Every finding on record at Riverside Manor NRSG & Rehab CTR

Based on observation, policy review and interview, the facility failed to dispose of opened insulin pens in accordance with manufacturer instructions and failed to consistently monitor medication refrigerator temperatures. This affected 14 residents (#2, #3, #4, #7, #10, #24, #30, #31, #41, #46, #50, #54, #58, and #69) of 47 residents who resided on the 200, 300 and 400 hallways. The facility census was 63. Findings include:1.On 08/11/26 at 2:31 P.M., observations of the 400 hall medication cart with Registered Nurse (RN) #138 revealed an opened humalog insulin pen for Resident #58 which was opened on 07/02/26. On 08/11/26 at 2:31 P.M., RN #138 verified Resident #58's humalog insulin pen had been opened 07/02/26 per the label. RN #138 stated the humalog pen should have been disposed of after 30 days. Review of a humalog medication insert revealed once opened, humalog pens should be thrown away after 28 days even if it still contained insulin. 2. On 08/11/26 at 2:35 P.M., observations in the medication room for 200 and 400 hall revealed the temperature of the refrigerator was 48 degrees. RN #138 stated the refrigerator had been open. RN #138 stated the refrigerator temperatures were supposed to be monitored every day. Review of temperature logs revealed in May 2026 there were 19 days with no temperature recorded. In June 2026 there were 20 days with no temperature recorded. In July 2026 there were 17 days with no temperature recorded. Between 08/01/26 and 08/11/26 there were four days with no temperature recorded. RN #138 verified the medication refrigerator logs did not reveal the temperatures were monitored on at least a daily basis. At 3:00 P.M. the medication refrigerator thermometer read 40 degrees. 3. On 08/11/26 at 2:50 P.M., observations of the 300 hall medication refrigerator logs for August 2026 revealed there was no temperature recorded on 08/09/26 or 08/10/26. This was verified by Licensed Practical Nurse (LPN) #116 at that time. The facility identified Residents #2, #3, #4, #7, #10, #24, #30, #31, #41, #46, #50, #54, #58, and #69 as having medications stored in the above refrigerators. Review of the facility's Medication Storage policy (effective 06/02/15) revealed medications requiring refrigeration were to be kept at temperatures between 36 and 46 degrees with a thermometer kept in the refrigerator to allow temperature monitoring. Outdated, contaminated or deteriorated medications were to be immediately removed from stock.

Based on observations, review of physician orders, review of medication inserts, policy review and interview, the facility failed to ensure medications were administered without error and the facility medication error rate remained less than five percent Two errors were identified out of 33 opportunities for error resulting in a 6% medication error rate. This affected two residents (#24 and #26) of four residents observed for medication administration. The facility census was 63. Findings include:1. Review of Resident #24's medical record revealed diagnoses including type two diabetes mellitus and cirrhosis of the liver. On 06/22/26, an order was written for fiasp flex touch subcutaneous solution pen-injector 100 units per milliliter (u/ml) (fast acting insulin plus vitamin B3 to speed absorption into the bloodstream) with instructions to inject 4 units three times a day and an order for fiasp in accordance with a sliding scale three times a day. A blood glucose reading of 201-250 required two units to be administered. On 08/11/26 at 11:02 A.M., Licensed Practical Nurse (LPN) #117 was observed monitoring Resident #24's blood glucose level with a reading of 215 obtained. While preparing fiasp insulin for administration via the flexpen, the dose selector was dialed to six units without priming the insulin pen. The needle was then applied to the pen and the insulin was administered at 11:04 A.M. On 08/11/26 at 11:05 A.M., LPN #117 verified she had not primed the insulin pen, stating it was not necessary for fiasp. Review of the drug insert for fiasp revealed before each injection a small amount of air might collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing, turn the dose selector to select two units. Hold the pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push button all the way in. The dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. After ensuring the dose selector was at zero, turn the dose selector to the number of units you need to inject. Review of the facility's policy for Multidose Pens of Injectable Medications (effective 06/02/15) revealed instructions to prime the pen in accordance with manufacturer's guidelines. 2. Review of Resident #26's medical record revealed a physician order to start fluticasone-salmeterol 100-50 micrograms per actuation aerosol powder (combination medication classified as an inhaled corticosteroid and long- acting beta2-adrenergic receptor) with instructions to inhale one puff orally twice a day for malignant neoplasm of the upper lobe, right bronchus or lung on 04/07/26. On 08/11/26 at 8:02 A.M., Registered Nurse (RN) #106 was observed preparing and handing the fluticasone-salmeterol inhaler to Resident #26 for administration. No water was offered or instruction provided to rinse Resident #26's mouth after the medication was inhaled. On 08/11/26 at 8:08 A.M., RN #106 verified she was unaware Resident #26's mouth should have been rinsed after the administration of the fluticasone-salmeterol. At that time, the instructions on the back of the box were reviewed with RN #106 who verified it indicated a person's mouth should be rinsed after administration. Review of the fluticasone propionate and salmeterol inhalation powder for oral inhalation insert revealed after removing the inhaler from one's mouth, breath should be held for about ten seconds or for as long as was comfortable. Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it.

Based on observation, review of physician orders, review of drug manufacturer information, policy review and interview, the facility failed to ensure a resident was free from a significant medication error. This affected one resident (#24) of four residents reviewed for insulin administration. The facility census was 63. Findings include:Review of Resident #24's medical record revealed diagnoses including type two diabetes mellitus and cirrhosis of the liver. On 06/22/26, an order was written for fiasp flex touch subcutaneous solution pen-injector 100 units per milliliter (u/ml) (fast acting insulin plus vitamin B3 to speed absorption into the bloodstream) with instructions to inject 4 units three times a day and an order for fiasp in accordance with a sliding scale three times a day. A blood glucose reading of 201-250 required two units to be administered. On 08/11/26 at 11:02 A.M., Licensed Practical Nurse (LPN) #117 was observed monitoring Resident #24's blood glucose level with a reading of 215 obtained. While preparing fiasp insulin for administration via the flexpen, the dose selector was dialed to six units without priming the insulin pen. The needle was then applied to the pen and the insulin was administered at 11:04 A.M. On 08/11/26 at 11:05 A.M., LPN #117 verified she had not primed the insulin pen, stating it was not necessary for fiasp. Review of the drug insert for fiasp revealed before each injection a small amount of air might collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing, turn the dose selector to select two units. Hold the pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push button all the way in. The dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. After ensuring the dose selector was at zero, turn the dose selector to the number of units you need to inject. Review of the facility's policy for Multidose Pens of Injectable Medications (effective 06/02/15) revealed instructions to prime the pen in accordance with manufacturer's guidelines.

Based on review of the medical record, review of resident funds and interview of staff the facility failed to timely disburse resident funds following resident death. This affected one resident (#73) of five residents reviewed for resident funds. The facility census was 63 residents. Findings include:Review of the medical record revealed Resident #73 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's, diabetes, hypertension, chronic fatigue, asthma, insomnia, dementia, major depressive disorder, colitis, anorexia, anxiety disorder, and dysphagia. Resident #73 expired on [DATE]. Review of the Trust History Transaction from [DATE] through [DATE] revealed Resident #73 had a closing balance of $80.02 on [DATE]. Review of the photocopy of the check dated [DATE] revealed the facility sent $80.02 to the Treasurer of The State of Ohio for reimbursement upon death for Resident #73. On [DATE] at 11:33 A.M. an interview with Business Office #180 stated reimbursement needed to be within 30 days. She verified Resident #73 reimbursement was not sent back within 30 days.

Based on record review, review of therapy records, review of the facility's investigation, review of employee conference reports, and interviews with resident(s), family, and staff, the facility failed to ensure a resident was transferred safely following physical therapy recommendations. This resulted in Actual harm on 04/12/26 when Resident #1 was improperly transferred resulting in a fractured arm. This affected one (#1) of three residents reviewed for accidents and injuries.Findings include:Medical record review revealed Resident #1 was originally admitted to the facility 05/06/25 and re-admitted on [DATE] with diagnoses that included displaced fracture of base of neck of right femur, nondisplaced fracture of surgical neck of right humerus, anemia, orthopedic aftercare, restless legs, heart failure, kidney disease, and hyperlipidemia. Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was admitted [DATE] with diagnoses including heart failure, renal disease, and hyperlipidemia. The resident had moderate cognition impairment. No limited range of motion and used a walker and wheelchair. The resident had no falls, no orthopedic surgeries, and was in a restorative program for walking. The resident's functional assessment included set up for eating, oral care, upper body dressing, and personal hygiene. She required partial to moderate assistance for toileting, lower body dressing, rolling, sitting to lying, lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer, and tub to shower transfer. The resident required supervision or touching assistance for showers, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. She required staff assistance with placing her footwear. Review of Resident #1's orders dated 04/01/26 revealed an active order to transfer with one assist walker and gait belt for transfers. On 04/09/26 new ordered added weight bearing as tolerated to right lower extremity and 04/20/26 transfer with two assistance and sit to stand. Review of Resident #1's progress note authored by the Director of Nursing (DON) dated 04/07/26 at 10:43 A.M., revealed on Easter Sunday the resident went out to church and then to family's home. She was up walking with daughter and didn't lift foot up high enough and had lost balance and family lowered her to the floor. The family then picked her up and placed her in a chair, got her to the car and brought her back to the facility. She was manually lifted by family to wheelchair and got back into the room to use bedside commode. She could not bear weight on the right leg. She was sent to emergency room for evaluation and diagnosed with a fractured hip per family and sent to another hospital for surgery. Plans were for her to return after stabilized. Review of Resident #1's progress note authored by Licensed Practical Nurse (LPN) #102 dated 04/09/26 at 7:51 P.M., revealed Resident #1 was re-admitted from the hospital following surgical repair of right femur neck fracture. The resident weight bearing status was noted as tolerated to right lower extremity.Review of Resident #1's hospital notes dated 04/09/26 revealed to follow the following intervention to prevent hip dislocation: do not pivot, do not bend hip beyond 90 degrees, do not bend forward, do not sit in a low chair, and weight bearing as tolerated to right lower extremity. Review of Resident #1's physical therapy note authored by Physical Therapist (PT) #106 dated 04/10/26 at 8:55 A.M., revealed the resident had poor standing balance and was unable to pivot. Recommend Sara Steady (manual lift) or sit to stand lifts for transfers.Record review revealed no evidence the PT's recommendation for Sara Steady or sit to stand lift was ordered or care planned.Review of Resident #1's discharge with anticipation to return MDS dated [DATE] revealed the resident had one major fall with injuries and was discharged on 04/05/26. She was now dependent on staff for toileting, partial assistance for showers, dependent for lower body dressing, and substantial to maximum assistance with rolling, sitting to lying, and lying to sitting. She was now dependent for sit to stand, bed/chair to chair transfer, toilet transfer, and tub to shower transfer. The walking section was skipped.Review of Resident #1's progress note authored by Registered Nurse (RN) #103 dated 04/12/26 at 7:33 P.M., revealed the RN was called to Resident #1's room after an incident during a two-person transfer. The resident was allowed to bear weight following a femur repair but had not been cleared to pivot yet. Two Certified Nursing Assistants (CNA's) were assisting the resident in transferring from wheelchair to recliner. The resident was bearing weight during transfer, then she stopped bearing weight allowing legs to slide out in front of her. The CNA on the resident's right side felt her shoulder move up and heard a crack noise. The CNAs were in front of the recliner and were able to safely set her down. One CNA stayed with the resident while the other got the nurse for an assessment. The resident complained of pain and mild numbness and had limited range of motion. No bruising or obvious deformity at this time. Offered pain medication but was declined, arm resting on pillow for comfort. The on call provider was made aware and x-rays were ordered to right shoulder. Resident #1's daughter and the DON were made aware. Review of Resident #1's x-ray results of the right shoulder dated 04/12/26 revealed no acute fractures or dislocation of the right shoulder. Review of the facility's investigation report dated 04/12/26 revealed Resident #1 was oriented to person, place, time, and situation. The resident had an injury to right shoulder. Updated provider and requested pain medication to be given and ice pack. Certified Nursing Assistant (CNA) #105 reported during a two assistant transfer of Resident #1 from the wheelchair to recliner, CNA #104 and CNA #105 each had the resident under the arm to support her weight on both sides. As we were turning her, her feet started sliding out from under her. CNA #105 heard a loud cracking noise and felt her shoulder move up like it dislocated. We were right in front of the recliner and were able to sit her down safely.CNA #104 reported that she and CNA #105 were assisting Resident #1 with a two person assist, transferring Resident #1 from her wheelchair to the recliner. They had their arms under her arms lifting her into her recliner. Midway through the transfer her feet started to come out from under her. She went dead weight and they quickly got her to the recliners seat. During that they heard a loud crack noise and Resident winced. They were able to lower her to the edge of the seat safely. Gripper socks were on.Further review of the investigation report revealed a note was added on the bottom dated 04/13/26 that revealed the initial x-ray indicated no fractures. Limited range of motion continued day two, so another x-ray was ordered and it showed angulated fracture of the humeral head. The resident was sent to the emergency room and will have an orthopedic follow up. The root cause of the injury was unsuccessful transfer of the resident when she began to slide, and staff had to bear all of her weight under her arms. Intervention was one on one conference with both aids and staff re-education on transfers. Review of Resident #1's progress note authored by Nurse Practitioner (NP) #101 dated 04/13/26 at 11:56 A.M., revealed staff reported during transfer the resident was noted to have a pop in the right upper extremity area. Resident complained of moderate pain. Shoulder x-ray was received and no acute process noted. Upon evaluation range of motion was limited to the right shoulder and the elbow had a large ecchymotic area noted to the internal portion of the right upper arm area and was warm and edematous. Will order for resident to have an x-ray of the clavicle, the proximal humerus, proximal radius and ulna, and venous doppler. Continue Oxycodone for pain or discomfort. Review of Resident #1's x-ray results of right clavicle, right humerus, right elbow, right forearm, and right wrist dated 04/13/26 revealed the right humerus had an acute mildly angulated fracture of the humeral neck, better seen on today's exam. Review of a progress note authored by LPN #102 dated 04/13/26 at 7:03 P.M., revealed the resident was transferred to the hospital due to humerus neck fracture. Review of Resident #1's emergency room note dated 04/13/26 revealed the resident had a closed fracture head of right humerus (the long bone in your upper arm). The facture is in the top part of the bone. Use the sling and swathe until follow-up with the referral to the orthopedic doctor. Review of Resident #1's orthopedic note authored by Medical Doctor (MD) #100 dated 04/15/26 revealed the resident had a right proximal humerus (upper arm) fracture. Surgery was not recommended at this time, due to most people with this type of fracture heal well with non-surgical treatment. You will need to wear a sling for about four weeks. Continue to follow up with her surgeon for the right hip fracture. You may put weight on your right leg as tolerated.Review of CNA #104's employee conference report dated 04/15/26 revealed the reason for the conference was the CNA had transferred a resident by lifting her under her arms instead of using a gait belt. The CNA was provided one on one reminding the CNA to use gait belt with transfers and not to lift residents under arms. Review of CNA #105's employee conference report dated 04/17/26 revealed the reason for the conference was the CNA had transferred a resident by lifting her under her arms instead of using a gait belt. The CNA was provided one on one reminding the CNA to use gait belt with transfers and not to lift residents under arms. Review of Resident #1's alternation immobility related to weakness and decreased endurance plan of care initiated on 07/01/25 revealed the resident ambulation/transfer was updated on 04/21/26 to two assist with sit to stand lift (mechanical lift).Review of Wikipedia revealed a humerus fracture was a break of the humerus bone in the upper arm. Symptoms may include pain, swelling, and bruising. The cause of a humerus fracture is usually physical trauma (excess physical stress, falls, etc.) Treatment options may include a sling, splint, brace, or surgery. In proximal fractures that remain well aligned, a sling was often sufficient.Interview on 04/24/26 at 8:08 A.M., with Resident #1 and her daughter revealed on Easter Sunday the family picked the resident up from the facility and took her home to visit. The resident had fallen while she was home and fractured her hip and it had to be surgically repaired. A week later the staff transferred Resident #1 and fractured her arm. The resident could not recall the incident with the arm and the daughter reported she didn't know exactly what happened with the arm but just knew the fracture occurred when staff were transferring her and not from a fall. The daughter confirmed the first x-ray of the shoulder was negative; however, the next day the resident was still having issues and the provider ordered additional x-rays, and they came back indicating her arm was fractured and the resident was sent to the emergency room. The emergency room ordered a sling due to the fracture that was non-surgical and sent her back to the facility. The daughter reported she didn't feel the staff fractured the resident's arm initially, but something was not right and she was not there when it happened.Interview on 04/24/26 at 8:47 A.M. and 2:00 P.M., with the DON confirmed Resident #1 had sustained a fractured hip while on a short leave of absence to visit family on Easter Sunday. The resident had to have the hip surgically repaired and returned to the facility on [DATE] with orders for full weight bearing. On 04/12/26, CNAs #104 and #105 were transferring Resident #1 with one staff on each side of the resident with their arms hooked under the resident arms without a gait belt. The residents' feet started to slide. The DON reported the aides were different heights and the taller aide CNA #105 was on the right side bearing most of the resident's weight and she heard the resident right arm pop. The resident was having pain and limited range of motion after the incident. The first x-ray was completed just on the right shoulder and was negative. The resident continued to have pain and additional x-rays and views were ordered that showed the resident had an angular right arm fracture. The DON confirmed she was not aware until today 04/24/26 that the physical therapist had evaluated Resident #1 on 04/10/26 and recommended a Sara Steady or sit to stand lift for transfers. The DON reported the usual facility procedure was therapy evaluates resident and verbally reports recommendation during morning meeting and the facility would implement the therapist recommendation. There was no written communication between therapy and the facility if new orders were recommended. The DON confirmed staff on 04/12/26 should have been using a [NAME] Stand and sit to stand lift per therapy and they should have been using a gait belt with any type of resident transfer. The DON reported that the facility did not have a transfer policy and the facility had started a performance improvement plan, however it was related to staff not utilizing gait belts during transfers because she was not aware of staff not following recommendation from therapy until today. The DON confirmed after the resident had fractured her arm and was having difficulty transferring, she had reached out to therapy on 04/20/26 and the staff started utilizing the Sara Steady for transfers unaware the PT had recommended the Sara Steady on 04/10/26.Interview on 04/24/26 at 9:24 A.M. and 12:57 P.M. with CNA #104 confirmed she was one of the CNA's that was transferring Resident #1 on 04/12/26 that resulted in Resident #1's right arm fracture. The CNA confirmed the resident had a history of not bending her legs or help pushing up during transfers and she felt it was a safety issue, but the resident wanted to remain independent. The CNA reported herself and CNA #105 were transferring Resident #1 from her wheelchair to recliner on 04/12/26 using the under-arm technique (one aide on each side of the resident with their arm hooked under the residents arm) and the resident's feet started sliding and the resident started to panic and became dead weight requiring the staff to apply pressure on the residents arms to hold her up. They heard a pop sound and knew it wasn't good. The resident was in pain and couldn't move her arm. They got the resident to the recliner safely and CNA #105 went to get the nurse, and she stayed with the resident. The CNA confirmed they were not utilizing a gait belt because neither one had a gait belt and there was not one in the room. The CNA confirmed she was unaware that therapy recommended a Sara Steady or sit to stand lift for transfers on 04/10/26. The CNA reviewed the physical therapy note dated 04/10/26 with the surveyor and confirmed the therapist had recommended a mechanical lift for transfers. The CNA confirmed staff should follow therapy recommendations and a gait belt should be utilized for all transfers. The CNA confirmed she was provided one on one training on using gait belt with all transfers. Interview on 04/24/26 at 11:52 A.M. with Physical Therapy Assistant (PTA)/Rehabilitation Director #107 confirmed on 04/10/26 the Physical Therapist (PT) had evaluated Resident #1. The PTA originally reported Resident #1 was a two person assist with gait belt; however, she would print the PT's notes for the surveyor to review. After reviewing the PT notes dated 04/10/26 with the PTA, the PTA confirmed the resident should have been utilizing a Sara Steady or sit to stand lift with transfers and not two person assist with gait belt. The PTA confirmed she was not aware of the PT's recommendation on 04/10/26 until today. The PTA confirmed staff should have been utilizing a gait belt as well with all transfers and Resident #1's arm fracture could have potentially been prevented if staff were utilizing a gait belt during the transfer on 04/12/26. The PTA reported she had provided an in-service on gait belts with transfers last week because of the incident involving Resident #1.The facility did not have a policy on transfers.This deficiency represents non-compliance investigated under Complaint Number 2984910.

