Every finding on record at Accura Healthcare of Knoxville, LLC

Based on staff interview, personnel file review, and facility policy review, the facility failed to designate a person to serve as the director of food and nutrition services who met the minimum qualifications to carry out the food and nutrition services. Findings include: During an interview on 2/16/26 at 9:15 a.m. with the Dining Services Manager, she revealed she had been promoted from cook to Dining Services Manager last month, January 2026. Further interview on 2/17/26 at 10:30 a.m. with the Dining Services Manager revealed she had been hired 9/8/23 as a housekeeper and soon after her hire, she then accepted a position in the facility's kitchen as dietary aide. She then accepted a position as [NAME] in January 2024. She stated another dietary aide and her had managed the dietary department during the month of December 2025, after the previous Dining Services Manager had abruptly quit. During that time she had accepted the role as Director of Dining Services and on January 1, 2026 she was fully in her role as the Dining Services Manager. She stated she was currently completing an online course for Food Manager Certification. She stated she had started the course on January 13, 2026 and was currently preparing to take the final test of the course. She agreed that she did not have the class completed prior to taking the position as Dining Services Manager and confirmed that she had not completed the course yet. She also confirmed she did not have a current ServSafe certification. During an interview on 2/18/26 at 11:50 a.m. with the Administrator, he stated he thought they had six months to get an individual qualified for the Dining Services Manager. Further interview that day at 12:16 p.m. with the Administrator revealed the job description Director of Dining Services was signed by the current Dining Services Manager on 12/12/25 and he agreed that he had hired a person who was not qualified. He stated that he had to get someone hired urgently as the previous dining services manager had quit abruptly. He confirmed the facility did not currently have a qualified Dining Services Manager. Personnel file review on 2/19/26 of the Dining Services Manager revealed her personnel file had not contained qualification or background that included one of the following: Certified dietary manager.Certified food service manager.National certification for food service management and safety from a national certifying body.An associate's or higher degree in food service management or in hospitality. Two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety and management that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. Review of the 7/18/24 job description for the Director of Dining Services revealed:Job Summary: The Director of Dining Services directs the day to day planning, organizing, developing and management of the overall operation of the Dietary Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility . Education and Qualifications: ServSafe certification or willingness to obtain ServSafe certification prior to employment. Certification as a food service manager preferred. Must also meet State requirements for food service managers or dietary managers.

Based on clinical record review, staff interview, and Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual review, the facility failed to complete a significant change in status assessment for one (1) of two sampled residents who had been admitted to hospice care (Resident#1). Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #1 without any memory problems and independent with his cognitive skills for daily decision making, which indicated intact cognition. The MDS listed diagnoses included: chronic obstructive pulmonary disease (a progressive, incurable, yet treatable lung disease that obstructs airflow and makes breathing difficult), congestive heart failure (CHF), diabetes mellitus, and peripheral vascular disease (a progressive condition where plaque buildup reduces blood flow to the legs and feet). The MDS documented the resident had one fall with major injury and two falls with no injury since his prior MDS assessment on 8/26/25. The MDS assessed the Resident #1 needed maximal assistance from staff for toileting, transfers, showers, lower body dressing, and footwear; moderate assistance from staff for upper body dressing and personal hygiene (combing hair, shaving, washing/drying face and hands); and was independent with eating, oral hygiene, and mobility once he was in his wheelchair. The MDS indicated the resident was always continent. The MDS indicated the resident had recently received hospice care. Review of Resident #1's Care Plan, Date Initiated: 1/18/24 revealed a Focus area to address Resident at risk for injury from falls/seizures related to his impaired mobility, CHF, morbid obesity, DM, and convulsions. Interventions included, in part: Encourage Resident to use walker when ambulating in room. Date Initiated: 6/24/25. Resident to use call light for assistance if he feels unsteady or weak at the time ofneeds. Education given. Date Initiated: 08/22/2025. Educate me to ask staff to place my walker and wheelchair away from me while not in use to promote use of call light. Date Initiated: 9/3/25. Resident #1's Care Plan had not addressed his need for hospice care, but had the following documentation for his Focus area addressing his advance directives On readmission [DATE], resident opted out of readmitting to hospice level of care. Date Initiated: 10/31/25. Review Resident #1's electronic medical record (EMR) revealed: He was admitted to the facility on [DATE]. A significant change in status MDS assessment dated [DATE] documented: readmission on [DATE] from a hospital stay. A Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had no condition or chronic disease that resulted in a life expectancy of less than 6 months. The resident had not recently received hospice care. A census change on 9/11/25 to Hospice Medicaid. A 9/11/25 hospice progress note at 7:12 p.m. documented Hospice came in to work on admit paperwork with resident. No significant change in status MDS assessment had been completed after the resident's admission to hospice care on 9/11/25 and prior to the resident's discharge to the hospital on [DATE]. A census change on 10/17/25 to Hospital Leave. A discharge return anticipated MDS assessment dated [DATE]. A census change on 10/28/25 to Managed Medicaid. A significant change in status MDS assessment dated [DATE]. During a staff interview on 2/19/26 at 2:00 p.m. with the Assistant Director of Nursing she revealed she had been working 17 years at facility as a Licensed Practical Nurse (LPN) which included five years as the MDS Coordinator before working as the Assistant Director of Nursing for the past seven years. She agreed that a significant change in status (SCSA) MDS assessment should have been completed when Resident #1 enrolled in a hospice program. She confirmed that a SCSA MDS assessment had not been completed when Resident #1 enrolled in a hospice program and that a SCSA MDS assessment had not been completed when Resident #1 discontinued the hospice program. She stated Resident #1 had been on a hospice program from 9/11/25 to 10/17/25. The October 2025 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual revealed: Item A310 Type of Assessment review stated If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS Significant Change in Status Assessment (SCSA). A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program. The ARD (Assessment Reference Date) must be within 14 days from the effective date of the hospice election. An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. It is a CMS [Center for Medicare and Medicaid Services] requirement to have an SCSA completed EVERY time the hospice benefit has been elected, even if a recent MDS was done and the only change is the election of the hospice benefit. The nursing home is required to complete an SCSA when the resident comes off the hospice benefit (revoke). An SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill. The 4/25/25 State Operations Manual, Appendix PP, F637 revealed the following guidance A Significant Change in Status MDS is required when: A resident enrolls in a hospice program. A resident receiving hospice services discontinues those services.

Based on clinical record review, staff interviews, and resident interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment correctly for 2 of 10 resident's reviewed in the sample (Resident #4 and Resident #6). The facility reported a census of 45 residents.Findings include:1. Resident #4, Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Diagnosis included malignant bladder cancer. Resident #4 was not coded for receiving hospice care. The Care Plan for Resident # 4 initiated 11/20/25 documented the resident received hospice services.The Clinical Census record for Resident #4 documented the resident entered the facility on 11/19/25 under hospice care.The Hospice Plan of Care report for Resident #4 revealed hospice were initiated on 11/14/25. On 2/18/26 at 1:18 PM Resident #4 reported participation of hospice visits three to five times a week, and expressed satisfaction with hospice services.2. Resident#6, Annual MDS assessment dated [DATE] revealed Resident #6 scored 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Psychiatric mood disorders included depression, bipolar and schizophrenia. The MDS did not code resident to have a serious mental illness or related condition. The Preadmission Screening and Resident Review (PASRR) screening dated 3/31/22 for Resident #6 identified evidence of a PASRR condition included serious mental illness or related condition and directed the MDS to reflect the findings in section A1500 and A1510 of the MDS. The Care Plan revision date of 1/20/25 reflected PASRR level II documented specialized services needed due to mental illness. On 2/19/26 at 11:12 AM the MDS nurse coordinator, Staff F relayed was new at this position, did not have a back ground in MDS assessments, included that several staff worked on MDS assessments in the recent past included staff nurses and corporate nurses. Staff F looked at Resident #4 and #6 MDS assessments and confirmed it was not coded correctly. On 02/19/2026 at 1:27 The Administrator relayed did not have a policy on MDS coding, expected staff to follow the standards of care, included should follow the Resident Assessment Instrument (RAI) manual for coding and is aware improvements are needed with MDS assessments and coding.

Based on resident interview, clinical record review, staff interview, the facility failed to provide the opportunity for the resident to participate in the development, review and revision of his care plan for 1 of 1 (Resident #3 ) reviewed for care conferences and failed to update a care plan for 1 of 2 reviewed for hospice (Resident #1 ). The facility reported a census of 45 residents. Findings include: 1. Resident #3 Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating moderately impaired cognition. The MDS further documented the resident had a diagnosis of diabetes and stroke. The Care Plan focus revised on 11/18/25 for Resident #3 revealed the resident would remain in long term care. Care Plan interventions included the following; staff to assist the resident to be independent as possible, resident would participate in activities of choice, staff to invite encourage and remind daily the resident to attend activities, documented the resident had impaired communication related to the stroke, is usually understood, and unclear at times. A goal for the resident to be able to communicate for needs to be met . On 2/16/2026 at 9:31 AM Resident #3 quired about care conferences, resident relayed he wanted to go to his care conferences, and only recalled attending a long time ago. On 2/19/2026 at 10:58 AM during follow up a interview Resident #3 reported probably would go to the care plan conference if invited and yelled loudly, felt they don't want to hear, what I have to say. On 2/19/2026 at 11:50 AM The MDS nurse coordinator, Staff F reported is new to the position, several changes in staff for the role included setting up care conferences, could not explain what happened in the past in regards to care plan meetings due to lack of documentation. Staff F reported they had ensured Resident #3's care conference was this week while surveyors were in the building. On 02/19/2026 at 1:27 PM the Administrator relayed could only locate three form letters over the last year sent to the emergency contact to inform of care conference dates. The form letters were not dated and relayed care conference to be held on 2/15/25, 5/2/25 and 2/17/26. The Administrator added could only locate two documents indicating the care meetings took placea. form dated 5/25/25 outlined summary ,box checked resident invited chose not to participate -noted is able to make needs knownb. form dated 2/17/26 took place during survey, box checked resident chose not to participateThe Administrator relayed realized the meetings should be quarterly, needed to work on process to ensure care conferences are conducted and documented, understood the resident right to participate, and did not have a policy on the process and should follow the standards of care. 2. Resident #1's MDS dated [DATE] identified the resident was without any memory problems and independent with his cognitive skills for daily decision making, which indicated intact cognition. The MDS listed diagnoses included: chronic obstructive pulmonary disease (a progressive, incurable, yet treatable lung disease that obstructs airflow and makes breathing difficult), congestive heart failure (CHF), diabetes mellitus (DM), and peripheral vascular disease (a progressive condition where plaque buildup reduces blood flow to the legs and feet). The MDS assessed Resident #1 needed maximal assistance from staff for toileting, transfers, showers, lower body dressing, and footwear; moderate assistance from staff for upper body dressing and personal hygiene (combing hair, shaving, washing/drying face and hands); and was independent with eating, oral hygiene, and mobility once he was in his wheelchair. The MDS indicated the resident was always continent. The MDS indicated the resident had recently received hospice care. A documented focus concern of discharge planning with initiated date of 1/18/24 on the residents Care Plan included the following intervention for the facility staff; Allow resident to express feelings and concerns about remaining in the nursing home. Review of Resident #1's Care Plan, Date Initiated: 1/18/24 revealed the following Focus areas: At risk for injury from falls and seizures. PASARR (Pre-admission Screening and Resident Review) identified rehabilitative services and other supports needed. Pain and pain control options. Activities of Daily Living self-care performance deficits. Potential for altered nutrition. Chronic Obstructive Pulmonary Disease (COPD) and hypertension (HTN, the medical term for high blood pressure). Use of side rails. Diabetes. Urinary incontinence. Anticonvulsant drug use. History of trauma. Advance Directives. Discharge Planning. Activity Involvement. Potential for behavior. Potential for risk of abnormal bleeding. Impaired cognitive function. At risk for alteration in blood glucose levels. At risk for fluid imbalance. At risk for dehydration. At risk for adverse effects from psychotropic medications. At risk for alteration in air exchange. Actual and potential for alteration in skin integrity. Review Resident #1's electronic medical record (EMR) revealed: He was admitted to the facility on [DATE]. A census change on 9/11/25 to Hospice Medicaid. A 9/11/25 hospice progress note at 7:12 p.m. documented Hospice came in to work on admit paperwork with resident. No significant change in status MDS assessment had been completed after the resident's admission to hospice care on 9/11/25 and prior to the resident's discharge to the hospital on [DATE]. A census change on 10/17/25 to Hospital Leave. A discharge return anticipated MDS assessment dated [DATE]. A census change on 10/28/25 to Managed Medicaid. During a staff interview on 2/19/26 at 2:00 p.m. with the Assistant Director of Nursing she revealed she: Had worked 17 years at the facility as a Licensed Practical Nurse (LPN) which included five years as the MDS Coordinator before working as the Assistant Director of Nursing for the past seven years. Stated Resident #1 had been on a hospice program from 9/11/25 to 10/17/25. Agreed that a significant change in status (SCSA) MDS assessment had not been completed when Resident #1 enrolled in a hospice program. Agreed that a SCSA MDS assessment had not been completed when Resident #1 discontinued the hospice program. Agreed that Hospice had not been addressed on the resident's individualized care plan. During an interview on 2/19/26 at 3:20 p.m. with the Administrator, he revealed the facility did not have a hospice policy. The October 2025 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual revealed An SCSA [Significant Change in Status Assessment] is required to be performed when a terminally ill resident enrolls in a hospice program. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. Refer to F637. Review of the facility's 12/3/25 policy on Comprehensive Care Plans revealed: The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The care plan will be updated in a timely manner to ensure that services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on clinical record review, policy review, and staff interviews, the facility failed to carry out a system to receive controlled substances for 1 of 1 residents reviewed for a missing narcotic(Resident #54). The facility reported a census of 45 residents. Findings included: The Minimum Data Set(MDS) assessment tool, dated 8/17/25, listed diagnoses for Resident #54 which included chronic pain syndrome, seizure disorder, and depression. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Controlled Substances, updated 11/18/25, stated the facility would ensure staff handled, stored, and disposed of controlled drugs properly and carried out proper record keeping. Resident #54's October 2025 Medication Administration Record(MAR) listed a 9/27/25 order for fentanyl(a powerful synthetic pain medication) transdermal(delivered through the skin) patch 72 hour 25 micrograms(mcg)/hour(hr), apply every 72 hours for chronic pain. A Packing Slip Proof of Delivery document, stated the facility received 1 fentanyl patch 25mcg/hr on 10/25/25 at 6:10 p.m. Staff A Registered Nurse(RN) signed the delivery form. An undated, untitled facility investigation stated on 10/27/25, Staff E Licensed Practical Nurse(LPN) notified the pharmacy that Resident #54 did not have a fentanyl patch available. On 10/28/25, the pharmacy notified the Assistant Director of Nursing(ADON) that the pharmacy delivered a patch on 10/25/25 at 6:10 p.m. The facility carried out a search for the patch without success. Staff A stated she signed in a tote of medications on 10/25/25 and notified Staff G RN that the medications were in the medication room. The facility attempted to contact Staff G for information but was unable to reach her. Staff C RN reported that on 10/25/25 at approximately 8:00 p.m., she and Staff G went to the locked medication room to retrieve a medication delivery bag. Staff D LPN stated that Staff G gave her a medication that she placed in the Cubex machine(a machine which securely stores medications). In a written statement on 10/28/25, Staff D stated the only medication she received from Staff G was a tramadol(an opioid medication used to treat pain).The facility lacked documentation of the location of the fentanyl patch delivered on 10/25/25 after Staff A signed for the medication from the pharmacy. The facility lacked a narcotic sheet for the patch which documented the receipt of the medication. On 2/18/26 at 11:08 a.m., via phone, Staff A stated on the shift in question, the pharmacy delivered the medication around shift change. She stated she was an agency staff member so she didn't know that she had to open the package. She stated she signed for the medication and placed it in the medication room around 6:00 p.m. She stated she informed another nurse who took over for her that the medications arrived. Staff A stated she did not know at the time she needed to go through all of the medications to make sure all was accounted for. On 2/18/26 at 9:43 a.m., Staff E Licensed Practical Nurse(LPN) stated she needed to place a patch on Resident #54 and it was not available. She stated staff received the patch but it was not available to give. On 2/18/26 at 11:26 a.m., via phone, Staff C stated on the night in question, the nurse that she worked with handed a medication to the nurse in back. She stated she did not remember details about the bag as the other nurse handled this. On 2/18/26 at 2:52 p.m., via phone, Staff G agency RN stated she did not remember anything about a patch. On 2/18/26 at 3:00 p.m., the Director of Nursing(DON) stated when a medication arrived from the pharmacy, the floor nurse signed in the medications and input it into the log. She stated nurses should verify that the medications received matched the packing slip. She stated for a controlled substance, they would add a log sheet to the book. She stated controlled substances were kept double locked.

Based on clinical record review, staff interview, family interview, provider interview, and facility policy review the facility failed to ensure 1 of 4 residents reviewed received only their prescribed medications. Resident #1 (R#1) became unresponsive and required emergency medical interventions. R#1 transferred to the hospital and admitted to the Intensive Care Unit (ICU) due to a multi-drug interaction with diagnoses of cardiogenic shock and toxic encephalopathy. The facility reported census was 41.The State Agency informed the facility of the Immediate Jeopardy (IJ) on 10/8/25 at 1:55 PM. The IJ began on 10/3/25, following the administration of Resident #3's (R#3) medications to R#1. The State Agency confirmed removal of immediacy on 10/9/25, The facility staff removed the Immediate Jeopardy on 10/3/25 by implementing the following actions:a. On 10/3/2025, the Director of Nursing initiated staff education to ensure all nurses and certified medication aides are aware of the medication administration and management process. All nurses and certified medication aides were educated on 10/3/2025 or prior to the start of their next shift.b. The Director of Nursing and/or designee performed competencies for medication administration on all nurses and certified medication aides on 10/3/2025, or prior to the start of their next shift. b. The Director of Nursing and/or designee initiated audits on 10/3/2025 for nurses and certified medication aides for compliance with medication administration. c. The Director of Nursing and/or designee will perform medication administration competencies on all nurses and certified medication aides completed on hire as part of the orientation process.d. On 10/3/2025, all residents profiles in [brand name of electronic health record redacted] were audited to ensure residents have up to date photo. The scope lowered from J to G at the time of the survey after verification the facility implemented processes including education, staff competencies and audits relating to medication administration. Findings include:R#1's Minimum Data Set (MDS) annual assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The MDS included diagnoses of stroke, kidney disease, diabetes, dementia, anxiety, and depression. The MDS reported no swallowing disorder. The MDS coded R#1 took antianxiety, antidepressant, anticoagulants, hypoglycemic, and anticonvulsant medications during the lookback period.The Care Plan Focuses reflected R#1 had a risk for adverse effects related to the following use of:a. Psychotropic medications.b. Antianxiety/anticonvulsant medicationsc. Pain medicationd. Diabetic medicationse. AnticoagulantsThe Care Plan included Interventions that directed staff to administer medications as ordered then monitor, document side effects, and effectiveness of the medications. R#1's October 2025's Medication Administration Record (MAR) directed to give the following medications at breakfast or in the morning (AM). The MAR revealed Staff A, Licensed Practical Nurse (LPN), documented the following medications administered to R#1.a. Effexor ER (extended release) capsule 150 milligrams (mg) by mouth (PO) for major depressive disorderb. Effexor ER capsule 37.5 mg PO for major depressive disorderc. Ferrous Sulfate 7.5 milliliters (ml) PO for anemiad. Multivitamin one tablet PO for wound healinge. Namenda 10 mg PO for dementiaf. Pantoprazole 20 mg PO for ulcersg. Vitamin D 2000 IU (international units) PO for Vitaminh. Calcium/Vitamin D 600-400 mg-unit PO for supplementi. Diazepam 5 mg PO for anxiety managementj. Eliquis 5 mg PO related to cerebral infarction (stroke)k. Lyrica 75 mg PO for foot painl. Mag-Oxide 400 mg PO for supplementm. Sennoside Docusate 8.6-50 mg PO for constipationn. Vitamin C 500 mg PO to promote wound healingo. Baclofen 5 mg PO for macular degeneration p. Buspirone 10 mg PO for depressionq. Insulin Aspart 100 unit/milliliter 5 units subcutaneous (SQ) for diabetesr. Insulin Basaglar 100 unit/milliliter 55 units SQ for diabetesR#3's October 2025 MAR directed to give the following medications at breakfast or in the morning (reported R#1's received R#3 medications in error). a. Aricept 10 mg PO for Alzheimer'sb. Aspirin 81 mg PO relating to strokec. Cholecalciferol 2000 units PO for supplementd. Clonazepam 0.25 mg PO for schizoaffective/bipolare. Lamotrigine 150 mg PO for schizoaffective/bipolar f. Metoprolol ER 75 mg PO for hypertensiong. Myrbetriq ER 25 mg PO for overactive bladder.h. Sertraline 50 mg PO for depressioni. Spironolactone 12.5 mg PO for supplementj. Calcium/Vitamin D 600-400 mg-unit PO for deficiencyk. Docusate Sodium 100 mg PO for constipationl. Fiber-Lax one capsule PO for bowelsm. Furosemide 40 mg PO for elevated BNP (hormone released by the heart) (lab test to indicate heart failure)n. Acetaminophen 500 mg PO for osteoarthritiso. Gabapentin 300 mg PO for painp. Quetiapine 100 mg PO for schizoaffective/bipolar.The Incident Note dated 10/3/25 at 8:00 AM Staff A documented as they passed medications, they gave R#1 her morning medications without incident. After passing medications to other residents, Staff A got R#3's medications ready. Staff A went to R#1, tapped her shoulder, called out to R#3, and R#1 opened her mouth. Staff A then gave R#3's medications to R#1. After approximately 5 minutes, Staff A noted they gave the medications to the wrong resident. The staff called the provider, once they explained the situation and reported all the medications given to R#1, the provider directed to monitor them, take their vital signs every hour and if R#1 became lethargic (extremely sleepy) or unable to rouse (wake up) then send to the Emergency Department (ED). The provider called back after approximately 15 minutes and stated the physician would like to add 15-minute checks along with intravenous (IV) normal saline, 1 liter at 75 milliliters (ml) per hour until completed to help flush the medications. If the facility didn't have that option available, then push fluids every 15 minutes. When Staff A got off the phone, they went to check R#1's vital signs and give her water to push fluids. Staff A found R#1 unresponsive to verbal or physical stimuli. Staff A immediately wheeled R#1 out of the dining room, to the back hallway where the Assistant Director of Nurses (ADON) and Staff D, MDS Coordinator Nurse, assisted her. Staff A called 911 while the ADON checked for resuscitation orders. The MDS Coordinator went into the room with the Certified Nurse Assistant (C.N.A.) to help monitor R#1 and attempt to rouse her. They gave R#1 one dose of Narcan to help with the extra narcotic she received. At this time, the Emergency Medical Team (EMT) showed up with fire and police assistance. R#1 remained unresponsive at that time but moved her arm slightly and they transferred her from the wheelchair to the gurney, she grimaced. R#1 transported to the ED via ambulance. The staff notified the Power of Attorney and Nurse Practitioner of R#1's transfer. A Facility Incident Report dated 10/3/25 at 8:00 AM documented, Staff A passed A.M. medication (md). During the med pass, Staff A noted she gave R#1, her medication and at a later time she also gave R#3's medication to R#1. The staff could only rouse R#1 by calling out her name and then she opened her mouth and Staff A administered crushed medications to her. The Immediate action included: Staff A assessed R#1 and notified the on-call Nurse Practitioner (NP) of the incident, who directed to take vital signs (VS) every hour and 15-minute checks. In addition, the NP ordered to push fluids if they couldn't provide R#1 IV fluids. If R#1 became unresponsive or lethargic, send her to the ED.A Hospital ED report dated 10/3/25 at 8:27 AM indicated R#1 presented for evaluation of medication overdose and unresponsiveness. R#1 received her normal medication around 7:00 AM, then shortly after accidentally received all of another resident's medication and subsequently became unresponsive. The Emergency Medical Services (EMS) reported pinpoint pupils, hypoxia (referring to insufficient oxygen) and a Glasgow Coma Scale (GCS) of 4 (response indicated brain injury). The GCS score improved with treatment. The hospital transferred R#1 to another hospital for treatment in the Intensive Care Unit (ICU).A Hospital admission report, dated 10/3/25 at 12:34 PM identified they admitted R#1 to the ICU for management of toxic encephalopathy (brain damage due to exposure to toxic substances) and cardiogenic shock (a life-threatening heart condition), hypotension (low blood pressure) and bradycardia (a low pulse rate) secondary to an accidental medication ingestion at the nursing facility. R#1 remained in the ICU for approximately 48 hours. Her encephalopathy and hemodynamic instability gradually resolved as the ingested medication metabolized (body broke down and wasted). They successfully weaned her off vasopressors (medication to raise blood pressure) and her mental status returned to baseline. On 10/4/25 R#1 demonstrated severe dysphagia (difficulty swallowing). The hospital transferred her to the medical floor for further management. An interview on 10/6/26 at 1:00 PM, Staff B, Hospital Nurse, reported R#1 remained hospitalized . R#1 came to the ED unresponsive and had shallow breathing after she received another resident's prescribed medication.An interview on 10/7/25 at 12:12 PM, the Assistant Director of Nurses (ADON) recalled R#1's emergency intervention. Staff A approached the ADON and asked if they could have IV fluids delivered. The ADON asked why and Staff A said she gave R#1 someone else's meds. Staff A reported she called the on-call provider, who gave an order to give IV fluids or oral fluids every 15 minutes. The ADON reported, finished her task, and saw Staff A push an unresponsive R#1 toward her room. R#1 responded to a sternal rub, but didn't verbalize. At that time, she held herself up and still breathed, Staff A called 911. The ADON reported R#1's had a low blood pressure with a slow and weak pulse. Staff A reported R #1 got double narcotics. The ADON reported she called the on-call provider directly on the cell phone and received an order for Narcan. As she gave the Narcan, the EMTs arrived and took over. R#1 responded only to pain and her eyes fluttered. They transferred R#1 to the hospital. The ADON reported she talked to a tearful Staff A. Staff A said she called out to R#3 and R#1 opened her mouth, so she gave R#3's medication to R#1. The ADON reported the electronic software revealed R#1 received her medication at around 7:00 AM and then received R#3's medications about 7:48 AM. The ADON believed at 7:55 AM, Staff A summoned her and at 8:00 AM when she met R#1 unresponsive in the hallway. The ADON explained she checked the time at 8:10 AM when the EMT's arrived.An interview on 10/7/25 at 12:20 PM, Staff A recalled on 10/3/25 she gave R#1 morning medications including her insulin. Staff A recalled shortly after they gave R#1's medications in the dining room, they called out to R#3 and said take your medicine. Staff A reported she didn't even think, R#1 sat in her chair with her eyes closed, and had her mouth open. R#1 had a shower and looked different. Staff A said she just spooned R#3's crushed medications into R#1's mouth, went back to the chart and realized she made an error. Staff A reported she told Staff D and proceeded to call the on-call doctor. Staff A reported she just gave R#3's medication to R#1 and knew it was her fault. Staff A talked to the ADON about getting IV fluids and went back to the dining room at about 7:50 to 8:00 AM. When she arrived, she found R#1 unresponsive. She called 911 while other staff worked with R#1. Staff A described herself as a hot mess and the situation as really bad. She just wanted to go home because she wasn't in her right mind. The doctor told her the main concern was R#1 getting the extra anti-psychotics.An interview on 10/7/25 at 12:50 PM, Staff D, explained she helped get residents up and the ADON said they needed help now in R#1's room. Staff D reported she entered R#1's room and saw her in the wheel chair. Staff D stated she yelled R#1's name but she didn't respond to verbal stimuli or to a sternal rub. The ADON said to administer Narcan. Staff A retrieved the Narcan from the medication cart. The ADON administered the Narcan while Staff A called the ambulance. Staff D reported she got the paper work ready for transfer that included both R#1 and R#3's lists of medications. She reported R#1 got both medications listed.An interview on 10/8/25 at 9:25 AM, Staff E, Provider RN, reported on 10/3/25 about 7:30 AM she received a call from Staff A. Staff A reported she gave R#1 her medications and R#3's medications in error. Staff E instructed Staff A to monitor R#1 every hour and to send her to the emergency room if she had changes including lethargy. Staff E hung up and consulted Staff F, NP, who directed to monitor R#1 with increased frequency and add IV fluids.An interview on 10/8/25 at 9:32 AM, R#1's Family Member stated the facility and hospital staff informed him that R#1 received someone else's medication. R#1's Family Member explained this forced him to make major decisions on treatments for sustaining her life. R#1's Family reported R#1 required ICU care, she now had new concerns regarding swallowing abilities, and continued receiving evaluation at the hospital.A Medication Management, Medication Administration policy updated 4/16/24 instructed general procedures to follow for all medications, included to identify the resident before administering medications.

Based on staff interview, resident interview, and clinical record review, the facility failed to treat residents with dignity and respect throughout cares provided for 1 of 3 residents reviewed (Resident #1).The facility reported a census of 46 residents.Findings include:Record Review of Resident #1 Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 09 indicating moderate cognitive impairment The MDS reflected Resident #1 diagnosis of Paranoid Schizophrenia, Delusional Disorders, Anxiety Disorder, and Major Depressive Disorder. The MDS further documented Resident #1 dependence on staff for performing activities of daily living (ADLs). A facility reported incident review dated 6/15/25 documented Staff A, Licensed Practical Nurse (LPN), with almost 30 years of experience as an LPN, attempted to assist Resident #1 during ADLs along with two other staff, Staff B, Certified Nursing Assistant (CNA), and Staff C, CNA. Resident #1 was agitated and in distress, and was refusing assistance from staff to complete dressing her lower body. Staff A continued the task despite Resident #1 yelling, hitting and biting staff. Staff A called Resident #1 degrading names and used offensive language during the reported incident. In an interview with Staff B on 8/4/2025 at 1:37 pm, she stated the interaction between Staff A and Resident #1 made her feel uncomfortable and she wouldn't want her loved one treated that way. She also stated Resident #1 was agitated, hitting Staff A and Staff A attempted to stop it by pushing resident's hands back out of her face instead of backing off. Staff B further revealed Staff A used demeaning word describing Resident #1's behavior prior to leaving the room. Staff A reported the incident to the Director of Nursing (DON). In an interview with Staff A on 8/5/2025 at 10:18 am, she confirmed the incident with Resident #1 on 6/15/25. She further confirmed she used degrading words while still inside the resident's room but she did not believe it was heard by Resident #1. Staff A stated she should have backed out of the room and left. In an interview with Staff C on 8/6/2025 at 10:42 am, she revealed Staff A used demeaning language towards Resident #1 to gain her cooperation with the cares, stating You are acting like a baby and We are not going to do that! Staff B further revealed she Staff B reported the incident to the DON.During an interviewed on 8/6/25 at 11:15 am, the DON stated she was notified by Staff B and Staff C about the incident with Resident #1 the same day and she notified Staff A that she will not be able to return to work until the investigation is completed. She confirmed Staff A has not worked at the facility since the incident on 6/15/25. During an interview on 8/6/25 at 12:15 pm, the Administrator stated she expected staff to step away from a resident if they refused cares or treatment, and attempt to use a different staff member. Also to have staff step away for 5 minutes and take a break before any escalation takes place. The Administrator stated that the facility did not have a policy for Resident Rights/Dignity but followed the regulations and/or standards of care.

