Every finding on record at Anson Health and Rehabilitation

Based on observations, record review, and staff interviews, the facility failed to provide a physician's ordered diet for 1 of 6 residents (Resident #40) reviewed for nutrition. The findings included: Resident # 40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired, required assistance with meal set up, and received a therapeutic, mechanical soft diet during the assessment period. Resident #40's comprehensive care plan was last updated 2/21/2022 and had a focus for difficulty eating related to side effects from [CONDITION(S)] therapy for [CONDITION(S)]. He required mechanically altered diet, puree with nectar thick liquids. A review of Resident #40's medical record revealed he had a physician's order for regular pureed diet with nectar thick liquids. The order had a start date of 11/3/2021 with no end date. Resident #40's medical record also reveal he was assessed by the Registered Dietician (RD) on 3/1/2022. The RD's assessment read in part, the resident's diet remains regular with puree texture and nectar thickened liquids, ice cream on lunch and dinner tray, and is supplemented with house supplement twice daily. On 3/1/2022 at 1:00 PM Nurse Assistant (NA) #1 was observed delivering a meal tray to Resident #40 that consisted of a hot dog in a bun with mustard and ketchup and a side item of steak fries. The NA provided tray set up and exited the room. The NA then walked out of the room and down the hall to assist meal tray delivery on another hall. At 1:03 PM on 3/1/2022 an interview was conducted with Nurse #1 who was seated at the nurse's station. When asked what diet was ordered for Resident #40, she stated he was on a pureed diet. When made aware the resident had a hot dog and fries on his meal tray, she notified NA #1 the resident was on a pureed diet. At 1:05 PM observed Nurse #1 and NA #1 remove meal tray from Resident #40. When asked if the resident had a meal tray ticket, NA #1 stated he did. When asked what the meal tray ticket indicated for diet. The NA and Nurse #1 both stated the meal ticked reflected the resident should have received regular puree diet. NA#1 stated it was an oversight, she only saw the word regular. On 3/01/2022 at 2:02 PM and interview was conducted with the Dietary Manager (DM). She stated she was training a new employee on the tray line. She stated the employee only read the first word, regular, and did not read the complete order which read, regular pureed. The DM stated she stepped away from the new employee briefly to plate a renal diet and she must have missed the error. An interview was conducted with the Director of Nursing (DON) on 03/03/2022 at 11:08 AM. She stated she was aware of the incident, and it was her expectation the resident's receive therapeutic diets prescribed by the physician.

Based on record review, observations and staff interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 3 residents reviewed for respiratory care (Resident #7). The findings included: Resident #7 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's active care plan revealed a problem area, last reviewed 12/28/21, for oxygen therapy secondary to [CONDITION(S)], chronic respiratory therapy and obstructive sleep apnea. The interventions included to administer oxygen per physician orders. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 had moderately impaired cognition and received oxygen therapy. On 2/28/22 at 12:00 PM, an observation was made of Resident #7 while she was lying in bed. The oxygen regulator on the concentrator was set at 2 liters flow by nasal cannula when viewed horizontally at eye level. On 3/1/22 at 11:55 AM, an observation was made of Resident #7 which revealed the oxygen regulator on the concentrator was set at 2.5 liters flow by nasal cannula when viewed horizontally at eye level. An observation was made of Resident #7 while she was lying in bed on 3/2/22 at 9:55 AM. The oxygen regulator on the concentrator was set at 2 liters flow by nasal cannula when viewed horizontally at eye level. On 3/2/22 at 2:00 PM, an observation was made of Resident #7 with the Director of Nursing (DON). The DON verified the oxygen regulator on the concentrator was set at 2 liters when viewed horizontally at eye level and adjusted the flow to administer 3 liters of oxygen as ordered.

Based on record review, observation, and staff interview, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors of 26 opportunities resulting in a medication error rate of 7.69% for 1 of 5 residents observed during the medication pass (Resident #36). Findings included: The facility's policy in administering medications through a metered dose inhaler dated October 2010 read in part Allow at least one minute between inhalations of the same medication and, at least 2 minutes between inhalations of different medications. The manufacturer's instruction for [MEDICATION(S)] inhalation indicated if your doctor has told you to use more sprays, wait at least one minute and shake the inhaler again. 1 a. Resident #36 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #36 had a doctor's order dated 11/3/21 for [MEDICATION(S)] 90 micrograms (mcg) - 2 puffs 4 times a day for [CONDITION(S)]. Resident #36 was observed on 3/2/22 at 8:25 AM during the medication pass. Resident #36 was observed to self- administer 2 puffs of the [MEDICATION(S)] with 5 seconds in between puffs, in front of Nurse #2. Nurse #2 was not observed to give instruction to Resident #36 on how to administer the [MEDICATION(S)]. Nurse #2 was interviewed on 3/2/22 at 9:15 AM. She stated that the facility's policy in administering medications through a metered dose inhaler was to wait 10 minutes or 15 minutes between puffs, but she was not sure. The Director of Nursing (DON) was interviewed on 3/3/22 at 11:10 AM. The DON stated that she expected the nurses to follow the facility's policy in administering medications through a metered dose inhaler. She stated that the facility's policy was to wait at least a minute between puffs of same medication and 2 minutes between puffs of different medications. 1 b. Resident #36 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #36 had a doctor's order dated 11/3/21 for [MEDICATION(S)] - 1 puff daily for [CONDITION(S)]. Resident #36 was observed on 3/2/22 at 8:25 AM during the medication pass. Resident #36 was observed to self- administer 2 puffs of the [MEDICATION(S)] in front of Nurse #2. After 10 seconds, Nurse #2 was observed to administer 1 puff of [MEDICATION(S)] to the resident. Nurse #2 was interviewed on 3/2/22 at 9:15 AM. She stated that the facility's policy in administering medications through a metered dose inhaler was to wait 10 minutes or 15 minutes between puffs, but she was not sure. The Director of Nursing (DON) was interviewed on 3/3/22 at 11:10 AM. The DON stated that she expected the nurses to follow the facility's policy in administering medications through a metered dose inhaler. She stated that the facility's policy was to wait at least a minute between puffs of same medication and 2 minutes between puffs of different medications.

Based on observations, resident and staff interviews and record review, the facility failed to ensure and monitor that a disposable lighter was secured when not in use or left unattended by a resident identified as a safe smoker. This was for 1 (Resident #36) of 3 residents reviewed for accidents. The findings included: Resident #36 was admitted on [DATE] with a diagnosis of a [CONDITION(S)]. Resident #36's quarterly Minimum Data Set, dated dated dated [DATE] indicated he was cognitively intact and exhibited no behaviors. Review of a smoking risk assessment dated [DATE] indicated Resident #36 was a safe independent smoker. Resident #36 was care planned dated 7/2/21 and revised 2/15/22 indicated he used tobacco. Interventions included explaining the smoking policy to him and to explaining to him where the designated area were located. An observation on 2/28/22 at 3:05 PM was completed. Resident #36 was not in his room. Observed on his bed visible from the hallway was a opened pack of cigarettes and a disposable lighter. An interview was completed on 3/1/22 at 9:25 AM with Nurse #4. She stated residents identified as a safe smoke were allowed to keep their cigarettes and lighter in their possession. Nurse #4 stated she was uncertain if lighters needed to be secured. She stated there were some residents with dementia known to wander into other residents rooms. An interview was completed on 3/1/22 at 9:28 AM with the Maintenance Director. He stated if the resident was a safe smoker, their lighters did not have to be secured. He said the safe smokers were told to keep the lighters in their possession at all times. An observation on 3/1/22 at 9:40 AM was completed. Resident #36 was not in his room. Observed on his bed side table was one cigarette and a disposable lighter. Resident #36 was observed outside smoking in the designated smoking area. An interview was completed on 3/2/22 at 9:50 AM with Nursing Assistant (NA) #3. She stated Resident #36 was a safe smoker and could go smoke whenever he wanted too. She stated he could keep his smoking materials (cigarettes and lighter) in his possession. NA #3 stated she did not think there was a secure place in the rooms to lock up a lighter when it wasn't in use. She stated Resident #36 knows to keep his disposable lighter in his possession at all times and to never leave it out unattended. An interview was conducted on 3/2/22 at 10:00 AM with NA #2. She stated the nurses complete an assessment to determine if a resident was a safe smoker. NA #2 stated supervised smokers had their smoking materials kept at the nurses station and someone had to go out with them to smoke. If the resident was identified as a safe smoker, they were allowed to keep their smoking materials (cigarettes and lighter) with them. NA #2 further stated the safe smokers had a lock on their nightstand to secure their lighters and were given a key to lock the top drawer. An interview was completed on 3/2/22 at 12:20 PM with Resident #36. He was sitting in his wheelchair eating lunch. There was no observed cigarettes or lighter out in the open. Resident #36 stated he was told he could keep his lighter and never told he had to keep his lighter locked up in his room when not in use or out of his room. Resident #36 stated he kept his disposable lighter in his pocket but on occasion, he would forget and leave it unsecured when he wasn't in the room. Resident #36 stated he did not have a place to secure his lighter even if he wanted too. He stated his nightstand did not have a lock on it and he had not been provided a box to lock his lighter and cigarettes in. Resident #36 stated some of the rooms in the facility had been renovated and the new nightstand in those rooms had a lock on them. He stated he assumed he would have to wait until his room was remodeled that he would have a new nightstand with a lock on it. An interview was completed on 3/2/22 at 4:14 PM with the Administrator. She stated safe smoking residents were told to keep their smoking materials (cigarettes and lighter) on their person at all times. She stated the facility had a quarterly meeting with the smoking residents and there had been no problems with the residents keeping their lighters secured. The Administrator stated she understood there was a risk and possibly the safe smoking residents should have a lock box or a new nightstand with a lock to secure smoking items. She stated the plan was to replace the nightstands during the room remodel but there had been delays in the remodeling. She stated if a resident wanted a lock box, the facility would provide it. An interview was completed on 3/3/22 at 9:29 AM with the Social Worker (SW). She stated they held smoking meetings quarterly and independent smokers could keep their smoking material (cigarettes and lighter) on their person or in a drawer. She stated the items should not be left out visible unattended. If it was discovered that a resident was not compliant with securing a lighter, the facility would meet with that person and discuss the smoking privileges. The SW stated Resident #36 had not been identified as being noncompliant with securing his lighter. She stated to her knowledge, no one person at the facility was actually completing observations rounds to ensure there was no unsecured lighters left out visible. She stated if the floor staff observed Resident #36 leaving his lighter out, they should report it for management to follow up. Resident #36 was observed sitting in his doorway on 3/3/22 at 10:20 AM. Observed on his bed was a gray colored lock box. He stated he didn't know why the lock box was in his room and stated it wasn't there earlier this morning. Resident #36 further stated he was remind to keep his lighter in his pocket yesterday.

