 09/02/19. This was confirmed by the DNS on 10/03/19 at 2 PM via telephone and identifies that the care plan does not reflect the resident's current status. 7. Per review of the person-centered care plan for Resident #4, last updated on 03/01/19 identifies that the resident receives insulin daily. The insulin is no longer ordered. The plan also identifies that the resident has pain related to kidney stones. The resident required surgical intervention to extract the stones on 03/14/19. There is no evidence in the care plan that identifies the intervention. Confirmation was made by the DNS on 10/02/19 at 8:30 AM, that the care plan does not reflect the resident's current status. 8. Per review of the of the Interdisciplinary Care Plan Meeting Record for Resident #27, who had a care plan meeting dated 08/22/19, does not identify the presence of all members of the Interdisciplinary Team (IDT). The members who were not present are the attending physician/nurse practitioner, a nurse's aide with the responsibility for the resident, a member of the food and nutrition services. The Director of Nurse (DNS) confirmed during interview on 10/1/19 and 10/2/19 that the full IDT have not consistently attended the care plan meetings, nor does the facility have a process for documenting the input of team members who did not attend. Also, per review of the Minimum Data Set (MDS) mandated assessment dated [DATE], identifies that the Resident #27 is totally dependent on staff for transfer between bed/chair/standing position by 2 staff who physically assist. The resident requires support of 2 staff members for ambulation in his/her room and/or corridor. Per review of the person-centered-care plan, last updated on 06/20/18 identifies that Resident #27, is at risk for falls/injury and walks all day long. Confirmation was made by the DNS on 10/02/19 that the person-centered care plan does not reflect Resident #27's current status. 9. Per review of the of the social service notes for Resident #19, who had a care plan meeting dated 07/30/19 at approximately 1:38 PM, does not identify presence all members of the Interdisciplinary Team (IDT). The members who were not present are the attending physician/nurse practitioner, a nurse's aide with the responsibility for the resident and a member of the food and nutrition services. The Director of Nurse (DNS) confirmed during interview on 10/1/19 and 10/2/19 that the full IDT have not consistently attended the care plan meetings, nor does the facility have a process for documenting the input of team members who did not attend. 10. Resident #34 had a care plan meeting on 8/27/19. The Social Services note documenting attendance indicates that only social services, nursing and activities staff were present, none of the other required members of the Interdisciplinary team (IDT) contributed to or attended the meeting as required. 11. Resident #43 had a care plan meeting on 9/26/19. The Social Services note documenting attendance indicates that only social services, nursing and activities staff were present, none of the other required members of the Interdisciplinary team (IDT) contributed to or attended the meeting as required. Per interview on 10/1/19 at approximately 2:09 PM The Director of Clinical Services confirmed that not all the interdisciplinary team members were present at the care plan meetings as required, and there is no process in place to consistently get input from those team members who did not attend.

Based on observation, staff and resident interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. This has the potential to affect all residents of the facility Findings include: Per interview on 9/30/19 at 10:45 AM, the Head Cook (HC) stated that there is no full time Registered Dietician or Food Service Director. The HC stated that h/she was an LNA (Licensed Nursing Assistant) and had been the HC for approximately 2 months. The Head cook also confirmed that h/she had no formal training in the role of Dietary/kitchen manager. The HC stated that food storage and food temperatures were not being properly recorded due to lack of training and qualified staff. On 10/1/19, a dietary aide stated during interview that h/she did not have enough training to do the job properly. During the 3 survey days, staff from other nursing facilities were observed assisting in the kitchen. Review of the kitchen schedule showed only 1 dietary staff on duty on several occasions. On 10/2/19, the Maintenance Director was observed doing dishes. On 10/2/19 at 11:30 AM, the Administrator and Director of Operations confirmed during interview the lack of qualified staff is due to non-qualified management overseeing the dietary department.

Based on staff interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. this has the potential to affect all residents of the facility. Findings include: Per interview on 9/30/19 at 10:45 AM, the Head Cook (HC) stated that there is no full time Registered Dietician or Food Service Director. The HC stated that h/she was an LNA (Licensed Nursing Assistant) and had been the HC for approximately 2 months. The Head cook also confirmed that h/she had no formal training in the role of Dietary/kitchen manager. On 10/01/19 at 11:01 AM, the facility Administrator confirmed there is not a full time Registered Dietician and that there is not a Dietary Director in place that meets regulatory requirements.

Based on record review and staff interview, the physician failed to ensure that the onsite review of the resident's total program of care included necessary lab testing and medication adjustments for 1 of 3 residents reviewed (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital after surgical insertion of a Cardiac Pacemaker. The resident had been on a long -term therapy of the anticoagulant medication [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation (A-Fib), and was admitted with orders for 1 mg. daily 6 days per week, with 2 mg. dose to be given on Mondays. The resident was seen by the physician at the facility on [DATE] for the new admission, and ordered therapeutic clotting times testing (PT/INR) by blood draw sent out to the lab on [DATE]. Per review of the record, the resident's lab results were not sent to the facility or the attending physician. There was no evidence that the physician had reviewed the results to make possible adjustments to the [MEDICATION NAME] dosage. The resident was seen at the facility by the same physician on [DATE], discussing the resident's general status, as well as family plan to have the resident discharge to home with their support, and that the Pacemaker was working well. There was no mention of the [MEDICATION NAME] therapy or necessary lab monitoring associated with use. On [DATE], this same attending physician made a facility visit to the resident, commenting that the resident was not feeling well, and that their appetite was poor. The MD questioned a Urinary Tract Infection [MEDICAL CONDITION], and ordered a urinalysis. There was no mention in the visit notes regarding the [MEDICATION NAME] Therapy or associated lab testing. On [DATE], a different attending physician from the same medical practice made a visit to the resident. The physician noted that the resident had blisters on both heels presumably from their footwear and refusing to remove them. The MD also noted that there was a probable UTI but that the lab results had not returned from the urinalysis. Again there was no mention of the [MEDICATION NAME] use, PT/INR testing, and possible adjustment made to the [MEDICATION NAME] based on the results. The resident was sent to the hospital emergently on [DATE] with Gastro- Intestinal bleeding, where they received Vitamin K Prodium and 3 Units of blood transfused, and sent back to the facility with Comfort Care orders from the Medical Director who saw them at the Emergency Department. The resident was discharged to home on [DATE] with a Hospice referral, and died at home on [DATE] The Medical Director is also an attending physician in the same practice as the previous physicians, and in a note written on [DATE], stated to the family that the anticoagulation therapy is usually strictly monitored but was not done. Per review of the other residents (one current and one discharged to home) at the facility taking [MEDICATION NAME], the lab testing intervals were ordered between 1 -3 weeks apart depending on the PT/INR results. Resident #1 had not been tested since [DATE], a time period of almost 6 weeks, prior to the GI bleed identified on [DATE]. Per interview on [DATE] at 8:40 AM, the consultant Pharmacist confirmed that the longest gap recommended for a very stable recipient of [MEDICATION NAME] would be 4 weeks at the longest, but is usually done 1 -3 weeks apart per the results of the lab reports and MD decision of when to test again next. Per interview on [DATE], the Director of Nursing confirmed that the resident had not had a PT/INR ordered since [DATE].

