Every finding on record at The Birches at Trillium Woods

Based on observation and interview, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was provided to each resident residing in the facility and displayed for residents, visitors and staff to review. This had the potential to affect all 40 residents currently residing in the facility as well as all staff and visitors.Findings include: On 5/27/26 at 7:27 a.m. displayed next to double doors to enter first floor unit was the RBOR, dated 4/14/09. On 5/27/26 at 7:52 a.m. displayed next to double doors to enter second floor unit was the RBOR, dated 4/14/09. On 5/27/26 at 7:56 a.m. displayed next to double doors to enter third floor unit was the RBOR, dated 4/14/09. On 5/27/26 at 8:26 a.m. administrator stated they were not aware there were changes to the RBOR. At 9:21 a.m. administrator returned, stated they have now started the process of providing updates to the residents and resident representatives. They have not yet ordered new postings for the units. Facility Resident Resident Rights policy dated 10/24, indicated copies of the resident rights was posted throughout the facility, however, the policy did not indicate when the facility would provide notification of any changes in any State of Federal laws related to resident rights or facility rules during the residents stay in the facility.

Based on observation, interview and document review, the facility failed to ensure residents were free of medication errors of less than 5% for 1 of 2 residents (R58) observed for medication administration resulting in a 7.69% error rate.Findings include: R58's electronic medical record (EMR) was reviewed, the EMR indicated R58 had orders for:Lidocaine external gel 4% (local anesthetic applied to the skin to temporarily numb the area) apply thin layer to the area enoxaparin injection thirty minutes prior to injection once daily.Enoxaparin sodium injection solution prefilled syringe 40millegram(mg)/0.4milliliters (ml) (prescription blood thinner) inject 0.4ml subcutaneously (subq) one time daily administer lidocaine prior to injection. R58 was observed on 5/27/26, at 9:54 a.m. during a medication pass. Registered nurse (RN) - A removed an enoxaparin sodium injection solution prefilled syringe from R58's medication cabinet, RN-A administered the injection into R58's abdomen. On 5/27/26, at 10:22 a.m. RN-A stated she would approach R58 in about five minutes and apply the lidocaine gel. RN-A reviewed R58's EMR and stated, oh I should have applied that before the injection was done, I did not do it. When interviewed on 5/27/26, at 2:19 p.m. director of nursing (DON) stated the expectation was for nurses to review the residents' orders prior to administering medications to ensure they were correctly administering the medications as they were ordered by the provider. Facility Administering Medications policy stated 4/19, indicated medications were administered in accordance with prescriber orders, this included any required time frame.

Based on observation, interview and document review the facility failed to ensure provider orders were followed which caused pain for 1 of 1 residents (R58) reviewed.Findings include: R58's admission Minimum Data Set (MDS) dated [DATE], indicated R58 had severe cognitive impairment and was dependent on staff for activities of daily living (ADLs). R58's diagnoses included presence of artificial hip joint, anxiety, pain, femur fracture, and Alzheimers disease R58's care plan revised 5/6/26, indicated R58 was on pain medication therapy related to hip surgery, the care plan included an intervention to administer medications as ordered. During interview on 5/26/26, at 3:37 p.m. family member (FM)-A stated they had asked for lidocaine to be applied to R58's skin before she was given her injection to help decrease the pain it caused her. FM-A stated the nurses were not consistently doing the lidocaine before the injection, some were doing it after, some were not doing it at all, some would put it on one area then do the injection somewhere else. On 5/26/26, at 3:51 p.m. licensed practical nurse (LPN)-A entered R58's room to administer R58's injection, FM-A asked LPN-A if the lidocaine was going to be applied before the injection was given so she has less pain, LPN-A stated to FM-A no, we put it on after to take away the pain FM-A stated no, the lidocaine was supposed to be put on at least fifteen minutes before so she doesn't feel the injection, LPN-A repeated the lidocaine was put on after. LPN-A proceeded to give the injection, R58 screamed out ouch, ouch don't do that you jerk' while striking out at the nurse. R58's electronic medical record (EMR) was reviewed, the EMR indicated R58 had orders for:Lidocaine external gel 4% (local anesthetic applied to the skin to temporarily numb the area) apply thin layer to the area enoxaparin injection thirty minutes prior to injection once daily.Enoxaparin sodium injection solution prefilled syringe 40millegram(mg)/0.4milliliters (ml) (prescription blood thinner) inject 0.4ml subcutaneously (subq) one time daily. On 5/27/26, at 9:54 a.m. registered nurse (RN) - A removed an enoxaparin sodium injection solution prefilled syringe from R58's medication cabinet, RN-A administered the injection into R58's abdomen, R58 screamed out ouch, damn it you jerk, that hurt resident continued yelling at RN-A, grabbed RN-As arm then scratched the back of RN-A's hand. Staff offered R58 breakfast, R58 stated I don't want breakfast damn it. When interviewed on 5/27/26, at 10:22 a.m. RN-A stated they would reapproach R58 to apply the lidocaine gel to the injection site after R58 had time to calm down from getting upset after the injection. RN-A stated it would not be a good idea to try it now due to R58 was too upset and would not allow her to apply the gel. RN-A reviewed R58's EMR then stated oh I should have applied that before the injection was done, I did not do it. When interviewed on 5/27/26, at 2:19 p.m. director of nursing (DON) stated the expectation was for nurses to review the residents' orders prior to administering medications to ensure they were correctly administering the medications as they were ordered by the provider. DON stated applying the lidocaine after the injection would not help R58 with the pain from administration. Facility policy Pain Assessment and Management dated 2001. indicated staff to observe from behavioral signs of pain which included negative verbalizations and vocalizations such as groaning, crying and screaming; be3havior such as resisting care, irritability decreased participation in usual physical/social activities.

Based on document review and interview, the facility failed to ensure all residents were offered written notice for bed hold for 1 of 3 residents (R7) who were reviewed for discharges / transfers from the facility. Findings include - In review of R7's admission Record (print date 5/27/26), documented were the following diagnoses: effusion right elbow (a buildup of excess fluid within the elbow joint capsule), peripheral vascular disease, and end stage real disease with dependence on dialysis. A review of R7's most recent quarterly Minimum Data Set (MDS) dated [DATE], documented R7 was cognitively intact and required substantial - maximal assistance with activities of daily living. In review of R7's electronic medical records (EMR), Resident's progress notes documented the facility received a phone call at 12:00 p.m., from R7's dialysis unit, reporting resident should be seen in the emergency room (ER) due to experiencing pain in her right arm. R7's primary clinic was updated and orders received to send resident to the ER upon her return to the facility. After returning to the facility at 2:10 p.m., the facility sent R7 to the ER for further evaluation. The facility received a call later that evening from Methodist Hospital, informing the facility R7 had been admitted for further testing and MRI (Magnetic Resonance Imaging is a non-invasive medical test that uses powerful magnets and radio waves to create detailed, cross-sectional images of your body's organs, tissues, and skeletal system). Resident returned to the facility on 5/9/26, 3 days later. During an interview on 05/26/2026 at 2:05 p.m., R7 stated she had gone to the hospital earlier in the month but could not remember if she had been offered or signed a bed hold for the transfer. In further review of R7's EMR, there was no evidence the facility had offered resident a bed hold in writing. During interview on 5/27/26 at 10:21 a.m., the facilities licensed social worker (LSW) stated, when residents are transferred to the hospital, the resident, family / significant other are offered a bed hold, which is reviewed with them and is signed if a bed hold is requested. LSW stated until the forms are scanned into the EMR, they are located in the resident's paper hard chart at the nurses station. A review of R7's hard paper chart lacked evidence R7 and / or her family were offered a bed hold in writing. In a interview on 5/27/26 at 2:10 p.m., the director of nursing (DON) stated the staff might not have offered a bed hold while it is the courtesy of the corporation to hold a bed when someone goes to the hospital. During an interview on 5/27/26 at 3:43 p.m., both the DON and the administrator (ADM) stated they were unable to locate a signed / written bed hold for the 5/6/26 hospitalization of R7. Both the DON and ADM stated it would be the facility's expectation a bed hold be offered either to the resident and/or their family. In review of the facility's admission Packet (undated), the following was documented: Section 6. BED HOLD POLICY, if you are absent from the Health Center, we shall hold your bed in accordance with our current bed hold policy. A copy of the current bed hold policy is included in these documents listed in the attached Checklist, We reserve the right to change our bed hold policy from time to time in accordance with applicable laws and regulations. A copy of the current bed hold policy shall be provided to you and your family member or legal Representative, Responsible party, or Resident Representative before your transfer. In review of the facility's Policy and Procedure form, entitled: Trillium Woods Policy and Procedure - Bed Hold / Leave of Absence Policy and Acknowledgement (undated), documented three types of resident stays, each with different requirements and time lines for bed hold: Medicare or Private Pay Resident, Medicaid Resident and Life Care Resident on the same form. However, for each resident stay type, the document read, Resident (and/or Resident's legal Representative, if applicable) hereby acknowledge(s) receipt of the Health Center Bed Hold Policy, with a line for a signature and date signed.

