Every finding on record at Valley View Villa

Based on record review and interviews, the facility failed to prevent a significant medication error for one (#1) of 10 residents reviewed for medication errors out of 10 sample residents.Specifically, the facility failed to ensure Resident #1 was not inadvertently administered another resident's opioid medication (medication used to treat moderate to severe pain).Findings include:I. Facility policy and procedure The Administration of Medications policy, reviewed 9/9/25, was received from the nursing home administrator (NHA) on 10/21/25 at 1:00 p.m. It read in pertinent part, The facility will ensure medications are administered safely and appropriately per physician orders to address residents' diagnoses and signs and symptoms. A medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: -The prescriber's order; -Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or -Accepted professional standards and principles which apply to professionals providing services. A significant medication error means one which causes the resident discomfort or jeopardizes his or her health and safety. Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration: right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation/response, right education and information.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included peripheral vascular disease (a circulatory disorder caused by narrowed or blocked blood vessels outside the heart and brain), orthostatic hypotension (a sudden drop in blood pressure when you stand up from a sitting or lying position), non-pressure chronic ulcer of right foot (a slow healing wound caused by underlying conditions like poor circulation), gangrene (death of tissue caused by loss of blood supply infection or injury), pain in right foot and essential hypertension (high blood pressure). The 10/2/25 minimum data set (MDS) assessment identified Resident #1 was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. Resident #1 was dependent upon staff to transfer from the bed to the chair.B. Record reviewThe physician's progress note, dated 8/21/25, documented Resident #1 was opioid tolerant on a relatively high-dose of fentanyl and the physician was going to start the resident conservatively on methadone (synthetic opioid medication used to treat severe, chronic pain) 2.5 milligrams (mg) twice a day and titrate up every five to seven days as needed while watching for sedation, confusion, respiratory depression and changes in heart rate.The progress note, dated 9/24/25 at 10:14 a.m., documented that during the morning medication count, it was noted that Resident #1's 9:00 p.m. methadone was not administered on 9/23/25. After investigation, it was discovered the resident was administered another resident's (Resident #11) Oxycontin (opioid pain medication) 30 mg instead. The physician was notified and a message was left for the resident's representative.The progress note, dated 9/24/25 at 10:37 a.m., revealed Resident #1's representative returned the phone call and was updated about the medication error.The progress note, dated 9/24/25 at 1:26 p.m., revealed Resident #1 had no signs or symptoms of adverse effects noted related to the administration of the Oxycontin medication.Review of Resident #1's September 2025 CPO revealed a physician's order for methadone HCL oral tablet 10 mg to be given by mouth two times a day for limb ischemia pain, ordered 9/20/25.-Review of Resident #1's September 2025 CPO did not reveal a physician's order for Oxycontin, the medication the resident was administered instead of methadone on 9/23/25.-However, review of another resident's (Resident #11) October 2025 CPO revealed a physician's order for Oxycontin 30 mg oral tablet, one tablet to be given by mouth two times a day for rheumatoid arthritis (an autoimmune disease that causes joint pain, swelling, and stiffness) pain, ordered 8/15/25. A Medication Discrepancy document, dated 9/24/25, was provided by the NHA on 10/20/25 at 6:17 p.m. The Medication Discrepancy document revealed that during the morning medication count, Resident #1's 9:00 p.m. methadone was not administered and instead, 30 mg of another resident's Oxycontin was administered. A report was made to the director of nursing (DON) and the physician. The document revealed no adverse effects to Resident #1 were noted throughout the night and the resident was easily aroused throughout the night. Vital signs were stable at the time and Resident #1 was alert and oriented to person. The document indicated education was to be done with registered nurse (RN) #3 and all nursing staff.III. Staff interviewsA certified nurse aide with medication authority (CNA-Med) who wished to remain anonymous was interviewed on 10/20/25 at 3:40 p.m. The CNA-Med said the facility was aware of a medication error that took place in September 2025 for Resident #1. The CNA-Med said they saw no adverse effects to Resident #1 after the error. The CNA-Med said after the medication error, staff were educated about completing the five rights of medication administration and were re-educated on how to use the medication narcotic book to ensure medication errors did not occur.Certified nurse aide (CNA) #4 was interviewed on 10/20/25 at 5:35 p.m. CNA #4 said she was not aware that the medication error for Resident #1 occurred on the night of 9/23/25 when she was working, but she said she heard about it a couple of days later. CNA #4 did not notice anything different about Resident #1 the night of the medication error. She said Resident #1 was not more tired or lethargic than normal. RN #2 was interviewed on 10/20/25 at 5:41 p.m. RN #2 said she was training RN #3 the night Resident #1's medication error occurred. RN #2 said she did not know if RN #3 was aware that RN #2 was supposed to be present during the medication administration process. RN #2 said she knew she was supposed to be present when RN #3 was passing medications, but she was needed elsewhere during the incident. RN #2 said Resident #1 was prescribed methadone for pain control. RN #2 said Resident #1 was accidentally given an Oxycontin pill instead of a methadone pill by RN #3. RN #2 said that RN #3 grabbed the wrong medication card (a type of pre-packaged medication used for dispensing and administering drugs to residents) and therefore grabbed the wrong resident's medication, which contained the Oxycontin instead of the methadone. RN #2 said Resident #1 did not have a physician's order for Oxycontin and the Oxycontin was another resident's medication. She said the medication error was not discovered until the next morning (9/24/25) during the shift change medication count. She said during the medication count, it was noted there was an extra methadone tablet in Resident #1's methadone medication cart and there was one less tablet of Oxycontin in Resident #11's Oxycontin medication card. RN #2 said the DON, the physician, and Resident #1's representative were notified. She said RN #3 completed an assessment and took a set of vital signs on Resident #1 after the medication error was discovered. RN #2 said the Resident #2 seemed the same that night 9/23/25) and that there were no changes in her pain or general status following the medication error. Following the incident, RN #2 said all nursing staff received education clarifying that preceptors must be physically present with nurse trainees during medication administration. RN #3 was interviewed on 10/20/25 at 6:02 p.m. RN #3 said she was new to the facility and was learning about the residents and their personalities. RN #3 said she administered medications for the whole floor on 9/23/25. She said the next morning (9/24/25) during the shift change medication count, a medication discrepancy was noted and upon review, she believed Resident #1 received another resident's Oxycontin instead of a methadone pill the previous evening. RN #3 said they did not find the Oxycontin medication that was missing from Resident #11's medication card anywhere else. She said she did not remember pulling Resident #11's Oxycontin medication card but that was the only rationale that could be explained because there was an Oxycontin tablet missing from Resident #11's card on the morning of 9/24/25 and there was an extra methadone tablet in Resident #1's medication card. RN #3 said at one point during her medication pass on 9/23/25, she got interrupted and came back to administer medications. RN #3 said she could not say whether or not her nurse trainer (RN #2) was with her at the exact time the medication error potentially occurred. RN #3 said she did not remember signing the controlled substance record book before she administered the medication to Resident #1. RN #3 said she was in and out of the room all night making sure Resident #1 was getting repositioned because Resident #1 was receiving end-of-life care at the time. RN #3 said nothing was abnormal for Resident #1 that night. She said Resident #1 did not have an increase in drowsiness or lethargy. RN #3 said she did not notice any new side effects at all and did not notice anything out of the ordinary for the resident. RN #3 said she called the physician and the DON after realizing she made an error. RN #3 said she completed an assessment and vital signs on Resident #1 within 15 to 20 minutes after finding out there had been a medication error. RN #3 said Resident #1's vital signs were at baseline. RN #3 said she received education on the five rights of medication administration after the error and she signed off on it. She said she was paired with a trainer for more shifts after the incident. She said she and the DON had a discussion about the incident. RN #3 said she was traumatized by the incident and she now triple checked her medications before administering them.The physician was interviewed on 10/21/25 at 9:50 a.m. The physician said he was aware that on 9/23/25 Resident #1 was given 30 mg of Oxycontin in error. The physician said Resident #1 had previous orders for Oxycontin 10 mg to be given every 12 hours, but the medication had been discontinued prior to the medication error on 9/23/25. The physician said that Resident #1 received 30 mg of Oxycontin in error but he did not think she was at much risk because she was already on narcotics so it was like substituting one medication for another. The physician said Resident #1 had active physician's orders for methadone at the time of the incident. The physician said Resident #1 was on narcotics at high doses before and tolerated them well. The physician said Resident #1 had been on high doses of fentanyl and methadone prior to the incident. The physician said he did not see a change in her level of consciousness or see her become more lethargic after being given Oxycontin 30 mg in error. The physician said he saw no lasting effects from the Oxycontin 30 mg being administered instead of the methadone. The physician said if someone who was opioid naive was given 30 mg of Oxycontin he would have been more concerned.The DON was interviewed on 10/21/25 at 11:44 a.m. The DON said she was told that during morning medication count on 9/24/25, RN #3 realized she pulled the wrong pain medicine and that she had pulled Resident #11's medicine and given it to Resident #1 by accident. The DON said 10 mg of methadone was scheduled for Resident #1 and RN #3 had administered Resident #11's Oxycontin 30 mg in place of the methadone. The DON confirmed RN #3 confused the methadone medication with the Oxycontin medication. She said Resident #1 had taken Oxycontin before but it was only 10 mg prior to the incident. The DON said the electronic medical administration record (EMAR) documented the methadone was given, but after investigation ,it appeared Resident #1 did not get the methadone and instead got 30 mg of oxycontin.The DON said she asked how the resident was and RN #3 said Resident #1 had no issues overnight. The DON said she herself did not see any change in Resident #1 after the incident. The DON said when she spoke to Resident #1, she would answer coherently and had a conversation with her. The DON said if Resident #1 was not opioid tolerant, the medication error could have caused decreased breathing, altered consciousness, confusion and drowsiness. The DON said the experienced nurse was supposed to stay with the new nurse during medication administration and also while they were learning new residents. The DON said RN #3 said her nurse preceptor (RN #2) was around but not hovering over her, or watching her at the time of the incident. The DON said the nurse preceptor (RN #2) was not watching exactly what RN #3 was doing. The DON said after the incident, she completed one-on-one education with RN #3 and stressed the importance of following the five rights of medication administration. The DON said she started an action plan to work on decreasing the amount of medication errors. The DON said she did medication audits with nursing staff which involved observing staff members during medication administration. She also completed continued education with staff.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure housekeeping staff followed appropriate cleaning practices by treating each side of the room as a separate patient zone, cleaning all high touch surfaces and cleaning items in the rooms from cleanest to dirtiest. Findings include: I. Professional reference According to The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures (3/19/24), retrieved on 12/23/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Change cleaning cloths between each patient zone (use a new cleaning cloth for each patient bed), High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bedrails; IV (intravenous) poles; sink handles; bedside tables; counters; edges of privacy curtains; patient monitoring equipment (keyboards, control panels); call bells; and, door knobs. II. Facility policy and procedure The Housekeeping Service policy, dated 6/4/24, was provided by the nursing home administrator (NHA) on 12/19/24 at 10:47 a.m. It read in pertinent part, Clean high-touch surfaces and equipment at least once per day. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Change cleaning cloths between each patient zone. III. Observations During a continuous observation on 12/18/24, beginning at 8:05 a.m. and ending at 8:31 a.m., the following was observed: Housekeeper (HSKP) #1 was cleaning room [ROOM NUMBER], a double occupancy room, which was currently occupied by two residents. HSKP #1 knocked and announced herself, washed her hands with soap and water and donned (put on) gloves. HSKP #1 gathered her supplies and cleaned the mirror and shared sink. HSKP #1 went to the toilet room, squirted the toilet bowl cleaner into the toilet and cleaned the toilet with a brush. HSKP #1 took her supplies back to the cart, removed her gloves, performed hand hygiene and donned clean gloves. HSKP #1 gathered five clean cloths, wetted them in the diluted bleach water on her cart and set them around the room. HSKP #1 set one cloth on the door handle, one on side A of the room, one on the sink and two in the toilet room. HSKP #1 began cleaning the A side dresser and night stand, then moved to the B side and wiped the dresser and night stand with the same cloth and gloved hands. HSKP #1 continued cleaning the B side, wiping the over bed table and walker. She did not clean the call light, television remote or bed controls. HSKP #1 went back to A side of the room and wiped the over bed table with the same cloth. -HSKP #1 cleaned the toilet before other areas in the room. HSKP #1 did not use a separate cleaning cloth for each resident area. HSKP #1 did not clean the call bells, remotes or bed controls. HSKP #1 did not change gloves between cleaning side A and side B of the room. HSKP #1 said she should have changed cloths between side A and B. HSKP #1 said she forgot to clean the high touch surfaces of call lights and bed controls. HSKP #1 said she was not sure if she should clean the cleanest to dirtiest or dirtiest to cleanest surfaces. HSKP #1 said she did not know the toilet should be cleaned last. During a continuous observation on 12/19/24, beginning at 10:46 a.m. and ending at 11:10 a.m., the following was observed: HSKP #1 was cleaning room [ROOM NUMBER], a double occupancy room, which was occupied by two residents. HSKP #1 knocked, entered the room and asked permission to clean the room. HSKP #1 washed her hands with soap and water and donned gloves. HSKP #1 gathered her supplies and began cleaning the mirror and sink. HSKP #1 squirted the toilet bowl cleaner into the toilet and returned to her cart. HSKP #1 removed her gloves, performed hand hygiene and donned clean gloves. HSKP #1 gathered four cloths wetted with bleach water. HSKP #1 sat the wet cloths around the room, one by the sink, one on the door handle and one on each side of the room. HSKP #1 wiped the sink and counter. HSKP #1 took a clean cloth and wiped side B of the room, including the call bell and television remote. -HSKP #1 did not clean the bed remote. HSKP #1 picked up a clean cloth and wiped side A of the room, including the call bell. -HSKP #1 did not clean the bed control and did not change gloves between A side and B side of the room. HSKP #1 took three mop heads from her bucket of mopping solution and sat them on the floor. HSKP #1 mopped the toilet room and removed the mop head with a gloved hand. HSKP #1 did not change gloves. HSKP #1 got another mop head and mopped B side. HSKP #1 changed the mop head and mopped B side. HSKP #1 moved the over bed table, touching the top of the table with the dirty glove that she had touched the dirty mop head with. HSKP #1 said she should have changed her gloves between side A and side B of the room. HSKP #1 said she should have changed her gloves after touching the dirty mop head and would go back and disinfect the over bed table. IV. Staff interviews The housekeeping supervisor (HSKS) was interviewed on 12/18/24 at 9:02 a.m. The HSKS said when cleaning a double room, gloves and cleaning cloths should be changed between side A and side B. The HSKS said surfaces should be cleaned from cleanest to dirtiest and the toilet should be cleaned last. The HSKS said high touch surfaces should be cleaned daily and include dressers, sinks, faucets, over bed tables, call bells and cords, bed controls, remotes and door handles. The infection preventionist (IP) was interviewed on 12/18/24 at 11:36 a.m. The IP said when cleaning a resident room the bathroom should be cleaned last. The IP said a different cleaning cloth and mop head should be used for each resident area in a double occupancy room. The IP said each resident area should be cleaned separately and gloves should be changed between sides of the room. The NHA was interviewed on 12/19/24 at 10:30 a.m. The NHA said the dirtiest surfaces should be cleaned last. The NHA said for double occupancy rooms each side should be treated as a separate area and cleaning cloths should be changed between sides of the room.

Based on record review, observations and interviews, the facility failed to ensure one (#9) of six residents received adequate supervision to prevent accidents out of 18 sample residents reviewed. Specifically, the facility failed to ensure Resident #9, who had been assessed as having a risk for falls upon admission, received the care and services to prevent a fall. The facility failed to ensure the resident was supervised after a fire drill. Record review and interviews showed after a fire drill on 5/31/23 staff failed to ensure resident safety when residents were left without adequate supervision when behind closed fire doors. After a fire drill, Resident #9 was hit by an interior fire door and sustained multiple injuries including a dislocated shoulder, fracture of the right shoulder and multiple fractures of the pubis rami (the inferior and superior pelvic bones). Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 8/15/23 to 8/17/23, resulting in the deficiency being cited as past noncompliance with a correction date of 6/1/23. I. Facility policies and procedures 1. The Fall Management policy, dated 6/4/2020, was requested and received from the nursing home administrator (NHA) on 8/16/23. It revealed in pertinent part, Purpose: to promote patient safety and reduce falls by proactively identifying, care planning, and monitoring of patients' fall indicators. Policy: the facility will assess the resident . with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Accident: refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Avoidable accident: means that an accident occurred because the facility failed to: -Identify environmental hazard and/or assess individual risk of an accident, including the need for supervision and/or assistive devices; Evaluate/analyze the hazards and risks and eliminate the, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; -Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident; Supervision/adequate supervision: facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required. This determination is based on the individual residents' assessed needs and identified hazards in the resident environment. Hazards: refer to the elements of the resident environment that have the potential to cause injury or illness. Hazards over which the facility has control - are those hazards in the resident environment where reasonable efforts by the facility could influence the risk for resulting injury or illness. Accurate and thorough assessment of the patient is fundamental in determining indicators for potential falls. Patient conditions may vary throughout the day, week, month, or other time period and the identification of patient fall indicators is an ongoing, interdisciplinary assessment process. 2. The Fire policy, dated 9/9/22, was requested and received from the (NHA) on 8/16/23. The policy documented in pertinent part,The facility will ensure that associates are trained and prepared to respond in the event of a fire within the facility, in accordance with current national fire protection association guidelines. Employees are periodically instructed and kept informed with their duties under the plan. The plan addresses the basic response required of staff. -Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Response to alarms -Clear hallways of persons and equipment, in the event a large-scale evacuation is needed; -Remove only those residents in immediate danger from fire and smoke; -Assist resident and visitors to safe areas of the facility, preferably behind a fire door or compartment Educational elements -Associates should be aware of their assigned work stations and duties when the fire alarm sound -All personnel should stand by their departments or work areas for directions after making their own department safe Actions based on job role at the facility -Administrator/incident commander -Once the fire alarm has been activated, determine the location of the activation. -Assess the situation -Supervise emergency operations Nursing staff -Report the location of the alarm activation and assess the situation -Mark doors and rooms as they are cleared of people -Perform a head count of staff and residents -Coordinate with the incident commander and other members of incident command Maintenance -Immediately respond to the area of the fire alarm activation -Coordinate with the incident commander. II. Resident #9 A. Resident status Resident #9, age 87, admitted on [DATE] and readmitted to on 6/6/23 from the hospital. According to the August 2023 computerized physician orders (CPO) the diagnoses included fracture of the pubis, fracture of the right ilium, fracture of upper end of right humerus (right shoulder), dislocation of right shoulder joint, Alzheimer's disease and dementia. The 3/21/23 minimum data set (MDS) assessment was cognitively intact with a score of 13 of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance from one staff member for dressing and toilet use. She required supervision from one staff member for bed mobility, transfers, locomotion on and off the unit and personal hygiene. She walked independently in her room and in the hallways. The resident was independent with eating after setup assistance from one staff member. Section J indicated the resident had no falls six months before her admission or falls after her admission to the facility. B. Observation On 8/16/23 at 11:07 a.m., Resident #9 was observed ambulating with a walker and a staff member provided stand by assist. The resident had a steady gait and appeared to tolerate the activity well. C. Record review The fall risk care plan initiated on dated 6/16/22 documented the resident was at risk for falls. The interventions included, in pertinent part, call light within reach encouraging the resident to use the call light when she needed assistance, physical and occupational therapy as ordered. -The care plan failed to identify risks for injury that could arise from environmental hazards. 1. Fall incident on 5/31/23 The 5/31/23 at 2:10 p.m. incident report documented, After facility fire drill staff was opening fire door, resident was standing behind door and fell when door was opened. Staff states resident was noted hitting head when falling. Resident lying on back when nursed assessed. Range of motion to extremities equal and strong. Right arm strong. Resident grabs left arm when assessed but denies pain when asked. Range of motion strong. Resident assisted by two staff members and gait belt into standing position and then sat in chair. Orthopedic assessments were initiated. No injuries noted. New intervention: Staff education on opening doors after fire drills. The report documented immediate action taken was education to all staff on opening fire doors after fire drills. Signs were placed on doors to remind staff to open doors slowly and for residents to ask for assistance. On 5/31/23 at 3:45 p.m. The nurse note read, After fall resident did ambulate down to the sun room for an activity, used walker and stand by assistance of staff member, no complaints of pain at this time. After activity resident was unable to get self out of the chair. Staff assistance was needed. Gait belt placed and she was unable to take any steps. She was placed in a wheelchair and taken to her room Physician was called, a verbal order was received to send the resident to hospital for treatment and evaluation. Call placed to husband, no answer and unable to leave voice mailbox full. Vital signs: temperature 98.7 (sic) 130/62. The nurses note dated 5/31/23 at 4:12 p.m. documented, the resident was transported to the hospital for evaluation and treatment related to the fall. The fall risk care plan was updated upon the residents return to the facility on [DATE]. The care plan documented, the resident was at risk for falls with injury related to weakness and limited mobility secondary to a recent fall with diagnoses of right arm fracture and right superior and inferior pubic rami (pelvis) fractures. She currently requires staff assistance of two to complete her activities of daily living (ADL) and transfers. Resident uses a wheelchair as her primary mode of locomotion. The interventions included, in pertinent parts, encourage and assist with repositioning as tolerated,. encourage not to sit on edge of bed as tolerated, required an assist of two with ADLs and transfers. Physical and occupational therapy as ordered. 2. Hospital records The resident required six nights in the hospital from 5/31/23 to 6/6/23 for evaluation and treatment. Hospital records revealed the resident sustained multiple injuries, dislocation of right shoulder with proximal humerus and glenoid fracture (shoulder) and multiple closed fracture of the right pubic rami (pelvis). III. Facility response to incident A record review revealed the facility completed a root cause analysis of the incident on 6/1/23. The analysis revealed a need to educate all staff members to open the fire doors very carefully, and to check behind the doors for people on the other side. New signs were ordered and placed on every fire to remind everyone to be careful when opening the doors. The root cause analysis read, Fire drill was held and after the fire drill staff was huddled by the nurse's station. After the huddle, the doors to the Resident's doors (sic) were still shut. Staff member pushed open the door and hit the resident as she was trying to come thru the doors. The root cause analysis documented the resident ambulated independently with a walker prior to the incident. Facility staff were educated on 5/31/23 and 6/1/23 to open the fire doors carefully. The education included instruction the fire doors can close during fire or tornado drills. The Quality Assurance and Process Improvement (QAPI) plan included Fire Door Safety. On 5/31/23 the facility identified action items to improve and monitor included: -All staff was educated on the fire doors and opening slowly. -Fire doors were labeled with signs to remind staff to open doors slowly. Follow up fire drills were held on 6/29/23 at 11:00 p.m. and 7/31/23 at 12:00 p.m. The notes documented for each drill the fire doors were reset and the doors were held open prior to staff post-drill huddle meetings. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/16/23 at 4:03 p.m. CNA #1 said he was familiar with Resident #9. He said prior to the fall the resident ambulated independently, however after the fall, she needed increased assistance from staff because of her fractures. He said the since the fall, the resident had shown improvement and was now able to transfer and ambulate with her walker requiring only stand by assistance of one staff member. The CNA said when he was hired he participated in training during orientation for fire drills. He said his duties during a fire drill were to assist residents to a safe area away from the fire and to clear the hallways. He would then respond as told and said that might be to find a fire extinguisher or monitor residents if an evacuation was necessary. The CNA said he received training to open the fire doors slowly and carefully after the resident fell but did not remember specific training before then. The director of nursing (DON) was interviewed on 8/17/23 at 10:23 a.m The DON said she had scheduled a fire drill on 5/31/23. The DON said during a fire drill a staff member was to always remain on each hallway to help residents to their rooms, close door, clear hallways and monitor for additional necessary responses. The DON said that when the fire alarm sounded, the fire doors closed automatically. After the fire alarm was deactivated, the fire door controls must be manually reset before the doors would remain open. She said on 5/31/23 the fire drill was finished and staff from the hallway attended the staff huddle (staff meeting) at the nurses desk. The fire doors had not been reset and closed behind staff as they proceeded to the nurses desk. When staff gathered at the huddle, Resident #9 was in her room, which was behind the closed fire doors. The resident left her room and ambulated towards the nurses desk. The DON said when the huddle ended, a staff member pushed the fire door open and hit the resident which caused the resident to fall to the floor. The corporate vice president (CVP) was interviewed on 8/17/23 at 10:35 p.m. She said the injury was an accident. The staff member was unable to see anyone behind the fire doors.

