Every finding on record at West Vue Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 119.Review of the facility's policy titled, Food Preparation and Service, revised April 2014, showed:- Food service employees shall prepare and serve food in a manner that complies with safe food handling practices;- All machines and equipment that require cleaning shall be cleaned after use and covered with a washable cover between uses;- Foods will not be thawed at room temperature, thawing procedures include thawing in the refrigerator in a drip-proof container;- Residents should be discouraged from saving anything from their meals for later consumption;- Snacks will not be left on trays or countertops beyond the established safe time and temperature requirements. Review of the facility's policy titled, Food Receiving and Storage, revised April 2014, showed:- Foods shall be received and stored in a manner that complies with safe food handling practices;- When food is delivered to the facility it will be inspected for safe transport and quality before being accepted;- Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date), such foods will be rotated using a first in - first out system;- Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods. The facility did not provide a policy regarding water temperature in the kitchen. Observation on 04/13/26 at 10:53 A.M., and 04/16/26 at 12:07 P.M., of the kitchen showed:- The commercial dishwasher exterior with flaky white grime (dirt ingrained on the surface) build-up and scattered debris on the floor beneath;- Debris, an oily film build-up, and food debris on the floor beneath and behind the range; - The commercial gas range with an oily grime build-up around each burner, exterior surfaces, door handle, control knobs, oven interior, and scattered food debris on the floor beneath; - An oily grime build-up behind the gas range on the floor and wall surfaces;- An oily grime build-up on the steam table control knobs and exterior surfaces;- Bread shelving with dust and grime build-up;- Floor with white grime build-up in the dishwashing area;- Metal electrical junction box with exposed wiring below the dishwasher;- One approximately 24 inch (in.) x 36 in. wall diffuser (one of the few visible parts of an air conditioning system) with dust build-up and a brown substance on the front exterior surfaces near the walk in refrigerator;- The three-compartment sink with water temperature at 90 degrees Fahrenheit ( F) in the main kitchen area;- The dishwashing area sprayer sink at 65 F. During an interview on 04/16/26 at 12:07 P.M., Dietary Aide (DA) T said he/she asked about the stove and oven being pulled back so the backside area could be cleaned. There were cleaning logs, but the four-burner gas range still needed some deep cleaning, the steam table would need some cleaning also. A drip from the top created grease on the knobs and on the front of the steam table. During an interview on 04/16/26 at 12:31 P.M., DA U said the dishwasher had been delimed this week on Tuesday, but it did build up with grime in between cleanings. The water temperature should be warmer at the sink for dishes. It was warmer earlier today, but it didn't stay hot. Observation on 04/13/26 at 10:53 A.M., of the dry food storage area showed:- Three undated white bins of flour, white sugar, and brown sugar covered with clear tops and food debris on the tops; - One undated 3 quart (qt.) dented can of black eye peas;- One undated 3 qt. dented cans of tapioca pudding with a brown substance located on the dent;- Two undated 3 qt. dented cans of mild nacho cheese with a brown substance located on the dent;- Two 50 ounce (oz.) dented cans of New England clam chowder with white and brown food debris, dated best used by 04/10/27;- One 50 oz. dented can of cream of mushroom soup with white and brown food debris, dated best used by 09/16/27;- One 25 pound (lb.) opened bag of Japanese breadcrumbs, dated 07/09/25. Observation on 04/13/26 at 10:00 A.M., of the walk-in refrigerator showed:- Scattered food debris and shredded cheese lay on the floor below the food storage shelves. Observation on 04/13/26 at 10:05 A.M., of the walk-in freezer showed:- The floor with 1 in. thick ice formation below the food shelves;- One case of pork chops, one case of Italian vegetables, and three storage bags with ice lay on the floor;- Scattered food debris and paper trash below the food storage shelves. Observation on 04/14/26 at 5:19 A.M., of the Whispering Pine kitchen showed:- Scattered debris on the floor below the main refrigerator and the food shelves;- Refrigerator exterior handles with a sticky film build-up and the meat drawer with scattered food debris;- Ice machine exterior surfaces with a white substance and the top door seal section with scattered black debris;- Two clear glass baking dishes partially filled with apple dump cake and cherry delight cream dessert sat on the counter, dated 4/12/26;- Dishwasher interior with a 12 in. non-stick skillet; - An electric griddle sat on top of the electric range with a black carbon build-up along the edge of the top cooking surface; - Electric range oven handles with a sticky film build-up and interior lower surface with carbon build-up;- The utensil drawer divider tray with a scattered black substance and food debris; - Pantry area food bin with scattered food debris and hard textured hot dog buns, dated best by 02/17/26 and one bag of stuffing croutons, dated best by 11/06/25. During an interview on 04/14/26 at 5:30 A.M., DA V said he/she had a daily task paper that should be followed. The cleaning part was mainly done by the third shift staff that were here all night. Dayshift should clean up as needed after meals and the table was cleaned after two meals. During the night shift, staff should wipe the appliance handles and throw out the expired foods. Observation on 04/14/26 at 6:00 A.M., of the Dogwood kitchen showed:- Ice machine exterior surfaces with a white substance, the top door seal section with scattered black debris, and the upper interior section with a brown grime build-up;- Refrigerator exterior handles with a sticky film build-up and the meat drawer with scattered food debris;- One 12 oz. refrigerated bottled tartar sauce, dated best by 03/13/26;- One 3.69 lb. beef brisket, dated 05/21/25, thawed inside the pantry area refrigerator on the top shelf;- Food debris lay in the pantry area floor below the food storage shelves. Observation on 04/14/26 at 6:14 A.M., of the Sleepy Oaks kitchen showed:- Two clear glass baking dishes partially filled with blueberry cream and peach dessert sat on the counter, dated 4/13/26;- Pantry area food bin with scattered food debris and three hard textured hot dog buns, dated received on 03/20/26;- Food debris lay in the pantry area floor below the food storage shelves;- One 12 oz. dented can of three bean salad, dated received on 02/21/26;- One 12 oz. dented can of tomato paste, dated received on 02/13/26;- One 12 oz. dented can of peaches, dated received on 01/17/26;- The pantry area freezer door bin partially splattered with an orange substance;- The pantry area refrigerator exterior handles with a sticky film build-up and the food shelves with scattered food debris and a dark spilled substance. During an interview on 04/14/26 at 6:30 A.M., DA W said he/she just started in the kitchen about a month ago and did not know there weren't supposed to be dented cans in the dry storage. During an interview on 04/13/26 at 10:53 A.M., the Dietary Manager said canned foods should at least have a use by date on the container, but some of the cans didn't. Normally she would not date the cans, but the staff went through the cans weekly when the truck delivered. She put a line on the front of a can to know which cans went first. Staff should place rusty and dented cans in the return cart, but some were on the rack. There should not be food boxes on the floor or trash under the shelves in the walk-in freezer. There should not be an opened bag of breadcrumbs under the sink that were out of date. During an interview on 04/16/26 at 1:30 P.M., the Administrator said the freezer and refrigerators should be clean. The wall vents should be clean and not have dust or grime build-up. All appliances, counter tops, and vents should be clean and work properly. Dented cans should not be put on the racks, desserts should not be left out, and expired foods should be thrown away. Expectations were to follow the facility's kitchen policy and always keep the kitchen clean.

Based on interview and record review, the facility failed to limit the use of as needed (PRN) psychotropic (medications that affect the mind, emotions, and behaviors) medication orders for 14 days for two residents (Residents #85 and #98) out of four sampled residents. The facility also failed to ensure an appropriate diagnosis for the use of an antipsychotic (medication that treats mental disorders characterized by a disconnection from reality) medication for one resident (Resident #108) and for the use of an antianxiety medication for one resident (Resident #10) out of four sampled residents. The facility census was 119.Review of the facility's policy titled, Psychotropic Medication Use, dated February 2025, showed:- Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record;- Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: non-pharmacological alternatives, the indications and rationale for the recommendation, the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings), and the resident's/representative's right to accept or decline the treatment;- PRN orders for psychotropic medications are limited to 14 days;- For psychotropic medications that are not antipsychotics: if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order. 1. Review of Resident #10's medical record showed:- Date of admission [DATE];- Diagnoses of Alzheimer's disease (a progressive brain disease that destroys memory, thinking skills, and eventually the ability to perform daily tasks), anxiety disorder (persistent worry and fear about everyday situations), bipolar disorder (a mental disorder that causes unusual shifts in mood), current episode manic (a period of abnormally high energy, elevated mood, or intense irritability) without psychotic (a loss of contact with reality) features, and insomnia (difficulty sleeping). Review of the resident's physician order sheet (POS), dated April 2026, showed:- An order for buspirone (an antianxiety medication) 5 milligram (mg) by mouth two times a day related to Alzheimer's disease, dated 10/01/25;- The facility failed to provide an appropriate diagnosis for the buspirone. 2. Revew of Resident #85's POS, dated April 2026, showed:- Date of admission [DATE];- Diagnoses of senile degeneration of the brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior), not elsewhere classified, dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) in other diseases classified elsewhere, moderate, with agitation;- An order for lorazepam (an antianxiety medication) 0.5 mg by mouth every eight hours PRN for anxiety, dated 02/03/26;- The facility failed to provide a 14-day stop-date order for the lorazepam. 3. Review of Resident #98's POS, dated April 2026, showed:- Date of admission [DATE];- Diagnoses of dementia in other diseases classified without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; depression (a serious medical illness that negatively affects how you feel, the way you think and how you act); parkinsonism (a broad, umbrella term for a clinical syndrome featuring movement problems); and Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors) with dyskinesia (a movement disorder characterized by involuntary, erratic, and uncontrollable body movements);- An order for lorazepam concentrate 2 mg/milliliter (ml) 0.25 ml sublingually (under the tongue) every four hours as needed for anxiety and for seizures may give 0.25 ml to 1 ml every four hours, dated 03/06/26, with no stop date;- The facility failed to provide a 14-day stop-date order for the lorazepam. 4. Review of Resident #108's medical record showed:- Date of admission [DATE];- Diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with anxiety. Review of the resident's POS, dated April 2026, showed:- An order for Zyprexa (an antipsychotic medication) 2.5 mg by mouth once daily for agitation and sundowning (a state of increased agitation, confusion, disorientation, and anxiety that typically occurs in the late afternoon or evening in some individuals affected with dementia), dated 01/21/26;- The facility failed to provide an appropriate diagnosis for the Zyprexa. During an interview on 04/16/26 at 8:50 A.M., the Medical Director said he would expect a 14-day stop-date order for psychotropic PRN medications. He would expect medications to have the correct diagnosis. During an interview on 04/16/26 at 3:40 P.M., the Director of Nursing (DON) said PRN psychotropic medications should have a stop date. If the physician did not include a stop date, the physician should be notified to clarify a stop date. She said sundowning and agitation were not acceptable diagnoses for an antipsychotic medication. During an interview on 04/16/26 at 4:26 P.M., the Administrator said sundowning and agitation were not acceptable diagnoses for an antipsychotic medication.

Based on interview and record review, the facility failed to ensure the accuracy of a resident's advance directive regarding cardiopulmonary resuscitation (CPR - an emergency life-saving technique used when a person's heart stops beating or they stop breathing) code status for one resident (Resident #81) out of 24 sampled residents. The facility census was 119.The facility did not provide a policy regarding a resident's code status. 1. Review of Resident #81's [DATE] physician order sheet (POS) showed:- An admission date of [DATE];- No code status order. Review of the resident's face sheet, dated [DATE], showed:- No code status. Review of the resident's Outside the Hospital Do Not Resuscitate (OHDNR) form showed:- Code status of do not resuscitate (DNR) with the resident's signature, dated [DATE], and the physician's signature dated [DATE]. Review of the resident's care plan, undated, showed:- Did not address a code status. During an interview on [DATE] at 10:46 A.M., Licensed Practical Nurse (LPN) F said if a resident's code status was not in their medical record and he/she was unsure, he/she would treat them as a full code (wants CPR). He/She would look in the electronic health record (EHR) for the code status. During an interview on [DATE] at 3:27 P.M., the Director of Nursing said staff should check the code status in the EMR. If a resident's code status was not on their face sheet, staff would have to check further in the EHR. During an interview on [DATE] at 3:37 P.M., the Administrator said the resident code status should be indicated on the face sheet in the EHR.

Based on interview and record review, the facility failed to include the bed-hold rate and complete the bed-hold policy upon transfer to the hospital and failed to identify the reason for the transfer/discharge and include the mailing and email address for the agency for protection and advocacy for residents with intellectual disabilities, and the mailing and email address and telephone number for the agency for protection and advocacy for residents with mental illness within the transfer and discharge notices for four residents (Residents #1, # 9, #11, and #124) out of four sampled residents. The facility census was 119.Review of the facility's policy titled, Bed-Holds and Returns, revised October 2022, showed:- All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave);- Residents, regardless of payer source, are provided written notice about these policies at least twice, notice 1: well in advance of any transfer (e.g., in the admission packet); and notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours);- The written bed-hold notices provided to the residents/representatives explain in detail the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; the reserve bed payment policy as indicated by the state plan (for Medicaid residents), the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and the facility return policy. Review of the facility's policy titled, Transfer or Discharge, revised March 2025, showed:- Once admitted to the facility, residents have the right to remain in the facility, transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record;- When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider, the basis for the transfer or discharge, that an appropriate notice was provided to the resident and/or legal representative, the date and time of the transfer or discharge, the new location of the resident, the mode of transportation, a summary of the resident's overall medical, physical, and mental condition, disposition of personal effects, disposition of medications, others as appropriate or as necessary, and the signature of the person recording the data in the medical record;- If the basis for the transfer or discharge is that the transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility, the resident's physician (or provider) documents the specific resident needs that cannot be met, the facility's attempt to meet those needs, and the receiving facility's service(s) that are available to meet those needs;- Upon notice of transfer or discharge, the resident is provided with a statement of his or her right to appeal the transfer or discharge, including the name, address, email, and telephone number of the entity which receives such requests, information about how to obtain, complete, and submit an appeal form, how to get assistance completing the appeal process, and the facility bed-hold policy. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE], and returned on 01/26/26;- Transferred to the hospital on [DATE], and returned on 02/18/26;- Transferred to the hospital on [DATE], and returned on 03/23/26. Review of the resident's Bed-Hold information, undated, showed:- No documentation the resident or resident representative elected to hold the bed;- No documentation of the daily bed hold rate;- No documentation of the resident's or resident representative's signature. Review of the resident's Notice of Transfer/Discharge forms, dated 01/26/26, 02/16/26, and 03/23/26, showed:- No documentation for the reason of the transfer/discharge;- No documentation of the agency contact information responsible for the protection and advocacy of individuals with developmental disabilities and the contact information for the agency for protection and advocacy of individuals with mental disorders. 2. Review of Resident #9's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE], and returned on 01/18/26;- Transferred to the hospital on [DATE], and returned 02/26/26;- Transferred to the hospital on [DATE], and returned on 03/25/26. Review of the resident's Bed-Hold information, undated, showed:- No documentation the resident or resident representative elected to hold the bed;- No documentation of the daily bed hold rate;- No documentation of the resident's or resident representative's signature. Review of the resident's Notice of Transfer/Discharge forms, dated 01/19/26, 02/26/26, and 03/21/26, showed:- No documentation for the reason of the transfer/discharge;- No documentation of the agency contact information responsible for the protection and advocacy of individuals with developmental disabilities and the contact information for the agency for protection and advocacy of individuals with mental disorders. 3. Review of Resident 11's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE], and returned on 10/04/25;- Transferred to the hospital on [DATE], and returned 10/26/25;- Transferred to the hospital on [DATE], and returned on 02/09/26. Review of the resident's Bed-Hold information, undated, showed:- No documentation the resident or resident representative elected to hold the bed;- No documentation of the daily bed hold rate;- No documentation of the resident's or resident representative's signature. Review of the resident's Notice of Transfer/Discharge forms, dated 09/30/25, 10/27/25, and 02/09/26, showed:- No documentation for the reason of the transfer/discharge;- No documentation of the agency contact information responsible for the protection and advocacy of individuals with developmental disabilities and the contact information for the agency for protection and advocacy of individuals with mental disorders. 4. Review of Resident #124's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE], and did not return. Review of the resident's Bed-Hold information, undated, showed:- No documentation the resident or resident representative elected to hold the bed;- No documentation of the daily bed hold rate;- No documentation of the resident's or resident representative's signature. Review of the resident's Notice of Transfer/Discharge forms, dated 01/26/26, showed:- No documentation for the reason of the transfer/discharge;- No documentation of the agency contact information responsible for the protection and advocacy of individuals with developmental disabilities and the contact information for the agency for protection and advocacy of individuals with mental disorders. During an interview on 04/16/26 at 1:05 P.M., the Social Services Designee (SSD) said she was unaware the Transfer/Discharge notice needed to be signed by the resident or the resident representative and returned to the facility, needed to identify the reason for the transfer/discharge, and include the mailing and email address for the agency for the protection and advocacy for residents with intellectual disabilities and the mail and email address and the telephone number for the agency for the protection and advocacy for residents with mental illness within the transfer and discharge notices. She also wasn't aware the resident or resident representative had the right to elect to hold the bed and the daily bed-hold rate needed to be documented on the form. During an interview on 04/16/26 at 4:02 P.M., the Administrator said she was not aware the Bed-Hold form had to have the daily rate along with the resident's or resident representative's signature. She also was unaware the Transfer/Discharge notice had to include the agency contact information responsible for protection and advocacy of individuals with developmental disabilities and contact information for the agency for protection and advocacy of individuals with a mental disorder.

Based on observation, interview, and record review, the facility failed to provide ongoing monitoring, supervision, and routine maintenance of the beds with the side rails in use and failed to ensure a bed rail was not used as a restraint for two residents (Residents #6 and #12) out of two sampled residents. The facility's census was 119.Review of the facility's policy titled, Bed/Side Rails, undated, showed:- Bed/Side rails may pose unwarranted hazards to patient safety and will only be used after careful evaluation for requested use by resident/family, for aid in mobility or to provide a sense of comfort and security. Safety is paramount and an evaluation is needed to assess the relative risk of using the bed/side rail compared to not using it for an individual resident. The decision to use or to discontinue use should be made in the context of an individual patient assessment with input from the resident or the legal guardian;- Side rail evaluations are completed by nursing to determine any risks associated with the use of bed/side rails;- Physician order obtained;- Resident bed/side rail consent explaining risks and alternatives is reviewed and signed by the resident or guardian;- Work order requesting bed rail installation sent to maintenance;- Bed/side rails installed after review of all forms by nursing;- Bed/side rail(s) installed. Review of the facility's policy titled, Use of Restraints, undated, showed:- Restraints shall never be used for the prevention of falls;- Physical restraints are defined as any manual method or physical or mechanical device, adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement;- The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition (i.e. side rails are put back down, rather than climbed over) and this restricts his/her typical ability to change position or place, that device is considered a restraint;- Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed;- Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 1. Review of Resident #6's medical record showed:- admitted on [DATE];- Diagnoses of heart failure (impaired heart function), chronic obstructive pulmonary disease (COPD - a lung disease), stroke, seizures (a sudden burst of electrical activity in the brain), atrial fibrillation (irregular heart rhythm), and repeated falls;- No order for the bilateral (both sides) quarter siderails;- No documentation of any attempts made with alternative methods prior to the side rail use;- No documentation of routine maintenance of the side rails. Review of the resident's Side Rail Evaluation, dated 03/27/26, showed:- No interventions trialed before considering the use of the side rails;- Resident used the assist rails on both sides;- Resident requested to use the side rails while in bed;- No cause/medical symptom justified the use. Review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment instrument completed by the facility), dated 04/01/26, showed:- Cognition severely impaired;- Maximum assistance from staff for bed mobility;- No side rail use. Review of the resident's care plan, dated 03/24/26, showed:- Did not address the bilateral quarter side rail use with goals and interventions. Observations on 04/13/26 at 11:12 A.M., 04/14/26 at 6:31 A.M., and 04/16/26 at 11:46 A.M., of the resident showed:- The resident lay in bed with the head of the bed elevated and the bilateral quarter side rails in the upward position and the left side of the bed up against the wall closest to the door. 2. Review of Resident #12's medical record showed:- admitted on [DATE];- Diagnoses of stroke, dysphagia (difficulty swallowing), high blood pressure, peripheral vascular disease (poor circulation), macular degeneration (eye disease affecting a person's central vision), anxiety (fear, unease, or worry about future events), and depression (persistent low mood, loss of interest and reduced energy);- An order for a quarter side rail for a positioning aid and for safety and security of the resident, dated 09/29/25;- No documentation of any attempts made with alternative methods prior to the side rail use;- No documentation of a side rail assessment completed;- No documentation of routine maintenance of the side rails. Review of the resident's quarterly MDS, dated [DATE], showed:- Cognition severely impaired;- Maximum assistance from staff for bed mobility;- No side rail use. Review of the resident's care plan, dated 03/19/26, showed:- Used a quarter side rail as an enabler for repositioning;- Required a Hoyer lift (a mechanical lift used to transfer residents from one position to another) for transfers, and a Geri chair (a medical reclining chair) for mobility. Be aware the resident has poor sitting balance, leans to the left, may need pillows to prop and for comfort. Observations on 04/14/24 at 12:32 P.M., and 04/16/26 at 12:17 P.M., of the resident's bed showed:- The bilateral quarter side rails in the upward position with the left side of the bed up against the wall closest to the door. Observation on 04/16/26 at 12:11 P.M., of the resident during incontinent care showed:- The resident did not utilize the bilateral side rails due to required max assistance from the staff with turning; - Certified Nurse Assistant (CNA) B put the right side rail in the downward position and the top of the side rail height remained approximately four inches above the top of the mattress. During an interview on 04/16/26 at 10:15 A.M., the Director of Nursing (DON) said the side rail inspections were completed by maintenance when the side rails were placed on the bed and if the resident ever changed beds or the mattress was changed. The side rail assessments for the need for a side rail should be completed quarterly and if the resident's condition changed. The side rails were not to be used for preventing a resident from moving or rolling out of the bed. Side rails were used as enablers. During an interview on 04/16/26 at 12:24 P.M., CNA B said the quarter side rails were placed in the lowered position which prevented Residents #6 and #12 from rolling out of bed due to the top of the rails sat above the mattress. Both residents had fallen, and the side rails were used to prevent the residents from falling out of bed. During an interview on 04/16/26 at 1:46 P.M., CNA C said the side rails were placed in the lowered position to keep Residents #6 and #12 in bed. Both residents had an incident a few months ago, where the residents landed on the floor. The side rails were used to keep them from falling out of bed. During an interview on 04/16/26 at 1:47 P.M., Licensed Practical Nurse (LPN) X said that when the quarter side rails were in the lowered position, they kept Resident #12 from rolling out of the bed due to the top of the side rail sat up above the mattress. During an interview on 04/16/26 at 4:02 P.M., the Administrator said side rails were used to promote independence and aid in turning. Side rails were not to be used to keep the residents in bed. Side rails assessments were completed initially and evaluated with care plans quarterly.

Based on observation, interview, and record review, the facility failed to develop and implement care plans with specific interventions to meet individual needs for two residents (Residents #4 and #7) out of 24 sampled residents. The facility census was 119.Review of the facility's policy titled, Care Plans-Comprehensive, undated, showed:- An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident;- Each resident's comprehensive care plan has been designed to: incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect treatment goals and objectives in measurable outcomes;- Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly. 1. Review of Resident #4's medical record showed:- admitted [DATE];- Diagnoses of stroke affecting the left side, persistent atrial fibrillation (irregular heartbeat), major depressive disorder (persistent sadness, loss of interest, and low energy lasting at least two weeks), muscle weakness, lack of coordination, and weakness. Review of the resident's Smoking Assessment, dated 09/15/25, showed:- Cognitively intact;- Educated on the smoking policy, including the designated areas;- Able to safely utilize a lighter;- Demonstrated safe smoking behavior while interacting with other residents. Review of the resident's care plan, revised 02/16/26, showed:- Did not address smoking with person-centered interventions. 2. Review of resident #7's medical record showed:- admitted [DATE];- Diagnoses of chronic respiratory failure (impaired lung function), diabetes mellitus (metabolic disease), atrial fibrillation (irregular rhythm), congestive heart failure (impaired heart function), chronic obstructive pulmonary disease (COPD - a lung disease), and paroxysmal (a sudden, intense, and temporary onset of symptoms) atrial fibrillation;- An order for Eliquis (a blood thinner) 2.5 milligram (mg) by mouth two times a day, dated 11/26/25. Review of the resident's care plan, revised 03/04/26, showed:- Did not address the Eliquis with person-centered interventions. During an interview on 04/16/26 at 3:27 P.M., the Director of Nursing (DON) said she would expect blood thinner medications and smoking to be addressed on a resident's care plan. She would expect person-centered interventions to be on the care plan as well. During an interview on 04/16/26 at 4:02 P.M., the Administrator said she would expect smoking, blood thinner medications, and individualized interventions to be on a resident's care plan.

Based on interview and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Resident #8) out of one sampled resident and one resident (Resident #88) outside the sample, whom the facility indicated on the facility's matrix (a form that is used to identify pertinent care categories for newly admitted residents in the last 30 days who are still residing in the facility and for all other residents) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event) or trauma (the lasting emotional response that often results from living through a distressing event) within the facility. The facility census was 119.Review of the facility's policy titled, Trauma Informed Care and Culturally Competent Care, revision date August 2022, showed:- Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being;- Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization;- Trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening;- Traumatic events which may affect residents during their lifetime include: - physical, sexual and emotional abuse; - neglect; - interpersonal or community violence; - serious injury or illness; - bullying; - forced displacement; - racism; - war, and; - generational or historical trauma;- Triggers are highly individualized. Some common triggers may include: - experiencing a lack of privacy or confinement in a crowded or small space; - exposure to loud noises, or bright/flashing lights; - certain sights, such as objects; and/or; - sounds, smells, and physical touch;- Include trauma-informed care as part of the quality assurance and performance improvement process, so that needs and problem areas are identified and addressed;- Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate;- Identify and decrease exposure to triggers that may re-traumatize the resident. 1. Review of Resident #8's medical record showed:- admitted on [DATE];- Diagnoses of bipolar disorder (a mood disorder that can cause intense mood swings), unspecified anxiety disorder (a mental health condition that cause fear, dread and other symptoms that are out of proportion to the situation), and paranoid personality disorder (a psychiatric condition distinguished by a pervasive distrust and suspicion of others, leading to impairments in psychosocial functioning);- No documented trauma informed consent assessment. Review of the facility's matrix, dated 04/13/26, showed:- Resident diagnosed with PTSD/trauma. Review of the resident's level one Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care), dated 07/10/24, showed:- No history of PTSD or trigger indicators. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/21/26, showed:- Cognition intact;- No diagnosis of PTSD. Review of the resident's Traumatic Event Assessment, dated 07/26/24, showed:- Positive screen for a traumatic event;- No triggers identified for the positive screen and no developed plan of care to minimize/avoid the triggers. Review of the residents' care plan, dated 04/16/26, showed:- Potential for a history of past trauma;- Will receive care based on the resident's past experiences and preferences to avoid triggers leading to re-traumatization;- Did not address the resident's past trauma or any triggers that would cause the resident trauma;- Did not address how the facility would address behaviors if they occurred or how the facility would provide support to the resident. During an interview on 04/16/26 at 12:15 P.M., the Administrator said trauma and/or PTSD should be addressed on Resident #8's care plan. The resident wanted the details of his/her trauma to be confidential and did not want people talking about what happened related to his/her trauma). The family had told the Administrator what had happened. In the past, the resident had requested a female counselor to treat him/her. During an interview on 04/16/26 at 3:20 P.M., Resident #8 said he/she used to see a counselor. Visiting and talking to others to keep his/her mind off things would help, but he/she had no one to talk to because the staff were busy. Maybe one-to-one visits in his/her room or playing cards might help when thoughts of his/her trauma occurred. 2. Review of Resident #88's medical record showed:- admitted on [DATE];- Diagnoses of pneumonia (infection and inflammation of the lung), acute kidney failure, and left femur fracture. Review of the facility's matrix, dated 04/13/26, showed:-The resident diagnosed with PTSD. Review of the resident's PASRR, dated 12/15/25, showed:- No history of PTSD or trigger indicators. Review of the resident's Trauma Informed Consent Assessment, dated 01/08/26, showed:- Experienced a traumatic event;- Had nightmares and unwanted thoughts about the event;- No triggers addressed. Review of the resident's care plan, revised 05/06/25, showed:- Did not address the resident's past trauma or any triggers that would cause the resident trauma;- Did not address how the facility would address behaviors if they occurred or how the facility would provide support to the resident. Review of the resident's Behavioral Notes, dated April 2026, showed:- No behaviors. During an interview on 04/14/26 at 8:14 A.M., Resident #88 said he/she was in a war and lots of men and women lost their lives during that time. The resident did not want to continue to talk about the war. During an interview on 04/15/26 at 2:00 P.M., the Social Services Director (SSD) said he/she completed the Trauma Informed Care screenings, but when he/she completed it, Resident #88 shut down and did not want to keep talking. He/She was not sure when the resident was diagnosed with PTSD but thought he/she came to the facility with the diagnosis. During an interview on 04/15/26 at 3:25 P.M., the Director of Nursing (DON) said if the resident had a diagnosis of PTSD, the care plan should include what triggered the behaviors with interventions. If no triggers were indicated at the time of the assessment, it should be documented on the resident's care plan as well. She said the trauma informed care assessment should be completed quarterly. During an interview on 04/15/26 at 3:48 P.M., the Administrator said the trauma informed care assessment was completed on every admission. If a resident had a diagnosis of PTSD, triggers and interventions should be addressed on the care plan. If the trauma informed care assessment showed no triggers, it should be addressed on the care plan for no triggers indicated and followed up on the next scheduled assessment.

Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for two out of two sampled medication carts. This practice had the potential to affect all residents. The facility census was 113.Review of the facility's policy titled, Controlled Substances, revised November 2022, showed:- Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up;- Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count;- The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the Director of Nursing (DON) services. 1. Review of the Licensed Practical Nurse (LPN)/Registered Nurse (RN) Narcotic Count records for the 200 Hall medication cart, dated 02/01/26 - 02/28/26, showed:- No signature and/or initials by the on-coming and off-going nurse on the shift verification of controlled substance count sheet for 12 missed opportunities out of 144 opportunities. Review of the LPN/RN Narcotic Count records for the 200 Hall medication cart, dated 03/01/26 - 03/31/26, showed:- No signature and/or initials by the on-coming and off-going nurse on the shift verification of controlled substance count sheet for 15 missed opportunities out of 158 opportunities. Review of the LPN/RN Narcotic Count records for the 200 Hall medication cart, dated 04/01/26 - 04/16/26, showed:- No signature and/or initials by the on-coming and off-going nurse on the shift verification of controlled substance count sheet for 10 missed opportunities out of 80 opportunities. 2. Review of the LPN/RN Narcotic Count records for the 400 Hall medication cart, dated 02/01/26 - 02/28/26, showed:- No signature and/or initials by the on-coming and off-going nurse on the shift verification of controlled substance count sheet for nine missed opportunities out of 120 opportunities. Review of the LPN/RN Narcotic Count records for the 400 Hall medication cart, dated 03/01/26 - 03/31/26, showed:- No signature and/or initials by the on-coming and off-going nurse on the shift verification of controlled substance count sheet for eight missed opportunities out of 144 opportunities. Review of the LPN/RN Narcotic Count records for the 400 Hall medication cart, dated 04/01/26 - 04/16/26, showed:- No signature and/or initials by the on-coming and off-going nurse on the shift verification of controlled substance count sheet for two missed opportunities out of 80 opportunities. During an interview on 04/16/26 at 10:20 A.M., LPN N said every shift should have two staff members count narcotics at each shift change. During an interview on 04/16/26 at 11:28 A.M., the DON said she expected the on-coming and off-going staff to count to reconcile the narcotics in the medication cart every shift and sign the narcotic count verification form. During an interview on 04/16/26 at 12:15 P.M., the Administrator said staff were to count the narcotics on the medication cart every shift. Two staff, the on-coming and off-going staff, should also sign the narcotic count verification form on each cart after performing the narcotic count together to ensure no discrepancies occurred on the prior shift.

Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organisms (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for three residents (Residents #7, #14, and #29) out of six sampled residents. The facility also failed to provide proper infection control techniques for hand hygiene and glove changes for six residents (Residents #1, # 5, #7, #13, #24, and #29) out of seven sampled residents. The facility census was 119.Review of the facility's policy titled, Enhanced Barrier Precautions, dated December 2024, showed:- Enhanced barrier precautions apply when a resident is not known to be infected or colonized with any MDROs, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained;- Indwelling medical devices include central lines, urinary catheters (a sterile tube inserted into the bladder to drain urine), feeding tubes, and tracheostomies;- Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen;- EBPs employ targeted gown and glove use in addition to standard precautions during high-contact resident care activities when contact precautions do not otherwise apply;- Gloves and gowns are applied prior to performing the high-contact resident care activity (as opposed to before entering the room);- Personal protective equipment (PPE) is changed before caring for another resident;- Face protection may be used if there is also a risk of splash or spray;- Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: changing briefs or assisting with toileting; device care or use (central line, urinary catheter, feeding tube, etc.); and wound care (any opening requiring a dressing). Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 04/22/14, showed:- This facility considers hand hygiene the primary means to prevent the spread of infections;- Employees must wash their hands for 10 to 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with residents; when hands are visibly dirty or soiled with blood or other body fluids; after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; after removing gloves; after handling items potentially contaminated with blood, body fluids, or secretions;- In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: before and after direct contact with residents; before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after handling used dressings, contaminated equipment, etc.; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and after removing gloves;- Hand hygiene is always the final step after removing and disposing of personal protective equipment;- The use of gloves does not replace handwashing/hand hygiene. Review of the facility's policy titled, Personal Protective Equipment - Gloves, revised April 2014, showed:- All employees must wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin;- The use of gloves will vary according to the procedure involved. The use of disposable gloves is indicated when handling soiled linen or items that may be contaminated, during all cleaning of blood, body fluids, and decontaminating procedures;- Wash your hands after removing gloves. 1. Observation on 04/13/26 at 2:33 P.M., of Resident #13's wound care showed:- EBP signage on the door;- Registered Nurse (RN) G performed hand hygiene, put on gloves and gown, turned off the wound vac (vacuum-assisted closure used to conduct negative pressure wound therapy to promote healing), clamped the tubing, disconnected the tubing, removed the canister from the wound vac, discarded the canister and tubing, did not perform hand hygiene, and did not change gloves;- RN G attached the new wound vac tubing to the wound vac dressing, attached the new canister to the wound vac, and turned on the wound vac;- RN G removed gown and gloves, performed hand hygiene, and exited the room. 2. Observation on 04/14/26 at 6:27 A.M., of Resident #5's incontinent care showed:- Certified Nurse Assistant (CNA) H and CNA I entered the resident's room, did not perform hand hygiene, and put on gloves;- CNA H and CNA I transferred the resident from the wheelchair to the toilet with a gait belt (device used to transfer residents from one position to another);- CNA H did not perform hand hygiene, changed gloves, did not perform hand hygiene, touched the linens to make the resident's bed, removed gloves, did not perform hand hygiene, exited the resident's room, retrieved washcloths, reentered the room, did not perform hand hygiene, entered the resident's bathroom, put on gloves;- CNA I removed the resident's shoes, urine-soiled underwear, did not perform hand hygiene, and did not change gloves;- CNA I pulled the resident's clean underwear and pants up to the resident's thighs, put the resident's shoes on, removed the gait belt, retrieved a clean shirt from the resident's closet, removed the resident's shirt, put deodorant on the resident, assisted CNA H to put the clean shirt on the resident, placed the gait belt on the resident, touched the wheelchair, and assisted the resident to stand;- CNA H did not perform hand hygiene, did not change gloves, applied lotion to the resident's back, did not perform hand hygiene, did not change gloves, assisted CNA I with placing the clean shirt on the resident, and assisted the resident to stand;- CNA H did not perform hand hygiene, did not change gloves, wiped fecal material from the resident's gluteal cleft (the crease between the right and left buttocks), did not change gloves, and did not perform hand hygiene;- CNA H and CNA I pulled the resident's clean underwear and pants into place and assisted the resident to his/her wheelchair;- CNA I did not perform hand hygiene and changed gloves;- CNA H did not perform hand hygiene and did not change gloves;- CNA H placed the resident's feet on the wheelchair foot pedals, removed the gait belt, removed gloves, and did not perform hand hygiene;- CNA H touched the resident's shirt, drink cup, and bedroom doorknob to exit the room, did not perform hand hygiene, reentered the room with clean linens, exited the room, and performed hand hygiene;- CNA I wet a washcloth and gave it to the resident to clean his/her face and hands, removed gloves, did not perform hand hygiene, propelled the resident in the wheelchair from the bathroom into the room, retrieved a brush from the sink counter and gave it to the resident, did not perform hand hygiene, put on gloves, gathered the soiled items and trash, removed gloves, did not perform hand hygiene, retrieved the brush from the resident and placed it on the bathroom sink counter, placed the resident's tray table on the arm of the wheelchair, did not perform hand hygiene, propelled the resident out of the room to the dining room with the trash bags of soiled items and trash in his/her bare hand, took the trash bags to the soiled utility room, placed the trash into the trash can, opened and dumped the bag of soiled clothing over the open washer, and performed hand hygiene. 3. Observation on 04/14/26 at 7:13 A.M., of Resident #14's urinary catheter care showed:- EBP sign and PPE affixed to the outside of the resident's door;- CNA B, CNA C, Nurse Assistant (NA) D, and NA E entered the resident's room, performed hand hygiene, put on gloves, did not put on gowns, and performed the resident's urinary catheter care;- CNA B, CNA C, NA D, and NA E removed gloves, performed hand hygiene, and exited the room. 4. Observation on 04/14/26 at 7:30 A.M., of Resident #1's wound care showed:- EBP signage on the door;- RN S performed hand hygiene, put on gloves and a gown, and entered the room with supplies;- RN S cleaned the wound, did not perform hand hygiene, did not change gloves, measured the wound with a paper ruler, did not perform hand hygiene, and did not change gloves;- RN S picked up a pen from the resident's bedside table, wrote the date on the clean wound dressing, placed the dressing to the wound area, removed gown and gloves, and did not perform hand hygiene;- RN S placed the unused wound treatment supplies in the resident's bathroom, did not perform hand hygiene, exited the room, and walked back to the nurse's office. 5. Observation on 04/14/26 at 8:30 A.M., of Resident #24's incontinent care and gait belt transfer showed:- CNA Q and CNA R performed hand hygiene, entered the room, and put on gloves;- CNA Q cleaned fecal material from the gluteal cleft, removed the brief filled with fecal material, did not perform hand hygiene, and changed gloves;- CNA Q assisted the resident to roll on to his/her back, removed the resident's pants, cleaned the middle of the perineal area two times with the same area of the wipe contaminated with fecal material, did not perform hand hygiene, did not change gloves, cleaned the middle perineal area again with a different wipe contaminated with fecal material, did not perform hand hygiene, and removed gloves;- CNA Q assisted the resident to put on a clean brief, placed socks on the resident, assisted the resident to put his/her feet through the pant legs, and sat up on the side of the bed, and did not perform hand hygiene;- CNA Q and CNA R assisted the resident to stand, pulled up his/her brief and pants, and transferred the resident to the wheelchair;- CNA R removed trash with the soiled items from the trash can, tied the bag and set aside, removed gloves, did not perform hand hygiene, applied deodorant to the resident, placed the foot pedals on the resident's wheelchair, touched the resident's doll, used a brush on the resident's hair, propelled the resident in the wheelchair to exit the room, and performed hand hygiene;- CNA Q did not perform hand hygiene, exited the resident's room, took the trash to the soiled utility room, and performed hand hygiene. 6. Observation on 04/14/26 at 9:14 A.M., of Resident #29's gastrostomy tube (g-tube - a tube surgically inserted into the stomach to provide hydration, nutrition, and medications) care showed:- EBP signage and PPE affixed to the outside of the resident's door;- Licensed Practical Nurse (LPN) F performed hand hygiene, put on gloves, and did not put on a gown;- LPN F cleaned the g-tube insertion site, did not change gloves, did not perform hand hygiene, performed the g-tube site dressing change, removed gloves, did not perform hand hygiene, and exited the resident's room. 7. Observation on 04/14/26 at 9:22 A.M., of Resident #13's urinary catheter dressing change showed:- EBP signage on the door;- RN G performed hand hygiene, did not put on gloves, touched gauze with his/her bare hands to put it in a cup, and poured normal saline (salt water) on the gauze;- RN G performed hand hygiene, put on a gown and gloves, cleaned the urinary catheter insertion site with the same area of the normal saline soaked-gauze three times, did not perform hand hygiene, did not change gloves, applied a new split sponge to the urinary catheter insertion site, did not perform hand hygiene, and did not change gloves;- RN G's glasses fell off his/her face onto the resident's bed, removed gloves, did not perform hand hygiene, picked up the glasses from the resident's bed, did not clean the glasses, placed them back on his/her face, performed hand hygiene, and exited the room. 8. Observation on 04/15/26 at 12:38 P.M. of Resident #7's wound care showed:- No EBP signage or PPE available outside of the resident's room;- LPN A did not perform hand hygiene, did not put on a gown, put on gloves, removed the soiled dressing, did not perform hand hygiene, changed gloves, cleaned the wound with a normal saline-soaked gauze, did not perform hand hygiene, and did not change gloves;- LPN A placed a new dressing to the wound, removed gloves, did not perform hand hygiene, and exited the room. During an interview on 04/16/26 at 9:19 A.M., CNA H and CNA I said hand hygiene should be performed before every care, when hands were visibly soiled, after care was complete, and between residents. Hand hygiene should be completed with glove changes after a dirty task and before touching anything clean. During an interview on 04/16/26 at 9:42 A.M., CNA R said hand hygiene should be performed when entering and before you leave a resident's room. Hand hygiene should be completed with glove changes, going from front to back care on a resident, when going from a dirty area to a clean area, or task. A resident should be clean and no fecal material should be left. During an interview on 04/16/26 at 9:52 A.M., CNA Q said hand hygiene should be completed before care, sanitize hands if not visibly dirty, after exiting a room, and between residents. Gloves should be used when providing care. Should change gloves and perform hand hygiene between dirty to clean tasks or areas but at least with glove changes. During an interview on 04/16/26 at 1:30 P.M., RN G said hands should be washed at the start of care and at the end of care. Hands should be sanitized in between glove changes when going from dirty to clean tasks. When cleaning a catheter site, a person should not go back over what had been cleaned with the same area of the cloth. During an interview on 04/16/26 at 2:44 P.M., CNA O said with incontinent care or catheter care, one should wash hands, put on gloves, perform the care, making sure to glove again when going from dirty to clean tasks, and wash hands at the end of care. With catheter care, a person should not go over the same site more than once with the same area of a cloth. During an interview on 04/16/26 at 2:46 P.M., CNA P said a person should wash hands before care, with glove changes, and at the end. Gloves should be changed when going from dirty to clean tasks. During an interview on 04/16/26 at 2:47 P.M., the Infection Preventionist said anytime staff gloves become visibly soiled, they should remove the gloves, perform hand hygiene, and put on a pair of clean gloves. When staff were providing incontinent care with fecal material, staff should wipe until the resident was clean and the washcloth did not show fecal material or urine. When nurses were providing wound care, they should be wearing PPE, which included gloves and gowns. Staff should be putting on PPE for any resident with a catheter, wound, or g-tube. If a resident required catheter care be provided by a CNA, the CNA should put on a gown prior to providing the care. During an interview on 04/16/26 at 2:50 P.M., CNA J said hands should be washed before and after care. Gloves should be used from the start and changed when going from dirty to clean tasks. With catheter care, a person should not go over the same site more than once with the same area of the cloth. During an interview on 04/16/26 at 2:53 P.M., CNA K and NA L said hands should be washed at the start and end of care. Gloves should be used during care and changed when soiled or when going from dirty to clean tasks. During an interview on 04/16/26 at 2:58 P.M., RN M and LPN N said hands should be washed at the start of care, when going from dirty to clean tasks or changing sites, and at the end of care. That should go for incontinent care, catheter care, and even wound care. With catheter care, a person should not go over the same site more than once with the same area of the cloth. During an interview on 04/16/26 at 3:27 P.M., the Director of Nursing said residents with catheters, wounds, or g-tubes had EBP in place. Staff should put on gloves and gowns whenever providing direct care to residents on EBP. She would expect staff that were providing incontinent care with fecal material to wipe the resident until clean. Staff should change gloves and perform hand hygiene when going from dirty to clean tasks. During an interview on 04/16/26 at 3:30 P.M., the Greenhouse Manager said hand hygiene should be performed before, after care, and when hands were visibly soiled. Hand hygiene should be performed with glove changes and when moving from dirty to clean tasks. Staff should wipe the resident until the resident was clean, sometimes the resident would need a shower if they couldn't be cleaned with a wipe or washcloth. During an interview on 04/16/26 at 4:02 P.M., the Administrator said EBP was put in place for residents with chronic wounds, urinary catheters, and g-tubes. She would expect staff that were providing incontinent care to change their gloves when going from dirty to clean tasks and to wipe a resident until clean. During an interview on 04/24/26 at 1:11 P.M., RN S said hand hygiene should be performed when entering a resident's room and when exiting. Hand hygiene should be performed with glove changes when going from dirty to clean tasks, after a dressing removal during wound care, and before a clean dressing was applied. For incontinent care, he/she would expect a wipe or washcloth to be used to either wipe one time and discarded or to fold the wipe or washcloth to a new section/clean area and then discard it. The resident should be wiped until clean.

Based on observation, interview, and record review, the facility failed to ensure placement of the urinary indwelling catheter (a sterile tube inserted into the bladder to drain urine) drainage bag was maintained for one resident (Resident #3) out of two sampled residents. The facility census was 119.Review of the facility's policy titled, Urinary Catheter Care, dated 02/03/15, showed:- The purpose of this procedure is to prevent infection of the resident's urinary tract;- Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of Resident #3's medical record showed:- admitted on [DATE];- Diagnoses of chronic kidney disease (impaired kidney function) and urinary retention (inability to completely or partially empty the bladder). Review of the resident's physician order sheet (POS), dated April 2026, showed:- An order to change the 16 French (Fr. - size of the catheter) with 10 milliliter (ml) bulb suprapubic (a sterile tube insert3ed into the bladder through the abdominal wall to drain urine) catheter every month on the 12th related to chronic kidney disease stage three, dated 03/12/26;- An order to change the urinary catheter drainage bag every month starting on the 12th and ending on the 13th, dated 02/12/26; - An order to cleanse the suprapubic catheter insertion site with normal saline (salt water), pat dry, and apply a split sponge (a type of dressing) daily and as needed, dated 01/28/26;- An order for urinary catheter care every shift for urinary retention, dated 01/22/26. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/29/26, showed:- Used a suprapubic catheter. Review of the resident's care plan, dated 02/11/26, showed:- Resident with a suprapubic catheter;- Cover the drainage bag when up to promote privacy;- Encourage fluids and monitor character of the urine;- Catheter care every shift. Observations on 04/14/26 at 5:15 A.M., and 9:22 A.M., of the resident showed:- The resident lay in bed and the catheter drainage bag lay on the floor. The bottom of the catheter drainage bag rested on the floor due to the privacy flap was intact and did not cover the bottom of the drainage bag. During an interview on 04/16/26 at 2:44 P.M., Certified Nursing Assistant (CNA) O said a catheter drainage bag should not touch the floor. During an interview on 04/16/26 at 1:30 P.M., Registered Nurse (RN) G said a catheter drainage bag should not touch the floor. During an interview on 04/16/26 at 2:50 P.M., CNA J said a catheter drainage bag should not be on the floor. During an interview on 04/16/26 at 2:53 P.M., CNA K and Nursing Assistant (NA) L said a catheter drainage bag should not touch the floor. During an interview on 04/16/26 at 2:58 P.M., RN M and Licensed Practical Nurse (LPN) N said a catheter drainage bag should not touch the floor. During an interview on 04/16/26 at 4:30 P.M., the Director of Nursing (DON) and the Administrator said they would expect staff to keep a resident's catheter drainage bag off of the floor.

Based on interview and record review, the facility failed to notify a resident's family in a timely manner after a transfer where the resident fell from a mechanical ceiling lift resulting in pain and subsequent injury for one resident (Resident #1) out of one sampled resident. The facility census was 115.The facility did not provide a policy regarding notification of a resident's change in condition to the resident's family/representative. Review of the facility's policy titled Falls – Clinical Protocol, dated 01/14/15, showed: - Families are to be notified of all falls; - The policy did not address the timeframe for notification of a fall to the family/representative; - The policy did not address post-fall assessments, monitoring or documentation. 1. Review of Resident #1's medical record showed: - An admission date of 11/16/22; - Diagnoses of arthritis, non-Alzheimer's dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), anxiety disorder (persistent worry and fear about everyday situations), muscle weakness, and history of falling; - No documentation of a post fall assessment dated [DATE]; - No documentation of a post fall skin assessment dated [DATE]; - No documentation of a post fall communication to Resident #1's physician or representative until 4:43 P.M. on 01/05/26. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 11/25/25, showed: - Severely impaired cognition; - No impairment to upper or lower extremities; - Dependent on staff for oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on or taking off footwear, personal hygiene, sit to lying, lying to sitting, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer. Review of the resident's Care Plan, revision date 01/08/26, showed: - Self-care deficit related to advancing dementia, weakness, history left ankle fracture (a broken bone), recent right tibia (the inner and usually larger of the two bones of the lower limb between the knee and ankle) fracture, and unable to ambulate; - At risk for falls, has history of falls, weakness, impaired vision, dementia, medication, unable to stand, periods of agitation and restlessness, and poor safety awareness. Interventions of anticipate and meet all needs, fall risk assessment, and resident is a Hoyer lift for transferring; family requested two staff members assist with all transfers using Hoyer lift after the incident. Review of the resident's progress notes showed: - On 01/05/26 at 8:58 A.M., Registered Nurse (RN) C swabbed the resident for streptococcus (a bacterial infection); - On 01/05/26 at 3:41 P.M., a portable x-ray was ordered, and the facility was notified the x-ray would be able to be completed until 01/06/26; - On 01/05/26 at 4:43 P.M., RN C documented he/she was alerted the resident was lowered to the floor per staff with help due to a mechanical ceiling lift transfer. The resident was assisted to the bed safely. RN C did a head-to-toe assessment with no injuries noted. Around lunch time, staff said the resident's right lower extremity (RLE) appeared bruised. Upon assessment, there was slight bruising noted to the RLE. The nurse contacted the physician for a STAT (immediate) x-ray to the RLE. The resident's family was aware. - On 01/05/26 at 4:56 P.M., the physician said may send the resident to the hospital per the family's request; - On 01/08/26 at 8:09 A.M., the Administrator documented a summary of the incident findings. On 01/05/26, the resident was lowered to the floor during a transfer with Certified Nursing Assistant (CNA) A while using a portable ceiling lift (a fixed battery-operated ceiling track hoist that is mounted in tracks that are installed into the ceiling). The CNA said he/she transferred the resident from the bed to a Geri chair after showering him/her. The CNA said during the transfer, he/she realized the resident was coming down, so he/she grabbed the resident and slid the resident against his/her body to a seated position and rested on the CNA's feet. The CNA called for assistance from another CNA. When CNA B entered the room, he/she said the resident was seated on the floor in front of CNA A. No distress was noted by either CNA A and CNA B. CNA A and CNA B assisted the resident to the Geri chair with a gait belt (an assistive device which is used to help safely transfer a person from one surface to another) and a fireman lift (a way to carry someone over a shoulder). Staff notified RN C regarding the incident. RN C assessed the resident while doing a throat swab in the resident's room and no injuries or immediate distress from the incident was noted. Mid-morning, staff reported the resident was developing a bruise to his/her RLE and the resident had some discomfort. The physician was notified, and an order was received for bedside x-rays; - There were no progress notes addressing a head-to-toe assessment, family contact or description of the incident on 01/05/26. Review of the facility's Incident report dated 01/05/26, showed: - A family member was notified on 01/05/26 at 4:42 P.M., of the resident's fall; - The cameras that service the hall ways and common area showed times staff entering, exiting Resident #1's room. At 8:46 A.M., RN C entered the room and stayed for 7 minutes and 11 seconds within an hour following the incident. RN C reported no visible signs of injury at that time. However, RN C's nurse's notes do not indicate this visit with the resident; - In an interview CNA B said the nurse was not immediately notified because they (CNAs A and B) didn't feel that Resident #1 was injured and the nurse was busy at that time; - In an interview CNA A said the lift broke and Resident #1 was going to drop to the ground, so he/she (CAN A) grabbed and pulled the resident towards his/her chest and slid the resident on to the floor. CNA A also said the nurse was not notified immediately and that he/she knew that wasn't what he/she should have done. During an interview on 01/14/26 at 4:45 P.M. the Director of Nursing (DON) said she would expect the nurse to contact a resident's physician and the family immediately following an assessment of the resident after an incident such as a fall. During an interview on 01/14/26 at 4:50 P.M., Licensed Practical Nurse (LPN) F said he/she came on shift on 01/05/26 at 2:00 P.M., and received report from RN C and the CNAs, which included the resident's fall from the mechanical ceiling lift. Following report, LPN F completed an assessment of the resident because he/she did not see one in the chart. LPN F also contacted the resident's family member to let them know the resident was being sent to the hospital for further assessment due to the resident's RLE started hurting, and then sent the resident to the hospital by ambulance. During an interview on 01/14/26 at 5:00 P.M., the resident's responsible party (RP) said he/she was not contacted until 2:15 P.M., on 01/05/26, and made aware of the resident's fall and what had happened. The RP's spouse was in the facility around 9:30 A.M., on 01/05/26, and no one said anything to him/her at that time about the resident's fall. RP came to the facility at 4:30 P.M., on 01/05/26, and resident's leg was black and blue and swelling. LPN F looked at the resident's right leg and called the physician since the mobile x-ray could not come until the next day. The resident was sent to the hospital. During an interview on 01/14/26 at 6:00 P.M., a Nursing Manager and the Administrator said it was the expectation of the facility that nurses should immediately assess the resident and contact the physician and the family after a fall. During an interview on 01/14/26 at 6:15 P.M., CNA B said on 01/05/26 at approximately 8:00 A.M., he/she heard someone yelling and went to see what was going on and found Resident #1 on the floor in front of CNA A. CNA B notified RN C of the resident's incident when RN C entered the building later that morning. RN C went to Resident #1's room to complete a swab for strep and assessed the resident at that time. CNA B did not know if RN C completed any forms or contacted the doctor of family. The administrator was notified on 01/16/26 of the Past Non-Compliance which occurred on 01/05/26. On 01/05/26, facility staff started an investigation, completed disciplinary action and began in-servicing all staff on policies and procedures related to contacting family/resident representatives in a timely manner following an event. The noncompliance was corrected 01/06/26.

