Every finding on record at Vanderman Place

Based on the tour of the kitchen, observations, review of facility policy and staff interviews, the facility failed to ensure hair coverings were worn while in the kitchen. The facility failed to ensure food was consistently labeled and dated and expired foods were discarded. The findings included: Tour of the kitchen on 5/19/25 at 9:57 AM during the initial walk through with the Administrator identified the following: 1.an Observation on 5/19/25 at 9:57 AM of Cook#1 in the kitchen without hair covering. Interview with Cook#1 on 5/19/25 at 9:57 AM indicated hair covering should be on while in the kitchen. [NAME] #1 also indicated he/she had a hat on but forgot to put it back on when he/she reentered the kitchen. b. Observation on 5/19/25 at 10:05 AM of the walk-in refrigerator identified 3 bags of waffles were opened with no labels of when it was opened or used by date. Observation further identified cooked turkey dated 5/16/25 with no label of a used by date. Interview with [NAME] #1 on 5/19/25 at 10:05 AM indicated food items should indicate when they were cooked and when items should be used by. c. Observation on 5/19/25 at 10:08 AM of the walk-in freezer identified frozen burgers with a use by date of 3/31/25. Interview with the Administrator and [NAME] #1 on 5/19/25 at 10:08 AM identified foods should be discarded by the use by date. They both were unable to explain why the burgers were not discarded. 2. Observation on 5/19/25 at 10:30 AM of the dry storage room identified 10 cases of expired California Farms evaporated milk can with expiration date August 2024. A telephone interview with the Food Service Director on 5/21/25 at 8:44 AM identified all kitchen staff should be checking dates to ensure food is not expired. She also indicated that her expectation is that food contains labels and dates once opened and a discarded date. The Food Service Director further indicated that a hair net or hat should be worn in the kitchen at all times. A request for the facility food service policy was made on 5/19/25 at 10:00 AM and on 5/22/25 at 10:30 AM, however, no policy was provided.

Based on observations , review of the facility Infection Control program, review of policy and interviews, the facility failed to ensure staff performed hand hygiene after providing care to a resident on Enhanced Barrier Precautions [EBP] and for 1 of 1 resident reviewed for wounds (Resident #52), the facility failed to ensure staff disposed of used gloves in a sanitary manner and failed to perform appropriate hand hygiene during a dressing change and failed to wear appropriate Personal Protective Equipment ( PPE) for a resident on precaution. The findings included: 1.An observation on 5/21/2025 at 6:25 AM identified NA #1 and NA #2 coming out of Resident #22 and roommate's room (signage for Enhanced Barrier Precautions [EBP] and Personal Protective Equipment (PPE) set up were noted outside the room) and into the hallway starting to walk down the hall. NA #1 had a used glove in his/her right hand, and nurse aides had not completed hand hygiene before coming out of the room. An interview with NA#1 identified she/he did not know when the sign went up outside the door of Resident # 22's room and s/he was not sure what had to be done. NA# 2 after thought indicated there was hand sanitizer on the wall inside the doorway and both staff members utilized the hand sanitizer to complete hand hygiene. The charge nurse LPN #1 then came out of the resident room without completing hand hygiene and told Nurse Aides # 1 and # 2 I am going to go to the nurse's station to make a note and proceeded to go down the hall. Upon the surveyor's inquiry, LPN #1 answered the isolation sign was for the roommate and after reading the sign motioned in a scrubbing motion with hands indicated she/he used hand sanitizer going in and out of the room then immediately. LPN #1 went to use the hand sanitizer for hand hygiene. The 3 staff members were assisting Resident #22 with care at the time of the observations. 2. Observation on 5/19/25 at 12:58 PM of Droplet precaution sign posted on a resident's room noted all people entering the room should put on Personal Protective Equipment (PPE). Observation on 5/19/25 at 12:58 PM identified two nurse aides entered the room with no PPE (Gloves, gown or mask). Interview with NA#2 identified PPE does not apply given they were just going in to drop off the meal. Interview with ADNS on 5/19/25 at 2:48 PM indicated if a Resident is on precaution staff entering the room should use the appropriate PPE. The DNS indicated staff have been educated on droplet precautions but would reeducate them again. 3. Resident #52's diagnoses included lymphedema (a chronic condition characterized by swelling in the soft tissues of the body) and neuropathy (nerve damage that can cause pain, numbness, tingling, or weakness in different parts of the body). The quarterly MDS assessment dated [DATE] indicated Resident #52 was cognitively intact and did not have any open lesions or ulcers. The MDS assessment further indicated the resident required substantial/maximal assistance to put on and take off shoes and socks. A nursing note dated 4/6/2025 indicated Resident #52 was noted to have a scab to the left second toe and indicated the supervisor was made aware. A wound provider note dated 4/16/2025 indicated the wound was not pressure-related, and contributing factors were the resident's lymphedema and neuropathy. A physician's order dated 4/30/2025 directed the application of a betadine external solution of 5% to the left second toe every day and evening shift, letting it dry and covering with a band-aid. On 5/22/2025 at 2:22 PM, LPN #4 was observed performing Resident #52's left second toe dressing. LPN #4 set up her working area prior to the surveyor entering the resident's room. Dressing materials were set up on an overbed table; there were food items such as an open tea, a pitcher of water, and unopened packages of cookies on the overbed table next to the clean dressing materials. LPN #4 donned clean gloves, removed the old dressing, and cleaned the area with saline. LPN #4 removed the gloves, inverted them, and placed them on the resident's bed. LPN #4 then donned new, clean gloves (hand hygiene was not observed). LPN #4 applied betadine to the wound area, removed her right-hand glove, and placed it on the resident's bed. LPN #4 donned a new glove on the right hand (hand hygiene was not observed). LPN #4 applied a skin protectant around the wound area and applied a new band-aid to the resident's left second toe. LPN #4 removed both gloves, placed them on the resident bed, reached into her pocket to grab a pen, and dated the band-aid. LPN #4 donned new, clean gloves (hand hygiene was not observed) and replaced the resident's sock. An interview with LPN #4 indicated she had cleaned the overbed table with an alcohol cleaner prior to placing the clean dressing change items on the table. Additionally, LPN #4 indicated hand hygiene should have been done after removing the old dressing. LPN #4 also indicated she was not aware that hand hygiene should be done after removing gloves and before putting on new gloves. On 5/23/2025 at 11:08 AM, an interview with the ADNS and the Wound Nurse (RN#2) identified having food items on the same overbed table as the clean dressing change items was acceptable if food items were closed and kept away from the dressing items. The ADNS and RN#2 further indicated LPN #4 should have performed hand hygiene after removing gloves. The facility policy titled Specific Personal Protective Equipment directed employees to wash their hands after removing gloves.

Based on observations of Wings 2 and 3 and staff interviews, the facility failed to ensure the medication refrigerator was free of food items and failed to keep medication rooms clean. The facility failed to ensure a medication cart was secure and accessible to only licensed staff. The findings included: 1 a. Observation on 5/23/25 at 11:45 AM of Wing 3 medication room with LPN #5 identified the following: The bottom door shelf of the medication refrigerator was observed to have an opened 12-ounce bottle of a tan-colored drink that had a manufacturer label indicating 20 grams of protein and with vanilla cream flavor. LPN #5 indicated the drink was not an item used by the facility. There were no labels indicating if the drink belonged to a resident. The shelf in the medication refrigerator was also noted to be stained with orange and tan residue. The medications stored in the refrigerator included: 2 boxes of formoterol fumarate 20mg/2ml vials (a medication used to treat respiratory conditions like asthma and COPD), two vials of latanoprost eye drops, 12 vials of insulin, seven bags of insulin pens, and four boxes of acetaminophen suppositories. b. The cabinet above the sink of Wing 3 medication room was observed to have a black plastic bottle, a purple plastic bottle, and a grey tumbler-style bottle with no labels. The grey-colored tumbler was noted to be stuck onto the shelf of the cabinet, and when removed, it left a sticky residue on the cabinet shelf. In addition to the bottles and a tumbler in the cabinet, there was also a tube of open toothpaste with blue residue on the opening of the tube. There was also a 30-gram tube of opened Lidocaine/Prilocaine 2.5%/2.5% cream with an expiration date of 2/2025. The tube of cream had a pharmacy label that was torn, and no resident name or prescription information was able to be read. Observation of the sink further identified sticky brown and white residue near an appliance used to crush resident medications. Behind the entry door of the medication room, there were eight jackets/sweatshirts that did not have resident labels on them. An interview with LPN #5 indicated she did not know who the water bottles and tumbler belonged to or how long they were there. LPN #5 also indicated she was not sure what the sticky residue in the cabinet and the sticky brown and white residue around the sink were at time of the observation. LPN #5 further indicated she did not know who the jackets and sweatshirts belonged to. LPN #5 did indicate that the staff had a locker room and break room to use. c.On 5/23/2025 at 12:28 PM, the Wing 2 medication room observed with LPN #4 identified the following: Next to the sink in the medication room, there was one pink-colored travel mug with a brown residue on the clear mug cover, a pink travel mug with a pink lid, and a pink ceramic-like mug with no lid. Behind the door, there were seven jackets with no resident labels. In the cabinet under the counter, there was a backpack and a black purse. An interview with LPN #4 indicated the purse belonged to her (LPN #4). LPN# 4 further indicated she did not know who the jackets belonged to, and the jackets had been there since she had started working at the facility about a year ago. On 5/23/2025 at 12:53 PM, an interview with the ADNS indicated the vanilla cream protein drink in the Wing 3 medication refrigerator should not have been stored there. The ADNS did not know whether jackets and personal belongings such as mugs or cups should have been stored in medication rooms. Additionally, the ADNS indicated that housekeeping cleaned the medication room and refrigerator but were not able to clean the room on the day in question yet. The facility policy for the Storage of Medications directs nursing staff to be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs are returned to the pharmacy or destroyed. Medications requiring refrigeration are stored separately from food. Although requested, the facility was unable to provide a policy for the storage of personal belongings in the medication rooms. 2.Observation on 5/19/25 outside room [ROOM NUMBER] from 120 PM to 1:28 PM identified medication cart outside room [ROOM NUMBER] unlocked and licensed staff not within eyesight of the medication cart. No residents were noted in the area. However, Nurse Aide (NA) 8 was noted entering and exiting room [ROOM NUMBER] while surveyor was present with the unlocked medication cart but did not alert LPN # 8 the medication cart was unlocked. LPN # 8 was noted talking to a resident in the bathroom at the time of the incident. Interview with LPN # 8 on 5/19/25 at time of the incident identified she ran to assist a resident in room [ROOM NUMBER] and forgot to lock the medication cart. LPN # 8 indicated she had been locking the medication cart all day but did not do so this one time. Surveyor: [NAME], Cesar

Based on clinical record reviews, observations and staff interviews for 3 of 3 (Residents #25, #63 and #78) with a history of wandering, the facility failed to ensure soiled utility on Units 1, 2, and 3 were not accessible to residents to prevent an accident.The findings included: 1. Resident #25's diagnosis includes Alzheimer's disease. Resident #25's Nursing Quarterly Evaluation dated 3/08/2025 at 11:18 AM indicated Resident #25 wanders without purpose. 2. Resident #63's diagnosis includes dementia with behavioral disturbance. Resident #63's Nursing Quarterly Evaluation dated 3/29/2025 at 7:46 PM indicated Resident #63 wanders without purpose, oblivious to needs and safety, and is confused. 3. Resident #78's diagnosis includes dementia with psychotic disturbance. Resident #78'sNursing quarterly evaluation indicted Resident #78 wanders without purpose, is oblivious to needs or safety and is disoriented and exit seeking An observation on 5/20/25 at 8:34 AM identified the dirty utility rooms on each unit accessible by pushing the door handle. Inside the soiled utility rooms were garbage cans and soiled linen in bags not covered, hazardous waste containers and equipment. Wing 1 had a specimen refrigerator with no lock and placed on an uneven surface when the door pulled open causing the person to tip forward (no specimens were in the refrigerator at this time). An observation and interview of each soiled utility room with the Director of Nursing Services (DNS) on 5/20/25 at 10:39 AM identified wing 1 had dirty linen, garbage, a hazardous waste box and a specimen refrigerator without a lock on an unsteady surface. The DNS indicated the refrigerator could be secured with a lock and a stable surface to sit on. Unit 2 had the same soiled linen, trash, hazardous waste container, no refrigerator but a small sink and a hopper (large open toilet bowl, no lid with a large sprayer to clean bed pans). Unit 3 had no refrigerator, a vacuum cleaner and a machine used for snaking pipes on the floor (per the DNS), a sink, and a hopper, several trash cans filled with bags, dirty linens with cans uncovered and one loose face cloth on top of the dirty bags. The DNS indicated the team had never really thought about the potential for residents who wander to enter the dirty utility rooms as no residents had ever tried. The DNS further indicated s/he would provide a list of all residents who wander and would meet with the Administrator and Maintenance Director about their concerns. An interview on 5/20/2025 at 2:00 PM with the Administrator indicated all 3 units soiled utility room doors now have passcode locks so only staff can enter.

