Every finding on record at Vista Grande Villa

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 42 residents who consume food products, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings Include:On 02/18/2026 at 9:17 A.M., The ambient air thermometer in the walk-in cooler was observed with accumulated and encrusted moist black droplets resting upon the metallic surface.On 2/18/2026 at 9:26 A.M., The walk in cooler metal wire shelving units was observed soiled with accumulated and encrusted food residue.On 2/18/2026 at 10:01 A.M., The clean equipment storage rack found two shallow pans with encrusted food residue on the rim. Director of Dining Services (DODS) P removed the pans to be washed.On 2/18/2026 at 10:04 A.M., The clean equipment drying rack surface was observed with accumulated and encrusted black residue. When the drying rack was wiped with a clean white paper towel, a grey/black residue accumulation was observed on the towel surface.On 2/18/2026 at 10:25 A.M., The can opener was observed with an accumulation of food residue on and around the blade. An interview at this time with (DODS) P found the cooks usually clean it every night, but it looks like they missed a day or two.On 2/18/2026 at 10:27 A.M., The meat slicer was observed soiled with accumulated and encrusted food residue at the base and back of the blade. An interview at this time with (DODS) P found the slicer is cleaned after each use and indicated the food residue present is greater than expected for a single use. Further observation found the table beneath the slicer soiled with a tacky residue.On 2/18/2026 at 10:30 A.M., The Robo Coupe food processor base and the Vita Mix blender base were both observed with accumulated and encrusted food residueOn 2/18/2026 at 10:33 A.M., The ice scoop holder was observed with pooling water at the bottom and black residue particles floating.On 2/18/2026 at 10:35 A.M., The char broiler (grates, side/back perimeter panels, and front collection tray) were observed with accumulated and encrusted food residue.On 2/18/2026 at 10:36 A.M., The deep fat [NAME] interior burner compartment was observed with accumulated and encrusted (food residue, cooking oil deposits, dust/dirt deposits).On 2/18/2026 at 12:07 P.M., The food product serving room paper towel dispenser undersurface was observed with accumulated and encrusted tacky food residue.The 2022 FDA Model Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. States: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.A record review of the facility provided Policy/Procedure entitled Equipment dated 9/2017 revealed under Policy Statement: All foodservice equipment will be clean, sanitary, and in proper working order. The procedures include: (3) All food contact equipment will be cleaned and sanitized after every use. (4) All non-food contact equipment will be clean and free of debris.On 02/18/2026 at 9:22 A.M., A bottle of red wine dressing was observed with a facility marked date 2/1/2026-3/1/2026. An interview at this time with the (DODS) P found the dressing was made in house and is date marked one month out.On 2/18/2026 at 9:28 A.M., A metal holding pan was observed unmarked, containing a liquid substance with plastic wrap covering the top. During this observation, when asked what was in the pan, (DODS) P stated Must be soup from last night.The 2022 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.A record review of the facility provided Policy/Procedure entitled Food Storage: Cold Foods dated 2/2023 revealed under Procedures: (5) All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.On 2/18/2026 at 9:40 A.M., An observation of the chemical storage room found broken drywall at the base of the wall creating a visible hole. Three tiles were observed missing from the baseboard. Further observation found the floor soiled with an accumulation of dirt and soil residue.On 2/18/2026 at 11:03 A.M., An observation of the mop room found the dry wall adjacent to the mop sink damaged leaving a visible hole in the wall.The 2022 FDA Model Food Code section 6-501.11 Repairing states: PHYSICAL FACILITIES shall be maintained in good repair.On 2/18/2026 at 9:52 A.M., The return air vent in the dry storage room was observed soiled with dust/dirt buildup and black residue.On 2/18/2026 at 10:00 A.M., The pan storage area was observed with an accumulation of debris beneath the storage rack.On 2/18/2026 at 10:23 A.M., The hand sink trash receptacle located near the three-compartment sink was observed with accumulated dirt/debris on the lid and surface.On 2/18/2026 at 10:38 A.M., An observation of the dish room found an accumulation of black buildup on the floor surface. Further observation found grey splash residue on the hand sink and trash receptacle. On 2/18/2026 at 11:01 A.M., An observation of the mop sink closet found the mop bucket wringer and interior soiled with an accumulation of black residue. The mop sink basin contained an accumulation of debris and soil. The broken glass container lid was observed with a buildup of black residue on the surface. During an interview at this time, (DODS) P stated they would throw the lid away. Further observation found the wall surface above the mop sink accumulated with black residue. An observation of the mop room ceiling revealed debris in the ceiling light and areas of peeling paint.The 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.On 2/18/2026 at 10:07 A.M., An observation of the cookware storage area found nine 8-inch pans, nineteen 12-inch pans and five 16-inch pans etched scored and worn. (DODS) P was observed setting pans aside, adjacent to the three-compartment sink, to be discarded.On 2/18/2026 at 11:07 A.M., The Metro C5 hot box unit was observed with a torn door gasket, preventing the surface from being easily cleanable.On 2/19/2026 at 12:21 P.M., The service pass through heating assembly was observed with three lightbulbs out and one missing.The 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.

Based on observation, interview, and record review, the facility failed to revise care plans for two (R16, R58) of 12 reviewed. Findings include:R16 Review of the medical record revealed R16 admitted to the facility on [DATE]. R16 was diagnosed with COVID-19 on 2/10/26. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/1/26 revealed R16 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 02/18/2026 at 9:15 AM, R16 was observed lying in bed. R16 reported she was recently diagnosed with COVID-19. There was no signage or Personal Protective Equipment (PPE) on the door. On 02/19/26 at 9:40 AM, R16 did not have signage or PPE available at the door. Review of the Progress Notes dated 2/10/26 revealed Resident tested positive for covid [at 11:35 AM]. [Symptoms] unproductive cough, runny nose, headache, nausea, and fatigue x 1 day. Review of R16's care plans revealed they were not updated to indicate R16 was diagnosed with COVID-19 or had transmission-based precautions implemented. In an interview on 02/19/2026 at 12:48 PM, Director of Nursing (DON) B and Unit Manager (UM) D reported COVID-19 transmission-based precautions should be implemented for 10 days. UM D reported R16 should still be on Droplet/Contact precautions at this time, but they were mistakenly discontinued on 2/17/26. On 02/19/26 at 2:32 PM, UM D agreed that R16 did not have a COVID-19 or TBP care plan in place until 2/19/26. R58 Review of the medical record revealed R58 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included hypertensive heart and chronic kidney disease, type 2 diabetes, congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease. The MDS with an ARD of 1/12/26 revealed R58 scored 15 out of 15 on the BIMS. R58's electronic medical record profile indicated R58 was a full code. Review of R58's care plan dated 1/16/26 revealed R58 had chosen a Do Not Resuscitate (DNR) code status. In an interview on 02/19/2026 at 12:35 PM, Director of Nursing (DON) B agreed R58's medical record indicated they were a full code, but the care plans indicated DNR. On 02/19/2026 at 2:07 PM, DON B reported R58 was supposed to be a full code and that the care plan was not updated.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse/misappropriation, and implement interventions to protect the resident, for one resident (#15) of one reviewed. Review of Resident 15s (R15) clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed R15 was admitted on [DATE] with diagnosis that included cardiac diagnosis, and anxiety. R15 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review of R15's clinical record included a progress note made by formal facility Social Worker (SW) L dated 1/23/25 at 10:04 and revealed SW L and Biller K had discovered on 01/22/25 that R15's family member had been misappropriating funds from R15's checking and savings account. The note continued to reveal that Adult Protective Services (APS) and the Ombudsman had been notified. A second progress note also written on 1/23/25 authored by SW L revealed SW L offered assistance in helping R15 notify the bank and calling the police, R15 did not want to get her family member in trouble and requested the police not be called. On 02/19/2026 at 1:33 PM, during an interview with Interim Nursing Home Administrator C and Director of Nursing (DON) B, neither were aware of the misappropriation of R15's funds. Interim NHA C searched for a facility reported incident or any other type of documentation/investigation and was unable to locate one. DON B had no recollection of the R15's funds being misappropriated. Neither were able to explain why former NHA R failed to investigate R15's stolen money. On 2/19/2026 at 1:59 PM, during an interview with Biller K she reported she and former SW L were trying to get R15's Medicaid application approved last January and upon them reviewing R15's bank statements they noticed several withdrawals from R15s checking and savings accounts that R15 could not have made. Biller K stated she and former SW L met with R15 who was very upset and called her family with them present asking why and how they could steal her money. When queried if the Police were called, Biller K stated they did not call the police per R15's request. When queried if they notified the Administrator at the time of the event (NHA R), Biller K provided an email dated 1/22/25 to former NHA R that listed concerns of charges on R15's bank statements to liquor stores, general stores, television streaming services and other large withdrawals. When queried what was done at this time to protect R15 and her assets, Biller K stated she was not sure how former NHA R handled it. On 02/19/26 at 5:00pm, during a phone interview with former SW L she reported DON B and former NHA R were on vacation when the misappropriation was discovered. SW L stated she thought she did the right thing by calling APS and the Ombudsman and honoring R15's wishes not to call the Police. When queried if she called DON B or former NHA R she reported she sent emails to former NHA R but didn't want to bother either of them while on vacation. When queried what was done to ensure R15's funds wouldn't be misappropriated again, former SW L stated she offered to help R15 call the bank, but she didn't want her assistance.

Based on observation, interview, and record review, the facility failed to justify the increased dose of an antipsychotic medication for one (R9) of five reviewed. Findings include: Review of the medical record revealed R9 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, delusional disorders, and vascular dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/24/26 revealed R9 scored 1 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 02/19/2026 at 10:13 AM R9 was observed sitting in a gerichair in his room watching television with headphones and a super ear hearing device. R9 appeared calm and was very talkative. Review of the Physician's Orders revealed R9 was ordered Seroquel (antipsychotic medication) 25 milligrams (mg) twice a day for vascular dementia until 12/15/25. On 12/15/25, the Seroquel was increased to 50 mg twice a day for anxiety. Review of the Psychiatry Follow-Up Note dated 2/4/26 revealed Chart review indicates that the patient has not had recent behaviors of note .continues managed with trazodone 50 mg at bedtime for sleep, Seroquel 25 mg twice daily [of note: resident's order at that time was for 50 mg twice daily], and Ativan 0.5 mg every 6 hours for anxiety per hospice. The note further revealed that Seroquel will continue with current medication regimen as it appears to be providing stability. Review of the Progress Notes and Behavior Monitoring task revealed no documented behaviors, hallucinations, or delusions after 2/4/26. Review of the hospice binder at the nurse's station revealed a Visit Communication Note dated 2/16/26 that indicated yelling out after lunch again-not consistent. Review of the Resident Progress Note dated 2/18/26 at 1:20 PM and authored by Licensed Practical Nurse (LPN) G, revealed Resident experiencing anxiety at lunch time per Hospice start Seroquel 25 mg one-time [by mouth] [every] day. Review of the Physician's Order dated 2/18/26 revealed an order for Seroquel 25 mg in the afternoon for anxiety. This was in addition to the already ordered Seroquel 50 mg twice daily. In an interview on 02/19/2026 at 10:50 AM, LPN G reported they worked with R9 for approximately two to three hours on 2/18/26 and prior to that, it had been approximately six to twelve months since working with R9. LPN G reported on 2/18/26, R9 had a decent day and in the morning was yelling out. LPN G reported R9 had a history of yelling there was a fire and to get the baby, but that did not happen on 2/18/26. LPN G reported they reported to the hospice nurse that these behaviors had been occurring. LPN G reported they spoke with the hospice nurse, and hospice added an additional dose of Seroquel 25 mg at lunch time. LPN G reported if R9 were having delusions or hallucinations, it would be documented in the progress notes. In an interview on 02/19/2026 at 9:51 AM, Social Worker (SW) E reported they had been at the facility since June 2026 and R9 had been pretty stable with behaviors since then. When asked how behaviors, hallucinations, and delusions were tracked, SW E reported the expectation was that staff entered a note in the medical record. When asked about R9's most recent behavior documentation, SW E reported the last noted behavior was in May 2025. SW E was not aware of where Certified Nursing Assistants (CNAs) documented behaviors. In an interview on 02/19/2026 at 12:03 PM, Director of Nursing (DON) B reported R9's orders indicated they were prescribed Seroquel for anxiety. DON B reported behaviors should be documented in the progress notes or in the CNAs charting and Social Services tracked the behaviors. Unit Manager (UM) D joined the interview at 12:21 PM. UM D reported they were aware that R9 had been yelling out more but was not yet aware that R9's Seroquel dose had increased. UM D reported they were aware there was a lack of documentation related to behaviors, hallucinations, and delusions. Review of the Medication Administration Record (MAR) revealed R9 received the additional dose of Seroquel 25 mg at 12:00 PM on 2/19/26.

Based on observation, interview, and record review, the facility failed to implement physician's orders for daily weights for edema monitoring for one (R27) of one reviewed. Findings include: Review of the medical record revealed R27 was admitted to the facility on [DATE] with diagnoses that included hypertension and spinal stenosis. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/4/26 revealed R27 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 02/18/2026 at 9:05 AM, R27 was observed sitting in a recliner in their room with their feet down on the floor. R27 reported they had concerns with worsening edema in their legs, especially the left leg. Both legs were observed to be edematous. Compression stockings were observed on R27's bed. On 02/18/2026 at 2:33 PM, R27 was observed in their recliner with their legs elevated and compression stockings on both legs. R27 reported she was weighed more frequently now, but not every day. When asked if she ever refused daily weights, R27 reported if it's too early and she does not want to get up yet, she may refuse. Review of the Physician's Order dated 1/8/26 revealed an order for daily weights for monitoring of edema interventions. The scheduled time was entered as 7:00 AM each day. Review of the Medication Administration Record (MAR) and weight summary revealed daily weights were not completed or documented as refused on 1/9/26, 1/10/26, 1/11/26, 1/13/26, 1/16/26, 1/17/26, 1/20/26, 1/22/26, 1/23/26, 1/27/26, 1/30/26, and 1/31/26. Review of the progress notes revealed R27 refused daily weights on 1/12/26, 2/2/26, 2/4/26, 2/7/26, 2/8/26, 2/9/26. Additional progress notes related to refusals revealed on 2/11/26, R27 wanted to wait until later in the morning, on 2/14/26, R27 wanted to wait until breakfast, and on 2/17/26, R27 wanted to wait until before breakfast. There was no documentation that weights were completed or that reattempts with refusals to weigh R27 were made on those days. In an interview on 02/19/2026 at 12:50 PM, Unit Manager (UM) D reported R27 was supposed to be weighed daily. UM D reported they were aware R27 did not like to get up early and had changed the weight time to 7:00 AM each day.

Based on observation, interview, and record review, the facility failed to implement pharmacy recommendations for one (R9) of 5 reviewed. Findings include: Review of the medical record revealed R9 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, delusional disorders, and vascular dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/24/26 revealed R9 scored 1 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 02/19/2026 at 10:13 AM R9 was observed sitting in a gerichair in his room watching television with headphones and a super ear hearing device. R9 appeared calm and was very talkative. Review of the Physician's Order dated 12/15/25, revealed an order for Seroquel 50 milligrams (mg) twice a day for anxiety. The Physician's Order dated 2/18/26 revealed an order for additional Seroquel 25 mg in the afternoon for anxiety. Review of the Note to Attending Physician/Prescriber dated 12/26/25 revealed Clarify Seroquel diagnosis to support Antipsychotic use. The Physician/Prescriber Response was checked as Agree with delusional disorder/delirium written. The form was signed by the Nurse Practitioner on 1/19/26. R9's Seroquel diagnosis was not updated and continued to reflect anxiety. In an interview on 02/19/2026 at 9:51 AM, Social Worker (SW) E reported R9's medical record reflected Seroquel was prescribed for anxiety. In an interview on 02/19/2026 at 12:03 PM, Director of Nursing (DON) B reported pharmacy recommendations came to her and then were printed off for the physicians who then review and write their own orders. DON B agreed pharmacy recommended a diagnosis change for Seroquel, the Physician/Prescriber agreed, and that the Seroquel continued to have anxiety listed as a indication/diagnosis.

