Every finding on record at Yuma Nursing Center

Based on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure a resident was free from a significant medication error for 1 of 4 sampled residents (Resident #3), when nursing staff failed to verify the resident's identity prior to medication administration, resulting in Resident #3 receiving medications prescribed for Resident #4. The deficient practice placed Resident #3 at risk for hypotension, bleeding, and other medication related complications.Findings include:-Regarding Resident #3 who received medications prescribed for another resident:Resident # 3 was admitted to the facility on [DATE], assigned to room [ROOM NUMBER] bed 2, with a diagnosis of paroxysmal l atrial fibrillation, acidosis, chronic diastolic heart failure, and Diabetes Mellitus due to underlying condition with hypoglycemia with coma.Resident #3's Physician orders revealed that the resident did not have orders for medications including amlodipine (Calcium Channel Blocker), Calcium-Vitamin D-Minerals (Supplement), Clopidogrel (antiplatelet agent), Fish Oil (Supplement), hydrochlorothiazide (antihypertensive and edema-reducing agent), lisinopril (angiotensin-converting enzyme (ACE) inhibitor), Theragran-M (Supplement), Cefuroxime Axetil (Antibiotic), Macrobid (Antibiotic), metoprolol succinate (beta-blockers), or Pantoprazole Sodium (proton pump inhibitor) prescribed to Resident #4.An Incident note dated July 30, 2026 documented that at approximately 10:00 a.m., Registered Nurse (RN/Staff #6) was notified by a Certified Medication Technician (CMT/Staff #15) that Resident #3 had received medications intended for another resident. Staff #15 reported recognizing the medication error after Resident #3 had ingested the medications.The incident report documented that Resident #3's vital signs were obtained and initially monitored every 15 minutes. The resident was encouraged to increase fluid intake and was positioned with legs elevated. A Physician was notified and a 500 ML (Milliliter) IV (Intravenous) normal saline bolus was ordered and administered. Continued monitoring for symptoms, hypotension, and adverse medication effects was implemented.The incident report further documented that Staff #15 was counseled and removed from medication administration duties and the medication administration record (MAR) and documentation were updated.Further review of the incident report did not identify the resident for whom the medications were prescribed or the specific medications administered to Resident #3.A physician progress note dated July 30, 2026 documented that Resident #3 had inadvertently received another resident's antihypertensive medications and subsequently developed hypotension. The resident remained alert and was at baseline mental status. Following administration of the 500 mL IV normal saline bolus, Resident #3's blood pressure improved. The note documented that the resident remained asymptomatic throughout the event without dizziness, lethargy, chest pain, shortness of breath, or changes in mental status. Review of a neurological checks log dated July 30, 2026 for Resident #3 revealed the following blood pressures:10:10 AM 120/6010:25 AM 105/5810:40 AM 112/6010:55 AM 120/7511:10 AM 122/7811:25 AM 125/8011:55 AM 130/8212:25 PM 126/8512:55 PM 122/861:55 PM 118/752:55 PM 120/623:55 PM 118/624:55 PM 120/60Resident #3's July 30, 2026 MAR revealed that after the medication error was identified, Staff #6 administered the following medications to Resident #3 ordered for Resident #3:Apixaban (an anticoagulant) 2.5 MG (Milligram) - 1 oral tablet for atrial fibrillation.Sertraline HCL (Hydrochloride) (selective serotonin reuptake inhibitors, SSRIs) Oral Tablet 100 MG -1 tablet for depressionSitagliptin (Gliptins) 50 MG- 1 oral tablet for diabetes mellitusHumalog KwikPen (Insulin) - 7 units for diabetes mellitus Cephalexin (Antibiotic) Oral Capsule 500 MG - 1 capsule for pneumoniaNS (Normal Saline) bolus - IV 500 mLJardiance (SGLT2 inhibitors) Oral Tablet 10 MG - 1 tablet for diabetes mellitusThe MAR documented the Lasix (Diuretic) Oral Tablet 40 MG 1 tablet for congenital heart failure was withheld due to hypotension.- Regarding Resident #4 - Medications involved in the error:Resident #4 was admitted to the facility on [DATE], assigned to room [ROOM NUMBER] Bed 1, with diagnosis of acute cystitis without hematuria, and ulcers of esophagus without bleeding.Resident #4's physician orders and July 30, 2026 MAR revealed the following medications were scheduled for administration during the morning medication pass: Amlodipine Besylate Oral Tablet 10 MG - 1 Tablet one time a day for hypertensionCalcium-Vitamin D-Minerals Oral Tablet Chewable 600-400 MG-Unit - 1 tablet one time a day for supplementClopidogrel Bisulfate Oral Tablet 75 MG - 1 tablet one time a day for antiplateletFish Oil Oral Capsule 1000 MG - 1 Capsule one time a day for supplementHydrochlorothiazide Oral Capsule 12.5 MG - 1 capsule one time a day for fluid retentionLisinopril Oral Tablet 10 MG - 1 tablet one time a day for ACE inhibitorTheragran-M Oral - 1 Tablet one time a day for supplementCefuroxime Axetil 500 MG - 1 oral tablet two times a day for infectionMacrobid (Antibiotic) 100 MG - 1 oral capsule two times a day for infectionPantoprazole Sodium 1 oral tabled 40 MG two times a day for gastroesophageal reflux disease (GERD)Further review of Resident #4's physician orders and MAR revealed that metoprolol succinate 25mg, 1 tablet by mouth, was ordered for hypertension and scheduled for administration at bedtime.The facility's written response to the surveyor's request for documentation, dated August 5, 2026, identified the medications administered in error to Resident #3 as Lisinopril 10 mg, Metoprolol Succinate 25 mg, and Hydrochlorothiazide 12.5 mg. However, Resident #4's physician orders and MAR indicated that metoprolol succinate 25mg was scheduled for administration at bedtime and was not scheduled for morning medication pass.During an interview on August 5, 2026, at 1:25 PM, Licensed Practical Nurse (LPN/Staff #4) stated that prior to administering medications, staff were expected to verify the correct resident by confirming the resident's name and comparing the resident to the photograph in the MAR.During an interview on August 5, 2026, at 2:03 p.m., the Director of Nursing (DON/Staff #127) stated, that her expectation when administering medications to residents is that the person administering the medications checks, rechecks, and checks a third time to make sure they have the right resident before administering the medications. The DON stated Staff #15 administered the medications to Resident #3 around 9:00-9:30 am. The DON stated that Resident #3 had received lisinopril 10 mg 1 tablet, metoprolol 25 mg 1 tablet, and hydrochlorothiazide 12.5 mg 1 tablet from Staff #15. The DON stated that she did not know why only those three medications were identified when Resident #4 had multiple morning medications ordered. The DON further stated that metoprolol was ordered for Resident #4 at bedtime rather than in the morning and she did not know why it had been administered to Resident #3.During a telephone interview on August 5, 2026, at 3:26 p.m., Staff #15 stated that after receiving shift report, she began administering morning medications. Staff #15 stated that Resident #3 and Resident #4 shared a room and that the report sheet incorrectly identified Resident #3 as occupying bed 1 and Resident #4 as occupying bed 2.Staff #15 further stated that she prepared what she believed were Resident #4's morning medications, entered the room, approached Resident #3, and addressed him using Resident #4's last name. According to Staff #15, Resident #3 did not correct her, commented, so many pills, and ingested the medications. Staff #15 stated that she administered what she believed were all of Resident #4's morning medications to Resident #3, which she estimated consisted of approximately 8-10 pills.Staff #15 further stated that she subsequently documented the medications as administered on Resident #4's MAR. Staff #15 stated that she discovered the error when she later approached Resident #4 to administer medications intended for Resident #3, addressed Resident #4 using Resident #3's last name, and Resident #4 indicated that Resident #3 was in the other bed. Staff #15 stated that she then notified Staff#6 of the medication error.Staff #15's account was inconsistent with the facility's written response, which identified only lisinopril 10mg, metoprolol succinate 25mg, and hydrochlorothiazide 12.5mg as having been administered in error to Resident #3.Review of facility documentation revealed a policy and procedure titled Administering Medications revised April 1, 2019. The policy and procedure documented; medications are administered in accordance with prescriber orders including any required time frame. The policy documented that the individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: checking identification band, checking photograph attached to the medical record; and if necessary, verifying resident identification with other facility personnel. The policy revealed that the individual administering the medication checks the label THREE times to verify the right resident, the right medication, the right dosage, right time, and right method of administration before giving the medication.

Based on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #4 was free from abuse from resident #5. The deficient practice could result in residents experiencing emotional, physical, and mental trauma from the abuse. Findings include: Related to resident #4- Resident #4 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Dementia, and unsteadiness on feet. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed resident #4 completed a Brief Interview for Mental Status (BIMS) and scored a 12 which indicated the resident was moderately cognitively impaired. Review of resident #4's Electronic Health Record (EHR) revealed a progress note dated December 1, 2024 at 7:45 p.m. The note indicated that a Certified Nursing Assistant (CNA) informed the nurse that resident #4 was slapped on the right forearm by male peer who stated, you need to stop crying. The progress note also noted that both residents were separated and there were no injuries. Related to resident #5- Resident #5 was admitted to the facility on [DATE] with diagnoses of acute kidney failure, history of strokes, and type 2 diabetes. Review of the admission MDS, dated [DATE], revealed resident #5 completed a BIMS and scored a 4 which indicated the resident was significantly cognitively impaired. Review of resident #5's care plan, created October 28, 2024, revealed a focus area related to behavior management. Interventions included encouraging the resident to participate in self-calming behaviors, reorient resident to person, place, time and situation, and to monitor for signs and symptoms related to infection. Review of resident #5's EHR revealed a progress note dated December 1, 2024 at 7:45 p.m. The note indicated that it was reported that resident #5 appeared agitated and propelled wheelchair next to female peer where he slapped her on the right forearm stating you need to stop crying. The note also indicated that residents were separated and the resident was administered a PRN (as necessary) medication of Sertraline (anti-depressant) 50 milligrams (mg). An interview with resident #5 was attempted on December 10, 2024 at 11:58 a.m. however, resident #5 refused interview and stated he wanted to sleep. An interview was conducted with Licensed Practical Nurse (LPN/Staff #15) on December 10, 2024 at 1:44 p.m. Staff #15 confirmed that she worked on December 1, 2024. She explained that she was walking down the hall when a CNA reported that resident #5 had slapped resident #4 with an open hand. Staff #15 indicated that she had asked both CNAs working the floor if there had been any triggers that led to the altercation and both CNAs had reported there were none and that resident #5 was a bit more irritable lately. Staff #15 also indicated that she contacted the provider notifying them of the incident and that resident #5 had been more irritable and requested to administer Sertraline, which the provider approved. An interview was conducted on December 10, 2024 at 2:40 PM with a Certified Nursing Assistant (CNA/Staff #4). Staff #4 confirmed she was working on December 1, 2024 with both resident #4 and #5. Staff #4 recalled that it was a normal shift that evening and resident #4 was crying and sitting in the common area between her and another CNA (staff #18) as they both were consoling her. Resident #5 was sitting in the common area in front of the TV when he approached the direction they were sitting at. Staff #4 indicated that she thought resident #5 was approaching her to ask her something but instead he slapped resident #4. When staff #18 asked resident #5 why he slapped resident #4, he stated that she needed to stop crying. Once resident #5 was moved away from the area, staff #4 consoled resident #4 and informed the nurse of the incident. A telephonic interview was conducted on December 10, 2024 at 3:23 PM with a CNA (CNA/Staff #18). Staff #18 recalled the altercation between resident #4 and #5 and indicated that she was in the common area with resident #4 consoling her because she was crying. Staff also indicated that resident #4 typically cries before bed. Resident #5 then wheeled himself next to resident #4 and looked at her while she was crying. Staff #18 indicated that resident #5 all of a sudden slapped resident #4 on her Right arm and said something to the affect of she needs to stop. Staff #18 added that both CNAs then took resident #4 to her room to put her into bed because she needed a Hoyer lift which required 2 CNAs. Staff #18 also indicated that the slap sounded hard but there was no bruising on her arm. An interview was conducted on December 10, 2024 with two Directors of Nursing (staff #20 and #21, respectively). When asked what would be the risks to the residents who might be abused in the facility, staff #21 responded they could suffer from psychological harm, physical harm, death, emotional harm, and it could affect their relationships with family. When asked what transpired between resident #4 and #5, staff #21 explained that resident #4 likes to cry and she was informed by the CNA that resident #5 slapped resident #4 opened handed and he said to stop crying. Staff #21 continued to explain that neither of the residents remember what happened and there were no injuries noted. Staff #20 added that resident #5 did not have prior incidents and she thought that resident #5 was trying to console resident #4 but he hit her too hard. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, indicated that residents have the right to be free from abuse. The policy also indicated that the facility will protect residents from abuse . from other residents.