Based on observations and staff interviews, the facility failed to maintain an environment in a clean, orderly condition, in good repair and with all odors kept under control through cleanliness and proper ventilation. The facility reported census was 49. Findings include: 1. During an observation on 4/16/25 at 11:00 a.m. several rooms with cosmetic and baseboard guards detached were detected: room [ROOM NUMBER] bathroom, baseboard guard split open exposing boiler pipe. room [ROOM NUMBER] bathroom had baseboard pulled away from the wall with peeling paint. The 500 hallway baseboard was removed from the wall leaving a jagged unfinished wall. In an interview on 4/16/25 at 2:05 p.m. Staff C, Maintenance, stated he relies on staff, aides and housekeeping to alert him to maintenance needs within the facility. When staff see an issue, they are to input the concern into the Tells app which then goes directly to his phone. From there he will make plans to repair the concern depending on the priority of the need. Staff C showed maintenance concerns in rooms 500, 508 and 509. Staff C indicated he would initiate repairs. 2. During an observation on 4/15/25 at 4:45 p.m. the facility noted urine odors, most noticeable on the 500 hall rooms. On 4/16/25 at 10:00 a.m. there was the same presence of odors on 500 hall. Rooms 505, 508, 509 and 510 were all swept and had their floors mopped that morning. room [ROOM NUMBER] had a urine soaked bed cover which added to the odor. The bed was later stripped. On 4/15/25 at 4:30 p.m. a wheelchair in room [ROOM NUMBER] was dirty with food debris on the sides and pedals and a bedside table in room [ROOM NUMBER] was dirty with food debris on the legs. On 4/21/25 at 11:15 a.m. urine odors were again noticed in rooms 508, 509 and 510. A wheelchair in room [ROOM NUMBER] remained filthy with food debris along the sides, seat and pedals. In an interview on 4/21/25 at 12:00 p.m. Staff G, Housekeeping supervisor, stated she has recently taken over as housekeeping supervisor and their department is fully staffed. Staff G was shown a bed stand in room [ROOM NUMBER] which is dirty and rusty. Staff G stated there are a lot of bed stands in that condition and they cannot be easily cleaned. Several of them should be thrown away. Staff G stated she plans on taking them outside and power washing them. Other furniture in room [ROOM NUMBER] was pointed out as in poor condition. Staff G stated the resident in 509 will urinate on his bed, furniture and floor and they are constantly in his room trying to control the odors. The resident in 508 can become combative if you try to take away his dishes or try to keep him dry from incontinence. Staff G stated they try their best to stay on top of the issues. In an interview on 4/16/25 at 1:50 p.m. Staff A, Certified Nurse Aide, acknowledged that controlling odors on 500 hall was challenging as the residents in rooms 505, 508 and 510 are incontinent and not always cooperative with allowing you into their rooms or allowing you to check and change them. Staff A stated the resident in room [ROOM NUMBER] was a heavy wetter and because of this, they will strip his linens and sanitize his bed every morning. Staff A was then shown and queried about who was responsible for cleaning wheelchairs and bed stands as the wheelchair in room [ROOM NUMBER] and bedstand in 510 had visible food debris on them. Staff A stated the overnight aides are responsible for cleaning wheelchairs and housekeeping should be cleaning the bed stands. 3. According to a Minimum Data Set (MDS) with a reference date of 3/16/25, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated an intact cognitive status. Resident #1 required maximal assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and was frequently incontinent of bladder and bowel. Resident #1's diagnoses included Alzheimer's disease, post traumatic stress disorder, hip fracture. Observations on 4/15/25 at 4:45 p.m. found Resident #1 was lying in bed with a sheet covering his face. The room was in disarray with what appears to be his lunch meal and dishes left on his bedside table. There were some paper items and clothing on the floor. and a stale odor of urine noted. The curtains were drawn creating a dark and dingy environment. On 4/16/25 at 9:30 a.m. Resident #1 was sitting up in bed. The room remained dark and dingy. Resident #1 was asked if there was anything he needed. Resident #1 responded he needed housekeeping to mop his floor. On 4/21/25 at 11:15 a.m. Resident #1 was lying in bed, asleep in a supine (on his back) position. There were dirty breakfast dishes sitting in a folding chair at his bedside and a light scent of urine odor. On 4/22/25 at 9:31 a.m. Resident #1 was lying in bed awake when the nurse aide, Staff G, entered his room to pass medications. Resident #1 was pleasant and cooperative, but when asked, refused to allow his breakfast plates to be removed. There was minimal urine odors detected. 4. According to a Minimum Data Set (MDS) with a reference date of 3/2/24, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated an intact cognitive status. Resident #2 required dependent assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and was always incontinent of bladder and bowel. Resident #2's diagnoses included Alzheimer's disease, Non-Alzheimer's dementia, cerebrovascular accident (stroke), hemiplegia, renal insufficiency, diabetes mellitus, chronic obstructive pulmonary disease. Observations on 4/15/25 at 5:45 p.m. Resident #2 was not in her room. This surveyor entered and noted a urine odor and pulled back the sheet and felt the pad. It was cool and damp and the sheet was wet with urine. When the pad was pulled back, there were several bits of what appeared was food debris. On 4/16/25 at 9:10 a.m. Resident #2 was propelled to her room by staff and transferred into bed using a full body mechanical lift and assistance of two staff members (Staff A CNA, Staff B CNA). The sling straps were attached to the lift carriage, green and green and then properly lifted into bed without incident. The bedside table was pulled over to the side of her bed and the phone placed alongside her. Resident #2 was checked for incontinence and noted as dry. Visible debris remained on the bed sheets as noted the day before. On 4/22/25 at 9:00 am. Resident #2 was lying flat, supine in bed asleep. There were no odors detected and some food debris on the floor from yesterday. 5. According to a Minimum Data Set (MDS) with a reference date of 2/9/25, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated an intact cognitive status. Resident #3 required moderate to maximal assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and was always incontinent of bladder and frequently incontinent of bowel. Resident #3's diagnoses included coronary artery disease, congestive heart failure, cerebrovascular accident (stroke), renal insufficiency, diabetes mellitus. 4/15/25 at 5:40 p.m. Resident #3 was observed from the hallway, lying in bed with a sheet pulled over her head and the bottom portion of her body exposed, wearing a brief. There was a medium odor of urine coming from the room. 6. According to a Minimum Data Set (MDS) with a reference date of 2/23/25, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated an intact cognitive status. Resident #4 was independent with transfers, mobility, dressing, toilet use and personal hygiene needs and was always incontinent of bladder and frequently incontinent of bowel. Resident #4's diagnoses included coronary artery disease, cerebrovascular accident (stroke), hemiplegia, bipolar disorder, schizophrenia. 4/16/25 at 9:35 a.m. Resident #4 was propelling himself in the hallways. This surveyor stepped into his room noticing an odor of urine. A purple bed cover was visibly soaked in urine. Resident #4's bed sheets and cover were stripped by 10:00 a.m.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure residents had the right to make choices about aspects of their lives which were significant to the resident by denying smoke breaks for 5 of 5 smokers reviewed (Residents #6, #7, #17, #27, and #30) and by not allowing a resident to lie down upon request for 1 of 6 residents reviewed for dignity (Resident #28). The facility reported a census of 50 residents. Findings include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 1/12/25, listed diagnoses for Resident #7 which included anxiety, depression, and unspecified intellectual disability. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. A 4/7/22 Care Plan entry stated she loved to participate in smoking breaks. A 1/6/25 Smoking Evaluation stated the resident smoked mornings, evenings, and afternoons supervised. On 1/30/25 at 8:44 a.m., Resident #7 stated that whenever she had a disagreement with staff they took away her smoking break. She stated staff considered smoking a privilege and when this happened she felt belittled. 2. The Annual MDS assessment tool, dated 11/3/24, listed diagnoses for Resident #17 which included heart failure, hemiplegia(one-sided paralysis), and seizures. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The MDS documented that the resident that it was very important to do his favorite activities. A 3/14/24 8:37 a.m. Health Status Note stated the resident cursed at staff and called them names. The nurse decided the resident would not be able to smoke this morning. A 3/25/24 Care Plan entry stated the resident was a smoker and participated in routine smoke breaks supervised by staff. A 12/17/24 Heath Status Note stated the resident had an outburst this morning directed at a Certified Nursing Assistant(CNA) for moving his leg. The resident called the CNA a name and yelled and swore at staff. The note stated the resident lost his 10:00 a.m. smoking break due to behaviors. A 1/22/25 Smoking Evaluation stated the resident smoked mornings, afternoons, and evenings with supervision. On 1/30/25 at 8:40 a.m., Resident #17 stated when he yelled, he was not allowed to go smoke. He stated his smoking breaks depended on if he was bad. He stated this made him feel kind of bad. 3. The Quarterly MDS assessment tool, dated 11/10/24, listed diagnoses for Resident #27 which included heart failure, coronary artery disease, and hemiplegia. The MDS listed his BIMS score as 15 out of 15, indicating intact cognition. An 8/7/24 Care Plan entry stated the resident utilized his vape pen during routine smoke breaks with staff supervision. A 1/27/25 Smoking Evaluation stated the resident smoked with supervision. On 1/30/25 at 8:29 a.m., Resident #27 stated staff took away his smoking break several times. He said this made him angry as he liked to go outside. A 2/2/25 Health Status Note stated the resident's son took him out to smoke and (staff) told him he was not allowed. The resident stated he would go no matter what. The resident had behaviors all day, refused to use the urinal, and alerted his call light every 5 minutes. 4. The Quarterly MDS assessment tool, dated 11/3/24, listed diagnoses for Resident #30 which included hemiplegia, anxiety, and depression. The MDS listed her BIMS score as 15 out of 15, indicating intact cognition. A 7/30/24 Care Plan entry stated the resident utilized a vape pen during routine smoke breaks with staff supervision. A 12/6/24 Health Status Note stated a staff member reminded the resident that the smoke break was not mandatory or required and the resident would not be going out to attend the morning smoke break due to her behaviors. A 1/22/25 Smoking Evaluation stated Resident #30 smoked in the mornings, afternoons, and evenings with supervision. On 1/30/25 at 8:32 a.m., Resident #30 stated if she talks back to the nurses, staff tell her she cannot to out to smoke. She stated this felt like punishment and she was not a little kid. 5. The MDS assessment tool, dated 11/10/24, listed diagnoses for Resident #28 which included Alzheimer's, non-Alzheimer's dementia, and age related physical debility. The MDS stated the resident required substantial/maximal assistance for chair to bed transfers and listed his BIMS score as 5 out of 15. An 8/31/22 Care Plan entry stated the resident required the assistance of 1 staff for transfers. On 1/27/25 at 2:27 p.m., Resident #28 sat in the hallway and yelled that he wanted to go to bed. Staff G Registered Nurse(RN) told him that he had to wait until after supper. On 1/29/25 at 1:04 p.m., Staff C CNA stated Staff G RN took away resident smoking breaks if they did such things as yell at staff or call them names. On 1/29/25 at 1:29 p.m., Staff D CNA stated they had one resident(Resident #17) who was rude and punched doors and when he did this, staff took away his smoking break. On 1/29/25 at 1:42 p.m., Staff E CNA stated there were times when Resident #17 swore at people and called them names. She stated times like that when he yelled and was disrespectful, staff took away his smoking break On 1/29/25 at 1:50 p.m., Staff F CNA stated sometimes staff took away Resident #17's smoking break because of the way he treated staff. She stated when he and his girlfriend started yelling and screaming and were disruptive, this would be a reason staff took the smoking break away. On 1/30/25 at 10:20 a.m., Staff G RN stated if residents broke the rules, staff would take their smoking break away. She stated staff could not turn them over their knee and spank them and this was the only thing they had. She stated if residents yelled, were very loud, used derogatory language to staff, or vaped in their rooms, she did not let them go out and smoke. She stated the behaviors could get serious if one didn't try to stop them now. Staff G stated the residents had rights but staff did also. She stated with regard to Resident #28, if it was pretty close to supper, they didn't have them lie down. She stated if they were going to lie down it was usually at 1:30 p.m. She stated they usually started to get residents to supper at 4:30 p.m. On 2/3/25 at 11:41 a.m., Staff H Nurse Specialist stated at times staff took away smoke breaks if residents bullied other residents or staff. She stated smoking was a privilege, not a right. She stated there was no reason that residents would not be able to lie down in the afternoon. On 2/3/25 at 1:26 p.m., the Administrator stated if there were instances where residents screamed, yelled, and called people names, staff may take their smoke breaks away. She stated it was a privilege to smoke and the facility had this system since she started 3 years ago. The facility policy Residents' [NAME] of Rights, dated November 2016, stated residents had the right to make choices about their activities and schedules, including sleeping and waking times). 42441 6. The Quarterly MDS dated [DATE] revealed Resident #6 had a BIMS of 14 indicating intact cognition. The MDS further documented the resident had diagnoses including anxiety disorder and depression. The Care Plan initiated 8/22/24 revealed Resident #6 was a smoker who smoked during routine smoke breaks with staff supervision. Review of Resident #6's smoking assessments dated 8/22/24, 11/13/24 and 1/30/25 revealed the resident smoked 2-5 times a day, liked to smoke in the morning, afternoon and evenings, and was safe to smoke with supervision. Review of facility form titled, Resident Smoking Assessment, updated 4/21/22 revealed Administrative/Nursing Leadership and/or charge nurse may also deny residents the privilege to smoke for any safety concerns such as inclement weather. Resident #6 signed the facility form upon admission 8/22/24. Review of Progress Notes for Resident #6 revealed effective 1/6/25 at 7:00 PM, Staff A, Licensed Practical Nurse (LPN) approached the resident and stated, this is unacceptable behavior after the resident yelled in the hallway. Staff A documented she explained to the resident that she needed to return to her room and she would not be attending a smoke break with increased behaviors. During an interview 1/29/25 at 2:53 PM, Resident #6 confirmed that on 1/6/25 she was told by Staff A that she would not be allowed to go out on a smoke break as a result of increased behaviors. During an interview 1/30/25 at 8:55 AM, Resident #6 revealed when she was told by Staff A that she could not go outside for a smoke break on 1/6/25 it made her feel angry, dehumanized and punished like, I'm telling mommy on you. Review of facility policy titled, Resident Smoking Process, updated 4/21/22 revealed Administrative/Nursing Leadership and/or charge nurse may also deny residents the privilege to smoke for any safety concerns such as inclement weather.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure residents were free from mental abuse by denying smoke breaks based on resident behaviors for 5 of 5 smokers reviewed(Residents #6, #7, #17, #27, and #30). The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set(MDS) assessment tool, dated 1/12/25, listed diagnoses for Resident #7 which included anxiety, depression, and unspecified intellectual disability. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. A 4/7/22 Care Plan entry stated she loved to participate in smoking breaks. A 1/6/25 Smoking Evaluation stated the resident smoked mornings, evenings, and afternoons supervised. On 1/30/25 at 8:44 a.m., Resident #7 stated that whenever she had a disagreement with staff they took away her smoking break. She stated staff considered smoking a privilege and when this happened she felt belittled. 2. The MDS assessment tool, dated 11/3/24, listed diagnoses for Resident #17 which included heart failure, hemiplegia(one-sided paralysis), and seizures. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. A 3/14/24 8:37 a.m. Health Status Note stated the resident cursed at staff and called them names. The nurse decided the resident would not be able to smoke this morning. A 3/25/24 Care Plan entry stated the resident was a smoker and participated in routine smoke breaks supervised by staff. A 12/17/24 Heath Status Note stated the resident had an outburst this morning directed at a Certified Nursing Assistant(CNA) for moving his leg. The resident called the CNA a name and yelled and swore at staff. The note stated the resident lost his 10:00 a.m. smoking break due to behaviors. A 1/22/25 Smoking Evaluation stated the resident smoked mornings, afternoons, and evenings with supervision. On 1/30/25 at 8:40 a.m., Resident #17 stated when he yelled, he was not allowed to go smoke. He stated his smoking breaks depended on if he was bad. He stated this made him feel kind of bad. 3. The MDS assessment tool, dated 11/10/24, listed diagnoses for Resident #27 which included heart failure, coronary artery disease, and hemiplegia. The MDS listed his BIMS score as 15 out of 15, indicating intact cognition. An 8/7/24 Care Plan entry stated the resident utilized his vape pen during routine smoke breaks with staff supervision. A 1/27/25 Smoking Evaluation stated the resident smoked with supervision. On 1/30/25 at 8:29 a.m., Resident #27 stated staff took away his smoking break several times. He said this made him angry as he liked to go outside. A 2/2/25 Health Status Note stated the resident's son took him out to smoke and (staff) told him he was not allowed. The resident stated he would go no matter what. The resident had behaviors all day, refused to use the urinal, and alerted his call light every 5 minutes. 4. The MDS assessment tool, dated 11/3/24, listed diagnoses for Resident #30 which included hemiplegia, anxiety, and depression. The MDS listed her BIMS score as 15 out of 15, indicating intact cognition. A 7/30/24 Care Plan entry stated the resident utilized a vape pen during routine smoke breaks with staff supervision. A 12/6/24 Health Status Note stated a staff member reminded the resident that the smoke break was not mandatory or required and the resident would not be going out to attend the morning smoke break due to her behaviors. A 1/22/25 Smoking Evaluation stated Resident #30 smoked in the mornings, afternoons, and evenings with supervision. On 1/30/25 at 8:32 a.m., Resident #30 stated if she talks back to the nurses, staff tell her she cannot to out to smoke. She stated this felt like punishment and she was not a little kid. On 1/29/25 at 1:04 p.m., Staff C CNA stated Staff G RN took away resident smoking breaks if they did such things as yell at staff or call them names. On 1/29/25 at 1:29 p.m., Staff D CNA stated they had one resident(Resident #17) who was rude and punched doors and when he did this, staff took away his smoking break. On 1/29/25 at 1:42 p.m., Staff E CNA stated there were times when Resident #17 swore at people and called them names. She stated times like that when he yelled and was disrespectful, staff took away his smoking break On 1/29/25 at 1:50 p.m., Staff F CNA stated sometimes staff took away Resident #17's smoking break because of the way he treated staff. She stated when he and his girlfriend started yelling and screaming and were disruptive, this would be a reason staff took the smoking break away. On 1/30/25 at 10:20 a.m., Staff G RN stated if residents broke the rules, staff would take their smoking break away. She stated staff could not turn them over their knee and spank them and this was the only thing they had. She stated if residents yelled, were very loud, used derogatory language to staff, or vaped in their rooms, she did not let them go out and smoke. She stated the behaviors could get serious if one didn't try to stop them now. Staff G stated the residents had rights but staff did also. She stated with regard to Resident #29, if it was pretty close to supper, they didn't have them lie down. She stated if they were going to lie down it was usually at 1:30 p.m. She stated they usually started to get residents to supper at 4:30 p.m. On 2/3/25 at 11:41 a.m., Staff H Nurse Specialist stated at times staff took away smoke breaks if residents bullied other residents or staff. She stated smoking was a privilege, not a right. She stated there was no reason that residents would not be able to lie down in the afternoon. On 2/3/25 at 1:26 p.m., the Administrator stated if there were instances where residents screamed, yelled, and called people names, staff may take their smoke breaks away. She stated it was a privilege to smoke and the facility had this system since she started 3 years ago. 42441 5. The MDS dated [DATE] revealed Resident #6 had a BIMS of 14 indicating intact cognition. The MDS further documented the resident had diagnoses including anxiety disorder and depression. The Care Plan initiated 8/22/24 revealed Resident #6 was a smoker who smoked during routine smoke breaks with staff supervision. Review of Resident #6's smoking assessments dated 8/22/24, 11/13/24 and 1/30/25 revealed the resident smoked 2-5 times a day, liked to smoke in the morning, afternoon and evenings, and was safe to smoke with supervision. Review of facility form titled, Resident Smoking Assessment, updated 4/21/22 revealed Administrative/Nursing Leadership and/or charge nurse may also deny residents the privilege to smoke for any safety concerns such as inclement weather. Resident #6 signed the facility form upon admission 8/22/24. Review of Progress Notes for Resident #6 revealed effective 1/6/25 at 7:00 PM, Staff A, Licensed Practical Nurse (LPN) approached the resident and stated, this is unacceptable behavior after the resident yelled in the hallway. Staff A documented she explained to the resident that she needed to return to her room and she would not be attending a smoke break with increased behaviors. During an interview 1/29/25 at 2:53 PM, Resident #6 confirmed that on 1/6/25 she was told by Staff A that she would not be allowed to go out on a smoke break as a result of increased behaviors. During an interview 1/30/25 at 8:55 AM, Resident #6 revealed when she was told by Staff A that she could not go outside for a smoke break on 1/6/25 it made her feel angry, dehumanized and punished like, I'm telling mommy on you. Review of facility policy titled, Resident Smoking Process, updated 4/21/22 revealed Administrative/Nursing Leadership and/or charge nurse may also deny residents the privilege to smoke for any safety concerns such as inclement weather.

Based on observation, clinical record review and staff interview the facility failed to ensure staff followed physician pre-op orders as directed prior to a resident procedure for 1 of 1 residents reviewed (Resident #43). Resident #43 did not receive a bath/shower the day of the procedure. The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #43 dated 1/12/25 included diagnoses of ulcerative colitis, Alzheimer's disease, anxiety disorder, and depression. The MDS identified a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. The MDS documented the resident required extensive assistance with bathing, personal hygiene, and transfers and was dependent on staff assistance for toileting. Review of pre-op orders dated 1/20/25 in preparation for a colonoscopy to be completed on 1/24/25, stated the day of surgery, Resident #43 was to receive a shower or bath the morning of the procedure. Resident #43 was noted to have powder in her groins that was wet and clumpy when she arrived for the procedure. Review of documentation in Point Click Care (PCC) (the facility's electronic healthcare records), Resident #43 received a shower on 1/20/25 on day shift. Review of the facility provided bath sheets, Resident #43 received a shower on 1/23/25 between 2 and 6 PM and was noted to have excoriated groins and abdominal fold at that time. It was noted the treatment was completed to the area. There was no documentation of a shower or bath being completed on 1/24/25, the day of the colonoscopy procedure. In an interview on 1/30/25 at 2:51 PM, the Administrator stated it was the expectation staff provide a bath/shower to the resident per the physician order prior to the procedure to ensure the resident was clean and ready to go for the day. On 1/30/25 at 2:08 PM, the Administrator reported per email the facility did not have policies for bathing or following physician's orders and that it was the expectation they follow the Standards of Care practices.

Based on personnel file review, staff interview, and policy review, the facility failed to assure 1 of 5 staff reviewed met the requirements for Dependent Adult Abuse Mandatory Reporter Training (Staff B). The facility reported a census of 50 residents. Findings include: Staff B, Housekeeper, had a start date of 5/29/24. Record review revealed Staff B had not completed the 2 hour Dependent Adult Abuse Mandatory Reporter Training that was due 11/29/24. In an interview on 1/29/25 at 1:00 PM, the Administrator acknowledged Staff B had not yet completed the Dependent Adult Abuse Mandatory Reporter Training. She stated the employee was currently in the facility completing the training. She was aware new employees were to complete the training within 6 months. In an interview on 1/30/25 at 2:48 PM the Administrator stated it was the expectation the Business Office Manager use a spread sheet with all staff and the dates they are due to complete or renew their Dependent Adult Abuse Mandatory Reporter Training and the Business Office Manager was to let the Administrator know when the staff were coming due and get them completed as required. The facility provided Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated 10/19/22 stated within six months of hire each employee shall be required to complete an initial 2-hour training course provided by the Iowa Department of Human Services relating to the identification and reporting of dependent adult abuse. Each employee will take a 1-hour recertification training within 3 years of the initial training and every three years thereafter.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food. The facility reported a census of 51 residents. Findings include: On 3/25/24 at 10:33 AM, a kitchen observation identified the following findings: Unit #1 freezer contained: 1) An unlabeled, undated, tied bag of folded, yellow items. 2) An unlabeled bag of meat links. Unit #2 freezer contained: 1) An unlabeled bag of chopped meat. 2) An unlabeled bag of 1/8 cut dough-like slices. 3) Two unlabeled blocks of sealed meat on shelves. Unit #3 refrigerator contained: 1) An unlabeled, undated metal pan with casserole-like contents and a used ladle stored on top. 2) An unlabeled, undated plastic bag of meat links. 3) An unlabeled bag of chopped, green contents. Unit #4 refrigerator contained: 1) An unlabeled, undated bag of diced, green contents. 2) An undated, plastic tub of sour cream. A cabinet contained two (2) unlabeled, undated plastic containers with cereal-like contents. An opened, undated bag of bread crumbs stored in the dry goods room. On 3/26/24 at 10:20 AM, a follow-up kitchen observation identified the following findings: Unit #1 freezer contained: 1) An unlabeled, undated, tied bag of bread-like contents that was also cut open. 2) An unlabeled, undated, tied bag of folded, yellow, egg-like items. 3) An unlabeled, undated, tied bag of white, disk-shaped items. Unit #2 freezer contained: 1) An unlabeled bag of chopped meat. 2) An unlabeled, undated plastic bag of meat links. Unit #4 refrigerator contained: 1) An undated, plastic tub of sour cream. A cabinet contained two (2) unlabeled, undated plastic containers with cereal-like contents. An opened, undated bag of bread crumbs stored in the dry goods room. On 3/28/24 at 9:23 AM, the Administrator stated all stored food should be dated and labeled. A policy titled Food Storage dated 2021 indicated all containers or storage bags must be legible, covered, and accurately labeled and dated.

Based on document review and staff interview, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a certified dietary manager. The facility reported a census of 51 residents. Findings include: On 3/25/24 at 10:33 AM, Staff A, Dining Manager stated she was not the Dietary Manager because she was not certified. On 3/26/24 at 11:07 AM, Staff A stated she had not had any formal course-work training in food safety and nutrition, but was an assistant dietary manager at another facility for 11/2 years. On 3/26/24 at 11:09 AM, the Administrator stated she planned to enroll Staff A in a six-month course in April. She stated the facility had a contract dietitian who was at the facility on Tuesdays. The contract dietitian was not present. On 3/28/24 at 9:23 AM stated the Dietary Manager should be certified within six (6) months of hire. The facility did not have a policy that addressed Dietary Manager certification. The Facility Assessment with updated date of 3/6/24 documented that a Dietary Supervisor was to be involved in completing the Facility Assessment. The Facility Assessment revealed that the average daily resident census was 47.

Based on observations, clinical record review and staff interviews, the facility failed to provide restorative services on 1/18/24 involving 29 residents. The facility reported census was 45. Findings include: In an interview on 1/18/24 at 10:23 a.m. Staff C, Rehabilitation Director, stated when residents complete a physical or occupational program, they will typically get a restorative plan. Staff C stated she reviews the plans and the restorative aides provide the services usually 3-5 times per week. Staff C stated the ADON oversees the restorative program. In an interview on 1/18/24 at 3:00 p.m. the Assistant Director of Nursing (ADON) stated she oversees the restorative program and indicated there were currently 35-40 residents with a program. The ADON stated Staff D was the facilities full time restorative aide and she provides the restorative services Monday through Friday. The ADON stated Staff D also has responsibilities ordering and putting supplies away and assisting with showers Mondays, Tuesdays and Wednesdays. The ADON stated she provided Staff D with a restorative program flow sheet and education on time management to help her better coordinate restorative services. In a follow up interview on 1/23/24 at 7:46 a.m. The ADON stated all passive range of motion (PROM), active range of motion (AROM) and transfer programs are to be completed the restorative aide or therapy. In an interview on 1/17/24 at 3:30 p.m. Staff D, Restorative Aide, stated she works Monday through Friday 8:00 a.m. to 4:00 p.m. doing restorative programs. Staff D stated there was currently about 40 residents with restorative programs. Staff D stated she assisted with showers in the morning and then goes to group activities and 1:1. Staff D stated she tracks services provided, in a folder for each resident. In a follow up interview on 1/23/24 at 9:57 a.m. Staff D was asked to clarify her direct involvement with residents receiving restorative care. Staff D stated she attempts to see at least 20 residents each day and noted it takes 15 minutes to complete each active range of motion (AROM) program and passive range of motion (PROM) program. Staff D stated in addition, those residents identified under the Dressing & Grooming category are assisted with toileting and Transfer category are assisted with transfers. Staff D stated she assists two residents under the Dining category at breakfast and one in his room at lunch. Staff D stated those residents identified under Ambulation are walked in the hall and most are walked in their room. Staff D stated she documents at the end of her shift and it takes 30 minutes or so. Staff D stated every resident in which she documented as Done was completed with her direct physical involvement. In an interview on 1/18/24 at 3:00 p.m. Staff E, Licensed Practical Nurse, stated Staff D was to provide restorative services Monday through Friday. Staff E stated Staff D does not manage her time well and does not complete restorative services consistently throughout the week. In an Employee Corrective Action Form dated 1/3/24, Staff D was given a written warning for failing to complete restorative services and ensure logs are completed daily. Expectations moving forward included ensuring logs are completed and turned into the restorative nurse (ADON) and check with the DON upon completion of her shift to ensure all tasks are completed for the day, including but not limited to restorative, showers, weights and vital signs if applicable. According to the Restorative Program sheet dated 1/18/24, Staff D documented she completed 20 resident AROM programs (x 15 minutes or 5 hours), 12 PROM programs (x 15 minutes or 3 hours), assisted with toileting of 11 residents (x 5 minutes or 1 hour), assisted with ambulating 8 residents (x 5 minutes or 40 minutes), assisted with transferring 4 residents (x 5 minutes or 20 minutes) and assisted with feeding 3 residents (x 20 minutes or 1 hour). Documenting restorative program 30 minutes. All totaling an estimated 11.5 hours of time to complete. According to Staff D's time sheet, she clocked in at 8:29 a.m. and clocked out at 4:37 p.m. on 1/18/24, totaling 8 hours and 8 minutes. Observations of Staff D throughout the day on 1/18/24 noted the following entries: 9:25 a.m. Staff D appears to be involved with weighing residents. 11:00 a.m. Staff D observed walking with Resident #8 with wheel walker and wheel chair pulled behind him. 11:32 a.m. Staff D was sitting in an office and appears to be documenting. 11:48 a.m. Staff D bringing in supplies from outside. 12:32 p.m. Staff D was observed leaving the break room and then pushing a supply cart in 100 hall. 12:48 p.m. Staff D was unpacking supplies. 1:27 p.m. Staff D observed leaving the break room. 2:01 p.m. Staff D observed propelling Resident #1 from the therapy room to the resident's room. 2:05 p.m. Staff D again observed removing supplies from boxes on 100 hall. 2:55 p.m. This surveyor walked the hallways on front and back halls several times without any sight of Staff D with a resident or in the therapy room.

