Every finding on record at Aneta Parkview Health CTR

Based on observation, review of professional reference, review of facility policy, and staff interview, the facility failed to store food and maintain kitchen equipment in a sanitary manner for 1 of 1 kitchen. Failure to properly store food, clean the ice machine, and maintain good repair of kitchen equipment may result in contamination of food and foodborne illness.Findings Include: The 2022 Food and Drug Administration (FDA) Food Code, reviewed 01/28/26, Chapter 3 Food, page 16 , Section 3-305 Preventing Contamination From the Premises, Section 3-305.11 stated, A. Food shall be protected from contamination by storing the food: . 2) Where it is not exposed to . dust, or other contamination.Review of the facility policy Sanitation and Safety Perishable Food Storage occurred on 01/28/26. This policy, revised in 1994, stated, 4. Refrigerator shelving will not be covered with . foil or other material because it interferes with air circulation.Observations on 01/25/26 and 01/27/26 showed the following in the main kitchen:* The ice machine chute covered in calcium build up.* The upright refrigeration unit had rusted and corroded shelving racks and the two lower racks were covered with tin foil.* The walk-in cooler unit had rusted and corroded free standing shelving units. * The upright freezer contained one unlabeled, undated, and open to air package of chicken patties. During an interview on 01/28/26 at 10:43 a.m., an administrative staff member (#1) confirmed shelving should be free of rust and corrosion and food should be stored properly.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents received adequate supervision and/or monitoring for 1 of 1 sampled resident (Resident #1) with an elopement. Failure to adequately monitor and supervise a resident with a known elopement risk placed the resident's health and safety at risk. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 10/22/24. The facility implemented corrective action and completed staff education on 10/22/24. Review of the facility policy titled Standards of Care and Practice occurred on 10/23/24. This policy, dated April 2018, stated, . Each of the following is part of the routine care provided by caregivers, unless otherwise directed. Complete rounds every 2-3 hours during the day and night. Review of Resident #1's medical record occurred on 10/23/24 and included the diagnoses of generalized anxiety disorder, unspecified dementia, and schizoaffective disorder. The care plan, edited 10/22/24, stated, . I may try [sic] elope and have a history of sleep walking. Wanderguard: Due to being disorientation [sic], there are concerns I may try to elope or even sleep walk. Please help redirect me and ensure my safety. A physician's order, dated 09/30/24, stated, Check wanderguard placement each shift . Resident #1's progress notes included the following: * 09/30/24 at 4:05 p.m. Resident noted to be anxious, confused, and wandering in common area. Resident stated she is looking for her brother. Resident's brother told SS [social services] that resident is risk for elopement and has hx [history] of UTI [urinary tract infection] with confusion and anxiety. Wanderguard brace applied on R) [right] wrist. * 10/22/24 at 1:00 a.m. Resident was anxious and confused this evening . sat one on one with resident in common area for awhile and resident calmed down, warm blanket given and walked resident back to her room and she laid down to go to sleep. * 10/22/24 at 5:50 a.m. Resident set off the door alarm this evening. Resident also then this morning followed the exit signs to the employee exit and got out without sounding the alarm. Writer found resident when writer was coming in from grabbing something from writer's car. Resident confused and was looking for a way home. During interviews on 10/23/24 an administrative nurse (#1) stated the facility investigation determined Resident #1 exited the building at 3:22 a.m. on 10/22/24 and staff returned the resident to the building at approximately 5:40 a.m. The staff member (#1) reported she expected night shift staff to complete rounds on residents every two hours at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m. She confirmed staff failed to complete rounds as expected, and failed to discover the resident's elopement in a timely manner. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions to ensure the deficient practice does not recur by: * All staff were educated on 10/22/24 as to the importance of monitoring residents at risk of elopement and those who currently utilize wanderguards. * The facility determined the wanderguard alarm system malfunctioned, and no alert sounded when Resident #1 exited the building. The facility contacted the alarm company immediately and reset the system to ensure proper functioning on 10/22/24. * Audits of the wanderguard system and staff rounding began 10/22/24.

Based on observation and record review, the facility failed to provide care and services to aid the healing or prevent the development of pressure ulcers for 1 of 2 sampled residents (Resident #32) with a history of pressure ulcers. Failure to apply barrier cream after toileting may result in the development of new pressure ulcers. Findings include: Review of Resident #32's medical record occurred on all days of survey. Diagnoses included a history of a pressure ulcer to the right buttocks. A nurse's note identified, . 10/10/23 Care conference note: No skin concerns. Pressure ulcer to his bottom is a scab, healing nicely. Skin protectant applied to buttocks after toileting. Current physician's orders included, Skin protectant to be applied after toileting Every Shift Day, Evening, Night. The resident's current care plan stated, . Problem Start Date: 10/12/2023 I have the potential of skin breakdown because I am incontinent and I have a diagnosis of Dementia. Approach Start Date: 10/12/2023 Protective ointment to my buttocks after toileting. Observation on 10/24/23 at 11:07 a.m. showed a certified nurse aide (CNA) (#1) assisted Resident #32 to the bathroom. Upon completion of toileting, the CNA failed to apply barrier cream to Resident #32's buttocks. Observation on 10/24/23 at 4:34 p.m. showed a CNA (#2) assisted Resident #32 to the bathroom. Upon completion of toileting, the CNA failed to apply barrier cream to Resident #32's buttocks.

Based on record review, the facility failed to ensure a rationale and duration for the use of an as needed (PRN) psychotropic medication for 1 of 3 sampled residents (Resident #31) with a prn psychotropic. Failure to ensure a rationale and duration of prn medications places residents at risk for receiving unnecessary medications and experiencing adverse consequences related to their use. Findings include:Review of Resident #31's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, insomnia, and unspecified psychosis. Physician's orders included trazodone (an antidepressant) PRN at bedtime, initiated 09/16/22. Communication with the physician regarding renewals of the trazodone failed to identify a rationale for its continued use or indicate a duration (i.e., end date) for the PRN order.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the resident's status for 1 of 2 sampled residents (Resident #27) with a change in mobility. Failure to revise the care plan may limit staff's ability to communicate care needs and ensure continuity of care for each resident. Findings include: Review of the facility's undated policy titled Care Plans/Care Conferences Procedure stated, . Care plans are to be reviewed at least quarterly and whenever there is any significant change in the resident's condition . Review of Resident #27's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS), dated [DATE], identified limited assistance with transfers and a significant change MDS, dated [DATE], identified extensive assistance for transfers. The current care plan showed the following: * 05/10/21 Assist of 1 for transfers with FWW [front wheeled walker]. Use stand lift PRN [as needed] if lethargic. * 05/10/21 Can stand pivot transfer independent in room form [sic] bed, chair, and toilet from w/c [wheelchair]. Assist with transfer and use stand lift PRN, if lethargic or weak. An Interdisciplinary Care Conference Form, dated 6/1/22, stated, . Care Conference 5/31/2022 . ADL [activities of daily living] functioning: Assist of one for bed mobility, transfers, . Currently not walking at all. Nursing staff failed to revise Resident #27's care plan to reflect her need for increased assistance with transfers. During an interview on 07/07/22 at 1:48 p.m., an administrative staff member (#2) agreed the facility failed to update Resident #27's care plan to reflect current mobility issues.

