**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure residents with limited range of motion received necessary equipment to prevent a further decrease in range of motion for 1 of 1 sampled resident (#3) reviewed for position and mobility. This placed residents at risk for worsening contractures. Findings include: Resident 3 was admitted to the facility in 2017 with diagnoses including contracture of multiple joints. Resident 3's 2/14/24 Quarterly MDS indicated the resident rarely/never made decisions, was dependent for all ADLs and experienced upper extremity impairment on both sides. A 3/6/24 Pediatric Physical Therapy Treatment Note indicated Resident 3 utilized hand splints. Resident 3's current HOB (Head of Bed) Care Plan directed the resident to wear hand splints when up in her/his wheelchair. Random observations of Resident 3 on 4/15/24 and 4/16/24 between 10:14 AM and 3:49 PM revealed the resident was up in her/his wheelchair without hand splints. The resident's fingers curled in towards the palm of her/his hands in the shape of a fist. On 4/17/24 at 11:12 AM Staff 3 (PT) stated Resident 3 was to wear hand splints when she/he was in her/his wheelchair and the splints were to be removed when the resident was in bed. On 4/17/24 at 11:27 AM and 3:49 PM Staff 4 (OT) stated Resident 3 was to wear hand splints when she/he was out of bed and in her/his wheelchair. Staff 4 further stated the hand splints were used for contracture prevention. On 4/17/24 at 12:22 PM Staff 5 (CNA) and at 12:24 PM Staff 6 (RN) indicated they found information about a resident's care needs in the resident's [NAME] (a tool that makes resident information accessible in a concise manner) or in the HOB care plan. Staff 5 and Staff 6 stated they had never seen Resident 3 wear hand splints and did not think the resident needed them. On 4/17/24 at 2:12 PM Staff 7 (RNCM) stated a resident's HOB care plan was the primary spot where direct care staff should go to find therapy-related information on residents, including the type of equipment used. Staff 7 reviewed Resident 3's HOB care plan and stated the resident should wear hand splints when she/he was up in her/his wheelchair. On 4/18/24 at 2:32 PM Staff 2 (DNS) and Staff 8 (Nurse Manager) acknowledged the findings of this investigation. Staff 2 confirmed information on resident equipment needs was found in the resident's HOB care plan and the types of equipment used by residents was determined by PT. Staff 8 stated she expected Resident 3 to wear hand splints when in her/his wheelchair.

