Every finding on record at Starr Regional Health & Rehabilitation

Based on facility policy review, medical record review, observations, and interviews, the facility failed to maintain infection control by storing oral hygiene equipment in an unsanitary manner for 2 residents (Residents #52 and #31), failed to use proper Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) for 1 resident (Resident #51), and failed to administer medications in a sanitary manner for 1 resident (Resident #6) of 54 residents reviewed in the facility.The findings include:Review of the facility's policy titled, Medication Administration ., dated 1/2018, revealed .Medications are administered as prescribed in accordance with good nursing principles and practices .Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), dated 12/2022, revealed .Enhanced Barrier Precautions .infection control interventions designed to reduce transmission of resistant organisms .use of gown and gloves during high-contact resident care activities .high contact resident activities .wound care .gloves and gowns will be used by all staff .performing the high-contact care .Review of the facility's policy titled, Oral Hygiene, dated 10/2023, revealed .objective .to lessen occurrence of mouth infections .brush teeth .dry resident's face .remove all equipment, clean and replace in bedside unit .Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Chronic Pain, and Osteoarthritis.Review of a comprehensive care plan dated 11/11/2025, revealed Resident #52 had interventions including .oral care: usual performance is substantial/maximum assist as needed .Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 scored a 2 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment, and was dependent on staff assistance for oral hygiene.Review of the medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Dementia, Heart Failure, and Crohn's Disease.Review of a comprehensive care plan dated 11/5/2025, revealed Resident #31 had broken teeth and interventions including .assist resident with mouthcare daily and PRN [as needed] .Review of an admission MDS assessment dated [DATE], revealed Resident #31 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact, and was independent with oral hygiene.During observations on 1/12/2026 at 11:40 AM, 1/13/2026 at 10:39 AM, and 1/14/2026 at 9:30 AM, the shared room of Residents #31 and #52 contained a metal shelf above the sink. Continued observation revealed 2 toothbrushes lay on the shelf together and were touching, were not labeled with resident identifiers, and were uncovered.During an observation and interview on 1/14/2026 at 11:10 AM, the Administrator confirmed the shared room of Residents #31 and #52 contained 2 resident toothbrushes laying on the shelf above the sink together and were touching, were not labeled with resident identifiers, and were uncovered. The Administrator stated the toothbrushes should be labeled and in toothbrush containers.Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Chronic Pain, and Osteoarthritis.Review of a quarterly MDS assessment dated [DATE], revealed Resident #51 had short and long-term memory loss, and had severe impairment for cognitive skills for daily decision making.Review of the current Physician's Orders for Resident #51 revealed an order dated 1/12/2026, .Enhanced Barrier Precautions for Chronic Wounds .During an observation of wound care on 1/13/2026 at 9:03 AM, revealed Licensed Practical Nurse (LPN) A performed wound care for Resident #51 in the resident's room. Continued observation revealed LPN A failed to don a gown prior or during the wound care as indicated for a resident in EBP.During an interview on 1/14/2026 at 11:26 AM, the Director of Nursing (DON) confirmed LPN A failed to follow infection control practices for EBP by not wearing a gown during direct contact wound care for Resident #51.Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Lung Disease, and Legal Blindness.Review of a quarterly MDS assessment dated [DATE], revealed Resident #6 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact.During an observation on 1/13/2026 at 8:21 AM, revealed Registered Nurse (RN) A prepared medications for Resident #6. During the preparation, a medicine tablet (escitalopram) (an antidepressant medication) fell from the package into an open drawer of the medication cart. Continued observation revealed RN A picked up the tablet and placed it into the medicine cup with the other prepared medications. Further observation during the medication administration with RN A, revealed a medicine tablet (potassium chloride) (potassium medication supplement) fell from the package onto the top of the medication cart. RN A picked up the tablet and placed it into the medicine cup with the other prepared medications. RN A continued placing medications into the medicine cup, then administered the medications to Resident #6, including the 2 tablets that had dropped.During an interview on 1/13/2026 at 8:45 AM, RN A confirmed the 2 medicine tablets that fell into the medication cart drawer and onto the top of the medication cart should have been discarded and not administered to Resident #6.During an interview on 1/14/2026 at 11:26 AM, the DON confirmed RN A did not follow infection control practices for the medication administration.

Based on review of facility policy, Quarterly Payroll Based Journal (PBJ) and interview, the facility failed to report PBJ for Quarter 4 2023 (July 1- September 30). The findings include: Review of the facility policy titled, Reporting Direct-Care Staffing Information (Payroll-Based Journal) showed, .Direct-care staffing and census information will be reported electronically to CMS though the Payroll-Based Journal System (PBJ) system . Review of Quarterly Payroll Based Journal (PBJ) dated 7/1/2023 - 9/30/2023 showed, .Failed to Submit Data for the Quarter . During an interview on 2/6/2024 at 9:22 AM, the Administrator confirmed the facility failed to submit the PBJ data, by the required deadline, for the fourth quarter of 2023.

Based on Resident Assessment Instrument (RAI) Manual, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (#46) of 27 residents reviewed. The findings include: Review of the Resident Assessment Instrument (RAI) Manual dated 10/2011 showed .The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals .the assessment process includes direct observation, as well as communication with the resident and direct care staff . Review of the medical record showed Resident #46 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease and Peripheral Vascular Disease. Review of the Quarterly MDS assessment dated [DATE] showed .Section K .Feeding tube . During an observation on 2/4/2024 at 10:40 AM, Resident #46 was sitting up in bed with no tube feeding in place. During an interview on 2/5/2024 at 7:45 AM, Registered Nurse (RN) #1 stated .Resident #46 has never had a tube feeding to his knowledge . During an interview on 2/5/2024 at 11:26 AM, with the Director of Nursing (DON), Minimum Data Set (MDS) Coordinator #1 and MDS Coordinator #2 confirmed the MDS completed on 1/15/2024 was not accurate.

Based on facility policy review, medical record review, and interview, the facility failed to update a Pre-Admission Screening and Resident Review (PASARR) after a new mental health diagnosis (Anxiety) was added for 1 resident (Resident #40) of 5 residents reviewed for PASARR. The findings include: Review of the facility's policy titled Screening and Resident Review (PASARR) dated 8/2019, showed, .federally mandated advocacy process that requires that anyone who is admitted to a Medicaid-funded NF [Nursing Facility] be screened to identify the presence of serious mental illness .purpose of conducting PASRR [PASARR] is to ensure that the nursing facility is the most appropriate place for the person to live and receive services . Resident #40 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Atrial Fibrillation, Anxiety and Dementia. Review of a PASARR dated 3/12/2021, showed Resident #40 had no mental health diagnosis known or suspected. Review of a Physician Admission/ Readmit Order dated 11/27/2023, showed Resident #40 had readmitted to the facility with Anxiety added as a new diagnosis. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], showed Resident #40 had an active diagnosis of Anxiety and received anti-anxiety medications. Review of Resident #40's comprehensive care plan revised 1/3/2024, showed .Dx [diagnosis] of Anxiety .observe for behaviors . During an interview on 2/6/2024 at 9:50 AM, the Business Development Coordinator confirmed Resident #40's PASARR had not been updated after a new mental health diagnosis (Anxiety) was added when readmitted .