Based on observation, record review, policy review and staff interview, the facility failed to provide adequate assistance for 1 of 5 sampled residents (Resident #27) observed during pivot transfers. Failure to lock wheelchair brakes and utilize a gait belt and front wheeled walker during transfer placed the resident at risk for falls, pain, and/or injury. Findings include: Review of the facility policy titled Transferring and Positioning Residents - Moving and Transferring occurred on 07/07/22. This policy, dated March 2011, stated, . Procedure: Assisting resident from bed to chair/wheelchair. 1. Place chair or wheelchair so it touches bed and faces foot of bed at a 45 degree angle. 2. Lock brakes on wheelchair and fold or lift up footrests. 3. Explain procedure to resident. 4. Assist resident to sit up and swing legs over side of bed. 5. Assist resident to step to floor, place legs close to chair, place hands on arms of chair, and sit in chair. A gait belt should be used to help support resident. Review of Resident #27's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, right femur fracture, and right artificial hip joint. A significant change Minimum Data Set (MDS), date 05/25/22, identified extensive assistance for transfers. The current care plan showed the following: * 05/10/21 Assist of 1 for transfers with FWW [front wheeled walker]. Use stand lift PRN [as needed] if lethargic. * 05/10/21 Can stand pivot transfer independent in room form [sic] bed, chair, and toilet from w/c [wheelchair]. Assist with transfer and use stand lift PRN, if lethargic or weak. * 03/02/22 I'm at risk for falling because I receive a daily scheduled antidepressant med. I have slipped and fallen in my bathroom and fractured my R) [right] hip. The facility's interventions of assist of 1 for transfers with FWW and can stand pivot transfer independent in room contradicted each other. See F657. A fall risk assessment completed 5/25/22 stated, . Gait/Balance . N/A-not able to perform function . Decreased muscular coordination . Balance Problem when walking . Requires use of assuasive devices (cane, w/c, walker, furniture) . Score=10 or more high risk for falls. Observation on 07/05/22 at 4:13 p.m. showed a certified nursing assistant (CNA) (#1) entered Resident #27's room to transfer the resident from the bed to a wheelchair. The CNA (#1) positioned the wheelchair near the foot of the bed at an angle and locked the left brake. The CNA stated she did not have a large enough gait belt and asked the resident if she needed assistance or if she could transfer on her own. The resident stated she would transfer by herself. The CNA assisted the resident to sit at the edge of the bed by holding onto the CNA's hands. The resident stood unsteadily and with much exertion, by holding onto the bed rail behind her on her right-hand side. The CNA (#1) provided no support on the resident's left-hand side until the resident was able to take three shuffling steps toward the wheelchair and grab the left arm rest. The resident then started to sit in the wheelchair as the right wheel started to swing backward. The CNA (#1) quickly stopped the resident, locked the right brake, and allowed the resident to sit down. The CNA (#1) failed to lock both wheelchair brakes, use a gait belt, or offer the front wheeled walker for support during the transfer. During an interview on 07/07/22 at 1:48 p.m., an administrative staff member (#2) stated she expected staff to lock the wheelchair brakes and provide transfer assistance as care planned.

Based on observation, review of facility policy, review of the Food and Drug Administration (FDA) Food Code 2013, and staff interview, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen (Main kitchen). Failure to ensure proper temperatures/procedures for food storage and cooling has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: Review of the facility policy titled USE OF LEFTOVERS occurred on 04/11/21. This policy, revised 06/20/19, stated, . Excess leftovers should be avoided. Leftovers will be properly handled and used . Fill containers only 4 inches deep for quicker cooling . Leftovers must be cooled to <41 degrees F [Fahrenheit] within 4 hours (or cooled to 70 degrees within 2 hours and then down to 41 degrees within 4 hours . The FDA Food Code 2013, page 90-91, stated, . Cooling . Cooked Time/Temperature Control for Safety Food shall be cooled . Within 2 hours from 57 degrees C [Celsius] (135 degrees F) to 21 degrees C (70 degrees F) and . Shall be cooled within 4 hours to 5 degrees C (41 degrees F) or less . The initial tour of the kitchen occurred on 05/10/21 at 12:15 p.m. Observation showed an unidentified dietary staff member placing leftover turkey with cranberry glaze and broccoli in three separate containers with lids. This surveyor measured the temperature of the food items, with a reading of 111.5 F for the turkey container #1, 115.2 F for the turkey container #2, and 111.5 F for the broccoli. On 05/10/21 at 2:15 p.m., this surveyor measured the temperature of the turkey with cranberry glaze and broccoli, which were tightly covered with a lid and showed large amounts of condensation. The temperature measured 74.2 F for the turkey container #1, 72.6 F for the turkey container #2, and 84.8 F for the broccoli. When asked, the administrative dietary staff member (#1) stated staff does not check the temperature of foods that are cooling and confirmed the food had not been cooled within the required time frame and discarded the items.

Based on observation, record review, review of the facility policy, and staff interview, the facility failed to follow infection control practices for 1 of 1 resident (Resident # 230) on transmission-based precautions. Failure to follow appropriate infection control practices has the potential for infections to be transmitted to other residents, staff, and visitors. Findings include: Review of the facility policy titled . Isolation - Initiating Transmission-Based Precautions occurred on 05/12/21. This policy, dated January 2012, stated, Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing Supervisor shall notify the Infection Preventionist and the resident's Attending Physician for appropriate Transmission-Based Precautions. Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Preventionist discontinues them, which should occur after pertinent criteria for discontinuation are met. Explain to the resident (or representative) the reason(s) for the precautions. Review of Resident #230's medical record occurred on all days of survey. The current care plan stated, . I am on quarantine [room isolation] until May 14th 2021 . I often wander, please redirect me as needed. Observations on 05/10/21 showed Resident #230 performed the following while unmasked: * At 12:17 p.m., ambulated into the dining room, sat down at a table with four other residents, and ate her noon meal. * At 1:58 p.m., participated in a group activity in the dining room. * At 3:34 p.m., conversed with staff member (#2) by the special care unit nurses' station before walking down the hall with staff (#2) to the dining room for a snack. During an interview on 05/11/21 at 8:45 a.m., an administrative staff member (#3) confirmed Resident #230 is on isolation for new admission until 05/14/21 and stated she would expect staff to encourage/redirect the resident to remain in her room. The administrative staff (#3) also stated staff are to provide/encourage surgical mask use when isolation residents are outside their room. Facility staff failed to encourage/redirect Resident #230 to remain in her room while on transmission-based precautions and also failed to provide/encourage her to wear a surgical mask when outside her room.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to review/revise the care plan for 2 of 12 sampled residents (Resident #13 and #20). Failure to revise the care plan limited the ability of staff to communicate care needs and ensure continuity of care for each resident. Findings Include: - Review of Resident #13's medical record occurred on all days of survey. A physician's orders [REDACTED]. Observation on 08/26/19 at 1:43 p.m. showed three certified nursing assistants (CNAs) (#1, #2, and #3) transferred Resident #13 from her wheelchair to the bed and removed her heel boots. After providing personal cares, the CNAs failed to reapply the heel boots. One CNA (#3) stated, She (Resident #13) doesn't need the boots when in bed, only when in the wheelchair. Observation on 08/26/19 at 5:29 p.m. showed Resident #13 in bed. Two CNAs (#4 and #5) entered her room and removed her blanket. One CNA (#4) stated, Where'd your boots go? The CNA (#4) found the boots on the wheelchair and placed them on Resident #13's feet. Resident #13's current care plan stated, . Heel protectors while in w/c (wheelchair) . The care plan failed to include the new order to wear heel boots at all times. During an interview on 08/29/19 at 10:49 a.m., an administrative nurse (#6) confirmed facility staff failed to revise Resident #13's care plan. Nursing (YEAR) Drug Handbook, 37th edition, Wolters and Kluwer, Pennsylvania, pg 148-149, stated for the anticoagulant Eliquis, INDICATIONS & DOSAGES: Reduction of risk of stroke and systemic embolism (blockage of an artery by material such as a blood clot) in patients with nonvalvular [MEDICAL CONDITION] (abnormal heart rhythm). ADVERSE REACTIONS: . [MEDICAL CONDITION] . nausea . major bleeding, [MEDICAL CONDITION], bruising . INTERACTIONS: Drug-drug. Aspirin and other antiplatelet (decreases ability of platelets to form blood clots) agents . (MONTH) increase bleeding risk . Drug-food. Grapefruit juice: (MONTH) increase drug level and risk of bleeding. NURSING CONSIDERATIONS: . Alert: Promptly evaluate signs and symptoms of blood loss. Drug can cause serious, potentially fatal bleeding. Black Box Warning: Monitor patients for neurologic impairment (midline back pain, sensory or motor deficits, such as numbness or weakness in lower limbs, bowel or bladder dysfunction). Treat impairment urgently. - Review of Resident #20's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A hospital discharge summary, dated 05/06/19, stated, . Impression: 1. status [REDACTED]. 2. [DIAGNOSES REDACTED] AF (sudden outburst of [MEDICAL CONDITION]): Post procedure AF. Continue with anticoagulation with Eliquis. Medication orders, dated 06/25/19, included Eliquis 5 milligrams (mg) twice a day and [MEDICATION NAME] coated aspirin 81 mg daily. A physician's progress note, dated 07/01/19, stated, . (Resident #20) had been in the hospital in early (MONTH) . She was with us for about a month and developed [MEDICAL CONDITION] and readmitted at (name of hospital) for a full 2 weeks, returning (06/25/19) . The current care plan failed to include a problem, goals, or interventions related to the increased risk of bleeding and other side effects related to the use of an anticoagulant medication.

