Every finding on record at Alexandria Rehabilitation and Healthcare Center

Based on observation, staff interview, and facility document review it was determined facility staff failed to air dry steam table pans completely prior to storing them and store a measuring scoop in accordance with professional standards for food service safety in one of one kitchen. The findings include: On 4/1/2024 at 11:57 a.m., an observation was conducted of the facility kitchen with OSM (other staff member) #6, regional dietary manager. Observation of the kitchen area revealed a plastic bin that OSM #6 identified as thickener. A plastic measuring scoop was observed inside of the plastic bin resting on the thickener. OSM #6 stated that the scoop was not normally stored in the thickener and the staff had just finished using it for the lunch service which was in process of being plated at that time. Additional observations of the kitchen revealed a metal cart which contained cooking utensil that OSM #6 stated were dried and available for use. Four small steam tray pans were observed stacked onto each other. The two inside steam tray pans were observed to have visible water droplets on the pan surface. On 4/2/2024 at 2:27 p.m., an interview was conducted with OSM #3, dietary manager. OSM #3 stated that they had been at the facility for about a month. She stated that steam tray pans were left upside down for drying on a rack and not stacked until they were completely dry. She stated that they were dried completely before stacking because it was not sanitary to stack them when wet. She stated that the measuring scoops were not stored in the product and were kept on a rack in the kitchen. The facility policy Food Receiving and Storage dated 11/2022 documented in part, .Foods shall be received and stored in a manner that complies with safe food handling practices . The facility policy Food Preparation and Service dated 11/2022 documented in part, .All food service equipment and utensils will be sanitized according to current guidelines and manufacturers ' recommendations . On 4/2/2024 at approximately 5:00 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide reasonable accommodation of needs for one of 37 residents in the survey sample, Resident #56. The findings include: For Resident #56 (R56), the facility staff failed to accommodate needs for access to personal belongings in their wardrobe from their wheelchair. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 2/13/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that they were cognitively intact for making daily decisions. Section GG coded R56 as using a manual wheelchair and being impaired on one side on the upper and lower extremity. On 4/1/2024 at 2:20 p.m., an interview was conducted with R56 in their room. R56 stated that the care at the facility was great but it was hard for him to move around on his side of the room in the wheelchair because it was so small. R56 was observed to reside in a semi-private room on the window side of the room with a privacy curtain separating the two residents. He stated that he was not able to access the wardrobe located in the corner of the room between the bed and wall with the wardrobe doors opening towards the bed. He stated staff had to get things from inside for him because his wheelchair did not fit over there. R56 was observed maneuvering the wheelchair towards the bed which was observed with the foot of the bed angled towards the window. He stated that the staff had angled the bed to the window so he could get the wheelchair up to the bed for transfers. On 4/2/2024 at 10:15 a.m., an observation was made of R56's room with OSM (other staff member) #1, the maintenance director. OSM #1 measured R56's side of the semi-private room to confirm square footage met 80 square feet minimum. He observed the wardrobe in the corner of the room and bed angled towards the window for R56 to access the bed in the wheelchair. He agreed the room was crowded with not much room for R56 to manipulate the wheelchair and would not be able to get the wheelchair to the wardrobe where it was located. On 4/2/2024 at 2:50 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that residents should have access to their wardrobes and personal belongings. She stated that it was their room and their home and they were supposed to have access to their things. She stated that if the resident was in a wheelchair they should have access to the wardrobe and if the staff had to get things for them because they could not access it with the wheelchair then they were not maintaining their highest level of ability. The facility policy Accommodation of Needs, documented in part, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being . The facility policy Bedrooms, documented in part, .Each resident is provided with: a. his or her own personal closet space with clothes racks and shelves accessible to the resident . On 4/2/2024 at approximately 5:00 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence what, if any, documentation was provided to the receiving facility upon hospital transfers for two of 37 residents in the survey sample; Residents #39 and #74. The findings include: 1. For Resident #39, the facility staff failed to evidence what, if any documentation was provided to the receiving facility upon a hospital transfer on 12/29/23. A review of the clinical record revealed a nurse's note dated 12/29/23 that documented, At 7:20am rounds done @ (at) this time. Vitals done with reading of 119/80 (blood pressure), 91 (pulse), 26 (respirations), 98.2 (temperature), 90% (oxygen saturation) @ 28% trachea collar. IV abt (antibiotic) (cefepime) (1) administered @ 9am, with no adverse reaction. Trachea suctioned as resident having large amounts of secretion @ trachea site. TARP (turn and reposition) as tolerated. Routine meds administered. At 11am, vitals obtained with reading of bp (blood pressure) 88/53, p (pulse) 117, r (respirations) 48, t (temperature) 98.2, B/S (blood sugar) reads 360. Chest x-ray result called in to MD (Medical Doctor) (name) by UM (unit manager). MD order to transfer resident to the ER (emergency room ) via 911 for Abnormal vitals and x-ray result. Resident left facility @11.25am. RP (responsible party) (name) notified of his transferred. Report given to ER nurse (name). A respiratory therapist note dated 12/29/23 documented, Resident has been having episodes of an increased work of breathing, desatting and excessive sweating. This condition started early morning yesterday. Today around 08:20am patient was tachypneic 30, tachycardia 148, SPO2 (oxygen saturation) 89% on 35% ATC (automatic tube compensation). Diaphoresis and copious yellowish/greenish secretion exhibited. Deep airway clearance was done, FIO2 (fraction of inspired oxygen) increase to 60%. Bronchodilators were administered (Atrovent) (2). RR (respiratory rate) dropped to 24 post bronchodilators. NP (nurse practitioner) made aware, metoprolol (3) given HR (heart rate) dropped to 117, SPO2 94%-96%. Patient responded well with these intervations and looked comfortable. He was awake and alert when all these were happening. At 11:00am, he experinced (sic) heavy breathing and sweating again. After the Neb treatments breathing improved however patient was very sluggish. MD (medical doctor) was notified order was received to send the patient to the hospital. 911 crew arrived around 11:25am. Resident was transferred to the hospital at 11:35am. A review of the eInteract Transfer form dated 12/29/23 that was sent did not include the resident's current medications, care plan goals, and other documentation as applicable (labs, notes, etc.) and did not indicate that these items were printed separately and sent. A review of the SNF/NF (Skilled Nursing Facility / Nursing Facility) to Hospital transfer form dated 12/29/23 that was send did not include the resident's current medications, care plan goals, and other documentation as applicable (labs, notes, etc.). The back page of this form included a checklist that documented, Copies of documents sent with resident/patient. Check all that apply. The items listed were a transfer form, personal belongings, face sheet, current medication list, change in condition progress note, advance directives, advance care orders. In addition, there was a section for Send these documents if available. This list included most recent history and physical, recent hospital discharge summary, recent physician/nurse practitioner or specialist orders, flow sheets (diabetic, wound care, etc.) relevant labs, relevant x-rays and other diagnostic test results, SNF/NF capabilities checklist. None of the items on the above checklist were checked as being provided. The facility did not retain a copy indicating any items were checked. The facility did not document in a nurses notes that any of the items were provided. In addition, the above checklist did not include the requirement to send the comprehensive care plan goals. On 4/3/24 at 8:50 AM an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that the items that are to be sent are the face sheet, orders, care plan, recent labs, change in condition form, and the transfer form. She stated that the transfer form has a section of what was sent and that a copy of the checklist should be retained. On 4/3/24 at 8:56 AM an interview was conducted with RN #2 (Registered Nurse), the unit manager. He stated that the face sheet, orders and medications should be sent. He stated that the care plan is not sent. He stated that it should be documented what was sent. He stated that he was unsure of the process. The facility policy, Transfer or Discharge, Facility-Initiated was reviewed. This policy documented, .Information Conveyed to Receiving Provider Comprehensive care plan goals; and All other information necessary to meet the resident ' s needs, including but not limited to: .medications (including when last received); most recent relevant labs, other diagnostic tests On 4/3/24 at 11:25 AM, ASM #1 (Administrative Staff Member) the Administrator was made aware of the findings. No further information was provided by the end of the survey. References: 1. Cefpime is used to treat certain infections caused by bacteria including pneumonia, and skin, urinary tract, and kidney infections. Information obtained from https://medlineplus.gov/druginfo/meds/a698021.html 2. Atrovent is used to prevent wheezing, shortness of breath, coughing, and chest tightness in people with chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways) such as chronic bronchitis (swelling of the air passages that lead to the lungs) and emphysema (damage to the air sacs in the lungs). Ipratropium is in a class of medications called bronchodilators. It works by relaxing and opening the air passages to the lungs to make breathing easier. Information obtained from https://medlineplus.gov/druginfo/meds/a695021.html 3. Metoprolol is used alone or in combination with other medications to treat high blood pressure. It also is used to treat chronic (long-term) angina (chest pain). Metoprolol is also used to improve survival after a heart attack. Metoprolol also is used in combination with other medications to treat heart failure. Metoprolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682864.html 2. For Resident #74, the receiving facility failed to evidence what, if any documentation was provided to the receiving facility upon a hospital transfer on 12/18/23. A review of the clinical record revealed a physician's progress note dated 12/19/23 that documented, .I was asked to see the patient today for stroke-like symptoms. With weakness of the left side. Ordered for the patient to be sent to the ER for further evaluation A nurse's note dated 12/19/23 documented, .Nursing observations, evaluation, and recommendations are: Resident needed more help with meals this am per CNA (certified nursing assistant) report was assessed unable to lift left arm and leg, no hand grasp on left hand, tactile response on left leg. Slight facial drooping on left side. Unit Manager notified and NP (nurse practitioner). Order to send to Hospital via 911 for further evaluation . Another nurse's note dated 12/19/23 documented, Resident was transferred to (hospital) for further evaluation due to Left sided weakness on Left arm and left leg new onset per order from NP (nurse practitioner) (name). Was Alert and verbally responsive during am rounds but needed more assistance during meals per CNA report. On assessment was unable to lift Left arm or grasp , tactile response on Left leg but unable to move leg. Supervisor notified. Per order call was placed to 911 at 1:50pm . Response at 2pm . Resident was transferred to ER (emergency room ) at 2:05pm. Report called in to (hospital) ER at 2:05pm spoke to (name) Charge Nurse . Unable to reach RP (responsible party) (name) but message left at 2:12pm on voicemail to call facility for an update. Remainder paperwork was faxed at 2:47pm. At 4:20 call placed to ER to check status of Resident spoke to (nurse) was told Resident was admitted . A review of the eInteract Transfer form dated 12/19/23 that was sent did not include the resident's current medications, care plan goals, and other documentation as applicable (labs, notes, etc.) and did not indicate that these items were printed separately and sent. A review of the SNF/NF (Skilled Nursing Facility / Nursing Facility) to Hospital transfer form dated 12/19/23 that was send did not include the resident's current medications, care plan goals, and other documentation as applicable (labs, notes, etc.). The back page of this form included a checklist that documented, Copies of documents sent with resident/patient. Check all that apply. The items listed were a transfer form, personal belongings, face sheet, current medication list, change in condition progress note, advance directives, advance care orders. In addition, there was a section for Send these documents if available. This list included most recent history and physical, recent hospital discharge summary, recent physician/nurse practitioner or specialist orders, flow sheets (diabetic, wound care, etc.) relevant labs, relevant x-rays and other diagnostic test results, SNF/NF capabilities checklist. None of the items on the above checklist were checked as being provided. The facility did not retain a copy indicating any items were checked. The facility did not document in a nurses notes that any of the items were provided. In addition, the above checklist did not include the requirement to send the comprehensive care plan goals. On 4/3/24 at 8:50 AM an interview was conducted with LPN #4 (Licensed Practical Nurse) who wrote the above note dated 12/19/23 that Remainder paperwork was faxed . She stated that the items that are to be sent are the face sheet, orders, care plan, recent labs, change in condition form, and the transfer form. She stated that the transfer form has a section of what was sent and that a copy of the checklist should be retained. She was not able to evidence what paperwork she sent. On 4/3/24 at 8:56 AM an interview was conducted with RN #2 (Registered Nurse), the unit manager. He stated that the face sheet, orders and medications should be sent. He stated that the care plan is not sent. He stated that it should be documented what was sent. He stated that he was unsure of the process. The facility policy, Transfer or Discharge, Facility-Initiated was reviewed. This policy documented, .Information Conveyed to Receiving Provider Comprehensive care plan goals; and All other information necessary to meet the resident ' s needs, including but not limited to: .medications (including when last received); most recent relevant labs, other diagnostic tests On 4/3/24 at 11:25 AM, ASM #1 (Administrative Staff Member) the Administrator was made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide written notice of hospital transfer for one of 37 residents in the survey sample, Resident #100. The findings include: For Resident #100 (R100), the facility staff failed to provide written notice of transfer to the resident representative and ombudsman when the resident transferred to the hospital on 11/8/22. A review of R100's clinical record revealed the resident was transferred to the hospital on 11/8/22 for aggressive behaviors. Further review of R100's clinical record failed to reveal evidence that the resident's representative and ombudsman was provided written notice of the transfer. On 4/3/24 at 10:02 a.m., an interview was conducted with OSM (other staff member) #5 (the director of social services). OSM #5 stated he faxes notices of resident discharges to the ombudsman every week. On 4/3/24 at 10:07 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated the admissions director prints out written notices of resident transfers and gives them to the receptionist, then the receptionist mails the notices to the resident representatives. On 4/3/24 at 11:26 a.m., ASM #2 stated she could not provide evidence that written notice of transfer was provided to R100's representative or the ombudsman. On 4/3/24 at 2:43 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Transfer or Discharge, Facility-Initiated documented, Notice of Transfer or Discharge (Emergent or Therapeutic Leave). 4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements).

