Every finding on record at White Pine Care Center

Based on observation, interview, record review and document review, the facility failed to ensure comprehensive care plans were created for 1) contractures and its management for 2 of 12 sampled residents (Resident 9 and 10) and 2) use of psychotropic medications with its corresponding indications and diagnoses for 5 of 12 sampled residents (Resident 9, 20, 36, 37 and 38). The deficient practice had potential for residents not to have care that is person centered pertaining to their diagnoses, medications, monitoring and care needs. Findings include: 1) Resident 9 (R9) R9 was admitted on [DATE], with diagnoses including hemiparesis following cerebral infarction and muscle weakness. R9 was observed on 05/05/2025 at 10:36 AM, wearing a right arm splint and deformity of the right lower extremity with right foot pointing inward and slight drop. R9 indicated staff applies the right arm splint. R9 physician's order dated 02/05/2025: Occupational Therapy (OT) clarification: Resident to participate in skilled OT services three times a week for 4 weeks. R9's OT Discharge Summary dated 02/26/2025, documented under Discharge Recommendations and Status: Functional Maintenance - Splint and Brace program established/trained: Wear schedule for right hand orthotic. R9's comprehensive care plan lacked documented evidence in addressing R9's contractures and use of splints. On 05/05/2025 at 3:12 PM, the consultant director of nursing (DON) confirmed R9 wears a right arm splint and indicated the importance of having a comprehensive care plan in addressing the application of the splint and also the care and maintenance needed for a resident wearing a splint. Resident 10 (R10) R10 was admitted on [DATE], with diagnoses including spastic hemiplegic cerebral palsy and scoliosis. On 05/04/2024 at 2:45 PM and 05/05/2025 at 10:10 AM, R10 was observed mobilizing self in a wheelchair. R10 was noted to have right arm pulled to upper chest and with wrist and hand curling. There was no support to the arm and hands preventing the involuntary flexion (a bending movement around a joint in a limb that decreases the angle between the bones of the limb at the joint of the muscles) of the right upper extremity. R10's Comprehensive Care Plan dated 10/24/2024 at 10:49 AM, documented R10 has limited physical mobility related to spastic hemiplegic cerebral palsy and multiple previous fractures. R10 will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Monitor/document/report as needed signs and symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. R10's current comprehensive care plan lacked documented evidence of any interventions to prevent and improve limitations of ROM and any interventions to prevent contractures. On 05/05/2025 at 3:12 PM, the DON confirmed had observed R10's right arm and hand contractures. The DON reviewed R10's medical record and confirmed R10's lack of care plan interventions. The consultant indicated care plan interventions for contractures could be as simple as nursing practices and be part of nursing assessments and interventions which should have been put into place to prevent progression of contractures. 2) Resident 9 (R9) R9 was admitted on [DATE], with diagnoses including major depressive disorder (MDD) and schizoaffective disorder. R9's physician's order documented two active psychotropic medications. Resident 20 (R20) R20 was admitted on [DATE], with diagnoses including hallucinations and insomnia due to other mental disorders. R20's physician's order documented three active psychotropic medications: Resident 36 (R36) R36 was admitted on [DATE], with diagnoses including bipolar disorder and depression. R36's physician's order documented three active psychotropic medications. Resident 37 (R37) R37 was admitted on [DATE], with diagnoses including major depressive disorder (MDD) and restlessness with agitation. R37's physician's order documented three active psychotropic medications. Resident 38 (R38) R38 was admitted on [DATE], with diagnoses including adult failure to thrive and depression. R37's physician's order documented two active psychotropic medications. R9, R20, R36, R37 and R38 lacked a comprehensive care plan addressing the residents' diagnoses and the psychotropic medications the residents are receiving. On 05/06/2025 at 1:55 PM, the Licensed Practical Nurse (LPN) indicated the nurse entering the medication order was responsible for ensuring side effect monitoring orders were entered in conjunction with psychotropic medications with black box warnings. The nurse indicated the DON in conjunction with MDS was responsible for entering care plans for the residents. On 05/07/25 at 9:15 AM, the Director of Nursing (DON) reviewed the medical records and confirmed the lack of care plans pertaining to the resident's diagnoses. The DON agreed psychiatric diagnoses and psychotropic medications should be carefully care planned due to the numerous interventions that had be covered in terms of behavioral interventions, care approaches and the management of psychotropic medications. The facility policy titled Use of Psychotropic Medications (undated), documented the effects of psychotropic medications on a resident's physical, mental, and psychological well-being will be evaluated on an ongoing basis, such as: In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice and the resident's comprehensive plan of care. The facility policy titled Comprehensive Care Plan (Undated), documented the facility is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and time frames to meet a resident's medical, nursing and mental and psychological needs and ALL services that are identified in the resident comprehensive assessment and meet professional standards of care.

Based on observation, interview, record review and document review, the facility failed to ensure a resident was assessed and interventions were implemented for upper extremity contractures for 1 of 12 sampled Residents (Resident 10). The deficient had potential for a resident not to maintain mobility and prevent the progression of contractures. Findings include: Resident 10 (R10) R10 was admitted on [DATE], with diagnoses including spastic hemiplegic cerebral palsy and scoliosis. On 05/04/2024 at 2:45 PM and 05/05/2025 at 10:10 AM, R10 was observed mobilizing self in a wheelchair. R10 was noted to have right arm pulled to upper chest and with wrist and hand curling. There was no support to the arm and hands preventing the involuntary flexion (a bending movement around a joint in a limb that decreases the angle between the bones of the limb at the joint of the muscles) of the right upper extremity. R10's last Occupational Therapy (OT) Discharge Summary dated 05/22/2023, documented R10 was able to raise arms straight out from shoulders. The prognosis is to maintain the current level of function was good with consistent staff follow-through. R10's Progress Notes documented the following assessments: 04/22/2024 at 9:27 PM, Note Text: This writer completed MDS interviews/assessments for R10. R10 had a right arm contracture. R10's Comprehensive Care Plan dated 10/24/2024 at 10:49 AM, documented R10 has limited physical mobility related to spastic hemiplegic cerebral palsy and multiple previous fractures. R10 will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Monitor/document/report as needed signs and symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. R10's medical record lacked documented evidence of any current involvement of rehabilitative services, physicians' orders to prevent and improve limitations of ROM and care plan interventions to prevent contractures. On 05/05/2025 at 3:12 PM, the Director of Nursing (DON) confirmed had observed R10's right arm and hand contractures. The DON reviewed R10's medical record and confirmed R10's lack of care plan interventions and orders to have rehabilitative services to assess R10's progression of right arm contracture from the last OT services. The DON indicated early detection of contractures should be part of nursing assessments and interventions should have been put into place to prevent progression. The facility policy titled Conducting an Accurate Assessment (undated), documented the physical, mental and psychological condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation services, activities, social workers, dieticians and other professionals in assessing the residents and in correcting resident assessments.

Based on interview, record review and document review the facility failed to ensure consent for psychotropic medications were obtained for psychotropic medications for 2 of 12 sampled Residents (Resident 37 and 38). The deficient practice had the potential for resident or resident representatives to be informed of the purpose and the possible side effects of medication affecting brain functions. Findings include: Resident 37 (R37) R37 was admitted on [DATE], with diagnoses including major depressive disorder (MDD) and restlessness with agitation. R37's physician's order documented the following psychoactive medications: Seroquel (an antipsychotic medication) 25 milligrams (mg) by mouth one time a day for agitation. Order date: 5/1/2025. Seroquel 50 mg by mouth at bedtime for agitation. Order date: 4/30/2025. Sertraline Hydrochloride (HCl) (an antidepressant medication) 100 mg by mouth one time a day for MDD. Order date: 1/4/2025. R37's medical record lacked documented evidence a consent was obtained prior to initiating the pharmacological intervention. Resident 38 (R38) R38 was admitted on [DATE], with diagnoses including adult failure to thrive and depression. R38's physician's order documented the following psychoactive medications: Duloxetine Hydrochloride (HCl) (an antidepressant medication) 30 milligrams (mg) by mouth at bedtime. Order date: 1/13/2025. Duloxetine HCl 30 mg by mouth two times a day for pain. Order Date: 2/25/2025. Olanzapine (an antipsychotic medication) 5 MG by mouth at bedtime for Depression. Order Date: 1/12/2025. R38's medical record lacked documented evidence a consent was obtained prior to initiating the pharmacological intervention. On 05/07/25 at 9:15 AM, the interim Director of Nursing (DON) reviewed the medical records and confirmed the listed medications were psychotropic medications and consents were not in the medical records. The DON indicated psychotropic medications consent should be filed in the medical records upon obtaining. The DON acknowledged consents for psychoactive medications were important to ensure disclosure of the effects of the medications and the possible side effects were discussed with the residents or their representatives. The facility policy titled Use of Psychotropic Medications (undated), documented prior to initiating or increasing a psychotropic medication, the resident, family, and/or representative must be informed of the benefits, risks, and the alternatives for the medication, including black box warnings for antipsychotic medications, in advance of such initiation or increase.

Based on interview, record review and document review the facility failed to ensure 1) monitoring of psychotropic medications were documented in the medical record for 2 of 12 sampled Residents (Resident 9 and 20), and 2) psychotropic side effect monitoring orders were obtained for 3 of 12 sampled Residents (Resident 36, 37, and 38). The deficient practice had a potential for residents not to be monitored for early signs of side effects caused by psychoactive medications. Findings include: 1) Resident 9 (R9) R9 was admitted on [DATE], with diagnoses including Major Depressive Disorder (MDD) and schizoaffective disorder. R9's physician's order documented the following psychoactive medications: Aripiprazole (an antipsychotic medication) 2.5 milligrams (mg) by mouth one time a day related to MDD. Order Date: 01/25/2024. Duloxetine Hydrochloride (an antidepressant medication) 60 mg by mouth at bedtime related to MDD. Order date: 09/03/2024. Both Aripiprazole and Cymbalta had a black box warning (the most severe warning the Food Drug Administration - FDA places on a medication's label) specifying: Increased risk of suicide in adults. High risk of major depressive or other psychiatric disorders (mania, hallucinations). Resulted in numerous Birth defect. R9's physician's order dated 09/28/2024, documented Administration Note: Increased risk of suicide in adults. High risk of major depression or other psychiatric disorders (mania, hallucinations). Resulted in numerous Birth defect. Monitor every day and night shift. The order was transcribed onto the Medication Administration Record (MAR). Review of the nurse entries on the MAR revealed numerous encodings of #9 followed by the nurse initials, (MAR numerical legend indicated #9 as, other/ see progress notes). There was a lack of documented entries in the progress notes to indicate what was observed from the numerical entry of #9 from the nurse. Resident 20 (R20) R20 was admitted on [DATE], with diagnoses including hallucinations and insomnia due to other mental disorders. R20's physician's order documented the following psychoactive medications: Seroquel (an antipsychotic medication) 37.5 mg by mouth at bedtime for Prophylaxis. Order date 04/08/2025. Sertraline (an antidepressant medication) 25 mg by mouth one time a day for dementia with depressed mood. Order date: 06/04/2024. Trazodone (an antidepressant medication) 50 mg by mouth in the evening for Depression causing insomnia. Order date: 07/10/2024. Both Sertraline and Trazodone had a black Box Warning. Indicating: Suicidality and antidepressant drugs. Antidepressants increased the risk of suicidal thoughts and behavior in adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. R20's physician's orders documented the following order: 09/28/2024, documented monitor for increased risk of suicide in adults. High risk of major depression or other psychiatric disorders (mania, hallucinations). Resulted in numerous Birth defect. Monitor every day and night shift 06/03/2024, Behaviors - Monitor for the following: hallucinations, two times a day. Review of April and May 2025, MAR revealed inconsistent monitoring of R20 wherein dates and shifts were not signed to attest monitoring of the behavior was completed. On 05/07/2025 at 9:15 AM, the Director of Nursing (DON) reviewed R9 and R20's MAR and progress notes. The DON confirmed entries of #9 on the MAR should be accompanied with a notation of the nurse in the progress notes. The DON indicated R20's MAR should be signed off every shift to verify the resident was monitored for the side effects of the psychotropic medication. 2) Resident 36 (R36) R36 was admitted on [DATE], with diagnoses including bipolar disorder and depression. R36's physician's order documented the following psychoactive medications: Bupropion (an antidepressant medication) 150 mg by mouth one time a day. Order date: 12/7/2024. Duloxetine Hydrochloride (and antidepressant medication) 60 mg by mouth one time a day. Order date: 12/7/2024. Clonazepam (a benzodiazepine sedative) 1 mg by mouth two times a day. Order date: 1/27/2025. Resident 37 (R37) R37 was admitted on [DATE], with diagnoses including major depressive disorder (MDD) and restlessness with agitation. R37's physician's order documented the following psychoactive medications: Seroquel (an antipsychotic medication) 25 mg by mouth one time a day for agitation. Order date: 5/1/2025. Seroquel (an antipsychotic medication) Oral 50 mg by mouth at bedtime for agitation. Order date: 4/30/2025. Sertraline (an antidepressant medication) 100 mg by mouth one time a day for MDD. Order date: 1/4/2025. Resident 38 (R38) R38 was admitted on [DATE], with diagnoses including adult failure to thrive and depression. R38's physician's order documented the following psychoactive medications: Duloxetine Hydrochloride (and antidepressant medication) 30 mg by mouth at bedtime. Order date: 1/13/2025 Duloxetine Hydrochloride (and antidepressant medication) 30 mg by mouth two times a day for pain. Order Date: 2/25/2025 Olanzapine (an antipsychotic medication) 5 mg by mouth at bedtime for Depression. Order Date: 1/12/2025 20:00 R36, R37 and R38's physician's orders for psychotropic medications had a corresponding block box warning indication to monitor for side effects. R36. R37 and R38's lacked documented evidence physician's orders for side effect monitoring was entered. On 05/06/2025 at 1:55 PM, a Licensed Practical Nurse (LPN) indicated the nurse entering the medication order was responsible for ensuring side effect monitoring orders were entered in conjunction with psychotropic medications with block box warnings. The nurse agreed some of the residents with psychotropic medications did not have the side effect monitoring orders placed as a physician's orders. On 05/07/25 at 9:15 AM, the Director of Nursing (DON) reviewed the medical records and confirmed the medications were psychotropic medications with block box warnings. The DON confirmed R36, 37 and R38 did not have any orders to monitor the side effects of the medications. The DON acknowledged the importance of the early detection of the side effects of the drug. The facility policy titled Use of Psychotropic Medications (undated), documented the resident's response to the medication, including progress towards goals and presence and absence of adverse consequences, shall be documented in the resident's medical record.

Based on interview, record review and document review, the facility failed to ensure timely reporting to the State Agency of an incident of abuse for 1 of 12 sampled Resident (Resident 30). The deficient practice had potential for an untimely review by the SA of the investigative process completed by the facility to ensure corrective actions were taken. Findings include: Resident 30 (R30) R30 was admitted on [DATE], with diagnoses including hypertension and chronic obstructive pulmonary disease. Resident 5 (R5) R5 was admitted on [DATE], with diagnoses including epilepsy and schizoaffective disorder. Review of R30's medical record documented an incident with R5. A summary of the incident is as follows: On 03/06/2025 at approximately 8:35 PM, R30 was having a conversation with one of the nurses. R5 walked over to the office to join the conversation and was standing in the doorway when R5 began to lean forward as if was going to fall. To regain balance, R5 reached out and placed hand on R30's left neck in the space between neck and shoulder. R30 put hand on R5's abdominal area to keep from falling. R5 then began to shout at R30 to not touch the resident. R5 repeated self three times. The nurse had already gotten out of the chair when two CNAs arrived at the office door to help and to redirect R5 back to the room. No restraint or force was needed or used. R30 stated having pain on the resident's left side from the weight of R5 trying to regain balance but declined further medical evaluation. R5 and R30's progress notes revealed no untoward effects of the incident. Review of the investigation packet completed by the facility revealed the facility had completed a thorough investigation of the incident. The compiled staff statements revealed R30 continuously alleged R5 of physical abuse after the incident. The report documented the Administrator in Training (AIT) was made aware of the incident on 03/07/2025 at 1:00 PM. The Facility Reported Incident was filed initially to the SA on 03/12/2025, and a final report on 03/14/2025. On 05/06/2025 at 2:50 PM, the AIT confirmed the reporting was delayed to the SA and the incident should have been reported within the 24-hour period. The AIT acknowledged the importance of reporting abuse to the SA and compliance with the regulations. The facility policy titled Abuse, Neglect and Exploitation (undated), documented reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified time frames: Not later than 24 hours if the event that caused do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, record review and document review, the facility failed to ensure 1) a neurological check after a head injury was completed for 1 of 12 sampled Residents (Resident 14). The deficient practice had potential for a resident not to be monitored for latent effects of a head injury and 2) splinting orders were obtained for 1 of 12 sampled Resident (Resident 9). The deficient practice had potential for not receiving continuity of care with prevention of contractures. Findings include: 1) Resident 14 (R14) R14 was admitted on [DATE], with diagnoses including Parkinson's disease and muscle weakness. R14's progress notes documented the following incident: On 04/08/2025 at 2:20 PM, Incident Note: Member of housekeeping alerted Nursing Staff about R14 falling after standing from wheelchair in front of nightstand. R14 fell and hit the right ear lobe and began bleeding. R14 is also on a blood thinner which could have increased the bleeding. R14 was helped back into the wheelchair by the staff. Nursing had bandaged the ear after hearing aid was removed. R14 was transported via facility van to the Emergency Department (ED) with two certified nursing aides. R14 was returned to the facility the same day after treatment and evaluation from the ED. A physician's visit note dated 04/09/2025 at 9:25 AM, documented ground-level fall on 04/08/2025 due to slippers around 2:00 PM, unwitnessed, sustained right ear laceration status post suture placement in emergency room , questionable head injury and loss of consciousness. Physical exam with right ear laceration with suture, no bleeding. Slow on cerebellar function with finger-to-nose test and alternate hand turning. Start neuro check for 3 days and head computerized tomography scan (CT). Continue trending vital signs 3 times daily for 1 week. Suture to be removed in 10 days. R14's medical records lacked documented evidence, a post fall assessment and neurological checks were completed after a fall causing a head injury. On 05/07/2025 at 9:28 AM, the interim director of nursing (DON) indicated remembering the incident. The DON reviewed R14's medical record and confirmed the absence of fall assessment and neurological checks. The DON acknowledged neuro checks should have been initiated after the fall and continued even with a negative CT of the head, to ensure the resident is monitored for any latent effects of a head injury. The facility policy titled Head Injury (Undated), documented 1) assess resident following a known, suspected, or verbalized head injury. 4) perform neuro checks as indicated or as specified by the physician. 2) Resident 9 (R9) R9 was admitted on [DATE], with diagnoses including hemiparesis following cerebral infarction and muscle weakness. R9 was observed on 05/05/2025 at 10:36 AM, wearing a right arm splint and deformity of the right lower extremity with right foot pointing inward and slight drop. R9 indicated staff applies the right arm splint. R9's physician's order dated 02/05/2025: Occupational Therapy (OT) clarification: Resident to participate in skilled OT services three times a week for 4 weeks for diagnosis: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, flaccid hemiplegia affecting right dominant side. Plan of Care (POC) to include the following: orthotic management and training, therapeutic activity, self-care training, therapeutic exercises, neuromuscular re-education. No directions specified for order. R9's OT Discharge Summary dated 02/26/2025, documented under Discharge Recommendations and Status: Functional Maintenance - Splint and Brace program established/trained: wear schedule for right hand orthotic. R9's medical record lacked physician order for the application and care/maintenance of the right-hand splint. On 05/05/2025 at 2:47 PM, the Occupational Therapist Assistant (OTA) indicated R9 has been diligent in requesting right arm splint to be applied by staff. The OTA confirmed there was no set schedule for the splint to be applied. The OTA agreed physician orders should have been placed to ensure staff would apply the splint according to specific orders. On 05/05/2025 at 3:12 PM, the Director of Nursing (DON) confirmed R9 wears a right arm splint and indicated the importance of having a physician's order to ensure implementation of splint care. The DON acknowledged nursing would take therapy discharge recommendations and implement it as a physician's order then transcribe the order onto the treatment administration record. The process ensures staff would be triggered to apply the splint and ensures continuity of care. The facility policy titled Provisions of Physician's Orders (undated), documented qualified nursing personnel will submit timely requests for physician ordered services from the appropriate entity. This policy is to provide reliable processes for the proper and consistent provision of physician ordered services according to professional standards of care.