Based on record review and staff interview, the facility failed to provide the resident and/or the resident's family/legal representative an accurate written notice of transfer, including the destination, and the most current contact information for a state agency for 1 of 1 sampled resident (Resident #101) given a notice of transfer or discharge in 30 days. Failure to provide a notice of transfer or discharge containing the correct information does not allow the resident and/or family to make an informed choice regarding their rights and ability to contact the Ombudsman. Findings include: Review of Resident #101's medical record occurred on all days of survey. A Notice of Transfer or Discharge, dated 07/20/18, lacked the correct telephone numbers for the State Long-Term Care Ombudsman, the correct name of the current Ombudsman, and as indicated on the form, the specific location for the transfer/discharge. During an interview on 08/09/18 at 10:16 a.m., an administrator (#2) confirmed the form lacked the correct information.

Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures For Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 5 sampled residents (Resident #17) with a newly diagnosed mental illness. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASARR Provider Manual page 13 stated, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Ascend (contracted service provider for screening process) to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability (referred to in regulatory language as related conditions or RC)) was not identified at the Level I screen process, and that condition later emerged or was discovered. Review of Resident #17's medical record occurred on all days of survey. The initial PASARR screening, dated 08/28/14, stated, . has no [DIAGNOSES REDACTED]. no signs and symptoms related to a major mental illness . The current care plan stated, . Start date 09/27/16 . having a dx of unspecified [MEDICAL CONDITIONS], [NAME]D, personality disorder, unspecified dementia without behavioral disturbances, anxiety disorder, and a h/o alcohol dependency and [MEDICAL CONDITION]. The record lacked evidence of an updated Level I screening/change in status assessment. During an interview on 08/09/18 at 10:30 a.m., an administrative nurse (#2) confirmed the facility failed to update the Level I screening/change in status assessment.

Based on observation, record review, staff interview, review of facility policy and procedure, and review of the operator's instruction manual, the facility failed to provide adequate assistance for 2 of 6 sampled residents (Resident #3 and #10) observed during transfers using assistive devices. Failure to ensure staff properly used assistive devices placed Resident #3 and #10 at risk for accidents with/without injury. Findings include: Review of the EZ Smart Stand Operator's Instructions occurred on 08/09/2018. These operator's instructions, revised 02/16/2018, stated, . Patients should be able to bear some weight, have upper body strength and be able to follow simple commands. If a patient does not meet each of these three criteria, an EZ way total body lift must be used. Review of the facility policy GAIT (TRANSFER) BELT occurred on 08/09/18. This policy, revised (MONTH) 2005, stated, . Gait belt should be used on any resident who needs assistance with walking or transfers . To aid residents in maintaining balance. To avoid injury to both residents and staff. - Observation on 08/06/18 at 4:43 p.m., showed two certified nurse aides (CNAs) (#5 and #6) transferred Resident #10 from bed to wheelchair using an EZ stand lift. Resident #10's right [DIAGNOSES REDACTED] arm hung during the process as the resident was unable to hold onto the lift. The CNA's completed incontinence/peri cares while the resident remained elevated in the EZ stand mechanical lift. Resident #10 remained elevated in the EZ stand for approximately 15 minutes with her entire body leaning toward the right [DIAGNOSES REDACTED] side. - Review of Resident #10's medical record occurred all days of survey. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified extensive assist of two persons for transfers. Resident #10's current care plan stated, . I require assist of 1-2 with cares because I cannot do them myself due to R) (right) sided [MEDICAL CONDITION] and decreased cognition. 2 person stand pivot transfer or stand lift prn (as needed). I also have [MEDICAL CONDITION] and have trouble communicating. I may answer by saying/repeating . 'yes,' or 'no'. I have pain at times because due to R) sided [MEDICAL CONDITION] and Hx (history) of muscle spasms. Monitor me for signs of pain whether verbal or non verbal because I may not always tell you if I am hurting. I wear a AFO (ankle and foot orthoses) to R) L/E (lower extremity) and splint to R) hand. During an interview on 08/09/18 at 10:15 a.m., an administrative nurse (#2) stated, I would not expect staff to keep resident elevated in the EZ stand for extended periods of time. - Observation on 08/07/18 at 10:25 a.m. showed Resident #3 in her bed. A CNA (#4) assisted the resident to a sitting position, bent down and placed her arms around the resident's waist and lifted her into the wheelchair. To reposition the resident in the wheelchair, the CNA lifted her again and moved her back in the wheelchair seat. Observation on 08/08/18 at 9:49 a.m. showed two CNAs (#7 and #8) transferred Resident (#3) using a gait belt. When asked how the resident usually transfers, one CNA (#7) stated The care plan says always with a gait belt and 1 or 2 staff. Review of Resident #3's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified extensive assistance of two persons with transfer. The current care plan identified an assist of one with a gait belt for transfer and a stand lift as needed. The current care plan conflicts with the MDS which states extensive assist of two. During an interview on 08/08/18 at 10:06 a.m., an administrative nurse (#2) stated, The CNA (#4) should have used a gait belt.

Based on resident and staff interview, the facility failed to have a system in place to ensure 2 of 7 interviewed residents (Resident #17 and #25) had ready access to personal funds on the weekend. Failure to provide residents access to their personal funds on the weekend limits a resident's right to their money. Findings include: During an interview on 08/07/18 at 8:57 a.m., when asked about obtaining money from the resident's personal fund account, Resident #17 stated, I can't get money on the weekends. During an interview on 08/07/18 at 2:29 p.m., when asked about obtaining money from the resident's personal fund account, Resident #25 stated, I can't get money on the weekends. I have to get it before 4:00 p.m. on Fridays. During an interview on 08/07/18 at 2:18 p.m., an administrative office staff member (#1) confirmed residents cannot get money on the weekends unless someone is there who has access. Only the administrator, director of nursing, licensed social worker and social service designee have access to check the balance before they can provide money to residents.

Based on observation, staff interview, review of facility policy and professional reference, the facility failed to ensure oxygen tanks were stored securely on 2 of 3 days of survey (June 27 and 28). Failure to secure oxygen tanks placed residents and staff at risk for injury. Findings include: NFPA 55, 7.1.4.4 states, Compressed gas containers, cylinders, and tanks in use or in storage shall be secured to prevent them from falling or being knocked over by corralling them and securing them to a cart, framework, or fixed object by use of a restraint, unless otherwise permitted by 7.1.4.4.1 and 7.1.4.4.2.7. Review of the facility policy titled Oxygen occurred on 06/29/17. This policy, dated March 2013, stated, . 11. Cylinder tanks should be secured in place when not being used and be secured on a movable cart when being used. Observations of the oxygen storage room, located in the hallway of the 100 wing, during the survey showed: *06/27/17 at 3:07 p.m. five tanks unsecured *06/28/17 at 8:18 a.m. six tanks unsecured During the environmental tour on 06/29/17 at 9:15 a.m. a staff member (#4), stated, they (tanks) should always be in a holder.