Based on review of the clinical record, review of facility documentation and staff interviews for 5 of 5 residents (Residents 24, 55, 56 and # 73) reviewed for Psychotropic medications, the facility failed to ensure informed consent for the use of a new psychotropic medication was obtained from the responsible party prior to the use of the medication. The findings included: 1. Resident #22's diagnosis included cognitive deficits following a cerebral infarction, unspecified intellectual disabilities and major depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #22 had severe cognitive impairment, The care plan dated 1/14/2025 indicated in part Resident #22 had a communication problem related to history of intellectual disability and cognitive deficits. Interventions included: to anticipate and meet needs, speech therapy as indicated, use of communication techniques which enhance interaction. A psychiatric prescribers note dated 2/05/2025 indicated Resident #22 was able to express his/her needs through gestures and limited verbalizations, reports feeling depressed over medical limitations, and appeared mildly depressed. Additionally, given Resident #22's symptoms and willingness to initiate treatment a trial of antidepressant will be initiated with monitoring of side effects. A physician's order dated 2/5/2025 directed to administer Sertraline HCL(Antidepressant) 25 Milligram (MG) tablet by mouth once daily for depression. An interview with the Director of Nursing Services (DNS) on 5/22/2025 at 12:28 PM indicated the psychotropic consent forms were in a binder in the MDS nurse's office but not available. The DNS also indicated this process is somewhat new; I will let you know what I find. An interview on 5/22/2025 1:30 PM with the Director of Nursing [NAME] (DNS) indicated even though Resident #22 had been receiving Sertraline since 2/5/2025 (105 days since medication was started) the informed consent for use of Sertraline for Resident #22 slipped through the cracks and staff is working on consent at this time. The DNS further indicted she/he was unable to find a progress note stating staff contacted Resident #22's Conservator for informed consent On 5/22/2025 at 1:10 PM the administrator approached the surveyor with the 2/05/2025 psychiatric provider note that indicated Resident #22 gave permission for use of the antidepressant. The surveyor pointed out Resident #22 has a conservator of person and requested documentation that informed consent for use of psychotropic medication was provided to the conservator. On 5/22/2025 at 1:20 PM the Administrator indicated the inability to find any documentation the conservator had been informed of and provided consent for use of psychotropic medication. On 5/23/2025 at 9:21 AM a consent form for Resident #22 obtained via phone on 5/22/2025 (106 days after the medication was started) not signed by the person who obtained consent. 2. Resident #24's diagnosis included unspecified dementia and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #24 was cognitively intact. A physician's order dated 11/14/2024 directed to administer Citalopram Hydrobromide (antidepressant) 20 MG tablet once daily by mouth along with a 10 MG tab for a 30 MG dose. The care plan dated 12/17/2024 indicated Resident #24 had a behavior problem being accusatory related to dementia. Intervention included anticipating needs, assisting to develop more appropriate methods of coping with and interacting with staff. A physician's order dated 2/3/2025 directed to administer risperidone (antipsychotic) tablet 1 MG once daily for behavioral disturbances related to dementia. An interview on 5/22/2025 at 1:30 PM with the Director of Nursing [NAME] (DNS) indicated staff is working on consents for many residents at this time. An interview on 5/23/2025 at 08:38AM with Registered Nurse (RN #8) the MDS Nurse indicated the scheduler had the psychotropic medication book with the consents. An interview and review of clinical documents of various residents kept in a binder on 5/23/2025 at 8:40 AM with the scheduler identified she and a nurse aide were assigned about 2 weeks ago to call the families of the residents on the list and obtain consent over the phone for medications. They also indicated if the family had questions they would be directed to a nurse. The scheduler provided 2 psychotropic medication consent forms, one for Citalopram (antidepressant and the other for Risperdal (antipsychotic) each dated 5/08/2025 indicating verbal consent was obtained on this date. (190 days and 107 days respectively after starting the medication) An interview on 5/23/2025 at 9:11 AM with the Administrator identified she/he was waiting for the facility psychotropic medication policy. At 9:40 AM the Administrator indicated s/he had called the DNS (not in the facility) who indicated there was no policy for psychotropic medications. 3. Resident #55 's diagnoses included unspecified dementia, paranoid schizophrenia and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #55 was cognitively impaired and required supervision/ touching assistance with eating, oral hygiene and maximal assistance for personal hygiene. The care plan dated 4/1/25 identified Resident #55 requires psychotropic drugs for dementia schizophrenia and appetite stimulant (Haldol, Prozac, Remeron, trazadone). Interventions included administering medications as ordered; monitor for therapeutic effect and side effects of medication; complete behavior monitoring sheets every shift. A physician's order dated 3/15/23 directed mirtazapine 15 MG tab give 1 tablet orally at bedtime for antidepressant, an order dated 9/5/24 directed Fluoxetine HCl Oral Tablet 10 MG (Fluoxetine)Give 3 tablet by mouth one time a day for depression and anxiety and an order dated 4/10/25 directed Haloperidol Tablet 0.5 MG Give 1 tablet by mouth at bedtime for anxiety, insomnia. (consent signed for 5/8/25) The Medication Administration Records March 2023 through May 2025 indicated the following medications administered prior to consent: Fluoxetine; started 9/5/24 consent obtained 5/8/25. Haloperidol Tablet: started 4/10/25 consent obtained 5/8/25 and mirtazapine, started 3/15/23 consent obtained on 5/8/25. The interview with ADNS on 5/23/25 at 10:34AM indicated the DNS is responsible for obtaining concerns and new staff are being trained to assume the role. She is unable to explain why consents were not obtained prior to admission. Review of the Psychoactive Drug System policy dated October 2019 directed a consent from the resident and or responsible party will be obtained when a resident is started on a psychoactive medication and the resident or responsible party will be notified when the dose of the psychoactive medication has been changed by the practitioner. 4. Resident #56's diagnoses included metabolic encephalopathy, anxiety disorder, and dementia with psychotic disturbance. A physician's order dated 6/21/23 directed to administer Olanzapine (Zyprexa) 5 MG by mouth two times a day and 2.5 MG by mouth every eight hours as needed for psychotic disorder. The quarterly MDS assessment dated [DATE] identified Resident #56 had severe cognitive impairment and required set-up assistance with oral hygiene, personal hygiene, and moderate assistance with toileting hygiene, shower, and lower body dressing. The Resident Care Plan (RCP) dated 3/13/25 identified Resident #56 with impaired cognition related to dementia. Intervention directs the conservator to remain involved and intervene as needed. The RCP dated 3/13/25 also identified Resident #56 used psychotropic medications related to history of agitated behaviors and delusions. Interventions included: to administer psychotropic medications as ordered by physician and monitor side effects, and discuss with Medical Doctor, family the need for use of medication. The Psychotropic Medication Therapy Informed Consent Form dated 5/19/25 for medication Olanzapine identified verbal consent from the conservator of person (COP) and no signature from the person who obtained verbal consent from the facility. Interview with the Nurse Scheduler on 5/23/25 at 10:21 AM identified that a request was made by the Director of Nursing Services to help and assist with making phone calls to family and responsible parties to obtain verbal consent for psychotropic medications. Nurse Scheduler indicated she was not aware of the process for obtaining consent for psychotropic medication and commented she was only asked to help and did not think, she was responsible for signing the form once she received a verbal consent. Nurse Scheduler identified she was not aware of the Psychoactive Drug System policy. Interview on 5/23/25 at 10:34 AM with the Assistant Director of Nursing Services (ADNS) identified she was not aware of the process for obtaining consent from the responsible parties for psychotropic medications. She identified the Director of Nursing Services (DNS), and RN #1 were the ones responsible for the completion. The ADNS further indicated she was not familiar with the Psychoactive Drug System policy. An interview on 5/23/25 at 11:06 AM with RN #1 identified the process for obtaining consents from responsible parties for psychotropic medications was a new project started at the beginning of the week. She identified the Nurse Scheduler and a Certified Nurse Aide (CNA) who was on light duty were asked to call family and responsible parties to obtain verbal consent, and they were not aware that the form required a signature. RN #1 identified she was not aware of the Psychoactive Drug System policy. DNS was unavailable for an interview. 5. Resident #73's diagnoses included Alzheimer's disease, depression, and Post- Traumatic Stress Disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #73 had severe cognitive impairment and required supervision (helper provides verbal cues and assistance) with oral hygiene, toileting hygiene, upper & lower body dressing, and toilet transfer. The RCP dated 12/5/24 identified Resident #73 had a new onset of antipsychotic medication related to an increase in behavioral symptoms and agitated behavior. Interventions included: discussing with Medical Doctor and family the ongoing need for use of medication, monitor and record target behavior symptoms, and monitor and report adverse reactions to Psychotropic medications A physician's order dated 11/20/24 directed to administer buspirone 5 MG by mouth one time a day for anxiety. A physician's order dated 12/5/24 directed to administer quetiapine fumarate (Seroquel) 25 MG by mouth in the morning for psychotic behaviors related to dementia. A physician's order dated 2/3/25 directed to administer trazodone 50 MG by mouth one time a day for anxiety. A physician's order dated 3/26/25 directed to administer Seroquel 25 MG by mouth in the evening for restlessness and agitation. A physician's order dated 3/28/25 directed to administer buspirone 7.5 MG by mouth three times a day for agitation/anxiety. A physician's order dated 4/9/25 directed to administer escitalopram oxalate (Lexapro) 20 MG by mouth one time a day for depression. . A physician's order dated 6/4/24 directed to administer Memantine 10 MG by mouth one time a day for anxiety/agitation. However, a review of the Psychotropic Medication Therapy Informed Consent Forms for Resident #73 dated 5/21/25 for medications; quetiapine, trazodone, escitalopram, and buspirone, identified verbal consent from the responsible party and no signature from the person who obtained verbal consent from the facility. Interview on 5/23/25 at 10:34 AM with the Assistant Director of Nursing Services (ADNS) identified she was not aware of the process for obtaining consent from the responsible parties for psychotropic medications. She identified the Director of Nursing Services (DNS), and RN #1 were the ones responsible for the completion. The ADNS further indicated she was not familiar with the Psychoactive Drug System policy. An interview on 5/23/25 at 11:06 AM with RN #1 identified the process for obtaining consents from responsible parties for psychotropic medications was a new project started at the beginning of the week. She identified the Nurse Scheduler and a Certified Nurse Aide (CNA) who was on light duty were asked to call family and responsible parties to obtain verbal consent, and they were not aware that the form required a signature. RN #1 identified she was not aware of the Psychoactive Drug System policy. Review of the Psychoactive Drug System policy dated October 2019 directed a consent from the resident and or responsible party will be obtained when a resident is started on a psychoactive medication and the resident or responsible party will be notified when the dose of the psychoactive medication has been changed by the practitioner.

Based on review of the clinical record and interviews for the only resident (Resident # 5) reviewed for Bowel and Bladder Incontinence (Resident #5), the facility failed to ensure the care plan was updated to include offering a bowel and bladder retraining trial and any refusals related to participation in a retraining program. The findings include. Resident #5's diagnosis included unspecified dementia with behavioral disturbances, anxiety, and diabetes. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 as moderately cognitively impairment, uses a wheelchair and a walker, noted independence for toilet transfers and frequently incontinent of bowel and bladder. The Care plan dated 3/25/25 indicated Resident #5 was incontinent of bowels related to impaired mobility and cognition. Interventions included: to check resident every 2 hours and assist as needed and observation of pattern of incontinence and to initiate toileting schedule if needed. The care plan further indicated Resident #5 has functional mixed bladder incontinence related to impaired mobility and cognition. The care plan also indicated Resident #5 was resistant to care including refusing weights, medication and care An interview and record review on 5/20/25 at 10:10 AM with RN #1 supervisor and MDS nurse indicated the MDS assessment dated [DATE] indicate Resident #5 was frequently incontinent of urine and bowels. However, there was no evidence that Resident #5 was offered a voiding trial or bowel and bladder retraining programs or that the resident refused to participate in any of the above. RN #1 indicated the quarterly nursing assessments documented Resident #5 as continent, but the MDS which looked at all documentation indicated Resident #5 was frequently incontinent of bowel and bladder. Although RN #1 indicated Resident #5's care plan included a specific care plan indicating resistance to care nowhere in the complete care plan where it mentioned the resident was offered bowel bladder retraining program and the resident refused.

Based on, review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents reviewed (Resident # 55) reviewed for unnecessary medication, the facility failed to ensure medications were given according to physician's orders. The findings include: Resident #55 's diagnoses included unspecified dementia, paranoid schizophrenia and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 was cognitively impaired and required supervision/ touching assistance with eating, oral hygiene and maximal assistance for personal hygiene. The care plan dated 4/1/25 identified Resident #55 requires psychotropic drugs for dementia schizophrenia and appetite stimulant (Haldol, Prozac, Remeron, trazadone). Interventions included administering medications as ordered; monitor for therapeutic effect and side effects of medication; complete behavior monitoring sheets every shift. a.A physician's order dated 4/10/25 directed Haloperidol Tablet 0.5 MG Give 1 tablet by mouth at bedtime for anxiety, insomnia. The Medication Administration Records (MAR) for May 2025 identified the following medication were not given on 5/5/25: Haloperidol, Melatonin, Mirtazapine, Trazadone HCL, Guaifenesin ER, Acetaminophen Extra strength in accordance to physician's orders. May 2025 MAR also noted the following were not given on 5/7/25: Trazadone and Morphine. A review of the nursing notes for the month of May 2025 did not identify Resident #55 refusing any medications. b The MAR for May 2025 also identified the following were not performed for Resident # 55) on May 5, 2025. Ensure Plus, assessing pain, assessing for shortness of breath, assessing signs and symptoms of antidepressant. Compression stockings/ ace wraps were not applied according to order. The MAR for May 2025 noted the following were not performed on 5/7/25 Ensure Plus, assessing pain, assessing for shortness of breath. A review of the nursing notes for the month of May 2025 did not identify Resident #55 refusing any supplements or assessments. The interview with the ADNS on 5/23/25 at 10:27 AM indicated the expectation is that the MAR should be signed off if the medications are administered. She further indicated if the resident refuses, then it should be documented. Facilities Administering Medications policy identifies in part Medications are administered in a safe and timely manner, and as prescribed. If drug is withheld, refused, or given at a time other than scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.