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to complete an accurate MDS assessment for three of 37 residents in the survey sample; Residents #22, #67, and #98. The findings include: 1. For Resident #22, the facility staff failed to ensure an accurate MDS (Minimum Data Set) assessment for the 3/20/24 quarterly MDS when the resident was not coded as having a nephrostomy tube. The resident was documented as having a nephrostomy tube since at least 9/14/23 upon readmission. Previous MDS assessments had this coded but failed to code it on the 3/20/24 quarterly MDS. A review of the clinical record revealed a nurse's note dated 9/14/23 that documented, readmitted from (hospital) Readmission diagnosis- Hydronephrosis On skin assessment noted Nephrostomy drainage bag on right lower abdomen . There were no notes indicating the nephrostomy was in place prior to 9/14/23. A review of the most recent MDS, a quarterly assessment dated [DATE], failed to code the resident as having this device in place in Section H - Bowel and Bladder. H0100. Check all that apply: A. Indwelling catheter (including suprapubic catheter and nephrostomy tube) Z. None of the above. Item Z was marked. Item A was left blank. On 4/2/24 at 3:06 p.m., an interview was conducted with RN #1 (Registered Nurse) #1 (the MDS Coordinator). She stated she follows the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments. She stated that the MDS was miscoded, and that it should be coded as the resident having a nephrostomy tube. A review of the RAI manual, version 1.18.11 dated October 2023 documented on page H-1, .Each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible Nephrostomy Tube: A catheter inserted through the skin into the kidney in individuals with an abnormality of the ureter (the fibromuscular tube that carries urine from the kidney to the bladder) or the bladder . On 4/3/24 at 11:25 AM, ASM #1 (Administrative Staff Member) the Administrator was made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #67, the facility staff failed to ensure an accurate MDS assessment for the 12/18/23 quarterly MDS (Minimum Data Set) when the resident was coded as having a restraint. A review of the 12/18/23 quarterly MDS revealed in Section P - Restraints and Alarms in P0100 Restraints, Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This section documented, Coding: 0. Not used; 1. Used less than daily; 2. Used daily .Used in Chair or Out of Bed .E. Trunk restraint . Item E was coded as 1. On 4/1/24 at 3:07 PM, Resident #67 was observed. He was up and ambulatory, completely independent without devices or difficulty. He did not demonstrate any signs of or need for any type of restraint or devices. A review of the clinical record failed to reveal any evidence of the use of any type of restraints. On 4/2/24 at 3:06 p.m., an interview was conducted with RN #1 (Registered Nurse) #1 (the MDS Coordinator). She stated she follows the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments. She stated that the MDS was miscoded, and that Resident #67 has never had any restraints. The facility policy, Comprehensive Assessments was reviewed. This policy documented, 1. The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident ' s functional capacity using the Resident Assessment Instrument specified by CMS. 2. The comprehensive assessment process includes direct observation and communication with residents, as well as communication with licensed and non-licensed direct care staff members on each shift. On 4/3/24 at 11:25 AM, ASM #1 (Administrative Staff Member) the Administrator was made aware of the findings. No further information was provided by the end of the survey. 31753 3. For Resident #98 (R98), the facility staff failed to accurately code the resident's discharge MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/5/24. A review of R98's clinical record revealed a discharge summary dated 1/3/24 that documented the resident was discharging to home on 1/5/24. A nurse's note dated 1/5/24 documented, Resident came back from LOA (leave of absence) with daughter (name) at 12:15pm. Scheduled discharge, went over medlist [sic] and discharge instructions with Daughter demonstrated understanding, with feedback on med times. Left with personal belongings . Section A2105 Discharge Status of R98's discharge MDS assessment with an ARD of 1/5/24 documented the resident discharged to, 04. Short-Term General Hospital. On 4/2/24 at 3:06 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated that according to R98's discharge summary and nurse's note, the resident was discharged home, but the discharge MDS coded the resident was discharged to the hospital. RN #1 stated the MDS was not accurate. RN #1 stated she follows the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments. On 4/2/24 at 5:10 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The CMS RAI manual documented, A2105: Discharge Status. This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly .Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident was discharged to a hospital that is contracted with Medicare to provide acute, inpatient care and accepts a predetermined rate as payment in full.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for three of 37 residents in the survey sample; Residents #22, #102, and #91. The findings include: 1. The facility staff failed to develop a comprehensive care plan for the care and services of a nephrostomy tube when Resident #22 returned from the hospital on 9/14/23 with one. A review of the clinical record revealed a nurse's note dated 9/14/23 that documented, readmitted from (hospital) Readmission diagnosis- Hydronephrosis On skin assessment noted Nephrostomy drainage bag on right lower abdomen . There were no notes indicating the nephrostomy was in place prior to 9/14/23. A review of the nurse's notes revealed multiple notes between 9/14/23 and the date of survey documenting the presence of a nephrostomy tube. The most recent was dated 3/10/24 and documented, Nephrostomy site is intact A review of the physician's orders revealed one dated 9/14/23 for Nephrostomy Tube care Every shift and one dated 10/23/23 for Cleanse Nephrostomy site with Saline wound wash and cover with Dry Dressing QD (every day) for protection. A review of the comprehensive care plan failed to reveal any for the presence and care of a nephrostomy tube. On 4/3/24 at 8:50 AM an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that a nephrostomy tube should be care planned. She stated that MDS develops care plans and the unit manager can update them. She stated the purpose of the care plan was a list of things you need to do for the resident. On 4/3/24 at 8:56 AM an interview was conducted with RN #2 (Registered Nurse) the unit manager. He stated that the care plan is to direct the resident's care. He stated that the nephrostomy tube and directions provided in the physician's orders should be in the care plan. He stated that he was not sure if anyone had looked at her care plan to see if it was there. On 4/3/24 at 9:25 AM an interview was conducted with RN #1, the MDS nurse. She stated that a care plan for the nephrostomy tube should have been developed when the resident returned from the hospital with one on 9/14/23, as part of the readmission assessment. The facility policy, Care Plans, Comprehensive Person-Centered documented, 7. The comprehensive, person-centered care plan: .b. describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being .12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident ' s condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment On 4/3/24 at 11:25 AM, ASM #1 (Administrative Staff Member) the Administrator was made aware of the findings. No further information was provided by the end of the survey. 32642 2. For Resident #102 (R102), the facility staff failed to implement the care plan for skin integrity related to a fungal infection. A review of R102's wound specialist's note dated 11/29/23 revealed, in part: Patchy erythema and excoriations of bilateral groin, bilateral buttocks, and sacrum. Scant serous draining; + odor consistent with fungal infection. Improved since last week .There are no other wound or signs of infection .Continue antifungal cream q (each) shift and prn (as needed). A review of R102's November and December 2023 MARs (medication administration records) and TARs (treatment administration records) revealed no evidence that R102 received antifungal treatment each shift between 11/29/23 and 12/6/23, when she was discharged from the wound specialist's care. A review of R102's care plan dated 11/15/23 revealed, in part: I have impaired skin integrity r/t (related to) fungal rash and excoriations .Administer treatments as ordered and monitor for effectiveness. On 4/2/24 at 2:50 p.m., LPN (licensed practical nurse) #2 was interviewed. LPN #2 stated the care plan tells the staff exactly what the IDT (interdisciplinary team) wants done for the resident. LPN #2 stated the care plan should be implemented by the nurse taking care of the resident. On 2/3/24 at 1:35 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. 31753 3. For Resident #91 (R91), the facility staff failed to develop a comprehensive care plan to include contact isolation (1). A review of R91's clinical record revealed a physician's order dated 2/9/24 for contact isolation on every shift for diagnoses of MRSA (2) and RSV (3). R91's comprehensive care plan dated 2/10/24 failed to reveal documentation regarding contact isolation. On 4/1/24 at 1:36 p.m., an observation of R91's room was conducted. An isolation sign was on the door and personal protective equipment was outside of the room door. On 4/2/24 at 2:36 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the purpose of the care plan is to take care of the resident, including exactly what the interdisciplinary team wants staff to do for the resident. LPN #2 stated contact isolation should be included on the care plan, so staff know how to care for that particular resident. On 4/2/24 at 5:10 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Care Plans, Comprehensive Person-Centered documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. References: (1) Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Ensure appropriate patient placement in a single patient space or room if available in acute care hospitals. In long-term and other residential settings, make room placement decisions balancing risks to other patients. Use personal protective equipment (PPE) appropriately, including gloves and gown. Limit transport and movement of patients outside of the room to medically-necessary purposes. Use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. Prioritize cleaning and disinfection of the rooms of patients on contact precautions ensuring rooms are frequently cleaned and disinfected . This information was obtained from the website: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html (2) MRSA stands for methicillin-resistant Staphylococcus aureus. It causes a staph infection that is resistant to several common antibiotics. This information was obtained from the website: https://medlineplus.gov/mrsa.html (3) Respiratory syncytial virus, or RSV, is a common respiratory virus. It usually causes mild, cold-like symptoms. But it can cause serious lung infections, especially in infants, older adults, and people with serious medical problems. This information was obtained from the website: https://medlineplus.gov/respiratorysyncytialvirusinfections.html

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 37 residents in the survey sample, Residents #44 and #72. The findings include: 1. For Resident #44 (R44), the facility staff failed to review and revise the resident's comprehensive care plan for bed rails. A review of R44's clinical record revealed a physician's order dated 2/8/22 to apply 1/2 upper bed side rails for positioning and bed mobility. R44's comprehensive care plan reviewed on 7/31/23 failed to reveal documentation regarding bed rails. On 4/1/24 at 1:31 p.m., R44 was observed lying in bed with bilateral 1/2 upper bed rails in the upright position. On 4/2/24 at 2:36 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the purpose of the care plan is to take care of the resident, including exactly what the interdisciplinary team wants staff to do for the resident. LPN #2 stated the care plan should be reviewed and revised to include the use of bed rails because of the risks associated with bed rails. On 4/2/24 at 5:10 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Care Plans, Comprehensive Person-Centered documented, 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 42106 2. For Resident #72 (R72), the facility staff failed to revise the comprehensive care plan for the use of grab bar bed rails. On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 2/9/2024, the resident scored 15 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 4/1/2024 at 3:25 p.m., an interview was conducted with R72 in their room. R72 was observed in bed with bilateral grab bars in place on the bed. When asked about the grab bars, R72 stated that they used them to hold onto during care and for repositioning. Additional observations of R72 in bed with the bilateral grab bars in place were made on 4/2/2024 at 8:18 a.m. and 4/2/2024 at 11:18 a.m. The comprehensive care plan for R72 documented in part, I have an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) disease process. Date Initiated: 02/03/2024. The care plan failed to evidence the use of the grab bars. On 4/2/2024 at 2:50 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the care plan was reviewed and/or revised by the unit managers. She stated that the purpose of the care plan was to take care of the resident and showed exactly what the IDT (interdisciplinary) team wanted them to do for the resident. She stated that if the resident used bed rails then they should be on the care plan because they used them. On 4/2/2024 at approximately 5:00 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the concern. No further information was obtained prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of care for one of 37 residents in the survey sample, Resident #102. The findings include: For Resident #102 (R102), the facility staff failed to transcribe a wound physician's recommendation into an order on 11/29/23. A review of R102's wound specialist's note dated 11/29/23 revealed, in part: Patchy erythema and excoriations of bilateral groin, bilateral buttocks, and sacrum. Scant serous draining; + odor consistent with fungal infection. Improved since last week .There are no other wound or signs of infection .Continue antifungal cream q (each) shift and prn (as needed). A review of R102's November and December 2023 MARs (medication administration records) and TARs (treatment administration records) revealed no evidence that R102 received antifungal treatment each shift between 11/29/23 and 12/6/23, when she was discharged from the wound specialist's care. A review of R102's care plan dated 11/15/23 revealed, in part: I have impaired skin integrity r/t (related to) fungal rash and excoriations .Administer treatments as ordered and monitor for effectiveness. On 4/3/24 at 10:05 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated she frequently makes rounds with the wound specialist, and is responsible for making sure his recommendations are transcribed into accurate orders for residents' care. She stated the specialist gives the order verbally, she writes it down, and then either she or the floor nurse enters the order into the electronic medical record. After reviewing R102's record, she stated: There was a drop in the ball. I can't see that we continued the antifungal cream beyond 11/29. She stated she accidentally failed to transcribe the order from the wound specialist. On 2/3/24 at 1:35 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Transcribing Diagnostic and Therapeutic Orders, revealed, in part: Transcribe order accurately on appropriate form. The policy did not contain any information related to transcribing a verbal order into the electronic medical record. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to provide the ADL (activities of daily living) care for one of 37 residents in the survey sample, Resident #87. The findings include: For Resident #87 (R87), the facility staff failed to properly groom the resident's chin hairs. On the following date and times, R87 was seen with multiple strands of hair about 1-2 inches on her chin: 4/01/24 at 1:42 p.m. and 3:05 p.m.; 4/02/24 at 9:15 a.m. and 2:15 p.m. R87 was unavailable for interview during the survey. A review of R87's clinical record revealed no evidence that she refused grooming assistance at any time. On 4/2/24 at 2:30 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated that she recently started taking care of the resident and that she did not ask about the resident's preferences. She also stated that she should have groomed the chin hairs and that she will do them now. She also stated that if the resident refuses that she has to write a note to document the refusal and then the nurse also documents. On 4/2/24 at 4:45 p.m., ASM (administrative staff member) #1, the administrator and ASM#2, the director of nursing, were notified of these concerns. A review of the facility policy, Activities of Daily Living (ADLs), Supporting, revealed, in part: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming and oral care). No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide physician oversight for one of 37 residents in the survey sample, Resident #102. The findings include: For Resident #102 (R102), the NP (nurse practitioner/physician extender) failed to accurately document R102's physical condition on multiple dates during the resident's stay in the facility. R102 was admitted to the facility on [DATE] and discharged on [DATE]. The resident's admitting diagnoses included a history of vaginal bleeding, heart attack, and sepsis (systemic infection). A review of R102's clinical record revealed these portions of ASM (administrative staff member) #3, the nurse practitioner's notes: 11/17/23 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 11/21/23 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 11/24/23 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 11/30/23 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 12/5/23 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 12/11/23 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 12/15/23 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 12/18/23 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 12/26/23 .I was asked to see the patient today for vaginal bleeding .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 12/29/23 .I was asked to see the patient today for vaginal bleeding .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 1/2/24 .I was asked to see the patient today for vaginal bleeding .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 1/5/24 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 1/8/24 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 1/10/24 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 1/12/24 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 1/15/24 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 1/17/24 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 1/19/24 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. 1/22/24 .Review of Systems .Constitutional: No fevers, +chills .Respiratory: +shortness of breath, no cough .Cardiovascular: +chest pain,+palpitations. Further review of R102's clinical record revealed no evidence of follow up for the chills, shortness of breath, chest pain, or palpitations as documented by ASM #3. On 4/3/24 at 10:34 a.m., ASM #3 was interviewed. She stated she remembered R102, and that I was on top of her the whole time; I followed her very closely. When asked about her physical assessment process, she stated she asks the resident how he/she is feeling, then does a complete physical assessment. She stated her assessments include listening to both heart and lung sounds at every visit. When asked about the note she wrote on 11/17/23, in which she documented R102's having chills, chest pain, and palpitations, she stated: You had to beg her to do things. I personally checked her vital signs then. I reviewed her lab results. She stated the resident's chills did not last long, and that the resident reported to her that she was having chest pains and palpitations. When asked what steps she took to acutely address a resident with a history of a heart attack and sepsis, who was reporting chills, chest pain, and palpitations, she stated: I asked if she wanted to go to the hospital. She didn't want to go. Her vital signs were fine. When asked about the note she wrote on 11/17/23, in which she documented R102's having chills, chest pain, and palpitations, she stated: She wasn't having chills. That was a mistake. That only happened in the beginning. She stated: I believe this was something I just did not take out. When asked for clarification of this, she stated she does not copy and paste her notes, but uses a template for her documentation. She stated: I do my physical assessment. I try to modify [the template] as much as I can. She admitted her documentation throughout R102's record of chills, chest pain, and palpitations were not accurate descriptions of her assessment findings. She stated the statements on 12/26/23, 12/29/23, and 1/2/24 that she was asked to see the resident because the resident was experiencing vaginal bleeding were also inaccurate. She added: I have a lot of patients here. When asked how the staff or anyone else reviewing her notes could ever get an accurate picture of what was actually happening physically with this resident, she did not answer. On 2/3/24 at 1:35 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Attending Physician Responsibilities, revealed, in part: Each Attending Physician will be responsible for .providing appropriate, timely, and pertinent documentation .During visits, the attending physician will determine each resident's overall condition and the status of specific medical issues .At each visit, the attending physician will provide a progress note .in a timely manner .Over time, these progress notes should address significant active problems and risk factors. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow infection control procedures during meal delivery for three of 37 residents in the survey sample, Residents #78, #33, and #310. The findings include: 1. For Residents #78 (R78) and #33 (R33), the facility staff failed to sanitize hands prior to delivering their meal trays on 4/1/24. On 4/1/24 at 12:14 p.m., CNA (certified nursing assistant) #1 was observed delivering meal trays. CNA #1 failed to sanitize her hands prior to picking up R78's tray from the meal cart. She delivered R78's meal tray, setting it on the resident's overbed table. CNA #1 touched some of the resident's personal items, bed linens, and the top of the overbed table. CNA #1 exited R78's room without sanitizing her hands. She picked up R33's meal tray, setting it on the resident's overbed table. She touched various items on the meal tray as she removed the cover from the plate, opened the iced tea, poured sweetener into the tea, and handled the resident's cutlery to prepare it for the resident's use. On 4/3/24 at 11:37 a.m., CNA #3 was interviewed. She stated she sanitizes or washes her hands every time she leaves a resident's room, especially if she has touched any items belonging to the resident. She stated she sanitizes her hands between residents when she is distributing meal trays. She stated this is important for infection control. On 2/3/24 at 1:35 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Handwashing/Hand Hygiene, revealed, in part: Indications for Hand Hygiene .after touching a resident's environment. No further information was provided prior to exit. 2. For Resident #310 (R310), the facility staff failed to sanitize hands before entering and before exiting the resident's room, as required by the enhanced barrier precautions. On 4/2/24 at 8:39 a.m., CNA (certified nursing assistant) #4 was observed entering R310's room with a meal tray. The resident's door contained a sign with the following information: Enhanced Barrier Precautions .Wash hands before entering and exiting. R310 failed to wash or sanitize her hands prior to entering and exiting R310's room. While in the resident's room, R310 touched the resident's overbed table, personal items on the overbed table, bed linens, and items on the meal tray. A review of R310's clinical record revealed the following order dated 4/1/24: Enhanced Barrier Precautions every shift. On 4/2/24 at 9:10 a.m., CNA #4 was interviewed. She stated she was not aware that she needed to wash her hands when delivering a R310's meal tray - either before or after delivery. On 2/3/24 at 1:35 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy Enhanced Barrier Precautions revealed no information related to washing/sanitizing hands prior to entering and exiting the resident's room. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review it was determined that the facility failed to protect one of 39 residents in the survey sample from resident-to-resident abuse, Resident #44. On 6/24/22, Resident #37 hit Resident #44, which required an emergency room visit where they were diagnosed with a closed fracture of the distal end of the left ulna (1), closed head injury, abrasion of the nose and a closed fracture of the nasal bone, resulting in harm. The findings include: Resident #44's (R44) most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/1/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. Section E documented no behaviors. Section G documented R44 requiring supervision with transfers, walking in the room and corridors and locomotion on and off the unit. Section G documented R44 not having any impairment in the functional range of motion to the upper and lower extremities and being not steady but able to stabilize without staff assistance when walking. On 6/27/2022 at 5:14 p.m., an interview was conducted with R44 in their room. R44 was observed lying in bed and was observed to have a splint wrapped with an elastic bandage on the left forearm. When asked about the splint on the left forearm R44 stated that they were hit by another resident with a cane in the solarium at the end of the hallway the previous Friday. R44 stated that they had a fracture in the arm and a fractured nose from the incident. R44 stated that they had gone to the emergency room and they had taken x-rays, applied the splint and advised them to follow up with an orthopedic physician to see if they needed surgery or not. When asked about the resident who hit them, R44 indicated that Resident #37 (R37) had approached them in the solarium and started hitting them with a cane over nothing and they were crazy. R44 stated that the staff were keeping R37 in their room and were watching them all the time after the incident. The progress notes for Resident #44 documented in part, - 6/24/2022 20:19 (8:19 p.m.) Note Text: Resident alert no respiratory distress noted. Resident came to nurses station with blood on his shirt and nose, bruises and bump (swelling) behind left ear. resident c/o (complains of) pain of left arm. Resident stated he was lying on couch watching TV in the solarium when resident [Room number identifying R37] approached and accused him of messing up his puzzle in the solarium. Nursing supervisor notified who then notified DON (director of nursing) and called 911. Resident sent to ER (emergency room ) for evaluation and treatment. - 6/25/2022 00:20 (12:20 a.m.) Note Text: Resident back from [Name of hospital] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . New order of [MEDICATION(S)]-clavulanate ([MEDICATION(S)]) 875-125mg take 1 tablet by mouth 2 times daily for 7 days. Resident denied pain at this time, back in his room at this time will continue to monitor. - 6/27/2022 16:16 (4:16 p.m.) Note Text: Resident was interview today with DSS (director of social services) about what happened between himself and other resident. Resident told writer what transpired. Resident told writer is feeling much better. Resident told writer he feel safe at [Name of facility] at this time. Resident told writer has no pain. Writer will continue to support resident as needed. The After Visit Summary dated 6/24/2022 for R44 from [Name of hospital] documented in part, .Reason for Visit: Facial laceration, arm injury. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .Imaging results: Wrist Left PA (postero anterior) lateral and oblique (final result) Redemonstrated mildly displaced ulnar fracture. No additional fracture or dislocation noted. Marked vascular calcifications are present .Forearm complete Left (final result) 1. Distal ulnar fracture 2. Dedicated 4 view study of the wrist is recommended to better evaluate the ulnar fracture and evaluate for underlying distal radial fracture .CT (computed tomography) head without contrast (final result) 1. No acute intracranial abnormality. 2. Right nasal bone fracture appears new compared to the prior exam . Resident #37's (R37) most recent MDS, a quarterly assessment with an ARD of 4/2/2022, the resident scored 15 out of 15 on the BIMS assessment, indicating the resident is cognitively intact for making daily decisions. Section E documented no behaviors. Section G documented R37 requiring supervision with transfers, walking in the room and corridors and locomotion on and off the unit. Section G further documented R37 being not steady but able to stabilize without staff assistance with walking and having no functional limitation in range of motion in the upper or lower extremities. Section G documented R37 using a walker. On 6/27/2022 at 1:56 p.m., an interview was conducted with R37 in their room. R37 was observed to have a staff member sitting outside of the room in a chair monitoring the room. R37 stated that the previous Friday they had a fight with another resident who lived across the hall. R37 stated that the police had come and the social worker had advised them they were going to be moved to another room. R37 stated that they did not understand why they were made to stay in their room and not allowed to go outside to smoke with their friends because they were only trying to defend themselves. R37 stated that the other resident hit them in their chest when they asked them a question and they had to fight back to protect themselves. R37 stated that they were disappointed because they were not able to walk around the facility currently or visit with their friends. When asked about the other resident, R37 stated that it was the resident in the room across the hall with the cast on the arm. R37 stated that they did not know why they had a cast now. R37 stated that the facility staff were making the fight into a bigger deal than it needed to be because they were just trying to defend themselves. The progress notes for Resident #37 documented in part: - 6/28/2022 13:46 (1:46 p.m.) Note Text: Addendum- On 6/24/2022 resident [Room number identifying R44] came to nurses station with blood on his nose, bruises and bump (swelling) behind his left ear. There was also blood on his shirt. Resident [Room number identifying R44] c/o pain on left hand. [Room number identifying R44] stated that he was lying on the couch watching TV in the solarium when above resident [Room number identifying R37] approached and accused him of messing up his puzzle in the solarium. [Room number identifying R44] stated he did not know anything about his puzzle. Then [Room number identifying R37] struck [Room number identifying R44] with his walking cane repeatedly. [Room number identifying R44] stated he used his left arm to cover and protect his face. [Room number identifying R37] then hit his arm too. [Room number identifying R44] ran to nurses station reported writer. Writer called nursing supervisor who then reported to DON and called 911. Resident [Room number identifying R44] was sent to [Name of hospital] ER (emergency room ) for evaluation and treatment. - 6/27/2022 23:47 (11:47 p.m.) Note Text: Resident transferred from room [Room number] to [Room number] with all medications and personal belongings. - 6/27/2022 18:25 (6:25 p.m.) Late Entry: Note Text: Resident was interviewed 6/27/22 about what happened between himself and another resident. Resident agreed to move to another room. [Name of Shelter] was contacted to see if they have a placement for resident. Writer left a message. [Name of Shelter] was contacted as well about placement and writer was told no bed is available at this time. -6/27/2022 15:00 (3:00 p.m.) .Behavioral problems are other socially inappropriate behaviors Slammed door on staff when angry and yelling at staff . - 6/27/2022 01:43 (1:43 a.m.) Note Text: Resident called for pain medication for generalized pain at 1:25 am. Writer was on [Name of unit] finishing up with another resident. Writer went to [Name of unit] at 1:30am to give [Name of R37] his [MEDICATION(S)]. While checking resident's order to pull medication, resident walked from his room to the nurses station and started yelling and cursing writer out. Resident stated that he had been waiting 15 minutes for someone to come and give him his [MEDICATION(S)]. Resident snatched medication out of nurses hand, refused water and told nurse, you drink it. Resident walked back to his room and slammed his door. I followed up with resident immediately and medication was taken. Resident remains in room, lying down. Writer will check on resident soon when he has calmed down to check on his pain. Supervisor notified of outburst. - 6/25/2022 07:19 (7:19 a.m.) Note Text: At 3:45am resident left his room stating his going outside to get fresh air, resident was told to wait until morning which he refused, was also told to sign LOA (leave of absence) which he refused too. Resident stated I'm not in prison, resident was told how unsafe it was to go out at that time of the night. Supervisor was made aware, resident went outside and came back to the unit at 4:10am. He is in his room at this time, will continue to monitor. - 6/23/2022 10:28 (10:28 a.m.) Note Text: Resident and I called [Name of Shelter] and left a voicemail. Resident was provide the number to give them a call later. Writer and I called have been trying to call [Name of Shelter] for the few days with no response. Writer left a voicemail. - 6/16/2022 11:00 (11:00 a.m.) .Behavioral problems are verbal behaviors (screaming, cursing, etc.) Screaming at Writer using foul Language told writer you are an animal go back where you came from with expletives. Slamming his door . - 5/4/2022 21:59 (9:59 p.m.) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Psych (psychiatry) deemed patient to have mental capacity discussed with DON. Patient is not safe to stay in the facility as he can be a risk to other residents or staff. - 5/4/2022 09:34 (9:34 a.m.) Note Text: slammed the door in my face. Resident asked if he can put his tray on the treatment cart, I said No, he cannot I asked him politely Can you give it to me please He handed the tray to me and slammed the door in my face. - 5/3/2022 18:13 (6:13 p.m.) Note Text: At approximately 2300 (11:00 p.m.) on 5/2 (5/2/2022), the evening nurse notified this writer that the damaged laptop was no longer working after resident poured water on it. Writer notified the police who returned to the facility at 0700 (7:00 a.m.) on 5/3 (5/3/2022) to document the destruction of property. Police stated that writer would have to go to magistrate independently to request the warrant for misdemeanor destruction of property. Police officers spoke with resident in the presence of the writer. Resident recounted the events of the previous night in great detail until the police asked, what happened with the water and the cart. Resident began stating he knew nothing about that started to become agitated. He stood up and left the interview saying, well if you are going to arrest me then arrest me. I would rather go to jail than be in the ****hole. Resident currently in room alone with 1:1 (one to one) supervision to ensure safety of those around him. Resident's guardian and physician updated on current status. - 5/2/2022 22:04 (10:04 p.m.) Note Text: This wirter [sic] received call from the nurse on resident's unit at approximately 8:45pm. Nurse reported that resident was upset about pain medication being administered every 6 hours instead of every 2 hours and that he was disrupting the unit. Writer could hear resident yelling in the background loudly and calling the nurse obscene names. Nurse reported that resident was slamming doors, yelling loudly and grabbed the unit phone off of the wall. The nurse stated that resident tried to pull the door shut when she attempted to enter to attend to [R37]'s roommate. Nurse also reported that resident intentionally knocked over the ice pitcher on the medication cart, damaging the medication laptop. Writer notified police and they responded to the building. Writer spoke with police officers on site who stated, well there is not much we can do in this setting other than speak with him and document. Police officer reported that resident was calm upon their arrival and denied doing anything the [sic] medication cart. Police officer stated the laptop remained on and working, but that if is [sic] stopped working to call back to document the damage. Increased supervision provided by CNAS (certified nursing assistants) during the remainder of the shift. Writer left message for resident's guardian and physician regarding his behavior. Writer also notified psych (psychiatrist), who stated he would come in the morning to see the resident. The geriatric psychiatry consult note dated 3/10/2022 for R37 documented in part, .asked to evaluate cognition. Pt (patient) is alert & engaging. Fully oriented. He admits he is easily frustrated. He feels staff don't care. He can be very aggressive verbally. Has been known to use racial slurs, hard to direct . The geriatric psychiatry consult note dated 5/3/2022 for R37 documented in part, .Pt has been struggling, he is frustrated he is here. Feels mistreated by staff. Last week was physically aggressive [medical abbreviation for with] behaviors that included breaking a laptop . The comprehensive care plan for R37 documented in part, [Name of R37] is at risk for behaviors (verbal/physical aggression, refusal of care, delusions) r/t (related to) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Initiated: 08/16/2021. Revision on: 11/08/2021. The FRI (facility reported incident) dated 6/25/2022 documented in part, . [Name of R44] reported resident-resident altercation that took place in the second floor solarium between himself and [Name of R37]. Head-to-toes assessment completed, [Name of R44] presented with nose bleed, and a bruise to the back of his neck. [Name of R37] sustained no injury. [Name of R44] transferred to the hospital for further evaluation. Responsible party and Physician notified. Resident send [sic] back to their room under 1:1 observation, one resident send to ED (emergency department) for further evaluation, facility investigation initiated including resident evaluations/interviews, staff interviews and staff education . On 6/28/2022 at 11:05 a.m., an interview was conducted with OSM (other staff member) #10, the director of social services. OSM #10 stated that they were not in the facility on 6/24/2022 when R37 and R44 had the altercation. OSM #10 stated that they were called and made aware of the incident that day and had followed up with both residents on 6/27/2022. OSM #10 stated that R37 had previous behaviors of slamming doors, destruction of facility property and being verbally abusive to staff members but had not displayed any aggression towards another resident that they were aware of prior to that day. OSM #10 stated that they had been attempting to find alternate housing for R37 since they had been to court and deemed competent but had not been able to find a safe discharge location for them. OSM #10 stated that R37 was alert and oriented and had stated that R44 had hit them in the chest first when they had interviewed them on 6/27/2022 regarding the incident. OSM #10 stated that the incident between R44 and R37 was not witnessed by any staff or other residents. OSM #10 stated that since 6/24/2022, R37 had been on 1 to 1 monitoring and staff were with them if they left the room for anything. OSM #10 stated that R44 had never displayed any behaviors and was always a quiet person who enjoyed sitting in the Solarium watching television. On 6/28/2022 at 12:54 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that R37 had anger issues and would throw things at staff when they became angry. LPN #7 stated that there were times when R37 was very pleasant and charming to the staff. LPN #7 stated that they were not aware of any aggression from R37 towards another resident prior to the altercation with R44 on 6/24/2022. LPN #7 stated that they had kept R37 in their room with 1 to 1 monitoring and a chaperone if they left the room since the altercation on 6/24/2022. LPN #7 stated that R44 had never displayed any aggressive behaviors and was always very social and friendly. LPN #7 stated that any resident to resident altercation was intervened upon and the residents were separated and it was immediately reported to the director of nursing or administrator. LPN #7 stated that both R37 and R44 were alert and oriented to person, place, time and situation. On 6/28/2022 at 1:48 p.m., an interview was conducted with LPN #4, unit manager. LPN #4 stated that residents were separated if involved in a resident to resident altercation. LPN #4 stated that the residents would be assessed, EMS (emergency medical services) and police would be notified and they would report the incident to the supervisor and the director of nursing. LPN #4 stated that they would assess the residents depending on the behavior of the residents involved and keep everyone safe. On 6/28/2022 at 2:00 p.m., an interview was conducted with LPN #1, unit manager. LPN #1 stated that R37 would lash out at staff at times and it was like walking on eggshells. LPN #1 stated that R37 had destroyed a facility laptop and did not care. LPN #1 stated that they had to keep other residents out of the way when R37 lashed out at the staff. LPN #1 stated that they were not aware of any incidents with other residents prior to 6/24/2022 with R37. LPN #1 stated that R37 mostly had verbal behaviors that were off and on. LPN #1 stated that they had not had any conversations with R37 since the incident on 6/24/2022. LPN #1 stated that R44 had no history of any behaviors and was always pleasant. On 6/28/2022 at 2:11 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that R37 was competent and had been to court to have the guardianship lifted. ASM #2 stated that R37 had previously damaged a facility laptop when the nurse would not give them additional pain medications. ASM #2 stated that R37 had been placed on 1 to 1 monitoring after the incident on 5/2/2022 when they damaged the facility laptop and displayed behaviors towards staff. ASM #2 stated that the police had come at that time and R37 had lied to the police saying they did not remember anything. ASM #2 stated that R37 did not lack capacity and the police knew they were lying but could not do anything. ASM #2 stated that the previous DON (director of nursing) had moved R37 to a private room and placed them on 1 to 1 monitoring at that time and there had been no further behaviors. ASM #2 stated that they had ended the 1 to 1 monitoring around 5/24/2022 because R37 was not displaying any behaviors and the physician had determined that it could be lifted. ASM #2 stated that they were having the physician fax over a note documenting this. ASM #2 stated that they felt that R37 waited until late on 6/24/2022 after administrative staff had left for the day before approaching R44 in the solarium. ASM #2 stated that on 6/24/2022 after 8:00 p.m., they received a phone call from the facility saying that R44 had been hit with a cane and was going to the hospital. ASM #2 stated that when they arrived R44 had already left for the hospital and R37 was in their room. ASM #2 stated that they spoke with R37 that night they said they did it because R44 touched their puzzle. ASM #2 stated that R37 had cussed me out when they were told they were going to have the 1 to 1 monitoring and going to move to another room. ASM #2 stated that they left the facility prior to R44 coming back from the hospital. ASM #2 stated that they saw R44 on 6/27/2022 with the bruise on the neck, broken nose and arm. ASM #2 stated that they asked R44 why they did not call for help on 6/24/2022 and what happened. ASM #2 stated that R44 explained that R37 thought they messed up their puzzle. ASM #2 stated that R44 would not press charges against R37 because they did not want them to get into trouble. ASM #2 stated that R37's actions were criminal. On 6/28/2022 at 4:36 p.m., an interview was conducted with CNA (certified nursing assistant) #9. CNA #9 stated that they were working on 6/24/2022 when the altercation between R37 and R44 occurred. CNA #9 stated that near the end of the evening shift they were at the nurses station when R44 came up to the nurses station with blood on their nose and said that R37 had hit them with a cane. CNA #9 stated that R44 had told them that R37 had accused them of messing up their puzzle. CNA #9 stated that the nurse had called 911 to send R44 to the emergency room and they had made sure R37 was in their room and monitored 1 on 1. CNA #9 stated that there were no staff or residents who witnessed the incident. CNA #9 stated that R44 normally sat down in the solarium every day watching television. CNA #9 stated that R37 was verbally abusive to staff at times and had slammed doors at times. CNA #9 stated that if a resident to resident altercation was witnessed they immediately separated the residents and called for help. CNA #9 stated that they reported any incidents to the nurse. CNA #9 stated that they reported this because residents could abuse other residents. On 6/29/2022 at 10:08 a.m., an interview was conducted with ASM #5, medical doctor. ASM #5 stated that they care for R37. ASM #5 stated that when R37 gets emotional they could become dangerous and verbally difficult and act out. ASM #5 stated that normally R37 was not dangerous. ASM #5 stated that R37 had destroyed some property but they did not feel that they could give someone a concussion. ASM #5 stated that they had not seen R37 since the incident on 6/24/2022 with R44 but based on what was going on with them they felt that everything was behavioral. ASM #5 stated that they felt that if R37 did not get what they wanted things would keep happening and R37 needed to be safely discharged . ASM #5 stated that they had recommended for the 1 on 1 monitoring to continue and for nursing to keep working on a safe discharge. ASM #5 stated that they felt that R37 did not like R44 for some reason and was mad at them. The facility policy Abuse, Neglect, Exploitation & Misappropriation with a revision date of 11/28/2017 documented in part, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Furthermore, the Administration of The Company recognizes that resident abuse can be committed by other residents, visitors, or volunteers . On 6/28/2022 at 3:48 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the concern for harm. No further information was provided prior to exit. Reference: 1. ulna Of the 206 bones in your body, three of them are in your arm: the humerus, radius, and ulna. this information was obtained from the website: https://medlineplus.gov/arminjuriesanddisorders.html

Based on observation, staff interview and facility document review, the facility staff failed to maintain the dumpsters in a sanitary manner for two of two dumpsters containing trash. On 6/28/22, the sliding side doors of two dumpsters were observed open and multiple flies were inside the dumpsters. The findings include: On 6/28/22 at 2:48 p.m., an observation of the facility dumpsters was conducted. Two of two dumpsters containing trash were observed with both sliding side doors completely open. Multiple flies were inside the dumpsters. No staff was utilizing the dumpsters at this time. On 6/28/22 at 2:50 p.m., an interview was conducted with OSM (other staff member) #4 (the dietary manager). OSM #4 stated the side doors on the dumpsters are supposed to be closed so rodents, flies and birds aren't attracted to the area. On 6/28/22 at 2:58 p.m., an interview was conducted with OSM #7 (the housekeeping manager). OSM #7 stated the side doors on the dumpsters should be closed if staff is not dumping trash. OSM #7 stated rodents, flies and anything can crawl into the dumpsters. On 6/28/22 at 5:40 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Dispose of Garbage and Refuse documented, All garbage and refuse will be collected and disposed of in a safe and efficient manner. No further information was presented prior to exit.