Based on observation, interview, and record review, the facility failed to complete a Level II screening for one (R9) of one reviewed.Findings include:Review of the medical record revealed R9 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, delusional disorders, and vascular dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/24/26 revealed R9 scored 1 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 02/19/2026 at 10:13 AM R9 was observed sitting in a gerichair in his room watching television with headphones and a super ear hearing device. R9 appeared calm and was very talkative. Review of R9's medical record revealed the Annual Resident Review (ARR) Level I screening was completed on 9/22/25. The Level I screening indicated Yes responses for questions one through four in Section II. The Level I screening revealed If any answer to items 1-6 in SECTION II is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 [level II screening] if an exemption is requested. R9 did not have a DCH-3878/Level II screening completed. In an interview on 02/19/2026 at 9:51 AM, Social Worker (SW) E reported they did not complete PASARR assessments and that they were completed by a third party MDS group. SW E agreed that R9's most recent Level I screening was dated 9/22/25 and that the medical record did not contain a Level II screening. In an telephone interview on 02/19/2026 at 10:04 AM, MDS Nurse N reported they worked for the third-party company hired by the facility. MDS Nurse N reported they were unable to locate a Level II screening/3878 for R9.

Based on observation, interview, and record review, the facility failed to implement transmission-based precautions according to the Centers for Disease Control and Prevention (CDC) for one (R16) of two reviewed. Findings include: R16 Review of the medical record revealed R16 admitted to the facility on [DATE]. R16 was diagnosed with COVID-19 on 2/10/26. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/1/26 revealed R16 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 02/18/2026 at 9:15 AM, R16 was observed lying in bed. R16 reported she was recently diagnosed with COVID-19. There was no transmission-based precautions (TBP) signage or Personal Protective Equipment (PPE) on the door. On 02/19/26 at 9:40 AM, R16 did not have signage or PPE available at the door. Review of the Progress Notes dated 2/10/26 revealed Resident tested positive for covid [at 11:35 AM]. [Symptoms] unproductive cough, runny nose, headache, nausea, and fatigue x 1 day. In an interview on 02/19/2026 at 12:48 PM, Director of Nursing (DON) B and Unit Manager (UM) D reported COVID-19 transmission-based precautions should be implemented for 10 days. UM D reported R16 should still be on Droplet/Contact precautions at this time, but the precautions were mistakenly discontinued on 2/17/26. According to the CDC Infection Control Guidance: SARS-CoV-2, Duration of Transmission-Based Precautions for Patients with SARS-CoV-2 Infection:Patients with mild to moderate illness who are not moderately to severely immunocompromised:At least 10 days have passed since symptoms first appearedandAt least 24 hours have passed since last fever without the use of fever-reducing medicationsandSymptoms (e.g., cough, shortness of breath) have improved .The criteria for the test-based strategy are:Patients who are symptomatic:Resolution of fever without the use of fever-reducing medicationsandSymptoms (e.g., cough, shortness of breath) have improved,andResults are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT. (Infection Control Guidance: SARS-CoV-2 | Covid | CDC) There was no indication in R16's medical record that the test-based strategy was used to discontinue the transmission-based precautions.

Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.for one resident (Resident #15) of one reviewed for abuse/misappropriation. Review of Resident 15s (R15) clinical record, including the Minimum Data Set (MDS) dated [DATE], revealed R15 was admitted on [DATE] with diagnosis that included cardiac diagnosis, and anxiety. R#15 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review of R15's clinical record included a progress note made by formal facility Social Worker (SW) L dated 1/23/25 at 10:04 and revealed SW L and Biller K had discovered on 01/22/25 that R15's family member had been misappropriating funds from R15's checking and savings account. The note continued to reveal that Adult Protective Services (APS) and the Ombudsman had been notified. A second progress note also written on 1/23/25 authored by SW L revealed SW L offered assistance in helping R15 notify the bank and calling the police, R15 did not want to get her family member in trouble and requested the police not be called. On 02/19/2026 at 1:33 PM, during an interview with Interim Nursing Home Administrator C and Director of Nursing (DON) B, neither were aware of the misappropriation. Interim NHA C searched for a facility reported incident and was unable to locate one. DON B had no recollection of R15's funds being misappropriated. Neither were able to explain why former NHA R failed to call the police or report it to the State Agency as required. On 2/19/2026 at 1:59 PM, during an interview with Biller K she reported she and former SW L were trying to get R15's Medicaid application approved last January and upon them reviewing R15's bank statements they noticed several withdrawals from R15's checking and savings accounts that R15 could not have made. Biller K stated she and former SW L met with R15 who was very upset and called her family with them present asking why and how they could steal her money. When queried if the Police were called, Biller K stated they did not call the police per R15's request. When queried if they notified the Administrator at the time of the event (NHA R), Biller K provided an email dated 1/22/25 to former NHA R that listed concerns of charges on the bank statements to liquor stores, general stores, television streaming services and other large withdrawals. On 02/19/26 at 5:00pm, during a phone interview with former SW L she reported DON B and former NHA R were on vacation when the misappropriation was discovered. SW L stated she thought she did the right thing by calling APS and the Ombudsman and honoring R15's wishes not to call the Police. When queried if she called DON B or former NHA R she reported she sent emails to former NHA R but didn't want to bother either of them while on vacation.

Based on interview and record review the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term CareOmbudsman for two (Resident 54 and 56) of two residents reviewed. Findings include:Review of the medical record reflected R54 was admitted to the facility on [DATE], with diagnoses that included heart failure. R54 no longer resided in the facility. According to a Progress Note, on 12/7/25, R54 was transferred out to a local hospital. Review of the medical record reflected R56 was admitted to the facility on [DATE], with diagnoses that included weakness. R56 no longer resided in the facility. According to a progress note, R56 arrived at the facility on 12/3/25 and discharged home on that same date.In an interview on 2/19/2026 at 12:22 PM, Social Worker E stated that she does not send the monthly list of transfers or discharges to the Ombudsman. In an interview on 2/19/2026 at 12:30 PM, Interim Nursing Home Administrator C stated that it was Social Works responsibility to send the Ombudsman the list of transfers and discharges monthly.In an interview on 2/19/2026 at 12:26 PM, Director of Nursing B and Executive Director A stated they were not sure who was sending the list to the Ombudsman.

This Citation Pertains to Intake #2624374Based on observation, interview and record review the facility failed to develop and implement a plan of care related to deep tissue injury for one resident (#2) of two reviewed for skin care plans. Review of the clinical record revealed Resident 2 (R2) was admitted to the facility on [DATE] for short term rehabilitation after a fall at home that resulted in a pelvic fracture. Review of R2's skin assessment dated [DATE] revealed R2 was admitted with a Deep Tissue Injury (DTI) on the sacrum that measured in length 0.6 centimeters, a width of 0.5 centimeters. R2 scored a 15 indicating she was at risk for skin breakdown on the Braden Scale dated 9/16/25. Review of the nursing admission progress note reflected R2 was alert and oriented x 4. R2's Minimum Data Set had not yet been completed. On 09/24/25 at 9:39 am, during a bedside interview, R2 was observed resting in her recliner, R2 reported she fell at home on fractured her pelvis and sustained a bruise on her tailbone because of the fall. When queried what was being done for the bruise R2 reported the nurses put some sort of cream on it daily. R2 reported being significantly less mobile since the fall with fracture and was at the facility for short term therapy. R2 reported pain with movement and repositioning. Review of R2's care plans revealed that there was no care plan in place regarding R2's DTI. There were no interventions for prevention of further skin breakdown, nor were there any interventions for treatment to promote healing of R2's DTI. On 09/24/25 at 1:55 pm, during an interview with the facility's Wound Nurse & Unit Manager /Registered Nurse (RN) C she reported being the facility's wound nurse and reported there was a DTI on R2's sacrum it was not opened. RN C stated R2 received a foam dressing to the sacrum, had a specialty bed, was provided a cushion, and should be repositioned frequently. RN C stated R2 can reposition self but would cause shearing and should be helped by staff for repositioning. Review of R2's care plans was done with RN C who agreed there was nothing in place to promote the healing of the DTI or prevent further pressure ulcers from developing.

This Citation Pertains to Intake #2622799Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from mental, verbal and physical abuse by staff, for one Resident #1, of three residents reviewed.Findings include:Resident 1 (R1) was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease,repeated falls and macular degeneration and was admitted for short term rehab after a fall from her walker while at home. Review of the Minimum Data Set (MDS)dated 9/11/25, revealed R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of the facility reported incident dated 09/08/2025 reveled R1 reported while toileting her on 09/07/25 Certified Nursing Assistant (CNA) E, CNA E kept demanding R1 lock the wheelchair, R1 stated she couldn't and CNA E huffed. R1 stated she had trouble pulling down her pants and CNA E finished pulling down her pants and made the comment These people need to learn to help themselves. and threw a clean brief at R1 and walked out. R1's statement reflected she was crying during the investigation. Further review of the facility's investigation included an interview with R1's roommate at the time (R4) who was discharged at the time of the State Agency's investigation and was not available for an interview. R4's clinical record revealed R4 scored 15 out of 15 on the BIMS dated 8/22/25. When queried about the incident that occurred with R1 and CNA E on 09/07/25 R4's statement revealed she too had an issue on or about 8/30/25 with CNA E, alleging CNA E was rude and stated Everyone around you don't understand why you can't get up and walk to the bathroom R4 statement further reflected she felt like she had to care for herself when CNA E was working. On 09/24/25 at 9:25 am, during a bedside interview with R1, she was observed resting in a recliner chair and observed frail. R1 stated she had the call light on because she needed to use the bathroom. R1 stated she has and uses both a wheelchair and a walker but felt weak on 09/07 and when entering the room CNA E told R1 to get up and get her walker, R1 said CNA E was irritated when R1 requested help to get into the wheelchair because she felt weak. R1 stated she was having trouble pulling her pants down and CNA E impatiently tugged them down, threw a clean brief at her and said something to the effect of being at the facility for rehab and needed to learn to help themselves. R1 stated after CNA E threw the brief at R1 she told her to get herself cleaned up and to let her know when she was done. R1 said she did her own peri care with no assistance and struggled to put the brief that was thrown at her on. R1 elaborated she was weak and scared to death that she was going to fall and stated she almost did fall. R1 elaborated that she cried after CNA E threw the brief at her. R1 says she plays the incident over and over in her mind and still cries about it. R1 stated this was the lowest point in her life due to health issues and nursing home placement and could not understand why or how anyone could be so cruel. Of note, R1 cried during interview with this surveyor. On 9/24/25 at 1:14pm during a phone interview with CNA E she reported she didn't know who R1 was or any incident regarding an abuse investigation. CNA E stated she was fired on 09/15/25 but wasn't sure why. CNA E then stated she did work 9/07/25 and they were very short staffed and that R1 must have her confused with a different CNA. On 09/24/25 at 2:21pm during an interview with CNA G, it was reported that she was assigned to R1 on 09/08/25 and R1 was tearful and didn't want help with anything but thanked CNA G for being kind. CNA G stated she could tell something was wrong and upon probing R1 became tearful and told her CNA E she was scared because the day before CNA E was mean and told her she could and should be doing things for herself. CNA G stated R4 chimed in stating CNA E was a mean. Review of the facility's Abuse, Neglect and Exploitation policy dated 11/15/23 page 6. defined Mental abuse Includes, but not limited to humiliation, harassments, threats of punishment or deprivation. Page 7 of the abuse policy defined Physical abuse Includes, but is not limited to hitting, punching, slapping, biting and kicking. It also includes controlling behavior through corporal punishment. Page 7. defined Verbal abuse as Means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability.On 09/24/25 at 1:07 PM, during an interview with NHA A he offered no explanation for CNA E's behavior and stated CNA E was terminated on 09/15/25 for customer service issues related to R1.

Based on observation, interview, and record review, the facility failed to revise, and update a comprehensive, individualized plan of care for two (Resident #15 and Resident #26) of 11 residents reviewed for care plans, had a care plan revised for changes in resident's needs, resulting in the potential for not receiving the care needed and psychosocial well-being. Findings include: Resident #15 (R15) Medical record reflected R#15 was admitted to the facility on [DATE]. Diagnoses of Left sided weakness from a Stroke, Dysphagia from the Stroke, Vascular Dementia, and Alzheimer's Disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2024, revealed R#15 had a Brief Interview of Mental Status (BIMS) of 03 (severe cognitively impaired) out of 15. Under section GG0130, Activities of Daily Living (ADL) assessment revealed R#15 requires substantial/maximum assistance with oral hygiene, toileting and dependent on shower/bathing, getting dressed. R#15 required substantial/maximum assist with repositioning in bed. R#15 is dependent on transfers from bed to wheelchair using a mechanical lift and 2 persons assist. During an interview on 11/19/24 at 11:27 AM, R15's family member O, stated R15 had not had his nails trimmed or cleaned as often as the family had requested that they be done. R15 is a 2-person mechanical lift transfer in and out of bed and is dependent of all care. During an observation on 11/19/24 at 11:53 AM, R15 sitting at the dining room table waiting for lunch to be served. Observed R15s fingernails are long and had a brown substance under the nail. During an observation on 11/20/24 at 11:41 AM, R15 sitting at the dining room table eating lunch. Observed his fingernails remained long with brown substance under the nails. During an interview on 11/20/24 at 2:02 PM, Unit Manager (UM) C stated the CNA's there at the facility provide showers to R15 two times a week. UM C also stated the hospice CNAs gave him showers during the week as well. Writer asked why R15's nails were long and had brown substance under his nails. UM C looked at writer with a blank look and then stated she would take care of this. During an observation on11/21/24 at 09:11 AM, R15 sitting in his wheelchair sitting in the activity room in front of the TV with his eyes closed. Observed R15's fingernails had been cut and cleaned. Record review of care plan revealed R15 had showers during the last 30 days on 10/23/24, 11/02/24, 11/06/24, 11/13/24, 11/20/24 by the facility CNAs. Hospice CNAs gave R15 showers on 10/21/24, 10/25/24, 10/28/24, 11/07/24, 11/18/24 and his nailcare had not been taken care of. Also noted that the care plan had not been revised or updated to reflect any collaboration between hospice and facility to ensure care was provided for this dependent resident. Record review did not reveal any coordination of care between the facility CNAs and the hospice CNAs and their task to complete. R15s care plan had not been revised or updated after the hospice admission reflecting any collaboration of care. Resident #26 (R26) Record review of Hospice Binder at the nurse's station contained a calendar dated from July 28, 24 through September 22, 24. Hospice binder did not contain the documents necessary for collaboration of care, current calendar with scheduled visits by the hospice team, plan of care (POC), interdisciplinary group (IDG) notes, certified nursing assistants (CNA) care plan, medication list, or visit notes. Nor were these hospice documents in R26's electronic medical record (EMR). During an interview on 11/20/24 at 12:20 PM, R26 stated his hospice CNA is a male, he helps him with his shower and comes in two times a week. R26 also stated that the facility CNAs would give showers on occasion. R26 stated that the water from the shower felt horrible on his skin and was very painful. R26 also added that he had to pace himself due to pain and shortness of breath. During an interview on 11/20/24 at 3:40 PM, Director of Nursing (DON) B brought a small binder of hospice information they found on a shelf in the nurse's station into the conference room to this writer. This information was not part of the hospice binder. During a record review on 11/21/24 at 09:41 AM, original hospice binder now contains the monthly calendar showing which discipline will be coming on which day, CNA care plan, POC, coordination of care, visit notes and IDG notes. According to the visit notes, R26 had a shower from the hospice CNA on 10/16/24, 10/18/24, 10/24/24, 10/25/24, 10/30/24, 11/01/24, 11/05/24, 11/06/24, 11/07/24, 11/12/24, 11/14/24, and 11/19/24. Record review also revealed that R26 did not have any of these documents uploaded into his EMR, nor was their a collaboration of care noted on the CNA's care plan. Record review of shower's given by facility CNAs for last 30 days were 10/25/24, 11/05/24, with one refusal of care on date 11/01/24. Nursing progress notes for the last 30 days did not show that the CNA's had reported the missed showers, attempts to reapproach or reason for not giving the showers to the nurse in charge. Record review revealed that R26 did not receive a shower on 10/15/24, documented on shower sheets, that the hospice CNA would shower the following day. No shower was provided due to hospice CNA coming that day or following day. On 10/25/24, R26 did not receive a shower due to hospice CNA gave him a shower that morning. On 11/01/24, R26 did not receive a shower because the hospice CNA gave him a shower that morning. On 11/06/24, R26 did not receive a shower due to the hospice CNA gave him one that morning. On 11/07/24, R26 did not receive a shower and documented, hospice CNA gave him his shower. On 11/08/24, R26 did not receive a shower and facility CNA documented hospice gave showers. On 11/12/24, R26 did not receive a shower and facility CNA documented that hospice gave showers. On 11/14/24, R26 did not receive a shower from facility CNA documented that hospice gave him showers. On 11/15/24 R26 did not receive a shower from facility CNA and documented that R26 refused shower due to hospice CNA provided the shower the day before. Record review of nursing progress notes, revealed a refused shower was documented for 10/18/24. No other refused showers were documented for the other dated and no offer to give him a shower at a different time. CNA care plan had not have any changes made to reflect collaboration of care between facility and hospice. During an interview on 11/21/24 at 10:13 AM, Licensed Practical Nurse (LPN) L reported the facility CNA's do give him showers and he refuses. LPN L also stated R26 would let the hospice CNA give him showers. LPN L stated the facility CNAs filled out a shower form for refusals and she signed off on them and they get turned into medical records and it gets scanned into his EMR. Record review on 11/21/24 at 10:08 AM did not indicate any hospice documents were uploaded other than the medication list dated1/19/24. During an interview on 11/21/24 at 1:08 PM, hospice CNA M stated they change the linen every time they provide showers for the hospice residents. CNA M also stated she feels the residents like the hospice CNAs to give them showers because they have the time to give undivided attention and can spend quality time with them. During an interview on 11/21/24 at 01:14 PM, CNA N stated she would ask the residents more than one time if she could shower them. CNA N stated that if the hospice CNA was coming in to shower the residents two times a week, then they were the ones who showered them instead of facility CNA's. CNA N also stated she did not know that hospice services were above and beyond of what the facility was to provide. CNA N also stated that happens a lot because facility CNAs didn't know the rules and they just wanted to make sure the residents were getting their showers. During an interview on 11/21/24 at 1:59 PM, DON B stated the hospice CNAs had schedules as to what they do, offer bed bath or shower, if residents refused. DON B also stated CNAs should be telling the nurse. DON B also stated CNAs should offer more than once, if they refused, tell the nurse, check preferences and see how to get them care. DON B stated they would find the root cause of resident's refusals and care plan it. Writer asked DON B when CNAs would chart NA. DON B started if a resident were out of the building. DON B also stated she would expect them to offer, reoffer, if they still say no, documentation would be on the shower sheet or in nurses progress notes charting. DON B stated she did not know anything about scheduling CNA's here with Hospice CNA's. DON B also stated she would hope the CNAs knew that hospice care is above and beyond. During an interview on 11/21/24 at 2:11 PM, unit manager (UM) C stated the days for showers were preset unless the resident wanted to have the day changed, or requested a different day and could change days or shifts. UM C stated residents get two showers a week. UM C also stated most of the residents that were on hospice, she coordinated care on admission. Hospice scheduled their CNAs days around the facility CNAs scheduled days. UM C stated if hospice residents didn't want a shower, offer bed bath, or ask what they would like. UM C stated that after 30 days of residents not getting their showers, she would have the Social Worker go talk to them. UM C stated that facility CNA's do not understand hospice rules, adding the nurse on the floor had to sign shower sheet stating they asked the residents a second time. Stated that R26 would spend his time outside, as a reason for not getting showers. UM C also stated they never got to his care plan to make any revision or updates on his care plan. Record review did not reveal any coordination of care between the facility CNAs and the hospice CNAs and their task to complete. R26s care plan had not been revised or updated after the hospice admission reflecting any collaboration of care.

