Every finding on record at The Gardens Rehab & Care Center

Based on documentation, staff interviews, and the facility's policy and procedures, the facility failed to ensure a registered nurse was scheduled for 8 consecutive hours, or the DON (Director of Nursing) to serve as a charge nurse when the facility has an average daily occupancy of 60 or fewer residents on May 26, 2025. The deficient practice could impact the quality of care provided to residents and support for the staff scheduled.Findings include:Review of the daily staff posting dated May 26, 2025, revealed that a Registered Nurse (RN) was not scheduled to work on the day shift, 6 AM to 6:30 PM, or on the night shift, 6 PM to 6:30 AM.Review of the daily assignment sheet dated May 26, 2025, revealed that there were two Licensed Practical Nurses (LPNs) scheduled for the day shift, 6 AM to 6:30 PM, and two LPNs scheduled to work the night shift, 6 PM to 6:30 AM.Review of the time cards dated May 26, 2025, revealed that there were two Licensed Practical Nurses (LPNs) who worked the day shift, 6 AM to 6:30 PM, and two LPNs who worked the night shift, 6 PM to 6:30 AM.During an interview conducted on January 7, 2026, at 11:33 AM, with the DON (Staff # 82) the daily staff posting, staff schedule, and time cards were reviewed for May 26, 2025. Staff #82 confirmed that there were not a RN scheduled to work for 8 consecutive hours on May 26, 2025. Staff #82 stated that the facility is expected to ensure an RN is scheduled and on shift, as an RN can delegate care and oversee the tasks of LPNs and nursing aides. Staff #82 also stated that the risk of not having an RN on shift can delay patient care, put patients at more risk for falls, lead to a lack of customer satisfaction, increase complaints of care, and lead to a lack of supervision for LPNs and nursing aides. Staff #82 stated that due to the bed occupancy of the facility, she can serve as the charge nurse and will review the timecards and schedule for the day of May 26, 2025. During an interview conducted on January 7, 2026, at 1:04 PM with the DON (Staff #82), she stated that she did not serve as the charge nurse on May 26, 2025, and that the facility is expected to have an RN working for 8 consecutive hours daily, or the DON to serve as the charge nurse to ensure registered professional coverage in the facility for 8 consecutive hours.During an interview conducted on January 7, 2026, at 1:18 PM with the Administrator (Staff #96) and the CEO (Chief Executive Officer/Staff #200), Staff #96 stated that the schedule expectations is to ensure there is a RN during either the day or night shift to ensure that there is a RN coverage for a consecutive 8 hours, 7 days a week. Staff #96 also confirmed that the DON did not serve as the charge nurse on May 26, 2025, so no hours could be considered applicable towards the requirement.In the facility assessment, last updated on October 24, 2025, under the part of the facility assessment titled Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, do not reveal staffing expectations regarding RN coverage. The facility assessment states that nursing services, such as the DON, RN, LPN, CNA (certified nursing assistant), medication technician, wound nurse, and MDS (Minimum Data Set) nurse are needed to provide support and care for residents.

Based on clinical record review, staff interview and policy review, the facility failed to ensure that 3 residents (#5, #15 and #4) out of 13 sampled had a PASARR (Preadmission Screening and Resident Review) level 2 completed and submitted to the state for review. The universe was 44. The deficient practice could impact the resident's ability to receive the care and services in the most integrated setting appropriate to their needs.Findings include:-Regarding Resident #5Resident #5 was admitted on [DATE] with diagnosis including schizophrenia, encephalopathy, unspecified psychosis, hallucinations, recurrent bipolar disorder, anxiety disorder and other depressive episodes.A review of the quarterly MDS (minimum data set) dated October 25, 2025 revealed a BIMS (brief interview of mental status) score of 12 indicating that the resident was moderately cognitively impaired.A review of the physician orders revealed that the resident was actively prescribed Risperidone (An Antipsychotic medication) and Duloxetine (An Antidepressant medication).A review of the PASSAR dated August 18, 2024 revealed diagnosis of schizophrenia, major depression, bipolar disorder and anxiety disorder as well as the prescribed medication of Duloxetine. The PASSAR was signed by staff #111, the admissions coordinator.-Regarding Resident #15Resident #15 was admitted on [DATE] with diagnosis including schizophrenia, anxiety disorder and recurrent major depressive disorder.A review of the quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating that the resident was cognitively intact.A review of the physician orders revealed that the resident had active orders for Fluoxetine for depression and Olanzapine for schizophrenia.A review of the PASSAR dated March 14, 2025 revealed documentation that the resident was diagnosed with schizophrenia, major depression, and anxiety disorder. The PASSAR further revealed that the resident was receiving Olanzapine and Fluoxetine. The PASSAR was signed by staff #111 admissions coordinator.-Regarding Resident #4Resident #4 was admitted on [DATE] with diagnosis including unspecified mood disorder, and bipolar disorder.A review of the admission MDS dated [DATE] revealed a BIMS score of 12 indicating that the resident was moderately cognitively impaired.A review of the PASSAR dated November 9, 2025 revealed diagnosis including major depression and anxiety disorder as well as the prescribed medication of Depakote. It was documented that staff #111 signed the PASSAR form.A review of the physician orders revealed a referral to psychiatry on December 8, 2025 and that Depakote was prescribed.An interview was conducted on January 7, 2026 at 1:23 PM with staff #111 admissions coordinator. Staff #111 stated that she reviews resident referrals for potential placement and that she conducts both the admission and 30-day PASSAR's as well as conducting any PASSAR's if there were behavioral changes with the resident. Staff #111 stated that the purpose of the PASSAR is to screen resident's for appropriate settings and supports. Staff #111 further stated if a resident has a diagnosis such as a bipolar disorder, they would require a level II PASSAR referral. Staff #111 read the facilities current policy and stated that based on the facilities policy all residents with an SMI (serious mental illness) diagnosis should be referred. She further stated that the risk for not submitting a referral as required could include the residents not being in the appropriate setting. Staff #111 stated that she had not sent resident #5, #15 and #4 for a level II PASSAR referral and that per the facilities policy, all 3 should have been referred.An interview was conducted on January 7, 2026 at 1:39 PM with DON (Director of Nursing/ Staff #84). Staff #84 stated that she knew that PASSAR's were conducted at admission if a resident had diagnosis that included things like psychotic disorder or depression. She stated that if a PASSAR was not conducted per policy the risk could include not getting the help or interventions needed.An interview was conducted on January 7, 2026 at 1:44 PM with staff #96, the administrator. Staff #96 stated that the expectations for PASSAR are that they are conducted as required and that there is a learning curve with appropriate implementation of the PASSAR, but that going forward the facility would be on the look out to ensure that PASSAR's are conducted as required and would conduct audits to ensure accuracy.A review of the facility policy titled Pre-admission screening and Resident Review signed March 1, 2025 revealed that all individuals with mental disorders and intellectual disability will be referred to the state for all level two determination.

Based on clinical record review, staff interviews, observation of current practice, and review of facility policy, the facility failed to ensure the smoking policy was followed for 7 out of 7 residents (Resident #8, #30, #21, #20, #40, #52, #38). The sample Size was 44. The deficient practice could result in injury to residents.Findings include:-Regarding resident #8:Resident #8 was admitted on [DATE], with diagnoses including end stage renal disease, hypotension of dialysis, hypertension, and atrioventricular block.A review of the care plan initiated on August 29, 2023 revealed no initial identified risk of smoking.Further review of the care plan revealed an identified smoking risk dated November 30, no year noted. The problem identified in the care plan indicated risk related to smoking, with interventions including order signed by medical doctor (MD), consent signed by responsible party, smoking only allowed with supervision in designated area, and a goal of no physical injury related to smoking with exception of health complications as recognized by Surgeon General.A review of the physician orders revealed no order for smoking.A review of the smoking contract signed on August 28, 2023 revealed a signature from the resident in acknowledgement of the facility policy regarding smoking. -Regarding resident #30:Resident #30 was admitted on [DATE] with diagnoses including history of malignant neoplasm of the large intestine, acute embolism and thrombosis of deep veins of lower extremity, and acute respiratory failure with hypoxia.A review of the care plan initiated on November 12, 2025 revealed no identified risk of smoking.Further review revealed that activities interests were care planned on November 14, 2025, and listed activities interventions including a desire to be included for smoking, written as, Come get me for smoke breaks.A review of the physician orders revealed no order for smoking.A review of the smoking contract signed on November 12, 2025 revealed a signature from the resident in acknowledgment of the facility policy regarding smoking. -Regarding resident #21:Resident #21 was admitted on [DATE] with diagnoses including hypertension, atherosclerotic heart disease, and chronic obstructive pulmonary disease.A review of the care plan initiated on August 24, 2025 revealed an identified smoking risk. Further review of the care plan revealed a problem area of risk related to smoking, with interventions including order signed by MD, consent signed by responsible party, smoking only allowed with supervision in designated area, and a goal of no physical injury related to smoking with exception of health complications as recognized by Surgeon General.A review of the physician orders revealed no order for smoking.A review of the smoking contract signed on August 23, 2024 revealed a signature from the resident in acknowledgment of the facility policy regarding smoking. -Regarding resident #20:Resident #20 was admitted on [DATE] with diagnoses including schizoaffective disorder, acute kidney failure, and history of traumatic brain injury.A review of the care plan initiated on October 13, 2025 revealed an identified smoking risk. Further review of the care plan revealed a problem area of risk related to smoking, with interventions including order signed by MD, consent signed by responsible party, smoking only allowed with supervision in designated area, and a goal of no physical injury related to smoking with exception of health complications as recognized by Surgeon General.A review of the physician orders revealed no order for smoking.A review of the smoking contract signed on October 13, 2025 revealed a signature from the resident in acknowledgment of the facility policy regarding smoking. -Regarding resident #40:Resident #40 was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, hypotension, and personal history of transient ischemic attack.A review of the care plan initiated on March 25, 2025 revealed an identified smoking risk. Further review of the care plan revealed a problem area of risk related to smoking, with interventions including order signed by MD, consent signed by responsible party, smoking only allowed with supervision in designated area, and a goal of no physical injury related to smoking with exception of health complications as recognized by Surgeon General.A review of the physician orders revealed no order for smoking. A review of the smoking contract signed March 14, 2025 revealed a signature from the resident in acknowledgment of the facility policy regarding smoking.-Regarding resident #52:Resident #52 was admitted on [DATE] with diagnoses including displaced fracture of the right tibia, atherosclerotic heart disease, and peripheral vascular disease.A review of the care plan initiated on January 2, 2026 revealed an identified smoking risk. Further review of the care plan revealed a problem area of risk related to smoking, with interventions including order signed by MD, consent signed by responsible party, smoking only allowed with supervision in designated area, and a goal of no physical injury related to smoking with exception of health complications as recognized by Surgeon General.A review of the physician orders revealed no order for smoking.A review of the smoking contract signed January 2, 2026 revealed a signature from the resident in acknowledgment of the facility policy regarding smoking.-Regarding resident #38:Resident #38 was admitted on [DATE] with diagnoses including hypertension, type 2 diabetes mellitus, and hypokalemia.A review of the care plan initiated on October 4, 2022 revealed an identified smoking risk. Further review of the care plan revealed a problem area of risk related to smoking, with interventions including order signed by MD, consent signed by responsible party, smoking only allowed with supervision in designated area, and a goal of no physical injury related to smoking with exception of health complications as recognized by Surgeon General.A review of the physician orders revealed no order for smoking.A review of the contract signed February 15, 2016 revealed a signature from the resident acknowledging facility policy, including regarding smoking. An interview was conducted on January 8, 2026 at 7:45 am, with a certified nursing assistant (CNA/staff #126). Staff #126 stated she was not sure if there was a place in the chart to identify if a resident was a smoker. She also stated she was made aware which residents are smokers when the other staff make her aware. She stated she did not know about the smoking policy.An interview was conducted on January 8, 2026 at 7:55 am with a licensed practical nurse (LPN/staff #104). Staff #104 stated he knew which residents were smokers because he had been employee at the facility for so long, he was familiar with them. Staff #104 further stated he did not think that residents needed an order for smoking and each resident signs the contract. When asked about the care plan interventions for smoking residents, staff #104 referred to the care plan for resident #8 and read aloud that interventions for smoking in the care plan included having a physician's order.An interview was conducted on January 8, 2026 at 8:08 am, with the admissions coordinator (staff #111). Staff #111 stated that she is not often aware of the smoking status of residents when they are admitted . She further stated that if she is aware of the smoking status of a resident when they are admitted , she initiates communication in the clinical record and on physical records that the resident is a smoker. Staff #111 stated she did not know what the policy was for smoking, but that she did know where to find the policy, that there are designated smoking times, and that the residents need to be accompanied. An interview was conducted on January 8, 2026 at 8:30am with the director of nursing (DON/staff #82). Staff #82 stated that upon admission, residents are required to sign the smoking contract, regardless of smoking status. She further stated that she was not aware of the smoking policy beyond what is outlined in the smoking contract. Staff #82 stated that the risk associated with not having smoking orders is that the provider may be unaware of the smoking status of residents, which could result in orders being placed that are contraindicated to the resident's total care.An interview was conducted on January 8, 2026 at 8:45 am with the administrator (staff #96). Staff #96 stated that the smoking policy includes supervision and the use of smoking aprons for safety. Staff #96 reviewed the facility policy regarding smoking and stated that, based on the policy, the care plan interventions would be included as part of the policy. A review of the facility policy titled, Resident Smoking, reviewed October 2, 2025, revealed, The following procedures will be abided by: . 4. Smoking safety is included in the Standard Care Plan and is reviewed at least quarterly.A review of the Standard Care Plan revealed the following problem and corresponding intervention: Problem: Risks related to smoking. Interventions: Smoking only allowed with supervision in designated area, at designated smoking times. Consent signed by responsible party. Order signed by MD. Smoking assess quarterly and follow protocol per assessment. Smoking supplies left with personnel. Visitors/family aware of smoking policy.

Based on observation, clinical record review, staff interview and policy review, the facility failed to ensure the resident's right to privacy and confidentiality was followed for one resident (Resident #40). The sample size was 44. The deficient practice could result in risk of unauthorized access.Findings include:Resident #40 was initially admitted on [DATE], and re-admitted on [DATE], with diagnosis that included hypotension, history of transient ischemic attack (TIA) and cerebral infarction without residual deficits; unspecified dementia; hypotension; acute respiratory failure with hypoxia; major depressive disorder; and anxiety disorder. A review of the care plan for resident #40 revealed a problem area for confusion and poor decision-making related to cognitive impairment. Interventions include explaining the procedure, determining limitations, and reorienting to situation as needed.A review of the physician orders revealed orders for medications including Loperamide HCl[hydrochloride) Oral Tablet 2mg[milligrams], give 2mg by mouth as needed for diarrhea; Ondansetron HCl Tablet 4mg, give one tablet by mouth every four hours as needed for nausea and vomiting; Hydroxyzine HCl Oral Tablet 25mg, give one tablet by mouth every four hours as needed for itching; and Aluminum and Magnesium Hydroxide Oral Suspension 200-200mg/5 mL[milliliters], give 20mL by mouth every 24 hours as needed for indigestion.On January 8, 2026, at 6:18 AM, a medication cart was observed unattended. On top of the cart, a device was unlocked and displayed resident #40's full name, date of birth , photo, room location, code status, and medications. An interview was conducted on January 8, 2026, at 6:20 AM with a nurse (LPN/staff #59). Staff #59 stated she thought she had locked the computer. Staff #59 further stated that the risk of not closing the computer is that people could access patient's information. She stated she could not remember the word for this. An interview was conducted on January 8, 2026, at 8:30 AM with the director of nursing (DON/Staff #82). Staff #82 stated that a medication cart computer being open would be a HIPAA violation. She further stated the facility policy for patient information as it relates to nursing computers is that computers should be locked in compliance with HIPAA.An interview was conducted on January 8, 2026, at 8:45 AM with the administrator (staff #96). Staff #96 stated that medication cart computers left open would be a HIPAA violation if someone saw them. He also stated that the facility policy regarding resident information being left out is to follow HIPAA, and that he would not want information left out, such as first and last names, and that resident information should be protected. He further stated the risk of having resident information out is personal information being left out. Review of a facility policy, Confidentiality of Information, reviewed March 1, 2025, revealed that resident information is to be treated confidentially. Further review of the procedure section of the policy revealed 1. The facility will safeguard all resident records, whether medical, financial, or social in nature, to protect the confidentiality of the information.

