Every finding on record at Westgate Gardens Care Center

Based on interview and record review, the facility failed to follow their policy and procedure when a refund was not issued to one of three sampled residents (Resident 1) within 30 days. This failure resulted in a delay in Resident 1's refund.Findings:During a review of Resident 1's Transaction Record (TR) dated 7/27/26, the TR indicated, Total due from share of cost (SOC).amount. (1,791.00) (indicating a credit balance) .During an interview on 7/27/26 at 11:17 a.m. with Business Office Manager (BOM), BOM stated Resident 1 paid the SOC in the amount of $1791.00 during the month of October 2025 to cover his Medicare (federal health insurance program) co-insurance cost. BOM stated Resident 1's co-insurance cost was paid by his Medicare supplement, and the check was received by the facility on 12/17/25. BOM stated when the co-insurance check was received the facility was trying to figure out if it was a true refund or if the insurance had made a mistake. BOM stated the facility waited way to long and the refund should have been sent within 30 days.During a review of the facility's policy and procedure (P&P) titled, Accounts Receivable Refund or Credit Balances dated 10/20/25, the P&P indicated, The facility Business Office is responsible for identifying and over payment on accounts. Once the refund is identified, the maximum time to complete the process is thirty (30) days (or in accordance with State guidelines).

Based on observation, interview, and record review the facility failed to ensure care plan was implemented for one of three sampled residents (Resident 1) when Resident 1 request for No Male Certified Nursing Assistant (CNA) to provide care. This failure resulted in violation of Resident 1's rights and potential for emotional harm.Findings:During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated, Focus RESIDENT IS REQUESTING NO MALE CNAS. Goal REQUEST WILL BE MET. Intervention FEMALE CNAS TO PROVIDE CARE.During a concurrent observation and interview on [DATE] at 11:28 a.m. in Resident 1's room, Resident 1 was sitting in a wheelchair. Resident 1 stated a male staff had gone in her room in the middle of the night and provide care for her. Resident 1 stated, I don't like men around me.During an interview on [DATE] at 1:04 p.m. with Director of Nurses (DON), DON stated CNA 1 (male staff) had provided care for Resident 1 on [DATE] and [DATE].During a concurrent interview and record review on [DATE] at 12:25 p.m. with DON, DON reviewed Resident 1's CPR, dated [DATE]. DON stated Resident 1's CPR indicated NO MALE CNAS were to provide care. DON stated CNA 1 shouldn't have provided care for Resident 1.During an interview on [DATE] at 12:31p.m. with Director of Staff Development (DSD), DSD stated CNA 1 shouldn't have been assigned [to Resident 1].During an interview on [DATE] at 4:28 p.m. with CNA 1, CNA 1 confirmed working with Resident 1 on [DATE] and [DATE] as well as I had worked with her [Resident 1] ever since she was admitted [[DATE]].During a review of the facility's policy and procedure (P&P) titled Resident's Rights, dated [DATE], the P&P indicated Policy Interpretation and Implementation . 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated [DATE], the P&P indicated Policy Interpretation and Implementation . 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to . g. receive the services and/or items included in the plan of care .

Based on interview and record review, the facility failed to ensure confidentiality for one of two sampled residents (Resident 1) when the wrong Physician Orders for Life-Sustaining Treatment (POLST-form contains full name, birthdate, and treatment preference) was printed and given to Emergency Medical Services (EMS). This resulted in violation of Resident 1's rights.Findings:During an interview on 4/6/26 at 8:04 a.m. with Resident 2's Responsible Party (RP), RP stated on 3/24/26 during the process in transferring Resident 2 to the acute hospital, Licensed Vocation Nurse (LVN) had given EMS the wrong residents POLST form. Resident 2's RP stated the POLST given to EMS was for Resident 1 and not for Resident 2.During an interview on 4/9/26 at 11:40 a.m. with LVN, LVN stated on 3/24/26 during the process in transferring Resident 2 to the acute hospital, a copy of Resident 2's POLST form was requested and received from Medical Records Assistant (MRA). LVN stated she did not verify the POLST form was for Resident 2 before giving it to EMS. LVN stated she was not aware the POLST received from MRA was for Resident 1 and not for Resident 2.During an interview on 4/14/26 at 1:22 p.m. with MRA, MRA stated on 3/24/26 LVN had requested a copy of Resident 2's POLST. MRA stated Resident 1 and Resident 2 shared the same last name and had given LVN Resident 1's POLST instead of Resident 2. MRA stated, Yes the wrong POLST was given.During a review of the facility's Policy and Procedures (P&P) titled, Confidentiality of Information and Personal Privacy, undated, the P&P indicated, 1. The facility will safeguard the personal and confidentiality of all residents personal and medical records.

Based on interview and record review, the facility failed to provide a clean mattress for one of six sampled residents (Resident 1). This resulted in Resident 1 sleeping on a stained mattress and potential for skin irritation and respiratory issues.Findings:During an interview on 2/17/26 at 10:39 a.m. with Licensed Vocational Nurse (LVN), LVN stated on 2/8/26 Resident 1's Low Air Flow mattress (a therapeutic medical device) had a dark, brown circle stain. LVN stated the mattress stain did not look appealing. it should have been changed.During an interview on 2/17/26 at 11 a.m. with Director of Nurses (DON) and Director of Housekeeping (DOH), DON and DOH reviewed a photo of Resident 1's mattress taken on 2/8/26. DON and DOH confirmed Resident 1's mattress had a dark brown stain. DON and DOH stated the mattress should have been removed and replaced.During a review of the facility's policy and procedure (P&P) titled, Homelike Environment dated 2001, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for cognition (a mental process of knowing and understanding) for one of three sampled residents (Resident 1) who had impaired cognition. This failure had the potential for staff unaware of Resident 1's cognitive impairment and not having his needs met.Findings:During a review of Resident 1's admission Record, dated 12/23/2025, the admission Record indicated Resident 1 has diagnoses of Parkinson's Disease (brain disorder that slows you down and makes you shake) and panic disorder (recurring, unexpected, sudden, and intense episodes of fear with physical symptoms like a racing heart, shortness of breath, and dizziness, often feeling like a medical emergency). During a review of Resident 1's Brief Interview for Mental Status (BIMS- a quick, 15-point test used in nursing homes to get a snapshot of someone's thinking and memory by asking them to recall words, identify the date/place, and remember those words later, helping staff spot potential cognitive decline and know when to get a doctor involved), dated 11/17/25, the BIMS indicated Resident 1's score is 3 (score of 0-7 means severe cognitive impairment). During a concurrent interview and record review on 12/22/25 at 3:03 p.m. with Director of Nursing (DON), DON reviewed Resident 1's care plan. DON stated due to his cognitive impairment, a care plan should be developed to set care for him which helps set specific goals and interventions. DON stated there was no care plan developed for Resident 1's cognitive impairment. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person- Centered, dated March 2022, the P&P indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.includes measurable objectives and timeframes.maintain the resident's highest practicable physical, mental, and psychosocial (mind/emotions) well-being.Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on interview and record review, the facility failed to notify the Attending Physician (AP) for one of three sampled residents (Resident 1) when Resident 1's scheduled dialysis (a medical procedure that filters the blood of a person whose kidneys are not functioning properly) treatment was missed. This failure had the potential for fluid retention and adverse outcome. Findings:During a review of Resident 1's admission Record (AR), dated 7/2025, the AR indicated Resident 1 had a diagnosis of End Stage Renal Disease (irreversible kidney failure) . Resident 1's Order Summary Report (OSR), dated 7/2025 indicated, Hemo Dialysis thru LUE (Left Upper Extremity) at (dialysis center name) on T (Tuesday), TH (Thursday), SAT (Saturday) at 0400 AM till 0700 AM.During a review of Resident 1's Progress Notes (PN), dated 7/26/25 at 9:56 a.m., the PN indicated, . Dialysis. Resident (Resident 1) did note [sic] attend r/t (related to) transport did not come pick up resident.During a concurrent interview and record review on 8/5/25 at 1:34 pm. with Director of Nurses (DON), DON reviewed Resident 1's clinical records and confirmed Resident 1 did not go to his scheduled dialysis treatment on Saturday 7/26/25. DON stated, He (Resident 1) didn't attend that day.During an interview on 8/5/25 at 3:17 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 did not go to his scheduled dialysis treatment on Saturday 7/26/25. LVN 1 stated it was the facility practice to notify the AP of any missed dialysis treatment. LVN 1 stated she had reviewed Resident 1's clinical records and found no evidence of his AP being notified of the missed dialysis treatment on 7/26/25.During an interview on 8/5/25 at 3:47 p.m. with LVN 2, LVN 2 stated she did not notify Resident 1's AP of his missed scheduled dialysis treatment on Saturday 7/26/25. LVN 2 stated, I didn't know he (Resident 1) didn't get picked up at all.During an interview on 8/5/25 at 4 p.m. with Registered Nurse (RN), RN stated it was the facility practice to notify the residents AP of any missed dialysis treatment.During an interview on 8/7/25 at 9:08 a.m. with Director of Nurses (DON), DON stated the expectation was for the nurses to notify the AP for missed dialysis treatment. DON confirmed Resident 1's AP was not notified of the missed dialysis treatment.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/21, the P&P indicated, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; . A significant change of condition is a major decline or improvement in the resident's that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self limiting); a. impacts more than one area of the resident's health status:

Based on interview and record review, the facility failed to ensure transportation was provided for one of three sampled residents (Resident 1). This failure resulted in Resident 1 missing hemodialysis treatment (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and potential for serious health risks and even death.Findings:During a review of Resident 1's admission Record (AR), dated 7/2025, the AR indicated Resident 1 had a diagnosis of End Stage Renal Disease (irreversible kidney failure) . Resident 1's Order Summary Report (OSR), dated 7/2025 indicated, Hemo Dialysis thru LUE (Left Upper Extremity) at [dialysis center name] on T (Tuesday), TH (Thursday), SAT (Saturday) at 0400 AM till 0700 (AM).During a review of Resident 1's Progress Notes (PN), dated 7/26/25 at 9:56 a.m., the PN indicated, . Dialysis. Resident (Resident 1) did note [sic] attend r/t (related to) transport did not come pick up resident.During a concurrent interview and record review on 8/5/25 at 1:34 pm. with Director of Nurses (DON), DON reviewed Resident 1's clinical records and confirmed Resident 1 did not go to his scheduled dialysis treatment on Saturday 7/26/25. DON stated, He (Resident 1) didn't attend that day.During an interview on 8/5/25 at 3:17 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 was scheduled for dialysis every Tuesday, Thursday, and Saturday. LVN 1 stated transportation company was not notified when Resident 1 was not picked up for his scheduled dialysis treatment on Saturday 7/26/25. LVN 1 stated it was the facility practice to notify transportation to find out what happened. LVN 1 stated Resident 1 missed his scheduled dialysis treatment on Saturday 7/26/25.During an interview on 8/5/25 at 3:47 p.m. with LVN 2, LVN 2 stated she did not notify the transportation company when Resident 1 was not picked up for his scheduled dialysis treatment on Saturday 7/26/25. LVN 2 stated Resident 1 had missed his scheduled dialysis treatment on Saturday 7/26/25. LVN 2 stated, I didn't know he (Resident 1) didn't get picked up at all.During an interview on 8/7/25 at 9:08 a.m. with Director of Nurses (DON), DON stated the expectation was for the nurses to notify transportation company why they didn't pick up Resident 1 for his scheduled dialysis treatment. DON confirmed transportation company was not notified.During a review of the facility's policy and procedure (P&P) titled, Transportation, Social Services, dated 12/08, the P&P indicated, Our facility shall help arrange transportation for residents as needed.

Based on interview and record review, the facility failed to follow their own policy and procedure for one of three sampled residents (Resident 1) when a gait belt was not used for a transfer. This failure resulted in Resident landing on her bed face down.Findings:During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 6/20/25, the MDS indicated, Functional Abilities.chair/bed-to-chair transfer.03 (Partial/moderate assistance-helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.During a review of the Facility Reported Event (FRE) dated 6/24/25, the FRE indicated, Describe incident: During a transfer the resident expressed that the CNA (Certified Nursing Assistant) and LVN (Licensed Vocational Nurse) had a rough transfer.Full investigation was completed and CAN (sic) and LVN did not transfer the resident appropriately.During a review of Resident 1's Progress Notes (PN) dated 6/24/25 at 9:32 a.m., the PN indicated, Resi (Resident) told LN (Licensed Nurse) that around 03:30 AM today a LN (Licensed Vocational Nurse) & CNA were rude with her. Did not transfer her correctly due to which she landed from w/c (wheelchair) into her bed face down.During an interview on 7/1/25 at 3:22 p.m. with Social Services Director (SSD), SSD stated Resident 1 reported that during a transfer from her wheelchair to the bed she stumbled and fell on the bed.During an interview on 7/1/25 at 3:46 p.m. with Director of Staff Development (DSD), DSD stated when she interviewed CNA 1 regarding the transfer, CNA 1 reported she had transferred Resident 1 from her wheelchair to the bed and during the transfer Resident 1 was wobbly and had to be assisted to turn her hips and sit on the bed. DSD stated CNA 1 was not using a gait belt to transfer Resident 1 and performed an inappropriate transfer.During an interview on 7/1/25 at 4:04 p.m. with Director of Nursing (DON), DON stated when Resident 1 was being transferred a gait belt was not used and Resident 1 flopped on the bed. DON stated a gait belt should have been used per policy when transferring Resident 1. During a review of the facility's policy and procedure (P&P) titled Transfer Assistance undated, the P&P indicated, Transfer from wheelchair to the bed.Place the gait belt snugly around the resident's waist to allow for both of your hands to fit beneath the belt.Assist to raise the resident, slightly, then to a standing position.If you are unable to raise the resident to a standing position, call for a second person to assist. The second person may assist form the back, or with one person assisting on each side of the resident.Assist the resident first to a sitting position on the side of the bed then to a comfortable lying position and remove the gait belt.During a review of the facility's policy and procedure (P&P) titled Gait Belt Policy and Procedure undated, the P&P indicated, It is the policy to always use a gait belt with any resident that is not completely independent. If the resident is unsteady with their gait or unable to transfer them, a gait belt should always be used. There is no exception to this rule.

Based on interview and record review, the facility failed to implement the care plan for one of five sampled residents (Resident 4) when staff witnessed Resident 4 invading Resident 5's personal space looking angry and aggressive and did not intervene. This failure resulted in Resident 4 cussing at and hitting Resident 5 on the left leg. Findings: During a review of Resident 4's Care Plan (CP) dated 11/26/24, the CP indicated, Has episodes of being verbally abusive behaviors r/t (related to) poor impulse control.Interventions/Tasks.gentle redirection when applicable. During a review of Resident 4's Minimum Data Set (MDS - a standardized, comprehensive assessment tool to evaluate the status of residents) dated 4/8/25, the MDS indicated, BIMS (Brief Interview for Mental Status - used to assess knowledge, manipulation of information, and reasoning with score ranging from 0 - 15. The higher the score the more intact the resident's cognition is) Summary Score.09 (moderately impaired cognitive status) .Behavior Symptom - Presence & Frequency.Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others).1 (behavior of this type occurred 1 to 3 days).Impact on others.Significantly intrude on the privacy or activity of others.1.Significantly disrupt care of living environment.1. During a review of Resident 4's S (Situation) B (Background) A (Appearance) R (Review and Notify) dated 6/10/25 at 2 p.m., the SBAR indicated, Writer made aware by CNA's (Certified Nursing Assistant) that resident was being verbally & physically abusive towards roommate [Resident 5]. Writer made aware that resident was cussing, slapping her roommate's legs and throwing her belongings on the floor. During a review of Resident 5's Progress Notes (PN) dated 6/10/25 at 6:21 p.m., the PN indicated, Writer made aware by CNA's that resident's roommate [Resident 4] was being verbally & physically abusive towards them. Writer made aware that roommate was cussing, slapping the resident's legs, and throwing the resident's belongings on the floor. During a review of Resident 5's MDS assessment dated [DATE], the MDS indicated, BIMS (Brief Interview for Mental Status-used to assess knowledge, manipulation of information, and reasoning) Summary Score.99 (resident was unable to complete the interview) . During an interview on 6/11/25 at 11:12 a.m. with CNA 1, CNA 1 stated on 6/10/25 she was providing care to a resident when CNA 2 came into the room and said Resident 4 was getting close to Resident 5 and something was going on in the room. CNA 1 stated when she arrived in Resident 4 and Resident 5's room, Resident 5 was laying in bed and Resident 5's blankets were on the floor and her flowers had been put in the trash can. Resident 4 was cussing at Resident 5 and hit her leg. CNA 4 stated Resident 5 was sleeping and hugging her baby doll. CNA 1 stated Resident 4 had acted like this before and she doesn't like Resident 5 laying in bed. CNA 1 stated Resident 4 is always yelling at Resident 5 to get out of the room and gets really upset. During an interview on 6/11/25 at 11:12 p.m. with CNA 2, CNA 2 stated on 6/10/25 as she was passing by Resident 4 and Resident 5's room, she witnessed Resident 4 in Resident 5's space looking aggressive and angry. CNA 2 stated she did not go near Resident 4 or Resident 5 but went to the next room and told CNA 1. During an interview on 6/11/25 at 2:08 p.m. with Director of Nursing (DON), DON stated when CNA 2 was walking by the room and seen Resident 4 in Resident 5's space she should have intervened right away and removed Resident 5 from a stressful situation. During a review of the facility's policy and procedure (P&P) titled, Behavior Management dated 12/31/15, the P&P indicated, It is the policy of this Center to make reasonable efforts to ensure when a resident displays mental or psychosocial adjustment difficulties, that he/she receives appropriate treatment and services to address the identified problem(s).Behavioral interventions are individualized non-pharmacological approaches (including direct care or activities) that are provided as part of a supportive physical or psychosocial environment directed toward preventing, modifying, and/or relieving a resident's distressed behavior.

