Every finding on record at River Place Nursing Center

Based on observation, interview, record review and facility policy review the facility failed to ensure that a call light was within reach for one (1) of forty-nine residents observed. Resident #30. Findings Include: Review of the facility policy, Call Light Policy with revision date of 01/12/15, revealed Procedure .8.When providing care to residents be sure to position the call light conveniently for the resident to use An observation on 12/16/25 at 11:00 AM and on 12/17/25 at 8:30 AM, revealed Resident #30 lying in her bed and the call light was not within reach. The call light cord was draped over her nightstand to the right of her bed with the red call button approximately two (2) feet from the head of her bed. During an observation and interview on 12/16/25 at 8:35 AM with Certified Nursing Assistant (CNA) #1, she confirmed that Resident #30's call light was draped over the nightstand to the right of her bed and it was not within her reach. CNA #1 revealed that Resident #30 was cognitive and could use the call light to voice her needs. She also revealed that the call light was supposed to be within reach at all times so she could call for help when needed and stated, If her call light is not in reach, it prevents her from getting the help she needs. An interview on 12/16/25 at 12:15 PM with Director of Nursing (DON), revealed that all call lights were supposed to be within reach of the residents. She also revealed that Resident #30 should have had her call light within her reach while in bed. DON revealed that failure to have a call light within reach could cause the resident to get up without assistance, and she could not call for help if she needed them. Record review of Resident #30's admission Record revealed an admission date of 10/06/17 and that she had diagnoses that included Unspecified Dementia and Unspecified Anxiety Disorder. Record review of Resident #30's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/14/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 09 which indicated that she had moderate cognitive deficits.

Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident's right for self-determination related to end-of-life care was respected as evidenced by resident not receiving the opportunity to sign her own code status directive for one (1) of 24 residents sampled. Resident #7Findings include: Record review of facility policy titled, Resident Rights, dated [DATE] revealed, The resident has the right to be informed of, and participate in, his or her treatment, including: . the right to request, refuse, and/or discontinue treatment . The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. Record review of facility policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE], revealed, It is the policy of the facility to adhere to residents' rights to formulate advance directives. Record review of Resident #7's Resident/Legal Representative Consent for Cardiopulmonary Resuscitation revealed, I understand that CPR constitutes an extraordinary measure and should not be done on me (the above-named resident). This was signed by the resident's representative and the physician on [DATE]. Record review of Resident #7's Order Summary Report revealed an order for DNR (Do Not Resuscitate) dated [DATE]. An interview with the Resident #7 on [DATE] at 2:58 PM, revealed she was capable of making her own decisions related to health care including her end-of-life care decisions and should have the opportunity to convey this decision in the documentation. She stated she would not want to be resuscitated if she arrested. During an interview on [DATE] at 3:20 PM, the Administrator acknowledged that each resident had the right to self-determination and the right to choose their end-of-life care. She acknowledged that Resident #7 was cognitive and fully oriented and should have been given the opportunity to receive information on end-of-life care and to sign her own code status form. She confirmed the facility failed to ensure the resident was given the opportunity to receive education and to consent to the end-of-life care she desired. Record review of Resident #7's admission Record revealed she was admitted by the facility on [DATE], with diagnoses that included Malignant Neoplasm of Bladder. Record review of Resident #7's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on record review, staff interview, and facility policy review, the facility failed to initiate and implement a physician's order obtained during a Gradual Dose Reduction (GDR) attempt for 1 (one) of five (5) residents reviewed for unnecessary medications. Resident #39.Findings Include: Review of the facility policy Gradual Dose Reduction of Psychotropic Drugs with revision date of 05/03/18 revealed Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Record review of Resident #39's Consultation Report revealed a pharmacy recommendation to change Trazodone to 50 milligrams (mg) at bedtime as needed (PRN) for insomnia for 90 days. Physician's Response: I accept the recommendation(s) above, please implement as written The Consultation Report was signed by the physician on 09/10/25. Record review of Resident #39's Order Summary Report revealed an order dated 10/11/25 for Trazodone HCL (Hydrochloride) 50mg by mouth in the evening related to insomnia, unspecified. Record review of Resident #39's Medication Administration Record revealed that he received Trazodone 50mg every evening. During an interview on 12/18/25 at 8:45 AM with Director of Nursing (DON), she pulled up Resident #39's orders on her computer and confirmed that his order for Trazodone 50mg every night was not changed to prn as recommended and ordered by the Physician. An interview on 12/18/25 at 9:05 AM with DON, revealed that when the pharmacist made the recommendations for a GDR, she was responsible for getting the recommendations to the physician and getting signatures. She revealed that once the physician signed and approved the recommendation, the DON was responsible for initiating the new orders in the computer. DON revealed that by not getting the order changed, Resident #39 continued to receive the Trazodone 50mg every night. She revealed that the goal was to get residents off as much medication and on the lowest dosage possible. She confirmed that they failed to follow through with the new order and this resulted in Resident #39 continuing his trazodone every night rather than only as needed. Record review of Resident #39's admission Record revealed an admission date of 10/22/21 and that he had diagnoses that included Unspecified Dementia and Unspecified Insomnia. Record review of Resident #39's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/08/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 12 which indicated that he had moderate cognitive deficits.

Based on observation, staff and resident interviews, record review and facility policy review the facility failed to provide services to maintain or prevent worsening of contractures for one of three residents reviewed with contractures. Resident #38.Findings Include: Review of the facility policy Range of Motion revealed Policy: To safely move the resident's joints as full a range of motion as possible; To improve or maintain joint mobility and muscle strength; To prevent contractures; To increase strength and activity tolerance; To reduce pain; To prevent complications of mobility. An observation on 12/15/25 at 3:05 PM revealed Resident #38 sitting up in her wheelchair in her room. She had contractures to her left wrist and four fingers on the left hand. Her left wrist was bent downward and her second, third, fourth and fifth fingers were bent at the second joints, and she was unable to straighten them. An observation and interview on 12/16/25 at 12:04 PM with Resident #38 revealed her sitting in her wheelchair in her room. She had contractures to her left wrist and four fingers. Resident #38 revealed that she could not open her fingers all the way and could not move her left wrist. She revealed that her hand had been this way for a long time, it was getting worse and she had a lot of pain with it. An interview on 12/17/25 at 11:42 AM with Occupational Therapist (OT) revealed that Resident #38 had contractures when she came into the facility. OT also revealed that she had just completed her quarterly assessment in November, and that Resident #38 had not reached the point of needing therapy. She revealed that they usually treated contractures if they started causing skin breakdown or if the resident complained of pain. OT revealed that she didn't like to use splints because they often made the contractures worsen or caused swelling, but she could put a soft hand roll in Resident #38's hand to help. OT revealed that she had not measured Resident #38's contractures and agreed that by not assessing and measuring the contractures, she would not know if they worsened. She revealed that she would look at Resident #38 again, measure her contractures, and put something in place to help prevent a decline. An interview on 12/17/25 at 11:09 AM, DON revealed that Resident #38 had a contracture when she admitted to the facility. She revealed that she had a previous stroke and had therapy when she first came in. DON revealed that Resident #38 complained of pain to her left arm often and they had pain medication ordered for her. She also revealed that they encouraged the residents to participate in activities and with their Activities of Daily Living (ADL) to promote independence and better use of their joints. DON also confirmed that they did not have any range of motion exercises in place for her. DON confirmed that Resident #38's contractures were on her left wrist and four fingers and agreed that these contractures should have been identified and interventions should be in place to prevent worsening of the contractures. She also stated that by not providing services, her whole arm could become contracted. During an interview on 12/17/25 at 2:05 PM with Administrator (ADM), she agreed that Resident #38's contractures should have been identified and interventions should have been in place to prevent worsening. She revealed that by not providing services, her contractures could become worse and cause her more pain. She also revealed that without proper positioning and interventions, her fingers could become contracted more and cause skin breakdown. Record review of Resident #38's OT Screening Form completed on 11/19/25 and signed by OT, revealed that her Upper Extremity range of motion was within functional limit. Record review of Resident #38's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/21/25 under Section GG0115 Functional Limitation in Range of Motion revealed that she had upper and lower extremity impairment on one side. Record review of Resident #38's admission Record revealed an admission date of 06/04/19 and that she had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side and Unspecified Pain. Record review of Resident #38's MDS with ARD of 11/21/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 10 which indicated that she had moderate cognitive deficits.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to store medications in a secure manner for one (1) of forty-nine (49) residents observed during the initial tour. Resident #47 Findings Include:Review of the facility policy titled Medication Storage undated, revealed under, Policy: Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologics must be stored securely and following the manufacturer's Labeled recommendations, or per facility policy. Also revealed under, 6. Medications will be stored on the medication cart, or in other designated area for extra supply of medications.During an observation on 12/15/25 at 11:04 AM, Resident #47 was observed lying in bed and he was verbal but confused. A bottle of Antacids 750-milligram, approximately one-quarter full, was observed on the resident's bedside dresser. The resident stated the medication belonged to him and that he took it when needed.An observation of Resident #47's room on 12/16/25 at 11:34 AM revealed the bottle of Antacids remained located on the bedside dresser.An observation and interview with the Director of Nursing (DON) on 12/16/25 at 11:45 AM confirmed Resident #47 had the bottle of Antacids at the bedside. The DON stated the resident had intermittent confusion and should not have access to the medication. She further explained the resident could take too many tablets or another resident could enter the room and access the medication.Record review of the admission Record revealed the facility admitted Resident #47 on 12/01/25 with medical diagnoses that included Unspecified Dementia.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/07/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 11, indicating Resident #47 was moderately cognitively impaired.