Based on interview and record review it was determined the facility failed to thoroughly investigate falls for 1 of 2 sampled residents (#8) reviewed for accidents. This placed residents at risk for unmet needs. Findings include: Resident 8 admitted in 5/2022 with diagnoses including Alzheimer's disease and a history of falls. Fall investigations revealed the following: *Fall #1: -On 6/25/22 Staff 23 (Former LPN) heard a noise from Resident 8's room and found the resident with her/his back to the toilet in a seated position on the floor. Resident 8 had a skin tear to the right elbow. Staff 16 (CNA) last toileted Resident 8 at 5:30 AM and Staff 16 indicated he assisted her/him to the bathroom roughly six times throughout the night. The bed alarm was not on when Resident 8 was found on the floor with her/his back to the toilet. The investigation revealed Staff Resident 8 transferred herself/himself to the bathroom unassisted however, Staff 16 forgot to reset the bed alarm after taking Resident 8 to the bathroom at 5:30 AM. Resident 8 had no attempts to get out of bed prior to the incident. No indication of abuse. -The investigation did not include any witness statements or if Resident 8 had any signs or symptoms of impulsiveness prior to the 6/25/22 incident. -Records reviewed from 6/12/22 through 6/24/22 revealed Resident 8 was confusion, was impulsive, attempted to get up out of bed frequently to utilize the bathroom. Resident 8 did not complain of pain with urination, urine was yellow in color with no odor. -A progress note dated 6/26/22 revealed during a shower, staff discovered a bruise on the back of Resident 8's head and she/he confirmed hitting her/his head on the ground during the fall on 6/25/22. *Fall #2 On 12/15/22 Staff 8 (RN) heard Resident 8 yelling help, pee pee from the nurse's station. Staff 8 entered the room and found Resident 8 on the floor with her/his back against the bed and the bed alarm was not sounding. Resident 8 stated owie, my bottom, I fell. No sign of injury and she/he did not hit her/his head. Staff indicated Resident 8 was checked on 30 minutes prior to the incident by Staff 15 (CNA). -Staff 22 (Former RN) indicated Resident 8 was checked 30 minutes before she/he was found on the floor. Staff 15 indicated she thought she set the bed alarm but stated she must not have. The investigation revealed Resident 8 self-transferred, no injury, resident did not use call light and was impulsive. No indication of abuse. -A 12/15/22 progress note prior to Resident 8's fall indicated she/he had increased confusion was impulsive during the shift and her/his right hip was red hot to the touch and the redness was moving outside of the previous markers. Cream was applied to the area and Resident 8 was easily redirected. -The investigation did not include any additional witness statements or if Resident 8 had any signs or symptoms of impulsiveness or other potential concerns prior to the 12/15/22 incident. On 1/27/23 at 11:33 AM Staff 3 (DNS) stated she was unable to locate any documentation related to the witness statements for the 6/25/22 or 12/15/22 fall incidents. Staff 3 stated she would expect staff to initiate the investigation and include who, what, when, where, why, and an analysis of what the resident was doing prior or possible behaviors. Staff 3 further stated what they would implement after and if the care plan needed to be updated. On 1/30/23 at 10:04 AM Staff 11 (Former DNS) stated Staff 12 completed the investigations for the 6/2022 and 12/2022 falls vand would expect any person or resident who witnessed or had information related to the resident prior to be interviewed and their information incorporated into the incident report. Staff 11 stated she expected witness statements to be documented. On 1/30/23 at 12:26 PM Staff 12 (Former Assistant Care Manager/Certified Recreational therapist) stated she completed the investigations on 6/25/22 and 12/15/22. Staff 12 stated she would interview all staff in relation to the incident and residents. Staff 12 stated she would summarize her analysis of the incident to rule out abuse and neglect and witness statements should be documented. Refer to F689

Based on interview and record review it was determined the facility failed to assure a Level I PASARR (Preadmission Screening for Individuals with a Mental Disorder and Individuals with Intellectual Disability) was completed for 1 of 2 sampled residents (#10) reviewed for PASARR. This placed residents at risk for inappropriate placement in a nursing facility and a lack of needed services. Findings include: Resident 10 was admitted to the facility in 10/2020 with diagnoses including Lennox-Gastaut syndrome (a seizure disorder) and cerebral palsy. A review of the resident's electronic health record revealed Resident 10 was admitted for long term care in 10/2020 without the completion of a screening Level I PASARR. On 1/25/23 at 8:58 AM Staff 2 (DNS) stated an emergency suspension of PASARR's was in effect at the time of Resident 10's admission into long term care and was not required. On 1/25/23 at 3:57 PM Staff 5 (Administrative Assistant) stated the facility attempted to obtain a Level I PASARR for Resident 10 on 9/28/20. On 1/27/23 at 10:14 AM, Staff 3 (DNS) and Staff 5 confirmed Resident 10 did not have a screening for a Level I PASARR and provided no further information.