Based on facility policy review, observation and interview, the facility failed to ensure proper infection control practices during the medication administration for 1 resident (#50) of 3 residents reviewed for medication administration. The findings include: Review of the facility policy titled Medication Administration-General Guidelines showed, .the person administering medications adheres to good hand hygiene .if breaking tablets are necessary to administer proper doses, hand hygiene is performed, and examination gloves are worn prior to handling tablets . Review of the medical record showed Resident #50 was admitted on [DATE] and readmitted on [DATE] with diagnoses including Chronic Respiratory Failure, Congestive Heart Failure and Dementia. Review of the current physician's recapitulation orders showed, .Baclofen (medication for muscle spasms) 5 mg (milligrams) .three times a day .Nuedexta (medication for Pseudobulbar affect) .two times a day . During observation of a medication administration on 2/5/2024 at 7:40 AM, Registered Nurse (RN) #1 prepared medications for Resident #50, dropped the Baclofen pill on the unclean medication cart, picked the medication up with an ungloved hand and put into a medication cup. Continued observation showed the RN obtained the Nuedexta with an ungloved hand, broke the tablet and placed the medication into the cup and administered the medications to Resident #50. During an interview on 2/4/2024 at 7:55 AM, RN #1 stated the Baclofen dropped on the medication cart should have been discarded and another pill obtained. RN #1 stated the hands should have been washed and gloves donned prior to breaking the Nuedexta tablet to obtain the prescribed dose. During an interview on 2/4/2024 at 9:20 AM, the Director of Nursing (DON) confirmed it was her expectation for medications dropped to be discarded and hands washed, and gloves donned prior to breaking of medications to be administered.

Based on facility policy review, observation and interview, the facility failed to post daily staffing information. The findings include: Review of the facility's policy titled Posting of Nurse Staffing dated 12/2023, showed .staffing information will be posted and/or updated at the beginning of each shift by the designated staff member . During an observation on 2/4/2024 at 10:15 AM, showed the daily staff posting was dated 2/2/2024. During an interview on 2/4/2024 at 11:32 AM, the Administrator stated it was his expectation daily staffing was posted. The Administrator confirmed the daily staffing was not updated and posted as required.

Based on facility policy review, medical record review, observation and interview, the facility failed to ensure a level I PASSAR [Preadmission screening and resident review]was submitted for 1 resident (#25) of 5 residents reviewed for PASSAR. The findings include: Review of the facility policy titled, Screening and Resident Review (PASSARR) dated 8/2019, showed .PASRR a federally mandated advocacy process that requires that anyone who is admitted to a Medicaid-funded NF [Nursing Facility] be screened to identify the presence of serious mental illness, intellectual disability, or development disability or related condition. The purpose of conducting PASRR is to ensure that the nursing facility is the most appropriate place for the person to live and receive services . Resident #25 was admitted to the facility on [DATE] with diagnoses including Psychosis (10/2016), Anxiety Disorder (2/2023), Adult Failure to Thrive (4/2023), and Dementia (10/2022). Review of Resident #25's Comprehensive Care Plan dated 11/04/2016, revealed Resident #25 had an Impaired cognitive function r/t (related to) Dementia with psychosis and Adult Failure to thrive. Medical record review revealed Resident #25 had no PASSAR included in the facility's record. During an observation/interview on 2/5/2024 at 3:18 PM, the Director of Nursing (DON) provided a document titled, Admission Notice and stated .there's not a level I PASSAR on file for [Resident #25 name] . During an interview on 2/6/2024 at 9:50 AM, revealed the Business Development Coordinator (BDC) confirmed Resident #25 was admitted to the facility without a level I PASSAR. The BDM stated she understood the resident was .grandfathered in and did not need a PASSAR . Interview confirmed Resident #25 had an additional mental health diagnoses of Anxiety Disorder and Adult Failure to Thrive. The facility failed to submit to the designated agency for a level I PASSAR for Resident #25.

Based on observation, review of manufacture instructions, and interview the facility failed to maintain the dishwasher in the manufacture parameters for low temperature machine parameters affecting 61 of 65 residents. The findings include: Observation of the facility dishwasher revealed the following parameters posted on dishwasher: .Chemical Sanitizing .Final rinse minimum temperature 120 degrees . Observation and interview with the Assistant Dietary Manager on 6/22/2021 at 8:45 AM, of the dishwasher revealed the washer was being used as a low temperature washer with chemical sanitation. Continued observation and interview revealed the washer minimum low temperature was 120 degrees when used as a chemical machine with the current reading after 2 attempts of 110 degrees maximum. Review of a Dishwashing/Warewashing Machine Temperature Log with the Assistant Dietary Manager revealed the recordings for 6/19/2021 through 6/21/2021 revealed wash temperature recordings of 106 degrees. Interview revealed the Assistant Manager was aware the final rinse temperature was to be 120 degrees minimum and unaware of the low temperatures on 6/19/2021 through 6/21/2021. Review of the manufacture instructions revealed .machine available in high or low temperature operation with specifications of being used as low temperature machine of final rinse temp (temperature) of 120 degrees . Interview with the dishwasher manufacture Branch Manager on 6/23/2021 at 8:17 AM, by phone, revealed the dishwasher was being used as a low temperature machine and the minimum temperature for low temperature chemical sanitation was 120 degrees. Interview with the Interim Dietary Manager on 6/22/2021 at 9:14 AM, confirmed the dishwasher was a being used as a low temperature machine and the minimum temperature was to be at 120 degrees on the final wash. Continued interview and observation with the Interim Dietary Manger confirmed he was unaware of the low temperature recordings prior to surveyor identification, and confirmed the facility failed to maintain the dishwasher in the required parameters.

Based on facility policy review, medical record review, and interview, the facility failed to accurately update a care plan for 1 resident (Resident #20) of 24 sampled residents. The findings include: Review of the facility policy Baseline Care Assessment and Comprehensive Care Plan, dated 7/2019, revealed .care plan is evaluated and changed .whenever there is a change in the resident .reviewed and revised no less than with the completion of each .MDS [Minimum Data Set] assessment . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment dated [DATE] revealed Resident #20 was unable to complete a Brief Interview for Mental Status (BIMS), and was dependent with toileting, hygiene, and bathing. Record review of the physician orders dated 11/10/2020, revealed the urinary catheter was discontinued. Medical record review of Resident #20's comprehensive care plan dated 4/1/2021 revealed the care plan was not revised to reflect the discontinuation of the indwelling catheter. Interview with the Director of Nursing, MDS Coordinator #1, and MDS Coordinator #2 on 6/23/2021 at 8:15 AM, confirmed Resident #20 did not have a urinary catheter and the care plan dated 4/1/2021 was incorrect. Continued interview confirmed the facility failed to revise Resident #20's care plan to reflect the changes in interventions after discontinuation of the indwelling urinary catheter.

