Gables Care Center Inc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, activity calendars review, review of facility policy and interview, the facility failed to ensure activities were available to meet the needs of the residents and included adequate activity staff members to assist the residents with activities as needed. This affected three residents (Residents #39, #50 and #70) of five residents reviewed for activities and three residents (Resident #3, #44 and #67) observed during a group activity of 20 residents involved in the activity. The facility census was 75.Findings include: 1. Review of Resident Council meeting minutes from November of 2025 revealed residents reporting that activities are getting cut short because not enough staff, and residents wanted to know why the facility was no longer having live entertainers for music. The Administrator's response was that the facility was not cutting any activity short due to staffing and that the facility policy was to require all entertainers to have a tax identification number to be issued a 1099 when paid by the facility. The Administrator further reported no entertainers were willing to do this now.Review of the monthly activity calendars revealed only one calendar of activities for the entire facility each month with no separation for activities for residents with cognitive impairments. The activities scheduled lacked variety and included daily coffee and discussion and passing out of the Daily Chronicle, at 10:00 A.M. There was a bible study every Tuesday at 2:00 P.M. and Church services every Sunday at 2:00 P.M. Bingo was held every Monday, Wednesday, and Friday at 2:00 P.M.Review of the monthly activities' calendars for December 2025, January 2026, and February 2026 revealed limited one on one activities. December 2025 revealed only three scheduled independent activities/room visits with activity cart on 12/05/25, 12/12/25 and 12/26/25. January 2026 revealed only three scheduled independent activities/room visits with activity cart on 01/17/26, 01/23/26, 1/30/26. February 2026 revealed only two scheduled independent activities/room visits with activity cart on 02/20/26 and 02/27/26.a. Interview on 02/10/26 at 10:05 A.M. Activities #90 stated the facility use to have pastors come in on Sundays for church services but now they watch a television service. Interview on 02/10/26 at 10:10 A.M. with Resident #50 revealed Resident #50 would like to have more religious services offered especially catholic related services. Resident #50 reported that watching services on television is not interactive.b. Observations on 02/10/26 at 9:47 A.M. revealed an activities assistant going room to room dropping off the Daily Chronicle newsletter to each resident. Observation further revealed the activities assistant appear rushed and only spoke good morning to each resident and offering the newsletter then moving onto the next resident. c. Observations on 02/10/26 between 1:55 P.M. and 3:57 P.M. revealed an activities assistant going room to room filling out menu selections with each resident for tomorrow's meals. d. Interview on 02/11/26 at 8:50 A.M. with an Anonymous Resident revealed the activities department lacked sufficient staff and were required to obtain menu selections for all residents after lunch, taking away an activity assistant to help residents participate in activities.Interview on 02/11/26 at 9:30 A.M. with Activities #127 revealed staff were told by the Administrator not to bring residents to a group activity if they needed help as it was not fair to the other residents. The activity staff also shared the department was only allowed one activity aide during any activity because the Administrator utilized an activity aide to help pass snacks in the morning with the Daily Chronicle delivery and someone has to do the menus (after the lunch meal for the following day's meals) which takes two hours. Interview on 02/10/26 at 10:34 A.M. with two anonymous employees revealed the Administrator had changed a lot of things since beginning employment with the facility including only allowing one activity aide during an activity and using another activity aide to get menu selections from the residents for the next day. The anonymous employees stated residents not cognitively intact or residents significantly disabled were not to come to activities, like bingo, if they couldn't do for themselves. The AE also stated there were no in person religious activities scheduled and the residents have to watch religious programming on TV. The staff verified it had been approximately two months since pastoral staff had been in the facility. e. Observation on 02/11/26 between 2:10 P.M. and 2:50 P.M. of the bingo activity revealed twenty residents seated with bingo cards. There were two activities assistants, one calling the bingo numbers and one assisting four residents needing help at one table. Observation further revealed Resident #3 sitting at a table without a activity assistant in a wheelchair with her head down and eyes closed throughout the activity. There was a bingo card and chips present for Resident #3 but no active participation. During the activity a certified nursing assistant (CNA) brought in by wheelchair Resident #44, who was noted to be cognitively impaired per list provided by facility of residents with Brief Interview of Mental Status (BIMS) score of seven or less. Resident #44 was placed at a table with no activity assistant and no bingo card or chips. Resident #44 was noted to continuously be chewing on a blanket that was draped over here. No one assisted Resident #44. The CNA then brought Resident #67, who was noted to have cognitive impairment per list provided by facility of residents with a BIMS score of seven or less, into to the activity and sat her at table without an activity assistant. Resident #67 was provided a bingo card and chips and was not able to follow along with the game. f. Interview on 02/11/26 at 8:50 A.M. with an Anonymous Resident revealed the activities department lacked sufficient staff and were required to obtain menu selections for all residents after lunch taking away an activity assistant to help residents participate in activities.g. Interview 02/11/26 at 11:55 A.M. with Employee #26 revealed there was room for improvement in activities. There was recently a changeover in activities. Employee #26 reported there was not a sufficient number of activities and the residents were bored. The employee revealed residents had reported to staff they did not feel their recommendations (for activities) were taken into consideration and they wanted new activities. 2. Review of the medical record for Resident #39 revealed admission to facility on 10/03/24 with diagnoses including dementia, severe, with anxiety, depression, insomnia, high blood pressure, and difficulty walking. Review of Resident #39's plan of care dated 10/14/25 revealed the resident was to have one on one room visits by activity staff daily to promote socialization and lessen boredom.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of six (out of 15) reflecting severe cognitive impairment. The MDS further indicated Resident #39 required a wheelchair for navigation and substantial/maximum (staff) assistance for dressing, bathing, and transfers.Review of Resident #39's electronic medical record for tasks completed for November 2025, December 2025, and January 2026 revealed no documentation of one-on-one room visits being completed.3. Review of the medical record for Resident #70 revealed admission to facility on 02/20/23 with diagnoses including dementia, moderate with anxiety, difficulty walking, and anorexia (inability to eat).Review of Resident #70 plan of care dated 02/21/23 and revised on 02/10/26 revealed the resident was to have one on one room visits by activity staff daily to promote socialization and lessen boredom.Review of the MDS assessment dated [DATE] revealed a BIMS score of 4 (out of 15) indicating severe cognitive impairment. The MDS further indicated Resident #70 required (staff) supervision navigation and supervision assistance for dressing, bathing, and transfers.Review of Resident #70's electronic medical record for task completed for November 2025, December 2025, and January 2026 revealed no documentation of one-on-one room visits completed.Review of the Activities policy dated 10/23/25 revealed activities would be designed with the intent to reflect cultural and religious interest of the residents as well development of person appropriate activities relevant to the specific needs and interest for the residents they were developed for. Further review revealed, the facility would consider accommodations in schedules, supplies, and timing in order to optimize a resident's ability to participate in activity of choice.This deficiency represents non-compliance investigated under Complaint Number 2709902.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the administrator job description, review of the resident rights policy and interviews, the facility failed to be administered in a manner that enabled all residents to attain/maintain their highest practicable physical, mental and psychosocial well-being. This had the potential to affect all 75 residents residing in the facility.Findings include: Review of the Resident Council Minutes dated 02/11/26 revealed residents want administration to be more present with the residents. Review of the administrator job description revealed the purpose of the administrator was to lead, guide, and direct the operations of the healthcare facility in accordance with local, state and federal regulations, standards and establish facility policies and procedures to provide appropriate care and services to residents period. Duties and responsibilities of the administrator include ensuring delivery of compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff, employee turnover, general cleanliness, physical plant condition, and optimal residence functioning physically and psychosocially. Duties of the administrator include performing rounds to observe residents and ensure overall needs were being met (expectations were for the administrator to know the residents by name and site) with practices by walking around and making themselves available to employees at all levels by participating in an open door policy. Duties of the administrator include managing and minimizing facility risk through team approach to achieve desired outcomes in customer service, key performance indicators, and employee retention and other areas as identified. Additional tasks of the administrator were to treat all residents with dignity and respect. Promote and protect all resident rights; And establish a culture of compliance by adhering to all facility policies and procedures and complies with standards of business conduct, and state and federal regulations and guidelines. Expectations for the administrator included having the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public. The administrator must have patience, tact, and willingness to deal with difficult residents, family, and staff.Review of the facility policy titled Resident Rights reviewed and revised on 07/30/25 revealed all residents would be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The facility would ensure all direct care staff and indirect care staff members, including contractors and volunteers were educated on the rights of residents and the responsibility of the facility to properly care for its residents.Information provided to the State agency revealed the current administrator had a start date of 02/20/2025.Interview on 02/10/26 at 2:20 P.M. with the Administrator revealed the facility did have a corporate compliance hotline if the staff wanted to report anything anonymously.Interview on 02/11/26 at 10:50 A.M. with Corporate Human Resources (HR) #1199 revealed the facility had multiple complaints called in about the administrator in the past year. Corporate HR #1199 revealed the complaints would have been given to the prior Regional Director, RD #2099 [the building was sold and the change went into effect on 01/01/26]. Corporate HR #1199 was unable to confirm if there was ever any official disciplinary action taken on the administrator but believed there was verbal coaching but the verbal coaching would probably not be in the personnel file [personnel file of the administrator]. Corporate HR #1199 also revealed resident complaints would go to the administrator of the facility. When staff reported concerns related to the administrator, they would mention residents were affected by the complaint.Observation of the Corporate Compliance Poster on 02/11/26 at 1:54 PM listed the facility administrator as the corporate compliance officer. Upon dialing the listed number a message revealed anyone calling could leave a detailed message and remain anonymous if wanting. All concerns would be forwarded to the corporate compliance officer at the facility.Interview on 02/11/26 at 2:43 PM with the Administrator revealed she became the facility compliance officer January 1 (2026) when the new company took over and there had only been two complaints about her. However, the Administrator revealed she believed the complaints were actually about another staff member who looked like her. The Administrator stated if there were complaints about her, someone else would investigate and she would get an email follow-up with information from the investigation. During the onsite survey the following concerns were voiced by staff/residents/representatives who wished to remain anonymous due to fear of retaliation from the Administrator: a. Interview on 02/10/26 8:41 A.M. with Anonymous Employee (AE) #923 revealed they were fearful of losing their job if the Administrator found out they spoke with the state survey agency (SSA). The AE revealed since the Administrator took over, a lot of things had changed. Residents weren't happy, the atmosphere was affecting them. Everyone was afraid to advocate and bring up concerns and suggestions because of the fear of retaliation. If someone was brave enough to do so [voice concerns and issues] then you were retaliated against. The administrator was not friendly or approachable, this went for staff and the residents.b. Interview on 02/10/26 at 10:12 A.M. with Resident Representative (RR) #712 revealed the Administrator of the facility was not approachable. They had witnessed her [the Administrator] yelling at staff in an area and way that was not professional in a work environment, especially one of this kind; inside of the residents' home where people were visiting. RR #712 felt they do not have a voice to advocate for their family. The RR shared it would be nice if the Administrator communicated better with the families and there were some things they believed the Administrator had said that they felt were not professional or appropriate. RR #712 shared they feared if they brought these specific things up they would be retaliated against, or their family [the resident] would be treated differently. c. Interview on 02/10/26 at 10:30 A.M. with Employee #323 revealed there were concerns with the facility Administrator. Employee #323 had witnessed the Administrator be rude and condescending. The employee revealed there was a shift awhile back, she came onto the unit and was immediately demanding, yelling, threatening aides if they did not leave [leave the building on their day shift] and come back later [come back for afternoon shift, because they were short] then it was going to affect their pay checks. This was done in front of residents, staff, visitors, and it was not a good look, it was embarrassing for the facility. A lot of those aides have since left due to the threats and toxic environment. The way she comes, and yells startles the residents, they deserved a calm- safe environment. The Administrator was still rude to staff, not only staff but the residents as well, were affected. Facility employee #323 stated there were some residents who were fearful of the Administrator due to her demeanor [yelling and argumentative] and they voiced she showed favoritism towards other residents [not saying hello, not interacting, not even making eye contact or small conversations with the residents]. There was a fear of retaliation from management, this made it difficult to advocate for yourself or your residents because when you did, your job was hung over your head and you were scared.d. Interview on 02/10/26 at 3:24 P.M. with AE #1738 revealed several residents had voiced concerns related to the Administrator and these concerns were regarding favoritism, and resident/staff treatment. AE #1738 revealed the favoritism was obvious, and it was upsetting to see the residents feeling the repercussions of this. When residents had concerns, she [the Administrator} was not open to suggestions or even provide some one on one time to listen to the residents. AE #1738 stated the Administrator would become defensive and there was a lot of fear of retaliation from staff and residents (no specific situations identified).e. Interview on 02/10/26 at 4:50 P.M. with AE #193 revealed if someone felt comfortable enough to bring up concerns or suggestions to the Administrator, they weren't listened to, and they barely got to speak. The AE said it was her way or no way [the Administrator] and there was no team collaboration. AE #193 felt there was a lack of support from administration and this was an issue between her [the Administrator] and the staff, but also the residents. AE #193 shared the residents (no specific residents identified) didn't feel the Administrator cared for them or had a genuine interest in their well being, concerns, or ideas. f. Interview on 02/11/26 at 8:13 A.M. with AE #299 revealed the Administrator had been reported several times to corporate, and nothing seemed to happen, there was no follow-up. The AE revealed the compliance line poster did say the Administrator was the compliance officer so maybe that had something to do with it, but the AE was unsure. The Administrator had made scenes at the nurse's station on more than one occasion. Staff, visitors, families, and residents had been there to witness the Administrator make scenes at the nurses station. The AE provided an example when one day the Administrator had a concern about a medication cart, and instead of educating the nurse, ensuring the issue was corrected, the Administrator began screaming at the nurse, pulled out her cell phone [the Administrator's cell phone] and began taking photos of something, screaming about the situation. The AE stated the visitors were astonished. The situation was embarrassing, it was not a good look for [NAME] [the facility], it was not a good look for the staff, and it was not a good reflection of the care staff provide. The AE revealed the Administrator was unprofessional, there was no one on one conversation, no privacy, no warning, no education, just an embarrassing scene leaving the family and residents with several questions and concerns. AE #299 stated they had never witnessed something like this in healthcare or in any previous job. The Administrator was rude, and the AE revealed our residents were being directly affected by this, the residents do not feel safe to report concerns and issues to her [the Administrator]. The Administrator does not interact with the residents, no hello or good morning. Residents were concerned about favoritism she [the Administrator] displays towards other residents. Staff fears retaliation from management and this causes staff and residents to not be able to advocate for the residents. AE #299 does not feel the Administrator has the resident's needs, care, or interests prioritized.g. Interview on 02/11/26 at 8:30 A.M. with AE #623 revealed they felt a lack of support from the facility Administrator. Since they've worked at the facility they've watched employees be demoted, retaliated against for speaking up on behalf of the residents, and yelled at in front of residents and visitors. If the Administrator doesn't like you, your job is always on the line. Residents felt that she [the Administrator] didn't advocate for their best interest, they [the residents] felt that they no longer had a voice, she [the Administrator] would immediately shut them [the residents] down if they brought up any suggestions or problems they had. AE #623 did fear retaliation from the administrator, and they were sure other staff felt this way. AE #623 posed the question how do you advocate for the best quality care and quality of life of the residents when you are so fearful of losing your job?. The work environment is so toxic, this affects the residents, they can see it's tense, they feel the tension, they witness her [the Administrators] outbursts. h. Interview on 02/11/26 at 8:50 A.M. with Anonymous Resident (AR) #1522 revealed the new Administrator made it hard for staff to do their jobs which included aides, activities, nurses. Any issues or concerns reported to her [the Administrator] or requests from residents, the Administrator always turned them down, she didn't listen to us or take our concerns into consideration. We [the residents] rarely saw the Administrator, she had her favorite residents she saw and talked to. She [the Administrator] was nasty to staff; just recently she yelled at one of nurses in front of the staff and residents at the nurse's station and the resident thought she [the nurse] was going to quit. AR #1522 stated they would quit a job if they were treated like that, and the nurse was a good nurse, and cared about the residents. The resident stated watching and hearing the Administrator yell like that was scary. AR #1522 feared retaliation if they reported concerns about the Administrator and indicated this would be getting kicked out of the facility. Lastly, the resident stated things at the facility were much better before this Administrator came to the facility.On 02/11/26 at 9:20 A.M. AR #1522 was observed crying. The resident was approached and asked what was wrong and they reported they were really concerned something was going to happen to them now, and they might get kicked out because they spoke with the SSA. AR #1522 reported they were going to try to calm down, and they may go do something to distract themselves and relax.i. Interview on 02/11/26 at 9:37 A.M. with AE #199 revealed they felt the Administrator was unprofessional and would scream at staff in front of other staff members, visitors, and residents. The right way to do it would be moving to a private space, where residents and their loved ones or whoever were visiting with them would not overhear and witness the altercation. The times AE #199 stated they had witnessed the Administrator scream at staff, the environment didn't feel safe or comfortable. The Administrator made small remarks and comments about other peoples' work or their work ethic to other staff members, which was inappropriate since it wasn't with the applicable staff member, in private. There was a specific altercation a few weeks ago, a nurse pulled her mask down to take a drink of water, the Administrator screamed and yelled, belittled and berated the nurse; in front of visitors and residents and other staff. AE #199 shared they were fearful that speaking up, and advocating would result in retaliation from management.j. Interview with Resident Representative #192 on 02/11/26 at 2:03 P.M. revealed the atmosphere at the facility seemed tense. They had only heard of but not personally witnessed the Administrator yelling at staff members, and treating them poorly. Resident Representative #192 stated they had talked to the Administrator occasionally but more often than not she [the administrator] did not get with them regarding concerns, as they seemed to be forgotten about or brushed under the rug.k. Interview on 02/11/26 at 2:15 P.M. with AE #12 revealed the Administrator did not handle situations professionally. She would yell and raise her voice louder and louder. She [the Administrator] would speak to staff and residents poorly. The Administrator does not treat you like an equal, she was patronizing and condescending. There was an incident, with a nurse, [not wish to name] and the Administrator. Something happened and the Administrator began yelling at the nurse, in a public space, with staff, residents, visitors witnessing the situation. The nurse was never taken to a private area, instead she was belittled by the Administrator with several people seeing and overhearing the scenario unfold. AE #12 stated staff were fearful, residents said they were not comfortable, and families reported they were concerned, especially when they witnessed these situations more than once. There was a corporate compliance line you could call and file complaints. Although it was allegedly anonymous, her name [the Administrator] was at the bottom of the number as the compliance officer. We [staff] are hesitant for fear of retaliation. The employee stated the Administrator was not approachable; she doesn't interact with the residents at all. Several staff members have left employment with the facility due to treatment by the Administrator. AE #12 shared there had been many residents who have complained about the Administrator and how they were treated and how the Administrator doesn't interact with them. The residents have also shared they have witnessed the Administrator yell at staff as well as family members have said they witnessed altercations between the Administrator and staff, too.l. Interview on 02/11/26 at 2:30 P.M. with AE #414 revealed AR #982 had approached them and was concerned about the Administrator being present at the resident council meeting that was scheduled with the SSA because the SSA would be present and the residents couldn't speak freely about their concerns with the Administrator if she was in the meeting due to fear of retaliation. A Resident Council Meeting was held on 02/11/26 with the SSA staff present. The meeting was called to order by Resident Council President #54. At 3:10 P.M. the Director of Nursing (DON) and Administrator entered the dining room [where the resident council was being held]. Resident #49 stated their main concern was not have enough aides [certified nursing assistants]. Resident #54 agreed Resident #49 stated there were enough nurses. The DON and Administrator stated they would complete audits for staffing. At approximately 3:40 P.M. the DON and Administrator were asked by the resident council president to exit the dining room so the residents could speak with the SSA privately. Staff exited the dining room. AR #511 then stated they would like a new Administrator as residents believed the Administrator did not have their best interests at heart. The resident further shared they were told, when concerns were shared with the Administrator, the facility doesn't have enough money or provides numbers to them they don't understand so they can't advocate for themselves. AR #511 reported the Administrator cuts them off and doesn't do anything to help the residents. AR #511, AR #1522 and AR #205 shared when they bring up concerns, the administrator becomes defensive and there's no follow-up or change. AR #1522 stated the Administrator made them feel like crap. AR #205 stated they felt the Administrator treated residents differently and would yell at staff in front of other staff, residents and visitors. AR in the council meeting also reported they fear more good staff were going to continue to leave due to how the Administrator speaks to them as the facility has had some good staff already quit. The residents stated the Administrator makes it hard to keep good staff.m. Interview on 02/11/26 at 3:59 P.M. with AE #58 revealed they felt they were unable to report concerns without retaliation from the Administrator. Employee #58 stated they did see how certain residents were treated differently by the Administrator. Employee #58 revealed they were fearful of retaliation from the administrator if concerns were voiced.This deficiency represents non-compliance investigated under Complaint Number 2709902.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident with contractures received appropriate services to maintain mobility and prevent further decrease in range of motion. This affected one (Resident #51) of one residents reviewed for position/mobility. The facility census was 79.
