Every finding on record at Villa Healthcare & Rehabilitation Center

Based on observations, interviews and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADL), specifically nail care, received necessary services to maintain good grooming and personal hygiene for one (Resident #59) of a total survey sample of 32 residents.The findings include: On 09/15/25 at 2:00 PM, an observation was made of Resident #59's fingernails, which had grown approximately 1/2 to ¾ inch beyond the tip of the nailbed on both her right and left hands. The resident reported that she did not like her fingernails as long as they were, and that she was afraid she might scratch herself with such long nails. She could not recall whether or not staff had offered to trim her fingernails. (Photographic evidence obtained) On 09/16/25 at 11:41 PM, a second observation was made of Resident #59's fingernails, which had grown approximately 1/2 to ¾ inch beyond the tip of the nailbed on both her right and left hands. They appeared the same as they had during the 09/15/25 observation at 2:00 PM. (Photographic evidence obtained) A review of Resident #59's medical record revealed that she was admitted to the facility on [DATE] with diagnoses including, but not limited to, Parkinsonism, muscle weakness (generalized), cognitive communication deficit, tremor, protein-calorie malnutrition and major depressive disorder. Minimum data set (MDS) assessment data for Resident #59 revealed a brief interview for mental status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. No delusions or hallucinations and no physical or verbal behavior towards others was documented. It was noted that it was somewhat important to the resident that she be interviewed for preferences related to her daily activities. She was noted as requiring limited assistance with personal hygiene. A review of the care plan revealed a focus area for ADL (activities of daily living)/Self-Care Performance Deficit related to a history of fracture, Parkinson's disease, depression and impaired functional mobility. The goal of the care plan was that the resident would maintain her current level of function through the next review date. Interventions included that for personal hygiene she required limited assistance. On 09/17/25 at 2:18 PM, an interview was conducted with Certified Nursing Assistant (CNA) A, who stated she had been employed by the facility for one month. She further stated she was assigned to Resident #59 and was familiar with her care needs. She explained that she had not provided nail care while working at the facility and that Employee C with Medical Records and Central Supply provided nail care. If she saw a resident with long nails, she would document it on a piece of paper and give it to the Activities Director, who also trimmed residents' nails. CNA A was informed that CNAs were permitted to provide nail care, but she was not certain that CNAs could provide both nail clipping and nail filing. If she were to trim fingernails and noticed a resident with long fingernails, she would first ask the resident if it was alright to trim the resident's nails, wash the resident's hands, go to Central Supply to retrieve a file or clippers, provide nail care, and wash the resident hands again. She would ensure that the resident's nails were not too long and that they would not risk scratching themselves or another resident. She would prefer to do nail care on shower days when fingernails were soft. She stated she believed that fingernails grown 1/2 to ¾ inch beyond the nail bed were too long and posed a scratching hazard. On 09/17/25 at 2:33 PM, CNA A observed Resident #59's fingernails and stated they were too long. On 09/17/25 at 2:35 PM, an interview was conducted with Registered Nurse (RN) B, who reported that she had been employed by the facility since December 2024 and was familiar with Resident #59's needs. When she administered medication, she spoke with the resident and made observations of the resident's appearance, looking at her skin to make sure it was not edematous, for nail length, etc. She stated she listened to the resident to see if she had any concerns. For male residents, long nails were considered long at any length beyond the nailbed. For female residents, long nails was considered any growth beyond 1/4 inch of the nailbed. RN B stated she always checked with the resident to see if the resident preferred to keep their fingernails long. She also explained that she always made sure to clean the resident's nails, no matter what the desired length was. On 09/17/25 at 2:40 PM, RN B observed Resident #59's fingernails and stated they were too long. On 09/17/25 at 2:45 PM, an interview was conducted with Employee C, Medical Records and Central Supply, who reported that she had been employed by the facility for more than 10 years. She said she was assigned to Resident #59's hall as part of her Guardian Angel rounds. Guardian Angel rounds included walking around the area, talking to residents and asking if they needed anything. She explained that the Activities Director was assigned to fingernail care duty, but she helped out last Friday with nailcare when the Activities Director was out. Her process for providing nail care only included those residents who were not diabetic. She either clipped and/or trimmed the fingernails and added fingernail polish if the resident requested it. On 09/17/25 at 2:54 PM, an interview was conducted with Activities Director D, who reported that she had been employed by the facility for one year and was assigned to provide resident fingernail care. She provided resident fingernail care either before or after lunch, three times per week on Mondays, Wednesdays and Fridays. Sometimes nurses would ask her to trim a resident's nails, and she maintained a paper list of residents needing nail care. The process to provide nail care required approximately 20 minutes. She always started the process by asking the resident if they wanted a nail trim. If the resident declined, she would inform the CNA and/or the nurse. She would shorten the nails with either a nail clipper or she would file them with a nail file. Nail care was listed on the Activity Schedule and was titled Pretty Nails. On 09/17/25 at 3:04 PM, an interview was conducted with the Director of Nursing, who reported that she had been employed by the facility for four years. She explained that when she attempted to speak to Resident #59, the resident's sister, who was Resident #59's roommate, usually spoke for her sister and attempted to intervene. She also declined care for Resident #59. A review of the facility's policy and procedure titled Standards and Guidelines: Nail Care (implemented 01/15/21, reviewed/revised 01/15/21), revealed: Standard: It will be the standard of this facility to provide nail care to residents per resident preferences and to maintain dignity . 3. Nail care includes regular cleaning and regular trimming, unless contraindicated by resident condition, specific behaviors or resident refusal or resident/family preference. 4. Proper nail care can aid in the prevention of skin problems around the nail bed . 6. Trimmed and smooth nails can help prevent the resident from accidentally scratching and injuring his or her skin .

Based on observation, staff and resident interviews, medical record review, and facility policy review, the facility failed to appropriately store resident's medication by leaving medication at bedside for one (Resident #4) of three residents sampled for unsecured medication. Resident #4 who had not been assessed for self-administration of medication was observed taking medications that had been left on his overbed table. These medications were also accessible to other residents who should not have access to them. The findings include: During an interview with Resident #4 on 04/23/2025 at 10:22 AM, the resident picked up a medicine cup from his overbed table containing multiple pills in it. When asked if the pills were his morning medications he stated, yes and then took them. A medical record review for Resident #4 indicated he was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 13/15, indicating intact cognition. A review of medication to be given to Resident #4 at 9:00 AM included the following: Aspirin 81mg tab; Atorvastatin 20 mg tablet; Clopidogrel Bisulfate 75 mg tablet; Glipizide 25 mg tablet; Jardiance 25 mg tablet; Meloxicam 7.5 mg tablet; and Sodium Chloride tablet 1gm. A review of physician's orders for Resident #4 revealed no order for the resident to self-administer medications. On 04/23/2025 at 11:42 AM, a follow interview was conducted with Resident #4. The resident was asked how often medications were being left for him to take later. He stated, It happens sometimes but not very often. A review of the electronic chart for Resident #4 revealed no assessment for the resident to self-administer medications. A review of the care plan for Resident #4 revealed no care plan initiated for self-administering medications. On 04/23/2025 at 11:55 AM, the Director of Nursing (DON) was asked if medications should be left in residents' rooms. She stated that the nurse that left the medication at the bedside was immediately taken off the cart. The medication administration policy was reviewed with her and she will be required to pass a medication administration competency as well as being monitored while administering medications. The DON stated the entire nursing staff will be re-educated on the medication administration policy immediately and the unit manager will observe nursing during medication administration times. When asked about a policy for self-administration of medications or assessments of residents for self-administration, she stated they did not have an assessment and would look for the policy. On 04/23/2025 at 12:32 PM, an interview was conducted with Employee D, Registered Nurse (RN). She stated she had worked at the facility for 2 years. When asked about leaving medication in Resident #4's room, she stated she was attempting to get therapy to assist her in replacing the resident's mattress. She got distracted and left the medication on his overbed table. She stated her normal procedure is to stay with the resident, assess for pain or changes and watch them take all of the medications before leaving the room. On 04/23/2025 at 12:50 PM, an interview was conducted with the Assistant Director of Nursing (ADON). When asked about residents' self-medicating, she stated they have a policy for this. When asked if they completed an assessment to ensure the resident is capable of self-medicating, she stated, No, we look at the BIMS score and we know the residents. A review of the facility's policy titled Self-Administration of Meds (revised 3/01/2021) read: Standard: It is the standard of this facility that residents who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. Guidelines: 1. As part of the overall evaluation, the staff and practitioner will assess or evaluate each resident's mental and physical abilities to determine whether a resident is capable of self-administering medications. (Photographic evidence obtained)

Based on observations, record reviews, staff interviews, and a review of the facility's policy and procedure for Standards and Guidelines for Wound Care, the facility failed to ensure that resident medical records were complete and accurately documented, in accordance with accepted professional standards and practices, for two (Residents #65 and #26) of 12 residents receiving pressure ulcer treatment, from a total sample of 28 residents. The findings include: 1. An observation of Resident #65 was made on 9/25/23 at 3:00 p.m. She was observed lying in bed with an air mattress, positioned with pillows. The resident's medical record was reviewed and revealed that she was admitted to the facility on [DATE]. Her diagnoses included the following: mild protein calorie malnutrition, unspecified contact dermatitis, and osteomyelitis of sacral and sacracoccygeal region. Her care plan was reviewed and noted that she had a pressure ulcer of the sacral area which reopened in December 2022. A 9/27/23 physician's treatment order was reviewed which revealed: Cleanse and rinse sacrum with Dankins for odor control, apply Metronidazole gel 1% and collagen powder, and cover with silicone foam border daily and as needed. The September 2023 Treatment Administration Record (TAR) was reviewed, which revealed that treatments were not signed off as having been provided by nursing on September 4, 6, 9, 12, or 14. A review of the progress notes revealed no wound care documentation on the days the pressure ulcer treatment verification was missing on the TAR. An interview was conducted with Licensed Practical Nurse (LPN) E on 9/28/23 at 11:00 a.m. She reported that dressing changes were sometimes performed by the nurses and were documented on the TAR after completion. An interview was conducted with RN A on 9/28/23 at 11:55 a.m. He reported dressing changes were documented on the TAR after completion. He reviewed the September 2023 TAR for Resident #65 and confirmed the missing initials to verify that treatment had been provided in September on the dates previously mentioned. A review of the facility's policy and procedure for Standards and Guidelines for Wound care (revised 1/15/21), noted the standard of the facility was to provide assessment and identification of residents at risk of developing pressure ulcers with the following guidelines: Wound care procedures and treatments should be performed according to physician's orders and documented in the clinical record when treatments are performed. An interview was conducted with the Director of Nursing (DON) on 9/28/23 at 12:23 p.m. The DON stated documentation of wound treatments should be documented on the TAR. 2. A review of Resident #26's medical record revealed a 9/22/23 physician's order that read: Zinc Oxide Ointment 10%: Apply to sacrum topically every day and evening shift for pressure wound and as needed. A review of Resident #26's September 2023 electronic treatment administration record (eTAR) revealed an order written on 9/22/23 for Zinc Oxide Ointment 10%: Apply to sacrum topically every day and evening shift for pressure wound and as needed. It was not signed off by nursing to indicate that the treatment had been administered on 9/22, 9/23, 9/24, 9/25, or 9/26. On 9/28/23 at 8:30 a.m. during an interview with RN A, he was asked why the Zinc Oxide treatment had not been signed off as having been completed on seven occasions in September 2023. He stated whoever provided the treatment should have signed it off in the record. He stated the expectation was that treatments were to be signed off after completion.

Based on observation, medical record review, staff interview, and a review of the facility's policies and procedures, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #26) of 12 residents receiving pressure ulcer treatment, from a total sample of 28 residents. The findings include: On 9/27/23 at 11:50 a.m., Registered Nurse (RN) A was observed preparing wound care supplies from the treatment cart for Resident #26. He dispensed Zinc Oxide 20% into a small medication cup. He was asked to explain the treatment order. He stated, It's Zinc Oxide ointment to his sacral area daily. RN A rubbed the Zinc Oxide ointment 20% on Resident #26's sacral area. The area was reddened and dusky in color. When RN A returned to the treatment cart, he was asked to look at the tube of Zinc Oxide ointment. He took it from the cart. He was asked what percent of Zinc Oxide the order was for. He stated, I'm not 100% sure; I know it's for Zinc. He was asked how he prepared for his wound care treatments. He stated he reviewed the orders in the computer in the morning and wrote the treatments on paper, then signed off all his treatments at the end of the day. He was asked to review the wound care order for Resident #26. Upon bringing the resident's orders up on the computer screen, RN A stated, Oh, the order states Zinc 10%. A review of Resident #26's medical record revealed a 9/22/23 physician's order that read: Zinc Oxide Ointment 10%: Apply to sacrum topically every day and evening shift for pressure wound and as needed. A review of Resident #26's September 2023 electronic treatment administration record (eTAR) revealed an order written on 9/22/23 for Zinc Oxide Ointment 10%: Apply to sacrum topically every day and evening shift for pressure wound and as needed. It was not signed off by nursing to indicate that the treatment had been administered on 9/22, 9/23, 9/24, 9/25, or 9/26. A review of the facility's policy and procedure for Standards and Guidelines for Wound care (revised 1/15/21), noted the standard of the facility was to provide assessment and identification of residents at risk of developing pressure ulcers using the following guidelines: Wound care procedures and treatments should be performed according to physician's orders and documented in the clinical record when treatments are performed. 42630