Based on interview and record review, the facility failed to ensure staff followed professional standards of practice when staff did not immediately assess one resident (Resident #1) out of two sampled residents after a witnessed fall. The facility census was 115.The facility did not provide a policy regarding assessments of a resident after a change in condition. Review of the facility's policy titled, Falls – Clinical Protocol, dated 01/14/15, showed: - According to the Centers for Medicare and Medicaid Services (CMS), Minimum Data Set (MDS – a federally mandated assessment to be completed by the facility) 3.0 Guidelines, a fall is defined as the unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (e.g., onto a bed, chair or bedside mat). An intercepted fall occurs when the resident would have fallen if he/she had not caught him/herself or had not been intercepted by another person – this is still considered a fall; - The nurse shall assess and document/report the following: vital signs, recent injury, especially fracture or head injury, musculoskeletal function, observing for change in normal range of motion, weight bearing, etc., change in cognition or level of consciousness, neurological status, pain, precipitation factors, details on how the fall occurred, all current medications, especially those associated with dizziness or lethargy; - The staff will evaluate and document the falls that occur while the individual is in the facility; - Residents who fall will be assessed for injury at the time of the fall. They will be assessed and charted on for that shift and for 72 hours total. Families are to be notified of all falls; - The staff, with the physician's guidance, will follow up with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma (a life-threatening medical emergency characterized by a buildup of blood on the surface of the brain) have been ruled out or resolved; - Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial (bleeding inside the skull) bleeding could occur up to several weeks after a fall; - The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Review of Resident #1's medical record showed: - An admission date of 11/16/22; - Diagnoses of arthritis, non-Alzheimer's dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), anxiety disorder (persistent worry and fear about everyday situations), muscle weakness, and history of falling; - No documentation of a post fall assessment dated [DATE]; - No documentation of a post fall skin assessment dated [DATE]. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 11/25/25, showed: - Severely impaired cognition; - No impairment to upper or lower extremities; - Dependent on staff for oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on or taking off footwear, personal hygiene, sit to lying, lying to sitting, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer. Review of the resident's Care Plan, revision date 01/08/26, showed: - Self-care deficit related to advancing dementia, weakness, history left ankle fracture (a broken bone), recent right tibia (the inner and usually larger of the two bones of the lower limb between the knee and ankle) fracture, and unable to ambulate; - At risk for falls, has history of falls, weakness, impaired vision, dementia, medication, unable to stand, periods of agitation and restlessness, and poor safety awareness. Interventions of anticipate and meet all needs, fall risk assessment, and resident is a Hoyer lift for transferring; family requested two staff members assist with all transfers using Hoyer lift after the incident. Review of the resident's progress notes showed: - On 01/05/26 at 8:58 A.M., Registered Nurse (RN) C swabbed the resident for streptococcus (a bacterial infection); - On 01/05/26 at 3:41 P.M., a portable x-ray was ordered, and the facility was notified the x-ray would be able to be completed until 01/06/26; - On 01/05/26 at 4:43 P.M., RN C documented he/she was alerted the resident was lowered to the floor per staff with help due to a mechanical ceiling lift transfer. The resident was assisted to the bed safely. RN C did a head-to-toe assessment with no injuries noted. Around lunch time, staff said the resident's right lower extremity (RLE) appeared bruised. Upon assessment, there was slight bruising noted to the RLE. The nurse contacted the physician for a STAT (immediate) x-ray to the RLE. The resident's family was aware; - On 01/05/26 at 4:56 P.M., the physician said may send the resident to the hospital per the family's request; - On 01/08/26 at 8:09 A.M., the Administrator documented a summary of the incident findings. On 01/05/26, the resident was lowered to the floor during a transfer with Certified Nursing Assistant (CNA) A while using a portable ceiling lift (a fixed battery-operated ceiling track hoist that is mounted in tracks that are installed into the ceiling). The CNA said he/she transferred the resident from the bed to a Geri chair after showering him/her. The CNA said during the transfer, he/she realized the resident was coming down, so he/she grabbed the resident and slid the resident against his/her body to a seated position and rested on the CNA's feet. The CNA called for assistance from another CNA. When CNA B entered the room, he/she said the resident was seated on the floor in front of CNA A. No distress was noted by either CNA A and CNA B. CNA A and CNA B assisted the resident to the Geri chair with a gait belt (an assistive device which is used to help safely transfer a person from one surface to another) and a fireman lift (a way to carry someone over a shoulder). Staff notified RN C regarding the incident. RN C assessed the resident while doing a throat swab in the resident's room and no injuries or immediate distress from the incident was noted. Mid-morning, staff reported the resident was developing a bruise to his/her RLE and the resident had some discomfort. The physician was notified, and an order was received for bedside x-rays; - There were no progress notes addressing a head-to-toe assessment or description of the incident on 01/05/26. Review of the facility's Incident report dated 01/05/26, showed: - The cameras that service the hallways and common area showed times staff entering and exiting Resident #1's room. At 8:46 A.M., RN C entered the room and stayed for 7 minutes and 11 seconds within an hour following the incident. RN C reported no visible signs of injury at that time. However, RN C's nurse's notes do not indicate this visit with the resident; - In an interview CNA B said the nurse was not immediately notified because they (CNAs A and B) didn't feel that Resident #1 was injured, and the nurse was busy at that time. - In an interview CNA A said the lift broke, and Resident #1 was going to drop to the ground, so he/she (CNA A) grabbed and pulled the resident towards his/her chest and slid the resident on to the floor. CNA A also said the nurse was not notified immediately and that he/she knew that wasn't what he/she should have done. During an interview on 01/14/26 at 4:40 P.M., CNA D said if a resident fell or was found on the floor, staff were to call the nurse immediately. Staff should grab the vital sign equipment, take the resident's vital signs, and help the nurse if needed. A nurse should be the only one to assess a resident after a fall, not a CNA, and the resident should not be moved until the nurse assessed the resident. Staff should follow the nurse's instructions if the resident was to be moved, or anything else needed to be done. The transfer method for a resident was on the resident's care plan. During an interview on 01/14/26 at 4:45 P.M., the Director of Nursing (DON) said she would expect a fall to be reported to the nurse immediately. The nurse should assess a resident as soon as he/she was told of a fall, skin tear, or anything. The nurse should always assess a resident first following a fall and before a resident was moved. The nurse then should call the physician and the family immediately. A CNA should not assess a resident but should get the nurse immediately. During an interview on 01/14/26 at 4:50 P.M., Licensed Practical Nurse (LPN) F said he/she came on shift on 01/05/26 at 2:00 P.M., and received report from RN C and the CNAs, which included the resident's fall from the mechanical ceiling lift. Following report, LPN F completed an assessment of the resident because he/she did not see one in the chart. LPN F also contacted the physician for further assessment due to the resident's RLE started hurting and then sent the resident to the hospital by ambulance. During an interview on 01/14/26 at 5:30 P.M., CNA E said if a resident fell or was found on the floor, the staff should make sure the resident was safe, turn the call light on or yell out to get help. The nurse should come to the resident and don't move the resident. The nurse was the one to assess the resident. During an interview on 01/14/26 at 6:00 P.M., the Nursing Manager and the Administrator said the nurse should be contacted immediately if a resident had a fall. The nurse should assess the resident immediately and contact the physician and the family immediately. The resident should not be moved until he/she was assessed by the nurse. During an interview on 01/14/26 at 6:15 P.M., CNA B said the incident happened to the resident on 01/05/27 at approximately 8:00 A.M. He/She helped transfer the resident from the floor to the Geri chair with CNA A without notifying the nurse and having the resident assessed prior to moving him/her. During a phone interview on 01/15/26 at 11:22 A.M., CNA A said if a resident fell, you notify the nurse and have the nurse come in and see the resident. The nurse should immediately assess the resident following a fall and before the resident was moved off the floor. This didn't happen with the fall for Resident #1 on 01/05/26. The administrator was notified on 01/16/26 of the Past Non-Compliance which occurred on 01/05/26. On 01/05/26, facility staff started an investigation, completed disciplinary action and began in-servicing all staff on policies and procedures related to post-fall assessments. The noncompliance was corrected 01/06/26.

Based on interview and record review of the facility policy, the facility failed to implement and maintain a training program for mechanical ceiling lift equipment training for one Certified Nursing Aide (CNA A). This failure to train CNA A had the potential to affect the care and services provided to any resident that might require lift transfers by CNA A. The facility census was 115.The facility did not provide a policy on employee training and competencies. Review of the facility policy titled, Orientation Program for Newly Hired Employees, Transfers, Volunteers, Revised May 2019, showed:- Did not address training on facility equipment. Review of CNA A's Training Record showed:- A hire date of 10/08/25;- No documentation of education and competencies provided on the safe use of mechanical lifts. During an interview on 01/14/26 at 10:27 A.M., the Administrator said she would expect CNAs to be trained and be competent to use mechanical lifts prior to transferring a resident. During an interview on 01/14/26 at 1:58 P.M., the Director of Staff Development said CNA A had not received training and a competency check for a mechanical lift. During an interview on 01/14/26 at 3:24 P.M., the Director of Nursing (DON) said she would expect CNAs to be trained on the mechanical ceiling lift if they cared for a resident that utilized them. CNA A did not have training on the mechanical ceiling lift. During an interview on 01/14/26 at 3:24 P.M., the Nursing Manager said no one trained CNA A on the mechanical ceiling lifts. She would expect staff to be trained on the mechanical ceiling lifts. During a phone interview on 01/15/26 at 11:22 A.M., CNA A said he/she had worked at the facility for three months and had not had any training or demonstrated competency on the mechanical ceiling lift used to transfer a resident.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 115. Review of the facility's policy titled, Sanitation, revised April 2014, showed: - The food service area shall be maintained in a clean and sanitary manner; - All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects; - All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, and cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair; - If a sink is used for washing utensils, cooking equipment, or dishes, and also used to wash produce or thaw food, it will be cleaned between uses with an approved cleaning and sanitizing agent; - Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime (dirt ingrained on the surface of something); - Food Service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. 1. Observations on 01/21/25 at 11:12 A.M., and 01/24/25 at 10:13 A.M., of the kitchen showed: - One partially full five-gallon clear plastic storage bin with powdered milk undated and unlabeled near the walk-in freezer; - The floor area behind the tilt skillet fryer with a glue trap, five attached bugs, and an electrical connection box with an oily film build up and brown grime; - Ice machine with white build up on the exterior surfaces; - The commercial style can opener with an oily film and white substance on the blade; - The walk-in refrigerator with scattered food debris and a pooled white liquid on the floor approximately 1 inch (in.) deep, below the left side food shelves with white grime build up; - The floor below the reach-in freezer, reach-in refrigerator, range, deep fryer, and ice machine, with scattered debris and an oily film; - The microwave oven interior with food debris build-up along the top surface; - The dishwasher with white build up on the exterior surfaces; - The floor below the dishwashing area counters with white build up; - A 10 foot (ft.) section of approximately 1 in. deep pooled water in the dishwasher and disposal sink area; - The sink disposal drain area with yellow food debris and white grime build up in the sink basin; - The air curtain (a device used to prevent air, contaminants or flying insects from moving from one space to another) above the back exterior door near the dry food storage room with a brown build up along the ventilation louvers; - The circular fan near the supply closet with a brown build up on the front and back guard; - One 6 ounce (oz.) red plastic drink cup, scattered food debris, and a glue trap with six bugs below a food shelf with drink supplements near the dry food storage room. 2. Observation on 01/21/25 at 11:15 A.M., of the walk-in freezer showed: - The floor near the door with approximately a 3 ft. diameter (dia.) area with ice build up; - Ice build up on most of the food shelving, ventilation louvers, and the ceiling area near the ventilation louvers approximately 1 in. thick; -One 5 pound (lb.) bag of fried okra dated, October 2025, covered with ice build up one-half in. thick; - One 4 lb. bag of mixed vegetables dated, November 2026, covered with ice build up one-half in thick; - Six 3 lb. packages of country ribs dated, October 2025, covered with ice build up one-half in. thick; - One 3 lb. bag of hash brown potatoes undated, covered with ice build up one-half in. thick. 3. Observations on 01/21/25 at 11:22 A.M., and 01/24/25 at 10:23 A.M., of the dry food storage area showed: - Two 6 lb. 12 oz. tapioca pudding cans undated, with a brown substance; - Scattered food debris and three individually wrapped cookies lay in the floor along the walls below the food shelves; - A 55.115 lb. brown sack of dried buttermilk mix lay on the floor beside a large 4 in. metal pipe; - A cardboard box with 72 individual containers of 4 oz applesauce cups lay on the floor beside the metal food racks. During an interview on 01/21/25 at 11:22 A.M., Dietary Aide (DA) F said he/she normally rinsed the food waste down the sink but must have missed a spot this morning. Water splashed out of the sink when rinsing dishes off and created a large pool of water in the floor in front of the dishwashing area and it had to be swept toward the floor drain. During an interview on 01/21/25 at 11:32 A.M., the Dietary Manager (DM) said the order for lime scale remover that removed the white build up from the ice machine had been ordered over a month ago but had been delayed. The air curtain and fan in the dishwashing area should not have dust build up on the louvers and will need to be cleaned by maintenance. An outside service company checked on the freezer about three months ago, but the ice build up occurred since the last service and should not be there. The Maintenance Director had been made aware of the frost build up in the walk-in freezer. The ice was normally scooped out when it was serviced. There were cleaning logs, and it was on the list to clean under the shelving, but those areas would need more work. Food containers should not have been placed on the floor in the dry storage area. 4. Observation on 01/24/25 at 8:12 A.M., of the Whispering Pines kitchen showed: - One 12 in. x 12 in. ceiling diffuser (one of the few visible parts of an air conditioning system) with dust build up and a brown substance on the front exterior surfaces near the food shelves. 5. Observation on 01/24/25 at 8:27 A.M., of the Flowering Dogwood kitchen showed: - The ice machine and refrigerator dispenser with a white substance along the outer surfaces and a brown substance on the ice machine ventilation louvers near the floor. 6. Observation on 01/24/25 at 8:35 A.M., of the Sleepy Oaks kitchen showed: - The dry food storage area floor with food debris below the shelves; - The top refrigerator shelf with a 2 in. dia. area of a red substance and black debris inside the door shelves; - The oven interior with a 1 in. diameter dried yellow substance near the door seal; - 12 recessed lighting canisters with a brown build up along the interior surface. During an interview on 01/24/25 at 8:47 A.M., DA G said the floors were normally swept after breakfast and should not have food debris near the shelves. The oven and refrigerator would have to be cleaned and should not have signs of grime or food debris. During an interview on 01/24/25 at 8:55 A.M., the DM said the recessed lighting housings should be clean and the maintenance department would have to be contacted and asked to clean. The floor should have been cleaned in the dry foods area. The refrigerator shelves with a dried red substance on the shelves and the door shelves should have already been cleaned. The oven should be clean inside and not have any grime build up. During an interview on 01/24/25 at 10:13 A.M., the Administrator said the dishwashing sink sprayer may need to be adjusted or replaced to prevent water from splashing in the floor. The freezer and some food items should not have frost and ice build up and the gasket had been replaced. The freezer would need to be checked to see what caused the issue. The ceiling vents and lighting should be kept clean. Food should not be stored on the floor and should be labeled and dated. Floor areas below the appliances should be clean and the refrigerator spills should not be left to dry. During an interview on 01/24/25 at 12:47 P.M., the Maintenance Director said he/she oversaw the cleaning and servicing for the walk-in freezer. Some of the ice build-up had been removed and it should not be there. The ceiling ventilation louvers and light fixtures in the kitchens with brown build up would need to be cleaned.

Based on observation, interview, and record review, the facility failed to follow physician's orders by not obtaining the segmental pressures (the measurement of blood pressures at different points along the leg to assess for potential blockages in the arteries) as ordered and for not obtaining the arterial duplex (a non-invasive imaging procedure that uses ultrasound technology to examine the blood flow in the main arteries of both legs) in a timely manner for one resident (Resident #28) out of one sampled resident. The census was 115. The facility did not provide a policy on following physician orders. 1. Review of Resident #28's Physician's Order Sheet (POS), dated 11/14/24, showed: - Diagnosis of hypertension (HTN - high blood pressure); - An order for segmental pressures bilateral (both) lower extremities, dated 11/14/24. Review of the resident's Provider Progress Notes, dated 11/14/24, showed: - Order for arterial duplex bilateral lower extremities. Review of the resident's medical record showed: - No documentation the segmental pressures bilateral lower extremities, ordered on 11/14/24, was completed; - No documentation of a segmental pressures bilateral lower extremities findings report. Review of the resident's Arterial Duplex report, completed on 01/23/23 and dated 01/24/25, showed: - Findings consistent with mild peripheral vascular disease (a circulatory condition that occurs when blood vessels narrow, spasm, or become blocked outside of the heart and brain) without occlusion, right lower extremity; - Findings consistent with moderate peripheral vascular disease without occlusion, left lower extremity; - Moderate stenosis (abnormal narrowing of a passageway in the body, such as a blood vessel, canal, or organ) between the left mid superficial femoral artery (SFA - major artery in the lower extremity) and the distal (far) SFA; - Moderate stenosis (50-75%) of the left mid SFA; - Mild plaque (a buildup of cholesterol, fat, and other substances that can narrow or block arteries) was noted within the visualized arteries, right; - Moderate plaque was noted within visualized arteries, left. Observations on 01/23/25 at 1:36 P.M., showed Resident #28 lay in bed with his/her bilateral legs and feet with no discoloration and dry, flaky skin. The resident complained of pain when LPN E touched his/her feet. He/She said the top and bottom of his/her left toes hurt. The resident had facial grimacing and said the pain was in the bottom of the foot, mostly at the arch. During an interview on 01/23/24 at 11:00 A.M., the Director of Nursing (DON) said the order for the segmental pressure bilateral lower extremities related to discoloring and increased pain was not followed up on, clarified, or completed due to the order not being put in the system. No one followed up on the NP Progress Note, dated 11/14/24, to check for an order which was where the arterial duplex bilateral lower extremities order was located. During an interview on 01/23/25 at 1:36 P.M., CNA C said the resident had been complaining about his/her feet hurting, especially when his/her shoes were put on. CNA C said he/she reported the discoloration, swelling, pain, and if there were any spots on the feet, like pressure spots, to the nurse. During an interview on 01/23/25 at 1:36 P.M., LPN E said Resident #28 had pain in his/her legs and feet, and they were doing the arterial duplex today. The resident had pain when the NP was here on 11/14/24. The left foot was cooler to the touch currently but he/she could feel the pulse on the top of the foot. During an observation and interview on 01/24/25 at 10:40 A.M., Resident #28 said sometimes he/she told the staff his/her feet hurt. The nurse would provide Tylenol, but it didn't always help. The bottom of his/her feet hurt now. The resident sat up in a recliner with the bilateral lower extremities resting on a pillow on the footrest and had non-slip socks on his/her feet. During an interview on 11/24/25 at 12:02 P.M., the DON said If tests or labs were ordered, she usually checked daily for results to let the physician know. She expected physician orders to be followed. She was not aware there was a new order for imaging for Resident #28 on 11/14/24.

Based on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic (a medication used to treat symptoms of psychosis, such as hallucinations and delusions) medication for one resident (Resident #16) and to limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medication to 14 days for two residents (Residents #71 and #267) out of six sampled residents. The facility census was 115. The facility did not provide a policy for an appropriate diagnosis for antipsychotic medication and PRN psychotropic medication use. 1. Review of Resident #16's January 2025 Physicians Order Sheet (POS) showed: - Diagnoses of unspecified dementia (a condition characterized by progressive loss of memory and thinking, sometimes resulting in personality change, resulting from disease of the brain), unspecified severity, with other behavior weakness (specific type of dementia is unknown, the severity is not clearly defined, and the patient exhibits behavioral disturbances beyond just memory loss, potentially including things like agitation, mood swings, social disinhibition, or unusual behaviors), anxiety disorder a mental health disorder characterized by feelings of worry, or fear that can be strong enough to interfere with daily activities), and epilepsy (a chronic neurological condition characterized by recurrent seizures, which are brief episodes of abnormal brain activity); - An order for Abilify (an antipsychotic medication) 10 milligram (mg) by mouth every day for unspecified dementia, unspecified severity, with other behavior weakness, dated 10/04/23; - Specific behaviors were not identified or addressed; - The facility failed to provide an appropriate diagnosis for the Abilify medication use. Observations of the resident on 01/21/25, showed: - At 11:18 A.M., the resident sat in a wheelchair at the dining room table waiting for lunch and with nonsensical speech; - At 12:25 P.M., the resident sat quietly in a wheelchair at the dining room table feeding self with assistance of staff; - At 3:15 P.M., the resident sat quietly in a wheelchair at the dining room table holding a doll. Observations of the resident on 01/22/25, showed: - At 9:30 A.M., the resident sat in a wheelchair at the dining room table yelling with nonsensical speech; - At 12:40 P.M., the resident sat in a wheelchair quietly feeding self and consumed 90% of lunch with assistance from staff; - At 2:45 P.M., the resident sat quietly in a wheelchair at the dining room table holding a doll. Observations of the resident on 01/23/25, showed: - At 11:30 A.M., the resident sat in a wheelchair quietly at the dining room table; - At 3:50 A.M., the resident lay quietly in bed. Observations of the resident on 01/24/25, showed: - At 8:38 A.M., the resident sat in a wheelchair at the dining room table holding a doll and laughing; - At 2:45 P.M., the resident sat quietly in a wheelchair at the dining room table during an activity. During an interview on 01/24/25 at 11:35 A.M., Licensed Practical Nurse (LPN) B said Resident #16 did yell out with nonsensical speech at times in the dining room when aggravated. The resident had been taking Abilify 10 mg for at least a year. 2. Review of Resident #71's January 2025 POS showed: - Diagnoses of dementia, anxiety disorder and insomnia (difficulty sleeping); - An order for hydroxyzine (an antianxiety medication) 25 mg three times a day PRN for agitation for anxiety, dated 11/11/24, with no stop date; - The facility failed to provide a 14 day stop date order for the hydroxyzine PRN order. 3. Review of Resident #267's January 2025 POS showed: - Diagnosis of depression (a serious medical illness that negatively affects how you feel, the way you think and how you act); - An order for lorazepam (an antianxiety medication) 2 mg/milliliter (ml) concentrate 0.25 ml to 1 ml sublingual (applied under the tongue) every one hour PRN for anxiety/restlessness, dated 01/15/25, with no stop date; - The facility failed to provide a 14 day stop date order for the lorazepam PRN order. During an interview on 01/22/25 at 1:24 P.M., Registered Nurse (RN) A said he/she was unaware PRN psychotropic medications required a stop date. During an interview on 01/24/25 at 10:52 A.M., the Director of Nursing (DON) said she would expect PRN psychotropic medications to have a 14 day stop date, or the physician would need reevaluate the resident for an extended period stop date. During an interview on 01/24/25 at 10:57 A.M., the Administrator said she would expect PRN psychotropic medications to have a stop date. If not for 14 days, then the order should be written for an extended period with a stop date, and the physician would have to reevaluate the resident before reordering. During an interview on 01/24/25 10:30 A.M., the DON said she would expect all antipsychotic medications to have a proper diagnosis when prescribed and for her staff to be knowledgeable of this. During interview on 01/24/25 10:55 A.M., the Administrator said she would expect a proper diagnosis for antipsychotics to be in place when a physician orders the medications. 46521 49150

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, homelike environment. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 115. The facility did not provide a policy for a homelike environment. 1. Observation on 01/24/25 at 8:05 A.M., of room [ROOM NUMBER] showed: -13 figurines from 1 inch (in.) to 3 in. tall on the light fixture beside the chair. 2. Observation on 01/24/25 at 8:10 A.M., of room [ROOM NUMBER] showed: - Eight figurines from 1 in. to 4 in. tall on the light fixture above the right side of the bed. 3. Observation on 01/24/25 at 8:15 A.M., of room [ROOM NUMBER] showed: - One 8 in. by 10 in. picture frame, one 8 in. by 5 in. picture frame, six stuff animals 4 in. tall, and one 12 in. gnome on the light fixture beside the chair. 4. Observation on 01/24/25 at 8:20 A.M., of room [ROOM NUMBER] showed: - One figurine approximately 5 in. tall and one plaque 8 in. by 5 in. on the light fixture above the bed. 5. Observation on 01/24/25 at 8:35 A.M., of room [ROOM NUMBER] showed: - Two decorative objects approximately 5 in. tall and three 5 in. by 7 in. picture frames on the light fixture above the bed. 6. Observation on 01/24/25 at 8:39 A.M., of room [ROOM NUMBER] showed: - Two angel figurines and a cross figurine from 6 in. to 8 in. tall on the top of the light fixture and one 6 in. snowman stuck to the front of the light fixture beside the bed. 7. Observation on 01/24/25 at 8:43 A.M., of room [ROOM NUMBER] showed: - One ball cap hung on the corner of the light fixture beside the bed. During an interview on 01/24/25 at 8:58 A.M., the Maintenance Supervisor said some residents did have items on their lights. The facility didn't recommend that being done. During an interview on 01/24/25 at 11:50 A.M., the Director of Nursing (DON) said it was not recommended but it happened. The residents usually had to purchase the shelves themselves and then the shelves were put up. During an interview on 01/24/25 at 12:05 P.M., the Administrator said items should not be on top of light fixtures in resident rooms. She would expect staff to inform maintenance and shelves be put up for the residents' belongings. 47445