Based on record review, observation and resident and staff interview, the facility failed to assess a resident whether the self-administration of medications was clinically appropriate for 1 of 1 sampled resident who was observed to have medication at bedside (Resident #36). Findings included: 1. Resident # 36 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #36 had a doctor's order dated 11/3/21 for [MEDICATION(S)] 90 micrograms (mcg) - 2 puff 4 times a day for [CONDITION(S)]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #36's cognition was intact. Resident #36 was observed on 3/2/22 at 8:25 AM to have the [MEDICATION(S)] inhaler in his room. When interviewed, he stated that he had been administering the [MEDICATION(S)] to himself and kept it in his room for more than a month now. Nurse #2, assigned to Resident #36 was interviewed on 3/2/22 at 12:08 PM. She stated that she was not sure whether Resident #36 was assessed for self- administration, but she knew that he had been self-administering the [MEDICATION(S)] inhaler and was keeping it in his room for a while now, more than a month. The Nurse Unit Manager was interviewed on 3/2/22 at 12:17 PM. She stated that she was not aware and was not informed that Resident #36 had been self-administering his inhaler. She reported that when she was informed on 3/2/22, she had completed the self-administration of medication assessment for Resident #21 and initiated the care plan. The Director of Nursing (DON) was interviewed on 3/2/22 at 4:10 PM. The DON stated that she expected that self-administration of medications assessment was completed, and care plan initiated before the resident could start self-administering medications. She also verified that she was not aware that Resident #36 was administering the [MEDICATION(S)] inhaler to himself. The DON added that she expected nursing to inform the Unit Managers and the MDS Nurse of resident's desire to self-administer medications.

Based on record reviews, observations and staff interviews, the facility failed to ensure the alternating pressure reducing air mattress was set according to the resident's weight (Residents #7 and #75). This was for 2 of 6 residents reviewed for pressure ulcers. The findings included: 1) Resident #7 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #7's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #7's weight history included the following: - On [DATE] was 229 pounds (lbs.) - On [DATE] was 232 lbs. - On [DATE] was 231.2 lbs. - On [DATE] was 221.8 lbs. Resident #7's care plan, last reviewed [DATE], included a problem area for the potential for skin breakdown secondary to incontinence, impaired mobility, fragile skin due to diabetes, history of unstageable pressure ulcers to the right and left buttocks, right outer ankle and a diabetic ulcer. The interventions included an air mattress. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 had moderately impaired cognition. She was coded with no pressure ulcers however had a pressure reducing device to the bed. Resident #7's weight on [DATE] was 222.2 lbs. On [DATE] an observation was made of Resident #7 while she was lying in the bed with her eyes closed. The alternating pressure reducing mattress machine was observed set on 350 lbs. The machine had weight settings from 90 to 660 lbs. and indicated to set according to the resident's weight per lbs. Resident #7 was observed lying in her bed on [DATE] at 11:55 AM and the alternating pressure reducing mattress machine was set at 350 lbs. On [DATE] at 9:55 AM, Resident #7 was observed lying in bed with her eyes closed. The alternating pressure reducing mattress machine was set at 350 lbs. The treatment nurse was interviewed on [DATE] at 10:05 AM and stated the nursing staff were responsible for checking the alternating pressure reducing mattresses every shift to ensure they were functioning properly. An interview occurred with Nurse #3 on [DATE] at 10:10 AM and stated nursing staff were to check the alternating pressure mattress to ensure they were inflated and functioning every shift but didn't change or check the settings for the weight. An interview was conducted with the maintenance supervisor on [DATE] at 10:40 AM and stated when an alternating pressure reducing mattress was ordered, he would put the mattress on the bed and ensure all the ports were hooked up correctly. The resident's weight was obtained from the nurse and entered at that time. The maintenance supervisor stated he made daily rounds only to ensure the CPR (cardio pulmonary resuscitation) settings were functioning. On [DATE] at 2:00 PM, an observation of Resident #7's alternating pressure reducing mattress was observed with the Director of Nursing (DON), as well as a review of Resident #7's weight history. The DON verified the weight setting should not have been 350 lbs. The DON added nursing staff checked the functionality of the mattresses every shift but was unsure if they checked the actual weight settings. 2. Resident # 75 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #75 had 4 stage 3 and 1 unstageable pressure ulcers. The assessment indicated that the resident's weight was 113 pounds (lbs.). Resident #75's care plan dated [DATE] was reviewed. The care plan problem was Resident #75 currently has stage 3 pressure ulcers to his right ankle, right heel, left and right ischium and coccyx. The goals were the resident will be free from further skin breakdown and his wounds will show signs of improvement/healing. The approaches included air mattress on bed to aid in pressure relief. Resident #75 was observed in bed on [DATE] at 10:30 AM, [DATE] at 10:35 AM and on [DATE] at 10:05 AM. He had an air mattress in his bed and the machine had a setting selection in lbs. and it was set at 290 lbs. The Treatment Nurse was interviewed on [DATE] at 10:06 AM. She stated that the nurses were responsible for checking the air mattress to ensure it was working and at the correct setting. She reported that the air mattress used by Resident #75 should have been set according to the resident's weight. She observed the air mattress of Resident #75 and verified that the machine was set at 290 lbs. Nurse # 3, assigned to Resident #75, was interviewed on [DATE] at 10:10 AM. She stated that she checked the air mattress daily to ensure the mattress was inflated and functioning properly. She reported that she had not been checking the settings on the machine including the weight setting. The Director of Nursing (DON) was interviewed on [DATE] at 4:10 PM. The DON stated that the Maintenance Director was responsible for the original setting of the air mattress and the nurses were responsible for monitoring the function and the setting daily. The DON verified that the air mattress machine should be set according to the resident's weight.

Based on record review, observation, and staff interview, the facility failed to follow ordered contact precautions when entering the room of a resident with active shingles infection (Resident #70) for 1 of 1 resident reviewed for contact precautions. Findings included: Resident #70 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident had a significant change Minimum Data Set completed on 8/20/19 which revealed total dependence of 2 staff for all transfers, bed mobility, toileting, and hygiene and extensive assistance of 1 for locomotion and dressing. The resident was severely cognitively impaired. The resident ' s comprehensive care plan was dated 5/21/19 and updated on 9/1/19 revealed contact precautions secondary to shingles infection with interventions to follow the facility ' s infection control policy, practice good hand washing, and use principles of infection control and universal/standard precautions. The physician order [REDACTED]. On 9/16/19 at 3:49 pm an observation was completed of Nursing Assistant (NA) #1 who entered the resident ' s room and there was a contact precaution notification on the door. The resident ' s door was labeled and had supplies for contact precautions which included hand hygiene and to wear a gown, mask, and gloves. NA #1 was observed to only wear a gown and touch the resident's bed and bed control with ungloved hands. NA #1 continued to touch the resident ' s bed without gloves and was asked to please follow the contact precautions as posted on the resident's room door. NA #1 began to glove without hand hygiene. NA #1 was asked to clean her hands before gloving and touching the clean box of gloves. An interview was conducted on 9/16/19 at 3:49 pm with NA #1 who stated that she was familiar with contact precautions. NA #1 stated that she would place her gloves on after this (which was touching the resident's bed and controller) before actually touching the resident. NA #1 commented that she was aware that shingles were highly contagious. NA #1 commented that she cleaned her hands and placed the gloves with direct care to the resident. On 9/16/19 at 4:30 pm an interview was conducted with the Director of Nursing (DON) who stated she expected all staff that enter the resident ' s room to follow the contact precautions as ordered and posted on the door to include cleaning hands and wearing gloves before touching the resident, her bed and objects. The DON commented that she would provide education for NA #1.

Based on resident and staff interviews and record review, the facility failed to maintain accurate Physician orders [REDACTED].#41) of 23 residents reviewed for accurate medical records. The finding included: Resident #41 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #41's medical record included a Physician order [REDACTED]. Review of Resident #41's quarterly Minimum (MDS) data set [DATE] indicated he was cognitively intact and exhibited no behaviors. He was coded for bilateral impairments to both his upper and lower extremities. Review of Resident #41's (MONTH) 2019 Physician orders [REDACTED]. In an interview on 9/16/19 at 3:12 PM, Resident #41 stated he was aware of his multiple contractures but did not want to wear any splints. In an interview on 9/17/19, the Rehabilitation Director stated Resident #41's splints were discontinued in (MONTH) (YEAR) due to his refusal. She stated he was last screened by therapy in (MONTH) 2019 and he continued to refuse his bilaterally upper extremity splints. In an interview on 9/19/19 at 9:57 AM, the Administrator stated with facility recently had a switch over in computer programs and it was at time the discontinued order for the daily splints must have repopulated into Resident #41 current active orders. She stated it was her expectation that Resident #41's medical record be accurate to include active Physician orders.

Based on record review, facility Nurse Practitioner and staff interviews, the facility failed to ensure an as needed (PRN) [MEDICAL CONDITION] medication ([MEDICATION NAME]) was time limited in duration for 1 of 5 residents reviewed for unnecessary medication use (Resident #6). The findings included: Resident #6 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed an order dated 5/10/19 for [MEDICATION NAME] 0.25 milligrams (mg) by mouth at bedtime PRN [MEDICAL CONDITION]. A review of the most recent Minimum Data Set (MDS) coded as a quarterly assessment and dated 6/8/19 revealed the resident was cognitively intact and had received 1 day of antianxiety medication out of the 7 day look back period. Review of the medical record revealed a recommendation from the Consultant Pharmacist to the Physician dated 6/20/19 stating per the guidelines the PRN [MEDICATION NAME] would need to have a stop date added or a progress note to document a longer duration for the use of [MEDICATION NAME]. The recommendation had not been addressed by the physician or the Nurse Practitioner. Review of Resident #6's (MONTH) 2019 Physician order [REDACTED]. A review of the Medication Administration Record [REDACTED]. A review of the (MONTH) 2019 Physician order [REDACTED]. The MAR for (MONTH) 2019 revealed Resident #6 had received the PRN [MEDICATION NAME] on 9/14/19. An interview occurred with the Director of Nursing (DON) on 9/17/19 at 2:45pm and indicated she was aware of the time limited duration for PRN [MEDICAL CONDITION] medication use. She further stated she would discuss with the NP plans for correction. On 9/18/19 at 10:30am, an interview was conducted with the Facility NP. He was aware of the [MEDICATION NAME] PRN order for Resident #6 but was not familiar with the time limited duration of [MEDICAL CONDITION] PRN medication use until he talked with the DON the day prior. In an interview on 9/19/19 at 8:45am, the Administrator stated it was her expectation that Resident #6's PRN [MEDICATION NAME] order was time limited in duration.

