Every finding on record at Alvarado Meadows Nursing & Rehabilitation

Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical and psychosocial status for one (Resident #1) of six residents reviewed for changes in condition.1. The facility failed to notify Resident #1's RP of Resident #1's antibiotic order for a skin infection on 05/31/26.2. The facility failed to notify Resident #1's RP of treatment for head lice 06/08/26.These failures could put residents at risk of not having their care needs and health changes communicated and addressed with their responsible party.Findings included:Record review of Resident #1's admission MDS dated [DATE] reflected she was admitted on [DATE] with diagnoses of Urinary tract infection, Vitamin B deficiency, weight loss, and visual hallucinations. Resident #1 had a Bims score of 3, indicating she had severe cognitive impairment. She required to set up clean up assistance with eating and supervision with dressing and grooming.Record review of Resident #1's physicians 'orders reflected on 5/31/26 a new physicians order was received for Cephalexin (an antibiotic used to treat infection) 500mg 1 capsule by mouth four times a day related to a diagnosis of cellulitis (a subcutaneous skin infection). Record review of Resident #1's nursing progress notes reflected there was no documentation on 5/31/26 of family notification related to new physicians' order or change in residents condition related to new diagnosis of cellulitis. Record review of Resident #1's physicians' orders reflected on 6/08/26 a new physicians order was received for Ivermectin (an antiparasitic used to treat head lice) External Lotion 0.5 % Apply to scalp topically one time for infestation for 1 day apply 4 oz to dry hair, rinse off after 10 minutes with water. Record review of Resident #1's nursing progress notes reflected on 6/08/26 there was no documentation of family notification related to new physicians' order or change in residents condition related to new order for Ivermectin. Record review of Resident #1's admission record dated 7/2/26 reflected emergency contact #2 was accurate and verified by family member interview. In an interview on 7/2/26 at 10:50 am Resident #1's responsible party/emergency contact #1 stated she was upset that the facility had not notified her of Resident #1's recent infection to her lower leg and treatment of lice in her hair. She stated she was shocked at the residents' condition upon her arrival at the facility. She stated the staff should have called and reported any changes in condition to her. She verified the emergency contact #1 had an incorrect phone number and then verified emergency contact #2 had a correct phone number. She stated neither were notified of changes in Resident #1's condition. In an interview on 7/2/26 at 3:21p.m., the DON said Resident #1's emergency contact #2 updated his phone number on 05/18/26 at his last visit. She stated the facility nurses had been trying for months to get an accurate phone number and address for both emergency contact #1 and #2. She finally saw the family member in the facility and stopped him and requested an accurate number to which she received at that time and updated the chart. She was not sure why no notification happened after the new number was obtained. She stated her expectation for notifying residents responsible party was that they be notified of any changes in residents' condition including new physicians' orders and treatments. She stated all attempts of family contact successful and unsuccessful should be documented in the resident's medical record. The DON stated the staff had been educated on family notification of changes in conditions. She stated she was responsible for monitoring nursing documentation. The DON stated negative effects for failing to notify representatives or families of changes in condition and new orders would be a lack of communication, loss of trust and credibility. In an interview on 7/2/26 at 3:39p.m., the ADM stated it was expectation that nurses would contact responsible party representatives or families when changes in residents' condition occur. She stated if a charge nurse were unable to contact the family, she expected the nurse to notify the DON or ADM. She stated nursing staff were trained on notifying contacts of changes in condition by the DON. The DON was responsible for monitoring and making sure documentation was in the chart with chart audits and daily review of orders. She stated negative effects for failing to notify responsible parties would be that it makes families angry. Record review of undated facility policy titled Notifying the Physician of Change in Status reflected. The resident' s family member or legal guardian should be notified of significant change in resident ' s status unless the resident has specified otherwise. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative of family notification of new order or change in condition related to new DX, the physician' s response, the physician orders, and the resident' s status and response to interventions.

Based on observations and interviews, the facility failed to ensure residents were treated with dignity and respect during meal service for 3 of 11 residents observed in the G Hall (Male Memory Care Unit) dining area.Resident 11, Resident 42, and Resident 51 were observed being served lunch on transport trays typically used for meal delivery rather than being provided with a standard dining setting appropriate for residents.This failure had the potential to compromise residents' dignity and created a non-traditional dining experience that did not promote a homelike environment.Observations conducted on 05/04/2026, at 12:41 PM, revealed residents eating lunch in the common dining area of the Male Secured Unit. Residents were observed being served meals on transport trays. A male staff member assisted with meal setup, including providing utensils such as forks, knives, and spoons when needed; however, the meals remained on the transport trays during dining service.Observations conducted on 05/05/2026, revealed residents in the Male Secured Unit continued to be served lunch on transport trays in the common dining room.During an interview on 05/06/2026, at 11:25 AM, CNA A stated that when residents were served meals in G Hall, staff placed the tray in front of the resident, removed the lid, assisted with meal setup, and prepared to serve the residents requiring assistance. CNA A stated staff also placed utensils in residents' hands when assistance was needed. CNA A further stated it had been standard practice for residents in the Memory Care Unit to receive meals on the transport trays. When asked whether the practice was facility policy, CNA A stated he did not know. CNA A stated he promoted a homelike environment by treating residents with respect and maintaining privacy.During an interview on 05/06/2026, at 11:40 AM, LVN A stated staff were responsible for removing tray lids and setting meals up for residents, and stated meals should have been removed from the transport trays prior to service. LVN A stated meals in G Hall were normally expected to be served similarly to meals in the main dining area to promote a homelike environment. LVN A further stated staff maintained a homelike environment by keeping doors closed, knocking before entering residents' rooms, and interacting respectfully with residents. LVN A also stated staff would be educated that meals should not be served on transport trays unless specifically care planned and stated additional staff training related to meal service practices would be needed.Record review of facility's policy titled: Resident Rights Policy revealed:SS 03-9.0a RESIDENT RIGHTSThe resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.The facility will provide the Resident Rights to each newly admitted resident and upon any revision to the Resident Rights to each resident and/or resident representatives.Respect and dignity - The resident has a right to be treated with respect and dignity, including:3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Based on observation, interview, and records review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administ ering of all drugs and biologicals) to meet the needs of each resident. for one of one medication room (Medication room [ROOM NUMBER]), and for one of five medication carts (Medication Cart #1) inspected on 5/5/2026. The facility failed to dispose of: one box of expired Loperamide Hydrochloride, 2mg tablet, (an anti-diarrheal medication), with expiration date July 2025 in medication cart #1 (G hall Nurse cart). 28 syringes of expired AB 1MG-25/GM T/D Gel (topical anti-anxiety medication), with use by date of 12/1/2025 in medication room [ROOM NUMBER]. 3 syringes of expired Morphine Sulfate solution 100/5ML (oral narcotic pain medication), with use by date of 6/4/2026 in medication room [ROOM NUMBER]. One bottle of expired Hydromoprhone4 MG/ML syrup (oral narcotic pain medication) with best used by date of 8/18/2025 in medication room [ROOM NUMBER] 8 boxes of expired influenza vaccines with expiration date of 4/28/2026 in medication room [ROOM NUMBER] acetaminophen 650 mg suppositories (over the counter pain medication) with expiration date of 01/2026 in medication room [ROOM NUMBER] These failures have the potential for residents to receive expired medications with reduced therapeutic results, injury, or illness. Findings: Observation on 5/5/2026 at 10:19 am during an inspection of medication cart #1 revealed anti-diarrheal mediation with an expiration date of 7/2025. Observation on 5/5/2026 at 10:28 am during an inspection of medication room [ROOM NUMBER], revealed in the locked refrigerator the following expired medications were observed: AB 1MG-25/GM T/D Gel (expired 12/1/2025), Morphine Sulfate solution 100/5ML (expired 6/2/2026), Hydromoprhone 4 MG/ML syrup (expired 8/18/2025), boxes of influenza vaccines (expired 4/18/2026) and acetaminophen suppositories(expired 1/2026). During an interview on 5/5/2026 at 10:19 am, LVN A acknowledged the expired loperamide medication and stated it was the nurse's responsibility to check the cart for expired medications. She stated carts were checked once a month and as needed. She stated she checked the cart two weeks ago and did not know where the expired loperamide medication came from. She stated expired medications should be pulled from the cart and put in the destruction box in the medication room so they will not be giving expired medications to residents. She stated using expired medications could make residents sick and residents may not get the therapeutic levels of the medication to treat their illness. During an interview on 5/5/2026 at 10:28 am, LVN B acknowledged the expired medications: 1MG-25/GM T/D Gel, Morphine Sulfate solution 100/5ML, Hydromoprhone4 MG/ML syrup, influenza vaccines and acetaminophen suppositories. LVN B stated giving a residents expired medications might cause the medication to not do what it was supposed to do. She further stated if they gave a resident expired pain medication, the medication could lose its effectiveness, and the residents could still be in pain. She stated she checked the narcotic medication in the medication room [ROOM NUMBER] every shift she works but did not check expiration dates. She stated she would need to start checking expiration dates when she checked medication counts. During an interview on 5/6/2026 at 9:20 am, RNC stated she had been made aware of the expired medications and stated the nursing staff was responsible for medications on the med carts, but she was unsure who was responsible for medication room [ROOM NUMBER]. She stated all medications should be checked for expiration dates before they were given to the residents. She stated pharmacy came in once a month and they are supposed to check those things. She acknowledged that the medications were expired and stated she would have concerns about the efficacy of the medication if given to a resident. During an interview on 5/6/2026 at 10:00 am, RNC stated the nursing staff that takes the cart at shift change was responsible for the cart and checking dates on medications She stated DON C was responsible for the medication room. She stated monthly pharmacy audits should include medication room, and she was not sure if this was being done but would follow up with pharmacy. During an interview on 5/6/2026 at 10:20 am DON C stated she had been at the facility for one month and was not aware of the expired medications in medication room [ROOM NUMBER]; she thought the nurses on the floor had been checking medication room [ROOM NUMBER] and the medication carts. She stated that the overall responsibility for medications rolled up to her as far as her area of responsibility. She stated a potential concern with giving residents expired medications was that the medications could be ineffective causing more medication needed to be given to address the need. She further stated a resident could have increased pain due to pain medication being expired and not available to treat their pain. During an interview on 5/6/2026 at 10:35 am, the MD stated he was not aware of the expired medications on the medication cart or in the medication room. He stated his concern with expired medication would be that the medications could be less effective if they expired and they would not be able to manage the resident's needs appropriately. He stated it was not okay to give expired medication per the facility policy but acknowledge medications could still be effective for a short period of time after they expired. Review of facility policy PCU027 - Medication Storage in the Facility, dated vs-2025 reflected: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further: 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exits.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.The facility failed to ensure food items in the kitchen were properly labeled and dated.These failures had the potential to place residents consuming food prepared by the kitchen at risk for foodborne illness.During an observation conducted on 05/04/2026, at 9:32 AM Refrigerator #1: contained one large container of [NAME] Deluxe Mayonnaise and one bottle of Louisiana Hot Sauce that had been opened but was not labeled or datedDuring an observation conducted on 05/05/2026, at 12:07 PM, Freezer #1, contained two packages of prepared bread and two bags of single-serve ice cream that had no labels or use-by dates.During an interview on 05/06/2026, at approximately 11:37 AM, the DM stated when new items were received in the kitchen, staff checked for damage and labeled and dated items appropriately. The DM stated all kitchen staff were responsible for labeling and dating food items. The DM stated the facility used Cambro StoreSafe Food Rotation Labels for labeling and dating food products. The DM further stated facility practice was to date fresh items for three calendar days and prepared items for six calendar days. In addition, the DM stated if a date label could not be read, the item should have been discarded.During an interview on 05/06/2026, at approximately 12:08 PM, [NAME] A stated when groceries were received in the kitchen, staff wrote dates on boxes when products were opened. [NAME] A stated fresh produce and prepared food items were stored in containers or zip-top bags with preparation dates, initials, and expiration dates. [NAME] A stated staff had not received formal training specifically related to labeling and dating practices, but staff generally followed a rule that produce should have been discarded after three days. [NAME] A stated all kitchen staff shared responsibility for labeling and dating products in the kitchen. In addition, [NAME] A stated he performed weekly checks to ensure food items were properly labeled and dated.During a group interview on 05/06/2026, at approximately 1:13 PM, with KW A , KW B, and KW C they stated when items were opened, they labeled and dated them for seven days; however, they were unsure whether items should have been dated for seven days from opening or three days from opening. KW A stated she understood they were responsible for labeling and dating food items along with the cook on duty. KW C further stated improperly labeled or undated food items could result in residents consuming spoiled food or becoming ill. Record review of facility's policy titled: Food Storage dated 2012 revealed:Food Storage and SuppliesAll facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects.

Based on interview and record review, the facility failed to ensure the completion of a significant change assessment for 1 of 5 residents reviewed for Significant Change Assessments. (Resident #39).The facility did not complete a significant change assessment for Resident #39 within 14 days of being admitted to hospice services. This failure could place residents at risk of not receiving adequate services and reimbursement to meet their needs.The findings included:Record review of Resident #39 annual MDS dated [DATE] reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (a lung disorder making it difficult to breathe), mild intermittent asthma (narrowing of the airway), anxiety, and vascular dementia (a decline in memory function). Resident #39 had impaired short term and long-term memory and was receiving hospice care. Record review of Resident #39's Physician's Order Summary report reflected an order for Resident #39 to admit to hospice services dated 01/09/2026. Record review of Resident #39's Individual Election Form for hospice services reflected a hospice admission dated 01/09/2026.Record review of Resident #39s' care plan dated 01/09/2026 reflected she had a terminal prognosis and/or is receiving hospice services date Initiated: 01/09/2026. Interventions included work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.Record review of undated MDS summary report reflected Resident #39 had a quarterly MDS completed on 12/24/25 and an annual MDS completed on 3/26/26. There was no significant change assessment completed after the elected admission to hospice services. In an interview on 05/06/2026 at 1:20p.m. the MDS LVN stated she was responsible for scheduling all MDS assessments including significant changes. She stated Resident #39 should have had a change in condition MDS completed within 14 days of her hospice admission. She stated she must have just missed that assessment. She stated that by not completing an MDS assessment after a change in condition the resident's plan of care may not accurately represent their needs. In an interview on 05/06/2026 at 1:27p.m. the RCN stated the MDS coordinator was responsible for scheduling all MDS assessments. She stated a significant change assessment should have been completed 14 days after the significant change in condition was recognized for Resident #39. She stated a hospice admission was considered a significant change in a resident's condition. Record review of facility policy titled Resident Assessment dated 2003 reflected Each resident will be reassessed at regular intervals related to the course of treatment or when the resident's physical, psychosocial, functional, or nutritional status significantly changes. Reassessment will occur quarterly thereafter or in response to a change in the residents' condition. Documentation reflecting assessment and changes in the plan of care will be reflected in the resident's medical record and/or plan of care.

Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 out of 6 residents (Resident #1) reviewed for abuse/neglect. The facility failed to protect Resident #1 from physical abuse when LVN A forcefully dragged him to his bed on 05/26/2025 after an unwitnessed fall. An Immediate Jeopardy (IJ) existed from 05/26/2025 - 06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This deficient practice could place residents at risk of abuse, injury, and psychosocial harm. Findings included: Record review of Resident #1's admission record, dated 06/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (brain disorder that causes memory loss), chronic kidney disease stage 3 (when your kidneys are damage and can't filter blood properly), muscle wasting and atrophy (decrease in size and wasting of muscle tissues), and lack of coordination (having difficulty controlling your movements and making them work together smoothly). Record review of Resident #1's Quarterly MDS assessment, dated 05/07/2025, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #1 required partial/moderate assistance in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #1's care plan, dated 06/05/2025, reflected Resident #1 was care planned for impaired cognitive function/dementia or impaired though processes with an intervention Communication: use resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Record review of Resident #1's nursing progress note, dated 05/26/2025, reflected resident had an unwitnessed fall in the resident room. Resident found with BM on him, the bed, chair, and all over the floor. Record review of Resident #1's nursing progress note, dated 05/26/2025, reflected fall follow up. Location of bruise: bilateral upper extremity size of bruise in cm: unknown blue/purple, Pain appears to be present: No, Intervention: Fall mat Record review of a written statement from CNA A, date 05/29/2025, reflected CNA A stated LVN A grabbed Resident #1 by the wrist and dragged him across the room so with me not knowing what to do I went under his arms and help him stand grabbing both sides of my arms to stay stable LVN A tried to take his hand away. I said no and help him to bed. From there LVN A took his vitals went out the room we assessed him saw elbow was bloody tried to tell LVN A she didn't respond. I then left to take care of my residents.[sic] Record review of a written statement from CNA B, date 05/29/2025, reflected CNA B stated LVN A grabbed Resident #1 by his wrist and proceeded to drag him back towards his bed. During an observation of Resident #1's room video surveillance, dated 05/26/2025, Resident #1 was observed laying on the floor unclothed. CNA A was observed attempting to clean Resident #1 when Resident #1 became combative. LVN A walked over to Resident #1 and stated that We are not going to do that today. Resident #1 then attempted to kick at LVN A. LVN A then grabbed Resident #1's right arm and pulled him up to a sitting position. LVN A then pulled Resident #1 by his right arm approximately three feet towards the resident's bed while CNA A & CNA B had his left arm. Resident #1 can be heard saying oh my arm and please don't during the improper transfer. Attempted to interview Resident #1 on 06/10/2025 at 11:30am., Resident #1 could not be interviewed due to his cognitive impairment. During an interview with the DON on 06/10/2025 at 2:45 PM, the DON stated Resident #1's RP showed the video of LVN A dragging Resident #1 towards his bed. The DON stated the incident is clearly abuse and that was not how staff were trained to assistance a resident from the floor after a fall. The DON stated the facility does not condone the behavior LVN A displayed and has referred her to the board of nursing. The DON stated that she expected for staff to report any witnessed or suspected abuse to ensure the residents' in the facility safety. During an interview with the ADM on 06/10/2025 at 3:00 PM, the ADM stated Resident #1's RP showed the video of LVN A dragging Resident #1 towards his bed. The ADM stated he considered the incident abuse because LVN A forcefully pulled the resident by his wrist/arm. The ADM stated that all staff have been inserviced on reporting abuse. The ADM stated that abuse would not be tolerated and expected for staff to report any witnessed or suspected abuse immediately. A record review of the facility's Abuse/Neglect policy, dated 09/09/24, reflected The resident has the right to be free of abuse neglect, and misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment or residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions 1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instance of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 05/26/25 and ended on 06/02/25. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance: - 05/29/25 LVN A, CNA A and CNA B and the ADM were suspended. - 05/29/25 All staff were in-serviced on ANE, trauma informed care, reporting allegations of abuse timely, pain management, notification in change of condition, fall prevention, fall risk, ambulatory, how to use Kardex, rounding Q2 hours, customer service, how to appropriately respond to a resident found on the floor initiated with nursing staff, safe surveys initiated with resident, skin assessment completed. - 05/29/25 All resident received a skin assessment. - 05/29/25 the facility held a QAPI meeting for ANE . - 05/29/25 - Gait Belt Transfer Skills Check list - 05/29/25 Family surveys - 05/29/25 ANE monitoring started and will continue from 6 weeks. - 05/30/25 Resident #1 had x-ray completed with no fractures. - 05/30/25 Administrator and DON inserviced on abuse and reporting. - 06/02/25 LVN A license was referred to the Texas Board of Nursing. During interviews with the 3 LVNs and 3 CNAs on 06/05/2025 from 10:22 AM - 2:14 PM, all staff stated they were inserviced on ANE, trauma informed care, reporting allegations of abuse timely, pain management, notification in change of condition, fall prevention, fall risk, ambulatory, how to use Kardex, rounding Q2 hours, customer service, how to appropriately respond to a resident found on the floor initiated with nursing staff, safe surveys initiated with resident, skin assessment completed. All staff interviews gave examples of abuse and who to report any suspected abuse to in a timely manner. Review of a police report, dated 05/26/25, reflected the ADM completed a police report for the incident with Resident #1. Review of the facility's Employee Disciplinary Report, dated 05/28/25, reflected LVN A, CNA A, and CNA B were terminated. Review of the facility's Ad Hoc QAPI Minutes, dated 05/29/25, reflected the ADM, DON, ADON, MD, SW, and ADO were in attendance. Review of witness statements, dated 05/29/25, reflected hand-written witness statements regarding the incident with Resident #1 from LVN A, CNA A, and CNA B. Review of a report of the residents' weekly skin assessments, dated 05/29/25, reflected all residents had a skin assessment completed with no new findings. Review of all resident Safe Surveys, dated 05/29/25, reflected all had been completed with no concerns. Review of an in-service, dated 05/29/25 - 05/30/25, reflected all staff from all shifts were in-serviced by the ADM on their Abuse and Neglect Policy. Review of Resident #1's x-ray results, results received 05/30/25, reflected no fractures or findings. An Immediate Jeopardy (IJ) existed from 05/26/2025 - 06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation.

Based on interview , and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care, in that: The facility failed to conduct weekly skin assessments for Resident #1 for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25. These failures placed residents at risk of physical harm, pain, and a decreased quality of life. Findings included: Record review of Resident #1's admission record, dated 06/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (brain disorder that causes memory loss), chronic kidney disease stage 3 (when your kidneys are damage and can't filter blood properly), muscle wasting and atrophy (decrease in size and wasting of muscle tissues), and lack of coordination (having difficulty controlling your movements and making them work together smoothly). Record review of Resident #1's Quarterly MDS assessment, dated 05/07/2025, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #1 required partial/moderate assistance in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #1's care plan, dated 06/05/2025, reflected Resident #1 was care planned for terminal prognosis and/or receiving hospice services, impaired cognitive function/dementia or impaired though processes, ADL self-care performance deficit, risk for falls r/t unsteady gait, and potential for pressure ulcer development. Review of Resident #1's weekly skin assessment in the EMR on 06/05/2024, reflect Resident #1 did not have a weekly skin assessment for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25. Attempted to interview Resident #1 on 06/06/2025 at 11:30am., Resident #1 could not be interviewed due to his cognitive impairment. During an interview with LVN B on 06/06/2025 at 12:00 PM, LVN B stated she was the nurse working with Resident #1 for 06/06/25. LVN B stated all resident in facility should be receiving weekly skin assessments. LVN B stated she was not sure why Resident #1 did not receive skin assessments for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25. LVN A stated the charge nurse was responsible to complete weekly skin assessments. LVN B stated if a weekly skin assessment wasn't not completed the resident could have skin issues that go untreated. During an interview with the DON on 06/06/2025 at 4:00 PM, the DON stated all residents were supposed to receive weekly skin assessments. The DON stated it was the nursing staffs' responsibility to complete the weekly skin assessments. The DON was not aware that Resident #1 had not had a skin assessment for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25. The DON stated the purpose of a skin assessment was to identity and address any new skin concerns. The DON stated that if a resident did not receive weekly skin assessments, then the resident could have a skin condition go untreated. The DON stated she expected for weekly skin assessments to be conducted as scheduled. During an interview with the ADM on 06/06/2025 at 5:00 PM, the ADM stated all residents were supposed to receive weekly skin assessments. The ADM stated it was the nursing staffs' responsibility to complete the weekly skin assessments. The ADM was not aware that Resident #1 had not had a skin assessment for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25. The ADM stated the purpose of a skin assessment was to ensure residents did not have any adverse skin issues from the previous week. The ADM stated that if a resident did not receive weekly skin assessments, then the resident could have a skin condition go untreated. The ADM stated she expected for weekly skin assessments to be conducted as scheduled. A record review of the facility's Skin Assessment policy, dated 12/24, reflected it is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate intervention be initiated in a timely manner. Procedure: 2. All residents should have a skin assessment on a weekly basis completed in (EMR system) .

Based on interviews , and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #2) reviewed for comprehensive care plans. Resident #2's comprehensive care plan did not reflect Resident #2 sustained a fracture to her upper right arm on 05/25/25. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: Record review of Resident #2's admission record, dated 06/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: unspecified dementia (the decline in thinking, remembering, and reasoning skills), cognitive communication deficit (difficulty with thinking and using language), muscle wasting and atrophy (decrease in size and wasting of muscle tissues), and lack of coordination (having difficulty controlling your movements and making them work together smoothly). Record review of Resident #2's Quarterly MDS assessment, dated 05/19/2025, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #2 was dependent in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #2's care plan, dated 06/05/2025, did not reflected Resident #2 sustained a fracture to her upper right arm on 05/25/25. A record review of Resident #2's progress notes dated 05/26/2025, reflected Resident #2 was transferred to a hospital on [DATE] 10:22am related to acute nondisplaced fracture of right humeral neck (a fracture to her upper right arm). Attempted to interview Resident #2 on 06/06/2025 at 11:10am., Resident #2 could not be interviewed due to his severe cognitive impairment. During an interview with LVN B on 06/06/2025 at 12:00 PM, LVN B stated that Resident #2 had a fall on 05/25/25 and sustained a fracture to her right upper arm. LVN B stated that a fracture/change of condition should be care planned so the resident could receive the proper care needed. During an interview with the DON on 06/06/2025 at 4:00 PM, the DON stated Resident #2 sustained an acute nondisplaced fracture of right humeral neck from a fall on 05/25/25. The DON stated that Resident #2's fracture should be care planned. The DON stated if a resident's fracture was not care planned there would be a chance that staff may not know how to manage the fracture. The DON stated the ADON , MDS Coordinator, IDT team as well as herself were responsible for updating residents' care plans. During an interview with the ADM on 06/06/2025 at 5:00 PM, the ADM stated Resident #2 sustained a fracture to her right arm from a recent fall. The ADM stated he was not aware Resident #2's care plan had not been updated to reflect the resident's right arm fracture. The ADM stated staff may not know how to appropriately care for the resident if the resident's care plan was not updated to reflect the fracture. The ADM stated that the DON and ADON were responsible for updating the acute care plans. The ADM stated he expected that anytime a resident has a fracture/change of condition that the residents' care plan be updated. A record review of the facility's Comprehensive Care Planning policy, undated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented .

Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 2 of 2 residents (Resident #4 and Resident #5) reviewed. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting for Resident #4 and Resident #5. This failure could place residents at risk of not receiving necessary care or specialized services which could diminish the residents' quality of life and highest level of functioning. Findings include: Record review of Resident #4's admission record, dated 06/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included: autistic disorder (a neurodevelopmental condition that affects how people interacts with others, communicate, and behave), bipolar disorder (mental health condition that cause extreme shifts in moods), anxiety disorder (mental health condition that causes excessive and persistent worry, fear, and nervousness), and dementia (decline in thinking, remembering and reasoning skills that affect a person's daily life) Record review of Resident #4's Quarterly MDS assessment, dated 05/05/2025, reflected the resident had a BIMS score of 15, which indicated cognitively intact. Review of Resident #4's Habilitation Service Plan, dated 03/14/25, reflected in Section 5, Outcome Action Plan identify NF specialized services PT, OT, and ST. Record review of Resident #5's admission record, dated 06/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: Dementia (decline in thinking, remembering and reasoning skills that affect a person's daily life), moderated intellectual disabilities (difficulty learning and understanding things), and Developmental disorder of scholastic skills (a learning difficulty that affects how a person acquires academic skills like reading, writing, and math.) Record review of Resident #5's Quarterly MDS assessment, dated 03/20 /2025, reflected the resident had a BIMS score of 03, which indicated severe cognitive impairment. Review of Resident #5's PASRR team IDT Sign-In Sheet), dated 01/13/25, reflected the purpose of the meeting to offer individual specialized services, habilitation coordination, and durable medical equipment to present CLO to the individual. During an interview with the DOR on 06/10/25 at 1:35 PM, the DOR stated that the NFSS should be completed 20 days after the IDT meeting. DOR stated that the services offered to residents are OT, PT, ST, and day hab services. The DOR stated that PASRR representative, MDS Coordinator, DOR and a family representative usually attend the meetings. DOR stated she was not the DOR at the time of Resident #4 or Resident #5's meetings. The DOR stated a negative outcome for the NFSS not being completed in time could be the resident decline or the resident wouldn't receive services. During an interview with the ADM on 06/10/25 at 1:45 PM , the ADM stated that the NFSS should be completed 20 days after the IDT meeting. The ADM stated that it's the DOR's responsibility to complete the NFSS within the appropriate time frame. The ADM stated there would be no way to verify the resident was receiving PASSR services if the NFSS wasn't completed timely. A record review of the facility's PASRR PCSP /IDT policy, dated 03/06/19, reflected Policy: it is the policy of Creative Solutions in Healthcare facilities to ensure the IDT meetings are schedule per regulations (with 14 days of admission for Positive Confirmed PE ). The LIDDA and/or LMHA are notified and invited to the IDT Meetings for all PASRR Positive Resident. The NF will enter the PCSP initial and/or annual meeting in the portal within 3 business days of the IDT Meeting. The NF will notify appropriate staff if the IDT determined Specialized Services are recommended. Procedure: Review of process prior to the IDT meeting: After an individual or resident is determined to have MI, ID, or DD from the PE or resident reviewed has been admitted to a nursing facility, the NF must: 9. Once the IDT makes its determinations about specialized services, the NF must: Include all specialized services and support activities in the resident's comprehensive Care Plan; Provide the NF Specialized Services within 20 business days of the IDT Meeting; and Annually document all specialized services in the portal.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3's call light was within reach on 06/05/2025. This failure could place residents at risk of their needs not being met. Findings include: Record review of Resident #3's admission record, dated 06/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: Alzheimer's disease with late onset (brain disorder that causes memory loss), bipolar disorder (mental health condition that cause extreme shifts in mood), essential primary hypertension (high blood pressure), and cognitive communication deficit (difficulty with thinking and using language). Record review of Resident #3's Quarterly MDS assessment, dated 05/08/2025, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #3 was dependent in the area of toileting hygiene. Resident #3 required substantial/maximal assistance in the areas of shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #3's care plan, dated 06/05/2025, reflected Resident #3 was care planned for ADL self care performance deficit Alzheimer's had an intervention of ensure the resident to use bell to call for assistance. During an interview and observation on 06/05/2025 at 9:05 AM., Resident #3's call light was observed pinned to the back upper left side of her bed, out her reach. Resident #3 was awake in bed at the time of the observation but could not be interviewed due to her cognitive impairment. The ADM observed Resident #3's call light pinned to the back upper left side of her bed and out of the resident's reach. During an interview with CNA C on 06/06/2025 at 2:10 PM, CNA C stated CNAs make rounds at least every two hours to check to see if residents' need assistance. CNA C stated it's everyone's responsibly to ensure call lights are within reach at all times. CNA C stated that if a resident's call light was not within reach, then the resident would not be able to call for assistance if needed. During an interview with the DON on 06/06/2025 at 4:00 PM, the DON stated all residents' call lights should be always within reach. The DON stated it was everyone's responsibility to ensure residents' call lights were always within reach. The DON stated if a resident's call light was not within reach, the resident would not be able to receive assistance if they needed it. During an interview with the ADM on 06/06/2025 at 5:00 PM, the ADM stated call lights should always be within reach. The ADM stated it was everyone's responsibility to ensure the call lights were within reach. The ADM stated if a residents' call light was not within reach, then the resident's needs would not be met in a timely manner. The ADM stated his expectation was for staff members to ensure call lights were within reach prior to exiting the residents' rooms. ADM stated the facility doesn't have call light policy. A request was made for a policy on call lights but was told by the ADM the facility doesn't have a call light policy.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for four residents of 12 residents (Residents # 28, #29, #33, and #47) reviewed for care plans. The facility failed to ensure Residents # 28, #29, #33, and #47 care plans were complete and accurate. These failures could place the residents at risk of not receiving appropriate care. Findings included: 1. Record review of Resident #28's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, morbid obesity, and muscle wasting. Record review of Resident #28's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Her Functional Abilities assessment indicated she was totally dependent on staff for toileting and needed maximum assistance with bathing and personal hygiene. Record review of Resident #28's care plan, dated 01/20/25, reflected she had impaired cognitive function/dementia or impaired thought processes which was not reflected in her diagnoses. Her care plan also reflected she was resistive to care related to mild cognitive impairment if uncertain etiology, which was again not reflected in her BIMS score. 2. Record review of Resident #29's undated Admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder-bipolar type, diabetes, left sided paralysis from a stroke, and anxiety. Record review of Resident #29's quarterly MDS, dated [DATE], reflected a BIMS score of 9 indicating she had moderate cognitive impairment. Her Functional Abilities assessment reflected she was totally dependent on staff for all ADLs except eating and oral hygiene. Record review of resident #29's care plan, dated 03/04/25, reflected she was allergic to (no allergies listed, resident is allergic to penicillin), and an ADL self-care deficit. 3. Record review of Resident #33's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included right sided paralysis related to a stroke, liver disease, seizures, and Schizoaffective disorder. Record review of Resident #33's quarterly MDS, dated [DATE], reflected a BIMS score not assessed. Her Functional Abilities assessment indicated she was totally dependent on staff for her ADLs. Record review of Resident #33's care plan, dated 02/24/25, did not reflect she had a self-care deficit related to her stroke and paralysis. 4. Record review of Resident #47's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, bone infection of the spine, paraplegia (paralyzed from waist down), and heart failure. Record review of Resident #47's admission MDS, dated [DATE], reflected only section A had been completed. Record review of Resident #47's care plan, dated 03/01/25, reflected she had hemiplegia related to (not indicated), she was at risk for falls related to (not indicated), potential fluid deficit related to (not indicated), and allergic to (not reflective of Aspirin, codeine, lisinopril, Septra, lithium, and NSAIDs allergies) Interview on 03/06/25 at 10:25 AM with LVN A revealed Residents #33 required total care did not get out of bed. She stated she did not know who was responsible for the care plans, but she thought it was the ADON. She could not state a risk for care plans not being accurate. Interview on 03/06/25 at 11:00 AM with LVN B revealed the baseline care plans were initiated by the admitting nurse, and then the DON and the MDS nurse completed the comprehensive care plan. She stated it was necessary for the care plan to be up-to-date and accurate, so the resident's needs were addressed. Interview on 03/06/25 at 1:03 PM with the DON revealed the interdisciplinary team was responsible for updating care plans during the resident's stay. She stated the risk of care plans not being complete could be anything. The RNC, who was present, interjected and stated care plans should be complete, accurate, and personalized to the resident in order to assure all needs and conditions of the resident were being met. She stated failing to do so could result in residents not receiving complete care. The care plans were updated when there was a change in condition or new orders were received. Record review of the facility's current, undated Comprehensive Care Planning policy reflected: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his preferences and goals, and address the resident's medical, physical, and psychosocial needs.