Based on interview and record review, the facility failed to implement its own policy when an allegation of abuse for one of three sampled residents (Resident 1) was not reported to Ombudsman, law enforcement, and state licensing agency. This failure had the potential to put residents at risk for abuse. Findings: During a review of the admission Record (AR) dated 6/12/25, the AR indicated, Resident 1 was admitted on [DATE] with the following diagnoses.metabolic encephalopathy (brain dysfunction due to metabolic [chemical changes that take place in a cell or an organism] disorder).dementia (impairment of at least two brain functions, such as memory loss and judgement).hemiplegia (paralysis on one side of the body) and hemiparesis ( muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (blood flow to the brain is blocked, causing brain tissue to die) affecting right dominant side. During a review of Resident 1's Cognitive Patterns (CP) dated 3/24/25, the CP indicated, Brief Interview for Mental Status (BIMS assesses cognitive status with scores ranging from 0 - 15, with the higher the score the more intact the resident's cognitive status is).08 (indicating moderate cognitive [mental process involved in knowing, learning, and understanding things] impairment) . During a review of Resident 1's Progress Notes (PN-written by Director of Staff Development [DSD]) dated 5/21/25 at 9:50 a.m., the PN indicated, Writer received complaint from staff member in regards to a possible altercation between CNA (Certified Nursing Assistant) and resident [1]. Resident [1] was interviewed by ADON (Assistant Director of Nursing) and DSD in regards [sic] the altercation. Resident stated it was just a playful banter (playful and friendly exchange of teasing remarks) and she is happy with the CNA and would still like the CNA to assist her. During an interview on 6/11/25 at 12:24 p.m. with Resident 1, Resident 1 stated approximately two to three weeks ago, CNA 1 was assigned to her. Resident 1 stated when she was on the phone with Family Member (FM) 1, CNA 1 was in the room and CNA 1 said something (unable to recall what was said) to her, and she (Resident 1) said something back and stuck her tongue out at CNA 1. CNA 1 then popped her with the back of her hand in the head and her head hit the side rail of the bed. During an interview on 6/11/25 at 1:15 p.m. with DSD, DSD stated on 5/21/25 the IP (Infection Preventionist) reported that FM 1 had made an allegation of abuse towards CNA 1 saying she had bopped Resident 1 over the head while she was on the phone with her. DSD stated CNA 1 was suspended and the allegation was reported to the Administrator, Human Resources (HR) and Director of Nursing (DON). DSD stated an investigation was initiated by the ADON and HR. DSD stated she did not report the allegation to any outside entity (Ombudsman, law enforcement, state licensing agency). During an interview on 6/11/25 at 1:28 p.m. with IP, IP stated on 5/21/25 FM 1 reported that when she was on the phone with Resident 1, CNA 1 went into Resident 1's room and Resident 1 offered her some food. CNA 1 declined the food and Resident 1 said oh you are going to be a diabetic today and CNA 1 said yes, she did not want her sugar to go up. CNA 1 then walked over to do something, and Resident 1 said 'ow' and when FM 1 asked what happened Resident 1 said CNA 1 bopped her over the head. IP stated she reported the incident to the Administrator who immediately removed CNA 1 from resident care. IP stated the allegation was not reported to any outside agencies and the alleged incident should have been reported within two hours. During an interview on 6/11/25 at 1:54 p.m. with DON, DON stated on 5/21/25 it was reported to her that Resident 1 had stated CNA 1 had bopped her in the head. DON stated the allegation was not reported to any outside agencies and it should have been. During an interview on 6/11/25 at 4:08 p.m. with Family Member (FM) 1, FM 1 stated during a phone call with Resident 1 on approximately 5/17/25 or 5/18/25 she heard Resident 1 offer CNA 1 some cinnamon balls from Taco Bell and then say your going to be diabetic and then Resident 1 said 'ow'. FM 1 asked Resident 1 what happened, and Resident 1 said CNA 1 bopped her over the head with her hand. FM 1 stated she reported the allegation to the IP. FM 1 stated she had a meeting with the Administrator, DSD and another staff on 6/5/25 regarding the incident. FM 1 stated I think it could be abuse, think she was very unprofessional and crossed the line. During an interview on 6/19/25 at 11:43 a.m. with Administrator, Administrator stated on 5/21/25 the IP informed him that FM 1 reported that CNA 1 had bopped Resident 1 on her head. Administrator stated CNA 1 was removed from resident care and an investigation was completed. Administrator stated he was aware of the allegation, and the allegation was not reported to any outside agencies. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 2021, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies.the state licensing/certification agency responsible for surveying/licensing the facility.the local/state ombudsman.law enforcement officials.Immediately is defined as.within two hours of an allegation involving abuse or result in serious bodily injury or.within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to ensure the staff used the Hoyer lift (mechanical device designed to assist individuals with limited mobility in safely transferring from one place to another) properly when the legs (base) of the Hoyer lift were not open during a transfer for one of three sampled residents (Resident 1). This failure resulted in the Hoyer lift tilting over causing Resident 1 to fall to the floor, sustaining a mild displaced (bone fragments are no longer together) distal (away from the point of attachment) coccygeal (tailbone) segment (completely detached from surrounding bone) fracture (break in a bone).Findings:During a review of Resident 1's admission Record (AR) dated 6/10/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including paraplegia (loss of impairment of motor (movement of body parts) and sensory (sensation) functions in the lower half of the body).neuralgia (nerve pain) and neuritis (inflammation of a nerve).congestive heart failure (heart does not pump blood well).During a review of Resident 1's Minimum Data Set (quarterly MDS - comprehensive assessment tool) dated 5/23/25, under the section Brief Interview for Mental Status (BIMS- an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS indicated, Resident 1 had a score of 13 (cognition intact). The MDS under the section GG (an assessment of the level a care a resident required), indicated, Resident 1 was dependent on staff for transferring from bed to chair/chair to bed.During a review of Resident 1's Fall Risk Observation/Assessment (FROA) dated 5/18/25, the FROA indicated, Score 22 (high risk for falls).During a review of Resident 1's Progress Notes (PN) dated 5/31/25 at 3:50 p.m., the PN indicated, Staff reported this writer that the resident had a fall during a transfer from bed to wheelchair using a Hoyer lift. Upon arrival, res (Resident 1) was found on the floor in between Hoyer lift and closet, having landed on buttocks with sling underneath. Incident occurred when staff attempted to move the res with Hoyer lift legs in the closed position and turned the resident, causing the lift to tip and res to fall.Resident c/o (complained of) pain right wrist.During a review of Resident 1's S (Situation) B (Background) A (Appearance) R (Review and Notify) Communication Form (SBAR - a communication tool used between healthcare professionals i.e. between the nurse and physician) dated 5/31/25, the SBAR indicated, Witnessed fall.Recommendations of Primary Clinicians.X-ray (medical imaging technique that uses radiation to create a picture of the inside of the body) Sacrum (triangular bone in the lower back) bone & Coccyx (tailbone) Bilateral Hips X-ray right wrist.During a review of Resident 1's PN dated 5/31/25 at 10:26 p.m., the PN indicated, (Physician name) notified of.mild displaced distal coccygeal segment fracture.MD (Medical Doctor) confirmed of res (resident) to already have Norco (narcotic pain [no dosage indicated] medication) and Tylenol (no dosage indicated) pain medication ordered. NNO (no new orders) at this time.During a review of Resident 1's Radiology Interpretation (RI - X-ray performed at the facility) dated 5/31/25, the RI indicated, mild displaced distal coccygeal segment fracture.During an interview on 6/4/25 at 12:35 p.m. with Resident 1, Resident 1 stated when Certified Nursing Assistant (CNA 1) and CNA 2 were transferring him with the Hoyer lift on 5/31/25, they got me in the air with the sling and was over there by the wood dresser and (I) was up in the air. Then boom hit the ground and the rubber cap on the Hoyer where the hook comes in and hit me in the head and stunned me and felt a jolt when I hit.hit my elbow and my hand.hand and elbow was hurting really bad.having spasms in back of shoulder and have to lay on a pillow.I am paralyzed (prior to the fall) from the navel down can't move legs or toes and now when lifting and lower right leg feel a click in front of the pelvis (large bony structure near the base of the spine (backbone) to which the hind limbs or legs are attached) where the femur (bone of the thigh) and acetabulum (structure located on the hip bone) meet.thank god I can't feel anything. Resident 1 stated CNA 1 apologized 20-30 times and said he should have opened the legs of the Hoyer lift.During an interview on 6/4/25 at 2:44 p.m. with CNA 2, CNA 2 stated on 5/31/25 she was assisting CNA 1 with transferring Resident 1 with the Hoyer lift from the bed to the wheelchair. CNA 2 stated she was guiding Resident 1 in the air as CNA 1 was raising him up and she did not notice the legs of the lift were not open. CNA 2 stated while she was guiding Resident 1 out from over the bed, Resident 1 fell. CNA 2 stated the legs of the Hoyer lift were closed and the legs should have been open to help stabilize the Hoyer lift, to prevent it from tipping over.During an interview on 6/4/25 at 3:10 p.m. with Director of Staff Development (DSD), DSD stated after Resident 1 fell on 5/31/25, she investigated the cause of the fall. DSD stated when CNA 1 and CNA 2 were transferring Resident 1 the legs of the Hoyer lift were not open causing the Hoyer lift to tip over and Resident 1 to fall to the floor. DSD stated both CNA 1 and CNA 2 had received transfer training with a Hoyer lift before the fall incident, and it was very important to open the legs of the Hoyer lift to prevent the Hoyer lift from tilting over.During an interview on 6/5/25 at 2:42 p.m. with CNA 1, CNA 1 stated on 5/31/25, CNA 1 and CNA 2 were transferring Resident 1 from the bed to the wheelchair. CNA 1 stated when he was operating the Hoyer lift, he placed the legs of the Hoyer lift under the bed closed and after Resident 1 was in the sling he pulled the legs out from under the bed closed and when he began turning the Hoyer lift with Resident 1, the Hoyer lift tipped over causing Resident 1 to fall to the floor. CNA 1 stated Resident 1 fell straight on his tailbone and grunted out in pain. CNA 1 stated he did not open the legs of the Hoyer lift due to the clutter in the room. CNA 1 stated he should have opened the legs of the Hoyer lift to stabilize it.During a concurrent interview and record review, on 7/3/25 at 2:20 p.m. with Director of Nursing (DON), Resident 1's care plans were reviewed. There was no care plan indicating how Resident 1 was to be transferred at the time of the fall. DON stated she could not find a care plan on how to transfer Resident 1 and there should have been one created at the time of admission [DATE]).During a review of the Vander-Lift II Transfer Procedures (VLTP-manufacturer user manual) dated 12/2019, the VLTP indicated, Transfer from a bed or stretcher.Make sure there is enough room in the patient's room to do the transfer.Open the base to its widest position.During a review of the facility ' s policy and procedure (P&P) titled, Lifting Machine, using a Mechanical dated 7/2017, the P&P indicated, Prepare the environment.clear an unobstructed path for the lift machine.Make sure the lift is stable and locked.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) home health services were set up prior to discharge. This failure had the potential to result in Resident 1 not receiving the assistance and care she needed upon discharge. Findings: During a review of the Physicians Orders (PO), the PO indicated, Discharge home (resident ' s address) with HH (Home Health), PT (Physical Therapy), OT (Occupational Therapy), RN (Registered Nurse) DME (Durable Medical Equipment): 2 WW (Wheel Walker) .order date 5/8/25 During a review of the Discharge Summary (DS), the DS indicated, discharge date and Time: 5/9/25.Reason for discharge.Resident discharging home.Discharge location.home.post-discharge services/referrals.home health.services ordered.PT.OT.RN.post-discharge supply needs.durable medical equipment.FWW (front wheel walker). During a review of Resident 1 ' s Progress Notes (PN) dated 5/9/25 at 10:55 a.m., the PN indicated, Residents brother (name) here to transport resident home via personal vehicle upon discharge. During a review of Resident 1 ' s PN dated 5/15/25 (6 days after discharge) at 12:06 p.m., the PN indicated, Referral sent to Focus Home Health for follow up on SOC (start of care) for resident that discharged on [DATE]. During a concurrent interview and record review on 5/15/25 at 11:25 a.m. with Social Service Director (SSD), Resident 1 ' s PN ' s were reviewed. SSD was unable to provide evidence of HH being notified of Resident 1 ' s discharge orders prior to Resident 1 being discharged . During a review of the facility policy and procedure (P&P) titled Discharge Summary and Plan dated 3/25, the P&P indicated, The discharge plan is based on the resident assessment, the goals for care, the desire for discharge and the resident ' s capacity for discharge.Discharge planning identifies the discharge destination, and ensures that it meets the resident ' s health and safety needs, as well as preferences.A member of the IDT (interdisciplinary team-group of individuals with diverse expertise and backgrounds who collaborate to achieve a common goal) reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place.The final discharge plan of care shows what arrangements have been made for the resident regarding.community care and support services.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was evaluated to self-administer medication when lidocaine (medication used to relieve pain) was left at the bedside. This failure resulted in Resident 1 having medication at bedside and the potential to self-administer medication incorrectly. Findings: During a concurrent observation and interview on 4/7/25 at 11:10 a.m. with Resident 1 in Resident 1's room, Resident 1 was holding a washcloth up to her mouth and appeared in pain. There was a medication cup with a clear gel looking substance on Resident 1's over bed table. Resident 1 stated she had a bad tooth, and was provided the lidocaine in the medication cup from the nurse so she could use it when she was in pain. During a concurrent observation and interview on 4/7/25 at 11:18 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, LVN 1 stated the medication cup that was on Resident 1's over bed table contained lidocaine. LVN 1 stated when a resident was to self-administer medication an evaluation was completed to make sure the resident was safe to administer the medication and understands the physician order. LVN 1 stated if the resident was deemed safe to self-administer medication, they will have the physician's orders at bedside and a lock box to keep the medication in. LVN 1 stated Resident 1 was not evaluated to self-administer medications. During an interview on 4/7/25 at 11:40 a.m. with LVN 2, LVN 2 stated when she administered Resident 1's medications in the morning the medication cup with the lidocaine was on the over bed table. LVN 2 stated Resident 1 will sometimes have the lidocaine at bedside so she can reapply a little over time. LVN 2 stated the lidocaine should not have been left at bedside. During an interview on 4/7/25 at 12:11 a.m. with Director of Nursing (DON), DON stated Resident 1 did not have physician orders to self-administer medications and there should not have been lidocaine at the bedside. During a review of the facility's policy and procedure (P&P) titled Self-Administration of Medications dated 2/2021, the P&P indicated, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. the medication is appropriate for self-administration; b. The resident able to read and understand medication labels; c. The resident can follow directions and tell time to know when to take the medication; d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff; e. The resident has physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and f. The resident is able to safely and securely store the medication.