Based on observation, interview and record review, the facility failed to develop an anti-coagulant Care Plan for one (Resident #19) of 11 reviewed for Care Plans, resulting in the potential for unmet care needs. Findings include: Review of the medical record revealed Resident #19 (R19) was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder and atrial fibrillation. Review of the Admission Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/24 revealed R19 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 11/19/24 at 11:56 AM, R19 was observed in her room, dressed and seated in her recliner. R19 reported that she had recently admitted for rehabilitation purpose. Review of the R19's Medication list revealed R19 was admitted to the facility on Apixaban Oral Tablet 5 milligram (Eliquis, an anticoagulant medication) with a start date of 10/24/24. Review of the Physician order's revealed no order for monitoring for bleeding, bruising, or any side effects related to taking an anticoagulant. Review of the Care Plan revealed no care plan associated to taking an anticoagulant. In an interview on 11/21/24 at 7:54 AM, Director of Nursing (DON) B stated that the expectation for resident's prescribed an anticoagulant included having Physician orders and a care plan in place for monitoring for skin bruising, labs (if applicable), checking for bleeding after any sort of injury especially a fall. DON B reviewed the Care Plan And Physician Order's for monitoring related to the high risk medication and confirmed the absence of both.

Based on observation, interview and record review, the facility failed to ensure proper communication/collaberation/documentation of Hospice services provided to two (Resident #15, Resident #26) of two residents reviewed for Hospice services, resulting in a lack of coordination of services and care provided. Findings Include: Resident #15 (R15) Medical record reflected R#15 was admitted to the facility on [DATE]. Diagnoses of Left sided weakness from a Stroke, Dysphagia from the Stroke, Vascular Dementia, and Alzheimer's Disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2024, revealed R#15 had a Brief Interview of Mental Status (BIMS) of 03 (severe cognitively impaired) out of 15. Under section GG0130, Activities of Daily Living (ADL) assessment revealed R#15 requires substantial/maximum assistance with oral hygiene, toileting and dependent on shower/bathing, getting dressed. R#15 required substantial/maximum assist with repositioning in bed. R#15 is dependent on transfers from bed to wheelchair using a mechanical lift and 2 persons assist. During an interview on 11/19/24 at 3:42 PM, Registered Nurse (RN) P came to the conference room and stated that the Unit Manager (UM) C reported that the hospice nurse may have been the one to put the documents in the hospice binder. This writer and RN P looked in the hospice binder of R15 for new orders or visit notes from the nurse visit on 11/18/24 and the hospice nurse did not leave a visit note. Record review revealed the hospice binder behind the nurse's station did not contain a Plan of Care (POC), Certified Nursing Assistant (CNA) care plan, current physician orders, or medication list. There was a 2024 calendar for the months of October and November which were blank. During an interview and observation on 11/20/24 at 11:10 AM, hospice liaison Q was asked to locate the CNA care plan, current plan of care, calendar with scheduled visits from all disciplines of her hospice team, Interdisciplinary group (IDG) notes and medication list. Hospice liaison Q stated she did not know the process for getting the hospice information into the hospice binder. Hospice liaison Q also stated she though the hospice agency e-faxed or emailed all the hospice notes to the facility to be put in the hospice binders for each resident. Hospice liaison Q was observed going through the hospice binder while calling her hospice agency's office for assistance. Hospice liaison Q was heard asking where the CNA care plan would be in the hospice binder. After listening to the hospice liaison Q asking for the information from two different hospice staff, it was determined that the information was not in the hospice binder. Hospice agency would re-fax the information to the facility. Record review revealed some new documents were put in the hospice binder after this writer reviewed the hospice binder at the end of day 11/19/24. R15's hospice binder now includes POC, medication list, admission check list (Not completed), IDG note but not a CNA care plan. During an interview on 11/20/24 at 11:45 AM, hospice liaison Q stated that on new admissions, they have 24 hours to get new hospice information to facility Director of Nursing (DON) B and she would print it off for the binder as well as scan it into R15's electronic medical record (EMR). Hospice Liaison Q then stated the hospice agency would e-fax the rest of the hospice admission information approximately eight days later, which would include IDG notes and visit notes from each discipline, would be e-faxed and emailed over to facility. Hospice Liaison Q stated, it is the facilities responsibility to print off the hospice information and put in the binder. R15's hospice admission was 07/25/24 and did not have any of the hospice documents in his hospice binder or his EMR. Hospice liaison Q stated hospice nurse was in the building and would be coming over to this unit by noon and would talk to this writer. During an interview on 11/20/24 at 12:47 PM, hospice RN R stated the hospice CNA would be giving R15 a bed bath instead of a shower due to increased fatigue with activity. Hospice RN stated she discontinued the dressing orders on R15's left gluteal fold on 08/12/24. Writer reported R15 had a dressing change with border foam dressing on his left gluteal fold dated 11/17/24, asked why the facility nurse would have done a dressing change that was discontinued. Hospice RN R stated she had no idea why a discontinued treatment had been completed. Hospice RN R also stated that she was not aware that this treatment was done and included that she wasn't the one that did it as she didn't work on Sunday. Hospice RN R also stated she wasn't aware of what documents were supposed to be in the hospice binder and she was going to get that information from her manager. Record review did not reveal any collaberation of care between hospice agency and facility regarding the wound care on R15's left gluteal fold. During an interview on 11/20/24 at 1:01 PM, Unit Manager (UM) C stated they found a hospice binder and it did not have any of the hospice information in it. UM C also stated they called the hospice agency to fax over the information. UM C also stated that the manager from this Hospice agency was in the facility and reported the binder had everything in it. UM C then stated that she never followed up to ensure the hospice binder had the necessary information in it. Writer asked UM C where the hospice documents would be found in the EMR. UM C stated that it would be under the miscellaneous tab in the EMR. Writer asked UM C if she could pull it up. UM C observed looking under the miscellaneous tab in the EMR and there was not any hospice documentation there. During this interview the DON B stated she identified the problem, the hospice agency had e-faxed the documents which went to her email, and they did not know they were supposed to print this off and put copies in the binders and upload them into EMR. During a record review on 11/21/24 at 09:26 AM, the facility still had not uploaded any hospice documentation that was e-faxed over from the hospice agency to this facility. During a record review on 11/21/24 at 09:41 AM, the hospice binder now contains the calendar for disciplines to write in their scheduled days to make visits, CNA care plan, POC, coordination of care, visit notes and IDG notes. According to the visit notes, R26 had a shower from the hospice CNA on 10/16/24, 10/18/24, 10/24/24, 10/25/24, 10/30/24, 11/01/24, 11/05/24, 11/06/24, 11/07/24, 11/12/24, 11/14/24, and 11/19/24. Facility CNAs gave R15 a shower on 10/25/24 and 11/05/24. Facility CNAs marked not applicable on 10/29/24, 11/08/24, 11/12/24, and on 11/19/24. R26 was not provided the personal care on the dates the facility CNA did not follow the showers scheduled for him. Facility CNA care plan did not include collaboration of care between facility and hospice agency. Resident #26 (R26) Medical record reflected R#26 was admitted to the facility on [DATE] and enrolled into the Hospice on 08/03/24. Diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow), Chronic Migraine Headache, Chronic Respiratory Failure, Spinal Stenosis Lumbar Region (spinal narrowing and can put pressure on the spinal cord), Depression, Anxiety, Chronic Pain Syndrome, Vertebrogenic Low Back Pain and Cardiomyopathy (heart muscle disease). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/2024, revealed R#26 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section GG0130, Activities of Daily Living (ADL) assessment revealed R#26 requires partial/moderate assistance with personal hygiene, toileting, shower/bathing, getting dressed, transferring from one surface to another. Record review of Hospice Binder at the nurse's station contained a calendar dated from July 28, 2024 through September 22, 2024. Hospice binder did not contain the documents necessary for collaboration of care, current calendar with scheduled visits by the hospice team, plan of care (POC), interdisciplinary group (IDG) notes, certified nursing assistants (CNA) care plan, medication list, or visit notes. Nor were these hospice documents in R26's electronic medical record (EMR). During an interview on 11/20/24 at 12:20 PM, R26 stated his hospice CNA is a male, he helps him with his shower and comes in two times a week. R26 also stated that the facility CNAs would give showers on occasion. R26 stated that the water from the shower felt horrible on his skin and was very painful. R26 also added that he had to pace himself due to pain and shortness of breath. During an interview on 11/20/24 at 3:40 PM, Director of Nursing (DON) B brought a small binder of hospice information they found on a shelf in the nurse's station into the conference room to this writer. This information was not part of the hospice binder. During a record review on 11/21/24 at 09:41 AM, original hospice binder now contains the monthly calendar showing which discipline will be coming on which day, CNA care plan, POC, coordination of care, visit notes and IDG notes. According to the visit notes, R26 had a shower from the hospice CNA on 10/16/24, 10/18/24, 10/24/24, 10/25/24, 10/30/24, 11/01/24, 11/05/24, 11/06/24, 11/07/24, 11/12/24, 11/14/24, and 11/19/24. Record review also revealed that R26 did not have any of these documents uploaded into his EMR. Record review of shower's given by facility CNAs for last 30 days were 10/25/24, 11/05/24, with one refusal of care on date 11/01/24. Nursing progress notes for the last 30 days did not show that the CNA's had reported the missed showers, attempts to reapproach or reason for not giving the showers to the nurse in charge. Record review revealed that R26 did not receive a shower on 10/15/24, documented on shower sheets, that the hospice CNA would shower the following day. No shower was provided due to hospice CNA coming that day or following day. On10/25/24, R26 did not receive a shower due to hospice CNA gave him a shower that morning. On 11/01/24, R26 did not receive a shower because the hospice CNA gave him a shower that morning. On 11/06/24, R26 did not receive a shower due to the hospice CNA gave him one that morning. On 11/07/24, R26 did not receive a shower and documented, hospice CNA gave him his shower. On 11/08/24, R26 did not receive a shower and facility CNA documented hospice gave showers. On 11/12/24, R26 did not receive a shower and facility CNA documented that hospice gave showers. On 11/14/24, R26 did not receive a shower from facility CNA documented that hospice gave him showers. On 11/15/24 R26 did not receive a shower from facility CNA and documented that R26 refused shower due to hospice CNA provided the shower the day before. Record review of nursing progress notes, revealed a refused shower was documented for 10/18/24. No other refused showers were documented for the other dated and no offer to give him a shower at a different time. During an interview on 11/21/24 at 10:13 AM, Licensed Practical Nurse (LPN) L reported the facility CNA's do give him showers and he refuses. LPN L also stated R26 would let the hospice CNA give him showers. LPN L stated the facility CNAs filled out a shower form for refusals and she signed off on them and they get turned into medical records and it gets scanned into his EMR. Record review on 11/21/24 at 10:08 AM did not indicate any hospice documents were uploaded other than the medication list dated1/19/24. During an interview on 11/21/24 at 1:08 PM, hospice CNA M stated they change the linen every time they provide showers for the hospice residents. CNA M also stated she feels the residents like the hospice CNAs to give them showers because they have the time to give undivided attention and can spend quality time with them. During an interview on 11/21/24 at 01:14 PM, CNA N stated she would ask the residents more than one time if she could shower them. CNA N stated that if the hospice CNA was coming in to shower the residents two times a week, then they were the ones who showered them instead of facility CNA's. CNA N also stated she did not know that hospice services were above and beyond of what the facility was to provide. CNA N also stated that happens a lot because facility CNAs didn't know the rules and they just wanted to make sure the residents were getting their showers. During an interview on 11/21/24 at 1:59 PM, DON B stated the hospice CNAs had schedules as to what they do, offer bed bath or shower, if residents refused. DON B also stated CNAs should be telling the nurse. DON B also stated CNAs should offer more than once, if they refused, tell the nurse, check preferences and see how to get them care. DON B stated they would find the root cause of resident's refusals and care plan it. Writer asked DON B when CNAs would chart NA. DON B started if a resident were out of the building. DON B also stated she would expect them to offer, reoffer, if they still say no, documentation would be on the shower sheet or in nurses progress notes charting. DON B stated she did not know anything about scheduling CNA's here with Hospice CNA's. DON B also stated she would hope the CNAs knew that hospice care is above and beyond. During an interview on 11/21/24 at 2:11 PM, unit manager (UM) C stated the days for showers were preset unless the resident wanted to have the day changed, or requested a different day and could change days or shifts. UM C stated residents get two showers a week. UM C also stated most of the residents that were on hospice, she coordinated care on admission. Hospice scheduled their CNAs days around the facility CNAs scheduled days. UM C stated if hospice residents didn't want a shower, offer bed bath, or ask what they would like. UM C stated that after 30 days of residents not getting their showers, she would have the Social Worker go talk to them. UM C stated that facility CNA's do not understand hospice rules, adding the nurse on the floor had to sign shower sheet stating they asked the residents a second time. Stated that R26 would spend his time outside, as a reason for not getting showers. UM C also stated they never got to his care plan to make any revision or updates on his care plan. Record review did not reveal any coordination of care between the facility CNAs and the hospice CNAs and their task to complete. R26s care plan had not been revised or updated after the hospice admission reflecting any collaboration of care.

Based on observation, interview and record review the facility failed to ensure proper storage and labeling of medications in one of one medication rooms. Findings include: On 11/20/24 at 4:08 PM, while conducting an observation of the facilities medication room with licensed practical nurse (LPN) L, a vial of Humalog insulin was observed in the medication refrigerator, inside the original box, which had been opened and the vial top had been removed. The vial was not labeled with the date opened or any resident information. The box was observed to have the numbers 1102 handwritten on it. LPN L stated that the insulin would need to be destroyed since it was not properly labeled. During the same observation of the medication room, a box containing Narcan nasal spray (medication used to reverse opioid overdose) was found in an unlocked drawer. The resident label had been removed (with some residual sticker remaining on the box) and the medication was not stored with other resident specific medications. On 11/21/24 at 4:15 PM, LPN L handed the open insulin vial and the box of Narcan nasal spray to director of nursing (DON) B, who reported that they would be discarded into a drug buster container. On 11/21/24 at 12:05 PM, an email was sent to the nursing home administrator (NHA) A requesting a policy specific to medication labeling. On 11/21/24 at 12:13 PM, NHA A, reported (via email) that the facility does not have a policy specific to medication labeling. On 11/21/24 at 3:39 PM, DON B was quired on what the expectation would be for labeling multi-use insulin vials. DON B stated that they should be labeled with the resident's name and room number, physician's name, and date opened. When asked how staff would know the labeling expectation if it's not outlined in a policy, they responded the information would be provided through education. A review of the facility's policy titled Medication Storage Policy, updated 8/24, documented in part .Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible, or missing labels .