Based on review of the facility Infection Control Program, facility documents and interview, the facility failed to ensure staff were offered education regarding the Covid 19 vaccination and alternative locations to receive the vaccine if the facility was unable to obtain the vaccine to offer to staff. The findings include: An interview with the Infection Control Nurse, Assistant Director of Nursing Services (ADNS) on 5/21/2025 at 11:50 AM identified she/he was not offered the Covid-19 immunization, and no education was provided about the Covid-19 vaccine or where the vaccine could be obtained if the facility was unable to offer and provide the vaccine. The ADNS further indicated the facility was unable to obtain the Covid 19 vaccine from the pharmacy for facility staff.

Based on review of clinical records, review of facility documentation, facility policy review and staff interviews for 3 out of 6 residents (Residents #30, # 75, 193) reviewed for abuse, the facility failed to ensure each resident was free from abuse. The findings included. 1. a. Resident #30's diagnosis included hemiplegia, hemiparesis, aphasia and anxiety. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated mild cognitive impairment. The care plan dated 3/3/2025 indicated Resident #30 was involved in an altercation with roommate (Resident #31) on 12/23/2024. Interventions included 1:1 visits with the social worker, offer a room change and place with an appropriate roommate, refer to psychiatric services for follow up and for staff to monitor for signs and symptoms of any changes in resident's moods or behaviors and address promptly. b. Resident #33's diagnosis included adjustment disorder and depressive episodes. The quarterly MDS assessment dated [DATE] indicated Resident #31 was cognitively intact. The care plan dated 2/25/2025 indicated Resident #33 had a history of agitation. Interventions included: to continue with medication as ordered 1:1 visits with the social worker as needed and refer to psychiatric services for follow up as needed. The care plan further indicated Resident #33 had potential for trauma related to history of being assaulted. Interventions included: to assist residents in identifying triggers and measures to relieve anxiety and to observe adjustment difficulties. The facility Incident Report indicated a Resident-to-Resident altercation occurred on 12/23/2024 at 6:15 PM where roommates (Resident #30 and #33), were witnessed arguing over closet space, came out of the room continuing to argue, Resident #30 allegedly grabbed Resident #33's arm over closet space and Resident #33 was observed striking Resident #30 in the face. The report further indicated that the supervisor (RN #4) notified the Director of Nursing Services immediately after placing the residents on 1:1 supervision, a room change was completed, the local police were notified, and an investigation was initiated. On 5/23/25 at 11:27 AM an interview and review of written statement with a charge nurse (LPN #8) who witnessed what transpired during the incident identified Resident #30 stated clothing in the shared closet each resident shared were claiming to be their own, Resident #33 was attempting to leave the room but Resident #30 was trying to block his/her exit. LPN #8 indicated s/he allowed Resident #33 to leave the room. Resident #30 followed Resident #33 out of the room, and both started to argue again, Resident #30 attempted to stop Resident #33 again while trying to get away from the situation at which time LPN #8 and other staff tried to separate the residents. LPN #8's statement indicated she/he saw Resident #33 strike Resident #30 in the cheek twice while he/she tried to separate them. LPN #8 further indicated the supervisor was notified and arrived on the unit and notified who needed to be called and the police came in. Attempts to reach NA #7 on 5/23/25 at 11:41 AM and NA# 9 05/23/25 11:47 AM who written statements indicated observing Resident #31 strike Resident #30 were not successful. On 5/23/25 at 1:34 PM an interview with the Nursing Supervisor (RN #4) indicated she/he did not recall to anything about the incident and was out of the country on vacation . RN # 4 asked the surveyor to refer to the written statement. 2. Resident #75 's diagnoses included vascular dementia, difficulty in walking and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #75 was cognitively impaired and required partial assistance with bed mobility and sit to stand transfers. MDS identified Resident #75 requires a manual wheelchair to ambulate. The care plan dated 8/23/24 identified Resident #75 is at risk for changes in mood/behavior. impaired cognition. Interventions included: to provide comfort and emotional (support) as needed and to refer to psychiatric services for intervention as needed. A nurse's note dated 9/23/24 at 5:48 PM identified Charge nurse reported resident was hit by another resident in the face. This incident was witnessed by nursing assists who stated resident when in the other person's bedroom and hit her/him in the face with her/his hands. Residents couldn't recall what happened due to cognitive loss dementia. On assessment no signs or symptoms of injury noted. The phone interview with NA #1 on 5/22/25 at 12:22 PM indicated Resident #75 and Resident #63 lived on different units at the time of the incident. NA#1 reported Resident #63 was a known wander who often wanders into other resident's room, particularly Resident # 63 wandered into Resident #75's room due to the room being at the end of the hallway, where Resident #63 likes to hangout. NA#1 stated the day of the incident she heard Resident #75 screaming stop bumping into me. She reported upon entering the room Resident #63 grabbed Resident #75s by the hair and pulled. NA#1 reported she was able to intervene and separate them. Interview with ADNS on 5/22/25 01:55 PM indicated any resident with known wandering behaviors should have been cued and supervised. She reported subsequent to the incident on 9/23/24 interventions were put in place to prevent Resident #63 from wandering into Resident #75's room. Facility abuse policy indicates in part It is the policy of the facility that each resident has the right to be free from abuse . it is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe place. 3 a. Resident #81's diagnosis included adjustment disorder with mixed anxiety and depressed mood. The care plan dated 4/14/2025 indicated Resident #81 had a diagnosis of major depression, sad and anxious mood. Interventions included: 1: 1 visit by the social worker for venting, socialization and emotional support. The care plan further indicated Resident #81 had potential for trauma related to medical condition, pending surgical procedure and depression/anxiety. Interventions included: to assist the resident to identify triggers and measures that relieve anxiety and to observe for adjustment difficulties. The care plan further indicated Resident #81 stated difficulty sleeping through the night. Interventions included: to evaluate room for noise, darkness, temperature and comfort and offer sleep aid as ordered. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #81 was cognitively intact. b. Resident #193's diagnosis included dementia, Parkinsons disease, and syncope with collapse(fall). A nursing progress note dated 5/20/2025 at 11:30 PM indicated Resident #193 arrived via ambulance from the hospital for admission. The resident was oriented to name and date of birth but otherwise confused. The Nursing admission /readmission Evaluation dated 5/21/2025 at 2:10 AM indicated in part Resident #193 was oriented to person, confused and cognitively impaired. The care plan dated 5/21/2025 indicated in part Resident #193 had impaired cognitive function. Interventions included: keeping the routine consistent and trying to provide consistent caregivers. The care plan further indicated Resident #193 was at risk for falls. Interventions included: to anticipate needs, call bell within reach, and to provide a safe environment. An observation 5/21/25 at 06:49 AM identified Resident #193 in the lounge in a reclining wheelchair with NA #8 present who indicated Resident #193 had come out of his/her room and she/he had been attempting to place the resident back to bed secondary fall risk and confused. On 5/21/2025 at 6:52 AM and interview and observation with the nursing supervisor (RN #) indicated NA#8 had been watching Resident #193 for safety due to agitation as Resident #193 had a verbal altercation with a threat made to Resident # 81 with the roommate last night so the staff brought Resident #193 out of the room. After being asked what process was followed the altercation RN #1 indicated to refer to the charge nurse for more information and her/his nurses note. On 5/21/25 at 6:53 AM an interview with charge nurse LPN #6 indicated the roommate, Resident #81 said s/he was going to strangle Resident #193. NA #8 stayed with the residents while LPN #6 obtained a wheelchair and brought it to the NAs in the room who then transferred Resident #193 into the wheelchair and brought Resident # 193\ to the lounge where NA #8 stayed with Resident # 193 for safety. LPN #6 further indicated Resident #81 was very unhappy. An interview on 5/21/25 at 06:54 AM with NA #8 with LPN #6 present indicated Resident #193 was in his/her room yelling and attempting to get out of bed. The roommate (Resident #81) indicated she/he did not want Resident #193 in the room and the resident should be somewhere else. NA #8 indicated she/he told Resident #81 s/he would need to speak with the social worker in the morning. NA#8 indicated while Resident #193 was yelling, Resident #81 told Resident #193 to shut the fuck up or I will strangle you. Resident #193 was brought out to the lounge in a wheelchair where NA#8 stayed with the resident. LPN #6 added the supervisor (RN#1) came to the unit. When asked what the process was when an altercation between two residents occurs, LPN #6 indicated she/he was taught to call the supervisor and separate the residents. LPN #6 and NA#8 indicated the supervisor suggested brining the resident to the lounge and asked what happened, no statements in writing were requested from them. A nursing note dated 5/21/2025 at 2:21:00 written by RN #1 indicated (Resident #193) was yelling and not getting along with roommate (Resident #81) Resident #193 was found walking in room, confused and placed in a wheelchair and indicated Resident # 193 was monitored by nurse aides. An interview with the DNS on 5/23/2025 at 2:12 PM indicated the incidents of abuse (Resident #30, #31 and #81, #193) were found to be substantiated. The facility policy labeled Abuse indicated in part notes verbal abuse is defined as oral written that willfully includes disparaging and derogatory terms to residents or within their hearing distance regardless of age, ability to comprehend, or disability. The policy further indicated some examples of verbal abuse include threats of harm and saying things to frighten a resident. The policy also indicated that allegations or observation of abuse must be reported immediately to the administrator and the DNS. After notification is made to the administrator and the DNS, the administrative staff or the nursing supervisor will assume responsibility for notifying the physician and conducting an immediate investigation into the alleged incident (during the shift it occurred). The incident needs to be reported to the state agency and the local law enforcement need to be notified within 2 hours of the abuse allegation or observed abuse.

Based on review of the clinical record, review of facility policy and interviews for the only residents (Resident # 87), reviewed for hospitalization, the facility failed to ensure staff notified the resident and responsible party in writing of reason for transfer/discharge to the hospital. The findings include. Resident #87's diagnosis included Gastroesophageal Reflux (GERD) without bleeding, gastrostomy status, dysphagia and cerebral infarction. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #87 had moderate cognitive difficulty. The care plan dated 5/22/2025 indicated Resident # 87 had a potential for bleeding secondary to use of anticoagulation therapy secondary to a new Cerebrovascular Accident (CVA). Intervention included: to administer medication as ordered, laboratory work as ordered, observe for adverse side effects and notify the physician immediately. The progress note dated 5/23/2025 at 5:36 AM indicated Resident #87 vomited a large amount of dark black emesis, the provider and responsible party were notified, and Resident #87 was sent to the hospital. An interview and record review on 5/23/25 at 2:27 PM with the Administrator and the Assistant Director of Nursing Services (ADNS), indicated the ADNS did not know what the process was for informing the resident and responsible party of a bed hold when a resident is transferred to the hospital. The ADNS also was unable to locate any documentation in the clinical record indicating verbally or in writing the responsible party had been notified of the bed hold options. The Administrator indicated there was a process and she/he would talk with the social worker and the Business Office Manager. On 5/23/25 at 2:37 PM the Administrator found information regarding the bed hold process on page 11 of the admission packet. However, the Administrator was unable to indicate how the facility informs the resident and/or responsible party of bed hold options in writing when a resident is transferred to the hospital. An interview with the Business Office Manager on 5/23/25 at 2:45 PM indicated the social worker would oversee notification in writing to the resident/responsible party and the ombudsman when there is a bed held, the bed hold information with payment option is in the admission packet. An interview on 05/23/25 2:50 PM with the Administrator indicated when she/he spoke to the social worker she/he indicated there was no form or documentation for tracking bed hold notification. The Administrator indicated the facility always holds each resident's bed. The facility policy labeled Bed-Holds and Returns indicated in part prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy.