Based on resident and staff interviews, record review, and facility policy review the facility failed to document a summary of the resident's repeated grievances regarding showers and any corrective actions and follow-up for the grievances for one (1) of 14 sampled residents. Resident #39. Findings include: Review of the facility policy titled, Resident and Family Grievances, with a review date of 2/3/2023 revealed, Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. D .The Grievance official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. An interview on 5/28/24 at 10:35 AM, Resident #39 revealed he is supposed to get his showers on Tuesday, Thursday, and Saturday but is lucky if he gets a shower two times a week. He revealed, I didn't get one this past Saturday and usually don't get them if Certified Nurse Aide (CNA) #3 is not here. CNA#3 is the shower aide but misses a lot because of her sick child. I've been telling the Social Services Director/Grievance Officer and Registered Nurse (RN) #2 but nobody has come to discuss this with me. I complain about it all the time to everyone, they know it's a problem. An interview on 5/29/24 at 12:45 PM, Resident #39 revealed, that he has talked with the Administrator (ADM) and the Social Worker/Grievance Officer multiple times about not getting his showers as scheduled. During an interview on 5/29/24 at 2:10 PM, RN #1 revealed she developed a sign-off sheet for showers and confirmed through review of the documented sign-off sheets that Resident #39 did not always get his three showers a week. During an interview on 5/29/24 at 3:15 PM, CNA #1 and CNA #2 both confirmed Resident #39 had complained about not getting his showers in the past. CNA #1 and CNA #2 confirmed if Resident #39 told you he didn't get a shower Saturday or was only getting showers two times a week then he was being truthful with you and stated, He shoots it straight. In an interview on 5/29/24 at 3:20 PM, the Social Services Director revealed she is also the Grievance Officer and revealed Resident #39 has voiced not getting showers many times. She confirmed that she did not fill out a formal grievance form and therefore it was not followed up on and validated therefore was no resolution to his grievance. During an interview on 5/29/24 at 3:30 PM, RN #2 stated, I don't think there's a soul in this building that Resident #39 hasn't told about not getting his showers. An interview on 5/29/24 at 4:05 PM, the Director of Nurses (DON) revealed she was unaware that Resident #39 was making specific complaints about his showers and confirmed if he was specifically complaining to staff about his lack of showers then he should have had a grievance filled out so his concerns could have been appropriately addressed and followed up on. During an interview on 5/29/24 at 4:25 PM, the Administrator revealed she was aware of the bathing concerns with Resident #39 and confirmed that it was not properly addressed through the grievance process and that there was no resolution or follow-up done for the complaint for Resident #39. Record review of the Face Sheet revealed Resident #39 was admitted to the facility on [DATE] with diagnoses that included Encephalopathy, Disorder of the skin and subcutaneous tissue, and Dementia. Record Review of Resident #39's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/21/24 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

Based on resident interview, staff interviews, and facility policy review, the facility failed to promptly deliver postal mail to residents on Saturdays for 54 of 54 residents in the nursing facility that would possibly receive postal mail. Resident #25 Findings include: Review of a document on facility letterhead from the Administrator dated 4/20/23, revealed, The Policy of (Proper Name of the facility) is to pass mail daily. Activities passes on the weekdays and the Registered Nurse (RN) supervisor or charge nurse is responsible for mail collection on the weekends. Review of the Resident's Rights with a copyright date of 2018, revealed, .7. Information and communication . i. The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through means other than a postal service. An interview on 4/18/23 at 3:45 PM with Resident #25, the Resident Council President, revealed there is no mail delivered to the residents on Saturday. He revealed he saw the staff member that works at the main entrance door bring in mail from the mailbox on a Saturday, could not recall which Saturday, but she refused to go through it to see if he had any mail delivered from the post office. He revealed the nursing staff will bring him his packages and the newspaper, if he tells them to look out for it on the weekend, but the young lady will not give him his Saturday mail. An interview on 4/19/23 at 2:35 PM, with the COVID Check Point Staff, revealed she had gotten the mail out of the mailbox one Saturday and took the mail to the nurse's desk to be placed in the main office to be passed out to the residents on the following Monday. She revealed it was taken to the nurse's desk because she did not have access to a key for the main office. An interview on 4/19/23 at 2:40 PM, with Licensed Practical Nurse (LPN) #2, revealed she has worked on Saturday and reported the mail was brought to the nurse's desk on Saturdays and to be passed out by the Activities Department, if they are working on Saturday. She stated there was not an Activities person at work every Saturday and the mail would then be placed in the main office to be passed on to the residents on the following Monday. An interview on 4/19/23 at 2:43 PM, with LPN # 3, revealed mail had been brought to the nurse's desk when she worked on a Saturday and would be placed in the main office to be passed out to residents on the following Monday if no one was working on Saturday from the activities department. An interview on 4/19/23 at 2:50 PM, with the Activities Coordinator revealed she had passed out mail before on a Saturday. But she was not at work this past Saturday, 4/15/23, and was not sure about what happened with the mail. She noted if she is at work, the nurses give the mail to her to pass it out to the residents. An interview on 4/19/23 at 2:55 PM, with the Administrator revealed the weekend RN Supervisors are responsible for getting the Saturday mail from the mailbox and distributing it to the residents. She revealed it was not the responsibility of the Activities department to distribute Saturday mail and was not aware that no staff was delivering Saturday mail to the residents every Saturday. She confirmed all residents should receive their mail the day it is delivered, and Resident #25 had the right to receive his postal mail, if there was some delivered for him, on Saturday. An interview 4/19/23 at 3:01 PM, with Registered Nurse (RN) Supervisor #1, revealed she would look for a newspaper or a package that was delivered on Saturday when Resident #25 would tell her he wanted the newspaper and if had a package coming. She revealed that she would be involved providing resident care and was not aware she was responsible to go to the mailbox to get resident mail and distribute it on a Saturday. She confirmed that she had not gotten mail out of the mailbox on any Saturday she had worked. Record review of the Face Sheet revealed that the facility admitted Resident # 25 to the facility on [DATE] with diagnoses of Vascular dementia with Sepsis, Unspecified dementia without behaviors, and Benign prostatic hyperplasia. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 3/28/23, revealed that Resident # 25 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated that she was cognitively intact.