Findings include:
Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, diabetes mellitus, acute respiratory failure with hypoxia, congestive heart failure, spinal stenosis, contracture left hand, and dementia.
Review of the Care Plan, dated 08/25/23 and revised on 04/10/24, revealed Resident #51 required double washcloth rolls to hands as tolerated to help prevent further decline in range of motion.
Review of the Minimum Data Set (MDS) quarterly assessment, dated 02/14/24, indicated Resident #51's Brief Interview for Mental Status (BIMS) score was 05, which indicated severe cognitive impairment. The resident was dependent on physical assistance from staff for bed mobility, transfers, dressing, eating, and toileting. The assessment indicated impairment of the upper and lower extremities.
During observation on 04/10/24 at 10:17 A.M. and on 04/11/24 at 9:05 A.M. and 11:19 A.M., Resident #51 was observed lying in bed and both hands were noted without rolled washcloths.
Review of Resident #51's current [NAME] and Task Log revealed the intervention to place double rolled washcloths into hands as tolerated to prevent contractures. The task was documented as completed for 04/11/24, day shift.
During interview on 04/11/24 at 11:35 A.M., State Tested Nursing Assistant (STNA) #255 confirmed Resident #51 did not have washcloths in both hands per his plan of care and she had not placed the washcloths in his hands during her shift. STNA #51 stated that she would get the washcloths and apply them.
During interview on 04/11/24 at 11:40 A.M., Registered Nurse (RN) Supervisor #259 confirmed Resident #51 should have had washcloths in both hands due to contractures and as documented in the electronic medical record by the STNA.

Based observation, record review, interview and policy review the facility failed to ensure an indwelling urinary catheter drainage bag and tubing were not resting on the floor. This affected one (Resident #3) of two residents reviewed for indwelling urinary catheter use. The facility identified eight residents (Residents #3, #4, #7, #15, #25, #32, #43 and #132) currently utilizing indwelling urinary catheters. The facility census was 79.
Findings include:
Review of Resident #3's medical record revealed an admission date of 03/25/21 with a readmission date of 06/29/23. Further review of the medical record including the minimum data set (MDS) 3.0 quarterly assessment with a reference date of 01/06/24 revealed Resident #3 had an intact and independent cognition level and used an indwelling urinary catheter (urinary collection device which is inserted into bladder and attached to an external drainage system and bag). Further review of the medical record revealed on 06/29/23 Resident #3 was ordered by the physician the use of an indwelling urinary catheter due to urinary obstruction causing urinary retention. Care plans for Resident #3 also indicated the use of an indwelling urinary catheter for urinary retention.
Interview with Resident #3 on 04/09/24 at 3:05 P.M. revealed the resident had long term use of an indwelling urinary catheter.
Observations on 04/09/24 at 3:05 P.M., 04/10/24 at 10:07 A.M. and 04/10/24 at 1:20 P.M. revealed the catheter drainage bag and tubing were touching the floor under the resident's wheelchair.
Interview with Licensed Practical Nurse (LPN) #252 on 04/10/24 at 1:21 P.M. verified Resident #3's urinary catheter drainage tubing and bag were resting on the floor and should not be.
Review of the facility policy titled Catheter Care with a revision date of 07/01/23 revealed to ensure catheter tubing and bag are not resting on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the infection control log, interview, and policy review the facility failed to ensure antibiotic use was appropriate and infections met treatment criteria. This affected one resident (#25) of two residents reviewed for antibiotic use. The facility census was 79.
Finding included:
Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including dementia, abnormal posture, dysphagia, pleural effusion, diabetes mellitus, and chronic obstructive pulmonary disease.
Review of Resident #25's urinalysis with culture and sensitivity, dated 01/15/24, revealed
greater than 100,000 CFU/ml Klebsiella Pneumonia (bacteria).
Review of Resident #25's physician order, dated 01/20/24, revealed the order to administer ciprofloxacin 500 milligrams (mg) one tablet by mouth, two times a day, for urinary tract infection until 01/30/24.
Review of the Infection Control Log, dated January 2024, revealed the resident was ordered ciprofloxacin for a UTI, with a start date of 01/20/24 and a stop date of 01/30/24.
Review of a communication message, dated 01/24/24, revealed the physician was notified that the antibiotic did not meet criteria for use based on Resident #25's absence of symptoms, aside from the abnormal urinalysis. Further review indicated the physician selected the option to continue the antibiotic.
Interview on 04/12/24 at 11:32 A.M., Infection Preventionist/Licensed Practical Nurse (LPN) #265 verified there was no indication for the use of ciprofloxacin as the resident's lack of symptoms and laboratory findings did not meet McGeer Criteria (criteria used to determine an infection) for treatment of a UTI. LPN #265 further stated that she notified the physician, however, he chose to continue the antibiotic.
Review of the facility policy titled, Antibiotic Stewardship Program, dated 05/30/23, revealed it is the policy of this facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The facility uses updated McGeer criteria or other surveillance tools to define infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure the advance directives/code status for Resident #26 and Resident #281 were consistent between each residents' electronic health record, the hard chart/paper record on the unit and the sticker on the first page of the hard chart for quick reference. This affected two residents (#26 and #281) of two residents reviewed for advanced directives.
Findings include:
1. Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE]. Resident #26 had diagnoses including acute and chronic respiratory failure with hypoxia, history of COVID-19, essential hypertension, hyperlipidemia, and atherosclerotic heart disease of native coronary artery without angina pectoris.
A review of Resident #26's physician's orders revealed his advance directives/code status was a Do Not Resuscitate Comfort Care Arrest (DNR CC-A). The order had been in place since 06/13/19.
A review of Resident #26's hard chart/paper record located on the unit revealed the first page was Resident #26's face sheet in a plastic sleeve. The plastic sleeve had a green sticker in the lower right corner of the pate that read Resuscitate. A do not resuscitate form was found in the hard chart that identified the resident's code status as DNR CC-A. If this box was checked, the DNR Comfort Care Protocol was to be implemented in the event of a cardiac arrest or a respiratory arrest. The form had been signed by the physician on 06/11/19.
On 05/02/22 at 1:37 P.M. interview with Registered Nurse (RN) #378 revealed residents advanced directives/code status were recorded in two different locations. They were identified in the electronic health record (EHR) and the hard chart/paper record. RN #378 opened Resident #26's EHR and revealed the advanced directive was DNR CC-A. RN #378 then opened Resident #26's hard chart and indicated the sticker on the plastic sleeve holding the face sheet read Resuscitate. RN #378 revealed the stickers were put on the face sheet sleeve for quick reference and verified the sticker was not correct for Resident #26. RN #378 revealed the paper do not resuscitate form in the physical chart was correct.
2. Review of Resident #281's medical record revealed the resident was admitted to the facility on [DATE]. Resident #281 had diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris and essential hypertension, history of COVID-19.
A review of Resident #281's physician's orders revealed his advance directives/code status was a DNR CC-A. The order had been in place since 03/14/22.
A review of Resident #281's hard chart located on the unit revealed a do not resuscitate form that identified the resident's code status as Do Not Resuscitate Comfort Care (DNR CC). If this box was checked, the DNR Comfort Care Protocol was to be implemented immediately. The form had been signed by the physician on 01/04/22.
On 05/02/22 at 1:43 P.M. interview with Registered Nurse (RN) #378 revealed residents advanced directives/code status were recorded in two different locations. They were identified in the electronic health record (EHR) and the hard chart/paper record. RN #378 opened Resident #281's EHR and verified the advanced directive was DNR CC-A. RN #378 then opened Resident #281's hard chart and verified the paper form identified the resident's code status as DNR CC. RN #378 verified there was a discrepancy between the EHR and hard chart advanced directive/code status documentation.
A review of the facility policy titled Advance Directives, revised 2022 revealed it was the policy of the facility to identify a code status consistent with resident wishes to facilitate providing emergency care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive plan of care. Advanced Directives should be reviewed and updated with the quarterly Minimum Data Set and/or as the resident indicates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #73's physician was notified as ordered when the resident's blood glucose level (blood sugar) was greater than 400. This affected one resident (#73) of five residents reviewed for unnecessary medication use.
Findings include:
Review of the medical record revealed Resident #73 was admitted to the facility on [DATE]. Resident #73 had diagnoses including Parkinson's disease, hypertension, bipolar disorder, gout, polyneuropathy, long-term use of insulin, anxiety disorder, chronic pain syndrome, chronic kidney disease, cerebral infarction, protein-calorie malnutrition, osteoarthritis, breast cancer, dementia and inflammatory spondylopathy.
Review of the May 2022 physician's order revealed Resident #73 had an order for Novolog (insulin) flex pen per sliding scale subcutaneously before meals and at bedtime. The sliding scale revealed for a blood glucose level from 0 to 150 give no insulin; for blood glucose level greater than 150- divide by 30 and minus three and this would be the total units to give. The sliding scale revealed if the blood glucose level was greater than 400 to call the physician.
Review of the quarterly Minimum Data Set 3.0 assessment, dated 04/04/22 revealed Resident #73 had intact cognition and received insulin seven out of seven days during the assessment reference period.
Review of the medication administration record for March 2022 revealed on 03/25/22 at 4:00 P.M. Resident #73 had a blood glucose level of 471.
Review of the progress note, dated 03/25/22 revealed no evidence the physician was notified of the blood glucose level of 471 for Resident #73 as ordered.
Review of the medication administration record for March 2022 revealed on 03/29/22 at 4:00 P.M. Resident #73 had a blood glucose level of 494.
Review of the progress note, dated 03/29/22 revealed no evidence the physician was notified of the blood glucose level of 494 for Resident #73 as ordered.
Review of the medication administration record for March 2022 revealed on 03/31/22 at 8:00 P.M. Resident #73 had a blood glucose level of 471.
Review of the progress note, dated 03/31/22 revealed no evidence the physician was notified of the blood glucose level of 471 for Resident #73 as ordered.
Review of the medication administration record for April 2022 revealed on 04/01/22 at 4:00 P.M. Resident #73 had a blood glucose level of 440.
Review of the progress note, dated 04/01/22 revealed no evidence the physician was notified of the blood glucose level of 440 for Resident #73 as ordered.
Review of the medication administration record for April 2022 revealed on 04/16/22 at 11:00 A.M. Resident #73 had a blood glucose level of 424.
Review of the progress note, dated 04/16/22 revealed no evidence the physician was notified of the blood glucose level of 424 for Resident #73 as ordered.
On 05/04/22 at 4:33 P.M. interview with the Director of Nursing verified there was no evidence the physician was notified of the blood glucose readings greater than 400 on 03/25/22 at 4:00 P.M., on 03/29/22 at 4:00 P.M., on 03/31/22 at 8:00 P.M., on 04/01/22 at 4:00 P.M. or on 04/16/22 at 11:00 A.M. for Resident #73.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to provide residents and resident representatives a written notice indicating the reason for the discharge and appeal rights. This affected two residents (#45 and #81) of 24 residents interviewed/reviewed for hospitalization.
Findings include:
1. Review of Resident #45's medical record revealed diagnoses including chronic obstructive pulmonary disease, heart failure, chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and malignant neoplasm of the urethra (a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body).
A nursing note, dated [DATE] at 10:41 A.M. indicated the Urology Department at Veterans Affairs was notified Resident #45's left urostomy drain was leaking at the site on his back and of low drainage output was noted in the bag. The Urology Department was also notified of Resident #45 having blood from his penis. Resident #45 had an appointment with nephrology the next day at 11:30 A.M.
A nursing note dated [DATE] at 1:44 P.M. indicated the nephrology department called the facility and requested Resident #45 be sent to the Emergency Department. Resident #45 was agreeable with the transfer.
A nursing note dated [DATE] at 2:45 P.M. indicated Resident #45 left the facility via the facility's van en route to the emergency room for evaluation and treatment. There was no evidence of a transfer/discharge notice being provided.
A nursing note dated [DATE] at 9:17 P.M. indicated Resident #45 was admitted to the hospital with a diagnosis of mechanical complications of the nephrostomy catheter.
On [DATE] at 1:15 P.M. [NAME] President (VP) of Clinical Operations #500 verified Resident #45 received no transfer/discharge notice/documentation when he was sent to the hospital [DATE].
2. Review of Resident #81's medical record revealed diagnoses including multiple sclerosis, chronic obstructive pulmonary disease, type two diabetes mellitus, heart disease, anemia, chronic congestive heart failure and dementia.
A nursing note dated [DATE] at 8:15 A.M. indicated at 7:55 A.M. Resident #81 was blue and had white froth at the left corner of his mouth. Cardiopulmonary Resuscitation (CPR) was initiated and Resident #81 was suctioned. CPR continued until paramedics arrived and took over CPR. Resident #81 was sent to the emergency room.
A dietary note dated [DATE] at 4:06 P.M. indicated Resident #81 was expected to return.
A nursing note dated [DATE] at 5:45 P.M. indicated Resident #81's son reported Resident #81 expired at the hospital. There was no evidence of a written notification of the reason for the transfer/discharge notice being provided at the time of the resident's transfer/discharge.
On [DATE] at 1:15 P.M. [NAME] President (VP) of Clinical Operations #500 verified neither Resident #81 or his responsible party received a transfer/discharge notice when the resident was sent to the hospital on [DATE].
Review of the facility policy titled, Notice of Transfer or Discharge (revised in 2022) revealed a notification would be sent to a resident being transferred or discharged from the nursing facility, including if an immediate transfer or discharge was required based on the resident's urgent medical needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to provide residents or resident representatives a written notice of the bed hold policy. This affected two residents (#45 and #81) of 24 residents interviewed/reviewed for hospitalization.
Findings include:
1. Review of Resident #45's medical record revealed diagnoses including chronic obstructive pulmonary disease, heart failure, chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and malignant neoplasm of the urethra (a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body).
A nursing note dated [DATE] at 10:41 A.M. indicated the Urology Department at Veterans Affairs was notified Resident #45's left urostomy drain was leaking at the site on his back and of low drainage output was noted in the bag. The Urology Department was also notified of Resident #45 having blood from his penis. Resident #45 had an appointment with nephrology the next day at 11:30 A.M.
A nursing note dated [DATE] at 1:44 P.M. indicated the nephrology department called the facility and requested Resident #45 be sent to the Emergency Department. Resident #45 was agreeable with the transfer.
A nursing note dated [DATE] at 2:45 P.M. indicated Resident #45 left the facility via the facility's van en route to the emergency room for evaluation and treatment. There was no evidence of a bed hold notice being provided.
A nursing note dated [DATE] at 9:17 P.M. indicated Resident #45 was admitted to the hospital with a diagnosis of mechanical complications of the nephrostomy catheter.
On [DATE] at 1:15 P.M. [NAME] President (VP) of Clinical Operations #500 verified Resident #45 received no bed hold notification when he was sent to the hospital [DATE].
2. Review of Resident #81's medical record revealed diagnoses including multiple sclerosis, chronic obstructive pulmonary disease, type two diabetes mellitus, heart disease, anemia, chronic congestive heart failure, and dementia.
A nursing note dated [DATE] at 8:15 A.M. indicated at 7:55 A.M. Resident #81 was blue and had white froth at the left corner of his mouth. Cardiopulmonary Resuscitation (CPR) was initiated and Resident #81 was suctioned. CPR continued until paramedics arrived and took over CPR. Resident #81 was sent to the emergency room.
A dietary note dated [DATE] at 4:06 P.M. indicated Resident #81 was expected to return.
A nursing note dated [DATE] at 5:45 P.M. indicated Resident #81's son reported Resident #81 expired at the hospital. There was no evidence of a written notification of the bed hold policy.
On [DATE] at 1:15 P.M. [NAME] President (VP) of Clinical Operations #500 verified neither Resident #81 or his responsible party received a bed hold when the resident was sent to the hospital [DATE].
Review of the facility Bed Hold Notice Upon Transfer policy (implemented [DATE]) revealed in the event of an emergency transfer of a resident, the facility would provide a written notice of the facility's bed hold policies within 24 hours. The facility would keep a signed and dated copy of the bed hold notice information given to the resident and/or resident representative in the resident's file.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #17 was invited to attend a quarterly care conference to be a part of the care planning process. This affected one resident (#17) of one resident reviewed for participation in care planning.
Findings include:
A review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE]. Resident #17 had diagnoses including bilateral below the knee amputations, emphysema, mild intellectual disability, schizophrenia, chronic obstructive pulmonary disease and the need for assistance with personal care.
A review of Resident #17's Minimum Data Set (MDS) 3.0 assessments revealed she had a significant change MDS assessment completed on 01/28/22. The prior MDS assessment was a quarterly MDS completed on 01/12/22. The significant change MDS indicated the resident had no communication issues and was cognitively intact. The resident was not known to have displayed any behaviors or reject care during that seven day assessment period. The assessment revealed the resident required an extensive assist of one to two staff for most of her activities of daily living.
A review of Resident #17's care plans revealed the resident was admitted for short term placement for rehabilitation. The resident wanted to be discharged to a group home or an assisted living facility.
Resident #17's electronic health record was absent for any documented evidence of care planning conferences being held for the resident. The facility provided paper care conference attendance records that had been held for the resident in the past 12 months. The facility indicated the resident's brother did not participate in meetings that were scheduled for September 2021 or April 2022. The care conference attendance records for 06/10/21 and 01/12/22 revealed the resident's brother attended both of those meetings via phone. The resident was not indicated to have attended either meeting held or part of the two meetings scheduled in September 2021 and April 2022, when the brother did not participate.
On 05/02/22 at 11:49 A.M. an interview with Resident #17 revealed she had not been invited to attend any of her care planning conferences. The resident revealed she was not aware of there being any meetings held on her behalf to discuss her care planning goals.
On 05/03/22 at 2:29 P.M. an interview with Registered Nurse (RN) #358 revealed care conferences were completed upon admission, quarterly and whenever the family requested to have one. RN #358 revealed care planning conferences were scheduled around the time of the resident's MDS assessments. The facility sent out a letter to the family and asked them to RSVP if they wanted to attend. She stated, if the resident's family did not respond, they still met to review the resident's care plans. The residents were invited to come, if they were cognitively intact. The care planning conferences were documented on a care conference attendance record and uploaded into the computer to be a part of the resident's electronic health record.
On 05/03/22 at 2:44 P.M. a follow up interview with RN #358 revealed the care conference attendance records for September 2021 and April 2022 were the only two they had documented evidence of care planning conferences being held for Resident #17. RN #358 confirmed the resident's brother did not attend the care planning conferences scheduled in September 2021 or April 2022. She reported they still reviewed the resident's care plans on that date. She denied they had any documented evidence of Resident #17 being invited to attend any of the care conferences held on her behalf. She acknowledged the resident reported she had not been invited to attend any of her care conferences, in which they had no documentation to show otherwise.
A review of the facility policy on Participation In Care Conference, revised 2021 revealed the purpose of the policy was to provide interdisciplinary communication with the resident and/or legal representative for purposes for review and further development of an individualized comprehensive plan of care. Care conferences for long term care residents shall occur on a regular basis (i.e., initial, quarterly, annual, significant change in status, and as needed). A letter informing the resident and/or their responsible party shall be provided two weeks in advance of the scheduled conference. The resident and/or resident representative would sign the attendance sheet to indicate attending of meeting. If the care conference was held via phone or zoom, facility representative would log all participants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of physician standing orders and interview the facility failed to recheck Resident 23's blood glucose level after an initial blood sugar check was below 65 milligrams/ deciliter (mg/dl). This affected one resident (#23) of five residents reviewed for unnecessary medication use.
Findings include:
Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis that included adult onset diabetes mellitus.
A review of Resident #23's physician's orders revealed an order to receive Lantus (long acting insulin) 19 units subcutaneously in the afternoon and 15 units at bedtime. The resident also had an order to receive Humalog (fast acting insulin) before meals and at bedtime as per sliding scale. The sliding scale included a formula to use dividing the blood sugar by 30 and then subtract 3 units.
A review of Resident #23's medication administration record (MAR) for April 2022 revealed the resident's blood sugar was recorded as being 57 mg/dl at 5:00 A.M. on 04/23/22, 04/29/22 and 04/30/22. (Normal blood sugar levels between 70-110 mg/dl). The MAR did not provide documented evidence of the resident's blood glucose levels being rechecked after her blood sugar levels were found to be low on those days.
A review of Resident #23's nursing progress notes revealed no documented evidence of the resident's blood glucose level being rechecked an hour after they were found to be low on 04/23/22, 04/29/22 and 04/30/22. The progress notes indicated the resident was provided a snack on two of those days but did not document the resident's low blood sugar was followed up/re-checked to ensure it came up after a snack was given.
A review of the physician's standing orders for hypoglycemia revealed if a resident's blood glucose level was below 65 mg/dl, the resident was to be given a house supplement orally, if able to consume. Staff were then to recheck the blood glucose level in one hour. If the blood glucose level remained low or the resident had adverse symptoms, staff were to then notify the physician.