Based on observation, interview and record review, the facility failed to document rationale for as needed (PRN) psychotropic medication orders that extended beyond 14 days for one (Resident #19) of five reviewed for unnecessary medications, resulting in the potential for an unnecessary medication regimen and adverse side effects. Findings include: Review of the medical record revealed Resident #19 (R19) was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder and atrial fibrillation. Review of the Admission Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/24 revealed R19 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 11/19/24 at 11:56 AM, R19 was observed in her room, dressed and seated in her recliner. R19 reported that she had recently admitted for rehabilitation purpose. Review of the R19's Medication list revealed R19 was admitted to the facility on Hydroxyzine Pamoate capsules 25 milligrams (Vistaril, an anxiety anxiety medication) with a start date of 10/24/24. Instructions on the medication order included give one tablet by mouth every 12 hours as needed for anxiety. There was no stop date for the medication. No rationale was located in the Electronic Medical Record for the use of the anti-anxiety medication past the 14 day period. In an interview on 11/21/24 at 7:54 AM, Director of Nursing (DON) B stated that the expectation for resident's prescribed a PRN medication would be to have a stop date that didn't exceed the 14 days.

Based on observation, interview, and record review the facility failed to provide necessary care to one (Resident #15) of two residents reviewed who were dependent of all activities of daily living (ADLs), resulting in this resident not receiving the care needed to maintain their highest practicable well-being. Findings include: Resident #15 (R15) Medical record reflected R#15 was admitted to the facility on [DATE]. Diagnoses of Left sided weakness from a Stroke, Dysphagia from the Stroke, Vascular Dementia, and Alzheimer's Disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2024, revealed R#15 had a Brief Interview of Mental Status (BIMS) of 03 (severe cognitively impaired) out of 15. Under section GG0130, Activities of Daily Living (ADL) assessment revealed R#15 requires substantial/maximum assistance with oral hygiene, toileting and dependent on shower/bathing, getting dressed. R#15 required substantial/maximum assist with repositioning in bed. R#15 is dependent on transfers from bed to wheelchair using a mechanical lift and 2 persons assist. During an interview on 11/19/24 at 11:27 AM, R15's family member O, stated R15 had not had his nails trimmed or cleaned as often as the family had requested that they be done. R15 is a 2-person mechanical lift transfer in and out of bed and is dependent of all care. During an observation on 11/19/24 at 11:53 AM, R15 sitting at the dining room table waiting for lunch to be served. Observed R15s fingernails are long and had a brown substance under the nail. During an observation on 11/20/24 at 11:41 AM, R15 sitting at the dining room table eating lunch. Observed his fingernails remained long with brown substance under the nails. During an interview on 11/20/24 at 2:02 PM, Unit Manager (UM) C stated the CNA's there at the facility provide showers to R15 two times a week. UM C also stated the hospice CNAs gave him showers during the week as well. Writer asked why R15's nails were long and had brown substance under his nails. UM C looked at writer with a blank look and then stated she would take care of this. During an observation on11/21/24 at 09:11 AM, R15 sitting in his wheelchair sitting in the activity room in front of the TV with his eyes closed. Observed R15's fingernails had been cut and cleaned. Record review of care plan revealed R15 had showers during the last 30 days on 10/23/24, 11/02/24, 11/06/24, 11/13/24, 11/20/24 by the facility CNAs. Hospice CNAs gave R15 showers on 10/21/24, 10/25/24, 10/28/24, 11/07/24, 11/18/24 and his nailcare had not been taken care of. Also noted that the care plan had not been revised or updated to reflect any collaboration between hospice and facility to ensure care was provided for this dependent resident. During a record review on 11/21/24 at 09:26 AM, hospice CNA care plan was not present to indicate what CNAs would be responsible for, during their care provided.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 34 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 10/16/23 at 06:56 A.M., An initial tour of the food service was conducted with Director of Food Services/Executive Chef D and Sous Chef E. The following items were noted: The Walk-In Cooler refrigeration unit fan blades and fan guards were observed heavily soiled with accumulated and encrusted soil deposits. The Walk-In Freezer automatic door closer assembly was observed weak, allowing the door to not completely close. Ice [NAME] were also observed protruding from the rear of the interior refrigeration unit. The entrance door air curtain clear plastic strips were additionally observed with accumulated ice deposits from excessive moisture entering the door cavity. Sous Chef E indicated he would contact maintenance for necessary repairs as soon as possible. The 4-door food preparation counter refrigeration unit door gaskets were observed heavily soiled with accumulated and encrusted dust, dirt, and a black watery substance. The Delfield 2-door reach-in cooler counter refrigeration door gaskets were observed heavily soiled with accumulated and encrusted dust, dirt, and a black watery substance. Sous Chef E indicated he would have dietary staff thoroughly clean and sanitize the soiled door gaskets as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The Metro C5 hot box interior door gasket was observed severely worn, chipped, and torn. The Walk-In Freezer entrance door was observed warped within the top right quadrant of the door surface, allowing moisture to enter the unit interior. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 10/17/23 at 03:45 P.M., Record review of the Policy/Procedure entitled: Environment dated 09/2017 revealed under Policy Statement: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Record review of the Policy/Procedure entitled: Environment dated 09/2017 further revealed under Procedures: (1) The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. (2) The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. (3) All food contact surfaces will be cleaned and sanitized after each use.

Based on observation, interview and record review, the facility failed to dispose of expired medications in two of two medication carts reviewed, resulting in the potential for decreased medication efficacy and adverse side effects in a current facility census of 34 residents. Findings include: On 10/18/23 at 10:50 AM, Team 2 Medication Cart was reviewed in the presence of Licensed Practical Nurse (LPN) R. During the review, a pharmacy label on both a plastic bag and the Insulin Glargine prefilled pen within was noted with a pharmacy label reflecting R11's name. The label on the bag contained a medication dispense date of 9/14/23 with the date opened label on both the bag and opened pen noted to remain blank. LPN R confirmed that R11's Glargine Insulin pen was opened, had been used, but as was unable to determine when pen was opened, would be discarding pen and getting a new one. Review of R11's medical record revealed an active order dated 5/22/23 for Lantus (Insulin Glargine) with daily administration at bedtime. Review of the R11's corresponding Medication Administration Record (MAR) dated 10/1/2023 - 10/31/2023 reflected daily Lantus administration from 10/1/23 through 10/17/23. During the same Team 2 Medication Cart review, a Calcitonin Salmon Nasal Spray was noted with a pharmacy label reflecting R4's name on both the medication box and bottle within. The label on the box contained a medication dispense date of 9/3/23 with no open date noted on either the medication box or open medication bottle. LPN R confirmed that R4's Calcitonin Spray had been opened, had been used, and that as no opened date could be located on either the box or bottle would be disposing of and obtaining a new one as was unsure of how long the medication was good for after opened but may be expired if opened on the 9/3/23 dispense date. Review of R4's medical record revealed an active order dated 9/17/2022 for Miacalcin Solution (Calcitonin) with daily administration. Review of the R4's corresponding MAR dated 10/1/2023 - 10/31/2023 reflected daily administration from 10/1/23 through 10/18/23. Additionally, during the same Team 2 Medication Cart review, a Metamucil 4-in-1 Fiber 30 packet box was noted to have an expiration date of 8/2023 with several unopened packets remaining within the box. LPN R confirmed that Metamucil was a facility stock medication, acknowledged that the medication had expired in 8/2023, and that the medication would be disposed of, and a new facility supply obtained. On 10/18/23 at 11:39 AM, Team 1 Medication Cart was reviewed in the presence of LPN S. During the review, a Metamucil 4-in-1 Fiber 30 packet box was noted to have an expiration date of 8/2023 with 12 unopened packets remaining within the box. LPN S confirmed that Metamucil was a facility stock medication, acknowledged that the medication had expired in 8/2023, and that the medication would be disposed of, and a new facility supply obtained. In an interview on 10/18/23 at 11:52 AM, Director of Nursing (DON) B stated that the nurse management team generally completed monthly medication cart audits which entailed checking the expiration date on all facility stocked over the counter medications as well as checking all resident specific multi-dose medications including insulin, eye drops, inhalers, and nasal sprays for an open date and would also ensure that the opened medication remained within the expiration date. DON B further stated that since the facility had recently transitioned to a new pharmacy, had received new medication carts, and 2 consultant nurses from the pharmacy had audited the carts on 10/6/23 that the facility staff had not completed the routine medication cart audits for the month of October. During the same interview, Unit Manager (UM) I present in the same room, confirmed that she had followed up on the expired medications in Team 2 Medication Cart, confirmed that R11's opened Insulin Glargine and R4's opened Calcitonin were expired, had disposed of, and new ones had been obtained. In a document titled Medications with Shortened Expiration Dates provided by UM I and confirmed to be utilized by facility for pharmacy services indicated that Lantus (Insulin Glargine) Pen was good for 28 days after opening and that Miacalcin (Calcitonin Nasal Solution) was good for up to 35 days after opening. Review of the facility policy titled, Medication Storage Policy with a 4/2021 date of initiation stated, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations .Policy Explanation and Compliance Guidelines .8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications .These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.

Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers and monitor pressure ulcers for 3 Resident (R3, R15, and R9) reviewed for alterations in skin integrity, resulting in the development of pressure ulcers and the potential for further skin breakdown, delayed wound healing, infection, and overall deterioration in health status. Findings: Resident #3 (R3) Review of an Admission Record revealed R3 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for R3, with a reference date of 6/10/22 revealed R3 was severely cognitively impaired. Review of the Functional Status revealed that R3 required extensive 2 person assist for bed mobility, total dependence of 2 persons for transferring and toileting, and total dependence of 1 person for personal hygiene. Review of R's Braden Scale for Predicting Pressure Score Risk dated 8/1/22 revealed R3 was At Risk for skin breakdown. Review of R3's Physician Order dated 6/11/22 revealed, Turn and reposition Q (every) hour. (Hourly repositioning was not documented on R3's Care Plan or Kardex). During an observation on 09/19/22 at 11:13 AM, R3 was sitting up in a gerichair in her room with no offloading devices in place. During an observation on 09/19/22 at 12:03 PM, R3 was sitting up in a gerichair in the dining room with no offloading devices in place. During an observation on 09/19/22 at 12:25 PM, R3 was sitting up in a gerichair in the dining room with no offloading devices in place. During an observation on 09/19/22 at 01:39 PM, R3 was sitting up in a gerichair in her room with no offloading devices in place. During an observation and interview on 09/19/22 at 02:23 PM, R3 was sitting up in a gerichair in her room with no offloading devices in place. Certified Nursing Assistant (CNA) O reported that R3 gets up before lunch and stays up in her gerichair until after dinner. During an observation and interview on 09/20/2022 at 8:06 AM, R3 was sitting up in a gerichair in her room with no offloading devices in place. Hospice Staff (HS) R reported that she had provide care for R3 and was going to feed her breakfast. HS R reported that R3 had a pressure ulcer on her buttocks. During an observation on 09/20/22 at 9:45 AM, R3 was sitting up in a gerichair in her room with no offloading devices in place. During an observation on 09/20/22 at 10:29 AM, R3 was sitting up in a gerichair in her room with no offloading devices in place. During an observation on 09/20/22 at 11:56 AM, R3 was sitting up in a gerichair in her room with no offloading devices in place. During an observation on 09/20/22 at 12:42 PM, R3 was sitting up in a gerichair in the dining room with no offloading devices in place. During an observation on 09/20/22 at 2:45 PM, R3 was sitting up in a gerichair in her room with no offloading devices in place. During an observation on 09/21/22 at 07:24 AM, R3 was laying in her bed with no offloading devices in place. During an observation on 09/21/22 at 08:57 AM, R3 was laying in her bed with no offloading devices in place. During an observation and interview on 09/21/2022 at 9:35 AM, R3 was laying in her bed with no offloading devices in place. Wound Care Nurse (WCN) Q completed a skin/wound assessment with the following wounds/measurements: *Known Stage II pressure ulcer to coccyx measuring 1.4cm x 0.8cm x superficial redness (worsened from assessment 9/14/22) *New area of non-blanchable redness to left buttock measuring 2.2cm x 1.7cm *New area of non-blanchable redness to left thigh above the catheter securement device 1.3cm x 0.8cm *New area to left medial aspect of knee measuring 0.9cm x 0.5cm Review of R3's Skin/Wound Note dated 9/14/22 revealed, Bilateral buttocks and Coccyx pink and blanchable . Review of R3's Hospice Note dated 9/15/22 revealed, .sacrum pressure wound nearly closed .small closed blood blister noted to left inner thigh . Review of R3's Skin/Wound Note dated 9/21/2022 at 9:56 AM revealed, Skin assessment completed .Scab noted to L medical aspect of knee measuring 0.9cm x 0.5cm, periwound free of redness. Nonblanchable area to L thigh superior to catheter secure measuring 1.3cm x 0.8cm. Stage 2 to coccyx measuring 1.4cm x 0.8cm, area of nonblanchable redness to L buttock measuring 2.2cm x 1.7cm, other areas of bilateral buttocks pink and blanchable .(provider name omitted) notified and treatment orders initiated for newly noted areas. During an interview on 09/20/22 at 2:00 PM, CNA K and CNA P reported that it was difficult to meet the needs of the residents because of inadequate staffing. CNA K and CNA P reported that they were not always able to reposition dependent residents every 2 hours (per standards of practice) nor check and/or change incontinent residents every 2 hours because CNA's scheduled to work on the unit were taken off the unit to attend appointments with residents, which would leave them short staffed. During an interview on 09/21/22 at 10:34 AM, CNA F reported that there were only 4 CNA's working at that time because one of the floor CNA's was sent to an appointment with another resident. CNA F reported that there were many 2 assist residents, and it was difficult to meet their needs with repositioning and changing with the amount of staff scheduled to work on the units. Resident #15 (R15) Review of an Admission Record revealed R15 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R15, with a reference date of 7/30/22 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated R15 was cognitively impaired. Review of the Functional Status revealed that R15 required extensive 2 person assist for bed mobility and toileting and extensive 1 person assist for personal hygiene and eating. Review of R15's Braden Scale for Predicting Pressure Score Risk dated 8/1/22 revealed R15 was High Risk for skin breakdown. During an interview and observation on 09/20/22 at 2:00 PM, CNA K and CNA P were changing R15 and providing incontinence care. R15 had a known Stage II Pressure Ulcer to her coccyx approximately the size of a pencil eraser. R15's skin was macerated (tissue becomes softened by soaking in a liquid/urine) and during her care 2 new areas of skin breakdown were noted and verified by CNA K and CNA P. The first pressure ulcer was on the left side of her rectum approximately the size of a pencil eraser. The wound bed was bright red, the edges of the wound were macerated, and there was frank blood noted on the wipe used to clean her. The second pressure ulcer was on the right side of her rectum, was oblong, and approximately the length of a quarter. The periwound was macerated and the wound bed was bright red with frank blood noted on the wipe used to clean her. CNA K and CNA P reported that the 2 pressure ulcers around R15's rectum were new. Review of R15's Electronic Health Record (EHR) on 9/21/22 revealed no documentation of the findings of the 2 new pressure ulcers noted on 9/20/22. During an observation and interview on 09/21/2022 at 9:25 AM, WCN Q was notified of R15's 2 new pressure ulcers. WCN Q had not been made aware of the 2 new pressure ulcers prior to the interview. During an observation, WCN Q measured the known pressure ulcer on R15's coccyx as 0.6cm X 0.6cm X 0.1cm (indicating the worsening of the wound from previous assessment). WCN Q measured R15's wound on the right side of her rectum as 2cm X 0.7cm X 0.1cm and the wound on the left side of her rectum as 0.2cm X 0.2cm X 0.2cm. R15 reported pain on her bottom. WCN Q reported she would obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R15's Skin/Wound Note dated 9/14/2022 revealed, Stage 2 to coccyx measuring 0.3cm x 0.3cm, wound bed pink, a scant amount of bleeding noted, wound edges well defined. Periwound pink and blanchable. Excoriation noted to rectum, area red, no bleeding noted. Resident expressed some discomfort during assessment. (Nurse Practitioner name omitted) notified and orders received for hydrocortisone cream BID until resolved . Review of R15's Skin/Wound Note dated 9/14/2022 at 11:49 AM revealed, Stage 2 to coccyx measuring 0.6cm x 0.6cm x 0.1, wound bed pink, a scant amount of bleeding noted, wound edges well defined. Periwound pink and blanchable. Stage 2 noted to rectal area, R side measuring 2cm x 0.7cm x 0.1cm, wound bed is pink with bleeding noted to area during treatment, open area stage 2 to L side of rectum measuring 0.2cm x 0.2cm x 0.2cm. Excoriation noted to periwound. Resident expressed some discomfort during assessment . Resident #9 (R9) Review of an Admission Record revealed R9 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for R9, with a reference date of 6/27/22 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated R9 was cognitively intact. Review of the Functional Status revealed that R9 required extensive 1 person assist for bed mobility, transferring, and toileting. Review of R9's weekly Skin Observation Tool reviewed on 9/21/22 revealed a weekly skin assessment was completed on 8/2/22, 8/23/22, 9/6/22, and 9/13/22. Indicating weekly skin assessments were not completed. Review of R9's Skin/Wound Note dated 7/15/2022 revealed, Right heel has a 1.4cm x 1.3cm area of flaking/peeling tissue. Tissue under edges is intact. Skin prep continues to be applied TID. Resident tolerating well. Review of R9's Skin/Wound Note dated 8/19/2022 revealed, Right heel scab measuring a 2cm x 1cm area. Treatment order continue. Resident tolerated assessment and treatment well. Review of R9's Skin/Wound Note dated 9/15/2022 revealed, Bilateral buttocks pink and blanchable, no open areas noted. Right heel scab measuring 0.5cm x 0.5cm. Treatment order continue. Resident tolerated assessment and treatment well. Indicating weekly wound evaluations were not completed for R9. During an observation and interview on 09/21/2022 at 9:20 AM, WCN Q verified weekly measurements/assessments were not completed for R9. During an interview on 09/20/2022 at 7:44 AM, WCN Q reported that full body skin assessments are completed on admission and weekly thereafter by facility nurses. WCN Q reported that ongoing and/or new wounds are discussed every morning in the IDT (interdisciplinary team) meeting. WCN Q reported that nursing staff document new skin breakdown in progress notes and skin assessments and WCN Q then measures and monitors wounds until they are resolved. Review of the facility policy Pressure Injury Prevention and Management last revised 11/21 revealed, .2.Assessment of Pressure Injury Risk a. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record .c. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task .4. Monitoring a. The RN Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record .

