Every finding on record at Vista View Post Acute

Based on interview and record review, the facility failed to honor resident rights for 1 of 4 sampled residents (Resident 1) when vaccinations were administered to Resident 1 without his consent.This failure had the potential for Resident 1 to experience unwanted side effects from the vaccinations, and emotional distress from not having his rights/preferences honored.Findings:According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (weakness of one side of the body) following cerebral infarction (a stroke) affecting right dominant side. The admission Record indicated Resident 1 was his own responsible party.During an interview with Resident 1 on 2/5/26 at 9:26 A.M., Resident 1 stated after he was admitted to the facility, he was given the Covid-19 and influenza vaccines via intramuscular injections (a shot which is given directly into the muscle). Resident 1 stated prior to his admission to the facility, he had never received the Covid-19 vaccination or the influenza vaccine, per his personal preference. Resident 1 stated, [The facility] told me I had to have [the vaccines]. I didn't know I could refuse.During a concurrent interview and record review with the Infection Preventionist (IP) on 2/5/26 at 11:32 A.M., the IP stated the Covid-19 and influenza vaccines were administered to Resident 1 on 1/8/26. The IP acknowledged Resident 1 did not sign any consent forms prior to receiving the Covid-19 and influenza vaccinations. The IP stated according to CAIR (California Immunization Registry- an online database which lists historical immunization information for California residents), Resident 1 had never received the Covid-19 or influenza vaccines. The IP stated consents needed to be obtained from residents, or from their representatives, prior to the administration of any vaccines.During an interview with the Director of Nursing (DON), the DON stated it was her expectation that consents were obtained from residents prior to administering any vaccines. The DON stated, [Residents] have the right to refuse if they don't want the vaccines.During a review of the facility's policy titled Informed Consent, revised 3/2024, the policy indicated, It is the responsibility of the healthcare professional who proposes any medical intervention or treatment that requires informed consent to provide information to the resident/resident representative regarding the resident's condition and circumstances that are pertinent to a decision to accept or refuse the proposed intervention or treatment.During a review of the facility's policy titled Resident Rights, dated 12/2022, the policy indicated, The resident has the right to be informed of, and participate in his or her treatment, including.The right to request, refuse, and/or discontinue treatment.

Based on observation, interview, and record review the facility failed to safeguard the resident personal property for one of the two sampled residents (1). As a result, the resident credit card was missing, and a report of unauthorized purchases were charged from Resident 1's credit card.This failure had cause emotional and psychological stress to Resident 1 and may affect the client's trust relationship with the staff.On 7/16/25 at 10 A.M., an unannounced visit at the facility was conducted to investigate a complaint related to a suspicious activity charges on Resident 1's credit card. Resident 1 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (a condition in which bacteria invade and grow in the urinary tract), per the facility's admission Record.On 7/16/25, a review of the minimum data set (MDS- an assessment tool), dated 4/25/25, indicated Resident 1's brief interview for mental status (BIMS - test the resident's cognition status) was 15 (13- 15 meant intact cognition).A review of the Interdisciplinary Team Care Conference (IDT -a group of healthcare professionals from various disciplines who collaborate to provide comprehensive patient care), dated 7/11/25, indicated, .IDT met to discuss an incident involving alleged financial abuse. A report was received from the resident assigned resource counselor regarding an unusual charge on Resident 1's credit card. The resident had given her credit card to a few of the CNA's (certified nursing assistant) to get snacks from the vending machine.On 7/16/25 at 10:50 A.M., an observation and an interview with Resident 1 was conducted in her room. Resident 1 was lying in her bed with the head of the bed elevated. Resident 1 stated she would give her credit card to a CNA to buy soda or snacks from the vending machine. Resident 1 stated she could not remember if her credit card was missing but a staff member found her credit card in the nightstand drawer. Resident 1 stated she could not remember the name or identify the staff member.On 7/16/25 at 11:05 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 1 would ask CNA 1 to get her soda or snacks from the vending machine, and Resident 1 would give her credit card to CNA 1. CNA 1 stated after buying snacks, she would return the credit card to Resident 1.On 7/16/25 at 11:26 A.M., an interview was conducted with the Social Service Director (SSD). The SSD stated on 6/23/25, Resident 1 came to her office and reported that her credit card was missing. The SSD and another staff member searched Resident 1's room and found her credit card in the nightstand drawer. The SSD stated, on 7/9/25, Resident 1 and the resident's resource counselor spoke to the SSD to discuss and review the list of unusual transactions received from the credit card company. The unusual transactions charged to Resident 1's card indicated:- 5/31/25 - The Grateful Head Glass - $50.00- 5/31/25 - The Grateful Head Glass - $102.83- 6/1/25 - The Grateful Head Glass - $102.84- 6/6/25 - [NAME] (Gas Station) - $6.30-6/6/25 - The Grateful Head Glass - $97.43-6//6/25 - The Grateful Head Glass - $ 97.43- 6/18/25 - The Grateful Head Glass - $97.43- 6/21/25 - Starbucks - $ 14.40On 7/16/25 at 11:48 A.M., a telephone interview was conducted with CNA 2. CNA 2 stated she was assigned to Resident 1 and familiar with Resident 1's care. CNA 2 stated Resident 1 would give her credit card to CNA 2 to get snacks from the vending machine then return back the credit card to Resident 1 after buying the snacks. CNA 2 stated in the month of June 2025, she forgot to return back the credit card to Resident 1. CNA 2 stated she was off for two days and had Resident 1's credit card with her. CNA 2 further stated she did not inform the facility and Resident 1 that the credit card was in her possession. CNA 2 stated she might have accidentally used Resident 1's credit card for purchase.On 7/16/25 at 12:18 P.M., an interview and joint review of the CNA 2's employee file review was conducted with the Director of Staff Development (DSD). The DSD stated on orientation; staff received training on theft and loss. The DSD could not find the signed acknowledgement form from CNA 2.On 7/16/25 at 12:45 P.M., an interview was conducted with the Administrator (ADM). The ADM stated the investigation started on 7/9/25 when Resident 1 and Resident 1's resource counselor reported an unusual charges in Resident 1's credit card. The ADM stated staff should not have taken residents' credit cards. Staff should accompany residents if they needed snacks in the vending machine. The ADM stated the facility reimbursed Resident 1's credit card charges. The ADM stated both CNA 1 and CNA 2 were interviewed separately during their investigation process. The ADM stated both CNA1 and CNA 2 acknowledged they accepted Resident 1's credit card to buy snacks from the facility's vending machine and would return the credit card back to Resident 1. The ADM stated he was not aware of staff accepting credit cards from the residents to buy snacks from the facility's vending machine. In addition, the ADM stated during an interview with CNA 1, CNA 1 denied knowing the place called Grateful Head Glass. CNA 1 stated she only used Resident 1's credit card to buy snacks from the facility's vending machine. The ADM stated during interview with CNA 2, CNA 2 acknowledged that she knew the Grateful Head Glass place and would purchase items from the Grateful Head Glass place.On 7/29/25 at 3:08 P.M., a telephone interview with Resident 1's resource counselor was conducted. The resource counselor (RC) stated she was assisting Resident 1 with her finances and noticed the unusual charges in Resident 1 credit card. The RC stated Resident 1 and the RC, contacted the credit card company and obtained an itemized list of unauthorized transactions. The list of charges in Resident 1's credit card was reviewed. The RC stated Resident 1 did not leave the facility since admission. The RC also stated Resident 1 used her card for snacks at the facility's vending machine. The RC stated she discussed and reviewed the itemized list of unusual charges in Resident 1's credit card with the facility social worker.On 7/31/25 at 8:50 A.M., an interview and record review were conducted with the SSD. The SSD stated the copy of the itemized transaction in Resident 1's credit card was provided by Resident 1 and Resident 1's resource counselor. The SSD stated Resident 1 used her credit card for the vending machine. The SSD further stated Resident 1 had not left the facility since admission.On 7/31/25 at 9:10 A.M., an interview and review of the itemized list of transactions in her credit card was conducted with Resident 1. Resident 1 stated she did not know the Grateful Head Glass, the [NAME], Starbucks charges in her card. Resident 1 stated she used her card for the vending machine for snacks. Resident 1 was upset about the unusual charges in her credit card. She stated she got a new credit card, and kept in the social worker's office.A review of the facility's policy and procedure titled, Theft and Loss of Resident Personal Property, dated 7/16/13, indicated . facility shall make reasonable efforts to protect the personal property of residents in a manner that will comply with regulatory requirements .

Based on interview and record review, the facility failed to ensure respect and dignity was provided to one of three sampled residents (Resident 2) when a certified nursing assistant (CNA) opened resident's drawer without permission and said inappropriate words towards Resident 2. This failure had the potential to make residents feel disrespected and may have resulted in diminished quality of life and lower self-esteem. Findings: Resident 2 was admitted on [DATE], with diagnoses which included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and bipolar disorder (a mental health condition that causes extreme mood swings), per the facility's admission Record. A review of Resident 2's minimum data set (MDS- an assessment tool), dated 4/16/25, indicated, her brief interview for mental status (BIMS - test the resident's cognition status) was 15 (13- 15 meant intact cognition). On 5/28/25 at 12:31 P.M., an interview was conducted with the Director of Social Services (DSS). The DSS stated a text message was received from Licensed Nurse (LN) 4 regarding the incident with Resident 2. The DSS stated on 5/19/25, an interview with Resident 2 was conducted. Resident 2 told DSS that CNA 2 went to Resident 2's room looking for diapers, opened her (resident) drawer without asking permission. Resident 2 stated while she was reporting the incident to LN 4 in the nursing station, CNA 2 told Resident 2 Shut the f** up. The DSS stated Resident 2 was upset with the incident but later calmed down. On 5/28/25 at 1:43 P.M., an interview was conducted with Resident 2. Resident 2 stated on 5/19/25 around 5 A.M., she was awake in her bed and was in her phone when CNA 2 came inside the room. CNA 2 opened her drawers looking for diapers without asking permission. Resident 2 stated she asked CNA 2 to stop rummaging her drawers, but CNA 2 responded You don't own these diapers. Resident 2 stated she went to the nursing station and reported to LN 4 regarding the incident with CNA 2. Resident 2 stated, while she was talking to LN 4, CNA 2 screamed at her and told her to shut the f** up. On 5/28/25 at 2:14 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated staff were trained on resident rights and different kinds of abuse, and who to report abuse at least annually. The DSD stated staff should treat residents with respect and dignity. On 6/9/25 at 7:34 A.M., a telephone interview was conducted with Licensed Nurse (LN) 4. LN 4 stated she worked on the date of the incident. LN 4 stated Resident 2 was alert and oriented, and able to make her needs known. LN 4 stated she was coming out in one of the rooms in front of the nursing station when she saw Resident 2 and CNA 2 in front of the nursing station and heard CNA 2 saying shut the f** up . Resident 2 told LN 4 that CNA 2 went inside her room and started opening her drawers looking for diapers without asking her permission and followed me in the nursing station and said the word shut the f** up. LN 4 stated CNA 2 was not assigned to Resident 2 on the date of the incident. LN 4 stated CNA 2 should have gone to the supply room for diaper instead of going through the resident's supply in resident's room. LN 4 further stated CNA 2 should have not said those inappropriate words to the resident at any time. On 6/10/25 at 4:03 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectation for her staff was to respect residents' privacy and treated with dignity. Staff should asked permission from the resident when opening their personal belongings and not to use vulgar words. A review of the facility's policy and procedures (P & P) titled, Resident Rights, dated 12/19/22, indicated . the resident has the right to a dignified existence, self -determination, and communication .4. Respect and Dignity . the resident has the right to be treated with respect and dignity .