On 05/04/22 at 9:41 A.M. an interview with Registered Nurse (RN) #379 revealed Resident #23's blood sugars were known to fluctuate between being low and being high. RN #379 revealed the resident was not always compliant with her diet and the family was known to bring her in snacks. That was when her blood sugars tended to go up. RN #379 revealed if a blood sugar was less than 50 mg/dl staff would give (the medication) Glucagon. If the blood sugar was between 50 and 60 mg/dl, staff gave a snack with sugar and re-checked the blood sugar in 15 minutes. The repeat blood glucose levels would be documented in the progress notes and show up under the electronic medication administration record (eMAR) progress notes.
On 05/04/22 at 10:10 A.M. an interview with the Director of Nursing (DON) confirmed, per their hypoglycemia standing orders, the nurse was to recheck a residents blood sugar an hour after a supplement had been given for a blood glucose level less than 65 mg/dl. The DON also confirmed if the blood glucose level remained low, after the supplement was given, the nurse would then have to notify the physician of the low blood sugar. The DON was unable to find documented evidence of Resident #23's blood sugar being re-checked on 04/23/22, 04/29/22 or 04/30/22, when the blood sugar was noted to be 57 mg/dl and a supplement had to be given.

Based on record review, facility policy and procedure review and interview the facility failed to complete accurate assessments and failed to update the physician regarding failure to heal and/or decline in a pressure ulcer for Resident #72 to determine if a change in treatment was indicated. This affected one resident (#72) of one resident reviewed for pressure ulcers.
Findings include:
Review of Resident #72's medical record revealed an admission date of 03/29/22. Resident #72 had diagnoses including generalized muscle weakness, obesity, chronic congestive heart failure, chronic atrial fibrillation, post-surgical malabsorption and iron deficiency anemia.
A wound assessment, dated 03/29/22 (admission) indicated Resident #72 had a pressure ulcer on the right heel which was assessed as a suspected deep tissue injury (SDTI) (a persistent non-blanchable deep red, maroon or purple discoloration). The wound bed had 100% necrosis (dead tissue). The ulcer measured three centimeters (cm) in length by three cm width with no depth noted. The physician was notified of the SDTI. Skin prep was applied to the heel and heel guards were applied.
A baseline care plan dated 03/29/22 indicated interventions to address skin impairment included observing/documenting the location, size and treatment. Report abnormalities, failure to heal, and signs of infection to the physician.
A wound assessment, dated 03/31/22 revealed Resident #72 had a SDTI caused by pressure to the right heel. The assessment also indicated the ulcer was a Stage I (non-blanchable erythema of intact skin) on admission and was a Stage I at the time of the assessment. The instructions on the form indicated not to down-stage as a wound healed. The assessment indicated the overall impression was unchanged but did not indicate the presence of necrotic tissue. Measurements remained three cm by three cm with no depth. The treatment remained the same.
A comprehensive care plan, created 04/07/22 indicated Resident #72 had impaired skin integrity related to a suspected deep tissue pressure ulcer to the right heel. Interventions included measuring the area every week. Record the size, color, presence and characteristics of drainage. Observe for signs of improvement or decline in healing. Consult with the physician as needed regarding improvement or decline in condition, effectiveness of treatment and/or need for treatment order change. Monitor/document location, size and treatment. Report abnormalities, failure to heal and signs of infection to the physician.
A wound assessment, dated 04/07/22 indicated the physician and family/power of attorney (POA) were last updated about the condition of the SDTI on 03/29/22. Although the assessment indicated the ulcer was a SDTI present on admission it continued to indicate it was a Stage I ulcer originally and at the time of the assessment. The assessment indicated the SDTI was unchanged. No necrosis was documented. Wound measurements continued to be recorded as three cm by three cm with no depth. The treatment remained the same.
A wound assessment, dated 04/14/22 indicated the physician and family were last updated about the wound on 03/29/22. The assessment continued to indicate the right heel present on admission was SDTI but indicated the original and current stage was listed as Stage I. The assessment indicated the overall impression was that the SDTI was worsening. The wound bed was documented as 100% necrosis. The wound continued to be measured as three cm by three cm with no depth. The treatment remained the same. Documentation indicated the area appeared darker in color.
A wound assessment, dated 04/21/22 indicated the family and physician were last updated about the SDTI on 03/29/22. The assessment continued to indicate there was a SDTI to the right heel with the original and current stage listed as a Stage I. The assessment indicated the SDTI was unchanged. The wound bed was described as 95% necrosis, 5% necrosis. The wound was measured as three cm by three cm with no depth. Another area of the assessment indicated there was a small area that looked like healthy tissue. Some of the heel had hardened. The back of the heel was still soft to touch.
A wound assessment, dated 04/28/22 indicated the family and physician were last updated 03/29/22. The assessment continued to indicate the ulcer was a SDTI but pressure ulcer stage was listed as (Stage) I. The assessment indicated the SDTI was improving. The wound bed was described as 95% necrosis and 5% epithelial.
On 05/04/22 at 7:45 A.M. interview with Licensed Practical Nurse (LPN) #382 revealed the SDTI never really deteriorated.
On 05/04/22 at 11:54 A.M. interview with LPN #382 revealed the SDTI was necrotic since admission even though she did not note it on all assessments. LPN #382 verified with the necrotic tissue she was unable to know for sure the depth of the wound but stated she was taught to record the depth as 0. LPN #382 verified although the assessments from 03/29/22 to 04/21/22 indicated the ulcer was either unchanged or deteriorated she did not notify the physician during that time frame to determine if a treatment change was indicated. LPN #382 revealed after reviewing the assessments, she should have indicated the wound remained unchanged on 04/14/22 as the area had always been necrotic (although it was not indicated on the prior week assessment). LPN #382 revealed the assessment on 04/21/22 which indicated the wound was 95% necrosis, 5% necrosis was incorrect as it was 95% necrosis and 5% epithelial which would have been an improvement instead of being unchanged. LPN #382 revealed she did not know why any of the assessments indicated the ulcer was a Stage I as it had never been a Stage I.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure fall interventions were in place for Resident #70, who had a history of falls to decrease the risk of additional falls. This affected one resident (#70) of two residents reviewed for falls.
Findings include:
Review of the medical record revealed Resident #70 was admitted to the facility on [DATE]. Resident #70 had diagnoses including edema, history of transient ischemic attack, cerebral infarction, protein-calorie malnutrition, cognitive communication deficit, polymyalgia rheumatica, bladder cancer, dementia, anxiety disorder, schizoaffective disorder and Alzheimer's disease.
Review of the May 2022 physician's orders revealed Resident #70 had an order (dated 03/16/22) to wear gripper socks when she was not wearing her shoes.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/22 revealed Resident #70 had severely impaired cognition and required extensive assistance of two staff members for transfers. Further review of the assessment revealed the resident had two or three falls with no injuries since her admission.
On 05/04/22 at 8:25 A.M. and 9:09 A.M. Resident #70 was observed without any type of shoe or gripper sock to her left foot. The resident had a dressing in place to her right foot at the time of both observations.
On 05/04/22 at 9:09 A.M. interview with Registered Nurse (RN) #379 revealed Resident #70 was ordered to have gripper socks on when not wearing shoes. At the time of the interview, observation of Resident #70 with RN #379 verified the resident was not wearing shoes or gripper socks as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #73 and Resident #32 had periodic care conferences in which either the resident and/or their responsible party were included with a comprehensive interdisciplinary team to ensure the residents individual needs were being addressed. This affected two residents (#73 and #32) of two residents reviewed for care conferences.
Findings include:
1. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD) required continuous oxygen and morbid obesity.
Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/18/19 revealed the resident was not interviewable and was totally dependent on staff for activities of daily living (ADL) care.
Review of the medical record revealed the only care conference notes for 2019 were dated 06/20/19 and there was no evidence the facility addressed all the family's concerns. Further review of the care conference revealed there were no direct care staff who participated in the meeting. The staff participating included the MDS Registered Nurse (RN) #315, social service, the activities director, the dietary manager and four family members. The family brought up many concerns.
On 07/17/19 at 1:25 P.M., interview with the resident's family revealed the family visited frequently and attended the care conference meetings when they were held but felt the facility did not address all their concerns including concerns related to the resident's oxygen tank running out of oxygen and no one monitoring the tank and the resident not being changed timely when she was incontinent resulting in developing and not being able to heal pressure ulcers. The family member stated they asked about different pressure relieving devices for her wheelchair but no one would assess this to see about different options. The family had to inform the staff many times the resident's oxygen tank was empty while in use and requested staff to change the resident. The family felt because the resident was a mechanical lift it took to much staff and time to check and change her timely.
On 07/17/19 at 2:57 P.M., interview with RN #315 revealed she ran the meetings and had the computer in the room in case the family had any questions. She verified she did not work the floor nor did she obtain any resident specific information from any direct care staff and verified they were not part of the care plan process. She verified the facility did not address all the family concerns from the 06/20/19 meeting. She verified there were no other care conferences in 2019. A care conference was scheduled on 01/24/19 but was needed to be canceled and then the resident was in the hospital so the first time available was 06/20/19. She was unable to find documentation to address the family's concerns related to oxygen and incontinence care.
2. Record review revealed Resident #32 was admitted to the facility on [DATE] with a diagnosis which included Parkinson's disease.
Review of the quarterly MDS 3.0 assessment, dated 05/18/19 revealed the resident was cognitively intact but needed extensive assistance of one or more staff for ADL care.
Review of the care conferences dated 01/03/19 and 05/16/19 revealed the resident did not attend and there was no evidence the resident was invited to attend. There was no evidence of any direct care staff attending or participating in the conference. The resident's wife attended and had many concerns.
On 07/17/19 at 6:50 P.M., interview with the resident's wife revealed the facility did not always address her concerns.
On 07/18/19 at 9:34 A.M., interview with RN #314 revealed she was the MDS nurse and did not work on the floor but was in charge of the care conferences. She verified there was no evidence the resident, who was alert and oriented, was invited to the care conferences and verified no direct care staff were interviewed or were approached to give input on the residents care needs. She was not aware this was a requirement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #32, who was on Medicaid, was not charged for personal care need items that should be covered under the State Medicaid program. This affected one resident (#32) of one resident reviewed related to paying for personal care items.
Findings include:
Record review revealed Resident #32 was admitted to the facility on [DATE] with a diagnosis including Parkinson's disease.
Review of the signed admission agreement revealed the resident was admitted on Medicaid services which continued throughout his stay.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/18/19 revealed the resident was cognitively intact but needed extensive assistance of one or more staff for activities of daily living.
On 07/17/19 at 6:50 P.M., interview with the resident's wife revealed the resident's non skid socks were old, lost their elasticity and the non skid part was worn down. She stated she asked Licensed Practical Nurse (LPN) #323 if she could get another pair for the resident and was told she would have to pay for them. The wife also revealed she purchased nutritional supplements, adult briefs and other personal care items and snacks for the resident as no one from the facility had informed her these items should be included in the resident's stay and provided by the facility.
On 07/18/19 at 9:07 A.M., interview with LPN #323 revealed she did tell residents, including Resident #32 they would have to pay for any additional pairs of non-skid socks after the initial pair was given.
On 07/18/19 at 10:05 A.M., interview with Admissions Director #355 revealed the Resident #32 was admitted on Medicaid services and continued on Medicaid services and should not be asked to pay for any personal care items because they were covered under Medicaid and should be supplied by the facility.
On 07/18/19 at 10:15 A.M., LPN #323 was observed to tell the Director of Nursing (DON) she thought residents only got one free pair on non-skid socks and had to pay for any additional pairs requested.
On 07/18/19 at 10:19 A.M., interview with the DON verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure an allegation of physical abuse by staff towards Resident #182 was reported immediately as required. This affected one resident (Resident #182) of two residents reviewed for physical abuse.
Findings include:
Review of Resident #182's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses which include dementia and anxiety. The resident passed away on 04/13/19.
Review of the behavior care plan initiated 10/23/18 revealed the resident had behaviors including taking other resident's belongings, yelling at other male residents, thinking they were her husband and being physically abusive towards staff.
Review of the attending physician note, dated 01/14/19 revealed the resident had become increasingly confused and was having more trouble with agitation at night and insomnia.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not interviewable had delusions and the only behavior identified was wandering.
Review of the nurse's notes from 02/10/19 through 02/11/19 revealed on 02/10/19 beginning at 9:27 P.M., the resident was at the nurse's station being verbally inappropriate with staff. Attempts to redirect back to bed were unsuccessful and all interventions ineffective. At 11:40 P.M., the resident continued to be verbally inappropriate with staff, yelling out profanity and entering other resident's rooms while they were sleeping. The resident was combative with staff, redirection, one on one and other interventions were ineffective. On 02/11/19 at 12:15 A.M., the physician was notified and ordered an intramuscular injection of Haldol, an antipsychotic medication used to make you feel less nervous, every six hours as needed for increased agitation. The medication was effective and the resident was sleeping in bed.
Review of the a self reported incident (SRI) submitted to the State agency on 03/28/19 revealed a nurse claimed that another employee, a State Tested Nursing Assistant (STNA) had accused a staff member of mistreatment during medication administration. The SRI revealed the alleged incident occurred on 02/11/19 at 12:35 A.M.; however it was not reported to the facility until 03/28/19.
Review of the Summary of the Incident form revealed an LPN (not named in the SRI) stated an STNA (not named in the SRI) said that a resident was mistreated during a medication administration. When interviewing others present at the facility who witnessed the administration no mistreatment was observed while stating that the staff intervened with the resident in a manner as to make sure the resident was cared for in a compassionate and safe manner. Further review of the investigation revealed there was no other documentation in the medical record related to the allegation.
Review of an interview with Licensed Practical Nurse (LPN) #376 revealed former STNA #500 informed her awhile ago but she could not recall when that an STNA and nurse held down Resident #182 in a chair to give her multiple injections of a medication.
On 07/23/19 at 10:15 A.M., interview with the Director of Nursing (DON) and Administrator verified LPN #376 did not immediately report an allegation of physical abuse according to the facility policy and State mandates.
Review of the Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy, revised 11/28/16, revealed facility staff should immediately report all allegations of abuse, neglect, exploitation, mistreatment of a resident tor misappropriation of resident property including inquiries of unknown source to the Administrator and to the Ohio Department of Health in accordance with the procedures in this policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #77 was admitted to the facility on [DATE] with a diagnoses including mood disorder, schizophrenia, dementia with behavioral disturbance, other symptoms and signs involving cognitive functions and awareness, anxiety, and depression.
Review of the Pre-admission Screening and Resident Review (PASRR) dated 08/03/13 (completed after a psychiatric stay) revealed it was determined the resident meet PASRR assessment requirements. The review revealed the resident had diagnoses of dementia with behavioral disturbance, schizophrenia, and psychotic disorder.
Review of Resident #77's MDS 3.0 assessment, dated 04/17/19 and 06/17/19 revealed the resident was not considered by the State level II PASRR process to have a serious mental illness.
Interview on 07/18/19 at 12:03 P.M., with Registered Nurse (RN) #315 verified the MDS 3.0 assessment, dated 04/17/19 and 06/17/19 were coded inaccurately related to PASRR/serious mental illness. She reported she would modify the MDS.
Review of the policy titled MDS 3.0 Process dated 08/29/16 revealed the initial and periodic comprehensive assessments were to be accurate and a standardized reproducible assessment of each residents functional capacity. The individual's signature who completed a portion of the assessment certify the accuracy of the assessment.
3. Record review revealed Resident #73 was admitted to the facility on [DATE] with a diagnoses which included chronic obstructive pulmonary disease.
Review of the nursing evaluation dated 06/16/19 revealed the resident had one Stage I pressure ulcers and two Stage II pressure ulcers.
Review of the annual MDS 3.0 assessment dated [DATE] revealed the resident had two Stage I pressure ulcers and one Stage II pressure ulcers.
On 07/22/19 at 1:05 P.M., interview with RN #420 verified the the MDS was incorrect related to the resident's pressure ulcers.
Review of the policy titled MDS 3.0 Process dated 08/29/16 revealed the initial and periodic comprehensive assessments were to be accurate and a standardized reproducible assessment of each residents functional capacity. The individual's signature who completed a portion of the assessment certify the accuracy of the assessment.
Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate. This affected three residents (#34, #73 and #77) of 30 residents reviewed for MDS 3.0 assessments.
Findings include:
1. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with a diagnosis including unspecified dementia without behavioral disturbance.
Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #34 was occasionally incontinent of bladder. Review of the MDS assessment look-back period, dated 05/15/19 through 05/21/19 revealed Resident #34 was incontinent of urine on 10 occasions.
On 07/17/19 at 4:30 P.M., interview with MDS Supervisor #383 revealed occasionally incontinent was defined as having less than seven episodes of incontinence and frequently incontinent was defined as having seven or more episodes of urinary incontinence, but at least one episode of continent voiding during the assessment period. MDS Supervisor #383 verified Resident #34's MDS assessment was inaccurate and should have been coded as being frequently incontinent of urine.
Review of the policy titled MDS 3.0 Process dated 08/29/16 revealed the initial and periodic comprehensive assessments were to be accurate and a standardized reproducible assessment of each residents functional capacity. The individual's signature who completed a portion of the assessment certify the accuracy of the assessment.
Review of the policy titled Bowel and Bladder Continence Care Management dated March 2017 revealed occasionally incontinent was less than seven episodes of bladder incontinence during the seven day look back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to incorporate the recommendations from the Pre-admission Screening and Review (PASRR) level II determination and the PASRR evaluation report into Resident #77's care to ensure the resident received adequate mental health services. This affected one resident (#77) of two residents reviewed for PASRR.
Findings include:
Record review revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including mood disorder, schizophrenia, dementia with behavioral disturbance, other symptoms and signs involving cognitive functions and awareness, anxiety, and depression. The resident's two brothers were listed as the emergency contact. There was no evidence the resident had a legal guardian/conservator. There was no evidence the resident was receiving any type of mental health counseling or ongoing medication review by a psychiatrist.
Review of PASRR documentation, dated 08/03/13 (completed after a psychiatric stay) revealed it was determined the resident meet PASRR assessment requirements and the following decisions had been made by the Ohio Mental Health and Addiction Services due to the residents diagnoses of dementia with behavioral disturbance, schizophrenia, and psychotic disorder:
The nursing facility was to provide occupational therapy, mental health counseling, ongoing medication review by a psychiatrist, ongoing medications review by a physician, behavior management, and guardian/conservator. The rationale for the recommendation revealed the resident would benefit if a guardian/conservator was appointed for decision making regarding health and safety and family involvement. A behaviorally-based treatment plan was recommended to reduce negative behaviors, ongoing evaluation of the effectiveness of current psychotropic mediation on target symptoms and ongoing medication review by a physician.
The resident would benefit from ongoing medication review by psychiatrist to insure his behavioral medication are managing his symptoms and by a physician to insure his medical medication are managing his medical symptoms.
Review of Resident #77's current plan of care for PASRR revealed an intervention to refer to the PASRR. There were no resident specific interventions developed or identified.
Review of Resident #77's Minimum Data Set (MDS) 3.0 assessments, dated 04/17/19 and 06/17/19 revealed the assessment inaccurately documented the resident was not considered by the State level II PASRR process to have a serious mental illness.
Interview on 07/17/19 at 10:56 A.M., with the Director of Nursing (DON) confirmed the resident was not receiving mental health counseling, ongoing medications review by a psychiatrist, and he did not have a court appointed guardian/conservator per the PASRR recommendations dated 08/03/13.
Interview on 07/17/19 at 11:21 A.M., with Registered Nurse (RN) #372 revealed the resident currently had verbally sexual behaviors. The RN stated in the past he had both verbal and physical sexual behaviors.
Interview on 07/18/19 at 12:03 P.M., with RN #315 verified the MDS 3.0 assessment, dated 04/17/19 and 06/17/19 were coded inaccurately to reflect PASRR/serious mental illness. She indicated the MDS would need modified and the resident's plan of care would need to be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure preadmission screening and resident review (PASRR) documentation was completed accurately to reflect Resident #53's serious mental illness. This affected one resident (#53) of two residents reviewed for PASRR.
Findings include:
Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnosis including psychosis not due to substance or known physiological condition and major depression. The resident had a previous short stay in 02/2018 that included the same diagnoses.
Review of Resident #53's PASRR dated 12/31/18 revealed the resident had no mental disorders.
Review of Resident #53's admission Minimum Data Set (MDS) 3.0 assessment, dated 01/12/19 revealed the resident was not currently considered by the State Level II PASRR (preadmission screening and resident review) process as had no serious mental illness identified.
Review of Resident #53's physician's orders, dated 01/24/19 to present revealed the resident was ordered Risperdal 0.5 milligrams (mg) twice daily for psychosis and Lexapro 20 mg daily for depression.