Based on record review and staff interviews the facility failed to ensure resident's controlled medications are not diverted for 4 of 4 residents reviewed. (Residents #1, #2, #3, #4) The facility reported census was 48. Findings include: RESIDENT #1 According to a Minimum Data Set (MDS) with a reference date of 2/14/23, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #1 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnoses included schizophrenia, bipolar disorder, traumatic brain injury, paraplegia and post traumatic stress disorder. In an interview on 4/3/23 at 5:14 p.m. Staff C, licensed practical nurse, stated on the evening of 2/25/23 she was working a 10:00 p.m. to 6:00 a.m. shift. Sometime after midnight on 2/26/23, Resident #1 requested a pain medication and Staff C discovered there were no scheduled or as needed (PRN) Hydrocodone available. Staff C contacted the pharmacy to get a code to receive a dose from the Cubex and was told 60 doses had been delivered on 2/23/23 at 7:00 p.m. Staff C contacted the DON and reported the issue. In an interview on 3/27/23 at 5:00 p.m. the Director of Nursing (DON) stated on 2/26/23 they first discovered Resident #1 was missing a (60) dose bubble pack of Hydrocodone/APAP 10-325 milligram. An investigation was initiated and pharmacy records indicated the bubble pack was sent by pharmacy on 2/23/23 at 7:00 p.m. and signed as received by Staff A. Staff A admitted to receiving the pharmacy delivery, but not verifying the controlled medication sent with the driver (not addressed in policy) and not securing the controlled medications in the locked compartment in the medication cart (not addressed in policy). The DON stated she began reviewing other controlled medication documentation and discovered on 2/23/23, the same evening (60) doses of Resident #1's Hydrocodone/APAP 10-325 milligram bubble pack was missing, (64) doses of Resident #2's Hydrocodone/APAP 10-325 milligram was recorded as allegedly destroyed by Staff A without a witness signature (per facility protocols). The DON stated they suspended Staff A and notified the Department of Inspections and Appeals. Review of Resident #1's pharmacy dispense records, controlled drug utilization records (CDUR) and medication administration records (MAR) found multiple incidents in which controlled medications were unaccounted for and not discovered by the facility. In a 3 month review of records and interviews, 160 doses of Hydrocodone 10-325 milligrams belonging to Resident #1 was found missing and unaccounted for. RESIDENT #2 According to a Minimum Data Set (MDS) with a reference date of 2/1/23, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #2 is independent with transfers, mobility, dressing, toilet use, and personal hygiene needs. Resident #2's diagnoses included [NAME] Syndrome and celiac disease. In an interview on 3/28/23 at 6:00 p.m. Staff G, licensed practical nurse, was questioned whether she ever recalls destroying Hydrocodone belonging to Resident #2 with Staff A. Staff G stated during the course of her job duties, she has at times witnessed the disposal of controlled medications. Staff G was shown two controlled drug use records (CDUR) dated 1/25/23 in which 26 doses and 6 doses of Hydrocodone/APAP 5-325 milligrams belonging to Resident #2 were allegedly destroyed by Staff A and with her as a witness. Staff G stated the signatures on the CDURs are not hers, noting she always combines her T with her B in a loop. Staff G stated her signature was forged on those documents. Review of Resident #2's pharmacy dispense records, controlled drug utilization records (CDUR) and medication administration records (MAR) found multiple incidents in which controlled medications were unaccounted for and not discovered by the facility. In a 3 month review of records and interviews, 387 doses of Hydrocodone at various strengths, belonging to Resident #2 was found either missing and unaccounted for or destroyed without a proper witness per facility protocols or with a forged witness signature. RESIDENT #3 According to a Minimum Data Set (MDS) with a reference date of 3/7/23, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14 indicating an intact cognitive status. Resident #3 is independent with transfers, mobility and toilet use and requires limited assistance with dressing and personal hygiene needs. Resident #3's diagnoses included schizophrenia, respiratory failure and diabetes mellitus. Review of Resident #3's pharmacy dispense records, controlled drug utilization records (CDUR) and medication administration records (MAR) found multiple incidents in which controlled medications were unaccounted for and not discovered by the facility. In a 3 month review of records, 84 doses of Hydrocodone/APAP 5-325 milligrams, belonging to Resident #3 was found missing and unaccounted for. 17.25 milliliters of liquid morphine and 11 doses of morphine sulfate 15 milligrams belonging to Resident #3 was allegedly destroyed under a suspicious witness signature. RESIDENT #4 According to a Minimum Data Set (MDS) with a reference date of 2/14/23, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #4 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #4's diagnoses included Alzheimer's disease, respiratory failure, renal failure and diabetes mellitus. According to a controlled drug use record (CDUR), 60 doses of Morphine Sulfate 60 milligrams ER was dispensed on 11/22/22 with the first dose administered on 11/27/22 at 9:40 a.m. and the last dose administered by Staff A on 12/9/22 at 4:30 p.m. leaving 48 doses remaining. On 12/9/22 Staff A signed as a witness destroying the 48 doses with a hospice nurse, Staff I. In an interview on 3/29/23 at 4:10 p.m. Staff I, registered nurse with hospice was asked if she recalled destroying 48 doses of Morphine 60 milligrams ER belonging to Resident #4 with Staff A on 12/9/22. Staff I stated she did not recall signing anything and typically refrains from signing facility documents since she works for hospice. Staff I stated she saw the document in question (CDUR) earlier today and stated that it was not her signature. Staff I stated she always dots her I with a heart and uses BSN, RN, CM following her name. Staff I stated the signature is similar, but not hers. Staff I provided a photo of her signature for comparison. The signature on the document does not include all the elements in which Staff I stated she always uses.

Based on record review and staff interviews the facility failed to establish a system and policy to ensure accurate acquiring, receiving, dispensing, and destruction of all controlled medications in sufficient detail to enable an accurate reconciliation and to mitigate the potential for diversion for 4 of 4 residents sampled. (Residents #1, #2, #3, #4) The facility reported census was 48. Findings include: RESIDENT #1 According to a Minimum Data Set (MDS) with a reference date of 2/14/23, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #1 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnoses included schizophrenia, bipolar disorder, traumatic brain injury, paraplegia and post traumatic stress disorder. In an interview on 4/3/23 at 5:14 p.m. Staff C, licensed practical nurse, stated on the evening of 2/25/23 she was working a 10:00 p.m. to 6:00 a.m. shift. Sometime after midnight on 2/26/23, Resident #1 requested a pain medication and Staff C discovered there were no scheduled or as needed (PRN) Hydrocodone available. Staff C contacted the pharmacy to get a code to receive a dose from the Cubex and was told 60 doses had been delivered on 2/23/23 at 7:00 p.m. Staff C contacted the DON and reported the issue. In an interview on 3/27/23 at 5:00 p.m. the Director of Nursing (DON) stated on 2/26/23 they first discovered Resident #1 was missing a (60) dose bubble pack of Hydrocodone/APAP 10-325 milligram. An investigation was initiated and pharmacy records indicated the bubble pack was sent by pharmacy on 2/23/23 at 7:00 p.m. and signed as received by Staff A. Staff A admitted to receiving the pharmacy delivery, but not verifying the controlled medication sent with the driver (not addressed in policy) and not securing the controlled medications in the locked compartment in the medication cart (not addressed in policy). The DON stated she began reviewing other controlled medication documentation and discovered on 2/23/23, the same evening (60) doses of Resident #1's Hydrocodone/APAP 10-325 milligram bubble pack was missing, (64) doses of Resident #2's Hydrocodone/APAP 10-325 milligram was recorded as allegedly destroyed by Staff A without a witness signature (per facility protocols). The DON stated they suspended Staff A and notified the Department of Inspections and Appeals. Review of Resident #1's pharmacy dispense records, controlled drug utilization records (CDUR) and medication administration records (MAR) found multiple incidents in which controlled medications were unaccounted for and not discovered by the facility. The following 3 month review found 160 doses of Hydrocodone 10-325 milligrams belonging to Resident #1 missing and unaccounted for. According to pharmacy dispense records, 90 doses of Hydrocodone/APAP 10-325 milligrams was delivered on 11/21/22 in two bubble packs. One had 30 doses and the other had 60 doses. The 60-dose bubble pack was used from 11/25/22 am through 12/7/22 8:00 p.m. The 30-dose bubble pack, along with the CDUR was missing and unaccounted for. According to pharmacy dispense records, 90 doses of Hydrocodone/APAP 10-325 milligrams was delivered on 12/5/22 in two bubble packs. One had 30 doses and the other had 60 doses. Both bubble packs and CDURs are missing. Based on the start date and time the last dose on the 11/21/22 bubble pack was used and the beginning dose on the 12/20/22 bubble pack, 78 doses were used with 2 additional doses used as PRN, leaving 10 doses unaccounted for. According to pharmacy dispense records, 90 doses of Hydrocodone/APAP 10-325 milligrams was delivered on 12/20/22 in two bubble packs. One had 30 doses and the other had 60 doses. The 60-dose bubble pack was used from 12/27/22 at 4:00 p.m. through 1/11/23 at 12:00 p.m. The 30-dose bubble pack and CDUR was missing and unaccounted for. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 10-325 milligrams was delivered on 1/10/23. The first dose used from the bubble pack was on 1/11/23 at 8:00 p.m. and the last dose used on 1/26/23 at 9:00 a.m. According to pharmacy dispense records, 90 doses of Hydrocodone/APAP 10-325 milligrams was delivered on 1/23/22 in two bubble packs. One had 30 doses and the other had 60 doses. The 60-dose bubble pack was used from 1/26/23 at 12:30 p.m. through 2/10/23 at 12:51 p.m. The 30-dose bubble pack and CDUR was missing and unaccounted for. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 10-325 milligrams was delivered on 2/8/23. The first dose used from the bubble pack was on 2/10/23 at 4:45 p.m. and the last dose used on 2/25/23 at 1:12 p.m. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 10-325 milligrams was delivered on 2/23/23. The 60-dose bubble pack and CDUR was missing and unaccounted for. RESIDENT #2 According to a Minimum Data Set (MDS) with a reference date of 2/1/23, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #2 is independent with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #2's diagnoses included [NAME] Syndrome and celiac disease. In an interview on 3/28/23 at 6:00 p.m. Staff G, licensed practical nurse, was questioned whether she ever recalls destroying Hydrocodone belonging to Resident #2 with Staff A. Staff G stated during the course of her job duties, she has at times witnessed the disposal of controlled medications. Staff G was shown two controlled drug use records (CDUR) dated 1/25/23 in which 26 doses and 6 doses of Hydrocodone/APAP 5-325 milligrams belonging to Resident #2 were allegedly destroyed by Staff A and with her as a witness. Staff G stated the signatures on the CDURs are not hers, noting she always combines her T with her B in a loop. Staff G stated her signature was forged on those documents. Review of Resident #2's pharmacy dispense records, controlled drug utilization records (CDUR) and medication administration records (MAR) found multiple incidents in which controlled medications were unaccounted for and not discovered by the facility. The following 3 month review found 387 doses of Hydrocodone at various strengths, belonging to Resident #2 either missing and unaccounted for or destroyed without a proper witness per facility protocols or with a forged witness signature. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 5-325 milligrams was delivered on 1/4/23. The CDUR connected with that bubble pack was missing, however according to the previous CDUR dispensed on 12/15/22, Staff A used the last dose on 1/6/23 at 9:30 a.m. and started the first dose at 4:30 p.m. on 1/11/23 on a new CDUR dispensed on 1/10/23. Resident #2 was receiving doses three times per day which would be 15 doses used during 1/6/23 to 1/11/23 from the bubble pack dispensed on 1/4/23, leaving 45 doses missing and unaccounted for. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 5-325 milligrams was delivered on 1/10/23. 54 doses were recorded as used through 1/25/23 at which time 6 doses were recorded as allegedly destroyed by Staff A and Staff G. In an interview, Staff G indicated her signature on that document was forged and not hers. According to pharmacy dispense records, 90 doses of Hydrocodone/APAP 5-325 milligrams was delivered on 1/19/23 in two bubble packs. One with 30 doses and the other with 60 doses. The CDUR connected with the 30 doses had 4 doses used and the remainder (26 doses) were allegedly destroyed by Staff A and Staff G. In an interview, Staff G indicated her signature on that document was forged and not hers. The 60-dose bubble pack and the CDUR connected with it was missing and unaccounted for. According to a progress note dated 1/25/23 at 4:13 p.m. Staff A writes Resident #2 continues to experience moderate pain most of the shift. Call placed to Metro Geriatrics to inquire about an increase Hydrocodone dose. The note is followed by another in which Staff A has obtained an order to increase the Hydrocodone dosage from 5-325 milligrams three times per day to 7.5-325 milligrams three times per day. (By initiating a new order, Staff A has created an opportunity to divert the old dosages. In this case 6 doses from CDUR dispensed 1/10/23 and 26 doses from CDUR dispensed 1/19/23 were allegedly destroyed by Staff A and Staff G as a witness. In an interview, Staff G had indicated her signature on that document was forged and not hers. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 7.5-325 milligrams was delivered on 1/25/23. According to the CDUR all 60 doses were used from 1/25/23 to 2/9/23. During that same time period, pharmacy dispense records indicate 60 doses of Hydrocodone/APAP 5-325 milligrams were delivered on 2/3/23 and 60 doses of Hydrocodone/APAP 7.5-325 milligrams were delivered on 2/8/23 and 2/15/23. The CDURs connected with each delivery was missing and all 180 doses missing and unaccounted for. According to a progress note dated 2/10/23 at 1:50 p.m. Staff A writes new orders to increase Resident #2's Hydrocodone. Discontinue all current Hydrocodone and begin Hydrocodone/APAP 10-325 milligrams four times per day. (Again, Staff A has initiated an order change under false pretenses and created an opportunity to divert the old dosages. The dosage was changed from 7.5-325 milligrams three times a day to 10-325 milligrams four times a day. Now making it necessary to destroy the 7.5-325 milligram doses). According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 10-325 milligrams was delivered on 2/10/23. The CDUR indicates 55 doses were used from 2/10/23 to 2/23/23 leaving 5 doses allegedly destroyed on 2/23/23 by Staff A without a witness, which was required per facility protocol. According to pharmacy dispense records, 59 doses of Hydrocodone/APAP 10-325 milligrams was delivered on 2/22/23. Those doses were destroyed on 2/23/23 by Staff A without a witness, which was required per facility protocol. According to a progress note dated 2/23/23 at 8:00 p.m. Staff A writes upon administration of bedtime medications, Resident #2 was very difficult to arouse. After speaking with two other nurses, this has been an issue since most recent increase in Hydrocodone 10-325 milligrams 4 times a day. Call placed to on-call physician to notify of concerns that this dose is too much. (Staff A's attempt to change a dosage on Hydrocodone under false pretenses was a pattern of hers in order to create opportunity to divert the old dosages through either falsifying destruction records or removing the remaining dosages and the CDUR document.) RESIDENT #3 According to a Minimum Data Set (MDS) with a reference date of 3/7/23, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14 indicating an intact cognitive status. Resident #3 is independent with transfers, mobility, and toilet use and requires limited assistance with dressing and personal hygiene needs. Resident #3's diagnoses included schizophrenia, respiratory failure and diabetes mellitus. Review of Resident #3's pharmacy dispense records, controlled drug utilization records (CDUR) and medication administration records (MAR) found multiple incidents in which controlled medications were unaccounted for and not discovered by the facility. The following 3 month review found 84 doses of Hydrocodone/APAP 5-325 milligrams, belonging to Resident #3 missing and unaccounted for and 17.25 milliliters of liquid morphine and 11 doses of morphine sulfate 15 milligrams allegedly destroyed under suspicious witness signature. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 5-325 milligrams was delivered on 11/25/22. The first dose used was on 11/26/22 at 7:00 a.m. and last dose used on 12/10/22 at 11:25 a.m. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 5-325 milligrams was delivered on 12/9/22. There was no CDUR available. Based on the last dose given from the 11/25/22 bubble pack on 12/10/22 at 11:25 a.m. and the first dose given from the 12/21/22 bubble pack on 12/22/22 at 7:35 a.m. 46 routine doses were given. The December medication administration record (MAR) indicated an additional dose was given as needed (PRN) indicating 13 doses unaccounted for. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 5-325 milligrams was delivered on 12/21/22. The first dose used was on 12/22/22 at 7:35 a.m. and last dose used on 1/6/23 at 7:45 a.m. signed out by Staff A. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 5-325 milligrams was delivered on 1/4/23. The first dose used was on 1/6/23 at 8:00 a.m. also signed out by Staff A, indicating Staff A removed two doses of Hydrocodone/APAP 5-325 milligrams on the morning of 1/6/23, when the resident was only to receive one. The last dose was given on 1/20/23 at 8:00 p.m. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 5-325 milligrams was delivered on 1/18/23. There was no CDUR available. Based on the last dose given from the 1/4/23 bubble pack on 1/20/23 at 8:00 p.m. and the first dose given from the 1/28/22 bubble pack on 1/28/23 at 7:45 p.m. 31 routine doses were given. The January medication administration record (MAR) indicated no additional doses were given as PRN, leaving 29 doses unaccounted for. According to a progress note dated 1/27/23 at 5:45 p.m. Staff A indicated she received a new order to discontinue Hydrocodone/APAP 5-325 milligrams four times a day and start Hydrocodone/APAP 7.5 milligrams three times a day. Staff A does not identify who gave the order. Interviews with the hospice nurse and facility nurse practitioner indicated there was no discussion or authorization from them to change the Hydrocodone dosage for Resident #3. (Staff A's attempt to change a dosage on Hydrocodone under false pretenses is a pattern of hers in order to create opportunity to divert the old dosages through either falsifying destruction records or removing the remaining dosages and the CDUR document.) According to pharmacy dispense records, 12 doses of Hydrocodone/APAP 5-325 milligrams was delivered on 1/28/23. Five doses were used through 1/30/23 at 7:40 a.m. leaving 7 doses remaining at the time of an increase in dosage. The 7 doses were destroyed by Staff A with Staff H as a witness. Staff H stated her signature on the CDUR was not typical for her, but she could not say with certainty, that it was not. Staff H provided a signature which was not consistent with the signature on the 1/28/23 CDUR. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 7.5-325 milligrams was delivered on 1/31/23 and again on 2/8/23. There was no CDURs available for these bubble packs. Based on the last dose given from the 1/30/23 Hydrocodone/APAP 5-325 milligrams bubble pack on 1/30/23 at 7:30 p.m. and the first dose given from the 2/20/23 Hydrocodone/APAP 5-325 milligrams at 4:20 p.m. and according to the January and February 2023 medication administration records, there were 86 routine doses administered using the Hydrocodone/APAP 7.5-325 milligram cards leaving 34 doses missing and unaccounted for. According to pharmacy dispense records, 60 doses of Hydrocodone/APAP 5-325 milligrams was delivered on 2/20/23. The dosage is wrong, however staff continued to use the dosages. The first dose was used on 2/21/23 at 4:20 p.m. and the last dose used on 3/8/23 at 12:19 p.m. without any noted discrepancies. According to pharmacy dispense records, 30 milliliters of Morphine Sulfate was delivered on 11/28/22. The CDUR indicated the first dose was administered on 12/2/22 at 5:50 p.m. and the last dose administered on 1/25/23 at 1:00 a.m. leaving a remaining 2.25 milliliters left. The remaining 2.25 milliliters were allegedly destroyed by Staff A and Staff H as a witness. Staff H stated her signature on the CDUR was not typical for her, but she could not say with certainty, that it was not. Staff H provided a signature which was not consistent with the signature on the 11/28/23 CDUR. According to pharmacy dispense records, 15 milliliters of Morphine Sulfate was delivered on 1/17/23. The CDUR indicated no doses were removed. The 15 milliliters were allegedly destroyed by Staff A and Staff H as a witness. Staff H stated her signature on the CDUR was not typical for her, but she could not say with certainty, that it was not. Staff H provided a signature which was not consistent with the signature on the 1/17/23 CDUR. According to pharmacy dispense records, 30 doses of Morphine Sulfate 15 milligrams was delivered on 1/20/23. The CDUR indicated 19 doses were used from 1/21/23 at 7:45 a.m. to 1/30/23 at 7:40 a.m. The remaining 11 doses were allegedly destroyed by Staff A and Staff H as a witness. Staff H stated her signature on the CDUR was not typical for her, but she could not say with certainty, that it was not. Staff H provided a signature which was not consistent with the signature on the 1/20/23 CDUR. RESIDENT #4 According to a Minimum Data Set (MDS) with a reference date of 2/14/23, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #4 required extensive assistance with transfers, mobility, dressing, toilet use, and personal hygiene needs. Resident #4's diagnoses included Alzheimer's disease, respiratory failure, renal failure and diabetes mellitus. According to a controlled drug use record (CDUR), 60 doses of Morphine Sulfate 60 milligrams ER was dispensed on 11/22/22 with the first dose administered on 11/27/22 at 9:40 a.m. and the last dose administered by Staff A on 12/9/22 at 4:30 p.m. leaving 48 doses remaining. On 12/9/22 Staff A signed as a witness destroying the 48 doses with a hospice nurse, Staff I. In an interview on 3/29/23 at 4:10 p.m. Staff I, registered nurse with hospice was asked if she recalled destroying 48 doses of Morphine 60 milligrams ER belonging to Resident #4 with Staff A on 12/9/22. Staff I stated she did not recall signing anything and typically refrains from signing facility documents since she works for hospice. Staff I stated she saw the document in question (CDUR) earlier today and stated that it was not her signature. Staff I stated she always dots her I with a heart and uses BSN, RN, CM following her name. Staff I stated the signature is similar, but not hers. Staff I provided a photo of her signature for comparison. The signature on the document does not include all the elements in which Staff I stated she always uses. According to the facility policy on Controlled Substances: 1. A controlled substance count is to occur by two authorized personnel (on-coming and off-going) at each shift change to ensure an accurate reconciliation of all narcotics on hand. If no discrepancies, the medication cart keys are passed to the on-coming nurse/designee. If the count is not accurate, the off going nurse is to remain on duty until the count is reconciled or the nursing supervisor approves leaving. Discrepancies found at any time are to be immediately reported to the Director of Nursing. The Director of Nursing will determine the cause of inaccuracy and consult with pharmacy for assistance. 2. When receiving controlled medications, the nurse will fill out the top portion of the CDUR with the initial count and staff signature recorded. Staff will then continue to utilize the CDUR to record dates, time, removal of doses, ending count, and signature. 3. Medications destroyed are to be placed in the drug disposal bottle located in the medication room. Patches are to be folded, sticky side to sticky side and placed in the drug disposal bottle. When disposing of controlled medications, two nurses must verify and document the count on the CDUR, dispose of the medication in the drug disposal bottle, and sign the CDUR.

Based on observations, resident interviews, and review of the facility identified meal times the facility failed to meet the resident's preferences regarding meals times for four of four residents reviewed (Residents #40, #13, #20, and #44). The facility reported a census of 50 residents. Findings include: Observations On 12/29/22 at 1:58 PM witnessed Resident 48 receive his noon meal delivered to his room. On 1/3/23 at 12:12 PM observed residents sitting in the dining room with beverages served. A white board in the main dining room defined the meal times as breakfast 7:30 AM, lunch 12:00 PM, and dinner 5:30 PM. On 1/3/23 at 12:37 PM watched residents eat banana cake (dessert) while waiting for their main course to be served. On 1/4/23 at 12:35 PM watched the staff serve the meal in the dining area. At that time, no one had delivered the room trays. On 1/4/23 at 1:20 PM observed the Kitchen Manager deliver the meal to the residents in the 400 hallway. On 1/9/23 at 1:10 PM watched the room trays get delivered to the residents in the 400 hallway. An undated, unlabeled document provided by the facility listed the meal times as breakfast, 7:30 AM, 12:00 PM, and 5:30 PM. 1. Resident #40's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 12/29/22 02:19 PM Resident #40 reported that the meals get served late. Resident #40 explained that the evening meal usually gets served about 6:30 PM. An undated facility policy titled Dining Room Service stated meals will be served promptly. On 1/9/23 at 1:30 PM Staff J, Certified Nursing Assistant (CNA), stated it was not uncommon for room trays to be late and the noon meal arrived typically around 1:30 PM. 35434 2. The Minimum Data Set (MDS) assessment tool, dated 11/15/22 identified Resident #13 had a Brief Interview for Mental Status (BIMS) score as 15, indicating intact cognition. On 1/3/23 at 8:45 a.m. Resident #13 stated they get their meals late and have been up to an hour late. 3. The MDS assessment tool, dated 11/15/22, listed Resident #20's BIMS score as 15, indicating intact cognition. During an interview on 1/3/23 at 9:33 a.m. Resident #20 stated breakfast was not on time. 4. On 1/3/23 at 9:26 a.m. observed the facility staff serve Resident #44's breakfast.

Based on testing logs, facility policy, and staff interview, the facility failed to test facility staff during an outbreak for 4 of 4 staff reviewed (Staff A, B, C, and D). The facility reported a census of 50 residents. Findings include: The undated facility document Covid Positivity documented the follow staff tested positive of COVID-19 a. Staff F, Laundry, tested positive on 12/8/22 b. Staff G, Licensed Practical Nurse (LPN), tested positive on 12/11/22 c. Staff H, Certified Nursing Assistant (CNA), tested positive on 12/28/22. The Facility Staff Covid-19 Test Result Forms documented that Staff C, CNA, tested negative on 12/9/22 and Staff A, Dietary, tested negative on 12/13/22. The facility lacked documentation of further tests conducted for Staff C or Staff A during the period of 12/8/22-1/5/23. The facility lacked documentation of tests conducted for Staff B CNA or Staff D CNA during the period of 12/8/22-1/5/23. The CDC(Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/23/22, directed the facility to perform testing for all residents and staff identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. The recommendations stated testing was recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test and stated as part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. The facility policy Testing Guidance dated 10/5/22, stated that upon a newly identified positive staff or resident, test all staff and stated testing should be completed every 7 days until no new cases identified for at least 14 days. During an interview on 1/9/23 at 8:06 a.m. the Infection Preventionist provided the above tests for Staff C and Staff A. She stated she had no further documentation of tests for Staff A, B, C, or D but stated they should have tested 2 times per week. She stated the facility tested unvaccinated staff on Tuesdays and Fridays and other staff get tested during outbreaks. She stated staff were supposed to test but they did not complete this.

Based on observations and an interview with a non facility kitchen equipment representative the facility failed to keep equipment in safe working conditions. The kitchen observation revealed an oven door falling off the frame due to a faulty hinge. The facility reported a census of 50. Findings include: On 1/5/23 at 12:30 PM observed the dietary manager placed pureed chicken and mechanical soft chicken into the oven. The observation determined the oven door did not have a hinge on the lower right corner, causing the door to fall off the frame when opened. The Dietary Manager used his foot to secure the door in place. The completion of temperature checks on the altered chicken diets required the oven door to be open and shut multiple times, each time the oven door fell off the frame only secured by the left lower door hinge. An interview with a non facility kitchen equipment representative (Representative) confirmed that the facility called to have the oven door repaired on 1/5/23. The Representative stated someone visited the facility on 1/6/23 and that a hinge repair kit is currently on order. A work order documented an onsite visit to the facility 1/6/23 to repair the oven door hinge. The facility lacked a maintenance or repair policy.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision and proper use of assistive devices to mitigate a resident's risk for elopement (when a resident leaves the facility without staff knowledge or permission) for 1 out of 3 residents reviewed for wandering/elopement risk. Resident #6 exited the facility unattended through a door that had not been latching properly for several weeks and did not have an alarm attached to alert staff to a resident's attempt to exit unattended. These findings constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 48 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] Resident #6 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating significant cognitive deficits. The MDS showed that the resident was independent with walking, transfer, toileting and personal cares and had diagnoses that included [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. According to the Care Plan updated on 8/27/21 Resident #6 was blind in one eye and deaf in one ear. The Care Plan included a focus area that stated that the resident was a smoker and would go outside for smoking breaks with staff supervision. The Care Plan showed that the resident had some confusion related to a stroke and wore a Wander Guard alarm bracelet to alert staff. The Care Plan alerted staff to the resident's attempts to go outside to smoke and directed them to monitor. According to an Elopement Risk assessment dated [DATE] Resident #6 was at moderate risk for elopement and had a monitoring bracelet to alert staff when she got close to a door to the outside. According to an Incident Report dated 8/26/21 at 11:59 PM, a Certified Nursing Assistant (CNA) reported to the Charge Nurse that she saw Resident #6 at 4:30 PM on that evening outside the building, near the smoking area. When the resident was asked what she was doing, she told the CNA that she had gone out the back door. The Incident Report stated that the Service Door did not have a Wander Guard alarm on it and did not always latch, therefore was unlocked. In an observation on 8/30/21 at 11:30 AM, the Service Entrance Door from the outside of the building was unlocked, it lead into a small hallway where staff completed their screening questions before starting their shifts. A second door opened into the 300 hallway of the facility and this door had a keypad lock with a code to open it from the inside. On 8/30/21 at 1:10, the Administrator said that on 8/26/21, Resident #6 had been seen around 4:15 PM heading down the hallway to her room which was close to the Service Door. The Administrator said she had been notified that morning that the Service Door hadn't been latching properly. She said that the resident was later seen by a CNA from room 106, walking up the driveway in the front of the building, toward the patio where the residents go out to smoke. On 8/30/21 at 3:20 PM, Staff F, Licensed Practicing Nurse (LPN) reported she did not realize the resident had gotten outside unattended until around 10:00 PM the evening of 8/26/21. She said that just before she was ready to leave for the night, Staff U, CNA told her that Resident #1 was outside unattended around 4:30 that afternoon. Staff F said that she did an assessment on the resident and initiated 15 minute checks on the resident at that time. Staff F said that she believed the resident had gotten out the Service Door because it's close to the resident's room and it did not have a Wander Guard alarm on it. She said that the residents had become accustomed to exiting the Service Door for their smoke brakes, and the door had not been latching properly for a couple of days. On 8/30/21 at 4:15 PM, Staff V, CNA said Resident #6 had come to the Nurses Station to get ice shortly before she was seen outside. Staff V asked Staff U to assist her with transferring a resident in room 106 when Staff U said she saw the resident on the sidewalk out front. Staff V reported the resident very confused when she came inside and Staff V thought the resident had gone out the Service Entrance. Staff V explained she told the nurse after the resident was brought back inside but the nurse did not reply so she didn't think it was a big deal. On 8/30/21 at 4:00 PM, Staff U, CNA said she had been working the back hallway on the afternoon of 8/26/21. She said she had taken some of the residents out for a smoking break around 3:00 PM out the Service Door and they were brought back in the same door around 3:30. She said that shortly after, Staff V asked her to help with a resident in room 106. As they were preparing to transfer the resident, she looked out the window and saw Resident #1 walking up the sidewalk toward the patio on the South side of the building. Staff U went down the 100 hallway to the patio and by the time she got outside, the resident was sitting down in one of the chairs on the patio. Staff U reported she asked the resident what she was doing and the resident said she was out for a walk and that she had gone out the back door. Staff U explained many of the residents call the Service Door the back door. On 8/30/21 at 4:15 PM, Staff W, CNA said she remembered taking the residents out for a smoke break at 3:00 PM and back inside at 3:30 PM. She said she took Resident #6's vital signs at that time and was the last time she saw the resident before she had exited the building. On 8/31/21 at 7:00 AM, the Maintenance Manager reported he had been notified the morning of 8/26/21 that the Service Exit Door had not been latching properly and he fixed the latch later that same morning. After the resident had exited the building, he was notified and came back to the facility and adjusted the closure at the top to make it tighter so it would pull closed. On 8/31/21 at 9:23 AM, Staff T, CNA stated the Service Door had not been latching properly for a couple of weeks. On 8/31/21 at 7:25 AM, Staff P, Registered Nurse (RN) reported she notified Maintenance the day before the resident had exited that the door was not latching properly. On 8/31/21 10:41 RN, Staff Z, RN stated she had been alerted to the problem of the door not closing a couple of weeks prior to the incident. On 9/1/21 at 1:53 PM, Staff BB, Housekeeping reported the latch on the Service Door hadn't worked properly and been on and off for a while she could not say if that was days or weeks. On 9/1/21 at 1:55 PM, Staff U, CNA explained the latch on the Service Door hadn't been working for a couple of weeks. According to the facility Missing Resident/Elopement Process last updated on 2/22/21, an elopement risk assessment will be completed upon admission, readmission, quarterly, annually and with a significant change. All staff will be educated on proper identification, assessment, and treatment of residents identified as an exit seeking risk. This education will occur during orientation and annually thereafter. Missing resident drill will be completed on all shifts quarterly. The State Agency informed the facility of the Immediate Jeopardy (IJ) on September 1, 2021 at 9:25 a.m. Facility Staff removed Immediate Jeopardy on 8/27/21 with the following corrective actions: a. Staff were educated on the process for reporting and addressing malfunctioning alarms and doors. b. Staff were informed that the Service Entrance was to be utilized by staff only and residents should not be exiting through there for smoke breaks. c. New hinges and door closure added and the door code changed. d. A door alarm placed on the Service Entrance Door. e. Auditing for proper functioning of the door alarms and doors will be completed. f. Staff were educated on the facilities Missing Resident/Elopement Process. g. An elopement drill was completed on 8/27/21 and all residents were reviewed for elopement risk and interventions put in place to address any wandering or exit seeking issues. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented interventions, education to staff and their policy and procedures reviewed/amended.