Based on resident interview, staff interviews, and facility policy review the facility failed to protect a resident's right to privacy in her room for one (1) of 54 residents reviewed for resident rights. Resident #39 Findings include: Review of the facility policy titled, Resident Rights, with a copyright date of 2018, revealed 1. Resident rights. The resident has the right to a dignified existence . 9. Safe environment. The resident has a right to a safe, clean, comfortable and Homelike environment, including but not limited to receiving treatment and support for daily living safely. An interview on 4/18/23 at 4:00 PM, with Resident #39, during the Resident Council Meeting, revealed Resident #36 had wandered into her room and she did not want uninvited men in her room. She revealed it makes her very uncomfortable for him to be in her room, she feels he was intruding in her private space. She revealed the staff would hear her tell him to get out and would come to convince him to leave. She shared that she would not want to be on the toilet or getting out of her clothes, and he was to come in her room. She revealed that she wanted the staff to assure her that she had the right to her private space, and that she would be comfortable and safe by not having to always watch for him to keep him out of her room. An interview on 4/19/23 at 1:10 PM, with the Registered Nurse (RN) Supervisor confirmed that Resident #36 exhibited wandering behaviors and had wandered in and out of other residents' rooms. She noted that she could not confirm or deny that the male resident had wandered into Resident #39's room before. An interview on 4/19/23 at 1:30 PM, with the Administrator, revealed she had a conversation with Resident #39 some time ago about Resident #36 when he entered her room, and that Resident #39 wanted the Administrator to tell her she would stop Resident #36 from coming in her room. She noted that she informed Resident #39 that she would do all that she could to keep Resident #36 out of her room but could not promise that he would not enter her room again. She confirmed Resident #39 had the right to privacy, that her right to privacy had been violated. An interview on 4/19/23 at 1:45 PM, with Social Services, confirmed Resident #39's complaint that Resident #36 unwantedly entered her room. She revealed that she did not think Resident #39's rights had been violated because Resident #39 did not present the complaint to her in that manner, that it was not a major occurrence with Resident #36 going into her room, and that she informed Resident #39 that Resident #36's mind does not function like hers anymore and he was not aware of what he was doing. An interview on 4/19/23 at 2:34 PM, with Licensed Practical Nurse, (LPN) #2, confirmed that Resident #36 did exhibit wandering behaviors and had been wandering in and out of different residents' rooms. An interview on 4/19/23 at 4:40 PM, with the Director of Nursing (DON), confirmed Resident #36 did wander in and out of other residents' rooms and that there had been residents that did not like him coming into their rooms. Record review of the Face Sheet for Resident #39 revealed an admitted [DATE] and a diagnosis of Adjustment disorder with Mixed Anxiety and Depressed Mood. Record review of the Patient Progress Note, from Resident #36's physician dated 2/10/23, revealed . [AGE] year-old out and about in the facility in his wheelchair . he's been a little agitated, going in and out of folks room but so far, he's been redirected. Impression: . 2. Dementia. Record review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 2/14/23, for Resident #39, revealed an interview dated 2/13/23 with a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #39 is cognitively intact.

Based on resident interview, staff interviews, record review, and facility policy review, the facility failed to record, initiate, and resolve a grievance for a resident, for one (1) of five (5) residents reviewed for grievances in Resident Council. Resident #39 Findings include: Review of the facility policy titled, Resident and Family Grievances, with the date implemented of March 1, 2019, revealed . Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance . 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. d. Verbal complaint during resident or family council meetings. 10. Procedure: . b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance from or assist the resident or family member to complete the form; . 11. Take any immediate actions needed to prevent further potential violations of any resident right . d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. 12. The facility will make prompt efforts to resolve grievances. During a Resident Council Meeting, on 4/18/23 at 4:00 PM, an interview with Resident #39 revealed that Resident #36 had wandered into her room. She did not want uninvited men in her room. It made her very uncomfortable for him to be in her room and she felt he was intruding in her private space. The staff would hear her tell him to get out, because they would come to her room to convince him to leave. She confirmed that she had spoken to the Administrator and the Social Worker about it, and nothing had been done. She revealed she knew nothing about a grievance being written up for this complaint and no one had come back to her to talk about it. On 4/19/23 at 1:30 PM, during an interview with the Administrator, confirmed that she had a conversation with Resident #39 some time ago about Resident #36 entering her room, and that she did not want an uninvited man coming in her room, and that Resident #39 wanted the Administrator to tell her she would stop Resident #36 from coming in her room. She noted that she had informed Resident #39 that she would do all that she could to keep Resident #36 out of her room but could not promise that he would not enter her room again. She also noted she did not document the conversation she had with Resident #39 and that a formal grievance had not been initiated and resolved for Resident #39's complaint. She confirmed that a formal grievance should have been filed, initiated, and resolved for Resident #39's grievance. The Administrator did confirm that Resident #36 had been confirmed to wander in and out of other residents' rooms. An interview on 4/19/23 at 1:45 PM with Social Services confirmed there was no formal grievance filed for Resident #39's complaint that Resident #36 unwantedly entered her room. Social Services also confirmed that Resident #36 did wander in and out of other resident's rooms. She noted that Resident #39 did not present the complaint to her in the manner of being bothered by Resident #36 entering her room, so she did not think Resident #39's complaint should have been written up as a grievance. She also noted Resident #39's complaint was not a major occurrence with Resident #36 going into her room. Social Services shared that she informed Resident #39 that Resident #36's mind did not function like hers anymore, and he was not aware of what he was doing. Record review of the Grievance Log revealed there was no grievance form initiated or resolved for Resident #39's complaint of the resident wandering into her room. Record review of the Face Sheet for Resident #39 revealed an admitted [DATE] and a diagnosis of adjustment disorder with Mixed Anxiety and Depressed Mood. Record review of the Quarterly Minimum Data Set (MDS) Assessment, with and Assessment Reference Date (ARD) of 2/14/23, for Resident #39, revealed an interview dated 2/13/23 with a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #39 is cognitively intact.

Based on observation, resident interview, staff interview, record review and facility policy review the facility failed to ensure a resident was free of the use of a restraint as evidenced by use of a body alarm that restricted the movements of a resident who could turn and position themselves and they could not easily remove the device for one (1) of 54 residents reviewed. Resident #43 Findings include: A review of the facility's policy titled SUBJECT: RESTRAINT POLICY, revealed, POLICY: As per OBRA (Omnibus Budget Reconciliation Act) requirements all residents have the right to be unrestrained. Restraints should be used only as a last alternative and only when other less restrictive measures have been tried and rejected. DEFINITION: Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body .PROCEDURE: 2.) All residents using a restraint are to be evaluated and re-evaluated approximately every quarter . A review of the facility's policy titled SUBJECT: PHYSICIAN'S ORDER FOR A PHYSICAL RESTRAINT DEVICE, revealed, POLICY: All residents requiring a physical restraint must have a Physician's Order . An interview with CNA #4 on 4/17/23 at 11:00 AM, revealed she provides care to Resident #43 at times and confirmed she would fuss when we had to put the alarms on, but we didn't want her to fall. An observation and interview on 4/17/23 at 1:43 PM, Resident #43 was asked why she had a body alarm clipped to the back of her blouse, she revealed the staff put it on her because she has had a couple of falls when she came in, but she is in therapy and stronger now. She stated, I hate the alarm and I feel insulted having to wear it, I can't even bend down to pick something up if I need to without it going off and when I'm in bed I hate to even turn over because the alarm scares me and wakes up the whole hall. She also revealed the staff had showed her how to put the alarm back together so it would stop alarming when she moves to much in the bed and stated, That's kind of hard to do when its dark or you can't reach it on the back of the chair, and confirmed she had told the staff over and over she wanted it off. Record review of the April 2023 Physician Orders revealed no order for a body alarm. An interview on 04/18/23 at 10:00 AM, with Certified Nurse Aide (CNA) #1, revealed Resident #43 was to wear the chair alarm all the time while up in the wheelchair to deter her from wanting to stand up and risk falling. She noted that each time she had been assigned Resident #43, she had placed the alarm on Resident #43 when she helped her get in the wheelchair. CNA #1 shared that she was told by the nurses the chair alarm had to be clamped onto Resident #43, because she had fallen not long after being admitted to the nursing facility. She stated that Resident #43 was out of her head when she admitted and was not safe to stand up but has not fallen again in a long time. She also confirmed that there was an alarm the CNAs were to place on Resident #43 when she was in the bed to deter her from getting up and risk falling at night. She admitted she had not asked Resident #43 if she agreed with wearing the chair alarm or if it bothered her to do so. An interview with the Director of Nurse (DON) and the Registered Nurse (RN) Supervisor on 4/18/23 at 1:15 PM, both nurses confirmed that Resident #43 had a body alarm on at all times because the resident's granddaughter insisted she have one after a fall on 3/31/23 and related to confusion on admission, not always using the call light, and she would get up unassisted at night but both nurses confirmed that she is much better now. The DON and RN Supervisor stated that the body alarm would be considered a restraint because it does restrict Resident # 43's movement in the chair and the bed. The RN supervisor confirmed Resident # 43 can turn and reposition herself in the bed and chair and confirmed that there was no physician's order for the body alarm, nor had there been a restraint assessment or consent completed. The DON confirmed that the use of a device restricting movement could cause withdrawal from activities or socialization and cause a decrease in the resident assisting herself. An interview with the Social Services on 4/18/23 at 2:18 PM, revealed that a restraint restricting a resident's movement could cause anxiety, decrease the desire to do things for themselves and they may isolate themselves to their room. An interview with the DON on 4/19/23 at 1:59 PM, she revealed Resident # 43 sometimes transfers with handheld assistance and other times may need extensive assistance for transfers. An interview with the Physical Therapist (PT) on 4/19/23 at 2:47 PM, revealed Resident # 43 can walk 150 feet with a rolling walker and that she required a lot of cueing related to left side impairment. PT stated she is riding the new step bike to strengthen her motor control and is extensive assist of one for transfers. An interview with the Speech Therapist (ST) on 4/19/23 at 2:49 PM, revealed Resident # 43 is alert and oriented at this time, and confirmed she was alert and oriented at the time of admission. Record review of the Face Sheet revealed that the facility admitted Resident # 43 to the facility on [DATE] with diagnoses of Hemiplegia following cerebral infarction affecting left side, Pulmonary Embolism without acute core pulmonale, Dizziness and giddiness, and Unspecified abnormality of gait. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on 2/11/23, revealed that Resident # 43 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated that she was cognitively intact.

