Every finding on record at Wellsburg Healthcare Center

Based on observation resident interviews, staff interviews and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the resident's personal products and unsanitary practices. Resident identifiers: #7, #31, #18, and #52. Facility Census: 52.Findings Included:a) Resident #7:During a facility walkthrough and resident interviews on 06/08/26 at 12:59 PM, it was observed that Resident #7's wheelchair had rips and tears on the edge of the seat and a round hole on each corner of the back rest by the handles exposing the inner padding. b) room [ROOM NUMBER]:Residents #31 and #18:During a facility walk through and resident interviews, on 06/09/26 at around 10:15AM, It was observed that Resident #31' s wheelchair was located at the end of her bed with a tear in the right side of the backrest, with the inner padding protruding outward. Also upon observation, the left footrest for her wheelchair, located on the counter next to the shared sink, had a tear approximately 1/2 inch long in the outer padding exposing the inner padding. Further investigation of room [ROOM NUMBER], found the guest chair near Resident #18's bed. The plastic covering on the end of the left arm rest, had an approximate 6 inch tear with 4 puncture holes, causing the plastic covering to hang loose off the sides, also exposing the inner padding. Also exposing the inner padding.c) Resident #52:During an interview with Resident #52, on 06/10/26 at around 2:05 PM, the surveyor observed that the back stabilizer pad on her electric wheelchair had 1/4-inch holes around the top edge, both corners of the shoulder pads, down the backrest, and in both corners of the seat pad. Infection Preventionist Interviews:On 06/08/26 at 1:10PM the infection preventionist confirmed the issues in Resident #7's wheelchair and stated she would have it replaced. On 06/10/26 at approximately 2:15 PM, during a facility walk through and interview with the Infection Preventionist, she confirmed that Resident #31's and #52's wheelchairs and #18's guest chair had rips, tears, and holes. She stated she would recheck all wheelchairs in the facility for repair and/or replacement.

Based on observations, and staff interviews, the facility failed to ensure resident's call lights were within reach. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #15 Facility Census: 52.Findings included:a) Resident #15During resident interviews and a facility walkthrough on 06/08/26 at 12:25 PM it was observed that Resident #15's call bell was under the resident's bed not within her reach. CNA #57 was interviewed on 08/08/26 at 12:30 PM. She verified the call bell was under the resident's bed, not within reach of the resident and stated, I'm sorry. It must have fallen under there when we repositioned her for her lunch tray. We didn't realize it. In an interview with the DON on 08/08/26 at 12:38 PM, she acknowledged Resident #15's call light was not within reach and stated, Thank you for letting me know.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents in room [ROOM NUMBER]. This was a random opportunity for discovery. Resident #33, #42. Facility census: 52.Findings included:a) room [ROOM NUMBER]During a facility walk-through on 06/08/26 in room [ROOM NUMBER]'s bathroom, a brownish substance was around the toilet base and debris had built up under the seat, accompanied by yellow and brown dried liquid marks down the toilet base.On 06/10/26 at 11:50 AM, a recheck of room [ROOM NUMBER]'s bathroom was conducted. It was observed that Housekeeping Survervisor (HS) #81 had just left the room. Further observation found a brownish substance approximately the size of a nickel on the toilet bowl, yellowish debris buildup on the rim of the toilet bowl and under the plastic raised toilet seat, with dried yellow and brown splashes down the sides and front of the base from the toilet bowl to the floor. During an interview with the Housekeeping Supervisor (HS) #81 on 06/10/26 at 11:55 AM. HS #81 confirmed she had just finished cleaning room [ROOM NUMBER] and the bathroom. Upon showing her the findings of the buildup of debris under the raised toilet seat and brown spot on the outside of the toilet bowl and dried splashes down the sides of the base, she confirmed and stated she had missed them.

Based on observation, Resident interviews, and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible in regard to an unlocked med cart in 100 hall, also a loose countertop and sink. this failed practice was a random opportunity for discovery that could effect a limited number of residents. Resident Identifier #16. Facility Census: 52. Findings Included: a) 100 hall med cart observation: On 06/09/26 at 9:15 AM the med cart was observed outside room [ROOM NUMBER] in the 100 hall unlocked and unattended while RN #56 was administering medications in another resident's room. An interview was conducted with RN #56 on 06/09/26 at 9:18 AM. She confirmed she had not locked the med cart before leaving it to administer meds in a resident's room on the 100 hall and apologized. In an Interview with the Nurse manager on 06/09/26 at 9:25 AM, she acknowledged the med cart was left unlocked in the 100 hallway and stated, She's new and has been very nervous here and learning a new facility with state . In an interview with the DON on 06/09/26 at 9:35 AM she acknowledged the med cart was left unlocked in the 100 hall and stated, Thank you for letting me know. b) Resident #16 On 06/09/26 at around 11:30 AM, during observation of Resident #16's room, the surveyor observed that the caulk along the sink edges—under the mirror and along the side wall to the right—was cracked and loose. When leaning against the countertop, the surveyor observed the sink was loose. Resident #16 reported, I noticed it being loose, I hope it doesn't come too loose and I fall when I wash my hands. On 06/09/26 at around 1:30 PM, during a follow-up observation of the sink in the room, the surveyor again observed that the caulk along the sink edges on the wall under the mirror and along the side wall to the right remained cracked and loose. The sink countertop remained loose. The resident reports, It's loose; I hope I don't fall. During an observation the Administrator was with the surveyor, and the administrator verified that this was loose and could cause injury. The Administrator reported, I will let our maintenance director know so he can get it corrected. This was true for one (1) of 32 rooms observed.

Based upon observation, record review and staff interview, the facility failed to maintain accurate medical records for Resident #6 wearing Ulnar Gutter Splint on the right hand every day. Resident identifier: #6. Facility census: 52.Findings included: a) Resident #6 An observation of Resident #6 on 06/09/26 at 10:00 AM (dining room during activity), 12:20 PM (dining room for lunch), and 2:00 PM (sitting by nurse station getting ready to go to an activity) revealed the resident was not wearing Ulnar Gutter Splint per physician's orders. During the 10:00 AM observation one surveyor made the observation. At 12:20 PM observation was made by two (2) surveyors, and the 2:00 PM observation was witnessed by Staff Member #40. A review of the Treatment Authorization Record (TAR) shows Employee #32 signed off for the day section of Resident #6 wearing the splint when observation proved otherwise. The surveyor discussed this with the Director of Nursing (DON) on 06/09/2026 at 2:15 PM. Her response was, We probably need to talk to the doctor because she may be able to discharge this now.

Based on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge which included the resident's right to submit an appeal and the name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman, was provided to residents/resident representatives for five (5) of five (5) residents reviewed for hospitalization s during the long-term care survey process. This had the potential to affect all residents being transferred or discharged . Resident identifiers: #20, #52, #12, #21 and #33. Facility census: 52 Findings included: a1) Resident #20 - 07/05/24 hospitalization A record review completed on 01/22/25 at 1:49 PM revealed that resident had been transferred to the hospital on 07/05/24. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. a2) Resident #20 - 09/20/24 hospitalization A record review completed on 01/22/25 at 1:49 PM revealed that resident had been transferred to the hospital on 09/20/24. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. a3) Resident #20 - 12/04/24 hospitalization A record review completed on 01/22/25 at 1:49 PM revealed that resident had been transferred to the hospital on 12/04/24. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. a4) Resident #20 - 01/06/25 hospitalization A record review completed on 01/22/25 at 1:49 PM revealed that resident had been transferred to the hospital on 01/06/25. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. a5) Resident #20 - 01/10/25 hospitalization A record review completed on 01/22/25 at 1:49 PM revealed that resident had been transferred to the hospital on 01/10/25. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. a6) Administrative Interview During an interview on 01/22/25 at 3:45 PM, the Administrator and the Director of Nursing (DON) acknowledged the facility's form did not include the resident's right to appeal and the Ombudsman's contact information. b1) Resident #52 - 01/05/25 hospitalization A record review completed on 01/22/25 at 6:37 PM revealed that resident had been transferred to the hospital on 01/05/25. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. b2) Administrative Interview During an interview on 01/22/25 at 3:45 PM, the Administrator and the Director of Nursing (DON) acknowledged the facility's form did not include the resident's right to appeal and the Ombudsman's contact information. c1) Resident #12 - 10/22/24 hospitalization A record review, completed on 01/22/25 at 1:26 PM revealed that resident had been transferred to the hospital on 10/22/24. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. c2) Resident #12 - 12/05/24 hospitalization A record review, completed on 01/22/25 at 1:26 PM revealed that resident had been transferred to the hospital on 12/05/24. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. c3) Administrative Interview During an interview on 01/22/25 at 3:45 PM, the Administrator and the Director of Nursing (DON) acknowledged the facility's form did not include the resident's right to appeal and the Ombudsman's contact information. d1) Resident #21 - 01/09/25 hospitalization A record review completed on 01/22/25 at 7:10 PM revealed that resident had been transferred tp the hospital on 01/09/25. The Notice of Transfer/Discharge given to resident did not have a statement of the resident's right to appeal and the name, address (mailing and email), and the telephone number of the long-term care ombudsman. d2) Administrative Interview During an interview on 01/22/25 at 3:45 PM, the Administrator and the Director of Nursing (DON) acknowledged the facility's form did not include the resident's right to appeal and the Ombudsman's contact information. 45171 Findings include: e) Resident #33 1) On 12/19/24 Resident #33 was transferred to the local hospital emergency room for evaluation. Review of transfer documentation shows the following required documents were completed as required: Ombudsman notification, bed hold authorization and the E interact transfer form. Review of the Acute Transfer Letter was reviewed and found it did not provide a written notice of transfer/discharge to the resident/resident's representative which included the resident's right to file a grievance. This was confirmed on 01/22/25 3:45 PM with the Director of Nursing. 2) On 12/31/24 Resident #33 was transferred to the local hospital emergency room for evaluation. Review of transfer documentation shows the following required documents were completed as required: Ombudsman notification, bed hold authorization and the E interact transfer form. Review of the Acute Transfer Letter was reviewed and found it did not provide a written notice of transfer/discharge to the resident/resident's representative which included the resident's right to file a grievance. This was confirmed on 01/22/25 3:45 PM with the Director of Nursing.

Based on record review and staff interview, the facility failed to maintain an accurate medical record for two (2) out of 21 records reviewed during the Long-Term Care Survey Process. Resident identifiers: #46 and #29. Facility census: 52 Findings included: a) Resident #46 During a record review, completed on [DATE] at 2:58 PM, the following discrepancy was found: -A Physician Orders for Scope of Treatment (POST) form, dated [DATE], listed Resident #46 as a Do Not Resuscitate (DNR) -A Physician Order, dated [DATE], read CPR (Cardiopulmonary Resuscitation). During an interview on [DATE] at 11:03 AM, the Director of Nursing (DON) was asked to explain how nursing staff were trained to determine a resident's code status. The DON demonstrated that staff would click on the Advance Directives hyperlink in the electronic medical record which would take them to the most recent POST form. The DON reported that the Resident #46 was considered a Do Not Resuscitate (DNR). The DON was then asked to pull up Resident #46's active physician order for code status. The DON acknowledged that the code status order entered on [DATE], read CPR. The DON stated that resident had been out to the hospital and had returned to the facility on [DATE]. She noted that LPN #33 had incorrectly entered the code status and immediately corrected the order. All three nursing staff who were responsible for entering orders were immediately re-educated and a whole house audit was completed to verify all code status orders were correct. [DATE] 11:21 AM DON provided information that the staff had been re-educated, there were no other identified issues, and all code status orders were correct in the building. 50795 b) Resident #29 On [DATE], at approximately 9:45 AM, a review of the immunization records for a random sample of residents was conducted. The records for Resident #29 included a completed Pneumonia vaccine consent/declination form. The facility indicated that the resident had declined the Pneumonia vaccine; however, the form lacked the resident's name. The documentation on the form stated, Verbal as per [NAME], and it had been signed by two witnesses. This discrepancy was brought to the attention of the Director of Nursing (DON) #13 and Administrator #15 at around 11:15 AM on [DATE]. They confirmed that the facility had failed to enter the resident's name on the form.

