Every finding on record at St Vincent's - A Prospera Community

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 5 of 13 residents (Resident #5, #6, #11, #77, and #80) observed during medication administration. Six medication errors occurred during staff administration of 49 medications which resulted in a 12 percent error rate. Failure to follow and/or clarify physician's orders and pharmacy recommendations may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health. Findings include:Review of the facility policy titled Medication: Administration Including Scheduling and Medication Aides occurred on 06/04/26. This policy, dated 03/30/26, stated, . PROCEDURE . Follow the 'Six Rights': Right medication, right dose . right route . Perform three checks: Read the label on the medication container and compare with the MAR [medication administration record] when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication .Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Carrying Out a Physician's Order. Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. Clarification from any other source is unacceptable and regarded as a departure from competent nursing practice.Prescribing information found at https://www.drugs.com/mtm/orphenadrine.html, reviewed 07/30/25, stated, . Orphenadrine is a muscle relaxer. Do not crush, chew, or break an extended-release [ER] tablet. Swallow it whole. Prescribing information found at https://www.drugs.com/pro/klor-con-m.html, reviewed 11/20/25, stated, . Klor-Con M20 (potassium chloride extended-release tablets) is an immediately dispersing extended-release oral dosage form . To take each dose without crushing, chewing or sucking the tablets . Prepare an aqueous (water) suspension . Place the whole tablet(s) in approximately 1/2 glass of water (4 fluid ounces). Allow approximately 2 minutes for the tablet(s) to disintegrate.Prescribing information found at https://www.drugs.com/dosage/voltaren-gel.html, reviewed 08/22/25, stated, . The proper amount of VOLTAREN GEL should be measured using the dosing card supplied in the drug product carton. The dosing card should be used for each application of drug product. The gel should be applied within the rectangular area of the dosing card up to the 2 gram [gm] or 4 gram line .- Review of Resident #5's medical record occurred on 06/03/26. Physician's orders included Voltaren gel (a topical pain medication) two grams to the shoulders and knees four times a day. Observation on 06/03/26 at 9:45 a.m. showed a medication aid (MA) (#7) dispensed an undetermined amount of the gel into a medication cup, entered the resident's room, and applied small amounts of the gel to the resident's left and right wrists, elbows, and shoulder joint areas.- Review of Resident #6's medical record occurred on 06/03/26. Physician's orders included Orphenadrine Citrate ER (an extended-release muscle relaxant) by mouth two times a day and Klor-Con ER (potassium) by mouth once a day. Orphenadrine and Klor-Con are non-crushable medications. Observation on 06/04/26 at 8:27 a.m. showed a nurse (#3) prepared Resident #6's medications, crushed the Orphenadrine and the Klor-Con, placed the medications in water, and administered the medications through the resident's peg tube.- Review of Resident #11's medical record occurred on 06/01/26. Physician's orders identified NovoLOG (a rapid-acting insulin) 12 units subcutaneously (under the skin) three times a day.Observation on 06/01/26 at 11:34 a.m. showed a nurse (#3) administered 12 units of Humalog (a rapid acting) insulin and failed to administer the physician's ordered NovoLog insulin.During an interview on 06/02/26 at 9:59 a.m., a nurse (#5) confirmed Resident #11's physician ordered NovoLog insulin. - Review of Resident #77's medical record occurred on 06/03/26. A physician's order, dated 10/11/25, identified Lidocaine External Patch (a topical pain patch) to the low back once a day. The treatment administration record (TAR) identified to apply the patch in the morning and remove in the evening. Observation on 06/03/26 at 9:16 a.m. showed a lidocaine patch on Resident #77's right lower back. The MA (#6), present during the observation, stated, They [nursing] forgot to take it off last night. The facility staff failed to remove Resident #77's lidocaine patch as ordered.- Review of Resident #80's medical record occurred on 06/03/26. A physician's order, dated 01/13/26, stated, Cranberry Oral Tablet 450 MG [milligrams] . Give 500 mg by mouth two times a day . Observation on 06/03/26 at 9:07 a.m. showed a MA (#6) removed an over-the-counter box (stock medication) of cranberry with vitamin C from the medication cart. The MA showed the surveyor the back of the box, explained a serving size as two caplets, or 500 mg, of cranberry, and administered two caplets to the resident. The facility staff failed to clarify Resident #80's order for the cranberry tablets and ensure the current stock medication formulary accommodated the order.During an interview on 06/03/26 at 2:45 p.m., an administrative staff member (#1) stated she expected staff to follow the six rights of medication administration, follow specific instructions for correct dosing, and clarify any ambiguous orders.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to provide care in accordance with professional standards for 1 of 1 sampled resident (Resident #6) with a peg tube (tube inserted in the stomach) and a peripherally inserted central catheter (PICC) (long term intravenous (IV) line). Failure to verify placement and patency of a peg tube prior to use, administer medications in prescribed forms and in individual doses, follow and/or clarify physician's orders, and document medications/treatments as completed on the correct date may result in adverse consequences to the resident. Findings include:Review of the facility policy titled Medication: Tube Administration occurred on 06/04/26. This policy, dated 03/02/26, stated, . The tube should be checked for placement and patency prior to administering medication . inject 5-10 ml [milliliters] of air through the tube to clear the tube. Then aspirate gastric contents to be sure the tube is in the stomach. Prepare medication as appropriate . It tablets can be crushed, crush finely, and mix with water . Administer each medication separately, Flush with 5 ml of water after each individual medication is given.Review of the facility policy titled Medication: Administration Including Scheduling and Medication Aides occurred on 06/04/26. This policy, dated 03/30/26, stated, . Follow the 'Six Rights' . right time, and right documentation .Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Carrying Out a Physician's Order. Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. Page 836, stated, . Document medication administration after giving it . The record [medication or treatment administration record (MAR/TAR)] should also include the exact time of administration . Review of Resident #6's medical record occurred on all days of survey. The record identified a peg tube and a PICC line to the resident's right upper chest. Physician's orders included the following:* Meds [medications] via peg tube .* . medication administration: Flush with 30 cc [cubic centimeters - one cc equals on milliliter) of water, 5 cc between medication and 30 cc after all medication .* . PICC line transparent dressing . change every week and PRN [as needed] change the clave [needle free IV port] to the PICC line when changing the dressing . every Wed [Wednesday] .* Change IV solution bag and all tubing every 96 hours which is 5 days . (96 hours equals four, not five days).- Observation on 06/04/26 at 8:27 a.m. showed a nurse (#3) prepared Resident #6's medications. The nurse (#3) dispensed 10 medications approved to be crushed and one medication prescribed as do not crush, placed them into a plastic sleeve, crushed them all at the same time, and emptied the contents into a medication cup. The nurse then dispensed two extended-release potassium tablets, prescribed as do not crush, placed them into a plastic sleeve, crushed them, and emptied the contents into a second medication cup. The nurse opened a package of banana flakes, emptied the contents into a water cup, and measured a dose of liquid iron into another medication cup. At 8:33 a.m., the nurse (#3) entered Resident #6's room, mixed the banana flakes with water and the crushed potassium with water. The nurse attached the outer peg tube and failed to check for tube placement or patency. When the nurse administered the banana flakes mixed with water, the peg tube clogged. The nurse removed the outer peg tube, removed the flakes from the tube with a syringe, placed the contents into a cup, and rinsed the tube in the bathroom sink. The nurse reattached the tube, added more water to the flakes removed from the tube, and readministered them. Without flushing the peg tube with water, the nurse administered the crushed potassium with water. Observation showed visible undissolved particles and the tube clogged again. The nurse removed the outer part of the peg tube, used the syringe to remove the potassium solution, placed the contents into the cup, and rinsed the tube in the bathroom sink. The nurse reattached the tube, added more water to the potassium mixture removed from the tube, and readministered the medication.The nurse (#3) failed to verify placement and patency of the peg tube prior to use, failed to administer the medications in the prescribed forms and in individual doses, and failed to use an appropriate amount of liquid to minimize clogging on the peg tube which resulted in unnecessary manipulation of the peg tube. - Observation on 06/04/26 at 9:40 a.m. showed the nurse (#3) accessed Resident #6's PICC line, programmed an IV pump, and the pump began to run fluid from an IV-solution bag (sodium chloride) present on the IV pole. The date on the solution bag showed 05/30/26 (five days prior). The date on the transparent dressing covering the PICC line site showed 05/23/26 (13 days prior). Observation on the afternoon of 06/04/26 showed facility staff changed and dated the PICC line dressing. Resident #6's TAR showed dressing changes completed and documented on 05/27/26 and 06/03/26. These dates failed to match the dates observed on the dressing. Facility staff failed to clarify the physician's orders related to how often to change the IV solution bag, failed to change the PICC line dressing and clave as ordered, and failed to document the dressing changes as completed on the correct date. During interviews on 06/03/26 at 2:45 p.m. and 06/04/26 at 3:30 p.m., an administrative staff member (#1) stated she expected staff to ensure placement and patency of a peg tube prior to medication administration, administer medications individually, in their prescribed form, and in a manner to avoid complications of clogging the tube, administer treatments/medications as ordered, accurately document in the MAR/TAR when medications and treatments are completed, and clarify ambiguous orders.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's medication regimen remained free of unnecessary medications for 1 of 3 sampled residents (Resident #3) reviewed for antipsychotic medications. Failure to complete a baseline assessment before starting an antipsychotic may result in undetected side effects and adverse consequences related to the antipsychotic medication. Findings include:Review of the facility policy titled Psychotropic Medications occurred on 06/04/26. This policy, dated 12/09/25, stated, . If the physician prescribes an antipsychotic for the resident, a registered nurse must complete . the Abnormal Involuntary Movement Scale [AIMS] .- Review of Resident #3's medical record occurred on all days of survey. Physician's orders included Seroquel (an antipsychotic) initiated on 03/18/26. The record lacked a baseline assessment or AIMS assessment. During an interview on 06/06/26 at 5:00 p.m., an administrative staff member (#1) confirmed the facility failed to complete a baseline assessment or AIMS assessment for Resident #3 upon initiation of the Seroquel.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #6) observed with a peripherally inserted central catheter (PICC) (long term intravenous (IV) line) during cares. Failure to practice infection control standards related to hand hygiene, glove use, and accessing PICC lines may result in adverse consequences to the resident and has the potential to spread infection throughout the facility. Findings include:Information found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, dated 02/27/24, stated, . Know when to clean your hands. Before performing an aseptic task such as . handling invasive medical devices. After touching a patient or patient's surroundings. After contact with . contaminated surfaces . Know when to wear (and change) gloves. Gloves are not a substitute for hand hygiene. Always clean your hands after removing gloves. When to change gloves and clean hands . If moving from work on a soiled body site to a clean body site on the same patient . have . body fluids on them after completing a task. Before exiting a patient room.Review of the Centers of Disease Control (CDC) guidance at https://www.cdc.gov/infection-control/hcp/intravascular-catheter-related-infections/summary-recommendations.html, reviewed 02/28/24, stated, . 19. Needleless Intravascular Catheter Systems . Minimize contamination risk by scrubbing the access port with an appropriate antiseptic .Review of Resident #6's medical record occurred on all days of survey. The record identified a peg tube (a tube inserted into the stomach) and a PICC (peripherally inserted central catheter) line. The care plan identified enhanced barrier precautions (EBP) related to a multidrug-resistant organism (MDRO), a PICC line, and a peg tube and instructed staff to wear a gown and gloves when performing high contact care activities. Observations on 06/04/26 of Resident #6 showed the following:* 8:33 a.m. through 9:10 a.m., two unidentified maintenance staff entered and exited the resident's room on four different occasions to work on a malfunctioning call light. The maintenance staff touched three different call lights throughout the room multiple times and failed to sanitize their hands when exiting the room on all four occasions.* 9:40 a.m., a nurse (#3) assisted the CNA (#4) with a brief change. The nurse failed to remove the soiled gloves, perform hand hygiene, and apply clean gloves prior to attaching a syringe to the resident's PICC line port and failed to sanitize the PICC line port prior to accessing the port with the syringe. During an interview on 06/04/26 at 3:20 p.m., an administrative staff member (#1) stated she expected staff to practice appropriate infection control when working with Resident #6 and all other residents.