Based on staff interviews, record review, and facility policy review the facility failed to develop a care plan for a resident who wanders, failed to develop a care plan for a resident with the use of a body alarm, and failed to implement a positioning care plan for a resident for three (3) of 24 residents reviewed for care plans. Resident #2, Resident #36, and Resident #43. Findings Include: A record review of the facility's policy titled, Care Plans updated 2/03/23, revealed Policy: Each resident will have a person-centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care .Definitions: Care plan- contains resident problems/needs/strengths, Resident goals and interdisciplinary approaches .Resident Care Summary- part of the Comprehensive Care plan and used as the tool to make staff aware of the resident's care needs as ADL (Activity of Daily Living) care plan . Record review of the facility care plan, titled, TURNING AND POSITIONING POLICY, with no date revealed, All residents will be .positioned as per the plan of care . Resident #2 Observation on 4/17/23 at 2:46 PM, revealed Resident # 2 lying in bed, propped on her left side. Her heels were not elevated and there were no heel booties in place. In an observation and interview on 4/17/23 at 5:30 PM, with Licensed Practical Nurse (LPN) # 1 she verified that Resident #2 should have had her heels floated and heel booties on and that not having them on could result in pressure ulcers. Record review of Resident #2's Care Plan, with a start date of 7/1/2019, revealed Care Plan Description, PRESSURE: I AM AT RISK FOR PRESSURE ULCER DUE TO INCONTINENCE, DECLINE IN ADL (Activities of Daily Living) FUNCTION, DEMENTIA & ALZHEIMER'S, Care Plan Goal: Skin will remain intact thru the next review date . Intervention .FLOAT HEELS WHILE IN BED, ENSURE HEEL BOOTIES ARE IN PLACE WHILE IN BED . An interview with the DON on 4/19/23 at 1:59 PM, revealed the purpose of the care plan is to guide care for each resident. Record review of Resident #2's Face Sheet revealed, she was admitted to the facility on [DATE] with diagnosis included Alzheimer's disease, unspecified, Ankylosing spondylitis of unspecified sites in spine. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/2023, the Brief Interview for Mental Status (BIMS) score is 9, indicating impaired cognition and Functional Status for bed mobility is extensive assistance of two staff members. Resident #36 An observation on 04/18/23 at 9:15 AM, revealed Resident #36 was sitting in his wheelchair at the exit door to the lobby of the nursing facility informing staff that he needed to go outside to find his car. Staff were observed to redirect Resident #36 away from the main door to the lobby to allow visitors to enter the hallway to the nursing facility. An observation on 4/18/23 at 9:30 AM, revealed Resident #36 was in his wheelchair wandering aimlessly throughout the building and was observed to make two (2) trips, back-to-back, from the nurse's desk, and back up the hall to one of the side exit doors to sit and look outside. An interview on 4/19/23 at 1:45 PM, with Social Services revealed she did not do a care plan for the resident being a wanderer. She confirmed that she did not think he should have been care planned as a wanderer because he did not exhibit exit seeking behaviors while wandering. An interview on 4/19/23 at 3:01 PM, with the Registered Nurse (RN) Supervisor revealed , that she did not think that a care plan had been developed for his wandering behavior. Record review of the care plan for Resident #36 revealed there was not a care plan for wandering behaviors. An interview on 4/19/23 at 4:40 PM, with the Director of Nursing (DON), revealed Resident #36 did wander aimlessly daily. She also revealed that he should have a had a wandering care plan done to ensure all staff were aware of his behaviors and need for staff to monitor him for his safety. Record review of the Face Sheet for Resident #36 revealed an admitted [DATE] and diagnoses of Unspecified Dementia, Unspecified Severity, with Behavioral Disturbance, Anxiety Disorder, Unspecified, Restlessness and Agitation. Record review of the Minimum Date Set (MDS) with an ARD of 2/22/23 revealed a BIMS score of 10 indicating Resident #36 had moderate cognitive impairment. 47157 Resident #43 During an interview and observation with Resident #43 on 4/17/23 at 1:43 PM, the State Agency (SA) asked the resident why she had a body alarm clipped to the back of her blouse. She revealed the staff put it on her because she had a couple of falls when she came into the facility. An interview on 4/18/23 at 10:00 AM, with Certified Nurse Aide (CNA)#1, revealed Resident # 43 was to wear the chair alarm all the time while up in the wheelchair to detour her from wanting to stand up and risk falling. An interview with the Director of Nurse (DON) and the Registered Nurse (RN) Supervisor on 4/18/23 at 1:15 PM, both nurses confirmed that Resident #43 has a body alarm on. An interview with the DON on 4/19/23 at 1:59 PM, revealed the purpose of the care plan is to guide care for each resident and revealed the alarm device should have been on the fall care plan and confirmed that a care plan had not been developed for the chair alarm device. A review of Resident #43's care plan titled, I HAD A FALL ON 02/23/23, 03/31/23 with a start date of 2/23/23, revealed no documentation of a body alarm, and further review of all care plans also revealed no use of a body alarm. Record review of the Face Sheet revealed that the facility admitted Resident # 43 to the facility on [DATE] with diagnoses that included Hemiplegia following cerebral infarction affecting left side and Dizziness and giddiness unspecified abnormality of gait. Record review of the Minimum Data Set (MDS) Section C with an ARD on 2/11/23, revealed that Resident # 43 had a BIMS score of 14 which indicated that she was cognitively intact. 47158