This citation is related to intake: MI 368 Based on observation, interview and record review the facility failed to prevent the administration of a narcotic medication to Resident #1 which was not prescribed for Resident #1 (belonged to Resident #2), resulting in a significant medication error, altered mental status, a state of stupor requiring emergency transport and admission to a local hospital for treatment. Findings Include: Resident #1 According to the Electronic Medical Record (EMR) on 10/10/18 at 10:37 AM, Resident (R) #1 was a [AGE] year old male admitted to the facility on [DATE]. allergies [REDACTED]. R1's admitting [DIAGNOSES REDACTED]. R1's Admission / 5 day Minimum Data Set (MDS: resident assessment tool) dated 9/26/18 reflected a Brief Interview for Mental Status (BIMS) score of 3 out of 15 (0-7 = severe cognitive impairment). Also, that R1 required extensive assistance of 1-2 persons for bed mobility, transfers, toilet use, dressing, hygiene, bathing, limited assistance of 1 person for walking in room, locomotion on/off unit, eating, and had occasional pain rated at an 5 (moderate pain) out of 10. A Facility Reported Incident (FRI) was received by the state agency via online submission on 09/30/18 reflecting that a Registered Nurse (RN G) had given liquid [MEDICATION NAME]/[MEDICATION NAME] (narcotic [MEDICATION NAME]) to R1 without an order on 09/27/18 at 08:30 AM. Progress Notes reflected: 9/28/2018 10:41 Discharge Note Note Text: At approximately 0910 RN Q was notified that R1 was not opening his eyes or responding to the CNA. Upon assessment by RN Q and this RN R1 was unable to open his eyes or raise any of his limbs. He would moan in response to his name, but could not open his eyes, or say any meaningful words. Dr. I notified by this nurse and gave the order to send to HFAH-ER. (Local hospital) called. Left for ER at approximately 0935. Wife notified and stated that she would meet him at ER. 10/3/2018 11:41 General Nursing Note Note Text: On 9-27-2018 @ approximately 2030 two CNA's reported this resident was swinging at staff, stripping his gown off and spitting. [MEDICATION NAME] 0.25mL was allegedly given by nurse to resident after report. 09-27-2018 2200-0630 shift CNA reports doing rounds and provided assistance with voiding into urinal. CNA reports resident became a little feisty as he put his arm out to push CNA away, easily redirected, then no other behaviors. At approximately 0430 09-28-2018 the assigned CNA entered residents room when she noticed oxygen tubing was removed from residents nares. Resident was alert, non combative, VS were obtained and baseline at that time. Hospital Records dated 09/28/18 at 10:11 AM emergency department notes reflected at 10:41 AM, Patient presents to the emergency department for evaluation of altered mental status. Patient was seen in the emergency room 2 days ago for epistaxis and headache anterior Rhino Rocket placed. I was actually the physician who saw him and placed the Rhino Rocket. Today, patient is acting much different than usual and is only responsive to painful stimuli. Patient's last normal night was last night. Patient is currently in [MEDICAL CONDITION] . The Mayo Clinic (MONTH) (YEAR) medical online reference defined [MEDICAL CONDITION] as: [MEDICAL CONDITION] is an irregular and often rapid heart rate that can increase your risk of stroke, heart failure and other heart-related complications. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The (MONTH) (YEAR) Treatment Administration Record (TAR) for R1 was negative for a pain assessment performed on 09/27/18 or any rating of pain on that day. On 09/28/18 a pain assessment completed on the 7p - 7a shift reflected the number 6 (more than moderate pain), of what appeared to be a 0-10 numbered pain scale, initialed by RN G. R1 did not have an doctor's order for the narcotic liquid [MEDICATION NAME]/[MEDICATION NAME], therefore there was no accompanying narcotic sheet. Nor, did R1 have any ordered as needed (prn) pain medications at that time. Resident #2 However according to the EMR, R2's (MONTH) (YEAR) MAR's reviewed at 08:45 AM on 10/10/18, reflected the following order: [MEDICATION NAME] (Concentrate) Solution 20 milligrams (mg)/milliliter (ml). Give 0.25 ml by mouth (po) every 4 hours as needed for pain. The EMR reflected R2 was admitted to the facility on [DATE], was a hospice patient and had a [DIAGNOSES REDACTED]. Later the same day at 02:35 PM R2 was observed to be in his room with family present. LPN P had revealed earlier at 02:08 PM that R2 was a hospice patient and was actively dying. The (MONTH) (YEAR) MAR for R2 reflected only (1) entry for administration of [MEDICATION NAME] 0.25 ml to R2 on 09/27/18 at 02:05 by LPN N, for a pain rating of the number 4 (less than moderate pain). The (MONTH) (YEAR) TAR for R2 reflected the following pain assessments: 09/27/18 7a - 7p shift, pain score the number 2 (mild pain) initialed by RN O 09/27/18 7p - 7a shift, pain score the number 0 (no pain) initialed by RN G 09/28/18 7a - 7p shift, pain score the number 0 by LPN F 09/28/18 7p - 7a shift, pain score the number 0 by RN G 09/29/18 7a - 7p shift, pain score the number 0 by LPN I 09/29/18 7p - 7a shift, pain score the number 0 by RN Q Consequently the Controlled Substances (narcotics) Proof Of Use sheet dated 09/25/18 for R2, with a receipt of 30 ml of [MEDICATION NAME] 20 mg/ml solution 100 mg/5 ml Give 5 mg (0.25 ml) by mouth every 4 hours as needed reflected the following sign-out administration times: 1. 09/26/18 at 21:00 PM, quantity used = 0.25, quantity remaining = 29.75, signature LPN P, comments with LPN N & P's first name listed. THIS ENTRY WAS NOT REFLECTED ON THE MAR'S. 2. 09/27/18 at 02:05 AM, quantity used = 0.25, quantity remaining = 29.5, signature LPN P, comments with LPN N & P's first name listed. THIS ENTRY WAS THE ONLY ENTRY REFLECTED ON THE MAR. 3. 09/27/18 at 20:00 PM, quantity used = 0.25, quantity remaining = 29.25, signature RN G, comments with RN G's first name only. THIS ENTRY WAS NOT REFLECTED ON THE MAR'S. 4. 09/28/18 at 00:00 AM, quantity used = 0.25, quantity remaining = 29, signature RN G, comments with RN G's first name only. THIS ENTRY WAS NOT REFLECTED ON THE MAR'S. 5. 09/28/18 at 04:00 AM, quantity used = 0.25, quantity remaining = 28.75, signature RN G, comments with RN G's first name only. THIS ENTRY WAS NOT REFLECTED ON THE MAR'S. 6. 09/28/18 at 20:00 PM, quantity used = 0.25, quantity remaining = 28.50, signature RN G, comments with RN G's first name only. THIS ENTRY WAS NOT REFLECTED ON THE MAR'S. 7. 09/29/18 at 02:00 AM, quantity used = 0.25, quantity remaining =28.25, signature RN G, comments with RN G's first name only. THIS ENTRY WAS NOT REFLECTED ON THE MAR'S. R1 had the potential to have received multiple doses of R2's [MEDICATION NAME]/[MEDICATION NAME] narcotic medication, by RN G on 09/27/18, 09/28/18 and 09/29/18. Also, R2 had the potential to have missed needed [MEDICATION NAME]/[MEDICATION NAME] narcotic pain medication administration. The Penn Medicine Onco Link (MONTH) (YEAR) online medication reference reflected the following related to [MEDICATION NAME] Oral Liquid ([MEDICATION NAME]): This is a liquid preparation of [MEDICATION NAME] that comes in various strengths. This form of [MEDICATION NAME] is taken with or without food, either as needed for pain or as a regularly scheduled medication decided by your care provider. This medication comes as a dosage per volume (milligrams per milliliter). A doctor will often prescribe a dosage in milligrams to take, so make sure the pharmacist has made it very clear how much volume (milliliters) you need to drink at a time to get a particular dosage. The medication will begin working to relieve pain in 15 to 30 minutes, and reaches its peak effect in 1 hour. It will continue to work for 2 to 4 hours. This form of [MEDICATION NAME] is used to treat breakthrough pain [MEDICAL CONDITION] patients who have been receiving opioids on a regular basis to treat their baseline pain. This medication can cause dizziness, sleepiness and confusion. You should not drive or operate machinery while taking this medication until you know how it will effect you. This medication can interact with other medications that depress the central nervous system like barbiturates (including [MEDICATION NAME]), tranquilizers (including [MEDICATION NAME]®, [MEDICATION NAME]® and [MEDICATION NAME] ®), other narcotics, MAOI ' s, cimitedine, and general anesthetic. Be sure to tell your healthcare provider about all medications and supplements you take. DO NOT share this medication or give it to someone else, as severe breathing problems and death can occur. Side effects listed consisted of constipation, somnolence, slow breathing, low blood pressure, addiction, nausea, vomiting and an allergic reaction. The RxList (MONTH) (YEAR) online medication reference reflected: [MEDICATION NAME] is indicated for the relief of severe acute and severe chronic pain. DOSAGE AND ADMINISTRATION CAUTION: [MEDICATION NAME] (Trademark) ([MEDICATION NAME] 20 mg/ml) is a HIGHLY CONCENTRATED solution of [MEDICATION NAME] for Oral Administration. Error in dosage or confusion between milligrams (mg) of [MEDICATION NAME] and milliliters (ml) of solution may cause significant over-dosage. Dosing instructions should be clearly pre-scribed in milligrams (mg) of [MEDICATION NAME] and milliliters (ml) of solution. VERIFY CORRECT DOSE AND VOLUME BEFORE ADMINISTRATION TO PATIENT The facility's MEDICATION ADMINISTRATION POLICY revised 08/12/14 reflected the following: POLICY It is the policy of this Health Center that all rules and regulations will be followed when dealing with medication administration. PR[NAME]EDURE 2. Medications will be passes according to the physicians order. 6. All medications given to resident, must be accompanied by a physician's orders [REDACTED]. 7. The nurse will verify that the appropriate resident is given the appropriate medications. Pictures of residents are available in the computer system. 11. Sign medications only after they have been administered. 15. The 7 Rights of Medication Administration will be followed; a. RIGHT drug b. RIGHT resident c. RIGHT dose d. RIGHT time e. RIGHT route f. RIGHT reason g. RIGHT documentation Resident #1 The facility's Unusual Occurrences Report dated 09/29/18 at 19:00 PM, signed by the Director of Nursing (DON) and post Administrator (ADM M) for R1 reflected the following Resident Statement or describe Event Scene: At 17:09 PM Licensed Practical Nurse (LPN F) called and notified this RN (Registered Nurse) that Certified Nursing Assistant (CNA E) had reported to her that on Thursday 09/27/18 R1 was agitated and combative. CNA E reported this to the RN on duty, RN G. RN G then came in the room with a small syringe. Describe Injury: Transferred to (name of local hospital) emergency room (ER) related to altered mental status. The form's Summary of Investigation section reflected: Investigation began 09/29/18 at 17:30 PM. Interviewed staff and took statements. Resident was transferred to the hospital 09/28/18 09:35 AM related to unresponsiveness .Hospital was informed of 0.25 cc (cubic centimeters) dose of liquid MS ([MEDICATION NAME]) given 09/27/18 at approx 20:30 PM so they were aware. Progress notes reflected the following: 9/28/2018 10:41 Discharge Note Note Text: At approximately 0910 RN Q was notified that R1 was not opening his eyes or responding to the CNA. Upon assessment by RN Q and this RN R1 was unable to open his eyes or raise any of his limbs. He would moan in response to his name, but could not open his eyes, or say any meaningful words. Dr.S notified by this nurse and gave the order to send to (local hospital)-ER. (Local hospital) called. Left for ER at approximately 0935. Wife notified and stated that she would meet him at ER. 10/3/2018 11:41 General Nursing Note Note Text: On 9-27-2018 @ approximately 2030 two CNA's reported this resident was swinging at staff, stripping his gown off and spitting. [MEDICATION NAME] 0.25mL was allegedly given by nurse to resident after report. 09-27-2018 2200-0630 shift CNA reports doing rounds and provided assistance with voiding into urinal. CNA reports resident became a little feisty as he put his arm out to push CNA away, easily redirected, then no other behaviors. At approximately 0430 09-28-2018 the assigned CNA entered residents room when she noticed oxygen tubing was removed from residents nares. Resident was alert, non combative, VS were obtained and baseline at that time. On 10/10/18 at 10:52 AM R1's wife was called by phone and revealed she never found out about the reason R1 was sent to the hospital until a week after the incident happened. I knew they rushed him to the ER after the incident. When he came home from the hospital last Thursday, they called me. The nurse said, she would like to talk to me about the incident. I had came to the facility that day at 2 PM. He was very sleepy still. My family came to visit R1 at around 5:30 PM and he slept through the visit and would not eat anything, and that's all I know about what happened Thursday night. Nobody told me the cause of what happened. The nurse was not able to give me any more information about it. R1's wife was asked if R1 was alert and oriented and replied, He does not even remember that night. He was at the ER for two nights. I went in there Saturday, his eyes were all puffy and he was totally out of it. He was taken in Friday 09/28/18, and was admitted to a room on Saturday afternoon. He stayed in the hospital until Wednesday, last Wednesday. He was admitted on [DATE] and discharged [DATE]. I was kept in the dark about everything. While he was at the hospital he was under duress, fighting everybody thinking they were going to kill him. During the interview R1s wife stated, I feel I should have been notified immediately of the cause, of my husband's admission to the hospital. I did not find out until 10/3/18. I knew nothing about him getting [MEDICATION NAME]. RN D called me on 9/29/18 and wanted to know my version of Thursday night, and I told her what I recalled about my family visit and that my husband was sleeping through visit. She said okay and hung up. The Administrator called on 10/4/18, and she asked if RN D called me and I said yes, but she never said anything about what happened, that's why I'm annoyed. On 10/10/18 at 11:30 AM the DON was asked about the medication error incident. The DON revealed a investigation had been completed. When asked if RN G still worked at the facility, the DON revealed that RN G was suspended, but she called back within 2 hours and quit. The DON's signed undated statement reflected RN G called her back at 09:36 PM, and the following: I told her that R1 was in the hospital and I needed to ask her about Thursday night. I asked if she had given any liquid medication to R1 Thursday night. She stated that she was not sure. I explained that I had 2 nursing assistants stating that she gave a pink liquid in a small syringe to him. I asked did that happen and she stated yes, it happened. I stated what did you given him RN G stated a 0.25 dose of liquid [MEDICATION NAME] I asked where did you get it. She stated it was R2's [MEDICATION NAME]. I stated why did you give that to him RN G stated because I felt he needed it I replied why would you do that, you are not a doctor, you do understand that this is highly illegal, why wouldn't you just call and get a one-time order for something? She stated I don't know. I explained that I was going to have to report this to the state and I then explained that she was suspended pending the completion of this investigation and that I needed a statement about this if she could e-mail it or send it to me in some way. I expressed that it was late and if she would like to talk tomorrow or if she thought of anything else she wanted me to know to call me tomorrow or Monday. She voiced understanding. On 10/10/18 at around 11:50 AM RN D was interviewed and revealed she was not working on 09/29/18 but was on call. LPN F called me Friday 09/29/18 and told me that when CNA E saw that R1 was sent to theER on that Friday 9/28/18 night. R1 was confused and combative and CNA E reported it to RN G. CNA E went back in and to assist R1 and RN G came back in with a syringe. CNA E questioned if R1 had an order for [REDACTED]. I also called CNA H and asked her about the incident. CNA H revealed R1 was combative and had a lot of issues. She said RN G came in and gave R1 medication. I asked her what kind and to describe it, and she said it was a pink liquid in a small syringe. CNA H was asked if she heard CNA E ask RN G if the medication was ordered. CNA H said she did not hear CNA E ask that. I then called the DON, and she said she would contact the ADM at the time. The DON told me to call the doctor, wife, get in there and check the residents, get all the narcotic sheets and get a statement from CNA E. The only resident who had [MEDICATION NAME] in the area during that time was R2. During the interview RN D staid that Thursday evening R1 was combative and that's when he receive the [MEDICATION NAME] from RN G. Friday morning RN Q day shift nurse said R1 had altered mental status, would moan and not speak. I went down and assisted with his transfer to the hospital. I called the wife and doctor. I was unaware of the [MEDICATION NAME] situation. RN D revealed she notified the doctor and he ordered