Based on observation, and review of facility policy, the facility failed to serve food under sanitary conditions in 1 of 1 kitchen. Failure to ensure staff changed gloves with each task during food service and when handling ready-to-eat (RTE) foods had the potential to result in a food borne illness. Findings include: Review of the facility policy Use of Plastic Gloves occurred on 06/29/17. This undated policy stated, . If used, single use gloves shall be used for only one task (such as working with ready to eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation . Remember gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. - Observation on 06/28/17 during the lunch meal showed a dietary staff member (#6) wore the same gloves throughout the time of observation and performed the following tasks: * Served food * Left the serving area to butter a slice of bread in the kitchen area * Served RTE food with gloved hands * Left the serving area, opened a drawer in the kitchen to retrieve a serving utensil * Served RTE food with gloved hands * Turned the plastic sleeved pages of the binder containing resident dietary orders/requirements * Served RTE food with gloved hands The staff member failed to change gloves after touching contaminated surfaces and/or leaving the serving area. During review of the dietary binder during the morning of 06/29/17, observation identified several plastic sleeves contained food particles and were greasy to the touch.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to identify and assess a one piece zip up garment as a restraint for 2 of 2 sampled residents (Resident #3 and #4). Failure to recognize the use of this garment as a restraint and attempt less restrictive measures to control a behavior limited freedom of movement and the resident's access to their own body. Findings include: Review of the facility policy titled Physical Restraints occurred on 06/29/17. This policy, dated August 2015, stated, POLICY: It shall be the policy of Aneta Parkview Health Center that every resident has the right to be free from any physical restraint imposed for the purpose of discipline or convenience, and not required to treat the resident's medical condition. A physician's order is necessary for the use of a physical restraint, . The use of the restraining device must first be explained to the resident family member or legal representative and used only after their approval . DEFINITION: 1. A physical restraint is defined as a manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom or movement or normal access to ones body. 2. Discipline is any action taken for the purpose of punishing or penalizing the resident. 3. Convenience is any action taken to control resident behavior or maintain residents with a lesser amount of effort which is not in the best interest of the resident. - Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] (an antipsychotic medication) twice a day. Observation on 06/29/17 at 8:45 a.m. showed Resident #3 sleeping in bed with a one piece garment on. At 12:30 p.m., while sleeping on the bed the resident remained in the same garment. Resident #3's care plan stated, Problem: My mood may fluctuate and I may have behaviors because of having dementia and depression. At times I wander, may become physically and verbally aggressive, disrobe, shake my fists, and bite. I like to rummage and I may refuse cares. Approach: . I may wear onesies (a one piece zip up garment) PRN (as need) (initiated 04/04/17) . During an interview on 06/29/17 at 11:05 a.m., an administrative nurse (#1) stated Resident #3's family approved the use of the one piece garment, however, the facility failed to obtain a physician's order and conduct an assessment prior to utilizing the garment. - Review of Resident #4's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A physician's order, dated 06/14/17, stated, May wear onesies PRN. The care plan stated, Problem: My mood may fluctuate and I may have behaviors because of having dementia, [MEDICAL CONDITION], anxiety, and depression. I have a history of . disrobing in public . Approach: . Onesies PRN (initiated on 06/14/17) . Observation on all days of survey showed Resident #4 in a one piece zip up garment. The facility failed to identify and assess Resident #4's one piece garment as a restraint.

Based on record review, review of facility policy, and staff interview, the facility failed to immediately report 1 of 1 alleged violation of neglect (Resident #1) to the State Survey Agency and report the results of the investigation within five working days. Failure to identify and report all alleged violations of neglect placed all residents at risk of neglect and subsequent injury. Findings include: Review of the facility policy titled ABUSE POLICY AND PROCEDURE occurred on 06/29/17. This policy, dated November 2016, stated, . Definitions: . H. Neglect: Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect includes failure to carry out resident services as directed or ordered by the physician or other authorized personnel, failure to give proper attention to residents, or failure to carry out resident services through careless oversight. 6. Investigation: . e. All suspected violations . will be promptly reported to state agencies and other entities or individuals as may be required by law. Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A physician's order, dated 04/13/17, stated, Hoyer lift (full body mechanical lift) for functional transfers with assist of 2 staff . The resident's current care plan identified the use of a full body mechanical lift for all transfers. A Safety Events--Fall Scene Investigation Report dated 06/20/17, stated, . DESCRIPTION: After bath CNA (should have stated Resident #1's name not CNA) (certified nurse assistant) was sitting on bath chair with feet on standing lift, CNA raised res. (resident) shoulders to place strap around back, res. became stiff, started slipping off of chair and needed to be lowered to floor. Sustained 8 cm (centimeter) x (by) 1.5 cm bruise to top of Lt (left) hand from hitting tub. No other injuries noted, did not hit head. ROM (range of motion) WNL (within normal limits), no s/s (signs/symptoms) of pain. Res. was bare foot, standing lift foot pads dry. EVALUATION: Discussed at manager's meeting 6/20/17. Care plan reveals resident is to use hoyer lift at all times. Staff member re-educated. During an interview on 06/29/17 at 10:30 a.m., an administrative nurse (#1) confirmed the facility failed to report the incident to the State Survey Agency. The administrative nurse (#1) stated, she completed a disciplinary action for the staff involved. By failing to identify the potential of neglect involved in Resident #1's fall, the facility subsequently failed to immediately report the incident to the State Survey Agency, failed to conduct a thorough investigation, and failed to report the results of their investigation within five working days.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to manage constipation for 1 of 4 sampled residents (Resident #5) with as needed (PRN) bowel medication. Failure to implement interventions to manage constipation in a timely manner and follow bowel protocol may result in resident discomfort and continued constipation. Findings include: Review of the facility policy titled Bowel Assessment occurred on 06/28/17. This policy, dated March 2016, stated, . 3. On day three of constipation, Milk of Magnesia (MOM) will be given. If the resident prefers a different laxative, an order will be obtained from the physician. 4. If no BM (bowel movement) is recorded, the morning of day 4 without a BM a suppository will be given. Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. PRN medications included polyethylene [MEDICATION NAME] (laxative) powder 17 gram PRN, and MOM (laxative) 400 milligram (mg) per 5 milliliter (mL) suspension PRN up to 3 times a week. Resident #5's significant change Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and continent of bowel. The current care plan stated, Problem: I have the potential to be constipated because I am not as active as I used to be and I have a Hx (history) of constipation. Goal: I will have a BM every 1-3 days . Approach: prune juice in the AM (morning) . Monitor my bowel elimination and implement bowel protocol PRN. The April 01 - June 27th, 2017 bowel movement records and electronic medication administration records (eMARS), identified the following: - No BM for 3 days and MOM administered on day four occurred on three occasions. - No BM for 3 days and no PRN bowel medication administered occurred on one occasion. - No BM for 4 days and no PRN bowel medication administered occurred on two occasions During an interview on 06/29/17 at 9:20 a.m., an administrative nurse (#1) verified staff failed to follow the bowel protocol.

Based on record review, observation, and facility policy review, the facility failed to provide adequate supervision and functioning safety devices to prevent accidents for 1 of 6 sampled residents (Resident #5) with falls. Failure of staff to supervise Resident #5 while in the bathroom and in bed and ensure functioning safety devices placed the resident at risk for falls and injury. Findings include: Review of the facility policy titled Falls Prevention occurred on 06/29/17. This policy, dated March 2013, stated, . initiate bed/chair alarms as appropriate. monitor use of assistive devices and/or equipment. Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and extensive assist of one person with toileting. The current care plan stated, I'm at risk for falling because I am unaware of my own safety concerns . I have a Hx (history) of falls . W/C (wheelchair), bed alarm, & hipsters . Assist me with walking, transfers and locomotion on/off unit . Observation on 06/28/17 at 3:41 p.m. showed two certified nursing assistants (CNAs) (#2 and #3) assisted Resident #5 with toileting in the bathroom. Both the CNAs left the resident alone in the bathroom. Twice the CNAs reentered the bathroom and found the resident standing. After the CNAs transferred the resident to bed, both CNAs left the room to retrieve new batteries for the bed alarm. The resident remained alone in bed without a functioning bed alarm. A CNA (#3) returned to the room after approximately 10 minutes to replace the bed alarm batteries. Review of the Resident #5's progress notes identified seven falls since February 2017 due to the resident self transferring. Staff failed to supervise and ensure functioning safety devices to prevent self transferring and further falls.