Based on record review, observation and staff, facility Nurse Practitioner, and pharmacist interviews, the consultant pharmacist failed to identify the maximum dose of an as needed medication (Resident #53) for 1 of 5 residents reviewed for unnecessary medication. The pharmacist failed to identify incorrect medication administration route (Resident #2) for 1 of 4 residents observed during medication pass. The facility failed to respond to a pharmacy consultant recommendation regarding the time-limited duration of as needed [MEDICAL CONDITION] medication (Resident #6) for 1 of 5 residents reviewed for unnecessary medication. Findings included: 1. Resident #53 had a physician medication order for [MEDICATION NAME] 0.4 milligram sublingual (under the tongue) every 5 minutes prn for chest pain (no maximum for the total amount) dated 2/20/19. The resident ' s annual Minimum (MDS) data set [DATE] revealed she had an intact cognition. The active [DIAGNOSES REDACTED]. The resident ' s care plan was updated 9/16/19 and revealed the problem of [MEDICAL CONDITION] with intervention to follow the physician orders. The monthly pharmacy review of medication for the past 12 months documented did not reveal that the Pharmacist identified the [MEDICATION NAME] as needed required a maximum dosage. On 9/18/19 at 11:10 am an interview was conducted with the facility Nurse Practitioner who stated the [MEDICATION NAME] was required to have a maximum milligram amount and would be corrected. On 9/18/19 at 4:43 pm an interview was conducted with the facility Pharmacist who stated that the resident's [MEDICATION NAME] should have had a maximum amount allowed of 3 doses with the order. The pharmacist stated that he did not identify the missing maximum dosage amount. On 9/19/19 9:40 am interview was conducted with Administrator and Director of Nursing who both agreed that the expectation was for the Pharmacist to identify irregularities in the medication orders to include a required maximum dosage for [MEDICATION NAME]. 2. Resident #2 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Most recent quarterly Minimum Data Set (MDS) completed on 9/6/2019 indicated Resident #2 was documented as receiving nutrition by tube feeding. Care plan for Resident #2 dated 7/11/2019 stated, Resident #2 required a feeding tube for adequate nutritional intake related to nothing by mouth (NPO) with dysphagia. Record review indicated on 4/5/19 speech and language pathology noted Resident #2 was not safe for oral intake. On 09/17/19 at 9:26 AM during an observation of medication administration Nurse #1 administered [MEDICATION NAME] 100mg tablet through Resident #2's feeding tube after crushing the medication. The order on the Medication Administration Record [REDACTED]. Review of all other medications for this resident revealed two other medication, [MEDICATION NAME] and [MEDICATION NAME], ordered by oral route with all other medications ordered via feeding tube. In an interview on 09/18/19 at 8:59 AM Nurse #1 stated Resident #2 does not take any medications or food by mouth. She further stated he was NPO per physician's orders [REDACTED].>In an interview with Nurse # 2, who was administering medications to Resident #2 on 9/18/19, she stated Resident #2 gets all medications by feeding tube and that no medications are given to Resident #2 by oral route. On 9/18/19 at 11:10 AM an interview with the facility's Nurse Practitioner was conducted. He stated he was familiar with Resident #2. He further stated the resident's medications are to be given by tube. When the Medication Administration Record [REDACTED]. He further stated pharmacy would typically send him a message to change the route of administration if it was ordered incorrectly. A physician's orders [REDACTED]. [MEDICATION NAME], schedule II, 10mg oral every 4 hours for pain was ordered with a start date of 3/16/2019. [MEDICATION NAME], schedule IV, 10mg tablet, oral, every 6 hours was ordered with a start date of 4/01/2019. Resident #2's medical record indicated pharmacy reviews were conducted on the following dates and times: 09/06/2019 12:07 PM, Resident medications were reviewed and no recommendations were issued for September. 08/05/2019 04:29 PM, Resident medications were reviewed and no recommendations regarding routes of administration were issued for August. 07/02/2019 09:52 PM. Resident medications were reviewed and no recommendations regarding routes of administration were issued for July. 06/04/2019 08:07 PM, Resident medications were reviewed and no recommendations were issued for June. 05/05/2019 09:44 PM, Resident medications were reviewed and no pharmacy recommendations for routes of administration were issued for May. 04/01/2019 10:11 PM Resident medications were reviewed and there were no recommendations made as to routes. A phone interview was conducted with the Pharmacist on 09/18/19 at 4:21 PM. The Pharmacist stated the [MEDICATION NAME], and [MEDICATION NAME] were on Resident #2's Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. In an interview with the administrator and the director of nursing on 9/19/19 at 09:57 AM, both stated that all medication administration records should reflect the accurate route of administration. 3) Resident #6 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed an order dated 5/10/19 for [MEDICATION NAME] 0.25 milligrams (mg) by mouth at bedtime as needed (PRN) [MEDICAL CONDITION]. A review of the most recent Minimum Data Set (MDS) coded as a quarterly assessment and dated 6/8/19 revealed the resident was cognitively intact and had received 1 day of antianxiety medication out of the 7 day look back period. Review of the medical record revealed a Consultant Pharmacist Communication to Physician form dated 6/20/19 stating per the guidelines the PRN [MEDICATION NAME] would need to have a stop date added or a progress note to document a longer duration for the use of [MEDICATION NAME]. The form was not reviewed or signed by the Physician or Nurse Practitioner (NP). An interview occurred with the Director of Nursing (DON) on 9/17/19 at 2:45pm. She stated the pharmacist provided her with the communication forms and she then handed them to either the physician or NP to address. She felt the Communication form dated 6/20/19 was not addressed in error. On 9/18/19 at 10:30am, an interview was conducted with the Facility NP. He could not explain why the Pharmacy Communication form addressing the continued order for PRN [MEDICATION NAME] had not been reviewed or signed. In an interview on 9/19/19 at 8:45am, the Administrator stated she expected the Physician or NP to address drug irregularity as recommended by the pharmacist in a timely manner.

Based on observations, record review and resident and staff interviews, the facility failed to apply splints to residents with contractures as ordered. This was for 2 of 6 residents reviewed for range of motion (Resident #58 and Resident #66). The findings included: 1) Resident #58 was originally admitted to the facility on [DATE] with the most recent readmission date of [DATE]. [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident to be cognitively intact with no behaviors or rejection of care. He received extensive to total assistance from staff for all Activities of Daily Living (ADL's) except for supervision with eating. He was coded for impairment to one upper and lower extremity. A review of Resident #58's active care plan revised 8/27/19 did not include a care plan for a contracture to the right hand. Review of the Restorative Nursing Program form dated 8/15/19 indicated Resident #58 was to have a right-hand splint for 4 to 6 hours a day 7 days per week. Review of the (MONTH) 2019 physician orders [REDACTED]. On 9/16/19 at 11:02am, Resident #58 was observed with limited range of motion to his right hand and stated he had not received any type of exercise or splint application to his right hand in a few days. The right-hand splint was observed on the sink counter in his room. During an observation on 9/17/19 at 9:00am Resident #58 was lying in bed with no splint to his right hand and stated he did not wear the splint the day prior. The hand splint was observed sitting on the sink counter in his room. During another observation on 9/17/19 at 4:42pm Resident #58 was sitting up in his gerichair and indicated he had not worn the right-hand splint that day. The right-hand splint was observed on the sink counter in his room. Several observations were made on 9/18/19 at 9:00am, 10:15am, 11:45am, 1:35pm. Resident #58's right hand splint was observed sitting on the sink counter in his room. An interview was conducted with the Rehab Director on 9/18/19 at 11:05am. She confirmed the resident was to have PROM and a splint applied to his right hand 4 to 6 hours a day 7 days per week. On 9/18/19 at 11:20am an interview occurred with Restorative Aide #1 (RA). She confirmed the resident was to have Restorative Nursing daily for PROM and splinting to his right hand. RA #1 stated she normally put splints on by 10:30am and removed them by 3:00 to 3:30pm or as tolerated by the resident. RA #1 further stated the aides would remove the splints during bathing and did not always put them back on or alert the Restorative Nursing staff for the need to reapply. She couldn't explain why the right-hand splint was not observed on the resident 9/16/19 through 9/18/19. Nurse Aide (NA) #1 was interviewed on 9/18/19 at 1:45pm. She was the regular aide assigned to Resident #58 during the day. NA #1 indicated splints were applied by the Restorative Aides normally after personal care had been rendered. She further stated if for some reason a splint had to be removed for care she would alert the RA to reapply. On 9/18/19 at 2:00pm Resident #58 was observed with the right-hand splint on. He confirmed the aide had just left his room from exercising his hand and applying the splint. An interview occurred with the Administrator and Director of Nursing (DON) on 9/19/19 at 9:40am. They both stated it was their expectation for the restorative aide to apply Resident #58's right hand splint as ordered. 2) Resident #66 was originally admitted to the facility on [DATE] with the most recent readmission date of [DATE]. [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident to have moderately impaired cognition with no behaviors or rejection of care. He received extensive to total assistance from staff for all Activities of Daily Living (ADL's) to include eating. He was coded for impairment to bilateral upper and lower extremities. A review of Resident #66's active care plan indicated he was to wear a right-hand splint and bilateral Ankle Foot Orthosis (AFO's) as ordered. Review of the Restorative Nursing Program form dated 8/15/19 indicated Resident #66 was to have a right resting hand splint on for 4 to 6 hours a day 7 days per week. Another Restorative Nursing Program form dated 8/28/19 indicated Resident #66 was to have right and left AFO's on for 4 to 6 hours a day 6 days per week. On 9/16/19 at 11:02am Resident #66 was observed with limited range of motion to his right hand and bilateral feet and ankles. He stated the splint and braces had not been on for a few days. The right-hand splint was observed on the sink counter and AFO braces were on the floor by the TV in his room. During an observation on 9/17/19 at 9:00am Resident #66 was lying in bed with no splint to his right hand or AFO braces to his right and left ankle. The right-hand splint was observed sitting on the sink counter and AFO braces on the floor by his TV in his room. During another observation on 9/17/19 at 4:42pm Resident #66 was observed sitting up in a gerichair and indicated he had not worn the right-hand splint or bilateral AFO's that day. The right-hand splint was observed on the sink counter and AFO braces on the floor by the TV in his room. Several observations were made on 9/18/19 at 9:00am, 10:15am and 11:45am. Resident #66's right hand splint was observed sitting on the sink counter and AFO braces on floor by the TV in his room. An interview was conducted with the Rehab Director on 9/18/19 at 11:05am. She confirmed the resident was to have a right-hand splint on for 4 to 6 hours a day, 7 days a week and bilateral AFO braces applied to his feet for 4 to 6 hours a day, 6 days per week. On 9/18/19 at 11:20am an interview occurred with Restorative Aide #1 (RA). She confirmed the resident was to have Restorative Nursing daily for splint application to his right hand and bilateral AFO braces to his feet. RA #1 stated she normally put splints on by 10:30am and removed them by 3:00 to 3:30pm or as tolerated by the resident. RA #1 further stated the aides would remove the splints during bathing and did not always put them back on or alert the Restorative Nursing staff for the need to reapply. She couldn't explain why the splint and AFO braces were not observed on the resident 9/16/19 through 9/18/19. On 9/18/19 at 1:35pm Resident #66 was observed with the right-hand resting splint on, as well as the bilateral AFO braces to his feet. He confirmed the aide had just left his room from applying the splint and braces. Nurse Aide (NA) #1 was interviewed on 9/18/19 at 1:45pm. She was the regular aide assigned to Resident #66 during the day. NA #1 indicated splints and braces were applied by the Restorative Aides normally after personal care had been rendered. She further stated if for some reason a splint or brace had to be removed for care she would alert the RA to reapply. An interview occurred with the Administrator and Director of Nursing (DON) on 9/19/19 at 9:40am. They both stated it was their expectation for the restorative aide to apply Resident #66's right hand splint and bilateral AFO braces as ordered.