Based on record review and interviews, the facility failed to ensure that residents were free from neglect for 1 of 3 residents reviewed (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital after surgical insertion of a Cardiac Pacemaker. According to the Discharge Plan, the resident wished to return home after rehab. The resident had been on a long-term therapy of the anticoagulant medication [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation (A-Fib), and was admitted with orders for continued anticoagulant therapy. The resident was last checked for therapeutic clotting times (PT/INR) by blood draw sent out to the lab on [DATE], but the facility or the attending physician did not receive the results. Per review of the record, the resident was sent to the emergency room at approximately 3:00 AM on [DATE] due to bleeding from the rectum and lethargic state. The resident was diagnosed with [REDACTED]. Resident #1 was treated with Vitamin K Prodium and transfused with 3 units of blood, and returned to the facility on comfort care when the family decided to not put him/her through any further interventions at the hospital. The resident was discharged to home on [DATE] with family caregivers and a Hospice referral, and died at home on [DATE]. The attending physician visits on [DATE], [DATE], and [DATE] did not document any reference to checking for PT/INR values by lab testing, or the medication adjustments possibly needed related to the results of the test. The consultant Pharmacist for the facility completed a Medication Regime Review on [DATE] and again on [DATE], and did not detect that the resident was not receiving PT/INR lab testing per normal protocol for [MEDICATION NAME] treatment and make the recommendation to the MD. Two of the nurses caring for the patient had noted bloody stools on both the day shift and the evening shift on [DATE], and did not notify the physician or the Director of Nursing of the change in condition of the resident. The nurse working overnight who sent the resident to the hospital at 0300 on [DATE] also did not alert the Director of Nursing, who had instructed staff to notify them of any transfers to the hospital even at night. The care plan for Anticoagulant use was not followed for the proper monitoring of the medication and reporting bleeding to the physician. Per review of this record, and multiple interviews, there was a facility multi-system failure to prevent medical neglect of Resident #1, and there was serious harm as a result. See citations at F580, F656, F658, F711, F756, and F757 for more detail and confirmations.

Based on record review and staff interview, the facility failed to provide services that meet professional standards of quality regarding nursing practice for a resident on anticoagulant therapy for 1 of 3 residents reviewed (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital after surgical insertion of a Cardiac Pacemaker. The resident had been on a long-term therapy of the anticoagulant medication [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation (A-Fib), and was admitted with orders for 1 mg. daily 6 days per week, with 2 mg. dose to be given on Mondays. The resident was seen by the physician at the facility on [DATE] for the new admission, and ordered therapeutic clotting times testing (PT/INR) by blood draw sent out to the lab on [DATE]. Per review of the record, the resident's lab results were not sent to the facility or the attending physician. The [MEDICATION NAME] was administered daily to the resident for nearly 6 weeks, and nursing staff failed to identify that there was no PT/INR results on file and no orders for labs to monitor the PT/INR level, which is typically monitored at the very least on a monthly basis. Nursing staff did not ensure a prompt response to the resident having bloody stools by failing to call the physician to report the change in condition, resulting in a delay of treatment. Per review of the nurse progress notes, the nurse working the day shift on [DATE] wrote that the resident had large incontinent BM (bowel movement) in bed which was dark red with blood clots. Per interview on [DATE] at 11:05 AM, the nurse stated that they had passed the information to the oncoming nurse at change of shift, and thought that they had told the nurse supervisor, but had not called the physician regarding this finding. Per review of the evening nurse shift note on [DATE], the nurse wrote Res. had lg. bloody stool prior to returning to bed. Per interview on [DATE] at 2:20 PM, the nurse stated that they had not called the physician regarding the bleeding. Per review of the record, the resident was sent to the emergency room at approximately 3:00 AM on [DATE] due to bleeding from the rectum and lethargic state. The resident was diagnosed with [REDACTED]. The resident required Vitamin K therapy and a transfusion of 3 units of blood to be stabilized with adequate clotting ability. The resident returned to the facility on [DATE] with comfort care orders, went home with family on [DATE] with a Hospice referral, and died at home on [DATE]. Reference for nursing care of a patient on anticoagulant therapy: Lippincott Manual of Nursing Practice (8th ed.). Wolters Kluwer Health/ Lippincott[NAME] & Wilkins, pg. ,[DATE].