Based on observations, chart review and interviews the facility failed to provide mental health treatment for 1 of 5 residents reviewed. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Pre-admission Screening and Resident Review (PASRR) dated [DATE], Resident #1 was admitted to the facility on [DATE] and according to the screening, it was recommended the resident participate in mental health services based on the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] staff discovered Resident #1 with a bag over her head and a cord wrapped tightly around her neck. The suicide attempt caused an Immediate Jeopardy (IJ) situation. The facility reported a census of 48 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 identified with a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive deficits. The MDS showed that she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated the resident required extensive assistance with the help of two for transfers, dressing and bed mobility and was totally dependent for toileting. The Care Plan included focus areas dated [DATE] such as pressure ulcer on left heel, at risk for skin breakdown due to immobility and presence of a urinary catheter due to paralysis. The Care Plan lacked any references to the PASRR recommendations or interventions related to the mental health needs of the resident until [DATE]. In an Incident Report dated [DATE] at 10:26 AM, Staff M, Certified Nursing Assistant (CNA) stated that she entered the room of Resident #1 on the morning of [DATE] and discovered the resident in her wheelchair with a black bag over her head and the call light cord wrapped and knotted around her neck. Staff M reported that she tore the bag open and tried to break the string around her neck but was unable to tear it. Staff P, Registered Nurse (RN) got scissors to cut the cord from the resident's neck and stated that it was so tight that it was difficult to get the scissors under the cord to cut it. Staff M said that the resident's lips were turning blue but once the string had been cut, they took the resident's vital signs which were within normal limits. Staff M asked the resident why she had the bag on her face and cord wrapped around her neck and the resident answered that she wanted to kill herself. A review of the Nursing Notes for Resident #1 from [DATE] through [DATE], showed the documentation lacked any mention of behaviors or statements that were out of the ordinary. According to an Initial Evaluation with a Psychiatric Nurse Practitioner (NP) on [DATE] at 12:04 PM, Resident #1 reported she wanted things to be over, was very depressed and she would agree to talk to therapy services for counseling. The resident admitted to a change in her moods with increased depression, crying at night and not sleeping well. Review of Nursing Notes included the following: a. On [DATE] at 11:18 AM, the resident seen by the Psych NP and reported that the resident very depressed and the plan was to write a prescription for another antidepressant medication. b. On [DATE] at 10:57 PM, the resident put self on the floor and said she was going to leave. The resident said there was someone in the wall that was talking about her and someone in the attic. c. On [DATE] at 1:42 PM, the resident was talking about the little boy she hears in the wall. When asked if she is having pain, the resident said she had pain in her heart and in her head that no one can fix. d. On [DATE] at 11:30 AM, the resident reported she could hear her son and a girl talking over the intercom and saying she was a bad mother. e. On ,d+[DATE] at 4:53 PM, the resident called her sister and the sister called the facility to say the resident wasn't making sense. The resident told her sister that her son died of AIDS and she was hearing people talking about her in the walls. The sister asked the nurse to call the doctor and have some labs drawn. f. On [DATE] at 6:15 PM, an order was received to have a urinalysis and culture and sensitivity tests completed. g. On [DATE] at 1:51 AM, the resident confused and tearful, reported that she was a horrible mother. h. On [DATE] at 11:30 PM, antibiotic started, the resident reported seeing bugs in the bed and she pulled out her urinary catheter. i. On [DATE] at 3:24, at about 2:00 AM, the resident requested to get up into her wheel chair because of the bugs in the bed. She was reported to be calm and coloring, but talked about Chinamen watching her from the ceiling. j. On [DATE] at 10:09 at about 8:45 AM, Staff M, CNA found the resident with the bag on her head and cord wrapped around her neck. k. On [DATE] at 9:38 AM, the resident sent to the hospital for suicide attempt. A History and Physical (H&P) completed in the Emergency Department (ED) on [DATE] at 9:58 AM stated Resident #1 presented to the ED with psychiatric problems and suicidal ideation. The report documented the resident reported not wanting to live and that she was trying to kill herself. She stated if she had to stay at a nursing home she did not want to live. The ED report showed at 2:30 PM on [DATE], Crisis Center Staff attempted an evaluation but the resident refused so the staff initiated an Involuntary Court Hold. According to the Court Hold Document dated [DATE] at 4:52, the staff received verbal approval for mental health hold. On ,d+[DATE] at 7:07 PM, signed by the physician the commitment was dismissed because not all of the requirements for inpatient mental health treatment had been met and because the patient had a mental health evaluation in the ED. They determined that the resident could return to the nursing home. According to the Integrated Telehealth Evaluation provided in the ED on ,d+[DATE] at 6:52 PM, the resident reported she would rather die than live in a nursing home. The report stated that the patient believed that there were people always listening and taking her information and that there were bed bugs around her. At the time of evaluation the patient denied suicidal or homicidal ideation. The assessment indicated that the patient with a urinary tract infection which may have contributed to the [CONDITION(S)] and that she would be safe at the nursing home with 24 hours round the clock monitoring. A Nursing Note dated [DATE] at 9:15 PM, documented that the resident returned to the facility and stated that there were men with guns following the ambulance behind them. According to the PASRR assessment dated [DATE], Resident #1 admitted to the facility on [DATE] and had participated in psychiatric services for over [AGE] years. The report stated that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The document include details related to the symptoms that she experienced such as manic episodes, roller coaster emotions, feeling hopeful and good one moment and then worried and depressed the next. The resident experienced anxiety, trouble getting to sleep, frequent nightmares, and hearing and seeing things that other people cannot see or hear. The report included references to paranoid thoughts and belief in things that were not true. Included in the PASRR report was a section that referred to Service Matters, a process in which information is reviewed and assistance offered to the facility to help develop a PASRR-Compliant Care Plan once the Level II Services approved. The report stated that on [DATE], the Service Matter was canceled because they needed information that had not been submitted from the facility. The PASRR report showed that services were approved for up to 180 days effective [DATE]. The specialized services included ongoing psychiatric medication management by a Psychiatrist or Psychiatric Advanced Registered Nurse Practitioner) ARNP and individual therapy by a licensed Behavioral Health Professional. The PASRR recommended that the health records from previous treatment providers be obtained, along with psychiatric records from previous mental health providers and collateral information from family was needed. The report directed that any records obtained should be shared with the resident's current and future behavioral health and physical health care providers so that history was as compete as possible and the resident received the best and most accurate care. A review of the Clinical Record reveled psychiatric history not gathered for Resident #1 upon admission to the facility. In an observation on [DATE] at 1:20, Resident #1 in her bed sleeping. The wheel chair, small refrigerator and call light cord had all been removed from the room. On [DATE] at 3:29 PM Resident #1 reported she had been hallucinating when she put the bag on her head. She said she didn't remember wrapping the cord around her neck but she remembered thinking people were shooting each other. The resident said she had a urinary tract infection ([CONDITION(S)]) and had been delusional. She denied having any suicidal thoughts and said that she wants to live and would never attempt to take her life. On [DATE] at 1:25 PM, Staff O, CNA Staff stated ever since the suicide attempt, staff were monitoring Resident #1 every 15 minutes and conducting a depression screening every hour. Staff O reported the resident's wheel chair had been taken out of the room and kept by the Nurses Station, because the resident was able to scoot herself into the chair and then get where she wants to go. On [DATE] at 1:35 PM, Staff M, CNA explained she found the resident with the bag on her head on the morning of [DATE]. Staff M said she had come into work a little before 6 AM that morning and was told in shift report that Resident #1 had been up in her chair since 2 or 3 AM. Staff M reported she went in to check on the resident when she first started her shift and asked her if she wanted to go to breakfast. The resident had been in her wheel chair behind the door, by the sink and she told Staff M at that time she did not want to go to breakfast. Staff M said she went to attend to other residents and get them to breakfast and when she came back down the hallway, she noticed the resident's call light had been on. Staff M said to Staff R, CNA that Resident #1 was probably ready to go out to breakfast. When she went into the room she saw Resident #1 with a black bag on her head and the call light wrapped around her neck very tightly and the cord was closed into the door of a small refrigerator that was sitting on a night stand. Staff M stated she tore the bag off of the residents' face and called for a nurse. The nurse cut the cord off of the resident's neck and called the ED and brought the resident out to the nurses' station until the ambulance arrived. Staff M said they took everything out of the resident's room, no strings and took her wheel chair out of the room and put her on 15 minute checks. Staff M said the resident hadn't ever done that before and when she took the bag off her head, she asked her why she did that and the resident responded she wanted to kill herself. On [DATE] at 6:48 AM, Staff P, Registered Nurse (RN) reported she was the nurse on duty when Resident #1 tried to hang herself. She reported she hadn't known the resident very long but in the time she had worked with her, she never heard statements of suicidal thoughts. Staff P said the Resident's call light had been on around 8:00 AM., and Staff M went in to check on her and soon after Staff M and Staff R, CNA were hollering down the hallway for her to come help. Staff P said she entered the room, saw the resident in her wheelchair, next to the nightstand with a small refrigerator on top. The call light string was wrapped around the resident's neck and a knot was tied in the front. Staff P reported the cord was very tightly wrapped and the resident's head hanging over the side of her wheel chair. The string was still connected to the wall and attached inside the refrigerator door. Staff P stated the resident's face was turning blue. Staff P stated she ran to get a scissors and could barely get the scissors under the cord it was so tight on the resident's neck. Staff P said the bag had been torn off the residents' head by the time that she got in the room and Staff M trying to rip the cord but was unable to. Staff P said she took the resident's vitals and remembered the oxygen saturation had been 97%. On [DATE] at 6:48 AM, Staff R, CNA reported he was present at the time of the suicide attempt. He said the resident had a change in condition with increased confusion and delusions in the days leading up to the suicide attempt and still believed that someone was trying to come in and kill her. He said she seemed to be going back to days when she was involved in drugs and dangerous people. When asked if he had been provided any education on mental health issues or suicidal ideation Staff R, CNA and Staff P, RN said that they had not. According to a report generated from an electronic education services, the RN and LPN staff were assigned a one-hour, annual education on Mental Health in Older Adults that covered medications used to treat mental health issues, and an overview of five mental health diagnosis. On [DATE] at 8:28 AM, the Director of Nursing (DON) reported the Administrator responsible for entering the PASRR information and once that was completed, the recommendations were passed onto the Minimum Data Set (MDS) Nurse to review and follow up. On [DATE] at 7:40 AM Staff N, Social Worker Pro-Tem explained she had been serving in the position of Social Worker for about a year, and to be a temporary position for her but with COVID-19, it had taken longer to find a Social Worker. She reported she was responsible for some of the Admission Assessments but not aware of the mental health history for Resident #1. Staff N said she had not seen the PASRR report and not familiar with the recommendations for services. She reported she had arranged for Resident #1 to see a psychiatric provider on [DATE] but she wasn't sure why, she had been asked by the MDS Coordinator to set up that appointment. Staff N stated not sure about any information regarding past psychiatric services that Resident #1 received before her admission to the facility. On [DATE] at 8:52 AM, the Administrator said the PASRR documents were started after a resident accepted for admission to the facility unless they were coming directly from the hospital. She said that once the resident was in the facility, the form was submitted and if recommend that the resident receive Level II services, it would take about a week to get that information back. She explained after about ,d+[DATE] weeks, they would get an email from Service Matters, a service that helped them to incorporate the recommendations into the residents Care Plan. The Administrator reported she had been doing the PASRR documents, but in the process of training the MDS Coordinator to be able to do them. She said the Resident #1 came to the facility directly from the hospital so they would have initiated the PASRR at the hospital. On [DATE] at 9:50 AM, Staff S, RN said when she got the PASRR recommendations, she would arrange services to the best of her ability. She said she was new to the position and at the time of admission for Resident #1, another staff person was doing this task and that person was no longer an employee at the facility. Staff S said she asked Staff N to arrange for Resident #1 to see a psychiatric provider on [DATE] because some staff had come to her and reported the resident was experiencing a change in condition with increased depression. She said she then looked into the resident's file and discovered that she had qualified for services that she was not getting. [DATE] at 10:31 AM, Staff M, CNA reported she remembered Resident #1 had been saying things that didn't make sense which was unusual for her and described in terms of talking out of her mind for about three weeks prior to the suicide attempt. On [DATE] at 9:10 AM, the Administrator and Staff S said at the time of the Annual Survey the beginning of July, the facility identified they failed to follow up on all the recommendations for psychiatric services for residents with mental health issues. On [DATE] at 12:15 PM, Staff S provided documentation that a call had been made on [DATE] to arrange for Resident #1 to be seen by a Psychiatric NP on [DATE]. On [DATE] at 11:00 AM, a family member for Resident #1 said at times, she would be in touch with the resident on a regular basis. She remembered the conversation she had with the resident on [DATE] and it was out of character for her to be so delusional and paranoid. She reported after having talked to the resident on the phone she called back to the facility and it took ,d+[DATE] times before she was finally able to talk to a nurse and ask them to call the doctor and get some labs drawn. The family member explained Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 7:32 AM, the Administrator stated the facility did not have any policies related to treatment and services offered for residents with mental health issues. According to the Facility Assessment last updated on [DATE], the facility offered and provided services for mental health conditions and behaviors. The Facility Assessment stated the facility had the capacity to provide for the medical conditions causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/[CONDITION(S)], other psychiatric diagnosis, intellectual or developmental disabilities. The State Agency informed the facility of Immediate Jeopardy on [DATE] at 12:15 p.m. The facility removed the Immediate Jeopardy on [DATE] when they implemented the following actions: a. The DON, Administrator and MDS Coordinator were educated on the process of ensuring a resident with a PASRR Level II Admission are screened and provided the recommended mental health services. b. All staff were educated on recognizing signs and symptoms of residents in psychiatric crisis and measures to take to ensure their safety. c. All staff were educated on how to intervene when a resident is experiencing an acute psychiatric episode. The scope lowered from J to a D at the time of the survey after ensuring the facility implemented interventions, educated staff and their policy/procedure reviewed/amended.

Based on record review and staff interview, the facility failed to ensure residents are free of significant medication errors (Resident #1). The facility reported census of 43 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool date 4/7/18, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated a severely impaired cognitive status. Resident #1 required extensive assistance with transfers, ambulation (walking), dressing, toilet use and personal hygiene needs. Resident #1's [DIAGNOSES REDACTED]. Progress Notes dated 5/20/18 at 1:25 a.m. written by Staff A, Licensed Practical Nurse (LPN) documented at approximately midnight a certified nursing assistant (CNA) summoned her to Resident #1's room because the resident was breathing funny. Staff A noted Blood pressure 74/37, pulse 89 beats per minute, respirations 24 per minute and shallow, with cool, clammy, gray-colored skin. Oxygen saturation level was 62% on room air and climbed to 71% with 2 liters per minute of supplement oxygen. Resident #1 was unresponsive and eyes rolled back into head upon sternal rub. Staff A received orders to transfer Resident #1 to emergency room for evaluation and treatment. Ambulance arrived at 12:15 a.m. to transport. A History and Physical final report from the emergency department printed 5/24/18 revealed Resident #1 found unresponsive and was given [MEDICATION NAME] at which time Resident #1 awoke immediately. Preliminary urine drug screen positive for [MEDICATION NAME], which patient does not normally take. Clinical Laboratory report dated 5/24/18 noted Resident #1 had urine sample collected on 5/21/18 which indicated the presence of [MEDICATION NAME] (MS Contin) and [MEDICATION NAME]. In an interview on 5/24/18 at 12:01 p.m. Staff B, licensed practical nurse, stated she worked the 2:00 p.m. to 10:00 p.m. shift on 5/19/18 and noted they were very busy that evening. Staff B recalls Resident #1 was her normal self. Resident #1 went to supper and at around 8:45 p.m. to 9:00 p.m. Staff B assisted Resident #1 into bed. Resident #1 was alert at that time, talking normally. Staff B stated Resident #2 is roommates with Resident #1 and Resident #2 takes both [MEDICATION NAME] milligrams ([MEDICATION NAME]) and [MEDICATION NAME] 10 milligrams at evening meal. That evening Staff B set up Resident #2's [MEDICATION NAME] at 4:00 p.m. and when she went to give it Resident #2 was in the bathroom. Staff B stated she returned to the cart, placed tape over the cup, labeled it and placed it back into the medication cart. Staff B stated she forgot about the pills until 6:00 p.m. at which time she delivered the medications to Resident #2. Staff B stated Resident #2 was upset about the delay, but took the pills in her presence. Staff B stated she gave Resident #2's bedtime pills (including [MEDICATION NAME]) around 9:00 p.m. and remained with her until the medications were ingested. Staff B admitted if Resident #1 had [MEDICATION NAME] in her system, it was most likely due to her making an error involving Resident #1's roommates medications. Staff B stated she believes the medications were passed correctly. In an interview on 5/24/18 at 5:03 p.m. the Pharmacist stated [MEDICATION NAME]([MEDICATION NAME]) is a slow release medication which enters the system within 30 minutes and has peak effect in 3 to 4 hours. [MEDICATION NAME] enters the body within 10 minutes and peaks in 30 to 60 minutes. The Pharmacist stated she would expect someone not routinely on [MEDICATION NAME] have a reaction, but noted it varies per individual. According to the Minimum Data Set (MDS) assessment tool with assessment reference date of 3/25/18, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated a minimally impaired cognitive status. Resident #2 is independent with mobility, dressing, toilet use and personal hygiene needs. Resident #2's [DIAGNOSES REDACTED]. Resident #2's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The Controlled Medication Utilization Record for Resident #2's [MEDICATION NAME] Staff B removed a dose at HS (bedtime), when the (MONTH) MAR indicated [REDACTED]. No extra doses of Resident #2's [MEDICATION NAME] were removed by Staff B that evening.

Based on observation, record review and interview, the facility failed to provide adequate supervision and consistently develop interventions to prevent an injury for 1 of 3 residents reviewed with falls (Resident #43). The facility reported a census of 41 residents. Findings: 1. According to the MDS (Minimum Data Set) assessment tool dated 11/4/17, Resident #43 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 1 staff for bed mobility, transfers, walking, dressing, toilet use, personal hygiene, and bathing, and listed the resident as not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, moving on and off the toilet, and transferring between the bed and chair or wheelchair. The MDS stated the resident had 2 falls without injury since the prior assessment and listed the resident's BIMS (Brief Interview for Mental Status) score as 10 of 15, which indicated a moderately impaired cognitive status. During an observation on 2/27/18 at 7:09 a.m., the resident lay in bed with a pressure pad under him connected wirelessly to an alarm in the hallway. The resident's bed was in a low position and a floor mat lay beside the bed. The resident's 11/26/17 Morse Fall Scale listed the resident's score as 80 with a score of 45 or higher indicating a high risk for falls. Facility Quality Assurance Monitoring Tools (incident reports) for the resident during the survey year revealed the following: a. On 1/13/17, the resident went to the bathroom by himself, fell at the foot of the bed, landed on his back, and sustained an abrasion to the back. b. On 1/18/17, a CNA (Certified Nursing Assistant) found the resident on the floor in front of the recliner. The resident stated he stood up to get into his chair. c. On 4/21/17, staff found the resident on the floor in the closet. d. On 8/3/17, the resident slid out of his recliner and sat on the floor. e. On 10/10/17, the resident transferred himself from bed to toilet and on the way back from the toilet went down on one knee. f. On 10/17/17, staff found the resident sitting in front of the recliner. g. On 12/28/17, the resident transferred himself and fell . h. On 1/15/18, a CNA found the resident lying on the floor. The resident had turned off the personal alarm. The facility sent the resident to the hospital due to hip pain. A 12/29/17 9:50 a.m. nursing note documented the resident continued to attempt self transfers after many reminders to wait for staff assistance. A 12/30/17 1:28 p.m. nursing note documented the resident continued to attempt self transfers after many attempts to educate; the personal alarm in place and functioning. A 1/5/18 6:30 p.m. nursing note documented the resident attempted to transfer himself prior to supper. A 1/6/18 11:15 a.m. nursing note documented the resident was noncompliant with assistance with walking and transfers and shut off the alarm and/or placed it in crevice of chair to muffle the sound so staff couldn't hear it. A 1/7/18 10:21 a.m. nursing note documented the resident continued to attempt self-transfers and shut off or hid the alarm. A 1/8/18 3:59 p.m. nursing note documented the resident continued to self-transfer and hid or turned off the alarm. A 1/10/18 3:20 p.m. nursing note documented the resident continued to self transfer and hid or shut off the alarm. A 1/15/18 hospital report documented the resident sustained [REDACTED]. A 1/19/18 10:50 a.m. nursing note documented the resident admitted to the hospital on [DATE] with a left [MEDICAL CONDITION] and had surgery on 1/16/18. A 1/19/18 12:20 p.m. nursing note documented the resident readmitted to the facility to a room closer to the nurse's station. The resident's care plan included the following entries/interventions: a. 10/28/16 Encourage the resident to wear gripper socks at night. b. 11/16/16 Keep call light in reach and remind to use. c. 10/10/17 Physical therapy/Occupational therapy evaluation/treatment. d. 1/4/18 Place alarm box out of reach. The facility lacked documentation of an additional intervention initiated completed between the dates of 1/4/18 and the resident's fall with fracture on 1/15/18. Nursing notes during this period revealed staff documented the resident continued to turn his/her alarm off. A care plan entry dated 1/19/18 (the resident's readmitted ) listed the following interventions: a floor mat, low bed, and cordless pressure alarm. The facility's undated policy Falls Management directed staff for residents at risk for falls, the nurse would review the resident's condition, put an appropriate intervention into place, and update the care plan. The policy also directed staff to monitor the care plan, monitor for effectiveness of interventions, and make changes as deemed necessary or when reviewed and updated. During an interview on 2/27/18 at 12:44 p.m., Staff C CNA stated on the night the resident fell , he tried to get up and down and the alarm sounded multiple times prior to the incident. When she completed rounds she saw the resident lying on the floor with his feet pointing toward the bathroom. The resident's alarm had been turned off and the resident told Staff C he shut it off. Staff C stated she thought he had already been to the bathroom because of the way he was positioned, and reported it didn't matter where one placed the alarm, the resident could get to it. She stated the resident currently had an alarm which was wireless and couldn't be disabled. During an interview on 2/27/18 at 1:27 p.m., Staff D CNA stated the resident currently used a wireless alarm and confirmed the resident knew how to turn off the old alarm. During an interview on 2/27/18 at 2:28 p.m., the DON (Director of Nursing) stated staff should have made sure the alarm was under the bed. She reported the resident went to the bathroom and fell on the way back to bed; the facility added a low bed and a fall mat after the resident sustained [REDACTED]. During an interview on 2/27/18 at 2:39 p.m., Staff A LPN (Licensed Practical Nurse) reported on the night of the fall, one of the CNAs alerted her the resident was on the floor. When she entered the room, the resident lay on his left side. She stated the alarm was within reach on the bedside table and Resident #43 could have easily reached it, and reported if it was placed under the bed, he could not have reached it. She reported the resident told her he turned off the alarm and reported she had seen him do this in the past. She stated after the fall, she called an ambulance for the resident. During an interview on 2/28/18 at 1:06 p.m., the ADON (Assistant Director of Nursing) reported if a care plan intervention was ineffective they would attempt something else. She stated the resident was able to turn off his alarm and added staff should have made sure it was out of his reach. During an interview on 2/28/18 at 1:42 p.m., the MDS Coordinator stated if an intervention didn't work, they would try to come up with something else. She verified she did not see another intervention added to the care plan after the intervention of placing the alarm out of the resident's reach.

Based on record review, staff interviews and resident interview, the facility failed to ensure residents are kept free from abuse. (Resident #1, #2). The facility reported a census of 54 residents. Findings include: According to the Minimum Data Set (MDS) assessment with an assessment reference date of [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognitive abilities. The MDS identified Resident #1 as independent with mobility, dressing, eating and personal hygiene needs and required limited assistance with toilet use and bathing. Resident #1's [DIAGNOSES REDACTED]. Resident #1 expired on [DATE] related to complications following a stroke. In an interview on [DATE] at 3:02 p.m. Staff A, Registered Nurse, stated on the afternoon of [DATE]; she was in the room of Resident #5 passing medications. Resident #5 stated Resident #1 told her that a black guy on night shift fondled him/her while she was in bed. Staff A stated she had planned on talking with Resident #1, but other things came up and she forgot. Staff A stated she returned to work on Wednesday [DATE] and informed the Administrator, Staff B. In an interview on [DATE] at 3:25 p.m. the Administrator stated on [DATE] Staff A reported to him that Resident #1 was dissatisfied with Staff D and didn't want him back in his/her room. The Administrator stated Staff A never reported Resident #1 had alleged of being inappropriately touched. The Administrator and Staff C met with Resident #1. Resident #1 stated on Saturday [DATE] Staff D was in his/her room and put his/her hand on his/her crotch. Resident #1 stated he/she did not report the incident. Resident #1 stated the next night ([DATE]) Staff D again placed his hand on his/her crotch. Resident #1 stated he/she told him to never return. In an interview on [DATE] at 4:30 p.m. Staff C, Director of Nursing (DON), stated on the afternoon of [DATE] the Administrator summoned her to his office stating there was an allegation and he wanted her present during the interview. Staff C and the Administrator interviewed Resident #1, who stated the black man who worked the overnight shift this weekend (Staff D) came into his/her room during the night and touched his/her vaginal area inappropriately. Resident #1 stated it was not like being cleaned up. It was not right. Staff C stated Resident #1 would not provide any further specific information, but noted it happened on both Saturday and Sunday. According to the Minimum Data Set (MDS) assessment with assessment reference date of [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 10 indicating a moderately impaired cognitive status. The MDS identified Resident #5 as independent with mobility, dressing, eating, toilet use and personal hygiene needs and required limited assistance with bathing. Resident #5's [DIAGNOSES REDACTED]. On [DATE] at 4:10 p.m. Resident #5 was interviewed and stated when she/he and other residents, including Resident #1 were sitting in a group when Resident #1 stated he/she didn't like the black guy. Resident #1 told the group that this guy was coming into his/her room and putting his finger in her rectum and stated it had happened several times. Resident #5 stated he/she reported it to the nurse. In an interview on [DATE] at 12:00 p.m. Staff D, certified nurse aide, stated he was not certain who Resident #1 was, but noted his care technique is the same with any resident. Staff D stated when providing incontinence care, he washes his hands, dons gloves and folds the wash cloth over his fingers. Staff D then wipes the areas affected by the incontinence. Staff D denies ever placing his fingers inside a resident ' s rectum or vagina while cleaning them. According to the staffing agency weekly time sheets, Staff D worked the following dates and times at the facility: [DATE] 2:00 p.m. to 10:00 p.m. [DATE] 2:00 p.m. to 10:00 p.m. [DATE] 10:00 p.m. to 6:00 a.m. [DATE] 2:00 p.m. to 10:00 p.m. [DATE] 10:00 p.m. to 6:00 a.m. [DATE] 2:00 p.m. to 10:00 p.m. Saturday [DATE] 10:00 p.m. to 6:30 a.m. [DATE] 2:00 p.m. to 10:00 p.m. Sunday [DATE] 10:00 p.m. to 6:30 a.m. 2. According to the Minimum Data Set (MDS) assessment with assessment reference date of [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4. A score of 4 identified the resident as severely cognitively impaired status. Resident #2 required extensive assistance with transfers, mobility, dressing, eating, toilet use, personal hygiene needs and with bathing. Resident #2's [DIAGNOSES REDACTED]. In an interview on [DATE] at 2:30 p.m. Staff F, certified nurse aide, stated she was working the day shift on Thursday [DATE] and getting residents up that morning. While passing by Resident #2's room, she saw Resident #2 in his/her bed half dressed with his/her pants pulled down and Staff G standing over him/her. Staff F heard Staff G say, We don't do that as she raised her arm and slapped Resident #2 across his/her stomach. Resident #2 said, Ow . Staff F stated she continued propelling the resident she was with to the dining room and reported what she saw to Staff H and Staff I. Staff I instructed Staff F to inform the Administrator. The Administrator instructed Staff F to write down what she saw and to continue getting residents up. Staff F stated she returned to Resident #2's room. Staff J was in the room and pointed out Resident #2 being partially dressed with one shoe on and the other resting on his/her stomach. Resident #2's pants remained pulled down as witnessed by Staff F earlier. There was a dirty brief and urine soaked pad on the floor. Staff F stated she asked Resident #2 where Staff G had went and he/she said, I pissed her off and she threw the shoe at me and left . Staff F stated Staff G seemed frustrated and not her normal self that morning. Staff F noted Resident #2 can be difficult and has seen Staff G get frustrated with him/her, but never abusive. In an interview on [DATE] at 3:43 p.m. Staff J, certified nurse aide, stated she was working the day shift, back hall on [DATE] and her partner was Staff G. They were running behind that morning and Staff F told her she would have to get Resident #2 up. Upon entering the room, Staff J noticed a urine soaked pad and brief on the floor. Resident #2 ' s pants were pulled down to his/her ankles and a shoe was sitting on his/her chest. Staff J also noted Resident #2 ' s wheelchair was sitting at his/her bedside which was a safety risk. Staff J asked what was going on and Resident #2 stated, I pissed her off and she left . Resident #1 then stated, She threw my shoe at me as he/she pointed at his/her stomach. Staff J stated she noticed a red mark on Resident #2's stomach. Staff J stated at the time she was unaware of the earlier altercation between Resident #2 and Staff G. On [DATE] at 10:20 a.m. the Administrator was interviewed and stated he and Staff C, Director of Nursing was informed of an alleged abuse involving Resident #2 and Staff G on the morning of [DATE]. They brought Staff G into the office and asked her to describe her morning and who she had cared for. Staff G was informed there was an allegation of abuse, but was not told who the resident was. Staff G described her morning and who she cared for, but never mentioned she had been in Resident #2's room. The Administrator then confronted her about being in Resident #2 ' s room and Staff G admitted she had been, but denied striking Resident #2. In an interview on [DATE] at 3:30 p.m. Staff C, Director of Nursing, stated upon becoming aware of the incident in which Staff G allegedly struck Resident #2, she and Staff H, Registered Nurse, completed a head to toe assessment and found no signs of injury or of Resident #2 complaining of pain. Resident #2 denied being struck. In an interview on [DATE] at 9:30 a.m. Staff G, certified nurse aide, stated on the morning of [DATE] she was in Resident #2 ' s room getting him/her dressed. She had him/her mostly dressed, pants on and pulled up to his/her knees. Staff G stated she went to the hallway and gathered Resident #2 ' s shoes and wheelchair. Staff G returned and put on Resident #2's left shoe and right brace. As she was putting his/her right shoe on, Resident #2 said, Ouch and struck Staff G on her right arm. Staff G stated this upset her, told the resident we can ' t do that and rather than retaliate she left the room. Staff G stated she did not inform anyone she had left Resident #2 partially dressed. Staff G denied striking back at Resident #2. When informed someone had witnessed her strike Resident #2 from the hallway, Staff G stated I don ' t know how that was possible, I know the door was shut. Facility daily assignment sheet indicated Staff G was working the day shift on [DATE] and assigned to the back hall where Resident #2 resides. The employee incident report dated [DATE], identified Staff G was suspended from the facility until an investigation was completed.