Based on interview and record review, the facility failed to notify and confirmed bed hold notice to the resident's family representative upon transfer to an acute care facility (hospital) for one of three sampled residents (Resident 1). This failure resulted in Resident 1' s family representative confusion related to bed hold payment. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a common lung disease causing restricted airflow and breathing problems), per the facility's admission Record. A review of Resident 1's Bed Hold Notification Informed Consent Form was conducted. There was no indication of Resident 1's family representative was notified and confirmed the bed hold when Resident 1 was transferred to an acute hospital. On 5/28/25 at 1 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated nursing staff, or social services would follow up with the family representative to offer bed hold when a resident was transferred to an acute care facility. On 6/9/25 at 9:32 A.M., a telephone interview was conducted with the Business Office Manager (BOM). The BOM stated nursing staff would contact the family to notify and confirmed bed hold when a resident transferred to an acute care facility. The BOM stated residents were not placed on bed hold right away. The nursing staff would notify and confirm with the family representative that they would like a bed hold. On 6/9/25 at 9:55 A.M., a telephone interview was conducted with the DON. The DON stated the nurse would contact the family representative to confirm and verify the bed hold. The DON stated nursing staff should have documented the notification and confirmation from the family representative. On 6/9/25 at 5 P.M., a telephone interview was conducted with Licensed Nurse (LN) 1. LN 1 stated when Resident 1 was transferred to an acute care facility on 1/22/25, he did not verify and confirmed the bed hold with the family representative. LN 1 stated family should be notified and verified bed hold with the resident or family representative and documented in the form. On 6/10/25 at 7:27 A.M., a telephone interview was conducted with LN 2. LN 2 stated she did not follow up with Resident 1's family representative to offer and confirmed bed hold when Resident 1 was transferred to an acute care facility on 1/22/25. LN 2 stated when the family confirmed the bed hold, it should have been documented in the bed hold form and or progress note. On 6/10/25 at 3:53 P.M., a telephone interview was conducted with the Social Service Director (SSD). The SSD stated nursing was responsible for contacting and following up with the resident and or family representative to offer bed hold when a resident was transferred out to an acute care facility. On 6/10/25 at 4:19 P.M., an interview was conducted with the DON. The DON stated Resident 1's Bed Hold Informed Consent Form did not have any documentation related to the notification, confirmation of transfer and bed hold provision. The DON stated the nursing staff should have completed and documented in the form and in the progress notes when Resident 1 was transferred out to an acute care facility. A review of the facility's policy and procedures (P&P), titled Bed Hold Notice, dated 12/19/22, indicated . at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and /or the resident representative a written notice which specifies the duration the bed hold policy .2. In the event of an emergency transfers of a resident, the facility will provide within 24 hours written notice of the facility's bed hold policies .

Based on observation, interview, and facility policy review, the facility failed to maintain the blinds in 5 resident rooms ( Rooms 107, 112, 130, 131, and 138) of 30 resident rooms on the first floor of the facility in good condition. Findings included: A facility policy titled, Safe and Homelike Environment, dated 12/19/2022, indicated, 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. During an observation on 05/01/2025 at 9:08 AM, room [ROOM NUMBER], located on the first floor, had horizontal window blinds in place with 22 missing blind slats (individual horizontal or vertical strips of material that made up the structure of the blind). The missing window slats created an open area that measured approximately four and one half feet by eight inches that potentially exposed residents to public view. During an observation on 05/01/2025 at 8:59 AM, room [ROOM NUMBER] had vertical blinds with 13 missing slats. During an observation on 05/01/2025 at 8:58 AM, room [ROOM NUMBER] had horizontal blinds that covered a sliding glass door with a view into a center courtyard, and two slats were missing from the blinds. During an observation on 05/01/2025 at 8:57 AM, room [ROOM NUMBER] had horizontal blinds that covered a sliding glass door with a view into a center courtyard. One slat was missing from the blinds, and one slat was noted lying on the floor. During an observation on 05/01/2025 at 9:28 AM, room [ROOM NUMBER] had vertical blinds that covered a sliding door, and the blinds were missing six slats which caused a gap of approximately one foot by seven feet. During a concurrent observation and interview on 05/01/2025 at 9:45 AM, Certified Nursing Assistant (CNA) #3 stated if something were broken in a resident's room she would report it in the maintenance log, and she demonstrated where the maintenance log was located at the nurses' station. CNA #3 confirmed by way of observation the broken blinds in room [ROOM NUMBER] and stated she had not noticed the broken blinds before. CNA #3 entered room [ROOM NUMBER] and stated she had not noticed the two slats missing, and stated it should be reported. CNA #3 entered room [ROOM NUMBER] and stated she had been aware of the broken blinds for more than a few weeks but had not reported it. During a concurrent observation and interview on 05/01/2025 at 10:03 AM, Registered Nurse (RN) #4 stated if there was a broken but not harmful item in a resident's room she would put it in the logbook. RN #4 stated she had not reported anything recently, and she had not seen anything broken. RN #4 revealed missing blinds was something she would report to the maintenance department. RN #4 entered room [ROOM NUMBER] and stated she observed 13 missing blind slats. RN #4 entered room [ROOM NUMBER] and stated there was two missing blind slats. RN #4 entered room [ROOM NUMBER] and stated she counted six missing blind slats, and that was something she would report immediately. During a concurrent observation and interview on 05/01/2025 at 10:27 AM, the Maintenance Director stated that when a staff member observed broken items in a resident's room the staff member was expected to log the item in the maintenance book. The Maintenance Director stated he had not received a maintenance request within the last couple of weeks to repair blinds. The Maintenance Director entered room [ROOM NUMBER] and stated the 13 missing blind slats was a concern because it allowed more heat to come into the room, and the apartment building behind the facility was about 200 feet away with a clear line of sight into the room. The Maintenance Director entered room [ROOM NUMBER] and noted the two missing blind slats. The Maintenance Director entered room [ROOM NUMBER] and noted one slat on the ground. The Maintenance Director stated the six blind slats missing in room [ROOM NUMBER] needed to be repaired. During an interview on 05/01/2025 at 12:15 PM, the Director of Nursing (DON) stated that when a clinical staff member identified a maintenance issue, the staff typically called the Maintenance Director and the leadership team if the issue was an emergency. The DON stated the clinical staff sent out a text message when something was found broken. The DON stated if the staff member was a nursing assistant they told the nursing supervisor, and the supervisor would notify the team. The DON stated there was a maintenance log to document when an issue was identified. The DON stated maintenance was expected to follow-up on the concerns in the maintenance book. During an interview on 05/01/2025 at 12:44 PM, the Administrator stated staff should place a maintenance issue on the maintenance log, which was checked by the Maintenance Director. The Administrator stated after the repair was made he checked the log against the repair to verify completion. The Administrator stated if something was broken it needed to be fixed.

Based on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASARR) when the resident was diagnosed with a new mental illness diagnosis for 1 (Resident #104) of 2 sampled residents reviewed for PASARR. Findings included: A facility policy titled, Resident Assessment - Coordination with PASARR Program, revised 12/18/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy specified, 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. An Admission Record revealed the facility admitted Resident #104 on 02/06/2023. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction. The Admission Record indicated the resident received a diagnosis of depression on 09/26/2024 and bipolar disorder on 11/26/2024. A quarterly Minimum Data Base (MDS), with an Assessment Reference Date (ARD) of 03/25/2025, revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses that included depression and bipolar disorder. Resident #104's Care Plan Report included a focus area initiated 05/07/2024, that indicated the resident used an antidepressant medication related to a diagnosis of depression. Resident #104's medical record revealed no evidence to indicate a level II PASARR was resubmitted after the resident was diagnosed with depression on 09/26/2024 or bipolar disorder on 11/26/2024. During an interview on 05/01/2025 at 9:00 AM, the Assistant Director of Nursing (ADON) stated she was one of the facility leadership staff who was responsible for PASARRs. The ADON stated that when a new mental illness diagnosis was added to a resident's record, a PASARR was completed and submitted to the state. The ADON stated the Social Services Director (SSD) and the Director of Health Information also had access to the system, and any one of them could submit a PASARR. Per the ADON, Resident #104 had a diagnosis of bipolar disorder, and a new PASARR should have been submitted. During an interview on 05/01/2025 at 9:32 AM, the SSD stated that when a new mental illness diagnosis was added to a resident record, a PASARR should be completed. According to the SSD, the ADON was responsible for submitting PASARRs. The SSD reviewed Resident #104's diagnoses list and stated she expected a PASARR to be resubmitted when the resident's bipolar disorder diagnosis was added. During an interview on 05/01/2025 at 11:43 AM, the Director of Nursing (DON) stated if another PASARR was required, the ADON submitted the screening. The DON stated a new mental illness diagnosis required a PASARR to be resubmitted. During an interview on 05/01/2025 at 11:26 AM, the Administrator stated the facility followed state and federal regulations. The Administrator stated he expected PASARR screenings to be submitted following the addition of a new mental illness diagnosis. The Administrator stated the ADON took the lead on the PASARR process; however, he tried to get several people involved so that alternate staff were always available to address PASARR concerns.