Based on observation, interview, and record review the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 12 residents (Residents #28, #31, #33, #47, and #56) reviewed for personal hygiene. The facility failed to ensure Residents #28, #31, #33, #47, and #56 received assistance with bathing, grooming, and personal hygiene. These failures could result in the resident having decreased sense of self-worth. Findings included: 1. Record review of Resident #28's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, morbid obesity, and muscle wasting. Record review of Resident #28's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Her Functional Abilities assessment indicated she was totally dependent on staff for toileting, and needed maximum assistance with bathing and personal hygiene. Record review of Resident #28's care plan, dated 01/20/25, reflected she had an ADL self-care performance deficit related to impaired balance with an intervention of Bathing: the resident requires assistance with bathing 3x a week, and as necessary. Interview on 03/04/25 at 10:02 AM with Resident #28 revealed she only got bathed every two weeks because there was only one CNA on the evening shift, which was when her bath was scheduled. Staff would not bathe her unless she demanded it. She stated not being bathed made her feel uncomfortable so she didn't go out of her room much. Record review of Resident #28's bathing task record from 2/09/25 to current date reflected she had been bathed twice (2/22/25 and 2/23/25). All other dates were documented as Activity did not occur. 2. Record review of Resident #31's undated Admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses which included heart failure, diabetes, seizures, and stroke. Record review of Resident #31's admission MDS, dated [DATE], reflected a BIMS score of 11 indicating he had mild cognitive impairment. His Functional Abilities assessment indicated he required maximum assistance with bathing and toileting. Record review of Resident #31's care plan, dated 02/22/25, reflected he had an ADL self-care deficit with an intervention for bathing to have 1 staff to assist. Observation and interview on 03/04/25 at 9:41 AM with Resident #31 revealed he had not been bathed in over a week. The resident's hair was unkempt and appeared greasy. The resident stated he asked the CNAs to shower him. He stated they would say they would do it, but they never came back, so it never happened. He stated he did not need a lot of attention, but there still did not seem to be enough staff to help the residents. Record review of Resident #31's bathing task record from 02/05/25 to current reflected he had been bathed twice (02/06/25, and 02/18/25), all other dates were documented Activity did not occur. 3. Record review of Resident #33's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included right sided paralysis related to a stroke, liver disease, seizures, and Schizoaffective disorder. Record review of Resident #33's quarterly MDS, dated [DATE], reflected a BIMS score not assessed. Her Functional Abilities assessment indicated she was totally dependent on staff for her ADLs. Record review of Resident #33's care plan, dated 02/24/25, did not reflect she had a self-care deficit related to her stroke and paralysis. Observation on 03/04/25 at 10:00 AM revealed Resident #33 appeared to be asleep. Her hair was unkempt and appeared greasy. Record review of Resident #33's bathing task record from 02/05/25 to current reflected she had been bathed on 02/26/25. All other dates were documented as Activity did not occur. Phone interview on 03/05/25 at 1:57 PM with Resident #33's family member revealed they were at the facility almost every evening to visit with the resident. The resident did not respond to anyone unless she knew them, but she was unable to do anything for herself. They stated they knew for sure the resident had not been bathed in the last four days. They stated the staff were always busy, and they rarely came to her room when they were there to check on the resident. The family member stated they had to seek out staff to change the resident's brief, and it still took a while for them to come change her. He stated there did not appear to be enough staff to care for the residents. 4. Record review of Resident #47's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, bone infection of the spine, paraplegia (paralyzed from waist down), and heart failure. Record review of Resident #47's admission MDS, dated [DATE], reflected only section A had been completed. Record review of Resident #47's care plan, dated 03/01/25, reflected she had an ADL self-care deficit with an intervention for bathing to have 1 staff assist. Interview on 03/04/25 at 10:07 AM with Resident #47 revealed she had not been bathed since she was admitted (02/08/25) and did not know there was a shower schedule. She stated she would like to be bathed twice a week at least. She stated she felt very dirty and her hair needed to be washed. Record review of resident #47's bathing task record from 02/09/25 to current reflected she had not been bathed. All dates were documented as Activity did not occur. 5. Record review of Resident #56's face sheet dated 03/06/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Record review of Resident #56's MDS sheet dated 12/24/24 revealed a BIMS score was not entered because Resident #56 was unable to complete the interview. Resident #56 functional abilities indicated she required substantial/maximal assistance with toileting hygiene, shower/bathing and personal hygiene. Resident #56's diagnoses included urinary tract infection (infection that affects part of the urinary tract), Type 2 Diabetes (high blood sugar), Dementia (group of symptoms affecting memory), abnormalities of gait and mobility, lack of coordination , and unsteady on feet. Record review of Resident #56's care plan as of 08/06/24 revealed Resident #56 had an activities of daily living self care performance deficit due to dementia. Goal included the resident will maintain or improve current level of function in transfers, eating, dressing, toilet use and personal hygiene. Interventions included resident uses a geri chair, Transfer: the resident required (X2) staff participation with transfer. Bathing: provide the resident with a sponge bath when shower can not be tolerated. Resident was totally depend on staff to provide a bath (3x a week) and as necessary. The Resident required (x1) staff participation with bathing. Interview on 03/04/25 at 3:36 PM with a family member of Resident #56 revealed she visited with Resident #56 daily. The family member stated she would find her soaked in her brief down to the sheets with urine and poop everyday, leaving her with an odor. According to the Family Member when she entered the facility, she would have to take matters into her own hands to clean and change Resident #56 along with her bedding. The Family Member stated they are very understaffed and do not have staff on the hall to care for the residents, it made me upset to see how they just leave my mom like that. The Family Member stated Resident #56 was on hospice which came in the mornings to bath, change and dress her for the day, however there was no one from the facility that checked on Resident #56 throughout the day to ensure she was dry or changed. The Family Member stated it would be nice to have someone check on her after lunch to change her brief. Interview on 03/05/25 at 10:25 AM with LVN A revealed residents were showered or bathed three times a week by the CNAs. She stated the CNAs bring her their shower sheets to the nurse if there is a new finding like a bruise, or if the resident refuses their shower. She would check with the resident and encourage them to be bathed. She stated the risk of not getting bathed was skin breakdown and irritation. Interview on 03/05/25 at 12:43 PM with the DON revealed showers and baths were documented in the computer under Tasks by the CNAs. She stated if it was not in the computer it did not happen. She stated there were no shower sheets. Interview on 03/06/25 at 8:20 AM with the RNC revealed they had stacks of old shower sheets from several months, going back to before the change of ownership. She stated the current policy was for the staff to document everything in the computer because shower sheets get lost, and were difficult to track. She stated the expectation was the CNAs would bathe residents three times a week, less if the resident preferred it. All documentation was to be done in the computer. Interview on 03/06/25 at 3:25 PM with CNA C revealed residents should be showered three times a week. When she showered a resident she filled out a shower sheet and turned it into the nurse. If a resident refused a shower she had them sign the shower sheet. She stated the risk of a resident not being showered was skin irritation or breakdown. Interview on 03/06/25 at 3:30 PM with the DON and the RNC revealed they both stated the CNAs did not use a shower sheet to document showers. They documented showers in the computer under Tasks. The DON and the RNC both stated the Task document was the most accurate record of the resident's showers. The DON stated the residents were being bathed, but if they were not the risk could be anything. Interview on 03/06/25 at 3:47 PM with CNA D revealed the residents should be showered three times a week. She stated she documented her showers on a shower sheet and then put it into the computer. The shower sheet was given to the nurse if there were findings like a bruise or redness found during the shower. She stated the risk of residents not being bathed was skin breakdown or irritation. Interview on 03/06/25 at 3:58 PM with CNA E revealed residents were showered three times a week. She documented her showers on a shower sheet and then put it into the computer. The shower sheet was then given to the nurse. She stated the risk of residents not being bathed could be skin breakdown. Interview on 03/06/25 at 4:04 PM with CNA F revealed she was supposed to be the designated shower aide Monday through Friday, but she was often called to be a CNA on one of the halls because someone called in. She stated she usually only had one day a week when she was functioning as the shower aide because the CNAs called in so often. Record review of the facility's current, undated Bath, Tub/Shower policy reflected: Bathing by tub bath or shower is done to removed soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation Frequency and type of bathing depends on resident preference, skin condition, tolerance, and energy level. Although daily bathing or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed

Based on observation, interview, and record review, the facility failed to ensure each resident had the right to be free from abuse for 2 of 7 residents (Resident #7 and Resident #22) reviewed for Resident Rights. CNA G verbally abused Residents #7 and #22 when the residents requested to return inside the building following a smoke break, and she yelled at them telling they could not go inside and blocked the door. The failure placed residents at risk of feelings of decreased self-worth. The non-compliance was identified as PNC. The noncompliance began on 02/15/25 and ended on 02/21/25. The facility had corrected the non-compliance before the investigation began. Finding included: Record review of Resident #7's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #7's entry MDS sheet dated 02/08/25 reflected a BIMS score of 13 indicating her cognition was intact. Resident #7's functional abilities indicated she required substantial/maximal assistance with toileting hygiene, shower/bathing and lower body dressing. Resident #7 was independent with eating, oral hygiene and upper body dressing, and partial assistance with personal hygiene. Resident #7's diagnoses included acquired absence of left leg above knee, muscle weakness, lack of coordination, and a history of falling. Record review of Resident #7's care plan as of 02/16/25 reflected Resident #7 was a smoker. The care plan reflected a goal to smoke in designated areas without occurrence of injury. The care plan interventions included perform smoking assessment according to facility policy. Explain/Show where designed smoking area was, and smoking times-repeat as needed. Monitor as needed when smoking to assure resident safety, keep all smoking material at nurse's station. The care plan reflected Resident #7 had a history of trauma that may have a negative impact. The trauma was related to being angry at CNA G for saying that she could not go back inside after smoking. The care plan goal included maintain resident's safety and integrity during post trauma episode, using appropriate interventions. The care plan interventions included to arrange a licensed mental health provider as ordered by the physician. Identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. These triggers could include verbal threats, and physical aggression. Record review of Resident #7's Safe Smoking assessment dated [DATE] and 03/04/25 reflected in summary: This resident required direct supervision while smoking: All smoking materials will be kept at the nurse's station: The evaluation has been explained to the family responsible party and to the resident. Record review of Resident #22's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #22's entry MDS sheet dated 02/19/25 reflected a BIMS score of 15 indicating her cognition was intact. Resident #22's functional abilities indicated she was independent with eating, oral hygiene, toileting hygiene and required set up or clean up with shower/bathing, upper and lower body dressing, and personal hygiene. Resident #22 had use of a walker. Resident #22's diagnoses included muscle weakness and difficulty walking. Record review of Resident #22's care plan as of 02/16/25 reflected Resident #22 was a smoker. The care plan gooal included to smoke in designated areas without occurrence of injury. The care plan interventions included perform smoking assessment according to facility policy. Explain/Show where designed smoking area was, and smoking times-repeat as needed. Monitor as needed when smoking to assure resident safety, keep all smoking material at nurse's station. The care plan reflected Resident #7 had a history of trauma that may have a negative impact. Record review of Resident #22's Safe Smoking assessment dated [DATE] reflected in summary: This resident required direct supervision while smoking: All smoking materials would be kept at the nurse's station: The evaluation has been discussed with the resident. Interview on 03/04/25 at 10:55 AM with Resident #7 revealed she liked to smoke at each smoke break. Resident #7 stated she was outside smoking with CNA G and finished earlier than others and wanted to return inside the facility. According to Resident #7, CNA G yelled at her saying, You can't go back inside until I go in. Resident #7 stated it made her upset. Resident #7 stated it was cold outside, and she should have been allowed to return inside the building if she wanted. Interview on 03/04/25 at 1:40 PM with Resident #22 revealed she enjoyed smoking on the smoke breaks provided by the facility. According to Resident #22, she was outside when CNA G would not allow Resident #22 to return inside the building when she was finished smoking. Resident #22 stated CNA G was the only staff member, who would make residents stay outside until everyone was finished, and they all came back inside at one time. Resident #22 stated she was upset that CNA G did not allow residents to return inside the building yelling, Do not go any further. No one can go in without me. Resident #22 also stated CNA G stood in the walkway blocking residents from leaving the patio. Resident #22 stated she reported to the front desk that Resident #7 was not allowed to return to the building and the Administrator followed up with her about the incident. According to Resident #22, CNA G no longer worked at the facility and there had not been any further issues with residents returning inside the building when they were finished smoking. Observation on 03/04/25 at 4:10 PM revealed residents on the patio with the Maintenance Director and revealed residents were able to exit the patio once they were finished smoking. Observation and interview on 03/05/25 at 4:00 PM with the Laundry Aide revealed there was a schedule sheet that he followed which notified when his department took residents out to smoke. The Laundry Aide stated he recognized all residents were able to safely smoke. Laundry Aide stated he was responsible for ensuring all residents were safe before, during, and after smoking and should stay together just in case they needed help returning to the facility, for example if they were a fall risk. The Laundry Aide stated he thought all residents were supposed to wait together to go inside the building after smoking, but he could not stop anyone from going back inside the building if they wanted to leave. Therefore, he allowed residents to leave when they were done smoking. According to the Laundry Aide, trying to stop residents from returning inside the building after smoking would go against their rights to move around as they want. Interview on 03/05/25 at 4:41 PM with RN I revealed she was aware of residents that smoked. There was a schedule that indicated nursing staff were responsible to take residents out during the evening hours. According to RN I, she was present on 02/15/25 when CNA G volunteered to take the residents out to the patio for smoking at 6:30 PM. RN I stated she was standing at the nursing station when Resident #22 informed RN H that Resident #7 wanted to return back into the building once she finished smoking and she was not allowed to and was told she had to wait. RN I stated according to Resident #22, she did not like that Resident #7 was told she could not leave, and that CNA G blocked the walkway to prevent anyone from leaving the patio. RN I stated she and RN H then began contacting the DON and the Administrator. Interview on 03/05/25 at 5:09 PM with the ADON revealed she was in-serviced on resident rights after the 02/15/25 incident when CNA G would not allow residents to reenter the building after smoking. The ADON stated whomever was scheduled to take residents out to smoke was responsible for residents while they were smoking. The ADON stated if there were multiple residents smoking and one wanted to come back inside, and you did not have to leave residents smoking unsupervised, residents who were able to safely return to the building could do so. The ADON expressed that residents had the right to be able to return in the building after smoking, or anytime they wanted to come inside or move about the facility, not doing so violated their rights. Interview on 03/06/25 at 9:10 AM with RN H revealed she was at the nursing station on 02/15/25 when CNA G took residents who smoke out to the patio at their 6:30 PM smoke break. RN H stated after the break, Resident #7 and Resident #22 reported to her that CNA G told them they could not come back in inside the building until everyone was done smoking. RN H stated, it was cold that night so residents were distraught they could not return in the building once they were done smoking. RN H stated she reported to the Administrator and the DON, what residents reported to her. RN H stated she was in-serviced on resident rights and the residents had the ability to move about the facility, being told they could not return in the building after they were ready, placed them at risk of their rights being violated. Interview on 03/06/25 at 10:00 AM with the Administrator revealed he was notified by RN H that CNA G took residents out to smoke; once they were finished smoking and wanted to return inside the building because they were cold. The Administrator stated he was told CNA G yelled No one can go in without me and stood in the walkway preventing them from leaving the patio. The Administrator stated he asked residents to be assessed to ensure they were ok and not harmed in any way and to gather statements. The Administrator stated he alerted his corporate office and the human resources and suspended CNA G. The Administrator stated he entered the facility on 02/16/25 to interview residents and started in-services and monitoring. The Administrator stated there was a schedule to advise which department was responsible for taking the residents out to smoke at designated times. The Administrator advised he expected staff to allow residents to go out on the patio and smoke, if they were done and wanted to come back inside the building staff should allow that as it was their right to do so. The Administrator stated they completed in-services to educate staff to monitor residents while outside on the patio during smoking breaks; however, you could not keep residents outside against their will. Interview on 03/06/25 at 10:07 AM with the DON revealed she was notified of the incident on 02/15/25 with CNA G refusing to allow residents to return in the building by standing in the walkway and yelling they had to wait on all residents to reenter together. The DON stated in-services on resident rights, abuse and neglect, and their smoking policy were started immediately. The DON stated she expected staff to follow the smoking schedule and take residents out to smoke. The DON stated at any time residents want to leave the patio after smoking, they have the right to do so and should be able to do so. The DON stated CNA G not allowing residents to return inside the building placed them at risk of not having their rights honored. Interview on 03/07/25 at 11:39 AM with CNA G revealed she did take residents out to the patio for a smoke break right before her shift ended at 6:30 PM on 02/15/25. According to CNA G it was a bit cooler that evening, and Resident #7 attempted to leave the patio when she finished smoking. CNA G stated she expressed to Resident #7 you have to wait to go inside all together. CNA G stated the reason she did not allow residents to leave the patio was because it was not feasible. She stated Resident #7 was in a wheelchair and could have fallen. CNA G stated, I admit I kept her from going in. It was for her safety. According to CNA G, she was responsible for ensuring residents returned in the building safely. CNA G stated she was suspended and later terminated. CNA G stated she was not thinking residents were placed at risk of rights not being honored, she stated I was thinking of their safety. Record review of a Employee Disciplinary Report for CNA G dated 02/15/25 reflected due to allegations, CNA G will be placed on unpaid investigatory suspension and will remain on investigatory suspension until the investigation is completed. CNA G will be notified when the investigation is completed. Record review of Resident #7's statement reflected: 6:30 Smoke Break At the 6:30 PM smoke break CNA G took the smokers outside the smoke area. When I was done smoking, I started to go back inside from the smoking area and CNA G stood in the opening that leads to sidewalk and said You can't go in until I go in. I stayed outside in the smoking area for about 15 minutes. I was cold and I did not have a coat on. When I came back inside, I told RN H and RN I what happened. Record review of Resident #22's statement reflected: 6:30 PM Smoke Break At the 6:30 PM smoke break CNA G took us outside. Before we went outside, she was talking really fast, and I could tell that she did not want to take us outside and stated she had other things to do. She did take us outside but kept coming back inside and to the smoke area. She was pacing back in forth in the smoke area and was yelling I do not want to talk to anyone. I am upset. Two of the smokers were finished and started to go down the sidewalk to go back inside like they normally do, and CNA G yelled Do not you go any further. No one can go in without me. She said she was going to search for everyone's lighters and cigarettes. I did not see her search anyone. CNA G stood in front of Resident #7 and would not let her leave the smoking area. I was still smoking. Another resident told her he was going inside when he finished his cigarette, and he went inside. CNA G was very short spoken with us while we were outside. When I returned to the building, I told RN H and RN I what happened during the smoke break. Once in my room I checked my cell phone, and I had a missed call from CNA G, I did not call her back. Record review of CNA G's Witness Statement reflected: I work every time I am asked to, I work nights, I worked my Saturday day off. Residents all they want to do is smoke, I have COPD. This was signed by CNA G 02/17/25 and the Administrator. An ADHOC QAPI meeting was held on 02/17/25 with the Interdisciplinary Team including the Medical Director to discuss the allegations and findings. Record review of the facility's Provider Investigation Report, completed by the Administrator on 02/21/25, reflected: Description of Allegation: [CNA G], CNA, took the residents out to smoke at the schedule[d] 6:30 PM time. Some of the residents were getting cold and wanted to go back inside after smoking a cigarette. [CNA G] yelled and told them that they couldn't go back inside without her, and she wasn't letting anyone back in until she was ready. [Residents #7 and #22] stated they felt this was verbal abuse by [CNA G] yelling and not letting them back inside. Provider Response: Details of this incident were found out after the staff member [CNA G] left after her shift. The staff member was immediately suspended pending investigation after administration found out about the incident. Safe surveys for smokers completed. Investigation Summary: Investigation summary shows that the incident did occur. [CNA G] was terminated on 2/18/2025 for verbal abuse occurring. Residents did not have any trauma from the incident. Provider Action Taken Post Investigaiton: In-serviced staff on abuse/neglect. [CNA G] was terminated for verbal abuse on 2/18/2025. No adverse effects for any residents involved. Record review of Payroll Input/Personnel Action Form signed 02/18/25 reflected CNA G was terminated on 02/18/25. CNA G has failed to adhere to the Corporate Code of Conduct. CNA G was aware of the corporate code of conduct as indicated by the signature of the employee handbook acknowledgment. CNA G meet criteria for immediate termination. Record review of an in-service record, dated 02/15/25 reflected the DON trained staff on the following topics: Abuse and Neglect, Resident Rights, and Smoking Policy. The in-service record reflected staff not present would receive the in-service training prior to assuming their duties on their next scheduled shift. Also, new and agency staff would received the in-service training prior to assuming patient care duties. Interviews on 03/06/25 with LVN A, LVN B, RN H, RN I, Laundry Aide, Dietary Aide, DON, ADON, CNA J revealed they had been trained on residents' rights and were aware to allow residents to return in the building as they were finished smoking, not doing so placed residents at risk of violation of their rights being honored. Record review reflected the facility implemented the following for monitoring from 02/16/25-02/21/25: ask 15-20 staff members per week; ask about 5 resident per week how staff is treating them; during incident/event review in standup; during facility rounds are there any sings of staff acting rudely or inappropriate with residents. Record review of the facility's Resident Rights policy, revised 11/28/16, reflected: Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. Respect and dignity - The resident has a right to be treated with respect and dignity, including: The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Self-determination - The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. 1. The resident has a right to choose activities, schedule and health care and providers of health care services consistent with his or her interest. 2. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident

Based on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 4 residents (Resident #1) reviewed for discharge requirements. The facility failed to ensure Resident #1 was readmitted to the facility, after being sent to the hospital for behaviors. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services. Findings included: A record review of Resident #1's face sheet dated 01/21/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnosis was unspecified dementia(memory loss), blindness right eye(unable to see), hearing loss(unable to hear), and essential primary hypertension(high blood pressure). A record review of Resident #1's Initial MDS assessment, dated 01/20/2025, reflected the resident had a BIMS score of 0, which indicated severe cognitive impairment. A record review of Resident #1's care plan, dated 02/05/2025, reflected focus of discharge from the facility is not feasible as evidence by dementia. The goal reflected Resident #1 would be provided an opportunity to receive information on returning to the community. The intervention for Resident # 1 was to respect resident's rights to view nursing facility as his home Review of Resident #1's 30-day discharge letter dated 01/21/2025, revealed Resident #1 was given the 30-day discharge letter on the same date (01/21/2025) he was discharged to the hospital. The discharge letter was delivered to hospitalER on [DATE] with Resident #1. Review of Resident #1's Discharge Planning and Summary date 01/21/2025, revealed Resident #1 was sent to the hospital for behaviors. Attempted an interview on 02/09/2025 at 12:10 p.m. left message for the local ombudsman to return call. During an interview on 02/09/2025 at 3:00 p.m., the RP stated he received a text message from someone at the facility on 01/21/2025 late that evening ,time not recalled, that Resident # 1 could not come back to the facility. The RP stated he was not notified by the facility that a discharge had been in place. The RP stated Resident # 1 was not able to make any decision's and he was not able to participate in finding Resident # 1 placement at another facility. The RP stated no discharge paperwork was given to him and he had not signed anything for the Resident to be placed at another facility. The RP stated Resident # 1 was sent to the hospital for non-emergency and was not allowed to return to the facility. The RP stated Resident # 1 was discharged from the hospital to another nursing facility. During an interview on 02/09/2025 at 3:30 p.m., the SW stated she was not aware Resident # 1 was discharged from the facility to the hospital on 01/21/2025. The SW stated she did not find out about the discharge until when she returned to the facility on [DATE]. The SW stated she had not been involved with an immediate discharge with Resident #1. During an interview on 02/09/2025 at 3:45 p.m., the BOM stated she did not partake in the immediate discharge of Resident # 1. The BOM stated she just discharged Resident #1 out of the system. The BOM stated that she did not partake in the immediate discharges. The BOM stated the ADM and the DON handled the immediate discharge for Resident #1. During an interview on 02/09/2025 at 4:16 p.m., the DON stated she had just started the facility on 02/07/2025 and was not in the facility when Resident # 1 was immediate discharged from the facility. During an interview on 02/09/2025 at 4:20 p.m., the ADM stated the immediate discharge was given on 01/21/2025 the same day he was sent to the hospital for behaviors. The ADM stated no 30-day notice was given an immediate discharge was initiated for the safety and well being of all residents. The ADM stated he had been working as an ADM for two weeks when Resident # 1 as immediately discharged . The ADM stated corporate was in the building and it was thought you could issue an immediate discharge if there was a safety concern for all the other residents. The ADM stated Resident # 1 was sent out to the hospital for behaviors and not for a medical emergency. The ADM stated when a 30 day notice was not provided the family would not be able to participate in the decision of resident's stay. Review of long-term care regulation provider letter dated 12/29/2022 reflected If a NF initiates a resident discharge, the facility must provide written notification of the discharge-in a language and manner the resident can understand-to the resident, the resident representative (if applicable), and a representative of the Long-Term Care Ombudsman Program, at least 30 days before the intended discharge date . Review of nursing policy and procedure manual titled facility-initiated discharge date d 12/2017 revised 04/10/2024 reflected The facility will permit each resident to remain in the facility and not transfer or discharge the resident from the facility. In the following circumstances this facility may initiate transfers and discharges. The safety of individuals in facility is endangered due to clinical behavioral status of the resident.

Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of five (5) residents reviewed for abuse, in that: The facility failed to prevent Resident # 1 from becoming sexually assaulted by Resident #2, who had a history of sexually inappropriate behaviors, when Resident #2 blocked Resident #1 in the shower room on 5/17/2024 and touched her breast, kissed her and masturbated in front of her. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/20/2024. The IJ template was provided to the facility on [DATE] at 5:17 pm. While the IJ was removed on 05/22/2024 at 4:00 pm, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of sexual abuse with potential for injuries, trauma, and hospitalization . Findings included: Review of Resident #1's face sheet dated 5/20/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: Vascular Dementia (Memory disorder caused by circulation issues in the brain), Type 2 Diabetes Mellitus (blood sugar regulation disorder), Hypertension, Cognitive Communication Deficit (difficulty understanding and communicating), Aphasia (difficulty speaking), Dysphagia (difficulty swallowing), and Cerebrovascular Disease (brain circulation degeneration) Review of Resident #1's optional state assessment MDS dated [DATE] reflected a BIMS of 3 suggesting severe cognitive impairment. Review of Resident #1's care plan dated 4/30/2024 reflected: Resident #1 has impaired cognitive function/dementia or impaired thought processes r/t VASCULAR DEMENTIA. With intervention: o The resident needs (Specify: supervision/assistance) with all decision making. Date Initiated: 04/28/2023 Review of Resident #1's progress notes dated 5/17/2024 at 4:38 pm by the ADON reflected: Note Text: At approximately 235 pm this resident was found in C Hall shower room with another male resident. Resident immediately removed from shower room and taken to her room. Head to toe assessment completed. No obvious injuries noted. Resident unable to give statement on what occurred in shower room due to cognitive impairment. Male resident stated he told resident to come in shower room and while in there he touched her breast outside her clothing and kissed her and started to masturbate. Abuse coordinator present and notified. Law enforcement notified and currently in building. Male resident currently on one on one pending new orders. Review of Resident #1's progress notes dated 5/17/2024 at 5:09 pm reflected: Resident transported to ER for exam per [city name] Police Department. Family notified Review of Resident #1's progress notes dated 5/17/2024 at 11:57 pm reflected: Received a phone call from [state name]Health Resource [city and state name] stating that the patient was coming back shortly. She was put on Antibiotic for 7 days for STD prophylaxis . [Preventative measures] Review of Resident #1's progress notes dated 5/18/2024 at 12:26 am reflected: Patient arrived to the facility via a wheelchair with one assist. No distress noted at this time vital signs are within patient parameters. New orders of Doxycycline (antibiotic) 100mg Capsule for 7 days and Metronidazole (antibiotic) 500 mg tablet for 7 days. Will continue to monitor. Review of Resident #2's face sheet dated 5/29/2024 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Cerebral Infarction (stroke), Intermittent Explosive Disorder (mood regulation disorder), Type 2 Diabetes Mellitus (blood sugar regulation disorder), Hypertension, Hemiplegia (partial paralysis), and abnormalities of gait and mobility. Review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS of 11 suggesting a mild cognitive impairment. Review of Resident #2's current care plan dated 5/19/2024 reflected the following problem: Behavior: Sexually inappropriate: watching porn in public areas. Date initiated 3/15/2019. Interventions were as follows: IF RESIDENT IS WATCHING PORN IN PUBLIC AREAS INTERVENE AND REINFORCE THAT WATCHING PORN NEEDS TO BE DONE IN HIS ROOM AND NOT IN PUBLIC AREAS FOR OTHERS TO SEE; o Psychiatric Services consult as needed o Reinforce with staff that clear, firm limits are healthy and required when resident makes inappropriate gestures or statements; oReport incidents of target behavior to charge nurse; o Resident to be placed on secure unit due to sexual behaviors and safety; o Staff will be trained to respond, but not react to resident's behavior. Review of Resident #2's progress note dated 5/17/2024 at 2:45 pm by the ADON reflected: this resident was found in c hall bathroom with another female resident with door closed and was found and told staff he was masturbating in front of female resident and kissed her and touched her breast. The female resident did not show any signs of distress but is cognitively impaired and not able to consent to any of the above and was not able to give statement on event due to not remembering what happened. Immediately separated both residents, notified law enforcement, MD, both parties Family and Abuse Coordinator who is our admin. MD stated to send resident out for psych eval . During an interview on 5/18/2024 at 4:50 pm, the ADON stated she was working on 5/17/2024 when the incident between Resident #2 and Resident #1 occurred. She stated she had worked at the facility over a year and to her knowledge Resident #2 had never attempted to touch a female resident before. She stated he had made some inappropriate remarks to staff and female residents, but this was the first physical time. She stated Resident #2 was care planned for inappropriate sexual behavior. She stated Resident #2 had been moved to the male secure unit after the incident on 5/17/2024 pending placement at another facility. During an interview on 5/18/2024 at 5:06 pm, LVN A stated she was Resident #2's regular nurse and there had been an incident near the end of last year sometime between Resident #2 and another female resident. Resident #2 was found in bed in his room with a female resident that lacked the capacity to consent to that behavior . Review of Resident #2's progress notes from 1/1/2023 to 05/19/2024 reflected no notes related to Resident #2 being found in his bed with a female resident. During an interview on 5/18/2024 at 7:48 pm, CNA B stated she had been working on 5/17/2024 and found Resident #2 in the shower room with Resident #1. She stated she had seen Resident #1 in the common area by the nurses station after lunch and told her she had to go down the other hall to take care of a resident but would come get her when she got back to take her to her room to lie down. She stated she was gone about 20 mins and when she came back, Resident #1 was not in the common area. She stated she started looking all around for her in the dining room, in her bedroom, tv room but could not find her. She stated she remembered walking past the shower room and the door was shut. She stated she alerted other staff that she was looking for Resident #1 and when she came back by the nurses station, she saw the door to the shower room cracked and she could see Resident #2 looking at her. She stated she went up to the shower room door and tried to push it open, but Resident #2 had his wheelchair against the door on the inside, blocking it from being opened. She stated she was able to get her head in and could see Resident #1 next to Resident #2, and behind the door on the inside. She stated she told Resident #2 to move out of the way or I was gonna shove the door open. She stated Resident #2 moved out of the way and she grabbed her wheelchair out of the bathroom and asked her if she was ok. She stated when she put her head in the door, Resident #2 had his hand on his private area over his clothes. She stated both residents were in their wheelchairs but Resident #1 was close enough to Resident #2 that he could touch her. She stated they both had all their clothes on, and she only witnessed Resident #2's hand on his lap on top his privates . She stated her and LVN A took Resident #1 to her room because she wanted to lie down. She stated LVN A checked Resident #1 over and she nodded her head that she was ok and stated she just wanted to lie down, so they changed her and put her to bed. CNA B stated Resident #2 made inappropriate comments that were very sexual towards her and other staff when they were showering him. She stated about 6-8 months ago there was another incident with Resident #2 where she had found him in bed laying right next to a female resident with their clothes on . She reported it to LVN A at the time and the AD. She stated she did not remember reporting it to the DON or ADON, but she thought LVN might have done it. She stated she thought the incident could have been prevented because he should have been gone already after the last incident. and this was a long time coming. She stated the previous incident happened before November of 2024 sometime and they just separated the residents but kept them on the same hall. She stated they kept an eye on [Resident #2] for a while. During an interview on 5/19/2024 at 9:19 am, LVN C stated she heard about the incident on 5/17/2024 with Resident #2 and felt it could have been prevented. She stated there was a previous incident with Resident #2 last year and if they had handled that situation better , the current incident could have been prevented. She stated she had witnessed Resident #2 talk to staff inappropriately in the past especially during his showers, but she had not witnessed any behaviors with other residents. During an interview on 5/19/2024 at 9:29 am, LVN A stated she had been working at the facility for 7 years and had been the weekend nurse on the hall for Residents #1 and #2 since Resident #2 was admitted last year. She stated after Resident #2 was found by CNA B in the shower room with Resident #1, they took Resident #1 to her room to assess her and make sure she was okay. Resident #1 could answer yes or no questions pretty well, but it took her a while to answer in a sentence. She stated Resident #1 denied any injury, could not remember what happened and stated she just wanted to go to bed and lie down. She stated Resident #2 had behaviors around female residents . She stated, We kind of watch him, he gets sexual in the shower. She stated, It's not every day, but they keep an eye on him around other female residents . She stated she caught Resident #2 in bed in his room with another resident last fall sometime. She stated they were both lying on top of the covers and had their clothes on but were not in there long enough to do anything. She stated the facility had talked to Resident #2 about his behaviors in the past, but the last AD decided he didn't have to go. She stated staff had refused to bathe him in the shower because of his inappropriate sexual remarks. She stated she reported it to the AD at the time but did not recall telling the DON or ADON. She stated she thought she had put a progress note in EMR but didn't remember. During an interview on 5/19/2024 at 11:01 am CNA D stated she had witnessed Resident #2's behavior. She stated, It starts by him fixating on a female resident. She stated Resident #2 would try to hold their hands and get close to them. She stated last week they were outside on the patio doing an activity and Resident #2 wanted her to bring Resident #1 up next to him to sit and she told him no and moved Resident #1 away from him. She stated the staff would just try to keep Resident #2 away from female residents. She stated she thought she said something to the nurse that day about the incident on the patio, but she didn't remember. She stated she felt the incident could have been prevented because we saw him grooming her. She stated Resident #2 had a history of seeking out females and was always wanting Resident #1 to sit with him or tried to come up next to her in his wheelchair. Every time they saw it they would move Resident #1 somewhere else. She stated, Everyone knew what was going on. She stated in the past she had witnessed Resident #2 grabbing another female resident's hand and putting it in his lap. She stated she believed the DON and ADON were aware of his behaviors. During an interview on 5/19/2024 at 11:14 pm, Resident #2 stated his room had been moved because something had happened and it was bad, bad, bad. He stated he was jacking off, kissing and titties and then he laughed. He stated it had happened in the bathroom with Resident #1 and that CNA E found them and came in the bathroom and took Resident #1 out. Resident #2 stated he was not hurt but the police came and talked to him. Resident #2 was observed in his room on the male, secure unit of the facility. During an interview on 5/19/2024 at 12:40 pm Resident #1's RP stated the facility called him on 5/17/2024 to tell him what had happened with Resident #1. He stated he came up to the facility and spoke to the police and Resident #1. He stated (Resident #1) had no idea what was going on and thought she had talked to the police because she left the store without paying. He stated he gave permission for them to send Resident #1 to the ED for an exam and testing. He stated once at the hospital they were able to swab Resident #1's neck and cheek, but he declined putting Resident #1 through the trauma of a SANE exam. He stated they discharged her from the ED with prescriptions for two antibiotics and she returned to the facility. He only agreed to her coming back to the facility because Resident #2 had been moved out of the general population. He stated he was told by a nurse that they found Resident #2 pleasuring himself and kissing Resident #1. The RP stated he put Resident #1 in the facility thinking she would be safe, and it made him very angry that the incident happened, that they didn't protect her. He stated fortunately with her memory issues, she didn't remember what happened but if she could, it would be a very traumatic event; it would be for anyone that experienced it and knew what was happening. He also said there was no telling what sort of trauma the event caused for her because she could not verbalize very well what happened. During an interview on 5/19/2024 at 1:46 pm, MDS E stated in the past Resident #2 had behaviors of watching porn videos in the main areas, so that was included in his current care plan. She stated she had opened up the intervention on his care plan on 5/17/2024 after the incident with him in the shower room, because they discussed moving Resident #2 to the secure unit. She stated she was getting ready to leave for vacation on Friday afternoon 5/17/2024 so she just opened that current problem for inappropriate sexual behavior on his care plan since they were moving Resident #2 to the secure unit pending placement at another facility and she had forgot to change the date showing it had been updated. During an interview on 5/19/2024 at 2:20 pm, the ADON stated she was not aware of a previous incident last year with Resident #2 when he was found in his room in his bed with another female resident. She stated that had not been reported to her. During an interview on 5/20/2024 at 12:17 am, the AD stated Resident #2 would remain on the secure unit until they had a placement for him. He stated the facility NP would be seeing the resident face to face that day and the facility Medical Director was completing a desk review of Resident #2's medications. The AD stated he had been at work on 5/17/2024 and had been in his office right off the common area near the shower room. He stated he saw Residents #1 and #2 together sitting in the common area. The AD stated then staff started looking for Resident #1 and they found her in the shower room with Resident #2. The AD stated Resident #2 had Resident #1 in the shower room for less than 10 minutes. He stated they had no video cameras in the building to record what had happened. The AD stated their policy was not to keep the shower room doors locked since they were right near the nurse's desk. He stated they had not had any problems in the past that he was aware of related to Resident #2 and inappropriate sexual behaviors, but he had only been at the facility about a month. During an observation and interview on 5/20/2024 at 12:29 pm with the AD and RGN revealed the shower room was noted to be just off the common area near the nurse's station. The shower room door was noted to have a locking mechanism on it on the inside. The AD and RGN remained inside the shower room and the Investigator locked the door from the inside and stepped outside the shower room. The door was observed to be locked and unable to be opened from the outside. It was observed there was a key slot on the outside of the door, but both the AD and the RGN denied knowing where the key was located. The RGN stated they would get the door rekeyed and start locking the shower room door. The RGN stated he had been the RGN since July of last year and was not aware of any incidents with Resident #2 watching porn or being in bed with another resident. During an interview on 5/20/2024 at 2:40 pm, the DON stated she was not aware of a previous incident from last year with Resident #2 where he had been found in bed in his room with another female resident. She stated the incident had not been reported to her and there was nothing in the progress notes about it for Resident #2 . During an interview on 5/20/2024 at 5:10 pm the RGN stated Resident #2's current care plan still had a problem on it for sexually inappropriate behavior. When asked why the area was still on the current care plan, the RGN stated he did not know. He stated he had updated Resident #2's care plan on 5/17/2024 to reflect he was being moved to the secure unit but was not sure why it did not show the revision date on the current care pan. During an interview on 5/21/2024 at 8:54 am, the former AD (FAD) stated he did not recall an incident from last year with Resident #2 being in bed with a female resident. He stated if there had been an incident like that he would have reported it. He stated there had been a couple incidents where he touched people - he touched other female residents by trying to hold their hands - - people that were incompetent at the time. He stated the touching incidents were a year or so ago an - he had completed a facility self-report. He stated he had had no concerns at that time with Resident #2 touching female residents in a sexual way. The FAD stated the interventions they put in place at the time were they sat down with him and told him he could not be with female resident unsupervised. He stated they thought about discharging him, but they had not seen any more behaviors at that time. He stated they had educated Resident #2 about his behaviors and tried to keep him in front of staff in the common area. He stated there was usually staff around the nurses desk in the common area and there had been no other incidents that he could recall. During an interview on 5/22/2024 at 3:13 pm, the AD stated everyone that worked at the facility was responsible for supervising and keeping an eye on the residents. Review of facility policy Preventing Resident Abuse dated June 2005 reflected: Our facility will not condone any form of resident abuse and will continually monitor our facilities policies procedures, training programs, systems, etc. to assist in preventing resident abuse. 1. The facility's goal is to achieve and maintain an abuse -free environment. 1j Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 1k. assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues.1o Identifying areas within the facility that may make abuse and or neglect more likely to occur (e.g. secluded areas) and monitoring these areas regularly. The AD was notified on 5/20/2024 at 5:17 pm that an Immediate Jeopardy (IJ) had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 5/22/2024: On 5/20/24 an abbreviated survey was initiated at [facility name]. On 5/20/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: Facility Failed to provide supervision on 5/17/2024 to prevent Resident #1 from getting Resident #2 into the shower room alone. All items listed will be completed by 5:00PM on 5/21/24 with continued follow-up for scheduled staff. 1. R#2 received MD order to be placed on All Male Secure Unit Placement 2. R#1 was provided a Head-to-Toe Assessment on 5/17/24 with no injuries identified 3. Emotional Distress Assessment completed for R#1 on 5/17, 5/18, 5/19 with no issues identified 4. R#2's Care Plan was updated by MDS Nurse 5. On 5/18/24 Administrator/DON completed 100% Incident/Accident Audit on every resident in facility to ensure no incidents of sexual inappropriate behavior were documented without any interventions. No other residents were identified as having sexually inappropriate behavior. Safe surveys were completed all female residents not residing on the secure unit. 6. Administrator/DON initiated Staff in-service for ALL STAFF on 5/20/24 on Resident Accidents/Supervision, Resident Supervision/Safety, Resident Rights, and Abuse and Neglect. Administrator/DON trained by Regional Clinical Director prior to start of in-service on 5/20/2024. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was first made aware of the Immediate Jeopardy 5/20/24 at 7:00PM and has been involved in developing the Plan of Removal. These conversations are considered a part of the QA process. A QAPI meeting was held on 5/20/2024 with attendance of the Administrator, Director of Nursing, Assistant Director of Nursing and Regional Clinical Director. This plan was initially implemented 5/20/24 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 5/21/24 by 5:00 pm with continuation of oncoming staff and follow up. A Surveyor monitored the POR on 5/22/2024 as followed: 05/22/2024 12:16 PM Observation of shower room (room in which incident occurred) door with handle which did not lock on the inside or outside of shower room. All shampoo and any supplies needed that could contain chemicals were locked in a cabinet and no residents could access them. 05/22/2024 12:22 PM Interview with Resident #2, he stated he was doing ok, and the staff were taking good care of him. He stated he felt safe in the facility, and he had been moved to the secure unit because of something bad he had done. He stated he had been jacking off, kissing, and titties. He stated that had never happened before and he was not sure if the other resident wanted to do it or not, but she was his friend and he liked her. He stated she never said no. Resident #2 was observed in secure unit in his room with call light in reach. Resident was dressed appropriately and in no sign of pain or distress. 05/22/2024 12:26 PM Interview with Resident #1, she shook her head yes when asked if she was doing ok and if she felt safe in the facility. Resident was sitting in her wheelchair in the dining room at the table visiting her family member. Resident appeared clean and was dressed appropriately. Resident was in no sign of pain or distress and smiled when meeting and talking with surveyor. 05/22/2024 12:28 PM Interview with FM, he stated he is doing well, and he is aware of the incident that occurred with the other resident. He stated his only concern is making sure resident is supervised correctly and that he is fine if the other resident remains in the secure unit, bit he is not sure about how he would feel if the resident was out of the secure unit. He stated resident is confused at times and she does not recall the incident. 05/22/2024 1:15 PM Interview with MA-F she stated she had worked in the facility for about 6 years, and she worked the day shift. She stated she was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect on this past Monday and Tuesday. She stated staffing was ok. She stated she felt as though she could meet the needs of her residents. She stated she had not had any residents complain to her about any inappropriate sexual behavior from any other residents. She stated an example of abuse was cursing at a resident and she had never witnessed abuse in this facility. She stated if she suspected abuse, she would have reported it to her charge nurse and the Administrator, which was the Abuse Coordinator. 05/22/2024 1:19 PM Interview with LVN - G, she stated she had worked in the facility for about 3 years and she worked the day shift. She stated she was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect on this past Monday, and they always have different materials for them to read. She stated staffing was generally ok and they make it work. She stated she felt as though she could meet the needs of her residents. She stated she had not had any residents complain to her about any inappropriate sexual behavior from any other residents. She stated an example of abuse was pulling a resident roughly and she had never witnessed abuse in this facility. She stated if she suspected abuse, she would have reported it to the Administrator, which was the Abuse Coordinator. 05/22/2024 1:27 PM Interview with LVN - H, she stated she had worked in the facility for about 4 years and she worked the day shift. She stated she was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect on yesterday. She stated staffing was ok. She stated she felt as though she could meet the needs of her residents. She stated she had not had any residents complain to her about any inappropriate sexual behavior from any other residents. She stated an example of abuse was involuntarily secluding a resident and she had never witnessed abuse in this facility. She stated if she suspected abuse, she would have reported it to the Administrator, which was the Abuse Coordinator. 05/22/2024 1:30 PM Interview with CNA - I, she stated she had worked in the facility for about 4 months, and she worked the day shift. She stated she was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect today. She stated this was her first day back since the weekend and she was off on Monday and Tuesday. She stated she was in-serviced prior to getting on the floor to work. She stated staffing was ok. She stated she felt as though she could meet the needs of her residents. She stated she had not had any residents complain to her about any inappropriate sexual behavior from any other residents. She stated an example of abuse was hitting a resident and she had never witnessed abuse in this facility. She stated if she suspected abuse, she would have reported it to the Administrator, which was the Abuse Coordinator. 05/22/2024 1:35 PM Interview with AD and RGN, they stated they had in-serviced staff regarding resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect. They stated there may be some staff that have not been in-serviced as of yet, but they will not be allowed to work until they have received the in-services. They stated 85% of staff have been in-service so far and there were only a few staff that had not been in-serviced yet. They stated the RN weekend supervisor was the one responsible for ensuring staff on the weekends have been in-serviced prior to working. They stated staffing was adequate to meet the resident's needs. They stated they felt as though their staff could meet the needs of their residents. They stated they were not aware of any residents that had complained about any inappropriate sexual behavior from any other residents. They stated an example of abuse was sexual a resident and they had never witnessed abuse in this facility. They stated if staff suspected abuse, they should have reported it immediately to Administrator which was the Abuse Coordinator. They stated Resident #2 would remain in the secure unit unless they had to staff available to perform one on one supervision. They stated they are actively trying to have resident placed at a different facility which is more suitable for him, but each facility has denied resident admitting so far and they may also suggest family taking him home. 05/22/2024 2:17 PM Interview with LVN - J, she stated she had worked in the facility for about 2 months, and she worked the 2-10 shift. She stated she was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect on Monday. She stated she was in-serviced prior to getting on the floor to work. She stated staffing was good. She stated she felt as though she could meet the needs of her residents. She stated she had not had any residents complain to her about any inappropriate sexual behavior from any other residents. She stated an example of abuse was cussing at a resident and she had never witnessed abuse in this facility. She stated if she suspected abuse, she would have reported it to the Administrator, which was the Abuse Coordinator. 05/22/2024 2:22 PM Interview with MA- K, he stated he had worked in the facility for about a year and a half, and he worked the 2-10 shift. He stated he was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect on Monday and Tuesday. He stated he was in-serviced prior to getting on the floor to work. He stated staffing was decent. He stated he felt as though he could meet the needs of his residents. He stated he had not had any residents complain to him about any inappropriate sexual behavior from any other residents. He stated an example of abuse was a resident-to-resident altercation and he had never witnessed abuse in this facility. He stated if he suspected abuse, he would have called and reported it to the Administrator, which was the Abuse Coordinator. 05/22/2024 Reviewed in-servicing which includes attendance forms with staff signatures dated 05/20/2024 given by the RGN for DON and AD over accidents and incidents, abuse and neglect, safety and supervision of residents, and resident rights. Reviewed in-servicing which includes attendance forms with staff signatures dated 05/20/2024 given by the DON over accidents and incidents, abuse and neglect, safety and supervision of residents, and resident rights. 05/22/2024 Reviewed documentation on QAPI meeting held 05/20/2024 regarding prevent reoccurrence and continued safety for all residents in which the DON and Administrator both attended. 05/22/2024 Reviewed documentation for 100% incident/accident audit performed for every resident in facility. 05/22/2024 Reviewed safe surveys dated 05/19/24 - 05/20/24 performed on female resident which resided outside of secure unit. 05/22/2024 Reviewed incident quiz given to staff and resident abuse questionnaires given to residents. On 5/22/2024 at 4:00 pm, the AD was informed the immediacy was removed. The IJ template was provided to the facility on [DATE] at 5:17 pm. While the IJ was removed on 05/22/2024 at 4:00 pm, the facili [TRUNCATED]

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #7) reviewed for comprehensive care plans. The facility failed to ensure Resident #7's comprehensive care plan included a new intervention for a fall mat after Resident #7 fell on [DATE]. This failure could place residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: A record review of Resident #7's face sheet, dated 02/06/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses that included Weakness (lack of strength), Muscle wasting and atrophy (decrease in muscle mass), lack of coordination (difficulties in controlling and organizing movement) Spastic Hemiplegia affecting right dominant side (causing muscle tightness and involuntary contractions in the limbs or extremities), unspecified abnormalities of gait and mobility (change in walking pattern), and other muscle spasm (when a muscle involuntarily or forcibly contract uncontrollably). A record review of Resident #7's Quarterly MDS assessment, dated 12/28/23, reflected Resident #7 had a BIMS score of 15, which indicated cognitively intact. Section GG of the MDS indicated Resident #7 had impairment to one side of his upper extremity and had impairment to both sides of his lower extremities. Section GG also indicated that Resident #7 was dependent in the following areas upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. A record review of Resident #7's Active Physicians Orders, dated 02/06/24, reflected there was an order, dated 11/30/23, for Resident #7 to have a fall mat at bedside. A record review of a Progress Note entry, dated 11/29/23, reflected Resident #7 was seen sitting on the floor next to the bed. According to the progress note Resident #7 stated that he slid to the floor trying to get out of bed. A record review of Resident #7's care plan, dated 12/18/23, did not reflect a fall mat for Resident #7 nor did it reflect Resident #7's most recent fall on 11/29/23. An observation of Resident #7 on 02/06/23 at 1:00 pm revealed the resident was lying in bed with the fall mat placed against the wall. An observation of Resident #7 on 02/07/23 at 10:00 am revealed the resident was lying in bed with the fall mat placed bedside the bed. In an interview with Resident #7 on 02/06/24 at 1:00 pm, Resident #7 stated sometimes the staff put the fall mat down and sometimes they don't. Resident #7 stated that his entire right side was contracted due to several strokes. Resident #7 stated his most recent fall was in October or November of 2023. Resident #7 stated his fall mat was not near his bed during his most recent fall. In an interview with the MDS Coordinator on 02/07/24 at 12:15 pm. The MDS Coordinator stated she had worked at the facility for [AGE] years. The MDS Coordinator stated she was responsible for completing and updating the Care Plans. The MDS Coordinator stated during the morning meeting the DON would notify her if a resident had a fall and would notify her of any updated interventions that needed to be added to the care plan. The MDS Coordinator stated that if a resident had a fall mat, then it should have been used while the resident was in bed, and the fall mat should have been care planned. The MDS Coordinator stated if a resident''s fall mat was not placed beside the resident's bed, then the resident could have injured themselves if they had a fall. In an interview with the DON on 02/07/24 at 12:25 pm. The DON stated that if the residents had reoccurring falls the care plan should have been updated, but not if a resident had an isolated fall. The DON stated if a resident had a fall mat, then it should have been used correctly, and care planned. The DON stated if the fall mat was not placed beside the resident's bed, then the resident could have sustained injuries such as broken or fractured bones. In an interview with the Administrator on 02/07/24 at 12:35 pm. the administrator stated that if a resident had a fall the care plan should have been updated to reflect that fall and new interventions should have been added to the care plan. The administrator stated the MDS Coordinator was responsible for completing and updating the care plans. The administrator stated that if a resident had a fall mat, then it should have been care planned. The administrator stated if a resident has a fall mat, then it should have been correctly placed near the resident's bed when the resident was lying down. The administrator stated that if the mat was not placed on the floor near the bed, then the resident could have sustained injuries from falling. Record review of the facility's Using the Care Plan policy, not dated, reflected The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Policy Interpretation and Implementation 1. Complete care plans are placed in the resident's chart and/or 3-ring binder located at the appropriate nurses station. 2. The Nurse supervisor uses the care plan to continue the CNAs daily/weekly work assessments sheets and/or flow sheets. 3. CNAs are responsible for reporting to the Nursing Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved. 4. Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and /or the MDS Assessment Coordinator. 5. Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made. 6. Documentation must be consistent with the resident's care plan. 7. Information contained on the care plan and other documents used by the nursing staff shall be maintained in a confidential manner in accordance with established facility policy.

Based on observation, interview, and record review, the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 8 residents (Resident #18) reviewed for comprehensive assessments. The facility failed to complete an accurate quarterly comprehensive assessment dated [DATE] for Resident #18 by not including hospice services. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided. The findings included: Record review of Resident #18's face sheet, dated 02/06/24, documented a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #18 had diagnoses which included: Parkinson's Disease (a chronic degenerative disorder of the central nervous system that affects both the motor system and non-motor systems), dementia (general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), heart failure (a syndrome, a group of signs and symptoms, caused by impairment of the heart's blood pumping function), and dysphagia (difficulty in swallowing). Record review of Resident #18's Quarterly MDS assessment dated [DATE], reflected that the resident was not receiving hospice services. Record review of Resident #18's Annual MDS assessment dated [DATE], reflected that Resident #18 had a BIMS score of 09 which revealed the resident was moderately cognitively impaired. Record review of Resident #18's Physician's Orders, dated 02/06/24, reflected the resident had an order to admit to hospice on 09/19/22. In an observation on 02/05/24 at 10:36 AM Resident #18 was outside smoking with staff present. Resident #18 appeared to be in no sign of distress. Resident #18 was dressed appropriately for temperatures. She stated things were fine and staff treated her well. She stated she had no complaints. In an interview on 02/07/24 at 11:25 AM with the MDS nurse, she stated she had worked in the facility for about [AGE] years. She stated Resident #18 was no longer on hospice services, but that Resident #18 had been on hospice services from 10/30/22 to 07/04/23. She stated she had not been aware Resident #18's quarterly MDS assessment, which was completed on 05/12/23, had not reflected Resident #18 received hospice services. She stated the MDS assessments should have reflected if a resident received hospice services. She stated there was no correction done to the MDS assessment completed on 05/12/23. She stated Resident #18's hospice orders should have been discontinued when the resident came off of hospice. She stated she had been trained on how to complete an MDS accurately and she was not sure how that MDS assessment which was completed on 05/12/23 got by. She stated if an MDS assessment was completed inaccurately, the facility could have money taken back or they could lose money. In an interview on 02/07/24 at 12:11 PM with the DON, she stated she had worked in the facility for about a year. She stated Resident #18 no longer received hospice care. She stated Resident #18 had received hospice care until around July of 2023. She stated they were not sure about taking Resident #18 off of hospice due to Resident #18's weight loss, so they had monitored Resident #18 closely. She stated the MDS nurse was responsible for completing all MDS assessments. She stated the MDS nurse worked at the facility before she did and she was not sure of the training the MDS nurse received. She stated she knew that the MDS's corporate supervisor came to the facility and worked with the MDS nurse on all those things. She stated she had not realized Resident #18's MDS assessment which was completed on 05/12/23 was not accurate. She stated MDS assessments should reflect if a resident was on hospice services. She stated a possible outcome could have been if the staff attempted to order medications from the hospice company, it could have prevented the medication from being delivered timely and could have caused all kinds of medication errors. She stated they had a process to keep them from doing that. In an interview on 02/07/24 at 12:42 PM with the ADM, he stated he had worked at the facility for about 2 years. He stated Resident #18 was not on hospice services at that time, but she had been on hospice before. He stated he was not sure when Resident #18 came off of hospice services, but he knew it was some time last year. He stated he was not aware that the MDS assessment completed on 05/12/23 was not accurate. He stated the MDS assessment should reflect if a resident was on hospice. He stated the MDS nurse was responsible for completing the MDS assessment and it was overseen by the DON. He stated the MDS nurse had been trained on accurate completion of the MDS assessments. He stated the outcome of an inaccurate MDS assessment could be a resident not receiving proper care, medications, or treatment. Record review of the facility's policy on Certifying Accuracy of the Resident Assessment, dated 2001, revised November 2019, reflected Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for one (Resident # 30) of six residents reviewed for infection control. CNA A failed to change gloves or wash her hands while performing perineal care when removing a soiled brief and applying a clean brief. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #30's undated Face Sheet reflected a [AGE] year-old female who was admitted on [DATE] with a diagnosis of cerebral infarction (damage to tissues in the brain due to loss of oxygen and blood to the area causing the tissue to die also called a stroke or brain attack), mild protein calorie malnutrition, weakness, hypothyroidism (a hormone deficiency) , and hemiplegia (paralysis) following cerebral infarction (stroke). Record review of Resident #30's Quarterly MDS assessment dated [DATE], reflected a BIMs score of 14 indicating Resident #30 was cognitively intact. Section H reflected Resident #30 was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #30's care plan initiated 04/27/2022 and revised 01/22/2024 reflected Resident #30 had a care plan for bladder incontinence. Resident #30's goal was to remain free from skin breakdown due to use of incontinence briefs through review date. The care plan included an intervention to check the resident every 2 hours and as required for incontinence care, wash rinse, dry perinium, and change clothing as needed. In an observation on 02/06/24 at 11:02 AM CNA A was observed performing incontinent care. CNA A washed her hands and donned gloves prior to the start of the observation. CNA A cleaned Resident #30's front perineal area. Resident #30 rolled over and CNA A was observed washing buttocks and patting it dry. CNA A then removed the soiled brief and proceeded to put a clean brief under the resident, fastened the brief sides, and covered Resident #30 up with her blanket. CNA A did not wash her hands or change gloves between removing soiled brief and applying a clean brief. In an interview on 02/06/24 11:36 AM with CNA A she stated she had been a CNA for [AGE] years. CNA A reported she had been verbally trained in an in-service on perineal care and handwashing techniques. CNA A reported she was not trained to remove her dirty gloves and wash hands prior to applying a clean brief. CNA A stated the risk to the resident could have been a urinary infection. In an interview on 02/07/24 at 12:15 PM with the ADON reported she expected the staff to follow policy and procedure for handwashing. The ADON reported the staff had been instructed on handwashing in an in-service. She reported the nursing staff were visually checked off annually on all skills including perineal care and handwashing. She stated she was responsible for ensuring the CNAs had been educated on handwashing techniques. The ADON stated the negative outcome for failing to wash hands between removing a soiled brief and applying a clean brief could lead to increased urinary tract infections. In an interview on 02/07/24 at 12:33 PM with the DON she reported her expectation was for the staff to wash, wash, wash their hands and change their gloves when performing resident care. The DON reported the ADON was responsible for monitoring handwashing education for staff members and the DON monitored the ADON to ensure tasks were completed. The DON reported the negative outcome for not cleaning or washing hands between dirty and clean surfaces could increase urinary tract infections. In a record review of a nurse aide proficiency dated 8/17/23 indicated CNA A had passed her handwashing skills check off and was signed by ADON. In a record review of an in-service dated 11/30/23 reflected that CNA A had signed she had viewed perineal care video in-service with handwashing techniques included. Record review of the facility's Policy and procedure for handwashing dated 2001 and updated in October 2023 reflected: 1) indications for hand hygiene -(c) after contact with blood, body fluids, or contaminated surfaces (f) before moving from work on a soiled body site to clean body site on the same resident and (g) immediately after glove removal.

Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of 1 (Resident # 1) of 5 residents reviewed for pharmacy services. The facility failed to follow the physician orders when administering Resident # 1's medications causing the resident to aspirate, have labored breathing and being sent to the hospital and being admitted due to aspiration. An (IJ) Immediate Jeopardy was identified on 8/24/2023 at 7:26pm. While the (IJ) Immediate Jeopardy was removed on 8/26/2023 at 5:00pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents at risk for inadequate therapeutic outcomes, and a decline in health. Findings included: Record review of Resident #1 face sheet dated 8/24/2023, reflected Resident # 1 was an 85- year- old man, admitted to the facility on [DATE]. Resident # 1 was diagnosed with ATHEROSCLEROTIC HEART DISEASE (damage or disease in the hearts blood vessels), DYSPHAGIA (difficulty swallowing foods or liquids) FOLLOWING CEREBRAL INFARCTION (disrupted blood flow to the brain due to problems with the blood vessels that supply it.) Record review of Resident # 1's care plan dated 6/27/2023, reflected Resident # 1 had a swallowing problem. Record review of Resident # 1's swallowing assessment reflected he required (Reg diet pureed texture, pudding thick consistency for fluids) Record review of Resident # 1 significant change MDS dated [DATE] reflected a BIMS- high level of cognitive functioning. In the MDS section K swallowing/nutritional status reflected; pureed textured, thickened liquids therapeutic diet. Record review of Resident # 1 physician orders dated 2/14/2023 reflected- Pureed texture, pudding consistency, for fortified at breakfast and an order dated 8/22/2023 reflected- Crushed medications and mix with food/fluids due to swallowing disorder, every shift related to Dysphagia, Oropharyngeal Phase. In an interview on 8/24/2023 at 1:07pm with LVN A, revealed on 8/22/2023 the MA admitted he administered Resident #1 medications without crushing and without thickened liquids. LVN A stated when she asked the MA were Resident # 1's medications administered crushed he stated no were they supposed to be? When asked if the medications were given with water not a thickened liquid he stated yes. She stated these medications were not administered as prescribed in the orders. LVN A stated Resident # 1 was coughing and had labored breathing. She stated they sent Resident # 1 was sent for further evaluation and treatment. In a phone interview on 8/22/2023 at 1:28pm with Resident # 1, revealed he had a choking incident on 8/22/2023, the resident was able to state he was feeling fine today. He stated on Tuesday he was not feeling very well. The resident stated he was not able to remember all of what happened but stated something was wrong. In a phone interview on 8/22/2023 with (RP) at 1:30pm, revealed she was contacted by the facility and advised that that Resident # 1 started choking and wasn't recovering well, continuing to cough and complain of chest pains so they sent him to the hospital to ensure that he did not aspirate. She stated when he got to the hospital, he was still having some choking problems and was not able to formulate his words. In an interview on 8/24/2023 at 5:53pm with MDS revealed, the MA administered the following medications to Resident # 1 without crushing or thickened liquid. The medications were as follows: Lodipine 10mg, Aspirin 81mg, Cholecalciferol 125mg 1 tablet, Clopidogrel Bisulfate tablet 75mg 1 tablet, Ferrous sulfate Iron 200mg 1 tablet, Finasteride tablet 5mg 1 tablet, Lactobacillus Capsule 1 caplet, Lasix tablet 20mg 1 tablet, Tamsulosin HCI Capsule 0.4 mg, Zinc tablet 50mg, buspirone HCI tablet 15mg 1 tablet, Metoprolol Tartrate tablet 25mg, Oxcarbazepine tablet 600mg, and Zanaflex tablet 4mg 1 tablet. Interview on 8/24/2023 at 1:54pm with hospital staff revealed, Resident # 1 was admitted to the hospital on 8/22/2023 for aspirations and shortness of breath. In an interview on 8/24/2023 at 2:23pm with the DON revealed, on 8/22/2023 a CNA (unknown) walking down the hall advised her that Resident # 1 was choking. She stated when she entered the room LVN C was already in the room assisting Resident # 1. She stated that's when she learned that the MA had given Resident # 1 his medications not crushed or with thickened liquids. She stated Resident #1 complained of his chest hurting really bad and that he stated he was choking. The DON stated she never spoke with the MA herself but did advise the nursing staff to in-service the MA before he administered medication to any of the other residents. The DON stated the nurses were responsible for ensuring that all agency staff are trained on the care needs for the residents. She stated Resident # 1 was sent to the hospital for further evaluation and possible aspiration. The DON stated Resident # 1 could have aspirated due to not having his medications crushed and administered with thickened liquids according to the orders. In an interview on 8/24/2023 at 12:30pm with the ADM revealed, the incident happened on 8/22/2023 and he has not yet completed his five -day report. He stated he was advised that the MA gave Resident # 1 his medications without them being crushed. He stated when a person is not given their medication according to the orders the Resident could have an adverse reaction and could be terminal. He stated he contacted the staffing agency and advised that the agency staff should be placed on the DNR (do not return) list and advised that they could make a referral on the staff's certification. Record review of facility progress note dated 8/22/2023 reflected, Resident # 1 was sent to the hospital on 8/22/2023 for aspirating. Record review of hospital records dated 8/22/2023, reflected Resident # 1 was admitted to the hospital for aspiration. Record review of facility Administering Medications policy dated April 2019, reflected Medications are administered in a safe and timely manner, and as prescribed. This was determined to be an (IJ) Immediate Jeopardy (IJ) on 78/24/2023 at 7:26pm. The ADM was notified. The ADM was provided with the IJ template on 8/24/2023 at 7:26pm. A Plan of Removal was first submitted by the ADM on 8/25/2023 at 9:14am. The Plan of removal accepted on 8/26/2023 at 12:18pm. Re: Plan of Removal of Immediate Jeopardy The following is a plan of removal, which has been immediately implemented for the facility to remedy the immediate jeopardy which was imposed 8/24/23 at 7:26pm for F-755 facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of resident 1. MA administered residents 1 medication whole and with water instead of the order which stated to crush all medications and serve with thicken liquids due to swallowing issues. All residents could potentially be affected by deficient practice. All items listed will be completed by 8/25/23 with continued follow up for scheduled staff. 1. Resident #1was assessed by LVN#1 post the event and sent to the hospital for evaluation. The initial radiological exam showed no obstructions or complications. Local Hospital is providing a higher level of care in place for this resident continues. 8-24-2023 thru 8-25-2023 2. All residents will be reviewed by DON for correct medication administration order that includes liquid administration order type. 8-25-2023 thru 8-25-2023 3. All residents were assessed by the DON/ADON regarding medication administration for crushed medication orders and/or the need for crushed medications due to diagnosis documented swallowing disorders. 8-24-2023 thru 8-25-2023 4. All residents' orders were reviewed by DON/ADON/MDS for crushed medication and orders for thickened liquids accuracy including order communication to EMAR (electronic medication administration record) regarding order. 8-24-2023 thru 8-25-2023 5. All residents requiring crushed mediations and thickened liquids care plans were reviewed by MDS/DON/ADON. 8-24-2023 thru 8-25-2023 6. All Medication aides and nurses were in-serviced by the DON/ADON regarding medication administration policy and procedure with a special focus regarding order for crushed medications and those residents requiring thickened liquids. 8-24-2023 thru 8-25-2023 7. Regional Director of Care in -serviced DON/ADON/Admin on physician orders for crushed medication and thickened liquids. All staff were in-serviced by the Admin/DON/ADON regarding following physician orders for crushed medications and thickened liquids. 8-24-2023 thru 8-25-2023 8. A medication observation will be conducted by the DON/ADON 3 times a week randomly for 3 weeks. All negative findings will be immediately corrected and forwarded to QAPI for intervention change. 8-24-2023 thru 9-8-2023 9. Contracted pharmacy consult was contacted regarding the medication administration error and involvement in QAPI process/interventions, to schedule Inservice for September 4,2023 8-24-2023 thru 8-25-2023. All residents' potential to be affected by this deficient practice. If staff are unable to attend any of the in-services, they will be required to complete before starting their assigned shift. Staff will sign the Inservice sheet for each service that will be kept at the nurses station in a binder. All PRN and Agency Staff will be in-service before the start of shift by the DON/ADON/designee. The Medical Director was initially made aware of the immediate jeopardy 8/24/23 at 10:11pm and has been involved in the development of the plan to removal. These conversations are considered a part of the QA process. To monitor for compliance the Administrator and/or designee will review all residents with swallowing disorders and medication administration passes as above with follow up if warranted for the next 30 days. The IDT will review and assess the orders in place to determine what further actions if needed are necessary. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. Any negative findings will be forwarded to the Administrator and the QA committee. This plan was initially implemented 8/24/23 and will be monitored through completion. It will be monitored thereafter 30 days by the regional director of care and regional director of operations. Plan of Removal completion date is 8/25/23 by with continuation of oncoming staff and follow up. The Surveyor monitored the Plan of Removal on 8/26/2023 as follows: 3:00pm Entrance of facility 3:10pm Entrance Conference with ADM and advised her the reason for the visit due to POR (Plan of Removal) monitoring. ADM was given a list of information needed. She stated the census is 58. Review of nurse's progress dated 8/22/2023 reflected the resident had been assessed prior to going to hospital. The note reflected that the resident continued to have coughing and breathing problems, so the resident was sent to the hospital for further evaluation. The resident returned to the facility on [DATE] late evening. Review of nurse's progress note dated 8/26/2023 reflected Resident # 1 was assessed upon return to the facility. Record review reflected that the ADM and DON were in-serviced by the regional director of Operations on abuse/neglect dated 8/25/2023 In an interview on 8/26/2023 at 3:30pm with the DON revealed she went through each resident's chart and reviewed their medications and orders to verify that they are current and correct for each resident. The DON stated she reviewed all orders for crushed medications and thickened liquids she stated she completed this on 8/26/2023. Record review of medication log for residents with crushed medications developed and placed on each medication cart for staff to review on every resident with crushed medications, thickened liquids and how to administer to resident. Record review 8/26/2023 of resident roster will all residents who have a diagnosis of swallowing disorder, the facility had 47 residents with swallowing disorder. The DON stated she completed this task during the medication pass with the MA to ensure that all residents received the correct medication in the form required to take. Records reviewed reflected all 47 residents with swallowing disorders, care plan and orders had been updated in PCC system The DON stated she reviewed all orders for crushed medications and thickened liquids she stated she completed this on 8/26/2023. In an interview with MDS on 8/26/2023 at 4:00pm, revealed she updated all care plans to reflect how to administration the medication and how to cleanse the resident's pallet. She stated she also developed a medication log that is kept placed on each medication cart that shows each resident with crushed medications and how they are to be administered, the log is updated daily to ensure all residents with crushed medications are listed and how to administer according to the order to help ensure that when giving medications the form is reviewed and checked off for each resident. Record review of in-services reflected 3 agency staff have completed the following in-services: Medication administration, crushing medications, Abuse/Neglect, Choking dated 8/26/2023. Record review reflected 4 agency staff completed the in-service on Where to find and read Physician orders dated 8/25/2023. Record review reflected 31 facility staff completed the following in-services Dysphagia dated 8/25/2023, 27 facility staff completed the in-service for Choking and Abuse/ Neglect dated 8/25/2023, 15 facility staff completed the in-service on Where to find and read physicians orders, crushing medications, and Medication administration dated 8/25/2023. Record review of in-service Physicians orders, crushed medications and thickened liquids dated 8/26/2023 completed by the regional director. Record review of two staff observations were completed by the DON administering medications. The staff were observed going through each step before administering to verify correct dosage, correct resident, and administered in the correct manner for, 1 MA and LVN on 8/25/2023 and 8/26/2023 Beginning at 3:56pm - Interview with 3 CNA's (agency staff) 6am to 6pm shift. Stated they have been in-serviced on where to find the care needs for the residents in PCC. Stated they have been in-serviced on abuse/neglect stated the protocol is to report immediately if they see or suspect abuse/neglect. Stated they have never seen or suspected abuse/neglect at this facility. Stated they have been trained on choking and protocols to take when a resident may choke, stated they do not pass medications. Beginning at 4:10pm -MA B (facility) doubles on the weekends 6am to 10pm. Stated she has been in-serviced on abuse/neglect, dysphagia, choking, crushed medications, medication administration and physician orders. She stated she looks in the MAR to verify what medication a resident requires the dosage, and how it is to be administered. She stated the protocol for abuse/neglect is to report immediately to the admin. who is the abuse/neglect coordinator, stated she has never seen or suspected abuse/neglect at this facility. Beginning at 4:34pm Interview with RN weekend supervisor double weekends (facility), LVN weekend nurse 6am- 10pn (facility) Stated they have been trained on abuse/neglect, physician orders, medication administration, crushed medications. Stated staff are to report if there is any discrepancy or error made when medications are administered. She stated a log has been placed on each medication cart as an added way for MA, and nurses will know which residents require crushed medications and thickened liquids, but they should still check the MAR. 4:40pm Interview with LVN B (facility staff) weekend nurse 6am- 10pm Stated they have been trained on abuse/neglect, physician orders, medication administration, crushed medications. Stated they check the medication log posted on the medication cart is one way to know and look in the MAR on the PCC system to see how medication is administered for the resident. 4:49pm Interview with Resident # 4 stated she as ok, stated she had no concerns at this time and stated she felt safe. 4:50pm Observation of Resident #1, appeared he was sleeping, did not appear to be in any pain or distress during this observation 5:00pm interview with Resident # 5 stated he was doing fine, stated he felt safe and had no concerns at this time. 4:53pm- Interview with ADMN. Stated it was his expectation that staff follow all the training and protocols they have been given to provide the resident with the care needs they require that will allow them to have the best quality of life possible. The ADM was informed that Immediate Jeopardy was removed on 8/26/2023 at 5:00pm. The facility remained out of compliance at the severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on Observation, interview, and record review the facility failed to ensure residents were free from abuse/neglect and exploitation for 2 ( Resident# 2 and Resident # 3) of 5 residents reviewed for abuse/neglect. The facility failed to ensure that Resident's # 2 and #3 were free from verbal abuse by staff. Resulting in the residents to be upset, feeling threatened and unsafe at the facility This failure could place residents at risk to be abused, neglected and or not provided needed care /treatment. Findings included: Record review of Resident #2 face sheet dated 8/24/2023, reflected Resident # 2 was a 47- year- old woman, admitted to the facility on [DATE]. Resident # 2 was diagnosed with Cerebral Palsy (a cognitive disorder of movement, muscle tone, and posture due to abnormal brain development), Cognitive Communication Deficit (difficulty in thinking and how someone uses language) and Epilepsy (brain disorder that causes seizures) and legal blindness. Review of Resident # 2's care plan dated 6/27/2023, reflected Resident # 2 has an ADL self-care performance deficit and is totally dependent on staff personal hygiene, dressing, bathing, eating, transfers and bed mobility. Review of Resident # 2's quarterly MDS dated [DATE] reflected a BIMS- 13 high level of cognitive functioning, section GG functional section reflected Resident # 2 required set -up and clean-up in the following areas hygiene, dressing, bathing, eating. In an interview on 8/24/2023 at 12:30pm with ADM, revealed his investigation of the incident he was able to confirm that staff was verbally abusive towards Resident # 2. He stated another staff member witnessed the verbal abuse. He stated this staff was terminated and the other staff were in-serviced on abuse/ neglect. In an interview on 8/26/2023 at 3:20pm with LVN C, revealed she was a witness to the incident that occurred on 5/31/2023 with Resident # 2. She stated she provided a statement of what she heard and didn't think that it was right. She stated the staff continued to argue with Resident # 2 about her jacket that she left in the shower, she stated she went into the shower and saw that the resident had left her jacket in the shower. In an interview on 8/25/2023 at 3:45pm with family member revealed, that she was in the activity room when she heard the staff CNA A yelling at Resident # 2. She stated Resident # 2 continued to get upset and she tried to get her to calm down. She stated Resident # 2 had advised CNA A that she left her jacket in the shower room. She stated she continued to argue and yell at the resident telling her that she did not leave her jacket in the shower room and tried to convince her that she never had a jacket. The family member stated that another staff LVN C heard them and stated she went and looked in the shower and got Resident # 2's jacket that she had left in the shower. The family member stated the staff instead of arguing and yelling at Resident # 2 should have just looked for the jacket and Resident # 2 would not have been upset and agitated. LVN C stated she had been trained on abuse/neglect and stated the ADM was the abuse/neglect coordinator if they see or suspected abuse/neglect to report immediately. In a face/time phone interview on 8/25/2023 at 4:00pm with Resident # 2, she stated she was doing fine. She was not able to recall the events of the incident. Resident # 2 appeared to be clean and dressed appropriate as she was wearing her favorite jacket when asked. Record review of facility investigation dated 7/26/2023 reflected CNA A was confirmed and terminated. Record review of the staff witness statement revealed, that CNA A was arguing with Resident # 2 about her jacket and stated she went into the shower and get Resident # 2 jacket. Record review of personnel file reflected; CNA A was terminated from the facility on 6/2/2023 confirmed for abuse. Record review of abuse/neglect in-service dated 7/28/2023 reflected staff had been in-serviced Record review of facility abuse/neglect policy dated April 2021 reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Record review of Resident #3 face sheet dated 8/24/2023, reflected Resident # 3 was a 71- year- old man, admitted to the facility on [DATE]. Resident # 3 was diagnosed with need for assistance with personal care, chronic respiratory failure with hypoxia (low blood oxygen levels that cause respiratory failure), intermittent explosive disorder (an impulse-control disorder characterized by sudden episodes of unwanted anger). Review of Resident # 3's care plan dated 5/4/2023, reflected Resident # 3 was at risk for fluid deficit. Goal: Resident # 3 will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor (elasticity). Interventions included the following: Ensue that the resident has access to cool water whenever possible, promote additional fluid intake. Review of Resident # 3's quarterly MDS dated [DATE] reflected a BIMS- 13 high level of cognitive functioning, section GG functional section reflected Resident # 3 required set -up and clean-up in the following areas hygiene, dressing, bathing, eating. In an interview on 8/24/2023 at 12:30pm with the ADM, revealed he felt that the staff took the other staff's statement out of content. He stated that Resident # 3 has behaviors and can be verbally aggressive with staff calling them derogatory names, he stated he had spoken with Resident # 3 a few times about calling staff derogatory names. He stated from his investigation he did verbally reprimand the staff and placed it in her personnel file. He stated he moved CNA B from the MC Unit, she was suspended pending the investigation, and the staff was in-serviced on abuse/neglect before returning to work. In an interview on 8/24/2023 at 4:45pm with Resident # 3 revealed, staff would not do anything for him. He stated the staff cursed at him and told him to get his ice himself, the resident was not able to recall the staff's name but stated it was an aide. Resident # 3 stated the staff said F you, get your own damn ice. Resident # 3 stated he did complain to the ADM because the aide would not do anything for him. Interview on 8/25/2023 at 12:07pm with CNA B, revealed she denied calling Resident # 3 any names. She stated Resident # 3 called her a dumb bitch because she was not able to get him any ice at the time that he wanted. CNA B stated he continued to call her names. She stated Resident # 3 continued to curse at her she stated, she did not go back and forth with the resident. CNA B stated she never told anyone that she called Resident # 3 a bitch. She stated the facility did suspend her pending the investigation, she stated she was moved from the MC unit, had to sign something, and was in-serviced on abuse/neglect before returning to work, she stated the ADM was the abuse/neglect coordinator. Record review of CNA D staff witness statement dated 7/25/2023 reflected, CNA B admitted to her that she did call Resident # 3 a Bitch and that he was going to quit calling her a bitch the statement also reflected that CNA B stated to Resident # 3 bitch, I'm not going to get you anything if you keep calling me names Record review of CNA B written statement dated 7/27/2023 reflected, she denied calling Resident # 3 a Bitch but stated he did call her a bitch and stated he continued to curse at her because she was unable to do what he wanted at that time. Review of Resident # 3 statement taken by ADM dated 7/27/2023 reflected, Resident stated the staff called him a Son of a Bitch get your own ice. Record review of facility investigation dated 7/26/2023 reflected CNA B was unconfirmed. Record review of the staff witness statement of CNA D reflected, that CNA B admitted to her that she cursed at Resident # 3 and called him a bitch. Record review of personnel file reflected, CNA B received personnel action, moved from the MC unit, and in-serviced on abuse/neglect. Record review of abuse/neglect in-service dated 7/28/2023 reflected staff had been in-serviced Record review of facility abuse/neglect policy dated April 2021 reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 45 of 45 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9 ,10 ,11 ,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 41, 43, 44, and 45) reviewed for infection control. A. The facility failed to screen employees as they entered the building. Staff allowed this surveyor entry into the building on two separate occasions without asking the required screening questions. B. The facility staff failed to don the proper PPE for residents that are positive for COVID-19. The facility failed to don the proper PPE for residents that are negative for COVID-19. The facility failed to don the proper PPE while monitoring smoke breaks with residents. C. The facility failed to ensure the safety of 2 of 45 (Resident #1 and Resident #2) residents who tested negative for COVID-19 but were still living in the locked units amongst an entire population of COVID-19 positive residents. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/20/2020. While the IJ was removed on 11/23/2020, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm at a scope as isolated due to staff needing more time to monitor the plan of removal for effectiveness. This deficient practice placed residents at risk of contracting healthcare-acquired infections, illness, and death. Findings Include: A. An observation on 11/19/20 at 11:00 p.m. revealed upon surveyor entry CNA #1 allowed this surveyor entry to the building. CNA #1 instructed this surveyor to step into a square marked on the floor so that an infrared scanner could digitally take this surveyor's temperature. CNA #1 then showed this surveyor where on the form to write the temperature. CNA #1 did not ask any of the required screening questions such as: fever defined as a temperature of 100.4 Fahrenheit and above, or signs or symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; signs or symptoms of COVID-19, including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; additional signs and symptoms as outlined by the Centers for Disease Control and Prevention (CDC) in Symptoms of Coronavirus at cdc.gov; contact in the last 14 days, unless to provide critical assistance, with someone who has a confirmed [DIAGNOSES REDACTED]. Interview on 11/19/2020 at 11:05 p.m. with CNA #1 revealed she knows that she is supposed to ask all the questions before allowing entry but thought since this surveyor was from the State that she did not have to. An observation and interview on 11/20/20 at 10:10 a.m. revealed upon surveyor entry CNA #4 showed this surveyor how to use the infrared scanner to take this surveyors temperature. CNA #4 proceeded to fill in all the other spots on the form without asking this surveyor any of the other questions associated with the blanks on the form which asked the following: Any signs or symptoms of COVID-19; Contact in the last 14 days with someone who has a confirmed [DIAGNOSES REDACTED]. Interview on 11/20/2020 at 6:00 p.m. with Administrator stated he did not think CNA #1 and CNA #4 allowed this surveyor to enter the building without screening. Stated he watched the video footage of the front entry and stated he saw the CNA's show this surveyor how to use the infrared temperature device. When this surveyor asked the Administrator to play the footage he was referring to, so this surveyor could point out the parts where the CNA's did not ask the questions he refused and stated, Moving on! in a loud tone. Review of TITLE 40 SOCIAL SERVICES AND ASSISTANCE PART 1 DEPARTMENT OF AGING AND DISABILITY SERVICES CHAPTER 19 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION SUBCHAPTER CC COVID-19 EMERGENCY RULE §19.2802. Nursing Facility COVID-19 Response states: (c) A nursing facility must screen all residents, staff, and people who come to the facility for the following criteria: (1) fever defined as a temperature of 100.4 Fahrenheit and above, or signs or symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; (2) signs or symptoms of COVID-19, including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; (3) additional signs and symptoms as outlined by the Centers for Disease Control and Prevention (CDC) in Symptoms of Coronavirus at cdc.gov; (4) contact in the last 14 days, unless to provide critical assistance, with someone who has a confirmed [DIAGNOSES REDACTED]. B. An observation on 11/19/2020 at 11:00 p.m. revealed upon entry to the facility had a table with PPE on it. Observed masks, hand sanitizer, gloves, plastic gowns but did not see face shields. CNA #1 was not wearing a face shield as she came to greet this surveyor at the door; CNA #2 was not wearing a face shield and she was observed going in and out of residents rooms on her hall; CNA #3 was not wearing a face shield and she was observed going in and out of residents rooms on her hall; Nurse #1 was not wearing a face shield as she was at the nurses station but donned one as this surveyor approached her to ask questions. In an interview on 11/19/2020 at 11:10 p.m. with Medication Nurse #1 stated the staff are on full PPE precautions. When asked what is considered full PPE precautions Medication Nurse #1stated that staff should be donned in face masks, face shields, plastic gowns and gloves if they are touching residents. In an interview on 11/19/2020 at 11:30 p.m. with CNA #1 and CNA #2 stated they know they are supposed to wear the face shields but they do not like the style they were issued, and they do not fit correctly and cannot be worn due to size being wrong. Stated they told the DON that they did not like that style, but they were never given any other kind to use. Stated the DON locks up the PPE in his office. An observation on 11/19/2020 at 11:30 p.m. revealed CNA #1 and CNA #2 attempting to use the face shields the facility gave them. They demonstrated how the snap-back strap for the shields is not secure and does not keep the shield tight on their forehead. Observed the shield sliding down and not being secure. In an interview on 11/20/2020 at 12:30 a.m. with DON stated staff should be donned in face shields. When this surveyor pointed out that there were no face shields on the table by the door DON stated he would go to his office and put some out. When asked if he would be surprised the night shift was not donned properly DON stated he was not. Stated if PPE runs out they can call him, and he can come in and unlock his office to put more out on the table. An observation on 11/20/2020 at 1:24 p.m. with Activities Assistant revealed she was outside monitoring a resident who was on a smoke break. Observed staff sitting less than six feet apart from the resident smoking at a small café table. Observed staff and resident without masks, face shields, or gloves as they both smoked cigarettes and touched the table. An observation on 11/20/2020 at 4:30 p.m. in the locked female memory care hall revealed CNA #5 distributing dinner plates to the three residents that live on that hall. Observed CNA #5 wearing scrubs, face mask and face shield. Observed CNA #5 walk into a COVID-19 positive resident's room, delivered lunch tray, and exited. Then CNA #5 entered a COVID-19 negative resident's room, dropped off a lunch tray, and exited. CNA #5 entered another COVID-19 positive resident's room, dropped off a lunch tray, and exited. CNA #5 did not don or doff new PPE as she entered and exited each room. CNA #5 had not used hand sanitizer at any point in distributing the trays; CNA #5 did not wash her hands before or after entering and exiting each room. In an interview on 11/20/2020 at 1:30 p.m. with Activities Assistant stated she was never told she needed to keep her PPE on while she smoked with the resident. Stated she was never instructed on sanitizing and wiping down the café table where everyone smoked. In an interview on 11/20/2020 at 1:45 p.m. with DON stated he thinks the staff had been educated and instructed on keeping the smoking section clean. Stated staff were trained to throw the cigarette butts away into the trash can after everyone is done smoking. Stated he is not sure if they were instructed to sanitize and disinfect the table where they and the resident's sit to smoke. An interview on 11/20/2020 at 4:35 p.m. with CNA #5 stated Resident #2 was the only COVID-19 negative resident in the facility. When asked if she was supposed to take special precautions to interact with Resident #2, CNA #5 stated that she was told the resident signed a waiver, so the facility does not have to don and doff every time. Stated they can just to go into her room like she was a COVID-19 positive resident. An interview on 11/20/2020 at 4:45 p.m. with DON stated Resident #2 was the only negative resident in the building. When asked what happened to the second negative resident the DON told this surveyor about the night before, DON stated he got a positive result for him on 11/18/20. When asked if they were taking any kind of precaution when interacting with the only remaining negative resident he stated that the resident's family signed a waiver, as did the first resident's family, allowing them to be in a COVID-19 facility. He stated they did not have to do anything differently for the remaining negative resident and they are to treat her the same as the COVID-19 positive residents. An interview on 11/20/2020 at 6:00 p.m. with Administrator stated facility does not have to do anything differently for the COVID-19 negative resident that they did not do for the COVID-19 positive residents. Stated they had the family sign a waiver. In an interview on 11/20/2020 at 6:00 p.m. with Administrator stated he did not think it was safe for staff to be smoking while wearing masks. Administrator asked this surveyor if it was a good idea for staff to be sitting more than six feet from the resident while he smoked in case the resident set himself on fire it would take that much longer to reach the resident and he thinks that is unsafe. Record Review of Consent Form dated 11/7/2019 revealed Resident #2 is a female of unknown age that was admitted to the facility on an unknown date and lives on the memory care female unit reveals I, {Responsible Party}, am declining the decision to have {Resident #2} transferred to a COVID negative facility and I understand that allowing my loved one to stay at(NAME)Meadows {Resident #2} will receive treatment from nurses and aides that are also working with COVID positive residents. Furthermore, he is also at risk for potentially catching COVID-19. Signed by the Responsible Party and the Administrator. Record Review of Consent Form dated 11/7/2019 revealed Resident #1 is a male of unknown age that was admitted to the facility on an unknown date and lives in the memory care men's unit revealed resident bottom of waiver stated was tested on [DATE] results returned 11/13 or 11/14 and were positive, per interview with ADON on 11/18/20 at 11:29 p.m. Review of TITLE 40 SOCIAL SERVICES AND ASSISTANCE PART 1 DEPARTMENT OF AGING AND DISABILITY SERVICES CHAPTER 19 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION SUBCHAPTER CC COVID-19 EMERGENCY RULE §19.2802. Nursing Facility COVID-19 Response states: (i) A nursing facility must implement a staffing policy requiring: (1) the facility to designate staff to work with each cohort and not change that designation from one day to another, unless required to maintain adequate staffing for a cohort; (2) staff to wear appropriate PPE, based on the cohort with which they work. C. An observation on 11/20/2020 at 4:30 p.m. in the locked female memory care hall revealed CNA #5 distributing dinner plates to the three residents that live on that hall. Observed CNA #5 did not use hand hygiene in between rooms. Observed all the doors were open. Observed CNA #5 had taken a dinner plate into the room for Resident #2. CNA #5 did not perform hand hygiene or use alcohol-based hand sanitizer before or after dropping off the resident's dinner. Observed CNA #4 open the sealed container and touched the resident's food to cut it. Observed resident begin to eat her meal. An interview on 11/20/2020 at 4:35 p.m. with CNA #5 revealed Resident #2 was the only COVID-19 negative resident left in the facility. When asked if she was supposed to take special precautions to interact with Resident #2 CNA #5 stated that she was told the resident signed a waiver, so the facility did not have to don and doff every time just to go into her room. An interview on 11/20/2020 at 4:45 p.m. with the DON revealed Resident #2 is the only negative resident in the building. When asked what happened to the second negative resident the DON told this surveyor about the night before, DON stated he got a positive result for him on 11/18/20. When asked if they were taking any kind of precaution when interacting with the last negative resident he stated that the resident's family signed a waiver, as did the first resident's family, allowing them to be in a COVID-19 facility. Stated they did not have to do anything differently for the remaining negative resident and they were to treat him/her the same as the COVID-19 positive residents. Record Review of Consent Form dated 11/7/2019 revealed Resident #1 is a male of unknown age that was admitted to the facility on an unknown date and lives in the memory care men's unit revealed resident was tested on [DATE] results returned 11/13 or 11/14 and were positive, per interview with ADON on 11/18/20 at 11:29 p.m. Record Review of Consent Form dated 11/7/2019 revealed Resident #2 is a female of unknown age that was admitted to the facility on an unknown date and lives on the memory care female unit reveals I, {Responsible Party}, am declining the decision to have {Resident #2} transferred to a COVID negative facility and I understand that allowing my loved one to stay at(NAME)Meadows {Resident #2} will receive treatment from nurses and aides that are also working with COVID positive residents. Furthermore, he is also at risk for potentially catching COVID-19. Signed by the Responsible Party and the Administrator. Review of TITLE 40 SOCIAL SERVICES AND ASSISTANCE PART 1 DEPARTMENT OF AGING AND DISABILITY SERVICES CHAPTER 19 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION SUBCHAPTER CC COVID-19 EMERGENCY RULE §19.2802. Nursing Facility COVID-19 Response states: (h) A COVID-19 positive resident must be isolated until the resident meets CDC guidelines for the discontinuation of transmission-based precautions. The Administrator was notified on 11/20/2020 at 6:11 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the Administrator on 11/22/2020 at 6:11 p.m. The following Plan of Removal was submitted by the Administrator on 11/20/2020 and accepted on 11/22/2020 at 8:41 p.m. Re: Plan of Removal of Immediate Jeopardy - Infection Control The following is a plan of removal, which has been immediately implemented at(NAME)Meadows Nursing & Rehabilitation, to remedy the immediate jeopardy as a result of alleged deficient practices, which was imposed on November 20, 2020 at 6:11pm. All staff in-serviced on Hand Hygiene and Infection Control on November 20, 2020 by Administrator, Director of Nursing (DON), and/or designee. All staff not present at time of in-service will not be permitted back to work until in-service and competency test is complete. DON and/or designee will monitor 5 meal services per week for the next 4 weeks and randomly thereafter to ensure substantial compliance. Any abnormal findings will be immediately addressed and brought to the QAPI committee. All staff in-serviced on Donning/Doffing PPE between resident care on November 20, 2020 by Administrator and DON. All staff not present at time of in-service will not be permitted back to work until in-service and competency test is complete. DON and/or designee will monitor 5 donning/doffings per week for the next 4 weeks and randomly thereafter to ensure substantial compliance. Any abnormal findings will be immediately addressed and brought to the QAPI committee. All staff in-serviced on Face Shield usage and face shield should be used in the common areas on November 20,2020 by Administrator and DON. All staff not present at time of in-service will not be permitted back to work until in-service and competency test is complete. DON and/or designee to monitor common area 5 times per week and randomly thereafter to ensure substantial compliance. Any abnormal findings will be immediately addressed and brought to the QAPI committee. All staff in-serviced on Screening Process on November 20, 2020 by Administrator and DON. All visitors, vendors, employees, essential caregivers must be screened in prior to entry. Facility employee should ask these individuals all questions on the screening log prior to entry. All staff not present at time of in-service will not be permitted back to work until in-service and competency test is complete. Administrator and/or designee to monitor 5 screening practices per week for the next 4 weeks and randomly thereafter to ensure substantial compliance. Any abnormal findings will be immediately addressed and brought to the QAPI committee. All staff in-serviced on Disinfecting Outside Patio furniture before and after use on November 20,2020 by Administrator and DON. All staff in-serviced on No Smoking while outside with residents that are smoking on November 20, 2020 by Administrator and DON. All staff not present at time of in-service will not be permitted back to work until in-service and competency test is complete. Administrator and/or designee to monitor 5 smoke breaks per week for the next 4 weeks and randomly thereafter to ensure substantial compliance. Any abnormal findings will be immediately addressed and brought to the QAPI committee. One resident has the potential to be affected by the this alleged deficient practice. The Medical Director, was initially made aware November 20, 2020 of the immediate jeopardy, and has been involved in the development of the plan to remove. These conversations are considered a part of the QA process. Next schedule QA meeting set for November 21, 2020 at 12pm. All in-servicing began 11/20/20 and will be completed by 6:30 am 11/21/20. Following is a list of all in-servicing completing pertaining to the alleged deficient practice: 1. All staff in-serviced on Hand Hygiene and Infection Control 2. All staff in-serviced on Donning/Doffing PPE 3. All staff in-serviced on the use of a Face Shield in the common areas 4. All staff in-serviced on the Screening Process and its completion entirely prior to entry 5. All staff in-serviced on the Disinfecting of Outside Patio Furniture before/after use and No Smoking while residents are smoking. Following is a list of competency test/checks to be completed at the conclusion of in-service 1. Hand Hygiene/Infection Control Competency Test 2. Donning/Doffing Competency Test 3. Face Shield Usage Competency Test 4. Screening Process Competency Test 5. Smoke Area Disinfecting/Smoking Competency Test This plan was initially implented 11/20/2020 and will be monitored, through personal pbservation, through completion by Regional Director of Operation, Regional Director of Clinical Services, and President/Chief Executive Officer. The survey team monitored the plan of removal on 11/23/2020 as follows: Monitoring of the POR began 11/23/2020 at 10:50 AM An observation on 11/23/2020 at 10:50 AM revealed Surveyor was screened upon entry and temperature taken. All screening questions were asked such as: if they have a fever defined as a temperature of 100.4 Fahrenheit and above, or signs or symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; signs or symptoms of COVID-19, including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; additional signs and symptoms as outlined by the Centers for Disease Control and Prevention (CDC) in Symptoms of Coronavirus at cdc.gov; contact in the last 14 days, unless to provide critical assistance, with someone who has a confirmed [DIAGNOSES REDACTED]. An observation at 11/23/2020 at 11:30 am revealed staff passing out trays to residents. Staff wiped hands with sanitizing wipes and then took trays into resident rooms. Staff would then come out and use sanitizing wipes again before taking the next tray into resident room. Signs posted on tray carts that stated that staff must sanitize their hands in between every resident. Several passes observed with no break in infection control. In an interview on 11/23/2020 at 12:18 with Medication Nurse #1, he has been in-serviced on hand hygiene and infection control, donning and doffing PPE, face shields, screening at the door, and disinfecting outdoor patio furniture in between smoke breaks. He stated that there was hand sanitizer on all medication carts, and that the facility had really stepped up infection control. PPE is more available. Required PPE are face shields, gowns and masks. Gloves required when going into rooms. Aide was reprimanded for not having a face shield on and got a verbal warning. He stated that they are cracking down. In an interview on 11/23/2020 at 12:23 pm with CNA #6, she stated she was in-serviced on doffing and donning, smoke area, hand hygiene and infection control, donning and doffing PPE, face shields, and screening at the door. She stated she learned to wear gloves when preparing foods and sanitizing her hands between each resident when delivering trays. Stated she also learned to take off her PPE for negative residents and did not wear PPE in negative resident's rooms. She stated that the facility looks a lot better, and sanitizing has gotten a lot better. In an interview on 11/23/2020 at 12:27 pm with CNA #7, she stated that she was in-serviced on PPE, hand washing, infection control, face shields, screening at the door, and disinfecting outdoor patio furniture in between smoke breaks. She stated that now they must wear PPE in the facility. The new process for delivering trays will be to: sanitize hands, take tray into the room, sanitize resident's hands, put on gloves, then set up their tray. In an interview on 11/23/2020 at 12:33 pm with Nurse #2, she stated she was in-serviced on PPE with proper donning and doffing, hand hygiene such as washing hands for 20 seconds, and doing so before and after a resident, and as needed, as an example. She stated hands can also be sanitized if they are not soiled. She stated that she also received in-services on infection control, face shields, screening at the door, and disinfecting outdoor patio furniture in between smoke breaks. She stated that everyone at the facility is doing their part and she has no concerns on infection control. An observation on 11/23/2020 at 12:40 pm revealed essential personnel were screened before being allowed admittance to the facility. An observation on 11/23/2020 at 1:28 pm revealed residents smoking with staff, Housekeeping #1 wore full PPE, changed gloves in between lighting cigarettes for each resident and sanitized her hands. Housekeeping #1 wiped down the smoking area after each resident was done with purple-topped wipes. There was a sign in the smoking area which stated that area must be sanitized after each use. Review of facility in-services revealed that they were conducted on hand hygiene and infection control, donning and doffing PPE, face shields, screening at the door, and disinfecting outdoor patio furniture in between smoke breaks. All were dated for 11/20/2020 and signed by employees. The IJ was removed on 11/23/2020 at 3:00 PM, the severity lowered from Immediate Jeopardy to no actual harm with the potential for more than minimal harm at a scope as isolated.