to send R1 to the ER. I called the wife and told her that R1 had altered mental status. That evening when I got the call from LPN F, I called CNA H to confirm story, called the doctor, called the DON, the wife and then the hospital. I told her we were looking back on the incident from the previous day Thursday, that he had received the wrong medication [MEDICATION NAME], that was not intended for him. She asked if that would have caused what had happened. I told her according to our doctor it should not have, but I was not a doctor and could not make that decision. I called her that Friday night 9/28/18. RN D made the correction, because she had got the dates mixed up and then stated, It happened Thursday, he went out Friday, and I called everybody Saturday about the [MEDICATION NAME]. On the other team there were resident's who had [MEDICATION NAME] but RN G did not have a key or access to the narcotics on the other team only her team and R2 was the only resident who had [MEDICATION NAME]. RN D continued revealing CNA E worked Thursday 9/27/18 and did not work again until 9/30/18 second shift. I peeked in on every resident that Saturday, checked all the narcotic sheets and there were no errors. RN D referred to her signed statement dated 09/29/18, which moreover reflected the above interview. The statement also reflected R1's doctor was notified of the medication error on 09/29/18 at 17:40 PM, R1's wife was notified of the medication error at 17:45 PM, and that RN D went to the facility at 18:00 PM to check that all resident were in their normal state of health and metal status. Also, that she checked the narcotic count on both medication carts and both were accurate. R2's [MEDICATION NAME] sheet was copied, and that R2 was the only resident on the hall where R1 was residing that RN G had access to. On 10/10/18 at 12:08 PM CNA E who witnessed RN G give R1 pinkish liquid ([MEDICATION NAME]- [MEDICATION NAME]) was interviewed. CNA E revealed the incident occurred on Thursday 9/27/18, and referred to her signed statement dated 10/2/18. When asked if there was anything she would like to add CNA E replied, I think he was hospitalized because of it. CNA E's statement dated 10/2/18 at 11:00 AM read: I was helping CNA H in the room related to he was combative. I had notified RN G that the resident was being combative. He was ripping his gown off and swinging at staff. We laid him down, he was still swinging, RN G came in a gave him a pinkish liquid in a small syringe, he was spitting and swinging still at the time. I have not had much interaction with this resident since his admission. Near the doorway, I asked RN G if he had an order for [REDACTED]. I had never questioned a nurse before, but knew that this liquid medication was usually given to hospice residents. I thought RN G would have taken care of this after the fact such as, called the doctor and received an order. RN G had left the room, myself and CNA H were still in the room. I said I'm surprised she did that, that she gave that medicine, CNA H replied I hope he is not allergic to it. I left CNA H in the room, she was bagging up laundry, the resident was in bed and calm at this point. I came in Saturday night and was advised he was in the hospital. I asked LPN F, why he was sent out. She told me he was unresponsive so he went to the hospital. I just wanted to make sure someone knew that the medication was given Thursday night. RN G who was observed by staff to administer the liquid [MEDICATION NAME]/[MEDICATION NAME] was interviewed on 10/10/18 at 12:38 PM by phone. RN G was asked to recall the night of 09/27/18 when R1 was given the above medication. RN G stated, I did contact an attorney and I can give you his number. I was advised to give his number for any questions. When asked if she was an employee at the facility, RN G revealed she was but was no longer an employee at the facility, and declined to answer further questions. CNA H was interviewed on 10/10/18 at 12:55 PM and asked to recall the incident dated 09/27/18. CNA H revealed that was her first night working on that hall with R1. When the nurse gave him his medicine, I just thought that was the medicine she was supposed to give. We got him in bed and the nurse gave him his medicine. He was trying to get up and was really confused. She gave him the medication in his mouth. CNA H was asked if she overheard CNA E questioning RN G about the medication prior to giving, CNA H revealed CNA E said something but could not recall what it was about. CNA H's statement, which she signed and dated on 10/01/18 at 01:45 PM reflected that between 08:00 PM - 08:30 PM RN G came into the room and gave R1 some medicine. RN G went around the bed with the syringe and squirted the medicine in his mouth, and then left the room. The Acting Administrator (ADM A) was interviewed on 10/10/18 at 1:08 PM about the medication error incident. ADM A denied interacting with R1 on 9/27/18 or 9/28/18. ADM A revealed she called the wife after the incident to follow up, I did had not spoke to her directly after the incident. I called her, I want to say the end of last week. The wife knew of the situation, that he was given medication. She said she was aware he received medication. I think I was right up front, that the medication had not been prescribed. At first she did not recall, and then said she was aware. LPN F was interviewed by phone on 10/10/18 at 01:23 PM, and asked to recall the medication error incident. LPN F revealed that a CNA told her, that another nurse had administered another resident's [MEDICATION NAME] to him. LPN F could not recall the day, but the CNA told her a few days ago, after the resident had went to hospital. LPN F revealed the last time she worked with R1, he was up in his recliner and with help could walk to the rest room. Once she was told about the error she notified the nurse manager, RN D. On 10/10/18 at 17:49 PM the DON was informed that entries on the MAR's for R1 and R2 were not coinciding with controlled the substance/narcotic sheets. The DON revealed that her nurse manager had reviewed the narcotic sheets and found errors of signatures of medication administered with sign out times, and was working on it.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE A THOROUGH ASSESSMENT AND treatment for [REDACTED].#3) WITH BEHAVIORAL PROBLEMS OF 7 RESIDENTS THAT WERE REVIEWED FOR [MEDICAL CONDITION] MEDICATIONS, EACH FROM A TOTAL SAMPLE OF 11 RESIDENTS RESULTING IN PAIN FOR RESIDENT #6 AND THE POTENTIAL FOR UNNECESSARY MEDICATION FOR RESIDENT #3. FINDINGS INCLUDE: ACCORDING TO THE FACILITY FACE SHEET DATED 8/20/2013, RESIDENT #6 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE HISTORY AND PHYSICAL DATED 12/28/2012 RESIDENT #6 WAS REadmitted to the facility on [DATE] WITH A [DIAGNOSES REDACTED]. ACCORDING TO THE FACILITY FORM TITLED "EVENT REPORT" DATED 12/25/2012, RESIDENT #6 WAS OBSERVED ON THE FLOOR OF HER ROOM AT APPROXIMATELY 7:00 A.M. ON 12/25/2012, AND HAD COMPLAINED OF LEFT KNEE PAIN AND THAT RANGE OF MOTION WAS DONE. THE NURSES NOTES DATED 12/25/2012 DID NOT REFLECT ANY INFORMATION REGARDING RESIDENT #6'S FALL OR IMMEDIATE ASSESSMENT. RESIDENT #6'S CONTROLLED MEDICATION RECONCILIATION SHEET DATED 12/25/2012 REFLECTED THE RESIDENT #6 RECEIVED 3 DOSES OF [MEDICATION NAME] ON 12/25/2012 AND 2 DOSES ON 12/26/2012. ACCORDING TO THE FACILITY'S 72 HOUR POST FALL PAIN ASSESSMENT ON 12/25/2012 RESIDENT #6 REPORTED HER PAIN LEVEL AS A 10. FROM A SCALE OF 1 TO 10, 10 INDICATED THE HIGHEST LEVEL OF PAIN. AFTER 1 HOUR OF BEING GIVEN A NARCOTIC PAIN MEDICATION THE LEVEL CAME DOWN TO A 5. ON 12/26/2012 RESIDENT #6 REPORTED THE PAIN BETWEEN 8-10 AFTER THE NARCOTIC MEDICATION SHE REPORTED THE PAIN WAS BETWEEN 2 AND 4. LATER THAT SHIFT RESIDENT #6 REPORTED THE PAIN TO BE AT A LEVEL 10, 1 HOUR AFTER THE MEDICATION WAS GIVEN SHE REPORTED THE PAIN WAS AT A LEVEL 5. THE 12/26/2012 NURSING NOTES REFLECTED RESIDENT #6 WAS MOANING, DIFFICULT TO TRANSFER, COMPLAINED OF PAIN, SWOLLEN AND WARM TO THE TOUCH, ..."YELLS OUT, GRABBING SIDE RAILS WHEN REPOSITIONED, CALL OUT TO DR....." A PHYSICIan order for [REDACTED]. ON 12/27/2012 THE NURSES NOTES REFLECTED RESIDENT #6 CONTINUED TO COMPLAIN OF PAIN, LEFT LEG MORE [MEDICAL CONDITION] THAN THE RIGHT LEG, RADIOLOGY RESULTS WERE OBTAINED AND SHOWED A LEFT FEMUR FRACTURE. "DAY SHIFT WILL NOTIFY DR. WHEN OFFICE OPENS." RESIDENT WAS THEN SENT TO THE HOSPITAL FOR HER FRACTURED LEFT FEMUR. ON 8/21/2013 AT 10:15 A.M., THE RESTORATIVE NURSE STAFF "I" THAT WAS ASSIGNED TO FOLLOW UP ON ALL FALLS WAS INTERVIEWED AND REPORTED THAT SHE WAS UNAWARE OF WHY THERE WAS A DELAY IN TREATMENT. THE NURSE THAT WAS ON DUTY DURING THE INCIDENT OF 12/25/2012 STAFF "W" WAS ON MEDICAL LEAVE DURING THE SURVEY DATES OF 8/20 THRU 8/23/2013 AND UNAVAILABLE FOR AN INTERVIEW. REGISTERED NURSE STAFF "X" WAS INTERVIEWED ON 8/22/2013 AT APPROXIMATELY 2:00 P.M. NURSE STAFF "X" REPORTED THAT SHE HAD NOTIFIED THE PHYSICIAN AFTER COMING ON DUTY ON THE AFTERNOON OF 12-26-13 BECAUSE RESIDENT #6'S LEFT LEG WAS SWOLLEN AND RESIDENT #6 COMPLAINED OF PAIN. ACCORDING TO THE UNDATED FACILITY "FALL PREVENTION AND MANAGEMENT" POLICY UNDER THE HEADING "FOLLOWING A FALL" 1. HEAD TO TOE ASSESSMENT BY A LICENSED NURSE COMPLETED BEFORE THE RESIDENT IS MOVED. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING ON 8/23/2013 SHE REPORTED THE HEAD TO TOE ASSESSMENT IS COMPLETED ON THE EVENT REPORT. THE DIRECTOR OF NURSING REPORTED THAT IS WRITTEN IN BY EXCEPTION, SUCH AS IF THERE WAS AN INJURY. WHAT WAS DOCUMENTED AS A HEAD TO TOE ASSESSMENT FOR FOR THE FALL ON 12/25/2012 WAS "SIC ROM DONE, SIC C/O L KNEE PAIN" THEN RESIDENT #6'S VITAL SIGNS FOLLOW. ON 8/22/2013 AT 3:15 P.M. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING REPORTED SHE WAS NOT SURE OF WHY THERE WAS A DELAY IN OBTAINING AN X RAY AND HAVING SENT RESIDENT #6 TO THE HOSPITAL. ON 8/23/2013 AT APPROXIMATELY 10:30 A.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH THE RESIDENTS FAMILY MEMBER. THE FAMILY MEMBER REPORTED SHE REMEMBERED THE DAY "WE WERE THERE LATER THAT DAY, IT WAS CHRISTMAS DAY, WE ALWAYS TAKE HER TO THE DINING ROOM OUTSIDE THE CARE CENTER, SHE SEEMED UNCOMFORTABLE UNTIL THE AID TRIED TO TRANSFER HER INTO HER WHEELCHAIR, SHE COMPLAINED LOUDLY." THE FAMILY MEMBER REPORTED SHE WAS AWARE OF THE FALL THAT OCCURRED AT 7:00 A.M., BUT ASSUMED RESIDENT #6 YELLED OUT BECAUSE SHE WAS SORE FROM THE FALL. ( ) ACCORDING TO THE FACE SHEET, DATED 5/7/13, RESIDENT #3 WAS AN [AGE] year OLD MALE admitted to the facility on [DATE], AND REadmitted on [DATE] AFTER A PSYCHIATRIC ADMISSION WITH CUMULATIVE [DIAGNOSES REDACTED]. ACCORDING TO THE FACILITY'S SOCIAL SERVICE PROGRESS NOTE, DATED 5/1/13, RESIDENT #3 HAS SEVERE COGNITIVE IMPAIRMENT AND MINIMAL DEPRESSION. ACCORDING TO THE MINIMUM DATA SET (RESIDENT ASSESSMENT), DATED 5/24/12, RESIDENT #3 WAS USUALLY UNDERSTOOD AND COULD UNDERSTAND CONVERSATION, AND REQUIRED THE ASSIST OF 1 STAFF PERSON FOR REPOSITIONING IN BED, TRANSFERS, TOILETING, HYGIENE AND BATHING. A REVIEW OF THE JULY 2013 physician's orders [REDACTED]. A REVIEW OF THE FOLLOWING CARE PLANS FOR RESIDENT #3 REFLECTED THE FOLLOWING RELATED TO BEHAVIORS: -PSYCHOSOCIAL WELL BEING, START DATE OF 4/11/13, NO REVISION DATE: "CONTACT DAUGHTER DIANE ANYTIME RESIDENT HAVING BEHAVIORS " . -PARANOIA, START DATE 4/11/13, NO REVISION DATE: "VALIDATE FEELINGS WHILE REINFORCING REALITY FOCUS, PROVIDE 1:1 PRN (AS NEEDED), REDUCE POSSIBLE STRESSORS, GIVE REASSURANCE, PROVIDE SCHEDULED ACTIVITIES PROMOTING FEELINGS OF SECURITY, CONSULT PSYCH. AS ORDERED AND MONITOR PARANOIA VIA BEHAVIOR LOG. -[MEDICAL CONDITION] DRUG, START DATE 4/11/13, NO REVISION DATE: "ASSIST WITH CALLS TO SPOUSE, CALM SOOTHING MUSIC IF AGITATED DURING CARE, UNHURRIED APPROACH, ENJOYS TALKING ABOUT PAINTING" . -ACTIVITIES, DATED 3/26/12, NO REVISION DATE: "PREFERS TO BE CALLED GIL, OFFER COMPLIMENTS R/T (RELATED TO) LIFE PRIDES, JOYS AND ACCOMPLISHMENTS, SIMPLIFY TASKS, EMPHASIZE LONGER-TERM MEMORY, TRY SMALLER GROUPS, INCLUDE GENTLE AND INFORMAL ORIENTATION TO THE HEALTH CENTER, OFFER 1:1'S IN A QUIET SETTING TO DECREASE STIMULATION. ACTIVITY INTERESTS INCLUDE: CRAFTS, WOODWORKING, MUSIC, RELIGION, TRIPS, OUTDOORS, TV, GARDENING, REMINISCING AND HELPING OTHERS". ON 8/21/13 AT 9:00 AM, STAFF "N" WAS INTERVIEWED ABOUT RESIDENT #3 'S CARE PLAN INTERVENTIONS FOR AGITATION, PARANOIA AND BEHAVIORS. WHEN ASKED, STAFF "N" SAID SHE WAS RESPONSIBLE FOR DEVELOPMENT OF THE BEHAVIOR, AND COGNITION AND PSYCHOACTIVE MEDICATION CARE PLANS. WHEN ASKED WHAT WERE THE PERSONALIZED, NONPHARMACOLOGIC BEHAVIOR INTERVENTION, STAFF "N" SAID RESIDENT #3 WAS NO LONGER ON 1:1 SUPERVISION. WHEN ASKED ABOUT PARTICULAR STRESSORS, STAFF "N" SAID BACKGROUND NOISE SOMETIMES INCREASED RESIDENT #3'S AGITATION AND COMBATIVE BEHAVIORS, AND SHIFT CHANGE WAS A PARTICULAR IRRITATION TO HIM. WHEN ASKED HOW RESIDENT #3 TOLERATED LARGE GROUP ACTIVITIES/ENTERTAINMENT, STAFF "N" SAID HE WAS A PASSIVE PARTICIPANT, AND WOULD COME AND LEAVE THE EVENT. WHEN ASKED WHAT TYPE OF MUSIC RESIDENT #3 ENJOYED, STAFF "N" SAID HYMNS. ALTHOUGH HE HAS NO EQUIPMENT FOR LISTENING TO MUSIC IN HIS ROOM, THE FACILITY ' S HAS A TELEVISION STATION FOR MUSIC LISTENING. WHEN ASKED ABOUT ART SUPPLIES, STAFF "N" SAID HE HAD COLORED PENCILS AND PAPER IN HIS ROOM. WHEN ASKED ABOUT INCLUDING THIS PERSONALIZED, SPECIFIC INFORMATION ON RESIDENT #3'S CARE PLAN, STAFF "N" AGREED IT WAS A GOOD IDEA. ON 8/21/13 AT 9:40, CERTIFIED NURSE ASSISTANT STAFF "V" WAS INTERVIEWED AND ASKED ABOUT SPECIFIC THINGS RESIDENT #3 RESPONDED TO/ENJOYED. STAFF "V" SAID RESIDENT #3 LOVES TO PAINT AND DRAW, BUT HE REQUIRED SET UP WITH HIS PERSONAL SUPPLIES. RESIDENT #3 ENJOYED HAVING HIS LEGS MASSAGED, AND WAS NOT A MUSIC LISTENER. RESIDENT #3 WAS NOT A TV WATCHER, BUT HE LIKED TO DISCUSS MOVIES HE HAD SEEN. RESIDENT #3 ENJOYED LOOKING AT FAMILY PHOTOS, BUT HAD NONE IN HIS ROOM, CURRENTLY. HE WAS EASILY AGGRAVATED IF TOO MANY INSTRUCTIONS WERE GIVEN WHILE BEING ASSISTED WITH DAILY CARES, AND WANTED TO DO HIS CARES HIMSELF. QUIETLY ASSISTING HIM WITH AS FEW WORDS POSSIBLE WAS EFFECTIVE. ON 8/21/13 AT 3:15 PM, CDNAS "O" AND "U" WERE INTERVIEWED ABOUT RESIDENT #3'S PREFERENCES. THEY WERE AWARE THAT RESIDENT #3 ENJOYED TALKING ABOUT THE FAMILY FLOWER BUSINESS, HIS PAINTINGS ON THE WALLS OF HIS ROOM AND HIS FAMILY. RESIDENT #3 DID NOT LIKE TO BE TOLD WHAT TO DO, NOR DID HE TOLERATE NOISE AND COMMOTION. WHEN RESIDENT #3 WHEELED HIMSELF TO HIS ROOM, HE WANTED "ALONE" TIME. HE LIKED HOT CHOCOLATE, PEPSI AND HIS SNACKS. "IF HE'S REFUSING FOOD, THERE'S SOMETHING WRONG". RESIDENT #3 WOULD BECOME FRUSTRATED IF ASKED, " IS THIS OK, IS THAT OK"? RESIDENT #3 LIKE TO LISTEN TO JAZZ OR CONTEMPORARY MUSIC ON THE MUSIC STATION. ON 8/22/13 AT 2:20 PM, THE 2 DAUGHTERS OF RESIDENT #3 WERE INTERVIEWED. WHEN ASKED ABOUT THEIR FATHER'S ACCOMPLISHMENTS DURING HIS LIFE, THEY MENTIONED HIS PAINTING. RESIDENT #3'S WIFE BRINGS IN SCRAPBOOKS OF HIS ARTWORK AND PROJECTS THAT HE LIKES TO LOOK THROUGH. THESE ARE NOT LEFT WITH RESIDENT #3, CURRENTLY. RESIDENT #3 WAS PROUD OF THE [AGE] year OLD FAMILY, FLOWER BUSINESS HE MAINTAINED UNTIL A FEW YEARS AGO. WHEN ASKED, THE DAUGHTERS SAID HE LIKES TO BE THE HEAD OF CREATIVE PROJECTS, AND ACTUALLY DESIGNED AND DEVELOPED AN ATRIUM WITH A FOUNTAIN AT A LOCAL COLLEGE. RESIDENT #3 HAD BEEN PRESIDENT OF SEVERAL GROUPS HE WAS IN. THE DAUGHTERS SAID HE LIKES TO DO THINGS FOR HIMSELF, AND WHEN THIS SURVEYOR MENTIONED THAT A STAFF PERSON RELATED THIS, BOTH DAUGHTERS SMILED AND SAID, "THEY FINALLY GOT IT". THE DAUGHTERS SAID THEIR DAD DIDN'T LIKE LOTS OF INFORMATION ABOUT WHAT STAFF WAS GOING TO DO FOR HIM, IT AGITATED HIM. THE DAUGHTERS MENTIONED HE DISLIKED COMMOTION AND LOVED HIS SNACKS. THE DAUGHTERS ALSO SAID RESIDENT #3 WAS INVOLVED IN AN ARTISTIC, 4-PART PROJECT WITH 4TH GRADERS AT THE FACILITY. THEY WERE PLEASED TO HEAR THAT RESIDENT #3 WAS OBSERVED DRAWING IN HIS ROOM. ALTHOUGH MUSIC AND TALKING ABOUT LIFE PRIDES, JOYS AND ACCOMPLISHMENTS ARE MENTIONED ON RESIDENT #3'S CARE PLAN, SPECIFICS SUCH AS TYPE OF MUSIC, BUSINESS OR ART WAS NOTED. THERE WAS NO MENTION OF RESIDENT #3'S BEHAVIORAL CUES, SUCH AS HIM GOING TO HIS ROOM WHEN HE NEEDS "ALONE TIME". THERE WAS NO INDICATION THAT THE BEHAVIOR TEAM MET AND REVISED NEW NONPHARMACOLOGIC INTERVENTIONS FOR BEHAVIORS PRIOR TO THE INCREASE OF [MEDICATION NAME] ON 6/12/13. ACCORDING TO FACILITY "CLINICAL NOTES REPORT", ON 6/6/13, RESIDENT #3 ATTEMPTED TO PUSH A WHEEL CHAIR HE THOUGHT HIS WIFE WAS IN. LATER THAT EVENING, HE ENTERED ANOTHER RESIDENT'S ROOM AND ATTEMPTED TO KICK THE NURSE STAFF WHO TRIED TO REDIRECT HIM. RESIDENT #3 WAS, AGAIN, COMBATIVE WITH CARES ON 6/7/13 AT 3:00 AM. RESIDENT #3 WAS, AGAIN, COMBATIVE WITH STAFF ON 6/7/13 AFTER AWAKENING FROM A NAP. NO MORE BEHAVIORS ARE DOCUMENTED. ACCORDING TO A PSYCHIATRY PROGRESS NOTE DATED 6/12/13, A SECOND DOSE OF [MEDICATION NAME] 0.25 MG WAS ADDED AT NOON, BESIDES THE DOSE OF [MEDICATION NAME] 1 MG AFTER DINNER, DESPITE NO BEHAVIORS BEING DOCUMENTED FOR RESIDENT #3 SINCE 6/7/13 AFTERNOON. ON 8/21/13 AT 3:20 PM, AN ATTEMPT WAS MADE TO CONTACT THE PSYCHIATRIC PHYSICIAN'S ASSISTANT "A" REGARDING INFORMATION ABOUT INITIATING NONPHARMACOLOGIC INTERVENTIONS BEFORE INCREASING THE DOSE OF AN ANTIPSYCHOTIC. ON 8/22/13, THE SURVEY TEAM WAS ADVISED PHYSICIAN ASSISTANT "A" WAS ON VACATION, EFFECTIVE IMMEDIATELY, AND PSYCHIATRIST "B" WOULD NOT SPEAK WITH US BY PHONE. ( )