Based on interview and record review, the facility failed to ensure the Ombudsman (government-appointed official who investigates and attempts to resolve complaints in the long-term care facility) was notified when one of three sampled residents (Resident 1) was provided a 30-day notice to discharge the facility for non-payment. This failure had the potential for Resident 1 to experience an inappropriate discharge. Findings: During a review of Resident 1's Notice of Proposed Transfer/Discharge (NPTD) dated 3/11/25, the NPTD indicated, Reason(s) for transfer/discharge: non-payment of share of cost assigned by medi-cal. You have failed, after reasonable and appropriate notice, to pay for your stay at the facility. If you became eligible for Medi-cal after admission to the facility the facility may charge you only allowable charges under Medi-cal.4/9/25 effective date of transfer/discharge.(signature of facility representative).3/12/25.(signature of Resident 1).3/12/25. During an interview on 3/28/25 at 12:23 p.m. with Administrator, Administrator stated Resident 1 was issued a 30-day notice signed by Resident 1 due to a past due bill. Administrator stated the facility did not need to report the discharge to the Ombudsman because the resident did not dispute the discharge. During an interview on 4/1/25 at 1:58 p.m. with the Ombudsman, Ombudsman stated the office was unaware the facility had provided Resident 1 with a 30-day notice. During a review of the facility policy and procedure (P&P) titled Transfer or Discharge, Facility-Initiated dated 10/22, the P&P indicated, Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at this facility.the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility.a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on interview and record review, the facility failed to ensure Advance Directives (AD-a legal document indicating resident preference on end-of-life treatment decisions) were offered and completed for two of 32 sampled residents (Resident 19 and Resident 103). This failure had the potential for residents' healthcare wishes to not be honored. Findings: During a concurrent interview and record review on 2/20/25 at 9:25 a.m. with Nursing Consultant (NC), NC was unable to provide documentation of an AD for Resident 19. NC stated there is no AD on file or no documentation of AD being offered or discussed with Resident 19 or Resident 19's responsible party. 51320 During a concurrent interview and record review on 2/24/25 at 11:28 a.m. with Social Services (SS), Resident 103's Advance Directive (AD), dated 6/06/24 was reviewed. The AD indicated, on 6/06/24 Resident 103 was interested in executing an AD. SS stated Resident 103 had checked that he was interested in the AD per the paperwork and there was no documentation on file that it was followed up. During a review of Resident 103's Minimum Data Set (MDS- a resident assessment tool) Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 2/14/25, the MDS indicated, Resident 103's BIMS was 13 [13-15 able to make decisions for self]. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated September 2022, the P&P indicated, Policy Statement: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. 1b. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state law (whether statutory or as recognized by the courts of the state), relating to the provisions of health care when the individual is incapacitated .Determining Existence of Advance Directive: 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

Based on interview and record review, the facility failed to ensure its arbitration agreement explicitly indicated that the resident or his or her representative had the right to rescind the agreement within 30 calendar days of signing the arbitration agreement. This failure had the potential for 92 of 138 residents who signed arbitration agreements not to understand their right to rescind the arbitration agreement within 30 days. Findings: During a concurrent interview and record review on 2/24/25 at 9:30 a.m. with the Admissions Director (AD), the facility's list of current residents who signed arbitration agreements was reviewed. A review of the list of current residents who signed arbitration agreements indicated 92 of 138 residents had signed it. The AD stated the facility offered arbitration agreement to all its residents. During a concurrent interview and record review on 2/24/25 at 11:34 a.m. with the Administrator, the facility's Arbitration Agreement (Agreement) (undated) was reviewed. The Agreement indicated, This Agreement may be rescinded by written notice within thirty (30) days of signature. The Agreement did not explicitly indicate that the resident or his or her representative had the right to rescind it within 30 days of signing it. The Administrator stated the Agreement should explicitly indicate that the resident or his or her representative had the right to rescind it within 30 days of signing it. During a review of the facility's policy and procedure (P&P) titled, Binding Arbitration Agreements, dated November 2023, the P&P indicated, Residents (or representatives) are provided 30 days after signing to fully review and rescind any agreement not understood at the time of admission.

Based on interview and record review, the facility failed to document the attendance of Quality Assurance and Performance Improvement (QAPI) committee meetings during ten of 12 meetings in 2024. This failure prevented the verification of attendance of the required QAPI committee members (Administrator, Director of Nursing, Medical Director, and Infection Preventionist). Findings: During a concurrent interview and record review on 2/24/25 at 3:22 p.m. with the Administrator, the facility's QAPI committee meeting minutes (the minutes) for 2024 were reviewed. The minutes indicated monthly meetings during 2024 but attendance sheets only for the November 2024 and December 2024 meetings. There was no documentation of who attended the meetings held from January 2024 to October 2024. The Administrator stated the facility started documenting the attendance of QAPI committee meetings in November 2024. The Administrator stated there was no documentation of who attended the meetings from January 2024 to October 2024. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance Performance Improvement Plan, (undated), the P&P indicated, Minutes of all meetings - QAPI Administrator is responsible for maintaining documentation.

Based on observation, interview, and record review, the facility failed to ensure three of 12 sampled residents (Resident 97, Resident 34, and Resident 13) were treated with dignity when they had to wait up to two hours for their call light request to be answered. This failure resulted in residents experiencing discomfort and feeling upset and the potential for skin breakdown. Findings: During a concurrent observation and interview on 2/19/25 at 7:48 a.m. with Resident 97 in Resident 97's room, Resident 97 was sitting up in bed. Resident 97 stated the longest she's waited for staff to answer her call light was approximately two hours for someone to help her and she needed her brief to be changed because she had soiled her brief. Resident 97 stated she needs two people to help her change her brief. Resident 97 stated, It made me feel like crap. During a review of Resident 97's Admission Record, (AR) dated 3/28/24, the AR indicated Resident 97 had a diagnosis of Unspecified Sequelae of Cerebral Infarction (Long-term complications from a stroke). During a review of Resident 97's Minimum Data Set, (MDS - a federally mandated resident assessment tool) dated 12/19/24, the MDS indicated Resident 97 had a (BIMS - Brief Interview for Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 (score of 13-15 means intact cognition). The MDS indicated Resident 97 required the assistance of two or more helpers with toileting hygiene. During a review of Resident 97's Care Plan, (CP) dated 12/16/24, the CP indicated, Interventions: Hygiene: Assist of substantial/maximal [total] assistance to dependent assistance. During an interview on 2/19/25 9:06 a.m. with Resident 34, Resident 34 stated he uses his call light for help with toileting and he had to wait more than 15 minutes for a certified nursing assistant to assist him. Resident 34 stated he felt upset because he had too wait long for someone to assist him. During a review of Resident 34's AR, dated 5/3/16, the AR indicated Resident 34 had a diagnosis of Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 34's MDS dated [DATE], the MDS indicated Resident 34 had a BIMS score of 13. The MDS indicated Resident 34 required, Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. During a review of Resident 34's CP, dated 1/20/25, the CP indicated, Interventions: Toileting: Assist of supervision or touching assistance. During an interview on 2/19/25 at 9:08 a.m. with Resident 13, Resident 13 stated she waited more than 15 minutes for her someone to answer her call light because she needed help with changing her brief. Resident 13 stated she was mad and felt discomfort. She waited more than 15 minutes for someone to answer her call light. During a review of Resident 13's AR, dated 12/20/23, the AR indicated Resident 13 had a diagnosis of Spinal Stenosis, Lumbar Region without Neurogenic Claudication (narrowing of the spinal canal in the lower back). During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 had a BIMS score of 15. The MDS indicated Resident 13 required, Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports truck or limbs, but provides less than half the effort. During a review of Resident 13's CP, dated 2/18/25, the CP indicated, Interventions: Toileting: Assist of partial/moderate assistance with hygiene and substantial/maximal assistance with transfer. During a review of the facility's Resident Council Minutes, (RCM) dated 12/10/24, the RCM indicated, MEETING NOTES - RESIDENT STATED CNAS [CERTIFIED NURSING ASSISTANTS] NOT COMING TO ROOM WHEN CALL LIGHT IS ON. During a review of the facility's RCM dated 1/14/25, the RCM indicated, Issue(s) Identified Resident Council: stating that CNAS [sic] don't have time. During a review of the facility's RCM dated 2/11/25, the RCM indicated, MEETING NOTES - CNAS GO TO LUNCH AND OTHER CNAS COVERING THE HALL DON'T WANNA TAKE CARE OF THE OTHER GROUP TO HELP OUT. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 10/2010, the P&P indicated, Purpose: The purpose of this procedure is to respond to the resident's requests and needs .General Guidelines: 8. Answer the resident's call as soon as possible. During a review of the facility's P&P titled, Dignity, dated 1/2021, the P&P indicated, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem .12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: b. promptly responding to resident's request for toileting assistance .