Based on facility policy review, observation and interview, the facility failed to ensure expired medications were not available for resident use for 4 residents (Resident #6, Resident #56, Resident #48, Resident #20) of 65 residents reviewed. The findings include: Review of a facility policy, Specific Medication Administration Procedures IIB1 Administration Procedures for all medications, undated, revealed .check expiration date on package/container before administering any medication . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses to include End Stage [CONDITION(S)], [CONDITION(S)], and Neuromuscular Dysfunction of Bladder. Review of a Physician's Order for Resident #6 dated 2/19/2021 revealed .[MEDICATION(S)] Solution [antibiotic] 40 mg/ml [unit of measure] [milligram per milliliter]. Use 80 mg [unit of measure] [milligram] via irrigation one time a day every Friday . Observation and interview with Licensed Practical Nurse (LPN) #1 and Director of Nursing (DON) on 6/23/2021 at 10:38 AM, at the A-Wing medication refrigerator revealed the following expired medication: (Resident #6) [MEDICATION(S)] Sulfate Solution 40 mg/ml bladder irrigation. Use 80 mg via irrigation one time a day every Friday. Continued observation revealed 100 ml remaining in a 400 ml bottle with an expiration date of 6/17/2021. Interview confirmed the expired medication was available for resident use and the facility failed to discard the expired medication. Review of the Medication Administration Record (MAR) for Resident #6 dated 6/18/2021 revealed Resident # 6 received one dose of the expired medication. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses to include Gastroesophageal Reflux Disease (GERD), Type2 Diabetes Mellitus, [CONDITION(S)] and Dysphagia (difficulty swallowing). Review of a Physician's Order for Resident #56 dated 7/21/2020 revealed .[MEDICATION(S)] Suspension [medication to reduce stomach acid in liquid form] 2 mg/ml. Give 10 ml by mouth one time a day . Observation and interview with LPN #1 and DON on 6/23/2021 at 10:40 AM, at the A-Wing medication refrigerator revealed the following expired medications: (Resident #56) [MEDICATION(S)] Suspension 2 mg/ml Give 10 ml by mouth one time a day. Continued observation revealed 90 ml remaining in a 240 ml bottle with an expiration date of 6/20/2021. Resident #56 [MEDICATION(S)] Suspension 2 mg/ml Give 10 ml by mouth one time a day. Continued observation revealed 130 ml remaining in a 240 ml bottle with an expiration date of 6/21/2021. Interview confirmed expired medications were available for resident use and the facility failed to discard the expired medication. Review of the MAR for Resident #56 dated 6/20/2021-6/23/2021 revealed Resident #56 received four doses of the expired medication. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses to include Type2 Diabetes Mellitus, Dysphagia, Essential Hypertension, and [CONDITION(S)] (irregular heartbeat). Review of a Physician's Order for Resident #48 dated 8/18/2020 revealed .[MEDICATION(S)] Suspension 2 mg/ml Give 10 ml by mouth one time a day . Observation and interview with LPN #1 and DON on 6/23/2021 at 10:42 AM, at the A-Wing medication refrigerator revealed the following expired medications: (Resident #48) [MEDICATION(S)] Suspension 2 mg/ml Give 10 ml by mouth one time a day. Continued observation revealed 110 ml remaining in a 240 ml bottle with an expiration date of 6/18/2021. Interview confirmed expired medications were available for resident use and the facility failed to discard the expired medication. Review of the MAR for Resident #48 dated 6/18/2021-6/22/2021 revealed Resident #48 received four doses of the expired medication. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses to include Chronic Heart Failure (CHF), Dysphagia, and Coronary Artery Disease (heart disease). Review of a Physician's Order for Resident #20 dated 8/18/2020 revealed .[MEDICATION(S)] Suspension 40 mg via PEG tube [percutaneous endoscopic gastrostomy] [feeding tube] one time a day . Observation and interview with Registered Nurse #1 and DON on 6/23/2021 at 10:50 AM, at the B-Wing medication refrigerator revealed the following expired medications: (Resident #20) [MEDICATION(S)] Suspension 20 mg/10 ml. Give 40 mg via PEG tube. Continued observation revealed 100 ml remaining in a 240 ml bottle with an expiration date of 6/8/2021. Interview confirmed expired medications were available for resident use and the facility failed to discard the expired medication. Review of the MAR for Resident #20 dated 6/8/2021-6/22/2021 revealed Resident #20 received 15 doses of the expired medication.

Based on medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #20) of 24 sampled residents. The findings include: Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment dated [DATE] revealed Resident #20 was unable to complete a Brief Interview for Mental Status (BIMS), and was dependent with toileting, hygiene, and bathing. Continued review showed the resident was assessed as having an indwelling urinary catheter. Record review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the significant change MDS assessment dated [DATE], revealed in Section H Resident #20 had an indwelling urinary catheter. Interview with MDS Coordinator #1 on 6/22/2021 at 1:35 PM, confirmed Resident #20's significant change MDS assessment dated [DATE], Section H, titled Bladder and Bowel indicated Resident #20 had an indwelling urinary catheter. Continued interview confirmed Resident #20 did not have a urinary catheter and his MDS was inaccurate and stated .that was my mistake . Interview with MDS Coordinator #2 on 6/22/2021 at 1:40 PM, confirmed Resident #20's significant change MDS assessment dated [DATE], Section H, titled Bladder and Bowel indicated Resident #20 had an indwelling urinary catheter. Continued interview confirmed Resident #20 did not have a urinary catheter and the MDS was inaccurate. Interview with Director of Nursing on 6/22/2021 at 1:50 PM, confirmed Resident #20 did not have an indwelling urinary catheter and the significant change MDS assessment dated [DATE] was inaccurate.

Based on facility policy review, facility record review of a contracted vender, observation, and interview, the facility failed to monitor for rodents and other pests in a sanitary manner for 1 of 1 kitchen possibly affecting 72 of 73 residents. The findings included: Review of the facility policy Food Preparation, Storage, Distribution revised 9/2016 revealed .procedures will be followed to ensure a safe food supply with food quality . Review of the contracted termite and pest control company invoice dated 6/26/18 revealed catchmaster glueboard 3 in (inch) (mouse and insect glue board, pre-baited to attract mice and insects). Observation and interview with the Dietary Manager (DM) on 7/30/18 at 9:45 AM, at the stove/oven in the kitchen, revealed food cooking on 2 of the gas burners on the stove top. Continued observation inside the oven revealed a 3 inch long box without sides labeled super catchmaster. Interview with the DM confirmed the super catchmaster .is glue tape .for monitoring traffic .shouldn't be in the oven . Interview with the Director of Dietary Services on 7/31/18 at 10:40 AM, in the Conference Room confirmed the facility failed to monitor for rodents and pests in a sanitary manner.