1. Based on record review, review of facility policy, and resident, family, and staff interviews, the facility failed to ensure residents remained free from physical and mental abuse for 1 of 1 confidential resident (Resident A) with allegations of abuse. Failure to provide services necessary to avoid mental/emotional distress and physical harm resulted in fear and an unsafe environment for Resident A and has the potential for all residents to experience psychosocial harm. Findings include: Review of the facility policy titled Abuse and Neglect occurred on 04/03/25. This policy, revised 07/22/24, stated, . The resident has the right to be free from abuse . Residents must not be subjected to abuse by anyone, including, but not limited to . employees . Review of Resident A's medical record occurred on all days of the survey. Diagnoses included vertigo and hemiplegia/hemiparesis of the left side. The annual Minimum Data Set (MDS), dated [DATE], identified intact cognition and substantial assistance required for activities of daily living. The current care plan identified assist of one with sit-to-stand lift for transfers when the resident had complaints of vertigo. During confidential interviews on 03/31/25 through 04/02/25, Resident A and a family member #1 reported the following: * Some staff are rough during cares and identified certified nurse aides (CNAs) (#7 and #8). * If Resident A expressed concern regarding roughness, the CNAs would be rougher the next time. * Resident A's hands would hit the side rail and door frames when turned and transferred by staff. * Staff pulled the resident to a sitting position by the back of Resident A's neck. * Resident A expressed fear and retaliation from a CNA (#8). * Resident A expressed emotional/mental distress regarding being a burden to the facility's staff. Observations on all days of survey showed a bruise to Resident A's left hand. The resident indicated the bruise occurred while staff transferred him/her about a week ago. Review of the medical record lacked documentation of the bruise. During an interview on 04/03/25 at 12:24 p.m., an administrative nurse (#2) confirmed she was aware of Resident A's abuse allegation but unaware of any bruises. Refer to 609 and 610 27221 2. Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #243) who had explosive outbursts and/or inappropriate behaviors towards other residents. Failure to assess, care plan, and operationalize an effective plan of care resulted in an unsafe environment and anxiety/fear for residents residing on the same unit as Resident #243. Findings include: Review of the facility policy titled Abuse and Neglect occurred on 04/03/25. This policy, revised 07/22/24, stated, . The resident has the right to be free from abuse . Residents must not be subjected to abuse by anyone, including, but not limited to . other residents . Alleged or suspected violations involving any mistreatment . or abuse . will be reported immediately to the administrator. Review of Resident #243's medical record occurred on all days of survey. Diagnoses included anxiety, cerebral infarction (stroke), dementia, and mental disorder requiring continuous supervision. The physician's orders, dated 03/26/25, showed the resident received Carbamazepine for aggressive behaviors and Hydroxyzine HCI and Olanzapine for anxiety and/or depression. The progress notes identified the following: * 01/10/25 at 1:19 a.m., Resident is moody, sarcastic, irritable, verbal aggression towards others with much swearing. Resident has explosive temper. * 01/11/25 at 9:55 p.m., Resident . Brought to commons area and he became angry . yelling obscenities . He was very inappropriate to the point of being abusive, and this took place in front of other residents. * 01/25/25 at 8:31, p.m., . Later on in dayroom, [Resident #243] urinated in emesis bag, and was yelling loudly . He was swearing, and urine noted to be on floor and table. * 01/28/25 at 9:27 a.m., Resident was in the family room spitting on the walls and floor. * 01/29/25 at 11:30 a.m., [Resident #243] was sitting at the nurse's station with several residents sitting around him. He . talked for several minutes on his cell phone continually using foul language in a loud voice. When he was done on phone this author informed him that if he is going to use that kind of language, he needed to go back to his room so the other people didn't have to hear it. He stated 'that they can't hear or see so what difference does it make.' * 01/29/25 at 3:40 p.m., resident spent most of the shift, yelling and swearing . Staff was putting other residents down that were sitting at the table he was at. * 01/30/25 at 9:00 p.m., [Staff] called [NAME] ER [emergency room ] to talk to Dr [doctor] about resident [sic] aggressive behavior towards . other residents. Explained that resident . has made comments that [sic] with residents around that they are all here to die, they just drool and stare he was told to not say those things and resident will keep saying them. Facility expressed to hospital ER that the resident was a risk to himself and others . Resident [sic] are nervous around him. Expressed our concern for safety of others due to resident behavior and that he poses a threat. * 01/31/25 at 9:00 a.m., Resident sitting at nurses station eating breakfast another male resident sitting at the nurses station. The other male resident stated 'to [Resident #243] why are you giving the nurses around here a hard time.' [Resident #243] stated 'what the hell do you know about it.' The other male resident stated 'you need to show some respect were you raised that way to show no respect.' [Resident #243] stated to other male resident 'I am going to kick your [blaspheme] you mother [blaspheme].' The other male resident stated 'I'm going to bust your [blaspheme] face up.' Nurse instructed caregiver to remove other male resident from the table. * 01/31/25 at 9:18 p.m., . Resident . Urinating in dayroom in urinal and leaving on table. Reported by staff from day shift that he was swearing directly to other residents. * 02/03/25 at 1:40 a.m., . Resident . Requests to sit at table in commons area with other residents and as he does will frequently urinate into an emesis bag and lay the bag on the table. He becomes angry at staff when the bag is removed, he continues to do this while sitting at the table and urinates in front of other residents . and family members that pass through the commons area. * 02/10/25 at 10:00 a.m., . Notified hospital that due [to] safety of residents . we were not going to be able to take [Resident #243] back to [facility] and that we were going to be discharging him effective today. Explained that we are just not able to meet his needs due to his aggression and behaviors . * 02/10/25 at 12:43 p.m., Notified Son that facility was going to be discharging resident due to safety concerns for other residents . and we are not able to meet his needs. Explained to [daughter] why the facility was discharging resident due to not being able to meet his needs, due to safety concerns from residents . * 02/10/25 at 1:51 p.m., Hospital called [facility] to discuss [Resident #243's] return. [Staff] talked with the hospital social worker about [Resident #243] and his behaviors . Facility is unable to meet [Resident #243's] needs, posing safety concerns to residents . * 03/24/25 at 9:21 a.m., Touched based with daughter to see how residents weekend was and if there was anything new the facility would need to know. Resident was started on a new anxiety medication and seemed to have a good weekend. Stated our plans was to still admit resident Wednesday morning at 10:30 am. * 03/27/25 at 12:59 p.m., . from 10pm to 12:40am [Resident #243] rang his call light 14 times, asked resident what could we do to help him make his transition back, resident stated that he will call when he needs staff. I did explain that we are going to have to talk more if it starts affecting other resident . We did also talk about appropriate place to urinate, explained that we can not urinate in emesis bags that is not what they are used for and it is an infection control concern. * 03/30/25 at 3:25 p.m., . [Resident #243] . is manipulating staff's time and screams and yells when he doesn't get immediate assistance. He was noted to roam the hallways and knocks and yells on other residents doors, opening them to look for staff to help him . He opened another residents door as staff was assisting this resident with putting her bra on. It was also reported several times from other residents and family members about his inappropriate language, complaints regarding food served and his appearance in the main dinning room. There has been requests to file formal complaints on this matter. It has been verbalized by other residents . of being fearful of this resident due to his explosive outbursts and behaviors. Staff have also been receiving complaints of behaviors in the commons area of urinating in emesis bags in front of other resident or family members . passing through. Educated resident about this behavior/habit but he continues with this behavior. Resident #243's current care plan stated, . [Resident #243] has a hx [history] of behavioral symptoms such as yelling and swearing at staff. At times he can be vulgar with his choice of words and say racist comments to the staff, and refused cares. Provide a calm, quite atmosphere . Re-direct resident to not swear . The care plan failed to address Resident #243's explosive outbursts and/or inappropriate behaviors towards other residents. During an interview on 04/03/25 at 12:20 p.m., when asked questions regarding the incident that occurred on 01/31/25, an administrative staff member (#1) stated, I didn't know about this. I will be submitting a report today and doing an investigation. The facility failed to assess and monitor Resident #243's patterns of behavior in an effort to protect other residents from abuse and minimize his aggressive and/or inappropriate behaviors towards other residents. The facility failed to ensure Resident #243 did not infringe upon the rights of other residents to be free from verbal abuse.