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of 64 sampled residents (Resident 42 and Resident 101). This failure had the potential to result in residents' needs not being met. Findings: During a concurrent observation and interview on 2/18/25 at 10:14 a.m. with Resident 42 in Resident 42's room, the call light was tied to the right side rail close to the top of the bed. When Resident 42 was asked how she would call for assistance, Resident 42 tried to reach the call light but could not. Resident 42 stated she could not reach the call light. During a concurrent observation and interview on 2/18/25 at 10:15 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 42's room, Resident 42's call light tied to the right side rail close to the top of the bed. CNA 1 stated Resident 42 could not reach the call light. CNA stated the call light should be within reach. 51320 During an observation 2/18/25 at 10:19 a.m. in Resident 101's room, Resident 101's call light was attached to the bed and not within reach. During an interview on 2/18/25 at 10:24 a.m. with CNA 2, CNA 2 stated the call light should be within reach. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 2010, the P&P indicated, 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to ensure a functioning overhead light was provided for one of eight sampled residents (Resident 37). This failure resulted in Resident 37 to not have a light available for personal use. Findings: During a concurrent observation and interview on 2/18/25 at 9:44 a.m. with Resident 37 in Resident 37's room, there was a light on the wall above Resident 37's bed, the string to turn on the light was detached. Resident 37 stated she has been unable to turn on the light and the string had been broken for a couple of weeks. During a review of Resident 37's Minimum Data Set [MDS - a federally mandated resident assessment tool], dated 1/30/25, the MDS indicated Resident 37 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 11 (score of 8-12 means moderate cognitive impairment). During an interview on 2/18/25 at 9:57 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the string to turn on the light should be longer for the resident to use. During an interview on 2/18/25 10:02 a.m. with Maintenance Assistant (MA), MA stated the light should have had a longer string for the resident to use. During a review of the facility's Maintenance Log, (ML) dated 2/17/25, the ML indicated, Area of Deficiency: 39A, Description of Deficiency: overhead light switch, Reported By (NAME) LVN (LVN 1), Date Corrected: 2/17/25 (day prior to observation). During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated December 2009, the P&P indicated, 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . 2b. Maintaining the building in good repair .

Based on observation, interview, and record review, the facility failed to ensure one of four shower beds (a medical device used to transport and shower people who are unable to stand or sit in a chair) was in a safe and operable manner for one of nine sampled residents (Resident 1). This failure resulted with one shower bed having a missing part which resulted in the shower bed collapsing while in use, Resident 1 falling from the shower bed, hitting her head on the shower wall, and the potential for significant injury. Findings: During a review of Resident 1's Admission Record (AR), the AR indicted, Resident 1 was admitted on [DATE] with multiple diagnoses including [CONDITION(S)] (paralysis of one side of the body) following unspecified [CONDITION(S)] disease (affects the blood vessel and blood supply to the brain), affecting left non-dominant side, and dementia (loss of cognitive functioning including thinking, remembering, and reasoning). During a review of the Minimum Data Set (MDS, a standardized clinical assessment tool) dated 1/24/21, the MDS indicated, Resident 1 had a BIMS (Brief Interview of Mental Status) score of 5 (0-7 severe impairment). The MDS indicated, Resident 1 required extensive assistance (individual would not be able to perform or complete the activity of daily living (ADL) without another person to aid in performing the complete task, by providing weight-bearing assistance) in bed mobility, transferring, and bathing. During an interview on 3/4/21, at 9:03 AM, with Certified Nursing Assistant (CNA 1) and the Director of Nurses (DON), CNA 1 stated, Resident 1 was safer in a shower bed during showers because Resident 1 slouches and can't sit up when placed in a shower chair. CNA 1 stated, on 2/25/21, she had obtained a shower bed from the station 3 front shower room and used a Hoyer lift (an assistive device to help with sit to stand) with CNA 2's assistance. CNA 1 stated, they transferred Resident 1 from her bed to the shower bed. CNA 1 stated, she transported Resident 1 out to the hallway and into station 3 front shower room. CNA 1 stated, she washed Resident 1 while she (Resident 1) was lying on the shower bed. CNA 1 stated, I had to turn her [Resident 1] to wash her backside. It all happened so fast, when I turned her [Resident 1] to her side, the bed started collapsing. The shower bed tilted to its side, with the wheels coming towards me and I saw her [Resident 1] falling to the ground. I heard her [Resident 1] hit her head on the wall first. CNA 1 stated, after the bed collapsed, the broken shower bed was inspected by facility Maintenance Director (MD) and was told the shower bed had a missing a PVC pipe (white plastic pipe commonly used for plumbing and drainage) located in front of the shower bed connecting the front two wheels. CNA 1 stated, she did not inspect the shower bed for any missing part prior to use and she did not know how long the shower bed had been missing a part. During a concurrent interview and record review, on 3/4/21, at 9:20 AM, with DON, DON stated, all staff were aware to write in the maintenance log for any broken or missing equipment including the shower bed. DON reviewed the maintenance log and confirmed there was no documentation of any shower bed with broken and/or missing parts in the Maintenance Log. During an interview on 3/4/21, at 9:26 AM, with MD, MD stated the facility had four shower beds. MD stated, the maintenance department inspected the shower beds monthly for integrity, checking the wheels, pins are all there, make sure all the connections are nice and tight. During an interview on 3/4/21, at 9:52 AM, with the Director of Staff Development (DSD), DSD stated, if staff noted an equipment, including shower bed to be broken or have missing part, staff were required to place signage on the broken/missing equipment, notify maintenance, and enter the information in the maintenance log. DSD stated she did not know any of the shower beds had missing parts. During an interview on 3/4/21, at 10:34 AM, with CNA 1, CNA 1 stated Someone must have known there was a piece that had fallen off [of the shower bed], if they [staff] let maintenance know, maintenance could have fixed it [shower bed]. It [shower bed] should have never been in the shower room with no sign. The incident could have been prevented. During an interview on 3/5/21, at 8:50 AM, with MD, MD stated, the missing PVC pipe connected the front wheels of the shower bed measured approximately 1 1/2 to 2 feet long. Maintenance stated, The PVC pipes are glued [together], the piece that came off, came un-glued. It would have been noticeable when it [PVC pipe] fell , it's a big piece. During an interview on 3/5/21, at 9:17 AM, with Licensed Vocational Nurse (LVN) , LVN stated, she responded to CNA 1's calls for help and found Resident 1 in station 3 front shower room lying on her left side facing the shower wall, [Resident 1] was covered in red marks everywhere, not talking, not responsive. During an interview on 5/7/21, at 10:25 AM, with CNA 3, CNA 3 stated, she was in-serviced when hired by the DSD and MD to always check for any loose parts on the shower bed before use. CNA 3 stated, They're [shower beds] old, after a while they become loose. We just have to make sure it still works and all the parts are there before we use it. During a concurrent observation and interview on 5/7/21, at 10:50 AM, with CNA 4, a shower bed, placed against the wall in hallway 3, was observed. CNA 4 stated, the PVC pipe missing from the front wheel would have been easily identified as missing. Using the shower bed placed against the wall, CNA 4 demonstrated on how to lock the wheel brakes by walking around the shower bed and using her foot, pressed down a lever located on each wheel. CNA 4 stated, When checking the lock on the wheels, you can tell if the bar [PVC pipe] is missing especially the bar connecting the wheels, plus you can compare from the other side that there is a part missing. CNA 4 stated, the missing PVC pipe connecting the front wheels could cause the shower bed to be off balance if missing. During a review of the Facility Reported Event dated 2/25/21, the report indicated, The results of the facility's interviews and thorough investigations reveal the integrity of the PVC pipes of the shower bed were compromised when they cracked. It's possible the missing PVC could have changed the balance of the shower bed causing the tilt of the shower bed. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service dated 2009, the P&P indicated, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe operable manner at all times.