Based on the facility policy review, observation and interview the facility failed to store foods in a sanitary manner in 1 of 1 walk-in freezer, and 1 of 1 walk-in refrigerator observed in the kitchen. The findings included: Review of the facility policy, Food Preparation, Storage, Distribution with an effective date 4/2009 revealed .All foods are kept in their originally labeled containers until opened .After opening, they are dated and labeled for storage .Any foods prepared for future use will be labeled with the content and date of expiration . Observation on 5/30/17 from 10:05 AM to 10:22 AM of the walk-in freezer and walk-in refrigerator with the Dietary Manager (DM) and the Chef Manager revealed the following: A) One 5 pound bag approximately half full of frozen french fries unlabeled, undated open to air in the walk-in freezer. B) One bag of 11 country fried chicken steak patties open to air, undated in the walk-in freezer. C) One bag containing 9 vegetable patties, undated, unlabeled in the walk-in freezer. D) One bag approximately 1/3 full of breakfast potatoes open to air, undated in the walk-in freezer. E) One bag approximately 1/3 full of parsley undated, unlabeled in the walk-in refrigerator. F) One 5 pound bucket of [MEDICATION NAME] (pimento) cheese approximately 1/3 full undated, in the walk-in refrigerator. All items were available for resident consumption. Interview with the DM on 5/30/17 at 10:24 AM in the kitchen, confirmed the facility failed to follow their policy. Continued interview confirmed the facility failed to store food in a sanitary manner with undated, open to air, and unlabeled items available for resident consumption in the walk-in freezer and the walk-in refrigerator.

Based on the facility policy review, medical record review, and interview the facility failed to assess 1 resident (#53) of 4 residents reviewed for nutrition of 29 residents reviewed. The findings included: Review of the facility policy, Nutrition Alert Committee (Nursing Home), with an effective date 11/2013 revealed .A systematic interdisciplinary approach is in place to identify, track, intervene, and monitor residents who are at risk for weight loss .The Committee will minimally consist of .Dietician/Designee .Director of Nursing .Nursing Mangers .The resident is reviewed by the Committee based on the following criteria .Has experience significant weight loss (5% in one month) .The interdisciplinary team is responsible for determining (but not limited to) .If the resident's diet order needs to be adapted or liberalized to better meet their needs .If supplements or fortified foods should be introduced .If the resident needs reassessing to assure their nutritional needs are being met . Medical record review revealed Resident #53 was admitted the facility on 2/8/17 with [DIAGNOSES REDACTED]. Medical record review of the Registered Dietician (RD) note dated 2/11/17 revealed .PO (by mouth) intake of regular diet varies from poor-good .Will monitor .Will continue current nutritional POC (plan of care) & (and) monitor wt (weight)/po intake . Medical Record Review of the Admission Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 (indicating the resident was severely cognitively impaired). Continued review revealed the resident had no swallowing difficulties and no weight loss. Further review revealed the resident was independent with eatting and required assistance with set up only. Medical record review of the Care Plan dated 2/27/17, revealed .Potential for nutritional needs not to be met related to [DIAGNOSES REDACTED]. Continued review of the interventions in place revealed .Monitor the weights .Registered Dietician consult as needed . Medical record review of the Weights and Vitals Summary from 2/9/17 to 4/18/17 revealed the following weights: A) 2/9/17 206 pounds. B) 2/13/17 199 pounds. C) 2/20/17 196 pounds. D) 3/17/17 194 pounds. E) 4/18/17 185 pounds. Continued review revealed Resident #53 had a significant weight loss of greater than 10% in less than 90 days. Medical record review of the Order Summary report dated 2/2017- 3/2017 revealed Resident #53 was prescribed a regular diet with a regular consistency, and regular thin liquids. Continued review revealed no order of supplements added the resident's diet. Interview with the Registered Dietician (RD) on 5/31/17 at 3:50 PM, in the conference room, confirmed the RD was unaware of Resident #53's weight loss of greater than 10% (significant weight loss) from 2/9/17- 4/18/17 until 4/18/17. Further interview confirmed the facility failed to identify the resident with significant weight loss. Interview with the Director of Nursing (DON) on 5/31/17 at 3:46 PM, in the conference room, confirmed the facility's computer system had failed to prompt the facility of the resident's significant weight loss from 2/9/17- 4/18/17. Continued interview confirmed the facility failed to review Resident #53 in the Interdisciplinary team Nutrition Alert Committee meeting for significant weight loss from 2/9/17- 4/18/17. Continued interview confirmed the facility failed to identify Resident #53 had significant weight loss until 4/18/17.

Based on medical record review and interview the facility failed to follow a nutritional care plan for 1 resident (#53) of 4 residents reviewed for weight loss. The findings included: Medical record review revealed Resident #53 was admitted to the facility on [DATE],with [DIAGNOSES REDACTED]. Medical record review of the Registered Dietician (RD) note dated 2/11/17, revealed .PO (by mouth) intake of regular diet varies from poor-good .Will monitor .Will continue current nutritional POC (plan of care) & (and) monitor wt (weight)/po intake . Medical record review of the Admission Minimum (MDS) data set [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 (indicating the resident was severely cognitively impaired). Continued review revealed the resident had no swallowing difficulties and no weight loss. Medical record review of the Care Plan dated 2/27/17, revealed .Potential for nutritional needs not to be met related to [DIAGNOSES REDACTED]. Continued review of the interventions in place revealed .Registered Dietician consult as needed . Medical record review of the Weights and Vitals Summary dated 2/9/17 - 4/18/17, revealed the resident had a significant weight loss of greater than 10% in less than 90 days. Interview with the Registered Dietician (RD) on 5/31/17 at 3:50 PM, in the conference room, confirmed the facility failed to follow Resident #53's care plan by not obtaining an RD consult for weight loss until 4/18/17. Interview with the Director of Nursing (DON) on 5/31/17 at 3:46 PM, in the conference room, confirmed the facility failed to follow the care plan by failure to obtain a RD consult.

Based on medical record review, observation, and interview the facility failed to accurately code a Minimum Data Set (MDS) for 1 resident (#34) of 3 residents reviewed for weight loss of 29 sampled residents. The findings included: Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's computerized weight tracking tool revealed Resident #34 weighed 204.6 pounds on 3/24/17 and 193.8 pounds on 4/13/17 revealing a 5.27% weight loss within a 30 day period. Review of a 30 day MDS assessment dated [DATE], Swallowing/Nutritional Status, Weight Loss section revealed, No or unknown had been marked. Interview with the Registered Dietitian (RD) on 05/31/2017 at 3:44 PM, in the conference room confirmed Resident #34 had a weight loss of 5.27 % in 30 days. Continued interview confirmed the facility failed to accurately code the MDS on 4/19/17 to reflect the significant weight loss. Interview with the MDS Coordinator on 05/31/2017 at 4:20 PM, in the conference room confirmed Resident #34 had greater than 5% weight loss during the MDS look back period for the MDS dated [DATE], and the facility failed to accurately code the MDS for weight loss.