Based on record review, review of a self-reported incident (SRI), interviews and policy review, the facility failed to ensure Resident #19 was free from verbal abuse. This affected one (Resident #19) out of three residents reviewed for abuse. The facility census was 70.Findings include:Review of the medical record revealed Resident #19 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dementia, anxiety, bipolar disorder, and schizophrenia. Review of the care plan dated 01/09/25 revealed Resident #19 had a behavior of yelling in the common area and in her room. Interventions included to return Resident #19 to her room after meals; if the resident is screaming, offer her favorite snacks ([NAME] Bar or potato chips); ask the resident if she would like to lie down in bed; and approach in a cheerful way. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated cognitive impairment. Resident #19 had verbal behaviors one to three days during the seven-day assessment period. Review of the medication administration record (MAR) revealed Resident #19 had no behaviors on 07/22/25. Review of the facility SRI tracking #263082 dated 07/22/25 revealed Resident #19 was sitting in the dining room with other residents getting ready to eat lunch. Resident #19 began screaming. Certified Nursing Assistant (CNA) #110 said Resident #19's name. Licensed Practical Nurse (LPN) #115 yelled, (Resident #19's name) shut up. Resident #19 was taken out of the dining room and placed in the common area by LPN #115. Resident #19 continued to yell, and LPN #115 took the resident to her room. CNA #110 fed Resident #19 in her room. CNA #110 updated a Registered Nurse (RN) that LPN #115 verbally abused Resident #19. The facility investigation revealed a handwritten interview with LPN #115 by RN #116. LPN #115 stated Resident #19 was yelling in the dining room with other residents around. LPN #115 stated she probably told Resident #19 to shut up. LPN #115 verified she took Resident #19 out of the dining room into the common area, and Resident #19 continued to yell. LPN #115 then took Resident #19 to her room, and CNA #110 fed the resident her lunch. A written statement dated 07/22/25 by CNA #110 revealed they took Resident #19 to the dining room for lunch, and she began screaming loudly. CNA #110 and LPN #115 were in the dining room. CNA #110 shouted Resident #19's name because the resident would often stop when she heard her name. LPN #115 then yelled (Resident #19's name) shut up really loud. LPN #115 then took Resident #19 to the lobby area. Resident #19 continued screaming, so LPN #115 took the resident to her room. CNA #110 served lunch and fed residents as needed and reported the incident as soon as they were able to do so. A handwritten statement by LPN #115 dated 07/22/25 revealed Resident #19 had been screaming since before breakfast. When Resident #19 was brought to the dining room at lunch, the resident continued screaming. Two residents at another table started telling Resident #19 to shut up. LPN #115 removed Resident #19 from the dining room and put the resident at a table in the common area. Resident #19 continued to scream in the common area. LPN #115 then took Resident #19 to her room where CNA #110 fed the resident. LPN #115 wrote that she did not remember what she said. Resident #19's continuous screaming and the other residents getting upset took a toll on LPN #115. A handwritten statement revealed RN #116 interviewed Resident #69 (a resident on the memory care unit). Resident #69 stated nothing happened at lunch. When Resident #69 was asked if he heard yelling, he said yes, a lady was yelling. When asked if staff said anything, Resident #69 said staff did not do anything inappropriately. Resident #69 did state he did not see the staff member, but the staff member was on the other side of the room, but he did hear yelling from the staff member. Resident #69 did not know what the staff member yelled. A handwritten note by CNA #118 (no date) revealed they were walking down the hallway and heard yelling coming from the dining room but did not hear what was said. The facility investigation also included an email from a legal consultant dated 07/23/25 at 4:05 P.M. revealed the following topics should be covered with staff: customer service; abuse, neglect, mistreatment policy with emphasis on verbal abuse, and behavior management as it pertains to preventing abuse. It was recommended that the intradisciplinary team review the resident's chart, reasons for underlying behaviors, medications, other relevant items, and then review the resident's care plan to make sure it addresses the verbal behaviors and how to avoid. The facility should probably not say that Resident #19 was made to eat in her room due to verbal outbursts as it might sound like involuntary seclusion. It should be shown that the facility was working to address Resident #19's behaviors. A chart review would also serve to claim there was no adverse impact to the resident. It should also be said that social service designee checked on the resident to assure them she remained free of adverse physical or psychosocial effects and check on the resident periodically as needed. It was also recommended that audits be done to make sure staff understand what you trained them on to make sure they are good to go, free of abuse. This likely will not constituted a harm tag but having a good action plan in place might help avoid a deficiency altogether even if Ohio Department of Health (ODH) considers it abuse just because she used the words shut up. We will have to look at the wording on the conclusion. Even if we say unsubstantiated, we will want ODH to know that we are owning the situation and taking thorough action. An email from RN #116 to legal consultant dated 07/23/25 at 3:49 P.M. revealed LPN #115 was written up and moved to another unit and received education with a ten-question quiz. Resident #19 will eat all meals in her room due to screaming. LPN #115 was walked to the time clock and put off until the investigation was complete. An interview on 12/04/25 at 3:32 P.M. Administrator verified LPN #115 was unprofessional but stated abuse did not occur because Resident #19 did not have a negative outcome, and LPN #115 did not confirm that she said, shut up. The Administrator verified LPN #115 continued to work after the altercation in the dining room and did not clock out on 07/22/25 until 1:30 P.M. Review of the Policy and Procedure for Prevention of Mistreatment, Neglect, and abuse of Residents and Misappropriation of Resident Property, dated 12/29/16, revealed verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance regardless of their ability to comprehend. When staff members become aware of a possible abuse incident, they should report it to their department head or charge nurse. If the incident involved a possible staff to resident abuse, the administrator and department head will not permit the staff member to work while an investigation is conducted. This deficiency represents non-compliance investigated under Complaint Number 2623349.