Based on observations, record review and interviews, the facility failed to ensure one (#1) of five sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to -Follow the hospital discharge recommendations from the speech therapist to crush Resident #1's medications for administration; -Provide ongoing assessment for Resident #1's ability to swallow whole medications; and, -Obtain a crush medication order prior to crushing and administering medications to Resident #1. Findings included: II. Resident #1 A. Resident status Resident #1 over the age of 65 was admitted [DATE] and discharged [DATE]. According to the July 2022 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) assessment revealed the resident had moderately impaired cognition as evidenced by a brief interview mental status (BIMS) score of eight out of 15. The resident required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident did not walk and needed constant cuing and prompts for swallowing while eating. The resident experienced coughing or choking during meals or when swallowing medications. B. Resident observation and interview Observations and interviews with the resident were not possible as the resident was discharged to the hospital on 7/31/22 and did not return to the facility. C. Record review Review of the hospital speech language dated 7/15/22 read in pertinent part: Patient required maximum cues to perform swallow strategies throughout session. Although no cough patient did exhibit, wet vocal quality after oral intake (p.o.) Patient also noted to silently aspirate during a prior assessment. Recommendations for inpatient facility: continue moderately thick liquids with swallow precautions and Frazier water protocol (allows patients with dysphagia swallowing problems to drink water that is not thickened, between meals). Continue ST (speech therapy), guarded prognosis. Speech plan of care discussion: Patient/family agrees with plan of care. -Recommendations: Swallowing precautions: 1:1 (one-to-one) assistance, no straws, small bites and sips, slow rate of eating and drinking, multiple swallows. -Medication administration recommendations: Crushed in puree food. Upon arriving at the facility the resident was evaluated by the facility speech therapy; recommendations included providing maximum assistance with dining as well as cueing to encourage multiple swallows per sip of water and bite of food. There was no documentation that the resident's ability to swallow whole pills was assessed and no recommendation on how to prepare the medications for oral intake. Review of the July 2022 CPO and medication administration record (MAR) revealed the resident did not have an order to crush and administer medications. -Though certified nurse aide (CNA) #1 with medication administration certification said in an interview (see below) that he crushed and administered the medications to the resident. Review of the resident medical record and nursing progress notes revealed the resident and the resident's representative declined to follow the speech therapy recommendation for modified diet for mechanically altered foods and honey thick liquids; but there was no documentation that the facility talked to the resident and/or resident representative about the recommendation for the resident to received medications crushed in pureed foods. III. Staff interview CNA #1 was interviewed on 10/5/22 at 11:12 a.m. CNA #1 said he had passed medications to Resident #1 and was told prior to medication pass by the nurse giving report to crush the Resident #1's medications for the and mix in applesauce for administration. The CNA acknowledged the resident did not have an order to crush the resident medications at that time.CNA #1 said he had since been provided education to check the resident record and to make sure their resident physician had given an order that it was ok to crush a resident's medications prior to crushing and administering medication by that method. Registered nurse (RN) #1 was interviewed on 10/5/22 at 11:38 pm. RN #1 said Resident #1 did not have an order to crush any medication. RN #1 did not crush the resident's medications for administration and gave the resident all medications whole with water. RN #1 said the resident had signs in his room, placed by speech therapist, that indicated that the resident was not to use any straws, in order to protect the resident from choking. RN #1 did not believe the resident needed his medications crushed so long as he had enough water to swallow the pills. RN #2 was interviewed on 10/5/22 at 1:55 pm. RN #2 said orders to crush a resident's medication could be verified by reviewing both the resident's MAR and CPO for the order. RN #2 said when administering medications to Resident #1, he crushed the medications and administered the medications to the resident in applesauce. RN #2 said the resident accepted the crushed medications without complaint and without any episodes of choking. RN #2 stated that he crushed the resident medications for administration because it was the right thing to do because the resident had difficulty swallowing solid foods and whole pills. RN #2 acknowledged that Resident #1 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The director of nursing (DON) was interviewed on 10/5/22 at 3:10 p.m. The DON said a resident needed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Some medications could not be crushed and the nurse administering the medications would have to know or double check which medications could and could not be crushed; with a crushed medication order. The DON said the resident had refused to accept the recommended mechanically altered diet and they did not think he would have accepted crushed medications in applesauce. The DON said the facility had conducted an audit in August 2022 of residents needing crushed medication. It was discovered that two residents known to need their medications crushed did not have orders to crush their medications. The DON said crushed medication orders were obtained and the residents' CPOs were updated immediately. The DON was not able to show that these orders carried over to the resident's MAR during the interview and acknowledged it could be a concern if the nurse administering medications was not familiar with the resident's swallowing needs. The DON acknowledged for verification purposes the resident's MAR should show the order for the resident to receive medications in crushed form. The DON said this would be corrected after the interview concluded.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to appropriately disinfect seven blood glucose meters on four medication carts shared by 19 residents who required blood glucose testing. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (6/2019): The CDC has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Meters requiring preloading of the test strip may come in direct or close contact with the resident's finger stick wound. Subsequent residents can be exposed when the meter is used on them. Staff hands can become contaminated with blood that is transferred to the meter when they obtain the reading. Blood remaining on the meter can be transferred to subsequent residents through staff hands when they perform the next procedure. People living with type 1 or type 2 diabetes mellitus have higher rates of [MEDICAL CONDITION] than the general population. People living with diabetes are at increased risk for [MEDICAL CONDITION] if they share blood glucose meters, finger stick devices or other diabetes-care equipment. According to the Federal Drug Administration (FDA) retrieved from http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm 5.htm on 8/7/19. A high rate of blood contamination of glucose meters raises the risk of blood-borne pathogen transmission. Sharing of blood glucose meters should be avoided, if possible. If shared, the device must be cleaned and disinfected after every use according to manufacturer ' s instructions. If there are no manufacturer ' s instructions, the device must not be shared. Selection of appropriate products and use of recommended procedures for cleaning and disinfection of point of care devices is critical to reduce risk of infectious cross-contamination. The use of 70% alcohol wipes is inadequate for disinfection. According to the FDA: The disinfection solvent you choose should be effective [MEDICAL CONDITION].[MEDICAL CONDITION], and [MEDICAL CONDITION] viruses . Please note that 70% [MEDICATION NAME] solutions are not effective against [MEDICAL CONDITION] blood borne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device. II. Facility Policy and procedure The policy, dated 4/15/19, was received from the nursing home administrator (NHA) on 8/1/19 at 11:20 a.m. The policy documented in pertinent part, disinfect the blood glucose meter with a Super Sani-cloth wipe or an equivalent product that kills [MEDICAL CONDITION] and blood Borne pathogens. Follow the manufacturer's guidelines for wet time (time the blood glucose meter must remain wet with the disinfectant product to be effective) when applying disinfectant. III. Manufacturer ' s instructions Sani-Cloth Wipes The Sani-cloth Bleach germicidal wipe by PDI, manufacturer ' s instructions, documented the product is effective against 50 microorganisms in four minutes including blood borne pathogens such as [MEDICAL CONDITIONS].The manufacturer instructions documented the product has a contact time (time the blood glucose meter must remain wet with the disinfectant product to be effective) of four minutes to disinfect microorganisms including [MEDICAL CONDITIONS], and HIV. The Sani-cloth Bleach germicidal wipe container was observed on 7/31/19 at 3:00 p.m. The container documented on the front of the label that the product disinfects in four minutes. [MEDICATION NAME] EZ blood glucose meter The [MEDICATION NAME] EZ blood glucose meter by Abbott manufacturer ' s instructions for healthcare professions documented acceptable cleaning solutions were 10% bleach, 70% alcohol, or 10% ammonia. IV. Observations On 7/31/19 at 3:01 p.m. registered nurse (RN) #1 was observed checking the blood glucose levels of a resident. The RN was observed at the mediation cart as she placed the blood glucose meter in a disposable plastic cup with cotton balls, alcohol wipes, lancets, and test strips. She proceeded to the resident ' s room. RN #1 put gloves on, placed a strip in the blood glucose meter, lanced the left ring finger to draw blood, held the meter to the resident ' s finger to catch the blood and waited for the reading. She placed the blood glucose meter back into the cup with the clean supplies and proceeded back to the medication cart. The blood glucose meter was not disinfected prior to or after obtaining the blood glucose level. At 3:23 p.m. the RN took the same blood glucose meter to a second resident ' s room. The unit manager (UM) began observing the RN completing her blood glucose checks. She reminded the RN at that time to clean the blood glucose meter. RN #1 cleaned the front and back of the blood glucose meter with a Super Sani wipe and placed it on a paper towel to dry. The time resting on the paper towel was from 3:42 p.m. to 3:43 p.m. (one minute). She did not wait for the four minute disinfection time, and the UM did not instruct her to wait and ensure the meter was in contact with the product for four minutes. She then picked up the blood glucose meter and placed a strip in the blood glucose meter, lanced the middle ring finger to draw blood, held the meter to the resident's finger to catch the blood and waited for the reading. On 8/1/19 at 10:44 a.m. RN #3 was observed as she checked the blood glucose level of a resident. The unit manager observed her at the medication cart as she prepared her supplies. The RN wiped the blood glucose meter, front and back with a Sani cloth wipe. The UM then walked away. The RN wrapped the blood glucose meter in a tissue and took it to the resident's room. The UM did not follow. In the room, the RN lanced the resident's finger to draw blood, brought the blood glucose meter to the resident ' s finger to obtain blood and got a reading. She then wiped the meter with a Sani cloth and wrapped it in a paper towel and carried it out of the room. The towel would have absorbed the disinfectant product and the disinfectant product did not remain on the machine for four minutes. The manufacturer's instructions failed to accompany the blood glucose meters. V. Interviews The nursing home administrator (NHA) was interviewed on 8/1/19 at approximately 4:00 p.m. She stated she believed the disinfectant product only had to be in contact with the meter for one minute, not four minutes. She further said the licensed nursing staff were being educated on the disinfection of the blood glucose meters beginning last night. She said they did not have anyone with [MEDICAL CONDITION] that they were aware of. She further said she didn ' t feel the residents needed their own blood glucose meters, and said that was just a recommendation from the CDC. On 8/1/19 at 11:07 a.m., RN #2 was interviewed. He said he cleaned the blood glucose meter with the orange top Sani cloth wipes. He said he left the disinfectant product on for five minutes or whatever the package says. The infection control preventionist (ICP) was interviewed on 8/5/19 at 4:20 p.m. She said she had started to in service the licensed nurses on 6/5/19 regarding proper cleaning of blood glucose meters. VI. Record review The in-service records from 6/5/19 were reviewed. There were only six of 24 licensed nurses who signed the in- service in regards to cleaning the blood glucose meter. The in service record documented in pertinent part, glucometers (blood glucose meters) must be cleaned with Sani-cloth wipes and allowed to dry for four minutes after each use. The in service did not instruct the nurses to keep the blood glucose meter wet with the product for four minutes as the product dries quickly and may need to be reapplied. VII. Facility Follow up On 8/1/19 at approximately 4:00 p.m. the regional nurse consultant (RNC) provided a copy of a list of nurse signatures on a form titled Glucometer Cleaning Education 1:1 with skills competency. There were 18 of the 24 licensed nurses who signed the form from 7/31/19 to 8/1/19. There was no individual competency checklists for each nurse indicating the steps reviewed with each nurse. The NC said the competency check was based on the policy and provided another copy of the policy. The policy included disinfecting the blood glucose meter with a Super Sani-cloth wipe or an equivalent product that kills [MEDICAL CONDITION] and blood Borne pathogens. Follow the manufacturer's guidelines for wet time (time the blood glucose meter must remain wet with the disinfectant product to be effective) when applying disinfectant and allowing the meter to dry per manufacturer ' s instructions. Licensed practical nurse (LPN) #1 was interviewed on 8/5/19 at 11:15 a.m. She said the facility in serviced her on how to clean the blood glucose meter on 7/31/19 or 8/1/19. She said she was instructed to keep the Sani Cloth product on the blood glucose machine and visibly wet for four minutes and the facility had now given them a timer on their cart to time it. LPN #2 was observed checking a blood glucose level on 8/5/19 at 4:40 p.m. She said the director of nursing (DON) trained her on Sunday 8/4/19 and had in-serviced her on how to clean the blood glucose meter. She said she was instructed to keep the meter wet with the product for four minutes. The LPN checked the resident ' s blood glucose level and then cleaned the front and back of the meter with a Sani Cloth wipe. She continued to check the meter for four minutes to ensure it was still wet with the product.