Based on record review and staff interview, facility nursing staff failed to report a significant clinical change in status to the physician for 1 of 3 residents sampled (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital after surgical insertion of a Cardiac Pacemaker. According to the Care Plan Discharge Plan, the resident wished to return home to their own apartment after rehab. The resident had been on a long -term therapy of the anticoagulant medication [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation (A-Fib), and was admitted with orders for 1 mg. daily 6 days per week, with 2 mg. dose to be given on Mondays. The resident was last checked for therapeutic clotting times (PT/INR) by blood draw sent out to the lab on [DATE], but those results were not communicated to the facility. Per review of the record, the resident was sent to the emergency room at approximately 3:00 AM on [DATE] due to bleeding from the rectum and lethargic state. The resident was diagnosed with [REDACTED]. Per review of the nurse progress notes, the nurse working the day shift on [DATE] wrote that the resident had large incontinent BM (bowel movement) in bed which was dark red with blood clots. Per interview on [DATE] at 11:05 AM, the nurse stated that they had passed the information to the oncoming nurse at change of shift, and thought that they had told the nurse supervisor, but had not called the physician regarding this finding. Per review of the evening nurse shift note on [DATE], the nurse wrote Res. had lg. bloody stool prior to returning to bed. Per interview on [DATE] at 2:20 PM, the nurse stated that they had not called the physician regarding the bleeding. Review of the nurse's note dated [DATE], it was noted that the resident had black stool x 1, liquid and a blood pressure reading ,[DATE] (abnormally low), and that resident was awake with care (time not indicated). Later at 0245 AM on [DATE], the nurse documented there was increased redness in lg. stool and that resident was not responding to attempts to wake them. The nurse called the physician, called EMS and the resident was transported to the hospital at 0300 AM. The nurse's note also included that the family was notified, and the report from the ED was that the resident was receiving a blood transfusion for a PT/INR of greater than 15. The resident returned to the facilty on comfort care on [DATE], was discharged to home on [DATE] with a Hospice referral, and died at home on [DATE]. Per interview on [DATE] at 2:40 PM, the Director of Nursing stated that they were not alerted of the transport of Resident #1 to the hospital as staff were instructed to do for any transfer, nor were they aware of the bloody stools noted by three different nurses until the following day, [DATE].

Based on record review and interview, the Licensed Pharmacist failed to ensure that an irregularity was identified and reported to the facility for 1 of 3 residents reviewed (Resident #1) Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital after surgical insertion of a Cardiac Pacemaker. The resident had been on a long -term therapy of the anticoagulant medication [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation (A-Fib), and was admitted with orders for 1 mg. daily 6 days per week, with 2 mg. dose to be given on Mondays. The resident was seen by the physician at the facility on [DATE] for the new admission, and was ordered therapeutic clotting times testing (PT/INR) by blood draw sent out to the lab on [DATE]. Per review of the record, the resident's lab results were not sent to the facility or the attending physician. There was no evidence that the physician had reviewed the results to make possible adjustments to the [MEDICATION NAME] dosage. The facility did not monitor lab results to detect missing lab tests for almost 6 weeks. When the resident had bloody stools noted by two different nurses on day and evening shifts on [DATE], the physician was not notified of the change in condition. The resident was sent to the hospital for treatment for [REDACTED]. The resident returned to the facility on comfort care, went back to their apartment with Hospice services on [DATE], and died there on [DATE]. Per the Consultant Pharmacist report made on [DATE], there were no irregularities noted, despite the fact that there were no results of lab monitoring required for the safe and therapeutic use of [MEDICATION NAME] since the resident's admission. The consultant Pharmacist also did a review on [DATE], and also had no recommendations or noted any irregularities in the resident's medication review. Per interview on [DATE] at 8:40 AM, the consultant Pharmacist confirmed that part of the required monthly consult is to review lab values, possible medication interactions and adverse effects in the medication regime. The Pharmacist confirmed that they had not addressed the lack of lab testing and monitoring of the therapeutic levels of the anticoagulant in the monthly review report.

Based on record review and staff interview, the facility failed to ensure that residents were free from unnecessary drugs for 1 of 3 residents reviewed (Resident #1), who did not have adequate monitoring of lab values to ensure medications were in therapeutic ranges. Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital after surgical insertion of a Cardiac Pacemaker, and was admitted on a long -term therapy of the anticoagulant medication [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation (A-Fib). The Resident was admitted with orders for [MEDICATION NAME] 1 mg. daily 6 days per week, with 2 mg. dose to be given on Mondays. The resident was seen by the physician at the facility on [DATE] for the new admission, and ordered therapeutic clotting times testing (PT/INR) by blood draw sent out to the lab on [DATE]. Per review of the record, the resident's lab results were not sent to the facility or the attending physician. There was no evidence that the physician had reviewed the results to make possible adjustments to the [MEDICATION NAME] dosage. Per the Consultant Pharmacist report made on [DATE], there were no irregularities noted, despite the fact that there were no results of lab monitoring required for the safe and therapeutic use of [MEDICATION NAME] since the resident's admission. The consultant Pharmacist also did a review on [DATE], and also had no recommendations or noted any irregularities in the resident's medication review. The resident had not received the necessary lab monitoring for close to 6 weeks, and ended up being sent to the hospital on [DATE] with Gastro-Intestinal bleeding that required 3 units of blood transfused and Vitamin K therapy. The resident was put on comfort care at that time, and returned to the facility on [DATE]. Resident #1 was discharged to home with family on [DATE] with a Hospice referral, and died at home on [DATE]. Per interview on [DATE] at 8:40 AM, the consultant Pharmacist confirmed that part of the required monthly consult is to review lab values, possible medication interactions, and adverse effects in the medication regime. The Pharmacist confirmed that they had not addressed the lack of lab testing and monitoring of the therapeutic levels of the anticoagulant in the monthly review report.