Based on observation, interview, and record review, the facility failed ensure that residents who needed respiratory care, received oxygen therapy as ordered for two (Residents #11 and #43) of 18 residents receiving oxygen therapy from a total sample of 28 residents. The findings include: 1. On 9/25/23 at 12:05 p.m., Resident #11 was observed lying in bed with the TV on, her eyes closed, and receiving oxygen via nasal cannula at 2.5 Liters per minute (L/min). (Photographic evidence obtained) A review of her medical record's active orders revealed a 2/9/23 physician's order for Oxygen at 2 L/min via nasal cannula every shift. Further review of the physician's orders revealed the following: A 2/9/23 order: Change oxygen tubing weekly and PRN (as needed) every night shift, every Sunday. A 2/9/23 order: Albuterol Sulfate Nebulization Solution (2.5 mg/3ml) 0.083%, 1 application inhale orally via nebulizer every 6 hours as needed for shortness of breath (SOB). A 2/9/23 order: Budesonide Inhalation Suspension 0.5 mg/2.0 ml (milligrams per milliliter), inhale orally two times a day for SOB. A 4/10/23 order: SPO2 every shift as needed for oxygen saturation. A 7/12/23 order: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3ml, inhale orally every 6 hours for SOB. A 9/25/23 order: Continuous Positive Airway Pressure (CPAP) at bedtime for SOB and every 24 hours as needed for SOB. A 9/26/23 order: Bilevel Positive Airway Pressure (BIPAP) can be used intermittently if needed and in the morning remove BIPAP. A 9/26/23 order: Clean CPAP filter once a week, every night shift, every Sunday, and clean CPAP and water chamber every night shift. On 9/25/23 at 2:23 p.m., another observation was made of Resident #11 lying in bed wearing her nasal cannula with the oxygen concentrator set at 2.5 L/min. (Photographic evidence obtained) On 9/26/23 at 11:13 a.m., another observation was made of Resident #11 lying in bed wearing her nasal cannula with an empty humidifier (turned off) and the oxygen concentrator set at 2.5 L/min. (Photographic evidence obtained) On 9/26/23 at 2:50 p.m., another observation was made of Resident #11 lying in bed wearing her nasal cannula with the oxygen concentrator set at 2.5 L/min. The humidifier was turned on and filled with water. (Photographic evidence obtained) A review of the medical record revealed that Resident#11 was readmitted to the facility on [DATE] with an initial admitted [DATE]. Her diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD); congestive heart failure (CHF); morbid (severe) obesity with alveolar hypoventilation; generalized anxiety disorder, and cognitive/communication deficit. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 6/30/23, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. The resident was assessed and required extensive assistance with two people for bed mobility and toileting. Transfer activity did not occur. A review of the care plan, initiated on 1/25/23, revealed that the resident had altered respiratory status/difficulty breathing related to sleep apnea. Interventions included administering medication/puffers as ordered. Monitor for effectiveness and side effects, change oxygen tubing weekly and PRN, and oxygen settings: oxygen via nasal prongs at 2L (liters per minute) as ordered. A review of the Treatment Administration Record (TAR) for September 2023 revealed: Oxygen at 2 L/min via nasal cannula every shift for oxygen, start date: 2/9/2023. (Copy obtained) A review of a 9/27/23 progress note at 3:39 p.m. revealed, Resident daughter was in to visit resident and resident asked her to turn up her oxygen and she did. Resident informed us of this when asked and daughter confirmed it over the phone. Educated daughter and resident to call for nurse when assistance is needed. On 9/27/23 at 3:00 p.m., Licensed Practical Nurse (LPN) F confirmed that Resident #11's oxygen setting was supposed to be 2.0 L/min. She stated Resident #11 did not change her own oxygen settings and she did not refuse oxygen therapy. Resident #11 would like to wear her CPAP 24 hours, but she was ordered to wear it at night and have it off during the day. When asked who provided ongoing monitoring of the resident's oxygen therapy, LPN F replied, the nurse. When asked who was responsible for ensuring the resident's oxygen flow rate was set according to the physician's order, she replied, the nurse. Correct oxygen settings are identified by checking orders. The night shift nursing staff are responsible for changing residents' oxygen tubing. Correct settings are communicated from one staff person to another via shift report. On 9/27/23 at 4:47 p.m., the Director of Nursing (DON) was asked how correct oxygen flow rate settings were communicated from one staff member to another. She replied, by checking the order in computer. On 9/28/23 at 9:04 a.m., a telephone interview was conducted with Resident #11's responsible party. She verified that her sister was at the facility visiting Resident #11 on Wednesday, 9/27/23, and accidentally hit the oxygen concentrator, readjusting the setting. She confirmed that her sister was not at the facility on Monday or Tuesday, 9/25/23 or 9/26/23. A review of the facility's policy and procedure titled Standards and Guidelines: Oxygen Administration, Manual-Nursing-Pulmonary (reviewed/revised: 01/15/2021) revealed: Guidelines: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 42630 2. On 9/25/23 at 12:00 p.m., Resident #43 was observed lying in bed with her oxygen (02) concentrator set at 2 L/min. Oxygen was being delivered via nasal cannula (n/c). On 9/26/23 at 9:00 a.m., Resident #43 was observed lying in bed awake with her O2 concentrator set at 2 L/min with oxygen being delivered via n/c. (Photographic evidence obtained) She was asked if she knew her O2 flow rate setting and whether she had ever changed her own oxygen setting. She stated, No, I can't reach that. The nurse does that. On 9/26/23 at 12:33 p.m., Resident #43 was observed lying in bed awake with her O2 concentrator set at 2 L/min with oxygen being delivered via n/c. (Photographic evidence obtained) On 9/27/23 at 8:25a.m., Resident #43 was observed lying in bed awake with her O2 concentrator set at 2 L/min with oxygen being delivered via n/c. (Photographic evidence obtained) LPN G entered the room to set up the resident's breathing treatment. She was asked what treatment the resident was receiving. She stated Ipratropium Albuterol. The nurse set up the breathing treatment and left the room without checking the resident's oxygen flow rate. On 9/27/23 at 8:41 a.m., LPN G was observed removing the resident's breathing treatment mask. She did not check the oxygen flow rate setting on the concentrator. It was set at 2 L/min. On 9/27/23 at 11:43 a.m., Resident #43 was observed lying in bed awake with her O2 concentrator set at 2 L/min with oxygen being delivered via n/c. (Photographic evidence obtained) On 9/28/23 at 5:34 a.m., Resident #43 was observed lying in bed with the head of her bed elevated. Her eyes were closed and her respirations were 18 per minute. Her nasal cannula was in place and her oxygen flow rate was set at 2 L/min. (Photographic evidence obtained) On 09/28/23 at 6:35 a.m., LPN D was asked if she was caring for Resident #43 this shift. She stated yes. She was asked who checked and monitored the oxygen settings for residents with oxygen ordered. She stated, the nurses do. She was asked how often oxygen rates/settings were checked. She stated, on rounds, every two hours. She was asked what Resident #43's oxygen setting orders were. She stated, I think it's 2 L/min. She was asked to confirm what the order was. She checked the physician's orders and stated, Oh, it's 3 L/min. She was asked to check the resident's flow rate setting. Upon entering the room and checking Resident #43's oxygen concentrator, the nurse stated, Oh, it's on 2 L/min right now. It's hard to see. I just changed it to 3 L/min. A review of the resident's medical record revealed an order dated 2/10/23 for Oxygen: 3 L/min via n/c with humidification every shift for Chronic Obstructive Pulmonary Disease (COPD). Further review of the medical record revealed a care plan: Focus (6/10/21, revised 9/11/23) The resident has altered respiratory status/difficulty breathing related to Congestive Heart Failure (CHF), COPD, sleep apnea. Goals: (revised 7/7/23) The resident will have no signs/symptoms of poor 02 absorption through the review date. Interventions: (7/1/21, revised 10/24/22) Oxygen settings: O2 @ 3 L/min per nasal cannula as ordered. A review of the facility's policy and procedure titled Oxygen Administration (revised 1/15/21) revealed: Standard: It is the standard of this facility to provide guidelines for safe oxygen administration. Guidelines: 1. Verify there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 2. Review the resident's care plan for any special needs of the resident. 4. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter as is ordered by the physician, or required to provide for the needs of the resident.

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that it's medication error rate was not 5% or greater. There were two errors with 28 opportunities for error resulting in an error rate of 7.14% and affecting one (Resident #74) of eight residents observed during medication administration. The findings include: On 9/26/23 at 9:30 a.m., Licensed Practical Nurse (LPN) B was observed preparing medications for Resident #74. LPN B administered the oral medications first, then set up a nebulizer inhalation treatment: Budesonide Inhalation: 0.5 milligrams (mg)/2 milliliters (ml) suspension. LPN B placed the inhalation mask over the resident's mouth and nose. She then told the resident she would return in 10 minutes to remove the mask. After 10 minutes had passed, LPN B returned and removed the mask. She was asked if she had completed medication administration for Resident #74. She stated yes. LPN B did not offer Resident #74 water or instruct her to rinse her mouth and spit after completing the inhalation treatment. In an interview with Resident #74 on 9/26/23 at 9:45 a.m., she was asked if staff ever assisted or instructed her to rinse her mouth with water and spit the water out after receiving an inhalation treatment. She stated no. Budesonide is a steroid-based inhalation medication for which professional standards of administering include educating and assisting the patient to rinse their mouth with water after each dose and spit the water out. Rinse your mouth with water and spit out the water. Do not swallow the water. This helps prevent hoarseness, throat irritation, and infections in the mouth. (www.mayoclinic.org/drugs-supplements/budesonide-inhalation-route/proper-use/drg-20071233 - Accessed on 9/26/23 at 10:30 a.m.) On 9/26/23 at 12:50 p.m., while reconciling the medications given to Resident #74, it was observed on the electronic Medication Administration Record (eMAR) that Formoterol Fumarate inhalation nebulizer solution 20 micrograms (mcg)/2 milliliters (ml): Inhale 2 ml twice a day was signed off as having been administered at 9:00 a.m. on 9/26/23. This medication was not observed as having been administered to Resident #74 during the morning medication administration observation. In an interview with LPN B on 9/26/23 at 12:55 p.m., she was asked if she had administered the Formoterol Fumarate inhalation nebulizer solution to Resident #74 this morning. She stated, No, I haven't given it yet, the two nebulizers are given separately, the second one is in the fridge, the Formoterol. She was asked if she had signed it off as given at 9:00 a.m. today. She stated Yes, I'm going to get it now and give it to her. A review of the facility's policy titled Standards and Guidelines: Medication Administration (revised 1/1/21) revealed: Standard: It will be the standard of this facility to administer medication in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Guidelines: 3. Medications should be administered in a timely manner and in accordance with the physician's orders. 7. After successfully identifying the resident to receive the medication administration, the individual administering the medication should ensure that the right medication, right dosage, right time, and right method of administration are verified. 13. When the medications are administered, the individual administering the medication must record in the resident's medical record/MAR.

Based on staff interviews, medical record review, and facility policy and procedure review, the facility failed to ensure its residents remained free of significant medication errors. This impacted one (Resident #74) of eight residents observed during medication administration, out of 28 residents in the total sample. Resident #74 received medication for low blood pressure outside of the ordered parameters for 44 of 128 doses administered. The findings include: During medication reconciliation completed for Resident #74, an order was reviewed, which read: Start date 5/23/23: Midodrine 5 milligrams (mg): Give 5 mg by mouth one time a day for low blood pressure; hold if systolic blood pressure is greater than 120. Further review of the medical record included the Electronic Medication Administration Record (eMAR), which revealed this medication was signed off as having been administered 44 times when the SBP was recorded above 120 mmhg (millimeters of mercury), out of 128 doses signed off as administered from the resident's date of admission through the date of medication reconciliation. The record review revealed a SBP greater than 120 on the following dates: 9/1/23: 142/81 9/2/23: 142/81 9/4/23: 142/81 9/5/23: 140/75 9/6/23: 140/75 9/7/23: 137/74 9/11/23: 124/64 9/13/23: 128/60 9/14/23: 153/47 9/15/23: 129/58 9/20/23: 123/36 9/21/23: 129/64 9/24/23: 157/66 9/25/23: 157/66 8/3/23: 121/70 8/4/23: 121/70 8/5/23: 121/70 8/6/23: 121/70 8/13/23: 128/68 8/14/23: 122/62 8/15/23: 136/63 8/26/23: 137/73 8/29/23: 122/68 8/30/23: 130/80 8/31/23: 130/80 7/2/23: 134/72 7/23/23: 122/70 7/24/23: 164/66 7/25/23: 128/72 7/26/23: 128/72 7/27/23: 128/72 7/28/23: 128/72 6/8/23: 135/65 6/14/23:126/60 6/15/23: 126/60 6/16/23: 123/60 6/17/23: 123/60 6/18/23: 123/60 6/19/23: 123/60 6/20/23: 123/60 6/21/23: 123/60 6/22/23: 123/60 5/24/23: 134/78 5/25/23: 136/82 In an interview with the Director of Nursing on 9/28/23 at 8:05 a.m., she was asked if the facility had a policy regarding checking vital signs in accordance with medication administration. She stated, No, there is no separate policy, it's a professional standard to check the resident's vital signs if the doctor ordered to check them with the medication. In an interview with the Advanced Practice Registered Nurse (APRN) on 9/28/23 at 11:42 a.m., she was asked about the Midodrine order for Resident #74. She stated, I came here at the end of July. I believe she's (Resident #74) had some transient hypotension with periodic blood pressure drops. She hasn't had any hypotension since August, so I will discontinue the Midodrine and see how she does. Systolic Blood Pressure (SBP) is the top number of the blood pressure reading. According to Mayo Clinic, Midodrine is used to treat low blood pressure (hypotension). It works by stimulating nerve endings in blood vessels, causing the blood vessels to tighten. As a result, blood pressure is increased. (mayoclinic.org/drugs-supplements/midodrine-oral-route/description/drg-20064821 - accessed on 9/28/23 at 4:00 p.m.) According to Drugs.com at www.drugs.com/mtm/midodrine.html - Accessed on 9/28/23 at 4:00 p.m.), Midodrine can increase blood pressure even when you are at rest. Midodrine should be used only if you have severely low blood pressure that affects your daily life. Your blood pressure will need to be checked before and during treatment with midodrine. Check your blood pressure while you are lying down, and check it again with your head elevated. Follow all directions on your prescription label. Do not take midodrine in larger or smaller amounts or for longer than recommended. Midodrine can increase your blood pressure even while you are lying down or sleeping (when blood pressure is usually lowest). Long-term high blood pressure (hypertension) can lead to serious medical problems. A review of the facility's policy titled Standards and Guidelines: Medication Administration (revised 1/1/21) revealed: Standard: It will be the standard of this facility to administer medication in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Guidelines: 2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication duties and functions. 3. Medications should be administered in a timely manner and in accordance with the physician's orders.