Based on observation, interviews, record review and document review, the facility failed to ensure Oxygen (O2) saturations (a measure of how much oxygen a person's blood is carrying, expressed as a percentage) were obtained as ordered for the titration of O2 for 2 of 12 sampled residents (Resident 4 and 36). The deficient practice had potential for a resident to receive more O2 than what the body requires. Resident 4 (R4) R4 was admitted on [DATE], with diagnoses including chronic kidney disease and hypertension. On 05/04/2025 at 3:45 PM, R4 was observed sitting by the bedside with an oxygen cannula. The resident's concentrator (a medical device that separates oxygen from air, providing a higher concentration of oxygen to individuals who need supplemental oxygen therapy) was set to deliver 4 liters of Oxygen. R4 shrugged shoulders when asked who adjusts the level of the Oxygen machine. R4 physician's order dated 10/12/2024, documented Oxygen: (2 to 4) Liters per minute, Delivery: Cannula or mask to keep Oxygen saturation (O2 sats) greater than 90%, every shift for low O2 sats. R4's April and May Medication Administration Record (MAR) revealed inconsistent documentation of obtaining the resident's O2 saturations. Resident 36 (R36) R36 was admitted on [DATE], with diagnoses including chronic ischemic heart disease and peripheral vascular diseases On 05/05/2025 at 8:47 AM, R36 was observed with the O2 concentrator set at 5 liters via nasal cannula. R5 indicated nurses were the ones adjusting the level of O2. R36 physician's order lacked any specific O2 liters to be delivered. A physician's order dated 12/07/2024, documented O2 saturation every shift. R36's April and May Medication Administration Record (MAR) revealed inconsistent documentation of obtaining the resident's O2 saturations. On 05/05/25 at 3:20 PM, the Director of Nursing (DON) reviewed R4 and R5's MAR and confirmed the inconsistent documentation of the resident's O2 saturations. The DON acknowledged the importance of monitoring O2 saturations and adjusting the O2 liters to the least possible amount while maintaining adequate oxygenation. The facility policy titled Oxygen Administration (undated), documented monitoring O2 saturation levels and/or vital signs as ordered by the physician.

Based on interviews and record review, the facility failed to ensure 12-hour annual in-service training, as required for five of five Certified Nurse Aides (CNAs) (CNA4, CNA6, CNA5, CNA3, and CNA2) reviewed for training requirements. This failure placed the residents at risk of lacking the required knowledge and competency to perform their duties. Findings include: All five employee files were provided by Human Resources on 04/18/24. 1. Review of CNA4's employee file revealed a hire date of 05/24/22. The file contained no documentation regarding the required 12 hours of in-service training having been completed in the last year. 2. Review of CNA6's employee file revealed a hire date of 11/20/20. The file contained no documentation regarding the required 12 hours of in-service training having been completed in the last year. 3. Review of CNA5's employee file revealed a hire date of 12/21/22. The file contained no documentation regarding the required 12 hours of in-service training having been completed in the last year. 4. Review of CNA3's employee file revealed a hire date of 01/21/22. The file contained no documentation regarding the required 12 hours of in-service training having been completed in the last year. 5. Review of CNA2's employee file revealed a hire date of 12/30/22. The file contained no documentation regarding the required 12 hours of in-service training having been completed in the last year. On 04/18/24 at 11:55 AM, the Director of Nursing (DON) was asked if had documentation of the 12 hours of in-service training to include abuse/neglect and dementia care. The DON stated that had just been hired at the facility in the last 16 days and was not aware of what in-service training had been provided. On 04/18/24 at 1:43 PM, the DON provided the following in-service training to the survey team: -06/08/23, Abuse/neglect. -[DATE]: infection control. - 03/19/24 (30 min): on the facility elopement process, cultural competency (no date/time) - COVID-19 on 11/25/23. There was no dementia care/behavior training in the last 12 months. The DON was asked if these in-services were 12 hours, as required in the last year. The DON stated, no, this is all I could find.

Based on observations, interview, record review, and facility policy review, the facility failed to provide interventions and meal assistance to address significant weight loss for one resident (Resident (R) 13) and ensure consistent weighing methods for one resident (R16) of the eight residents reviewed for nutritional status out of 17 sampled residents. This deficient practice placed the residents at risk for new or continued weight loss potentially impacting the resident's quality of life. Findings include: Facility policy titled, Nutrition (Impaired)/Unplanned Weight Loss Clinical Protocol, revised 03/03/24, revealed: 1. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. a. Treatment decisions should consider all pertinent evidence and relevant issues (e.g., food intake, resident patient wishes, overall condition and prognosis, etc.), and should not be based solely on lab [laboratory] or diagnostic test results (albumin, cholesterol, swallowing studies, etc.). 2. The physician will authorize appropriate interventions, as indicated. a. This may include tapering, stopping, or switching medications known to be associated with undesirable weight gain or anorexia or weight loss. b. The physician will document if cause-specific interventions could not be identified or are not feasible. Facility policy titled, Weights, revised 03/03/24, revealed: For residents on dialysis, the center uses weights from the dialysis center. Any weight with a 5-lb. variance is re-weighed within 24 hours. Only after a re-weight has been completed, will a weight be recorded on the permanent Weight Record. Resident 13 (R13) R13's Face Sheet documented R13 was admitted on [DATE] with diagnoses of cerebral palsy (CP), autistic disorder, and severe intellectual disabilities. R13's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/17/23 revealed, R13 needed limited assistance eating with one person assist. R13's Brief Interview for Mental Status (BIMS) was a zero, meaning that R13 was not able to be interviewed. Physician order dated April 2024, documented Regular, finger foods diet, soft and bite sized texture diet. No evidence of an appetite stimulant and/or supplements were ordered. Physician orders dated 04/01/23-present, revealed no evidence of an appetite stimulant and/or tube feeding being ordered. This included current and discontinued orders. On 04/17/24 at 3:55 PM, R13's guardian indicated a major concern was R13's constant weight loss. The guardian verbalized at the last two care conferences had asked the facility for a list of snacks and/or food that R13 would eat, and the guardian would provide to the facility; however, to this date, the guardian had not received anything from the facility. R13's guardian stated the facility did not inform the guardian when R13 began losing weight and had attended the care conferences all the time. The guardian indicated the facility had not talked with the guardian about tube feeding (TF). The guardian indicated the former Director of Nursing (DON) stated that R13 had outlived the life expectancy based on the resident's diagnosis. The guardian expressed feelings that the facility forgets about R13. A Nutrition/Dietary Note dated 10/11/23, revealed Quarterly Registered Dietitian (RD) note .Significant weight loss x six months likely related to poor by mouth (PO) intake .Have trialed magic cup, did not like .10/03/23 weight: 79.8 pound (lb.), 09/07/23 weight: 80 lb. (-.25% x one month), 07/18/23 weight: 83.8 lb. (-4.7% x three months), 04/03/23 weight: 90.8 lb. (-12.1% x six months) .Continue plan of care (POC). A Physician Visit note dated 11/08/23, revealed .Oral surgery with total teeth removed on 05/11/23. Has been eating ok now. Revealed no evidence of weight loss was mentioned. A Nutrition/Dietary Note dated 12/06/23, revealed Weight change .Per nursing, patient does not like to eat much .Have trialed magic cup, did not like. Dietary Manager (DM) has trialed house protein shakes with little to no intake .Appetite stimulant and tube feeding (TF) discussed; however, denied at this time due to previous attempts and failures .12/06/23 weight: 74.4 lb., 11/07/23 weight: 75.2 lb. (-1.1% x one month), 09/07/23 weight: 80 lb. (-7.0% x three months and 06/07/23 weight: 85.8 lb. (-13.3% x six months) .Continue POC. A Physician Note dated 04/03/24, revealed R13 was noted by nutritionist and pharmacy to have ongoing weight loss over the last year 2023 after starting Topamax 200 milligrams (mg) for R13's seizure control. No seizures since 03/12/23 .Decrease Topamax to 150 mg, encouraging oral diet. A Nutrition/Dietary Note dated 04/04/24, revealed Quarterly RD note PO intake variable, refusing meals at times. Have trialed supplements, special meals .discussed tube feeding with the DON/MD, declined. Enjoys ice cream, apple juice. DON will occasionally bring [name of outside food restaurant] for R13, which R13 enjoys Requires supervision with meals. Body mass index (BMI) is 15.0, underweight. Significant weight loss for six months is likely related to poor PO intake. Encourage PO intake. Offer snacks between meals .03/07/24 weight: 72 pounds (lb.), 02/06/24 weight: 75 lb. (-4.0% x one month), 12/06/23 weight: 74.4 (-3.2% x three months), and 09/07/23 weight: 80 lb. (-10.0% x six months) Continue plan of care (POC). A Nutrition/Dietary Note dated 04/09/24, revealed High risk RD note: weight change patient does not like many things, refuses supplements. Discussed TF, appetite stimulant with Director of Nursing (DON)/Medical Doctor (MD), declined Significant weight loss times one year .04/08/24 weight: 72.6 lb.04/03/23 weight: 90.8 lb. (-20% x one year) .Continue POC. A Physician Note dated 04/11/24, revealed Clinically stable .Patient was discussed during table rounds today for MDS; most recent change was decreasing Topamax from 200 mg to 150 mg on 04/03/24 secondary to weight loss. Review of R13's Nursing Notes dated 04/01/23-present, revealed no evidence of TF and/or appetite discussed and denied. Review of R13's Physician Notes dated 04/01/23-present, revealed no evidence of TF and/or appetite discussed and denied. On 04/18/24 at 8:02 AM, R13 was sitting at a table in the main dining room with a breakfast tray in front of the resident. R13's tray had French toast casserole, bite sized sausage, yogurt, and eggs with eight-ounce glasses of orange juice (OJ), milk, apple juice, and water. At 8:13 AM, R13 was observed to eat 50% of the breakfast meal. R13 drank all of the OJ, 75% of the milk, and 95% of the apple juice. R13 refused the water and yogurt. R13 ate 50% of the food on the tray. R13 was able to feed self after staff placed food on the fork. When R13 was done with breakfast, R13 gently pushed the staff's hand away and removed the clothing protector. When R13 was done, staff removed the resident from the dining room and went back to the resident's room. Review of facility provided R13's Dietary Slip, dated 04/18/24, revealed Nutrition enhanced meal (NEM), soft bite (SB6), Finger foods (FGRFD). Preferences: French toast, hashbrown potatoes, pancakes, sausage, and toast. Beverages/Equipment: apple juice eight ounce, OJ eight-ounce, strawberry yogurt, water eight-ounce, whole milk eight ounce, and scoop plate. Allergies/Dislikes: bacon, cereal, ham and waffles. On 04/18/24 at 8:17 AM, the Medical Director indicated in the last two to three weeks had started tapering down R13's Topamax dosage. The Medical Director stated R13 picked and chose what the resident wanted to eat. The Medical Director verbalized back in September 2023, had recommended a [NAME] diet due to this diet prevented seizures but was unsure if R13 was receiving this diet. The Medical Director indicated must look at balancing the resident's seizures and weight loss; however, the last seizure was over a year ago. The Medical Director stated would expect the nursing staff to notify the guardian of R13's weight loss. The Medical Director verbalized there had been no discussion about an appetite stimulant for R13. The Medical Director stated that anything new introduced to R13 was very hard due to te resident's behavioral issues and felt that a tube feeding would be way too invasive for R13. The Medical Director indicated R13 tended to fight staff, attempted to bite, and slapped staff. On 04/18/24 at 9:26 AM, the DM indicated there has been no talk about an appetite stimulate; however, did indicate that the RD recommended an appetite stimulate due to R13's continued weight loss. The DM indicated R13 was very hard to feed, and seemed as if R13 liked kids food. The DM stated had tried hot pockets, chicken nuggets, ice cream, hot dogs, hamburgers, pizzas, burritos. Also, indicated R13 has been trialed on different supplements such as magic cup, boost, and protein shakes, which R13 had refused to drink. The DM stated R13 currently was into mashed potatoes and hashbrowns. The DM explained the mashed potatoes had powered milk inside of them for increased protein, and extra butter for increased calories. The DM indicated R13 had never been on a keto diet. On 04/18/24 at 9:55 AM, Certified Nursing Assistant (CNA4) weighed R13 in the resident's wheelchair. CNA4 indicated R13's wheelchair weighed 35 pounds and total together the observed weight was 105.2 pounds. When the wheelchair weight was substantiated, R13's actual weight was 70.2 pounds. This end weight was confirmed by CNA4, indicating a 2.4-pound loss in 17 days. On 04/18/24 at 11:55 AM, R13's lunch tray was placed in R13's bedroom on the overbed table, while R13 was lying in the bed asleep. At 11:56 AM, surveyor went into R13's bedroom, to see R13's lunch tray. The tray had eight-ounce glasses of milk, water, and apple juice. On R13's plate, was a piece of cake, piece of bread, medium portion of mash potatoes with brown gravy, small amount of fresh fruit, and large portion of ground beef topped with spaghetti sauce. The resident's tray was untouched and covered. On 04/18/24 at 12:00 PM, staff entered R13's bedroom, turned around and left. At 12:06 PM, staff entered R13's bedroom again, picked up some of R13's clothing and left the room. At 12:26 PM, R13's lunch tray remained on the over bed table, untouched and covered. At 12:44 PM, staff obtained R13's lunch tray from the resident's room and placed it on an open metal cart. At 1:07 PM, R13's lunch tray was observed and was untouched. Review of facility provided R13's Dietary Slip, dated 04/18/24, revealed NEM, SB6, FGRFD. Preferences: mashed potatoes/gravy. Beverages/Equipment: apple juice eight-ounce, water eight-ounce, whole milk eight ounce, and scoop plate. Allergies/Dislikes: bacon, ham, rice and side vegetables. On 04/18/24 at 1:10 PM, the Social Service Designee (SSD) indicated weight loss had been an on-going concern for R13. The SSD indicated one day R13 would eat and the next day, R13 would throw the food. The SSD was unaware when the guardian had been notified of the beginning of R13's weight loss. On 04/18/24 at 1:21 PM, the Director of Nursing (DON) stated was aware of R13's weight loss, but unaware of discussing an appetite stimulant and/or tube feeding. The DON confirmed staff should have attempted to feed R13 the lunch tray and not just leave the tray in the resident's room. On 04/18/24 at 2:00 PM, the RD stated the first time that an appetite stimulant and/or tube feed was discussed with the DON was on 11/08/23. However, in a follow up on 12/06/23, was told that both have been tried and did not work, so the recommendation was denied. The RD was unaware of the type of TF and/or appetite stimulant that was used prior. The RD indicated had asked no further questions. The RD explained there was no nutritional committee, and the RD did not communicate with the physician. The RD verbalized the facility had done special meals, the previous DON had brought in outside food for R13, had tried supplements which R13 has refused, and there had been trials of different foods to see what R13 would eat. The RD's understanding was R13 was a 1:1 assistant for feeding. The RD indicated not feeding and/or not offering R13's lunch today was unacceptable and would have expected staff to offer R13 snacks and/or an alternative since R13 did not eat. On 04/19/24 at 9:28 AM, the DM indicated the only enhanced foods R13 got this week was mashed potatoes with extra butter and powdered milk and macaroni and cheese. On 04/19/24 at 9:30 AM, R13 was in bed sleeping, a breakfast tray was sitting on the overbed table. R13 had drank 100% of the eight-ounce glasses of milk, orange juice, and apple juice. R13's plate still had one small hash brown, one piece of toast cut in half, and bite size sausage. The hash brown and toast had not been touched and it appeared that the bite sized sausage had approximately two percent eaten. On 04/19/24 at 10:00 AM, Licensed Practical Nurse (LPN 1) indicated was unaware of R13 not eating lunch on 04/18/24, and would have expected the staff to make the LPN aware of. LPN 1 indicated R13's food intake and weight has been going down ever since R13 had teeth extracted. LPN 1was unsure of the timeframe but thought it was sometime summer 2023. LPN 1 indicated dietary had been trying different foods over and over, and R13 was getting tired of those foods. LPN 1 verbalized sometimes would bring in outside food for R13 because some food was better than nothing at all. LPN 1 confirmed R13 was forgotten about sometimes, not on purpose, but R13 did not get the attention the resident needed and deserved. To the LPN's knowledge a by mouth (PO) appetite stimulate had never been considered for R13. LPN 1 expected staff would always offer R13meals and was aware of the 2.4-pound weight loss in 17 days. On 04/19/24 at 12:01 PM, R13's lunch tray was sitting on the overbed table with eight-ounce glasses of milk, apple juice, and water. R13's lunch plate had mashed potatoes with white gravy and bite sized country fried steak with white gravy. There was one roll, and a small cup of ice cream. The lunch tray was not touched and still covered. At 1:15 PM, R13's lunch tray remained on the overbed table with the eight-ounce glass of milk 75% drank, and 95% apple juice drank. However, the plate still had the mashed potatoes and bite sized country fried steak untouched. The ice cream and roll had been untouched. On 04/19/24 at 12:05 PM, LPN2 indicated R13 had never had a tube feeding and/or had one been discussed. Resident 16 (R16) R16's significant change MDS with an ARD of 02/15/24, revealed R16 had a readmitted [DATE]. R16 had a BIMS score of 10 out of 15, indicating R16 had moderately impaired cognition and diagnoses of end stage renal disease, diabetes mellitus, congestive heart failure, malnutrition, and received dialysis. R16's Diet Profile, dated 03/29/23, revealed no food preferences. R16's Care Plan revised 12/13/23, revealed R16 is at risk for unplanned/unexpected weight loss r/t [related to] poor food intake. The goal included R16 will consume 75% of two of three meals/day. Interventions included: Give R16 supplements as ordered. Alert nurse/dietitian if not consuming on a routine basis and weigh per center protocol. R16's clinical record revealed orders for Renal diet, 7 Regular texture, Regular consistency, CCHO [controlled carbohydrates]; 1.5L [liter] fluid restriction, dated 12/09/23, and may have between meal and HS [bedtime] snack within dietary parameters dated 03/30/23. No supplements were ordered. Review of R16's Nutrition- Amount Eaten form dated 03/19/24 to 04/17/24, revealed R16 consistently consumed 76-100% of meals. No documentation was found for snack consumption. An RD [Registered Dietitian] Nutritional Assessment, dated 04/09/24, revealed a 12% increase weight change from 204 pounds (Lbs.) and Comments: HD [hemodialysis] MWF [Monday Wednesday Friday]. No sig [significant] changes, sig wt [weight] loss x 1-month, likely r/t [related to] fluid shifts dt [due to] ESRD [end-stage renal disease] on HD. Weekly wts. Review of R16's weight history, revealed R16 had lost 6% of the resident's body weight in three months and 13% in 10 days. This included: On 04/18/24 at 10:09 AM R16's weight was observed at 177.2 Lbs. while standing On 04/08/24 at 204.0 Lbs. while in a wheelchair On 03/07/24 at 181.0 Lbs. while in a wheelchair On 02/27/24 at 181.2 Lbs. while in a wheelchair On 02/13/24 at 182.6 Lbs. while in a wheelchair On 02/07/24 at 173.6 Lbs. while in a wheelchair On 02/06/24 at 173.6 Lbs. while in a wheelchair On 01/25/24 at 187.0 Lbs. while standing On 01/17/24 at 190.0 Lbs. while in a wheelchair On 01/09/24 at 187.8 Lbs. while in a Wheelchair On 01/05/24 at 190.0 Lbs. while standing Review of R16's dialysis communications revealed R16's post weight was 80.8 [177.8 Lbs.]) on 04/08/24 and 80.2 [176.4 Lbs.] on 04/17/24. These weights were a difference of 26.2 Lbs. and 27.6 Lbs., respectively, from the facility's weight for R16 dated 04/08/24. On 04/16/24 at 11:56 AM, R16 was served lunch which included lettuce, quesadillas, refried beans, fruit, a glass of water, and tea. R16 consumed the meal well. On 04/18/24 at 7:58 AM, R16 was served breakfast that included milk, coffee, french toast casserole, and a sausage patty. Cereal was not included as per the menu. R16 was asked why hadn't receive cereal, and stated didn't know, but liked cereal. R16 consumed the meal well. Review of the CCHO/renal menu for breakfast on 04/18/24, provided by the facility, revealed cereal, sausage patty, and french toast casserole. On 04/18/24 at 12:10 PM, R16 was served lunch which included tea, coffee, pasta with meat balls, a [NAME] salad, grapes, and garlic bread. R16 ate well. On 04/18/24 at 8:28 AM, the Medical Director (MD) was asked if was aware R16 had lost weight and there were discrepancies between the facility weights and the dialysis weights. MD confirmed R16 was on dialysis, but relied on the facility's weights, not the dialysis weights. MD gave no further explanation. On 04/18/24 at 10:02 AM, CNA4 confirmed was the person who weighed the residents. CNA4 was asked about how R16 was weighed. CNA4 stated sometimes weighed R16 standing and other times in a wheelchair. CNA4 stated didn't rely on the dialysis weights and didn't review them. On 04/18/24 at 10:23 AM, LPN1 was asked about the facility's method in obtaining R16's weight. LPN1 stated the facility weighed R16 but weren't consistent with obtaining weights as sometimes R16 was weighed in a wheelchair and other times standing. LPN1 stated was aware the dialysis also weighed R16, but did not use their weights, but the MD used the dialysis weights. During a telephone interview on 04/18/24 at 2:28 PM, the RD was asked if was aware of R16's weight loss and the RD stated yes. The RD stated R16 was on dialysis and the resident's weight fluctuated due to fluid shifts. The RD was asked if was aware R16 ate well but was weighed today, 04/18/24, at 177.2 Lbs., which was down from 204 Lbs. on 04/08/24, a difference of 26 Lbs. The RD indicated was not aware. The RD was asked about R16's post weight at the dialysis center of 80.8 [177.8 Lbs.] that was taken on 04/08/24 same day the facility weighed R16 at 204 Lbs. The RD stated residents should be reweighed if the dialysis weights were different from the facility weights. The RD asked if any interventions were in place for R16, and the RD indicated would have to check. On 04/19/24 at 9:22 AM, the DM and Dietary Supervisor (DS) were asked why R16 didn't receive cereal at breakfast 04/18/24. DS reviewed R16's meal ticket and menu and confirmed there was no reason why R16 shouldn't have received cereal. DS stated it was the DS's mistake and confirmed R16 had not been receiving cereal at breakfast since the resident's readmission. DM indicated thought R16 had requested no cereal, but there was no documentation of this. DM confirmed this was a missed opportunity for additional calories. DM confirmed R16 only received bedtimes snacks and additional snacks would only be upon request. On 04/19/24 at 12:32 PM, DON asked for the R16 weight record from 04/19/24. DON stated was aware of the 26 Lbs. difference from 04/08/24 to 04/18/24. DON stated would be implementing a better system to ensure more accuracy. 36190