Based on record review and staff interview, the facility failed to ensure that the care plan interventions were implemented for 1 of 3 residents reviewed (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital after surgical insertion of a Cardiac Pacemaker. The resident had been living alone in their own apartment, and it was his/her wish to go back there after rehab. The resident had been on a long-term therapy of the anticoagulant medication [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation (A-Fib), and was admitted with orders for 1 mg. daily 6 days per week, with 2 mg. dose to be given on Mondays. The plan of care included the use of anticoagulant medication and listed: Problem/Need related to: New Pacemaker, A-Fib, resulting in Risk of bleeding; Goal listed related to the care plan area was: Will be free of bleeding; The following interventions in this care plan were listed: Provide anticoagulant therapy per physician order, Monitor for bruising, If bleeding noted, contact physician and follow first aide measures to stop bleeding, Monitor and report lab results to physician, Avoid bumping and handle gently when hands on care provided, Monitor blood pressure every shift. Problem/Need related to: New Pacemaker, A-Fib, resulting in Risk of bleeding; Goal listed related to the care plan area was : Will be free of bleeding. Per review of the resident's record, the appropriate lab monitoring was not completed since [DATE], and the physician was not notified when bleeding was noted by nursing on [DATE]. Per interview on [DATE], the Director of Nursing confirmed that the plan of care was not implemented as written. The resident was seen by the physician at the facility on [DATE] for the new admission, and ordered therapeutic clotting times testing (PT/INR) by blood draw sent out to the lab on [DATE]. Per review of the record, the resident's lab results were not sent to the facility or the attending physician. There was no evidence of any physician orders [REDACTED]. Nursing did not monitor lab results as directed by the plan of care, so did not detect missing lab tests for a period of almost 6 weeks. When the resident had bloody stools noted by two different nurses on day and evening shifts on [DATE], the physician was not notified of the change in condition as required by the plan of care. The resident was sent to the hospital for treatment on [DATE] which included Vitamin K and 3 units of blood transfused. The resident returned to the facility on comfort care, went back to their apartment with Hospice services on [DATE], and died there on [DATE].

Based on record review and staff interview, the facility failed to assure that the medical record of 1 of 3 residents reviewed (Resident #1) was accurately and completely documented. Findings include: 1. A faxed medical order from a podiatrist (doctor with foot specialty) was received by the facility on 8/21/17 at 3:48 PM. This medical order included specifics regarding an antibiotic medication, a request for a vascular (blood flow) consultation appointment, and orders for care of a wound on the right foot which was found to have wet gangrene (serious infection) and resting ischemia (lack of blood flow). Per review of the medical record of Resident #1, the vascular appointment was made for 8/24/17 at noon, and the antibiotic was started. The dressing order specified that the right foot wound should be washed with soap and water, patted dry, and a wet to dry dressing applied twice daily. The nursing staff did not transcribe the foot care order as per protocol, thus resulting in missed foot cleansing and dressing changes twice on 8/22/17, and once during the day of 8/23/17. During an interview on 9/12/17 at 1:55 PM, the Registered Nurse (RN) supervisor confirmed that the medical order for cleansing and dressing the right foot of Resident #1 was not transcribed until 8/23/17 on the evening shift, resulting in 3 missed treatments. 2. Per review of a skin sheet for Resident #1, dated 8/23/17 and signed by a Licensed Practical Nurse (LPN), the LPN transcribed the physician's orders [REDACTED]. The order for foot care was incorrectly transcribed as being daily, not twice daily as ordered. During an interview on 9/12/17 at 1:55 PM, the RN supervisor confirmed that the medical order was for twice daily cleansing and dressing change on the right foot of Resident #1. 3. A corresponding nurse note to the skin sheet of 8/23/17 (2 PM-10 PM), signed by the same LPN who signed the skin sheet, documented that the foot was washed and dressing applied as per the physician's orders [REDACTED].#1 had an appointment next morning at hospital. During an interview on 9/12/17 at 2:39 PM, the LPN who did the dressing change and foot care on the evening of 8/23/17, stated he/she examined the right foot of Resident #1 at approximately 8:30 PM, discovered that the tissue on the foot looked dead and there were maggots (fly larvae) on the toe area. When asked by the surveyor whether the LPN had told anyone about this finding, the LPN stated that the night nurse coming on at 10:00 PM was advised. The LPN did not document accurately the condition of the foot wound either on the skin sheet or in the nurse note. The lack of accurate and timely medical order transcription resulted in failure to provide at least 3 cleansing and dressing change treatments from the evening of 8/21/17 to the evening of 8/23/17. Also the lack of accurate documentation of the deteriorated condition of the tissue and the presence of maggots on the wound on the evening of 8/23/17 resulted in inaction by the night nurse, as well as the day nurse of 8/24/17. The lack of notification/information resulted in an inability by either the physician or the nursing administration to take prompt action for the medical care of Resident #1 from 8/23/17 evening forward. Resident #1 went to the hospital vascular appointment on the morning of 8/24/17 where medical staff discovered a severely deteriorated, gangrenous right foot infested with maggots. Resident #1 was admitted to hospital and underwent an emergency surgery and intravenous antibiotic treatment.