Based on observations, resident and staff interviews and record review, the facility failed to ensure an activities of daily life (ADLs) dependent resident was free from unwanted facial hair. This was for 1 (Resident #40) of 3 residents reviewed for ADLs. The findings included: Resident #40 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #40's care plan last revised 5/2/19 read she was at risk for a deterioration in her ADLs to include personal hygiene due to an overall decline. Review of Resident #40's quarterly Minimum Data Set ((MDS) dated [DATE] indicated she was able to make herself understood and understood others. The MDS indicated her vision was severely impaired, she was cognitively intact and exhibited no behaviors. The MDS further indicated she required extensive assistance with her personal hygiene which included shaving. Review of an undated Total Plan of Resident Care utilized by the nursing assistants (NA) when rendering care read Resident #40 was legally blind and required assistance with grooming. Review of Resident #40 electronic Point of Care History record from 9/3/19 through 9/17/19 indicated the NA's provided limited, extensive to total assistance with her personal hygiene. In an observation on 9/16/19 at 1:06 PM, Resident #40 was sitting in her wheelchair in the main dining room. Resident #40 stated she was blind, and staff assisted her with her ADLs. Observed on her chin was facial hair. In an observation on 9/17/19 at 1:40 PM, Resident #40 was in the rehabilitation room working the therapy. She had visible facial hair to her chin. In an observation on 9/18/19 at 9:03 AM, Resident #40 was sitting in her wheelchair in the main dining room. Observed on her chin was facial hair. Resident #40 stated she could not see but when asked to feel her chin, she noted facial hair and stated she unaware that she had visible facial hair. Resident #40 stated she recalled someone shaving her facial hair a few weeks ago but she was not aware how grown out her facial hair was. In an interview on 9/18/19 at 9:09 AM, NA #2 stated Resident #40 liked to get up early so third shift completed her morning ADLs. NA #2 stated she did not notice Resident #40's facial hair but would address it immediately. In an observation on 9/18/19 at 10:20 AM, Resident #40 was sitting in her wheelchair in the main dining room attending a Resident Council Meeting. There was no observed facial hair. In a telephone interview on 9/18/19 at 4:40 PM, NA #3 confirmed she worked third shift with Resident #40 on 9/16/19 and 9/17/19. She stated Resident #40 gets up daily at around 6:00 AM. NA #3 confirmed she was responsible for completing Resident #40's personal hygiene on 9/16/19 and 9/17/19. NA #3 stated she did not notice the facial hair on Resident #40's chin, but it was a responsibly of the aides to shave her as needed. She stated it was an oversight. In an interview on 9/19/19 at 9:57 AM, the Administrator and Director of Nursing (DON) stated it was their expectation that Resident #40 be free of unwanted facial hair and expected the aides to complete the task for Resident #40 since her vision was impaired.

Based on observations, resident and staff interviews and record review, the facility failed to complete a comprehensive care plan for desired weight loss (#74) and contractures (#65, #37, #70 and #58). This was for 5 of 23 residents reviewed for comprehensive care planning. The findings included: 1. Resident #74 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #74's significant change Minimum Data Set ((MDS) dated [DATE] indicated she was cognitively intact and exhibited no behaviors. She was coded for supervision with eating, a weight of 230 pounds, no weight loss and on a Physician prescribed weight gain regimen. Review of Resident #74's Care Area Assessment (CAA) for nutrition dated 8/4/19 read as follows: mechanical soft, low concentrated sweets (LCS) and no added salt (NAS), no fired foods and diet soda. Weight of 230 and body mass index (BMI) of 55.4 ([MEDICAL CONDITION]). Agree with current plan and will continue to monitor weights. The goal read to maintain weight or 1-2 pound slow weight loss for the next 30 days. Review of Resident #74's nutrition care plan revised 8/21/19 read she would not experience further significant weight loss. Interventions included staff to encourage oral intake of food and fluids, offer substitutes and praise attempts to complete her meal. Review of Resident #74's (MONTH) 2019 Physician orders [REDACTED]. In an interview on 9/16/19 at 4:03 PM, Resident #74 stated she missed fried foods but was trying to lose some weight. In an interview on 9/18/19 at 11:45 AM, the MDS Nurse confirmed the nutrition care plan dated 8/21/19 was for significant weight loss and not therapeutic or desired weight loss as intended. She stated it was an oversight. In a telephone interview on 9/18/19 at 2:21 PM, the Registered Dietician stated Resident #74's weight loss was desired, and she had expressed a desire to lose weight. In an interview on 9/19/19 at 9:57 AM, the Administrator and Director of Nursing (DON) stated it was their expectation that Resident #74's care plan be accurate and comprehensive to include her desired weight loss. 2. Resident #65 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #65's Occupational Therapy Discharge Summary dated 8/16/19 read she discharged from therapy with a resting hand splint to her left hand for contracture prevention. Review of Resident #65's quarterly Minimum Data Set ((MDS) dated [DATE] indicated she was cognitively intact and exhibited no behaviors. She was coded for no impairment to her bilateral upper extremities. Review of a Restorative Nursing Program referral form dated 8/28/19 read Resident #65 was to wear her resting hand splint 4-5 hours daily. Review of Resident #65's Restorative Care Plan and Flow Record for (MONTH) 2019 read she was wearing her resting hand splint 4-6 hours daily. Review of Resident #65's care plan revised on 9/4/19 did not include a care plan addressing the left hand contracture or restorative nursing for splinting. In an observation on 9/16/19 at 11:52 AM, Resident #65 was noted with a contracture to her left hand that did not include her thumb and pointer finger. All other fingers were affected. Resident #65 stated she had a splint for her left hand, but staff did not always put it on. In an interview on 9/18/19 at 9:12 AM, Restorative Aide (RA) #1 stated she applied Resident #65's left hand splint daily and she tolerated it at a maximum of 4 hours and on occasion less than the prescribed duration. In an interview on 9/18/19 at 11:07 AM, the MDS Nurse stated she was not aware she should be completing a care plan for contractures or splinting. She stated the facility used the Restorative Care Plan and Flow Record as the care plan that was kept in the restorative notebook. The MDS Nurse stated Resident #65's contracture should be part of the comprehensive care plan. In an interview on 9/19/19 at 9:57 AM, the Administrator and Director of Nursing (DON) stated it was their expectation that Resident #65's care plan be comprehensive to include her left hand contracture with splinting. 3. Resident #37 was admitted on to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of the physical therapy notes revealed that the last treatment was dated 10/18/18. No further progress. The resident was not currently on a nursing restorative program. The resident ' s quarterly MDS (Minimum Data Set) dated 7/22/19 revealed that she was severely cognitively impaired and dependent for all activities of daily living. The active [DIAGNOSES REDACTED]. A review of the comprehensive care plan dated for Resident #37 did not reveal an identified problem or interventions for limited range of motion (ROM) and contracture prevention. On 7/1/19 at 10:15 am an observation was done of Nursing Assistant #1 provide incontinence care. The resident had limited ROM to all extremities and was bed/chair bound. Brief passive range of motion was provided. On 9/19/19 at 9:40 am interview was conducted with the Administrator and Director of Nursing who both agreed that the expectation was to have a comprehensive care plan to meet the specific need of each resident to include addressing contracture prevention. 4. Resident #70 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. The resident ' s record revealed she was observed to have upper extremity decline and Occupational Therapy (OT) was ordered. The resident also had decline in multiple areas. The resident had a significant change MDS completed on 8/20/19 which revealed total dependence of 2 staff for all transfers, bed mobility, toileting, and hygiene and extensive assistance of 1 for locomotion and dressing. The resident was documented as having had functional limitation in ROM, impairment on both sides of upper extremities. The resident ' s active [DIAGNOSES REDACTED]. The resident ' s comprehensive care planned dated 5/21/19 included side rails for turning and repositioning. There was no identified problem or interventions for range of motion and contracture prevention. On 9/18/19 at 3:45 pm an interview was conducted with the Rehabilitation Director (RD) who knew the resident and stated she was discharged from services because of pain in her hands. an order for [REDACTED]. RD agreed that the decreased use of the resident ' s hands and pain was a decline. On 9/19/19 9:40 am interview was conducted with Administrator and Director of Nursing who both agreed that the expectation was to have a comprehensive care plan to meet the specific need of the resident to include addressing contracture prevention. 5) Resident #58 was originally admitted to the facility on [DATE] with a most recent readmission date of [DATE]. [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident to be cognitively intact with no behaviors or rejection of care. He received extensive to total assistance from staff for all Activities of Daily Living (ADL's) except for supervision with eating. He was coded for impairment to one upper and lower extremity. Review of Resident #58's Occupational Therapy Discharge Summary dated 8/14/19 read he was discharged from therapy with a right-hand splint for contracture and tightness. Review of a Restorative Nursing Program referral form dated 8/15/19 read Resident #58 was to wear a right-hand splint for 4 to 6 hours a day, 7 days per week. A review of Resident #58's active care plan revised on 8/27/19 did not include a care plan addressing the right-hand contracture or restorative nursing for splinting. Review of the Restorative Care Plan and Flow Record for (MONTH) 2019 indicated he was wearing the right-hand splint 4 to 6 hours daily. In an observation on 9/16/19 at 11:02am, Resident #58 was noted with a contracture to his right hand and stated he had a splint for his right hand, but staff did not always put it on. An interview occurred with Restorative Aide (RA) #1 on 9/18/19 at 11:20am. She stated Resident #58's right hand splint was applied daily and was tolerated 4 to 6 hours with no complaints of discomfort. The MDS Nurse was interviewed on 9/18/19 at 11:07am and stated she was not aware a care plan was to be completed for contractures or splinting. She stated the facility used the Restorative Care Plan and Flow Record as the care plan that was kept in the restorative notebook. The MDS Nurse stated Resident #58's contracture should be part of the comprehensive care plan. An interview occurred with the Administrator and Director of Nursing (DON) on 9/19/19 at 9:40am. They both stated it was their expectation for the care plan to be comprehensive and include the right-hand contracture with splinting.