Based on staff interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that services provided met professional standards of quality for one (Resident #74) of 28 residents in the total sample. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. The findings include: During medication reconciliation completed for Resident #74, an order was reviewed, which read: Start date 5/23/23: Midodrine 5 milligrams (mg): Give 5 mg by mouth one time a day for low blood pressure; hold if systolic blood pressure is greater than 120. Further review of the medical record included the Electronic Medication Administration Record (eMAR), which revealed this medication was signed off as having been administered 44 times when the SBP was recorded above 120 mmhg (millimeters of mercury), out of 128 doses signed off as administered from the resident's date of admission through the date of medication reconciliation. The record review revealed a SBP greater than 120 on the following dates: 9/1/23: 142/81 9/2/23: 142/81 9/4/23: 142/81 9/5/23: 140/75 9/6/23: 140/75 9/7/23: 137/74 9/11/23: 124/64 9/13/23: 128/60 9/14/23: 153/47 9/15/23: 129/58 9/20/23: 123/36 9/21/23: 129/64 9/24/23: 157/66 9/25/23: 157/66 8/3/23: 121/70 8/4/23: 121/70 8/5/23: 121/70 8/6/23: 121/70 8/13/23: 128/68 8/14/23: 122/62 8/15/23: 136/63 8/26/23: 137/73 8/29/23: 122/68 8/30/23: 130/80 8/31/23: 130/80 7/2/23: 134/72 7/23/23: 122/70 7/24/23: 164/66 7/25/23: 128/72 7/26/23: 128/72 7/27/23: 128/72 7/28/23: 128/72 6/8/23: 135/65 6/14/23:126/60 6/15/23: 126/60 6/16/23: 123/60 6/17/23: 123/60 6/18/23: 123/60 6/19/23: 123/60 6/20/23: 123/60 6/21/23: 123/60 6/22/23: 123/60 5/24/23: 134/78 5/25/23: 136/82 In an interview with the Director of Nursing on 9/28/23 at 8:05 a.m., she was asked if the facility had a policy regarding checking vital signs in accordance with medication administration. She stated, No, there is no separate policy, it's a professional standard to check the resident's vital signs if the doctor ordered to check them with the medication. Systolic Blood Pressure (SBP) is the top number of the blood pressure reading. According to Mayo Clinic, Midodrine is used to treat low blood pressure (hypotension). It works by stimulating nerve endings in blood vessels, causing the blood vessels to tighten. As a result, blood pressure is increased. (mayoclinic.org/drugs-supplements/midodrine-oral-route/description/drg-20064821 - accessed on 9/28/23 at 4:00 p.m.) A review of the facility's policy titled Standards and Guidelines: Medication Administration (revised 1/1/21) revealed: Standard: It will be the standard of this facility to administer medication in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Guidelines: 2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication duties and functions. 3. Medications should be administered in a timely manner and in accordance with the physician's orders.

Based on observations, staff interviews, and a review of the facility's policies and procedures for Infection Control and Guidelines for Wound Care, the facility failed to prevent the potential development and transmission of infection by not following infection prevention techniques during a wound dressing change for one (Resident #65) of three residents observed during wound care, from a total sample of 28 residents. The findings include: An observation of Resident #65 was made on 9/25/23 at 3:00 p.m. She was observed lying in bed with an air mattress, positioned with pillows. The resident's medical record was reviewed and revealed that she was admitted to the facility on [DATE]. Her diagnoses included the following: mild protein calorie malnutrition, unspecified contact dermatitis, and osteomyelitis of sacral and sacrococcygeal region. Her care plan was reviewed, and it noted that she had a pressure ulcer of the sacral area which reopened in December 2022. A 9/27/23 physician's treatment order was reviewed which revealed: Cleanse and rinse sacrum with Dakin's (antiseptic solution) for odor control, apply Metronidazole gel 1% and collagen powder, and cover with silicone foam border daily and as needed. An interview with Registered Nurse (RN) A was conducted on 9/27/23 at 2:30 p.m. He stated the resident's wound was improving. The wound care physician saw her weekly and had changed treatments multiple times. RN A stated the resident had a large wound on her sacrum which was a Stage IV. The order for the treatment was reviewed and supplies were gathered. RN A washed his hands and applied gloves. Two staff members were holding the resident on her right side. The old dressing was removed by RN A. He did not remove his gloves and wash his hands after removing the old dressing. Instead, he proceeded to clean the wound with antiseptic solution, then applied Metronidalzole 1%, which was mixed with collagen powder. He then applied a gauze dressing and a border dressing. The dressing was dated. He then closed a red biohazard bag with supplies and the old dressing, wash his hands and took the bag to the soiled utility room. He washed his hands again and asked how he did. When he was asked about his process of removing the soiled dressing, cleansing the wound and applying a new dressing, he confirmed that he did not wash his hands or change gloves after removing the soiled dressing. A review of the facility's policy and procedure: Nursing Infection Control (dated 1/15/21), revealed that gloves should be changed during patient care when moving from a contaminated body site to a clean body site. A review of the facility's policy and procedure: Standards and Guidelines for Wound Care (revised 1/15/21) revealed that the standard of the facility was to provide assessment and identification of residents at risk of developing pressure ulcers using the following guidelines: Wound care treatment should maintain proper technique as indicated by the type of wound and physician orders. An interview was conducted with the Director of Nursing (DON) on 9/28/23 at 12:23 p.m. The DON reported when staff were changing dressings, going from soiled to clean and removing old dressings, gloves should be removed, hands should be washed and new gloves should be donned. .

Based on observation, interviews and record reviews, the facility failed to ensure that one (Resident #1) out of five sampled residents who required extensive assistance for toileting, received appropriate and timely assistance for toileting. The findings include: A record review for Resident #1 revealed an admitted [DATE] and a re-entry date of 11/10/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission minimum data set (MDS) assessment, dated 11/16/21, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. The assessment also documented his need for extensive assistance with toilet use with one-person physical assist. (Copy obtained) On 01/21/22 at 10:35 AM, a call light was observed activated for room [ROOM NUMBER]. After knocking on the door and asking whether Resident #1 was alright, he was observed laying on his back, sitting on a bed pan. He reported, he wanted to get help to get off the bed pain and Employee A, Certified Nursing Aid (CNA) said, she would come back in 10 minutes, but she never came back. When Resident #1 was asked how long he was sitting on the bed pan, he stated, About 25 minutes. He reported that this was a problem that happened a lot. He stated, he had to wait up to an hour at times. Resident #1 also stated, he was totally dependent on staff for his toileting needs. Resident #1 was care planed for ADL self-care performance deficit related to activity intolerance and ADL needs and participation vary related to fatigue. Intervention included assist with toilet use. (Copy obtained) On 1/21/22 at 10:43 AM, the call light remained illuminated over the doorway to Resident #1's room. Employee C, Housekeeping Aide was observed in the hallway outside the room. Employee C, Housekeeping Aide was interviewed on 1/21/22 at 10:46 AM. She indicated that she could check in on residents who had a call light on but if they had any nursing needs, she would be responsible for getting someone from the nursing staff to assist the resident. She confirmed that she did not respond to Resident #1's call light and did not inform any. On 1/21/22 at 10:48 AM, Employee B, CNA was observed at the west wing nurse's station. Employee B, CNA confirmed that Employee A, CNA was assigned to care for Resident #1. Employee B, CNA and Employee C, Housekeeping Aide then went to Resident #1's room. On 1/21/22 at 10:50 AM, Employee A, CNA was observed in room [ROOM NUMBER] helping a resident eat. Employee A, CNA confirmed that she was assigned to take care of Resident #1 and put him on the bed pan next door. She then went to room [ROOM NUMBER] to assist feeding another resident. On 1/21/22 at 10:53 AM, Resident #1 was observed in his room being cleaned up by staff. An interview was conducted with the Executive Director (ED) on 1/21/22 at 2:44 PM regarding call light response times. The ED confirmed that Resident #1 should not have waited on a bedpan for more than 20 minutes. She stated, the standard of care for call light response times is that when they come on, you answer them. Everyone should be answering the call lights. If you see a light on, you go in. On 1/21/22 at 2:50 PM, Employee A, CNA was observed responding to Resident #1's call light. When Employee A, CNA was asked when she placed Resident #1 on a bedpan, she stated she didn't remember. She confirmed that she told Resident #1 that she would return in 15 minutes to help him, but she did not. She said, she assumed that other staff members would respond to his call light.

Based on observations and employee interviews, the facility failed to distribute and serve food in accordance with professional standards for food service safety, by failing to practice appropriate hand hygiene and glove use during food preparation activities to prevent cross-contamination. This failure potentially affected all residents receiving food from the facility's kitchen. The findings include: A food service observation was conducted in the kitchen at 11:55 AM on 12/2/2021. At 12:00 PM, the Chef was observed setting up the food items for lunch service. The Chef was observed with a pair of gloves on during the set up. He was observed pouring the sauce for the meal from a pot into a stainless steel pan, then taking the pot to the dishwashing area and rinsing it out with the hand-held nozzle. He then returned to the food service area and began to stir the sauce in the the stainless steel pan without doffing the gloves, washing or sanitizing his hands, and donning a new pair of clean gloves. At 12:07 PM on 12/2/2021, the Chef was interviewed about hand hygiene while in the kitchen. When asked what should have taken place prior to returning to the service area, the Chef stated he should have changed his gloves. He then doffed his gloves, walked over to the handwashing station located next to the 3-compartment sink and across from the dishwasher, washed and dried his hands, and donned a new pair of gloves. An interview was conducted with the Certified Dietary Manager (CDM) at 12:56 PM on 12/2/2021. During the interview, the CDM stated all staff received training on hand hygiene during orientation, and there were reminders posted in each hand washing area of the kitchen. He stated he brought the Chef from his previous facility, and did not know why the cook did not change his gloves and wash his hands prior to returning to the serving station. The Hand Hygiene policy was requested at 1:00 PM on 12/2/2021. A review of the facility's Hand Hygiene policy entitled Standards and Guidlines: Hand Hygiene, did not address hand hygiene during food service, however, Guideline 2 read, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.

Based on observations, staff and resident/resident representative interviews, and a review of resident and facility records, the facility failed to ensure residents who were dependent for grooming and hygiene, received the appropriate nail care to prevent soiled, jagged or excessively long nails for three (Residents #9, #35 and #78) of five residents reviewed for activities of daily living (ADLs), from a total of 41 residents in the sample. The findings include: 1. A record review for Resident #9 found an Annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/27/21. It noted Resident #9 was not able to make himself understood. He had memory problems to include no recall of staff names, the current season, his room location or that he was in a nursing facility. Resident #9 had moderately impaired cognitive skills for daily decision making. There was no rejection of care over the assessment look-back period. Resident #9 required extensive assistance with hygiene. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 was care planned on 8/20/21 for his multiple medical and care needs, including for his activities of daily living (ADL)/self-care performance deficit. The focus noted his needs and participation varied. The goal was for Resident #9 to have no complications related to the deficit, and to maintain his current level of functioning through the next review date. Interventions included explaining procedures prior to starting and encouraging Resident #9 to participate to the fullest extent possible. (Photographic evidence obtained) A telephone interview was conducted with Resident #9's family member on 11/29/21 at 10:45 AM. The family member reported that during the last visit with Resident #9, his toenails were thick and had black matter under the nails. They were so long, they rolled over the end of Resident #9's toes. An observation of Resident #9 conducted on 11/29/21 at 11:36 AM, found his fingernails were long and jagged. Upon a second observation on 11/30/21 at 10:20 AM, Resident #9's fingernails were still long and jagged. On 12/1/21 at 9:30 AM, Resident #9 was asked to show his fingernails. He held his hands out. Both thumb nails were excessively long. The right thumbnail extended approximately 1/2 inch beyond the nail bed and was broken off. The edges were jagged and un-filed. The left index fingernail was so long it curved around the tip of his finger toward the finger pad. On 12/1/21 at 10:05 AM, verbal consent to photograph Resident #9's fingernails was obtained from the resident's representative via telephone. An interview was conducted with Resident #9 on 12/1/21 at 10:40 AM. He was asked if he wished to have his fingernails cut. He looked at them and said, Si (Yes in Spanish). He also granted permission to photograph his hands and fingernails. (Photographic evidence obtained) 2. A record review for Resident #35 found a Quarterly MDS assessment with an ARD of 9/21/21. Resident #35 was noted as being rarely understood. He had severely impaired cognitive skills for daily decision making, and required extensive assistance with personal hygiene. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35 was care planned for an ADL/Self Care Performance Deficit related to his limited mobility. The goal was to be free from complications related to the deficit through the next review date. Interventions included explaining procedures prior to performing tasks and reporting changes in self-performance to the nurse. Interventions also noted Resident #35 required extensive assistance with ADLs. There was no indication this resident refused ADL care. (Photographic evidence obtained) Resident #35 was observed on 12/1/21 at 10:31 AM. He was unable to respond verbally, but was able to make, and maintain, constant eye contact. Resident #35 reached out his hand. At this time, his fingernails were observed to be long, un-filed and with dark matter under the nails. During an observation of Resident #35 on 12/22/21 at 10:01 AM, his fingernails were in the same condition as the prior day's observation. Licensed Practical Nurse (LPN) F stated in an interview on 12/1/21 at 2:51 PM, that Resident #35 was dependent on staff for all ADL care. An interview was conducted with Resident #35's representative on 12/2/21 at 10:28 AM. He reported he had visited multiple times and found Resident #35's fingernails long and un-filed. He had to go find a nurse and ask them to take care of Resident #35's fingernails. The resident representative gave permission to photograph Resident #35's hands and nails. (Photographic evidence was obtained on 12/2/21 at 10:45 AM.) Resident #35's spouse, who shares the room with him, was present when photographs were taken. She volunteered that staff did not do Resident #35's nails very often. His fingernails were often too long. She explained it was important for his nails to stay trimmed and filed as he scratched at his face and eyes. An interview was conducted with Certified Nursing Assistant (CNA) I on 12/1/21 at 2:07 PM. She stated the CNAs performed fingernail care for the residents. This included cleaning them and trimming/ filing as needed. The podiatrist (foot doctor) did resident toenails. Activities Assistant (AA) G was interviewed on 12/2/21 at 11:00 AM. She was in the common area painting a resident's fingernails. She had a plastic bin full of nail polishes, nail clippers and a cuticle pusher. AA G explained activities went around and did resident nails about three days a week. Additional nail care was performed on an as-needed basis, or when the CNA or nurse reported the need. There was no set schedule, and she depended on others to make her aware that there was a need. CNA H was interviewed on 12/2/21 at 11:03 AM. She said fingernail care, which included cleaning, trimming and filing for non-diabetic residents, could be done by the CNA or Activities staff. There was no particular schedule. CNAs did it when they had time, however, they were often busy providing other needed care. CNAs could tell Activities staff if nail care was needed, but they were really busy too. In a second interview with LPN F on 12/2/21 at 11:13 AM, she confirmed nail care could be done by either the CNAs or Activities staff. She was shown the condition of Resident #9 and Resident #35's nails. She stated Resident #35 often refused nail care, but she was not stating the condition observed was acceptable. LPN F acknowledged that both Resident #9 and #35's excessive nail growth had progressed over an extended period of time. A review of the facility Standards and Guidelines: Nail Care, implemented 1/15/21 and revised 1/15/21, found: Standard: It will be the standard of this facility to provide nail care to residents per resident preferences and to maintain dignity. Guidelines: 1. Review resident's medical record to assess for any special needs of the resident. 2. Assemble equipment and supplies needed. 3. Nail care includes regular cleaning and trimming, unless contraindicated by resident condition, specific behaviors or resident refusal. 4. Proper nail care can aid in the prevention of skin problems around the nail bed. 5. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory problems. 6. Trimmed and smooth nails can help prevent the resident from accidentally scratching and injuring his or her skin . .10. Notify the supervisor if the resident refuses the care. Document history of refusal of provision of care in the clinical record. (Photographic evidence obtained) 3. On 11/30/21 at 10:30 AM, Resident #78 was observed lying in bed with the covers off and her feet exposed, revealing very long, jagged toenails. On 12/1/21 at 9:10 AM, the resident's toenails remained untrimmed and jagged. On 12/2/21 at 10:20 AM, during an interview with LPN F, she was asked how often the podiatrist visited. She said she wasn't sure, but she thought he visited monthly. She was asked how the podiatrist knew which residents to see. She said nursing kept a book at the nursing station, and the residents' names were placed in the book if they needed to be seen. The Social Worker (SW) was at the nursing station and stated she checked the book and then called the podiatrist and let him know who was to be seen. She was asked when the podiatrist last saw Resident #78. She said she would review the record. After her review, she said that the last visit was on 3/12/21. When asked if Resident #78 was on the list to receive care from podiatry this month, she said she did not see her name on the list but would add her name. On 12/2/21 at 10:30 AM, LPN F was asked to observe Resident # 78's toenails. LPN F confirmed the nails were very long and needed the podiatrist. She said she would let the SW know.