Based on observation, record review, and staff interview, the facility failed to provide foods to meet the special nutritional needs for 2 of 9 sampled residents (Resident #3 and #5). Failure to provide ice cream as directed by the dietician (Resident #3) and cut foods into bite side pieces (Resident #5) may result in avoidable weight loss or aspiration. Findings include: - Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Resident #3's care plan stated, Problem: I have had significant weight loss on 4/13/17 due to a decline and hospital stay . Approach: plus 2 (a nutritional supplement) tid (three times a day); 8oz. (ounces) ensure (a nutritional supplement) tid between meals with a scoop of ice cream in it. dish of ice cream with topping at noon and evening meal. I like pop and ice cream . Review of Resident #3's dietary meal sheet showed the same approaches as the care plan. Resident #3's dietary progress notes showed the facility added interventions to help with weight loss as follows: * 04/19/17 - Ensure (a nutritional supplement) 4 oz three times a day * 05/05/17 - increased Ensure to 8 oz three times a day * 05/31/17 - added a calorie protein enhancement program * 06/02/17 - Plus 2 (a nutritional supplement) 4 oz three times a day * 06/07/17 - ice cream added to Ensure as needed and a dish of ice cream with the noon and evening meals The weight records showed Resident #3 had a weight gain of three pounds from 06/07/17 to 06/28/17. Observation on 06/28/17 at 12:15 p.m. and on 06/29/17 at 12:30 p.m. showed facility staff failed to give Resident #3 ice cream at the noon meal. During an interview on 06/29/17 at 11:05 a.m., an administrative nurse (#1) stated she was unaware the dietary staff were not providing Resident #3 with ice cream at the noon meal. During an interview on 06/29/17 at 12:30 p.m., an unidentified certified nursing assistant (CNA) stated the dietary department is to provide ice cream on Resident #3's meal tray and confirmed Resident #3 did not receive ice cream. - Review of Resident #5's medical record occurred on all days of survey. The current physician order [REDACTED]. The current care plan stated, . Diet as ordered. I receive ground meat and my other foods are cut up due to I like to take big bites. I may have some difficulty chewing or swallowing at times due to [MEDICAL CONDITION]. I have had an (sic) SLP (speech language pathologist) eval (evaluation). Suggest to have all foods cut into bite size pieces. It was suggested that I eat in the dining room. Resident #5's Speech Therapy Evaluation & Plan of Treatment, completed on 02/16/17, recommended . Mechanical Soft textures, thin liquids, and distant supervision. dentures in place for eating. All foods pre-cut to bite size pieces. Observation on 06/28/17 at 11:05 a.m. showed Resident #5 at the dining table sleeping with his lunch placed in front of him. His lunch included a serving of lasagna, not cut into bite size pieces. Observation on 06/28/17 at 5:36 p.m. showed Resident #5 at the dining table for supper meal. He had a toasted peanut butter and jelly sandwich cut in half. Staff failed to ensure Resident's #5's food items consisted of bite size pieces.