Based on medical record review, review of facility investigation, and interview, the facility failed to execute a safe transfer using an assistive device (gait belt), which resulted in a fractured right shoulder with pseudosublixation (partial separation) requiring immobilization, for 1 resident (#7), of five residents reviewed for accidents, of 10 sampled residents, which resulted in harm to Resident #7. The findings included: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and unable to complete the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of two for transfers, and was totally dependent on 2 staff members for dressing and hygiene/bathing. Medical record review of the resident's plan of care dated 11/17/15 revealed .Transfers - Assist X (times) 2 with use of gait belt. Avoid use of lift . Medical record review of an Order Summary Report run on 2/1/17, revealed an order dated 8/23/16, .2 Person assist with Gait Belt (Do not use lift) every shift . Medical record review of a nurse's note dated 1/31/17 at 4:56 PM, revealed .CNAs were putting the resident to the bed when they heard a pop .examined her and it appears the right affected shoulder may have dislocated. I called (physician) and received orders for an xray . Medical record review of the X-ray report dated 1/31/17 revealed, .suspect fracture of the humeral head/neck and inferior subluxation of the humeral head . Review of a facility investigation witness statement dated 1/31/17, completed by Certified Nurse Aide (CNA) #3, revealed, at 4:30 PM, .(CNA #7) and I asked (Resident #7) if she wanted to lay down and she said yes. We took (Resident #7) to her room and changed her into a gown. We picked (Resident #7) up under her arm and by the waist line of her pants. During the middle of her transfer we heard a loud pop and immediately laid her down and checked her, we notified our nurse. I was looking at (Resident #7) shoulders because they looked different and asked my nurse if that was normal . Review of a facility investigation witness statement dated 1/31/17, completed by CNA #7, revealed at 4:30 PM, .Me and my partner took (Resident #7) into her room to lay her down and change her. We put her into a gown we picked her up under her arm and by the pants waist line. During the transfer we heard a loud pop. We layed (Resident #7) down and checked her to make sure everything was alright. We notified .our nurse .Her right shoulder looked different then before . Medical record review of a physician's orders [REDACTED].use a gait belt (with) all transfers - use of 2 (or more) staff . Medical record review of a Progress Noted dated 1/31/17 at 8:16 PM, revealed, .New orders for gait belt to transfer and to use 2 or more staff members . Medical record review of a physician's orders [REDACTED].N.O. (new order) for sling & swath . Medical record review of a computed tomography (CT) report dated 2/1/17, revealed, .Proximal humeral fracture as described with inferior subluxation of the humeral head . Medical record review of a physician's progress note dated 2/1/17 revealed .right shoulder is not dislocated but there is a subluxation noted . Medical record review of a physician's orders [REDACTED].Continue sling to Rt (right) arm .Obtain xray of right shoulder in 7 to 10 days . Observation of Resident #7 on 2/16/17 at 9:30 AM, revealed the resident was up in her wheelchair self-propelling around the dining room. Continued observation revealed the resident was pleasantly confused and unable to answer questions. Telephone interview with CNA #3 on 2/16/17 at 10:55 AM, revealed she and CNA #7 were transferring Resident #7 to the bed when they heard a pop. Continued interview revealed .two CNAs always transfer (the resident) due to she is very fragile and doesn't stand well . Further interview revealed both CNA #7 and #3 had a hand under each of the resident's arms and had hold of the resident's pants waistband to transfer the resident. Continued interview revealed .this is how we transfer (the resident) .did not know we should have used a gait belt . Continued interview revealed CNA #3 was unaware a gait belt was to be used for transfers for Resident #7 and confirmed a gait belt was not used during the transfer of Resident #7 on 1/31/17. Interview with CNA #7 on 2/21/17 at 2:00 PM, in the Board Room, revealed on 1/31/17 the resident was in the hallway and the CNA asked the resident if she wanted to lie down. Continued interview revealed .(Resident #7) can say yes or no .we (CNA #3 and #7) took the resident into her room to lie her down .we raised her good arm to remove the shirt and then removed the shirt from her bad arm and put a clean gown on .we lifted (the resident) up close to the bed with each having 1 hand under an arm and the other hand on the waistband of the (resident's) pants .we stood her up with her left foot touching the floor and heard a pop sound .(the resident) made no sound and had no changed facial expressions .we laid (the resident) down and examined her and went to report to the nurse .(the resident) fell to sleep and did not show any signs of pain .the shoulder just did not look normal .we lifted her the same as we always have lifted her with no problems in the past . Further interview revealed .never thought of using a gait belt before . Interview with the Director of Nursing (DON) on 2/16/17 at 11:00 AM, in the Board Room, confirmed the resident was to be transferred by two staff persons and with use of a gait belt, and the two CNAs failed to use a gait belt while transferring Resident #7 to bed on 1/31/17, resulting in injury to the resident.

Based on medical record review, review of facility investigation, and interview, the facility failed to implement care plan interventions to prevent injury while transferring a resident, which resulted in a fractured right shoulder with pseudosublixation (partial separation) requiring shoulder immobilization, for 1 resident (#7), of five residents reviewed for accidents, of 10 sampled residents, resulting in harm to Resident #7. The findings included: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and unable to complete the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of two for transfers and was totally dependent on 2 staff members for dressing and hygiene/bathing. Medical record review of the resident's care plan, initiated 11/17/15, revealed the resident had a self care deficit and an intervention initiated 11/17/15 was, .Transfers - Assist X (times) 2 with use of gait belt. Avoid use of lift . Continued review of the care plan revealed the resident was a fall risk and an intervention for prevention of falls, initiated on 11/29/16, was .2 person lift with gait belt . Medical record review of a nurse's note dated 1/31/17 at 4:56 PM, revealed .CNAs were putting the resident to the bed when they heard a pop .examined her and it appears the right affected shoulder may have dislocated. I called (physician) and received orders for an xray . Medical record review of the X-ray report dated 1/31/17 revealed, .suspect [MEDICAL CONDITION] head/neck and inferior subluxation of the humeral head . Review of a facility investigation dated 1/31/17 revealed Certified Nursing Assistant (CNA) #3 and CNA #7 .stated around 4:30 PM the 2 CNA's went to change (Resident #7) and lay her down to bed .CNAs took the resident to her room and changed her into a gown .picked the resident up under her arm and the waist line of her pants .During the middle of the transfer the CNAs heard a 'loud pop' and immediately laid (the resident) down and checked her .CNAs noted when looking at the shoulders they looked different .CNAs notified the nurse and the Director of Nursing (DON) of the incident . Telephone interview with CNA #3 on 2/16/17 at 10:55 AM, revealed she and CNA #7 were transferring Resident #7 to the bed when they heard a pop. Continued interview revealed .two CNAs always transfer (the resident) due to she is very fragile and doesn't stand well . Further interview revealed both CNA #7 and #3 had a hand under each of the resident's arms and had hold of the resident's pants waistband to transfer the resident. Continued interview revealed .this is how we transfer (the resident) .did not know we should have used a gait belt . Continued interview revealed CNA #3 was unaware a gait belt was to be used for transfers for Resident #7 and confirmed a gait belt was not used during the transfer of Resident #7 on 1/31/17. Interview with CNA #7 on 2/21/17 at 2:00 PM, in the Board Room, revealed confirmed a gait belt was not used to transfer the resident and the CNA .never thought of using a gait belt before . Interview with the DON on 2/16/17 at 11:00 AM, in the Board Room, confirmed the 2 CNAs failed to follow the resident's care plan for use of a gait belt during transfers, resulting in harm to Resident #7 on 1/31/17. Refer to F323