Based on documentation, staff interviews and the facility policy and procedures, the facility failed to ensure that one resident (#12) was free from abuse from other residents (#12). This deficient practice could result in other residents being abused. Findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses that included Alheimer's disease, anxiety, generalized muscle weakness. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 08 indicating the resident had a moderate cognitive impairment. Review of a nurse practitioner note dated October 4, 2024 revealed that resident #12 is an [AGE] year old female with a past medical history of Alzheimer's disease and a mixed mood disorder and the resident resides in a memory care unit in a long-term care facility. Review of the progress notes revealed a late entry dated October 4, 2024 at 7:25 p.m. by the Director of Nursing (DON/staff #1), which stated that she was called into the hallway, where a certified nursing assistant (CNA/staff #7) told her that she witnessed how another resident had struck resident #12 with an open hand. The resident was removed from the area as well as other residents. The resident was remove from the area, quickly assessed and offered emergency medical services, which the resident denied. A progress note dated October 5, 2024 revealed that a licensed practical nurse (LPN/staff #10) was called into the hall and was notified that the resident was slapped by another resident with an open hand on the left cheek, which was witnessed by the (CNA/staff #7). The resident did not lose consciousness, was startled, but reported being fine. Upon examination, the resident presented with a slight discoloration on the right cheek. The provider and the DON were notified by phone at around 7:45 p.m. as well as a relative of the resident at around 8:30 p.m. The resident was removed immediately from the proximity of the aggressor. The resident was in good spirits and denied any pain. -Resident #87 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder, and depression. Review of the care plan did revealed a plan dated April 11, 2024 for anti-anxiety, antidepressants, mood disorder medication use. Interventions included to monitor patterns of target behaviors. The MDS dated [DATE] included a brief interview for mental status score of 99 indicating the resident had significant cognitive impairment. A progress note dated October 4, 2024 at 12:38 p.m. revealed that the resident had a physical altercation with residents and staff, and that resident #87 was sent out to the emergency room . A behavior note dated October 4, 2024 at 5:12 p.m. revealed that resident #87 was refusing all medications, being belligerent and aggressive towards staff and residents. The provider was notified. A progress note dated October 4, 2024 at 8:26 p.m. revealed that around 7:25 p.m. the writer was notified that resident #87 slapped resident #12. The other resident was examined and made sure she was not harmed. Resident #87 had been aggressive all afternoon, and when the other resident got too close to her, she slapped her on the left cheek. The DON was called at 7:36 p.m. and made aware of the situation and staff was advised to call emergency medical services to send resident #87 to the emergency room (ER) due to being a threat to others. At 8:34 p.m. the ER called to ask if they could send resident #87 back to the facility, but the writer was not comfortable having the resident back due to her attacking other residents. An interview was conducted on October 17, 2024 at 2:07 p.m. with (CNA/staff #7), who stated that , she has received training on abuse and when a resident hits another resident that is abuse. She stated that she was charting by the TV area and resident #87 was within 3 to 4 feet of her. Resident #12 said, hey you're in my way because she was trying to get by resident #87 in the hallway. Resident #87 was already irritated and she was trying to wheel away when she swung out her left arm and hit resident #12 on the left cheek. The residents were separated. She stated that by the end of the the shift, around 9:40 p.m., she noticed a small bruise, red in color, about the size of a nickel on resident #12's cheek, and she reported the bruising to the nurse. She stated that the police and the paramedics came resident #87 was taken away at about 9:00 p.m. She stated that resident #87 is always hitting the staff and staff try to keep her away from the other residents. An interview was conducted on October 17, 2024 at 2:49 p.m. with the Director of Nursing (DON/staff #1), who stated that resident #12 didn't have a bruise, but did have some redness on her cheek. She stated that both residents wander and they were separated as soon as possible. She also stated that she and all there staff have received training on abuse, which occurs when anybody intentionally inflicts harm. The facility Abuse Prevention Program stated that the facility will not tolerate verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property by employees, family members, visitors, or other residents.

Based on closed clinical record review, staff interviews, facility documentation and policy review and the State Agency (SA) database, the facility failed to ensure that an allegation of abuse for one resident (#20) was reported to the State Agency as required. The deficient practice could result in abuse not being identified and investigated. Findings include: -Resident #20 was admitted to the facility on [DATE], with diagnoses that include Calculus of Kidney, Cystocele, Metabolic encephalopathy, anxiety, and dementia. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had significant cognitive impairment. -Resident #100 was admitted to the facility on [DATE], with diagnoses that include Urinary tract infection, metabolic encephalopathy, Alzheimer's disease, dementia, anxiety, and restlessness. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had significant cognitive impairment. A progress note dated March 29, 2024 at 11:32 p.m. revealed that at 7:30 p.m, resident #20 had stated to the nurse that they had been struck in the head by another resident, and that part of their scalp was sore. Further review of the progress notes revealed that at 8:25 p.m. in a separate incident two staff members witnessed another resident striking resident #20 on top of the head, and the residents were put into rooms far apart. However, there was no evidence found in the clinical record and facility documentation that this incident was reported to the SA as required. The SA database received an online report dated April 10, 2023 at 8:43 p.m. from an anonymous source that revealed a report of multiple resident to resident interactions on March 29, 2024. The report alleged that a resident was admitted in an unsafe manner, and that documentation and staffing were sub-par. The report further revealed that the same resident had struck resident #20 on top of the head. An interview with a CNA (CNA/staff #120) was conducted on April 24 at 2:30 p.m. The CNA stated that that she was working the day the incident happened, there was a call off and so they were short staffed that day also. The CNA stated a resident hit resident #20 that day. The CNA further stated that the resident that hit resident #20 had two incidents that day, but that two was probably it. An interview with the Director of Nursing (DON/staff #80) was conducted on April 24, 2024 at 2:53 p.m. The DON stated the event on March 29 involving resident #20 was reported to her by the staff, and stated she told the executive director. The DON further stated that they are both the abuse coordinators, but the executive director handles the reportable. The DON stated that her expectation in an incident is that residents are assessed to ensure there are no injuries, do vitals and keep the resident's separated. An interview with the Administrator (staff #35) was conducted on April 24, 2024 at 3:05 p.m. The administrator stated that there were no facility reportable incidents for resident #20. He further stated that he was aware of the incident on March 29 but there were no injuries, so he thought he didn't have to make a report. A review of facility policy titled Abuse, Neglect, Exploitation or misappropriation - reporting and investigating revealed that all reports of resident abuse (including injuries of unknown origin) are reported to local, state and federal agencies and thoroughly investigated by facility management.

Based on clinical record review, staff interviews, facility documentation, and policy, the facility failed to implement their abuse policy, by failing to report an allegation of abuse within the required time for two residents (#100 and #20). This deficient practice could result in further incidents of abuse not being reported. Findings include: -Resident #20 was admitted to the facility on [DATE], with diagnoses that include Calculus of Kidney, Cystocele, Metabolic encephalopathy, anxiety, and dementia. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had significant cognitive impairment. -Resident #100 was admitted to the facility on [DATE], with diagnoses that include Urinary tract infection, metabolic encephalopathy, Alzheimer's disease, dementia, anxiety, and restlessness. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had significant cognitive impairment. A progress note dated March 29, 2024 at 11:32 p.m. revealed that at 7:30 p.m, resident #20 had stated to the nurse that they had been struck in the head by resident #100, and that part of their scalp was sore. Further review of the progress notes revealed that at 8:25 p.m. in a separate incident two staff members witnessed resident #100 striking resident #20 on top of the head, and the residents were put into rooms far apart. An interview with the Director of Nursing (DON/staff #80) was conducted on April 24, 2024 at 2:53 p.m. The DON stated the event on March 29 between resident #100 and #20 was reported to her by the staff, and stated I had told my executive director. The DON further stated that they are both the abuse coordinators, but the executive director handles the reportable. An interview with the Administrator (staff #35) was conducted on April 24, 2024 at 3:05 p.m. The administrator stated that there were no facility reportable incidents for resident #100. He further stated that he was aware of the incident on March 29 but there were no injuries, so he thought he didn't have to make a report. A review of facility policy titled Abuse, Neglect, Exploitation or misappropriation - reporting and investigating revealed that all reports of resident abuse (including injuries of unknown origin) are reported to local, state and federal agencies and thoroughly investigated by facility management.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#20) was free from physical abuse by other residents (resident #100). The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #20 was admitted to the facility on [DATE], with diagnoses that include Calculus of Kidney, Cystocele, Metabolic encephalopathy, anxiety, and dementia. A behavioral care plan dated January 30, 2024 revealed the resident was at risk of wandering and intruding on another residents' privacy. The goal was noted to be wandering will not contribute to injury, with noted interventions of alerting staff when the resident is wandering, and place resident in area where frequent observation is possible. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had significant cognitive impairment. -Resident #100 was admitted to the facility on [DATE], with diagnoses that include Urinary tract infection, metabolic encephalopathy, Alzheimer's disease, dementia, anxiety, and restlessness. A review of the clinical record progress notes dated March 29, 2024 at 3:21 a.m. revealed the resident was anxious and not easily redirected. A second progress note dated March 29, 2024 at 11:32 p.m. revealed that at 7:30 p.m, resident #20 had stated to the nurse that she had been struck in the head by resident #100, and that part of her scalp was sore. However, no corrective measure was noted for this incident. Further review of the progress notes revealed that at 8:25 p.m. in a separate incident two staff members witnessed resident #100 striking resident #20 on top of the head, and the residents were put into rooms far apart. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had significant cognitive impairment. A behavioral care plan dated April 8, 2024 revealed the resident was at risk of wandering and intruding on another residents' privacy. The goal was noted to be wandering will not contribute to injury, with noted interventions of redirect resident when wandering into other resident's rooms, place resident in area where frequent observation is possible, and provide diversional activities. An interview was conducted with a Registered Nurse (RN/staff #25) on April 24, 2024 at 2:07 p.m who stated that resident #100 had struck her for the first time prior to the interview. The RN further stated that was the first time but there had been many instances of resident #100 striking at staff and other residents because she doesn't understand staffs are trying to help her and that re-orienting resident #100 is tough because she doesn't make sense when she speaks. An interview with a Certified Nursing Assistant (CNA/staff #80) was conducted on April 24, 2024 at 2:13 p.m. The CNA stated that resident #100 is very confused and very hard to understand. The CNA also stated that at times resident #100 can be nice, but most of the time she is aggressive and swats at other people. An interview with a CNA (CNA/staff #120) was conducted on April 24 at 2:30 p.m. The CNA stated that when resident #100 admitted she was trying to kiss at other residents, but that quickly turned into her acting like she was going to smack them. The CNA also stated they were short staffed that day and only had two CNA's on the unit. When asked about the above incidents on March 29, 2024, the CNA stated that she was working that day, there was a call off and so they were short staffed that day also.The CNA further stated that the nurse working that day was new hire nurse who was untrained and she felt that the nurse needed more training. An interview with the Director of Nursing (DON/staff #80) was conducted on April 24, 2024 at 2:53 p.m. The DON stated resident #100 was Spanish speaking only, and speaks only gibberish. The DON further stated resident #100 was on isolation for an infection, and was isolated in her room because she would turn over tables. The DON stated that they removed everything in her room for her safety, and that eventually resident #100 was sent to the hospital for behaviors that couldn't be controlled. The DON stated that her expectation in an incident is that residents are assessed to ensure there are no injuries, do vitals and keep the resident's separated. The DON concluded that she didn't want to bring the resident back into the facility but was over-ruled. A review of facility policy titled ''Abuse Prevention Program revealed Protection of residents' revealed that the facility will have a system in place to prevent abuse.