Based on observations, interviews, record review, and policy review, the facility failed to develop and implement a comprehensive person-centered care plan that addressed hearing and vision deficits for one (Resident #32) of 41 residents in the sample. The findings include: On November 29, 2021 at 12:10 p.m., Resident # 32 was observed sitting on the edge of her bed, clipping her nails. She was unaware of the knocking on her door and calling her name for permission to enter. When her name was called out somewhat louder, she looked up and stated, I didn't hear you. I'm almost deaf. She was asked if she had hearing aides or a communication board. She stated, No. I've been here three months. I need to see a specialist; I keep telling them that but nothing happens. I used to have hearing aides, but I lost one and the other broke. The girl from therapy gave me this thing (amplifier with headphones), but it doesn't work, even with new batteries. My daughter bought this thing (hearing aide-looking device for one ear from a box marked amplifier), but it doesn't work either, even with new batteries. Resident #32 continued, And my eyes, I'm going blind. I told them but nothing is being done. I saw their eye doctor here, but he said I need to see a specialist. I've told them my eyes hurt. I see shooting lights and they're photo sensitive. I keep the shades closed, but no one has done anything. Room shades were observed to be closed, and the resident's bed was next to the window. Resident #32 was asked if she kept her window shade closed. She stated, Yes, if I don't keep it closed, it hurts my eyes, it's so painful. On November 30, 2021 at 10:05 a.m., Resident # 32 was observed lying in bed with her eyes closed. She did not respond to her name being called. Her window shades were closed. An interview was conducted on December 1, 2021 at 12:11p.m. with the Social Services Director (SSD). She was asked how staff communicated with Resident #32 due to her hearing deficit. The SSD stated, Well, I know her daughter did bring her in some little ear amplifiers, but they didn't work or didn't help. But I know from speaking with [Resident #32] myself, that if you sit face-to-face and speak up, and directly to her, she can hear you. You do have to speak loudly. An interview was conducted on December 1, 2021 at 1:39 p.m. with Licensed Practical Nurse (LPN)/Unit Manager A. She was asked if Resident #32 had any hearing deficits. She stated, She can hear. We do have to repeat things, and she likes to read lips, but she can hear. She was asked if she had to speak loudly to Resident # 32 in order for her to hear her. She stated, No, not really. That's not necessary. Her daughter says she's hard of hearing and reads lips, but she can hear us. She was asked about Resident #32's vision. She stated, I'm not for sure on that. She can see well to my knowledge. I know she has an eye appointment scheduled. An interview was conducted on December 1, 2021 at 2:10 p.m. with Certified Nursing Assistant (CNA) B. She was asked if she was assigned to Resident #32 today. She stated yes. She was asked about Resident #32's hearing ability. She stated, Oh, she doesn't hear well. I have to get close so she can hear me. She was asked if the resident wore hearing aides, and she replied, I'm not sure, but the nurses hold the hearing aides and they put them in, not us. She was asked about Resident #32's vision, and replied, She seems okay with vision. She just needs help to stand because her legs are weak, but I think she can see okay. She was asked if the resident had complained of light bothering her eyes. She stated No, I don't think so. I know she likes the shades closed. An interview was conducted on December 1, 2021 at 2:45 p.m. with Registered Nurse (RN) C. He was asked if he was assigned to Resident #32 today. He stated yes. He was asked if Resident #32 had any trouble hearing him. He stated no. He was asked if Resident #32 had ever complained about hearing loss to him, and he replied that she hadn't. He was asked if she wore hearing aides, and he said, No, I don't think so. I've never seen any for her. She would have a doctor's order, because we lock them up at night and then place them in their ears in the morning, so they don't get lost, and also charge them overnight if they are the rechargeable kind. He was asked if Resident #32 had any visual problems. He stated 'no'. He was asked if she had ever complained to him about being sensitive to the light, and he replied no. On December 1, 2021 at 3:15pm, an interview was conducted with RN D, Minimum Data Set (MDS) Coordinator. She was asked if she had created the care plan for Resident # 32, specifically the focus, goal and interventions concerning this resident's hearing deficit. She stated yes. She was asked whether she had created this section of the care plan today, and she replied yes'. She was asked if the resident had previously been care planned for a hearing deficit, and she replied no. She was asked why she created this section of the care plan today, and she replied, I was reviewing her care plan earlier today, and I saw that under her fall risk focus, she had a risk due to vision/hearing loss, so I added that as a focus today. She was asked if she had also added a care plan focus, goal and interventions for vision deficit. She stated no. She was asked where she obtained the information to create the hearing deficit focus, goals and interventions, and she replied, From her admission paperwork and her hospital discharge paperwork. She was asked if she spoke with the resident to develop the care plan regarding the focus on hearing deficit. She stated, Well, not today, but I did interview her when she was admitted . We call it a meet and greet. So, I did gather information in person then. Actually, I did have to talk loud and face her, and speak in her left ear, so I guess that should have given me a clue that she was hard of hearing then. On December 2, 2021 at 12:06 p.m., Resident #32 was observed sitting up in her bed. The shades on the window were drawn. She was asked why her shades were closed. She stated, I have the shades closed because my eyes are super sensitive. It just kills my eyes, it's so painful. There's a name for it, um, photo something, oh, photo sensitive. My eyes are getting so bad. I try to fill out my menu but the print just looks smaller and blurry, even when I use my magnifying glass. The resident pointed out the magnifying glass on her bedside table. She was asked if staff kept her shades closed. She stated, Sometimes I have to tell them; some of them don't know. When I tell them about my situation, they do close them. [RN C] came in the other day and opened them and said, You need some sunshine, but I asked him to please close them. I told him the light just kills my eyes. [Speech Language Pathologist (SLP) J] from therapy knows; she makes sure they are closed when she sees me. An interview was conducted on December 2, 2021 at 1:10 p.m. with CNA E. She was asked if she was assigned to care for Resident #32 today. She stated yes. She was asked if the resident had any issues with her hearing. She stated, Well, I speak loudly to her and make sure I'm right in front of her, close, so she can hear me. She was asked if the resident preferred her window shades closed. She stated, Yes, she does. She was asked if she knew why. She stated, No, I don't why. I just know she likes them closed and she will ask us to close them if they're open. An interview was conducted on December 2, 2021 at 2:36 p.m. with SLP J. She was asked if she had worked with Resident #32. She stated Yes, I saw her when she was first admitted , and I actually saw her yesterday for a new evaluation. I just certified her for speech services 4 times a week for 4 weeks for cognition. She was asked if the resident had any issues hearing her. She stated, Yes, I use amplifiers with her. I brought her in an older one I had to use with headphones, and I helped her daughter find one for over her ear, like a hearing aid but just an amplifier. Her daughter did get one for her. I have one in my office that I use with her that seems to work the best. I did try a communication board in the past, but she really didn't care for that, so I stopped. She will use gestures in her room and point to things. She was asked if the resident had any issues with vision. She stated, I personally have no issues with her because I tend to keep everything I use in black and white, and I print everything in large scale because this population generally needs plain larger print, so I'm just proactive. She was asked if the resident had complained about being sensitive to the light. She stated Yes, she has. She is light sensitive. She does have sunglasses in her room, but she prefers to keep the blinds pulled, so the sunlight doesn't come in. If she and I are in my office for therapy, I'll close the blinds and use a desk lamp, which she prefers because she says that doesn't bother her. A review of the Minimum Data Set (MDS) assessment, dated September 13, 2021, revealed that Resident #32 was evaluated for hearing, speech, and vision. Ability to hear was marked: Minimal difficulty (difficulty in some environments, e.g., when person speaks softly or setting is noisy) Hearing aid or other appliance used? Yes. A review of the Nursing Admission Assessment, dated September 9, 2021, revealed: Uses hearing aide left, uses hearing aide right. Hearing Care Plan with baseline Focus (Resident has problems hearing), Goal (Resident will be able to hear as needed/as desired, and Intervention (Resident is hard of hearing. Speak loudly, clearly and slowly. Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Take care to not startle the resident when approaching or entering the room). A review of a Monthly Summary, dated November 12, 2021, revealed: Hearing, Speech, Vision with hearing listed as hard of hearing and vision listed as impaired. A review of an eye exam consultation for Resident #32 with a service date of November 12, 2021 revealed: Chief complaint: Possible blurred vision reported per staff. The consultation revealed a prescription attached for an ophthalmology consult for diabetes and photophobia. A review of a Speech Therapy Evaluation and Plan of Treatment with a Start of Care date of September 11, 2021 revealed: Chart review/Patient interview: Hearing = functional with increased volume. A review of exams performed by the Nurse Practitioner and dated September 17, 2021, September 27, 2021 and November 12, 2021 revealed the following as part of the physical exam: September 17, 2021: ENT (ears, nose, throat): Reported: Hearing impairment. HOH (hard of hearing) September 27, 2021: Eyes: Reported: vision loss, blurry vision. ENT: Hearing impairment. November 12, 2021: Eyes: Reported: blurry vision. ENT: Hearing impairment. A review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 10/13/21: Ophthalmology consult 11/24/21: MD appointment Central Florida 12/28/21 at 10:15 a.m. 10/13/21: Audiology consult and treat as needed 09/09/21: Ophthalmology/podiatry/dental as needed A review of the Care Plan revealed no focus/goal/intervention entries for hearing deficit or vision deficit/photophobia. A review of the facility's policy/procedure titled, Standards and Guidelines: Hearing and Vision (January 15, 2021) included Guideline #4: Review of the resident's care plan to assess for any special needs of the resident and #16: Hearing and vision deficits should be addressed in the person-centered plan of care.

Based on record review, observations and staff interview, the facility failed to ensure oxygen therapy was administered as ordered by the physician for one (Resident #65) of nine sampled residents reviewed for oxygen therapy from a total sample of 41. The findings include: A review of Resident #65's medical record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She required total assistance with all activities of daily living (ADLs) except eating. She was ordered continuous oxygen at 1 liter per minute via nasal cannula. An observation of Resident #65's oxygen concentrator on 11/29/21 at 10:55 AM, found the oxygen rate was set at 2 liters per minute. An observation of the oxygen concentrator on 11/30/21 at 12:20 PM, found the flow rate set at 2.5 liters per minute. On 12/2/21 at 2:15 PM, the oxygen flow rate was set at 2.5 liters per minute. An interview was conducted with Licensed Practical Nurse (LPN) F on 12/1/21 at 2:20 PM. She was asked what oxygen flow rate was ordered for Resident #65. She reviewed the record and stated the order was for 1 liter per minute. She was asked to observe the resident's oxygen concentrator, and she confirmed that the flow rate was set at 2.5 liters per minute and needed to be adjusted.