This deficiency relates to incident -I Based on record review, abuse policy, resident and staff interviews, the facility failed to ensure one of three residents were free from abuse and received adequate supervision. On 4/17/16, staff found Resident #5 inappropriately touching Resident # ' 6. Staff interview revealed Resident #5 had been obsessed with Resident #6 for a few months prior to the incident and he/she had attempted to kiss Resident #6 a couple of times. Record review identified no provisions to protect Resident #6 from abuse. The facility reported a census of 52 residents. Findings include: The facility abuse policy dated 4/2002 titled Catastrophic Reaction with Potential for Harm to Self or Others (resident to resident abuse) revealed would be free from abuse from one another. The procedure documented steps will be taken if a resident displays unpredictable behavior that endangers the safety of others. The policy indicated monitoring of the resident with potential for harm to others for next 24 hours, with the DON discussing the situations with further actions or interventions. 1. According to Resident #5's Minimum Data Set (MDS) assessment with assessment reference date of 1/15/16, Resident #5 had a brief interview for mental status (BIMS) score of 5 indicating short and long term memory deficits and severely impaired cognitive skills for daily decision making. Resident #5 required extensive assistance to total dependence with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #5 was independently mobile in his/her wheelchair. Resident #5's [DIAGNOSES REDACTED]. Resident #5's behavior included physical behavior directed towards others (e.g. grabbing or abusing others sexually) was coded at (0), behavior not exhibited. Verbal behavior symptoms directed toward others (e.g. threatening, screaming, cursing) is coded as (2) occurring 4-6 days weekly. Behavioral symptoms not directed towards others (e.g. public sexual acts, disrobing in public) was coded at (0), behavior not exhibited. Resident #5's Care Plan with dated 1/20/16 indicated a potential for behavior/altered coping due to resident's medical condition ([MEDICAL CONDITION]) and circumstances. Resident #5 exhibited behaviors such as yelling, screaming, cursing, swinging, hitting, biting, confrontation, womanizing and grabbing. Resident #5 ' s goal was for him/her to display appropriate interactions with peers, staff and visitors over the next review period. Interventions included: 1) Redirection as indicated. 2) Move resident to quiet area to deescalate behavior. 3) Provide 1:1 as needed. 4) Increase supervision as needed. 5) Placed on 15 minute checks for 3 days. (4/19/16) The nurse ' s notes dated 4/17/16 at 9:50 a.m. documented Resident #5 had an interaction with another resident (Resident #6) & staff completed an unusual event (form). 2. According to Resident #6's Minimum Data Set (MDS) assessment with assessment reference date of 1/29/16, Resident #6 had a brief interview for mental status (BIMS) score of 6 indicating short and long term memory deficits and severely impaired cognitive skills for daily decision making. Resident #6 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #6's [DIAGNOSES REDACTED]. Resident #6 had no behavior symptoms. Nurse ' s notes dated 4/17/16 at 9:00 a.m., revealed Resident #6 had an interaction with another resident. In an interview on 4/21/16 at 11:35 a.m. Resident #6 was questioned regarding Resident #5 touching him/her. Resident #6 identified Resident #5 by name and that he/she had touched him/her and was told to leave him/her alone. Resident #6 was not able to provide specific dates, time or locations, but noted Resident #6 had touched him/her a couple of times. In an interview on 4/20/16 at 2:10 p.m. Staff E, laundry supervisor, indicated on Sunday, 4/17/16 at around 9:30 a.m. she was making rounds and as she scanned the back hallway lounge area she noticed Resident #5 had his/her left hand on Resident #6's left breast. Resident #6's eyes were closed and as Staff E approached him/her Resident #6 opened his/her eyes and stated, You're not suppose to do that. Staff E repeated that to Resident #5 and Resident #5 removed his/her hand and began propelling his/her wheelchair towards his/her room. Staff E looked around and saw no other staff. Staff E walked up the hall and found Staff F and 2-3 other staff in the therapy room. In an interview on 4/20/16 at 3:53 p.m. Staff F, Licensed Practical Nurse, stated at around 9:50 a.m. on Sunday, 4/17/16 she and other co-workers were in the therapy room serving themselves a pot luck meal. Staff F stated they were in the room for just a few minutes when Staff E approached her and reported Resident #5 had his/her hand on the breast of Resident #6. Staff F notified on-call supervisor, Staff G. Resident #5 and #6 were separated. Staff F spoke with Resident #6 who reported Resident #5 had put his/her hand on Resident #6's breast. Staff F stated Resident #5 was assisted into bed and remained in bed through lunch. Staff F instructed her staff to maintain awareness of Resident #5's whereabouts and reported the incident during shift change report. Staff F stated Resident #5 had been known to touch female caregivers inappropriately and make sexually suggestive comments, but she had never known him/her to touch a female resident inappropriately. In an interview on 4/20/16 at 2:30 p.m. Staff G, on-call supervisor, stated she received a call from Staff F around 10:00 to 11:00 a.m. on Sunday, 4/17/16. Staff F described an incident involving Residents #5 and #6. Staff G instructed Staff F to keep the residents separated and to contact the physician and family. Staff G stated Resident #5 had been known to grope female caregivers, but she had never known him/her to bother other residents. In an interview on 4/21/16 at 11:43 a.m. Staff H, certified nurse aide (CNA), stated on Sunday, 4/17/16 there was a pot luck meal brought in on the back hallway. Staff H stated all the staff were in the room eating that morning for probably 30 minutes or so when Staff E reported an incident involving Resident #5 and Resident #6. Staff H stated she and other aides had periodically checked on the residents during the time they were in the therapy room. Staff H stated Resident #5 can be aggressive and will grab at female caregivers breasts. Staff H had never known Resident #5 to touch other residents inappropriately, but noticed a few months ago he/she was very obsessed with Resident #6. Resident #5 would follow Resident #6 around and sometimes block him/her from exiting an area. Resident #6 reported to Staff H that Resident #5 had tried to kiss him/her a couple of times. Resident #5 was moved further away from Resident #6 in the dining room. Resident #6 never reported he/she had ever been touched inappropriately. In an interview on 4/20/16 at 3:00 p.m. Staff I, certified nurse aide, stated she was in the therapy room when Staff E reported Resident #5 had touched Resident #6's breast. Staff I, stated they were in the therapy room for about 10 minutes. Staff I stated Resident #5 can be violent and call aides names. Staff I, had never known Resident #5 to grope staff or any residents or be violent or aggressive towards another resident. In an interview on 4/20/16 at 3:45 p.m. the Director of Nursing (DON), stated she was informed on Tuesday, 4/19/16 of the incident involving Resident #5 and #6. The DON stated they moved Resident #6 onto another hall away from Resident #5 and also placed Resident #5 on 15 minute checks. The DON stated Resident #5 had been known to grab female caregivers in the groin and breast area and he/she frequently curses. The DON stated she had never known Resident #5 to target another resident.

Based on observation, clinical record review, resident and staff interviews, and policy, the facility failed to administer all medications as ordered by the physician. The facility used an e-mar (electronic medication administration record) to track medication administration for residents. Staff interviews revealed the computer system/e-mar failed to accurately retained medications that were administered, failed to track updates in residents medications, and or staff did not always have access to the most current medications and yet staff continued to administer medications to residents. Multiple staff reported they alerted the management about their concerns with the computer system/e-mar and nothing had been done to address the issues. Observation of the medication pass showed the e-mar identified Resident #27 had not received his/her insulin medication and the medication was overdue, however a nearby staff called out he had already given Resident #27 his/her insulin and the e-mar did not save the data he entered. The on-site observation revealed staff continued to use the e-mar system to pass residents medications. The findings constitute an immediate jeopardy to residents health and safety. The facility identified medications errors occurred for Residents #14, #13 and #22 on several shifts and the residents medications were not available; and staff failed to follow Resident #26's physician's orders [REDACTED]. The facility identified a census of 64. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 recorded a BIMS (Brief Interview for Mental Status) score of 12 indicative of mild cognitive impairment with no signs or symptoms of [MEDICAL CONDITION] present. The MDS identified [DIAGNOSES REDACTED]. The assessment revealed the resident required the assistance of 1 person for bed mobility, dressing, hygiene, and 2 persons for transfers, and toilet use. According to the Long Term Care Note dictated by the resident's physician on 8/25/15, the resident spent 17 days in the hospital in August 2015 and returned to the facility on [DATE]. The physician documented the hospital treated the resident for [DIAGNOSES REDACTED], nursing home acquired pneumonia, and [MEDICAL CONDITION] ([MEDICAL CONDITION] bacterial infection). The dictated note revealed the resident had a low potassium level of 2.9 on 8/24/15. The physician restarted the resident on potassium 20 mEq (millequivalents) daily with a repeat potassium to be done in 3 days. The resident ' s weight had been reported at 105 pounds. The potassium level drawn on 8/27/15 revealed a low level of 3.2 mmol/L (millimole per liter) with the normal reference range to be 3.5-5.1 mmol/L. The physician faxed an order to continue the potassium at 10 mEq PO (orally) QD (every day) as improvement was seen. August 2015 Medication Records recorded potassium 20 mEq PO given on 8/26/15, 8/27/15, 8/28/15, 8/29/15 and; potassium 10 mEq PO given 8/29/15, 8/30/15, and 8/31/15. The Physician Notification form dated 9/8/15 notified the physician the resident had a change in condition with the resident experiencing 2 + [MEDICAL CONDITION] in BLE's (bilateral lower extremities), 2+ [MEDICAL CONDITION] in the right hand, and 1+ [MEDICAL CONDITION] in the left hand. The physician signed the fax form with new orders to fax 02 (oxygen) sat (saturation of 02 in the blood) results with the patients weights since readmission or 8/25/15, and wanted a current weight from that day. The physician ordered [MEDICATION NAME] (a diuretic medication) 40 mg (milligrams) be given PO now (a onetime order to be given right away). September 2015 Medication Records recorded the entry for [MEDICATION NAME] 40 mg PO now was not signed as given on 9/8/15; the area was left blank. The Physician Notification form dated 9/9/15 notified the physician that the resident's PO2 (also known as oxygen saturation (sats) in the blood) sats were 90-95% on RA (room air), the resident on 2L (liters of oxygen), and his/her weight 121.4 lbs(pounds) on 9/8/15 was up from a weight of 110.6 lbs. on 9/1/15 . The physician ordered to give [MEDICATION NAME] 20 mg PO daily for 1 week and continue till the following week with weights, O2 sats, and monitoring lung sounds. September 2015 Medication Records recorded [MEDICATION NAME] 20 mg PO was not signed as given on 9/9/15. The physician's handwritten script written dated 10/2/15 had several new orders as follows: a). restart potassium at 10 mEq PO daily. b). restart [MEDICATION NAME] at 20 mg QD. c). weigh weekly due to weight gain and notify if > (greater than) 5 pounds. d.) oxygen to keep sats > 92 %. e). [MEDICATION NAME] (an antibiotic) 100 mg PO BID (2 times a day) x 10 days f). frequent use of acupella (device like an incentive spirometer), and go to ER if fever develops or O2 sats (less than) <92% on RA. According to the September 2015 Medication Record, staff signed potassium 10 mEq PO as given from 9/1/15 through 9/30/15. The Medication Error Report sheet, completed by the Director of Nursing (DON) on 10/7/15, identified a medication error occurred prior to 9/18/15 for several shifts. The report documented the resident had an order for [REDACTED]. (A card contained a month of individual dose tablets.) The report listed the type of error as drug omitted and the medication had not been given. The form identified the reason for the error related to a pharmacy error. The report documented the doctor notified on 10/7/15 and the family notification line was left blank. The nurses notes lacked any documentation of a medication error or any assessment of the resident following the dates the error was identified. The October 2015 Medication Record recorded potassium 10 mEq PO given 10/1/15 to 10/3/15. The order was rewritten in another section with start date 10/3/15 and documented there given through 10/8/15. In an interview on 10/8/15 at 9:03 a.m., the DON stated no nurse had reported anything related to medications missing or not available prior to 9/18/15. The DON stated she had not done any random or routine audits of the nurses on medication administration. The DON revealed she expected the nurses to follow the MAR (medication administration record ) when administering medications. The DON explained the MAR on the computer (also known as Medication Record) should be checked against the medication card (also known as a blister pack). The DON stated there had been no training in or in-services on medication administration. In an interview on 10/8/15 at 1:55 p.m., the pharmacist for the facility reported the pharmacy filled a new order on 8/29/15 for potassium 10 mEq to be given PO QD. The pharmacist stated the medication was documented as sent to the facility on [DATE] and that it was enough medication for the month of August 2015 and September 2015. The pharmacist explained the medication exchange would have already been prepared for the facility and the delivery sheet documentation they had would reflect the caps sent to get through until the medication exchange. The pharmacist stated their record lacked any documentation of the facility notifying them of any missing medications. The pharmacist revealed they received an order from Staff F, licensed practical nurse (LPN), on 10/2/15 to change the potassium to 10 mEq PO QD. The pharmacist stated the record showed only having an order for [REDACTED]. The Consolidated Delivery Sheets signed 8/29/15 recorded 3 caps of potassium chloride 10 mEq delivered to the facility. In a call with the doctor's office on 10/9/15 at 4:30 p.m., the physician's nurse relayed the resident's physician stated he was not aware of the medication error. The nurse stated the doctor said he was treating the resident for recurrent [DIAGNOSES REDACTED] (low potassium levels) and felt the error put the resident at risk of harm for cardiac [MEDICAL CONDITION] and if the potassium level too low for too long, acute [MEDICAL CONDITION]. The nurse commented the record showed the facility called on 10/7/15 to ask for confirmation of the potassium dose but was not made aware of any med errors. In an interview on 10/12/15 at 3:10 p.m., the DON stated she became aware of the resident's medication errors when a nurse passing meds (medications) brought it to her attention. The DON said the resident did not have a potassium medication card. The DON reported the person doing medication changeover at the beginning of the month was not very thorough and it just got missed that there was no potassium medication card. The DON acknowledged the potassium on the MARS was signed as given 9/1/15 through 9/18/15. The DON stated she believed the error had occurred since 9/1/15 based on the fact med change over happens monthly. The DON reported she called the pharmacy and told them the medication was missing but did not check after that to see if they had sent more. The DON stated she typically notified physicians of med errors by phone or fax. The DON verbalized she missed completing the resident's med error report before 10/7/15 because she set other stuff on top of the form in her office. The DON reported she notified the physician via phone on 10/7/15 and she did not document the conversation. The DON reported she did not notify the resident or the family of the med error. The DON stated she does not expect med errors to be charted in the clinical record or for assessments to be completed after med errors occur. In an interview on 10/13/15 at 3:00 p.m., Resident #13 stated s/he was not aware of the med error. Resident #13 commented s/he did not follow his/her medications that closely but knew there were times s/he took potassium and times s/he didn't take it. 2. The MDS assessment dated [DATE] for Resident #27 identified [DIAGNOSES REDACTED]. The August 2015 Physician order [REDACTED]. a. acidophilus lactobacillius powder (a [MEDICATION NAME] medication), give 1 packet oral morning med pass b. [MEDICATION NAME] tartate (an anti-hypertensive medication) 25 mg oral morning and afternoon for essential hypertension unspecified, hold if SBP (systolic blood pressure) <90 or P (pulse) <60 c. [MEDICATION NAME] (an anti-hypertensive medication) 5 mg oral morning med pass d. [MEDICATION NAME] 100 units per ml solution SSI (sliding scale insulin) subcutaneous before meals e. [MEDICATION NAME] 100 units per ml solution, give 17 units in addition to SSI before meals The October 2015 MARS included listings for the following medications: [REDACTED] a. acidophilus lactobacillius powder, give 1 packet oral morning med pass b. [MEDICATION NAME] tartate 25 mg oral morning and afternoon for essential hypertension unspecified, hold if SBP <90 or P <60 c. [MEDICATION NAME] 5 mg oral morning med pass d. [MEDICATION NAME] 100 units per ml solution SSI (sliding scale insulin) subcutaneous before meals e. [MEDICATION NAME] 100 units per ml solution, give 17 units in addition to SSI before meals Observation on 10/12/15 at 8:30 a.m., revealed Staff G, Certified Medication Aide (CMA), conducted a medication pass for Resident #27. Staff G stated at this time, she did not check a blood pressure (BP) or pulse (P) for the resident. Staff G demonstrated a computer pop up box (on the emar) that requested the BP and P be input into the computer system. Staff G signed the pop up box as did not perform the task. Staff G said the nurses check BP and P in the mornings and therefore she does not need to. Staff G gave the resident his/her morning medications that included [MEDICATION NAME] and [MEDICATION NAME]. Staff G signed all the morning medications as given by checking a box yes on the computer MAR, except the order for acidophilus lactobacillius. Staff G commented she did not have the acidophilus in the medication cart so she would check the stock room up front later to see if available. When asked how Staff G knew the [MEDICATION NAME] was safe to give, Staff G responded that was a good question because the nurses put the BP and pulse into the computer later in the day. During the same medication pass, the computer emar also showed [MEDICATION NAME] (an insulin) flagged red and Staff G stated that indicated the medication had not been given and overdue. A nearby staff (Staff D, LPN) called out at this time, the resident had already eaten breakfast and he already administered the insulin prior to breakfast. Staff D reported he attempted 3 times to enter the insulin as given into the computer (emar) but the computer would not save the information. At that time, Staff D successfully input the information into the computer at the back nurses station desk and the information saved into the computer system flagging the insulin as given. Staff D then entered a note for the insulin that it was given as ordered, not late. Observation on 10/12/15 at 8:58 a.m. revealed Staff D, Licensed Practical Nurse (LPN) logged onto the computer system (emar) located at the back nurses station desk. Staff D showed Resident #27's profile listed the [MEDICATION NAME] and [MEDICATION NAME] as not given even though Staff G signed the medications as given on the laptop computer at the med cart. Staff D stated the nursing staff had a meeting on 10/9/15 with the DON and Administrator present to discuss the computer issues. Staff D reported the nursing staff was asked to take a vote on going back to paper MARS. Staff D said they were informed the DON was leaving on 10/22/15 and he felt she did not truly care about the issues. In an interview on 10/12/15 at 9:13 a.m., Staff D stated he would have expected Staff G to immediately get the acidophilus during the med pass due to all the problems they had been having with the computer systems. Staff D said he would have expected Staff G to check the BP and pulse parameters before giving the [MEDICATION NAME]. Observation on 10/12/15 at 2:37 p.m., revealed the computer system/emar listed Resident #27's [MEDICATION NAME] and [MEDICATION NAME] as given at 11:58 a.m. with a note not late. The acidophilus medication was signed with the note medication not available. In an interview on 10/12/15 at 3:50 p.m., the DON stated she expected CMA's to check apical or radial pulses and BP's before giving [MEDICATION NAME]. After being informed of the computer glitches that occurred in the a.m. with Resident #27, the DON responded she would let the corporate office know. Observation on 10/13/15 at 8:07 a.m. revealed nursing staff continued to use the computer system emars to pass medications. 3. The MDS assessment dated [DATE] for Resident #26 identified [DIAGNOSES REDACTED]. The August 2015 Physician order [REDACTED]. The October 2015 Medication Record listed an order for [REDACTED]. Observation on 10/12/15 at 7:55 a.m., revealed Staff C, registered nurse (RN), prepared Resident #26's morning medications. Staff C used an iron tablet from a stock bottle medication labeled [MEDICATION NAME] sulfate 325 mg tabs. Staff C administered the meds to the resident. Resident #26 chewed on the whole pills and after having difficulty swallowing, spit some pills out. The resident was able to swallow the potassium capsules that Staff C opened and put into applesauce. Staff C returned to the med cart computer and documented the resident refused by spitting out. Observation on 10/12/15 at 8:10 a.m., revealed Staff C pulled a bottle of [MEDICATION NAME] sulfate from the med cart drawer labeled with the resident's name and a strength of 220 mg per 5 ml. When asked why she did not use the liquid iron instead of the stock iron tablets so the resident could swallow it, Staff C responded she did not normally work the floor. Staff C stated she should have read the MAR better as she did not see it called for liquid. Staff C acknowledged it was a mistake and confirmed the tablets contained 105 mg more iron than the liquid dose. The facility policy called Administration of Medication revised 07/10 instructed the following purpose: Point 1. To assure that each resident receives the proper medications at the correct time as ordered by their physician. Point 2. To provide correct medications in correct dose to correct resident. Point 3. To establish a systematic approach of administering medications to the resident. Procedure - Point 3. Identify resident by bracelet. Check the MAR -each medication is verified for the right dose, right medication and right time as well as right route by comparing the label on the medication container to MAR. Point 4. Read the label 3 times before dispensing the medication into the medication cup. Point 5. Administer the medication and observe the act of swallowing. Point 6. Record the medication given on the MAR by initialing the proper square. Point 7. If the resident refuses medication, indicate by circling on the MAR and charting on the PRN record or the nurses' notes the reason for the refusal. 4. The MDS dated [DATE] for Resident #14 identified [DIAGNOSES REDACTED]. The MDS assessment revealed the resident required the assistance of 1 person for bed mobility, dressing, hygiene, and toilet use. The physician's order [REDACTED]. The August 2015 Medication Record documented [MEDICATION NAME] sodium ([MEDICATION NAME]) 125 mg ECC ([MEDICATION NAME] coated) tablet oral morning, midday, afternoon, and bedtime to be given with 500 mg tab to equal 625 mg. The record reflected the medication given in tablet form only and never a liquid form. The September 2015 and October 2015 Medication Records continued to reflect the medication given in tablet form only with no listings for liquid [MEDICATION NAME] (also known as valporic acid). The September 2015 Medication Record documented the resident received the 625 mgs of [MEDICATION NAME] 4 times a day 9/1/15 through 9/18/15 except for 1 held entry on 9/2/15. The September 2015 record also documented the resident received 20 mg of [MEDICATION NAME] every day 9/1/15 through 9/18/15. The records documented the medications as given despite the Medication Error Report documenting the meds not available to give. The Medication Error Report sheets, completed by the DON on 10/7/15, identified two separate medication errors occurred prior to 9/18/15 on several shifts. The reports documented the resident did not have a [MEDICATION NAME] medication card in the medication cart. ([MEDICATION NAME] is an anti convulsant and mood stabilizing drug.) The reports documented the resident did not have [MEDICATION NAME] medication card in the medication cart. The reports listed the type of errors as drugs omitted and not given. The reason for the medications errors related to pharmacy error. The reports documented the doctor notified on 9/29/15 and the family notification lines were left blank. Nurses notes lacked any documentation of the medication errors or any assessment of the resident following the dates the errors were identified. In an interview on 10/8/15 at 9:03 a.m., the DON stated part of the reason the medication errors occurred for Resident #14 was related to the resident's declining condition. The DON summarized the doctor ordered discontinuation of all PO medications to obtain a hospice consult but the resident did not meet criteria for hospice. The DON reported the resident's labs were out of whack but they stabilized, the resident began eating again, and they reinstated the medications. The DON commented the pharmacy failed to reinstate the [MEDICATION NAME] and [MEDICATION NAME] medications. In an interview on 10/8/15 at 10:26 a.m., Staff D, LPN, reported he had been asked to write an order that he did not obtain from the doctor for Resident #14 two weeks prior. Staff D stated the resident had an order previously for a hospice consult and to discontinue all PO meds. Staff D said the resident then began to take meds again but there was no order to resume giving medications. Staff D reported the resident's medications were never taken from the medication cart with the original order to discontinue PO meds. In an interview on 10/8/15 at 1:55 p.m., the pharmacist for the facility reported the pharmacy received an order on 8/6/15 to change [MEDICATION NAME] to liquid form. The pharmacist dispersed a 10 day supply (473 ml bottle) with the instructions to give 12.5 ml (milliliters) PO QID (four times a day). The pharmacist stated they then received an order on 8/14/15 to discontinue all PO meds. The pharmacist said on 8/31/15 they received an order to restart liquid [MEDICATION NAME] and 2 more bottles (946 mls total) were sent to the facility. The pharmacist reported the pharmacy was notified of a new order to reinstate the [MEDICATION NAME] (also known as [MEDICATION NAME]) on 9/18/15 and they sent out 12 tabs of [MEDICATION NAME] 20 mg. The pharmacist stated their record lacked any documentation of the facility notifying them of any missing medications. The Consolidated Delivery Sheets signed 8/31/15 and 9/18/15 respectively recorded 946 mls of valporic acid 250 mg per 5 ml and 12 tabs of [MEDICATION NAME] 20 mg delivered to the facility. In an interview on 10/12/15 at 11:20 a.m., Staff G, certified medication aide (CMA), reported she returned from vacation and noticed the MARS had not been changed to list liquid form instead of pill form. Staff G stated the med errors for Resident #14 occurred due to the nurses not knowing where to look in the med cart for the medications because the nurses don't normally pass them. Staff G recalled finding both pill and liquid forms of [MEDICATION NAME] and potassium in the med cart for Resident #14. Staff G said she pulled the [MEDICATION NAME] and potassium medication cards out and gave them to Staff D. Staff D confirmed Staff G gave him the pill cards. Staff G commented the other staff were either giving double doses or switching on and off from using pills and liquids. Staff G stated the nurses should have pulled the pills out of the med cart when the orders changed to liquid form. At this time, Staff G pulled a liquid bottle of [MEDICATION NAME] from the med cart with the resident's name on it. The pharmacy label on the bottle documented: a filled date of 8/31/15, 473 mls per bottle, a total of 946 mls sent (2 bottles), solution strength of 250 mg per 5 mls, directed to give 12.5 mls (625 mg) PO QID, and the bottle was approximately half full. Staff G stated the other bottle had already been used up. Staff G then pulled another unopened 473 ml bottle of [MEDICATION NAME] from the cart that contained a pharmacy label fill date of 10/10/15. Staff G confirmed the bottles sent on 8/31/15 should have been used up by 10/12/15 if staff were giving just liquid, as 946 mls equaled only a 20 day supply. Staff G pulled a liquid bottle of potassium from the med cart with the resident's name on it stating it was the 2nd of 2 bottles sent in August. The pharmacy label on the bottle documented: a filled date of 8/12/15, 473 mls per bottle, solution strength of 40 mEq per 15 mls, directed to give 15 mls PO BID (twice a day), the bottle was approximately 1/4th full, and 2 full bottles would have equaled a 30 day supply. In a phone interview with the resident's doctor's office on 10/12/15 at 1:55 p.m., the doctor's triage nurse relayed the doctor was not aware of the med errors. The nurse reported the doctor said she did not feel the errors put the resident at risk of harm. The nurse stated the doctor's office clinical record for the resident showed an order given 8/7/15 to change potassium to sprinkles form and the [MEDICATION NAME] to liquid form. She reported on 8/10/15 the record documented an ok given to restart the PO meds. In an interview on 10/12/15 at 3:22 p.m., the DON stated the resident's original orders to discontinue all PO medications was signed by the physician 8/7/15. The DON reported the nurse on duty 8/8/15 said the resident started taking meds again and they sought an order to reinstate medications. The DON stated she did notify the pharmacy of the order to reinstate medications and the pharmacy failed to reinstate the [MEDICATION NAME] and [MEDICATION NAME] medications. The DON verbalized when the facility reinstated medications on the MAR the pharmacy did not put the orders back into the pharmacy system. The DON commented she found out after she completed the med error sheets, and after surveyors came to the building, that there was actually liquid medications in the bottom drawer. The DON stated she expected staff to complete a med error sheet and notify the pharmacy when they cannot find pills. The DON acknowledged the August 2015, September 2015, and October 2015 MARS still showed tablet form instead of liquid form for the [MEDICATION NAME] on the MAR because the nurses didn't change it. The DON stated she expected whoever processed a new order to do it from start to finish including pulling old medications from the cart. The DON confirmed the clinical record lacked documentation of an order to reinstate medications. The DON responded she educated her staff that it made it look like they were giving meds without an order. In an interview on 10/15/15 at 11:15 a.m., the pharmacist reported receiving an order on 8/4/15 for potassium 20 mEq PO TID (three times a day). The pharmacist said the next order came on 8/6/15 to change the potassium to liquid form and the caplets were discontinued. Then on 8/12/15 the pharmacy received an order to change the potassium dose from 20 mEq to 40 mEq PO BID and a new bottle was sent out. The pharmacist stated 2 days later on 8/14/15 the pharmacy received an order to discontinue all PO medications. The pharmacist stated they received a renewal order on 9/15/15 to restart the potassium. 5. The MDS dated [DATE] for Resident #22 identified [DIAGNOSES REDACTED]. The MDS assessment revealed the resident required no assistance from staff for activities of daily living other than bathing. The August 2015 Medication Record listed an order for [REDACTED]. The report reflected the medication started on 8/28/15 and signed as given on 8/31/15. The September 2015 Medication Record listed the same order and reflected the medication signed as given on 9/2/15, 9/7/15, 9/11/15, 9/14/15, and 9/18/15. The Transaction Report for the September 2015 Record documented 9/4/15 that the medication was not available and would be ordered from pharmacy and given when it arrived. The next entry for [MEDICATION NAME] on 9/16/15 recorded no medication available. The Medication Error Report sheet, completed by the DON on 10/7/15, identified a medication error occurred prior to 9/18/15 for several shifts. The report documented the resident had an order for [REDACTED]. The report listed the type of error as drug omitted and not given. The reason for the error related to a pharmacy error with the pharmacy not sending a medication card during the monthly medication exchange. The report documented the doctor notified on 9/18/15 and the family notification line was left blank. Nurses notes lacked any documentation of the med errors or any assessment of the resident following the date the error was identified. In an interview on 10/8/15 at 1:55 p.m., the pharmacist for the facility reported the pharmacy record reflected no order ever for [MEDICATION NAME] on the resident's profile and confirmed [MEDICATION NAME] had never been sent to the facility for the resident. In a phone interview on 10/12/15 at 1:55 p.m., the triage nurse for the resident's physician reported their record reflected no communication on 9/18/15 regarding any med errors. The nurse stated their record also lacked documentation of an order for [REDACTED]. In an interview on 10/12/15 at 3:50 p.m., the DON stated she called the doctor to notify of the med error. The DON said the resident returned from the hospital with an order for [REDACTED]. The DON stated she thought she documented the conversation and new order in the nurses notes on 9/18/15. The DON acknowledged the clinical record lacked an order to start or stop the [MEDICATION NAME] medication. The DON stated she could not explain how the [MEDICATION NAME] was on the MAR or how it was signed off as given. The DON stated she had already begun working on an action plan to go back to using paper MARS. Staff Interviews: In an interview on 10/8/15 at 10:07 a.m., Staff E, LPN, stated she had reported med (medication) errors in the last month to the DON. Staff E reported the MAR did not match quite right. Staff E said there was a blood sugar check that should not have been on the MAR and medications that were on the MAR that were not in the medication cart. Staff E stated she did not notify the physician or the family because she got so busy that the DON took over handling the situation. Staff E reported she did not receive any feedback after the DON took over. Staff E stated after the incident she implemented using paper MARS instead of the computer system MARS because the system (computer system) kept knocking her offline. Staff E revealed that when she got knocked offline any documentation saved, gets flushed and she had to reenter it. Staff E commented she had worked for the facility for 2 months. Staff E said she had just started printing the MARS for the front of the building the previous week but the nurses were not signing off on them yet. Staff E reported the correct technique to pass medications was to take the medications out of the drawer, compare to the MAR, match to stock meds, and take the medications to the resident. Staff E stated that if the resident takes the medications she does nothing, but if not, then she makes a note of their refusal to transcribe to the MAR later. Staff E said she writes down blood sugars and blood pressures and transcribes them after a medication pass when she is able to get online to document this information. Staff E reported management had been aware the MARS were cumbersome and management was not doing anything about it. In an interview on 10/8/15 at 9:32 a.m., Staff D, LPN, revealed he had worked for the facility since the end of March 2015. Staff D commented he had never reported any med errors. Staff D stated the correct technique to pass medications was to compare the blister pack or the stock medication bottle to the MARS and to ensure the correct medication and correct dose were given to the correct resident. In an interview on 10/8/15 at 10:26 a.m., Staff D, licensed practical nurse (LPN) stated he had multiple times he dealt with computer system not connecting. Staff D said he reported the issues to the Administrator and the DON was already aware. Staff D reported the issues occurred off and on since May 2015 till about a month prior. Staff D revealed that if you went to the dining room with the medication cart to pass medication, you might have to go back to the hallway to find a spot for internet connection. Staff D stated in times where he couldn't get connection he would try to print paper MARS to complete the med pass. Staff D acknowledged there had been times he just grabbed the medication cards (blister pack) from the medication cart and passed medications without using a MAR. Staff D commented the Administrator and DON responded to the issue by saying they were working on the issue and would get paper MARS. Staff D revealed Staff F, LPN, printed MARS for the residents the previous week without the help of the DON or