Based on interview, record review and review of the facility policy, the facility failed to ensure that indications and signs and symptoms for use of antibiotic medications were documented for 1 of 17 sampled residents (Resident (R) 2) resulting in the potential for adverse side effects from unnecessary medications. Findings include: Facility's policy titled, Urinary Tract Infection/Bacterial Protocol, dated 03/03/24, documented, .Empirical treatment should be based on a documented description of an individual's symptom and on consideration of relevant test results, co-existing illnesses and conditions, and pertinent risk factors .Bacteriuria alone (an asymptomatic UTI) should not be treated routinely . and .decisions should be made primarily on the basis of clinical signs and symptoms . Resident 2 (R2) R2's undated Admission Record revealed R2 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder, chronic respiratory failure, and hypertension. R2's quarterly Minimum Data Set (MDS) revealed R2 had a Brief Interview for Mental Status (BIMS) of 15 of 15 which indicated the resident was cognitively intact. R2's Progress Notes revealed no documentation prior to 02/26/24 which indicated R2 was showing signs and symptoms of a urinary tract infection (UTI). -Urinalysis (UA) results on 02/26/24, revealed .Nitrites positive, Leukocytes large and Bacteria 2+ . -The culture and sensitivity (C&S) final results on 02/29/24 revealed .Greater than 2 organisms recovered, none predominant. Please submit another sample if clinically indicated . No documentation was noted in R2's Progress Notes to indicate whether another urine specimen was collected, or clinically indicated. R2's Progress Notes revealed R2 was treated with Cefdinir (an antibiotic) 300 mg (milligrams) orally twice a day for five days. Review of R2's February 2024 Medication Administration Record (MAR) revealed R2 received the antibiotic from 02/27/24 through 03/03/24. R2's Progress Notes revealed R2 was sent to the Emergency Department (ED) on 02/28/24 for Acute Kidney Failure, based on elevated labs ordered on 02/27/24 by R2's attending physician. While at the ED, R2 was diagnosed with a UTI, an indwelling urinary catheter was inserted, and R2 was started on Keflex (an antibiotic) 500 milligrams (mg) orally (po) three times a day for seven days. When R2 returned to the facility the nursing staff failed to notify R2's attending physician of the new order for the antibiotic. Review of R2's March 2024 MAR revealed R2 continued with the Keflex (oral antibiotic) 500 mg po three times a day for five days from 03/03/24 through 03/08/24. Review of R2's EMR revealed a UA was ordered on 03/23/24 for .change in urine color/strong odor . R2's Progress Notes dated 03/23/24, revealed no documentation which indicated R2's urine had a change in color or strong odor. No further documentation was noted which indicated the facility attempted any non-pharmacological interventions, such as increasing fluids, for R2. R2's EMR lab results revealed UA results for 03/23/24, revealed - .Nitrites positive, Leukocytes - trace and Bacteria 4+ . -UA C&S [culture and sensitivity] final culture report dated, 04/01/24, revealed .Gram negative rods, Morgenella morganii 25,000 - 50,000 . -Cultures showing bacterial growth less than 100,000 are not clinical indicators of a UTI. No documentation was noted in R2's Progress Notes indicating R2 was showing any signs and symptoms of a UTI. Review of R2's March 2024 MAR revealed R2 was treated with Bactrim DS (antibiotic) orally one tab twice a day for seven days from 03/25/24 through 03/31/24. On 04/19/24 at 11:45 AM, Licensed Practical Nurse (LPN 1) verbalized was unable to recall R2 showing any clinical indicators for a UTI and indicated there was no documentation in R2's Progress Notes which indicated R2 had a UTI. On 04/19/24 at 1:30 PM, Director of Nursing (DON) confirmed R2's Progress Notes did not have documentation that clearly indicated R2 was showing signs and symptoms related to a UTI. The DON also stated the expectation was nursing staff clearly document indications of a possible UTI, the rationale for obtaining a urine specimen and starting an antibiotic.

Based on interview and record review, the facility failed to ensure the licensed consultant pharmacist performed a monthly medication regimen review for December 2023, for two of five residents (Residents (R) 16 and R18) reviewed for unnecessary medications of 17 sampled residents. This failure placed the residents at risk of the physician and nursing staff not being aware of irregularities. Findings include: Resident 18 (R18) An Admission Record, provided by the Director of Nursing (DON), revealed R18 was admitted to the facility on [DATE] with diagnoses including alcohol induced dementia with violent behaviors and diabetes. R18's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/23, revealed R18 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R18 was severely impaired in cognition and was administered antipsychotic and antidepressant medications daily during the observation period. Review of the Medication Regimen Review book, provided by the DON, revealed no December 2023 medication reviews. Review of R18's Progress Notes did not reveal pharmacy documentation. On 04/17/24 at 12:50 PM, the DON confirmed the December 2023 Medication Regimen Reviews were not available. The DON further stated, had called the pharmacist, and was told the pharmacist did not have the reviews. 36190 Resident 16 (R16) R16's admission MDS with an ARD of 11/28/23, revealed R16 had a readmitted [DATE]. R16 had a BIMS score of 8 out of 15, indicating R16 had moderate cognitive impairment. Diagnoses included chronic kidney disease, congestive heart failure, hypertension, end stage renal disease, diabetes mellitus, depression, and malnutrition, receives dialysis, and medications that included insulin, antidepressant, and anticoagulant. Review of R16's orders revealed: -Zoloft [antidepressant] Oral Tablet 100 MG [milligrams] -Sertraline HCl [hydrochloric acid]) Give 100 mg, start Date 11/23/23 -Atorvastatin Calcium [cholesterol lowering medication] Oral Tablet 20 MG (Atorvastatin Calcium), start date 11/22/23 -Gabapentin [seizure medication] Oral Capsule 300 MG (Gabapentin), start date 11/22/23 -Lasix [diuretic] Oral Tablet 40 MG (Furosemide), start date 11/23/23 -Carvedilol [heart medication] Oral Tablet 6.25 MG (Carvedilol), start date 11/22/23. R16's care plan, dated 11/22/23, revealed R16 has depression r/t [related to] placement outside of family's home and an intervention that included: Pharmacy review monthly or per protocol. Review of the pharmacist's monthly medication records and EMR for December 2023 revealed no evidence R16's medications were reviewed.

Based on interview, record review, and facility policy review, the facility failed to ensure an investigation was performed and a root cause analysis was established for 1 of 1 residents (Resident (R) 5) reviewed for falls out of 17 sampled residents. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings include: Facility's policy titled, Fall Evaluation and Management, dated 03/03/24 revealed, .Post-Fall Documentation .After the resident has been evaluated and cared for and appropriate notifications have been made, the licensed nurse .Completes an interdisciplinary progress note, including a brief summary of the fall, the nursing evaluation, actions taken, who was notified and resident's condition .The nurse completes orthostatic vital signs as able .The LN [licensed nurse] evaluated neuro checks for 72 hours for all falls unwitnessed by staff or falls that involve the resident's head striking a surface .The nurse completes a blood glucose reading at the time of the fall (if diagnoses diabetic) .Updates the Morse Scale .Reviews and updates the care plan with newly identified interventions, as needed .Updates Care Directives with new interventions, as needed .Alerts following shifts to fall and care plan/care directive changes by verbal report as well as documentation in the 24-hour report .Resident is monitored for 72 hours post fall .Follows up with the physician and responsible party, as needed, to provide updates .Continues to follow the resident every shift for the next 72 hours, documents findings and resident's condition in the Nurse's Notes . Resident 5 (R5) R5's Admission Record, provided by the Director of Nursing (DON) revealed R5 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, adult failure to thrive, and blindness. R5's Fall Care Plan, dated 08/05/22 and revised on 05/09/23 included: -R5 is HIGH risk for falls r/t [related to] confusion, poor communication/comprehension, unaware of safety needs, vision/hearing problems. R5 had two unwitnessed falls without injury on 08/14/23 and a fall on 05/08/23.Approaches included to anticipate and meet R5's needs. Entry dated 08/05/22 and revised on 05/15/23. -Educate R5, family/caregivers about safety reminders and what to do if a fall occurs. Dated 08/05/22 and revised on 05/15/23. -Grab bars and assistive devices are wrapped in bright green tape to assist as visual aid. Dated 08/10/22. -Hi-Lo bed with landing mats for injury prevention. Dated 08/05/22. -PT/OT [Physical Therapy/Occupational Therapy] to evaluate and treat as ordered or PRN [as needed]. Dated 08/05/22 and revised on 05/15/23. -R5 needs a landing mat in front of the w/c [wheelchair] to prevent injuries and should be supervised at all times while up in chair. Dated 08/05/22. -R5 needs a safe environment with the bed in low position at all times; personal items within reach; fall mats on floor. Dated 08/05/22 and revised on 05/15/23. -R5 needs activities that minimize the potential for falls while providing diversion and distraction. Dated 08/05/22 and revised on 05/15/23. -R5 will sit at the nurses' station for 1:1 when able. Dated 05/15/23. R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/12/23, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated the resident was severely impaired in cognition, required assistance for transfers, did not ambulate, and had no falls since previous assessment. Review of the Transfer to Hospital Summary, dated 01/17/24, revealed R5 was found on the floor mat with a small laceration on the top of head. A General Note, dated 01/17/24 revealed, ambulance returned R5 from ER [emergency room ]. Head bandaged to keep resident from playing with staples .Resident was put to bed with 1:1 observation for safety. An MD Visit Note dated 01/17/24, revealed .Patient was seen today for fall yesterday, sent to ER with now three staples. No CT [cat scan] was done .Staple removal in 7 to 10 days, continue neuro check for three days. Have discussion with family in case of hemorrhagic stroke if they want further intervention . During an initial observation on 04/16/24 at 12:18 PM, R5 was seated in a recliner in room. There was music playing on the CD player on the table next to the resident. R5 was asked how the resident was doing today. R5 stated, I'm lonely and there was no one to talk to. A fall mat was observed on the floor underneath the raised footrest of the recliner. On 04/17/24 at 1:19 PM, R5 was observed asleep in the wheelchair, in the resident's room. The fall mat was angled off to the left side of the wheelchair. R5 was unsupervised. On 04/17/24 at 2:51 PM, Certified Nurse Aide (CNA 4) was asked why R5 was unsupervised while alone in the room when R5's care plan documented the resident needed supervision. CNA 4 stated wasn't aware of that intervention. CNA 4 was told of R5's fall care plan approaches, dated 05/15/23. CNA 4 indicated when the resident is in the room, I will attach the call light to the resident's pants, so when the resident tries to stand up or move away from the wall, the light gets pulled out and the call light goes off. CNA 4 was asked how the CNA is made aware of the care plan approaches, especially updates. CNA 4 stated, I will review them if I know someone has a change, but I was not told about this. On 04/17/24 at 3:02 PM, the DON was asked if there had been daily charting, by nursing, to monitor for a change in condition. The DON stated, I was not here at the time of R5's fall, and I did not see it in the Progress Notes. The DON further stated, It is my expectation that nursing is to document for 72 hours on the resident, after a fall or change in condition. On 04/18/24 at 8:49 AM, The DON was asked if there was a fall investigation, as the DON had only provided copies of the Progress Notes. The DON stated, There was no investigation on the fall from 01/17/24, no care plan revision or root cause analysis was established.

Based on interview, record review, and review of facility policy, the facility failed to provide appropriate person-centered and individualized treatment and services for one of two residents (Resident (R) 19) reviewed for behavioral healthcare needs of 17 sampled residents. This failure placed the resident at risk for increased distress and a diminished quality of life. Findings include: A facility policy titled, Behavior Management, dated 03/03/24, revealed, .If a resident exhibits a new behavior symptom, staff implements the Behavior Monitor Flowsheet and notified the Social Services Director (SSD) and the IDT [interdisciplinary team] via the 24-Hour report .If the resident has an order for psychotropic medications or medications used for psychiatric diagnosis, the side effects are monitored and documented as indicated. The resident's record is reviewed for evidence of signs or symptoms of side effects related to psychotropic medication as part of the IDT review process . A facility policy titled, Suicide Threats, dated 03/03/24, revealed, .All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately . Resident 19 (R19) R19's Admission Record provided by the Director of Nursing (DON) revealed R19 was admitted to the facility on [DATE] with diagnoses which included depression and urinary tract infection. An MD Visit note, dated 03/13/24, revealed Patient did state during emergency evaluation 3/10/24 resident does not want to be here anymore and want (sic) to overdose on pain medication .Chronic pain .recently decreased on hydrocodone 10/325 from 3 pills a day to 2 pills a day by the resident's PCP [primary care physician] on 3/6/2024, likely secondary to suicidal ideation on pain medication . Review of the Admission Social Services assessment, dated 03/14/24 and provided by the Social Services Designee (SSD) revealed that R19 was agitated with placement, had a diagnosis of depression and was on an antidepressant medication. The assessment further revealed that R19 had no behavioral concerns and had no history of behavioral symptoms or interventions. R19's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/24, revealed R19 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15, which indicated the resident had intact cognition and had no behaviors. The MDS further revealed R19 was asked if had little interest in doing things or if the resident felt down, depressed, or hopeless R19 was coded as No. The question of if the resident had thoughts of being better off dead or if was going to hurt herself in some way were not asked during the interview process. R19's Care Plan, dated 03/18/24 revealed, R19 uses antidepressant medication r/t [related to] Depression. Approaches included: -Administer Antidepressant medications as ordered by physician. Dated 03/19/24. -Monitor/document side effects and effectiveness q [every] shift. Dated 03/19/24. -Monitor/document/report PRN [as needed] adverse reactions to Antidepressant therapy. Dated 03/19/24. A Behavior Note, dated 04/04/24 at 10:37 AM revealed .Upon entering the room [R19] was found to be speaking to housekeeping. [R19] was stating was upset and was speaking very loudly to the housekeeper about not being able to poop, then got medicine to poop and now has diarrhea .While trying to get information from [R19] the resident yelled, What the hell do I have to do, die around here for someone to do something . A Communication with Family form dated 04/04/24 at 12:00 PM documented, .Talked to (resident representative) regarding what had occurred this morning .(she) Informed me that [R19] has an extensive Mental Health Background which had resulted in [R19] being placed in Mental Facilities for extended periods of time . A Behavior Note dated 04/09/24, revealed .Resident became hostile saying nothing helps with the pain. Resident stated, I may as well die if I can't get help for the pain .Resident started screaming at me and I redirected resident to calm down . The Behavior Monitoring Sheet dated April 2024, revealed and updated behavior which included staff were to monitor R19 for crying. R19's Care Plan was not updated with this new behavior nor were new approaches developed. On 04/17/24 at 8:56 AM, R19 stated, I began to experience significant pelvic pain and it wasn't getting any better, so I went to the hospital. I finally got one answer which was I had a blockage in my upper colon. R19 further stated, I had been on narcotics at the time. R19 was asked if was taking more narcotics than should. R19stated, No, not at all. I really didn't take them very much. R19 was asked if was taking an antidepressant medication for depression, resident stated, Yes, I have been on it a long time. It does help. I was hospitalized in California a long time ago for depression. R19 was asked if the resident could tell me more about that hospitalization , R19 stated, Well, I was pretty depressed, my husband left, and the kids grew up and left home. R19 was asked if had been offered counseling services since admission to the facility, R19 stated, no. R19 was asked if thought was wanting to hurt self or if would be better off being dead, since resident came to the facility, R19 replied, no, I haven't, and I don't have a plan. I am [AGE] years old and tired. On 04/17/24 at 9:33 AM, the SSD provided a paper copy of the admission social service assessment. The SSD was asked if was responsible for developing the Behavior Care Plan. The SSD stated, I do the social services part of the MDS and the Care Plan. The SSD further stated, R19 did not tell me was depressed, had no sad affect and when I did the resident's depression scale, it was zero. The SSD was asked if was aware of any potential suicide threats as voiced by R19 since admission and how does the SSD become aware of these if they occur. The SSD stated, I will go through the 24-hour sheet and look for what was said between nursing. The SSD further stated, I knew R19 wanted to be home with family, when I asked R19 about it, the resident had said no. The SSD was asked if the facility has a contract with a behavioral health care professional, the SSD stated, Yes. On 04/17/24 at 9:52 AM, the DON was asked if was aware of the statements of R19 wanting to die, as documented in the Progress Notes. The DON stated, to my knowledge, I was not aware of the statements. The DON further stated was recently hired to be the DON about 16 days ago and became aware that the psychotropic meds, behaviors, and care plans needed to correlate. The DON stated, I do read the 24-hour report, but I am trying to get the nurses to follow through when they document a behavior, specifically if there were statements of wanting to die, including the physician. On 04/18/24 at 8:16 AM, the Medical Director (MD) was asked how became aware of R19 wanting to use pain medication as a means of suicide, as documented in the MD's admission note. The MD stated, R19 was seen in the ER [emergency room ] due to Norco (Hydrocodone-a pain medication). The resident was shown in the previous few weeks to have mentioned this to an outside PCP and the PCP had cut back on the amount of Norco prescribed. When R19 came in to the ER, was having increased pain, constipation, and UTI [urinary tract infection]. R19 had stated to the ER physician was taking more than should. The MD further stated had carried over the documentation from the hospital (when the MD wrote the MD Visit note.) The MD was asked if was aware of the other statements, as voiced by R19, of wanting to die. The MD stated, No, I was not aware of this. The MD further indicated had recently had behavioral health services start back and it would be great if they would see the resident.

