Every finding on record at St. George Rehabilitation

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 of 43 sampled residents, staff were observed to provide direct resident care for a resident on Enhanced Barrier Precautions (EBP) without wearing the required Personal Protective Equipment (PPE). Resident identifier: 86.Findings included:Resident 86 was admitted to the facility on [DATE] with diagnoses which included rhabdomyolysis, anxiety disorder, type 2 diabetes mellitus, cellulitis of the left lower limb, sepsis, congestive heart failure, acute kidney failure, atrial fibrillation, hypertension, emphysema, and cognitive communication deficit. On 8/4/26 at 9:25 AM, an observation was made of resident 86. Resident 86 was sleeping in bed. The bed was in the lowest position with the right side against the wall and fall mats were located on the left side of the bed. Resident 86 was observed with bilateral dressing on his feet. An EBP sign was posted on the door and PPE was located on the inside of the door. Resident 86 was heard yelling Hey, Help and that he needed help going to the bathroom. Registered Nurse (RN) 2 and Certified Nursing Assistant (CNA) 2 entered resident 86's room and donned gloves. CNA 2 moved resident 86's wheelchair to the bedside, moved the fall mats aside, moved the bed linens aside, repositioned resident 86's legs to the side of the bed, and assisted resident 86 to the wheelchair. RN 2 placed their arm under resident 86's arm and lifted the resident for a pivot transfer assist to the wheelchair while CNA 2 held the wheelchair. CNA 2 wheeled resident 86 to the bathroom. Both staff were observed to come in direct contact with resident 86 and his environment and both staff were not wearing a gown. Resident 86's physician orders revealed the following:a. On 7/6/26, an order was initiated for Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: Indwelling Catheter every shift. The order was discontinued on 8/3/26. b. On 8/3/26, an order was initiated for Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: wounds every shift. Resident 86 had a care plan initiated on 7/6/26, for at risk for infection related to wound care. An intervention identified on the care plan was ENHANCED BARRIER PRECAUTIONS during the provision of close contact care and was initiated at the time the care plan was created. On 8/4/26 at 2:05 PM, an interview was conducted with RN 2. RN 2 stated that EBP was for conditions that the resident had going on. EBP required gloves and gowns for any resident care and if they were in contact with the patient at all. RN 2 stated that the resident 86 was on EBP for wounds with infections. RN 2 stated that they should have been wearing gowns when assisting the resident with toileting this morning. On 8/4/26 at 2:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that for any patient on EBP if there was contact with the patient or their environment the staff should wear a gown and gloves.

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, for 1 out of 43 sampled residents, the facility did not assess and treat a resident's skin breakdown or injury. Resident identifier: 129. Findings included:Resident 129 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage, hemiplegia, metabolic encephalopathy, aphasia, Parkinson's Disease, cognitive communication deficit, repeated falls, polyneuropathy, atrial fibrillation, urinary tract infection, pain, and hypertension.Resident 129 physician orders were reviewed and no documentation was found for wound care or treatment of skin conditions. Resident 129's progress notes revealed:a. On 12/6/25 at 12:36 AM, the note documented, Redness and bumps to tip of penis, wound nurse notified.b. On 12/6/25 at 2:49 AM, the Daily Skilled Note documented, Sore noted to tip of penis with reported discomfort. Mild redness noted to coccyx. Preventative PUPs [unknown abbreviation] in place to BL [bilateral] heels. Dry skin noted to BL feet. No other skin issues noted. Wound nurse aware. c. On 12/8/25 12:51 AM, the Daily Skilled Note documented, Sore noted to tip of penis with reported discomfort. Mild redness noted to coccyx. Preventative PUPs in place to BL heels. Dry skin noted to BL feet. No other skin issues noted. Wound nurse aware. There are No active symptoms effecting [sic] the Integumentary system observed. Active SX [symptoms]: skin injury / ulcer. Active SX: surgical wound. Active SX: moisture associated skin damage (MASD). Skin injury is located Head of penis Surgical Wound(s)is [sic] located Crown of head Moisture Associated Skin Damage (MASD) is located Coccyx, head of penisResident [sic] response to treatment is Compliant with cares. Skin condition is Not a new onset. Pressure reducing device for bed is used to maintain skin integrity.Other observations and interventions include Pressure reducing device for bed per protocol, tolerating well with no issues noted.d. On 12/9/25 at 1:44 AM, the Daily Skilled Note documented, Overall skin description is: Not fully assessed. Visible skin appears CDI [clean, dry, intact], is warm to the touch, has fair turgor, and color is appropriate for age and ethnicity. Closed surgical site to L [left] side of crown of head, sutures removed; OTA [open to air]. Site does not exhibit any s/s [signs and symptoms] of infection. Sore noted to tip of penis with reported discomfort. Mild redness noted to coccyx. Preventative PUPs in place to BL heels. Dry skin noted to BL feet. No other skin issues noted. Wound nurse aware.There are No active symptoms effecting [sic] the Integumentary system observed. Active SX: skin injury / ulcer. Active SX: surgical wound. Active SX: moisture associated skin damage (MASD). Skin injury is located Head of penis Surgical Wound(s)is [sic] located Crown of head Moisture Associated Skin Damage (MASD) is located Coccyx, head of penis. Resident response to treatment is Compliant with cares. Skin condition is Not a new onset. Pressure reducing device for bed is used to maintain skin integrity. Other observations and interventions include Pressure reducing mattress per facility. It should be noted that resident 129's Daily Skilled Noted on 12/10/25 and 12/11/2,5 contained the exact same documentation for the resident's skin condition. e. On 12/12/25 at 12:28 AM, the Daily Skilled Note documented, Overall skin description is: See skin assessment. There are No active symptoms effecting [sic] the Integumentary system observed. Pressure reducing device for bed is used to maintain skin integrity. Other observations and interventions include Pressure reducing mattress in place, tolerating well.f. On 12/13/25 at 1:51 AM, the Daily Skilled Note documented, Overall skin description is: Full skin assessment notcompleted [sic] this shift. Closed surgical site to L side of crown of head, sutures removed; OTA. Site does not exhibit any s/s of infection. Sore noted to tip of penis with reported discomfort. Other visible skin appears CDI, warm to the touch, color appropriate for ethnicity.There are No active symptoms effecting [sic] the Integumentary system observed. No active skin condition(s) or treatments observed.g. On 12/14/25 at 12:58 AM, the Daily Skilled Note documented, Overall skin description is: Closed surgical site to L side of crown of head, sutures removed; OTA. Site does not exhibit any s/s of infection. Sore noted to tip of penis, wound nurse aware. No other skin issues noted.There are No active symptoms effecting [sic] the Integumentary system observed. Active SX: skin injury / ulcer. Active SX: surgical wound. Skin injury is located Head of penis Surgical Wound(s)is located Crown of head Resident response to treatment is Compliant with cares. Skin condition is Not a new onset.It should be noted that resident 129's Daily Skilled Note on 12/16/25, 12/17/25, 12/19/25, and 12/20/25, contained the exact same documentation for the resident's skin condition. On 12/12/25, the Skin Evaluation documented, Closed surgical site to L side of crown of head, sutures removed; OTA. Site does not exhibit any s/s of infection. Sore noted to tip of penis, wound nurse aware. Mild redness noted to coccyx. Dry skin noted to BL feet. No other skin issues noted. On 12/20/25, the Skin Evaluation documented, Closed surgical site to L side of crown of head, sutures removed; OTA. Redness to coccyx. No other issues noted at this time. Resident 129 had a care plan initiated on 12/5/25, for had a pressure ulcer or potential for pressure ulcer development related to decreased mobility, weakness, and fragile skin. Interventions identified on the care plan included administering treatments as ordered and monitor for effectiveness, encourage fluid intake to keep skin hydrated, and weekly head to toe skin at risk assessment. It should be noted that no documentation could be found of a care plan that was specific to resident 129's injury to the head of the penis. On 8/6/26 at 8:17 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1 who was also the facility wound nurse. LPN 1 stated that staff informed her of newly identified skin issues after they completed an admission skin assessment and it would be documented in a progress note. LPN 1 stated that the nurses would usually text her with any skin conditions. LPN 1 obtained her computer to review her documentation. LPN 1 stated that she did not recall resident 129 or what his skin condition would have been. LPN 1 stated she followed all identified wounds but only did assessments for pressure ulcers and anything chronic. LPN 1 stated that she did not remember if she evaluated the sore on resident 129's penis. LPN 1 stated she would have documented any wound assessment or care in a progress note and she did not have any documentation for resident 129. LPN 1 stated that she thought she referred resident 129 to the doctor, but could not find documentation of the referral. LPN 1 stated that she did not recall the sore on resident 129's penis. LPN 1 stated she typically observed and assessed all wounds. LPN 1 stated that if the nurse documented the wound and that she was informed, she should have observed the wound, assessed it, and documented it somewhere. LPN 1 stated that she did not have any documentation that she assessed and treated resident 129's wound. LPN 1 stated that if it wasn't documented it didn't happen. LPN 1 stated that a preventative PUP was a foam bandage placed on bony prominences that hospitals put on resident heels or the coccyx. LPN 1 stated that when a resident arrived with a PUP in place or identified wounds she notified the wound Physician Assistant (PA) 1 and then put the resident on the list to be seen when that provider was in the building next. LPN 1 stated that PA 1 was in the facility on Mondays and would write wound care orders for all residents that he treated. LPN 1 stated that if the resident continued to have a PUP bandage applied the facility would need orders for that treatment from PA 1. LPN 1 stated that they had no standing orders for wound care at the time of resident 129's admission. LPN 1 reviewed resident 129's progress notes and stated that it appeared that the nurses were copying and pasting the same progress note about resident 129's skin condition. On 8/6/26 at 9:46 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nurses should conduct a head to toe skin assessment on admission, weekly, and as needed for residents. The DON stated that the nurses communicated skin conditions to the wound nurse on whatsapp or by text. The DON stated that the nurse should also notify the medical provider and resident representative of any identified skin conditions. The DON stated that the wound nurse should then conduct a skin assessment, document wound care notes, update the skin care plan, enter wound care orders, and notify PA 1 so the skin condition could be assessed. The DON stated that if a resident was seen by an outside wound care provider it would be documented in a progress note. The DON confirmed that resident 129 did not have an evaluation of his skin condition by the wound nurse and no treatment orders were implemented and provided.

Based on interview and record review, the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living (ADL) did not diminish unless circumstances of the resident's clinical condition demonstrated that it was unavoidable. Specifically, for 1 out of 43 sampled residents, the facility did not provide a resident with bathing hygiene per the resident's scheduled preferences. Resident identifier: 5.Findings included:Resident 5 was admitted to the facility on [DATE] with diagnoses which consisted of polyarthritis, bronchitis, stiff-man syndrome, type 2 diabetes mellitus, cirrhosis of liver, asthma, functional quadriplegia, urinary tract infection, cognitive communication deficit, chronic kidney disease, gastroparesis, thrombophilia, anxiety disorder, depression, atrial fibrillation, pulmonary hypertension, and need for assistance with personal care. On 8/3/26 at 1:55 PM, an interview was conducted with resident 5. Resident 5 stated that her bathing was scheduled for Tuesday and Friday. Resident 5 stated that she did not receive a shower last Friday and that she did not always get them as scheduled. Resident 5's bathing task for the last 30 days was reviewed. The task documented that resident 5 received a bed bath on 7/7/26, 7/14/26, 7/17/26, 7/23/26, and 7/28/26. Resident 5 refused a bed bath on 7/21/26. According to resident 5's twice weekly bathing schedule the resident should have received eight showers in the last 30 days instead of the documented six showers provided. Resident 5 had a care plan for ADL's self care performance deficit initiated on 1/19/24. Interventions identified on the care plan for bathing documented that resident 5 required substantial to maximal assistance for bathing. On 8/4/26 at 1:13 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 5 required substantial assistance for showering. CNA 1 stated that she had never provided resident 5 with a bed bath but believed that it was scheduled twice weekly like all other residents. CNA 1 stated that she documented shower refusals on the shower sheet and the resident had to sign the refusal. On 8/4/26 at 1:18 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that CNAs documented shower refusals in the electronic medical record and on a shower sheet. RN 1 stated that resident 5 refused bed baths, brief changes, and personal hygiene frequently. RN 1 stated that resident 5 was scheduled for showers on Tuesday and Friday on the PM shift. On 8/4/26 at 3:25 PM, a follow-up interview was conducted with RN 1. RN 1 confirmed that per resident 5's shower schedule she was not provided a shower on 7/10/26, 7/31/26, and there were no documented refusals for those days.

Based on observation, interview, and facility policy review, the facility failed to store, prepare, and serve food in a sanitary manner for 1 of 2 nourishment refrigerators and 1 of 1 kitchen. Specifically, the staff failed to date foods brought in from visitors to be stored in the nourishment refrigerators and discard opened food items that were undated and had been in the nourishment refrigerators for an indeterminate amount of time. Additionally, the staff failed to change gloves and wash their hands after touching high-contact surfaces and before touching food items. This had the potential to affect 96 of 96 residents who received food from the dietary department. Findings included: 1. A facility policy titled, [Facility Name] Policy / Procedure, revised 11/2016. specified, Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal/resident room refrigeration units will be monitored by designated facility staff for food safety. An undated facility policy titled, Food Storage, specified, Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. An observation of the nourishment refrigerator outside of the 100 Unit on 06/03/2024 at 2:57 PM revealed an opened, undated resealable plastic bag of five hotdogs and an opened, undated jar of pasta sauce. During an interview on 06/04/2024 at 2:22 PM, the Dietary Manager stated that nursing staff were responsible for labeling and dating food items brought in from visitors. During an interview on 06/05/2024 at 11:19 AM, Certified Nursing Assistant (CNA) #18 stated that whoever puts the food in the nourishment refrigerator was responsible for labeling and dating them. During an interview on 06/05/2024 at 11:26 AM, CNA #10 stated that the CNA staff were responsible for labeling and dating foods for the nourishment refrigerators. CNA #10 stated that the dietary staff were responsible for cleaning the refrigerators, including discarding food items that had been in the refrigerator for longer than three days. An observation of the nourishment refrigerator outside of the 100 Unit on 06/06/2024 at 2:27 PM revealed an open, undated resealable bag of three hotdogs. An observation of the nourishment refrigerator outside of the 100 Unit on 06/07/2024 at 8:33 AM revealed a fully cooked rotisserie chicken that had been opened but not dated. During an interview on 06/06/2024 at 4:56 PM, the Director of Nursing (DON) revealed that dietary staff were responsible for cleaning and maintaining the nourishment refrigerators. She stated that all staff were responsible for labeling and dating food items in the nourishment refrigerators. She did not know if it was a concern that an open undated resealable bag of hotdogs had been in the nourishment refrigerator since 06/03/2024. During an interview on 06/06/2024 at 5:01 PM, the Dietary Manager stated that nobody had told her the dietary department was responsible for maintaining the nourishment refrigerators. 2. An undated facility policy titled Meat and Vegetable Preparation, specified, All raw vegetables are thoroughly washed before being cooked or served. An undated facility policy titled Food Safety, specified, Train staff to wash hands prior to working with food, after using the restroom or soiling hands in any way. During an observation of food preparation on 06/04/2024 at 10:30 AM, Dietary Aide (DA) #16 touched her microphone button to call for someone and then, without changing gloves or washing hands, continued to touch the meat to prepare seven sandwiches. At 10:31 AM, DA #16 changed gloves without washing her hands. She then opened the walk-in refrigerator and emerged with three tomatoes. She grabbed a knife and began cutting them. DA #16 did not wash the tomatoes. At 10:32 AM, DA #16 put lettuce on a sandwich without changing gloves or washing her hands. At 10:33 AM, the backdoor rang and DA #16 answered the backdoor. She changed her gloves but did not wash her hands. She then opened the walk-in refrigerator went in and came back out. After this, she touched sandwiches to cut and to wrap them. During an observation of food service on 06/04/2024 at 12:05 PM, DA #17 touched a drawer beneath the food line to retrieve a scoop for serving mashed potatoes. Without changing gloves or washing hands, he handled four rolls of bread. During an interview on 06/04/2024 at 2:15 PM, DA #17 stated he should have washed his hands and changed gloves after touching a high-contact surface and before touching food. During an interview on 06/04/2024 at 2:19 PM, DA #16 stated she should not have touched food/lunchmeat after using the microphone button without changing gloves or washing her hands. She also confirmed she should have washed her hands and changed gloves after opening the walk-in refrigerator and before touching the tomatoes. She did not know if tomatoes should be washed prior to food preparation. During an interview on 06/04/2024 at 2:22 PM, the Dietary Manager stated DA #16 should have washed her hands and changed gloves after touching the microphone button and after touching the refrigerator handle and before touching food items. She also indicated that DA #17 should have used tongs to serve the bread rolls rather than his hands, especially since he had just opened the drawer to get a scoop for serving mashed potatoes. During an interview on 06/05/2024 at 3:31 PM, the Dietary Manager indicated that tomatoes should be washed before being prepared. During an interview on 06/07/2024 at 8:58 AM, both the Administrator and the Director of Nursing (DON) said they expected staff to change gloves and wash their hands after touching high-contact surfaces and before touching foods.

Based on observation, interview, record review, and facility policy review, the facility failed to develop a care plan to address the supplemental oxygen usage for 2 (Resident #37 and Resident #76) of 2 sampled residents reviewed for respiratory care. Findings included: An undated facility policy titled, Care Planning, indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident and care plans will be updated as necessary with resident changes to help promote optimal care to the resident. 1. An Admission Record revealed the facility admitted Resident #37 on 09/05/2023. According to the Admission Record, the resident had a medical history that included diagnoses of acute respiratory failure with hypoxia and chronic respiratory failure with hypercapnia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/02/2024, revealed Resident #37 received oxygen therapy. Resident #37's Order Summary Report, for active orders as of 06/04/2024, revealed an order dated 09/05/2023, for supplemental oxygen by way of nasal cannula at 2 liters/minute if oxygen saturation was less than 90%, as needed. Resident #37's comprehensive care plan, with an admitted [DATE], revealed no evidence to indicate the resident had a care plan that addressed their supplemental oxygen usage. An observation on 06/03/2024 at 11:48 AM, revealed Resident #37 lying in their bed with a nasal cannula properly placed around the resident's head. During an interview on 06/05/2024 at 8:33 AM, Certified Nursing Assistant #9 stated Resident #37 always wore their oxygen nasal cannula while in bed. 2. An Admission Record revealed the facility readmitted Resident #76 on 05/16/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of acute and chronic respiratory failure with hypoxia. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/2024, revealed Resident #76 received oxygen therapy. Resident #76's Order Summary Report, for active orders as of 06/04/2024, revealed an order dated 05/16/2024, for supplemental oxygen by way of nasal cannula at 2 liters/minute if oxygen saturation was less than 90%, as needed. Resident #76's comprehensive care plan, with an admitted [DATE], revealed no evidence to indicate the resident had a care plan that addressed their supplemental oxygen usage. An observation on 06/03/2024 at 10:40 AM, revealed Resident #76 lying in bed with a nasal canula properly placed around their head. During an interview on 06/07/2024 at 11:17 AM, Registered Nurse Supervisor #20 stated if a resident had a physician order for supplemental oxygen, they should have a care plan that listed the resident's diagnosis, a rational for why they received supplemental oxygen, how many liters the resident received, and instructions for changing the nasal cannula tubing. During an interview on 06/06/2024 at 9:44 AM, the Assistant Director of Nursing (ADON) stated every resident who had an order for supplemental oxygen should have a care plan that listed the diagnosis for the use of the supplemental oxygen. The ADON stated the care plan should include interventions related to the monitoring of resident's vital signs, change in condition, respiratory concerns, and instructions for care of the supplemental oxygen machine. During an interview on 06/07/2024 at 11:46 AM, the Director of Nursing stated she would expect a care plan be in place for a resident who had supplemental oxygen.

Based on observation, interview, record review, and facility policy review, the facility failed to follow a physician's order to hold a nicotine patch when the resident was smoking for 1 (Resident #86) of 4 sampled residents reviewed accidents. Findings included: An Admission Record indicated the facility admitted Resident #86 on 03/29/2024. According to the Admission Record, the resident had a medical history that included diagnoses of cerebral infarction (a stroke) due to embolism of right middle cerebral artery and essential primary hypertension (high blood pressure). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2024, indicated Resident #86 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. Resident #86's care plan, initiated on 04/16/2024, indicated the resident had the potential for injury related smoking. Resident #86's Medication Administration Record [MAR], for June 2024, revealed a transcription of an order dated 05/22/2024, for nicotine patch 24 Hour, 7 milligrams (mg) 24 hour, apply one patch one time a day for smoking cessation, hold if smoking. Licensed Practical Nurse (LPN) #1 initialed the MAR to indicate she placed a patch on the resident's right arm on 06/03/2024 at 7:29AM. During an observation on 06/03/2024 at 1:12 PM, Resident #86 was observed outside smoking with a nicotine patch present on their right arm. During an interview on 06/04/2024 at 10:30 AM, Resident #86 stated they smoked one to two times a day. The resident stated they tried to stop smoking, but did not want to stop. During an interview on 06/04/2024 at 11:14 AM, LPN #1 stated on 06/03/2024 was the first time she caught the resident smoking with a nicotine patch on. During an interview on 06/06/2024 at 10:48 AM, the Director of Nursing (DON) stated Resident #86 wore a nicotine patch since 05/22/2024, smoked one to two times a day, and the patch was not held. The DON stated Resident #86 smoked at random times, so staff would not have always been aware the resident smoked while wearing the nicotine patch. During a follow-up interview on 06/06/2024 at 12:59 PM, the DON stated she expected the nurses to administer medication as ordered. During an interview on 06/06/2024 at 12:59 PM, the Administrator stated his expectation was for the medications to be given according to physician orders.

Based on interview, record review, and facility policy review, the facility failed to revise the care plan to include added new interventions after a fall for 1 (Resident #86) of 4 sampled residents reviewed for accidents. Findings included: An undated facility policy titled, Care Planning, indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident and care plans will be updated as necessary with resident changes to help promote optimal care to the resident. The policy indicated, 7. Care plans will be updated with resident changes to promote optimal resident care. An Admission Record indicated the facility admitted Resident #86 on 03/29/2024. According to the Admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke) due to embolism of right middle cerebral artery and essential primary hypertension (high blood pressure). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2024, revealed Resident #86 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required partial/moderate assistance with toileting. Resident #86's care plan, initiated on 03/29/2024, indicated the resident was at risk for falls related to weakness, decreased mobility, abnormalities of gait and mobility, and a history of falls. An incident report dated 04/19/2024 at 6:35 PM, revealed as a certified nursing assistant assisted Resident #86 onto the toilet, the resident slid on their buttocks off the wheelchair. Per the incident report, the resident stated their socks were slippery. Resident #86's Fall Committee IDT note dated 04/26/2024 at 1:26 PM, revealed Resident #86 sustained a witnessed fall when they slipped during a transfer to the bathroom. Per the note, the IDT met and the resident's care plan was updated to anticipate and meet the resident's needs with reminders for appropriate footwear with transfers. Resident #86's care plan, initiated on 03/29/2024, indicated the resident was at risk for falls related to weakness, decreased mobility, abnormalities of gait and mobility, and a history of falls. There was no evidence the intervention to anticipate and meet the resident's needs with reminders for appropriate footwear with transfers was added to the resident's care plan. An incident report dated 05/02/2024 at 2:53 PM, revealed Resident #86 attempted to come back inside from the smoking area and their wheelchair rolled out from underneath them. Per the incident report, the resident stated they could not get the brakes on their wheelchair to work and they landed on their buttocks. Resident #86's Fall Committee IDT note dated 05/09/2024 at 11:05 AM, revealed Resident #86 sustained a witnessed fall coming back from smoking. Per the note, the IDT met and the resident's care plan was updated to indicate a non-slip pad was added to the seat of the resident's wheelchair to prevent further slipping. Resident #86's care plan, initiated on 03/29/2024, indicated the resident was at risk for falls related to weakness, decreased mobility, abnormalities of gait and mobility, and a history of falls. There was no evidence the intervention to add a non-slip pad to the resident's wheelchair to prevent further slipping was added to the resident's care plan. During an interview on 06/06/2024 at 11:16 AM, the Director of Nursing (DON) reviewed Resident #86's care plan and stated the intervention to use appropriate footwear and the intervention to add a non-slip pad to the resident's wheelchair were not added to the resident's care plan, but they should have. During an interview on 06/06/2024 at 11:27 AM, the Administrator stated the fall program was a nursing program and he deferred the specifics to the DON; however, he expected the staff to follow the policy.