Based on staff and resident interviews and record review, the facility failed to accurately code the Minimum Data Set (MDS) in the area of nutritional status for 1 (Resident #74) of 23 residents reviewed for MDS accuracy. The findings included: Resident #74 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #74's weights revealed a 14% weight loss in the past 6 months. Review of Resident #74 significant change Minimum Data Set ((MDS) dated [DATE] indicated she was cognitively intact and exhibited no behaviors. She was coded for supervision with eating, a weight of 230 pounds, no weight loss and on a Physician prescribed weight gain regimen. Review of Resident #74's Care Area Assessment (CAA) for nutrition dated 8/4/19 read as follows: mechanical soft, low concentrated sweets (LCS) and no added salt (NAS), no fired foods and diet soda. Weight of 230 and body mass index (BMI) of 55.4 ([MEDICAL CONDITION]). Agree with current plan and will continue to monitor weights. The goal read to maintain weight or 1-2 pound slow weight loss for the next 30 days. Review of Resident #74's nutrition care plan revised 8/21/19 read she would not experience further significant weight loss. Interventions included staff to encourage oral intake of food and fluids, offer substitutes and praise attempts to complete her meal. Review of Resident #74's (MONTH) 2019 Physician orders [REDACTED]. In an interview on 9/16/19 at 4:03 PM, Resident #74 stated she missed fried foods but was trying to lose some weight. In an interview on 9/18/19 at 11:45 AM, the MDS Nurse confirmed she completed section K of the significant change MDS dated [DATE] and she incorrectly coded the MDS. She stated she should have coded the MDS for a prescribed weight loss regimen and that it was an oversight. In a telephone interview on 9/18/19 at 2:21 PM, the Registered Dietician stated Resident #74 weight loss was desired and she had expressed a desire to lose weight. In an interview on 9/19/19 at 9:57 AM, the Administrator and Director of Nursing (DON) stated it was their expectation that Resident #74's significant change MDS dated [DATE] would have been coded accurately to reflect a prescribed weight loss regimen.

Based on record review, and interviews with staff, Nurse Practitioner, physician, and Pharmacy Consultant, the Pharmacy Consultant failed to identify and address the use of with risk versus benefit and timeframe for hormone therapy (Resident #53 and #79) for 2 of 2 residents reviewed for hormone therapy, and failed to identify and address the use of an antibiotic prescribed on an indefinite basis and without an adequate clinical indication for use (Resident #28) for 1 of 3 residents reviewed for antibiotic therapy. Findings included: 1. Resident #53 was admitted to the facility on [DATE] and the documented [DIAGNOSES REDACTED]. Physician order [REDACTED]. The care plan dated 6/19/18 had goals and interventions for altered mobility, therapeutic diet, impaired vision, potential for skin breakdown, activities of daily living self-care deficit, potential for falls, potential for urinary tract infection, pain, communication deficit, diabetes, hypertension, respiratory deficit, and occasional smoker, The quarterly Minimum (MDS) data set [DATE] revealed Resident #53 had adequate hearing, clear speech, and was understood and understands. The cognition was moderately impaired. The resident required one-person physical assistance for activities of daily living (ADL) except transfers was extensive assistance of one and meal was set up. Active [DIAGNOSES REDACTED]. The resident received scheduled and as needed pain medication. The monthly physician order [REDACTED]. Resident #58 had a monthly pharmacy medication review documented with recommendations for the six-month look-back. There were no recommendations for [MEDICATION NAME]. A review of Resident #53 ' s past six-months of nurses ' notes and physician progress notes [REDACTED]. On 9/5/18 at 2:20 pm an interview was conducted with the Nurse Practitioner (NP) who stated the resident was receiving [MEDICATION NAME] 0.5 mg (reordered each month), which was decreased from 1 mg for menopausal symptoms. The resident had not had a breast exam or mammogram, one would not be considered unless there was a lump. The NP stated she would evaluate the resident today and consider discontinuing the [MEDICATION NAME] due to the potential risks. On 9/6/18 at 10:35 am an interview was conducted with the physician regarding Resident #53 ' s administration of [MEDICATION NAME] 0.5 mg each day. The physician stated he was not aware when the [MEDICATION NAME] was first started before admission to the facility; the resident was admitted with the order and the [DIAGNOSES REDACTED]. On 9/6/18 at 3:44 pm an interview was conducted with the pharmacist who stated that he assumed the physician had monitored and assessed Resident #53 for hormone replacement therapy, [MEDICATION NAME]. The pharmacist stated he expected the physician to evaluate the risk versus benefits during ongoing treatment before reordering. 2. Resident #79 was readmitted to the facility on [DATE] and the [DIAGNOSES REDACTED]. Physician order [REDACTED]. The significant change Minimum (MDS) data set [DATE] revealed the resident had adequate hearing, clear speech, sometimes understands and sometimes understood. The cognition was unable to be assessed due to the inability to answer the questions. The resident required extensive assistance of 2 staff for bed mobility and all transfers including toileting. Total dependence for locomotion and extensive assistance of 2 staff for personal care, bathing, and dressing. One-person assistance was needed for meals. The active [DIAGNOSES REDACTED]. The care plan dated 8/11/18 was updated and revealed goals and interventions for impaired thought process and memory loss, regular diet, potential for skin breakdown, potential for falls, pain, communication deficit, diuretic, in-room socialization, Hospice services, at risk for pneumonia, cardiac, and at risk for urinary tract infection. On 09/06/18 at 8:15 am during medication pass it was identified that Resident #79 had received [MEDICATION NAME] for [MEDICAL CONDITION], the resident had also received Hospice services and there was not an oncologist following since admission to the facility. A review of Resident #79 ' s record since admission did not reveal an assessment and/or monitoring nor a care plan for [MEDICAL CONDITION] and oncological treatment. There was no consultation with an oncologist. There was no start date for the [MEDICATION NAME] or a timeframe for how long the resident had been taking the [MEDICATION NAME] documented. On 9/6/18 at 10:30 am an interview was conducted with the attending physician regarding medication order of [MEDICATION NAME] 1 mg for Resident #79. The physician stated the resident was admitted from assisted living on [MEDICATION NAME] and was followed by Oncology. The resident ' s [MEDICATION NAME] medication continued by reorder each month at the facility and the management was not continued by Oncology since 8/31/17. The physician stated that he did not know when the [MEDICATION NAME] was first started before admission to the facility and the usual timeframe for administration was 5 years. The physician stated other than the [DIAGNOSES REDACTED].e. active [MEDICAL CONDITION] or metastasis for pain control) and the [DIAGNOSES REDACTED]. The physician stated that the resident was admitted to the facility on Hospice services and the goals for care would not be in line with [MEDICATION NAME] administration because it was an oncological treatment. The physician stated that he would not typically manage [MEDICATION NAME], it would be ordered and followed by an oncologist. The physician indicated that the risk versus benefit had not been evaluated and he would discuss this with the family. The risks included chronic pain and [MEDICAL CONDITION]. On 9/6/18 at 3:44 pm an interview was conducted with the pharmacist who stated that he assumed the physician had monitored and assessed resident #79 [MEDICAL CONDITION] and the treatment in consultation with an oncologist for aromatase therapy which is a [MEDICAL CONDITION] drug ([MEDICATION NAME]). The pharmacist assumed the physician had consulted an oncologist and stated that he read the physician progress notes [REDACTED]. On 9/7/18 at 2:00 pm an interview was conducted with the Director of Nursing (DON) who stated that she called Resident #79' s resident representative (RR) who stated the resident had been on [MEDICATION NAME] for 4 to 5 years and an oncologist had been following the [MEDICAL CONDITION] and administration of [MEDICATION NAME] before admission to the facility. The RR did not know the exact start date nor who the oncologist' s name. The DON stated she was not familiar with [MEDICATION NAME] and would expect the physician to evaluate for risk versus benefit and to know the timeframe for administration. 3. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility ' s Antibiotic Stewardship Program ' s policy, last revised 12/2016, indicated appropriate indications for use of antibiotics included: a. Criteria met for clinical definition of active infection or [MEDICAL CONDITION]; and b. Pathogens susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). The policy additionally stated that if an antibiotic was ordered that a start and stop date or number of days of therapy was to be indicated on the order. A Nurse Practitioner (NP) note dated 3/14/18 indicated Resident #28 had recurrent Urinary Tract Infections (UTIs). A trial of [MEDICATION NAME] (antibiotic) was to be initiated as a [MEDICATION NAME] (preventative) medication as discussed with the physician and Resident #28 ' s family member. A physician's order [REDACTED].#28. There was no stop date for this order. Nursing notes dated 3/14/18, 3/25/18, 3/29/18, and 4/7/18 indicated Resident #28 continued to receive a maintenance antibiotic for recurrent UTIs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 ' s cognition was moderately impaired. She was administered antibiotics on 7 of 7 days during the MDS review period. Resident #28 was assessed with [REDACTED]. A review of Resident #28 ' s current physician's order [REDACTED]. The orders included the [MEDICATION NAME] 25 mg twice daily that was initiated on 3/14/18 as a [MEDICATION NAME] measure related to Resident #28 ' s recurrent UTIs. A further review of Resident #28 ' s record revealed there continued to be no stop date for this antibiotic. There was no evidence in Resident #28 ' s medical record of the Pharmacy Consultant identifying and addressing the use of [MEDICATION NAME] prescribed indefinitely. An interview was conducted with the Director of Nursing (DON) on 9/5/18 at 2:30 PM. She stated that Resident #28 was on [MEDICATION NAME] for [MEDICATION NAME] related to recurrent UTIs and had no stop date. An interview was conducted with the NP on 9/5/18 at 4:00 PM. The order for Resident #28 ' s [MEDICATION NAME] that had been in place since 3/14/18 was reviewed with the NP. The NP reported that Resident #28 had recurrent UTIs and the [MEDICATION NAME] was initiated as a preventative measure because Resident #28 ' s family wanted to try something to prevent UTI reoccurrence. The NP indicated she was going to discontinue the [MEDICATION NAME] on this date (9/5/18). A physician's order [REDACTED].#28. An interview was conducted with the facility ' s Medical Director/Resident #28 ' s physician on 9/6/18 at 10:32 AM. The order for Resident #28 ' s [MEDICATION NAME] that had been in place since 3/14/18 was reviewed with the physician. He indicated the [MEDICATION NAME] was initiated based on Resident #28 ' s family member ' s insistence on wanting to try something to prevent the resident ' s recurrent UTIs. He stated that it was prescribed [MEDICATION NAME] and at a very low dose. He confirmed there was no stop date for the [MEDICATION NAME], reporting that [MEDICATION NAME] were normally ordered indefinitely. He indicated that the [MEDICATION NAME] should have been re-evaluated and discontinued prior to 9/5/18 when the NP wrote the order to discontinue it. A phone interview was conducted with the Pharmacy Consultant on 9/6/18 at 3:30 PM. Resident #28 ' s [MEDICATION NAME] that had been in place since 3/14/18 was reviewed with the Pharmacy Consultant. He confirmed he had made no recommendations related to Resident #28 ' s [MEDICATION NAME]. He stated that he had identified that this antibiotic was prescribed [MEDICATION NAME] with no stop date and assumed that the prescriber was monitoring it to ensure it was still appropriate for use. A follow up interview was conducted with DON on 9/7/18 at 2:25 PM. She stated she expected Pharmacy Consultant to identify and address the use of an antibiotic prescribed with no stop date and without an adequate clinical indication for use during the monthly drug regimen reviews.