Based on observation, interview, record review, and facility policy review, the facility failed to provide treatment to maintain or prevent further decrease in range of motion for 1 of 2 residents (Resident (R) 10) reviewed for range of motion out of 17 sampled residents. The deficient practice placed the resident at risk for developing decreased motion or contractures. Findings include: Facility policy titled, Restorative Nursing Services, revised 03/03/24 revealed, 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies). 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care . 5. Restorative goals may include, but are not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b. developing, maintaining or strengthening his/her physiological and psychological resources; c. maintaining his/her dignity, independence and self-esteem . Facility policy titled, Rehabilitation Services, revised 03/03/24 revealed, 1. The rehabilitative potential and requirements for residents are noted on the initial nursing assessments/evaluations completed by the RN [Registered Nurse] within 30 days of move-in or as required by state regulations. Resident 10 (R10) R10's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/24, revealed R10 had an admitted [DATE]. R10 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating the resident had moderate cognition impairment and diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. R10's care plan, dated 01/29/24, revealed R10 has an ADL self-care performance deficit r/t [related to] Stroke, with an intervention of Contractures: R10 has contractures of the right hand. On 04/17/24 at 11:56 AM, R10 was in the dining room sitting in the wheelchair with right hand contracted. No positioning device in place and resident was feeding self with the left hand. R10's right leg was noted to be strapped to the wheelchair bar. On 04/18/24 at 11:23 AM, the Physical Therapist (PT) was asked about R10. PT stated R10 was not receiving therapy at this time, but at previous nursing homes R10 did receive therapy services and was prescribed a splint. PT stated wasn't sure if R10 still had the splint. PT stated R10 wasn't compliant at the previous nursing home. PT went on to say R10 didn't need additional services from therapy because the resident was maintaining range of motion with the activities program exercise. PT was asked if the facility had a restorative nursing program (RNP) and PT stated yes, but wasn't sure if R10 was on the RNP. On 04/18/24 at 11:34 AM, Certified Nurse Aide (CNA 1) stated was the restorative nurse aide. CNA1 was asked about the RNP. CNA1 stated if a resident was on the RNP it would have been reflected in the task tab in the EMR. CNA1 then reviewed the EMR and did not find the task for the RNP for R10. CNA1 confirmed R10 was not on RNP and stated it was because there was no order. CNA1 stated the order would have to come from therapy with specific instructions. On 04/18/24 at 12:23 PM, R10 was asked if received exercise beyond the activity program and R10 said no. R10 was asked if that was sufficient and R10 said, no. R10 then pointed to the leg that was strapped to the bar of the wheelchair and picked up the right hand with the left hand and let it drop on the lap. R10 was asked if had a hand splint for the right hand and the resident said, no. On 04/19/24 at 11:27 AM, Licensed Practical Nurse (LPN1) was asked about R10's right side impairment. LPN1 stated R10's right hand was contracted, and a brace may help with preventing further contractures. LPN1 stated physical therapy didn't have to be the one to write an order for RNP, the doctor could write it. LPN1 was asked, according to facility's rehabilitation services policy, if R10 should have been assessed within 30 days of admission. LPN1 stated physical therapy would have completed one. During a follow up interview on 04/19/24 at 12:17 PM, PT was asked if an assessment had been conducted for R10 per facility policy. PT stated would have needed an order from nursing to conduct an assessment for therapy. PT stated could tell R10 hadn't declined because the PT was familiar with R10 from another facility. PT was asked how it was known R10 hadn't declined and if the PT used measurements. PT stated, no, didn't use measurements, just observation.

Based on observations, interviews, record review, and facility policy review, the facility failed to provide an ongoing program of activities designed to support the physical, mental, and psychosocial well-being for 1 of 17 sampled residents (Resident (R) 13). This failure had the potential to negatively impact R13's quality of life. Findings include: Review of facility's policy titled, Activity Evaluation, revised 03/03/24, revealed Policy Interpretation and Implementation .The activity evaluation is used to develop individual activities care plan (separate from or as part of the comprehensive care plan) that will allow the resident to participate in activities of his/her choice and interest .Each resident's activities care plan relates to his/her comprehensive assessment and reflects his/her individual needs .Through the interdisciplinary process, the activity evaluation and activities care plan identify if a resident is capable of pursuing activities independently, or if supervision and assistance are needed .The completed activity evaluation is part of the resident's medical record and is updated as necessary, but at least quarterly. Resident 13 (R13) R13's Face Sheet indicated R13 was admitted on [DATE] with diagnoses of cerebral palsy (CP), autistic disorder, and severe intellectual disabilities. R13's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/24, indicated R13 had a Brief Interview for Mental Status (BIMS) score of zero of 15 which indicated R13 had severely impaired cognition. The assessment indicated R13 preferred staying up past 8:00 PM, receiving a shower, snacks between meals, participating in favorite activities and listening to music. R13's Care Plan revised 07/17/23, indicated R13 is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, immobility, physical limitations .Intervention: R13 has graduated from public school. In order to maintain mental and social stimulation R13 will have 1:1 meaningful activities at least five times per week. During the initial observational tour of the facility on 04/16/24 at 9:56 AM, R13 was lying in bed, asleep. At 1:00 PM, R13 was lying in bed, alert and awake. No evidence of R13 participating in activities on day one of the survey. During observations on 04/17/24 at 12:30 PM, R13 was lying in bed with a stuffed animal, saying baby when approached. At 4:28 PM and 5:23 PM, R13 was lying in bed asleep. No evidence of R13 participating in activities on day two of the survey. On 04/17/24 at 3:55 PM, R13's guardian indicated was concerned with R13 not getting out of the room for activities. The guardian indicated R13 loved water, and the facility had a plastic pool and last summer they allowed R13 to play in the pool. Additionally, the guardian indicated R13 had a mat which staff used to bring out of the resident's room and place at the nursing station, which allowed R13 to interact with others. The guardian verbalized this had not been happening. During observations on 04/18/24 at 7:50 AM, R13 was sitting on the bed alert, calling out baby. At 8:13 AM, after R13 ate breakfast in the main dining room, staff removed R13 from the dining room and placed resident back into bed. At 9:20 AM, R13 was asleep in bed. During additional observations on 04/18/24 at 11:40 AM, R13 was lying on the bed, awake and at 11:55 AM, R13 was asleep. At 12:26 PM, R13 was in bed, asleep. No evidence of R13 participating in activities on day three of the survey. During observations on 04/19/24 at 9:30 AM, R13 was observed asleep in bed. At 12:01 PM, R13 was observed asleep in bed. No evidence of R13 participating in activities on day four of the survey. R13's Record of one-on-one Activities, provided by the facility, revealed R13 received one to one activity on the following dates: 01/06/24, 01/18/24, 01/29/24, 02/02/24, 02/19/24, 02/23/24, 02/29/24, 03/03/24, 03/14/24, 03/21/24, 03/24/24, 03/29/24, 04/04/24, and 04/12/24. This resulted in 13 out of 80 visits conducted, resulting in a 16.25% participation rate. R13's Record of one-on-one Activities, provided by the facility, revealed R13 did not receive one to one activities, five times a week, during the following weeks: 12/31/23-01/06/24, 01/07/24-01/13/24, 01/21/24-01/27/24, 02/04/24-02/10/24, 02/11/24-02/17/24, and 04/14/24-04/20/24. This resulted in 65 out of 80 visits not being conducted, resulting in an 81.25% non-participation rate. R13's Activities-Quarterly/Annual Participation Review dated 03/22/24, revealed R13 does activities when the resident wants to. Forcing R13 is not in the resident's best interest. Reading to the resident with a book the resident likes could last up to 15-20 minutes .The resident enjoys listening to music and dancing (swaying back and forth) to the songs the resident likes . R13 still loves to play in the water. R13 has 1:1's with activities five times a week. On 04/18/24 at 10:00 AM, the Activity Director (AD) indicated R13 was to get one to one activities five times a week and the AD confirmed R13 had not received one to one activity since 01/24. The AD indicated R13 was not able to join in the scheduled activities of the facility. The AD stated R13 liked water, reading books, musical instruments, singing and dancing. The AD indicated if R13 was asleep when staff went by the resident's room to do a one to one, there should have been a follow up visit conducted that day and confirmed that this was not happening. On 04/19/24 at 10:00 AM, Licensed Practical Nurse (LPN) 1 indicated R13 did not get the activities as the resident should have. The LPN confirmed R13 loved water, music, and loved to dance.

Based on observation, interview, record review, and facility policy review, the facility failed to assist with a communication deficit for one of one resident (Resident (R) 10), reviewed for communication out of 17 sampled residents. Findings include: The facility's policy titled, Activities of Daily Living [ADL], Supporting, revised 03/03/24 revealed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .e. communication (speech, language, and any functional communication systems). Resident 10 (R10) R10's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/24, revealed R10 had an admitted [DATE]. R10 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R10 had moderately impaired cognition, and diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, stroke, and aphasia. R10's Personal Directives for Quality of Living, dated 01/29/24 documented, I want my care partners to know A. I communicate better with pictures and A Good Day for me would be (things I value about my day) F. unable to answer. R10's Care Plan, dated 02/01/24 revealed, R10's Personal Directives for Quality of Living with an intervention that included I want my Care Partners to know: I communicate better with photos. A progress note, dated 04/12/24 revealed, Dx. [diagnosis] Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Patient with unclear speech at times but able to make needs known. Usually understood and usually understands others. Hearing adequate. Vision impaired-wears glasses. Patient unable to read words aloud however was able to decipher small print shapes. DX [diagnosis] of aphasia . During an observation and interview on 04/18/24 at 12:23 PM, R10 was sitting in the wheelchair in the resident's room watching television. R10 was asked questions about lunch and R10 was having difficulty communicating. R10 was then asked if the resident had a communication board with pictures to make communication easier and R10 said, no. R10 was then asked if would like one and the resident replied,yes. On 04/18/24 at 12:39 PM, Social Services Designee (SSD) was asked if R10 had a communication board with pictures to enhance R10's communication. SSD stated not aware of the resident having one. SSD stated R10 communicated pretty well with staff, but R10 couldn't read or write. SSD was informed R10 stated a communication board with pictures would improve communication. On 04/18/24 at 1:21 PM, Certified Nurse Aide (CNA) 2 was asked if R10 had a communication board with pictures and CNA2 stated no. CNA2 was asked if thought R10 would benefit from a communication board with pictures. CNA2 stated yes, because R10 could only say yes, no and a few other words such as shower. CNA2 stated thought the facility had a board R10 could use. On 04/19/24 at 10:30 AM, Hospitality Aide (HA) 3 was asked if R10 had limited speech and did R10 have difficulty communicating. HA3 stated yes, R10 could only say yes, no, water, and just a few other words so the HA3 tried to simplify communication with R10. HA3 was asked if R10 had an alternative way to communicate and HA3 stated, no. HA3 was asked if R10 had a communication board with pictures and HA3 stated, no. HA3 was asked if a board with pictures would help with R10's communication and HA3 stated definitely. On 04/19/24 at 11:20 AM, Licensed Practical Nurse (LPN) 1 stated R10 had a communication deficit and could make needs known in the resident's normal realm but outside of the resident's norm,had trouble communicating. LPN1 stated for example, R10 came to the LPN a little while ago trying to communicate was having trouble with a roommate and holding up fist to express anger. LPN1 went on to say, at times some staff struggle to understand R10. LPN1 recommended staff use a white board when communicating with R10.

Based on observations, interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident (Resident (R) 13) reviewed for range of motion (ROM) and nutrition, had the care plans revised, and one resident (R5) reviewed for falls, had the care plan revised out of 17 sampled residents. The deficient practices placed the residents at risk for not receiving the care based upon their needs. Findings include: Review of the Long-term Care Facility Resident Assessment Instrument 3.0 User's Manual, revised October 2023, revealed Chapter 4: Care Area Assessment (CAA) Process and Care Planning, 4.1 Background and Rationale .Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine, vision, and continence). The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive plan of care. Resident 13 (R13) R13's Face Sheet indicated R13 was admitted on [DATE] with diagnoses of cerebral palsy (CP), autistic disorder, and severe intellectual disabilities. R13's Care Plan revised 12/22/21, revealed R13 could have nutrition, hydration status altered or at risk for alteration related to cognitive/intellectual disability, behavior issues, potential for dehydration. Interventions: Adaptive devices used, scoop plate, etc .house supplements to be added to all meals .magic cup supplement to be added to all meals. During breakfast meal observation on 04/18/24 at 8:13 AM and on 04/19/24 at 9:30 AM, R13's tray had no scoop plate, house supplement and/or magic cup. During lunch meal observation on 04/18/24 at 11:55 AM and 04/19/24 at 12:01 PM, R13's tray had no scoop plate, house supplement and/or magic cup. During breakfast meal observation on 04/18/24 at 8:13 AM, R13's tray was sitting on a table in the main dining room without a scoop plate, house supplement, and/or magic cup. During lunch meal observation on 04/18/24 at 11:55 AM, R13's untouched tray was sitting on R13's overbed table without a scoop plate, house supplement and/or magic cup. During breakfast meal observation on 04/19/24 at 9:30 AM, R13's finished tray was sitting on R13's overbed table without a scoop plate, house supplement and/or magic cup. During lunch meal observation on 04/19/24 at 12:01 PM, R13's untouched tray was sitting on R13's overbed table without a scoop plate, house supplement and/or magic cup. Physician Orders dated 05/15/18 documented, house supplements with meals discontinued. Physician Orders dated 03/26/19 documented, magic cup with meals discontinued. Physician Orders dated 05/30/23 documented, nutritional enhanced meal (NEM) diet, regular texture .scoop plate discontinued. R13's Care Plan revised 08/13/20, revealed R13 had limited physical mobility related to Cerebral palsy, seizure disorder, and behaviors that prevent care at times. Interventions: Nursing rehab/restorative: AROM program and PROM program. Physician Orders revealed, Restorative Nursing program to include active range of motion (AROM), passive ROM (PROM) was discontinued on 12/21/23. On 04/18/24 at 1:21 PM, the Director of Nursing (DON) confirmed R13's care plan for AROM and PROM has not been updated and indicated it should have been. At 4:19 PM, the DON confirmed R13's nutritional care plan has not been updated for scoop plate, and nutritional supplements that were discontinued. 32513 Resident 5 (R5) R5's Admission Record revealed R5 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. R5's Fall Care Plan, dated 08/05/22 and revised on 05/09/23 revealed, R5 is HIGH risk for falls r/t [related to] confusion, poor communication/comprehension, unaware of safety needs, vision/hearing problems. R5 had two unwitnessed falls without injury on 08/14/22 and on 05/08/23. A Transfer to Hospital Summary dated 01/17/24, revealed R5 was found on the floor mat with a small laceration on the top of head. The Fall Care Plan was not updated/revised with the 01/17/24 fall with injury. In addition, there were no approaches developed to keep R5 safe. The quarterly MDS with an ARD of 02/12/24 revealed, R5 had a BIMS score of 3 out of 15 which indicated R5 was severely impaired in cognition. On 04/17/24 at 3:02 PM, the DON confirmed the Fall Care Plan for R5 was not updated/revised after the 01/17/24 fall with injury.