Based on observation and interview, the facility failed to provide a clean, comfortable, and homelike environment over which it had control, Specifically by not ensuring that a P-Tac unit was cleaned and maintained. This was true for one (1) of thirty-two (32) rooms surveyed during the long-term care survey process. This was a random opportunity for discovery. Room Identifier: room [ROOM NUMBER]. Facility Census: 52. Findings Included: a) room [ROOM NUMBER] During an observation of room [ROOM NUMBER] on 01/21/25 at approximately 1:45 PM, lint and debris were observed inside the vent grille of the P-Tac unit. A repeat inspection of the P-Tac unit on 01/22/25 at 1:35 PM revealed that it had still not been cleaned. On 01/23/25 at approximately 10:00 AM, the Director of Nursing (DON) #13 and Corporate Nurse (CN) # 71 were notified of the dirty P-Tac unit. They inspected it and stated that it would be cleaned immediately. At approximately 10:15 AM on 01/23/25, a maintenance worker was observed servicing the P-Tac unit.

Based on medical record review and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. Staff's failure to roll a resident towards self and instead rolling the resident towards the opposite side of the bed resulted in harm from a fall with major injury. This is true for one (1) of four (4) residents reviewed for quality of care. Resident identifier: #100. Facility census: 55. Findings included: a) Resident (R) #100 Review of the medical record on 07/05/23, noted Resident #100 had a diagnosis of Alzheimer's Disease and dementia with severe cognitive impairment. The significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date of 04/02/23 noted Resident #100 was totally dependent on one (1) staff member for bed mobility, dressing, toileting, and hygiene. The care area assessment identified Resident#100's potential for fall/major injury from fall because of potential medication side effects, severe cognition deficits, mobility and balance impairments, incontinence, poor/absent safety awareness, and mechanical lift transfers. Review of the medical record found the resident rolled out of bed while receiving incontinence care on 06/11/12 at 11:50 PM. At this time the resident had no pain. On 06/12/23 at 12:09 AM, the physician and family were notified of the fall. A post fall evaluation, dated 06/12/23 at 12:09 AM, noted the resident was not complaining of any pain. She had a bruise to the back of her left hand. On 06/12/23 at 7:36 AM, the Resident began complaining of left hip and upper leg pain. An x-ray was ordered. At 10:15 AM on 06/12/23, the facility was notified the left hip and pelvis x-rays were negative for a fracture. A fall follow up, dated 06/12/23 at 12:05 PM, notes extremities moving within normal limits for this resident. The Resident was experiencing pain. 6/12/2023 a root cause analysis was completed with the interdisciplinary team for the fall on 06/11/23. An education on incontinent care for a resident in bed was completed with the nurse aide who was providing care when Resident #100 rolled out of bed. On 06/14/23 at 10:49 AM, the floor nurse notified the Assistant Director of Nursing the resident has bruising to the medial and dorsal aspects of the right foot and right great toe. The Resident was grimacing and flinching with the movement of both legs. A second x-ray was ordered. A SBAR (Situation Background Assessment Recommendation) communication form dated 06/14/23 at 2:10 PM, noted the Resident has new pain, facial grimacing, tense, fidgeting and distressed pacing. On 06/14/23 at 2:20 PM, the facility notified the physician of the x-ray results noting bilateral distal femoral fractures. The physician gave orders to transfer the Resident to the hospital. There was no information in the medical record to indicate the Resident had any other falls or accidents between the time the resident rolled out of bed on 06/11/12 until the x-ray report on 06/14/23 noting the Resident had bilateral distal femoral fractures. . The incident statement form, dated 06/11/23 written and signed by Nurse Aide (NA) #45 stated during a bed bath the NA rolled Resident #100 away from him to dry off the resident and place a clean brief. The resident's feet and legs rolled off the bed and NA #45 was unable to prevent her from falling to the floor. Staff identified non-verbal signs of discomfort with movement of her legs three (3) days after the fall. Portable x-rays on 06/14/23 revealed distal fractures of both femurs. Resident #100 was transferred to an acute care center. During an interview on 07/05/23 at 9:30 AM, the Administrator acknowledged Resident #100 rolled out of bed onto the floor after NA #45 rolled her towards the opposite side of the bed from where he was standing during care. The Administer acknowledged the fall resulted in harm from a major injury and the resident was transferred to an acute care center once the injuries were identified.

43340 Based on record review and staff interview, the facility failed to notify the resident's representative in a timely fashion when the resident experienced a fracture. This was true for one (1) of three (3) residents reviewed for notifications in the complaint survey process. Resident identifier: #43. Facility census: 55. Findings included: a) Resident #43 A medical record review, completed on 07/05/23 at 10:20 AM, revealed the following details: Resident #43 was admitted to the facility on [DATE]. Resident #43 has the following diagnoses: Huntington's Disease; Depression; Dysphagia; Hypothyroidism; Anxiety Disorder; Dementia in Other Diseases Classified Elsewhere, Moderate with Agitation; and Nondisplaced Fracture of Middle Phalanx of Left Little Finger (pinky finger), Initial Encounter for Closed Fracture. A Physician Determination of Capacity, dated 01/25/23, revealed Resident #43 demonstrated incapacity to make medical decisions. The [NAME] Virginia Department of Health and Human Resources (DHHR) was appointed the Legal Guardian and Legal Guardianship Paperwork was on file. A nurses note, dated 06/18/2023 at 10:06 AM, stated, Resident noted to have swelling and a dark purple discoloration to her left 5th finger (pinky). Resident not showing signs of pain when finger is touched or moved at this time. This nurse called and notified MD (Medical Doctor). MD gave telephone order for an x-ray to be done to finger and to tape 4th and 5th fingers together with a paper tape loosely. This nurse called [x-ray company's name] and placed x-ray order. This nurse called and left a message for case worker. A second nurses note, dated 06/18/2023 at 2:25 PM, stated, X-ray result received, there is a fracture of the proximal metaphysis, middle phalanx, fifth finger (pinky finger). This nurse called and notified MD (Medical Doctor). MD gave order to tape fourth and fifth fingers together. Resident not showing any signs of pain or discomfort at this time. There was no evidence in Resident #43's medical chart to indicate resident's legal guardian had been notified of the x-ray results and that Resident #43 had a fractured pinky finger. During an interview on 07/05/23 at 11:30 AM, the Director of Nursing (DON) stated the facility was unable to produce any evidence that the Legal Guardian was notified of x-ray results / fracture.

Based on record review, facility concern/grievance review, staff interviews and individual interviews, the facility failed to ensure prompt efforts were made to resolve grievances for three (3) of five (5) residents reviewed. Resident identifiers: Resident #3, #21 and #150. Census: 52. Findings included: a) Policy review A review of Policy, NS 1601-00, titled: Resident Grievance, effective date, 01/12/2017,showed under Section 1. a., upon receipt of an oral, written, or anonymous grievance submitted by a resident, the Grievance Official would take immediate action to prevent further potential violations. The policy noted, under Section 4., the grievance review will be completed in a reasonable time frame consistent with the type of grievance. Under Section 5. a., the policy showed upon the completion of the review, the Grievance Officer would complete a written grievance decision that included the following: the date the grievance was received, a summary of the resident's grievance, the steps taken to investigate the grievance, the summary of pertinent findings or conclusions regarding the resident's concern, a statements to whether the grievance was confirmed or not confirmed, whether corrective action was taken and a summary of the corrective action if taken and the date the decision was issued. Under Section 6, the policy showed the Grievance officer would meet with the resident and inform the resident of the results of the investigation and how the grievance was resolved or will be resolved. b) Resident #3 An interview with Resident #3, on 01/30/23 at 09:14 AM, revealed the resident was missing a quilt/blanket she had received as a Christmas gift and this had been reported to staff It was further stated, by Resident #3, the quilt/blanket had been sent to laundry to be labeled and it had not come back. A record review for Resident #3 showed a current assessment noting the residents Brief Interview for Mental Status (BIMS), reflected a score of 15, which indicated the resident had no cognitive impairment. On 01/31/23 at 10:38 AM, an inspection of the laundry area and interviews with the Laundry/Housekeeping Supervisor and HK #48 were conducted. At this time, the surveyor told of the issue with #3 missing a blanket/quilt that was a Christmas gift. In the presence of the surveyor, The Laundry/Housekeeping Supervisor and HK #48 did not locate any blanket/quilt with Resident #3's name on it or one that resembled the description provided by the surveyor to facilty staff. An interview with Resident #3, on 02/01/23 at 08:50 AM, verified the resident had complained to staff repeatedly and the blanket had not been found. During this time, the Housekeeping/Laundry Supervisor entered the room, and it was verified the missing blanket was not in the resident's closet. An interview with the Social Service Director, on 02/01/23 at 11:40 AM , revealed the Laundry/Housekeeping Supervisor brought the missing item to her attention that surveyor had discussed 01/31/23 and provided a copy of the concern/grievance form dated 01/31/23, even though Resident #3 stated she had been complaining to staff for an extended period of time. During the interview, the Social Service Director verified Resident #3 was a reliable historian added she was not happy with the way staff failed to notify her of concerns/grievances in a timely manner. b) Resident #21 An interview with Resident #21, on 01/30/23 at 09:18 AM, revealed this resident also had received a blanket for Christmas, was sent to laundry for labeling and was never returned to her. The blanket was described to the surveyor during tour. On 01/31/23 at 11:42 AM, an inspection of the laundry area and interviews with the Laundry/Housekeeping Supervisor and HK #48 were conducted. At this time, the surveyor told of the issue with #21 missing a blanket/quilt that was a Christmas gift. In the presence of the surveyor, the Laundry/Housekeeping Supervisor and HK #48 was showing the surveyor the labeling process, and the blanket description matched a blanket laying on the shelf with a label with Resident #21's name on it. An interview, with the Housekeeping/Laundry Supervisor on 02/01/23 at 08:30 AM, revealed Resident #21's roommate had told her about the missing blankets and this was told to the Social Services Director no later than January 2023 if not before. An interview with Resident #21 on 02/01/23 at 08:50 AM, revealed no blanket had been returned to her. At this time, Resident #21, requested and gave permission to surveyor to open the closet and check. There was a black and gold Steeler blanket in the closet but not the blanket that was seen in laundry the previous day that was light gray, black and yellow with the resident's name on it. At 09:00 AM, the Laundry/Housekeeping Supervisor and HK #29 entered the resident's room. Hk/Laundry staff verified the blanket was not in the laundry area and confirmed it could not be located in Resident #21's room at this time. HK #7 verified the blanket was labeled and was in the laundry yesterday, ( 01/31/23) and verified the blanket was observed on the cart in the clean laundry room and verified it was not there today. HK #7 stated the blanket should have been delivered yesterday because the process was to mark clothes and then deliver them the same day or the next day. An interview with the Social Service Director, on 02/01/23 at 11:40 AM , revealed the Laundry/Housekeeping Supervisor brought the missing item to her attention that surveyor had discussed 01/31/23, but thought Resident #21's blanket had been found. The Social Service Supervisor stated Resident #21's roommate had complained on her behalf regarding the missing blankets. During the interview, the Social Service Director verified Resident #3 and Resident #21 were both reliable historians and stated both ladies have been affected by a prolonged time frame of missing items and the process for grievance/concerns was not a good process. c) Resident #150 A review of the concern/grievance form for Resident #150, showed a concern was submitted to the facility by a family member on 12/23/22. A summary of the concern related to Resident 150's missing items The form showed an investigation was conducted 12/23/22 showed one item listed on the concern had been found and one item had not been found. The Summary/resolution of the concern/grievance dated 12/23/22, showed the confirm was not confirmed with findings of the missing items were not included on the inventory sheet and staff interviews showed 'spoke with staff- staff unable to remember ornament. Under the area of notification to patient or individual of the resolution showed on 12/23/22, the social worker spoke to the family per phone. The concern form was signed by the Grievance Officer on 12/23/22. Further review of the investigation, of the concern of missing ornaments. Showed eight (8) staff statements of the event or incident in question. Two (2) of the eight (8) confirmed the staff verified the ornaments had been seen in Resident 150's room. Additionally, the eight witness statements had been provided on 12/27/22, when the concern/grievance was documented resolved on 12/23/22 and signed off by the Grievance Officer on 12/23/22 confirming the grievance was not confirmed. An interview with the Social Services Director, on 02/01/23 at 11:50 AM, revealed the Social Services Director stated she had not called the resident's family member on 12/23/22 as the form noted to speak about the concern/grievance concern as documented on the complaint/grievance form. The Social Service Director stated at this time, she only investigated the concerns and stopped there. When asked why her name was documented as calling the family, she stated it is what it is. An interview, with the facility administrator, on 02/01/23 at 02:15 PM, verified the concern/grievance form was signed as resolved prior to obtaining the staff statements, stating possibly the incorrect date was documented.