Based on clinical record reviews, facility documentation, review of policy and interviews for 1 out of 6 residents (Resident #193) reviewed for abuse, the facility failed to ensure staff immediately reported an episode of verbal abuse to the Administrator, the Director of Nursing Services, local authorities, start the investigation and timely report the abuse to the state agency. The findings included: 1 a Resident #81's diagnosis included adjustment disorder with mixed anxiety and depressed mood. The care plan dated 4/14/2025 indicated Resident #81 had a diagnosis of major depression, sad and anxious mood. Interventions included: 1:1 visits by the social worker for venting, socialization and emotional support. The care plan further indicated Resident #81 had potential for trauma related to medical condition, pending surgical procedure and depression/anxiety. Interventions included: to assist the residents to identify triggers and measures that relieve anxiety and to observe for adjustment difficulties. The care plan further indicated Resident #81 stated difficulty sleeping through the night. Interventions included: to evaluate room for noise, darkness, temperature and comfort and offer sleep aid as ordered. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #81 was cognitively intact. b. Resident #193's diagnosis included dementia, Parkinsons disease, and syncope with collapse(fall). A nursing progress note dated 5/20/2025 at 11:30 PM indicated Resident #193 arrived via ambulance from the hospital for admission to the facility. The resident was oriented to name and date of birth but otherwise confused. The Nursing admission /readmission Evaluation dated 5/21/2025 at 2:10 AM indicated in part Resident #193 was oriented to person, confused and cognitively impaired. The care plan dated 5/21/2025 indicated in part Resident #193 had impaired cognitive function. Intervention included: to keep the routine consistent and try to provide consistent caregivers. The care plan further indicated Resident #193 was at risk for falls. Interventions included: to anticipate needs, call bell within reach, and to provide a safe environment. An observation 5/21/25 at 6:49 AM identified Resident #193 in the lounge in a reclining wheelchair with NA #8 present who indicated Resident #193 had come out of his/her room and she/he had attempted to put the resident back to bed secondary to fall risk and confusion. On 5/21/2025 at 06:52 AM and interview and observation with the nursing supervisor (RN #1), indicated NA#8 had been watching Resident #193 for safety due to agitation as Resident #193 had a verbal altercation with a threat made to Resident #193 with the roommate (Resident # 81) last night. The staff brought Resident #193 out of the room due to the threat. After being asked what process was followed after the altercation RN #1 indicated to refer to the charge nurse for more information and her/his nurses notes. On 5/21/25 at 06:53 AM an interview with charge nurse LPN #6 indicated the roommate (Resident #81) said s/he was going to strangle Resident #193 so while NA #8 stayed with the residents LPN #6 obtained a wheelchair. LPN # 6 brought the wheelchair to the nurse aides in the room and Resident #193 was transferred into the wheelchair and brought to the lounge where NA #8 stayed with Resident # 193 for safety. LPN #6 further indicated Resident #81 was very unhappy. An interview on 5/21/25 at 06:54 AM with NA #8 with LPN #6 present indicated Resident #193 was in his/her room yelling and attempting to get out of bed. The roommate (Resident #81) indicated not wanting Resident #193 in the room and the resident should be somewhere else. NA #8 indicated telling Resident #81 s/he would need to speak with the social worker in the morning. NA#8 indicated while Resident #193 was yelling, Resident #81 told Resident #193 to shut the fuck up or I will strangle you. Resident #193 was brought out to the lounge in a wheelchair where NA#8 stayed with the resident. LPN #6 added the supervisor (RN#1) came to the unit. When asked what the process was when an altercation between two residents occurs, LPN #6 indicated she/he have been taught to call the supervisor and separate the residents. LPN #6 and NA#8 indicated the supervisor suggested brining the resident to the lounge and asked what happened, no statements in writing were requested from them. A nursing note dated 5/21/2025 at 9:21 PM written by RN #1 indicated (Resident #193) was yelling and not getting along with roommate (Resident #81) Resident #193 was found walking in room, confused and placed in a wheelchair where she/he could be monitored by the nurse aides. An interview with the Director of Nursing Services (DNS) on 5/21/25 at 7:39 AM upon arrival at the facility indicated she/he had not received any calls from the nursing supervisor overnight. An interview and clinical record review with RN#1 on 5/21/25 at 7:45 AM identified she/he did not write any details about the altercation between the two residents because s/he did not hear Resident #81 threaten Resident #193. RN #1 response to being asked if s/he documented in the aggressor's clinical record (Resident #81) RN#1 indicated no note was written and verified during the record review no other staff members wrote any notes related to the incident. An interview and record review on 5/21/25 at 8:49 AM with the DNS indicated s/he would have expected a phone call to her/him immediately and separation of the residents for safety. If the residents are under control, call the physician and report the incident if not, send the resident(s) to the hospital for an evaluation. The DNS further indicated she/he would report the incident to the state agency after the interview, since she/he was just informed (7.5 hours after it occurred). The DNS further indicated a room change for Resident #193 was completed this am and she/he would be reaching out to psychiatric services for both residents. An interview with the DNS on 5/23/2025 at 02:12 PM indicated the incidence of abuse for (Residents #81, #193) was substantiated. The facility policy labeled Abuse indicated in part that allegations or observation of abuse must be reported immediately to the administrator and the DNS. After notification is completed to the administrator and the DNS, the administrative staff or the nursing supervisor will assume responsibility for notifying the physician and conduct an immediate investigation into the alleged incident (during the shift it occurred). The incident needs to be reported to the state agency and the local law enforcement within 2 hours of the observation or allegation of abuse.

Based on clinical record reviews, observation, record review, and staff interviews for 1 of 4 residents reviewed for Abuse (Resident # 63),the facility failed to ensure a person-centered care plan with identified interventions for known behaviors and for 1 of 1 resident reviewed for positioning (Resident #30), the facility failed to develop and implement a care plan that addressed the resident's refusal of a hand splint. The findings included: 1.Resident #63's diagnoses included dementia, anxiety disorder and Alzheimer's disease. The care plan initiated 1/9/25 and revised on 3/25/25 identified, Resident #63 has the potential for elopement; wanders self-propelling in wheelchair, at times can be intrusive wandering, disrupting others and poor self-awareness. Interventions include attempting to redirect when wandering, encouraging participation in recreational activities, and observing for safety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #63 was cognitively impaired. The MDS identified the resident uses walker and [NAME] chair to ambulate and noted the resident exhibited wandering behaviors that occurred daily. A physician's order dated 9/5/24 directed to assess placement of wander guard every shift. A nurse's note dated 9/23/24 at 4:59 PM identified in part Resident #63 hit another resident in the face (Resident # 75). On assessment resident with increased agitation talking loudly . both residents were separated immediately and aggressor (Resident #63) placed on 1.1 supervision. A review of the Interview with Assistant Director of Nursing Services (ADNS) on 5/22/25 1:55 PM indicated any resident with known wandering behaviors should have been cued and supervised. She also reported after the incident on 9/23/24 interventions were put in place to prevent Resident #63 from wandering into Resident #75's room Interview with on LPN #8 on 5/23/25 at 2:29 PM indicated, given the behaviors were identified prior to incident, there should have been a care plan with interventions to address the behavior. She also indicated that the staff or department who triggered the behaviors on the MDS should have ensured it was included on the care plan. Facilities Comprehensive Person-Centered care plan policy indicates in part Disciplines will be responsible for updating the care plan when there is a new problem that requires that discipline to intervene. : 2.Resident #30 was admitted with diagnoses that included right-sided paralysis, stroke, and difficulty speaking. A physician's order dated 10/13/2024 directed Resident #30 to wear a right wrist/hand orthosis daily: on at noon meal and off after evening meal. The physician's order identified the resident was able to don and doff the orthosis independently and further directed to remind Resident #30 daily at noon meal to put on the splint and help per resident preference. The quarterly MDS assessment dated [DATE] identified Resident #30 had unclear speech and moderate cognitive impairment. Additionally, the MDS assessment indicated Resident #30 had not exhibited behaviors of rejecting evaluation or care. A care plan revised on 4/1/2025 identified Resident #30 required a splint to the right hand worn continuously. Interventions included a resting hand split placed at noon meal if it was not already in place and removed at bedtime, to assist the resident as needed for proper application. A review of the Treatment Administration Record (TAR) from 5/1/2025 through 5/21/2025 indicated Resident #30 had refused the right-hand splint on 5/6/2025, 5/10/2025, 5/16/2025, and 5/19/2025. A nursing note dated 5/16/2025 indicated Resident #30 refused his/her hand splint twice. An observation on 5/19/2025 at 12:09 PM identified Resident #30 as not wearing a right-hand split. An observation on 5/20/2025 at 12:00 identified the resident was not wearing a right-hand splint. On 5/22/2025 at 12:45 PM, an interview with LPN #3 identified the LPN thought that Resident #30 had a splint on and the aides were responsible for applying splints. On 5/22/2025 at 12:47 PM, an interview with NA #5 indicated Resident #30 does not like to wear the right-hand splint and the resident removes it when it is placed by the nurse aides. NA#5 indicated she had not offered the splint on 5/22/2025 and indicated she was not aware of when the resident should be reminded to apply the hand splint. On 5/22/2025 at 1:01 PM, an observation with NA#5 identified that NA#5 had difficulty in locating Resident #30's splint and eventually found it in the resident's wardrobe on the top drawer. Resident #30 was observed applying the hand splint independently. On 5/22/2025 at 1:30 PM, Resident #30 was observed in the hallway wearing the right-hand splint. On 5/23/2025 at 11:21 AM, an interview with the ADNS indicated although the resident has a physician's order to remind to wear right hand splint, she would not have expected staff to remind the resident to put on the right-hand splint because the resident is alert and oriented. Additionally, the ADNS indicated that if the resident was refusing the splint, as staff had identified, then there should have been a care plan addressing the resident's refusal of the right-hand splint. The facility policy for the use and monitoring of splinting devices indicated that it was the nursing unit's responsibility to ensure that the splint was worn and cared for properly.

[NAME], [NAME] P. Based on clinical record review, facility documentation review, facility policy review, and interviews for four of four residents (Resident #1 and #3) reviewed for comprehensive care plans, the facility failed to ensure the care plans included bed rail usage/interventions. The findings include: 1. A. Resident #1's diagnoses included dementia and contractures. Physician order dated 1/28/2025 directed to provide half side rails on every shift. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen (0/15), indicative of severe impaired cognition and was dependent with ADLs (activities of daily living). The Resident Care Plan (RCP) dated 2/15/2025 identified Resident #1 had an ADL self-care deficit related to dementia. Interventions directed required staff to turn and reposition in bed and allow staff to maximize independence with turning and repositioning in bed. A nursing quarterly evaluation dated 2/15/2025 identified Resident #1's side rail/grab bar recommendation was to use bilateral side rails. The side rail/grab bar decision indicated that the side rail(s) were indicated and serve as an enabler to promote independence at this time. Record review failed to identify a care plan that directed use of the side rails. B. Resident #3's diagnoses included dementia and anxiety disorder. Physician order dated 2/6/2025 directed to provide two, quarter side rails bilaterally on every shift. A nursing quarterly evaluation dated 3/20/2025 identified Resident #3's side rail/grab bar recommendation was bilateral side/grab rails. The side rail/grab bar decision indicated that the side rail/grab bar(s) were indicated and serve as an enabler to promote independence at this time. The Quarterly MDS assessment dated [DATE] identified Resident #3 had a BIMS score of thirteen out of fifteen (13/15), indicative of cognitively intact and required assistance with ADLs. The RCP dated 4/2/2025 identified Resident #3 has an ADL self-care deficit related to dementia with the inability to initiate or follow through consistently. Interventions directed to assist with ADLs and was independent for bed mobility and moving side to side. Intermittent observations on 4/30 and 5/1/2025 during the 7:00 AM to 3:00 PM shift identified bilateral top bed rails were being utilized. Record review failed to identify a care plan that directed use of the side rails. Interview with DON on 5/1/2025 at 2:50 PM identified the care plans for Resident #1 and Resident #3 did not include a side rail indication or include side rail use. The DON identified all residents should have care plans reflecting the use of side rails. The DON was unable to indicate why Resident #1 and Resident #3's care plans did not include use of side rails. Review of the Side Rail Policy dated 5/2017 directed in part, upon admission, re-admission, significant change, a change in bed mobility, and as needed, the resident will be evaluated for the need for partial side rails to assist with bed mobility. The resident/significant other/responsible party will be provided with education regarding the decision on use of partial side rails to assist with bed mobility. The use of side rails or partial side rails will be documented on the resident's plan of care.