Based on and interview and record review it was determined the facility failed to ensure a bowel protocol was implemented for 1 of 5 sampled residents (#30) reviewed for medications. This placed residents at risk for constipation. Findings include: Resident 30 was admitted to the facility in 12/2022 with diagnoses including hydrocephalus (a brain disorder in which excess fluid accumulates in the non-fluid chambers of the brain), diabetes and schizoaffective disorder. Resident 30's 1/2023 physician orders instructed staff to administer the following: - polyethylene glycol (Miralax) powder for constipation daily as needed starting on 12/28/22; - senna (Senokot) tablet for constipation two times daily as needed starting on 12/28/22. Resident 30's 1/2023 bowel tracking revealed she/he had no bowel movement for four consecutive days (1/10, 1/11, 1/12 and 1/13/23). Resident 30 had a bowel movement on 1/14/23 and then no bowel movement for five consecutive days (1/15, 1/16, 1/17, 1/18 and 1/19/23). Resident 30's 1/2023 MAR revealed no medication was administered for constipation in 1/2023. There was no evidence Resident 30's physician was notified of the resident's lack of bowel movements and no clarification regarding the resident's bowel protocol. On 1/30/23 at 10:30 AM Staff 2 (DNS) stated bowel protocols were resident specific and she expected staff to administer medications as ordered. She stated the bowel medication orders for Resident 30 were to be administered as needed and they did not specify how many days to wait before they should be administered. Staff 2 confirmed Resident 30 did not have clear bowel care orders, was at risk for constipation due to the amount of time she/he did not have a bowel movement and was not administered medication for constipation. On 1/30/23 at 11:00 AM Staff 14 (CNA) Staff 24 (RN) and Staff 25 (RN) were present at the nursing station. Staff 14 reviewed Resident 30's bowel tracking with the state surveyor and confirmed she/he had no bowel movement from 1/10/23 through 1/13/23 and 1/15/23 through 1/19/23. Staff 24 and Staff 25 stated constipation medication would be administered to residents when a resident did not have a bowel movement for three days unless otherwise specified. Staff 25 stated bowel protocols were specific to each resident. Staff 24 and Staff 25 indicated the physician was to be called when orders were not clear. Staff 25 confirmed Resident 30 did not receive medication for constipation in 1/2023, her/his bowel orders were not clear.

Based on interview and record review it was determined the facility failed to ensure fall safety measures were in place for 1 of 2 sampled residents (#8) reviewed for accidents. This placed residents at risk for increased falls. Findings include: Resident 8 admitted in 5/2022 with diagnoses including Alzheimer's disease and a history of falls. Fall investigations revealed the following: *Fall #1 on 6/25/22: -Staff 23 (Former LPN) heard a noise from Resident 8's room and found her/his back to the toilet in a seated position on the floor. Resident 8 had a skin tear to the right elbow. Staff 16 (CNA) last toileted Resident 8 at 5:30 AM and Staff 16 indicated he assisted her/him to the bathroom roughly six times throughout the night. The bed alarm was not on when Resident 8 was found on the floor with her/his back to the toilet. The investigation revealed Resident 8 self-transferred herself/himself to the bathroom however Staff 16 forgot to reset the bed alarm after taking Resident 8 to the bathroom at 5:30 AM. Resident 8 had no attempts to get out of bed prior to the incident. No indication of abuse. *Fall #2 on 12/15/22: -Staff 8 (RN) heard Resident 8 yelling help, pee pee from the nurse's station. Staff 8 entered the room and found Resident 8 on the floor with her/his back against the bed and the bed alarm was not sounding. Resident 8 stated owie, my bottom, I fell. No sign of injury and Resident 8 did not hit her/his head. Staff indicated Resident 8 was checked on 30 minutes prior to the incident by Staff 15 (CNA). Staff 22 (Former RN) indicated Resident 8 was checked 30 minutes before she/he was found on the floor. Staff 15 indicated she thought she set the bed alarm but stated she must not have. The investigation revealed Resident 8 self-transferred, no injury, resident did not use call light and was impulsive. No indication of abuse. On 1/24/23 at 1:15 PM Staff 8 stated he was present on 12/15/22 and heard Resident 8 yelling, when he entered the room. Resident 8 was sitting on the ground, she/he had three side rails up and a table to block the other side of the fourth rail. Resident 8 pushed the bedside table away to exit the bed and the bed alarm did not sound and was not on. Staff 8 stated she/he had some minor bruising but no injuries. Staff 8 stated three staff assisted Resident 8 back into bed. On 1/24/23 at 1:25 PM Staff 15 (CNA) stated she was present on 12/15/22 but not in the room when Resident 8 swung her/his legs over the bed and was found on the floor by Staff 8. Staff 15 stated the bed alarm did not sound. Staff 15 stated Staff 8 heard the resident and entered the room and found her/him on the floor. Staff 15 indicated she had worked with Resident 8 prior to the fall and could not recall if she ensured the bed alarm was on or not. Staff 15 stated Resident 8 was often confused and impulsive. On 1/25/23 at 1:12 PM Staff 16 (CNA) stated Resident 8 was a fall risk, impulsive and attempted to get out of bed often. Staff 16 indicated on 6/25/22 when Resident 8 attempted to get out of her/his bed and her/his bed alarm did not sound and she/he did not use her/his call light. Staff 16 stated he forgot to turn the bed alarm back on after assisting with her/his ADL care needs prior to the fall. Staff 16 further stated he took Resident 8 to the bathroom multiple times on his shift that night. On 1/27/23 at 11:33 AM Staff 3 (DNS) acknowledged the bed alarm was not turned back on after ADL care was provided on 12/25/22 but she could not speak to the 6/2022 incident but would expect staff to follow and implement the care plan. On 1/30/23 at 10:04 AM Staff 11 (Former DNS) stated she recalled the incident with Resident 8 in 6/2022 and Staff 16 toileted the resident multiple times and forgot to ensure the bed alarm was turned back on. Staff 11 did not recall the 12/2022 incident but would expect staff to follow the care plan.