Based on record review and staff interview, the facility failed to provide services according to professional standards of practice for 1 of 3 residents reviewed (Resident #1) regarding implementing physician orders. Findings include: A faxed medical order from a podiatrist (doctor with foot specialty) was received by the facility on 8/21/17 at 3:48 PM. This medical order included specifics regarding an antibiotic medication, a request for a vascular (blood flow) consultation appointment, and orders for care of a wound on the right foot which was found to have wet gangrene (serious infection) and resting ischemia (lack of blood flow). Per review of the medical record of Resident #1, the vascular appointment was made for 8/24/17 at noon, and the antibiotic was started. The dressing order specified that the right foot wound should be washed with soap and water, patted dry, and a wet to dry dressing applied twice daily. The nursing staff did not transcribe the foot care order as per protocol, thus resulting in missed foot cleansing and dressing changes twice on 8/22/17, and once during the day of 8/23/17. Per review of a skin sheet for Resident #1, dated 8/23/17 and signed by a Licensed Practical Nurse (LPN), the LPN transcribed a physician's orders [REDACTED]. The order for foot care was incorrectly transcribed as being daily, not twice daily. A corresponding nurse note of 8/23/17 (2-10), signed by the same LPN who signed the skin sheet, documented that the foot was washed and dressing applied as per the physician's orders [REDACTED].#1 had an appointment next morning at hospital. During an interview on 9/12/17 at 2:39 PM, the LPN who did the dressing change and foot care on the evening of 8/23/17, stated he/she examined the right foot at approximately 8:30 PM, discovered that the tissue of the foot looked dead and there were maggots (fly larvae) on the toe area. When asked by the surveyor whether the LPN had told anyone about this finding, the LPN stated that the night nurse coming on at 10:00 PM was advised. As confirmed in the interview, the LPN failed to notify the physician of the significantly deteriorated condition of the right foot wound on the evening of 8/23/17, nor did the LPN contact a Registered Nurse (RN) or supervisor, nor document accurately the condition of the wound on the skin sheet or the nurse note. There was no evidence to indicate that the night nurse, also an LPN, had examined Resident #1, nor contacted the physician or an RN supervisor, nor documented any findings of the shift for the foot wound of Resident #1. There is no evidence that the day shift nurse (6:00 AM to 2:00 PM) of 8/24/17 examined Resident #1 in the morning prior to the transport to the hospital appointment, thus continuing the failure to notify the physician or administration of the significant deterioration of the wound. This was also a missed foot cleansing and dressing change opportunity. The next nurse notes in the medical record were dated 8/24/17 at 3:30 PM, regarding a report of admission to hospital of Resident #1. During an interview on 9/12/17 at 1:55 PM, the RN supervisor confirmed that the medical order from the podiatrist was received on 8/21/17 at 3:48 PM, and that 3 cleansing and dressing change opportunities were missed until 8/23/17 evening. During interview on 9/12/17 at 2:55 PM, the Director of Nursing denied any knowledge of the development of maggots on the right foot of Resident #1 until being advised by the surveyor. The lack of accurate and timely medical order transcription resulted in failure to provide at least 3 cleansing and dressing change treatments from the evening of 8/21/17 to the evening of 8/23/17. Also the lack of accurate documentation of the deteriorated condition of the tissue and the presence of maggots on the wound on the evening of 8/23/17 resulted in inaction by the night nurse, as well as the day nurse of 8/24/17. The lack of notification/information resulted in an inability by either the physician or the nursing administration to take prompt action for the medical care of Resident #1 from 8/23/17 evening forward. Resident #1 went to the hospital vascular appointment on the morning of 8/24/17 where medical staff discovered a severely deteriorated, gangrenous right foot infested with maggots. Resident #1 was admitted to hospital and underwent an emergency surgery and intravenous antibiotic treatment. Reference regarding failure to implement physician's orders [REDACTED]. Nursing: Scope and Standards of Practice (3rd Ed.). Silver Spring, MD: ANA (pg. 61). Reference regarding failure to implement physician's orders [REDACTED].). Wolters Kluwer Health/Lippincott Williams & Wilkins, pg 17. Reference regarding failure to implement the strategy of care: Vermont Nurse Practice Act, VT Statute Title 26, Chapter 28: Nursing § 1572. See also F157, F309 and F514.

Based on record review and staff interview, the facility failed to notify the physician immediately when a significant change of physical condition was identified for 1 of 3 residents (Resident #1) in the sample reviewed. Findings include: During an interview on 9/12/17 at 2:39 PM, the LPN stated that on the evening of 8/23/17, he/she examined the right foot of Resident #1 at approximately 8:30 PM, and discovered that the tissue of the foot looked dead and there were maggots on the toe area. When asked by the surveyor whether the LPN had told anyone about this finding, the LPN stated that the night nurse coming on at 10:00 PM was advised. As confirmed in the interview, the LPN failed to notify the physician of the significantly deteriorated condition of the right foot wound, did not contact a Registered Nurse or supervisor, and did not document accurately the condition of the wound on the skin sheet or the nurse note. A faxed medical order from a podiatrist (doctor with foot specialty) was received by the facility on 8/21/17 at 3:48 PM. This medical order included specifics regarding orders for care of a wound on the right foot which was found to have wet gangrene (serious infection) and resting ischemia (lack of blood flow). The dressing order specified that the right foot wound should be washed with soap and water, patted dry, and a wet to dry dressing applied twice daily. The nursing staff did not transcribe the foot care order as per protocol, thus resulting in missed foot cleansing and dressing changes twice on 8/22/17, and once during the day of 8/23/17. Per review of a skin sheet for Resident #1, dated 8/23/17 and signed by a Licensed Practical Nurse (LPN), the LPN incorrectly transcribed a once daily treatment for [REDACTED]. A corresponding nurse note of 8/23/17 (2-10), signed by the LPN who also signed the skin sheet, documented that the foot was washed and dressing applied as per the physician's orders [REDACTED].#1 had an appointment the next morning at hospital. There was no evidence to indicate that the night nurse, also an LPN, had contacted the physician or an RN supervisor, or documented any findings from the shift for the foot wound of Resident #1. The next nurse notes are dated 8/24/17 at 3:30 PM, regarding a report of admission to hospital of Resident #1. There is no evidence that the day shift nurse (6:00 AM to 2:00 PM) on the morning of 8/24/17 examined Resident #1 in the morning prior to the transport to the hospital appointment, thus continuing the failure to notify the physician. The lack of accurate documentation of the deteriorated condition of the tissue and the presence of maggots on the wound on the evening of 8/23/17 may have resulted in inaction by the night nurse, as well as the day nurse of 8/24/17. Certainly the lack of information resulted in an inability by either the physician or the nursing administration to take prompt action for the medical care of Resident #1. Resident #1 went to the vascular appointment on the morning of 8/24/17 where medical staff discovered a severely deteriorated, gangrenous right foot infested with maggots. Resident #1 was admitted to hospital and underwent an emergency surgery and intravenous antibiotic treatment. During interview on 9/12/17 at 2:55 PM, the Director of Nursing denied any knowledge of the development of maggots on the right foot of Resident #1 until being advised by the surveyor.