Based on staff interview and employee record review, it was determined that the facility staff failed to ensure that 5 of 10 CNAs (certified nursing assistants) received annual performance reviews. The findings include: On 06/28/2022 a record review was conducted of the annual performance reviews of five CNAs. This review failed to evidence the annual performance reviews for the following CNAs: 1. CNA # 3 - hire date 12/17/2019, no evidence of performance review between 12/17/2019 and 12/17/2020. 2. CNA # 4 - hire date 10/18/2019, no evidence of performance review between 10/18/2019 and 10/19/2020. 3. CNA # 5 - hire date 05/20/2019, no evidence of performance review between 05/20/2019 and 05/20/2020. 4. CNA # 6 - hire date 4/27/2018, no evidence of performance review between 04/27/2021 and 04/27/2022. 5. CNA # 7 - hire date 01/05/2017, no evidence of performance review between 01/05/2021 and 01/05/2022. On 06/29/2022 at approximately 1:05 p.m. an interview was conducted with ASM (administrative staff member) # 2, director of nursing and OSM (other staff member) # 8 director of human resources. When asked for the competency reviews for the CNAs listed above ASM # 2 stated that they did not have the competency reviews. When asked who was responsible for completing the competency reviews ASM # 2 stated that the unit managers were responsible for completing them due to the fact that they knew the CNAs. When asked to describe the procedure for the competency reviews OSM # 8 stated that the reviews were completed annually with the CNAs hire date as the anniversary date for completing the competency reviews. The facility's policy Employee j=Job Performance Evaluations [sic] documented in part, Policy: It is the policy of The Company to evaluate each employee's job performance on a continual and ongoing basis. Employees will receive an evaluation of their performance prior to the completion of their Introductory Period and annually thereafter . Written performance evaluations are to be prepared by the employee's immediate supervisor in conjunction with the department head, or in the absence of a supervisor, by the department head. All evaluations for facility employees must be reviewed and approved by the facility Executive Director prior to being reviewed with the employee. Anniversary Date: The anniversary of your start date is the date you should receive your formal review and performance evaluation, unless a job change has taken place. If a job change includes a change in compensation, you generally will be reviewed again one year from the date of the job change. If no compensation change takes place, you will retain your original review date. On 05/29/2022 at approximately 12:40 p.m., ASM # 1, executive director, ASM # 2, director of nursing and ASM # 4, regional director of clinical services, were made aware of the findings. No further information was presented prior to exit.

Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to evidence bed inspection for risk of entrapment for 4 of 39 residents in the survey sample, Resident #16, Resident #66, Resident #96 and Resident #45. 1. The facility staff failed to inspect Resident #16's bed for risk of entrapment. Resident #16 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: [CONDITION(S)] and anxiety disorder. Resident #16's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/20/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status, coded the resident as requiring extensive assistance in bed mobility and transfers. Observation of Resident #16 resting in bed on 6/27/22 at 1:45 PM, 6/28/22 at 10:00 AM and 6/29/22 at 8:30 AM. 1/4 side rails were observed to be in use. On 6/27/22 at 5:00 PM, a request was made for evidence of the documentation of the annual bed safety inspection for the entire facility. There was no evidence of the requested documentation for Resident #16. The physician's order dated 7/28/20, revealed the following, Side Rails: 1/4 side rails for bed mobility and positioning. A review of the side rail evaluation dated 10/23/21, revealed the following, Bed mobility: will the bed rail (s) assist the resident in turning side to side/holding self to one side? Yes. Will the bed rail (s) assist the resident in moving up and down in bed? Yes. Will the bed rail (s) assist the resident in pulling self from lying to sitting position? Yes. Recommendations: Side rails recommended. A review of Resident #16's care plan dated 6/28/19 revealed the following, FOCUS: has an ADLs (activities of daily living)elf-care performance deficit related to General debility, Muscle wasting, Limited Mobility, Contractures of lower extremities INTERVENTIONS: Quarter Side rails for bed mobility & positioning. An interview was conducted on 6/27/22 at 1:45 PM with Resident #16. When asked if the resident used the side rails, Resident #16 stated, Yes, I use them to help move in bed. An interview was conducted on 6/28/22 at 2:40 PM with OSM (other staff member) #2, the maintenance technician. When asked for the evidence of the annual bed safety inspection, OSM #2 stated, no, there is nothing in TELS (team electronic library system) for all beds. When asked what was checked on the beds, OSM #2 stated, we look at the side rails every week, but we do not track the bed rails. The previous director told me everything was in the computer and to not worry about tracking anything on paper. When asked if OSM #2 was given specific room and bed numbers, could a report of inspection for that bed be ran, OSM #2 stated, no, there is no report for specific beds. When asked for the manufacturer's recommendation for checking the side rails, OSM #2 stated, no I do not have that information. When asked how OSM #2 was checking bed rails per the manufacturers, OSM #2 stated, I am not sure, this is my first time seeing this policy. OSM #2 stated, this is all the information I have as we were provided a TELS Logbook Documentation form which revealed the following: Beds & Mattresses: Inspect Bed Rails: Maintenance Check: Inspect connectors on rails and tighten as necessary. Remove any burs or rough edges to prevent injury. Verify the function on the spring latch-knob assembly, if applicable. Ensure the latch is free of dirt and/or foreign material that could impair its function. Ensure that the rails engage and lock as specified. Tighten, adjust or replace any parts such as end caps, knobs, bolts, screws, etc., that are loose, show signs of wear or are missing. The facility policy, Side Rail/Bed Rail was reviewed. This policy documented, Policy: The Center, will attempt alternative interventions, and document in the medical record, prior to the use of side rail/bed rail. Side rail/bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. Procedure: 1. prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/or resident representative. 3. Obtain consent from the resident and/or resident representative. 4. Obtain physician order for side rail/bed rail. 5. Update the care plan and kardex. 6. Re-evaluate the use of side rail/bed rail, quarterly, with a change in condition or as needed. 7. Follow the manufacturers' recommendations and specifications for installing and maintaining side rails/bed rails. The policy did not address routine or periodic maintenance and inspections of side rails and beds. The facility did not have a manual of the manufacturer's recommendations and specifications for the side rails. The facility was not logging and tracking routine or periodic bed and side rail inspections. On 6/29/22 at 12:40 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was provided prior to exit. 2. The facility staff failed to inspect Resident #66's bed for risk of entrapment. Resident #66 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: [CONDITION(S)]. Resident #66's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/20/22, coded the resident as scoring 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status, coded the resident as requiring extensive assistance in bed mobility; total dependence for transfers. Observation of Resident #66 resting in bed on 6/27/22 at 1:40 PM, 6/28/22 at 9:45 AM and 6/29/22 at 8:25 AM. 1/4 side rails were observed to be in use. On 6/27/22 at 5:00 PM, a request was made for evidence of the documentation of the annual bed safety inspection for the entire facility. There was no evidence of the requested documentation for Resident #66. The physician's order dated 7/28/20, revealed the following, Side Rails: 1/4 side rails for bed mobility and positioning. A review of the side rail evaluation dated 10/23/21, revealed the following, Bed mobility: will the bed rail (s) assist the resident in turning side to side/holding self to one side? Yes. Will the bed rail (s) assist the resident in moving up and down in bed? Yes. Will the bed rail (s) assist the resident in pulling self from lying to sitting position? Yes. Recommendations: Side rails recommended. A review of Resident #66's care plan dated 11/8/ daily living) self-care performance deficit related to MS ([CONDITION(S)]), wheelchair bound she prefers 18 revealed the following, FOCUS: has an ADL (activities of to wear hospital gown despite having clothing from home. INTERVENTIONS: Bilateral quarter bed rails for mobility and reposition. An interview was conducted on 6/27/22 at 1:35 PM with Resident #66. When asked if the resident used the side rails, Resident #66 stated, Oh yes, I use them to help myself turn and get repositioned. An interview was conducted on 6/28/22 at 2:40 PM with OSM (other staff member) #2, the maintenance technician. When asked for the evidence of the annual bed safety inspection, OSM #2 stated, No, there is nothing in TELS (team electronic library system) for all beds. When asked what was checked on the beds, OSM #2 stated, we look at the side rails every week, but we do not track the bed rails. The previous director told me everything was in the computer and to not worry about tracking anything on paper. When asked if OSM #2 was given specific room and bed numbers, could a report of inspection for that bed be ran, OSM #2 stated, no, there is no report for specific beds. When asked for the manufacturer's recommendation for checking the side rails, OSM #2 stated, no I do not have that information. When asked how OSM #2 was checking bed rails per the manufacturers, OSM #2 stated, I am not sure, this is my first time seeing this policy. OSM #2 stated, this is all the information I have as we were provided a TELS Logbook Documentation form which revealed the following: Beds & Mattresses: Inspect Bed Rails: Maintenance Check: Inspect connectors on rails and tighten as necessary. Remove any burs or rough edges to prevent injury. Verify the function on the spring latch-knob assembly, if applicable. Ensure the latch is free of dirt and/or foreign material that could impair its function. Ensure that the rails engage and lock as specified. Tighten, adjust or replace any parts such as end caps, knobs, bolts, screws, etc., that are loose, show signs of wear or are missing. The facility policy, Side Rail/Bed Rail was reviewed. This policy documented, Policy: The Center, will attempt alternative interventions, and document in the medical record, prior to the use of side rail/bed rail. Side rail/bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. Procedure: 1. prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/or resident representative. 3. Obtain consent from the resident and/or resident representative. 4. Obtain physician order for side rail/bed rail. 5. Update the care plan and kardex. 6. Re-evaluate the use of side rail/bed rail, quarterly, with a change in condition or as needed. 7. Follow the manufacturers' recommendations and specifications for installing and maintaining side rails/bed rails. The policy did not address routine or periodic maintenance and inspections of side rails and beds. The facility did not have a manual of the manufacturer's recommendations and specifications for the side rails. The facility was not logging and tracking routine or periodic bed and side rail inspections. On 6/29/22 at 12:40 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was provided prior to exit. 3. The facility staff failed to inspect Resident #96's bed for risk of entrapment. Resident #96 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: [CONDITION(S)] and [CONDITION(S)]. Resident #96's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/18/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status, coded the resident as requiring extensive assistance in bed mobility and transfers. Observation of Resident #96 revealed the resident was resting in bed on 6/27/22 at 1:30 PM, 6/28/22 at 9:15 AM and 6/29/22 at 8:15 AM. Grab bars/assist rails bilateral were observed to be in use. On 6/27/22 at 5:00 PM, a request was made for evidence of the documentation of the annual bed safety inspection for the entire facility. There was no evidence of the requested documentation for Resident #96. The physician's order dated 10/19/21, revealed the following, Grab bars/assist rails bilateral to aid in bed mobility and repositioning. A review of the side rail evaluation dated 1/26/22, revealed the following, Bed mobility: will the bed rail (s) assist the resident in turning side to side/holding self to one side? Yes. Recommendations: Assist rail/grab bar recommended. A review of Resident #96's care plan dated 11/1/18 revealed the following, FOCUS: ADL (activities of daily living) self-care performance deficit related to debility, knee pain and [CONDITION(S)]. INTERVENTIONS: Side rails: ¼ rails to aid in bed mobility. An interview was conducted on 6/27/22 at 1:30 PM with Resident #96. When asked if the resident used the side rails, Resident #96 stated, Yes, I use them to help turn in bed. An interview was conducted on 6/28/22 at 2:40 PM with OSM (other staff member) #2, the maintenance technician. When asked for the evidence of the annual bed safety inspection, OSM #2 stated, No, there is nothing in TELS (team electronic library system) for all beds. When asked what was checked on the beds, OSM #2 stated, we look at the side rails every week, but we do not track the bed rails. The previous director told me everything was in the computer and to not worry about tracking anything on paper. When asked if OSM #2 was given specific room and bed numbers, could a report of inspection for that bed be ran, OSM #2 stated, no, there is no report for specific beds. When asked for the manufacturer's recommendation for checking the side rails, OSM #2 stated, no I do not have that information. When asked how OSM #2 was checking bed rails per the manufacturers, OSM #2 stated, I am not sure, this is my first time seeing this policy. OSM #2 stated, this is all the information I have as we were provided a TELS Logbook Documentation form which revealed the following: Beds & Mattresses: Inspect Bed Rails .Maintenance Check: Inspect connectors on rails and tighten as necessary. Remove any burs or rough edges to prevent injury. Verify the function on the spring latch-knob assembly, if applicable. Ensure the latch is free of dirt and/or foreign material that could impair its function. Ensure that the rails engage and lock as specified. Tighten, adjust or replace any parts such as end caps, knobs, bolts, screws, etc., that are loose, show signs of wear or are missing. The facility policy, Side Rail/Bed Rail was reviewed. This policy documented, Policy: The Center, will attempt alternative interventions, and document in the medical record, prior to the use of side rail/bed rail. Side rail/bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. Procedure: 1. Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/or resident representative. 3. Obtain consent from the resident and/or resident representative. 4. Obtain physician order for side rail/bed rail. 5. Update the care plan and kardex. 6. Re-evaluate the use of side rail/bed rail, quarterly, with a change in condition or as needed. 7. Follow the manufacturers' recommendations and specifications for installing and maintaining side rails/bed rails. The policy did not address routine or periodic maintenance and inspections of side rails and beds. The facility did not have a manual of the manufacturer's recommendations and specifications for the side rails. The facility was not logging and tracking routine or periodic bed and side rail inspections. On 6/29/22 at 12:40 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was provided prior to exit. 4. Resident #45 was observed in bed with bilateral half length side rails up bilaterally on 6/27/22 at 2:30 PM. The facility was not able to evidence that any bed inspections were done to ensure the safety of the side rails. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 4/27/22, Resident #45 scored a 13 out of a possible 15 on the BIMS (Brief Interview for Mental Status). The resident was coded as requiring supervision for eating and extensive to total care for all other areas of activities of daily living. On 6/27/22 at 2:30 PM, Resident #45 was observed in bed with bilateral half length side rails up bilaterally. A review of the clinical record revealed a physician's order dated 2/10/21 for Bilateral 1/4 side rails to aid in positioning and mobility. Further review of the clinical record revealed side rail assessments completed on 2/10/21, 3/9/21, 4/28/21, 7/21/21, and 10/21/21. An Informed Consent for Use of Bed Rails was completed on 2/10/21. A review of the comprehensive care plan revealed one dated 10/2/18 for [Resident #45] has an ADL (activities of daily living) self-care performance deficit r/t (related to) aging process, Arthritis and limited mobility. This care plan included an intervention dated 10/2/18 and revised on 2/10/21 for SIDE RAILS: Bilateral 1/4 side rails to aid in positioning and mobility. On 6/28/22 at 2:41 PM, an interview was conducted with OSM #2 (Other Staff Member) the Maintenance Technician. She stated that she checks for side rail and bed safety. She stated that she does not log or track bed and side rail inspections and what components were inspected and what bed and/or room number and date of inspection. When asked about a manufacturer's manual for recommendations and specifications, she stated that she does not have one. She stated that she has not had a maintenance director for about 6 months and was told not to worry about anything on paper, just follow what is in the electronic maintenance system. OSM #2 then provided a print out from the facility's electronic maintenance system. A review of this facility document revealed instructions for how to conduct bed and side rail inspections but still did not evidence that any actual inspections of any beds or dates of inspections. It also did not address the frequency of conducting the inspections. This document, Beds & Mattresses: Inspect Bed Rails documented, Maintenance Check: Inspect connectors on rails and tighten as necessary. Remove any burs or rough edges to prevent injury. Verify the function on the spring latch-knob assembly, if applicable. Ensure the latch is free of dirt and/or foreign material that could impair its function. Ensure that the rails engage and lock as specified. Tighten, adjust or replace any parts such as end caps, knobs, bolts, screws, etc., that are loose, show signs of wear or are missing. The facility policy, Side Rail/Bed Rail was reviewed. This policy documented, Policy: The Center, will attempt alternative interventions, and document in the medical record, prior to the use of side rail/bed rail. Side rail/bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. Procedure: 1. Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/or resident representative. 3. Obtain consent from the resident and/or resident representative. 4. Obtain physician order for side rail/bed rail. 5. Update the care plan and kardex. 6. Re-evaluate the use of side rail/bed rail, quarterly, with a change in condition or as needed. 