Based on interview and record review it was determined the facility failed to have a contract with the dialysis provider for 1 of 1 sampled resident (#83) reviewed for dialysis services. This placed the resident at risk for unmet needs. Findings Include: Resident 83 was admitted to the facility in 1/2023 with diagnoses including end-stage renal disease requiring dialysis. Resident 83 received dialysis three days each week. On 1/27/23 at 3:27 PM Staff 1 (Administrator) confirmed the facility did not have a contract with the dialysis clinic that served Resident 83. She stated the facility had no contracts with any other dialysis facilities and would need to develop those for future needs.

2. Resident 30 was admitted to the facility in 12/2022 with diagnoses including hydrocephalus (a brain disorder in which excess fluid accumulates in the non-fluid chambers of the brain), diabetes, tardive dyskinesia (a condition affecting the nervous system, often caused by long-term use of psychiatric medication) and schizoaffective disorder. a. A physician order with a start date of 12/27/22 directed staff to administer one drop of latanoprost eye solution to both eyes nightly. The 12/2022 MAR revealed on 12/27/22 at 8:03 PM the medication was not available. b. A physician order with a start date of 12/27/22 directed staff to administer one 40 mg capsule of valbenazine (a medication used to treat tardive dyskenisia) nightly. The 12/2022 and 1/2023 MAR revealed the following dates and times the medication was not available: - 12/27/22 at 8:03 PM - 12/28/22 at 8:17 PM - 12/29/22 at 8:06 PM - 12/30/22 at 8:53 PM - 12/31/22 at 8:16 PM - 1/1/23 at 9:23 PM c. A physician order with a start date of 12/28/22 directed staff to administer one CertaVite Senior tablet one time daily. The 12/2022 MAR revealed the medication was not available on: - 12/28/22 at 10:00 AM - 12/29/22 at 8:29 AM d. A physician order with a start date of 12/30/22 directed staff to administer one tablet of multivitamin with minerals one time daily. The 1/2023 MAR revealed the medication was not available on 1/3/23 at 9:25 AM. On 1/30/23 at 10:30 AM Staff 2 (DNS) stated she expected staff to administer medications as ordered. On 1/30/23 at 11:00 AM Staff 25 (RN) reviewed Resident 30's 12/2022 and 1/2023 MAR and confirmed Resident 30's medications were documented as not having been administered and were noted to have been unavailable. Staff 25 stated the facility utilized so many contracted staff and they did not always know where to go to obtain medications especially if the medications were house stock medications. Staff 25 stated Resident 30 should have received her/his medications as ordered. On 1/30/23 at 12:57 PM Staff 1 (Administrator) was informed of the findings of this investigation and stated Resident 30 should have received her/his medications as ordered. Based on observation, interview and record review the facility failed to provide pharmaceutical service to ensure accurate acquiring, receiving and dispensing of medications for 2 of 5 sampled residents (#s 8 and 30) reviewed for medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 8 admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease and a pelvic fracture. a. A physician order start date on 11/2/22 directed staff to administer Tylenol two tablets three times daily for pain. The 12/2022 MAR revealed the following: -12/31/22 at 9:22 AM and 2:06 PM Tylenol was not available. b. A physician order start date on 1/3/23, (a new order was placed approximately every seven days) 1/7/23, 1/14/23 and 1/21/23 directed staff to apply miconazole (antifungal medication) cream twice daily following perineal care. Ensure groin area was thoroughly dried prior to application of miconazole to her/his groin area bilaterally for Resident 8's rash. The 1/2023 MAR revealed the following: -1/3/23 at 9:25 AM indicated not administered at 8:26 PM miconazole was applied. -1/4/23 at 8:56 AM indicated not administered at 8:22 PM miconazole was applied. -1/6/23 at 9:30 AM miconazole was applied at 8:18 PM indicated not administered. -1/8/23 at 9:53 AM indicated not administered at 8:10 PM miconazole was applied. -1/14/23 at10:54 AM indicated not administered at 8:59 PM miconazole was applied. -1/21/23 at 10:25 AM and 8:23 PM indicated miconazole was not administered. -1/22/23 at 7:25 AM and 8:29 PM indicated miconazole was not administered. -1/23/23 at 9:43 AM indicated not administered at 8:04 PM miconazole was applied. On 1/26/23 at 10:02 AM Staff 8 (RN) stated on 12/31/22 he did not administer two doses of the resident's Tylenol because the medication was not available and needed to be reordered through the house stock. Staff 8 stated there were multiple days Resident 8's miconazole cream was not applied because the cream was not available. Staff 8 stated he re-ordered the miconazole cream through the pharmacy which was delayed for a couple of days (1/21/23 and 1/22/23) and Resident 8 did not get her/his miconazole cream applied. Staff 8 further stated at times it was difficult to receive or know if medication and creams were followed up on because the facility often utilized agency staff. On 1/26/23 at 2:59 PM Staff 9 (Pharmacist) stated Tylenol was typically on the unit and not something staff would have to order. The miconazole would be ordered through the pharmacy and if the facility was out on the unit staff could request stat which would be filled quickly and dispensed to the unit. In an interview and observation on 1/26/23 at 4:35 PM Staff 6 (RN) stated the facility had OTC (over the counter) Tylenol in the medication storage room and in the top drawer of the medication cart. Staff 6 showed the surveyor the medication room with the OTC medications and the medication cart which both included Tylenol. Staff 6 stated not all staff were aware of the medication room or what was stocked and available in the medication room. Staff 6 stated Resident 8's miconazole cream was applied twice daily and if the cream was almost out staff were expected to place an order through the pharmacy and follow-up on the order. Staff 8 further stated staff were not always good at following up on pharmacy orders because the facility utilized agency staff. On 1/27/23 at 11:33 AM Staff 3 (DNS) acknowledged the Tylenol not being administered on 12/31/22 and the miconazole cream not being applied when it was available. Staff 3 stated staff were expected to follow physician orders and if unsure on were to locate or order medication or creams staff were expected to ask for assistance.