Based on record review and staff interview, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents in the sample reviewed (Resident #1). Findings include: A faxed medical order from a podiatrist (doctor with foot specialty) was received by the facility on 8/21/17 at 3:48 PM. This medical order included specifics regarding an antibiotic medication, a request for a vascular consultation appointment, and orders for care of a wound on the right foot which was found to have wet gangrene (serious infection) and resting ischemia (lack of blood flow). Per review of the medical record of Resident #1, the vascular appointment was made for 8/24/17 at noon, and the antibiotic was started. The dressing order specified that the right foot wound should be washed with soap and water, patted dry, and a wet to dry dressing applied twice daily. The nursing staff did not transcribe the foot care order as per protocol, thus resulting in missed foot cleansing and dressing changes twice on 8/22/17, and once during the day of 8/23/17. Per review of a skin sheet for Resident #1, dated 8/23/17 and signed by a Licensed Practical Nurse (LPN), the LPN transcribed the physician's orders [REDACTED]. A corresponding nurse note of 8/23/17 (2-10), signed by the same LPN who signed the skin sheet, documented that the foot was washed and dressing applied as per the physician's orders [REDACTED].#1 had an appointment next morning at hospital. During an interview on 9/12/17 at 2:39 PM, the LPN who did the dressing change and foot care on the evening of 8/23/17, stated he/she had upon examining the right foot at approximately 8:30 PM, discovered that the tissue looked dead and there were maggots (fly larvae) on the toe area. When asked by the surveyor whether the LPN had told anyone about this finding, the LPN stated that the night nurse coming on at 10:00 PM was advised. As confirmed in the interview, the LPN failed to notify the physician of the significantly deteriorated condition of the right foot wound on the evening of 8/23/17. Neither did the LPN contact a Registered Nurse (RN) or supervisor, nor document accurately the condition of the wound on the skin sheet or the nurse note. There was no evidence to indicate that the night nurse, also an LPN, had examined Resident #1, nor contacted the physician or an RN supervisor, nor documented any findings of the shift for the foot wound of Resident #1. There is no evidence that the day shift nurse (6:00 AM to 2:00 PM) of 8/24/17 examined Resident #1 in the morning prior to the transport to the hospital appointment, thus continuing the failure to notify the physician or administration of the significant deterioration of the wound. In an interview on 9/12/17 at 9:15 AM, the Licensed Nurse Assistant (LNA) who did morning personal hygiene and dressing with Resident #1 denied having noticed anything unusual about the right foot of Resident #1 while donning footwear. The next nurse notes in the medical record were dated 8/24/17 at 3:30 PM, regarding a report of admission to hospital of Resident #1. During an interview on 9/12/17 at 1:55 PM, the RN supervisor confirmed that the medical order from the podiatrist was received on 8/21/17 at 3:48 PM, and that 3 cleansing and dressing change opportunities were missed until 8/23/17. During interview on 9/12/17 at 2:55 PM, the Director of Nursing denied any knowledge of the development of maggots on the right foot of Resident #1 until being advised by the surveyor. The lack of accurate and timely medical order transcription resulted in failure to provide at least 3 cleansing and dressing change treatments from the evening of 8/21/17 to the evening of 8/23/17. Also the lack of accurate documentation of the deteriorated condition of the tissue and the presence of maggots on the wound on the evening of 8/23/17 resulted in inaction by the night nurse, as well as the day nurse of 8/24/17. The lack of notification/information resulted in an inability by either the physician or the nursing administration to take prompt action for the medical care of Resident #1 from 8/23/17 evening forward. Resident #1 went to the hospital vascular appointment on the morning of 8/24/17 where medical staff discovered a severely deteriorated, gangrenous right foot infested with maggots. Resident #1 was admitted to hospital and underwent an emergency surgery and intravenous antibiotic treatment.

Based on interview and record review, the facility failed to ensure residents are free from mistreatment for 1 of 20 residents. (Resident #15) Findings include: Per interview and record review, Resident #15 was physically restrained by staff in order to administer an intramuscular (IM) injection of an antipsychotic medication against his/her will. Resident #15 had [DIAGNOSES REDACTED]. The physician wrote orders for antipsychotic medication that was to be used to alleviate aggressive behaviors as needed. There is a signed order from 4/29/13 for an oral medication [MEDICATION NAME] 2 milligrams (mg.) one tab QID (four times daily)PRN (as needed) for aggression. The same telephone order has also [MEDICATION NAME] 2 mg IM (Intramuscular injection) BID (twice daily) if unable to take PO. Per review of the nurse's notes from 1/20/15, at approximately 2:00 PM the resident was acting aggressively toward the nurse on duty by trying to take the Medication Administration Record [REDACTED]. The note stated that the resident was escorted to their room by an LNA (Licensed Nursing Assistant) and the LPN (Licensed Practical Nurse), and offered an oral dose of [MEDICATION NAME] 2 mg., which Resident #15 refused to take. The note continued to state that the nurse "gave [MEDICATION NAME] 0.4 ml (2 mg.) IM to R butt cheek with LNAs assisting me to restrain (him/her)". Per interview on 2/24/15 at 2:45 PM, the LPN who administered the injection stated that Resident #15 was very riled on the afternoon of 1/20/15, and was getting very aggressive, especially targeting the nurse. There was concern for the safety of others, so Resident #15 was escorted to their room by staff and offered a PRN [MEDICATION NAME] by mouth. After the resident refused, the nurse chose to give the medication by injection. The account given by the nurse was that one LNA held the residents arms and another held the resident's legs, and the nurse gave the injection into the buttocks of the resident. The nurse stated that the resident did not agree to the injection, but the behaviors warranted the antipsychotic administration to keep everyone safe, and the nurse admitted to having staff hold the resident down while administering the injection. Per interview on 2/24/15 at 1:50 PM, the Director of Nursing stated that they had learned of this nurse's note in Resident #15's record on the evening of 2/23/15, and spoke to the nurse about how they worded their documentation, but did not take any further action at that time. Per interview on 2/24/14 at 4:55 PM, the evening supervisor stated that they had not heard about the incident until the surveyor informed the facility staff on 2/24/15. The RN supervisor stated that the nurse who gave the injection could have consulted with the supervisor, especially since the resident seemed to be angry at that nurse specifically, but the supervisor was not told. The expectation in this instance would be that the nurse attempt to talk the resident into willingly receiving the injection, however, restraining someone to give them the injection was not an acceptable practice. Per review of the medical record of Resident #15, there was no consent for the use of restraints, and no physician order for [REDACTED]. See also F155, F221, F225 and F329.