Based on observations, interviews, record review, review of the Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to ensure that 1 of 17 sampled residents (Resident (R) 10) had a comprehensive care plan developed that addressed communication needs and failed to ensure 2 of 17 sampled residents (R19 and R28) had a comprehensive care plan developed that addressed nutrition. The deficient practices placed the residents at risk for not receiving appropriate patient centered care. Findings include: Review of the Long-term Care Facility Resident Assessment Instrument 3.0 User's Manual, revised October 2023, revealed, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, 4.1 Background and Rationale .Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine, vision, and continence). The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive plan of care. Resident 10 (R10) R10's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/24, revealed R10 had an admitted [DATE]. R10 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R16 had moderate cognitive impairment and diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, stroke, and aphasia. R10's Care Area Assessment (CAA) Summary with an ARD date of 01/31/24, revealed 4. Communication triggered for a care plan. R10's Personal Directives for Quality of Living, dated 01/29/24 documented, I want my care partners to know A. I communicate better with pictures and A Good Day for me would be (things I value about my day) F. unable to answer. R10's care plan, dated 02/01/24, revealed R10's Personal Directives for Quality of Living, with an intervention that documented, I want my Care Partners to know I communicate better with photos. No care plan was found addressing R10's communication deficit that included measurable objectives and timeframes. On 04/18/24 at 12:23 PM, R10 was sitting in the wheelchair in the resident's room watching TV. R10 was asked questions about lunch and R10 was having difficulty communicating. R10 was then asked if the resident had a communication board with pictures to make communication easier and R10 said, no. R10 was then asked if the resident would like one and responded yes. On 04/18/24 at 12:39 PM, Social Services Designee (SSD) was asked who was responsible for care planning communication. SSD stated either nursing, social services, or activities. SSD reviewed the EMR and confirmed there was no care plan addressing R10's communication deficit that included measurable objectives and timeframes. On 04/19/24 at 11:59 AM, Director of Nursing (DON) was asked who developed the care plans. DON stated the MDS coordinator, but the coordinator was unavailable. DON was asked if there was a care plan addressing R10's communication deficit as the MDS triggered for a care plan. DON reviewed the EMR and the CAA and confirmed it should have been fully care planned. Resident 19 (R19) Review of the Admission Record, provided by the DON, revealed R19 was admitted to the facility on [DATE] with diagnoses that included dehydration, urinary tract infection, and diarrhea. A Nutrition/Dietary Note, dated 03/15/24 revealed, .Diet: NAS [no added salt], chopped meat, thin liquids .Able to feed self with tray set-up. No swallowing issues noted .Allergies; citrus products, strawberry, tomato, turkey . A Nutrition/Dietary Note, dated 03/17/24 revealed, .Pt. requested soft and bite sized texture, allow bread-pref (sic) for white bread; rt [related to] chewing difficulties, missing teeth. Requested ice cream .No seeds/nuts rt diverticulitis (an inflammation in the colon) . The admission MDS with an ARD of 03/19/24, revealed R19 had a BIMS score of 13 out of 15 which indicated R19 was cognitively intact. The admission MDS titled, CAA (Care Area Assessment) determined that nutrition was triggered and that a care plan would be developed. Review of the Comprehensive Care Plan revealed no Nutrition Care Plan was developed. On 04/16/24 at 2:57 PM, R19 stated, The food is good, but it's my diet. I don't think I am served food that meets my sensitive stomach. On 04/18/24 at 2:15 PM, the Registered Dietician (RD) was asked if the RD was responsible for developing the Nutrition Care Plan. The RD stated, no, it would be the CDM (Dietary Manager-DM). On 04/18/24 at 2:31 PM, the DM was asked if the DM was responsible for developing the Nutrition Care Plan. The DM stated, yes, I do the care plans. The DM was asked if a Nutrition Care Plan had been developed for R19. The DM confirmed that there was no Nutrition Care Plan for R19. Resident 28 (R28) R28's Admission Record, undated, indicated R28 was admitted to the facility on [DATE] with diagnoses of acute hepatitis C without hepatic coma, colon and rectal cancer, and diabetes. R28's Care Plan revealed R28's comprehensive care plan dated 09/22/23, did not include prevention for weight loss, refusals of meals or interventions to prevent weight loss. On 04/18/24 at 2:15 PM, the RD stated the RD does not implement, complete or revise care plans for nutritional issues and that was completed by the DM. The RD also stated would not be aware if the care plan did not include nutritional concerns. On 04/18/24 at 3:00 PM, the DM confirmed was responsible for resident care plans related to nutritional issues but was unable to state why R28 did not have care plan interventions for weight loss. 36190 36461

Based on interview, record review, and review of the RAI (Resident Assessment Instrument) manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 17 sampled residents (Resident (R) 5). The facility failed to accurately assess a fall with injury and this failure placed R5 at risk of having unmet care needs and a diminished quality of life. Findings include: The RAI Manual 3.0, dated 10/23, revealed .If an MDS assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected . R5's Admission Record provided by the Director of Nursing (DON), revealed R5 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. The quarterly MDS, with an Assessment Reference Date (ARD) of 02/12/24, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident was severely impaired in cognition and had no falls since the previous assessment. Review of a Transfer to Hospital Summary, dated 01/17/24, revealed R5 was found on the floor mat with a small laceration on the top of head. On 04/18/24 at 8:43 AM, the DON was asked if the quarterly MDS coding was accurate for falls. The DON stated, It was a coding error.

Based on interview and record review, the facility failed to ensure the medical record was completed and accurate which included full completion of the care conference notes and accurately documenting the date, time, and attendees of the care conference for two residents (Resident (R) 18 and R13) and failed to obtain a physician order for an indwelling urinary catheter for one resident (R2) of 17 sampled residents. This failure placed residents at risk for inaccurate and incomplete medical information and potential unmet care needs. Findings include: Resident 18 (R18) R18's Admission Record, provided by the Director of Nursing (DON), revealed R18 was admitted to the facility on [DATE] with diagnosis of alcohol induced dementia and diabetes. R18's quarterly Minimum Data Set (MDS) revealed R18 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R18 was moderately impaired in cognition. Review of the Multidisciplinary Care Conference form, dated 05/23/23 revealed Section A, which included the date and time of the meeting, as well as Section B, attendance at the meeting was left blank. In addition, the Care Conference form was still in progress, and had not been closed out and locked. Review of the Multidisciplinary Care Conference form, dated 02/05/24 revealed Section A, which included the date and time of the meeting, as well as Section B, attendance at the meeting was left blank. In addition, the Care Conference form was still in progress, and had not been closed out and locked. On 04/16/24 at 11:41 AM, R18 was asked if had been invited or attended the resident's Care Conferences. R18 stated, I have not been invited and do not attend. On 04/17/24 at 1:25 PM, the Social Service Designee (SSD) stated, it is my responsibility to complete the care planning notes when we hold the Care Conferences and did not fully document them, and they should have been closed out and not say in progress. The SSD further stated, If I get busy and can't finish them at the time of the meeting, it's a good chance they don't often get done. On 04/18/24 at 9:08 AM, the DON was asked what the expectations were regarding ensuring all documentation at the Care Conferences was completed and locked. The DON stated, It is my expectation that all documentation is completed at the time of the meeting. 25232 Resident 13 (R13) R13's Face Sheet indicated R13 was admitted on [DATE] with diagnoses of cerebral palsy (CP), autistic disorder, and severe intellectual disabilities. R13's Multidisciplinary Care Conference dated 04/11/23 revealed, Unsigned, and in progress. There was no evidence that the social worker summary, physician summary, pharmacy summary and/or restorative care/physical therapy (PT)/occupational therapy (OT) summary were completed. R13's Multidisciplinary Care Conference dated 07/17/23, revealed Unsigned, and in progress. There was no evidence that the dietary, social worker summary, physician summary, pharmacy summary and/or restorative care/PT/OT summary were completed. In addition, there was no evidence that there was a meeting date and/or time along with no staff in attendance. R13's Multidisciplinary Care Conference dated 10/09/23, revealed Unsigned, and in progress. There was no evidence that the dietary, social worker summary, physician summary, pharmacy summary and/or restorative care/PT/OT summary were completed. On 04/18/23 at 1:10 PM, the Social Service Director (SSD) indicated responsibility for conducting the care conferences, and each department was responsible for filling out their information on the multidisciplinary care conference assessment before the SSD signed them. The SSD confirmed the multidisciplinary care conference assessments, dated 04/11/23, 07/17/23, and 10/09/23, were incomplete and indicated these should have been completed. 36461 Resident 2 (R2) R2's Admission Record revealed R2 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder, chronic respiratory failure, and hypertension. R2's quarterly MDS revealed R2 had a BIMS score of 15 out of 15 which indicated R2 was cognitively intact. A Progress Note dated 02/28/24, revealed R2 went to the Emergency Department (ED) on 02/28/24 for acute kidney failure, based on elevated blood work. Upon return to the facility R2 had an indwelling urinary catheter and had been diagnosed with a urinary tract infection (UTI), and started on an antibiotic. R2's EMR revealed no order for the urinary catheter. On 04/16/24 at 3:00 PM, R2 stated had the catheter for a while, but was unable to state when it was put in. On 04/18/24 at 1:30 PM, the DON stated was unable to find a physician's order for the urinary catheter and the DON was unable to state when the urinary catheter was inserted, or rationale for it. On 04/18/24 at 3:00 PM, the DON acknowledged the facility had no documentation for R2's ED visit on 02/28/24. The DON stated would reach out to the hospital for additional information. The DON presented this surveyor documentation for R2's ED visit at 4:00 PM. The ED did not provide documentation related to UA results, only that R2 had been diagnosed with a UTI, an antibiotic started, and the urinary catheter inserted. On 04/19/24 at 11:45 AM, Licensed Practical Nurse (LPN 1) stated when residents returned from ED visits with any medication changes or urinary catheters inserted, the process was for nurses to notify the facility attending physician for approval. On 04/19/24 at 1:30 PM, the DON stated the expectation was nursing staff would notify the attending physician with any new or changed orders for residents after an ED visit and information would be documented in the resident's EMR.

Based on interviews, record reviews, and facility policy review, the facility failed to timely assess and monitor 1) a resident for changes of condition following a fall and failed to revise a care plan to prevent further falls (Resident (R) 31) and 2) failed to monitor a resident during the use of anticoagulant medication (and R29) for 2 of 15 sampled residents. Findings include: 1. Review of the facility's policy provided by the Administrator titled, Assessing Falls and Their Causes, dated ,d+[DATE], revealed .The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall Falls are a leading cause of morbidity and mortality among the elderly in nursing homes .found on the floor without a witness to the event, evaluate for possible injuries . Review of R31's undated admission record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include dizziness and giddiness, dementia, unsteadiness on feet, multiple fractures of ribs, syncope and collapse, major depressive disorder ([DATE]), and insomnia. The resident was discharged (expired) on [DATE]. R31 complained of rib pain after the resident suffered a suspected unwitnessed fall (found in floor) on [DATE], leading to a diagnosis on [DATE] of multiple rib fractures with a pneumothorax (collapsed lung) at the local hospital. Review of R31's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) with a score of one out of 15 indicating R31 was severely cognitively impaired, had Alzheimer's, dementia, depression, dizziness, syncope and muscle weakness, and unsteadiness on his feet. Review of R31's Progress Notes revealed the following: [DATE] at 6:06 AM .Resident was observed in sitting position on the floor by the bedside table .c/o [complained of] .pain . written by Licensed Practical Nurse (LPN)1. Further review of this progress note revealed no physical assessment was completed after the fall and complaints of pain. [DATE] at 9:47 AM .daily clonidine 0.1 mg patches for increased muscle spasticity .c.o (sic) [complained] recent pain in back .increased muscle spasticity, increase clonidine patches to 0.2 mg a day for 2 weeks . documented by the Medical Director. Documentation lacked mention of the fall on [DATE]. [DATE] at 3:03 PM .Resident with lower right back/rib/abdominal pain earlier this shift at approx. [approximately] 12:30. Resident appeared to be holding lower rib on that side when approached with facial grimacing noted . written by LPN1. Further review of this progress revealed no physical assessment was completed after the complaints of pain. [DATE] at 5:01 PM .Acetaminophen .Give .as needed for pain right side abdominal/rib pain . written by LPN1. No physical assessment was documented as being completed at the time the Acetaminophen was administered. [DATE] at 5:18 PM .Lidocaine Pain .Patch .was Ineffective . written by LPN1. [DATE] at 3:28 PM .Resident observed on the floor on the side of closet in room . written by LPN1. Further review revealed no change in condition assessment was completed after this fall. [DATE] at 9:21 AM .transported by EMS [Emergency Medical Service] .hypoxia [low oxygen levels] . written by LPN2. [DATE] at 10:45 AM .his frequent falls has been worse since starting clonidine patches .Patient is transferred to the emergency room for acute hypoxia to rule out PE [pulmonary embolism] .will consider decreasing clonidine patches dosage for frequent falls . written by the Medical Director. [DATE] at 12:15 PM .admitted .pneumothorax with multiple fractures . Review of R31's Emergency Department Note, dated [DATE] revealed .Fall yesterday, Low O2 [oxygen] sats [saturations] .Patient sent over from care center long-term .apparently found off the bed .Patient also has palpable pain to the right lateral rib cage at rib 4 - 5 .pneumothorax .multiple right lateral rib fractures .some significantly displaced . Review of R31's Emergency Department Note dated [DATE] revealed .sent by facility .found off bed .palpable pain to the right lateral rib cage ant rib 4 5 .and R31's document provided by the facility titled General Med revealed .hypoxia .sats 83% it is presumed that patient fell yesterday, as mechanism of potential injury concerned were unwitnessed .notable right rib tenderness with absent lung sounds .X-ray confirmed 100 % pneumothorax with tension .multiple right rib fractures . The facility failed to revise R31's care plan interventions following the fall on [DATE] to prevent further falls, and R31 suffered additional falls on [DATE] and [DATE]. R31 expired at the facility on [DATE]. During an interview on [DATE] at 3:50 PM, LPN 2 confirmed had sent R31 to the hospital per physician's order on [DATE], the resident was admitted and diagnosed with multiple rib fractures and pneumothorax. LPN2 confirmed R31 died at the facility on [DATE]. During an interview on [DATE] at 8:00 AM, R31's Family Member (FM) 1 stated R31 had a fall at the facility around [DATE] and was sent to the emergency room and was diagnosed with rib fractures and a collapsed lung on [DATE]. During an interview on [DATE] at 10:08 AM, Certified Nursing Assistant (CNA) 1 stated R31 suffered a fall on [DATE] and complained of pain and pointed to the rib area. During interview on [DATE] at 10:39 AM, LPN1 stated R31 was observed on the floor on [DATE] and complained of pain. LPN 1 stated had not completed a change of condition assessment on [DATE] when R31 fell and complained of rib pain. LPN1 verified per R31's progress note written by LPN1, R31 had pain at 12:30 PM on [DATE] and did not assess the resident for pain, did not notify the resident's physician about complaints of pain or provide interventions for pain management. LPN1 verified on R31's Medication Administration Record (MAR) had documented administering Tylenol for pain at 5:00 PM on [DATE] with a pain rated as a 7 out of 10 and entered a U (unknown) for the pain medication follow up results. LPN1 stated no new interventions were implemented for R31's fall preventions and R31 suffered another unwitnessed fall (found on the floor) on [DATE]. LPN1 verified that no change of condition assessment was completed after the second fall on [DATE]. LPN1 verified R31 was sent out to the emergency roiagnom on [DATE] and diagnosed with multiple rib fractures and pneumothorax. On [DATE] at 12:25 PM the Director of Nursing (DON) confirmed the note was documented on [DATE] at 6:00 AM by LPN 1 and indicated R31 was found on the floor. The DON reviewed the note and stated some things were missing in the documentation including how the resident got on the floor, if the resident had nonskid socks on their feet, and a skin assessment. The DON confirmed R31's blood pressure was low. The DON confirmed the progress note did not indicate if R31 suffered injuries but did mention the resident had complained of pain. The DON stated expected the facility staff to complete a change of condition assessment for the residents with complaints of pain after found on the floor. The DON confirmed R31 complained of rib pain on [DATE] at 12:00 PM according to LPN 1's progress note, and LPN 1 did not document notifying the physician or providing pain interventions including pain medications until 5 PM on [DATE] with an administration of Tylenol. The DON confirmed LPN 1 documented on R31's MAR a pain rating of 7 out of 10 and had entered U for unknown indicating no results were entered for the effectiveness of the Tylenol administration. The DON confirmed R31 was found on the floor again on [DATE]. The DON confirmed R31 was sent to the emergency room for evaluation on [DATE] and was diagnosed with multiple rib fractures and pneumothorax. On [DATE] at 6:25 PM, the Administrator and the Director of Nursing (DON) were notified of an immediate jeopardy (IJ) situation. The Immediate Jeopardy began on [DATE] when the facility failed to timely identify and assess R31's complaints of rib pain after the resident suffered a suspected unwitnessed fall (found on the floor) on [DATE], leading to R31's diagnosis on [DATE] of multiple rib fractures and a pneumothorax at the local hospital. The facility failed to revise R31's care plan interventions to prevent falls and R31 suffered additional falls on [DATE] and [DATE]. The facility provided an acceptable plan for removal of the immediate jeopardy on [DATE] at 5:23 PM which included the following: The facility would take immediate actions beginning on [DATE] in the form of assessment of residents and education of direct care staff to correct noncompliance that caused or is likely to cause serious injury, serious harm, serious impairment, or death to residents. All direct care staff would be educated by [DATE], [DATE] & prior to their return to work. Audits would be performed weekly on Tuesdays for a period of one year, by the DON/designee for Change of Condition, Pain Assessments, Fall management and Care Plans tools. A Qapi plan for falls, pain, change of condition and care plans, would be put in place, to be reviewed at monthly QA committee meetings for the period of one year. The survey team verified all elements of the facility's IJ Removal Plan and removed the IJ on [DATE] at 3:25 PM. 17281 2. Review of the facility's policy titled, Acute Condition Changes - Clinical Protocol dated [DATE] documented, .The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having additional complications . The physician will help identify medications. The physician will help identify medications and medication combinations that are associated with adverse consequences that could cause significant changes in condition . Review of R29's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (PVD) and status post left lower extremity revascularization. Review of the Physician Orders dated [DATE], revealed an order for Clopidogrel Bisulfate (antiplatelet medication that can cause bruising or bleeding) 75 milligrams (mg) in the morning for peripheral vascular disease and Aspirin 81 mg every day. Review of the Nurses Note dated [DATE] documented, .Upon admission it is noted that resident has several areas of concern. The right forearm and hand are deep purple, infiltration noted and IV [intravenous] present. This writer removed IV intact, no bleeding, redness, or pain noted. Resident has bilateral bruising on upper and lower arms. Bruising noted on chest, right hip, and lower legs . Review of the admission MDS with an ARD of [DATE] revealed a BIMS score of 8 of 15 which indicated R29 was moderately cognitively impaired, required limited assistance for personal hygiene and dressing. Review of the Skin Assessment Tool dated [DATE] documented, bruising on collarbones - unknown cause bilateral bruising (old) and forearms. Review of the resident's Care Plan dated [DATE], revealed the resident has peripheral vascular disease with interventions that included to be free from complications related to PVD and education on importance of foot care, proper fitting shoes, wash and dry feet thoroughly, and inspect feet daily. Review of the Skin Assessment Tool dated [DATE], documented, bilateral bruising noted. Review of the EMR revealed no other assessments of R29's bruising. Review of the Nurses Notes dated [DATE] revealed, .Resident with left arm between wrist and elbow completely bruised. Resident states is unaware of what happened. Resident denies pain or discomfort to area. No visible opening or sore {soreness} at this time to cause bruising. Resident is currently on blood thinners. MD/DON/Family aware. Observation on [DATE] at 12:30 PM, [DATE] at 9:30 AM, and [DATE] at 12:00 PM revealed R29's bilateral forearms from the wrist to the elbow were dark purple in color with different shades of bruising. In an interview on [DATE] at 11:30 AM, the DON stated R29 was observed with dark purple colored skin and bruising on the upper and lower arms, chest, right hip, and left lower leg on admission to the facility on [DATE]. The DON stated the bruising was a side effect of the antiplatelet medication and should be monitored every shift to determine whether the condition is improving or deteriorating. The DON stated monitoring the skin for increased bleeding is the facility policy and a standard of care when a resident is receiving an antiplatelet medication and has complications of the therapy. The monitoring would be documented in the nurse progress notes. The DON confirmed R29's EMR did not include monitoring of the bruising per standards of practice. In an interview on [DATE] at 11:52 AM, the Medical Director stated the resident is receiving two antiplatelet medications for PVD and recent revascularization surgery. The bruised and deep, purple-colored areas on the resident's bilateral arms, chest, and legs are from these medications. The Medical Director stated the resident must take these medications and bleeding under the skin can and has occurred. The areas should be monitored for increased bleeding and reported to the physician if there are any changes.