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 105. Review of the facility's policy titled, Cleaning Instructions, dated 2000, showed: - Can opener will be cleaned after each use, wash in sink filled with soapy water, pay special attention to blade and moving parts; - Kitchen and dining room floors, tables, and chairs will be kept clean and sanitary, kitchen floors will be swept and cleaned after each meal; - Freezers will be defrosted monthly or as needed when frost is one quarter inch (in.) thick, freezer should be defrosted; - The ice machine and equipment (scoops and trays) will be cleaned on a regular basis to maintain a clean, sanitary condition, wash interior thoroughly using detergent solution, rinse and drain with clean hot tap water, clean exterior of machine with detergent solution; - The microwave oven will be kept clean, sanitized and odor free, remove any food particles from interior of oven with a clean wet cloth; - The refrigerators will be washed thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month, or as needed, spills and leaks will be wiped up as they are noticed. Review of the facility's policy titled, Sanitation and Infection Control, dated 2000, showed: - Dry storage areas will be kept in a condition which protects stored foods from infestation; - Floors must be swept clean at all times and mopped at least weekly; - Poisonous and toxic material should be stored outside the food storage and preparation area or in cabinets, which are used for no other purpose; - The floors, walls, shelves and equipment in the storeroom are clean, cleaning products are stored separately from food. Observation on [DATE] at 9:50 A.M., of the kitchen showed: - Debris, oily film build-up, and food debris on the floor beneath and behind the range; - Black grime build-up on the pipes behind the range; - The commercial style can opener knife with a worn cutting edge and black grime build-up; - Two ceiling diffusers (one of the few visible parts of an air conditioning system) with brown grime build-up on the front exterior surfaces and between the ventilation louvers; - A wall mounted fan rotated with dust and grime build-up between the ventilation louvers; - Bread and canned food shelving with dust and grime build up below the fan; - Floor with standing water in the dishwashing area. Observation on [DATE] at 9:56 A.M., of the dry food storage room showed: - Two cases of bottled water sat on the floor; - Scattered debris below the food storage shelves; - Two undated opened bags of corn chips lay on the food racks; - Bug debris on the floor near a glue trap under the food shelving. Observation on [DATE] at 10:00 A.M., of the walk-in refrigerator showed: - Debris on the floor below the food shelves; - Dust and grime build-up between the ventilation louvers; - All metal wire food shelves with a chipped, non-intact surface and a brown substance. Observation on [DATE] at 10:01 A.M., of the walk-in freezer showed: - Two 6 in. ice formations hung 12 in. from the area below the ventilation louvers; - A 1 in. ice build-up on ventilation louvers; - A 12 in. diameter by 1 in. thick ice build up on the ceiling above the ventilation louvers; - Two food boxes below the ventilation louvers covered with 1 in. ice build-up; - The floor with 1 in. thick ice formation below the food shelves; - The freezer door separated with seal damage; - Nine clear bags with vegetables partially covered in 1 in. frost build-up; - Metal food shelves covered entirely with 1 in. thick frost build up. Observation on [DATE] at 8:50 A.M., of the Activities refrigerator showed: - Lower shelf with four black, gray and white expired tomatoes; - Temperature at 50 degrees Fahrenheit (F.). During an interview on [DATE] at 8:50 A.M., Housekeeping Aide C said the activities refrigerator was used to store extra food for the residents. Expired foods should be thrown away and the refrigerator temperature should be checked daily. Observation on [DATE] at 9:30 A.M., of the Sleepy Oaks kitchen showed: - Scattered debris and a battery on the floor below the main refrigerator and the food shelves; - Food build-up spilled on the glass turntable and splattered inside the microwave interior; - Ice machine with brown and white grime build-up; - Dust pan with debris and a plant fertilizer container located near the food shelves; - One 12 in. x 12 in. ceiling diffuser with brown grime build-up on the front exterior surfaces and between the ventilation louvers over the pantry refrigerator near the food shelves. During an interview on [DATE] at 9:35 A.M., Dietary Aide (DA) D said expectations were to clean up before leaving for the day. The refrigerator, ice machine, microwave, floors and vents should be kept clean but need some work. Food should not be stored near chemicals or cleaning supplies and the items will be moved. Observation on [DATE] at 9:50 A.M., of the Whispering Pine kitchen showed: - Pantry refrigerator temperature at 46 degrees (F.). - Broom and dust pan with debris in the pantry area near the food storage shelves; - One 12 in. x 12 in. ceiling diffusers with brown grime build-up on the front exterior surfaces and between the ventilation louvers over the pantry refrigerator near the food shelves; - Scattered debris on the floor below the main refrigerator and the food shelves. During an interview on [DATE] at 9:52 A.M., DA E said the temperature should be adjusted on the refrigerator. Expectations were to clean up before leaving for the day. The refrigerator, ice machine, microwave, floors and vents should be kept clean but need some work. Food should not be stored near chemicals or cleaning supplies and the items will be moved. During an interview on [DATE] at 8:20 A.M., the Registered Dietician said the dishwasher, appliances and floor surfaces should be clean, and expectations were that staff follow the facility's kitchen policy to keep the kitchen clean. The walk in refrigerator and freezer should be clean and frost free. The food boxes and bags should not have ice build-up. Walls, ceilings and floors in the freezer should be clean and frost free. The door gasket should be fixed by maintenance. Maintenance should clean the ventilation louvers. Rack storage for the canned foods and bread should be kept clean and not have dust build-up. During an interview on [DATE] at 8:30 A.M., the Dietary Manager said the kitchen can opener should be cleaned after each use, it should look clean. The walk-in freezer and food boxes should not have ice build-up. It should be working properly but wasn't. The Maintenance Director had been notified about the concern a few days ago. There should not be ice coated on the food boxes or on the floor of the freezer, ice machines and all appliances should be clean. Water always stands in the floor when the dishes were cleaned by staff. During an interview on [DATE] at 8:33 A. M., DA F said the freezer should be clean and frost free. The refrigerator shelves should be clean and paint should not be chipped. The maintenance director was supposed to clean the refrigerator and vents. During an interview on [DATE] at 8:20 A. M., DA G said expectations were to follow the facility's kitchen policy and keep the kitchen clean. Staff usually swept and mopped after each meal and got as far as possible under counters and appliances. A regular broom was used to get behind appliances and it was limited to how well they could clean behind the appliances. The walk-in freezer had been an issue and had had ice build-up for over two years. The freezer should not have build-up and attempts had been made to knock it loose with a hammer. During an interview on [DATE] at 3:27 P.M., the Administrator said the freezer and refrigerators should be clean. The ceiling vents should be clean and not have dust or grime build up. All appliances, counter tops and vents should be clean and work properly. Expectations were to follow the facility's kitchen policy and always keep the kitchen clean.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #70) out of a sample of two residents had a physician's order to keep nasal spray, prescription cream, and a prescription shampoo at the bedside and to store medications in a safe and effective manner when staff left the medication cart unlocked and unattended, leaving the narcotics behind only one lock. This had the potential to affect all residents. The facility census was 105. Review of the facility's policy titled, Self-Administration of Drugs, dated [DATE], showed: - As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications; - In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: Ability to read and understand medication labels; Comprehension of the purpose and proper dosage and administration time for his or her medications; and Ability to recognize risks and major adverse consequences of his/her medications; - The staff and practitioner will document their findings and the choices of residents who are potentially capable of self-administering medications; - For self-administering residents, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications were taken; - Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them; - Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage, for return to the family or responsible party; - The nursing staff will rotate bedside stock and will remove expired, discontinued, or recalled medications; - Nursing staff will review the bedside medication record on each nursing shift, and they will transfer pertinent information to the Medication Administration Record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered; - The staff and practitioner will periodically reevaluate a resident's ability to continue to self-administer medications. 1. Review of Resident #70's Physician Order Sheet (POS), dated [DATE], showed: - Date of admission of [DATE]; - Diagnoses of allergic rhinitis (an allergic response causing itchy, watery eyes, sneezing, and other similar symptoms), actinic keratosis (a rough, scaly patch on the skin that develops from years of sun exposure), hemiplegia (paralysis of one side of the body) following a stroke that affected the left side; major depressive disorder (long-term loss of pleasure or interest in life), anxiety disorder (persistent worry and fear about everyday situations), and congestive heart failure (CHF) (an inability of the heart to pump sufficient blood flow to meet the body's needs); - An order for Flonase (a nasal spray that treats allergy symptoms like sneezing, itching and a runny or stuffy nose) 50 microgram (mcg) nasal spray suspension two sprays each nostril twice a day for allergic rhinitis, dated [DATE]; - An order for Afrin (a topical decongestant medication used to relieve nasal discomfort caused by colds, allergies, and hay fever) 0.05 percent (%) nasal mist two sprays every eight hours for nasal congestion, dated [DATE] and with a stop date of [DATE]; - Ketoconazole 2% topical cream (used to treat infections caused by a fungus or yeast) apply topically three times a day as needed for a rash, dated [DATE]; - Ketoconazole 2% shampoo (used to treat tinea versicolor (a common fungal infection of the skin) apply topically two times per week for actinic keratosis, dated [DATE]; - Visine Dry Eye Relief one drop both eyes four times a day as needed for dry eyes (may keep at bedside), dated [DATE]; - No order for Vicks [NAME] Severe nasal spray (nasal decongestant); - No order to keep Flonase, Afrin, ketoconazole cream and shampoo, and Vicks [NAME] Severe nasal [NAME] medications at the bedside or that the resident could self-administer any of the medications; - No documentation of the evaluation assessment for the resident to self-administer the medications; - No documentation of education provided to the resident regarding medication kept at the bedside. - Review of the resident's Interdisciplinary Notes rounding note, dated [DATE], showed the resident was seen by his/her family nurse practitioner (FNP) for nasal congestion and his/her ears clogged. Discussed ordering Afrin but can only use it for three days due to causing rebound congestion (constant nasal congestion that develops from the overuse of nasal sprays) if used for longer periods of time. New orders include Afrin two sprays each nostril every eight hours for three days. Review of the resident's MAR, dated ,d+[DATE], showed: - Afrin nasal mist self-administered [DATE] at 6:00 A.M., 2:00 P.M., and 10:00 P.M.; - Flonase nasal spray self-administered at 9:00 A.M., 21 out of 31 days and 9:00 P.M., 20 out of 31 days; - No documentation of the ketocanazole 2% topical cream administration. Review of the resident's MAR, dated ,d+[DATE] showed: - Afrin nasal mist self-administered on [DATE] - [DATE] at 6:00 A.M., 2:00 P.M., 10:00 P.M., - Flonase nasal spray self-administered at 9:00 A.M., on [DATE] -[DATE] and at 9:00 P.M., on [DATE] -[DATE]; - No documentation of the ketocanazole 2% topical cream administration, dry eye relief drops Review of the resident's care plan, dated [DATE], showed; - Provide eye medications as ordered; - Eye drops for dry eyes; - Did not address the resident self-administered the medications or kept the medications at his/her bedside. Observations of the resident's room showed: - On [DATE] at 12:15 P.M., and 3:33 P.M., the Flonase, Vicks [NAME] Severe nasal spray, , Afrin nasal decongestant, and dry eye relief lubricant eye drops sat on the table at the foot of the bed; - On [DATE] at 10:15 A.M., and 6:10 P.M., the Flonase, Vicks [NAME] Severe nasal spray, dry eye relief drops, Afrin nasal decongestant, and dry eye relief lubricant eye drops sat on the table at the foot of the bed; - On [DATE] 8:40 A.M., the dry eye relief lubricant eye drops sat on the bedside table next to the resident's recliner. The Flonase, Vicks [NAME] Severe nasal spray, dry eye relief drops, and the Afrin nasal decongestant sat on the table at the foot of the bed; - On [DATE] at 2:20 P.M., the ketoconazole cream sat in the resident's shaving cup in his/her bathroom and the ketoconazole shampoo sat on a shelf in the bathroom. During an interview on [DATE] at 8:40 A.M., Resident #70 said he/she administered the medications his/herself. No staff came into his/her room to administer them. He/She knew when to take the medication and did it. The Afrin was taken every eight hours with one spray up each nostril, but he/she didn't know for how long he/she was supposed to take it. The Afrin didn't have any refills. He/She used the Flonase with one spray per nostril one time a day, same as the Afrin. The physician said not to rely on the Vicks [NAME] nasal spray, but just use it sometimes because it loses its effectiveness. He/She only used the eye drops in the left eye, and knew to use it when the eye started burning, that's he/she knew it wasn't lubricated. He/she probably used it twice a day. During interview on [DATE] at 12:46 P.M., with Director of Nursing (DON) she said Resident #70 had nasal spray in his/her room and self-administered it. She said the physician educated him/her on how to administer it and when to use it. She said no evaluation was done, but the resident was high functioning. During an interview on [DATE] at 2:20 P.M., Resident #70 said he/she used both the ketoconzole shampoo twice a week. The ketoconzole cream he/she put on his/her rash and it did a great job. During interview on [DATE] at 2:55 P.M., the DON said she would expect there to be an order for all medications prescribed and/or over the counter for the residents. She would expect the order to show the resident was allowed to keep the medications at the bedside. She would expect the care plan to address self-administration of medications. She would expect an evaluation of the resident to be completed per the facility's policy and an assessment be completed to ensure the resident was competent and safe. She would expect documentation of medications and treatments to be on the MAR and/or the Treatment Administration Record (TAR). Review of the facility's policy titled, Storage of Medications, undated, showed: - The facility shall store all drugs and biological's in a safe, secure and orderly manner; - The nursing staff shall be responsible for maintaining medication storage; - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 2. Observations during the medication pass on [DATE] of the 400 Hall showed: - At 8:08 A.M., Registered Nurse (RN) A left the unlocked and unattended medication facing the hall and entered room [ROOM NUMBER] to administer medications to the resident; - At 8:16 A.M., RN A left the unlocked and unattended medication facing the hall and entered room [ROOM NUMBER] to administer medications to the resident; - At 8:21 AM, RN A left the unlocked and unattended medication facing the hall and entered room [ROOM NUMBER] to administer medications to the resident; - At 8:24 AM RN A left the unlocked and unattended medication facing the hall and entered room [ROOM NUMBER] to administer medications to the resident; - At 8:26 AM RN A left the unlocked and unattended medication facing the hall and entered room [ROOM NUMBER] to administer medications to the resident; - At 8:35 A.M., RN A returned to the unlocked medication cart. Observation of the medication cart on the 400 hall on [DATE] showed; - At 10:52 A.M., the unlocked and unattended medication cart sat in the hall between rooms [ROOM NUMBERS], facing the hall, with no staff present; - At 10:58 A.M., RN A walked by the unlocked and unattended medication cart that sat in the hall between rooms [ROOM NUMBERS]; - At 11:02 A.M., RN A returned to the unlocked and unattended medication cart; - At 11:06 A.M., RN A walked away from the unlocked medication cart which sat between rooms [ROOM NUMBERS], facing the hall, and entered into room [ROOM NUMBER] which left it unlocked and unattended. During an interview on [DATE] at 11:35 A.M., Certified Medication Technician (CMT) B said both locks should be locked on the medication cart before walking away from it. The keys should never be left in the lock. At times, he/she had left the main lock unlocked if the cart was in the doorway of the resident's room while passing medications in that room and it was in the line of vision. During an interview on [DATE] at 11:49 A.M., RN A said he/she should've locked the medication cart when he/she left it. He/She was busy and just didn't lock it. During an interview on [DATE] at 1:30 P.M., the DON said the medication carts should be locked at all times when left unattended. During an interview on [DATE] at 1:45 P.M., the Administrator said it was expected that the medication cart was locked when left unattended or not in use. 47445

Based on interview and record review, the facility failed to implement a baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for one resident (Resident #153) out of one sampled resident. The facility census was 105. Review of the facility's policy titled, Care Plan - Preliminary, dated May 2014, showed: - A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within 24 hours of admission; - The Interdisciplinary (members from different disciplines working together for a common purpose) Team will review the physicians orders and implement a nursing care plan to meet the resident's immediate care needs; - The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. 1. Review of Resident #153's medical record showed: - An admitted [DATE]; - Diagnosis of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough); - No documentation of a baseline care plan with specific interventions related to dementia care or pressure ulcer treatment. During an interview on 11/03/23 at 12:36 P.M., the Director of Nursing (DON) said nursing staff was responsible for the care plan and she would expect an interim care plan to be completed within 48 hours of the resident's admission, but one for this resident couldn't be found so it must not have been completed. During an interview on 11/03/2023 at 1:52 P.M., Registered Nurse (RN) A said the RN on shift during a resident's admission was responsible for the interim care plan. During an interview on 11/03/2023 at 12:14 P.M., the Administrator said she would expect the baseline care plans to be completed on all new admissions.

Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1) from abuse when a facility staff (Licensed Practical Nurse (LPN) B) had sex with the resident on two separate occasions. A sample of four residents was selected in a facility with a census of 111. The administrator, Director or Nursing (DON) and Chief Executive Officer (CEO) were notified on 9/24/19, at approximately 5:40 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 8/30/19 and 9/7/19. On 0[DATE], the CEO became aware of the violation of the facility's abuse/neglect policy. The staff member was suspended pending investigation and later terminated. The facility inserviced the staff on the abuse/neglect policy and procedures. The IJ was removed and corrected on 9/18/19. Record review of the facility policy entitled Abuse Protection and Response Policy, dated April 2017, included the following information: -The center will provide supervision and support services designed to reduce the likelihood of abusive behaviors; -All supervisory staff who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors; -Identification sub-policy includes any resident event that is reported to any partner by resident, family, other partner, or any other person will be considered an allegation of either abuse, neglect, misappropriation of patient property, or exploitation if it meets any of the following criteria: -Any allegation or indication of possible willful infliction of injury to include unexplained bruising; -Unreasonable confinement, to include unwanted restriction of access to all resident areas of the building; -Any resident or family complaint of physical or verbal harm, pain, or mental anguish resulting from the action of others; -Any complaint of sexual harassment, sexual coercion, sexual assault, or inappropriate touching; -Any instances of hitting, slapping, pinching, kicking, or other potentially harmful action; -Reporting: Any staff member having either direct or indirect knowledge of an event that might constitute abuse, neglect, misappropriation of patient's property, or exploitation must report the event immediately to their supervisor, Director of Nursing, or State Agency; -All alleged violations and all substantiated incidents will be reported immediately to the administrator or his/her representative and to other officials in accordance with State and Federal law (including to the State Survey and Certification Agency); -All events will be investigated to determine whether alleged abuse, neglect, misappropriation of patient property, or exploitation did or did not take place, the Administrator, DON, or the President/CEO will determine the direction of the investigation once notified of the alleged incident; -The investigation is started immediately under the following circumstances: when it is identified that an alleged incident of abuse may have occurred, as soon as any staff member has knowledge and reports an alleged abusive event; -Ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of resident's property, are reported immediately and no later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that caused the allegations did not involve abuse and do not result in serious bodily injury to the Administrator, DON, or to the President/CEO and to other officials including to the State Survey Agency, Department of Health and Senior Services (DHSS); -The individual conducting the investigation will, as a minimum, ensure protective oversight, suspend any staff member that may be involved until completion of the investigation, review and compile all documentation, review the resident's medical record to determine events leading up to the incident, interview the person reporting the incident, any witnesses, the resident, other staff members, and other residents, and review all events leading up to the alleged incident. 1. Record review of Resident #1's face sheet (admission data) showed the following: -Resident admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/16/19, showed the following: -No cognitive impairment; -No behaviors; -Independent with bed mobility, transfers, and dressing; -Pain almost constantly with 10 out of 10 on a pain scale of one to ten; -Received anti-anxiety medication seven days out of the last seven days; -Received anti-depressant medication seven days out of the last seven days. Record review of the facility's investigation, dated [DATE] at 2:00 P.M. to 4:00 P.M., showed the following: -Staff Member A asked the CEO to go to the office to receive a report made by the resident; -The resident reported LPN B had sexual intercourse with him/her on two different occasions. The first incident occurred on 8/30/19 and the second incident occurred on 9/7/19; -The resident said LPN B initiated the sexual encounters; -The resident did not report the incidents because LPN B told him/her not to tell anyone, because they both could be in trouble. Record review of the facility's self-report to the Department of Health and Senior Services (DHSS) dated [DATE] at 3:40 P.M., showed the CEO reported the resident told Staff Member A that LPN B had sexual intercourse with him/her. The resident said the incidents happened on 8/30/19 and 9/7/19. The facility contacted the police. The facility started their investigation and notifications had been made. Record review of LPN B's employee warning report, dated 9/17/19 verbally given at 4:20 P.M., by the DON and CEO, showed an allegation of sexual misconduct by the resident. The resident reported having sexual relations with the nurse. Investigation in progress with the police investigation. The staff person suspended pending outcome of the investigation. Record review of LPN B's employee termination report dated 9/18/19 at 12:50 P.M., showed the facility prohibits and does not tolerate sexual abuse (inappropriate sexual contact of a criminal nature or interaction for gratification of an adult who is caregiver and responsible for resident's care) in the workplace or in any organization related activity; -Termination details: On 9/17/19, reported to the DON that LPN B had allowed a resident under his/her care to touch him/her in a sexual manner on two occasions (prior to 09/09/19) and failed to report the behavior to the supervisor. LPN B denied touching the resident in a sexual manner. This information was obtained after the resident involved reported the incident to another employee and the police were contacted to investigate. The facility has zero tolerance for any sexual abuse committed by an employee. Record review of the Probable Cause Statement, dated 09/18/19, showed the following information: -The detective had probable cause to believe LPN B committed a criminal offense of two counts of sexual conduct with a nursing facility resident; -On 0[DATE], the police were dispatched to the facility due to a report by the resident that he/she had sex with a nurse on two occasions, 8/30/19 and 9/7/19; -On 9/17/19, the resident identified LPN B as the suspect. The resident said on 08/30/19, the sex was consensual and LPN B said it had to be secret. The second time, 9/7/19, the LPN jumped in his/her bed and began having sex with him/her. LPN B gave him/her one of his/her pain pills each time he/she had sex with him/her. The resident said he/she has reported it to a nurse and the nurse said he/she had to report it or the nurse would. (It was determined the nurse was CMT E.) -On 09/17/19, CMT E said he/she was giving medication to the resident and the resident told him/her he/she got some. The resident then said it was LPN B and after the second time he/she was getting scared. The CMT told the resident he/she had to tell someone or the CMT was going to. -On 9/17/19, LPN B admitted to having sex with the resident. Record review of the resident's care plan, revised on 9/20/19, showed the following: -The resident may have strong, unexpected feelings due to perceived trauma. Staff should observe for shock, embarrassment, fear, depression, blame, guilt, shame and anger. Staff should refer the resident to social services and provider if these are observed; -Staff should refer the resident to a counselor for emotional or mental symptoms; -The resident has a tendency to provide unsolicited touching. The resident jokes inappropriately. Staff should redirect the resident. Observation and interview on 9/20/19 at 6:00 P.M., showed and the resident said the following: -On or about the night of Friday, 8/30/19, LPN B entered the resident's room while the resident lie awake in bed. The LPN removed the resident's right leg from his/her pajama pants and scooted him/her down to the foot of the bed. The LPN pulled down the front of his/her pants exposing his/her genitalia, then had sexual intercourse with the resident. The resident did not tell the LPN no, but he/she did not want to have sex with the LPN. The resident said the LPN offered him/her a pain pill after the sexual encounter. The resident took the pain pill; -The following Monday (9/2/19), the resident told Certified Medication Technician (CMT) E that LPN B offered him/her an extra pain pill to have sex with him/her. The CMT told the resident to report the incident to someone. The resident did not report this to any other staff; -On or about the night of Saturday, 9/7/19, LPN B entered the resident's room, while he/she slept on his/her left side facing the wall. The nurse slammed a water pitcher down on the resident's over bed table, waking the resident. The LPN pulled on the resident's shoulder flipping him/her onto his/her back. He/She pulled down the resident's pajama pants, got on top of the resident and had sexual intercourse with him/her. After it was over, the LPN offered the resident a pain pill and the resident took the pill; -On the night of 8/30/19, before LPN B had sexual intercourse with him/her, the LPN entered the resident's room, several times, asking the resident questions about his/her work experiences. The second time (9/7/19), the resident did not know what happened; the LPN entered his/her room while he/she slept. The resident thought both instances of sexual abuse occurred around 1:00 A.M.; -On Friday 9/13/19, the resident knew LPN B would be returning to work, because he/she worked Friday through Sunday. The resident was afraid for LPN B to be in his/her room for any length of time or to be in his/her room with the door shut. The resident asked Certified Nurse Aide (CNA) C to keep an eye on his/her room and to check on him/her if anyone was in his/her room for too long or shut his/her room door; -On or about the night of 9/15/19, LPN B entered the resident's room while he/she laid in bed. The LPN began rubbing the resident's thigh and started moving his/her hand upward, toward the resident's perineal area. The resident pushed the LPN's hand away, but the LPN would again, place his/her hand on the resident's thigh moving it closer and closer to his/her private area. About this time, CNA C entered the resident's room and talked to the LPN about another resident, making an excuse for LPN B to leave the resident's room. When the CNA entered the resident's room, the LPN did not move his/her hand from the resident's thigh. The resident knew the CNA saw LPN B's hand on his/her leg; -LPN B frequently kept pain medication rolled up in the bottom of his/her shirt. After each sexual encounter, LPN B offered the resident an extra pain pill. When the resident agreed to take the extra pill, the LPN unrolled the medication from his/her shirt and handed it to the resident; -The resident's hips were sore after the sexual encounters; -After the resident reported the incidents to Staff Member A, staff asked him/her if he/she wanted to talk to a psychologist. At first, the resident did not want to, he/she did not want to refresh what he/she let LPN B do. His/Her family member said he/she needed to since it did not sit right with him/her (the resident); -When the resident thought about the sexual encounters, it made him/her sick to his/her stomach. He/She did not want to see anyone. He/She looked at people and wondered if they knew about the sexual abuse. He/She was not going to let anyone get close to him/her again; -At the conclusion of the interview, the resident wanted the door left open to his/her room, because he/she did not want to be alone; -During the interview, the resident became upset and tearful. During an interview on 9/20/19 at 10:04 P.M., CNA C said the following: -On Friday 9/13/19, after talking to RN D, the CNA told LPN B the resident had asked him/her (CNA C) to watch the resident's room very closely. The CNA asked LPN B not to go in the resident's room by himself/herself, for his/her safety. LPN B said he/she had already been in the resident's room and the resident acted fine. The CNA told LPN B the resident would act like nothing happened. The CNA again asked the LPN to not go into the resident's room alone. The CNA told LPN B if he/she saw him/her go into the resident's room, he/she would soon follow. LPN B said to go ahead, that was fine; -Every time CNA C saw the LPN go into the resident's room that weekend, he/she would wait a couple of minutes and then go to the resident's room. He/She just stood in the resident's doorway and watched LPN B with the resident. The LPN did not close the resident's door; -On Saturday 9/14/19, the CNA walked into the resident's room and found LPN B holding the resident's hand while the resident lie awake on the bed. LPN B's hand was positioned on top of the resident's hand, resting on the resident's outer mid-thigh. When the CNA entered the resident's room, the LPN turned to the CNA and said, Oh, I've been waiting for you to come. The LPN let go of the resident's hand. Record review of Staff Member A's written statement, dated [DATE], showed the following: -The resident asked to speak with Staff Member A. The resident wanted to talk about what upset him/her last week; -The resident said he/she had sexual intercourse with LPN B on two occasions; -On 8/30/19 around 1:00 A.M., LPN B slammed the resident's water jug down on the bedside table to administer his/her breathing treatment. LPN B lowered his/her scrub pants, removed the resident's legs from his/her pajamas, and had sexual intercourse with him/her on the edge of his/her bed; -On 9/7/19 around 1:00 A.M., LPN B crawled into bed with the resident and had sexual intercourse with him/her. During an interview on 9/23/19 at 1:10 P.M., Staff Member A said the following: -On Thursday 9/12/19, the resident stopped him/her in the hall. The resident had a worried look and told Staff Member A there was something wrong and it was pretty serious, but would not tell Staff Member A what it was. Staff Member A said he/she did not report this conversation to anyone; -On Monday [DATE], another staff member called Staff Member A and said the resident wanted to speak with him/her; -Staff Member A took the resident into one of the offices at the facility; -The resident reportedly said, I don't know how to say this, so I am just going to say it, I had sex with a nurse. The resident then identified the nurse as LPN B and said the sex happened on two occasions; -Staff Member A and the resident looked at a calendar and determined the sex occurred on 8/30/19 and on 9/7/19; -Staff Member A said the resident was anxious, upset, flustered, and his/her skin was pale in color during their conversation; -The resident said during the first sexual encounter, he/she did not tell LPN B yes or no, and the second time LPN B did not ask the resident's permission; -The resident said he/she sometimes told inappropriate jokes to LPN B; -The resident told Staff A the encounters started by LPN B rubbing the resident's legs in the resident's room; -The resident said he/she had LPN B's DNA; -The resident said the LPN B gave the resident a pain pill; -Staff Member A told the resident they needed to tell the CEO (acting administrator) and the resident agreed; -The CEO came into the office and the resident told the same story to the CEO; -The resident said LPN B asked the resident to keep quiet about the sex; -Staff Member A said the resident was generally honest and up front. Record review of the DON's statement, dated 9/17/19, showed on 9/17/19 at 3:45 P.M., LPN B called her and said he/she screwed up. He/She told the police the resident touched him/her through his/her pants. He/She should have reported it, but was scared and did not know what to do. This happened a second time and the resident collected fluids and put it on his/her underwear. LPN B said the resident initiated the contact. LPN B denied touching the resident or any penetration. The DON informed LPN B he/she was suspended from working at the facility pending the outcome of the investigation, and to not enter the building. During an interview on 9/24/19 at 4:02 P.M., the DON said the following: -The CEO notified her of the resident's accusations on Monday [DATE]; -The DON spoke to LPN B on the phone on the afternoon of [DATE]; -During this conversation, LPN B informed the DON that the resident was friendly and made a comment that he/she wanted CNA C in the room. LPN B said the resident asked for medication over the weekend, but the LPN only spent two to three minutes in the room; -The LPN said, several weeks prior, the resident asked LPN B if he/she knew of any people of the opposite gender that were not dead from the waist down; -The LPN denied any sexual contact with the resident during the phone conversation; -On Tuesday 9/17/19, LPN B contacted the DON by phone and asked the DON to meet him/her in the facility parking lot, which she did; -LPN B told the DON he/she had, screwed up. LPN B said the resident touched him/her through his/her pants and that it happened twice; -The DON told the LPN he/she was suspended from work at that time; -The DON said she later terminated LPN B by phone; -The DON said what allegedly occurred to the resident would be considered sexual abuse. Record review of Certified Medication Technician (CMT) E's statement, dated 9/21/19, showed the resident told CMT E in the first week of September that he/she had a sexual encounter. CMT E thought the resident was talking about another resident who he/she was dating on the other side of the facility. The resident later told CMT E he/she knew him/her. CMT E thought it was a resident. The resident told CMT E that he/she worked at the facility. The resident said he/she said too much. The resident said CMT E knew the staff member who worked the weekend. CMT E said LPN B's name to the resident. The resident shook his/her head yes. The resident said LPN B came in and it was consensual between them. CMT E shut the door and talked with the resident. The resident said 'how much money could I get for this'. CMT E told the resident he/she needed to tell someone. The resident asked CMT E if LPN B would lose his/her license and job. CMT E told the resident yes. The resident said he/she did not want anyone to get in trouble. The resident asked CMT E not to say anything, because he/she was worried it would come back on him/her. CMT E completed the medication pass. CMT E left the facility and returned to work 9/10/19. The resident spoke again to the CMT E later in the week. The resident was upset and seemed worried because the weekend was approaching. The resident told CMT E that LPN B came into his/her room. The resident pretended to be asleep and LPN B took his/her water pitcher and slammed it on the table. CMT E told the resident he/she needed to tell someone. The resident was worried about what people would say or not believe him/her. CMT E told the resident to say something or CMT E would. CMT E said the resident trusted him/her. CMT E said he/she knows now he/she should have reported this. CMT E said he/she encouraged the resident to tell someone. CMT E passed medications on [DATE] and the resident was in an activity and told CMT E that he/she reported the incident. CMT E told the resident he/she was proud of him/her. During an interview on 9/23/19 at 2:00 P.M., CMT E said the following: -One day during the week of 9/2/19 to [DATE], the CMT went to the resident's room to give the resident medication; -The resident told the CMT he/she had a sexual encounter. The CMT first assumed the resident was talking about another resident. The resident did not give any details at that time. Later the same night, the CMT returned to the resident's room and the resident said he/she had a sexual encounter and then said, He/She works here on the weekends. The CMT asked if the staff member was LPN B and the resident shook his/her head up and down, indicating yes. The resident said he/she did not want to get anyone into trouble. The resident asked if someone could lose their job over this, and the CMT told the resident yes. The CMT told the resident that the resident needed to tell someone. The resident said he/she worried about what others would think of the resident or feared staff would not believe the resident. The resident appeared a little anxious and asked the CMT not to tell anyone. The CMT then left the resident's room and returned to passing medications to the other residents. The CMT did not believe that a staff member had sex with the resident. The CMT said the resident likes to tell tales and the resident mentioning money caused the CMT not to believe the resident. The CMT did not report the incident to anyone. The CMT was off work from [DATE] to [DATE]. The CMT returned to work on 9/10/19 thru 9/13/19. The CMT said on Thursday 9/12/19 or Friday 9/13/19, the resident started talking about the sexual encounters again, the CMT said this time the resident was anxious and scared. The resident said he/she worried about the approaching weekend when LPN B would return to work. The resident asked the CMT how to put a chair in front of his/her door to block the door. The resident said he/she pretended to be asleep the last time LPN B had sex with him/her. The CMT told the resident to tell someone and the resident said he/she was going to. The CMT told the resident to either tell someone about the sex or he/she would. The CMT left work for the weekend without reporting the sexual abuse to anyone. The CMT said he/she did not report the sexual abuse because he/she put him/herself into the resident's shoes and wanted the resident to be able to trust him/her. Record review of the resident's progress notes, dated 9/23/19, showed the DON documented the nurse practitioner assessed the resident for a follow up visit from the emergency department visit. The resident stated I don't have many good days. The emergency department did not do a sexual assault exam. The nurse practitioner assessed the resident's perineal area. The resident said he/she wasn't stupid, I saved my pajamas and underwear. The nurse practitioner questioned the resident about counseling. The resident said staff talked him/her into counseling. The resident reported increased anxiety. The resident stated he/she stayed in his/her room and was not looking at anyone. The nurse practitioner offered to move the resident to another facility. The resident declined. The nurse practitioner offered the resident an intense short inpatient hospital stay if he/she is having trouble coping. The resident refused and asked if he/she should have even told. The resident said he/she just stays in his/her room and is afraid people are looking at him/her. The nurse practitioner recommended the resident to change facilities because he/she cannot stay in his/her room forever. The resident said I want to stay here. During an interview on 9/24/19 at 4:02 P.M., the DON said the following: -Any allegation of abuse should be reported to the DON, administrator, or CEO of the facility; -Sexual abuse should be reported to DHSS within two hours; -What allegedly occurred to the resident would be considered sexual abuse; -Any sexual relations between a resident and a staff member should be reported to DHSS and would be considered a crime and reported to police; -CMT E should have reported the resident's comments about LPN B having sex with the resident to the supervisor/DON; -She did not find out that CMT E had prior knowledge of the sexual abuse until a phone conversation with CMT E on [DATE]. This phone conversation occurred after the CMT had been questioned by police regarding the matter; -CMT E received disciplinary action and was written up and educated for not timely reporting the sexual abuse. During an interview on 9/24/19 at 4:51 P.M., the facility administrator and CEO/President of the facility said the following: -CMT E had prior knowledge of LPN B sexually abusing the resident and did not report the abuse; -CMT E knew about the abuse after the first alleged occurrence; -The administrator and CEO were not informed of CMT E's knowledge of the abuse until [DATE] when the police informed them of the information; -Expected CMT E to have reported the allegation to supervisor. MO 810 and MO 822