Based on clinical record review, facility documentation review, facility policy review, and interviews for four of four residents (Resident #1, #2, #3, and #4) reviewed for quality of care, the facility failed to provide education and obtain consents for use of bed rails, and the facility failed to date completed bed rail testing/audits, and failed to perform bed rail audits at six-month intervals in accordance with facility policy, and failed to ensure staff accurately performed a side rail test for risk of entrapment per device manufacture guidelines. The findings include: 1. A. Resident #1's diagnoses included dementia and contractures. Physician order dated 1/28/2025 directed to provide half side rails on every shift. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen (0/15), indicative of severe impaired cognition and was dependent with ADLs (activities of daily living). The Resident Care Plan (RCP) dated 2/15/2025 identified Resident #1 had an ADL self-care deficit related to dementia. Interventions directed required staff to turn and reposition in bed and allow staff to maximize independence with turning and repositioning in bed. A nursing side rail quarterly evaluation dated 2/15/2025 identified Resident #1's side rail/grab bar recommendation was to use bilateral side rails. The side rail/grab bar decision indicated that the side rail(s) were indicated and serve as an enabler to promote independence at this time. Review of Resident #1's clinical record failed to identify a consent was obtained for bed rail use. B. Resident #2's diagnoses included dementia with behavior disturbance and anxiety disorder. The Quarterly MDS assessment dated [DATE] identified Resident #2 had a BIMS score of twelve out of fifteen (12/15), indicative of moderately impaired cognition and was independent with ADLs. A nursing side rail quarterly evaluation dated 2/28/2025 identified Resident #2's side rail/grab bar recommendation was side rails were not indicated at this time. The RCP dated 3/7/2025 identified Resident #2 had an ADL self-care deficit related to dementia, arthritis, left shoulder pain, and weakness. Interventions directed use of side rails to include one (1) grab bar and one and half (1 ½) side rails on the window side of the bed. Physician order dated 4/28/2025 directed to provide one (1) grab bar and one (1) half side rail (window side) to assist with bed mobility. Intermittent observations on 4/30/2025 and 5/1/2025 during the 7:00 AM to 3:00 PM shift identified bilateral top bed rails were being utilized. Review of Resident #2's clinical record failed to identify consent of bed rail use was obtained. C. Resident #3's diagnoses included thrombocytosis, dementia and cerebral infarction. Physician order dated 2/6/2025 directed to provide two (2) quarter side rails bilaterally on every shift. A nursing side rail quarterly evaluation dated 3/20/2025 identified Resident #3's side rail/grab bar recommendation was to use bilateral grab bars. The side rail/grab bar decision indicated that the side rail/grab bars were indicated and serve as an enabler to promote independence at this time. The Quarterly MDS assessment dated [DATE] identified Resident #3 had a BIMS score of thirteen out of fifteen (13/15), indicative of cognitively intact and required assistance with ADLs. The RCP dated 4/2/2025 identified Resident #3 has an ADL self-care deficit related to dementia with the inability to initiate or follow through consistently. Interventions directed assist with ADLs and was independent for bed mobility and moving side to side. Intermittent observations on 4/30/2025 and 5/1/2025 during the 7:00 AM to 3:00 PM shift identified bilateral top bed rails were being utilized. Review of Resident #3's clinical record failed to identify consent of bed rail use was obtained. D. Resident #4's diagnoses included Parkinson's disease, dementia, and morbid obesity. Physician order dated 2/11/2025 directed to provide two (2) quarter side rails. The Quarterly MDS assessment dated [DATE] identified Resident #4 had a BIMS score of zero out of fifteen (0/15), indicative of severely impaired cognition and was dependent with ADLs. The RCP dated 4/7/2025 identified Resident #4 required assistance with bed mobility. Interventions directed two (2) ¼ side rails up as ordered while in bed A nursing side rail quarterly evaluation dated 4/7/2025 identified Resident #4's side rail/grab bar recommendation was bilateral side rails. The side rail/grab bar decision indicated that the side rails were indicated and serve as an enabler to promote independence at this time. Record review failed to identify the resident and/or family were educated on the risks associated with side/grab bar use. Intermittent observations on 4/30/2025 and 5/1/2025 during the 7:00 AM to 3:00 PM shift identified bilateral top bed rails being utilized. Review of Resident #4's clinical record failed to identify consent of bed rail use was obtained. Interview and record review with DON (Director of Nursing) on 5/1/2025 at 2:50 PM identified residents and/or the responsible parties should be provided education regarding use of side rails, and consents should be obtained. The DON indicated she had reviewed Resident #1, #2, #3, and #4's records, and was unable to provide documentation that education was provided and that consents were obtained for the use of the bedrails/side rails. The DON identified she was informed that the previous DON had removed the consent for bedrails that had been located within the admission paperwork, and indicated that was why the residents did not have consent paperwork. Review of the Side Rail Policy dated 5/2017 directed in part, The resident/significant other/responsible party will be provided with education regarding the decision on use of partial side rails to assist with bed mobility. The Policy further directed, use of partial side rails will be documented on the resident's plan of care. 2. Review of facility documentation for Resident #1, #2, #3, and #4's bed, mattress, side rail, entrapment and safety audit form identified all resident's beds had passed inspection in March and April 2025 and May 2024. Additionally, there was no date listed on any of the audit forms. Documentation review failed to identify the side rails were audited twice a year. Interview with DOM (Director of Maintenance) on 5/1/2025 at 1:45 PM identified he performs the audits on the bed rails annually. The DOM indicated if there is an open time in his schedule to perform the audits on a random basis (the beds are not assigned a scheduled time), he will conduct them, but he does not document the dates of the audits on the paperwork. The DOM was unable to provide documentation of the dates that the beds were audited. Review of the Bed and Side Rail Safety, Assessment, and Audit Policy dated 8/01/2023 directed in part, twice annually, at six-month intervals, and as needed, the residential site manager, or the manager's designee, shall visibly assess the bed and side rails, using the Bed and Side Rail Safety Checklist. Any issues identified in the checklist shall be documented by the person completing the checklist along with a proposed plan to address the identified issues. 3. Observation of Resident #3's bed on 4/30/2025 at 12:45 PM identified the left upper side railing was loose and was able to extend outward by approximately three (3) to four (4) inches. Interview with DOM on 4/30/2025 at 1:30 PM identified the facility utilized the Bionix B4000 Bed System Measurement Device (BSMD) to perform entrapment assessments on all resident beds. Review of the Bionix B400 BSMD instruction manual for Zone 3 (side rail zone) directed in part the following instructions: 1. Firmly push the mattress away from the rail being measured until it stops. 2. Put the cone near the rail being tested and attach the safety strap. 3. Put the cone horizontally in the gap. Do not push the tool down into the gap. 4. Turn the cone until the line on the end is horizontal. 5. Let the cone sink into the space by its own weight. If the cone is tilted, use one hand to gently level it. Do not push the tool down in the gap. 6. Determine whether the cone's center sinks completely below the surface of the mattress. 7. Interpret test results and record the results on the data sheet. Interview and observation of an audit of the Bionix B4000 BSMD guidelines performed on Resident #3's bed on 4/30/2025 at 2:00 PM with the DOM identified DOM did not accurately perform Zone 3 of the testing requirements. The DOM did not follow the manufacture guidelines for Zone 3, and instead, the test DOM performed was indicated for Zone 4. The test for Zone 3 was not performed. Subsequent to surveyor inquiry, Resident #3's bed side railing was fixed, prior to retesting for Zone #3 on 5/1/2025. Interview with DOM on 5/1/2025 at 1:45 PM identified although he did not test Zone #3 accurately, he believed Resident #3's bed passed the test due to all other zones had passed the testing/audit and met the expected range of distance allowed of 4 ¾ (four and three-quarter) inches within the gaps. The DOM was unable to explain how the bed would pass if Zone 3 was not tested.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for behaviors, the facility failed to ensure that behavior monitoring was completed on a resident receiving antipsychotic medications. The findings include: Resident #1's diagnoses included anxiety disorder, schizoaffective disorder and bipolar disorder. A physician's order dated 10/9/24 directed to administer Aripiprazole 5 milligram (mg) tablet by mouth at bedtime for bipolar disorder. A physician's order dated 6/11/24 directed to administer Cariprazine (an antipsychotic medication used to treat schizophrenia, bipolar disorder and major depression) 6 milligram (mg) capsule by mouth once daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and was dependent on staff for transfer assistance. The Resident Care Plan (RCP) dated 12/26/24 identified that Resident #1 uses psychotropic medications related to diagnoses of bipolar disorder and schizoaffective disorders with interventions that included to administer psychotropic medications as ordered by physician and monitor for side effects and effectiveness every shift and monitoring/recording occurrences of target behavior symptoms and document per facility protocol. A physician's order dated 1/27/25 and discontinued on 2/13/25 directed to administer Seroquel (an antipsychotic medication used to treat schizophrenia, bipolar disorder and depression) 25 milligram (mg) tablet by mouth at bedtime. A physician's order dated 2/13/25 directed to administer Seroquel 25 milligram (mg) tablet by mouth at bedtime. Review of physician's orders dated 1/1/25 through 2/28/25 failed to identify a physician's order directing staff to monitor Resident #1's behaviors associated with the use of antipsychotic medications. Review of the January and February 2025 Medication Administration Records for Resident #1 failed to identify that behaviors were being monitored alongside the use of antipsychotics. Review of nurse's notes dated 1/1/25 through 2/19/25 failed to identify documentation related to behavior monitoring every shift. Interview with APRN #1 (psychiatric) on 3/6/25 at 11:40 AM identified that Resident #1 should have had behavior monitoring in place every shift, as he/she was on several antipsychotic medications. She identified that she was new to the facility, so she did not identify the omissions but stated that behavior monitoring is used to identify any increased or improved behaviors and guides a resident's treatment. She identified that at the least, the resident should have been monitored every shift for mood, anxiety, paranoia and agitation. Interview with the ADNS on 3/6/25 at 11:50 AM identified that although she was unable to locate any documented behavior monitoring on Resident #1, she would expect that a physician's order be obtained when a resident is placed on any antipsychotics and that target behaviors are monitored every shift. She reported that she was unsure why a physician's order had not been obtained and why target behaviors were not monitored on Resident #1, as they should have been. Review of the Behavioral Assessment, Intervention and Monitoring policy (undated) directed, in part, that behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. Residents will have minimal complications associated with the management of altered or impaired behavior. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Review of the Antipsychotic Medication Use policy (undated) directed, in part, that the attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms and risks to the resident and others. The attending physician and facility staff will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting why the benefits of the medication(s) outweigh the risks or suspected or confirmed adverse consequences.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for hospitalizations, the facility failed to ensure complete and accurate documentation including an oxygen level when the resident was noted to have increased respirations and breathing heavily, provider notification and ensuring documentation of a physician's order related to a Emergency Department (ED) transfer. The findings include: Resident #2's diagnoses included acute and chronic respiratory failure, congestive heart failure, chronic kidney disease and kidney failure. The Resident Care Plan (RCP) dated 1/15/24 identified that Resident #2 has altered cardiovascular status related to atrial fibrillation (irregular heartbeat) with interventions that included to assess for chest pain, shortness of breath, monitor vital signs and notify the physician of significant abnormalities, and monitor/document/report as needed any changes in lung sounds on auscultation, edema and changes in weight. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required substantial assistance with bed mobility and was dependent on staff for transfers and ambulation. A nurse's note dated 2/15/24 at 5:20 AM identified that Resident #2 was scheduled for dialysis and was to be transported by his/her spouse. The note identified that it took an assist of three (3) staff to get the resident into the wheelchair and the resident was then brought out to the nurses station awaiting his/her spouse to bring the car to the side door. While waiting, the resident started breathing heavily, skin was noted to be pale and cold, the resident complained of blurry vision and weakness but denied any pain. Vital signs were obtained to include a blood pressure of 101/92, heart rate of 60 beats per minute, body temperature of 97.6 degrees Fahrenheit and respirations between 24 and 28. The note identified that the nursing supervisor was present and 911 was called at 5:40 AM and the ambulance arrived and transported Resident #2 to the hospital. Review of nurse's notes dated 2/15/24 through 2/16/24 failed to identify any additional notes or documentation that an RN assessment was completed, the provider was notified or that an oxygen (Sp02) level was obtained. Review of physician's orders dated 2/15/24 through 2/16/24 failed to identify a physician's order directing staff to transfer the resident to the hospital for an evaluation. A social service note dated 2/16/24 at 8:07 AM identified that per nursing, Resident #2 was transferred to the hospital on 2/15/24 and passed away at the hospital. Interview with RN #2 (Nursing Supervisor) on 3/6/25 at 1:19 PM identified that staff identified promptly that Resident #2 had a change in condition, as he/she had a very brittle health status stating she was notified by RN #1, and the resident was immediately sent to the ED for evaluation. She reported that although she did not document a note and she should have, she assessed the resident to include lung sounds and stated they obtained an oxygen level on the resident but stated she was unsure why it wasn't documented in the clinical record. She identified that she also notified the provider of the change and obtained a physician's order to transfer the resident to the ED but stated that she must have forgotten to enter the order and document who she notified and at what time, stating it was a hectic morning. RN #2 reported that it was facility practice that the assessment, provider notification and time of transfer for a change in condition was to be documented in a nurse's note, stating they didn't have a SBAR assessment in their system. Interview with RN #1 on 3/6/25 at 1:52 PM identified that as soon as Resident #2's spouse went to get the car, the resident became pale, diaphoretic and his/her respirations increased. She identified that although the vitals were documented except for the oxygen level, she was aware the resident appeared to be short of breath and they would have checked his/her oxygen and must have forgot to document the result. She identified that RN #2 was responsible for notifying the physician and obtaining and entering the order to transfer the resident to the ED for evaluation. Interview with the ADNS on 3/6/25 at 3:3 PM identified that all care provided to a resident and communication with a provider regarding a resident should be documented in the clinical record timely. Review of the Change in a Resident's Condition or Status policy (undated) directed, in part, that the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition or the need to transfer the resident to a hospital/treatment center. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the SBAR Communication Form. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) who was at risk for elopement , the facility failed to develop an at risk for elopement care plan . The findings include: Resident #1's diagnoses included Parkinson's disease, dementia with behavioral disturbances, adjustment disorder (excessive reactions to stress) and repeated falls. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required supervision assistance with transfers and ambulation with a walker. Review of the Elopement Risk Evaluation dated 6/24/24 identified that Resident #1 was at risk for elopement. A nurse's note dated 9/7/24 at 9:21 AM identified that the resident insisted on leaving the facility to attend church and he/she was unable to be redirected. The nurse supervisor followed the resident out the front door, and he/she became 'belligerent' and proceeded down the driveway accompanied by staff. The police were called and when they arrived the resident was agreeable to returning to the facility. A nurse's note dated 9/7/24 at 9:47 AM identified that a Wanderguard was applied to the resident's walker, after being previously removed by the resident. A nurse's note dated 9/9/24 at 3:31 PM identified that the resident once again went out to the front porch unattended and was resistive to the staffs request and redirection to return inside, reporting that staff stayed with the resident, and he/she did eventually return inside but then refused to use the walker. The clinical record lacked any physician's orders for a Wanderguard to be placed to Resident #1 from 6/24/24 through 9/10/24 (please cross reference F 684). A physician's order dated 9/11/24 directed to check for placement of the Wanderguard to the left shoe every shift and to check the function of the device daily on the 11:00 PM to 7:00 AM shift. A physician's order dated 9/18/24 directed to check for placement of the Wanderguard in the tennis ball on the foot of the walker every shift and to check the function of the device daily on the 11:00 PM to 7:00 AM shift. A nurse's note dated 10/4/24 at 7:12 PM identified that the resident was agitated and running down the hallway without his/her walker. The resident became upset and was yelling and swearing at the staff and insisted that he/she was leaving. The police were called and were able to calm the resident down. A nurse's note dated 10/5/24 at 5:20 PM identified that at 5:00 PM, the resident stated he/she was going outside, refused the walker and was unable to be redirected, The note identified that he/she then 'burst open' the door on the second wing and a male staff accompanied him/her to sit in the sun. A nurse's note dated 10/23/24 at 11:58 AM identified that the resident took off down the driveway towards the street. Staff attempted to encourage the resident to return back inside the facility, but the resident was unable to be redirected and became aggressive, swinging at the staff. The police were called for assistance. A Psychiatric Emergency Certificate (PEC, a document used for psychiatirc emergencies) was initiated, and the resident was transported to the hospital. Interview with the DNS on 12/11/24 at 11:58 AM identified that the resident had exited through both the front entrance and the emergency exits throughout his stay at the facility, most recently on 9/7/24, 10/5/24 and 10/23/24, however was accompanied by staff. She identified that the resident did not have an at risk for elopement care plan and should have, since the elopement assessment on 6/24/24 identified that the resident was at risk for elopement. Review of the Person Centered Care plan policy identified that care plans will contain the necessary information to properly care for the resident. Review of the Wanderguard policy dated 12/6/21 directed, in part, that the resident will be evaluated to determine if they are at risk for wandering out of the facility. Should the resident be deemed at risk for wandering out of the facility, a physician's order will be obtained to have the Wanderguard applied, the care plan and care card will be updated to reflect the use of the device. The resident's Wanderguard will be checked every shift for placement and will be checked for function every 11-7 shift. Wanderguard placement and function checks will be documented on the [NAME].