Based on interview and document review, the facility failed to follow physician orders for the administration of insulin for 1 of 1 resident (R21) reviewed for medication errors. Findings include: R21's significant change Minimum Data Set (MDS) dated [DATE], identified R21 had severe cognitive impairment and required substantial and/or maximal assistance with most activities of daily living, such as hygiene, dressing, and walking ten feet. R21's diagnoses included hypertension (high blood pressure), peripheral vascular disease (narrowed arteries which reduce blood flow to the arms or legs), diabetes mellitus (chronic disease which occurs when the body does not produce enough or respond normally to insulin), dementia (decline in cognitive abilities which affects ability to think, remember and perform daily activities), and cerebral infarction (blood flow to the brain is blocked). During the look-back period of seven days for the MDS, insulin injections were received all seven days. R21's medication administration record (MAR) included an order with a start date of 5/15/24, for insulin aspart pen-injector 100 unit/mL (milliliters) 5 units subcutaneously at 0800 (8:00 a.m.), and insulin aspart pen-injector 100 unit/mL 5 units subcutaneously at 1700 (5 p.m.) with a start date of 5/14/24. Both orders had directions to hold if blood glucose levels were less than 200. The MAR indicated R21's blood sugar was 194 on the 9/8/24 morning blood sugar check and insulin was administered on 9/8/24 at 08:33 [8:33 a.m.], and R21's blood sugar was 191 on the 9/11/24 evening blood sugar check and insulin was administered on 9/11/24 at 17:06 [5:06 p.m.]. R21's progress notes lacked further information on the two noted blood glucose levels and insulin administration but indicated the following on 9/8/24 at 22:30 (10:30 p.m.): Resident BG @ [at] 3:15pm was 53 per report. OJ [orange juice] and snacks given and f/u [follow-up] BG was 87 before dinner. Ate100% of dinner with 500cc. Insulin was held. HS BG was 168. Asymptomatic for hypoglycemia. Northern Lights communication updated for the MD/NP. Will update the next shift. During interview on 9/12/24 at 9:57 a.m., licensed practical nurse (LPN)-A stated they check blood glucose levels, verify insulin administration parameters, and either give short-acting insulin close to meals or hold insulin when blood glucose levels are below the ordered parameters. LPN-A documented in MAR or progress notes when insulin held. LPN-A reviewed R21's physician orders and MAR and verified R21's insulin was given the morning of 9/8/24 and evening of 9/11/24 when R21's blood glucose was less than 200, and R21's insulin should have been held. During interview on 9/12/24 at 12:47 p.m., registered nurse (RN)-B reviewed R21's blood glucose levels, insulin administration, and progress notes. RN-B verified the two instances and stated the insulin should not have been administered and were medication errors. During interview on 9/12/24 at 1:49 p.m., the director of nursing (DON) expected staff to follow physician orders and hold insulin when blood glucose less than 200. During interview on 9/12/24 at 3:19 p.m., the consultant pharmacist reviewed R21's orders, MAR, and blood glucose levels. Consultant pharmacist stated the expectation was for staff to hold the insulin when blood glucose levels were less than 200 per physician order or call the provider and document provider communication. Consultant pharmacist stated following insulin orders and blood glucose parameters were important to keep blood glucose at functioning levels and did not want too much insulin in R21's system. Consultant pharmacist stated the two noted insulin administrations had a mild risk to R21. Facility policy Insulin Administration dated 9/14, directed staff to check and document blood glucose per physician order or facility protocol and to check the order for the amount of insulin at least three times during insulin administration.

Based on interview and document review, the facility failed to ensure orthostatic blood pressure monitoring was in place for 2 of 5 residents (R27, R30) reviewed for unnecessary medications. Findings include: R27 R27's quarterly Minimum Data Set (MDS), indicated he had moderate cognitive impairment and exhibited physical behavioral symptoms 1-3 days during the lookback period. Additionally, R27's MDS listed his diagnoses as Parkinson's disease (a progressive movement disorder of the nervous system) with dyskinesia (involuntary muscle movements and reduced voluntary movement), dementia (a loss of cognitive function, like thinking, remembering, and reasoning), anxiety, depression, bradycardia (slow heart rate), and psychotic disorder (severe mental illness causing a person to lose touch with reality and have abnormal thinking and perceptions). The MDS indicated R27 received an antipsychotic medication on a routine basis only, and the most recent gradual dose reduction (GDR) was attempted on 2/1/24. Furthermore, the MDS indicated R27 received an antianxiety medication. The MDS also indicated R27 required extensive assistance with mobility, transfers, and toileting. R27's Care Area Assessment (CAA) for falls dated 2/1/24, was triggered due to a history of falls. The CAA indicated R27 had four recent falls with no injuries related to self-transfers. The CAA identified risk factors of a prescription antipsychotic Seroquel, and diagnoses of heart disease, dementia, and Parkinson's disease. The CAA guided staff to follow the care plan. R27's CAA for psychotropic drug use dated 2/1/24, was triggered due to his Seroquel use. The CAA indicated falls not noted to be from medication use. No noted adverse signs or symptoms of medication use at this time. The CAA indicated staff would continue to monitor R27 and would follow his care plan. R27's order summary printed 9/12/24, included an order for weekly orthostatic blood pressure monitoring (for Seroquel use) to be assessed once per day every Thursday, starting 5/7/24. R27's medication administration record (MAR) dated 9/2024, indicated he was receiving the following medications on a scheduled basis as ordered: - citalopram hydrobromide (for depression) oral tablet 10 milligrams (mg), Give 20mg by mouth one time a day, dated 9/4/24. - buspirone hydrochloride (HCl) (for anxiety) oral tablet 5mg, Give 5mg by mouth two times a day, dated 4/4/24. - Seroquel (for dementia with psychosis) oral tablet 25mg, Give 25mg by mouth at bedtime, dated 2/1/24. R27's treatment administration record (TAR) dated 9/2024, indicated his orthostatic blood pressure was administered with a checkmark under the due date of 9/5/24. R27's MAR dated 8/2024 indicated he was receiving the following medications on a scheduled basis as ordered: - citalopram hydrobromide (for depression) oral tablet 10 milligrams (mg), Give 10mg by mouth one time a day, dated 7/17/24. - buspirone hydrochloride (HCl) (for anxiety) oral tablet 5mg, Give 5mg by mouth two times a day, dated 4/4/24. - Seroquel (for dementia with psychosis) oral tablet 25mg, Give 25mg by mouth at bedtime, dated 2/1/24. R27's TAR dated 8/2024, indicated his orthostatic blood pressure was administered with a checkmark under the due dates of 8/8/24, 8/15/24, 8/22/24, and 8/29/24. R27's MAR dated 7/2024 indicated he was receiving the following medications on a scheduled basis as ordered: - citalopram hydrobromide (for depression) oral tablet 10 milligrams (mg), Give 5mg by mouth one time a day, started 7/2/24, discontinued 7/16/24. - citalopram hydrobromide (for depression) oral tablet 10 milligrams (mg), Give 10mg by mouth one time a day, dated 7/17/24. - buspirone hydrochloride (HCl) (for anxiety) oral tablet 5mg, Give 5mg by mouth two times a day, dated 4/4/24. - Seroquel (for dementia with psychosis) oral tablet 25mg, Give 25mg by mouth at bedtime, dated 2/1/24. R27's TAR dated 7/2024, indicated his orthostatic blood pressure was administered with a checkmark under the due dates of 7/4/24, 7/11/24, 7/18/24, and 7/25/24. R27's MAR dated 6/2024 indicated he was receiving the following medications on a scheduled basis as ordered: - buspirone hydrochloride (HCl) (for anxiety) oral tablet 5mg, Give 5mg by mouth two times a day, dated 4/4/24. - Seroquel (for dementia with psychosis) oral tablet 25mg, Give 25mg by mouth at bedtime, dated 2/1/24. R27's TAR dated 6/2024, indicated his orthostatic blood pressure was administered with a checkmark under the due dates of 6/6/24, 6/13/24, 6/20/24, and 6/27/24. R27's MAR dated 5/2024 indicated he was receiving the following medications on a scheduled basis as ordered: - buspirone hydrochloride (HCl) (for anxiety) oral tablet 5mg, Give 5mg by mouth two times a day, dated 4/4/24. - Seroquel (for dementia with psychosis) oral tablet 25mg, Give 25mg by mouth at bedtime, dated 2/1/24. R27's TAR dated 5/2024, indicated his orthostatic blood pressure was administered with a checkmark under the due dates of 5/9/24, 5/16/24, 5/23/24, and 5/30/24. R27's care plan revised on 12/12/23, indicated he was at risk for falls and identified an intervention of orthostatic blood pressure monitoring after a fall on 12/1/23. Additionally, the care plan identified R27 used an antipsychotic, antidepressant, and antianxiety medication and indicated staff would monitor vital signs as ordered. A review of the blood pressures in Point Click Care (PCC) on 9/12/24, revealed a lack of orthostatic blood pressure documentation for the dates above in which the orthostatic blood pressures were listed as administered. A medication regimen review (MRR) dated 7/15/24, was performed with no irregularities noted and no medication changes recommended. A consultation report by pharmacist dated 7/19/24, indicated R27 recently experienced a fall on 6/25/24, 6/27/24, 7/12/24, and 7/11/24. A comprehensive review of the medical record was conducted and based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, the resident's MRR does not appear likely to have contributed to falls. R27 is on medications that can cause dizziness and drowsiness. It is not apparent that either dizziness or drowsiness played a part in these falls. The report indicated in at least 2 of the falls, R47 put himself on the floor. No medication changes were recommended in the report. R27's electronic health record (EHR) was reviewed on 9/12/24 and lacked documentation of orthostatic blood pressures or rationale for missed monitoring. During interview on 8/12/24 at 11: 35 a.m., registered nurse (RN)-A verified there was no orthostatic blood pressure documentation for R27. RN-A stated his transfer status had changed recently and R27 had increased difficulty with standing. RN-A stated if a resident was unable to stand for an orthostatic blood pressure, the laying and sitting blood pressures should be collected and the standing blood pressure should include documentation to why it could not be performed. RN-A stated an orthostatic blood pressure could be re-attempted later, and the provider should be updated. RN-A stated R27 had not reported dizziness with sitting to standing and denied seeing any visual floaters or spots. Documentation of R27's orthostatic blood pressure monitoring was requested from RN-B but was not received. R30 R30's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition, had no behaviors, and received an antipsychotic on a routine basis only. R30's Care Area Assessment (CAA) for psychotropic drug use dated 2/17/24, was triggered because she was on Seroquel for dementia and problems sleeping per orders and MAR. The CAA indicated there were no signs or symptoms of adverse effects noted and directed staff to follow her care plan. A diagnosis report dated 9/11/24, listed R30's diagnoses as Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills), dementia (a loss of cognitive function, like thinking, remembering, and reasoning), high blood pressure, muscle weakness, and difficulty walking. R30's order summary report last reviewed and signed on 9/5/24, indicated the following orders: - quetiapine fumarate (for psychosis) oral tablet 25 mg, Give 25 mg by mouth at bedtime, dated 6/20/24. - orthostatic BP's monthly, one time a day every 1 month starting on the 24th, dated 5/24/24. R27's treatment administration record (TAR) dated 5/2024, lacked an orthostatic blood pressure monitoring order. R27's TAR dated 6/2024, indicated an orthostatic blood pressure was administered with a checkmark under the due date of 6/24/24. R27's TAR dated 7/2024, indicated an orthostatic blood pressure was administered with a checkmark under the due date of 7/24/24. R27's TAR dated 8/2024, indicated an orthostatic blood pressure was administered with a checkmark under the due date of 8/24/24. A progress note dated 7/24/24, indicated R30's orthostatic blood pressure (measured in millimeters of mercury (mmHg) was: laying 137/73 sitting 157/68 standing 150/80. R30's electronic health record (EHR) was reviewed on 9/11/24 and lacked documentation of orthostatic blood pressures for 5/2024, 6/2024, and 8/2024. During interview on 9/12/24 at 11:36 a.m., registered nurse (RN)-A stated orthostatic blood pressures should be assessed monthly for residents taking antipsychotic medications. RN-A verified documentation for 7/24/24, but was unable to locate documentation for any other orthostatic blood pressures. A request was made for documentation of R30's orthostatic blood pressures but it was not received. During interview on 8/12/24 at 11: 53 a.m., RN-B stated residents receiving psychotropic medications should have side effect monitoring in place, including orthostatic blood pressure monitoring. RN-B stated without monitoring a resident's orthostatic blood pressure while taking a psychotropic medication, a resident could be a higher risk for falls. RN-B stated there was a new process in place for auditing orders of residents receiving psychotropics to ensure orthostatic blood pressures were in place due to a newly hired health unit coordinator (HUC). RN-B stated staff were in the process of reviewing charts and entering the monitoring order as needed. During interview on 9/12/24 at 1:49 p.m., the director of nursing (DON) stated orthostatic blood pressures were expected to be completed for residents taking psychotropic medications. The DON stated it was important to monitor for side effects of psychotropic medications, including orthostatic blood pressures, so we are not missing something. The DON reported a process was initiated immediately to create a new template for orthostatic blood pressure monitoring for residents taking psychotropic medications and verified the importance of identifying side effects and reducing falls. A facility policy titled Antipsychotic Medication Use revised 7/2022, indicated antipsychotic medications would be subject to re-review and directed nursing staff to monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: Akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or transient ischemia attach (TIA).