Based on observation, staff interview, and facility policy review, the facility failed to apply heel booties and float heels while in bed for one (1) of 24 residents reviewed. Resident #2 Findings include: Record review of the facility policy, TURNING AND POSITIONING POLICY, with no date, revealed All residents will be .positioned as per the plan of care .Procedure: .2. Charge Nurse is responsible for visually observing .positioning as needed . An observation on 4/17/23 at 2:46 PM, revealed Resident # 2 lying in bed, propped on her left side. Her heels were not elevated and there were no heel booties in place. In an observation and interview with Certified Nursing Assistant (CNA) # 2 on 4/17/23 at 5:26 PM, she verified that Resident #2 did not have her heels floating or have heel booties in place. CNA #2 verified that Resident # 2 should have had heels floating and have heel booties in place. She stated that Resident #2's right heel bothered her and if Resident #2 did not have the heel booties in place she could get a sore. CNA # 2 stated that she used the kiosk to know what interventions the residents need. In an observation and interview on 4/17/23 at 5:30 PM, with Licensed Practical Nurse (LPN) # 1 she verified that Resident #2 should have had her heels floated and heel booties on and that not having them on could result in pressure ulcers. She stated that the CNAs were responsible for ensuring these interventions were in place. LPN # 1 stated that the interventions trigger on the electronic Treatment Administration Record (eTAR) for the nurse to check to be sure that they are in place. She stated that the treatment nurse checks on day shift, and the floor nurses check during the evening and night. In an interview with the Director of Nursing (DON) on 4/17/23 at 5:35 PM, she stated that the CNA who put the resident back to bed should have made sure the heel booties were in place. An interview with Treatment Nurse on 4/19/22 at 8:15 AM, verified that she checks the residents when she comes in in the morning to make sure that heels are floated, and heel booties are in use. She stated that she signs off the eTAR for the day shift and the floor nurses check them and signs off the eTAR for the evening and night shift. She stated that floating heels and use of heel booties were used to prevent pressure ulcers. An interview with the DON on 4/19/23 at 2:45 PM, she verified that failure to provide these interventions could result in a pressure ulcer. Record review of the April 2023 Physician Orders revealed an order dated 9/2/22 Float heels in bed. Record review of Resident #2's eTAR revealed FLOAT HEELS IN BED, with an onset date of 9/2/22, and ENSURE HEEL BOOTIES ARE IN PLACE WHILE IN BED, with an onset date of 11/13/22. The AM shift was initialed indicating the heel booties were in place and heels were floated. Record review of Resident #2's Face Sheet revealed, she was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified, Ankylosing spondylitis of unspecified sites in spine. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/2023 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of nine (9), indicating impaired cognition and review of Section G indicated functional status for bed mobility is extensive assistance of two staff.

Based on facility incident report, staff and resident interviews, record reviews and facility policy review, the facility failed to prevent abuse and neglect as evidenced by an incident of verbal and physical abuse by a Certified Nursing Assistant (CNA) involving a resident during care for one (1) of 11 residents reviewed for abuse and neglect, Resident #53. Findings include: Review of the facility policy titled, Abuse Program, dated 05/23/17 stated, It is the policy of this facility to take all steps necessary to maintain an environment free of abuse and neglect. Each resident has the right to be free from verbal, sexual, physical, and mental abuse. The facility is committed to protecting the residents from abuse by anyone including, facility staff. Procedures to Prevent, Training: All facility staff and volunteers will be trained/in-serviced at least annually and as needed regarding Resident Rights, including freedom from abuse, neglect and mistreatment. Review of the facilities investigation of an incident that occurred on 12/01/20 was reviewed. Resident #47 reported to the therapy staff, Physical Therapist (PT) #1, that Certified Nursing Assistant (CNA) #1 had gotten her roommate up this morning and had been rough with her roommate. CNA#1 had pulled her by her arms and talked to her in a rude and hateful manner. The facility immediately began an investigation and CNA #1 was suspended until the investigation was complete. The staff performed a body audit on Resident #53 and no redness or bruising was noted to the resident. The facility interviewed Resident #47 who reported the incident and she stated, I was scared and didn't know what to do and I just closed my eyes because I was worried about my safety and my roommate's safety. The facility reported the incident to the appropriate agencies and immediately began in-services and investigations at the time the incident occurred. In an interview on 02/23/21 at 10:45 AM, Resident #47 stated she remembered this day that this occurred and recalled the events to the State Agency (AS). Resident #47 stated that she was a CNA for [AGE] years at a nursing home and she was aware of how residents were supposed to be treated and what it was like to be a caregiver. Resident #47 stated she knew it was not right how this CNA was talking to her roommate and how rough she was with her. Resident #47 stated that she felt safe living here at the facility now and has not seen this CNA again since that day. Resident #47 stated that she has not seen any other incidents of abuse and that her roommate gets good care. In an interview on 02/25/21, at 11:20 AM, Physical Therapist (PT) #1 stated, I went into (proper name) Resident #47's room early that morning to get her up for therapy and she said that she wanted to talk to me about something that happened early this morning and she told me she was scared and upset for her roommate and wanted to make sure her roommate was safe. She told me that a CNA had come into her room and was trying to get (proper name) Resident #53 up and was physically rough with her and grabbed her by her wrists and that (proper name) Resident #53 stated that she wanted to go home, and the CNA responded to her in a hateful way and said, 'This is your home now and you're not going anywhere'. Resident #47 said that she was scared for her roommate and didn't know what to do so she closed her eyes. PT #1 stated that Resident #47 described the CNA as a dark black female, and she was very upset while explaining the story to me and stated she was concerned about Resident #53 continuing to stay here for her own safety and I assured her that I was going to notify the Administrator and she would take care of it. PT#1 confirmed that she had followed up with Resident #47 later and she had not seen the CNA anymore and that the facility took care of it and she felt safe now. In an interview, on 02/24/21 at 3:00 PM, the Administrator stated that when the incident occurred it was around 7:00 AM at the end of shift. After review of the schedule and resident assignments, the Administrator stated she knew who the CNA was that Resident #47 was referring to and she had called CNA #1 later that day to obtain a statement from her and CNA #1 refused to give her a statement regarding the incident and refused to come to the facility to be interviewed as well so the Administrator terminated the CNA #1 for failure to comply with the investigation and marked her file as ineligible for rehire. The Administrator stated that CNA #1 had confirmed that she had pulled Resident #53 by the arms that morning but had stated she had done it because she was falling off the bed. The Administrator stated that CNA #1 was not a stellar employee and that the facility had issues with her in the past with using a loud voice with residents and the facility had talked to her about this but had not had concerns with her being physically abusive to residents. Review of CNA #1's employee file revealed that she was hired on 06/01/15, and the CNA had a signed Disciplinary Action dated, 05/19/20 that stated, Offense: Carelessness, Poor Performance, not completing timely rounds, leaving residents wet, and talking to residents inappropriately. Further actions that will be taken if conduct is repeated: Termination. Record review of CNA #1's Personnel Termination Notice, dated 12/02/20 revealed, Terminated: speaking abruptly to resident. Review of CNA #1's timecard, dated 12/01/20, revealed that CNA #1 was in the facility until 7:13 AM when she clocked out for the end of her shift. The SA attempted to make contact with CNA #1 on two (2) attempts at two (2) separate phone numbers. Neither were working numbers and the SA was not able to reach CNA #1 to obtain an interview. Review of the employee's file for CNA #1 indicated that she had a signed in-service for Abuse Prevention and Vulnerable Adults, dated 05/29/15. An interview with the Administrator, on 02/25/21 at 10:00 AM, revealed that the facility was not able to find an in-service that the employee attended since that date. The Administrator stated, We in-service our staff on abuse and neglect four (4) times a year and she was an 11-7 CNA and should have attended in-services for abuse and neglect since 2015, but we have not been able to find her signature on any of the other in-services. Record review of the Face Sheet revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident's Brief Interview for Mental Status (BIMS) assessment, dated 10/27/20, revealed a score was 15 at the time of the incident, indicating resident had full cognitive ability. Record review of the Face Sheet revealed Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident's BIMS score dated 11/12/20 was 14, indicating full cognitive ability. The resident's most recent BIMS dated 02/03/21 was a 9, indicating moderate cognitive impairment.