Based on record review and interviews with staff, Nurse Practitioner (NP), Physician and Pharmacy Consultant, the facility failed to identify and address the use of [MEDICATION NAME] (preventative) antibiotics prescribed on an indefinite basis for 1 of 3 residents (Resident #28) reviewed for antibiotic therapy. The findings included: Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility ' s Antibiotic Stewardship Program ' s policy, last revised 12/2016, indicated appropriate indications for use of antibiotics included: a. Criteria met for clinical definition of active infection or [MEDICAL CONDITION]; and b. Pathogens susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). The policy additionally stated that if an antibiotic was ordered that a start and stop date or number of days of therapy was to be indicated on the order. A Nurse Practitioner (NP) note dated 3/14/18 indicated Resident #28 had recurrent Urinary Tract Infections (UTIs). A trial of [MEDICATION NAME] (antibiotic) was to be initiated as a [MEDICATION NAME] (preventative) medication as discussed with the physician and Resident #28 ' s family member. A physician's order [REDACTED].#28. There was no stop date for this order. Nursing notes dated 3/14/18, 3/25/18, 3/29/18, and 4/7/18 indicated Resident #28 continued to receive a maintenance antibiotic for recurrent UTIs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 ' s cognition was moderately impaired. She was administered antibiotics on 7 of 7 days during the MDS review period. Resident #28 was assessed with [REDACTED]. A review of Resident #28 ' s current physician's order [REDACTED]. The orders included the [MEDICATION NAME] 25 mg twice daily that was initiated on 3/14/18 as a [MEDICATION NAME] measure related to Resident #28 ' s recurrent UTIs. A further review of Resident #28 ' s record revealed there continued to be no stop date for this antibiotic. There was no evidence in Resident #28 ' s medical record of the Pharmacy Consultant identifying and addressing the use of [MEDICATION NAME] prescribed indefinitely. An interview was conducted with the Director of Nursing (DON) on 9/5/18 at 2:30 PM. She stated that Resident #28 was on [MEDICATION NAME] for [MEDICATION NAME] related to recurrent UTIs. The DON confirmed that [MEDICATION NAME] antibiotics prescribed on an indefinite basis were not in accordance with the facility ' s Antibiotic Stewardship Program ' s (ASP) policy. An interview was conducted with the NP on 9/5/18 at 4:00 PM. The NP was asked what the facility ' s Antibiotic Stewardship Program ' s policy stated about the use of [MEDICATION NAME] antibiotics prescribed indefinitely. She indicated that she was aware that [MEDICATION NAME] antibiotics prescribed on an indefinite basis were not in accordance with the facility ' s ASP ' s policy. The order for Resident #28 ' s [MEDICATION NAME] that had been in place since 3/14/18 was reviewed with the NP. The NP reported that Resident #28 had recurrent UTIs and the [MEDICATION NAME] was initiated as a preventative measure because Resident #28 ' s family wanted to try something to prevent UTI reoccurrence. The NP indicated she was going to discontinue the [MEDICATION NAME] on this date (9/5/18). A physician's order [REDACTED].#28. An interview was conducted with the facility ' s Medical Director/Resident #28 ' s physician on 9/6/18 at 10:32 AM. The order for Resident #28 ' s [MEDICATION NAME] that had been in place since 3/14/18 was reviewed with the physician. He indicated the [MEDICATION NAME] was initiated based on Resident #28 ' s family member ' s insistence on wanting to try something to prevent the resident ' s recurrent UTIs. He stated that it was prescribed [MEDICATION NAME] and at a very low dose. He confirmed there was no stop date for the [MEDICATION NAME], reporting that [MEDICATION NAME] were normally ordered indefinitely. The Medical Director confirmed that he was aware [MEDICATION NAME] antibiotics were not in accordance with the facility ' s Antibiotic Stewardship Program ' s policy. He indicated that the [MEDICATION NAME] should have been re-evaluated and discontinued prior to 9/5/18 when the NP wrote the order to discontinue it. A phone interview was conducted with the Pharmacy Consultant on 9/6/18 at 3:30 PM. The Pharmacy Consultant was asked what the facility ' s Antibiotic Stewardship Program ' s policy stated about the use of [MEDICATION NAME] antibiotics prescribed indefinitely. He indicated he was not sure what the ASP ' s policy stated about [MEDICATION NAME] antibiotics, but that generally [MEDICATION NAME] were prescribed with no stop date because they were for infection prevention. Resident #28 ' s [MEDICATION NAME] that had been in place since 3/14/18 was reviewed with the Pharmacy Consultant. He confirmed he had made no recommendations related to Resident #28 ' s [MEDICATION NAME]. He stated that he had identified that this antibiotic was prescribed [MEDICATION NAME] with no stop date and assumed that the prescriber was monitoring it to ensure it was still appropriate for use. A follow up interview was conducted with DON on 9/7/18 at 2:25 PM. She stated that she expected the facility ' s staff and providers to be aware of the Antibiotic Stewardship Program ' s policy and for the policy to be followed.

Based on observations, staff interviews and record review, the facility failed to complete a significant change Minimum Data Set (MDS) for a resident with 3 areas of decline. This was for 1 (Resident #83) of 1 residents reviewed for a significant functional and medical decline. The findings included: Resident #83 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Review of (MONTH) (YEAR) physician orders [REDACTED]. Review of a Wound assessment dated [DATE] indicated Resident #83's developed an unstageable pressure ulcer to her sacrum. Review of Resident #83's monthly weights indicated an approximate 15-pound weight loss since 1/9/18. (MONTH) 9,2018 weight was recorded as 118.6 pounds and as of (MONTH) 1, (YEAR) her weight was recorded as 103.8 pounds. Review of Resident #83's quarterly Minimum Data Set ((MDS) dated [DATE] indicated moderate cognitive impairment and she exhibited no behaviors. She was coded for total assistance with her activities of daily living (ADLs) except for supervision eating. Resident #83 was coded as incontinent of bladder and bowel, coded for one unstageable pressure ulcer and no weight loss. There was no evidence of a care plan for actual weight loss or an actual pressure ulcer. In an observation on 9/6/18 at 8:45 AM, Nursing Assistant (NA) #3 stated Resident #83 was not eating well but was able to feed herself after tray set-up. In a wound care observation on 9/6/18 at 11:25 AM, the Treatment Nurse and Director of Nursing (DON) stated since Resident #83's diet was downgraded to pureed, she has not been eating well. Observation of the sacrum revealed a pen-point site and the upper part of the sacrum. There were no concerns with technique or healing. In an interview on 9/7/18 at 12:40 PM, NA #4 stated Resident #83 had no appetite. Observation of NA #4 set up Resident #83's lunch meal. Resident #83 stated she was starving. She was observed feeding herself without difficulty and ate 75% of the meal. In an interview on 9/7/18 at 2:15 PM, the MDS Nurse stated instead of a quarterly MDS done on 8/15/18, she should have completed a significant change MDS. She stated she completed significant change MDS on 9/6/18 for Resident #83. In an interview on 9/7/18 at 3:20 PM, the Administrator stated it was her expectation that a significant change MDS would have been completed on 8/15/18 due to Resident #83's decline in weight, skin and diet.