Based on observation, interview, and review of manufacturer's information, the facility failed to ensure they maintained a medication error rate of less than 5 percent (%). The facility had 2 errors out of 34 opportunities, resulting in a medication error rate of 5.88 %, affecting 1 (Resident #14) of 3 residents observed during medication administration. Findings included: An Admission Record indicated the facility admitted Resident #14 on 03/04/2021. According to the Admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus with diabetic neuropathy. Resident #14's Order Summary Report, listing active orders as of 06/07/2024, contained an order, dated 07/25/2023, for insulin glargine subcutaneous solution 100 units per milliliter (units/mL), inject 75 units subcutaneously every morning and at bedtime for type two diabetes mellitus. The Order Summary Report also contained an order, dated 03/04/2021, for NovoLog Solution 100 units/mL, inject as per sliding scale (a progressive increase in insulin dose, based upon predefined blood glucose levels): less than 81= no insulin required, 81-150 = 5 units, 151-200 = 9 units, 201-250 = 13 units, 251-300 = 17 units, 301-350 = 21 units, 351-400 = 25 units, and greater than 400 = call physician. Manufacturer's information for insulin glargine revealed Instructions for Use of the prefilled pen specified, after attaching the needle, Step 3. Perform a Safety Test Always perform a safety test before each injection. Performing the safety test ensures that you get an accurate dose by: -ensuring that pen and needle work properly -removing air bubbles A. Selects a dose of 2 units by turning the dosage selector. B. Take off outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. C. Hold the pen with the needle pointing upwards. D. Tap the insulin reservoir so that any air bubbles rise up towards the needle. E. Press the inject button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. -If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove then. -If still no insulin comes out, the needle may be blocked. Change the needle and try again. -If no insulin comes out after changing the needle, your [insulin glargine prefilled pen] may be damaged. The manufacturer's information further specified that when administering the prescribed dose, C. Deliver the dose by pressing the injection button in all the way. The number in the dose window will return to 0 as you inject. D. Keep the injection button pressed all the way in. Slowly count to 10 before you withdraw the needle from the skin. This ensures the full dose will be delivered. Manufacturer's information for NovoLog FlexTouch Pen revealed Instructions for Use of the prefilled pen specified, after attaching the needle, Priming your NovoLog FlexTouch Pen: Step 7: -Turn the dose selector to select 2 units. Step 8: -Hold the Pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. Step 9: -Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. -A drop of insulin should be seen at the needle tip -If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. -If you still do not see a drop of insulin, change the needle and repeat steps 7 to 9. The manufacturer's information further specified then when administering the prescribed dose, Step 13: -Press and hold down the dose button until the dose counter shows 0. -The 0 must line up with the dose pointer. You may then hear or feel a click. -Keep the needle in your skin after the dose counter has returned to 0 and slowly count to 6. -When the dose counter returns to 0, you will not get your full dose until 6 seconds later. During an observation of medication administration on 06/05/2024 beginning at 7:31 AM, Licensed Practical Nurse (LPN) #2 was observed administering medications for Resident #14. When administering Resident #14's insulin glargine and NovoLog, LPN #2 did not prime either insulin pen prior to injection, and LPN #2 immediately removed the needles after administration, instead of waiting the amount of time specified by the manufacturers. During an interview on 06/05/2024 at 10:24 AM, LPN #2 acknowledged there were errors during insulin preparation and administration. During an interview on 06/06/2024 at 12:59 PM, the Director of Nursing (DON) stated she expected the nurses to follow protocol for effective administration of medications. The DON agreed the nurse should have waited after injecting the insulin, instead of immediately removing the needles. The DON further stated she would have to review the manufacturer's information regarding the requirements for priming the insulin pens.

Based on interview, record review, document review, and policy review, the facility failed to ensure an allegation of verbal abuse was reported immediately to the Administrator for 1 (Resident #47) of 13 sampled residents reviewed for abuse. Specifically, on 08/21/2023 at approximately 7:00 PM/8:00 PM, Certified Nursing Assistant (CNA) 27 and CNA #28 heard Licensed Practical Nurse (LPN) #29 verbally abuse the resident; however, the staff did not report the allegation of abuse to the Administrator until 10:15 PM. Findings included: A facility policy titled, Abuse: Prevention of and Prohibition Against, revised in 02/2024, indicated, 1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. An Admission Record revealed the facility admitted Resident #47 on 07/28/2022. According to the Admission Record, the resident had a medical history that included diagnoses of dementia with behavioral disturbance, anxiety disorder, and need for assistance with personal care. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2023, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had adequate hearing and used no hearing aid or other hearing appliance. According to the facility's investigation, CNA #27 reported she heard a nurse, later identified as LPN #29, yell at a resident. Per the investigation, CNA #27 went in the direction of the yelling and saw Resident #47 swing at the nurse and the nurse yell at the resident. The investigation revealed, another CNA, CNA #28, reported she heard yelling from the nurse, but did not remember what was being yelled by the nurse. Per the investigation, LPN #29 stated the resident would not take their medication and as she started to place the resident back in the bed, the resident tried to punch her. According to investigation, LPN #29 stated she tried to communicate with Resident #47 to get them into bed and to stop hitting her. During an interview on 06/04/2024 at 1:35 PM, CNA #28 stated on 08/21/2023 around 7:00 PM/8:00 PM, as she assisted another resident in a room, she heard yelling and overheard LPN #29 raise their voice at Resident #47. According to CNA #28, Resident #47 had no hearing issues and the nurse, LPN #29, was new to the facility. CNA #28 stated the incident was reported to the Abuse Coordinator. Per CNA #38, she felt the incident was verbal abuse. During an interview on 06/04/2024 at 2:36 PM, CNA #27 acknowledged she heard LPN #29 yell at Resident #47. CNA #27 stated she reported what she heard to the Administrator by way of a text message when she got home from work at 10:15 PM. Per CNA #27, she stated based on her training, what she heard was verbal abuse. During an interview on 06/05/2024 at 11:22 AM, the Administrator stated when staff witnessed abuse, he expected them to first make sure the resident was safe and then call him immediately day or night to report the abuse.

Based on interview, record review, document review, and policy review, the facility failed to implement their abuse policy for 2 (Resident #47 and Resident #395) of 13 sampled residents reviewed for abuse. Specifically, the facility failed to remove the accused staff member rom care of any resident after staff reported to the Administrator they heard Licensed Practical Nurse (LPN) #29 verbally abuse Resident #47 on 08/21/2023. The facility also failed to interview the alleged perpetrator and other residents when it was alleged that Resident #396 poked Resident #395 in the breast in the hallway on 04/09/2023. Findings included: A facility policy titled, Abuse: Prevention of and Prohibition Against, revised in 02/2024, indicated, 2. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Per the policy, 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. The policy indicated, 5. The investigation will include the following: * An interview with the person(s) reporting the incident; * An interview with the resident(s); *Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; * A review of the resident's medical record; * An interview with staff members (on all shifts) who may have information regarding the alleged incident; * Interviews with other residents to who the accused employee provides care or services or who may have information regarding the alleged incident; * An interview with staff members (on all shifts) having contact with the accused employee; and * A review of all circumstances surrounding the incident. According to the policy, 8. The investigation, and the results of the investigation, will be documented, The policy specified, 3. If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves an employee, the Facility will: * Immediately remove the employee from the care of any resident. 1. An Admission Record revealed the facility admitted Resident #47 on 07/28/2022. According to the Admission Record, the resident had a medical history that included diagnoses of dementia with behavioral disturbance, anxiety disorder, and need for assistance with personal care. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2023, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had adequate hearing and used no hearing aid or other hearing appliance. According to the facility's investigation, Certified Nursing Assistant (CNA) #27 reported she heard a nurse, later identified as LPN #29, yell at a resident. Per the investigation, CNA #27 went in the direction of the yelling and saw Resident #47 swing at the nurse and the nurse yell at the resident. The investigation revealed, another CNA, CNA #28, reported she heard yelling from the nurse, but did not remember what was being yelled by the nurse. Per the investigation, LPN #29 stated the resident would not take their medication and as she started to place the resident back in the bed, the resident tried to punch her. According to investigation, LPN #29 stated she tried to communicate with Resident #47 to get them into bed and to stop hitting her. During an interview on 06/04/2024 at 1:35 PM, CNA #28 stated on 08/21/2023 around 7:00 PM/8:00 PM, as she assisted another resident in a room, she heard yelling and overheard LPN #29 raise their voice at Resident #47. According to CNA #28, Resident #47 had no hearing issues and the nurse, LPN #29, was new to the facility. CNA #28 stated the incident was reported to the Abuse Coordinator. Per CNA #38, she felt the incident was verbal abuse. During an interview on 06/04/2024 at 2:36 PM, CNA #27 acknowledged she heard LPN #29 yell at Resident #47. CNA #27 stated she reported what she heard to the Administrator by way of a text message when she got home from work at 10:15 PM. Per CNA #27, she stated based on her training, what she heard was verbal abuse. During a telephone interview on 06/04/2024 at 7:19 PM, LPN #29 stated she felt she did nothing wrong. LPN #29 stated after the incident, she continued on with her medication pass and continued to watch the staff and other residents for the remainder of her shift. LPN #29's time card for the time period 08/20/2023 to 08/27/2023, revealed on 08/21/2023, she clocked in on 08/21/2023 at 5:59 PM and clocked out on 08/22/2023 at 3:16 AM, then clocked back in 3:47 AM and clocked out at 6:25 AM. During an interview on 06/05/2024 at 11:22 AM, the Administrator, also the Abuse Coordinator, stated he received a call from CNA #27, who reported she heard LPN #29 raise their voice at Resident #47. The Administrator stated LPN #29 did admit that she raised her voice at the resident, but only to make sure the resident heard her. The Administrator stated he did not know if the resident had issues with hearing; however, he informed LPN #29 that she should have just walked away from the resident. According to the Administrator, once an allegation of abuse was made, the accused staff member should be suspended and sent home until the investigation was completed. 37683 2. An Admission Record revealed the facility admitted Resident #395 on 01/22/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of unspecified dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2023, revealed Resident #395 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #395's Care Plan included a focus area, initiated on 01/24/2023, that indicated the resident was at risk for re-traumatization r/t [related to] history of trauma (Neglect and emotional). An Admission Record revealed the facility admitted Resident #396 on 04/06/2023. According to the Admission Record, the resident had a medical history that included diagnoses of history of traumatic brain injury (TBI), cognitive communication deficit, major depressive disorder, and unspecified dementia. Per the Admission Record, Resident #386 was discharged to another facility on 04/10/2023. Resident #396's Care Plan, included a focus area, initiated on 04/06/2023, that indicated the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to adjustment to the facility, medications, age, dementia, history of TBI, and cognitive communication deficit. Another focus area, initiated on 04/08/2023, indicated the resident had the potential for a behavior problem related to a history of TBI and dementia. An Initial Report, dated 04/09/2023, completed by the Administrator, revealed the facility reported an allegation of sexual abuse involving Resident #395 and Resident #396 to the state survey agency. Per the report, on 04/09/2023 at 4:30 (AM or PM not specified), Resident #395 reported Resident #396 poked [Resident #395] in the breast. The report indicated the alleged incident occurred in the hallway of the facility. An undated Follow-up Investigation Report revealed that for the portions of the report specific to Summary of interview(s) with the alleged victim, Summary of interview(s) with witness(es), Summary of interview(s) with the alleged perpetrator(s), Summary of interview(s) with other residents who may have had contact with the alleged perpetrator, Summary of interview(s) with staff responsible for oversight and supervision of the location where the alleged victim resides, and Summary of interview(s) with staff responsible for oversight and supervision of the alleged perpetrator reflected, See Attached Paperwork. The attached paperwork, undated, revealed, the 2. Summary of Interviews reflected that as part of their investigation, the facility interviewed Resident #395 (alleged victim), Licensed Practical Nurse (LPN) #3, Certified Nursing Assistant (CNA) #4, and Therapist #7. There was no indication the facility interviewed Resident #396 (alleged perpetrator) or other residents in the area of the alleged incident as directed by the facility's abuse policy. During an interview on 06/06/2024 at 10:24 AM, the Administrator said that when he was notified of abuse allegations, he immediately started an investigation. The Administrator said the investigation process included speaking with staff members, residents, alleged victims, alleged perpetrators, and those who may have seen the incident. The Administrator said they tried to talk with other residents in the same area to determine if they had experienced any similar concerns. During a follow-up interview on 06/06/2024 at 10:24 AM, the Administrator reported he did not interview any of the surrounding residents as per their facility protocol; however, the Administrator said he asked Resident #396 if they touched Resident #395, and Resident #396 denied the allegation, although this information was not reflected in the facility's summary of interviews. During an interview on 06/07/2024 at 9:00 AM, the Director of Nursing (DON) said her expectation regarding abuse investigations was to follow the facility's policy.

Based on interview, record review, document review, and policy review, the facility failed to protect residents' rights to be free from verbal abuse and physical abuse by staff and by a resident for 2 (Resident #33 and Resident #47) of 13 sampled residents reviewed for abuse. On 08/21/2023, Licensed Practical Nurse (LPN) #29 was heard by staff to verbally abuse Resident #47. In addition, Resident #145 physically abused Resident #33 on two occasions, on 04/17/2024 resulting in knuckle marks to the resident's forehead and on 04/28/2024 resulting in scratches to the resident's face. Findings included: A facility policy titled, Abuse: Prevention of and Prohibition Against, revised in 02/2024, indicated, It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy specified, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Per the policy Physical Abuse includes but is not limited to hitting, slapping pinching, and kicking. It also includes controlling behavior through corporal punishment. The policy indicated, Verbal Abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. 1. An Admission Record revealed the facility admitted Resident #47 on 07/28/2022. According to the Admission Record, the resident had a medical history that included diagnoses of dementia with behavioral disturbance, anxiety disorder, and need for assistance with personal care. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2023, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had adequate hearing and used no hearing aid or other hearing appliance. According to the facility's investigation, Certified Nursing Assistant (CNA) #27 reported she heard a nurse, later identified as LPN #29, yell at a resident. Per the investigation, CNA #27 went in the direction of the yelling and saw Resident #47 swing at the nurse and the nurse yell at the resident. The investigation revealed, another CNA, CNA #28, reported she heard yelling from the nurse, but did not remember what was being yelled by the nurse. Per the investigation, LPN #29 stated the resident would not take their medication and as she started to place the resident back in the bed, the resident tried to punch her. According to investigation, LPN #29 stated she tried to communicate with Resident #47 to get them into bed and to stop hitting her. During an interview on 06/04/2024 at 1:35 PM, CNA #28 stated on 08/21/2023 around 7:00 PM/8:00 PM, as she assisted another resident in a room, she heard yelling and overheard LPN #29 raise their voice at Resident #47. According to CNA #28, Resident #47 had no hearing issues and the nurse, LPN #29, was new to the facility. CNA #28 stated the incident was reported to the Abuse Coordinator. Per CNA #38, she felt the incident was verbal abuse. During an interview on 06/04/2024 at 2:36 PM, CNA #27 acknowledged she heard LPN #29 yell at Resident #47. CNA #27 stated she reported what she heard to the Administrator by way of a text message when she got home from work at 10:15 PM. Per CNA #27, she stated based on her training, what she heard was verbal abuse. During a telephone interview on 06/04/2024 at 7:19 PM, LPN #29 stated she felt she did nothing wrong. During an interview on 06/05/2024 at 11:22 AM, the Administrator, also the Abuse Coordinator, stated he received a call from CNA #27, who reported she heard LPN #29 raise their voice at Resident #47. The Administrator stated LPN #29 did admit that she raised her voice at the resident, but only to make sure the resident heard her. The Administrator stated he did not know if the resident had issues with hearing; however, he informed LPN #29 that she should have just walked away from the resident. 19186 2. An Admission Record revealed the facility admitted Resident #145 on 09/11/2023. According to the Admission Record, the resident had a medical history that included diagnoses of cognitive communication deficit, insomnia, anxiety disorder, major depressive disorder, and unspecified dementia, A quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 03/29/2024, revealed Resident #145 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident had hallucinations, physical behavioral symptoms, and wandering behaviors one to three days during the assessment period. Resident #145's Care Plan included a focus area initiated on 09/12/2023, that indicated the resident used psychotropic medications for behavior management (hallucinations and verbalized aggression). Interventions directed staff to monitor and document the effectiveness of the medication (initiated 09/12/2023). Resident #145's Care Plan included a focus area initiated 09/12/2023 that indicated the resident was at risk for elopement and wandering related to disorientation and impaired safety awareness. Interventions directed staff to provide structured activities and reorientation strategies (initiated on 03/05/2024). An Admission Record revealed the facility admitted Resident #33 on 09/13/2019. According to the Admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, major depressive disorder, anxiety, stroke, and vascular dementia. A quarterly MDS, with ARD of 03/09/2024, revealed Resident #33 had a BIMS score of 00, which indicated the resident had severe cognitive impairment. The MDS revealed that the resident exhibited verbal behavioral symptoms directed toward others, rejected care, and exhibited wandering behaviors on one to three days during the seven-day assessment look back period. Resident #33's care plan included a focus area revised 06/07/2023, that indicated the resident had the potential for a psychosocial well-being problem related to Alzheimer's disease, anxiety, depression, and post-traumatic stress disorder. Interventions directed staff to allow the resident time to answer questions and to verbalize feelings, perceptions, and fears (initiated 12/23/2022), provide one on one therapy to help balance mood and behaviors (initiated 12/23/2022), and ensure no triggers related to a diagnosis of post-traumatic stress disorder (initiated 02/20/2024). A Facility Reported Incidents report dated 04/17/2024, revealed on 04/17/2024 at 5:45 PM there was an altercation between Resident #145 and Resident #33 on the memory care unit. Resident #145's Progress Notes, dated 04/17/2024, revealed a certified nursing assistant (CNA) reported that Resident #145 came into the dining area and began attacking another resident. The note revealed the other resident tried to stop Resident #145 from hitting them; however, Resident #145 hit the resident on the forehead before staff were able to safely separate the residents. The note revealed the residents were separated safely into their own rooms, and the Administrator and Director of Nursing (DON) were notified of the incident. Resident #33's Progress Notes dated 04/17/2023 revealed another resident hit Resident #33 on the forehead resulting in three small marks to the forehead. Resident #33's care plan included a focus area initiated 09/17/2019 that indicated the resident had the potential for a behavior problem related to dementia, Alzheimer's, anxiety, and depression. The care plan revealed that the resident was in a resident-to-resident altercation on 04/17/2024 and was noted with knuckle marks to [the] forehead at initial evaluation. The facility's Resident to Resident Questionnaire for Staff dated 04/19/2024, revealed CNA #28's interview was completed by text message. According to the document, the CNA witnessed the residents in a small altercation. The document revealed CNA #28 and a coworker were in an office when they saw Resident #145 walk into the dining room and start attempting to hit Resident #33. CNA #28 indicated that her and another coworker ran to intervene immediately and pulled them apart. CNA #28 stated once they pulled them apart, Resident #145 and Resident #33 were taken to their respective rooms. During an interview on 06/07/2024 at 11:58 AM, CNA #26 stated she witnessed Resident #145 hit Resident #33 on 04/17/2024. CNA #26 said staff was in an office area in the dining room and Resident #33 was in the dining room sitting in the recliner. CNA #26 stated Resident #145 stated, You [NAME] me and attempted to hit Resident #33. CNA #26 indicated before they separated the residents, Resident #145 hit Resident #33 on the forehead with their fist. CNA #26 said Resident #33 had a mark on their forehead. The facility's Follow-Up Investigation Report, dated 04/19/2024, revealed the investigation results were inconclusive. The facility's report revealed there was not enough information to determine whether abuse could be substantiated. The report revealed no one witnessed what happened before or after the situation or what led to the incident. According to the report, there was contact between the resident, and even though Resident #33's Progress Notes and care plan revealed the resident sustained injury, according to the facility's Follow-up Investigation Report, no injuries were found. A second Facility Reported Incidents report dated 04/28/2024 revealed that on 04/28/2024 at 4:00 PM there was another resident-to-resident altercation between Resident #33 and Resident #145. According to the report, Resident #33 was yelling and pounding at a door trying to get out of the memory care unit. The report revealed Resident #145's room was next to the exit door and Resident #33's behavior annoyed Resident #145. According to the report, Resident #145 swatted at Resident #33 to try to get the resident to stop. A review of Licensed Practical Nurse (LPN) #2's Resident to Resident Questionnaire for Staff dated 04/30/2024 revealed the LPN witnessed the 04/28/2024 incident. LPN #2's statement revealed she saw Resident #33 hitting the door and yelling and Resident #145 came up and hit Resident #33. Resident #145's Progress Notes, dated 04/28/2024 at 5:22 PM, revealed the resident was witnessed standing in the doorway of their room when the resident suddenly started screaming at another resident who was standing at the doors of the unit. The note revealed Resident #145 crossed the hallway towards the other resident and slapped the resident on the face. The note revealed the other resident put their hands up in defense and both parties were separated immediately and moved safely to their rooms. Resident #33's Progress Notes dated 04/28/2024 at 5:45 PM revealed a resident slapped Resident #33 on the face resulting in a scratch to Resident #33's forehead, the right side of their nose, and the right side of their lip. The facility's Follow-Up Investigation Report, dated 04/30/2024 revealed while it was clear the resident [Resident #33] was 'swatted' by the other resident [Resident #145] it was extremely unclear as to what led to the incident. It was also unclear as to how much contact was made. The report revealed there was one witness that saw the incident, but she was to busy running to break up the pair rather than see how hard the patient [resident] was hit. The facility's report revealed there was no injury or bruising, even though Resident #33's Progress Notes revealed the resident sustained scratches to the forehead, the right side of their nose, and the right side of their lip. Further review of the facility's report revealed there had been a pattern of Resident #145 getting frustrated with other residents and the facility had tried a couple of different things to get the resident to be a little nicer to staff and residents. The report revealed the family agreed that this could not keep happening and agreed to take Resident #145 home. During an interview on 06/07/2024 at 1:47 PM, the DON stated she expected close monitoring and interventions to prevent resident-to-resident altercations. During an interview on 06/07/2024 at 1:47 PM, the Administrator stated his expectation was for the facility to implement interventions to prevent resident-to-resident altercations from happening.