Based on record review, review of a self-reported incident (SRI), interviews, and policy review, the facility failed to ensure Resident #18 was not restrained in a wheelchair without adequate training, assessments, and orders. This affected one (Resident #18) out of three residents reviewed for abuse. The facility census was 70.Findings include:Review of the medical record revealed Resident #18 was admitted on [DATE] with diagnoses that included dementia, history of transient ischemic attack, down syndrome, type 2 diabetes, and dysphagia.Review of the plan of care dated 02/20/25 revealed Resident #18 had the potential for injury related to poor decision-making skills. An intervention dated 06/06/25 for the resident to have a custom fitted wheelchair with adaptations for safety when in chair to be delivered after measured and approved by Medicaid. Review of a general progress note dated 06/02/25 at 6:00 A.M. revealed Resident #18 was on the floor in front of the chair. The resident had red drainage noted from the mouth. The resident had a one centimeter (cm) long, 0.1 cm wide, and 0.1 cm deep cut on the inner upper lip and an abrasion 2.0 cm long and 3.0 cm wide in the middle of the forehead. A general progress note dated 06/02/25 at 9:50 A.M. revealed Resident #18's sister requested the resident be sent to the hospital for evaluation. A general progress note dated 06/02/25 at 7:47 P.M. revealed Resident #18 returned to the facility at 7:40 P.M. A general progress note dated 06/03/25 at 2:48 P.M. revealed Resident #18's sisters were concerned about how Resident #18 fell out of her chair. It was explained that the resident went forward out of the chair. The Director of Nursing (DON) spoke to therapy to do a face-to-face so the resident could get a new wheelchair adapted for the resident's body size and with support straps if warranted for safety. Review of the facility SRI tracking #261249 dated 06/05/25 revealed on 06/02/25 Resident #18 lunged forward in chair and fell to the floor. Resident #18 was sent to the hospital for evaluation. On 06/04/25 at 8:45 P.M. the emergency doctor called the facility and reported Resident #18 had a cervical five fracture. Resident #18's family asked if a chest strap could be used while Resident #18 was in the Broda chair (a specialized positioning wheelchair). The DON informed the family that Resident #18 could not release the strap upon command, and it would be considered a restraint. The DON talked with therapy about a custom wheelchair that could be adapted to the resident and consist of lateral supports, tilt in space mechanics, chest harness, and lap belt to promote correct posture and allow Resident #18 to be up in a wheelchair safely and ensure hips remained in the proper position when in the chair to reduce the resident's fall risk. Review of the medical record revealed on 10/06/25 at 6:13 P.M. Resident #18 weighed 106 pounds and was 56 inches tall.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had severely impaired cognitive skills. The MDS also revealed the resident used a wheelchair and was dependent on staff for eating and transfers.Review of the quarterly fall risk tool dated 10/14/25 revealed Resident #18 did not have a fall in the last 30 days. The resident had agitated behavior that occurred less than daily and was confined to a chair and disoriented. The plan of care was ongoing. Review of a general progress note dated 10/21/25 at 12:07 P.M. revealed the DON was notified the new custom wheelchair would be delivered on 10/28/25 at 9:00 A.M. Resident #18's sister stated they would be present for the delivery and fitting of the wheelchair. The sister would be educated by the delivery representative on the safety features of the chair to include the harness which would allow the resident to be up in a chair longer and reduce leaning forward and to the side. In the resident's current chair, she scoots down and bends neck forward.Review of a general progress note dated 10/28/25 at 6:52 P.M. revealed Resident #18 received her new chair this morning. Resident #18 leaned to the right and forward and was repositioned several times.Review of a typed note (no date) revealed Resident #18's new chair 'holister' is to be used only if needed. She does not need to be strapped in unless falling, combative, or leaning.Review of the Occupational Therapy (OT) evaluation dated 10/28/25 revealed treatment may include wheelchair management training. The reason for the referral was a new custom fit wheelchair delivered this date with vendors addressing education with Resident #18's family regarding fit, features/appliances and specialized seating. OT will be required to remain engaged with the wheelchair to promote highest comfort, skin integrity, and positioning in wheelchair. Occupational Therapist Registered (OTR) signed the evaluation and plan of treatment on 10/29/25 at 8:27 P.M. The OTR assessment summary revealed the OTR was not at the location when Resident #18 was fitted to the new wheelchair. Resident #18 was in bed and was no longer in custom wheelchair when OTR arrived to assess the resident. Review of a Safety Device Screen dated 10/29/25 at 4:56 P.M. revealed recommendations to achieve the residents highest physical, mental, and psychosocial well-being included a seat belt and harness to wheelchair for positioning. A summary/explanation of equipment/restraint revealed a new wheelchair was discussed with family and the family opted to proceed with having Resident #18 measured and authorized through Medicaid to get a new wheelchair. When the wheelchair arrived, it was a reclining back tilt in space adaptive wheelchair with a seatbelt and harness to be used for positioning. Resident #18 was not ambulatory and dependent on staff for all transfers; therefore, the use of the harness or seatbelt were not restraints. The seatbelt and harness were enablers to allow Resident #18 to sit up safely in the chair without fear of falling forward and to promote better posture so that the resident could set up after meals because of her severe dysphagia. Review of a general progress note dated 10/29/25 at 5:34 P.M. revealed Resident #18 continued in the new chair and was noted to be leaning more to the right side. The resident was repositioned multiple times and a pillow was placed on the resident's right side. Resident #18 removed the pillow multiple times. At one point the resident was completely sideways on her right side and was leaning all the way out where the resident's hand was on her wheel. Review of a physician order dated 10/29/25 at 6:07 P.M. revealed Resident #18 to be in adaptive wheelchair, with seatbelt, to aid in positioning and harness to be applied as needed for positioning if leaning over the side of the chair. The treatment administration record (TAR) was marked the evening of 10/29/25 and the morning and evening 10/30/25 that Resident #18 was in adaptive wheelchair, with seatbelt, to aid in positioning and harness to be applied as needed for positioning, if leaning over the side of the chair. Review of an OT treatment encounter note signed 10/29/25 at 7:27 P.M. authored by Certified Occupation Therapy Assistant (COTA) #120 revealed staff education and training on proper use, positioning, and safety features of the new wheelchair at 12:00 P.M. prior to lunch. Staff present for the initial training included Physician Therapy Assistant (PTA) #121, Certified Nursing Assistant (CNA) #113, and Restorative Aide/CNA #112. Upon arrival, Resident #18 was observed seated improperly in wheelchair, requiring repositioning with the use of mechanical lift pad to achieve proper alignment and postural support. The resident demonstrated agitation during the session; therefore, the harness was not applied to prevent escalation of behaviors and ensure resident safety. The therapist provided comprehensive education on correct harness placement, including securing harness across the back corner of the chair and fastening the zipper to ensure safe positioning while maintaining adequate comfort and trunk mobility. Instruction was provided on the proper alignment of the harness along the curved contour of the chair back to promote upright posture and reduce fall risk. The therapist also educated staff on appropriate use of the seat belt for positioning purposes, emphasizing its role in maintaining safety, comfort, and fall prevention. The wheelchairs reclining and tilt features were demonstrated to all staff, with detailed explanation of clinical indications for each function to optimize pressure relief and postural stability. Licensed Practical Nurse (LPN) #102 received verbal education regarding the intended purpose and safe use of both harness and seat belt and agreed to place an order for as needed use of the harness for positioning and fall-prevention purposes, consistent with recommendations provided by the medical group during the initial wheelchair fitting. LPN #102 verbalized full understanding of the education provided. Therapists will continue to monitor staff compliance with harness and seat belt protocols, assess resident tolerance and positioning during ongoing sessions, and provide re-education as needed to ensure continued safe use in accordance with manufacturer and clinical guidelines. Review of the facility SRI tracking #266952 dated 10/30/25 revealed an allegation of neglect. On 10/29/25 the DON received a call that Resident #18's sister was upset about the new wheelchair. The resident's sister arrived at the facility and saw the harness strap was on Resident #18 and there was a red area on the resident's neck. The DON stated she had not seen the new wheelchair yet but would check it out as soon as she went back to work. The DON messaged LPN #102 and asked what was going on and that the resident's sister was upset over the harness and that Resident #18 had a red mark. LPN #102 stated the staff were educated to put the harness on when Resident #18 was in the chair and leaning over and when eating. Resident #18 was leaning so far over that LPN #102 thought the safest thing would be for the harness to be applied. Resident #18's sister took the harness off and said it was too tight and that was why there was a red mark. It was explained if Resident #18 was moving around that could cause the red mark. The therapy manager stated Resident #18 was to wear the seat belt for positioning and the harness was to only be worn as needed where there was a danger of falling. The resident's sister wanted the state agency notified and an investigation completed for abuse because Resident #18 was restrained. A meeting was held on 10/30/25 and it was agreed that the harness and seatbelt would not be used. The DON discussed the safety features of the wheelchair and the fact that Resident #18 was so small she was at risk of choking herself if she slid down into the chair like she did in the Broda chair. The DON explained she was under the impression Resident #18 was to wear the harness at all times in the chair. The Administrator, DON, and Resident #18's sisters went to observe the resident. Resident #18 was in the new wheelchair with the seatbelt on. The chair was reclined; however, the resident was sitting straight up. It was observed at there was a notable gap between the arm rest and the chair back that the resident's body most definitely could fit in between and did not appear safe. Resident #18 was transferred back to her old Broda chair until the wheelchair representative could be contacted about more adaptations. The staff were informed that the new wheelchair was not to be used.Review of a handwritten statement dated 10/29/25 by CNA #108 revealed Resident #18 was leaning in her wheelchair with her head hanging way over the side. The staff were concerned for the resident's safety so the harness was placed on the resident on 10/29/25. On 10/28/25 when the new wheelchair arrived, staff put the harness on the resident at 3:45 P.M. when the resident was got up for dinner because she was leaning. PTA #121 came to the memory care unit on 10/29/25 and said the harness could be put on the resident for meals because the resident needed to sit up straight when she ate. A handwritten statement dated 10/29/25 by CNA #109 revealed Resident #18 was sideways in her chair leaning to the right. The nurse and CNA's thought it was in the resident's best interest to use the harness for the resident to sit upright to eat dinner. The harness was adjusted by therapy, and it seemed tight so CNA #109 and another CNA loosened it. The harness was loose enough for the resident to still move around. CNA #109 went to get Resident #18's dinner tray and when she came back Resident #18's sister was livid and demanded to talk to someone in charge because Resident #18 was not to be in the harness at all. The sister stated the seatbelt would keep the resident from falling out of the chair. The sister then said it was okay for the resident to be in harness if absolutely needed but not all the time. A handwritten statement (no date) by CNA #110 revealed on 10/28/25 Resident #18 was fitted for a new wheelchair that was equipped with a harness. Resident #18 was up at 3:45 P.M. (on 10/28/25) and the harness was placed on the resident by the CNA's and nurse. Resident #18's sister arrived at approximately 5:00 P.M. and stated they did not want the harness on the resident except in really bad situations and if it was absolutely necessary. CNA #108 and CNA #111 came over, and they all agreed to pass on the sister's request. On 10/29/25 around 3:15 P.M. CNA #110 and CNA #109 got Resident #18 out of bed. Around 4:15 to 4:20 P.M. CNA #109 noticed Resident #18 was leaning significantly. CNA #108, CNA #109, and LPN #102 discussed the harness. CNA #110 told them about the conversation with Resident #18's sister on 10/28/25 and that the family did not want the harness used. It was stated that PTA #121 educated them (staff) this morning and proceeded to fasten the harness. The restraint seemed higher up on Resident #18's body than yesterday but they thought they were able to adjust it properly. At approximately 4:30 P.M. Resident #18's sister arrived and was upset that the harness was on and there was a red mark on the resident. Abuse concerns were discussed. There was a note at the desk that stated the harness could be used in certain situations. The sign was made and signed by CNA #111 and approved by the resident's sister on 10/28/25. Review of a typed statement dated 10/30/25 by CNA #112 revealed on the afternoon of 10/28/25, Resident #18 was observed in the hallway wearing a harness, and it appeared tight. CNA #112 asked CNA #108 and CNA #110 what the contraption was, and CNA #110 said apparently this is Resident #18's new chair but no one showed us how she is supposed to be in it. CNA #112 stated that she did not think it was safe and looked like it was pinching the resident's neck. CNA #110 unzipped the harness and took Resident #18 to her room to put the resident in bed. During morning meeting on 10/29/25, CNA #112 asked what the harness was because it looked tight. PTA #121 said it was a new chair and had a harness and seatbelt. It was stated in morning meeting that the restraint should not be on. PTA #121 stated the wheelchair people said it was fine due to positioning. It was discussed how it needed to be looked at if it was a restraint or an order had to put in for safety. Around 11:45 A.M. PTA #121 and COTA #120 asked CNA #112 if she wanted to come back and be educated about the new wheelchair. Resident #18 was in the activity room and did not have a seatbelt or harness on. PTA #121 then showed how the chair worked with the tilt back and recline and showed the seatbelt and the left harness strap. It was not physically put on the resident, but it was shown how it wrapped around the wheelchair. PTA #121 asked who else could be trained because the regular aides on the memory unit were not there. CNA #113 went into the activity room as PTA#121 and COTA #120 were putting the seat belt on Resident #18. PTA #121 explained to CNA #113 how the chair worked and how the harness went around the chair but did not apply the harness. CNA #113 asked if Resident #18 was to wear the harness when eating. PTA #121 said yes that she believed it would be a good idea. Social Worker (SW)/RN #123 walked in the room and PTA #121 was explaining to SW/RN #123 about the harness and seatbelt and how it could be written up as an order so it was not referred to as a restraint. SW/RN #123 was unsure if that was acceptable. Resident #18 continued to wear the seatbelt, but the harness was never applied. Review of a general progress note dated 11/04/25 at 10:24 revealed the DON, wheelchair representative, and Resident #18's two sisters met and reviewed the new wheelchair. The wheelchair was modified and adaptations were made to allow the chair to be tilted but not reclined. This prevented Resident #18 from having access to lean over the side between the back and arm rest. An interview on 12/04/25 at 11:30 A.M. CNA #110 verified they were not educated on how to put the harness on Resident #18. CNA #110 verified the staff should have waited, but the purpose of new wheelchair was to have the harness. Therapy had educated some of the staff, so they used the harness. There was conflicting information because the family wanted the harness and then only wanted the harness used in extreme situations. CNA #110 verified Resident #18 would lean forward and to the right a lot. An interview on 12/04/25 at 11:39 A.M. SW/RN #123 verified she questioned the harness and seatbelt being a restraint. SW/RN #123 stated the harness was not used that she knew of. An interview on 12/04/25 at 11:44 A.M. LPN #102 stated it was explained to her how the wheelchair/harness/seatbelt worked and it was ready. The harness had straps that were hooked in the front. LPN #102 stated Resident #18's family removed the harness when they arrived. The family wanted the harness and then did not want it used. Interviews on 12/04/25 at 11:53 A.M. COTA #120 and PTA #121 verified staff were not supposed to put the harness and seatbelt on Resident #18 until therapy evaluated the wheelchair. The harness was only to be used if Resident #18 would not sit up straight. The people of the wheelchair company put the harness on the wheelchair and OT was not even aware the wheelchair would have a seatbelt and/or harness. There was nothing in the notes. COTA #120 and PTA #121 verified they gave verbal education to some of the staff but never put the harness on Resident #18 to show how it should fit. Additional training needed to be completed, but the nursing staff started using the harness and seatbelt before giving therapy time to evaluate how the harness would fit Resident #18. An interview on 12/04/25 at 1:17 P.M. Resident #18's Sister #300 verified Resident #18 was wearing the harness on 10/28/25. Sister #300 told the staff not to use the harness and had a CNA write a note to put at the nurse's station. The next day Sister #301 arrived at the facility and saw Resident #18 had the harness on and there was a red mark on the resident's neck. Sister #300 stated a new wheelchair was ordered because Resident #18 was so small and they hoped it would help keep the resident from falling out of the chair. The staff at the nursing home started using the wheelchair immediately. Therapy staff stated they trained staff, but the nursing staff stated they were not trained. The harness and seatbelt were no longer being used due to fear of choking the resident when the resident slid down in the chair. An interview on 12/04/25 at 2:49 P.M. Administrator verified therapy was not present when the wheelchair arrived on 10/28/25. Resident #18's family were educated by the wheelchair company. An interview on 12/04/25 at 2:50 P.M. DON verified the orders and assessments for the harness and seatbelt were not completed until after the harness and seatbelt were used. An additional interview on 12/04/25 at 3:57 P.M. PTA #121 verified the wheelchair was not evaluated by therapy on 10/28/25. The OTR would have to be the person to evaluate the proper use of the harness. Review of the undated Restraint Management and Reduction policy revealed residents have the right to function at their highest practicable level in the least restrictive environment possible. Restraints/seclusion will not be used unless the facility's interdisciplinary team has completed an assessment and evaluation to determine causative medical factors and consider less restrictive alternative approaches. Restraint or seclusion must not result in harm or injury to the resident. In the event the resident if found incapable of making decisions, the responsible party will exercise the right to refuse or accept the use of restraints. A physical restraint is any manual method, physical or mechanical device, material, or equipment attached or adjacent to the resident's body in a way that the individual cannot easily remove, which restricts freedom of movement or normal access to one's body. This deficiency represents non-compliance investigated under Complaint Number 2623349.

Based on record review, review of self-reported incidents (SRI), interviews and policy review, the facility failed to ensure allegations of verbal abuse by staff towards Resident #19 were immediately reported. This affected one (Resident #19) out of three reviewed for abuse. The facility census was 70.Findings include:Review of the medical record revealed Resident #19 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dementia, anxiety, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated cognitive impairment. Resident #19 had verbal behaviors one to three days during the seven-day assessment period. Review of SRI tracking #263082 dated 07/22/25 at 2:49 P.M. revealed Resident #19 was sitting in the dining room with other residents getting ready to eat lunch. Resident #19 began screaming. Certified Nursing Assistant (CNA) #110 said Resident #19's name. Licensed Practical Nurse (LPN) #115 yelled, (Resident #19's name) shut up. Resident #19 was taken out of the dining room and placed in common area by LPN #115. Resident #19 continued to yell, and LPN #115 took the resident to her room. CNA #110 fed Resident #19 in her room. CNA #110 updated a Registered Nurse (RN) that LPN #115 verbally abused Resident #19. The facility investigation revealed a handwritten interview with LPN #115 by RN #116. LPN #115 stated Resident #19 was yelling in the dining room with other residents around. LPN #115 stated she probably told Resident #19 to shut up. LPN #115 verified she took Resident #19 out of the dining room into the common area and Resident #19 continued to yell. LPN #115 then took Resident #19 to her room and CNA #110 fed the resident her lunch. A written statement dated 07/22/25 by CNA #110 revealed they took Resident #19 to the dining room for lunch and she began screaming loudly. CNA #110 and LPN #115 were in the dining room. CNA #110 shouted Resident #19's name because the resident would often stop when she heard her name. LPN #115 then yelled (Resident #19's name) shut up really loud. LPN #115 then took Resident #19 to the lobby area. Resident #19 continued screaming so LPN #115 took the resident to her room. CNA #110 served lunch and fed residents as needed and reported the incident as soon as they were able to do so. A handwritten statement by LPN #115 dated 07/22/25 revealed Resident #19 had been screaming since before breakfast. When Resident #19 was brought to the dining room at lunch, the resident continued screaming. Two residents at another table started telling Resident #19 to shut up. LPN #115 removed Resident #19 from the dining room and put the resident at a table in the common area. Resident #19 continued to scream in the common area. LPN #115 then took Resident #19 to her room where CNA #110 fed the resident. LPN #115 wrote that she did not remember what she said. Resident #19's continuous screaming and the other residents getting upset took a toll on LPN #115. The employee timesheet revealed LPN #115 worked on 07/22/25 at 6:45 A.M. to 1:30 P.M.An interview on 12/04/25 at 3:32 P.M. Administrator verified CNA #110 did not immediately report the allegation of abuse. LPN #115 moved Resident #19 from the dining room to the common area and then to the resident's room after allegedly verbally abusing Resident #19. The Administrator verified allegations of abuse should be reported to the Administrator or designee immediately. If the allegation involved a staff member, the staff member should be removed from the facility immediately until an investigation was completed. This deficiency represents non-compliance investigated under Complaint Number 2623349.

Based on observation, interview with staff, and review of the facility policy, the facility failed to maintain a safe and clean environment free from discarded cigarette butts in the resident smoking area. This had the potential to affect all residents residing in the facility. The facility census was 62. Findings include: Observation on 01/27/25 at 11:15 A.M. the resident smoking area with Housekeeper #201 revealed several cigarette butts on the concrete pad under the awning and in the stones by the building where the residents smoked. There were several leaves laying around the area which could catch on fire. Interview on 01/27/25 at 11:20 A.M. with Housekeeper #201 confirmed the cigarettes were not discarded properly in the fireproof container. Review of the undated policy titled, Smoking/Electronic Cigarettes revealed the purpose was to educate all staff and residents on the policy and procedure in regard to smoking and electronic cigarettes. The policy made no mention of proper discarding of cigarettes. Review of the undated policy Staff Smoking revealed cigarettes were to be discarded in a metal self-closing ash tray. No paper was to be placed inside the ash tray. Maintenance would check ash tray and empty as needed. A fire extinguisher was available and located in the staff smoking area for use if necessary. The policy stated to discard cigarette butts in the ash tray and to not throw cigarette butts on the ground.