Based on observation, interview, and record review, the facility failed to perform a pain re-assessment and implement effective pain medication in a timely manner for one of 24 sampled residents (11). This failure resulted in prolonged and unrelieved pain. Findings: During a concurrent observation and interview with Resident 11, on 10/4/16, at 10:54 AM, Resident 11 was observed in bed with facial swelling and bruising to cheeks, lower jaw and upper neck area. Resident 11 stated she had all of her upper teeth extracted and some of her lower. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3 and Certified Nursing Assistant (CNA) 5, on 10/4/16, at 10:55 AM, LVN 3 stated she had seen Resident 11 and had asked about her pain. LVN 3 stated she did not use a pain scale number (scale to determine the severity of pain) but saw Resident 11 touching her face and asked if she wanted something for pain. LVN 3 stated, She said no, so I offered an ice pack. I had her (CNA 5) translate for me because I don't speak Spanish. CNA 5 was present and stated I translated this morning for you (LVN 3) and no that's not what I translated, I was told to ask (Resident 11) to place the ice pack on her cheek for periods of 15 minutes. I was not asked to ask about her pain. LVN 3 proceeded to ask Resident 11 Do you have any pain? What would you like for pain? No pain assessment was completed. LVN 3 did not inquire about the intensity of the pain, she did not inquire if the ice pack was helpful in relieving Resident 11's pain, nor did she do an oral assessment. During an interview with Resident 11, on 10/4/16, at 1:23 PM, she stated I was in severe pain all night long and I felt I was going to pass out from the pain. I can't even explain the horrible pain, my pain was severe 10 out of 10 (on pain scale- 10= worst pain imaginable). I felt as if my eyes were going to bulge out of my head and my ears drums were going to burst. Resident 11 stated staff knew she has going to have teeth extractions and why didn't the staff offer her something for her severe pain. Resident 11 began to cry with tears rolling down her checks and stated, I'm crying because I don't know why they didn't come and check on me and attend to my horrible pain last night. I haven't sleep from the horrible pain, did they ignore me because I only speak Spanish. Resident 11 stated the oral surgeon told her that she had infection to multiple teeth and 13 of the teeth were really difficult to extract so he preferred to wait and perform extractions on the remaining teeth at another time. Resident 11 stated that she was extremely fearful of the next procedure and she would like to ask that when she returns for the remaining extraction the lack of pain medication and attention to her condition does not repeat again. Resident 11 stated, I would not like for this to happen again, I just ask for them to pay more attention to me. During a review of the clinical record for Resident 11, the document titled OMFS (Oral and Maxillofacial Surgery) procedure note dated 10/03/16, indicated (Resident 11) presents today for full mouth extractions, extractions of teeth #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 18, 22, 23, 24, 25, 26, 27, 28, 31. The oral surgeon wrote after surgical care instructions which included an order for [REDACTED]. During a concurrent record review and interview with the Director of Nurses (DON), on 10/5/16, at 9:35 AM, she stated after Resident 11's procedure the nurse should have re-assessed the resident's change in condition, and performed a pain assessment to evaluate the level of pain management needed to keep the resident comfortable. The DON stated We did not do that, we all missed it, including me. The DON reviewed the plan of care for pain management and stated it should have been updated to reflect pain management after the procedure. It was confirmed by the DON that in spite of Resident 11 having her 22 teeth extracted, she did not get any PRN (as needed) pain medication between midnight to six AM on 10/4/16. It was also confirmed that there was no documented evidence staff had assessed Resident 11's need for the PRN pain medication or had a pain assessment done. During an interview with CNA 6, on 10/5/16, at 1:10 PM, she stated in report she was told Resident 11 had some teeth pulled out. CNA 6 stated I just guess maybe 10. She stated that the nurses did not ask her to take vital signs or to ask Resident 11 about her pain. CNA 6 stated the CNA from the last shift told her that Resident 11, Is probably in a lot of pain because of her teeth being pulled. CNA 6 stated Resident 11 usually used the restroom by herself, was very independent and never liked to bother us. CNA 6 stated Resident 11 needed to be reminded that it was okay to ask for help but she is very quiet and does not like to bother us. CNA 6 stated today she was really different this time she asked for help with everything, even to go to the restroom. She is able to do all of that independently but not today . During a review of the clinical record for Resident 11, the Medication Administration History, dated 10/01/16 to 10/04/16, indicated Resident 11 had an order for [REDACTED]. During a review of the clinical record for Resident 11, a care plan, dated 1/13/15, indicated Resident 11 was Spanish Speaking only and required interpreters for communication needs. The care plan indicated for staff to allow time (for Resident 11) to express needs and concerns. A care plan for pain, dated 12/12/14, indicated to encourage resident to discuss feelings about pain .to evaluate verbal and nonverbal cues of resident to assess the degree and severity of pain. The facility policy and procedure titled Pain-Clinical Protocol revised 10/2010, indicated the physician and staff will identify individuals who have pain or who are at risk for having pain . The nursing staff will assess each individual for pain . will identify any situations or interventions where an increase in the resident's pain may be anticipated . The facility policy and procedure titled Pain Assessment and Management revised 4/2009, indicated it is important to recognize cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain . Pain assessment, as indicated per facility protocol . Possible behavioral signs of pain: Facial expressions, changes in gait, difficulty eating . Assessing pain: Characteristics of pain: Intensity, Description, Pattern, Location, Frequency .

Based on observation, interview, and record review, the facility failed to assess and treat severe pain for one (7) of 24 sampled residents which resulted in continued severe pain to his left heel that negatively impacted his quality of life. Findings: During a concurrent observation and interview with Resident 7, on 1/11/16, at 1:04 PM, Resident 7 was observed lying in his bed with a rolled-up blanket placed underneath his left heel. The right leg was amputated below the knee. Resident 7 stated, They cut it (right leg) off because I had sores that wouldn't heal . I can't get in and out of the bed. I have a lot of pain to my heel. Resident 7 was asked about pain severity he stated 8 out of 10 (Scale of 0 to 10- No pain O- severe pain 10). He was asked if he told a staff member of the pain and Resident 7 stated, Yes, I call them on my call light .yesterday at 7 PM I told the nurse that I needed a pain pill and she told me that it's too late, the doctor was gone for the day and she never returned. Resident 7 was asked about the severity of pain when he asked for the pain pill. Resident 7 stated, 10 out of 10. Resident 7 stated he then asked the night CNA (Certified Nursing Assistant) at around 2 AM and again they never gave me anything. But around 6 AM I got my pain pill but I needed something between those times. Resident 7 indicated that he received pain pills three times a day. Resident 7 was asked about his rest and sleep. Resident 7 stated, I sleep on and off. The pain is really bad. As soon as I move the pain is so bad that it wakes me up . I've been in pain since last week. My pain medication is not working. When asked if he reported to the nurse, he stated, Yes, I did several times but they said I am already taking [MEDICATION NAME] (strong narcotic pain medication) every 8 hours. I tell the nurses but no one did anything. When asked about the severity of pain since last week Resident 7 stated, It's an 8 to a 10. I'm so scared of losing my leg and foot. They cut my other foot off because of sores and I had bed sores on my left heel already. Resident 7 pointed to the heel and stated, It (pain) feels like a sore. Resident 7 became tearful. I'm sorry sometimes I get upset but I really don't want my only leg to be cut off. The left heel was noted with two deep indentations (scars) to the left side of the heel. The heel was slightly red and swollen. Resident 7 stated I was able to stand on it before the pain but I can't do it with this pain, I stay in bed . During a review of the clinical record for Resident 7, on 1/12/16, at 9 AM, no plan of care was noted for the left heel change in condition and no care plan for new onset of pain to left heel. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 3, on 1/12/15, at 3:38 PM, she was asked if she was familiar with Resident 7's ability to make his needs know, she stated, Yes I'm his CNA four days out of the week .he knows what he wants, and when he wants it .he is very alert. CNA 3 was asked about Resident 7's pain, she stated We turn him to alleviate the pain. When asked about the location of Resident 7's pain CNA 3 stated, His back .but sometimes I don't ask him. She was asked about Resident 7's left heel, she stated that Resident 7 wears heel protector to prevent sores but he really doesn't need them. CNA 3 walked into Resident 7 room and asked him about his pain. Resident 7 stated, My pain is a 9. CNA 3 ask for the location of the pain Resident 7 stated, It's on my heel. CNA 3 stated Okay and left the room. Registered Nurse (RN) 1 was two rooms down the hall. CNA 3 walked into the room next to Resident 7's room without talking to the RN 1 about Resident 7's complaints of pain. During a concurrent observation and interview with RN 1, on 1/13/16, at 4 PM, RN 1 walked into Resident 7's room and asked him to rate his pain. Resident 7 stated, 10. Resident 7 was grimacing (facial expressions of pain). RN 1 asked for the location of the pain and Resident 7 indicated left heel. RN 1 attempted to touch the left heel and Resident 7 stated, Oh please don't touch, it really hurts. RN 1 was asked when the pain to the heel began and RN 1 stated, He told me since last week. RN 1 reviewed the PRN pain medication and the Medication Administration Record [REDACTED]. She stated Resident 7 was not receiving the medication as he should. RN 1 was asked if Resident 7's physician was notified of the increased pain to his heel. RN 1 reviewed the clinical record and was unable to find documentation and stated No, I did not call the doctor. RN 1 was asked about the condition of the heel when Resident 7 informed her of his pain and she stated I did not perform an assessment to his heel. RN 1 was asked about documentation of Resident 7's complaint of increased pain to his heel and she stated, I didn't document. RN 1 was asked about a plan of care for the new onset of the increase complains of pain to the heel and RN 1 stated I didn't do a care plan. During a concurrent observation and interview with the License Vocational Nurse (LVN) 5, on 1/12/16, at 4:23 PM, she was asked about current treatments to Resident 7's left heel. LVN 5 stated, He doesn't have anything wrong with his heel. We healed two stage three pressure sores to that heel a few months ago . He can wear a heel protector but he doesn't have anything. It's his choice if he wears it or not . He really doesn't need to wear it. He (Resident 7) always tells me that he really wants to take care of it (heel), because he doesn't want to lose his only foot. LVN 5 walked into Resident 7's room and stated, No one told me that something was going on with his foot . I did not know . RN 1 walked into the room and told LVN 5 I told you about it last week . LVN 5 did not respond. LVN 5 was asked if she had documented the increase pain to Resident 7's heel and she stated I didn't document . I didn't inform the doctor. LVN 5 was asked about the facility's policy and procedure when there is a change in a resident's condition and she stated that an assessment must be performed and the doctor notified as soon as possible. Resident 7 looked at LVN 5 and stated You didn't look at my foot, you came looking for her. During an interview with the Administrator, on 1/13/16, at 4:31 PM, he stated, He (Resident 7) has [MEDICAL CONDITION] (pain and numbness due to damaged nerves), he will always have pain .he is very alert and able to communicate his needs. He knows and is very clear and can ask for pain medication. During an interview with the Administrator, Director of Nursing Services (DNS), and the Clinical Operations Consultant (COC), on 1/14/16, at 1:01 PM, the COC stated, The reason no one called the doctor is because he had nothing on his heel visually. The Administrator stated, The doctor was here (1/12/16) and he ordered an X-Ray. The X-Ray showed that he has bone spurs on the heel. The DNS was asked about the facility policy when a change in condition occurs and she stated I expect my staff to call the physician with a change of condition. The DNS was asked for a policy and procedure for pain management, no additional information was provided. The facility policy and procedure titled Change in a Resident's Condition or Status dated 4/2007, read in part, Our facility will promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition .

Based on observation, interview, and record review, the facility failed to provide adequate and appropriate social services for two of 24 sampled residents (22 and 2). 1. For Resident 22, the facility failed to provide proper discharge planning services and support a resident's rights in the discharge process which resulted in an unnecessary transfer and emotional distress to Resident 22. 2. For Resident 2, the facility failed to provide timely dental care referrals which resulted in a decreased ability to eat regular foods and potential for use of unnecessary medications. Findings: 1. During a review of the closed record for Resident 22, on 1/15/15, at 2 PM, the following documents were reviewed: The Social Services Resident Progress Notes, dated 12/22/14, (100 days after admission) at 4:16 PM, indicated in part, "RP ( responsible party, family member) came to social service office, he is aware of discharge date , he states that he would like long term care, RP is aware per agreement upon admit that resident is short term and if long term is needed, we would assist in proper placement. The Resident Progress Notes, dated 12/30/14 at 11:24 AM indicated Resident 22 was discharged to Facility B on 12/30/14 at 10:30 AM per transport (103 days after admission), "Resident discharged to Facility B at approx (approximately) 10:30 this morning. Resident was sent by transport. Resident was apprehensive and had mixed emotions about leaving." The "Discharge Plan of Care" dated 12/29/14, created by Social Service Aide (SSA) 1 indicated, "Resident 22 was admitted on [DATE] for rehabilitation, Resident 22 has completed therapy and the RP has requested long term care, RP agreed for SSA to assist with finding a SNF (Skilled Nursing Facility)." During an interview with Resident 22's Responsible party (FM 1), on 1/16/15, at 3 PM, he stated "She was really happy there (the facility). She liked all the people and her roommate. My relatives told me she shouldn't have to move to Facility B, that the facilities were the same. I wish I would have listened to them. A few days before she transferred out they told me she would have to leave and go to a long term care facility, they said she was here for rehab and a short stay, that I had no choice for her to stay. But she doesn't like it at Facility B. She was starting to get better at (facility), she liked the nurses, now she's so sad, cries, she misses all the people she got close to. When we came in they never told me she would have to leave." During an interview on 1/15/15, at 3:05 PM, the Social Services Director (SSD) stated, "We accepted her as a short term placement. We have a stand up meeting in the morning with the administrator and admitting and they tell us who is a short term resident. The original plan was that Resident 22 was a short term placement and I found her placement in a long term care facility. The front hallway is for short term rehab (rehabilitation) Residents." When asked if she spoke to Resident 22 and asked how she felt about a move, she stated, "No". We offered options. Was it an option to stay in Facility A? "No it was not because she was in the short stay wing for rehab." When asked if the facility had a paper or verbal agreement she stated, "I think a paper agreement, they agree that they are coming for rehab. I will ask admitting for the form." The SSD was unable to provide the form when requested by the surveyor. When the SSD was asked what services Facility B offered that Facility A didn't offer she stated, "they are a SNF with long term beds. During an interview with the Assistant Administrator (AA) of Facility B, on 1/20/15, at 11 AM, she stated she had not received the following information upon admission for Resident 22: Transfer Assessment, Progress notes, Physical Therapy notes, Restorative Nursing notes, Social Service notes or a discharge summary. She further stated that she requires this documentation for continuation of care. The AA stated, upon admission, Resident 22 required a wheelchair, specialized bed for wound care, special eating utensils and a rimmed plate. Facility B's Admission record dated 12/30/14 at 11:20 AM, indicated Resident 22 was admitted for long term care with a [DIAGNOSES REDACTED]. 2. During a concurrent observation of the lunch meal and interview with Resident 2, on 1/13/15 at 12:40 AM, he stated, "I have no teeth, I need some teeth. Can I get some dentures?" He opened his mouth and pointed to his two lower teeth and one upper tooth. Resident 2 ate his mashed potatoes, bread, vegetables and dessert. Resident 2 attempted to eat his meat, but stopped after a few bites. During a review of the clinical record for Resident 2 on 1/15/15 at 2 PM, the Dental Service Progress note indicated on "6/24/11 (2011) wants to see dentist for partials or dentures." The Psychosocial Psychotropic Review dated 9/5/14, indicated, "Behavioral Summary: POOR APPETITE, Medication: Remeron daily for Medical Diagnosis: [REDACTED]. During an interview with Social Services Assistant (SSA) 1 on 1/13/15 at 1:30 PM, she stated, "I wasn't aware he wanted dentures. I remembered his son said he couldn't have them because of bone issues. We will get him seen by the dentist. SSA 1 was unable to provide Social Service Progress notes regarding Resident 2's dental care. During an interview with Resident 2's family member (FM 2), on 1/16/15 at 3 PM, he stated he was unaware of Resident 2's request or need for dentures and that he knew of no reason he could not be provided dentures.

Based on interview and record review, the facility failed to: 1. Fully inform one of 24 sampled residents (22) of the scope of service offered by the facility which resulted in a discharge that caused emotional distress and violated Resident 22's rights. 2. Fully inform two of 24 sample residents (3 and 13) and/or their responsible parties of the accurate dosages of anti-depressant medications given to the residents which had the potential to violate the residents' right to informed treatment. Findings: 1. During a review of the closed record for Resident 22, on 1/15/15, at 2 PM, the following documents were reviewed: The "Social Services Resident Progress Notes", dated 12/22/14 (100 days after admission), at 4:15 PM, indicated in part, "RP ( responsible party, family member) came to social service office, he is aware of discharge date , he states that he would like long term care, RP is aware per agreement, upon admit, that resident is short term and if long term is needed, we would assist in proper placement to a Skilled Nursing Facility." The "Resident Nurses Progress Notes", dated 12/30/14 at 11:24 AM, indicated Resident 22 was discharged to (Facility B) on 12/30/14 at 10:30 AM per transport (103 days after admission), "Resident discharged to (Facility B) at approx (approximately) 10:30 this morning. Resident was sent by transport. Resident was apprehensive and had mixed emotions about leaving." The "Discharge Plan of Care", dated 12/29/14, created by Social Service Aide (SSA) 1 indicated, "Resident 22 was admitted on [DATE] for rehabilitation, Resident 22 has completed therapy and the RP has requested long term care, RP agreed for SSA 1 to assist with finding a SNF (Skilled Nursing Facility)." The "Notice of proposed Discharge and Transfer" dated 12/29/14, indicated, "As per admission agreement, the facility shall transfer/discharge a resident when the facility determines that such action is appropriate in order to meet the resident's need for health care services. This is to inform you that Resident 22 will be transferred on 12/30/14." This form was signed by Family Member (FM) 1 on 12/30/14, the day of discharge. The facility "Admission" document, dated 5/2011, given to all residents upon admission, indicated under "Patient Rights, (6) To be transferred and discharged on ly for medical reasons or the patient's welfare or that of other patients or for non-payment and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record." During an interview with FM 1, on 1/16/15, at 3 PM, he stated "She was really happy there (facility). She liked all the people and her roommate. My relatives told me she shouldn't have to move to Facility B, that the facilities were the same. I wish I would have listened to them. A few days before she transferred out they told me she would have to leave and go to a long term care facility. They said she was here for rehab and was a short stay, that I had no choice for her to stay. But she doesn't like it at Facility B. She was starting to get better here, she liked the nurses, now she's so sad, cries, she misses all the people she got close to. When we came in they never told me she would have to leave." During an interview on 1/15/15, at 3:05 PM, the Social Services Director (SSD) stated, "We accepted her as a short term placement. We have a stand up meeting in the morning with the administrator and admitting and they tell us who is a short term resident. The original plan was that Resident 22 was a short term placement and I found her placement in a long term care facility. The front hallway is for short term rehab residents. When asked if she spoke to Resident 22 to determine how she felt about a transfer, she stated no she had not. The SSD stated "We offered options." When asked if it was an option for Resident 22 to stay in the facility, the SSD responded "No, it was not because she was in the short stay wing for rehab (rehabilitation)." When asked if the facility had a paper or verbal agreement, she stated, "I think a paper agreement. The residents agree that they are coming for rehab. I will ask admitting for the form." The SSD was unable to provide the form when requested by the surveyor. When the SSD was asked what services Facility B offered that the facility did not offer she stated, "They are a SNF with long term beds (Skilled Nursing Facility)." The SSD was unable to provide documentation of a medical reason for discharge. During an interview with Assistant Director of Nursing (ADON) 2, on 1/15/15, at 4 PM, she stated, "Resident 22 came here from the hospital with a stroke, she needs maximum assist, she left because her short stay is up, they knew about it and agreed upon it. We talk about it at standup in the morning with the administrator and the DON (Director of Nurses). I don't know how the family felt about leaving, I know they were nervous about it. Social Services talks to them. Everyone on the front wing is told they are short stays." During an interview with Physician (MD) 1 on 1/23/15, at 9 AM, he stated, "I was not aware that Resident 22 went to another long term facility, I thought she went home. If they go to another long term care facility, it should be because of the resident's wishes." The facility license indicated that facility is licensed for 140 Skilled Nursing Beds. Facility B is licensed for 99 Skilled Nursing Beds. Neither facility is licensed for short term care. Both of these long term care facilities offer the same scope of service. 2. A. During a review of the clinical record for Resident 3, on 1/13/15, at 9 AM, the "Benefit to Risk Assessment of Antipsychotic Treatment" indicated "[MEDICATION NAME] (medication used in the treatment of [REDACTED]. The current physician orders [REDACTED]." During an interview with ADON 1, on 1/14/15, at 2 PM , she stated, "the assessment should have said 75 mg." 2. B. During a review of the clinical record for Resident 13, on 1/13/15, at 9 AM, the "Consent-Family Verification or Resident Informed Consents-Psychotherapeutic Meds" indicated [MEDICATION NAME] (medication used to treat depression) 15 milligram (mg) 1 tablet QHS (every evening). The consent was received from the Responsible Party on 10/13/14. Resident 13's, "Physician order [REDACTED]. No consent for the increase in medication dose was located for [MEDICATION NAME] 30 mg. During an interview with the ADON 1 on 1/14/15, at 11:46, she stated, "The consent form is updated when there is a change in the medication order, when the medication dosage is increased."