THIS CITATION PERTAINS TO INTAKE # MI 138 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE TRANSFER TECHNIQUES AND ADEQUATE SAFETY MEASURES TO PREVENT A FALL WITH INJURY FOR ONE (#502) AND MULTIPLE FALLS FOR ONE (#504) OF 4 SAMPLED RESIDENTS AT RISK FOR FALLS FROM A TOTAL SAMPLE OF FOUR RESIDENTS, RESULTING IN HIP FRACTURE FOR (502) AND THE POTENTIAL FOR SERIOUS INJURY FOR (504). FINDINGS INCLUDE: RESIDENT #502 ACCORDING TO THE FACE SHEET FOR THE CLOSED RECORD REVIEW FOR RESIDENT #502, REVEALED THE RESIDENT WAS ORIGINALLY admitted INto the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE], REVEALED RESIDENT #502 WAS COGNITIVELY INTACT FOR DECISION MAKING SKILLS AND REQUIRED EXTENSIVE ASSISTANCE WITH TWO PERSON PHYSICAL ASSISTANCE FOR TRANSFER. THE MDS CODED RESIDENT #502, AS "NOT STEADY" AND ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE, FOR MOVING FROM SEATED TO STANDING POSITION, MOVING ON AND OFF TOILET. ADDITIONALLY, THE MDS CODED RESIDENT #502, AS "UNABLE TO DETERMINE FOR FALLS", ANY TIME IN THE LAST 2-6 MONTHS PRIOR TO ADMISSION/ENTRY OR REENTRY INTO THE FACILITY. REVIEW OF NURSING NOTES DATED 12/14/12 AT 6:11 P.M., DOCUMENTED: "ON 12/14/12 CNA (CERTIFIED NURSE ASSISTANT) WAS TRANSFERRING RESIDENT (#502) FROM THE TOILET TO HER WHEELCHAIR HER LEGS GAVE WAY AND THE CNA AMBULATED HER (#502) TO THE FLOOR AND CALLED ME (LPN #10) TO THE ROOM FOR HELP. I (LPN#10) DID A HEAD TO TOE ASSESSMENT AND GOT HER VITALS AND DECIDED WE (LPN #10 AND CNA #8) COULD GET HER UP IN HER CHAIR THEN INTO BED. I (LPN #10) MADE SURE SHE WAS STABLE THEN WENT TO CALL THE DOCTOR, THEN I (LPN #10), CALLED FOR A STAT X-RAY OF THE LEFT HIP AND FEMUR. THE DOCTORS ORDERS ARE TO TRANSPORT THE RESIDENT TO THE ER IF THE XRAY IS POSITIVE FOR FRACTURE. THE FAMILY HAS BEEN NOTIFIED. WILL CONTINUE TO MONITOR." REVIEW OF THE UNUSUAL OCCURRENCE/FALL INVESTIGATION (I/A) FORM FOR RESIDENT #502, DATED 12/14/12, DOCUMENTED "RESIDENT LOWERED TO FLOOR DURING ASSISTED TRANSFER FROM TOILET TO WHEELCHAIR WITH CNA..." THERE WAS NO DOCUMENTED EVIDENCE THAT INDICATED RESIDENT #502 WAS INTERVIEWED REGARDING THE INCIDENT. THE I/A FORM ONLY DOCUMENTED THAT RESIDENT #502 COMPLAINED OF HIP PAIN. REVIEW OF RADIOLOGY REPORT (DATE OF SERVICE 12/14/12), DOCUMENTED: REASON: RULE OUT FRACTURE. EXAMINATION: LEFT HIP TWO VIEWS. CONCLUSION: 1. ACUTE NONDISPLACED INTERTROCHANTERIC FEMORAL. REVIEW OF RESIDENT #502'S "AT RISK FOR INJURY RELATED TO FALLS" CARE PLAN, DATED 10/17/12 DOCUMENTED: PROBLEMS-PSYCHOTROPICS, ANTIHYPERTENSIVES, NARCOTICS, COGNITIVE IMPAIRMENT, VISION, FREQUENTLY INCONTINENT OF BOWEL/BLADDER. GOALS-WILL REMAIN FREE FROM SERIOUS INJURY. APPROACHES-"...TWO PERSON PHYSICAL ASSIST WITH TRANSFERS, NON-AMBULATORY..." REVIEW OF RESIDENT #502'S UNDATED, "RESIDENT CARE GUIDE" (INSTRUCTIONS USED TO DIRECT CNA'S CARE RENDERED FOR RESIDENTS), DOCUMENTED: TRANSFERS "GAIT BELT. TWO PIVOT ASSIST. AMBULATION: UNABLE TO WALK. MISCELLANEOUS: NO WEIGHT BEARING (NWB) RIGHT SIDE AND RIGHT LOWER EXTREMITY. PARTIAL WEIGHT BEARING ON LEFT LEG. ON 3/20/13 AT 10:10 A.M., DURING A TELEPHONE INTERVIEW WHEN QUERIED, CNA #8 STATED "I WAS WITH RESIDENT #502 IN HER BATHROOM. I HAD HER (#502) STANDING IN FRONT OF THE GRAB BAR. SHE (#502) WAS WEARING A LEG BRACE. SHE TURNED KIND OF FUNNY. I AMBULATED HER TO THE FLOOR." WHEN QUERIED, CNA #8 EXPLAINED HE WAS ALONE WITH THE RESIDENT. THERE WAS NO OTHER STAFF PRESENT DURING THE TRANSFER; NOR DID HE USE A GAIT BELT TO TRANSFER THE RESIDENT. WHEN FURTHER QUERIED CNA #8 EXPLAINED HE WAS NOT AWARE NOR COULD RECALL IF RESIDENT #502 HAD ANY WEIGHT BEARING RESTRICTIONS. ON 3/20/13 AT 12:05 P.M., DURING AN INTERVIEW WITH OT (OCCUPATIONAL THERAPY REHAB DIRECTOR #9, WHEN QUERIED REGARDING RESIDENT #502'S FUNCTIONAL STATUS STATED, "THE RESIDENT WAS discharged FROM REHAB (REHABILITATION) THERAPY ON 10/31/12. HER INSURANCE WOULD NOT AUTHORIZE ADDITIONAL SERVICES. THE RESIDENT, HER DAUGHTER AND HER CAREGIVER (FACILITY'S CNA) WERE PROVIDED A HOME EXERCISE PROGRAM AT THAT TIME, AND THE RESIDENT AND DAUGHTER REPORTED GOOD UNDERSTANDING." OT #9 FURTHER EXPLAINED RESIDENT #502, REMAINED A TWO PERSON TRANSFER WITH GAIT BELT AND NON-WEIGHT BEARING ON THE RIGHT LEG UPON DISCHARGE FROM REHAB; THE RESIDENT (#502) WAS NOT TRANSFERRED TO RESTORATIVE SERVICES. HOWEVER, THE CNA'S WERE INSTRUCTED VERBALLY AND BY DEMONSTRATION FOR TRANSFER SAFETY. OT #9 FURTHER EXPLAINED GAIT BELTS SHOULD BE USED FOR ALL RESIDENT TRANSFERS. ON 3/20/13 AT 3:05 P.M., DURING AN INTERVIEW WITH LPN #10, WHEN ASKED TO EXPLAIN WHAT HE OBSERVED DURING THE INCIDENT WITH RESIDENT #502, THAT OCCURRED ON 12/14/12 STATED, "I RECEIVED A CALL OVER THE RADIO (FACILITY'S WALKIE TALKIE). THE RESIDENT WAS SITTING ON THE FLOOR IN HER RESTROOM BY THE TOILET. CNA #8 WAS THERE. I ASKED THE RESIDENT WHAT HAPPENED. SHE (RESIDENT #502) SAID 'I THINK MY LEG GAVE OUT'." WHEN FURTHER QUERIED LPN #10 STATED "ONLY CNA #8 WAS WITH THE RESIDENT. I DON'T RECALL IF THE CNA (#8) USED A GAIT BELT." ON 3/20/13 AT 1:35 P.M., DURING AN INTERVIEW WITH RESTORATIVE LPN #6, WHEN QUERIED STATED, "RESIDENT #502 SHOULD HAVE BEEN ASSISTED BY TWO PERSON ASSIST FOR ALL TRANSFERS." ON 3/20/13 AT 3:15 P.M., DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON #5) WHEN QUERIED REGARDING RESIDENT #502'S INCIDENT THAT OCCURRED ON 12/14/12 THAT RESULTED IN THE FRACTURED FEMUR STATED, "THE CNA (#8) DID NOT FOLLOW OUR POLICY AND RESIDENT CARE GUIDES." NO FURTHER EXPLANATION WAS PROVIDED. REVIEW OF THE FACILITY'S UNDATED "TRANSFERS" POLICY, DOCUMENTED: GAITBELTS: "GAIT BELTS ARE TO BE USED DURING TRANSFERS AND AMBULATION OF RESIDENTS FOR SAFETY MEASURES." TRANSFERS: "PRIOR TO TRANSFERRING A RESIDENT, THE CARE GUIDE MUST BE CHECKED AND FOLLOWED..." REVIEW OF THE FACILITY'S UNDATED, "FALL PREVENTION AND MANAGEMENT" POLICY, DOCUMENTED: #8. "CNA'S WILL BE MADE AWARE OF RESIDENTS AT HIGH RISK FOR FALLS VIA CARE GUIDE INFORMATION SHEETS." ( ) RESIDENT #504 A CLINICAL RECORD REVIEW ON 03/20/2013 AT 10:30 A.M. REVEALED THAT RESIDENT #504 WAS AN [AGE] year OLD FEMALE readmitted INto the facility on [DATE]. HER [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] REVEALED A BIMS SCORE OF 8 WHICH SUGGESTED THAT RESIDENT #504 HAD MODERATELY IMPAIRED COGNITION. THE RESIDENT WAS TOTALLY DEPENDENT ON STAFF FOR BED MOBILITY AND TRANSFERS AND REQUIRED ASSISTANCE FROM ONE PERSON. ACCORDING TO THE HOSPITAL DISCHARGE SUMMARY DATED 12/05/2012 (PRIOR TO ADMISSION INTO THE FACILITY) "...THE PATIENT...fell AND HIT HER BACK...CT SHOWED ...COMPRESSION FRACTURE..." THE INITIAL FALL RISK ASSESSMENT REVEALED A SCORE OF 20. (A SCORE OF 10 OR MORE REPRESENTED HIGH RISK FOR FALLS) ACCORDING TO THE CARE PLAN ENTITLED "AT RISK FOR INJURY RELATED TO FALLS" IMPLEMENTED ON 11/30/2012 THE FOLLOWING APPROACHES WERE IN PLACE: 1. OT/PT AS ORDERED BY MD. 2. KEEP CALL LIGHT IN REACH IN ROOM AT ALL TIMES 3. 3. TOILET RESIDENT PER SCHEDULE INDICATED ON CENA CARE PLAN. 4. INSTITUTE WHEELCHAIR ALARM-TAB 5. INSTITUTE BED ALARM-PRESSURE 6. FREQUESNT STAFF FIRST 72 HOURS. 7. ONE PERSON PHYSICAL ASSIST WITH TRANSFERS 8. WHEELCHAIR FOR MAIN MODE OF MOBILITY 9. AMBULATE WITH WALKER WITH STAFF ASSIST 10. 12/24/12 NON SKID FOOTWEAR AT ALL TIMES 11. 12/31/12 THERAPY SCREEN 12. FALLING STAR PROGRAM ACCORDING TO "FALL REPORTS AND UNUSUAL OCCURRENCE" FORMS PROVIDED BY THE FACILITY, RESIDENT #504 HAD SEVERAL FALLS WHILE AT THE FACILITY. FALL REPORTS WERE REVIEWED WITH THE RESTORATIVE NURSE,LPN #6 . THE FOLLOWING FALLS WERE REVIEWED: 1.ON 06/18/2012 AT 2055 P.M."RESIDENT UP TO THE SINK TO WASH UP FOR BED, TURNED AND LOST BALANCE AND fell on RIGHT SIDE ...ABRASION TO RIGHT UPPER BACK.." INTERVENTION PROVIDED WAS "..PRESSURE ALARM INITIATED TO CHAIR." 