Based on observation, record review, and review of the North Dakota Resident's Rights Guide, the facility failed to ensure residents remained free of chemical restraints for 1 of 1 sampled resident (Resident #37) with an as needed (PRN) psychotropic medication. Failure to assess resident behaviors in an effort to determine causative/precipitating factors, develop a behavioral care plan, and implement individualized interventions in an attempt to manage behaviors resulted in the frequent utilization of psychotropic medications to control Resident #37's behavior. Findings include: Review of the North Dakota Long Term Care Ombudsman Program Resident's Rights Guide, dated 03/21/23, pages 12-13 stated, . Chemical . Restraints may not be used for the convenience of the staff or for disciplinary reasons . Chemical Restraints means a 'psychopharmacological drug that is used for discipline or convenience' . Review of Resident #37's medical record occurred on all days of survey. Diagnoses included vascular dementia, anxiety disorder, Alzheimer's Disease, restlessness and agitation. Physician's orders identified the following: * 12/17/24 Ativan (an antianxiety medication) 0.5 milligrams (mg) every six hours PRN for restlessness, agitation, and anxiety. * 01/14/25 Ativan 0.5 mg at 4:00 p.m. and continue 0.5 mg every six hours PRN for agitation, restlessness and anxiety. * 03/04/25 Change order to ativan 0.5 mg twice a day at 4:00 p.m. and bedtime. Continue PRN 0.5 mg every six hours as needed for agitation, restlessness and anxiety. Observations of Resident #37 showed the following: * 03/31/25 at 12:55 p.m. asleep in the recliner, curled up in a ball. A certified nurse aide (CNA) (#15) shook the resident's right shoulder and stated the resident's name several times. The resident did not respond and her eyes remained closed. Two CNAs (#14 and #15) utilized the sit to stand lift (mechanical lift) to transfer the resident from the recliner to the wheelchair and to the bathroom. The CNAs physically placed the resident's hands on the assist bars of the sit to stand lift. The resident's eyes remained closed with no response during toileting. * 04/01/25 at 11:35 a.m. asleep in the wheelchair with head resting on chest. * 04/02/25 at 10:20 a.m. asleep in the recliner and leaning to the left side. A CNA (#16) shook the resident's right shoulder and stated the resident's name several times. The resident did not respond and her eyes remained closed. Another CNA (#15) stated, We'll need to use the pal lift [sit to stand lift]. Resident #37's current care plan stated, . has impaired cognitive function or impaired thought processes R/T [related to] Alzheimer's Disease . AMBULATION/LOCOMOTION/TRANSFERS: [Resident's name] is able to walk with Ax1 [assist of one staff] gait belt and FWW [front wheeled walker] on the unit. Ativan for anxiety . has a mood problem r/t major depressive disorder and anxiety . (depression and anxiety): Attempt non-pharmacological interventions: loves visiting with the staff and enjoys listening to the TV. The care plan failed to address and specify Resident #37's behaviors and types of non-pharmacological interventions. An admission Minimum Data Set (MDS), dated [DATE] and a quarterly MDS, dated [DATE], showed Resident #37 did not exhibit wandering, rejection of care, verbal, physical and/or other behaviors. Review of Resident #37's electronic medication administration record (EMAR) from December 18th, 2024, through February 28, 2025, (approximately 73 days), identified staff administered PRN Ativan 50 times. The nursing progress notes indicated the facility staff administered PRN Ativan due to the resident's restlessness, agitation, rudeness to staff, refusing cares, aggression to the staff, and wanting to leave the facility. The medical record included the following progress notes: * 01/14/25 at 11:02 a.m., . Seen by psych, [psychiatry] resident improved. * 01/19/25 at 3:09 p.m., . Mood and behavior team met for month of December [2024] she comments about going home and becomes restless at times . * 01/30/25 at 2:10 p.m., . Mood and behavior team met for the month of January [2025] her behaviors have been much. [sic] No new concerns for mood or behavior were noted at this time. * 02/26/25 at 4:43 p.m., . Mood and behavior team met for the month of February [2025]. There are no concerns with mood or behavior wise noted for the month. * 03/13/25 at 2:34 p.m., . Behavior team met for month of March [2025]. Resident less anxious and wanting to sleep more. A physician's progress note dated, 03/04/25, stated, . Review of MAR does indicate PRN ativan is used often. Will schedule a bedtime dose in addition to afternoon dose and continue PRN. has PRN Ativan 0.5 mg [milligrams] every 6 hours as needed. MAR indicates that in the last month, she did use ativan 10x [times] with needing it twice on two of those days. Overall improved and not so problematic . Failure to assess and implement behavioral and non-pharmacological interventions before utilization of PRN Ativan may have contributed to the resident's increased sleeping, and decreased responsiveness to staff.

Based on observation, review of facility policy, test tray, and resident interviews, the facility failed to serve foods at palatable temperatures in 3 of 3 units ([NAME] Place, Sacred Heart Place, and [NAME] Place). Failure to serve food at a temperature that is acceptable and palatable to residents' places residents at risk of decreased intake, weight loss, and nutritional decline. Findings include: Review of the facility policy titled Dining Service Standards occurred on 04/03/25. This policy, dated 06/13/24, stated, . Definitions: Food Distribution - the process of getting food to the resident. This may include holding hot foods in a steam table or cold foods under refrigeration for temperature control, dispensing food portions for individual residents, and dining services including service to resident room. Meals assembled in the kitchen and delivered to residents' rooms or dining area must be covered individually or in a mobile food cart. PURPOSE: To provide an overview of desired expectations for a pleasant and positive dining experience . POLICY: . Residents will be provided meals that are nourishing, attractive, and palatable and are served at . appetizing temperature. Review of the facility policy titled Food Temperature Monitoring - Food and Nutrition Services occurred on 04/03/25. This policy, dated 12/16/24, stated, . Definitions: . Proper serving temperature - A temperature that is appetizing to the resident . this is the temperature when the food reaches the resident. Procedure: . Test tray monitoring occurs as a part of quality assurance monitoring to ensure temperatures are acceptable when the location uses room trays or satellite dining rooms. Temperatures for test trays are based on proper serving temperature, not tray line holding temperatures based on food safety. Test tray is checked after all residents have been served. Sacred Heart Place and Emmanual Place Resident Interviews and Observations: - Observation on 03/31/25 at 11:40 a.m. showed Resident #393 in his room eating lunch. The resident stated, The food is always cold. - During an interview on 03/31/25 at 11:58 a.m., Resident #44 stated the hot food is not always hot, she always eats in her room, and the toast is always cold because they make it ahead of time. -During an interview on 03/31/25 at 12:17 p.m., Resident #33 stated he always eats in his room for the evening meal and the food is not hot. - During an interview on 03/31/25 at 12:25 p.m., Resident #40 stated most of the time the food is cold, as I get my tray late. - Observation on 04/01/25 at 8:40 a.m., showed Resident #38 laying in bed with his breakfast tray at the bedside. The resident stated, I'm waiting to eat. She [the CNA assisting him] went to go make me some toast that is warm. - During an interview on 04/01/25 at 10:14 a.m., Resident #8 stated, Dining room food is cold when served. - Observation on 04/01/25 at 11:20 a.m. showed Resident #393 assisted to the dining room by a CNA. The resident stated, I'm going to the dining room because when I get my food in my room it is ice cold. - During an interview on 04/01/25, at 11:58, Resident #44 stated, the food is not hot - During an interview on 04/01/25 at 12:05 p.m., Resident #11 stated she ate in the dining room today and the temperature of the food was hot, but when she eats in her room by the time it gets to me it is cool. [NAME] Place Test Tray: Upon request, the kitchen staff sent a meal test tray in a cart to [NAME] Place. The cart arrived at 11:52 a.m. A staff member took the last tray out of the cart at 12:15 p.m. and delivered it to a resident. The surveyor took the test tray out at the same time, brought it to the conference room, and checked the temperatures of each food item. Temperatures were as follows: Chicken 104.8 degrees Fahrenheit (F), Zucchini 98 degrees F, Pasta 94 degrees F. The surveyors tasted the meal, and all confirmed the food was lukewarm, not hot. 51999 52000

Based on observation, review of professional reference, and staff interview, the facility failed to maintain cold storage areas and kitchen equipment in a sanitary manner for 1 of 1 kitchen. Failure to clean fans, ceilings, walls in areas where food is stored and failure to ensure a cleanable surface for kitchen equipment has the potential for contamination of food and may result in a foodborne illness. Findings Include: The 2022 Food and Drug Administration (FDA) Food Code, Chapter 3 Food, Section 3-305 Preventing Contamination From the Premises, Section 3-305.11 states, A. Food shall be protected from contamination by storing the food: . 2) Where it is not exposed to . dust, or other contamination. The 2022 Food and Drug Administration (FDA) Food Code, Annex 3, Chapter 4 Equipment, . Section 4-101.11 Characteristics . equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens . Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. The initial observation of the kitchen occurred on 03/31/25 at 11:40 a.m.m The final observation of the kitchen occurred on 04/03/25 at 12:00 p.m. with an administrative dietary staff member (#9). Observation on both days showed the following: * Walk in Cooler - accumulation of thick, dark black dust/dirt on the fan and accumulation of dust on the ceiling/wall around two separate condenser fans. * Walk in Freezer - accumulation of dark black dust/dirt on the fan and accumulation of dust on the wall/ceiling around the condenser fan. * Oven - handles of one reach-in oven covered with peeling/tattered duct tape, making it a non-cleanable surface. During an interview on 04/03/25 at 1:00 p.m., the administrative dietary staff member (#9) confirmed the presence of peeling/tattered duct tape on the oven doors and confirmed he expected staff to clean the black dust/dirt from the fans, walls, and ceilings in the walk-in cooler and freezer.