During the standard recertification survey on 07/14/15, the team determined a potential Immediate Jeopardy (IJ) situation existed. The IJ potential resulted from an observation at 11:05 a.m. on the special care unit when an unattended cleaning cart in the hallway was identified with open buckets of potentially hazardous cleaning solutions. After observation and interview with the facility staff using the cleaning cart, the survey team met at 11:20 a.m. and determined that corrective action needed to occur. At 11:30 a.m., the survey team met with the administrator and the cleaning cart was removed from service. The team then continued to gather further information and interview staff regarding the observed process. At 12:38 p.m. the team contacted the management staff at the State Agency (SA) to report the findings and to discuss a potential IJ situation. At 1:20 p.m. the survey team notified the facility administrator of the IJ and that they must develop a plan for abatement. At 3:45 p.m. the facility provided a written plan of correction for the IJ. A copy of the plan was also given to the RO (Regional Office) staff person present with the team and a faxed copy was sent to the SA office. The team, RO, and SA reviewed and accepted the written plan. At 4:50 p.m. the team determined the IJ situation abated, reduced the scope and severity level to E, and informed the administrator of this action. 1. Based on observation, staff interview, and review of Material Safety Data Sheets (MSDS), the facility failed to maintain a safe environment regarding chemicals used by staff while cleaning the facility. The practice of leaving these chemicals unattended placed cognitively impaired and wandering residents at risk for accidents and injury. Findings include: Observation on 07/14/15 at 11:00 a.m. showed an unattended cleaning cart in the hallway of the facility's special care unit. The cart contained the following cleaning chemicals: * an open bucket on the top of the cart contained a mixture of water and HDQ (a disinfectant that can cause eye damage, skin burns, and is harmful if swallowed) * an open bucket on the second shelf of the cart contained a toilet bowl cleaning sponge and a mixture of water and NABC Plus IV (a cleaning product that may cause eye and skin irritation and harmful if swallowed) * the lower level contained an open mop bucket containing HDQ mixed with water for cleaning the floors * other cleaning products on the top of the cart and/or hanging in spray bottles on the side were as follows: Comet, Febreze, Drano, Pledge, shower and glass cleaner, Spitfire cleaner, and Brawny wipes with HDQ (all identified as harmful if swallowed and/or can cause eye irritation) During this observation, Resident #1, #13, #14, and #15 walked by the cart in the hallway, at one point during the observation, Resident #13 approached the cart with an empty drinking glass. During an interview on 07/14/15 at 11:10 a.m., a housekeeping staff member (#3) identified the above cleaning products and stated it is her normal practice to leave the cart unattended when she is cleaning residents' rooms. The staff person (#3) stated, she parks the cart with the side with the spray bottles by the wall so they don't take them. When asked about the items on the cart, she stated, no one has taken anything that I know, but they have touched it and I've found a donut and a sock in the mop bucket. The staff member (#3) reported she is not able to view the cart all the times as she is in the room cleaning and has to leave the cart in the hallway. During an interview on 07/14/15 at 12:01 p.m., an administrative staff member (#1) reported that she had reviewed the video tape from the unit and saw Resident #1, #13, and #14 in the hallway and that staff had left the cart unattended for about five minutes. FALLS 2. Based on observation, record review, and staff interview, the facility failed to provide an environment free of accidents, and to provide adequate supervision to prevent falls for 3 of 5 sampled residents (Resident #2, #3, and #7) who reside in the special care unit. Failure to adequately assess, monitor, and revise interventions in a timely manner resulted in frequent falls and avoidable injury. Findings include: Review of the facility policy titled FALLS PREVENTION occurred on 07/16/15. This policy, revised March 2013, stated, PURPOSE: To identify each resident at risk for accidents and/or falls and provide a safe environment. To reduce the number of falls by identifying and implementing individualized fall prevention strategies. PROCEDURE . 2. Fall prevention strategies for residents at risk are to be documented on the care plan. 3. E. Place call light, personal items, and assistive devices within easy reach. (This may not be appropriate for the dementia resident.) . K. Review bowel and bladder for level of continence and initiate toileting assistance as appropriate. 4. Falls committee will meet prn (as needed) to discuss specific falls . Fall Committee will activate or discontinue strategies as appropriate. - Observations in the special care unit on the morning and between 5:00-6:00 p.m. on 07/14/15, showed Resident #2 self propel in his wheelchair (w/c) with his shoulders touching the back of the w/c and his buttocks on the front edge of the seat. Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Review of a Significant Change in Status Minimum Data Set (MDS), dated [DATE], identified the resident with short and long term memory problems and moderately impaired cognition, requiring extensive assist of two persons for bed mobility, transfers, dressing, toilet use and personal hygiene; frequently incontinent of bowel and bladder; two or more falls with no injury and with injury; and a trunk restraint used daily. Review of Resident #2's falls report and progress notes revealed the following: * 08/19/14, 6:50 a.m., Fall in res (resident) bathroom attempting to transfer self to toilet . * 08/20/14, 4:00 a.m., Found lying on the floor. * 08/23/14, 6:55 a.m., Res. found lying on the floor in the hallway . * 08/24/14, 7:35 p.m., Resident was found on floor in bathroom doorway. * 08/28/14, 6:45 a.m., Resident found on floor. * 09/18/14, 10:30 p.m., Resident found on the floor. * 09/22/14, 3:15 p.m., Resident found on floor next to wheelchair by the exit doors. Skin Tear to L) (left) elbow. C/o (complained of) pain to left side of lower abd (abdomen). The Fall committee hand wrote the following note on the fall report, . continue TP (toileting plan) 4-6am or when awake and b/4 (before) 6pm. The current care plan failed to contain this intervention. * 10/10/14, 6:30 a.m., Res. found on floor in (another resident's bathroom) . Res. had taken brief off and was saturated with urine. * 10/11/14, 7:26 a.m., Had gotten out of w/c (wheelchair) & (and) walked . Was found lying on the floor . * 10/12/14, 5:30 a.m., Resident was found sitting on carpeted floor in the TV room . * 10/15/14, 4:00 a.m., Found resident lying on the floor in his room between the bathroom door & the foot of his roommate's bed. No apparent injury . * 10/15/14, 5:20 a.m., Found resident lying on the floor in the hallway with w/c nearby. No injuries noted. Apparently resident does not call out when he falls, or call for help once he's on the floor as nothing is heard. Was in another room assisting another resident with am (morning) cares & found him on the floor in hall . * 10/20/14, 7:30 p.m., Resident found on floor on (sic) sitting position in BR (bathroom) . * 10/20/14 11:17 p.m., Staff heard bang noise from DR (dining room) in SCU (special care unit) and noted resident was laying on floor. Res's w/c was about 5 ft (feet) from him. The Fall committee hand wrote the following note on the fall report, get up and ready first on nights and do activity 10/20/14. The current care plan failed to contain this intervention. * 11/10/14, 11:55 p.m., Found resident lying on the floor at the foot of his bed, naked from the waist down & urine on the floor. * 11/15/14, 11:00 p.m., Resident found on floor mat next to his bed on back position. Moderate amount of blood noted on floor. Laceration noted to the back of head. Res stated, 'I tried to stand up and lost my balance, hit my head with (sic) the nightstand.' . Dressing applied to laceration per SO (standing orders) Neuro and VS (vital signs) . * 11/29/14, 7:30 p.m., Resident found on the floor at 7:30 pm in his room, bleeding from a laceration to his L) forehead near his hairline, approx (approximately) 3.6 cm(centimeters) x (times) 0.7 cm . Also small laceration to ear & skin tear 3.0 cm x 1.5 cm at L) elbow . transported to ER (emergency room ) per ambulance . Has 9 sutures in forehead . * 11/30/14, 2:35 p.m., Resident found on floor near to BR (bathroom) door . * 12/02/14, 6:30 a.m., Res found on floor in residents BR. Res brief was off and t-shirt was soiled with urine. Res stated 'I was trying to go to the bathroom' . Bed was in low position and fall mat was in place by bed . Res noted to have skin tear to R) (right) brow and R) forearm . The Fall committee hand wrote the following note on the fall report, silent bed alarm placed helmet attempted bedside table moved to BR The current care plan listed the intervention of a silent bed alarm but failed to contain the other interventions. * 12/26/14, 5:19 p.m., Res found on floor in SCU dining room on buttocks in front of w/c . Res was wearing hipsters, non slip foot wear, res has anti roll backs on w/c, low bed fall mat and silent bed alarm. * 12/27/14, 9:45 p.m., Resident found on floor in back position in SCU salarium (sic). Res was in w/c and wandering prior to fall . * 12/29/14, 6:55 p.m., Res found on floor on sitting position in SCU solarium attempted to transfer himself to regular chair . * 01/05/15, 11:48 a.m., CNA (certified nurse aide) checking on resident and found resident lying on his back, with head by door. * 01/18/15, 4:30 p.m., Res found on back in SCU by nurses station by w/c. * 01/25/15, 11:10 p.m., The CNA reported res was sliding from his w/c and this CNA tried to assisted (sic) him to recliner res came forward, down in (sic) knees and hit the (sic) face . Abrasion noted to nose and 3 x 2 cm laceration to nose bridge . The Fall committee hand wrote the following note on the fall report, falls remain (arrow down) * 02/04/15, 11:25 p.m., Per CNA report, resident was in SCU dining room moving chairs around. CNA heard resident whistle and went to dining room. Resident was found lying on his back on the floor . * 02/06/15, 1:15 p.m., Res was sitting in w/c. Another res family witnessed fall and stated res slid out of w/c . * 02/08/15, 7:20 a.m., Resident found on floor mat next to bed laying on his right side . * 03/01/15, 8:15 p.m., Resident found on floor laying on R) side position. 