7. Follow the manufacturers' recommendations and specifications for installing and maintaining side rails/bed rails. The policy did not address when and how to conduct any routine or periodic maintenance and inspections of side rails and beds and tracking documentation of these inspections. The facility did not have a manual of the manufacturer's recommendations and specifications for the side rails as documented in the policy. The facility was not logging and tracking routine or periodic bed and side rail inspections. On 6/29/22 at approximately 1:00 PM, ASM #1 (Administrative Staff Member) the Executive Director, ASM #2 the Director of Nursing, and ASM #3 the Regional Director of Clinical Services, were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, family interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to accommodate a resident's need for a reclining chair for one of 39 residents in the survey sample, Resident #1 (R1). The facility staff failed to provide a reclining chair for R1 to enable the resident to get out of bed. The findings include: R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/14/22, R1 was coded as having no cognitive impairment for making daily decisions. R1 was coded as requiring the extensive assistance of staff members for transferring from bed to chair. R1 was observed on the following dates and times: 6/27/22 at 1:47 p.m. and 5:14 p.m.; 6/28/22 at 9:29 a.m. At all observations, R1 was sitting up in bed, with eyes closed. R1 had tube feeding running, and oxygen was administered at 2 liters per minute via [CONDITION(S)]. R1 was supported in bed by multiple pillows, and a positioning device at the foot of the bed was in place to prevent further foot drop. R1 was unavailable for interview throughout the survey due to being asleep at every observation. On 6/27/22 at 4:22 p.m., R1's spouse was interviewed. R1's spouse stated the only concern about R1's care at the facility was that the facility staff had not gotten R1 out of bed into a chair since R1 was readmitted from the hospital in June 2022. A review of R1's clinical record revealed the resident was discharged to the hospital on 6/7/22 and readmitted to the facility on [DATE]. A review of R1's point of care/ADL (activities of daily living) records for June 2022 revealed no evidence that R1 was transferred from bed to chair between 6/14/22 and 6/27/22. On 6/28/22 at 2:03 p.m., CNA (certified nursing assistant) #2 was interviewed. She stated she took care of R1 frequently. She stated, We haven't been getting out of bed because of the chair situation. When asked for more information, she stated R1 needed a reclining chair in order to get out of bed. She stated R1's chair disappeared while the resident was in the hospital, and the staff has not been able to find another one for the resident. When asked if the resident usually gets out of bed, she stated R1 usually gets out of bed on Monday, Wednesday, and Friday. She stated she did not know what happened to R1's reclining chair when the resident went to the hospital. When asked if she had reported this to anyone, she stated she had reported it to the unit manager. On 6/29/22 at 8:24 a.m., OSM #3, the director of rehabilitation, was interviewed. OSM #3 stated he was familiar with R1, as R1 had been a resident at the facility for several years. He stated he thought R1 did not require a specially fitted chair, but only required a generic reclining chair. He stated he had never encountered issues with the facility's reclining chair supply. He stated, I think we have one on each floor. He stated if a new reclining chair is needed, he goes first to the unit manager, then to the director of nursing or the executive director. He stated the resident did not need a therapy screening or referral in order to be approved for transfer by nursing from bed to a reclining chair. On 6/29/22 at 9:18 a.m., LPN (licensed practical nurse) #1, the interim unit manager, was interviewed. She stated she just became aware of R1's need for a reclining chair one the surveyors had arrived at the building. She stated when R1 was discharged to the hospital, another resident had an immediate need for a reclining chair, and the staff gave that resident R1's reclining chair. She stated, We had to make a choice. We had that one reclining chair. She stated, They are looking into getting a new chair for [R1]. She stated she is talking to our ED (executive director) about it. She stated the executive director has to get approval for the purchase. She stated she had spoken earlier with OSM #3, and had asked OSM #3 to help expedite the procurement of the recliner chair. She stated OSM #9, central supply clerk, would know whether a new chair had been ordered yet. On 6/29/22 at 9:23 a.m., OSM #9 was interviewed. He stated a new recliner chair had not yet been ordered. On 6/29/22 at 12:39 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #4, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Social Services - Accommodation of Needs, revealed no information related to the provision of medical equipment to meet the needs of the resident. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review it was determined that the facility staff failed to implement their abuse policy and procedures to ensure one of 39 residents in the survey sample was free from abuse, Resident #44. On 6/24/22, Resident #37 hit Resident #44, which required an emergency room visit where they were diagnosed with a closed fracture of the distal end of the left ulna (1), closed head injury, abrasion of the nose and a closed fracture of the nasal bone. The findings include: Resident #44's (R44) most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/1/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. Section E documented no behaviors. Section G documented R44 requiring supervision with transfers, walking in the room and corridors and locomotion on and off the unit. Section G documented R44 not having any impairment in the functional range of motion to the upper and lower extremities and being not steady but able to stabilize without staff assistance when walking. On 6/27/2022 at 5:14 p.m., an interview was conducted with R44 in their room. R44 was observed lying in bed and was observed to have a splint wrapped with an elastic bandage on the left forearm. When asked about the splint on the left forearm R44 stated that they were hit by another resident with a cane in the solarium at the end of the hallway the previous Friday. R44 stated that they had a fracture in the arm and a fractured nose from the incident. R44 stated that they had gone to the emergency room and they had taken x-rays, applied the splint and advised them to follow up with an orthopedic physician to see if they needed surgery or not. When asked about the resident who hit them, R44 indicated that Resident #37 (R37) had approached them in the solarium and started hitting them with a cane over nothing and they were crazy. R44 stated that the staff were keeping R37 in their room and were watching them all the time after the incident. The progress notes for Resident #44 documented in part; - 6/24/2022 20:19 (8:19 p.m.) Note Text: Resident alert no respiratory distress noted. Resident came to nurses station with blood on his shirt and nose, bruises and bump (swelling) behind left ear. resident c/o (complains of) pain of left arm. Resident stated he was lying on couch watching TV in the solarium when resident [Room number identifying R37] approached and accused him of messing up his puzzle in the solarium. Nursing supervisor notified who then notified DON (director of nursing) and called 911. Resident sent to ER (emergency room ) for evaluation and treatment. - 6/25/2022 00:20 (12:20 a.m.) Note Text: Resident back from [Name of hospital] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . New order of [MEDICATION(S)]-clavulanate ([MEDICATION(S)]) 875-125mg take 1 tablet by mouth 2 times daily for 7 days. Resident denied pain at this time, back in his room at this time will continue to monitor. The After Visit Summary dated 6/24/2022 for R44 from [Name of hospital] documented in part, .Reason for Visit: Facial laceration, arm injury. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .Imaging results: Wrist Left PA (postero anterior) lateral and oblique (final result) Redemonstrated mildly displaced ulnar fracture. No additional fracture or dislocation noted. Marked vascular calcifications are present .Forearm complete Left (final result) 1. Distal ulnar fracture 2. Dedicated 4 view study of the wrist is recommended to better evaluate the ulnar fracture and evaluate for underlying distal radial fracture .CT (computed tomography) head without contrast (final result) 1. No acute intracranial abnormality. 2. Right nasal bone fracture appears new compared to the prior exam . Resident #37's (R37) most recent MDS, a quarterly assessment with an ARD of 4/2/2022, the resident scored 15 out of 15 on the BIMS assessment, indicating the resident is cognitively intact for making daily decisions. Section E documented no behaviors. Section G documented R37 requiring supervision with transfers, walking in the room and corridors and locomotion on and off the unit. Section G further documented R37 being not steady but able to stabilize without staff assistance with walking and having no functional limitation in range of motion in the upper or lower extremities. Section G documented R37 using a walker. On 6/27/2022 at 1:56 p.m., an interview was conducted with R37 in their room. R37 was observed to have a staff member sitting outside of the room in a chair monitoring the room. R37 stated that the previous Friday they had a fight with another resident who lived across the hall. R37 stated that the police had come and the social worker had advised them they were going to be moved to another room. R37 stated that they did not understand why they were made to stay in their room and not allowed to go outside to smoke with their friends because they were only trying to defend themselves. R37 stated that the other resident hit them in their chest when they asked them a question and they had to fight back to protect themselves. R37 stated that they were disappointed because they were not able to walk around the facility currently or visit with their friends. When asked about the other resident, R37 stated that it was the resident in the room across the hall with the cast on the arm. R37 stated that they did not know why they had a cast now. R37 stated that the facility staff were making the fight into a bigger deal than it needed to be because they were just trying to defend themselves. The progress notes for Resident #37 documented in part; - 6/16/2022 11:00 (11:00 a.m.) .Behavioral problems are verbal behaviors (screaming, cursing, etc.) Screaming at Writer using foul Language told writer you are an animal go back where you came from with expletives. Slamming his door . - 5/4/2022 21:59 (9:59 p.m.) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Psych (psychiatry) deemed patient to have mental capacity discussed with DON. Patient is not safe to stay in the facility as he can be a risk to other residents or staff. - 5/4/2022 09:34 (9:34 a.m.) Note Text: slammed the door in my face. Resident asked if he can put his tray on the treatment cart, I said No, he cannot I asked him politely Can you give it to me please He handed the tray to me and slammed the door in my face. - 5/3/2022 18:13 (6:13 p.m.) Note Text: At approximately 2300 (11:00 p.m.) on 5/2 (5/2/2022), the evening nurse notified this writer that the damaged laptop was no longer working after resident poured water on it. Writer notified the police who returned to the facility at 0700 (7:00 a.m.) on 5/3 (5/3/2022) to document the destruction of property. Police stated that writer would have to go to magistrate independently to request the warrant for misdemeanor destruction of property. Police officers spoke with resident in the presence of the writer. Resident recounted the events of the previous night in great detail until the police asked, what happened with the water and the cart. Resident began stating he knew nothing about that started to become agitated. He stood up and left the interview saying, well if you are going to arrest me then arrest me. I would rather go to jail than be in the ****hole. Resident currently in room alone with 1:1 (one to one) supervision to ensure safety of those around him. Resident's guardian and physician updated on current status. - 5/2/2022 22:04 (10:04 p.m.) Note Text: This wirter [sic] received call from the nurse on resident's unit at approximately 8:45pm. Nurse reported that resident was upset about pain medication being administered every 6 hours instead of every 2 hours and that he was disrupting the unit. Writer could hear resident yelling in the background loudly and calling the nurse obscene names. Nurse reported that resident was slamming doors, yelling loudly and grabbed the unit phone off of the wall. The nurse stated that resident tried to pull the door shut when she attempted to enter to attend to [R37]'s roommate. Nurse also reported that resident intentionally knocked over the ice pitcher on the medication cart, damaging the medication laptop. Writer notified police and they responded to the building. Writer spoke with police officers on site who stated, well there is not much we can do in this setting other than speak with him and document. Police officer reported that resident was calm upon their arrival and denied doing anything the [sic] medication cart. Police officer stated the laptop remained on and working, but that if is [sic] stopped working to call back to document the damage. Increased supervision provided by CNAS (certified nursing assistants) during the remainder of the shift. Writer left message for resident's guardian and physician regarding his behavior. Writer also notified psych (psychiatrist), who stated he would come in the morning to see the resident. The geriatric psychiatry consult note dated 3/10/2022 for R37 documented in part, .asked to evaluate cognition. Pt (patient) is alert & engaging. Fully oriented. He admits he is easily frustrated. He feels staff don't care. He can be very aggressive verbally. Has been known to use racial slurs, hard to direct . The geriatric psychiatry consult note dated 5/3/2022 for R37 documented in part, .Pt has been struggling, he is frustrated he is here. Feels mistreated by staff. Last week was physically aggressive [medical abbreviation for with] behaviors that included breaking a laptop . The comprehensive care plan for R37 documented in part, [Name of R37] is at risk for behaviors (verbal/physical aggression, refusal of care, delusions) r/t (related to) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Initiated: 08/16/2021. Revision on: 11/08/2021. The FRI (facility reported incident) dated 6/25/2022 documented in part, .[Name of R44] reported resident-resident altercation that took place in the second floor solarium between himself and [Name of R37]. Head-to-toes assessment completed, [Name of R44] presented with nose bleed, and a bruise to the back of his neck. [Name of R37] sustained no injury. [Name of R44] transferred to the hospital for further evaluation. Responsible party and Physician notified. Resident send [sic] back to their room under 1:1 observation, one resident send to ED (emergency department) for further evaluation, facility investigation initiated including resident evaluations/interviews, staff interviews and staff education . On 6/28/2022 at 11:05 a.m., an interview was conducted with OSM (other staff member) #10, the director of social services. OSM #10 stated that they were not in the facility on 6/24/2022 when R37 and R44 had the altercation. OSM #10 stated that they were called and made aware of the incident that day and had followed up with both residents on 6/27/2022. OSM #10 stated that R37 had previous behaviors of slamming doors, destruction of facility property and being verbally abusive to staff members but had not displayed any aggression towards another resident that they were aware of prior to that day. OSM #10 stated that they had been attempting to find alternate housing for R37 since they had been to court and deemed competent but had not been able to find a safe discharge location for them. OSM #10 stated that R37 was alert and oriented and had stated that R44 had hit them in the chest first when they had interviewed them on 6/27/2022 regarding the incident. OSM #10 stated that the incident between R44 and R37 was not witnessed by any staff or other residents. OSM #10 stated that since 6/24/2022, R37 had been on 1 to 1 monitoring and staff were with them if they left the room for anything. OSM #10 stated that R44 had never displayed any behaviors and was always a quiet person who enjoyed sitting in the Solarium watching television. On 6/28/2022 at 12:54 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that R37 had anger issues and would throw things at staff when they became angry. LPN #7 stated that there were times when R37 was very pleasant and charming to the staff. LPN #7 stated that they were not aware of any aggression from R37 towards another resident prior to the altercation with R44 on 6/24/2022. LPN #7 stated that they had kept R37 in their room with 1 to 1 monitoring and a chaperone if they left the room since the altercation on 6/24/2022. LPN #7 stated that R44 had never displayed any aggressive behaviors and was always very social and friendly. LPN #7 stated that any resident to resident altercation was intervened upon and the residents were separated and it was immediately reported to the director of nursing or administrator. LPN #7 stated that both R37 and R44 were alert and oriented to person, place, time and situation. On 6/28/2022 at 2:00 p.m., an interview was conducted with LPN #1, unit manager. LPN #1 stated that R37 would lash out at staff at times and it was like walking on eggshells. LPN #1 stated that R37 had destroyed a facility laptop and did not care. LPN #1 stated that they had to keep other residents out of the way when R37 lashed out at the staff. LPN #1 stated that they were not aware of any incidents with other residents prior to 6/24/2022 with R37. LPN #1 stated that R37 mostly had verbal behaviors that were off and on. LPN #1 stated that they had not had any conversations with R37 since the incident on 6/24/2022. LPN #1 stated that R44 had no history of any behaviors and was always pleasant. On 6/28/2022 at 2:11 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that R37 was competent and had been to court to have the guardianship lifted. ASM #2 stated that R37 had previously damaged a facility laptop when the nurse would not give them additional pain medications. ASM #2 stated that the police had come at that time and R37 had lied to the police saying they did not remember anything. ASM #2 stated that R37 did not lack capacity and the police knew they were lying but could not do anything. ASM #2 stated that the previous DON (director of nursing) had moved R37 to a private room and placed them on 1 to 1 monitoring at that time and there had been no further behaviors. ASM #2 stated that they had ended the 1 to 1 monitoring around 5/24/2022 because R37 was not displaying any behaviors and the physician had determined that it could be lifted. ASM #2 stated that they were having the physician fax over a note documenting this. ASM #2 stated that they felt that R37 waited until late on 6/24/2022 after administrative staff had left for the day before approaching R44 in the solarium. ASM #2 stated that on 6/24/2022 after 8:00 p.m., they received a phone call from the facility saying that R44 had been hit with a cane and was going to the hospital. ASM #2 stated that when they arrived R44 had already left for the hospital and R37 was in their room. ASM #2 stated that they spoke with R37 that night they said they did it because R44 touched their puzzle. ASM #2 stated that R37 had cussed me out when they were told they were going to have the 1 to 1 monitoring and going to move to another room. ASM #2 stated that they left the facility prior to R44 coming back from the hospital. ASM #2 stated that they saw R44 on 6/27/2022 with the bruise on the neck, broken nose and arm. ASM #2 stated that they asked R44 why they did not call for help on 6/24/2022 and what happened. ASM #2 stated that R44 explained that R37 thought they messed up their puzzle. ASM #2 stated that R44 would not press charges against R37 because they did not want them to get into trouble. ASM #2 stated that R37's actions were criminal. On 6/28/2022 at 4:36 p.m., an interview was conducted with CNA (certified nursing assistant) #9. CNA #9 stated that they were working on 6/24/2022 when the altercation between R37 and R44 occurred. CNA #9 stated that near the end of the evening shift they were at the nurses station when R44 came up to the nurses station with blood on their nose and said that R37 had hit them with a cane. CNA #9 stated that R44 had told them that R37 had accused them of messing up their puzzle. CNA #9 stated that the nurse had called 911 to send R44 to the emergency room and they had made sure R37 was in their room and monitored 1 on 1. CNA #9 stated that there were no staff or residents who witnessed the incident. CNA #9 stated that R44 normally sat down in the solarium every day watching television. CNA #9 stated that R37 was verbally abusive to staff at times and had slammed doors at times. CNA #9 stated that if a resident to resident altercation was witnessed they immediately separated the residents and called for help. CNA #9 stated that they reported any incidents to the nurse. CNA #9 stated that they reported this because residents could abuse other residents. On 6/29/2022 at 10:08 a.m., an interview was conducted with ASM #5, medical doctor. ASM #5 stated that they care for R37. ASM #5 stated that when R37 gets emotional they could become dangerous and verbally difficult and act out. ASM #5 stated that normally R37 was not dangerous. ASM #5 stated that R37 had destroyed some property but they did not feel that they could give someone a concussion. ASM #5 stated that they had not seen R37 since the incident on 6/24/2022 with R44 but based on what was going on with them they felt that everything was behavioral. ASM #5 stated that they felt that if R37 did not get what they wanted things would keep happening and R37 needed to be safely discharged . ASM #5 stated that they had recommended for the 1 on 1 monitoring to continue and for nursing to keep working on a safe discharge. ASM #5 stated that they felt that R37 did not like R44 for some reason and was mad at them. The facility policy Abuse, Neglect, Exploitation & Misappropriation with a revision date of 11/28/2017 documented in part, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Furthermore, the Administration of The Company recognizes that resident abuse can be committed by other residents, visitors, or volunteers . The policy further documented, .The center is committed to the prevention of abuse, neglect, misappropriation of resident property, and exploitation. The following systems have been implemented: .Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition or other non-verbal indication of abuse . On 6/28/2022 at 5:30 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the concern. No further information was provided prior to exit. Reference: 1. ulna Of the 206 bones in your body, three of them are in your arm: the humerus, radius, and ulna. this information was obtained from the website: https://medlineplus.gov/arminjuriesanddisorders.html