Based on observation, interviews, review of documentation, and review of facility policies, the facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for one resident (#54). The deficient practice could lead to a failure of the facility to report allegations of abuse timely, and could lead to continued abuse for a resident. -Regarding Resident # 54: Resident # 54 was admitted to the facility on [DATE] and discharged [DATE], with diagnoses that included displaced transverse fracture of right patella, subsequent encounter for closed fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, altered mental status, unspecified, mild cognitive impairment of uncertain or unknown etiology. The Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 03, indicating the resident had severe cognitive impairment. A nursing progress note dated January 05, 2025, revealed that at approximately 5:53 PM, revealed the following note residents' spouse at the. Resident was in w/c in commons area and spouse pushed resident towards door of room. This writer was sitting at nurses station an overheard spouse talking to resident and stated, You fucking idiot, I can't take you home. You're so stupid, why can't you listen to me? You're fucking worthless. Nurse intervened and stepped between resident and spouse, and removed spouses' hands from w/c. Spouse continued to attempt to talk to resident stating, I can't take care of you, I'm not taking you home. This writer had another staff member stay with resident and escorted spouse out of facility and informed him that he isn't allowed to talk to resident in that way or tone. Administration updated per night supervisor A Communication Note- with family/NOK/POA dated January 6, 2025 at 1:18 PM, Administrator in Training ((AIT/Staff # 12) revealed Assistant Administrator spoke with husband this morning regarding the interaction between resident's spouse and wife [NAME] yesterday afternoon. Resident's spouse told Assistant Administrator that his dog is very sick and having seizures. He was upset about the dogs' condition and then shared that information with resident #54 (he admitted to this being a mistake). Resident #54 then got very agitated and was wanting to leave. Resident's spouse said he got frustrated with everything going on and lost his temper. He was apologetic and said it won't happen again. He also told the Assistant Administrator that she had been calling him this morning wanting him to come in. Assistant Administrator and DON interviewed the resident. Resident doesn't recall the incident therefore resident did not seem negatively affected by the incident with her husband on 1/5/25. Resident stated she felt comfortable with her husband and doesn't feel uncomfortable with him at all. A Psychiatry/Mental Health note dated January 7, 2025 at 5:15 PM revealed that the provider met with Resident #54 for follow up to report of incident between spouse and resident and planned discharge. The note revealed that provider was informed by the facility that husband had cursed at resident #54 and told her that she was worthless. The report further revealed the resident's husband was escorted from the facility without incident. Resident #54 reported to the provider that the incident does not bother her. We always kiss and makeup. Review of the facility's Internal Investigation dated January 10, 2025 indicated the date of event was January 5, 2025. Further review of the facility investigation revealed the online report was submitted online to the state agency on January 7, 2025 at 2:30p with the notification of [NAME] Police Department Case Number 25-000571, APS, Physician, Family/Guardian, Ombudsman. An interview was conducted with the Licensed Practical Nurse (LPN/Staff # 17) on January 15, 2025 at 324 PM. Staff #17 stated she was sitting at the nurses station when she observed the spouse pushing the resident #54 in her wheelchair and he was leaned over as he pushed her talking to her loudly, calling the resident stupid, you're not listening to me, worthless, I can't take care of you, you can't go home, dropped a few F- bombs Staff #17 stated she walked over asked him to step back and told him I can't have you talk to her like that and he continued to try talking to her. Staff #17 stated she told the husband that he would have to leave and escorted him to the door and he left. She stated she contacted the DON. Staff #17 reported no changes observed with the resident and did not recall the incident with her husband did not seem phased by it. She reported no prior incidents that she is aware of and has always been pleasant with his wife during his daily visits. An interview was conducted with the Administrator (Staff #6) on January 15, 2025 at 3:58 PM. Staff #6 stated the incident occurred on Sunday, January 5, 2025 and was not reported to the state agencies until Tuesday, January 7, 2025. Staff #6 stated the AIT/Staff #12 was unaware that the incident was a reportable for verbal abuse. Staff #6 stated she had a conversation with staff #12 as why to the alleged abuse had not been reported to the state agencies. Staff # 6 stated he informed her that the spouse was gone, but did not ask any further questions or ask what was said to the resident. Staff # 6 stated it is her expectation that staff are able to identify abuse. Staff #6 stated staff #12 was provided with abuse education, training in identifying abuse and timely reporting. Staff #6 stated the risk s with not reporting in a timely manner are citations and fines for the facility. An interview was conducted with the Director of Nursing (DON/Staff #13) on January 15, 2026 at 4:45 PM. The DON stated that she was made aware of the incident regarding resident #54 and her spouse and considered it to be verbal abuse. The DON stated any allegations for abuse are reported to the state agencies in within two hours. The DON stated the risks with not reporting in a timely manner are further complications for the people involved and the spouse could continue to speak to the resident that way. The DON stated Staff # 12 spoke to the spouse and the care plan was revised to provide supervised visits for resident #54 and her spouse. The DON stated it was her understanding that the husband had a lot of personal issues going on with the dog dying, concerned about his wife going home and his ability to care for her with her dementia. The DON stated the spouse was frustrated at the time of the incident and there had been no prior concerns with his visits. Review of the facility policy Abuse Reporting states all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state and federal; agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 2. Suspected abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property will be reported within two hours.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that resident (#30) was not abused by resident (#2). The deficient practice could result in residents being harmed emotionally and physically. Findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, chronic kidney disease, encephalopathy, and hypertension. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident had a moderate cognitive impairment. A progress note dated January 30, 2024 revealed that residents were interviewed and notified appropriate agencies as per protocol. Resident #30 made an allegation of abuse to his therapist. The therapist alerted administration and this nurse at 3:10 p.m. and an investigation was started immediately. The responsible party, the resident's mother, was present when the resident was interviewed at 3:15 p.m. A psych consult was ordered for psychosocial well-being. A care plan dated January 30, 2023 revealed that resident #2 was involved in an allegation of abuse. Interventions included to order a psych consultation related to psychosocial well-being. A skin assessment dated [DATE] did not reveal any injuries. -Resident #2 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, post traumatic stress disorder, and Rhabdomyolysis. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 5 indicating the resident had a severe cognitive impairment. The care plan dated January 6, 2023 did not reveal a plan for behaviors or PTSD. The progress note dated January 27, 2023 revealed that the resident had a verbal altercation with his roommate. The resident was moved to room [ROOM NUMBER]. The power of attorney is aware. A progress note dated January 30, 2023 revealed that the resident was involved in an allegation of abuse. Administration and this nurse were notified at 3:10 p.m. and an investigation was started immediately. The appropriate parties were notified and a psych consult was ordered. A care plan dated January 30, 2023 revealed that resident #2 was involved in an allegation of abuse. Interventions included to order a psych consultation related to psychosocial well-being. The progress note dated January 30, 2023 revealed that the resident was moved to another room per his request. A skin assessment dated [DATE] did not reveal any injuries. Review of the 5-day investigation dated February 3, 2023 revealed: -a physical therapy assistant (staff #21) informed the nurse that resident #30 was inquiring about the altercation that took place him and his roommate. The staff informed the administrator on January 30, 2023 and started an investigation immediately by interviewing the two residents. - a certified nursing assistant (CNA/staff #9). Staff #9's statement revealed that on January 27, 2023, dietary staff (#62) reported to her that two residents were arguing and when she entered the room, resident #2 was close to resident #30's bed, and she heard resident #2 tell resident #30, if I ever get my hands on you, you're a dead man. The argument appeared to be over something on the TV. Staff #9 took resident #2 out of the room to avoid further arguing. -a statement from the dietary staff (#62), which stated that staff #62 worked on January 27, 2023 when resident #30 told staff #62 to come to his room because his roommate was threatening him. Staff #62 notified staff #9. -a psych evaluation for resident #30 dated February 3, 2023 where resident #30 stated that he was watching a TV program about a black man being assaulted by the police and resident #2 called him a n*****, n***** lover and said he would come over and kill him, beat him up. -a psych evaluation for resident #2 dated February 30, 2023 revealed that resident #2 stated that he was in bed and then that he did not remember going over to the resident 30's bed, threatening to kill him, or kicking the bed. An interview was conducted on November 19, 2024 at 11:58 a.m. with the Director of Nursing (DON/staff #1), who stated that she has received training on abuse which includes verbal abuse. She stated that verbal threats to harm with intimidation is a form of verbal abuse along with racial slurs, such as, n***** and n***** lover. During the interview, staff #1 reviewed the 5-day investigation dated February 3, 2023, which included a statement from: -a certified nursing assistant (CNA/staff #9). Staff #9's statement revealed that on January 27, 2023, dietary staff (#62) reported to her that two residents were arguing and when she entered the room, resident #2 was close to resident #30's bed, and she heard resident #2 tell resident #30, if I ever get my hands on you, you're a dead man. Staff #1 stated that this was a threat and considered it verbal abuse. -a statement from the dietary staff (#62), which stated that staff #62 worked on January 27, 2023 when resident #30 told staff #62 to come to his room because his roommate was threatening him. Staff #62 notified staff #9. -a psych evaluation for resident #30 dated February 3, 2023 where resident #30 stated that he was watching a TV program about a black man being assaulted by the police and resident #2 called him a n*****, n***** lover and said he would come over and kill him, beat him up. Staff #1 stated that it sounded like resident #2 was set off by the news that resident #30 was watching on TV. An interview conducted on November 19, 2024 at 2:43 p.m. with the certified nursing assistant supervisor (CNA/staff #17), who stated that she has received training on abuse and verbal abuse includes cussing, name calling, derogatory comments, and threats. The facility policy, Abuse Prohibition states that it is the policy of this facility to screen and train employees to provide for the protection of residents and for the prevention, identification, investigation, and reporting of abuse, exploitation, neglect, mistreatment, and misappropriation of property.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to report an allegation of verbal abuse to the state agency based on the regulatory timeframe for one resident (#30). The deficient practice could result in residents not being protected from abuse. Findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, chronic kidney disease, encephalopathy, and hypertension. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident had a moderate cognitive impairment. A progress note dated January 30, 2024 revealed that residents were interviewed and notified appropriate agencies as per protocol. Resident #30 made an allegation of abuse to his therapist. The therapist alerted administration and this nurse at 3:10 p.m. and an investigation was started immediately. The responsible party, the resident's mother, was present when the resident was interviewed at 3:15 p.m. A psych consult was ordered for psychosocial well-being. A care plan dated January 30, 2023 revealed that resident #2 was involved in an allegation of abuse. Interventions included to order a psych consultation related to psychosocial well-being. A skin assessment dated [DATE] did not reveal any injuries. -Resident #2 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, post traumatic stress disorder, and Rhabdomyolysis. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 5 indicating the resident had a severe cognitive impairment. The care plan dated January 6, 2023 did not reveal a plan for behaviors or PTSD. The progress note dated January 27, 2023 revealed that the resident had a verbal altercation with his roommate. The resident was moved to room [ROOM NUMBER]. The power of attorney is aware. A progress note dated January 30, 2023 revealed that the resident was involved in an allegation of abuse. Administration and this nurse were notified at 3:10 p.m. and an investigation was started immediately. The appropriate parties were notified and a psych consult was ordered. A care plan dated January 30, 2023 revealed that resident #2 was involved in an allegation of abuse. Interventions included to order a psych consultation related to psychosocial well-being. The progress note dated January 30, 2023 revealed that the resident was moved to another room per his request. A skin assessment dated [DATE] did not reveal any injuries. Review of the 5-day investigation dated Review of the 5-day investigation dated February 3, 2023 revealed: -a physical therapy assistant (staff #21) informed the nurse that resident #30 was inquiring about the altercation that took place with him and his roommate. The staff informed the administrator on January 30, 2023 and started an investigation immediately by interviewing the two residents. - a certified nursing assistant (CNA/staff #9). Staff #9's statement revealed that on January 27, 2023, dietary staff (#62) reported to her that two residents were arguing and when she entered the room, resident #2 was close to resident #30's bed, and she heard resident #2 tell resident #30, if I ever get my hands on you, you're a dead man. The argument appeared to be over something on the TV. Staff #9 took resident #2 out of the room to avoid further arguing. -a statement from the dietary staff (#62), which stated that staff #62 worked on January 27, 2023 when resident #30 told staff #62 to come to his room because his roommate was threatening him. Staff #62 notified staff #9. -a psych evaluation for resident #30 dated February 3, 2023 where resident #30 stated that he was watching a TV program about a black man being assaulted by the police and resident #2 called him a n*****, n***** lover and said he would come over and kill him, beat him up. -a psych evaluation for resident #2 dated February 30, 2023 revealed that resident #2 stated that he was in bed and then that he did not remember going over to the resident 30's bed, threatening to kill him, or kicking the bed. Review of the online report revealed that the facility reported the allegation of verbal abuse that was reported by resident #30 to facility staff on January 27, 2024 and the facility reported the allegation to the state agency on January 30, 2024. An interview was conducted on November 19, 2024 with the Director of Nursing (DON/staff #1), who stated that she has received training on abuse which includes verbal abuse. She stated that verbal threats to harm with intimidation is a form of verbal abuse along with racial slurs, such as, n***** and n***** lover. Staff #1 reviewed the 5-day investigation, which included a statement from a certified nursing assistant (CNA/staff #9), and stated that the CNA's statement revealed that the incident occurred on January 27, 2023. An interview conducted on November 19, 2024 at 2:43 p.m. with the certified nursing assistant supervisor (CNA/staff #17), who stated that she has received training on abuse and verbal abuse includes cussing, name calling, derogatory comments, and threats. She stated that if a resident makes an allegation of abuse, she reports it immediately to the supervisor because they only have two hours to report it to the state agency. The facility policy, Abuse Prohibition states that it is the policy of this facility to screen and train employees to provide for the protection of residents and for the prevention, identification, investigation, and reporting of abuse, exploitation, neglect, mistreatment, and misappropriation of property. The policy did not reveal the timeline in which allegations are to be reported to the state agency.

Based on clinical record reviews, facility documentation, staff interviews, policy review, and the State Agency (SA) complaint tracking system, the facility failed to ensure that a resident (resident #1) was free from verbal abuse from another resident (resident #2). Findings include: Regarding Resident #1: Resident #1 was admitted at the facility on July 22, 2020 with diagnoses of syncope and collapse, major depressive disorder, schizophrenia. Regarding Resident #2: Resident #2 was admitted at the facility on November 30, 2023 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, spastic hemiplegia affecting right nondominant side, major depressive disorder, anxiety disorder. Brief Interview Mental Status (BIMS) 15, cognitively intact. A review of resident #2's progress notes revealed on September 19, 2024 10:30 AM, staff member #5, was at the nursing station and heard cussing. The staff member went to [NAME] Hall and heard resident state, She called me a psycho bitch. The staff member immediately spoke with both residents to deescalate and Resident #2 stated, I know, I am sorry, I should not have said that, I am just so stressed. The staff member then immediately reported to Assistant Administrator and Administrator. The staff member de-escalated situation, ensured residents were safe. Contacted responsible parties. To prevent further disagreements, resident was presented with a room change. Resident agreed, signed advance notice of room change paperwork with Social Services director and moved rooms. Resident #2 was moved to another room in a different Hall. A review of documentation revealed that Resident #2 was served with a 30 day notice of discharge and said to staff member #5 that she should not of said that to resident #1 yesterday and was sorry. Documented on 09/20/2024 at 1133AM. An interview was conducted with Resident #1 on October 15, 2024 at 6:10PM. The resident stated that it was a big misunderstanding. Resident #2 wanted Resident #1 to wake them up at a certain time. I don't smoke so I did not pay attention. She was saying bad things and called me a crazy bitch. She is no longer here (resident #2), she wanted me to wake her up. Resident concluded the interview with stating, feeling safe in the facility. Care plans were updated on 09/19/2024 for both residents regarding the verbal abuse. Resident #2 had a care plan in place for verbal behavior, makes loud verbal outbursts Manifested by: swearing and insults during meals and activities. Disturbs other individuals. Will yell out/curse at other when uncomfortable in current situation. Resident Rights policy reviewed and the policy states under Procedure 3: Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Abuse Prevention Program policy reviewed and states: It is the policy of this facility for our residents to have the right to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment and involuntary seclusion.