Based on observation, interview, record review, and document review, the facility failed to protect residents from harm for 2 of 24 sampled residents (Resident #4 and Resident #9) and one unsampled resident (Resident #21), and ensure residents were protected from potential resident-to-resident altercations due to a resident's wandering behavior for 15 of 24 sampled residents (Resident #9, #10, #25, #20, #14, #35, #8, #38, #17, #1, #11, #18, #15, #21 and #22) and eight unsampled residents (Resident #39, #34, #5, #23, #24, #29, #37 and #16). Findings include: Resident #4 Resident #4 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE], documented Resident #4 wandered daily and had significant risk of getting into a potentially dangerous place and would significantly intrude on the privacy or activities of others. A care plan for elopement risk/wanderer created 03/16/18, documented to monitor Resident #4's location every 15 minutes. Intervene as appropriate for wandering. A behavior note dated 03/07/18, documented Resident #4 was found roaming into other residents' rooms. A behavior note dated 03/15/18, documented Resident #4 had been up multiple times throughout the night wandering into other residents' rooms. On 09/10/18 at 4:56 PM, Resident #4 was ambulating independently and wandering from room to room. Resident #4 was heard saying incoherent words. On 09/10/18 at 5:58 PM, Resident #4 went to the main dining room and touched other residents' food and utensils. On 09/11/18 at 5:00 PM, Resident #4 entered the conference room while an Inspector was working. There was no staff present with Resident #4 for a period of 20 minutes until staff was informed. The Activity Director came in and redirected Resident #4 out of the conference room. On 09/26/18 at 7:40 AM, Resident #4 woke up and had wandered inside rooms 303 and room [ROOM NUMBER]. Resident #9 Resident #9 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE], documented Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. 1) On 09/25/18 at 4:03 PM, Resident #9 indicated on one occasion, Resident #4 had pinched and grabbed Resident #9 in the arm while Resident #9 had been sleeping and had caused a bruise. The incident happened back in (MONTH) (YEAR). Resident #9 indicated being very upset at the time and continued to be scared every time Resident #4 would go inside Resident #9's room. A general note dated 04/29/18, documented Resident #9 had shown the marks on her to the Certified Nurses Aide which Resident #4 had grabbed the other night. The note indicated Resident #9 had appeared frightened and had asked the aide to keep watch. There was no documented evidence the responsible party and the physician were made aware of the altercation, and a nursing and skin assessment was done. As of 09/25/18, there was no documented evidence of a Facility-Reported Incident submitted to the state agency, the Division of Public and Behavioral Health (DPBH) regarding the resident-to-resident altercation on 04/29/18. On 09/27/18 at 8:11 AM, the Business Office Manager revealed the nurse aide assigned to Resident #9 on 04/29/18, who wrote the note was no longer an employee of the facility since (MONTH) (YEAR) and was not available for interview. On 09/26/18 at 8:30 AM, Resident #9 indicated having to inform the DON of the incident on 04/29/18. Resident #9 was informed a report would be completed for the incident. Resident #9 also indicated informing the Administrator of the incident on Friday 09/21/18. A behavior note dated 05/15/18, documented Resident #9 had informed the Director of Nursing (DON) about being afraid of another resident. On 09/27/18 at 8:15 AM, the Business Office Manager revealed the nurse who wrote the behavior note on 05/15/18, was no longer an employee of the facility and was not available for interview. The nurse had been put on the inactive list of employees because the nurse had indicated being very busy and could not attend the facility's dementia and abuse training. On 09/27/18 at 9:30 AM, the DON revealed Resident #9 had informed the previous DON about the incident on 04/29/18. The DON indicated not being aware there was an incident on 04/29/18 because it was a different DON working at the time. On 09/26/18 at 7:36 AM, a Certified Nurse Assistant indicated a resident pinching and grabbing another resident's arm would be considered physical abuse and would need to be reported immediately to the Abuse Coordinator. On 09/26/18 at 1:12 PM, the Licensed Practical Nurse indicated the incident on 04/29/18, should have been reported and investigated immediately. On 09/26/18 at 4:11 PM, the Administrator was contacted via a phone call and revealed not being aware of the incident on 04/29/18 until last Friday 09/21/18, when Resident #9 informed the Administrator of the incident. The Administrator confirmed the resident-to-resident altercation had been documented on 04/29/18 in Resident #9's medical record. The Administrator acknowledged a facility-reported incident had not been submitted on 04/29/18. The Administrator indicated after being made aware of the incident on 09/21/18, a facility-reported incident was started but it was still with the Administrator as of 09/26/18 and has not been submitted to the DPBH. Resident #10 Resident #10 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Admission MDS assessment dated [DATE], documented Resident #10 had a BIMS score of 5, which indicated severe cognitive impairment. On 09/10/18 at 4:15 PM, Resident #10 was inside the room seated in the wheelchair. The resident was agitated and refused to speak to the Inspector. The Inspector respected Resident #10's decision and left the room. A care plan initiated 02/08/18, documented Resident #10 could be verbally aggressive. Interventions included to intervene before the resident's agitation could escalate and the resident would be guided away from the source of distress. 2) A general note dated 08/24/18, documented Resident #10 had struck another person in the dining room. An Hour of Administration note dated 08/24/18 in Resident #4's medical record, documented two other residents reported Resident #4 was hit on the face by another resident during dinner. The family member, physician and abuse person for the center were notified of the incident. The medical record lacked documented evidence the resident-to-resident altercation on 08/24/18, was reported to the DPBH or the Ombudsman and had been investigated. The medical record lacked documented evidence Resident #4's care plan was revised following the incident on 08/24/18, 1:1 monitoring occurred immediately after the incident, if the two residents involved were immediately separated and what interventions took place to prevent Resident #4 from possible future altercations with Resident #10 after the incident on 08/24/18. As of 09/25/18, there was no documented evidence of a Facility-Reported Incident submitted to the DPBH regarding the resident-to-resident altercation on 08/24/18. A general note dated 08/25/18, documented Resident #4 had no signs and systems of adversity to being hit by another person yesterday and no bruising had been noted. A behavior note dated 08/26/18, documented Resident #4 was okay and had no signs of problems from being hit by another person. On 09/19/18 in the morning, the Ombudsman indicated the incident on 08/24/18, had not been reported to their office. The Ombudsman expected all incidents of resident-to-resident altercations would be reported by the facility immediately to their office. On 09/25/18 at 5:00 PM, the Administrator was not in the facility and had appointed the Business Office Manager as the person-in-charge during the Administrator's absence. The Business Office Manager confirmed there was no evidence the incident on 08/24/18 had been reported to the State Agency and investigated. The Business Office Manager revealed the nurse who had written the notes on 08/24/18, 08/25/18, and 08/26/18, was not available for interview because the nurse was on medical leave. On 09/26/18 at 4:15 PM, the Administrator was contacted via a phone call and revealed not being made aware by staff of the incident, even though the Administrator was in the facility on 08/24/18. The Administrator confirmed the nurse documented on 08/25/18 and 08/26/18, follow-up notes regarding Resident #4 being hit by Resident #10 on 08/24/18, and acknowledged the nurse failed to inform the Administrator regarding the incident. The Administrator confirmed a facility-reported incident had not been submitted to the DPBH and the resident-to-resident altercation had not been investigated. 3) A behavior note dated 09/08/18, documented Resident #4 went into Resident #10's room and started to yell. The Licensed Practical Nurse saw Resident #10 pulling and twisting Resident#4's arm. Resident #4 was removed from the room and Resident #10 stated to keep Resident #4 out of the room or Resident #10 would hurt Resident #4 again. Resident #10 stated Resident #10 would cause Resident #4 harm if Resident #4 goes to Resident #10's room again. Resident #4's arm was a little red but Resident #4 stated it did not hurt. There was no documented evidence the resident-to-resident altercation on 09/08/18, was reported to the DPBH or the Ombudsman, or had been investigated by the facility; the family member and the physician were made aware of the incident. The medical record lacked documented evidence Resident #4's care plan was revised following the incident on 09/08/18. On 09/11/18 at 4:40 PM, the Certified Nurse Assistant indicated if an incident of physical abuse had been witnessed, the charge nurse would be made aware as soon as possible. On 09/11/18 at 4:42 PM, the CNA explained if an incident of physical abuse or even a suspicion of abuse would be reported immediately to the Administrator, who was the facility's Abuse Coordinator. On 09/12/18 at 10:37 AM, the Licensed Practical Nurse explained incidents of abuse, whether between staff-to-resident or resident-to-resident would be immediately reported to the Abuse Coordinator/Administrator. The LPN indicated being the nurse assigned to Resident #4 on 09/08/18. The LPN verbalized seeing Resident #10 pulled and twisted Resident #4's arm. The LPN revealed during the time of the incident, the Administrator-in-Training (AIT) was with the LPN. The LPN thought because the AIT was with the LPN during the incident, the LPN did not need to inform the Administrator regarding the incident and assumed the AIT would report it. The LPN acknowledged it was the LPN's fault for not reporting it and not the AIT's. On 09/12/18 at 10:45 AM, the AIT revealed not informing the Administrator regarding the incident on 09/08/18, because the AIT thought the LPN had reported it to the Administrator. On 09/12/18 in the morning, the Administrator was made aware of the resident-to-resident altercation incident on 09/08/18. On 09/12/18 at 5:34 PM, the Administrator indicated not being made aware by the LPN or the AIT regarding the incident on 09/08/18. The Administrator confirmed the incident was not reported to the external entities (police, physician, family, ombudsman and state agency) and had not been investigated. The Administrator explained the expectation was for every staff member to report an incident of abuse to the Administrator immediately, so it could be appropriately reported and investigated timely. The Administrator verbalized there was no excuse for the incident on 09/08/18, not to be reported immediately. On 09/26/18 in the afternoon, a document completed by the Administrator regarding the AIT was provided to the Inspector. The document indicated the AIT had been trained on abuse and dementia and provided the Annual Staff Training on abuse and dementia on 08/23/18, and yet had failed to report potential abuse while working as a shift nurse on 09/08/18. The Administrator acknowledged the AIT had lacked the proactiveness to follow up and follow through which was needed to lead the facility. Resident #25 Resident #25 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE], documented Resident #25 had a BIMS score of 4, which indicated severe cognitive impairment. 4) An incident note dated 09/15/18, documented the Housekeeper informed the nurse Resident #4 was observed coming out of Resident #25's room. Resident #4 had informed the Housekeeper Resident #25 punched Resident #4 on the chest. On 09/26/18 at 8:46 AM, the Housekeeper indicated hearing Resident #25 shouting from inside the room. The Housekeeper went to see and had observed Resident #4 holding chest and had stated Resident #25 hit Resident #4's chest. The Housekeeper informed the incident to the nurse. On 09/26/18 at 10:00 AM, Resident #25 had not been able to recall the incident or who Resident #4 was. Resident #21 Resident #21 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE], documented Resident #21 had a BIMS score of 15, which indicated intact cognition. 5) An incident note dated 09/16/18, documented Resident #4 had been involved in a resident-to-resident altercation. The facility-reported incident dated 09/17/18, documented Resident #4 had picked up Resident #21's silverware in the dining room. Resident #21 had asked Resident #4 to put the silverware down and grabbed Resident #4's finger. Resident #4 slapped Resident #21. An aide had witnessed the incident. On 09/25/18 at 2:43 PM, Resident #20 revealed being present during Resident #4's altercation with Resident #21. Resident #20 indicated other residents were angry with Resident #4 and they would frequently tell Resident #4 to get away from them. Resident #20 indicated Resident #21 had twisted Resident #4's finger while trying to redirect Resident #4 from taking the silverware in the dining room. Resident #20 had witnessed Resident #4 slap Resident #21 in the forehead. On 09/27/18 at 9:25 AM, Resident #4's spouse indicated not being made aware of the incident when a resident pulled on Resident #4's arm. The spouse revealed recalling a few weeks ago when Resident #4 had been complaining of pain in the arm and shoulder. The facility policy Responsive Behaviors (undated), documented when an individual's responsive behaviors escalate, it could lead to altercations among residents or staff and could be harmful or abusive. A key aspect of resident care would be to prevent or minimize the situations in which a resident would exhibit responsive behaviors. The plan of care would include procedures to minimize the risk of altercations (between the residents or staff) or responsive behaviors for staff or residents who were at risk of harm or who may had been harmed. The facility policy Abuse, Neglect and Misappropriation of Resident Property Prohibition updated (MONTH) (YEAR), documented anyone who was an employee of a Medicare or Medicaid certified nursing facility was considered a mandatory reporter. The center would conduct a thorough investigation of allegations of abuse. The center would report allegations to the state survey and certification agency and appropriate state agency per state regulation. On 09/25/18 at 2:43 PM, Resident #20 revealed a couple of months ago Resident #4 defecated in Resident #20's room. The incident happened during the night. The staff were informed. Resident #4 frequently went inside Resident #20's room. Resident #20 indicated if Resident #4 would defecate in the room again, Resident #20 would be very upset. This incident was also relayed to the Administrator-in-Training. Staff would always say they would take care of it and Resident #20 discussed concerns regarding Resident #4 during resident council meetings where the Activity Director would always be present and hear their concerns regarding Resident #4 who frequently had wandering behavior. Resident #20 revealed other residents were angry with Resident #4 and they would frequently tell Resident #4 to get away from them. Resident #20 revealed being present during Resident #4's altercation with another resident last week when the other resident had twisted Resident #4's finger while trying to redirect Resident #4 from taking silverware in the dining room. Resident #20 had witnessed Resident #4 slap the other resident. Review of the Resident Council Minutes from (MONTH) (YEAR) to (MONTH) (YEAR), revealed Resident #20 had attended the meetings every month except in (MONTH) (YEAR). On 09/25/18 at 3:18 PM, Resident #11 indicated Resident #4 would frequently visit Resident #11's room and this would get Resident #11 very upset. Resident #11 verbalized it was like having strangers going into your home. Resident #11 was very frustrated because Resident #11's concerns were relayed to the staff during resident council meetings when Resident #11 used to attend. Resident #11 indicated having to stop attending the resident council meetings because the staff were not doing anything to address Resident #11's concerns regarding Resident #4 frequently wandering inside Resident #11's room. Resident #11 indicated the facility needed to have a staff member monitor Resident #4 all the time to stop Resident #4 from wandering into other residents' rooms. Review of Resident Council Minutes from (MONTH) (YEAR) to (MONTH) (YEAR), revealed Resident #11 had attended the meetings on (MONTH) 20, (YEAR) and (MONTH) 22, (YEAR). On 09/25/18 at 3:24 PM, Resident #18 indicated not liking Resident #4 going into Resident #18's room. On 09/25/18 at 3:26 PM, Resident #5 revealed if the door to Resident #5's room was closed, Resident #4 would open the door and would go inside the room uninvited. Resident #5 indicated Resident #4 would upset Resident #5 every time Resident #4 would touch Resident #5's personal items. On 09/25/18 at 3:28 PM, Resident #23 indicated having a stop sign on the door could not stop Resident #4 from going into Resident #23's room. Resident #4 had been able to take the stop sign down and continued to enter Resident #23's room. Resident #4 would go inside Resident #23's room, would touch Resident #23's personal belongings. Resident #23 indicated this was bothersome and upsetting because Resident #23 did not appreciate having somebody touch Resident #23's personal belongings. Resident #23 expressed how the facility was failing to monitor Resident #4 and revealed the other day, Resident #4 went into the dining room and touched and broke a plate. Resident #23 indicated the stop barriers did not prevent Resident #4 from going into the rooms because Resident #4 had been able to remove them. Resident #23 indicated Resident #4 needed to be monitored at all times. On 09/25/18 at 3:39 PM, Resident #16 revealed not wanting Resident #4 to go inside the room because Resident #4 took Resident #16's glasses before. On 09/25/18 at 3:44 PM, Resident #14 revealed Resident #4 touched Resident #14's toes while Resident #14 was sleeping during the night. Resident #14 indicated being scared to death and almost jumped out of the bed. Resident #4 then took Resident #14's blanket and threw it out on the floor. On 09/25/18 at 3:48 PM, Resident #24 indicated Resident #4 would go inside the room and would check everything in the room. Resident #24 indicated Resident #4's behavior bothered Resident #24 and considered it rude. Resident #4 had taken Resident #24's rabbit plush toy which was a gift from Resident #24's family member. Resident #24 indicated having to value the toy and had been depressed the toy had not been returned. Resident #24 indicated not liking Resident #4 touching Resident #24's personal belongings especially the photographs inside Resident #24's room. On 09/25/18 at 3:53 PM, Resident #22 and Resident #22's family member both indicated being frustrated about Resident #4's wandering behavior. Both indicated talking to staff was fruitless because they could not prevent Resident #4 from going into the room. Both indicated Resident #4 needed to be monitored more. The family member revealed Resident #4 went into Resident #22's room one day and the family member attempted to redirect Resident #4 but Resident #4 became combative. Staff had to intervene to take Resident #4 out of Resident #22's room. A behavior note dated 09/19/18, documented Resident #4 had been wandering all day. Resident #4 had upset Resident #34 by going inside Resident #34's room and dropping Resident #34's things onto the floor. Resident had a hard time with redirection. On 09/26/18 in the morning, the LPN indicated Resident #34 had complained Resident #4 went inside Resident #34's room. On 09/26/18 at 7:22 AM, Resident #34 verbalized wanting to be left alone by Resident #4. Resident #4 would frequently go inside the room, would touch everything even if Resident #4's hands were dirty and sometimes would have feces on them. Resident #4 would leave dirty tissues inside Resident #34's bed which Resident #4 had used to blow nose. Resident #34 indicated being scared of getting an infection because Resident #4 would touch every thing in the facility, even others' belongings. Resident #4 indicated being scared of Resident #4 touching utensils in the dining room with Resident #4's dirty hands. Resident #34 expressed frustration with Resident #4. Resident #34 indicated the only way to get Resident #4 out of the room would be to push Resident #4 out. Resident #34 indicated Resident #4 would sometimes push Resident #34 over the edge. On 09/26/18 at 7:39 AM, Resident #37 indicated not liking every time Resident #4 would go inside Resident #37's room because Resident #4 would touch Resident #37's personal belongings. Resident #37 indicated staff had been told several times but the staff told Resident #37 they couldn't do anything for Resident #4. On 09/26/18 at 12:51 PM, Resident #39's family member indicated Resident #4 had been inside Resident #39's room last week. Resident #39 got upset because Resident #39 had not been aware Resident #4 had been inside the room. On 09/26/18 at 3:42 PM, a Certified Nurse Assistant indicated a resident wandering into other residents' rooms without their permission would be a violation. A unwanted resident going inside your room without your permission would be like someone going into your own home and robbing you. Even if a resident would not take anything in your room, if the resident touched your personal items, it would be a violation because there was no permission granted for the resident to touch those items. On 09/26/18 at 3:51 PM, the Licensed Practical Nurse indicated Resident #4 violated the other residents' quality of life in the facility. The Resident Concern Log from (MONTH) (YEAR) to (MONTH) (YEAR), lacked documented evidence a concern form was filled out for Resident #11's complaints. On 09/13/18 at 10:13 AM, the Administrator acknowledged being aware of the residents' concern regarding Resident #4 who frequently wandered inside other residents' rooms. The Administrator acknowledged there were no concern forms in the Resident Concern Log for (YEAR), but they were addressing the situation. On 09/10/18 in the afternoon on the tour, Resident #15 advised Resident #4 came into her room and laid down on the extra bed in her room. The night nurse came in to give her medications and discovered Resident #4 in her room laying on the extra bed. Resident #15 stated Resident #4 would come into her room and throw the things on her tray table on the floor and the staff would not do anything. Resident #4 took the pillow cases off the bed and moved her clothes around. Resident #15 indicated this made her angry. On 09/25/18 at 2.40 PM, Resident #14 indicated Resident #4 wandered into her room. Resident #14 revealed this did not bother her, but it bothered others in the facility. On 09/ at 2:45 PM, Resident #24 indicated Resident #4 came in and out of her room all the time. Resident #4 goes in and out of everyone's room. Resident #4 usually played and touched her things like her stuffed rabbit, knickknacks and sat in the chair in her room. Resident #24 revealed it made her angry when Resident #4 just walked in and out. Resident #4 wandered around the place and staff were not with her. Resident #24 would like this to stop. On 09/25/18 at 2:55 PM, Resident #35 advised she did not like Resident #4 in her room especially when she had visitors. Resident #35 indicated Resident #4 wandered into her room. Resident #35 revealed the staff have to take her by the arm to escort her out of the room only after she turned on the call light. Resident #35 indicated Resident #4 was a nescient. Resident #35 stated staff were aware and nothing was done. On 09/25/18 in the afternoon, Resident #15 advised Resident #4 came into her room and threw the things on her tray table on the floor. Resident #15 told the staff she does not want Resident #4 her in her room. Resident #15 advised last week Resident #4 had hit Resident #21 in the head in the dining room. Resident #15 stated she had been told this by Resident #9 and Resident #21. Resident #15 revealed Resident #4 came into her room at night and was in her dresser, was messing with the pictures on her wall that were drawn on paper. Resident #15 advised this made her so angry and staff did not do a thing. Resident #4 just walked up and down the hallway by herself. Resident #15 advised a stop sign was placed on the doorway to her room a few days ago, but Resident #4 just took it off and entered her room. Resident #15 advised Resident #4 had never hit her and she would hit Resident #4 back if she did. On 9/25/18 at 3:50 PM, Resident #8 advised he has had a lot of problems with Resident #4 coming into his room. Resident #8 stated he has hand painted statues in his room that were too fragile for Resident #4 to be touching. Resident #8 advised he had won awards for the hand painted statues. These were painted with his wife who had passed away 2 years ago. Resident #8 stated he had spoken with staff and it was like talking to a wall. Resident #4 walked all over the facility without staff. According to Resident #8, the only time staff were with Resident #4 was when the State was here. The resident stated he was afraid Resident #4 would will take or brake his statues. Resident #8 had a stop sign on his doorway for one week and Resident #8 indicated it did no good, because Resident #4 could remove the sign. Resident #4 had not hit him, hurt him and had not seen Resident #4 hurt another resident. Resident #8 stated he paid $8,500 a month to live here and Resident #4 was infringing on his rights. The Resident stated what about our rights. Resident #8 stated this was his home and he should have the right to defend it and not have someone come in and touch their stuff. Resident #8 indicated he was told he could not do anything to Resident #4 to defend his belongings. Resident #8 indicated if you think about it she was breaking and entering my home. Resident #8 stated Resident #4 went into the dining room and played with the silverware and napkins. Resident #8 stated, we had to eat off that. How do we know where her hands had been. Its not right. Resident #8 revealed he wanted to have his door open and not worry about Resident #4 in his room. On 09/26/18 at 12:50 PM, a Physical Therapist (PT) indicated Resident #4 wandered around the facility and in the therapy room. Sometimes Resident #4 slept in other resident's rooms. The PT stated Resident #38 had told her he had awoken with Resident #4 sitting on the edge of his bed and was surprised to see Resident #4 there. This had occurred 1-2 times. On 9/27/18, Resident #21 revealed there was a resident at the facility who was driving all the resident's crazy. Resident #21 indicated Resident #4 was given too much freedom to wander all over the facility and entered other resident's rooms. Resident #21 indicated she paid rent for the room and was upset this was occurring and there was not much she could do about it. The resident indicated staff have been aware of this for a long time. Resident #21 had a stop sign attached to the door frame outside her room for about 3 weeks. The resident indicated she placed the stop sign up when she was not in her room and closed the door. Resident #21 indicated she knew Resident #4 cannot help it, but the other residents were being put in a situation of being her baby sitter. Resident #21 stated on 9/16/18 in the afternoon at 6:20 PM, in the area where they sit for their meals, Resident #4 was playing with the stuff on the table and Resident #21's garlic bread stick from the meal. The resident stated she had politely tried to move Resident #4 out of the area because their was no staff in the area. Resident #21 indicated when they reached the arch way in between the two dining rooms Resident #4 pushed her. Resident #21 verbalized she did not move when Resident #4 pushed her and Resident #4 then slapped her in the face. According to Resident# 21, the palm of Resident #4's hand hit just above the bridge of her nose. The resident verbalized she was shocked Resident #4 had slapped her. The resident indicated two other residents were in the dining room and saw this happen. There were no staff in the area. Resident #21 explained she had been directed by the Charge Nurse to document what had occurred in the dining room and provide it to her. The resident indicated this had been completed and the information was given to the Charge Nurse the same night of the incident. Resident #21 explained Resident #4 came into her room earlier and had peed in her recliner and had tried to climb into bed with her. Resident #21 indicated when she awoke and saw Resident #4 it scared her. The resident indicated she was aware Resident #4 could not help her condition and felt bad for her, but things were getting worse. Resident #4 wandered around and the other residents were getting very tired of it. On 09/10/18 in the evening, Resident #17 explained Resident #4 was allowed to wander into residents' rooms and the staff could not handle Resident #4. Resident #17 indicated Resident #4 walked into other residents' rooms and took their stuff. Resident #17 verbalized after he returned from church Resident #4 was found in his bed and had peed on his bed. Resident #17 explained Resident #4 was allowed to wander the halls freely and nobody did anything. Staff was aware of Resident #4's wandering in rooms. Resident #17 indicated the facility did not have enough staff to keep a close eye on Resident #4. Resident #17 mentioned not liking Resident #4 in his room and felt the facility was not doing anything to keep Resident #4 out of residents' rooms. On 09/10/18 at 4:52 PM, Resident #21 explained the stop sign draped across her door was used because Resident #4 went into her room and took her stuff. On 09/10/18 in the evening, observed a Velcro Stop Sign Door Banner attached to the door frame of the resident's room. The resident indicated the Stop Sign Banner was on the door because Resident #4 wandered into the room and took things. The resident indicated the stop sign did not stop Resident #4 from entering the room. The resident indicated she kept her door closed, but will request a knob lock. The resident indicated Resident #4 still opened the door even though the stop sign. Resident #4 enters everyone room without permission. Resident #1 recalled one day in the dining room Resident #4 pulled her hair. Resident #1 indicated she had to grab Resident #4 by the arm and pull her away. Resident #1 indicated Resident #4's family was