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for elopement, the facility failed to obtain a physician's order timely for a Wanderguard to be placed after the resident was identified as at risk for elopement and failed to ensure that staff was monitoring the placement and functionality of the Wanderguard in accordance with facility policy. The findings include: Resident #1's diagnoses included Parkinson's disease, dementia with behavioral disturbances, adjustment disorder (excessive reactions to stress) and repeated falls. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required supervision assistance with transfers and ambulation with a walker. Review of the Elopement Risk Evaluation dated 6/24/24 identified that Resident #1 was at risk for elopement. There was no care plan for elopement risk (please reference F 656). A nurse's note dated 9/7/24 at 9:21 AM identified that the resident insisted on leaving the facility to attend church and he/she was unable to be redirected. The nurse supervisor followed the resident out the front door, and he/she became 'belligerent' and proceeded down the driveway accompanied by staff. The police were called and when they arrived the resident was agreeable to returning to the facility. A nurse's note dated 9/7/24 at 9:47 AM identified that a Wanderguard was applied to the resident's walker, after being previously removed by the resident. A physician's order dated 9/11/24 directed to check placement of the Wanderguard to the left shoe every shift and to check the function of the device daily on the 11:00 PM to 7:00 AM shift. The clinical record lacked any documentation or physician's orders for a Wanderguard, and to check for placement and functionality from 6/24/24 (when the elopement assessment identified a wander risk) through 9/10/24. Interview with the ADNS on 12/19/24 at 11:29 AM identified that the resident was identified as at risk for elopement on admission on [DATE]. The ADNS identified that while looking through the clinical record she located an order for the Wanderguard to be placed to Resident #1 on 7/29/24, however, the order did not specify the location of the Wanderguard, and it did not carry over to the Treatment Administration Record (TAR) for the nurses to ensure the placement and functionality of the Wanderguard. Review of the Wanderguard policy dated 12/6/21 directed, in part, that the resident will be evaluated to determine if they are at risk for wandering out of the facility. Should the resident be deemed at risk for wandering out of the facility, a physician's order will be obtained to have the Wanderguard applied, the care plan and care card will be updated to reflect the use of the device. The resident's Wanderguard will be checked every shift for placement and will be checked for function every 11-7 shift. Wanderguard placement and function checks will be documented on the [NAME].

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #4) reviewed for a room change, the facility failed to ensure a room change was documented and social service support was provided regarding a room change. The findings include: Resident #4's diagnoses included major depressive disorder and conversion disorder (mental health issues causing physical symptoms). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and was independent with bed mobility and required moderate assistance for transfers and ambulation. Review of the facility census identified that Resident #4 was admitted to the facility on [DATE] and his/her room was changed on 1/17/23. A nurse's note dated 1/17/23 at 4:34 AM identified that Resident #4 expressed agitation with the roommate's behaviors of blasting music and television during the night. A voice message was left for social services. A nurse's note dated 1/18/23 at 4:02 AM identified that Resident #4 was adjusting to new room and roommate. Review of social service notes for January 2023 failed to identify any documentation until 1/26/23, which did not note a room change had occurred. Interview with Social Worker #1 on 12/11/24 at 2:16 PM identified that although she was not employed by the facility in 2023, social services is responsible for handling all room changes, including touring potential new rooms for residents and their families, getting approval from the resident representative if applicable, documenting on the initial room change and then following-up with the resident for two (2) days after the room change to ensure the resident is adjusting well to their new environment. She identified that all encounters are to be documented in the clinical record, and she was unsure why Resident #4's room had been changed and there was no documentation from social services in the clinical record. Interview with the DNS on 12/11/24 at 2:32 PM identified that social services is responsible for the coordination of all room changes including communication to families regarding the room change, following up with the resident for 2-days following the room change and documentation in the clinical record. She identified that anytime that there's communicated issues with a resident's roommate, they do their best to accommodate a change as early as possible and was unsure what had transpired with Resident #4 or who changed the resident's room on 1/17/24. Review of the Transfer, Room to Room policy dated 12/2016 directed, in part, that the following information should be recorded in the resident's medical record: The date and time the room transfer was made, the name and title of the individual who assisted in the move, all assessment data obtained during the move and how the resident tolerated the move.

46040 Based on review of the clinical record, facility documentation, facility policy and interviews, for 3 of 4 residents (Resident #6, 13 and 229), the facility failed to ensure advance directives were reviewed with the resident or the resident representative to ensure that their choices were honored. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis of the left knee, bipolar disorder, and schizophrenia. The admission record also identified that Resident #6 had a conservator of person (COP). The quarterly MDS dated [DATE] identified Resident #6 had intact cognition and required assistance of one staff member with transfers and bathing. The care plan dated [DATE] identified Resident #6 had an advance directive status of full code, (full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR). Interventions included to discuss advance directives with the resident, family or legal representative on admission to the facility and as needed, and to review advance directives quarterly and as needed. A review of the clinical record identified an undated advance directive form for Resident #6 with a check mark at the line next to full code. The areas of the form acknowledging review, verification and signature by the resident or resident representative were blank. 2. Resident #13 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, siabetes, and aftercare for a right hip replacement. The quarterly MDS dated [DATE] identified Resident #13 had moderately impaired cognition and required supervision with personal hygiene, locomotion on and off unit, and was independent with all other activities of daily living. The care plan dated [DATE] identified Resident #13 had an advance directive status of full code. Interventions included to discuss advance directives with the resident, family or legal representative on admission to the facility and as needed, and to review advance directives quarterly and as needed. A review of the clinical record identified an advance directive form for Resident #13 dated [DATE] with a check mark at the line next to full code. The areas of the form acknowledging review, verification and signature by the resident or resident representative were blank. An initial request was made to the facility on [DATE] at 8:30 AM for any documentation related to discussion, review and signed advance directives for Resident #6 and Resident #13. Interview on [DATE] at 9:58 AM with the DNS identified that the admission supervisor was responsible to get the advance directive form filled out and completed within 24 - 48 hour of admission. On [DATE] at 11:00 AM, RN #3 provided a signed advance directive form for Resident #13 which was dated [DATE]. RN #3 identified that the facility was unable to locate any previously signed advance directive forms in Resident #13's clinical record. Further, RN #3 identified that the facility was attempting to contact the COP for Resident #6, as the facility was also unable to locate a signed advance directive form in Resident #6's clinical record. RN #3 also identified she was unable to locate any documentation in the clinical records for each resident to show the facility had previously discussed and reviewed advance directives with the residents. RN #3 identified that the advance directive form should be reviewed with the resident or conservator, completed, and signed upon admission to the facility. The advance directives policy directed that advance directives will be respected, and that upon admission to the facility, residents would be provided written information including the right to formulate advance directives. The policy further directed that residents have the right to change advance directives at any time, and the facility interdisciplinary team would review advance directives with residents annually to ensure that such directives are still the wishes of the resident. 3. Hospital discharge summary dated [DATE] identified Resident #229 requested do not resuscitate (DNR). Resident #229 was admitted to the facility on [DATE] with diagnoses that included diabetes, cardiomyopathy, and schizophrenia. Rehabilitation screen written by Speech Therapist #1 dated [DATE] indicated Resident #229 had intact cognition. A physician's order dated [DATE] directed DNR. The admission MDS dated [DATE] identified Resident #229 had intact cognition and required extensive assistance with transfers, toileting, and personal hygiene. Review of clinical record on [DATE] at 11:00 AM identified the advance directive form for code status was not filled out or signed by the Resident #229 or physician. Interview with LPN #3 on [DATE] at 11:45 AM indicated she was the charge nurse for Resident #229. LPN #3 indicated on admission the charge nurse was responsible for getting the advance directives completed within the first 24 - 48 hours. LPN #3 indicated right now, based on the hospital discharge paperwork, Resident #229 was a DNR, and so on admission the nurse would just put in physician's orders the DNR code status from the hospital however, LPN #3 indicated Resident #229's code status had not been completed. LPN #3 indicated Resident #229 may have been a DNR at the hospital but once at the facility may change his/her mind and want to be a full code. LPN #3 indicated that was why it was important to be discussed at admission. LPN #3 indicated Resident #229 was responsible for him/herself. LPN #3 indicated she did not feel Resident #229 was a good historian and that the family member should have filled out the advance directive form on admission or the nurse could call the family to find out the wishes for the code status. LPN #3 indicated the advanced directive form for Resident #229 was blank and was not signed by the resident, resident's representative or the physician. Interview with the DNS on [DATE] at 9:58 AM indicated the admission supervisor was responsible to get the code status form filled out and completed within 24 - 48 hours of admission to the facility. The DNS indicated Resident #229 was a DNR at the hospital and the code status from the hospital was only good for 48 hours from the time of admission. The DNS indicated if Resident #229 had refused to sign the advance directives form, her expectation was the nurse would write a progress note as to why the resident had refused. The DNS indicated there was no progress note from admission until now indicating Resident #229 refused to sign the form. The DNS indicated Resident #229 could sign the advance directive form him/herself. The DNS indicated Resident #229 would be a full code after the initial 48 hours until the code status form was signed by Resident #229 and the APRN or physician. The care plan dated [DATE] identified the advance directive status as a DNR. Interventions included discussing advance directives with patient, family, or legal representative at admission and as necessary. After surveyor inquiry, the Physicians Order for Advanced Directive Form dated [DATE] identified that Resident #229 signed the form as a DNR and the APRN signed the form on [DATE]. Interview with the DNS on [DATE] at 1:15 PM indicated Resident #229 was a DNR from [DATE] -[DATE] but was a full code from [DATE] until the advance directive form was completed by the APRN signing it on [DATE]. The DNS indicated she had spoken with Resident #229 on [DATE] (21 days after admission) and Resident #229 signed the advance directive form as a DNR. The DNS indicated she had left the code status form in a book for the physician to sign and that was why it was not in Resident #229's medical record. The DNS indicated she gave the signed advance directive form to the APRN today and the APRN had signed it. Review of facility Advance Directive Policy identified upon admission of a resident to the facility, the social worker or designee will provide written information on the right to formula advance directives. The resident has the right to change his/her advance directives at any time. Although requested, a CPR/DNR policy was not provided.

Based on clinical record review, facility documentation review, interviews, and policy review for one of three residents (Resident #1) reviewed for accidents, the facility failed to maintain the safety. The finding includes: Resident #1 had diagnoses that included Alzheimer's disease, polyarthritis, multisystem inflammatory syndrome, syncope (fainting or passing out) and collapse, hypo-osmolality, hyponatremia, and malignant neoplasm of the colon. The Resident Care Plan (RCP) dated 8/23/2022 identified Resident #1 had an ADL self-care deficit and poor safety awareness related to dementia and was at risk for falls. Interventions directed to provide an assist of one for toileting and transfers, keep area well-lit and clutter free, apply anti-rollback to wheelchair, and place call bell within reach. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment with no behavioral issues, required extensive assistance for toilet use, and was frequently incontinent of urine. The MDS further identified that Resident #1 was not steady and was only able to stabilize with the assistance of staff for moving on and off toilet, and surface to surface transfers. A fall risk assessment dated [DATE] (completed after a fall on 10/11/2022 at 6:50 PM) identified Resident #1 had intermittent confusion, had one to two falls in the last three months, was incontinent, had issues with balance, required the use of an assistive device and had one to two diagnosed conditions present that predisposed or put Resident #1 more at risk for falls. A nurse's note dated 10/12/2022 at 8:20 AM, written by RN #1, identified she was called to assess Resident #1. Resident #1 was observed lying on his/her left side on the floor in front of bathroom door with an elevated toilet seat on the floor next to Resident #1 and blood was noted from the left side of Resident #1's face. The note further identified that Resident #1 was unresponsive at the time of the assessment but had responded to another nurse and had tried to move before RN #1 arrived. The APRN was notified and ordered to send Resident #1 to the hospital for evaluation. Facility incident report dated 10/12/2022 at 5:30 PM (for fall that occurred at 7:40 AM) identified Resident #1 was transferred to the bathroom by a NA and the NA left Resident #1 alone in the bathroom with the call bell in reach, then left the resident's room. When the NA returned, Resident #1 was laying on the floor in the bathroom with the elevated toilet seat on the floor next to Resident #1. An RN assessment identified an altered mental status (AMS) and blood on Resident #1's head, and Resident #1 was transferred to the hospital for evaluation. A written (undated) statement by NA #1 identified that she assisted Resident #1 to the toilet and the went across the hall to assist NA #2 to transfer another Resident when she heard Resident #1 fall. Review of the hospital record dated 10/12/2022 identified Resident #1 was diagnosed with a subarachnoid hemorrhage, intracranial hemorrhage, pelvic fracture, and facial trauma. Resident #1 was initiated on comfort measures only (CMO). A nurse's note dated 10/14/2022 at 2:53 PM identified Resident #1 was readmitted to the facility with a diagnosis of intracranial hemorrhage, fractures, pneumonia, multiple bruises to left side of body and face, and laceration to left temple area. An interview with NA #1 on 10/25/2022 at 2:05 PM identified NA #2 assisted her to transfer Resident #1 into the wheelchair then to the bathroom because Resident #1 was feeling very weak. She identified that she did not report to the charge nurse that Resident #1 was feeling weak because she thought that was his/her baseline. Although the resident previously required assist of one staff to transfer, NA #1 and #2 failed to notify the charge nurse when Resident #1 was weak and required the assistance of two staff and failed to ensure the resident's safety while utilizing the bathroom. Although attempted, RN #2 (shift supervisor) and RN #3 (charge nurse) were unavailable for interviews during the survey. Interview with DNS on 10/25/2022 at 4:05 PM identified Resident #1 previously required assist of one staff for transfers and toileting and was safe to be left alone when he/she required assistance of one staff. However, on 10/12/2022 Resident #1 required assistance of two staff due to weakness after a fall on 10/11/2022, the NAs did not notify the charge nurse of a change in condition requiring increased assistance. A review of facility, undated, Fall Risk Policy directed in part, staff should evaluate functional, and psychological factors that may increase fall risk including ambulation, mobility, gait, balance, excessive motor activity, ADL capabilities, activity tolerance, continence, and cognition. The Policy further directed, staff should collaborate to identify and address modifiable fall risk factors and intervene to try and minimize the consequences of risk factors that are not modifiable.