Based on observation, record review, and interviews with staff, the physician, and the Nurse Practitioner, the facility failed to monitor an identified lesion on Resident #39 ' s right great toe that progressed to a stage 2 pressure ulcer and failed to provide treatment to the pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. The findings included: Resident #39 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's order [REDACTED].#39. Resident #39 ' s plan of care included the problem/need of the potential for skin breakdown secondary to incontinence of bowel and impaired mobility. This area was initiated on 8/16/17 and most recently updated on 7/18/18 to include the problem of an unstageable pressure ulcer to Resident #39 ' s sacrum. The goal was for Resident #39 to not present with any evidence of pressure induced skin impairment for the next review on 10/20/18. The interventions included, in part, to provide routine skin assessments to monitor for any evidence of skin breakdown, report and record any red or open areas, provide treatment accordingly if impairments were noted, and heel inspections every night at bedtime. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #39 ' s cognition was severely impaired. He had no behaviors and no rejection of care. Resident #39 required the extensive assistance 2 or more staff with bed mobility and toileting. He required the extensive assistance of 1 staff for transfers, dressing, and personal hygiene. Resident #39 had impairment on 1 side of his upper and lower extremities and had an indwelling urinary catheter. He was assessed with [REDACTED]. A wound assessment note dated 8/28/18 indicated Resident #39 had a facility acquired unstageable pressure ulcer on his sacrum. Resident #39 was identified with no other wounds. A Nurse Practitioner (NP) note dated 8/30/18 indicated Resident #39 ' s reported skin conditions included a toe ulcer. The NP ' s assessment of Resident #39 ' s toe ulcer indicated he had a (Right) great toe plantar surface with purpuric (purple spots that occur when small blood vessels burst, causing blood to pool under the skin) bullous (fluid filled blisters) lesion 0.8 centimeters (cm) x 1.4 cm no (discharge), pustules (small collection of pus) x 2 noted to the lower portion. This was the first mention in the medical record of an identified skin issue on Resident #39 ' s right great toe. A review was conducted of the physician's order [REDACTED]. There were no physician's order [REDACTED].#39 ' s identified lesion to his right great toe. A review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) from 8/30/18 through 9/6/18 indicated a nurse had signed off on Resident #39 ' s heel inspection every night at bedtime. There was no nursing documentation in the medical record related to the lesion on Resident #39 ' s right great toe identified by the NP on 8/30/18. A review of the Nursing Assistant (NA) skin monitoring forms, utilized for the NAs to document skin issues identified during the resident ' s shower, from 8/30/18 through 9/6/18 were reviewed. There was no documentation of the identified lesion on Resident #39 ' s right great toe. The medical record, both hard copy and electronic, from 8/30/18 through 9/6/18 was reviewed and contained and no mention of the identified lesion on Resident #39 ' s right great toe after the NPs note dated 8/30/18. In an observation on 9/6/18 at 9:15 AM the Wound Care (WC) Nurse provided pressure ulcer treatment to Resident #39 ' s sacral ulcer. Treatment was provided as ordered to Resident #39 ' s sacral pressure ulcer. During this observation, Resident #39 was observed with an area on his right great toe that had a dark, almost black, circular area of approximately 2.5 cm with dark red scant drainage. An interview was conducted with the WC Nurse on 9/6/18 at 9:20 AM. The WC Nurse was asked if she had observed the area on Resident #39 ' s right great toe and she indicated she had not observed the area. An interview was conducted with the Director of Nursing (DON) on 9/7/18 at 10:50 AM. The 8/30/18 NP documentation of Resident #39 ' s right great toe, the 9/6/18 observation of Resident #39 ' s right great toe, the interview with the WC Nurse on 9/6/18 that indicated she had not observed his right great toe, and the medical record review that showed no mention of Resident #39 ' s great toe lesion after the 8/30/18 NP note were all reviewed with the DON. She stated she was going to observe and assess the area on Resident #39 ' s right great toe. A second interview was conducted with the DON on 9/7/18 at 11:20 AM. She revealed she observed Resident #39 ' s right great toe with the WC Nurse on 9/7/18 and the area was assessed as a stage 2 pressure ulcer. She confirmed that the WC Nurse had not previously identified this pressure ulcer, there was no mention of this pressure ulcer in the medical record aside from the NPs 8/30/18 note that assessed the area as a lesion, and there were no orders for treatment in place. A second interview was conducted with the WC Nurse on 9/7/18 at 11:30 AM. She confirmed she observed Resident #39 ' s right great toe with the DON on 9/7/18. The WC Nurse denied seeing this wound on Resident #39 ' s right great toe previously or having any knowledge of its existence. She stated that when she was completing wound care on a resident she was focused solely on the area where the treatment was ordered. She reported she made every effort to keep any area of the resident ' s body that was not being provided with treatment covered to promote the resident ' s dignity. She indicated this was most likely the reason why she herself had not identified the area on Resident #39 ' s right great toe as his treatment orders were for his sacrum. The WC Nurse stated that normally, any new skin issues would have been reported to her by the physician, NP, or nursing staff verbally, so she would know to assess the area. She confirmed that no information was communicated to her by these parties regarding Resident #39 ' s right great toe. The WC Nurse was unable to explain why she had not observed Resident #39 ' s right great toe on 9/6/18 when the area was brought to her attention during the interview on 9/6/18 at 9:20 AM following the provision of wound care to Resident #39 ' s sacral pressure ulcer. She stated that she was going to write a wound assessment of today ' s observation (9/7/18) of Resident #39 ' s right great toe. The Wound Assessment Report dated 9/7/18 and completed by the WC Nurse indicated Resident #39 ' s right great toe had wound measurements of 0.8 cm x 1.4 cm with no depth noted. The skin around the wound had some [MEDICAL CONDITION], the wound bed was dark and scaly in color, and no drainage was noted. A physician's order [REDACTED].#39 ' s right great toe area with normal saline and pat dry. Apply Skin Prep (a liquid-film dressing that forms a protective film to help reduce friction) twice daily. This order also indicated the addition of Prostat (protein supplement) 30 milliliters (ml) daily for wounds. The care plan related to Resident #39 ' s skin breakdown and unstageable pressure ulcer to his sacrum was updated on 9/7/18 to include the problem of a stage 2 pressure ulcer to his right great toe. An intervention was also added on 9/7/18 that indicated the administration of treatment to Resident #39 ' s stage 2 pressure ulcer on the right great toe per physician's order [REDACTED]. A phone interview was conducted with Nurse #6 on 9/7/18 at 12:35 PM. She confirmed she had worked with Resident #39 on 8/30/18, completed the inspections of his heels that evening, and signed off on the MAR and TAR. She stated that she physically completed the heel inspections via visual observation and denied noticing any skin issues on Resident #39 ' s right great toe. A phone interview was conducted with Nurse #5 on 9/7/18 at 12:40 PM. She confirmed she had worked with Resident #39 on 8/31/18, 9/2/18, 9/3/18, and 9/6/18. She stated she had not physically completed Resident #39 ' s heel inspections with visual observation, but she had signed off on the MAR and TAR. She revealed she depended on the NAs to report any new issues on the resident ' s feet. Nurse #5 denied being informed of and/or noticing any skin issues on Resident #39 ' s right great toe. A phone interview was conducted on 9/7/18 at 1:11 PM with Nurse #4. She confirmed she had worked with Resident #39 on 9/3/18 and 9/4/18. She stated that sometimes she physically completed heel inspections via visual observation, but that sometimes she depended on the NAs to report any new issues on the residents ' feet. She revealed she could not recall if she or the NA had observed Resident #39 ' s heels on 9/3/18 and 9/4/18, but she had signed off on the MAR and TAR. Nurse #4 denied being informed of and/or noticing any skin issues on Resident #39 ' s right great toe. An interview was conducted with the Assistant Director of Nursing (ADON) on 9/7/18 at 12:53 PM. She confirmed she had worked with Resident #39 on 9/5/18, completed the inspections of his heels that evening, and signed off on the MAR and TAR. She stated she physically completed the heel inspections via visual observation and denied noticing any skin issues on Resident #39 ' s right great toe. She explained that she was focused specifically on Resident #39 ' s heels and had probably just not glanced at his toes. A phone interview was conducted with the NP on 9/7/18 at 1:50 PM. She was asked about her note dated 8/30/18 that indicated a toe ulcer was reported to her on 8/30/18. She indicated she was unsure about who informed her of Resident #39 ' s toe ulcer. She reported the information was probably written in the physician/NPs communication book, a hard copy book where nurses document notes for the physician/NP. The NP was asked about her assessment of Resident #39 ' s right great toe on 8/30/18. She reported that based on her assessment she had not written any orders for treatment, but that she would have expected the area to be monitored by nursing staff and to inform herself and/or the physician of any changes. The NP was asked if she provided a report on her assessment to nursing staff and she revealed that she probably told one of the nurses about her assessment and asked them to monitor the area. She indicated she was unable to recall this information with certainty. The NP reported her expectation was for nursing staff to monitor any skin issues as part of their normal nursing routine and report any changes to herself and/or the physician. She indicated she had not observed the area on Resident #39 ' s right great toe since 8/30/18 and she was provided with no nursing updates on the area. A review was conducted of the hard copy physician/NPs communication book on 9/7/18 at 2:00 PM. There was no documentation in this book related to the pressure ulcer and/or lesion on Resident #39 ' s right great toe. A phone interview was conducted with Resident #39 ' s physician on 9/7/18 at 1:30 PM. He stated he had reviewed the NPs note dated 8/30/18 and had spoken with the NP and the DON by phone on this date (9/7/18) regarding Resident #39 ' s stage 2 pressure ulcer on his right great toe. He reported he was unaware of this skin issue on Resident #39 ' s right great toe prior to this date (9/7/18). The physician indicated that based on the NPs assessment of Resident #39 ' s right great toe as a purpuric bullous lesion he would not necessarily have expected a treatment order to have been put in place or a for a wound consult to have been ordered at that time. He stated his expectation would have been for the NP to notify nursing staff of the assessment, request them to monitor the area, and for nursing staff to keep herself and/or himself informed of any changes. The physician additionally indicated that his expectation was for nursing staff to monitor any skin issues for all residents on a daily basis and to provide himself and/or the NP with notification verbally or through the physician/NPs communication book of any new or worsened areas. A follow up interview was conducted with the DON on 9/7/18 at 2:25 PM. The DON was unable to explain who initially informed the NP of a toe ulcer for Resident #39 as there was no documentation in the physician/NP communication book. The DON was asked about her expectations for the NP, WC Nurse, floor nurses, and NAs. She stated that following the NPs assessment of the lesion on Resident #39 ' s right great toe on 8/30/18 she expected the NP to write an order if treatment was indicated and to inform the floor nurse, DON, or WC Nurse verbally of her assessment so the area could be monitored in an attempt to prevent the progression of lesion to a stage 2 pressure ulcer. She indicated she expected the WC Nurse to assess any new areas that were reported to her and to communicate with the physician and/or NP to obtain treatment orders if indicated. The DON stated she expected the floor nurses to physically complete a visual observation of a resident ' s heels prior to signing off on the MAR/TAR. She explained that ideally, she would have expected the nurses to also observe the toes of Resident #39 when the heel inspections were completed, but that the nurses could have been focused primarily on his heels based on the physician's order [REDACTED].#39 ' s right great toe, initially assessed as a lesion on 8/30/18, to have been identified during these routine skin assessments. She revealed that NAs should not be depended upon to complete the heel inspections for the nurses. The DON then spoke about the NA skin monitoring forms and indicated this was a new form for the NAs and was still in the development process for performance improvement. She stated that the form was to provide supplemental information to the nursing staff on a resident ' s current skin issues observed during the shower process. She explained that based on the newness of the form, she was not surprised the NAs had not identified the area on Resident #39 ' s right great toe.