Based on record review, staff and resident interviews and review of the facility Abuse Policy and Procedures, the facility failed to ensure that residents are free from abuse from other residents. This review involved 3 of 31 residents sampled (Resident #15, #17, and #28). The facility reported a census of 64 residents. Findings include: 1. The physician progress notes [REDACTED].#17, listed [DIAGNOSES REDACTED]. According the MDS (Minimum data set) assessment tool with a reference date of 08/19/15, Resident #17 documented the resident with a BIMS (Brief Interview for Mental Status) score of 11 out of 15. The MDS identified Resident #17 as independent with all activities of daily living (ADL) except for bathing in which the resident requiring physical assist of one staff member to complete. Review of Resident #17's physician progress notes [REDACTED]. The resident was readmitted to the other facility until 1/23/14 when the resident became physically and verbally abusive at the facility. The resident was discharged from that facility and admitted to the current on 2/10/14. The Care Plan with an initial date of 2/27/2015 identified the resident taking medications to stabilize mood and behaviors. The Care Plan listed interventions that directed staff to: 1. Staff to administer the resident ' s medications and monitor lab values and GDR (gradual dose reduction) as ordered by the resident ' s physician. 2. Staff is to redirect resident if resident becomes agitated or shows behaviors. 3. Staff is to monitor resident for any adverse side effects of medication and report as needed. 4. Staff is to report to the resident ' s physician if change in resident ' s mood or behaviors. The plan of care for resident lacked the information of the altercations the resident had with other resident, Resident #16 on 5/6/15 and Resident #15 on 6/25/15 (that resulted in an injury to Resident #15). The care plan lacked the known behaviors, of verbal altercations, pushing other residents in their wheel chair, and the resident being rude and impatience with other residents and staff members, which staff and other residents reported occurs frequently. Review of Resident #17's clinical record revealed only one month of Behavior Monitoring and Intervention Documentation Form for the March 2015. The March 2015 form revealed documentation completed only 10 times on the day shift, 7 times on second shift, and 6 times on the night shift, out of 31 days. Review of the current October Behavior Monitoring and Intervention Documentation Form, kept in a book at the nurses ' station, revealed no Behavior Form for Resident #17. Resident #17's clinical lacked documentation of continued monitoring of the resident 's behaviors. The Interdisciplinary Progress Nursing Notes for Resident #17 dated 5/6/2015 at 11:07 a.m. documented at approximately 8:20 a.m., Resident #17 attempting to leave the dining room area when two other residents sitting in wheel chairs were in front of Resident #17 pathway. Resident #17 unable to navigate between the two residents wheel chair and choose not to go around them. Resident #17 attempted to move one of the wheel chair bound residents out of the way when the second wheelchair bound resident, Resident #16, reached out to stop Resident #17 from doing so. Resident #17 became angry and began to punch Resident #16 with a closed fist to the left side of the resident face while holding the residents arms down with Resident #17's free hand. Staff intervened and asked Resident #17 to go to his room. Resident #17 stated the other resident hit first and if the resident does it again Resident #17 will punch him again . The staff contacted Resident #17's physician and orders received for an inpatient psychiatric evaluation. At 9:26 p.m. Resident #17was transferred to a Geriatric Psychiatric Unit at this time. The Quality Assurance Monitoring Tool dated 5/6/15 at 8:20 a.m. indicated Resident #17 attempting to leave the dining room area and two other residents sitting in wheel chairs in the pathway of Resident #17 and he/she unable to navigate between them and chose not to go around them. Resident #17 attempted to move one of the wheel chair bound residents out of the way when the second wheelchair bound resident, Resident #16, reached out to stop Resident #17. Resident #17 became angry and began punching Resident #16 in the face with a closed fist while holding Resident #16 ' s arm down with Resident #17's his/her free hand. Staff intervened and asked Resident #17 to return to his/her room. The nurse went to the Resident #17's room and the resident stated he/she hit me first and if he/she does it again, I will punch him/her again . Resident #17 attempted to return to the dining room and the nurse asked the resident to remain in his/her room and finish breakfast, the resident hesitantly agreed. Review of written statement by Staff N indicated he/she witnessed Resident #17 walking by the second resident and the second resident. Resident #16, told Resident #17 to go ahead and leave. Resident #17 then started hitting Resident #16 at least three times before they were separated. Staff N documented Resident #17 has no patience for people to move out of his/her way. The Interdisciplinary Progress Notes dated 5/14/15 at 9:38 p.m., indicated Resident #17 admitted back to the facility and admitted to skilled care for nursing observation for 5 days. The Interdisciplinary Progress Note dated 6/21/15 at 12:44 p.m. indicated Resident #17 having behaviors this shift of yelling and cursing at staff. The Interdisciplinary Progress Notes of the Social Services, dated 6/25/15 at 12:53 p.m. the administrator spoke with Social Services today about Resident #17 getting into a confrontation with another resident, Resident #15. The resident involved seemed to have instigated the situation. Resident #17 has had behaviors in the past with other residents and Resident #17 appeared to be calm and under control. The administrator said he would talk with Resident #17 about eating all meals in his/her room so that Resident #17 is removed from any other possible situation that may arise. The Interdisciplinary Progress Notes dated 6/26/15 at 3:26 p.m. (Late Entry For 6/25/15 at 12:20 p.m.) indicated Resident #17 had altercation with Resident #15 in dining room. Resident #15 put his/her hands on Resident #17 and Resident #17 pushed the Resident #15 to the floor causing injury to Resident #15. The Quality Assurance Monitoring Tool dated 6/25/15 at 12:30 p.m., indicated Resident #17 pushed other resident (#15) after being assaulted by Resident #15. Resident #15 after being pushed fell backwards and hit head on a wheel chair resulting in deep laceration to crown of head. The facility implemented 15 minute checks for two days for Resident #15 and nothing implemented for Resident #17. 2. According the MDS (Minimum data set) assessment tool with a reference date of 08/29/15, indicated Resident #15 to have [DIAGNOSES REDACTED]. The MDS documented the resident with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. The MDS identified Resident #15 as independent with all activities of daily living (ADL) except for bathing in which the resident requiring physical assist of one staff member to complete. The Quality Assurance Monitoring Tool dated 6/25/15 at 12:30 p.m., indicated Resident #17 pushed other resident (#15) after being assaulted by Resident #15. Resident #15 after being pushed fell backwards and hit head on a wheel chair resulting in deep laceration to crown of head. The facility implemented 15 minute checks for two days for Resident #15 and nothing implemented for Resident #17. The Care Plan with an initial date of 6/4/15 identified a concern the resident use of taking [MEDICAL CONDITION] medications use with a goal the resident will have adequate control of mood and behavior with use of the medications, and a concern that the resident exhibits explicit behaviors at times (lacked what the behaviors are). The Care Plan listed interventions that directed staff to: 1. Staff to administer the resident's medications and monitor lab values and GDR (gradual dose reduction) as ordered by the resident's physician. 2. Staff is to report any side effects of the medication to the resident's physician. 3. Staff is to assist the resident to have a psychiatric evaluation. 4. Staff is to have the resident's medication as necessary. 5. Staff is to redirect resident if resident becomes agitated or shows behaviors. 6. Staff is to assess for the effectiveness of the resident's medications. 7. When resident begins to exhibit these behaviors, staff is to redirect resident back to room. . The plan of care lacked the information of the altercations the resident had with other resident on 6/25/15, which resulted in an injury to Resident #15. The care plan lacked the known behaviors, of verbal altercations, pushing other residents in their wheel chair, and inappropriate behaviors towards staff and other residents being rude with other residents which staff and other residents reported occurs frequently. The Behavior Monitoring and Intervention Documentation Form lacked documentation completed for resident ' s behaviors of the following months: - For the month of June 2015 only 5 shifts out of 90 shifts (1st, 2nd, and 3rd) documented on the resident's behaviors, the rest of the shifts are blank. -The month of July 2015 31 on shifts only 33 out of 93 shifts documented the resident's behaviors, and nothing documented for 6/25/15 in regards to the altercation with Resident #17. The Month of August 2015 only 14 shifts documented behaviors out of 93 shifts. -The month of September 2015 only 8 shifts out of 90 shifts documented on the resident's behaviors. The Interdisciplinary Progress Notes for Resident #15, dated 6/25/15 at 12:48 p.m., documented the resident had an altercation with another resident (Resident #17). Resident #17 pushed Resident #15 backwards causing Resident #15 to fall breaking his/her head open in multiple place, the lacerations are very deep. The Resident #15 family member is here at the facility, working, and notified of incident and injury to the resident. The resident's family member is taking the resident to the emergency room for treatment of [REDACTED]. Review fax communication sent and returned to Resident #15 physician dated 6/25/15, indicated the resident sent to the emergency room and received 19 stitches to the top of his/her head. The physican gave an order to remove the stitches in 10 days at the facility. 3. According the MDS (Minimum data set) assessment tool with a reference date of 04/13/15, indicated Resident #16 to have [DIAGNOSES REDACTED]. The MDS documented the resident with a BIMS (Brief Interview for Mental Status) score of 12 out of 15. The MDS identified Resident #16 requiring physical assist of one staff member for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS indicated the resident use a wheel chair for mobility device. The Care Plan with dated 4/6/15 identified a concern the resident to require assist with ADLs due to having left sided [MEDICAL CONDITION], history [MEDICAL CONDITION] The Care Plan listed interventions that directed staff to: 1. One staff to physically assist the resident with ADLs. 2. The resident uses an electric wheel chair for mobility device. Review of Resident #16 ' s physician clinical notes dated 4/10/15, indicated the resident seen for initial nursing home visit since admit of 4/6/15. The physician documented the resident is at the facility due to spouse having surgery and unable to take care of the resident during this time. The Quality Assurance Monitoring Tool dated 5/6/15 at 8:20 a.m. indicated Resident #17 attempting to leave the dining room area and two other residents sitting in wheel chairs in the pathway of Resident #17 and he/she unable to navigate between them and chose not to go around them. Resident #17 attempted to move one of the wheel chair bound residents out of the way when the second wheel bound resident, Resident #16, reached out to stop Resident #17. Resident #17 became angry and began punching Resident #16 in the face with a closed fist while holding Resident #16 ' s arm down with Resident #17's his/her free hand. Staff intervened and asked Resident #17 to return to his/her room. The nurse went to the Resident #17's room and the resident stated he/she hit me first and if he/she does it again, I will punch him/her again . Resident #17 attempted to return to the dining room and the nurse asked the resident to remain in his/her room and finish breakfast, the resident hesitantly agreed. Review of the Interdisciplinary Notes dated 5/7/15 at 2:00 p.m., documented Resident #16 denies pain related to being hit in the face by Resident #17. Staff noted no bruising, redness, or swelling noted. The above entry of the Interdisciplinary Notes is the first entry regarding the altercation that occurred on 5/6/15. The Interdisciplinary Notes lacked indication that the resident's physician or family notified of the altercation and the resident getting punched in the face 3 to 4 times. Record review indicated that all three resident to resident altercations occurred in the main dining room. Interview with Staff O, on 10/7/15 at 1:39 p.m., indicated Resident #17 attempting to leave the main dining room on 5/6/15 around 8-8:15 am. Staff O stated Resident #17 pushing another resident ' s wheel chair out of his pathway when Resident #16 , who is in a wheel chair, attempted to stop Resident # 17 from pushing the other resident, and Resident #16 grabbed Resident ' s #17 arm with an open hand. Staff O stated Resident #17 then started to punch Resident # 16 with a closed fist to his/her left side of the face while Resident #17 held down Resident #16 ' s arms. Staff O stated Resident #17 hit Resident #16 at least 4 times to the face, and hits were hard blows causing Resident ' s #16 head to go sideways. Staff O stated he/she was standing at the serving cart with two trays in hand and yelled for help. Staff O indicated that Resident #17 is known to yell at residents and staff and is impatient with other residents. Staff O stated this occurs often. Interview with Staff N, on 10/7/15 at 2:00 p.m. indicated the CNA ' s (Certified Nurse Aide) assist feeding the resident in the small dining room and are unable to see the other resident's in the main dining room or to hear them. Staff N stated that after the nurse finish passing medications then the nurse leaves and no staff are in the main dining room. Staff N indicated Resident #17, #16, and #15 all eat in the main dining room. Staff N indicated that Resident #17 is known to confront other resident ' s in the main dining room, he/she gets verbally abusive with other residents and is known to push resident ' s in their wheel chair. Staff N stated Resident #17 wants to leave the dining room he/she does not want anyone in the way and will push them out of the way. Staff N stated he/she heard Resident #17 and #15 get into verbal arguments with each other and other residents in the main dining room. Staff N indicated just the other day, Resident #15, got in a verbal altercation with a resident in the dining room and staff had to intervene. Interview with Staff I, on 10/7/15 at 2:20 p.m., indicated when the nurses get done passing residents medications in the dining room, and the meals are served to the residents, there are no staff members in the main dining room. Staff I stated when staff assisting resident with eating they cannot see or hear the other resident's in the main dining room. Staff I indicated when the altercation between Resident #17 and Resident #15, he/she was assisting resident with eating and did not see the altercation. Staff I stated he/she took Resident #15 to the emergency room after the altercation and the resident had a head injury that required sutures. Staff I stated he/she brought Resident #15 back to the facility after receiving treatment for [REDACTED]. Interview with Staff C, on 10/8/15 at 10:18 a.m., indicated being the nurse assigned to Resident #15 on 6/25/18. Staff C stated he/she was told by staff that in the dining room Resident #17 and Resident #15 got into a physical altercation. Staff C stated it was reported to her/him that Resident #17 pushed Resident #15, causing him/her to fall backwards striking his/her head on another resident's wheelchair. Staff C stated not being in the dining room when this altercation occurred. Staff C stated Resident #17 is known to be mean to other residents and will push them out of his/her way. Staff C stated he/she talked to Resident #15 after the altercation and the resident stated that he/she got into an altercation with Resident #17, and was not going to back down from Resident #17. Staff C stated Resident #15 reported Resident #17 pushed him/her to get out of his/her way. Staff C stated Resident #15 was transported to emergency room for treatment of [REDACTED].#17. Interview with Staff P, on 10/8/15 at 2:08 p.m., indicated no behavioral sheets for Resident #17 besides for the month of 3/15. Staff P stated the Director of Nursing (DON) will be calling the office personnel to see if any other behavior sheets for Resident #17. Staff P reported that all behavior sheets are to be filled out all shifts on all dates. State P indicated that if the resident has no behaviors then the behavior sheet should still be documented on each shift, every day. Interview with Staff Q, on 10/14/15 at 8:53 a.m., indicated when assisting residents with feeding assist, staff cannot see or assist other residents in the main dining room. Staff Q states at times there is no staff in the main dining room. Staff Q reports that Resident #17 gets agitated, verbal and will push other resident's that are in wheelchairs out of his/her way when entering or exiting the dining room. Staff Q states the alterations occur in the main dining room. Staff Q indicated Resident #15 is known to get grouchy with staff and other resident's and is flirtatious with female residents and female staff. Interview with Resident #20 and #21 on 10/2/15 at 9:50 a.m. revealed they have witnessed the altercation between resident #15 and #17 that occurred in the main dining room. The residents reported seeing Resident #15 choking Resident #17 and Resident #17 then pushed Resident #15 causing the resident to fall backwards hitting his/her head on another resident ' s wheel chair. The resident's report that Resident #15 has patted Resident #21 butt on a few occasions and also has seen the resident do the same to other female residents and staff members. Resident #21 stated it makes her/him very uncomfortable with the behavior that occurs frequently. Both resident's stated Resident #15 along with other male resident's, in the main dining room, will use foul language and get into verbal altercations. The resident's state this make them feel uncomfortable to eat meals in the main dining room. Review of the facilities Abuse Policy/Procedure, dated 4/02, included Residents have the right to be free from verbal, mental, sexual, physical, involuntary seclusion, neglect, and misappropriation of property and free from abuse from one another. The Policy/procedure included staff will identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property are more likely to occur. Their will be analysis of that including assessment, care planning, and monitoring of resident with needs and behaviors that might lead to conflect or neglect. The Care Plan tam will udate the care plan dealing with resident behavior and interventions. As part of the overall plan of care, assessment of contributing factors should be explored.

Based on record review, resident and staff interviews, the facility failed to ensure care plan interventions were implemented/followed to provide adequate supervision to prevent resident to resident altercation resulting in injuries to 3 of 3 residents (Resident #15, #16 & #17). The facility reported a census of 64 residents. Findings include: 1. According the Minimum Data Set (MDS) assessment tool with a reference date of 08/19/15, Resident #17 documented the resident had a BIMS (Brief Interview for Mental Status) score of 11 out of 15. The MDS identified Resident #17 as independent with all activities of daily living (ADL) except for bathing in which the resident requiring physical assist of one staff member to complete. The physician progress notes [REDACTED].#17, listed [DIAGNOSES REDACTED]. Review of Resident's #17 physician progress notes [REDACTED]. The resident had been readmitted to the other facility until 1/23/14 when the resident became physically and verbally abusive at the facility. The resident was discharged from that facility and admitted to the current on 2/10/14. The Care Plan with an initial date of 2/27/2015 identified the resident taking medications to stabilize mood and behaviors. The Care Plan listed interventions that directed staff to: 1.Staff to administer the resident's medications and monitor lab values and GDR (gradual dose reduction) as ordered by the resident's physician. 2. Staff is to redirect resident if resident becomes agitated or shows behaviors. 3. Staff is to monitor resident for any adverse side effects of medication and report as needed. 4. Staff is to report to the resident's physician if change in resident's mood or behaviors. Review of Resident #17's clinical record revealed only one month of Behavior Monitoring and Intervention Documentation Form for the March 2015. The March 2015 form revealed documentation completed only 10 times on the day shift, 7 times on second shift, and 6 times on the night shift, out of 31 days. Review of the current October Behavior Monitoring and Intervention Documentation Form, kept in a book at the nurses' station, revealed no Behavior Form for Resident #17. Resident's #17 clinical lacked documentation of continued monitoring of the resident's behaviors. The Interdisciplinary Progress Nursing Notes for Resident #17 dated 5/6/2015 at 11:07 a.m. documented at approximately 8:20 a.m., Resident #17 attempted to leave the dining room area when two other residents sitting in wheelchairs were in front of Resident #17 pathway. Resident #17 unable to navigate between the two residents ' wheelchairs and choose not to go around them. Resident #17 attempted to move one of the resident ' s wheelchair out of the way, when the second resident (Resident #16), reached out to stop Resident #17 from doing so. Resident #17 became angry and began to punch Resident #16 with a closed fist to the left side of the resident ' s face while holding the residents arms down with Resident #17's free hand. Staff intervened and asked Resident #17 to go to his/her room. Resident #17 stated, the other resident hit first and if the resident does it again Resident #17 will punch him/her again. The staff contacted the resident's physician and orders received for an inpatient psych evaluation. At 9:26 p.m. Resident #17 was transferred to a Geri Psych Unit at this time. The Quality Assurance Monitoring Tool dated 5/6/15 at 8:20 a.m. indicated Resident #17 attempted to leave the dining room area and two other residents sitting in wheelchairs in the pathway of Resident #17; and he/she unable to navigate between them and chose not to go around them. Resident #17 attempted to move one of the resident ' s wheelchairs out of the way when Resident #16 reached out to stop Resident #17. Resident #17 became angry and began punching Resident #16 in the face with a closed fist while holding Resident #16's arm down with Resident #17's his/her free hand. Staff intervened and asked Resident #17 to return to his/her room. The nurse went to the Resident #17' s room and the resident stated he/she hit me first and if he/she does it again, I will punch him/her again. Resident #17 attempted to return to the dining room and the nurse asked the resident to remain in his/her room and finish breakfast, the resident hesitantly agreed. Review of written statement by Staff N indicated he/she witnessed Resident #17 walked by the second resident and Resident #16, told Resident #17 to go ahead and leave. Resident #17 then started hitting Resident #16 at least three times before they were separated. Staff N documented Resident #17 has no patience for people to move out of his/her way. The Interdisciplinary Progress Notes dated 5/14/15 at 9:38 p.m., indicated Resident #17 admitted back to the facility. The Interdisciplinary Progress Note dated 6/21/15 at 12:44 p.m. indicated Resident #17 had behaviors this shift of yelling and cursing staff. The Interdisciplinary Progress Notes of the Social Services, dated 6/25/15 at 12:53 p.m. the Administrator spoke with Social Services today about Resident #17 getting into a confrontation with another resident, Resident #15. The resident involved seemed to have instigated the situation. Resident #17 has had behaviors in the past with other residents and Resident #17 appeared to be calm and under control. The Administrator said he would talk with Resident #17 about eating all meals in his/her room so that Resident #17 is removed from any other possible situation that may arise. The Interdisciplinary Progress Notes dated 6/26/15 at 3:26 p.m. (Late Entry for 6/25/15 at 12:20 p.m.) indicated Resident #17 had altercation with another resident in dining room. The other resident put his/her hands on Resident #17 and Resident #17 pushed the resident to the floor causing injury to the resident. The Quality Assurance Monitoring Tool dated 6/25/15 at 12:30 p.m., indicated Resident #17 pushed Resident #15 after being assaulted by Resident #15. Resident #15 after being pushed fell backwards and hit head on a wheelchair resulting in deep laceration to crown of head. The facility implemented 15 minute checks for two days for Resident #15 and nothing implemented for Resident #17. The plan of care for resident lacked the information of the altercations the resident had with other residents (Resident #16 on 5/6/15 and Resident #15 on 6/25/15 (that resulted in an injury to Resident #15). The care plan lacked the known behaviors of verbal altercations, pushing other residents and or impatience with other residents (and staff members). 2. According the MDS (Minimum data set) assessment tool with a reference date of 08/29/15, indicated Resident #15 with [DIAGNOSES REDACTED]. The MDS documented the resident with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. The MDS identified Resident #15 as independent with all activities of daily living (ADL) except for bathing in which the resident requiring physical assist of one staff member to complete. The Care Plan with an initial date of 6/4/15 identified a concern the resident use of taking psychotropic medications use with a goal the resident will have adequate control of mood and behavior with use of the medications, and a concern that the resident exhibits explicit behaviors at times (lacked what the behaviors are). The Care Plan listed interventions that directed staff to: 1. Staff to administer the resident's medications and monitor lab values and GDR (gradual dose reduction) as ordered by the resident's physician. 2. Staff is to report any side effects of the medication to the resident's physician. 3. Staff is to assist the resident to have a psychiatric evaluation. 4. Staff is to have the resident's medication as necessary. 5. Staff is to redirect resident if resident becomes agitated or shows behaviors. 6. Staff is to assess for the effectiveness of the resident's medications. 7. When resident begins to exhibit these behaviors, staff is to redirect resident back to room. The Interdisciplinary Progress Notes for Resident #15, dated 6/25/15 at 12:48 p.m., documented the resident had an altercation with another resident (Resident #17). Resident #17 pushed Resident #15 backwards and hit his/her head on the wheelchair of another resident, causing Resident #15 to fall breaking his/her head open in multiple place. The note identified the lacerations are very deep. The Resident #15 family member is here at the facility, working, and notified of incident and injury to the resident. The resident's family member is taking the resident to the emergency room for treatment of [REDACTED]. Review fax communication sent and returned to Resident #15 physician dated 6/25/15, indicated the resident sent to the emergency room and received 19 stitches to the top of his/her head. The physician gave an order to remove the stitches in 10 days at the facility. The Quality Assurance Monitoring Tool dated 6/25/15 at 12:30 p.m., indicated Resident #17 pushed Resident #15 after being assaulted by Resident #15. Resident #15 fell backwards and hit his/her head on a wheelchair resulting in deep laceration to crown of head. The facility implemented 15 minute checks for two days for Resident #15 and nothing implemented for Resident #17. The Behavior Monitoring and Intervention Documentation Form lacked documentation completed for resident's behaviors of the following months: June 2015 only 5 shifts out of 90 shifts (1st, 2nd, and 3rd) documented on the resident's behaviors, the rest of the shifts are blank. -The month of July 2015 only 33 shifts out of 93 shifts documented the resident's behaviors, and nothing documented for 6/25/15 in regards to the altercation with Resident #17. The Month of August 2015 only 14 shifts documented behaviors out of 93 shifts. -The month of September 2015 only 8 shifts out of 90 shifts documented on the resident's behaviors. The plan of care lacked the information of the altercations the resident had with the other resident on 6/25/15. The care plan lacked the known behaviors including but not limited to: verbal altercations, inappropriate behaviors towards staff and other residents. 3. According the MDS (Minimum data set) assessment tool with a reference date of 04/13/15, indicated Resident #16 to have [DIAGNOSES REDACTED]. The MDS documented the resident with a BIMS (Brief Interview for Mental Status) score of 12 out of 15. The MDS identified Resident #16 requiring physical assist of one staff member for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS indicated the resident use a wheel chair for mobility device. The Care Plan with dated 4/6/15 identified a concern the resident to require assist with ADLs due to having left sided hemiparesis, history of CVA (cerebral vascular accident) The Care Plan listed interventions that directed staff to: 1.One staff to physically assist the resident with ADLs. 2. The resident uses an electric wheel chair for mobility device. Review of Resident #16's physician clinical notes dated 4/10/15, indicated the resident seen for initial nursing home visit since admit of 4/6/15. The physician documented the resident is at the facility due to spouse having surgery and unable to take care of the resident during this time. The Quality Assurance Monitoring Tool dated 5/6/15 at 8:20 a.m. indicated Resident #17 attempted to leave the dining room area and two other residents sitting in wheelchairs in the pathway of Resident #17 and he/she unable to navigate between them and chose not to go around them. Resident #17 attempted to move one of the resident ' s wheelchair out of the way when the second resident (Resident #16), reached out to stop Resident #17. Resident #17 became angry and began punching Resident #16 in the face with a closed fist while holding Resident #16's arm down with Resident #17's his/her free hand. Staff intervened and asked Resident #17 to return to his/her room and the nurse asked the resident to remain in his/her room and finish breakfast, the resident hesitantly agreed. Review of the Interdisciplinary Notes dated 5/7/15 at 2:00 p.m., documented Resident #16 denies pain related to being hit in the face by Resident #17. Staff noted no bruising, redness, or swelling noted. The above entry of the Interdisciplinary Notes is the first entry regarding the altercation that occurred on 5/6/15. The Interdisciplinary Notes lacked indication that the resident's physician or family notified of the altercation and the resident getting punched in the face 3 to 4 times. Record review indicated that all three resident to resident altercations occurred in the main dining room. Interviews: Interview with Staff O, Housekeeping Supervisor on 10/7/15 at 1:39 p.m., indicated Resident #17 attempted to exit the main dining room on 5/6/15 around 8-8:15 am. Staff O stated Resident #17 pushed another resident's wheelchair out of his/her pathway when Resident #16, attempted to stop Resident # 17 from pushing the other resident. Resident #16 grabbed Resident #17 ' s arm with an open hand. Staff O stated Resident #17 then started to punch Resident #16 with a closed fist to his/her left side of the face. Staff O stated Resident #17 hit Resident #16 at least 4 times to the face, and hits were hard blows causing Resident's #16 head to go sideways. Staff O stated he/she was standing at the serving cart with two trays in hand and yelled for help. Staff O indicated that Resident #17 is known to yell at residents and staff and is impatient with other residents. Staff O stated this occurs often. Interview with Staff N, on 10/7/15 at 2:00 p.m. indicated the CNA's (Certified Nurse Aide) assist feeding the resident in the small dining room and are unable to see the other resident's in the main dining room or to hear them. Staff N stated that after the nurse finish passing medications then the nurse left and no staff are in the main dining room. Staff N indicated Residents #17, #16, and #15 all eat in the main dining room. Staff N indicated that Resident #17 is known to confront other resident's in the main dining room. Staff N reported he/she gets verbally abusive with other residents and is known to push residents in their wheelchair ' s. Staff N stated Resident #17 wanted to leave the dining room he/she does not want anyone in the way and will push them out of the way. Staff N stated she heard Residents #17 and #15 get into verbal arguments with each other and other residents in the main dining room. Staff N indicated just the other day, Resident #15, got in a verbal altercation with a resident in the dining room and staff had to intervene. Interview with Staff I, on 10/7/15 at 2:20 p.m., indicated when the nurses got done passing residents ' medications in the dining room, and the meals are served, there are no staff members in the main dining room. Staff I stated when staff assisting resident with eating they cannot see or hear the other resident's in the main dining room. Staff I indicated when the altercation between Resident #17 and Resident #15, he/she was assisting resident with eating and did not see the altercation. Staff I stated he/she took Resident #15 to the emergency room after the altercation and the resident had a head injury that required sutures. Staff I stated he/she brought Resident #15 back to the facility after receiving treatment for [REDACTED]. Interview with Staff C, on 10/8/15 at 10:18 a.m., indicated being the nurse assigned to Resident #15 on 6/25/18. Staff C stated she was told by staff that in the dining room Resident #17 and Resident #15 got into a physical altercation. Staff C stated it was reported to her that Resident #17 pushed Resident #15 and caused him/her to fall backwards striking his/her head on another resident's wheelchair. Staff C stated she was not being in the dining room when this altercation occurred. Staff C stated Resident #17 is known to be mean to other residents and will push them out of his/her way. Staff C stated he/she talked to Resident #15 after the altercation and the resident stated that he/she got into an altercation with Resident #17, and was not going to back down from Resident #17. Staff C stated Resident #15 reported Resident #17 pushed him/her to get out of his/her way. Staff C stated Resident #15 was transported to emergency room for treatment of [REDACTED].#17. Interview with Staff P (MDS/care plan coordinator) on 10/8/15 at 2:08 p.m., indicated no behavioral sheets for Resident #17 besides for the month of 3/15. Staff P stated the Director of Nursing (DON) will be calling the office personal to see if any other behavior sheets for Resident #17. Staff P reported that all behavior sheets are to be filled out all shifts on all dates. State P indicated that if the resident has no behaviors then the behavior sheet should still be documented on each shift, every day. Interview with Staff Q, Certified Nurse Aide 10/14/15 at 8:53 a.m., indicated when assisting residents with feeding assist, staff cannot see or assist other residents in the main dining room. Staff Q states at times there is no staff in the main dining room. Staff Q reports that Resident #17 gets agitated, verbal and will push other resident's that are in wheelchairs out of his/her way when entering or exiting the dining room. Staff Q states the alterations occur in the main dining room. Staff Q indicated Resident #15 is known to get grouchy with staff and other resident's and is flirtatious with female residents and female staff. Interview with Resident #20 and #21 on 10/2/15 at 9:50 a.m. revealed they witnessed the altercation between Residents #15 and #17 that occurred in the main dining room. The residents reported seeing Resident #15 choke Resident #17 and Resident #17 then pushed Resident #15 causing the resident to fall backwards hitting his/her head on another resident's wheelchair. These residents reported Resident #15 had patted Resident #21's butt on a few occasions and also had seen the resident do the same to other female residents and staff members. Resident #21 stated it makes her/him very uncomfortable with the behavior that occurs frequently. Both residents stated Resident #15 along with other male resident's, in the main dining room will use foul language and get into verbal altercations. The resident's stated this made them feel uncomfortable to eat their meals in the main dining room.