Based on medical record review, observation, and interviews, the facility failed to ensure splints/braces were applied per orders and plan of care. This affected one (Resident #18) of one resident reviewed for positioning/mobility. The facility census was 62. Findings include: Review of Resident #18's medical record review revealed an admitted [DATE] with diagnoses including Parkinsonism, chronic pain, rhabdomyolysis, and limited range of motion. Review of Resident #18's Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired range of motion to bilateral upper extremities. The resident had no rejection/refusal of care. Review of Resident #18's active physician's orders revealed an order dated 02/12/24 to apply wrist braces daily at 8:00 A.M. and remove daily at 8:00 P.M. The order indicated the braces could be removed for meals. The order did not specify which wrist, or both, the brace/braces should be applied to. An additional order dated 05/13/24 stated to place finger splints on left fingers one hour per day for boutonniere deformities with the instructions for application listed as, in the bag with the splints. Review of Resident #18's care plan dated 07/24/22 revealed the resident had an alteration in ability to perform activities of daily living (ADL) related to generalized weakness. Listed interventions included to place finger splints on left fingers one hour per day for boutonniere deformities (instructions in bag with splints), to apply wrist brace daily at 8:00 A.M. and remove at 8:00 P.M. and may remove for meals. Review of Resident #18's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated January 2025 revealed staff signed off the resident's wrist splint was applied daily, except on 01/26/25, 01/28/25, and 01/29/25 when there was no documented evidence that the wrist splint was applied, and on 01/27/25 when staff documented the resident refused the wrist splint. There was no evidence of the finger splints order being listed on the MAR/TAR to ensure it was applied or refused. Review of Resident #18 task tab for Certified Nursing Assisting (CNA) charting revealed no evidence of wrist or finger splints. Interview and observation on 01/27/25 at 10:14 A.M., of Resident #18 revealed she had pain, especially in her hands and fingers, and was not receiving therapy, restorative, or any type of services to prevent further decline in limited range of motion. The resident had no splints in-place at the time of interview. There were no splints observed in the resident's room. Observation on 01/28/25 at 8:41 A.M., of Resident #18 revealed the resident was in bed, eating breakfast. Resident #18 utilized a cup with a lid and was noted to have limited range of motion in her hands and fingers. Resident #18 was not wearing any splint or brace. Observation of Resident #18 and interview on 01/29/25 at 11:41 A.M., with Licensed Practical Nurse (LPN) #147, CNA #112, and CNA #161 confirmed Resident #18 did not have a wrist splint in place. CNA #161 reported she forgot to put the wrist splint on today because the resident usually refuses to wear it. CNA #161 reported she didn't know the frequency or time the splint was to be worn. CNA #112, CNA #161, and LPN #147 reported that the CNAs were responsible for applying the splints. The splints were not on the task tab for the CNAs to document or see the orders for the splints. LPN #147 reported the finger splints were not on the TAR to sign off when the finger splints were applied, however the splint to the wrist was listed on the TAR. Staff could not locate the wrist or finger splint initially. CNA #161 later found the wrist splint in a chair under a pile of linen; however, the CNA could not locate the finger splints. The wrist splint was marked with an R (right). CNA #161 applied the splint to the resident's right wrist. CNA #112 returned to the resident's room and found the finger splint. CNA #112 reported she would apply the finger splints after lunch. Interview on 01/29/25 at 12:09 A.M., with LPN #106 confirmed the order, TAR, and care plan for Resident #18's wrist splint don't indicate which wrist to apply the splint to and verified the application of the finger splints were not listed on the TAR. The CNAs were responsible for applying the splints; however, the splints were not on the task for the staff to sign off that the splints were applied. Interview on 01/29/25 at 12:32 P.M. and 1:25 P.M. via email with the Director of Nursing (DON) confirmed the range of motion assessment was inaccurate and Resident #18 had limited range of motion in the wrist and fingers. The facility did not have access to therapy notes prior to October 2024 as the facility had switched therapy companies. The DON stated the facility was going to have occupational therapy to evaluate the resident to see what splints were needed or not needed.

Based on review of the medical record, review of the facility investigation, resident interview, staff interview, and review of facility policy and procedure, the facility failed to ensure Resident #6 was not abused by a staff member. This affected one resident (Resident #6) of four residents reviewed for abuse. Findings included: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included hypertensive heart disease, depression, vitamin D deficiency, anxiety disorder, cirrhosis of the liver, malignant neoplasm of the large intestine, diabetes, heart failure, osteoarthritis of the hip, atrial fibrillation, lymphedema, adrenocortical insufficiency, and insufficiency. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #6 had intact cognition. Review of the progress note dated 09/11/24 at 8:45 P.M. revealed a Certified Nursing Assistant (CNA) #210)) was assisting Resident #6 in the shower when the resident started to get loud with the CNA because the CNA was washing her face with soap. A second nursing assistant (CNA #137) was called into the shower room to assist. Resident #6 then started complaining that she got a neck injury today and medicare paid the facility thousands of dollars just for all of the staff to torture her here. Review of the progress note dated 09/13/24 at 1:13 P.M. revealed Resident #6 asked to speak to the Director of Nursing (DON) about the shower she received two nights ago. She felt the nursing assistant verbally abused her when the resident stated she was going to report her, and the CNA told the resident to go ahead and report her. An investigation was initiated. Review of the facility investigation dated 09/13/24 revealed on 09/12/24 it was reported that a resident was yelling at an aide during her shower because the aides were using soap on her. The resident was yelling that her insurance paid thousands of dollars for her to be at the facility and they were torturing her. The DON and Social Services #190 both spoke to her and she made no allegation of abuse, however on 09/13/24 Resident #6 reported to the Unit Manager/Licensed Practical Nurse (LPN) #194 that she wanted to report an aide because when she was showering her, the aide wiped her face too hard with the wash cloth. The DON asked the Unit Manager to write a statement of what Resident #6 had told her. The DON then interviewed Resident #6 and she stated that the aide was giving her a shower and she rubbed her face too hard. The resident stated she had sensitive skin and did not want her to wash her face. The resident stated she told the aide she was going to report her and the aide told her to go ahead. The resident denied a second aide came into the room. The DON assessed her face while interviewing her and her face was free of any scrapes, scratches, bruising or rashes. The resident had makeup on which she wears daily and would take pride in doing herself. The DON stated to the resident she would speak to CNA #137 and complete staff education that the resident would prefer to wash her face by herself. The resident stated again that her insurance paid a lot of money to be here and she should not have her face rubbed that hard. The DON asked her if she was physically abused and she stated no, but she said she was verbally abused when the aide told her to go ahead and report her. The DON attempted to clarify with her, asking if the aide was inappropriate when she responded to her the way she did or did she abuse her. Resident #6 stated the aide verbally abused her when she told her to go ahead and report her. Resident #6 stated she did not want CNA #137 to take care of her anymore and the DON reassured her she would not be her aide. Social Services #190 was informed to check on the resident on Monday to follow up to make sure she was free of any psychosocial issues from the incident. The DON spoke to four other residents on the hall to see if they had any issues with CNA #137 being verbally or physically abusive and they all stated they had no issues with the aide. The DON contacted the medication aide who was working that night. Medication Aide (MA) #135 stated she went into Resident #6's room and the resident told her the aide washed her face and she did not want it washed. MA #135 said she told Resident #6 there was food on her face and the aide needed to get it off. MA #135 stated there was not any abuse at all and stated that Resident #6 had never liked CNA #137 since day one and she did not know why. The DON spoke to CNA #137 and she stated it was CNA #210 who was showering Resident #6 and Resident #6 was yelling out, so she (CNA #137) entered the room to see what was going on. She stated Resident #6 was not cooperating with her shower and all she wanted to do was get rinsed off, so the aide told Resident #6 she needed to get washed off because she had food hardened on her face. CNA #137 stated she gently washed the residents face and the resident was upset and said she was going to report her, and CNA #137 told her to go ahead. The DON called CNA #210 to get her statement and she stated she was doing the shower and Resident #6 did not want soap and just wanted to get rinsed off. Resident #6 start yelling and CNA #137 came in and spoke to her and Resident #6 agreed to have soap on her. Then CNA #137 washed her face and she was not rough. Resident #6 stated she was going to report CNA #137 and CNA #137 told her to go ahead. CNA #210 stated CNA #137 did tell Resident #6 they could not leave food on her face. Review of the undated, unsigned, text message witness statement from CNA #210 revealed she was giving Resident #6 a shower and the resident just got herself wet with water and said she was done. CNA #210 called CNA #137 in the shower room to ask her if she could use soap and wash her body and Resident #6 allowed her to. CNA #137 then asked to wash her face to get the food off and she let her wash one side of her face. Then Resident #6 began to yell about her makeup, so CNA #137 quickly washed the other side of her face and Resident #6 started screaming at CNA #137. The statement stated nothing was verbally abusive from CNA #137. Review of the undated, printed, text message witness statement signed by CNA #137 revealed CNA #210 was showering Resident #6 and put the call light on to ask for help because Resident #6 would not wash with soap. Resident #6 eventually agreed to wash with soap. The CNA told Resident #6 she had food on her face and they could not leave it. Resident #6 stated she had wipes in her room. CNA #137 stated she told the resident the wipes she saw in her room were not made for her face so why not use just a wash cloth with water, because they could not leave food on her face. Resident #6 became very angry and stated she was going to report her. CNA #137 stated she told Resident #6 to go ahead and report her, but that she could not leave food on her face. Review of the handwritten witness statement from LPN #194 dated 09/13/24 revealed the nurse went into the room of Resident #6 to ask if she was ready for her morning medications. Resident #6 stated that CNA #137 had abused her and explained she washed her face too hard and when she told her to stop, the aide told her no, it needed done. On 01/28/25 at 9:40 A.M. an interview with Resident #6 revealed a few months ago staff came and got her for a shower. She stated she could not believe how CNA #137 had acted. She stated she told both of them (CNA #210 and CNA #137) that she did not want her hair or face washed because she got her hair done at the beauty shop and she liked to wash her face with the makeup wipes in her room. She stated CNA #137 told her she needed to wash her face and get the make up off. Resident #6 told the CNA no, but she did it anyways and she started to scrub her face hard. The resident stated she kept telling the CNA to stop, but she just said she was going to get it off her face. The resident stated she was in shock. She stated she told CNA #137 that she was going to report her and CNA #137 told her go ahead and report her because she did not care. The resident stated she had a dermatologist for her eczema and she had issues with some soaps irritating her skin. She stated CNA #137 was not allowed in her room anymore, but she came in one time since the incident to answer her roommate's call light and the resident stated to her roommate she (CNA #137) better get out of here because she was not allowed in here. On 01/29/25 at 12:27 P.M. an interview with the Director of Nursing revealed she had not completed a formal write up for CNA #137, but like the Self-Reported Incident stated, she spoke to her one-on-one about it and informed her Resident #6 did not want her to care for her anymore. On 01/29/25 at 7:45 P.M. an interview with CNA #137 revealed another aide was completing Resident #6's shower and the resident did not want to use any soap. She stated the other aide called her into the shower room to see if she could convince her to use soap. She stated the resident still had food on her face from dinner time and she offered her a wash cloth to wash her face. She stated Resident #6 started to argue with her, telling her that she was verbally abusing her and she would use the wipes in her room. She stated she told Resident #6 the wipes (baby wipes) in her room were not really made to be used on her face and they could harm her face. She stated Resident #6 stated she was going to report her, and she told her to go ahead. She stated she did not press the issue anymore, and she left the room without washing the residents face. She stated she told the medication aide what had happen and spoke to the Director of Nursing the next day and was told to not go into the residents room to avoid any conflict with Resident #6. On 01/29/25 at 7:51 P.M. an interview with CNA #210 revealed she was giving Resident #6 a shower and she would not let her wash her face so she called CNA #137 in to see if she could talk her into washing her face. She stated the resident became really upset, started yelling at them, and did not want to wash her face. She stated CNA #137 walked out, CNA #210 got her dressed, and took her back to her room. After questioning CNA #210 about her witness statement, CNA #210 changed her story and verified CNA #137 did wash the food off of Resident #6's face and the resident was yelling at her to stop the whole time. She stated CNA #137 never used soap on her face, only a wet wash cloth. She stated they were now not allowed to wash the residents face, and just to offer to wash her face, but she did not allow staff to wash her face. She stated CNA #137 was not allowed to go into the residents room to provide care. Review of the facility policy titled, Policy and Procedure for Prevention of Mistreatment, Neglect and Abuse of Resident and Misappropriation of Resident Property, revealed all residents in the facility would be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect and misappropriation of property, exploitation and adverse events. The definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Willfully, as used in the definition of abuse, meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observation, interview, and review of facility policy, the facility failed to ensure multi-dose insulin pens were dated as to when they were first accessed. This affected two residents (Resident #32 and #166) out of 11 residents identified by the facility as receiving insulin injections. The facility census was 62. Findings include: Observation on 01/27/25 at 11:20 A.M. of the rehabilitation hall medication cart with Licensed Practical Nurse (LPN) #158 revealed two multi-dose insulin pens were accessed but were not dated as to when they were first opened and accessed. The two pens were Resident #32's Glargine Solostar (insulin) 100-unit pen and Resident #166's Tresiba (insulin) 200-unit pen. Interview on 01/27/25 at 11:30 A.M. with LPN #158 confirmed the two multi-dose insulin pens were not dated as to when they were first opened and accessed. An interview on 01/30/25 at 10:26 A.M. with the Director of Nursing (DON) revealed all insulin was to be dated when accessed for the first time. Review of the facility policy titled, Multi-dose Pens of Injectable Medications, dated 06/02/15 revealed pens were to be dated when opened and have the initials of the first person to use the pens recorded on the multi-dose pen.

Based on medical record review, psychiatrist billing list, and interview, the facility failed to ensure residents records were complete and included in-house psychiatric progress notes and Nurse Practitioner (NP) notes. This affected two (Resident #5 and #18) of five residents reviewed for unnecessary medications. The facility census was 62. Findings include: 1. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia with psychotic disturbance, depression, coronary artery dissection, Alzheimer's disease, allergic rhinitis, constipation, ulcerative colitis, anxiety, insomnia, chronic kidney disease, heart disease, mood disorder, gout, gastro-esophageal reflux, hyperlipidemia, hypothyroidism, overactive bladder, sleep apnea, Parkinsonism, anemia, and atrial fibrillation. Review of the psychiatrist billing list dated 01/17/24 to 12/20/24 revealed Resident #5 was seen by the psychiatrist on 09/25/24, 10/23/24, and 11/20/24. Review of Resident #5's medical record revealed no evidence of psychiatrist notes for 09/25/24, 10/23/24, and 11/20/24. Interview on 01/30/25 at 7:48 A.M., with the Director of Nursing (DON) confirmed the resident was seen by psychiatry, however the notes were not in the resident medical record, and she had reached out to the psychiatrist office for progress notes. Interview on 01/30/25 at 11:39 A.M., with Licensed Practical Nurse (LPN) #106 confirmed the Resident #5 was seen by psychiatry on 09/25/24, 10/23/24, 11/20/24, and in January 2025. However, the psychiatrist office only sent over the 09/25/24 visit due to the 10/23/24 and 11/20/24 notes had not been typed and were unavailable. 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, insomnia, bipolar, anxiety, chronic pain, hypotension, dementia with behavioral disturbance, schizoaffective disorder, anemia, suicidal ideations, hemorrhage, psychotic disorder with hallucination, bipolar, acute kidney failure, low back pain, gastro-esophageal reflux, heart disease, and hyperlipidemia. A. Review of psychiatry billing list dated 01/17/24 to 12/20/24 revealed the resident was seen by psychiatry on 01/17/24, 03/19/24, 05/22/24, 06/21/24, 08/26/24, 10/23/24, and 11/20/24. Review of Resident #18's medical record revealed no evidence of psychiatrist notes for 01/17/24, 03/19/24, 05/22/24, 06/21/24, 08/26/24, 10/23/24, and 11/20/24. Interview on 01/30/25 at 11:39 A.M., with Licensed Practical Nurse (LPN) #106 confirmed Resident #18 was seen by psychiatry on 01/17/24, 03/19/24, 05/22/24, 06/21/24, 08/26/24, 10/23/24, and 11/20/24. However, the progress notes were not provided to the facility. The psychiatry office was contacted and faxed over the progress notes for 01/17/24, 03/19/24, 05/22/24, 06/21/24, and 08/26/24. The progress notes for 10/23/24 and 11/20/24 had not been typed and were unavailable. B. Review of Resident#18's primary provider notes revealed the resident had not been seen by her primary provider since September 2024. Interview on 01/30/25 at 10:11 A.M. with the DON verified the resident's medical record contained no evidence she had been seen by her primary provider since September 2024. The DON stated she had called the provider's office, and the office reported a Nurse Practitioner (NP) had seen the resident on 11/05/24 and the office was going to fax over the progress notes for the resident medical record.