Based on staff interviews, facility in-service review, record review and facility policy review, the facility failed to provide in-services to staff as required for federal and state requirements regarding abuse and neglect for one (1) of six (6) employee files reviewed, Certified Nursing Assistant (CNA) #1. Findings include: Review of the facility's Abuse Program policy, dated 05/23/17 noted, It is the policy of this facility to take all steps necessary to maintain an environment free of abuse and neglect. Each resident has the right to be free from verbal. sexual, physical, and mental abuse. The facility is committed to protecting the residents from abuse by anyone including, facility staff. Procedures to Prevent, Training: All facility staff and volunteers will be trained/in-serviced at least annually and as needed regarding Resident Rights, including freedom from abuse, neglect and mistreatment. Review of the employee file for CNA #1 indicated that she had a signed in-service for Abuse Prevention and Vulnerable Adults, dated 05/29/15 that the employee attended when her employment began. The State Agency (SA) was unable to find another in-service since that date that CNA #1 had attended. An interview with the Administrator on 02/25/21, at 10:00 AM, revealed that the facility was not able to find an in-service that the employee attended since 5/29/15. The Administrator stated, We in-service our staff on abuse and neglect four times a year and she was an 11-7 CNA and should have attended in-services for abuse and neglect since 2015, but we have not been able to find her signature on any of the other in-services. An interview with the Staff Development Nurse, on 02/25/21 at 10:15 AM, revealed that the facility will utilize an employee roster from this point on to ensure that all employees have attended in-services and confirmed that they could not find CNA #1's signature on any of the recent in-services that the facility completed on abuse and neglect. The SA attempted to make contact with CNA #1 on two (2) attempts at two (2) separate phone numbers. Neither were working numbers and the SA was not able to reach CNA #1 to obtain an interview. Record review of a document signed by CNA #1 titled, Teachable Moments, dated 11/04/15, stated, You are responsible for signing all in-services that are put out by the facility. After today, when these are checked, if you have not signed them, this will result in a write up.

Based on observation, staff interview, and facility policy review, the facility failed to ensure foods were stored, prepared, and served under sanitary conditions for one (1) of two (2) kitchen observations. Findings include: Review of the facility's Monitoring Temperatures of Cooked Foods policy, dated 10/08, noted, Policy: The temperature of potentially hazardous cooked foods will be monitored to insure that the foods are not in the danger zone (above 41 degrees Fahrenheit and below 135 degrees Fahrenheit) for more than six (6) hours. 5. All parts of reheated cooked foods must reach 165 degrees Fahrenheit for 15 seconds. Foods are discarded after being re-heated once. Review of the facility's Sanitary Conditions of the Food Service Department policy, dated 9/04, noted: Policy: Facilities and equipment used in the preparation and serving of food provided to residents are safe and sanitary. Observation on 03/25/19 at 11:00 AM, with the Dietary Manager revealed the following: Strawberries, biscuits, pancakes, and peppers and onions stored in the freezer were not labeled or dated to note when they were opened and placed in the freezer; Food particles were observed on the grill cover of the mixer; An accumulation of grease was noted on the inside of the microwave; An accumulation of dust was observed on the ceiling around the air vent near freezers over the mixer; and, A build up of ice was noted around the sides of the ice cream freezer. Observation of food temperatures on the tray line revealed the temperature of hot foods were as follows: Pureed broccoli 120; Chopped chicken - 120; and, Pureed corn -120. Pureed broccoli was re-heated to130 degrees Fahrenheit (F), re-heated again to 135 degrees F, re-heated again to 150 degrees F; and re-heated again to 160 degrees F. This item was served to residents after being re-heated more than once. Chopped chicken was reheated to 130 degrees F, and re-heated to 150 degrees F. This item was served to residents after being re-heated more than once. Corn was reheated to 130 degrees F, and re-heated to 150 degrees F. This item was served to residents after being re-heated more than once. Interview on 3/28/19 at 10:40 AM, with the Dietary Manager, confirmed foods were re-heated three (3) times and served to residents; and, foods in refrigerated areas were not dated and labeled to note when the food items were placed in the freezer. Interview on 3/28/19 at 10:40 AM, with the Interim Administrator and Director of Clinical Operations, acknowledged foods were served to residents after being re-heated more than once and sanitation issues that were observed in the dietary area.

Based on observation, staff interview, resident interview, record review, and facility policy review the facility to ensure a resident was assessed for self administration of medications for one (1) of one (1) residents reviewed for self administering medications, Resident #6. Findings include: Review of the facility's Self Administration Protocol, not dated, noted: Policy: Bedside medication storage is permitted for residents are willing and able to self-administer medications upon the written order of the prescriber, when it is deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team, and in accordance with the law. Observation on 3/25/19 at 12:25 PM, revealed a clear medication cup containing pills on the over bed table in the room of Resident #6. Interview with Resident #6 regarding the medications, revealed Resident #6 stated, I'm going to take them. Record review review the 11 medications that were in the medication cup for Resident #6 were [MEDICATION NAME], [MEDICATION NAME] Blend capsule, Vitamin D3 capsule, Vitamin B12 capsule, [MEDICATION NAME], Singular, [MEDICATION NAME], and [MEDICATION NAME]. Interview on 3/27/2019 at 3:35 PM, with the Director of Nursing (DON), revealed there were no residents the facility that had been assessed to self administer medication. The DON was informed of the medication cup observed on the overbed table on 3/25/19 at 12:30 PM in the room or Resident #6. The DON stated, That is not our policy. The DON confirmed the facility's policy on self administration of medication had not been followed. Interview on 3/28/2019 at 10:40 AM, with the Interim Administrator and Director of Clinical Operations, acknowledged they were aware that Resident #6 had not been assessed to safely self administer the medications left on the overbed table in Resident #6's room. Record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #6 is cognitively intact.

Based on observation, staff interview, resident interview, and facility policy review, the facility failed to ensure Resident #19 and #23's privacy and dignity during the staff's provision of personal care. This concern was identified for two (2) of 16 sampled residents observed for privacy and dignity. Findings include: Review of the facility's policy titled, Resident Rights, with no date, revealed the resident has a right to be treated with respect and dignity. Resident #19 On 6/27/18 at 10:07 AM, an observation during Resident #19's medication administration through a Percutaneous Endoscopic Gastrostomy (PEG) tube revealed Licensed Practical Nurse (LPN) #2 pulled the residents shirt up to his upper abdomen, and the bed covers down to his lower abdomen exposing his abdomen, top of briefs and PEG tube. The privacy curtain between Resident #19 and his room mate was pulled out approximately five (5) feet from the wall between their beds. The door was closed, but there was no privacy curtain pulled that provided full body privacy around the resident. LPN #2 checked for placement of the PEG tube, and attempted to flush the tube with water while Resident #19 was fully exposed to anyone entering or exiting the room. Resident #19 was fully exposed to a visitor when he opened the door and walked past the resident to visit his room mate at 10:20 AM. The visitor looked at Resident #19 with his abdomen, and upper part of his brief exposed. On 6/27/18 at 10:45 AM, an interview with LPN #2 confirmed she did not provide privacy during checking placement of the PEG tube, and the attempt to flush the tube with water. LPN #2 revealed she had been inserviced on privacy, and was just very nervous and forgot. LPN #2 confirmed leaving a resident exposed would be a dignity issue. On 6/27/18 at 11:45 AM, an interview with Resident #19 revealed he was aware that the visitor saw him during the medication administration, and his stomach was exposed. Resident #19 revealed it had happened before, and he would rather be covered up. Review of the Face Sheet revealed Resident #19 was admitted by the facility, on 8/23/15, and readmitted on [DATE]. The Current [DIAGNOSES REDACTED]. Review of Resident #19's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/20/18, revealed Basic Interview for Mental Status (BIMS) score was 3, which indicated severe cognitive impairment. Further review of the MDS revealed Resident #19 was coded for a feeding tube, and received 51% (percent) or more of his caloric intake via the feeding tube. Resident #23 On 06/27/2018 at 2:15 PM, an observation revealed Resident #23 was on his bed in his room with Certified Nursing Assistant (CNA) #1 at his bedside facing the door. Resident #23's door was open, and his privacy curtain was pulled to his mid chest area exposing the resident from his waist down to anyone passing his room, and/or looking into his room. Resident #23 was observed on the bed with only a brief on his lower body. No pants were on, and no bed linens were covering the residents lower body. CNA #1 looked at the surveyor at the door and did not pull the curtain. The surveyor requested Registered Nurse (RN) # 1 to come to Resident #23's room, and when RN #1 entered the room she immediately pulled the curtain to provide privacy. On 6/27/18 at 2:25 PM, an interview with CNA #1 confirmed she did not pull the privacy curtain, and was aware that the door was not shut. CNA #1 stated she knew she should provide privacy, it is a dignity issue, and she has been inserviced on privacy. On 6/27/18 at 2: 35 PM, an interview with RN #1 confirmed the door was open, and the resident was exposed to anyone walking down the hall. Review of the Face Sheet revealed Resident #23 was admitted by the facility, on 4/21/17. The Current [DIAGNOSES REDACTED]. The Additional [DIAGNOSES REDACTED]. Review of Resident #23's Annual MDS, with an ARD of 4/8/18, revealed a BIMS Score of 10, which indicated moderate impaired cognition. Further review of the MDS revealed the resident required extensive assistance with two person physical assist with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident #23 was also coded for Range of Motion (ROM) impairment on one side of his extremities.