Based on observation, interview, and record review, the facility staff failed to report all allegations of abuse in a timely manner when one resident (Resident #1) reported sexual abuse by a staff member (Licensed Practical Nurse (LPN) B) to Certified Medication Technician (CMT) E and the CMT failed to report the allegation to management resulting in a second occurrence of the abuse. A sample of four residents was selected for review. The facility census was 111. The administrator, Director or Nursing (DON) and Chief Executive Officer (CEO) were notified on 9/24/19, at approximately 5:40 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 8/30/19 and 9/7/19. On [DATE], the CEO became aware of the violation of the facility's abuse/neglect policy. The staff member was suspended pending investigation and later terminated. The facility inserviced the staff on the abuse/neglect policy and procedures. The IJ was removed and corrected on 9/18/19. Record review of the facility policy entitled, Abuse Protection and Response Policy, dated April 2017, showed the policy included the following information: -All supervisory staff who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors; -Identification sub-policy includes any resident event that is reported to any partner by resident, family, other partner, or any other person will be considered an allegation of either abuse, neglect, misappropriation of patient property, or exploitation if it meets any of the following criteria: -Any allegation or indication of possible willful infliction of injury to include unexplained bruising; -Unreasonable confinement, to include unwanted restriction of access to all resident areas of the building; -Any resident or family complaint of physical or verbal harm, pain, or mental anguish resulting from the action of others; -Any complaint of sexual harassment, sexual coercion, sexual assault, or inappropriate touching; -Any instances of hitting, slapping, pinching, kicking, or other potentially harmful action; -Reporting: Any staff member having either direct or indirect knowledge of an event that might constitute abuse, neglect, misappropriation of patient's property, or exploitation must report the event immediately to their supervisor, DON, or State Agency; -All alleged violations and all substantiated incidents will be reported immediately to the administrator or his/her representative and to other officials in accordance with State and Federal law (including to the State Survey and Certification Agency); -Ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of resident's property, are reported immediately and no later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that caused the allegations did not involve abuse and do not result in serious bodily injury to the Administrator, DON, or to the President/CEO and to other officials including to the State Survey Agency, Department of Health and Senior Services (DHSS), 1. Record review of Resident #1's face sheet (admission data) showed the following: -admitted on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 7/16/19, showed the following: -Cognitive skills intact; -No behaviors; -Independent with bed mobility, transfers, dressing, and toilet use; -Pain almost constantly with 10 out of 10 on a pain scale of one to ten; -Anti-anxiety medication administered seven out of the last seven days; -Anti-depressant medication administered seven out of the last seven days. Record review of the facility's investigation, dated [DATE] from 2:00 P.M. to 4:00 P.M., showed the CEO was called to the office by Staff Member A to receive a report made by the resident. The resident reported LPN B had sexual intercourse with him/her on two different occasions. The first occasion was on 8/30/19 and the second time on 9/7/19. The resident stated the sexual encounters were upon LPN B's initiation. The resident said he/she had not reported the incidents because LPN B told him/her not to tell anyone, because they both could be in trouble. During an interview on 9/23/19 at 1:10 P.M., Staff Member A said the following: -On Thursday 9/12/19, the resident stopped him/her in the hall. The resident had a worried look and told Staff Member A there was something wrong and it was pretty serious, but would not tell Staff Member A what it was. Staff Member A said he/she did not report this conversation to anyone; -On Monday [DATE], another staff member called Staff Member A and said the resident wanted to speak with him/her; -Staff Member A took the resident into one of the offices at the facility; -The resident reportedly said, I don't know how to say this, so I am just going to say it. I had sex with a nurse. The resident then identified the nurse as LPN B and said the sex happened on two occasions; -Staff Member A and the resident looked at a calendar and determined the sex occurred on 8/30/19 and on 9/7/19; -Staff Member A said the resident was anxious, upset, flustered, and his/her skin was pale in color during their conversation; -The resident said during the first sexual encounter he/she did not tell LPN B yes or no and the second time LPN B did not ask the resident's permission; -The resident said he/she sometimes told inappropriate jokes to LPN B; -The resident told Staff Member A the encounters started by LPN B rubbing the resident's legs in the resident's room; -The resident said he/she had LPN B's DNA; -The resident said the LPN B gave the resident a pain pill; -Staff Member A told the resident they needed to tell the CEO (acting administrator) and the resident agreed; -The CEO came into the office and the resident told the same story to the CEO; -The resident said LPN B asked the resident to keep quiet about the sex; -Staff Member A said the resident was generally honest and up front. Record review of the facility's self report to the Department of Health and Senior Services (DHSS), dated [DATE] at 3:40 P.M., showed the CEO said the resident reported to Staff Member A that LPN B had sexual intercourse with him/her. The resident said the incidents happened on 8/30/19 and 9/7/19. The facility contacted the police. The facility started their investigations and notifications have been made. Record review of the Probable Cause Statement, dated 9/18/19, showed the following information: -The detective had probable cause to believe LPN B committed a criminal offense of two counts of sexual conduct with a nursing facility resident; -On [DATE], the police were dispatched to the facility due to a report by the resident that he/she had sex with a nurse on two occasions, 8/30/19 and 9/7/19; -On 9/17/19, the resident identified LPN B as the suspect. The resident said on 8/30/19, the sex was consensual and LPN B said it had to be secret. The second time, 9/7/19, the LPN jumped in his/her bed and began having sex with him/her. LPN B gave him/her one of his/her pain pills each time he/she had sex with him/her. The resident said he/she had reported it to a nurse and the nurse said he/she had to report it or the nurse would. (It was determined the nurse was CMT E); -On 9/17/19, CMT E said he/she was giving medication to the resident and the resident told him/her he/she got some. The resident then said it was LPN B and after the second time he/she was getting scared. The CMT told the resident he/she had to tell someone or the CMT was going to; -On 9/17/19, LPN B admitted to having sex with the resident. Observation and interview on 9/20/19 at 6:00 P.M., showed the resident said the following: -On or about the night of Friday 8/30/19, LPN B entered the resident's room while the resident lie awake on the bed. The LPN removed one of the resident's pajama pant legs and scooted the resident down to the foot of the bed. The LPN pulled down the front of his/her pants exposing his/her genitalia. The LPN had sexual intercourse with the resident. The resident did not tell the LPN no, but the resident did not want to have sex with the LPN. The resident said the LPN offered the resident a pain pill after the sexual encounter and the resident took the pain pill; -On or about Monday (9/02/19), the resident had a conversation with CMT E. The resident told CMT E that LPN B offered the resident an extra pain pill to have sex with LPN B (14 days before Staff Member A reported the allegation of abuse). -On or about the night of Saturday 9/7/19, LPN B entered the resident's room, while the resident slept. The nurse slammed a water pitcher down on the resident's over bed table, waking the resident. The resident lay on his/her left side facing the wall. The LPN pulled the resident's shoulder, flipping the resident onto his/her back. The LPN pulled the resident's pants down and got onto the bed on top of the resident. The LPN had sexual intercourse with the resident. The LPN offered the resident a pain pill and the resident took the pill; -On or about the night of Friday 9/13/19, the resident said he/she knew LPN B would be returning to work, because he/she worked Friday through Sunday. The resident was afraid for LPN B to be in the resident's room very long or to be in the resident's room with the door shut. The resident said he/she told CNA C to keep an eye on the resident's room. The resident asked the CNA to come check on the resident if anyone came into his/her room for too long or shut the resident's door; -On or about the night of 9/15/19, LPN B again entered the resident's room while the resident lie on the bed. The LPN began rubbing the resident's thigh and started moving his/her hand upward, toward the resident's peri-area. At this time, CNA C entered the resident's room and began talking about another resident, making an excuse to get LPN B out of the resident's room; -The resident believed both instances of sexual abuse occurred around 1:00 A.M. The resident said LPN B frequently kept pain medications rolled up in the bottom of his/her shirt. The resident said LPN B offered the resident an extra pain pill before and after the sexual encounters and the resident took the pills. The resident said his/her hips were sore after the sexual encounters. The resident said, since the sexual abuse, he/she does not want to see anyone. The resident said he/she looks at people and wonders if they know about the sexual abuse; -At the conclusion of the interview, the resident wanted the door left open to his/her room because he/she did not want to be alone; -The resident was upset and tearful during the interview. Record review of Certified Medication Technician (CMT) E's written statement, dated 9/21/19, showed the resident told CMT E in the first week of September that he/she had a sexual encounter. CMT E thought the resident was talking about another resident who the resident was dating on the other side of the facility. The resident later told CMT E he/she knew him/her. CMT E thought it was a resident. The resident told CMT E that he/she worked at the facility. The resident said he/she said too much. The resident said CMT E knew the staff member who worked the weekend. CMT E said LPN B's name to the resident. The resident shook his/her head yes. The resident said LPN B came in and it was consensual between them. CMT E shut the door and talked with the resident. The resident said 'how much money could I get for this'. CMT E told the resident he/she needed to tell someone. The resident asked CMT E if LPN B would lose his/her license and job. CMT E told the resident yes. The resident said he/she did not want anyone to get in trouble. The resident asked CMT E not to say anything, because he/she was worried it would come back on him/her. CMT E completed the medication pass, left the facility, and returned to work 9/10/19. The resident spoke again to the CMT E later in the week. The resident was upset and seemed worried because the weekend was approaching. The resident told CMT E that LPN B came into his/her room. The resident pretended to be asleep and LPN B took his/her water pitcher and slammed it on the table. CMT E told the resident he/she needed to tell someone. The resident was worried about what people would say or not believe him/her. CMT E told the resident to say something or CMT E would. CMT E explained to the resident that what LPN B did is wrong and not the resident's fault. CMT E said he/she knows now he/she should have reported this. CMT E said he/she encouraged the resident to tell someone. CMT E passed medications on [DATE] and the resident was in an activity and told CMT E that he/she reported the incident. CMT E told the resident he/she was proud of him/her. During an interview on 9/23/19, at 2:00 P.M., CMT E said the following: -One day during the week of 9/2/19 through [DATE], the CMT went to the resident's room to give the resident medication; -The resident told the CMT he/she had a sexual encounter. The CMT first assumed the resident was talking about another resident. The resident did not give any details at that time. Later the same night, the CMT returned to the resident's room and the resident said he/she had a sexual encounter and then said, He/she works here on the weekends. The CMT asked if the staff member was LPN B and the resident shook his/her head up and down, indicating yes. The resident said he/she did not want to get anyone into trouble. The resident asked if someone could lose their job over this, and the CMT told the resident yes. The CMT told the resident that the resident needed to tell someone. The resident said he/she worried about what others would think of the resident or feared staff would not believe the resident. The resident appeared a little anxious and asked the CMT not to tell anyone. The CMT then left the resident's room and returned to passing medications to the other residents. The CMT did not believe that a staff member had sex with the resident. The CMT said the resident likes to tell tales and the resident mentioning money caused the CMT not to believe the resident. The CMT did not report the incident to anyone. The CMT was off work from [DATE] to [DATE]. The CMT returned to work on 9/10/19 thru 9/13/19. On Thursday 9/12/19 or Friday 9/13/19, the resident started talking about the sexual encounters again, the CMT said this time the resident was anxious and scared. The resident said he/she worried about the approaching weekend when LPN B would return to work. The resident asked the CMT how to put a chair in front of his/her door to block the door. The resident said he/she pretended to be asleep the last time LPN B had sex with him/her. The CMT told the resident to tell someone and the resident said he/she was going to. The CMT told the resident to either tell someone about the sex or he/she would. The CMT left work for the weekend him/herself into the resident's shoes and wanted the resident to be able to trust him/her. During an interview on 9/20/19 at 10:04 P.M., CNA C said the following: -On Friday 9/13/19, after talking to Registered Nurse (RN) D, the CNA told LPN B the resident had asked him/her (CNA C) to watch the resident's room very closely. The CNA asked LPN B not to go in the resident's room by himself/herself, for his safety. LPN B said he/she had already been in the resident's room and the resident acted fine. The CNA told LPN B the resident would act like nothing happened. The CNA again asked the LPN to not go into the resident's room alone. The CNA told LPN B if he/she saw him/her go into the resident's room, he/she would soon follow. LPN B said to go ahead, that was fine; -The resident did not make an allegation of abuse, the CNA watched the residents room because the resident seemed uneasy, but nothing that indicated abuse; -Every time CNA C saw the LPN go into the resident's room that weekend, he/she would wait a couple of minutes and then go to the resident's room. He/She just stood in the resident's doorway and watched LPN B with the resident. The LPN did not close the resident's door; -On Saturday 9/14/19, the CNA walked into the resident's room and found LPN B holding the resident's hand while the resident lie awake on the bed. LPN B's hand was positioned on top of the resident's hand, resting on the resident's outer mid-thigh. When the CNA entered the resident's room, the LPN turned to the CNA and said, Oh, I've been waiting for you to come. The LPN let go of the resident's hand. During an interview on 9/24/19, at 4:02 P.M., the DON said the following: -The CEO notified her of the resident's accusations on Monday [DATE]; -He/she spoke to LPN B on the phone on the afternoon of [DATE]; -During this conversation, LPN B informed the DON that the resident was friendly and made a comment that he/she wanted CNA C in the room. LPN B said the resident asked for medication over the weekend, but the LPN only spent two to three minutes in the room; -The LPN said, several weeks prior, the resident asked LPN B if he/she knew of any people of the opposite gender that were not dead from the waist down; -The LPN denied any sexual contact with the resident during the phone conversation; -On Tuesday 9/17/19, LPN B contacted the DON by phone and asked the DON to meet him/her in the facility parking lot, which she did; -LPN B told the DON he/she had, screwed up. LPN B said the resident touched him/her through his/her pants and that it happened twice; -Told the LPN he/she was suspended from work at that time; -She later terminated LPN B by phone; -Any allegation of abuse should be reported to the DON, Administrator, or CEO of the facility; -Sexual abuse should be reported to DHSS within two hours; -What allegedly occurred to the resident would be considered sexual abuse; -Any sexual relations between a resident and a staff member should be reported to DHSS and would be considered a crime and reported to police; -CMT E should have reported the resident's comments about LPN B having sex with the resident to the supervisor/DON; -She did not find out that CMT E had prior knowledge of the sexual abuse until a phone conversation with CMT E on [DATE]. This phone conversation occurred after the CMT had been questioned by police regarding the matter; -CMT E received disciplinary action and was written up and educated for not timely reporting the sexual abuse. During an interview on 9/24/19 at 4:51 P.M., the facility Administrator and CEO/President of the facility said the following: -CMT E had prior knowledge of LPN B sexually abusing the resident and did not report the abuse; -CMT E knew about the abuse after the first alleged occurrence; -The Administrator and CEO were not informed of CMT E's knowledge of the abuse until [DATE] when the police informed them of the information; -Expected CMT E to have reported the allegation to supervisor. MO 810 and MO 822