Based on observations, record review, and interviews, the facility failed to ensure one (#19) of seven residents reviewed for [MEDICAL CONDITION] medications of 29 sample residents was free from unnecessary medications. Specifically, the facility failed to: -Appropriately and thoroughly assess the resident's reported appearance of physical or emotional discomfort and rule out any medical reason for the change in behavior, specifically a urinary tract infection [MEDICAL CONDITION]; -Document the rationale for the increased dosage of [MEDICATION NAME] (an anti-anxiety medication); -Document the rationale for the increased dosage of [MEDICATION NAME] (an anti-depressant medication); -Assure the [MEDICAL CONDITION] medication consent form and the medical durable power of attorney (MDPOA) were signed by a cognitively competent individual; and -Monitor and track specific behaviors on the behavior monitoring form. Findings include: I. Professional references According to Sollitto, M. (2019) UTIs in the Elderly: Signs, Symptoms, and Treatments, retrieved from: https://www.agingcare.com/Articles/urinary-tract-infections-elderly- 6.htm (8/2019) .Older individuals with UTIs may exhibit signs of confusion or [MEDICAL CONDITION], agitation, hallucinations, unusual behavioral changes .acute behavioral and/or functional changes are often the only symptoms present in the elderly . According to Marshall, K. & Hale D. (2017) Urinary Tract Infections. Home Healthcare Now. 35(8), pp. 448-449. Retrieved from: https://www.nursingcenter.com/journalarticle?Article_ID= 16 *8/2019) .Patients with cognitive impairment may show a change in mental status such as increased confusion and disorientation, withdrawal, increased falls related to functional decline, agitation, and behavioral changes .Changes in functional ability and mental status in the cognitively impaired person can easily be considered a normal progression of dementia and are often overlooked as artifacts of the disease . Kizior, R. & Hodgson, K., (2020) Saunders Nursing Drug Book 2020, pp. 784-785; [MEDICATION NAME] is an antidepressant used to treat major [MEDICAL CONDITION] and should be used with caution in elderly patients taking [MEDICATION NAME] ([MEDICATION NAME]), as it may increase impairment of cognition. The Black Box warning was attached to the medication (a black box warning appears on the label of a prescription medication to alert consumers and healthcare providers about safety concerns, such as serious adverse effects or life-threatening risks. A black box warning is the most serious medication warning required by the U.S. Food and Drug Administration (FDA)). Kizior, R. & Hodgson, K., (2020) Saunders Nursing Drug Book 2020, pp. 718-719; [MEDICATION NAME] ([MEDICATION NAME]) is an anti-anxiety medication used for the management of anxiety disorders. Elderly population may be more susceptible to cognitive impairment and [MEDICAL CONDITION]. II. Facility policy The Psychopharmacological Medication Management policy, revised on 8/23/17, was provided by the nursing home administrator (NHA) on 8/6/19 at approximately 1:00 p.m. It read, in pertinent part: .to support effective utilization of psychopharmacological medications in the appropriate treatment of [REDACTED].Accurate and thorough assessment of the resident ' s indicators and medication side effects are fundamental in determining the appropriate utilization of psychopharmacological medications . III. Failure to properly assess Resident #19 for a change in behavior related to a medical reason A. Resident status Resident #19, age 70, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 6/6/19 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. She required extensive two-person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene, and extensive one-person assistance with eating. The MDS showed the resident did not report feeling down, depressed, or hopeless, however documented behaviors of delusions. B. Observation The resident was observed on 8/5/19 at 9:24 a.m. She sat in her room and held a purple stuffed bear. She talked to herself, as there was no one else in the room and made loud indecipherable noises. The resident intermittently yelled get out of here. Licensed practical nurse (LPN) #1 entered the resident ' s room and escorted her to the activities director (AD) for a one on one activity. The resident was observed on 8/6/19 at 11:13 a.m. She sat in her room while music played in the background. She talked to herself, as there was no one else in the room and made loud indecipherable noises. The resident intermittently yelled get out of here. Staff did not enter the residents room during this observation. C. Record review The (MONTH) 2019 Medication Administration Record [REDACTED]. IV. Failure to document the rationale for adding an anti-anxiety medication and increasing the dosage of an anti-depressant medication A. Record review The (MONTH) 2019 Medication Administration Record [REDACTED] --On 7/23/19, in the absence of the facility physician, the on-call physician prescribed for the resident an antianxiety medication [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg two times a day for generalized anxiety. Despite the fact that the resident was being treated for [REDACTED]. The physician's and nursing progress notes failed to document associated behaviors or rationale for the dosage increase and continued use of [MEDICATION NAME]. --On 7/25/19, the physician's orders [REDACTED]. The physician's and nursing progress notes failed to document associated behaviors or rationale for the dosage increase. The physician's progress note dated 7/25/19 revealed staff had reported a change in the residents character. The physician reported the resident seemed to be in physical and emotional discomfort; more agitated, angry, and appeared uncomfortable. The order for [MEDICATION NAME] was increased to 30 mg at bedtime. The facility physician progress notes [REDACTED]. A review of the Resident #19's medical record revealed the [DIAGNOSES REDACTED]. B. Staff interview The licensed practical nurse (LPN) #1 was interviewed on 8/5/19 at 10:35 a.m. She was unable to verbalize the residents behaviors associated with each medication. The social service director (SW) was interviewed on 8/5/19 at 1:18 p.m. She said the physician had recently increased the residents prescription of [MEDICATION NAME] from 15 mg to 30 mg, but she had not seen much of a change in the resident's behaviors. She was not certain how long the physician wanted to wait to see if the increase was effective. The facility physician (MD) was interviewed on 8/6/19 at 10:54 a.m., in the presence of the nursing home administrator (NHA) and the administrator in training (AIT). The physician said he relied on the facility to document Resident #19's behaviors. The physician said staff had reported the resident continued to exhibit behaviors of anxiety, hollering and yelling, and she did not seem happy but rather uncomfortable. He said the on-call physician started the resident on [MEDICATION NAME] 0.5 mg, which was increased to 1 mg on 7/30/19. The antidepressant [MEDICATION NAME] dose was increased from 15 mg to 30 mg a day, despite the fact that the resident was started on Bactrim (an antibiotic) to treat the infection [MEDICAL CONDITION], a treatable underlying condition. The MD said UTI could exhibit the same symptoms as what was being observed and documented; hollering, yelling, agitation, and confusion. He said it was the art of medicine, depended on the situation and knowing your patient as to the effectiveness of the medication. The MD was unable to provide a direct response if it was more appropriate to resolve the infection before the [MEDICAL CONDITION] and antidepressant medications were prescribed and dose increased. V. Failure to have the psychoactive medication informed consent forms signed by a competent individual A. Record review The medical durable power of attorney (MDPOA) dated 11/16/17, were signed by the resident and the resident's daughter, who was the appointed authorized agent for Resident #19. The medical order for scope of treatment (MOST) form dated 11/15/18, was signed by both the resident and resident's daughter. The psychoactive medication informed consent forms, dated 12/2/16, 11/20/17, 1/17/18, 3/13/18, and 7/23/19 were provided by the director of nursing (DON) on 8/6/19 at approximately 2:00 p.m. Each one of the five consent forms were signed by Resident #19. B. Staff interview The SW was interviewed on 8/6/19 at approximately 1:00 p.m. She said the resident's daughter was the MDPOA. She said the resident's cognition was severely impaired. The SW said she was told the resident could sign her own forms, but did not elaborate on who told her the resident was able to sign the forms. The SW said she believed the resident understood that she was going to be given a new medication, but could not cognitively understand the risk. The SW said numerous attempts were made to call the residents daughter. VI. Failure to monitor and track specific behaviors on the behavior monitoring form A. Record review The behavior monitoring form provided by the director of nursing (DON) on 8/6/19 at approximately 2:00 p.m., failed to document the resident had displayed any of the targeted behaviors of delusions, hallucinations, crying, or disruptive behaviors (yelling and hollering.) B. Staff interview The restorative nursing aide (RCNA) was interviewed on 8/5/19 at 10:10 a.m. She said the resident was kind and gentle and not aggressive. She liked to sing and conversed about the past. She may have had hallucinations of going to a concert, but could be easily redirected to the present. The certified nursing aide (CNA) #1 was interviewed on 8/5/19 at 10:29 a.m. She said the resident used to sing, but with the progression of her dementia, she may have forgotten the words and now only yelled out. She said the resident was not aggressive and had not observed the resident having delusions or hallucinations. The LPN #1 was interviewed on 8/5/19 at 10:35 a.m. She said the resident was not aggressive. The targeted behaviors were disruptive behaviors that consisted of yelling, singing and negative remarks like get out of here. The resident may have been delusional at one time, but she was not now, nor has the LPN observed the resident having hallucinations. The LPN said the resident was easily redirected by conversation or a change in scenery. The social service director (SW) was interviewed on 8/5/19 at 1:18 p.m. She said at one time the residents targeted behaviors were verbal and physical aggression toward staff, but now it was just the disruptive behavior of yelling and hollering loudly. More recently, the resident had a grimacing look on her face, that at times, scared the other residents. The activities director (AD) was interviewed on 8/6/19 at 10:22 a.m. She said the resident was confused, but she was not aggressive. The AD said she had never seen the resident sad, crying or depressed. She said the resident called out and yelled repetitively. The resident liked to listen to old country music, color, and talk about her horses. The NHA was interviewed on 8/6/19 at 10:50 a.m. She said Resident #19's behaviors were documented by exception; meaning, behaviors were only documented if they were displayed by the resident and observed by staff.

Based on observations, record review and interviews, the facility failed to determine for one (#25) of three residents reviewed for self-administration out of 21 sample resident. Specifically, the facility failed to: -Provide an assessment for Resident #25 regarding self- administration of Hydrogen peroxide 3% (percent) solution and Super Beta Prostate P3 Advanced capsules before leaving the medications at the resident bedside; and -Honor the residents right to self administer medications. Findings include: I. Facility policy and procedure The Self-Administration of Medications policy and procedure, last revised 9/6/17, provided by facility on 6/14/18, included in part: Each resident who desire to self-administer medication is permitted to do so if the facilities interdisciplinary team had determined the practice would be safe for the resident and other residents in the facility. The procedures included, if the resident desires to self-administer medication, an order for [REDACTED]. If the resident demonstrates the ability for safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. According to the OSHA (Occupational Safety and Health Administration) Chemical Sampling Information Hydrogen peroxide: Toxicity Health effect(s) of exposure to each substance, listed by OSHA Health Code and Health Effects included Irritation-Eye, Nose, Throat, Skin-Marked (HE14); Acute lung damage (HE11); Mutagen (HE2). The chemical could be absorbed into the body by inhalation, ingestion, skin and /or eye contact. Symptoms included eye, nose, throat irritation; sore throat, cough, shortness of breath, [MEDICAL CONDITIONS]; dizziness; headache; blurred vision, corneal ulcer; redness, pain, vesicles on skin; [MEDICATION NAME] of hair; Ingestion Acute could lead to sore throat; abdominal pain, distention; nausea, vomiting; possible embolism (oxygen bubbles) in the blood resulting in shock or symptoms of a stroke. Target organs were eye, skin and respiratory system. (https://www.osha.gov/dts/chemicalsampling/toc/toc_chemsamp.html), Last Updated: (YEAR)/04/01 and reviewed on 6/18/18. II. Resident status Resident #25, age 64, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders, [DIAGNOSES REDACTED]. According to the 4/8/18 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. No mood noted, but exhibited verbal behavior directed toward other. He required extensive assistance for bed mobility, transfer, dressing and toilet use. He required setup only for eating. A. Observations -On 6/11/18 at 3:57 p.m., the resident was in bed watching television, the following medications were observed on top of the resident's bedside table, these medications were visible from the hallway: -One opened bottle of Hydrogen peroxide 3% solution. -One opened bottle of Super Beta Prostate P3 Advanced capsule. On 6/12/18 at 9:38 a.m., the resident was in bed, an opened bottle of Hydrogen peroxide 3% and an opened bottle of Super Beta Prostate P3 Advanced capsule were observed on the resident bedside table. -At 3:30 p.m., the resident was asleep in bed, an opened bottle of the Hydrogen peroxide and Super Beta Prostate P3 Advanced capsule were observed on the resident bedside table. The bottle of the Hydrogen peroxide was covered with purple embroidered felt 750 ml (milliliter) bottle holder bag. On 6/13/18 at 8:15 a.m., the resident was observed in bed eating his breakfast, an opened bottle of the Hydrogen peroxide and Super Beta Prostate P3 Advanced capsule were observed on the resident bedside table, the Hydrogen peroxide was not covered. The bottle of Super Beta Prostate P3 Advance capsule was covered and was beside the breakfast tray. -At 1:30 p.m., the opened bottle Hydrogen peroxide and Super Beta Prostate P3 Advanced capsule were observed on the resident bedside table. -At 2:19 p.m., the opened bottle of the Hydrogen peroxide and Super Beta Prostate P3 Advanced capsule were observed on the resident bedside table. The bottle of the Hydrogen peroxide was covered with purple embroidered felt 750 ml bottle holder bag. -At 2:47 p.m., registered nurse (RN) #1 was observed in Resident #25 room. The RN removed the opened bottles of the Hydrogen peroxide and Super Beta Prostate P3 advanced capsules from the bedside table and took them out of the resident's room, and out of reach of the resident. B. Resident interview Resident #25 was interviewed on 6/11/18 at 4:00 p.m. He said he mixed the Hydrogen peroxide solution with herbs. He said he conducted a research on some natural herbs and discovered those herbs were good for pain management when mixed with Hydrogen peroxide solution. He said he heard about the Super beta prostate advanced capsule over the TV (television) commercial and he ordered the medication for a test. He said he would rather take the natural herbs and not take the medications administered in the facility. He said he had informed the nurses and made his intention known that he would like to try natural remedies, but he said the nurses were not listening to him. Resident #25 was interviewed again on 6/13/18 at 2:48 p.m. He said he started using the Super Beta Prostate P3 Advance capsule about a week ago and had been using the Hydrogen peroxide solution since (MONTH) (YEAR), (the resident was admitted on [DATE]). He said the bottle of the Hydrogen peroxide had being on his bedside table since (YEAR) and no one ever care to ask the reason for using the Hydrogen peroxide solution. He said the staff had not conducted a self-administration assessment to test his capability of using the Hydrogen peroxide, or the Super Beta Prostate P3 Advanced and or if he could keep the bottle by his bedside. He said there was a time the nurse unit manager (UM) #1 was in his room. He said the nurse unit manager removed the bottle of Hydrogen peroxide in (MONTH) (YEAR), and she never returned it or conducted a self-administration assessment. He said he used the Hydrogen peroxide solution in two ways. First, he said he used the Hydrogen peroxide solution two drops in every beverages served and swallowed. Secondly, he said he gargled the Hydrogen peroxide solution to freshen and whiten his teeth and spit it out. He said he had been taking the Super Beta Prostate P3 Advance capsule twice a day with his meals for about a week without physician order. He said he was not sure whether the nurses are aware of the Super Beta Prostate P3 Advance capsule. He said the bottle of the Hydrogen peroxide had being on his bedside table for a while. C. Record review Failures 1. Care plan There was no care plan for the resident to have the Hydrogen Peroxide and Super Beta Prostate P3 Advanced capsule by the bedside. 2. Physician order The review of the physician order from (MONTH) 1, (YEAR) through (MONTH) 12, (YEAR) revealed there was no physician order for [REDACTED]. 3. Assessment There was no evidence Resident #25 had an assessment conducted by the IDT to self-administer medication. III. Staff interview RN #1 was interviewed on 6/13/18 at 2:20 p.m. He said the resident did not have a physician order for [REDACTED]. He said the resident would need to have a self-administration of medication assessment and the physician order to have medication by the bedside table. He said it was not acceptable for the resident to have medication by his bedside without an assessment. The Director of nursing (DON) was interviewed on 6/13/18 at 3:17 p.m. She said residents were not allowed to keep medication by their bedside unless assessed for self-administration of medication. She said if any resident wishes to self-administer medication, she said the resident could do so but the facility would have to conduct an assessment and have the physician order for [REDACTED]. She said the resident could keep the medication in a locked box. She said she would expect the nurses to check the resident's room if they found or see something that was questionable and follow up. She said if a nurse noticed medication on the bedside, she would expect the nurse to inform the physician to rule medication sensitivity or contraindication. She said she would expect the nurse to assess the resident for self- administration review if the resident wishes to self-administer their medication. UM #1 was interviewed on 6/13/18 at 3:30 p.m. in the presence of the DON. She said she discovered the resident was having a clear bottle of rubbing alcohol on his bedside table around (MONTH) (YEAR). She said she removed the bottle and the resident was not happy with her. Later during the interview, UM #1 said, she was mistaken the bottle of Hydrogen peroxide for clear rubbing alcohol. She said the resident had a physician order for [REDACTED]. Certified nurse aide (CNA) #1 was interviewed on 6/13/18 at 4:40 p.m. She said she noticed the bottle of Hydrogen peroxide and some natural herbs on the resident's bedside table around (MONTH) (YEAR). She said she informed one of the nurses but could not remembered the nurse she informed. She confirmed the bottle of the Hydrogen peroxide had been on the resident's bedside table for a long time.

Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for one (#16) of two residents reviewed for respiratory care of 13 sample residents. Specifically, the facility failed to develop a respiratory care plan for Resident #16 to include her use of oxygen. Findings include: I. Resident status Resident #16, age 79, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the 3/14/18 Minimum Data Set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. II. Record review The resident did not have a care plan specifically for the use of oxygen, the goals nor interventions. Review of 3/31/18 physician oxygen orders, revealed an order for [REDACTED]. III. Staff interviews The MDS Coordinator was interviewed on 6/14/13 at 8:58 a.m. She said it was her responsibility to write the respiratory care plans and the resident ' s that utilize oxygen should have a care plan in place regarding their oxygen goals and interventions. She said she was not aware that the resident was utilizing oxygen and said she had to look into why there was not a care plan in place for her use of oxygen. -At 9:48 a.m. the MDS coordinator returned and said the resident had a care conference in (MONTH) and it was noted on the care conference note that the resident utilized oxygen and that her family and doctor were aware. She said at that time she should have written a care plan. -At 12:28 the MDS coordinator said her previous statement that she should have written a care plan for the resident ' s use of oxygen at the time her care plan meeting was held. She said the resident was in the middle of her MDS assessment and the facilities policy and practice was to put a care plan in place regarding new [DIAGNOSES REDACTED]. She said the only time she would have needed to write a care plan any sooner or upon use of new medications or conditions were if that condition triggered a significant change in the resident ' s status or upon admission. She said if the staff needed to know what the goals of use were or monitoring of any symptoms or side effects they could refer to the physician's order [REDACTED]. The director of nursing (DON) was interviewed on 6/14/18 at 12:00 p.m. She said she understood why it was important to have a care plan in place as it pertained to new orders for oxygen that needed monitoring but the facility did not have a policy in place to begin a care plan within a certain amount of time after a new medication order began. She said without a care plan in place for the use of oxygen the staff should be able to follow the physician's order [REDACTED]. IV. Follow of of actions during the survey The facility developed a comprehensive care plan on 6/14/18 to include the resident ' s risk of [MEDICAL CONDITION] due to her daily use of oxygen. The goals included that she would not have signs and symptoms of shortness of breath or respiratory distress and her saturations would stay above 90 percent until the next review. The interventions on the care plan that were not indicated on the resident ' s physician orders [REDACTED].

Based on observations, record review, and staff and resident interviews, the facility failed to ensure for one (#16) of two residents reviewed for respiratory care received necessary respiratory care and services out of 13 sample residents. Specifically the facility failed to: - Identify and thoroughly address the reason for the use of oxygen and the continuous use of oxygen; - Complete accurate respiratory assessments; and - Develop and implement a respiratory care plan to identify the resident ' s use of oxygen, goals and interventions. (Cross reference F656) Findings include: I. Resident status Resident #16, age 79, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the 3/14/18 Minimum Data Set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15.The MDS indicated the resident did not require oxygen during that review. II. Resident interview The Resident #16 was interviewed on 06/11/18 at 1:46 p.m. She said she did not know why she needed to use oxygen. She said she was sent out to the hospital in (MONTH) of (YEAR) and when she returned her doctor put her on oxygen and never took it off. She said she had used oxygen in the past when she was sick and when she got better she no longer had to use it. She said she did not like that she had to use it for so long this time and said the facility had not tried to take her off it to see if she really needed it. She said no one spoke with her about the reason or cause for her oxygen saturations to drop. She said maybe it was because she used to smoke. She said if someone figured it out to let her know. III. Record review Review of the care plan revealed the resident did not have a respiratory care plan in place that indicated the resident ' s use of oxygen for two and a half months while utilizing oxygen at 2 liters per minute (LPM). The minimum data set (MDS) coordinator did not initiate a care plan until the last day of the survey (6/14/18) because the resident was not due for her MDS assessment. See full interview below. Review of 3/31/18 physician oxygen orders, revealed an order for [REDACTED]. The 24 hour report, dated 3/31/18, was received from the director of nursing (DON) on 6/14/18 at 2:00 p.m. It revealed the resident had been placed on 1 LPM of oxygen because the resident ' s saturations had dropped between 84 and 88 percent. It read, the resident ' s responsible party needed to be notified, indicating the nurse had not done that when they first applied oxygen to the resident. On 4/1/18 the 24 hour report revealed the resident had a new standing order to receive oxygen at 2 LPM and notify the physician if her saturations fell below 90 percent. No note was found in the resident's chart that explained the need to increase the resident ' s oxygen from 1LPM to two LPM. Review of the physician ' s notes dated 5/15/18, 6/12/18 did not document any information related to the resident ' s new need for full time oxygen use, nor did it address the possible cause for the resident ' s saturations to have dropped, there were not any respiratory related [DIAGNOSES REDACTED]. The history and physical dated 3/30/18 under review of respiratory symptoms read, no cough or shortness of breath. The next day she began long term use of oxygen without any indication or full assessment of what could have caused the drop in oxygen saturation. The resident ' s Routine respiratory assessments were provided by the nursing home administrator (NHA) on 6/14/18 at 12:30 p.m. The respiratory assessments were completed frequently, however, the liter flow of oxygen recorded on the assessments fluctuated and did not match the physician ' s oxygen order. The respiratory assessments dated 4/2/18, 4/3/18, 4/4/18, 4/5/18, 4/6/18, 4/7/18, 4/12/18 and 5/9/18 all indicated the resident had been receiving oxygen at 1 LPM per minute. The respiratory assessments dated 3/31/18, 4/1/18, 5/12/18, 5/14/18 and 6/12/18 all indicated the resident was receiving oxygen at 2 LPM , according to the 3/31/18 physician order. IV.Staff interviews The licensed practical nurse (LPN) #1 was interviewed on 6/13/18 at 3:44 p.m. She said the resident had needed to use oxygen for the last two months. She said she was sent out to the hospital on [DATE] due to a fall and after she returned from the hospital her oxygen saturations fell below 90 percent and the doctor started the order for oxygen. She said the nursing and certified nurse ' s aides checked the resident ' s saturations each shift and where to report to the physician if they fell below 90 percent. The (MONTH) (YEAR) treatment administration record revealed the resident ' s oxygen saturations were monitored and documented three times each day, during the day, evening and night shift. After review, It was documented, the resident ' s oxygen saturation never fell below 90 percent documented while utilizing oxygen. She had not been reassessed given her oxygen saturations were about 90 % to see if she could be titrated off oxygen. She said she was unsure of why the resident was having low oxygen saturations but said it was most likely because she used to smoke. She was unaware if there was ever a work up put in place to determine the reason for the resident ' s new need or ongoing need for oxygen. She said she thought it was just because they knew her saturations will drop to an unsafe level without it. She said, her oxygen saturations may stay low because the resident did not get up and move around a lot and did get a lot of exercise or deep long breathing. The MDS Coordinator was interviewed on 6/14/13 at 8:58 a.m. She said it was her responsibility to write the respiratory care plans. She said resident ' s that utilized oxygen should have a care plan in place regarding their oxygen goals and interventions. She said she was not aware Resident #16 was utilizing oxygen and said she had to look into why there was not a care plan in place for her use of oxygen. See cross reference tag F656. The DON was interviewed on 6/14/18 at 12:00 p.m. She said the resident received the order for oxygen two days after she returned from a hospital visit. She said the resident had to use oxygen in the past as well for an acute condition that caused her oxygen saturations to fall below the 90 percent mark. She said her documentation showed her the facility discontinued the oxygen order when she began having saturations greater than the 90 percent. She said that because the resident had still been recorded to have saturations on 90 percent while on two liters of oxygen, it indicated the need to continue use as it would have fallen below that with no oxygen, however, she was unable to provide proof the resident ' s saturations would drop as the facility had not attempted to reduce or take the resident ' s oxygen off when checking her saturation level. She said she did not know what the cause was and the facility policy was not to find the cause for need of the oxygen. She said they were monitoring her saturations and conducting regular respiratory assessments. She said the assessments helped determine the need for oxygen and determined what how the resident was responding to oxygen therapy treatment. She said the assessments should be done accurately and the liter flow recorded on the assessments should have matched the physician's orders [REDACTED]. The Medical Doctor (MD) was interviewed on 6/14/8 at 12:45 p.m. He said the resident started on oxygen after her saturation fell below 90 percent so he wrote the order for oxygen. He said the order read to notify him if her saturation fell below 90 percent as a basic rule of thumb. The parameters put in place were not specific to the resident. It read he reviewed the resident ' s need for oxygen on an ongoing basis and he recalled the reason she needed it were for an acute reason of a possibility of pneumonia after her hospital visit in (MONTH) (YEAR). He said he thought she would probably need oxygen for long term. He said if a person could not keep their saturations above 90 percent then they need oxygen. He said he did not do an in depth evaluation of what was causing her saturations to fall below 90 percent because she had a long term history of smoking and probably had an undiagnosed [MEDICAL CONDITION]. He said the resident never mentioned to him that she was unhappy she had to utilize oxygen. V. Follow up of facility after survey The NHA sent information via email on 6/18/18. The information included follow up regarding the resident ' s need for oxygen and status. Included was a physician ' s progress note, that read, the chief complaint was the residents oxygen therapy. The MD included a physical exam, review of past medical imaging and a plan to address the underlying cause of the resident ' s need for oxygen therapy and included the discussion with the resident regarding testing for a formal [MEDICAL CONDITION] diagnosis.