Based on clinical record review, facility documentation, staff interviews, personnel file review, and policies and procedures, the facility failed to ensure one sampled resident (#158) was free from staff to resident abuse, which resulted in psychosocial harm as evidenced by increased yelling, screaming, agitation, and the resident being afraid of the staff member. The census was 55. The deficient practice could result in other residents being abused. Findings include: Resident #158 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on January 16, 2020 to hospice. Review of a care plan initiated on January 10, 2019, revealed that the resident exhibited behaviors of physical and verbal aggression towards staff as evidenced by a history of physical behaviors of resisting cares, and yelling which were related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan also included the resident had verbal behavior as evidenced by loud outbursts. Interventions included to provide calm, non-rushed environment. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognition impairment. The MDS assessment included the resident had physical behavioral symptoms directed toward others 4 to 6 days of the 7-day lookback period, verbal behavioral symptoms directed towards others daily, other behavioral symptoms not directed toward others 1 to 3 days of the 7-day lookback period, and rejected care 4 to 6 days of the 7-day lookback period. The assessment also included the resident was total dependent for transfer and toilet use, required extensive assistance for bed mobility and dressing, and limited assistance for personal hygiene. Review of the facility's Investigation Report dated October 7, 2019 revealed that on October 2, 2019 at approximately 6:00 AM, a Certified Nursing Assistant (CNA/staff #94) witnessed another CNA (staff #93) place a rag and then a pillow over the resident's face as they were providing care. CNA #94 stated that she was beginning her shift and went into the resident's room to assist the night shift CNA (staff #93) because she heard the resident calling out. Staff #94 reported seeing the alleged perpetrator (staff #93) place a cloth on the resident's mouth, which the resident removed. She further reported that as the care progressed the resident continued to yell out and then staff #93 placed a pillow across the resident's face. At this point the CNA (staff #94) reported that she removed the pillow and talked to the resident to calm the resident. Review of the Investigation Report revealed a body assessment was completed on resident #158 after it was reported at 3:00 PM on October 2, 2019 and that there were no signs of injury or bruising. The investigation report included the following witness statement for staff #94 dated October 2, 2019 at 3:15 PM: - I clocked in at 6:00 AM on October 2, 2019 and went to my scheduled hall. As I entered the hall I could hear resident #158 screaming very loudly in her room where she was being changed and dressed by CNA #93. I asked if CNA #93 needed help and started assisting with the resident's care. The resident was still screaming as we continued to get her clothes on when staff #93 tried to silence the resident by putting a rag onto her mouth, telling me that the resident just needed something to bite down on. The resident did not like this and removed the rag and shortly after, CNA #93 placed a pillow over the resident's face while trying to have a conversation with me. I removed the pillow and remained quiet and tried to calm the resident down verbally. We finished the care and CNA #93 gave me report and then clocked out. Staff #93's (alleged perpetrator) statement dated October 3, 2019, included that when she starting dressing the resident, the resident behavior escalated to yelling and the resident resisted getting her shirt on by holding her arms down. During this time CNA #94 came in because it was 6:00 AM, and she assisted with dressing and Hoyering. Everything went normal with the care, and once the resident was in her chair she was content. We finished rounds for the hall and everything else went good until 6:30 AM when I clocked out. A student CNA's (staff #301) statement dated October 3, 2019, included that on October 2, 2019, staff #301 started the shift as a CNA student for clinicals arriving on the hall a few minutes after 6:00 AM. Staff #301 heard as well as others, a resident yelling, screaming very upset but did not go to see what was going on. Staff #301 stated a resident made the comment that resident #158 is not usually that voicetourous, the resident was obviously upset about something. Another student CNA's (staff #302) statement dated October 3, 2019, revealed that on October 2, 2019, staff #94 was demonstrating how to properly change a resident, when she told them of an incident that happened that morning. Staff #302 stated staff #94 stated that she had come onto her shift on the [NAME] hall and heard the resident screaming very loudly, that she was concerned so she went to see what was going on and noticed that staff #93 was cleaning the resident who was very agitated, and that staff #93 was not explaining to the resident what she was doing or what she needed the resident to do. The student CNA statement included staff #94 stated that she tried to calm the resident down when staff #93 shoved a rag in the resident's mouth and placed a pillow on top of the resident's face. Staff #302 statement further revealed staff #94 told her that she was in shock and did not know what to do or say. The statement included staff #94 stated that they then went into another resident's room and that resident asked staff #93 if she was going to work the next night to which staff #93 replied she did and then this resident asked staff #93 what she was going to do with her and that staff #93 stated that she was going to kill her, laughed and told the resident to just shut up. The report included resident #158's family was notified of the incident on October 3, 2019. The family member stated that she had talked to the resident on Friday and Saturday and the resident was telling her that a CNA taking care of her that is pregnant is abusing her on the night shift, that the resident stated she was hit and abused by the CNA and had bruises on her hands and arms. The family member stated resident #158 is scared and terrified of her. Further review of the Investigation report revealed resident #158 was interviewed on October 4, 2019 and stated she slams me into the wall and hit me. Girl told me she has 4 kids she is pregnant, works at night When asked if she wanted to share anything else the resident stated help me. Resident #158 stated she would scream at her and hit her. The report included an interview on October 4, 2019 with the resident whose room staff #93 and staff #94 went into after providing care for resident #158. This resident stated that a blonde girl at night throws her weight around, wants to get rid of people, she'll be here tonight, afraid drag me outside. NOC shift, blonde hair and pregnant, she scares me, she is mean and angry, she has piercing eyes tells people to shut up. The report included that on October 4, 2021 a Licensed Practical Nurse had stated that resident #158 was yelling louder than normal. The investigation report documentation dated October 4, 2019 by the Director of Nursing (DON/staff #303) revealed that no bruising was noted on any resident. Further review of the Investigation Report included a skin assessment form dated October 10, 2019, which revealed resident #158 had an old small bruise on the left medial arm, below the elbow. The Administrator (staff #304) wrote in the investigation report on October 7, 2021 that he had spoken with the investigating officer who stated that based off of the interviews he had conducted and due to eyewitness account that CNA #93 did place the rag over the resident's mouth and the pillow over the resident's face, and due to two residents being afraid of staff #93, the officer felt it was in the best interest of the residents to terminate staff #93. Review of the personnel file for the alleged perpetrator (staff #93) revealed the CNA had received education/orientation for abuse, and resident rights. The file included an Employee Termination form dated 10/10/2019 that an allegation of abuse was brought against staff #93 and that after investigating the allegation, it was determined that two residents on the [NAME] unit were afraid of staff #93 and that they were not able to continue employment due to the residents being afraid of her. The file also included staff #93 had been educated on resident abuse and customer service on July 29, 2019, and that the impact of residents being afraid of employees negatively affects the well-being of the residents. A telephone interview was attempted with the resident's family member on October 18, 2021 at 11:50 PM. There was no answer and no option to leave a message. A telephone interview was attempted on October 19, 2021 at 2:49 PM with the alleged perpetrator (CNA/staff #93). The person answering the call stated that the number was now a business, and they were not familiar with staff #93. A telephone interview was attempted on October 19, 2021 at 2:57 PM with the witness (CNA/staff #94). There was no answer and no voicemail available to leave a message. An interview was conducted October 20, 2021 at 9:24 AM with the DON (staff #43), who stated that she was employed at the facility when the incident occurred in 2019. She stated that it was related to resident abuse, that the witness (CNA/staff #94) was coming on shift and the alleged perpetrator (CNA/staff #93) was going off shift. She stated that it was reported by staff #94 that staff #93 had put a pillow over a resident's face while changing the resident. She further stated that this does not meet the facility expectation for resident care. The DON stated that there was an investigation conducted, and the alleged perpetrator (staff #93) did not return to work and was terminated, but she is not aware of the reason. An interview was conducted on October 20, 2021 at 10:15 AM with an LPN (staff #73), who stated that she has worked at the facility since July 2019. She stated that she is familiar with resident (#158) and that she was very confused, combative, resistant to care and refused a lot of care. She stated that she was aware of an incident with a staff member and the resident. Staff #73 stated that she was working on the unit that day and the CNA (staff #94) told her that the night shift CNA (staff #93) had put something over the resident's mouth. The LPN stated that the residents had not reported concerns to her regarding the alleged perpetrator, prior to the incident. She stated that staffing was consistent at the time, and that this type of treatment was totally unexpected from this CNA. An interview was conducted on October 20, 2021 at 10:52 AM with a CNA (staff #78) who stated that she has worked at the facility for over 3 years. Staff #78 stated new employees receive orientation that includes a handbook, review the abuse policy, resident rights and Hand in Hand Crisis to Care (dementia and Alzheimer's) training, and that they also receive these in-services annually. She stated that she is familiar with the resident that she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated that she was aware of the staff to resident incident that occurred. Staff #78 stated that she did not see any abuse/behaviors toward residents from staff #93 and she was not aware of any complaints from residents about staff #93. Review of the facility policy titled, Abuse Prevention Program, revealed that residents have the right to be free from abuse, and corporal punishment. The facility is committed to protecting residents from abuse by anyone including facility staff, other residents or any other individual. Review of the facility policy titled, Abuse Prohibition, revealed that the facility will train employees to provide for the protection of residents and for the prevention, identification, and reporting of abuse, exploitation, neglect, and mistreatment. At the time of new hire orientation, all employees will be educated regarding abuse. Ongoing mandatory training is provided to all employees regarding identifying and reporting abuse.

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that one resident's (#51) provider was consulted of a change in status regarding blood pressure. The sample size was 18. The deficient practice could result in providers not being notified of changes in residents' conditions. Findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if pulse is less than 60 or systolic blood pressure (SBP) is less than 100. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if pulse is less than 60 or SBP is less than 100. A quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 indicating the resident had intact cognition. The assessment also included hypertension as an active diagnosis. Review of the clinical record did not reveal a care plan related to hypertension. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the MAR for August 2021 revealed the resident's SBP was below ordered parameters twice on 08/04 - 97/59 (day shift) and 99/56 (night shift); and once on 08/05 - 97/70; 08/16 - 93/61; 08/19 - 97/55; 08/20 - 95/53; 08/21 - 90/54; 08/25 - 96/51; and 08/30 - 97/54. Review of nursing progress notes dated August 4 through 30, 2021 did not reveal evidence that the physician had been notified or consulted regarding the SBPs below 100. Review of the September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes dated September 1 through 22, 2021 did not reveal evidence to indicate the physician had been notified or consulted regarding the instances of [CONDITION(S)]. A review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the October 1 through 19, 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing progress notes dated October 1 through 19, 2021 did not reveal evidence the physician had been notified or consulted regarding the blood pressures. An interview was conducted on 10/21/21 at 11:03 a.m. with the Director of Nursing (DON/staff #43), who stated that her expectation would be for nurses to notice when a resident's blood pressure has dropped. The DON stated that she would expect nursing to ensure resident safety, to recheck the vitals, review the medication information, and to notify the physician. She stated that she would know that staff has notified the physician through review of the progress notes. She reviewed the resident's progress notes and stated that she did not see any notes related to the blood pressures. Staff #43 stated that she would additionally anticipate that the resident's care plan would be updated to reflect the blood pressure had dropped below acceptable parameters. On October 21, 221 at 12:48 p.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #35). He stated that if a resident's blood pressure is significantly below baseline, he would anticipate that the Certified Nursing Assistant (CNA) would tell the nurse. He stated that the nurse would be expected to recheck the resident's blood pressure. The LPN stated that if the BP was still significantly low, the expectation would be that the nurse would notify the provider and document the notification in a progress note. The LPN stated that the resident's family may not always be notified, because the provider may order an intervention which may stabilize the resident. The facility policy titled Adverse Consequences and Medication Errors stated that it is the policy of the facility that each facility evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side-effects. Adverse consequences shall be reported to the attending physician. Residents that receive any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. An adverse drug reaction (ADR), a form of adverse consequences, is defined as a secondary and usually undesirable effect of a drug and is different from the therapeutic and helpful effects of a drug. An ADR is any noxious and unintended response to a drug that occurs in doses or prophylaxis, diagnosis, or therapy. The staff shall report clinically significant adverse medication consequences and medication errors with adverse clinical consequences to the resident's attending physician immediately.

Based on clinical record reviews, staff interviews, and policies and procedures, the facility failed to ensure two residents (#38 and #51) were not administered unnecessary medications, by failing to ensure medications were administered in accordance with physician orders. The sample size was 6. The deficient practice could result in residents receiving medications that may not be necessary. Finding include: -Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Acetaminophen Suppository 650 milligrams (mg) insert 1 suppository rectally every 4 hours as needed for mild pain (1-4). Dosing not to exceed 3000 mg/24 hours. -Acetaminophen Tablet 325 mg give 2 tablets by mouth every 6 hours as needed for mild pain. Tylenol dosing not to exceed 3000 mg/24 hours. -[MEDICATION(S)] Tablet 50 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain, pain scale 5-10. The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) with a score of 15 indicating the resident was cognitively intact. The assessment included the resident was administered pain medication as needed during the 5-day look-back period. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on October 21, 2021 at 1:45 p.m. with a Licensed Practical Nurse (LPN/staff #73). The LPN stated that prior to administering as needed pain medications, she assesses the resident's pain on a scale of 1 to 10, reviews the orders for pain medication, and administers the pain medication according to the pain scale on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During the interview, she reviewed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated that she supposed that these were medication errors and that there is a risk when administering medication outside of the parameters when it is not needed because it could lead to addiction. On October 21, 2021 at 2:45 p.m., an interview was conducted with the Director of Nursing (DON/staff #43). She stated that if a pain medication was administered outside of the pain scale on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that when pain medication is given outside of the pain scale on the order, there is a risk of giving too little and the resident could still be in pain or giving too much pain medication, which may affect/impact the resident ability to response and could impact the resident ability to participate in therapy. During the interview, she reviewed the resident's clinical record, which included the progress notes, and the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated these were medication errors and the pain medication was given by the same nurse. -Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Regarding pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] A chronic pain care plan dated 12/30/20 had a goal to be free of pain. Interventions included to administer pain medication as ordered. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] revealed the resident scored 14 on the BIMS, indicating the resident had intact cognition. The assessment included the resident reported frequent pain of 3 out of 10 on a pain scale, and received opioid pain medication for 7 out of 7 days during the lookback period. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR for September 2021 revealed Oxycodone was administered on 09/03 for a pain level of 0, 09/12 for a pain level of 3, and 09/28 for a pain level of 0. On 10/20/21 at 8:32 a.m., an interview was conducted with an LPN (staff #35). He stated that according to his understanding, pain levels between 1-4 indicate mild pain, 5-7 indicate moderate pain, and 8-10 would be severe pain. The LPN stated that it would not be appropriate to administer Oxycodone for pain levels of 0, 3, or 4. An interview was conducted on 10/20/21 at 12:40 p.m. with the DON (staff #43). She stated that a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that it is written as such in the Pain Management documentation that has been provided to the nursing staff. The DON stated that her expectation is that nursing would follow the order parameters. She reviewed the resident's MARs and stated that administration of an opioid pain medication for the lower pain levels did not meet her expectation and she would consider this a medication error. The facility's policy, Pain Management, revised December 5, 2018 stated it is imperative to their residents' comfort and quality of life that they keep their pain well managed. PRN (as needed) pain meds must be given within the ordered parameters of the medication. Mild pain: 1-4. Moderate: 5-7. Severe: 8-10. Their standing order for Tylenol is for MILD pain: 1-4. Regarding antihypertensive medications: [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if pulse is less than 60 or systolic blood pressure (SBP) is less than 100. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if pulse is less than 60 or SBP is less than 100. A review of the August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR for September 2021 revealed [MEDICATION(S)] was administered for a BP of 94/56 on 09/30. Review of the MAR for October 2021 revealed [MEDICATION(S)] and [MEDICATION(S)] were administered on 10/05 for a BP of 80/51; and [MEDICATION(S)] was administered on 10/13 for a BP of 87/52. On 10/20/21 at 8:32 a.m., an interview was conducted with an LPN (staff #35). He stated that antihypertensives should not be administered if either the resident's pulse or BP was less than the parameters in the physician orders. The LPN stated that the risks for doing so would include [CONDITION(S)]. An interview was conducted on 10/20/21 at 12:40 p.m. with the DON (staff #43). She stated that her expectation is that nursing staff will follow the order parameters when administering medications. The DON stated that risks associated with administering antihypertensive medications to a resident whose BP or pulse was below the parameters would include [CONDITION(S)], dizziness, and weakness. The facility policy titled Medication Administration included that it is the policy of the facility that medications shall be administered in a safe and timely manner, and as prescribed. Orders will be checked for administration instructions and parameters and will be administered accordingly. The facility's policy, Following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy included that should an order not be completely carried out as ordered the following will be completed: Medications, the facility will follow the Adverse Consequences and Medications Errors policy and procedure. The facility policy titled Adverse Consequences and Medication Errors included it is the policy of the facility that each facility evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side-effects. A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record review, staff interview, and policy review, the facility failed to ensure one resident (#55) and/or the resident representative were informed of the risks and benefits of a [CONDITION(S)] medication prior to administration of the medication. The sample size was 6. The deficient practice could result in residents and/or their representatives not being aware of the risks and benefits of psychoactive medications. Findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Records for August 2021, September 2021, and October 2021 revealed the resident was administered [MEDICATION(S)] as ordered. However, further review of the clinical record did not reveal evidence that the resident and/or the resident's representative had been informed of the risks and benefits of the [CONDITION(S)] medication prior to the medication being administered to the resident. An interview was conducted with the Director of Nursing (DON/staff #43) on October 20, 2021 at 10:21 a.m. The DON stated that when the physician writes an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's [CONDITION(S)] Medication Use policy signed by the administrator on July 5, 2021 stated the purpose of this policy is for [CONDITION(S)] medication therapy to be used only when it is necessary to treat a specific condition. The procedure included to obtain verbal consent for all [CONDITION(S)] medication ordered during stay in facility. [CONDITION(S)] medication will not be administered prior to verbal consent being obtained.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that an allegation of abuse for one resident (#158) was reported to the Administrator, State Agency, and Adult Protective Services (APS) within 2 hours. The sample size was one. The deficient practice could result in allegations of abuse not being reported within the required time frame. Findings include: Resident #158 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on January 10, 2020 to hospice. Review of the facility's Investigation Report dated October 7, 2019 revealed that on October 2, 2019 at approximately 6:00 AM, a Certified Nursing Assistant (CNA/staff #94) witnessed another CNA (staff #93) place a rag and then a pillow over the resident's face as they were providing care. CNA #94 stated that she was beginning her shift and went into the resident's room to assist the night shift CNA (staff #93) because she heard the resident calling out. Staff #94 reported seeing the alleged perpetrator (staff #93) place a cloth on the resident's mouth, which the resident removed. She further reported that as the care progressed the resident continued to yell out and then staff #93 placed a pillow across the resident's face. At this point the CNA (staff #94) reported that she removed the pillow and talked to the resident to calm the resident. According to the Investigative Report, the Administrator reported the allegation of abuse on the State Agency after-hours phone line on October 2, 2019 at 5:00 PM. Continued review of the facility's allegation report revealed the allegation of staff to resident abuse was not reported to the Director of Nursing until approximately 3:00 PM on October 2, 2019; and documentation by the Administrator (staff #304) that due to staff #94 not reporting this incident immediately, all staff would be provided education regarding abuse reporting. Review of the facility's Initial Notification of Alleged Abuse/Neglect document revealed the allegation of abuse was reported to the Administrator on October 2, 2019 at 2:45 PM, to APS via online report on October 2, 2019 at 3:31 PM, and to the State Agency after hours on October 2, 2019 at 5:00 PM. An interview was conducted on October 20, 2021 at 9:24 AM with the current Director of Nursing (DON/staff #43), who stated that she was employed at the facility when the incident occurred in 2019 involving resident #158. The DON stated that the facility expectation is to report resident abuse or suspected abuse immediately to the direct supervisor. She stated that there is a supervisor available in the facility at all times. The DON stated that the witness (CNA #94) observed the incident as she was coming onto the unit at 6:00 AM, and did not report the incident until 2:30 or 3:00 PM. She stated that this does not meet the facility expectation. An interview was conducted on October 20, 2021 at 10:15 with a Licensed Practical Nurse (LPN/staff #73), who stated that she was the nurse assigned to the unit at that time of the alleged abuse allegation regarding a staff member and resident #158. She stated that the resident was very confused, combative, resistant to care, and refused a lot of care. She further stated that she was working on the unit that day and a CNA (staff #94) told her that the night shift CNA (staff #93) had put something over the resident's mouth. The LPN stated that she said to the CNA (staff #94) and you're reporting to me right now? and the CNA stated to her what am I supposed to do?. The LPN stated that she told the CNA (staff #94) to report the incident to the DON. The LPN also stated that it is the facility policy to report suspected abuse immediately to the immediate supervisor. An interview was conducted on October 20, 2021 at 10:52 AM with an CNA (staff #78), who stated that she has worked at the facility for 3 years and 4 months. She stated that she is familiar with resident (#158) who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The CNA stated that if staff to resident abuse is observed or suspected it should be reported to a supervisor immediately. She also stated that the facility policy/expectation would be to notify a supervisor immediately in the event of suspicion of a crime. Review of the facility policy titled, Abuse Reporting, stated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly report to local, state, and federal agencies as defined by current regulations. The policy included the Administrator or his/her designee will report all alleged violations involving abuse to the State Agency and APS. The policy also stated that suspected abuse, neglect, exploitation or mistreatment will be reported within two hours.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure one sampled resident (#38) received proper treatment and assistive devices to maintain hearing abilities, by failing to assist the resident in obtaining hearing aids and scheduling an audiology appointment. The deficient practice could result in residents not being able to understand and communicate effectively with others. Findings include: Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Clinical Admission Evaluation dated September 13, 2021 revealed the resident had moderate difficulty with hearing and that hearing aids or other hearing appliances were not used when the resident's hearing was evaluated. Review of the baseline care plan dated September 13, 2021 did not include the resident used hearing aids due to hearing loss. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) with a score of 15 indicating the resident was cognitively intact. The assessment also included the resident had moderate difficulty with hearing and that no hearing aid or hearing appliance was used during the hearing assessment. A review of the comprehensive care plan dated September 20, 2021 did not include the use of hearing aids due to hearing loss. During the initial part of the survey, an interview was conducted with resident #38 on October 18, 2021 at 1:37 p.m. The resident kept stating that she could not hear what was being said to her. The resident stated that she had asked staff to help her with getting hearing aids and was told no, that she would have to wait until she was discharged . On October 21, 2021 at 1:57 p.m., an interview was conducted with the Director of Social Services (staff #46). Staff #46 stated that she has met with the resident and the resident is hard of hearing. She stated that she has spoken to the resident's family and was told that the resident has hearing aids at home and that there were no family members that could go and get the hearing aids. Staff #46 stated that the family told her that the resident has trouble hearing with and without the hearing aids. Staff #46 stated that she told a nurse that the resident needed hearing aids, but she did not remember the name of the nurse. During the interview, she reviewed the clinical record and stated that the resident transferred to long-term care on September 27, 2021 and the appointment process should have been initiated. Staff #46 stated it is the responsibility of the Unit Coordinator (staff #6) to schedule outside appointments. An interview was conducted on October 21, 2021 at 2:03 p.m. with the Unit Coordinator (staff #6). Staff #6 stated that when she receives an order from the nurse for an appointment, she schedules the appointment. She stated that she schedules appointments for vision, dental, and hearing. Staff #6 stated that she has not received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview conducted on October 21, 2021 at 2:13 p.m. with the MDS Coordinator (staff #30), she stated that it is the nurse's responsibility to complete the section for hearing on the MDS assessment. Staff #30 stated the Director of Social Services (staff #46) has the responsibility to follow up on hearing aids and should contact the insurance case manager to see if new ones can be obtained. The Director of Nursing (DON/staff #43) was interviewed on October 21, 2021 at 2:34 p.m. She stated that an order is needed from the physician to schedule appointments and that once an order has been received, the nurse would contact the Unit Coordinator to arrange for a consult. The DON stated that it is her expectation that staff will begin the appointment process when they become aware of the concern. The facility's policy, Obtaining Orders for Consults Outside the Facility dated July 5, 2021 stated it is the policy of this facility that the responsible party will be contacted when there is an assessment finding that would indicate a need for a consult outside the facility prior to contacting the primary physician, unless the assessment demonstrates the needs for emergent care. When a change in assessment is noted in the resident level of function the responsible party will be contacted for permission to coordinate corresponding consults such as dental and ophthalmic services. Once the responsible party has communicated the desire for the outside consult t to be obtained: -The primary physician will be notified of the request and an order will be obtained. -The order will be given to the unit clerk to arrange the consult. -The responsible party will be notified of when the appointment is scheduled. The policy also stated that the assessment, discussion with the responsible party, and outcome will be documented in the medical record.