Based on observations, interviews and record reviews, the facility failed to ensure that it made prompt efforts to resolve grievances for one resident (Resident #57) who voiced concerns about execution of the facility grievance process, out of 48 residents sampled. The findings include: During the initial tour and sampling of residents with concerns, an interview was conducted on 12/09/2019 at 2:31 PM with Resident #57. Resident #57 stated that Employee D, Director of Maintenance, came in some months ago and fixed the air conditioner (A/C) to remain at 71 degrees Fahrenheit (F). Resident #57 stated that he asked Employee D why this happened, and Employee D told him that corporate told him to do it and it was out of his hands. Resident #57 asked the surveyor to turn down the A/C to 60 degrees F and the A/C turned off. Resident #57 stated that he told the facility that he wanted his A/C to run like every one else and was told he could not. An interview was conducted with Employee F, CNA, on 12/11/2019 at 1:02 PM and she stated that Resident #57 complained to her about the A/C today. Employee F confirmed that the A/C does go off when it was turned down. An interview was conducted with Employee D on 12/11/2019 at 2:21 PM and he confirmed that only one or two rooms had special restrictions. He stated that the resident had the right to adjust the A/C temperature to what makes the resident feel comfortable; but that Resident #57's room was fixed so that he could not lower the A/C. Employee D confirmed that the A/C was locked at 71 degrees F. Employee D stated that the DON told him to restrict the A/C for Resident #57 because Resident #57 kept turning the A/C down. Employee D also stated that the resident had a right to set the A/C at a comfortable level. Employee D confirmed that when the A/C was turned below 71 it would turn off. Employee D stated he was not aware of any options provided to Resident #57 when he voiced concerns about wanting the room cooler. On 12/11/2019 at 2:33 PM Employee E, LPN Unit Manager, and the Director of Nursing (DON) were asked for documentation that Resident #57's concern related to his A/C was resolved. It was confirmed that no formal grievance was entered by Employee D; Employee E; Employee G, Social Service Director; the DON or the Administrator related to locking the A/C in Resident #57' room. Both Employee [NAME] and the DON confirmed that Resident #57's A/C had been locked out for about two months. Resident #57 was interviewed on 12/11/2019 at 2:35 PM and he confirmed he knew that the A/C was fixed so he could not use it like everybody else. He complained that he had voiced this concern for eight months and the Social Worker knew about the concerns and was working with Resident #57 about this and Resident #57 even wanted to move out at one time. An interview was conducted on 12/11/2019 at 2:40 PM with Employee G, Social Service Director, about concerns discussed with Resident #57. She reviewed the last Social Service quarterly assessment, dated 10/07/2019, and stated that Resident #57 had no complaints at the review. However, she confirmed that Resident #57 had concerns about his room being too warm and this was an ongoing issue that he cannot have the temperature below 70 degrees F. Employee G stated that she did not have a refusal of Resident #57 to change rooms to accommodate his needs. She also confirmed that the concern Resident #57 had about the room temperature being too warm had been for a couple of months. An interview was conducted with the Director of Nursing (DON) on 12/11/2019 at 2:51 PM. She confirmed that Resident #57 did not decline moving to other rooms. There was an offer to actually transfer Resident #57 to another facility and when the transfer came through, he declined to transfer. The DON confirmed that the facility locked the A/C some time ago. There was discussion about the use of private rooms as an option; but no evidence was provided that the concern was moved through the formal complaint and grievance process. On 12/12/2019 at 10:25 AM an interview was conducted with Employee G who confirmed that the complaint and grievance list from (MONTH) (YEAR) to present did not contain a specific grievance related to Resident #57's concern about room temperatures. On 12/12/2019 at 1:53 PM an interview was conducted with the Administrator and the DON who confirmed that no formal grievance process was provided for the events surrounding Resident #57's A/C concern. A review of the facility resident rights at K. grievance policy revealed, Filing a grievance will not result in any form of adverse personal action, reprimand or retaliation by facility management or staff. All persons are encouraged to use steps as set out below to address problems or file grievances: 1. A person filing a grievance on any matter, which affects him or her, should complete a Grievance/Concern report form, which may be obtained at each Nurse's Station, the front desk, or the Social Service Department. If the Resident is unable to complete the form for any reason, the Resident will be referred personally to the Social Service Department for assistance with filing the Grievance; 3. If the Grievance is not satisfactorily resolved within five (5) business days, the Social Service Department will refer the matter to the Facility Administrator for resolution; 4. If the grievance is not resolved to the satisfaction of the Resident, that matter may be referred to any one of the following areas: Ombudsman, Department of Children and Families or Elder Abuse, State Survey Agency for the State and Care Line. A review of the Patient Rights documentation provided to residents at the facility was conducted that outlined requirements under patient rights for 483.10 that residents have the right to voice grievances and the facility must make prompt efforts to resolve grievances and make the resident aware of how to file a grievance.

Based on observations during medication administration, staff interviews, and a review of the Standards and Guidelines for instilling eye drops, the facility failed to ensure a medication error rate of 5% or less (error rate 8.82%) by not cleaning hands before or between, or changing gloves before eye drop instillation for 2 to of 6 residents with 34 opportunities (Residents #25 and #17). The findings include: A medication administration observation was conducted on 12/10/19 at 4:21 PM with Employee A, Registered Nurse (RN) for room [ROOM NUMBER] B (Resident #25). Employee A gathered the [MEDICATION NAME] eye drops (1 drop in both eyes), [MEDICATION NAME] (1 spray in each nostril), and Dorzolamide eye drops (1 drop in left eye.) After entering room, Employee A washed hands, applied gloves and administered the [MEDICATION NAME] spray for Resident #25. After administering the [MEDICATION NAME], Employee A did not change gloves or wash hands after handling the [MEDICATION NAME] and administering. Employee A proceeded to instill a drop of [MEDICATION NAME] in the right eye, changed gloves, and instilled a drop of [MEDICATION NAME] in the left eye. He did not wash his hands or apply gloves before administering the eye drops, and he did not wash his hands before applying the eye drop in the left eye. The RN washed his hands, applied gloves after waiting 5 minutes and instilled the Dorzolamide eye drops to both eyes after coaching from the Licensed Practical Nurse (LPN), Unit Manager on West. An interview was conducted with Employee A at 4:40 PM on 12/10/19 after exiting the room. Employee A reported he should wash hands after removing gloves and especially in between instilling eye drops for both eyes. Employee A confirmed he did not change his gloves or wash his hands after administering [MEDICATION NAME] to the resident. He stated, I should have washed my hands again and applied new gloves before administering the eye drops. I should have washed my hands before changing gloves for instilling the eye drops to the second eye. A medication administration observation was conducted on 12/11/19 at 8:03 AM with Employee B, LPN for room [ROOM NUMBER] W (Resident #17). Employee B gathered the following medications after reviewing the Medication Administration Record [REDACTED]. After assembling the medications, the LPN entered the resident's room, and gave the resident the oral mediations, and the inhaler. After the resident finished her medications the LPN washed her hands, applied gloves and administered the Artificial Tears eye drop in each eye. The LPN did not change her gloves or rewash hands before administering the eye drop in the left eye. After the LPN exited the resident's room an interview was conducted at 8:19 AM on 12/11/19. The LPN confirmed she did not change gloves between administering the eye drops, and reported gloves would be changed if administering another eye medication. An interview was conducted with Employee C, RN Staff Educator, at 12/11/19 at 9:20 AM The RN reported education was provided to Employee B concerning the administration of eye drops in both eyes, including the need for glove change and hand hygiene must be done in between each eye per standards and guidelines. A copy of the standards and guidelines was provided. Employee C reported staff should wash hands, and change gloves after administering nasal meds, and between the administration of eye drops for each eye. The Standards and Guidelines Instillation of Eye Drops issued 10/23/2008 were reviewed. Guidelines included: explain procedure to resident, cleanse hands with alcohol cleanser or wash hands thoroughly with soap and water, put on gloves, and continue with steps to instill eye drops. Guideline #19 notes clean hands with alcohol hand cleaner or wash hands thoroughly with soap and water. Guideline #20 states repeat procedure for the other eye if ordered.

Based on observations, staff interviews, and facility record review, the facility failed to provide the texture consistency specifications of a pureed diet for 16 of 16 residents with an order for [REDACTED].#1, #17, #22, #24, #32, #36, #42, #49, #75, #84, #108, #111, #120, #134, #163, and #210), out of a total of 51 sampled residents. The findings included: During a follow up kitchen tour on 7/25/17 at 7:50 a.m., the pureed breakfast meal tray consisted of pureed oatmeal, pureed pork, pureed eggs, and pureed bread. A closer examination of the pureed oatmeal and pureed pork revealed various pieces of pork were not pureed, and the oatmeal had lumps that were not completely pureed. A finger test confirmed the unsmooth textures of the pureed pork and pureed oatmeal. Breakfast had already been served to the residents. An interview was conducted with the Regional Registered Dietitian on 7/25/2017 at 8:00 a.m. She confirmed the texture of the pureed pork and pureed oatmeal was not appropriate. A follow-up interview was conducted with the Regional Registered Dietitian on 7/25/2017 at 11:30 a.m. She provided the standards and guidelines titled Pureed Diet Consistency, revised 8/26/2008. Review of the policy revealed the standard of the pureed diet in this facility was considered a dysphagia puree. All foods served on a pureed diet were to be processed to a pudding or mashed potato consistency.

Based on observations, record review, and staff interviews, the facility failed to ensure that residents were properly assessed to self-administer medications for 1 (Resident #148) of 5 sampled residents observed for medication administration. The findings include: On 7/26/2017 at 8:25 am, Employee E, Licensed Practical Nurse, was observed passing medication to Resident #148. She prepared her medication, including a [MEDICATION NAME] Inhaler. Employee E handed the inhaler to the resident to do it herself. She stated the resident was capable of self-administration using the inhaler. Resident #148 was observed putting the inhaler up to her mouth, but did not close her lips around the mouthpiece. She then depressed the inhaler, but did not take a deep breath. The nurse was looking at her watch, and instructed the resident to wait between puffs. About 20 seconds later, the resident went to take another puff and the nurse told her not yet, it was too soon. Then approximately 15 seconds later, the resident performed the same procedure (did not close her lips around the mouthpiece, and not take a deep breath). Afterwards, the nurse removed the inhaler and left the room. The resident was not observed to rinse her mouth after using the inhaler. On 7/26/2017 at 8:30 a.m., Employee E was interviewed. She confirmed Resident #148 did not administer the inhaler correctly. She did not wait long enough between puffs, did not close her lips/ mouth, and not rinse afterwards. She stated that the resident self administered it, but she should have reminded her to do all of those things. Record review for Resident #148 revealed no physician order to self-administer her medications. There was no documentation that the interdisciplinary team assessed her ability to self-administer. The resident had a 1/24/2016 order for [MEDICATION NAME] Aerosol, 2 puffs, inhale orally two times a day for shortness of breath. Resident #148 was interviewed on 7/26/2017 at 8:50 a.m. She knew that she should rinse her mouth afterwards, and the nurse forgot to remind her to do it. She stated she might not have closed her mouth because her nose was stuffy and she couldn't breathe. The Manufacturer's Specification for [MEDICATION NAME] revealed, Rinse your mouth with water, and spit the water out after each dose (2 puffs). Do not swallow the water. This will help to lessen the chance of getting a fungal infection (thrush) in the mouth and throat. The facility's policy on Self-Administration of Medications, dated 12/2004, revised 7/2015, was reviewed. It revealed the staff and practitioner would assess or evaluate each resident's mental and physical abilities to determine whether a resident was capable of self-administering medications. On 7/26/2017 at 11:30 a.m., the Director of Nursing confirmed that there was no physician order for [REDACTED].

Based on observations, resident and staff interviews, and resident record reviews, the facility failed to comprehensively assess cognitive patterns through means that included direct communication with the resident for 1 of 51 sampled residents (Resident #115) whose records were reviewed. The findings included: An interview was conducted with Resident #115 on 7/25/2017 at 2:59 PM. He stated he was doing well. He was asked about his medications, and while he did not know all of the prescriptions he took, he insisted scheduled pain medications minimized potential pain. He knew to report any signs of possible medication side effects, stating the nursing staff had educated him regarding the same. Resident #115 said he received his medications on time, and as scheduled. He was also aware he was on [MEDICATION NAME] (a blood thinner), and knew to not pick at his skin (to minimize risk of bleeding.) An interview was conducted with Employee L, Licensed Practical Nurse (LPN), on 7/26/2017 at 12:02 PM. She confirmed Resident #115 received medication for leg pain. She stated he exhibited no behavioral symptoms, but that she monitored him for verbally aggressive behaviors. Record review for Resident #115 revealed he was admitted to the facility on [DATE]. He had an annual Minimum Data Set (MDS) assessment with an assessment reference date of 5/10/17. Section C - Cognitive Patterns, Sub -section C0100 asked, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted? Instructions were to Attempt to conduct interview with all residents. Section C0100 was coded with the answer Not assessed', and was authored by Employee K, MDS Coordinator. Staff performed the remainder of the assessment for this resident, indicating he had no problems with short or long term memory. Resident #115 required modified independence for daily decision making. Section Q of the assessment titled Participation in Assessment and Goal Setting indicated Resident #115 participated in the completion of his assessment. Further record review for Resident #115 revealed a quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 2/10/17. Section C- Cognitive Patterns, Sub - section C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted? was coded 'Not assessed', and was authored by Employee K. Staff performed the remainder of the assessment for the resident. Section Q, Participation in Assessment and Goal Setting, indicated Resident #115 participated in the completion of his assessment. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 11/10/16 was reviewed. Section C- Cognitive Patterns, Sub section C0100 - Should Brief Interview for Mental Status (C0200 - C0500) be Conducted? was coded with the answer 'Not assessed', and was authored by Employee K. Staff performed the remainder of the assessment for the resident. Section Q, Participation in Assessment and Goal Setting, indicated Resident #115 participated in the completion of his assessment. Resident #115 was care planned on 5/24/17 for impaired cognitive function or impaired thought processes related to requiring modified independence with making decisions. The goal was to maintain his current level of cognitive function through the next review date. Approaches included, but were not limited to, monitoring, documenting, and reporting any unanticipated changes in his cognitive functioning. An interview was conducted with Employee K on 7/27/2017 at 10:57 AM. She reviewed the MDS assessments for the last 3 quarters for Resident #115. When asked why this resident did not participate in his own assessment, she stated perhaps he had been in activities or on an outing when she attempted the interview(s). She did not know. She confirmed Resident #115 was alert and oriented. Employee K also confirmed she had a total of 7 days over the assessment period to complete the assessment with the resident. Employee K agreed that the BIMS assessment was a tangible measurement of cognitive functioning, and was a critical element in the development of the individual care plan. The Regional MDS Coordinator interjected into the conversation at approximately 11:00 AM. She confirmed the importance of involving the resident in the assessment for cognitive functioning, and that Resident #115 was alert and oriented. The Regional MDS Coordinator agreed that on-going evaluation of cognitive functioning per the care plan was dependent on a BIMS score. She instructed Employee K to amend the MDS assessment today, and obtain a BIMS score for Resident #115.