Based on interview and document review, the facility failed to ensure an allegation of abuse were reported to the State Agency (SA) immediately (within two hours) for 3 of 4 residents (R31, R34, R35) reviewed for abuse. Findings include: Resident #31 R31's quarterly Minimum Data Set (MDS) dated [DATE], indicated R31 had mild cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R31's care plan reviewed on 6/1/22, indicated R31 was vulnerable due to residing in a long-term care setting and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/31/22, at 3:10 p.m. R31 stated she was hit in the back by a staff member last week. R 31 further stated she told other staff about it, but nothing was done. During an interview on 5/31/22, at 3:18 p.m. the Administrator received the above allegation from the surveyor. The administrator further stated she was aware of R31 having increased behaviors recently but was not aware of R31's allegation of being hit by staff. The facility's Nursing Home Incident Report (NHIR) dated 5/31/22, indicated R31's allegation was reported to the SA on 5/31/22, at 8:32 p.m. This report was not made immediately (within 2 hours) of receiving R31's allegation of abuse. Resident #34 R34's admission Minimum Data Set (MDS) dated [DATE], indicated R34 had moderate cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's care plan reviewed on 6/2/22, indicated R34 was vulnerable due to residing in a long-term care setting. The facility's Nursing Home Incident Report (NHIR) dated 2/16/22, indicated R34's family member (FM)-A reported the facility staff forcibly changed [R34] to the social worker (SW)-A on 2/16/22 at 10:30 a.m. The SW-A spoke with R34 immediately after speaking with FM-A when R34 reported the allegations of the alleged perpetrator molested me, touched me and I didn't like it, it mentally hurt, and I felt violated and the alleged perpetrator put a diaper on [R34] and wasn't allowed to go to the bathroom. However, the facility reported to the SA on 2/16/22, at 3:14 p.m. This report was not made immediately (within 2 hours) of receiving R34's allegation of abuse. Resident #35 R35's admission Minimum Data Set (MDS) dated [DATE], indicated R35 was cognitively intact and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's care plan reviewed on 6/2/22, indicated R35 was vulnerable due to residing in a long-term care setting. The facility's Nursing Home Incident Report (NHIR) dated 5/6/22, indicated R35's allegation of a facility staff member stating shut up to R35 was reported to SW-A on 5/5/22, at 10:00 a.m. However, the facility reported to the SA on 5/6/22, at 9:53 a.m. This report was not made immediately (within 2 hours) of receiving R35's allegation of abuse. During an interview on 6/1/22, at 4:11 p.m. the director of nursing (DON) stated staff followed the facility policy when reporting allegations of abuse. DON expected staff to report any allegations to the Administrator or herself immediately and then the facility had 2 hours to report to the SA if abuse was determined or if the resident had serious bodily harm. During interview on 6/1/22, 4:13 p.m. the director of nursing (DON) verified the allegation of R35 stating NA-D told R35 to shut up was verbal abuse and should have been reported within two hours. During an interview on 6/1/22, at 5:08 p.m. Administrator stated allegations of abuse are reported within 2 hours if there was serious bodily injury, otherwise allegations were reported within 24 hours. The Administrator expected staff to report allegations right away. Administrator further stated a report of staff hitting a resident was considered physical abuse and had to be reported within 24 hours if there was no serious bodily harm. During an interview on 6/2/22, at 3:04 p.m. Administrator acknowledged the facility policy had an addendum reflecting federal regulations and reporting but acknowledged that time frame had not been followed. Administrator further stated policy revision and staff education had been started. The Trillium Woods Elder Justice Act policy dated August 2019, indicated an event suspicion resulting in serious bodily injury, the individual shall report the suspicion within two hours of forming a suspicion. If the event causing the suspicion does not result in serious bodily injury, the individual shall report the suspicion in 24 hours of forming a suspicion.

Based on interview and document review, the facility failed to immediately put measures in place to prevent further potential abuse while the investigation was in process for 3 of 4 residents (R3, R34, R35) reviewed for abuse. Furthermore, the facility failed to thoroughly investigate an allegation of abuse for 1 of 4 residents (R34) reviewed for abuse. Findings include: Resident #3 R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's care plan reviewed on 6/1/22, indicated R3 was a vulnerable adult due to residing in a long-term care facility. A Nursing Home Incident Report (NHIR) dated 3/22/22, indicated R3 reported to the facility nursing assistant (NA)-E stated R3 would be moved down with the crazies. The report further stated NA-E was suspended and a facility investigation was initiated. The facility investigation file dated 3/22/22, indicated NA-E was not suspended during the investigation of R3's allegations. The investigation file indicated R3's allegation was reported on 3/22/22. NA-E and other resident interviews were not completed until 3/24/22. On 3/24/22, NA-E was instructed to continue work, but do not enter R3's room until the investigation was completed. During an interview on 5/31/22, at 12:49 p.m. R3 stated NA-E had told her she was going to put me downstairs with the crazies. R3 further stated she felt threatened, but also felt safe. R3 stated NA-E had not provided cares since then. During an interview on 6/1/22, at 10:30 a.m. NA-E stated there has been no contact with R3 for months. NA-E verified working during the timeframe of the investigation. NA-E further stated on 3/23/22, R3 kicked her out of R3's room when NA-E went in to provide cares. At that time, NA-E was not aware of any allegations R3 had made, and had not found out until 3/24/22, when interviewed by the Administrator. NA-E stated she was not suspended and was told the concern was not serious enough. During an interview on 6/1/22, at 4:25 p.m. the director of nursing (DON) stated it was standard procedure to suspend staff immediately from all residents until investigation can determine if allegation can be substantiated. During an interview on 6/1/22, at 5:15 p.m. the Administrator stated the facility always wanted to ensure resident safety when any allegation was made. The Administrator verified the timeline in the investigation file. The Administrator stated R3 was ok with NA-E providing cares if NA-E kept her mouth shut on 3/22/22, and that was likely the reason NA-E was not suspended. The Administrator acknowledged there was a gap of time between when the allegation was known and when NA and other residents were interviewed and acknowledged NA-E should not have worked during that time. R34's admission Minimum Data Set (MDS) dated [DATE], indicated R34 had moderate cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's care plan reviewed on 6/2/22, indicated R34 was vulnerable due to residing in a long-term care setting. The facility's Nursing Home Incident Report (NHIR) dated 2/16/22, indicated R34's allegation was reported to the SA on 2/16/22, at 3:14 p.m. This report did not indicate R34 was protected from the alleged perpetrator during the investigation and did not reveal R34's complete allegation. A facility provided document titled Time Detail, with a time period of 2/6/22 through 2/22/22, indicated the alleged perpetrator worked on 2/15/22 from 10:23 p.m. to 6:57 a.m., 2/16/22 from 10:23 p.m. to 7:16 a.m., and 2/18/22 from 10:23 p.m. to 6:59 a.m. A written statement (undated) from social worker (SW)-A, indicated on 2/16/22, R34 reported the alleged perpetrator molested me, touched me and I didn't like it, it mentally hurt, and I felt violated when describing the night of the allegation. Further, R34 reported the alleged perpetrator put a diaper on [R34] and wasn't allowed to go to the bathroom. A written statement dated 2/17/22, nursing assistant (NA)-D indicated being busy and R34 kept calling so the diaper was placed for R34's safety. The statement did not address the complete allegation. A written statement dated 2/17/22, at 4:00 p.m. registered nurse (RN)-B indicated R34's family member (FM)-A reported placing a diaper on R34 scares [R34] and should not have been placed on R34. The statement did not address the complete allegation. After reviewing the facility investigation file, no evidence was provided of protection of R34, other resident interviews, other staff interviews, no body assessment was completed, and no five-day investigative report. After reviewing the SA reporting system, no evidence was noted the facility had completed the investigation and filed a five day investigative report. R35's admission Minimum Data Set (MDS) dated [DATE], indicated R35 was cognitively intact and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's care plan reviewed on 6/2/22, indicated R35 was vulnerable due to residing in a long-term care setting. Further, the care plan did not have any evidence of R35 making false allegations towards staff. The facility's Nursing Home Incident Report (NHIR) dated 5/6/22, indicated R35's allegation was reported to the SA on 5/6/22, at 9:53 a.m. The report indicated R35 reported to SW-A on 5/5/22, at 10:00 a.m. NA-D came into R35's room and told R35 to shut up. The report further indicated NA-D was suspended during the investigation however, NA-D continued to work. A facility provided document titled Time Detail, with a time period of 5/5/22 through 5/11/22, indicated the alleged perpetrator worked on 5/6/22 from 10:27 p.m. to 7:00 a.m., 5/7/22 from 10:24 p.m. to 6:43 a.m., 5/9/22 from 10:24 p.m. to 7:02 p.m., and 5/10/22 from 10:27 p.m. to 7:02 a.m. The Trillium Woods Investigation Statement dated 5/6/22, indicated R35 reported to RN-C no one can tell me to shut up and informed RN-C I don't want NA-D to take care of me. The facility investigation file did not have any evidence of RN-C reporting the allegation to a supervisor. During an interview on 6/1/22, 4:13 p.m. the director of nursing (DON) verified the allegation of R35 stating NA-D told R35 to shut up was verbal abuse. During an interview on 6/1/22, at 4:24 p.m. SW-A stated when R34 was reporting the allegations of the alleged perpetrator molested me, touched me and I didn't like it, it mentally hurt, and I felt violated and the alleged perpetrator put a diaper on [R34] and wasn't allowed to go to the bathroom the thought process was R34 was expressing feeling forced to wear a diaper. Further stated, yes forcing a resident to do anything is abuse however, SW-A stated being hesitant to call anything abuse since it's such a bad statement. During an interview on 6/1/22, at 4:25 p.m. the DON stated it is the standard to suspend an alleged perpetrator until the facility decides the allegation can't be substantiated. Further, stated it is not a formal suspension but rather it's between me and the employee. The DON verified the employee was able to work the same day for both allegations. The Trillium Woods Elder Justice Act policy dated August 2019, indicated employees of this community who have been accused of abuse, neglect, or mistreatment will be immediately suspended until the results of the investigation have been reviewed by the administrator or designee. Any incident or allegation involving abuse, neglect, or financial exploitation will result in an abuse investigation. The administrator or designee is responsible for submitting a final written report of the results of the investigation and of any corrective action taken to the Minnesota Department of Health (MDH) within five working days of the reported incident.