Based on observations, staff interviews, and policy and procedure, the facility failed to ensure call-lights for two residents (#2 and 27) were functioning correctly. The census was 55. The deficient practice could result in residents not receiving care and services in a timely manner. Findings include: -Resident #2 was readmitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] include a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The assessment also included the resident was totally dependent on staff assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. -Resident #27 was admitted to the facility on [DATE] with diagnoses that included chronic pain and depression. The quarterly MDS assessment dated [DATE] include a BIMS score of 9 which indicated the resident had moderately impaired cognition. The assessment also included the resident was totally dependent on staff assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. During an interview conducted with resident #2 on October 19, 2021 at 9:04 a.m., resident #2 stated the call-light had not been working for a couple of days and she needed assistance with continent care. The resident stated that she has yelled and banged on the wall to get help. The resident stated that she has pushed the call-light button and no one came to help her. The call-light was observed plugged into the call-light unit at the wall, but the call-light unit was not mounted to the box in the wall and there was no cover plate, so the unit and wires were exposed. It was also observed that when the call light was activated, the light for the call light just outside the resident's door was not on. During this time, the resident roommate, resident #27 stated that her call light did not work. Resident #27's call-light cord was also observed plugged into the call-light unit, but was not mounted to the box in the wall and there was no cover plate, so the unit and wires were exposed. Resident #27 pushed the call-light button and it was observed that the call-light outside the resident's room did not go on. An interview was conducted on October 19, 2021 at 9:07 a.m. with a Certified Nursing Assistant (CNA/staff #51). She stated that typically the residents use the call-light to let staff know they need assistance. The CNA stated that she knew the facility was having problems with call-lights not working. She stated that a resident could yell for help if a call-light was not working and she thought staff would hear. She also stated that staff make rounds every 2 hours to see if the residents need something. During the interview, she observed that the call-light outside resident #2's and #27's room was not working and that the call-light units were not mounted to the box and neither one had a plate cover. Following this observation, the CNA and the surveyor went to the nurses' station where the CNA pointed out that the call light for the residents' room was showing up on the call-light control unit as normal, which indicated the resident had pushed the call-light and needed assistance. The control unit was beeping. The CNA acknowledged that staff would need to be near the nurses' station to hear the beeping. On October 21, 2021 at 8:53 a.m., an interview was conducted with the Director of Nursing (DON/staff #43), who stated that the purpose of the call-light is to give residents a way to contact staff when they need assistance. She stated call-light audits are conducted by the Resident Care Coordinator (staff #78). The DON stated that maintenance should be notified if a call-light is not working, so it can be fixed. She stated that it is her expectation that if maintenance is unable to fix the call-light in a timely manner, staff would need to come up with a secondary plan, such as moving the resident to another room. The DON stated that she expected the call-light to be fixed the same day. The DON stated that if the call-light is not working, rounds should occur more frequently, every 10 to 15 minutes. The facility's policy, Call Lights, dated July 5, 2021 stated it is the policy of this facility to have an operational call system for resident use. The call light system will be installed in each resident room, bathing, and toilet area to allow residents to summon for assistance. The call lights will be responded to by staff in a reasonable amount of time.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure 1 of 6 sampled residents (#20) was free from unnecessary drugs, by failing to administer blood pressure medications according to the physician ordered parameters. The deficient practice could result in low blood pressures and residents receiving medications which may not be necessary. Findings included: Resident #20 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. was less than 120. Review of the Medication Administration Record [REDACTED]. The MAR for (MONTH) (YEAR) also revealed the resident was administered [MEDICATION NAME] on (MONTH) 17 with a BP of 109/86 and (MONTH) 30 with a BP of 116/55. Review of the MAR for (MONTH) (YEAR) revealed the resident was administered [MEDICATION NAME] on (MONTH) 4 with a BP of 114/88, (MONTH) 9 with a BP of 114/73, (MONTH) 15 with a BP of 118/67, (MONTH) 16 with a BP of 109/68, (MONTH) 18 with a BP of 102/86, and (MONTH) 30 with a BP of 115/51. Continued review of the MAR for (MONTH) (YEAR) revealed the resident was administered [MEDICATION NAME] on (MONTH) 4 with a BP of 114/88, (MONTH) 9 with a BP of 114/73, and (MONTH) 15 with a BP of 118/67. Review of the MAR indicated [REDACTED]. Further review of the MAR for (MONTH) (YEAR) revealed the resident was administered [MEDICATION NAME] on (MONTH) 12 with a BP of 107/72, (MONTH) 28 with a BP of 119/57, and (MONTH) 29 with a BP of 118/58. Review of the MAR for (MONTH) (YEAR) revealed the resident was administered [MEDICATION NAME] more than ten times when his SBP was less than 120. Additionally, in the same month, the resident was administered [MEDICATION NAME] on (MONTH) 8 with a BP of 115/69, (MONTH) 17 with a BP of 114/63, (MONTH) 21 with a BP of 103/56, (MONTH) 22 with a BP of 111/66, (MONTH) 26 with a BP of 116/75, and (MONTH) 27 with a BP of 118/74. Review of the MAR indicated [REDACTED]. Further review of the MAR for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] on (MONTH) 4 with a BP of 119/63), (MONTH) 6 with a BP of 111/67, (MONTH) 8 with a BP of 102/65), and (MONTH) 12 with a BP of 114/84. Review of the MAR indicated [REDACTED]. The MAR for (MONTH) 2019 also revealed [MEDICATION NAME] was administered to the resident on (MONTH) 2 with a BP of 119/75, (MONTH) 6 with a BP of 117/74, (MONTH) 16 with a BP of 119/74, (MONTH) 17 with a BP of 119/67, (MONTH) 18 with a BP of 106/61, and (MONTH) 26 with a BP of 116/62. Review of the MAR for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] on (MONTH) 9 with a BP of 117/64, (MONTH) 15 with a BP of 114/77, (MONTH) 16 with a BP of 118/68, (MONTH) 18 with a BP of 103/69, and twice on (MONTH) 30 with BPs of 111/62 and 103/61. On (MONTH) 8, (MONTH) 14, and (MONTH) 17, there was no documentation that the medication was administered. Continued review of the MAR for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] on (MONTH) 9 with a BP of 117/64, (MONTH) 18 with a BP of 103/69), and (MONTH) 30 with a BP of 103/61. Review of the MAR indicated [REDACTED]. The resident was also administered [MEDICATION NAME] on (MONTH) 1 with a BP of 113/63, (MONTH) 24 with a BP of 118/70, and (MONTH) 30 with a BP of 112/65. Review of the MAR for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] on (MONTH) 1 with a BP of 116/60 and (MONTH) 3 with a BP of 115/61. The MAR for (MONTH) 2019 also revealed the resident was administered [MEDICATION NAME] on (MONTH) 1 with a BP of 116/60 and (MONTH) 3 with a BP of 115/61). An interview was conducted on (MONTH) 8, 2019 at 8:48 AM with a Licensed Practical Nurse (LPN/staff #65). The LPN stated that before administering [MEDICATION NAME] or [MEDICATION NAME], he reviews the physician's orders [REDACTED]. An interview was conducted on (MONTH) 8, 2019 at 9:09 AM with a Registered Nurse (RN/staff #6). She stated that before she administers antihypertensive medications, she checks the resident's vital signs. The RN stated that if the vital signs are within the ordered parameters, she would administer the medication. She stated that if a medication was administered outside of the ordered parameter, it would be a medication error and would have to be reported to the supervisor and the physician. After reviewing the MAR, the RN acknowledged a medication error had been made and that she had not noticed the ordered parameter before. An interview was conducted on (MONTH) 8, 2019 at 9:22 AM with the Director of Nursing (DON/staff #9). The DON stated her expectation is that the nurses verify the rights of medication administration before administering medications and follow infection control practices. She acknowledged that the nurses did not follow the physician's parameters when administering resident #20's antihypertensive medications. The facility's policy for Medication Administration revealed all medications must be administered in accordance with the physician's orders [REDACTED]. The policy also included vital signs, if applicable, must be checked for each resident prior to administering medications.