Based on interview and record review it was determined the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless deemed appropriate by the attending physician for 1 of 5 sampled residents (#23) reviewed for medications. This placed residents at risk for receiving unnecessary medications and adverse side effects. Findings include: Resident 23 admitted to the facility in 11/2022 with diagnoses including stroke and anxiety. A physician order start date of 11/27/22 directed staff to administer prochlorperazine (anti-anxiety and used to control severe nausea and vomiting) PRN for nausea. A Pharmacist Consult Report dated 12/8/22 and 1/25/23 revealed prochlorperazine was an antipsychotic and required a 14-day review/renewal. The 12/23/22 MAR revealed Resident 23 was administered prochlorperazine for nausea. A review of Resident 23's revealed no written rationale or indication of ongoing use of the prochlorperazine by her/his physician after the 11/27/22 start date (58 days). On 1/26/23 at 03:05 PM Staff 9 (Pharmacist) stated he completed monthly chart reviews and made recommendations regarding 14-day PRN antipsychotic use. Staff 9 stated he was not sure why the requested recommendation was not reviewed or addressed by the physician. On 1/26/23 at 4:52 PM Staff 3 (DNS) acknowledged the 12/8/22 and 1/25/23 pharmacy recommendation was not addressed or followed up on regarding ongoing use of prochlorperazine.