Based on observation, interview, and record review, it was determined the facility failed to ensure each resident received adequate supervision to prevent falls, injuries of unknown origin, and resident-to-resident altercations, for eight (#1, #2, #11, #12, #13, #18, #19, and #20) of twenty residents (Residents #1- #20) reviewed for quality of life. 1. In less than one month, Resident #11 was involved in at least seven incidents in which he either fell or was found with injuries of unknown origin. The facility did not implement any interventions to prevent Resident #11's potential for injury with falls. 2. Resident #12 had bruising on his upper hand down to the knuckles of his right hand, and a skin tear to the elbow of the right hand with a dressing covering the area. There was no documentation in the Accident/Incident report or the nurse's notes as to what happened. On 07/21/11 Resident had bruising to the left upper elbow with a dressing to the area. The bruising went from his elbow down to the knuckles of his left hand. Resident #12 was diagnosed with [REDACTED]. After discussions with the surveyors, the facility went and assessed Resident #12 and found he had pain to his right side area and was lying still in bed. 3. Resident #2 stated a tall bearded man came to his room and started punching him and the man bit his left ring finger. Resident #2 had bruises to the left knuckle areas and two scabbed areas with the bite mark. 4. Resident #13 had more than ten falls, some with injuries, within a three-month period according to the I/A investigation report from May 2011 though July 2011. There were no measurable interventions on some of the falls to prevent further falls with injuries. The DON and Physical Therapist were not familiar with appropriate interventions to secure the resident's safety at the facility. 5. Resident #1 fell on [DATE] and again on 07/05/11. There was inadequate supervision or interventions to prevent re-occurrence. 6) Resident #18 slapped Resident #19 in the face and Resident #19 hit Resident #18 in the arm on 06/05/11. Resident #18 bumped into Resident #20's legs several times without staff noticing the incident on 07/19/11 at 12:25 p.m. An Immediate Jeopardy (IJ) was indentified on 07/21/11. While the IJ was removed on 07/21/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm" because the facility was still monitoring the implementation of the Plan of Removal. These failures are likely to cause the residents to fall and sustain injuries such as bruises, hematomas, skin tears and fractures and/or suffer resident to resident altercations. Findings included: 1. A review of the July 2011 physician's orders [REDACTED]. Review of Resident #11's MDS assessment dated [DATE] revealed his [DIAGNOSES REDACTED]. Resident #11's MDS assessment reflected he was moderately impaired in his cognitive skills for decision-making, and he had a history of [REDACTED]. The fall risk assessment for Resident #11 reflected the most recent assessment was dated 04/10/11. Resident #11's total score for this date was 19. The assessment form reflected a score of ten or more represented the resident was a high risk for falls. The surveyor observed Resident #11 during the initial rounds on 07/19/11 at 9:35 a.m. resting in his bed. At that time, the facility's only ADON stated Resident #11 was ambulatory and incontinent of bowel and bladder. Resident #11 was confused and required assistance with all his ADL needs. She also stated Resident #11 fed himself in the dining room, had skin tears on his arm and had a history of [REDACTED]. A review of the Incident/Accident (I/A) report dated 06/16/11 at 11:00 a.m. revealed Resident #11 was observed with blood on his bed linens as he was lying in bed sleeping. He was wakened, his skin tear was cleaned, Triple Antibiotic Ointment (TAO) was applied to the area and covered with bandages. According to the diagram on the report, Resident #11 had skin tears on his right hand thumb area and two areas between the 2nd and 4th finger areas of his left hand. No measurements of the skin tears were documented. The summary/final disposition of the report reflected there were no signs/symptoms of infection and no signs of this injury noted. The I/A report reflected the "interventions" as a result of the incident "Dementia - etiology unknown - resident indep ambulated." The form was signed and dated 06/20/11 by the DON and the Administrator. There was no evidence to reflect an investigation had been conducted. Review of the I/A report dated 06/19/11 at 9:00 p.m. revealed the location of the incident was unknown. The report reflected Resident #11 was found in Resident #2's room with a skin tear on his left arm area. Staff cleaned and applied a dressing to the area. The report reflected staff heard Resident #2 yelling. When she went to the room, staff observed Resident #11 in the room with a skin tear on his left arm. The statement from staff revealed Resident #2 was not holding Resident #11. The I/A report also reflected Resident #11 "goes in and out of rooms and agitates other Residents because of this." The "intervention" reflected Resident #11 was in a "secure unit for wandering." The care plan area to indicate an update reflected there were no recent changes made to his care plan at that time. Review of the I/A report dated 07/06/11 at 6:30 p.m. revealed Resident #11 was sitting in a chair with a CNA sitting beside him. He started scooting and slipped out of the chair, sustaining a 2.0 cm x 2.0 cm skin tear on his right elbow. Review of the I/A report dated 07/11/11 at 10:30 a.m. revealed staff heard another (unidentified) resident screaming. Staff found Resident #11 in his room with blood around his right eye and a laceration. Staff applied a dressing to the site. The report reflected on the summary/final disposition only vital signs and a signature from the facility ADON dated 07/19/11. The intervention area was blank, and the care plan update was also left blank. The final signature was the DON's dated 07/19/11. The I/A report dated 07/19/11 at 1:30 p.m. reflected Resident #11 fell , which was witnessed by CNA B. Resident #11 went to sit down on the bed or recliner, missed and sat down on the floor. There were no injuries. The surveyor was observing the residents in the men's locked unit on 07/19/11 at 12:00 p.m. LVN A had finished assisting with meals and left for F hall on 07/19/11 at approximately 1:00 p.m. CNA B took a resident to his room. There was no other staff in the hallway or dining room. The surveyor heard a loud thump and looked around. The surveyor observed another resident, who was standing and telling another resident to get up. On further observation, the surveyor observed Resident #11 on the floor between the dining room and the big screen television room. CNA B came running to the dining room. CNA B touched Resident #11, telling him to wait and then she ran outside the unit to get help. CNA B came back to the area, asking the resident if he was okay. It took approximately 12 minutes for the charge nurse, LVN A, to come back to the unit to assist with getting Resident #11 up from the floor. The surveyor observed LVN A with CNA B assist Resident #11 to stand up and escorted him to his room. The surveyor next observed LVN A coming out of the resident's room and leaving the unit while CNA B was observed escorting Residents #11 and #3 down the hall. CNA B was talking to the surveyor about both residents being wanderers. Resident #11, who was walking behind CNA B, went into Resident #22's room. Resident #11 had already fallen when CNA B entered the room. The wife of Resident #22 told Resident #11 not to get up because staff needed to check him out. Review of Resident #11's I/A reports for three months revealed LVN A did not document the first fall in the dining room on 07/19/11. LVN A was interviewed on 07/21/11 at 9:50 a.m. LVN A stated he did not write up an I/A Report on Resident #11's fall in the dining room on 07/19/11 at 1:00 p.m. LVN A stated he was told Resident #11 sat down on the floor and had not fallen. The surveyor asked if the second fall he documented was a fall, or if the resident sat down. LVN A stated it was a fall, and he documented it. The interview revealed LVN A observed the surveyor in the dining room area when he came to assess Resident #11 for the fall the first and second time. LVN D stated on 07/22/11 at 1:30 p.m. that since the time of admission Resident #11 would sit himself on the floor. She also stated the facility had tried a Hipster (a padded garment worn around the hip) in order to prevent injuries, but the resident kept removing the Hipster. However, review of the care plan for Resident #11 with the ADON and LVN D revealed a fall care plan initiated 07/26/10 approximately 12 days after admission. The care plan reflected no new changes including the use of a Hipster to prevent injuries, except for a therapy screen 07/02/11 for multiple falls and no therapy was required at that time. Review of Resident #11's care plan, with a problem onset of 07/26/10 and revised 07/14/11, revealed Resident #11 had the potential for falls. The care plan reflected: "...provide with diversional activities. Notify the physician when he does have a fall promptly. Eye exam as q yearly and as necessary. And, Provide environment with adequate lightening, free of glare." Approaches on the care plan reflected a handwritten note, which documented Resident #11 had a therapy screen on 07/02/11 for multiple falls. There were no changes made to the approaches on the care plan since adopted 07/26/10. In a confidential interview, it was revealed the facility had a lot of falls on the F and G halls. The Interviewee stated the facility only had one CNA on F hall and one on G hall, with one CNA between the two halls to relieve the CNAs for breaks. The Interviewee revealed the facility did not have sufficient staff to monitor residents on F and G halls. The surveyor interviewed the DON on 07/21/11 at 10:50 a.m. The interview revealed Resident #11 was in a closed unit, and there was nothing else to do. The DON stated he was aware Resident #11 sometimes would seat himself on the floor and said it was a behavior the resident was admitted with. The surveyor discussed the observation on 07/19/11 with Resident #11 falling twice. The DON stated since the fall was unobserved, staff should have written the incident report of the fall for further review. 2. Review of Resident #12's most recent MDS assessment dated [DATE] revealed he was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #12 scored 12 of 15 (the higher the score the better the cognition) on the Brief Interview for Mental Status and had no falls before and during admission. Resident #12 was observed during the initial rounds on 07/19/11 at 9:45 a.m. The ADON stated Resident #12 was ambulatory with his walker, he was incontinent of bowel and had a Foley catheter. Resident #12 was alert and oriented to person and required assistance with ADL needs, he fed himself and had no history of falls. The surveyor observed LVN A on 07/20/11 at 7:50 a.m. entering the G hall closed unit. The call light in room 57 was on so staff went into the room. LVN A came out of the room and went straight to the cart near the dining room and obtained 4 x 4 gauzes, a red trash bag and small pink bottle normal saline (NS) bottles. He left the area to obtain more NS. When LVN A came back to the cart he took the supplies off the cart and went back to Resident#12's room. The surveyor observed some blood on the floor by the B bed at the foot of the bed and the resident was lying in bed. Resident #12 was observed with a dark purple bruise from the upper hand to the knuckles of his right hand. Resident #12 also had a skin tear to the right elbow area approximately 3.0 cm x 4.0 cm with the skin flap covering the skin tear. During the treatment, LVN A stated Resident #12 fell last week while sitting at the bedside. He fell asleep and fell , got up and called for assistance. LVN A stated when he entered the room "There was blood everywhere. He got his elbow very well." Resident #12 requested from LVN A some Tylenol for pain to the right side after the treatment. The surveyor went to Resident #12's room on 07/21/11 at 8:40 a.m. to observe his Foley catheter. The surveyor requested the assistance of CNA B. CNA B uncovered Resident #12 halfway and could not find the catheter bag. CNA B completely uncovered Resident #12 and discovered the resident now had bilateral bruising to the left hand area from the elbow area down to his left hand knuckles. CNA B stated Resident #12 fell yesterday (07/20/11) in the evening. Resident #12 now had both hands with dark bruises and skin tears to both elbow areas with opsite dressing (an airtight water tight dressing). The right elbow dressing was observed still oozing blood at this time. Before CNA B and the surveyor left Resident #12's room, Resident #12 requested Tylenol for pain. Review of the I/A report dated05/27/11 at 2000 (8:00 p.m.) revealed Resident #12 fell while getting out of bed without turning his call light on and tripped on his walker. He sustained a 2.0 cm x 2.0 cm skin tear. The intervention was "recent UA (urinalysis)." Review of the nurse's note dated 05/27/11 at 2000 (8:00 p.m.) revealed Resident #12 was going to the restroom when he tripped on his walker and fell . Review of the incident report dated 05/29/11 at 23:50 (11:50 p.m.) revealed Resident #12 fell in his room transferring himself. The incident questionnaire attached to the report, reflected Resident #12 stated he was going to the bathroom when he fell . Review of the nurse's note dated 05/29/11 at 23:50 p.m. (11:50 p.m.) revealed Resident #12 stated he slid off his bed when attempting to go to the bathroom. The fall risk assessment dated 06/28/11 reflected a total score of 18. The assessment work sheet reflected a score of ten or above was "high risk." Review of Resident #12's most recent care plan dated 06/30/11 revealed Resident #12 had decreased vision and a history of falls. Approaches identified for these problems were: Eye exam every year and as necessary, Give resident verbal reminders not to ambulate or transfer without assistance, Assess resident's need for assistive/supportive device, Maintain resident environment free of clutter and safety hazards and provide environment with adequate lightening, free of glare. Review of the incident report dated 07/20/11 at 1540 (3:40 p.m.) revealed Resident #12 was ambulating to the bathroom, lost his balance and fell . The I/A report also revealed Resident #12 sustained two skin tears to the left elbow measuring 2.0 cm x 2.0 cm. There was a 1.0 cm x 1.0 cm area to the left side, top of foot. In an interview with the facility ADON and the MDS Coordinator (LVN D) on 7/22/11 at 1:30 p.m. LVN D stated there had not been any changes on Resident #12's care plan because the family was only concerned about his Foley catheter, so facility ordered a condom catheter for him. LVN D stated she believed staff toileted Resident #12 every two hours, but she was not sure about that. The ADON stated, the facility had not tried the alarms to notify staff of the resident needing assistance and getting out of bed. The ADON added Resident #12 actually stayed in his room because he did not want to be away from the bathroom. Interview with both LVN D and the ADON on 07/22/11 at 3:15 p.m. and 3:35 p.m. respectively revealed Resident #12 did not have any skin problems previous to the bruising to both his hands. The surveyor requested the report of the X-ray done 07/22/11 a.m. for Resident #12, after Resident #12 complained of pain. At 5:15 p.m., the DON gave the surveyor an X-ray report for Resident #12 dated 07/22/11. The report reflected, "the sixth and perhaps fifth anterolateral ribs demonstrate undisplaced fracture." Another report from an area hospital reflected Resident #12 had "Right Lower Lobe Pneumonia. Small Right Pleural Effusion." 3. The surveyor observed Resident #2 during the initial rounds on 07/19/11 at 9:55 a.m. The ADON stated Resident #2 was ambulatory with a walker and continent of bowel and bladder. Resident #2 was alert and oriented to person and place and was forgetful at times. Resident #2 required assistance with his ADL needs and fed himself. The ADON stated Resident #2 did not like ladies coming for him or other residents going into his room. He yelled and screamed at people when his privacy was violated. On entry into Resident #2's room, the surveyor introduced the purpose of the visit to the resident. Resident #2 stated "Oh in that case let me give you something to do." Resident #2 stated in the presence of the ADON that a tall bearded man came to his room last weekend (07/15/11 to 07/17/11) while he was lying in his bed. Resident #2 said the bearded man started punching him in the bed and he fought back and punched him, too. Resident #2 showed the surveyor bruises in the left hand knuckle area and two marks to the ring finger of the left hand stating the man also bit his finger. The ring finger had two scabbed areas resident stated were bite marks. The surveyor told the resident the complaint would be looked into and the ADON would take care of the problem. The most current MDS assessment dated [DATE] revealed Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Psychiatry Services note dated 06/16/11 revealed Resident #2's thought process was appropriate with no gross cognitive difficulty. His past memory was good, immediate was fair and recent memory was impaired. The surveyor reviewed Resident #2's nurses notes dated from 03/21/11 at 1400 (2:00 p.m.) to 5/31/11 at 2315 (11:15 p.m.) The nurse's note reflected on 04/9/11 at 12:45 (does not say a.m. or p.m.) a CNA reported to the charge nurse that Resident #2 came to the dining room and asked her to come get a resident out of his room. The other resident was lying in his bed. Resident #2 slapped the other resident, who he thought was not getting up fast enough from his bed and the other resident fought back. The CNA removed the other resident from Resident #2's room without further incident. The nurse's notes did not reflect any documentation regarding the incident on 07/14/11. The review of I/A reports for three months revealed Resident #2 did not have any I/A reporting records for these months. Interview with CNA B on 07/19/11 at 1:05 p.m. revealed an incident occurred approximately two to three weeks prior. CNA B stated she was not in the hall but heard Resident #2 yelling out, so she ran to his room and found Resident #11 in his room. Resident #2 hit Resident #11 because he was not moving fast enough. The interview also revealed Resident #3 also went into Resident #2's room. CNA B stated Residents #2 and #3 "got into it" as Resident #3 would go into his room. CNA B stated Resident #2 must have sustained the injury on his left hand knuckles and ring finger in one of the altercations, but the CNA was not sure. CNA B stated CNA F or P would know. Interview with CNA P on 07/12/11 at 2:30 p.m. revealed Resident #3 went to Resident #2's room and Resident #2 pushed him toward the door about without injuries approximately three weeks ago on a weekend. She reported the incident to the weekend nurse. CNA P stated she did not see Resident #3 entering the room. She just heard Resident #2 yelling at the resident. She went to the room to see what was going on. The interview also revealed the facility had one CNA per hall F and G halls with another CNA floating or relieving staff for breaks. Interview with the charge nurse for the 2:00 p.m. to 10:00 p.m. shift (LVN E) on 07/22/11 at 3:10 p.m. revealed she knew anything about the altercation between Residents #2 and #3. The interview also revealed the facility had one CNA for each shifts on the G hall and F hall. There was another CNA who floated between F and G halls. LVN E stated she started working in the facility two weeks ago. Interview with CNA F on 07/22/11 at 3:15 p.m. revealed he worked the G hall most of the time for the past nine months. CNA F stated Resident #3 went into rooms but never got aggressive with other residents. He also stated he did not observe any altercations between the two residents. In the confidential resident group meeting held 07/20/11 10:30 a.m. two of the nine residents in the meeting stated "There is a lot of fights on the G Hall" The surveyor interviewed the ADON and the Administrator on 07/19/11 at 3:15 p.m. regarding the supervision of residents in the F and G halls to prevent accidents and altercations. The ADON stated the facility normally has one CNA on every hall and 1 float for the front halls (A-D halls) and 1 float for the back halls (F&G). The ADON stated unfortunately the facility had a couple of people call in, but if the CNA needed help she can call and she or one of the office staff , like the MDS coordinator will came and assist the aide. The ADON stated "one CNA floats to ABCD and one CNA floats F&G halls. The interview revealed if there was a call in the facility would pull the floats to work a hall. The facility had a call in today, so the float for halls F and G was pulled to replace staff on the hall with the call in leaving one CNA for the F and G hall. The ADON stated facility used agency staff and had called them in this past weekend, if not the administrative staff like the MDS coordinator or herself would work the floor. The surveyor asked what type of residents resided in the F and G halls. The ADM and ADON stated "Alzheimer's, Dementia, Combative residents." The surveyor shared concerns with observing a CNA helping one resident go to the restroom while all the other residents were on their own and the charge nurse been off the unit. When asked if they were comfortable having one CNA on these floors? The ADM and ADON both stated "No, I am not." The surveyor interviewed the ADON on 07/22/11 at 10:30 a.m. The interview revealed she had notified one of the "higher ups" after the initial tour of Resident #2's complaint of been bite and punched by Resident #3. The ADON stated she thought she told the DON about Resident #2's complaint but was not sure who exactly she reported it. The ADON came back at 11:50 a.m. stating she asked the DON and he stated she did not tell him about the complaint. 4. The surveyor observed Resident #13 on 07/20/11 at 8:00 a.m. in the Secured Unit on F hall. She wandered the hallway, and she appeared frail and thin. A review of the July 2011 physician's orders [REDACTED]. Review of the initial MDS assessment dated [DATE] for Resident #13 revealed short/long term memory problems, severe cognitive impairment, wandering about the facility daily; required limited assistance with transfer and ambulation but had unsteady gait, required extensive assistance with toileting and was always incontinent of bowel and bladder. The assessment reflected the resident had a history of [REDACTED]. The quarterly MDS assessment dated [DATE] for Resident #13 reflected the same areas as the initial MDS assessment with the inclusion of a bowel and bladder program and therapy program in order to evaluate the frequent falls. Review of a Bladder Retraining assessment dated [DATE] revealed Resident #13 was to begin a 3-day voiding pattern in order to determine a possible toileting pattern. The only fall risk assessment was dated 05/17/11, with a total score of 14. The assessment form reflected a score of ten or more represented the resident was a high risk for falls. The initial plan of care dated 05/07/11, under the falls section, reflected Resident #13 was on a scheduled toileting program and on a fall-prevention program. However, there was no mention in the care plan about how facility staff was to execute the scheduled toileting program or what the fall-prevention program entailed. A review of the I/A report dated 05/08/11 at 7:20 p.m. reflected Resident #13 was found on the floor after hitting her head on the floor. She sustained a bruise to her bilateral eyes and forehead. The resident was transferred to the local emergency room . The admitting [DIAGNOSES REDACTED]. The section under interventions reflected, the resident was transferred to the local emergency room for evaluation. Review of the I/A report dated 05/18/11 at 6:00 p.m. revealed Resident #13 fell while walking in the dining area, hit the right side of her head on the wall, and blood was noted to her right elbow. The I/A reflected in the summary/final disposition section, the resident continued to ambulate in the hallway without any complaints. As a result of this incident, the interventions section reflected physical therapy and occupational therapy would screen Resident #13 to determine if any additional interventions could be utilized. Record review of the therapy screen revealed a walker was recommended but the resident would not use it effectively. A review of the I/A report dated 06/06/11 at 3:55 a.m. revealed the roommate of Resident #13 activated the call bell to alert staff the resident had fallen in her room. Upon assessment, Resident #13 was noted with a swollen area on the back of her head. There was no measurement of the injury, but the report reflected the resident went back to bed after neurological checks were done. The intervention section of the report reflected Resident #13 was, "Disoriented. Independent with ambulation." A review of the I/A report dated 06/10/11 at 2:00 p.m. revealed a CNA observed Resident #13 sitting on the side of the bed in her room, with her hand on her forehead. The resident stated she had fallen and there was a raised area to the right side of her forehead with a bluish colored bruise. The intervention section of the report reflected Resident #13 did not sustain a fracture after an x-ray was performed. The intervention section reflected, "Dementia cont (tinue) independent ambulation." A review of the I/A report dated 06/12/11 at 4:30 a.m., revealed the roommate of Resident #13 informed staff the resident was on the floor in her room, and there were no injuries. The intervention reflected, "Disoriented. Independent ambulation." The I/A report dated 06/13/11 at 5:55 a.m. reflected the CNA heard Resident #13 crying, and the resident's roommate yelled that the resident had fallen to the floor in her room. The report reflected there was no injury and the resident was referred to PT and OT for a screen. The I/A report dated 06/25/11 at 4:15 p.m. reflected the CNA witnessed Resident #13 trip over another resident's wheelchair and fall to the floor hitting her head against a wall. There was no summary/final disposition on the report and the section under interventions reflected, "Sutures to head." The I/A report dated 07/15/11 at 11:40 p.m. reflected Resident #13 fell to the floor and there was a "knot to her L (left) hip." The resident was transferred to the local emergency. She returned without a fracture. There was no summary/final disposition on the report and the section under interventions reflected, the resident went to the emergency room and came back without a fracture. The I/A report dated 07/16/11 at 4:30 a.m. reflected the roommate for Resident #13 yelled for a CNA after she saw the resident on the floor in her room. There were no injuries. There was no summary/final disposition on the report and the section under interventions reflected a tangible intervention where the facility would initiate a toileting program after a 72-hour evaluation. The I/A was signed and dated 07/19/11 by the DON and the Administrator. The I/A reports dated 07/21/11 at 3:55 p.m. reflected the roommate for Resident #13 cautioned CNA U, who attended to the resident, that the resident had just awakened from a nap and her gait was unsteady. According to the report CNA U left the resident in the television area, the resident got up, attempted to walk, hit her forehead against the corner of the wall, and sustained a bleeding golfball-sized lump on the left side of her forehead. The resident was transferred to the emergency room and came back with a concussion to her forehead. All the I/A reports for Resident #13 were signed by the DON and the facility Administrator with minimal to no intervention in preventing Resident #13 from further falls with injuries, or provide an environment where she would have a safer fall with no injuries. On 07/22/11 at 12: 05 p.m. Resident #7, who was also the roommate for Resident #13, expressed frustration because she felt Resident #13's falls with injuries could be avoided. She revealed, "...Often she (Resident #13) tries to toilet herself and falls. They don't toilet her but that's what she needs. She's (Resident #13) unsteady on her feet when she wakes up from sleep...That really upsets me...They tell me I'm a patient so I'm not supposed to help her (Resident #13). We are short all the time in the unit." According to the I/A reports, four of the ten falls Resident #13 experienced occurred in her room between 3:00 a.m. and 6:00 a.m. The DON was interviewed on 07/22/11 at 3:30 p.m. He stated concerning the numerous falls and injuries sustained by Resident #13 that therapy should screen residents after they fell . The DON continued that therapy had not been effective. He stated the facility did not have a policy for the "falling star" (fall-prevention) program. When he was queried about a toileting program for Resident #13, he stated he did not initiate the 3-day voiding program he had documented as an intervention when Resident #13 fell on [DATE]. The DON admitted he was not familiar with implementing appropriate interventions after residents fell and further stated the secured unit, where Resident #13 resided, should have more staff to meet the residents' needs. Review of CNA U's assignment sheet for Resident #13's care revealed, "PACEMAKER. Very disoriented. Redirect from secure unit doors. Redirect from others rooms. Likes candy. Watch for disrobing." CNA U was interviewed on 07/22/11 at 4:00 p.m. He stated it would be helpful if the facility wrote the care he was to provide for each resident on his assignment sheet. He revealed he did not know Resident #13 had unsteady gait after she woke up from a nap. He further stated he was not aware the resident should be toileted. He stated that they were routinely short of staff on the secured unit and it was impossible to supervise all the residents who resided there.

Based on observation, interview, and record review, it was determined the facility failed to: 1) thoroughly investigate injuries of unknown origin, complaints of injury and resident-to-resident altercations; and 2) have in place preventive measures for further potential injuries and or altercations for nine (Residents #1, #2, #3, #4, #11, #12, #17, #18, and #20) of twenty residents (Residents #1- #20) reviewed for quality of life and quality of care. 1) Resident #11 had a resident-to-resident altercation that resulted in a 1.5 cm. laceration to his right lateral forehead and a nose bleed on 05/17/11. He had skin tears on both hands which were injuries of unknown origin on 06/16/11. He had a resident-to-resident altercation that resulted in a skin tear to his left arm on 06/19/11. He had a laceration to the right eye area with bleeding which was an injury of unknown origin on 07/11/11. There was no investigation as to how the two injuries of unknown origin were sustained and no preventive measures were put in place to prevent reoccurrence of resident-to-resident altercations. Resident #11 fell twice on 07/19/11 within a few minutes time but the facility documented only one fall. 2) Resident #12 sustained bruising from the right upper hand down to the knuckles of his right hand and a skin tear to the right elbow area that was bleeding through the dressing. 3) Resident #2 alleged a tall bearded man came to his room. Resident #2 stated the man started punching him and he (Resident #2) punched back. The bearded man also allegedly bit Resident #2's left ring finger. Resident #2 had bruises to the left knuckle areas and two scabbed areas with the bite marks. There was no investigation as to who the bearded man was. 4) Resident #1 fell on [DATE] and again on 07/05/11. 5) Resident #4 sustained a 5 cm x 5 cm bruise to the right upper arm on 07/10/11. The Injury was of unknown origin and was not investigated. 6) Resident #17 sustained bruises of unknown origin on 07/04/11. An Immediate Jeopardy (IJ) was identified on 07/21/11. While the IJ was removed on 07/22/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm" because the facility was still monitoring the implementation of the Plan of Removal (POR). These failures are likely to cause residents to be at risk of further abuse and/or neglect. Findings included: 1) Review of Resident #11's care plan with a problem on set of 07/26/10 and revised 07/14/11 revealed Resident #11 had the potential for falls. Approaches included: 1) Resident #11 was to be provided with diversional activities, 2) Notify the physician when he does have a fall promptly, 3)Eye exam as q (every) year and as necessary and 4) Provide environment with adequate lightening, free of glare. There was a handwritten notation on the care plan, reflecting Resident #11 had a therapy screen 07/2/11 for multiple falls. There were no changes made to the care plan since adopted 07/26/10. Review of the fall risk assessment reflected the last assessment was dated 04/10/11. Resident #11's total score for this date was 19. The assessment form revealed a score of ten or more represented the resident was a high risk for falls. A review of the I/A report dated 05/17/11 at 8:30 p.m. revealed Resident #11 went to another resident's room where he lay next to him in the bed. The other resident got up and started yelling at Resident #11 to get out of his bed. As the CNA entered the room the CNA observed the resident hit Resident #11 on his face with his fist. Resident #11 sustained a 1.5 cm laceration to the right fore head area and a nose bleed. Further review of this I/A report revealed in the intervention, "Dementia-In wrong bed." The care portion of the report reflected a blank space no changes was made to the care plan at that time. Review of the I/A report dated 06/16/11 at 11:00 a.m. revealed Resident #11 was observed with blood on his linen sheet as he lay in bed sleeping. Staff woke him up, cleaned a skin tear and applied Triple Antibiotic Ointment (TAO) to area, then and covered it with bandages. According to the diagram Resident #11 had a skin tear on his right hand by the thumb and two skin tears to his left hand between the fingers. No measurement of the skin tears was documented. The summary/final disposition of report reflected "no sign/symptoms of infection and no signs of this injury noted." The interventions as a result of this incident reflected, "Dementia - etiology unknown- resident indep (independently)ambulated." The form was signed and dated on 06/20/11 by the DON and the facility ADM. There was no further attachment indicating investigation to the injury was initiated. Review of the I/A report dated 06/19/11 at 2100 (9:00 p.m.) revealed the location of the incident was unknown. The report reflected Resident #11 was found in another resident's room with skin tear to his left forearm area. Staff cleaned and applied dressing to sight. Further review of the report reflected staff heard Resident #2 yelling, when the staff went to the room, she observed Resident #11 in the room with a skin tear on his left arm. The statement from staff revealed Resident #2 was not observed holding Resident #11. The incident report also reflected Resident #11 "goes in and out of rooms and agitates other residents because of this." The intervention revealed Resident #11 was in a "secure unit for wandering." Further review of the I/A report revealed under "care plan updates as a result of this incident", revealed there was no recent changes made to his care plan at that time, space was blank. Review of the I/A report dated 07/06/11 at 1830 (6:30 p.m.) revealed Resident #11 was sitting in a chair with a CNA sitting besides him when he started scooting and slipped out of the chair sustaining a 2.0 cm (centimeter) by 2.0 cm skin tear to the right elbow area. Further review of the I/A revealed a blank for the intervention and care plan changes space. Review of the I/A report dated 07/11/11 at 10:30 a.m., revealed staff heard another resident screaming, on entry to the room, the staff did not observe any problems. However, Resident #11 was found in his room with blood around his Right Eye and a laceration found to the area. Staff applied a dressing to the sight. Further review of the I/A revealed on the summary/final disposition of report reflected only vital signs and a signature from the facility ADON dated 07/19/11, the intervention area was blank and the care plan update was also left blank. The final signature was the DON dated 07/19/11. Review of Resident #11's most recent MDS assessment dated [DATE] revealed he was admitted [DATE] and his active [DIAGNOSES REDACTED]. Resident #11's MDS assessment also indicated he was moderately impaired in his cognitive status, and he had history of falls. The surveyor observed Resident #11 during the initial rounds on 07/19/11 at 9:35 a.m. resting in his bed. The facility ADON on rounds stated Resident #11 was ambulatory and incontinent of bowel and bladder. Resident #11 was confused and required assistance with all his activity of daily living needs. She also stated Resident #11 fed himself in the dining room, he had skin tears to his arm and had history of falls. The I/A report dated 07/19/11 at 1330 (1:30 p.m.) revealed the fall was witnessed by CNA B. Resident #11 went to sit down on bed, missed and sat on the floor. The surveyor was observing from the the secured unit when the incident occurred. LVN A had finished assisting with meals and left to go to F hall on 07/19/11 at approximately 1:00 p.m. CNA B was taking another resident to his room. There was no other staff in the hall or dining room. The surveyor heard a loud noise and began to search for the source of the noise. Resident #11 was on the floor between the dining room and the television room. CNA B came running to the dining room. CNA B was telling the resident to wait and she ran outside the unit to get help. CNA B came back to the area asking the resident if he was okay. It took approximately twelve minutes for the charge nurse (LVN A) to come back to the unit to assist with getting Resident #11 off the floor. The surveyor observed LVN A and CNA B assist Resident #11 up and escort him back to his room. The surveyor observed LVN A coming out of the resident's room and leaving the unit while CNA B was observed escorting Resident #11 and another resident down the hall. CNA B was talking to the surveyor about both residents. She stated both residents were wanderers. Resident #11, who was walking behind her, went into room [ROOM NUMBER]. Resident #11 had already fallen when CNA B entered the room. A family member in room [ROOM NUMBER] was telling the resident not to get up and that staff would come to check him out. Review of Resident #11's I/A for three months revealed LVN A failed to document the first fall in the dining room on 07/19/11 at approximately 1:00 p.m. LVN A was interviewed on 07/21/11 at 9:50 a.m. LVN A stated he did not write up an I/A report on Resident #11's fall in the dining room on 07/19/11 at 1:00 p.m. LVN A stated he was told Resident #11 sat down on the floor and did not fall. The surveyor asked if the second fall he documented was a fall. LVN A stated it was a fall and he documented it. The surveyor interviewed the DON on 07/21/11 at 10:50 a.m. The DON revealed Resident #11 was in a secured unit and there was nothing else to do for him. The DON stated he was aware Resident #11 sometimes would lower himself to the floor and stated it was a behavior the resident had when he was admitted . The surveyor discussed the falls observed on 07/19/11 with Resident #11 falling twice. The DON stated since the fall was unobserved staff should have made an I/A report of the falls for further review. The interview also revealed the DON would institute all falls (including a residents sitting himself/herself on the floor) must be documented for monitoring purposes. Interview on 07/21/11 at 11:00 a.m. with the ADM revealed he was not aware of the previous bruise on Resident #11 and only had one incident report for the fall last night. The ADM stated there was only one incident report for one fall on Tuesday for Resident #11. Surveyor informed ADM there had been two falls for Resident #11 on Tuesday within a few minutes. ADM stated there was no incident report for Resident #11. In an interview with the facility ADON and the MDS coordinator, LVN D on 7/22/11 at 1:30 p.m. LVN D stated Resident #11 would sit himself on the floor, since admission. She also stated facility had tried Hipster (padded protection that could be inserted into clothing to cushion a fall) to prevent injuries, but resident kept removing the hipster. However, review of the care plan for Resident #11 with the ADON and LVN D revealed a fall care plan initiated 07/26/10 approximately 12 days after admission. The care plan reflected no new changes except for a therapy screen 07/02/11 for multiple falls and no therapy required at that time. 2) Review of Resident #12's most recent MDS assessment dated [DATE] revealed he was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #12 scored 12 of 15 (Resident #12 had modified independence with some difficulty in new situations only) on the Brief Interview for Mental Status and had no falls before and during admission. Resident #12 was observed during the initial rounds on 07/19/11 at 9:45 a.m. The ADON stated Resident #12 was ambulatory with his walker, he was incontinent of bowel and had a Foley catheter. The ADON stated Resident #12 had an order for [REDACTED]. The surveyor observed LVN A on 07/20/11 at 7:50 a.m. entering the G hall closed unit. The call light in Resident #12's room was on so staff went into the room. LVN A came out of the room and went straight to the cart near the dining room and obtained 4 x 4 gauzes, a red trash bag and small pink bottle normal saline (NS) bottles. He left the area to obtain more NS. When LVN A came back to the cart he took the supplies off the cart and went back to Resident #12's room. The surveyor observed some blood on the floor by the B bed at the foot of the bed and the resident was lying in bed. Resident #12 was observed with a dark purple bruise from the upper hand to the knuckles of his Right hand. Resident #12 also had a skin tear to the Right Elbow area approximately 3.0 cm x 4.0 cm with the skin flap covering the skin tear. During the treatment, LVN A stated Resident #12 fell last week while sat at the bedside. He fell asleep and fell , got up and called for assistance. LVN A stated when he entered the room "there was blood every where, he got his elbow very well." Resident #12 requested from LVN A some Tylenol for pain to the right side after the treatment. The surveyor went to Resident #12's room on 07/21/11 at 8:40 a.m. to observe his Foley catheter. The surveyor requested for the assistance of CNA B. CNA B uncovered the Resident #12 half way and could not find the catheter bag. CNA B completely uncovered Resident #12 and discovered the resident now had bilateral bruising to the left hand area from the elbow area down to his left hand knuckles. CNA B stated Resident #12 fell yesterday 07/20/11 in the evening. Resident #12 now had bilateral hands with dark bruises and skin tears to both elbow areas with opsite (a clear dressing that you can see the wound through) dressing. The right elbow dressing was observed still oozing blood at this time. Before CNA B and the surveyor left Resident #12's room, Resident #12 requested Tylenol for pain. Review of the I/A report 05/27/11 at 2000 (8:00 p.m.) revealed Resident #12 fell while getting out of bed without turning his call light on and tripped on his walker. He and sustained a 2.0 cm x 2.0 cm skin tear. The intervention was "recent UA (urinalysis)." Review of the nurse's note dated 05/27/11 at 2000 (8:00 p.m.) revealed Resident #12 was going to the restroom when he tripped on his walker and fell . Review of the incident report dated 05/29/11 at 23:50 (11:50 p.m.) revealed Resident #12 fell in his room transferring himself. The incident questionnaire attached to the I/A report, reflected Resident #12 stated he was going to the bathroom when he fell . Review of the nurse's note dated 05/29/11 at 23:50 p.m. (11:50 p.m.) revealed Resident #12 stated he slid off his bed when attempting to go to the bathroom. Review of the incident report dated 07/20/11 at 1540 (3:40 p.m.) revealed Resident #12 was ambulating to the bathroom lost his balance and fell . The I/A report also revealed Resident #12 sustained two skin tears to the left elbow measuring 2.0 cm x 2.0 cm. There was a 1.0 cm x 1.0 cm areas to the left side, top of foot. The fall risk assessment dated [DATE] revealed a total score of 18. The assessment work sheet reflected a score of ten or above was "high risk." Review of Resident #12's most recent care plan dated 6/30/11 revealed Resident #12 has decreased vision and history of falls. Approaches included: 1) Eye exam every year and as necessary, 2) Give resident verbal reminders not to ambulate or transfer without assistance, 3) Assess resident's need for assistive/supportive device, 4) Maintain resident environment free of clutter and safety hazards and 5) provide environment with adequate lightening, free of glare. In an interview with the facility ADON and the MDS coordinator, LVN D on 7/22/11 at 1:30 p.m. LVN D stated there had not been any changes on Resident #12's care plan because the family was only concerned about his Foley catheter so facility ordered a condom catheter for him. LVN D stated she believes staff toileted Resident #12 every two hours but she was not sure about that. The ADON stated facility had not tried the alarms to notify staff of the resident needing assistant and getting out of bed. The ADON added Resident #12 actually stays in his room because he does not want to be away from the bathroom. Interview with both LVN D and the ADON on 7/22/11 at 3:15 p.m. and 3:35 p.m. respectively revealed Resident #12 did not have any skin problems previous to the bruising to both his hands. The surveyor requested the report of the X-ray done 07/22/11 a.m. for Resident #12. The X-ray was ordered due to Resident #12 complaining of pain to his right side. At 5:15 p.m., the DON gave the surveyor an X-ray report for Resident #12 dated 07/22/11. The report reflected, "the sixth and perhaps fifth anterolateral ribs demonstrate undisplaced fracture." Another report from an area hospital reflected Resident #12 had "Right Lower Lobe Pneumonia. Small Right Pleural Effusion." On 07/21/11 at 9:50 a.m., LVN A told the surveyor Resident #12 fell last week Thursday (07/14/11). 3) The surveyor observed Resident #2 during the initial rounds on 07/19/11 at 9:55 a.m. The ADON stated Resident #2 was ambulatory with a walker and continent of bowel and bladder. Resident #2 was alert and oriented to person and place and was forgetful at times. Resident #2 required assistance with his ADL needs and fed himself. The ADON stated Resident #2 did not like female staff taking care of him or other residents going into his room. He yelled and screamed at people when his privacy was violated. On entry into Resident #2's room, the surveyor introduced the purpose of the visit to the resident. Resident #2 stated "oh in that case let me give you something to do." Resident #2 stated a tall beard man came to his room last weekend (07/15/11 to 07/17/11) while he was lying in his bed (the ADON was present during this interview). The man started punching him in the bed and he fought back and punched him, too. Resident #2 showed the surveyor bruises in the left hand knuckle area and two marks to the ring finger of the left hand stating the man also bite his finger. The ring finger had two scabbed areas resident stated were bite marks. The most current MDS assessment dated [DATE] revealed Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Psychiatry Services notes dated 06/16/11 revealed Resident #2's thought process was appropriate with no gross cognitive difficulty. His past memory was good, immediate was fair and recent memory was impaired. The surveyor reviewed Resident #2's nurses note dated from 03/21/11 at 1400 (2:00 p.m.) to 5/31/11 at 2315 (11:15 p.m.) The nurse's note reflected on 04/9/11 at 12:45 (does not say a.m. or p.m.) a CNA reported to the charge nurse that Resident #2 came to the dining room and asked her to come get a resident out of his room. The other resident was lying in his bed. Resident #2 slapped the other resident who he thought was not getting up fast enough from his bed and other resident fought back. The CNA removed the other resident from Resident #2's room without further incident. The review of I/A reports for three months revealed Resident #2 did not have any I/A reporting records for these months. Interview with CNA B on 07/19/11 at 1:05 p.m. revealed an incident occurred approximately two to three weeks prior. CNA B stated she was not in the hall but heard Resident #2 yelling out. CNA B stated she ran to his room and found Resident #11 in his room. Resident #2 hit Resident #11 because he was not moving fast enough. The interview also revealed Resident #3 also goes into Resident #2's room. CNA B stated Residents #2 and #3 gets into it as Resident #3 would go into his room. CNA B stated Resident #2 must have sustained the injury on his left hand knuckles and ring finger in one of the altercations but was not sure. CNA B stated CNA F or P would know. Interview with CNA P on 07/12/11 at 2:30 p.m. revealed Resident #3 went to Resident #2's room and Resident #2 pushed him towards the door about without injuries approximately three weeks ago on a weekend. She reported the incident to the weekend nurse. CNA P stated she did not see Resident #3 entering the room. She just heard Resident #2 yelling at the resident. She went to the room to see what was going on. The interview also revealed the facility had one CNA per hall F and G halls with another CNA floating or relieving staff for breaks. Interview with the charge nurse for the 2:00 p.m. to 10:00 p.m. shift LVN E on 07/22/11 at 3:10 p.m. revealed she did not know anything about the altercation between Resident #2 and #3. The interview also revealed the facility had one CNA for the shifts on the G hall and another CNA floating between F and G halls. LVN E stated she started working in the facility two weeks ago. Interview with CNA F on 07/22/11 at 3:15 p.m. revealed he worked the G hall most of the time for the past nine months. CNA F stated Resident #3 goes into rooms but never gets aggressive with other residents. He also stated he did not observe any altercations between the two residents. The surveyor interviewed the ADON on 07/22/11 at 10:30 a.m. The interview revealed she had notified one of the "higher ups" after the initial tour of Resident #2's complaint of been bite and punched by Resident #3. The ADON stated she thought she told the DON about Resident #2's complaint but was not sure who exactly she reported it. The ADON came back at 11:50 a.m. stating she asked the DON and he stated she did not tell him about the complaint. Review of the form CMS-802 (Roster/Sample Matrix) provided by the facility on 07/19/11 revealed Resident #3 had Mental Illness and was cognitively impaired with behavior symptoms. 4) Review of the facility face sheet dated 01/05/11 revealed Resident #1 was a [AGE] year-old female admitted to the facility 10/05/10 and resided on the women's locked unit. Observation on 07/19/11 at 5:00 p.m. revealed Resident #1 sat in her wheelchair with a large amount of thick white sputum that extended all down her sweatshirt to the knee of her pants. There were no staff present to supervise the residents in the dining room at this time. Observation on 07/20/11 at 4:40 p.m. revealed Resident #1 ambulated with an unsteady gait from her room into the hall unassisted. CNA C ran down the hall and assisted Resident #1 to sit in her chair in her room. CNA C stated they did not let Resident #1 ambulate unassisted because of her risk for falls. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #1 scored 2 of 15 on the Brief Interview for Mental Status and had physical and verbal behavioral symptoms directed toward others. [DIAGNOSES REDACTED]. Resident #1 was totally dependent on one person for toileting and was frequently incontinent of bowel and bladder. Resident #1 required the assistance of one person for ambulation. Review of the I/A reports for June and July 2011 revealed Resident #1 fell on her right hip in the hallway of the women's locked unit on 07/01/11 at 10:45 a.m. and the intervention was "currently treating UTI." There were no witness statements included with the report. The DON and the ADM signed the incident report on 07/12/11. Resident #1 fell again on 07/05/11 at 4 p.m. and the written statement from the CNA on duty reflected Resident #1 was yelling so the CNA "went down there" and found Resident #1 on the floor. Another written statement from another CNA on duty reflected she heard a thud and Resident #1 crying so she went in Resident #1's room and found her on the floor. Nurse's assessment revealed Resident #1 was found lying on the floor with a hematoma on the right side of her head. Resident #1 had tried to transfer herself to the toilet, and the resident stated to the nurse that she needed to go to the bathroom. The report reflected Resident #1's condition before the incident was confused and agitated. The section on the report for Summary/Final Disposition of Report was blank except for vital signs and was signed by DON on 07/12/11. The sections on the report for Interventions and Care Plan Updates were blank. DON and ADM signed the report on 07/12/11. 5) Review of the face sheet dated 01/05/11 revealed Resident #17 was a [AGE] year-old female readmitted to the facility 05/08/09 and resided in a room that was not in a locked unit. Observation on 07/22/11 at 12:25 p.m. revealed Resident #17 was clean, dressed, and sat in the dining room. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #17 scored 2 of 15 on the Brief Interview for Mental Status, had verbal behavioral symptoms directed at others, and rejected care. Resident #17 was independent with ambulation with a steady gait and no assistive devices. [DIAGNOSES REDACTED]. Review of the I/A Report dated 07/04/11 revealed two bruises of unknown origin were found on Resident #17's left side and hip during care. One bruise was 8 cm. x 6.5 cm. and purple. The bruise on the hip was 4 cm. x 3 cm. yellow and purple. There was only one statement from the CNA who discovered the bruises. The section for the Summary/Final Disposition of Report was blank except for vital signs and signed on 07/19/11 by ADON. The section for Interventions reflected, "Bruise noted during shower unknown origin. Was observed during care. Resd. (Resident) denied any pain or discomfort." The section for the Care Plan Update was blank. The DON and the ADM signed the Incident Report on 07/19/11. 6) The surveyor observed Resident #4 during the initial rounds on 07/19/11 at 10:45 a.m. LVN G stated Resident #4 was mobile in the facility via a wheelchair assisted by staff, she was incontinent of bowel and bladder and required total assistance from staff for all her ADL needs. LVN G stated Resident #4 was alert and oriented to person and confused most times.