Based on resident and staff interview and record review the facility failed to ensure one resident (#2) of six sample residents was fully informed of changes in her treatment. Specifically, the facility failed to notify the resident when her phsycian prescribed over the counter medication changed from twice a day to once a day. Findings include: Facility Policy The Resident Rights facility policy, revised 11/9/16, documented, in pertinent part: .The resident has the right to be informed of, and participate in, his or her treatment . Resident Status Resident #2, age 80, was admitted on [DATE]. The (MONTH) (YEAR) computerized physician orders [REDACTED]. The 2/7/18 minimum data set (MDS) documented the resident was cognitively intact with a brief interview for mental status (BIMS) of 14 out of 15. She required extensive assistance from staff with all activities of daily living. Resident Interview The Resident #2 was interviewed on 2/27/18 at 11:18 a.m. Resident #2 said that she had a problem with the way the facility communicated with her regarding a medication, specifically the Chondrinol Joint Supplement. She said she was made aware, while receiving her medication, that there had been a change in a pill that she took for her arthritis. When her pills were being administered, she noticed a pill was missing. She inquired and found it was the Chondrinol Joint Supplement. She said she was not made aware of any change to the Chondrinol Joint Supplement. She said it was important to her that she received this particular medication. She said it made her mad that they did not communicate this change with her. In the future she would be more aware and count her pills after receiving them. She said in a recent care conference it was discussed that she was not receiving the same amount of the Chondrinol Joint Supplement medication she had in the past. She said she was the one that had to bring it to the facility staff. Record Review The care plan record, dated 2/15/18, documented in pertinent part, Nursing: Discussed HS (evening) medications. The care plan record did not document any information regarding a medication change or that this was discussed. The (MONTH) (YEAR) MAR indicated [REDACTED]. Upon review of the progress notes, there were no notes which indicated the resident was notified of the medication change. The physician's clarification telephone order, dated 2/15/18, documented Chondrinol Joint Supplement take 1 tab(let) PO (by mouth) 2 x(times)/(per) day. Staff Interviews The licensed practical nurse (LPN) #1 was interviewed on on 2/27/18 at 3:45 p.m. The LPN said she said would always notify the resident of medication change. She said she would also write a progress note to document the change. The director of nursing (DON) and nursing home administrator (NHA) were interviewed on 2/27/18 at 4:37 p.m. The DON said that the resident's family always brought in the resident's Chondrinol Joint Supplement and the error was made at the end of (MONTH) during the month end medication reconciliation. She said during (MONTH) the resident was taking two tablets daily of the supplement and when (MONTH) started, because of the directions on the bottle, indicated one tablet should be taken daily, the resident began taking one tablet per day. She said the nurse who completed the month end medication reconciliation did not write a telephone order for the change to one tablet per day but made the change on the Medication Administration Record [REDACTED]. She confirmed there was no progress note indicating that resident was notified of the change. The DON said she would expect a resident to be notified of any medication change and a telephone order be written.

Based on observation, record review and staff interview, the facility failed to ensure it was free of a medication error rate of five percent or greater. Specifically, there was an error rate of 14%, with 4 errors out of 28 opportunities for error. These errors affected four (#21, #47, #125, and #83) 14 residents. The findings included: 1. Professional Reference According to Fundamentals of Nursing by Lippincott Williams &Wilkins, 8th Edition (copyright 2011), page 794: Three Checks and the Rights of Medication Administration -The nurse observes the three checks and the rights of medications to ensure medications are being administered safely. The use of technology such as bar cod labeling and medication administration, does not remove from the nurse the primary responsibility for assuring safe medication administration. -The label on the medication package or container should be checked three times during medication preparation and administration. The label should be read: 1. When the nurse reaches for the container or unit dose package; 2. After retrieval from the drawer and compared with the MAR (medication administration record), or compared with the MAR indicated [REDACTED] 3. When replacing the container to the drawer or shelf or before giving the unit dose medication to the patient. The rights of medication administration help to ensure accuracy when administering medications. The nurse ensures that the (1) right medication is given to the (2) right patient in the (3) right dosage through the (4) right route at the (5) right time. Additional rights have been suggested to include ensuring (6) the right reason and (7) the right documentation. Validating the right reason requires the nurse to understand the rationale for administration and answer the question, Does it make sense? The right documentation refers to accurate and timely documentation of administration. The importance of the three checks and the rights of medication administration cannot be overemphasized. The safe nurse does not allow automatic habits of preparing medications or technology to replace constant thinking, purposeful action, and repeated checking for accuracy. Facility Policy The facility policy Administration of Medication included in pertinent part: .All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnosis. Read each order entirely. Read label three times: when removing from the drawer, before pouring and after pouring. Read and follow any special instructions written on labels . 2. Medication errors a. Resident #21 Licensed practical nurse (LPN) #2 was observed to prepare and administer medications to resident #21 on 12/15/16 at 5:09 p.m. According to the CPO the order read, [MEDICATION NAME] aerosol inhaler 230mcg (microgram)-21mcg/actuation two puffs inhaled twice daily. Rinse mouth with water after use. According to GlaxoSmithKline manufactures recommendations for [MEDICATION NAME]: -Shake the inhaler well for five seconds before each spray. -Wait about 30 seconds before repeating. -[MEDICATION NAME] can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using [MEDICATION NAME] to help reduce your chance of getting thrush. The LPN did not shake the inhaler or have the resident shake the inhaler for at least five seconds before each spray and did not have the resident wait 30 seconds between sprays. The LPN had the resident rinse and spit with lemonade instead of water as per manufactures recommendations and physician's orders [REDACTED].>Interview: Registered nurse (RN) staff development coordinator (SDC) was interviewed on 12/19/16 at 1:10 p.m. She said the nurses should have the resident's rinse and spit after receiving a steroid inhaler with water. She said lemonade was not appropriate to use. She said she had provided education to the nurses on the proper use of insulin pens on 12/16/16 after being notified of the above. b. Resident #47 Licensed practical nurse (LPN) #2 was observed to prepare and administer medications to resident #47 on 12/15/16 at 3:23 p.m. According to the CPO the order read, the resident's order was for [MEDICATION NAME] 0.5mg (milligram)/2ml (milliliter) suspension one [MEDICATION NAME] per nebulizer twice daily. Rinse mouth with water after use. According to AstraZeneca manufactures recommendations for [MEDICATION NAME]: -Always rinse your mouth with water after using this medicine, to help prevent thrush (a fungal infection in the mouth or throat). - If you are using a nebulizer with a face mask, wash the mask area of your face after each use. The LPN did not have the resident rinse with water after using [MEDICATION NAME] as per manufactures recommendations and physician's orders [REDACTED].>c. Resident #125 Licensed practical nurse (LPN) #1 was observed to prepare and administer medications to resident #125 on 12/16/16 at 11:48 a.m. According to the CPO the order read, the resident's order was for [MEDICATION NAME]100units/ml four units subcutaneously (SQ) three times daily before each meal. The LPN screwed on the needle without wiping the rubber [MEDICATION NAME] first and dialed up the ordered dose of four units without priming the needle first. According to the manufacturer's instruction leaflet of information from Novo [MEDICATION NAME] approved by the United States Food and Drug Administration on proper administration of [MEDICATION NAME], April, 2015 stated in pertinent part: Preparing the [MEDICATION NAME] -Pull off the pen cap and wipe the rubber [MEDICATION NAME] with an alcohol swab. Screw the needle tightly onto the [MEDICATION NAME]. -Give an air shot (prime the needle) before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: -Turn the dose selector to two units -Hold the [MEDICATION NAME] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. -Keep the needle pointing upwards; press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. If you do not see a drop of insulin after six times, do not use the [MEDICATION NAME]. Giving the injection -Insert the needle into your skin. -Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer. Be careful only to push the button when injecting. -Keep the needle in the skin for at least six seconds and keep the push-button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given. The LPN administered the insulin to resident # 125 without priming the insulin pen needle and did not keep the needle in the skin for at least six seconds to ensure that the full dose had been given. (Cross reference F333) Interview: Registered nurse (RN) staff development coordinator (SDC) was interviewed on 12/19/16 at 1:10 p.m. She said she had provided education to the nurses on the proper use of insulin pens on 12/16/16 after being notified of the above. d. Resident #83 LPN #6 was observed to prepare and administer medications to resident #83 on 12/19/16 at 3:45 p.m. According to the 11/16 CPO the order read, the resident's order was for [MEDICATION NAME] 4mg by mouth daily. The order was received on 12/19/16 at 3:00 p.m. The LPN administered [MEDICATION NAME] 5 mg instead of the ordered [MEDICATION NAME] 4mg. (Cross reference F333) Interview: LPN #6 was interviewed on 12/20/16 at 8:40 a.m. She said when a order had been received to change the dose of a medication a telephone order should be written, the old dose was yellowed out on the MAR, and then the new order was written in a new box on the MAR. The [MEDICATION NAME] flow sheet was updated, and the pharmacy was notified and the old card of medication was removed from the cart.

Based on observation, interviews and record review, the facility failed to establish and maintain an Infection Control Program designed to help prevent the development and spread of infection and disease. Specifically, --The facility failed to the facility failed to label residents` personal items in shared rooms to prevent cross usage between roommates; and --The facility failed to ensure that oxygen/nebulizer equipment was cleaned and stored in a sanitary manner. The findings included: Professional Reference: The Standards for Environmental Disinfection in Long Term Care facilities, as published by the Centers for Disease Control and Prevention, indicated the following in pertinent part: Regarding use of chemicals: Environmental surfaces (i.e. the resident ' s room and shower room) can be a source of cross contamination in facility outbreaks. Appropriate use of disinfectants on environmental surfaces is a part of prevention of transmission of infections. The use of EPA registered disinfectants must be consistent with the on label instructions for use. The Centers for Disease Control and Management, Guidelines for Disinfection and Sterilization in Healthcare Facilities , (2008), http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf (December 20, 2016) Observations: Personal items On 12/15/16 from 11:26 a.m. to 11:52 a.m. several rooms were observed with unmarked personal items that could cause a bridge in infection control and disease prevention: room [ROOM NUMBER] was observed with an unmarked tooth brush and a shaving razor at the sink. room [ROOM NUMBER] had an unmarked tooth brush at the sink. room [ROOM NUMBER] had an unmarked tooth brush at the sink room [ROOM NUMBER] had an unmarked tooth brush at the sink room [ROOM NUMBER] had an unmarked tooth brush, a hair brush and a bed pan. room [ROOM NUMBER] also had an unmarked hair brush at the sink. These items were unidentifiable as to which of the two residents who shared the room they belonged to. Staff interviews The infection control nurse was interviewed on 12/15/16 at 12:36 p.m. She said her expectation was that all personal items would be marked to distinct what belong to one resident versus the other. She said she was going to discard all the unmarked person items that were found in the residents` rooms. She said moving forward she was going to ensure that the certified nurse aide (CNAs) complied with marking the residents` personal items. She said she would hold an in-service with the CNAs and all the housekeeping staff so everybody was on the same page on infection control measures. 2. Cleaning/Storing of equipment: Facility policy The policy for respiratory medication administration, documented in pertinent part: Correctly disassemble equipment, rinse equipment, dry and place in plastic bag and leave in resident's room to maintain equipment function and to prevent contamination of equipment. Manufacturer recommendations: According to Air Products and Chemicals, Incorporated recommendations containers must be stored, handled and transported in the upright position. When moving, never tip, slide or roll containers on their side. e.g., Safetygram 6, Liquid Oxygen, 2015, www.airproducts.com <http://www.airproducts.com> ([DATE]). Observations The following observations were made on 12/13/16: -At 11:55 a.m. in room [ROOM NUMBER] oxygen tubing was lying on the recliner with the nasal cannula in the seat. The following observations were made on 12/14/16: -At 9:43 a.m. in room [ROOM NUMBER] bed B nebulizer equipment was connected to the machine and had not been rinsed after use and stored. -At 9:45 a.m. in room [ROOM NUMBER] bed B nebulizer equipment was connected to the machine and had not been rinsed after use and stored. -At 4:09 p.m. in room [ROOM NUMBER] bed B nebulizer equipment was connected to the machine and had not been rinsed after use and stored. -At 4:36 p.m. in room [ROOM NUMBER] bed B the B nebulizer equipment was still connected to the machine and had not been rinsed after use and stored. Oxygen tubing was lying across the concentrator with the end connector lying on the floor. The following observations were made on 12/15/16: -At 8:55 a.m. in room [ROOM NUMBER] bed B nebulizer equipment was connected to the machine and had not been rinsed after use and stored. -At 2:05 p.m. in room [ROOM NUMBER] bed B nebulizer equipment was stored in a plastic bag on the nightstand. The following observations were made on 12/16/16: -At 8:35 a.m. in room [ROOM NUMBER] bed B nebulizer equipment was connected to the machine and had not been rinsed after use and stored. -At 8:40 a.m. in room [ROOM NUMBER] a portable oxygen tank was positioned inside the resident's room right inside the door on the floor. -At 10:07 a.m. in room [ROOM NUMBER] a portable oxygen tank was positioned next to bed A on the floor. Oxygen tubing was lying across the bed. The oxygen tubing connector for the C-PAP machine next to bed B was touching the surface of the night stand. -At 10:47 a.m. in room [ROOM NUMBER] a portable tank was positioned inside the resident's room right inside the door on the floor. -At 11:00 a.m. in room [ROOM NUMBER] the oxygen nasal cannula was lying on the seat of a walker. -At 1:37 p.m. in room [ROOM NUMBER] bed B the nebulizer equipment was rinsed and laying on a paper towel. The following observations were made on 12/19/16: -At 10:45 a.m. in room [ROOM NUMBER] bed B nebulizer equipment was connected to the machine and had not been rinsed after use and stored. The following observations were made on 12/20/16: -At 10:25 a.m. in room [ROOM NUMBER] bed B nebulizer equipment was sitting on the bedside table and not stored in a bag. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 12/20/16 at 3:47 p.m. She said oxygen tubing should be folded up and put on the concentrator when not in use. If it touched the ground it should be wiped off. Nebulizer equipment is cleaned with soap and water then put on a paper towel to dry. LPN #1 was interviewed on 12/20/16 at 3:45 p.m. She said oxygen tubing should be placed in bag on the concentrator or portable oxygen. Portable oxygen should not be put on the floor related to infection control. She further stated, nebulizer equipment should be rinsed and placed in a bag after use. The DON was interviewed 12/20/16 at 4:45 p.m. She said oxygen tubing should be kept in bags when not in use. She said nebulizer equipment should be rinsed after each use and stored properly.

Based on observation, record review, and interviews, the facility failed to ensure one (#29) of one evaluated for the use of a restraint out of a total of 44 sampled residents was free from any physical restraints. Specifically, the facility failed to assess the resident for the use of the wedge while the residnt was in bed. The findings included: A. Facility policy The restraint use policy revealed in pertinent part: The need of each resident for restraint use is assessed on admission, at regularly scheduled interdisciplinary care plan conference reviews and as needed .Monthly documentation in clinical notes includes type of restraint, date and time of use, reason for use, and resident tolerance .Restraints are used to prevent unsupervised ambulation of residents with documented impaired and unsafe ambulation skills Resident, family, or responsible person signs the Informed Consent Form for restraint use .The interdisciplinary approved plan for restraint use is outlined in resident care plans and is revised as needed 1. Resident #29 Resident #29, age 91, was admitted on [DATE]. According to the 12/16 computerized physician orders [REDACTED]. According to the 10/10/16 minimum data set (MDS) assessment indicated the resident had cognitive impairments. She required extensive assistance for bed mobility, transfers, and locomotion on and off the unit. The assessment indicated the resident did not use a restraint in bed. Observations 12/13/16 -- At 3 p.m. the resident was observed sitting at the nursing station. The resident ' s room was observed to have a low bed next to the mat against the wall, a mat on the floor, and a wedge cushion standing against the wall. - 12/14/16 -- At 9:19 a.m. the resident was observed sitting at the nursing station. The resident ' s room was observed in the same manner as the previous day. --At 4:48 p.m. the resident was observed in bed with the wedge placed under the mattress on the upper half of the bed 12/15/16 --At 11:30 a.m. the resident was observed in bed with the wedge in place. - At 2:00 p.m. the resident was observed in bed with the wedge in place. --At 3:11 p.m. the resident was observed in bed with the wedge in place. 12/19/16 --At 10:45 a.m. the resident was observed in bed; the wedge was not in place. Record review The falls care plan, initiated on 8/5/15, revealed the resident was at risk for falls related to limited mobility and weakness due to a history of falls. Interventions included refer the resident to therapy per current orders, low bed with a mat to the floor while the resident was in bed, a wedge to the bed while the resident was in bed, and staff to provide assistance when the resident got up and walked throughout the facility. The medical record failed to show that the wedge was assessed as a potential restraint, quarterly reviews of the wedge and a care plan for the wedge. According to the resident/family education assessment and interdisciplinary flow record, nursing staff educated the resident and family on 8/20/15 the resident would be placed on a low bed with a mat and a wedge to the bed related to impaired safety awareness. According to the 12/16 CPO, the medical doctor (MD) gave an order on 7/18/16 for a wedge to bed every shift while the resident was in bed related to a [DIAGNOSES REDACTED]. Interviews Certified nurse aide # 4 (CNA) was interviewed on 12/15/16 at 11:30 a.m. She said the wedge was used while the resident was in bed, because the resident liked to crawl out of bed. CNA #1 was interviewed on 12/15/16 at 4:28 p.m. She said wedge was used for residents who could not use the call light and prevented the residents from crawling out of bed. Registered nurse #1 (RN) was interviewed on 12/16/16 at 1:22 p.m. She said when the resident was first admitted she could get up from the chair and bed and walk by herself. She said the wedge was put into place to keep the resident from falling out of bed. She said she was unsure if the wedge had every been evaluated as a restraint. She said she would classify a restraint as a something a resident could not get out of or get off. She confirmed the resident could not get over the wedge in the residents ' current condition. She confirmed a restraint assessment, a restraint care plan, and a restraint consent were not in the resident's medical record. The physical therapy assistant (PTA) was interviewed on 12/20/16 at 8:24 a.m. She said nursing had referred the resident over the past weekend for a therapy screen to evaluate the use of the wedge while the resident was in bed. She said the resident was unable to get up out of bed on her own with or without the wedge in place. She said she noted a change in the resident ' s ability for transfers, ambulation and bed mobility. She said she recommended the resident begin physical therapy treatment. She said the resident was able to get up out of bed, transfer, and ambulate before the wedge was put into place.