Based on interview and record review it was determined, for 1 out of 6 sampled residents, that the facility did not ensure that all violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to the administrator (ADM) of the facility, the State Survey Agency (SSA), adult protective services (APS) and law enforcement. Specifically, a resident reported an allegation of sexual abuse with incontinence care on 10/26/22 and the allegation was not reported to the ADM, SSA or APS until 1/11/23. Resident identifier: 1. Findings included: Resident 1 was readmitted to the facility on [DATE] with diagnoses which consisted of gastro-esophageal reflux disease, neuromuscular dysfunction of the bladder, rheumatoid arthritis, contracture of the right and left knee, contracture of the right and left ankle, and reduced mobility. On 10/26/22, a Grievance Resolution Form documented that resident 1's representative reported that a Certified Nurse Assistant (CNA) talked to resident 1 about personal things making her uncomfortable. The department response documented, Will educate staff member on appropriate thing to say in resident rooms. The form was signed by the CNA Coordinator, the Executive Director and the Grievance Official on 10/26/22. The grievance log documented under Issue and resolution: Concerns with Staff CNA talking to resident about personal things making the resident uncomfortable. Grievance's follow-up: SS [social services] followed up with the Resident regarding concerns; the Resident was notified of staff training and actions taken to resolve the grievance. On 1/11/23 at 11:45 AM, the facility notified the State Survey Agency (SSA) of an allegation of sexual abuse by CNA 1. The initial report documented that Resident 1 had reported the allegation of sexual abuse and that the resident felt uncomfortable. The form documented that resident 1 had reported to the state surveyor that she had feared that CNA 1 would walk into her room at any time. The form documented that the ADM was notified of the incident on 1/11/23 at 11:30 AM. On 1/13/23, the facility final investigation report documented that resident 1 had reported that she filed a grievance that stated CNA 1 was talking about something personal and it made her feel uncomfortable. The facility followed up on the grievance and made sure that the cna would be scheduled on a different hall. The final report documented that while the Annual State Survey was being conducted resident 1 informed the surveyor that not only did the CNA make her feel uncomfortable with the conversation but felt sexually abused. The summary of the events documented, The incident started with the cna talking about personal issues going on in her home life. The resident asked the cna to stop and thought that the cna became offended The resident needed some cream on her female parts. The CNA did not describe what she was doing, and just shoved her fingers up there. She felt like the CNA shoved her fingers to far up there and more than she had to. The report documented that the allegation of abuse was verified and CNA 1 was terminated. On 1/13/23 at 12:44 PM, a Social Service progress note documented that resident 1 was visited regarding the abuse allegations and abuse investigation. The SSW informed resident 1 that they conducted an investigation into the allegation of abuse by a staff member. The SSW informed resident 1 that the facility substantiated the allegation and that the staff member had been terminated. It should be noted that no other progress notes were found for the allegation of abuse on 10/26/22. On 3/21/23 at 3:11 PM, an interview was conducted with resident 1. Resident 1 stated that she had wounds in her perineum area that required cream applications. Resident 1 stated that CNA 1 was applying cream inside her vagina, that it had hurt her, and CNA 1 was doing something that she was not supposed to. Resident 1 stated that it made her feel uncomfortable and she did not want CNA 1 in her room anymore. Resident 1 stated that she believed that the wound nurse mixed up Chamosyn cream to be applied to the perineum area. Resident 1 stated that she was having a personal conversation with CNA 1 at the time of the incontinence care. Resident 1 stated that CNA 1 had said that she loved to watch movies with gay people and was jealous when she would see movies with girls kissing each other. Resident 1 stated that she did not say much of anything to CNA 1 about the topic but that it made her feel uncomfortable. Resident 1 stated that she told the staff that she did not want CNA 1 in her room anymore. Resident 1 stated that other staff had told her that CNA 1 was saying that she did not want her caring for her because she was gay. Resident 1 stated that she did not have any problems with gay people, if that was her lifestyle fine but she did not need to tell her about it. Resident 1 stated that CNA 1 had also said that she did not have problems watching males kiss each other only that she was jealous when she watched females kissing each other. Resident 1 stated that she spoke with the SSW and the CNA Coordinator at the same time about this incident. Resident 1 reported that CNA 1 was putting ointment inside her vagina at the time of the conversation. Resident 1 stated that she had pain in the vaginal area prior to the cream application because she had blisters there. Resident 1 stated that she informed CNA 1 that it was hurting during the application of the cream and CNA 1 had replied that she could cure her Urinary Tract Infection (UTI). Resident 1 stated that she informed the SSW of the incident of inappropriate conversation and the sexual abuse allegation in October. Resident 1 stated that it was not until January 2023 when the state surveyor notified the ADM that any action was taken and CNA 1 was terminated. On 3/21/23 at 4:14 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated that the process for investigating grievances was to fill out the grievance log, forward the complaint to the appropriate department head, and they had 24 hours to have a plan of action to resolve the grievance. The SSW stated that he would then inform the resident of the resolution. The SSW stated initially he would talk to the resident and fill out the grievance form. The SSW stated that he and the CNA Coordinator tried to resolve the problem and come up with a plan of action together. The SSW stated that findings of the grievance investigation were documented in a progress notes. The SSW stated that the incident on 10/26/22 was that CNA 1 was providing resident 1 with care and it made resident 1 feel uncomfortable. The SSW stated that the conversation between CNA 1 and resident 1 was about how CNA 1 was a lesbian and CNA 1 talked about this while she was providing resident 1 with personal cares. The SSW stated that at the time of the conversation about sexual orientation and lifestyle, CNA 1 was cleaning resident 1's genitals and this made resident 1 feel uncomfortable. The SSW stated that he did not discuss the incident with resident 1, and did not ask resident 1 what was said during the conversation. The SSW stated that the CNA Coordinator talked to resident 1 and gathered the details of the conversation between resident 1 and CNA 1. The SSW stated that if the conversation made resident 1 uncomfortable while perineal care was being provided that he would want to gather more information. The SSW stated that the CNA Coordinator reported that she had spoken to CNA 1. The SSW was asked how he determined that the grievance was not an allegation of abuse and the SSW replied, I don't have an answer for that. The SSW stated that if he suspected an allegation of abuse he was supposed to inform the ADM. The SSW stated that he does not recall if he talked to the ADM and informed him of the incident. On 3/21/23 at 4:42 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that with grievances the SSW would obtain the complaint information and if it pertained to a CNA they would discuss the incident. The CNA Coordinator stated that if it was with a specific aide she would discuss the incident with that aide and provide education if needed. The CNA Coordinator stated that resident 1's grievance in October was reported by the resident representative to the SSW. The CNA Coordinator stated that she spoke with CNA 1 about what was appropriate to talk to residents about. The CNA Coordinator stated that she had determined that CNA 1 was talking to resident 1 about her sexuality and preference for women. The CNA Coordinator stated that she reminded CNA 1 about professional conduct. The CNA Coordinator stated that CNA 1 did not say what was said in the conversation with resident 1 specifically and the Coordinator stated she did not ask. The CNA Coordinator stated that she reminded CNA 1 to not talk about sexuality with residents. The CNA Coordinator stated that at the time of the conversation between CNA 1 and resident 1, CNA 1 was performing a brief change. The CNA Coordinator stated that resident 1 required heavy cream application to the perineum during incontinence care. The CNA Coordinator stated that it was reasonable for resident 1 to think that it was sexual in nature if it was being discussed while perineal care was being provided. The CNA Coordinator stated that it was unprofessional conduct on CNA 1's part. The CNA Coordinator stated that resident 1 had every right to address the issue, that it was not an appropriate conversation topic, and they should care for the resident and make them feel comfortable. The CNA Coordinator stated that she informed the SSW specifically what was reported by resident 1. The CNA Coordinator stated that it was a sexual conversation that made resident 1 feel uncomfortable, but that she did not feel that was CNA 1's intent. On 3/21/23 at 5:06 PM, an interview was conducted with the ADM. The ADM stated that resident 1's representative had left a voicemail in October that reported that CNA 1 was talking about some things that had made resident 1 feel uncomfortable. The ADM stated that the grievance was investigated by the SSW and was followed up by the CNA Coordinator. The ADM stated that he started at the facility right after the incident occurred and he signed off that the grievance was completed. The ADM stated that the SSW informed him that CNA 1 was saying personal things to make resident 1 feel uncomfortable. The ADM stated that it was not reported to him as an allegation of abuse or something to look into until January 2023. The ADM stated that anything of a sexual nature that made the resident feel uncomfortable needed to be reported to him and he would conduct an abuse investigation. The ADM stated that in regards to a grievance maybe more details would have helped and needed to be included. On 3/21/23 at 5:23 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she never spoke with resident 1 about the conversation she had with CNA 1. The DON stated that if it was an allegation that was sexual in nature while performing cares in the genital area and made the resident feel uncomfortable, then it should be taken to the abuse coordinator so an investigation could be conducted. The DON stated that resident 1 was completely alert and oriented times 4 (person, place, time, and situation). Review of the facility policy on Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment documented that Sexual abuse was non-consensual sexual contact of any type with a resident. The policy further stated in response to allegations of abuse, the facility would ensure that all alleged violations were reported immediately but not later than 2 hours after the allegation was made to the ADM, SSA, and APS. The policy was last revised on 10/2022. [Cross-refer F600]

Based on interview and record review it was determined, for 1 out of 6 sampled residents, that the facility did not ensure that in response to allegations of abuse that the facility had evidence that all alleged violations were thoroughly investigated. Specifically, a resident reported an allegation of sexual abuse with incontinence care on 10/26/22 and the facility did not have sufficient evidence to demonstrate that the allegation was thoroughly investigated. Resident identifier: 1. Findings included: Resident 1 was readmitted to the facility on [DATE] with diagnoses which consisted of gastro-esophageal reflux disease, neuromuscular dysfunction of the bladder, rheumatoid arthritis, contracture of the right and left knee, contracture of the right and left ankle, and reduced mobility. On 10/26/22, a Grievance Resolution Form documented that resident 1's representative reported that a Certified Nurse Assistant (CNA) talked to resident 1 about personal things making her uncomfortable. The department response documented, Will educate staff member on appropriate thing to say in resident rooms. The form was signed by the CNA Coordinator, the Executive Director and the Grievance Official on 10/26/22. The grievance log documented under Issue and resolution: Concerns with Staff. CNA talking to resident about personal things making the resident uncomfortable. Grievance's follow-up: SS [social services] followed up with the Resident regarding concerns; the Resident was notified of staff training and actions taken to resolve the grievance. On 1/11/23 at 11:45 AM, the facility notified the State Survey Agency (SSA) of an allegation of sexual abuse by CNA 1. The initial report documented that Resident 1 had reported the allegation of sexual abuse and that the resident felt uncomfortable. The form documented that resident 1 had reported to the state surveyor that she had feared that CNA 1 would walk into her room at any time. The form documented that the Administrator (ADM) was notified of the incident on 1/11/23 at 11:30 AM. On 1/13/23, the facility final investigation report documented that resident 1 had reported that she filed a grievance that stated CNA 1 was talking about something personal and it made her feel uncomfortable. The facility followed up on the grievance and made sure that the cna would be scheduled on a different hall. The final report documented that while the Annual State Survey was being conducted resident 1 informed the surveyor that not only did the CNA make her feel uncomfortable with the conversation but felt sexually abused. The summary of the events documented, The incident started with the cna talking about personal issues going on in her home life. The resident asked the cna to stop and thought that the cna became offended The resident needed some cream on her female parts. The CNA did not describe what she was doing, and just shoved her fingers up there. She felt like the CNA shoved her fingers to far up there and more than she had to. The report documented that the allegation of abuse was verified and CNA 1 was terminated. On 1/13/23 at 12:44 PM, a Social Service progress note documented that resident 1 was visited regarding the abuse allegations and abuse investigation. The SSW informed resident 1 that they conducted an investigation into the allegation of abuse by a staff member. The SSW informed resident 1 that the facility substantiated the allegation and that the staff member had been terminated. It should be noted that no other progress notes were found for the allegation of abuse on 10/26/22. On 3/21/23 at 3:11 PM, an interview was conducted with resident 1. Resident 1 stated that she had wounds in her perineum area that required cream applications. Resident 1 stated that CNA 1 was applying cream inside her vagina, that it had hurt her, and CNA 1 was doing something that she was not supposed to. Resident 1 stated that it made her feel uncomfortable and she did not want CNA 1 in her room anymore. Resident 1 stated that she believed that the wound nurse mixed up Chamosyn cream to be applied to the perineum area. Resident 1 stated that she was having a personal conversation with CNA 1 at the time of the incontinence care. Resident 1 stated that CNA 1 had said that she loved to watch movies with gay people and was jealous when she would see movies with girls kissing each other. Resident 1 stated that she did not say much of anything to CNA 1 about the topic but that it made her feel uncomfortable. Resident 1 stated that she told the staff that she did not want CNA 1 in her room anymore. Resident 1 stated that other staff had told her that CNA 1 was saying that she did not want her caring for her because she was gay. Resident 1 stated that she did not have any problems with gay people, if that was her lifestyle fine but she did not need to tell her about it. Resident 1 stated that CNA 1 had also said that she did not have problems watching males kiss each other only that she was jealous when she watched females kissing each other. Resident 1 stated that she spoke with the SSW and the CNA Coordinator at the same time about this incident. Resident 1 reported that CNA 1 was putting ointment inside her vagina at the time of the conversation. Resident 1 stated that she had pain in the vaginal area prior to the cream application because she had blisters there. Resident 1 stated that she informed CNA 1 that it was hurting during the application of the cream and CNA 1 had replied that she could cure her Urinary Tract Infection (UTI). Resident 1 stated that she informed the SSW of the incident of inappropriate conversation and the sexual abuse allegation in October. Resident 1 stated that it was not until January 2023 when the state surveyor notified the ADM that any action was taken and CNA 1 was terminated. On 3/21/23 at 4:14 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated that the process for investigating grievances was to fill out the grievance log, forward the complaint to the appropriate department head, and they had 24 hours to have a plan of action to resolve the grievance. The SSW stated that he would then inform the resident of the resolution. The SSW stated initially he would talk to the resident and fill out the grievance form. The SSW stated that he and the CNA Coordinator tried to resolve the problem and come up with a plan of action together. The SSW stated that findings of the grievance investigation were documented in a progress notes. The SSW stated that the incident on 10/26/22 was that CNA 1 was providing resident 1 with care and it made resident 1 feel uncomfortable. The SSW stated that the conversation between CNA 1 and resident 1 was about how CNA 1 was a lesbian and CNA 1 talked about this while she was providing resident 1 with personal cares. The SSW stated that at the time of the conversation about sexual orientation and lifestyle, CNA 1 was cleaning resident 1's genitals and this made resident 1 feel uncomfortable. The SSW stated that he did not discuss the incident with resident 1, and did not ask resident 1 what was said during the conversation. The SSW stated that the CNA Coordinator talked to resident 1 and gathered the details of the conversation between resident 1 and CNA 1. The SSW stated that if the conversation made resident 1 uncomfortable while perineal care was being provided that he would want to gather more information. The SSW stated that the CNA Coordinator reported that she had spoken to CNA 1. The SSW was asked how he determined that the grievance was not an allegation of abuse and the SSW replied, I don't have an answer for that. On 3/21/23 at 4:42 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that with grievances the SSW would obtain the complaint information and if it pertained to a CNA they would discuss the incident. The CNA Coordinator stated that if it was with a specific aide she would discuss the incident with that aide and provide education if needed. The CNA Coordinator stated that resident 1's grievance in October was reported by the resident representative to the SSW. The CNA Coordinator stated that she spoke with CNA 1 about what was appropriate to talk to residents about. The CNA Coordinator stated that she had determined that CNA 1 was talking to resident 1 about her sexuality and preference for women. The CNA Coordinator stated that she reminded CNA 1 about professional conduct. The CNA Coordinator stated that CNA 1 did not say what was said in the conversation with resident 1 specifically and the Coordinator stated she did not ask. The CNA Coordinator stated that she reminded CNA 1 to not talk about sexuality with residents. The CNA Coordinator stated that at the time of the conversation between CNA 1 and resident 1, CNA 1 was performing a brief change. The CNA Coordinator stated that resident 1 required heavy cream application to the perineum during incontinence care. The CNA Coordinator stated that it was reasonable for resident 1 to think that it was sexual in nature if it was being discussed while perineal care was being provided. The CNA Coordinator stated that it was unprofessional conduct on CNA 1's part. The CNA Coordinator stated that resident 1 had every right to address the issue, that it was not an appropriate conversation topic, and they should care for the resident and make them feel comfortable. The CNA Coordinator stated that she informed the SSW specifically what was reported by resident 1. The CNA Coordinator stated that it was a sexual conversation that made resident 1 feel uncomfortable, but that she did not feel that was CNA 1's intent. On 3/21/23 at 5:06 PM, an interview was conducted with the ADM. The ADM stated that resident 1's representative had left a voicemail in October that reported that CNA 1 was talking about some things that had made resident 1 feel uncomfortable. The ADM stated that the grievance was investigated by the SSW and was followed up by the CNA Coordinator. The ADM stated that he started at the facility right after the incident occurred and he signed off that the grievance was completed. The ADM stated that the SSW informed him that CNA 1 was saying personal things to make resident 1 feel uncomfortable. The ADM stated that it was not reported to him as an allegation of abuse or something to look into until January 2023. The ADM stated that anything of a sexual nature that made the resident feel uncomfortable needed to be reported to him and he would conduct an abuse investigation. The ADM stated that in regards to a grievance maybe more details would have helped and needed to be included. Review of the facility policy on Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment documented that Sexual abuse was non-consensual sexual contact of any type with a resident. The policy further stated that the facility should Conduct a prompt, thorough and complete investigation in response to reportable allegations of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property. Maintain evidence that all allegations of abuse, neglect mistreatment, exploitation, or misappropriation of resident property are thoroughly investigated. The policy was last revised on 10/2022. [Cross-refer F600]

Based on interview and record review it was determined, for 1 out of 6 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse. Specifically, a resident reported an allegation of sexual abuse while incontinence care was provided. Resident identifier: 1. Findings included: Resident 1 was readmitted to the facility on [DATE] with diagnoses which consisted of gastro-espophageal reflux disease, neuromuscular dysfunction of the bladder, rheumatoid arthritis, contracture of the right and left knee, contracture of the right and left ankle, and reduced mobility. On 8/18/22 the Quarterly Minimum Data Set Assessment documented that resident 1 had a Brief Interview for Mental Status score of 15 out of 15, which would indicate that the resident was cognitively intact. The assessment documented that resident 1 did not have any hallucinations or delusions. The assessment documented that resident 1's functional status for bed mobility was an extensive 2-person assist and for toileting was an extensive one-person assist. Resident 1's care plan documented a care area for impairment to skin integrity related to yeast in skin folds of the groin, ulcer to the labia and a history of bullous pemphigoid to right lower extremity. The care plan was initiated on 12/9/21. The interventions identified were to educate the resident of causative factors and measures to prevent skin injury; encourage good nutrition and hydration to promote healthier skin; identify and document causative factors and eliminate/resolve where possible; and monitor/document location, size, and treatment of skin injury. On 10/26/22, a Grievance Resolution Form documented that resident 1's representative reported that a Certified Nurse Assistant (CNA) talked to resident 1 about personal things making her uncomfortable. The department response was, Will educate staff member on appropriate thing to say in resident rooms. The form was signed by the CNA Coordinator, the Executive Director and the Grievance Official on 10/26/22. The grievance log revealed a section Issue and resolution: Concerns with Staff CNA talking to resident about personal things making the resident uncomfortable. Grievance's follow-up: SS [social services] followed up with the Resident regarding concerns; the Resident was notified of staff training and actions taken to resolve the grievance. On 1/11/23 at 11:45 AM, the facility notified the State Survey Agency (SSA) of an allegation of sexual abuse by CNA 1. The initial report documented that Resident 1 had reported the allegation as sexual abuse and that the resident felt uncomfortable. The form documented that resident 1 had reported to the state surveyor that she had feared that CNA 1 would walk into her room at any time. The form documented that the Administrator (ADM) was notified of the incident on 1/11/23 at 11:30 AM. On 1/13/23, the facility final investigation report documented that resident 1 had reported that she filed a grievance that stated CNA 1 was talking about something personal and it made her feel uncomfortable. The facility followed up on the grievance and made sure that the cna would be scheduled on a different hall. The final report documented that while the Annual State Survey was being conducted resident 1 informed the surveyor that not only did the CNA make her feel uncomfortable with the conversation but felt sexually abused. The summary of the events documented, The incident started with the cna talking about personal issues going on in her home life. The resident asked the cna to stop and thought that the cna became offended The resident needed some cream on her female parts. The CNA did not describe what she was doing, and just shoved her fingers up there. She felt like the CNA shoved her fingers to far up there and more than she had to. The report documented that the allegation of abuse was verified and CNA 1 was terminated. On 1/13/23 at 12:44 PM, a Social Service progress note documented that resident 1 was visited regarding the abuse allegations and abuse investigation. The SSW informed resident 1 that they conducted an investigation into the allegation of abuse by a staff member. The SSW informed resident 1 that the facility substantiated the allegation and that the staff member had been terminated. It should be noted that no other progress notes were found for the allegation of abuse on 10/26/22. On 3/21/23 at 3:11 PM, an interview was conducted with resident 1. Resident 1 stated that she had wounds in her perineum area that required cream applications. Resident 1 stated that CNA 1 was applying cream inside her vagina, that it had hurt her, and CNA 1 was doing something that she was not supposed to. Resident 1 stated that it made her feel uncomfortable and she did not want CNA 1 in her room anymore. Resident 1 stated that she believed that the wound nurse mixed up Chamosyn cream to be applied to the perineum area. Resident 1 stated that she was having a personal conversation with CNA 1 at the time of the incontinence care. Resident 1 stated that CNA 1 had said that she loved to watch movies with gay people and was jealous when she would see movies with girls kissing each other. Resident 1 stated that she did not say much of anything to CNA 1 about the topic but that it made her feel uncomfortable. Resident 1 stated that she told the staff that she did not want CNA 1 in her room anymore. Resident 1 stated that other staff had told her that CNA 1 was saying that she did not want her caring for her because she was gay. Resident 1 stated that she did not have any problems with gay people, if that was her lifestyle fine but she did not need to tell her about it. Resident 1 stated that CNA 1 had also said that she did not have problems watching males kiss each other only that she was jealous when she watched females kissing each other. Resident 1 stated that she spoke with the SSW and the CNA Coordinator at the same time about this incident. Resident 1 reported that CNA 1 was putting ointment inside her vagina at the time of the conversation. Resident 1 stated that she had pain in the vaginal area prior to the cream application because she had blisters there. Resident 1 stated that she informed CNA 1 that it was hurting during the application of the cream and CNA 1 had replied that she could cure her Urinary Tract Infection (UTI). Resident 1 stated that she informed the SSW of the incident of inappropriate conversation and the sexual abuse allegation in October. Resident 1 stated that it was not until January 2023 when the state surveyor notified the ADM that any action was taken and CNA 1 was terminated. On 3/21/23 at 3:49 PM, an interview was conducted with the Wound Nurse (WN). The WN stated that resident 1 had barrier cream and nystatin powder that was ordered for her labia and vaginal area. The WN stated that barrier cream was a standing house order and they used A & D ointment. The WN stated that Chamosyn was a hyped up barrier cream with manuka honey in it. The WN stated that the Chamosyn was a barrier cream that the aides could apply with incontinence care. The WN stated that resident 1 was a one-person extensive assist for toileting, perineal care and brief changes. On 3/21/23 at 4:14 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated that the process for investigating grievances was to fill out the grievance log, forward the complaint to the appropriate department head, and they had 24 hours to have a plan of action to resolve the grievance. The SSW stated that he would then inform the resident of the resolution. The SSW stated initially he would talk to the resident and fill out the grievance form. The SSW stated that he and the CNA Coordinator tried to resolve the problem and come up with a plan of action together. The SSW stated that findings of the grievance investigation were documented in a progress notes. The SSW stated that the incident on 10/26/22 was that CNA 1 was providing resident 1 with care and it made resident 1 feel uncomfortable. The SSW stated that the conversation between CNA 1 and resident 1 was about how CNA 1 was a lesbian and CNA 1 talked about this while she was providing resident 1 with personal cares. The SSW stated that at the time of the conversation about sexual orientation and lifestyle, CNA 1 was cleaning resident 1's genitals and this made resident 1 feel uncomfortable. The SSW stated that he did not discuss the incident with resident 1, and did not ask resident 1 what was said during the conversation. The SSW stated that the CNA Coordinator talked to resident 1 and gathered the details of the conversation between resident 1 and CNA 1. The SSW stated that if the conversation made resident 1 uncomfortable while perineal care was being provided that he would want to gather more information. The SSW stated that the CNA Coordinator reported that she had spoken to CNA 1. The SSW was asked how he determined that the grievance was not an allegation of abuse and the SSW replied, I don't have an answer for that. The SSW stated that if he suspected an allegation of abuse he was supposed to inform the ADM. The SSW stated that he does not recall if he talked to the ADM and informed him of the incident. On 3/21/23 at 4:42 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that with grievances the SSW would obtain the complaint information and if it pertained to a CNA they would discuss the incident. The CNA Coordinator stated that if it was with a specific aide she would discuss the incident with that aide and provide education if needed. The CNA Coordinator stated that resident 1's grievance in October was reported by the resident representative to the SSW. The CNA Coordinator stated that she spoke with CNA 1 about what was appropriate to talk to residents about. The CNA Coordinator stated that she had determined that CNA 1 was talking to resident 1 about her sexuality and preference for women. The CNA Coordinator stated that she reminded CNA 1 about professional conduct. The CNA Coordinator stated that CNA 1 reported that she and resident 1 had a good relationship, and she understood that what she did was wrong. The CNA Coordinator stated that CNA 1 was assigned to care for other resident's and not resident 1 per the resident's request. The CNA Coordinator stated that CNA 1 did not say what was said in the conversation with resident 1 specifically and the Coordinator stated she did not ask. The CNA Coordinator stated that she reminded CNA 1 to not talk about sexuality with residents. The CNA Coordinator stated that at the time of the conversation between CNA 1 and resident 1, CNA 1 was performing a brief change. The CNA Coordinator stated that resident 1 required heavy cream application to the perineum during incontinence care. The CNA Coordinator stated that she informed CNA 1 to not enter resident 1's room or provide her with care. The CNA Coordinator stated that she informed CNA 1 that resident 1 was uncomfortable, and that CNA 1 did not realize this. The CNA Coordinator stated that CNA 1 thought it was a normal conversation. The CNA Coordinator stated that at the time she did not think it was an allegation of abuse. The CNA Coordinator stated that it was reasonable for resident 1 to think that it was sexual in nature if it was being discussed while perineal care was being provided. The CNA Coordinator stated that it was unprofessional conduct on CNA 1's part. The CNA Coordinator stated that it was a learning situation for the aides, especially those that were 16 to [AGE] years old. The CNA Coordinator stated that she instructed them that they could not talk about whatever they wanted to. The CNA Coordinator stated that resident 1 had every right to address the issue, that it was not an appropriate conversation topic, and they should care for the resident and make them feel comfortable. The CNA Coordinator stated that she informed the SSW specifically what was reported by resident 1. The CNA Coordinator stated that she could not recall if kissing was a part of the conversation, but that the SSW had all of the documentation. The CNA Coordinator stated that it was a sexual conversation that made resident 1 feel uncomfortable, but that she did not feel that was CNA 1's intent. On 3/21/23 at 5:06 PM, an interview was conducted with the ADM. The ADM stated that resident 1's representative had left a voicemail in October that reported that CNA 1 was talking about some things that had made resident 1 feel uncomfortable. The ADM stated that the grievance was investigated by the SSW and was followed up by the CNA Coordinator. The ADM stated that he started at the facility right after the incident occurred and he signed off that the grievance was completed. The ADM stated that the SSW informed him that CNA 1 was saying personal things to make resident 1 feel uncomfortable. The ADM stated that it was not reported to him as an allegation of abuse or something to look into until January 2023. The ADM stated that anything of a sexual nature that made the resident feel uncomfortable needed to be reported to him and he would conduct an abuse investigation. The ADM stated that in regards to a grievance maybe more details would have helped and needed to be included. The ADM stated that when he spoke with resident 1 initially she mentioned that the conversation made her feel uncomfortable. Then the aide applied cream to resident 1's private parts, and resident 1 stated that CNA 1 did not know what they were doing. The ADM stated that initially it was reported as a conversation about personal issues that were going on in CNA 1's life, and then later it changed to putting cream on the genitals that made her feel uncomfortable. The ADM stated that CNA 1 was still employed in October and after the grievance was moved to a different hallway than resident 1. The ADM stated that when they had the additional details about the cream on the genitals making resident 1 uncomfortable, then CNA 1 was terminated on 1/13/23. On 3/21/23 at 5:23 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she never spoke with resident 1 about the conversation she had with CNA 1. The DON stated that if it was an allegation that was sexual in nature while performing cares in the genital area and made the resident feel uncomfortable, then it should be taken to the abuse coordinator so an investigation could be conducted. The DON stated that resident 1 was completely alert and oriented times 4 (person, place, time, and situation). Review of the facility policy on Abuse: Prevention of and Prohibition Against documented that Sexual abuse was non-consensual sexual contact of any type with a resident. The policy further stated that each resident had the right to be free from abuse. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from [sic] abuse, neglect, misappropriation of resident property, and exploitation. The policy further stated under Prevention that the facility would act to protect and prevent abuse and neglect from occurring within the facility by Supervising staff to identify and correct any inappropriate or unprofessional behaviors. The policy was last revised on 10/2022.