Based on review of the State Agency (SA) facility files, survey findings, review of facility policy, and staff interview, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems and opportunities to improve services/outcomes, decrease or prevent likelihood of problems or occurrence of adverse events, and ensure compliance with federal requirements. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement - QAPI occurred on 04/03/25. This policy, revised on 10/09/23, stated, . The QAPI program uses data to monitor the effectiveness and safety of services and quality of care; identify and prioritize problems and process improvement opportunities and takes action to address areas in need of improvement. Performance Improvement project activity will be monitored for progress and sustainability by the location. Review of the state agency files indicated the facility failed to maintain compliance at F657, F725, F761, F804, F812, and F880 as indicated by deficiencies cited during the last standard survey on 02/29/24. Refer to the F657, F725, F761, F804, F812, and F880 for specific findings. During an interview on 04/03/25 at 12:00 p.m., two administrative staff members (#18 and #19) indicated they developed a plan of correction, conducted audits throughout the year, and monitored performance. They also completed spot audits to ensure improvements were maintained. Failure of the facility to effectively utilize QA resulted in continued noncompliance in the following areas: * F657 Care Plan Revisions * F725 Sufficient Nursing Staff * F761 Label and Store Medications * F804 Palatable Foods * F812 Store, Prepare, and Serve Food in Sanitary Manor * F880 Infection Control

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 5 of 23 sampled residents (Residents #37, #76, #243, and #443). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plan occurred on 04/03/25. This policy, dated 12/02/24, stated, . POLICY: Residents will receive and be provided with the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. Each resident will have an individualized, person-centered, comprehensive plan of care . The plan of care will be modified to reflect the care currently required/provided for the resident. - Review of Resident #37's medical record occurred on all days of survey. Diagnoses included dementia and anxiety. A physician's order, dated 12/17/24, stated ativan (an antianxiety medication) 0.5 milligrams (mg) every six hours PRN for restlessness, agitation, and anxiety. Resident #37's current care plan stated, . has impaired cognitive function or impaired thought processes R/T [related to] . Alzheimer's Disease . document/report to health care provider any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. DEMENTIA / IMPAIRED THOUGHTS: Attempt non-pharmacological interventions: Reduce any distractions- turn off TV [television], radio, close door etc. [ec cetera] . Ativan for anxiety . has a mood problem r/t . major depressive disorder and anxiety . (depression and anxiety): Attempt nonpharmacological interventions: loves visiting with staff and enjoys listening to TV. Review of Resident #37's electronic medication administration record (EMAR) from December 18th, 2024, through February 28, 2025, (approximately 73 days), identified staff administered PRN Ativan 50 times. The nursing progress notes indicated the facility staff administered PRN Ativan due to the resident's restlessness, agitation, rudeness to staff, refusing cares, aggression to the staff, and wanting to leave the facility. Resident #37's care plan failed to address and specify the resident's behaviors and types of non-pharmacological interventions. - Review of Resident #76's medical record occurred on all days of survey. The record identified a lesion/boil to the resident's inner thigh on 03/16/25 and to the back of the head on 03/19/25. The provider ordered Bacitracin (topical antibioitic) and a warm compress to the area on 03/16/15 and Doxycycline (an antibiotic medication) on 03/19/25. Resident #76's care plan failed to address the skin issues and antibiotic use. - Review of Resident #243's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, anxiety, dementia, depression, and mental disorder. Staff indicated the resident posed a serious threat to other residents and described him as having an explosive temper and indicated he put other residents down, yelled obscenities at/in front of other residents, threatened other residents, roamed the halls knocking on/opening the doors to other residents' rooms while looking for staff, spit on the walls and floor in the family room, and urinated in emesis bags in front of other residents/their family members in the commons area. Resident #243's care plan failed to address his behaviors towards other residents residing in the facility. Resident 243's medical record also showed a diagnosis of diabetes mellitus. The current physician's orders included 100 units/milliliter Insulin Lispro Injection Solution per sliding scale four times a day for diabetes. Resident #243's care plan failed to address symptoms of diabetes and/or the possible complications that may occur. - Review of Resident #443's medical record occurred on all days of survey. Diagnoses included quadriplegia and an abdominal wound. A quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #443 is at risk for developing pressure ulcers. Resident #443's care plan lacked a problem, goal, and interventions related to the resident's abdominal wound and high risk for developing pressure ulcers. 40489 27221

Based on observation, record review, review of facility policy, review of facility assessment, review of resident council meeting minutes, review of call light logs, review of staffing schedule, confidential resident and family interviews, and staff interviews, the facility failed to ensure sufficient nursing staff and related services are available at all times to meet the residents' needs for 2 of 23 sampled residents (Resident #243 and #293) and 11 confidential residents (Resident A, B, C, D, E, F, G, H, I, J, and K) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for the residents. Findings include: Review of the facility assessment occurred on 04/03/25. The assessment stated, . [Facility] utilizes an interdisciplinary approach to meet the needs of our population and its individuals across all shift [sic] including nights and weekends . As the needs of the population change as indicated by the number of residents served, acuity levels, MDS [Minimum Data Set] results and care plans the staffing pattern is adjusted to meet those needs. We consider variability in care needs across day, evening, and night shifts, including weekends and holidays, and adjust as necessary. We confirm needs are met by engaging in frequent communication with residents, their families and representatives with regular care conferences, rounding, quality assurance audits, resident group meetings, availability of suggestion/concern forms and email surveys. Review of the facility policy titled Call Light occurred on 04/02/25. This policy, revised 07/29/24, stated, When resident's call light is observed/heard, go to the resident's room promptly. Review of the resident council meeting minutes, dated November 2024-February 2025, identified the following resident concerns: * Call light was on for long periods of time. * Call light was on for 30 minutes to a hour. The Resident Council met on 03/31/25 at 1:20 p.m. The residents voiced the following concerns during the meeting: * Resident F stated he/she has waited 30 minutes for his/her call light to be answered. He/she also reported activities are often delayed and/or cut short due to a lack of staff. * Resident G stated he/she has waited 30 minutes for his/her call light to be answered, especially at 8:00 a.m., 2:00 p.m., or 10:00 p.m. * Resident H stated he/she has waited over 30 minutes for his/her call light to be answered, and has experienced pain/discomfort waiting to go to the bathroom. He/she also reported the activities department was short staffed. Confidential resident and family interviews identified the following: * 03/31/25 Resident A stated, call lights were not answered around shift change, certified nurse aides (CNAs) seem rushed, and he/she has been left in the bathroom for long periods of time. * 03/31/25 Resident B stated, staff are so busy and rushed in the evening and after 10:00 p.m., they don't always check on me during the night. * 03/31/25 Resident C stated, he/she has waited 30-40 minutes at times for the call light to be answered. Stated, it is worse around 3:00 p.m. Sometimes they forget about me, they forget my breakfast and lunch and then they bring it to me late. Resident C stated one time they forgot to give me the call light (Resident not able to access call light on his/her own) and I was without it from 10:00 p.m. until 3:00 a.m. and then I started yelling and they came. Resident C stated there have been a few other times staff have forgotten to place the call light and he/she has just had to wait for a staff member to come. The resident stated he/she has tried calling the nurses' station, but not able to get through. * 03/31/25 Resident D stated, staff are so busy in the evening, I have to wait about 1/2 hour for my call light to be answered. * 03/31/25 Resident E stated, one time they came in and turned off the call light and said someone would be right in, but then they didn't come back for an hour. * 03/31/25 Resident J stated, I had to wait one hour for help to the bathroom. I can't hold it that long. Review of the call light log confirmed a wait time of 59 minutes on 03/30/25. * 03/31/25 Resident K stated, The aide [CNA] told me to press the light when I was done on the toilet. I kept calling and calling and she never came back. * 03/31/25 Family Member #1 stated when she called on the phone, she could not get ahold of the nurse's station, the call light was not always placed in reach of the resident, oral cares were not completed, and the resident was not dressed/toileted timely for appointments. * 03/31/25 Family Member #2 stated the facility is short of staff on weekends and evenings and there is not enough staff to assist residents who need help with eating * 04/01/25 When asked about staff's response time after the call light is activated, Resident I stated, I have to wait 30 to 45 minutes, and staff are rushed and short, not enough help. Review of the call light logs from 03/26/25 to 04/01/25 showed the following: * Resident C waited 22 minutes or greater on 14 occasions, with the longest time being 51 minutes. * Resident D waited 20 minutes or greater on ten occasions, with the longest time being 33 minutes. - Review of Resident #243's medical record occurred on all days of survey. The progress notes identified the following: * 01/26/25 at 3:21 p.m., resident was yelling, swearing at staff in the AM, upset about PM shift the previous night. Upset about having to wait for his call light to be answered at bedtime. * 02/01/25 at 5:46 a.m., Resident slept till 0330 [3:30] am he stated he put on his light and was waiting to long for the cna. Nurse was notified by cna that resident called the police to help him, police had asked if resident was safe and the cna stated he is sitting in his wheelchair at the nurses table. Police officers left facility at that time . - Review of Resident #293's medical record occurred on all days of survey. The care plan stated, . TOILET USE: Resident requires check and change. Resident can be unaware of when he is wet/soiled. BRIEF USE: Resident uses incontinence products for heavy incontinence. Check every 2-3 hours and prn [as needed]. Observations of Resident #293 on 03/31/25 showed the following: * At 2:12 p.m., seated in a wheelchair in the activity room, attempted to self-propel, and stated, I have to go, let me go. A CNA (#11) told the resident to stay there and sit down. * At 3:50 p.m., seated in a wheelchair stated, I have to go. The resident attempted to self-propel the wheelchair down the hallway and two CNAs (#11 and #12) told the resident to stay there and did not assist the resident to the bathroom. * At 4:21 p.m., showed urine ran down the wheelchair and on to the floor in the activity room. Review of Resident #293 toileting documentation for 03/31/25 showed the staff last toileted the resident at 1:33 p.m. During an interview on 03/31/25 at 5:18 p.m., an administrative nurse (#10) stated he expected staff to toilet residents as care planned and as needed. On 03/31/25 at 3:36 p.m. and 5:00 p.m., staff interviews identified the following: * A nurse (#21) reported being responsible for 37 to 57 residents during each shift. She also indicated there are days she is not able to complete all her assigned duties during the shift. * An administrative staff member (#22) reported staffing is based on the census, and stated weekends are staffed the same as weekdays, except for baths. Residents are bathed Monday-Friday. During an interview on 04/03/25 at 8:38 a.m. an administrative staff member (#1) stated she expected call light wait times under 15 minutes or under 20 minutes during mealtimes. 19410 39685 52000 51999

Based on observation, review of facility policy and staff interview, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity and individuality for 2 of 2 supplemental residents (Resident #6 and #16) who received insulin and blood glucose checks. Failure to administer insulin and perform blood glucose checks in a private area does not preserve the resident's personal dignity, infringes upon the resident's rights to privacy, and has the potential to affect the resident's psychosocial well-being. Findings include: Review of the facility policy titled Resident Dignity occurred on 04/03/25. This policy, revised 12/11/24, stated, PURPOSE: To assist with respecting and ensuring residents rights . The interdisciplinary team will assist all staff members in maintaining the dignity of every resident . respecting resident's private space . providing the resident with privacy . confidentiality. Observations showed nursing procedures completed in the commons area as follows: * 04/01/25 at 11:43 a.m., a nurse (#20) performed a blood glucose check, pulled up Resident #6's shirt and administered insulin in the resident's abdomen as multiple residents and staff observed. * 04/02/25 at 8:25 a.m., a nurse (#20) performed a blood glucose check, pulled up Resident #16's shirt and administered insulin in the resident's abdomen as multiple residents and staff observed. During an interview on the afternoon of 04/03/25, an administrative nurse (#2) stated she expected staff to take residents to a private area to perform blood glucose checks and administer insulin.