Based on a review of the clinical record, staff interviews, a review of the facility documentation, and a review of the facility policy for 1 of 2 residents (Resident #47) reviewed for accidents, the facility failed to provide adequate supervision to prevent a fall that resulted in an injury. The findings include: Resident (R) #47 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, [CONDITION(S)], and [CONDITION(S)]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified moderate cognitive impairment, required limited assistance of one person for transfers, toileting, personal hygiene and ambulating in the room and hallway. Additionally, R #47 had unsteady balance when moving from a seated to a standing position, while walking, turning around, and was only able to stabilize with human assistance. The physical therapy discharge summary dated 5/4/20 identified R #47 was a fall risk and required stand by and contact guard assistance for ambulation, and the use of a rolling walker to maintain gait stability and tolerance. The fall risk assessment dated [DATE] identified R #47 was a high risk for falls. The care plan dated 5/19/20 identified a problem of noncompliance with transfers, required assistance of one person and fell secondary to walking without assistance. Interventions included to educate, explain and document potential consequences of noncompliance. The reportable event form dated 6/21/20 at 1:20 PM identified R #47 fell and hit the right side of his/her head on a wheelchair and landed on his/her right hip and buttock. R#47 was alert with intermittent confusion and required assistance of one person for transfers, ambulation and toileting with interventions that included close monitoring and place the resident in common areas when restless. The fall investigation report dated 6/21/20 identified R #47 was standing across from the nurse's station with his/her walker prior to the fall and refused to sit in the chair. Review of a statement written by LPN # 5 identified R#47 was standing across from the nurse's station with his/her walker and refused to sit in a chair. Additionally, LPN #5 indicated she heard a sound and observed R# 47 on the floor laying on his/her right buttocks, with the right side of his/her head against a wheelchair. The physicians order dated 6/21/20 directed imaging of the right hip. The radiology report dated 6/21/20 at 4:45 AM identified a subcapital impaction right hip fracture. The physicians order dated 6/21/20 directed to transport R #47 to the emergency room secondary to a right hip fracture. The facility interagency referral form identified R #47 was transferred to the hospital on 6/21/20 at 8:00 PM. The hospital discharge summary dated 6/25/20 identified R #47 required a surgical pinning of the right hip, required minimal assistance of one person for transfers and ambulation and directed a physical and occupational therapy evaluation. The physical therapy discharge evaluation identified R#47 received physical therapy services 6/26/20 through 7/22/20 for gait training, transfer training, standing balance activities and bilateral lower extremity strengthening. The occupational therapy discharge summary dated 7/24/2020 identified R#47 received occupational therapy services from 6/26/20 through 7/23/2020 for toileting hygiene training, bathing and dressing and identified therapy was necessary for decreased balance, decreased strength and activity tolerance and pain. The physician's orders dated 6/29/2020 directed R#47 to be transferred out of bed with the assistance of one person to a standard wheelchair and to ambulate R#1 with assistance of one person and a rolling walker. Interview with LPN #5 on 9/18/20 at 12:25 PM identified R #47 walked out of his/her room alone with his/her walker into the hallway and refused to sit down. LPN #5 indicated she could not redirect the resident and left R#47 by him/herself in the hallway because she had to take care of other residents. LPN #5 indicated R#47 was restless and confused and she could not be redirected. LPN #5 identified she was behind the desk when R #47 fell and indicated the nurse aides on the unit were in other residents' rooms. LPN #5 notified RN #5 who assessed R#47. Three staff members transferred R #47 to the wheelchair. LPN #5 identified R #47 limped after they stood him/her and three staff members performed a stand pivot transfer of R# 47 into the bed. The APRN was notified, imaging was ordered, and Tylenol 650 milligrams (mg) was administered with fair effect. Interview with RN #5 (Nurse Supervisor) on 9/18/20 at 11:28 AM identified R#47 was non-compliant with safety and staff could not keep him/her still. R #47 was standing in the hallway near the nurse's desk with his/her walker by him/herself and fell hitting his/her head on the side of a wheelchair. RN #5 indicated she assessed R #47, there was no apparent injury, and three staff members transferred R#47 back into bed. Additionally, RN# 5 identified R#47 should have been assisted by one person for transfers and walking in the hall, and was not because staff were busy caring for other residents. RN #5 indicated the best she could do was watch R#47 from a distance. RN #1 identified other interventions were not put into place because there was not enough staff. Interview with the Director of Nursing (DNS) on 9/18/20 at 1:00 PM identified R#47 required the assistance of one staff member for transfers and walking. The DNS indicated it was the responsibility of RN #5 and LPN #5 to ensure R#47 was supervised and assisted for ambulation in the hallway in accordance with the plan of care. Additionally, the DNS identified RN#5 and LPN #5 received a written corrective action for leaving R#47 unattended prior to the fall. Review of the fall policy directed in part that the facility would identify residents at risk for falls and implement interventions to minimize and/or eliminate contributing factors for falls for residents that were at risk.

Based on review of the clinical record and staff interview for one of three sampled residents (Resident #72) who were reviewed for pressure ulcers, the facility failed to provide care and services to prevent the development of a pressure ulcer. The findings include: Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The skin assessment dated [DATE] identified the skin on the right stump was intact. The Braden Scale dated 12/30/14 identified a score of 9, which represents a high risk for skin breakdown. physician's orders [REDACTED]. The admission care plan dated 12/30/14 identified the resident had a high risk for pressure ulcers with interventions that included to wash and dry skin as needed, notify dietition, turn and reposition every two hours, provide incontinent care every two hours, complete daily skin checks and weekly skin observation by nurse, and report breakdown. The admission MDS dated [DATE] identified the resident had intact cognition, required total assistance with bed mobility, did not transfer/ambulate, and had no pressure ulcers. physician's orders [REDACTED]. a. Review of the nurse's note dated 1/14/15 and the clinical record failed to reflect an assessment for the excoriated area to the right stump. physician's orders [REDACTED]. A wound/skin healing record dated 1/15/15 identified a 1.5cm by 1.5cm pink area on the right stump. Additionally, a different wound/skin healing record dated 1/15/15 identified a stage I pressure ulcer that measured 3.1cm by 2.5cm on the right stump. physician's orders [REDACTED]. A wound/skin healing record dated 1/20/15 identified a stage I pressure ulcer that measured 3.2cm by 2.5cm on the right stump. A wound care specialist initial evaluation dated 1/26/15 identified the resident had a stage III pressure ulcer on the right calf that measured 3.2cm by 2.5cm by 0.1cm with 50% yellow necrotic tissue on the right stump. Recommendations incuded to apply Santyl daily. b. Review of the clinical record and the treatment administration record for January 2015 failed to reflect that the skin assessments were completed as per the physician's orders [REDACTED]. c. The clinical record lacked documentation of how the resident's right stump was offloaded prior to the breakdown on 1/15/15. d. Review of the wound/skin record dated 2/2/15 and 2/9/15 failed to reflect the stage of the right stump pressure ulcer. On 2/16/15, the wound/skin record documentation identified the right stump area as a stage II, however the wound care specialist evaluation dated 2/26/15 identified the same area as a stage III with 50% yellow necrotic tissue that required surgical debriedement. Interview with RN#3 on 4/30/15 at 12:00PM identified that he/she found the area on the right stump and it was a stage I pressure ulcer. The intital treatment was to offload the area and apply triad paste. Additionally, RN#3 indicated that although documentation on 1/20/15 identified the area had 50% slough and was being treated with silver alginate, he/she staged the area as a stage I because it started as a stage I. The facility failed to accurately assess Resident #72's skin integrity and/or failed to implement measures to prevent skin breakdown.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #2) who required a mechanical lift for transfers in and out of the bed and/or chair, the facility failed to provide the appropriate supervision of the lift to prevent an injury. The findings include: Resident #2's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented, required extensive two person assistance with transfers in and out of the bed and/or chair, utilized a wheelchair for mobility and had a weighed 399 pounds. The resident care plan dated 8/11/14 identified an alteration in mobility; the resident requires a mechanical lift to transfer. Interventions directed to transfer with via a mechanical lift. A physician's orders [REDACTED]. The occupational therapy note dated 9/11/14 identified staff education for transfers and positioning Resident #2 in the Custom Wheel Chair (CWC), nursing and nurse aides. The Caregiver Education Record dated 9/11/14 directed to tilt the CWC back, there has to be weight into the chair to tilt. One person may sit in the chair while the other person tilts. Lift the resident in the Hoyer with appropriate weight sling. One person drives the Hoyer 1-2 people guide resident not push. Drive Hoyer straight into the chair, legs of Hoyer open, one leg may be inside the wheels of the chair and one on the outside. Lower the resident into the chair, guiding the back evenly with handle on Hoyer sling. DO NOT PULL. Hoyer goes forward as resident is lowered. Once resident is in the chair, put the leg rests on the chair and the resident is able to reposition self. The nurse's note dated 9/15/14 at 10:45 AM identified that Resident #2's head hit the mechanical lift during a transfer and the resident sustained [REDACTED]. The note identified the resident's head was struck by the lift while being transferred. The physician was notified and the resident was transferred to the hospital for an evaluation. The hospital discharge summary dated 9/15/14 identified Resident #2 sustained a right parietal laceration that required five staples for closure, to be removed in 7 to 10 days. The Reportable Event Form dated 9/15/14 at 11:30 AM identified Resident #2 was being transferred via mechanical lift from the bed to the wheelchair when the resident's head hit the lift causing a laceration when the lift tipped. The facility's investigation dated 9/15/14, in a written statement Nurse Aide (NA) #1 identified that she was behind the wheelchair pulling the resident back so Resident #2 could sit properly. The Hoyer lift went forward, hit the resident on the head, the lift tilted sideways and the Hoyer fell on Resident #2. In a written statement dated 9/15/14 NA #2 identified that he was trying to help his co-worker to transfer Resident #2 from the bed to the wheelchair in the Hoyer lift. The Hoyer lift split and hit the resident on the head. The statement dated 9/16/14 identified that the manufacturer's representative had reviewed and evaluated the functional status of the lift (weight capacity was 500 pounds). The inspection indicated that the lift was found stable, safe and functional for the intent designed, the lift was capable of functioning at the capacity of 500 pounds for the purpose of a two person transfer. All mechanical fittings, joint attachments and battery qualities were assessed as spot-on correct and in superior condition. At the conclusion of the investigation it was suggested that the lift used on 9/15/14 be returned to the manufacturer and as a measure to support Resident #2 a new mechanical lift classified as a 600 pound capacity was supplied to the facility. Interview with Resident #2 on 3/10/15 at 12:00 PM identified that he/she was being transferred from the bed to the chair and while suspended over chair the lift tilted, the top of the lift hit him/her in the head and he/she kind of fell into the chair. Interview with NA #1 on 3/11/15 at 12:40 PM identified that while transferring Resident #2 into the wheelchair, the resident's body shifted as she pulled the resident into the chair, the lift shifted and hit the resident. Interview with NA #2 on 3/10/15 at 2:45 PM identified that he was guiding the lift and NA #1 was behind the chair pulling the sling. NA #2 stated that he pushed the lift forward and it tilted causing the resident to fall into the chair and the lift to hit the resident's head. NA #2 was unable to recall if the brakes were on. Interview with Licensed Practical Nurse (LPN) #1 on 3/10/15 at 2:55 PM identified that she was called to Resident #2's room. Upon entering the room she observed the Hoyer bar over the residents head. LPN #1 indicated that she could not recall if she spoke to the nurse aides about what happened and/or checked the lift and pad after the incident. Interview with Registered Nurse (RN) #1 on 3/10/15 at 3:10 PM identified that when she entered Resident #2's room she saw the lift in a tilted position over the resident and the bar of the lift behind the resident's back between the wheelchair and the resident. RN #1 stated that she spoke to the nurse aides after and was told that as they were transferring the resident to the chair the lift tilted. RN #1 stated she looked at the lift and pad and didn't see anything wrong with it. RN #1 stated she assessed the resident and identified a reddened mark on the back and a laceration to the right scalp. Interview with Person #1 (Mechanical lift company representative) on 3/11/15 at 12:45 PM identified that the day after the incident with Resident #2 9/16/14, he came out to check the lift and found no mechanical default and that the incident was most likely user error that caused the lift to tilt and hit the resident. Person #1 stated the lift that was being used on Resident #2 was the appropriate weight and size for the resident. Person #1 indicated that if a staff person was pulling the resident back using the pad and the lifts brakes were on it could cause the lift to go forward. Interview with the former Director of Nurses (DON) on 3/11/15 at 1:00 PM identified that nurse aides always make decisions on how many people they use to transfer a resident with a mechanical lift. The DON stated that the incident was unpredictable and after the incident the physician order [REDACTED].#2 assist of three via the mechanical lift.