Based on interview and document review, the facility failed to complete annual performance reviews for 3 of 5 nursing assistants (NA-A, NA-B, and NA-C) whose employee files were reviewed. This had the potential to affect all 32 residents who resided at the facility. Findings include: A facility provided document which was unnamed (undated) identified NA-A was hired on 4/25/2016, NA-B was hired on 1/25/2016, and NA-C was hired on 1/25/2016. Performance reviews were requested from the respective employee files of NA-A, NA-B, and NA-C, however, not provided by the facility. During an interview on 6/2/22, at 3:03 p.m. the director of nursing (DON) verified she did not complete staff performance evaluations in 2021/2022 for NA-A, NA-B, and NA-C. Further, The DON stated performance evaluations should had been completed annually for feedback to help with resident care. During an interview on 6/2/22, at 3:05 p.m. the administrator stated employee performance evaluations should be completed annually so the supervisor could give feedback on the employee's performance and the opportunity for the employee to provide feedback. An email dated 6/2/22, at 3:32 p.m. with the subject line Performance Evals, indicated Performance evaluations are conducted to ensure that you have a clear understanding of your job performance. During the evaluation process, your strengths, weaknesses, potential, and work quality will be identified. Performance evaluations are normally completed at the end of any introductory period and annually thereafter.

Based on observation, and interview, the facility failed to follow infection control practices to prevent the spread of infection for 7 of 7 residents (R30, R28, R18, R90, R91, R24, R240) reviewed for medication administration. In addition, failed to properly use gloves and complete hand hygiene during and after catheter cares reviewed for indwelling catheter. Findings included: R30's medication set up and administration was observed on 1/21/20, at 7:03 p.m. by licensed practical nurse (LPN)-D, who brought the laptop into R30's room to administer medications. While setting up R30's medications LPN-D set the laptop on the sink in the bathroom. No barrier was placed, no disinfecting was done to the computer following medication administration. R18's medication set up and administration was observed. LPN-D went into R18's room to complete medication administration, placed laptop on the sink, no barrier placed. Then LPN-D stopped to assist R18 and was observed to set the laptop on the bedside table again with no barrier. During the medication observation no disinfection of the laptop was completed when going from room to room. On 1/23/20, at 12:54 p.m. registered nurse (RN)-B stated she took the computer into residents room all the time and would set it on the counter by the bathroom sink. RN-B acknowledged never thinking of cleaning it after and between rooms. RN-B further stated except for when a resident was on contact precautions she did not set it anywhere in the room and would hold it. On 1/23/20, at 1:00 p.m. the director of nursing (DON stated because the nurses had to do the medication checks and documentation when in the room administering medications the nurse would put the computer on the bathroom sink. The DON stated after and between the rooms the nurses were supposed to clean the computer with alcohol wipes. The DON further stated he had educated nurses about cleaning the computers between rooms and when a resident was on precautions. Surveyor requested the education presented to the nurses. On 1/23/20, at 3:48 p.m. no further information was provided. R28, on 1/23/20, at 8:25 a.m. nursing assistant (NA)-C was observed to switch the overnight catheter bag to the leg bag for the day. During the observation, NA-C wore gloves and was holding the leg bag as she attempted to disconnect/separate the tubing that extends out of R28's bladder. At the time of the observation, NA-C continued to maneuver the tubing despite one of the fingers on the glove being punctured. After the disconnection and connection to the leg bag, NA-C proceeded to the bathroom, removed gloves, and re-applied another pair without washing or cleansing hands. NA-C then approached R28 and assisted R28 to stand up, and used wet wipes to clean around the site where the tubing enters the urethra. NA-C then proceeded to wipe R28's bottom, and with the same gloves, pulled R28's pants up and zipped them. NA-C then went to the bathroom, looked at the night bag with urine remaining and drained it into the toilet, cleaned the bag with soapy water, drained it and hung the bag in the shower. NA-C then removed gloves and washed hands. On 1/23/20, at 8:41 a.m. when asked about hand hygiene during cares and between cares, NA-C stated she completed it before care and after care and in between cares she would change the gloves. On 1/23/20, at 12:22 p.m. during a follow up interview NA-C acknowledged she had a punctured glove as she continued to maneuver the urine tubing when attempting to switch R28 from the night to the day time leg catheter bag. On 1/23/20, at 12:41 p.m. both licensed practical nurse (LPN)-B who was the infection control nurse and the director of nursing (DON) were interviewed together. When asked about hand hygiene both stated all staff were supposed to complete hand washing before going to a residents room, between residents, during cares if they do pericares and then after prior to leaving the room. Both acknowledged if the glove breaks, staff were supposed to remove the glove and wash hands before they proceeded with cares. In addition both stated staff were supposed to use an alcohol wipe to cleanse the connection area for the catheter when switching a night and day leg catheter bag for residents. Policy titled Handwashing/Hand Hygiene dated (MONTH) (YEAR) directed staff to complete routine hand hygiene using alcohol-based rub or soap and water before and after handling an invasive device (e.g. urinary catheters), after removing gloves, and after contact with residents intact skin. During observation on 1/22/20, at 7:39 a.m. RN-A was administering medications to four residents R90, R91, R24, and R240. RN-A was observed bring the computer into each room and set it down by the bathroom sink in three of the rooms (R90, R91, R240) and on the bedside table in one of the rooms (R24) without using a barrier prior to setting the computer down. After the observations and between the rooms the computer was not cleaned. During an interview on 1/23/20, at 12:24 p.m. LPN-A said when she administered medications she was supposed to clean the computer in between rooms with wipes. LPN-A also stated she sets the computer by the bathroom sink in each room and on occasion sets it on the shelf by the television.

Based on observation, interview, and document review, the facility failed to ensure facial hair was removed for 1 of 1 dependent resident (R5) reviewed for activities of daily living (ADLs). Findings include: R5's [DIAGNOSES REDACTED]. R5's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R5 had severely impaired cognition, and required extensive assistance for ADLs. R5's care plan dated 7/19/19, identified R5 had a functional ADL decline related to dementia. The care plan further indicated that staff were to anticipate her needs and re-approach at another times if behaviors existed. On 1/21/20, at 4:19 p.m. R5 was observed to have several white facial hairs on the chin approximately 1/2 inch long and when asked who assisted her with grooming R5 stated I don't know. On 1/22/20, at 8:44 a.m. R5 was observed sitting at the dining room table and dressed for the day. R5 observed to still have 1/2 inch white facial hairs on her chin. On 1/22/20, at 1:35 p.m. R5 was still observed with the long white facial hairs on the chin. On 1/22/20, at 1:49 p.m. licensed practical nurse (LPN)-C approached R5 and asked her to come with her. time R5 was all dressed and NA-A was standing with R5 by the bathroom sink combing her hair. NA-A looked at R5's face but never offered to remove the facial hairs. On 1/23/20, at 7:45 a.m. NA-A and NA-B acknowledged they had not offered to shave R5 and indicated that they would do it after breakfast. Review of the resident summary sheets dated 1/21/20, indicated NAs are to assist with shaving R5. On 1/23/20, at 8:17 a.m. LPN-B stated aides are supposed to offer to remove facial hair and if a resident refuses then they were to let the nurse know and to re-approach. On 1/23/20, at 12:53 p.m. R5's family member (FM) explained that this was very important to another family member that R5 have facial hair removed. On 1/23/20, at 3:10 p.m. director of nursing stated staff should do something about the facial hair.