Based on observations, resident record review, and staff interviews, the facility failed to meet professional standards of quality based on failure to properly administer an inhaler for 1 of 5 sampled residents observed for medication administration, Resident #148. Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner 'practice of practical nursing' as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or infirmed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The findings include: On 7/26/2017 at 8:25 a.m., Employee E, Licensed Practical Nurse (LPN), was observed passing medication to Resident #148. She prepared her medication including a [MEDICATION NAME] Inhaler. Employee E handed the inhaler to the resident to do it herself. She stated the resident was capable of self-administration of her [MEDICATION NAME] via inhaler. Resident #148 was observed to put the inhaler up to her mouth, but did not close her lips around the mouthpiece. She then depressed the inhaler, but did not take a deep breath. The nurse was looking at her watch, and instructed the resident to wait between puffs. About 20 seconds later, the resident went to take another puff and the nurse told her not yet, it was too soon. Then approximately 15 seconds later, the resident performed the same procedure (did not close her lips around the mouthpiece, and not take a deep breath). Afterwards, the nurse removed the inhaler and left the room. The resident was not observed to rinse her mouth after using the inhaler. On 7/26/2017 at 8:30 a.m., Employee B was interviewed. She confirmed Resident #148 did not administer the inhaler correctly. She did not wait long enough between puffs, did not close her lips/ mouth, and did not rinse afterwards. She stated that the resident self-administered the medication, but she should have reminded her to do all of those things. Record review for Resident #148 revealed no physician's order to self-administer her medication. There was no documentation that the interdisciplinary team assessed the resident's ability to self-administer. The resident had a 1/24/2016 order for [MEDICATION NAME] Aerosol, 2 puffs, inhale orally two times a day for shortness of breath. Resident #148 was interviewed on 7/26/2017 at 8:50 a.m. She knew that she should rinse her mouth afterwards, and the nurse forgot to remind her to do it. She stated she might not have closed her mouth because her nose was stuffy and she couldn't breathe. The manufacturer's specification for [MEDICATION NAME] revealed Rinse your mouth with water and spit the water out after each dose (2 puffs). Do not swallow the water. This will help to lessen the chance of getting a fungal infection (thrush) in the mouth and throat.

Based on record review and interviews the facility failed to provide adequate supervision during implementation of a transfer from the wheelchair to the bed to prevent accidents for 1 resident (Resident #153) who was at risk for accidents during transfer due to paralysis on one side, treatment with anticoagulants that can lead to bleeding, and a requirement for 2 person assistance, resulting in harm exhibited by severe pain, shoulder strain and chest bruising, out of 4 residents reviewed for accidents, out of 40 stage one residents. The findings include: During an interview with Resident #153 on 7/14/14 at 10:30 am, he stated that in October of 2013, he was treated roughly by a Certified Nursing Assistant (CNA), Employee F. The CNA lifted him out of the wheelchair and into the bed. He stated he was supposed to have two staff to transfer him, but the CNA did the transfer alone. While transferring him, she squeezed him very hard around his rib cage and left shoulder, and threw him onto the bed. The resident stated that after the transfer, he woke up with severe pain in the left shoulder. He reported the incident to the nurse, and requested pain medication. He stated that when the pain was not relieved, he asked to go to the hospital. He stated he could not wait, and called 9-1-1 himself and was transported to the emergency room . Review of Resident #153's record revealed there was no documentation regarding the resident's complaint of being injured during transfer to the bed. Review of a nursing note dated 10/19/13 at 6:24 PM revealed that the resident complained in the afternoon of shoulder pain not relieved by Tylenol, and wanted to go to the hospital. The resident called 9-1-1, and told the paramedics he needed pain medication. He was transported to the hospital. Nursing note on 10/20/13 at 1:09 AM revealed that the resident called 9-1-1 again due to unrelieved pain, and was transported to the hospital. Nursing note on 10/20/13 at 1:00 PM revealed that the resident returned to the facility from the hospital, complaining of pain to the left arm and chest. " A bruise was noted under his left arm pit and his left arm was slightly swollen with slight bruising. " The note stated, "Resident was change to a two person for ADL (Activities of Daily Living) care." Review of Resident #153's hospital records, dated 10/19/13, revealed the reason for the visit was left shoulder pain, constant. The onset was just prior to arrival, when lifted at the nursing home. X-rays of the left ribs and left arm were negative for a fracture. The resident was diagnosed with [REDACTED]. A chest CT (computerized series of X-rays) performed on 10/20/13 at 2:21 AM revealed a large left upper and anterior chest wall hematoma (bruise), and edema (swelling) in the left anterior chest wall. A follow-up chest CT performed on 10/20/13 at 7:33 AM revealed the large hematoma in the left chest wall extended into the left axilla (underarm). Review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed his weight was 163 pounds (lbs). Active [DIAGNOSES REDACTED]. The resident required extensive assistance during transfers, with staff providing weight-bearing support. Functional ability was coded as 2 person assistance required for bed mobility and transfers. In section J the resident was coded as rarely having pain at a 7, on a scale of 1-10, that did not limit his activity. He did not receive a scheduled pain medication, but did receive as needed pain medication. Review of Resident 153's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident weighed 208 pounds. In section J the resident was coded as frequently having pain at a 6, on a scale of 1-10, that did not limit his activity. He did not receive a scheduled pain medication, but did receive as needed pain medication. Review of the facility's abuse log revealed no documentation that an investigation had been done regarding Resident #153's injuries, or that the Administrator and Director of Nursing (DON) were notified of the incident. Statements were taken on 10/20/13 from the 2 CNAs involved in the transfer (Employees F and T). Employee F's statement revealed that Employee T asked her to help with putting the resident back to bed. Employee F said in her statement that during the transfer, the resident told her that "his chest got caught with my name tag." Employee T's statement revealed that she got Employee F to help transfer the resident from his wheelchair to the bed. Neither statement revealed how the transfer was performed. Interview with the DON on 7/16/14 at 1:40 pm revealed the resident was on Plavix and Aspirin (anticoagulants that can lead to bleeding). She stated that review of the nursing notes did not reveal any indication that the resident made any allegations toward staff at the time of the incident. She stated the resident mentioned the incident at the May, 2014 care plan meeting, and it should have been reported then. When asked whether the resident's bruising had been investigated, the DON stated, "There are a lot of things that should have happened with this. An incident report should have been completed. The documentation in the chart is vague at best. I just did not know. Honestly, it was dropped somewhere." She stated that the participants at the May, 2014 care plan meeting "should have done something." She stated, "It will be reported within the next ten minutes." Review of Resident #153's record revealed there was no documentation regarding the resident's complaint of being injured during transfer to the bed. Review of a nursing note dated 10/19/13 at 6:24 PM revealed that the resident complained in the afternoon of shoulder pain not relieved by Tylenol, and wanted to go to the hospital. The resident called 9-1-1, and told the paramedics he needed pain medication. He was transported to the hospital. Nursing note on 10/20/13 at 1:09 AM revealed that the resident called 9-1-1 again due to unrelieved pain, and was transported to the hospital. Nursing note on 10/20/13 at 1:00 PM revealed that the resident returned to the facility from the hospital, complaining of pain to the left arm and chest. "A bruise was noted under his left arm pit and his left arm was slightly swollen with slight bruising." The note stated, "Resident was change to a two person for ADL (Activities of Daily Living) care." An interview was conducted on 7/16/14 at 3:05 pm with the West Wing Unit Manager, LPN. When asked if she was aware of an incident in October, 2013 regarding Resident #153, she stated that the incident occurred when 2 CNAs transferred the resident from the wheelchair to the bed. The Unit Manager said that the resident reported that one of the CNAs was rough with him during the transfer, and he didn't want her to take care of him anymore. The Unit Manager stated that one of the CNAs involved no longer worked at the facility, and the other CNA was no longer assigned to the resident. When asked if one person did the transfer, she replied, "Yes, I think so." When asked if an investigation had been conducted, she replied, "No," because they knew how the resident had been injured. When asked what the facility did to follow-up on the resident's allegation that the CNA was rough with him, she stated that she called the Director of Nursing (DON) and notified her. When asked why no investigation was done by the facility, she replied, "Since the resident was at the hospital, if they thought there was any abuse they would have investigated it." She stated that since the incident, the resident is transferred with a mechanical lift. The Unit Manager stated that the day after the incident the resident continued to have pain related to the injury, and went back to the hospital. Review of care plan notes dated 5/22/14 revealed that a care plan meeting was conducted on that date for Resident #153. The meeting was attended by the resident, his mother, significant other, care plan coordinator, Certified Dietary Manager, and Social Worker/Abuse Coordinator. Care plan notes revealed the resident requested records of his "assault" by a staff member. He also stated the staff member still comes in his room and he doesn't want her to. The nursing summary section stated, "Will make Unit Manager and DON aware of resident concerns." An interview was conducted on 7/15/14 at 1:30pm with the Social Worker/ Abuse Coordinator. When asked if she was aware of injuries that occurred during transfer of the resident last October, she stated she was aware that the resident had requested that a particular CNA not be assigned to him. When asked if she was aware that Resident #153 alleged that a CNA was rough with him and had caused him injuries, she stated it had not been reported to her. During further interview with the Social Worker/Abuse Coordinator on 7/17/14 at 12:38 pm, when asked if she attended the care plan meeting on 5/22/14, she stated she did. When asked if she was aware of Resident #153's request to see his records regarding an "assault" by a staff member, she stated she was aware and that the information was passed on to nursing. When asked if she thought the resident's request raised any concerns and should be investigated, she stated it was her understanding that nursing would address it. Further interview on 7/17/14 at 12:40 pm with the DON revealed that when asked if she was notified after the May, 2014 care plan meeting that the resident requested records regarding his assault by a staff member, she stated, "No." She stated that if she had been notified, she would have initiated an investigation. The facility failed to implement their Abuse and Neglect policy by failing to report and investigate this incident, and protect the resident. .

Based on record reviews and interviews, the facility failed to implement policies and procedures to prohibit mistreatment, neglect, and abuse for 1 resident (Resident #153), who was at risk for neglect during transfer due to paralysis on one side, treatment with anticoagulants that can lead to bleeding, and a requirement for 2 person assistance, and who experienced severe pain, shoulder sprain and chest bruising during a transfer, out of 3 residents who expressed concerns with abuse, out of 40 stage one residents. The facility also failed to implement policies and procedures to prohibit mistreatment, neglect, and abuse for 1 resident from the adverse incident log (Resident #129), who was unable to communicate and whose husband intentionally slapped her leg and covered her mouth. These facility actions resulted in actual harm for Resident #153. The findings include: 1. During an interview with Resident #153 on 7/14/14 at 10:30 am, he stated that in October of 2013, he was treated roughly by a Certified Nursing Assistant (CNA), Employee F. The CNA lifted him out of the wheelchair and into the bed. He stated he was supposed to have two staff to transfer him, but the CNA did the transfer alone. While transferring him, she squeezed him very hard around his rib cage and left shoulder, and threw him onto the bed. The resident stated that after the transfer, he woke up with severe pain in the left shoulder. He reported the incident to the nurse, and requested pain medication. He stated that when the pain was not relieved, he asked to go to the hospital. He stated he could not wait, and called 9-1-1 himself and was transported to the emergency room . Review of Resident #153's record revealed there was no documentation regarding the resident's complaint of being injured during transfer to the bed. Review of a nursing note dated 10/19/13 at 6:24 PM revealed that the resident complained in the afternoon of shoulder pain not relieved by Tylenol, and wanted to go to the hospital. The resident called 9-1-1, and told the paramedics he needed pain medication. He was transported to the hospital. Nursing note on 10/20/13 at 1:09 AM revealed that the resident called 9-1-1 again due to unrelieved pain, and was transported to the hospital. Nursing note on 10/20/13 at 1:00 PM revealed that the resident returned to the facility from the hospital, complaining of pain to the left arm and chest. "A bruise was noted under his left arm pit and his left arm was slightly swollen with slight bruising." The note stated, "Resident was change to a two person for ADL (Activities of Daily Living) care." Review of Resident #153's hospital records, dated 10/19/13, revealed the reason for the visit was left shoulder pain, constant. The onset was just prior to arrival, when lifted at the nursing home. X-rays of the left ribs and left arm were negative for a fracture. The resident was diagnosed with [REDACTED]. A chest CT (computerized series of X-rays) performed on 10/20/13 at 2:21 AM revealed a large left upper and anterior chest wall hematoma (bruise), and [MEDICAL CONDITION] (swelling) in the left anterior chest wall. A follow-up chest CT performed on 10/20/13 at 7:33 AM revealed the large hematoma in the left chest wall extended into the left axilla (underarm). Review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed his weight was 163 pounds (lbs). Active [DIAGNOSES REDACTED]. The resident required extensive assistance during transfers, with staff providing weight-bearing support. Functional ability was coded as 2 person assistance required for bed mobility and transfers. In section J the resident was coded as rarely having pain at a 7, on a scale of 1-10, that did not limit his activity. He did not receive a scheduled pain medication, but did receive as needed pain medication. Review of Resident 153's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident weighed 208 pounds. In section J the resident was coded as frequently having pain at a 6, on a scale of 1-10, that did not limit his activity. He did not receive a scheduled pain medication, but did receive as needed pain medication. Review of statements taken on 10/20/13 from the 2 CNAs involved in the transfer (Employees F and T). Employee F's statement revealed that Employee T asked her to help with putting the resident back to bed. Employee F said in her statement that during the transfer, the resident told her that "his chest got caught with my name tag." Employee T's statement revealed that she got Employee F to help transfer the resident from his wheelchair to the bed. Neither statement revealed how the transfer was performed. An interview was conducted on 7/16/14 at 3:05 pm with the West Wing Unit Manager, LPN. When asked if she was aware of an incident in October, 2013 regarding Resident #153, she stated that the incident occurred when 2 CNAs transferred the resident from the wheelchair to the bed. The Unit Manager said that the resident reported that one of the CNAs was rough with him during the transfer, and he didn't want her to take care of him anymore. The Unit Manager stated that one of the CNAs involved no longer worked at the facility, and the other CNA was no longer assigned to the resident. When asked if one person did the transfer, she replied, "Yes, I think so." She stated that since the incident, the resident is transferred with a mechanical lift. The Unit Manager stated that the day after the incident the resident continued to have pain related to the injury, and returned to the hospital. Review of care plan notes dated 5/22/14 revealed that a care plan meeting was conducted on that date for Resident #153. The meeting was attended by the resident, his mother, significant other, care plan coordinator, Certified Dietary Manager, and Social Worker/ Abuse Coordinator. Care plan notes revealed the resident requested records of his "assault" by a staff member. He also stated the staff member still comes in his room and he doesn't want her to. The nursing summary section stated, "Will make Unit Manager and DON aware of resident concerns." The facility failed to implement their Abuse and Neglect policy by failing to report and investigate this incident, and protect the resident. 2. Review of the facility's adverse incidents revealed that on 5/26/14, a CNA reported that Resident #129's husband slapped the resident on the leg, covered her mouth and pinched her nose to keep her from yelling. The documentation did not indicate whether the family member was asked to leave, or if supervision of the resident was provided to prevent further occurrences. Interview with Employee G, CNA, on 7/16/14 at 3:04 pm revealed that the resident's husband helped put the resident to bed at night. On the night of the incident, the resident was very loud when she was getting ready for bed. The resident wouldn't quiet down and was getting louder and louder. Employee G saw the resident's husband slap the resident's leg. The resident made a sound and "kind of jumped." Then the husband put his hand on the resident's mouth, and closed her nose so she couldn't talk. Employee G stated that she had seen the husband do that to the resident before. Review of Resident #129's closed record revealed that she had [DIAGNOSES REDACTED]. Review of Resident #129's MDS dated [DATE] in section C Cognitive, the resident was coded as severely impaired and rarely or never understood. Review of a nursing note dated 5/26/14 at 10:00pm revealed that the CNA reported that the resident's husband hit his wife on the leg with an open hand, and earlier in the shift he covered up the resident's nose and mouth with his hand when she was making a lot of noise. The husband reported that the resident was agitated and possibly in pain multiple times throughout the shift, and asked the nurse to medicate the resident. The nurse documented that she reported this incident to the oncoming shift, and left a note for the DON. There was no documentation that the physician was notified, or that the nurse performed a physical assessment to determine any injuries. On 5/27/14 at 5:00pm the DON documented that she received notification of the incident on 5/27/14, and reported it to the administrator. The documentation revealed that the DON did not interview the CNA who witnessed the incident until she came on duty on the evening shift on 5/27/14. Law enforcement was notified on 5/27/14, and supervised visits with the resident's husband were initiated. The DON's note stated, "Social services to be informed of the above upon her return." Review of the facility's policies and procedures titled Abuse Prevention Program (no date) included the following: "The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This will be done by: Immediately protecting residents involved in identified reports of possible abuse, and Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences. Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation. Employees who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator. Employees accused of possible mistreatment shall not complete the shift as a direct provider of care to the residents." .

Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property, are reported immediately to the administrator of the facility and to other officials in accordance with State law, and are investigated thoroughly. The facility also failed to ensure that corrective actions were taken, and the results of all investigations were reported to officials within 5 working days for 1 resident (Resident #153) who experienced severe pain, shoulder strain and chest bruising due to neglect during a transfer, out of 3 residents who expressed concerns with abuse, out of 40 stage one residents, and 1 resident from the adverse incidents log (Resident #129), whose husband intentionally slapped her leg and covered her mouth. These facility actions resulted in actual harm for Resident #153. Cross reference to F225 and F226. The findings include: 1. During an interview with Resident #153 on 7/14/14 at 10:30 am, he stated that in October of 2013, he was treated roughly by a Certified Nursing Assistant (CNA), Employee F. The CNA lifted him out of the wheelchair and into the bed. He stated he was supposed to have two staff to transfer him, but the CNA did the transfer alone. While transferring him, she squeezed him very hard around his rib cage and left shoulder, and threw him onto the bed. The resident stated that after the transfer, he woke up with severe pain in the left shoulder. He reported the incident to the nurse, and requested pain medication. He stated that when the pain was not relieved, he asked to go to the hospital. He stated he could not wait, and called 9-1-1 himself and was transported to the emergency room . Review of Resident #153's record revealed there was no documentation regarding the resident's complaint of being injured during transfer to the bed. Review of a nursing note dated 10/19/13 at 6:24 PM revealed that the resident complained in the afternoon of shoulder pain not relieved by Tylenol, and wanted to go to the hospital. The resident called 9-1-1, and told the paramedics he needed pain medication. He was transported to the hospital. Nursing note on 10/20/13 at 1:09 AM revealed that the resident called 9-1-1 again due to unrelieved pain, and was transported to the hospital. Nursing note on 10/20/13 at 1:00 PM revealed that the resident returned to the facility from the hospital, complaining of pain to the left arm and chest. "A bruise was noted under his left arm pit and his left arm was slightly swollen with slight bruising." The note stated, "Resident was change to a two person for ADL (Activities of Daily Living) care." Review of Resident #153's hospital records, dated 10/19/13, revealed the reason for the visit was left shoulder pain, constant. The onset was just prior to arrival, when lifted at the nursing home. X-rays of the left ribs and left arm were negative for a fracture. The resident was diagnosed with [REDACTED]. A chest CT (computerized series of X-rays) performed on 10/20/13 at 2:21 AM revealed a large left upper and anterior chest wall hematoma (bruise), and [MEDICAL CONDITION] (swelling) in the left anterior chest wall. A follow-up chest CT performed on 10/20/13 at 7:33 AM revealed the large hematoma in the left chest wall extended into the left axilla (underarm). Review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed his weight was 163 pounds (lbs). Active [DIAGNOSES REDACTED]. The resident required extensive assistance during transfers, with staff providing weight-bearing support. Functional ability was coded as 2 person assistance required for bed mobility and transfers. In section J the resident was coded as rarely having pain at a 7, on a scale of 1-10, that did not limit his activity. He did not receive a scheduled pain medication, but did receive as needed pain medication. Review of Resident 153's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident weighed 208 pounds. In section J the resident was coded as frequently having pain at a 6, on a scale of 1-10, that did not limit his activity. He did not receive a scheduled pain medication, but did receive as needed pain medication. Review of Resident 153's Active Orders for October, 2013 revealed that [MEDICATION NAME]-[MEDICATION NAME] 7.5-500mg was ordered as needed for pain on 10/20/13. Review of the facility's abuse log revealed no documentation that an investigation had been done regarding Resident #153's injuries, or that the Administrator and Director of Nursing (DON) were notified of the incident. Statements were taken on 10/20/13 from the 2 CNAs involved in the transfer (Employees F and T). Employee F's statement revealed that Employee T asked her to help with putting the resident back to bed. Employee F said in her statement that during the transfer, the resident told her that "his chest got caught with my name tag." Employee T's statement revealed that she got Employee F to help transfer the resident from his wheelchair to the bed. Neither statement revealed how the transfer was performed. An interview was conducted on 7/15/14 at 1:30pm with the Social Worker/ Abuse Coordinator. When asked if an abuse report had been filed regarding Resident #153, she stated, "No." When asked if she was aware of injuries that occurred due to transfer of the resident last October, she stated she was aware that the resident requested that a particular CNA not be assigned to him. When asked if she was aware that Resident #153 alleged that a CNA was rough with him and had caused him injuries, she stated it had not been reported to her. An interview was conducted on 7/16/14 at 3:05 pm with the West Wing Unit Manager, LPN. When asked if she was aware of an incident in October, 2013 regarding Resident #153, she stated that the incident occurred when 2 CNAs transferred the resident from the wheelchair to the bed. The Unit Manager said that the resident reported that one of the CNAs was rough with him during the transfer, and he didn't want her to take care of him anymore. The Unit Manager stated that one of the CNAs involved no longer worked at the facility, and the other CNA was no longer assigned to the resident. When asked if one person did the transfer, she replied, "Yes, I think so." When asked if an investigation had been conducted, she replied, "No," because they knew how the resident had been injured. When asked what the facility did to follow-up on the resident's allegation that the CNA was rough with him, she stated that she called the Director of Nursing (DON) and notified her. When asked why no investigation was done by the facility, she replied, "Since the resident was at the hospital, if they thought there was any abuse they would have investigated it." She stated that since the incident, the resident is transferred with a mechanical lift. The Unit Manager stated that the day after the incident the resident continued to have pain related to the injury, and went back to the hospital. Review of care plan notes dated 5/22/14 revealed that a care plan meeting was conducted on that date for Resident #153. The meeting was attended by the resident, his mother, significant other, care plan coordinator, Certified Dietary Manager, and Social Worker/Abuse Coordinator. Care plan notes revealed the resident requested records of his "assault" by a staff member. He also stated the staff member still comes in his room and he doesn't want her to. The nursing summary section stated, "Will make Unit Manager and DON aware of resident concerns." An interview was conducted on 7/17/14 at 12:38 pm with the Social Worker/Abuse Coordinator. When asked if she attended the care plan meeting on 5/22/14, she stated she did. When asked if she was aware of Resident #153's request to see his records regarding an "assault" by a staff member, she stated she was aware and that the information was passed on to nursing. When asked if she thought the resident's request raised any concerns and should be investigated, she stated it was her understanding that nursing would address it. When asked if an abuse report was filed, she stated, "No." Interview with the DON on 7/16/14 at 1:40 pm revealed the resident was on [MEDICATION NAME] and Aspirin (anticoagulants that can lead to bleeding). She stated that review of the nursing notes did not reveal any indication that the resident made any allegations toward staff at the time of the incident. She stated the resident mentioned the incident at the May, 2014 care plan meeting, and it should have been reported then. When asked whether the resident's bruising had been investigated, the DON stated, "There are a lot of things that should have happened with this. An incident report should have been completed. The documentation in the chart is vague at best. I just did not know. Honestly, it was dropped somewhere." She stated that the participants at the May, 2014 care plan meeting "should have done something." She stated, "It will be reported within the next ten minutes." Further interview on 7/17/14 at 12:40 pm with the DON revealed that when asked if she was notified after the May, 2014 care plan meeting that the resident requested records regarding his assault by a staff member, she stated, "No." She stated that if she had been notified, she would have initiated an investigation. The facility failed to implement their Abuse and Neglect policy by failing to report and investigate this incident, and protect the resident. 2. Review of the facility's adverse incidents revealed that on 5/26/14, a CNA reported that Resident #129's husband slapped the resident on the leg, covered her mouth and pinched her nose to keep her from yelling. The documentation did not indicate whether the family member was asked to leave, or if supervision of the resident was provided to prevent further occurrences. Review of Resident #129's closed record revealed that she had [DIAGNOSES REDACTED]. Review of Resident #129's MDS dated [DATE] in section C Cognitive, the resident was coded as severely impaired and rarely or never understood. Review of a nursing note dated 5/26/14 at 10:00pm revealed that the CNA reported that the resident's husband hit his wife on the leg with an open hand, and earlier in the shift he covered up the resident's nose and mouth with his hand when she was making a lot of noise. The husband reported that the resident was agitated and possibly in pain multiple times throughout the shift, and asked the nurse to medicate the resident. The nurse documented that she reported this incident to the oncoming shift, and left a note for the DON. There was no documentation that the Administrator, Abuse Coordinator, or DON were notified at the time of the incident. There was no documentation that the physician was notified, or that the nurse performed a physical assessment to determine any injuries. Interview with Employee G, CNA, on 7/16/14 at 3:04 pm revealed that the resident's husband helped put the resident to bed at night. On the night of the incident, the resident was very loud when she was getting ready for bed. The resident wouldn't quiet down and was getting louder and louder. Employee G saw the resident's husband slap the resident's leg. The resident made a sound and "kind of jumped." Then the husband put his hand on the resident's mouth, and closed her nose so she couldn't talk. Employee G stated that she had seen the husband do that to the resident before. On 5/27/14 at 5:00pm the DON documented that she received notification of the incident on 5/27/14, and reported it to the administrator. The documentation revealed that the DON did not interview the CNA who witnessed the incident until she came on duty on the evening shift on 5/27/14. Law enforcement was notified on 5/27/14, and supervised visits with the resident's husband were initiated. The DON's note stated, "Social services to be informed of the above upon her return." Review of the Social Services/Abuse Coordinator progress note, dated 5/28/14 at 4:28pm, revealed that she was notified of the incident and investigation at 10:15am on the morning of her documented note. She filed an immediate federal abuse report, and reported the incident to the Department of Children and Families (DCF). Her note stated that the resident and her husband "will have supervised visits." In an interview with the Social Services Director/Abuse Coordinator on 7/16/14 at 12:37pm, when asked about staff witnessing the resident's husband striking the resident, she stated that her expectation was for staff to take immediate action to safeguard the resident, and provide supervision to prevent further abuse. When asked if she was notified on 5/26/14 regarding an allegation of abuse to Resident #129, she stated, "No." The Abuse Coordinator stated that she was not informed until 5/28/14. When asked about the 2 day delay in reporting the incident, she replied, "I'm not sure. I must have had a doctor's appointment." She confirmed that upon learning of the incident, she called it in to the Abuse Hotline. An interview was conducted on 7/17/14 at 12:40pm with the DON. When asked if she was notified on 5/26/14 regarding an allegation of abuse to Resident #129, she stated she was not made aware of the incident until the following morning, 5/27/14. She said she immediately reported the incident to the Administrator, and initiated an investigation. When asked why she did not report the allegation to DCF, she stated that she was busy with the investigation. She stated that she notified law enforcement. When asked if a physical assessment of the resident was performed after the incident, she stated the nurse did not document any findings. When asked if she examined Resident #129 when notified of the incident, she stated that she did not. Review of the facility's policies and procedures titled Abuse Prevention Program (no date) included the following: "The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This will be done by: Immediately protecting residents involved in identified reports of possible abuse. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; and Filing accurate and timely investigative reports. Abuse is defined as (among other things) any physical injury inflicted upon a resident other than by accidental means in the facility. Abuse is the willful infliction of injury...with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain well-being. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Neglect is defined as (among other things) the failure to provide goods and services necessary to avoid physical harm. Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or the administrator. Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator shall initiate investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing documentation and reporting to the administrator or designee. If the resident complains of physical injuries or if harm is suspected, the resident physician will be contacted for further instructions. Step V: Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation. Employees who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator. Employees accused of possible mistreatment shall not complete the shift as a direct provider of care to the residents. If, during the course of an incident investigation, the administrator or designee has determined that there is reasonable cause to suspect mistreatment has occurred, the resident's representative and the Department of Children and Family Services Abuse Hotline and Agency for Health Care Administration will be notified." The Resident Protection Investigation Procedure for Possible Physical Abuse (no date) listed steps including: "Do a full body exam, particularly in area of resident complaint. The Resident Protection Investigation Procedure for Possible Neglect stated: Determine if the goods or services were not provided because of a pattern of deliberate negligence, carelessness, or indifference. If goods or services were not provided and harm resulted because of deliberate negligence, neglect may have taken place. Proceed with the investigation procedures in step 5 and interview witnesses (in step 6). If there is not a pattern of deliberate negligence or harm to the resident, but merely an accidental oversight in the provision of services, refer the employee for supervisory counseling." Cross reference to F224 and F226. .