Based on medical record review, policy review, and interview, the facility failed to ensure antibiotics were utilized only when medically necessary. This affected one (Resident #61) of two residents reviewed for antibiotic use. The facility census was 62. Findings include: Review of Resident #61's medical record revealed an admitted [DATE] and diagnoses including urinary tract infection, fracture of the surgical neck of the left humerus (long bone in the arm that runs from the shoulder to the elbow), and diabetes mellitus. Resident #61 was sent to the hospital 12/12/24 for an acute fracture of the proximal right femur (thigh bone). Resident #61 returned to the facility 12/14/24 with orders for Doxycycline (antibiotic) 100 milligrams (mg) twice a day for post-operative infection prevention to the right hip for a total of 19 administrations. A nursing progress note dated 12/15/24 at 7:05 P.M. indicated an unnamed Certified Nursing Assistant (CNA) alerted the nurse Resident #61's urine was dark colored. Resident #61 complained of her bladder burning. A nursing progress note dated 12/15/24 at 7:57 P.M. indicated an order was received for a urinalysis and culture and sensitivity the following day. Review of Resident #61's urinary analysis with culture and sensitivity if indicated, the specimen collection and received date was 12/16/24 and the results reported to the facility date of 12/18/24, revealed the urine culture read that 40 to 50,000 colony forming unit per milliliter (CFU/ml) enterococcus faecium and less than 10,000 CFU/ml gram negative rods (GNR) were noted in the urine. It stated no sensitivity would be completed. Review of the Urinary Tract Infection (UTI) without Catheter form revealed hand written writing at the top that stated Resident #61's name, 40 to 50,000 CFU/ml enterococcus faecium, Nitrofurantoin for five days, and 12/18-12/23. The form was used to assist the physician in decision making if the resident had a UTI or not. Under the Laboratory Results section of the form, it asked if the urine sample had at least 100,000 CFU/ml of no more than two species of microorganisms and No=NO UTI was check marked. If yes had been check marked, it stated to evaluate for symptoms of UTI. Under the Signs and Symptoms of UTI section of the form, question number one, it asked if the resident had acute dysuria or acute pain, swelling or tenderness of the testes, epididymis, or prostate and Yes=UTI was check marked. Under the Signs and Symptoms of UTI section of the form, question number two, it asked if the resident had a fever or leukocytosis AND one of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marker increase in urgency, or new or marked increase in frequency. It stated if the answer was yes, to update the doctor and document or no, and no meant no UTI. No was check marked. A nursing progress note dated 12/18/24 at 1:34 P.M. indicated the nurse practitioner reviewed the urine culture and gave orders for Nitrofurantoin (antibiotic) for five days due to a urinary tract infection. On 01/28/25 at 4:09 P.M., Licensed Practical Nurse (LPN) #106 acknowledged when she evaluated Resident #61's December 2024 urinalysis laboratory tests she determined the resident did not meet the criteria for treating the resident's UTI with antibiotic therapy. LPN #106 verified there was no documentation indicating she had contacted the nurse practitioner or doctor about the results and the infection criteria not being met. LPN #106 acknowledged the risk for multi-drug resistant organisms due to frequent antibiotic use as Resident #61 had been admitted to the facility on antibiotics in November 2024, had prophylactic antibiotics ordered after her hip surgery, and received Nitrofurantoin when UTI treatment criteria was not met. On 01/29/25 at 12:07 P.M., LPN #106 verified the facility's antibiotic stewardship policy did not address the use of prophylactic antibiotics. Review of the facility policy Antibiotic Stewardship (signed by a physician on 07/02/18) revealed the infection control nurse would evaluate all new admissions and determine if the resident met the McGeer's criteria for the antibiotic use and if they did not, they would contact the physician and/or Certified Nurse Practitioner (CNP) as soon as possible to see if they wanted the antibiotic continued or discontinued. The facility recognized that even though a resident was not meeting the McGeer's criteria, the physician had the right to order the antibiotic based on other clinical signs and symptoms. The facility would establish protocols utilizing the McGeer's guidelines in order to determine if a resident had an infection or not. The information from those guidelines have been communicated to the facility physicians/CNP to help them in determining if an antibiotic should be used. The policy indicated the facility would monitor all antibiotics used and communicate with the physician if an antibiotic was started prior to any testing results and the results came back all within normal limits to see if the physician wanted the antibiotic to continue or not.

Based on medical record review, review of employee disciplinary conference report, review of staff schedules, resident interview, staff interview, and policy review, the facility failed to ensure resident concerns with personal care were addressed timely. This affected one (Resident #5) of four reviewed for abuse. Findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia with psychotic disturbance, depression, coronary artery dissection, Alzheimer's, allergic rhinitis, constipation, ulcerative colitis, anxiety, insomnia, chronic kidney disease, heart disease, mood disorder, gout, gastro-esophageal reflux, hyperlipidemia, hypothyroidism, overactive bladder, sleep apnea, Parkinsonism, anemia, and atrial fibrillation. Review of the care plan dated 03/28/24 for Resident #5 revealed the resident had an alteration in bowel function related to needing assistance with mobility with interventions that the resident was dependent upon staff assistance with toileting hygiene. The care plan dated 03/28/24 revealed the resident had an alteration in ability to perform activities of daily living related to generalized weakness with interventions that the resident required independent assistance with personal hygiene. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and the resident required partial to moderate assistance with toileting and bathing, and required set up or clean up assistance for personal hygiene. Review of a behavioral note dated 01/15/25 revealed Resident #5 had been picking on the (unnamed) aide on this night, when it came to the residents personal care. The resident told the aide that she couldn't wipe herself because it hurt so bad. The aide did it for her, but the resident complained by saying it was completed too hard. The note also stated that the resident was being picky and demanding, and told the aide to shave her again, and then complained that aide made her chin bleed. Review of the staffing schedule revealed CNA #102 worked Resident #5's unit on 01/14/25 from 7:00 P.M. until 01/15/25 at 7:00 A.M. Review of the employee disciplinary conference report, dated 01/15/25 and signed by Resident #5, revealed the resident had concerns regarding a midnight shift employee (Certified Nursing Assistant (CNA) #102). The resident had communicated on three occasions that the CNA did not assist her with hygiene care after a bowel movement unless the resident asked her to. The CNA would ask the resident if she wiped herself with a smart tone of voice, per the resident, and the CNA would stand with her hand on her hips while talking. The CNA also asked the resident why she did not wipe herself and the resident said she had good and bad days and when someone talked to her like that it made her feel bad. Interview on 01/27/25 at 10:20 A.M. with Resident #5 revealed CNA #102 sprayed water on her face and was rough with care recently, and she felt like it was abusive. The resident confirmed she had reported the CNA to staff. Interview on 01/29/25 at 9:49 A.M. with Social Service (SS)/Registered Nurse (RN) #104 revealed Resident #5 had requested to speak to her on 01/15/25 regarding CNA #102. RN #104 reported she could not recall the details; however, she completed a form and gave it to the Director of Nursing (DON) to address. Interview on 01/29/25 at 9:55 A.M. with the DON confirmed RN #104 completed an employee disciplinary conference form on 01/15/25; however she went on vacation on 01/16/25 and did not have time to address the resident's concerns at the time. Interview on 01/29/25 at 11:25 A.M. with Social Service (SS)/Registered Nurse (RN) #104 confirmed she had filed the resident complaint on an employee disciplinary conference report per the facility's process. The RN reported that after she completed the employee disciplinary conference report, she gave it to the DON to investigate to determine if abuse occurred. The RN reported she did not have the authority to discipline staff and that was just the name of the form she completed to report complaints to the DON. The RN confirmed the resident had a history of hallucinations in the past, however she took everything reported to her seriously. Interview on 01/29/25 at 3:59 P.M. with the DON revealed she recalled RN #104 calling her via phone and reporting Resident #5's concerns, however she never mentioned abuse. The next day she found the employee's disciplinary conference report on her desk. The DON confirmed she had not spoken to CNA #102 regarding the employee disciplinary conference report yet because she had not seen CNA #102. The DON also stated the resident reported to her that the CNA must of had a bad day. The facility had initiated a Self-Reported Incident (SRI) since the resident had reported abuse to the surveyor. Review of the undated grievance process revealed that the resident, staff, or representative of a resident may file a grievance to assure that the facility management would address their concerns and ensure a prompt resolution.

Based on review of medical records, resident interview, representative interview, and staff interview, the facility failed to ensure residents and/or resident representatives were provided a written summary of the baseline care plan. This affected two (Residents #61 and #165) of six residents reviewed for baseline care planning. Findings include: 1. Review of Resident #61's medical record revealed an admitted [DATE] with diagnoses including displaced fracture of the base of the neck of the right femur, depression, vitamin D deficiency, hyperlipidemia, hypertension, diabetes mellitus and displaced fracture of the surgical neck of the left humerus. The medical record revealed no indication that Resident #61 or her representative were provided a summary of the baseline care plan. Interview on 01/27/25 at 10:28 A.M., Resident #61's representative revealed he did not recall receiving a summary of the plan of care. Interview on 01/30/25 at 7:17 A.M., the Director of Nursing (DON) verified she was unable to locate evidence that a summary of the baseline care plan was provided to Resident #61 and/or her responsible party. 2. Review of Resident #165's medical record revealed an admitted [DATE]. Resident #165's diagnoses included malignant neoplasm of the right ovary, insomnia, sepsis, gastrointestinal hemorrhage, heart failure, type two diabetes mellitus, adult failure to thrive, anemia, protein-calorie malnutrition, vitamin D deficiency, and fistula (an abnormal connection of two body cavities or a body cavity and the skin) of the intestine. There was no indication Resident #165 or her representative were provided a summary of the baseline care plan. Interview on 01/27/25 at 10:28 A.M., Resident #165 revealed she did not recall receiving a summary of the baseline plan of care. Interview on 01/30/25 at 7:17 A.M., the Director of Nursing (DON) verified she was unable to locate evidence that a summary of the baseline care plan was provided to Resident #165 and/or her responsible party.

Based on observation, staff interview, and medical record review, the facility failed to ensure comprehensive care plans were revised timely. This affected two residents (Residents #10 and #61) of 24 residents reviewed for care plans. The facility census was 62. Findings include: 1. Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included hemiplegia affecting the left side, actinic keratosis, bipolar disorder, chronic obstructive pulmonary disorder, peptic ulcer disease diabetes, anxiety disorder, osteoarthritis, benign prostatic hyperplasia, chronic pain, insomnia, hypertension, atherosclerotic heart disease, major depressive disorder, cerebrovascular disease, and paralytic syndrome. Review of the plan of care dated 10/27/22 revealed Resident #10 was a smoker and required a smoking apron. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #10 had intact cognition and had one side upper extremity impairment. Review of the smoking assessment dated [DATE] revealed Resident #10 did not have any dexterity problems, he could light his own cigarette, he required a smoking apron and supervision. In the comment section of the assessment it stated Resident #10 had been wearing a smoking apron due to a recent report of him dropping a cigarette on himself. Resident #10 denied the occurrence. The assessment noted on the day the resident dropped the cigarette on himself, it was very windy outside and he stated he dropped it due to the wind. Resident #10 had been reassessed for smoking and was monitored for safety and he did demonstrate safe actions when smoking. He could go without an apron with the understanding if he dropped another cigarette he would be required to wear the apron. Observation of the resident smoking area on 01/27/25 at 11:15 A.M. revealed the Resident #10 was outside on the patio with supervision provided by Housekeeper #201. Housekeeper #201 lit Resident #10's cigarette, but did not put a smoking apron on him. Interview on 01/27/25 at 2:00 P.M. with Housekeeper #201 revealed residents only wore a smoking apron if the resident was dropping stuff on themselves. Interview on 01/28/25 at 8:55 A.M. with the Director of Nursing (DON) revealed she did not know why they were charting Resident #10 as needing a smoking apron because on 05/21/24 she reassessed him and felt he was fine without one. A follow up interview on 01/28/25 at 2:30 P.M. with the DON verified the plan of care for Resident #10 was incorrect in indicating the resident needed a smoking apron. 22653 2. Review of Resident #61's medical record revealed an admitted [DATE] with medical diagnoses including diabetes mellitus and urinary tract infection (UTI). Resident #61 admitted with orders for Cefdinir (antibiotic) 300 milligrams (mg) twice a day for UTI for five days. Review of Resident #61's care plan initiated 11/27/24 indicated a potential for alteration in bowel function related to Resident #61 needing assistance with mobility. Interventions indicated Resident #61 needed maximal assistance with toileting hygiene. Staff were instructed to apply protective ointment as ordered, assist to the bathroom upon request, assist on and off the bedpan per request, encourage fluids, and provide incontinence care as needed. Review of an acute care plan initiated 11/27/24 indicated Resident #61 had an alteration of the urinary system. Interventions included administering medications as ordered, encouraging fluids, monitoring and reporting change of condition, monitoring labs as ordered and monitoring for odor, color and painful urination. The goal indicated Resident #61 would have no signs/symptoms of infection. Review of a nursing note dated 12/15/24 at 7:05 P.M. indicated an unnamed Certified Nursing Assistant (CNA) alerted the nurse that Resident #61's urine was dark and Resident #61 complained of her bladder burning. A urinalysis and culture and sensitivity was ordered for 12/16/24. On 12/18/24, the results were sent to the Certified Nurse Practitioner (CNP). A new order was received for Nitrofurantoin (antibiotic) 100 mg every six hours for five days for a UTI. Review of Resident #61's acute care plan dated 12/18/24 revealed another acute care plan for alternation of the urinary system was initiated with the same goals and interventions as the care plan developed on 11/27/24. Review of a nursing note dated 01/16/25 at 5:37 A.M. indicated a new order was received for Resident #61 to have a urinalysis and culture and sensitivity test performed on 01/17/25 due to frequency of urination, burning and pain. Review of Resident #61's acute care plan dated 01/19/25 revealed the same goals and interventions as those initiated on 11/27/24 and 12/18/24. A nursing note dated 01/19/25 at 6:07 P.M. indicated the CNP was notified of the urinalysis and culture and sensitivity results. A new order was received for Cefdinir 300 mg twice a day for ten days for a UTI. Interview on 01/29/25 at 2:43 P.M. with the DON revealed the DON was questioned regarding the lack of care planning for recurrent UTIs. The DON staff did acute care plans which addressed UTIs and antibiotic use. Interview on 01/30/25 at 7:31 A.M. with Registered Nurse (RN) #105 verified Resident #61 had recurrent UTIs and had multiple antibiotics ordered since November 2024. When asked if the interdisciplinary team (IDT) had addressed the recurrent UTIs and investigated the cause and any additional preventative measures as each acute care plan had the exact same interventions, RN #105 stated she would have to check. Follow up interview on 01/30/25 at 9:08 A.M. with RN #105 revealed interventions beyond what was on the acute care plans for UTIs included encouraging Resident #61 to use the call light when her brief was wet and toileting her every two hours. RN #105 verified those interventions had not prevented UTIs. She also stated that staff provided incontinence care. RN #105 stated after discussing the recurrent UTIs, Resident #61 was placed on the nurse practitioner's list to see if she might benefit from use of a cranberry tablet and staff could start using anti-bacterial wash for perineal care due to the propensity for UTIs.