Based on observation and interview, it was determined, for 4 of 24 sampled residents, that the facility did not provide each resident with a safe, clean homelike environment. Specifically, a resident had plastic in the corner of her room where the roof had leaked, there were gashes in the drywall behind a resident's bed, wheelchair was soiled, and rooms had trash and debris on the floor. Resident identifiers: 8, 28, 73 and 128. Findings included: 1. On 1/9/23 at 4:16 PM, resident 73 was interviewed. Resident 73 stated that approximately 1 week ago, it had rained and that the wall and ceiling near the window had leaked water. Resident 73 stated that the maintenance stopped by and told her the room was being looked at. Resident 73 stated that the ceiling and wall leaked one more time a few days after the initial leak. Resident 73 stated the facility did not offer a room change. An observation was made of resident 73's room, room [ROOM NUMBER]. The ceiling and wall in the corner of resident 73's room was covered with translucent plastic held in place by blue tape. On 1/11/23 at 10:20 AM, a follow up interview was conducted with resident 73. Resident 73 stated the facility had not offered a room change. Resident 73 stated that the ceiling and wall had leaked one additional time after the initial leak. Resident 73 was residing in the same room with the leak. The wall and ceiling were both covered with plastic. On 1/11/23 at 10:39 AM, the Director of Maintenance (DOM) was interviewed. The DOM stated that he was unaware of whether or not resident 73 had been offered a room change. The DOM stated that he had scraped the ceiling in Resident 73's room and the roof was in the process of being repaired. The DOM stated that initially the resident was a little nervous about the water coming in and was worried about getting wet. The DOM stated there was another room in the 500 hall that was leaking and was offered a room change. On 1/11/23 at 11:14 AM, the Social Worker (SW) was interviewed. The SW stated he did not offer resident 73 a room change when the roof leaked. On 1/11/23 at 2:58 PM, the Director of Nursing (DON) was interviewed. The DON was unaware if resident 73 had been offered a room change. 2. On 1/9/23 at 3:10 PM, an observation was made behind resident 28's bed. There were gashes on the wall behind resident 28's bed. 3. On 1/9/23 at 3:35 PM, an observation was made of resident 8's wheelchair. Resident 8's wheelchair was soiled with a dried white liquid, crumbs, and debris. On 1/10/23 at 8:39 AM, a follow-up observation was made of resident 8's wheelchair. Resident 8's wheelchair was soiled with dried white liquid, crumbs, and debris. 4. On 1/10/23 at 2:35 PM, an interview was conducted with resident 128. Resident 128 stated housekeeping had not cleaned since she threw-up under her bed, on her night stand and over bed table. An observation was made under resident 128's bed. There was observations of debris and dried liquid under her bed. Resident 128 stated that since the facility had flooded housekeeping has not moved her bed and cleaned under it. 5. On 1/10/23 at 8:00 AM, a follow up tour of the facility was completed. room [ROOM NUMBER] was noted to have debris under the bed. room [ROOM NUMBER] was noted to have debris on the floor. room [ROOM NUMBER] was noted to have debris on the floor by the entrance. room [ROOM NUMBER] was noted to have a plastic glove laying in the doorway. room [ROOM NUMBER] was noted to have a scrap of paper laying in the doorway. On 1/12/23 at 8:39 AM, the Director of Housekeeping (DOH) was interviewed. The DOH stated that each resident's room was cleaned daily by whichever housekeeper was assigned to each hall for the day.

Based on observation and interview, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there was dust in a vent above the food preparation area, food splatter on the ceiling, uncooked bacon stored above ready to eat food, an open beverages was not dated, and another beverage was served after the use by date. Findings included: On 1/11/23 at 11:28 AM, an initial tour of the kitchen was conducted. The following was observed: a. There were food splatters on the ceiling above food preparation areas. b. There was dust in a ceiling vent directly over a food preparation station c. There were food splatters above the clean dish area of the dishwashing room. There was a fan with dust blowing onto the clean dish area. d. There was a package of uncooked bacon stored above butter in the refrigerator. The pack date was listed as November 12th 2022. 2. On 1/11/23 at 12:34 PM, an observation was made of the 200 hallway dining room. There was a container of Soy milk in an ice bath with no open date. There was a pink liquid with an open date of 1/8/23 and a use by date of 1/10/23. On 01/11/2023 at 11:52 AM, the Dietary Manager (DM) was interviewed. The DM stated that the vents above the food preparation area were cleaned as needed, the vents were not on a set cleaning schedule.

Based on observation, interview and record review it was determined, for 1 of 24 sampled residents, that the facility did not ensure proper treatment and assistive devices to maintain vision abilities. Specifically, a resident with dementia's glasses were missing and staff were not aware. Resident identifier: 127. Findings include: Resident 127 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included displaced intertrochanteric fracture of right femur, dysphagia, type 2 diabetes mellitus, Alzheimer's disease, dementia, major depressive disorder, anxiety and scabies. On 1/10/23 at 9:59 AM, a phone interview was conducted with resident 127's family member. The family member stated resident 127's glasses had been missing for over 2 years. The family member stated resident 127 had multiple falls which might have been from not being able to see. On 1/10/23 at 8:46 AM, an observation was made of resident 127 in the memory care unit dining room. Resident 127 did not have glasses on. On 1/11/23 at 12:34 PM, an observation was made of resident 127. Resident 127 was observed in her bed with the head of bed elevated. Resident 127 was eating and was not wearing glasses. Resident 127's medical record was reviewed. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 127's vision was adequate and she did not have corrective lenses. A quarterly assessment dated [DATE] revealed that resident 127 had corrective lenses. Resident 127's MDS's from 8/9/19 until 6/1/22 revealed that resident 127 had corrective lenses. An Admission Inventory of Personal Effects form without a date revealed resident 127 had eye glasses and case. An Initial Admission Record dated 7/23/19 revealed that resident 127 had adequate vision with corrective lenses and corrective lenses were present on admission. An Initial Admission Record dated 1/2/23 revealed that resident 127 had adequate vision and did not wear corrective lenses or have corrective lenses upon admission. Resident 127's progress notes revealed the following entry by the facility Social Worker (SW) on 1/9/23 at 3:42 PM, IDT (interdisciplinary team). [Family members name removed] attended the phone for the IDT [names removed] .[Family member name removed] asked about glasses. SS (social services) will contact the optometrist and have him come to see her and get an Rx (prescription) for glasses. Resident 127's falls were reviewed. A fall occurred on 12/26/22 at 2:00 PM, when resident 127 was ambulating in the dining room and tripped over another resident's foot that was sitting in the dining room. The report revealed the fall was witnessed. It should be noted the fall resulted in a displaced intertrochanteric fracture of the right femur. On 1/11/23 at 1:01 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated she was not sure if resident 127 wore glasses. On 1/11/23 at 1:01 PM, an interview was conducted with Nurse Aide (NA) 1. NA 1 stated she had not seen resident 127 with glasses since she started working at the facility 3 months ago. On 1/11/23 at 1:18 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 127 had not had glasses in the previous 4 months. LPN 1 stated she did not think glasses were safe for resident 127 because she shuffled her feet when she walked and she would probably take them off. LPN 1 stated resident 127 could take glasses off and break them. LPN 1 stated resident 127 removed socks so she would probably remove glasses. On 1/12/23 at 8:04 AM, an interview was conducted with CNA 1. CNA 1 stated there were cubby's for the residents at the nurses station with personal items. CNA 1 stated resident glasses were kept in the cubby's. CNA 1 was observed to look in resident 127's cubby and there were no glasses. CNA 1 stated resident 127 might have kept her glasses at her bedside. CNA 1 was observed to look in resident 127's night stand and stated there were no glasses. CNA 1 stated she was then going to ask around to staff until they found her glasses. CNA 1 stated she was not sure who to report missing glasses to but would probably ask my supervisor. On 1/12/23 at 7:55 AM, an interview was conducted with the Social Worker (SW). The SW stated that resident 127 had glasses and she lost them. The SW stated he had a new eye doctor coming into the facility to see the residents. The SW stated the eye exam was covered through Medicaid. The SW stated if a resident needed glasses then he reached out to family to buy the glasses. The SW stated he was not sure how long resident 127 was without glasses. The SW stated that he saw resident 127 wearing another resident's glasses. The SW stated that glasses come and go so often that, he had not filled out a grievance form for any residents' glasses. On 1/12/23 at 8:51 AM, a follow-up interview was conducted with the SW. The SW stated he did not have a grievance for resident 127. The SW stated he was not aware that resident 127 was missing glasses. The SW was provided the note from 1/9/23 regarding family asking about glasses. The SW did not have additional information. On 1/12/23 at 9:30 AM, an interview was conducted with the memory care unit Activities Director (AD). The AD stated resident 127 was admitted with glasses and did not wear them very much. The AD stated that resident 127 had dementia and her vision was starting to box which meant she was not able to see as far with her peripheral vision. The AD stated he was not sure the last time he saw her with glasses. The AD stated resident 127 was a wanderer for her gazing. The AD stated if he noticed a resident's glasses were missing he first looked in hiding spots like in pillow cases, shoes, and other residents rooms that have glasses. The AD stated he would then report to the SW if he was unable find them because the SW was in charge of all appointments. On 1/12/23 at 8:59 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 127 has had glasses in the past. The DON stated that resident 127 wandered into other residents rooms and took things and left things all over the unit. The DON stated she discussed resident 127's glasses with her family member but resident 127 did not have eye insurance. The DON stated she talked to the SW about resident 127's eye insurance. The DON stated she was not sure how long resident 127's glasses had been gone. The DON stated there were lots of new staff so she did not know why the MDS had corrective lenses until June of 2022 and then no corrective lenses. The DON stated if glasses were lost in the facility, then it was the facilities responsibility to replace them.

Based on observation, interview and record review it was determined, for 1 of 24 sample residents, that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition. Specifically, a Speech Language Pathologist (SLP) wrote a physician's order to provide a resident with maximum assistance with eating and the resident was observed to be eating in her room without assistance. Resident identifier: 127. Findings include: Resident 127 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included displaced intertrochanteric fracture of right femur, dysphagia, type 2 diabetes mellitus, Alzheimer's disease, dementia, major depressive disorder, anxiety and scabies. On 1/10/23 at 10:00 AM, an interview was conducted with resident 127's family member. The family member stated resident 127 had lost a lot of weight. The family member stated Registered Nurse (RN) 1 told her that resident 127 fed herself. The family member stated that while resident 127 was at the hospital, she was told that resident 127 was unable to feed herself. On 1/10/23 at 8:46 AM, an observation was made of resident 127 in the memory care unit dining room. Resident 127 was observed to be seated at a table in her wheelchair. Resident 127 was observed to have a fork in her hand and was unable to get eggs onto the fork. Resident 127 was observed to pick up scrambled eggs with her fingers and place half of what she picked up into her mouth. The other half of the eggs were observed to fall on the ground. Resident 127 was observed to use her fingers to pick up cereal. At 9:02 AM, the Activities Director (AD) was observed to remove resident 127 from the dining room. Resident 127 was observed to eat food off her lap using her fingers as she was taken out of the dining room. The AD was observed to sweep the food resident 127 dropped on her lap onto the floor. Resident 28 was observed at the same table as resident 127. Resident 28 stated to the AD that there was a lot of food on the floor. On 1/11/23 at 12:37 PM, an observation was made of resident 127. Resident 127 was observed to be eating sitting upright in her bed with her food on an over bed table. Resident 127 was not observed to be provided assistance. Resident 127 was observed to put her pointer finger into her glass and hold the outside of the glass with the rest of her hand to drink the liquids. Resident 127 was observed to feed herself a roll using her fingers. Resident 127 was observed eating rice and meat with her hands. No assistance was observed to be offered. The Certified Nursing Assistant (CNA) Coordinator was observed going in and out of resident 127's room but no assistance was observed to be provided. At 12:49 PM, Nursing Assistant (NA) 1 was observed to pick up food out of resident 127's bed. Resident 127 was observed to be holding the fork tines end of the utensils. NA 1 was observed to use resident 127's fork and feed her a few bites and remove the tray from the room. Resident 127's medical record was reviewed. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 127 extensive 1 person physical assistance with eating. A care plan dated 9/6/19 and revised on 12/29/21 revealed [Resident 127] has ADL (activities of daily living) Self Care Performance Deficit r/t dementia, muscle weakness and abnormalities with gait and mobility, type II DM, depression, anxiety, Asperger's syndrome, cardiac murmur, mild cognitive impairment, sciatica, insomnia. The goal developed was Will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene through the review date. Interventions included Explain all procedures/tasks before starting; Therapy evaluation and treatment as per MD orders and; Encourage to participate to the fullest extent possible with each interaction. A physician's order dated 1/4/23 written by a SLP revealed Carbohydrate Controlled Diet with mechanical soft diet texture and thin liquids. The order further revealed Max assist feeding for safe pacing of intake. Resident 127's weights in pounds were: a. On 7/12/22 was 197.6. b. On 11/9/22 was 193.6. c. On 12/14/22 was 193.4. d. On 1/2/23 was 178.79 Hospital WT (weight) A Registered Dietitian (RD) note dated 1/10/23 revealed Pt's (patients) current wt is 178.8 (BMI-29.8 =overweight). PO (oral) intake of CCHO, mechanical soft diet remains ~90% providing 1776kcals (calories), 79gm (grams) protein, which meets nutrition goals of 1750kcals (25kcals/ABW (actual body weight)), 68gm protein (1.2gm/kg IBW (Ideal body weight) for bone FX (fracture) healing). Continue to monitor pt's wt (weight), intake for adequacy. There was no information regarding resident 127's assistance needed when eating. On 1/11/23 at 12:42 PM, an interview was conducted with the CNA coordinator. CNA coordinator stated that max assist with eating was when the CNA helped the resident with eating the whole time. On 1/11/23 at 12:46 PM, an interview was conducted with NA 1. NA 1 stated that max assist for eating was making sure the resident got the drinks and nutrition they needed because the resident was not able to get the nutrition themselves. NA 1 stated resident 127 did not require max assist with eating. On 1/11/23 at 12:44 PM, an interview was conducted with CNA 3. CNA 3 stated max assist meant a resident was totally dependent and had to be fed. CNA 3 stated staff did everything for the resident including feeding the resident. On 1/11/23 at 12:48 PM, an interview was conducted with RNA (Restorative Nursing Assistant)/CNA 2. RNA/CNA 2 stated resident 127 required minimal assistance with eating in the dining room. RNA/CNA 2 stated that when resident 127 was in bed she required max assistance and needed to be fed her meals. On 1/12/23 at 8:08 AM, an interview was conducted with CNA 1. CNA 1 stated resident 127 was declining in health and needed more assistant sometimes. CNA 1 stated resident 127 did not use utensils to eat anymore. CNA 1 stated resident 127 needed to be supervised and guided when she was eating. CNA 1 stated that max assistance was when a resident had food in front and the resident did not try to eat. On 1/12/23 at 8:59 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 127's assistance with eating varied everyday. The DON stated resident 127 sometimes ate 100% independently and other times required full assistance. The DON stated most of the time resident 127's in the dining room for meals and staff provide supervision and cueing. The DON stated she was not aware of the physician's order by the SLP for max assist with eating.

Based on interview and record review it was determined, for 1 of 24 sampled residents, that the facility did not ensure that residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed in the clinical record. Specifically, a resident was prescribed an anti-psychotic medication without a supporting clinical diagnosis and no gradual dose reduction. Resident identifier 11. Findings include: Resident 11 was admitted to the facility on [DATE] with diagnoses which include,Cerebral infarction, Major depressive disorder, recurrent, Unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and Cognitive communication deficit. Review of resident 11's physician's orders revealed the following: a. Quetiapine 25 milligram (mg), give 25 mg by mouth in the evening for major depressive disorder (MDD). The order was initiated on 3/8/22. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 11 received antipsychotics on a routine basis. In addition, there were no diagnoses checked on the MDS to indicate resident 11 required a psychotropic medication. Review of the Nursing 2019 Drug Handbook documented under Quetiapine Fumarate Black Box Warning: Drug isn't indicated for use in elderly patients with dementia-related psychosis because of increased risk of death from CV disease or infection. Wolters Kluwer. Nursing 19 Drug Handbook Thirty-ninth Edition. Philadelphia, PA. (2019), pp. 1302 On 1/11/23 at 2:57 PM, the Director of Nursing (DON) was interviewed. The DON stated resident 11 was on Quetiapine because of behaviors. At 3:30 PM, a follow up interview was conducted with the DON. The DON stated that they were unable to locate information regarding rational for resident 11 to be on an psychotropic medication. The DON stated she was changing the psychotropic medication tracking and resident 11 had not been reviewed.