Based on observation, resident interview, record review and staff interview, the facility failed to ensure a resident's accommodation of needs were meet. Specifically, the facility failed to monitor the positioning of a transfer pole to accommodate the needs of one (#31) of 44 totlal sampled residents. The findings included: A. Resident status Resident #31, age 76, was admitted on [DATE]. According to the 12/16 computerized physician orders, [DIAGNOSES REDACTED]. According to the 10/7/16 minimum data set (MDS) assessment, the resident's short and long term memory was okay but a brief interview for mental status was not done. No mood or behaviors documented for the resident who had a depression score of zero. She required extensive assistance with one person assist with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Record review and interviews revealed the resident had a [DIAGNOSES REDACTED]. B. Facility Failure The transfer pole was observed to be positioned on the resident's post stroke affected right side, until it was brought to the staff members' attention the resident had great difficulty reaching it with her non-affected left side, by reaching across her body to utilize it to assist with her transfers. C. Resident observations On 12/13/16 at 11:30 a.m. the resident was sleeping in her recliner and the transfer pole was on the right side her chair which was her stroke affected side. On 12/14/16 at 8:46 a.m. the resident was sleeping in her recliner and the transfer pole was on the right side of her chair which was her stroke affected side. On 12/15/16 at 9:42 a.m. the resident was sleeping in her recliner and the transfer pole was on the right side of her chair which was her stoke affected side. On 12/15/16 at 1:20 p.m. the resident was assisted by certified nurse aide (CNA) #3 from her recliner to her wheelchair. At this time the resident's transfer pole was on the left side of the recliner, her non affected side, and the resident used her left hand to grab the transfer pole to assist the CNA with her own transfer. D. Resident interview On 12/15/16 at 1:45 p.m. the resident was waiting in her wheelchair with clothes on her lap. When asked if she was waiting to get dressed she nodded her head yes. When asked if she could move her right arm she shook her head no. When asked if she could move her left side she lifted her left arm without difficulty. When asked if she liked her transfer pole on the left side of her chair she nodded yes, and shook her head no when asked if she liked the transfer pole on the right side of her chair. E. Record review On 12/20/16 at 3:00 p.m. the director of nursing provided a document titled Transfer Pole, dated 5/29/14 and last updated on 8/16/16, which included the following: Patient deems this transfer pole is necessary for quality of life for this resident for the following reasons: 1. It helps patient with rolling side to side, from supine to sit on edge of bed increasing level of independence and safety. 2. It increases safety with bed to wheelchair and wheelchair to bed transfers. (Resident is currently sleeping in a recliner; she has no actual bed in her room there for the recliner is now her bed.) -Quarterly comprehensive rehab screens have been done to indicate the residents need for the transfer pole. Fall Risk Assessment: According to the 8/13/16 fall risk evaluation, the resident scored 16. Any resident with a score of 10 or higher was at risk and the staff should consider environmental risk factors in the resident's interventions. Care Plan/Care Conference: According to the care plan, initiated on 1/29/12 and last updated on 10/12/16, the resident was at risk for activities of daily living (ADLs) deficit related to weakness, limited mobility, pain secondary to [MEDICAL CONDITION] disease with right sided [MEDICAL CONDITIONS] and can't make needs known. Interventions included: encourage resident to use transfer pole by bedside and to assist resident with ADLs as needed. -The resident was at risk for falls related to weakness, limited mobility secondary to post [MEDICAL CONDITION] disease, right [MEDICAL CONDITION]. Interventions included: encourage resident to use transfer pole by bedside; anti-skid strips to bedside; resident to use proper footwear for all transfers; resident to work with therapy with transfer pole at recliner side. -According to the 10/20/16 care plan meeting the resident was documented to need one-to-two person staff assistance with ADLs and transfers. Therapy Notes: The director of nursing (DON) provided a copy of two documents entitled Therapy multidisciplinary screening form. One was dated 12/15/16 and time stamped at 12:57 p.m., and documented the following information: Res on speech for communication. Physical therapist reports that she wears splint at night and sometimes during the day. No change in range of motion (ROM). Able to complete self-passive range of motion (PROM). Patient had room rearranged in past few weeks. Moved pole to better place to facilitate transfers. (This notation was made in the resident's chart before the therapy director was interviewed regarding the position of the resident's transfer pole - see below.) The second therapy multidisciplinary screening form, added to the resident chart after the therapy director (DRS) was interviewed, was dated 12/15/16 and time stamped at 2:51 p.m. The following information was documented, Educated patient that although she can transfer without pole and with pole on the left of her chair (strong side getting in recliner, weak getting out). It is optimum on the right because chair is lower than recliner and she could benefit from using it to stand. This additional statement contradicted staff and resident interviews regarding the positon of the transfer pole. F. Staff interviews Registered nurse (RN) #1 was interviewed on 12/15/16 at 9:41 a.m. When asked about the transfer pole being on the right side of the resident, she said the resident will sit at the edge of her recliner and try to use her left hand, reaching across her body to grab it, with one staff member to assist her to stand or transfer. When asked if the transfer pole is utilized for residents on their post stroke side she said normally no. She said her transfer pole was on her left side before she had her furniture moved in her room. When asked if this is the best position for the resident's transfer pole she said no, but staff help her. The director of rehabilitation services (DRS) was interviewed on 12/15/16 at 1:50 p.m. She said the resident had [MEDICAL CONDITION] affected her right side. She said the resident did utilize a transfer pole and a palm roll for accommodation of her needs. She said depending on how a resident would transfer is where the transfer pole would be positioned. She said the resident transfer pole for her was on her left side originally, but the furniture was moved in her room and she was not notified by the staff when the furniture was moved in the resident's room. She was unaware of when the resident's furniture was moved, and did not realize the resident's accommodations were no longer assisting her appropriately according to her past therapy screens. The DRS acknowledged the pole had been on the resident's stroke affected side which she could not use. Certified nurse aide (CNA) #1 was interviewed on 12/16/16 at 10:56 a.m. She said the resident's transfer pole is positioned on her left side because her right side was her side of her body that was affected by the stoke. She confirmed the resident could not use her right side of her body for transfers. The DON was interviewed on 12/20/16 at 1:17 p.m. When asked what side the adaptive equipment would go on for a resident who was post stroke, she said it would not go on the affected side.

Based on observation, record review and interviews the facility failed to ensure that three (#61, #11 and #29) out four out of 44 total sampled residents received an ongoing program of activities designed to meet the needs in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The findings included: 1. Resident #61 Resident #61, age 103, was admitted on [DATE]. According to the 12/16 computerized physician order [REDACTED]. According to the 10/7/16 minimum data set (MDS) assessment, the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 10/15. She had clear speech and was able to comprehend most conversations. The resident had moderate difficulty with hearing and moderately impaired vision. The resident required extensive assistance with one-person physical assistance with activities of daily living (ADL) and locomotion on and off the unit, and supervision with one-person physical assistance with walking in the corridor. Resident interview Resident #61 was interviewed on 12/15/16 at 2:10 p.m. She said she has always liked BINGO and would love to go but she is too old to walk to the activity and back to her room. The resident said she would go to activities but she is not ever taken to the activity and is left at the activity when it is over because staff do not take her back to her room. She said this had made her not want to attend activities any longer. She said she feels neglected by the staff and said she doesn't bother to ask to go to activities anymore. Observation On 12/16/16, the following continuous observations were made from 8:30 a.m. through 9:46 a.m.: - At 8:30 a.m., the resident was observed to be in her room with the door open. The resident was sitting in her recliner with no meaningful activity occurring. - At 9:46 a.m. the resident was observed to be in her room with the door open. The resident was sitting in her recliner, watching television. - Activity staff were observed, during the continuous observation, to enter three resident rooms and invite some residents to the 9:30 a.m. fun and fit activity. No staff member entered resident #61 room or invited her to activities. On 12/19/16, the following continuous observations were made from 1:00 p.m. through 2:05 p.m. - At 1:56 p.m. a certified nurse aide (CNA) was observed inviting a resident to attend the singing performance activity in the dining room. - At 1:58 p.m. a resident sitting at the nursing station looked at his watch, got up, and walked to the dining room for the activity. No staff member was observed reminding or inviting the resident to the group activity. - At 1:50 p.m. an activity assistant and the activity director (AD) were observed walking down the hallway to invite a resident to the group activity. They did not enter resident #61 room. - At 2:01 the group activity was observed to have begun. Resident #61 was observed sitting in her room in her recliner watching television. No staff had entered the residents room to invite or escort her to the group activity. Record review The activities care plan, last updated on 7/6/16, indicated the resident would attend activities in the past such as BINGO. The goal was for the resident to attend one to two group activities per week. The approaches included: staff would assist as needed to group activities, staff would initiate interaction with the resident, staff will offer one to one visits, and offer large printed items to the resident. The psychosocial care plan, initiated on 10/14/13, indicated the resident was at risk for self-isolation and the resident felt she was not able to walk like she used to. The goal was for the resident to show no signs and symptoms of loneliness or boredom. The approaches included: one to one as needed and to invite, encourage and escort the resident to activities of her choice as needed. The 12/16 daily activity participation flow sheet indicated the resident was offered to attend the group activity and refused on both 12/16/16 and 12/19/16. During a continuous observation on both dates, no activity staff or facility staff were observed entering the residents room to invite her to group activities. The 12/16 record of one to one activities revealed the resident had two one to one visits; on 12/2/16 and 12/15/16. The 12/2/16 visit indicated the one to one visit was in the hallway and the activity assistant assisted the resident to her room; 5 minutes spent with the resident were documented. The 12/15/16 visit indicated the one to one was in the resident's room while the resident's daughter was visiting; 10 minutes spent with the resident were documented. No other months of one to one visits were provided by the end of the survey. Staff interview The AD was interviewed on 12/19/16 at 4:28 p.m. She said she was not aware the resident no longer wanted to attend activities because staff would not take her to the activity or back to her room after the activity. She said the activity staff has to set up the dining room following an activity and felt that cut into the time the staff have to spend with the residents. She said the resident should be receiving one to one activities and she considered a one to one activity to be 20 minutes in length. She said if the one to one was less than 20 minutes then it would not be considered a one to one. She said the goal of one to one activities is to integrate residents into attending group activities. She presented the daily participation log and said the activity staff should not be documenting refused when a resident was not offered to attend an activity. 2. Resident #29 Resident #29, age 91, was admitted on [DATE]. According to the 12/16 computerized physician orders [REDACTED]. According to the 10/10/16 minimum data set (MDS) assessment, a staff assessment for cognition had to be completed due to the resident's severe cognitive impairment. The staff assessment indicated she had both short term and long term memory impairment. She required extensive assistance for bed mobility, transfers, and locomotion on and off the unit. The assessment indicated the resident did not exhibit socially inappropriate behaviors. Observations On 12/15/16, the following observations were made from 9:00 a.m. through 11:01 a.m.: - At 9:00 a.m., resident #29 was observed sitting with three other residents at the nurses station. No meaningful activities were provided to any of the residents. - At 9:07 a.m., resident #29 was observed to be sleeping at the nurses station. - At 9:24 a.m., resident #29 was observed to wake up at the nurses station. The resident was offered a cup of water by a certified nurses aide (CNA). No meaningful activities were provided to the resident. - At 9:44 a.m., resident #29 and five other residents were observed still sitting at the nurses station with no meaningful activities provided. - At 10:47 a.m., the resident was observed in the activity room during the BINGO activity asleep. - At 10:49 a.m., the resident was observed to wake up during the activity. The resident did not have a BINGO card in front of her. The resident was looking at another residents BINGO card and watching other residents participate in the activity. - At 10:54 a.m., the resident fell asleep during the BINGO activity. - At 10:58 a.m., the activity ended. The resident was observed to still be asleep and was not interacted with by staff during the activity. - At 11:01 a.m. the activity assistant assisted the resident from the activity room to the nurses station and did not provide the resident with any meaningful activity. Record review The activities care plan, initiated on 8/5/15, indicated the resident had an alteration of activities related to a [DIAGNOSES REDACTED]. The goal was for the resident to attend three group activities per week. The approaches included: staff would escort the resident to group activities, staff would offer one to one visits, and staff would provide a CD player and music for the resident to listen to. The record of one to one activities revealed the staff had completed one to one visits on the following dates: 1/13/16 - no amount of time documented, 1/18/16 - no amount of time documented, 11/21/16 - indicated 20 minutes spent with the resident, 12/12/16 - indicated 15 minutes spent with the resident, and 12/15/16 - indicated 10 minutes spent with the resident. The facility was unable to provide documentation of one to one visits with the resident from 2/16 to 10/16. Staff interviews The activity director (AD) was interviewed on 12/16/16 at 4:28 p.m. She said during the activity BINGO, all residents should be given their own personal BINGO card. She said the activity staff should have provided a BINGO card for the resident. She said she did not have enough staff to sit next to the resident to ensure the resident could have the full experience of the activity. She said the resident would benefit from someone sitting next to her and assisting her during the activity. 3. Resident # 11, age 98, was admitted on [DATE]. According to the 12/16 computerized physician orders, [DIAGNOSES REDACTED]. According to the 10/14/16 minimum data set (MDS) assessment, the resident had severely impaired cognitive skills with a BIMs score of three out of 15. She had little interest or pleasure in doing things, feeling down, depressed or hopeless several days during the assessment period. She felt bad about herself, that she was a failure or have let herself or her family down more than half of the days during the assessment period. The care plan identified the resident as being accepting of her need to be at the facility. She stated an interest in a variety of activities and is able to choose which groups to attend. She does not prefer group activities or to leave her room. One to one visits needed. She may have some limitations related to lower mobility, and impaired cognition. Interventions included: -Staff would invite and assist to group activities of stated or potential interest such as card games, music groups; -Provide materials for independent use such as books to read as needed; -Provide opportunities to socialize with other residents such as coffee club invitations; and -Introduce resident to other residents with similar interests as needed/able. Record review According to the quarterly social service progress note on 7/6/16 the resident was alert and oriented and able to make her needs known. She spent her time resting in her room, or socializing with staff/peers in the hallway by her room. She also enjoyed manicures/getting her nails done. She was limited by low mobility and low hearing, which may have hindered activity participation. No other concerns at that time. According to the quarterly social service progress note on 10/10/16 the resident preferred to spend most of her day in her room resting. She stated she just wanted to die because there was nothing for her to do. Talked to her about attending activities she said no she tried them before. The note further documented the resident was offered counseling or a chaplain to visit, and she stated she did not want to try that. She said she was content where she was. She did state that she would like it if her family visited her more often, According to the quarterly activity progress note on 10/18/16, the resident was alert and oriented and able to make her needs known. She preferred to spend her time in her room, resting in her chair. She did not attend group activities. She preferred one to one visits. Family lives close and was able to visit often. No other concerns at that time. According to the social service progress note on 11/1/16, the resident stated that she was bored but did not want to get up to attend activities. She preferred to spend most of her day in her room resting between meals. She liked to people watch from her recliner. According to the social services note on 11/15/16, the resident seemed to be sleeping more during the day than at night. Encouraged her to attend activities but she had very little to no interest in going to them. According to the one to one activity record it documented one to one visits on 2/12/16 for ten minutes, 4/20/16 for 40 minutes, 6/10/16 for 15 minutes, 7/6/16 for 45 minutes, 12/3/16 for 20 minutes, 12/14/16 for 30 minutes and 12/17/16 for 20 minutes. According to the record of one-to-one activities documentation on 12/14/16 a one to one was done in the resident's room for 30 minutes. The resident's response was documented as She loves to visit! According to the daily activity participation flow sheet for 12/16 the resident was documented as being involved in one to one activity 8 times in 19 days. These consisted of conversation and visitors. No refusals for one to one visits were documented. Manicures/having nails polished were not documented as being done or offered even though she enjoyed this. According to the daily activity participation flow sheet for 11/16 the resident was documented as being involved in one to one activity ten times in 30 days. These consisted of conversation and visitors. No refusals for one to one visits were documented. Manicures/having nails polished were not documented as being done or offered even though she enjoyed this. According to the daily activity participation flow sheet for 10/16 the resident was documented as being involved in one to one activity seven times in 31 days. These consisted of conversation and visitors. No refusals for one to one visits were documented. Manicures/having nails polished were not documented as being done or offered even though she enjoyed this. Observations 12/14 16 --At 8:30 a.m. the resident was sitting in her recliner in her room wide awake with no music or TV on. --At 3:52 p.m. the resident was sitting in her recliner in her room wide awake. At 3:54p.m. the activity assistant came into room and was talking to resident about her nails. She was in the room less than five minutes. She told the resident she would be right back. --At 4:24 p.m. no one ever returned to resident's room. 12/15/16 --At 8:50 a.m. the resident was sitting in her recliner in her room wide awake with no music or TV on. --At 2:00 p.m. the resident was sitting in her recliner in her room wide awake with no music or TV on and the door partially closed to where she could not watch people in the hallway. 12/16/16 --At 8:35 a.m. the resident was sitting in her recliner in her room wide awake with no music or TV on. --At 10:11 a.m. the resident was sitting in her recliner in her room wide awake with no music or TV on. --At 1:37 p.m. the resident was sitting in her recliner in her room wide awake with no music or TV on and the door partially closed to where she could not watch people in the hallway. 12/19/16 --At 10:40 a.m. the resident was sitting in her recliner in her room wide awake with no music or TV on and the door partially closed to where she could not watch people in the hallway. 12/20/16 --At 10:25 a.m. the resident was sitting in her recliner in her room wide awake with no music or TV on. Staff interviews The activity director was interviewed on 12/19/16 at approximately 3:45 p.m She said the resident was difficult to get to come to activities. She said the frequency of the resident's one to one visits was as needed. She said she would greet her every day since her office was across the hallway. She agreed that her socialization needs were probably not being met.