Based on medical record review, review of facility investigation, and interview, the facility failed to ensure a resident was free of chemical restraints used as means of convenience and discipline for 1 resident (#1) of 10 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Further review revealed Resident #1 required extensive assistance for transfer, dressing, and hygiene/bathing. Medical record review of a nursing progress note dated 11/6/16 at 8:50 PM, written by Licensed Practical Nurse (LPN) #2, revealed .(Resident #1) called to be gotten out of bed right now .it was time to smoke .told by aide it would be a few minutes .got mad and asked to speak to nurse .this nurse did try to explain to resident that other residents were still being put to bed and that we would get him up .stated he didn't care about them that he was going to smoke .stated he was gonna knock my head off and to get out of his way that he was getting up NOW by himself and going to smoke and we couldn't stop him .exhibited actions that suggested he was gonna try to get up and I asked resident to wait .an aide was found and resident was assisted grudgingly to be helped into his chair. Resident came up hall demanding to be let out to smoke .explained it was gonna be a few minutes .Security just happened to be making rounds and resident saw him and stated he 'didn't give a (expletive) if we called the police or not we were not gonna stop him from smoking' and said he would tear up as much as possible till he got what he wanted .new order for [MEDICATION NAME] (sedative medication) 5 mg (milligrams) IM (intramuscular) was received and given . Further review of the progress notes revealed LPN #2 documented [MEDICATION NAME] 5 mg IM was administered at 9:50 PM. Review of the note, documented by LPN #2, revealed the resident's response the medication was .Resident was somewhat calmer 30 minutes after injection. Once he was taken out to smoke. Review of the facility's investigation witness statement dated 11/7/16 and completed by the Occupational Therapist (OT) revealed the resident reported to the OT .The red headed nurse said I couldn't have any coffee, (LPN #2). I went off on them last night .I pushed my call light and waited and waited so I was gonna get up myself .(Resident #1 reported to the therapist) The nurse said 'I have 9 other patients to take care of also.' (Resident #1) reported after dinner he was in dining room and the security guard told him he will be getting a shot because of his behaviors .(Resident #1) reported the nurse stated 'you're going to take that shot no matter what' . Review of the facility's investigation revealed an interview was conducted by the Director of Nursing (DON) with Resident #1 on 11/7/16. Review revealed .(Resident #1) stated the red headed nurse (LPN #2) came in and he told her he wanted up to smoke and get coffee .she (LPN #2) told him no and he said would get himself up .(Resident #1) stated the other girls (Certified Nurse Aides (CNAs)) got him some coffee and he went to the dining room .(Resident #1) stated nurse (LPN #2) came in and told him he was going to get a shot . Resident #1 stated, after two CNAs came in and helped him transfer to his wheelchair, he went up to the nurses desk where he told LPN #2 all she did was sit all night. Resident #1 stated the CNAs got him some coffee and he went to the dining room where he watched TV and the security guard came and sat with him. Later the nurse came in and told him he was going to get a shot and the security guard, two CNAs and LPN #2 gave him the shot. After the shot the security guard sat with him and he continued to watch TV. He stated CNA #4 then took him out to smoke. Review of the facility's investigation witness statement dated 11/7/16, completed by LPN #2, revealed LPN #2 stated the CNAs were putting residents to bed and she was passing medications at 8:50 PM. LPN #2 stated she told Resident #1 he would have to wait to go smoke because they were still putting residents to bed. The resident stated he didn't care and he was going to smoke. LPN #2 stated she asked the resident to be patient but he said to get him up now before he knocked my head off. The resident stated if I didn't get him up he would get up by himself and threw the covers back and started grabbing his legs to pull them toward the edge of the bed. The nurse told him again to be patient because she couldn't get him up by herself. LPN #2 went and got assistance to get Resident #1 out of bed. LPN #2 then went back to the nurses' station, charting, when Resident #1 came up the hall and demanded to go smoke. LPN #2 told the resident again it was going to be awhile. LPN #2 stated the resident then stated if he couldn't do what he wanted to do he was going to mess[***]up. Review of the statement revealed, .(LPN #2) called the physician and got an order for [REDACTED].#2) went and got two CNAs and the security guard and lifted the resident up in a semi-standing position so I could give him the shot . Review of the facility's investigation witness statement dated 11/8/16, completed by the Security Guard, revealed .(Resident #1) was complaining about not having a smoking break and the nurse was saying his smoking was not a priority and other resident needs would have to be taken care of before his break .(Resident #1) became more agitated and swinging his left arm at the nurse who was standing on his left side .(resident) continued to be upset and cursing the nurse and at that time (Resident #1) was notified he had lost his smoking time for the rest of the night .after I returned from my rounds I was requested to assist with the shot .I went to the dining room where (the resident) was sitting .About 5-10 minutes later 3 nurses entered and told (Resident #1) the doctor had ordered a shot .(the resident) resisted vigorously but the nurse was able to administer the shot in his left hip .(the resident) calmed down almost immediately . The security guard stated when he had been sitting and talking with Resident #1, the resident appeared calm. Review of the facility's investigation witness statement dated 11/9/16, completed by CNA #4, revealed .(CNA #10) came to me and said (LPN #2) was ready to give (Resident #1) the shot .(LPN #2) told (Resident #1) she had a shot for him to calm him down .We sat him back down in the chair then (LPN #2) said something like that will teach you a lesson .(LPN #2) then stated there would be no smoking tonight . CNA #4 stated she did take the resident out to smoke. While outside CNA #4 stated she told Resident #1 she was sorry that all this happened. Medical record review revealed no documentation of distress by the resident and no changes in behavior or mood were noted. Review of a psychotherapy note on 11/10/16 revealed the resident was managing his previous symptoms well and there was no change in his mental health. During an interview with CNA #4 on 2/16/17 at 11:30 AM, in the Board Room, CNA #4 stated, at shift change, the day shift nurse stated Resident #1 wanted to get up on the last round to smoke, and LPN #2 replied they were not going to get him up. CNA #4 stated when the resident's call light went off and he wanted up, CNA #4 reported to LPN #2. LPN #2 went into Resident #1's room and CNA #4 went into another resident's room. CNA #4 stated she overheard both of them screaming at each other from Resident #1's room. LPN #2 came and asked CNA #4 to get assistance to get the resident up or he was going to attempt to get up himself. The resident was helped out of bed by two CNAs. The resident requested coffee and the CNAs went to the break area to make fresh coffee. While making the coffee, the CNAs overheard Resident #1 and LPN #2 arguing again. CNA #4 stated later CNA #10 came and got her to give the resident a shot. Resident #1 was sitting in the dining room calmly, and the security guard and CNA #9 assisted with positioning the resident for administration of the shot. After the shot, LPN #2 made a comment you're not in charge or you'll realize who is in charge. Resident #1 continued to sit in the dining room to watch TV. CNA #4 later took the resident out to smoke and then the two CNAs helped him to bed. CNA #4 stated the resident apologized for his behavior to the CNAs, but not for his behavior with LPN #2. Interview with Resident #1 on 2/16/17 at 2:25 PM, in his room, revealed he .got into it with the red headed nurse .after getting out of bed I went to the nurses station and me and (LPN #2) had a few more words .(LPN #2) came in and told me she was giving me a shot to calm down .it took 5 people to give me the shot . Interview with CNA #9 on 2/21/17 at 7:15 AM, in the Board Room, revealed she was at another nurses' station on the evening of 11/6/16, when LPN #2 came to get her for help. Continued interview revealed .(LPN #2) told (Resident #1) he had just earned himself a [MEDICATION NAME] shot .(CNA #9) went into the dining room (Resident #1) was watching TV and when (LPN #2) came in (the resident) said .you are not giving me a (expletive) shot . Interview with the Administrator and the DON on 2/22/17 at 11:15 AM, in the Board Room, confirmed LPN #2 administered a sedative medication ([MEDICATION NAME] - a chemical restraint), to Resident #1.

Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to honor resident rights to refuse administration of a medication for 1 resident (#1) of 10 residents reviewed. The findings included: Review of the facility's policy titled Refusal of Treatment dated May 2013, revealed .Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician .The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by a physician . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Medical record review of the physician's orders [REDACTED]. Medical record review of a nursing progress note dated 11/6/16, written by Licensed Practical Nurse (LPN) #2, revealed .new order for [MEDICATION NAME] 5 mg IM was received and given . Further review of the progress notes revealed LPN #2 documented [MEDICATION NAME] 5 mg IM was administered at 9:50 PM. Review of the note, documented by LPN #2, revealed the resident's response to the medication was .Still mad .refusal of meds . Review of a facility investigation witness statement dated 11/7/16, completed by the Occupational Therapist (OT), revealed the resident reported to the OT .after dinner he (Resident #1) was in dining room and the security guard told him he will be getting a shot because of his behaviors .(Resident #1) reported he was getting upset and said 'I'll take my pills but you are not giving me a shot.' (Resident #1) reported the nurse stated 'you're going to take that shot no matter what . Review of the facility's investigation revealed an interview was conducted by the Director of Nursing (DON) with Resident #1 on 11/7/16; .(Resident #1) stated he received a shot after refusing it from the nurse (LPN #2) .(Resident #1) stated nurse (LPN #2) came in and told him he was going to get a shot and he said he refused the shot . Continued review revealed Resident #1 stated the security guard and two Certified Nurse Aides (CNAs) were in the dining room when the nurse gave him the shot and he was trying to scoot out of the chair to get away from the shot. Review of the facility's investigation witness statement dated 11/7/16, completed by LPN #2, revealed .(LPN #2) called the physician and got an order for [REDACTED].#2) went and got two CNAs and the security guard and lifted the resident up in a semi-standing position so I could give him the shot .(resident) said he wasn't taking a shot .we just turned him up on to the right side so I could get the shot in the left hip . Review of the facility's investigation witness statement dated 11/8/16, completed by a Security Guard, revealed .after I returned from my rounds I was requested to assist with the shot .I went to the dining room where (Resident #1) was sitting .About 5-10 minutes later 3 nurses entered and told (resident) the doctor had ordered a shot .(the resident) became very upset and said he would take some pills but he wouldn't take a shot .the nurse was able to administer the shot in his left hip . Review of the facility's investigation witness statement dated 11/9/16, completed by CNA #4, revealed .(CNA #10) came to me and said (LPN #2) was ready to give (Resident #1) the shot .(LPN #2) told (Resident #1) she had a shot for him to calm him down .He stated he did not want the shot .(Resident #1) tried sliding out of the chair to get away from the shot .(LPN #2) stated to turn him up and she gave him the shot . Review of the facility's investigation written statement dated 11/9/16, completed by CNA #9, revealed .(Resident #1) was sitting in the dining room calmly when (LPN #2) came in .(Resident #1) immediately began swinging at the nurse and telling her he wasn't taking any shot but he would take a pill .(Resident #1) was tilted enough to administer the injection in his left hip . Medical record review revealed no documentation of distress by the resident and no changes in behavior or mood were noted. Review of a psychotherapy note on 11/10/16 revealed the resident was managing his chronic ongoing symptoms well and there was no change in his mental health. Interview with CNA #4 on 2/16/17 at 11:30 AM, in the Board Room, revealed CNA #10 asked CNA #4 to come help the nurse give the resident a shot and .(Resident #1) stated he didn't want the shot because he doesn't know what is in it . CNA #4 stated the security guard and CNA #9 assisted with positioning the resident for the shot administration. Interview with Resident #1 on 2/16/17 at 2:25 PM, in his room, revealed he .after getting out of bed I went to the nurses station and me and (LPN #2) had a few more words .(LPN #2) came in and told me she was giving me a shot to calm down and I told her I ain't taking no dern thing . Resident #1 stated LPN #2 administered the medication after he refused. Interview with CNA #9 on 2/21/17 at 7:15 AM, in the Board Room, revealed on the evening of 11/6/16, .(CNA #9) went into the dining room. (Resident #1) was watching TV and when (LPN #2) came in (Resident #1) said .you are not giving me a (expletive) shot .I'll take a pill . Interview with the Administrator and the DON on 2/22/17, at 11:15 AM, in the Board Room, confirmed LPN #2 did not follow the facility's policy related to refusal of treatment and administered the injection of [MEDICATION NAME] after the resident refused.