Based on observation, facility record review and staff interview, the facility failed to provide a meaningful activity prior to lunch in the dining room. This is true one of one reviewed for activities but has the potential to affect all 16 residents eating in the dining room. Resident identifiers: 20, 5, 10, 41, 38, 31, 23, 34, 201, 13, 7, 1, 6, 12, 4, 2. Facility census: 52. Findings include: a) An observation on 01/30/23 at 12:00 PM. found staff escorting residents into the dining room for lunch. No activities or drinks were offered until the food truck arrived at 12:25 PM. During this time, Resident (R) #1 repeatedly stated I am bored and asked for something to do before lunch arrived. Registered Nurse (RN) #31 repeatedly escorted R#1 back to her table and offered to talk with her. R#1's mood escalated, she refused to stay at the table and her voice got louder as she stated I am [AGE] years old and I can get mad. I do not want to talk, I am bored. You better watch out. R#1 continued to roam the room and complain when staff started to serve trays. R#1 initially refused to eat when her lunch was served and again stated, I am mad, you better watch out. R#1 threatened to throw the plate on the floor. At 12:30 PM on 01/30/23, Registered Nurse (RN) #31, acknowledged there were no activities or drinks for the residents while they waited for lunch to be served. RN #31 agreed she could have turned on the TV or put on some music to try and occupy R#1 during her wait for food. The activities calendar notes the following scheduled events for 01/30/2023: Morning cafe at 10:00 AM, Chronicle Trivia at 10:30 AM, Exercise at 11:00 AM and music at 2:30 PM. There are no activities scheduled before lunch. The Director of Nursing and Corporate Nurse #61 agreed there should be an activity in the dining room while residents are waiting for their meals, during an interview on 01/30/23 at 12:45 PM.

Based on record review and staff interview, the facility failed to maintain an accurate medical record for four (4) of 18 sampled residents reviewed in the Long-Term Care Survey process. Resident identifiers: #3, #4, #11, and #6. Facility census: 52. Findings included: a) Resident #3 A brief record review, completed on 01/30/23 at 2:22 PM, identified resident had a Physician Orders for Scope of Treatment (POST) form on file. The attending physician signed the form on 01/15/22. However, Resident #3 had never signed the form. The 2021 POST Form Guidance instructs the signature section provides a declaration on behalf of the patient related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient must sign and date this section for the form to be legally valid. During an interview on 01/31/23 at 9:32 AM, Social Worker #50 acknowledged the facility had failed to obtain a written signature from Resident #3 stating it must have been an oversight and that it would be addressed. b) Resident #4 A brief record review, completed on 01/30/23 at 11:30 AM, identified resident had a POST form on file. The facility had obtained verbal consent from Resident #4's Health Care Surrogate (HCS) on 04/26/22. The 2021 POST Form Guidance instructs, If the incapacitated patient's MPOA representative or Health Care Surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. During an interview on 01/31/23 at 9:34 AM, Social Worker #50 acknowledged verbal consent had been accepted over nine (9) months ago and the facility had failed to obtain a written signature from the HCS. c) Resident #11 A brief record review, completed on 01/30/23 at 1:15 PM, identified resident had a POST form on file. The facility had obtained verbal consent from Resident #11's Medical Power of Attorney (MPOA) on 04/07/20. During an interview on 01/31/23 at 9:36 AM, Social Worker #50 acknowledged verbal consent had been accepted over a year and nine (9) months ago and the facility had failed to obtain a written signature from the MPOA.

Based on observation, medical record review, and staff interview, the facility failed to maintain an effective infection control program. Residents were not given the opportunity to sanitize/wash their hands prior to dining. Isolation rooms were not identified with correct/accurate signage and staff failed to follow hand hygiene practices consistent with accepted standards of practice. This practice has the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: 20, 5, 10, 41, 38, 31, 23, 34, 201, 13, 7, 1, 6, 12, 4, 2, 22, 21. Facility census: 52. Findings included: a) Dining Room An observation of the lunch meal on 01/30/23, found 16 of 16 residents (#20, 5, 10, 41, 38, 31, 23, 34, 201, 13, 7, 1, 6, 12, 4, 2) were not given the opportunity to wash or sanitize their hands prior to eating. Registered Nurse (RN) #31 confirmed all 16 residents were not given a chance to clean or sanitize their hands prior to eating during an interview at 12:30 PM on 01/30/23. During an interview on 1/30/23 at 12:45 PM, the Director of Nursing acknowledged the lack of hand sanitizing before meals is an infection control concern. b) Isolation Room Signage An observation on 01/30/23 at 9:20 AM, revealed personal protective equipment (PPE) on the doors of rooms [ROOM NUMBERS] with no signage indicating the residents were in isolation and the type of personal protective equipment (PPE) required. At 9:35 AM the Infection Preventionist (IP) / Licensed Practical Nurse #34 reported Resident (R) # 22 in room [ROOM NUMBER] was on isolation for Clostridia difficile and R#21 in room [ROOM NUMBER] was in isolation for Extended-spectrum beta-lactamases (ESBL) in the urine. Staff are to don a gown and gloves when entering either room. IP #34 acknowledged neither room was labeled with signage identifying the isolation and the type of PPE staff and visitors are to use upon entering. A follow up observation on 01/30/23 at 10:00 AM, found Isolation signs on both rooms stating Airborne Precautions Keep the door closed and staff are to don gown, respirator mask and gloves on all room entries. An interview with IP #34 at this time confirmed the wrong isolation signs were hung. IP #34 reported both residents are on contact precautions and not airborne. 31518

Based on observation and staff interview, the facility failed to provide food services in accordance with professional standards. The facility failed to ensure food was labeled and dated. This practice had the potential to affect a limited number of residents. Facility census: 52. Findings included: a) Unlabeled and Undated Food During a tour of the kitchen with the Food Services Manager, on 01/30/23 at 8:05 AM: -In the dry storage area one (1) clear bag of what was identified as egg noodles had been opened and half-used but was not labeled. -In the refrigerator there was a two-quart container of vanilla pudding that was unlabeled and undated. The Food Services Manager stated kitchen staff had failed to follow facility protocol for labeling and dating all open/prepared food items.

Based on observation and staff interview, the facility failed to honor privacy of resident medical records by leaving a narcotic book open and on top of an unattended medication cart. This was a random opportunity for discovery. Resident identifiers: #9 and #21. Facility census: 52. Findings included: a) Open Narcotic Book Surveyor observation on the 200 Hall, on 01/31/23 at 10:33 AM, found the medication cart unattended. The nurse assigned to the cart had walked down the hallway out of site of the cart and had left the narcotic book open leaving medical records out for public view. In the presence of Corporate Registered Nurse (CRN) #61 by the medication cart at 10:38 AM confirmed the narcotic book had been left open on the medication cart by Licensed Practical Nurse (LPN) #52 and stated, That is a problem. CRN #61 also confirmed that it was readily visible to any passerby that Resident #9 received traMADol [a medication is used to help relieve moderate to moderately severe pain] 50 mg every six hours as needed for pain and Resident #21 received Gabapentin [a medication used to relieve nerve pain] 100 mg three times a day for neuropathy.

Based on record review and staff interview, the facility failed to ensure a resident fall resulting in serious bodily injury was reported in a timely manner to the appropriate state agencies. The failure to make a timely report was true for one (1) of two (2) sampled residents for falls. Resident identifier: #44. Facility census: 52. Findings included: a) Resident #44 An electronic medical record review, completed on 01/31/23 at 12:48 PM, revealed Resident #44 had experienced a fall on 01/11/23 at 2:30 AM. Additionally there was a Nurses Noted on 01/12/2023 at 11:54 AM where the Assistant Director of Nursing (ADON) documented, Spoke with NP [Nurse Practitioner] this AM regarding x-ray to shoulder done at [local hospital]. They recommended an immobilizer to be worn to help with proper healing of shoulder. Therapy is aware and will order one. Daughter aware. Awaiting final report to be faxed. The facility received the faxed x-ray results received on 01/12/23 at 12:52 PM. Findings on the x-ray noted, There is a new comminuted proximal left humeral fracture. Review of the facility reportable for the injury found the initial fax reporting form was sent to the appropriate state agencies on 01/19/23, seven (7) days after the facility had knowledge of the serious bodily injury. During an interview on 02/01/23 at 10:10 AM, the Administrator confirmed the x-ray results were faxed to the facility on [DATE] but it was not reported as a serious bodily injury the appropriate state agencies until 01/19/23. The Administrator acknowledged the facility failed to meet the two (2) hour time frame for reporting a serious bodily injury.

Based on observation, medical record review and staff interview, the facility failed to develop and implement comprehensive person-centered care plans for residents with dementia. This is true for two of two residents reviewed for dementia. Resident identifiers: 1 and 15. Facility census: 52. Findings include: a) Resident (R) #1 Review of the medical record revealed R#1's diagnoses include Alzheimer's disease, non-Alzheimer's dementia, anxiety and depression. The quarterly minimum data set (MDS) assessment with an assessment reference date of 01/03/23 notes R#1 displays behaviors not directed towards others four to six days a week. An observation in the dining room on 01/30/23 from 12:00 PM to 12:30 PM, found Resident (R) #1 repeatedly stating I am bored and asking for something to do before lunch arrived. Registered Nurse (RN) #31 repeatedly escorted R#1 back to her table and offered to talk with her. R#1's mood escalated, she refused to stay at the table and her voice got louder as she stated I am [AGE] years old and I can get mad. I do not want to talk, I am bored. R#1 continued to roam the room and complain when staff started to serve trays. R#1 initially refused to eat and threatened to throw the plate on the floor. **No activities other than talking were offered R#1 during this observation. At 12:30 PM on 01/30/23, Registered Nurse (RN) #31, acknowledged there were no activities in the dining room before lunch and agreed she could have turned on the TV or put on some music to try and occupy R#1 during her wait for food. The care plan identifies R#1's diagnoses of Alzheimer's disease, dementia, anxiety and depression, the use of antipsychotic medications and her behaviors including throwing things, anger and hostility towards others and refusing medications. The care plan lacks individualized interventions related to these behavioral symptoms and outburst. The care plan was reviewed with corporate nurse #61 during an interview on 01/31/23 at 02:30 PM, She confirmed R#1's care plan lacks personal non-pharmacological interventions for staff to utilize when R#1 demonstrates behaviors. b) Resident (R) #15 Review of the medical record revealed R#15 receives monthly psychiatric reviews and her diagnoses include Alzheimer's disease with late onset, anxiety and depression, and was deemed incapacitated after a recent hospitalization . Her current daily medication regimen includes an antipsychotic, antianxiety and an antidepressant. The care plan identifies the above diagnoses and the administration of psychoactive medications with a long history of psychiatric problems and medication use. There are no non-pharmacological interventions listed to assist the resident with her psychosocial needs as her disease process continues. During an interview on 01/31/23 at 1:16 PM, Licensed Practical Nurse (LPN) #10 acknowledged R#15's diagnoses include Alzheimer's disease with late onset, anxiety and depression. LPN #10 reviewed R#15's care plan and confirmed the care plan identifies R#15's current psychotropic medications and notes the goals are to utilize the lowest dose possible and not display any medication side effects. LPN #10 agreed the care plan focuses on the psychotropic meds and possible side effects and is silent for person centered non-pharmacological interventions to assist R#15 with any symptoms or behaviors related to her Alzheimer's disease process, anxiety and depression.