Based on interview and record review it was determined the facility failed to obtain therapy services for 1 of 1 sampled residents (#23) reviewed for therapy services. This placed residents at risk for a decline in functional abilities. Findings include: Resident 23 re-admitted to the facility in 11/2022 with diagnoses including stroke and anxiety. A physician order on 12/29/22 directed staff to request an evaluation and treatment for OT and PT. A Communication Result Report (a fax document) dated 1/10/23 (12 days later) requested PT and OT from Staff 7 (Administrator Coordinator/Care Manager). On 1/23/23 at 12:15 PM Resident 23 stated she/he was frustrated because she/he was not working with therapy services. On 1/26/23 at 10:18 AM Staff 8 (RN) stated Resident 23 was upset because she/he was not provided PT or OT. Staff 8 stated he reported his concerns to Staff 7 and she thought it would be a good idea to initiate therapy services. On 1/26/23 at 11:04 AM Staff 7 acknowledged Resident 23 requested PT and OT in 12/2022 and the physician initiated the orders. Staff 7 stated the request was delayed due to the holidays and her being sick. Staff 7 further stated she sent a second fax on 1/26/23 for PT and OT for Resident 23. A Communication Result Report dated 1/26/23 (28 days later) requested PT and OT evaluation. On 1/30/23 at 8:27 AM Staff 3 (DNS) acknowledged the delay in therapy services for Resident 23.

Based on interview it was determined the facility failed to ensure residents were provided with the opportunity to develop a Resident Council for 1 of 2 residential units (the adult unit) reviewed for Resident Council. This placed residents at risk for a lack of participation in group discussions regarding facility policies, procedures and resident rights. Findings include: The adult unit of the faciity had a census of eleven. Four of the eleven residents resided on the unit longer than 6 months. On 1/23/23 at 10:36 AM Staff 3 (DNS) stated the adult residential unit did not have a Resident Council. On 1/27/23 at 3:27 PM Staff 1 (Administrator) stated the adult unit did not have a Resident Council.

Based on observation, interview and record review it was determined the facility failed to ensure residents' personal information was not visible to the public for 1 of 2 resident care units. This placed residents at risk for unprotected personal heath information. Findings include: Observations from 1/23/23 to 1/27/23 revealed the presence of a large dry erase board in the main area of the adult care unit visible to all staff, residents and visitors. The board had documentation of room number and initials of each resident with care notes such as transfer status, appointments, hospice, dialysis, and behaviors. On 1/26/23 at 10:02 AM Staff 8 (RN) confirmed the facility utilized the white board as a means of communication for all staff and it was helpful when agency staff worked on the floor. Staff 8 stated it was easier than sifting through the electronic record to locate the care plan which was not easily accessible. On 1/27/23 at 9:17 AM Staff 6 (RN) indicated the facility had discussed options other than the white board for direct care communication but had not implemented an alternative process. On 1/30/23 at 10:32 AM Staff 3 (DNS) confirmed the facility was posting too much personal information on the white board by the nurses' station and the facility had plans to find other means to communicate resident care needs to direct care staff.

Based on observation, interview and record review it was determined the facility failed to accurately document and display the DCSDR (Direct Care Staff Daily Report) in a prominent place readily accessible to residents and visitors for 33 of 33 days reviewed for staffing and for 2 of 2 units. This placed residents and visitors at risk for being uninformed of available staff and hours worked by facility staff. Findings include: Random observations from 1/23/23 through 1/26/23 revealed the DCSDR forms on the unit downstairs were posted in a hallway adjacent to the entrance not visible to the public and the form was sideways. The DCSDR forms were blank or inaccurate and missing census, current staff and hours worked. The upstairs unit had a DCSDR posted outside the medication storage room and the forms were inaccurate, dated incorrectly, missing daily census, number of working staff and hours worked. A review of the two separate DCSDR's, dated from 12/25/22 through 1/26/23 revealed 33 instances where the forms did not indicate the same information for both units and portions of the forms on each unit were inaccurate. The incomplete or inaccurate information included daily census number, signatures, number of working staff and hours worked by staff. On 1/24/23 at 9:21 AM and 1/26/23 at 3:15 PM Staff 2 (DNS) stated there was only one DCSDR which was completed and posted on the downstairs unit. Staff 2 was shown the forms from upstairs and indicated she would discuss with Staff 3 (DNS) in regard to the two separate DCSDR postings. Staff 2 acknowledged the DCSDR forms were not accurate or completed each shift and the DCSDR should be posted in a prominent area readily accessible to residents and visitors.