Based on observation, interview and record review, it was determined the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical and psychosocial well-being for nine (Residents #1, #2, #3, #11, #12, #13, #18, #19, and #20) of 20 residents (Residents #1- #20) reviewed for quality of life. 1. Resident #12 had four unwitnessed falls with lacerations, bruises, bleeding and complaints of pain, with the need for evaluation and treatment at the ER. Resident #12 returned to the facility with the [DIAGNOSES REDACTED]. 2. Two of nine in the residents' confidential interviews reported staffing shortages with several resident-resident altercations in the secured units. 3. LVN A he was overwhelmed with providing professional nursing care, passing his medications in two secured units (F and G), in addition to assisting the CNA with ADLs and managing 25 to 26 resident with no assistance. 4. On 07/19/11 at 9:20 a.m. on the Closed Unit, F hall had 11 residents and G hall had 13 residents with a total of 24 residents, there was only LVN A for the two secured Units, F and G halls with one CNA for each and another one CNA floating between the two halls. 5. Resident #3 was observed to wander in and out of other residents' rooms. Resident #2, stated Resident #3 came to his room and punched and bite him on the Left hand ring finger. There was no staff monitoring and redirecting the residents in the hallway. These failures were likely placed Resident #3 at risk for the potential of harm by wandering in and out of other residents' rooms with other residents potentially reacting negatively to the resident entering their rooms, possibly physically injuring her. 6. On 07/19/11 after the noon meal residents were left, unattended in the dining room without monitoring. Resident #11 fell during this time, and the fall was unwitnessed by the staff. 7. Resident #13 had more than ten falls, some with injuries within a three month period according to the I/A investigation report from May 2011 though July 2011. Resident #13 sustained a concussion to her forehead from one of the falls, when CNA X left the resident unattended in the television area. 8. Resident #1 fell on [DATE] and again on 07/05/11. 9. Resident #18 slapped Resident #19 in the face and Resident #19 hit Resident #18 in the arm on 06/05/11. Resident #18 bumped into Resident #20's legs several times without staff noticing the incident on 07/19/11 at 12:25 p.m. An Immediate Jeopardy (IJ) was identified on 07/21/11. While the IJ was removed on 07/22/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm" because the facility was still monitoring the Plan of Removal. These failures are likely to cause residents to have falls, resident to resident altercations, and not receiving care and assistance when needed. Findings included: 1) Women's Secured Unit: Observation on 07/19/11 from 11:45 a.m. through 12:10 p.m. revealed only one staff member, (CNA K) was working on the women's locked unit during this time. Interview on 07/19/11 at 11:50 a.m. with CNA K revealed the nurse had not yet arrived on the women's locked unit. She added the nurse usually would come at lunchtime. Observation on 07/19/11 from 12:15 through 12:20 revealed residents on the women's locked unit were unsupervised while the one CNA who worked on the unit (CNA K) assisted a resident in her room. 2) Observation on 07/19/11 at 12:25 p.m. revealed Resident #18 wheeled herself in her wheelchair in the dining room on the women's locked unit and bumped into Resident #20's legs. Resident #20 said, "Ouch!" Resident #18 continued to bump into Resident #20's legs several times and said each time, "Please move your legs." CNA K and LVN N were in the dining room at this time serving trays but did not see the incident. HA O came into the dining room at this time and took Resident #18 out of the locked unit. Review of the form CMS-802 (Roster/Sample Matrix) provided by the facility on 07/19/11 revealed Resident #20 had Mental Illness and was cognitively impaired with behavior symptoms. Review of the face sheet dated 01/05/11 revealed Resident #18 was a [AGE] year-old female admitted to the facility 06/29/10 and resided on the women's locked unit. Observation on 07/22/11 at 12:30 p.m. revealed CNA M was feeding Resident #18. Review of the Incident/Accident Report dated 06/05/11 at 7:30 p.m. revealed Resident #18 had hit Resident #19 in the face. There was only one witness statement in the investigation. The written witness statement from the CNA on duty reflected, "I was dealing with a resident complaint when I heard yelling coming from the dining room. I walked in as (Resident #18) hit (Resident #19) in the face." The report reflected the CNA reported the incident to the nurse. The section for Interventions reflected, "Does not recall incident - assess for possible move off secure unit." The section for Care Plan Update was blank. The ADM and previous DON signed the report on 06/07/11. Review of the Annual MDS assessment dated [DATE] revealed Resident #18 scored 3 of 15 on the Brief Interview for Mental Status, had [MEDICAL CONDITION], verbal behavioral symptoms directed toward others, and used a wheelchair for mobility. Resident #18 required extensive assistance of one person for transfers, bed mobility, locomotion on the unit, dressing, personal hygiene, and was frequently incontinent of bowel and bladder. [DIAGNOSES REDACTED]. 3)Review of the face sheet dated 01/05/11 revealed Resident #19 was a [AGE] year-old female re-admitted to the facility on [DATE] and resided on the women's locked unit. Observation on 07/22/11 at 12:30 p.m. revealed Resident #19 sat in a chair in the dining room eating lunch. Review of the Incident/Accident Report dated 06/05/11 revealed Resident #19 held onto Resident #18's shirt and Resident #18 slapped Resident #19 in the face. There was only one witness statement in the investigation. The written witness statement from the CNA on duty reflected, "I was dealing with a resident complaint when I heard yelling coming from the dining room. I walked in as (Resident 19) had a hold of (Resident 18's) shirt and (Resident #18) slapped (Resident #19) in the face." The report reflected the CNA reported the incident to the nurse and Resident #19 had hit Resident #18 on the arm and Resident #18 hit Resident #19 in the face. The section for Interventions reflected, "Continues with Dementia." The section for Care Plan Update was blank. The ADM and previous DON signed the report on 06/07/11. The Annual MDS assessment dated [DATE] revealed Resident #19 was rarely/never understood, was moderately cognitively impaired, had physical and verbal behavioral symptoms directed toward others, and rejected care. Resident #19 required extensive assistance for personal hygiene, occasionally incontinent of urine, was totally dependant on one person for dressing, and independent in ambulation. [DIAGNOSES REDACTED]. 4) Observation on 07/19/11 at 5:00 p.m. revealed Resident #1 sat in her wheelchair on the women's locked unit with a large amount of thick white sputum that extended all down her sweatshirt to the knee of her pants. Resident #13 who had a history of [REDACTED]. There was no staff present to supervise the residents in the dining room at this time. Observation on 07/20/11 at 4:40 p.m. revealed Resident #1 ambulated with an unsteady gait from her room into the hall unassisted. CNA C ran down the hall and assisted Resident #1 to sit in her chair in her room. CNA C stated they did not let Resident #1 ambulate unassisted because of her risk for falls. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #1 scored 2 of 15 on the Brief Interview for Mental Status and had physical and verbal behavioral symptoms directed toward others. [DIAGNOSES REDACTED]. Resident #1 was totally dependent on one person for toileting and was frequently incontinent of bowel and bladder. Resident #1 required the assistance of one person for ambulation. Review of the accident/incident reports for June and July 2011 revealed Resident #1 fell on her right hip in the hallway of the women's locked unit on 07/01/11 at 10:45 a.m. and the intervention was "currently treating UTI." There were no witness statements included with the report. The DON and the ADM signed the incident report on 07/12/11. Resident #1 fell again on 07/05/11 at 4 p.m. and the written statement from the CNA on duty reflected Resident #1 was yelling so the CNA "went down there" and found Resident #1 on the floor. Another written statement from another CNA on duty reflected she heard a thud and Resident #1 crying so she went in Resident #1's room and found her on the floor. Nurse's assessment revealed Resident #1 was found lying on the floor with a hematoma on the right side of her head. Resident #1 had tried to transfer herself to the toilet, and the resident stated to the nurse that she needed to go to the bathroom. The report reflected Resident #1's condition before the incident was confused and agitated. The section on the report for Summary/Final Disposition of Report was blank except for vital signs and was signed by DON on 07/12/11. The sections on the report for Interventions and Care Plan Updates were blank. DON and ADM signed the report on 07/12/11. 5) The surveyor observed Resident #13 on 07/20/11 at 8:00 a.m. in the Women's Secured Unit on F hall. She wandered the hallway, and she appeared frail and thin. A review of the July 2011 physician's orders [REDACTED]. A review of the I/A report dated 07/21/11 at 3:55 p.m. reflected the roommate for Resident #13 cautioned CNA U, who attended to the resident, that the resident had just woken up from a nap and her gait was unsteady. According to the report, CNA U left the resident in the television area unattended, the resident got up, attempted to walk, hit her forehead against the corner of the wall, and sustained a bleeding golf size lump on the left side of her forehead. The resident was transferred to the emergency room and came back with a concussion to her forehead. On 07/22/11 at 12:05 p.m. interview with Resident #7, who was also the roommate for Resident #13 expressed frustration because she felt Resident #13's falls with injuries could have been avoided. She revealed, "...Often she (Resident #13) tries to toilet herself and falls. They don't toilet her but that's what she needs. She's (Resident #13) unsteady on her feet when she wakes up from sleep....That really upsets me...They tell me I'm a patient so I'm not supposed to help her (Resident #13). We are short all the time in the unit." CNA U, who left Resident #13 unattended in the television area was interviewed on 07/22/11 at 4:00 p.m. He complained that they were routinely short of staff on the secured unit and it was impossible to supervise all the residents who resided there. Mens Secured Unit: 6) Interview on 07/20/11 at 9:10 a.m. with CNA B revealed she had worked alone on the men's unit on 07/19/11, there were two falls within a few minutes time, and had said, "I can't do this." CNA B stated she was glad the staffing was now changed and there would be two CNAs for each locked unit on the day shift. 7) Resident #2 alleged during the initial rounds on 07/19/11 that Resident #3 came to his room punched him, then bit his left hand ring finger, leaving two bite marks. The Surveyor observed Resident #3 on 07/19/11 at 11:50 a.m. wandering around in Resident #2's bathroom and room. Resident #2's roommate came out to the hall, down to the dining room and came back to his bed. There was no facility staff in the hall and/or the dining room area to assist them with removing Resident #3 from their room. The Surveyor observed Resident #3 again on 07/22/11 at 2:55 p.m. forcefully opening Resident #2's room. Resident #2 started yelling, "Get out of here, get out of here" very loudly, when finally CNA F came running and took the resident out of Resident #2's room. Review of the form CMS-802 (Roster/Sample Matrix) provided by the facility on 07/19/11 revealed Resident #3 had Mental Illness and was cognitively impaired with behavior symptoms. 8) The surveyor observed Resident #11 in the dining room area on 07/19/11 at 1:00 p.m. Resident #11 fell while in the dining room. Other residents in the dining room area tried to assist him get up as there were no facility staff members around. The LVN had left for the other unit and the CNA was assisting a resident in their room. 9) Resident #12 had an unwitnessed fall in his room transferring himself to the bathroom [ROOM NUMBER]/14/11. Resident #12 sustained a large bruise from his mid upper right hand to the knuckle areas of his right hand from the fall. Resident #12 fell again 07/20/11 at 3:40 p.m. transferring himself to the bathroom with no assistance and he sustained another large bruising to the left elbow down to the knuckles of the left hand and a large skin tear to his left elbow area. Resident #12 was diagnosed with [REDACTED]. 10) Interview on 07/19/11 at 3:30 p.m. with ADM and the facility's only ADON revealed there were a lot of combative and confused residents on the two locked units. The staffing pattern for the women's and men's locked units for the day shift was one CNA for each unit and another CNA "floated" between the units as needed. One nurse "floated" between both locked units as needed. There was no CNA to float on the units on the day of this interview because there were two CNAs who had called in. The ADON stated she had not called an agency to obtain agency staffing for the units because the Administrator had to approve the call to the agency. She stated she had not asked the Administrate for his approval to call the agency. Observation on 07/19/11 at 3:40 p.m. revealed there was one CNA on each locked unit (womens and men's) with a third CNA to "float" between the units as needed. In an interview with LVN A on 07/20/11 at 12:25 p.m. he stated the facility were short of staff. LVN A stated he spoke with the ADM before going on vacation in June 2011 about the staff for the closed units. He was promised that staffing for the closed unit would be changed where he would not have both halls. LVN A stated the new pattern was for a staff to have F hall and another of the regular hall and another nurse would have G hall with another regular hall. He came back from vacation and noticed there had not been any changes. LVN A stated he had as many residents as the other nurses do. The other nurses did not have the behavior he had to deal with daily, nor did they do their own medication pass. The interview revealed the other nurses had medication aides to pass their medications while he had to provide care, do his treatments and pass medications. The interview also revealed that if there was a staff member who called in, the facility would take the float from his hall. on the secured unit(s). 11) In the confidential resident group meeting held 07/20/11 at 10:30 a.m., two of the nine residents (identified by the facility as interviewable) in the meeting stated, "There were a lot of fights on the G Hall." 12) In a confidential interview, it was revealed the residents had a lot of falls on the men's and women's locked units due to no supervision and insufficient staffing. The Interviewee stated the facility only had one CNA on each of the locked units with one CNA floating or releasing another CNA for breaks. The Interviewee revealed the facility did not have sufficient staff to safely monitor the residents on the halls and to prevent them from entering each other's rooms and to prevent aggressive and agitated behaviors. The Interviewee stated residents were not safe in the two locked units due to insufficient staffing. 13) On 07/21/11 at approximately at 3:20 p.m. an IJ was identified. On 07/21/11 at 3:20 p.m. the ADM, DON, and AIT were informed of an IJ in the area of Resident Behavior/Facility Practice. A plan of removal was requested at that time. 14) Review of the Plan of Removal, accepted on 07/22/11 at 1:00 p.m. revealed Residents (Residents #2, #3, #4, #11, #12, #17, #18, and #19) all had a complete and thorough investigation to determine if any abuse/neglect had occurred. This was completed by 07/21/11 by the Administrator. All 79 residents in the facility were assessed to determine if they had any physical signs of abuse/neglect. This was completed by 07/22/11 by DON and RDR T. The Social Worker interviewed all alert and interviewable residents to unsure they felt safe in the facility and were free from abuse/neglect. This was completed by 07/22/11. The Medical Director was notified and was involved in the Plan of Removal process. Facility staff was inserviced on abuse/neglect prohibition, and reporting abuse/neglect, by DON. Licensed nursing staff was inserviced on timely and accurate investigation of incidents and the criteria for reporting any incidents to Administration. This was completed on 07/23/11 by DON. The incident reporting system was as follows: 1) All incidents will require an incident report to be completed by the charge nurse. Any witnesses would complete a witness statement at that time. 2) If abuse/neglect was suspected, resident-to-resident altercations or injuries sustained, Administration would be notified immediately. 3) Incident reports were to be completed before the end of the shift and were to be kept in the nursing communication box at the nurses ' station. 4) The DON, or designee, would collect all incident reports and the 24 hour report and review them in the Daily Stand-up Meeting. 5) The Administrator, as the Abuse Prohibition Coordinator, would consult with the Regional Director of Operations on any suspected allegations of abuse or neglect to determine if they met the criteria spelled out in Provider Letter #06-43. The facility would ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, were reported immediately to DADS. 6) All of Administration would be inserviced on the system by Regional Director of Operations on 07/22/11. To monitor for compliance the Administration and/or designee would run a weekly Standards of Care meeting to include monitoring of all incident and accidents. All reports for the week would be reviewed for completion, accuracy, appropriate interventions, reportability and the final disposition. In addition, tracking and trending of incidents and accidents would be completed and analyzed. Any negative findings would be forwarded to the Administrator and the QA committee. Interviews on 07/22/11 from 1:20 p.m. through 4:50 p.m. were conducted with the following staff: CNA I, CNA K, SW V, LVN H, AD, LVN N, CNA M, ADA S, CNA U, and CNA C. They were all able to identify the Administrator as the Abuse Coordinator. They would report any identified abuse/neglect allegations and injuries of unknown origin immediately. 15) On 07/22/11 at 8:15 p.m. the ADM, DON, and AIT were informed the IJ was removed. 16) The census provided by the facility on 07/19/11 reflected 24 residents resided on the locked units (11 on the women's locked unit and 13 on the men's locked unit.)

Based on observation, interview, and record review it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 9 (Residents #1, #2, #3, #11, #12, #13, #18, #19, and #20) of twenty residents (Residents #1-#20) reviewed for quality of life. 1) Resident #12 had four falls from 05/29/11 through 07/20/11 with lacerations, bruises, bleeding and complaints of pain, with the need for evaluation and treatment at the ER. Resident #12 returned to the facility with the [DIAGNOSES REDACTED]. 2) Resident #13 had more than ten falls, some with injuries within a three month period according to the I/A investigation report from May 2011 though July 2011. Resident #13 sustained a concussion to her forehead from one of the falls, when CNA X left the resident unattended in the television area. 3) Resident #3 was observed to wander in and out of other residents' rooms. Resident #2, stated Resident #3 came to his room and punched and bite him on the Left hand ring finger. There was no staff monitoring and redirecting the residents in the hallway. 4) Resident #1 fell on [DATE] and again on 07/05/11. 5) On 07/19/11 after the noon meal residents were left, unattended in the dining room without monitoring. Resident #11 fell during this time, and the fall was unwitnessed by the staff. 6) Resident #18 slapped Resident #19 in the face and Resident #19 hit Resident #18 in the arm on 06/05/11. Resident #18 bumped into Resident #20's legs several times without staff noticing the incident on 07/19/11 at 12:25 p.m. 7) Two of nine in the residents' confidential interviews reported staffing shortages with several resident-resident altercations in the secured units. An Immediate Jeopardy (IJ) was identified on 07/21/11. While the IJ was removed on 07/22/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm" because the facility was still monitoring the implementation of the Plan of Removal. These failures are likely to cause residents to be exposed to further neglect. Findings included: 1) Review of Resident #12's most recent MDS assessment dated [DATE] revealed he was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #12 had no falls before and during admission. Resident #12 was observed during the initial rounds on 07/19/11 at 9:45 a.m. The ADON stated Resident #12 was ambulatory with his walker, he was incontinent of bowel and had a Foley catheter. Resident #12 was alert and oriented to person and required assistance with activity of daily living needs and had no history of falls. The surveyor observed LVN A on 07/20/11 at 7:50 a.m. entering the G hall closed unit. The call light in Resident #12's room was on so staff went into the room. LVN A came out of the room and went straight to the treatment cart and obtained supplies to provide a treatment to a wound. The surveyor observed some blood on the floor by the B bed at the foot of the bed and the resident was lying in bed. Resident #12 was observed with a dark purple bruise from the upper hand to the knuckles of his Right hand. Resident #12 also had a skin tear to the Right Elbow area approximately 3.0 cm x 4.0 cm with the skin flap covering the skin tear. During the treatment, LVN A stated Resident #12 fell last week while sat at the bedside. He fell asleep and fell , got up and called for assistance. LVN A stated when he entered the room "there was blood every where, he got his elbow very well." Resident #12 requested from LVN A some Tylenol for pain to the right side after the treatment. The surveyor went to Resident #12's room on 07/21/11 at 8:40 a.m. CNA B completely uncovered Resident #12 and it was discovered the resident now had bilateral bruising to the left hand area from the elbow area down to his left hand knuckles. CNA B stated Resident #12 fell yesterday 07/20/11 in the evening. Resident #12 now had bilateral hands with dark bruises and skin tears to both elbow areas with opsite (a clear dressing that you can see the wound through) dressing. The right elbow dressing was observed still oozing blood at this time. Before CNA B and the surveyor left Resident #12's room, Resident #12 requested Tylenol for pain. Review of the I/A report 05/27/11 at 2000 (8:00 p.m.) revealed Resident #12 fell while getting out of bed without turning his call light on and tripped on his walker. He and sustained a 2.0 cm x 2.0 cm skin tear. The intervention was "recent UA (urinalysis)." Review of the nurse's note dated 05/27/11 at 2000 (8:00 p.m.) revealed Resident #12 was going to the restroom when he tripped on his walker and fell . Review of the I/A report dated 05/29/11 at 23:50 (11:50 p.m.) revealed Resident #12 fell in his room transferring himself. The incident questionnaire attached to the I/A report, reflected Resident #12 stated he was going to the bathroom when he fell . Review of the nurse's note dated 05/29/11 at 23:50 p.m. (11:50 p.m.) revealed Resident #12 stated he slid off his bed when attempting to go to the bathroom. The fall risk assessment dated [DATE] revealed a total score of 18. The assessment work sheet reflected a score of ten or above was "high risk." Review of Resident #12's most recent care plan dated 6/30/11 revealed Resident #12 has decreased vision and history of falls. Approaches included: 1) Eye exam every year and as necessary, 2) Give resident verbal reminders not to ambulate or transfer without assistance, 3) Assess resident's need for assistive/supportive device, Maintain resident environment free of clutter, and 4) and safety hazards and provide environment with adequate lightening, free of glare. Review of the incident report dated 07/20/11 at 1540 (3:40 p.m.) revealed Resident #12 was ambulating to the bathroom lost his balance and fell . The I/A report also revealed Resident #12 sustained two skin tears to the left elbow measuring 2.0 cm x 2.0 cm. There was a 1.0 cm x 1.0 cm areas to the left side, top of foot. In an interview with the facility ADON and the MDS coordinator, LVN D on 7/22/11 at 1:30 p.m. LVN D stated there had not been any changes on Resident #12's care plan because the family was only concerned about his Foley catheter so facility ordered a condom catheter for him. LVN D stated she believed staff toileted Resident #12 every two hours but she was not sure about that. The ADON stated facility had not tried the alarms to notify staff of the resident needing assistant and getting out of bed. The ADON added Resident #12 actually stayed in his room because he did not want to be away from the bathroom. Interview with both LVN D and the ADON on 7/22/11 at 3:15 p.m. and 3:35 p.m. respectively revealed Resident #12 did not have any skin problems previous to the bruising to both his hands. The surveyor requested the report of the X-ray done 07/22/11 a.m. for Resident #12, after Resident #12 complained of pain. At 5:15 p.m., the DON gave the surveyor an X-ray report for Resident #12 dated 07/22/11. The report reflected, "the sixth and perhaps fifth anterolateral ribs demonstrate undisplaced fracture." Another report from an area hospital reflected Resident #12 had "Right Lower Lobe Pneumonia. Small Right Pleural Effusion." On 07/21/11 at 9:50 a.m., LVN A told the surveyor Resident #12 fell last week Thursday (07/14/11). 2) The surveyor observed Resident #13 on 07/20/11 at 8:00 a.m. in the Secured Unit on F hall. She wandered the hallway, and she appeared frail and thin. A review of the July 2011 physician's orders [REDACTED]. Review of the initial MDS assessment dated [DATE] for Resident #13 triggered short/long term memory problems, severe cognitive impairment, wandered about the facility daily, required limited assistance with transfer and ambulation but had unsteady gait, required extensive assistance with toileting and was always incontinent of bowel and bladder. The assessment reflected the resident had a history of [REDACTED]. The quarterly MDS assessment dated [DATE] for Resident #13 triggered the same areas as the initial MDS assessment with the inclusion of a b/b (bowel and bladder) program and therapy program in order to evaluate the frequent falls. Review of a Bladder Retraining assessment dated [DATE] revealed Resident #13 was to begin a 3-day voiding pattern in order to determine a possible toileting pattern. The only fall risk assessment was dated 05/17/11, with a total score of 14. The assessment form revealed a score of ten or more represented the resident was a high risk for falls. The initial plan of care dated 05/07/11, under the section falls, reflected Resident #13 was on a scheduled toileting program and on a fall-prevention program. However, there was no mention in the care plan about how facility staff was to execute the scheduled toileting program or what the falling star program entailed. Furthermore, the care plan was never updated because the facility did not toilet the resident and the facility did employ tangible approaches that would reduce the incidents of falls with injuries. A review of the I/A report dated 05/08/11 at 7:20 p.m. reflected Resident #13 was found on the floor after hitting her head on the floor and sustained a bruise to her bilateral eyes and forehead. The resident was transferred to the local emergency room . The admitting [DIAGNOSES REDACTED]. The section under interventions reflected, the resident was transferred to the local emergency room for evaluation. A review of the I/A report dated 05/18/11 at 6:00 p.m. revealed Resident #13 fell while walking in the dining area, hit the right side of her head on the wall, and blood was noted to her right elbow. The I/A reflected in the summary/final disposition section, the resident continued to ambulate in the hallway without any complaints. As a result of this incident, the interventions reflected physical therapy and occupational therapy would screen Resident #13 to determine if any additional interventions could be utilized. Record review of the therapy screen revealed a walker was recommended but the resident would not use it effectively. A review of the I/A report dated 06/06/11 at 3:55 a.m. revealed the roommate of Resident #13 activated the call bell to alert staff the resident had fallen in her room. Upon assessment, Resident #13 was noted with a swollen area on the back of her head. There was no measurement of the injury but the report reflected the resident went back to bed after neurological checks were done. The intervention revealed Resident #13 was, "Disoriented. Independent with ambulation." A review of the I/A report dated 06/10/11 at 2:00 p.m. revealed a CNA observed Resident #13 sitting on the side of the bed in her room, with her hand on her forehead. The resident stated she had fallen and there was a raised area to the right side of her forehead with a bluish color bruise. The intervention revealed Resident #13 did not sustain a fracture after an x-ray was performed. The intervention reflected, " Dementia cont (tinue) independent ambulation." A review of the I/A report dated 06/12/11 at 4:30 a.m., revealed the roommate of Resident #13 informed staff the resident was on the floor in her room, and there were no injuries. The intervention reflected, "Disoriented. Independent ambulation." The I/A report dated 06/13/11 at 5:55 a.m. reflected the CNA heard Resident #13 crying, and the resident's roommate yelled that the resident had fallen to the floor in her room. The report reflected there was no injury and the resident was referred to PT and OT for a screen. A review of the I/A report dated 06/25/11 at 4:15 p.m. reflected the CNA witnessed Resident #13 trip over another resident's wheelchair and fell to the floor hitting her head against a wall. There was no summary/final disposition on the report and the section under interventions reflected, "Sutures to head." The I/A report dated 07/15/11 at 11:40 p.m. reflected Resident #13 fell to the floor and there was a "knot to her L (left) hip." The resident was transferred to the local emergency. She returned without a fracture. There was no summary/final disposition on the report and the section under interventions reflected, the resident went to the emergency room and came back without a fracture. A review of the I/A report dated 07/16/11 at 4:30 a.m. reflected the roommate for Resident #13 yelled for a CNA after she saw the resident on the floor in her room. There were no injuries. There was no summary/final disposition on the report and the section under interventions, revealed a tangible intervention where the facility would initiate a toileting program after a 72 hour evaluation. The I/A was signed and dated 07/19/11 by the DON and the administrator. A review of the I/A report dated 07/21/11 at 3:55 p.m. reflected the roommate for Resident #13 cautioned CNA U, who attended to the resident, that the resident had just woken up from a nap and her gait was unsteady. According to the report CNA U left the resident in the television area, the resident got up, attempted to walk, hit her forehead against the corner of the wall, and sustained a bleeding golf size lump on the left side of her forehead. The resident was transferred to the emergency room and came back with a concussion to her forehead. All the I/A report for Resident #13 were signed by the DON and the facility Administrator with minimum to no intervention in preventing Resident #13 from further falls with injuries, or provide an environment where she would have a safer fall with no injuries. On 07/22/11 at 12:05 p.m. interview with Resident #7, who was also the roommate for Resident #13 expressed frustration because she felt Resident #13's falls with injuries could be avoided. She revealed, "...Often she (Resident #13) tries to toilet herself and falls. They don't toilet her but that's what she needs. She's (resident #13) unsteady on her feet when she wakes up from sleep...That really upsets me...They tell me I'm a patient so I'm not supposed to help her (Resident #13). We are short all the time in the unit." Based on the I/A report, it was evident that four of the ten falls Resident #13 experienced occurred in her room, between 3:00 a.m. and 6:00 a.m. However, the facility did not initiate a toileting program in order to ensure the resident negotiated her way to the restroom safely. The DON was interviewed on 07/22/11 at 3:30 p.m. He stated concerning the numerous falls and injuries sustained by Resident #13 that therapy should screen residents after they fall. The DON continued that therapy had not been effective. He stated the facility did not have a policy for the falling star program. When he was queried about a toileting program for Resident #13, he stated he did not initiate the 3-day voiding program he had documented as an intervention when Resident #13 fell on [DATE]. The DON admitted he was not familiar with implementing appropriate interventions after residents fell and further stated the secured unit, where Resident #13 resided, should have more staff to meet the resident's needs. Review of CNA U's assignment sheet for Resident #13's care revealed, "PACEMAKER. Very disoriented. Redirect from secure unit doors. Redirect from others rooms. Likes candy. Watch for disrobing." CNA U was interviewed on 07/22/11 at 4:00 p.m. He stated it would be helpful if the facility wrote the care he was to provide for each resident on his assignment sheet. He revealed he did not know Resident #13 had unsteady gait after she woke up from a nap. He further stated he was not aware the resident should be toileted. He complained that they were routinely short of staff on the secured unit and it was impossible to supervise all the residents who resided there. On 08/02/11 at 8:50 a.m., an interview with PT V, who was familiar with Resident #13, stated he tried to get the resident to walk with a walker and a Merry Walker but the resident was forgetful and would abandon the walker. He stated the resident tried to climb out a the Merry-Walker once so he discontinued that approach. He stated he did not want to restrain the resident and was therefore left without any solutions to minimize her falls. There was no nurses' station on the unit. Therefore, residents were monitored at the main nurses' station by an electric monitoring device, which was outside of the Secured Unit. 3) Resident #2 alleged during the initial rounds on 07/19/11 that Resident #3 came to his room punched him, then bit his left hand ring finger, leaving two bite marks. The Surveyor observed Resident #3 on 07/19/11 at 11:50 a.m. wandering around in Resident #2's bathroom and room. Resident #2's roommate came out to the hall, down to the dining room and came back to his bed. There was no facility staff in the hall and/or the dining room area to assist them with removing Resident #3 from their room. The Surveyor observed Resident #3 again on 07/22/11 at 2:55 p.m. forcefully opening Resident #2's room. Resident #2 started yelling, "Get out of here, get out of here" very loudly, when finally CNA F came running and took the resident out of Resident #2's room. Review of the form CMS-802 (Roster/Sample Matrix) provided by the facility on 07/19/11 revealed Resident #3 had Mental Illness and was cognitively impaired with behavior symptoms. 4) Review of the facility face sheet dated 01/05/11 revealed Resident #1 was a seventy-seven year-old female admitted to the facility 10/05/10 and resided on the women's locked unit. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #1 scored 2 of 15 which indicated the resident was moderately impaired in her cognitive skills, on the Brief Interview for Mental Status and had physical and verbal behavioral symptoms directed toward others. [DIAGNOSES REDACTED]. Resident #1 was totally dependent on one person for toileting and was frequently incontinent of bowel and bladder. Resident #1 required the assistance of one person for ambulation. Review of the I/A reports for June and July 2011 revealed Resident #1 fell on her right hip in the hallway of the women's locked unit on 07/01/11 at 10:45 a.m. and the intervention was "currently treating UTI." There were no witness statements included with the report. The DON and the ADM signed the incident report on 07/12/11. Resident #1 fell again on 07/05/11 at 4 p.m. and the written statement from the CNA on duty reflected Resident #1 was yelling so the CNA "went down there" and found Resident #1 on the floor. Another written statement from another CNA on duty reflected she heard a thud and Resident #1 crying so she went in Resident #1's room and found her on the floor. Nurse's assessment revealed Resident #1 was found lying on the floor with a hematoma on the right side of her head. Resident #1 had tried to transfer herself to the toilet, and the resident stated to the nurse that she needed to go to the bathroom. The report reflected Resident #1's condition before the incident was confused and agitated. The section on the report for Summary/Final Disposition of Report was blank except for vital signs and was signed by DON on 07/12/11. The sections on the report for Interventions and Care Plan Updates were blank. DON and ADM signed the report on 07/12/11. Observation on 07/19/11 at 5:00 p.m. revealed Resident #1 sat in her wheelchair with a large amount of thick white sputum that extended all down her sweatshirt to the knee of her pants. There were no staff present to supervise the residents in the dining room at this time. Observation on 07/20/11 at 4:40 p.m. revealed Resident #1 ambulated with an unsteady gait from her room into the hall unassisted. CNA C ran down the hall and assisted Resident #1 to sit in her chair in her room. CNA C stated they did not let Resident #1 ambulate unassisted because of her risk for falls. 5) A review of the July 2011 physician's orders [REDACTED]. Review of Resident #11's MDS assessment dated [DATE] revealed his [DIAGNOSES REDACTED]. Resident #11's MDS assessment reflected he was moderately impaired in his cognitive skills for decision-making, and he had a history of [REDACTED]. Review of the fall risk assessment reflected the most recent assessment was dated 04/10/11. Resident #11's total score for this date was 19. The assessment form reflected a score of ten or more represented the resident was a high risk for falls. The surveyor observed Resident #11 during the initial rounds on 07/19/11 at 9:35 a.m. resting in his bed. At that time, the facility's only ADON stated Resident #11 was ambulatory and incontinent of bowel and bladder. Resident #11 was confused and required assistance with all his ADL needs. She also stated Resident #11 fed himself in the dining room, had skin tears on his arm and had a history of [REDACTED]. A review of the Incident/Accident (I/A) report dated 06/16/11 at 11:00 a.m. revealed Resident #11 was observed with blood on his bed linens as he laid in bed sleeping. According to the diagram on the report, Resident #11 had skin tears on his right hand thumb area and two areas between the 2nd and 4th finger areas of his left hand. No measurements of the skin tears were documented. The summary/final disposition of the report reflected there were no signs/symptoms of infection and no signs of this injury noted. The I/A report reflected the interventions as a result of the incident "Dementia - etiology unknown - resident indep ambulated." The form was signed and dated 06/20/11 by the DON and the Administrator. There was no evidence to reflect an investigation had been conducted. Review of the I/A report dated 06/19/11 at 9:00 p.m. revealed the location of the incident was unknown. The report reflected Resident #11 was found in Resident #2's room with a skin tear on his left arm area. The report reflected staff heard Resident #2 yelling. When she went to the room, staff observed Resident #11 in the room with a skin tear on his left arm. The statement from staff revealed Resident #2 was not holding Resident #11. The I/A report also reflected Resident #11 "goes in and out of rooms and agitates other Residents because of this." The intervention reflected Resident #11 was in a "secure unit for wandering." The care plan area to indicate an update reflected there were no recent changes made to his care plan at that time. Review of the I/A report dated 07/06/11 at 6:30 p.m. revealed Resident #11 was sitting in a chair with a CNA sitting beside him. He started scooting and slipped out of the chair, sustaining a 2.0 cm x 2.0 cm skin tear on his right elbow. Review of the I/A report dated 07/11/11 at 10:30 a.m. revealed staff heard another (unidentified) resident screaming. Staff found Resident #11 in his room with blood around his right eye and a laceration. The report reflected on the summary/final disposition only vital signs and a signature from the facility ADON dated 07/19/11. The intervention area was blank, and the care plan update was also left blank. The final signature was the DON's dated 07/19/11. The I/A report dated 07/19/11 at 1:30 p.m. reflected Resident #11 fell , which was witnessed by CNA B. Resident #11 went to sit down on the bed or recliner, missed and sat down on the floor. There were no injuries. The surveyor was observing the residents in the men's locked unit on 07/19/11 at 12:00 p.m. LVN A had finished assisting with meals and left for F hall on 07/19/11 at approximately 1:00 p.m. CNA B took a resident to his room. There was no other staff in the hallway or dining room. The surveyor heard a loud thump and looked around. The surveyor observed another resident, who was standing and telling another resident to get up. On further observation, the surveyor observed Resident #11 on the floor between the dining room and the television room. CNA B came running from room [ROOM NUMBER] to the dining room. CNA B told Resident #11 to wait and then she ran outside the unit to get help. CNA B came back to the area, asking the resident if he was okay. It took approximately 12 minutes for the charge nurse, LVN A, to come back to the unit to assist with getting Resident #11 up from the floor. The surveyor observed LVN A with CNA B assist Resident #11 stand up and escort him to his room. The surveyor next observed LVN A coming out of the resident's room and leaving the unit while CNA B was observed escorting Residents #11 and #3 down the hall. CNA B was talking to the surveyor about both residents being wanderers. Resident #11, who was walking behind CNA B, went into another residents room (occupied room). Resident #11 had already fallen when CNA B entered the room. The family member of the resident in the room was telling Resident #11 not to get up so staff could check him out. Review of Resident #11's I/A reports for three months revealed LVN A failed to document the first fall in the dining room on 07/19/11. LVN A was interviewed on 07/21/11 at 9:50 a.m. LVN A stated he did not write up an I/A Report on Resident #11's fall in the dining room on 07/19/11 at 1:00 p.m. LVN A stated he was told Resident #11 sat down on the floor and had not fallen. The surveyor asked if the second fall he documented was a fall, or if the resident sat down. LVN A stated it was a fall, and he documented it. The interview revealed he observed the surveyor in the dining room area when he came to assess Resident #11 for the fall the first and second time. LVN D stated on 07/22/11 at 1:30 p.m. Resident #11 would sit himself on the floor since admission. She also stated facility had tried Hipster (cushions that are inserted into pants to cushion falls) to prevent injuries, but the resident kept removing the hipster. However, review of the care plan for the resident with the ADON and LVN D revealed a fall care plan initiated 07/26/10 approximately 12 days after admission. The care plan reflected no new changes including the use of a hipster to prevent injuries, except for a therapy screen 07/02/11 for multiple falls and no therapy required at that time. Review of Resident #11's care plan, with a problem onset of 07/26/10 and revised 07/14/11, revealed Resident #11 had the potential for falls. The care plan reflected: "...provide with diversional activities, Notify the physician when he does have a fall promptly, Eye exam as q yearly and as necessary and. And, Provide environment with adequate lightening, free of glare." Approaches on the care plan reflected a handwritten note, which documented Resident #11 had a therapy screen on 07/02/11 for multiple falls. There were no changes made to the approaches on the care plan since adopted 07/26/10. In a confidential interview, it was revealed the facility had a lot of falls on the F and G halls. The Interviewee stated the facility only had one CNA on F hall and one on G hall, with one CNA, who floated between the two halls to relieve the CNAs for breaks. The Interviewee revealed the facility did not have sufficient staff to monitor residents on F and G halls. The surveyor interviewed the DON on 07/21/11 at 10:50 a.m. The interview revealed Resident #11 was in a closed unit, and there was nothing else to do. The DON stated he was aware Resident #11 sometimes would seat himself on the floor and said it was a behavior the resident was admitted with. The surveyor discussed the observation on 07/19/11 with Resident #11 falling twice. The DON stated since the fall was unobserved, staff should have made an inside report of the fall for further review. 6) a. Review of the face sheet dated 01/05/11 revealed Resident #18 was a [AGE] year-old female admitted to the facility 06/29/10 and resided on the women's locked unit. Review of the Annual MDS assessment dated [DATE] revealed Resident #18 scored 3 of 15 which reflected the resident's cognition was severely impaired on the Brief Interview for Mental Status, had [MEDICAL CONDITION], verbal behavioral symptoms directed toward others, and used a wheelchair for mobility. Resident #18 required extensive assistance of one person for transfers, bed mobility, locomotion on the unit, dressing, personal hygiene, and was frequently incontinent of bowel and bladder. [DIAGNOSES REDACTED]. Observation on 07/19/11 at 12:25 p.m. revealed Resident #18 wheeled herself in her wheelchair into the dining room on the women's locked unit and bumped into Resident #20's legs. Resident #20 said, "Ouch!" Resident #18 continued to bump into Resident #20's legs several times and said each time, "Please move your legs." CNA K and LVN N were in the dining room at that time serving trays, but they did not see the incident. HA O came into the dining room at that time, saw Resident #18 bumping into Resident #20's legs and took Resident #18 out of the locked unit. Review of the form CMS-802 (Roster/Sample Matrix) provided by the facility on 07/19/11 revealed Resident #20 had Mental Illness and was cognitively impaired with behavior symptoms. Review of the I/A Report dated 06/05/11 at 7:30 p.m. revealed Resident #18 had hit Resident #19 in the face. There was only one witness statement in the investigation. The written witness statement from the CNA on duty reflected, "I was dealing with a resident complaint when I heard yelling coming from the dining room. I walked in as (Resident #18) hit (Resident #19) in the face." The report reflected the CNA reported the incident to the nurse. The section for Interventions reflected, "Does not recall incident-assess for possible move off secure unit." The section for Care Plan Update was blank. The ADM and previous DON signed the report on 06/07/11. b. Review of the face sheet dated 01/05/11 revealed Resident #19 was a [AGE] year-old female re-admitted to the facility on [DATE] and resided on the women's locked unit. The Annual MDS assessment dated [DATE] revealed Resident #19 was rarely/never understood, was moderately cognitively impaired, had physical and verbal behavioral symptoms directed toward others, and rejected care. Resident #19 required extensive assistance for personal hygiene, occasionally incontinent of urine, was totally dependant on one person for dressing, and independent in ambulation. [DIAGNOSES REDACTED]. Observation on 07/22/11 at 12:30 p.m. revealed Resident #19 sat in a chair in the dining room eating lunch. Review of the I/A Report dated 06/05/11 revealed Resident #19 held onto Resident #18's shirt and Resident #18 slapped Resident #19 in the face. There was only one witness statement in the investigation. The written witness statement from the CNA on duty reflected, "I was dealing with a resident complaint when I heard yelling coming from the dining room. I walked in as (Resident 19) had a hold of (Resident 18's) shirt and (Resident #18) slapped (Resident #19) in the face." The report reflected the CNA reported the incident to the nurse and Resident #19 had hit Resident #18 on the arm and Resident #18 hit Resident #19 in the face. The section for Interventions reflected, "Continues with Dementia." The section for Care Plan Update was blank. The ADM and previous DON signed the report on 06/07/11.