Based on clinical record reviews, facility documentation, interviews and policy and procedures, the facility failed to ensure one resident (#178) was free from misappropriation of resident property, failed to ensure one resident (#68) was free from physical abuse by staff, and failed to ensure one resident (#37) was free from physical abuse by resident (#35). Findings include: -Resident #178 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. The resident was discharged to another facility on (MONTH) 13, (YEAR). Review of a Minimum Data Set (MDS) Discharge assessment dated (MONTH) 9, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. Review of the facility's investigative report revealed that the social services director (staff #157) had been terminated on (MONTH) 29, (YEAR) for multiple reasons, including failing to efficiently manage the ALTC case for the resident and failure to apply for VA benefits for the resident. The report further included that following staff #157's termination, they determined that staff #157 had been receiving the resident's bank statements, as she was assisting the resident with the ALTC process. However, staff #157 had told the administrator that she did not know how much the resident had. Also, staff #157 had told the family that this account had been closed. The facility also identified the following concerns regarding the resident's bank statements: -Staff #157 had talked about having her dog spayed and there was a charge on the resident's bank statement the same day she had this procedure done. -Staff #157 was not at work for two days during the month and stated that she would be at appointments in Flagstaff. On the same dates, there were charges in Flagstaff on the resident's statement. -The business office manager (staff #116) and medical records director (#128) noted a payment to the person who does staff 157's nails. -Staff #157 informed staff that she had gotten tickets to the North Pole Experience, and a charge for this also appeared on the resident's statement. -A withdrawal notice dated (MONTH) 8, (YEAR) was completed in staff #157's handwriting. In addition, the report included that on (MONTH) 9, (YEAR), the resident's wallet was located in staff #157's desk, minus the debit card. Staff #157 had told multiple staff that she did not know where the wallet was located and that she did not have it. Continued review of the investigative report revealed that the facility found evidence which lead them to believe that staff #157 was using the resident's funds for her personal gain, without permission. The police were notified on (MONTH) 9, (YEAR). An interview was conducted with the administrator (staff #46) on (MONTH) 13, (YEAR) at 1:30 p.m. Staff #46 stated the facility did not become aware of the potential misappropriation of funds, until after the social worker (staff #157) was terminated on (MONTH) 9, (YEAR) for not completing her duties. Staff #46 stated the resident's bank statements were forwarded to the facility, after staff #157 had been terminated. Staff #46 stated it was determined that staff #157 may have been using the resident's debit card for personal use, as there were expenditures on the resident's bank statement, which corresponded to days staff #157 had taken off. The administrator stated that on (MONTH) 9, (YEAR), the resident's wallet was located in staff #157's desk and the debit card was missing. An attempt was made to contact staff #157, however, she was unable to be reached. A phone interview was conducted with the police officer assigned to the case. The officer reported that the staff person (staff #157) was arrested and charged with misappropriation of funds of resident #178's bank account. According to the police report, staff #157 had taken and used the resident's credit card at various locations and spent over $10,000, and was charged with theft. Review of the facility's Abuse policy and procedure revealed the residents have the right to be free from abuse, neglect and misappropriation of resident property. The facility is committed to protecting residents from abuse by anyone, including facility staff. -Resident #68 was admitted to the facility on (MONTH) 17, (YEAR) and readmitted on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 13, (YEAR) at 10:14 a.m., with resident #68. The resident stated that on the morning of (MONTH) 12, two Certified Nursing Assistants (CNAs) were trying to put her in the Hoyer lift and that she didn't want to go in it, but was pushed until she went in. Resident #68 stated that she wanted to get up without the Hoyer, but they said she had to use it. Resident #68 stated that she felt it was abuse, because she was shoved onto the Hoyer. The resident stated she did not get hurt and had not told anyone else about what happened. Following the interview with the resident, her allegation of abuse was reported immediately to the Administrator (staff #46) by this surveyor. Review of a care plan initiated on (MONTH) 5, (YEAR) revealed the resident exhibited the following behaviors: verbal and physical behaviors, anxious mood, signs of sad mood or crying, and resistive to care. Another care plan initiated on (MONTH) 12, (YEAR) included the resident had hallucinations and delusional thoughts. An intervention was to have two-persons when providing care at all times. According to the facility's initial investigative report dated (MONTH) 13, (YEAR), the resident reported an incident of staff to resident abuse, which occurred on (MONTH) 12, (YEAR) at 4:30 a.m., when she was getting out of bed. Resident #68 identified the staff involved as CNA (staff #80) and CNA (staff #75). The resident reported that she was pushed and hit by two CNAs while being assisted out of bed using the Hoyer lift. The resident reported that she was forced to use the Hoyer lift, even after she told the CNAs that she did not want to use it. A written statement by staff #80 included that the resident was unable to stand so they brought in the Hoyer lift. When the Hoyer lift was brought into the resident's room, she began to yell and tried to hit staff #75. Further review of the investigative report revealed that staff #80 and staff #75 were immediately suspended, pending the investigation. The report included that during the investigation, the resident later stated that it was only one CNA (staff #75) who had pushed and hit her, when getting into the Hoyer. Per the documentation, the resident was free of any new bruising, open areas, or lacerations. The report contained interviews with other residents of which two described that staff #80 could be rude and rushes through care and could be rough. Staff #80 was terminated effective (MONTH) 19, (YEAR), due to comments from other residents. The report concluded that the allegation of physical abuse was unsubstantiated. The report was amended on (MONTH) 22, (YEAR) to reflect that staff #75 was terminated, due to findings during the investigation. Review of the 14-day Minimum Data Set assessment dated (MONTH) 14, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. In a telephone interview conducted with CNA (staff #80) on (MONTH) 15, (YEAR) at 1:22 p.m., staff #80 stated that she was in the room of resident #68 and attempted to get her up, but she was not really able to stand. She said the resident had to be up for [MEDICAL TREATMENT]. Staff #80 stated she made the decision to use a Hoyer lift, because her care plan indicated a Hoyer lift should be used. Staff #80 stated she asked another CNA (staff #75) to assist her and we put her pants on and then started to get her up using the Hoyer lift. She said the resident started hitting them and cussing and tried to pull the Hoyer straps off. Staff #80 stated she told the resident the Hoyer lift was for her safety, but the resident kept trying to hit them and was cussing at them. Staff #80 stated she told the nurse they were having trouble getting the resident up, so the nurse talked with the resident and said this was the only way to get her up. Staff #80 stated that the resident then agreed to use the Hoyer lift to put her in the chair. She said when the resident started yelling again and said no she stopped, but staff #75 kept putting her on the sling and was rough with her. Staff #80 stated that when staff #75 rolled the resident, the resident yelled ow, but staff #75 kept pulling her to roll and put on her brief and pulled up her pants. Staff #80 stated that staff #75 seemed very rough and continued to roll her and push her, without stopping. Staff #80 stated while the resident was being pushed and turned and was yelling to stop, she was just standing there. She stated the resident had never refused to allow her to use the Hoyer lift before, and had never yelled like that when she was turned, and that the resident will usually help with turning. Staff #80 further stated that she did not report the incident to anyone. A telephone interview was conducted on (MONTH) 15, (YEAR) at 2:19 p.m. with the LPN (staff #89), who was working the night shift on (MONTH) 12. Staff #89 stated she was passing medications when staff #80 and staff #75 were getting the residents up, and neither of them came to get her to talk about the resident not wanting to be transferred with the Hoyer lift. Staff #89 stated she was not made aware of any resident concerns during that shift. In a follow-up interview with resident #68 on (MONTH) 16, (YEAR) at 11:55 a.m., resident #68 stated that the CNA (staff #75) was the CNA that was pushing, pulling, and shoving her and being rough, while putting her on the sling. She said that she told her to stop and she kept doing it. Resident #68 stated that staff #80 was just standing there. The resident stated she was not hurt, but staff #75 wouldn't stop pushing, pulling and shoving her when she said to stop. In an interview conducted with staff #75 on (MONTH) 16, (YEAR) at 7:21 p.m., staff #75 stated that on (MONTH) 12, (YEAR) between 4:30 a.m. and 5:30 a.m., staff #80 was trying to get the resident up and could not do it on her own, so she asked for help. Staff #75 stated when she got in the room, the resident's pants were down and her brief was not up. Staff #75 stated she rolled resident #68 to get her brief on and pulled up her pants, and put the Hoyer sling under her. Staff #75 stated the resident was upset the entire time, because they were using the Hoyer lift. Staff #75 stated the resident started calling them names. Staff #75 stated resident #68 said she wanted me to stop. She said when she rolled resident #68 and put on her brief, and pulled up her pants, and pushed the Hoyer sling under her, staff #80 just stood there. Staff #75 stated the resident has the mentality of it is her way or the highway. She said at one point she explained what they had to do, and the resident didn't say anything, so she thought it was ok, but then the resident started yelling again when she was up on the sling. She said they got her safely into the chair, but the resident was still upset. Staff #75 also stated, You know when you argue with someone and they get that feeling of defeat, well that is the way she got, so I think she knew that I was right. Whether or not a resident has the right to say no to things depends on whether or not the resident is in their right mind or not. I say this because she was sent to the hospital for an altered mental state recently. She did have the right to say no, but I don't think she was in her right mind. She further stated if a resident is not cognitively aware, they don't have the right to say no, but it is kind of a gray area. -Resident #37 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated (MONTH) 28, (YEAR) revealed a BIMS score of 5, which indicated the resident had severe cognitive impairment, and required supervision with most activities of daily living. A care plan identified that the resident exhibited verbal outbursts, as evidenced by swearing and making insults during meals and activities, and disturbing other residents. Another care plan included the resident exhibited physical behaviors such as hitting, kicking, spitting and biting directed towards others. A physician's orders [REDACTED]. A nurse's note dated (MONTH) 29, (YEAR) included resident #37 reported that he was hit twice by another resident (#35). No injuries were noted. During an interview on (MONTH) 12, (YEAR) at 12:01 p.m. with resident #37, he stated that another resident had hit him a while ago, but he hit like a girl and was not injured. -Resident #35 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated (MONTH) 27, (YEAR) revealed a BIMS score of 9, which indicated that the resident had moderate cognitive impairment, and required extensive assistance with most activities of daily living. The MDS also included the resident exhibited verbal behaviors such as cursing or threatening others. According to a behavioral care plan, resident #35 exhibited physical behaviors manifested by hitting, kicking, spitting, pinching or biting towards others. A goal was that the resident would be free of physical altercations with injury involving other residents. Interventions included to provide a calm, non-rushed environment, remove person from situation if he begins to show signs of agitation, and remind the resident of the necessity to refrain from physically acting out. Review of the facility's investigation revealed that on (MONTH) 29, (YEAR) at 7:10 p.m., an altercation between resident #35 and resident #37 occurred. Per the documentation, resident #37 reported that he was hit twice by resident #35, while in the hallway. Resident #35 reported that resident #37 was blocking his way to his room and he told resident #37 that he wanted to rest, but resident #37 provoked him by saying that he was lazy and wanted people to push him to his room. Per the report, resident #35 stated that he got mad and hit resident #37 on his chest two times. No injuries were noted. During an interview conducted on (MONTH) 14, (YEAR) at 3:39 p.m. with the Administrator (staff #46), she stated that resident #35 has a history of irritating others and having strong opinions. She stated that they have tried to move the resident to other facilities who could provide different support for him, but have not been able too. She said the resident is monitored daily for behaviors. During an interview conducted on (MONTH) 15, (YEAR) at 12:04 p.m., with a licensed practical nurse (staff #65), she stated that she monitors the resident's behaviors and uses redirection as the first option in dealing with behavior issues. An interview was conducted on (MONTH) 15, (YEAR) at 12:14 p.m. with a licensed practical nurse (staff #21). Staff #21 stated when residents are exhibiting behaviors, he talks through the problem with the residents and redirects them. Review of the facility's Abuse policy and procedure revealed the residents have the right to be free from abuse, neglect and misappropriation of resident property. The facility is committed to protecting residents from abuse by anyone, including facility staff and other residents.

Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to ensure that care and services met professional standards of practice regarding medication administration and treatments for two residents (#20 and #32). Findings include: -Resident #20 was readmitted on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. According to the (MONTH) and (MONTH) (YEAR) recapitulation of physician's orders [REDACTED]. -Accuchecks before meals and at bedtimes with Humalog Insulin, subcutaneous (SQ) per sliding scale at 6:00 a.m., 11:00 a.m., 4:00 p.m. and 8:00 p.m. as follows: 70-199 = no coverage; 200-250 = 2 units; 251-300 = 4 units; 301-350 = 6 units; 351-400 = 8 units and 401-449 = 10 units. Contact physician if less than 70 or greater than 450. -Zinc Sulfate 220 mg 1 tablet daily at 8:00 a.m. for wound healing. -Multivitamin with minerals 1 tablet daily at 8:00 a.m. for wound healing. -[MEDICATION NAME] 10 mg 1 tablet daily at 8:00 a.m. for hypersensitivity -[MEDICATION NAME] 24 mg 1 tablet twice a day at 8:00 a.m. and 8:00 p.m. Hold if pulse is less than 60 and systolic blood pressure is less then 100 for hypertension. -NAME] DR 40 mg 1 tablet twice a day at 6:00 a.m. and 8:00 p.m. for [MEDICAL CONDITION] reflux disease. -[MEDICATION NAME] Sodium 150 mcg (microgram) 1 tablet daily at 6:00 a.m. for [MEDICAL CONDITION]. -[MEDICATION NAME] 40 mg 1 tablet daily at 8:00 a.m. for [MEDICAL CONDITION]. Hold if systolic blood pressure is less than 100. -Cranberry 400 mg 2 tablets (800 mg) twice a day at 8:00 a.m. and 8:00 p.m. for prevention. -[MEDICATION NAME]-Salmeterol 250mcg/50mcg aerosol powder breath activated, 1 puff inhaled twice a day at 8:00 a.m. and 8:00 p.m. for [MEDICAL CONDITION]. -[MEDICATION NAME] Bisulfate 75 mg 1 daily at 8:00 a.m. for prevention -[MEDICATION NAME] 25 units SQ at 8:00 p.m. for diabetes -Potassium Chloride 10 meq (milliequivalent) ER 1 tablet daily at 8:00 a.m. (mineral supplement). Hold if [MEDICATION NAME] is held. -[MEDICATION NAME] 3.5 mg 1 tablet daily at 12:00 p.m. for [MEDICAL CONDITION]. -[MEDICATION NAME] HCl 200 mg 1 tablet twice a day at 8:00 a.m. and 8:00 p.m. for [MEDICAL CONDITION]. Hold if apical pulse is less than 60. -[MEDICATION NAME] 325 mg 1 tablet twice a day at 8:00 a.m. and 8:00 p.m. (supplement) Review of the (MONTH) (YEAR) MAR (medication administration record) revealed the following: -accuchecks were not done on (MONTH) 16 (on 4 shifts), 17, 18, 19, 23, 25, and 31 (at 6:00 a.m.) and on (MONTH) 24 (on 2 shifts). -[MEDICATION NAME] was not administered on (MONTH) 30. -Pantaprzole Sodium was not administered on (MONTH) 24. - [MEDICATION NAME] Sodium was not administered on (MONTH) 26. -[MEDICATION NAME], Cranberry, [MEDICATION NAME] Bisulfate and [MEDICATION NAME]-Salmeterol were not administered on (MONTH) 16. Review of the (MONTH) (YEAR) MAR revealed the following: -accuchecks were not done on (MONTH) 1 (at 6:00 a.m.), (MONTH) 5 (at 4:00 p.m. and at 8:00 p.m.), (MONTH) 6 (at 6:00 a.m.), (MONTH) 8 (at 6:00 a.m. and at 8:00 p.m.), (MONTH) 12 (at 6:00 a.m. and at 8:00 p.m.), (MONTH) 13 (at 6:00 a.m. and at 8:00 p.m.), (MONTH) 14 and 15 (at 6:00 a.m.) -[MEDICATION NAME] and Comadin were was not administered on (MONTH) 6 and 8. An interview was conducted on (MONTH) 16, (YEAR) at 8:30 a.m. with the Administrator (staff #46), who stated that there had been numerous in-services with nursing staff about completing documentation. Staff #46 stated the nurses should document when medication is given, but no later than the end of the shift. An interview was conducted with a licensed practical nurse (LPN/staff #27) on (MONTH) 16, (YEAR) at 9:05 a.m. Staff #27 stated the nurses are to document med administration at the time the meds are given or as soon as possible. Staff #27 stated that blood sugar monitoring and vital signs are to be taken prior to administering medications, per the orders. On (MONTH) 16, (YEAR) at 9:10 a.m., an interview was conducted with a LPN (staff #129), who stated that medication should be documented on the resident's MAR at the time of administration. Another interview was conducted on (MONTH) 16, (YEAR) at 10:06 a.m., with staff #27. Staff #27 stated the resident had been given pain medication earlier on another shift. At this time, the Controlled Substances Countdown Sheet for [MEDICATION NAME]/[MEDICATION NAME] was reviewed. The documentation showed that the resident was given [MEDICATION NAME]/[MEDICATION NAME] on (MONTH) 15, (YEAR) at 8:00 p.m. The (MONTH) (YEAR) MAR was then reviewed and revealed there were orders for [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg, 1 tablet every 12 hours as needed for moderate to severe pain. However, there was no documentation on the MAR that the resident had received this narcotic pain medication on (MONTH) 15, at 8:00 p.m. On (MONTH) 16, (YEAR) at 10:51 a.m., a telephone interview was conducted with a RN (registered nurse/staff #28). She stated that she had given the resident a pain pill early this morning (on (MONTH) 16) and she must have forgotten to document it. Staff #28 stated that medications were to be documented on the MAR at the time of administration. Review of the Insulin Administration and Documentation policy revealed that scheduled and sliding scale insulin should be administered, per the physician's orders [REDACTED]. Scheduled doses of insulin are to be documented by initialing the order on the MAR in the appropriate space for the time of administration. Prior to administering insulin per sliding scale, a blood glucose check will be performed as ordered and insulin will be administered per the sliding scale. Documentation will include the results of the blood glucose check and the amount of insulin administered, if any. -Resident #32 was admitted on (MONTH) 27, 2012, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Controlled Substance Countdown Sheet for [MEDICATION NAME] 15 mg one tablet every 4 hrs as needed, revealed that from (MONTH) 10, (YEAR) through (MONTH) 6, (YEAR), the resident was administered [MEDICATION NAME] 15 mg ten times. However, review of the MARs for this same time period revealed documentation that the resident had only been administered [MEDICATION NAME] six times, instead of ten times as documented on the Controlled Substance Sheet. An interview with the administrator (staff #46) was conducted on (MONTH) 16, (YEAR) at 8:45 a.m. Staff #46 stated that the nurses are suppose to record on the MAR, when any medications are administered. During an interview conducted on (MONTH) 16, (YEAR) at 8:54 a.m. with staff #27, she stated when the nurses pass medications, it should be recorded in the MAR. Review of the job descriptions for facility RN's and LPN's revealed that the nurses are to ensure the accuracy of their work and to conduct complete, accurate, and truthful documentation including initialing and signing all MARs and TARs when administering medications, treatments, or dietary supplements. The documentation included that the nurses are to implement all orders received and to transcribe them on to the MARs and TARs. Review of a policy regarding Medication Administration revealed that the individual administering the medication must initial the resident medication record on the appropriate area, after giving each medication and before administering the next.