Based on observation, interview and document review, the facility failed to conduct root cause analysis in an attempt to reduce falls for 2 of 3 residents (R16, R7) reviewed for falls. This resulted in actual harm for R16 who sustained multiple falls with head injuries. Findings include: R16's significant change Minimum (MDS) data set [DATE], indicated she was severely cognitively impaired and requested extensive assistance from two staff for bed mobility, transfers, ambulation and toileting. A care area assessment (CAA) dated 5/23/19, indicated CAA triggered due to unsteadiness and fall since last assessment. Other risk factors included incontinence and dementia. Call light and frequently used items kept in reach. Proceed to care plan. R16's care plan dated 5/21/19, identified a risk for falls related to dementia and medication use. The care plan directed staff to ensure proper foot wear, remind R16 to use her call light, toilet every hour, provide 15 minute checks and turn around and make sure she R16 was not following staff as they left the room. During continuous observation on 5/29/19, at 8:31 a.m. R16 was up seated in a reclining wheel chair in the common area of the unit. At 9:22 a.m. staff escorted her to the dining room and assisted her to eat. At 10:10 a.m. R16 was escorted back to the common area of the unit. At 10:18 a.m. she remained in the common area where she sat looking around, not engaged in the activity. At 10:22 a.m. she was calling out hey, hey to which staff replied, we're coming. R16 remained in the common area of the unit until 11:13 a.m. when surveyor inquired about taking her to the bathroom. A review of facility incident reports and Clinical Notes Reports identified R16 had experienced numerous fall, with a variety of interventions, but failed to conduct a root cause analysis to determine interventions to minimize or prevent further falls. In addition, not all staff were familiar with interventions identified: An incident report from 10/26/18, indicated R16 had fallen in her bedroom attempting to ambulate with the walker. An intervention was modified from 30 minute checks to15 minute checks. An incident report from 12/7/18, indicated R16 had fallen in her bedroom and sustained a rug burn to her elbow and right knee. Interventions were modified to include physical therapy and 15 minute checks. An incident report from 12/9/18, indicated R16 had fallen again in her room, and had been found sitting on the floor next to her bed. The report indicated R16 had stated she'd gotten up to use the bathroom. Interventions were modified for safety checks to be changed from 15 minutes at night, to every 15 minutes and to ensure assistance to toilet every two hours at night. An incident report from 12/11/18, indicated R16 had been found sitting on the floor in her room between the bed and the bathroom. Interventions again included a physical therapy evaluation, and also indicated a medication adjustment would be attempted, and R16 would be encouraged to use the call light. An incident report from 12/14/18, indicated R16 had stood up in the common area, walked a few feet and fell . An intervention was modified to sit next to resident for close proximity. An incident report from 12/14/18, indicated R16 had been found on the floor in the dining room. The report indicated R16 had stood up, got dizzy and fell . Interventions identified R16 would have medication changes. An incident report from 12/18/18, indicated R16 stood up from the dining table, tripped over a chair, and fell to the floor. Although R16 was known to be cognitively impaired, interventions included 15 minute checks and reminders to ask for assitance when wanting to stand. An incident report dated 12/25/16, indicated staff had responded to a loud noise in R16's room to find her lying on the floor on her right side. The report indicated R16 had stated she was trying to get up to go to the bathroom when she fell . Interventions identified to toilet R16 every two hours during the day. On 1/14/19, a progress note indicated R16 had fallen in the activity area at 6:14 p.m. The note indicated R16 had received Tylenol and an ice pack had been used to treat her right elbow pain. An incident report dated 1/24/19, indicated R16 had been found lying on her back on the floor in her bathroom. An intervention was added to complete a three day voiding diary. (When requested by the surveyor, the facility was unable to locate documenation of a voiding diary.) A progress note dated 1/24/19, indicated R16 sustained a 5 centimeter (cm) x 5 cm hematoma to her forehead and was taken to the hospital for evaluation. An After Visit Summary provided by the hospital dated 1/24/19, indicated Diagnosis: [REDACTED]. An incident report from 2/6/19, indicated staff had responded to noise and found R16 on the floor next to her bed. Intervention to check on her every 15 minutes. An incident report from 2/7/19, indicated staff went to check on R16 and found her lying on the floor. The report indicated R16 had complained of generalized pain. Interventions were modified to take R16 to the bathroom every hour at night. An incident report from 2/10/19, indicated R16 had been observed to stand up and start walking independently and to fall to the floor before staff could get to her. The interventions included to monitor every 15 minutes, toilet every two hours, and to monitor for any side effects of [MEDICATION NAME] which had been initiated 2/17/19. A progress note from 2/14/19, indicated R16 was sitting in a chair in the living room area, stood up from chair and landed on the floor. Intervention to provide R16 with a sign reminding her to stay seated. An incident report dated 3/11/19, indicated R16 was sitting on the toilet with staff present, stood up slightly and began to lean and fell hitting her head on the walker. R16 sustained two lacerations to her head. Intervention to remind staff to not leave resident without contact, to do labs and med changes. A progress note dated 3/11/19, indicated R16 was sent to the emergency department where they applied staples for the laceration on her head and gave orders for an ice pack to reduce swelling and pain. A hospital After Visit Summary dated 3/11/19, indicated the resident had fallen and had confusion. [DIAGNOSES REDACTED]. A progress note from 4/8/19, indicated R16 had been found lying on the floor next to her bed. The note indicated an hourly bathroom program had been implemented. A progress note dated 4/10/19, indicated R16 had a physical restraint trial initiated per her family's request. An incident report from 4/15/19, indicated staff had heard a loud noise and found R16 on the floor next to the toilet in her bathroom. The plan included an intervention to get R16 up between 7:00 a.m and 7:30 a.m. A corresponding progress note dated 4/15/19, indicated R16 had self transferred from bed to toilet and was found lying on the floor holding her head.The note indicated R16 had a moderate amount of blood coming from a laceration to the left side of her head. R16 was sent to the hospital and returned with three staples in her head. A hospital after visit summary dated 4/15/19, indicated Diagnosis: [REDACTED]. 5/14/19, R16 was found lying on her back on the floor in her room. Staff to turn and check that resident not following them when leaving room. 5/19/19, Staff heard a sound and found R16 lying on her back. R16 sustained a bump to her forehead. Intervention included order Immodium for loose stools. A Progress note dated 5/22/19, indicated at the time of the fall on 5/19/19, R16 could be having loose stools. During interview on 5/29/19, at 11:15 a.m. nursing assistant (NA)-A stated the last time R16 had been toileted was around 8:30 a.m. NA-A stated R16 was on an every two hour toileting plan, or sometimes every one hour. During interview on 5/29/19 at 10:54 a.m., licensed practical nurse (LPN)-D stated, The NA's know when to reposition people and it's on the summary in the IPad. During interview on 5/29/19 at 10:59 a.m., NA-B stated R16 was on hospice and required two staff to assist her. NA-B stated R16 was toileting on checks every hour to two hours, it depends. NA-B stated R16 was a fall risk which was why she was on checks. NA-B stated, (R16's) falls usually happened very early in the morning around 5:00 a.m. to 6:00 a.m. and stated, maybe she wants to get out of bed and go to the bathroom. NA-B looked at her IPad and stated there were no fall interventions listed. During interview on 5/29/19, at 1:53 p.m. the administrator stated after a resident fell , the nurse on the unit filled out an incident event report and picked an initial intervention. The administrator stated the interdisciplinary team (IDT) reviewed all of the falls and determined whether they needed to add or change the interventions. The administrator further stated the falls were discussed during quality assurance meetings, and during fall committee meetings. However, stated the discussions were related to specific trends and not individual residents. The administrator stated during a risk meeting the IDT reviewed all of R16's falls but did not have documentation related to what was discussed. The administrator stated the IDT had noticed most of R16's falls occurred in the morning, and stated R16 had a private duty caregiver after dinner a few nights each week which had tapered off. During a subsequent interview on 5/30/19, at 9:26 a.m. the administrator stated she did not document what was discussed during the IDT review of the falls. She stated the facility's standard of practice was to document each fall and the end result. R7's quarterly Minimum Data Set ((MDS) dated [DATE], indicated she was severely cognitively impaired, required assistance for transfers and toileting and was always incontinent of bowel and bladder. The MDS further indicated R7 has sustained a fall with injury since admission to the facility. R7's Care Plan with an evaluation date of 3/7/19, indicated severe cognitive impairment. The Care Plan identified a risk for falls related to unsteadiness and medication use with a goal for R7 not to have any injuries related to a fall while in the health center through the next 90 days. The interventions in place to prevent falls included use of assistive devices, wear appropriate footwear such as non-skid shoes, slippers or socks, and to toilet every 2 hours. During observation on 5/29/19, at 11:33 a.m. R7 was sitting at a table in the living room area. Staff attempted to move R7 from the table to an area that a staff member was playing the piano, R7 stated ouch, nursing assistant (NA) asked what is that you want to do, R7 stated I want to lay down. The NA told R7 it was soon time for lunch, (lunch started at 12:30 p.m.) and asked R7 if she wanted to have lunch. The NA asked R7 if she wanted to lay down after lunch and R7 replied yes. At 11:38 a.m. R7 was seated near piano and next to fell ow residents with eyes closed and head down and appeared to be sleeping. A fall risk assessment Morse Fall Scale completed on 5/25/19, indicated R7 was at a high fall risk and needing implementation of high risk fall prevention interventions. Review of the Event Reporting Fall reports identified the following: 10/19/18, at 12:15 a.m. R7 was found between wall and bed. Interventions for R7 included 30 minute checks at night, bed in low position and call light within reach. 11/15/18, at 8:30 a.m. R7 was found lying on the floor by the foot of her bed. Interventions for R7 included 30 minute checks and call light within reach. 1/22/19, at 5:30 a.m. R7 was found sitting by the nursing station. R7 had been restless all night. Intervention for R7 included 1 to 1 when agitated. 1/26/19, at 6:15 a.m. R7 was found sitting by her bed with her back leaning close to bed. R7 stated that she was tied up in the sheets and was trying to get out. Interventions included R7 started back on [MEDICATION NAME] (medication for [MEDICAL CONDITION] disorder). 2/2/19, at 9:30 a.m. R7 stood up from wheelchair and was noted sitting on floor by the nurses desk. Intervention included NA to ambulate R7 in hallway. 2/18/19, at 6:20 found R7 on knees in the salon. R7 stated I was going to your house. Interventions included R7 to remain on 30 minute checks at all times, before leaving resident turn back to ensure stable. 4/3/19, at 12:35 a.m. R7 was found lying in a prone position on the floor in the spa room. R7 indicated she was going to see her son. Nurse noted that R7's pad was wet with urine. R7 was sent to emergency room for evaluation due to arm and shoulder pain. Interventions included R7 to be toileted every 2 hours, and check frequently while in bed with call light within reach at all times. 5/16/19, at 8:00 a.m. R7 was found lying on the floor opposite of bed. Interventions included check on resident when day shift comes in to see if she's awake and get up early. On 5/30/19, at 8:05 a.m. NA-A was asked what they do when R7 became agitated. NA-A stated staff tried to walk R7 and and stated ice cream was R7's favorite and she became less agitated if staff offered ice cream. On 5/30/19 at 1:35 p.m. registered nurse (RN)-A was asked how and when the interventions were put in place on the Event Reporting Fall reports, RN-A indicated that typically it started with the floor nurse. RN-A stated when the fall happened they (nurses) initiate something right away to prevent any further falls for the day or night. She stated the falls were discussed in morning meeting and the team decided if the intervention was appropriate. RN- A stated they might add, modify or discontinue the intervention if needed. RN-A indicated that in the meeting they discussed what might have been happening leading up to the fall, they review nursing notes, and assessed if the fall was at shift change. RN-A indicated that fall reduction was an area they needed to work on. A facility policy titled Fall Management dated (MONTH) (YEAR), was reviewed. The policy indicated the focus of fall prevention was to identify residents at risk for falls, identify precipitating events that lead to falls, identify patterns of falls and define interventions for the prevention of falls. Falls to be tracked and trended for time of day, location of fall, root cause analysis and system causes.