2. ON 12/21/2012 RESIDENT 504 WAS "OBSERVED RESIDENT ON THE FLOOR ON THE RIGHT SIDE WITH BODY ALARM IN HAND, WHEELCHAIR BEHIND HER." THE INTERVENTION PROVIDED WAS TO REMIND RESIDENT TO CALL FOR ASSISTANCE AND NON SKID FOOTWEAR INITIATED. 3. ON 12/23/2012 "RESIDENT WAS DISCOVERED ON THE FLOOR OF HER BATHROOM AFTER HER ROOMMATE CAME TO ME AND SAID SHE WAS ON THE FLOOR." ACCORDING TO LPN#6 RESIDENT #504 REPORTEDLY TOOK OFF HER PERSONAL ALARM. THE INTERVENTION WAS TO INITIATE SAFETY ALARM. IT WAS UNCLEAR WHY THE INITIATION OF A SAFETY ALARM WAS LISTED AS A NEW INTERVENTION WHEN LPN#6 AND THE CARE PLAN INDICATED THAT RESIDENT #504 HAD ALARMS IN PLACE AS OF 11/30/12. AN INTERVIEW WAS CONDUCTED WITH LPN # 10 WHO EXPLAINED THAT HE WAS THE LPN ASSIGNED TO RESIDENT #504 ON 12/23/2012. LPN#10 SAID THAT RESIDENT #504 WAS UNABLE TO MAINTAIN HER BALANCE. LPN#10 REPORTED THAT UPDATED THE FALL RISK ASSESSMENT WHICH INDICATED THAT HER (#504 ' S) FALL RISK WAS 8 ON 12/23/2012. LPN#10 WAS UNABLE TO EXPLAIN WHY RESIDENT #504 ' S FALL RISK WAS NOT A HIGH RISK AS OF 12/23/12. 4. ON 12/31/2012 "CNA STATED RESIDENT STOOD AND THEN SAT AND SLID OUT OF HER CHAIR. THE INTERVENTION LISTED WAS TO INITIATE TAB AND SENSOR PAD AS WELL HAD A THERAPY SCREEN. LPN #6 COULD NOT EXPLAIN WHY THE INITIATION OF A TAB AND SENSOR ALARM WAS USED AGAIN AS A NEW INTERVENTION. LPN#10 WAS QUERIED ABOUT THE INITIATION OF ALARMS AS INTERVENTION AND HE STATED THEY'RE JUST TRYING TO GET SOMETHING DOWN." THE FALL RISK ASSESSMENT WAS AGAIN UPDATED AND THE SCORE WAS 16, WHICH INDICATED A HIGH RISK FOR FALLS. ALTHOUGHT LPN#10 COMPLETED BOTH FALL RISK ASSESSMENT, HE WAS UNABLE TO EXPLAIN THE DIFFERRENCE IN THE ASSESSMENT SCORES IN ONE WEEK. 5. ON 01/08/2013 "RESIDENT SAID SHE WAS GOING TO WASH HER HANDS AND LOST HER BALANCE. "ACCORDING TO THE IDT TEAM POST FALL ASSESSMENT THE RESIDENT WAS LEFT IN THE BATHROOM UNATTENDED BY A CNA. LPN#6 REPORTED THAT A CNA TOILETED RESIDENT #504 AND LEFT THE RESIDENT IN THE BATHROOM TO WASH HER HANDS. LPN#6 SAID THAT THE CNA WHO LEFT RESIDENT #504 UNATTENDED RECEIVED EDUCATION. HOWEVER, REVIEW OF THE EVENT REPORT DATED 01/08/2013 "RESIDENT SELF PROPELLED IN WHEELCHAIR TO BATHROOM-NO CALL LIGHT ACTIVATED. RESIDENT ATTEMPTED TO TOILET SELF WITHOUT ASSISTANCE. ACCORDING TO THE INVESTIGATION REPORTS DATED 01/08/2013 AND 01/10/2013, THE CNA ASSIGNED TO CARE FOR RESIDENT #504 ON THE DAY OF THE INCIDENT DAY DOCUMENTED "OBSERVED RESIDENT ON THE BATHROOM FLOOR. SAYS SHE WAS TRYING TO GET UP FROM THE BATHROOM; HOWEVER, I HAD JUST CAME FROM THE ROOM NO MORE THAN 5 MINUTES AND ALARM WAS INTACT AND HOOKED ON HER." "SHE (RESIDENT #504) WAS LEFT UNATTENDED BUT WHEN I CAME INTO HER ROOM SHE (#504) WAS ALREADY IN HER WHEELCHAIR WITH HER ALARM CONNECTED, WASHING HER HANDS. I'M NOT SURE IF ANOTHER CNA PUT HER IN HER WHEELCHAIR OR NOT..." THIS INCIDENT WAS UNCLEAR BECAUSE OF THE CONFLICTING ACCOUNTS OF THE DETAILS SURROUNDING THE INCIDENT. THE CAN ASSIGNED TO CARE FOR RESIDENT #504 WAS UNABLE TO BE REACHED BY TELEPHONE. 6. ON 02/20/2013 "RESIDENT OBSERVED SITTING ON FLOOR IN BATHROOM IN FRONT OF WHEELCHAIR WITH HEAD AND RIGHT ARM LEANING ON WASTE BASKET. WHEN ASKED WHAT SHE WAS TRYING TO DO, SHE REPLIED "I DON'T REMEMBER."THE UNUSUAL OCCURRENCE FORM REVEALED "RESIDENT IN BATHROOM WITHOUT SAFETY ALARM PROPERLY ATTACHED TO RESIDENT." THE INTERVENTION DOCUMENTED WAS "INITIATE SAFETY ALARM IF REPEAT FALL: KEEP ON RESIDENT EVEN ON TOILET." LPN#6 EXPLAINED THAT THE RESIDENT'S CHAIR ALARM WAS ON THE CHAIR AND NOT ATTACHED TO THE RESIDENT WHILE SHE WAS ON THE TOILET. THERE WAS NO UPDATED FALL RISK ASSESSMENT COMPLETED FOR THIS INCIDENT. 7. ON 03/18/2013 AT 11:45 A.M. "LYING ON FLOOR ON BACK NEXT TO WHEELCHAIR...NO INJURY NOTED...DENIES PAIN...HEAD TO TOE COMPLETED. THE INTERVENTION DOCUMENTED WAS "RESIDENT EDUCATED OF CALL LIGHT..." THE RESIDENTS FALL RISK CARE PLAN WAS NOT UPDATED SINCE THE FALL THAT OCCURRED ON 12/31/2012, AND ACCORDING TO THE RESIDENT CARE GUIDE "RESIDENT TO AMBULATE TO BATHROOM, DINING ROOM, ETC. WITH STAFF...HIGH FALL RISK MONITOR FREQUENTLY!" IT WAS UNCLEAR WHY THE LISTED INTERVENTIONS DID NOT OCCUR.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF UNSTAGEABLE PRESSURE ULCERS ON BOTH HEELS FOR 1 (#1) OF 3 RESIDENTS REVIEWED FOR PRESSURE ULCERS OUT OF A TOTAL SAMPLE OF 15 RESIDENTS RESULTING IN THE DEVELOPMENT OF AVOIDABLE WOUNDS, PAIN, AND DECREASED MOBILITY AND LIMITATION TO THE USE OF THE WHEELCHAIR. FINDINGS INCLUDE: RESIDENT #1 WAS AN ALERT AND ORIENTED [AGE] year OLD MALE ORIGINALLY admitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. RESIDENT #1'S MEDICAL RECORD WAS REVIEWED AND REFLECTED THE FOLLOWING: THE ADMISSION MINIMUM DATA SET (MDS) assessment dated AS COMPLETED ON 8/3/2011 REFLECTED RESIDENT #1 DID NOT PRESENT WITH PRESSURE ULCERS UPON ADMISSION. THE FUNCTIONAL STATUS FOR BED MOBILITY WAS DOCUMENTED AS EXTENSIVE ASSISTANCE WITH ONE PERSON PHYSICAL ASSIST, LOCOMOTION ON AND OFF THE UNIT WITH LIMITED ASSISTANCE WITH A ONE PERSON ASSIST UTILIZING A WALKER AND WHEELCHAIR FOR MOBILITY. THE FACILITY'S DOCUMENT TITLED "DAILY SKILLED NURSE'S NOTE" DATED 8/8/11 AND TIMED 0130 (1:30 A.M.) REFLECTED UNDER THE SECTION TITLED, "COMMENTS/CONCERNS: NIGHT SHIFT, RESIDENT #1 COMPLAINED OF HEEL DISCOMFORT AND WAS GIVEN HEEL PROTECTORS". THE FACILITY'S DOCUMENT TITLED "BODY CHECK", DATED 8/9/11, REFLECTED A REDDENED AREA ON THE OUTER SIDE OF RESIDENT'S RIGHT HEEL. A physician's orders [REDACTED]. (PRESSURE ULCER)". THIS NOTATION BY THE PHYSICIAN IDENTIFIED THE DEVELOPMENT OF PRESSURE ULCERS. THE FACILITY'S DOCUMENT TITLED, "BODY CHECK" AND DATED 8/16/11 REFLECTED A REDDENED AREA WITH A CIRCLE AROUND THE RIGHT HEEL ON THE BODY CHART. THE FACILITY'S DOCUMENT TITLED, "NURSE'S NOTES" DATED 8/16/11 STATED, "RESIDENT WITH UNSTAGEABLE ULCERS TO BILATERAL HEEL. LEFT HEEL MEASURES 2.2 X 1.0 X 0.0 CM (CENTIMETERS). RIGHT HEEL MEASURES 2.5 X 2.0 X 0.0 HARD ESCHAR LIKE TISSUE DARK RED/PURPLE SKIN INTACT..." ON 6/20/12 AT 9:55 A.M. AN OBSERVATION WAS MADE OF A DRESSING CHANGE ON RESIDENT #1. THE PROCEDURE WAS CONDUCTED IN THE RESIDENT'S ROOM BY RESIDENT CARE COORDINATORS, STAFF "J" AND STAFF "G" , WITH RESIDENT #1 COMPLAINING OF PAIN WHEN THE WOUNDS ON BOTH HEELS WERE TOUCHED. STAFF "J" MEASURED THE WOUNDS. THE RIGHT HEEL WOUND MEASURED 3.4 X 2.8 CM (CENTIMETERS) AND THE LEFT HEEL MEASURED 3.4 X 3.4 CM. ON 6/21/12 AT 10:00 A.M. AN INTERVIEW WITH RESIDENT CARE COORDINATOR, STAFF "J", WHO ALSO WAS DESIGNATED AS THE FACILITY'S WOUND CARE NURSE, WAS CONDUCTED IN THE RESIDENT CARE COORDINATOR'S OFFICE. STAFF "J" INDICATED HE WAS UNAWARE OF HOW THE PRESSURE ULCERS DEVELOPED AND WAS ONLY NOTIFIED ABOUT RESIDENT #1'S PRESSURE ULCERS ON 6/16/12. A QUARTERLY MDS WITH A COMPLETION DATE OF 2/7/2012 REFLECTED A DECREASE IN FUNCTIONAL STATUS WITH LOCOMOTION ON AND OFF THE UNIT WITH EXTENSIVE ASSISTANCE WITH ONE PERSON ASSIST AND ONLY UTILIZING A WHEELCHAIR FOR MOBILITY. THIS WAS IN CONTRAST TO THE ADMISSION ASSESSMENT ON 8/3/2011 WHEREIN RESIDENT #1 HAD LIMITED MOBILITY TO USE BOTH A WALKER AND WHEELCHAIR. RESIDENT #1 ACQUIRED PREVENTABLE PRESSURE ULCERS ON BOTH HEELS IN THE FACILITY. THERE IS ACCOMPANYING PAIN AND DISCOMFORT AS EVIDENCED DURING THE DRESSING CHANGE. IN ADDITION, RESIDENT #1'S MOBILITY DECLINED WITH THE DEVELOPMENT OF THE BILATERAL PRESSURE ULCERS. RESIDENT ALTERNATED BETWEEN USING A WALKER AND WHEELCHAIR TO BEING LIMITED TO A WHEELCHAIR. ( )