Based on observation, interview and record review the facility failed to keep one resident (Resident #1), with severe cognitive impairment and an aspiration risk, as free of accident hazards as possible when the resident received a second-degree burn (damage the outer layer of skin and the layer underneath the skin) from hot coffee spilled while unsupervised by staff. The facility failed to assess the resident's ability to drink hot liquids safely, failed to monitor the temperature of hot liquids accessible to residents, and failed to identify and implement interventions to protect the resident from burns. A sample of 20 residents was reviewed in a facility with a census of 114. Record review of the Scald Injury Prevention Educator's Guide (a community fire and burn prevention program supported by the United States Fire Administration Federal Emergency Management Agency), published by the American Burn Association showed the following information: -Older adults, people with disabilities, and young children are most likely to incur scald burns; -Most scald burn injuries occur in connection with the preparation or serving of hot foods or beverages or from exposure to hot tap water in bathtubs or showers; -Both behavioral and environmental measures may be needed to protect those vulnerable to scalds because of age or disability; -The severity of a scald injury depends on the temperature to which the skin is exposed and how long exposed; -When the temperature of a hot liquid equals or exceeds 140 degrees Fahrenheit it takes only five seconds or less for a serious burn to occur; -Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 degrees Fahrenheit, resulting in almost instantaneous burns that could require surgery; -Older adults have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults; -Individuals who may have physical, mental or emotional challenges or require some type of assistance from care givers are at high risk for all types of burn injuries including scalds; -Mobility impairments, slow or awkward movements, muscle weakness or fatigue or slower reflexes increase the risk of spills while moving hot liquids; -Burns to the lap are common when a person attempts to carry hot liquids or food while seated in a wheelchair; -Changes in a person's intellect, perception, memory, judgment or awareness may hinder the person's ability to recognize a dangerous situation or respond appropriately to remove themselves from danger; -Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death; -Prevention of scald injuries is always preferable to treatment and can be largely accomplished through simple changes in behavior and in the home environment. 1. Record review of the facility's policy titled Accidents and Incidents-Investigating and Reporting dated December 2016, showed direction for facility staff to do the following: -All accidents or incidents involving residents occurring in the facility shall be investigated and reported to the administrator; -The nurse supervisor/charge nurse and/or department director or supervisor shall promptly initiate and document in the electronic medical record (EMR), the investigation of the accident or incident; -The following data, as applicable, shall be included in the documentation of the Incident Tracking section in the EMR: the condition of the injured person, including his/her vital signs, disposition of the injured and any corrective action taken. Record review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated comprehensive assessment tool completed by the facility staff, dated 10/28/16, showed the following: -Initial admission date of [DATE]; -Severely impaired cognition; -Extensive staff assistance of two required for transfers and dressing; -Set-up staff assistance required for meals; -No routine or as needed pain medications administered in the last five days; -[DIAGNOSES REDACTED]. Record review of the resident's medication record, dated January 2017, showed the following physicians' orders: -Special instructions included aspiration precautions and nectar thickened liquids; -The resident may have sips of regular water between meals, thin water only, not with meals, snacks or medications. Record review of the resident's medical record showed staff did not complete a hot beverage assessment on the resident. Record review showed staff did not provide documentation of monitoring of the temperature of coffee accessible to residence prior to 01/11/17. Record review of the facility's Incident Tracking report, dated 01/11/17, showed the following information: -At 6:45 A.M., the resident suffered an injury in the facility café (area adjacent to the dining room and community area); -Under the Description of the Incident section staff documented the resident spilled coffee on his/her lap. Staff took the resident to his/her room and removed the resident's wet clothing as quick as possible. Staff documented there was redness to the resident's bilateral (left and right sides) inner thighs. Staff applied cold, wet washcloths to the areas; -The resident stated he/she spilled a cup of coffee. The resident did not really understand what was happening; -Staff documented there were no witnesses; -The dietary manager was the first staff member on the scene; -Staff documented the injury as a burn/scald; -Staff documented the resident was oriented to name only and showed symptoms of anxiety and dementia; -In the contributing/environmental factors section staff documented the resident required extensive staff assistance to walk prior to the incident; -Instructed staff to cool coffee when giving it to the resident. (Staff did not complete the pain assessment section or current risk assessment section of the facility Incident Tracking report.) Record review of the resident's skin evaluation form completed by Licensed Practical Nurse (LPN) G showed the following: -On 01/11/17 at 9:13 A.M., staff classified the resident's left thigh burn wound as a partial thickness burn; -On 01/11/17 at 9:18 A.M., staff assessed the resident's right thigh burn wound; -LPN G documented the treatment included cleaning the areas with antibacterial soap and applying Silvadene (a topical antibiotic used to treat or prevent infections on areas of burned skin) twice a day until healed; -The LPN documented the residents' bilateral inner thigh burns were red with blisters; -The LPN did not complete the care planning section for the burn wound assessments; -The LPN did not document the burn wound measurements; -The LPN did not complete the resident's pain level section. Record review of the resident's progress notes showed staff documented the following information: -On 01/12/17 at 4:15 P.M., nursing staff assessed the resident's bilateral thigh burn wounds and noted the areas were covered with large fluid filled blisters with deep redness along the burn lines. Some of the larger blisters had burst with new blisters starting to form; -On 01/15/17 at 12:14 P.M., LPN H documented there was a large amount of serous (clear, thin, watery) drainage from the inner thigh burn wounds. The wounds were covered with loose slough (dead tissue), irregular in shape and had multiple degrees of burns. The resident was squirming and pulling at the dressings. Record review of the resident's January 2017 treatment administration record (TAR) showed an order dated 01/12/17 for a treatment to the residents' bilateral inner thighs. The treatment instructed staff to cleanse the areas with sterile water and antibacterial soap and to provide light debridement (removal of damaged tissue) with gauze when cleansing. Pat the areas dry and apply Silvadene cream and cover the areas with a telfa dressing (specialized gauze pads) twice a day until the areas were healed. The order instructed staff to monitor for infection. Record review of a Physician's Assistant (PA) progress note, dated 01/17/17, showed the following information: -The PA documented the resident had second degree burns on both the inner thigh areas after spilling coffee in his/her lap; -The PA documented the resident's burn areas were red and blistered with some intact and others had already popped; -The PA documented the resident's skin showed irregular patterned blistering to bilateral (both) inner thighs with two spots on the inner left thigh which seem to go in to a full thickness burn. Record review of the resident's skin evaluation form for the right thigh, dated 01/22/17, showed LPN H documented the following information: -At 12:31 P.M., the right thigh wound was classified as a burn, described as bilateral inner thigh burns with large amount serous (transparent to pale yellow fluid) drainage, wound beds covered with adherent yellow slough (pus and fibrin material attached to the wound), edges were intact, with the surrounding tissue red and frail; -No wound measurements were recorded; -The resident rated his/her pain as an eight, on a scale of one to ten, with ten being the most severe pain; -Staff did not document care plan interventions related to the burn. Record review of the resident's skin evaluation form for the left thigh, dated 01/22/17, showed LPN H documented the following information: -At 12:44 P.M., the left thigh wound was classified as a burn with a large amount of serous drainage. The wound beds were covered with adherent slough, the edges of the burn are intact with surrounding skin red and frail; -No wound measurements were recorded; -The resident rated his/her pain as a six on a scale of one to ten; -No care plan interventions were recorded. Record review of the dietary manager's progress note dated 01/25/17, at 12:57 P.M., showed he/she documented the resident was on a thickened liquid diet and sometimes gets his/her hands on regular drinks from the café. Record review of the resident's left thigh skin evaluation forms showed LPN H documented the following: -On 01/29/17 at 12:12 P.M., the burn wound had a large amount of serous drainage, the burn bed was covered with slough, the edges were intact and the surrounding skin was red and frail. Slough covered 50% of the burn and eschar (dark, dead tissue) surrounded the burn. The resident rated his/her pain at a six on a one to ten scale. (Staff did not document burn wound measurements. Staff did not document care plan interventions.) -On 02/05/17 at 10:22 A.M., the left thigh burn wound had a large amount of serous drainage noted from bilateral inner thigh wounds. The burn wound beds are marbled with slough and granulation tissue with slough covering 50% of the burn wound. The resident rated his/her pain at a six on a scale of one to ten. The burn wound treatment included cleaning the areas with antibacterial soap, applying Santyl (an ointment used to remove dead skin from wounds) ointment to the burn wound bed and cover with a Vaseline gauze daily until the area healed. Eschar was surrounding the burn wound. (Staff did not document care plan interventions.) Record review of the resident's care plan, dated 02/03/17, showed staff identified the resident was at risk for falls due to his/her impaired mobility and the resident was unaware of personal safety limitations. (The care plan did not interventions to prevent future burns from hot beverages.) Record review of the resident's progress notes, dated 02/06/17, showed staff transferred the resident to their Memory Care Unit (MCU) and documented due to increased confusion and wandering. Record review of the resident's February 2017 treatment record showed the following information: -On 02/08/17, the physician changed the burn wound treatment order to wash with normal saline (sterile solution) and cover the areas with petroleum gauze once a day until healed; -On 02/16/17, the physician changed the burn wound treatment to twice a day, until healed. Observation on 03/07/17, at 1:40 P.M., on the MCU showed a two burner coffee maker equipped with a spigot for HOT water, on the counter allowing staff and residents' full access to the coffee pots. During an interview on 03/07/17, at 2:05 P.M., LPN I said Resident #1 burned him/her self in the main dining room while drinking coffee that was too hot. LPN I said he/she was shocked the first time he/she saw the burns. Observation on 03/07/17, at 4:55 P.M., showed the coffee pot continued to drip hot water in the coffee pot. One of the MCU residents walked around the kitchen counter area where the coffee pot was located. During an interview on 3/8/17, at 8:35 A.M. the Dietary Manager (DM) said: -The café area is open all the time to residents and visitors. The dietary staff refills the juice dispensers, and coffee and sugar dispenser. Any staff can make more coffee when the dispensers are low. The dispensers are always on so coffee is available at any time of the day or night; -On 1/11/17, at about 6:00 A.M., the DM saw the resident in the dining room. He/she did not have a cup of coffee at that time. There were no other residents or staff in the dining room. The DM went into the kitchen, and a few minutes later heard the resident say Ow, Ow. When she came out of the kitchen, the resident was in the dining room and said he/she had spilled coffee; -She took the resident out of the dining room, and found staff to care for her; -She did not know how the resident got a cup of coffee; -She had never seen the resident get coffee without assistance; -The DM talked with the two aides that were working that morning. Both aides said they did not give the resident a cup of coffee; -The administrator did an investigation of this incident. The DM did not think it had been determined if the resident got the coffee on her own, or if someone gave it to her; -On 1/11/17, the DM checked the temperature of the coffee in the café area. The decaffeinated coffee temperature was at 173.2 degrees Fahrenheit (F). The regular coffee was at 186.7 degrees F; -An outside company calibrates the temperature of the dispensers. According to the coffee company, the water temperature needs to be at 192 degrees F to brew coffee; -The DM contacted the coffee company on 1/12/17 and asked to have the temperature on the coffee dispensers turned down. The company came on 1/26/17 and set the dispensers at 170 degrees F. After this, the residents and visitors complained about the coffee being cold. The DM called the coffee company, and the company came back two weeks later, on 2/9/17, and set the temperature at 180 degrees F. Observation on 03/08/17, at 9:00 A.M., of the cafe showed the decaf coffee was turned off. The decaf coffee when dispensed measured 128.4 degrees F. Observation on 03/08/17, at 9:05 A.M., of the cafe showed the regular coffee was turned on. The coffee when dispensed measured 170 degrees F. During an interview on 03/08/17, at 9:15 A.M., the Director of Nursing (DON) said the following: -Staff thought a visitor gave the resident the coffee; -The resident was often seen in the cafe with a cup of coffee; -After the resident received the burn the DON, the DM, administrator, and LPN G discussed checking the coffee temperature. The DM called the coffee company; -The resident was not assessed regarding ability to drink hot beverages safely; -Residents do not have access to hot beverages on the MCU; -The temperature of the coffee was lowered; -Resident specific interventions to prevent future burns included offering snacks and drinks between meals. During an interview on 03/08/17, at 9:45 A.M., the administrator said the following: -The dietary manager contacted the dietician for interventions to prevent resident burns from hot liquids; -The dietician suggested using carafes to dispense coffee; -She did not interview other residents or other staff members following the resident's burn because she knew the resident spilled hot coffee on his/her self; -MCU residents have access to hot drinks. During an interview on 3/8/17, at 11:30 A.M., Certified Nurse Aide (CNA) B said the resident propelled him/herself in a wheelchair. The resident spent time in the café area during the day. CNA B saw the resident get coffee from the coffee makers in the café area without assistance. In the days prior to the resident moving to the MCU, the resident declined in his/her ability to feed him/her self and needed staff to feed him/her at times. The resident continued to drink coffee from a cup without a lid after he/she was burned. The resident poured out or spilled his/her drinks. CNA B was not aware of any new interventions put in place for the resident after the resident was burned. During an interview on 3/8/17, at 11:50 A.M., LPN G said he/she saw the resident often in the café area before the resident moved to the MCU. The resident liked to get up early and would propel his/her wheelchair to the café area in the mornings. The resident had some confusion, but knew his/her way around the building. On 1/11/17, around 6:30 A.M., the DM told LPN G the resident spilled hot coffee in his/her lap. LPN G assessed the resident and put cool cloths on the resident's legs. The resident was confused and thought he/she was in the beauty shop. LPN G contacted the PA and received orders for Silvadene Cream to apply to the burn area. The resident's burn developed blisters later that day. LPN G asked, but no one knew where the resident got the coffee. LPN G said it would be unusual to have visitors that early in the morning and did not recall seeing anyone in the café that morning. The resident was physically and cognitively capable of getting coffee in the cafe area without assistance. On 1/11/17, LPN G told the day shift staff the resident was not to have coffee since the resident should have nectar thick liquids. He/She passed the information on during the shift-to-shift report. The resident returned to his/her normal activities within a few days, propelling him/her self around the facility. The staff did not complete hot beverage assessment. He/She discussed interventions involving hot liquid assessments with the DON today. During an interview on 3/8/17, at 1:05 P.M., CNA D said the following: -He/She cared for the resident before the resident moved to the MCU. The resident had become increasingly confused and wandered to other halls and did not recognize when he/she was in his/her own room; -The staff had to assist the resident with meals prior to the burn incident because the resident would raise his/her cup up above his/her head in front of him/her and pour out the liquids, including coffee; -The resident had been able to get coffee for his/her self approximately eight months ago, but since then had not been capable of getting coffee by his/her self; -The resident poured hot coffee in his/her lap once while sitting in the café. CNA D said he/she was unsure who gave the resident coffee because the resident's diet included thickened liquids; -CNA D said he/she arrived at work at approximately 6:00 A.M. and saw the resident sitting at a table in the café with a cup of coffee in front of him/her with no staff assisting the resident or present in the café; -After the resident poured hot coffee in his/her lap the DM brought the resident to CNA D and got the nurse. CNA D and the nurse immediately took off the resident's clothing, placed cold wet cloth's on his/her legs. The resident did not express a lot of pain at that time; -CNA D said the coffee should not have burned the resident like that, and it seemed too hot for regular coffee drinking temperature. There was an accessible microwave in the café, so a staff member or resident could have possibly heated the coffee in the microwave. CNA D said he/she had never seen any staff heat a resident's coffee in the microwave, but management had never told the staff they could not heat coffee in the microwave; -The resident was an avid coffee drinker and continued to drink coffee on a regular basis after the incident; -The dietary staff stopped using the coffee pot in the café after the incident until the coffee company came to check the temperature of the coffee; -The facility moved the resident to the MCU approximately two to three weeks after he/she spilled coffee on his/her self. Observation and interview on 3/8/17, at 2:00 P.M., showed the following: -LPN E said the resident resided on the MCU and propelled him/her self in a wheelchair; -LPN E said the resident required staff set-up assistance at meals and verbal prompting and on occasion the resident needed staff assistance with eating. -LPN E said he/she had not seen the resident attempt to get coffee unassisted. -LPN E said the residents could access the coffee maker with a hot water dispenser on the unit and the staff is to supervise the coffee area at all times. -LPN E said he/she was aware the resident was burned by hot coffee, but there were no interventions in the resident's care plan related to the burns. -Observation showed the maintenance staff removed the coffee makers from the MCU. There were no coffee makers in the café area and a sign directed residents and visitors to go to the kitchen for coffee. During an interview on 3/8/17, at 2:15 P.M., CNA F said the resident resided on the MCU. The resident propelled his/her wheelchair around the unit. The resident required staff set-up assistance and prompting at meals. The resident liked to drink coffee, but did not like the thickened coffee. The resident had a lot of confusion and CNA F did not know if the resident was able to get coffee without assistance prior to moving to the MCU. CNA F was aware the resident received a burn from hot coffee. There were no interventions in the resident's care plan related to the burns. The MCU staff members try to watch the kitchen area where the coffee maker was located, but the residents had access to the coffee maker. During an interview on 03/08/17, at 2:20 P.M., LPN I said he/she recalled an alert in the EMR advising the nursing staff of Resident #1's burn by the hot coffee. He/She said there were no interventions provided with the alert to prevent additional injury. Record review of the resident's care plan, dated 03/08/17, showed the following updates: -A risk for injury related to dementia and a history of burns to his/her legs from hot coffee and is unable to remember that he/she needs thickened liquids; -A posted listing of residents on thickened liquids are at each station; -Coffee will be located in the dietary department; -Remind staff to ask the charge nurse or see care plan when unsure whether the resident needs thickened liquids. Observation on 03/08/17, at 2:25 P.M., showed the following: -LPN I prepared supplies for the dressing change on the resident's burns; -LPN I removed the dressing from the resident's left inner thigh burn wound; -The left inner thigh burn wound measured approximately eight inches in length by two and a half inches at the widest point, with visible slough in the center of the burn was reddened and; -LPN I cleaned the left thigh burn wound and covered the wound with petroleum gauze, then a thick gauze pad and secured in place with rolled gauze; -LPN I removed the dressing from the right inner thigh burn wound; -The right inner thigh burn wound was reddened and measured approximately ten inches in length by two inches in width with two dime-sized open blister areas visible in the center of the burn wound; -LPN I cleaned the right thigh burn wound and covered with petroleum gauze, a thick gauze pad and secured the dressing. During an interview on 3/8/17, at 4:10 P.M., Care Plan Coordinator (CPC) C said he/she receives information about the residents at the morning stand-up meeting. He/she took notes at the meeting and put the information from the meeting on the residents' care plans. He/She updated Resident #1's care plan on 1/11/17 with the increased risk of infection due to the burns. CPC C said he/she did not put interventions in the resident's care plan to address the resident's safety with hot liquids. Staff did not assess the resident to determine his/her safety in handling hot liquids. The interdisciplinary team (IDT) held the resident's care plan meeting on 1/27/17. The IDT did not add interventions to the resident's care plan to address the resident's safety with hot liquids. The IDT should add specific interventions to the resident's care plans when a resident had an accident. During an interview on 03/09/17, at 9:20 A.M., the PA said the following: -She has been seeing the resident for approximately four years; -The resident ambulated with a walker and self-propelled a wheelchair prior to the burn incident; -She learned today the resident received thickened liquids; -Staff notified her the day the burn occurred and she gave treatment orders for the burns; -She examined the resident the day after the burn occurred; -The resident had second degree burns with fluid filled blisters; -Some of the blisters ruptured and she debrided (removed the dead tissue) those areas; -She did not measure the wounds following the burn incident; -The staff nurses measure the wounds; -She gave orders to monitor the burn wounds for infection and to monitor the resident for complaints of pain; -She advised the facility administrator to check the temperature of the coffee on 01/12/17; -This burn incident could have been prevented by removing the coffee pots and placing lids on the cups; -The resident's confusion declined over the past six months; -The burn wound is currently 66 percent healed; -There are other residents at risk for burns on the MCU; -It is a problem to have hot coffee pots accessible to the residents on the MCU; -She hoped the facility would have planned interventions for all of the residents to prevent a reoccurrence of this happening again to anyone. During an interview on 03/09/17, at 11:15 A.M., the MDS coordinator said she added interventions to the resident's care plan on 03/08/17 at the direction of the administrator. There were no care plan interventions initiated on the 02/03/17 care plan following the burn. During an interview on 03/09/17, at 11:50 A.M., LPN H said the following: -He/She provides the resident's wound care and treatments on the residents weekly; -He/She does the resident's weekly skin assessments; -He/She did not measure the resident's burn wounds because of the location, the irregular shape and the resident was in a lot of pain, but he/she would normally measures wounds on residents. He/she should have measured the burn wounds but there were so many layers of the burns it would have been difficult; -There was dead tissue visible in the center of the burn wound when he/she initially saw the area; -The wound had blisters when he/she first examined the burns; -He/She does not recall any directions after the burn incident and is not aware of any interventions in place following the incident. Observation and interview on 3/9/17, at 3:15 P.M., showed the following: -A new coffee maker on the counter in the MCU. The coffee maker was in the on position with hot coffee in the pot. The coffee maker was hot to the touch and easily accessible to all the memory care residents. No staff members were present in the area of the coffee pot. A resident propelled his/her wheelchair through the dining area. -CNA A said staff brought the coffee maker to the Memory Care Unit last night. The staff had been directed by the administrator to bring the coffee maker to the unit for the residents and staff member's use. The staff did not receive any instructions on where to put the coffee maker. During an interview on 3/9/17, at 3:30 P.M., the administrator said she bought the coffee pot for the Memory Care Unit last night. The residents on the unit like to have coffee and she did not want to take that away from the residents. She did not instruct the staff to put the coffee maker where it would not be accessible to the residents. Observation on 03/09/17, at 3:42 P.M., showed a hot pot of coffee on the counter of the MCU. The coffee maker was in the on position and was one-third full of hot coffee. The coffee temperature measured 164 degrees F.

Based on observation, interview and record review, the facility failed to timely administer time-sensitive pain medication to provide adequate pain management for one resident (Resident #24) following recent hip surgery. This caused the resident sleepless nights due to unrelieved pain. Staff failed to provide additional interventions or contact the physician to address unrelieved pain for one resident (Resident #13) suffering from jaw and neck nerve pain from the recent onset of a condition. The facility also failed to administer a prescribed anti-anxiety medication prior to a medical procedure for one resident (Resident #7) causing the resident undue anxiety, and cancellation and postponement of the procedure. Twenty residents were chosen for review out of a facility with a census of 113. 1. Record review of the facility policy titled, "Pain - Clinical Protocol" dated April 2007, showed in part the following information: -The staff and physician will identify the nature and severity of pain including characteristics (location, intensity, frequency, duration, etc.); -Staff should use a standardized pain assessment instrument appropriate to the resident's cognitive level; -The staff and physician will also evaluate how pain is effecting mood, activities of daily living (ADL), sleep, and selected quality of life measures, including complications such as de-conditioning, gait disturbances, social isolation, and falls; -Staff will evaluate and report how much and how often the individual asks for as needed (PRN) pain medication; -Depending on the severity and location of pain, the physician may start with PRN doses or supplement standing doses with PRN doses for breakthrough pain; -If there are more than occasional [MEDICATION NAME] requests, the physician will consider changing to regular administration of at least one [MEDICATION NAME] with another medication for PRN use, increasing the standing dose of an existing [MEDICATION NAME], or switching to another [MEDICATION NAME]; -Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain; -Staff will reassess the individual's pain and consequences of pain at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain; -The physician will adjust medications accordingly, based on effectiveness and side effects. 2. Record review of Resident #13's recent comprehensive annual minimum data set (MDS) a federally mandated assessment tool required to be completed by facility staff, dated 02/27/14, showed the following information: -Cognition intact; -Arthritis; -Occasional moderate pain. Record revie of the resident's current care plan showed instructions for staff to monitor and treat the resident for pain. Record review of the April 2014 Physician's Order Sheet (POS) showed the following information: -[DIAGNOSES REDACTED] (A temporary paralysis of one side of the face due to damage or trauma of the facial nerve. The severity of symptoms can vary from person to person. Pain around the jaw and behind the ear can be associated with this condition); -Monitor pain four times daily; -[MEDICATION NAME] (medication used to treat nerve pain) 100 milligram (mg) three time a day (TID); -APAP/[MEDICATION NAME] #3 ([MEDICATION NAME] and Opioid [MEDICATION NAME]) one tablet two times a day (BID); -APAP/[MEDICATION NAME] #3 one to two tablets every four hours PRN -[MEDICATION NAME] (Tylenol - [MEDICATION NAME]) 650 mg every four hours as needed (PRN). Record review of the April 2014 Medication Administration Record [REDACTED] -On 04/14/14, at 7:47 A.M., staff administered one PRN APAP/[MEDICATION NAME] #3 tablet for left ear and side of neck pain. The resident rated the intensity of his/her pain as a 9 to 9 ? on a 0 to 10 scale (10 being the worst). -On 04/14/14, at 8:00 A.M., nursing documented cleaning the resident's ears with warm water and removed a moderate amount of wax from the ear canal and assessed the eardrum noting redness and irritation. Staff did not document any further interventions to relieve the resident's pain. -On 04/14/14, at 9:27 A.M., (two hours later) staff assessed the medications effectiveness. The nurse documented "no relief" and the resident continued to rate his/her pain as a "9". No pain medication was administered and the nurses' notes showed no non-medicated interventions were provided in an attempt to ease the resident's pain. Staff did not notify the physician about the resident's continued intense pain. -On 04/15/14, at 8:57 A.M., staff administered PRN APAP/[MEDICATION NAME] #3 for ear pain. The resident rated the intensity of his/her pain as "8". -On 04/15/14, at 10:43 A.M., staff assessed the medication's effectiveness. The nurse documented "little relief." The resident rated his/her pain as "7". Staff did not administer any other pain medication and the nurses' notes showed staff did not provide any non-medicated interventions in an attempt to ease the resident's pain at that time. Staff did not notify the physician of the resident's unrelieved pain. -On 04/15/14, at 4:10 P.M., the nurse documented the Physician's Assistant (PA) called the nurse to the resident's room to observe left sided facial drooping of the resident. The resident continued to complain of headache/earache. The PA suspected [DIAGNOSES REDACTED] and ordered the resident sent to the emergency room for evaluation to rule out stroke. -On 04/15/14, at 7:37 P.M., the evening shift nurse documented the resident returned to the facility from the hospital with [DIAGNOSES REDACTED]. The nurse documented contacting the on-call physician for instruction/clarification but the physician did not know the resident well and told the nurse to contact the resident's primary physician in the morning for instruction. -On 04/16/14, at 7:21 A.M., staff administered one PRN APAP/[MEDICATION NAME] #3 tablet for left ear pain. The resident rated the intensity of his/her pain as "8". -On 04/16/14, at 9:04 A.M., staff assessed the medications effectiveness. The nurse documented "no relief" and the resident continued to rate his/her pain as "8". Staff did not notify the physician of the resident's unrelieved pain. -On 04/16/14, at 12:30 A.M., showed the nurse documented he/she taped the resident's left eye shut at 11:00 P.M. (one and a half hours previously) at the resident's request but did not document he/she provided any non-medicated interventions in an attempt to ease the resident's pain following the 9:04 A.M. PRN follow up pain assessment. -On 04/22/14, at 12:30 A.M., showed staff administered PRN APAP/[MEDICATION NAME] #3 for left ear pain. The resident rated the intensity of his/her pain as "8". -On 04/22/14, at 7:37 A.M., showed staff administered PRN APAP/[MEDICATION NAME] #3 for left ear and neck pain. The resident rated the intensity of his/her pain as "10" (worst pain). -On 04/22/14, at 8:46 P.M., staff assessed the medications effectiveness. The nurse documented the resident rated his/her pain as "8". -On 04/22/14, at 12:42 P.M., staff administered one PRN APAP/[MEDICATION NAME] #3 tablet for left ear and side of neck pain. The resident rated the intensity of his/her pain as "8". -On 04/22/14, at 1:52 P.M., staff assessed the medications effectiveness. The nurse documented "no relief" and the resident continued to rate his/her pain as "8". Staff did not notify the physician of the resident's unrelieved pain. -On 04/22/14, at 4:09 P.M., the nurses' notes showed no non-medicated interventions were provided in an attempt to ease the resident's pain. The nurse practitioner (NP) was in the facility, assessed the resident and instructed nursing to increase the resident's [MEDICATION NAME] to twice a day for one week then increase it again to three times a day routinely. Observation on 04/28/14 at 3:45 P.M., showed the resident in bed. The left side of his/her face drooped so that it looked liked he/she spoke out of the right side of his/her mouth. He/she was unable to close the left eye when blinking. He/she was very alert and communicated well. When he/she talked about his/her pain, he/she cupped the left side of his/her face and jaw with his/her hand. The resident said he/she had [DIAGNOSES REDACTED] effecting the left side of his/her face and neck and said it was painful. During an interview on 05/01/14, a certified nurse assistant (CNA) N said the resident has [DIAGNOSES REDACTED] and it really hurts his/her neck and jaw. The CNA said the resident used to get out of bed more but not since the [DIAGNOSES REDACTED]. During an interview on 05/01/14, at 8:35 A.M., licensed practical nurse (LPN) O said he/she treats a resident's pain for whatever level the resident says it is. If the pain medication is not effective, staff are to provide some kind of intervention. LPN O said he/she cleaned the resident's ears out on 04/15/14 and provided a warm pack for the jaw and ear. The LPN said the NP told him/her all we can do is treat the symptoms with pain medication and warm packs. The LPN said he/she did not document providing a warm pack intervention on 04/15/14. During an interview on 05/01/14, at 11:20 A.M., the resident said staff provided a warm pack to his/her jaw only once after looking in his/her ears. The resident said he/she receives Tylenol #3 (APAP/[MEDICATION NAME] #3) and regular Tylenol twice a day but the pain is not always relieved. "It really does hurt." The resident said the staff check to see if the pain medication is effective but do not provide any intervention when he/she tells them his/her pain is still there and not relieved. The resident said staff tell him/her "It's not time for you to have another pain pill." A massage over the painful area would feel good and perhaps reduce the pain or even a hot or cold pack would help but staff do not provide this. 3. Record review of Resident # 24's admission nursing notes written on 4/26/14 at 5:36 P.M. showed: -admission date of [DATE]; -Total left hip replacement on 4/23/14; -Alert and oriented x4 (name, place, date and time); -Had physician's order for [MEDICATION NAME] (narcotic pain medication) 30 mg as needed every 6 hours for pain; -Gave 30 mg [MEDICATION NAME] at 1:30 P.M. as resident stated he/she was hurting from the ride to the facility. Record review of the resident's admission data sheet showed the following Diagnoses: [REDACTED]. Also called [MEDICAL CONDITION] joint disease) pelvic region and thigh; -Hip joint replacement; -Chronic pai[DIAGNOSES REDACTED]. Record review of the resident's current physician's order showed: -[MEDICATION NAME] ER (Extended Release narcotic pain medicine) 60 mg, give one tablet by mouth every 12 hours; -[MEDICATION NAME] 30 mg tablet, one tablet by mouth every 6 hours as needed (PRN) for pain. Record review of the resident's Treatment Administration Record (TAR) for April 2014 showed: -[MEDICATION NAME] ER 60 mg scheduled for 8:00 A.M. and 8:00 P.M. beginning on 4/26/14; -[MEDICATION NAME] 30 mg, one tablet every 6 hours PRN for pain; -The MAR indicated [REDACTED].M. and 8:00 P.M. Staff initialed in these columns that they gave the [MEDICATION NAME] ER twice daily. However, the columns did not allow staff to document the exact time they administered the [MEDICATION NAME] ER. -On 4/30/14, staff administered PRN [MEDICATION NAME]; -Staff did not document the resident's level of pain prior to administering the as needed [MEDICATION NAME]. Record review of a nursing note written on 4/30/14 at 3:21 A.M. showed: -Resident received PRN [MEDICATION NAME] at 10:30 P.M. on 4/29/14; -At 12:00 A.M. resident asked for more pain medication; -Nurse explained it was not time yet, but would bring it when it was time; -Resident used call light worried about left hip incision, thought it was hotter than it should be; -Wound was not hot, back part of leg was warm where resident had previously been lying on it; -Resident requested [MEDICATION NAME] again; -Again told the resident he/she was unable to have any more until 4:30 P.M.; -Resident said he/she had not been able to sleep all night. Record review of the resident's TAR for May 2014 showed: -Staff initialed they administered the routine [MEDICATION NAME] ER at 8:00 A.M. and 8:00 P.M. but not the exact time they administered the medication. -Staff administered PRN [MEDICATION NAME] on 5/1/14; -Staff did not document the resident's level of pain prior to administering the PRN [MEDICATION NAME]. During observation and interview on 5/1/14 at 2:00 P.M. the resident was in bed eating a snack. He/she was alert and readily verbalized his/her concerns about his/her pain without being asked. He/she said the following: -Had hip replacement surgery prior to coming to the facility; -Lived at home before going to the hospital; -Had been at the facility since 4/26/14 (five days); -Had been on [MEDICATION NAME] for several years due to pain related to [MEDICAL CONDITION]; -While at home consistently took [MEDICATION NAME] ER routinely at 7:00 A.M. and 7:00 P.M.; -Did not have to take the PRN 30 mg [MEDICATION NAME] as long as he/she did not let more than 12 hours lapse between the extended release doses; -Staff had not been consistent with giving the [MEDICATION NAME] ER doses no more than 12 hours apart; -Staff gave the morning doses of [MEDICATION NAME] ER at 7:00 A.M. since admission; -Some evenings it had been as late as 10:00 P.M. before staff gave the 60 mg [MEDICATION NAME] ER; -His/her pain was at a 10 (on a scale of 1-10 ) on the days staff gave the evening dose of [MEDICATION NAME] later than 12 hours after the morning dose; -Asked for and received as needed [MEDICATION NAME] last night but it did not relieve his/her pain; -Staff did not offer any other pain relieving interventions; -Did not sleep at all last night due to pain. During an interview on 5/1/14 at 4:00 P.M. the resident's family member said: -The resident took [MEDICATION NAME] ER every 12 hours at home; -Doesn't need the PRN [MEDICATION NAME] if he/she takes the [MEDICATION NAME] on schedule; -Has visited his/her family member every day since he/she was admitted 5 days ago; -On 4/28/14 the resident asked for the evening dose of [MEDICATION NAME] ER at 7:00 P.M.; -Staff brought the medication at 8:30 P.M.; -One other occasion, staff did not administer the resident's evening dose of [MEDICATION NAME] ER until 10:30 P.M.; -The resident was in a lot of pain while waiting for the medication. 3. During an interview on 05/02/14, at 2:10 P.M., the Director of Nurses (DON) said staff should assess for PRN pain medication effectiveness no sooner than one hour after administration. The facility has a new electronic documentation system for medication administration and follow up but the electronic timing is off. Staff must make identification notes of the correct time but are not doing this. The DON said she would expect staff to reassess the resident if pain remains. Non-medicated interventions can be utilized by restorative therapy to provide the resident with heat packs etc. Non-pharmacological interventions should be documented in the nurses' notes. Would expect the nurse to contact the physician if a resident received no relief from PRN pain medications. The DON said she was not aware the resident was not getting relief from the prescribed PRN pain medication. 4. Record review of Resident #7's medical record showed the following information: - [DIAGNOSES REDACTED]. - An appointment for an Magnetic Resonance Image (MRI) test on 4/29/14 at 10:15 A.M; - an order for [REDACTED]. According to the website: MRI scan - How it's performed - NHS Choices included the following information for those having an MRI scan: -An MRI scanner is a short cylinder that is open at both ends. You will lie on a motorized bed that is moved inside the scanner. You will enter the scanner either head first or feet first, depending on the part of your body being scanned. -In some cases, a frame may be placed over the body part being scanned, such as the head or chest. This frame contains receivers that pick up the signals sent out by your body during the scan and it can help to create a better quality image. -To avoid the images being blurred, it is very important that you keep the part of your body being scanned still throughout the whole of the scan. -The whole procedure will take between 15 and 90 minutes. -The MRI scanner will make loud tapping noises at certain times during the procedure. -You can ask for a mild sedative to help you relax if you are claustrophobic Record review of the resident's most recent quarterly MDS dated [DATE] showed in part the following information: -Cognition intact; -[MEDICAL CONDITION]; -[MEDICAL CONDITION]; -High blood pressure; -Depression. During an interview on 4/29/14 at 8:00 A.M. the resident said he/she had an appointment later that day for an MRI. He/she said he/she did not like that test because the noise of the machine made and the tight space he/she had to lie in during the test made him/her nervous. He/she said he/she always had to take "a pill" because he/she becomes anxious during the procedure. During an interview on 4/29/14 at 11:30 A.M. the resident said the staff forgot to give him/her the pill before leaving so the test was canceled. He/she said the staff thought he/she was having an ultra-sound, not an MRI. He/she said the test had been rescheduled for a later date to be done the same day as the ultra-sound. During an interview on 5/2/14 the Director of Nurses (DON) said a staff member in the transportation department schedules the appointments for the residents. She said the orders are in the residents chart and should be reviewed by the staff prior to the appointment.