Based on observations, record review and staff interviews the facility failed to ensure professional standards of practice were followed for three (#47, #69 and #36) of 44 total sample residents. Specifically, the facility failed to: -Follow orders to discontinue a medication for resident #47; -Write an order for [REDACTED].# 36; and -Follow orders to administer a narcotic and sign out a narcotic in a timely manner for resident # 69. The findings included: Professional Reference According to Lippincott, Fundamentals of Nursing, The Art and Science of Nursing Care, 7th edition, 2014, Nurses are legally responsible for carrying out the order of the physician . According to Fundamentals of Nursing by Lippincott Williams &Wilkins, 8th Edition (copyright 2011), page 794: Three Checks and the Rights of Medication Administration -The nurse observes the three checks and the rights of medications to ensure medications are being administered safely. The use of technology such as bar cod labeling and medication administration, does not remove from the nurse the primary responsibility for assuring safe medication administration. -The label on the medication package or container should be checked three times during medication preparation and administration. The label should be read: 1. When the nurse reaches for the container or unit dose package; 2. After retrieval from the drawer and compared with the MAR (medication administration record), or compared with the MAR immediately before pouting from a multi-dose container and 3. When replacing the container to the drawer/shelf or before giving the unit dose medication to the patient. The rights of medication administration help to ensure accuracy when administering medications. The nurse ensures that the (1) right medication is given to the (2) right patient in the (3) right dosage through the (4) right route at the (5) right time. Additional rights have been suggested to include ensuring (6) the right reason and (7) the right documentation. Validating the right reason requires the nurse to understand the rationale for administration and answer the question, Does it make sense? The right documentation refers to accurate and timely documentation of administration. The importance of the three checks and the rights of medication administration cannot be overemphasized. The safe nurse does not allow automatic habits of preparing medications or technology to replace constant thinking, purposeful action, and repeated checking for accuracy. According to Wanda Lockwood, RN, BA, MA, Narcotic Drugs: Handling and Documentation, 2015, www.rn.org <http://www.rn.org> ([DATE]), When administering a controlled substance, documentation should include: patient name, medication, dosage, route and time. This information should be recorded immediately after administration and not at a later time or at the end of the shift. In automated systems, this information is recorder when the drugs are removed, so they should be administered promptly so that the recorded time is accurate. If there is a delay between the times the medication is given, then the next dose may be given too soon. Facility policy On 12/19/16 the director of nursing (DON) provided the facility's policy and procedure on controlled drugs, not dated, which included in pertinent part: A 'controlled drugs proof of use sheet' is accurately maintained on all residents requiring controlled medications. Strict control of narcotics is always maintained. A physician order [REDACTED]. Licensed personnel administer controlled drugs. Appropriate storage, recording, and use of controlled drugs are maintained on all units. Narcotic proof of use sheet is accurately maintained on residents requiring such medication. 1. Resident # 47, age 88, was admitted on [DATE]. According to the 12/16 computerized physician orders [REDACTED]. According to the 10/9/16 minimum data set (MDS) assessment, the resident had moderately impaired cognitive skills with a brief interview for mental status (BIMS) score of 12out of 15. Record review According to the 12/16 CPO the resident had orders for Tamsulosin 0.4milligram (mg) by mouth daily. According to a telephone order written on 12/12/16 at 2:20 p.m. the Tamsulosin was to be discontinued. According to 12/12/16 nursing progress note, the resident had a Urology appointment and new orders were received to discontinue the Tamsulosin. The resident and family were notified. According to the 12/16 MAR, the Tamsulosin was initialed, indicating that it was given daily, until 12/19/16 instead of being discontinued on 12/12/16 as ordered. 2. Resident #36, age 103, was admitted on [DATE]. According to the 12/16 CPO, [DIAGNOSES REDACTED]. According to the 9/11/16 MDS assessment, the resident had moderately impaired cognitive skills with a BIMs score of eight out of 15. The care plan identified the resident being at risk for impaired skin integrity; last revised 10/20/16. Interventions included: -Weekly skin assessments; -staff not to dress resident in the bathroom; -re-approach resident when she is upset. Record review According to nursing progress note 10/20/16 at 1:15 p.m. the resident was noted to have a skin tear to the back of her left hand about one centimeter (cm) circular and bruising to both forearms. She got upset with staff members as they were performing cares and began swinging her arms around. Resident is unable to report what she hit herself on and the staff that was performing cares is also unable to report what caused the injuries. Skin tear site was cleansed with wound cleanser; triple anti-biotic ointment was applied, and covered with [MEDICATION NAME]. No drainage was noted. Resident denied pain at site. Sites of bruising with skin intact, purple in color, no pain reported. Physician was notified at 9:00 a.m. No orders were received. Resident's friend was notified at 1:00 p.m. No order was found in the resident's record for the above treatment to the skin tear. According to the nursing progress note 10/24/16 at 1:44 p.m. Assessment was completed. No report of discomfort related to bruising or skin tear. Skin tear has steri-strips in place, no indication of infection. There was no documentation in the resident's record for an order for [REDACTED]. 3.Resident # 69, age 87, was admitted on [DATE]. According to the 12/16 CPO, [DIAGNOSES REDACTED]. According to the 11/17/16 MDS assessment, the resident had no cognitive impairment with a BIMs score of 14 out of 15. Record review: According to the 12/16 CPO, the resident had orders for [MEDICATION NAME] 100 mg by mouth twice a day. According to the 12/16 MAR, the [MEDICATION NAME] was initialed as being given on 12/15/16 at 9:00 a.m. According to the controlled drugs proof of use sheet for the resident's [MEDICATION NAME], the medication was signed out for 12/15/16 at 8:00a.m. Then it was crossed out indicating the resident did not receive the [MEDICATION NAME] as ordered. There was no documentation in the resident's chart as to why the resident did not receive this medication as ordered. Observation On 12/19/16 at 11:35 a.m. the controlled drugs proof of use sheet for the resident's [MEDICATION NAME] was compared to the actual medication card and the number of pills did not match. Registered nurse (RN) #6 said he had given a pill at 9:00 a.m. but did not sign it out at that time. This discrepancy in the narcotic count was witnessed by the RN staff development coordinator (SDC). Staff Interviews RN#6 was interviewed on 12/19/16 at 11:35 a.m. he said that he always signs out the narcotics before he even initials it on the MAR and did not realize he had not signed the [MEDICATION NAME] out. He said he must have gotten distracted at that moment. The SDC was interviewed on 12/19/16 at 11:35 a.m. she said narcotics should be signed out when they are given. Licensed practical nurse (LPN) # 2 was interviewed on 12/15/16 at 3:33 p.m. he said the facility has standing orders for skin tears that were kept in a binder at the nurse's desk. He said a telephone order should be written then the order would be put into the computer, written on the current CPO and then on the treatment administration record (TAR). The physician should be notified that a standing order was started. The family should be notified and follow up documentation done if required. RN #3 was interviewed on 12/15/16 at 4:15p.m. She said a telephone order should be written for any standing orders that are started. The DON was interviewed on 12/20/16 at 12:50p.m. She said a telephone order should be written for any treatment that was done. The DON was interviewed again on 12/20/16 at 4:45 p.m. She was notified of resident #47 receiving the Tamsulosin for seven more days after it was supposed to be discontinued. She said when an order is received to discontinue the medication, it should be discontinued on the MAR immediately and the medication card should be pulled from the cart. She said if the medication was not stopped when ordered and the resident continued to receive the medication, a medication error report should be started as soon as it was realized. She said a medication error report would be started at that time for the Tamsulosin. She also said narcotics should be signed out after the medication was administered and agreed that it needed to be in a timely manner. She said the only reason a medication would be crossed out on the controlled drugs proof of use sheet would be if the nurse accidently signed out on the wrong sheet. She agreed the resident missed one dose of [MEDICATION NAME] on 12/15/16 and said a medication error report would be started on the error at that time also.

Based on observations, record review and interviews, the facility failed to provide one (#29) of four out of 44 sampled residents the necessary services to ensure the resident ' s abilities in mobility (ambulation) did not diminish. The findings included: 1. Resident #29, age 91, was admitted on [DATE]. According to the 12/16 computerized physician orders [REDACTED]. According to the 10/10/16 minimum data set (MDS) assessment, the resident had both short-term and long-term memory impairment and moderately impaired decision making skills and requiring cues and supervision. She required extensive assistance for bed mobility and transfers with two-person physical assistance. 2. Observations --12/13/16 at 11:31 a.m. the resident was observed being assisted in her wheelchair into the dining room for lunch. --12/13/16 at 5:17 p.m. the resident was observed in bed with a wedge in place. The wedge was observed to be approximately 12 inches in height, placed underneath the mattress of the bed located on the top half of the bed. --12/16/16 at 11:10 a.m. the resident was observed being pushed in her wheelchair into the dining room for lunch. --12/15/16 at 11:30 a.m. the resident was observed in bed with the wedge in place. Two certified nurse aides (CNA) were observed entering the resident ' s room and attempted to get the resident up for lunch. The resident refused to get up out of bed. --12/15/16 at 2:00 p.m. the resident was observed in bed with the wedge in place. --12/15/16 at 3:11 p.m. the resident was observed in bed with the wedge in place. --12/15/16 at 4:28 p.m. the resident was observed in bed with the wedge in place. Two CNAs were observed entering the resident ' s room to get the resident out of bed. The resident said she wanted to continue sleeping and not get up out of bed. --12/19/16 at 5:18 p.m. the resident was observed being pushed in her wheelchair into the dining room for dinner. 3. Resident ' s mobility status on admission to early 2016 The activities of daily living (ADL) care plan, initiated on 8/5/15, revealed the resident was at risk for ADL deficit. However, the care plan, revised on 2/1/16, revealed the resident was capable of getting up out of chairs and walking throughout the facility. No approaches were indicated to assist the resident with walking throughout the facility other than stand by assistance. The CNA monthly flow sheets from 11/15 to 1/16 revealed the resident ambulated in the hallway and in her room daily with either staff supervision or with some physical assistance. 4. Falls and decline in ambulation Falls: The medical record indicated the resident fell five times from 12/15 to 6/16. Interventions to prevent additional falls included, per care plan, therapy per current orders, low bed with a mat to the floor while the resident was in bed, a thick, approximately 12-inch wedge cushion to the bed while the resident was in bed, and staff to provide assistance when the resident got up and walked throughout the facility. In addition, per a 12/29/15 nursing progress note, the resident was placed on the restorative program for two to three weeks to maintain the resident ' s functional mobility. The program consisted of sitting on the edge of the mat, balloon and ball toss, hand held walking, and the activity of folding towels. The program was discontinued 1/29/16 as the resident had reached maximum potential but she was to continue on a ' walk to dine ' program. Decline: Although a 1/27/16 rehabilitation post fall screening tool indicated the resident had no change in bed mobility, transfers, and ambulation, and revealed the resident was able to get herself up out of bed, the 3/7/16 rehabilitation screen noted the resident did not walk anymore. Review of the CNA monthly flow sheets from 2/16 to 11/16 confirmed resident ambulated only sporadically in the hallway and room. The flow sheets also indicated the activity did not occur on the majority of days throughout these months. The activity did occur the following times: - 2/16: walk in hallway: 17/29 days, walk in room: 24/29 days - 3/16: walk in hallway: 17/31 days, walk in room: 9/31 - 4/16: walk in hallway: 3/30, walk in room: 16/30 - 5/16: walk in hallway: 4/31, walk in room: 19/31 - 6/16: walk in hallway: 4/30, walk in room: 9/30 - 7/16: walk in hallway: 9/31, walk in room: 15/31 - 8/16: walk in hallway: 12/31, walk in room: 18/31 - 9/16: walk in hallway: 2/30, walk in room: 13/30 - 10/16: walk in hallway: 3/31, walk in room: 18/31 - 11/16: walk in hallway: 2/30, walk in room: 12/30 Review of nursing monthly summaries, likewise, showed a decline in the resident ' s ambulation. --6/5/16 monthly nursing summary revealed the resident needed assistance with walking and walked for brief periods of time with the use of a walker. --9/5/16 monthly nursing summary revealed the resident required extensive assistance of one person with ambulation. --10/5/16 monthly nursing summary revealed the resident required total assistance of one person with ambulation. --12/5/16 monthly nursing summary revealed the resident required limited assistance of two people with ambulation. 5. Failure to put interventions in place to maintain and promote resident #29 ' s mobility. See above; the resident ' s restorative program ended 1/29/16. Record review revealed no attempts to restart the program when staff documented the resident ' s decline in mobility. Moreover, while the plan in 1/29/16 was for the resident to continue on a ' walk to dine ' program, the facility had no evidence such a program was implemented. See observations and care plan above; the resident had a wedge cushion while in bed which limited her mobility. There was no accompanying assessment to show the wedge was applied as the least restrictive device and for the least amount of time in order not to limit the resident ' s mobility. Cross refer F221. Finally, the facility was unable to provide documentation of a rehabilitation screen after 3/27/16 to address the decline in ambulation noted in the CNA flow sheets and monthly nursing summaries. 6. Record review and staff interview confirmed facility knowledge of and failure to timely respond to the resident ' s decline in mobility. Record review: The facility provided a therapy screening form on 12/19/16, completed on 12/17/16 (during survey). The therapy screening form revealed the resident had a recent change in bed mobility, transfers, and ambulation. The physical therapy assistant (PTA) identified the resident was unable to get up out of bed by herself and required the assistance of one person. The PTA recommended the wedge be discontinued and pursue physical therapy treatment. Interviews: Registered nurse #2 (RN) was interviewed on 12/19/16 at 1:18 p.m. She said the resident used to be able to walk throughout the facility but currently was only able to at times. She said she had requested a therapy screen for the past weekend to determine if the use of the wedge in the bed was still needed. She said she discussed it with therapy and it was determined the resident no longer needed the wedge while in bed. The director of rehab services was interviewed on 12/19/16 at 3:45 p.m. She said a resident should be referred for a rehabilitation screen if there was a change in the resident ' s condition or if staff had a concern regarding the resident ' s mobility, positioning, and safety. She said all residents should be reviewed quarterly based off the MDS schedule. She did not indicate resident #29 had been referred since 3/7/16 or that the decline documented at that time had been addressed. The staff development coordinator was interviewed on 12/19/16 at 3:55 p.m. She said staff should report a change in condition of a resident through the stop and watch program, although interview with two CNAs (#7 and #8) at 4:05 p.m. revealed they were unfamiliar with this program. She said all staff should fill out the form indicating which area the staff member has noticed a decline and give it to the nurse. She said the nurse will then initiate an assessment, call the doctor and family. She said from the assessment, the nurse would initiate a therapy screen. The physical therapy assistant (PTA) was interviewed on 12/20/16 at 8:24 a.m. She said the resident was able to get up out of bed, transfer, and ambulate before the wedge was put into place. The PTA said nursing had referred the resident over the past weekend for a therapy screen to evaluate the use of the wedge while the resident was in bed. She said the assessment revealed the resident was unable to get up out of bed on her own with or without the wedge in place. She said she noted a change in the resident ' s ability for transfers, ambulation and bed mobility. She said she recommended the resident begin physical therapy treatment. The unit manager was interviewed on 12/20/16 at 9:00 a.m. She said residents were put onto the restorative program to maintain their current functional level. She said the resident was on the restorative program for hand held walking, sit on the edge of the mat, ball/balloon toss, and folding towels two to three times per week. She confirmed the resident was taken off the restorative program on 1/29/16 and was never put back onto the restorative program. The 1/29/16 nursing progress noted revealed the resident had reached her maximum potential related to her impaired cognition. CNA #4 was interviewed on 12/20/16 at 9:09 a.m. She said she had worked with the resident since the resident was admitted to the facility. She said last year and earlier in 2016, the resident was able to walk throughout the hallways. She said the resident was now was only able to walk a few steps to get into her wheelchair with assistance. She said staff try and keep the resident in the wheelchair now because it keeps the resident more safe.

Based on observation, record review and staff interview, the facility failed to ensure two (#31 and #115) of 35 sample residents, who were unable to carry out activities of daily living (ADLs), received the necessary services to maintain good oral hygiene. Specifically, the facility failed to consistently provide oral care, denture care and assistance to wear dentures for residents #31 and #115. The findings included: I. Facility Policy The facility's oral hygiene policy, provided by the interim nursing home administrator on 12/20/16 at 12:46 p.m., included the following information: Purpose is to cleanse and freshen the resident's mouth, clean the resident's teeth, and decrease the risk of infections within the mouth. -Key procedural points: provide dental care before breakfast and at bedtime. Instruct the resident to rinse his/her mouth out after each meal . -Reporting procedures: the certified nurse aide (CNA) must report the following information to the staff/charge nurse - if the resident refused the procedure and why . II. Resident #31 A. Resident status Resident #31, age 76, was admitted on [DATE]. According to the 12/16 computerized physician orders [REDACTED]. According to the 10/7/16 minimum data set (MDS) assessment, the resident's short and long term memory was okay, but a brief interview for mental status was not done. No mood or behavioral symptoms were documented. She required extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. B. Resident observations Observation and medical record review revealed the resident had a [DIAGNOSES REDACTED]. She generally responded to questions with yes or no answers. On 12/13/16 she was sleeping in her recliner at 11:30 a.m. with her upper dentures in her mouth. She was sleeping with her mouth open and a yellowish pasty substance was seen on the front of her teeth. -According to review of the meal intake log, the resident did not eat breakfast this day and had not had lunch yet to explain why her dentures were dirty and still in her mouth. On 12/14/16 at 8:36 a.m. the resident was in her recliner with her eyes closed. She responded to verbal stimuli when asked if she ate breakfast yet, and she said no. Her upper dentures were in place. When asked where her bottom denture plate was, she pointed to the sink. Her bottom dentures were in a pink denture cup at the sink. At this time her top dentures in her mouth had a yellowish pasty substance on the surface of the teeth and the corners of her mouth contained the same substance. -Review of the meal intake log confirmed the resident's statement that she had not eaten breakfast. On 12/15/16 at 8:45 a.m. the resident was seen again with her upper dentures in her mouth while sleeping in her recliner. -The intake log revealed the resident did not eat breakfast. On 12/15/16 at 1:45 p.m., after registered nurse (RN) #1 was interviewed, see below, the resident's upper and lower teeth were observed in the pink denture cup at the sink. C. Record review According to the care plan, initiated on 1/29/12 and last updated on 10/21/16, the resident was at risk for problems with her mouth or teeth related to no natural teeth. The resident had upper and lower dentures. No problems with dentures were noted. The intervention was for staff to assist with oral care twice a day and as needed. The care plan further identified a risk for activities of daily living deficit related to weakness, limited mobility, and [MEDICAL CONDITION] disease with right sided [MEDICAL CONDITION]. An intervention for dental was for the staff to encourage and assist with oral care twice a day and as needed. Documentation of any resident refusal of activities of daily living assistance was requested from the director of nursing (DON) on 12/15/16. One notation was provided of the resident refusing breakfast on 12/15/16, documented by RN #1. See meal intake record documentation under resident observations above. D. Staff interviews RN #1 was interviewed on 12/15/16 at 9:41 a.m. She said the resident refused breakfast this morning. The resident liked to get up late because she stayed up really late with another resident watching television. She confirmed the resident had her upper dentures in her mouth and the lower dentures were in the pink denture cup on the sink. CNA #1 was interviewed on 12/16/16 at 11:05 a.m. She said she normally worked on the evening shift with this resident and she would take out her dentures at night (both the top and bottom) and put them in the pink denture cup to soak with a denture tablet. When she was asked if she came in to work a morning shift and noticed the resident had their dentures left in from the night before, would she take them out and clean them, she said yes. III. Resident #115 A. Resident Status Resident #115, age 65, was admitted on [DATE] and readmitted on [DATE]. Medical record review revealed [DIAGNOSES REDACTED]. According to the 12/13/6 MDS assessment, the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. She required extensive assistance for bed mobility, transfer, locomotion on and off the unit, dressing, toileting and personal hygiene. She had dentures. B. Resident Observations/Initial Interview On 12/13/16 at 2:29 p.m. the resident was in her room and was observed to be edentulous (without teeth). During the initial resident interview on 12/13/16 at 2:40 p.m., she was asked if she was provided oral care daily and as needed. She said no. On 12/14/16 at 1:30 p.m. the resident was not in her room but her dentures were observed on top of her dresser in her room. On 12/16/16 at 8:29 a.m. the resident was observed in the dining room eating breakfast. She did not have her dentures in her mouth. On 12/20/16 at 9:48 a.m. the resident was observed in her room in her wheelchair. She had her upper and lower dentures in her mouth (see resident interview below). C. Record review According to an interdisciplinary progress note dated 12/15/16, the resident required substantial/maximal assistance with oral hygiene. According to the care plan, initiated on 10/4/16 and last updated on 11/30/16, Resident has no natural teeth. Resident has upper and lower dentures. No problems noted with dentures at this time. She is at risk for activities of daily living deficit related to weakness, limited mobility secondary to [DIAGNOSES REDACTED]. The interventions were for the staff to assist with oral care twice a day and as needed. -The staff would continue to monitor for problems or difficulties with eating and chewing during meals. -Provide an oral assessment daily as needed, schedule a dentist appointment when needed, assist with applying/taking out and cleaning dentures daily and as needed and administer [MEDICATION NAME] medication order as ordered. D. Follow-up Resident Interview (after staff were made aware of the above observations) On 12/20/16 at 9:50 a.m., the resident was observed wearing her dentures. When asked about her dentures, she said staff came in and talked to her about the importance of wearing her dentures to help her chew her food better. She said someone had come in to talk to her over the weekend about wearing her dentures. She said she would wear them when the staff reminded and encouraged her to wear them. E. Staff interviews Licensed practical nurse (LPN) #6 was interviewed on 12/15/16 at 9:02 a.m. She said the resident did have both upper and lower dentures. She confirmed this by searching for the resident's dentures in her room, and found them on top of the resident's dresser in a pink container. She said maybe the resident did not want to wear them today. There was no notation of refusal found in the resident's chart. CNA #2 was interviewed on 12/20/16 at 10:30 a.m. She said this resident did not refuse care. She said she was very pleasant; she sometimes needed extra time getting ready. The director of nursing (DON) was interviewed on 12/20/16 at 1:25 p.m. When she was asked if a resident refused care what should be done, she said the CNA should tell the nurse on the floor so that nurse could chart it and update the plan of care accordingly. She said the resident would be encouraged to do the ADL that they were refusing themselves, or be offered assistance with the ADL. She said if there were refusals, the care plan should be updated to reflect the resident's refusals and there would be nursing documentation to back the refusals.