Based on observations, clinical records, staff interviews and facility policy, the facility failed to ensure adequate supervision was provided to prevent elopement for two residents (#178 and #179). The deficient practice could result in increase the risk of resident for harm and injury. Findings include: -Resident #178 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, restlessness, agitation and wandering. A progress note dated January 8, 2021 included the resident was admitted at the facility, was alert, oriented to self only, pleasant and responding well and had a steady gait and balance with sufficient strength to extremities. A progress note dated January 10, 2021 revealed the resident was roaming and refused to go to her room. Per the note the resident made statement about wanting to go outside and was told that she was not able to at this time. Per the documentation, staff attempted to divert the resident's attention but had no positive effect and the resident continued to refuse to comply. A progress note dated January 16, 2021 included the resident was alert to self only, was responding, was wandering in the hallway and was monitored for safety. Per the documentation, the door alarm was set to on. Another progress note dated January 16, 2021 included the resident was ambulating throughout the unit; and that, the resident was experiencing auditory and visual hallucinations. A progress note dated January 18, 2023 at 12:02 a.m. included the resident was alert to self only, confused and restless. It also included that the resident wandered in the hallway and attempted to tear the plastic isolation barrier in the hallway. Another progress note dated January 18, 2023 revealed that at approximately 3:24 p.m. the resident eloped using the fire exit in the COVID unit, crossed the street and refused to come in. Per the documentation, the resident became agitated, aggressive, was yelling and confronted the police officer. The note included that at approximately 4:15 p.m., the resident was transported to the hospital for evaluation and treatment. The progress note dated January 19, 2021 included that resident was outside the building yesterday (January 18, 2021) and was in the grass area; and that, the nurse attempted to get the resident back in the building but the resident started walking away from the building. Per the documentation, the resident yelled vulgarities at the nurses, refused to come back in the building, continued to walk away to the streets, fell and refused to be assisted by staff. It also included that the police were called to assist with the de-escalation; and that the police were able to get the resident to sit in the wheelchair in the parking lot across the street of the facility. Further, the note included that EMS (emergency medical services) were called and the resident was taken to the ER (emergency room ) for danger to self. A self-reported intake dated January 19, 2021 included that the resident went out of the fire door on the 100 hall; and that, a staff nurse saw her and attempted to have the resident come back inside the facility. Per the report, the resident became highly agitated and would not return, police and EMS were called and the resident was transferred to the emergency room . The facility report dated January 25, 2021 included that at approximately 3:30 p.m. (January 18), the resident was witnessed by staff exiting the 100 unit exit door. Per the documentation, it was determined that the 100 unit exit door was disarmed for trash disposal. Per the documentation, the 100 unit was a designated COVID hall and the exit door was used by housekeeping and laundry; and that, the unit was not a COVID unit as of January 19, 2021 An interview with a housekeeping manager (staff #58) was conducted on June 22, 2023 at 2:22 p.m. The housekeeping manager stated that staff takes the solid trash to the outside and that staff have a master key in laundry to go outside. He said that housekeeping staff take the alarm off and then they come inside and put the alarm on; and that, most of the time the housekeeping staff do remember to enable the alarm. Further the housekeeping manager said that he checks this regularly. An interview was conducted with the Director of Nursing (DON/staff #66) on June 22, 2023 at 2:41 p.m. the DON stated that the trash door was supposed to be locked and that several of the staff have keys to the door. The DON said that when staff comes in through the door, staff had to lock it to reset the alarm. Regarding resident #178, the DON stated that she believed that the resident exited a different door; and, she was not there at the time of this elopement. An interview was conducted on June 22, 2023 at the same time with the Assistant Director of Nursing (ADON/staff #74) who said that the door was an emergency exit door and resident #178 came out of the door on the COVID unit. -Resident #179 was readmitted on [DATE] with diagnoses of dementia, wandering, anxiety disorder, restlessness and agitation. The 48-hour discharge planning care plan dated November 10, 2022 included and intervention of social services special considerations for wandering. The behavior care plan dated November 10, 2022 included resident had wandering behaviors. Interventions included to place resident in an area where frequent observation is possible, provide diversional activities; note which exits resident favors for elopement from facility and alert staff working near those areas; implement facility protocol for locating eloped resident; if wandering away, instruct staff to stay with resident, converse and gently persuade to walk back to designated area with them; alert staff to wandering behavior; and remove and change exit combination numbers so patients does not have access to door codes. An Admission Minimum Data Set (MDS) assessment dated [DATE] included resident had severe cognitive impairment; and that, the resident had wandered 4 to 6 days of the last 7. A progress note dated November 18, 2022 included that the resident went on a leave of absence (LOA) with a family at 4:30 p.m. Per the documentation, the facility received a call from another facility across the street that resident #179 was there. According to the documentation, at the family member had signed the resident back in at the front desk; and that, the family was asked to bring the resident back and sign the resident back in the locked unit. Further, the document included that the resident could not recall how he got to the other facility. The facility report dated November 25, 2022 revealed that on November 17, 2022 the resident went out of the facility for lunch with family. Per the documentation, at around 4:15 p.m., front office staff witnessed resident and family enter the lobby and went through lobby door. The investigation included that family left the resident in the hallway unattended with no staff present; and the resident walked to the west side entrance, left the building and walked across the street. Further, the documentation included that the resident was able to read the code to exit posted by the door. The care plan dated November 29, 2022 included the resident required assistance with self-care. Interventions included to assist resident to find his room when he feels lost or cannot find it; to assist and meet needs, concerns and ADL (activities of daily living) by anticipation; and, supervision to limited assist for ADLs and 1-person assist. A progress note dated December 5, 2022 included that a staff noted that this resident was outside and across the street and that he was returned without difficulty. A social service note dated December 15, 2022 included resident needed a higher level of security as the resident was actively exit seeking. A provider note dated December 18, 2022 included the resident was alert and had a history of dementia and wandering. The progress note dated December 26, 2022 included the resident continued to wander inside the unit on and off, was on 15 minutes continuous monitoring and was high risk for elopement. An interview was conducted with the Director of Nursing (DON/staff #66) on June 22, 2023 at 2:41 p.m. The DON stated that she remembered that the staff had specifically showed the family the book that the family was supposed to sign; and that, the family was supposed to go onto the unit and sign the resident back in the unit. However, the DON stated that the family brought the resident back and let the resident out right in the hall, not the unit. She said that the resident looked like a visitor as he was wearing blue jeans and he walked well. Further, the DON said that the staff in the front of the building did not know the resident. The DON stated that resident #179 eloped in 2020 and was due to the resident removing his wanderguard. Further, she stated that it was their policy that their residents do not elope from the building. The facility policy on Wandering and Elopements revealed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. This document included that if residents are identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety

Based on employee record reviews, facility documentation, staff interview, and facility policy and procedures, the facility failed to conduct COVID-19 testing based on the frequency set forth by state and federal guidelines for three staff (#3, #57, #62). The deficient practice could result in the spread of the COVID-19 virus. Findings include: Review of facility documentation revealed that the county positivity rate was substantial/high from May 9, 2022 through May 23, 2022 and required COVID-19 testing 2 times per week. -Staff #3's (Speech Therapist) employee record included an exemption form from the COVID-19 vaccine approved on December 5, 2021. Review of staff #3's employee records revealed that he received a POC (Point of Care) COVID-19 test on May 10, 13, and 24 and the results were negative. The Time Card from May 9, 2022 through May 23, 2022 for staff #3 revealed that staff #3 worked at the facility on May 9, 10, 11, 13, 17, 18, 23, and 24. Comparison of the test dates and Time Card revealed that staff #3 worked on May 17 and 18, 2022, but was not tested for COVID-19 during that week. -Staff #57's (Certified Nursing Assistant) employee record included an exemption form from the COVID-19 vaccine approved on December 5, 2021. Staff #57's employee records revealed that staff received a POC COVID-19 test on May 14, 15, and 23, 2022 and the results were negative. Review of staff #57's Time Card revealed that staff worked at the facility on May 16, 18, 19, and 21, 2022. Comparison of the test dates and Time Card revealed that staff #57 was tested on e time for COVID-19 on May 15, 2022, and worked multiple days that week. -Staff #62's (Registered Nurse) employee record included an exemption form from the COVID-19 vaccine approved on December 5, 2021. Review of staff #62's employee records revealed that staff received a POC COVID-19 test on May 9, 15, 20, and 23, 2022 and the results were negative. Review of staff #62's Time Card revealed that staff worked on May 9, 12, 15, 19, 20, 21, 23, and 25, 2022. Comparison of the test dates and Time Card reveal that staff #62 revealed that staff was tested on e time on the week of May 9, 2022, but worked in the facility two times that week. An interview was conducted on May 27, 2022 at 8:21 a.m. with the Director of Nursing (DON/staff #83). She stated that the county positivity rate has been substantial/high since May 9, 2022. She said staff who are not fully vaccinated or have an exemption are required to be tested for COVID-19 two times a week when the county positivity rate is high. She stated that staff #3 has an exemption, so staff #3 should have been tested 2 times a week since May 9, 2022. She reviewed the staff #3's test dates and Time Card and stated that staff #3 should have been tested for COVID-19 two times the week of May 16, 2022. Staff #83 reviewed the test dates and Time Card for staff #57 and stated that staff #57 was tested on e time the week of May 9, 2022, one time the week of May 16, 2022, and one time the week of May 23, 2022 and should of have been tested two times the week of May 16, 2022. Then, she reviewed the test results and Time Card for staff #62 and stated that staff #62 should have been tested 2 times the week of May 9, 2022. The DON stated the Assistant DON/Infection Control Preventionist (ICP/staff #25) is responsible for following up on the COVID-19 testing to make sure that it is being done. The DON stated the purpose is to make sure staff are not entering the facility with COVID, which could jeopardize the health of the residents and other staff, and could result in an outbreak. The facility policy, COVID-19 Vaccine Policies and Procedures, updated March 2022 stated that staff who receive an exemption to the COVID-19 vaccine will be subject to additional precautions to mitigate the transmission and spread of COVID-19, which included POC/PRC testing per current community transmission rates. The facility policy, Coronavirus Disease (COVID-19) - Testing and Return to Work Criteria for Healthcare Personnel, stated routine testing of facility staff who are not up-to-date (those who are asymptomatic and have no known or suspected exposure to [CONDITION(S)]-CoV-2) is based on the extent of the virus in the community. Frequency of retesting is based on the following criteria, high/substantial COVID-19 Transmission is twice a week.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure transmission-based precautions for one resident (#157) were implemented. The deficient practice could result in the spread of the COVID-19 virus. Findings include: Resident #157 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline care plan dated May 20, 2022 included a plan for the resident to self-quarantine for 7 days. The Summary Orders included an order dated May 20, 2022 for COVID-19 screening - monitor for cough, shortness of breath, fever, headache, repeated shaking with chills, new loss of taste of or smell, diarrhea, muscle pain, sore throat or vomiting every shift. Review of the clinical documentation dated May 23, 2022, revealed that the resident's family members declined to have the resident vaccinated for the COVID-19 virus. On May 24, 2022 at 8:30 a.m., resident #157 was observed in the dining room eating lunch with the rest of the residents. The resident was sitting at a table across from the dining room entrance. The resident's back was to the door. There were three other residents observed sitting at the table within 6 feet of the resident. The resident was observed eating and therefore observed not wearing a mask. During an interview conducted on May 27, 2022 at 8:53 a.m. with the Assistant Director of Nursing (ADON/staff #25) and the Director of Nursing (DON/staff #83). Staff #25 stated that resident #157 is on observation for 7 days because the resident is a new admission and is not vaccinated for the COVID-19 virus. She said the resident cannot leave their room for the first 7 days and should be eating meals in their room at this time. She also said that the purpose for the 7-day observation is to ensure that a resident is not exhibiting symptoms for the COVID-19 virus. The ADON stated that if the resident does not remain in their room, there is a risk of exposing other residents to the virus. Staff #83 reviewed the resident's clinical record and stated that the resident was admitted to the facility on [DATE], which means the resident was on the third day of observation on May 24, 2022 when observed eating with the other residents in the dining room. Review of the facility COVID-19 Room Isolation Plan stated that all new admissions are to be going into a 14-day isolation room for admission precautions. The facility policy, COVID-19 Vaccine Policies and Procedures, updated March 2022 did not reveal an observation/quarantine plan for new admissions who have not been vaccinated for the COVID-19 virus.

Based on personnel record review and staff interviews, the facility failed to provide evidence that one of ten sampled staff (#61) was provided training on dementia management. The deficient practice could result in staff not being knowledgeable of how to care for residents with dementia. Findings include: A review of the personnel file for a Certified Nursing Assistant (staff #61) revealed a hire date of 6/30/2021. Continued review of the personnel file revealed the orientation checklist for staff #61 was completely blank. An interview was conducted on 05/27/2022 at 11:36 PM with the Administrator (staff #7) and the Director of Nursing (staff #83) who indicated that they have no evidence to prove that staff #61 was provided training on dementia management. In an interview conducted with Human Resources (staff #56) on 05/27/2022 at 11:36 PM, staff #56 stated there was no policy on required annual training for staff.