Based on interview, record review, and facility policy review, the facility failed to resubmit a level I preadmission screening and resident review (PASARR) to the appropriate state-designated authority for 1 (Resident #81) of 2 sampled residents reviewed for PASARR. Findings included: A facility policy titled, Resident Assessment - Coordination with PASARR Program, revised 12/18/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. An Admission Record indicated the facility readmitted Resident #81 on 12/16/2024. According to the Admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, anxiety disorder, and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/28/2025, revealed Resident #81 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was moderately impaired in cognitive skills for daily decision making. The MDS revealed Resident #81 had active diagnoses to include anxiety disorder, depression, and schizophrenia. Resident #81's Care Plan Report included a focus areas initiated 02/23/2022, that indicated the resident used anti-anxiety medications related to a diagnosis of anxiety disorder. The Care Plan Report also included a focus area initiated 09/27/2023, that indicated the resident used antidepressant medication related to a diagnosis of depression. The Care Plan Report included a focus area initiated 02/11/2025, that indicated the resident had a diagnosis of schizophrenia, including symptoms such as delusions, hallucinations, disorganized speech, disorganized behavior, and negative behaviors. A letter from the California Department of Health Care Services dated 12/27/2024, revealed a level II mental health evaluation was required for Resident #81 due to the resident's serious mental illness. A letter from the California Department of Health Care Services dated 12/27/2024, revealed a level II evaluation was unable to be completed for Resident #81's serious mental illness due to the facility staff being unresponsive on two or more separate communication attempts within 48 hours. Per the letter, the facility must resubmit a new Level I Screening. During an interview on 05/01/2025 at 8:56 AM, the Assistant Director of Nursing (ADON) stated she was in charge of the PASARR program and had access to the PASARR portal. The ADON stated she had not seen the notice from the state about not being able to reach the facility. According to the ADON, Resident #81's PASARR should have been resubmitted when the facility received the notice. During an interview on 05/01/2025 at 11:43 AM, the Director of Nursing (DON) stated the ADON oversaw the PASARR screenings in the facility. Per the DON, if a level I PASARR was positive and the facility could not be reached for further information, she expected the screening to be resubmitted. The DON stated Resident #81's PASARR should have been resubmitted for evaluation and recommendations from the state office. During an interview on 05/01/2025 at 11:25 AM, the Administrator stated that he expected the facility to follow the state and federal requirements for reviewing and submitting PASARR screenings. He stated that if a resident had a positive level I, he expected a letter of determination to be in the resident's record and a follow up completed. According to the Administrator, the ADON was the lead for PASARRs, and multiple facility nurses had access as well. The Administrator stated Resident #81's PASARR should have been resubmitted to the PASARR office when the letter was received indicating communication could not be made with the facility.

Based on interview, document review, and facility policy review, the facility failed to post the actual hours worked by staff directly responsible for resident care for 12 of 12 shifts reviewed. This deficient practice had the potential to affect all residents who currently resided in the facility. Findings included: A facility policy titled, Nurse Staffing Posting Information, dated 03/10/2025, indicated, It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides. The facility Nurse Staff Projection, documents dated 04/25/2025, 04/27/2025, 04/28/2025, and 04/29/2025, revealed the documents did not indicate the actual hours worked for all three shifts each day for the staff directly responsible for resident care. During an interview on 05/01/2025 at 8:54 AM. the Scheduler stated he had been the staffing coordinator for the past two years and was responsible for the posting of nurse staffing data. The Scheduler stated he tried to maintain the nurse staffing records but sometimes forgot to print or post them. During an interview on 05/01/2025 at 9:49 AM, the Director of Staff Development (DSD) stated she worked closely with the Scheduler to provide oversight. The DSD stated she did not update the nurse staffing data sheets on 04/25/2025, 04/27/2025, 04/28/2025, or 04/29/2025 to show the actual hours worked by the staff. The DSD stated she expected 100 percent compliance with the data for nurse staffing postings. During an interview on 05/01/2025 at 10:48 AM, the Director of Nursing stated she expected the nurse staffing data to be adjusted as needed for call outs, have the appropriate disciplines included in the count, and to be correct. During an interview on 05/01/2025 at 11:02 AM, the Administrator stated the nurse staffing postings should be accurate. The Administrator stated that staff should be able to go back and adjust staffing data based on staffing changes.

Based on interview and record review, the facility failed to ensure choice was offered to accomodate a preference for a shower for one resident (Resident 304). This failure had the potential to cause psychological harm to Resident 304. Findings. Resident 304 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (the spaces inside the bones of the spine gets too small) and Discogenic Pain (localized back pain that worsens with activities that increase pressure on the spine). On 4/7/25 at 10:20 A.M., an interview with Certified Nursing Assistant (CNA) CNA 1 was conducted. CNA 1 stated on 3/21/25 in the morning, she and CNA 2 went into Resident 304 ' s room and told Resident 304 she was getting a shower then immediately transferred from the bed to the shower. CNA 1 stated during transfer, Resident 304 had urinated on herself and bowel movement. CNA 1 stated they had to put Resident 304 back to bed to clean her up, then place in the Hoyer lift to transfer Resident 304 to the shower chair. On 4/7/25 at 11:20 A.M., an interview with Resident 305 was conducted. Resident 305 stated she had been Resident 304 ' s roommate since she got admitted to the facility. Resident 305 stated she seen and witnessed the incident on 3/21/25 when Resident 304 was to have a shower that day. Resident 305 stated she had seen Resident 304 yanked out of her bed and hoist Resident 304 up from the bed. A review of Resident 305 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/21/25 indicated Resident 305 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 305 ' s cognition (thought process) was intact. On 4/7/25 at 11:35 A.M., an interview with Resident 304 was conducted. Resident 304 stated CNA 1 and CNA 2 went into her room and stated you are getting a shower. Resident 304 stated she was not given a choice if she wanted the shower or not. Resident 304 stated she felt bad when she started peeing and pooping on herself while being transferred to the shower chair with both CNA 1 and CNA 2. Resident 304 stated CNA 1 and CNA 2 were both arguing about how to operate the Hoyer lift and that made Resident 304 upset and worried. Resident 304 stated after the incident, a psychiatrist came to see her to discussed and offered anti-anxiety medication, but Resident 304 refused. Resident 304 stated it was her first time in a convalescent home and did not know what to expect. A review of Resident 304 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/27/25 indicated, Resident 304 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 304 ' s cognition (thought process) was intact. A review of Resident 304's MDS dated [DATE], section E indicated, Resident 304 had 0 behaviors. On 4/7/25 at 12:20 P.M., an interview with CNA 3 was conducted. CNA 3 stated Resident 304 was alert and oriented and would stand and transfer from the wheelchair to her bed with minimal assistance. CNA 3 stated Resident 304 would just complain of pain in her back at times. CNA 3 stated it was important to explain to Resident 304 what was being done prior to proceeding with her care. An interview on 4/7/25 at 12:35 P.M., with the Social Service Director (SSD) was conducted. The SSD stated the facility had a meeting with Resident 304 ' s son to discuss his complaint regarding staff being rough to his mother. Resident 304 ' s son stated his mother, Resident 304 was forced to get a shower and was naked while on a device on 3/21/25. An interview on 4/7/25 at 1:45 P.M., with Licensed Nurse (LN) 1 was conducted. LN 1 stated Resident 304 was alert and oriented x4, and did not have any behaviors. LN 1 stated Resident 304 was cooperative with her care and treatment, and was on routine Tylenol (medication for pain) for her back pain. An interview on 4/7/25 at 2:30 P.M., with the Assistant Director of Nursing ( ADON) was conducted. The ADON stated it was important to let Resident 304 have a choice or preference regarding her shower or any care to be provided by the staff. The ADON stated the facility will have more positive outcome if Resident 304 was made aware and given a choice before proceeding with the shower. The ADON stated it was important to respect resident ' s wishes and to treat them with dignity and respect. A review of the facility ' s policy dated 12/10/2022 titled, Resident Rights indicated .2.Planning & implementing care .c. the right to be informed in advance, of the care to be furnished .e. the right to refuse , and /or discontinue treatment , to participate in or refuse to participate .3.Policy explanation & compliance guidelines .#11 the facility will ensure that all direct staff .are educated on the rights of residents .5.a. the resident has the right to choose activities, schedules .

Based on interview and record review, the facility failed to ensure privacy was maintained for one of one resident (Resident 304) when the two CNAs (1, 2) left Resident 304's naked body exposed during the delivery of care. This failure violated Resident 304's right to dignity and privacy. Findings. Resident 304 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (the spaces inside the bones of the spine gets too small) and Discogenic Pain (localized back pain that worsens with activities that increase pressure on the spine). An interview on 4/7/25 at 11:20 A.M., with Resident 305 was conducted. Resident 305 stated she had been Resident 304 ' s roommate since she got admitted to the facility. Resident 305 stated she had seen and witnessed the incident on 3/21/25 when Resident 304 was to have a shower that day. Resident 305 stated she had seen Resident 304 yanked out of her bed, hoist Resident 304 up, and was naked. Resident 305 stated Resident 304 was in the Hoyer Lift hanging from the ceiling while being transferred to the shower chair by CNA 1 and CNA 2. Resident 305 stated there was no privacy provided during the delivery of care allowing anyone to view Resident 304's naked body since the curtain between them was pulled all the way back. A review of Resident 305 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/21/25 indicated Resident 305 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 305 ' s cognition (thought process) was intact. On 4/7/25 at 11:35 A.M., an interview with Resident 304 was conducted. Resident 304 stated CNA 1 and CNA 2 went into her room and stated you are getting a shower. Resident 304 stated she was not given a choice if she wanted the shower or not. Resident 304 stated she felt bad when she started peeing and pooping on herself while being transferred to the shower chair with both CNA 1 and CNA 2. Resident 304 stated CNA 1 and CNA 2 were both arguing about how to operate the Hoyer lift and that made Resident 304 upset and worried. Resident 304 stated after the incident, a psychiatrist came to see her to discussed and offered anti-anxiety medication, but Resident 304 refused. Resident 304 stated it was her first time in a convalescent home and did not know what to expect. A review of Resident 304 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/27/25 indicated Resident 304 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 304 ' s cognition (thought process) was intact. A review of Resident 304's MDS dated [DATE], section E indicated Resident 304 had 0 behaviors. An interview on 4/7/25 at 12:35 P.M., with the Social Service Director (SSD) was conducted. The SSD stated the facility had a meeting with Resident 304 ' s son to discuss his complaint regarding staff being rough to his mother. Resident 304 ' s son stated his mother, Resident 304 was forced to get a shower and was naked while on a device on 3/21/25. An interview on 4/7/25 at 2:30 P.M., with the Assistant Director of Nursing ( ADON) was conducted. The ADON stated the staff should have provided privacy when performing any resident's care to ensure residents privacy were provided and their dignity were respected. A review of the facility ' s policy dated 12/10/2022 titled, Resident Rights indicated .4.Respect & dignity .c.The right to reside & receive services in the facility with reasonable accommodation of needs and preference .5. Self-determination .5.a. the resident has the right to choose activities, schedules . b.The resident has the right to make choices about aspects of his or her life . Policy explaination and Compliance Guidelines .11. the facility will ensure that all direct staff .are educated on the rights of residents .