Based on observation, clinical record review, staff interviews, and policies and procedures, the facility failed to ensure that physician orders [REDACTED].#18). Findings include: Resident #18 was admitted (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. Regarding wound care: A physician's orders [REDACTED]. Another physician's orders [REDACTED]. A physician's orders [REDACTED]. According to the (MONTH) (YEAR) recapitulation of physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR (treatment administration record) revealed that on (MONTH) 6, 7, 8, and 10, no treatment was documented as being provided for two unstageable pressure ulcers on the left heel, and on (MONTH) 7, no treatment was provided to the left lateral deep tissue injury. An interview was conducted with the Administrator (staff #46) on (MONTH) 15, (YEAR) at 9:50 a.m. Staff #46 stated that the nurses are supposed to document when wound care is provided. A telephone interview was conducted on (MONTH) 15, (YEAR) at 12:30 p.m. with a Licensed Practical Nurse (LPN/staff #36), who stated that she had provided wound care to the resident, but had not documented it on the TAR. A telephone interview was conducted on (MONTH) 14, (YEAR) at 1:07 p.m., with a LPN (staff #19). Staff #19 stated she had provided wound care to resident #18, but got busy and didn't go back and document it. Staff #19 stated the facility policy is for care to be documented when completed. A telephone interview was conducted with a LPN (staff #89) on (MONTH) 15, (YEAR) at 1:13 p.m. Staff #89 stated she remembered providing wound care to the resident, but must have forgotten to document it. Staff #89 further stated that if care was not documented, then it wasn't completed. A telephone interview was conducted with a RN (registered nurse/staff #28) on (MONTH) 16, (YEAR) at 10:51 a.m. Staff #28 stated she had provided wound care to resident #18, but must have forgotten to document the treatment. Staff #28 further stated that the treatment should have been documented when completed or by the end of the shift. Regarding the application of multipodus boots: A physician's orders [REDACTED]. Review of the resident's TAR for (MONTH) (YEAR) revealed the above order. However, there was no documentation of the application of the multipodus boots on the night shift on (MONTH) 16, 17 and 24. Review of the resident's TAR for (MONTH) (YEAR), revealed no documentation of the application of the multipodus boots on the night shift on (MONTH) 6. During an observation of the resident's wound care on (MONTH) 14, (YEAR) at 3:22 p.m., resident #18 was observed to be in bed, without the multipodus boots on. The multipodus boots were observed to be on top of the wardrobe in the resident's room. An interview was conducted with a CNA (certified nursing assistant/staff #6) on (MONTH) 14, (YEAR) at 3:45 p.m. Staff #6 stated he had assisted resident #18 to bed after lunch. Staff #6 stated he had not applied the resident's multipodus boots, after putting the resident in bed. Staff #6 further stated that he was aware that the multipodus boots were to be applied, when the resident was in bed. Review of a Pressure Ulcer policy revealed that a resident having pressure ulcers receives the necessary medical treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Review of a Medication/Treatment policy revealed that the individual administering the treatment must initial the treatment administration record on the appropriated area, after providing the treatment.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure an incident of staff to resident abuse involving one resident (#68) was immediately reported to the administrator. Findings include: Resident #68 was admitted to the facility on (MONTH) 17, (YEAR) and readmitted on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 13, (YEAR) at 10:14 a.m., with resident #68. The resident stated that on the morning of (MONTH) 12, two Certified Nursing Assistants (CNAs) were trying to put her in the Hoyer lift and she didn't want to go in it, but was pushed until she went in. Resident #68 stated that she wanted to get up without the Hoyer, but the CNAs said she had to use it. Resident #68 stated that she felt it was abuse, because she was shoved onto the Hoyer. The resident stated she did not get hurt and had not told anyone else about what happened. Following the interview with the resident, her allegation of abuse was reported immediately to the Administrator (staff #46) by this surveyor. Review of a care plan initiated on (MONTH) 5, (YEAR) revealed the resident exhibited the following behaviors: verbal and physical behaviors, anxious mood, signs of sad mood or crying, and was resistive to care. Another care plan initiated on (MONTH) 12, (YEAR) included the resident had hallucinations and delusional thoughts. An intervention was to have two-persons when providing care at all times. According to the facility's initial investigative report dated (MONTH) 13, (YEAR), the resident reported an incident of staff to resident abuse, which occurred on (MONTH) 12, (YEAR) at 4:30 a.m., when she was getting out of bed. Resident #68 identified two CNAs (staff #80) and CNA (staff #75). The resident reported that she was pushed and hit by two CNAs, while being assisted out of bed using the Hoyer lift. The resident reported that she was forced to use the Hoyer lift, even after she told the CNAs that she did not want to use it. A written statement by staff #80 included that the resident was unable to stand, so they brought in the Hoyer lift. When the Hoyer lift was brought into the resident's room, she began to yell and tried to hit staff #75. Further review of the investigative report revealed that staff #80 and staff #75 were immediately suspended, pending the investigation. The report included that during the investigation, the resident later stated that it was only one CNA (staff #75) who had pushed and hit her, when getting into the Hoyer. Per the documentation, the resident was free of any new bruising, open areas, or lacerations. The report contained interviews with other residents of which two described that staff #80 could be rude and rushes through care and could be rough. Staff #80 was terminated effective (MONTH) 19, (YEAR), due to comments from other residents. The report concluded that the allegation of physical abuse was unsubstantiated. The report was amended on (MONTH) 22, (YEAR) to reflect that staff #75 was terminated, due to findings during the investigation. Review of the 14-day Minimum Data Set assessment dated (MONTH) 14, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. A telephone interview was conducted with a CNA (staff #80) on (MONTH) 15, (YEAR) at 1:22 p.m. Staff #80 stated that she was in the room of resident #68 and attempted to get her up for [MEDICAL TREATMENT], but she was not really able to stand. Staff #80 stated she made the decision to use a Hoyer lift, because her care plan indicated a Hoyer lift should be used. Staff #80 stated she asked another CNA (staff #75) to assist her. she said they put her pants on and then started to get her up using the Hoyer lift. She said the resident started hitting them and cussing and tried to pull the Hoyer straps off. Staff #80 stated she told the resident the Hoyer lift was for her safety, but the resident kept trying to hit them and was cussing at them. Staff #80 stated she told the nurse they were having trouble getting the resident up, so the nurse talked with the resident and said this was the only way to get her up. Staff #80 stated the resident then agreed to use the Hoyer lift to put her in the chair. She said when the resident started yelling again and said no she stopped, but staff #75 kept putting her on the sling and was rough with her. Staff #80 stated that when staff #75 rolled the resident, the resident yelled ow, but staff #75 kept pulling her to roll and put on her brief and pulled up her pants. She stated that staff #75 seemed very rough and continued to roll her and push her, without stopping. Staff #80 stated while the resident was being pushed, turned and was yelling to stop, she was just standing there. She stated the resident had never refused to allow her to use the Hoyer lift before, and had never yelled like that when she was turned, and that the resident will usually help with turning. Staff #80 further stated that she did not report the incident to anyone. A telephone interview was conducted on (MONTH) 15, (YEAR) at 2:19 p.m. with the LPN (staff #89), who was working the night shift on (MONTH) 12. Staff #89 stated she was passing medications when staff #80 and staff #75 were getting the residents up, and neither of the CNAs told her that the resident was not wanting to be transferred with the Hoyer lift. Staff #89 stated she was not made aware of any concerns with the resident during the night shift. In a follow-up interview with resident #68 on (MONTH) 16, (YEAR) at 11:55 a.m., resident #68 stated that CNA (staff #75) was the one who was pushing, pulling, and shoving her and was being rough, while putting her on the sling. The resident said she told the CNA to stop, but she kept doing it and staff #80 was just standing there. The resident stated she was not hurt, but staff #75 wouldn't stop pushing, pulling and shoving her when she said to stop. An interview was conducted with staff #75 on (MONTH) 16, (YEAR) at 7:21 p.m. Staff #75 stated that on (MONTH) 12, (YEAR) between 4:30 a.m. and 5:30 a.m., staff #80 was trying to get the resident up, but she could not do it on her own, so she asked for help. Staff #75 stated when she got in the room, the resident's pants were down and her brief was not up. Staff #75 stated she rolled resident #68 to get her brief on and then pulled up her pants, and put the Hoyer sling under her. Staff #75 stated the resident was upset the entire time and was calling them names, because they were using the Hoyer lift. Staff #75 stated the resident said she wanted me to stop. Staff #75 stated when she rolled resident #68 and was putting on her brief and pulling up her pants, and pushing the Hoyer sling under her, staff #80 was just standing there. Staff #75 stated with this resident, she has the mentality of it is her way or the highway. She said at one point when she had explained what they had to do, the resident didn't say anything, so she thought it was ok, but then the resident started yelling again, when she was up on the sling. Staff #75 stated we got her safely into the chair, but the resident was still upset. Review of the facility's Abuse policies revealed that the policies did not address the need to immediately report all alleged violations to the administrator.

Based on clinical record reviews, staff interviews and review of facility policies, the facility failed to ensure care and services were provided for one resident (#201) to prevent the development of multiple pressure ulcers, and for one resident (#104) who was admitted with pressure ulcers. Findings include: -Resident #201 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE], to the hospital. The admission nursing note dated March 17, 2015, included that the resident's heels were clear. There was no documentation of any skin integrity issues. A Braden Risk assessment dated [DATE], included documentation that the resident was not at risk for skin breakdown. A physician's orders [REDACTED]. While the March 2015 TAR reflected that the [MEDICATION NAME] had been applied prn, the order for the heel protectors had only been transcribed as an FYI (for your information) and therefore; the TAR did not include any evidence that the heel protectors had actually been applied. A risk for skin breakdown care plan was developed on March 18, 2015, and included the following interventions: reposition every two hours; keep heels off the bed; and heel protectors as physician ordered. A facility form titled, Monthly Body Survey dated March 19, 2015, included that the resident had no open areas or wounds present. The admission MDS (Minimum Data Set) assessment dated [DATE], included that the resident's BIMS (Brief Interview for Mental Status) score was 10, which indicated moderate cognitive impairment. The MDS assessment also included that the resident was non-ambulatory and required extensive assistance for bed mobility, transfers, toileting and hygiene. Per the assessment, no pressure ulcers were present. Another Braden Risk assessment dated [DATE], now included that the resident was at risk for the development of skin breakdown. A skin breakdown care plan was updated on March 26, 2015, and included the following intervention: Treatment per protocol and per physician's orders [REDACTED]. A physician's orders [REDACTED]. The orders were to cleanse open area to side of right heel with Saf cleanse, apply [MEDICATION NAME] AG, cover with gauze and apply Allevyn, wrap heel with Kerlix and change daily until healed. The order also noted that the opened area measured 5.5 by 5.5 cm (centimeters). The order also included to cleanse open area on left buttocks with Saf cleanse, apply [MEDICATION NAME] AG, cover with [MEDICATION NAME] border and change daily until healed and that the opened area measured 1 by 2.5 cm. A review of the March 2015 TAR revealed no documented evidence that the above treatments had been administered on March 26. physician's orders [REDACTED]. -Discontinue heel protectors; -MP (Multi Podus) boots on at all times; -Right medial ankle with a fluid filled area, which is now opened. Order changed to cleanse with Saf cleanse, apply [MEDICATION NAME], cover with [MEDICATION NAME] border then apply Allevyn, wrap with Kerlix, secure with [MEDICATION NAME] and change daily. Despite the documentation of an order change, there was no evidence of a previous order, as this was the first documentation of a wound to this area. -Friction sheer to left buttocks, coccyx, and lower back. Cleanse with Saf cleanse, apply [MEDICATION NAME], cover with [MEDICATION NAME] border and change daily. There was no further clinical record documentation regarding a wound to the right heel. Although friction sheers were identified on the resident's left buttocks, coccyx, and lower back, and an opened area on the resident's right medial ankle, none of the areas were thoroughly assessed to include a description of the wound bed, any measurements and surrounding skin. Further review of the skin breakdown care plan revealed the physician's orders [REDACTED]. However, there was no documented evidence that the multi podus boots had been applied as ordered. Although the March 2015 TAR included the prescribed treatments for the friction sheers on the resident's coccyx, lower back and right ankle, it did not include the transcription of the prescribed treatment order for the left buttocks. Furthermore, no assessments regarding the four wounds were able to be located in the clinical record until March 31, 2015, at which time the wound assessments were entered as a late entry for March 27, 2015. This was five days after the friction sheers and opened areas had been identified. The wound assessments included the following documentation: -Area #3 right medial ankle wound: fluid filled area which was now opened and measured 6.2 by 6.7 cm, with light serosanguineous drainage, wound bed with granulation tissue and the surrounding skin was red. Per the documentation, the wound was now larger, however, there was no previous assessment documentation which included any measurements of this wound. The nursing interventions included the application of multi podus boots, however, there was no documentation that they had been applied as ordered. -Area #4 left buttocks wound: friction sheer, which measured 2.5 by 2.7 cm, with light serosanguineous drainage, wound bed with granulation tissue and surrounding skin was red. Per the documentation, the wound was now larger, however, there was no previous assessment documentation which included any measurements of this wound. The nursing interventions included the use of a geri chair to help prevent the resident from scooting. The clinical record revealed no documented evidence that a geri chair had actually been obtained. -Area #5 coccyx wound: friction sheer, which measured 2.3 by 1 cm, with serosanguineous drainage, wound bed with granulation tissue, and surrounding skin was red. Per the documentation, the wound was now larger. -Area #6 lower mid back wound: friction sheer, which measured 0.9 by 0.7 cm, with light serous drainage, wound bed with granulation tissue, and surrounding skin was red. Per the documentation, this wound was now smaller, however, there were no previous wound measurements documented. A continued review of the clinical record revealed that the next wound assessments were completed on April 7, 2015. It was noted that there were two new opened areas (with an onset date of April 6), one on the left buttocks (area #8) and one on the right buttocks (#9). These areas were identified as friction sheers. Per the documentation the following was noted: -Area #8 to left buttocks was opened and measured 2.2 by 1.5 cm, with light amount of serosanguinous drainage, wound bed with granulation tissue, and surrounding tissue was red. -Area #9 to right buttocks was opened and measured 4 by 3 cm, with light serosanguinous drainage, wound bed with granulation tissue, and surrounding skin was red. A physician's orders [REDACTED]. The order included to cleanse with Saf cleanse, apply [MEDICATION NAME] AG, cover with [MEDICATION NAME] border, and to change it daily. On April 13, 2015, new physician' orders were obtained to treat the wounds on the residents left and right buttock, and coccyx. The physician's orders [REDACTED]. On April 14, 2015, the resident's wounds were assessed again and included the following: -Area #3 right medial ankle: measured 1.2 by 1.5 cm, had light serosanguineous drainage, wound bed with granulation tissue, and surrounding tissue was red. Per the documentation, the wound was now smaller. -Area #4 left buttock friction sheer: measured 4.2 by 3.7 cm, had light serosanguineous drainage, wound bed with granulation tissue and slough, and surrounding tissue was red. Per the documentation, the wound was smaller. However, on the previous late entry assessment from March 27, this wound measured 2.5 by 2.7 cm. -Area #5 coccyx friction sheer: measured 3 by 1.2 by 1 cm, had light serosanguineous drainage, wound bed with granulation tissue and slough, and surrounding tissue was red. According to the documentation, slough and depth were now present. -Area# 6 lower mid back friction sheer: measured 6.0 by 4.9 cm, had light serous drainage, wound with granulation tissue and slough, and surrounding tissue was red. This wound was much larger than the previous assessment. -Area #8 left buttocks friction sheer: measured 2 by 0.9 cm, with light serosanguineous drainage, wound bed with granulation tissue and surrounding tissue red. Per the documentation, this wound was now smaller. -Area #9 right buttocks friction sheer: measured 6.9 by 3.8 cm, which was an increase in size. The wound had a light amount of sanguineous drainage, wound bed with granulation tissue and surrounding tissue was red. A physician's orders [REDACTED]. -Wound clinic consultation for wound to coccyx (area #5). Friction sheer now presenting as an open area with 100% necrotic tissue. Treatment order for coccyx (area #5) included cleanse with Saf cleanse, apply Santyl, cover with [MEDICATION NAME], then [MEDICATION NAME] border and change daily. -Treatment orders for areas #4, #6, #8 and #9 included to cleanse with Saf cleanse, apply [MEDICATION NAME] AG, cover with [MEDICATION NAME] border and change daily. The next wound assessment was conducted on April 22, 2015, which was eight days after the last assessment and included the following: -Area #3 right medial ankle healed. -Area #4 left buttocks friction sheer now a stage 2 pressure ulcer, which measured 3.5 by 2.5 cm. The documentation included that light drainage was present, but did not describe the type of drainage. The documentation also did not include a description of the wound bed or the surrounding tissue. -Area #5 coccyx friction sheer now a stage 4 pressure ulcer, which measured 4 by 2 by 2 cm. The documentation included that a moderate amount of drainage was present, but did not include the type of drainage or the condition of the wound bed or surrounding tissue. This wound was larger than the previous assessment. -Area #6 lower mid back friction sheer, now an unstageable pressure ulcer, which measured 5 by 3.5 cm (now smaller) and was covered with slough and/or eschar. The surrounding skin condition was not included in the assessment. -Area #8 left buttocks friction sheer, now a stage 2 pressure ulcer, which measured 3 by 1 (larger). Although the assessment included that drainage was present, the type of drainage was not documented, nor a description of the wound bed and the surrounding tissue. -Area #9 right buttocks friction sheer now a stage 2 pressure ulcer, which measured 2.5 by 3.5 cm. Again, the assessment was incomplete regarding the type of drainage that was present and a description of the wound bed and surrounding tissue. On April 22, 2015, treatment order changes were obtained and included the following: -Area #4 left buttock stage 2 pressure ulcer: cleanse with Saf cleans, apply [MEDICATION NAME], and duoderm. Change daily until resolved. -Area #5 coccyx stage 4 pressure ulcer: cleanse with Saf cleanse, pack with [MEDICATION NAME] Ag rope, cover with gauze and duoderm. Change twice a day until resolved. -Area #6 unstageable pressure ulcer on the low mid back: cleanse with Saf cleans, apply thin layer of Santyl only to the eschar then hydrofoam, and [MEDICATION NAME]. Change daily until resolved. -Area #8 left buttocks stage 2 pressure ulcer: cleanse with Saf cleanse, apply [MEDICATION NAME] and duoderm and change daily until resolved. On April 23, 2015, another physician's orders [REDACTED].#5) pressure ulcer, laboratory studies, and to administer [MEDICATION NAME] (an antibiotic) daily for five days. However, a review of the April 2015 MARs (Medication Administration Records) revealed that the [MEDICATION NAME] had only been administered for four days and not five, as physician ordered. An interview was conducted on November 4, 2015, with the DON (Director of Nursing). Following a review of the clinical record, she confirmed that the geri chair had not been obtained for this resident and that the clinical record did not include documented evidence that the heel protectors and multi podus boots had been applied as ordered. Another interview was conducted on November 5, 2015, with the Corporate Nurse, who agreed that the wound assessments were incomplete. She stated that she was unable to locate any documented evidence that the geri chair had been obtained or that the heel protectors and multi podus boots had been applied as ordered. -Resident #104 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was admitted with a stage 4 coccyx pressure ulcer and had orders for a wound vac. A skin care plan included a goal that the resident will remain free of avoidable skin breakdown. The care plan noted that a stage 4 pressure ulcer was present to the sacrum area. Interventions included for treatments as ordered, low air loss mattress and turn every hour. The admission physician orders [REDACTED]. A physician's orders [REDACTED]. A weekly pressure ulcer assessment dated [DATE] included the coccyx wound measured 13.9 x 8.6 x 4.1 cm. A wound assessment dated [DATE], included the coccyx wound measured 12.4 x 11.2 x 3.2 cm. Further review of the clinical record revealed the coccyx pressure ulcer was not assessed again until November 1, 2015, which was 13 days after the last assessment. Per the wound assessment dated [DATE], the coccyx wound now measured 15.1 x 11.8 x 5.2 cm. A wound treatment observation was conducted on November 5, 2015, with a licensed nurse. During the observation, the nurse measured the coccyx pressure ulcer. The wound measured 18.1 x 11.3 x 5.2 cm. In an interview conducted on November 5, 2015, the Director of Nursing was unable to locate any pressure ulcer assessments that were completed from October 20-31. She stated that the nurses are responsible for completing the weekly wound assessments and measurements and the assessments should be documented on the weekly skin report. Review of the facility's policy regarding Skin/Wound assessments revealed that pressure ulcers will be assessed and measured weekly and will include the progress of the wound. A facility policy titled, Following physician's orders [REDACTED]. The policy also included the following: 1. Once a physician order [REDACTED]. The order will be transcribed as necessary to the administration records. d. The orders will be followed by the staff providing care for the duration of treatment. e. Should an order not be completely carried out as ordered the following will be completed regarding treatments: the facility will notify the prescribing physician and carry out any new order. Another facility policy titled, Pressure Ulcer Prevention and Treatment, included that their policy was to promote the prevention of pressure ulcer development and to promote the healing of pressure ulcers that are present, including preventions of infection to the extent possible. The policy also included the following: 1. A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. 2. A resident having pressure ulcers receives medical treatment and services to promote healing, prevent infections and prevent new pressure ulcers from developing. 6. The licensed nurse performing the skin assessment will be responsible for obtaining orders for skin treatments as necessary. A facility policy titled, Wound Documentation included It is the policy of this facility to have accurate and complete documentation related to resident's wound assessments. The policy also included the following: An assessment of the wound will be documented no less than weekly and any time there is a change in the assessment of the wound the following will be included: -Type of wound-classification or staging. -Description of wound: Wound base tissue type, document the percent of tissue noted in wound bed, presence/lack of drainage and if present note amount, color, consistency, presence/lack of odor, presence/lack of tunneling/undermining, wound edges curled, callused, macerated, detached, and description of surrounding tissue/periwound. Another facility policy titled, Pressure Ulcers included the following: -Stage 2 characterized by: Presents as an abrasion, fluid filled area, or shallow crater. -Treatment: If superficial, [MEDICATION NAME] to be applied after each instance of peri care and showers until resolved. -Scant amount of drainage: Buttocks-cleanse with Saf cleanse, apply Medhihoney, then cover with Duoderm. Change every other day until resolved. -Heel: Cleanse with Saf cleanse, apply [MEDICATION NAME], cover with gauze, Allevyn heel, Kerlix then [MEDICATION NAME]. Change every other day until resolved. The policy also included to use [MEDICATION NAME] Ag if drainage is purulent or has odor. -Stage 4 characterized by: Full thickness ulcer involving Epidermis, Dermis, Subcutaneous Tissue, Fascia, and underlying structures, such as: muscle, bone, muscle, tendon, and joints, may have extensive necrosis. -Refer to wound clinic. -If small area pack with strips of Calcium Alginate or [MEDICATION NAME] AG. Cover with gauze and Duoderm and change dressing every other day unless too much drainage, then change daily until resolved. Unstageable Ulcers: -Depth is unknown. -Cannot be staged as wound bed cannot be visualized. -Wound bed is covered with slough or eschar. Another facility policy titled, Charting and Documentation included the following: 1. A complete clinical record is maintained for each resident in accordance with accepted professional standards and practices that are a) Complete. b) Accurately documented. 2. The clinical record will contain the following for each resident: c) The care and services provided. A facility policy titled, Change in Resident Condition included: 1. The facility will immediately inform the resident, consult with the resident's physician, and notify the resident's legal representative or interested family member when there is a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly.