Based on observation, clinical record review, resident and staff interviews, and policy reviews, the facility failed to ensure that one sampled resident's (#39) needs and preferences were addressed, regarding a wheelchair and cushion. The deficient practice could result in residents' needs/preferences not being addressed. Findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation and interview conducted on May 24, 2022 at 10:00 AM revealed the resident lying in the bed. During an interview with the resident, she stated that she asked for a bigger wheelchair, and that some people came in to talk to her about it a month ago, but she has not heard back. The resident further stated that she cannot go to activities because the wheelchair is not comfortable. Review of a care conference progress note dated February 17, 2022 revealed the therapy goal for resident #39 was to sit in the wheelchair 1-2 hours a day and participate in activities, and to encourage family visits in the facility courtyard sitting in the wheelchair to avoid the bed all day. Review of the care plan dated February 25, 2022 revealed the following: -The resident required staff assistance with ADL's (activity of daily living) due to obesity, end stage renal disease ([CONDITION(S)]) and decreased mobility. Interventions stated Physical Therapist to work with transfers and ambulation, and Hoyer transfers with two-person assistance. -Pressure Injury due to decreased mobility, obesity, DM, [CONDITION(S)], sitting in [CONDITION(S)], with interventions to provide pressure reducing surfaces on bed and chair. -Activities: the resident unable to participate in the usual daily routine with interventions that included assisting to preferred activities. -Renal disease: requires [CONDITION(S)] with interventions that stated Hoyer transfers, two-person assistance, provide/coordinate transportation to the [CONDITION(S)] center. Review of a social service note dated April 4, 2022 revealed a gel wheelchair cushion was not covered by insurance, the Social worker notified the family so they could have the option to private pay, and nursing and the therapy department was notified. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident moderate cognitive impairment. The assessment indicated the resident had a range of motion limitation in both lower extremities. Review of a therapy services referral/screening form dated April 20, 2022 revealed the resident was non-mobile and was currently at baseline per nursing. The referral/screening did not include an evaluation for a wheelchair or wheelchair cushion. A quarterly care conference progress note dated April 21, 2022 revealed a request for a therapy referral to assess wheelchair and seat cushion recommendation, the resident voiced wanting a bigger wheelchair or recliner wheelchair and cushion. Review of the medical record progress notes after April 21, 2022 revealed no documentation that a therapy evaluation was completed regarding the resident request for a bigger wheelchair, or recommendations regarding other wheelchair cushion options. Review of the medical record revealed no written physician orders for a therapy evaluation for a wheelchair or wheelchair cushion. An interview was conducted on May 25, 2022 at 2:18 PM with a physical therapist (PT/staff #6), who stated that central supply has different sizes/types of wheelchairs and physical therapy will complete a screening to see if a wheelchair is appropriate for the resident. He also stated that screening is documented in the medical record for long-term care residents. He reviewed the medical record and stated that the resident was discharged from physical therapy on February 25, 2022. He further stated that he did not see any documentation that an evaluation of the wheelchair had been completed for this resident. An interview was conducted on May 25, 2022 at 2:22 PM with a PT technician (staff #70), who stated that he makes sure that all the documentation is taken care of. He also stated that a wheelchair evaluation would ensure that the wheelchair fits the resident well. He reviewed the medical record, including therapy documentation and stated that therapy had not completed an evaluation for a wheelchair for this resident. Later that day at 3:07 PM, staff #70 stated that there were no notes in the medical record documenting a referral for a wheelchair cushion or wheelchair for this resident. He stated he also checked the files in the therapy room and that there were no further notes or referrals for a wheelchair evaluation or cushion. An interview was conducted on May 25, 2022 at 2:49 PM with the Social Services Director (staff #36), who stated that if a resident would request a new wheelchair she would be contacted by nursing, and then therapy would be notified to complete an assessment, and an order would be written. She also stated that if it was for a long-term care resident, the facility would rent/purchase the wheelchair. The social services director reviewed the progress notes in the medical record and stated that this resident is in the long-term care unit. She further stated that the physician gave her a written prescription for a wheelchair cushion, and it was submitted to central supply, then on to the DME (durable medical equipment) supply company. She stated that the resident's insurance did not cover a wheelchair cushion. Staff #36 stated that she had notified therapy that the cushion was not covered, and that therapy was going to look into a different cushion. She stated that this took place on April 21, 2022, when she was made aware that therapy did not recommend a gel cushion, and they were going to evaluate for another option. She said that she spoke with the occupational therapy assistant (OTA/staff #68) at that time. She further stated that she did not keep the original prescription that the physician had given to her for the gel cushion. She also stated that she would assume that a physician order would be documented in the medical record. She reviewed the medical record and stated that it is not in the physician orders in the medical record for a wheelchair cushion, or referral for evaluation of a wheelchair. An interview was conducted on May 26, 2022 at 9:25 AM with the Director of Nursing (DON/staff #83), who stated that the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She also stated that a social worker can accept an order from a provider, but the orders should be entered into the EMR (electronic medical record), and there should be a care plan. The DON also stated that for a wheelchair or cushion order, if therapy felt the cushion ordered was not good for the resident, the provider should have been notified and the notification documented. She reviewed the medical record and stated that the care plan meeting documentation on April 21, 2022 revealed that therapy would make recommendations on the wheelchair and cushion. She also stated that she would expect that therapy would research and document their recommendations. She stated that for this meeting they should have gotten back to the resident if they could not get the cushion or wheelchair, and an alternative should have been recommended and documented. She further stated that she did not see any documentation in the medical record that therapy had completed an evaluation regarding a wheelchair or cushion. The DON stated that according to the facility policy they should have continued collaborating until this was solved, and that it did not meet the facility policy or the resident's preferences. An interview was conducted on May 26, 2022 at 10:35 AM via telephone with the OTA (staff #68), who stated that she is the rehabilitation director. She stated that for long-term care residents, nursing would inform them if there was a need to complete a screening for a wheelchair and/or wheelchair cushion, and that they would document the screening and the recommendations in the medical record. She further stated that she was aware of the care plan meeting on April 21, 2022, and that social services did request she evaluate for a wheelchair and a seat cushion. The OTA stated that she did not document that this had been conducted or her recommendations, and that the resident was not notified. She also stated that she did not follow through with the screening for the wheelchair or cushion as requested in the care planning meeting. Staff #68 also stated that this does not meet the facility expectations. An interview was conducted on May 26, 2022 at 11:33 PM with a Central Supply/certified nursing assistant (CNA/staff #29) who stated that for a resident that is in the long-term care unit she would check inventory if she received notice from therapy that a resident required a wheelchair or cushion. She also stated that physical therapy would inform her what type of wheelchair or cushion was needed. She further stated that when a provider writes a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that the process for requests of durable medical equipment (DME), is that PT would complete a screening to see if the product is a good fit for the resident, then they would notify central supply of what product they wanted. She stated that she did not receive any order for a wheelchair cushion or wheelchair for this resident. Review of the facility policy titled, Therapy Specific Evaluation, revealed a therapy evaluation will be performed and documented for all patients with written therapy orders from a licensed physician. The results of the evaluation are documented within the EMR system. In the event that upon completion of the evaluation, the therapist determines that there is no need to proceed with the treatment, the therapist will clearly document why the patient does not qualify and what indicators lead to the evaluation. This supports the initial decision to perform the evaluation. Review of the facility policy titled, Resident rights, revealed that the resident has a right to and facility must promote and facilitate self-determination through support of resident choice. The facility must consider the views of a resident and act promptly upon grievances and recommendations of such groups concerning issues of resident care and life in the facility. The resident has the right to be informed of and participate in their treatment including the right to: -Be fully informed in a language they can understand. -Participate in establishing expected goals and outcomes of factors related to effectiveness of the plan of care. -Have been included in the plan of care for the resident's needs. - Be informed of treatment and treatment alternatives or treatment options and to choose alternative or option they prefer. Review of the facility policy titled, Patient care: Admission, Treatment and Discharge, revealed that treatment modalities will be selected based on the needs of each individual patient to support reaching their personal goals based on functional deficits and underlying impairments. Details regarding patient and caregiver education should be documented within the patient's medical record via the EMR system utilized by the therapy department. Each patient chart will contain completed any additional documentation/reports pertinent to the patient's treatment/care, evaluation/plan of care.

Based on clinical record review, staff interviews, facility investigative report, and policy review, the facility failed to ensure that an allegation of possible verbal abuse for one sampled resident (#18) was reported immediately to the facility administrator. The deficient practice could result in additional abuse allegations not being reported to the administrator. Findings include: Resident #18 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During the initial part of the survey, an interview was conducted with resident #18 on May 23, 2022 at 12:19 PM, who stated that a CNA (certified nursing assistant) had said the resident was fat, and was a problem to move and was lazy. The resident also stated that she asked the CNA to get out of there, or get another staff member to assist, but the CNA continued the care and gave her an evil smile. The resident stated that she had not told administration, but that she did tell nurses. She also stated that she had told other CNAs and they said they don't like her either. The resident further stated that the CNA worked on the day shift yesterday, and she still made fun of her. The resident stated that this causes her emotional pain. She further stated that she knows she's fat, but the CNA does not need to be mean. On May 23, 2022 at 1:14 PM, the Administrator (staff #7) was notified regarding the resident's allegation of verbal abuse and stated that she would begin the investigation process. Review of the facility investigation report dated May 27, 2022, revealed that on May (no day documented), 2022 the resident #18 stated to a surveyor that a certified nursing assistant (CNA/staff #77) was name calling. The report included the facility DON (Director of Nursing/staff #83), social services (staff #36) and Administrator (staff #7) were notified, and social services visited the patient to discuss how she felt and obtain feedback. The report was currently ongoing and did not have a resolution documented on the grievance/complaint report. The investigation report included the following witness statements: -Staff #84 (licensed nursing assistant) stated he had heard resident #18 say that other staff members called her demeaning names, almost a week ago, but he could not remember the day it happened. He stated he thinks it is staff #77 (CNA), but was not sure because he works in the evenings. He stated that he did not report it. -Staff #82 (CNA) reported that the resident had told her that the alleged perpetrator (staff #77) calls her fat, and that she does not like staff #77. -Staff #45 (CNA) reported that the resident complained of someone giving her an evil look. She stated that the resident would just say that she knows. She stated that she did not want to be too pushy with the resident to find out the name, because the resident may be uncomfortable. An interview was conducted via telephone on May 26, 2022 at 11:26 AM with a CNA (staff #82), who stated that one day (does not remember the day), she and the alleged perpetrator (staff #77) were providing care to the resident, and the alleged perpetrator said that the resident was fat, and needed to get on a diet because she was fat, and did not look good. Staff #82 said that she gave the CNA (staff #77) a look, then they completed the resident's care and left the room. She also stated that the resident told the alleged perpetrator (staff #77) to stop it, and that she was short and fat. Staff #82 stated that she did not report the incident immediately, because she was not sure if they were kidding or not. The CNA stated that telling a resident she is fat and needs to lose weight is verbal abuse, and that she should have reported it immediately, per the facility policy. An interview was conducted on May 26, 2022 at 11:30 AM with a CNA (staff #45), who stated that she had worked with resident #18 before she went to the hospital, and currently. The CNA stated that the resident had stated that she did not like the way someone looked at her, and that this person was really good friends with the kitchen lady. She stated that when the resident told her this she advised her to tell social services, if she felt uncomfortable. She further stated that this occurred in normal conversation, and the resident was not frightened or making accusations. The CNA also stated that she did not report this to administration, as she did not think that anything was going on. She further stated that she has received training for all types of abuse including verbal, physical and emotional, and to report abuse to the charge nurse. An interview was conducted on May 26, 2022 at 2:17 PM with the Administrator (staff #7), and a Nurse Consultant (staff #100) was in attendance. The Administrator stated that she started the investigation immediately after the surveyor reported the resident complaint of abuse. She also stated that the state agency was notified via the facility reported incident process. The Administrator stated that according to facility policy it is never okay for a staff member to say to a resident that he/she is fat or needs to lose weight, even if they are kidding. She further stated that the CNA that observed the interaction (staff #82) should have reported it immediately. She also stated that during another staff interview the staff member stated that the resident mentioned to him about a lady who called her a name, who works during the day, but the resident did not seem distraught. Review of the facility policy titled, Abuse Prevention Program, revealed zero tolerance of verbal abuse by employees. Verbal abuse is defined as any use of oral language that willfully includes disparaging and derogatory terms to a resident. Examples include berating, ridiculing, and teasing. Inappropriate joking around or cutting up may be misunderstood as verbal abuse. Any witnessed incidents, allegations of incidents, or suspected incidents, are to be immediately reported to a supervisor or charge nurse. The charge nurse is to notify the DON or administrator immediately of the report. Reports are to be made as soon as the incident, potential incident, or suspicion, is made known. Any person observing resident abuse is to report the concern to their supervisor immediately.