Review of Resident #53's plan of care revealed to follow PASRR recommendation. However, there were no evidence of resident specific interventions. Further review plan of care revealed the resident was at risk for drug related complications related to psychotropic medication use of antidepressant, antipsychotic for depression and psychosis.
Review of verification of diagnoses letter from Resident #53's physician dated 07/16/19 revealed the resident had been on Risperdal for greater than eight years for bipolar two disorder and psychosis. The resident had been treated by mental health care in the past.
Interview on 07/16/19 at 1:06 P.M., and 3:13 P.M., with the Director of Nursing (DON) verified the PASRR dated 12/31/18 was inaccurately completed and did not reflect the resident's mental disorders/diagnoses. The DON confirmed the resident had a history of psychosis that was noted from a previous stay in 2018. She called the physician's office on this date to clarify the psychosis diagnosis since it was not listed on the physician progress notes or in the hospital records. The physician's office reported the resident had a diagnosis of bipolar disorder in addition to psychosis and had received treatment from a mental health facility. The resident had been on medication for these disorders for over eight years. The DON verified the facility was not aware of the bipolar diagnosis until this date. The DON reported the hospital completed the PASRR, however it the PASRR documents were reviewed by the admission clerk and herself. She confirmed the facility should have verified the diagnosis and resubmitted a new PASRR to reflect the resident serious mental illnesses.
Review of PASRR policy and procedures 12/06/18 revealed the facility would ensure all new admissions were appropriately screened prior to admission to determine if the individual required nursing facility level of care and to identify any specialized services that may be necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure comprehensive and individualized restorative programs, including programs for ambulation, toileting and/or range of motion were developed and implemented to meet the needs of Resident #32, #34 and #54. This affected three residents (#32, #34 and #54) of five residents reviewed for restorative services.
Actual Harm occurred when the facility failed to consistently implement restorative ambulation, range of motion and toileting programs for Resident #32 resulting in a significant decline in ambulation status. Between 01/28/19 and 03/08/19 the resident's ambulation ability declined from being ambulatory with a walker to non-ambulatory. The resident currently required extensive assistance from two staff for ambulation.
Findings include:
1. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, multi-system degeneration of the autonomic nervous system, orthostatic hypotension, benign prosthetic hypertrophy and overactive bladder.
Review of the residents falls from 01/01/19 through 07/15/19 revealed the resident had 13 falls related to attempting to toilet himself.
Review of the current care plan revealed there was no evidence the resident was on a restorative toileting program or a range of motion program. The current care plan revealed the resident was on a restorative ambulation program which was to be provided four times a day seven days a week.
Review of the Physical Therapy (PT) evaluation and treatment plan dated 01/12/19 revealed the resident was able to ambulate 200 feet with a walker. Further review of the Discharge summary dated [DATE] revealed the resident was able to ambulate an unlimited distance with the walker. The discharge summary recommended restorative ambulation and active ROM to maintain current level of performance and prevent decline.
Review of the restorative program note dated 01/28/19 revealed the resident was on restorative ambulation with the walker daily for 15 minutes and restorative toileting program to offer toileting at 7:00 A.M., 9:00 A.M., 11:00 A.M., 1:00 P.M., 3:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M., 3:30 A.M. and as needed for fall prevention despite having no assessments to evaluate the programs.
Review of the PT evaluation and treatment plan dated 03/08/19 revealed the resident was referred back to therapy because the resident was not able to ambulate at this time. Further review of the Discharge summary dated [DATE] revealed the resident was able to ambulate 250 feet with walker. The discharge summary recommended restorative ambulation and active ROM to maintain current level and prevent decline.
Review of the restorative participation grids for May 2019 revealed the resident was encouraged to ambulate four times a day yet there was only one entry available for each day. The resident was ambulated only 11 days for the month and only one time each of the 11 days.
Review of the restorative toileting grid revealed to offer toileting at 7:00 A.M., 8:30 A.M., 10:00 A.M., 11:00 A.M., 1:30 P.M., 3:00 P.M., 4:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M., 3:30 A.M. and as needed for fall prevention. The grids did not indicate the resident was on a ROM program. Further review of the State Tested Nurse Aid (STNA) documentation revealed the resident infrequently was able to walk in him room with assistance.
Review of the restorative program note dated 05/02/19 revealed the resident continued on the ambulation program with unlimited distance with the walker daily and the toileting programs at scheduled times. This was not accurate and there were no assessments completed and there was no documentation the resident was able to walk an unlimited distance.
Review of the Occupational Therapy (OT) evaluation and treatment plan on 05/16/19 revealed the resident needed maximum assistance for toileting. On 06/16/19 unable to test the resident's ability to transfer to the toilet due to safety concerns with his blood pressure dropping.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/18/19 revealed he was cognitively intact but needed extensive assistance of one or more staff for activities of daily living (ADL). He needed extensive assistance of one person to walk in his room. He was frequently incontinent of bladder and continent of bowel. The assessment revealed he received restorative services for ambulation one day, dressing six days and eating seven days (did not indicate toileting of ROM).
Review of the physician's order dated 05/23/19 revealed the resident was to be walked four times a day as tolerated.
Review of the restorative participation grids for the month of June 2019 revealed the resident was encouraged to ambulate four times a day. Staff had the ability to enter two entries a day. The resident ambulated nine days and only once for each of the nine days for the month. Review of the restorative toileting grid revealed offer toileting at 7:00 A.M., 8:30 A.M., 10:00 A.M., 11:00 A.M., 1:30 P.M., 3:00 P.M., 4:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M., 3:30 A.M. and as needed for fall prevention. The grids did not indicate the resident was on a ROM program. Further review of the STNA documentation revealed the resident infrequently was able to walk in him room with assistance.
Review of the 06/10/19 restorative program note revealed the resident was tolerated the toileting program well with goals met and no decline. Continue to offer ambulation program daily but resident ambulates in his room and to and from the bathroom.
Review of the OT progress note dated 06/21/19 revealed OT staff were not able to test the residents ability to transfer to the toilet due to safety concerns with his dropping blood pressure. Further review of the Discharge summary dated [DATE] reveled the resident demonstrated a medical decline and decreased safety awareness to self with attempting to get up on his own. The resident needed the assistance of two staff at all times for ADL's and mobility. Restorative ROM (which was not implemented) was recommended.
Review of the restorative participation grids for July 2019 revealed the resident was encouraged to ambulate four times a day. Staff had the ability to document two entries a day. The resident was ambulated twice on 07/02/19 and once on 07/07/19 but no other times during the month. Review of the restorative toileting grid revealed offer toileting at 7:00 A.M., 8:30 A.M., 10:00 A.M., 11:00 A.M., 1:30 P.M., 3:00 P.M., 4:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M., 3:30 A.M. and as needed for fall prevention. The grids did not indicate the resident was on a ROM program. Further review of the STNA documentation revealed the resident infrequently was able to walk in him room with assistance.
Review of the 07/16/19 restorative program note revealed the resident was tolerating the toileting program well with no changes. The resident met his 15 minute daily ambulation program and no decline in ambulation was noted. There was no acknowledgement of the previous therapy recommendations for ROM programs to be implemented.
On 07/15/19 at 11:00 A.M., interview with the resident revealed he used to be in a walking program but no one had offered to walk him in a while. The resident stated it had been months since he was consistently walked with staff and recently he kept falling when trying to ambulate himself to the toilet because he was not getting enough exercise.
On 07/16/19 at 3:50 P.M., interview with State tested nursing assistant (STNA) #375 revealed there were not enough staff to walk all the residents who needed it. The floor staff were responsible for completing the restorative programs. She verified the resident was not walked and was usually not taken to the toilet but handed the urinal when he asked to use the restroom. She tried to check the resident three times on her shift but at no set times. She verified she did not complete any ROM with the resident.
On 07/16/19 at 4:15 P.M., interview with STNA #414 revealed the resident had an increase in incontinence the last couple of months and needed more help. The resident had a urinal he used but needed assistance with using it. The STNA stated time did not always permit to get the restorative programs completed. He was not aware the resident was on a restorative ambulation, toileting or ROM programs.
On 07/17/19 at 11:29 A.M., when walking past the resident's room he was observed moaning out and he requested assistance with activating the call light because it was not within his reach. The resident indicated he needed to use the restroom. At 11:31 A.M., STNA # 317 entered the resident's room and handed him the urinal and did not even ask if he wanted to go to the restroom. This was verified by STNA #317 at the time of the observation.
On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed staff were supposed to take the resident to the toilet but he needed at least two staff to assist to the toilet and at times he passed out so staff would give him a urinal if he requested to urinate and required him to have bowel movements in his adult brief if he couldn't hold it. The STNA stated the resident was not on any toileting programs and staff just responded to him when he used his call light for assistance. The STNA stated the resident was on a restorative ambulation program which was supposed to be done once on each shift but they did not have time to do it. She was not aware the resident was to be on a restorative ROM program.
On 07/17/19 at 11:40 A.M., interview with STNA #330 verified the resident was supposed to be walked for restorative programming on each shift but stated he had not been able to complete it due to time constraints. She was not sure if the resident was on any other restorative programs.
On 07/17/19 at 1:56 P.M. interview with STNA #395 revealed she knew Resident #32 was on a restorative ambulation program but could not say the last time she walked the resident but it had been awhile because there was not enough time to complete the program and the resident needed two staff while walking. She was not aware of the resident being on any other restorative programs. She stated the resident used the urinal and they tried to take him to the toilet for a bowel movement but he wore an adult brief just in case.
On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed she was in charge of the restorative programs and she wrote the program notes. The assessments completed consisted of talking to staff, reviewing sections G, H and J of the five day initial MDS, review of the therapy referral sheets and the tasks section of the computer where the STNA staff input their assignments. When asked if she evaluated for the effectiveness of the programs she was not able to answer and stated frequently restorative toileting was implemented as a fall intervention but she was not part of the fall team, they just told her what times to add to the plan. She verified this description was not what a restorative program was designed to be as it was supposed to assist the resident to restore as much function as possible. She verified the task section did not indicate each time the resident was toileted but the documentation was entered once per shift, which prevented her from getting an accurate reflection of the resident's continence status or progress or decline in the program. She verified there were no assessments competed in an attempt to ensure the residents' did not have a decline and the current programs remained appropriate. She revealed she only implemented up to two programs per resident even if skilled therapy recommended more because staff were not able to spend an hour a day completing restorative programs. She verified the inconsistencies with her notes, the STNA grids and the therapy notes and recommendations as noted above.
On 07/17/19 at 6:50 P.M., interview with the resident and his wife revealed she visited daily and he had not been walked in months nor had he been taken to the toilet regularly as he was supposed to be to keep his strength up. She stated he had episodes of black outs due to low blood pressure and needed two staff to assist him with ambulation and toileting and the STNA staff did not want to walk him in case he blacked out so they provided him with a urinal and he wore adult briefs for bowel movements (BM) accidents. She stated he also needed assistance with the urinal because of his shaking.
On 07/18/19 at 2:20 P.M., interview with physical therapist assistant (PTA) #501 revealed Resident #32 had been on physical therapy (PT) for ambulation off and on to keep him as independent with his ambulation as possible. The resident had a lot of falls related to attempts to take himself to the toilet and they wanted him to stay strong enough to do this safely. She verified with the last two PT discharges reviewed the resident was referred to restorative for ambulation. She verified the resident had a decline in ambulation and when he was evaluated most recently he was not able to ambulate even though he had been ambulatory at the time of discharge (250 feet). She did not know if the resident was receiving the restorative ambulation program as recommended.
2. Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included cerebral vascular accident (CVA) with left sided hemiplegia.
Review of the current list of residents receiving restorative services did not indicate the resident was receiving restorative services for transfers but indicated she was getting services for ROM.
Review of the therapy screen dated 12/20/18 revealed the resident presented with a decline in commode transfers according to the nursing staff. Further review of the OT evaluation and treatment plan dated 12/20/18 revealed the resident had a new onset of decrease in strength, functional mobility, transfers and increased need for assistance. The resident was totally dependent, with attempts to initiate, for toileting.
Review of the Discharge summary dated [DATE] revealed to continue on restorative program for commode transfers with assist of two staff.
Review of the restorative program note dated 05/1/19 revealed the resident was on passive ROM for bilateral upper and lower extremities and transfers with two staff to encourage to stand for 30 seconds daily. The note indicated the resident had met her goals and no decline was noted despite no evidence of any restorative assessments being completed from 01/2019 through 05/2019. Further review of the May 2019 STNA documentation revealed the staff documented the resident was receiving ROM services daily but was not receiving the transfer program regularly.
Review of the quarterly MDS 3.0 assessment, dated 06/10/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for ADL care. The resident received restorative therapy for transfers five of the seven days reviewed and no ROM.
Review of the 06/10/19 restorative program note revealed the restorative programs were tolerated, goals were met and no decline was noted despite no assessments being completed. Further review of the June 2019 STNA documentation revealed the resident was receiving the ROM services daily but was not receiving the transfer program regularly.
On 07/15/19 at 12:10 P.M., interview with the resident's husband, who visited daily for the majority of the day, revealed the resident was not receiving restorative ROM or transfer services to include standing for at least 30 seconds a day. He stated at times the resident was taken to the toilet and other times she was provided incontinence care in bed.
On 07/15/19 at 12:11 P.M., 2:59 P.M., 4:23 P.M. and 5:38 P.M., the resident was observed in her room with her husband and without any staff.
Review of the 07/16/19 restorative program note revealed the programs were tolerated, goals were met and no decline was noted despite no assessments being completed. Further review of the July 2019 STNA documentation revealed the resident was receiving the ROM services daily but was not receiving the transfer program regularly.
On 07/16/19 at 9:40 A.M., 3:00 P.M. and 3:49 P.M., the resident was observed in her room with her husband and without any staff.
On 07/17/19 at 10:43 A.M. and 11:34 A.M., the resident was observed in her room with her husband and without any staff.
On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed she was not aware of the resident being on any restorative programs and the STNA floor staff were responsible for completing any planned restorative programs because the facility did not have separate restorative STNA's despite staff signing off on the restorative participation grids indicating services were completed.
On 07/17/19 at 12:55 P.M. and 3:45 P.M., the resident was observed in her room with her husband and without any staff.
On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed she was in charge of the restorative programs and she wrote the program notes. The assessments completed consisted of talking to staff, reviewing sections G, H and J of the five day initial MDS, review of the therapy referral sheets and the tasks section of the computer where the STNA staff input their assignments. When asked if she evaluated for the effectiveness of the programs she was not able to answer and stated frequently restorative toileting was implemented as a fall intervention but she was not part of the fall team, they just told her what times to add to the plan. She verified this description was not what a restorative program was designed to be as it was supposed to assist the resident to restore as much function as possible. She verified the task section did not indicate each time the resident was toileted but the documentation was entered once per shift, which prevented her from getting an accurate reflection of the resident's continence status or progress or decline in the program. She verified there were no assessments competed in an attempt to ensure the residents' did not have a decline and the current programs remained appropriate. She revealed she only implemented up to two programs per resident even if skilled therapy recommended more because staff were not able to spend an hour a day completing restorative programs. She verified the inconsistencies with her notes, the STNA grids and the therapy notes and recommendations as noted above.
3. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, anxiety and depression.
Review of the Physical Therapy (PT) Discharge summary dated [DATE] revealed Resident #34's baseline on 02/12/19 and status at time of discharge on [DATE] from therapy was as follows:
a. Sit-to-stand baseline was resident required moderate assist and at the time of PT discharge the resident required CGA (contact guard assist).
b. Stand-Pivot Transfers to reduce falls baseline was resident was total dependent with attempts and at the time of PT discharge the resident required maximum assist.
PT Discharge Recommendations included restorative nursing program (RNP) to facilitate patient maintaining current level of performance and to prevent decline. Development of and instructions in active range of motion (AROM) and transfer RNP's were completed with the Interdisciplinary Team. Prognosis to maintain the current level of functioning was excellent with consistent staff support.
Review of the restorative progress note dated 03/13/19 revealed physical therapy was discontinued, encourage ROM added to ADL (activities of daily living) program and encourage resident to maintain gait and weight bear as tolerated during toilet transfers.
Review of the PT evaluation dated 04/30/19 to 06/12/19 recommend RNP including transfers and AROM.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was severely impaired for daily decision-making, required extensive assist with dressing, personal hygiene, and toileting and had received no restorative nursing during the seven day assessment period.
Review of the medical record revealed no evidence of a restorative assessment, methodology, care plan or comprehensive monitoring of the resident's restorative program.
On 07/17/19 at 12:35 P.M., interview with the Director of Nursing (DON) verified there were no restorative evaluations, assessments or data to review for Resident #34.
On 07/17/19 at 1:20 P.M., interview with the DON verified restorative programs were not comprehensive and programs should be provided if needed to restore or maintain the health and well-being of residents.
On 07/17/19 at 3:50 P.M., interview with MDS Supervisor #383 revealed she does not complete a nursing restorative assessment but just uses the therapy discharge recommendations. MDS Supervisor #383 verified the progress notes for restorative programs were not comprehensive, there was no methodology and she only puts a resident on a maximum of two restorative programs because staff would not be able to spend an hour a day completing restorative programs. MDS Supervisor #383 stated she normally won't write a ROM range of motion program because that is done when completing ADL's, she may write a transfer program but mainly ADL and ambulation were the programs she wrote. She stated she does not have evidence the restorative toileting program was evaluated to meet the needs of the resident or to identify patterns of incontinence. She stated Resident #34 had been on the every two hour (q2hr) while awake toileting program and this was mainly to help keep her from falling. The MDS Supervisor verified this was not a program initiated to restore bladder function. She stated there was no pattern to her incontinence and staff do not document every time the resident's toileting program was implemented.
Review of the policy titled Establishment of an Individual Restorative Program, dated October 2016 revealed the facility was to provide restorative nursing programming services to residents based on initial evaluation, referrals and other clinical indicators to maintain and /or improve the residents functional abilities. Residents recommended for restorative programming would be referred to he nurse in charge of restorative programming using the electronic documentation restorative program evaluation and/or progress note. This would be utilized to determine the baseline function to identify the resident's individual restorative needs and determine the appropriateness for a restorative nursing program.
Review of the policy titled Therapy Screens, revised October 2016 revealed residents were routinely screened by the therapy department on a quarterly basis and as needed. Residents were to be monitored by nursing staff for improvement or decline in physical and cognitive functioning. When a decline or improvement was observed this shall be communicated to the therapy department and based on the results of the screen the therapy department shall evaluate, monitor for improvement/decline, recommend restorative programming or recommend functional maintenance programming.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #64, who was dependent on staff for eating received adequate and timely assistance and monitoring with meals and failed to ensure Resident #73 received adequate and timely incontinence care. This affected two residents (#64 and #73) of two dependent residents reviewed for activities of daily living (ADL) care.
Findings include:
1. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances and unspecified psychosis.
Review of the care plan titled Restorative Dining Program, dated 03/09/15 revealed the resident was unable to focus on and complete meals without staff assistance due to cognitive deficits. Interventions included to provide verbal cueing, provide instructions in simple one to two step commands, monitor for coughing or symptoms of aspiration after meals, and monitor for difficulty swallowing, chewing, or pocketing of food during meals.
Review of the Restorative Dining Description, revised 11/03/15 revealed set up for meals, provide cueing, hands on assist and spoon feeding as needed to consume meal. The goal was for the resident to assist with self-feeding and to stay on task.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #64 was severely impaired for daily decision-making, required extensive assist with eating and participated in seven days of restorative eating and/or swallowing.
On 07/15/19 between 12:15 P.M. and 12:28 P.M., observation of the lunch meal revealed Resident #64 was served a hamburger, ice cream and a glass of juice. Resident #64 was observed taking a bite of the hamburger, chewing, then taking two additional bites of the hamburger prior to swallowing. State Tested Nursing Assistant (STNA) #395 sat next to Resident #64 and began to feed Resident #66. Resident #64 continued to chew and took an additional bite of the hamburger. STNA #395 cued the resident to take a drink, as he was still chewing, held his glass of juice up to his mouth and after the resident took a drink he coughed. The resident took another bite of the hamburger and then continued to intermittently cough approximately eight times. STNA #395 asked the resident if he was okay and continued to assist Resident #66. Resident #64 would open his mouth, lean up and back in the wheelchair and then would cough. At that time, Licensed Practical Nurse (LPN) #354 came into dining room, began assisting residents and Resident #64 continued to cough intermittently.
Review of the record revealed no documented evidence of an assessment or monitoring for aspiration/choking between 07/15/19 and 07/22/19.
On 07/22/19 at 12:43 P.M., interview with the Director of Nursing verified Resident #64 did not have any changes to the restorative dining program from 11/03/15 until today. The DON verified the resident required assistance with meals otherwise he would not eat, the family had declined speech therapy and due to the resident's cognition he would not have the capability to restore independent eating. The DON also verified there was no evidence LPN #354 had assessed the resident for possible aspiration per care plan.
On 07/22/19 at 12:51 P.M., interview LPN #383 verified the resident would not be able to be independent with a dining program due to his cognition however staff had continued the same restorative program without any changes to meet the resident's total care needs.
2. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included muscle wasting, chronic obstructive pulmonary disease and morbid obesity. There was no evidence an admission bowel and bladder tracker was completed in an attempt to determine continence capability nor was this assessment completed from admission through current date.
Review of the residents current care plan for skin integrity revealed to provide toileting needs and incontinence care on routine rounds and reposition the resident on routine rounds and avoid pressure to the affected area. Further review of the bowel and bladder elimination plan of care revealed to provide toileting needs and incontinence care on routine rounds.
Review of the bowel and bladder evaluation dated 04/22/19 revealed the resident was always incontinent of bladder and frequently incontinent of bowel. The resident was a fair candidate for a restorative bowel and bladder program but under the comments it stated the resident was not appropriate and the program was not initiated.
Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/18/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for toileting and was totally dependent on staff for transfers using a mechanical lift. The resident was not trialed on a toileting program since admission and was always incontinent of bladder and frequently incontinent of bowel.
On 07/17/19 at 1:25 P.M., interview with the resident's family revealed they visited frequently and had brought up the concern the resident was frequently saturated in urine. The family stated the resident was a heavy wetter because of being on a diuretic medication. The resident was transferred using a mechanical lift and staff did not check on her once she was up in her wheelchair for the day until either she laid down after lunch or after dinner. The family member indicated family had ben told the staff were supposed to check and change her every two to three hours but this was not happening. The family stated they were worried because she keeps getting pressure ulcers on her buttock and then she sits in her urine so she can't get rid of the pressure ulcers.
On 07/17/19 continuous observation of the resident between 1:30 P.M. and 6:30 P.M., revealed the resident was not checked for incontinence or changed during this time period.
On 07/17/19 at 1:35 P.M., interview with State Tested Nursing Assistant (STNA) #330 revealed she provided incontinence care to the resident at 11:45 A.M. just before she got her up for lunch and to her knowledge the resident had not been laid back down or changed since. She verified the resident was not on any type of toileting program and was changed before and after getting in and out of bed.
On 07/17/19 at 6:25 P.M., the resident activated her call button and asked STNA #334 to put her to bed because she was tired. At 6:27 P.M., STNA #334 brought in the mechanical lift and STNA #332 also entered the room. The resident's lift pad was hooked up to the mechanical lift bar and the resident was raised out of the chair. As the resident was being raised a continuous drip, like when making coffee, was observed coming from the resident's buttock area and had a slight smell of urine. The wheelchair was saturated with and had a smell or urine. Both STNA's verified it was urine that was dripping from the resident's bottom and as the resident was carried to the bed the drips continued and made continuous drip puddles on the floor all the way to the bed until the resident was lowered in the bed. Both STNA's verified the resident was not on any type of a toileting program.
On 07/17/19 at 6:45 P.M., interview with STNA #332 revealed this STNA said she had changed the resident at 3:00 P.M. but could not remember if she had any visitors at the time she provided care or who assisted her.
On 07/17/19 at 7:45 P.M., the Director of Nursing (DON), Registered Nurse (RN) #420 and the Administrator were informed of the above observation and the fact that STNA #322 indicated the resident was changed at 3:00 P.M. but verified with continuous observation the resident was not observed being changed.
On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed the resident was a mechanical lift for transfers and was changed during transfers in and out of bed and was not able to say how often the resident was changed daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #54's anti-embolitic compression stockings (AECS) were in place as ordered and failed to ensure a leg positioning device was ordered, assessed and properly care planned prior to use. The facility failed to ensure comprehensive and individualized bowel protocols were developed and implemented for Resident #5, #23 and #44 when the residents were without consistent bowel movements (BM) as planned. This affected three residents (#5, #23 and #44) of five residents reviewed for elimination and one resident (#54) of two residents reviewed for assistive devices.
Findings include:
1. Record review revealed Resident #54 was admitted to the facility on [DATE] with a diagnosis which included cerebrovascular accident (CVA) with left sided hemiplegia.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/10/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for dressing.
On 07/15/19 at 12:09 P.M., the resident was observed in her wheelchair with her left leg Velcro strapped to the wheelchair on the left rest.
Review of the physician's orders, assessments, progress notes, care plan and resident appliance checklist revealed there was no indication in the medical record for the use of a left leg strap (a one inch wide piece of Velcro strap which wrapped around the pole of the wheelchair and the resident's left leg to keep the residents leg secure on the leg rest).
On 07/15/19 at 12:10 P.M., interview with the resident's husband revealed he kept asking the facility to do something because the resident's left leg kept falling off the leg rest and he did not want her to get hurt but no one did anything so he brought in a Velcro strap that secured the resident's leg in place and on the leg rest. He verified staff would apply the Velcro strap which had been in place for a while and no one questioned him about it.
On 07/15/19 at 2:59 P.M., 4:23 P.M. and 5:38 P.M., the resident was observed in her wheelchair with her left leg Velcro strapped to the wheelchair and on the leg rest.
On 07/16/19 at 9:40 A.M., 3:00 P.M. and 3:49 P.M., the resident was observed in her wheelchair with her left leg Velcro strapped to the wheelchair and on the leg rest.
On 07/17/19 at 10:43 A.M. and 11:34 A.M., the resident was observed in her wheelchair with her left leg Velcro strapped to the wheelchair and on the leg rest.
On 07/17/19 at 11:35 A.M., interview with State Tested Nursing Assistant (STNA) #406 revealed the resident had the leg strap for awhile and she placed it on the resident this morning.
On 07/17/19 at 12:05 P.M., interview with the Director of Nursing (DON) revealed the resident was not supposed to be wearing any kind of left leg strap and she was not aware the resident had one in place.
On 07/17/19 at 12:55 P.M. and 3:45 P.M., the resident was observed in her wheelchair without the left leg strap in place and her leg was dangling below the leg rest.
On 07/18/19 at 9:10 A.M., interview with Licensed Practical Nurse (LPN) #323 revealed she was aware the resident had the left leg strap in place for awhile because her leg would not stay on the leg rest. She stated the resident's husband was worried about her leg dangling and not being able to stay on the leg rest and staff or the husband would apply the strap daily.
In addition, review of the physician's order dated 06/02/17 revealed the resident was to wear bilateral AECS when out of bed.
Review of the resident appliance checklist, updated 07/15/19, revealed the resident was to wear AECS when out of bed.
Review of the July 2019 treatment administrator record revealed the AECS were applied daily from 07/01/19 through 07/22/19. Further review of the STNA task revealed there was no indication the resident was to wear AECS.
On 07/15/19 at 12:09 P.M., 2:59 P.M., 4:23 P.M. and 5:38 P.M., the resident was observed in her wheelchair with no AECS on.
On 07/16/19 at 9:40 A.M., the resident was observed in her wheelchair with no AECS on.
On 07/16/19 at 9:41 A.M., interview with STNA #366 revealed she had cared for the resident for awhile and was not aware the resident was to wear AECS and verified she did not have any on at this time.
On 07/16/19 at 3:00 P.M. and 3:49 P.M., the resident was observed in her wheelchair with no AECS on.
On 07/17/19 at 10:43 A.M. and 11:34 A.M., the resident was observed in her wheelchair with no AECS on.
On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed the resident was not able to put on or remove any clothing including socks and verified she did not put on the resident's AECS today.
On 07/17/19 at 12:55 P.M. and 3:45 P.M., the resident was observed in her wheelchair without her AECS on.
On 07/18/19 at 9:07 A.M., the resident was observed in her wheelchair without her AECS on.
On 07/18/19 at 9:10 A.M., interview with LPN #323 verified the resident did not have on AECS as ordered.
On 07/18/19 at 1:50 P.M., the resident was observed in her wheelchair without her AECS on.
On 07/22/19 at 7:45 A.M., the DON was informed of the above findings. No additional information was provided as to why the resident did not have the AECS on as ordered.
On 07/22/19 at 12:06 P.M., the resident was observed in her wheelchair without her AECS on which was verified by her husband.
2. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included dementia and constipation.
Review of the current bowel elimination care plan revealed the resident was at risk for constipation because the resident had a history of constipation. The only goal was to keep her clean, dry and odor free with interventions which included toilet as needed and check and change on routine rounds. There were no interventions related to attempting to prevent constipation.
Record review revealed the resident had standing orders for a bowel protocol that was signed by the physician on 03/27/18 which indicated if the resident went without a BM in three days bowel sounds was be assessed and check for abdominal distention. If hypoactive bowel sounds or absence of bowel sounds and abdominal distention do not implement the bowel protocol and notify the physician immediately. If no BM in three days give Dulcolax, a stimulant laxative, 10 milligrams (mg) orally or rectal suppository every day as needed or give fleets enema, a fast acting laxative, rectally every day as needed for constipation. If no BM after fleets enema given call the physician.
Review of the annual MDS 3.0 assessment, dated 04/08/19 revealed the resident was not interviewable and needed assistance from staff for ADL care including toileting.
Review of the BM record for May 2019 revealed the resident went without a BM from 05/16/19 until 05/22/19 (seven days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician. Further review revealed the resident went without a BM from 05/24/19 until 05/30/19 (seven days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician.
Review of the BM record for June 2019 revealed the resident went without a BM from 06/10/19 until 06/13/19 (four days), from 06/14/19 until 06/18/19 (five days) and from 06/21/19 until 06/24/19 (four days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician.
Review of the BM record for July 2019 revealed the resident went without a BM from 07/03/19 until 07/10/19 (eight days) and from 07/11/19 until 07/15/19 (five days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician.
On 07/22/19 at 7:45 A.M., the above findings were reviewed with the DON and she verified the facility had no additional information, the bowel protocol was not implemented as planned, no assessments of bowel sounds were completed, the care plan was not individualized and the physician was not notified.
3. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses which included dementia and constipation.
Review of the current care plan for requiring assistance with toileting revealed the resident had a history of constipation. The only goal was to keep her clean, dry and odor free with interventions which included monitor for constipation and ensure a medium to large formed BM every three days. Provide as needed laxatives per protocol. Encourage increased physical activity and adequate hydration.
The resident had standing orders for a bowel protocol that was signed by the physician on 02/21/16 which indicated if the resident went without a BM in three days bowel sounds was be assessed and check for abdominal distention. If hypoactive bowel sounds or absence of bowel sounds and abdominal distention do not implement the bowel protocol and notify the physician immediately. If no BM in three days give Dulcolax, a stimulant laxative, 10 milligrams (mg) orally or rectal suppository every day as needed or give fleets enema, a fast acting laxative, rectally every day as needed for constipation. If no BM after fleets enema given call the physician.
Review of the quarterly MDS 3.0 assessment, dated 06/28/19 revealed the resident was not interviewable and needed assistance from staff for ADL care including toileting.
Review of the BM record for April 2019 revealed the resident went without a BM from 04/17/19 until 04/24/19 (eight days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician.
Review of the BM record for June 2019 revealed the resident went without a BM from 06/22/19 until 06/26/19 (five days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician.
Review of the BM record for July 2019 revealed the resident went without a BM from 07/06/19 until 07/12/19 (seven days). There was no evidence of any assessments, implementation of the BM protocol or notification of the physician.
On 07/22/19 at 7:45 A.M., the above findings were reviewed with the DON and she verified the facility had no additional information, the bowel protocol was not implemented as planned, no assessments of bowel sounds were completed and the physician was not notified.
4. Medical record review revealed Resident #23 was admitted on [DATE] with diagnoses including constipation.
Review of the BM (bowel movement) report dated April 2019 and May 2019 revealed Resident #23 had no BM between 04/15/19 and 04/22/19, no BM between 05/04/19 and 05/07/19, no BM between 05/09/19 and 05/13/19 and no BM between 05/19/19 and 05/24/19.
Review of the Medication Administration Record dated April and May 2019 revealed no as needed (PRN) medications were administered per the resident's standing physician orders related to elimination.
Review of the care plan titled At Risk for Constipation related to decreased mobility, a history of constipation and medication use dated 06/09/19 revealed interventions included to encourage the resident to drink fluids, observe bowel movement status, frequency, amount, and consistency, observed for signs of constipation and update the physician as needed.
Review of the undated physician Standing Orders revealed if a resident had no BM in three days, the nurse must assess for bowel sounds and check for abdominal distention, give Dulcolax 10 milligrams (mg) orally or by rectal suppository daily as needed or may give a fleets enema rectally daily as needed for constipation. If there was no BM after the fleets enema had been given, the nurse was to call the physician.
On 07/18/19 at 12:12 P.M., interview with the DON revealed each resident had a copy of the standing orders in the chart and the nurses were to use these, if needed, including no BM within three days. The DON stated sometimes the resident would use the bathroom independently without telling staff and verified this was not documented on the care plan or in the record. The DON verified the facility did not identify or implement orders as written for a resident without a BM for greater than three days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #73 was transferred safely with the mechanical lift to prevent an accident/injury and failed to ensure fall interventions were in place as planned for Resident #11, #34 and #59 to decrease the residents risk for falls. This affected four residents (#73, #34, #11 and #59) of six residents revealed for accident hazards.
Findings include:
1. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included muscle wasting, chronic obstructive pulmonary disease and morbid obesity.
Review of the current mobility care plan revealed the resident was to be transferred using a mechanical lift. The intervention included two staff to assist the resident for transfers.
Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/18/19 revealed the resident was not interviewable and was totally dependent on staff for transfers utilizing a mechanical lift.
Review of the nurse aid skill and competency review revealed State Tested Nurse Aide (STNA) #332 passed for mechanical lift transfers on 06/26/19 and STNA #334 passed on 06/27/19.
On 07/17/19 at 6:27 P.M., STNA #334 was observed bringing the Invacare Reliance 600 mechanical lift into the resident's room. STNA #334 and #332 were then observed hooking up the resident's lift pad to the lift to begin transferring the resident from the wheelchair into bed. The wheelchair was at the left side at the foot of the bed facing the window, the lift was long ways with the left side of the bed with the right lift leg between the front and back wheels of the wheelchair. The lift left leg was in front of the wheelchair and the lift legs were in the closed position. STNA #334 operated the lift, lifted the resident out of the wheelchair and the resident continued to face the window and not STNA #334 which was a 90 degree turn away from facing STNA #334. As the resident was lifted STNA #334 pulled the lift back from the wheelchair about six feet and the turned the lift 90 degrees and pushed the lift legs under the resident's bed. The legs of the lift continued in the closed position as the resident was lowered into the bed.
On 07/17/19 at 6:46 P.M., interview with STNA #334 verified the lift legs were closed during the entire transfer and the resident did not face the lift operator during the transfer. STNA #334 verified the lift legs were only opened when necessary because it was safer to keep the legs closed. If approaching the wheelchair from the front the legs would need to be opened but would be closed when able to move the wheelchair. At 6:48 P.M., interview with STNA #332 verified she operated the lift the same way as STNA #334.
On 07/17/19 at 7:45 P.M., the Director of Nursing (DON), the Administrator and Registered Nurse (RN) #420 were informed of the above observation.
On 07/18/19 at 11:25 P.M., interview with the DON, with RN #420 present, revealed according to the Invacare lift manual, STNA #332 and #334 did not transfer the resident properly. She verified the facility policy indicated staff needed to be trained and observed for competency and they were trained on hire and observed for competency on their yearly reviews but no in-services were completed for the staff. No documentation was available besides the manufacturer's recommendations for how to transfer a resident using the mechanical lift.
Review of the facility safe lifting and movement of resident's policy, revised July 2017, revealed to ensure direct care staff were trained in the use of the mechanical lifting devices and only staff with documented training would be able to use the mechanical lifts.
Review of the facility hoyer lift policy, dated 10/15/97, revealed the facility would follow the manufacturer's recommendations for transfers.
Review of the Invacare reliant 600 manufacturer's user manual, dated 2018, revealed the legs of the lift must be in the maximum opened position before lifting the resident and the shifter handle locked into place for optimum stability and safety. The resident's arms should be inside the straps and when raising the resident turn the resident so he/she faces the assistant who was operating the lift.
2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including history of falls, unsteadiness on feet, muscle weakness, cognitive communication deficit involving cognitive function and awareness, Alzheimer's disease, dizziness, and dementia. The resident sustained 19 falls from 10/15/18 to 07/02/19.
Review of Resident #11's falls plan of care revealed the resident was at risk for falls and fall related injuries related to cognitive impairment, vision impairment, medication use, required assist with ambulation, required assist with transfers and had an unsteady gait. The resident's intervention included to assist the resident with wearing appropriate footwear and gripper socks always on.
Observation on 07/17/19 at 3:05 P.M., with STNA #394 revealed the resident had regular white ankle socks on. Confirmed findings with STNA #394 during observation. The STNA verified the resident was to always wear gripper socks.
Review of fall policy dated 05/06/19 revealed staff would identify interventions related to resident specific risk and causes to try to prevent the resident from falling and try to minimize complication from falling. If interventions have been successful in preventing falls, staff would continue the interventions.
3. Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including muscle weakness, lack of coordination, osteoporosis with pathological fracture of right femur, unsteady on feet, hearing loss, muscle wasting and atrophy, difficulty walking, and intellectual disabilities. The resident had two noted in falls from 12/16/18 to 04/05/19.
Review of Resident #59's fall plan of care revealed a sign would be hung in the resident's room to remind the resident to lock her wheelchair brakes before getting up.
Observation of Resident #59's room on 07/17/19 at 2:00 P.M. and 2:13 P.M. with STNA #317 and the Director of Nursing (DON) revealed no evidence a sign was hung in the resident's room to remind her to lock wheelchair brakes before getting up. The DON reported the sign should have been a picture of her wheelchair brakes to show the resident how to lock her brakes.
Review of fall policy dated 05/06/19 revealed staff would identify interventions related to resident specific risk and causes to try to prevent the resident from falling and try to minimize complication from falling. If interventions have been successful in preventing falls, staff would continue the interventions.
4. Medical record review revealed Resident #34 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbance.
Review of the care plan titled At Risk for falls and fall related injury dated 09/06/18 revealed the resident had cognitive impairment, a history of falls, impaired vision, poor safety awareness, an unsteady gait, and required assistance with ambulation and transfers. Interventions included to assist with toileting needs, toileting program, incontinence care on routine rounds and as needed, and to provide restorative nursing or rehabilitation programs as indicated.
Review of the quarterly Minimum Data Set 3.0 (MDS) 3.0 assessment dated [DATE] revealed the resident had two or more falls with no injuries and the quarterly MDS assessment dated [DATE] revealed Resident #34 had one fall with no injury.
Review of the policy titled Falls and Fall Risk, Managing revised 05/06/19 revealed the staff were to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
Review of the quarterly Fall Risk assessment dated [DATE] revealed Resident #34 was at high risk for falls.
Review of the Accident/Incident Reports, the Fall Investigation Forms and the Post Fall Head to Toe assessments revealed the following:
On 12/05/18 at 3:03 A.M., Resident #34 was found on her knees at the bedside. The resident was assisted off the floor, toileted, dressed, and put in her chair for the day. The new intervention was for speech therapy to evaluate and treat. There was no evidence of an immediate intervention implemented to prevent a fall from reoccurring.
On 01/29/19 at 6:10 A.M., Resident #34 stood up and lost her balance when she leaned on the bedside table. The new intervention was for occupational therapy (OT) to evaluate and treat. There was no evidence of an immediate intervention implemented to prevent a fall from reoccurring.
On 02/09/19 at 5:00 P.M., Resident #34 attempted to rise unassisted and fell. The new intervention was for physical therapy to evaluate and treat. There was no evidence of an immediate intervention implemented to prevent a fall from reoccurring.
On 06/30/19 at 9:06 P.M., an alarm was sounding and staff found Resident #34 lying on her right side on the floor. The resident stated she was reaching for the floor. Staff toileted the resident, assisted her to the chair and brought her to a common area. An OT referral was ordered. There was no evidence of an immediate intervention implemented to prevent a fall from reoccurring.
Review of the Task List: Restorative-Toileting revealed to offer toileting every two hours while awake for fall prevention at 12:00 A.M., 3:30 A.M., 7:00 A.M., 9:00 A.M., 11:00 A.M., 1:00 P.M., 3:00 P.M., 5:00 P.M., 7:00 P.M. and 9:00 P.M Review of the record revealed no documented evidence an individualized restorative toileting program was developed and no evidence the routine check and change for incontinence program was implemented as written for Resident #34.
On 07/17/19 at 2:09 P.M., interview with the DON verified there were no immediate interventions implemented on 12/05/18, 01/29/19, 02/09/19 and 06/30/19 to keep the resident from falling again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to comprehensively assess for the type of incontinence demonstrated by residents and failed to develop and implement comprehensive and individualized bladder programs to restore normal bladder function for Resident #29, #32, #34 and #73 to assist each resident to remain as continent as possible. This affected four residents (#29, #32, #34 and #73) of five residents reviewed for incontinence.
Findings include:
1. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included muscle wasting, chronic obstructive pulmonary disease and morbid obesity. There was no evidence an admission bowel and bladder tracker was completed in an attempt to determine continence capability.