Based on resident interview, record review, staff interview, and facility policy review, the facility failed to develop a comprehensive care plan for Resident #34, #41, #48, and #57, for four (4) of 16 resident care plans reviewed. Findings Include: Review of the facility's policy title, Comprehensive Care Plans, with a review and revised date of 12/1/17, revealed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will be developed within 7 (seven) days after the completion of the comprehensive MDS (Minimum Data Set) assessment. Resident #34 On 06/26/18 at 4:00 PM, an interview with Resident #34 revealed he was having increased phantom pain in his right lower extremity amputation. Review of Resident #34's (MONTH) (YEAR) physician's orders [REDACTED]. (milligrams) caplet twice daily for shoulder pain starting (2) 6/27/18, and [MEDICATION NAME] 500 mg. caplet twice daily for shoulder pain starting 6/28/18. (3) 8/15/17, [MEDICATION NAME] 600 mg. by mouth at noon for pain in right leg. (4) 8/15/17, [MEDICATION NAME] 325 mg. - give 2 (two) tablets by mouth every four hours as needed for pain. (5) 8/15/17, [MEDICATION NAME]-Actaminophen 10-325, take one tablet by mouth every four hours as needed for pain related surgical amputation. Record review of the Care Plans for Resident #34 revealed that a care plan for pain had not been developed. On 06/27/18 5:45 PM , during an interview with Licensed Practical Nurse #1/Minimum Data Set (MDS) Coordinator, revealed she stated a care plan for pain was not developed. She stated, I guess I just skipped over it when I did his care plans. The purpose of a care plan is so that everybody knows what we are supposed to be doing for the resident, so he can get the care he needs. During an interview with the Director of Nursing (DON), on 06/27/18 6:04 PM , regarding a care plan for pain for Resident #34, she stated, He should have had one. She stated that the purpose of a care plan is, So everybody would know what their treatment plan was. Review of the Face Sheet revealed Resident #34 was admitted by the facility, on 7/9/17, and readmitted on [DATE]. The Current [DIAGNOSES REDACTED]. The Additional [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/13/18, revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The MDS also revealed Resident #34 had received PRN (as needed) pain medicatoins during the assessment observation period. Further review of the MDS revealed Resident #34 required extensive assistance with two person physical assist with bed mobility and transfers. Resident #34 required extensive assistance with one person physical assist with dressing, toilet use, and personal hygiene. Resident #34 was coded for impaired Range of Motion (ROM) to one side of his lower extremities. Resident #41 Review of Resident #41's Face Sheet revealed she was admitted by the facility, on 4/19/18. Review of Resident #41's Admission MDS revealed the MDS was dated 4/19/18, and the 14 Day MDS was dated 5/2/18. Review of Resident #41's Care Plan revealed an Immediate Care Needs - Baseline Care Plan, dated 4/20/18. Further review of the Care Plan revealed no Comprehensive Care Plan completed seven days after completion of the Comprehensive Assessment. Resident #48 Review of Resident #41's Face Sheet revealed she was admitted by the facility, on 5/14/18. Review of Resident #41's Admission MDS revealed the MDS was dated 5/21/18, and the 14 Day MDS was dated 5/27/18. Review of Resident #41's Care Plan revealed an Immediate Care Needs - Baseline Care Plan, dated 5/16/18. Further review of the Care Plan revealed no Comprehensive Care Plan completed seven days after the completion of the Comprehensive Assessment. Resident #57 Review of Resident #57's Face Sheet revealed she was admitted by the facility, on 5/18/18. Review of Resident #57's Admission MDS revealed the MDS was dated 5/25/18, and the 14 Day MDS was dated 5/31/18. Review of Resident #57's Care Plan revealed an Immediate Care Needs - Baseline Care Plan, dated 5/21/18. Further review of the Care Plan revealed there was no Comprehensive Care Plan completed seven days after completion of the Comprehensive Assessment. An interview with Licensed Practical Nurse (LPN) #1/Minimum Data Set (MDS) Coordinator, on 06/28/2018 at 11:30 AM, revealed the comprehensive care plan for Resident #41, Resident #48, and Resident #57 had not been completed. An interview with Registered Nurse (RN) #1, on 06/28/2018 at 11:45 AM, revealed the RN on duty completed the baseline care plan when the resident was admitted , and updated it as needed. An interview with the Director of Nursing (DON), on 06/28/2018 at 11:50 AM, revealed she was not aware the comprehensive care plan on Resident #41, Resident #48, and Resident #57 was not complete. An interview with the Administrator, on 06/28/2018 at 12:00 PM, revealed she was not aware the comprehensive care plan for any residents was not completed on time.

Based on observation, staff interview, and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by the nurse failed to wash hands and change gloves appropriately, and failed to place supplies on a clean barrier during care for two (2) of two (2) Percutaneous Endoscopic Gastrostomy (PEG) tube site treatments; which included two (2) of five (5) care observations. Resident # 10 and Resident #11. Findings include: Facility policy titled Standard Policy, undated, revealed Standard Precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infections (HAI) agents among patients and healthcare personnel. The procedure included to wash hands when visibly soiled, after contact with blood, body fluids, secretions, excretions, patient's intact skin or wound dressings and contaminated items and immediately after removing gloves and between patient contacts. Facility policy titled Dressing Change, undated, revealed the procedure included to use paper towels or a barrier to set up work area if appropriate. Resident #11: During an observation of PEG site care of Resident #11, on 3/2/17 at 9:00 AM, Registered Nurse (RN) #1 donned gloves outside Resident #11's door at the treatment cart, knocked on the door, positioned the privacy curtain, adjusted the bed, performed care and did not change gloves for the entire care observation and did not wash hands after removing gloves upon completion of the procedure. RN #1 also placed supplies for PEG care on the bedside table without the use of a clean barrier. Interview on 3/2/17 at 10:00 AM, with RN #1, confirmed she put her gloves on before entering the room, did not change gloves appropriately, contaminated supplies by placing them on the bedside table without a barrier, and did not wash her hands or use hand sanitizer at any time during the procedure. RN #1 confirmed she had attended in-services on Infection Control. Interview on 3/2/17 at 11:00 AM, with the Infection Control Nurse (ICN), Licensed Practical Nurse (LPN) #1, confirmed infection control in-services are done and prn (as needed) staff are notified about them. She stated that the written in-service documentation is placed at the nurse's desk for staff who do not attend the in-service to read. Record review revealed on 1/16/17 an in-service titled, Infection Control was provided by LPN #1 and documentation revealed RN#1 attended. The facility admitted Resident #11 on 9/7/16, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/02/16, revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated that Resident #11 had moderately impaired cognition. Resident #10: On 3/2/17 at 9:25 AM, an observation of Registered Nurse (RN) #1 revealed she performed PEG site treatment on Resident #10. RN #1 gathered gauze, normal saline and moisture barrier from the drawer of her treatment cart, setting it all on top of the unclean top of the cart. RN #1 entered Resident #10's room and placed the supplies on the resident's bed linen, pulled the privacy curtain, and then moved the supplies onto the edge of the incontinent pad under the resident. RN#1 then performed the treatment to the PEG site with contaminated supplies. On 3/2/17 at 10:00 AM, an interview with RN #1 confirmed she placed the gauze, normal saline and moisture barrier on Resident #10's bed linens and incontinent pad. RN #1 confirmed she then used the contaminated supplies to perform the PEG treatment on Resident #10. RN #1 confirmed using contaminated supplies could cause potential infection to Resident #10. RN #1 revealed she had attended in services and check off's for infection control. On 3/2/17 at 10:30 AM, an interview with the Director of Nursing (DON) confirmed nurses should use a clean barrier for supplies when performing treatments on residents. The DON stated prn staff are notified when in-services are scheduled and if they do not attend, the written in-service is placed at the nurse's desk for review. The DON stated RN #1 knew when to wash her hands, change gloves and use a barrier to place supplies on. The DON stated, There is no way I can defend that. The facility admitted Resident #10 on 10/3/14, with [DIAGNOSES REDACTED]. Review of Resident #10's Quarterly MDS with an ARD of 12/4/16, revealed a BIMS score of zero (0) which indicated a severely impaired cognition.