Based on resident interview, staff interview, facility document review and clinical record review it was determined that the facility staff failed to report to the State Survey Agency timely, an allegation of abuse, for one of 39 residents in the survey sample, Resident #44; which required an emergency room visit where they were diagnosed with a closed fracture of the distal end of the left ulna (1), closed head injury, abrasion of the nose and a closed fracture of the nasal bone. The findings include: Resident #44's (R44) most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/1/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. Section E documented no behaviors. On 6/27/2022 at 5:14 p.m., an interview was conducted with R44 in their room. R44 was observed lying in bed and was observed to have a splint wrapped with an elastic bandage on the left forearm. When asked about the splint on the left forearm R44 stated that they were hit by another resident with a cane in the solarium at the end of the hallway the previous Friday. R44 stated that they had a fracture in the arm and a fractured nose from the incident. R44 stated that they had gone to the emergency room and they had taken x-rays, applied the splint and advised them to follow up with an orthopedic physician to see if they needed surgery or not. When asked about the resident who hit them, R44 indicated that Resident #37 (R37) had approached them in the solarium and started hitting them with a cane over nothing and they were crazy. R44 stated that the staff were keeping R37 in their room and were watching them all the time after the incident. The progress notes for Resident #44 documented in part, - 6/24/2022 20:19 (8:19 p.m.) Note Text: Resident alert no respiratory distress noted. Resident came to nurses station with blood on his shirt and nose, bruises and bump (swelling) behind left ear. resident c/o (complains of) pain of left arm. Resident stated he was lying on couch watching TV in the solarium when resident [Room number identifying R37] approached and accused him of messing up his puzzle in the solarium. Nursing supervisor notified who then notified DON (director of nursing) and called 911. Resident sent to ER (emergency room ) for evaluation and treatment. - 6/25/2022 00:20 (12:20 a.m.) Note Text: Resident back from [Name of hospital] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . New order of [MEDICATION(S)]-clavulanate ([MEDICATION(S)]) 875-125mg take 1 tablet by mouth 2 times daily for 7 days. Resident denied pain at this time, back in his room at this time will continue to monitor. The After Visit Summary dated 6/24/2022 for R44 from [Name of hospital] documented in part, .Reason for Visit: Facial laceration, arm injury. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .Imaging results: Wrist Left PA (postero anterior) lateral and oblique (final result) Redemonstrated mildly displaced ulnar fracture. No additional fracture or dislocation noted. Marked vascular calcifications are present .Forearm complete Left (final result) 1. Distal ulnar fracture 2. Dedicated 4 view study of the wrist is recommended to better evaluate the ulnar fracture and evaluate for underlying distal radial fracture .CT (computed tomography) head without contrast (final result) 1. No acute intracranial abnormality. 2. Right nasal bone fracture appears new compared to the prior exam . Resident #37's (R37) most recent MDS, a quarterly assessment with an ARD of 4/2/2022, the resident scored 15 out of 15 on the BIMS assessment, indicating the resident is cognitively intact for making daily decisions. Section E documented no behaviors. On 6/27/2022 at 1:56 p.m., an interview was conducted with R37 in their room. R37 was observed to have a staff member sitting outside of the room in a chair monitoring the room. R37 stated that the previous Friday they had a fight with another resident who lived across the hall. R37 stated that the police had come and the social worker had advised them they were going to be moved to another room. R37 stated that they did not understand why they were made to stay in their room and not allowed to go outside to smoke with their friends because they were only trying to defend themselves. R37 stated that the other resident hit them in their chest when they asked them a question and they had to fight back to protect themselves. R37 stated that they were disappointed because they were not able to walk around the facility currently or visit with their friends. When asked about the other resident, R37 stated that it was the resident in the room across the hall with the cast on the arm. R37 stated that they did not know why they had a cast now. R37 stated that the facility staff were making the fight into a bigger deal than it needed to be because they were just trying to defend themselves. The progress notes for Resident #37 documented in part: - 6/28/2022 13:46 (1:46 p.m.) Note Text: Addendum- On 6/24/2022 resident [Room number identifying R44] came to nurses station with blood on his nose, bruises and bump (swelling) behind his left ear. There was also blood on his shirt. Resident [Room number identifying R44] c/o pain on left hand. [Room number identifying R44] stated that he was lying on the couch watching TV in the solarium when above resident [Room number identifying R37] approached and accused him of messing up his puzzle in the solarium. [Room number identifying R44] stated he did not know anything about his puzzle. Then [Room number identifying R37] struck [Room number identifying R44] with his walking cane repeatedly. [Room number identifying R44] stated he used his left arm to cover and protect his face. [Room number identifying R37] then hit his arm too. [Room number identifying R44] ran to nurses station reported writer. Writer called nursing supervisor who then reported to DON and called 911. Resident [Room number identifying R44] was sent to [Name of hospital] ER (emergency room ) for evaluation and treatment. The FRI (facility reported incident) dated 6/25/2022 documented in part, Facility Name: [Name of Facility], Report Date: 06/25/2022, Incident Date: 06/24/2022 . The FRI further documented, .[Name of R44] reported resident-resident altercation that took place in the second floor solarium between himself and [Name of R37]. Head-to-toes assessment completed, [Name of R44] presented with nose bleed, and a bruise to the back of his neck. [Name of R37] sustained no injury. [Name of R44] transferred to the hospital for further evaluation. Responsible party and Physician notified. Resident send [sic] back to their room under 1:1 observation, one resident send to ED (emergency department) for further evaluation, facility investigation initiated including resident evaluations/interviews, staff interviews and staff education . The attached fax confirmation documented notification to the state agency on 6/25/2022 at 16:37 (4:37 p.m.). On 6/28/2022 at 2:11 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that on 6/24/2022 after 8:00 p.m., they received a phone call from the facility saying that R44 had been hit with a cane and was going to the hospital. ASM #2 stated that when they arrived at the facility, R44 had already left for the hospital and R37 was in their room. ASM #2 stated that they left the facility prior to R44 coming back from the hospital. ASM #2 stated that they had come back to the facility on [DATE] to send the FRI to the state agency. ASM #2 stated that they had come to the facility on [DATE] because they thought that they had a two hour window to report the incident and they had debated on the window. ASM #2 stated that they had reviewed their policy and talked with a corporate contact who advised them that they had twenty-four hours to send the report. ASM #2 stated that when they came in on 6/24/2022 they knew that R37 had hit R44 and caused bodily injury requiring them to have to go to the emergency room so they may have dropped the ball on sending the report in the two hour timeframe. The facility policy Reporting Reasonable Suspicion of a Crime with a revision date of 11/28/2017 documented in part, .If the event that causes the reasonable suspicion results in serious bodily injury, the report must be made immediately after forming the suspicion (but not later than 2 hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming the suspicion. 3. Where an alleged violation of abuse, neglect, misappropriation of resident property, or exploitation also gives rise to a reasonable suspicion of a crime, reports will be made to the Administrator, to the State Survey Agency, and to local law enforcement .Time period for Individual Reporting, Serious Bodily Injury- 2 hour limit: If the event that caused the reasonable suspicion results in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion . On 6/28/2022 at 5:30 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the concern. No further information was provided prior to exit. Reference: 1. ulna Of the 206 bones in your body, three of them are in your arm: the humerus, radius, and ulna. this information was obtained from the website: https://medlineplus.gov/arminjuriesanddisorders.html

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to complete a significant change MDS for one of 39 residents in the survey sample, Resident #82. Resident #82 was admitted to hospice on 12/22/21. There was no significant change MDS completed for the provision of hospice services. The findings include: On the most recent MDS (Minimum Data Set) a quarterly assessment with an ARD (Assessment Reference Date) of 6/8/22, Resident #82 scored a 15 out of a possible 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was cognitively intact in ability to make daily life decisions. The resident was coded as requiring supervision for eating and extensive to total care for all other areas of activities of daily living. A review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed a nurse's note dated 12/22/21 that documented, Resident admitted into [name of] Hospice, with Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the above MDS for Section O Special Treatments, Procedures, and Programs revealed Resident #82 as being coded for hospice. The MDS prior to this was also a quarterly MDS, dated [DATE] and also coded the resident as being on hospice. However, further review of the MDS's revealed that the most recent significant change MDS was dated 12/6/21, before the resident was ordered hospice services. The resident was not coded on this MDS as being on hospice. There were no significant change MDS's completed to reflect the significant change of beginning admitted to hospice services, in conjunction with either the 12/22/21 hospice order or 4/1/22 hospice order. On 6/29/22 at 9:30 AM, an interview was conducted with RN #1 (Registered Nurse) the MDS nurse. She stated that when a resident goes on or off of hospice services, a significant change MDS has to be done. She reviewed the clinical record and verified that it was not done. When asked about policies for completing the MDS, she stated the facility uses the RAI Manual. A review of the RAI Manual (Resident Assessment Instrument) Version 1.17.1 dated October 2019, documented as follows: On page 2-22, Assessment Management Requirements and Tips for Significant Change in Status Assessments and continued on page 2-23 was documented, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). 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 . On page O-5 was documented, O0100: Special Treatments, Procedures, and Programs: O0100K, Hospice care - Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider . On 6/29/22 at approximately 1:00 PM, ASM #1 (Administrative Staff Member) the Executive Director, ASM #2 the Director of Nursing, and ASM #3 the Regional Director of Clinical Services, were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to complete an accurate MDS (minimum data set) assessment for one of 39 residents in the survey sample, Resident #90. The facility staff failed to complete an accurate annual assessment MDS for Resident #90. The findings include: Resident #90 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #90's most recent MDS, an annual assessment, with an assessment reference date of 3/29/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section J1300- coded the resident as current tobacco use no. A review of Resident #90's care plan dated 9/17/19 revealed the following, FOCUS: Resident is a smoker. INTERVENTIONS: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. A review of the smoking evaluations revealed that smoking evaluations had been completed for Resident #90 on 9/1/20, 12/1/20, 3/1/21, 11/24/21 and 3/3/22. A review of the smoking evaluation dated 3/3/22 revealed, Summary of Evaluation: Resident is determined to be a safe smoker. On entrance a request was made for the smoking times and locations as well as a list of residents that smoke. The smoking times listed were 8-8:15 AM, 1:15-1:30 PM, 4-4:15 PM and 6:15-6:30 PM. Resident #90 was on the list. Resident #90 was observed during the smoking time at 4:00 PM on 6/27/22. An interview was conducted on 6/27/22 at 4:00 PM with Resident #90, when asked how long she has been smoking at the facility, Resident #90 stated, I have been smoking since I came here. An interview was conducted on 6/29/22 at 9:25 AM with RN (registered nurse) #1, the MDS coordinator. When asked to review Resident #90's 3/29/22 MDS, RN #1 stated, .tobacco use coded as no. I see that it was done by another coordinator, probably what she (MDS coordinator) did was look at the 7 day look-back period and she looked for documentation. There is hardly any progress notes, she would have looked for the safe smoking evaluation, but maybe didn't use it because it was outside of the 7 day window (3/3/22). I see it is on the care plan and dated 2019. I was not here, she probably just looked at progress notes. If I was coding this, I would have called the nurses after seeing smoking on the care plan. Technically no it is not accurate, she should have looked at the care plan. When asked what the standard is for the MDS coding, RN #1 stated, We use the RAI (Resident Assessment Instrument) manual. On 6/29/22 at 12:40 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and services according to professional standards to maintain a resident's highest level of well-being, resulting in harm for one of 51 residents in the survey sample, Resident #16. The facility staff failed to implement the proper positioning technique while repositioning Resident #16 in bed on 2/14/19. CNA (Certified nursing assistant) #7 repositioned Resident #16 by grabbing both sides of the resident's torso and pulling on the resident. This improper technique resulted in a right shoulder dislocation and a transfer to the emergency room for a dislocation reduction (returning the shoulder to the normal position) under sedation. The findings include: Resident #16 was admitted to the facility on [DATE]. Resident #16's [DIAGNOSES REDACTED]. Resident #16's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/23/19, coded the resident as being cognitively intact. Section G coded Resident #16 as requiring extensive assistance of two or more staff with bed mobility. Resident #16's quarterly MDS assessment with an ARD of 12/21/18 coded the resident as being cognitively intact. Section G coded Resident #16 as requiring extensive assistance of one staff with bed mobility. Resident #16's comprehensive care plan dated 9/24/18 documented, (Name of Resident #16) has an ADL (activities of daily living) self-care performance deficit r/t (related to) left BKA ([MEDICAL CONDITION]) and burn wounds to right leg .Interventions: BED MOBILITY: (Name of Resident #16) requires extensive assistance by (1-2) staff to turn and reposition in bed at times and at times is able to turn self with use of quarter side rails . Review of Resident #16's clinical record revealed a nurse's note dated 2/14/19 that documented Resident #16 complained of right arm and shoulder pain. The night shift supervisor and physician were notified, a physician order [REDACTED]. A right shoulder x-ray dated 2/14/19 documented an anterior dislocation of the humerus (arm/shoulder). Resident #16 was transferred to the emergency roiagnom on [DATE]. An emergency room history and physical dated 2/14/19 documented Resident #16's shoulder dislocation was reduced under sedation. A FRI (facility reported incident) form submitted to the state agency on 2/14/19 documented, Report date: 2/14/19 Incident date: 2/14/19 Describe incident, including location, and action taken: On 2/14/19 resident (name of Resident #16) complained of pain to her right shoulder. Resident medicated for pain and STAT (immediate) x-ray was completed. At approximately 2:30 pm Director of Nursing, (name), received x-ray results showing the resident had an anterior dislocation of the right humerus. MD (Medical doctor) notified and orders received to send resident to the ER (emergency room ). DON (Director of nursing) spoke with resident who stated the night CNA 'pulled' her arm to try to get her back in bed. CNA identified as (name of CNA #7). Employee suspended immediately pending investigation. Local police notified . A final FRI report form submitted to the state agency on 2/20/19 documented, Summary of Investigation: (Name of Resident #16) is a [AGE] year old female resident, initially admitted to the Center on 9/14/18. (Name of Resident #16's) medical [DIAGNOSES REDACTED]. (Name of Resident #16's) most recent BIMS (brief interview for mental status) (a scale to rate the level of one's cognition) was 14 (on a scale from 0 to 15). (Name of Resident #16) has a low to the floor bed with mats on the floor due to a care planned behavior of crawling out of bed on to the floor. On 2/14/19 at approximately 6:55 am CNA (name of another CNA) entered (Name of Resident #16's) room to provide morning care to her. (Name of other CNA) stated that (sic) asked (Name of Resident #16) if she was ready to get up and (name of Resident #16) replied, 'No way.' (Name of other CNA) asked (name of Resident #16) why she did not want to get up and (name of Resident #16) replied, 'My arm is killing me.' (Name of other CNA) asked what happened to her arm and (name of Resident #16) replied, 'it was how the night aide moved me.' (Name of other CNA) informed the nurse, (name of LPN (licensed practical nurse) #12), who medicated (name of Resident #16) with PRN (as needed) [MEDICATION NAME] (1). (Name of LPN #12) evaluated (name of Resident #16) and notified the physician, who ordered a STAT (immediate) x-ray of the right arm. After receiving the pain medication (name of Resident #16) told (name of LPN #12) she was 'okay.' (Name of other CNA) stated that after (name of Resident #16) received pain medication she requested to get up into the wheelchair. (Name of LPN #12) notified the night shift supervisor, (name) at approximately 7:10 am saying (name of Resident #16) had a complaint about how the night aide 'positioned her.' (Name of ASM (administrative staff member) #2 (the director of nursing)) arrived at the Center at approximately 7:55 am and went to speak with (name of Resident #16). When (name of ASM #2) asked (name of Resident #16) what happened during the night she replied, 'I don't want to talk about it right now.' (Name of Resident #16) denied pain at that time but was observed holding her right arm close to her body. (Name of ASM #2) spoke with the night shift CNA, (name of CNA #7), regarding what occurred during the night shift with (name of Resident #16). (Name of CNA #7) stated that she pulled the resident up in bed at approximately 1:00 am but that she did not complain of any pain at that time or throughout the night. X-ray of the right shoulder and arm was completed at approximately 12:00 pm. The Director of Nursing received the results at approximately 2:30 pm showing an anterior dislocation of the right humerus. The physician was notified and a new order was received to send the resident to the emergency room for evaluation and treatment. (Name of ASM #2) went to notify (name of Resident #16) of the ordered transfer and speak with her about what occurred. (Name of Resident #16) stated, 'it was the night aide, she pulled me up in bed by my arm.' (Name of Resident #16) stated she was checking on some things in the hallway when the CNA, (name of CNA #7), entered the room and pulled her up in bed by her arm. (Name of Resident #16) stated her roommate was asleep and there was no other employee in the room when this occurred. (Name of ASM #2) notified the local police who responded to the Center and interviewed (name of Resident #16). The police officers asked (name of Resident #16) to explain what occurred during the night shift. (Name of Resident #16) stated the incident occurred around 1:00 am. (Name of Resident #16) stated she was 'checking on somethings (sic) in the hallway,' when the CNA entered the room and 'pulled me up' by her arm. The police officer asked (name of Resident #16) if the CNA was yelling at her or saying bad things to her and (name of Resident #16) replied, 'No, but she wasn't in a good mood.' The police officer then asked (name of Resident #16) if she felt the CNA had intentionally hurt her and (name of Resident #16) replied, Intentionally? No.' The police officer then asked (name of Resident #16) if she felt the CNA 'just got her improperly into bed?' and (name of Resident #16) replied, 'Yes.' On 2/15/19 (name of ASM #2) had an additional interview with (name of CNA #7) regarding the care she provided to (name of Resident #16) during the night of 2/14/19. (Name of CNA #7) stated that at approximately 1:00 am she observed (name of Resident #16's) call light on and she went to the room. Upon entering the room (name of CNA #7) stated she observed (name of Resident #16's) bed very high in the air and she was sitting with her legs dangling near the foot of the bed. (Name of CNA #7) stated that she was concerned (name of Resident #16) was going to fall so she laid her down and then pulled her up in bed by grabbing both sides of her torso. (Name of CNA #7) stated there was no pad or draw sheet underneath (name of Resident #16) to aid in pulling her up in bed. (Name of CNA #7) stated after she positioned the resident in bed and lowered the bed to the floor; (LPN #7) entered the room and provided medication to (name of Resident #16). (Name of CNA #7) stated she checked on (name of Resident #16) every 1.5-2 hours throughout the night and she made no complaints of pain and was observed sleeping during the remainder of the shift. Based on the completed investigation the Center has determined that (name of Resident #16) obtained a dislocation of the right humerus due to improper positioning technique performed by a CNA. Corrective Measures Implemented to Prevent Recurrence: 1. (Name of CNA #7) is no longer employed at the Center. 