Based on resident and staff interviews, the facility investigation report and document, clinical record review, and policy review, the facility failed to ensure one resident (#18) was treated in a dignified manner. The sample size was 15 residents. The deficient practice could negatively impact the psychosocial wellbeing of residents. Findings include: Resident #18 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During the initial part of the survey, an interview was conducted with resident #18 on May 23, 2022 at 12:19 PM, who stated that a CNA (certified nursing assistant) had said the resident was fat, and was a problem to move and was lazy. The resident also stated that she asked the CNA to leave or get another staff member to assist, but the CNA continued the care and gave the resident an evil smile. The resident stated that she had not told the administration staff, but that she did tell the nurses. She also stated that she had told other CNAs and they said they don't like her either. She stated that she did not want to disclose the CNA's name because she did not want the CNA to lose her job, and she was afraid of retaliation. The resident further stated that the CNA worked on the day shift yesterday, and still made fun of her. The resident stated that this causes emotional pain. The resident further stated that she knows she's fat, but the CNA does not need to be mean. On May 23, 2022 at 1:14 PM, the Administrator (staff #7) was notified of the resident's allegations and stated that she would begin the investigation process. Review of the comprehensive care plan dated March 10, 2022, revealed the following: -ADL: requires staff assistance with activities of daily living (ADL) with interventions that stated the resident is mostly dependent for all ADL with 1-2-person assistance, has poor participation with ADL, and needs a lot of encouragement to participate. A Medicare 5-day MDS (minimum data set) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The assessment also revealed the resident required extensive assistance with bed mobility, personal hygiene, and was totally dependent with transfer, dressing, toilet use, and bathing. Review of nursing progress notes dated March 2022 through May 25, 2022, revealed no evidence that the resident or other staff had reported any concerns regarding the resident's care/treatment by the Certified Nursing Assistants (CNAs). Review of the facility investigation report dated May 27, 2022, revealed that May (no day documented), 2022 resident #18 stated to a surveyor that a CNA was name calling. The report included the facility DON (Director of Nursing/staff #83), social services (staff #36) and Administrator (staff #7) were notified, and social services visited the resident to discuss how the resident felt and obtain feedback. The report was currently ongoing and did not have a resolution documented on the grievance/complaint report. The investigation report included the following witness statements: -Staff #84 (licensed nursing assistant) stated he had heard resident #18 say that other staff members called her demeaning names, almost a week ago, but he could not remember the day it happened. He stated he thinks it is staff #77 (CNA), but was not sure because he works in the evenings. He stated that he did not report it. -Staff #82 (CNA) reported that the resident had told her that staff #77 calls her fat, and that she does not like staff #77. -Staff #45 (CNA) reported that the resident complained of someone giving her an evil look. She stated that the resident would just say that she knows. She stated that she did not want to be too pushy with the resident to find out the name, because the resident may be uncomfortable. -The investigative report included a family member's statement dated May 25, 2022, which included that the family member did recall that sometime back in April resident #18 told the family member a staff said something to the resident about moving her from place to place, and somebody made her feel bad and that the resident did not want to cause problems. The resident had said that she knew she was big/fat, because she did not take care of herself and she did not need a worker to tell her that. -The investigative report included staff #77's statement dated May 25, 2022, which included that she denied ever calling the resident overweight or fat. She denied saying anything that would cause this resident to make allegations. She reported that when cleaning the resident up, she asked the resident to assist with repositioning because she could not hold the resident on her side by herself. She also reported that she tried to encourage the resident to eat because she knew the resident was diabetic and could have low blood sugars at times. She stated the resident does not like to be told she needs to eat. She reported that she is really patient with the residents. Review of facility grievance documentation, revealed no complaints involving resident #18 had been submitted to the facility, per the administrator on May 24 2022. Another interview was conducted on May 25, 2022 at 12:07 PM with the Administrator (staff #7) who stated that they had identified the CNA as staff #77. She stated that she did interview the CNA, and that staff #77 denied saying anything about the resident being fat, but stated she has asked the resident to assist with repositioning because she cannot hold the resident by herself. The Administrator further stated that the resident's roommate (resident #52) was also interviewed and she stated that yes, she has heard a CNA saying a resident was fat, but declined naming the resident or staff. An interview was conducted on May 25, 2022 at 1:30 PM with resident #18's roommate (resident #52), who stated that she cannot tell if any staff have talked to her meanly, or to any other resident. An interview was conducted via telephone on May 26, 2022 at 11:26 AM with a CNA (staff #82), who stated that one day (does not remember the day), she and the staff #77 were providing care to the resident, and staff #77 said that the resident was fat, and needed to get on a diet because she was fat, and did not look good. Staff #82 said that she gave staff #77 a look, then they completed the resident's care and left the room. She also stated that the resident told staff #77 to stop it, and that she was short and fat. Staff #82 stated that she did not report the incident immediately, because she was not sure if they were kidding or not. Staff #82 also stated that she had not heard staff #77 talk to any other residents that way, or the resident joke with other staff that way. An interview was conducted on May 26, 2022 at 11:30 AM with a CNA (staff #45), who stated that she had worked with resident #18 before she went to the hospital, and currently. The CNA stated that the resident had stated that she did not like the way someone looked at her, and that this person was really good friends with the kitchen lady. She stated that when the resident told her this she advised her to tell social services, if she felt uncomfortable. She further stated that this occurred in normal conversation, and the resident was not frightened or making accusations. The CNA also stated that she did not report this to administration, as she did not think that anything was going on. An interview was conducted via telephone on May 26, 2022 at 12:04 PM with staff #77, who stated that the last time she cared for resident #18 was on the previous Saturday. The CNA also stated that she did not recall providing care with another CNA and telling the resident that she was fat and needed to lose weight. She stated that she never said anything like that to the resident and was surprised. She also stated that she did not remember or note the resident was unhappy with her when she was providing care, and the resident has never said anything mean to her. An interview was conducted on May 26, 2022 at 2:17 PM with the Administrator (staff #7), and a Nurse Consultant (staff #100) in attendance. The Administrator stated that according to facility policy it is never okay for a staff member to say to a resident that he/she is fat or needs to lose weight, even if they are kidding. She further stated that the CNA (staff #82) that observed the interaction, should have reported it immediately. The Administrator stated that they had substantiated inappropriate words/behavior, that what staff #77 said was not appropriate and did not follow the facility policy, or resident rights. An interview was conducted on May 27, 2022 at 10:33 AM with the Administrator (staff #7) and the Nurse Consultant (staff #100). The administrator stated that social services had conducted one last visit with the resident to see if she was okay, and reported that the resident stated that she felt good, that the comments had offended her, and she felt upset when it happened. The Administrator stated that based on the resident statement, they are verifying that staff #77 did make those statements or something to that effect. Review of the facility policy titled, Resident Rights, revealed the facility must treat each resident with respect and dignity and care for each resident in a manner that promotes enhancement of their quality of life. The facility must protect and promote the rights of the residents. The resident has the right to be treated with respect and dignity.

Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that care plan interventions for pressure ulcers were implemented for one resident (#36). The sample was 15 residents. The deficient practice could affect the quality of residents' care. Findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated October 8, 2021 revealed the resident had a pressure ulcer to the right ischial hip. Interventions included performing wound care as ordered, assessing skin daily with routine care, full skin evaluation with bath/shower, and assessing the wound healing weekly. Review of paper weekly skin/body assessment forms completed by the CNAs (certified nursing assistant) after a shower/bath had been provided revealed no evidence that the weekly skin/body assessments were completed from November 24, 2021 to April 14, 2022. Review of the medical record revealed no wound observations in the medical record related to hospice care/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility medical record and records provided by hospice revealed no documentation of wound assessment and care by facility nursing or hospice nursing on the facility wound assessment report form, or hospice wound/skin assessment form for the following: -No documentation between 10/7/2021 and 10/22/21 -No documentation between 10/22/2021 and 11/5/21 -No documentation between 11/19/2021 and 11/28/21 -No documentation between 11/31/2021 and 12/09/21 Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The assessment included the resident had an unstageable pressure ulcer that was not present upon admission. Further review of the Skin Wound Observation forms (provided by hospice) revealed incomplete wound documentation including no wound measurements and no wound assessment on the following dates: 11/11/21 - no measurements/assessment 11/19/21 - no measurements/assessment 12/23/21 - no measurements/assessment. 12/30/21 - no measurements/assessment. 1/13/2022 - no measurements/assessment 1/18/2022 - no measurements/assessment 1/20/2022 - no measurements/assessment 1/26/2022 -no measurements/assessment Further review of the medical record revealed there was no skin/wound observation documentation from hospice between January 26, 2022 through February 1, 2022 and on 3/10/22 no measurements/assessment. An interview conducted on May 26, 2022 at 8:40 AM with the Registered Nurse (RN) wound nurse (staff #54), who stated that the CNAs will look for open areas on the resident's skin during showers/baths and document it on the weekly skin/body assessment form. The RN stated that a care plan for wound care would be completed by the MDS nurse or wound nurse. She also stated that if the care plan interventions stated to assess the resident's skin during bath/shower or to complete wound care weekly, that it should be done as written in the care plan. She also stated that the resident was receiving hospice care when the wound started, and that hospice would have completed the wound assessments and showers/baths and documented them. She further stated that the facility would complete the wound care and showers/baths when hospice did not and document it. An interview was conducted on May 26, 2022 at 9:25 AM with the Director of Nursing (DON/staff #83), who stated that she would expect the care plan interventions to be implemented as written. The DON stated that the MDS nurse or Assistant DON would complete the care plan for wound/skin, but any nurse can update the care plan. The DON stated that she reviewed the medical record and that they had no documented weekly skin/body assessments completed between 11/24/2021 and 4/13/2022. She further stated that the hospice CNAs should have completed the forms when they provided showers to the resident. She stated that she was not aware that this was not being completed by hospice. She further stated that the skin/body assessments were not completed as ordered, or according to the facility policy. The DON stated that the facility is to have copies of hospice notes scanned into the EMR (electronic medical record). She stated the risk of not communicating with hospice could result in a skin issue not being identified. She stated that she would have expected there to be weekly wound assessments documented by hospice and the facility staff. She also stated that the facility process is to complete care plan interventions as written. An interview was conducted on May 26, 2022 at 1:07 PM with a restorative nurse (staff #45) who stated that the MDS nurse is responsible for updating the care plans. She stated that during baths/showers the CNA would look for any skin issues and would document on the shower/skin form. She also stated that the form needs to be completed every time a resident receives a shower/bath. The nurse further stated that hospice staff are to complete the shower/bath forms and have the nurse sign them. She stated the risk of not completing the shower forms could result in a shower not being performed or a new skin issue not being identified. An interview was conducted on May 27, 2022 at 8:32 AM with a RN (staff #62), who stated that the facility process is to implement care plan interventions as needed. She also stated that the CNAs complete the weekly shower/bath skin forms and place them in a notebook at the nursing station. An interview was conducted on May 27, 2022 at 8:33 AM with a certified nursing assistant (CNA/staff #37) who stated that the facility process is to document the care they give the resident, and follow the care plan interventions. She stated that they complete a skin/bath assessment form and document any skin issues that are observed during a resident's shower. Another interview was conducted on May 27, 2022 at 9:06 AM with the DON (staff #83) who stated the facility policy is to measure, assess and document wound status every week, including care/treatment performed by hospice nurses/staff. She stated that there were multiple hospice wound care assessments that contained no documentation of the wound measurements or assessments in the medical record per her review. She also stated that hospice should be following the facility policy and procedures, and documenting the wound measurements and assessments. She also stated that the risk of documentation not being completed accurately could impact the care of the patient. The DON stated that hospice needs to communicate and document their care to support the care/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she has reviewed the shower sheets for November 2021 through April 2022, and that there were multiple bath/shower, skin assessments that had not been completed. She also stated that it is the facility policy that the forms be completed with each bath/shower/bed bath. She then stated that the shower forms are scanned into the medical record. Later that day at 10:10 AM, the DON stated that she reviewed the medical record and that it was the hospice CNA documentation that was missing for the shower/skin assessments. She further stated that they have no CNA documentation on the unit bath shower/care notebook for December 2021 through March 2022, and that this did not follow the facility policy or the care plan interventions. Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revealed that a care plan to meet the resident's physical and functional needs is developed and implemented for each resident. A review of the facility policy titled, Bath, Shower/tub, revealed the purpose is to promote cleanliness, and to observe the condition of the resident's skin. All assessment data obtained (reddened areas, sores on the resident's skin) should be documented. Review of facility policy titled, Wound care, revealed that documentation to be recorded in the resident's medical record includes all assessment date (wound bed color, size, drainage) obtained when inspecting the wound and to review the care plan to assess for any special needs of the resident. A review of the facility policy titled, Pressure Ulcer Assessment, revealed a resident-centered care plan is created to address the modifiable risks. Conduct a comprehensive skin assessment with every risk assessment, once inspection of skin is completed document the findings on a facility-approved skin assessment tool.