Based on observation, record review, staff interview and facility policy review, the facility failed to administer the correct dose of the medication [MEDICATION NAME] for one (1) of six (6) residents observed during medication administration. (Un-sampled Resident #A). Findings Include: Review of facility policy entitled Medication Administration General Guidelines, not dated, revealed medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. Prior to administration, the medication and dosage schedule on the residents MAR (Medication Administration Record) is compared with the medication label. Information on the medication should be checked against the MAR indicated [REDACTED]. If the label and MAR indicated [REDACTED]. If the medication is discontinued, outdated or unusable, remove the medication for proper disposal. Review of Un-sampled Resident #A's physicians orders revealed an ordered dated 2/21/17, which read: [MEDICATION NAME] 20 MG (milligram)Tablet per Peg (Percutaneous Endoscopic Gastrostomy) tube Daily. Observation of Medication Administration on 03/01/17 at 09:30 AM, revealed License Practical Nurse (LPN) #2 administered Un-sampled Resident # A a 40 mg dose of [MEDICATION NAME] (one tablet). During an interview on 03/01/17 at 11:15 AM, LPN #2 confirmed the medication error for Unsampled Resident #A. She confirmed the order had changed to 20 mg of [MEDICATION NAME] per day and said she had been breaking the 40 mg tablets in half to give a 20 mg dose. LPN #2 revealed there should have been a change in order sticker on the [MEDICATION NAME] 40 MG medication card. She said she should have just pulled the 40 MG card of [MEDICATION NAME] doses and used the 20 MG [MEDICATION NAME] doses. LPN #2 stated she was nervous and had never been observed by a state surveyor. Review of the medication card revealed the 40 mg dose pack of [MEDICATION NAME] for Unsampled Resident #A was filled on 02/18/17, and was missing 10 tablets out of 14 tablets in the card that had been ordered. Review of the medication card revealed the 20 mg dose pack of [MEDICATION NAME] for Unsampled Resident #A was filled on 02/22/17, and was unopened, with 14 of the 14 tablets ordered remaining in the card. During an interview on 03/02/17 at 10:30 AM, The facility Director of Nursing (DON) revealed that LPN #2 was trying to use the rest of the 40 mg pack of [MEDICATION NAME] for Unsampled Resident #A. She revealed the 40 mg [MEDICATION NAME] tablets were scored tablets and could easily be broken in half. She revealed that an order change sticker notification should have been attached to the 40 mg card of medication, but was not. Record Review revealed the facility admitted Un-sampled Resident A on 02/18/17, with [DIAGNOSES REDACTED]. Record Review of a hospital document titled Discharge Summary(date 02/09/17) revealed Un-sampled Resident A was hospitalized prior to admission to the Long Term Care Facility due to acute kidney injury due to dehydration.

Based on record review, observation, staff interview, and facility policy review, the facility failed to provide a safe environment, free of accidents and hazards, for one (1) of two (2) incidents of abuse and neglect allegations reviewed. (Resident #1). Findings included: Resident #1 Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] , with diagnosis' of: Subtrochanteric Closed Fracture, Obstructive Chronic Bronchitis, Diabetes, Muscle Weakness , Congestive Heart Failure Unspecified, Venous Insufficiency and Atherosclerosis. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/2012 revealed that Resident #1 had a Brief Interview Mental Status (BIMS) score of 10, which indicates moderately impaired cognitive status. Review of Resident #1's admission assessment to local acute care hospital Emergency Department dated, 08/31/2012 at 5:21 p.m., revealed that Resident #1 was treated for [REDACTED]. Report stated, "The patient presents with complaints of having a weight accidently dropped on her right lower leg. The Patient was in the process of receiving physical therapy and a weight fell on top of her leg. She is in the nursing home for rehab due to her right hip replacement. No other problems." Procedure from this report revealed that the laceration was measured to be 9 centimeters and was closed with sutures/staples. Review of Resident #1's Care Plan with the Problem/ Need titled, "Laceration to Lower Leg," with onset date of 08/31/12, revealed that the laceration area was not determined to be healed until 02/07/13. Care Plan revealed that Resident #1 required interventions of dressing changes, pain control and treatment from local wound care center prior to wound healing. Review of Resident #1' assessment at local wound care center titled, "Wound Care Progress Note (Name of Hospital), dated 11/13/12, revealed that resident required debridement to the lower extremity wound measuring 3.1 X 3.3 X0.2. Progress report stated, "Several weeks ago she (Resident #1) had some weights during therapy fall on her right leg. She required several sutures and has had a residual wound ever since. She has had problems with chronic venous hypertension and venous stasis wounds in the past." This report further stated, "Open wound right lower extremity caused by trauma but failing to heal due to chronic venous hypertension and edema." Review of the facility's investigation report titled, "Supervisor Investigation Summary Form" revealed that the investigation into the incident resulted in the laceration to Resident #1's leg began on 8/31/12. Interview with the Director of Therapy, Therapist #2, on 2/26/13 at 11:50 p.m. revealed that Therapist #1 was utilizing an Upper Body Exerciser (UBE) (arm bike) that was placed on an over the bed table, which has rolling wheels. Therapist # 2 stated, "She was using it (weights), to keep the table from shaking. They learn to use this (UBE) in school." Interview with Therapist #1, by phone on 2/26/13 at 12:15 p.m., Therapist #1 stated, "It (UBE) was on the bedside table, was weighted down with flat weights and bar bell hand weights. I was looking at her leg and I did not look to see if everything was aligned." Therapist #1 described while pulling bedside table with UBE placed on table with weights (flat weights and two hand weights), one hand weight fell on Resident #1's leg. Therapist #1 further confirmed that this was the UBE which was used in facility regularly and always had weights on it for stability. Therapist #1 further confirmed that the weights on bedside table where not to be used for Resident's #1 therapy. Therapist #1 stated, "That was a lessoned learned." Observation of yellow bar bell hand weight shown by Therapist #2 as the type of barbell weight which caused injury to Resident #1 on 2/26/13, revealed that weight was four (4)pounds. Interview with Resident #1 on 2/26/13 at 12:30 p.m., Resident #1 stated, "I got 26 stitches. They (UBE) are fastened down now in memory of me after all my suffering. Thank God." Resident #1 further stated, "Bike (UBE) was secured down with dumbbells to keep it from moving." Resident #1 also stated," No I was not going to use them (weights), they had it to secure the bike (UBE) down." Observation of UBE on 2/26/12 revealed that UBE is now bolted to bedside table for stability with no weights observed. Review of form titled, "Supervisor Investigation Summary Form," dated 8/31/12, stated, "All arm and leg bikes were inspected by the Maintenance Supervisor and appropriately bracketed and bolted to the over the bedside tables to prevent slippage and ease of mobility and safety for the residents and therapists." Policy titled, "Arm Bike Use on Table Top", dated 09/03/12, stated, "Each arm bike will be secured to table using screws/bolts, clamps, and/or brackets, that will prevent shifting and movement so to decrease the risk of injury to the resident." Therapist #2 noted at the bottom of this policy dated 2/26/13, "There was no policy addressing the securing of an arm bike to a table." Review of facility policy titled, "Policy/Procedure for the Prevention of Accidents," revealed, "This policy is written to ensure that (name of facility) employees, contractors and visitors follow safe work practices, report unsafe work conditions promptly, report accidents and incidents and work to prevent reoccurrence. Accidents include all sudden or non-sudden events that cause injury to a person. Even minor injuries such as cuts or sprains are considered accidents."