Based on interview and record review, the facility failed to: 1. Act upon the pharmacy reports for one of 24 sampled residents (16), which caused a delay in pain management. This failure had the potential to cause the resident uncontrolled pain. Findings: During a review of the clinical record for Resident 16, the Pharmacy Medical Record Review Report dated 1/22/13 indicated start [MEDICATION NAME] (MS)[MEDICATION NAME] mg by mouth every twelve hours, discontinue [MEDICATION NAME] 5/500 mg one tablet by mouth every 4 hours... and change [MEDICATION NAME] to every 4 hours as needed for moderate to severe pain. Further review of the record did not indicate the pharmacist recommendation had not been followed up on. Resident 16's diagnosis, per admission record, indicated the resident had pain in their joint, pelvis/thigh-RT-hip, degeneration lumbar... disorder bone/cartilage... pain in joint shoulder, [MEDICAL CONDITION] (joint pain and stiffness), lumbago (low back pain). The Minimum Data Set (MDS, an assessment tool) dated 12/26/12, indicated Resident 16 experienced pain almost constantly. The level of pain the resident experienced was rated a 9/10 (zero being no pain and ten the worst pain you can imagine). During a interview with Resident 16, on 2/21/13, at 5:05 PM, she indicated the pain medication she was presently taking was not controlling her pain. The resident stated "I'm always in pain". During an concurrent interview and record review with the Assistant Director of Nurses (ADON), 2/25/13, at 10:25 AM, the ADON she stated, "I haven't had a chance to do the pharmacy recommendation, I have a month to complete." The facility policy and procedure for the Pharmacy Review was not provided after two requests on 2/25/13, at 10:25 AM and again at 5:20 PM.

Based on interview and record review, the facility failed to meet professional standards of quality when it failed to: 1. To allow physician orders [REDACTED]. 2. To clarify medication orders written without frequency in administration for one of 24 sampled residents (6). This had the potential for overdosing. 3. To follow the plan of care for one of 24 sampled residents (4), this resulted in resident experiencing pain. Findings: 1. During a review of the clinical record for Resident 15, 1. The Diabetic Management flowsheet dated 2/1/2013-2/28/2013 indicated the resident was to receive insulin (medication to control blood sugar). The amount of insulin the resident was to receive was based upon her blood sugar level. Upon further review of the record, it was noted that on 2/13/13 Resident 15 received insulin however, there was no blood sugar reading recorded for that time. During an interview with the Assistant Director of Nursing (ADON), on 2/25/13, at 11:15 AM, she reviewed the clinical record for Resident 15 and was unable to find documentation of fasting blood sugar for 2/13/13 at 11:30 AM. The facility policy and procedure titled "Preparation and General Guidelines" dated 2007, indicated medications are administered in accordance with written orders of attending physician. 2. During a review of the clinical record for Resident 6, the "As Needed (PRN) Medications Flowsheets" dated 2/11/13, indicated 1. Tylenol ([MEDICATION NAME]) 1 tablet = 325 milligrams oral as needed 2. Tylenol 2 tablets = 650 milligrams oral as needed. During an interview with ADON, on 2/25/13, at 12:25 PM, she reviewed the electronic clinical record for Resident 6. She stated, "The Tylenol order is missing the frequency, this is a med error." The facility policy and procedure titled "2. Physician Medication Orders" dated December 2008, indicated orders for medication must include, name...dosage and frequency of administration. 3. During an interview with Resident 4 in his room on 2/20/13, at 12:40 PM, he stated Certified Nursing Assistant (CNA) 1, during the night shift, after Superbowl Sunday (2/3/13) was rough while turning him. Resident 4 yelled at him to stop. Resident 4 stated CNA 1 turned him over and dropped his foot on the pillow roughly, causing him pain and discomfort. During a review of the electronic clinical record for Resident 4 on 2/25/13, at 11:45 AM, the admitting documents indicated Resident 4 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan dated 10/07/11 indicated, Resident 4 had chronic pain related to arthritis; pain site: right hip and leg; approach: "Handle gently... position for comfort with physical support as necessary, provide rest to affected joints to relieve pain and provide stability." During an interview with the Administrator, on 2/21/13, at 1:25 PM, he stated he was aware of Resident 4's allegation.

Based on interview and record review, the facility failed to protect one resident (A) from injury when she fell from a mechanical lift onto the floor while in the facility. This resulted in injuries to Resident A, including a compression fracture to her spine, a contusion and swelling to her head, bruises to her body, and increased pain throughout her body that persisted for several days. Findings: During a review of the clinical record for Resident A, the "Resident Progress Notes" dated 12/8/12 at 9:42 AM read she was "lying on floor with lift (a mechanical device used to 'lift' a resident safely) tipped over on resident... indentation on right side of head noted." At 1:25 PM, the "Progress Notes" read "complains of severe nausea, headache, pain..." The "Progress Notes" indicate Resident A left the facility via ambulance at 2:02 PM for evaluation and treatment at a local emergency department, and returned at 10:20 PM later that day. During a review of Resident A's clinical record for her 12/8/12 visit to the Emergency Department of a local General Acute Hospital (GACH E), the document titled "Physician Documentation" indicated she complained of ankle and back pain. The documentation also indicated she received an injection of narcotic medication morphine for her pain, which was repeated sixteen minutes later. The document titled "Discharge Instructions" read Resident A was diagnosed with [REDACTED]. physician. Over the next five (5) days after returning to the facility, the "Progress Notes" indicated Resident A complained of pain to her back, shoulders, in between her shoulder blades, complained of nausea, refused to eat for "days", "hurts to take a deep breath", "lump to head", "severe headache", and "bad pain to whole body." The "Progress Notes" on 12/9/12 at 3:17 AM note a "discolored area blue - purple area to back of right heel and dark pink to right upper arm." The "Progress Notes" dated 12/12/12 at 10 AM, contained the following entries: "IDT (Interdisciplinary Team) Root Cause Analysis - fell while bumping head sustained while being mechanically lifted from bed to shower gurney (sic)... bumped head on bedside table... Recommendation: ... inservice all CNA's (Certified Nursing Assistants) on appropriate safety precautions and proper use of lifts." During a review of the clinical record for Resident A, the Minimum Data Set (MDS) (an assessment tool) dated 11/14/12 indicated she was able to make herself understood and understand others without any difficulties, had no cognitive deficits, did not suffer from delirium or mood disorder, and was without behavior issues. The MDS indicated Resident A needed two person physical assist for mobility in bed and to transfer to and from bed due to physical health issues. The MDS also indicated that during transfers, Resident A was "not steady, only able to stabilize with staff assistance." During an interview with Resident A on 12/27/12 at 12:55 PM, she stated she recalled the event where she fell to the floor during a lift transfer on 12/8/12. Resident A stated "As soon as I was away from the bed, the lift fell over, I was on the floor. I hit my head on the bedside table. Later, I had a headache and was sick to my stomach." Resident A also indicated she had been transferred many times in the past with the same lift without incident. Resident A stated "There had been no problems in the past, no falls. The only thing I knew of that was different about this transfer, was that (Licensed Nurse B) told me the lift's legs weren't apart like they were supposed to be. I was in a lot of pain, to my back, headaches, throwing up, I didn't eat, my heels were bruised from the fall." During an interview with CNA C on 12/27/12 at 1:20 PM at the facility, she stated she was one of two staff that was transferring Resident A on 12/8/12 when she fell to the floor. CNA C indicated the lift used was the "Vander-Lift II Model B-450", by pointing to it during the interview and stating "I'm pretty sure it was this one." CNA C indicated that during the transfer, "We had her (Resident A) up on the lift, she moved her arm a little, it tilted, the legs, they weren't open all the way, because they wouldn't fit under the bed." CNA C also stated Licensed Nurse B (LN B) came in the room after the fall. During an interview with LN B on 1/8/13 at 9:15 AM, he stated he recalled the event on 12/8/12. He stated when he entered the room, the legs of the lift were closed. LN B stated he asked the two CNA's about that, and they answered they hadn't opened the legs yet. During an interview with CNA D on 1/8/13 at 9:30 AM, she stated she recalled the event with Resident A on 12/8/12. CNA D indicated she and CNA C were the two staff assisting Resident A at the time of the fall. CNA D stated at the time of the fall, the legs of the lift "weren't completely open." CNA D stated she has since received training from the facility to make sure the legs of mechanical lifts were all the way open before using them to lift residents. The document titled "Operating Manual" for the Vander-Lift II (Model B-450) was reviewed. It contained the following entries: "Make sure there is enough room in the patient's room to do the transfer. Move furniture or other things that may be in the way", and, "Move the Vander-Lift II into position... Open the base to its widest position... The base of the Vander-Lift II should be open to its widest position for all transfers."