Based on record reviews and interviews, the facility failed to implement policies and procedures to prohibit mistreatment, neglect, and abuse of residents, failed to fully investigate and report abuse and neglect, and failed to identify neglect for 1 resident (Resident #153)who required two person assistance during a transfer and experienced harm after a transfer exhibited by severe pain, shoulder sprain and chest bruising, out of 3 residents who expressed concerns with abuse, out of 40 stage one residents. These facility actions resulted in actual harm for resident #153. The facility also failed to implement policies and procedures to prohibit mistreatment, neglect, and abuse of residents, and failed to fully investigate and timely report abuse for 1 resident from the adverse incidents log (Resident #129), whose husband intentionally slapped her leg and covered her mouth. The findings include: 1. During an interview with Resident #153 on 7/14/14 at 10:30 am, he stated that in October of 2013, he was treated roughly by a Certified Nursing Assistant (CNA), Employee F. The CNA lifted him out of the wheelchair and into the bed. He stated he was supposed to have two staff to transfer him, but the CNA did the transfer alone. While transferring him, she squeezed him very hard around his rib cage and left shoulder, and threw him onto the bed. The resident stated that after the transfer, he woke up with severe pain in the left shoulder. He reported the incident to the nurse, and requested pain medication. He stated that when the pain was not relieved, he asked to go to the hospital. He stated he could not wait, and called 9-1-1 himself and was transported to the emergency room . Review of Resident #153's record revealed there was no documentation regarding the resident's complaint of being injured during transfer to the bed. Review of a nursing note dated 10/19/13 at 6:24 PM revealed that the resident complained in the afternoon of shoulder pain not relieved by Tylenol, and wanted to go to the hospital. The resident called 9-1-1, and told the paramedics he needed pain medication. He was transported to the hospital. Nursing note on 10/20/13 at 1:09 AM revealed that the resident called 9-1-1 again due to unrelieved pain, and was transported to the hospital. Nursing note on 10/20/13 at 1:00 PM revealed that the resident returned to the facility from the hospital, complaining of pain to the left arm and chest. "A bruise was noted under his left arm pit and his left arm was slightly swollen with slight bruising." The note stated, "Resident was change to a two person for ADL (Activities of Daily Living) care." Review of Resident #153's hospital records, dated 10/19/13, revealed the reason for the visit was left shoulder pain, constant. The onset was just prior to arrival, when lifted at the nursing home. X-rays of the left ribs and left arm were negative for a fracture. The resident was diagnosed with [REDACTED]. A chest CT (computerized series of X-rays) performed on 10/20/13 at 2:21 AM revealed a large left upper and anterior chest wall hematoma (bruise), and [MEDICAL CONDITION] (swelling) in the left anterior chest wall. A follow-up chest CT performed on 10/20/13 at 7:33 AM revealed the large hematoma in the left chest wall extended into the left axilla (underarm). Review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed his weight was 163 pounds (lbs). Active [DIAGNOSES REDACTED]. The resident required extensive assistance during transfers, with staff providing weight-bearing support. Functional ability was coded as 2 person assistance required for bed mobility and transfers. In section J the resident was coded as rarely having pain at a 7, on a scale of 1-10, that did not limit his activity. He did not receive a scheduled pain medication, but did receive as needed pain medication. Review of Resident 153's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident weighed 208 pounds. In section J the resident was coded as frequently having pain at a 6, on a scale of 1-10, that did not limit his activity. He did not receive a scheduled pain medication, but did receive as needed pain medication. Review of Resident 153's Active Orders for October, 2013 revealed that [MEDICATION NAME]-[MEDICATION NAME] 7.5-500mg was ordered as needed for pain on 10/20/13. Review of the facility's abuse log revealed no documentation that an investigation had been done regarding Resident #153's injuries, or that the Administrator and Director of Nursing (DON) were notified of the incident. Statements were taken on 10/20/13 from the 2 CNAs involved in the transfer (Employees F and T). Employee F's statement revealed that Employee T asked her to help with putting the resident back to bed. Employee F said in her statement that during the transfer, the resident told her that "his chest got caught with my name tag." Employee T's statement revealed that she got Employee F to help transfer the resident from his wheelchair to the bed. Neither statement revealed how the transfer was performed. An interview was conducted on 7/15/14 at 1:30pm with the Social Worker/ Abuse Coordinator. When asked if an abuse report had been filed regarding Resident #153, she stated, "No." When asked if she was aware of injuries that occurred due to transfer of the resident last October, she stated she was aware that the resident requested that a particular CNA not be assigned to him. When asked if she was aware that Resident #153 alleged that a CNA was rough with him and had caused him injuries, she stated it had not been reported to her. An interview was conducted on 7/16/14 at 3:05 pm with the West Wing Unit Manager, LPN. When asked if she was aware of an incident in October, 2013 regarding Resident #153, she stated that the incident occurred when 2 CNAs transferred the resident from the wheelchair to the bed. The Unit Manager said that the resident reported that one of the CNAs was rough with him during the transfer, and he didn't want her to take care of him anymore. The Unit Manager stated that one of the CNAs involved no longer worked at the facility, and the other CNA was no longer assigned to the resident. When asked if one person did the transfer, she replied, "Yes, I think so." When asked if an investigation had been conducted, she replied, "No," because they knew how the resident had been injured. When asked what the facility did to follow-up on the resident's allegation that the CNA was rough with him, she stated that she called the Director of Nursing (DON) and notified her. When asked why no investigation was done by the facility, she replied, "Since the resident was at the hospital, if they thought there was any abuse they would have investigated it." She stated that since the incident, the resident is transferred with a mechanical lift. The Unit Manager stated that the day after the incident the resident continued to have pain related to the injury, and returned to the hospital. Review of care plan notes dated 5/22/14 revealed that a care plan meeting was conducted on that date for Resident #153. The meeting was attended by the resident, his mother, significant other, care plan coordinator, Certified Dietary Manager, and Social Worker/Abuse Coordinator. Care plan notes revealed the resident requested records of his "assault" by a staff member. He also stated the staff member still comes in his room and he doesn't want her to. The nursing summary section stated, "Will make Unit Manager and DON aware of resident concerns." An interview was conducted on 7/17/14 at 12:38 pm with the Social Worker/Abuse Coordinator. When asked if she attended the care plan meeting on 5/22/14, she stated she did. When asked if she was aware of Resident #153's request to see his records regarding an "assault" by a staff member, she stated she was aware and that the information was passed on to nursing. When asked if she thought the resident's request raised any concerns and should be investigated, she stated it was her understanding that nursing would address it. When asked if an abuse report was filed, she stated, "No." Interview with the DON on 7/16/14 at 1:40 pm revealed the resident was on [MEDICATION NAME] and Aspirin (anticoagulants that can lead to bleeding). She stated that review of the nursing notes did not reveal any indication that the resident made any allegations toward staff at the time of the incident. She stated the resident mentioned the incident at the May, 2014 care plan meeting, and it should have been reported then. When asked whether the resident's bruising had been investigated, the DON stated, "There are a lot of things that should have happened with this. An incident report should have been completed. The documentation in the chart is vague at best. I just did not know. Honestly, it was dropped somewhere." She stated that the participants at the May, 2014 care plan meeting "should have done something." She stated, "It will be reported within the next ten minutes." Further interview on 7/17/14 at 12:40 pm with the DON revealed that when asked if she was notified after the May, 2014 care plan meeting that the resident requested records regarding his assault by a staff member, she stated, "No." She stated that if she had been notified, she would have initiated an investigation. The facility failed to implement their Abuse and Neglect policy by failing to report and investigate this incident, and protect the resident. 2. Review of the facility's adverse incidents revealed that on 5/26/14, a CNA reported that Resident #129's husband slapped the resident on the leg, covered her mouth and pinched her nose to keep her from yelling. The documentation did not indicate whether the family member was asked to leave, or if supervision of the resident was provided to prevent further occurrences. Interview with Employee G, CNA, on 7/16/14 at 3:04 pm revealed that the resident's husband helps put the resident to bed at night. On the night of the incident, the resident was very loud when she was getting ready for bed. The resident wouldn't quiet down and was getting louder and louder. Employee G saw the resident's husband slap the resident's leg. The resident made a sound and "kind of jumped." Then the husband put his hand on the resident's mouth, and closed her nose so she couldn't talk. Employee G stated that she had seen the husband do that to the resident before. Review of Resident #129's closed record revealed that she had [DIAGNOSES REDACTED]. Review of Resident #129's MDS dated [DATE] in section C Cognitive, the resident was coded as severely impaired and rarely or never understood. Review of a nursing note dated 5/26/14 at 10:00pm revealed that the CNA reported that the resident's husband hit his wife on the leg with an open hand, and earlier in the shift he covered up the resident's nose and mouth with his hand when she was making a lot of noise. The husband reported that the resident was agitated and possibly in pain multiple times throughout the shift, and asked the nurse to medicate the resident. The nurse documented that she reported this incident to the oncoming shift, and left a note for the DON. There was no documentation that the Administrator, Abuse Coordinator, or DON were notified at the time of the incident. There was no documentation that the physician was notified, or that the nurse performed a physical assessment to determine any injuries. On 5/27/14 at 5:00pm the DON documented that she received notification of the incident on 5/27/14, and reported it to the administrator. The documentation revealed that the DON did not interview the CNA who witnessed the incident until she came on duty on the evening shift on 5/27/14. Law enforcement was notified on 5/27/14, and supervised visits with the resident's husband were initiated. The DON's note stated, "Social services to be informed of the above upon her return." Review of the Social Services/Abuse Coordinator progress note, dated 5/28/14 at 4:28pm, revealed that she was notified of the incident and investigation at 10:15am on the morning of her documented note. She filed an immediate federal abuse report, and reported the incident to the Department of Children and Families (DCF). Her note stated that the resident and her husband "will have supervised visits." In an interview with the Social Services Director/Abuse Coordinator on 7/16/14 at 12:37pm, when asked about staff witnessing the resident's husband striking the resident, she stated that her expectation was for staff to take immediate action to safeguard the resident, and provide supervision to prevent further abuse. When asked if she was notified on 5/26/14 regarding an allegation of abuse to Resident #129, she stated, "No." The Abuse Coordinator stated that she was not informed until 5/28/14. When asked about the 2 day delay in reporting the incident, she replied, "I'm not sure. I must have had a doctor's appointment." Upon learning of the incident, she called it in to the Abuse Hotline. An interview was conducted on 7/17/14 at 12:40pm with the DON. When asked if she was notified on 5/26/14 regarding an allegation of abuse to Resident #129, she stated she was not made aware of the incident until the following morning, 5/27/14. She said she immediately reported the incident to the Administrator, and initiated an investigation. When asked why she did not report the allegation to DCF, she stated that she was busy with the investigation. She stated that she notified law enforcement. When asked if a physical assessment of the resident was performed after the incident, she stated the nurse did not document any findings. When asked if she examined Resident #129 when notified of the incident, she stated that she did not. Review of the facility's policies and procedures titled Abuse Prevention Program (no date) included the following: "The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This will be done by: Immediately protecting residents involved in identified reports of possible abuse. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; and Filing accurate and timely investigative reports. Abuse is defined as (among other things) any physical injury inflicted upon a resident other than by accidental means in the facility. Abuse is the willful infliction of injury...with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain well-being. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Neglect is defined as (among other things) the failure to provide goods and services necessary to avoid physical harm. Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or the administrator. Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator shall initiate investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing documentation and reporting to the administrator or designee. If the resident complains of physical injuries or if harm is suspected, the resident physician will be contacted for further instructions. Step V. Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation. Employees who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator. Employees accused of possible mistreatment shall not complete the shift as a direct provider of care to the residents." The Resident Protection Investigation Procedure for Possible Physical Abuse (no date) listed steps including: "Do a full body exam, particularly in area of resident complaint. The Resident Protection Investigation Procedure for Possible Neglect stated: Determine if the goods or services were not provided because of a pattern of deliberate negligence, carelessness, or indifference. If goods or services were not provided and harm resulted because of deliberate negligence, neglect may have taken place. Proceed with the investigation procedures in step 5 and interview witnesses (in step 6). If there is not a pattern of deliberate negligence or harm to the resident, but merely an accidental oversight in the provision of services, refer the employee for supervisory counseling." Cross reference to F224 and F225. .