Based on interview and record review, the facility failed to ensure the licensed nurses (LN) had specific competencies and training related to Central Venous Catheter site (CVC- a soft plastic tube inserted into a vein to provide vascular access for hemodialysis [a treatment that filters waste and excess fluid from the blood of people whose kidneys were not functioning properly] for 5 of 7 licensed nurses (LN). This failure had the potential to result in inaccurate assessment and delayed care and treatment of a resident with a CVC line. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (ESRD- kidney failure) per the Admission Record. On 8/22/24 at 4:30 P.M., an interview was conducted with LN 3. LN 3 stated that to assess the CVC site, LNs had to examine the site and document the signs and symptoms of infection and the condition of the dressing. LN 3 further stated there would be no bruit [a whooshing sound] that happens when the blood flows to the body and trill [vibration over the blood vessel]. LN 3 stated the bruit and trill would be heard and felt for residents with AVF (arteriovascular fistula- a surgical connection between an artery and a vein). A review of Resident 1's Dialysis Communication Form was conducted. Under the Dialysis Center Information section, dated 7/24/24 through 8/7/24, Resident 1 had a CVC line in the left chest that the dialysis center used during dialysis treatment. On 7/24/24, 7/29/24, and 8/3/24, under the post-dialysis information [assessment performed by the facility], LN 1 documented the presence of bruit and trill. On 7/26/24, under the post-dialysis information section, LN 6 documented the catheter was patent (no obstruction), and bruit and trill were present. LN 6 was a licensed vocational nurse (LVN). On 7/31/24, under the post-dialysis information section, LN 4 documented the presence of bruit and trill. On 8/5/24, under the post-dialysis information section, LN 6 documented the presence of bruit and trill. On 8/7/24, under the post-dialysis information section, LN 5 documented the presence of bruit and trill. On 8/22/24 at 3:16 P.M., an interview was conducted with LN 1. LN 1 stated she had cared for Resident 1 and did not have proper training for CVC for hemodialysis. On 8/22/24 at 4 P.M., an interview was conducted with LN 2. LN 2 stated there was no formal training about the CVC for hemodialysis. Per LN 2, It was verbal instructions during endorsement (report). On 8/28/24 at 4:30 P.M., an interview was conducted with LN 4. LN 4 stated he did not have formal training for CVC for hemodialysis. On 8/29/24 at 12:30 P.M., an interview was conducted with LN 5. LN 5 stated he had formal training in CVC assessment. However, on 8/7/24, many things were happening, and human error occurred. LN 5 further stated he documented check marks on the bruit and trill (dialysis communication form) without assessing the site, and should not have. On 8/29/24 at 1:15 P.M., an interview was conducted with LN 6. LN 6 stated she watched many videos upon hire and could not recall if one was about CVC assessment and care. LN 6 stated she should not have documented that the catheter was patent because it was beyond her scope (as a LVN) to check the CVC line's patency, and she was not allowed to touch the CVC. LN 6 further stated she assumed the line was patent because Resident 1 returned from hemodialysis. On 9/3/24 at 4:40 P.M., an interview was conducted with the Director of Nursing (DON). The DON acknowledged the LNs should have competencies and training (for CVC), and stated assessment for the CVC site should have been monitored for bleeding, signs and symptoms of infection, and if the dressing was intact. The facility could not provide a policy and procedure for CVC care, training, and skills checks for the CVC line.

Based on observation, interview, and record review, the facility failed to ensure prescribed medications were completely administered to one of three residents (Resident 1). This had the potential to affect the goal of treatment and put Resident 1 ' s health and safety at risk. Findings: An observation and interview was conducted on 4/26/23 at 12:50 P.M. inside Resident 1 ' s room. A white pill was inside a medicine cup lying on the bedside table. Resident 1 identified the white pill was her Baclofen (brand name of a pain medication). Resident 1 stated she did not know there was one white pill left in the medication cup and further stated she did not get the three tablets scheduled at 8:00 A.M. A review of Resident 1 ' s electronic medication administration record (EMAR, electronic version of medications received by a resident) dated, April 26, 2023 indicated, Baclofen (brand name, pain medication) Oral Tablet 5 milligrams (mg, unit of measurement). Give 3 tablets by mouth four times a day for pain management. A review of Resident 1 ' s minimum data set (MDS, an assessment tool) dated 4/10/23 indicated, the BIMS (brief interview for mental status)score was 14 out of 15 which meant, she was cognitively intact. On 4/26/23 at 12:55 P.M., an interview with the licensed nurse (LN A) was conducted. LN A acknowledged the above observation and stated she administered the medications at 8:00 A.M. LN A further stated Resident 1 should have received three tablets of Baclofen. An interview was conducted with the charge nurse (CN) on 4/26/23 at 1:00 P.M. The CN stated licensed nurses should wait and verify resident ' s medications were safely and completely administered before leaving the resident. On 4/26/23 at 1:25 P.M., an interview was conducted with the director of nursing (DON). The DON stated all LNs should observe the residents while taking prescribed medications to ensure the residents were able to take correct dose. Review of the facility ' s policy titled Medication Administration dated 9/2/22, indicated Observe resident consumption of medication

Based on observation, interview, and record review, a Certified Nusing Assistant (CNA) 1 failed to perform hand hygiene and failed to change PPE (personal protective equipment) when care was provided to three observed residents (1, 2, 3). This failure had the potential to transmit infection to residents, staff, and visitors. Findings: On 3/23/21, at 10 A.M., an unannounced visit to the facility was conducted. On 3/23/21, at 2:50 P.M., CNA 1, was observed wearing a mask, face shield, and gown. CNA 1 was rounding the corner from the hall of Unit 2F and stopped at Resident room [ROOM NUMBER]. CNA 1 removed her gloves, did not use hand sanitizer, nor wash her hands and proceeded into room [ROOM NUMBER] to take the vital signs of Resident 1. CNA 1 came out of room [ROOM NUMBER] and proceeded to Resident room [ROOM NUMBER]. CNA 1 removed her gloves, did not sanitize nor wash her hands and puts on a new pair of gloves and entered room [ROOM NUMBER] A, and preceeded to take Resident 2's vital signs. CNA 1 did not remove nor change her gown before going into room [ROOM NUMBER] A to take Resident 2's vital signs. On 3/23/21 at 2:53 P.M., CNA 1 came out of Resident room R250 A, sanitized the blood pressure cuff and thermometer with sanitizer wipes. CNA 1 took off her gloves, used hand sanitizer, and put on a new set of gloves. CNA 1 did not remove or change her gown. CNA 1 went to Resident room [ROOM NUMBER] B and checked on Resident 3. CNA 1 stated I have been looking for you to take your vital signs. CNA 1 takes off her gloves, used hand sanitizer, changes into new gloves, and proceeded back to room [ROOM NUMBER] B to take Resident 3's vital signs. CNA 1 did not remove or change her gown. On 3/23/21 at 3 P.M., CNA 1 was observed coming out of Resident room [ROOM NUMBER] B, sanitized the blood pressure cuff, and thermometer, took off her gloves, and entered the soiled utility room to wash her hands. CNA 1 was wearing the same gown and face shield she used in Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER] A and B. During a concurrent interview with CNA 1 on 3/23/21 at 3:15 P.M., CNA 1 stated, We wear PPE (personal protective equipment), such as gowns and gloves. CNA 1 further stated the staff were trained to wear the same gown when taking vital signs and picking up the food trays from residents' room. During an interview with the Director of Staff Development (DSD) and the Infection Control Preventionist (ICP), at 3:34 P.M. on 3/23/21, the DSD and the ICP, stated the expectation for the staff was to change gloves and gowns between direct patient care of the residents. The DSD and ICP further stated communication regarding PPE changes were done by text messaging and in-services. During an interview with the Director of Nurse (DON), at 4:45 P.M. on 3/23/21, the DON stated her expectation for the CNAs were to change gowns between each resident's care. The in-service training, dated 12/28/20, titled, Use of Appropriate PPE, was reviewed and stated, Complete PPE (N95, face shield, gown and gloves) must be worn at all times when providing resident care. Gowns are not to be reused, not to be worn on the hallways, must be changed even when just passing trays. NO EXTENDED use. The undated, Policy and Procedure, titled, Chapter 4: Standard and transmission Based Precautions, was reviewed and indicated, Put on a clean isolation gown upon entry into the patient room or area .Disposable gowns should be discarded after use. The Centers for Disease Control and Prevention, updated Jan. 21, 2021, was reviewed and indicated, Once gown availability returns to normal; healthcare facilities should promptly resume conventional practices.

Based on observation, interview, and record review, the facility failed to ensure appropriate Social Services were provided to meet the psychosocial needs of three Residents (1,2,3). This failure had the potential to affect Residents psychosocial well-being. Findings: On 12/14/20, the department received a report related to a resident rights incident. On 12/15/20, the department received two reports related to a resident rights incident. On 12/29/20 an unannounced visit to the facility was conducted. Resident 1 was admitted to the facility on [DATE] with diagnoses including COVID-19, [CONDITION(S)], and a history of falling per the facility's Admission Record. Resident 2 was admitted to the facility on [DATE] with diagnoses including COVID-19, and history of falling per the facility's Admission Record. Resident 3 was admitted to the facility on [DATE] with diagnoses including cancer of the liver per the facility's Admission Record. No observational opportunity was available for Resident 1 as he had been transferred to the hospital. On 12/29/20 at 12:40 P.M., Resident 2 was observed in her room, sitting in a chair. Resident 2 stated, The CNA was not nice. On 12/29/20 at 12:44 P.M., Resident 3 was observed in her room, reclining on the bed. Resident 3 stated she did not want to talk about anything. On 12/29/20 at 10:10 A.M., a review of Resident 1, 2, and 3 was conducted; there were no notes from the social services department regarding visits to the residents following an incident. On 12/29/20 at 12:20 P.M., a concurrent record review and interview was conducted with the Director of Nursing (DON). The DON stated no social service notes were located in the progress notes for any of the three Residents. The DON stated, The incident was not followed up. On 12/29/20 at 12:25 P.M., an interview was conducted with the Social Services Director (SSD). The SSD stated, The three residents were not followed up for 13 days; they were not seen by social services; visiting residents after an incident is in our job description. A review of the facility's job description, titled, Social Services Director Job Description Primary, indicated, Position Summary .directs the Social Services Department to ensure all medically-related emotional and social needs of patients are met . A review of the facility's policy, undated, titled, Chapter 12: Event Management and Emergency Procedures, indicated, .Procedure: 10. Following the report of suspected abuse and/or neglect, the administrator will designate a resident advocate (i.e.,social services) to support the resident through his/her feelings about the incident .