Based on observation and staff interview, the facility failed to ensure drugs and biologicals, used in the facility, were stored in accordance with current accepted professional practices. The facility failed to ensure medications were not being stored for use after the Manufacturer's discard date for use. This was true for medications stored in one (1) of two (2) medication carts inspected. This practice had the potential to affect a limited number of residents. Resident identifier: Resident #35. Facility census: 52. Findings included: An observation, of the 200 Medication Cart, on 01/31/23 at 09:06 AM, revealed a vial of Novolog Insulin for Resident #35, with the opened date of 12/31/22 verifying when the medication was put into use. An interview, on 01/31/23 at 09:06 AM, with LPN #52, revealed the Novolog insulin for Resident #35 should have been discarded and was still in the medication cart available for use. A review of manufacture's discard date for Novolog Insulin is to discard after 28 days of use. An interview, with the DON, on 01/31/23 at 09:30 AM, confirmed it is facility policy to abide by the manufacturer's direction to discard after 28 days of use for the Novolog insulin. The DON stated further, the insulin should not have been stored in the medication cart for use.

Based on review of the concern/grievance log, record review and staff interview, the facility failed to ensure a dental referral was made in a timely manner for a resident who had lost or damaged dentures. This deficient practice was identified through a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: Resident #34 Census: 52. Findings included: a) Resident #34 A review of the Concern/Grievance log for 01/2023, showed Resident #34 was identified as having a concern/grievance of missing dentures, date of notification documented as 01/10/23. There was no indication of a resolution date. The Concern/Grievance Form review showed the date the concern/grievance was made as 01/09/23. An interview with Nursing Assistant (NA) #6, on 02/01/23 at 11:03 AM, revealed Resident #34 had dentures but stated they came up missing a few weeks ago and she did not currently have dentures. An electronic medical record review showed a progress note, dated 1/18/2023 at 10:19, where Registered Nurse (RN) #31 had spoken with a family dentistry group regarding a plan to obtain new dentures. An interview the Social Services Director, on 02/01/23 at 12:33 PM, revealed she was made aware of the lost dentures on 1/10/23, however, staff were aware of the lost dentures on the 01/09/23. The Social Service Director verified a referral for dental services was not made until 01/16/23. Further, the Social Service Director revealed she was not familiar with a time frame requirement for obtaining a dental referral for a resident who had broken or lost dentures. Further review of the electronic medical record, showed lack of evidence showing extenuating circumstances that led to the delay of the dental referral. An interview, with the Administrator, on 02/01/23 at 02:00 PM, revealed no additional information.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure that a resident who displayed and/or was diagnosed with [REDACTED]. Resident #66 was admitted to the facility in December 2016, with a [DIAGNOSES REDACTED]. Resident #66 began displaying verbal and physical behaviors towards staff in January 2017. These physical behaviors included punching and choking. No psychological assessments or treatments were started and Resident #66 assaulted another Resident on 04/04/17. These combative behaviors continued towards staff and other residents and on 07/08/17 Resident #66 pinned a tearful female Resident by the throat against the wall. The primary care physician started [MEDICATION NAME] an antidepressant on 07/10/17, but no orders were given for a psychiatric evaluation. Resident #66's verbal and physical aggression towards staff, residents and visitors continued. He received his first in house psychiatric evaluation on 08/29/17, despite medication changes he was transferred out of the facility for a psychiatric evaluation on 09/12/17 after he hit another resident in the back of the head. There are circumstances in which the survey team may apply the reasonable person concept to determine severity of the deficiency. To apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficient practice may have had on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance.) A reasonable person, if verbally or physically assaulted by another person, hit, choked, or pulled out of a chair would feel harm including; pain, fear, anxiety and/or stress. This practice resulted in harm to the resident and potential to cause harm and affect all residents, visitors and staff. Resident identifier: #66. Facility census: 55 Findings include: a) Resident #66 A review of the medical record on 09/12/17 at 11:00 a.m. revealed Resident #66 was admitted to the facility from an in house psychiatric unit in December 2016, with a [DIAGNOSES REDACTED]. The nurse's admission note, dated 12/28/16 noted Resident #66 was alert with confusion and walked frequently. Resident #66 wandered the halls unescorted through the day and night. The current [DIAGNOSES REDACTED]. His admission medications included Donepezil ([MEDICATION NAME] inhibitor) 5 milligram (mg) at bed time for dementia with behaviors. This medication was discontinued on 01/09/17 and no other [MEDICAL CONDITION] meds were prescribed until 07/11/17. At that time, the Nurse Practitioner #89 prescribed [MEDICATION NAME] an antidepressant 50 mg daily. [MEDICATION NAME] an antipsychotic medication was started on 08/30/17 after his first psychiatric evaluation since admission. The primary care physician evaluated Resident #66 on admission and diagnosed him with dementia. His plan stated to continue the same medications and treatment at this time. The physician visit note dated 01/15/17 stated, No new complaints voiced by patient or staff .[MEDICAL CONDITION]/ataxia, weakness, CAD ([MEDICAL CONDITIONS](hypertension) .plan: Continue same medications and treatments at this time. The physician note dated 03/19/17 states No new complaints voiced by patient or staff .Dementia, CAD ([MEDICAL CONDITION]) stable, Vit (vitamin) B12 def (deficiency) on supp (supplement),[MEDICAL CONDITION] .Continue same medications and treatments at this time. The physician note dated 05/17/17 states No new complaints voiced by patient or staff .Continue same medications and treatments. The physician note dated 07/14/17 again states No new complaints voiced by patient or staff .Continue same medications and treatments at this time. The psychiatric note dated 08/29/17 states the resident was seen for the first time by Psychiatrist #88. He was admitted in December from (name) psychiatric facility. The patient has some agitation and apparently has been increasing in the recent past. He hit a Nurse's Aide on March 24, on April 4th another resident, on July 8th another resident. On August 26th and two days ago hit another resident. The patient upon interviewing has severe cognitive deficits .Dr. #88's assessment is [MEDICAL CONDITION] with behavioral difficulties and [MEDICAL CONDITION] disorder. The plan is to start [MEDICATION NAME] an antipsychotic medication, increase the drugs if needed and follow up in one month. -On 01/01/17, the daily skilled note states .He does have periods where he is a bit testy, and will fight with you over little things, such as time to get into your pjs (pajamas). He can be redirected while giving him gentle guidance. When he is clapping or trying to get into your face, that is when he starts being combative. -On 01/02/17 the daily skilled note states .He ambulates throughout the building on the unit. Sometimes he needs redirection to prevent him from going into rooms not his own .Resident does not take direction well . - On 01/08/17 the daily skilled note states .ambulating out into the hallway without pants. We keep putting pants on him and he keeps removing his pants. Gets angry when you put them back on. -On 01/09/17 the daily skilled note states Resident going room to room, taking bed linen off the beds and throwing them in the hall way. Redirection works with resident briefly then he returns to doing the same thing, .When we try to approach resident he becomes combative, redirection becomes very difficult at this time. -On 01/09/17 a mood behavior note written by Registered Nurse (RN) #91 wrote Resident is approaching CNAs (Nurse Aides) in a threatening manner. Told resident he could not hit people. Redirected resident to room. He forgets and will start to get aggressive again . -On 01/10/17 the daily skilled note states Resident gets agitated easily, claps hands for you to move, hollers at ppl (people). Resident needs redirected often with no success, remains non-compliant, walks up and down hall . -On 01/18/17 the Nurse's note states Resident attempts to take things off my cart, redirection was difficult resident put fist up to me . -On 01/19/17 the Nurse's note states Resident needs constant redirection, but ineffective. Resident lifts fist up and stutters at you but, unable to understand his speech . -On 01/20/17 the Nurse's note states Resident came out of his room and removed pudding from the med cart. Asked him not to remove anything from the med cart, and he started to shake his finger in my face . -On 02/26/17 the Nurse's note states Resident shuffles up and down hallway clapping his hands at everyone. Needs lots of redirecting . -On 03/01/17 the Nurse's note states Resident approached CNA (Nurse Aide) who was doing documentation. She did not say anything to him and he punched her three times in the left arm. She removed herself from the situation and he remained standing in place making threatening gestures . -On 03/24/17 a mood behavior note states Resident became agitated while waiting for his dinner tray. Punched an aide in the arm when the tray she had was not his . -On 04/05/17 the incident / accident typed witness form states I hears (sic) the CNA (name) yelling, .Resident #66 punched Resident ___ in the left eye . -On 04/13/17 the Nurse's note states Resident is being sexually inappropriate during shower, attempting to grope CNAs. After resident's shower, he attempted to pull CNA into room making inappropriate physical gestures . -On 04/18/17 the Incident / Accident report states While working ___ wing hallway, resident came up to CNAs and placed a cup on table beside CNAs. He then started touching one of the CNAs with his finger. He had his hands around CNA's neck all at once . -A typed witness statement from Nurse Aide (NA) #7 states .Resident came up to us and placed a cup by us, then started pointing at (name). He then started touching her neck with his finger, then all at once he had both of his hands around her neck . -On 04/18/17 the Nurse's note states Dr. (Name) #90 notified of resident having his hands on CNA's neck, with no injuries sustained by resident. Steps to prevent recurrence include encouraging CNA to not be down ___ wing . -On 05/04/17 the Nurse's note states Became combative with housekeeping today . -On 06/25/17, the Nurse's note stated, During 3-11 shift this resident attempted to choke CNA. She put her arm up to defend herself and he punched her in the arm . -On 07/01/17, the Nurse's note stated, .Resident became verbally aggressive with residents and staff this shft, . -On 07/08/17, at 18:24 (6:24 p.m.) the Nurse's note stated, CNA came down the hall stating resident had another resident up against the wall by her throat, . -On 07/08/17, the hand-written witness statement by Hospitality Aide (HA) #6 stated, .(name) Resident #66 had grabbed (name) Resident #69 by the throat pushing her up to the wall slammin (sic) her up to it, (name) R#69 trying to get away started kicking at him then I got between them to separate and started yelling help . -On 07/08/17 at 22:14 (10:14 p.m.) the Nurse's note states Resident going across the hall to other residents room agitating the resident, clapping his hands at her and sticking his tongue out at her, redirected several times. -On 07/10/17, the Nurse's note stated, Spoke with NP (Nurse Practitioner), new orders to start [MEDICATION NAME] (antidepressant) 50 milligrams daily . -On 07/20/17, the Nurse's note stated, Resident was in another resident's room and confronted their daughter when she asked him to leave the room, he got aggressive and the nurse interceded and Mr. (name) got aggressive with the nurse and punched her in the chest .social services made aware of the situation at this time. -On 08/05/17, the typed incident witness form for Licensed Practical Nurse (LPN) #72 stated, resident #66 walked over yelling curse words and hitting his fist, he pulled the resident #20 out of the chair by his right arm. -On 08/05/17, the Nurse's note stated, Resident removed from the situation after he continued to yell and hit his fist . -On 08/06/17, the monthly Nurse's assessment stated, Resident confused to place and time. Garbled speech, but makes himself clear when he needs to, becomes physically and verbally aggressive to others with closed fists punching his hand (showing this sign often). Resident makes verbal and physical outbursts with other residents, resident families and staff and needs redirected and separated from others often. -On 08/12/17, the Nurse's note stated, Resident making inappropriate sexual hand gestures walking down the hall, redirected at this time, this happened several times and need to be redirected. -On 08/26/17, the Nurse's note stated, Resident approached peer (Resident #54), who was sitting outside of dining room in her wheelchair. He punched her in the forehead and began yelling at her . -The incident / accident report form states Redirected resident, to assess peer. Resident is known to wander up and down halls . -On 08/29/17, the Nurse's note stated, Dr. (name) Psychiatrist #88 visited, new orders received . -A second Nurse's note states .resident to start [MEDICATION NAME] (tricyclic antidepressant) 10 mg bid (twice a day), [MEDICATION NAME] (antipsychotic) 12.5 mg in AM (morning) and 25 mg at HS (bedtime), and BMP (basic metabolic panel), mag (magnesium level), and H&H (hemoglobin and hematocrit) . -On 08/30/17, the Nurse's note stated, Resident started on [MEDICATION NAME] HS 25 he slept most of the night. -On 09/08/17, the Nurse's note stated, Resident being argumentative and confronting other residents and staff, swearing at them and shoving his fist at them. Redirected multiple times throughout the shift. -On 09/10/17, the Nurse's note stated, Resident getting aggressive with other residents' family members this afternoon. Also with another resident at the vending machine . -On 09/11/17, the Nurse's note stated, Resident wandering into other residents' rooms . -On 09/12/17 at 09:34 (9:34 a.m.) the Nurse's notes state Resident verbally aggressive and shouting out to staff members . On 09/12/17 at 23:00 (11:00 p.m.) the Nurse's note states Reported that resident had a altercation with another resident -The hand written witness statement states (Name) Resident #66 hit (name) in the back of the head . On 09/12/17 at 23:04 (11:04 p.m.) the Nurse's note states .resident sent to (name) for Psych evaluation d/t (due to) increase of aggressive behaviors, 911 notified and resident transferred . During an interview on 09/12/17 at 3:40 p.m. Resident #68 reported Resident #66's behaviors have worsened over the past few months. His behaviors occur every day and every night and are more aggressive. He hits staff and other residents and usually approaches them from behind. He recently hit another male resident at the candy machine for no reason at all. Two nights ago, Resident #68 observed Resident #66 heading towards the back of a female volunteer. Resident #68 stated she stood up and interrupted his attempt to hit the volunteer. Resident #74 reported she is afraid to sleep at night during an interview on 09/13/17 at 9:15 a.m. She reported she has seen (name) Resident #66 in action. He has punched a nurse on night shift (name) and another nurse (name) who sometimes works the night shift. He also attacked another resident (name). During an interview on 09/13/17 at 9:50 a.m. the Assistant Director of Nursing (ADON) reviewed the medical record and stated Resident #66 is easily redirected by some but not everyone. She reported they assessed the resident for pain and started him on Tylenol in April and later changed this to [MEDICATION NAME] (non-steroidal anti-[MEDICAL CONDITION]). She agreed there were no arrangements made to obtain an in-house our outside psychiatric evaluation for Resident #66's behaviors until 08/29/17. The ADON was unaware the resident had put the Tylenol in his pocket on two separate occasions and staff were unable to retrieve these pills or that Resident #66 had removed items from the medication cart. The ADON was unable to identify the staff who were choked or assaulted by Resident #66. The ADON acknowledged they did not address Resident #66's aggressive behaviors towards others and stated, we fixed the little things by moving a nurse aide to the other hall and redirecting with snacks. The Social Services Director (SSD) #76 was interviewed on 09/13/17 at 10:50 a.m. She reported Resident #66 was admitted from an in house psychiatric unit following an incident of wandering the neighborhood unclothed and confused. She was given an admitting [DIAGNOSES REDACTED]. She stated Resident #66's behaviors started with hand clapping and he initially could be redirected and deescalated. The SSD reported the interdisciplinary team met to address Resident #66's behaviors to assess the situation and identify any triggering factors. She agreed no in-house our outside psychiatric evaluations were completed on Resident #66's until 08/29/17. In summary, Resident #66 was picked up by police in December 2016 after he was found wondering the neighborhood confused and unclothed. He was admitted to a local psychiatric facility for eleven days and then admitted to this facility with a [DIAGNOSES REDACTED]. He was never scheduled for any psychiatric evaluations until 08/29/17. He began displaying verbal and physical behaviors towards staff in January 2017. These physical behaviors included punching and choking. No psychological assessments or treatments were started and Resident #66 assaulted another Resident on 04/04/17. These combative behaviors continued towards staff and other residents and on 07/08/17 Resident #66 pinned a tearful female Resident by the throat against the wall. The primary care physician started [MEDICATION NAME] an antidepressant on 07/10/17, but no orders were given for a psychiatric evaluation. Resident #66's verbal and physical aggression towards staff, residents and visitors continued. He received his first in house psychiatric evaluation on 08/29/17, despite medication changes he was transferred out of the facility for a psychiatric evaluation on 09/12/17 after he hit another resident in the back of the head.