Based on interviews, record review and policy review, the facility failed to implement procedures that prohibited mistreatment and abuse for one unsampled resident. (Resident #11). Findings include: Resident #11 Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The clinical record documented an incident had occurred on 5/6/14 at approximately 11:29 AM, involving Resident #11 and spouse. Resident #11 was heard screaming from the room with the spouse present. Multiple staff members responded and separated Resident #11 and the spouse. Resident #11 reported the spouse had slapped her. During a simultaneous interview the spouse admitted to "tapping" Resident #11's mouth to get her to stop screaming. The incident was reported to the state agency (Division of Public and Behavioral Health) and the following action steps were documented: -Spouse was educated by the "Executive Director" and Director of Nursing in training that the spouse's actions were "inappropriate and cannot continue." Resident 11's spouse and son were also educated on the "regulatory responsibilities and the agencies that would be notified." -Follow up in-servicing with staff to discuss abuse "in general, what to look for with this resident especially during spousal visits, and possible interventions." -Staff will monitor spousal visits "closely in the future." On 4/3/14, a physician's progress note documented Resident #11 was generally happy with the situation in the long term care setting, but the spouse was not tolerating it well. A form titled, "Care Directive (undated)," indicated under the subheading miscellaneous: "monitor for agitation or arguments while spouse is visiting and report to the charge nurse." The care plan titled, "Agitated Behavior," documented on 5/6/14: Resident #11 was slapped in the face by spouse, the goal dated 5/6/14 documented Resident #11 "will have no adverse affect from slapping incident." Care plan documented the measures taken were "monitor for agitation or arguments while spouse is visiting and report to CN (charge nurse) and monitor for pain, mood change, or skin integrity to face every shift for 72 hours (undated). A separate care plan titled, "Agitated Behavior," documented on 5/6/14: Resident was slapped in the face by spouse. The causal factor handwritten at the bottom (undated) indicated over stimulation by spouse. The goals section handwritten at the bottom dated 5/6/14, indicated will have no adverse effect from slapping incident. 1-1 visits within common areas. The measures section (undated) documented monitor for agitation or arguments while spouse is visiting and report to charge nurse. The care plan also documented monitor for pain, mood change, and skin integrity to face every shift for 72 hours. The 24 hour alert charting log dated 5/6/14, 5/7/14, and 5/8/14, documented Resident #11 was slapped in the face by the spouse and staff were to monitor every shift mood changes, pain, and skin integrity to the face. On 5/6/14 (not timed), a social work note revealed Resident #11 denied any problems. On 5/7/14 (not timed), social services note indicated Resident #11 verbalized "we were just playing around", and "you need to forget about that and leave it alone." On 5/7/14 (not timed), activity progress note indicated resident #11 was cranky, antagonistic, demonstrated unfiltered behavior/verbal expression and acted almost infantile in response to basic questions after the event. On 7/1/14 at 6:30 PM, the nurses' notes documented Resident #11 was in her room with the spouse during the dinner meal. A Certified Nursing Assistant (CNA) was in room when spouse struck Resident #11. Resident #11 then struck the spouse. The two were separated and the spouse left the facility. The Licensed Practical Nurse (LPN) documented no swelling, tenderness, denied pain, no blurred vision per resident report, skin intact. The LPN documented notification was made to the physician, Registered Nurse Supervisor and the family. A self report was made to the state agency (Division of Public and Behavioral Health) and the Sheriff's department was notified. The clinical record lacked documented evidence a head to toe assessment or a neurological assessment was completed by a Registered Nurse after Resident #11 was struck in the head. The clinical record lacked documented evidence monitoring was conducted every shift for 72 hours after Resident #11 was struck in the head. On 7/2/14 (not timed), social services progress notes indicated Resident #11 was agitated following the incident with the spouse last evening. On 7/3/14 (not timed), social services progress notes indicated Resident #11 was calling out and not as agitated as yesterday. There was not evidence of change in mood or behavior. The Activities Care Area Assessment (CAA) (undated), indicated Resident #11 wanted to ignore the altercation and has become sensitive to any questions. Resident #11 "appeared more guarded" and "hones in on the incident by verbally becoming abusive and using profanity and demanding everyone mind their own business." On 7/10/14 in the afternoon, the Director of Nursing Services in training (DON) verbalized (the interim Administrator and Director of Social Services were present) on 5/6/14, during a mealtime visit staff heard the resident scream out. The DON in training reported the spouse admitted ly "popped her on the mouth." The DON in training directed the spouse to leave the area and explained this was unacceptable. The plan was to "monitor the spouse and 1:1 in the common areas." The facility could not provide documentation the 1:1 had occurred after the 5/6/14 incident. The facility lacked documentation an inservice was completed regarding the plan for Resident #11 during spousal visits. The Director of Social Work verbalized routine abuse training was conducted with all departments, which included the "PRIDE" program. PRIDE stands for protect, report, invest, develop, plan and evaluate. The Director confirmed training specific to Resident #11's plan had not occurred. The Director of Social Work verbalized Resident #11 was not offered counseling, psychiatric or any psychosocial services after either event. The interim Administrator indicated a police report was not filed after the 5/6/14 incident. The interim Administrator indicated "there was a gray area." The interim Administrator explained the gray area was Resident #11 verbalized the spouse slapped her and the spouse indicated "he may have tapped her on the mouth." The interim Administrator indicated further investigation had not been conducted to determine what a "tap on the mouth" meant. The interim Administrator indicated the police were notified after the July 1, 2014 incident, because it was "the second incident." The DON in training verbalized there was not a head to toe skin assessment and neurological assessment had not been conducted after Resident #11 was struck in the head on July 1, 2014. The DON in training agreed both assessments should have been completed. The DON in training confirmed an LPN examined Resident #11 and a Registered Nurse should have conducted an assessment. The DON in training confirmed monitoring was not conducted for 72 hours after the July 1, 2014 incident. The DON in training explained the police should have been notified after the first incident. The interim Administrator verbalized the plan to keep Resident #11 safe was to have a 1:1 with the new intervention of a sign-in log. The interim Administrator expressed 1:1 after the May 6, 2014, was for staff to monitor visits within the "line of sight." The interim Administrator also confirmed a 1:1 was not in place as the spouse was " out of town" however, the facility was unaware of any anticipated return date. The interim Administrator explained the 1:1 after July 1, 2014 incident was supervised visits in the common area. The facility lacked documented evidence of in-service specific to the plan after the 5/6/14 incident regarding monitoring spousal visits and how staff would "monitor closely". The facility lacked documented evidence monitoring occurred after the 5/6/14 incident or 7/1/14 incident. The facility lacked documentation of in-service of the specific plan to ensure the safety of Resident #11. Interviews conducted with direct care staff members on 7/10/14 in the morning, revealed they could not verbalize a plan to monitor Resident #11. The staff were aware Resident #11 "had been hit by spouse" and "monitoring" would occur. The staff could not verbalize what the monitoring plan was or how it was implemented. The staff confirmed general annual abuse training had occurred, but not specific training for either event with Resident #11. On 7/10/14 at 2:40 PM, the interim Administrator was notified an Immediate Jeopardy was called, due to the lack of protection from physical and potential for emotional harm from her spouse after the incident on 5/6/14, and another subsequent incident on 7/1/14. On 7/10/14 at 3:50 PM, as part of the plan of correction, Resident #11 was placed on a one to one (staff member with the resident at all times until spouse could be notified). Resident #11 was observed with a staff member. The plan included the following: -spouse to pre-arrange visits. -spouse check-in with staff and sign-in on the log for visits. -staff will supervise visits in a public area. -spouse must maintain an arm's length distance from the resident during visits. -psychiatric evaluation ordered. -Staff inservice regarding the individualized plan, reporting, and abuse prevention/recognition. -If a visit occurs, staff will complete a visitation report with attention given to limitations. -The reports will be reviewed by the Executive Director. On 7/10/14 at 5:10 PM, the interim Administrator was notified the Immediate Jeopardy was abated with the above plan of correction. On 7/11/14 at 11:00 AM, Resident #11 was observed in the dining room without a 1:1. The interim Administrator was called and asked which staff member was monitoring Resident #11. The interim Administrator verbalized it was him until he could locate the staff member. The interim Administrator verbalized the facility had not been able to reach the spouse and did not know when his anticipated return date. Facility policy titled, "Event Reporting and Investigation," indicated in part: B.) Regulatory Reporting 1). ..."Additional reporting may be required to the facility ombudsman, adult protective services and the police per state requirements." Nursing Procedure When Responding to an Event documented in part: "...complete a head to toe evaluation, check for injury ...complete a neurological check evaluation if it is known or suspected that resident struck head...Document information related to the event...be specific D). what has been done to prevent reoccurrence? E.) Document what preventative actions are in place and what changes have been implemented F). If changes have been made to the care plan conduct and document inservice of direct care givers. G) ...If a crime has been committed, notify local law enforcement.