Review of the residents current care plan for skin integrity revealed to provide toileting needs and incontinence care on routine rounds and reposition the resident on routine rounds and avoid pressure to the affected area. Further review of the bowel and bladder elimination plan of care revealed to provide toileting needs and incontinence care on routine rounds.
Review of the bowel and bladder evaluation dated 04/22/19 revealed the resident was always incontinent of bladder and frequently incontinent of bowel. The resident was a fair candidate for a restorative bowel and bladder program but under the comments it stated the resident was not appropriate and the program was not initiated.
Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/18/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for toileting and was totally dependent on staff for transfers using a mechanical lift. The resident was not trialed on a toileting program since admission and was always incontinent of bladder and frequently incontinent of bowel.
On 07/17/19 at 1:25 P.M., interview with the resident's family indicated they visited frequently and they had brought up the concern the resident was frequently saturated in urine. The family member stated the resident was a heavy wetter because of being on a diuretic medication. The resident was transferred using a mechanical lift and staff did not check on her once she was up in her wheelchair for the day until either she laid down after lunch or after dinner. The family member stated family was told the staff were supposed to check and change her every two to three hours but this was not happening. The family was worried because she keeps getting pressure ulcers on her buttock and then she sits in her urine so she can't get rid of the pressure ulcers.
On 07/17/19 continuous observation of the resident between 1:30 P.M. and 6:30 P.M., revealed the resident was not checked for incontinence or changed during that time period.
On 07/17/19 at 1:35 P.M., interview with State Tested Nursing Assistant (STNA) #330 revealed she provided incontinence care to the resident at 11:45 A.M. just before she got her up for lunch and to her knowledge the resident had not been laid back down or changed since. She verified the resident was not on any type of toileting program and was changed before and after getting in and out of bed.
On 07/17/19 at 6:25 P.M., the resident activated her call button and asked STNA #334 to put her to bed because she was tired. At 6:27 P.M., STNA #334 brought in the mechanical lift and STNA #332 also entered the room. The resident's lift pad was hooked up to the mechanical lift bar and the resident was raised out of the chair. As the resident was being raised a continuous drip, like when making coffee, was observed coming from the residents buttock area and had a slight smell of urine. The wheelchair was saturated with and had a smell or urine. Both STNA's verified it was urine that was dripping from the resident's bottom and as the resident was carried to the bed the drips continued and made continuous drip puddles on the floor all the way to the bed until the resident was lowered in the bed. Both STNA's verified the resident was not on any type of a toileting program.
On 07/17/19 at 7:45 P.M., the Director of Nursing (DON), Registered Nurse (RN) #420 and the Administrator were informed of the above observation.
On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed a bowel and bladder tracker had not been completed on the resident since admission and verified she was not able to provide any type of assessment that was completed in an attempt to keep the resident as continent as possible. She stated the resident was a mechanical lift for transfers and was changed during transfers in and out of bed and was not able to say how often the resident was changed daily.
Review of the bowel and bladder continence care management policy, dated March 2017 revealed it was to facility goal for improvement in bowel and bladder function in those who could improve and to prevent deterioration in function. The program included to evaluate for incontinence, promote continence, appropriate toileting routines and the evaluation of each resident's care plan to ensure the continence program was being managed effectively. The plan was to develop individualized toileting needs. Programs included rehabilitation/bladder retraining which required the resident to resist or inhibit the sensation of urgency and to urinate according to a timetable rather than to the urge. Prompted voiding which included regular monitoring with encouragement to report continence status using a schedule. Habit training/scheduled voiding which was a behavioral technique with scheduled toileting at regular intervals. Check and change which was to check on the resident at regular intervals using incontinence products. The type of urinary incontinence should be determined such as urge, overflow, mixed or functional. The resident should be evaluated on admission, quarterly and after any change in condition for patterns and potential to restore function. This included to initiate a voiding and bowel movement monitoring record that included incontinence and continent episodes. Complete for three to seven days to establish an individual voiding and bowel movement pattern and observe for trends. An individualized care plan should then be developed and document the effectiveness of the interventions developed.
2. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease and multi-system degeneration of the autonomic nervous system.
Review of the resident's current care plans for toileting/elimination of bowel and bladder indicated to provide assistance with toileting and incontinence care on routine rounds and as needed.
Review of the resident's falls from 01/01/19 through 07/15/19 revealed the resident had 13 falls related to attempting to toilet himself.
Review of the restorative program note dated 01/28/19 revealed the resident was on restorative toileting program to offer toileting at 7:00 A.M., 9:00 A.M., 11:00 A.M., 1:00 P.M., 3:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M. and 3:30 A.M. Further review of the medical record revealed there was no evidence the program was implemented.
Review of the bowel and bladder evaluation dated 02/02/19 revealed the resident needed extensive assistance of staff for mobility was frequently incontinent of urine at least daily and was occasional incontinent of stool less than daily. The resident was a fair candidate for restorative bowel and bladder programs and the resident was willing to participate in the programs.
Review of the May 2019 bladder elimination record revealed the resident was always incontinent of urine. Review of the bowel elimination record revealed the resident had seven bowel incontinence episodes for the month. Review of the restorative toileting program revealed there was no evidence the program was implemented.
Review of the bowel and bladder evaluation dated 05/02/19 revealed the resident needed extensive assistance of staff for mobility was frequently incontinent or urine at least daily and was always continent of stool. The resident was a fair candidate for restorative bowel and bladder programs and the resident was willing to participate in the programs.
Review of the quarterly MDS 3.0 assessment, dated 05/18/19 revealed the resident was cognitively intact but needed extensive assistance of two or more staff for transfers and toileting. He was frequently incontinent of bladder and continent of bowel.
Review of the June 2019 bladder elimination record revealed the resident was always incontinent of urine. Review of the bowel elimination record revealed the resident had 11 bowel incontinent episodes for the month. Review of the restorative toileting program revealed there was no evidence the program was implemented.
Review of the July 2019 bladder elimination record revealed the resident was always incontinent of urine. Review of the bowel elimination record revealed the resident had seven bowel incontinent episodes thus far for the month. Review of the restorative toileting program revealed there was no evidence the program was implemented.
On 07/15/19 at 11:00 A.M., interview with the resident revealed he was supposed to be taken to the restroom for toileting but the staff gave him a urinal and at times had to defecate in his adult brief because staff did not want to take him to the restroom even when he asked. The resident stated he fell many times attempting to toilet himself.
On 07/16/19 at 3:50 P.M., interview with STNA #375 revealed the resident needed the assistance of two staff for toileting and they just gave him the urinal and he used his adult brief when he had to have a bowel movement unless staff could get to him in time. The STNA indicated the resident was not on any toileting program but she tried to check the resident three times on her shift for his toileting needs.
On 07/16/19 at 4:15 P.M., interview with STNA #414 revealed the resident had an increase in incontinence the last couple of months and needed more help assistance from staff. The resident had a urinal he used but needed assistance with using it and used his adult brief for bowel movements if staff could not get to him. The STNA indicated the resident was not on any toileting program and would call for help when needed to urinal or defecate.
On 07/17/19 at 11:29 A.M., when walking past the resident's room he was observed moaning out and he requested assistance with activating the call light because it was not within his reach. The resident indicated he needed to use the restroom. At 11:31 A.M., STNA # 317 entered the residents room and handed him the urinal and did not even ask if he wanted to go to the restroom. This was verified by STNA #317 at the time of the observation.
On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed staff were supposed to take the resident to the toilet but he needed at least two staff to assist to the toilet and at times he passed out so staff gave him a urinal and would try to take him to the toilet for bowel movements but wears an adult brief just in case. The STNA indicated the resident was not on any toileting programs and staff just assisted him when he used his call light for assistance.
On 07/17/19 at 11:40 A.M., interview with STNA #330 revealed she was not aware the resident was on a toileting program
On 07/17/19 at 1:56 P.M., interview with STNA #395 revealed she was not aware the resident was on a toileting program.
On 07/17/19 at 3:15 P.M., interview with LPN #383 revealed she was in charge of the restorative programs and she wrote the program notes. The assessment consisted of talking to staff, reviewing sections G, H and J of the five day initial MDS, review of the therapy referral sheets and the tasks section of the computer where the aids input their assignments. When asked if she evaluated for the effectiveness of the programs she was not able to answer and stated frequently restorative toileting was implemented as a fall intervention but she was not part of the fall team, they just told her what times to add to the care plan. She verified the task section did not indicate each time the resident was toileted but the documentation was entered once per shift and this resulted in the inability to get an accurate reflection of the resident's continence status. She verified there were no assessments competed in an attempt to ensure the resident did not have a decline. She verified the only way a resident was on a toileting program was to put them on a restorative program. She verified all residents were either independent or checked and changed every two to three hours as able. When asked the difference between Resident #32's restorative program which indicated to toilet him every two hours and a check and change she indicated a check and change was when the staff could get to a resident but if specific times were entered the resident needed toileted at those times usually because they had a fall at that time while attempting to toilet themselves. She verified the resident had many falls attempting to toilet himself and stated this was because he had an overactive bladder.
On 07/17/19 at 6:50 P.M., interview with the resident and his wife revealed she visited daily and staff did not routinely take the resident to the bathroom. She stated he had episodes of black outs due to low blood pressure and needed two staff to assist him with ambulation and toileting and she thought maybe they were afraid to walk him so they provided him with a urinal and he wore adult briefs for bowel movements (BM).
3. Medical record review revealed Resident #34 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbance.
Review of the annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] and the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was continent of bowel and occasionally incontinent of urine.
Review of the Bowel/Bladder Evaluation V.1 - V 4 dated 05/14/19 revealed the resident was severely impaired for daily decision-making and was frequently incontinent of urine and of bowel at least daily. The resident was a fair candidate for restorative bowel and bladder program and the resident was willing to participate. A program was to be initiated; however, a program was already in place for fall prevention.
Review of the record revealed no comprehensive restorative toileting assessment or care plan for Resident #34.
Review of the MDS assessment look-back dated 05/15/19 through 05/21/19 revealed Resident #34 was incontinent of urine on 10 occasions. The quarterly MDS assessment dated [DATE] revealed Resident #34 was occasionally incontinent of bladder.
Review of the Task List: Restorative-Toileting revealed Resident #34 was to be offered toileting every two hours while awake and as needed. There was no evidence of an individualized program for Resident #34 and no bowel program to restore function.
On 07/17/19 at 4:30 P.M., interview with MDS Supervisor #383 stated occasionally incontinent was defined as having less than seven episodes of incontinence and frequently incontinent was defined as having seven or more episodes of urinary incontinence, but at least one episode of continent voiding during the assessment period. MDS Supervisor #383 verified Resident #34's MDS assessment was inaccurate and should have been coded as being frequently incontinent of urine.
Review of the quarterly MDS assessment dated [DATE] revealed the resident was occasionally incontinent of bladder and bowel. Review of the look back indicated the resident had 10 urine incontinent episodes and one incontinent bowel episodes.
Review of the care plan titled Alteration in Bowel Elimination revised 07/15/19 revealed goals including to maintain current status. Interventions included to assist with toileting needs and incontinence care on routine rounds and as needed (PRN).
Review of the care plan titled Requires Assist with Toileting revised 07/15/19 revealed the resident required a restorative toileting program due to falls. Goals included to maintain current status and interventions included to assist with toileting needs and incontinence care on routine rounds and PRN. Provide and/or offer toileting every two hours as directed while awake to assist in the prevention of falls. Change or add scheduled times as needed. Complete a bladder assessment per facility policy and monitor voiding, awareness of need and pattern to provide toileting as appropriate to meet the resident's need and ability.
On 07/17/19 at 4:30 P.M., interview with MDS Supervisor #383 verified Resident #34's MDS assessment was inaccurate, the resident had declined in urinary continence without implementing new interventions to restore bowel/bladder function.
Review of the policy titled Bowel and Bladder Continence Care Management dated March 2017 revealed the purpose was to maintain an interdisciplinary team approach to bowel and bladder continence management, to facilitate improvement in bowel and bladder function in those who can improve and to prevent deterioration of bowel/bladder function. Appropriate strategies and interventions were to be initiated and resident outcomes and product effectiveness was to be evaluated and monitored.
4. Medical record review revealed Resident #29 was admitted on [DATE] with diagnoses including Parkinson's disease and urinary urgency.
Review of the care plan titled Requires Assist with Toileting and Risk for UTI, dated 11/03/17 revealed to assist with toileting needs and incontinence care on routine rounds and PRN, when soiled or upon request. Check and change on routine rounds and monitor voiding, awareness of need and pattern to provide toileting as appropriate to meet the resident's need and ability.
Review of the annual MDS 3.0 assessment dated [DATE] and the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was not on a toileting program and was continent of bladder.
Review of the Care Area Assessment: Urinary Incontinence dated 11/09/18 revealed the resident required assistance with toileting with modifiable factors contributing to transitory urinary incontinence including psychological or psychiatric problems, urinary urgency and the need for assistance in toileting. The urinary incontinence care plan objective was to slow or minimize decline, avoid complications and maintain current level of functioning. A referral to another discipline was warranted; however, none was identified.
Review of Resident #29's quarterly MDS 3.0 assessment dated [DATE] revealed the resident was continent of urine with no toileting program and the quarterly MDS assessment dated [DATE] revealed the resident had declined to occasionally incontinent of urine with no toileting program.
Review of the quarterly Bowel/Bladder Evaluation dated 05/12/19 revealed the resident required extensive assistance with mobility, was occasionally incontinent of urine due to functional incontinence, was a good candidate for restorative program and resident was willing to participate, States program was already in place and was tolerating well.
Review of the Task List: Bladder Elimination dated 06/17/19 through 07/16/19 revealed Resident #29 was incontinent of urine on 06/23/19, 07/05/19 and 07/07/19 at 7:20 A.M., 10:24 A.M., and 10:29 A.M
Review of the record revealed no evidence of a comprehensive and individualized toileting program to restore bladder continence was implemented.
Review of Resident #29's medical record revealed no evidence of a urinary incontinence care plan.
On 07/16/19 at 1:11 P.M., interview with the Director of Nursing (DON) verified Resident #29 was not on a restorative toileting program and the resident had declined from being continent of urine as of 02/09/19 to occasionally incontinent of urine 05/12/19 with no intervention to restore bladder function.
On 07/16/19 at 2:20 P.M., interview with MDS Supervisor #383 revealed Resident #29 only had one episode of incontinence during the assessment period, did not feel that warranted a toileting program and considered that to be isolated even if the resident was previously continent of urine. MDS Supervisor #383 also verified the bowel/bladder assessment indicated the resident was on a toileting program; however, she was only on a routine check and change program while awake, she did not implement an incontinence care plan or identify the type of urinary incontinence because she did not think of that.
On 07/16/19 at 2:26 P.M. and 3:17 P.M., interview with the DON stated the resident had never been started on a restorative toileting program, was picked up by therapy due to falls and there was no documented evidence in the therapy notes that therapy was working on toileting.
On 07/16/19 12:56 P.M., the surveyor knocked on Resident #29's door and announced self. The resident peaked around the door, wearing only an incontinence brief and stated she had to get changed because she was wet. The resident was holding another incontinence brief in her hand. No staff was observed in the room with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #73's oxygen was monitored and on as ordered. This affected one resident (#73) of one resident reviewed for oxygen use.
Findings include:
Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD) required continuous oxygen and morbid obesity.
Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not interviewable and was totally dependent on staff for activities of daily living (ADL) care.
Review of the physician's order, dated 06/18/19 revealed the resident had continuous oxygen at two liters per minute.
Review of the 06/20/19 care conference notes revealed the family had a concern with the resident's oxygen not being on as ordered due to the E tanks not being maintained with oxygen.
Review of the July 2019 Medication Administration Record (MAR) and Treatment Administrator Record (TAR) revealed there was no evidence of monitoring the resident's use of oxygen including ensuring the E tanks had an adequate supply of oxygen.
On 07/17/19 at 1:25 P.M., interview with the resident's family revealed family visited frequently and attended care conference meetings where they had discussed their concerns with the E tanks being empty while the resident was supposed to be using the oxygen continuously. She stated the resident could not always tell when the oxygen was not functioning properly.
On 07/17/19 at 1:35 P.M., the resident was observed in the hall outside the main dining room waiting to attend bingo. The resident had an E tank which read empty and the resident was to be receiving the oxygen via the nasal cannula which the tubing was in her nose. The resident was asked if her oxygen was working and she said yes but then she put the nasal cannula in her mouth and started to panic and said no nothing is coming out. The resident did not appear to be struggling for breath. At 1:38 P.M., State Tested Nursing Assistant (STNA) #405 was walking down the hall and verified the E tank was empty and the resident was not receiving any oxygen at that time.
On 07/17/19 at 1:38 P.M., interview with STNA #405 revealed Licensed Practical Nurse (LPN) #396 had to put a new E tank on at 11:45 A.M. because the other tank was empty so it should not be empty. STNA #405 verified only the nurses had the key to change or adjust the oxygen.
On 07/17/19 at 1:40 P.M., interview with Registered Nurse (RN) #372 verified the E tank was empty and brought a new tank for the resident. She had difficulty adjusting it to ensure it was functioning properly but was able to adjust it to ensure the oxygen was flowing at two liters per minute at 1:45 P.M. At 1:48 P.M., the resident's pulse oxygen was taken and read 92 percent and RN #372 verified they wanted it to read between 92 and 100 percent.
On 07/17/19 at 2:57 P.M., interview with RN #315 verified the family had concerns with the E tank running out of oxygen. She was not able to show any evidence the facility addressed the concern.
On 07/22/19 at 7:45 A.M., the Director of Nursing was informed of the above concerns and verified there was no documentation to show the oxygen was periodically monitored to ensure proper flow.
Review of the oxygen administrator policy, revised October 2010, revealed to observe the resident periodically to ensure the oxygen was being tolerated. Documentation should include the date and time the oxygen was administered, name and title of individual administering, rate of flow and route, frequency and duration and how the resident tolerated the oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain sufficient levels of nursing staff to ensure personal care services including restorative nursing services for toileting were provided to meet the total care needs of all residents. This affected three residents (Resident #32, #54 and #73) and had the potential to affect all 79 residents residing in the facility.
Findings include:
1. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, multi-system degeneration of the autonomic nervous system, orthostatic hypotension, benign prosthetic hypertrophy and overactive bladder.
Review of the residents falls from 01/01/19 through 07/15/19 revealed the resident had 13 falls related to attempting to toilet himself.
Review of the restorative program note dated 01/28/19 revealed the resident was on restorative ambulation with the walker daily for 15 minutes and restorative toileting program to offer toileting at 7:00 A.M., 9:00 A.M., 11:00 A.M., 1:00 P.M., 3:00 P.M., 6:00 P.M., 8:30 P.M., 12:00 A.M., 3:30 A.M. and as needed for fall prevention despite having no assessments to evaluate the programs.
Review of the PT evaluation and treatment plan dated 03/08/19 revealed the resident was referred back to therapy because the resident was not able to ambulate at this time. Further review of the Discharge summary dated [DATE] revealed the resident was able to ambulate 250 feet with walker. The discharge summary recommended restorative ambulation and active ROM to maintain current level and prevent decline.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/18/19 revealed he was cognitively intact but needed extensive assistance of one or more staff for activities of daily living (ADL). He needed extensive assistance of one person to walk in his room. He was frequently incontinent of bladder and continent of bowel. The assessment revealed he received restorative services for ambulation one day, dressing six days and eating seven days (did not indicate toileting of ROM).
Review of the physician's order dated 05/23/19 revealed the resident was to be walked four times a day as tolerated.
On 07/15/19 at 11:00 A.M., interview with the resident revealed he used to be in a walking program but no one had offered to walk him in a while. The resident stated it had been months since he was consistently walked with staff and recently he kept falling when trying to ambulate himself to the toilet because he was not getting enough exercise.
On 07/16/19 at 3:50 P.M., interview with State tested nursing assistant (STNA) #375 revealed there were not enough staff to walk all the residents who needed it. The floor staff were responsible for completing the restorative programs. She verified the resident was not walked and was usually not taken to the toilet but handed the urinal when he asked to use the restroom. She tried to check the resident three times on her shift but at no set times. She verified she did not complete any ROM with the resident.
On 07/16/19 at 4:15 P.M., interview with STNA #414 revealed the resident had an increase in incontinence the last couple of months and needed more help. The resident had a urinal he used but needed assistance with using it. The STNA stated time did not always permit to get the restorative programs completed. He was not aware the resident was on a restorative ambulation, toileting or ROM programs.
On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed staff were supposed to take the resident to the toilet but he needed at least two staff to assist to the toilet and at times he passed out so staff would give him a urinal if he requested to urinate and required him to have bowel movements in his adult brief if he couldn't hold it. The STNA stated the resident was not on any toileting programs and staff just responded to him when he used his call light for assistance. The STNA stated the resident was on a restorative ambulation program which was supposed to be done once on each shift but they did not have time to do it.