Based on record review, policy review, observation and interview the facility failed to ensure a resident does not have a foley catheter unless clinically necessary. The use of the catheter caused skin impairment which resulted in pain and physical harm to the resident. This involved 1 of 3 residents reviewed related to the use of an indwelling foley catheter. (Resident #28.) Findings include: Review of the medical record for Resident #28 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record for Resident #28 revealed an admission nursing assessment dated [DATE]. The assessment noted Resident #28 was measured to be 58 inches tall and weighed 96.4 pounds. Resident #28 was also assessed to to be disoriented and confused. The assessment also revealed the Resident had unclear speech, was sometimes able to make himself understood and sometimes understood others. There were no areas of skin impairment noted on the assessment. The mobility section of the admission assessment was not completed. Further review of the admission assessment revealed Resident #28 was admitted with an indwelling foley catheter. Review of the document titled Bladder Incontinence Assessment and Progress Notes revealed that on 09/19/12 Registered Nurse (RN) #40 documented that Resident #28 was admitted to the facility with an indwelling foley catheter and the catheter was reportedly inserted due to [MEDICAL CONDITION] during treatment of [REDACTED]. Review of the admitting physician's orders [REDACTED]. The physician ordered list of medications did not include an antibiotic. Review of the physician's progress notes for Resident #28 revealed the physician examined the resident on 09/12/12. The progress notes made no mention of the Resident's foley catheter or a [DIAGNOSES REDACTED]. Review of the interim plan of care for Resident #28 included the use of a foley catheter with no mention of a goal or interventions related to the foley catheter. An area on the form specific for urinary tract infections was left blank. Review of the nurses notes for Resident #28 revealed an entry dated 09/15/12 at 5:04 P.M., which stated the Resident was found with an area of erosion on the underside of the penis from the foley catheter. The area was described as white with dark spots and was observed to be bleeding. There is no further mention of the skin erosion in the nurses notes. A nurse's note dated 09/17/12 at 1:00 P.M., stated the foley catheter had been removed. Review of the physician's orders [REDACTED]. Review of the facility's policy dated 10/07 related to foley catheters revealed a form titled, "Bladder Catheter Use/ Infection Prevention". The policy stated "This facility provides a process to assess the resident for the appropriateness of a bladder catheter on admission, readmission, quarterly and when a related significant change occurs thus maintaining the resident's physical, mental and physiological well being". The procedures listed for this policy were the following: 1. The resident will be assessed for appropriateness of catheter use/[DIAGNOSES REDACTED]. 2. The physician will establish the [DIAGNOSES REDACTED]. 3. The physician will provide documentation of the [DIAGNOSES REDACTED]. Further review of the facility's policy revealed a policy dated 10/07 titled, "Catheter Care, Urinary". The policy stated to secure the catheter utilizing a leg band. During interview with the DON on 09/18/12 at 4:50 P.M., it was verified Resident #28 had no documented clinical indication for the use of an indwelling foley catheter. The DON stated during the interview she had phoned RN #40, who had completed the admission assessment. RN #40 stated she had documented [MEDICAL CONDITION] as an indication for the foley catheter because the discharging nurse from the acute care hospital had given her that [DIAGNOSES REDACTED]. The DON verified during the interview that the hospital discharge paper work did not include a [DIAGNOSES REDACTED]. During interview with Certified Nurse Aide (CNA) # 26 on 09/19/12 it was stated the kardex is used to direct the care for residents. Review of the kardex for Resident #28 was absent for any mention of a leg strap for the foley catheter. During interview with RN #23 on 09/19/12 at 9:02 A.M., she stated she was aware that Resident #28's foley catheter had been removed on 09/15/12 due to possible irritation. On 9/19/12 at 3:50 P.M., the area of skin erosion was observed with the Director of Nursing (DON) and Registered Nurse #34, identified by the facility as the treatment nurse. The area on Resident #28's penis measured 0.7 centimeters long and 0.8 centimeters wide. RN #34 described the wound as, "red beefy tissue with distinct edges". During interview with Licensed Practical Nurse (LPN) #47 on 09/20/12 at 10:43 A.M., it was stated she was in the facility on 09/15/12 working in the capacity of the treatment nurse. LPN #47 stated she was alerted by a CNA that Resident #28 had a small amount of blood on his adult incontinence brief. LPN #47 stated she made an observation of the Resident and discovered a wound to the resident's penis and stated Resident #28 had pain related to the wound. LPN #47 also stated she had phoned the physician and reported that a painful area of erosion had been found related to the indwelling foley catheter. LPN #47 verified there was no leg strap on Resident #28 at the time the wound was discovered. LPN #47 also stated during the interview that there are certain papers that are filled out when incidents like this happen. LPN #47 stated she filled out the paper work and left it for the DON's review. Review of a document on 09/20/12 provided by the DON and titled "Incident/Accident Report" revealed that on 09/15/12 an area of skin erosion was identified on the underside of the resident's penis that was consistent with catheter tubing against the skin. Another form titled "Incident/Accident Follow Up Investigation Form" dated 09/17/12 revealed an intervention to the incident was to discontinue the indwelling foley catheter. During interview on 09/20/12 at 3:04 P.M. with LPN #21 it was verified she was the nurse that discontinued the foley catheter on 09/17/12 and stated she thought it was due to a sore on the resident's penis. During interview on 09/20/12 the DON verified Resident #28 had completed treatment with antibiotics for a UTI while in the acute care hospital and had not been treated for [REDACTED].