Based on medical record review, interview, observation, and review of facility policy, the facility failed to ensure Resident #49 received assistance with oral care. This affected one (Resident #49) of four residents reviewed for activities of daily living. The facility census was 62. Findings include: Review of Resident #49's medical record revealed an admitted [DATE] with diagnoses including diabetes, severe protein-calorie malnutrition, adult failure to thrive, kidney disease, gastro-esophageal reflux, weakness, and heart disease. Review of Resident #49's Minimum Data Set (MDS) dated [DATE] revealed the resident was dependent on staff for oral care. There was no evidence of refusals or rejection of care. Review of Resident #49's interdisciplinary team (IDT) progress note dated 01/17/25 revealed the resident required set up assistance for oral hygiene. Review of Resident #49's care plan indicated the resident had an alteration in dental status related to own teeth. The resident's plan of care stated to assist the resident twice daily with oral care. Review of Resident #49's task documentation for CNA's dated 12/28/24 to 01/27/25 revealed no documented evidence oral care was completed on 12/28/24, 12/29/24, 12/30/24, 01/03/25, 01/04/25, 01/08/25, 01/11/25, 01/13/25, 01/16/25, 01/21/25, 01/22/25, 01/23/25, 01/24/25, 01/25/25, 01/26/25, and 01/27/25. Observation on 01/27/25 at 10:33 A.M., revealed Resident #49 had build up on her bottom teeth. Observation on 01/28/25 at 10:39 A.M. of Resident #49 with Certified Nursing Aide (CNA) #112 confirmed the resident had build up on her bottom teeth. The CNA reported that the resident had refused oral care earlier that morning. The Occupational Therapist (OT) was present and assisted the resident with oral care. The resident had a battery-operated toothbrush in her bathroom and the toothpaste appeared unused. The resident confirmed she had seven natural teeth on the bottom and no teeth on the top. The CNA reported she did not report refusal of oral care to the nurse. Interview on 01/28/25 at 3:22 P.M., with the Director of Nursing (DON) confirmed there was no documented evidence Resident #49 had received oral care 12/28/24, 12/29/24, 12/30/24, 01/03/25, 01/04/25, 01/08/25, 01/11/25, 01/13/25, 01/16/25, 01/21/25, 01/22/25, 01/23/25, 01/24/25, 01/25/25, 01/26/25, and 01/27/25. The DON reported the facility had removed the task that included oral care on 01/21/25 due to the amount of charting the CNA's had to do, however she was going to add the task back. Review of the undated policy titled Activities of Daily Living (ADL) revealed residents would be provided with care, treatment, and services as appropriate to maintain and improve their ability to carry out activities of daily living (ADL). Residents who are unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. If a resident with cognitive impairment or dementia resist care, staff would attempt to identify the underlying cause of the problem and not just assume the resident was refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate.

Based on observations, record review, interview, and review of facility policy, the facility failed to ensure residents with non-pressure related skin issues were comprehensively assessed and treated in a routine manner. This affected two (Residents #51 and #165) of two residents reviewed for non-pressure related skin impairment. The facility census was 62. Findings include: 1. Review of Resident #165's medical record revealed an admitted [DATE]. Medical diagnoses included malignant neoplasm of the right ovary, methicillin resistant staphylococcus aureus (MRSA), adult failure to thrive, diabetes mellitus type two, anemia, and fistula of the intestine. A pre-admission hospital history and physical dated 12/25/24 indicated an abdominal drain in the right lower quadrant of the abdomen had accidentally been pulled out ten days previous. A Computed Tomography (CT) scan showed a complex right cystic lower abdominal intraperitoneal mass likely ovarian origin which appeared to have a fistula tract through the anterior abdominal wall exiting the skin on the right side. Review of Resident #165's admission assessment on 01/01/25 indicated Resident #165 had pus in an area on the right lower quadrant of the abdomen. A nursing note dated 01/01/25 at 6:35 A.M. indicated Resident #165 had a wound to the right lower quadrant with moderate serosanguineous drainage. A nursing note dated 01/01/25 at 3:02 P.M. indicated the wound nurse practitioner consulted regarding the fistula on the right abdomen and a new treatment order was obtained and completed. Review of wound Nurse Practitioner (NP) #300's consultation note dated 01/01/25 indicated Resident #165 had an area on the right upper quadrant of the abdomen and referred to it as a surgical site with full thicken loss measuring 0.6 centimeters (cm) x 0.7 cm x 0.1 cm with mucoid drainage. A treatment was recommended with alginate and to cover with a foam dressing to be changed every day and as necessary. Documentation on a wound/skin healing record revealed on 01/01/25 the area had a moderate amount of purulent and serosanguineous drainage. The skin surround the area was dark red/purple. A second assessment dated [DATE] indicated there was a large amount of serosanguineous drainage with the skin surrounding the area being normal. It was measured as 0.6 cm x 0.7 cm. The assessment indicated the area was a fistula and there was fat tissue in the wound bed. The fistula went to the mass. A subsequent assessment dated [DATE] indicated the area was 0.5 cm x 0.7 cm with copious amounts of purulent and serosanguineous drainage. The surrounding skin was black/brown. The assessment indicated the area was improved. An entry dated 01/15/25 indicated the fistula was not followed by the facility's wound nurse. There was no evidence nurses were completing comprehensive assessments of the open area following 01/08/25. Interview on 01/27/25 at 2:54 P.M. with Resident #165 revealed she previously had a drain in her abdomen which had been pulled out by mistake at another healthcare facility, and it left a hole. Interview on 01/28/25 at 12:40 P.M. with the Director of Nursing (DON) revealed she understood the concerns raised regarding monitoring the open area and evaluation of the current treatment. The DON stated nurses observed the area daily and would know if there was a change in condition or if the treatment did not appear to be effective. Observation on 01/30/25 at 8:50 A.M. revealed Licensed Practical Nurse (LPN) #149 changed Resident #165's abdominal dressing. A small opening to the skin was noted to the right abdomen with serous drainage. The skin was pink to the right side and above the open area. Interview on 01/30/25 at 9:00 A.M. with LPN #149 revealed she worked three to four days a week and the color of the wound was the same. LPN #149 stated generally, when the dressing was changed once a day, there was usually a stronger odor and more drainage than what was observed during the dressing change which had just been completed. LPN #149 stated she believed the reason there was not as much drainage and odors was the night shift had changed the dressing for some reason. LPN #149 stated it was her understanding the nurse practitioner no long followed the wound because it was a non-healing wound. LPN #149 stated the nurses monitored the area with dressing changes and Resident #165 also had outside appointments (unsure if oncology or surgeon) but her appointment the week of 01/20/25 had been rescheduled due to weather. On 01/30/25 at 10:15 A.M., Wound Nurse Practitioner (NP) #300 verified she did not follow Resident #165's abdominal wound because it was a surgical wound. Nurses should be assessing for changes, drainage, and any changes in appearance. Wound NP #300 stated due to Resident #165's ovarian cancer, which had developed into a fistula and would always have a foul odor, drainage, and would not improve. Wound NP #300 stated nurses should be monitoring the area, as the wound may eventually need pouched. Skin surrounding the area should be monitored for breakdown. It should also be monitored to determine if the dressing was able to hold the drainage. The information should be included in the resident's wound documentation. 47569 2. Review of Resident #51's medical record revealed admitted [DATE] with diagnoses including but not limited to unspecified dementia, anxiety, high blood pressure, repeated falls, and anemia. Resident #51 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of three out of a possible 15 dated 12/24/24. Resident #51 used a walker and wheelchair for mobility assistance, required assistance for toilet use and personal hygiene care. Review of Resident #51's at risk for injury care plan dated 02/27/22 revealed Resident #51 was at risk for injury related to decreased cognition, decreased mobility, and poor safety awareness. Interventions included for Resident #51 to wear long sleeved shirts to help protect from accidental bruising and skin tears to Resident #51's upper extremities. Review of Resident #51's iron level and complete blood count (CBC) laboratory results dated [DATE] revealed Resident #51's iron level result was at 81 (normal), Hemoglobin level results were low at 12, and Hematocrit level results were low at 36.1 which indicated Resident #51 was considered anemic and had the potential to bruise easily. Review of Resident #51's progress notes dated 01/06/25 at 1:25 P.M. authored by Licensed Practical Nurse (LPN) #101 revealed a bruised area to Resident #51's right elbow was observed with a small open area in the middle of the bruise. The area was cleaned and covered with a foam dressing. Further review of Resident #51's progress notes dated 01/07/25 to 01/28/25 revealed no further entries or documentation related to monitoring of the bruise and open area to Resident #51's right elbow. Review of Resident #51's physician orders dated 01/06/25 to 01/28/25 revealed no treatment order was implemented on 01/06/25 for treatment of the bruise with an open area observed on Resident #51's right elbow. Review of Resident #51's Treatment Administration Record (TAR) dated 01/01/25 to 01/28/25 revealed there were no treatment orders to be completed regarding the bruise and open area located on Resident #51's right elbow which was first observed on 01/06/25. A review of the bruise investigation form dated 01/06/25 at 1:35 P.M. completed by LPN #101 revealed staff observed blood on the floor in Resident #51's room. Resident #51 was in the common area at the time of the discovery. LPN #101 assessed Resident #51 and observed the skin had cracked and there was a small bruise surrounding the cracked skin on Resident #51's right elbow. The area was cleaned, and a foam dressing was placed to the area. Observation on 01/28/25 at 8:15 A.M. revealed Resident #51 was sitting in a wheelchair located in the dining room eating the breakfast meal. Resident #51 was wearing a long-sleeved sweatshirt and sweatpants. Interview on 01/28/25 at 1:00 P.M. with LPN #123 revealed the facility has a standard physician order which is used when there has been skin impairment observed. The facility wound nurse will be notified, as well as the physician and family member. The nurse will assess, treat and implement treatment orders as needed upon the initial observation. Interview on 01/28/25 at 2:21 P.M. with the Director of Nursing (DON) confirmed Resident #51 did not have any treatment order initiated or implemented for the cracked skin with bruise observed on 01/06/25. The DON stated when there's an area identified which requires a treatment order, the assessing nurse should implement a treatment order initially and then continue to monitor and document on the area until it is healed. A review of the facility policy Skin Assessments dated 01/19 revealed a treatment will be initiated as ordered by the either the physician or nurse practitioner to promote healthy skin integrity.

Based on observation, interview, medical record review, and review of the facility policy, the facility failed to ensure fall interventions were in place for a resident at risk for falls. This affected one (Resident #42) of three residents reviewed for accidents. The facility census was 62. Findings include: Review of the medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, anxiety disorder, paroxysmal atrial fibrillation, type two diabetes mellitus, hypertension, chronic lung disease and depression. Review of the Minimum Data Set (MDS) 3.0 significant change assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) Score of 5, indicating severely impaired cognition. Resident #42 was assessed to require assistance with activities of daily living (ADLs) including setup for eating and oral care and hands-on assistance with bathing, dressing, and transfers. Resident #42 used a wheelchair for mobility. Further review revealed the resident had fallen prior to the assessment and had experienced two or more falls since the last assessment. Resident #42 was frequently incontinent of bowel and bladder. Review of Resident #42's care plan dated 02/16/24 revealed the resident was care planned as at risk for injury related to decreased safety awareness. Listed interventions included to keep call light in reach, monitor the environment for any potential hazards, and for signage in room as a reminder to ring for help. On 06/21/24, an additional intervention of dycem was to be applied underneath the (incontinence) bed pad. On 07/06/24, an additional intervention to place a sign in the room to remind the resident to use his walker was placed. On 08/17/24, Resident #42's bed was moved to the side of the wall. On 09/30/24, dycem was applied to Resident #42's wheelchair. Review of Resident #42's active physician's orders revealed an order dated 09/30/24 for dycem to the resident's wheelchair as a fall intervention. Observation on 01/30/25 at 8:04 A.M. of Resident #42 revealed the resident was seated in his wheelchair in the hallway. Certified Nursing Assistant (CNA) #193 was attaching leg rests to the resident's wheelchair. There was no dycem observed in the wheelchair. CNA #193 pushed the resident in his wheelchair to the dining room. Observation of the resident's room revealed no signs were posted in the resident's room as indicated in the care plan as fall prevention interventions. The resident's bed was not against the wall, and no dycem was noted to the resident's bed underneath the pad as specified in the resident's care plan. Observation and interview on 01/30/25 at 8:13 A.M. with Registered Nurse (RN) #104 confirmed Resident #42's dycem was not in his wheelchair, on the bed, and there were no signs placed in the room as stated in the resident's care plan. RN #104 stated the resident's care plan needed to be updated to reflect the current fall interventions. Interview on 01/30/25 at 9:10 A.M. with the Director of Nursing (DON) revealed the process for completing fall investigations included the nurse assessment at the time of the fall and initiation of the post fall packet. Every morning, the shift report was reviewed for incidents and interventions. Falls were reviewed with residents, if able, and a root cause analysis was performed. Afterwards, the intervention was added to the resident's plan of care. Care plans were then reviewed and revised monthly or with interdisciplinary team (IDT) meeting to monitor for effectiveness of interventions. Review of the undated policy titled Falls revealed the policy provided guidelines to investigate and document falls in an attempt to reduce and prevent injury from further falls. The procedure indicated after a fall, nursing staff was to initiate an immediate intervention to prevent another incident. The intervention must be appropriate. The interventions must be documented in the nurses' notes and placed on the resident's care plan and CNA worksheets. It stated to monitor the effectiveness of the intervention to prevent further incidents, document effectiveness and/or lack of effectiveness of intervention in the resident's record, notify the supervisor if the intervention was not effective and another intervention would need initiated to prevent resident injury.