Based on medical record review, facility Policy and Procedure review, observation and interview, the facility failed to prevent pressure sore development for two residents (#1, #3) resulting in harm to the residents, and failed to accurately assess and provide pressure sore treatment in a timely manner for one resident (#16) of twenty-six residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted to the facility on November 16, 2011, after a five day hospital stay with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident required extensive assistance for bed mobility and limited assistance for transfers. Medical record review of a Braden Risk scale (Predicts Pressure Sore Risk) dated November 11, 2011, revealed the resident was high risk for pressure sore development. Further medical record review revealed no documention a Braden Scale assessment had been completed for the readmission to the facility on [DATE]. Medical record review of the Nurse's Note dated November 16, 2011, revealed "...skin intact..." Medical record review of a Specialized Services dated November 16, 2011, revealed the resident was non-weight bearing for the left lower extremity. Medical record review of a Nurse's Note dated November 25, 2011, revealed "...3 cm (centimeter) x (by) 3 cm darkened area on residents R (right) heel..." Medical record review of a Physician's Order Sheet dated November 25, 2011, revealed "...Apply skin prep to R heel daily until healed..." Medical record review of a Nurse's Note dated December 2, 2011, revealed "...order obtained for heel protectors and off loading (floating) of heels while in bed..." Medical record review of the Physician's Order Sheet dated December 2, 2011, revealed "...Heel protectors to be worn at all times (right heel)...off loading of heels while in bed, heel protector to be worn on left heel except for transfers and ambulating..." Medical record review of the Care Plan dated December 4, 2011, revealed "...at risk for skin breakdown...on admission evaluate skin risk with Braden Scale...perform full body skin assessment...inspect skin daily...consult Registered Dietician as needed..." Medical record review of the Nutrition Note dated December 6, 2011, revealed "...res (resident) wt (weight) down to 120# (pounds) from 127...pt (patient) with wound (unstageable) will initiate...(nutritional supplement) and stress tab (tablet) wt weekly..." Medical record review of a Physician's Order Sheet dated December 6, 2011, revealed "...Stress Tab daily...Ensure 80 ml (milliliters) four times a day...second to wound... weight loss...needs with wound healing..." Medical record review of the Medication Record dated December 2011, revealed the first dose of the Stress Tab and Ensure was initialed as administered on December 7, 2011. Medical record review revealed the following Skin Assessment Forms: December 4, 2011, "...R heel 3 X 3..." December 23, 2011, "...R heel hard black tx (treatment) continue..." December 30, 2011, "...R heel 7.5 X 3 cm..." January 7, 2012, "...R heel 2.25 X 2.75..." January 12, 2012, "...R heel 2.15 X 2.5..." Review of a facility (untitled) policy and procedure , effective date August 2, 2001, revealed "...patient who enters the facility without pressure sores does not develop pressure sores...skin assessment made according to wound protocol...Braden Risk scale will be performed on admission..." Review of the facility's policy (undated) Skin and Wound Protocol revealed "...notify physician of wound status changes...obtain physician order for [REDACTED]. Observation on January 9, 2012, at 2:15 p.m., on the B-Wing revealed the resident sitting in a wheel chair with no heel protectors in place. Observation on January 9, 2012, at 3:00 p.m., in the resident's room, revealed the resident lying on the bed and heel protectors were not in place and the heels were not floated. Observation on January 10, 2012, at 8:00 a.m., on B-Wing hallway, revealed the resident sitting in the wheel chair and no heel protectors in place. Observation on January 10, 2012, at 3:30 p.m., in the resident's room, revealed the resident lying on the bed without heel protectors in place and the heels not floated. Interview on January 11, 2012, at 8:30 a.m., with the Director of Nursing (DON), in the B-Wing Nurse's Station confirmed the resident was moderately impaired for decision making, and confirmed the Braden Scale was not completed upon readmission (November 16, 2011); the right heel pressure sore was not identified until November 25, 2011, and a physician's order was not obtained until December 2, 2011, for heel protectors on at all times to the right heel. The DON confirmed the facility policy did not specify the frequency for skin assessments and confirmed weekly skin assessments had not been consistently completed. Further interview with the DON confirmed the pressure sore was identified on November 25, 2011, and the Registered Dietician did not assess the resident's nutritional status for pressure sore healing until December 6, 2011, when an order was obtained for nutritional interventions to promote wound healing. The DON confirmed the pressure sore was avoidable and the physician's orders for heel protectors and floating of the heels had not been consistently implemented. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident had severe cognitive impairment. Medical record review of a Braden Scale completed October 14, 2011, revealed the resident was high risk of developing a pressure sore. Review of the facility provided documentation (progress note) dated November 16, 2011, revealed "...abrasion right heel/blue/purple...1.5 X (by) 1 cm (centimeter)...reddened area around the abrasion, area closed, had tennis shoes on with no socks...could have potentially caused abrasion..." Medical record review of a Physician's Order Sheet dated December 5, 2011, revealed "...skin prep (preparation) daily until healed...2.5 cm X 2.3 cm darkened area on R (right) heel..." Review of the facility policy (undated) Skin and Wound Protocol revealed "...notify physician of wound status...obtain order for treatment..." Observation on January 9, 2012, at 9:40 a.m., revealed the resident was seated in a wheel chair and propelled self by sliding the feet in a back/forward motion on the floor to move self up and down the hallway outside of the resident's room. Interview and documentation review of a Nutritional Note dated December 27, 2011, with the ADON and the Registered Dietician (RD) on January 10, 2012, at 9:00 a.m. in the facility billing office confirmed there was no documentationthe RD was notified of the pressure sore (discovered on November 16, 2011) until December 27, 2011, at which time a Stress Tablet and a [MEDICATION NAME] level was recommended. Continued interview and review of the [MEDICATION NAME] level (ordered by the physician on December 29, 2011) results obtained on December 30, 2011, revealed the [MEDICATION NAME] results were 14.6 (low) ( range Low =18.0, High = 38). Observation with Charge Nurse #1 and the Assistant Director of Nursing (ADON) on January 10, 2012, at 11:12 a.m. in the resident's room revealed the resident had two dark areas on the right heel measuring 1 cm X .8 cm and .2 cm X .3 cm. Interview with the ADON on January 12, 2012, at 8:50 a.m., in thr Director's office confirmed the resident developed an avoidable pressure sore on the right heel; confirmed the facility failed to ensure socks were worn with shoes, and the resident used the feet to propel self in a wheel chair by sliding the feet on the floor. Continued interview confirmed the RD was not notified of the pressure sore until December 27, 2011. Resident #16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was at risk for developing pressure ulcers; always incontinent of bladder and bowel, and required total dependence cleansing self after elimination. Observation with the Assistant Director of Nursing (ADON), on January 11, 2012, at 3:20 p.m., in the resident's room revealed the resident had a sore to the left Great toe with a black area to the inner aspect of the sore and the second toe had a red area, draining clear fluid, to the inner aspect of the toe. Interview with the ADON on January 11, 2012, at 3:30 p.m., in the resident's room confirmed the resident had developed sores and the ADON stated the Licensed Practical Nurse would complete a wound assessment and notify the physician for orders. Medical record review of a Nurse's Note dated January 11, 2012, at 4:00 p.m., revealed "...checked all of residents wounds...left lower buttocks 1cm x .5 cm... " and no documentation of an assessment of the toes. Medical record review of the Skin Assessment Form dated January 11, 2012, revealed "Lt. (left) buttocks 1 cm X .5 cm area..." and no documentation of an assessment of the sores on the left foot. Medical record review completed on January 12, 2012, at 8:20 a.m., of the January 2012, Treatment Record revealed no new orders/treatments for the sores on the resident's buttocks/toes identified on January 11, 2012. Observation with the Director of Nursing (DON) and the ADON, on January 12, 2012, at 8:45 a.m., in the shower room, revealed the resident had a stage two pressure sore to left buttocks measuring 1cm x .5 cm. Medical record review of a Physician's Order Sheet dated January 12, 2012, at 1:00 p.m., revealed "...pt (patient) with new sores reported...great toe and buttocks...will continue to have breakdown periodically second to chronic medical problems..." Review of an undated facility policy titled Skin and Wound Protocol revealed "...notify physician of wound status changes...obtain physician order for [REDACTED]. Interview with the DON on January 12, 2012, at 8:50 a.m., at the B-Wing Nurse's Station, confirmed the resident had new areas of skin breakdown observed on January 11, 2012 and the skin assessment form completed January 11, 2012, did not include an assessment of the sores on the left toes. Further interview with the DON confirmed the physician was notified of the sores on January 11, 2012 and a treatment order was not obtained until January 12, 2012.