Based on clinical record review, staff interviews, and policies and procedures, the facility failed to ensure timely assessments and consistent treatments were provided to one sampled resident (#36) with pressure ulcers. The deficient practice could result in delayed healing of pressure ulcers. Findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was receiving hospice care. The assessment also included the resident did not have one or more unhealed pressure ulcers at stage 1 or higher. Review of wound assessment documentation in the medical record revealed the pressure ulcer to the right buttock was initially present on October 7, 2021. A physician order dated October 7, 2021 stated to apply zinc barrier cream to the right ischial hip pressure ulcer as needed with brief change. Review of the care plan dated October 8, 2021 revealed the resident had a pressure ulcer to the right ischial hip. Interventions included performing wound care as ordered and assessing wound healing weekly. Review of the physician's orders revealed the following: -an order dated November 11, 2021 to cleanse the open area on the right ischial hip with normal saline, pat dry with gauze, apply xeroform to the wound bed, and secure with a bordered foam dressing 3 times per week. -an order dated November 28, 2021 to cleanse the stage 4 pressure ulcer to the right buttock with wound cleanser, apply a sterile packing strip moistened with [MEDICATION(S)] gel to the wound cavity, and loosely cover with a foam dressing every Monday, Wednesday, Friday. -an order dated December 2, 2021 to cleanse the open area on the right ischial hip with normal saline, pat dry with gauze, apply skin prep to the periwound, apply [MEDICATION(S)] to the wound bed, apply a crushed [MEDICATION(S)] 500 milligrams tablet in the wound bed, fill the void with fluffed gauze, and cover with a nonadherent dressing. Review of the Treatment Administration Records (TARs) for October 2021- February 2022 revealed the treatment was provided as ordered. However, continued review of the medical record revealed no wound assessments in the medical record related to hospice care/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the wound assessment forms for the facility and for hospice revealed no evidence that wound assessments were conducted between 10/7/2021 and 10/22/21, 10/22/2021 and 11/5/21, 11/19/2021 and 11/28/21, and 11/31/2021 and 12/09/21 Review of the hospice Skin Wound Observation forms revealed no measurements/assessment on 11/11/21, 11/19/21, 12/23/21, 12/30/21, 1/13/2022, 1/18/2022, 1/20/2022, and 1/26/2022. Additional review of wound assessments forms for the facility and for hospice revealed no evidence of wound assessments for January 26, 2022 through February 1, 2022. Further review of wound assessment documentation in the medical record revealed the pressure ulcer to the right buttock healed on February 17, 2022. Review of the clinical record did not reveal physician, Nurse Practitioner (NP), or Physician Assistant progress notes regarding wound assessment, treatment, and progress. An interview conducted on May 24, 2022 at 2:27 PM with the wound nurse (staff #54), Registered Nurse (RN), who stated that the resident's wound is healed at this time and no longer receives dressing changes. She further stated that she had observed that when hospice was documenting information about the buttock wound, they were calling it a right hip ischial wound, rather than a right buttock pressure ulcer. She stated it was the same area. Another interview was conducted with staff #54 on May 26, 2022 at 8:40 AM, who stated that a provider order is needed for wound care treatment. She stated the physician does not see the resident weekly, but the NP or PA will follow the wound nurse weekly to assess the wounds. She stated that the NP will document progress notes, including if there are any changes in orders. The RN stated that it is the facility process to follow physician orders. She stated that it is the facility policy that wound assessments/treatment be completed accurately and as ordered, and be available in the medical record. The RN stated that the resident was on hospice care when the wound started, and that hospice wrote the wound orders, and would document wound assessments/treatment. She also stated that the facility would complete the wound care assessments/treatments when hospice did not. She further stated that both hospice and the facility nurses were expected to document the wound assessments, including measurements and wound tissue appearance. An interview was conducted on May 26, 2022 at 9:25 AM with the Director of Nursing (DON/staff #83), who stated that she would expect the physician orders to be completed as written. The DON stated that the facility is to have copies of hospice notes scanned into the EMR (electronic medical record). She stated that she would have expected there to be weekly wound assessments documented by hospice and/or facility nursing that included measurements of the wound and description of the wound tissue. The DON stated that they do not have any documentation from the provider regarding wound care evaluation/treatment in the medical record. She stated the risk of not communicating with hospice could result in a skin issue not being identified. Another interview was conducted on May 27, 2022 at 9:06 AM with the DON (staff #83), who stated the facility policy is to measure, assess and document wound status every week, including care/treatment performed by hospice nurses/facility nurses. She stated that there were multiple hospice wound care assessments that contained no documentation of the wound measurements or assessments in the medical record per her review. She also stated that hospice should be following the facility policy and procedures, and documenting the wound measurements and assessments in the medical record. The DON further stated that she reviewed the medical record and there were multiple days in October and December, 2021, that there were no wound care/assessments completed by the facility or hospice nurses. She also stated that the risk of documentation not being completed, or completed accurately, could impact the care of the patient. She further stated that she will talk with hospice about this, including that the hospice nurses were calling the wound a hip wound. The DON stated that hospice needs to communicate and document their care to support the care/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of facility policy titled, Wound Care, revealed that documentation is to be recorded in the resident's medical record that includes all assessment data (wound bed color, size, drainage) obtained when inspecting the wound. Review of the facility policy titled, Resident Assessment, included that pressure ulcers will be assessed weekly to ensure physician notification, wound characteristics and treatment plan remains appropriate to promote improvement. If skin breakdown is present, protocols for wound care will be followed to include documentation and treatments. A review of the facility policy titled, Pressure Ulcer Assessment, revealed the purpose of the procedure is to provide guidelines for structured assessment and identification of residents at risk of developing pressure ulcers/injuries. Once inspection of the skin is completed, document the findings on a facility-approved skin assessment tool. A review of the facility policy titled, Physician Services, revealed that physician orders and progress notes are maintained in accordance with current regulations and facility policy.

Based on clinical record review, facility documentation, hospital record review, and staff interviews, the facility failed to ensure one resident (#1) was free from an accident during a transfer with a Hoyer lift. The sample size was 3 residents. The deficient practice could result in residents being transferred in an unsafe manner. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbance, [CONDITION(S)], and End Stage [CONDITION(S)] (ESRD). A nursing note dated [DATE] included that the resident required extensive assistance with her Activities of Daily Living (ADL) and this included the use of a Hoyer lift with 2 person assist for transfers. Review of the care plan revealed a hospice aide care plan dated [DATE] which included that the resident required assistance with transfers and turning and positioning. The resident's care plans did not include any documentation on the use of a Hoyer lift. A significant change Minimum Data Set (MDS) dated [DATE] included that the resident scored a 5 on the Brief Interview for Mental Status (BIMS) indicating impaired cognition. The resident was coded as requiring extensive assistance with dressing, toilet use, and personal hygiene and required total assistance with bathing and transfers. Two staff members were noted as being required for transfers. Review of the [DATE] medication recapitulation revealed the following orders: -Adaptive equipment as indicated. -Pain Assessment, scale of 1 to 10 every shift, ,d+[DATE]=Mild Pain, ,d+[DATE]=Moderate Pain, ,d+[DATE]=Worst Pain. -Tylenol 650 milligrams (mg) by mouth every 4 hours as needed for mild pain, not to exceed 3 grams in 24 hours. -Acetaminophen (Tylenol) 500 mg, one tablet by mouth twice daily for chronic pain. -[MEDICATION(S)] suppository 25 mg, 1 suppository per rectum every 8 hours as needed for nausea/vomiting. -Hospice care to be provided through an outside hospice company. Further review of the physician's orders revealed no evidence that there was an order regarding the use of a Hoyer lift for transfers. A nursing note dated [DATE], documented at 8:30 pm, included the resident was lying supine on the floor in her room between the base legs of a Hoyer lift. The resident reported to the nurse she had pain in her right leg. There was no redness, swelling or open areas to the right leg. An additional nursing note dated [DATE], documented at 11:00 pm, included the resident was vomiting yellow/green emesis. The resident complained of a headache, stomachache, right knee, and right leg pain. The right knee had swelling without redness or open areas. The note included that the resident was medicated for the vomiting. The note did not indicate if the provider was notified of the change in condition. Review of the physician's orders revealed an order dated [DATE] for [MEDICATION(S)] solution 20 mg/mL (milligrams per milliliter), give 0.25 mL by mouth every 4 hours as needed for pain. There was no pain level associated with the administration of this medication. A nursing note dated [DATE], documented at 12:00 am, included that hospice was notified of the resident's right leg swelling, right leg/knee pain, and vomiting. The note included that the medication for vomiting was effective. The note included that hospice would evaluate the resident in the morning. Review of a nursing note dated [DATE], documented at 9:30 am, included the resident was crying and yelling/moaning when repositioned. The note also included that the writer of the note attempted to medicate the resident but the resident spit the medication out. A review of the Medication Administration Record (MAR) for [DATE] revealed the resident had 12 pain assessments from [DATE] through [DATE]. On [DATE] it was documented on the evening shift that the resident had pain. The resident had received the scheduled 500 mg acetaminophen that morning and the MAR indicated that a dose of as needed Tylenol (Acetaminophen) was administered on [DATE]. However, the MAR does not indicate a time or pain level for administration of the as needed Tylenol. Further review of the MAR revealed the resident had pain documented on the morning shift on [DATE]. The resident had received scheduled 500 mg acetaminophen that morning and it is documented the resident received [MEDICATION(S)] for pain on [DATE] but it does not indicate a time or pain level. The MAR also indicated the resident received [MEDICATION(S)] for nausea/vomiting however there is no time documented for the administration of this medication. On [DATE], the MAR had pain documented for the resident on two shifts (evening and night shifts). The resident had received the scheduled 500 mg acetaminophen that morning and it is documented on the MAR the resident received [MEDICATION(S)] for pain on [DATE] but it does not indicate a time or pain level. A physician's order dated [DATE] included to X-ray the resident's right leg including the hip, knee, and the right foot related to the resident's complaints of pain. Review of the X-ray report indicated that while there was no fracture noted, the view was obscured and that if there was clinical suspicion of a fracture, a radiographic follow-up was recommended. A nursing note dated [DATE] indicated that X-ray results were provided to the physician. It was also reported that the resident had 3 episodes of emesis. Physician's orders for [DATE] included a new order for [MEDICATION(S)] to be given immediately for the resident's vomiting as well as an order to send the resident to the emergency room for evaluation and treatment. The diagnosis for this included to rule out fracture. The MAR for [DATE] indicated the resident received the [MEDICATION(S)] as ordered at 7:15 p.m. on [DATE]. Further clinical record review revealed the resident was transferred to the hospital on [DATE] at 7:48 pm. Review of the hospital records, dated [DATE] through 9, 2021, revealed multiple X-rays had been conducted on [DATE] of the resident's right leg. These included the following findings: -An acute (new) oblique fracture (broken bone) of the right distal tibia (lower leg bone) and medial angulation. -An acute fracture of the right distal fibula (lower leg bone) was suspected -An acute fracture of the right distal femur (upper leg bone) with impaction. -For all the X-rays, the resident's bones were noted as being severely osteopenic (weak). The hospital records indicate that the resident's kidneys had failed and she needed [CONDITION(S)] and that surgery to repair the fractures was considered, however it was not performed. After having [CONDITION(S)] at the hospital, the resident's health declined and the decision was made to put her on comfort care. The resident was discharged back to the facility on [DATE]. She expired in the facility on the same day. Review of the facility's investigation regarding the fall, dated [DATE], revealed that on [DATE], the resident was being transferred by two Certified Nursing Assistants (CNAs) using a Hoyer lift. During the transfer, the resident slid out of the sling and fell to the floor resulting in multiple fractures to the resident's right leg. The investigation concluded that the two CNAs did not attach the sling correctly to the Hoyer lift resulting in the injury. The resident was noted to have had increased pain with vomiting and was transferred to the hospital on [DATE]. Education was provided to the two CNAs on [DATE]. The education provided to the two CNAs on [DATE] included information on the correct procedure for what the staff needed to do when attaching a sling to a Hoyer lift. This included that the sling straps being used must all be the same color on all sides of the lift's sling bar. The staff completed a return demonstration with the Hoyer lift to ensure they understood the education. A mandatory Hoyer lift in-service was provided for all CNAs in the facility on [DATE], and 18, 2020. Sign-in sheets revealed facility CNAs had attended the training. Telephonic interviews were attempted on [DATE] to discuss the incident with the two CNAs who were involved in the incident with the Hoyer lift, but the CNAs did not answer or call back. They were also no longer employed by the facility. An interview with a CNA (staff #7) was conducted on [DATE] at 7:35 am. She stated that she would look in the chart or the care plan to see if a resident needed a Hoyer lift for transfers. She stated she received training in the last year for the Hoyer lift. She stated the training included using the lift with two staff, positioning the resident correctly and choosing the correct color on the sling for connecting it to the lift. She stated the colors on the top have to match each other and the colors on the bottom of the sling have to match to ensure the resident does not slip out. She stated this resident had a change in condition that required the staff to use a Hoyer lift for transfers starting in [DATE]. She stated she never had any difficulty transferring the resident while caring for her. An interview with a CNA (staff #8) was conducted on [DATE] at 7:55 am. She stated she received Hoyer lift training in the last six months and that training covered positioning of the resident in the sling, the proper protocol for using the colored sling straps, and that two people have to use the lift when transferring residents. She stated that she has never had a resident slip out of a lift. During an interview with a Licensed Practical Nurse (LPN/staff #14) on [DATE] at 8:24 am, she stated that the resident had a Hoyer lift ordered for transfers for staff safety. She stated the resident had a hard time assisting the staff with transfers to the wheelchair and shower chair. She stated that the resident was transferred daily to get her out of bed. She stated she did receive the training on positioning, proper use of the sling, and that two people needed to be present when using the Hoyer lift. An interview with the Director of Nursing (DON/staff #41) and an Assistant Director of Nursing (ADON/staff #51) was conducted on [DATE] at 8:55 am. The DON stated that staff are provided training when they are hired and are required to have completed training prior to caring for residents. She stated new hire/annual/and as needed training is provided through computerized training and through in-person in-service education. She stated that transfer training including the use of Hoyer lifts is provided every six months. The interview continued with the DON and ADON, and at 9:03 am the administrator (Staff #21) entered the interview. The ADON stated that Hoyer lift training was provided to all clinical staff following the fall on [DATE]. She stated the training included the process for transferring with the Hoyer. She stated that transfers require two staff members, that the resident has to be positioned correctly, and that the colors on the sling have to match on the top and bottom when attached to the lift. She stated the training required sign in and return demonstration. The Administrator stated that the [DATE] fall from the Hoyer lift was included in the [DATE] Quality Assurance and Performance Improvement (QAPI) meeting and a plan was created to address the concerns with transfers. The ADON stated that there was no auditing or surveillance for the training that was provided in [DATE] to ensure compliance. As the interview continued, the Administrator stated she was unable to locate a policy or procedure for transfers with the Hoyer lift. She stated that a process was provided with the education in [DATE], however there is not a policy or procedure available at this time. Another interview was conducted with the DON (staff #41) on [DATE] at 9:55 am. She stated it is the expectation of staff to follow the facility protocol for the Hoyer lifts for resident safety. She stated that she has only been in the DON position for 4 weeks but she requires staff to complete the training for the Hoyer lifts with documented return demonstration. She stated that she has made observations in resident rooms and showers with the staff using the lifts. She stated the staff know which residents require a lift because it is should be documented in their care plan. An interview with the Administrator (staff #21) was conducted on [DATE] at 10:05 am. She said that she was not able to locate a policy for Hoyer lift usage. She stated the investigation into the accident on [DATE] revealed that two CNAs did not use the Hoyer lift correctly resulting in an injury of a resident. She stated the clinical staff received training on the process for using a Hoyer lift for transfers. She stated that the accident was addressed in the May and June QAPI meetings but that she would have to review the notes to identify the exact performance improvement plan including the monitoring that was put into place. Some QAPI information was provided, but there was no evidence of a performance plan that included monitoring for safe Hoyer life usage in the facility.