Based on record review and staff interviews, the facility failed to provide the necessary care and services to attain the highest physical well-being for one (1) resident of a sample of five (5). Resident #56 did not receive physician intervention for a fall and as a result of the fall sustained a [MEDICAL CONDITION] and clavicle. The resident was medicated with Tylenol one (1) time for pain. An hour after the Tylenol was administered, the pain persisted, but there was no evidence of any additional interventions. The resident was not transferred to the hospital until six (6) days after the fall. When the resident was admitted to the hospital six (6) days later, the physician at the hospital diagnosed the resident with pneumonia, intractable pain, and a fracture to the hip and clavicle. Resident identifier: #56. Facility census: 54. Findings include: a) Resident #56 This resident was admitted on [DATE] and discharged on [DATE]. The resident's [DIAGNOSES REDACTED]. 1) A review of the medical record for Resident #56 included a review of the minimum data set (MDS), with an assessment reference date (ARD) of 07/03/12. Section C - Cognitive Patterns, of the MDS reflected the resident had memory problems and was moderately impaired for decision making (decisions poor, cues/supervision required). The resident did not have capacity to make healthcare decisions. Section G - Functional Status, indicated the resident was totally dependent on staff for all activities of daily living. Section J, item 1800 - Any falls since admission was coded as major injury - bone fractures. 2) A review of the care plan, with a date of 05/18/12 to 08/16/12, revealed the resident was at risk for falls related to dementia, poor safety awareness, and need for extensive assistance from staff for care. The goal, was "Resident (name) will have her risk of falls minimized through next review." Interventions included, physical therapy and occupational therapy three (3) times a week for four (4) weeks, anticipate and meet needs, coordinate with appropriate staff to ensure a safe environment with bed in low position at night, side rails as ordered, personal items within reach, evaluate for and supply adaptive equipment or devices as needed. Re-evaluate as needed for continued appropriateness and to ensure least restrictive device or restraint, ensure that resident is wearing appropriate footwear (shoes, bedroom slippers, non-skid socks) when ambulating or up in wheelchair, tab alarm to chair, pad alarm to bed and check every shift." A revision was completed on 06/01/12 to include, "restorative AROM (active range of motion) to BLE (bilateral lower extremities) and BUE (bilateral upper extremities) to prevent contractures, maintain functional ability, maintain strength and endurance and relieve joint stiffness and provide socialization until further orders." On 06/27/12, another revision was completed to include, "X-ray of left shoulder, elbow and ribs s/p (status [REDACTED]. On 06/28/12 a revision to the care plan was made for, "Anti tippers (rear) on wheelchair for safety. Check every shift." 3) A nursing note, dated 06/26/12 at 8:00 p.m., described "At 7:45 p.m. heard a thump behind me. Resident was on floor in front of wheel chair sitting outside of the TV room. LPN and CNA got her from floor to wheel chair before I could get there from med cart. VS checked 97.2 - 74 - 20 - 142/76, pulse ox 96% on room air. Assisted back to room for further assessment. Upon inspection, bluish discoloration on scalp above left eye, red skin on left shoulder and left upper arm. Slight skin shear seen at left shin, cleansed with NSS and left open to air. Resident ROM wnl (within normal limits) for her with no increase in s/s (signs and symptoms) or c/o (complaint of) pain. PEARLA (pupils equal and reactive to light and accommodation), grips equal and strong. No red or open areas noted on butt or hips. Socks on feet and wet. Call placed to daughter MPOA message left requesting return call for update. Physician (name) contacted. Step to prevent recurrence is resident to wear shoes when up in wheel chair." An assessment for range of motion was completed, but did not reveal what specific areas the range of motion was performed. There was no information concerning the resident's legs, hips (other than there were no red or open areas), or shoulders. It was later leaned the resident had sustained fractures to both the left hip and the left clavicle At 8:15 p.m. on 06/26/12, a nursing note revealed, "Daughter MPOA called back was updated on resident's fall, injuries noted and neurochecks initiated and stable so far. She stated understanding and that the local daughters and caregiver will be in to see her tomorrow." On 06/27/12 at 2:00 a.m., a nursing note revealed, "LG (large) hematoma noted to left arm. Sm (small) skin tear to left elbow. Sm hematoma to temple. No change in neuro status." A nursing note (no time recorded) on 06/27/12 revealed, "new order for rear anti tippers put on wheel chair for safety." On 06/27/12 at 3:42 p.m., a nurse wrote, "Resident has no signs or symptoms of pain related to fall. Resident does have some bruising and a skin tear to her left elbow no other concerns at this time. Resident has no neuro deficits and will continue to monitor her according to neuro protocol." On 06/27/12 at 3:45 p.m., a nursing note revealed, "Family expressed concern re: resident's left shoulder and ribs from previous fall. Also think resident shows s/s of respiratory congestion. Infection monitoring begun. Physician (name) notified of family concerns. Order received for x-ray left shoulder and ribs. Mobile x-ray called and will be here in AM to x-ray. Also received order for [MEDICATION NAME] nebulizer treatments 3x day as needed for congestion. MPOA notified." A nursing note on 06/27/12 at 11:00 p.m. revealed, "Resident assessed during neurochecks - neurochecks remain stable. Resident showed s/s pain - guarding left shoulder, ROM decreased when changing resident's shirt, medicated with Tylenol - faces "8" at time of administration, faces "6" one hour later. No cough or. respiratory discomfort noted while in dining room or after assisted to bed. Lung sounds diminished, but clear. Resident remains febrile. Steri strips dry and intact to left elbow. Bruising noted on Left upper posterior arm. Area that had been discolored and slightly raised on left side of head no longer discolored or raised." ("Faces" is a method of determining the severity of pain. The scale has faces with different expressions and goes from 0 to 10 - with 10 being the most severe pain.) The facility's "Pain Management Flowsheet" on 06/27/12 revealed, the resident was exhibiting pain and was assessed with [REDACTED]. The resident was listed as an" 8 hurts whole lot." After receiving the Tylenol and the nurse waiting an hour, the resident described the pain as a "6 hurts even more. (although this is less than 8, it still represents a significant level of pain)" The nurse did not notify the physician of the continuing pain. An interview with the Director of Nursing, Employee #53, revealed the nurse told her that an hour after the resident received the Tylenol, the resident was at a 6 and later in the evening the resident did not have pain. Documentation was not found to support the resident was not having pain later in the evening of 06/27/12. A nursing note, written on 06/28/12 at 12:00 a.m., revealed, "No neurologic change noted. Resident resting in bed with eyes closed. New order received for skin protector to bilateral arm. Steri strip dry and intact hematoma noted to left upper arm. Sm (small) hematoma noted to left temporal area. Medicated with tussi for a dry non productive cough." (Although the nursing entry of 06/27/12 at 11:00 p.m. noted ". . . Area that had been discolored and slightly raised on left side of head no longer discolored or raised." this entry noted, ". . . Sm (small) hematoma noted to left temporal area. . . ." The family interceded and requested the resident receive an x-ray for the left shoulder and ribs. Also the family told the nursing staff, the resident was showing signs and symptoms of respiratory congestion. An order was received to x-ray the resident's shoulder and ribs. On 06/29/12, the facility received an x-ray of the resident's left ribs, left shoulder, and left elbow. All x-rays were negative for a fracture. A nursing note on 06/28/12 at 10:30 a.m. revealed, "Spoke to MPOA (name) discussed x ray done this am (morning) to left ribs shoulder and elbow and skin tear to left elbow with voiced understanding." On 06/28/12 at 2:00 p.m., a nurse noted, "Resident has jerking motion to bilateral legs and arms. Awaiting return call from resident's neurologist. Medicated with Tussi and [MEDICATION NAME] for dry cough Tylenol given for c/o shoulder pain" On 06/28/12 at 4:30 p.m. a nursing note revealed, "Dr. (name) office returned call regarding jerking motion to bilateral legs and arms. Dr. (name) he will see her for her appointment on 07/11/12. Advised to make Dr. (name) aware. Dr. (name) notified, MPOA notified." On 06/30/12 (no time listed) a nursing note revealed, "No further bruising or skin tear noted. Left hip bruise starting to fade and steri strip left elbow still dry and intact." This is the first nursing note that mentioned a bruise to the resident's left hip after the fall on 06/26/12. On 07/01/12 at 11:35 p.m., a nursing note revealed, "Resident in bed, CNA reported that resident was complaining of pain to left hip when transferring and when walking from wheel chair to bed. Bruise to left hip green blue in color with fading edges. Resident guarding left hip when gentle ROM attempted while laying on right side. Legs equal length when laying on back." On 07/02/12 (no time listed) a nursing note revealed, "Staff reports resident coughing and expectorating thick greenish mucus. Afebrile. Dr. (name) notified and order obtained for chest x ray. At 1:45 p.m. a nursing note revealed, "chest x ray obtained as ordered. No results as yet. Lung sounds are clear, but diminished. Infrequent cough noted." The chest x ray was received on 07/02/12 (no time listed). The x ray indicated "no acute process." On 07/02/12 an order was received to obtain an x-ray of the resident's left hip to be completed on 07/03/12. The x-ray was completed and showed the resident had a fracture of her left hip. The resident was sent to the hospital on [DATE] and admitted . A "Discharge Summary" from the facility, on 07/05/12 revealed, "Pertinent diagnostic findings: CT brain 06/08/12 - Moderate cerebral atrophy. X ray let ribs, left shoulder, left elbow on 06/28/12 all negative. A chest x ray negative. 07/03/12 x ray left hip post fall, mildly impacted subcapital left femoral fracture." In an interview on 07/11/12 at 11:00 a.m., the administrator stated, "I don't think the nurse did an adequate assessment of the resident when she fell ." ==== The hospital triage record, dated 07/03/12, included under "Chief Complaint Summary": ". . . Significant yellow/purple bruising noted to left shoulder, left elbow, left hip and left shin. . . . Lung sounds with rales bilaterally. . . ." The hospital history and physical, for 07/03/12 at 22:40, included: "History of present illness. History came from the patient's daughter. The patient is asleep from [MEDICATION NAME] and is demented. Patient lives in a nursing home and six days prior to admission the patient fell from a wheelchair, landing on her left side. The nurses from the nursing home informed the daughter about the situation and said everything was fine. Due to persistence of pain the patient was brought to the emergency department. The patient's daughter also noticed some greenish sputum and cough coming from their mom. No fever, no chills. The patient seems to be more sleepy compared to days prior to the fall." The hospital physical examination revealed, "Vital signs: Temperature 99, pulse 82, respiratory rate 20, blood pressure 132/78. O2 saturation 99. Skin: Positive hematoma on the left shoulder with different stages of healing." Hospital Investigations: CT of the head and neck showed no acute intracranial bleed. Chest x-ray reveals there is patchy diffuse bilateral airspace disease, although not specific considerations are [MEDICAL CONDITIONS] versus patchy areas of infection. There is no pneumothorax or any pleural effusion. X-ray of pelvis showed single frontal view of the pelvis demonstrates symmetric hip joint space. There is diffuse osteopenia. There is some abnormality at the left femoral neck. This is suspicious for a fracture. Left hip x-ray showed frontal and cross table lateral views are obtained of the left hip and demonstrates a subcapital left [MEDICAL CONDITION]. X-ray of the shoulder showed three views of the left shoulder demonstrates marked osteopenia. There is an acute fracture, which is not displaced involving the distal clavicle. The fracture is vertically oriented. There is no dislocation." The hospital record, under "Assessment" listed: -- Pneumonia, -- Intractable pain secondary to clavicular and [MEDICAL CONDITION], -- Dementia, -- [MEDICAL CONDITION], -- [MEDICAL CONDITION]. Under "Plan", the hospital record listed: 1. Admit the patient under the service of physician (name) 2. For the pneumonia the patient was started on [MEDICATION NAME] 750mg q 24 hours. 3. For the intractable pain, secondary to the fractures, [MEDICATION NAME] 1mg q 3hrs will be given pain. 4. The patient will have incentive spirometer given to her. The resident fell from a wheelchair at he facility and was not sent to the hospital for six (6) days. The resident was only administered Tylenol for pain. The resident was diagnosed at the hospital with pneumonia, intractable pain, and fractures to the left hip and left clavicle. .