1.5 x 1 cm T-shape laceration noted the back of head . * 03/11/15, 1:52 p.m., Res found on buttock next to w/c at TV area in SCU . Res received a 2 x 3 blood blister to R) upper thumb area . Res has anti-roll backs to w/c, geri sleeves, hipsters, low bed, wing mattress . * 03/14/15, 6:51 a.m., fall: 3/13 at 1030pm, stood out of w/c and grabbed side rail to pull himself up, fell down onto but (sic) and layed down on back no injures . * 03/14/15, 2:15 p.m., found on floor in solarium on back position. The CNA reported res was sliding from his w/c Res stated, 'I slide from this damn w/c' No injury noted. Dycem in placed (sic) to w/c to prevent sliding . * 03/30/15, 11:00 p.m., found laying on back in front of w/c by his bedroom door, denies pain, said he just slid out of the chair, . dycem was in place . The Fall committee hand wrote the following note on the fall report, all interventions in place. * 04/05/15, 11:55 a.m., Resident slid out of his wheelchair landed on the floor . * 04/11/15, 7:00 p.m., resident slid out of wheelchair onto buttocks on floor in front of the desk in the living room * 05/01/15, 5:52 a.m., Pt (patient) found on floor next to w/c lying on right side in common area * 05/03/15, 4:09 p.m., Resident slipped in between love seat and wheelchair when attempting to self transfer * 05/03/15, 8:30 p.m., Slid out of wheelchair x 2 . * 05/04/15, 5:54 p.m., Resident slid from recliner in SCU solarium to floor while attempting to self transfer * 05/10/15, 7:35 p.m., Res was sitting in w/c in solarium. Author had just given res. his meds and was passing meds to another res, Female res stated 'Hey (name) on the floor . The report lacked a note by the Fall committee. * 05/11/15, 7:30 p.m., Res got up from his w/c, attempted to walk by himself and fell on floor per witness. Res hit the (sic) head. Skin tear noted to R) ring and little finger and L) elbow . All injury and fall preventive measures implemented . * 05/16/15, 5:25 p.m., Resident found on floor in solarium. Res stated that he slide (sic) from w/c . * 05/19/15, 4:00 p.m., Res stood up from w/c and tried grabbing onto table and fell backwards . * 05/19/15, 7:00 p.m., Resident was sitting with staff and attempted to scoot self back in chair and slipped out of his chair on to his butt * 05/21/15, 2:00 p.m., Res had just been transferred to w/c from tub chair. Res leaned forward and fell before staff could get him repositioned into chair. Res noted to have seizure type activity. Res noted to be bleeding from his forehead and L) arm and hand . This review contained a note dated 05/21/15, which stated, seat belt ordered by (physician's name) for injuries due to falls * 05/25/15, 5:00 p.m., Resident slid out of his wheelchair onto his butt . self release seat belt reapplied A handwritten note on the right side of the fall report stated, lap buddy ordered last week d/t (due to) falls (with) injury. Activities state (arrow up) behaviors (with) PM activity * 07/01/15, 5:56 p.m., Res found on floor in SCU tv area on back. WC next to res. Safety belt to wc un-clipped . Resident #2's current care plan, dated 07/07/15, stated, Problem: I have trouble with my mobility . I have unstable balance and a w/c is my primary mode of mobility . Approach: . Assist me with walking, transfers . I may roll myself out of bed at times and sleep on the floor . Provide me with assistive devices as needed . Problem: I'm at risk for falling . I have a dx (diagnoses) of dementia, hx (history) of falls, unsteady gait, balance problems which staff assist with stabilization and I am unaware of my own safety concerns at times . I have a self releasing safety belt to w/c for positioning purposes . Approach: Complete a Fall risk assessment as scheduled/indicated and implement appropriate safety measures, Dicem (sic) to w/c to prevent sliding, Encourage me to wear non-slip footwear. Keep my personal items within my reach. Keep my room clutter free . Orientate me to my room. Silent bed alarm . Review of Resident #2's current care plan lacked the following interventions that were listed on the fall report sheets: hipsters, anti-roll brakes on his wheelchair, low bed with winged mattress, bedside table removed, helmet attempted, get resident up first on nights and do activity, toilet around 4:00 a.m. or when awake and before 6:00 p.m. Review of a Physical therapy assessment, dated 07/29/14, stated, . Reason for referral: recent falls . Pt uses w/c for most mobility . Pt was educated to not get up on his own secondary to fall . encourage staff to assist (with) all mobility to reduce fall risk . This assessment lacked information regarding w/c positioning. When an administrative nurse (#2) was asked about any further therapy assessments, the staff member provided an occupational therapy form dated 06/01/15, which stated, OT consult for dining room audit . This audit lacked any resident names. The care plan identified the seatbelt is used for positioning, however, the Fall Event report identified the physician ordered it to prevent falls. Refer to F221. During interview on the morning 07/16/15, an administrative nurse (#2), in reference to the frequent number of falls for Resident #2's stated, we put the belt on because he had 3 head injuries. The facility failed to adequately assess the causative factors contributing to the recurring falls experienced by Resident #2 who required extensive assistance with toileting and failed to implement/provide appropriate and effective interventions to prevent or decrease the number of falls/injury Resident #2 experienced. - Observation on the SCU on 07/14/15 at 11:00 a.m. showed Resident #3 standing near the entrance door of the unit holding onto the hand rail. The resident swayed and appeared unsteady as he stood by the wall, an activity staff member assisted him to sit in a nearby recliner. Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Review of an admission MDS, dated [DATE], indicated the resident had a history of [REDACTED]. Review of Resident #3's fall report and progress notes revealed the following: * 04/08/15, 4:30 p.m., Resident was trying to rearrange furniture and pulled the recliner over on top of himself. Resident hit right top of head and got an abrasion . * 04/14/15, 1:45 p.m., Res was found on floor in hallway outside of his room . * 04/28/15, 3:46 p.m., Res was pushing around a dining room hair in solarium and fell . * 05/17/15, 7:00 p.m., Found on floor in SCU dining room. Has small bruise to rt (right) hip as well as inner rt elbow . * 05/27/15, 4:43 p.m., Res found on back in res room on floor . * 05/28/15, 1:16 p.m., General decline-Res has had increased incontinence, decreased cognition and gait has become more unsteady . * 05/31/15, 7:55 p.m., Res found on floor in hallway on L) side position. Res was wandering up and down in hallway prior to fall. Res c/o back and R) hand pain . The Fall committee hand wrote the following note on the fall report, pushing furniture frequently, decline - change of condition, (arrow up) psych meds due to aggressive outbursts, activity -sorting/stacking * 06/08/15, 9:37 a.m., Resident fell from wheelchair onto dining room floor. No injury noted fall unwitnessed. * 06/08/15, 6:14 p.m., Resident fell in room without witnesses. CNA heard fall and found resident laying behind door on floor. CNA stated resident loss (sic) consciousness for about 30 seconds and hit the back of his head against the corner of the dresser . * 06/09/15, 8:50 p.m., Resident found on floor in between bathroom and bedroom . * 06/13/15, 3:45 p.m., Resident attempted to transfer self out of wheelchair and got tangled in foot rests and fell to right side. Fall was witness (sic) by writer . * 06/21/15, 1:02 a.m., Writter (sic) heard some noises from room, writer went and checked every room and found resident on the floor by his bed. * 06/21/15, 8:00 p.m., Resident was found laying on floor by his recliner . The Fall committee hand wrote the following note on the fall report, decline in status, unsteady gait -in w/c now. Event details forms, dated 06/13/15 and 06/21/15, stated, resident continuing with decline, anticipate further falls and continue with interventions * 07/07/15, 10:53 p.m., Res had been sitting in recliner with feet up in solarium. Author walked away to help another res and heard a chair tip. Res noted to be lying on the floor in front of recliner . * 07/07/15, 11:59 a.m., Res was sitting in recliner in room. Housekeeper found res on floor in room . * 07/08/15, 6:55 p.m., Res found on floor in DR on L) side position next to recliner . res wears hip hipsters, has lower bed, and bed alarm . * 07/09/15, 9:00 a.m., Res found on buttock on floor next to w/c in DR of SCU . Chair alarm applied to wc. * 07/14/15, 6:30 a.m., Res found on floor on back position by SCU northeast exit door . Resident #3's current care plan, dated 06/08/15, stated . Problem: I'm at risk for falling because I have hx of falls, I wander and I receive daily scheduled antipsychotic and antidepressant meds . r/t (related to) Lewey Body Dementia and balance problems. 6/11/15 Recent decline in balance d/t progression of disease process Anticipate further decline. I an unaware of own safety concerns . Approach: Complete a Fall risk assessment as scheduled/indicated and implement appropriate safety measures, Encourage me to wear non-slip footwear. Keep my personal items within my reach. Keep my room clutter free. Orientate me to my room. 6/11/15 may use w/c prn (as needed) if unsteady. Review of Resident #3's current care plan lacked the following interventions that were listed in progress notes/fall reports: hipsters, bed alarm, and low bed. The facility failed to adequately assess the causative factor contributing to Resident #3's recurring falls and implement interventions and provide additional assistance in regards to his changing condition and ongoing behaviors. - Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Review of the fall event reports identified the following as current fall interventions in place; low bed, fall mat, non-slip footwear, and hipsters. The current care plan stated, . Problem: I'm at risk for falling because I have an unsteady gait, I have balance problems with ambulation and transitioning, I wander, I am unaware of my own safety concerns, I have a Hx (history) of falls and I receive a daily scheduled anti anxiety and antidepressant meds (medications). Sometimes is (sic) purposely lower myself to the floor mat from my bed. Approach: Complete a Fall risk assessment as scheduled/indicated and implement appropriate safety measures. Encourage me to wear non-slip footwear. Keep my personal items within my reach. Keep my room clutter free. Orientate me to my room. The facility failed to revise the care plan to include current fall interventions During interview on the morning 07/16/15, an administrative nurse (#2) reported staff look at the times of the day falls occur, review with the Medical Director and review the videos to see what happened. The facility failed to implement effective interventions individulized to the needs and the specific conditions of residents living in the SCU of the facility. Though the facility reviewed incidents after the occurrence, they failed to act proactively to minimize the frequency and injuries of these residents. The facility failed to update the plan of care for those individuals who are a higher risk for falls and injury related to problems with behavior and cognition. SAFETY 3. Based on observation, review of staff education records, and staff interview, the facility failed to maintain a safe environment regarding 3 of 7 bathroom doors (201, 204, and 205) in the special care unit. The ability for residents to lock themselves in the bathroom unattended placed cognitively impaired, and wandering residents at risk for accidents and injury. Findings include: During the extended survey, on July 28-29, 2015, it was identified three rooms in the special care unit had bathroom door locks which allowed residents to lock the door from inside the bathroom. Review of the staff education record titled Resident Bathroom Locks occurred on July 28-29, 2015. This record, dated August 2014, stated, Several bathroom doors have the ability to be locked from the inside. This includes rooms 102, 105, 106, 108, 112, 109, 114, 115, 201, 204 and 205. To open them use the side of a key (like a screwdriver) and turn. Observation on 07/29/15 at 9:17 a.m. showed the bathroom doors in room 201, 204, and 205 had locks which could be locked from inside. During an interview on the afternoon of 07/28/15, three certified nursing assistants (CNA) (#15 , #17, and #18) stated there were no bathroom doors in the facility that lock. When informed that three bathroom doors had locks, the CNA's were unaware of how to unlock these bathroom doors if a resident locked themselves in the bathroom. During an interview on 07/29/15 at 11:35 a.m., an administrative nurse (#2) stated she was unaware of any resident bathroom doors having the ability to lock from the inside of the bathroom.