Based on record review, review of the facility's policy, and staff interview, the facility failed to ensure the right to participate in the development and implementation of the person-centered plan of care for 1 of 1 sampled resident (#243) reviewed for care planning. Failure to afford Resident #243 and/or a family representative the opportunity to participate in the care planning process restricted their right to make decisions/provide input regarding any potential changes to Resident #243's care, treatment, and/or interventions. Findings include: Review of the facility policy titled Advanced Care Planning occurred on 04/03/25. This policy, revised on 12/02/24, stated, . Purpose: To provide each resident the opportunity to make decisions regarding medical care . assist residents to make their choices known regarding well-being and treatment . Residents and resident surrogate or proxy decision makers have the right to make decisions concerning medical care, including the right to accept or to refuse medical . treatment. During an interview on 04/03/25 at 12:24 p.m., an administrative nurse (#2) reported staff conduct care conferences every quarter, after a significant change, and after a hospitalization . Review of Resident #243's medical record occurred on all days of survey. The progress notes lacked evidence the facility invited Resident #243 and/or a family representative to care conferences following admission/quarterly assessments on 05/06/24, 10/30/24, and 01/30/25. Facility staff failed to afford Resident #243 and/or his family representative the opportunity to participate in the care planning process on a quarterly basis and/or after each hospitalization and failed to inform him, in advance, of changes to the plan of care.

Based on record review, review of the facility's policy, and resident, family, and staff interviews, the facility failed to ensure all alleged violations involving abuse were reported immediately to the administrator of the facility and to other officials (including the State Survey Agency) for 1 of 1 sampled resident (Resident #243) and 1 confidential resident (Resident A). Failure to report Resident A's allegation of abuse to the state agency, and an incident involving Resident #243 and another resident to the administrator and State agency placed all residents at risk of mistreatment, verbal abuse, and/or experiencing anxiety/fear. Findings include: Review of the facility policy titled Abuse and Neglect occurred on 04/03/25. This policy, revised on 07/22/24, stated, . suspected violations involving any mistreatment . or abuse . will be reported immediately to the administrator. Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certification agency . - Review of Resident A's medical record occurred on all days of the survey. The annual Minimum Data Set (MDS), dated [DATE], identified intact cognition and required substantial assistance for activities of daily living. During confidential interviews on 03/31/25 through 04/02/25, Resident A and a family member #1 reported the following: * Staff are rough during cares. * When assisted to a seated position, staff grab the resident by the back of his/her neck. * Indicated a bruise to his/her left hand occurred when Resident A's hand hit the side rail while staff transfered him/her. * Staff disregard requests when answering the his/her call light. During an interview on 04/03/25 at 12:24 p.m., an administrative nurse (#2) confirmed the facility failed to report Resident A's allegations to the state agency. - Review of Resident #243's medical record occurred on all days of survey. Diagnoses included anxiety, cerebral infarction (stroke), dementia, and mental disorder requiring continuous supervision. A progress note, dated 01/31/25 at 9:00 a.m., stated, Resident [#243] sitting at nurses station eating breakfast another male resident sitting at the nurses station. The other male resident stated to [sic] [Resident #243] 'why are you giving the nurses around here a hard time.' [Resident #243] stated 'what the hell do you know about it.' The other male resident stated 'you need to show some respect were you raised that way to show no respect.' [Resident #243] stated to other male resident 'I am going to kick your [blaspheme] you mother [blaspheme].' The other male resident stated 'I'm going to bust your [blaspheme] face up.' Nurse instructed caregiver to remove other male resident from the table. During an interview on 04/03/25 at 12:20 p.m., when asked what steps the facility took when Resident #243 threatened another resident on 01/31/25, an administrative staff member (#1) stated, I didn't know about this. Facility staff failed to identify Resident #243's explosive outbursts and/or inappropriate behaviors as abusive and failed to report the incident that occurred on 01/31/25 to the administrator and State agency. 52000

Based on record review, review of facility policy, and resident, family, and staff interviews, the facility failed to thoroughly investigate alleged violations of abuse for 1 of 1 sampled resident (Resident #243) and 1 confidential resident (Resident A). Failure to thoroughly investigate Resident #243's incidents of abusive behavior and Resident A's allegations of abuse, ensure the protection of other residents during the investigation, implement corrective actions, and evaluate the effectiveness of the actions, placed all residents at risk for mistreatment, verbal abuse, and/or experiencing anxiety/fear. Findings include: Review of the facility policy titled Abuse and Neglect occurred on 04/03/25. This policy, revised on 07/22/24, stated, . The location will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in process. If the alleged or suspected violation is verified, appropriate corrective action will be taken. - Review of Resident A's medical record occurred on all days of the survey. The annual Minimum Data Set (MDS), dated [DATE], identified intact cognition and required substantial assistance for activities of daily living. During confidential interviews on 03/31/25 through 04/02/25, Resident A and a family member #1 reported the following: * Staff are rough during cares. * When assisted to a seated position, staff grab the resident by the back of his/her neck. * Indicated a bruise to his/her left hand occurred when Resident A's hand hit the side rail while staff transfered him/her. * Staff disregard requests when answering the his/her call light. An administrative staff member (#1) provided a document regarding CNA (#7's) performance. An excerpt, dated 12/04/24 stated, . [administrative staff member name] sent [administrative staff member name] and I an e-mail letting us know that she talked to [name of CNA (#7)] this morning about the abuse allegation and sent her home for administrative leave. The document failed to show any information about the allegation/investigation. During an interview on 04/03/25 at 12:24 p.m., an administrative nurse (#2) confirmed she was aware of Resident A's allegations. - Review of Resident #243's medical record occurred on all days of survey. Diagnoses included anxiety, cerebral infarction (stroke), dementia, and mental disorder requiring continuous supervision. A progress note, dated 01/31/25 at 9:00 a.m., stated, Resident [#243] sitting at nurses station eating breakfast another male resident sitting at the nurses station. The other male resident stated to[Resident #243] 'why are you giving the nurses around here a hard time.' [Resident #243] stated 'what the hell do you know about it.' The other male resident stated 'you need to show some respect were you raised that way to show no respect.' [Resident #243] stated to other male resident 'I am going to kick your [blaspheme] you mother [blaspheme].' The other male resident stated 'I'm going to bust your [blaspheme] face up.' Nurse instructed caregiver to remove other male resident from the table. During an interview on 04/03/25 at 12:20 p.m., when asked what steps the facility took when Resident #243 threatened another resident on 01/31/25, an administrative staff member (#1) stated, I didn't know about this. The facility failed to thoroughly investigate the incident that occurred on 01/31/25 between Resident #243 and another resident and the allegations by Resident A, prevent further potential verbal abuse and mistreatment while the investigation is in process, and implement appropriate corrective actions. 52000

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer or a copy of the notice to the State Long Term Care Ombudsman for 2 of 6 sampled residents (Resident #78 and #243) reviewed for hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights and does not allow the ombudsman to be aware of facility practices regarding transfer and discharge or advocate on the resident's behalf. Findings include: Review of the facility policy titled Discharge and Transfer occurred on 04/03/25. This policy, revised on 03/28/25, stated, . Before a location transfers or discharges a resident, the location must . Notify the resident and the resident's representative of the transfer . and the reason for the move in writing . When a resident is temporarily transferred on an emergency basis to an acute care center, a notice of transfer must be provided to the resident and resident representative as soon as practicable before the transfer. Copies of notices for emergency transfers must also still be sent to the ombudsman . A location must provide and document sufficient preparation and orientation to residents to ensure safe and orderly . discharge from the location. Sufficient preparation and orientation means the location informs the resident where he or she is going and takes steps under its control to minimize anxiety and ensure safe transportation. - Review of Resident #78's medical record occurred on all days of survey and identified a hospital transfer on 01/07/25. The medical record lacked evidence the facility provided the resident and/or representative with a written transfer notice or a copy of the transfer to the ombudsman. During an interview on 04/02/25, a social service staff member (#17) confirmed the facility did not have a copy of the transfer notice provided to Resident #78 or their representative or to the ombudsman for the hospitalization on 01/07/25. - Review of Resident #243's medical record occurred on all days of survey and identified hospital transfers on 03/30/25. A Notice of Transfer for Hospitalization form, dated 03/30/25, indicated the resident received written notification on 04/01/25, two days after the transfer. The facility failed to provide Resident #243 with a written notice prior to transferring him to the hospital on [DATE].

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual and staff interview, the facility failed to complete a significant change in status assessment (SCSA) for 1 of 3 sampled residents (Resident #37) who experienced a significant change in status. Failure to determine the need for and complete a SCSA in response to a resident's decline limited the facility's ability to accurately assess the resident's status and identity and implement appropriate care approaches. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.18.11), dated October 2023, page 2-24 stated, . A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without staff intervention . 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. and Page 2-27 stated, A SCSA is appropriate if there are either two or more areas of decline or two or more areas of improvement. Any decline in an ADL [activities of daily functioning] physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning. Review of Resident #37's medical record occurred on all days of survey. An admission Minimum Data Set (MDS), dated [DATE], identified supervision required with oral hygiene and moderate/partial assistance required with taking on/off socks and shoes. A quarterly MDS, dated [DATE], identified as moderate/partial assistance required with oral hygiene, maximum/substantial assistance required with taking on/off shoes and socks and a weight loss. The record lacked evidence facility staff identified and/or completed a SCSA following Resident #37's decline in activities of daily living and weight loss. During an interview on 04/03/25 at 11:16 a.m., an administrative staff nurse (#13) verified Resident #37 declined with oral hygiene, taking on/off shoes and socks, and had a weight loss.