Based on observation, review of medical records, manufacturer's guidelines, infection control log, medical director reports, housekeeper job description, housekeeping isolation procedure policy, standard precaution policy, tracking and monitoring infection policy, hand washing policy, Infection Control & Isolation Guidelines, Centers for Disease Control (CDC) guidelines, and staff interview, the facility failed to ensure cleaning practices were in place to reduce and prevent the spread of nosocomial (facility-acquired) infections and that staff were educated on practices to reduce the spread of infection. This resulted in Immediate Jeopardy for one resident (Resident #114) who developed a Clostridium difficile(C-diff) infection in the facility and had to be isolated and receive antibiotics. [DIAGNOSES REDACTED] is an infectious, often life-threatening diarrhea that can result in dehydration, malnutrition and sepsis. The facility also failed to have an effective Infection Control program that promptly identified infection patterns and trends and failed to document a complete and accurate tracking system for all infections. The failure to have an effective infection control system in place could affect all 87 residents in the facility. On 02/26/15 at 12:45 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 02/13/15 when Resident #114 was diagnosed with [REDACTED]. On 02/25/15, Housekeepers (HSKPs) #6 and #34 were observed cleaning isolation rooms using cross-contaminated mops and toilet brushes, not using bleach-based cleaners according to manufacturer ' s guidelines for killing[DIAGNOSES REDACTED], using a disinfectant to mop floors that was not effective against[DIAGNOSES REDACTED], and not using personal protective equipment or appropriate hand hygiene. The Immediate Jeopardy was removed on 02/27/15 at 4:33 P.M. when the facility implemented the following corrective actions: · On 02/25/15, the DON provided in-service education for HSKPs #6, #8, #9, #34, #122 and #439, six of nine facility housekeeping staff, on the new[DIAGNOSES REDACTED] cleaning procedures revised 02/25/15. · On 02/26/15, the DON provided in-service education for HSKP #17 on the new[DIAGNOSES REDACTED] cleaning procedure. · On 02/26/15, the DON performed competency evaluation and training with return demonstration for HSKPs #6, #8, #9, #34, #122 and #439. · On 02/26/15, the facility ' s[DIAGNOSES REDACTED] policy and procedure was revised to include updated isolation protocols, linen handling and food service protocols. · On 02/26/15 and 02/27/15, the DON provided mandatory education on the new[DIAGNOSES REDACTED] policy and procedure to 105 of the 110 staff in the facility - 39 State tested Nurse Aides (STNAs), 15 Licensed Practical Nurses (LPNs), 15 dietary staff, 12 Administrative staff, nine Registered Nurses (RNs), nine Housekeepers, and six Therapy staff. Five staff were unable to attend the mandatory sessions. The DON and designee planned to call each of the five staff members on 02/27/15 and provide notice of the in-service material. Each employee would be in-serviced by the DON or designee prior to returning to work their next scheduled shift. · On 02/26/15, the DON performed mandatory competency evaluation with return demonstration on gowning and gloving with 16 STNAs, five LPNs, eight dietary staff, one Administrative staff, five RNs, five Housekeepers, two activity staff and six Therapy staff. Eight staff were unable to attend the mandatory sessions. The DON or designee planned to call each of the eight staff members on 02/27/15 and provide notice of the in-service material. Each employee would be in-serviced by the DON or designee prior to returning to work their next scheduled shift. · On 02/27/15, the DON provided in-service education for HSKPs #43 and #97 on the new[DIAGNOSES REDACTED] cleaning procedure. · On 02/27/15, the remaining housekeepers, HSKPs #17, #43 and #97, completed a return demonstration competency for cleaning a resident room and bathroom with[DIAGNOSES REDACTED]. · On 02/27/15, the DON performed competency evaluation and training with return demonstration on gowning and gloving for 22 STNAs, three housekeepers, seven Administrative staff, seven dietary staff, nine LPNs, five RNs, two Therapy staff and one activity staff. · On 02/27/15, the DON provided mandatory education to 39 STNAs, 15 LPNs, 15 dietary staff, 12 Administrative staff, nine RNs, nine Housekeepers, and six Therapy staff on the environmental services policy including linen handling, hand washing, isolation, personal protective equipment (PPE), and gowning and gloving. Additional topics included dietary infection control and perineal care. Seven staff were unable to attend the mandatory sessions. The DON and designee planned to call each of the seven staff members on 02/27/15 and provide notice of the in-service material. Each employee would be in-serviced by the DON or designee prior to returning to work their next scheduled shift. · On 02/27/15, all residents were screened for signs and symptoms of[DIAGNOSES REDACTED] and infection control protocols were implemented if appropriate. · On 02/28/15, the DON provided mandatory education to three STNAs on the environmental services policy including linen handling, hand washing, isolation, PPE gowning and gloving. Additional topics included dietary infection control and perineal care. · On 03/02/15, the DON provided mandatory education and competency on gowning and gloving to two STNAs, one Administrative staff and one therapist on the environmental services policy including linen handling, hand washing, isolation, PPE gowning and gloving. Additional topics included dietary infection control and perineal care. · On 03/02/15, interview with HSKPs #9 and #34, revealed knowledge of isolation precautions and facility protocol on cleaning isolation rooms. Although the Immediate Jeopardy was removed when the facility re-educated the nine housekeeping staff on proper room cleaning related to infection control and isolation procedures, the facility remained out of compliance at Severity Level 2 (no Actual Harm with potential for more than minimal harm that is not Immediate Jeopardy) because not all facility staff had been re-educated on isolation procedures, a comprehensive system to track and trend infections had not been implemented, and the facility was still implementing the ongoing monitoring of corrective actions. Findings include: 1. Review of the Center for Disease Control (CDC) guidelines related to[DIAGNOSES REDACTED] in Healthcare Settings, dated 2010, revealed to use contact precautions for patients with known or suspected[DIAGNOSES REDACTED] infections. The guidelines included wearing a gown and gloves when entering patient rooms and during care, and performing hand hygiene after removing gloves because alcohol-based hand sanitizers did not kill the[DIAGNOSES REDACTED] spores. The guidelines included dedicating patient care equipment such as stethoscopes, blood pressure cuffs and thermometers to a resident with[DIAGNOSES REDACTED], or performing adequate cleaning of shared equipment. The guidelines further identified the contact precautions should continue until the diarrhea ceases, and because the infected resident will continue to shed the organism spores for a number of days following cessation of diarrhea, the isolation may continue. Review of the facility ' s undated Infection Control & Isolation Guidelines policy revealed contact precautions were to be used if organisms were transmitted by direct contact with the patient when caring for residents or when touching surfaces in room or equipment used by the resident. The resident should stay in the room or be sure infective material was contained and that the resident ' s hands were washed before leaving the room. Gloves were to be worn when entering the room. Change gloves if contact with infectious material. Remove gloves and wash hands. Gowns were to be worn when entering room if there will be contact with the resident or clothing may touch anything in the room. Review of the facility ' s Housekeeping Isolation Procedure policy, undated, revealed staff were to don disposable gown, mask, and gloves upon entering an isolation room. The mop and bucket with disinfectant solution was to be placed inside the door and the solution was to be emptied into the commode when the procedure was completed. The mop bucket was to be cleaned with a sanitizing solution and the mop head was to be marked " Isolation " and sent to the laundry. The isolation room was to be the last room cleaned for the day. Staff was to remove the isolation gown, gloves and mask, and go to the utility room to wash their hands. Wiping cloths were to be discarded and double-bagged in the room; all cleaning equipment disinfected in the room after use; mop heads must be double-bagged and then laundered separately and thoroughly dried. All trash and disposables should be double-bagged and taken to the dumpster. Medical record review revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #114 was severely impaired for daily decision-making, required extensive assistance with toilet use and was frequently incontinent of bowel. Review of Resident #114 ' s Progress Notes revealed on 02/12/15, the resident had two episodes of diarrhea and a new order was obtained to check stool for[DIAGNOSES REDACTED] related to frequent diarrhea. On 02/13/15, the resident had diarrhea with a foul odor. Stool samples were obtained and contact isolation implemented. Review of the Stool Specimen Laboratory result dated 02/13/15 at 2:00 A.M. revealed Resident #114 was positive for[DIAGNOSES REDACTED]. Review of the General Progress Notes dated 02/14/15 revealed Nurse Practitioner #200 was notified of Resident #114 ' s stool culture results and ordered [MEDICATION NAME] 500 milligrams three times a day for 10 days. On 02/25/15 at 10:00 A.M., observation revealed HSKP #34 prepared to clean Resident #114 ' s room. HSKP #34 stated the resident was on contact isolation for[DIAGNOSES REDACTED] and she had already wiped down the furniture but needed to clean the bathroom. At 10:01 A.M., HSKP #34 donned gloves without washing her hands, did not apply an isolation gown, and took a rag that had been in a bucket of pink solution from the cart. HSKP #34 then gathered a toilet brush, a bottle of Activate Bleach and a bottle of Re-Juv-Nal from the housekeeping cart and entered the resident ' s room carrying the supplies. At 10:01 A.M., HSKP #34 sprayed Activate Bleach into the toilet. HSKP #34 then sprayed Re-Juv-Nal onto the bathroom sink, the toilet bowl, tank, and lid. At 10:02 A.M., HSKP #34 used the toilet brush to clean the inside of the toilet bowl and when she removed the toilet brush, a drop of water dropped onto the floor while she was returning the brush to the holder. At 10:03 A.M., HSKP #34 returned the toilet brush and Activate Bleach to the cart and this was the only toilet brush observed on the cart. At 10:03 A.M., HSKP #34 re-entered the bathroom wearing the same gloves and wiped the top and bottom of the toilet seat, the exterior bowl and tank, the sink, faucets and toiletry shelf, all in that order, with the same rag. She then discarded the rag into an open plastic bag with other rags on the cart. At 10:06 A.M., HSKP #34 removed her gloves, did not wash her hands or don new gloves, and grasped the mop handle. HSKP #34 re-entered the resident's room, flushed the toilet with her bare hand, mopped the bathroom floor, and closed the bathroom door with her bare hand. At 10:08 A.M., HSKP #34 returned the mop to the mop bucket on the housekeeping cart and left the isolation room without washing her hands. The rag used to clean the isolation bathroom was observed on top of other soiled rags hanging out of the unsealed bag. At 10:08 A.M., HSKP #34 pushed her cart with her left hand and grasped the vacuum cleaner with her right hand and went to the next resident room. HSKP #34 stated she was ready to clean the next room, stepped towards the threshold of the next room and the surveyor intervened. On 02/25/15 at 10:09 A.M., interview with HSKP #34 stated she had worked at the facility for a month, had two days of training and had not been observed cleaning an isolation room before that day. HSKP #34 verified the above observation and that there was one resident on isolation precautions on the memory care unit. HSKP #34 verified she cleaned the bathroom items within one minute of spraying the Activate Bleach, she used the same toilet brush to clean resident, staff and public restrooms, and emptied the mop water and sanitizing bucket solution after all rooms and bathrooms were cleaned on each hallway. HSKP #34 stated she was assigned to clean resident rooms on two of the four halls within the facility, the 300 and 400 halls. On 02/25/15 at 10:11 A.M., the DON was walking down the hallway and was informed of the above observation by the surveyor. The DON verified hand washing was to be completed before entering or leaving an isolation room, gloves and isolation gowns were to be worn, an isolation room was to be cleaned last and the mop water and sanitizing bucket was to be emptied after an isolation room was cleaned. On 02/25/15 at 11:03 A.M., observation revealed HSKP #6's housekeeping cart was half way across the threshold of Resident #149 ' s doorway. HSKP #6 stated the resident was on contact isolation for[DIAGNOSES REDACTED] and she was finishing up after cleaning his room. HSKP #6 entered the room without washing her hands, applying an isolation gown or donning gloves. HSKP #6 held a red biohazard bag as she entered the resident's bathroom. At 11:05 A.M., HSKP #6 lifted the lid of the isolation barrel with her bare hands, rested the lid against her uncovered left arm and placed the biohazard bag over the outer edge of the barrel. HSKP #6 replaced the isolation barrel lid, walked over to her cart that was in the resident room and pushed the cart into the hallway. HSKP #6 did not wash her hands prior to exiting the room. On 02/25/15 at 11:09 A.M., interview with HSKP #6 verified the housekeeping cart was pushed into the isolation room and she did not apply an isolation gown or gloves prior to placing the biohazard bag into the isolation barrel. HSKP #6 stated she had already cleaned the bathroom and did not need to wear an isolation gown or gloves. HSKP #6 verified she did not wash her hands prior to exiting the room and stated she had cleaned two of the four halls within the facility, the 100 and 200 halls. Review of the undated Activate 5.25% Institutional Bleach manufacturer guidelines revealed the product had to be left on surfaces for four minutes prior to wiping it off to kill[DIAGNOSES REDACTED] spores. Review of the Re-Juv-Nal manufacturer ' s guidelines dated 11/30/10 revealed no documented evidence the disinfectant was effective against[DIAGNOSES REDACTED]. Review of the Infection/Antibiotic Log dated January 2014 through February 2015 revealed 11[DIAGNOSES REDACTED] infections (Residents #6, #32, #34, #59, #64, #81, #114, #122, #149, #150 and #151) were acquired in the facility during that time period. Review of the Log revealed a color coded facility map by type of infections for all four halls. The log revealed a pattern of nosocomial infections with no documented evidence the pattern had been identified by the facility. Review of the infection control log revealed incomplete documentation of culture results, organisms, antibiotic use, and no documented evidence isolation precautions were initiated or the date the infection was resolved. There was also no documented evidence of possible infection trends, interventions implemented, staff education regarding infection control or a log for March 2014. Medical record reviews revealed nine of the 11 residents (Residents #6, #34, #59, #64, #81, #122, #149, #150 and #151) identified by the facility with nosocomial[DIAGNOSES REDACTED] had received antibiotics within 30 days before developing[DIAGNOSES REDACTED] or had a history of [REDACTED]. Review of the monthly Medical Director Reports dated February 2014 through January 2015, revealed no documented evidence of review of infection control trends or patterns. Review of the Medical Director Reports revealed the Medical Director attended the Infection Control Committee meetings on 03/26/14, 05/07/14, 06/25/14, 07/02/14, 08/06/14, 09/03/14, 10/01/14 and 01/07/15. Review of Staff Education for the last documented training for infection control revealed: STNAs #25, #41, #54, RNs #47 #119, Administrative Staff #112, Maintenance Staff #181, LPN #13 and Certified Nurse Aide #69 had no documented evidence of education. RN #19 had not been educated since 2009. RN #27 had not been educated since 2010. STNAs #33, #102, LPN #15, Administrative Staff #100 and the Administrator had not been educated since 2011. STNAs #11, #32, #39, #42, #59 and #70 and Administrative Staff #80 and #175 had not been educated since 2012. STNAs #16,#20, #44, #51, and #125,Dietary Staff #2, #5, #10, #45, #78 and #83, HSKPs #6, #8, #9, #43 and #122, LPNs #36, #60 and #170, RN #92, and Administrative Staff #79 had not been educated since 2013. Review of the facility ' s Orientation for Housekeepers, revised May 1989, revealed it included no direction on how to clean a resident room in isolation precautions. Review of the Standard Precautions policy revised December 2007, revealed gloves were to be worn when staff anticipated direct contact with potentially infected materials, handling or touching resident-care equipment that was visibly soiled or potentially contaminated with blood, body fluids or infectious organisms. Gloves were to be promptly removed after use and hands immediately washed to avoid transfer of microorganisms to other residents or environments. Environmental surfaces and other frequently touched surfaces were to be appropriately cleaned. Review of the undated Hand Washing policy revealed to thoroughly cleanse the hands with friction, soap and water. Proper hand-washing techniques must be followed at all times to reduce transmission of organisms from resident-to-resident. Universal precautions, other infection control standards and CDC guidelines for hand washing were to be followed. Review of the facility ' s undated Tracking and Monitoring Infections policy, revealed the facility was to identify infections, follow nursing process and reporting/notification procedures, complete infection control/antibiotic communication log, map out infections on facility maps and report findings to the administrator, medical director and other agencies as needed. On 02/25/15 at 10:15 A.M., interview with HSKP #9 revealed the laundry washing machines were hot water temperature machines and the chemicals including bleach were automatically dispensed when the washing machine cycle was started. HSKP #9 stated the facility did not check or log the water temperature or sanitizing agent, and did not have any testing supplies to check the concentration of the chemicals used in the washing machines. On 02/25/15 at 10:17 A.M., interview with HSKP/Laundry Supervisor #8 verified infection control procedures were reviewed with new staff, but she did not observe how the housekeepers actually cleaned the isolation rooms. HSKP/Laundry Supervisor #8 stated all isolation linens were washed twice and dried on medium heat so the clothing did not wrinkle, and verified the facility did not log water temperatures or test the concentration of the washing machine chemicals. At 10:18 A.M., interview with HSKP/Laundry Supervisor #8 stated there was a company that came to the facility every two weeks that tested the concentration of the washing machine chemicals but they did not inform her of the results. On 02/25/15 at 11:00 A.M., interview with LPN #7 stated a resident requiring isolation was to have a physician order [REDACTED]. LPN #7 stated gowns and gloves were to be worn if entering a contact isolation room and the isolation barrel was emptied at the end of each shift. LPN #7 verified staff had to enter an isolation room to don protective equipment because the equipment carts were kept inside the room. On 02/25/15 at 12:50 P.M., interview with the DON verified Re-Juv-Nal cleaner was used in both housekeeping cart mop buckets and the manufacturer guidelines had no evidence it killed[DIAGNOSES REDACTED]. The DON stated HSKP Supervisor #8 verbally reviewed isolation procedures with staff upon hire, but did not observe the cleaning of an isolation room. On 02/25/15 at 12:58 P.M., interview with LPN #15 stated Resident #114 used the bathroom in his room and verified the isolation cart containing personal protective equipment (PPE) was on the opposite side of the resident room away from the door. LPN #15 verified staff had to walk past the bathroom and the resident ' s bed to obtain PPE. LPN #15 then picked up the isolation cart with her bare hands and no isolation gown, walked past the resident ' s bathroom and bed, and moved it by the door. LPN #15 did not wash her hands when she left the room. LPN #15 verified the above at the time of the observation. On 02/25/15 at 1:12 P.M., interview with STNA #57 stated Resident #114 had diarrhea on 02/23/15 and 02/24/15, soft bowel movements on 02/25/15 and was showered in the central shower room. STNA #57 stated she only wore gloves to shower the resident and used bleach spray to clean the shower room. On 02/26/15 at 8:42 A.M., interview with the DON verified Resident #114 ' s[DIAGNOSES REDACTED] was facility-acquired. The resident had no use of antibiotics within 30 days of developing the infection and had no history of[DIAGNOSES REDACTED]. On 02/26/15 at 10:02 A.M., interview with RN #92 verified Resident #114 had suspected[DIAGNOSES REDACTED] on 02/12/15, however, isolation precautions were not started until 02/13/15. On 02/26/15 at 10:08 A.M., interview with Chemical Manager #109 revealed he came to the facility every other week to ensure the washing machine was dispensing the proper amount of soap/chemical. Chemical Manager #109 verified he had a test kit to check the sanitizing chemical, but did not document the results and did not know how much sanitizing agent was required in the machine to ensure organisms including[DIAGNOSES REDACTED] were killed. Chemical Manager #109 stated he did not know what was required for a hot water temperature washing machine and stated "if the clothes come out clean, it was working". Chemical Manager #109 stated he did not know what the sanitizing agent in the washing machine should register and had no documentation that the sanitizing agent was tested . On 02/26/15 at 10:35 A.M., interview with the Administrator, the DON and RN #92, revealed RN #92 was the interim DON at the facility from 01/25/15 to 02/16/15. RN #92 verified the facility ' s infection control program was not comprehensive and did not identify trends or patterns, and they were unaware that isolation precautions and cleaning procedures were not being completed correctly. RN #92 verified staff completed education independently on a computer system and there was no face-to-face education regarding isolation precautions, PPE or cleaning procedures within the last year. The Administrator stated the facility tracked employee illnesses but only " sick " and verified they did not track staff illness by symptoms. The Administrator verified the Quality Assurance (QA) Committee had not identified any concerns with the infection control program. The Administrator verified the QA committee had not identified any patterns or trends regarding[DIAGNOSES REDACTED] between January 2014 and January 2015. RN #92 stated any patterns or trends identified by the Infection Control Committee would be action planned with interventions and monitoring initiated. The DON verified there was no documented evidence the Infection Control Committee has identified any concerns regarding nosocomial infections, and verified no action plans had been implemented for nosocomial[DIAGNOSES REDACTED] between January 2014 and January 2015. The DON verified no documented evidence the QA committee had identified concerns regarding isolation precautions or cleaning of isolation rooms. On 02/26/15 at 1:04 P.M., interview with Medical Director (MD) #110 revealed he attended Quality Assurance and Infection Control meetings monthly, and had not reviewed the facility policy regarding infection control, housekeeping or other policies within the past year. MD #110 stated there were no trends or patterns except a few cases of urinary tract infections and[DIAGNOSES REDACTED] over the past year. MD #110 verified any action taken by the facility would be documented on the back of the Medical Director Report. MD #110 was unaware of any infection control concerns regarding cleaning of isolation rooms, implementation of the infection control program,[DIAGNOSES REDACTED] infections or trends. MD #110 verified he was unaware there was no return demonstration of isolation precaution protocols prior to new staff working on their own, and the only training was computer generated. MD #110 stated it was his expectation that staff was competent and demonstrated appropriate infection control practices. On 02/27/15 at 10:05 A.M., interview with HSKP/Laundry Supervisor #8 verified HSKP #6 and HSKP #34 began their shift mopping and cleaning resident rooms, then mopped the main dining room and memory care dining room at approximately 9:00 A.M., and then returned to cleaning/mopping resident rooms on the four hallways. Second and Third shift housekeeping staff only mopped the floors in resident rooms if needed. HSKP/Laundry Supervisor #8 stated on 02/25/15, HSKP #34 cleaned resident rooms on the 300 and 400 hallways, and HSKP #6 cleaned resident rooms on the 100 and 200 hallways. HSKP/Laundry Supervisor #8 verified HSKP #6 and HSKP #34 did not follow infection control protocols, had been mopping the floors in dining areas and resident rooms with Re-Juv-Nal disinfectant, and was unaware it was not an effective disinfectant against[DIAGNOSES REDACTED]. 2. Review of the facility's Infection/Antibiotic form revealed the facility failed to identify the following nosocomial infection trends: -21 nosocomial infections in January 2014, including two urinary tract infections (UTIs), one eye infection and one respiratory infection on the 100 hall. Three respiratory infections, two UTIs and one wound infection (osteo[DIAGNOSES REDACTED]) on the 200 hall. Three UTIs on the 300 hall. Six UTIs, one respiratory and one skin infection on the 400 hall. -23 nosocomial infections in February 2014 including one UTI and one methicillin resistant staphylococcus aureus (MRSA) eye infection on the 100 hall. Two wound infections with MRSA, two respiratory and one UTI on the 200 hall. Four UTI (including one UTI with MRSA), and three respiratory infections on the 300 hall. Three UTIs, three respiratory, one skin, one eye and one vaginal infection on the 400 hall. -No documented evidence of an infection control log for March 2014. -21 nosocomial infections in April 2014, including five respiratory infections on the 100 hall. One respiratory, one UTI, one skin and one wound infection with MRSA on the 200 hall. Two respiratory infections and two UTI on the 300 hall. Four respiratory infections, two UTI, one skin and one[DIAGNOSES REDACTED] on the 400 hall. -35 nosocomial infections in May 2014, including four UTIs, three eye, two respiratory and one[DIAGNOSES REDACTED] infection on the 100 hall. Two UTIs, two skin, one[DIAGNOSES REDACTED], and one wound infection on the 200 hall. Three respiratory, two UTIs, two eye and one skin infection on the 300 hall. Four respiratory, three UTIs, three eye and one[DIAGNOSES REDACTED] infection on the 400 hall. -36 nosocomial infections in June 2014, including three respiratory, two eye, and one UTI on the 100 hall. Six respiratory, one eye and one[DIAGNOSES REDACTED] infection on the 200 hall. Three respiratory, three eye, three UTIs and one skin infection on the 300 hall. Seven respiratory, two UTIs, two eye and one[DIAGNOSES REDACTED] infection on the 400 hall. -31 nosocomial infections in July 2014, including three UTIs, two respiratory, one skin and one ear infection on the 100 hall. One respiratory, one eye and one[DIAGNOSES REDACTED] infection on the 200 hall. Nine UTIs, two[DIAGNOSES REDACTED], one skin, one eye, and one wound infection (osteo[DIAGNOSES REDACTED]) on the 300 hall. Two respiratory, two ear, one skin, one[DIAGNOSES REDACTED] and one on-going[DIAGNOSES REDACTED] infection on the 400 hall. -24 nosocomial infections in August 2014, including three skin, two respiratory and one UTI on the 100 hall. Three UTIs, two respiratory and one eye infection on the 200 hall. Two respiratory, two UTIs and one eye infection on the 300 hall. Four UTIs, two respiratory and one skin infection on the 400 hall. -22 nosocomial infections in September 2014, including three UTIs, one respiratory (Staphylococcus) and one[DIAGNOSES REDACTED] infection on the 100 hall. Three UTIs, one respiratory and one eye infection on the 200 hall. Four UTIs, one respiratory, one eye and one infection categorized as "other" on the 300 hall. Three UTIs, one respiratory and one wound (Staphylococcus) on the 400 hall. -24 nosocomial infections in October 2014, including three UTIs, two respiratory, one skin and one infection not classified by type of infection on the 100 hall. One UTI, one respiratory, one skin and one eye infection on the 200 hall. Four UTIs, one respiratory, one MRSA skin infection and one eye MRSA infection on the 300 hall. Two UTIs, two respiratory and two eye infections on the 400 hall. -21 nosocomial infections in November 2014, including one UTI and one respiratory infection on the 100 hall. Four UTIs, one respiratory and one eye infection on the 200 hall. Four UTIs, two respiratory, one skin and two infections categorized as "other" on the 300 hall. Two UTIs, one respiratory and one skin infection on the 400 hall. -37 nosocomial infections in December 2014, including three gastrointestinal (flu), two respiratory, one UTI and one skin infection on the 100 hall. Five respiratory, one UTI and one gastrointestinal (flu) infections on the 200 hall. Nine UTIs, three respiratory and one gastrointestinal (flu) infections on the 300 hall. Five respiratory, three UTIs, one skin and one gastrointestinal (flu) infections on the 400 hall. -29 nosocomial infections in January 2015, including two UTIs, two respiratory, two eye, one skin and one infection categorized as "other" on the 100 hall. Four UTIs, one respiratory and one skin infection on the 200 hall. Four UTIs, two skin, one respiratory and one eye infection on the 300 hall. Four UTIs, two respiratory and one wound infection on the 400 hall. -27 nosocomial infections in February 2015, including four respiratory, two UTIs, two skin and one[DIAGNOSES REDACTED] infection on the 100 hall. Four respiratory and one skin infection on the 200 hall. Four UTIs, one respiratory and one[DIAGNOSES REDACTED] infection on the 300 hall. Four UTIs and three respiratory infections on the 400 hall. On 02/26/15 at 10:35 A.M., interview with the Administrator, DON and RN #92 verified the facility's infection control program was not comprehensive, and did not identify trends or patterns.