Based on observation, interview, and document review, the facility failed to determine if the practice of self-administration of medications (SAM) was safe for 3 of 3 residents (R13, R6, R184) who were observed to have medications at bedside without an order to self administer. Findings include: R6's [DIAGNOSES REDACTED]. In addition, the MDS indicated R6 had intact cognition. On 5/28/19, at 6:48 p.m. during medication storage review in R6's room, a bottle of chewable Calcium [MEDICATION NAME] Tums was observed on the bedside table. Half of the Tums were gone. During the observation licensed practical nurse (LPN)-C was present. LPN-C stated R6 did not have an order to keep the Tums at bedside after he reviewed the medical record. LPN-C further stated we don't have an order for [REDACTED]. We need to know what residents are taking so it is added to the care plan and assessment LPN-C also stated staff were supposed to watch for those and ask the nurses if the resident had orders to keep them at their bedside. On 5/29/19, at 7:40 a.m. when asked about the TUMS, R6 stated she took a few each day as she had problems with her stomach being upset, that acid. R6's care plan dated 5/7/19, indicated R6 had a [DIAGNOSES REDACTED]. R13 [DIAGNOSES REDACTED]. In addition, the MDS indicated R13 had intact cognition. R13's medication management care plan dated 7/13/18, indicated okay to self administer medications after nurse set up and was okay to leave medications at bedside. The care plan did not address R13 was okay to have Xylimelts tabs for dry mouth at bedside. The care plan did not address the dry mouth tablets until concern was brought to the facility attention and an order was obtained. On 5/28/19, at 12:44 p.m. during interview with R13 a card of Xylimealts tablets for dry mouth were observed on top of the bedside table. The card had 13 out of 24 gone. At 12:44 p.m. when asked about the medications R13 stated he used the tablets for dry mouth all the time because he had a problem with dry mouth. R13 stated he got them from over the counter at the pharmacy and he had been using them for a while and thought staff had seen them as they were in and out of the room all the time to assist him. On 5/28/19, at 6:57 p.m. surveyor informed LPN-C about the medication observed on the bedside stand. LPN-C reviewed the orders and verified R13 did not have an order for [REDACTED]. At 7:00 p.m. LPN-C stated R13 had stated he got the dry mouth tablets over the counter and thought staff had seen them. On 5/30/19, at 11:39 a.m. the resident assessment coordinator registered nurse stated if a resident wanted to self administer medication, the nurses were supposed to get a physician order [REDACTED]. R184's [DIAGNOSES REDACTED]. A 5 day Minimum Data Set ((MDS) dated [DATE], indicated R184 had intact cognition. R184's care plan with an effective date of 5/14/19, indicated R184 will be informed of the medication regimen. On 5/28/19, at 12:50 p.m. R184 was observed to have a bottle of Pepto-Bismol in pill form on a bedside table and a bottle of [MEDICATION NAME] in liquid form on a night stand next to the bed. On 5/28/19 at 3:55 p.m. LPN-A indicated there should be a doctor order, both in the chart and in the computer for people that self-administer medications in their room. When asked if anyone was self-administering medications at this time, LPN-A stated no one that I can think of is self-administering medications. On 5/28/19 at 3:59 p.m. R184 stated the Pepto-Bismol and [MEDICATION NAME] was brought just in case it was needed. When asked if anyone from the facility had come talk to R184 about having medications at the bedside, R184 stated no one from the facility has come in to talk to me about having medications at the bedside. On 5/28/19 at 4:45 p.m. after concern was brought to LPN-A's notice, LPN-A indicated both Pepto-Bismol and [MEDICATION NAME] were removed from R184's room. The medications were locked up in the medication cart, a phone call to update the nurse practitioner about medications was made to obtain an order for [REDACTED]. The facility Self Administration of Medications policy dated (MONTH) (YEAR), indicated an order was supposed to be obtained for all medications a resident was capable to self administer, the health coordinator was to document all the medications administered by the resident and the resident plan of care was to reflect the assessment of resident abilities.

Based on record review and interview, the facility failed to ensure staff properly used assistive devices for mobility for one of five residents (R1) reviewed for falls when a staff member transported the resident a long distance from her room using a rolling 4-wheeled walker as a wheelchair. R1's care plan interventions included bringing a wheelchair for extended distances. R1 was harmed when staff seated R1 on the the 4-wheeled walker and while transporting R1 across an uneven floor and the resident fell backwards and fractured a [MEDICATION NAME] vertebrae. Findings include: The facility's Elder Justice Act Policy, Exhibit A: Actions that are Crimes Policy, dated (MONTH) (YEAR), defines neglect as as failure or omission to provide care or services including but not limited to food, clothing, shelter, health care or supervision which is reasonable and necessary to obtain or maintain the resident's mental health or safety, considering the physical and mental capacity or dysfunction of the resident and which is not the result of an accident or therapeutic conduct. This includes the abscence or likelihood of abscence of care or services. R1's medical record was reviewed. R1 had recently moved from the independent living section of the building to the long term care section but still attended appointments and activities on the independent living side, including hair appointments at the salon. R1's [DIAGNOSES REDACTED]. R1's basic interview of mental status (BIMS) dated 6/5/18 was 4, indicating severe cognitive impairment. R1 could make her needs known. R1's care plan, dated 1/25/18, indicated R1 had self care deficits in activities of daily living (ADLs) and required assistance with bed mobility, transfers and ambulation. R1 used a walker for ambulation but staff also needed to bring a wheelchair for extended distances if needed. R1's care plan, dated 1/25/18 indicated R1 was at risk for falls related to unsteadiness and medication. The goal was no fall related injury while in the health center through the next 90 days with a goal date of 8/10/18. Nursing assistant (NA)-A's training transcript dated 2/5/18, indicated NA-A completed 0.25 hours of web based training on the learning module Preventing Slips, Trips and Falls and scored 100 on the final exam. A care plan intervention note, dated 2/7/18 at 13:50, indicated R1 fell and was found seated on the floor of her room near her bed and reported to staff she reached for her walker and it rolled away. R1 landed on her left arm to break the fall and complained of pain in her arm. A care plan intervention note, dated 3/28/18 at 9:15, indicated R1 fell and was seated under her plant by the window in her room trying to lift a shade. A care plan intervention note, dated 5/18/18 at 9:10, indicated R1 fell while being wheeled to a hair appointment seated on a 4-wheeled walker seat when the walker got stuck in a crack and tipped over. An event form, dated 5/18/18, indicated R1 and nursing assistant (NA)-A were near the basement elevator when the fall occurred. R1 was assessed by LPN-B as oriented and uninjured but with poor standing balance. R1's neurological flowsheet, dated 5/18/18, indicated nursing staff monitored R1's vital signs and neurological status 12 times during the 10 hours following her fall. A nurse practitioner (NP) progress note dated 5/18/18 indicated R1 was seen in her room for an acute visit after falling backwards from a walker onto a concrete floor. R1 complained of pain in the epigastric area and around the ribs to her back. The nurse practitioner assessed R1 and ordered [MEDICATION NAME] 2.5 - 5 mg as needed every 4 hours for pain and ordered staff to send R1 to the emergency department if any new symptoms or increase in pain occurred. R1 declined to go to the hospital during the NP assessment. R1's 5/22/18 treatment administration record (TAR) indicated orders for R1 to wear back brace at all times when sitting, standing or walking, including while in the shower. A facility corrective action notice, dated 5/22/18, indicated NA-A was re-educated on the unsafe transport of a resident. A physician's progress note, dated 5/23/18 indicated R1 had a T11 closed wedge compression fracture when admitted to the hospital for increased back pain and was discharged back to the facility with a thoracolumbosacral brace. R1 suffered ongoing pain and back spasms. During an interview on 7/9/18 at 11:50 a.m., NA-A said she was escorting R1 to the Trillium Woods hair salon on the independent living side of the building. R1 had previously walked to the salon using her 4-wheeled walker. The long term care and independent living sections are separated by a long hallway on the main level. Halfway down the hall R1 said she was tired, wanted to sit and rest. NA-A said R1 rested, sitting on her walker for 5 minutes because there was no seating nearby. R1 said she was still tired and didn't want to walk the rest of the way to the salon. NA-A said since they were so close to the elevator to go downstairs she pushed R1 into the elevator seated on the walker. When they exited the elevator in the basement, NA-A said she wheeled R1 out, still seated on the walker, and the wheels caught on a raised section of the floor where the tile changed height. R1 fell on to her back. NA-A fell on top of the walker and R1. NA-A said R1 was alert after the fall. NA-A said she called for help; staff exiting the elevator went to get the nurse. During an interview on 7/9/18 at 1:02 p.m., director of nursing (DON)-B said she was shocked that NA-A didn't use the wheelchair. DON-B said staff does encourage R1 to use the 4-wheel walker and R1 prefers that to the wheelchair but it is not a replacement for a wheelchair and that is taught in orientation and annual safety training During an interview on 7/9/18 at 12:41 p.m. licensed practical nurse (LPN)-C said she has seen other staff use a wheeled walker as a wheelchair to move a resident and she's has stopped and corrected them. LPN-C said she didn't understand why NA-A thought it was a good idea to have R1 walk that far. R1 declined to be interviewed. An undated internal investigation interview summary from NA-A indicated she understood residents should only be transferred with an appropriate wheelchair or mobilizing themselves with an appropriate assistive device. A facility policy titled Fall Management, dated (MONTH) (YEAR), indicated the interdisciplinary team develops a plan of specific interventions for the resident to prevent future falls and the plan shall be integrated into the resident's care plan. A facility policy titled Corridor Assistance, dated (MONTH) (YEAR), indicated associates will monitor the corridors for residents who may have difficulty navigating through the corridors; if a resident is observed or reported to be having difficulty navigating through the corridors, an associate will provide appropriate assistance to the resident; appropriate assistance may include but is not limited to holding a resident's hand as they walk or guiding a resident in a wheelchair to the next handrail or to their desired destination. The manufacturer's guidelines for R1's 4-wheel walker were requested from the facility but were not provided.