Based on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 75) reviewed for abuse and neglect, was free from physical and verbal abuse and neglect when: 1. Certified nursing assistant (CNA) 1 handled Resident 75 in a rough manner during incontinence (an inability to control the release of urine or feces) care. Furthermore, CNA 1 did not stop providing care when Resident 75 requested for her to stop. 2. CNA 1 told Resident 75, No one likes you here. You complain too much, and called the resident a racist. 3. CNA 1 did not clean Resident 75 after an incontinence episode as per the resident's request. As a result of these failures, Resident 75 experienced physical pain and was in fear of CNA 1. The day after the incident with CNA 1 (6/17/21), Resident 75 felt upset and stressed, lacked her usual appetite, was nauseous, and vomited. Findings: A review of Resident 75's Admission Record dated 6/18/21, indicated the resident was readmitted to the facility on [DATE], and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/18/21 at 9:06 A.M., an observation and interview was conducted with Resident 75 inside the resident's room. Resident 75 was in bed with approximately 8 pillows in total that were arranged underneath the resident's arms, legs, between her legs, and behind her head and neck. Resident 75 wore a hospital gown and the lower half of her body was covered with a sheet. Resident 75 stated she had had an incident with her assigned CNA (CNA 1) the other night on 6/16/21. Resident 75 stated she had a specific way she preferred to be cleaned after an incontinence episode and that her personal hygiene routine took time. Resident 75 stated she saw CNA 1 around 4 P.M. on 6/16/21, and they both agreed upon 9:30 P.M. as the time to change her incontinence brief. Resident 75 stated CNA 1 had seemed nice at that time. Resident 75 stated CNA 1 arrived to change her after 10 P.M. Resident 75 stated she had asked CNA 1 what took her so long to arrive, and CNA 1 told her that she had to care for other residents. Resident 75 stated CNA 1 seemed to have been in a bad mood. Resident 75 stated CNA 1 began to yank the pillows out from behind her body. Resident 75 stated CNA 1 did not explain what she was doing. Resident 75 stated when CNA 1 pulled the pillow out from under her neck, her head hit the mattress causing neck pain. Resident 75 stated CNA 1 then pulled the sheet off her body and threw it onto the empty bed nearby. Resident 75 stated all her pillows were also thrown onto the empty bed. Resident 75 stated she asked CNA 1 to stop, and that she did not want to continue the care because it seemed CNA 1 did not have time to change her. Resident 75 stated CNA 1 grabbed the draw sheet (a sheet placed under the resident to aid in repositioning) and pushed her over onto her side. Resident 75 stated CNA 1 had not spoken to her or explained what was going on. Resident 75 stated without verbal cueing, she had not anticipated being pushed, and her right arm hit the side rail causing pain. Resident 75 stated CNA 1's action was so forceful, she thought it would cause her to fall out of the bed. Resident 75 stated, I asked her what she was doing and she told me 'No one likes you here. You complain too much.' Resident 75 stated CNA 1 then ripped off my diaper. Resident 75 stated CNA 1 pulled the diaper off so fast and hard that it had torn in the process. Resident 75 stated CNA 1's actions had caused her pain. Resident 75 stated CNA 1 started shoving a new diaper in while she was still on her side. Resident 75 stated CNA 1 grabbed her right upper arm and pulled her on to her back without saying anything to her. Resident 75 stated CNA 1's actions caused her pain in her arm and shoulder. Resident 75 touched her right leg and stated that CNA 1 had lifted her sensitive leg up to put the diaper through and then let her leg drop onto the mattress. Resident 75 stated, She [CNA 1] hurt me. Resident 75 stated she asked CNA 1 to clean her private area as she had a urine incontinence episode. Resident 75 stated CNA 1 told her she did not need to be cleaned and did not clean her. Resident 75 stated CNA 1 began putting the pillows and sheet back on her. Resident 75 stated, I was afraid of her. Resident 75 stated no other staff had mistreated her before. Resident 75 stated it had been the first time CNA 1 was her CNA. Resident 75 stated the day after the incident (6/17/21), she did not feel well and had neck, shoulder, and arm pain. Resident 75 stated she did not have her usual appetite and her stomach was upset from the stress of it all. Resident 75 stated she had also thrown up twice because of the stress. A review of Resident 75's Annual History and Physical dated 4/5/21, indicated the resident needed staff assistance with ambulation, bathing, continence, dressing, grooming, toileting, and transfers. A review of Resident 75's MDS Assessment (Minimum Data Set, an assessment tool), dated 5/14/21, indicated the resident scored 13 out of 15 on the Brief Interview for Mental Status (an assessment of the resident's attention, orientation, and ability to register and recall information. A score of 13-15 was considered cognitively intact). On 6/18/21 at 11:04 A.M., an interview was conducted with licensed nurse (LN) 5. LN 5 stated he had provided care to Resident 75 on 6/17/21. LN 5 stated Resident 75 told him she could not take her morning medications (on 6/17/21) because her stomach was upset due to having nerves from what had happened the night before (6/16/21). LN 5 stated Resident 75 told him that she had been verbally abused by the CNA the night before and had been handled very roughly. LN 5 stated Resident 75 was cognitively intact and a reliable historian. LN 5 stated the morning CNA had reported to him on 6/17/21 that Resident 75 had thrown up during her shift. LN 5 stated Resident 75 has had occasional complaints of neck pain in the past. LN 5 stated Resident 75 had complained of increased neck pain on 6/17/21 and he had called the medical doctor and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LN 5 stated the only medication Resident 75 accepted from him on 6/17/21 was a pain pill. LN 5 stated it was unusual for Resident 75 to complain of nerves, nausea, and to throw up. A review of Resident 75's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The June 2021 eMAR further indicated Resident 75 had requested and was administered acetaminophen (pain medication) at 12 A.M. on 6/17/21. The June 2021 eMar indicated Resident 75 had not requested nor been administered acetaminophen before 6/17/21. The June 2021 eMAR indicated Resident 75 requested and was administered [MEDICATION(S)] (antiemetic [prevents nausea and vomiting] medication) on 6/17/21 at 3:31 A.M. The June 2021 eMar indicated [MEDICATION(S)] had not been administered before 6/17/21. The June 2021 eMar indicated Resident 75 requested and was administered [MEDICATION(S)] (a controlled pain medication) on 6/17/21 at 3:11 A.M. and at 7:49 A.M. The 7:49 A.M. [MEDICATION(S)] dose was electronically signed by LN 5. The June 2021 eMar indicated the last time Resident 75 requested and was administered [MEDICATION(S)] was on 6/11/21. A review of Resident 75's Administration Note dated 6/17/21 at 12 A.M., indicated, Acetaminophen tablet . c/o [complains of] right shoulder pains, A review of Resident 75's Health Status Note dated 6/17/21 at 12:44 A.M., indicated, Received resident at 2350 [11:50 P.M.]. Alert and responsive, she stated I feel nervous and she c/o pain on her right shoulder, LN noted resident able to moved [sic] her shoulder with slight facial grimacing, resident said it's just discomfort when the CNA moved me roughly. LN asked what was her pains scal [sic] and she said 4/10 [self-rated pain scale where zero is no pain and 10 the most pain] On 6/18/21 at 11:13 A.M., an interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 75 and the resident's incontinence care routine. CNA 3 stated Resident 75 was alert and nice. CNA 3 stated Resident 75 insisted on her incontinence care being done according to her preferences. CNA 3 stated it took about 45 minutes to thoroughly perform Resident 75's incontinence care. CNA 3 stated it took a long time to provide the care according to Resident 75's preferences and that the resident would refuse to receive care if staff did not have enough time. CNA 3 stated Resident 75 would schedule time for incontinence care with CNAs once a shift. CNA 3 stated Resident 75 had a right to choose preferences for care and to have a personalized routine. On 6/18/21 at 12:16 P.M., a telephone interview was conducted with LN 7 in the presence of the director of nursing (DON). LN 7 stated he was the LN taking care of Resident 75 on 6/16/21. LN 7 stated around 10:55 P.M. (on 6/16/21), he went to answer Resident 75's call light. LN 7 stated resident 75 seemed angry and told him CNA 1 had been rough with her causing her pain and had yanked her blankets and pillows out and threw them. LN 7 stated Resident 75 told him CNA 1 had called her a racist. LN 7 stated he had not been able to talk to CNA 1 about the incident as CNA 1 had clocked-out and was not in the facility after he spoke to Resident 75. LN 7 stated he notified the charge nurse of the incident between Resident 75 and CNA 1. LN 7 stated the charge nurse then came to assess the resident. A review of Resident 75's Event Note date 6/16/21 at 10:55 P.M., and authored by LN 7, indicated, Resident reported that she was mistreated by the CNA that had changed her and gotten her ready for bed at 10:30 P.M., stated that the CNA roughly removed all her sheets and pillows and while changing her handled her roughly while changing her and almost making her fall off the bed when she had turned her. She also stated that she was verbally abused with CNA stating that no one liked her [Resident 75] and that she did not like black people . On 6/18/21 at 2:28 P.M., an interview was conducted with CNA 1 in the presence of the DON. CNA 1 stated she was assigned to provide care to Resident 75 on 6/16/21. CNA 1 stated she had met with Resident 75 around 4:15 P.M. to arrange a time to do the resident's incontinence care. CNA 1 stated Resident 75 was very particular with care and the way she wanted things done. CNA 1 stated it would take a long time to complete Resident 75's incontinence care because of the specific way the resident wanted things done. CNA 1 stated they both agreed to do the care at 9:30 P.M. CNA 1 stated she fell behind schedule and went to do Resident 75's care after 10 P.M. CNA 1 stated she had asked CNA 4 to come in and help. CNA 1 stated Resident 75 seemed upset that she was late. CNA 1 stated, She [Resident 75] wasn't mad or irate though. CNA 1 stated she went and got the supplies for incontinence care and then came back into the room and started to remove Resident 75's pillows from her bed. CNA 1 denied removing any pillows that were behind Resident 75's head. CNA 1 stated she placed Resident 75's pillows, that were around the resident's arms and legs, onto the empty bed next to the resident's bed. CNA 1 gestured with her hands a gentle motion of putting the pillows down. CNA 1 stated twice that she had placed Resident 75's pillows down gently. CNA 1 denied throwing Resident 75's pillows twice. When CNA 1 was asked to clarify the issue, she made a third statement that she had tossed the resident's pillows onto the empty bed. When asked how Resident 75's incontinence brief was removed, CNA 1 stated she pulled and made a quick pulling motion with her hand while speaking, then stopped mid-sentence and stated, removed it and motioned a slow, gentle gesture of removing the straps on an incontinence brief with her hands. CNA 1 stated she did not explain the steps of the procedure with Resident 75. CNA 1 stated she did not speak with the resident because the resident had known the routine and knew that she was going to be changed. CNA 1 stated she should have explained the steps to the resident and what was happening so the resident would have a feeling of control and of being part of their own care. CNA 1 stated, I was tired. CNA 1 stated she told Resident 75 she did not have 45 minutes to change her and the resident had asked her to stop providing care. CNA 1 stated she did not stop because she was in the middle of providing care. CNA 1 stated Resident 75 had not objected to anything else while providing care. CNA 1 denied removing any blankets or sheets from the resident. CNA 1 stated Resident 75 had a sheet on, and she had folded the sheet up over the resident's chest as that was the resident's preference during care. CNA 1 stated she removed Resident 75's brief that had urine in it and put a clean brief on the resident. CNA 1 twice denied cleaning or wiping Resident 75 after removing the soiled brief. CNA 1 then made an inconsistent statement by saying that she had wiped the resident once. CNA 1 stated she had used Resident 75's draw sheet to turn the resident onto her side. CNA 1 stated three times that she had pulled Resident 75 back from a side-lying position onto her back using the draw sheet. CNA 1 denied touching Resident 75 during the process of turning the resident back. CNA 1 stated Resident 75 had held a side-lying position and did not roll back during care. CNA 1 was asked to clarify how a resident maintaining a side-lying position was pulled onto her back using the draw sheet. CNA 1 then changed her previous statements by saying she had put her hand on Resident 75's torso and gently aided the resident back onto her back. CNA 1 denied touching or using Resident 75's arm to pull the resident back onto her back. CNA 1 acknowledged there were parts of her statements that were inconsistent, but she did not provide a reason for that. CNA 1 stated three times that there had been no other dialog, conversation, or words between herself and Resident 75 after she had informed the resident that she did not have 45 minutes to change the resident. CNA 1 stated she put the pillows and sheet back over Resident 75 and was on her way out of the room carrying the soiled supplies and trash when CNA 4 entered the room to help. CNA 1 stated nothing else took place as she had been in a hurry to leave and clock-out. A review of CNA 1's signed statement dated 6/17/21, indicated, . [Resident 75] called me into her room @ [at] 4:15 P.M. to set up a time to change her, we both agreed on 9:30 P.M. would be good. Unfortunately I was not able to keep that time due to giving care to my other PT [patient] on my last run for the night. So I reached out to my fell ow coworker and asked if she could assist me around 10:15 P.M. to assist [Resident 75]. By 10:24 [P.M.] my coworker was still charting [documenting] so, I decided to go change [Resident 75] on my own like I have done before. When I got to room [number omitted] [Resident 75] was already upset because I was late. She asked why I was late and I explained and said sorry. So I proceeded to go ahead and change her. When I turned her on her side to remove wet diaper, I told her that I can't do the 45 mins [minutes] and she went off, saying 'oh no I don't want to be changed' it takes time, so she push back to lay on her back while I was removing wet diaper, I told [sic] please don't fight I'm just trying to get you dry, so I rolled her back to her side, slightly lifted up her leg to pull diaper through. She said you didn't wash me, I said you wouldn't let me. I asked her why are you being mean to me, I'm just here to help you. She say back, 'your [sic] the mean one changing me and not clean [sic] and hurting my leg. I'm reporting you . I said that's fine I didn't touch you in a bad way, you are being mean to me. By then [CNA 4] comes in and sees us and [Resident 75] says to her 'am I mean [sic] and [CNA 4] says 'No she's nice.' After that I just left the room and threw away the trash On 6/18/21 at 3:19 P.M., a telephone interview was conducted with CNA 4 in the presence of the DON. CNA 4 stated she had provided care to Resident 75 many times and was familiar with the resident. CNA 4 stated Resident 75 was alert and oriented and would use the call light to ask staff for help when she needed care. CNA 4 stated Resident 75 would ask staff when it was a good time for them to provide care and would let staff finish what they were doing before helping her. CNA 4 stated Resident 75 had very specific preferences and was an active participant in her care. CNA 4 stated Resident 75 was known to refuse care or ask for someone else to do the care if staff rushed or did not follow her preferences. CNA 4 stated she had been working on 6/16/21 when CNA 1 had asked her to assist with Resident 75's care. CNA 4 stated CNA 1 had asked for her assistance after 10 P.M. CNA 4 stated she told CNA 1 she would be in to help after she finished documenting her assigned residents' care. CNA 4 was asked to describe what she saw when she entered Resident 75's room to help with care. CNA 4 stated, Oh, wow. CNA 4 stated CNA 1 had been completely finished and no longer needed her help. CNA 4 stated eleven minutes had passed from the time CNA 1 asked for her help until the time she entered Resident 75's room. CNA 4 stated she knew it was eleven minutes because she saw the time on the computer she was charting on. CNA 4 stated it usually took 45 minutes to complete Resident 75's care and that eleven minutes was too fast. CNA 4 stated, I wasn't expecting it to be that quick. CNA 4 stated CNA 1 was coming out of Resident 75's room carrying trash and CNA 1 stated to her, She's [Resident 75] a racist. CNA 4 stated CNA 1 made that statement in front of Resident 75 and that the resident heard the statement. CNA 4 stated after CNA 1 had left the room, Resident 75 told her, I'm not a racist. CNA 4 stated Resident 75 was distressed by CNA 1's comment. CNA 4 stated CNA 1's comment to Resident 1 was not acceptable. CNA 4 further stated that Resident 75 was strong enough to help with turning in bed and that the resident did not require staff to turn her with the draw sheet. CNA 4 stated Resident 75 was able to hold a side-lying position and would turn herself back over onto her back with verbal cueing from staff. CNA 4 stated Resident 75's care routine involved taking her sheet or blanket entirely off during the care. CNA 4 stated she was not familiar with folding the sheet over the resident's chest. CNA 4 stated Resident 75 considered a thorough cleaning of her private area after an incontinence episode as an important part her care. CNA 4 stated staff were allowed to stay overtime if it was needed in order to finish providing care to a resident. A review of Resident 75's Psychosocial Note dated 6/17/21, indicated, MSW [medical social worker] met with the resident at bedside in regards to the resident's complaint of rough handling and verbal abuse to the DON . Resident stated 'last night the CNA came to change me and during the process the CNA was rough and hurt my neck. I already have neck issues due to my arthritis, but when the CNA removed my pillow from my head, she pulled it out hard and my head fell back. Also while moving me, I asked her to please be careful, but she kept pulling me around hard. When she removed my diaper, she pulled it from the bottom so hard that it tore.' MSW asked resident if anything else occurred, and resident stated, 'the CNA was telling me nobody likes me here and that none of the staff could stand her.' Resident informed MSW that she felt hurt and upset because of those comments On 6/21/21 at 8:31 A.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated she managed CNAs and they reported to her. The DSD stated she was also responsible for providing staff education to include abuse prevention training. The DSD stated she was aware of Resident 75's preferences related to incontinence care. The DSD stated it was her expectation that CNAs honored Resident 75's preferences and performed the care the way the resident preferred it, no matter the time it required. The DSD stated it was her expectation that CNAs explained the care to the resident and included the resident in the care. The DSD stated it was unacceptable to not communicate with a resident. The DSD stated when a resident asked for staff to stop providing care, the staff should have immediately stopped. The DSD stated being rough with a resident could be perceived by a resident as abusive. The DSD stated providing cleaning to a resident after an incontinence episode was an expectation. The DSD stated not providing cleaning after an incontinence episode could be perceived as neglect. The DSD stated causing a resident pain by being rough during care and telling a resident that no one liked them and calling them a racist could be perceived as abuse. The DSD stated the incident that occurred on 6/16/21 between CNA 1 and Resident 75 was abusive to the resident. The DSD stated, This is abuse. The DSD stated when Resident 75 experienced being upset to her stomach and complained of having nerves after the incident on 6/17/21 that this was a psychosocial outcome. The DSD reviewed CNA 1's abuse and neglect prevention training that was done on CNA 1's orientation (5/20/21). CNA 1's Checklist for New Facility Associate Orientation with date of hire: 5/20/21, indicated, The following policies were provided to me during facility orientation: .Elder Justice Act, Resident Abuse Policy, .Respect/Harassment, Resident Rights, Associate Code of Conduct .The above information has been explained to me during facility orientation. I understand I am responsible for knowing and following the policies and procedures relating to these topics . The Checklist for New Facility Associate Orientation was signed by CNA 1 on 5/20/21. The DSD stated CNA 1 had received abuse and neglect prevention training. The DSD stated CNA 1 would have known that her conduct on 6/16/21 was wrong and went against her training. On 6/21/21 at 1:15 P.M. a joint interview was conducted with the DON and the facility's administrator (ADM). The DON stated when Resident 75 asked CNA 1 to stop providing care, CNA 1 should have stopped. The DON stated when Resident 75 was treated roughly, told no one liked her, and was called a racist by CNA 1, that it was abuse. The ADM stated the incident that occurred on 6/16/21 between CNA 1 and Resident 75 could be perceived as abuse by the resident. The ADM stated this was an ugly situation that should never have happened. The ADM stated CNA 1 had made inconsistent statements. The ADM stated he found Resident 75 to be credible in her accounting of the events on 6/16/21, and that the facility had substantiated Resident 75's allegation of verbal abuse. The ADM stated Resident 75 may have been exhibiting anxiety on 6/17/21 related to the incident on 6/16/21 when the resident complained of nausea and vomiting. The ADM stated CNA 1's conduct had been totally unacceptable. The ADM stated the facility had zero tolerance that type of behavior. A review of the facility's policy titled Protection of Residents: Reducing the Threat of Abuse and Neglect, reviewed 5/15/20, indicated, . Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone . Residents must not be subjected to abuse by anyone