Based on observations, staff interviews, clinical record review, and policy review, the facility failed to provide adequate supervision for one sampled resident (#38) that wandered. The deficient practice could result in avoidable accidents. Findings include: Resident #38 was admitted [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely impaired regarding cognitive skills for daily decision making. The assessment included the resident had wandering behavior which significantly intruded on the privacy or activities of others and placed the resident at significant risk of getting to a potentially dangerous place. Review of the care plan initiated 8/28/19 revealed the resident wanders the hall and goes into other residents' room. The goal was that the resident would not display any inappropriate or disruptive behaviors. Interventions included monitoring and documenting resident#38's behavior, removing the resident from public area when behavior is disruptive and unacceptable and for activity staff to visit with the resident and provide diversional activities as needed. The care plan interventions were updated 9/21/19 to include redirecting the resident not to go into other residents' room and separating residents and redirecting resident #38 out of other residents' rooms. Review of nursing notes from 9/4/19 - 10/9/19 revealed multiple entries of the resident pacing, going into other residents' rooms, pulling blankets off of sleeping residents, pushing residents in wheelchairs down the hall, and hitting a Certified Nursing Assistant (CNA) in the face causing the CNA's lip to bleed. On 10/7/19 at 1:41 PM, resident #38 was observed pacing in the hallway, going through the unattended locked housekeeping cart that contained floor mop water and gloves on top pushing it down the hallway. Approximately 5 minutes later, a staff member redirected the resident to the lobby of the dementia unit and encouraged the resident to sit in a chair. The resident started pacing the hallway again and took another resident's wheelchair and pushed it down the hallway. No staff members were observed to redirect resident #38. During an observation conducted on 10/09/19 at 10:33 AM, the resident was observed walking down the hallway going in and out of three rooms. No staff members were observed to redirect the resident. On 10/09/19 at 12:45 PM, resident #38 was observed pacing in the hallway with her clothing protector still on from lunch. A medication cart was observed at the far end of the hallway with cartons of supplement on the top of the cart. The resident was observed trying to open the cartons. No staff members were observed present to redirect the resident. During an interview conducted with a Certified Nursing Assistant (CNA/staff #67), the CNA confirmed resident #38 wanders constantly. The CNA stated they try to redirect the resident and that at times the resident becomes aggressive. An interview was conducted with a Registered Nurse (RN/staff #6) on 10/7/19 at 2:00 PM. The RN stated that she was aware resident #38 goes in and out of other residents' rooms. The RN stated the resident is on a dementia unit and that is expected behavior. She stated that the other residents did not mind resident #38 going into their rooms. The RN was unable to say if the residents who are unable to communicate objected to resident #38 going into their rooms. During an interview conducted with another CNA (staff #18), the CNA stated that she knows at times resident #38 pushes residents in their wheel chair down the hallway. The CNA stated that it is very hard to redirect the resident because the resident gets very angry. An interview was conducted with the Director of Nursing (DON/staff #65) on 10/09/19 at 10:25 AM. The DON stated that she is aware resident #38 wanders into other residents' room. The DON stated that it is OK for residents to go into each other rooms because they reside on a dementia unit. The DON further stated that she was not aware resident #38 was in the housekeeping cart and the supplements on the medication cart. During an interview conducted with social services (staff #22), staff #22 stated that they expect residents to go into each other's rooms on the dementia unit. She stated that they redirect the residents as soon as they can. Staff #22 also stated that they need to be more creative to prevent resident #38 from going into other residents' rooms. A review of the facility's policy and procedure Wandering, Unsafe Resident revised (MONTH) 2011, revealed the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering. The staff will assess at risk residents for potentially correctible risk factors related to unsafe wandering. The policy included nursing staff will document circumstances related to unsafe actions, including wandering, by a resident as needed.

Based on observations, staff interview, clinical record review, and policy review, the facility failed to consistently implement the care plan for one sampled resident (#38) with wandering behavior. The deficient practice could result in residents' care plan not being implemented resulting in avoidable incidents. Findings include: Resident #38 was admitted [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely impaired regarding cognitive skills for daily decision making. The assessment included the resident had wandering behavior which significantly intruded on the privacy or activities of others and placed the resident at significant risk of getting to a potentially dangerous place. Review of the care plan initiated 8/28/19 revealed the resident wanders the hall and goes into other residents' room. The goal was that the resident would not display any inappropriate or disruptive behaviors. Interventions included monitoring and documenting resident #38's behavior, removing the resident from public area when behavior is disruptive and unacceptable and for activity staff to visit with the resident and provide diversional activities as needed. The care plan interventions were updated 9/21/19 to include redirecting the resident not to go into other residents' room and separating residents and redirecting resident #38 out of other residents' rooms. Review of nursing notes from 9/4/19 - 10/10/19 revealed multiple entries of the resident pacing, going into other residents' rooms, pulling blankets off of sleeping residents, pushing residents in wheelchairs down the hallway, and hitting one Certified Nursing Assistant (CNA) in the face causing the CNA's lip to bleed. Review of Behavioral Intervention Monthly Flow Records dated (MONTH) 2019 and (MONTH) 2019 revealed the resident was being monitored for continuously pacing and impulsiveness. Interventions included redirection. On 10/7/19 at 1:41 PM, resident #38 was observed pacing in the hallway, going through the unattended housekeeping cart and pushing it down the hallway. Approximately 5 minutes later, a staff member redirected the resident to the lobby of the dementia unit and encouraged the resident to sit in a chair. The resident started pacing the hallway again and took another resident's wheelchair and pushed it down the hallway. No staff members were observed to redirect resident #38. During an observation conducted on 10/09/19 at 10:33 AM, the resident was observed walking down the hallway going in and out of three rooms. No staff members were observed to redirect the resident. On 10/09/19 at 12:45 PM, resident #38 was observed pacing in the hallway with her clothing protector still on from lunch. A medication cart was observed at the far end of the hallway with cartons of supplement on the top of the cart. The resident was observed trying to open the cartons. No staff members were observed present to redirect the resident. An interview was conducted with the Director of Nursing (DON/staff #65) on 10/09/19 at 10:25 AM. The DON stated that she is aware resident #38 wanders into other residents' room. The DON stated that it is OK for residents to go into each other rooms because they reside on a dementia unit. During an interview conducted with social services (staff #22), staff # stated that they expect residents to go into each other's rooms on the dementia unit. She stated that they redirect the residents as soon as they can. Staff #22 also stated that they need to be more creative to prevent resident #38 from going into other residents' rooms. A review of the facility's policy regarding care plans, comprehensive person-centered revised (MONTH) (YEAR), revealed the care plan interventions are derived from a though analysis of the information gathered as part of the comprehensive assessment. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. The policy included care plan interventions are chosen only after careful data gathering, proper sequencing of events, and careful consideration of the relationship between the resident's problem areas and their causes, and relevant decision making. The facility's policy regarding unsafe resident wandering revised (MONTH) 2011 revealed the resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan.

Based on clinical record review, staff interviews and policies and procedures, the facility failed to report an injury of an unknown source involving one resident (#73) to the State Survey Agency, within 2 hours as required. The deficient practice could result in additional incidents regarding injuries of an unknown source not being reported to the State Agency; resulting in the State Agency not being informed of possible abuse situations. Findings include: Resident #73 was admitted to the facility on (MONTH) 12, (YEAR) and readmitted on (MONTH) 21, 2019, with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment dated (MONTH) 19, 2019, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had a severe cognitive impairment. The MDS also revealed the resident was totally dependent on staff assistance when moving from one place to another on the unit. Review of a progress note dated (MONTH) 4, 2019 revealed the resident was observed lying on her left side on the floor by her wheelchair. The resident had left hip and groin pain and the left leg was shorter than the right leg when extended. Per the note, the resident was transferred to the hospital and was admitted due to a femoral neck fracture. The facility was unable to provide any evidence that the incident regarding an injury of an unknown source was reported to the State Agency. On (MONTH) 9, 2019 at 10:13 a.m., an interview was conducted with a LPN (staff #10), who stated that a male activities volunteer found the resident on the floor next to her wheelchair in the 300 hall by the (RNA) room. She said that she was at the nurse's station when staff called her. She said that when she arrived, she found the resident lying on the floor by her wheelchair which was by the RNA door on the 300 unit. She said that she does not know how the resident got there, as the resident is not able to self-propel herself. She said if a CNA assists the resident with leaving her room, the CNA usually takes the resident to the area where the TV is located. On (MONTH) 9, 2019 at 10:30 a.m., an interview was conducted with an activities volunteer (staff #139), who stated that he remembered that he was taking a resident from the dining hall back to the room, when he saw a woman lying on the floor by the RNA door on the Unit 300. He said that her wheelchair was next to her. He said he could hear her moaning and asked her what happened, but she kept saying Please help me. He said that he did not witness the incident and did not know what had happened to her. An interview was conducted on (MONTH) 9, 2019 at 11:27 a.m. with the Director of Nursing (DON/staff #65), who stated that when there is an injury of unknown origin, the nurse is to report the incident to DON as soon as possible. She said it is her responsibility to notify the State agency, within 2 hours. She said that she was notified about the resident being found lying on the floor and that no one was around when it occurred, but it was thought that the resident fell . At this time, the facility's Abuse policy was reviewed and staff #65 stated that the incident should have been reported to the State Agency. Review of the facility's Abuse policies revealed that allegations of abuse, neglect, mistreatment, exploitation, including injuries of unknown source, are to be immediately reported to a supervisor/charge nurse, who will report the incident to the Administrator/designee. All alleged violations of abuse, neglect, exploitation, mistreatment, including injuries of unknown source will be reported immediately to the State Survey agency, but no later than 2 hours if involves abuse or has resulted in serious bodily injury.