Based on observation, interview and document review, the facility failed to implement appropriate hand hygiene practices for 1 of 1 resident (R10) reviewed for pressure ulcers and failed to assure hand hygiene was conducted after leaving a contact precaution room for 1 of 1 resident (R238) reviewed for contact precautions. Findings include: R10 On 8/15/18, at 7:45 a.m. nursing assistant (NA)-A entered R10's room to provide cares. NA-A approached R10, wearing gloves, stating she was going to assist R10 to get ready for the day. -At 7:46 a.m. NA-A approached R10's bed, moved the bedside table out of the way, took the blanket off R10, applied compression stockings on R10 and then lowered the bed. R10 was assisted to sit on the edge of the bed and NA-A applied shoes on R10. NA-A then cued resident she was going to raise the bed up and NA-A applied a transfer belt around R10's waist. -At 7:52 a.m. NA-A cued R10 to stand and ambulated with R10 to the bathroom, assisted R10 to remove the pad and assisted R10 to sit on the toilet, who indicated she needed to urinate. -At 7:57 a.m. NA-A cued R10 to stand and was observed to use moist wipes to provide personal hygiene cares to R10. NA-A then, with the same gloves, pulled both R10's pull-up and pants then assisted R10 to sit on the wheelchair as she held onto the transfer belt. After R10 was seated in the wheelchair NA-A removed the gloves and wheeled R10 to the sink area. -At 7:59 a.m. NA-A came out of bathroom, without washing hands, and took the bed remote with her right hand and then asked R10 if she needed the sling on her right arm removed, which R10 stated yes. NA-A went into the bathroom and removed the sling and then NA-A washed her hands. -At 8:51 a.m. NA-A acknowledged she had not removed gloves and washed hands after providing pericare on R10. NA-A stated she was supposed to remove gloves and wash her hands. During an interview on 8/15/18, at 1:26 p.m. the director of nursing stated staff were always supposed to wash their hands before and after cares. She further stated that staff should wash their hands each time after removing soiled gloves. R238's admission face sheet dated 1/4/17, indicated [DIAGNOSES REDACTED]. R238's quarterly Minimum (MDS) data set [DATE], indicated R238 was able to make self understood and was able to understand others and was cognitively intact. Care plan dated 1/16/17, indicated self care deficit in regards to bed mobility, dressing, grooming, feeding, toileting, transfers and locomotion on and off unit which R238 would perform self care activities with assistance and used walker for mobility with limited assist. Care plan further indicated R238 was at risk for pain due to shingles and to monitor pain every shift. During random observations on 8/15/18, at 7:47 a.m. nursing assistant (NA)-B was in R238's room and asked for assistance. Licensed practical nurse (LPN)-A was observed to don a gown and gloves and entered R238's room. R238 had a sign on door for contact precaution. NA-B and LPN-A were observed to use the mechanical stand to transfer R238 from the bathroom to R238's chair in R238's sitting area. LPN-A was observed to remove the gown and gloves, then walked out of R238's contact precaution room to the hallway. LPN-A then took the medication cart to go to another resident's room, take out a cup with medications already set up out of the medication cart drawer, and placed the cup on top of the medication cart. As LPN-A was about to give the medications to another resident surveyor intervened and suggested that LPN-A wash hands or use hand sanitizer. During an interview on 8/15/18, at 7:57 a.m. LPN-A confirmed she should have washed hands after leaving a contact precaution room. During an interview on 8/16/18, at 9:29 a.m. the DON indicated she expected staff to remove gloves and PPE (personal protective equipment) and wash hands when leaving contact precaution rooms. The facility Handwashing/Hand Hygiene policy dated (MONTH) (YEAR), directed staff to wash their hands or use an alcohol-based hand rub containing at least 62% or soap and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; h. Before moving from a contaminated body site to a clean resident care; j. After contact with blood or body fluids; m. After removing gloves; n. Before and after entering isolation precaution setting .

Based on interview and document review, the facility failed to ensure 1 of 3 residents (R36) or legal representatives had been informed of bed hold rights at the time of hospitalization . Findings include: R36's [DIAGNOSES REDACTED]. In addition the MDS indicated resident had intact cognition. A review of the interdisciplinary notes revealed on 7/16/18, a staff nurse had noted at 7:20 a.m. R36 was extremely drowsy, dizzy, was difficult to arouse and was not able to communicate. Follow up nurse note at 8:30 a.m. indicated R36's oxygen reading was 81% at 4 liters of oxygen, blood pressure was 88/48, pulse was 71, respirations were 16 and temperature was 96.4. The nurse practitioner had assessed R36 and gave an order to send R36 to the hospital. In addition, the note indicated R36 had black/tarry extra large stool with foul smelling odor. The note further noted the ambulance had transported R36 to the hospital at 12:10 p.m. Review of the interdisciplinary notes lacked evidence of the facility providing or attempting to inform R36 or the responsible representative of the bed hold during the hospital transfer. On 8/14/18, at 2:06 p.m. the licensed social worker (LSW) stated at the time R36 was being sent to the hospital he was not in the state to review the notice with him. LSW stated a call had been made to the a family member who indicated R36 was not doing to well. When asked for the documentation of staff informing the family member about the bed hold notice, LSW stated she would find the documentation and the nurse to find out the details as she was unclear and there was no documentation in the medical record. On 8/15/18, at 1:26 p.m. the director of nursing (DON) explained that at the time of a transfer to a hospital the staff were supposed to fill the transfer form out, call family and ask if the resident or family wanted to hold the bed. The DON stated sometimes the staff did not get a straight answer. The DON further stated on the next day after the transfer, the admissions staff would follow up to ask if to hold or not hold the bed. When asked if this information was documented somewhere she stated she did not know and directed this surveyor to the administrator. On 8/15/18, at 1:42 p.m. the administrator stated all the residents regardless of the payment source were supposed to be given a bed hold notice. When asked where staff were supposed to document or if staff were supposed to document, the administrator stated it was standard of practice and staff were supposed to provide the form to the resident to sign before the transfer. The administrator further stated the staff was supposed to write a note in the medical record about discussion of the bed hold and if staff had made a follow up call regarding the bed hold to the resident and/or the family representative.

Based on interview and document review, the facility failed to ensure allegations of abuse were reported timely to the administrator and State Agency (SA) for 1 of 3 residents (R76) reviewed for abuse. Findings include: R76's 30 day Minimum Data Set ((MDS) dated [DATE], indicated R76 was cognitively intact. R76's care plan dated 6/20/17, identified R76 as a vulnerable adult in a long term care community. On 7/17/17, at 2:23 p.m. R76 was interviewed and stated she felt she had been abused. R76 stated approximately a week ago, a nursing assistant (NA) entered her room, and she had requested her incontinent product be changed. R76 stated the NA told her her incontinent product wasn't wet enough to be changed, and threw a clean incontinent product back at R76, hitting her in the chest area. R76 stated this occurred during the late hours, and therefore she was unaware of who the staff member was. R76's family member (FA)-A was present in the room during the interview. FM-A stated after the incident occurred, she had informed the director of nursing (DON). On 7/17/17, at 3:58 p.m. the DON was interviewed and denied being made aware of the incident. On 7/17/17, at 6:47 p.m. the DON stated she was made aware of the incident via a telephone call from FM-A prior to 7/4/17, right after the incident occurred. The DON stated since FM-A informed her she believed it was a male employee, the DON followed up with the one male employee that was working that shift, but stated she hadn't talked to R76 or other staff members regarding the incident. On 7/19/17, at 7:41 a.m. NA-A was interviewed and stated approximately 2 weeks ago at 6:30 a.m. R76 reported to her that she was so mad due to an overnight nursing assistant refusing to assist her, and throwing an incontinent product at her. NA-A stated R76 was yelling and sad about what occurred. NA-A stated she offered R76 assurance and attempted to calm her down. NA-A believed this situation to be neglect, and abuse. NA-A stated she informed the charge nurse (Registered Nurse (RN)-A) on duty, and expected her to inform the DON. On 7/19/17, at 8:04 a.m. NA-B stated approximately 2 weeks ago at 6:30 a.m. NA-A requested her to come to R76's room because she noticed something different about R76. NA-B stated when she entered R76's room R76 was very upset, angry, and crying. NA-B stated R76 was upset because on the overnight shift she had an incontinent product thrown at her and the nursing assistant did not want to help her. NA-B stated she observed incontinent products on the floor in R76's room. NA-B stated R76's attitude was completely different than normal, she didn't want to do anything, or even go to breakfast because she was so upset. NA-B stated she offered R76 assurance and reported the incident to RN-A. NA-B stated she felt this situation was abuse due to how it made R76 feel. NA-B stated she would have expected the charge nurse to inform the DON of this situation. On 7/19/17, at 1:00 p.m. the DON was interviewed and stated she expected the charge nurse to call the administrator if there was suspected abuse. The DON stated if there is injury to the resident, the facility will submit a report to the SA within 2 hours. The DON further indicated if there is no injury to the resident, a report will be made to the SA within 24 hours, and an internal investigation will begin immediately. The DON stated if a nursing assistant suspects abuse they are expected to report it to the charge nurse who will report it to administration. The DON stated she would not expect a nursing assistant to call the administrator or herself to report abuse. The facility policy Abuse Prevention Policy dated 9/1/16, directed if an allegation occurs and there is not serious bodily injury, and all other reports will be submitted to the SA immediately but not later than 24 hours after forming the suspicion of abuse. The policy further directed all incidents will be documented, whether or not abuse occurred, was alleged or suspected. All incidents or allegations involving abuse, neglect or financial exploitation will result in an abuse investigation. The policy further directed employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or financial exploitation they observe, hear about, or suspect immediately to the administrator (primary) or director of nursing (secondary). The policy also directed all incidents will be documented, whether or not abuse occurred, was alleged or suspected. All incidents or allegation involving abuse, neglect, or financial exploitation will result in an abuse investigation.