Based on observation, interview, and record review, the facility failed to ensure it had an effective QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) program in place to identify and make good faith attempts to correct care issues identified by Resident 81 during a complaint investigation, which included: - Wound treatments (See F-Tag 684) - Pharmacy Services (See F-Tag 755) - Medication Error Rate Greater than Five Percent (See F-Tag 759), and - Staffing, which was a repeat deficiency identified during the re-certification survey conducted on 6/15/21 through 6/21/21 (See F-Tag 725). As a result of this deficient practice, systemic care issues were identified by the survey team during a revisit conducted on 9/1/21 through 9/8/21. These failures had the potential to impact the quality of care delivered to all residents. Findings: Resident 81 was readmitted to the facility on [DATE], and was her own responsible party, per the facility's Admission Record. On 8/10/21 at 1:10 P.M., an interview was conducted with Resident 81 during the investigation of a complaint. Resident 81 stated the facility was providing medications to the residents late and at times residents were given the wrong medication or wrong dosage. Resident 81 stated there was no treatment nurse on Saturdays and that her treatments were not consistently being done. Resident 81 stated the facility had a staffing problem as it was difficult to get help when you needed it. Resident 81 described all shifts as having a staffing problem. Resident 81 stated she was interested in sharing these concerns with the administrator (ADM) and director of nursing (DON). On 8/10/21 at 2:22 P.M., a joint interview was conducted with Resident 81, DON, and ADM. Resident 81 told the ADM and DON of her concerns regarding receiving late and incorrect medications, not receiving consistent treatments, and not receiving help in a timely manner. The ADM and DON told Resident 81 that her concerns would be thoroughly looked into and investigated. On 9/3/21 at 9:10 A.M., an interview was conducted with the director of nursing (DON). The DON stated the facility's staffing was a problem. The DON stated he was aware the nurses' workloads were different on the first and second floors. The DON stated he was aware nurses on the first floor averaged 18-19 residents each and they had a supervisor on the unit while the second floor nurses averaged 27-28 residents each and were without a supervisor. The DON stated nurse workloads and resident acuity levels (the amount of care a resident required) had not been reviewed in order to facilitate timely medication administration, consistent treatments, and more efficient responses to resident needs. On 9/7/21 at 12:25 P.M., an interview was conducted with the director of staff development (DSD). The DSD stated staffing has been an issue. The DSD stated the facility should have discussed nurse workload and resident acuity to help ease the current staffing burden. On 9/7/21 at 4:10 P.M., another interview was conducted with the DON. The DON stated he was informed and aware of Resident 81's concerns on 8/10/21 regarding late and incorrect medication administration, treatments not being provided, and not getting help timely. The DON stated more should have been done after he received Resident 81's complaints about medication administration, treatment, and staffing on 8/10/21. The DON stated Resident 81's concerns should have been looked into more thoroughly. On 9/8/21 at 2:50 P.M., an interview was conducted with 23 members of the facility's QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) Committee. The interim administrator (IADM) and social services director (SSD) both stated the QAPI/QAA used resident grievances, feedback from resident council, and resident complaints as methods for identifying care issues for the QAPI/QAA program to respond to. The IADM stated Resident 81's care concerns should have been identified by the QAPI/QAA Committee and acted upon for performance improvement. The IADM stated the QAPI/QAA Committee had room for improvement. A review of the facility's policy titled Quality Assessment and Assurance Committee Roles and Responsibilities, dated 12/2019, indicated, .4. The QAA committee must meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues .Develop and implement appropriate plans of action to correct identified quality deficiencies