Based on observation and interview it was determined, for 1 of 24 sample residents, that the facility did not ensure that each shared room bed had ceiling suspended curtains, which extend around the bed to provide full visual privacy in combination with adjacent walls and curtains. Resident identifier 127. Findings included: On 1/11/23 at 1:05 PM, an observation was made of resident 127. Resident 127 was observed in bed with a sheet over her. Certified Nursing Assistant (CNA) 3 was observed to turn and pull resident 127's privacy curtain and there was no privacy curtain. Resident 127's roommate and visitor were in the room. CNA 3 stated she did not know why resident 127 did not have a privacy curtain to cover her bed. CNA 3 was observed to stand between resident 127 and her roommate to try and cover resident 127 while she changed the sheet. Resident 127 was observed in a brief and shirt under the sheet. On 1/12/23 at 8:00 AM, staff were observed changing resident 127 in a shared room. Resident 127 did not have a privacy curtain and resident 127's roommate was in the room during this time. On 1/12/23 at 8:52 AM, the Director of Housekeeping (DOH) was interviewed. The DOH stated that the facility staff were aware that resident 127 did not have a privacy curtain to separate her and her roommate. The DOH explained that there was a laundry backup due to a scabies outbreak in the memory care unit. On 1/12/23 at 8:58 AM the Director of Nursing (DON) was interviewed. The DON stated that every resident should have a privacy curtain or some form of continued privacy if the privacy curtain was taken down. 47432

Resident 1 was admitted to the facility on [DATE] for a five day hospice respite stay with [DIAGNOSES REDACTED]. On 8/11/20 an abuse log was received from the facility and reviewed. An investigation was conducted for resident 1 on allegations of new excoriation, redness, and blistering on his sacral/coccyx area, and redness to his feet toes, and heel. The investigation was conducted on 6/2/20 by the Director of Nursing (DON), and stated: DON reviewed clinical charting and interviewed all direct care staff including wound nurse, LN's (licensed nurses), and CNA's (certified nursing assistants). It was reported by wound nurse and CNA's that (resident 1) had mild redness on his coccyx/buttocks that was noticed Friday (May 29) through Sunday (May 31) afternoon. The Sunday afternoon CNA reported that they changed (resident 1's) brief and cleaned his peri-area prior to placing him in his recliner around 1600 (4:00 PM). (Resident 1's) coccyx/sacral region was noted to have mild redness at this time. The CNA checked on the resident throughout the shift and was able to convince the resident to get into bed around 0400 (4:00 AM). A brief change was done at that time and it was noted the resident had increased redness with a darker area with blistering. (The CNA) did not report her finding to the nurse or oncoming shift. The DON concluded the investigation with: Upon chart review, staff interviews and other investigations, it was noted that (resident 1) was a confused gentleman that admitted to (the facility) for a hospice respite stay with significant co-morbidities, is a high risk of increased breakdown (Braden of 12) and also has a history of skin breakdown. (Resident 1) was noted to have poor nutritional intake, which would compromise his increased protein needs. The resident was also noted to refuse care and repositioning throughout his stay and preferred to sleep in recliner. He received brief changes and was repositioned as resident would allow, with increased breakdown noted the morning of 6/1/20. In light of this investigation, it is determined the resident breakdown was not preventable due to the items stated above. On 8/12/20 a copy a facility Quality Improvement review was provided, the review was conducted on 6/2/20 and stated Description of Specific Issue: Residents at risk for skin breakdown/Pressure sore are not being repositioned timely or frequently. Interventions listed were Educate direct care staff on importance of repositioning resident identified at high risk for skin breakdown. Provide in-service to staff regarding repositioning protocols and checking for skin alteration. (redness, open skin, DTI (deep tissue injury)). Notification to nurse or wound nurse for immediate up. Continue education regarding repositioning, CNA/LN notification to wound nurse regarding new skin alterations. On 8/12/20 resident 1's medical record was reviewed. A review of resident 1's history revealed no documentation of previous issues with skin breakdown. An admit skin assessment was conducted on 5/27/20 and documented that resident 1 had a skin issue on his scalp, as well as the front and back of his right lower leg r/t (related to) banging on wC (wheelchair). An admit Braden Scale for Predicting Pressure Sore Risk was conducted on 5/27/20 and determined that resident 1 was High Risk for skin breakdown related to sensory perception rating of Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. Skin moisture rating of Very Moist: Skin is often, but not always moist. Linen must changed at least once a shift. Activity rating of Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weights and /or must be assisted into chair or wheelchair. A mobility rating of Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. A nutritional rating of Probably Inadequate and a friction and shear rating of Problem: Requires moderate to maximum assistance in moving. Complete lifting with without sliding against sheets is impossible. Frequently sliding down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation leads to almost constant friction. A bowel and bladder assessment conducted on 5/27/20 documented that resident 1 was completely incontinent of bowel and bladder. A nurses' progress note dated 5/27/20 documented .Patient is mildly confused at times, requires 2 or more persons to transfer r/t weakness. Patient does not have any obvious behaviors or issues and at this time denies pain. A nurses' progress noted dated 5/28/20 documented .(Resident 1) has been quiet and compliant. Takes meds, tolerates meals, has no complaints. No concerns at this time. A nurses' progress note dated 5/29/20 documented resident pleasant and cooperative at this time, was alert this morning and took meds well with no difficulty, is adjusting well. A nurses' progress noted dated 5/31/20 at 3:33 PM documented (Resident 1) is a five day respite in self isolation from recent admission. He was very tired this morning and refused cares and breakfast. Note: this was the only documentation of resident 1 resisting or refusing cares. A nurses' progress note dated 5/31/20 at 9:51 PM documented Resident adjusting well to facility, compliant with taking medications and obtaining vitals. He expressed that he is looking forward to going home tomorrow. A late entry progress note on 6/1/20, after resident 1 was discharged home, documented (Resident 1's) spouse informed DON of excoriation, redness, and blistering found on his sacral/coccyx area along with redness to his feet, toes, and heel. Discussed findings with Hospice nurse and found to be consistent with what spouse reports. Charts reviewed, Staff interviewed. Resident was noted to have breakdown around 0400 on morning of 06/01. Staff reports mild redness up until 06/01. Note: There was no documentation of resident 1 having any skin breakdown or treatment of [REDACTED]. A review of resident 1's physician orders [REDACTED]. A care plan problem initiated on 5/29/20 stated (Resident 1) has potential for pressure ulcer development r/t impaired mobility and circulation. (Braden score: 12) Interventions initiated on 5/29/20 included Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Weekly head to toe skin at risk assessment. On 8/11/20 at 1:27 PM, an interview was conducted with Nurse Assistant (NA) 2. NA 2 stated that residents should be repositioned every 2 hours, and that staff should remind independent residents to reposition themselves. NA 2 stated that any skin issues that were observed had to be immediately reported to the nurse. On 8/12/20 at 4:34 PM, a phone interview was conducted with the facility Administrator. The Administrator stated that resident 1 had come to the facility for a 5 day respite stay. The Administrator stated that resident 1's family member later came to talk about skin breakdown found on resident 1's buttocks and feet. The Administrator stated that based on the pictures provided by the resident 1's family member, the facility DON determined the skin breakdown to be Kennedy ulcers. Note: A Kennedy Ulcer as defined by https://www.ncbi.nlm.nih.gov/ is an unavoidable skin breakdown which occurs in some patients as part of the dying process. It often appears on the sacrum or coccyx, but can appear elsewhere. On 8/13/20 at 9:31 AM, a phone interview was conducted with resident 1's family member. The family member stated that when resident 1 came home she changed resident 1's brief and found 15 blisters on resident 1's buttocks and heels, stated that resident 1 had no skin issues prior to being admitted to the facility. The family member stated that the facility DON told her they were Kennedy ulcers which meant resident 1 was imminently dying, and that the ulcers were unavoidable. The family member stated that as of 8/13/20 resident 1 was still alive and most of the wounds had healed. The family member stated that resident 1 had no prior history of skin breakdown, and his only previous wounds were skin tears. On 8/17/20 at 9:11 AM, a phone interview was conducted with resident 1's hospice nurse. The hospice nurse stated that she assessed resident 1 on 6/1/20 after he came home from the facility, stated she also called the hospice medical director to come and assess resident 1. The hospice nurse stated that the medical director confirmed that the wounds to resident 1's buttocks and feet were not Kennedy ulcers and were in fact pressure ulcers. The hospice nurse stated that resident 1 had been bed ridden at home since 4/1/20, and was bed ridden at a previous facility prior to that. The hospice nurse stated that despite the extended time of being bed ridden, resident 1 had not had any pressure ulcers or skin issues of any kind prior to being admitted to the facility for the 5 day respite stay. The hospice nurse stated that after resident 1 came home he required twice weekly nursing care for his wounds, as well as daily wound care by family members. The hospice nurse stated that the nurse and family were able to heal resident 1's wounds and that they resolved on 7/7/20. On 8/17/20 at 11:02 AM, a phone interview was conducted with the DON. The DON stated that a high risk Braden score indicated to staff that the resident needed additional encouragement for repositioning and brief changes. The DON stated that the facility did not have policies for preventative skin breakdown interventions for high risk residents; stated that over time the CNA's learned the residents' needs and who needed assistance with repositioning. The DON stated that resident 1 could move but he didn't want to, stated that resident 1 would tell the CNA's that he was fine and didn't need to move. The DON stated that the last night resident 1 was at the facility (May 31), resident 1 stayed in his recliner from 4:00 PM until sometime the next morning, and the night CNA did not reposition or change resident 1. The DON stated that he interviewed the CNA's and they reported that resident 1 had redness on his bottom prior to the last night of his stay, but the CNA's did not report it or document it anywhere. The DON stated that he suspected resident 1 had Kennedy ulcers because he had seen one once before and resident 1's wound appeared similar. The DON stated that the CNA's were educating resident 1 on repositioning, but stated the facility did not have any documentation of that education and encouragement.

Based on observation, interview, and record review, it was determined for 3 of 44 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, one resident had a delay in treatment after a change in condition, one resident had pain and burning with urination and was not assessed by the physician and one resident had a respiratory decline that was not called into the physician. The deficient practice identified for resident 209 for the delay in treatment after a change in condition, was found to have occurred at a harm level. Resident Identifiers: 5, 47 and 209. Findings Include: HARM 1. Resident 209 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. On 3/8/18, resident 209's medical record was reviewed and revealed the following: Nursing progress notes for resident 209 revealed the following: a. 9/25/17 at 11:58 AM, resident 209's respirations were normal. Resident 209's oxygen saturation was at 88% on room air. The responsible party and Medical Director (MD) were notified, and oxygen therapy was started. (NOTE: Resident 209 was not admitted with orders for oxygen. No physician order for [REDACTED]. b. 9/26/17 at 11:58 AM, resident 209's respirations were shallow and resident 209 had labored breathing. Resident 209's oxygen saturation was documented to be normal at 96% on room air. Decrease in grasp on both right and left sides. Decreased movement of both the right and left upper extremities. Decreased movement of both the right and left lower extremities. Abnormal pupil reaction on both the right and left eye. Pupils are unequal in size, both are reactive to light but are sluggish. Nursing staff documented that resident 209's daughter was concerned that patient was declining cognitively and physically and she had requested an appointment to follow up with her primary care physician. c. 9/26/17 at 1:08 PM, resident 209 received [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg 2 tablets. The nursing progress note documented that the medication was given related to patient requests and that resident 209 had a fall today. (NOTE: No other documentation could be located in the medical record regarding the time of the fall, where the fall had occurred nor how resident 209 fell . Additionally, no documentation could be located in the medical record to show resident 209 was experiencing pain, what her pain level was nor where the pain was located.) d. 9/26/17 at 2:44 PM, a call was placed to notify resident 209's family and primary care physician (PCP) of resident 209's fall. Facility nursing staff documented that the receptionist at the PCP's office stated that resident 209 was not their patient. (NOTE: The attempt of notification to the physician was documented approximately 5 and a half hours after neurological checks were initiated on resident 209.) e. 9/26/17 at 3:19 PM, facility nursing staff notified resident 209's surgeon of her unwitnessed fall. f. 9/26/17 at 4:19 PM, resident 209 was sent to the emergency room via emergent transport due to change in mental status, [MEDICAL CONDITION] and respiratory distress. Family here at time of transport and indicated they wanted her sent as well. g. 9/26/17 at 11:22 PM, facility nursing staff called the emergency room to get a report on resident 209. The facility nursing staff was informed that resident 209 went into [MEDICAL CONDITION] while in the emergency room and discovered she had a hiatal hernia blocking blood flow to the heart, which needed emergency surgery. An Initial Admission Record assessment dated [DATE], was completed by facility nursing staff and revealed the following baseline status for resident 209 upon admission: a. Resident 209's blood pressure (BP) was 133/62, Pulse 89, b. Resident 209's had normal respirations at a rate of 18 without shortness of breath (SOB). Resident 209's Oxygen Saturation was 99% on room air. c. Resident 209's speech was clear. d. Resident 209's pupils were of equal size and reactive to light. e. Resident 209's bilateral hand grips were equal. No weakness was documented. The hospital Discharge Summary dated 9/24/17, revealed the following: a. Resident 209 had some [MEDICAL CONDITION] on the morning of postoperative day 1. This has improved with holding narcotics. b. Resident 209's pupils were equally round and reactive to light. c. Resident 209's oxygen saturation was 98% and she had no respiratory distress.) On 9/26/17 at 9:05 AM, a Neurological Assessment form was initiated for resident 209 and revealed the following: Blood Pressure: a. 9:05 AM, 144/89 b. 9:20 AM,140/92 c. 9:35 AM, 130/74 d. 9:50 AM, 132/86 e. 10:20 AM, 126/74 Pulse: a. 9:05 AM, 88 b. 9:20 AM, 89 c. 9:50 AM, 80 d. 9:50 AM, 89 e. 10:20 AM, 76 Respiration rate: a. 9:05 AM, 12 b. 9:20 AM, 12 c. 9:35 AM, 14 d. 9:50 AM, 12 e. 10:20 AM, 12 The Neurological Assessment for for resident 209 further revealed that resident 209's right pupil was consistently larger than her left pupil. Both pupils were documented as reactive to light. Resident 209's upper and lower extremities were documented as weak and resident 209's speech was documented as garbled. (NOTE: The Neurological Assessment form revealed the last documented observation was at 10:20 AM, one hour and 15 minutes after the Neurological Assessment form was initiated. The form indicated that neurological checks should have continued until 9/27/18.) Physician's orders dated 9/24/17 for resident 209 included orders for [MEDICATION NAME]-[MEDICATION NAME] 7.5/325 milligrams (mg) 1-2 tablets every 4 hours as needed. The Controlled or Antibiotic Drug Record for resident 209 revealed the following: a. 9/24/17 at 9:15 PM, resident 209 received [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg 2 tablets. (Note: According to resident 209's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Pain scales are on a scale of 0 to 10 with 10 being the most painful. The pain medication was documented to be effective with a follow-up pain score of 3. There was no identification of the location of resident 209's pain.) b. 9/25/17 at 8:00 AM, resident 209 received [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg 2 tablets. (Note: This administration was not documented on resident 209's MAR. There was no documentation assessing resident 209's pain level or location of pain at this time.) c. 9/26/17, resident 209 received [MEDICATION NAME]-[MEDICATION NAME] 7.5/325 mg 2 tablets at the following times: i. 2:55 AM, (Note: This administration was not documented on resident 209's MAR. There was no documentation assessing resident 209's pain level or location of pain at this time.) ii. 7:10 AM, (Note: No documentation of resident 209's pain medication for 7:10 AM could be located on resident 209's MAR. There was an entry on resident 209's MAR indicated [REDACTED]. Resident 209's pain level was documented as an 8 at administration at 9:15 AM. At 12:46 PM, the pain medication was documented as effective with a pain score of 2. There was no identification of the location of resident 209's pain.) iii. 11:15 AM, (Note: The administration of pain medication at 11:15 AM, was after nursing staff discontinued documentation for neurological checks on resident 209 after an unwitnessed fall. No documentation of resident 209's pain medication for 11:15 AM could be located on resident 209's MAR. There was an entry on resident 209's MAR indicated [REDACTED]. Resident 209's pain level was documented as a 5 at administration. At 2:09 PM, the pain medication was documented as effective with a pain score of 1. There was no identification of the location of resident 209's pain.) iv. 3:25 PM. (Note: This administration was after nursing staff documented that resident 209 had weaken bilateral grip strength, weakness in extremities, that her pupils were sluggish when reacting to light and that resident 209 had garbled speech. Resident 209's MAR indicated [REDACTED]. There was no identification of the location of resident 209's pain. Resident 209 was discharged to the hospital within an hour after the last dose of [MEDICATION NAME]-[MEDICATION NAME] was administered.) A Physical Therapy Treatment Encounter Note dated 9/26/17 revealed the following: a. Patient had fall today morning and due to that complaint of feeling pain in Left hip. Nursing is taking care of pain with pain medications. b. Patient had a fall today morning and due to that complaint of feeling pain in left hip. Patient required frequent rest breaks to avoid pain and fatigue. Pain limits functional mobility including transfer, standing and walking. (Note: The Physical Therapy note was signed at 3:31 PM on 9/26/17, the time of therapy was not indicated on the note.) An Occupational Therapy Treatment Encounter Note dated 9/26/17 revealed the following: a. OT instructed pt. in deep breathing strategies d/t (due to) SOB/fatigue. b. Pt. able to don over-head nightgown with set up A (assistance) from OT d/t decreased functional mobility. c. Pt. had a fall just prior to OT arriving, cleared by nurse for therapy. Post hip precautions. SOB. Fatigue. (Note: The OT note was signed at 4:03 PM on 9/26/17, the time of therapy was not indicated on the note.) The Facility's Nursing Home to Hospital Transfer Form, dated 9/26/17 at 6:11 PM, documented that resident 209 was receiving oxygen via Nasal cannula at 3 liters per minutes at the time of her discharge. (NOTE: Resident 209 was sent to the hospital on [DATE] at 6:11 PM, approximately 9 hours and 2 minutes after the Neurological Assessment form was initiated for resident 209's unwitnessed fall.) The hospital History and Physical (H&P) dated 9/26/17, revealed that resident 209's chief complaint was listed as decreased oxygen saturation at care center. The H&P documentation revealed that resident 209 had altered mental status and that Emergency Medical Services (EMS) had administered [MEDICATION NAME] 2 mg to resident 209 which resulted in increased alertness. The 'History of Present Illness' revealed that resident 209 presented with several days of worsening altered mental status, abdominal pain, shortness of breath. She presents with episodes of desaturation, v-tach ([MEDICAL CONDITION]), leukocytosis. Imaging demonstrates herniation of a majority of colon into chest with severe distention of the bowel and complete collapse of the lung with deviation of the mediastinum. She also has dislocation of new left (hip) arthroplasty. The physical examination revealed that resident 209 was receiving supplemental oxygen and experienced diminished left breath sounds and increased work of respiration. The Operative Final Report dated 9/27/17 at 6:46 AM for resident 209, revealed that resident 209 had emergency expiratory laparotomy, repair of recurrent hiatal hernia with incarcerated bowel with impending strangulation. Grade 4 [MEDICAL CONDITION] hernia. Left lateral thoracotomy, left thoracotomy tube placement, open [DEVICE] placement. On 3/7/18 at 11:09 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that if a resident had an unwitnessed fall he would take the residents vital signs and notify the DON and the resident's physician. RN 1 stated that if a resident had signs of a change in condition he would hold narcotics, notify the physician, and take the residents vital signs. On 3/7/18 at 11:20 AM, RN 6 was interviewed. RN 6 stated that if a resident had an unwitnessed fall, a complete head to toe assessment would be completed. If the resident hit their head or did not know if they hit their head, neurological assessments would be started and completed for 24 hours. RN 6 stated that the MD should be notified of the fall and any changes from baseline. RN 6 stated that if a resident was experiencing neurological changes and requested narcotics, it would depend on the significance of the changes. RN 6 stated that she would likely consult with other floor nurses and the resident's physician. On 3/7/18 at 2:45 PM, the facility Director of Nursing (DON) was interviewed. The facility DON stated that resident 209 fell when she went to sit on her bed and missed her bed, sliding to the ground. The facility DON stated that the nursing staff were going to complete an incident report and investigation regarding the fall, but did not process it after the family informed them that resident 209 would not be returning to the facility. The facility DON further stated that the neurological checks should have continued for 24 hours for resident 209 or for as long as she had remained in the facility and that he did not know why they had been discontinued the neurological assessments after one and a half hours. The facility DON stated that resident 209 was sent out to the hospital due to the daughter's concern of her change in condition and the physical decline that the daughter had noticed. On 3/08/18 at 11:31 AM an interview was conducted with the Director of Nursing (DON). The DON stated that he would expect staff to initiate neuro checks for any unwitnessed fall. The DON stated that neurological assessments should be completed Q (every)15 min. (minutes) x (times) 1 hr (hour), Q30min. x 1 hr, then hourly for 72 hrs. The DON stated that he would expect there to be documentation if the staff deviate from this neuro check protocols. NOT HARM 2. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/06/18 at 2:36 PM an observation was made of resident 5 in activities playing bingo. Resident 5 was observed to be wearing oxygen at 2 L (liters) via NC. On 3/6/18 resident 5's medical record was reviewed. Nursing progress notes for resident 5 revealed the following: a. 1/13/18 Note Text: (residents name) sister thinks he may be ill. Took his vitals and they were all relatively normal. His O2 (oxygen) was at 73 on room air, so I put his NC (nasal cannula) on him and turned the O2 up to 10 and it was 82. He says his stomach and head hurt. I informed (registered nurse) and he will schedule a Dr appointment for him. Physician's orders revealed that there was no order for supplemental oxygen. Review of care plan revealed no focus area for dependence on supplemental O2 nor for resident 5's history of acute and chronic [MEDICAL CONDITION]. No documentation could be located in the medical record to show that resident 5's physician had been notified of the change in condition, nor for a full assessment for the possibility of an episode of [MEDICAL CONDITION]. On 3/8/18 at 4:04 PM an interview was conducted with the facility DON. The facility DON stated that 10 L of O2 was not an appropriate treatment for [REDACTED]. The facility DON further stated that there should be an order from the physician for the supplemental oxygen use, and that the nurse should have notified resident 5's physician of the change in condition. The facility DON further stated he would expect to have a care plan related to resident 5's [DIAGNOSES REDACTED]. No other information was provided at this time. On 3/12/18 additional information was provided by the facility. The documented note revealed: Resident with [MEDICAL CONDITION]. It is noted on 1/27/17 O2 sats (saturation) decreased to 88% and had an increase of oxygen. VS (vital signs) noted to pulse 70, Resp (respirations) 18, Temp (temperature) 97.5, B/P (blood pressure) 166/87 (Range for month of [DATE]/100-130/78) The resident seen physician a couple days later and back to baseline. It is felt there was no harm and resident did not exhibit any s/s (signs and symptoms) of infection. (Note: It should be noted that the additional information provided was not the date of the incident.) 3. Resident 47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/6/18 resident 47's medical record was reviewed. Review of the nursing progress notes revealed the following: a. 3/1/18, PT (patient) was complaining of pain down in her groin area with light bleeding. When assessed we found what we assumed was a prolapsed uterus. PT was laid down on her side and I helped push her uterus back into place. She complained of slight cramping in her lower abnormal (sic) area. Cream was placed in her peri-area due to slight redness. No documentation could be found to indicate that the physician was notified, or an order to push the uterus back inside of the resident. b. 2/22/18, Note Text: CNA said that the pt stated she feels burning when urinating and also noted the pt was having difficulty swallowing water. (Physician's name) office notified. Physician orders revealed that there was no order for the treatment to push the assumed prolapsed uterus back into place. The care plan for acute/chronic pain related to age revealed no documentation of frequent pain with urination, interventions for this type of pain, nor for facility staff to push resident 47's uterus back into place. No documentation could be found for a care plan with interventions for a prolapsed uterus. On 3/08/18 at 2:24 PM an interview was conducted with the facility DON. The facility DON stated that no documentation was available to indicate that the physician was notified of the assumed prolapsed uterus on 3/1/18. The facility DON further stated that Registered Nurse (RN) 2 notified the physician and the physician instructed the nurse to push the uterus back in. The facility DON stated that the physician notification on 2/22/18 was a message left at the physicians office, and that this physician is usually pretty good about calling us back when we leave a message. The facility DON stated that his expectation of facility nursing staff was to follow-up with reports of burning with urination, and that the nurses should have called the physician's office back within 24 hours. No documentation could be located in the medical record to indicate that the interventions to push the uterus back into place was ordered by the physician or that the physician was notified. No documentation could be located in the medical record to indicate that facility nursing staff followed up with resident 47's burning with urination. On 3/12/17 the facility provided the following additional information, typed on paper by facility staff that resident 47 had Resident with [DIAGNOSES REDACTED]with psychotic behaviors. She also has a history of prolapsed uterus and has episodes which causes pain with urination. On 2/22/17, MD (Medical Doctor) was notified of resident complaint of pain. No fever was noted and VS stable. No new orders from MD and no further complains of pain with urination. (NOTE: The additional information that was provided by the facility was not in the form of a physician order, history and physical or documentation from the medical record.)