Based on interview and document review, the facility failed to operationalize their abuse prevention policy and procedure to immediately report allegations of abuse to the administrator and State Agency for 1 of 3 (R76) residents reviewed for abuse. Findings include: The facility policy Abuse Prevention Policy dated 9/1/16, directed if an allegation occurs and there is not serious bodily injury, and all other reports will be submitted to the SA immediately but not later than 24 hours after forming the suspicion of abuse. The policy further directed all incidents will be documented, whether or not abuse occurred, was alleged or suspected. All incidents or allegations involving abuse, neglect or financial exploitation will result in an abuse investigation. The policy further directed employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or financial exploitation they observe, hear about, or suspect immediately to the administrator (primary) or director of nursing (secondary). The policy also directed all incidents will be documented, whether or not abuse occurred, was alleged or suspected. All incidents or allegation involving abuse, neglect, or financial exploitation will result in an abuse investigation. R76's 30 day Minimum Data Set ((MDS) dated [DATE], indicated R76 was cognitively intact. R76's care plan dated 6/20/17, identified R76 as a vulnerable adult in a long term care community. On 7/17/17, at 2:23 p.m. R76 was interviewed and stated she felt she had been abused. R76 stated approximately a week ago, a nursing assistant (NA) entered her room, and she had requested her incontinent product be changed. R76 stated the NA told her her incontinent product wasn't wet enough to be changed, and threw a clean incontinent product back at R76, hitting her in the chest area. R76 stated this occurred during the late hours, and therefore she was unaware of who the staff member was. R76's family member (FA)-A was present in the room during the interview. FM-A stated after the incident occurred, she had informed the director of nursing (DON). On 7/17/17, at 3:58 p.m. the DON was interviewed and denied being made aware of the incident. On 7/17/17, at 6:47 p.m. the DON stated she was made aware of the incident via a telephone call from FM-A prior to 7/4/17, right after the incident occurred. The DON stated since FM-A informed her she believed it was a male employee, the DON followed up with the one male employee that was working that shift, but stated she hadn't talked to R76 or other staff members regarding the incident. On 7/19/17, at 7:41 a.m. NA-A was interviewed and stated approximately 2 weeks ago at 6:30 a.m. R76 reported to her that she was so mad due to an overnight nursing assistant refusing to assist her, and throwing an incontinent product at her. NA-A stated R76 was yelling and sad about what occurred. NA-A stated she offered R76 assurance and attempted to calm her down. NA-A believed this situation to be neglect, and abuse. NA-A stated she informed the charge nurse (Registered Nurse (RN)-A) on duty, and expected her to inform the DON. On 7/19/17, at 8:04 a.m. NA-B stated approximately 2 weeks ago at 6:30 a.m. NA-A requested her to come to R76's room because she noticed something different about R76. NA-B stated when she entered R76's room R76 was very upset, angry, and crying. NA-B stated R76 was upset because on the overnight shift she had an incontinent product thrown at her and the nursing assistant did not want to help her. NA-B stated she observed incontinent products on the floor in R76's room. NA-B stated R76's attitude was completely different than normal, she didn't want to do anything, or even go to breakfast because she was so upset. NA-B stated she offered R76 assurance and reported the incident to RN-A. NA-B stated she felt this situation was abuse due to how it made R76 feel. NA-B stated she would have expected the charge nurse to inform the DON of this situation. On 7/19/17, at 1:00 p.m. the DON was interviewed and stated she expected the charge nurse to call the administrator if there was suspected abuse. The DON stated if there is injury to the resident, the facility will submit a report to the SA within 2 hours. The DON further indicated if there is no injury to the resident, a report will be made to the SA within 24 hours, and an internal investigation will begin immediately. The DON stated if a nursing assistant suspects abuse they are expected to report it to the charge nurse who will report it to administration. The DON stated she would not expect a nursing assistant to call the administrator or herself to report abuse.

Based on observation, interview, and record review, the facility failed to ensure medication regime was free from unnecessary medications for 1 of 5 residents (R85) reviewed for unnecessary medication. Findings include: R85's Face Sheet printed 7/20/17, indicated [DIAGNOSES REDACTED]. R85's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R85 had severely impaired cognition. R85's Physician order [REDACTED]. R85's [MEDICATION NAME] had been started on 9/12/16. On 7/19/17, at 7:56 a.m. R85 was observed awake and alert in his wheelchair. R85 was unable to engage in conversation, but smiled with greeting. On 7/19/17, at 11:00 a.m. nursing assistant (NA)-C was interviewed and stated R85 was usually in a good mood. NA-C stated R85 was usually awake during the day, and liked participating in activities during the day. NA-C stated R85 rarely became upset and when he did, he was very easily redirected. On 7/19/17, at 7:43 a.m. licensed practical nurse (LPN)-A stated R85 slept well during the night, and did not have behavior issues during the night. On 7/20/17, at 12:01 p.m. social worker (SW)-A stated she monitored all psychoactive medications residents were taking, and when they were due for a gradual dose reduction (GDR). SW-A stated the facility conducted lifestyle support meetings monthly. SW-A explained the lifestyle support meetings consisted of the administrator, SW, MDS coordinator, the activities director and the director of nursing (DON). SW-A further explained during the meetings, they discussed resident behaviors, reviewed recommendations from the monthly pharmacist's review of medications, and reviewed residents who were due for a GDR. SW-A stated if the group thought a resident should have a change in antipsychotic medications, they would notify the medical provider. SW-A reviewed the lifestyle support meeting minutes for R85 since admission. SW-A stated there were no recommendations from these meetings to address GDR status of R85's [MEDICATION NAME]. R85's medical record lacked GDR recommendations for [MEDICATION NAME] from pharmacist monthly review since 8/8/16. Provider notes lacked indication R85 had ever had a GDR trial done or documentation for why a GDR was not attempted. R85's behavior notes reviewed from 4/20/17-7/20/17 indicated resident had behaviors of resisting staff care 1-2 times per month with no aggressive behaviors documented. On 7/20/17, at 12:21 p.m. the pharmacist was interviewed and stated when a resident with a [DIAGNOSES REDACTED]. The pharmacist explained a GDR should be requested if frequent behavioral concerns were not noted. The pharmacist further explained the physician would then decide if they wanted to reduce the dosage. The pharmacist stated if the physician did not want to implement the recommended GDR, the physician would have to document the rationale. On the same day at 1:15 p.m. the pharmacist stated he could not find any information in R85's chart recommending a GDR for the [MEDICATION NAME]. The pharmacist stated a GDR should have been recommended in 3/17, and there was no reason why this was not done. The pharmacist further stated there should be a note from a pharmacist why a GDR was not recommended. The facility policy and procedure Psychoactive Medication Management dated 6/15, directed gradual dose reductions will be attempted per regulations, or documentation of clinical rationale will be provided by the physician. The policy further directed success and results of medication reduction attempts would be logged, and if it was determined that the medication reduction attempt was not successful, the physician would write a note regarding the continued use of the medication.

Based on interview and record review, the consultant pharmacist failed to provide a gradual dose recommendation for 1 of 5 residents (R85) reviewed for unnecessary medications. Findings include: R85's Face Sheet printed 7/20/17, indicated [DIAGNOSES REDACTED]. R85's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R85 had severely impaired cognition. R85's Physician order [REDACTED]. R85's Zyprexa had been started on 9/12/16. R85's medical record lacked GDR recommendations for Zyprexa from pharmacist monthly review since 8/8/16. Provider notes lacked indication R85 had ever had a GDR trial done or documentation for why a GDR was not attempted. R85's behavior notes reviewed from 4/20/17-7/20/17 indicated resident had behaviors of resisting staff care 1-2 times per month with no aggressive behaviors documented. On 7/20/17, at 12:21 p.m. the pharmacist was interviewed and stated when a resident with a [DIAGNOSES REDACTED]. The pharmacist explained a GDR should be requested if frequent behavioral concerns were not noted. The pharmacist further explained the physician would then decide if they wanted to reduce the dosage. The pharmacist stated if the physician did not want to implement the recommended GDR, the physician would have to document the rationale. On the same day at 1:15 p.m. the pharmacist stated he could not find any information in R85's chart recommending a GDR for the Zyprexa. The pharmacist stated a GDR should have been recommended in 3/17, and there was no reason why this was not done. The pharmacist further stated there should be a note from a pharmacist why a GDR was not recommended. The facility policy and procedure Psychoactive Medication Management dated 6/15, directed monthly pharmacy consultant reviews will ensure appropriate .potential for gradual dose reductions.