Based on record review, observations and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and elements in the environment and the health service supervisor failed to plan for and direct the nursing care services in order that the resident ' s needs are met with transfers (Resident #1). The sample consisted of 8 residents reviewed and the facility reported a census of 53 residents Findings include: 1. The resident had a Minimum Data Set (MDS) assessment with a reference date of 1/21/2013 which revealed the resident required total dependence of two staff for transfers, bed mobility, and using the toilet. The assessment documented poor memory and not able to make own decisions. The MDS assessment, with a reference date of 2/11/2013, identified pertinent [DIAGNOSES REDACTED]. Review of the Major Injury Determination Form dated 2/3/13 and completed by the facility, revealed Resident #1 dependent on a Hoyer lift and two people for transfers. Record review of the Resident's Care Plan dated 7/11/05 and most recent full review on 2/12/13 revealed a problem identified; at risk for falls, staff interventions are to assist to change position frequently, assure safe dry footing for all transfers, Dyes in wheelchair, pressure alarm in the bed, one to two for assistance to transfer and use of gait belt or Hoyer lift. Review of the Fall Risk Assessment for Resident #1 dated 2/14/13 revealed a score of 19. The same assessment dated [DATE] revealed a score of 17, any score 10 or higher represents the resident is at high risk for falls. Review of the Incident/Accident Report form dated 2/3/13 for Resident #1 revealed the resident slid from h/her wheelchair, Staff A, CNA assisted the resident to the floor. Assessment done and found left leg painful to move. No alarm for the resident, Dycem found in place in the wheelchair. Review of the Incident/Fall Assessment & Investigation Sheet dated 2/3/13 for Resident #1, revealed the resident had been in a wheelchair and had no alarm present in the chair. Review of the Physical Therapy Plan of Care (evaluation only) dated 11/1/12 revealed adequate strength and range of motion (ROM) to complete stand lift transfer but not recommended due to past history of compression fractures and current osteoarthritis pain of back. The resident able to stand well enough and assist of two could don or doff pants if needed but the inability to weight shift and step makes the resident dependent upon a Hoyer lift for transfers at this time. During an observation on 2/18/13 at 3:10 PM, Resident #1 laid in bed, resting on left side, call light next to right hand, oxygen on, clean and no odors noted. The resident voiced pain all over but not able to be specific. Noted an immobilizer on left leg. Heel protectors on both feet and pillows used for positioning and comfort. During observation on 2/19/13 at 9:05 AM, Resident #1 found up in wheelchair, in the dining room. Staff G, CNA pushed the resident to h/her room, prepared the bed, Staff H obtained the Hoyer lift, the sling had been in position under the resident, both Staff G and H assisted the resident into bed, keeping left leg straight, during the time of the transfer, the resident moaned out in pain, as soon as h/she had laid down, h/she had become quiet and more relaxed. Pillows used for positioning and the immobilizer on left leg placed on pillows, pressure relief boots placed on both feet. Heels floated when positioning had been completed. Review of the February MAR (Medication Administration Record) revealed the resident received routine Hydrocodone-APAP 7.5 milligrams-325 milligrams at 6:00 a.m., 2:00 p.m. and 10:00 p.m. for pain control beginning January 14, 2013. The resident also received additional medication as needed for pain. The resident received additional medication (Lortab 5/325 milligrams) on 2/3/2013 (once), 2/4/2013 (twice), and 2/7/2013 (twice) and 2/13/2013 (once) and 2/17/13 (once). The resident received Lortab for pain on 2/19/2013 at 1:45 a.m., 10:45 a.m. and 8:00 p.m. The resident received additional pain medication on 12:50 p.m. on 2/20/2013. On 2/19/13 at 9:45 AM, Staff A, CNA stated she had taken Resident #1 to his/her room after lunch, Resident #1 complained of pain in the left leg and foot and she knew she had a sore on the foot. She then removed the foot pedals and the calf support from the wheelchair. She could not say for sure if the resident's feet touched the ground or not. She stated she turned away from the resident, walked into the hall, about 3 feet away, to obtain the Hoyer lift and then she heard the resident say something like a moan or hey, she turned and the resident had been leaning forward in the wheelchair, to the right, h/her left foot caught behind the left front wheel on the chair and the resident's left knee flexed and almost touching the floor. She stated she could not lift h/her alone so she slowly lowered h/her to the floor. She stated she placed a pillow under the resident's head, left h/her alone and ran to get the nurse. She stated she had been the only one working on the floor on her end, since all other staff had been in the dining room. She stated they always do what they can first then call for the second staff member to come and complete the transfer. She stated it happened so fast. On 2/20/13 at 10:05 AM, Staff C, CNA stated she has worked at the facility for over a year. She stated then the resident had been a one assist but she and several other staff would only transfer the resident by two staff assisting. She stated the care plan said 1-2 assist but from experience she felt 2 assist would be safer. She stated they are expected to remove the foot pedals just prior to the transfer and they had already been in-serviced about that recently. On 2/20/13 at 11:35 AM, Staff D (LPN and charge nurse) was interviewed and stated if a CNA removes the foot pedals from a resident's chair, they should not step away for more than a couple seconds and if the resident, like Resident #1, is not able to rest feet on the floor, they should not leave them unattended. On 2/20/13 at 11:05 AM, Staff E (LPN/ charge nurse) was interviewed and stated she knew the resident well. Staff E stated the resident had always been a 2 person assist transfer and they had always been expected to remove the foot pedals just before the transfer or move the resident with you to where ever the place is your going. She stated they are never to leave them (the resident) alone. On 2/20/13 at approximately 1:30 PM, the Director of Nursing (DON) was interviewed and stated she did not have a policy and procedure for wheelchair transfers. She stated policy and procedures tends to get them in trouble. She stated the CNA's are expected to follow the care plan and if any further questions then they are to ask the charge nurse. She stated she had not completed another in-service after the 2/3/13 fall because she had just done one. She stated she did talk to some staff one to one to assure they knew to leave the foot pedals on a residents' chair until right before the resident is ready to transfer and the second person is there to help.

resident as impatient. An interview conducted on 8/15/12 at 2:00 p.m. with Staff T, LPN, revealed the resident got up alone often due to being very impatient and needing things done right now. Staff T stated the resident yelled out and he felt some communication barriers present even though the resident able to speak English if took time. Staff T stated the resident seemed to focus on certain things such as needing the restroom, wanting coffee and cookies. Staff T stated the resident didn't respond well to redirection. Staff T stated at times the staff provided 1 to 1 supervision due to extreme restlessness and the constant getting up and down. Staff T stated he knew the resident had fallen and required the use of alarms at all times. Staff T stated he Based on observation, record review, and staff interviews, the facility failed to provide complete assessments and interventions for 5 of 15 residents reviewed (Residents #4, #5, #9, #12, #14). The facility reported a census of 63 residents. Resident #9 experienced pain after a fall and the facility failed to assess the resident and provide pain medication to relieve pain. Residents #4, #5, #12, #14 experienced falls and the staff failed to adequately assess the residents after the falls. Findings include: 1. The Minimum Data Set (MDS) assessment with a reference date of 07/12/12 identified Resident #9 with [DIAGNOSES REDACTED]. The Nursing Progress Notes and incident/accident report dated 04/02/12 identified the an alarm sounded and staff found Resident #9 on the floor in his/her room and on his/her left side holding self-up with left arm. The incident report indicated the resident tried to transfer self from wheelchair to bed. The steps taken to prevent recurrence The nurse's notes dated 04/05/12 at 4:40 p.m. documented a phone call to the doctor's office in regard to left sided pain. The nurse's notes dated 04/06/12 at 11:00 a.m. documented an order for [REDACTED]. The Portable X-ray report dated 04/06/12 documented no definite rib fracture identified, though a subtle non-displaced [MEDICAL CONDITION] ribs could not be excluded. The April 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The nurse's notes and the incident/accident report dated 04/17/12 at 9:30 a.m. indicated the resident as found lying on pillow that had landed on the matt beside his/her bed. Documentation revealed the resident complained of right shoulder pain. The nurse's notes and the MAR indicated [REDACTED]. The nurse's notes and incident/accident report dated 04/17/12 at 3:05 p.m. indicated the resident as found on the floor, lying on his/her left side in front of the recliner. It was noted the foot rest of the recliner under resident's buttock and the resident ' s glasses as broken. The resident was noted to have an area of bruising with two small abrasions around the left eye. The resident complained of left hip pain. Documentation revealed the resident complained of left hip pain and injured his/her left eye. The nurse's notes and the MAR indicated [REDACTED]. 2. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #4 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance for bed mobility, transfers, and ambulation. The MDS documented the resident required moderate assistance for dressing and personal hygiene. The MDS documented the resident had a history of [REDACTED]. Review of the Incident/Accident report dated 5/3/12 at 1:15 p.m. revealed the staff lowered the resident to the floor in the bathroom. The incident report recorded vital signs but lacked documentation of a physical assessment. The nurse's notes dated 5/3/12 at 1:15 p.m. lacked documentation of an assessment after the resident fell . Review of the Incident /Accident Report dated 5/17/12 at 11:30 a.m. revealed staff lowered the resident to the floor. The incident report recorded vital signs but lacked documentation of a physical assessment. The nurse's notes dated 5/17/12 lacked documentation of an assessment after the fall. During an interview on 8/14/12 at 3:22 p.m. Staff D (Director of Nursing), confirmed the nurses need to include an after fall assessment in the nurse's notes. 3. The MDS dated [DATE] documented Resident #5 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance for transfers and ambulation. The Incident/Accident Report dated 1/11/12 at 5:03 p.m. indicated the resident rolled from the bed. The incident report failed to document if the alarm sounded. The incident report instructed staff to place the resident's shoes in the closet. The nurse's notes dated 1/11/12 at 5:10 p.m. documented vital signs but lacked a physical assessment. 4. The care plan dated 8/8/12 documented Resident #12 had [DIAGNOSES REDACTED]. The care plan documented the resident had a history of [REDACTED]. The Incident/Accident Report dated 3/26/12 at 9:00 p.m. recorded vital signs but lacked documentation of a physical assessment. The incident report failed to record an intervention for the fall. The incident report lacked documentation if the alarm sounded. The nurse's notes dated 3/26/12 at 9:00 p.m. documented vital signs but did not include a physical assessment. The Incident/Accident Report dated 3/27/12 at 7:40 p.m. recorded vital signs but lacked documentation of a physical assessment. The incident report did not record an intervention for the fall. The incident report lacked documentation if the alarm sounded. The nurse's notes dated 3/27/12 (no time noted) documented vital signs but did not include a physical assessment other than an abrasion on the knee. 5. The MDS dated [DATE] documented Resident #14 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance for transfers and did not ambulate. The MDS documented the resident had a history of [REDACTED]. The Incident/Accident Report dated 2/14/12 at 3:18 p.m. documented the resident fell . The report lacked a physical assessment. The nurse's notes dated 2/14/12 at 3:18 p.m. documented the resident fell . The nurse's notes did not have documentation to identify vital signs or a physician assessment. The Incident/Accident Report dated 2/16/12 at 6:50 documented the resident fell . The report recorded vitals but failed to document a physical assessment. The nurse's notes dated 2/16/12 (no time) documented the resident fell . The nurse's notes documented vitals but failed to document a physical assessment. The Incident/Accident Report dated 2/18/12 at 11:15 a.m., documented the resident fell . The report recorded vital signs but failed to document a physical assessment. The nurse's notes dated 2/18/12 at 11:15 a.m. documented the resident fell . The nurse's notes lacked documentation of vital signs and a physical assessment (only a neurological assessment). The Incident/Accident Report dated 2/18/12 at 3:30 p.m., documented the resident fell . The report recorded vital signs but failed to document a physical assessment. The Incident/Accident Report dated 2/20/12 at 8:45 a.m. documented the resident fell . The report recorded vital signs but lacked documentation of a physical assessment. The nurse's notes dated 2/20/12 at 6:30 p.m. documented the resident fell . The nurse's note lacked documentation of vital signs and a physical assessment

Based on record review, observation, review of facility policy/protocols and staff and resident interviews, the facility failed to assess and provide interventions to prevent pressure areas for 1 of 2 residents reviewed with pressure areas (Resident #4). The facility reported a census of 63 residents. Resident #4 returned to the facility from the hospital on [DATE]. The facility policy directed staff to perform an assessment on admission and on a regular basis. The clinical record lacked an assessment when the resident returned from the hospital. The facility did not implement adequate interventions to prevent the development of pressure ulcers. The facility policy directed the dietary staff to implement interventions to promote wound healing. The care plan did not address dietary interventions. The resident had an open shear pressure sore located on the inner buttock. The standing orders directed staff to apply [MEDICATION NAME] barrier film as a preventive dressing. The standing order did not direct staff to apply the film to an open wound. Findings include 1. Resident #4 had an MDS ( Minimum Data Set) assessment with a reference date of 8/6/12 which identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident could independently eat without staff assistance. The MDS documented the resident's height as 71 inches weighed 172 pounds. The MDS indicated the resident required extensive assistance from staff for bed mobility, transfers, and ambulation. The MDS documented the resident as at risk for developing pressure ulcers. The MDS reflected the facility had implemented pressure reducing devices for the chair and bed. The MDS reflected the facility did not implement a turning/reposition program (this resident required extensive assistance with bed mobility). A Braden Score for the prediction of pressure sore risk dated 7/13/12 identified a score of 17 out of 23. A score of 12 or less represented high risk. A facsimile dated 7/12/12 listed a dietary recommendation of 1 scoop protein powder three times a day due to a low [MEDICATION NAME] level. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurse's notes dated 7/30/12 at 2:20 p.m. documented the resident returned from the hospital (had been hospitalized for [REDACTED]. The nurse's notes dated 8/6/12 at 1:05 p.m. documented a weekly skin assessment. The nurse's notes documented no open areas. The nurse's notes dated 8/6/12 at 5:20 p.m. documented a pressure area to the left heel that measured 2.5 x 3.2 centimeters. Staff sent a facsimile to the physician and notified the family. The Weekly Pressure Ulcer Record indicated on 8/6/2012 the staff identified a left heel pressure ulcer which measured 2.5 cm by 3.2 cm and 0.5 deep. On 8/10/12 the nurse documented a vitamin protocol began, Meplix dressing used and heels floated (to prevent pressure) and the resident had boots. A facsimile dated 8/6/12 indicated the staff notified the physician of the pressure area to the left heel. The physician ordered the resident to wear bunny boots on feet when not ambulating and float heels in bed or in recliner. The Weekly Pressure Ulcer Record indicated on 8/13/2012, the left heel to be a Stage II, measured 2.5 cm by 3.0 cm and had a depth of 0.3 (improved). The note indicated the resident had the vitamin protocol and received supplement shake. The resident continued to use the boot and dressed with [MEDICATION NAME] dressing. A nutritional progress note dated 8/2/12 recommended to add protein powder to appropriate foods up to 5 times a day. The August 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 8/14/12 at 11:08 a.m., the Director of Nursing, stated nursing did not document the administration of protein powder and unsure if dietary kept track of the protein supplement. According to the dietitian's recommendations for specific resident nutrition care provided by the dietary manager, the resident disliked the protein powder and the dietary department used fortified milk in ice cream instead. Dietary did not document the dietary intervention. The care plan dated 7/13/12 failed to address dietary interventions. The care plan dated 7/13/12 documented the resident as at risk for pressure areas and skin tears. The care plan listed the following interventions Minimize skin exposure to moisture Administer supplements per physician orders Utilize barrier cream as needed Provide perineal care after incontinence Provide treatment per physician orders Pressure relieving cushion in wheelchair and pressure relieving mattress on bed Monitor skin with all cares and showers Assess Braden score quarterly Turn every 2 hours due to red area on buttock dated 6/3/12 The staff updated the care plan on 8/6/12 to include the open area on the heel and listed the following interventions: Put foot booties on the resident ' s feet as resident allows Encourage the resident to float heels Provide treatment per physician orders Physician to note the open area Notify dietary of the open area Monitor the heel frequently, record and report The care plan continued to lack dietary interventions to promote wound healing. (Although the care plan was up dated on 8/6/2012, the heel pressure ulcer was found on 8/13/2012 and the care plan needed up dated again to reflect dietary interventions for staff to follow). On 8/13/12 at 12:18 p.m., observation revealed Staff A, (Certified Nurse Aide) and Staff B (Certified Nurse Aide), assisted the resident with personal cares. The resident voiced complaints of pain at the buttocks area. The staff observed a dime sized open area to the right buttock. Both Staff A and Staff B stated the resident did not have this area before and will report the new area to the charge nurse. The recliner did not have a pressure relieving cushion. Staff verified the resident only had the pressure relieving cushion in the wheelchair and not in the recliner. The nurse's notes did not reflect the open area to the right inner buttocks and did not identify notification to the physician and family, however, did identify the notification and size of open area on the Skin Condition Record. The Skin Condition Record indicated on 8/13/2012, the resident had a friction shear located on the right inner buttock which measured 1 cm (centimeter) by .8 cm. The resident had a friction shear on left heel pressure ulcer on 8/6/2012 and a right buttock open area on 8/13/12. The Skin Condition Record identified the physician and family had been notified on 8/13/2012. The facility Skin Assessment Prevention & Treatment Protocol (not dated) directed staff to perform the following: a. A head to toe body assessment shall be done on admission and on a regular basis. b. A head to toe assessment shall be done weekly. c. A Braden Scale will be completed within 24 hours of admission with risk factors and exiting skin condition identified. The Braden Scale will be updated quarterly or as needed. d. If a suspected pressure related condition occurs, immediate pressure risk factors shall be determined and interventions for removal of the suspected pressure source shall be made. The care plan will be updated. A Skin Condition Report sheet shall be started with all pertinent wound or condition data documented. e. Physician notification shall be made with assessment findings and interventions. A physician visit shall be made as soon as possible. A [DIAGNOSES REDACTED]. The family or responsible party will be notified. f. When a [DIAGNOSES REDACTED]. g. Dietary shall be notified of any pressure related skin diagnosis. h. Photo documentation shall be made if appropriate of any pressure related wound. i. Dietary assessment, recommendations and interventions shall be placed on the resident ' s care plan. Dietary interventions shall be included in the resident ' s clinical record by the dietary consultant. The facility had standing orders for wounds include: Triple antibiotic or [MEDICATION NAME] ointment to minor wounds, Dressing of choice, change daily as needed Air mattress or pressure relieving devices as needed Barrier cream for Stage I ulcers Wound nurse consult if indicated Wound cleanser prior to dressing change [MEDICATION NAME] barrier film for prevention of recurrent breakdown Allevyn dressing or equivalent to wound Vitamin protocol as recommended by the dietician. The Treatment Administration Record for August 2012 directed staff to spray [MEDICATION NAME] barrier film to the open area on the right buttock then cover with Mepore dressing. The standing orders directed staff to use [MEDICATION NAME] barrier film for prevention of recurrent breakdown; not an open wound. On 8/14/12 at 7:35 a.m. observation revealed the resident in bed and lying supine (on back). The bed lacked a pressure relieving mattress. The resident's feet rested directly on the mattress and not floated. On 8/14/12 at 8:12 a.m. observation revealed the recliner lacked a pressure relieving device. On 8/14/12 at 10:31 a.m., observation revealed the resident lying in bed in a supine position. The bed lacked a pressure relieving mattress. Staff positioned the resident onto the right side. Staff C (Licensed Practical Nurse) completed the wound treatment to the right buttock. An open area was noted. The area was red, had irregular borders of flaky skin, and had redness surrounding the wound. After completing the treatment, staff positioned the resident again in a supine position. On 8/14/12 at 3:15 p.m. observation revealed the resident sitting in the recliner with both feet on the floor. The left foot had a foam boot in place but the feet were not floated. The resident's recliner lacked a pressure relieving cushion. During observation on 8/15/12 at 9:31 a.m. the resident sat in the recliner. The recliner had no pressure relieving cushion. During observation on 8/15/12 at 10:12 a.m. observation revealed an air cushion in place in the recliner. The facility applied an air mattress to the bed. During an interview on 8/13/12 at 3:48 p.m. Staff E, Registered Nurse, stated the resident did not have an open area, only shearing on the buttocks. On 8/14/12 at 11:00 a.m., Staff C provided a facsimile which informed the physician of an area of shearing measuring 1 x .8 centimeters. Staff C informed the physician of the treatment of [REDACTED]. The facsimile lacked the time and date staff sent the facsimile and lacked a physician's response. During an interview on 8/14/12 at 3:22 p.m. Staff D, (Director of Nursing) stated Staff E informed her of shearing on the resident's buttocks not an open area. Staff D stated Staff E was in charge of starting the wound treatment. During an interview on 8/14/12 at 4:15 p.m. Staff E stated the friction caused the shearing on the resident's buttocks and started treatment of [REDACTED]. Staff E confirmed the resident did not have a pressure relieving device for the recliner or bed. During an interview on 8/15/12 at 9:50 a.m., Staff D stated nursing staff failed to complete an admission skin assessment when the resident returned from the hospital. Staff D thought the resident possibly had the pressure ulcer to the heel when the resident returned from the hospital. Staff D stated prior to hospitalization , staff did not utilize pressure relieving devices for the heels because the resident put feet up on the foot rest so the heels floated. During an interview on 8/15/12 at 11:00 a.m. Staff B stated the open area seen on 8/13/12 had just developed and Staff A had informed the Staff C (charge nurse) of the area.

Based on record review, observation and interviews with facility staff, residents, and physician, the facility failed to timely asses and provide interventions for mental health changes (Resident #10, #13) and failed to assess the resident ' s wheelchair for proper positioning (Resident #13). Nine residents were reviewed. The facility identified a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) assessment with a reference date of 7/3/11 documented Resident #10 had intact memory and the ability to make decisions for activities of daily living. The MDS reflected the resident had several days where the resident had little interest or pleasure in doing things, several days of sleep disturbances, several days of feeling tired or low energy, several days of feeling negative thoughts, and several days of being unable to concentrate. The MDS documented the resident as independent with ambulation, dressing, eating, toilet use, and personal hygiene. The MDS documented the resident had [DIAGNOSES REDACTED]. The care plan dated 7/5/11 identified a problem with [MEDICAL CONDITION] depression, anxiety, and withdrawal from things that brought the resident pleasure. The care plan listed the following interventions: Visit resident in room to establish a trusting relationship Allow resident to express fear and anxiety Talk to resident to provide a trusting and open relationship Actively listen Maintain calm confident environment Encourage socialization A physician progress notes [REDACTED]. The resident refused medications, oral sustenance or fluids. The resident stabilized and admitted to the long term care facility. A mental health service provided to the resident is a web based organization in Texas. Residents receive their services through a web cam. The mental health service progress note dated 4/5/11 recommended an increase participation in social activities, and an increase in physical activity. A physician order [REDACTED]. The mental health service progress note dated 5/23/11 recommended the resident increase participation in social activities and to increase physical activity. The mental health service progress note dated 6/22/11 did not have recommendations. The mental health service progress note dated 7/27/11 documented the resident had depression and anxiety and recommended milieu interventions, an increase participation in social activities, and increased physical activity. The mental health service progress note dated 8/9/11 documented the resident had depression, anxiety, and [MEDICAL CONDITION] and recommended milieu interventions, an increase participation in social activities, and increased physical activity. The mental health service progress note dated 8/30/11 documented the resident's mood as depressed and recommended milieu interventions, increased participation in social activities, increased physical activities, and individual counseling. The level II/mental illness assessment completed on 6/15/11 by the psychological nurse practitioner indicated the resident required continuous specialized services for mental illness. The daily notes dated 7/26/11 at 10:20 a.m. documented the resident had a conference with the mental health provider via the Internet. The resident reported she/he was down due to respiratory health decline, frustration with the doctor and residing in the nursing facility. The daily notes dated 8/26/11 at 10:00 a.m. documented the resident had a conference with the mental health provider via the Internet. The resident reported feeling blue. The mental health person suggested the facility provide counseling weekly. The daily note dated 9/12/11 at 11:30 a.m. documented the resident as sad, depressed, and tearful. Staff spoke with the resident until he/she felt better. During an interview on 9/12/11 at 4:08 p.m. Staff I, social worker designee, stated Staff Z, MDS coordinator, sets up the mental health sessions via a web cam. Staff I stated Staff Z communicated the mental health provider recommendations. Staff AA, Activity Director, provided the 1:1 visits. Staff I stated he did not do anything about counseling with the resident but thought Staff BB, social worker designee provided 1:1 counseling. Staff I stated he had difficulty finding a provider to complete counseling therapy in the facility. Staff I made several attempts to find a provider but did not have documentation of the attempts he made for the resident. On 9/13/11 at 9:07 a.m. Staff Z stated she sets up the sessions. If the resident had a medication change then the mental health provider would assess the resident every two weeks but if the provider makes no changes then the provider assesses the resident monthly. Staff Z stated she gives the recommendations to the physician. Staff Z informed the Activity Director to monitor the resident's socialization. Staff Z stated the resident had a walk to dine program for increased physical mobility. Staff Z stated she informed the mental health provider the facility's difficulty in finding a counselor to provide care within the facility but stated the social worker designee provided 1:1 visits The restorative care plan strengthening template dated 10/12/11 instructed staff to complete bilateral upper extremity exercises. The clinical record lacked documentation that staff assisted the resident with exercises. The therapy progresses note dated 12/29/10 documented occupational therapy discharged the resident and did not implement a restorative program because the resident completed activities of daily living independently. The plan of treatment for [REDACTED]. The clinical record failed to contain documentation of a walk to dine program. Review of the social progress notes revealed documentation of 1:1 visits on 9/27/10, 10/5/10, 10/13/10, 10/19/10, 11/10/10, 12/29/10, 3/25/11, 4/12/11, and 4/26/11. The social service designee had no further documentation of 1:1 visits since April 2011. Review of the activities progress notes revealed evaluation of the resident's activity program on 9/23/10, 12/28/10, 4/2/11, and 7/2/11. Daily activity participation records revealed in April 2011, the resident attended 55 group activities. In June 2011, the resident attended 59 group activities and four 1:1 visits. In July 2011, the resident attended 38 group activities and seven 1:1 visits. In August 2011, the resident attended 55 group activities and nine 1:1 visits. During an interview on 9/13/11 at 8:20 a.m. Staff AA, Activity Director, stated the resident had a decline in activity participation when the resident's roommate went home but had since attended multiple group activities. Staff AA stated she was not aware of the recommendations by the mental health provider to increase activity participation. During an interview on 9/13/11 at 11:02 a.m. the resident expressed many concerns. The resident had several health complaints and stated she/he gets depressed. The resident was tearful while speaking. The resident stated she/he would like to speak to someone from the facility not daily but at least weekly about her/his mood. The resident had concerns over declining health. The resident stated she/he has shortness of breath and needs to takes many breaks. The resident stated she/he had not participated in an exercise program but stated she/he would agree to participate in an exercise program. The resident expressed relief after speaking about concerns and willing to talk to the facility about her/his concerns. During an interview on 9/15/11 at 4:07 p.m. the resident's primary care physician, stated he did not have knowledge of the mental health provider recommendations. The physician stated he expected the facility to communicate the recommendations of the mental health provider, Brighter Day so he could evaluate them as the resident's primary physician and write orders if needed. The physician had no knowledge of the recommendation to provide individual counseling. The physician would of wrote an order and help facilitate a counselor. The physician stated the resident cries and gets upset about living at the facility whenever he examined the resident. During an interview on 9/20/11 at 7:45 a.m., Staff DD, Nurse Practitioner for the mental health provider, stated she examined the resident on 8/30/11. The resident expressed depression over losses and she recommended individual counseling for the resident. Staff DD expected the facility to inform the resident's physician of her recommendations. Staff DD asked the resident and facility staff if the facility followed through with the recommendations but did not receive any documentation from the facility on recommendations. Staff DD stated the social worker designee could provide the counseling if the facility could not find a provider to come to the facility. Staff DD stated the recommendations needed to be communicated to the physician. Staff DD stated she only recommended individual counseling only in severe cases. The facility failed to communicate the recommendations made by the mental health provider, Brighter Day, regarding the need to have counseling. The clinical record lacked documentation the resident's physician had knowledge of the recommendations since April 2011. The Activity Director had no knowledge of the recommendation to increase activity participation although the activity calendar did reflect the resident attended multiple activities. The Social Worker lacked knowledge of the recommendation for the resident to have counseling. Staff did not implement an exercise program based on the recommendation to increase physical activity. The care plan lacked documentation of the recommendations. Choking episode: The daily note dated 8/13/11 at 7:30 a.m. indicated the resident coughing at breakfast. The resident choked on ground sausage and reported the night before had choked on corn. The daily note dated 8/19/11 at 8:00 a.m. documented the physician ordered a dysphagia diet level 1 or pureed diet. The daily note dated 9/9/11 at 4:00 p.m. documented a new order for mechanical soft diet. The daily note dated 9/10/11 at 8:00 a.m. documented the resident had no difficulty eating breakfast. The daily notes had no further documentation on the resident's tolerance of the advanced diet. The nutritional assessment dated [DATE] and 7/6/11 documented the resident received a regular low concentrated sweets diet. The nutritional progress notes documented the Dietitian assessed the resident on 7/20/11 and had no further documentation of the doctor order to provide a pureed diet and advancing the diet on 9/9/11 to mechanical soft diet. During an interview on 9/15/11 at 4:07 p.m. the resident's primary physician stated he expected speech therapy to evaluate the resident to upgrade the resident's diet from pureed to mechanically soft diet. During an interview on 9/20/11 at 8:31 a.m. Staff O, the facility Dietitian, stated the facility needed to obtain a speech evaluation to advance the resident's diet from pureed to mechanical soft diet. The dietitian stated after the facility advanced the resident's diet, the facility needed to document the resident's tolerance of the advanced diet. 2. According to the MDS (Minimum Data Set) assessment with a reference date of 8/4/11, identified Resident #13 had [DIAGNOSES REDACTED]. The MDS identified a Brief Interview for Mental Status (BIMS) summary score of 13 (The BIMS score of 13 to 15 identified the resident demonstrated intact cognition). The MDS documented the resident required limited assistance of one staff for transfer, dressing and personal hygiene and extensive assistance of 1 staff for toileting. The MDS documented the resident ' s demonstrated behaviors which fluctuated (comes and goes, changes in severity) of inattention (easily distracted), disorganized thinking (switches from subject to subject) and altered level of consciousness (lethargic-dozed off when asked questions). The MDS mood interview documented the resident identified symptoms of feeling hopeless, tired, little energy, restless, poor concentration, bad feelings about yourself, and trouble falling or staying asleep or sleeping too much 7-14 days in a two week time frame. The care plan dated 8/2/11 directed staff to monitor signs and symptoms of behaviors, to approach the resident calmly and to provide the resident a diversional activity. The care plan also directed staff to allow the resident to vent and to make decisions. The care plan dated 8/2/11 identified the start of a behavior enhancement program on 4/12/11. The care plan instructed staff to get the resident up at 6 a.m. The record failed to provide further instructions to staff of the interventions for the behavior enhancement program. The record review revealed on 3/15/11 and on 3/18/11 the social service personnel discussed with the resident concern of sleeping in the front foyer in the wheelchair. The record identified the resident expressed feeling tired all the time. The record documented Staff I notified the Administrator and Staff U. The record revealed the Administrator recommended and provided a recliner for the resident. The record dated 3/31/11 revealed the resident signed a contract for the recliner. The record dated 5/2/11 identified the resident continued to sleep in the wheelchair in the halls. The Social Service note dated 8/4/11 identified an interdisciplinary meeting held and referenced to see checklist for details. The record lacked the checklist. The Behavior Enhancement Program failed to contain documentation of review and approval from the physician and the medical director for the facility to initiate the program. An interview conducted with the Administrator on 9/12/11 at 4:30 p.m. revealed the facility purchased the pop as the "reward" for the resident. The Administrator stated the resident swore, yelled and awakened other residents at night, although she made no reference to her presence at night to witness the behavior. The Administrator referenced those behaviors as the reason why the resident could not be up at night and described the Behavior Enhancement Program a positive plan for the resident. The Administrator denied the plan was punitive. The Behavior Enhancement Program dated 4/12/11 revealed signatures of Resident#13, Director of Nursing, social services person, Dietary Supervisor and Administrator. The program described the resident exhibited belligerence, yelling and swearing at staff and waking other residents. The program documented the resident's refusals to return to bed, roaming the halls, making noise and demands for food and coffee. The record also documented the resident falls asleep during the day in the wheelchair, blocks hallways and doors and slides down in the wheelchair increasing the risk of falls. The program reiterated the resident unable to sleep in the bed provided and indicated the facility provided a recliner for the resident to be in their room from 10 p.m. to 6 a.m. The program documented the reward as a can of pop twice a day if the resident was compliant with the program and demonstrated no behaviors in a 24 hour time frame. The record documented if the resident failed to comply, the resident would not be punished but would not receive any rewards for the day. The documentation referred to the tracking sheets for behaviors. The behavior enhancement tracking sheet for the month of June 2011 revealed the resident swore and/or yelled at staff four times. The behavior enhancement tracking sheet for the month of July 2011 revealed a total of 9 behavioral episodes. The behavior enhancement tracking sheet for the month of August 2011 failed to contain documentation for August 1-August 11, 2011. The record revealed 7 behavioral incidents and 2 incidences of the resident eating food in the recliner or in bed. The Administrator expressed the nursing staff had the directions for the program at the nursing station. Staff Y when asked for the program directions related the sheet had been missing the last few days. Record review of the nursing notes dated 4/13/11-4/20/11 documented the resident slept and demonstrated no behaviors. On 4/20/11 the record entry not timed identified the resident swore at staff when told of sleeping in the hallway and refused food at 11:00 p.m. The record review dated 4/21/11 at 4:00 p.m., 5/24/11 at 4:45 p.m. 7/5/11 at 9:00 p.m. identified swearing, irritability and denial of sleeping in the wheelchair while in the hallway. The record lacked further documentation of behaviors. Observations completed 9/6/11-9/8/11 and 9/12/11 through 9/13/11 revealed the resident self propelled a wheelchair throughout the facility. Observations noted the resident dozed in the wheelchair after the lunch hour. The observations revealed the resident demonstrated no behaviors. The facility Resident's Bill of Rights provided to the resident on admission identified the facility maintains policies, procedures and programs to ensure that the rights of each resident. The information highlighted dignity and respect. On 9/13/11 at 8:35 a.m. the resident was interviewed and revealed the Administrator had been stopped the Behavior Enhancement Program this a.m. The resident expressed it had been related to the state survey process not liking the program. The resident defined to be good meant no bad behaviors. The resident identified bad behaviors as swearing, yelling and waking up others at night. The resident expressed when good he/she received pop. The resident voiced that he/she received 2 pieces of toast at night if good. The resident revealed no contact person or awareness of who decided if he/she had good or bad behaviors. The resident identified feelings of being tired, lonely, and missing family members. The resident revealed feeling of being treated like a child with the behavior program. Wheelchair: Record review of the Plan of treatment for [REDACTED]. The nursing daily notes documented on 8/12/11 at 9:45 p.m. indicated the staff found the resident sitting on the floor. The record documented the resident stated had leaned forward to remove socks and shoes and the wheelchair flipped forward and dumped the resident to the floor. Clinical record review identified the staff notified the physician on 8/12/11 that the resident had fallen out of the wheelchair at 9:45 p.m. Record review revealed on 8/14/11 the physician returned an order to complete a physical therapy evaluation. The quarterly Multidisciplinary Screening Form dated 8/31/11 identified the resident last fell [DATE]. The record noted the resident continued to require assistance for mobility and activities of daily living. The document identified no interventions required at this time. The record revealed no physical therapy assessment as ordered for the 8/12/11 resident fall. The record review did not provide documentation pertinent to the resident posture and appropriateness of the current used wheelchair. Periodic observations on 9/6/11 at 11:00 a.m. continued through 9/13/11at 10:00 a.m. which revealed the resident self propelled his/her own wheelchair by use of the feet. Observations revealed the resident positioned self in the wheelchair in a "reclined-position". The resident ' s head was not supported and rested above the top edge of back of the wheelchair seat. The shoulders leaned back on to the top edge of the wheelchair back and the chest, abdomen, buttocks and thighs edged out of the seat in a 45 degree angle. An interview conducted 9/13/11 at 8:30 a.m. with the resident confirmed the posture concern. The resident voiced ability to sit further back into the chair but expressed the feeling of being uncomfortable in the upright position.