Based on observations, clinical record review, staff and resident interviews, facility documentation and policy review, the facility failed to provide care and services for one resident (#57) with a pressure ulcer. Findings include: Resident #57 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Skin assessment dated [DATE], revealed the resident's heels were clear and firm. According to a physician's order dated March 5, 2014, skin assessments were to be done weekly, every Wednesday. A nursing note dated March 6, 2014, also documented that the resident's heels were clear and firm. A Braden Scale for predicting pressure ulcer risk dated March 6, 2014, identified that the resident was not at risk for skin breakdown. Despite this, a care plan was developed dated March 6, for the Potential for Skin Breakdown related to incontinence, immobility, and a low [MEDICATION NAME]. Interventions included to assess skin condition when performing care; keep heels off bed, pressure relieving mattress, gel cushion, and heel protectors or multi podus boot, as per physician order. Review of a Significant Change MDS assessment dated [DATE], revealed the resident was not at risk for pressure ulcer development and had no pressure ulcers. Review of a Dietary Progress Note dated March 12, 2014, revealed the resident was a high risk for pressure ulcers, due to weight loss, diabetes mellitus, urinary tract infection, malnutrition, depression and poly pharmacy. A 14 day Minimum Data Set (MDS) assessment dated [DATE], identified the resident was cognitively intact, required extensive assistance of two staff for bed mobility and transfers, and used a wheelchair. The MDS also assessed the resident to not be at risk for developing pressure ulcers and included that no pressure ulcers were present. However, a nursing note dated March 19, 2014, now documented the resident's left heel had a blister and the right heel had a dry, flat scab. No measurements were documented. Review of the clinical record revealed there was no documentation that the physician was notified, nor were there any treatment orders. According to a Wound Nurse Progress note four days later dated March 23, 2014, the resident now had a stage 3 pressure ulcer on the left heel, which measured 4.4 centimeters (cm) x 4.8 cm. The wound bed was described as having slough and moderate amounts of serous drainage. The note also included the following wound treatment was done: cleansed with saf cleanse, applied [MEDICATION NAME] AG, covered with allevyn, heel wrapped with Kerlix, and will continue treatment and monitor changes. However, further review of the clinical record revealed no physician's order could be located for this treatment. A physician's order dated March 23, 2014, included for multi podus boots while in bed and to float the resident's heels off of the mattress. According to the March 2014 Treatment Administration Record (TAR), the order for the resident's heels to be floated off the mattress and for multi podus boots while in bed were included. However, there was no documentation that these interventions were done. The resident's left heel wound was not reassessed until 15 days later, on April 7, 2014. The Wound Nurse Progress Note documented the wound measured 3.1 cm x 3.8 cm and that eschar (necrotic tissue) was present to the wound bed. Review of the Wound Nurse Progress Note dated April 12, 2014, revealed the pressure ulcer was described as a stage 3, despite documentation that the wound bed had eschar present. The pressure ulcer measured 2.9 cm x 3.5 cm. The resident's left heel wound was not reassessed until 10 days later, on April 22, 2014. The Wound Nurse Progress Note again documented a stage 3 to the left heel with eschar present. The wound measured 2.9 cm x 3.8 cm. The next wound assessment was done eight days later on April 30, 2014. Per the Wound Nurse Progress Note, the resident had a stage 3 pressure ulcer with eschar and measured 3.2 cm x 4.1 cm. Further review of the April 2014 TAR, revealed that the orders to float the resident's heels while in bed and for multi podus boots were included, however, there was no documentation that these interventions were done. On May 1, 2014, a physician's order included the following wound treatment to the stage 3 left heel: cleanse with saf cleanse, apply [MEDICATION NAME] AG, cover with [MEDICATION NAME] border, cover with Allevyn heel, wrap with Kerlix, and change every other day in the morning until resolved. A Wound Nurse Progress Note dated May 3, 2014, documented the left heel measured 2.8 cm x 3.9 cm, and the wound bed presents with eschar. A physician's clarification order dated May 8, 2014, included that the left heel was unstageable and ordered a wound clinic consult. The next wound assessment was not completed until 10 days later on May 13, 2014. Per the Wound Nurse Progress Note, the left heel pressure ulcer was unstageable with eschar and measured 3.3 cm x 3.9 cm. Continued review of the TARS for May, June and July, and August 2014, revealed the orders for the resident's heels to be floated off the mattress and for multi podus boots while in bed. Again, there was no documentation that these interventions were being implemented. Further review of the clinical record revealed there was no documentation that the resident had any multi podus boots in place. A Quarterly MDS assessment dated [DATE], identified the resident was not at risk for developing pressure ulcers, however, it also documented that the resident had a stage 3 pressure ulcer. During an interview conducted on August 27, 2014 at 1:40 p.m., a nursing assistant (NA) stated that she receives information regarding the care of the residents from the prior shift and from the care plans. During an interview conducted on August 28, 2014 at 1:00 p.m., a licensed practical nurse (LPN) stated she was aware of the orders to float the resident's heels and for the use of multi podus boots while in bed. She further stated ultimately it was the nurse's responsibility to ensure care is provided to the resident, such as floating the heels while in bed and implementing multi podus boots, and to make sure it is documented on the TAR. During an interview on August 28, 2014 at 2:45 p.m., the Director of Nursing (DON) stated she would expect the nurses and nursing assistants to provide and document care that was given to residents to prevent the development of pressure ulcers. The DON stated if the care was not documented, it was not done. On September 2, 2014, the resident was observed lying in his bed, without his heels being floated off the mattress. The resident was also observed to not have any multi podus boots on his feet. During an interview conducted with the resident on September 3, 2014 at 12:30 p.m., the resident stated that he was given a multi podus boot for his left foot months ago, but it had fallen apart. He stated that he told the staff, but has not received another one. The resident also stated that when he is in bed, his feet are not on pillows to keep the heels off the mattress. An observation of the dressing change to the left heel was conducted on September 4, 2014 with licensed staff. The left heel pressure ulcer measured 2.6 cm x 3.3 cm and had granulation tissue in the wound bed, no slough or eschar was present. Review of the facility's policy titled Pressure Ulcer Prevention and Treatment included that a resident that enters the facility without pressure ulcers does not develop pressure ulcers unless the individual 's clinical condition demonstrates that they were unavoidable. The policy also included if the heels were noted to be red and/or mushy, or if there were open areas to the heels, a wound treatment order was to be obtained, the heels were to be floated while in bed and for multi podus boots while in bed.