Based on observation, clinical record review, family and staff interviews, and policy review, the facility failed to ensure one sampled resident (#73) had the right to personal privacy during visits with family by allowing another resident (#38) to wander into resident #73's room. The deficient practice could result in residents not having privacy when visiting with family. Findings include: -Resident #73 was readmitted to the facility on (MONTH) 21, 2019, with [DIAGNOSES REDACTED]. -Resident #38 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of nursing notes from 9/4/19 - 10/9/19 revealed multiple entries of resident #38 pacing, going into other residents' rooms, pulling blankets off of sleeping residents, pushing residents in wheelchairs down the hall, and hitting a Certified Nursing Assistant (CNA) in the face causing the CNA's lip to bleed. An interview was conducted with resident #73's family member on (MONTH) 7, 2019 at 3:14 p.m., who stated that she had concerns involving resident #38. The family member stated that she observed resident #38 pulling resident #73's blouse. The family member stated that resident #38 walks into resident #73's room and will not leave. The family member also stated that if she closes resident #73's room door, resident #38 keeps pushing the door. The family stated that she has reported these incidents to the nurse (Licensed Practical Nurse/staff #10) and to some of the Certified Nursing Assistants (CNAs). The family member stated that she was told staff will keep an eye on resident #38. During an observation conducted on (MONTH) 9, 2019 at 10:33 a.m., resident #38 was observed pacing up and down the hallway and entering resident #73s room. No staff members were observed present to redirect the resident. An interview was conducted on (MONTH) 9, 2019 at 2:56 p.m. with a CNA (staff #48), who stated that resident #38 pushes residents in their wheelchairs down the hall and keeps going into other residents' rooms. The CNA stated that one resident kept asking resident #38 to leave her room and that resident #38 pushed the resident. The CNA also stated that she has seen resident #38 in resident #73's room and resident #73's family members have complained. She said the CNAs try to redirect resident #38 when she is in another resident's room, but that resident #38 gets angry and she has behaviors. She said that she has witnessed resident #38 getting into other residents' faces. An interview was conducted with a Registered Nurse (RN/staff #6) on 10/7/19 at 2:00 PM. The RN stated that she is aware resident #38 goes in and out of other residents' rooms. The RN stated the resident is on a dementia unit and that is expected behavior. She stated that the other residents did not mind resident #38 going into their rooms. The RN was unable to say if the residents who are unable to communicate objected to resident #38 going into their rooms. Review of the facility's Resident's Rights policy revised (MONTH) (YEAR), revealed that a resident has the right to personal privacy. The policy included personal privacy shall include accommodations, and visits and meetings with family. The facility's policy titled Confidentiality of Information and Personal Privacy revised (MONTH) (YEAR) revealed the facility will strive to protect the resident's privacy regarding his or her visits and accommodations.

Based on clinical record review, facility documentation, staff interviews, hospital documentation and policy and procedures, the facility failed to ensure one resident (#163) was free of a significant medication error. Findings include: Resident #163 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and had [DIAGNOSES REDACTED]. The MDS also assessed the resident to require extensive assistance with transfers, dressing, and personal hygiene. A respiratory care plan dated April 5, 2015 identified that the resident was at risk for respiratory difficulties related to [MEDICAL CONDITION]. Interventions included to monitor his respiratory rate, assess lung sounds, report any abnormalities, and to administer oxygen at 2 liters via nasal cannula to keep oxygen saturations (O2 sats) greater than 90%. A physician's orders [REDACTED]. The orders also included for an antibiotic for a UTI. Review of the chest x-ray results dated May 14, 2015, revealed that there was no active cardiopulmonary process. The nursing notes dated May 15, 2015 included that the resident had a choking episode during lunch and the nurse practitioner (NP) was notified. Review of the orders by the NP dated May 15, 2015 revealed to change the resident's diet to mechanical soft consistency and to have speech therapy to evaluate. A nursing note dated May 18, 2015 included that the resident's O2 sats were at 90% on room air. Review of a nursing noted dated May 19, 2015 at 2 p.m., revealed the resident accidentally consumed opiates at 8 a.m., and the NP and Director of Nursing (DON) were notified. Review of the orders by the NP dated May 19, 2015 revealed the following: -Administer [MEDICATION NAME] (used to block the effects of opioids) 0.4 mg intramuscular (IM) for respiratory distress as needed in relation to the accidental narcotic medication administration. -Monitor resident closely and if a second dose of [MEDICATION NAME] is needed, send resident to the emergency room (ER) for accidental opiate overdose. -Hold [MEDICATION NAME], and [MEDICATION NAME] (pain medications) until further notice. -Okay to not send to ER at this time, may have more [MEDICATION NAME] as needed. Further review of the nursing notes dated May 19, 2015 revealed the resident received [MEDICATION NAME] at 11:40 a.m. and 1:40 p.m., after some coughing during lunch and that the NP was notified. The resident was receiving 2 liters of oxygen per nasal cannula, which was keeping the resident's O2 sats at 90%. A nursing note dated May 19, 2015 at 9 p.m. included that the resident's O2 sats were in the 80's, and a third dose of [MEDICATION NAME] was given at 7:30 p.m. Oxygen was increased to 6 liters per mask and the resident's O2 sats increased to 92%. The NP was notified and an order was received to send the resident to the hospital. The resident left the facility at 8:40 p.m. Review of the facility's investigative report revealed that around 8:00 a.m. on May 19, 2015, a licensed practical nurse (LPN) was preparing medications for a resident, when resident #163 came up to him and asked for his medication. The nurse prepared a second cup of medication and gave resident #163 the wrong medication cup. The medication which was accidentally given to resident #163 was [MEDICATION NAME] (narcotic pain medication) 150 milligrams (mg) SR (slow release). Per the report, the nurse immediately realized the error. The NP was in the facility, at the time and was notified, as well as the DON. The NP assessed the resident, ordered [MEDICATION NAME] and ordered the resident to be watched closely. The resident was administered several doses of [MEDICATION NAME], but had a decline in his condition and was sent to the hospital. According to the hospital records dated May 19, 2015, the resident arrived in critical condition. The resident was noted to have a fever of 100.1 degrees Fahrenheit (F) and his O2 sats on a non rebreather mask were 96%. The resident was being treated for [REDACTED]. The hospital documentation included that the resident was given 150 mg of [MEDICATION NAME] which was intended for another resident. The resident was admitted with acute [MEDICAL CONDITION], septic shock, and pneumonia and was transferred to the intensive care unit, because of severe [MEDICAL CONDITION]. Per the documentation, the resident passed away on May 20, 2015 from [MEDICAL CONDITION]. In an interview with the DON (staff #123) at 1:40 p.m. on April 12, 2016, she stated that the LPN set up medications for one resident and resident (#163) went up to him and asked for his medications. The LPN gave the resident the other resident's medication, which included 150 mg of [MEDICATION NAME] SR. She said the nurse realized what had happened right away and notified the NP who assessed the resident and ordered [MEDICATION NAME]. She said the resident received about three doses of [MEDICATION NAME] but was declining, so he was sent to the hospital. She said in the hospital, he was diagnosed with [REDACTED]. During an interview with the NP (staff #124) at 8:23 a.m. on April 13, 2016, she said the resident had [MEDICAL CONDITION] and was not doing well overall with his health. She said that after the medication error, she made the decision to provide the resident with [MEDICATION NAME] and told the staff to watch the resident very closely. She said the resident received an extremely high dose of [MEDICATION NAME] and that 150 mg is not a typical dose that most residents receive. In an interview with a registered nurse (RN/staff #112) at 8:40 a.m. on April 13, 2016, she said that she never sets up more than one resident's medications at a time, because this is risky as she could accidentally give the wrong medications to a resident. She said that if a resident comes up to her while she is setting up another resident's medications and asks for their medications, she will explain to them that they will have to wait a little bit, so she can finish administering the first resident's medications. An interview was conducted on April 13, 2016 at 9 a.m., with the LPN (staff #126) who administered the incorrect medication to resident #163. He stated that he had started setting up medications for another resident and was trying to help this resident out by getting him his medications quickly. He said he gave 150 mg of [MEDICATION NAME] to the wrong resident. He said that he should not have set up two different medication cups at once. He said he was watching the resident closely, but the resident was not doing well, as he had an infection and was not healthy. He said at first, the resident seemed okay but a while later the resident declined and required oxygen, and was eventually sent out to the hospital. Review of facility's policy and procedure regarding administering oral medications revealed that the purpose is to provide guidelines for the safe administration of oral medications. The policy included that staff are always to verify the 5 rights before administering medications. These include: the right medication; the right dose; the right resident; the right route; and the right time. The policy also noted to verify the identity of the resident, prior to administering medications.

Based on clinical record review, review of facility documentation, and staff interviews, the facility failed to ensure care and services to maintain one resident's (#67) highest practicable physical and psychosocial well-being by failing to provide an accurate and timely assessment after the resident began complaining of pain on June 9, 2012. On June 9, 2012 resident #67 sustained a [MEDICAL CONDITION]. The sample size was four. Findings include: Resident #67 was admitted to the facility April 10, 2009, with [DIAGNOSES REDACTED]. Review of the resident's clinical record for fall risk assessment was assessed to be at high risk for falls (score of 10 or greater) on the day of admission. The resident scored a 10. On October 3, 2011, the resident was still assessed to be a high risk for falls and scored a 13. Review of the resident's care plan dated January 17, 2011, interventions were applied to include low bed with mats, motion alarms to be used on wheelchair and bed and for staff not to allow resident to ambulate without assistance. The resident was reassessed for fall risk on December 25, 2011, and again the score was 13 and remained at high risk. On June 9, 2012, the clinical records failed to identify documented evidence that the resident had complaints of pain. A nurse's note by staff #1 dated June 10, 2012, stated that at 11:00 a.m. that the resident was medicated for right leg pain with Tylenol 650 milligrams (mg) and that footrests were added to resident's wheelchair to alleviate discomfort. Nurses note entry for evening shift again mentions that the foot rests remain on the wheelchair to alleviate right leg pain. Additional record review provided no evidence that a visual assessment was done comparing the resident's left and right leg for both length and rotation differences. Resident's clinical record for June 11, 2012, revealed a note written at 10:15 a.m. approximately 24 hours later, a LPN was informed by a certified nursing assistant (CNA) that the resident was not bearing weight on her right leg and seemed to be in pain when that right leg was touched. The nurse's assessment of the resident stated that the right leg was externally rotated and appeared shorter then the left leg. The LPN notified the nurse practitioner of her findings and ordered an x-ray. At 12:30 p.m. the resident was transferred to the hospital for her x-ray where it was revealed that she had sustained a right [MEDICAL CONDITION] and was being admitted to the hospital. Review of facility documents revealed that staff #1 was working double shifts or 16 hours on both Saturday and Sunday, June 9 through June 10, 2012. She worked both the day and evening shift each day. Even though a review of the resident's clinical record for June 9 through June 10, 2012, revealed little documented evidence that the resident was in any discomfort, a review of the facility's investigation into an injury of unknown cause conducted June 13 through 14, 2012, revealed that the CNA's as early as Saturday June 9, 2012, had alerted staff #1 that the resident was in pain and not bearing weight on the right leg. In a CNA statement during the facility's investigation the CNA said that on June 9, 2012, when she was transporting the resident via wheelchair, to the dining room the resident complained and seemed to be favoring her right leg. The CNA said that she notified staff #1 and the evening shift staff. On Sunday June 10, 2012 she noticed that the resident did not want to bear weight on the right leg and again notified staff #1 of this. She also added that she placed footrests on the wheelchair so the resident's legs would not touch the floor. On June 11, 2012, the CNA once again notified the day shift LPN of the weekend occurrences and of the increase in pain exhibited by the resident that morning. Review of facility documentation of the investigation of injury of unknown cause dated June 14, 2012, stated that the CNA had notified staff #1 on evening shift of June 9, 2012, that the resident when transferred to her bed, was moaning and appeared to be in pain. She went on to add that once in bed she and the other CNA assisting the resident noted that the right leg was swollen and notified the staff #1 of these findings. In the investigation document the CNA went on to add that the next day (June 10, 2012) was the same as far as pain and swelling and staff #1 was again notified. An Interview was conducted on July 11, 2012 at 2:20 p.m. with the day shift CNA that cared for the resident on the weekend of June 9 through June 10, 2012, she remembered that on Saturday June 9, 2012, that she reported to staff #1 that the resident when attempting to transfer was experiencing some pain and not bearing as much weight on her right leg. She added that staff #1 went in to her room to check on her. She stated that on Sunday June 10, 2012, she noticed again the resident was in pain and not bearing weight on the right leg and reported to the same staff #1 that the pain seemed worse on Sunday and also reported that the thigh above the knee was swollen. She stated that staff #1 medicated her and she had placed foot rests on her wheelchair to assist with pain relief as her legs were dangling and causing pain when in the wheelchair. An interview was conducted via phone with staff #1 on July 11, 2012 at 2:50 p.m. Staff #1 was asked about her care for the resident for the weekend of June 9 and 10, 2012. The staff member stated that she could not recall anything she did for the resident on that Saturday. On Sunday she stated that the CNA reported that the resident was experiencing some pain and she said that she did assess the resident. When asked where and how she assessed the resident she stated that she pressed on the resident's leg above the right knee while the resident was seated in her wheelchair. She was asked if she had assessed the rest of the resident's leg and she said that her focus was on the knee only and did not assess the rest of the leg at all. An interview was conducted with the facility's Director of Nurses (DON) on July 12, 2012 at 8:30 a.m. The DON stated that the resident's nurse practitioner did not use mobile x-ray as she just did not like them, and insisted on sending her residents to an outside facility. She also stated that a staff member working two double shifts was not uncommon and while she recalled that staff #1 had told her she had assessed resident #67's leg, she was unaware that the assessment was conducted only while the resident was in her wheelchair and not in bed. Review of the facility's policy and procedure for assessing falls it stated, "...after a fall, nursing staff will notify the resident's attending physician and family in an appropriate time frame...nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and will document findings in the medical record. Documentation will include at least statements about observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility..."