Based on observation and interview it was determined, for 2 of 44 sample residents, that the resident was not able to make choices about aspects of his or her life, in the facility, that were significant to the resident. Specifically, one resident who wanted to move to another facility and had been accepted to move to the facility, was not provided the opportunity to move and one resident was told by the facility RA (Resident Advocate) that he had already had a soda and would have to wait for another. The deficient practice identified for resident 6 was found to have occurred at a harm level. Resident identifiers: 6 and 14. Findings include: HARM 1. Resident 6 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/6/18 at 1:30 PM, an interview was conducted with resident 6. Resident 6 stated I hate it here, I don't feel wanted here. I feel like I'm being ignored, I don't want to die here. Resident 6 stated that she had been at (Name of Facility) before and It has a completely different feel. Resident 6 was observed to be upset, crying, and to wave her arms as she stated, I have rights, and it is my right to leave here and be transferred to the facility that I want to be at. Resident 6 further stated You can't tell me that they have not had a room available for a whole year, and if they haven't, then why are we not looking over here? Resident 6 was observed to point in a different direction. Resident 6 stated that this is why I have stomach issues and It makes me physically sick that I cannot go to the facility that I want to go to. On 3/6/18 resident 6's medical record was reviewed. Resident Advocate (RA) Progress Notes revealed the following entries: a. 8/25/17 at 9:53 AM, Resident is waiting on ombudsman to come and visit her today and is very anxious. (Name of facility) did accept her to transfer to the facility but her doctor believes that she is safer here and will not approve the transfer. Ombudsman was contacted per (Resident 6's) request to get involved in this to get her transferred. b. 9/15/17 at 11:09 AM, Resident visited with RA and ED (unknown) today regarding trying to transfer to (name of facility). She is very anxious and still wanting to transfer. She is not understanding that now (name of facility) is not willing to except her. Her confusion is very bad today and she is having a bad day. RA and ED spoke with her at length to try and help ease her anxiety . c. 9/22/17 at 1:44 PM, Resident is very tearful today. She is confused as to why she can not discharge to (name of facility) SNF (skilled nursing facility). RA has explained to her once again that they do not have any LTC (long term care) bed available at this time and that she is on the waiting list for a LTC bed. She has spent several minuets (sic) with RA in tears. RA comforted her and helped her to calm down. Once she was calm RA took her (to a) friends location and they were working on a craft together. d. 10/20/17 at 9:54 AM, RA visited 1:1 (one on one) with resident today. They discussed her wanted (sic) to be moved to (name of facility) SNF again. RA reminder (sic) her that they call (name of facility) every other Monday to check on bed availability. Resident is very anxious and confused this morning. RA will continue to visit with resident when needed. e. 10/23/17 at 10:40 AM, Resident and RA contacted (name of facility) SNF to inquire about room availability. They both spoke with (Admissions Director) at (name of facility) and she notified them that there was not LTC room availability. f. 10/30/17 at 11:55 AM, (Resident 6) is a 85 y/o Caucasian female whom is here for LTC placement. Her cares/treatments are being covered by medicaid and her PCP (Primary Care Physician) is (Physician 3). She does have a level I on her chart and does not require a level II. She needs assistance with ADL's (Activities of Daily Living) to include transfers, toileting, bathing and cueing reminders for grooming and dining. She does have glasses for reading and can see regular print with them on. She does not have hearing aids nor does she require them. She does have dentures. She tends to self isolate but staff encourages her to dine in the main dining room and attend activities of her choice. Plans are continued LTC and placement is appropriate. g. 12/21/17 at 4:09 PM, Resident came to RA complaining again about not being able to transfer to another SNF. Once again RA contacted (Name of Facility) to check on bed availability. Resident does not understand that (Name of Facility) has to accept her in order for her to be able to transfer to them. They will not accept her because of behaviors on a previous stay there and she does not understand that either. She believes that this facility is holding her captive. RA has offered to contact other SNF's and ALF's (Assisted Living Facilities) but she is set on (Name of Facility). RA will continue to f/u (follow up) with (Name of Facility) in hopes that they will some day accept her. h. 1/22/18 at 1:33 PM, RA spent 1:1 time today with resident. They placed a call to (Name of Facility) SNF to check on LTC bed availability. No beds available . i. 1/30/18 at 11:55 AM, (Resident 6) is a 85 y/o Caucasian female whom is here for LTC placement. Her cares/treatments are being covered by medicaid and her PCP (Primary Care Physician) is (Name of Physician). She does have a level I on her chart and does not require a level II. She needs assistance with ADL's to include transfers, toileting, bathing and cueing reminders for grooming and dining. She does have glasses for reading and can see regular print with them on. She does not have hearing aids nor does she require them. She does have dentures. She tends to self isolate but staff encourages her to dine in the main dining room and attend activities of her choice. Her daughter comes to visit with her twice a week. Plans are continued LTC and placement is appropriate. j. 3/6/18 at 1:30 PM, RA spent one on one time with resident today. She is still confused as to why she is not being transferred to another facility. RA explained to her once again that the one facility that she wants to go to will no (sic) accept her. Resident is insistent that this facility is holding her hostage. RA reassured her that this facility is not holding her hostage and that the staff her (sic) loves her and will take care of her the best that she will let us. RA will continue to remind her of her cares here and that this facility is not holding her hostage. On 3/7/18 at 9:01, a telephone interview was conducted with the Admissions Director (AD) at (Name of Facility). The AD stated that the staff at resident 6's current facility had called quite a few times but that she had not heard from them for approximately 1 to 1 1/2 months. The AD stated that the reason that resident 6 had been denied so many times was that we can't meet her needs, due to (Resident 6) being a high acuity and we already have so many residents that are a high acuity. The AD stated that the administration at resident 6's current facility had informed them that resident 6 was a high acuity. The AD stated that they did have a bed available in (MONTH) and were willing to take resident 6 but that resident 6's physician would not sign orders for her. The AD stated that she was not aware of any prior behavior for resident 6. On 3/7/18 at 10:40 AM, an interview was conducted with the facility RA. The RA stated that she called (Name of Facility) every Monday with the resident in her office to see about placement and that (Name of Facility) would not accept resident 6 because of her behaviors. When asked what behaviors the resident had and why the facility was not tracking behaviors, the facility RA stated that she did not know what behaviors resident 6 had nor why the facility staff was not tracking her behaviors. The RA stated that she had had a failed placement at (Name of Facility) before and her physician thought she was safer in their facility. When asked how resident 6 had failed placement at the other SNF, the facility RA stated that they had not taken care of her and she lost weight. The facility RA provided a letter from resident 6's physician and all of the notes that had documentation of the time spent in trying to find another facility. The RA stated that the facility Ombudsman had been notified via message that resident 6 had been accepted to another facility and would like to meet with her regarding the move.(NOTE: Documentation provided by the facility RA shows that facility staff was calling the other facility every other Monday, not every Monday per the RA's interview. In addition, the documentation provided by the facility RA did not show any other facility that had been called nor if they would evaluate, accept or decline resident 6 as a resident. In addition, resident 6 only knew that the other facility did not have a bed available and no documentation could be located in the medical record that resident 6 had been notified of her behaviors, that her physician had decided against her move, nor that she was a high acuity and the other facility could not accept her.) A physician's letter dated 1/8/18 revealed: To whom it may concern: This is in regards to (Resident 6) and her [DIAGNOSES REDACTED]. Unfortunately she thinks that people are out to get her and take her stuff, and that no one is taking care of her. This is not true; (Current Facility) has done an excellent job with her care. They do all that is requested of our office and they try their best to keep (Resident 6) happy and healthy . (NOTE: No documentation could be located in the physician's letter regarding resident 6 being safer at the current facility nor of a failed placement at the other facility that resident 6 would prefer to be.) On 3/7/18 resident 6's medical record was reviewed. A Social Services Assessment/Evaluation dated 1/30/18 section D Discharge Needs revealed that resident 6 was considered LTC placement within this facility. No discharge planning needed. An Elopement/Wandering Evaluation dated 1/23/18 revealed that resident 6 scored 2.0 or low risk for an elopement risk. The Minimum Data Set (MDS) assessment dated [DATE] for resident 6 revealed that resident 6 required supervision and set up help only for her bed mobility, transfers, ambulation, dressing, eating, toileting, hygiene and bathing. The MDS assessment dated [DATE] revealed that resident 6 required supervision and set up help only for her bed mobility, transfers, ambulation, dressing, eating, toileting, hygiene and required a one person assistance for bathing. On 3/7/18 at 12:04 PM, a call was placed to the facility Ombudsman. The facility Ombudsman did not answer and a message was left for her to please return the call. On 3/7/18 at 3:04 PM, a telephone interview was conducted with the facility Ombudsman. The facility Ombudsman stated that she had not been made aware that resident wanted to move and had not been in on any meetings regarding a move for resident 6. The facility Ombudsman stated that the only meeting she had been to regarding resident 6 was sometime last spring when it was discovered that resident 6's daughter was taking her money. Stated that APS (Adult Protective Services) was in on that meeting as well. On 3/8/18 at 11:10 AM, an interview was conducted with the facility RA. The facility RA stated they had called around to so many different facilities and that nobody would accept resident 6. The facility RA stated that she did not prompt resident 6's physician to write the letter dated 1/8/18, that the letter had been written by the physician for a nurse that worked with resident 6 on the floor that was no longer working for the facility. The RA stated that the nurse had gotten the letter because resident 6 would go to the nurses about transferring facilities as well. The facility RA stated that resident 6 was always very teary when she would come in to talk about moving and that just last week, she was very angry with me for not getting her moved. On 3/8/18 at 11:40 AM, an interview was conducted with the facility Administrator. The facility Administrator stated that they had called and had been able to secure a room for resident 6 on 8/25/17 and that resident 6's physician stated that he would not approve the move to (Name of Facility) and would not write the orders for resident 6 to be admitted there. The facility Administrator stated that he told resident 6's physician that they could not do that, that this was resident 6's choice and that she had a right to be transferred somewhere else if she wanted to go. The facility Administrator further stated that he had personally contacted multiple facilities for resident 6 and that resident 6 had been denied. The facility Administrator stated that he had told resident 6 numerous times that she had not been accepted by (Name of Facility and did not sugar coat things with resident 6. The facility Administrator stated that he did not have any documentation of any of the conversations with resident 6's physician nor with any of the facilities that he had contacted. No documentation could be located in the medical record to show that multiple facilities had been called for resident 6 to find other placement for her by the facility Administrator nor the facility RA. On (MONTH) 8, (YEAR), after inquiring about resident 6's wish to move to a different facility, the Director of Clinical Services (DCS) set up a meeting for resident 6 with the AD for (Name of Facility) and a facility representative from another SNF to come into the facility to meet with resident 6 and to bring resident 6 some brochures regarding their facility. Additional information provided by the facility on 3/12/18 included a letter written by physician 3 and revealed March 8, (YEAR) To whom it may concern: In (MONTH) (YEAR) (Resident 6) was being forced from her home/apartment. At this time our office contacted (Current Facility) to help in housing of (Resident 6). (Resident 6) at that time was very fragile, and unable to care for herself, meds (medications) were not being taken and or were being taken wrong. (Insulin, etc.) (Current Facility) did help in finding a room for (Resident 6) at this time. After a while, (Resident 6) stated that she wanted to go to her previous facility. We thought it was better for her to stay in her current residence. (Resident 6) continued with the request to be transferred and after talking with (the) administrator at (Current Facility) the request was honored, the other facility denied her admission . (NOTE: Per the interview with the facility Administrator and the AD as well as progress notes from the facility RA, (resident 6's) physician would not sign orders for resident 6 to be transferred to the other facility. At no time did facility documentation reveal that resident 6 had been denied by the other facility except for the reason that they did not have a bed available. Interviews with facility staff or staff at the other facility stated that resident 6 had been denied to move to their facility by the physician in August.) Not Harm 2. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 3/05/18 at 4:02 PM, an observation was made of resident 14 asking the Resident Advocate (RA) for a soda. The RA was heard replying to resident 14 that he couldn't have a soda now because he just had one and he needed to wait for dinner. At the time the statement was made two surveyors were present. On 3/6/18 resident 14's medical records was reviewed and revealed the following: Physician orders [REDACTED]. A care plan dated 5/28/18 revealed a focus area of potential for loss of personal money related to inability to handle the wallet himself. An intervention listed under this focus area revealed .soda/snacks will be kept in the nutrition room and be available to him at any time. On 3/07/18 at 10:58 AM, an interview was conducted with the RA. The RA stated that the resident is a diabetic and will eat everything he is given. The RA stated that resident 14's family brings him a lot of snacks and diet soda. The RA further stated that the resident can't be denied any food requests as it is his choice. The RA stated that her recollection of the interaction was that she was trying to redirect the resident. The RA stated that if resident 14 continued to request snacks, I will give it to him. On 3/07/18 at 11:04 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff expectation was to provide snacks and food requested when the resident wanted them. The DON further stated that resident 14 was able to independently feed himself with setup assist, and we try to give him what he wants because he gets upset if we don't. The DON stated that the staff try to redirect the resident if its close to meal times, but that if he continues with his food requests the expectation is to provide the resident with what he wants. The DON further stated that it was the resident right to have what he requests. The DON was informed of the statement made by the RA on 3/5/18 and that the statement was heard by two surveyors, no additional information was provided.

Based on observation, interview and record review, it was determined that the facility did not ensure that residents maintained acceptable parameters of nutritional status, such as body weight and protein levels for 2 residents who presented with a significant weight loss out of a total sample of 52 residents Resident identifiers: 15 and 87. Findings include: 1. Resident 87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/13/12 from 6:50 AM to 7:45 AM an observation of the morning meal was made in the "Country Cottage" dining room. At 7:17 AM, breakfast was served to resident 87. Certified Nurse Aide (CNA) 7 sat at the table next to resident 87 and assisted her with eating. At 7:24 AM, CNA 7 stated that resident 87 was "too tired to eat" and removed resident 87 from the dining room. Resident 87 was removed from the dining room after eating only three bites of eggs for the nurse to evaluate. Resident 87's breakfast tray was removed from the table. At 7:29 AM Licensed Practical Nurse (LPN) 3 propelled resident 87 back to the dining room. LPN 3 stated that resident 87 was "OK." and seated resident 87 at the table. Resident 87 was removed from the dining room at 7:50 AM, twenty minutes after being propelled back to the dining room. Resident 87 was not offered more food, a substitute, or something to drink during the 20 minutes she remained in the dining room. CNA 7 documented that resident 87 consumed 20% of the morning meal. On 2/13/12 at 12:49 PM, LPN 3 was interviewed. LPN 3 stated that resident 87 was receiving Ensure 240 milliliters (ml) daily. Resident 87's medical record was reviewed on 2/16/12. On 11/17/11, the facility staff completed an admission Minimum Data Set (MDS) assessment. Review of the assessment revealed that resident 87 required total assist with one person physical assistance with meals. The MDS further documented that resident 87 was 5 feet 2 inches tall and weighed 110 pounds. Resident 87 was assessed as not having a swallowing disorder, was receiving a mechanically altered diet and had no weight loss. A Care Area Assessment (CAA) triggered for nutritional status. The facility staff documented that the CAA would be addressed in a care plan. A care plan for "Nutrition" related to activity intolerance, dementia and significant wt (weight) flucuations (sic)" developed 2/14/12 was reviewed. The care plan listed the goals to be achieved as (1) Hydration and nutrition will be maintained, (2) Will consume > (greater than) 65% of meals, (3) Will tolerate mechanically altered foods, and (4) to maintain wt as able." The approaches listed to achieve those goals were "(1) Diet as ordered, regular, puree with small portions, (2) monitor % (percentage) of food/fluids consumed, (3) Monitor acceptance/tolerance and report difficulties, (4) To eat in Country Cottage dining room at all meals, (5) Dietary supplement as ordered, (6) Notify RD (Registered Dietitian) and MD (Medical Doctor) of significant weight changes, abnormal labs, skinbreakdown (sic) and/or dehydration, (7) Continue to monitor weights, labs, PO (oral) intake and other nutritional parameters with each nutritional review, and (8) Refer to restorative for dining assistance as necessary." (Note: The Nutrition care plan was developed on 2/14/12.) A "Medical Nutrition Therapy Assessment" was completed by the Registered Dietitian (RD) on 11/16/11. The RD documented the following: (1) Regular puree diet, (2) Average food/beverage intake at 90-100%, (3) Height 62 inches (5 feet 2 inches), (4) Weight 110 for an ideal body weight of 99-121 pounds (lbs). The RD calculated caloric needs to be 1250 - 1500 calories, 1950 cc (cubic centimeter) of fluids and 50 grams of protein. The nutrition goals were (1) Maintain weight, (2) oral intake to be greater than 50%, (3) skin to heal/remain intact, and (4) labs to be within normal limits. (Note: Body Mass Index (BMI) was calculated to be 20, which indicated a healthy weight.) Review of the laboratory values obtained on 11/30/11 for resident 87 revealed an [MEDICATION NAME] of 3.1 grams/deciliter (g/dL), and total protein of 5.3 g/dL. (Note: The normal value for [MEDICATION NAME] listed on the laboratory sheet was 3.5 - 4.7 g/dL. The normal value for total protein listed on the laboratory sheet was 6.0-8.5 g/dL.) drawn on 11/30/11. On 1/5/12 resident 87's [MEDICATION NAME] was 2.9 g/dL with a total protein of 5.3 g/dL. (Note: Resident 87's [MEDICATION NAME] decreased from the previous laboratory obtained on 11/30/11.) Review of the "Nutrition Progress Notes" completed by the RD revealed the following: a) 11/29/11 - "Significant loss of 3 # (pounds) X 1 week identified to wt of 108 #. (Resident 87) is currently receiving a regular puree diet dining in Country cottage with assistance - physical & (and) verbal stimulation/reminders to eat. No chew/swallow problems identified. PO wt continues to fall within IBW (Ideal Body Weight) range. Labs to be drawn and will review. Will cont. (continue) with current care monitoring for further significant change." b) 12/16/11 - "Significant wt gain of 4# X 1 week. ...Alb ([MEDICATION NAME]) 3.1 (low). ...Wt is within IBW range. Will continue with current plan of care as current diet should be adequate to meet estimated protein needs." (Note: Laboratories obtained on 11/30/11.) c) 12/28/11 - "...PO of regular puree diet 30-100% fluctuates. Requires extensive assist with meals. Current diet exceeds estimated nutrient requirements. ...mild [MEDICAL CONDITION] - insignificant. ...Recommend small portions." d) 1/18/12 - "...Alb 2.9. [MEDICATION NAME] slightly low - current diet sufficient to meet estimated needs. ..." (Note: Laboratories obtained on 1/5/12.) e) 1/31/12 - "...exhibited signs & symptoms consistent with norovirus 3rd week of January - PO charting inconsistent during time of illness. Resident now free of all symptoms with adequate PO." f) 2/13/12 - "Significant wt loss of 11# X 1 month identified to wt of 107#. (Note: Weight on 2/6/12 documented on the February, 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].) (Resident 87) continues to receive a regular, puree diet with marginal intake of 20-75% of most meals, requires total assistance for eating. New order of ensure plus daily r/t (related to) low [MEDICATION NAME] and for wt. maintenance. To continue small portions as resident will not eat any more than what is provided and small portions exceed estimated needs. Observed resident at lunch and identified new trend of pocketing..." (Note: BMI calculated to be 18.7 which indicated resident 87 was underweight.) g) 2/16/12 - "Significant wt loss of 5# X 11 days identified to wt of 101.8#. (Resident 87) was previously on resperdal (sic) which was discontinued on 1/29/12 (Note [MEDICATION NAME] 0.25 mg at HS was ordered on [DATE] and discontinued 1 day later). Wt. loss began subsequent to medication D/C. Possible side effect of [MEDICATION NAME] is wt. gain. No labs since [DATE] at which time [MEDICATION NAME] was 2.9. Per staff report resident is having days when alert and other days when she needs tactile stimulation to respond. On those days she does not eat as well. Has dx (diagnosis) of dementia, on comfort measures as of 1/28/12. Son notified and proposed plan for [MEDICATION NAME] foods and increased amount of Ensure. Discussed labs and appetite stimulants. Son agree to [MEDICATION NAME] foods, supplements and lab. MD notified. orders for ensure 120 ml PO BID (twice a day) in addition to current 240 ml daily. MD did not agree to order labs because of family's previous wish for comfort measures only. Will add the [MEDICATION NAME] cereal and [MEDICATION NAME] mashed potatoes as per son (resident 87) is a 'meat and potatoes person.' Start regular proteins." (Note: The interventions above were initiated after the significant weight loss was brought to the attention of the RD.) Review of the "Weight History" revealed the following weights that were obtained for resident 87 (weights listed in pounds): a) 11/15/11 - 110 b) 11/22/11 - 108 c) 12/4/11 - 110 d) 12/14/11 - 114 e) 12/18/11 - 115 f) 1/1/12 - 118 g) 1/8/12 - 119 h) 1/17/12 - 119 (Note: Weight obtained two days after an episode of nausea, vomiting, and diarrhea.) i) 2/5/12 - 107 Review of the "physician's orders [REDACTED]. a) 12/11/11 - Weekly weights to be obtained every Monday for 3 weeks related to "Following water wt." b) 12/28/11 - "Regular puree (diet) with small portions r/t significant wt gain." (Note: There was no documented weight on or around 12/28/11. Resident 87's weight on 12/18/11 was 115 pounds, 5 pounds higher than her admission weight.) c) 12/28/11 - "Weigh weekly on Mondays observed for weight gain & report MD (Medical Doctor)." d) 1/28/12 - "[MEDICATION NAME] 0.25 mg (milligrams) PO (by mouth) HS (hour of sleep)." e) 1/29/12 - "D/C (discontinue) [MEDICATION NAME] 90.25 mg PO q HS per MD." f) 2/8/12 - "Ensure Plus 240 ml PO daily r/t low [MEDICATION NAME] 2.9. Schedule separate from meals." g) 2/16/12 - "D/C small portions. Give regular, puree diet. Ensure Plus 120 ml PO BID in addition to current ensure 240 ml." (Note: This order was obtained after the surveyor addressed the concern of weight loss to the RD's attention.) Review of the "Resident Progress Notes" revealed the following entries by the licensed nursing staff: a) 12/11/11 - "...MD in to make rounds. New order to weigh pt. weekly on Mondays and nurses to observe for weight gain related to previous chest x-ray results. ..." b) 12/13/11 - "...Pt. sleepy @ (at) dinner. (No) solids consumed. Pt. able to be aroused. Light conversation noted. Pt. answered yes/no questions. Some fluids consumed. ..." c) 12/16/11 - "...lungs clear. Respirations even without labored breathing." d) 12/25/11 - "Weight gain of approx (approximately) 2# noted in one week. MD notified. VS (vital signs) wnl's (within normal limits) for pt. No congestion noted. In take at meals has significantly increased. MD continue to monitor for next few weeks." e) 12/28/11 - "Noted order for regular puree diet (with) small portions r/t significant wt. gain as noted by dietician. MD notified. ..." f) 1/15/12 - "NOC (night) nurse reported N/V (nausea and vomiting) (at) 0400 (4:00 AM) and (large) loose stool on 1/14/12 during night at 1045 VS: BP (blood pressure) 104/67, P (pulse) 84, T (temperature) 98.7 oral, R (respirations) 12, O2 - 93% 2L (2 liters of oxygen) T @ 1430 (2:30 PM) - 07.3. Pt. received flu vaccine on 1/12/12. Pt. given 30 mls of Milk of Magnesia according to bowel protocol on 1/13/12. Nurse noted formed stool during day. (No c/o (complaints of) N/V or pain. g) 1/15/12 - "late entry. pt. had nauses (sic) & vomiting (with) loose stools. Complete bed (change) done. Pt. denies pain. Encouraged extra fluids. Axillary temp 98.9. Reported to day nurse." h) 1/16/12 - "...Pt. unresponsive/unable to stay awake. Pt. unable to take 0800 (8:00 AM) meds. MD notified, order given to hold medications until pt. becomes responsive." i) 1/16/12 - "Pt. currently sleeping. No N/V or diarrhea noted. Pt. denies pain. ...Pt. is responsive to speech & touch." j) 1/17/12 - "...(No) s/s (signs or symptoms) of N (nausea), V (vomiting), or diarrhea. M (medium) BMs today. Pt. alert (with) eyes closed. Able to swallow pills. Able to answer yes, no questions." (Note: Resident 87's weight obtained on 1/17/12 was 119 lbs, two days after first episode of nausea/vomiting/diarrhea.) k) 1/18/12 - "pt. responds appropriate to stimuli. Pt. denies pain. No N/V/D (nausea/vomiting/diarrhea)." l) 1/18/12 - "(No) nausea, vomiting or diarrhea. Pt. responds to questions. Able to answer yes, no questions." m) 1/19/12 - "...Pt. alert (with) confusion. (No) s/s of nausea, vomiting, diarrhea noted." n) 1/20/12 - "(No) s/s of nausea, vomiting, diarrhea noted on shift." o) 1/21/12 - "Pt. son in today. Requested to have an appointment made for pt. to discuss medical condition (with) pts MD. ..." p) 1/21/12 - "(No) s/s of nausea, vomiting, diarrhea noted." q) 1/22/12 - "pt has no s/s of N/V/D. pt. denies pain & is currently sleeping. ..." r) 1/28/12 - "MD ordered comfort measures and to notify him or (resident 87's) son prior to transferring to hospital." t) 1/29/12 - "D/C of [MEDICATION NAME] today will monitor side effects & behaviors. Family notified of change resident is unable to understand change due to cognitive impairment." u) 2/14/12 - "Pt's wt. as weigh (sic) today was 101 lbs." Review of the February, 2012 MAR indicated [REDACTED]. Review of the "Individual Meal Intake Record" revealed that resident 87s average meal consumption was: a) 12/1/11 through 12/31/1 (39 meals had no consumption documented) 1) Breakfast - 45% 2) Lunch - 20% 3) Dinner - 42% b) 1/1/12 through 1/30/12 (51 meals had no consumption documented) 1) Breakfast - 30% 2) Lunch - 17% 3) Dinner - 32% c) 2/1/12 through 2/15/12 (ten meals had no consumption documented) 1) Breakfast - 45% 2) Lunch - 40% 3) Dinner - 51% On 2/16/12 at 2:00 PM, the RD was interviewed. The RD stated that resident 87 was taken off of weekly weights after the facility received a three week run of "stable weights". The RD stated that according to the facility policy, a resident was changed from weekly weights to monthly weights after a stable weight was obtained for three weeks in a row. She stated that the first weight obtained on 2/5/12 was 107 pounds. The RD was shown the weight documented on the February, 2012 MAR indicated [REDACTED]. The RD stated that she "missed that." A reweigh was requested by the survey staff. The RD propelled resident 87 onto the wheelchair scale with the foot petals and an oxygen tank in place. The survey staff requested that the oxygen tank be removed from the wheelchair. The RD stated "the tank shouldn't make that big of a difference." The RD was asked again to remove the oxygen tank. The re-weigh for resident 87 was 101.8 (weight of 152.6 pounds minus 50.8 pounds for the wheelchair weight with foot petals)pounds, down another five pounds from the weight obtained on 2/7/12. The RD stated that she did not if the restorative aide weighed resident 87 with or without the oxygen tank. 2. Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 2/15/12 an observation was made of the lunch meal in the Assisted dining room. At 12:10 PM resident 15 was served his food. Resident 15 was observed to be at the table with his eyes closed and was slumped over in his chair. Resident 15 made no independent attempts to eat or drink. Resident 15 was not cued when his meal was served. By 12:28 PM, no staff assistance or cueing had occurred. At 12:31 PM, more than 20 minutes after being served, a staff member sat next to resident 15 and began to assist him with lunch. Resident 15's medical record was reviewed on 2/15/12. A care plan regarding resident 15's "eating self-care deficit" was developed on 1/20/12. The care plan documented that resident 15 was experiencing a "deteriorating physical condition" and that resident 15 was "totally dependent on staff for all ADL's (sic) (Activities of Daily Living)" related to his progressive uncontrolled diabetes. The goal was to have resident 15 feed himself with minimal assistance. The approaches listed on the care plan included to provide verbal cues as necessary, allow time to feed self, supervise with prompting and verbal cueing, and assist as needed. A discharge summary from the Occupational Therapist (OT) dated 1/13/12 documented that resident 15 "had c/o (complained of) (decreased) self feeding in the self feeding dining room. (At) eval (evaluation) he needed mod (moderate) (assistance) for a lunch meal." On 2/16/12 at 11:25 AM an interview was conducted with OT 2 regarding resident 15. OT 2 stated that resident 15 was moved to the Assisted Dining Room to "help him with his eating." OT 2 stated that resident 15 required increased assistance with dining as well as cueing. OT 2 also stated that the purpose of the Assisted Dining room was to increase assistance and cueing during meals. OT 2 also stated that resident 15 "eats better when he receives cueing." On 2/16/12 at 7:40 AM an interview was conducted with Certified Nurse Aide (CNA) 10. CNA 10 stated that resident 15 required assistance with transfers, but "needs more help eating." CNA 10 further stated that resident 15 "forgets what he is doing or falls asleep. He needs to be cued and sometimes you have to keep coming back because he is so tired." When asked about why resident 15 was moved to the Assisted dining room, CNA 10 stated that resident 15 was falling asleep in the main dining room and other residents were finished eating before resident 15 woke up. CNA 10 further stated that the Assisted dining room "had more aides to help people who can't feed themselves." On 2/16/12 at 1:00 PM an interview was conducted with CNA 6 regarding resident 15. CNA 6 stated that she was assigned to work in the Assisted dining room on a regular basis. CNA 6 stated that resident 15 "needs cueing" and that he had slept through the first 35 minutes of a meal on 2/15/12. CNA 6 further stated that resident 15 "sometimes just sleeps" during meals. CNA 6 also stated that she was "unsure of his needs since he's only been back here (in the assisted dining room) for 2 to 3 weeks." CNA 6 then stated "I could probably try to cue him more if I see that he is sleeping." Minimum Data Sets (MDS) for resident 15 documented the following weights: a) Entry 10/15/11 186 lbs b) Quarterly 1/5/12 178 lbs c) Significant change 2/22/12 168 lbs. (Note: The MDS noted a 10% weight loss in three months for resident 15). Resident 15's "Nutrition Progress Notes" documented the following: a) 10/26/11 No concerns were identified. b) 11/15/11 "Wt (weight) at time of assessment 186# (pounds), now 182# stable." c) 12/6/11 "resident has periods of sleepiness during meals. wt without significant change at 182#". d) 1/4/12 Quarterly note "Wt is stable and within IBW (ideal body weight) range at 178#." e) 1/17/12 No concerns were identified f) 2/13/12 "Significant wt loss of 14# x 3 months identified to 168#. (Resident 15) has shown significant changes in condition recognized and followed by nursing with new orders for neurology consult for follow-up. Working with OT on self-feeding and is now dinng (sic) in assisted dining room for observation and encouragement. Glucerna supplementation continues. wt is appropriate for ht (height) and po (by mouth) good at lunch and breakfast.To cont. with current diet (and) nursing follow-up." (Note: The 14# weight loss did not include the additional 4# that resident 15 had lost in the first three weeks after admission.) g) 2/16/12 "CMP (complete metabolic panel) with slight decrease in [MEDICATION NAME] to 3.1 (low). (Resident 15) . . . intake is fluctuating - Excellent at breakfast and lunch (70 - 100%) with slight decline at dinner (15 - 70%). Glucerna is offered before resident goes to bed at HS (hour of sleep). Wt decline in wt (sic), (decreased) po and (decrease) in [MEDICATION NAME] recommend increasing Glucerna to 240 ml (milliliters) po BID (twice a day). . . Continue with dining in (Assisted Dining room) with encouragement and assistance as needed." On 1/20/12 a nutrition care plan for resident 15 was developed. The care plan documented that resident 15's goal was to "maintain adequate nutritional status as evidenced by maintaining wt". Approaches listed on the care plan included weigh monthly, monitor percentage of food consumed, offer snack, and encourage intake at meals. The care plan was updated at an unknown date when the RD documented that resident 15 had experienced significant weight loss of 7.7% in three months related to "altered mental status with (decreased) po (by mouth intake). . . Now in (assisted) dining room. Receiving supplements." On 2/16/12 at 10:20 AM an interview was conducted with the RD regarding resident 15. The RD stated that resident 15 was being weighed monthly, not weekly, even though he had been steadily losing weight since being readmitted to the facility. The RD stated that she did not know why resident 15 was not put on weekly weights in December 2011 or January 2012 after showing a weight loss. When asked what interventions had been put into place to prevent further weight loss, the RD stated that resident 15 was experiencing increased "sleepiness" during meals, and he had been moved to the Assisted Dining room as of "a couple of weeks ago." When asked about resident 15's most recent weight loss, the RD stated that resident 15 had been weighed on 2/5/12, but she had not reviewed the weights until 2/13/12, more than a week later. On 2/15/12 at 6:30 PM, an additional interview was conducted with the RD. The RD stated that the "resident at risk" meeting was held weekly. The RD stated that this meeting was to "identify residents for weight loss, high risk for weight loss, pressure sores, high risk for pressure sores, and for a significant change of condition", but that the "meetings are not being held anymore, and have not been held since November 2011". The RD further stated that she did not know why. On 2/15/12 a review of the facility's Nutrition Policy and Procedure was conducted. The Policy revealed that "resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible". The Compliance Guidelines revealed that 1. The Center provides nutritional care and services to each resident, consistent with the resident's comprehensive assessment. 2. The Center recognizes, evaluates, and addresses the nutritional needs of every resident, including but not limited to, the resident at risk and the resident already experiencing impaired nutrition. 3. The nutritional status of the resident is assessed upon admission, quarterly, annually, when a significant change occurs and/or more frequently as deemed necessary by the Interdisciplinary Team (IDT). (According to the American Dietetic Association, "Nutritional assessment is a systematic process of obtaining, verifying and interpreting data in order to make decisions about the nature and cause of nutrition-related problems.") 4. The Nutrition Assessment is used to define meaningful interventions to address any nutrition-related problems. 5. The IDT clarifies nutritional issues, needs, and goals in the context of the resident's overall condition, by using observation and gathering and considering information relevant to each resident's eating and nutritional status. 6. The Center identifies key individuals who should participate in the assessment of nutritional status and related causes and consequences. (For example, nursing staff provides details about the resident's nutritional intake. Health care practitioners (e.g., physicians and nurse practitioners) help define the nature of the problem (e.g., whether the resident has anorexia or sarcopenia), identify causes of anorexia and weight loss, tailor interventions to the resident's specific causes and situation, and monitor the continued relevance of those interventions. Qualified dietitians help identify nutritional risk factors and recommend nutritional interventions, based on each resident's medical condition, needs, desires, and goals.) 7. A qualified dietitian completes an in-depth nutritional assessment utilizing existing information from sources, such as the Resident Assessment Instrument (RAI). 8. Information from multiple sources to include, but not limited to, the RAI, and additional nutritional assessments as indicated is analyzed to determine a resident's nutritional status. 9. The IDT develops an individualized care plan based on information generated by the comprehensive assessment and any pertinent additional nutritional assessment. The care plan: 10. Addresses, to the extent possible, identified causes of impaired nutritional status, 11. Reflects the resident's goals and choices, and 12. Identifies resident-specific interventions and a time frame and parameters for monitoring. 13. The IDT monitors residents with impaired or at-risk nutritional status, as well as for those whose current nutritional status is stable after care plan implementation. 14. Monitoring may include, but is not limited to: 15. Observing for and recognizing emergence of new risk factors, 16. Evaluating consumption of meals and between-meal snacks and nutritional supplements, and 17. Reviewing the continued relevance of any current nutritional interventions (e.g., therapeutic diets, tube feeding orders or nutritional supplements). 18. The care plan is updated and modified as needed, depending on factors such as: 19: Change of condition, 20. Further clarification of underlying causes, 21. Identification of specific treatable causes of nutrition-related problems, 22. Goals are met, and 23. Responses to current interventions. 24. If nutritional goals are not achieved, different or additional pertinent approaches are considered and implemented as indicated. An explanation is documented to explain any decisions to continue current interventions when the resident's nutritional status continues to decline. 25. Based on analysis of relevant information, the IDT identifies a clinically pertinent basis for any conclusions that a resident could not attain or maintain acceptable parameters of nutritional status.