Based on observation, interview, and record review, the facility failed to ensure it had an effective QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) program in place to identify and make good faith attempts to correct care issues identified by Resident 81 during a complaint investigation, which included: - Wound treatments (See F-Tag 684) - Pharmacy Services (See F-Tag 755) - Medication Error Rate Greater than Five Percent (See F-Tag 759), and - Staffing, which was a repeat deficiency identified during the re-certification survey conducted on 6/15/21 through 6/21/21 (See F-Tag 725). As a result of this deficient practice, systemic care issues were identified by the survey team during a revisit conducted on 9/1/21 through 9/8/21. These failures had the potential to impact the quality of care delivered to all residents. Findings: Resident 81 was readmitted to the facility on [DATE], and was her own responsible party, per the facility's admission Record. On 8/10/21 at 1:10 P.M., an interview was conducted with Resident 81 during the investigation of a complaint. Resident 81 stated the facility was providing medications to the residents late and at times residents were given the wrong medication or wrong dosage. Resident 81 stated there was no treatment nurse on Saturdays and that her treatments were not consistently being done. Resident 81 stated the facility had a staffing problem as it was difficult to get help when you needed it. Resident 81 described all shifts as having a staffing problem. Resident 81 stated she was interested in sharing these concerns with the administrator (ADM) and director of nursing (DON). On 8/10/21 at 2:22 P.M., a joint interview was conducted with Resident 81, DON, and ADM. Resident 81 told the ADM and DON of her concerns regarding receiving late and incorrect medications, not receiving consistent treatments, and not receiving help in a timely manner. The ADM and DON told Resident 81 that her concerns would be thoroughly looked into and investigated. On 9/3/21 at 9:10 A.M., an interview was conducted with the director of nursing (DON). The DON stated the facility's staffing was a problem. The DON stated he was aware the nurses' workloads were different on the first and second floors. The DON stated he was aware nurses on the first floor averaged 18-19 residents each and they had a supervisor on the unit while the second floor nurses averaged 27-28 residents each and were without a supervisor. The DON stated nurse workloads and resident acuity levels (the amount of care a resident required) had not been reviewed in order to facilitate timely medication administration, consistent treatments, and more efficient responses to resident needs. On 9/7/21 at 12:25 P.M., an interview was conducted with the director of staff development (DSD). The DSD stated staffing has been an issue. The DSD stated the facility should have discussed nurse workload and resident acuity to help ease the current staffing burden. On 9/7/21 at 4:10 P.M., another interview was conducted with the DON. The DON stated he was informed and aware of Resident 81's concerns on 8/10/21 regarding late and incorrect medication administration, treatments not being provided, and not getting help timely. The DON stated more should have been done after he received Resident 81's complaints about medication administration, treatment, and staffing on 8/10/21. The DON stated Resident 81's concerns should have been looked into more thoroughly. On 9/8/21 at 2:50 P.M., an interview was conducted with 23 members of the facility's QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) Committee. The interim administrator (IADM) and social services director (SSD) both stated the QAPI/QAA used resident grievances, feedback from resident council, and resident complaints as methods for identifying care issues for the QAPI/QAA program to respond to. The IADM stated Resident 81's care concerns should have been identified by the QAPI/QAA Committee and acted upon for performance improvement. The IADM stated the QAPI/QAA Committee had room for improvement. A review of the facility's policy titled Quality Assessment and Assurance Committee Roles and Responsibilities, dated 12/2019, indicated, .4. The QAA committee must meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues .Develop and implement appropriate plans of action to correct identified quality deficiencies

Based on observation, interview, and record review, the facility failed to provide routine medications to four of four residents (Residents 7, 81, 39, and 75) in a timely manner according to the physician's orders (cross reference F 759). This deficient practice had the potential to not meet the medical needs of all residents. Findings: Resident 7 was readmitted to the facility on [DATE], and was her own responsible party (medical decision maker), per the facility's Admission Record. Resident 81 was readmitted to the facility on [DATE], and was her own responsible party, per the facility's Admission Record. Resident 39 was readmitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms characterized by memory loss that interferes with daily functioning), per the facility's Admission Record. Resident 75 was readmitted to the facility on [DATE], and was her own responsible party, per the facility's Admission Record. On 8/10/21 at 1:10 P.M., an interview was conducted with Resident 81 in the resident's room. Resident 81 stated the facility was providing medications to the residents late and at times residents were given the wrong medication or wrong dosage. Resident 81 stated she would call the receptionist to get in contact with the licensed nurse (LN) in order to get her medications on time. Resident 81 stated she insisted on having her medication on time but was concerned about the other residents who received medications late. Resident 81 stated she felt as though she needed to advocate for the other residents who could not speak for themselves. Resident 81 stated she was interested in sharing these concerns with the administrator (ADM) and director of nursing (DON). On 8/10/21 at 2:22 P.M., a joint interview was conducted with Resident 81, DON, and ADM. Resident 81 told the ADM and DON of her concerns regarding receiving late and incorrect medications. The ADM and DON told Resident 81 that her concerns would be thoroughly looked into and investigated. On 9/2/21 at 10:35 A.M., an interview was conducted with licensed nurse (LN) 1. LN 1 stated she was currently responsible for 28 residents. LN 1 stated they used to have three nurses on the second floor to care for residents and to administer medications. LN 1 stated there was currently only two nurses on the second floor and it had been this way for a couple months. LN 1 stated she was a regular employee who was late administering medications because she had too many residents to care for. LN 1 stated it was after 10 A.M. and she was still administering medications scheduled for 9 A.M. to residents. LN 1 stated medication administration time was an hour before or an hour after the physician's scheduled time. On 9/2/21 at 10:57 A.M., a medication administration observation was conducted with LN 1. LN 1 prepared and administered 15 physician ordered medications to Resident 7. All 15 observed medications were administered 57 minutes late. On 9/2/21 at 11 A.M., an interview was conducted with Resident 7. Resident 7 stated medications were often given to her late. Resident 7 stated the 15 medications she took at 10:57 A.M. were scheduled to be administered at 9 A.M. Resident 7 stated she felt the facility did not have enough staff and that was effecting the medication administration times. On 9/2/21 at 11:20 A.M., an observation was conducted on the second floor. Lunch meal trays were observed being brought to the unit. On 9/2/21 at 11:22 A.M., a medication administration observation was conducted with LN 2. LN 2 was preparing to administer medications to Resident 75. Resident 75 stated to LN 2 that she did not want to take her medications because they were late. LN 2 educated Resident 75 on the importance of the medications. Resident 75 stated the medications should have been given to her earlier and that taking them this close to lunch would upset her stomach. A review of Resident 75's clinical record indicated the resident was scheduled to receive five (5) physician ordered medications at 9 A.M. Two of the five medications were an anticoagulant (prevents the formation of blood clots) and an antibiotic (treats infection). A review of Resident 75's progress notes, dated 9/2/21 at 11:32 A.M., indicated, . Late medication pass; resident refused all routine meds [medications] . Resident stated, 'I don't want the medication because it's too close to meal time; my lunch.' Resident would like medication before 10 am On 9/2/21 at 11:57 A.M., a medication administration observation was conducted with LN 2. LN 2 prepared and administered seven (7) medications to Resident 39. All seven observed medications were administered one hour and 57 minutes late. Resident 39 was not able to participate in an interview due to cognitive impairment. On 9/2/21 at 12:05 P.M., an interview was conducted with LN 2. LN 2 stated she was a registry nurse (nursing staff provided by an agency). LN 2 stated she had an assignment of 28 residents. LN 2 stated she still had morning medications scheduled for 9 A.M. to administer to many of the residents, at least half of my run [assigned residents]. On 9/2/21 at 5:25 P.M., an interview was conducted with Resident 75. Resident 75 stated she had always been a punctual person and that she refused her morning medications because they were so late. Resident 75 stated she was frustrated her medications were not provided to her on time, and that she would have taken them had they been timely. Resident 75 stated even when she lived at home, she took her medications after her meal in order to prevent having an upset stomach. Resident 75 stated she never took medication on an empty stomach. Resident 75 stated the facility's morning medications were often not administered before 10 A.M., and that today's situation had been really bad. On 9/3/21 at 9:10 A.M., an interview was conducted with the director of nursing (DON). The DON stated the facility's staffing was a problem. The DON stated he was aware the nurses' workloads were different on the first and second floors. The DON stated he was aware nurses on the first floor averaged 18-19 residents each while the second floor averaged 27-28 residents each. The DON stated nurse workloads and resident acuity levels (the amount of care a resident required) had not been reviewed in order to facilitate a timely medication administration. On 9/7/21 at 11:30 A.M., another interview was conducted with LN 1. LN 1 stated she was still struggling with having 27 assigned residents. LN 1 stated she had finished the morning medication administrations scheduled for 9 A.M. close to 11 A.M. LN 1 stated that Resident 81 was very particular about her medications. LN 1 stated Resident 81 would call the receptionist looking for the nurse or wait in the doorway to her room to call for the nurse. LN 1 stated Resident 81 would not let her medications arrive late. On 9/7/21 at 12:25 P.M., an interview was conducted with the director of staff development (DSD). The DSD stated residents should receive their physician ordered medications as ordered and according to the scheduled time. On 9/7/21 at 4:10 P.M., another interview was conducted with the DON. The DON stated it was his expectation that medication administration was performed accurately and timely by LNs. The DON stated he had been aware of Resident 81's complaint on 8/10/21 regarding late and incorrect medication administration. The DON stated he had not done his own medication administration observation nor reached out to the facility's pharmacy in August 2021 to determine if there was a facility issue with medication administration. The DON stated more should have been done after he received Resident 81's complaint about medication administration on 8/10/21. A review of the facility's policy titled Administration of Medications, revised 5/2020, indicated, .All medications are administered safely and appropriately per physician order