Based on record review and staff interview, the facility failed to ensure that residents were free from physical restraints for 1 of 20 residents (Resident #15). Findings include: Per interview and record review, Resident #15 was physically restrained by staff in order to administer an intramuscular (IM) injection of an antipsychotic medication against his/her will. Resident #15 had [DIAGNOSES REDACTED]. The physician wrote orders for antipsychotic medication that was to be used to alleviate aggressive behaviors as needed. There is a signed order from 4/29/13 for an oral medication [MEDICATION NAME] 2 milligrams (mg.) one tab QID (four times daily)PRN (as needed) for aggression. The same telephone order has also [MEDICATION NAME] 2 mg IM (Intramuscular injection) BID (twice daily) if unable to take PO. Per review of the nurse's notes from 1/20/15, at approximately 2:00 PM the resident was acting aggressively toward the nurse on duty by trying to take the Medication Administration Record [REDACTED]. The note stated that the resident was escorted to their room by an LNA (Licensed Nursing Assistant) and the LPN (Licensed Practical Nurse), and offered an oral dose of [MEDICATION NAME] 2 mg., which Resident #15 refused to take. The note continued to state that the nurse "gave [MEDICATION NAME] 0.4 ml (2 mg.) IM to R butt cheek with LNAs assisting me to restrain (him/her)". Per interview on 2/24/15 at 2:45 PM, the LPN who administered the injection stated that Resident #15 was very riled on the afternoon of 1/20/15, and was getting very aggressive, especially targeting the nurse. There was concern for the safety of others, so Resident #15 was escorted to their room by staff and offered a PRN [MEDICATION NAME] by mouth. After the resident refused, the nurse chose to give the medication by injection. The account given by the nurse was that one LNA held the residents arms and another held the resident's legs, and the nurse gave the injection into the buttocks of the resident. The nurse stated that the resident did not agree to the injection, but the behaviors warranted the antipsychotic administration to keep everyone safe, and the nurse admitted to having staff hold the resident down while administering the injection. Per interview on 2/24/15 at 1:50 PM, the Director of Nursing stated that they had learned of this nurse's note in Resident #15's record on the evening of 2/23/15, and spoke to the nurse about how they worded their documentation, but did not take any further action at that time. Per interview on 2/24/14 at 4:55 PM, the evening supervisor stated that they had not heard about the incident until the surveyor informed the facility staff on 2/24/15. The RN supervisor stated that the nurse who gave the injection could have consulted with the supervisor, especially since the resident seemed to be angry at that nurse specifically, but the supervisor was not told. The expectation in this instance would be that the nurse attempt to talk the resident into willingly receiving the injection, however, restraining someone to give them the injection was not an acceptable practice. Per review of the medical record of Resident #15, there was no consent for the use of restraints, and no physician order for [REDACTED]. See also F155, F224, F225 and F329.

Based on interview and record review, the facility failed to assure that 1 of 20 residents had the right to refuse medication (Resident #15). Findings include: Per interview and record review, Resident #15 was physically restrained by staff in order to administer an intramuscular (IM) injection of an antipsychotic medication against his/her will. Resident #15 had [DIAGNOSES REDACTED]. The physician wrote orders for antipsychotic medication that was to be used to alleviate aggressive behaviors as needed. There is a signed order from 4/29/13 for an oral medication [MEDICATION NAME] 2 milligrams (mg.) one tab QID (four times daily)PRN (as needed) for aggression. The same telephone order has also [MEDICATION NAME] 2 mg IM (Intramuscular injection) BID (twice daily) if unable to take PO. Per review of the nurse's notes from 1/20/15, at approximately 2:00 PM the resident was acting aggressively toward the nurse on duty by trying to take the Medication Administration Record [REDACTED]. The note stated that the resident was escorted to their room by an LNA (Licensed Nursing Assistant) and the LPN (Licensed Practical Nurse), and offered an oral dose of [MEDICATION NAME] 2 mg., which Resident #15 refused to take. The note continued to state that the nurse "gave [MEDICATION NAME] 0.4 ml (2 mg.) IM to R butt cheek with LNAs assisting me to restrain (him/her)". Per interview on 2/24/15 at 2:45 PM, the LPN who administered the injection stated that Resident #15 was very riled on the afternoon of 1/20/15, and was getting very aggressive, especially targeting the nurse. There was concern for the safety of others, so Resident #15 was escorted to their room by staff and offered a PRN [MEDICATION NAME] by mouth. After the resident refused, the nurse chose to give the medication by injection. The account given by the nurse was that one LNA held the residents arms and another held the resident's legs, and the nurse gave the injection into the buttocks of the resident. The nurse stated that the resident did not agree to the injection, but the behaviors warranted the antipsychotic administration to keep everyone safe, and the nurse admitted to having staff hold the resident down while administering the injection. Per interview on 2/24/15 at 1:50 PM, the Director of Nursing stated that they had learned of this nurse's note in Resident #15's record on the evening of 2/23/15, and spoke to the nurse about how they worded their documentation, but did not take any further action at that time. Per interview on 2/24/14 at 4:55 PM, the evening supervisor stated that they had not heard about the incident until the surveyor informed the facility staff on 2/24/15. The RN supervisor stated that the nurse who gave the injection could have consulted with the supervisor, especially since the resident seemed to be angry at that nurse specifically, but the supervisor was not told. The expectation in this instance would be that the nurse attempt to talk the resident into willingly receiving the injection, however, restraining someone to give them the injection was not an acceptable practice. Per review of the medical record of Resident #15, there was no consent for the use of restraints, and no physician order for [REDACTED]. See also F221, F224, F225 and F329.