Based on interview and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for two sample residents. Specifically, facility staff did not provide timely and appropriate interventions to address the pain of 2 of 52 sample residents. Resident identifiers: 61 and 119. Findings include: 1. Resident 119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/14/12 at 8:25 AM, an interview was conducted with resident 119. When asked if his current pain medication regimen was adequate, resident 119 stated that the pain medication he was being given "don't hardly touch it." Resident 119 further stated that he had fallen at home and broken his pelvis and arm. Resident 119 stated that his arm and pelvis were "hurting" him and that the physician "never comes in to give me more meds and the nurses can only give what the doctors tell them to." Resident 119 also stated that in addition to the arm and pelvic fracture, he had pain that was "shooting" down his left leg. On 2/16/12 at 8:00 AM, a second interview was conducted with resident 119 regarding his pain. Resident 119 stated that he saw his orthopedic surgeon the day before and that the surgeon told him the pelvic fracture was affecting the nerves in the leg, causing leg pain. Resident 119 stated that the surgeon wanted resident 119 to see a neurologist to address the leg pain, but that the facility could not get an appointment until 3/21/12 and "I wish I could get in sooner." When asked about what interventions were in place to address his pain, resident 119 stated that the therapy department was using "e-stim" for his leg pain, but that it "doesn't work." Resident 119 also stated that he was taking [MEDICATION NAME], but it was ineffective. Resident 110 stated that his surgeon told him to take [MEDICATION NAME] an alternating schedule to help with pain. Resident 119 stated that he had never been offered any other pain medication besides the [MEDICATION NAME]. Resident 119 further stated that his pain was present "anytime I move." Resident 119 further stated "I can't sleep because every time I move it wakes me up and is painful. I'm ready to sleep in the chair." Resident 119's medical record was reviewed on 2/14/12. Resident 119's medical record included a "Pain Assessment" dated 2/2/12. The assessment documented that upon admission, resident 119 described his pain as an ache, prick, tingling, burn, tender, sharp, throbbing, sore, tight, tiring and exhausting. The pain asessment also documented that resident 119's pain was affecting his ability to sleep; toilet, bathe, and dress himself; and perform personal hygiene. The pain assessment documented that the pain had resulted in anger as well as changes in weight and bowel habits. The assessment further documented that the pain was caused and increased by "movement". Resident 119's acceptable level of pain was listed as a 4/10, and that the current regimen of [MEDICATION NAME] and [MEDICATION NAME] were effective. In addition, the assessment noted that resident 119 was experiencing pain at a level of 10/10 in his left leg and left hand at all times. On 2/2/12 a "Patient Nursing Evaluation" for resident 119 was completed. The nursing evaluation documented that resident 119 was experiencing pain at a severity of 10/10 at all times in his leg with movement. The evaluation also documented that resident 119 experienced pain in his hand at a level 3 or 4/10. On 2/3/12 a "Physical Therapy (PT) Evaluation" for resident 119 was completed. The PT documented that resident 119 was experiencing pain in his left leg at a level of 8/10 with movement, and no pain at rest. On 2/3/12 an "Occupational Therapy (OT) Evaluation" for resident 119 was completed. The OT documented that resident 119 was experiencing pain in his left leg and wrist at a level of 8 to 10/10 with movement. Resident 119's nurses notes documented the following: a) On 2/2/12 at 7:30 PM, Admit nursing note: "Pt (patient) rates pain 10/10 with movement." b) On 2/3/12 at 6:50 PM, "Pt had c/o (complaints of) pain and prn (as needed) meds (medications) given." c) On 2/3/12 at 12:00 AM, "Pain rate 7/10 to left hand." d) On 2/4/12 at 6:00 PM, "Pt c/o pain x 2 and requested prn pain med. Pt noted that med does relieve pain." e) On 2/4/12 at 2:00 PM, "Discussed with pt . . pain controll (sic) including motify (sic) sn (staff nurse) of pain when mild . . . splint pelvic girdle with pillow when coughing to (decrease) pain, frequent position (change). . ." f) On 2/5/12 at 11:30 PM, "Requested pain meds (with) HS (hour of sleep) medication." g) On 2/6/12 at 5:00 PM, "Pt c/o pain q (every) 4 (hours) medicated (with) [MEDICATION NAME] 5/325 (2 tabs). Pt's pain he reports is from the hips." h) On 2/7/12 at 11:00 PM, "Pt had c/o pain 8/10 at HS. PRN [MEDICATION NAME] given." i) On 2/10/12 at 1:15 PM, "Ortho (orthopedic) doctor notified of pt's (left) leg pain. Nurse reported that pain meds alleviated pain x 1 (hour) but then pain is back. Pt notes pain occurs primarily when pt moves legs. Answering service relayed info (information) to (undecipherable) and nurse was notified that PA (physician assistant) will call nurse back (with) any (changes) to care. Pt does have appt (appointment) (with) ortho on 2-15-12." j) On 2/10/12 at 3:55 PM, "PA called back (with) instructions to continue (with) current pain management options such as use of [MEDICATION NAME] 400 mg (milligrams) q 4 (hours) in between other prn pain med until pt has appt (with) ortho dr (doctor) on 2-15-12. PA will notify ortho of concerns." k) On 2/11/12 at 2:15 PM, "Pt had c/o pain x 1 and requested prn pain meds." l) On 2/11/12 at 9:00 PM, "c/o pain to BLE (bilateral lower extremity). Pain managed well (with) PRN [MEDICATION NAME]." m) On 2/12/12 at 6:00 PM, "c/o pain during the day in arm and hip." n) On 2/12/12 at 11:50 PM, "pt requested pain pills . . " o) On 2/13/12 at 11:50 PM, "Pt requested (2) pain pills. . . " p) On 2/14/12 at 11:00 PM, "Requested pain pills . . " Physician admission orders [REDACTED]. A review of resident 119's February 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The February 2012 MAR indicated [REDACTED]. A care plan dated 2/15/12 regarding resident 119's pain was developed by facility staff. The care plan listed a goal on the care plan that resident 119 will have decreased signs and symptoms of pain and discomfort as evidenced by a verbal pain scale of less than four. Approaches listed on the care plan included administering pain medication per physician's orders [REDACTED]. The facility's "Pain Management" policy was reviewed on 2/16/12. The policy included the following "compliance guidelines": "1. Residents will be screened for pain upon admission/readmission, quarterly, with any new complaints, or with significant status change resulting in pain thereafter. 2. Residents complaining of pain and/or exhibiting signs of pain . . . are assessed with [REDACTED]. 3. A care plan is developed and implemented, using pharmacologic and/or non-pharmacologic interventions to manage the pain and/or try to prevent the pain consistent with the resident's goals. . . " On 2/15/12 an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that she had placed a call on 2/10/12 to a neurologist to make an appointment for resident 119. RN 2 stated that she left a message for the neurologist but that he had not yet returned her phone call. When asked about resident 119's pain management regimen, RN 2 stated that she encouraged resident 119 to take pain medication in a preventative manner. RN 2 also stated that facility staff were using alternating doses of [MEDICATION NAME] and [MEDICATION NAME] to control resident 119's pain. On 2/15/12 an interview was conducted with RN 4. RN 4 stated that resident 119 was receiving alternating doses of [MEDICATION NAME] and [MEDICATION NAME] to control resident 119's pain. After reviewing resident 119's MAR, RN 4 stated that she was not aware that resident 119 was not receiving [MEDICATION NAME]. On 2/16/12 at 7:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 10. CNA 10 stated that it was normal for resident 119 to complain of pain during transfers, repositioning, and when lifting his leg onto the wheelchair footrest. CNA 10 stated that resident 119 expressed pain by grunting and grimacing. CNA 10 stated that resident 119 usually asked for pain pills three to four times a day. On 2/16/12 at 8:05 AM, an interview was conducted with RN 5. RN 5 confirmed that resident 119 had been complaining of pain in his pelvis that "shoots" down his leg. RN 5 stated that she had been administering [MEDICATION NAME] to resident 119 for pain control. RN 5 also stated that resident 119 always asked for two tablets of [MEDICATION NAME] instead of one tablet. RN 5 stated that resident 119 asked for pain medication three to four times a day. When asked if the pain medication was effectively controlling resident 119's pain, RN 5 stated that the medication was effective as long as resident 119 did not try to bear weight. RN 5 then stated that the medication only lasted for "about two hours, and then he starts feeling the pain come in." 2. Resident 61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/14/12 at 9:00 AM, an interview was conducted with resident 61. When asked if his current pain medication regimen was adequate, resident 61 stated that he suffered from arthritis pain prior to the motor vehicle accident, and did not expect to be "pain free," however, he did not feel that his pain was under control at the facility. Resident 61 stated that he was on a [MEDICATION NAME] pump at the hospital, but that the facility would not allow him to have that medication upon admission. Resident 61 stated that he had physician orders [REDACTED]. Resident 61 stated that he wished he could receive additional pain medication. Resident 61 stated that sometimes when he was offered pain medication from the nurse, he would ask her to delay the administration an hour or two because he knew the "pain would be worse" when he attended physical therapy. Resident 61's medical record was reviewed on 2/14/12. On 12/24/11 a "Pain Assessment" was completed by facility staff for resident 61. The assessment documented that resident 61 was experiencing pain in his neck, arm, ribs, and legs from the motor vehicle accident. The assessment also documented that resident 61 had chronic "arthritic pain" for years at varying times of the day. On 12/24/11 a "Patient Nursing Evaluation" for resident 61 was completed. The nursing evaluation documented that resident 61 was experiencing daily pain at a severity of 10/10. A care plan dated 1/5/12 regarding resident 61's pain was developed by facility staff. The care plan listed a goal on the care plan that resident 61 will have decreased signs and symptoms of pain and discomfort as evidenced by patient verbal report. Approaches listed on the care plan included administering pain medication per physician's orders [REDACTED]. Review of the hospital discharge orders dated 12/23/11 documented that when resident 61 was discharged from the hospital on [DATE], the physician ordered the administration of the following pain and anxiety medications: a) [MEDICATION NAME] 10 mg every 4 hours as needed b) [MEDICATION NAME] 2 mg IV (intravenous) push every 4 hours as needed c) [MEDICATION NAME] 100 mcg every 72 hours d) [MEDICATION NAME] 10 mg/[MEDICATION NAME] 325 mg, 2 tabs every 4 hours as needed e) [MEDICATION NAME] 800 mg every 6 hours as needed f) [MEDICATION NAME] 0.25 mg every day as needed g) [MEDICATION NAME] 1 mg every 12 hours h) [MEDICATION NAME] 100 mg three times a day Physician telephone orders documented that on 12/24/11 resident 61's IV and [MEDICATION NAME] were discontinued. Nurses notes for resident 61 during the months of December 2011 and January 2012 documented the following: a) On 12/24/11 at 11:45 AM, "Pt admitted (with) IV peripheral for [MEDICATION NAME] sulfate to be administered IV push. Nurse got order for D/C (discontinue) of [MEDICATION NAME] sulfate IV push and to D/C IV line. Nurse made several attempts (with) 3 MDs (medical doctors) to give order for equivalent pain po (by mouth) medication. Pt has scheduled [MEDICATION NAME] and scheduled [MEDICATION NAME]. Pt has prn (as needed) [MEDICATION NAME] and prn [MEDICATION NAME] presently. Will attempt to contact pain management MD on 12-26-11. MDs would not give pain medication order that is equivalent to [MEDICATION NAME] sulfate at this time." b) On 12/24/11 at midnight, "Medicated for severe pain x 2." c) On 12/25/11, "Pt states he is worried about pain not being under control. Educated on the importance of asking for pain meds before it becomes to (sic) high d/t (difficulty) getting it under control. . . Pain assessed frequently (2) [MEDICATION NAME] given (with) pain (at) 7 rechecked in 2 hours pain still (at) 7. [MEDICATION NAME] given. Pain had (decreased) to 5." d) On 12/26/11, "Pt has been medicated for pain x 4 this shift alternating [MEDICATION NAME] (and) [MEDICATION NAME]. Pt still c/o pain." e) On 12/27/11 at 11:00 AM, "Pt was d/c (discharged ) to us (with) [MEDICATION NAME] IV. We D/Cd the [MEDICATION NAME] but pt pain is not being managed very well. I called (name of pain specialist) to see if they could help (with) the pain management." f) On 12/27/11 at 11:00 PM, "Pt requested PRN [MEDICATION NAME] for pain 7/10." g) On 12/28/11 at 5:00 PM, ". . . (representative from pain specialists) called to f/u (follow-up) on pain management. She told me that they aren't going to follow pt d/t him being admitted to rehab (rehabilitation) facility. I informed the pt about the decision from pain management. Pt was upset and said that he was going to call (pain specialists) himself. He is going to see (name of physician) to f/u on his (right) arm. If pain isn't managed well by appt (appointment) we will report pain problems to (physician) for his help." h) On 12/28/11 at midnight, "Pt had c/o pain at HS (hour of sleep). 8/10. PRN pain medication given." i) On 1/1/12 at 11:00 PM, "Pt continues to complain of unrelieved pain. [MEDICATION NAME] (and) [MEDICATION NAME] have been given." j) On 1/2/12, "Pt continues to ask for pain medications frequently." (NOTE: A referral to resident 61's physician dated 1/4/12 documented that "Pt continues to c/o severe pain even (with) current medication regimen for pain. is there something else you can provide?" No documentation was provided on the sheet regarding resident 61's complaint of severe pain.) k) On 1/8/12, "Pt c/o pain and recieves (sic) medication several times/day." l) On 1/11/12, "Pt continues to have pain 8/10 and requests PRN pain meds which are given." m) On 1/12/12, "Pt had c/o pain x 2 during shift and prn pain med (medications) given. . . pt . . . states . . 'getting up yesterday (with) therapy has caused me to really hurt today.'" n) On 1/13/12, "Pain 6-8/10 managed well per current MD orders." o) On 1/17/12, "Pt had c/o pain 8/10 at HS. . . Pt stated that pain never totally goes away PRN pain medication just helps him tolerate it." p) On 1/18/12, "Pt continues to have c/o pain 8/10. and requests PRN pain medication." q) On 1/19/12, at 3:05 PM "Pt reported 8/10 pain this am prn pain med given (with) reported relief of 6/10 pain 1 (hour) later." r) On 1/19/12, at 11:00 PM "Pt c/o pain 8/10 PRN pain medication given." On 1/24/12 a physician wrote a telephone order for resident 61 to "follow up (with) pain clinic regarding narcotics (and) pain management." No information could be located that documented resident 61 had been seen by the pain clinic. A review of resident 61's January 2012 MAR indicated [REDACTED]. Twenty-nine of 31 mornings and 29 of 31 evenings were listed as a pain level at or above 7/10. (Note: The MAR indicated [REDACTED].) The MAR indicated [REDACTED]. In addition, the MAR indicated [REDACTED]. Nurses notes for resident 61 during the month of February 2012 documented the following: a) On 2/1/12 "Pt expressed discouragement over continued pain and upcoming surgery. . . Pt had PRN [MEDICATION NAME] (2) given for pain 8/10." b) On 2/2/12 "He continues to c/o pain often (every 4 hours) requests [MEDICATION NAME] for pain relief." c) On 2/5/12 "Pt requested [MEDICATION NAME] d/t pain 6/10. pt stated he didn't notice much difference." d) On 2/7/12 "Pt. had c/o pain 8/10 at HS. . . [MEDICATION NAME] barely lessens the pain. [MEDICATION NAME] (2) given and pt was able to go to sleep." e) On 2/9/12 "Pt continues to have c/o pain 8/10. [MEDICATION NAME] given." f) On 2/14/12 "c/o pain all the time gets his prn pain medcation (every four hours)." On 2/11/12 a physician wrote a telephone order for resident 61 to have his [MEDICATION NAME] discontinued. A review of resident 61's February 2012 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The February 2012 also revealed that resident 61 had not been administered any [MEDICATION NAME] during the month of February 2012. In addition, the MAR indicated [REDACTED]. On 2/16/12 at 8:05 AM, an interview was conducted with RN 5 regarding resident 61. When asked about resident 61's pain regimen, RN 5 stated that resident 61 was currently receiving a [MEDICATION NAME] every 72 hours, and [MEDICATION NAME] as needed. RN 5 stated that resident 61 was also receiving [MEDICATION NAME] to assist with some of the underlying arthritis pain. RN 5 stated that resident 61 was requesting the [MEDICATION NAME] at least once a day and sometimes twice a day. RN 5 further stated "I think the pain management is effective. . . He's never been in such extreme pain that he is not functioning. . . he usually asks for pain pills at a pain level of 7/10. A level 4 or 5/10 is the lowest I've ever seen his pain level." When asked if she thought a pain level of a 5 was effective pain management for resident 61, RN 5 stated that resident 61 had never mentioned pain to her and that he was always "laughing and joking", making her think resident 61 was not in pain. RN 5 then stated that she was the nurse on duty when resident 61 was admitted to the facility. RN 5 confirmed that resident 61's [MEDICATION NAME] was discontinued upon admission to the facility. When asked the reason for discontinuing resident 61's [MEDICATION NAME] upon admission, RN 5 stated that "his pain is managed without something as complicated as changing an IV line every 3 to 5 days." An interview was conducted with RN 2 on 2/16/12 regarding resident 61. RN 2 stated that the IV [MEDICATION NAME] was administered as an IV push, and since the IV itself was discontinued upon admission to the facility, the [MEDICATION NAME] was also discontinued. When asked why the facility did not provide an alternative oral pain medication, RN 2 stated that the doctor chose not to give it to him and just "stay with what he had." When asked about current interventions for pain management, RN 2 stated that there were no concerns. On 2/19/12 a physician wrote the following progress note regarding resident 61: "Reported concern re (regarding) pain. Patient has narcotic abuse history. [MEDICATION NAME] IVP (intravenous pump) discontinued on admission r/t history and need to evaluate patient. [MEDICATION NAME] discontinued r/t low BP (blood pressure) 90s/60s. [MEDICATION NAME] added prn at the time. Had discussed pain management with patient. Offered to refer to pain clinic as was previously patient there, but patient decided not to go. . . Is now agreeing to pain clinic follow-up." A review of resident 61's pain clinic visit notes dated 10/17/11 (prior to resident 61's motor vehicle accident) revealed that resident 61 was "happy with medication regimen and is requesting no changes at this time. . . . currently taking the following medications for pain: [MEDICATION NAME] 4 mg 10 per day and [MEDICATION NAME] 10mg tid (three times a day). (Resident 61) reports that his pain is well controlled by his current pain medication regimen. . . (Resident 61) shows no suspicious signs of aberrant behavior in regards to his medication usage, such as: lost or stolen medication, noncompliance with prescribed dosing regimen, or multiple early refills."