Based on clinical record review, review of facility documentation and staff interview for 3 of 6 sampled residents identified with falls and/or injuries, (R#26, R#68, and R#168) the facility failed to ensure assistive devices were in place and functioning properly to prevent a fall and/or injury. The findings include: 1. Resident #26's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified R#26 as severely cognitively impaired, requiring extensive assistance with bed mobility, and transfers, non-ambulatory, unsteady with balance from surface to surface and without falls. Review of the fall risk assessment dated [DATE] identified R#26 as a high fall risk. A RCP dated 12/11/12 identified a potential for falls related to poor compliance, decreased cognition and a history of falls. Interventions included to provide a low bed with mats on the floor, and a personal alarm while in bed and chair. Additionally, the care plan identified on 1/8/13 that R#26 occasionally disconnects the alarm boxes from the cord. Intervention included to continue to do safety check rounds for placement and functioning of the alarm system. Nurse's notes dated 2/27/13 at 10:45 PM identified that at 4:30 PM, RN#4 heard the resident screaming and upon entering the resident's room, RN #4 found the resident on the floor next to the bed, lying on his/her back. The resident was assessed and found to have pain in the right leg with an indentation noted on the anterior aspect of the right ankle. The physician was notified and the resident was transferred to the hospital and diagnosed with [REDACTED]. Review of RE dated 2/27/13 at 4:30 PM identified the resident was found on the floor next to the bed and complained of pain to the right lower leg. The fall investigation report identified although R#26 had alarms (bed and chair) ordered, at the time of the fall the alarms were not in place, functioning and/or sounding. Additionally, the investigation noted that R#26 had a history of [REDACTED]. Interview with NA#3 on 7/8/13 at 12:44 PM indicted that R#26 frequently removes the alarms and/or disconnects them either while in the bed and/or in the wheelchair, and the alarms are to be placed out of the resident's reach. Additionally, NA#3 stated that after providing care, she placed the alarm on the night stand next to the resident's bed, but did not check to see if the alarm was out of reach of the resident. Interview with RN#4 on 7/8/13 at 12:10 PM indicated that she heard R#26 screaming and upon entering the resident's room found the resident lying on the floor next to the bed, and the alarm cord was noted to be disconnected from the alarm box. Additionally, RN#4 stated that the resident usually disconnects the alarm box and that the nurse aides are to place it where the resident cannot reach it. Interview with the DNS on 7/08/13 at 1:15 PM identified that R#26 is known to disconnect the alarms that are placed on for safety and that staff is to ensure they are out of the residents reach and view. 2. Resident #68's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident as alert and oriented, without behaviors, extensive assistance with ADL's, requiring a mechanical lift for transfers and receiving anticoagulant therapy. A RCP dated 6/21/12 identified a potential for falls related to decreased mobility and chronic pain. Interventions included mechanical lift for transfers and assist of 2. Additionally, the care plan identified anticoagulant therapy. Interventions included to handle and/or care for resident carefully. Physician orders [REDACTED]. Nurse's notes dated 9/10/12 at 10:30 AM identified R#68's leg bumped into the mechanical lift support bar causing a hematoma to the left leg that measured 7.5 cm by 6.5 cm by 2.5 cm. At 1:20 PM the nurse's notes identified that the Supervisor was asked to see the bruised area. The area was observed to measure at that time 16 cm by 9 cm by 4 cm, the skin was taut and cold to touch. Additionally, the area had opened causing blood to flow out. Pressure was applied, the physician notified and the resident was transferred to the hospital. Review of a RE dated 9/10/12 at 10 PM identified that while being lifted with a mechanical lift, the wheels of the lift became stuck and the residents leg swung into the center bar of the lift, resulting in a large hematoma to the right lower leg initially measuring 9 cm by 3 cm by 2 cm. Additionally, the investigation indicated that to prevent further incident, staff is to guide the residents legs to avoid hitting the bar. Review of the hospital discharge summary dated 9/10/12 identified the residents left lateral calf with a 15 cm by 8 cm hematoma. Additionally, the resident stated that the left lateral calf was struck while being transferred and began to bleed. A pressure dressing was applied and the resident was transferred back to the facility. Physician orders [REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. Review of the non-pressure skin condition report sheet dated 9/12/12 identified an area measuring 10 cm by 15 cm with serous drainage and a dark red wound bed. Non-pressure skin condition report sheet dated 9/25/12 noted a 15 cm by 12 cm area and within the area was a 10 cm by 10 cm raised hematoma with serosanguinous drainage and a blood clot within the wound bed. Non-pressure skin condition report dated 10/3/12 (s/p surgery) identified a 15 cm by 7 cm area with serosanguinous drainage and a wound vac applied to the area. Review of the wound notes dated 9/25/12 identified an area to the LLE measuring 15 cm by 12 cm of bruise with a 10 cm by 10 cm clot resting atop of the bruise and a skin tear 10 cm in length along the shin. Interview with NA#4 on 7/8/13 at 2:00 PM indicated that while transferring the resident from the bed to the chair via the mechanical lift, the wheels of the lift jammed and caused the resident to swing forward and hit the right lower leg on the center bar of the lift. NA#4 further stated that the nurse who was assisting with the transfer was behind the residents chair and that no one was guiding the residents body/legs. Additionally, NA#4 stated that there had been several problems/repairs with the mechanical lift regarding the wheels getting stuck. Interview with the Maintenance Director on 7/3/13 at 2:20 PM indicated that the mechanical lift had been repaired several times involving the wheels and the hydraulic lift piece. Additionally, the Maintenance Director stated that monthly service checks are completed on all lifts and that the lift involved in the incident with R#68 was taken out of service. Interview with the DNS on 7/3/13 at 2:50 PM indicated that when a resident is transferred via a mechanical lift, 2 staff members are always used. One to guide the lift the other to guide the resident. 3. Resident #168's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident as severely cognitively impaired, being short-tempered and easily annoyed, physical/verbal behaviors towards others, rejection of care, requiring extensive assistance with transfers, and surface to surface transfers unsteady and requires staff assistance to stabilize self, and a history of falls. The RCP dated 8/15/12 identified a potential for falls/ injury related to weakness and non-compliance. Interventions included to transfer with assist of 2 persons, if upset and/ or agitated make resident safe and reapproach later. Nurse's notes dated 10/6/12 at 1:15 PM identified R#168 sustained a laceration to the left shin measuring 9 cm long and 2 cm deep. The area was cleansed and a pressure dressing applied and the resident was transferred to the hospital and received sutures to the wound. A RE dated 10/6/12 at 1:15 PM identified that after the resident was transferred from the wheelchair to the bed by two nurse aides, an open area was observed on the left shin measuring 9 cm long and 2 cm deep. Additionally, the documentation identified that the resident was agitated during the transfer. Interview with NA#5 on 7/3/13 at 11:35 AM identified that he/she and another NA were transferring the resident from the wheelchair to the bed and that the resident was agitated, yelling, pinching and moving legs about while sitting in chair and during transfer. When they pulled the resident up in bed they saw blood on the residents leg and got the nurse. Additionally, NA#5 stated that although they are trained to wait to provide care if a resident is agitated, R#168 is always agitated, yelling and pinching and they just wanted to get the resident in bed. Interview with the Corporate Nurse on 7/3/13 at 11:20 AM indicated that after the incident the residents bed was inspected for sharp edges and none where found. Additionally, the Corporate Nurse indicated the resident is to be always transferred with 2 people because you don't know how the resident will react. Interview with the DNS on 7/03/13 at 2:30 PM indicated that if a resident is agitated or being aggressive, staff is to stop care, ensure the resident's safety, and allow the resident to calm down and reapproach later.

Based on clinical record review, observation and interview for one of one sampled resident reviewed for behaviors (R#13) the facility failed to provide appropriate treatment and services to correct the problem. The findings include: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review identified frequent emergency room visits for psychiatric breakdown and with attention seeking behaviors. An admission MDS dated [DATE] identified R#13 as alert and oriented, had inattention focusing, recent mental status changes, feeling depressed, physical and verbal behaviors directed toward others, refusals of care and required limited assistance with locomotion on the unit, and extensive assistance with dressing and transfers and complaints of having frequent pain. The Admission Interim care plan dated 5/17/13 identified the resident with behaviors. Interventions included to establish a therapeutic relationship and to obtain a physician order [REDACTED]. Physician admission orders [REDACTED]. An admission nurse's note dated 5/17/13 identified R#13 as very demanding, continuously screaming out and disruptive to other residents. Additionally, the note identified multiple attempts to redirect R#13, with a negative outcome. Nurses note dated 5/19/13 at 9:00 AM identified R#13 as screaming and swearing at staff, grabbing and threatening to hurt staff. Additionally R#13 became aggressive and scrapped his/her fingernails down a staff members arms verbalizing, "if you come in my room again I will kill you". Further review of the nurses notes identified R#13 threw a water pitcher and commode toward staff, again stating, "I will attack and kill you, get out of my room". The physician was made aware, 911 was called and R#13 was transferred to the hospital for evaluation. Review of the hospital discharge summary dated 5/19/13 identified violent actions while at the facility as evidenced by threatening staff and/or throwing objects and a [DIAGNOSES REDACTED]. Interim care plans dated 5/20/13 identified R#13's physical and/or verbal behavioral issues. Although the care plan identified behaviors and an intervention was put in place to monitor for behavior and provide care with assistance of 2 staff members, the care plan failed to address interventions to decrease the behavior and/or provide psychosocial support. Review of a Psychiatric Consultation report dated 7/03/13 identified R#13 as quite irritable and agreed with recommendations of medication changes. Physician orders [REDACTED]. Additionally, new orders were obtained to start [MEDICATION NAME] 5 mg 4 times daily and [MEDICATION NAME] 100 mg at bedtime. A nurse's note dated 7/03/13 identified R#13's physician was notified of R#13's refusal of the new medication changes. The medication were discontinued and the previous medication orders were reinstated. Interview and review of the clinical record with the Corporate Nurse on 7/08/13 at 2:45 PM identified the last time R#13 was seen by the physician was on 5/24/13. Although a nurse's note dated 5/29/13 at 4 PM identified that the physician saw R#13, the clinical record lacked documentation of the physician visit. Nursing notes from 5/17/13 through 7/3/13 identified the resident as screaming, shouting, sometimes continuously throughout the shift at peers, visitors and staff, threats of tearing the place apart, accusations about staff, throwing items, profanity use, refusals of care and refusals of medications. However the resident's escalating behaviors were only addressed until 5/19/13 when the resident was transferred to the hospital and not addressed again until 7/03/13. Review of the clinical record with SW#1 on 7/10/13 at 10:30 AM failed to identify R#13 was seen by a Psychiatric provider until 7/03/13 at which time medications were adjusted. SW#1 further stated that Resident #13 was seen by the outside Psychiatric provider for grievance counseling and that the case workers came to visit at the facility but that there was no communication between the facility and the outside entities regarding Resident #13's psychosocial needs. A nursing note dated 7/6/13 at 5:50 PM identified Resident #13 became increasingly loud, yelling and screaming, making accusatory statements and was threatening to staff. Additionally Resident #13 continued to repeat he/she wanted to go to an inpatient psychiatric facility. Although the nurses note identified the physician was notified of the blood sugar and insulin refusals, the clinical record failed to identify the physician was made aware of Resident #13's behavior and requests to be hospitalized . Interview and review of the care plans on 7/8/13 at 2:45 PM with the LPN #2, identified that interventions that are written in by hand or checked are the only approaches currently in effect. Although behaviors were addressed in the care plan, the care plan lacked interventions to meet Resident #13's psychosocial needs. Interview and review of facility documentation with APRN#1 and the Corporate Nurse on 7/10/13 at 10:00 AM identified that MD #1 (a covering physician) had ordered a Psychiatric evaluation on 5/17/13. On 5/19/13 MD #1 directed R#13 to the ER for evaluation due to being a threat to staff and other patients in the facility. APRN #1 identified she could not recall if she had spoke with MD#1 regarding R#13's behavior and that APRN #1 was unaware that R#13's behaviors had continued to escalate since admission although she was aware of the resident's behaviors. APRN #1 indicted that she would have expected to have been notified of escalating behaviors, could have established a pattern of behaviors if she had been notified, and may have gone to see R#13. However APRN#1, indicated she would not have changed the medication or treatment because she is not a Psychiatric APRN. APRN #1 and the Corporate Nurse identified that the APRN and R#13's physician are responsible to review the information from the Psychiatric provider and make a decision regarding R#13's care. APRN #1 identified that the first information provided to her regarding R#13's mental health had been on 7/03/13 when orders from the psychiatrist were given to her to be approved. APRN #1 indicated she was not aware that according to the nurse note dated 7/06/13 R#13 was requesting treatment by an inpatient Psychiatric provider but would have expected that a Psychiatric provider would have been notified. APRN #1 further identified that she would have expected that Resident #13 would have been seen by a mental health professional sooner than the initial Psychiatric evaluation visit on 7/03/13. Interview with MD#2 on 7/10/13 at 11 AM identified that efforts were made by the facility on 6/21/13 to attempt to provide psychiatric intervention at the hospital and that the crisis team from the outside behavioral health center was called and waiting at the hospital for R#13. MD #2 identified that he received a call from the Hospital ED Psychiatrist who directed MD #2 to stop efforts to send R#13 because they were no longer willing to deal with R#13. Further interview with the Social Worker and Corporate Nurse identified that R#13 continually accepted and/or refused Psychiatric services. Review of the clinical record at that time with the Social Worker and Corporate Nurse failed to identify R#13's physician was made aware that R#13 had not seen a Psychiatric provider. The Social Worker identified she was responsible for arranging Psychiatric services for Resident #13.