Based on observation, interview and record review the facility failed to ensure staff developed and implemented appropriate interventions to address two residents, residing on the memory care unit, (Resident #1 and Resident #2), exhibited behaviors when one licensed nurse (LPN) and three certified nurse aides (CNAs) forcibly held one resident (Resident #1) who became combative during incontinent care. Staff held down the resident's arms and legs causing bruising to the top of the resident's hands and two skin tears to the resident's arm. After transfer to his/her wheelchair, staff transported him/her to the dining room where staff again held the resident's extremities while the LPN dressed the skin tears. The resident remained resistive and combative "yelling, screaming and cursing". After staff let the resident go, the nurse documented that the resident "remained out of control with other residents". The resident propelled his/her wheelchair and grabbed a walker from a resident, attempted to swing it around, then with an open-hand, slapped another resident. Staff also held down another resident (Resident #2) to give an injection, resulting in bruising to the resident's forearms. Staff did not implement the facility's policy and acceptable standards of nursing care when dealing with the behaviors of these confused residents before physically restraining them. Four residents from the unit were chosen out of a total sample of seven for review in this facility with a census of 114. Record review of the facility's policy entitled "Behavior Assessment and Monitoring" revised April 2007, showed, in part, the following: *Policy statement: -Problematic behavior will be identified and managed appropriately; -Residents will have minimal complications associated with the management of problematic behavior. -The facility will comply with regulatory requirements related to the use of medications to manage problematic behaviors. *Policy interpretation and Implementation: -Identify and document mental status, behavior and cognition; -Identify of non-pharmacological approaches; -Ongoing reassessments of changes in behavior, mood and function; -Use of the behavioral assessment form. Record review of the facility's policy entitled "Unmanageable Residents" revised August 2006, showed, in part, the following: *Policy Statement:: Each resident will be provided with a safe place of residence. *Policy Interpretation and Implementation: -Should a resident's behavior become abusive, hostile, assaulting, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the charge nurse should immediately provide for the safety of all concerned, notify the physician for instruction, notify the director of nursing (DON) and the resident's representative. -The DON has the authority to order an emergency restraint in accordance with our facility's established restraint policy. -Every effort shall be made to calm the resident. Record review of the facility's policy entitled "Use of Restraints" revised December 2008, showed, in part, the following: *Policy Statement: Restraints shall only be used for the safety and well-being of the residents and only after alternatives have been tried unsuccessfully. Restraints shall only be used to treat a residents medical symptoms and never for discipline or staff convenience. *Policy Interpretation and Implementation: -"Physical Restraints" are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the residents body that the individual cannot remove easily, which restricts freedom of movements or restricts normal access to ones body. -Emergency use of restraints are permitted if their use is immediately necessary to prevent the resident from injuring him/herself or others and/or to prevent the resident from interfering with life-sustaining treatment, and no other less-restrictive interventions are feasible. -Treatment restraints may be used for the protection of the resident during treatment procedures if the resident and/or representative has consented to the treatment and the use of treatment restraints. -Restraints shall be used in such a way as not to cause physical injury to the resident and to insure the least possible discomfort to the resident. 1. Record review of Resident #1's face sheet (admission data) showed staff admitted the resident to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff dated 05/27/13, showed the following information: -Brief interview for Mental Status (BIMS) assessment showed no score , the resident is rarely or never understood and the interview was not conducted which shows cognition was severely impaired with poor decision making. -Staff did not identify any behavioral concerns. -Needs extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and transfers; -Needs limited assistance of one staff physical assist with eating; -Needs total assistance of staff with bathing; -Uses a wheel chair for mobility; -The resident received anti-anxiety and antidepressant medications. Record review of the care plan, dated 03/13/2013 and last updated 08/2013, showed the following: -All care is related to [MEDICAL CONDITION]; -Chronic cognitive deficit unable to make needs known; -At risk for falls unable to stand without support; -Resident at risk for cognitive or functional decline due to [MEDICAL CONDITION] medications and staff should assess any behavior/mood changes, assess memory loss and notify the physician of status change; - Staff did not address behaviors or interventions to address behaviors. Record review of the nurses notes dated 05/01/13-5/028/13, showed the following information: -The resident was pleasantly confused; -Resident wanders in and out of other resident rooms; -The resident was easily re-directed; -(Staff did not administer any PRN [MEDICATION NAME] (anti psychotic medication) to the resident for any behaviors during this period. Record review of the nurses notes, dated 06/07/13-08/02/13, showed the following information: -The resident was pleasant and cooperative; -The resident propelled self up and down halls and wandered in and out of other resident rooms; -The resident was easily re-directed; -The resident liked to set off the door alarms. Record review of the nurses notes dated 08/03/13-08/16/13, showed the following information: -On 08/03/13, the resident pushed on the 800 hall door until it alarmed, released and resident propelled out of the unit approximately 10 feet. Staff brought the resident back into the unit (Special Care Unit) with difficulty; -On 08/04/13, the resident continues with the same behaviors as yesterday, going back and forth between the hallway doors making the alarm doors sound, open and propels self out of the unit; -While attempting to shave the resident, he/she became physically combative, hitting, kicking staff and was verbally abusive cursing and yelling even after the staff was done shaving, the resident continued to be aggressive; -The resident was up in wheelchair propelling self about, pleasant then turned hateful; -The resident propelled self up and down halls and wandered in and out of other resident rooms; -The resident was easily re-directed; -On 08/08/13, at 8:38 P.M., the staff found the resident in the living room holding the television and took the television off of the residents hands, no injury noted; -At 8:45 P.M., staff reported the resident went into another residents room and hit the resident on the left forearm, no injury noted to that resident. -On 08/09/13, at 9:50 A.M., the nurse practitioner was made aware of the resident's behaviors on 08/08/13, and gave a new order for scheduled [MEDICATION NAME] 0.5 mg two times daily. -The resident started on scheduled [MEDICATION NAME]; -The resident exhibited some physical aggression with staff during cares; -At 11:00 P.M., the resident "stripped off his/her shirt", occasionally pleasant and other times angry; -On 08/10/13, at 9:45 A.M., the resident was on the second day of scheduled [MEDICATION NAME] and no negative behaviors on this shift; -At 1:00 P.M., the resident becoming agitated and somewhat physical and verbally aggressive as the morning dose of [MEDICATION NAME] starts to wear off. -On 08/11/13, no negative behaviors noted; -On 08/12/13, at 8:00 A.M., the resident was very pleasant, smiling and talking, no negative behaviors noted; -At 10:30 A.M., the resident becoming agitated propelling self in wheelchair faster than usual, going up behind other residents wheelchairs and pushing them; When staff re-directed, the resident began cursing, yelling and hitting staff. -The nurse practitioner made aware of behaviors and gave an order for [REDACTED]. -At 9:00 P.M., the resident has been pleasant and cooperative with care. -On 08/13/13, at 11:45 A.M., the resident became agitated and staff administered PRN [MEDICATION NAME] (Staff did not describe what behaviors the resident was exhibiting.) -On 08/14/13, at 101:15 P.M., staff gave PRN [MEDICATION NAME] for agitation (Staff did not describe what behaviors the resident was exhibiting.) -On 08/15/13, at 7:35 P.M., staff gave PRN [MEDICATION NAME] for agitation (Staff did not describe what behaviors the resident was exhibiting.) -On 08/16/13, no negative behaviors noted. Record review of the August 2013 PO showed an order dated 08/08/13, for scheduled [MEDICATION NAME] 0.5 mg to be given two times daily. Further review showed the Resident did not receive any aspirin or blood thinning medications. Record review of the nurses notes dated 08/17/13, showed the following information: -At 12:00 P.M., the resident was in a very good mood, laughing, smiling, talking with both staff and residents. No negative behaviors have been observed; -At 1:30 P.M., the resident became agitated, aggressive and combative when staff got the resident out of bed to visit with spouse; -The resident visited with spouse, appeared to have a good visit. During a telephone interview on 08/29/2013 at 8:30 A. M., LPN A (the charge nurse on the memory care unit) said on 8/17/13, the resident was fine that morning and after lunch. The resident was in a "good mood." The aides went to check the resident for incontinence and lay him/her down after lunch. The aide came and got the LPN. The resident was lying sideways in the bed with his/her shirt off. They checked the resident for incontinence and he/she was dry. The resident was fighting the staff, hitting, and scratching at them. The staff finally got the resident into the wheelchair and wheeled the resident to the common area for a visit with his/her spouse. The resident visited with his/her spouse for about 45 minutes, then the spouse left. During a telephone interview on 08/28/3013 at 4:45 P.M., Resident #1's spouse said the following; -The resident remains calm during his/her visits which are usually twice a week. -Felt staff working in unit were dominating and causing tension in the unit. -He/she came to unit on 08/17/2013 and found the resident lying halfway in the bed and went to get staff. While searching for the staff in the unit, staff members went to the room and provided care. -The spouse stated when his/her visit was over, the resident was in a pleasant mood and smiling. Record review of nursing notes showed the following: -After the spouse left, the resident became increasingly physically aggressive and combative, hitting, slapping and kicking staff; The resident was also verbally abusive towards staff; -Staff took the resident to his/her room to toilet and he/she became completely aggressive and combative with staff. During an interview on 08/27/13 at 2:45 P.M., CNA D said on 08/17/13, CNA E and CNA F called him/her to the resident's room to assist with peri-care. There were three of us, in case the resident became agitated or combative. The resident became violent with us and began cursing. One of the other CNAs went to get LPN A to assist. LPN A instructed us to hold the resident so he/she could not hit us while providing incontinent care. As the resident lay in bed CNA D held the resident's wrists near his/her waist. As staff transferred the resident from the bed into his/her wheelchair, the LPN instructed us to hold the resident's arms and legs and the resident received skin tears to his/her arm from fighting the CNAs. During an interview on 8/28/13 at 4:15 P.M., CNA F said:-Resident #1 required extensive assistance of two staff for care;-The resident got combative when staff were changing him/her and providing incontinence care;-On 8/17/13 during the 4:00 P.M., rounds, he/she and another aide transferred the resident into bed and started to remove his/her pants and he/she was combative. CNA D came into the room and LPN A was also in the room. They continued to remove his/her pants and check the resident for incontinence. The resident was dry, so they pulled his/her pants back up. He/she saw the resident had skin tears, he/she was not sure when the skin tears occurred just saw blood on the resident's sheets;-They got the resident in the wheelchair and took him/her out in the hall to the nurses station. The resident was being verbal at that point but not hitting them. During a telephone interview 08/28/2013 at 2:12 P.M., CNA E said on 08/17/2013 during 4:00 P.M., rounds, he/she, CNA D and CNA F took the resident to his/her room to check the resident for incontinence. They explained what they were doing. Resident #1 became combative and agitated and started swinging. The staff assisted the resident to the bed and the resident continued to be agitated. CNA E left the room to obtain LPN A. CNA E said he/she stayed in the dining room, while CNA D and F and LPN A assisted the resident. During a telephone interview on 08/28/2013 at 2:37 P.M., LPN A said on 08/17/2013 at 4:00 P.M., the resident started hitting and yelling at staff when they attempted to turn him/her in his/her bed to provide peri-care. The resident's brief was dry. LPN A instructed two CNA s (D and F) to place the resident in his/her wheelchair. The resident fought the staff as he/she transferred to the wheelchair. LPN A then said the skin tears, "friction tears" occurred during the transfers to the wheelchair. The resident's skin tears were just "basic" skin tears, very small amount of blood. LPN A assisted CNA D and F with transfer of the resident to nursing station to dress skin tears. LPN A instructed three CNAs (D, E, F) to hold the resident's hands and feet while he/she dressed the resident's skin tears. The LPN said there was not a lapse of time for interventions prior to providing care for skin tears. Record review of nursing notes on 8/17/13, showed LPN A documented the resident did receive two, 1 cm skin tears to his/her right forearm and right elbow. The resident also received bruises to the backs of both hands from staff having to restrain him/her. Record review of the facility's form entitled Accident or Incident Report dated 08/17/13, completed by LPN A showed the following: -At 4:00 P.M.., the resident became increasingly agitated when staff got him/her up from resting to visit with his/her spouse; -When the visit was over the resident became combative, verbally and physically aggressive, hitting, slapping, cursing and kicking staff; -Places of injuries illustrated on this report showed the resident had a 1 centimeter (cm) x 1 cm skin tear to his/her right forearm and a 1 cm x 1 cm skin tear to his/her right elbow. The resident also had 3 cm x 3 cm bruises to the tops of both hands. -The assessment on the back of this report showed the resident received the skin tears to the right forearm and the right elbow both while staff toileted the resident and placed him/her back in the wheelchair. Record review of nursing notes on 8/17/13, showed LPN A documented the following: -Staff brought the resident back to the dining area and he/she became out of control with other residents. He/she grabbed another resident's walker and attempted to swing it around. Staff removed the walker from the resident's hands with difficulty. -The resident then proceeded toward another resident and before staff could get to the resident he/she open-handedly slapped the other resident on the right side of the face. -Staff removed the resident from the area and staff did one-on-one (monitoring). -The nurse contacted the necessary nursing home staff and the on call physician; -The physician ordered the PRN [MEDICATION NAME] to be increased to 0.5 mg PO (by mouth)or IM ( in the muscle) every four hours as needed. During an interview on 08/27/13 at 2:45 P.M., CNA D said on 08/17/13, LPN A told us to take the resident to the nurses station so he/she could tend to the resident's skin tears. The resident was still combative and we were still holding him/her. CNA D held the resident's arms while standing behind his/her wheelchair. CNA F held the resident's legs and CNA E held the resident's right arm so the LPN could dress the skin tear. The resident was yelling, screaming and cursing. During a telephone interview 08/28/2013 at 2:12 P.M., CNA E said CNA D wheeled the resident to nurse station. LPN A instructed CNA E to hold the resident's right arm that had two skin tears and CNA D and CNA F held the residents arms and legs. Once LPN A did the treatment, the resident was allowed to self propel his wheelchair around the unit. The resident then wheeled back into common area, grabbed a walker and threatened to hit staff. The staff removed the walker from the resident. The resident then proceeded to slap another resident in the face. During an interview on 8/28/13 at 4:15 P.M., CNA F said:-They got the resident in the wheelchair and took him/her out in the hall to the nurses station. The resident was being verbal at that point but not hitting them;-When LPN A tried putting a bandage on the resident's skin tears, he/she hit at the nurse;-LPN A told staff to hold the resident's arms and legs to prevent him/her from kicking or hitting them;-He/she said the resident was "fighting" against them as they held his/her arms. The resident's skin tear were not horrible;-He/she had never been a situation like that before. Resident #1 was angry and upset;-After LPN A did the treatment, they let him/her go, and he/she propelled up the hall;-He/she thought the resident had calmed down some but he/she hit another resident in the face. During a telephone interview on 08/28/2013 at 2:37 P.M., LPN A said the following: -The aides were "just holding" the resident so he/she could complete the treatment to his/her skin tears, that was when the bruising occurred on the resident's right and left hands/wrists;-He/she let the resident go and allowed the resident to self-propel in his/her wheelchair in the unit. The resident had a "wild look" in his/her eye. - The resident then returned to common area. The resident grabbed another resident's walker and swung it around at the staff. The resident then slapped another resident in the face. -LPN A said he/she did not have any medication to give the resident for the combative behavior. -The DON instructed the LPN to call the physician on call to get directions for agitated behaviors. He/she called the on-call Physician H. The DON wanted the resident sent to the hospital for a shot to "calm" him/her down;-Physician H wanted to know why and that he was not sending the resident to the hospital. Staff could treat the resident at the facility just the same way. LPN A told physician H the resident had routine [MEDICATION NAME] and PRN [MEDICATION NAME]. Physician H gave him/her an order for [REDACTED]. During an interview on 8/30/13 at 9:05 A.M., Physician H, who was on call for the resident's physician said the following:-He orders [MEDICATION NAME] when a resident has an exacerbation of aggressive behaviors that may present as [MEDICAL CONDITION];-He orders the [MEDICATION NAME] for acute episodes of [MEDICAL CONDITION]. The medication dose can be adjusted and given in an emergency situation when behaviors have increased;-[MEDICATION NAME] should not be used as a first treatment option. Staff should try other interventions prior to giving the [MEDICATION NAME];-Basic agitation was not a valid reason for staff to administer [MEDICATION NAME] to resident. -He recalls the staff wanted Resident #1 sent to the hospital, the staff just did not want to deal with the resident; -The nurse did not give him the whole story. He was not aware staff restrained the resident twice. "No wander he/she was agitated." During a interview on 08/29/2013 at 8:30 A. M., LPN J said the following: -On 08/17/2013 at 6:30 P.M., he/she was called to offer care to Resident #1. Upon arrival to unit, RN supervisor asked LPN J to take resident outside. The resident remained calm during visit to courtyard which lasted approximately 30 minutes. -LPN states that he/she saw the skin tears on arms and bruising on his/her hands but did not recall if told the source of injury. -Has worked in the special care unit for three months. -Had received restraint training at the facility by an outside source. -For combative, aggressive residents, redirection, re-approach and removal from other residents would be an appropriate intervention. -LPN stated it would not be appropriate to restrain a resident during a procedure or incontinence care. -Stated he/she had worked with the resident at a previous facility and "knows his/her" behaviors that they can be managed. "It is all in the approach". During a telephone interview 08/28/2013 at 2:12 P.M., CNA E said normally when Resident #1 was agitated, if staff just walked away and left him/her alone, he/she would "calm down." During an interview on 08/26/13, at 1:20 P.M., LPN C said Resident #1 could be calmed down by re-approaching and talking to him/her. During an interview on 8/30/13 at 10:05 A.M., care plan/MDS LPN L said the following:-LPN L said Resident #1 can be "cantankerous" at times but most of the time pretty "mellow";-If staff approached Resident #1 wrong or he/she was anxious, he/she could be combative. Staff should then walk away from the resident and approach him/her at a later time;-He/she was not aware of any previous altercations with the resident, he/she thought things had "toned down". Record review of a document the facility provided to surveyors on 08/27/13, (dated 08/19/13) regarding the incident that took place on 08/17/13 with Resident #1 showed, in part, the following: -LPN A was on duty this weekend when a resident in the memory care unit became agitated and ended up slapping another resident. -Upon looking into the situation, several areas of concern were noted in regards to the LPN's job performance that included the LPN's approach to the resident's behavior was improper. If the charting accurately describes what took place, the LPN should have stopped care with the resident and let him/her calm down. The resident should not have been toileted if he was as resistant as charting indicates. During a telephone interview with LPN A on 08/28/2013 at 2:37 P.M., said the following: -Has worked in the special care unit for one month. -Did not receive any specialized dementia training since employed. -Stated appropriate interventions with an agitated resident would be to leave alone, allow them to self-propel in wheelchair, keep away from other residents, contact family or provide distractions. -LPN A was not aware of the facility policy on when to hold residents. -LPN A was aware that holding a resident was a form of restraint. -The LPN did not contact the resident's physician prior to advising CNAs to hold resident. -LPN A said he/she did not intend for the bruising to occur;-He/she did not intend for the resident to be in an "abusive" situation. He/she was just trying to treat the skin tears. During a telephone interview on 08/28/3013 at 4:45 P.M., Resident #1 spouse said the following; -The staff called and notified him/her of an incident on 08/17/2013. An hour after his/her visit, the resident became upset and slapped another resident. -Staff never notified him/her of bruising, skin tears or that staff had to restrain the resident during the events prior. -The spouse stated the resident does not like to be restrained and felt like other interventions would be preferred before medication is used. -The resident loved gospel music, he/she brought him/her some gospel music and it was in his/her room to help the resident;-In the past the resident would wander up and down the hall and in and out of rooms looking for their son who had passed away. During an interview on 8/29/13 at 9:25 A.M., Physician I said the following:-She works in a medical group and shares the residents and rotation with the Medical Director and another physician.-When staff call the physicians with concerns and updates, she expected them to have the resident's chart and any necessary information readily available so they can give a full report on the resident;-She knew Resident #1 had anti-anxiety medications and medication to treat depression/stimulate his/her appetite;-She was unaware of the incident on 08/17/13; -It is very unusual for staff to restrain a resident. During an interview on 8/29/13 at 10:50 A.M., the administrator and DON said the following:-Regarding the incident that occurred with Resident #1 on 8/17/13:-LPN A reported Resident #1 hit another resident on the special care unit;-The administrator came into the facility on [DATE]. He talked to the staff on the unit as a group about what occurred;-They knew staff notified Resident's #1's spouse of the resident to resident altercation;-DHSS surveyors told the administrator and DON the information received from LPN A, CNA D,E and F during interviews;-The administrator and DON were not aware the four staff physically held/restrained the resident to provide care and perform a treatment;-The administrator and DON were not aware the resident received skin tears and bruising as a result of staff restraining the resident;-The administrator assumed the bruising and skin tears were from prior incidents when the resident had been combative with care;-The administrator and DON spoke with LPN A prior to his/her termination. LPN A said staff did not really "restrain" the resident.-The staff should not have restrained/held the resident for any care and/or treatments;-The staff should have re-approached the resident at later time;-The staff should not have tried to transfer or check the resident for incontinence. They should have stepped away from the situation, re-approached at later time and/or got different staff to approach the resident;-The staff should have report the skin tears and bruising and how they occurred to the resident's spouse;-LPN A should have reported the entire incident to Physician H, including the resident's increased behaviors, resident to resident altercation and staff restraining the resident resulting in skin tears and bruising. During a telephone interview 08/28/2013 at 2:12 P.M., CNA E said the following : -Staff "holding" a resident was not a standard of practice.-CNA E said staff first tried to transfer the resident and he/she became agitated, it would have been appropriate to step away from the resident;-CNA E said there was not a lot of blood coming from the resident's skin tears, just a little. It would have been appropriate to step away from the resident this time as well;-Stepping away and re-approaching the resident had worked in the past; -CNA E has not received any additional education on dementia or holding residents since the 08/17/2013 incident. Observations of the resident from 08/26/13-08/30/13, showed the following: -The resident slept on a low bed with a scooped mattress and bed alarm; -The resident sat in his/her wheelchair with a lap buddy in place; -The resident fed self during meals; -The resident was quiet, spoke to surveyors and seemed pleasantly confused and smiling, interacted with residents and staff with no behaviors noted. -Observed pea sized scabbed area to right elbow and inner right forearm; -Both hands and wrists had multiple bruises purple in color and in varying degrees of healing. 2. Record review of Resident #2's admission MDS assessment dated [DATE], showed the following: -Severely impaired cognitive level; -[DIAGNOSES REDACTED]. -Mood symptoms were not present during screening; -Symptoms identified included physical and verbal behaviors towards others. -Receiving antipsychotic and antidepressant medications; -Requires extensive assistance with activities of ADLs and limited assistance with walking; - No restraints indicated. Record review of Resident #2's June 2013 Physician order [REDACTED]. - On 06/18/2013, an order for [REDACTED]. -On 06/20/2013 [MEDICATION NAME] IM discontinued and changed to [MEDICATION NAME] 0.5 mg PO ( by mouth)1 tab every 6 hours PRN (as needed); -On 06/25/2013 [MEDICATION NAME] 1-2 mg IM PRN every 4 hours for anxiety added to medications. -Resident is not receiving any aspirin or blood thinning medications. Record review of Resident #2's care plan dated 7/29/2013 showed the following; -Requires assist with ADL's due to Alzheimer's; -Resident is combative, resistive to care, wanders, elopement risk;-Staff instructed to redirect, explain all care prior to starting, and do not force the resident to accept care, if he/she and others around him/her were safe, walk away and approach at later time. Record review of nurses notes dated 07/04/2013 showed the following information: -At 12:00 P.M., the resident became agitated, cursing, stomping feet, hitting staff, kicked a trash can and spat on floors and desk. LPN B attempted PO form of [MEDICATION NAME] and the resident refused the medication. LPN B noted [MEDICATION NAME] IM (An anti-anxiety medication)given with the assistance of three staff "to hold" the resident while injection administered in his/her right buttock. LPN B did not document whether staff attempted behavioral modifying interventions prior to administering the [MEDICATION NAME]. -At 1:45 P.M., LPN C documented the resident had bruises on both forearms. LPN C described the bruising as 6.0 centimeter (cm) x 4.0 cm reddish bruise on left forearm and several smaller bruises approximately 2.0 cm reddish bruises on the resident's right forearm. During a telephone interview on 09/03/2013 at 2:15 P.M., LPN B reviewed his/her notes on 07/04/2013, and stated the aides reported the resident was having the same agitated behaviors as the night before.) -Staff removed the resident from other residents and did not pose a threat to others. -The resident was standing up and combative with the injection. -LPN B said the nurse supervisor held one arm and another nurse held the other arm. -When asked if any behavior modifying interventions were used he/she stated "I'm sure we walked away". -He/she did not believe the resident was a danger to himself or hurting others. -LPN B did not obtain consent for holding the resident during the injection from the physician or family member. -LPN B stated he/she had not had any formal training on safe restraint techniques. During an telephone interview on 09/03/2013 at 2:00 P.M. the Director of nursing (DON) said regarding the 07/04/13, incident, she would review the resident's record and check for an incident report. When an incident to a resident occurred, she expected the staff to interview everyone involved, notify her and the family. The DON stated she was not aware of the incident and would need to investigate. Observations on 08/27/13, at 11:47 A.M., showed Resident #2 seated at a dining room table with one other resident and CNA G assisting with the meal. The resident became restless and stood up. CNA G and LPN C applied a transfer belt and allowed the resident to walk. The resident took several steps and then requested his wheelchair to sit. The resident became calm and returned to the table to finish his/her meal. 3. During an interview on 08/27/13 at 2:45 P.M., CNA D said the following: -Has worked at the facility for five months and was only in the unit for a month. -Had done clinical CNA training while in high school that included dementia and peri-care; -He/she had in-services on falls, transfers and customer service; -He/she had no training on combative residents or res