Based on record review and staff interviews, the facility failed to ensure three of four out of 44 total sampled resident (#59, #111 and #77) received treatment and services to restore as much normal bladder function as possible. Specifically, the facility failed to: ---Implement individualized interventions in response to incontinence. The findings included: Policy: According to the restorative bladder function policy of 11/28/16, professionals were expected to choose appropriate interventions and implement a fluid and bowel management program and evaluate the effectiveness of such program. 1. Resident Status a. Resident #77 age 90, was re-admitted on [DATE]. According to the face sheet [DIAGNOSES REDACTED]. According to the most recent minimum data set ((MDS) dated [DATE] documented the resident had cognitive impairments. The MDS indicated the resident required extensive assistance with activities of daily living and toileting needs. The resident was coded as being frequently incontinent of urine. The urinary continence assessment dated [DATE] documented the resident had urge incontinence The resident required assistance with toileting. The form indicated she required cueing. The assessment indicated the resident was not able to comprehend or follow directions and that sometimes she had the sensation to void. The assessment instructed for a three day bladder flow record to assist with choice of program. However, the three-day bladder flow assessment was not completed. Therefore, the proper program for the resident could not be determined. The rehabilitation services multidisciplinary screening tool dated 11/25/15 documented the nursing report small increase in incontenence. The form was signed, however, no further action was taken. b. Lack of individualized interventions Review of the resident's care plan, revised 11/21/16, revealed a care plan had identified the resident was frequently incontinent of bladder. The resident was alert with some confusion and able to make needs known. However, the care plan failed to address the resident's individualized toileting needs, goals, and expectations of staff to ensure the resident achieved her highest level of continence. Moreover, the care plan did not show that staff were monitoring the effectiveness of planned interventions or had revised interventions. c. Interviews: The rehabilitation manager was interviewed on 12/20/16 at approximately 4:00 p.m. the RM said that she was not aware of the screen which was completed on 11/25/15 and was not able to provide any information which showed the concern was addressed. The RM said that she was not in charge of the bowel and bladder retraining program. The director of nurses was interviewed on 12/20/16 at 4:50 p.m. She said that a three day bladder study was to be completed on all residents in order to determine if the resident has had any changes and to determine a baseline. 2. Resident #111, age 82, was admitted on [DATE] and discharged on [DATE]. According to the physician order [REDACTED]. According to the MDS of 9/11/16 resident had minimal cognitive impairment with a BIMS score of 13 out of 15. Resident required extensive physical assistance with ADLs and ambulation. Record review The care plan of 9/4/16 identified frequent bladder incontinence and the goal was to maintain resident`s dignity and ensure resident was free from any embarrassment due to incontinence. Interventions were for staff to anticipate and assist with toileting needs as needed. The bladder flow pattern record of 9/4, 9/5 and 9/6/16 documented resident was continent of bladder. The bladder and bowel assessment of 9/11/16 documented resident was occasionally incontinent. The bladder pattern flow record of 10/4, 10/5 and 10/6/16 documented resident was frequently incontinent. On 10/10/16 bladder and bowel MDS assessment documented resident had an indwelling catheter due to incontinence. It also documented no toileting program was attempted or being used to manage resident`s bladder incontinence. 3. Resident #59, age 82, was admitted on [DATE]. According to the computerized physician order [REDACTED]. According to the minimum data set (MDS) assessment of 11/30/16 resident had severe cognitive impairment with a BIMS of 3 out of 15. Record review The care plan of 11/14/16 identified resident was at risk for activities of daily living related to limited mobility, weakness and confusion. It also documented resident had ineffective communication related to confusion. It also identified resident was frequently incontinent of bladder and staff to anticipate resident`s needs. According to the urinary incontinence assessment tool of 6/12/16, resident was incontinent of urine. It documented resident`s risk factors were impaired mobility and pain. It documented resident was capable of comprehending directions, was aware of the urge to void but could not control the urge. Assessment utilized by the facility to determine eligibility for a personalized or timed toileting program to improve continence was done on 4/22/16, 6/12/16, 9/14/16 and 11/4/16; but no program was established to improve resident`s urinary incontinence. The 6/16/16, and 9/8/16 MDS identified resident was frequently incontinent of bladder. It also documented resident was not on any retraining program. Staff Interviews CNA #1 was interviewed on 12/20/16 at 1:26 p.m. She said resident preferred to stay in his room and hardly went out except for some activities and he was frequently incontinent of urine. She said they would check and change to ensure the resident was clean and dry as he could only say yes and no and was not able to clearly communicate his needs. The restorative nurse was interviewed on 12/20/16 at 3:02 p.m. She said she was not sure who was in charge of the bladder retraining program. She said she thought the rehabilitation director was in charge of coordinating the bladder retraining program. The licensed practical nurse (LPN) was interviewed on 12/20/16 at 4:00 p.m. She said the nurses were responsible for doing the bladder assessment and then informed the director of nursing (DON) who would decide what bladder retaining program would be established for that resident. The DON was interviewed on 12/20/16 at 4:54 p.m. She said if a CNA notified the nurse that a resident had become incontinent then they would do a care plan and refer the resident to occupational therapy for the biofeedback (device which was used to evaluate bladder function) assessment. She said the normal process was to do a three-day bladder assessment to see if someone was capable of a retraining program. She said she did not have anybody in the building on an individual retraining program at this time.

Based on observations, record review, and interviews the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#11 and #72) out of four sampled residents for accident hazards. Specifically, the facility failed to use gait belts when ambulating residents. The findings included: A. Facility policy The policy for Gait Belts for Transfer, not dated, was provided by the director of nursing (DON) on 12/20/16 at 12:40 p.m. It stated in pertinent part: Gait belts are provided to assist staff to safely transfer or ambulate the resident. Use of the gait belt will be noted in the care plan. 1. Resident # 11, age 98, was admitted on [DATE]. According to the 12/16 computerized physician orders, [DIAGNOSES REDACTED]. According to the 10/14/16 minimum data set (MDS) assessment, the resident had severely impaired cognitive skills. She required extensive assistance of one person for transfers and ambulation. Balance with walking using assistive device was not steady, she was only able to stabilize with human assistance. She used a walker as her mobility device. The care plan identified the resident as being at risk for falls and activities of daily living (ADL) deficit related to weakness and limited mobility, initiated 1/27/16. Interventions included: -Extensive to limited assist with transfers, toileting and bed mobility as needed; -Assist times one with transfers with front wheeled walker (FWW) as needed; -Uses FWW for ambulation as primary mode of locomotion and -Staff to encourage proper footwear and call light use. Use of gait belt was not on the resident's care plan as per facility policy. Observations On 12/15/16 at 11:01 a.m. the resident was observed to be ambulating down the hallway to the dining room using FWW with a certified nurse aide (CNA) walking next to her. No gait belt was used. On 12/15/16 at 5:11 p.m. the resident was observed to be ambulating down the hallway to the dining room using FWW with a CNA walking next to her. No gait belt was used. On 12/19/16 at 11:30 a.m. the resident was observed to be ambulating down the hallway to the dining room using FWW with a CNA walking next to her. No gait belt was used. Interviews CNA #6 was interviewed on 12/20/16 at 10:30 a.m. She said resident #11 was a one person extensive assistance for her ADL's. A gait belt should be used on her with all transfers and ambulation. Licensed practical nurse (LPN) #1 was interviewed on 12/20/16 at 3:45p.m. She said gait belts were used for people that require extensive assistance with transfers and ambulation. LPN #3 was interviewed on 12/20/16 at 3:47 p.m she said she used a gait belt if the resident was unsteady or weak or if they had an order for [REDACTED]. The director of nursing (DON) was interviewed on 12/20/16 at 4:45 p.m. She said a gait belt should be used for anyone that was an extensive assist. The stand in executive director was present during the interview with the DON on 12/20/16 at 4:45 p.m. He said a gait belt should be used on anyone that required hands on assistance, providing weight-bearing support. 2. Resident #72 was admitted on [DATE]. According to the 11/16 computerized physician orders [REDACTED]. According to the 10/15/16 MDS the residnt had cognitive issues. She required extensive assistance with ambulation and activities of daily living. Observations: --On 12/15/16 at approximately 11:30 a.m., the resident was observed to be walking down the hallway with her front wheeled walker. The certified nurse aide was walking next to the resident. A gait belt was not used while walking with the resident. -- On 12/16/16 at approximately 11:00 a.m., the resident was observed to be walking down the hallway with her front wheeled walker. The certified nurse aide was walking next to the resident. A gait belt was not used while walking with the resident. Record Review: The 9/12/16 care plan identified the resident was at risk for falls related to limited mobility. The goal was the resident would have a decreased risk for falls. Pertinent approaches included, front wheeled walker for walking to meals with assistance and to encourage resident to use walker and assist with stand by assistance. Interview: A registered nurse (RN) was interviewed on 12/20/16 at approximately 11:00 a.m. The RN said that the resident was not to walk alone as she was at risk for falls. She said that a gait belt needed to be used while the CNA walked with the resident.

Based on observation, record review, staff and resident interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, the facility failed to ensure two of 30 sample residents received treatment and services in a timely manner (#110 and #90). Specifically, the facility: -Failed to respond in a timely manner when resident #90 experienced low oxygen saturation levels. -Failed to address nausea and vomiting in a timely manner for resident #110. These failures contributed to respiratory distress for resident #90 and ongoing nausea with vomiting for resident #110. The findings include: 1. Resident #90 According to the admission record, [AGE] year old resident #90 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Observations On 10/17/12 at: -9:25 a.m., during medication administration observation, a certified nurse aide (CNA) reported to the registered nurse the resident's oxygen saturation level was 72%. She indicated that she kept trying to get a better reading but the best she could get was 80%. She then showed the nurse the vital sign sheets; the resident's blood pressure was 90/60. The nurse remained at the medication cart and told the CNA to "round up some oxygen." -9:29 a.m., the CNA took an oxygen concentrator into the resident's room. -9:35 a.m., the CNA told the nurse that she had started the resident on oxygen at 2 liters/min. She indicated that she had tried again to get a reading for the oxygen saturation level, but was unable too. -9:39 a.m., the RN went to the resident's room and asked the resident if he felt bad. When the resident said, "Yes," the nurse stated, "I guess I will go get a machine." The nurse then left the room and returned with a vital sign machine. He attempted to obtain an oxygen saturation level for approximately seven minutes. However, during that time he did not assess the resident. The RN was not observed to listen to the resident's lungs, re-check his blood pressure or ask the resident pertinent questions related to the acute condition. -9:47 a.m., the RN obtained an oxygen saturation reading of 40%. After several more minutes, the reading increased to 83%. -9:50 a.m., the RN increased the oxygen flow to 3 liters/min. The resident's respirations were shallow; his color was ashen and he was breathing through pursed lips. The CNA told the nurse the resident was having difficulty with his balance "this morning," and said he fell over when she tried to sit him up. The nurse looked at the resident's fingers for approximately 3 minutes. -10:00 a.m., the RN left the room. -10:02 a.m., the RN called the physician's office. A chest x-ray and lab work were ordered and the results were within normal limits. Interview On 10/18/12 at 10:07 a.m., the director of nursing (DON) and the executive director (ED) were interviewed. The DON indicated she expected that anytime a CNA reported abnormal vital signs to a nurse, the nurse should follow up on it immediately; especially with low oxygen saturation levels. She indicated that 14 minutes with low oxygen saturation levels was a long time to wait for a nurse to assess and said, "It can seem like a very long time to a resident if they can't breathe." 2. Resident #110 Resident #110, [AGE] years old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The initial registered nurse (RN) admission note, dated 10/10/12, documented the resident was oriented to person, place and time with intermittent confusion. She was able to communicate her needs with clear speech and her eye sight was poor. The note further documented the resident had left lower extremity [MEDICAL CONDITION] and her right leg was amputated above the knee. However, that portion of the note was inaccurate, as the resident had no left hip and her right leg was intact. (Cross reference F514, Clinical Records) The physician's notes, dated 10/10/12, documented the resident had pain and it was controlled. However, the note read, "Stomach gets upset after taking [MEDICATION NAME]. Felt better after drinking lemon-lime soda." According to the history and physical, dated 10/11/12, the physician noted the resident was experiencing nausea, and the documented plan was to manage the resident's diabetes. Documentation revealed the physician was not sure if the resident was on insulin, so he was seeking the resident's prior records. The resident had chronic wounds and was a high risk for skin breakdown and wound infection with resistant organisms. The notes read, "Will treat wounds as best we can but healing and long term prevention will be a huge challenge." There was no additional reference regarding the nausea. The physician's notes, dated 10/15/12, five days after the first notation about the nausea was written, documented the resident had been sick the past two days. The notes read, "No vomiting. Think [MEDICATION NAME] upsets her stomach. Nausea, no pain despite not having [MEDICATION NAME] for two plus days. If necessary would choose [MEDICATION NAME] and [MEDICATION NAME] as needed." The nurse's notes dated from 10/10/12 - 10/13/12, had no documentation of the resident's nausea, even though the physician's note, dated 10/15/12, noted the resident had complained of nausea the past two days. On 10/14/12 at 10:13 a.m., the RN documented the resident refused all medications throughout the shift. The resident stated she was refusing all medications until she spoke to her physician. The notes read, "Resident complained of occasional nausea. No vomiting noted at this time." There was no documentation to show the physician was informed of the nausea or medication refusals. On 10/14/12 at 1:20 p.m., the RN documented the resident refused all medications and refused her dietary supplement. The resident stated she was unable to keep any thing down, and gagged on all items offered. However, there was no documentation to show the physician was contacted about this. On 10/15/12 at 8:25 a.m., the staff development coordinator (SDC) nurse documented the resident stated she would not take her medication until she saw her physician. On 10/15/12 at 2:44 p.m., the licensed practical nurse (LPN) documented the resident, "Refused the [MEDICATION NAME] this morning; stating, 'it makes me sick.' Spoke to physician who discontinued her medication." (See above 10/15/12 physician's note). On 10/16/12, the nurse's notes documented the resident refused to get up for breakfast. "Resident refused all medications including the dietary supplements, stating, 'You guys don't understand.' Refused to eat breakfast." On 10/16/12 at 3:20 p.m., there was no documentation of nausea and no mention of the meals refused. On 10/17/12 at 3:23 a.m., the resident refused to take anything for pain, stating that made her sick. The medication administration records (MAR) for October 2012 revealed the resident refused the afternoon dose of [MEDICATION NAME] on 10/13/12 and continued to refuse it up to and during the survey. In addition, she refused another medication (senna) from 10/11/12, through 10/17/12, and she refused the two nutritional supplements, as well as a multivitamin for the same time period. The resident was observed in her room at various times on 10/16/12. The resident had a wash cloth on her forehead and a basin sitting next to her on the bed. She stated she had a terrible headache and she was nauseated. The resident was pale and she stated the headache made her sick to her stomach. She said she had not vomited, however, said she could feel the "acid/ bile" in her esophagus. The resident was observed on 10/17/12 at approximately 8:30 a.m. She stated her stomach was just rolling and she was still nauseated and was vomiting. On 10/17/12 at approximately 8:35 a.m., the RN caring for the resident was informed of the findings and the resident's complaints. The RN was seated at the nurse's station at the time. However, after being informed, she did not look at the MAR. During an interview with the RN at the time, when asked about the resident's condition, the RN looked at the MAR and stated the resident had nothing ordered for nausea or vomiting. The RN further stated she felt sure the physician was aware of the ongoing nausea as any resident issues were discussed at the stand up meeting every morning. The director of nursing (DON) was interviewed on 10/17/12 at approximately 9:15 a.m. After she was informed of the findings and the resident's complaints of nausea, she stated, "We could discuss it with the physician." Thirty minutes later, at 9:45 a.m., the DON returned and stated the physician had ordered the anti-emetic medication [MEDICATION NAME] for the nausea. At 3:20 p.m. on 10/17/12, the RN on the 2 p.m. - 10 p.m. shift was interviewed. She stated the pharmacy did not make deliveries until around the evening meal service. However, she said she could get the medication from the E (emergency) kit. The resident was re-interviewed after the RN and stated she was interested in trying the medication to see if it would help. [MEDICATION NAME] was then administered at 3:30 p.m. However, that was more than six hours after it was ordered. On 10/18/12, the resident was interviewed at approximately 8:30 a.m. She stated she was feeling a little better. On 10/18/12 at 8:40 a.m., the DON and nursing home administer (NHA) were interviewed about the delay in administration of the [MEDICATION NAME]. They stated they would have to interview the RN. The DON stated the physician really did not want to order the medication because he wanted to wait and see if the [MEDICATION NAME] was the cause of the resident's headache and nausea. The DON then stated the [MEDICATION NAME], "Does not work anyway." About three minutes later, the NHA reported that she spoke to the RN on duty that day. The NHA said the nurse was in the room multiple times and the resident never stated she was sick. Following the interview with the NHA, the resident was interviewed on 10/18/12 at approximately 8:55 a.m. She stated that she had been continuously nauseated for the last 6 days. The certified nurse aides (CNAs) were interviewed on 10/18/12. Specifically: -One was interviewed at 9:16 a.m. She stated the resident had been sick every day, especially during any movement. -Four CNAs were interviewed at approximately 2:15 p.m. They all stated they were familiar with the resident or had taken care of her and all reported the resident had been nauseated since her admission back on 10/10/12. The resident experienced ongoing nausea from admission until 10/17/12. Documentation and interviews revealed the physician and staff were aware of the nausea. However, it was not addressed for the resident until after it was brought to the facility's attention. As a result of the delay in treatment for [REDACTED].