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide medically-related social services for 3 of 3 sampled residents (Resident #2, #3, and #8) and 2 supplemental residents (Resident #13 and #14) who exhibited and/or experienced physical, and abusive behaviors. The facility failed to: 1. Implement the facility's own policy to identify residents and/or situations with potential for the occurrence of injury, prevent resident to resident injury, and protect residents from recurring resident to resident injury. 2. Adequately assess resident behaviors, including monitoring for patterns/trends, causative factors, including time, place, persons involved, happenings prior to and at the time of the behavior, and implement appropriate interventions to prevent behaviors from escalating. 3. Monitor the effectiveness of interventions and revise interventions as appropriate. 4. Implement an interdisciplinary approach to address behaviors which have the potential to result in resident to resident altercation. Failure to adequately assess and monitor residents' behaviors and implement effective interventions or evaluate current interventions to prevent further behaviors resulted in other residents being victims of physical, verbal, and mental abuse. Finding include: Review of the policy/procedure titled Behavior Management Committee occurred on 07/16/15. This policy/procedure dated 02/10/11, stated, . PURPOSE: To identify residents who have aggressive or abusive behavior and whose personal histories render them at risk for conflict, abusing or harming self or others, to develop and implement appropriate intervention strategies to prevent occurrences, to review intervention strategies on regular basis to assure continued effectiveness, and to monitor for any changes that could trigger abusive behavior.PROCEDURE: . 2. When residents have aggressive or abusive behaviors or behaviors that have the potential to cause injuries to self or others, they are identified in this manner: a. Aggressive/Behavior Events are completed to relay the behavior to the multidisciplinary team. c. Incident Reports are used when a behavior requires investigation, when there is injury, or resident to resident harm/injury.4. Care plans are updated to reflect changes. Changes in care plan approaches are communicated to staff at report at change of shift. - Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS), dated [DATE], indicated intact cognition. A quarterly MDS, dated [DATE], indicated moderately impaired cognition. Review of a Behavior and Mood Event -Aggressive Combative Behavior dated 02/04/15, 6:24 p.m., stated, . Physical Observation: Behavior: Per CNA (certified nurse aide) report, (Resident #13) was following this resident around and 'nagging' him. This residen (sic) then grabbed (Resident #13) by the hair causing her to fall backwards and hit her head on a chair. Residents were separated at this time . 24 hour behavior (sic) started d/t (due to) resident on resident behavior . The report indicated that the physician and families were notified. Review of the progress notes linked to the above event stated the following: * 02/05/15, 12:22 p.m., (recorded as late entry on 02/06/15 at 10:24 a.m.), stated, Behavior: (Resident #3) asked (name of CNA) if she had heard what he did last night. Resident stated that he shouldn't have done what he did but 'she' wouldn't leave him alone and kept slapping her hands in front of her (sic) face. Resident remorseful. * 02/09/15, 01:08 p.m., stated, Author spoke with res (Resident #3) in r/t (relation to) behavior on 2/04/15. Res stated he shouldn't have done what he did but she wouldn't leave him alone. Res is remorseful and hopes (Resident #13) has forgiven him Review of a progress note for Resident #3 stated the following: 04/11/15, 5:23 p.m., Behaviors: Writer contacted (physician name) at the (hospital name) . informed him of residents history with episodic mood disorder and his past history of pulling another residents (sic) hair approx (approximately) 6 weeks ago. Writer informed him of residents (sic) most recent behavior of injuring another resident physically by punching him . inform him that they are currently separated and resident is calm and had no current aggression or behaviors. (physician name) asked that resident just be monitored for now and observe for increased aggression or behaviors, and resident will need to be admitted if aggression increases or behaviors begin . asked that (another physician name) be contacted on Monday in regards to possible medication changes or medication increases. Review of a Progress note, dated 06/08/15, at 2:00 p.m., stated, Care plan Meeting: . Behaviors are most often toward roommate during the night . Discussed impulse control and Depakote and Seroquel increases. Resident understands and is re-directable and apologetic after out bursts. According to Behavior Management Meeting notes, dated 06/24/15, . Resident #3 was started on 24 hr behavior monitoring. Responsible parties and (physician name) were contacted. Incident report completed, behavior event created, care plan updated. Addendum: (Resident #3) has had a significant decline since this particular event. There was a med change on 5/17/15 and a change in roommate on 6/3/15. The incident referenced at the behavior meeting occurred on 04/11/15, two months prior to the date of this meeting. The facility failed to address Resident #3's behaviors in a timely manner and implement effective interventions to prevent further incidents of physical aggression. A progress note for Resident #3, dated 07/12/15 at 5:00 p.m., stated, Combative behavior: Res. (resident) cornered and punched res (Resident #14) in the SCU (special care unit) dining room by the fridge and then punched res in the face. CNA's seperated (sic) res. Review of an incident report dated 07/12/15, stated, . Resident to Resident . Location: Special Care Dining Room . (Resident #3) Cornered res (Resident #14) into a corner et (and) punched him in the face. Review of Resident #3's current care plan stated, . Problem: My mood may fluctuate and I may have behaviors because of having dementia. When people get to close into my space I may become physically aggressive. I have pulled the hair of (Resident #13). I have put my hands on/punched (Resident #2). I wander into other's rooms . Approach: Contact my family when needed. Contact my MD and Psychiatrist PRN (as needed). Give me an anti-depressant as it is ordered . Give me anti-psychotic medications as it is ordered . Let me sleep anywhere and at anytime assuring mine and my neighbors safety. Monitor interactions with (Resident #13) and (Resident #2). Allow me to eat at a different table during meals. Give me activities at the opposite end of the SCU (special care unit) . Redirect me by conversation or making jokes . Problem: I have a Dx (diagnosis) of Dementia, mood disorder . Approach: . Have 1-1 visits with me about all the places I've been . assistance with setup and supplies for independent activities of rummaging, wandering, visiting and observing others . Review of a Behavior and Mood Event -Aggressive Combative Behavior dated 04/11/15, at 2:30 p.m., stated, . Description: (Resident #3) punched another resident in the face causing bodily harm . Physical Observation: Behavior: Resident (Resident #3) was having a discussion with (Resident #2) about vehicles in the hallway near the SCU dining room, when the discussion quickly escalated and (Resident #3) punched (Resident #2) in the face causing him to scream out for help and (Resident #2) got a bloody lip. Residents were quickly separated and (Resident #3) was started on 24 hour behavior monitoring . This resident (Resident #3) had his care plan behavior section updated as well . Review of an incident report, dated 04/11/15, in regards to the injury to Resident #2, stated, . Type of injury: abrasion . Intervention Provided/Ordered First Aid stopped the bleeding . This form was signed as reviewed by the administrator and social services on 07/06/15 and by the director of nursing on 05/01/15. Social services failed to review these resident behaviors until approximately three months after the incident. Failure of the facility to monitor, track, and trend Resident #3's behaviors and thoroughly assess the causative/precipitating factors leading up to, or resulting in aggressive and abusive behavior, develop and implement effective interventions (proactive approach versus reactive), as well as revise them as necessary; resulted in altercations and harm to residents. - Review of Resident #8's medical record occurred on 07/16/15 and [DIAGNOSES REDACTED]. Review of an admission MDS, dated [DATE], identified moderately impaired cognition and physical and verbal behaviors occurring 1 to 3 days during the seven day assessment period. Review of Resident #8's progress notes stated the following: * 05/04/15, 4:02 p.m., Resident was heard yelling at his roommate (Resident #3) today, because roommate was rummaging through residents belongings. Resident stated, 'I pay rent here too, you can't just go through my things.' Residents than (sic) stated, 'I am gonna hit you.' Staff intervened and resident was easily redirected. * 05/11/15, 11:05 p.m., Resident noted to be walking in hallway naked this evening and reported, 'that guy is taking my stuffs (sic)' Res (resident) redirected to his room and assisted to bed. His roommate (Resident #3) was rummaging (sic) resident's dresser . * 05/17/15, 9:29 a.m., Abrasion: 0.5 cm (centimeter) linear abrasion noted to L) (left) eyebrow. Res stated, 'I don't know how it happened.' Res denied bumped (sic) with something or fall. Slightly swelling and puffiness noted to L) upper eye. Res's glasses firm (sic) noted to be bent to L) side . * 06/03/15, 2:53 p.m., Room change: Moved to room (room number) Resident #8 was a roommate of Resident #3. * 07/14/15, 3:38 p.m., Behavior: (Resident #3) wandered into res room. Both res noted to have red marks on face. Res. stated 'he came into my room and we boxed.' (Resident #3) removed from this res room. On 07/14/15 between 5:04 p.m. and 5:20 p.m. observation in the dining room of the SCU showed a CNA (#16) sat at a table with Resident #3 when another CNA (#12) brought Resident #8 into the dining room and attempted to seat him at the same table next to Resident #3. The CNA (#16) stated, don't sit him here next to (Resident #3) they just got into a fight. The CNA (#12) indicated she was unaware of the altercation. During an interview on 07/14/15 at 6:10 p.m., a staff nurse (#11) stated, Resident #3 and #8 were roommates before and have a history of not getting along. Review of Resident #8's current care plan lacked information regarding a history of behaviors between Resident #3 and #8 and failed to identify their past as roommates. During an interview on the morning of 07/16/15, an administrative staff member (#23) stated, they have a contract with a licensed social worker and she has been to the facility on [DATE], 14 and May 20, and 21 of 2015. This staff member (#23) reported a date of hire for the current Social Service Designee as 04/28/15. During an interview on the morning of 07/16/15, an administrative nurse (#2) stated, when there is a behavior, staff create an aggressive behavior event and implement 24 hour monitoring. The administrative nurse (#2) reported she has been monitoring falls, behaviors, and screening perspective residents as the facility has experienced three changes in staff in the social services department in the last year.