Based on medical record review, policy review and staff interview, the facility failed to manage Resident #120's pain, and failed to monitor Resident #39's bowel movements. Actual Harm occurred on 11/15/14, when Resident #120 was screaming and moaning in pain and the facility did not provide an intervention to relieve the resident's pain. This affected one of three residents reviewed for pressure ulcers (Resident #120), and one of seven residents reviewed for constipation (Resident #39). Findings include: 1. Review of the medical record revealed Resident #120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Pain assessment dated [DATE], revealed Resident #120 exhibited verbal expression of distress/crying. The Pain Assessment revealed Resident #120 stated she experienced severe pain daily, to her back, hip, and joints, but indicated most of her pain was caused by the post operative incision of the hip. The Pain Assessment indicated Resident #120's current pain medication regime was narcotics and current nonpharmological interventions were therapy and distraction. The Pain Assessment revealed Resident #120 had satisfactory pain management. Review of the physician orders [REDACTED].#120 was ordered [MEDICATION NAME] Tablet 5 - 325 milligram (mg) one tablet every six hours, as needed for pain and Tylenol 325 mg two tablets, every four hours, as needed for pain. Review of the physician orders [REDACTED].#120 was ordered [MEDICATION NAME] Tablet 5 - 325 mg two tablets every six hours as needed for pain, and give one tablet as needed for pain every six hours. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #120 was moderately cognitively impaired and had received as needed pain medication for pain that had occurred in the last five days. Resident #120 indicated the pain was almost constant, had limited her day-to-day activities, and it was hard for her to sleep at night. Resident #120 rated the worse intensity of her pain over the last five days as severe. Review of the nurses notes dated 11/15/14 at 1:48 P.M. revealed Resident #120 was moaning out in pain. The nurse received an order for [REDACTED].#120 was medicated with two [MEDICATION NAME] tablets on 11/15/14 at 2:04 P.M. On 11/15/14 at 3:05 P.M. the nurses notes revealed Resident #120 was still screaming and moaning in pain. There was no evidence the physician was notified that the as needed ordered pain medication was not effective in alleviating Resident #120's pain. There was no evidence that any non pharmacological attempts were made to relieve Resident #120's pain. There was no documented evidence that Resident #120 was offered Tylenol 325 mg two tablets, when the [MEDICATION NAME] was ineffective. There was no further documentation until 11/15/14 at 7:20 P.M. when Resident #120 was medicated with [MEDICATION NAME] 5 - 325 mg two tablets for pain. On 03/02/15 at 4:25 P.M., the Director of Nursing (DON) verified that on 11/15/14 at 2:04 P.M. Resident #120 was assessed as moaning out in pain and was given [MEDICATION NAME] 5 - 325 mg two tablets, and on 11/15/14 at 3:05 P.M. the resident was still screaming and moaning in pain. The DON verified there was no documented evidence the physician had been notified that the [MEDICATION NAME] was ineffective. There was no documented evidence that Resident #120 was offered the as needed Tylenol 325 mg two tablets for breakthrough pain. There was no documented evidence that Resident #120 was offered non pharmacological interventions or any comfort measures. The DON verified that Resident #120 was not provided any further intervention for pain until 11/15/14 at 7:20 P.M. when the nurse provided Resident #120 with [MEDICATION NAME] 5 - 325 mg tablets. Review of the facility's Pain - Clinical Protocol, last revised April 2007, revealed the staff would evaluate and report how much and how often the individual requested as needed pain medication. If there were more than occasional [MEDICATION NAME] requests, the physician would consider changing to regular administration of at least one [MEDICATION NAME] with another medication for as needed use, increasing the standing dose of an existing [MEDICATION NAME], or switching to another [MEDICATION NAME]. Staff would provide the elements of a comforting environment and appropriate physical and complementary interventions, for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain. Review of the facility's Pain Assessment policy, last revised August 2002, revealed the purpose of the policy was to assess the resident's pain level and provide optimal comfort through a pain control plan, which was mutually established with the resident , family, and members of the health care team. The steps in the procedure for pain assessment included the staff were to ask the resident if she was experiencing any pain. The location of pain and the level of the pain was to be noted. The pain assessment was to include onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms. The resident was to be medicated as ordered by the physician, and if the pain was not relieved the staff were to give further medication as the physician had ordered. If there were no orders, the physician was to be notified and an order obtained. 2. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#39's last bowel movement was on 12/20/14. Review of the Admit/Readmit Screener assessment dated [DATE] revealed the resident needed an occasional use of a laxative or enema for bowel movements. There was no documented evidence of the resident's last bowel movement prior to admission. Review of the Bowel and Bladder Data Collection Form dated 12/24/14 through 12/27/14 revealed Resident #39 did not have a bowel movement. Review of the admission Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED] -on 12/27/14 at 4:40 P.M., [MEDICATION NAME] 50 milligrams (mg) PRN (as needed) for pain was administered. -between 12/24/14 and 12/27/14, [MEDICATION NAME] 50 mg every six hours for pain was administered 11 times. -on 12/27/14 at 6:34 P.M., Milk of Magnesia (MOM) 400 mg/5 milliliters (ml) 30 ml was administered PRN for constipation. The MOM was effective. Review of the Medication Administration Notes revealed the following: -dated 12/27/14, Resident #39 complained of abdomen tightness and pain. -dated 12/28/14, no bowel movement for three days as of 12/27/14, MOM was effective and PRN suppository was also administered on 12/28/14. Review of the facility's Bowel Movement policy, undated, included if the resident had no bowel movement for three days, MOM was to be administered as ordered, and if no bowel movement in eight to 12 hours a suppository was to be administered. On 02/25/15 at 12:34 P.M., interview with Registered Nurse (RN) #92 verified Resident #39 was admitted to the facility from home, her last bowel movement was on 12/20/14 and the resident did not have a bowel movement until 12/27/14. RN #92 verified the facility did not assess the resident's last bowel movement when she entered the facility, was not administered MOM until 12/27/14, and the bowel protocol was not followed.