Based on observation, record review, staff interview, and policy review, the facility failed to provide necessary care and services to attain or maintain each resident's highest practicable physical well-being. Two (2) of twenty-three (23) Stage II sample residents (#79 and #36), who were recently admitted to the facility, were receiving medications from medicine bottles brought from home. Review of the medical records for Residents #79 and #36 found no evidence these home medications had been examined by a physician or consultant pharmacist prior to administration to the residents, to verify the contents of the bottles (right drug) and to verify the labels on the bottles matched the current physician's orders [REDACTED]. These practices placed two (2) current residents at immediate risk for serious harm related to the potential to receive medications the identity of which had not been verified and for which the dispensing instructions on the labels were inconsistent with current physician's orders [REDACTED]. After removal of the immediate jeopardy, the potential for more than minimal harm continued to exist for newly admitted residents until the facility corrected its system related to verifying medications (and their dispensing instructions) brought from home. Resident identifiers: #36 and #79. Facility census: 49. Findings include: a) Resident #79 During medication pass at 8:50 a.m. on 06/30/10, observation found the nurse (Employee #73) pouring medications for Resident #79 from brown medicine bottles, not from the bubble packs used for the other residents. When questioned, Employee #73 stated it was facility practice to use up any medications brought in from a resident's home before ordering them from the facility's vendor pharmacy. This practice was verified by two (2) other nurses on the floor (Employees #48 and #57). Examination of the brown medicine bottles for Resident #79 found the labels on the bottles did not always correlate with the resident's current physician's orders [REDACTED]. 1. The dispensing instruction on the label read, "[MEDICATION NAME] (a stool softener) 100 mg by mouth twice daily." According to the physician's orders [REDACTED]." 2. The dispensing instruction on the label read, "[MEDICATION NAME] (a [MEDICAL CONDITION]-acid pump inhibitor used to treat reflux) DR (Delayed Release) 20 mg by mouth daily." According to the physician's orders [REDACTED]. 3. The dispensing instruction on the label read, "[MEDICATION NAME] (a glucocorticosteroid) 4 mg ? tab twice daily." According to the physician's orders [REDACTED]." [MEDICATION NAME] 2 mg was administered correctly, but this required the nurse to break a 4 mg tablet in half. The nurse commented that she would be glad when the pills were gone, so they would no longer have to break the pills each time. Further record review revealed Resident #79 was admitted to the facility on [DATE]. -- b) Resident #36 During medication pass at 8:59 a.m. on 06/30/10, observation found Employee #73 pouring medications for Resident #36 from brown medicine bottles, not from the bubble packs used for the other residents. Employee #73 confirmed these brown medicine bottles were brought from Resident #36's home. The label on the brown medicine bottle for Resident #36 included the instructions: "[MEDICATION NAME] 25 mg by mouth twice daily." According to the physician's orders [REDACTED]. Further record review revealed Resident #36 was admitted to the facility on [DATE]. -- c) The director of nurses (DON), when asked about this practice during an interview at 10:00 a.m. on 06/30/10, verified that home medications were administered to residents but that a nurse always verified them with the physician. A copy of the facility's current pharmacy policy and procedure manual was requested at that time. -- d) During a telephone interview with the facility's consultant pharmacist at 11:15 a.m. on 06/30/10, he acknowledged he was aware the facility used medications brought by new residents from home on admission to the facility until they were gone. He added that, at times, payment was refused when a prescription had recently been filled and a resident was on Medicare Part D. He stated he "usually" reviewed them with a nurse over the phone, because coming to the facility each time to personally check them would "be a hardship", although he had no documentation that this telephone review was done for Residents #79 and #36. He further offered his opinion that using medications brought from home was not an ideal practice, because "... You didn't know where they had been stored or that pills in the bottle were the correct ones." He agreed the label on the medicine bottles did not always match the physician's orders [REDACTED]. When asked if there were a policy for the use of medications brought from home, he stated he knew of none. -- e) At about 12:00 p.m. on 06/30/10, the DON produced the facility's pharmacy policy and procedure manual for review by the survey team. Review of the manual revealed the following, on page 37 under "12. Medications Brought to Facility by Resident or Family Member", "Policy: Medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the facility's guidelines. Other unauthorized medications are not accepted by the facility." Elsewhere in the manual, on pages 4 and 5 under "2. Provider Pharmacy - Requirements", "d. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to ... 7) Performing an initial medication use assessment for each new residents to ensure that the medication regimen meets the resident's needs." -- f) Review of the medical records for Residents #79 and #36 which found no evidence these home medications had been examined by a physician or consultant pharmacist prior to administration to the residents, to verify the contents matched the labels on the bottles. Additionally, there were no orders from the physician authorizing the administration of these home medications, and there were no notations on the residents' MARs to indicate that medications brought from home were to be administered. The survey team determined these practices placed both Residents #36 and #79 in immediate jeopardy, due to the potential for medication errors associated with administering medications without verification by a qualified health care professional that the contents of these medicine bottles matched the labels on the bottles and the current physician's orders [REDACTED]. The administrator and the DON were notified of the finding of immediate jeopardy at 1:55 p.m. on 06/30/10. -- g) Review of the contents of the facility's medication carts (to determine what additional home medications were available for administration to residents), in the presence of two (2) facility nurses (Employee #73 and #48) beginning at 2:00 p.m. on 06/30/10, found a total of thirteen (13) medicine bottles for Resident #79. Three (3) of the bottles were empty; three (3) medications had been discontinued but not removed from the cart, and one (1) over-the-counter medication had no label at all. This review also found five (5) medicine bottles for Resident #36, two (2) of which were empty. Employee #73 confirmed Resident #36 was receiving [MEDICATION NAME] (an antidepressant) 50 mg daily, [MEDICATION NAME] (an antihypertensive) 0.3 mg twice daily, and [MEDICATION NAME] (an antihypertensive) 50 mg daily from the medicine bottles brought from home. -- h) The DON presented a proposed plan of correction (POC) at 3:30 p.m. on 06/30/10, which stated, "In coordination with pharmacy a policy and procedure will be written and thoroughly in-serviced to all nurses." The DON expressed surprise when informed there already was a policy in the manual to address this. The POC was initially rejected as it did not address all aspects of the immediate jeopardy situation. A revised POC was approved at 4:05 p.m. on 06/30/10, and the immediate jeopardy situation was declared removed at 4:13 p.m., after verification by the survey team that the revised POC had been implemented, to include verification that all medications brought from home were removed from the medication carts and were no longer available for use. -- i) The DON agreed, when interviewed at 4:15 p.m. on 06/30/10, the discontinued medications should have been removed from the cart. She also acknowledged the differences between the labels on the medicine bottles from home and the current physician's orders [REDACTED]. -- j) Review of the monthly pharmacy review reports for 2010, at 8:15 a.m. on 07/08/10, found the last pharmacy review was completed on 06/12/10. There was no mention in the report to indicate the reviewer acknowledged the presence of home medications in the medication carts. .

Based on observation, record review, staff interview, facility policy review, the facility's governing body failed to ensure the facility was administered in an effective and efficient manner, as evidenced by the presence of system failures in the area of medication administration. On 06/28/07, the contracted vendor pharmacy provided the facility with a pharmacy policy and procedure manual. Review of the manual found no evidence it had been initially adopted, by the facility's governing body or designee, or periodically reviewed / revised thereafter to ensure the policies and procedures contained therein were consistent with current accepted standards of professional practice. Two (2) of twenty-three (23) Stage II sample residents (#79 and #36), who were recently admitted to the facility, were receiving medications from medicine bottles brought from home. Review of the medical records for Residents #79 and #36 found no evidence these home medications had been examined by a physician or pharmacist prior to administration to the residents in accordance with facility policy, to verify the contents of the bottles (right drug) and to verify the labels on the bottles matched the current physician's orders [REDACTED]. These practices placed two (2) current residents at immediate risk for serious harm related to the potential to receive medications the identity of which had not been verified and for which the dispensing instructions on the labels were inconsistent with current physician's orders [REDACTED]. After removal of the immediate jeopardy, the potential for more than minimal harm continued to exist for newly admitted residents until the facility corrected its system related to verifying medications (and their dispensing instructions) brought from home. Facility census: 49. Findings include: a) Resident #79 During medication pass at 8:50 a.m. on 06/30/10, observation found the nurse (Employee #73) pouring medications for Resident #79 from brown medicine bottles, not from the bubble packs used for the other residents. When questioned, Employee #73 stated it was facility practice to use up any medications brought in from a resident's home before ordering them from the facility's vendor pharmacy. This practice was verified by two (2) other nurses on the floor (Employees #48 and #57). Examination of the brown medicine bottles for Resident #79 found the labels on the bottles did not always correlate with the resident's current physician's orders [REDACTED]. 1. The dispensing instruction on the label read, "[MEDICATION NAME] (a stool softener) 100 mg by mouth twice daily." According to the physician's orders [REDACTED]." 2. The dispensing instruction on the label read, "[MEDICATION NAME] (a [MEDICAL CONDITION]-acid pump inhibitor used to treat reflux) DR (Delayed Release) 20 mg by mouth daily." According to the physician's orders [REDACTED]. 3. The dispensing instruction on the label read, "[MEDICATION NAME] (a glucocorticosteroid) 4 mg ? tab twice daily." According to the physician's orders [REDACTED]." [MEDICATION NAME] 2 mg was administered correctly, but this required the nurse to break a 4 mg tablet in half. The nurse commented that she would be glad when the pills were gone, so they would no longer have to break the pills each time. Further record review revealed Resident #79 was admitted to the facility on [DATE]. -- b) Resident #36 During medication pass at 8:59 a.m. on 06/30/10, observation found Employee #73 pouring medications for Resident #36 from brown medicine bottles, not from the bubble packs used for the other residents. Employee #73 confirmed these brown medicine bottles were brought from Resident #36's home. The label on the brown medicine bottle for Resident #36 included the instructions: "[MEDICATION NAME] 25 mg by mouth twice daily." According to the physician's orders [REDACTED]. Further record review revealed Resident #36 was admitted to the facility on [DATE]. -- c) The director of nurses (DON), when asked about this practice during an interview at 10:00 a.m. on 06/30/10, verified that home medications were administered to residents but that a nurse always verified them with the physician. A copy of the facility's current pharmacy policy and procedure manual was requested at that time. -- d) During a telephone interview with the facility's consultant pharmacist at 11:15 a.m. on 06/30/10, he acknowledged he was aware the facility used medications brought by new residents from home on admission to the facility until they were gone. He added that, at times, payment was refused when a prescription had recently been filled and a resident was on Medicare Part D. He stated he "usually" reviewed them with a nurse over the phone, because coming to the facility each time to personally check them would "be a hardship", although he had no documentation that this telephone review was done for Residents #79 and #36. He further offered his opinion that using medications brought from home was not an ideal practice, because "... You didn't know where they had been stored or that pills in the bottle were the correct ones." He agreed the label on the medicine bottles did not always match the physician's orders [REDACTED]. When asked if there were a policy for the use of medications brought from home, he stated he knew of none. -- e) Two (2) hours after the initial request was made, at about 12:00 p.m. on 06/30/10, the DON produced the facility's pharmacy policy and procedure manual for review by the survey team. A review of the manual failed to disclose any evidence to reflect the facility's governing body or duly-appointed designee had initially reviewed, approved, and adopted the manual; at the bottom of each page of the manual was "Effective Date: _______" with no date entered in the blank provided. There was no evidence, after a review of the entire manual, to reflect its contents had been periodically revised and revised (as needed) since it was provided to the facility on [DATE], to ensure it was reflective of current standards of professional practice. On pages 4 and 5 of the manual under "2. Provider Pharmacy - Requirements", "d. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to ... 7) Performing an initial medication use assessment for each new residents to ensure that the medication regimen meets the resident's needs." On page 37 under "12. Medications Brought to Facility by Resident or Family Member", "Policy: Medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the facility's guidelines. Other unauthorized medications are not accepted by the facility." -- f) Review of the medical records for Residents #79 and #36 which found no evidence these home medications had been examined by a physician or pharmacist prior to administration to the residents, to verify the contents matched the labels on the bottles. Additionally, there were no orders from the physician authorizing the administration of these home medications, and there were no notations on the residents' MARs to indicate that medications brought from home were to be administered. The survey team determined these practices placed both Residents #36 and #79 in immediate jeopardy, due to the potential for medication errors associated with administering medications without verification by a qualified health care professional that the contents of these medicine bottles matched the labels on the bottles and the current physician's orders [REDACTED]. The administrator and the DON were notified of the finding of immediate jeopardy at 1:55 p.m. on 06/30/10. -- g) Review of the contents of the facility's medication carts (to determine what additional home medications were available for administration to residents), in the presence of two (2) facility nurses (Employee #73 and #48) beginning at 2:00 p.m. on 06/30/10, found a total of thirteen (13) medicine bottles for Resident #79. Three (3) of the bottles were empty; three (3) medications had been discontinued but not removed from the cart, and one (1) over-the-counter medication had no label at all. This review also found five (5) medicine bottles for Resident #36, two (2) of which were empty. Employee #73 confirmed Resident #36 was receiving [MEDICATION NAME] (an antidepressant) 50 mg daily, [MEDICATION NAME] (an antihypertensive) 0.3 mg twice daily, and [MEDICATION NAME] (an antihypertensive) 50 mg daily from the medicine bottles brought from home. -- h) The DON presented a proposed plan of correction (POC) at 3:30 p.m. on 06/30/10, which stated, "In coordination with pharmacy a policy and procedure will be written and thoroughly in-serviced to all nurses." The DON expressed surprise when informed there already was a policy in the manual to address this. The POC was initially rejected as it did not address all aspects of the immediate jeopardy situation. A revised POC was approved at 4:05 p.m. on 06/30/10, and the immediate jeopardy situation was declared removed at 4:13 p.m., after verification by the survey team that the revised POC had been implemented, to include verification that all medications brought from home were removed from the medication carts and were no longer available for use. -- i) The DON agreed, when interviewed at 4:15 p.m. on 06/30/10, the discontinued medications should have been removed from the cart. She also acknowledged the differences between the labels on the medicine bottles from home and the current physician's orders [REDACTED]. -- j) In an interview with the pharmacist at 1:30 p.m. on 07/06/10, he stated the pharmacy manual had been provided to the facility on [DATE], and he provided a letter verifying this. The letter stated, "Please find enclosed a (sic) updated Policy and Procedures (sic) to be reviewed for approval and placed into your manuals." The pharmacist also stated he did not remember attending any meetings where the manual was reviewed. During an interview with the DON at 8:10 a.m. on 07/07/10, she stated she could locate no documentation of any committee review of this manual. During an interview with the administrator (who was also responsible for overseeing the facility's quality assurance activities) at 9:30 a.m. on 07/07/10, he explained the owner of the facility was, in effect, the "governing body" of the facility and was responsible for these functions. He stated the owner attended committee meetings periodically but not on a regularly scheduled basis. On 07/08/10 at 9:15 a.m., the administrator verified the pharmacy policy and procedure manual was not signed by the governing body to reflect review and approval of its contents. On 07/08/10 at 9:15 a.m., the administrator verified the pharmacy policy and procedure manual was not signed by the governing body to reflect review and approval of its contents. The administrator also verified the facility did not identify this area as a potential concern. At the time of exit at 10:00 a.m. on 07/08/10, no additional information was provided by the facility as evidence to the contrary. .