Based on observation, record review, and interview the facility failed to implement its written policy on abuse/neglect prevention. The facility failed to investigate or thoroughly investigate injuries of unknown origin and resident-to-resident altercations for nine residents (Residents #1, #2, #3, #4, #11, #12, #17, #18, and #20) of twenty (Residents #1 - #20) residents reviewed for quality of life and quality of care. 1) Resident #11 had a resident-to-resident altercation that resulted in a 1.5 cm. laceration to his right lateral forehead and a nose bleed on 05/17/11. He had skin tears on both hands which were injuries of unknown origin on 06/16/11. He had a resident-to-resident altercation that resulted in a skin tear to his left arm on 06/19/11. He had a laceration to the right eye area with bleeding which was an injury of unknown origin on 07/11/11. There was no investigation as to how the two injuries of unknown origin were sustained and no preventive measures were put in place to prevent reoccurrence of resident-to-resident altercations. Resident #11 fell twice on 07/19/11 within a few minutes time but the facility documented only one fall. 2) Resident #12 sustained bruising from the right upper hand down to the knuckles of his right hand and a skin tear to the right elbow area that was bleeding through the dressing. 3) Resident #2 alleged a tall bearded man came to his room. Resident #2 stated the man started punching him and he (Resident #2) punched back. The bearded man also allegedly bit Resident #2's left ring finger. Resident #2 had bruises to the left knuckle areas and two scabbed areas with the bite marks. There was no investigation as to who the bearded man was. 4) Resident #4 sustained a 5 cm x 5 cm bruise to the right upper arm on 07/10/11. The Injury was of unknown origin and was not investigated. 5) Resident #1 fell on [DATE] and again on 07/05/11. 6) Resident #17 sustained bruises of unknown origin on 07/04/11. An Immediate Jeopardy (IJ) was identified on 07/21/11. While the IJ was removed on 07/22/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm" because the facility was still monitoring the implementation of the Plan of Removal (POR). These failures are likely to cause residents to be at risk of further abuse and/or neglect. Findings included: 1) The facility's undated policy and procedure titled Freedom from Abuse or Neglect reflected, "...each resident has the right to be free from mistreatment, neglect, abuse, and misappropriation of property by anyone..." The policy and procedure also reflected, "4. Identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse; and to determine the direction of the investigation. 5. Investigate different types of incidents and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting the results to the proper authorities. 6. Protect residents from harm during an investigation...." 2) Review of Resident #11's care plan with a problem on set of 07/26/10 and revised 07/14/11 revealed Resident #11 had the potential for falls. Approaches included: 1) Resident #11 was to be provided with diversional activities, 2) Notify the physician when he does have a fall promptly, 3)Eye exam as q (every) year and as necessary and 4) Provide environment with adequate lightening, free of glare. There was a handwritten notation on the care plan, reflecting Resident #11 had a therapy screen 07/2/11 for multiple falls. There were no changes made to the care plan since adopted 07/26/10. Review of the fall risk assessment reflected the last assessment was dated 04/10/11. Resident #11's total score for this date was 19. The assessment form revealed a score of ten or more represented the resident was a high risk for falls. A review of the I/A report dated 05/17/11 at 8:30 p.m. revealed Resident #11 went to another resident's room where he lay next to him in the bed. The other resident got up and started yelling at Resident #11 to get out of his bed. As the CNA entered the room the CNA observed the resident hit Resident #11 on his face with his fist. Resident #11 sustained a 1.5 cm laceration to the right fore head area and a nose bleed. Further review of this I/A report revealed in the intervention, "Dementia-In wrong bed." The care portion of the report reflected a blank space no changes was made to the care plan at that time. Review of the I/A report dated 06/16/11 at 11:00 a.m. revealed Resident #11 was observed with blood on his linen sheet as he lay in bed sleeping. Staff woke him up, cleaned a skin tear and applied Triple Antibiotic Ointment (TAO) to area, then and covered it with bandages. According to the diagram Resident #11 had a skin tear on his right hand by the thumb and two skin tears to his left hand between the fingers. No measurement of the skin tears was documented. The summary/final disposition of report reflected "no sign/symptoms of infection and no signs of this injury noted." "The interventions as a result of this incident reflected, "Dementia - etiology unknown- resident indep (independently)ambulated." The form was signed and dated on 06/20/11 by the DON and the facility Administrator. There was no further attachment indicating investigation to the injury was initiated. Review of the I/A report dated 06/19/11 at 2100 (9:00 p.m.) revealed the location of the incident was unknown. The report reflected Resident #11 was found in another resident's room with skin tear to his left forearm area. Staff cleaned and applied dressing to sight. Further review of the report reflected staff heard Resident #2 yelling, when the staff went to the room, she observed Resident #11 in the room with a skin tear on his left arm. The statement from staff revealed Resident #2 was not observed holding Resident #11. The incident report also reflected Resident #11 "goes in and out of rooms and agitates other residents because of this." The intervention revealed Resident #11 was in a "secure unit for wandering." Further review of the I/A report revealed under "care plan updates as a result of this incident", revealed there was no recent changes made to his care plan at that time, space was blank. Review of the I/A report dated 07/06/11 at 1830 (6:30 p.m.) revealed Resident #11 was sitting in a chair with a CNA sitting besides him when he started scooting and slipped out of the chair sustaining a 2.0 cm (centimeter) by 2.0 cm skin tear to the right elbow area. Further review of the I/A revealed a blank for the intervention and care plan changes space. Review of the I/A report dated 07/11/11 at 10:30 a.m., revealed staff heard another resident screaming, on entry to the room, the staff did not observe any problems. However, Resident #11 was found in his room with blood around his Right Eye and a laceration found to the area. Staff applied a dressing to the sight. Further review of the I/A revealed on the summary/final disposition of report reflected only vital signs and a signature from the facility ADON dated 07/19/11, the intervention area was blank and the care plan update was also left blank. The final signature was the Director of Nurses (DON) dated 07/19/11. Review of Resident #11's most recent MDS assessment dated [DATE] revealed he was admitted [DATE] and his active [DIAGNOSES REDACTED]. Resident #11's MDS assessment also indicated he was moderately impaired in his cognitive status, and he had history of falls. The surveyor observed Resident #11 during the initial rounds on 07/19/11 at 9:35 a.m. resting in his bed. The facility Assistant Director of Nurses (ADON) on rounds stated Resident #11 was ambulatory and incontinent of bowel and bladder. Resident #11 was confused and required assistance with all his activity of daily living needs. She also stated Resident #11 fed himself in the dining room, he had skin tears to his arm and had history of falls. The I/A report dated 07/19/11 at 1330 (1:30 p.m.) revealed the fall was witnessed by CNA B. Resident #11 went to sit down on bed, missed and sat on the floor. The surveyor was observing from the the secured unit when the incident occurred. LVN A had finished assisting with meals and left to go to F hall on 07/19/11 at approximately 1:00 p.m. CNA B was taking another resident to his room. There was no other staff in the hall or dining room. The surveyor heard a loud noise and began to search for the source of the noise. Resident #11 was on the floor between the dining room and the television room. CNA B came running to the dining room. CNA B was telling the resident to wait and she ran outside the unit to get help. CNA B came back to the area asking the resident if he was okay. It took approximately twelve minutes for the charge nurse (LVN A) to come back to the unit to assist with getting Resident #11 off the floor. The surveyor observed LVN A and CNA B assist Resident #11 up and escort him back to his room. The surveyor observed LVN A coming out of the resident's room and leaving the unit while CNA B was observed escorting Resident #11 and another resident down the hall. CNA B was talking to the surveyor about both residents. She stated both residents were wanderers. Resident #11, who was walking behind her, went into room [ROOM NUMBER]. Resident #11 had already fallen when CNA B entered the room. A family member in room [ROOM NUMBER] was telling the resident not to get up and that staff would come to check him out. Review of Resident #11's I/A for three months revealed LVN A failed to document the first fall in the dining room on 07/19/11 at approximately 1:00 p.m. LVN A was interviewed on 07/21/11 at 9:50 a.m. LVN A stated he did not write up an I/A report on Resident #11's fall in the dining room on 07/19/11 at 1:00 p.m. LVN A stated he was told Resident #11 sat down on the floor and did not fall. The surveyor asked if the second fall he documented was a fall. LVN A stated it was a fall and he documented it. The surveyor interviewed the DON on 07/21/11 at 10:50 a.m. The DON revealed Resident #11 was in a secured unit and there was nothing else to do for him. The DON stated he was aware Resident #11 sometimes would lower himself to the floor and stated it was a behavior the resident had when he was admitted . The surveyor discussed the falls observed on 07/19/11 with Resident #11 falling twice. The DON stated since the fall was unobserved staff should have made an I/A report of the falls for further review. The interview also revealed the DON would institute all falls (including a residents sitting himself/herself on the floor) must be documented for monitoring purposes. Interview on 07/21/11 at 11:00 a.m. with the ADM revealed he was not aware of the previous bruise on Resident #11 and only had one incident report for the fall last night. The ADM stated there was only one incident report for one fall on Tuesday for Resident #11. Surveyor informed ADM there had been two falls for Resident #11 on Tuesday within a few minutes. ADM stated there was no incident report for Resident #11. In an interview with the facility ADON and the MDS coordinator, LVN D on 7/22/11 at 1:30 p.m. LVN D stated Resident #11 would sit himself on the floor, since admission. She also stated facility had tried Hipster (padded protection that could be inserted into clothing to cushion a fall) to prevent injuries, but resident kept removing the hipster. However, review of the care plan for Resident #11 with the ADON and LVN D revealed a fall care plan initiated 07/26/10 approximately 12 days after admission. The care plan reflected no new changes except for a therapy screen 07/02/11 for multiple falls and no therapy required at that time. 3) Review of Resident #12's most recent MDS assessment dated [DATE] revealed he was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #12 scored 12 of 15 (Resident #12 had modified independence with some difficulty in new situations only) on the Brief Interview for Mental Status and had no falls before and during admission. Resident #12 was observed during the initial rounds on 07/19/11 at 9:45 a.m. The ADON stated Resident #12 was ambulatory with his walker, he was incontinent of bowel and had a Foley catheter. The ADON stated Resident #12 had an order for [REDACTED]. The surveyor observed LVN A on 07/20/11 at 7:50 a.m. entering the G hall closed unit. The call light in Resident #12's room was on so staff went into the room. LVN A came out of the room and went straight to the cart near the dining room and obtained 4 x 4 gauzes, a red trash bag and small pink bottle normal saline (NS) bottles. He left the area to obtain more NS. When LVN A came back to the cart he took the supplies off the cart and went back to Resident #12's room. The surveyor observed some blood on the floor by the B bed at the foot of the bed and the resident was lying in bed. Resident #12 was observed with a dark purple bruise from the upper hand to the knuckles of his Right hand. Resident #12 also had a skin tear to the Right Elbow area approximately 3.0 cm x 4.0 cm with the skin flap covering the skin tear. During the treatment, LVN A stated Resident #12 fell last week while sat at the bedside. He fell asleep and fell , got up and called for assistance. LVN A stated when he entered the room "there was blood every where, he got his elbow very well." Resident #12 requested from LVN A some Tylenol for pain to the right side after the treatment. The surveyor went to Resident #12's room on 07/21/11 at 8:40 a.m. to observe his Foley catheter. The surveyor requested for the assistance of CNA B. CNA B uncovered the Resident #12 half way and could not find the catheter bag. CNA B completely uncovered Resident #12 and discovered the resident now had bilateral bruising to the left hand area from the elbow area down to his left hand knuckles. CNA B stated Resident #12 fell yesterday 07/20/11 in the evening. Resident #12 now had bilateral hands with dark bruises and skin tears to both elbow areas with opsite (a clear dressing that you can see the wound through) dressing. The right elbow dressing was observed still oozing blood at this time. Before CNA B and the surveyor left Resident #12's room, Resident #12 requested Tylenol for pain. Review of the I/A report 05/27/11 at 2000 (8:00 p.m.) revealed Resident #12 fell while getting out of bed without turning his call light on and tripped on his walker. He and sustained a 2.0 cm x 2.0 cm skin tear. The intervention was "recent UA (urinalysis)." Review of the nurse's note dated 05/27/11 at 2000 (8:00 p.m.) revealed Resident #12 was going to the restroom when he tripped on his walker and fell . Review of the incident report dated 05/29/11 at 23:50 (11:50 p.m.) revealed Resident #12 fell in his room transferring himself. The incident questionnaire attached to the I/A report, reflected Resident #12 stated he was going to the bathroom when he fell . Review of the nurse's note dated 05/29/11 at 23:50 p.m. (11:50 p.m.) revealed Resident #12 stated he slid off his bed when attempting to go to the bathroom. Review of the incident report dated 07/20/11 at 1540 (3:40 p.m.) revealed Resident #12 was ambulating to the bathroom lost his balance and fell . The I/A report also revealed Resident #12 sustained two skin tears to the left elbow measuring 2.0 cm x 2.0 cm. There was a 1.0 cm x 1.0 cm areas to the left side, top of foot. The fall risk assessment dated [DATE] revealed a total score of 18. The assessment work sheet reflected a score of ten or above was "high risk." Review of Resident #12's most recent care plan dated 6/30/11 revealed Resident #12 has decreased vision and history of falls. Approaches included: 1) Eye exam every year and as necessary, 2) Give resident verbal reminders not to ambulate or transfer without assistance, 3) Assess resident's need for assistive/supportive device, 4) Maintain resident environment free of clutter and safety hazards and 5) provide environment with adequate lightening, free of glare. In an interview with the facility ADON and the MDS coordinator, LVN D on 7/22/11 at 1:30 p.m. LVN D stated there had not been any changes on Resident #12's care plan because the family was only concerned about his Foley catheter so facility ordered a condom catheter for him. LVN D stated she believes staff toileted Resident #12 every two hours but she was not sure about that. The ADON stated facility had not tried the alarms to notify staff of the resident needing assistant and getting out of bed. The ADON added Resident #12 actually stays in his room because he does not want to be away from the bathroom. Interview with both LVN D and the ADON on 7/22/11 at 3:15 p.m. and 3:35 p.m. respectively revealed Resident #12 did not have any skin problems previous to the bruising to both his hands. The surveyor requested the report of the X-ray done 07/22/11 a.m. for Resident #12. The X-ray was ordered due to Resident #12 complaining of pain to his right side. At 5:15 p.m., the DON gave the surveyor an X-ray report for Resident #12 dated 07/22/11. The report reflected, "the sixth and perhaps fifth anterolateral ribs demonstrate undisplaced fracture." Another report from an area hospital reflected Resident #12 had "Right Lower Lobe Pneumonia. Small Right Pleural Effusion." On 07/21/11 at 9:50 a.m., LVN A told the surveyor Resident #12 fell last week Thursday (07/14/11). 4) The surveyor observed Resident #2 during the initial rounds on 07/19/11 at 9:55 a.m. The ADON stated Resident #2 was ambulatory with a walker and continent of bowel and bladder. Resident #2 was alert and oriented to person and place and was forgetful at times. Resident #2 required assistance with his ADL needs and fed himself. The ADON stated Resident #2 did not like female staff taking care of him or other residents going into his room. He yelled and screamed at people when his privacy was violated. On entry into Resident #2's room, the surveyor introduced the purpose of the visit to the resident. Resident #2 stated "oh in that case let me give you something to do." Resident #2 stated a tall beard man came to his room last weekend (07/15/11 to 07/17/11) while he was lying in his bed (the ADON was present during this interview). The man started punching him in the bed and he fought back and punched him, too. Resident #2 showed the surveyor bruises in the left hand knuckle area and two marks to the ring finger of the left hand stating the man also bite his finger. The ring finger had two scabbed areas resident stated were bite marks. The most current MDS assessment dated [DATE] revealed Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Psychiatry Services notes dated 06/16/11 revealed Resident #2's thought process was appropriate with no gross cognitive difficulty. His past memory was good, immediate was fair and recent memory was impaired. The surveyor reviewed Resident #2's nurses note dated from 03/21/11 at 1400 (2:00 p.m.) to 5/31/11 at 2315 (11:15 p.m.) The nurse's note reflected on 04/9/11 at 12:45 (does not say a.m. or p.m.) a CNA reported to the charge nurse that Resident #2 came to the dining room and asked her to come get a resident out of his room. The other resident was lying in his bed. Resident #2 slapped the other resident who he thought was not getting up fast enough from his bed and other resident fought back. The CNA removed the other resident from Resident #2's room without further incident. The review of I/A reports for three months revealed Resident #2 did not have any I/A reporting records for these months. Interview with CNA B on 07/19/11 at 1:05 p.m. revealed an incident occurred approximately two to three weeks prior. CNA B stated she was not in the hall but heard Resident #2 yelling out. CNA B stated she ran to his room and found Resident #11 in his room. Resident #2 hit Resident #11 because he was not moving fast enough. The interview also revealed Resident #3 also goes into Resident #2's room. CNA B stated Residents #2 and #3 gets into it as Resident #3 would go into his room. CNA B stated Resident #2 must have sustained the injury on his left hand knuckles and ring finger in one of the altercations but was not sure. CNA B stated CNA F or P would know. Interview with CNA P on 07/12/11 at 2:30 p.m. revealed Resident #3 went to Resident #2's room and Resident #2 pushed him towards the door about without injuries approximately three weeks ago on a weekend. She reported the incident to the weekend nurse. CNA P stated she did not see Resident #3 entering the room. She just heard Resident #2 yelling at the resident. She went to the room to see what was going on. The interview also revealed the facility had one CNA per hall F and G halls with another CNA floating or relieving staff for breaks. Interview with the charge nurse for the 2:00 p.m. to 10:00 p.m. shift LVN E on 07/22/11 at 3:10 p.m. revealed she did not know anything about the altercation between Resident #2 and #3. The interview also revealed the facility had one CNA for the shifts on the G hall and another CNA floating between F and G halls. LVN E stated she started working in the facility two weeks ago. Interview with CNA F on 07/22/11 at 3:15 p.m. revealed he worked the G hall most of the time for the past nine months. CNA F stated Resident #3 goes into rooms but never gets aggressive with other residents. He also stated he did not observe any altercations between the two residents. The surveyor interviewed the ADON on 07/22/11 at 10:30 a.m. The interview revealed she had notified one of the "higher ups" after the initial tour of Resident #2's complaint of been bite and punched by Resident #3. The ADON stated she thought she told the DON about Resident #2's complaint but was not sure who exactly she reported it. The ADON came back at 11:50 a.m. stating she asked the DON and he stated she did not tell him about the complaint. Review of the form CMS-802 (Roster/Sample Matrix) provided by the facility on 07/19/11 revealed Resident #3 had Mental Illness and was cognitively impaired with behavior symptoms. 5) Review of the facility face sheet dated 01/05/11 revealed Resident #1 was a [AGE] year-old female admitted to the facility 10/05/10 and resided on the women's locked unit. Observation on 07/19/11 at 5:00 p.m. revealed Resident #1 sat in her wheelchair with a large amount of thick white sputum that extended all down her sweatshirt to the knee of her pants. There were no staff present to supervise the residents in the dining room at this time. Observation on 07/20/11 at 4:40 p.m. revealed Resident #1 ambulated with an unsteady gait from her room into the hall unassisted. CNA C ran down the hall and assisted Resident #1 to sit in her chair in her room. CNA C stated they did not let Resident #1 ambulate unassisted because of her risk for falls. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #1 scored 2 of 15 on the Brief Interview for Mental Status and had physical and verbal behavioral symptoms directed toward others. [DIAGNOSES REDACTED]. Resident #1 was totally dependent on one person for toileting and was frequently incontinent of bowel and bladder. Resident #1 required the assistance of one person for ambulation. Review of the accident/incident reports for June and July 2011 revealed Resident #1 fell on her right hip in the hallway of the women's locked unit on 07/01/11 at 10:45 a.m. and the intervention was "currently treating UTI." There were no witness statements included with the report. The DON and the ADM signed the incident report on 07/12/11. Resident #1 fell again on 07/05/11 at 4 p.m. and the written statement from the CNA on duty reflected Resident #1 was yelling so the CNA "went down there" and found Resident #1 on the floor. Another written statement from another CNA on duty reflected she heard a thud and Resident #1 crying so she went in Resident #1's room and found her on the floor. Nurse's assessment revealed Resident #1 was found lying on the floor with a hematoma on the right side of her head. Resident #1 had tried to transfer herself to the toilet, and the resident stated to the nurse that she needed to go to the bathroom. The report reflected Resident #1's condition before the incident was confused and agitated. The section on the report for Summary/Final Disposition of Report was blank except for vital signs and was signed by DON on 07/12/11. The sections on the report for Interventions and Care Plan Updates were blank. DON and ADM signed the report on 07/12/11. 6) Review of the face sheet dated 01/05/11 revealed Resident #17 was a [AGE] year-old female readmitted to the facility 05/08/09 and resided in a room that was not in a locked unit. Observation on 07/22/11 at 12:25 p.m. revealed Resident #17 was clean, dressed, and sat in the dining room. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #17 scored 2 of 15 on the Brief Interview for Mental Status, had verbal behavioral symptoms directed at others, and rejected care. Resident #17 was independent with ambulation with a steady gait and no assistive devices. [DIAGNOSES REDACTED]. Review of the Incident/Accident Report dated 07/04/11 revealed two bruises of unknown origin were found on Resident #17's left side and hip during care. One bruise was 8 cm. x 6.5 cm. and purple. The bruise on the hip was 4 cm. x 3 cm. yellow and purple. There was only one statement from the CNA who discovered the bruises. The section for the Summary/Final Disposition of Report was blank except for vital signs and signed on 07/19/11 by ADON. The section for Interventions reflected, "Bruise noted during shower unknown origin. Was observed during care. Resd. (Resident) denied any pain or discomfort." The section for the Care Plan Update was blank. The DON and the ADM signed the Incident Report on 07/19/11. 7) The surveyor observed Resident #4 during the initial rounds on 07/19/11 at 10:45 a.m. LVN G stated Resident #4 was mobile in the facility via a wheelchair assisted by staff, she was incontinent of bowel and bladder and required total assistance from staff for all her ADL needs. LVN G stated Resident #4 was alert and oriented to person and confused most times. Resident #4 had a bed and chair alarm, was on hospice care and fed via a gastrostomy tube. Resident #4 received [MEDICATION NAME] at 75 cc/hr from 7:00 p.m. to 7:00 a.m. Resident #4 also receives [MEDICATION NAME] at 10:00 a.m. and 3:00 p.m. and also pleasure feedings during meals. LVN G also stated Resident #4 was combative during activity of daily living. Review of Resident #4's clinical records, revealed on the nurse's notes dated 07/10/11 at 0200 (2:00 a.m.) that Resident #4 sustained a 5 cm x 5 cm bruise to the right upper arm and the Injury was of unknown origin. Review of the I/A for three months provided to the surveyors by the facility ADM on 07/19/11 revealed there was no I/A report, nor investigation regarding the bruise. 8) Observation on 07/19/11 from 11:45 a.m. through 12:10 p.m. revealed CNA K was the only staff member, who was assigned on the women's locked unit during this time. Interview on 07/19/11 at 11:50 a.m. with CNA K revealed the nurse had not yet arrived on the women's locked unit but usually came at lunchtime. Observation on 07/19/11 from 12:15 p.m. through 12:20 p.m. revealed residents on the women's locked unit were left unsupervised when CNA K assisted a resident in her room. Observation on 07/19/11 at 12:25 p.m. revealed Resident #18 wheeled herself in her wheelchair into the dining room on the women's locked unit and bumped into Resident #20's legs. Resident #20 said, "Ouch!" Resident #18 continued to bump into Resident #20's legs several times and said each time, "Please move your legs." CNA K and LVN N were in the dining room at that time serving trays, but they did not see the incident. HA O came into the dining room at that time, saw Resident #18 bumping into Resident #20's legs and took Resident #18 out of the locked unit. 9) The surveyors interviewed the facility's only ADON and the Administrator on 07/19/11 at 3:15 p.m. regarding the staffing pattern and the supervision of residents in the men's locked unit (hall G) and women's locked unit (hall F) to prevent accidents and altercations. The ADON stated the facility normally had one CNA on every hall and one "float" for the front halls (A-D halls) and one "float" for the back halls (F&G, the two locked units). The ADON stated unfortunately, the facility had a couple of people call in "today." The ADON further stated if the CNA needed help on her floor, she could call her for help. The ADON again stated, one CNA floated to halls A, B, C, D and one CNA floated to the F and G halls. The ADON also stated she had to pull the float from the F&G halls to work the other hall today, because of the CNAs, who called in. The ADON stated the facility used agency staff and had called them in the past, even this past weekend. When the surveyor inquired if the ADON had called the agency for additional staffing today, the ADON stated it would have to be cleared with the ADM. When the surveyor inquired if the ADON asked the ADM if she could call the agency for staffing, the ADON stated she had not. The surveyor asked what type of residents resided in the F and G halls. The ADM and ADON stated there were a lot of combative, confused residents on those units. The surveyor reported observing a CNA helping one resident go to the restroom while all the other residents were left unsupervised, and the charge nurse was off the unit. The surveyor reported another observation of a resident bumping into another resident's legs several times with her wc during lunch service and the two staff members present at that time did not see the incident. When asked if they were comfortable having one CNA on the locked units, the ADM. and ADON each stated, "No, I am not." 10) Observation on 07/19/11 during the second shift revealed there was one CNA on each locked unit with a third CNA to "float" between the units as needed. 11) Interview on 07/20/11 at 9:10 a.m. with CNA B revealed she had worked alone on the men's unit on 07/19/1. CNA B stated there were two falls within a few minutes time, and had said, "I can't do this." CNA B stated she was glad the staffing was now changed and there would be two CNAs for each locked unit on the day shift. 12) In the confidential resident group meeting held 07/20/11 at 10:30 a.m., two of the nine residents (identified by the facility as interviewable) in the meeting stated, "There were a lot of fights on the G Hall." 13) In a confidential interview, it was revealed the residents had a lot of falls on the men's and women's locked units due to no supervision and insufficient staffing. The Interviewee stated the facility only had one CNA on each of the locked units with one CNA floating or releasing another CNA for breaks. The Interviewee revealed the facility did not have sufficient staff to safely monitor the residents on the halls and to prevent them from entering each other's rooms and to prevent aggressive and agitated behaviors. The Interviewee stated residents were not safe in the two locked units due to insufficient staffing. 14) The surveyor interviewed the facility ADM on 07/20/11 at 2:30 p.m. The surveyor asked the ADM how injuries of unknown origins were