Based on observation, interview, and record review it was determined that the facility did not maintain an infection control program that prevented the development and transmission of scabies. Specifically, 20 residents were treated for [REDACTED].. Resident identifiers: 2, 3, 4, 5, 6, 7, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26. Scabies is a contagious skin infestation caused by microscopic parasites that burrow under the skin creating small, raised areas that cause intense itching. Reference Taber's Medical Dictionary, 13th edition. Findings include: On 4/30/09 at 8:30 AM an interview was held with Licensed Practical Nurse (LPN) 1. LPN 1 stated the facility had recently experienced an outbreak of scabies in which 20 residents and 9 employees were infected. LPN 1 stated the outbreak of scabies was realized on 4/28/09. LPN 1 stated at approximately 11:00 AM on 4/28/09, she received a telephone call from Registered Nurse (RN) 1 stating that several staff members had rashes. LPN 1 stated the staff members were sent to a clinic and had been diagnosed with [REDACTED]. LPN 1 stated the Medical Director was notified and subsequently visited the facility and diagnosed 18 residents as having scabies; 1 on the Special Needs Unit (SNU), 1 on the 100 Hall, and 16 on the 300 Hall. Note: 20 residents were prescribed treatment for [REDACTED]. LPN 1 stated on 4/29/09, a medicated cream was applied to each of the infected residents and on 4/30/09 all infected residents' rooms were disinfected while the residents were showered. LPN 1 stated that the treatment for [REDACTED]. LPN 1 stated all infected residents were to remain in isolation until 5:00 PM on 4/30/09. LPN 1 stated that approximately six weeks prior, three residents had rashes, but that they were residents who "all have a skin condition." On 4/30/09 at 9:15 AM and 10:50 AM, interviews were held with CNA 1. CNA 1 stated he has had a rash with "bumps" on his arms for approximately 5 weeks; since the end of March 2009. CNA 1 stated at first he thought the rash was an allergic reaction to a recent medication change and did not report the rash until about a week after it developed; at the beginning of April 2009. CNA 1 stated he reported his rash to LPN 3 and the Director of Nursing (DON). CNA 1 stated that LPN 3 and the DON told him they did not know the cause of the rash. CNA 1 stated he reported the rash to the DON a second time in mid-April, approximately. CNA 1 stated when he reported the rash the second time, he had 10 to 15 bumps on each arm and "a lot" of bumps on his legs and back, which he stated he showed the DON. CNA 1 stated when he reported the rash to the DON the second time, he also reported that several residents (residents 3, 5, 6, 7, 13, and 14) had the same type rash. CNA 1 stated the DON responded, "We will look into it." CNA 1 stated some of the residents were itching "so hard they were bleeding." CNA 1 stated resident 13 had no arms and in the process of trying to scratch his back on the wheelchair, the resident worsened an open area on his buttocks while stating "I'm itchy." CNA 1 stated he worked on 4/22/09 when he was "itchy" and that he again reported the rash and bumps, which were open, to the DON and LPN 2. CNA 1 stated the DON responded, "We are going to look into it." CNA 1 stated he continued to work on 4/22/09, 4/23/09, 4/24/09, 4/25/09, and 4/28/09 with the rash and bumps that were open. CNA 1 stated that on 4/28/09 he "couldn't stand the itching anymore" and went to LPN 2. After seeing the rash, CNA 1 stated LPN 2 notified the facility physician. On 4/30/09 at 9:25 AM and 11:40 AM interviews were held with the DON. The DON stated in mid-April CNA 1 approached her to report a rash the CNA was experiencing. The DON stated CNA 1 "only showed me one little bump on his arm" and it was "not raised." The DON stated that CNA 1 "was concerned it was scabies" but that she did not "know what scabies looks like" so she sent RN 2, the facility's infection control nurse until April 22, 2009, to look at CNA 1's arm. The DON stated RN 2 reported the bump was not scabies. The DON also stated at the time CNA 1 showed her the bump, CNA 1 was "worried that other residents had it. He (CNA 1) said that (resident 5) and (resident 15) had it." The DON stated that she sent RN 2 to check on residents 5 and 15, but that RN 2 reported "it wasn't anything." When asked if she had conducted any further investigation into CNA 1, resident 5 or resident 15's rash, the DON responded she had not. The DON stated CNA 1 "did not complain any more about it." The DON further stated that she had "turned over the investigation" to RN 2. On 4/30/09 at 9:00 AM and 2:50 PM interviews were held with LPN 2. LPN 2, had been the facility's infection control nurse since April 22, 2009, but had been employed as a staff nurse since August 2008. LPN 2 stated in mid-April CNA 1 showed her, and RN 2, a rash. LPN 2 stated RN 2 reported she did not think the rash was something to be concerned about. LPN 2 stated CNA 1 had approximately 10 bumps on his arms. LPN 2 also stated she had spoken to several CNAs since 4/28/09 and that many of the CNAs told her they had reported the residents' rashes to several nurses, prior to the [DIAGNOSES REDACTED]. LPN 2 stated she believed the rashes were not reported in a timely manner and that the nurses had not been including documentation of rashes in their weekly skin checks. On 4/30/09 at 12:45 PM an interview was held with CNA 2. CNA 2 stated that she observed CNA 1's rash at the beginning of April. CNA 2 also stated that resident 4 had an unusual rash between her legs that started at the end of March 2009. CNA 2 stated she told a nurse about resident 4's rash, reporting "I think it's scabies." CNA 2 stated the nurse told her to "treat it like a rash" and put [MEDICATION NAME] lotion on it. CNA 2 stated resident 4's rash did not improve, and that multiple CNAs had reported to multiple nurses that resident 4 had an unusual rash. CNA 2 stated, "the nurses weren't listening to the aides." On 4/30/09 at 11:20 AM an interview was held with LPN 3. LPN 3 stated that she "had residents complaining of rashes last week." LPN 3 stated that on 4/24/09 a CNA had told her that resident 6 had a rash on his legs. LPN 3 stated that RN 2 looked at the rash on resident 6 but "we weren't thinking it was scabies." When asked about resident 13, LPN 3 stated that resident 13 was "always itchy" and was on medication for it. LPN 3 stated she knew that resident 14 also had a rash but, "thought it was dry skin." On 4/30/09 a list of residents who were diagnosed with [REDACTED]. The following 20 residents were identified as having scabies: Residents 2, 3, 4, 5, 6, 7, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26. All residents listed were on placed in isolation for 24 hours, had [MEDICATION NAME] ([MEDICATION NAME])cream applied to their entire body that was left on overnight, had their personal belongings placed in plastic bags for three days, and were to have a second application of [MEDICATION NAME] applied seven days from the initial application. The following information was obtained relative to residents 2, 3, 4, 5, 6, 7, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26: a. Resident 2: 1. A 2/9/09 skin check sheet documented that resident 2 had a "scattered rash" on her upper waist and the right side of her back. 2. A 3/10/09 skin check sheet documented that resident 2 had "scratch marks upper abdomen from itching." Nurses notes for the same day also include "some irritation under armpits also." 3. Nurses notes dated 4/3/09 documented that resident 2 had complained of itching on her right shoulder blade 4. Nurses notes dated 4/14/09 documented that resident 2 had a "small sore" on her right upper thigh. 5. Physician notes dated 5/5/09 documented that on 4/20/09 resident 2 had a red mark on the center of her back and the back of her neck. 6. Nurses notes dated 4/28/09 documented that resident 2 had complained of "some itching" on her arms with "evidence of itching." 7. On 4/30/09 at approximately 11:00 AM resident 2 was observed to be in the special needs unit (SNU) of the facility. Resident 2 was observed to be sitting in her wheelchair in the SNU dining room with approximately eight other residents and three staff members. Note: An interview was held with LPN 2 on 4/30/09. LPN 2 stated that all residents currently infected with scabies were "still on isolation precautions. No one should be out of there rooms until 5:00 PM today." An interview was held with LPN 4 on 4/30/09 at 10:50 AM. LPN 4 stated he was aware resident 2 had been diagnosed as having scabies and was to be in isolation. LPN 4 stated there was not an empty room on the SNU and that resident 2 probably would not stay in her room anyway, so he made the decision to allow her out of her room. b. Resident 3: 1. Nurses notes dated 4/29/09 documented that resident 3 had an eye surgery "canceled due to scabies." 2. On 4/30/09 at 3:15 PM an interview was held with resident 3. Resident 3 stated that he was "itchy as all get out." c. Resident 4: 1. Physician notes dated 5/5/09 documented that on 4/2/09 resident 4 had a "few spots on leg from rash." 2. Nurses notes dated 4/3/09, 4/9/09, 4/16/09, and 4/22/09 documented that resident 4 continued to have a rash on her legs. d. Resident 5: 1. Physician notes dated 5/5/09 documented that on 4/9/09 and 4/22/09 resident 5 had "redness on buttock." 2. Nurses notes dated 3/20/09 documented that resident 5 had "itching (and) excoriation of scalp, which is scaly and bleeding." e. Resident 6: 1. On 4/30/09 at 3:00 PM an interview was held with resident 6. Resident 6 stated "I've been itching for two weeks. It drives me crazy. . . they don't seem to know what it is. . . It's miserable. . . Please get them to help faster." Resident 6 also stated that he told the nurse about his rash and that facility staff members had given him some ointment, but that it had not helped. Resident 6 was observed to have several red spots on his chest, head, abdomen, armpit, legs and neck. f. Resident 7: Physician notes dated 5/5/09 documented that on 4/19/09 resident 7 had a "red rash on abdomen". g. Resident 13: 1. Physician notes dated 5/5/09 documented that on 4/22/09 resident 13 had symptoms of "chronic dermatitis" and a one centimeter area on his left buttock. 2. Resident 13 was observed to be in his room on 4/30/09 at 3:30 PM. Resident 13 was observed to have no arms, and was trying to scratch his back by moving his back and buttocks from side to side on his wheelchair. Resident 13 was attempting to use his shoulders to scratch his face. Resident 13 stated that his back was "itchy" and asked if any staff members could scratch his back. At 3:35 PM a CNA was observed to enter resident 13's room and scratch resident 13's back for several minutes. h. Resident 14: Physician notes dated 5/5/09 documented that on 4/22/09 resident 14 had several small scabs on his legs and feet. i. Resident 16: 1. Physician notes dated 5/5/09 documented that on 4/26/09 resident 16 had a scab on his left calf. 2. On 4/30/09 at 3:10 PM an interview was held with resident 16. Resident 16 expressed concern that he had to stay isolated in his room. Resident 16 stated, "Is there anything you can do for us?" j. Resident 17: 1. Physician notes dated 5/5/09 documented that on 4/22//09 resident 17 had redness on her breast. 2. On 4/30/09 at 3:20 PM an interview was held with resident 17. Resident 17 stated that she had had a rash for two weeks and that it was "itchy" and that she was "uncomfortable." k. Resident 19: Physician notes dated 5/5/09 documented that on 4/24/09 resident 19 had red scabbed spots on her chest, upper arms, and upper back. l. Resident 20: Physician notes dated 5/5/09 documented that on 4/23/09 resident 20 had an "irritated" right and left breast. m. Resident 26: Physician notes dated 5/5/09 documented that on 4/22/09 resident 26 had a red nose and forehead due to a "chronic rash." The facility's policy and procedure for "Infection Control" was reviewed. The policy stated that "Employees with a communicable disease or infected skin lesions are prohibited from direct contact with residents . . . if direct contact will transmit the disease."

Based on observation of medication administration, interviews and record review, it was determined the facility did not ensure that 2 residents were free of significant medication errors. Specifically, Resident 1 received another resident's medications, and resident 9 received a medication when physician ordered parameters indicated the medication should have been held. Resident identifiers: 1 and 9. Findings Include: Unobserved Significant Medication Error: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] after a three day hospital stay for observation and treatment after a significant medication error occurred at the facility. Resident 1's [DIAGNOSES REDACTED]. An interview was held with the Director of Nursing (DON) on 4/30/09 at approximately 11:30 AM. The DON explained the significant medication error that occurred with resident 1 on 12/29/08. The DON explained that resident 1 received another resident's medications in error. The DON further explained that Licensed Practical Nurse (LPN) 5 had prepared medications a resident other than resident 1, and placed the medications in a medication cup. The DON explained the facility nurse placed the other resident's medications, in the cup, on a bedside table. The DON stated that a facility nurse aide, reportedly assumed the medications were for resident 1 and handed resident 1 the medication cup. On 4/30/09, the DON provided a medication error form, dated 12/29/08, which had been completed by LPN 5. LPN 5 documented resident 1 received, in error, the following medications: [REDACTED] a) [MEDICATION NAME] 10 milligrams (mg.) This medication is used for the treatment of [REDACTED]. b) [MEDICATION NAME] 25 mg. This medication is for the treatment of [REDACTED]. c) [MEDICATION NAME] 0.5 mg. This medication is for the treatment of [REDACTED]. d) [MEDICATION NAME] 4.5 mg. This medication is for the treatment of [REDACTED]. e) [MEDICATION NAME] XL 12.5 mg. This medication is for treatment of [REDACTED]. f) [MEDICATION NAME] 2 mg. This medication is for the treatment of [REDACTED]. g) [MEDICATION NAME] 15 mg. This medication is for the treatment of [REDACTED]. h) [MEDICATION NAME] 20 mg. This medication is for the treatment of [REDACTED]. i) Calcium 600 mg. This medication is for calcium supplementation. j) [MEDICATION NAME] 20 mg. This medication is for the treatment of [REDACTED]. Per review of MEDICATION ORDERS FOR [REDACTED] a) [MEDICATION NAME] 200 mg. This medication is for treatment of [REDACTED]. b) [MEDICATION NAME] 5 mg. This medication is for the treatment of [REDACTED]. A Medication Variance Report Worksheet was completed by a LPN 5 on 12/29/08 at 9:40 AM. LPN 5 documented the resident 1 had experienced the following effects related to the medication error: "Change in blood pressure" and "Cognitive change (Sedated)". LPN 5 documented the medication error was a rated "Category F", meaning the error, ". . . may have contributed to or resulted in temporary harm to the resident and required initial or prolonged hopsitalization." On 12/29/08 at 12:25 PM, LPN 5 documented the following nursing note entry for resident 1: "(Resident 1) administered the wrong meds (medications). Notified supervising DON, family and MD (Medical Doctor). MD ordered (1) all meds to be held today (2) Hospitalize if severly (sic) sedated (3) Hospitalize if unable to urinate (4) Resume meds tomorrow. Pt. (Patient) experienced unwitnessed fall. VS (Vital Signs) dropped to 68/38 (blood pressure) 65 (pulse) 14 (respirations) 95.7 (temperature) due to sedation. Notified MD and family of pt. (change) in condition. (name of resident 1's physician) ordered pt. transfer to ER (emergency room )". A History and Physical, written by the emergency room physician, and dated 12/29/08, contained the following entries: a) "The patient is an [AGE] year old while female who presented herself to our emergency room today with [MEDICAL CONDITION]. Apparently, the patient was given incorrect medicines at the nursing home today. She had been fine for about an hour and then was noted to be quite hypotensive. She was confused, more so than her usual state." b) "The medications that she was given at the nursing home that were not hers were [MEDICATION NAME], [MEDICATION NAME], calcium, [MEDICATION NAME], and [MEDICATION NAME]." c) "Plan- Supportive care, avoid any further medications for now, try to control her dementia as best we can and follow her closely." The Discharge Summary, written by the emergency room physician, and dated 12/31/08 contained the following entries: a) "HOSPITAL COURSE AND PROGRESS: The patient was placed in the hospital for observation and supportive care. She was placed on IV fluids and (nothing by mouth) simply because she was having [MEDICAL CONDITION] when she was sitting up to eat. After 24 hours, her blood pressure stabilized and she no longer had any [MEDICAL CONDITION] after that. She was gradually able to ambulate on her own. She was able to feed herself on her own. Her mental status did clear somewhat. She became a little less confused and her memory seemed to be somewhat better towards the end of the hospitalization ." The facility Medication Administration policy was reviewed. The DON stated that this was the policy the facility was to follow regarding medication pass rules and regulations. The following items were noted in this policy: Procedure 14, ". . . During a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart."; and Procedure 15, "Take the medication to the resident's location, and identify the resident. Use at least two resident identifiers (i.e., name band, resident pronouncing name, picture, etc.) whenever administering a medication. Caution: The resident should be available before any medication is removed from its container. If the resident is not at his/her location, flag that resident's medication sheet for follow-up, and continue the medication pass to the next resident in sequence . . . ". Observed Significant Medication Errors: On 4/30/09 at 8:25 AM, LPN 4 was observed administering medications to resident 9. Prior to administering resident 9's medications, LPN 4 asked a facility nursing assistant to take resident 9's blood pressure. The facility nursing assistant reported to LPN 4 that resident 9's blood pressure reading was 120/56. The facility nursing assistant also wrote the blood pressure reading on a piece of paper and placed the paper LPN 4's medication cart. LPN 4 was then observed to prepare and administer [MEDICATION NAME] 5 milligrams mg to resident 9. A review of MEDICATION ORDERS FOR [REDACTED]. Included with the order were the following instructions: "Hold and notify MD (Medical Doctor) (with) systolic (blood pressure) less than 90 or diastolic (blood pressure) less than 60." An interview was held with LPN 4 on 4/30/09 at 9:50 AM. The surveyor asked LPN 4 if resident 9's [MEDICATION NAME] should have been held due to the resident's diastolic blood pressure reading of 56. LPN 4 responded, "Was that too low?" The surveyor reviewed the physicians order with LPN 4 and explained that the physicians order stated that the medication should have been held since resident 9's diastolic blood pressure was below 60 (56). LPN 4 stated, "Oh, my bad."