Based on observation, record review, staff interview, facility policy review, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies - of which it should have been aware - that were reflective of system failures in the area of medication administration, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. Two (2) of twenty-three (23) Stage II sample residents (#79 and #36), who were recently admitted to the facility, were receiving medications from medicine bottles brought from home. Review of the medical records for Residents #79 and #36 found no evidence these home medications had been examined by a physician or pharmacist prior to administration to the residents in accordance with facility policy, to verify the contents of the bottles (right drug) and to verify the labels on the bottles matched the current physician's orders [REDACTED]. Members of the facility ' s QAA committee, including the director of nursing (DON) and the pharmacist, were aware of the practice of administering to newly admitted residents medications they had brought from home. When interviewed, the pharmacist stated he "usually" reviewed these home medications with a nurse over the phone, because coming to the facility each time to personally check them would "be a hardship", although he had no documentation that this telephone review was done for Residents #79 and #36. He further offered his opinion that using medications brought from home was not an ideal practice, because "... You didn't know where they had been stored or that pills in the bottle were the correct ones." He agreed the label on the medicine bottles did not always match the physician's orders [REDACTED]. The QAA committee should have been aware of this quality deficiency and should have developed and implemented a corrective plan of action to ensure residents could safely use medications brought from home. This failure placed two (2) of twenty-three (23) Stage II sample residents (#79 and #36) at immediate risk for serious harm related to the potential to receive medications the identity of which had not been verified and for which the dispensing instructions on the labels were inconsistent with current physician's orders [REDACTED]. After removal of the immediate jeopardy, the potential for more than minimal harm continued to exist for newly admitted residents until the facility corrected its system related to verifying medications (and their dispensing instructions) brought from home. Facility census: 49. Findings include: a) Resident #79 During medication pass at 8:50 a.m. on 06/30/10, observation found the nurse (Employee #73) pouring medications for Resident #79 from brown medicine bottles, not from the bubble packs used for the other residents. When questioned, Employee #73 stated it was facility practice to use up any medications brought in from a resident's home before ordering them from the facility's vendor pharmacy. This practice was verified by two (2) other nurses on the floor (Employees #48 and #57). Examination of the brown medicine bottles for Resident #79 found the labels on the bottles did not always correlate with the resident's current physician's orders [REDACTED]. 1. The dispensing instruction on the label read, "[MEDICATION NAME] (a stool softener) 100 mg by mouth twice daily." According to the physician's orders [REDACTED]." 2. The dispensing instruction on the label read, "[MEDICATION NAME] (a [MEDICAL CONDITION]-acid pump inhibitor used to treat reflux) DR (Delayed Release) 20 mg by mouth daily." According to the physician's orders [REDACTED]. 3. The dispensing instruction on the label read, "[MEDICATION NAME] (a glucocorticosteroid) 4 mg ? tab twice daily." According to the physician's orders [REDACTED]." [MEDICATION NAME] 2 mg was administered correctly, but this required the nurse to break a 4 mg tablet in half. The nurse commented that she would be glad when the pills were gone, so they would no longer have to break the pills each time. Further record review revealed Resident #79 was admitted to the facility on [DATE]. -- b) Resident #36 During medication pass at 8:59 a.m. on 06/30/10, observation found Employee #73 pouring medications for Resident #36 from brown medicine bottles, not from the bubble packs used for the other residents. Employee #73 confirmed these brown medicine bottles were brought from Resident #36's home. The label on the brown medicine bottle for Resident #36 included the instructions: "[MEDICATION NAME] 25 mg by mouth twice daily." According to the physician's orders [REDACTED]. Further record review revealed Resident #36 was admitted to the facility on [DATE]. -- c) The DON, when asked about this practice during an interview at 10:00 a.m. on 06/30/10, verified that home medications were administered to residents but that a nurse always verified them with the physician. A copy of the facility's current pharmacy policy and procedure manual was requested at that time. -- d) During a telephone interview with the facility's consultant pharmacist at 11:15 a.m. on 06/30/10, he acknowledged he was aware the facility used medications brought by new residents from home on admission to the facility until they were gone. He added that, at times, payment was refused when a prescription had recently been filled and a resident was on Medicare Part D. He stated he "usually" reviewed them with a nurse over the phone, because coming to the facility each time to personally check them would "be a hardship", although he had no documentation that this telephone review was done for Residents #79 and #36. He further offered his opinion that using medications brought from home was not an ideal practice, because "... You didn't know where they had been stored or that pills in the bottle were the correct ones." He agreed the label on the medicine bottles did not always match the physician's orders [REDACTED]. When asked if there were a policy for the use of medications brought from home, he stated he knew of none. -- e) Two (2) hours after the initial request was made, at about 12:00 p.m. on 06/30/10, the DON produced the facility's pharmacy policy and procedure manual for review by the survey team. A review of the manual failed to disclose any evidence to reflect the facility's governing body or duly-appointed designee had initially reviewed, approved, and adopted the manual; at the bottom of each page of the manual was "Effective Date: _______" with no date entered in the blank provided. There was no evidence, after a review of the entire manual, to reflect its contents had been periodically revised and revised (as needed) since it was provided to the facility on [DATE], to ensure it was reflective of current standards of professional practice. On pages 4 and 5 of the manual under "2. Provider Pharmacy - Requirements", "d. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to ... 7) Performing an initial medication use assessment for each new residents to ensure that the medication regimen meets the resident's needs." On page 37 under "12. Medications Brought to Facility by Resident or Family Member", "Policy: Medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the facility's guidelines. Other unauthorized medications are not accepted by the facility." -- f) Review of the medical records for Residents #79 and #36 which found no evidence these home medications had been examined by a physician or pharmacist prior to administration to the residents, to verify the contents matched the labels on the bottles. Additionally, there were no orders from the physician authorizing the administration of these home medications, and there were no notations on the residents' MARs to indicate that medications brought from home were to be administered. The survey team determined these practices placed both Residents #36 and #79 in immediate jeopardy, due to the potential for medication errors associated with administering medications without verification by a qualified health care professional that the contents of these medicine bottles matched the labels on the bottles and the current physician's orders [REDACTED]. The administrator and the DON were notified of the finding of immediate jeopardy at 1:55 p.m. on 06/30/10. -- g) Review of the contents of the facility's medication carts (to determine what additional home medications were available for administration to residents), in the presence of two (2) facility nurses (Employee #73 and #48) beginning at 2:00 p.m. on 06/30/10, found a total of thirteen (13) medicine bottles for Resident #79. Three (3) of the bottles were empty; three (3) medications had been discontinued but not removed from the cart, and one (1) over-the-counter medication had no label at all. This review also found five (5) medicine bottles for Resident #36, two (2) of which were empty. Employee #73 confirmed Resident #36 was receiving [MEDICATION NAME] (an antidepressant) 50 mg daily, [MEDICATION NAME] (an antihypertensive) 0.3 mg twice daily, and [MEDICATION NAME] (an antihypertensive) 50 mg daily from the medicine bottles brought from home. -- h) The DON presented a proposed plan of correction (POC) at 3:30 p.m. on 06/30/10, which stated, "In coordination with pharmacy a policy and procedure will be written and thoroughly in-serviced to all nurses." The DON expressed surprise when informed there already was a policy in the manual to address this. The POC was initially rejected as it did not address all aspects of the immediate jeopardy situation. A revised POC was approved at 4:05 p.m. on 06/30/10, and the immediate jeopardy situation was declared removed at 4:13 p.m., after verification by the survey team that the revised POC had been implemented, to include verification that all medications brought from home were removed from the medication carts and were no longer available for use. -- i) The DON agreed, when interviewed at 4:15 p.m. on 06/30/10, the discontinued medications should have been removed from the cart. She also acknowledged the differences between the labels on the medicine bottles from home and the current physician's orders [REDACTED]. -- j) In an interview with the pharmacist at 1:30 p.m. on 07/06/10, he stated the pharmacy manual had been provided to the facility on [DATE], and he provided a letter verifying this. The letter stated, "Please find enclosed a (sic) updated Policy and Procedures (sic) to be reviewed for approval and placed into your manuals." The pharmacist also stated he did not remember attending any meetings where the manual was reviewed. During an interview with the DON at 8:10 a.m. on 07/07/10, she stated she could locate no documentation of any committee review of this manual. During an interview with the administrator (who was also responsible for overseeing the facility's quality assurance activities) at 9:30 a.m. on 07/07/10, he explained the owner of the facility was, in effect, the "governing body" of the facility and was responsible for these functions. He stated the owner attended committee meetings periodically but not on a regularly scheduled basis. On 07/08/10 at 9:15 a.m., the administrator verified the pharmacy policy and procedure manual was not signed by the governing body to reflect review and approval of its contents. The administrator also verified the facility did not identify this area as a potential concern. At the time of exit at 10:00 a.m. on 07/08/10, no additional information was provided by the facility as evidence to the contrary.

Based on medical record review, observation,and staff interview, the facility failed to provide the necessary care and services to prevent new pressure sores from developing for one (1) of three (3) residents whose medical records were reviewed for pressure ulcers. Resident #16 had been assessed as being at low risk for development of pressure ulcers. Medical record review revealed the resident developed a pressure ulcer, which was treated, healed, and then re-opened, because the facility failed to provide a pressure relieving device for chairs in which the resident spent most of the day sitting. Resident identifier: #16. Facility census: 53. Findings include: a) Resident #16 Medical record review revealed Resident #16 developed a pressure ulcer on 01/08/09. The resident was treated, and staff recorded the wound was healed on 02/16/09, after which preventive treatment was used. Review of the resident's Braden Scale, used to predicting pressure sore risk, revealed the resident was rated as being at mild risk for the development of pressure sores. During a treatment on 03/17/09 at 10:00 a.m., observation revealed the resident had a red area on the lower coccyx at the cleft of the buttocks. When the treatment nurse cleansed the red area, observation revealed two (2) small areas open areas which measured 0.2 x 0.2. Interview with the treatment nurse (Employee #80) during this observation revealed the area had been healed and these two (2) areas had just re-opened. When the treatment nurse was questioned as to why the resident had developed a pressure ulcer and why the area had re-opened, the nurse indicated the resident spent a large part of her day sitting in a chair at the nurse's station, and she stated the resident probably needed a pressure relieving cushion. On 03/17/09, observations found the resident moved independently in bed and was ambulatory with a walker and staff assistance. Observations beginning at 11:00 a.m. found the resident sitting in a chair in front of the nurse's station; at 2:15 p.m., staff assisted the resident to bed to be seen by the physician. The chair in which the resident sat was wooden with a curved back and a small flat cushion built onto the chair seat. Review of physician's orders [REDACTED]. On 03/18/09 at 11:30 a.m., observation again found the resident sitting in the wooden chair in front of the nurse's station. During a subsequent interview at 12:05 p.m. on 03/18/09, the treatment nurse (Employee #80) was asked if the small flat cushion which was built onto the resident's chair was adequate as a pressure relieving device, and she stated it was not adequate. .