Based on observation, interview and record review, it was determined the Administrator failed to use the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psycho-social well-being of residents. 1. The Administrator failed to ensure eight (six confidential interviewees and two unidentified residents) of eight residents interviewed were included with decorating activities when the facility was decorated for the holidays. The Administrator did not allow the facility's residents to assist with decorating, telling them their decorating efforts looked "tacky." This failure left six residents with the sense of a loss of control over their home and with feelings of low self-esteem and self-worth, which could affect all 80 of the facility's residents. 2. The Administrator stopped providing the residents with milk at the lunch meals, as a means to control the budget. The facility failed to provide: Fifty-eight of 74 residents, who were served meals from the facility's only kitchen, the opportunity to make a choice in beverages for the lunch meal; Ten (Residents #3, #4, #6, #7, #8, #9, #10, #11, #13. and #14) of fourteen residents with milk at the lunch meal, as requested per their tray cards. Two (Residents #21 and #73) of four residents with milk at lunch as they preferred, even though the other residents at the same table were served milk. These failures could result in a loss of self-worth and empowerment, leading to a decreased quality of life and could affect all 74 residents served meals from the facility's kitchen. Findings included: 1. On 12/14/10 at 9:00 a.m. the Administrator revealed she had been at the facility for approximately two to three months. The Administrator was requested for staff to "schedule a Resident Group meeting with six to eight interviewable residents only." 2. During a confidential staff interview, when asked about the Christmas decorations, it was said, "Administrator decorated. The staff were not allowed. I didn't see residents participate in decorating for Christmas." On 12/14/10 at 11:30 a.m., a confidential group interview was conducted with six residents identified by the facility as interviewable, and who were brought to the meeting by the facility staff. During the confidential group interview, residents were asked about decorating the facility for the holidays. With [MEDICATION NAME] and rapid response, residents responded, "We didn't get to decorate for Christmas. The Administrator did it on her own. She said the way we did it looked tacky." When asked how they felt about not being allowed to decorate for Christmas, the residents replied, "It made me feel worthless, left out and put down, like we were nothing and had no rights. It makes me feel like I'm not part of Christmas here. We were all involved last year. It's her (Administrator's) way or the highway. She doesn't ask our opinion. It doesn't matter if we like it; we just have to live with it. It doesn't seem like our home anymore; it's her facility." At the conclusion of the interview, three residents said they were "afraid for the Administrator to find out about what was said. It will make things worse." On 12/14/10 following the group meeting, two unidentified residents in the hallway were randomly queried regarding decorating the facility for Christmas. Both residents said they would have helped if they had been given the opportunity. On 12/14/10 at 1:44 p.m. in an interview, the Social Worker was asked whether the residents had participated in decorating the facility for Christmas. The Social Worker named four residents who were in the lobby when the tree was being decorated, but stated they did not participate in the decorating. 3. During one confidential interview, it was revealed the "new" administrator "came in and made some budget cuts. She cut out milk for the residents at lunch. If they ask for it, they can have it. We were instructed to offer other beverages. Some residents were upset about it. Some don't understand and are too confused to ask for it." During a second confidential interview, it was revealed when the "new" administrator came, "There were budget cuts, and we stopped serving milk to the residents with lunch. If residents asked for it, we were told to get the Administrator. I saw the Administrator try to talk a resident out of drinking milk at lunch. Now we don't serve milk on a regular basis at lunch. It's not still happening except for those residents who don't know to ask for it (milk). We can't offer it." During a third confidential interview, it was revealed the Administrator told staff, "No more milk at lunch." The interviewee stated, "I heard her lie to a resident and tell them we didn't have milk available. We were threatened about it. We were told Texas is a right to work state, and we can be fired at any time. Residents who don't know to ask, don't get milk." On 12/14/10 at 11:30 a.m., a confidential group interview was conducted with six residents identified by the facility as interviewable, who were brought to the meeting by the facility staff. During the confidential group interview, the six residents were queried about the beverage service at lunch. Five of the six residents agreed, "We get milk only if we ask for it. We used to get it on our tray." One of the six residents said, "I don't get milk at lunch. I didn't know I had to ask for it." When asked when the milk was discontinued, the residents stated, "When the new administrator came, about two months ago. They just quit giving it to us. We were not told (prior to it being stopped)." Review of the tray cards for 14 sampled residents in the main dining room or on the six halls (A, B, C, D, F, and G) during the lunch meal revealed all 14 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) had either milk or chocolate milk identified as their beverage of choice for the lunch service on 12/14/10. During the noon meal observation on the A, B, C, and D halls and in the main dining room on 12/14/10, six residents (Residents #6, #7, #8, #9, #10, and #11) did not receive milk with their meals. Review of the dietary tray cards revealed these residents had either milk or chocolate milk identified as their beverage of choice for the lunch meal. During the noon meal observation on the secured units for the cognitively impaired residents (halls F and G), Residents #3, #4, #13, and #14 did not receive milk with their meals. Review of the dietary tray cards revealed these resident had milk identified as their beverage of choice for the meal. Observation revealed these cognitively impaired residents did not ask for milk. On 12/14/10 at 11:56 a.m., observation of the lunch cart for C and D halls revealed coffee, tea, and water were available for the residents. At that time in a confidential interview, the interviewee said, "We have a few (residents) who ask for milk. If they don't ask, they don't get it." When asked if the residents used to get milk routinely, the interviewee responded, "Yes. They used to get milk. It's been about three months since milk was stopped at lunch." When asked whether Resident #71 received Chocolate Milk, the confidential interviewee said, "She (Resident #71) asks for it." On 12/14/10 at 12:03 p.m., observation of the lunch cart for A and B halls revealed coffee, tea, and water were available for the residents with one exception, Resident #1. Resident #1 received milk. An unidentified staff member said, "____ (Resident #1) gotta have it (chocolate milk) with every meal." On 12/14/10 at 12:10 p.m., observation of the lunch cart for F (secured) hall revealed Resident #2, who was on thickened liquids, received thickened milk. No other residents on the secured hall for demented/cognitively impaired residents received milk. A confidential interviewee revealed, "Residents on F and G (secured) halls do not know to ask for milk. They don't get milk. They used to get it. It was stopped right after the administrator came." On 12/14/10 at 12:15 p.m., observation of lunch service on G (secured) hall revealed there was no milk available on the drink cart for cognitively impaired residents to be offered milk. Resident #15 received thickened milk with her tray. On 12/14/10 at 12:18 p.m., observation of the dining room lunch service revealed only Residents #5 and #12 received milk during the dining room lunch service. Review of the residents' tray cards revealed milk was the beverage of choice. On 12/14/10 at 12:42 p.m., when asked when the milk at lunch was discontinued, the Dietary Service Manager (DSM) said it had been a "couple of months. Since the new administrator came. She was trying to cut the budget. When I had to come up with an answer as to why I was over budget by $44,000, I said we were serving milk at all three meals." A confidential interviewee revealed., "Milk was discontinued at lunch about two to three weeks after the new (current) administrator came. It was to pull the budget in line. (Resident #72) likes chocolate milk but does not have the cognition to ask for it. They can't have it unless they ask." The interviewee further revealed under the administrator's instructions that if the residents ask for milk, "We are to offer other liquids, tea, coffee or water at lunch. The administrator said she had talked to the State, Ombudsman and our Medical Director about discontinuing the milk at lunch, and there was no problem and she didn't want to hear any more about it." On 12/14/10 at 1:44 p.m. in an interview, the Social Worker stated, "I don't see it being a problem for residents. At lunch, it was never part of the menu but they did get it at lunch before it was changed with the budget." When asked what she did to advocate for the residents, who could not make their needs known as to whether or not they wanted milk for lunch, the Social Worker stated, "I don't understand the question." When asked specifically about how it was determined if the cognitively impaired residents on F and G secured halls wanted milk with their meals, the Social Worker did not respond. A confidential interviewee revealed, "On F and G (secured halls), residents we knew liked milk no longer got milk anymore, because they couldn't ask for it. Dietary was told to write staff up if they asked for milk for the residents." This confidential interviewee revealed, "There were statements about dietary being over budget." When asked about the cognitively impaired residents, the confidential interviewee said, "The ones we know drink it (milk at lunch), we should give it to them, but we don't. The residents on F and G secured hall don't get milk now even though we know they drank it in the past." The confidential interviewee stated, "There was staff who bought milk for the residents out of their own pockets." On 12/14/10 at 3:15 p.m., the Administrator stated the Social Worker had interviewed all the residents in the facility before the milk was ever discontinued at lunch. The surveyor requested to see the list of residents interviewed regarding milk preference. The Administrator provided a list with 24 names. Review of the list of interviewed residents provided by the Administrator revealed names of 24 residents, 19 of whom were current residents. The list reflected ten current residents were interviewed and three (Residents #74, #75, and #77) of the interviewed current residents identified milk as the beverage of choice for the lunch meal per day. Comparison of the interview list provided with the facility's Resident Roster dated 12/14/10 revealed 58 of the 74 current residents who were served food from the facility's kitchen were not interviewed for beverage choices: Resident #1, #2, #3, #4, #5 #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #61, #62, #63, #64, #65, #66, #67, #68, and #69. Note: Although Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 were not interviewed prior to stopping the serving of milk at lunch, all still had milk identified as the beverage of choice. Review of the dietary menu matrix for 2010-11 Winter Cycle - Week One with dates including 12/14/10 and 12/16/10 revealed for lunch, "beverage of choice" was on the menus. On 12/14/10 at 4:00 p.m. the Administrator was interviewed regarding the facility not providing the residents with milk when it was their beverage of choice. The Administrator stated she had instructed the staff to conduct interviews with the residents, including the cognitively impaired resident on the secured halls (F and G). The Administrator provided a list of questions the staff was to use in the interviews. Review of the questionnaire revealed, although it did not mention milk specifically, Question #3 was, "Do you have other preferences of beverage for any of the meals other than what is currently being served at each meal? If so, what are they?" On 12/16/10 at 12:00 p.m. observation of the delivery of the lunch trays revealed Residents #4 and #14 received chocolate milk. LVN B sent another employee to the kitchen to get regular milk for Resident #18; two chocolate milks for Resident #19 and two chocolate milks for Resident #71. Review of the 12/16/10 lunch list provided by the DSM revealed Resident #14 was to receive a container of buttermilk in addition to the chocolate milk; however, Resident #14 did not receive his identified preference for buttermilk. On 12/16/10 at 12:30 p.m. the surveyor queried the DSM about how the facility had determined which cognitively impaired residents on F hall preferred milk at lunch. The DSM stated facility staff interviewed all residents on F hall and talked with family members of these residents on 12/14/10, in order to determine their beverage preference for lunch. During this interview the DSM provided a list of residents on F hall who were to be served milk at lunch. The list of residents included Resident #21, who was to receive a container of 2% milk and Resident #73 was to receive a carton of chocolate milk. The DSM further stated Resident #73 was admitted to the facility on [DATE]. On 12/16/10 at 12:35 p.m. LVN A, when asked if she participated in the survey of residents and used the questionnaire provided by the Administrator, she replied, "Yes. I asked the residents back here on F (secured unit) hall." When asked how they responded to the question (surveyor read the question #3 to LVN A), LVN A said, "Well they didn't understand. Their wants change frequently." When asked if there was milk to offer to the confused residents on the secured hall, LVN A stated, "No." On 12/16/10 at 1:00 p.m. observation of the lunch meal on F hall revealed both Residents #21 and #73 ate their meals while CNA C attended to them. Milk was not served to them. Two other residents who sat at the same table with Residents #21 and #73 did receive milk with their meals. During this observation, CNA C stated, when questioned about milk not being served to Resident #21 and #73, she did not know why these residents did not receive milk with their lunch trays. The DON overheard the surveyor's concern and ordered the Activity Director to get milk from the kitchen for the residents 3. CMS form 672 (Resident Census and Conditions of Residents) dated 12/14/10 and the CMS 802 (Roster Sample Matrix) provided by the MDS Coordinator reflected a census of 80; 70 residents with cognitive impairment, and six residents receiving tube feedings.

Based on observation, interview and record review, it was determined the facility failed to promote resident rights regarding choices in resident activities and health care consistent with his/her interests and plans of care and make choices about aspects of his/her life in the facility, which were significant to the resident. 1. Six of six residents in a confidential interview were not allowed to help with decorating the facility for the holidays and were told by the Administrator that their decorating would look "tacky." This failure left six residents with the sense of a loss of control over their home and with low self-esteem and self-worth. This failure could affect all 80 of the facility's residents. 2. The facility stopped providing residents with milk at the lunch meals, as a means to control the budget. The facility failed to provide: Fifty-eight of 74 residents, who were served meals from the facility's only kitchen, the opportunity to make a choice in beverages for the lunch meal; Ten (Residents #3, #4, #6, #7, #8, #9, #10, #11, #13. and #14) of fourteen residents with milk at the lunch meal, as requested per their tray cards. Two (Residents #21 and #73) of four residents with milk at lunch as they preferred, even though the other residents at the same table were served milk. These failures could result in a loss of self-worth and empowerment, leading to a decreased quality of life and could affected all 74 residents served meals from the facility's kitchen. Findings included: 1. On 12/14/10 at 9:00 a.m. the Administrator was requested for staff to "schedule a Resident Group meeting with six to eight interviewable residents only." On 12/14/10 at 10:53 a.m., during a confidential staff interview, when asked about the Christmas decorations, this staff member said, "Administrator decorated. The staff were not allowed. I didn't see residents participate in decorating for Christmas." On 12/14/10 at 11:30 a.m., a confidential group interview was conducted with six residents identified by the facility as interviewable and who were brought to the meeting by the facility staff. During the confidential group interview, residents were asked about decorating the facility for the holidays. With [MEDICATION NAME] and rapid response, residents responded, "We didn't get to decorate for Christmas. The Administrator did it on her own. She said the way we did it looked tacky." When asked how they felt about not being allowed to decorate for Christmas, the residents replied, "It made me feel worthless, left out and put down, like we were nothing and had no rights. It makes me feel like I'm not part of Christmas here. We were all involved last year. It's her (Administrator's) way or the highway. She doesn't ask our opinion. It doesn't matter if we like it; we just have to live with it. It doesn't seem like our home anymore; it's her facility." At the conclusion of the interview, three residents said they were "afraid for the Administrator to find out about what was said. It will make things worse." On 12/14/10 following the group meeting, two unidentified residents in the hallway were randomly queried regarding decorating the facility for Christmas. Both residents said they would have helped if they had been given the opportunity to help. On 12/14/10 at 1:44 p.m. in an interview, the Social Worker was asked whether the residents had participated in decorating the facility for Christmas. The social worker named four residents who were in the lobby when the tree was being decorated, but stated they did not participate in the decorating. 2. On 12/14/10 at 9:00 a.m. the Administrator revealed she had been at the facility for approximately two-three months. The Administrator was requested for staff to "schedule a Resident Group meeting with six to eight interviewable residents only." On 12/14/10 at 10:30 a.m., a confidential staff interview revealed the "new" administrator "came in and made some budget cuts. She cut out milk for the residents at lunch. If they ask for it, they can have it. We were instructed to offer other beverages. Some residents were upset about it. Some don't understand and are too confused to ask for it." On 12/14/10 at 10:53 a.m., a confidential staff interview revealed when the "new" administrator came, "There were budget cuts and we stopped serving milk to the residents with lunch. If residents asked for it, we were told to get the Administrator. I saw the Administrator try to talk a resident out of drinking milk at lunch. Now we don't serve milk on a regular basis at lunch. It's not still happening except for those residents who don't know to ask for it (milk). We can't offer it." On 12/14/10 at 11:11 a.m., a confidential staff interview revealed the Administrator told staff, "No more milk at lunch." The interviewee stated, "I heard her lie to a resident and tell them we didn't have milk available. We (staff) were threatened about it. We were told Texas is a right to work state and we can be fired at any time. Residents who don't know to ask don't get milk." On 12/14/10 at 11:30 a.m., a confidential group interview was conducted with six residents identified by the facility as interviewable and who were brought to the meeting by the facility staff. During the confidential group interview, the six residents were queried about the beverage service at lunch. Five of the six residents agreed, "We get milk only if we ask for it. We used to get it on our tray." One of the six residents said, "I don't get milk at lunch. I didn't know I had to ask for it." When asked when the milk was discontinued, the residents stated, "When the new administrator came, about two months ago. They just quit giving it to us. We were not told (prior to it being stopped)." Review of the tray cards for 14 sampled residents in the main dining room or on the six halls (A, B, C, D, F, and G) during the lunch meal revealed all 14 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) had either milk or chocolate milk identified as their beverage of choice for the lunch service on 12/14/10. During the noon meal observation on the A, B, C, and D halls and in the main dining room on 12/14/10, six residents (Residents #6, #7, #8, #9, #10, and #11) did not received milk with their meals. Review of the dietary tray cards revealed these residents had either milk or chocolate milk identified as their beverage of choice for the lunch meal. During the noon meal observation on the secured units for the cognitively impaired residents (halls F and G), Residents #3, #4, #13, and #14 did not received milk with their meals. Review of the dietary tray cards revealed these resident had milk identified as their beverage of choice for the meal. Observation revealed these cognitively impair residents did not ask for milk. On 12/14/10 at 11:56 a.m., observation of the lunch cart for C and D halls revealed coffee, tea, and water were available for the residents. At that time in a confidential interview, a staff member said, "We have a few who ask for milk. If they don't ask, they don't get it." When asked if the residents used to get milk routinely, the staff member responded, "Yes, they used to get milk. It's been about 3 months since milk was stopped at lunch." When asked whether Resident #71 received Chocolate Milk, the confidential interviewee said, "She (Resident #71) asks for it." On 12/14/10 at 12:03 p.m., observation of the lunch cart for A and B halls revealed coffee, tea, and water were available for the residents with one exception, Resident #1. Resident #1 received milk. An unidentified staff member said, "(Resident #1) gotta have it (chocolate milk) with every meal." On 12/14/10 at 12:10 p.m., observation of the lunch cart for F (secured) hall revealed Resident #2, who was on thickened liquids, received thickened milk. No other residents on this secured hall for demented/cognitively impaired residents received milk. On 12/14/10 at 12:10 p.m., a confidential staff interview revealed, "Residents on F and G (secured) halls do not know to ask for milk. They don't get milk. They used to get it. It was stopped right after the administrator came." On 12/14/10 at 12:15 p.m., observation of lunch service on G (secured) hall revealed there was no milk available on the drink cart for cognitively impaired residents to be offered milk. Resident #15 received thickened milk with her tray. On 12/14/10 at 12:18 p.m., observation of the dining room lunch service revealed only Residents #5 and #12 received milk during the dining room lunch service. Review of the residents tray cards revealed milk was the beverage of choice. On 12/14/10 at 12:42 p.m., when asked when the milk at lunch was discontinued, the Dietary Service Manager (DSM) said it had been a "couple of months. Since the new administrator came. She was trying to cut the budget. When I had to come up with an answer as to why I was over budget by $44,000. I said we were serving milk at all three meals." A confidential staff interview revealed on 12/14/10 at 1:19 p.m., "Milk was discontinued at lunch about two to three weeks after the new (current) administrator came. It was to pull the budget in line. (Resident #72) likes chocolate milk but does not have the cognition to ask for it. They can't have it unless they ask." The interviewee further revealed under the administrator's instructions that if the residents ask for milk, "We are to offer other liquids, tea, coffee or water at lunch. The administrator said she had talked to the State, Ombudsman and our Medical Director about discontinuing the milk at lunch and there was no problem and she didn't want to hear any more about it." On 12/14/10 at 1:44 p.m. in an interview, the Social Worker stated, "I don't see it being a problem for residents. At lunch, it was never part of the menu but they did get it at lunch before it was changed with the budget." When asked what she did to advocate for the residents who could not make their needs known as to whether or not they wanted milk for lunch, the social worker stated, "I don't understand the question." When asked specifically about how it was determined if the cognitively impaired residents on F and G secured halls wanted milk with their meals, the social worker did not respond. On 12/14/10 at 2:00 p.m., a confidential staff interview revealed, "On F and G (secured halls), residents we knew liked milk no longer got milk anymore because they couldn't ask for it. Dietary was told to write staff up if they asked for milk for the residents." This confidential staff interview revealed, "There were statements about dietary being over budget." When asked about the cognitively impaired residents, the confidential staff interview said, "The ones we know drink it (milk at lunch), we should give it to them, but we don't. The residents on F and G secured hall don't get milk now even though we know they drank it in the past." The confidential staff interviewee stated, "There was staff who bought milk for the residents out of their own pockets." On 12/14/10 at 3:15 p.m., the Administrator stated the Social Worker had interviewed all the residents in the facility before the milk was ever discontinued at lunch. The surveyor requested to see the list of residents interviewed regarding milk preference. The Administrator provided a list with 24 names. Review of the list of interviewed residents provided by the Administrator revealed names of 24 residents, 19 of which were current residents. The list reflected ten current residents were interviewed and three (#74, #75, and #77) of the interviewed current residents identified milk as the beverage of choice for the lunch meal per day. Comparison of the interview list provided with the facility's Resident Roster dated 12/14/10 revealed 58 of the 74 current residents who were served food from the facility's kitchen were not interviewed for beverage choices (Resident #1, #2, #3, #4, #5 #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #61, #62, #63, #64, #65, #66, #67, #68, and #69). Note: Although Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 were not interviewed prior to stopping the serving of milk at lunch, all still had milk identified as the beverage of choice. Review of the dietary menu matrix for 2010-11 Winter Cycle - Week One with dates including 12/14/10 and 12/16/10 revealed for lunch, "beverage of choice" was on the menus. On 12/14/10 at 4:00 p.m. the Administrator was interviewed regarding the facility not providing the residents with milk when it was their beverage of choice. The Administrator stated she had instructed the staff to conduct interviews with the residents, including the cognitively impaired resident on the secured halls (F and G). The Administrator provided a list of questions the staff was to use in the interviews. Review of the questionnaire revealed, although it did not mention milk specifically, Question #3 was, "Do you have other preferences of beverage for any of the meals other than what is currently being served at each meal? If so, what are they?" On 12/16/10 at 12:00 p.m. observation of the delivery of the lunch trays revealed Resident #4 and #14 received chocolate milk. LVN B sent another employee to the kitchen to get regular milk for Resident #18; two chocolate milks for Resident #19 and two Chocolate milks for Resident #71. Review of the 12/16/10 lunch list provided by the DSM revealed Resident #14 was to receive a container of buttermilk in addition to the chocolate milk; however, Resident #14 did not receive his identified preference for buttermilk. On 12/16/10 at 12:30 p.m. the surveyor queried the DSM about how the facility had determined which cognitively impaired residents on F hall preferred milk at lunch. The DSM stated facility staff interviewed all residents on F hall and talked with family members of these residents on 12/14/10, in order to determine their beverage preference for lunch. During this interview the DSM provided a list of residents on F hall who were to be served milk at lunch. The list of residents included Resident #21, who was to receive a container of 2% milk and Resident #73 was to receive a carton of chocolate milk. The DSM further stated Resident #73 was admitted to the facility on [DATE]. On 12/16/10 at 12:35 p.m. LVN A, when asked if she participated in the survey of residents and used the questionnaire provided by the Administrator, she replied, "Yes. I asked the residents back here on F (secured unit) hall." When asked how they responded to the question (surveyor read the question #3 to LVN A), LVN A said, "Well they didn't understand. Their wants change frequently." When asked if there was milk to offer to the confused residents on the secured hall, LVN A stated, "No." On 12/16/10 at 1:00 p.m. observation of the lunch meal on F hall revealed both Residents #21 and #73 ate their meals while CNA C attended to them. Milk was not served to them. Two other residents who sat at the same table with Residents #21 and #73 did receive milk with their meals. During this observation, CNA C stated, when questioned about milk not being served to Resident #21 and #73, that she did not know why these residents did not receive milk with their lunch trays. The DON overheard the surveyor's concern and ordered the Activity Director to get milk from the kitchen for the residents 3. CMS form 672 (Resident Census and Conditions of Residents) dated 12/14/10 and the CMS 802 (Roster Sample Matrix) provided by the MDS Coordinator reflected a census of 80; 70 residents with cognitive impairment, and six residents receiving tube feedings.

Based on observation, interview and record review, it was determined the facility failed to promote care in a manner that maintained and enhanced dignity and respect in full recognition of residents' individuality. 1. Six of six residents in a confidential interview were not allowed to help with decorating the facility for the holidays and were told by the Administrator that their decorating would look "tacky." This failure left six residents feeling they had no control over their home's environment and with low self-esteem and self-worth. This failure could affect all 80 of the facility's residents. 2. The facility stopped providing the residents with milk at the lunch meals, as a means to control the budget. The facility failed to provide: Fifty-eight of 74 residents, who were served meals from the facility's only kitchen, the opportunity to make a choice in beverages for the lunch meal; Ten (Residents #3, #4, #6, #7, #8, #9, #10, #11, #13. and #14) of fourteen residents with milk at the lunch meal, as requested per their tray cards. Two (Residents #21 and #73) of four residents with milk at lunch as they preferred, even though the other residents at the same table were served milk. These failures could result in a loss of self-worth and empowerment, leading to a decreased quality of life and could affect all 74 residents served meals from the facility's kitchen. Findings included: 1. On 12/14/10 at 9:00 a.m. the Administrator was requested for staff to "schedule a Resident Group meeting with six to eight interviewable residents only." On 12/14/10 at 10:53 a.m., during a confidential staff interview, when asked about the Christmas decorations, this staff member said, "Administrator decorated. The staff were not allowed. I didn't see residents participate in decorating for Christmas." On 12/14/10 at 11:30 a.m., a confidential group interview was conducted with six residents identified by the facility as interviewable and who were brought to the meeting by the facility staff. During the confidential group interview, residents were asked about decorating the facility for the holidays. With [MEDICATION NAME] and rapid response, residents responded, "We didn't get to decorate for Christmas. The Administrator did it on her own. She said the way we did it looked tacky." When asked how they felt about not being allowed to decorate for Christmas, the residents replied, "It made me feel worthless, left out and put down, like we were nothing and had no rights. It makes me feel like I'm not part of Christmas here. We were all involved last year. It's her (Administrator's) way or the highway. She doesn't ask our opinion. It doesn't matter if we like it; we just have to live with it. It doesn't seem like our home anymore; it's her facility." At the conclusion of the interview, three residents said they were "afraid for the Administrator to find out about what was said. It will make things worse." On 12/14/10 following the group meeting, two unidentified residents in the hallway were randomly queried regarding decorating the facility for Christmas. Both residents said they would have helped if they had been given the opportunity to help. On 12/14/10 at 1:44 p.m. in an interview, the Social Worker was asked whether the residents had participated in decorating the facility for Christmas. The social worker named four residents who were in the lobby when the tree was being decorated, but stated they did not participate in the decorating. 2. On 12/14/10 at 9:00 a.m. the Administrator revealed she had been at the facility for approximately two-three months. The Administrator was requested for staff to "schedule a Resident Group meeting with six to eight interviewable residents only." On 12/14/10 at 10:30 a.m., a confidential staff interview revealed the "new" administrator "came in and made some budget cuts. She cut out milk for the residents at lunch. If they ask for it, they can have it. We were instructed to offer other beverages. Some residents were upset about it. Some don't understand and are too confused to ask for it." On 12/14/10 at 10:53 a.m., a confidential staff interview revealed when the "new" administrator came, "There were budget cuts and we stopped serving milk to the residents with lunch. If residents asked for it, we were told to get the Administrator. I saw the Administrator try to talk a resident out of drinking milk at lunch. Now we don't serve milk on a regular basis at lunch. It's not still happening except for those residents who don't know to ask for it (milk). We can't offer it." On 12/14/10 at 11:11 a.m., a confidential staff interview revealed the Administrator told staff, "No more milk at lunch." The interviewee stated, "I heard her lie to a resident and tell them we didn't have milk available. We (staff) were threatened about it. We were told Texas is a right to work state and we can be fired at any time. Residents who don't know to ask don't get milk." On 12/14/10 at 11:30 a.m., a confidential group interview was conducted with six residents identified by the facility as interviewable and who were brought to the meeting by the facility staff. During the confidential group interview, the six residents were queried about the beverage service at lunch. Five of the six residents agreed, "We get milk only if we ask for it. We used to get it on our tray." One of the six residents said, "I don't get milk at lunch. I didn't know I had to ask for it." When asked when the milk was discontinued, the residents stated, "When the new administrator came, about two months ago. They just quit giving it to us. We were not told (prior to it being stopped)." Review of the tray cards for 14 sampled residents in the main dining room or on the six halls (A, B, C, D, F, and G) during the lunch meal revealed all 14 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) had either milk or chocolate milk identified as their beverage of choice for the lunch service on 12/14/10. During the noon meal observation on the A, B, C, and D halls and in the main dining room on 12/14/10, six residents (Residents #6, #7, #8, #9, #10, and #11) did not received milk with their meals. Review of the dietary tray cards revealed these residents had either milk or chocolate milk identified as their beverage of choice for the lunch meal. During the noon meal observation on the secured units for the cognitively impaired residents (halls F and G), Residents #3, #4, #13, and #14 did not received milk with their meals. Review of the dietary tray cards revealed these resident had milk identified as their beverage of choice for the meal. Observation revealed these cognitively impair residents did not ask for milk. On 12/14/10 at 11:56 a.m., observation of the lunch cart for C and D halls revealed coffee, tea, and water were available for the residents. At that time in a confidential interview, a staff member said, "We have a few who ask for milk. If they don't ask, they don't get it." When asked if the residents used to get milk routinely, the staff member responded, "Yes, they used to get milk. It's been about 3 months since milk was stopped at lunch." When asked whether Resident #71 received Chocolate Milk, the confidential interviewee said, "She (Resident #71) asks for it." On 12/14/10 at 12:03 p.m., observation of the lunch cart for A and B halls revealed coffee, tea, and water were available for the residents with one exception, Resident #1. Resident #1 received milk. An unidentified staff member said, "(Resident #1) gotta have it (chocolate milk) with every meal." On 12/14/10 at 12:10 p.m., observation of the lunch cart for F (secured) hall revealed Resident #2, who was on thickened liquids, received thickened milk. No other residents on this secured hall for demented/cognitively impaired residents received milk. On 12/14/10 at 12:10 p.m., a confidential staff interview revealed, "Residents on F and G (secured) halls do not know to ask for milk. They don't get milk. They used to get it. It was stopped right after the administrator came." On 12/14/10 at 12:15 p.m., observation of lunch service on G (secured) hall revealed there was no milk available on the drink cart for cognitively impaired residents to be offered milk. Resident #15 received thickened milk with her tray. On 12/14/10 at 12:18 p.m., observation of the dining room lunch service revealed only Residents #5 and #12 received milk during the dining room lunch service. Review of the residents tray cards revealed milk was the beverage of choice. On 12/14/10 at 12:42 p.m., when asked when the milk at lunch was discontinued, the Dietary Service Manager (DSM) said it had been a "couple of months. Since the new administrator came. She was trying to cut the budget. When I had to come up with an answer as to why I was over budget by $44,000. I said we were serving milk at all three meals." A confidential staff interview revealed on 12/14/10 at 1:19 p.m., "Milk was discontinued at lunch about two to three weeks after the new (current) administrator came. It was to pull the budget in line. (Resident #72) likes chocolate milk but does not have the cognition to ask for it. They can't have it unless they ask." The interviewee further revealed under the administrator's instructions that if the residents ask for milk, "We are to offer other liquids, tea, coffee or water at lunch. The administrator said she had talked to the State, Ombudsman and our Medical Director about discontinuing the milk at lunch and there was no problem and she didn't want to hear any more about it." On 12/14/10 at 1:44 p.m. in an interview, the Social Worker stated, "I don't see it being a problem for residents. At lunch, it was never part of the menu but they did get it at lunch before it was changed with the budget." When asked what she did to advocate for the residents who could not make their needs known as to whether or not they wanted milk for lunch, the social worker stated, "I don't understand the question." When asked specifically about how it was determined if the cognitively impaired residents on F and G secured halls wanted milk with their meals, the social worker did not respond. On 12/14/10 at 2:00 p.m., a confidential staff interview revealed, "On F and G (secured halls), residents we knew liked milk no longer got milk anymore because they couldn't ask for it. Dietary was told to write staff up if they asked for milk for the residents." This confidential staff interview revealed, "There were statements about dietary being over budget." When asked about the cognitively impaired residents, the confidential staff interview said, "The ones we know drink it (milk at lunch), we should give it to them, but we don't. The residents on F and G secured hall don't get milk now even though we know they drank it in the past." The confidential staff interviewee stated, "There was staff who bought milk for the residents out of their own pockets." On 12/14/10 at 3:15 p.m., the Administrator stated the Social Worker had interviewed all the residents in the facility before the milk was ever discontinued at lunch. The surveyor requested to see the list of residents interviewed regarding milk preference. The Administrator provided a list with 24 names. Review of the list of interviewed residents provided by the Administrator revealed names of 24 residents, 19 of which were current residents. The list reflected ten current residents were interviewed and three (#74, #75, and #77) of the interviewed current residents identified milk as the beverage of choice for the lunch meal per day. Comparison of the interview list provided with the facility's Resident Roster dated 12/14/10 revealed 58 of the 74 current residents who were served food from the facility's kitchen were not interviewed for beverage choices (Resident #1, #2, #3, #4, #5 #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #61, #62, #63, #64, #65, #66, #67, #68, and #69). Note: Although Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 were not interviewed prior to stopping the serving of milk at lunch, all still had milk identified as the beverage of choice. Review of the dietary menu matrix for 2010-11 Winter Cycle - Week One with dates including 12/14/10 and 12/16/10 revealed for lunch, "beverage of choice" was on the menus. On 12/14/10 at 4:00 p.m. the Administrator was interviewed regarding the facility not providing the residents with milk when it was their beverage of choice. The Administrator stated she had instructed the staff to conduct interviews with the residents, including the cognitively impaired resident on the secured halls (F and G). The Administrator provided a list of questions the staff was to use in the interviews. Review of the questionnaire revealed, although it did not mention milk specifically, Question #3 was, "Do you have other preferences of beverage for any of the meals other than what is currently being served at each meal? If so, what are they?" On 12/16/10 at 12:00 p.m. observation of the delivery of the lunch trays revealed Resident #4 and #14 received chocolate milk. LVN B sent another employee to the kitchen to get regular milk for Resident #18; two chocolate milks for Resident #19 and two Chocolate milks for Resident #71. Review of the 12/16/10 lunch list provided by the DSM revealed Resident #14 was to receive a container of buttermilk in addition to the chocolate milk; however, Resident #14 did not receive his identified preference for buttermilk. On 12/16/10 at 12:30 p.m. the surveyor queried the DSM about how the facility had determined which cognitively impaired residents on F hall preferred milk at lunch. The DSM stated facility staff interviewed all residents on F hall and talked with family members of these residents on 12/14/10, in order to determine their beverage preference for lunch. During this interview the DSM provided a list of residents on F hall who were to be served milk at lunch. The list of residents included Resident #21, who was to receive a container of 2% milk and Resident #73 was to receive a carton of chocolate milk. The DSM further stated Resident #73 was admitted to the facility on [DATE]. On 12/16/10 at 12:35 p.m. LVN A, when asked if she participated in the survey of residents and used the questionnaire provided by the Administrator, she replied, "Yes. I asked the residents back here on F (secured unit) hall." When asked how they responded to the question (surveyor read the question #3 to LVN A), LVN A said, "Well they didn't understand. Their wants change frequently." When asked if there was milk to offer to the confused residents on the secured hall, LVN A stated, "No." On 12/16/10 at 1:00 p.m. observation of the lunch meal on F hall revealed both Residents #21 and #73 ate their meals while CNA C attended to them. Milk was not served to them. Two other residents who sat at the same table with Residents #21 and #73 did receive milk with their meals. During this observation, CNA C stated, when questioned about milk not being served to Resident #21 and #73, that she did not know why these residents did not receive milk with their lunch trays. The DON overheard the surveyor's concern and ordered the Activity Director to get milk from the kitchen for the residents 3. CMS form 672 (Resident Census and Conditions of Residents) dated 12/14/10 and the CMS 802 (Roster Sample Matrix) provided by the MDS Coordinator reflected a census of 80; 70 residents with cognitive impairment, and six residents receiving tube feedings.