Based on record review and interview, the facility failed to provide necessary treatment and services to promote healing and prevent new sores from developing for 1 applicable resident. (Resident #2) Findings include: Per record review on 09/22/11, Resident #2 developed a pressure ulcer and did not receive necessary monitoring, assessment and/or treatment to promote healing and/or prevent worsening. A nursing note dated 8/30/11 2 PM -10 PM shift states, " resident ' s daughter report that the buttocks has a red spot on it. Daughter put baza cream on her and put (resident) to bed, I was not able to verify but told daughter I would document and pass on information " . The nursing note of 08/31/11 states the physician made a visit, however, there was no physician's order [REDACTED]. A nursing note on 09/01/11 contained no information regarding the pressure ulcer. A nursing note dated 09/06/11 states " noted to have stage 2 wound, MD changed order from [MEDICATION NAME] to [MEDICATION NAME]& baza cream b.i.d (twice daily)." Per review of the Pressure Ulcer flow sheet with a start date of 09/06/11, it directs staff to measure the wound weekly and apply cream b.i.d. (twice daily). The pressure ulcer was first measured on 09/06/11 as 1.3 cm (centimeters) [MEDICAL CONDITION] cm and had increased in size when measured again on 09/19/11 as 1.3 cm x 1 cm. The pressure ulcer was not measured as directed on 9/12/11. In addition, [MEDICATION NAME]& baza cream that was ordered to be applied twice a day was documented as being applied only once on 9/6, 9/7, 9/11, and 9/19/11. Per review of the Treatment Administration Record (TAR), it directs staff to assess the skin every day (QD), however, for the months of July and August 2011, the documentation indicates the skin assessment was completed only 4 days each month. In addition, the care plan noted in the chart was not updated to reflect the new pressure ulcer. Per interview on 09/22/11 at 3:00 PM the Director of Nursing Services (DNS) & the Clinical Manager confirmed the resident did not receive necessary care and services for the pressure ulcer.

Based on interview and record review, the facility failed to ensure that 1 of 2 residents with pressure sores received the necessary treatment and services to prevent pressure sores from developing and to idenify pressure sores at an early stage. (Resident #44) Findings include: 1. Per record review, a wound consult on 3/8/11 revealed a stage 3 pressure ulcer (an open sore that involves full thickness skin loss) that measured 2 centimeters (cm) by 1 cm on Resident #44's coccyx, and 2 unstageable pressure areas on the resident's bilateral heels. Prior to the 3/8/11 wound consult, nursing staff were documenting completion of a daily skin assessment on the Treatment Record, as indicated by initialing the corresponding box on the Treatment Record every day. Resident #44 is totally dependent on staff for care and is unable to communicate his/her needs. Per record review, there was no documentation prior to 3/8/11 regarding any skin integrity issues on Resident #44's coccyx or left heel. Documentation was present in the record regarding the right heel. During an interview on 3/23/11 at 11:15 AM, the Unit Manager was not able to explain why there was no previous documentation as a result of the daily skin assessments about any skin integrity issues regarding the coccyx and the left heel, despite the daily skin assessment being signed off as completed. See also F272.

Based on record review and interviews, the facility failed to assure staff honored 1 applicable resident's right to refuse treatment (Resident #66). Findings include: Per review of written statements, interview, and record review, LPN #1 failed to honor Resident #66's right to refuse disrobing and bathing on 3/11/11. Per review of written incident reports dated 3/11/11, two Licensed Nurse Assistants (LNA) summoned the Licensed Practical Nurse (LPN #1) on duty when Resident #66 resisted their effort to take him/her for a scheduled bath. The LNA's documented their witness of LPN #1 then wheeling Resident #66 backward toward the tub room while s/he screamed. Furthermore, per written incident report dated 3/11/11, and confirmed during an interview on 3/22/11 at 2:15 PM, LPN #2 (who came to the tub room from a nearby unit to investigate the screaming) confirmed that LPN #1 continued his/her attempts to pull down the pants of Resident #66 while the resident was "screaming for her to stop", the resident also begged for help, saying s/he was bring attacked, and stated "look what they're doing to me." LPN #2 further wrote in his/her statement and confirmed during the interview on 3/22/11 at 2:15 PM that Resident #66 calmed down enough to have a bath when LPN #2 used reassuring approaches as outlined in the plan of care for alteration in psychosocial/mood/behavior. Per record review on 3/23/11, the written plan of care for Resident #66 specified staff approaches for alteration in psychosocial/mood/behavior including: Allow "R" (Resident) to express frustrations, anxiety and allow "R" space; validate feelings with TLC (Tender Loving Care); and Reassure. In an interview on 3/23/11 at 12:56 PM, the Director of Nursing (DON) confirmed that the actions of the nurse on 3/11/11 were not consistent with the written approaches on the plan of care for alteration in psychosocial/mood/behavior, as s/he wheeled the resident backwards and attempted disrobing while the resident screamed and resisted. See also F241, F282.