2. Facility staff re-educated about abuse, neglect, and injuries of unknown origin. 3. Licensed nursing staff re-educated about safe methods to position and reposition residents . A witness statement signed by CNA #7 on 2/14/19 documented, I was assign (sic) to (name of Resident #16). At around 1 AM resident pull (sic) the call light and I went there. I met her at the feet (sic) of the bed and I help (sic) her by putting my hands around her and pull (sic) her up on the bed. A witness statement signed by CNA #7 on 2/15/19 documented, When I came on duty I met the resident. Call light was on and I met the resident sitting on the edge of the bed which is by the feet (sic) side and I (blank space) her down on the bed and I put my hands around her body and I pull her up the bed and I position her while I was doing that the nurse went in the room to give her a medication and I also told her that she was trying to hurt herself. She was putting the bed all the way up and the nurse told me that (sic) the same thing she was doing yesterday which was on Tuesday and I put the bed down and I hide (sic) the bed remote so she will not get to it. Still then, I was been (sic) checking on her not complaind (sic) of any pain until when (name of another CNA) came in the morning. She was dress (sic) her. She came and tell (sic) the nurse that the resident complained (sic) that her shoulder is hurting her. On 1/29/20 at 9:41 a.m., an interview was conducted with Resident #16. Resident #16 was asked to describe the events that occurred in February 2019 when her right shoulder was dislocated. Resident #16 stated, I forgot what happened but I wound up on the floor and an aide came and dragged me by my arm and picked me up and put me back to bed by herself. Resident #16 stated she did not experience pain at that time but later on that same night she was lying in bed and felt pain. Resident #16 stated she told staff something was wrong with her shoulder and the staff obtained an x-ray. On 1/29/20 at 3:42 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked how a resident should be repositioned if he/she was on the edge of the bed at the foot of the bed. LPN #3 stated this depended on the resident. LPN #3 stated she would ask the resident to stand up, move over and sit back down if he/she was ambulatory. LPN #3 stated if the resident required physical assistance, then the staff should call someone to help and use a draw sheet to reposition the resident. LPN #3 stated two staff and a draw sheet should be utilized for a resident who requires physical assistance. LPN #3 was asked if a staff should reach around both sides of a resident and pull them up. LPN #3 stated a staff should not do this because he/she does not want to cause any injury. LPN #3 stated Resident #16 is able to sit up but will call if she needs assistance with positioning. LPN #3 confirmed the assistance of two staff and a draw sheet should be used if Resident #16 is seated at the foot and edge of the bed. On 1/29/20 at 4:19 p.m., an interview was conducted with CNA #5. CNA #5 stated residents' bed mobility and transfer needs are communicated to CNAs via a kardex. CNA #5 was asked how a resident should be repositioned if he/she was on the edge of the bed at the foot of the bed. CNA #5 stated the staff member should call for a co-worker and two people should reposition the resident using a draw sheet. CNA #5 stated, You don't pull them up. It's a no no no to pull them with their arms. You can dislocate something or injure them in another way. CNA #5 was asked what should be done if the resident does not have a draw sheet under them. CNA #5 stated a staff member should go get a draw sheet because a resident cannot be pulled by his/her arms. On 1/29/20 at 4:43 p.m., an interview was conducted with ASM #2. ASM #2 was asked to describe the events regarding Resident #16's dislocated right shoulder on 2/14/19. ASM #2 stated she was initially told that Resident #16 reported arm pain so an x-ray was obtained and showed a dislocated shoulder. ASM #2 stated there was no immediate explanation for the cause of the dislocation so Resident #16 was transferred to the hospital and she (ASM #2) began an investigation. ASM #2 stated CNA #7 told her that she entered Resident #16's room and the resident was almost falling off the edge of the bed. ASM #2 stated CNA #7 said she had to get Resident #16 back on the bed and prevent her from falling. ASM #2 stated CNA #7 said there was no pad or draw sheet on the bed and the bed was in a high position so CNA #7 grabbed Resident #16's waist on each side, pulled the resident up then put the bed in a low position and removed the bed remote. ASM #2 stated she asked CNA #7 why she didn't just lower the bed and get help instead of pulling the resident up or tell the resident to sit and yell for someone to help. ASM #2 stated CNA #7 only provided the response that the situation was critical. ASM #2 stated CNA #7 was terminated due to the improper positioning technique and because there was inconsistencies in her story. When asked to elaborate, ASM #2 stated CNA #7 said she got Resident #16 repositioned in bed then the nurse came in to administered medications but the nurse said Resident #16 was in a sitting position when she administered medications. ASM #2 stated Resident #16 said the CNA pulled her up in bed and the resident was reliable, alert and oriented. ASM #2 confirmed CNA #7 used an improper positioning technique. When asked what should have been done, ASM #2 stated a resident should be repositioned by two people using a draw sheet, pad or moving device; not by grabbing his/her body and physically moving him/her. ASM #2 was asked if this technique should be used even when a resident is on the edge of the bed. ASM #2 stated CNA #7 could have repositioned the resident's legs back on the bed and get staff to assist or stand with the resident and yell for help. ASM #2 stated she thought there were other ways the CNA could have repositioned Resident #16 without hurting her. ASM #2 was asked for the facility policy or standard of practice regarding positioning. ASM #2 stated she would look and the best practice is to have two people at all times for the safety of the resident and proper body mechanics for the staff. On 1/29/20 at 5:01 p.m., an interview was conducted with LPN #12 (the nurse caring for Resident #16 during the night shift on 2/14/19). LPN #12 stated that between 12:00 a.m. and 2:00 a.m. she was completing rounds and CNA #7 was in the room with Resident #12 and providing care. LPN #12 stated Resident #16 was lying down on the bed during her observation. LPN #12 stated a couple hours later, at approximately 5:15 a.m. or 5:30 a.m., a CNA told her that Resident #16 was complaining of her arm hurting. LPN #12 stated she talked to the resident who told her that her right arm and shoulder was hurting so she administered pain medication to the resident and notified the supervisor. LPN #12 stated someone else notified the physician and obtained an x-ray. On 1/29/20 at 5:10 p.m., another interview was conducted with ASM #2. ASM #2 stated she could not access Resident #16's kardex from February 2019 (because the kardex is updated when the resident's condition changes) and the facility did not have a policy or standard of practice (from Lippincott) regarding positioning. On 1/29/20 at 5:39 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern and the concern for harm. On 1/30/20 at 10:18 a.m., an interview was conducted with OSM (other staff member) #7 (the rehab director). OSM #7 was asked how a resident should be repositioned if he/she was on the edge of the bed at the foot of the bed. OSM #7 stated if the resident has any lower extremity strength then staff could help the resident scoot to the head of the bed and assist the resident with lying down but this depended on the resident's needs. OSM #7 was asked if a staff member should put his/her hands on each side of a resident's torso and pull the resident up. OSM #7 stated staff should use a transfer gait belt or just guide the resident with contact guard by placing his/her hands on the resident's torso. OSM #7 stated she would not grab a resident up by under the resident's arms and confirmed this is not a preferred or proper technique. Review of an employee corrective action form revealed CNA #7 was terminated on 2/21/19. Review of education in-service attendance records revealed nursing staff was educated regarding resident positioning from 2/15/19 through 2/17/19. Education of the nursing staff was verified via multiple interviews during the survey. No other concerns regarding positioning were identified during the survey. No further information was presented prior to exit. PAST NON-COMPLIANCE REFERENCE: (1) [MEDICATION NAME] is used to treat pain. This information was obtained from the website: https://medlineplus.gov/ency/article/ 5.htm

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility failed to maintain a functional call bell system on five of five units. 1. The facility staff failed to maintain functional call bells in the following units/rooms: · Terrace Unit (basement level) rooms 6B, and 2B (two of 23 beds) · LTC (Long Term Care) 1 (first floor) rooms 102 A, 102B, 104A, 104B, 106A, 106B, 108A, 108B, 108 bathroom, 109A, and 109B (ten of 22 beds) · MSU (Medical Skilled Unit) 1 (first floor) room 121A (one of 18 beds) · LTC2 (second floor) rooms 204B and 206A (two of 26 beds) · MSU2 (second floor) rooms 209B, 212B, 213B, and 216B (four of 22 beds) · This resulted in the identification of Immediate Jeopardy (level four - pattern) on 12/9/15 at 3:00 p.m. · · 2. The call bell in Resident room # 210A was defective; the red plunger used to activate the bell was missing. · The findings include: · · 1. On 12/8/15 at approximately 12:20 p.m. during the initial tour of the facility on LTC1, Resident #7 asked the surveyor if she would get a staff member to help her back to bed. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].*serious problems with two or more brain functions, such as memory and language), high blood pressure, and a history of a stroke (*loss of blood flow to the brain for a period of time). On the most recent MDS (minimum data set), a quarterly assessment with assessment reference date 10/9/15, Resident #7 was coded as being moderately cognitively impaired for making daily decisions. She was coded as having scored 12 out of 15 on the BIMS (Brief Interview for Mental Status). She was also coded as being completely dependent on the assistance of two staff members for transferring from a chair to her bed. When the surveyor asked the resident to please ring her call bell, Resident #7 stated: I can ring it, but it won't work. It's been broke (sic) for a month. The surveyor handed the call bell to the resident and the resident pressed down on the plunger to activate the bell. This occurred at 12:20 p.m. At 12:21 p.m., a CNA (certified nursing assistant) walked into Resident #7's room and replaced an empty box of gloves on the wall with a full box of gloves. The CNA never acknowledged the resident or indicated that the call bell had been activated. At 12:22 p.m., another staff member walked by the doorway to Resident #7's room. This staff member looked inside the room, waved to Resident #7, and continued to walk down the hall without entering the room. This staff member never indicated that she was aware that the call bell had been activated. When asked if she had alerted any staff member about the call bell not working, Resident #7 stated: I've told them. Many times. Resident #7 stated she did not know the names of the staff members she had told, but stated that they were people who helped take care of her. · · A review of the comprehensive care plan for Resident #7 dated 5/15/15 and updated on 11/15/15 revealed, in part, the following: The resident has an ADL (activities of daily living) Self Care Performance Deficit .The resident will receive appropriate staff support with bed mobility, transfers, eating, dressing, toilet use, personal hygiene .Call bell in reach . · · On 12/8/15 at approximately 12:24 p.m., the surveyor began testing the call bells in the rooms on Resident #7's hall. The testing took approximately 15 minutes. As a result of this testing, the call bells in the following rooms were observed to not be functioning: 102A, 102B, 104A, 104B, 106A, 106B, 108A, 108B (all rooms on Unit LTC1). · · On 12/8/15 at 12:45 p.m., CNA (certified nursing assistant) #7 was interviewed regarding how she became aware that a dependent resident needed assistance. She stated that the resident activates a call bell at their bedside, and that a light comes on at the nurses' station panel and outside the resident's room above the door. When asked if she was aware of any call bells on the hall that were not working at that time, she stated: No. I don't know of any. When asked whom she would notify regarding a malfunctioning call bell, she stated: I would tell the nurse and she would fill out a maintenance request. Or sometimes we just tell them (the maintenance staff) when they are walking by in the hall. They always fix it. · · On 12/8/15 at 12:47 p.m., ASM (administrative staff member) #6, the assistant director of clinical services, was interviewed regarding how facility staff members become aware that a dependent resident needs assistance. He stated: They have call lights. It shows up on this panel at the nurses' station (pointing to the panel on the wall in the nurses' station). He also stated the lights outside the residents' rooms light up if a call bell has been pressed. The surveyor asked ASM #6 to accompany her to the rooms which had been identified as having non-functioning call bells. ASM #6 verified each of the rooms which the surveyor identified earlier in the tour as not working (102A, 102B, 104A, 104B, 106A, 106B, 108A, 108B). When ASM #6 was asked what would be done about this concern, he stated, I need to tell someone. · · On 12/8/15 at approximately 3:15 p.m., the survey team tested each call bell in each resident's room. The call bells observed not to be functioning during these tests were as follows: Terrace Unit (basement level) - room 6B; Unit MSU1 room 121A; Unit LTC2 rooms 204B, 206A, and 209B; Unit MSU2 rooms 209B, 212B, and 213B. During this test, at approximately 2:25 p.m., there was no change in functionality of the call bells identified during the initial tour of LTC1 as not functioning (rooms 102A, 102B, 104A, 104B, 106A, 106B, 108A, and 108B). By each resident's bedside, the facility had placed a manual tap bell for the resident to use to alert the staff of their needs. · · On 12/8/15 at approximately 4:10 p.m., Resident #10 approached the surveyor in the hall. Resident # 10 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED].*fractured femur (broken thigh bone), *[MEDICAL CONDITION] (makes your bones weak and more likely to break) and *vitamin D deficiency (Vitamin D is an oil-soluble vitamin that has several important functions in the body: It helps to absorb dietary calcium and phosphorus from the intestines). On the most recent MDS, an annual assessment with assessment reference date 10/15/15 the resident was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS. She was coded as requiring extensive assistance of one staff member for transfers from bed to chair/wheelchair, and limited assistance of one staff member for bathing. Resident #10 stated: You know the call bells don't work on one side of LTC1. When asked how she knew this information, she stated: I heard it through Resident Council. She stated that OSM (other staff member) #4, the director of maintenance, told her that there is something wrong with the wiring, and that they will have to rip out the wiring from the walls to fix it. · · On 12/8/15 at 4:40 p.m., the survey team returned to the rooms identified at 3:15 p.m. with non-functioning call bells. At approximately 4:40 p.m., the call bells in the following rooms were once again functioning correctly: Unit LTC2 -rooms 204B, 206A, and 209B; Unit MSU2 rooms 209B, 212B, and 213B. · · On 12/9/15 at approximately 11:00 a.m. on unit LTC1, the surveyor tested the call bell in Room 109, both A and B. Neither call bell was functioning. In a second test at 11:25 a.m., the call bell was still not working in room 109 A and 109B. · · On 12/9/15 at 12:20 p.m., the supervisor was notified of the concerns regarding call bells. The supervisor instructed the survey team to test the bell in every resident's room and bathroom. As a result of these tests, conducted at approximately 1:00 p.m. on 12/9/15 by various members of the survey team, the following rooms were identified as having call bells which were not functioning correctly: LTC1, all the same rooms from the initial tour (rooms 102A, 102B, 104A, 104B, 106A, 106B, 108A, 108B), with the addition of the bathroom in room 108; MSU2 rooms 213B and 216B; Terrace Unit room 2B. · · On 12/9/15 at 1:15 p.m., the daughter or Resident #13 spoke to a surveyor regarding call bells. Resident #13 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS, a quarterly assessment with assessment reference date 11/27/15, Resident #13 was coded as being moderately cognitively impaired for making daily decisions, having scored 12 out of 15 on the BIMS. Resident #13 was coded as being completely dependent on the assistance of two staff members for transfers from bed to chair/wheelchair and for toileting. She was coded as being totally dependent on the assistance of one staff member for dressing and personal hygiene. Her daughter stated: A lot of the call bells don't work. · · On 12/9/15 at 1:45 p.m., Resident #1, who resided on MSU2, was interviewed. · Resident #1 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS, a five-day assessment with assessment reference date 11/26/15, Resident #1 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS. Resident #1 was coded as requiring limited assistance from one staff member for transfers from bed to chair/wheelchair, walking in the room, and for toileting. He was coded as requiring the extensive assistance of one staff member for dressing and personal hygiene. He was asked if there were ever any issues with his call bell working correctly. He stated that one out of ten times, it did not work since he had been a resident. When asked if anyone had come to look at his call bell, he stated: I try to be patient. They are not always consistent. · · · On 12/9/15 at 1:50 p.m., Resident #14, who resided on MSU2, was interviewed. Resident #14 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED].*high blood sugar). On the most recent MDS, a significant change assessment with assessment reference date 9/15/15, Resident #14 was coded as sometimes understanding and as sometimes being understood by others. She was coded as being moderately cognitively impaired for making daily decisions, having scored 11 out of 15 on the BIMS. She was coded as being completely dependent on the assistance of one staff member for bed mobility, toileting, and personal hygiene. She was asked if there were any problems with her call bell working correctly. She stated: It did not work last night. They had to come in here. I don't know what they did to fix it. But sometimes it works and sometimes it doesn't. · · On 12/9/15 at 2:00 p.m., OSM (other staff member) #4, the maintenance director, was interviewed regarding the facility's call bell system. He was asked about the general functionality of the facility's call bell system over the past 12 months. He stated that the system was functioning okay with the exception of one unit, LTC1. He stated that one room on that unit had electrical issues. He identified this as room 104. He stated that there were issues with other rooms on that unit on occasion, and stated that sometimes the call bell rang at the nurses station, but did not light up outside the residents' rooms. He stated that at other times, the signal would light up outside the residents' rooms, but not signal at the nurses' station. He stated that a local contractor was called to the facility to troubleshoot the system in late July 2015 or early August 2015. He stated: I had checked out the system and found a short. When asked how he became aware of a call bell functionality problem, he stated that it had been identified in some of the facility's mock surveys. He stated that a mock survey occurs each morning for each resident room. A member of the management team inspects the room for items that might be identified by a surveyor as needing repair. He stated that in late July 2015 when he identified the short in the system, it took him a couple of days to check all the units. He stated that he spoke with ASM (administrative staff member) #1, the executive director, and that he was instructed to call the contractor to the building. OSM #4 stated that the contractor came to the building. He stated: The contractor said that the system is outdated and not working. They told us they were going to order us a new system. OSM #4 stated two days later, the same contractor called to notify him that they were unable to locate a compatible replacement system because of the age of the current system. When asked how old the current system is, OSM #4 stated that the Terrace Unit (located on what floor of the facility) has a system between two and three years old. He stated that the system in the other four units is the same age as the building. OSM #4 stated that he thought the building was constructed in the 1960s. He stated: Each room has its own separate brain for the call bells. Each room has a separate alerting system. OSM #4 stated that when the contractor informed him that they could not obtain a suitable replacement system, he called his boss, ASM #5, the regional director of maintenance. OSM #4 stated that ASM #5 told him that he was going to make some contacts and get back to me. He stated that ASM #5 told him that he was going to call the same vendor who sold the facility the updated call bell system for the Terrace Unit. OSM #4 stated: (ASM #5) told me he would get some proposals and come down and look at it. When asked if he was aware if ASM #5 had come to the building to look at the call bell system since this conversation in late July 2015 or early August 2015, OSM #4 stated, I couldn't say either way. · · A review of the facility maintenance logs for January 2015 through the present date provided by OSM #4 revealed the following concerns with facility call bells: · - Unit MSU2 · 2/25/15 - 222B Call light socket needs to be fixed · 4/10/15 - Call light in 222B broken · · - Unit LTC1 · 3/24/15 - Room 102B Call light not working · 4/8/15 - Call light not working in Room 108B · 4/14/15 - Room 106B - Call light not working · 4/28/15 - 102B - Call light not working · 6/28/15 - Room 106 - Call lights not working · 7/2/15 - Room 106 - Call lights not working · · - Terrace Unit · 2/6/15 - Room 12B - Call light not working · 8/17/15 - Room 10B-A - Need call bell · 8/24/15 - Room 10A - Call bell broken · · - Unit LTC2 · 6/8/15 - Bed rooms 2 call lights for the following rooms not working, 204A, and 201A · 12/8/15 - Call light in room 206 Bed A not working Each of these maintenance repair requisitions was designated by a member of the maintenance staff as completed. On 12/9/15 at 2:28 p.m., the Supervisor from Virginia Department of Health, Office of Licensure and Certification was contacted, and the above situation was described. On 12/9/15 at 3:00 p.m., the Supervisor from Virginia Department of Health, Office of Licensure and Certification advised the team, the supervisors had reviewed the situation and the team and the supervisors determined the facility was in immediate jeopardy at a level four pattern, and advised the survey team to alert the facility administrative team. On 12/9/15 at 3:15 p.m., ASM #1, the executive director, ASM #2, the director of clinical services, and ASM #3, the regional director of clinical services, met with the survey team. ASM #1 was asked if she was aware that some of the facility call bells were not working. She stated: That's correct. It's not working. There is one light that's not working. We have provided those residents with a hand bell. When asked if she knew which call bells were not working, she stated: I will let you know which one. At this time, ASM #1 was informed of the call bells on the Terrace Unit, LTC1, MSU1, LTC2, and MSU2 which were not working. She stated: This is the first I'm hearing of this. The survey team informed ASM #1 that ASM #6 had been made aware of the malfunctions on Unit LTC1 at 12/8/15 at 12:47 p.m. ASM #1 was told that staff had placed manual call bells at the bedside of each resident on LTC1 with a malfunctioning call bell. ASM #1 was then informed of the random malfunctioning/functioning which the survey team had discovered on 12/8/15 in Unit LTC2 in room 204B, 206A, and 209B; and in Unit MSU2 on floor of facility in room 209B, room 212B, and room 213B. ASM #1 was then informed of the additional non-functioning call bells discovered by the survey team on 12/9/15, including the bathroom in room 108 on LTC1; rooms 213B, and 216B on the MSU2 unit; and room 2B on the Terrace Unit. ASM #1 was informed of the results of the resident interviews already conducted, which revealed that residents were aware of intermittent malfunctioning call bells. ASM #1 was also informed of the interview with OSM #4 on 12/9/15 at 2:00 p.m. which revealed that the facility had identified a problem as early as late July 2015 or early August 2015. ASM #1 told the survey team that prior to the contractor who came to the facility in July/August 2015, another contractor had come in to the facility to look at the call bell system. She stated that this contractor was not able to fix the system. ASM #1 stated: It will be capitalized for the future. When asked what this meant, ASM #1 stated that the money for a new call bell system would be included in a future budget for the facility. She stated: We were only aware of the first floor. I did not know about more rooms than two. She stated that she was unaware of the problem on 12/8/15. She stated that the call bells in the facility are on two different systems, depending on the location of the unit. On 12/9/15 at 3:25 p.m., the survey team informed ASM #1, ASM #2 and ASM #3 that the facility was in immediate jeopardy at a level four pattern, and requested that the facility management team present the survey team with an acceptable plan of correction. On 12/9/15 at 4:20 p.m., ASM #1, ASM #2 and ASM #3 presented an initial plan of correction for the removal of immediate jeopardy to the survey team. This plan was rejected by the survey team. ASM #1 was asked to provide more verifiable details for the plan. On 12/9/15 at 5:40 p.m., ASM #1 and ASM #2 presented a plan of correction for removal of immediate jeopardy to the survey team. This plan included the following points: 1. The Department Heads conducted rounds throughout the facility to identify rooms that do not have functioning call lights. Residents will be provided with hand bells for staff notification. II. The Department Heads or designee will make rounds every 30 minutes to ensure that residents' needs are addressed until hand bells are placed. Parts for repair or replacement of the system will be ordered on Monday, 12/14/2015 and installed or repaired once parts are on site and available (see below for details of this). Residents who are unable to utilize a hand bell will be placed on 30 minute checks (as outlined in the staff education section below). III. The ADCS (assistant director of clinical services) or designee will in-service staff and residents on the use of hand bells. IV. The mock surveyors or designee will conduct daily audits on the rooms to ensure that there is a means of staff notification until the current system is fully functioning or replaced. The results of the audits will be reviewed by the QA/PI (quality assurance/performance improvement) committee during the monthly PI until 12/23/2015. Additionally, the plan included the following elements: Education: Residents: 1) If you need assistance please use your hand bell to alert staff. Education: Staff: 1)Staff will make rounds every 30 minutes on each unit to ensure that residents' needs are addressed until hand bells are placed. Staff will make rounds every 30 minutes on each unit to identify needs for residents who are unable to use hand bells. Mock surveyors or designee will conduct daily audits on the rooms to ensure that there is a means of staff notification until the current system is fully functioning or replaced. ASM #1 provided the survey team with a list of residents who were unable to use the hand bells. The survey team told ASM #1 that this plan of correction for removal of immediate jeopardy would be accepted at the time the survey team would be able to verify all the elements of the plan. ASM #1 told the survey team that she would inform the team when all the hand bells had been purchased and placed at the residents' bedsides and when all the education for current residents and currently working staff had been completed. On 12/9/15 at 6:35 p.m., ASM #1 presented the survey team with evidence of 30 minute checks being done on all residents, pending the arrival of the hand bells. They also presented the survey team with an updated list of residents who cannot use the hand bells. Additionally at this time, ASM #1 presented the team with an email from ASM #7, the corporate vice-president of facilities management. The email was addressed to ASM #1, and was dated 12/9/15 at 4:35 p.m. The email stated: I've spoken with (ASM #1) about the issue of the nurse call system just sighted (sic) today by the state. Here is our plan: 1. The facility will insure (sic) every room has some form of manual bell for residents to use until the current system is repaired or replaced. It is (ASM #1)'s opinion that implementing this emergency procedure will remove the IJ (immediate jeopardy) just received. 2. (ASM #5 - regional director of maintenance) is contacting the Maintenance Director to have him obtain counts of room devices, restroom devices and notified (sic) lights need (sic) for each hallway, as well as the length of each corridor for every floor. This information is needed to order any new system that we will need. 3. (ASM #5) will discuss with the maintenance director ways to trouble shoot the system (particularly the new system that was installed on the ground floor 2 years ago. 4. Friday on his way home (ASM #5) will stop by the facility to evaluate the current systems in place. In particular, he will evaluate the current system installed 2 years ago to determine if it is or can be made operational. He will also verify the count of equipment needed for the replacement of any section of complete nurse call system within the facility. 5. If a section, floor, or entire nurse call system has to be installed, parts will be ordered and expedited on Monday. Manpower will be routed to install the system next week once equipment is on site and available. On 12/9/15 at 7:55 p.m., ASM #1, ASM #2 and ASM #3 returned to the survey team and informed the team that all residents able to use hand bells now had access to them at all the besides and in all the bathrooms. They presented the survey team with evidence that staff members had been educated on all five units (Terrace, LTC1, LTC2, MSU1, and MSU2) regarding the above plan of correction. The survey team made observations of each and every bedside and bathroom in the facility and verified that the plan of correction had been implemented (including staff and resident education.) Staff members were observed on all units (Terrace, LTC1, MSU1, LTC2, and MSU2) to be checking residents who were not able to answer call bells. Resident #7, who resided on LTC1, was interviewed on 12/9/15 at 8:05 p.m. She stated that she had been educated by LPN #2 to use the tap bell instead of her call bell. Resident #14 was interviewed on 12/9/15 at approximately 8:05 p.m. She did not identify which staff member had educated her on the use of the tap bell, but she verified that a staff member had come into her room and instructed her to use the tap bell if her call bell did not function at any time. On 12/9/15 at 8:05 p.m., Resident #10, who resided on the Terrace Unit, was interviewed by a surveyor. She verified that a staff member (she declined to identify the staff member specifically) had delivered her call bell to her bedside and instructed her to use it if she felt her regular call bell was not working. At that time, Resident #10 tapped her hand bell. Less than 30 seconds later, a facility CNA came to ask Resident #10 what she needed. On 12/9/15 at approximately 8:00 p.m., CNA #8, CNA #15, CNA #4, CNA #5, CNA #6, LPN (licensed practical nurse) #8, and LPN #2 correctly answered questions regarding the use of the hand bells, the 30 minute checks, and identified correctly residents who were not able to use the hand bells. The immediate jeopardy was abated on 11/9/15 at 8:10 p.m., reducing the scope and severity level of the remaining deficient practice to level two pattern. On 12/10/15 at 8:15 a.m., ASM #1 presented the survey team with evidence of 30 minute safety checks performed since the previous evening on residents who were unable to use the hand bells. ASM #1 also provided the survey team with copies of the outside contractor reports regarding the call bells. The first report was dated 5/8/15 and stated: Checked the electrical to the call station. There are (4) rooms that do not call properly. Either it calls up front and the light doesn't go on at room or it doesn't do both. Believe it's an electronics problem. Advised customer to call a low voltage specialist. The second report (from a different contractor) was dated 8/31/15 and stated: Reason for call: Electrical miscellaneous. Diagnosis: [REDACTED]. No parts are included and all work comes with a five year labor warranty. Invoice Notes: We will check if we can get a new system to fix the problem. We will contact (name of OSM #4) to let him know. Maybe costumer (sic) has to contact specialist in hospital equipment. We don't fix electronic equipment for hospitals. Constumer (sic) has bad electronic signals equipment. It's not working. ASM #1 also presented the survey team with a document which included capital requests for the facility. The document was not dated. However, ASM #1 stated: This is our approved capital budget for 2016. She stated that the regional/corporate staff was involved in approval of the capital budgets. The budget included a line item of $25,000 for a nurse call system .needed for LTC1. On 12/11/15 at 8:15 a.m., ASM #1 presented the survey team with evidence of daily audits of call bell functioning/hand bells/30 minute checks of all resident rooms on all units. On 12/11/15 at 9:15 a.m., the surveyor spoke by phone with ASM #5, the regional director of maintenance. He was asked when he became aware of malfunctioning call bells at the facility. He stated: I was just aware of it. When asked if he had been involved in approving a capital expenditure for a new call system on LTC1 of this facility, he stated: I'm not aware of that. When asked if he had been called by the facility maintenance director regarding the malfunctioning call bell system, he stated that he could not remember. When asked if he had told the facility maintenance director in September 2015 that he would check the system and research possible vendors for a new system, he stated that he could not remember. He stated: I know it's an older system. I was not aware of any consistent malfunctioning. Years ago - yes, but not recently. A review of the facility policy entitled Maintenance revealed, in part, the following: Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. Procedure: The Director of Environmental Services will follow all policies regarding routine periodic maintenance. The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition. All employees will report physical plant areas or equipment in need of repair or service to their supervisor. All items needing maintenance assistance will be reported to maintenance using the Maintenance Repair Request form. The form will be completed and placed in a designated area on the nursing unit or in the maintenance office. Environmental Services personnel will check for completed forms throughout the day. The Requests will be prioritized and completed according to need. If unable to complete the request in a reasonable period of time, the originator will be notified as to the current status and future resolution. A review of the facility policy entitled Call Light revealed, in part, the following: If call bell in defective, report immediately to maintenance. Check room frequently until bell is repaired and provide portable bell. No further information was provided prior to exit. * This information was obtained from the website <https://www.nlm.nih.gov/medlineplus/mplusdictionary.html> 2. Call bell in Resident room # 210A was defective; the red plunger used to activate the bell was missing. During a tour of Resident rooms on 12/8/15 at 3:22 p.m. to ascertain whether the call bell system was working, the call bell in resident room 210A was observed to be defective; there was no red plunger. The red plunger is pushed to activate the call bell system. This call bell was again observed on 12/8/15 at 4:00 p.m., 12/9/15 at 10:35 a.m., 12/9/15 at 2:45 p.m., and 12/9/15 at 3:04 p.m. During an interview on 12/9/15 at 2:00 p.m. with CNA (certified nurse's assistant) # 13 call bells were discussed. CNA # 13 was asked how staff checks on Residents that are unable to activate their call bells. CNA # 13 stated that she checks on them frequently, every two hours the staff turn them but if they are unable to use the bell she checks them every 30 minutes. During an interview on 12/9/15 at 3:04 p.m. with LPN (licensed practical nurse) # 1, the call bell in Resident room 210A was observed. LPN # 1 immediately noticed that the red button was missing. LPN # 1 stuck his finger into the hole left by the missing button and attempted to activate the call bell. The action of sticking his finger in the hole did not activate the call bell system. LPN # 1 stated that he would report the call bell. Observation of the call bell on 12/9/15 at 5:50 p.m. revealed that the call bell in Resident room 210A had a functioning call bell with a red button. An interview on 12/9/15 at 6:12 p.m. with CNA # 3 revealed that if there are any maintenance concerns one is to put the request into the (maintenance) log book located on each unit. If it is something that must be taken care of right away one can tell the nurse or contact the maintenance department. CNA # 3 further stated that the maintenance department response time is good. On 12/9/15 at 7:35 p.m. a list that was provided by ASM (administrative staff member) # 1, the executive director, revealed documentation that resident room # 210A was listed as a room and bed that was occupied by a Resident that was unable to use a call bell and/or a hand bell. This Resident (in 210A) was on 30 minute checks list. During an interview on 12/10/15 at 10:20 a.m. with OSM (other staff member) # 4, the director of maintenance, OSM # 4 stated that he did not replace the call bell in Resident room 210A; his maintenance helper probably did. OSM # 4 stated that the process to report maintenance issues is to document the item needing repair in the Maintenance Log Book. OSM # 4 stated that there is a log book on each unit. OSM # 4 stated that he