On 07/17/19 at 11:40 A.M., interview with STNA #330 verified the resident was supposed to be walked for restorative programming on each shift but stated he had not been able to complete it due to time constraints.
On 07/17/19 at 1:56 P.M. interview with STNA #395 revealed she knew Resident #32 was on a restorative ambulation program but could not say the last time she walked the resident but it had been awhile because there was not enough time to complete the program and the resident needed two staff while walking. She was not aware of the resident being on any other restorative programs. She stated the resident used the urinal and they tried to take him to the toilet for a bowel movement but he wore an adult brief just in case.
On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed she was in charge of the restorative programs and she wrote the program notes. She revealed she only implemented up to two programs per resident even if skilled therapy recommended more because staff were not able to spend an hour a day completing restorative programs.
On 07/17/19 at 6:50 P.M., interview with the resident and his wife revealed she visited daily and he had not been walked in months nor had he been taken to the toilet regularly as he was supposed to be to keep his strength up. She stated he had episodes of black outs due to low blood pressure and needed two staff to assist him with ambulation and toileting and the STNA staff did not want to walk him in case he blacked out so they provided him with a urinal and he wore adult briefs for bowel movements (BM) accidents. She stated he also needed assistance with the urinal because of his shaking.
2. Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included cerebral vascular accident (CVA) with left sided hemiplegia.
Review of the current list of residents receiving restorative services did not indicate the resident was receiving restorative services for transfers but indicated she was getting services for ROM.
Review of the therapy screen dated 12/20/18 revealed the resident presented with a decline in commode transfers according to the nursing staff. Further review of the OT evaluation and treatment plan dated 12/20/18 revealed the resident had a new onset of decrease in strength, functional mobility, transfers and increased need for assistance. The resident was totally dependent, with attempts to initiate, for toileting.
Review of the Discharge summary dated [DATE] revealed to continue on restorative program for commode transfers with assist of two staff.
Review of the restorative program note dated 05/1/19 revealed the resident was on passive ROM for bilateral upper and lower extremities and transfers with two staff to encourage to stand for 30 seconds daily. The note indicated the resident had met her goals and no decline was noted despite no evidence of any restorative assessments being completed from 01/2019 through 05/2019. Further review of the May 2019 STNA documentation revealed the staff documented the resident was receiving ROM services daily but was not receiving the transfer program regularly.
Review of the quarterly MDS 3.0 assessment, dated 06/10/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for ADL care. The resident received restorative therapy for transfers five of the seven days reviewed and no ROM.
Review of the 06/10/19 restorative program note revealed the restorative programs were tolerated, goals were met and no decline was noted despite no assessments being completed. Further review of the June 2019 STNA documentation revealed the resident was receiving the ROM services daily but was not receiving the transfer program regularly.
On 07/15/19 at 12:10 P.M., interview with the resident's husband, who visited daily for the majority of the day, revealed the resident was not receiving restorative ROM or transfer services to include standing for at least 30 seconds a day. He stated at times the resident was taken to the toilet and other times she was provided incontinence care in bed.
On 07/15/19 at 12:11 P.M., 2:59 P.M., 4:23 P.M. and 5:38 P.M., the resident was observed in her room with her husband and without any staff.
Review of the 07/16/19 restorative program note revealed the programs were tolerated, goals were met and no decline was noted despite no assessments being completed. Further review of the July 2019 STNA documentation revealed the resident was receiving the ROM services daily but was not receiving the transfer program regularly.
On 07/16/19 at 9:40 A.M., 3:00 P.M. and 3:49 P.M., the resident was observed in her room with her husband and without any staff.
On 07/17/19 at 10:43 A.M. and 11:34 A.M., the resident was observed in her room with her husband and without any staff.
On 07/17/19 at 11:35 A.M., interview with STNA #406 revealed she was not aware of the resident being on any restorative programs and the STNA floor staff were responsible for completing any planned restorative programs because the facility did not have separate restorative STNA's despite staff signing off on the restorative participation grids indicating services were completed.
On 07/17/19 at 12:55 P.M. and 3:45 P.M., the resident was observed in her room with her husband and without any staff.
On 07/17/19 at 3:15 P.M., interview with Licensed Practical Nurse (LPN) #383 revealed she was in charge of the restorative programs and she wrote the program notes. She revealed she only implemented up to two programs per resident even if skilled therapy recommended more because staff were not able to spend an hour a day completing restorative programs. She verified the inconsistencies with her notes, the STNA grids and the therapy notes and recommendations as noted above.
3. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses which included muscle wasting, chronic obstructive pulmonary disease and morbid obesity.
Review of the residents current care plan for skin integrity revealed to provide toileting needs and incontinence care on routine rounds and reposition the resident on routine rounds and avoid pressure to the affected area. Further review of the bowel and bladder elimination plan of care revealed to provide toileting needs and incontinence care on routine rounds.
Review of the bowel and bladder evaluation dated 04/22/19 revealed the resident was always incontinent of bladder and frequently incontinent of bowel.
Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/18/19 revealed the resident was not interviewable and needed extensive assistance of two or more staff for toileting and was totally dependent on staff for transfers using a mechanical lift.
On 07/17/19 at 1:25 P.M., interview with the resident's family indicated they visited frequently and they had brought up the concern the resident was frequently saturated in urine. The family member stated the resident was a heavy wetter because of being on a diuretic medication. The resident was transferred using a mechanical lift and staff did not check on her once she was up in her wheelchair for the day until either she laid down after lunch or after dinner. The family member stated family was told the staff were supposed to check and change her every two to three hours but this was not happening. The family was worried because she keeps getting pressure ulcers on her buttock and then she sits in her urine so she can't get rid of the pressure ulcers.
On 07/17/19 continuous observation of the resident between 1:30 P.M. and 6:30 P.M., revealed the resident was not checked for incontinence or changed during that time period.
On 07/17/19 at 1:35 P.M., interview with State Tested Nursing Assistant (STNA) #330 revealed she provided incontinence care to the resident at 11:45 A.M. just before she got her up for lunch and to her knowledge the resident had not been laid back down or changed since.
On 07/17/19 at 6:25 P.M., the resident activated her call button and asked STNA #334 to put her to bed because she was tired. At 6:27 P.M., STNA #334 brought in the mechanical lift and STNA #332 also entered the room. The resident's lift pad was hooked up to the mechanical lift bar and the resident was raised out of the chair. As the resident was being raised a continuous drip, like when making coffee, was observed coming from the residents buttock area and had a slight smell of urine. The wheelchair was saturated with and had a smell or urine. Both STNA's verified it was urine that was dripping from the resident's bottom and as the resident was carried to the bed the drips continued and made continuous drip puddles on the floor all the way to the bed until the resident was lowered in the bed. Both STNA's verified the resident was not on any type of a toileting program.
On 07/17/19 at 7:45 P.M., the Director of Nursing (DON), Registered Nurse (RN) #420 and the Administrator were informed of the above observation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide the necessary behavioral health care and services to Resident #44 to allow the resident to attain or maintain her highest practicable physical, mental, and psychosocial well-being and to attempt to reduce observed behaviors. This affected one resident (#44) of two residents reviewed for behaviors.
Findings include:
Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses which included dementia with behaviors and psychosis.
Review of the current plan of care revealed there was no plan that addressed behaviors despite the resident being on antipsychotic medication and having a plan to monitor for the side effects of the medications. Further review of the nursing notes from May 2019 through July 2019 revealed there were no documented behaviors for the resident.
Review of the psychiatric progress notes dated 02/15/19, 03/21/19, 04/25/19 and 05/17/19 revealed the resident was not exhibiting any behaviors. The resident does make repetitive grunting sounds in her throat and was unable to hold any goal directed conversation. The notes revealed to continue on the current regimen of antipsychotic medications.
However, review of the May 2019 medication administrator record (MAR) revealed the resident was fearful, restless and/or irritable from 05/23/19 through 05/29/19 on both shifts.
Review of the June 2019 MAR revealed there were no behaviors noted.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/28/19 revealed the resident was not interviewable but had physical symptoms towards others one to three days in the seven day look back period.
Review of the 06/29/19 social service note revealed the resident's affect remained flat and pleasant. During periods of restlessness and/or anxiety the resident would become tearful.
Review of the July MAR revealed the resident was fearful, restless and/or irritable from 07/13/19 through 07/17/19 on both shifts.
On 07/16/19 at 3:35 P.M., while standing at the nurse's station the surveyor heard yelling off and on down the resident's hall, it was Resident #44 yelling non-sensically off and on while in bed.
On 07/16/19 at 3:40 P.M., Licensed Practical Nurse (LPN) #404 entered the resident's room and asked the resident what she needed, the resident was mumbling but the nurse was not able to understand and informed the resident they would get her up soon for dinner and the resident stated okay.
On 07/16/19 at 3:42 P.M., interview with LPN #404 revealed this was a normal off and on behavior for the resident. She stated the State tested nursing assistant (STNA) was in the resident's room a little bit ago but was not able to calm her down. She got better for a while when the doctor changed her medications but had begun the behavior again a couple weeks ago. She stated at times the resident can understand and be understood. At 3:53 P.M., the resident was brought out to the common area near the nurse's station but continued yelling out. She was placed in front of the television but not given anything to do. At 4:03 P.M., the resident continued yelling off and on but then was heard saying clearly I have to go to the bathroom. LPN #404 also heard this and asked STNA #405 if she had changed her lately and she stated yes. STNA #405 approached the resident and tried to distract her by talking with her which was not very effective and then STNA #405 walked away as the resident continued yelling out non-sensically . LPN #404 verified small lolly pops work in calming her down but since she had been on a pureed diet for awhile we don't give her any. The LPN was not sure what else would be effective and stated staff had not tried anything else.
On 07/17/19 at 11:25 A.M., the resident was observed being wheeled out of her room by STNA #337 and was crying out as she was placed in the common area near the nurse's station in front of the television. STNA #337 left the resident in the area as she continued to cry out.
On 07/17/19 at 11:26 A.M., interview with STNA #337 revealed this was an on going behavior the resident had but she did not even think the resident knew she was doing it and thought it was a habit. The STNA stated when the resident gets louder staff ask her if she wants to lay down, wants a drink or if she is in pain. The STNA revealed the one thing that was effective were the small lolly pops but she stated she hadn't given them to her in a while and didn't know if the facility had any.
On 07/17/19 at 4:46 P.M., the resident was observed being wheeled out of her room by STNA #414. The resident was crying out as she was placed in the common area near the nurse's station in front of the television and left by staff as she continued to cry out.
On 07/22/19 at 9:40 A.M., interview with the Director of Nursing (DON) revealed she was aware of the resident's crying and yelling out. When informed there were no interventions attempted besides putting the resident in front of the television which was not effective, the DON stated small lolly pops were affective but since the resident was changed to a pureed diet she had not been given them. When asked if speech therapy was involved to see if the lolly pops would be okay or if there was another similar candy that would be okay and she stated no. She verified there was no behavior care plan in place and no evidence of any effective interventions in an attempt to satisfy or calm the resident.
On 07/22/19 at 3:30 P.M., phone interview with the resident's daughter revealed this behavior started when the hospital gave the resident a medication she should not have had which had since been discontinued. She stated she visited her in the evening and she seemed to be better and staff tell her she is not yelling out or crying anymore but now she saw that she had been. She stated on occasion when she does it she would give her a small lolly pop and that was effective and the behavior would stop but they won't give her any now because she is on a pureed diet but they won't try anything else either. She stated she had talked to staff about trying something else but they don't listen to anything she says. The resident's daughter believed the resident moaned and yelled out when she gets scared and staff put her in front of the television and when they put other residents near her it seemed to scare her. The daughter thought this might be because she couldn't move at all by herself and she felt stuck there. The resident' daughter indicated the only intervention she saw staff do were to put the resident in front of the television.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #182 and #23, who had dementia, were provided adequate dementia care to ensure optimal psychosocial well being. This affected two residents (#182 and #23) of five residents reviewed for dementia care.
Findings include:
1. Review of Resident #182's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses which include dementia and anxiety. The resident passed away on 04/13/19.
Review of the behavior care plan initiated 10/23/18 revealed a plan of care related to the resident taking other resident's belongings, yelling at other male residents, thinking they were her husband and being physically abusive towards staff. There were no individualized interventions for the resident. Further review of the care plan revealed there was no plan of care related to the resident's diagnosis of dementia.
Review of the attending physician note dated 01/14/19 revealed the resident had become increasingly confused and was having more trouble with agitation at night and insomnia.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/23/19 revealed the resident was not interviewable, had delusions but the only behavior identified was wandering.
Review of the social service note dated 01/26/2019 revealed the resident continued to exhibit severe cognitive decline relative to her diagnosis of dementia. Most recently she had exhibited an increase in restlessness and anxiety which caused crying that did not resolve when consoled, expression of painful past memories related to her husband and poor appetite. She becomes anxious with excessive stimulation. The psychiatrist was consulted and an order was obtained for Buspar, an anti-anxiety medication.
Review of the nurse's note, dated 01/30/19 revealed the resident was having hallucinations, mood swings, tearfulness, going in other residents rooms looking in their drawers and closets and arguing with staff and other residents. She refused to stay in bed because she thought someone was going to kill her. She was given a shower and put to bed at midnight.
Review of the neurologist note dated 02/01/19 revealed the resident was being combative with staff and not sleeping sell with increased agitation which worsened at night. The medication Depakote (an anti-convulsant medication that can be used during manic phases of bipolar) was started at night.
Review of the February 2019 medication administrator record (MAR) for behavior monitoring documentation revealed the only behaviors were on 02/01/19 and 02/02/19.
Review of the nurse's note, dated 02/02/19 revealed the resident continued to have increased agitation with other residents accusing them of stealing her shoes, radio and clothes. The resident was attempting to go into other residents rooms to get her shoes or find her husband. No interventions were effective.
Review of the nurse's note, dated 02/05/19 revealed the resident was wandering throughout the hallway attempting to go into other resident's rooms. Attempts to redirect the resident back to bed were unsuccessful. The resident was taking to the lounge to watch television.
Further review of the February 2019 MAR reveled there were no behaviors noted on 02/10/19 or 02/11/19.
Review of the nurse's notes from 02/10/19 through 02/11/19 revealed on 02/10/19 beginning at 9:27 P.M., the resident was at the nurse's station being verbally inappropriate with staff, attempts to redirect back to bed were unsuccessful and all interventions ineffective. At 11:40 P.M., the resident continued to be verbally inappropriate with staff, yelling out profanity and entering other resident's rooms while they were sleeping. The resident was combative with staff, redirection, one on one and other interventions were ineffective. On 02/11/19 at 12:15 A.M., the physician was notified and ordered an intramuscular injection of Haldol, an antipsychotic medication used to make you feel less nervous, every six hours as needed for increased agitation. The medication was effective and the resident was sleeping in bed.
On 07/18/19 at 10:15 A.M., interview with the Director of Nursing (DON) revealed the facility has been working towards educating the physicians and nurses to contact the resident's psychiatrist, if applicable, when a change in behavior was noted because currently the attending physician was also ordering psychotropic medications if notified of a possible change in behavior and that is what happened in this case.
On 07/18/19 at 11:12 A.M., interview with the DON revealed the facility was unable to print off the education provided to staff regarding dementia care, managing challenging behaviors or delirium.
On 07/22/19 at 9:40 A.M., interview with the DON verified the documentation did not warrant the use of an intramuscular injection antipsychotic. There was no evidence of the resident attempting to do anything different that prior notes which did not warrant medications contained. The DON verified there was no care plan related to dementia just related to behavior problems which were not individualized to the resident. The DON verified the facility did not address the resident's change in not being able to sleep at night which had been on going and should not have lead to the need for Haldol on 02/11/19. The DON verified the resident saw the psychiatrist for the first time on 01/25/19 but they were not able to find the note.
On 07/22/19 at 7:00 P.M., phone interview with State Tested Nurse Aide (STNA) #387 revealed she did not recall having any dementia training since being employed at the facility since 01/08/19.
On 07/23/19 at 5:50 A.M., phone interview with STNA #314 revealed she did not recall having any dementia training since being employed at the facility since 08/09/18.
2. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including dementia with behavior disorder, delusions and schizophrenia.
Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #23 was severely impaired for daily decision-making and received daily antipsychotic medications.
Review of the Psychiatric Progress Notes revealed on 04/25/19 the resident's behavior was in control and the resident's antipsychotic medication, Seroquel was decreased from 25 milligrams (mg) to 12.5 mg. On 05/17/19, the psychiatric progress note indicated to continue Seroquel 12.5 mg at bedtime.
Review of the Physician's Orders dated May 2019 revealed Resident #23 received Seroquel 12.5 milligrams (mg) at bedtime related to psychosis. On 05/23/19, the attending physician ordered as needed (PRN) Haldol, an antipsychotic 1 mg intramuscularly (IM) for increased agitation and on 05/29/19 ordered Risperdal, an antipsychotic 0.25 mg daily for agitation.
Review of Resident #23's Progress Notes revealed the following:
On 05/23/19 at 8:46 P.M., the resident was angry, yelling and screaming due to her roommate's daughter visiting. The resident had increased agitation, anxiety and was combative with staff. The attending physician was notified and new orders were received.
On 05/28/19, Resident #23 was very agitated and had aggressive behavior towards staff and her room mates daughter. The attending physician was notified and new orders were received.
On 06/04/19, the physician was notified of Resident #23's increased confusion along with foul-smelling, cloudy urine and a urinalysis/culture sensitivity was ordered. On 06/05/19 at 4:22 P.M., the NP ordered Ceftin (antibiotic) 500 mg after being notified of the urinalysis results.
On 06/06/19 at 4:32 P.M., Resident #23's psychiatrist was updated on the resident's psychotic episode and that the attending physician had started the resident on Risperdal and has since started treatment for a urinary tract infection. The psychiatrist discontinued the Risperdal.
Review of the Medication Administration Record (MAR) dated May 2019 revealed Resident #23 received one dose of Haldol 1 mg IM for increased agitation on 05/23/19 at 9:00 P.M. in the left arm. The attending physician also ordered the resident to receive Risperdal 0.25 mg daily starting on 05/30/19 and Haldol 1 mg IM for increased agitation as needed (PRN).
Review of the MAR dated June 2019 revealed Risperdal 0.25 mg was administered daily between 06/01/19 and 06/06/19. The PRN Haldol was discontinued on 06/04/19.
Further review of the MAR's revealed the resident had no documented behaviors until 05/23/19 (night shift) through 05/29/19 and on 06/02/19 through 06/05/19. No other atypical behaviors were documented and there was no documented evidence of what targeted behaviors were exhibited other than what was documented in the progress notes.
Review of the record revealed no documented evidence Resident #23's psychiatrist was notified of the resident's behavior between 05/23/19 and 06/04/19 and no evidence the facility investigated the reason why Resident #23 became agitated when the roommates daughter visited.
Review of the record revealed no documented evidence non-pharmacological approaches were attempted prior to the notification of the attending physician or the administration of PRN Haldol.
Review of the current care plan titled At Risk for Drug Related Complications due to the use of psychotropic medication (last revised 06/07/18) revealed to observe for drug related side effects including increased confusion. Interventions included to attempt non-pharmacological interventions prior to medicating with PRN psychotropic medications i.e., redirection, calm environment, and 1:1 interaction, observe results and share effective interventions with other staff members. Review of the record revealed the facility had not identified or documented individualized interventions that were effective for the resident.
On 07/18/19 at 10:15 A.M., interview with the Director of Nursing (DON) revealed the facility has been working towards educating the physicians and nurses to contact the resident's psychiatrist, if applicable, when a change in behavior was noted because currently the attending physician was also ordering psychotropic medications if notified of a possible change in behavior and that was what happened in this case. Later a urinalysis was ordered and it was realized that the increased behavior was possibly due to an infection, the behaviors were related to this and the antipsychotics administered were not necessary. The DON stated when the psychiatrist was notified he discontinued the Risperdal.
On 07/18/19 at 11:12 A.M., interview with the DON revealed the facility was unable to print off the education provided to staff regarding dementia care, managing challenging behaviors or delirium.
On 07/18/19 at 11:17 A.M., further interview with the DON revealed she looked at new orders everyday and communicated with nursing staff to provide individualized care but it was a shift in thinking. The DON verified the facility did not identify or address possible issues that caused the agitation and the resident received unnecessary antipsychotic medication when actually the behavior was more than likely from the infection.