Based on record review, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #1) with high blood glucose readings. Failure to notify the provider of high blood glucose levels as ordered may result in adverse outcomes for the resident. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText 2021, Pearson, Boston, Massachusetts, page 63, stated, Carrying Out a Physician's: Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #1's medical record occurred on all days of survey and included a diagnoss of type 2 diabetes mellitus. A physician's order, dated 10/10/24 stated, ACCU-CHECKS [blood glucose monitoring] before meals. Call PCP [Primary Care Provider] if BS [blood sugar] is < [less than] 60 or > [greater than] 400. Review of Resident #1's Blood Sugar Summary, dated January 1 - March 31, 2025, showed the following blood glucose readings: * 01/24/25 at 12:22 p.m. - 567.0 mg/dL [milligrams per deciliter] * 01/26/25 at 5:21 p.m. - 404.0 mg/dL The medical record lacked documentation the facility notified Resident #1's provider of the elevated blood glucose levels. During an interview on 04/03/25 at 2:47 p.m., an administrative staff member (#1) confirmed staff failed to notify the physician of Resident #1's high blood sugar levels on the above dates.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to provide appropriate toileting and perineal care for 1 of 4 sampled residents (Resident #293) observed for toileting who required staff assistance. Failure to provide toileting assistance as care planned and proper perineal care may result in a loss of dignity and placed the resident at risk for skin breakdown, decreased self-esteem, and urinary tract infections (UTI). Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 892, stated, Fecal and Urinary Incontinence: Moisture from incontinence promotes skin maceration [tissue softened by prolonged wetting or soaking] and makes the epidermis [skin] more easily eroded and susceptible to injury . Page 1221 stated, . scheduled toileting, attempts to keep clients dry by having them void at regular intervals, such as every 2 to 4 hours. The goal is to keep the client dry . - Review of Resident #293's medical record occurred on all days of survey. The care plan stated, . TOILET USE: Resident requires check and change. Resident can be unaware of when he is wet/soiled. BRIEF USE: Resident uses incontinence products for heavy incontinence. Check every 2-3 hours and prn [as needed]. Observations of Resident #293 on 03/31/25 showed the following: * At 2:12 p.m., seated in a wheelchair in the activity room attempted to self-propel and stated to staff, I have to go, let me go. A CNA (#11) told the resident to stay there and sit down. * At 3:50 p.m., seated in a wheelchair and stated, I have to go and attempted to self-propel the wheelchair down the hallway. Two CNAs (#11 and #12) told the resident to stay there and did not assist the resident to the bathroom. * At 4:21 p.m., urine ran down Resident #293's wheelchair and on to the floor in the activity room. Review of Resident #293 toileting chart on the afternoon of 3/31/2025 showed staff toileted the resident at 01:33 p.m. and 05:00 p.m. (39 minutes after the incontinent episode observed in the activity room). During an interview on 03/31/25 at 5:18 p.m., an administrative nurse (#10) stated he/she expected staff to toilet residents as care planned and as needed. The facility staff failed to toilet Resident #293 as care planned.

1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate assessment and/or assistive devices necessary to prevent accidents for 2 of 7 sampled residents (Resident #25 and #37) who required assistance with transfers. Failure to provide appropriate assessment and use assistive devices during transfers placed the residents at risk of accidents and injury. Findings include: Review of the facility policy titled Gait-Transfer Belt occurred on 04/02/25. This policy, revised 05/02/24, stated, . a device used for stability and/or support for a short time during the actual transfer . Review of the facility policy titled Safe Resident Handling occurred on 04/03/25. This policy, stated, . Skilled . Licensed Nurses . Responds timely to caregivers reports of changes in the resident mobility and . The following documentation is used: To identify the resident's most appropriate method of transfer: Sit-Stand-Walk Data Collection Tool . used to identify resident needs for appropriate method of transfer . - Review of Resident #25's medical record occurred on all days of the survey. The care plan stated, . AMBULATION/TRANSFERS/MOBILITY: Assist of 1, gait belt . Observation on 04/01/25 at 11:05 a.m. showed a certified nurse aide (CNA) (#3) transferred Resident #25 from the bed to the wheelchair. The CNA reached under Resident #25's buttocks, assisted her to stand and stabilized her at the waist/arm to pivot to the wheelchair. The resident verbalized weakness in her legs during the pivot. The CNA (#3) reached under Resident #25's arm to boost and stabilize the resident, then transferred Resident #25 from the toilet back to the wheelchair. The CNA (#3) failed to use a gait belt during the transfers. - Review of Resident #37's medical record occurred on all days of survey. The care plan stated, . [Resident's name] has an ADL [activities of daily living] self care performance deficit . is able to walk with Ax1 [staff assistance of 1] gaitbelt and FWW [front wheeled walker] on the unit. WC [wheelchair] if needed for distances. Nurse to assess for changes in transfer. Observation on 03/31/25 at 12:55 p.m. showed Resident #37 asleep in the recliner. A (CNA) (#15) shook the resident's right shoulder and called her name several times as she attempted to wake the resident. The resident did not respond, and her eyes remained closed. Two CNAs (#14 and #15) used the sit to stand lift (mechanical lift) to transfer the resident from the recliner to the wheelchair, assisted the resident to the bathroom, and again used the sit to stand lift to transfer Resident #37 to the toilet. The CNAs physically placed the resident's hands on the assist bars of the sit to stand lift. The resident's eyes remained closed with no response during toileting. The facility failed to ensure a licensed nurse or therapy completed an assessment to ensure this method of transfer was safe for the resident. Observation on 04/02/25 at 10:20 a.m. showed Resident #37 asleep in the recliner, and leaned to the left side. The sit to stand lift was located beside the recliner chair. A CNA (#16) shook the resident's right shoulder and called her name several times as he attempted to wake the resident. The resident did not respond, and her eyes remained closed. When asked how the resident is to be transferred the CNA (#16) stated, We can pivot transfer her with one or we can use the pal lift [sit to stand mechanical lift]. The CNA (#15) stated they were going to assist the resident to the bathroom and they need to use the pal lift. The CNA (#16) stated, I will go ask the nurse. The CNA (#16) returned from talking to the nurse and stated, She [the nurse] said to not toilet her right now, and just to reposition her. The medical record lacked documentation to identify the resident's most appropriate method of transfer. During an interview on the afternoon of 04/03/25, an administrative nurse (#2) stated if gait belts are used, it would be reflected in the care plan and confirmed the medical record lacked a therapy or nursing sit-stand-walk data collection tool/assessment for Resident #37. 27221 2. Based on record review, review of the facility reported incident (FRI) and investigation, and review of facility policy, the facility failed to provide appropriate supervision and/or assistance to prevent an accident for 1 of 1 sampled resident (Resident #243) who fell during transport from the facility van. Failure to properly position the anti-rollbacks resulted in Resident #243's fall/injury and placed all residents transferred with the van at risk for falls/injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 10/11/24. The facility implemented and completed corrective action on 10/16/24. Review of the facility policy titled Vehicle Transfer occurred on 04/03/25. This policy, revised 12/02/24, stated, . Incorporating safe resident handling practices . into . vehicle transfers reduces the risk of injury for both the resident and employee. It is the responsibility of the licensed nurse to determine the most appropriate method of transfer based on the resident's support needs. Occasionally employees will accompany the resident to medical appointments. Review of Resident #243's medical record occurred on all days of survey. Diagnoses included abnormal posture, dementia, hemiparesis secondary to cerebral vascular accident (CVA), and obesity. The care plan, dated 03/14/25, stated, . [Resident #243] has an ADL [activities of daily living] self-care performance deficit . Continuous oxygen per nasal cannula. 3 liters. Anti-tip bars on wheel chair . When Loading/Unloading into facility Van. Staff will position upwards while going up and down the ramp for safety. Once situated in the van or off the ramp staff will be [sic] position anti-tip bars on wheel chair downward. [Resident #243] is at risk for falls R/T needing assist for transfers with complete mechanical lift . 10/11/24 Resident had a fall while coming out of the van going to an appointment. Review of the FRI, dated 10/11/24, stated, Resident was being transferred to eye appointment, driver had completed the transport safely she [driver] had removed all safety devices and was starting to back wheelchair out of the van down the ramp. While taking the resident down the ramp resident anti roll back [bar] caught the edge of the ramp, with the weight of the resident, oxygen and wheelchair the staff member was not able to hold on to the resident and the resident was lowered down to the floor of the ramp. Driver was not able to say for sure if the resident hit his head resident state [sic] he did. Driver did call 911 clinic staff did come out and help until EMS arrived. A progress note, dated 10/11/2024 at 4:28 p.m., stated, Resident denies pain or nausea, denies dizziness. Describes incident this am, and states he may have landed on the back of his head. No lump or bruising seen. He is requesting tylenol and cyclobenzaprine [a muscle relaxant]. The facility final FRI investigation report stated, Facility went out and checked all residents' wheelchairs and made staff aware of what residents have anti-rollbacks on their chairs, we did add statement under ADLs on their care plan [sic] that follows * Anti Rollbacks PREFERENCES: When loading/Unloading into facility Van. Staff will position upwards going up and down the ramp for safety. Once situated in the van or off the ramp Anti Rollbacks will be positioned downward. The facility failed to ensure Resident #243's anti-rollbacks were properly positioned while being transferred up/down the van ramp. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions for other residents who may be affected by the deficient practice as follows: * Completed an investigation into Resident #243's fall, * Updated the care plan for all residents with anti-rollback wheelchairs, * Re-education and competency evaluations provided to all facility drivers regarding anti-rollback wheelchairs on 10/11/24, and * Implemented audits on van transfers. 52000

Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 5 sampled residents (Resident #77) identified with weight loss. Failure to evaluate Resident #77's weights, monitor intake of nutritional supplements, and implement additional interventions resulted in a significant weight loss. Findings included: Review of the facility policy titled Weight and Height occurred on 02/29/24. This policy, revised 09/18/23, stated, . To ensure that the resident maintains acceptable parameters of nutritional status regarding weight . to monitor weight loss or gain in a resident . Residents at nutritional risk will be weighed weekly . Weight Procedure . 7. If weight varies by more than three percent, reweigh resident and document. Report weight to licensed nurse. 8. The licensed nurse should notify the director of food and nutrition (DFN) within 24 hours regarding any significant weight change. Significant weight change is defined as five percent in 30 days, 7.5 percent in 90 days, and 10 percent in 180 days. Review of Resident #77's medical record occurred on all days of survey. Diagnoses included dementia, congestive heart failure, edema, and protein calorie malnutrition. Review of physician's orders included: * 12/19/23 - House Supplement Plus (a nutritional supplement) two times a day for 8 oz (ounces). * 12/13/23 - Gelatein (a protein jello) one time a day. * 12/22/23 - Knee high compression socks on in the morning off at bedtime for edema. * 12/18/23 - 01/18/24 - Furosemide 20 mg (milligrams) in the morning for hypertension related to edema. * 01/24/24 - Furosemide 20 mg in the morning for hypertension. The current care plan stated, . has nutritional problem or potential nutritional problem R/T [related to] diagnoses including but not limited to protein-calorie malnutrition . dementia . edema . Interventions . order for medical nutritional supplement . Weigh per policy . Review of Resident #77's weight record showed the following: * 12/18/23 173.6 Lbs (pounds) * 12/25/23 173.2 Lbs * 01/02/24 168.0 Lbs * 01/09/24 157.0 Lbs (11 pounds or 6% in 7 days) * 01/16/24 155.0 Lbs (a loss of 18.6 pounds or 10% in 30 days) * 01/23/24 154.0 Lbs * 01/30/24 158.4 Lbs * 02/06/24 153.0 Lbs * 02/13/24 151.4 Lbs * 02/20/24 147.6 Lbs * 02/27/24 145.0 Lbs (28.6 pound loss or 16% loss in less than 90 days) Review of Resident #77's medication administration record for February 2024 showed the resident consumed 50% of the house supplement and protein supplement each day. The medical record lacked nursing assessments related to edema and monitoring of weekly weights, documentation of re-weighs, notification of the DFN or dietician of significant weight loss, evaluation of existing interventions, and the implementation of additional interventions to prevent further significant weight loss. During an interview on 02/28/24 at 11:20 a.m., the dietician (#18) confirmed staff failed to obtain re-weighs and notify her or the DFN that Resident #77 only consumed 50% of the supplements on a consistent basis. During an interview on 02/28/24 at 3:15 p.m., an administrative nurse (#5) identified that the system did not trigger a weight loss percentage for certified nurse aides, they would have to identify a 3% weight loss on their own and notify the nurse. She stated Resident #77 received a diuretic and some weight loss could be attributed to that. She agreed the medical record lacked re-weighs for Resident #77, documentation of weight loss due to diuretic use, and notification of the dietician or DFN of significant weight loss.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 11/15/12. 1. Based on observation, record review, and staff interview, the facility failed to provide necessary care and services regarding proper incontinence/skin care to 1 of 1 sampled resident (Resident #9) who expressed pain during perineal cares. Failure to use appropriate skin care wipes resulted in pain and impaired skin integrity for Resident #9. Findings include: Review of Resident #9's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Resident #9's current care plan stated, ". . . Unable to complete own cares due to recent [MEDICAL CONDITION]. . . . Skin prevention and protection measures in place . . . SAGE WIPES (a type of skin wipe which contains moisture barrier cream) ONLY. . . . Potential for alteration in skin integrity related to needing assist with bed mobility and bowel and bladder incontinence. . . . Sage wipes only . . ." (During an interview on 12/18/13 at 2:43 p.m., a staff member (#19) identified the facility recently replaced Sage wipes with a different brand of wipes containing moisture barrier cream.) A nurse's note, dated 11/21/13, stated, ". . . She (Resident #9) complained of burning yesterday with normal wipes after urinating. Sage wipes initiated. . . ." Observation on 12/16/13 at 2:29 p.m. showed two certified nursing assistants (CNAs) (#13 and #14) performed incontinence cares for Resident #9 as she lay in bed. A CNA (#13) wiped Resident #9 with regular skin care wipes, not the moisture barrier wipes as identified in her care plan. Observation showed several small reddened areas to the resident's buttocks. Resident #9 stated, "Ouch, that's sore," as the CNA (#13) wiped her buttocks. The resident also stated, "[MEDICAL CONDITION] there," and repeated, "Ouch, that's sore." Observation on 12/17/13 at 1:16 p.m. showed two CNAs (#10 and #11) performed incontinence cares for Resident #9 as she lay in bed. The resident was incontinent of a large amount of stool. Observation showed a CNA (#10) began performing incontinence cares using regular skin care wipes, not the moisture barrier wipes as care planned. Observation also showed no moisture barrier wipes available in the room. The CNAs removed the resident's pants and incontinence brief, and began wiping her legs/front perineal area with regular skin care wipes. The resident became agitated and stated, "Ouch! Stop, please stop!" She further stated, "I don't know what you did but [MEDICAL CONDITION] fire," and "Too much soap." A CNA (#11) left the room to get an incontinence brief. Observation showed the CNA returned with moisture barrier wipes also, but failed to use them and instead used the regular wipes already in the room. The CNAs rolled Resident #9 on her side and began wiping her buttocks. Observation showed reddened areas to her buttocks. Resident #9 stated, "Oh, please don't do that," as the CNA (#10) wiped her buttocks. The CNA (#10) stated, "I'm sorry (Resident #9), I know. I have to get you cleaned up." Resident #9 again stated, "It burns, [MEDICAL CONDITION] fire!" The CNA (#10) applied [MEDICATION NAME] cream (a moisture barrier cream) to the resident's buttocks and told Resident #9 the burning would "go away in a little while." Observation on 12/18/13 at 1:49 p.m. showed two CNAs (#5 and #15) assisted Resident #9 onto a bed pan. A CNA (#15) performed frontal perineal cares using moisture barrier wipes. Resident #9 stated, "I must have an owie 'cuz [MEDICAL CONDITION] fire," and "Oh, that burns, [MEDICAL CONDITION] fire. Oww, oww, oww!" The CNA (#15) stated, "The area is real, real red." The CNAs rolled Resident #9 on to her side and wiped her buttocks area. Resident #9 stated, "Oww, don't do that. That's an open sore," and "I can't handle this. Oh, please. No more! I can't handle this!" Observation showed reddened areas to the resident's buttocks, and the CNA (#15) stated, "It's red down there." The CNA (#15) applied [MEDICATION NAME] to the resident's buttocks and perineal area. Resident #9 stated, "I got an owie bottom." The CNA (#15) replied, "I put cream on it." Resident #9 stated, "I know but it still hurts." The CNA (#15) then stated, "I'll tell the nurse." The CNAs left Resident #9's room and entered another resident's room. Observation showed a nurse (#18) with a medication cart in the hallway near Resident #9's room. During an interview on 12/18/13 at 2:20 p.m., a CNA (#17) stated the CNAs use Sage (i.e., moisture barrier) wipes for sensitive skin as they are more gentle. Another CNA (#16) stated they use moisture barrier wipes if skin is reddened or sore. During an interview on 12/19/13 at 8:47 a.m., the nurse (#18) (observed near Resident #9's room on 12/18/13) stated she was not aware of Resident #9's reddened perineal area until the CNAs gave report on the afternoon of 12/18/13. The nurse stated she passed the information on to the evening shift, but was unsure if the evening shift assessed the area. She also identified she did not receive any information regarding Resident #9's perineal redness/discomfort that morning during report. Review of nurses' notes showed no assessment of Resident #9's pain with perineal care and/or reddened perineal area/buttocks until 12/19/13 at 9:34 a.m. A nurse's note dated 12/18/13 at 7:35 p.m. stated, "Received fax from (provider name) with new orders for: [MEDICATION NAME] (an anti-anxiety medication) 0.25 mg (milligrams) Q (every) 6 hours PRN (as needed), tylenol 650 mg TID (three times per day) and PRN, biofreeze BID (twice per day) to back, and psych (psychiatric) consult with (provider name) for behavioral management. Updated daughter and POA (power of attorney) (daughter's name) on new orders. (Daughter name) does not want resident to receive [MEDICATION NAME] at this time. . . . (Daughter name) verbalized understanding of resident's anxiety and discomfort and is not opposed to anxiety medications but does not want a medication with sedating effects at this time. . . ." A telephone order dated 12/18/13 at 8:00 p.m. identified the provider discontinued the [MEDICATION NAME]. Although staff contacted the provider on the evening of 12/18/13 and received an order for [REDACTED]. A nurse's note, dated 12/19/13 at 9:34 a.m., stated, "(Resident #9) has a reddened area to left buttock fold as well as peri-area (perineal area). Elta-seal (a moisture barrier cream) applied after toileting hygiene. Fax sent to (provider name) r/t (related to) above." Failure to use moisture barrier incontinence wipes as care planned, promptly assess the area, and notify Resident #9's provider of her skin condition resulted in pain, discomfort, and worsening perineal skin breakdown. 2. Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to manage behavioral and/or pain symptoms for 2 of 2 sampled residents (Resident #6 and #11) who received as needed (PRN) medications for behaviors and/or pain prior to attempting non-pharmacological interventions. Failure to identify target behaviors, assess the reason/causative factor(s) for behaviors, and establish accurate on-going monitoring of the behaviors has the potential for these residents not to obtain their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of the facility policy titled "Behavior Management Program" occurred on 12/19/13. The policy, dated 08/23/13, stated, ". . . Through assessment and observation staff identifies . . . behaviors that alter or disturb the overall safety, quality of life, and ability of staff to care for the individual needs of a resident. . . . The resident specific care plan includes specific interventions to protect staff, resident, and other residents from threatening behaviors as they occur. . . . Staff uses the approaches care planned and documents the resident's response and/or outcome. . . . Psychopharmacological medications are used when clinically indicated and documented by the . . . provider." - Review of Resident #6's medical record occurred during all days of survey. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairment, little interest in doing things, moderate depression, little energy, poor appetite, trouble concentrating, and restlessness. Review of Resident #6's current plan of care identified, "Problem: Resident on [MEDICAL CONDITION] medication . . . Approach: . . . Medicate only if necessary. Offer non-Pharmacological interventions before giving PRN medications, ie: 1 to 1 visits, assisting to Bathroom, back rub, fluids, snack, walking with him, Activities, telephone call to his daughter during waking hours. . . ." Review of Resident #6's physician's orders identified: * [MEDICATION NAME] 0.50 milligrams (mg) (an antipsychotic) daily at 8:00 p.m., started 12/05/12 * [MEDICATION NAME] 1 to 2 mg every four hours prn (as needed), started 12/05/12 and discontinued 08/07/13 * [MEDICATION NAME] 0.25 mg daily at 8:00 a.m., started 04/04/13 * [MEDICATION NAME] 0.5 mg every four hours prn started on 08/07/13 * [MEDICATION NAME] 0.5 mg (an anti-anxiety) twice a day prn, started on 09/02/11 * [MEDICATION NAME] 1 to 2 mg injection twice a day prn, started on 07/03/12 Review of Resident #6's Progress Notes identified the following: * 12/18/12 at 2:58 p.m., "Resident continues to exit seeking (sic) refused to take [MEDICATION NAME] and [MEDICATION NAME]. was combative towards staff sticking (sic) out when he wanted to go out the south doors . . . daughter . . . said to try to give him something and maybe he will sleep" . . . at 3:00 p.m., ". . . res. (resident) given IM (intra-muscular) [MEDICATION NAME]" . . . at 4:00 p.m., "res. calming down and able to take snack. . . ." * 01/12/13 at 5:26 p.m., "res. telling staff that he had to find his car and head for home. unable to redirect. res. given [MEDICATION NAME] oral and one on one with staff. res. eventually calmed down and slept in his recliner." * 02/13/13 at 1:10 a.m., "Resident self transferred from reliner at this time and had fall landing on buttocks. Resident states 'I was going home.' Redirect to time and place. Medicated with [MEDICATION NAME] . . . at 1:00 a.m., for restlessness and agitation . . ." * 03/31/13 at 1:43 p.m., ". . . resident was . . . aggressive when encouraged to sit down for resident was unsteady. resident was upset and unable to be redirected. 12:15 p.m. PRN [MEDICATION NAME] 1 mg was given. resident was calm enough by 12:45 p.m. that CNA was able to redirect resident to bedroom to toilet and lay in recliner . . . is currently resting quietly in chair at this time." * 04/13/13 at 1:40 a.m., "Resident in recliner with eyes closed at this time. Medicated with [MEDICATION NAME] . . . for restlessness, anxiety and unable to redirect at 11:50 p.m. Effective at present time." * 04/20/13 at 12:44 a.m., "Restless at 11:10 p.m. crawling out of bed, and restless. Medicated with [MEDICATION NAME] . . ." * 04/23/13 at 4:00 p.m., ". . . Resident having hallucinations talking to people not in the room, hollering out, climbing out of bed and chair, wanting to look for his truck, unable to redirect, becoming more agitated with each intervention. Resident medicated at this time with [MEDICATION NAME] 2 mg po (orally)." * 05/03/13 at 2:32 a.m., "Resting in bed with eyes closed at this time. Restless at 12:30 a.m. and crawling out of bed wanting to 'go home.' Unable to redirect resident. [MEDICATION NAME] given . . . at 12:30 a.m. for restlessness/behaviors." * 05/15/13 at 5:28 a.m., "Resident wanting to leave the facility and of being loud medicated with respriadol (sic) . . . at 12:30 a.m. resident rested well after and was more cooperative with staff." * 05/20/13 at 12:53 a.m., "Resident restless and crawling out of bed. Redirection ineffective. [MEDICATION NAME] given . . . for comfort." * 06/08/13 at 2:26 a.m., "Resident received [MEDICATION NAME] at 11:00 p.m. for agitation, crawling out of bed, wanting to go home, and get dressed. . . ." * 07/12/13 at 3:02 p.m., "resident came to med (medication) room at noon . . . was pacing. . . . within 20 minutes resident was still upset and unable to be redirected and stating 'wanting to get out of here.' PRN [MEDICATION NAME] given PO (orally) at 11:45 a.m., at 12:30 p.m., resident was cooperative and no longer upset." * 07/21/13 at 9:40 p.m., "res. exiting and wandering throughout facility. res. medicated (sic) at 7:00 p.m. with [MEDICATION NAME] and no effect of slowing res. down. staff returned res. to unit with some resistance. res. would leave room or lounge after a short period of time. chair alarm placed on res. while in recliner after last exit. res. left building times 3 and wandered times 3 within building." * 08/15/13 at 3:22 p.m., "Resident called CNA (certified nurse assistance) 'Crazy old heifer and fat ass' . . . Resident took [MEDICATION NAME] . . . Administered AM meds with [MEDICATION NAME] PRN due to resident being combative . . . Resident sleeping in recliner till lunch. . . ." * 09/30/13 at 10:32 p.m., "resident very confused, wandering hallways. prn [MEDICATION NAME] given with good results for calming resident when attempts at redirection were unsuccessful." * 12/06/13 at 3:15 p.m., "Received [MEDICATION NAME] .5 mg at 3:15 p.m. as restlessness turned to agitation. Unable to redirect. Wandering. [MEDICATION NAME] was effective." During an interview on the afternoon of 12/19/13, an administrative nurse (#1) confirmed staff failed to identify the non-pharmacological interventions they attempted prior to administering Resident #6's prn [MEDICATION NAME]/[MEDICATION NAME]. Failure to attempt non-pharmacological interventions and monitor the effectiveness of those interventions prior to administering an anti-anxiety/anti-psychotic medication does not allow staff to evaluate what interventions were most effective for Resident #6's behavior. - Review of Resident #11's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications included Tylenol every four hours for pain or fever and [MEDICATION NAME] every two hours PRN for anxiety. The significant change MDS, dated [DATE], identified the resident had both long and short term memory problems, total dependence on staff for all activities of daily living (ADLs), and experienced non-verbal signs of pain two to three times during the assessment period. Review of Resident #11's current care plan identified the following: * Problem: ". . . severe cognitive loss . . . Approach: . . . he laughs and smiles and likes hugs when feeling well. If he is frustrated, in pain or not feeling well, he may hit out, pull hair or bite . . ." * Problem: "Behaviors: He can be restless at times, will yell out and makes sounds. This is how he communicates, and at times it seems to be a behavior that may be expected due to his [MEDICAL CONDITION] . . . Approach: . . . He has cd's (compact discs) in his room that play bird sounds and polka music that he really (sic) likes. He likes stories and to be talked to, he will laugh at the sound of his farting machine. He likes tapping on his chest, his vibrating fish on his chest and to hear his name. Use these interventions as they often calm him. If he is making disturbing noises, try and calm him with soothing talk, getting him to laugh, giving him something soft to hold, putting on his favorite music, try change of position, etc. If these don't work and he is disturbing others, move him from the area as he may not have any contol (sic) over it . . ." Resident #11's care plan failed to identify the use of [MEDICATION NAME] as an intervention for behaviors. Review of Resident #11's PRN [MEDICATION NAME] Medication a Administration Records (MARs) from November 7 to December 17, 2013 identified the following: * November: [MEDICATION NAME] administered 14 of 23 days. Three of the 14 days, staff administered Tylenol simultaneously with the [MEDICATION NAME]. * December: [MEDICATION NAME] administered seven of 17 days. Two of the seven days, staff administered Tylenol simultaneously with the [MEDICATION NAME]. * Resident #11 received [MEDICATION NAME] for pain, yelling, agitation, restlessness, flailing extremities, moaning, calling out, facial grimacing, behavioral issues, rigidity, crying out, and thrashing in bed. * Non-pharmacological interventions attempted prior to the [MEDICATION NAME]/Tylenol included repositioning, redirected, activity of choice, call/involve family, assess pain, and 1 to 1 visits. The facility failed to assess the reason/causative factors which may have contributed to Resident #11's behaviors and failed to specifically identify the individualized interventions (as identified in the resident's care plan) attempted prior to the administration of [MEDICATION NAME]. 3. Based on record review, review of facility policy, and staff interview, the facility failed to attempt non-invasive interventions, such as dietary interventions or oral medications, prior to the use of a suppository for 2 of 2 sampled residents (Resident #8 and #11) who received as needed (PRN) medication for constipation. Failure to implement bowel interventions according to the facility's policy resulted in inconsistent bowel management and may result in unrelieved constipation, and the use of unnecessary medications. Findings include: Review of the facility policy titled "Bowel Management Program" occurred on 12/19/13. This policy, dated August 2013, stated: ". . . PURPOSE: To provide a planned, individualized bowel program according to individual residents' needs and according to their physician preference. PROCEDURE: 1. Check elimination/BM (bowel movement) book to assure that resident is constipated - no bowel movement for 2-3 days . . . 3. Start with MOM (milk of magnesia) or other oral laxative (unless otherwise told by physician) before advancing to suppositories . . . 4. Mark results . . . to ensure over use of laxatives does not occur. 5. Observe for pattern of prn laxative use and notify physician for need of possible scheduled laxative medication. 6. Notify Dietician (LRD) of need for laxative use and pattern . . ." - Review of Resident #11's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. PRN medications included a [MEDICATION NAME] suppository for constipation. Review of Resident #11's bowel elimination records and PRN Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] *11/07/13 - two BMs * 11/10/13 - BM * 11/12/13 - BM * 11/14/13 - suppository administered/BM * 11/15/13 - BM * 11/17/13 - BM * 11/19/13 - suppository administered/BM * 11/21/13 - BM * 11/23/13 - BM * 11/25/13 - suppository administered/BM * 11/27/13 - suppository administered/BM * 11/29/13 - suppository administered/BM * 11/30/13 - two BMs * 12/02/13 - suppository administered/BM * 12/03/13 - suppository administered/BM * 12/04/13 - BM * 12/06/13 - two BMs * 12/08/13 - suppository/ two BMs The bowel records MAR indicated [REDACTED]. The facility failed to notify the resident's physician and the facility's dietician regarding the frequent administration of suppositories failed to attempt a non-invasive intervention before the use of a suppository. - Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. PRN bowel elimination medications included MOM and a [MEDICATION NAME] suppository. Review of Resident #8's bowel elimination records and PRN MAR from November 14 to December 13, 2013 identified the following BMs and MOM/suppository use: * 11/14/13 - BM * 11/17/13 - suppository administered/BM * 11/19/13 - MOM administered * 11/23/13 - BM * 11/26/13 - BM * 11/29/13 suppository administered/BM * 12/01/13 - BM * 12/02/13 - two BMs * 12/03/13 - BM * 12/06/13 - suppository administered/BM * 12/09/13 - BM * 12/12/13 - suppository administered/BM * 12/13/13 - suppository administered/ four BMs The BM records and MAR indicated [REDACTED]. During an interview on the afternoon of 12/19/13, an administrative nurse (#1) stated facility staff are expected to follow the facility policy and procedure related to constipation and PRN medication use.