Based on policy review, record review and interviews, the facility's staff members failed to repeatedly follow facility policies regarding post fall follow-up; failed to secure the brakes of a resident's wheelchair to avoid the resident's fall and subsequent hospitalization ; and failed to secure a cigarette lighter. Findings include: According to the facility's policy, "Fall Evaluation and Management (updated January 2014)," the facility "implements a fall management plan based on the resident evaluation...4. Falls are referred to the Daily Clinical Meeting for review. Management: a. Staff notifies the licensed nurse, who will: ---Provide immediate care and first aid, including a complete head-to-toe evaluation. ---Stay with the resident (Residents should not be left unattended). ---Complete a neurological evaluation, if the resident hit his or her head, or if the fall is not witnessed. ---Call 911---Emergency Medical Services (EMS)---if needed. ---Notify the physician and the resident's responsible party. Post-Fall Documentation: 1. After the resident has been cared for, the licensed nurse: ---Completes an interdisciplinary progress note, including a brief summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's condition. ---Updates the Care Plan with newly identified interventions, as needed. ---Updates Care Directives with new interventions. ---Alerts following shifts to fall and care plan changes per protocol. ---Residents are monitored for 72 hours post fall. ---Follows up with the physician and responsible party, as needed, to provide updates. ---Continues to follow the resident every shift for the next 72 hours, documents findings and resident condition in the Interdisciplinary Notes. Resident #4 On 4/22/14, Resident #4 was admitted with [DIAGNOSES REDACTED]. On 4/23/14, Resident #4 had a fall with a bruised and swollen lower lip and slight bruising over the pacemaker sight. On 5/15/14 at 9:10 PM, nursing documented Resident #4's fall in the nursing notes. On 5/30/14 at 1:45 PM, nursing documented Resident #4's fall in the nursing notes. On 6/9/14 at 10:48 AM, nursing documented Resident #4's fall with a right arm abrasion. There was no documented evidence of interdisciplinary progress notes as required by policy post fall. On 7/1/14 at 2:00 PM, nursing documented Resident #4's fall near the bathroom. Neuro checks were completed for 56 hours post fall with several undocumented gaps in between. There was no documented evidence of interdisciplinary progress notes as required by policy post fall, of care plan revisions post fall, or the resident being monitored for 72 hours post fall. There were no notes dated after 10:30 AM on 7/2/14. The fall note in the nursing notes indicated the Director of Nursing in Training checked the resident, yet there was no documented evidence by the Director of Nursing in Training. On 7/10/14 in the late morning, the interim Administrator and the Director of Nursing in Training were interviewed regarding the falls. The interim Administrator identified the policy requirements during the interview, and the Director of Nursing in Training indicated there should have been a note, interdisciplinary note, care plan/intervention review, 72 hour monitoring along with physician/significant other notification. Resident #8 On 12/18/12, Resident #8 was admitted with [DIAGNOSES REDACTED]. On 2/2/14 at 10:00 PM, nursing documented Resident #8's fall on the floor mat near the bed in the nursing notes. The neurological check flow sheet showed the facility performed vital signs and neuro checks over a period of 50 hours post fall. The medical record lacked interdisciplinary team notes. On 7/9/14 at 1:45 PM, the Administrator in Training indicated the previous Activity Director had problems meeting facility duties and standards, was unorganized with paperwork, and neglected to file resident council documentation. An incident during which Resident #8 sustained a fractured nose was described as occurring because of the previous Activity Director's failed attempt to monitor multiple residents simultaneously, while boarding residents on a bus. An in-service regarding wheelchair brakes and transfer safety followed as a result. On 3/4/14 at 3:45 PM, a caregiver noted in the nursing notes, "Resident went on van ride for lunch outing. It was reported that (resident) fell out of (resident's) wheelchair and had a bloody nose and was taken to (a local hospital) to get checked. (Physician) and family was notified." Further back in the medical record a hospital physician's consultation, dated 3/4/14 at 10:54 PM, noted under history of presenting illness: "...usual state of health today when near the bus stop, (resident's) aide forgot to lock (resident's) wheelchair and (resident) slipped down and fell on the pavement with (resident's) face down, with no loss of consciousness..." Imaging showed a right-sided subdural and nasal fracture. The previous Activity Director's personnel record revealed a disciplinary action dated 3/7/14, referring to the incident on 3/4/14. The previous Director of Nursing indicated the previous Activity Director violated 8.4 Standards of Conduct in the Employee Handbook: "Employees are to perform their duties with care and attention to the resident's needs not carried out as evidenced by resident being left unattended without breaks (sic) being locked and resident falling from wheelchair sustaining injury..." The previous Activity Director was terminated as a result. On 7/10/14 at 8:15 AM, the Maintenance Director did not recall a specific directive regarding checking the safety of residents' wheelchair brakes following Resident #8's fall and hospitalization on [DATE]. The Maintenance Director denied having any possible paperwork related to such a directive, because such documentation was only kept for a couple months. On 7/10/14 in the afternoon, the interim Administrator, the Administrator in Training, and the interim Director of Nursing indicated an in-service was conducted regarding checking the safety of residents' wheelchair brakes following Resident #8's fall and hospitalization on [DATE]. The aforementioned employees were unable to produce documentation of the in-service. On 7/10/14 at 5:00 PM, a licensed practical nurse was interviewed regarding the in-service. The licensed practical nurse indicated the in-service was held after 3/4/14, and before the facility readmitted Resident #8 on 3/7/14. The licensed practical nurse failed to recall where documentation of the in-service would be found. On 7/11/14 in the morning, the interim Administrator indicated wheelchair safety regarding Resident #8's incident was conducted at 8:00 PM on 7/10/14 and again at 8:00 AM on 7/11/14. Copies were provided. On 7/11/14 in the afternoon, the Administrator in Training provided the facility's in-services for 2014. One in-service, dated 2/2014, did not address the facility's fall policy, did not address wheelchair safety, and predated Resident #8's incident. Cigarette Lighter: On 7/9/14 at 4:45 PM, a cigarette lighter was observed for approximately 20 minutes left out on a medication cart in full view. The cart was parked in a hallway between the activity room and the dining room in full view of passing residents. On 7/9/14 at 4:50 PM, a certified nursing assistant indicated the cigarette lighter was placed on the medication cart within the past hour, because the nurse was not present. On 7/9/14 at 5:00 PM, a licensed practical nurse indicated the cigarette lighter should be locked up and it was used for the 3:00 PM resident smoking break. According to the facility's policy, "Nursing Center Smoking 7.01 (updated July 2013):" "...4. Resident smoking materials are kept at nurses' station or Center designated area..."

Based on record review and interview, the facility failed to ensure residents received 1) adequate pain management; and 2) were assisted to the bathroom in a timely manner to attain the highest practicable, mental, and psychosocial well-being for 2 of 12 residents (Residents #10, # 9). Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #10's nursing notes revealed the resident had been complaining of pain in her mouth, right ear, and right neck area since [DATE]. Nursing frequently medicated her with Tylenol, ear drops, antibiotics prescribed for her sore tongue. The medications provided short term relief. Review of Resident #10's record revealed she had a long history of complaining of pain. On [DATE], the physician documented, "...feeling well except that her tongue feels big. States that she needs to see her dentist." Subsequent physician visits documented on [DATE], "complains of ear pain, gum pain. Recently seen by dentist." On [DATE], the physician documented "complains of right ear pain. Recently seen by dentist. History of extractions." The physician diagnosed otitis externa with complaint of pain. "However suspect most likely referred pain." On [DATE], the physician saw Resident #10, and documented, "...the patient has a lot of pain, especially in mouth." Resident #10 was seen by an ear, nose, and throat physician in [DATE]. An endoscopy was done, and a mass was found at the base of the Resident #10's tongue. Resident #10 had a CT scan of the neck on [DATE]. The impression of the radiologist was, "There is a prominent mass involving the right side of the tongue and a malignant neoplasm such as squamous cell [MEDICAL CONDITION] is not excluded." Review of Resident #10's care plans revealed a care plan for pain related to contractures, [MEDICAL CONDITION], and foot drop initiated on [DATE], and renewed on [DATE], with a goal date of ,[DATE]. The goals were listed as "decreased or no vocalizations related to pain." The approaches were the standard approaches of pain evaluations on admission and quarterly, evaluate effectiveness of routine/PRN (as needed) pain medications each shift, ask resident to describe pain and location, and pain medications as ordered by MD (medical doctor). A pain evaluation for Resident #10 was done on [DATE], with quarterly reviews done [DATE] and [DATE]. The quarterly review completed on [DATE] indicated the resident was complaining of 10 out of 10 pain and after pain medication, reported ,[DATE]. The nurse documented "question drug seeking." The quarterly review done on [DATE] indicated the resident continued to complain of 10 out of 10 pain. The nurse documented the pain was "frequently associated with behavioral issues." A pain evaluation for Resident #10 was done on [DATE], and the nurse documented the resident complained pain was 10 out of 10, and the resident became "very tearful during interview." [MEDICATION NAME] was given as needed, and a referral was made to the physician. A second care plan for Resident #10 was initiated on [DATE] for the mass of unknown type at the back of the throat. The goal of this care plan was the resident would have adequate pain control. The approaches listed did not include anything to attain the goal of adequate pain control. The care plans were not revised for the pain management of a terminal illness. Review of Resident #10's physician orders [REDACTED]. [MEDICATION NAME] 300 milligrams (mg) three times a day for [MEDICAL CONDITION] [MEDICATION NAME] 1 mg at 12:00 PM, [MEDICATION NAME] 2 mg at 8:00 PM, for anxiety [MEDICATION NAME] 600 mg every 6 - 8 hours as needed for general pain [MEDICATION NAME] ear drops, to affected ear every two hours as needed for ear pain [MEDICATION NAME] ,[DATE] mg every 6 hours as needed for anxiety Antipyrine [MEDICATION NAME] ear drops, 4 - 10 drops to affected ear as needed [MEDICATION NAME] topical, apply to gums as needed for mouth pain [MEDICATION NAME] system 25 mcg/hr (micrograms per hours) every three days [MEDICATION NAME] HCL [MEDICATION NAME] solution 2 %, 5 ml every 2 hours as needed On [DATE], a physician order [REDACTED].#10's pain. On [DATE], the physician wrote to start [MEDICATION NAME] ,[DATE] mg 1 - 2 tablets every 4 hours as needed for pain. Review of Resident #10's [DATE] MARS revealed the resident's pain was frequently recorded as 10 out of 10. Results of the pain medication were not consistently documented. On [DATE], the results were documented as pain was now 9 out of 10. Review of Resident #10's medication administration records (MARs) revealed on [DATE], the resident received [MEDICATION NAME] 600 mg at 10:30 PM, for a stated pain of 10 out of 10, with results recorded as pain was rated as 8 out of 10. The resident had received one [MEDICATION NAME] ,[DATE] mg at 8:00 AM, and one [MEDICATION NAME] ,[DATE] mg at 3:30 PM. There was no further nursing documentation regarding the pain medication or effectiveness of pain medication on [DATE]. Review of the remaining [DATE] MARs revealed the resident's pain was between 4 out of 10 to 10 out of 10. The resident never received two tablets of [MEDICATION NAME] ,[DATE] mg. Resident #10 was transferred to the acute hospital on [DATE], and died on [DATE]. On [DATE] at 3:30 PM, during a group interview, the residents reported Resident #10 frequently would be at the nurses station in her wheelchair, holding her right ear and neck area in pain, and requesting something to help the pain. On [DATE] and [DATE], staff nurses were interviewed and reported, they probably could have done a better job managing Resident #10's pain, that the resident probably was in need of more pain medication. One staff nurse reported the resident had "cried wolf" over the years and that may have made it difficult to accurately assess her pain. Cross reference F223, F226 Dining Room Observation On [DATE], at 8:55 AM, following the breakfast meal, Resident # 9 was pleading for someone to take her to the bathroom. The resident indicated she was [AGE] years old, continent, needed help to the bathroom and did not want to wet herself. The resident was distressed and tearful. When the med nurse was asked if she could find some one to assist the resident, the nurse did not offer to assist the resident herself or to find someone. The nurse simply indicated one of the aides would be back (to the dining room).

Based on interview and document review, the facility failed to ensure residents were free from verbal abuse from a staff member for 1 of 12 residents (Resident #10). Findings include: Employee #5 On 9/11/12 at 3:00 PM, a group interview was held with five residents. One of the residents indicated she would like to speak with the surveyors privately. After all the questions were asked, the residents were asked if there was anything else they would like to discuss? A resident then reported a nurse had told a dying resident who was holding the side of her face in pain to, "Shut up. I've given you everything you could have." During the group interview, the residents indicated they were being denied having ice cream in the evening by one nurse. After the group interview, a second resident came into the conference room to speak with the surveyors and confirmed she had witnessed the nurse say, "Shut up. I've given you everything you could have." The resident identified the resident, but declined to name the nurse. The resident was tearful and visibly distressed about the incident and stated, "I can't think about it any more, it upsets me so much." The resident left the conference room at that point. On 9/11/12 at 4:00 PM, the Administrator was interviewed and reported there was an incident involving a nurse and Resident #10. Resident #10 had passed away in July 2012. The Administrator reported the incident was reported to the State Agency, and the incident had been unsubstantiated by the facility. The "Initial And Final Summary of Event to HCQC" report was reviewed and revealed under the investigation, "Social services interviewed several residents who are alert and oriented regarding any concerns they may have about nursing, Employee #5 in particular." The report indicated the two residents were angry with Employee #5, as they thought she told the kitchen not to give them ice cream. The investigation did not include interview with the resident of concern, or with other residents or nursing staff who may have had knowledge of the incident. The investigation did not identify the alert and oriented residents who were interviewed. On 9/12/12, a staff nurse came to the surveyors and reported Resident #10 had reported to her that LPN-Employee #5 told her to, "Shut up, I've given you everything you could have," and that she reported the allegation of verbal abuse to the former Director of Nurses. The former Director of Nurses no longer worked for the facility and could not be interviewed. On 9/13/12 at 1:30 PM, LPN-Employee #5 was interviewed and denied she had told Resident #10 to shut up. LPN-Employee #5 became angry as the surveyors asked her about the ice cream incident. Employee #6 On 9/11/12, a unsampled resident was interviewed and reported concerns regarding one certified nursing assistant (CNA, Employee #6) who talked to residents in a very intimidating manner. On 9/11/12, the Administrator was interviewed and asked about the concerns of the resident regarding Employee #6. The Administrator reported no concerns had been brought to her regarding Employee #6. On 9/12/12, Employee #6 was interviewed regarding abuse prohibition and prevention. Employee #6 demonstrated a flippant attitude while answering the standard abuse prohibition and prevention questions. Employee #6 reported she never intended to continue working as a CNA after finishing her nurse aide training. CNA-Employee #6, indicated she had worked at the facility for approximately [AGE] years, starting at the age of 15. The CNA was not aware when she had last received training on abuse and was not familiar with who was the facility Abuse Coordinator. The CNA was not knowledgeable of all the different types of abuse. When discussing reporting of falls and bruising of unknown origin with the CNA- Employee #6, the CNA indicated that everyone (residents) should be restrained with a lap buddy (to prevent falls). In discussion of the risks associated with restraining residents, the CNA was not knowledgeable of the risks and lacked interest in the discussion. Cross reference Tag F 226.

Based on interview, policy and document review, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress for 1 of 12 residents (Resident #10), and as part of their investigation the facility failed to include adequate detail and to identify educational needs for 1 of 12 residents (Resident #2). Findings include: On 9/11/12 at 3:00 PM, a group interview was held with five residents. One of the residents indicated she would like to speak with the surveyors privately. After all the questions were asked, the residents were asked if there was anything else they would like to discuss? A resident then reported a nurse had told a dying resident (Resident #10) who was holding the side of her face in pain to, "Shut up. I've given you everything you could have." After the group interview, a second resident came into the conference room to speak with the surveyors and confirmed she had witnessed the nurse say, "Shut up. I've given you everything you could have." The resident identified the resident, but declined to name the nurse. The resident was tearful and visibly distressed about the incident and stated, "I can't think about it any more, it upsets me so much." The resident left the conference room at that point. On 9/11/12 at 4:00 PM, the Administrator was interviewed and reported there was an incident involving a nurse and Resident #10. Resident #10 had passed away in July 2012. The Administrator reported the incident was reported to the State Agency on 7/27/12, and the incident had been unsubstantiated by the facility. The "Initial And Final Summary of Event to HCQC" report was reviewed and revealed the incident was reported to the Administrator by the Ombudsman on 7/26/12. Review of the investigation revealed, "Social services interviewed several residents who are alert and oriented regarding any concerns they may have about nursing, LPN-Employee # 5 in particular." The report indicated the two residents were angry with LPN-Employee #5, as they thought she told the kitchen not to give them ice cream. The investigation did not include interview with the resident of concern, or with other residents or nursing staff who may have had knowledge of the incident. The investigation did not identify the alert and oriented residents who were interviewed. On 9/12/12, a staff nurse came to the surveyors and reported Resident #10 had reported to her that LPN-Employee #5 told her to, "Shut up, I've given you everything you could have," and that she had reported the allegation of verbal abuse to the former Director of Nurses, Employee #11. The former Director of Nurses no longer worked for the facility and could not be interviewed. Resident #10 was transferred out of the facility on 7/7/12, and did not return. On 9/12/12, the Administrator was interviewed and reported she was informed of the allegation of verbal abuse by the Ombudsman. The Administrator reported she was not aware of the allegation being reported to the Director of Nurses. The Administrator confirmed she had not suspended LPN-Employee #5 pending the outcome of the investigation, as Employee #5 was on her days off. Review of the facility policy, "Abuse, Neglect and Misappropriation of Resident Property Prohibition Policy", 1.01, with an effective date of 10/2010, revealed the following: "F. Protection 1. The facility protects residents from harm during the investigation... 3. The facility suspends the employee, if employee is involved as alleged perpetrator." The policy indicated each employee receives the abuse prohibition training during orientation and annually and more often as determined by the facility. On 9/11/12, during the group interview, one resident reported she told LPN-Employee #5 that someone had taken a roll of quarters ($10.00) from her room. The resident reported no one had ever followed up with this resident regarding the missing money. On 9/12/12, LPN-Employee #5 was interviewed regarding abuse prohibition policies. LPN-Employee #5 reported she had been in nursing for over [AGE] years and at the facility for six years and was unable to explain the process for protecting the resident during the investigation. LPN-Employee #5 indicated she did not recall the resident reporting the missing money. LPN-Employee #5 denied she had told Resident #10 to shut up. LPN-Employee #5 stated, "It just makes me so upset...," regarding the allegation of verbal abuse. Regarding the allegation she had told the kitchen not to give the residents ice cream, LPN-Employee #5 indicated one of the residents had been eating another resident's ice cream, so the resident did not need more ice cream. LPN-Employee #5 became increasingly angry while discussing the ice cream allegations and the residents' right to have a bedtime snack. On 9/11/12, an unsampled resident reported a certified nursing assistant (CNA, Employee # 6) had a very intimidating tone when speaking to the residents. This resident reportedly could handle it, but was concerned about the residents who could not speak for themselves. On 9/11/12, the Administrator was interviewed and asked about the concerns of the resident regarding CNA-Employee #6. The Administrator reported no concerns had been brought to her regarding Employee #6. On 9/12/12, CNA-Employee #6 was interviewed regarding abuse prohibition and prevention. Employee #6 demonstrated a flippant attitude while answering the standard abuse prohibition and prevention questions. Employee #6 reported she never intended to continue working as a CNA after finishing her nurse aide training. On 9/11/12, during the group interview, Resident #11 reported an incident while being showered by a CNA (Employee #12). Resident #11 reported she and CNA-Employee #12 both knew the same person from the community and were arguing about this person. Resident #11 reported that CNA-Employee #12 was mad, and the resident fell in the shower, and the CNA left her there on the floor in the shower. Review of the facility's investigation revealed it was reported as a fall without injury and an allegation of resident rights regarding choices. Review of the investigation revealed the resident was left alone in the shower and fell while attempting to reach a towel. The investigation did not include a statement from the resident about the sequence of events. Random employees were interviewed regarding facility abuse prohibition and prevention policies. Three of the employees were unable to identify the facility abuse coordinator. Resident #2 Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident required extensive-to-total assistance with her care, including transferring, toileting, hygiene, bathing and grooming needs. Resident #2 was [AGE] years of age, had a petite body frame, was approximately 5 feet 2 inches tall and weighed between 97 to 101 pounds. The resident had a history of [REDACTED]. Review of Resident #2's medical record and the facility's event reports indicated between September 2011 to present, the resident sustained [REDACTED]. The bruise of unknown origin was discovered on 8/16/12, which resulted in the resident having to be checked out in the emergency room to determine the extent of injury. Resident #2's most recent fall, which was an assisted fall, happened on 6/25/12. In review of Resident #2's event report for 6/25/12, which involved an assisted fall, the nurse's aide was found at fault for not using a gait belt when transferring the resident. The fall resulted in an injury to the resident, but did not require emergency room intervention. As a result the aide was given a disciplinary action for failing to comply with company policy. The facility failed to identify the need to 1) re-educate staff regarding negligence, patient safety, transferring techniques, 2) the need to observe and monitor staff's techniques when transferring Resident #2, or to 3) have the resident re-assessed by Physical Therapy for recommendations. In review of Resident #2's event report for 8/16/12, for the bruise and bump of unknown origin, the facility was unable to determine the cause of the incident. In this situation, the facility failed to identify the need to re-educate staff on abuse and educate them how bruising occurs. On 9/11/12, the situation involving Resident #2's bruise of unknown origin was discussed with the Administrator (Employee #1), who was also a Licensed Practical Nurse and the facility's abuse coordinator. The Administrator indicated she had not considered the possibility that the bruise and bump, which were of a substantial size on first observation, would have to have been sustained by a significant impact. The Administrator indicated since she could not determine a cause, she had not thought there was a need to re-educate staff. In the situations involving Resident #2, both in the initial and final investigation reports, the facility investigations were not comprehensive, did not provide sufficient detail, identify the staff involved, or plans to avoid injury in the future. On the afternoon of 9/12/12, while there was no longer a bump, the bruising on Resident #2's head was still visible and extended from the left side of the temporal area extending towards the back of the head. The bruised area measured approximately 5- 5 1/2 inches by 3 1/2 - 4 inches in size. Cross reference Tag F 223.