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 20 percent. Six (6) medication errors were observed, a total of 30 opportunities, during the medication administration process for two (2) of three randomly observed residents (Residents 36 and 39). As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 9/2/21 at 9:45 A.M., an observation of medication administration was conducted with licensed nurse (LN) 4. LN 4 prepared and administered medications to Resident 36, including: Two (2) tablets of vitamin D3 50 mcg (micrograms) (2000 IU) (international unit). One (1) tablet of [MEDICATION(S)] 400 mcg. One (1) tablet of sennosides-[MEDICATION(S)] sodium (prevents constipation) 8.6-50 mg (milligrams). A review of Resident 36's physician orders, dated 6/8/21, indicated: Vitamin D3 tablet 25 mcg (1000 IU). Give 2 tablets in the morning . [MEDICATION(S)] tablet 1 mg. Give once a day. Sennosides-[MEDICATION(S)] sodium 8.6-50 mg. Give 2 tablets twice a day. On 9/7/21 at 11 A.M., a joint interview and record review was conducted with LN 4. LN 4 reviewed Resident 36's clinical record and stated that she had given the resident the incorrect dose of vitamin D3 on the morning of 9/2/21. LN 4 stated on 9/2/21 she had given Resident 36 too much vitamin D3 when she administered two tablets. LN 4 stated she had given an incorrect dose of [MEDICATION(S)] to Resident 36 on the morning of 9/2/21. LN 4 stated she later realized Resident 36 had [MEDICATION(S)] that was dispensed from the pharmacy as a 1 mg dose in the prescription drawer of the medication cart. LN 4 stated on 9/2/21 she had not administered enough [MEDICATION(S)] to the resident. LN 4 stated she had also given Resident 36 an incorrect dose of sennosides-[MEDICATION(S)] sodium 8.6-50 mg on 9/2/21. LN 4 stated she had not administered enough to Resident 36 and should have given the resident two tablets. LN 4 stated residents should receive medications without errors and according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. On 9/2/21 at 11:57 A.M., an observation of medication administration was conducted with licensed nurse (LN) 2. LN 2 prepared and administered medications to Resident 39, including: One (1) tablet of vitamin D3 25 mcg (1000 IU). One (1) tablet of vitamin B12 500 mcg. LN 2 took Resident 39's vital signs and stated the resident's blood pressure was 114/64 and the resident's heart rate was 74 beats per minute. LN 2 stated, I'm holding the [MEDICATION(S)] [blood pressure/heart medication]. A review of Resident 39's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Vitamin B12 1000 mcg. Give 1 tablet once a day. Vitamin D3 1000 IU. Give 2 tablets once a day. [MEDICATION(S)] Tart 25 mg. Give half a tablet twice a day for hypertension (high blood pressure). On 9/7/21 at 12:25 P.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD reviewed Resident 39's clinical record and stated on 9/2/21 the resident had been incorrectly administered vitamin B12 and vitamin D3. The DSD stated there was no hold parameter in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DSD stated there was nothing concerning with Resident 39's blood pressure reading of 114/64 and heart rate of 74 that would indicate the [MEDICATION(S)] should have been held. The DSD stated if the nurse were concerned about a resident's vital signs, the physician should have been called to discuss the vitals and administration of [MEDICATION(S)]. The DSD stated there was no documentation the physician had been called. The DSD stated she could not understand why LN 2 held Resident 39's [MEDICATION(S)]. The DSD stated this was a medication error by omission. The DSD stated it was important that medications be administered accurately to residents. LN 2 was not available for interview. On 9/7/21 at 4:10 P.M., an interview was conducted with the director of nursing (DON). The DON stated it was his expectation that medication administration was performed accurately and timely by LNs. The DON stated medication errors could cause harm to a resident. The DON was informed the facility had a 20 percent medication error rate during the medication administration observation conducted on 9/2/21. The DON stated the medication error rate was concerning. The DON further stated he had been aware of Resident 81's complaint on 8/10/21 regarding late and incorrect medication administration. The DON stated he had not done his own medication administration observation nor reached out to the facility's pharmacy in August 2021 to determine if there were a facility issue with medication administration. The DON stated more should have been done after he received the resident's complaint about medication administration on 8/10/21. A review of the facility's policy titled Administration of Medications, revised 5/2020, indicated, .All medications are administered safely and appropriately per physician order [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility's medical director (MD) failed to ensure medical care was provided to residents according to acceptable standards of practice for the following: - Development and Implementation of Care Plans (See F-Tag 656) - Quality of Care/Treatment (See F-Tag 684) - Accidents and Hazards (See F-Tag 689) - [CONDITION(S)] Assessments (See F-Tag 698) - Sufficient Nursing Staff (See F-Tag 725) - Pharmacy Services (See F-Tag 755) - Medication Errors Greater than Five Percent (See F-Tag 759) - Lab Reports (See F-Tag 775) - Medical Records (See F-Tag 842) - Infection Control (See F-Tag 880) As a result, resident care was not provided in accordance to the facility policies and procedures, which could potentially result in physical and psychosocial harm to the residents. Findings: On 9/8/21 at 9:10 A.M., a telephone interview with the MD was conducted. The MD stated he was aware of results of the facility's re-certification survey completed on 6/21/21. The MD stated he knew there would be a revisit wherein the facility would be expected to be in compliance with their plan of correction (POC) for deficiencies identified during the re-certification survey. The MD stated the facility was experiencing a nursing staff shortage as there had been a mass exodus of nurses. The MD stated the facility was using registry staff (nursing staff provided by an agency) and had several new hires. The MD stated he had some input in the facility's POC and felt the facility was doing their best to monitor and perform audits for POC compliance. The MD stated he felt the facility had done a good job with compliance under the circumstances, but that the facility could not ensure 100 percent of the POC was done due to unprecedented staff turnover. The MD was informed that the facility had areas of repeated noncompliance and that the facility had not fully implemented their POC. The MD stated he thought the past issues related to laboratory results had been fixed. The MD stated he was not aware the issue with laboratory results was ongoing and that the providers were not being informed of lab results. The MD stated he had been unaware that the facility was not following their POC and was not conducting consistent audits for compliance. The facility's issues identified with medication administration were discussed. The MD stated the facility should check the medication administration competency of registry nurses. The MD stated it was important to ensure registry staff were providing care correctly. The MD stated the facility's POC was not fully implemented as there had been so many challenges. The MD stated, Care should have been given to the residents according to acceptable standards of practice. On 9/8/21 at 2:50 P.M., an interview was conducted with 23 members of the facility's QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) Committee. The interim administrator (IADM) stated after the QAPI/QAA Committee met, the facility would conduct the Medical Director and Facility Oversite Committee which included the medical director, the administrator, and the director of nursing. The IADM reviewed the QAPI/QAA minutes for 7/20/21 and 8/24/21 and stated there was no documentation of the Medical Director Facility Oversight Committee meeting. The IADM stated he would not expect the medical director to raise questions and provide guidance and oversight about POC compliance if the medical director were not made aware of the results of the facility audits and other care issues. The IADM further stated the QAPI/QAA minutes were unclear as to what was specifically discussed during the QAPI/QAA meetings. The IADM stated based on the content of the QAPI/QAA minutes, the medical director would not know what was going on. A review of the facility policy and procedure titled Medical Director, revised 8/2021, indicated, .The facility will have a designated medical director who is responsible for implementing care policies and coordinating medical care . 2.responsibilities must include .: .Coordinating and planning for improvement of medical care in the facility .Ensuring the appropriateness and quality of medical care and medically related care; . Any issues related to the facility performance improvement, regulatory compliance concerns, and any quality of care or safety issues should be recorded on the Medical Director Facility Oversight Committee Minutes .5. The facility's responsibilities in relation to its medical director include: Working with the medical director to ensure adequate resident care