Based on observation, record review and interviews, the facility failed to provide wound care interventions to promote healing and prevent additional pressure ulcers for 1 of 12 residents reviewed (Resident #2). The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) assessment, dated 07/02/10, Resident #2 required extensive assistance with bed mobility, transfers, and personal hygiene, and depended on staff for toilet use. The MDS documented Resident #2's [DIAGNOSES REDACTED]. The Resident Assessment Protocol (RAP) for pressure ulcers dated 07/11/10 documented Resident #2 had areas on his/her heels. Pressure reducing devices were in place, treated and medicated per orders. Resident #2 scored 14 on the Braden scale. According to the Prevention Protocol - Skin Protocol #2, a Braden score of 14 indicated moderate risk of developing pressure sores. A resident at moderate risk of developing pressure sores indicated the need for the following interventions: a. Turn/reposition every 2 hours and prevent direct contact between bony prominences. b. Protect heels. c. If in a wheelchair, provide standard pressure reducing seat cushion. d. Manage moisture from incontinence. e. Manage nutrition. f. Monthly nutritional assessment. g. Reduce friction/shear. h. Provide wedges/repositioning aids for 30 degree lateral positioning. i. Supplement turning schedule with small position shifts (hourly). To manage moisture initiate a bowel/bladder program or scheduled toileting, incontinence care every 2 hours, incontinence barriers, briefs, absorbent under-pads, fecal bag (if frequent stools). The facility Skin Care Program dated 06/21/10 directed: a. Any individual in bed assessed at risk for developing pressure ulcers should be repositioned at least every 2 hours if consistent with overall resident goals. A written schedule for systematically turning and repositioning should be used. b. Any individual assessed at risk for developing pressure ulcers should be placed when lying in bed on a pressure reducing device, such as foam, static air, alternating air, gel or water mattress. c. Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in any chair or wheelchair. The RAP for Activities of daily living (ADL's) dated 07/11/10 documented Resident #2 required extensive assistance to dependence on staff for most ADL's, see the Kardex. The CNA Kardex dated August 2010 directed staff to turn Resident #2 frequently. The Kardex documented use of an air mattress for pressure relief. Resident #2's toileting schedule directed to check and change upon rising, between meals, bedtime, as needed; and toilet upon request. The Kardex directed to notify the charge nurse of skin issues and lay Resident #2 down 1-2 hours in the a.m. and the p.m. Resident #2's Care Plan with a team conference date of 04/28/10 directed the approaches: a. Notify the charge nurse of any skin issues. b. Examine skin at every cares. c. Maintain strict skin hygiene. d. Provide complete pericare after any incontinence. e. Turn and reposition frequently as needed. f. Utilize pressure reducing devices. g. Treatments as ordered. h. Check and change upon rising, between meals, bedtime and as needed. i. Transfers with assist of 2 using ARGO or Sara lift with 1 or 2 depending on strength/condition dated 08/13/10. j. Assess at each cares for skin rash/open areas; notify the physician if observed. A facsimile (fax) dated 07/12/10 notified the physician an area re-opened on Resident #2's coccyx. The area measured 1.5 by 1.2 centimeters. Would you like us to continue normal saline cleansing and Baza application 3 times a day? The physician replied they could continue with the above treatment, place in bed 1-2 hours 2 times a day, and update the physician in one week. A Weekly Pressure Ulcer Record dated 07/12/10 identified Resident with a Stage 2 pressure ulcer to his/her coccyx (tailbone) area. a. On 07/12/10 the area measured 1.5 by 1.2 centimeters (cm) with a beefy red wound bed, and pink surrounding skin and wound edges. b. On 07/19/10 the area measured 1.5 by 1.2 cm with a beefy red wound bed, and pink surrounding skin and wound edges. c. On 07/26/10 the area measured 1.5 by 1.3 cm with a beefy red wound bed, and pink surrounding skin and wound edges. d. On 08/02/10 the area measured 1.5 by 1.3 cm with a beefy red wound bed, and pink surrounding skin and wound edges. e. On 08/09/10 the area measured 1.4 by 1.2 cm with a beefy red wound bed, and pink surrounding skin and wound edges. f. On 08/16/10 the area measured 1.3 by 1.2 cm with a beefy red wound bed, and pink surrounding skin and wound edges. A fax dated 07/29/10 from the physician directed to elevate Resident #2's lower extremities as much as possible, and lay down 1-2 hours in the a.m. and p.m. to offload weight to the sacrum and elevate the lower extremities. During an observation on 08/18/10 at 8:14 a.m. Staff S and Staff U provided morning cares. Staff S washed resident #2 in the front/genital area. Staff S and Staff U rolled Resident #2 to his/her left side. Resident #2 had a bowel movement. Staff S cleansed the buttocks. An open sore was noted on Resident #2's upper buttock near the coccyx, and the right lower buttock. Staff S and Staff U rolled Resident #2 to the right side, and noted both upper buttocks with open areas. Staff S cleansed Resident #2's buttocks again. Staff S applied skin protectant to Resident #2's entire buttock area. At 8:35 a.m. Staff S and Staff U transferred Resident #2 to his/her wheelchair. The Assistant Director of Nursing (ADON) observed throughout the cares and transfer. During an observation on 08/18/10 at 8:35 a.m. Staff S and Staff U transferred Resident #2 to his/her wheelchair. During an interview on 08/18/10 at 11:06 a.m. Staff V stated she and Staff S changed halls and she was now down Resident #2's hall. Staff V stated the only thing she had done with Resident #2 was his/her face. Staff V stated she had done nothing else with Resident #2 and didn't think Staff S had done anything either. During an interview on 08/18/10 at 11:09 a.m. Staff S stated she had not done anything with Resident #2 since a.m. cares. Resident #2 remained up in the wheelchair. During an observation on 08/18/10 at 11:32 a.m. Resident #2 sat in the wheelchair in the hall. Resident #2's legs were not elevated. At 12:20 p.m. Resident #2 sat in the dining room at the table. At 1:04 p.m. staff wheeled Resident #2 from the dining room to the nurses station. Resident #2's legs were not elevated. During an observation on 08/18/10 at 1:51 p.m. Staff V and Staff Q Transferred Resident #2 to his/her bed, (5 hours and 26 minutes after he/she got up in the chair). Staff V washed Resident #2's front/genital area. Staff V and Staff Q rolled Resident #2 to his/her left side. Resident #2 had a large amount of loose black stool on his/her buttocks and lower back, covering the open areas. Staff V washed Resident #2. Staff V stated she noticed a new area on Resident #2's right buttock. Staff V also confirmed an area on each side of Resident #2's coccyx area. Resident #2's left lower buttock was reddened. Staff V went to tell the charge nurse about the new open area. At 2:05 p.m. Staff V returned followed by Staff I. After Staff V and Staff Q finished cleaning the buttock area, Staff I applied Baza to the open areas on Resident#2 ' s buttock. Staff I did not cleanse with normal saline. Resident #2 stated "It still hurts". Staff Q told Resident #2 they put ointment on it. At 2:12 p.m. Staff V and Staff Q transferred Resident #2 back to his/her wheelchair. The ADON observed throughout the care. During an interview on 08/18/10 at 3:14 p.m. Staff S stated they were supposed to lay Resident #2 down 2 times a day, but it didn't always get done. Staff S stated it did not get done today. During an observation on 08/18/10 at 3:30 p.m. Resident #2 remained up in the wheelchair. Resident #2's feet were not elevated. At 3:50 p.m. Staff N wheeled Resident #2 to the living room by the front nurse's station. At 4:20 p.m. Resident #2 wheeled self in the hall, and a CNA pushed Resident #2 into his/her room. At 4:30 p.m. Resident #2 remained in the wheelchair in his/her room. At 4:40 p.m. Resident #2 stated he/she had been in the wheelchair all afternoon. Resident #2 stated he asked to lay down and was told he couldn't because his/her heel wasn't healed. Resident #2 nodded yes when asked if he/she would like to lay down. At 5:00 p.m. Resident #2 sat in the dining room (still up in wheel chair, 2 hours and 48 minutes). During an observation on 08/19/10 at 8:33 a.m. Resident #2 sat in his/her wheelchair in the dining room. At 9:42 a.m. Resident #2 sat in the wheelchair in his/her room. Resident #2's legs were not elevated. At 9:50 a.m. staff took Resident #2 to therapy. At 10:35 a.m. Resident #2 remained in the wheelchair in the therapy room. At 11:24 a.m. Resident #2 sat in the wheelchair by the nurses station. Resident #2's legs were not elevated. At 11:59 a.m. Resident #2 sat at the dining room table. At 1:29 p.m. Resident #2 laid in bed (over 4 hours since first observed in the wheelchair). Resident #2 had loose stool. Staff MM stated she had cleaned him/her up and he/she went again. After Staff MM cleansed the resident again, Staff I measured the wounds on Resident #2's buttock area (per request of the surveyor): a. The Right buttock wound measured 2.5 cm, with a red/pink wound base. Staff I stated she thought it was bigger than yesterday. b. The left buttock noted with persistent redness, and did not blanch. c. Left of the coccyx extending into the crease measured 1.5 by 3 cm, with brown tissue in the wound base. d. Right of the coccyx measured 4 by 1 cm, and had a dark wound base. e. A smaller area below the left coccyx wound measured 1 cm with a pink/red base. Resident #2 stated his/her bottom hurt. Staff I applied Baza to all areas of skin breakdown without cleansing with normal saline. The Treatment Administration Record dated 08/01/10 to 08/31/10 included the treatment to apply Baza 3 times a day and as needed, and continue to cleanse with normal saline, (apply topically to groin area). The TAR lacked the treatment to Resident #2's coccyx wound. The TAR included the entry to place Resident #2 in bed 1-2 hours 2 times a day, 6-2 and 2-10 dated 07/12/10. The TAR also included an entry to reposition Resident #2 frequently dated 08/04/10, FYI (for your information). The hours were labeled 6-2 and 2-10, and 08/18/10 contained initials, indicating it was done. At the time of concerns and findings on 08/19/10 at 4:30 p.m. the clinical record lacked any documentation of the multiple skin impairments on Resident #2's coccyx/buttocks (except the pressure ulcer identified on 07/12/10). During concerns and findings the DON stated Resident #2 went to the wound clinic and they would look at all his/her skin impairments, not just the left heel ulcer. The ADON stated Resident #2 had a special mattress on his/her bed. On 08/19/10 at 5:56 p.m. the Nurse Consultant and the DON went to Resident #2's room with the surveyor to check the mattress. Resident #2 did not have an air mattress. Resident #2 had a 2-tone mattress on his/her bed. The DON stated it was a pressure reduction mattress. The surveyor requested information on the mattress. At 5:59 p.m. staff brought Resident #2 back from supper. Resident #2 stated his/her butt hurt. Staff stated hopefully they will lay you down soon. At 6:59 p.m. Resident #2 laid in bed on his/her left side. A facsimile to the physician dated 08/19/10 at 8:20 p.m. requested an order for [REDACTED]. The fax requested to decrease the stool softener to bedtime only or change to give as needed. The facility faxed current skin issues and requested treatment orders for the 4 areas. During an interview on 08/20/10 at 7:25 a.m. the Director of Nursing stated she measured the wounds herself the previous evening and faxed the physician and notified the family of the areas. Prior to the exit conference on 08/20/10, the Nurse consultant stated they would fax information to the office regarding Resident #2's mattress. The TAR described a Stage 2 wound as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (necrotic tissue). It may also present as an intact or open/ruptured serum-filled blister. A Stage 3 wound described as full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss An unstageable wound is full thickness tissue loss in which the base of the ulcer is covered by slough (yellow tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

? Based on record review, observation, staff interviews and review of facility policy/procedures, the facility failed to provide wound care by means of prevention, timely identification, assessment and measures to promote healing for 2 of 4 residents reviewed with pressure ulcers. The facility identified a census of 60 residents. Findings: 1. Resident #6 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 12/24/2009 and an annual MDS with a reference date of 3/20/2010 which both reflected the resident required extensive assistance for bed mobility and transfers and did not ambulate. The annual assessment indicated the staff used a mechanical lift to transfer Resident #6 to a wheelchair. The assessments reflected the resident did not have pressure ulcers and the chair and bed had pressure relieving devices present. The assessments indicated the staff did not utilize a turning and repositioning program. The MDS reflected the resident had [DIAGNOSES REDACTED]. The RAP (Resident Assessment Protocol) dated 3/31/2010 reflected a pressure risk assessment score of 10 (8 or above represents high risk). Left outer ankle: The weekly pressure ulcer record reflected on 4/21/2010 the facility identified a pressure ulcer on the left outer ankle. The area measured 1.5 cm by 1.5 cm. A stage 2 ulcer represented a partial thickness skin loss which would involve epidermis, dermis or both and can be an abrasion, blister or shallow crater. The wound had yellow drainage present with a yellow wound bed and red skin surrounding the wound. On 4/21/2010 at 2:00 p.m. a fax was sent to the physician about the left outer ankle and the facility began the house protocol for pressure ulcer treatment. The area measured 1.5 cm by 1.5 cm. The physician ordered [MEDICATION NAME] (antibiotic) 875 milligrams twice a day for 10 days and [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 100 milligrams three times a day. The facility intervention was to keep booties in place and keep the pressure off of the ankle. The weekly pressure ulcer record reflected on 4/26/2010 the wound measured 1.4 cm by 1.4 cm with the wound bed as yellow and redness surrounding the wound. The intervention indicated staff began turning the resident every 2 hours. On 5/3/2010 the wound continued as a stage 2 but enlarged in size to 2 cm by 2 cm with a yellow wound bed and redness surrounding the wound. The facility did not implement new interventions. The nurse ' s notes indicated on 5/6/2010 the left outer ankle continued to worsen each day. The Hospice nurse ordered a new extra pressure relief mattress and the physician was notified for a new wound care order. On 5/8/2010 (5 days later) the physician ordered a wound care specialist or wound nurse assess the left outer ankle for treatment as the wound continued to become larger. On 5/10/2010 the wound depth increased to less than or equal to 0.5 centimeter and the size of the wound increased with a measurement of 4 cm by 3.5 cm with a large amount of serosanquinous drainage present, beefy red and yellow wound bed and redness sounding the wound. The facility identified the wound as stage 3. Stage 3 pressure ulcers are described as full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. The facility only provided high protein supplements to the resident as an additional intervention. A Hospice Clinical Note sheet dated 5/10/2010 at 3:30 p.m. indicated Hospice had received a telephone call from the facility with a request for the wound care specialist consult for the left ankle wound (a week later after the wound was noted to enlarge on 5/3/2010). A Griffin Nursing and Rehab Center sheet indicated the facility did not notify the physician of the left ankle wound ' s increase in size and the yellow serosanguinous drainage until 5/11/2010 (8 days later). The facility then requested an order from the physician for the resident to receive Z-Gen (vitamin) and Glucerna (dietary supplement). On 5/12/2010 the physician responded to the request and ordered Z-Gen, Glucerna and to obtain a wound culture if the wound appeared to be infected. The physician ordered [MEDICATION NAME] cream to be applied each day if the wound seemed infected. The facility began the Z-bec vitamin on 5/13/2010 and Glucerna 2 ounces 3 times a day on 5/12/2010. A Hospice Comprehensive Assignment Update sheet dated 5/11/2010 indicated the Wound Center had been notified and the resident needed to be transported to the Wound Center for evaluation. The Hospice nurse notified the Director of Nursing and a nurse at the facility. During a telephone interview with the Hospice nurse on 6/15/2010 at 2:02 p.m., the Hospice nurse stated transportation had not been available to take the resident to the Wound Clinic and the resident required an ambulance for transportation. The nurse stated she/he requested and received a physician order [REDACTED]. The nurse ' s notes reflected the staff obtained a culture of the wound on 5/12/2010 and sent the specimen to the laboratory On 5/17/2010 the wound measured 3 cm by 3 cm, stage 3 and less than or equal to 0.5 cm depth (stage 3) with a large amount of serosanguinous drainage, odor present and the wound bed as beefy red with redness surrounding the wound. Staff T was interviewed on 6/9/2010 at 1:50 p.m. and stated [MEDICATION NAME] (antibiotic) [MEDICATION NAME](Antibiotic) had been initiated on 5/18/2010 after the ankle wound culture revealed the resident had a staphylococcus and pseudomonas infection in the left ankle. Review of the laboratory culture report from the left outer ankle identified Staphylococcus Aureus and Pseudomonas Aeruginosa organisms. The nurse ' s notes of 5/19/2010 at 10:00 a.m. indicated the resident had a temperature of 99.2 and the size of the wound as 3.8 by 3.2 cm and depth to the ankle bone (stage 4). The wound had copious amounts of sero-sang drainage. On 5/20/2010 the physician ordered [MEDICATION NAME] (antibiotic) to be applied to the ankle and then cover with Kirlin twice a day. (this had been ordered on [DATE]). On 5/21/2010 at 3:00 p.m. the resident was transferred to the hospital. Review of the monthly Plan of Care Kardex document (for nursing staff) dated January 2010 to April 2010 did not direct staff how to care for the resident to prevent further decline or promote healing of the ankle. It was not until the pressure ulcer was identified that the Kardex directed staff how to care for the resident with pressure ulcers. The Kardex did not have interventions present to direct staff how to prevent pressure ulcers. The Care Plan dated 3/25/2010 identified a problem with pressure ulcers, however, did not provide approaches to promote healing. The only approach for pressure sore prevention was an approach to utilize pressure reducing devices as needed. Rt. Thumb The skin condition record indicated on 4/10/2010 the staff first identified the resident ' s right thumb as purple and black from the tip to the knuckle bone due to circulation and the resident holding the thumb against the chest area. The nurse ' s notes indicated on 4/11/2010 at 10:30 a.m., the staff sent a fax to the physician because the right thumb had discoloration, swelling and the nail was loose with white substance/color under the nail. On 4/12/2010 the right thumb remained unchanged. On 4/14/2010 at 9:30 a.m. (4 days later) the physician examined the nail. The physician instructed the staff to keep the right arm straight and extended. The note indicated the physician felt the pressure from the brachial artery caused the bluish color of the nail. The skin condition record revealed on 4/19/2010 the thumb wound measured 2 cm by 2 cm with purple skin color surround the wound. On 4/26/2010 the thumb wound continued to measure 2.2 cm by 2.2 cm with purulent drainage and blood present. The wound bed had a purple and black appearance with surround skin purple in color and the wound edges red. The note indicated the thumb had deteriorated. On 4/20/2010 at 10:00 a.m. the nurse ' s note reflected the thumb nail loose and ready to fall off. The staff faxed the physician on 4/21/2010. The physician ordered [MEDICATION NAME] 875 milligrams twice a day for 10 days and [MEDICATION NAME] 400 milligrams three times a day for 10 days. The nurse ' s notes dated 4/25/2010 at 9:00 a.m. indicated the resident ' s arms, hand and thumb were pressed against the chest lightly. The note at 6:00 p.m. indicated staff propped the right hand up to decrease the pressure of the thumb pushing into the chest. On 4/26/2010 at 10:00 a.m. the right thumb nail fell off and the hand was padded from the chest area as the resident involuntarily rubbed the thumb into the chest area. The skin condition sheet dated 4/26/2010 continued to reflect a size of 2.2 cm by 2.2 cm and purulent drainage/blood present with a deterioration present. The skin condition record indicated on 5/3/2010 the size remained at 2.2 by 2.2 cm and continued to have purulent drainage/blood present. The facility did not provide treatment changes. On 5/10/2010 the size remained at 2.2 cm by 2.2 cm and drainage remained. The thumb nail came off and the record identified the thumb continued to deteriorate. The facility did not provide changes or additional interventions. The nurse ' s notes dated 5/13/2010 at 10:30 a.m. indicated the resident ' s son approached the nurse and said " What is going on with my Mom ' s thumb? It doesn ' t even look (expletive deleted), human " . The nurse directed the son to speak with the Hospice nurse. On 5/17/2010, the skin condition record identified the thumb had improved, however, the size remained unchanged and the resident continued to have a moderate amount of purulent drainage present. hospitalization : The hospital History and Physical document dated 5/21/2010 indicated the resident had presented to the emergency room for an evaluation of a non-healing and worsening left ankle pressure ulcer and left thumb ulcer. The document indicated the resident had an advanced movement disorder, did not communicate at the time, and had constant movement of the tongue and right hand third finger. The document identified both hips were abducted; both knees flexed inward and the resident ' s ankles everted. A surgical consultation dated 5/24/2010 identified contractures at the elbows, wrists, fingers, hips, knees, ankles, toes and the resident sat in a criss-cross legs pattern. The wound required 2 to 3 people to rotate the legs and dress and examine the wounds. The consultation indicated a [MEDICAL CONDITION] due to the severity of the infection may needed to be performed. The hospital progress note of 5/27/2010 indicated the family had been presented with options for wound debridement or [MEDICAL CONDITION]. The family made the decision to amputate the leg below the knee. The Hospital Progress Note of 6/4/2010 indicated the resident went to surgery for [REDACTED]. The operative report dated 6/7/2010 documented the resident had a left [MEDICAL CONDITION] due to a Stage IV left lateral malleolar ulcer with osteo[DIAGNOSES REDACTED] (bone infection) and unresponsive to medical therapy. The 5/2010 Plan of Care Kardex instructed staff to place wash clothes in each hand at all times, reposition frequently and to float the resident ' s heels at all times. The Kardex did not have measures to prevent pressure to the chest from the resident ' s thumb and for positioning of the left outer ankle. The Kardex directed staff to reposition frequently but did not indicate a specific amount of time needed (every 1-2 hours, etc). Review of the monthly record of weights identified the resident had a significant weight loss of 8.67 % from February 1 to March 1, 2010. The February 2010 weight was documented as 237.4 pounds and March weight as 216.8 pounds. The resident continued to lose weight in April and May. The April weight of 209.4 reflected a 10.7% significant weight loss in 3 months and a May weight of 205. The May weight reflected a further significant weight loss of 13.6% in 3 months. Review of the nutritional progress note dated 3/2/2010 indicated the Dietician identified the weight loss related to the recent hospitalization (February). The Dietician recommended continued general diet due to Hospice resident. The progress note did not reflect the resident ' s blood sugar test results or additional laboratory test results. The right thumb had a wound present on 4/11/2010 and the dietician did not recommend nutritional products to enhance healing. It was not until after the facility identified a wound located on the left ankle on 4/21/2010 did not facility request vitamins and a protein drink (Glucerna) on 5/11/2010 (20 days later). Interviews: On 6/15/2010 at 2:45 p.m., the Hospice nurse stated the " 250 " mattress had been used for skin breakdown prevention. The Hospice nurse continued to state the resident ' s mattress had been changed to an alternating pressure pad mattress on 5/6/2010 and the new mattress was meant to be used for a resident that required constant pressure relief and did not get out of bed. On 6/10/2010 at 10:00 a.m., Staff C (Certified Nursing Assistant) was interviewed. When the surveyor asked what types of interventions the facility implemented when a resident had a pressure ulcer risk assessment of 8 or above (indicating high risk), Staff F5 stated the facility added weekly skin assessments, a vitamin (Z-bec) and a nutritional supplement after the resident had skin breakdown. Staff F5 and Staff C3 stated the facility lacked a policy related to pressure ulcer risk. Staff C3 stated when a resident required additional interventions; the interventions were added to the 24 hour sheet and the nurse on duty would be responsible to ensure the interventions were carried out. Staff C3 stated permanent interventions are added to the Kardex the nursing aides used. Review of the 24 hour sheets revealed from February to May, 2010 the facility had failed to document any interventions related to pressure reduction measures for the resident. On 6/18/2010 at 9:10 a.m., the Director of Nursing stated A2 (Licensed Practical Nurse) would document on the skin sheets but not always the same day a wound had been observed. The Director of Nursing stated staff had been instructed to start a wound sheet as soon as a wound had been observed and not wait for Staff A2 to initiate the skin assessment sheet. On 6/9/2010 at 8:37 a.m. the resident ' s physician stated he/she had observed the resident ' s right thumb wound prior to the hospitalization of 5/21/2010. The physician stated Hospice had reported the thumb had drained pus, a culture had been obtained and the resident had been prescribed 2 antibiotics. The physician continued to state he/she had not observed the left ankle wound prior to hospitalization and had not been aware of the necrosis in the wound. The physician stated diabetes and constant pressure may have prevented blood from flowing to the ankle and stated pressure relief measures such as elevation, pressure relief boots or off loading of any sort may have prevented worsening and necrosis of the ankle ulcer. The physician stated the resident had been eating and drinking so additional supplements may have prevented the resident ' s low [MEDICATION NAME] level. On 6/18/2010 at 9:20 a.m. Staff A2 was interviewed and stated she began employment at the facility 2/2010 and had received skin care training from the nurse prior but had not received any formal skin assessment training. 2. A hospital History and Physical dated 5/10/10, documented Resident #2 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], documented the resident had short and long term memory impairment, modified independence with cognitive skills for daily decision making, required extensive assistance with bed mobility, transfers, dressing, personal hygiene and bathing. The MDS assessment documented the resident had frequent bowel incontinence and multiple daily episodes of bladder incontinence. The MDS documented the resident had two Stage II pressure ulcers. During an observation of morning cares on 6/4/10 at 8:10 a.m., Staff A3 (Certified Nurse Aide, CNA) and Staff W (CNA) removed the resident's blue foam padded boots from the resident's feet and lower legs. Observation revealed the resident had an approximate 1.5 centimeter (cm) by 1.5 cm black discoloration on the right heel without dressing or covering. Observation revealed the resident's left heel was covered with a gauze wrap. Staff C3 stated they were unaware if the right heel required a dressing without checking the resident's chart. Staff A3 and Staff W reapplied the bilateral blue foam padded boots to the resident's feet and lower legs following morning cares. Observation during wound care on 6/10/10 at 10:30 a.m., the resident's right heel remained open to air and had a purple dry discolored area. Staff B (Licensed Practical Nurse, LPN) provided wound care to the left heel, applied [MEDICATION NAME] cream to the resident's bilateral feet and lower legs and applied the Prevalon heel boots to the resident's bilateral feet. Review of the resident's Weekly Pressure Ulcer Record sheets revealed the resident was admitted [DATE] with a right inner heel pressure ulcer. The sheets documented the pressure ulcer as healed on 5/17/10. Review of the resident's current skin sheets revealed the resident's left heel pressure ulcer with a date of onset of 4/24/10 and the last assessment as documented 6/7/10. Review of the sacral Weekly Pressure Ulcer Record documented the sacral ulcer with an onset date of 4/19/10 and was last assessed on 6/7/10 and had healed. During an interview 6/17/10 at 1:27 p.m., Staff A2 (LPN) stated the resident had been admitted with heel wounds, checked the right heel wound Weekly Pressure Ulcer Record and stated the right heel wound had been healed 5/17/10. When the surveyor informed Staff A2 they had given the surveyor the resident's current skin sheets and the record lacked a skin sheet for the right heel skin impairment, the surveyor had observed on two occasions, Staff A2 stated they were not sure about that. On 6/17/10 at 1:40 p.m., Staff A2 revealed a Skin Condition Record For Non-Pressure Ulcer Skin Conditions with a date first observed as 6/14/10. The sheet documented the resident had a discolored 1 cm by 1 cm purple abnormal shaped discoloration on the left heel without drainage, wound bed purple, surrounding skin pink and surrounding tissue/wound edges purple. When the surveyor stated the skin sheet documented skin impairment on the resident's left heel, Staff A2 visualized the sheet and stated she/he meant to write right heel on the skin sheet. Record review revealed the Daily Notes from 6/1/2010 to 6/17/2010 at 11:00 a.m., lacked assessments, family, or physician notifications of a right heel skin impairment. During an interview on 6/18/10, at 9:10 a.m., Staff C3 (Director of Nursing) stated Staff A2 documented skin sheets but not always the same date a wound had been observed. Staff C3 stated staff had been instructed to start a wound sheet as soon as a wound had been observed. Staff A2 reviewed the 24 hour sheets staff used to document resident concerns and stated the 24 hours sheets lacked documentation of right heel skin impairments for Resident #2.