Review of the policy titled Psychotropic Medication Use (Antipsychotic's, Anxiolytics, Antidepressants, Hypnotics), dated November 2017 revealed psychotropic medications may be considered for residents with dementia, depression, anxiety and/or other mental disorders, but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Residents were only to receive psychotropic medications when necessary to treat specific conditions for which they were indicated and effective. The attending physician and facility staff were to identify acute psychiatric episodes and differentiate them from enduring psychiatric conditions. Diagnoses alone did not warrant the use of antipsychotic medication. In addition, antipsychotic medications would generally only be considered if the following conditions were also met: the behavioral symptoms present a danger to the resident or others and the symptoms are identified as being due to mania or psychosis (such as auditory, visual or other hallucinations; delusions, paranoia or grandiosity) or behavioral interventions have been attempted and included in the plan of care except in an emergency (which was an acute onset or exacerbation of symptoms or immediate threat to the health or safety of a resident or others).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #53 and #42's pharmacy recommendations contained physician responses with adequate rational for the continued use of medications including psychotropic medications. This affected two residents (#53 and #42) of five residents reviewed for unnecessary medication use.
Findings include:
1. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnosis including psychosis not due to substance or known physiological condition and major depression. Further review of physician's notes and hospital records revealed no documented evidence of a diagnosis of psychosis.
Review of Resident #53's physician's orders dated 01/24/19 to present revealed the resident was ordered the antipsychotic medication, Risperdal 0.5 milligrams (mg) twice daily for psychosis and the antidepressant medication, Lexapro 20 mg daily for depression. The resident's behaviors were identified to be restlessness, irritability and fearfulness. There was no evidence of targeted behaviors for the psychosis diagnosis.
Review of Resident #53's pharmacy recommendation dated 03/12/19 and 06/27/19 revealed the recommendation for a gradual dose reduction (GDR) of the Lexapro and Risperdal. On 03/12/19 the physician checked the behaviors were improved/maintained on current doses and no apparent side effects at this time. There was no evidence of individual rational for declining the GDR. On 06/27/19 the physician checked a box on the form that indicated a GDR would cause more risk than benefit. There was no evidence of individual rational for declining the GDR or how the GDR would cause more risk than benefit.
Review of Resident #53's behavior monitoring dated 01/05/19 to 07/16/19 revealed no evidence the resident had atypical behaviors including being restless, irritable or fearful.
Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment, dated 01/05/19 to 06/19/19 revealed the resident had no behaviors.
Interview on 07/16/19 at 3:48 P.M., with the Director of Nursing (DON) confirmed the pharmacy recommendation did not include an individual rational for declining the GDR requests. She confirmed the resident did not have any noted behaviors except two refusals of care since admission on [DATE]. She verified neither the physician progress notes nor the hospital records confirmed the diagnosis of psychosis.
2. Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses which included dementia with behaviors, congestive heart failure with insertion of a pacemaker, dementia, atrial fibrillation and ischemic cardiomyopathy.
Review of the resident's current physician orders included an order for Eliquis, an anticoagulant (blood thinner), Aspirin, a blood thinner, Plavix an antiplatelet medication, Zoloft, an antidepressant and Risperdal, an antipsychotic.
Review of the resident's 05/27/19 quarterly MDS 3.0 assessment revealed the resident was not interviewable and did not exhibit any behaviors.
Review of the pharmacy recommendation dated 12/17/18 revealed the resident was receiving Aspirin and Plavix together which was not advised for greater than 90 days. Review of the physician's response, dated 01/07/19 revealed to continue the current medications as ordered by the cardiologist.
Review of the pharmacy recommendation dated 02/15/19 revealed a recommendation for a GDR for Risperdal 1.0 milligrams (mg) and Zoloft 50 mg. The physician's response on 02/15/19 revealed the medications were controlling and improving the targeted symptoms and to continue the medications at the current doses.
Review of the cardiologist note dated 02/25/19 revealed the resident was ordered Aspirin and Eliquis and the Plavix was to be discontinued.
Review of the April, May, June and July 2019 medication administrator records (MAR) revealed the resident's targeted behaviors for the Risperdal were fearfulness, restlessness, irritability, verbal and sexual inappropriateness and paranoia. The targeted behaviors for the Zoloft were fearfulness, restlessness and irritability. The resident was not identified to have any of the above behaviors for the past four months.
On 07/15/19 at 9:52 A.M., 3:05 P.M. and 4:20 P.M., the resident was observed sitting in his recliner in his room. On 07/15/19 at 5:52 P.M., the resident was observed in the dining room attempting to feed himself but kept falling asleep. On 07/15/19 at 8:59 A.M., the resident was observed in his bed sleeping. On 07/16/19 at 12:33 P.M., the resident was observed reclined in his chair watching television (TV). On 07/16/19 at 2:27 P.M. and 3:51 P.M., the resident was observed laying in his bed sleeping. On 07/17/19 at 9:10 A.M., 10:45 A.M., the resident was observed laying in his bed sleeping.
On 07/18/19 at 3:00 P.M., interview with the DON verified the resident was still on the Aspirin, Eliquis and Plavix and they did not discontinue the Plavix as recommended by the pharmacist or ordered by the cardiologist. The DON verified the facility did not attempt any GDR's despite not having any documented behaviors.
On 07/22/19 at 8:45 A.M., the resident was observed laying in his bed sleeping.
Review of the consulting pharmacist monthly drug review policy, dated November 2016 revealed the pharmacist should report any identified medication irregularities, unnecessary drugs and review psychotropic medications for excessive doses, duration, monitoring, adverse consequences monthly and documented on a separate written report. The physician must document in the medical record the irregularities had been reviewed and what if any action had been taken. If no change in the recommendation the physician must document on the next visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure psychotropic medication use was justified and only used to treat appropriate behaviors, failed to ensure behavioral symptoms were monitored and/or failed to ensure gradual dose reductions were attempted as required to meet the needs of Resident #5, #44 and #53. This affected three residents (#5, #44 and #53) of five residents reviewed for unnecessary medication use.
Findings include:
1. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including psychosis not due to substance or known physiological condition and major depression. Review of Resident #53's discharge hospital records dated 12/26/18 revealed no evidence of a bipolar or psychosis diagnoses.
Review of Resident #53's physician's orders, dated 01/24/19 to present revealed the resident was ordered the antipsychotic medication, Risperdal 0.5 milligrams (mg) twice daily for psychosis and the antidepressant medication, Lexapro 20 mg daily for depression. The resident's identified behaviors were noted to be restlessness, irritability and fearfulness. There was no evidence of targeted behaviors for the psychosis diagnosis.
Review of Resident #53's physician's office notes, dated 03/12/19, 03/21/19 and 05/16/19 revealed the resident was on Risperdal 0.25 mg daily at bedtime. There was no evidence of a bipolar or psychosis diagnosis.
Review of Resident #53's behavior monitoring dated 01/05/19 to 07/16/19 revealed no evidence the resident had atypical behaviors including restlessness, irritability or fearfulness.
Review of Resident #53's Minimum Data Set (MDS) 3.0 assessments, dated 01/05/19 to 06/19/19 revealed the resident had no behaviors, including psychosis behaviors.
Review of a verification of diagnoses letter from Resident #53's physician dated 07/16/19 revealed the resident had been on Risperdal for greater than eight years for bipolar two disorder and psychosis. The resident had been treated by mental health care in the past. The letter indicated the resident's current Risperdal order was 0.25 mg daily at bedtime, however the treatment indicated to continue Risperdal 0.5 mg daily. The resident's orders indicated the resident was ordered Risperdal 0.5 mg twice daily since 01/15/19.
Interview on 07/16/19 at 1:06 P.M. and 3:13 P.M. and 07/17/19 at 10:32 A.M. with the Director of Nursing (DON) verified the resident's psychosis diagnosis was initially documented from a previous stay in the facility in 2018. She called the physician's office to clarify the psychosis diagnosis since it was not listed on the physician progress notes or in the hospital records. The physician's office reported the resident had a diagnosis of bipolar disorder in addition to the psychosis and had received treatment in the past from a mental health facility. The resident had been on medication for these disorders for over eight years. The DON verified the facility was not aware of the bipolar diagnosis until today. She reported targeted behaviors were determined by interviewing the resident and medication review. The DON verified there were no noted targeted behavior (delusion, hallucination) for the psychosis diagnosis. She verified the physician notes were inaccurate to reflect the resident current dose of Risperdal.
Interview with the mental health facility on 07/17/19 at 10:14 A.M. revealed the resident had not been seen since 09/2018 and was only seen for medication management. She was not seen for counseling. The mental health facility offered services for primary care, therapy, case mangers (arrange transportation and appointments), and they have a nurse practitioner that does medication management for behaviors medication such as depression, anxiety, psychosis, etc.
Interview on 07/17/19 at 9:39 A.M., interview with Resident #53 revealed she had never been diagnosed with bipolar disorder or psychosis. She stated she had some issues with depression and anxiety related to losing a son four years ago and had been on medication for that. She stated she had not been hospitalized or received counseling services for mental health.
2. Record review revealed Resident #5 was admitted to the facility on [DATE] with a diagnosis which included dementia with behaviors.
Review of the current psychotropic medication care plan revealed to address pharmacist recommendations. There was no actual behavior care plan developed for the resident to identify behaviors and/or the use of psychotropic medications.
Review of the resident's initial physician orders, dated 04/17/18 until current revealed the resident was on Ativan, an antianxiety medication, 0.25 mg at night. The resident was on the antipsychotic medication, Seroquel 50 mg twice a day and 150 mg at night.
Review of the pharmacy recommendations, dated 10/13/18 recommended a GDR for the Ativan. The physician's response, dated 11/19/18 revealed the dose, duration and indications were clinically appropriate but did not indicate why attempted reductions were contraindicated. At the time of the survey, the facility was not able to locate the December 2018 recommendations.
Review of the pharmacy recommendations dated 01/11/19 continued to recommend a GDR for the resident's Ativan. The physician's response, dated 01/31/19 revealed no changes-check with the psychiatrist. Further review revealed there was no documented evidence the psychiatrist was contacted.
Review of the pharmacy recommendations dated 02/15/19, 04/04/19 and 05/09/19 continued to recommend a GDR for Ativan and stated the resident was on a high dose of Seroquel, an antipsychotic, at night and maybe the Ativan might no longer be needed. Further review revealed the physician did not make any changes nor give any rationale as to why no changes should be made.
Review of the annual MDS 3.0 assessment, dated 04/08/19 revealed the resident was not interviewable and had behaviors of rejecting care one to three days during the assessment reference period.
Review of the medication administrator record (MAR) for May, June and July 2019 revealed the resident continued on the Ativan 0.25 mg at night and Seroquel 150 mg at night as well as 50 mg twice a day. Further review of the MAR revealed the resident was being monitored for behaviors including fearfulness, irritability, being combative with care and verbal aggression but there was no evidence the resident displayed any of these behaviors in the past three months.
On 07/15/19 at 12:50 P.M., the resident was observed being fed lunch. On 07/15/19 at 3:00 P.M. and 4:17 P.M., the resident was observed sleeping in bed. On 07/16/19 at 8:59 A.M. and 3:35 P.M., the resident was observed sleeping in bed. On 07/17/19 at 9:05 A.M. and 10:41 A.M., the resident was observed in sleeping in bed. On 07/17/19 at 3:44 P.M., the resident was observed in her wheelchair in the common area looking around. On 07/22/19 at 8:40 A.M., the resident was observed sleeping in bed.
On 07/22/19 at 9:40 A.M., interview with the DON verified there was no documented evidence to support the continued use of the Ativan without attempted a GDR and verified the physician had not addressed the GDR since 10/13/18.
3. Record review revealed Resident #44 was admitted to the facility on [DATE] with a diagnosis which included dementia with behaviors and psychosis.
Review of the 01/28/19 pharmacy recommendation revealed the resident had been on Zoloft 50 mg at night, an antidepressant, since 03/02/17 without a GDR. On 01/28/19 the physician agreed to reduce the medication. Further review of the nurse note on 01/28/19 revealed the daughter was notified and did not want the dose reduced therefore the dose was not reduced.
Review of the pharmacy recommendations dated 02/26/19, 04/29/19 and 05/20/19 revealed recurrent recommendations to reduce the Zoloft because it continued at 50 mg. With each recommendation the physician declined the reduction without giving justification.
Review of the MAR's for targeted behaviors revealed the medication was used for repetitive sounds, crying, fidgeting and restlessness. Further review of the MAR revealed the resident had few behaviors documented for May and July 2019 and none for June 2019.
On 07/22/19 at 9:50 A.M., interview with DON verified originally the physician agreed to try a GDR on 01/28/19 but when the daughter was notified she refused and the physician continued at the original dose of 50 mg. No additional attempts to reduce the medication had been attempted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure beneficiary notices and elopement assessments were legible and accurate. This affected one resident (#34) of two residents reviewed for elopement and one resident (#9) of three residents reviewed for beneficiary notices.
Findings include:
1. Medical record review revealed Resident #34 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbance.
Review of the care plan titled At Risk for Elopement revised 06/11/18 revealed a wander guard/code alert (electronic device that sounds when the device goes through a door leading outside the facility) was to be worn daily, check function weekly and placement every shift.
Review of the quarterly Wander Risk Evaluation dated 11/15/18, 02/13/19 and 05/18/19 revealed Resident #34 was not at risk for elopement.
Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #34 used a wander elopement alarm daily.
Review of the Physician Orders dated July 2019 revealed staff was to check placement and function of Resident #34's code alert every shift.
On 07/16/19 at 9:42 A.M., Resident #34 was observed self-propelling in a wheelchair wearing a code alert.
On 07/17/19 at 11:50 A.M., interview with the Director of Nursing verified the elopement assessment and the care plan: At Risk for Elopement were inaccurate.
2. Record review revealed Resident #9 was admitted on [DATE] with diagnoses including chronic respiratory failure.
Review of Resident #9's Beneficiary Protection Notification revealed a Medicare Non-Coverage note dated 02/09/19 for skilled services to in February 2019. The day the skilled services was to end and the date written by the resident's signature was not legible.
On 07/16/19 at 11:11 A.M. interview with Director #378 verified the original date typed on the notice had been written over and not legible stating it had been changed because the wrong date was entered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the infection control log, policy review and interview the facility failed to ensure infection control practices were maintained during meal services to prevent the spread of infection. The facility also failed to ensure the infection control log was comprehensive to include all infections. This had the potential to affect all 79 residents residing in the facility.
Findings include:
1. Observation of lunch meal on 07/15/19 at 12:04 P.M. revealed Staff member #391 applied a gown and gloves and entered room [ROOM NUMBER], a contact isolation. The staff member was observed to touch the resident's bedside table and set up the resident's meal tray. The staff member removed her gloves and gown and left the room without providing hand hygiene.
An interview with Staff member #391 immediately following the observation verified the staff member did not complete any type of hand hygiene after removing gloves and exiting room [ROOM NUMBER] for a resident who was in contact isolation.
Review of the isolation policy dated 01/2012 revealed for contact isolation to remove gloves before leaving the room and perform hand hygiene.
2. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including urinary tract infections (UTI), overactive bladder and benign prostatic hyperplasia.
Review of Resident #26's physician's orders and medication administration records (MAR) dated 06/28/19 to 07/03/19 revealed Resident #26 received Bactrim DS twice daily for UTI.
Review of Resident #26's progress notes dated 05/28/19 to 07/04/19 revealed no evidence the resident had urinary symptoms. On 05/28/19 there was a note indicating to recheck urinalysis in one month. On 06/28/19 there was a note for new orders for the Bactrim, however no evidence of urinary symptoms.
Review of Resident #26's urine culture results dated 06/25/19 revealed the urine was positive for providencia stuartii and was sensitive to Bactrim.
Review of the infection control log dated 06/19 to 07/19 revealed no evidence Resident #26 was noted on the log.
Interview on 07/18/19 at 12:43 P.M., with Registered Nurse (RN) #359 confirmed the resident received Bactrim DS twice daily for a UTI from 06/28/19 to 07/03/19, however he was not included on the infection control log.
Review of infection policy and procedure, dated 07/2019 revealed resident infection would be monitored and reported on the line listing of infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of antibiotic stewardship log, review of McGeer criteria and interview the facility failed to implement a comprehensive antibiotic stewardship program to monitor and prevent the unnecessary/inappropriate use of antibiotics. This affected two residents (#26 and #47) and had the potential to affect all 79 residents residing in the facility.
Findings include:
1. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including urinary tract infections (UTI), overactive bladder, and benign prostatic hyperplasia.
Review of Resident #26's physician's orders and medication administration records (MAR) dated 06/28/19 to 07/03/19 revealed Resident #26 received Bactrim DS twice daily for UTI.
Review of Resident #26's progress notes dated 05/28/19 to 07/04/19 revealed no evidence the resident had urinary symptoms. On 05/28/19 there was a note indicating to recheck urinalysis in one month. On 06/28/19 there was a note for new orders for the Bactrim, however no evidence the resident had urinary symptoms.
Review of Resident #26's urine culture results dated 06/25/19 revealed the urine grew less than 100,000 colony-forming units per milliliter (CFU/ml) providencia stuartii and was sensitive to Bactrim.
Review of the antibiotic stewardship log dated 06/19 to 07/19 revealed no evidence Resident #26 was noted on the log or met criteria for treatment.
Review of McGeer criteria for UTI revealed the resident without an indwelling catheter must meet both criteria one and two.
Criteria one included the resident must meet one of the following sign or symptoms:
A. acute dysuria or acute pain, swelling, tenderness of the testes, epididymis, or prostate.
B. Fever or leukocytosis and one of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase incontinence, urgency, or frequency.
C. In the absence of fever or leukocytosis, then two of more of the following localizing urinary tract sub criteria must be meet: suprapubic pain, gross hematuria, new or marked increase incontinence, urgency, or frequency.
The second criteria in which one of the following must be met:
A. at least 10 5 cfu/ml or more than two species of microorganisms in a voided urine sample or
B. at least 10 2 cfu/ml of any number of organisms in a specimen collected in-and-out catheter.
Interview on 07/18/19 at 12:43 P.M., with Registered Nurse (RN) #359 confirmed the resident received Bactrim DS twice daily for a UTI from 06/28/19 to 07/03/19, however he was not included on the antibiotic stewardship log nor was there a McGeer form completed to ensure resident met criteria. The urine culture was only obtained as it was ordered on 05/28/19 to be rechecked in one month.
2. Record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including dementia, cataract, and Methicillin-resistant Staphylococcus aureus (MRSA) of the left eye.
Review of Resident #47's progress notes, culture results, Medication Administration records (MAR), and orders dated 07/03/19 to 07/06/19 revealed on 07/03/19 the resident's left eye looked swollen, red, tender/painful to touch. The physician was updated, and new orders were received for Tobrex eye drops two drops four times day and culture left eye. If no improvement after 48 hours notify the physician.
On 07/06/19 the culture results returned and was positive for MRSA and sensitive to Gentamicin and resistant to Erythromycin. The lab suggested recollecting the specimen as the specimen was missing the resident's date of birth on the specimen.
On 07/06/19 new orders were received for Gentamicin 0.3% ointment three times daily until clear and warm compresses three times daily until healed. The Gentamicin was noted to be on back order and new orders were received for Erythromycin ointment 5% three times a day for seven days, which the culture indicated was resistant to the organism.
The MAR indicated the resident received two doses of the Erythromycin on 07/06/19.
Another physician was notified of the culture results later that day on 07/06/19 and new orders were given for Polytrim drops two drops to left eye three times daily, Keflex 250 milligrams (mg) three times daily for seven days, Probiotic twice a day for seven days, and to place the resident on contract isolation.
Review of physician's progress notes revealed no evidence the physician assessed the resident 72 hours after prescribing antibiotics over the phone. The last time the physician saw the resident was on 06/27/19.
Review of the McGeer Criteria infection Surveillance checklist dated 07/09/19 revealed for conjunctivitis the resident must meet at least one of the criteria:
Pus from one or both eyes greater than 24 hours, new or increased conjunctival erythema and new or increased conjunctival pain for greater than 24 hours. The resident form indicated she met the criteria because she had pain for greater than 24 hours only. There was no evidence the resident had received the Erythromycin; however, the form included the Tobrex, Polytrim, and Keflex.
Review of the antibiotic stewardship log and infection control log dated 07/2019 revealed no evidence the resident received Erythromycin.
Review of antibiotic stewardship policy and procedure, dated 11/2017 revealed antibiotics would be prescribed and administered to residents under the guidance of the facility Antibiotic Stewardship Program. To ensure the facility would use a format to track and trend antibiotic usage. When antibiotics were prescribed over the phone the primary care practitioner would assess the resident within 72 hours of the telephone order.
Interview on 07/18/19 at 10:49 A.M., with RN #359 verified the resident had not been seen by the physician within 72 hours after receiving the telephone order for antibiotic treatment per policy, the culture was resistant to Erythromycin and the resident received two doses. She verified she was on vacation the end of June 2019 and the first of July 2019 and the McGeer criteria and logs for the resident were not completed until she returned to work the following week.
3. Review of the infection/antibiotic trending surveillance dated 04/2019 to 07/2019 revealed there were five to seven residents who were noted not to have met the McGeer criteria and received antibiotic treatments.
Interview on 07/18/19 at 10:49 A.M., with RN #359 verified these findings and reported she had just started transitioning into the program in April 2019. RN #359 revealed she was going to meet with the physician to try to decrease antibiotic use. She was also scheduled to attend training.