Based on record review, observation and interview the facility failed to consistently assess, monitor and effectively treat moderate pain and signs and symptoms of moderately severe depression for one resident (Resident #9) with a history of anxiety and who had recorded pain from a large pressure ulcer on his/her lower back, drains on each side of the chest and hip joint pain from a past history of a severe right [MEDICAL CONDITION]. Twenty-one residents were sampled out of a facility census of 117. Record review of the facility's Pain-Clinical Protocol, revised April 2007, showed the following information: -Staff will evaluate and report how much and how often an individual asks for prn (as needed) pain medication; -Staff will provide elements of a comforting environment and appropriate and complementary interventions-for example local heat or ice, repositioning, massage and the opportunity to talk about chronic pain; -Staff will assess the individual's pain and consequences of pain every four hours during the day and one time on the night shift for acute (sudden onset) pain or significant changes in levels of chronic pain; -Staff will discuss significant changes in levels of comfort with the attending physician who will adjust interventions accordingly. This may include adjustments of regular and as needed [MEDICATION NAME] doses to find the best combination of effectiveness and tolerable side effects or possible addition of non-pharmacological interventions. According to the American Medical Association AMA (<http://www.ama-cmeonline.com/pdf/ama_painmgmt_04.pdf>) Patients with a substance abuse history are at increased risk of receiving inadequate pain management due to lack of knowledge about addiction, physician barriers including inadequate training in pain management and addiction medicine, and fear of regulatory sanctions contributing to under-treatment. 1. Record review of Resident #9's information sheet, located at the front of the medical record, showed staff admitted the resident to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Record review of the February physician's orders [REDACTED]. -[MEDICATION NAME] (medication used to treat anxiety) 0.5 milligrams (mg) three times a day for anxiety; -Evaluate the resident's pain level, scale 9-10, administer medication; -[MEDICATION NAME] (narcotic pain medication) patch 50 micrograms (mcg)/hour, apply one patch to the skin every 72 hours for pain; -[MEDICATION NAME] ([MEDICATION NAME], a narcotic pain medication) 2 mg, one tablet, every four hours as needed for pain; -[MEDICATION NAME] 1-2 tablets at bedtime as needed for [MEDICAL CONDITION] (sleeplessness); -Tylenol 650 mg every six hours as needed for pain or fever; -Dakin's solution (a mixture of bleach, baking soda and water that kills germs and prevents germ growth in wounds) 0.25% wet to dry dressing to sacral (the triangular-shaped bone at the base of the spine) area; -Denver drain (an indwelling, tunneled catheter to drain fluid from the lungs) drain every 72 hours. Record review of the nurses' notes, dated 02/04/12-02/07/12, showed the following information: -On 02/04/12, at 6:00 P.M., staff admitted the resident to the facility. The resident had a wound to the sacral area that measured 5 centimeters (cm) x 4.5 cm with a depth of 1.5 cm and two Denver drains, one on each side of the chest. Staff observed a scar on the right hip from a previous [MEDICAL CONDITION]; -On 02/06/12, at 10:40 A.M., staff administered [MEDICATION NAME] 1 mg for complaints of pain; -On 02/06/12, at 8:00 P.M., the resident was a "little needy" and may be frightened in a new place. The resident complains of discomfort in his/her leg and buttocks. Staff administered [MEDICATION NAME] for pain control. Record review of the February 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Staff did not document a follow up assessment to ensure the pain medication was effective at relieving the resident's pain. Record review of the initial progress note, completed by a Nurse Practitioner (NP), dated 02/07/12, at 9:29 A.M., showed the following information: -The resident had a large Stage III (full thickness skin loss involving damage or death of subcutaneous tissue that may extend down to but not including the bone) pressure ulcer to the sacrum; -Past medical history included a severe right [MEDICAL CONDITION]; -Other problems included backache, hip joint pain and [MEDICAL CONDITION], drug abuse with dependence, anxiety with depression; -Past surgical history included right hip surgery; -A review of the systems showed the following: Appetite loss, fatigue, feeling sick, back pain, joint pain, joint stiffness, arm and/or leg pain, anxiety, frequent crying, hypersomnia (excessive sleepiness), memory loss, mood swings, nervousness and tension; -A physical exam showed the following: The resident was lethargic/slow, sickly and not depressed. The NP described the resident's mood as sad, not angry and not anxious. The resident had "exquisite" tenderness to touch to the left hip and upper thigh region and had tenderness to the right hip. Record review of the nurses' notes, dated 02/07/12-02/12/12, showed the following information: -On 02/07/12, at 5:30 P.M., when the nurse asked the resident if he/she was in pain, the resident said yes but he/she just had a pain pill. When the nurse asked the resident where the pain was, the resident first said the pain was in his/her chest then he/she said it was in his/her bottom; -On 02/08/12, at 9:55 P.M., the resident denies needs except for more frequent pain medication. The nurse told the resident the physician was aware but was not going to increase his/her pain medications at that time; -On 02/09/12, at 9:55 P.M., the resident had no signs and symptoms of increased pain; -On 02/11/12, at 10:30 P.M., the resident requested the presence of the nurse. The resident wanted to know if he/she was "okay" so he/she could stop worrying and go to sleep; -On 02/12/12, at 8:00 P.M., the resident requested pain medication. The resident continues to worry about his/her on-going care. The resident had anxiety about going to sleep and about his/her care; -On 02/13/12, 2:40 P.M., the resident complained of generalized pain; he/she received [MEDICATION NAME] and [MEDICATION NAME] for pain control; -On 02/13/12, at 9:45 P.M., the resident denied increased pain. Record review of the February 2012 MAR indicated [REDACTED]. Staff did not document a follow up assessment to ensure the pain medication was effective at relieving the resident's pain. Record review of a physician progress notes [REDACTED].M., showed the following information: -Staff report the resident was constantly asking for [MEDICATION NAME] and pain medications. The resident was not sleeping well, was confused and anxious; -Review of the resident's skin showed an enlarging [MEDICAL CONDITION] (large pressure ulcer on the sacrum); -Review of the resident's musculoskeletal system (muscles, tendons, ligaments and bones) showed the resident had back pain and joint stiffness; -Review of the resident's mental and emotional function showed the resident had anxiety; -The physician's plan included a wound clinic referral for the enlarging pressure ulcer and provide comfort measures. Record review of the Minimum Data Set (MDS), a federally mandated comprehensive assessment tool, completed by facility staff, dated 02/14/12, showed the following information: -Cognition severely impaired; -Felt down, depressed or hopeless nearly every day (12-14 days out of 14 days); -Had trouble falling or staying asleep or slept too much nearly every day (12-14 days out of 14 days); -Felt tired or had little energy nearly every day (12-14 days out of 14 days); -Poor appetite or overate nearly every day (12-14 days out of 14 days); -Felt bad about yourself nearly every day (12-14 days out of 14 days); -The resident scored a "15" on the mood interview indicating moderately severe depression; -Required extensive assistance with bed mobility, transfers, dressing and personal hygiene; -[DIAGNOSES REDACTED]. -Had moderate pain almost constantly; -Pain made it difficult for the resident to sleep at night and limited day-to-day activities; -One Stage IV pressure ulcer (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures) ; -Received anti-anxiety medications. Record review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3, dated May 2010, showed Care Areas are triggered by MDS responses and indicate the need for additional assessment. The Care Area Assessment (CAA) process guides staff to look for casual or confounding factors, some of which may be reversible. The assessment of the causes and contributing factors gives the interdisciplinary team additional information to help them develop a comprehensive plan of care. The care plan then addresses these factors, with the goal of promoting the resident's highest practicable level of functioning. Record review of the CAA summary for the admission MDS, dated [DATE], showed the following information: -The resident was admitted with two Denver drains but the left one was recently removed; -Mood: The resident has an anxiety disorder, is taking anti-anxiety medication three times a day and scored "15" (moderately severe depression) on the mood interview. The resident says he/she is down and depressed because he/she knows he/she will never get any better. The resident was previously on an antidepressant while at the hospital. Will refer the resident to the NP regarding possible need for antidepressant medication; -Medications: The resident is taking an anti-anxiety medication three times a day, yet per physician's progress note is constantly asking for more medication. The resident scored very high on the mood interview and has been referred to the NP for possibility of needing an antidepressant. The resident is a smoker but had not smoked since admission and this is probably adding to his/her anxiety; -Pain: The resident said he/she had constant moderate pain during the interview. The resident said the pain is in his/her leg caused by a recent femur fracture. The resident has a [MEDICATION NAME] and as needed [MEDICATION NAME] which he/she is taking two-three times a day. The resident continues to ask for more pain medication per the 02/13/12 physician's progress note. The resident's persistent pain may be due, in part, to depression (see mood CAA). Will care plan to reduce pain to an acceptable level. Record review of the nurses' notes, dated 02/14/12-02/19/12, showed the following information: -On 02/14/12, at 4:10 A.M., the resident was upset with the nurse for not sitting with him/her. The nurse explained that he/she would be glad to sit with the resident if he/she had any free time. The resident said his/her pain is never under control but states "no" when asked if it was any worse. The resident was very upset and said we need to think about his/her needs; -On 02/15/12, at 5:55 P.M., the resident is not calm or pleasant and is difficult for staff to help. Staff reported to the nurse the resident said he/she could see through his/her skin and see his/her pain and staff could not see his/her pain. The resident wanted staff to cut a hole in the wall so he/she could see through it. The resident is constantly requesting pain and anti-anxiety medication; -On 02/15/12, at 11:35 P.M., the resident was asking the nurse again why he/she could not have more pain medication and more [MEDICATION NAME]; -On 02/16/12, at 9:35 P.M., the resident continues to complain of all over pain and said he/she just wanted someone to stay with him/her; -On 02/19/12, at 8:30 P.M., the resident requested pain medication and voiced concerns about not sleeping. The nurse talked with the resident about his/her concerns and promised to check on the resident throughout the night. The resident calmed down and closed his/her eyes. Record review of the February 2012 MAR indicated [REDACTED]. Staff did not document if the pain medication was effective at relieving the resident's pain. Record review of the care plan, dated 02/20/12, showed the following information: -Required assistance with bathing, dressing, hygiene and mobility due to weakness; -Monitor for pain and treat; -Alteration in mood due to resident stating he/she was depressed and has an anxiety disorder; -Provide one-on-one visits; -Administer medication as ordered; -Invite to activities but be aware the resident tires easily and cannot tolerate being up for long; -Establish a relationship of trust; -Treat the resident as an equal and allow him/her to make as many of his/her own decisions as he/she can; -Alteration in comfort: Pain related to right leg pain after fracture, arthritis and Stage IV pressure ulcer; -[MEDICATION NAME] as ordered; -Monitor for breakthrough pain and administer as needed pain medication; -Monitor effectiveness of pain medication; -Monitor for depression; -Instruct the resident to report pain on onset. Record review of the February 2012 MAR indicated [REDACTED]. Staff did not document a follow up assessment to ensure the pain medication was effective at relieving the resident's pain. During an interview conducted on 02/23/12, at 10:25 A.M., the resident said he/she has moderate pain almost constantly in his/her back. Staff administers pain medication if the physician says it is okay. The resident said the pain medication does not really help the pain. An observation and interview on 02/23/12, at 11:15 A.M., Certified Nurse Aide (CNA) O and CNA S entered the resident's room to provide cares. The aides rolled the resident onto his/her left side and when the aides rolled the resident onto his/her back the resident yelled out, "Ouch, ow ow", and placed his/her hands over the dressing located on the resident's lower back (sacrum). CNA O asked the resident where he/she hurt and the resident said his/her back; the resident's hand remained on the dressing, on his/her lower back (sacrum). When CNA O and CNA S rolled the resident onto his/her right side the resident yelled out, "Ow, ow, ow", and placed his/her hand over the dressing covering the Denver drain, located on the upper right side of his/her chest. CNA O asked the resident if he/she wanted a pain pill and the resident said, yes. CNA O said they (the aides) would let the nurse know the resident wanted a pain pill. The aides completed the resident's cares and left the room. An observation on 02/23/12, at 11:30 A.M., showed Licensed Practical Nurse (LPN) T and CNA O enter the resident's room to change the resident pressure ulcer dressing. Record review of the February 2012 MAR indicated [REDACTED].M. approximately one hour and 15 minutes from the time the resident requested the pain medication. During an interview conducted on 02/28/12, at 9:26 A.M., CNA O said the resident has pain in his/her bottom (sacrum) and often asks for pain medication; sometimes the pain medication works, sometimes it does not. Sometimes the resident will ask for pain medication and when staff re-enter the room, the resident is asleep. Sometimes the resident has pain with cares and yells out, other times he/she does not, or at least does not say anything about pain. The resident does seem anxious at times, and requests a lot of staff attention. During an interview conducted on 02/28/12, at 10:25 A.M., the Director of Nursing (DON) said the resident has had substance abuse issues in the past and the physician said he was not going to increase the resident's pain medications. The resident always asks for pain medications but the DON was not sure how often. The DON said the resident does have periods of relief; the nights the DON came to the facility the resident was asleep. The resident is more restless after dressing changes and cares. During an interview conducted on 02/28/12, at 11:15 A.M., the NP said she saw the resident on 02/07/12 and on 02/13/12. The resident is an addict. The NP said the physician had taken care of the resident for years. The NP thought the resident used to have pain. She thinks the resident has anxiety and it is hard to know if it is anxiety or pain. The resident used to take an antipsychotic; the NP will ask the physician if he wants the resident to resume taking an antipsychotic. The NP said she did not doubt the resident had pain but it is a fine line between caring for his/her pain and sedating him/her. The resident is hard to read, therefore, it is hard to know if he/she really is having pain. During an interview conducted on 02/28/12, at 1:17 P.M., Registered Nurse (RN) U said he/she uses the 1-10 pain scale, when assessing residents' pain, and documents the assessment on the back of the MAR. The RN completes a medication follow-up about an hour after staff administers the medication and documents the results on the back of the MAR. During an interview conducted on 02/28/12, at 1:20 A.M., the DON said staff assesses cognitively intact residents' pain by visual indicators. For residents with dementia, staff assesses the residents' pain using non-verbal cues. Staff document by exception and will document, in the nurses' notes, if the resident has pain. Some staff documents a pain score, but other staff does not but all staff documents medication follow-ups on the back of the MAR.

Based on observation, record review, and staff interview, the facility failed to provide adequate feeding assistance and offer food substitutes for one resident (Resident #14), who had a 33.5 pound or 17.6% weight loss in six months, a 12.2 pound or 7.2% weight loss in three months and an 11.9 pound or a 7.2% weight loss in one month, in a selected sample of 21 residents. The facility's census was 117. 1. Record review of Resident #14's admission information, located at the front of the medical record, showed the resident [DIAGNOSES REDACTED]. Record review of the weight change report, dated 08/24/11, showed staff documented the resident weighed 190 pounds. Record review of a dietary consult/assessment report, completed by the dietitian, 12/23/11, showed in the last 30 days, the resident often had poor intake of meals which was a nutritional concern. Continue efforts to provide much encouragement to eat well and offer alternatives for dislikes. Record review of the weight change report showed the following information: -On 12/27/11 staff documented the resident weighed 168.7 pounds; -On 01/03/12 staff documented the resident weighed 164.8 pounds. During an interview on 02/27/12, at approximately 11:30 A.M., the Director of Nursing (DON) said the resident lived on the special care unit. Staff moved the resident to his/her current room on 01/05/12. Record review of the annual MDS, dated [DATE], showed the following information: -Severely impaired cognition; -Disorganized thinking, fluctuated (comes and goes); -Required extensive assistance with bed mobility, transfers, dressing and personal hygiene; -Required limited assistance for eating; -[DIAGNOSES REDACTED]. -Weighed 165 pounds; -No weight loss; -Received a mechanically altered diet (change in texture of food, for example pureed food or thickened liquids). Record review of the care plan, last updated 01/07/12, showed the following information: -The resident has difficulty chewing/swallowing, poor intake and had lost weight; -Provide No Concentrated Diet as ordered; -Moist pureed food, nectar-thickened liquids; -Monitor and document intake; -Monitor weight; -Dietary consult; -Alternate food and fluids; -Remind the resident to eat slowly and take small bites; -Remind the resident to hard swallow; -Encourage the resident to drink all of his/her fluids on the meal tray. Record review of the weight change report showed the following information: -On 01/24/12 staff documented the resident weighed 168.4 pounds; -On 02/01/12 staff documented the resident weighed 164 pounds; -On 02/08/12 staff documented the resident weighed 159.5 pounds; -On 02/16/12 staff documented the resident weighed 157 pounds. Record review of a dietary note, dated 02/19/12, showed the resident receives a pureed, consistent carbohydrates diet with nectar thickened liquids. The resident received flavored fortified milk three times a day and sugar-free super pudding with lunch and dinner. The resident is consuming 31% of his/her meals. Record review of a Nurse Practitioner's (NP) progress note, dated 02/21/12, showed over the past month the resident's weight had decreased from 168.4 pounds to 157 pounds. Staff recently reported the resident was lethargic and not doing well with meals. [MEDICATION NAME] (an antipsychotic medication) was tapered and ultimately discontinued today. Staff reports the resident's appetite and intake had started to improve. Observations of the breakfast on 02/22/12 showed the following: -At 8:43 A.M. the resident sat in his/her wheelchair, at a table in the sub-station (a small common area, located on the resident's hall, used for meals and activities). Eight residents sat at two square dining room tables. Certified Nurse Aide (CNA) V sat between the resident and another resident assisting both of them with their meals. CNA W sat on the opposite side of the table assisting two other dependent residents with their meals; -At 8:52 A.M. the resident told CNA V he/she needed to go. CNA W left the table, entered a resident's room then asked CNA V for assistance. CNA V told CNA W to find someone to assist because he/she did not want the resident to leave the table. CNA V gave the resident a bite then moved to the opposite side of the table and assisted the other two dependent residents; -At 8:56 A.M. the resident backed his/her wheelchair away from the table. CNA V left the sub-station, entered a resident's room and returned carrying a meal tray; -At 9:00 A.M. CNA V sat next to the resident and asked if he/she was hungry. The resident said no. CNA V wheeled the resident closer to the dining table and fed him/her a bite; -At 9:03 A.M. CNA V left the table to assist a resident at the other table. The resident, again, backed his/her wheelchair away from the table. CNA V sat next to the resident and fed him/her a bite. CNA V continued to be the only staff member in the sub-station; -At 9:04 A.M. CNA V moved to the opposite side of the table and assisted the other two dependent residents; -At 9:05 A.M. the resident took drinks of his/her milk and juice unassisted. The resident did not take bites of food unassisted. As CNA V sat down next to the resident, a resident at the other table asked for assistance; CNA V left the tale and assisted him/her; -At 9:10 A.M. CNA V sat next to the resident and gave him/her a bite. The resident backed his/her wheelchair away from the table. CNA V asked the resident where he/she was going and the resident said he/she needed to go. CNA V told the resident he/she needed to take a drink before he/she left. The resident picked up the juice and took a drink; -At 9:12 A.M. CNA W returned to the sub-station and assisted two residents with their meals. CNA V fed the resident a bite. The resident backed his/her wheelchair away from the table. CNA V wheeled the resident closer to the table and gave him/her a bite. CNA V then asked the resident, "are you done eating?" The resident nodded his/her head yes. The CNA did not encourage the resident to eat and did not ask the resident if he/she wanted a substitute. CNA V removed the resident's clothing protector and the resident wheeled away from the table. The resident ate some bites of his/her eggs and hot cereal, and drank half of his/her milk, juice and coffee. During an interview conducted on 02/22/12, at 9:20 A.M., CNA V said it is sometimes difficult to feed the resident when we have to answer call lights. Record review of the weight change report, dated 02/23/12, showed staff documented the resident weighed 156.5 pounds (a 33.5 pound or 17.6% weight loss in six months, a 12.2 pound or 7.2% weight loss in three months and an 11.9 pound or a 7.2% weight loss in one month). Observations of breakfast on 02/24/12 showed the following: -At 8:37 A.M. staff had already served the resident's breakfast, consisting of pureed egg and sausage, a bowl of hot cereal, a small bowl of pureed fruit, a small bowl of pudding, a glass of water and a glass of milk, and placed it on the dining room table in front of the resident. The resident sat in his/her wheelchair, approximately three feet from the dining room table. A staff member asked the resident what he/she was doing then pushed him/her closer to the dining room table and walked away. The resident again pushed his/her wheelchair away from the table. CNA X pushed the resident closer to the dining room table then walked away. CNA Y said the resident keeps pushing away from the table. As CNA Y assisted other residents, the resident pushed away from the dining room table. CNA Y pushed the resident closer to the table and gave him/her a glass of water. The resident took a drink, placed the glass on the table then back away from the table; -At 8:45 A.M. CNA Y sat next to the resident and asked him/her if he/she wanted a bite of cereal. The resident said no. The CNA then asked the resident if he/she wanted a bite of eggs. The resident shook his/her head no. The CNA scooped a small amount of hot cereal on a spoon and fed it to the resident without difficulty; -At 8:47 A.M. CNA Y left the table to answer a call light. The resident took a drink of water then scooted himself/herself away from the table; -At 8:49 A.M. CNA Y returned to the table and gave the resident a bite. The resident ate a few more bites and when the CNA attempted a third bite the resident shook his/her head "no." CNA Y gave the resident a glass of water and asked if he/she wanted another bite. The resident said no. The CNA left the table; -At 8:53 A.M. the resident drank water and milk, unassisted, and backed away from the table; -At 9:04 A.M. as CNA Y cleared the resident's plate, bowls and glasses from the table he/she asked the resident if he/she wanted these, pointing to the dishes. The resident said no. CNA Y placed the dishes on the tray cart. The resident took a drink and again backed away from the table. The resident only ate bites of his/her cereal, sausage and eggs and drank about half of his/her milk. The CNA did not encourage the resident to eat and did not ask the resident if he/she wanted a substitute. Observations of the noon meal on 02/24/12 showed the following: -At 12:38 A.M. CNA X wheeled the resident to the dining room table; -At 12:42 P.M. staff served the resident his/her meal tray which consisted of pureed fish, coleslaw, okra, dessert and a glass of flavored milk and a glass of juice; -At 12:43 Licensed Practical Nurse (LPN) B asked CNA X if staff fed the resident. CNA X said yes. LPN B sat next to the resident and assisted him/her with the meal; -At 12:55 P.M. LPN B asked the resident if he/she wanted a bite, the resident said no. LPN B asked the resident if he/she was full. The resident said yes. LPN stood up, removed the resident's clothing protector and left the dining room. The resident ate bites of fish, okra and dessert and drank about a third of the juice and flavored milk. The LPN did not encourage the resident to eat and did not ask the resident if he/she wanted a substitute. Observations of the evening meal on 02/27/12 showed the following: -At 5:20 P.M. dietary staff delivered the hall trays to the sub-station. The resident scooted back from the table; -At 5:23 P.M. staff started passing trays to residents in their rooms; -From 5:20-5:51 P.M. the resident was restless and attempted to leave the table several times. Each time the resident scooted away from the table, staff would push him/her closer to the table and say it was almost time to eat; -At 5:51 P.M. staff served the resident his/her meal. CNA AA said the resident had a glass of flavored milk, a glass of water, pureed salad, pureed chicken, super pudding, bread and a small bowl of something he/she could not identify. The CNA then walked away; -From 5:51 P.M.-6:05 P.M. the resident sat at the table and occasionally, unassisted, took a drink of his/her fluids. The resident did not attempt to take a bite of his/her food; -At 6:05 P.M. CNA AA gave the resident his/her first bite of the evening meal; -From 6:05-6:12 P.M. CNA AA assisted the resident and another resident to eat; -At 6:12 P.M. the resident pushed his/her wheelchair away from the table. CNA AA said stay here while we feed, okay? The CNA gave the resident a bite then left the table to assist another resident; -From 6:14 P.M.-6:22 P.M. CNA Z assisted the resident to eat; -At 6:22 P.M. CNA Z left the table to assist another resident. The resident pushed his/her wheelchair away from the table. CNA BB asked the resident if he/she was done eating then handed him/her the glass of water. The resident did not answer; -At 6:24 P.M. CNA BB again asked the resident if he/she was done. The resident said yes; -At 6:28 P.M. the resident left the table and wheeled himself/herself down the hall. The resident ate bites of salad, chicken, pudding and bread and drank half of the milk and juice. The CNA did not encourage the resident to eat and did not ask the resident if he/she wanted a substitute. During an interview conducted on 02/28/12, 10:25 A.M., the DON said she expected staff to serve the meal trays as soon as possible. Staff should pass the hall trays first then serve the residents in the dining area. When assisting a resident to eat, staff should sit next to the resident and explain what the resident is eating. If a resident is not eating well, the DON expects staff to ask the resident if he/she would like a substitute.