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that three of 15 sample residents (#1, #12, #13) and two supplemental sample residents (#18 and #20) received adequate supervision and assistive devices to prevent accidents. Specifically: -The facility failed to consistently implement interventions to prevent falls resulting in resident #1 and #12 sustaining fractures after a fall. -The facility failed to take steps to address resident #12's inappropriate behaviors toward residents #13, #18, and #20. Cross-reference F225; failure to thoroughly investigate incidents of abuse. Findings include: I. Falls A. Facility policy and practice Review of an undated facility policy, titled "Falls management," revealed it read in pertinent part: -Each resident will be assessed throughout the course of treatment for [REDACTED]. An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. The interdisciplinary team (IDT) will attempt to balance safety needs, resident rights and quality of life issues that will positively impact each resident's individual situation and reduce the risk of occurrence. Residents who experience a fall will receive prompt medical attention. Immediate needs will be quickly assessed and responded to. The physician and family will be notified of the incident and a plan will be identified and implemented as necessary to protect the resident and/or others from recurrence. In an interview with the facility rehabilitation manager (rehab manager) on 5/13/10 at 1:05 p.m., the rehab manager stated the facility utilized, in addition to the above policy, the "Falling Star" program. Under this program, a star was placed on the resident's door to remind staff the resident was a high fall risk. B. Resident failures 1. Resident #12 Review of resident #12's record revealed he was admitted on [DATE], discharged to a behavioral health unit (BHU) on 4/22/10 and re-admitted on [DATE]. [DIAGNOSES REDACTED]. a. Resident status - identified fall risk factors - high fall risk The resident's most recent MDS (minimum data set) assessment, dated 1/31/10, revealed he had problems with memory and severe difficulty with decision making. -The following behaviors were present but not of recent onset: easily distracted, periods of altered perception or awareness of surroundings, disorganized speech, periods of restlessness, periods of lethargy and mental function varies over the course of the day. His communication was assessed as usually understood and sometimes understands. -Indicators of depression, anxiety and sad mood included: repetitive questions, repetitive verbalizations, persistent anger with self or others, repetitive anxious complaints/concerns, sad, pained, worried facial expressions, withdrawal from activities of interest and reduced social interaction. -Behavioral symptoms included: socially inappropriate/disruptive behavior. He needed extensive assistance with bed mobility, transfer, walking, locomotion, dressing, eating, toilet use, hygiene and bathing. He had no limitation in range of motion but had a history of [REDACTED]. Review of resident #12's fall assessments (10/29/09-5/12/10) revealed he had been assessed seven times (5/12/10, 5/11/10, 4/18/10, 3/18/10, 12/18/09, 11/4/09, and 10/29/09). He consistently scored at high risk with scores ranging from 20 to 24 points. Review of resident #12's care plans revealed the facility had identified the following problems: -"ADL deficit related to CVA (stroke) and weakness (12/30/99);" -"Cognitive impairment (7/13/09);" -"Issues with vision (5/5/09)." -"Short term memory problems and impaired decision making at times (11/5/08)." -"Potential for injury related to history of falls, poor vision and poor safety awareness (11/5/08)." Nurse's notes (reviewed from 10/29/09-5/12/10) documented unsafe transfers (11/9/09 and 11/11/09) and ambulating by self (2/24/10 and 4/18/10). b. History of five falls: 10/29/09-5/12/10 - facility response (1) Fall 10/29/09: Review of nurse's notes 10/29/09 disclosed: "Alert with mild confusion, neuro's WNL (within normal limits) and no injury noted. Review of the 10/29/09 fall incident report revealed it read: Tried to get out of bed to w/c, had socks and slid to floor. Recommendations: rehab screen, falling star, continue pad alarm. Follow-up: put tab alarm on w/c and grip socks. Review of the post fall screening tool revealed it read: Independent stand from bed, call light tangled, socks slippery and fell . grip socks with pad alarm-to have on him at all times. (2) Fall 11/4/09: Review of nurse's notes 11/4/09 disclosed: "Found in floor in dining room at lunch time." Stated he was "going to the house" and "wanted to call (name of son)." Found lying on back, knees bent up and head was supported. Neuro's started per protocol. Doctor notified, no injuries noted. Denied pain, son contacted. Alarm in place. Reminded to ask and wait for help. Review of the 11/4/09 fall incident report revealed it read: Found on floor at lunch. Recommendations: falling star, rehab screen, had pad alarm, put on tab. Provided one on one. Follow-up: pillowcase removed and non-skid placed on cushion. Review of the post fall screening tool (11/6 for 11/4/09) revealed it read: Found on floor in dining room. Increased agitation all day, constant redirecting. Began Lexapro. W/c cushion covered with pillowcase, removed and cover with nonskid w/c cushion cover. (3) Fall 2/13/10 Review of nurse's note on 2/13/10, read: Alarm went off, CNA went to check and resident was on floor next to his w/c. No injuries noted, neuro's WNL and range of motion WNL. Reminded to use call light. Notified son and doctor. Review of the 2/13/10 fall incident report revealed it read: Alarm went off and resident was on floor next to w/c. Recommendations: anti-rollbacks, rehab screen, falling star, safety awareness with resident. Follow-up: anti-rollbacks put on w/c. Review of the post fall screening tool 2/17 for fall on 2/13/10, revealed it read: Stood independently no lock brakes. Nursing will put anti-rollbacks on. Not appropriate for skilled intervention at this time. (4) Fall 4/18/10 Review of nurse's notes on 4/18/10 read: Noted ambulating in hallway and housekeeper noted resident fall down to floor backward before she could get to him. Upon assessment, noted some redness to the back of resident's head. Neuro's initiated and WNL (within normal limits). ROM WNL and denies pain. Notified doctor and son. Review of the 4/18/10 fall incident report revealed it read: Was ambulating in hallway and fell backwards. Has tab alarm, was not attached. Recommendations: falling star, rehab screen, has tab alarm, will assess different alarms. Follow up: new alarm ordered, currently out of facility. Review of the post fall screening tool 4/19 for fall 4/18/10, revealed it read: Found on floor in hallway, independent ambulation, mobility alarm not sounding, check neck pain. Poor safety was written next to cognition, poor vision next to visual deficits and denied neck pain. Not appropriate for skilled intervention at this time. A note on 4/27/10 for MDS assessment on 4/18/10 read: check w/c and ROM, safety devices. Poor safety was written in next to cognition and removed assistive device next to be mobility. (The resident was out of the facility 4/22/10 and returned 5/11/10.) (5) Fall 5/12/10 Review of nurse's notes on 5/12/10 read: Found on floor lying face down. Laceration above right eye brow and line. Neuro's completed. Full ROM. Denies pain and no injuries noted on exam. Resident had been toileted by CNA staff prior to incident. Residents alarm attached but not sounding. An additional notes on 5/12/10 read: Had recent fall in facility last night from bed. Pad alarm in place. Now placed in low bed with mat and put tab alarm on resident in bed. Son notified and physician order [REDACTED]. Further notes on 5/12/10 read: Returned from ER (emergency room ). Report from ER, has fracture to nose . . . Dermabond to laceration above right eye. . . Review of the 5/12/10 fall incident report read: Resident found on floor next to bed, laceration above right eyebrow. Alarm not sounding when RN responded. Sent to ER for eval and treat. Recommendations included: eye dermabonded at (hospital name), falling star, rehab screen, low bed with mat and has alarm for all times. Review of the post fall screening tool revealed it read: fell out of bed, ER and back. Recommend a low bed with fall mat. The form revealed there was no change to the resident's functional screen area (w/c positioning, environmental causes, cognition, visual deficit, and change in abilities, using proper adaptive equipment, appropriate transfer techniques, balance issues, ROM, strength, musculoskeletal pain and other). Currently on case load. c. Failures in facility response (1) Failure to monitor application and functioning of alarms a) Failure to re-evaluate continued use of tab alarm: In an interview on 5/13/10 at 2:30 p.m., the DON revealed the pad alarm sounds when one steps off or gets off the pad (attached with a black wire to the pad). The mobility or tabs alarm is attached to a box by a magnet and attached to the resident by a clip. The DON revealed the tabs alarms are generally attached when he residents are in the dining room. Record review and interviews revealed the resident was known to remove his tab alarm. -A nurse's note on 2/24/10 further read, "Had removed tab alarm from clothing." A restorative nurse's note, dated 4/22/10, read: "Resident removed alarm at times and makes attempts to ambulate." -See above; fall on 4/18/10 - when the resident fell , his tab alarm was not attached. -In an interview on 5/13/10 at 1:05 p.m., the rehab manager disclosed the resident knew how to remove the alarm and would throw it in the toilet. Nonetheless, the restorative note, dated 4/22/10, following the resident's fourth fall (4/18/10) read: "will continue use of tab alarm at this time." Observations of the resident 5/11 and 5/12/10 revealed that his tab alarm was not attached to the resident at "all times" as expected per 5/11/10 physician orders [REDACTED]. Specifically: -On 5/11/10 at around 1:55 p.m., observation disclosed resident #12 in his room in his wheelchair, looking at the wall. He was wearing glasses, and had bandage over his right brow and a splint on his left hand. His tabs alarm clip was not attached to his clothing. The door to his room was open and the surveyor observed the resident from the door. As the surveyor left the area, a CNA entered the room and attached the tabs clip. -Observation on 5/11/10 at 5:25 p.m., revealed resident #12 in a side dining room seated at a table with another male resident. His tab alarm clip was not attached to his clothing. There was no black wire going down to the seat area. -Observation on 5/12/10 at 5:54 p.m., revealed resident #12 in a side dining room. His tab alarm clip was not attached to his clothing. b) Failure to monitor functioning of alarms: Prior to the resident's discharge to BHU on 4/22/10, physician orders [REDACTED]. -check pressure pad weekly for functioning (Mon 6-2), -tab alarm on at all times related to decreased safety awareness, and -change tab alarm battery monthly (15th 2-10 shift). Review of physician orders [REDACTED]. -5/12/10 low bed with mat (decreased safety awareness), -5/11/10 tab/pad alarm at all times (decreased safety awareness). On re-admission on 5/11/10, there were no orders for checking pressure pad weekly, changing/checking battery or ensuring the tabs alarm was on at all times. In an interview on 5/13/10 at 1:30 p.m., the rehab manager stated she did not know how staff checked residents' alarms to ensure they functioned properly. See above; fall on 5/12/10 with injury - when the resident fell from bed, his alarm did not sound. (2) Failure to ensure the resident was adequately supervised See above; observation on 5/12/10 at 5:54 p.m., revealed resident #12 in a side dining room. His tab alarm clip was not attached to his clothing. During this observation, which continued for approximately ten minutes, there was no staff in the side dining room or hallway entrance to the dining room. Although in an interview on 5/12/10 at 6:00 p.m., a CNA and a licensed nurse stated the resident did not need the tabs alarm clipped to his clothing since he was under constant supervision in the dining room, based on the observations on 5/12/10 (see above), there was no staff in the dining room for a period of ten minutes. Moreover, at this time, other residents with tab alarms had their alarms attached and residents with pad alarms had their alarms attached as evidenced by a black wire going down to the seat area of the wheelchair. Review of the resident's care plan for "Potential for injury related to history of falls, poor vision and poor safety (11/5/08) failed to include any direction to staff to ensure the resident - who was known to self-transfer, known to ambulate independently, and known to remove his alarm - was adequately monitored for safety. While the care plan referenced "Falling Star Program," there was no instruction to staff, either in the resident's care plan or in the facility policy (see above) that explained what this meant in terms of the resident's supervision. (3) Failure to incorporate recommendation from BHU The Behavioral Health Unit (BHU) where the resident resided between 4/22/10 and 5/11/10, included in its discharge recommendations: (Resident #12) scoots himself to the edge of his w/c and needs frequent reminders to scoot back in chair. Has a pommel cushion in w/c while on BHU. There was no indication that this recommendation had been incorporated into the resident's care plan for safety from falls. 2. Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. a. Resident status - fall risk - facility response The resident's MDS, dated [DATE], revealed short and long-term memory loss. The resident wandered and resisted cares. He had falls in the past 31-180 days. His care plan for falls, dated 4/2/10, had under problems, at risk for falls related to poor safety awareness, impaired vision, dementia, non compliance with pad alarm/seatbelt and a history of falls. The approaches were in pertinent part: -continual reminders to use call light, -assist with toileting often and change incontinent products with incontinent episodes, -falling star program, -therapy evaluation, -PAD alarm at all times when seat belted in wheelchair, self releasing seatbelt with alarm while in wheelchair. The Quarterly Restraint Assessment Form, dated 9/18/09, noted alarm in bed and self release seat belt in wheelchair. The resident's score was 22, indicating the resident needed additional care plan interventions. An assessment, dated 12/18/09, revealed the resident again scored 22, indicating care plan changes were needed. He also had a fall in the past 30 days. b. Fall 4/16/10 with injury Record review revealed that on 4/16/10, the resident was found on the floor in his room. He was sitting on the floor leaning on the right side with his feet under him. He had socks on and no shoes. The resident stated, "I was getting up." The intervention was to put new alarm on the bed. According to the nurse's notes, the resident was did not express pain until two days later. A note on 4/18/10 at 6:00 a.m., resident complained of left hip pain. At 10:20 a.m., the notes documented the resident expressed pain when weight applied to left leg. Grabs leg and grimaces with pain. He was sent to the hospital for X-rays. A note on 4/18/10 at 9:30 p.m. read that X-ray results showed a fractured left hip. The radiology report, dated 4/18/10, noted a non displaced left obturator ring fracture. c. Facility failure The facility incident manager was interviewed on 5/24/10 concerning the resident's fall on 4/16/10. She explained that at the time of the fall, the resident was using a tab alarm that had to be switched from his wheelchair to his bed and from his bed back to his wheelchair. The alarm had not been transferred from the wheelchair to the bed on 4/18/10. The incident manager stated that the resident now had a new alarm, a PAD alarm, for on the bed as well as the wheelchair. II. Resident to Resident altercations - Cross-reference F225. A. Facility policy Review of the facility abuse policy dated 2/09, disclosed the following, in pertinent part: -Protection from abuse: Social services staff ensure that all residents are protected from further abuse, trauma related to injury and retaliation. The social services staff assess and document relevant information regarding residents' adjustment following their involvement in alleged abuse situations. If needed, the social services staff provide or arrange for counseling for residents, other associates, and family members involved in alleged abuse situations. -Screening residents at risk: All residents will be assessed to determine a history of abuse to self or others, the potential to be abusive, other the potential to be at risk for abuse and/or neglect. At risk residents may be identified through the RAI process or other assessment tools. The care plan will incorporate resident specific interventions designed to reduce the risk of abusive or neglectful occurrences. B. Resident to resident - potential abuse involving residents #12, #13, #18, and #20 1. Resident #12 See above; review of resident #12's record revealed he was admitted to the facility on [DATE], discharged to a behavioral health unit (BHU) on 4/22/10, and re-admitted to the facility on [DATE]. The resident's most recent minimum data set MDS) assessment, dated 1/31/10, revealed in pertinent part: -The following behaviors were present but not of recent onset: easily distracted, periods of altered perception or awareness of surroundings, disorganized speech, periods of restlessness, periods of lethargy and mental function varies over the course of the day. His communication was assessed as usually understood and sometimes understands. -Indicators of depression, anxiety and sad mood included: repetitive questions, repetitive verbalizations, persistent anger with self or others, repetitive anxious complaints/concerns, sad, pained, worried facial expressions, withdrawal from activities of interest and reduced social interaction. -Behavioral symptoms included: socially inappropriate/disruptive behavior. He needed extensive assistance with bed mobility, transfer, walking, locomotion, dressing, eating, toilet use, hygiene and bathing. He had no limitation in range of motion but had a history of [REDACTED]. Review of physician orders [REDACTED]. Prior to this, he was receiving Paxil (antidepressant) and Depakote (dementia with behavior disturbance). a. Incidents of inappropriate behavior (1) Review of nurse's notes disclosed the following references to inappropriate behavior toward other residents: -4/21/10 Propels self in w/c (wheelchair). Resident grabbed the chest of another resident (#18) in hallway. Taken to room and started on Q (every) 15 minute checks. Notified physician and family. Labs drawn. Order received to transfer to BHU in morning. Being monitored closely for inappropriate behaviors. -12/13/09 Two inappropriate sexual behaviors. Resident told this was inappropriate and did acknowledge. Continues to be on 15 minute watches. -12/9/09 (late entry for 12/8/09) Witnessed to be touching left breast of resident (#13) while they were sitting in the lounge in w/c (wheelchair). CNA (certified nurse aide) took resident #13 back to her room per her wishes to go to bed. CNA told resident #12 he could not touch others like that and he said, "She likes it." Monitored for remainder of the shift for behaviors. Physician, family and ombudsman notified. Resident remains on every 15 minute (Q15) watches and is being kept at a distance from female residents. Administrator and DON made aware. -12/3/09 Sexually inappropriate behavior in dining room and did correct self when asked. (2) Review of social service notes disclosed the following: -5/11/10 readmitted from BHU. Came back with following meds-Celexa 10 mg and Aricept 10 mg. -3/1/10 quarterly note-On Depakote 250 mg and Paxil 10 mg. Has history of being sexually in appropriate but has been stable at this time. -12/9/09 Possible involved in an incident with resident #13. This is a state reportable incident. Resident interviewed and has no knowledge of incident. Was placed on Q15 minute watches. -12/1/09 Had behaviors and been put on Paxil 10 mg. Having increased behaviors, sexually inappropriate with staff and kicking things. b. Facility failure to thoroughly investigate incidents and to take steps to prevent additional incidents of abuse. (1) Investigation failures a) The nursing home administrator (NHA) and social services director (SSD) were interviewed on 5/13/10 at 3:17 p.m. The SSD was interviewed again on 5/13/10 at 5:45 p.m. The NHA disclosed there were three separate incidents involving resident #12's sexually inappropriate behavior towards female residents. He provided dates of the incidents (4/21/10, 12/8/09 and two weeks prior to 12/8/09 - the date was unknown). -The NHA stated one staff reported seeing the resident inappropriately touch a female resident but reported it two weeks late. He stated the incidents were reported as occurrences to the Department of Health and following the incidents in 2009, staff were trained on abuse. -The NHA revealed that sometime in 11/09, resident #12 was in the lobby, asked a CNA to rub his shoulders, and then grabbed her breast. The CNA left the resident alone and then saw him on the left side of resident #20, touching her chest. The NHA said the CNA told the resident he could not do that. -The NHA said that regarding the 12/8/09 incident, resident #12 was seated to the left of resident #13, and he was observed touching her left breast. The residents were separated. According to the NHA, resident #12 had stated "she liked it" and resident #13, who remembered the incident, stated she was fearful of resident #12. -The NHA said he did not know how many other female residents were affected by resident #12's sexually inappropriate behavior. The NHA kept the investigation reports in his hand and did not allow the surveyor to review the reports. The SSD revealed she interviewed the residents involved in the two incidents that had occurred in 2009. -The SSD stated resident #20 was involved in the first incident and did not recall anything. The SSD said this resident was not in fear. -The SSD stated resident #18 had told her that she did not recall anyone hurting her and was not fearful; however, resident #13 had revealed she was fearful. The SSD did not clarify whether resident #13 was fearful of resident #12 and why. On 5/13/10 at 5:00 p.m., the Director of Nursing (DON) revealed she had interviewed four staff and two additional residents regarding resident #12's behavior on 4/21/10. Documentation including other incidents, nurse's notes, care plans, social service notes and behavior monitoring regarding the incidents for residents #13, #18 and #20 were requested from the DON. Abuse training records and investigations reports were also requested. The DON provided her notes. On 5/13/10 5:15 p.m., the nurse consultant disclosed the facility had a soft file with information pertaining to the incidents but they could not locate the file. She stated she had reviewed the information in the soft file but could not recall the specifics. In summary, the facility failed to thoroughly investigate the incidents involving resident #12 to determine if other female residents were affected by resident #12's sexually inappropriate behaviors. (2) Failure to protect residents subject to resident #12's inappropriate behaviors. a) Review of resident #12's care plans revealed the following plans, in pertinent part: -(undated) Problem: Inappropriate sexual behaviors - remind behavior is inappropriate, two person assist with all cares, monitor behavior daily and record, redirect when exhibiting sexually inappropriate behaviors, meds as ordered, to be monitored by staff at all times, monitor location of resident within facility at all times and report to nurse any inappropriate gestures, comments and behaviors. Handwritten additions to the care plan included (4/22/10) had witnessed episode of being sexually inappropriate with another resident, (4/22/10) on 15 minute checks and (4/22/10) will be sent to BHU for behaviors. -(undated) Problem: Cognitive impairment-approach calmly and offer reassurance before initiating care of providing direction, provide clear simple direction or cues, monitor behavior and cognitive status and report changes to physician. Handwritten addition dated to the care plan 8/26/09 has occasional behavior of being sexually inappropriate, reminders that behavior is inappropriate, two person assist with cares during episodes of behaviors, monitor and document behavior, redirect when exhibiting sexually inappropriate behaviors, on Q15 minute watches x six days and to be monitored by staff at all times. -7/13/09 Problem: Verbally abusive behavior at times as well as physically abusive. Has behaviors of being sexually inappropriate at times - two person assist with cares when resident experiencing negative behaviors, approach warmly and positively, allow resident to make choices and participate in cares, reinforce with unacceptability of resident's verbal abuse, do not argue with resident, remove resident from public area when behavior is disruptive, talk with resident calmly when behavior is disruptive, praise resident for desired behavior, social services to evaluate resident and visit within next 90 days. Handwritten additions to the care plan included (4/22/10) had witnessed episode of being sexually inappropriate with another resident, (4/22/10) currently on 15 minute checks for whereabouts in facility and (4/22/10) placement in BHU for behaviors. While the care plans identified inappropriate behaviors with other residents, the plans did not alert staff that the resident should be monitored around female residents. There were no directives on what type of supervision the resident required (other than the instances when Q15 minute checks were instituted). See above; observations on 5/12/10 at 5:54 p.m. revealed the resident was unsupervised in the dining room for approximately ten minutes. Finally, review of the BHU notes, dated 5/11/10, revealed the following: Discharge recommendations: He occasionally kicks things out, it is usually an attempt to find something-ask him what he needs. If he behaves inappropriately, very straight forward but non-threatening conversations such as "we really like you and want other people to also, so you can't behave like that." If he feels the need to (self stimulate sexually) provide privacy and not do this in public. There was no indication this recommendation had been reviewed and incorporated into the resident's care plan. b) Review of resident #13, #18, and #20's records - no safety plans and no social services support. Resident #13: Observation on 5/11 at 5:10 p.m. and on 5/12/10 at 7:52 a.m., revealed resident #13 in the assisted dining room in a w/c. Her head was bent down and she looked continually at the floor. She smiled when spoken to and responded to questions with short phrases. Review of resident #13 record revealed she was admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Her most recent MDS assessment, dated 3/28/10, revealed she had problems with memory and severe difficulties with decision making. She had periods of lethargy, not of recent onset. She was assessed as rarely/never understood and sometimes understands. The resident had no mood or behavioral indicators. She required extensive assistance with eating and was totally dependent on staff for bed mobility, transfers, locomotion, dressing, hygiene, toilet use and bathing. She had limited range of motion on both sides of her body from her neck to her feet with partial loss of voluntary movement. She had a history of [REDACTED]. Nurse's notes regarding the incident with resident #12 on 12/9/09 were requested but not received prior to the end of the survey. Review of care plans disclosed there was no mention of the 12/9/09 incident and no interventions to ensure the resident was protected from further inappropriate behaviors by resident #12. Although in interviews (see above), the NHA said resident #13 was "fearful of resident #12, there was no documentation in social services notes addressing either the incident or support for the resident's psychosocial needs. Review of the resident's care plans disclosed there was no mention of the incident, contrary to the facility's abuse policy, that read for at risk residents, "the care plan will incorporate resident specific interventions designed to reduce the risk of abusive or neglectful occurrences." Resident #18: Review of resident #18's record revealed she was re-admitted on [DATE], with [DIAGNOSES REDACTED]. Her most recent MDS assessment, dated 4/25/10, revealed she had problems with short-term memory and difficulty making decisions in new situations. -The following behaviors were assessed as present over the last seven days and appears different from the resident's usual functioning: disorganized speech, periods of restlessness, periods of lethargy and mental function varies over the course of the day. -Her cognitive status was assessed as deteriorated. Her communication was unclear, slurred, mumbled words but usually understood and usually understands. Her communication was assessed as having deteriorated. -Indicators of depression, anxiety and sad mood included: negative statements, repetitive questions, repetitive verbalizations, persistent anger with self or others, self deprecation, expressions of what appear to be unrealistic fears, recurrent statements that something bad is going to happen, repetitive health complaints, repetitive anxious complaints/concerns, unpleasant mood in the morning, insomnia/change in sleep pattern, sad, pained, worried facial expressions, crying tearfulness, withdrawal from activities of interest and reduce social interaction. -She was assessed as having a change in mood and deteriorated but no change in behavioral symptoms. She required extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, hygiene and bathing. She had limited range of motion in one arm, hand, leg, foot and other body part with partial loss of movement. -Her ADL function was assessed as deteriorated. Review of nurse's notes revealed: -4/21/10 Resident sitting in hallway after lunch. CNA observed a male resident touching the resident's chest. Resident pushed male resident's hand away. Resident moved away from the area. Doctor and family notified. No signs or