Based on observations, current and closed clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to ensure interventions were consistently implemented and that adequate supervision was provided to help prevent falls for three residents (#12, #199 and #200), and failed to ensure one resident (#20) had been assessed for the safe use of side rails. Findings include: -Resident #200 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the nursing notes dated October 2, 2013 at 9:00 p.m., revealed the resident was heard crying and was found on the mat next to her bed. The resident had rolled off of her bed, possibly hitting her head, and was transferred to the emergency room by ambulance to rule out a head bleed. A nursing note dated October 3, 2013, included the resident returned to the facility at 1:55 a.m. Safety interventions included a scoop mattress, bed alarm and floor mat. Review of the interim fall care plan dated October 3, 2013, revealed the following interventions: 30 minute safety checks, tab/pressure alarms for bed and wheelchair, and a two hour toileting schedule. A Fall Risk assessment dated [DATE], identified that the resident was at risk for falls. A nursing note dated October 11, 2013, documented the resident continued to decline; is weak and frail, and is total assist for all cares. The note further stated that the resident is alert and confused, was a high risk for falls, and that visual checks are being done. Review of a falls care plan dated October 14, 2013, revealed the resident was at risk for falls, due to confusion and poor safety awareness. Interventions included the following: with each fall staff will investigate the cause for the fall, reassess the need for appropriate assistive devices, rule out a urinary tract infection (UTI), and keep the resident's environment free of clutter. The care plan did not include for 30 minute safety checks, nor for tab/pressure alarms for the bed and wheelchair, as previously care planned. Review of a nursing note dated December 3, 2013, revealed the resident was found on the floor of her room and sustained a skin tear to the right hand. Per the note, the resident stated she was reaching for some paperwork and fell forward out of her wheelchair. Review of the clinical record and investigative information revealed there was no documentation if the tab alarm/pressure alarms and the 30 minute checks were in place at the time of the fall. The falls care plan was revised on December 3, 2013, to reflect a new intervention of 15 minute safety checks. A nursing note dated December 21, 2013 at 4:13 a.m., included the resident was found on the floor of her room, and the floor mat was out from underneath her. The resident was sitting with her back against the bed frame. No injuries were noted. The note stated that a bed alarm was in place. However; there was no documentation if the alarm was sounding at the time of the fall or if 15 minute checks were being done. A nursing note dated December 21, 2013, documented that at 2:15 p.m., the resident was found on the floor in her room, after transferring without assistance from her wheelchair. No injures were noted. There was no documentation that the tab alarm was on and if 15 minute checks were in place at the time of the fall. The falls care plan was revised on December 21, 2013, and revealed the following interventions: low bed with safety mat and a pressure alarm in chair and bed. A Quarterly MDS (Minimum Data Set) assessment dated [DATE], identified the resident had severe cognitive impairment and required extensive assistance of two persons with transfers. Per the MDS, ambulation had not occurred. Also documented was that the resident had falls, with an injury. According to a nursing note dated January 8, 2014, the resident had an unobserved fall from bed at 3:23 p.m. The resident was found on the mat bedside her bed. The resident complained of neck pain and 911 was called and the resident was transferred to the hospital. Again, there was no documented evidence that the low bed, tab alarm/pressure alarm, and 15 minute checks were in place at the time of the fall. The falls care plan was revised on January 8, 2014, to include 15 minute safety checks for seventy-two hours and a low bed with a safety mat. Review of a nursing note dated January 10, 2014, revealed at 10:15 p.m., the resident had fallen asleep in her wheelchair and fell forward, hitting her head and sustaining a three centimeter (cm) laceration to the top of her head. There was no documentation that the tab alarm/pressure alarm and the 15 minute checks were in place at the time of the fall. Further review of the falls care plan revealed there was no evidence that additional interventions were implemented after this fall. A nursing note dated January 14, 2014 at 12:00 p.m., included the resident was found by her roommate on the floor next to her bed. The resident was attempting to transfer without assistance from her wheelchair. No injuries were noted. There was no documentation that the tab alarm/pressure alarms were in place at the time of the incident. The falls care plan did not reflect any additional interventions that were implemented after this fall. A nursing note dated January 19, 2014 at 12:30 p.m., included the resident slid from her chair while transferring. No apparent injuries were noted. There was no documentation that the tab alarm/pressure alarms were in place at the time of the fall. The care plan was revised on January 20, 2014, to include the following revisions: 15 minute safety checks for seventy-two hours, non-skid socks, and to move the resident closer to the nurse's station. There was no clinical record documentation that the resident was moved closer to the nurse's station at this time. Review of a nursing note dated March 8, 2014 revealed that at 9:00 p.m., the resident got out of bed and was trying to get to a box that was in her room and attempted to climb into her wheelchair and fell . No apparent injuries were noted. There was no documentation if the tab alarm/pressure alarms were in place, or if the bed was in the low position, or if a mat was on the floor at the time of the fall. The falls care plan was revised on March 8, 2014, to include the following interventions: 15 minute safety checks for seventy-two hours and moved the resident close to the nurse's station, however, this was unable to be verified. Review of a nursing progress note dated March 12, 2014, revealed that at 9:45 a.m., a CNA responded to an alarm and found the resident on the floor next to her wheelchair, which was next to her bed. No injuries were noted. The resident stated that she does not know how she fell , as she was just reaching. Review of the fall care plan revealed there were no revisions implemented after this fall. A nursing note dated March 13, 2014 included at 5:30 p.m., the resident fell forward out of her wheelchair to the floor in the hallway. The resident hit her head and sustained two lacerations to the top of her head. 911 was called and the resident was transferred by ambulance to the emergency room . There was no documentation that the tab alarm/pressure alarms were in place. In addition, the falls care plan was not revised after this fall. A nursing note dated March 20, 2014, included that at 2:59 a.m., the resident was transferring without staff assistance and was found on the floor and hit her head. The resident stated that she was getting out of bed to get dressed for the morning. There was no documentation that the bed was in the low position with a floor mat, and if the tab alarm/pressure alarms were in place at the time of the fall, as care planned. A nursing note dated March 20, 2014, revealed that at 5:40 p.m., the resident was getting out of her wheelchair and attempted to walk and fell , hitting her head. Review of the facility documentation revealed the resident hit her head and had a large bump on her right forehead. The resident was transported by ambulance to the emergency room . There was no evidence that the tab alarm/pressure alarms were in place at the time of the fall. Review of the fall care plan dated March 20, 2014 revealed the following interventions: 15 minute safety checks, non-skid socks, bed close to floor, floor mat, Neuro checks, psychiatric consult, physical therapy evaluation for restorative for increased falls, pharmacy medication review with each fall, pressure alarm in bed, tab alarm while in wheelchair, closest to the nurses station, keep environment free of clutter, and every two hour turning and toileting. Clinical record documentation showed that the resident returned to the facility. Review of the nursing note dated March 22, 2014, revealed that at 4:35 a.m., the resident was observed falling from her wheelchair in front of the nurse's station and hitting her head on the counter, resulting in a laceration to the head. There was no documentation that the tab alarm/pressure alarms were in place and that 15 minute safety checks were being done as care planned. A nursing note dated March 22, 2014 included the resident had a fall earlier this morning from the wheelchair and sustained a small laceration on the top of her head. The note also included that the resident continues to lean to the right when in the wheelchair. A care plan for safety awareness was implemented on March 22, 2014, with the following interventions: 15 minute safety checks, anticipate the resident's needs, every two hour toileting and as needed, mats next to the bed, tab alarm, and notify physician of any needs or changes. A care plan for leaning to the right in the wheelchair dated March 27, 2014, revealed the following interventions: place a floor mat in front of the wheelchair, place a bedside table and a pillow in front of the resident's wheelchair, and to offer to place the resident in bed when leaning forward while sleeping in the wheelchair. Review of the nursing note dated March 31, 2014 revealed that at 11:45 a.m., the resident fell out of her wheelchair hitting her head. The resident sustained [REDACTED]. There was no documentation that the floor mat had been in front of the wheelchair, and if the bedside table and a pillow were in front of the wheelchair and if the tab alarm was in place, as care planned. In addition, there was no documentation that any increased supervision was provided, despite multiple falls. Further review of the care plan for leaning forward and sliding out of the wheelchair dated March 31, 2014, now revealed the following intervention: Do not leave resident alone in her room while in her wheelchair. According to the nursing note dated April 2, 2014, the resident was discharged to another facility after multiple falls and trips to the emergency room . An interview was conducted with a certified nursing assistant (CNA) on August 28, 2014. The CNA stated that if resident's are a high risk for falls, they try to do lots of activities to keep them involved and safe. An interview was conducted on August 28, 2014, with a licensed practical nurse (LPN). The LPN stated that when a resident is admitted to the facility who is a fall risk, a care plan is done with appropriate interventions and updated as needed, after each fall. An interview was conducted with the Director of Nursing (DON) on August 28, 2014. The DON stated that this resident was transferred to another facility as it was determined that they could not keep the resident safe. -Resident #199 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An interim care plan for falls which was undated included the following interventions: monitor any needed interventions such as safety checks, alarm, assist in ambulating and transferring, toileting-check comfort level every two hours, bed in low position, assess for need of other safety interventions such as low bed, toileting schedule, and observe, record and correct all unsafe conditions. Review of a nursing note dated December 1, 2013, revealed the resident had fallen out of bed at 5:45 a.m. The resident was found with her back touching the mattress and her feet were on the floor, with one leg resting on the pegs of the wheelchair. No injuries were noted. A falls care plan dated December 1, 2013, included the following interventions: staff will investigate the cause for the fall, encourage resident to rest, reassess the need for appropriate assistive devices, engage resident in activities of choice, rule out urinary tract infection (UTI), and keep environment free of clutter. A nursing note dated December 13, 2013, revealed the resident tried to get up to go to the bathroom and slipped while transferring from the bed to the wheelchair, without assistance. The resident sustained [REDACTED]. The falls care plan was revised on December 13, 2013 with the following interventions: tab/pressure alarm for bed and wheelchair, two hour toileting schedule, low bed with safety mat, and concave mattress on bed. Review of the nursing note dated January 3, 2014, revealed the resident had lowered herself out of bed onto her knees on top of the safety mat next to her bed. No apparent injuries were noted. There was no documentation that the bed was in the low position, and that a tab alarm/pressure alarm was in place at the time of the fall. The falls care plan was revised on January 3, 2014 to include a two hour turning schedule and for a urinalysis screen. Review of a nursing note dated February 7, 2014, revealed the resident was observed on the floor. The resident stated that she fell out of bed. No injuries were noted. There was no documentation if the bed was in the low position with the mat and if the tab alarm/pressure alarms were in place. The falls care plan dated February 7, 2014 included for 30 minute safety checks to be done. A nursing note dated February 11, 2014, revealed the resident was observed on the floor in her room. The resident stated she slid from her wheelchair and landed on her knees in front of her bed. No injuries were noted. There was no documentation if the tab alarm/pressure alarms were in place and if the 30 minute safety checks were being done, as care planned. According to a Quarterly MDS assessment dated [DATE], the resident had moderate cognitive impairment and required extensive assistance of one person for transfers and that ambulation did not occur. The MDS also included that the resident has had falls with injuries. The falls care plan was again revised on February 22, 2014 to reflect for 15 minute safety checks to be done for seventy-two hours. Review of the nursing note dated April 15, 2014 at 2:14 a.m., revealed that the resident was observed on the floor with a hematoma and bruise to the right side of her forehead above the right eye. The resident stated that she had rolled out of bed and fell to the floor, hitting her head on the bedside table. The resident was transported to the hospital and diagnosed with [REDACTED]. There was no documentation that the bed was in the low position with the floor mat in place and if the tab alarm/pressure alarms were in place at the time of the fall. In addition, there was no documentation of any increased supervision that was provided, despite multiple falls. Further review of the clinical record revealed the resident left the faciity on [DATE]. An interview was conducted on September 3, 2014, with an LPN. The LPN stated that residents at risk for falls are care planned with appropriate interventions. She stated that when a resident falls, an incident report is completed, but she is not aware if staff document the interventions that are in place at the time of the fall. An interview was conducted on September 3, 2014, with the DON. The DON stated that when a resident has a fall, an incident report is done. However, she also stated that the nurse's had not been documenting the fall interventions that were in place at the time of the fall. -Resident #12 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of a falls care plan dated February 10, 2014, revealed the following interventions: assist in ambulating, transferring, and toileting, bed in low position, assess for need of other safety interventions, and monitor any needed interventions; examples include safety checks and alarms, and review as needed. A quarterly Minimum Data Set (MDS) assessment dated [DATE], identified the resident was cognitively intact. In addition, the resident was assessed as using a wheelchair for mobility and required supervision with setup during transfers. However, the resident was also assessed to be unsteady when moving from a seated to a standing position and was only able to stabilize with human assistance. The resident was also noted to have had no falls in the last three months. A fall risk assessment dated [DATE], identified that the resident was not at risk for falls. According to a nursing note and the facility's investigation, the resident fell on [DATE] at 5:30 p.m., while transferring herself without staff assistance. Per the documentation, the resident stated "I was moving from the toilet to my wheelchair and I slipped." The resident was assessed to have no apparent injuries. Some of the interventions put into place after this fall included the following: the resident was instructed on how to use the call light and to ask for help with transfers, 30 minute safety checks, and for a pressure alarm to the bed and wheelchair. A nursing note dated August 23, 2014, included the resident was found on the floor in her room, during the evening shift. Per this entry, only the right wheel was locked on the wheelchair, causing it to roll from underneath the resident. No injuries were noted. Interventions included to instruct the resident to use her call light and ask staff for help. These were the same interventions when the resident fell on [DATE]. According to the facility's investigation, the fall occurred at 5:06 p.m. The interventions listed as in place before the fall included 30 minute safety checks, two hour toileting, education on assistive devices, and use of the call light. Per the report, there was no documentation that the tab alarm/pressure alarm to the wheelchair was in place, at the time of this fall. An observation of the resident in her room was conducted on August 28, 2014 at 12 p.m., with a CNA present. The resident was observed in her recliner with her wheelchair next to her side. The CNA verified that the resident did not have a tab alarm or a pressure alarm on her while in the recliner and could not explain why it was not in place. Also, a pressure alarm was observed in the seat of the wheelchair, in the off position. In addition, there was no alarm on the resident's bed. The CNA explained that a bed alarm was not used for the resident. The CNA clarified this with the nurse, and then stated the resident was to have a pressure alarm to her bed. On August 28, 2014 at 1:12 p.m., a LPN stated that a resident identified as a fall risk would have a fall care plan initiated, which would be updated with each fall, including adding new interventions. During an interview with the DON on August 28, 2014 at 5:09 p.m., the DON stated that when a resident has their first fall in the facility, a resident would be monitored for 72 hours to evaluate and determine the root cause for the fall. The DON further explained that within those 72 hours it would also be determined whether interventions such as safety checks should be continued or discontinued. She stated that although staff monitor the resident 72 hours following a fall, which included interventions such as safety checks and tab/pressure alarms, she recognized that documentation was lacking that this was being done. She further stated that any post fall assessments or monitoring would be documented in the nursing notes. Review of the policy on Safety and Supervision of Residents revealed the facility "strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities..." Review of the facility's policy on Fall Risk Management revealed for staff to identify interventions related to the resident's specific risks and causes to try to prevent falls and to try and minimize complications of falls; and that these interventions are to be based on previous evaluations and current data. Review of a policy on Fall Documentation revealed "...The fall will be documented in the resident's plan of care with fall interventions and goals listed A policy for Monitoring Subsequent Falls and Fall Risk stated that "1. Staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling." -Resident #20 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], included the resident had severe cognitive impairment and that a bed rail was not used by the resident. Review of a fall care plan dated August 3, 2014, included that the resident had a history of [REDACTED]. The care plan did not include for the use of side rails. During a random observation conducted on August 27, 2014 at 9:05 p.m., resident #20 was observed to be in bed with two, quarter length side rails in the upright position. The bed was positioned against one wall. An interview was conducted with a licensed staff member on August 27, 2014 at 9:20 p.m., who stated that side rails were only used with a physician's order, and would be included in the resident's plan of care. The staff member further stated that the resident should not have the side rails up. Review of the clinical record revealed no documented evidence that the resident had been assessed for the safe use of the side rails and there was no physician's order for their use. During an interview conducted on August 27, 2014, another licensed staff member stated that the facility does not use side rails. The staff member added that side rails would only be implemented after all other interventions had been tried, and that the risks and benefits would be explained to the resident and family, and they required a physician's order. In interviews with licensed staff conducted on August 27 and 28, 2014, staff were unable to locate any assessments that were done prior to the use of the side rails, in order to determine if they were safe for this resident. During an interview conducted on August 28, 2014, the Administrator in training stated that upon review of the resident's records, they were unable to locate any assessments that were done in 2014, regarding the use of side rails. A facility policy regarding side rail assessment, implementation, and evaluation included that an order for [REDACTED]. Documentation of the use of side rails included how many side rails shall be raised, and specifications to the times or duration of side rail use. The policy also included that once side rails had been implemented, the device was to be assessed quarterly and with a change of condition and documented in the medical record. Another facility policy regarding safety and supervision of residents included that safety risks and environmental hazards are identified on an ongoing basis and that information from assessments and observations would be analyzed to identify any specific accident hazards or risks for the resident. Additionally, the policy included ensuring that interventions were implemented correctly.

Based on closed clinical record review, facility documentation, and staff interviews, the facility failed to ensure that one resident (#85) received sufficient fluid intake to maintain proper hydration. Findings include: Resident #85 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed hospital transfer documentation dated April 30, 2014, which showed that the resident's chemistry panel levels were within normal limits. Physician admission orders [REDACTED]. A physician's orders [REDACTED]. Review of the daily fluid intake amounts for May 2014 revealed the following: May 3 total fluid was 180 ml May 4 total fluid was 480 ml May 5 total fluid was 260 ml May 6 total fluid was 240 ml May 7 total fluid was none May 8 total fluid was 480 ml According to the Nutritional Care Plan dated May 8, 2014, the resident was identified to be at risk for dehydration due to dysphagia, swallowing problems and poor intake of less than 50%, with [DIAGNOSES REDACTED]. Interventions included the following: monitor daily intakes, monitor labs, and meds as ordered. A dietary note dated May 8, 2014 included the resident was at high risk for dehydration, due to fluid consumption of less than 1,000 milliliters (ml) per day. Per the note, his fluid requirements were assessed to be 2,959 ml per day, which were far below what he was consuming. The tech also wrote that the resident is now on restorative dining. According to the admission MDS (Minimum Data Set) assessment dated [DATE], the resident was cognitively intact and required limited assistance of one with eating. The MDS also included the resident had difficulty swallowing and was on a mechanically altered diet. Review of the daily fluid intake amounts revealed the following: May 9, 2014 total fluid was 480 ml My 10, 2014 total fluid was 480 ml A physician's orders [REDACTED]. Review of the daily fluid intake amounts included the following: May 11, 2014 total fluid was 720 ml May 12, 2014 total fluid was 240 ml A nursing note dated May 13, 2014 included the resident is on puree/honey thick liquids and makes it clear that he does not like it at all. Daily fluid intake amounts included the following: May 13, 2014 total fluid was none May 14, 2014 total fluid was none May 15, 2014 total fluid was 240 ml A nursing note dated May 15, 2014 included that the resident shows no interest in attending therapies, participating in activities of daily living, or taking meals. Resident just wants to lay in bed. A nursing note dated May 16, 2014 included the resident requires the assistance of one for eating to provide encouragement and supervision, as resident has difficulty swallowing and refuses to participate, causing him to make slow progress. Review of a dietary note dated May 16, 2014 revealed a new assessment for fluid hydration needs, which decreased to 2,755 ml per day. Review of the daily fluid intake amount for May 16 was noted to be none. A nursing note date May 17, 2014 documented the resident skin was pale, with poor skin turgor. Review of the daily total fluid intake amounts revealed the following: May 17, 2014 total fluid was none May 18, 2014 total fluid was none Clinical record documentation by the MDS nurse dated May 18, 2014, included the resident stated "I can't drink thickened fluids." The documentation further included that they spoke with kitchen staff to make the resident a milk shake with magic cup and other high calorie items. A physician's orders [REDACTED]. Per the clinical record documentation, the liter of IV fluids was administered. Review of the daily fluid intake amounts included the following: May 19, 2014 60 ml May 20, 2014 none Clinical record documentation showed that on May 20, 2014, the resident had gone out for gastric tube placement for extreme weight loss and had returned to the facility. physician's orders [REDACTED]. A dietary note dated May 21, 2014 documented new hydration requirements of 2,659 ml per day. Clinical record documentation showed that the tube feeding was being administered. A physician's orders [REDACTED]. Review of the laboratory results revealed "Critical Values" as follows: Sodium was critical/high at 152 mEq/L (milliequivalents per liter); normal range is 135 to 145 BUN was critical/high at 191 mg/dl (milligrams per deciliter); normal range is 6 to 20 Chloride was high at 119 mEq/L; normal range is 100 to 108 Potassium was high at 5.1 mEq/L; normal range is 3.5 to 5 Creatinine was high at 9.0 mg/dL; normal range is 0.5 to 1.2 [MEDICATION NAME] was low at 2.5 grams/dL; normal range is 3.4 to 5.0 Total Billirubin was high at 1.2 mg/dL; normal range is 0.20 to 1.00 ALT (SGPT) was high at 95 U/L; normal range is 30 AST (SGOT) was high at 191 U/L; normal level is 15 to 37 Alkaline [MEDICATION NAME] was high at 203 U/L; normal range is 45 to 117 Osmolality, Calculated High at 367 mOs/kg; normal range is 275 to 285 GFR was low at 6 mL/min/SA; normal range is > 60 A physician's orders [REDACTED]. An interview was conducted with a licensed practical nurse (LPN) on September 4, 2014 who stated that it is the nurses responsibility to monitor the fluid intake of the resident. She said that after each meal she obtains the meal intake for the residents to note how much they are consuming for both food and fluids. She said that she gets a report from the nursing aides if a resident is not consuming very much fluid. An interview was conducted on September 4, 2014 with the diet technician who remembered the resident. She said at first, the resident was started on a pureed diet, but he did not like it and was switched to a mechanical soft diet, with honey thick liquids. She said he did not like the honey thick liquids either. She said at times they made magic cup shakes for him, as she thought it was a way to get more nourishment and fluid into him, because he did not like the thickened water. A policy for fluid maintenance and hydration policy was requested. The Administrator and Director of Nursing confirmed that there was no policy and procedure for fluid maintenance to prevent dehydration.