Based on record review and staff interview the facility failed to accurately code the minimum data set for active [DIAGNOSES REDACTED].#79) for 2 of 5 residents reviewed for medications and for dental (Resident #83) for 1 of 1 resident reviewed for dental. Findings included: 1. Resident #53 was admitted to the facility on [DATE] and the documented [DIAGNOSES REDACTED]. A physician order [REDACTED]. The care plan updated 6/19/18 had goals and interventions for altered mobility, therapeutic diet, impaired vision, potential for skin breakdown, activities of daily living self-care deficit, potential for falls, potential for urinary tract infection, pain, communication deficit, diabetes, hypertension, respiratory deficit, and occasional smoker, The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #53 had adequate hearing, clear speech, and was understood and understands. The cognition was moderately impaired. The resident required one-person physical assistance for activities of daily living except transfers was extensive assistance of one and meal was set up. Active [DIAGNOSES REDACTED]. The resident received scheduled and as needed pain medication. The physician progress notes [REDACTED]. A review of Resident #53 ' s record revealed the care plan had no goal or intervention documented for menopausal syndrome/hot flashes and risk for hormone replacement therapy, and the MDS did not reflect the [DIAGNOSES REDACTED]. On 9/7/18 at 3:15 pm an interview was conducted with the MDS nurse who stated the menopausal syndrome [DIAGNOSES REDACTED]. On 9/7/18 at 3:45 pm an interview was conducted with the Director of Nursing (DON) who stated she expected the MDS to be coded accurately. 2. Resident #79 was readmitted to the facility on [DATE] and the [DIAGNOSES REDACTED]. Physician order [REDACTED]. physician progress notes [REDACTED]. The significant change Minimum (MDS) data set [DATE] revealed the resident had adequate hearing, clear speech, sometimes understands and sometimes understood. The cognition was unable to be assessed due to the inability to answer the questions. The resident required extensive assistance of 2 staff for bed mobility and all transfers including toileting. The resident also had total dependence for locomotion and extensive assistance of 2 staff for personal care, bathing, and dressing. One-person assistance was needed for meals. The active [DIAGNOSES REDACTED]. Hospice services were in place. The care plan dated 8/11/18 was updated and revealed goals and interventions for impaired thought process and memory loss, regular diet, potential for skin breakdown, potential for falls, pain, communication deficit, diuretic, in-room socialization, Hospice services, at risk for pneumonia, cardiac, and at risk for urinary tract infection. A review of Resident #79 ' s record revealed the care plan had no goal or intervention documented for [MEDICAL CONDITION] nor risk and timeframe for [MEDICAL CONDITION] treatment, and the MDS did not reflect the [DIAGNOSES REDACTED]. On 9/7/18 at 3:15 pm an interview was conducted with the MDS nurse who stated the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. On 9/7/18 at 3:45 pm an interview was conducted with the DON who stated she expected the MDS to be coded accurately. 3. Resident #9 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #9's annual Minimum Data Set ((MDS) dated [DATE] 7/4/18 indicated he was cognitively intact and exhibited no behaviors. He was coded with no dental concerns. Review of a physician order [REDACTED].#9 was to be referred for a full mouth extraction. Review of a dental consult dated 7/10/18 read a comprehensive evaluation with Resident #9's but noted refusal for any dental intervention. In an interview and observation on 9/5/18 at 3:00 PM, Resident #9 stated he was experiencing no dental or oral discomfort. He stated he went to a dentist about his teeth awhile back and they wanted to pull all his teeth. He stated he declined having all his remaining teeth extracted. Resident #9's oral civility was observed with multiple missing, broken and decaying teeth. In an interview on 9/6/18 at 8:30 AM, Nursing Assistant (NA) #2 stated Resident #9 often refused oral care and voiced no oral discomfort. In an interview on 9/7/18 at 2:15 PM, the MDS Nurse stated she completed the section L (Oral and Dental Status) for the annual MDS dated [DATE]. She stated she was aware Resident #9 was missing teeth, but she coded the MDS inaccurately. In an interview on 9/7/18 at 3:20 PM, the Administrator stated it was her expectation that section L for oral/dental status of Resident #9 would have been coded accurately on the annual MDS dated [DATE].

Based on observations, staff and resident interviews and record review, the facility failed to complete a comprehensive care plan for actual weight loss and pressure ulcer for 1 (Resident #83) of 3 residents reviewed for weight loss. The facility also failed to complete a comprehensive care plan for restorative nursing and refusal for 1 (Resident #9) of 2 residents reviewed for range on motion. The findings included: 1. Resident #83 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Review of (MONTH) (YEAR) physician orders [REDACTED]. Review of a Wound assessment dated [DATE] indicated Resident #83's developed an unstageable pressure ulcer to her sacrum. Review of Resident #83's monthly weights indicated an approximate 15-pound weight loss since 1/9/18. (MONTH) 9, (YEAR) weight was recorded as 118.6 pounds and as of (MONTH) 1, (YEAR) her weight was recorded as 103.8 pounds. Review of Resident #83's quarterly Minimum Data Set ((MDS) dated [DATE] indicated moderate cognitive impairment and she exhibited no behaviors. She was coded for total assistance with her activities of daily living (ADLs) except for supervision eating. Resident #83 was coded as incontinent of bladder and bowel, coded for one unstageable pressure ulcer and no weight loss. There was no evidence of a care plan for actual weight loss or an actual pressure ulcer. In an observation on 9/6/18 at 8:45 AM, Nursing Assistant (NA) #3 stated Resident #83 was not eating well but was able to feed herself after tray set-up. In a wound care observation on 9/6/18 at 11:25 AM, the Treatment Nurse and Director of Nursing (DON) stated since Resident #83's diet was downgraded to pureed, she has not been eating well. Observation of the sacrum revealed a pen-point site and the upper part of the sacrum. There were no concerns with technique or healing. In an interview on 9/7/18 at 12:40 PM, NA #4 stated Resident #83 had no appetite. Observation of NA #4 set up Resident #83's lunch meal. Resident #83 stated she was starving. She was observed feeding herself without difficulty and ate 75% of the meal. In an interview on 9/7/18 at 2:15 PM, the MDS Nurse stated she did not care plan Resident #83 for the actual pressure ulcer with interventions and for actual weight loss with interventions. She stated she only added the presence of the unstageable pressure ulcer to Resident #83's sacrum to the interventions listed for the potential of pressure ulcers. The MDS Nurse stated it was the responsibility of the Dietary Manager (DM) to complete the care plan for actual weight loss. In an interview on 9/7/18 at 2:48 PM, the DM stated she was not aware that Resident #83 had lost weight and noted she was only care planned for the potential for weight loss. The DM stated she should have completed a care plan for actual weight loss when she reviewed the quarterly MDS completed on 8/15/18. In an interview on 9/7/18 at 3:20 PM, the Administrator and DON stated it was their expectation that Resident #83's care plan be comprehensive and include the presence of an actual pressure ulcer with interventions. Both stated the comprehensive care plan should have also included a care plan for Resident #83's actual weight loss. 2. Resident #9 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #9's quarterly Minimum Data Set ((MDS) dated [DATE] indicated he was cognitively intact and exhibited no behaviors. He was coded for impairments to both lower extremities and one upper extremity. Review of a Therapy Screen dated 7/24/18 read Resident #9 refused to wear his elbow and wrist splint and had a history of [REDACTED]. Review of Resident #9's (MONTH) (YEAR) physician orders [REDACTED]. In an interview and observation on 9/5/18 at 3:00 PM, Resident #9 stated the restorative aides ask him if he would wear his left wrist splint, but he refused because it was painful. He was observed wearing an elbow splint to his left arm. He stated he sometimes wore splints to his bilateral lower extremities, but the splints impede is mobility when he wanted to out to smoke. In an interview on 9/6/18 at 8:30 AM, Nursing Assistant (NA) #2 stated Resident #9 Nursing Assistant (NA) #2 stated the restorative aides did his does splinting and ROM but she knew he usually refused to wear his splints. In an interview on 9/6/18 at 9:40 AM, the Rehabilitation Director stated Resident #9 was screened quarterly for worsening of his contractures or for a change in his compliance and wiliness to participate in therapy. In an observation on 9/6 at 11:20 AM, Resident #9 was sitting up in his wheelchair wearing his left elbow splint and his bilateral lower extremity splints. In an interview on 9/6/18 at 2:35 PM, the Restorative Aide (RA) stated she performed passive ROM to Resident #9's bilateral lower extremities, left elbow and left wrist. The RA stated Resident #9 often refused splinting and would never allow her to place the left wrist splint on. The RA stated Resident #9 also refused his bilateral lower extremities because the splints limit his mobility to go smoke. Review of Restorative Nursing Notes from 8/1/18 to present included multiple refusals for splinting. In an interview on 9/7/18 at 2:15 PM, the MDS Nurse stated she was aware that Resident #9 was receiving passive ROM and splinting. She also stated she was aware of his refusal of his splints on occasion. She was unable to offer an explanation why the restorative nursing and refusal were not care planned. In an interview on 9/7/18 at 3:20 PM, the Administrator and Director of Nursing stated it was their expectation that Resident #9's care plan be comprehensive and include the restorative nursing and his refusal of splinting.

Based on record review, staff, Licensed Clinical Social Worker (LCSW) and psychiatrist interviews, the facility failed to protect 1 (Resident # 2) of 3 sampled residents from abuse. Resident #1, who was exhibiting behaviors of paranoia assaulted Resident #2, who was cognitively impaired. Resident #2, was admitted to the hospital on [DATE] and died on [DATE]. On [DATE], Resident #1 was moved to reside in the same room with Resident #2. Immediate jeopardy began on [DATE] at 7:20 PM when Resident #1 assaulted Resident #2. Resident #2 was discovered on the floor with blood on his face, head, chest, pants, and floor. Resident #1 was discovered sitting in the room in his wheelchair with a set of keys in his hands with blood present on his hands. The immediate jeopardy is present and ongoing. Findings included: Resident #2 was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. Resident #2's last Minimum Data Set (MDS) was a comprehensive annual assessment with an Assessment Reference Date (ARD) of [DATE]. The resident was coded as having had severe cognitive loss. The resident had a Brief Interview for Mental Status (BIMS) score of 3. The resident had no behaviors coded. The resident was coded as requiring extensive assistance of one person for bed mobility, transfer, and toilet use. The resident was not coded as having had any swallowing difficulty. The resident was not coded as having had received [MEDICAL CONDITION] medications. Resident #2's care plan, most recently updated on [DATE], revealed the resident needed monitoring for inappropriate actions (yelling at spouse, threatening to hit/strike spouse, being argumentative with spouse, etc .) towards spouse and having periods of confusion. Interventions included: removing the resident from his spouse's surroundings when she appeared to be upsetting or agitating him for her safety. The resident's spouse was moved out of the resident's room to another room on [DATE]. Per an interview conducted on [DATE] at 3:52 PM with the unit manager the resident's spouse was moved out of the resident's room due to an altercation between Resident #2 and his spouse. Resident #1 was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set (MDS) was an annual comprehensive assessment with an Assessment Reference Date (ARD) of [DATE]. The resident was coded as being cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident's behaviors included feeling depressed and feeling bad about himself for ,[DATE] days of the 7 day assessment period. The resident was coded as having had delusions and verbal behavioral symptoms directed toward others during ,[DATE] days of the 7 day assessment period. The resident's behaviors put the resident at risk for illness/injury. The resident was coded as requiring extensive assistance of one person for bed mobility and toilet use. The resident was coded as requiring extensive assistance of two people for transfers, i.e. from bed to chair. The resident was coded as requiring supervision and one person physical assist with eating. The resident was coded as having had received an antipsychotic and antidepressant for each of the 7 days of the assessment period. The resident was coded as having had received an antianxiolytic for 4 days of the 7 day assessment period. The Care Area Assessment (CAA) triggered for Cognitive Loss/Dementia. Review of the CAA revealed the following: The resident had a history of [REDACTED]. The resident required staff redirection/reorientation during periods of confusion/disorientation and required assistance with appropriate decision making at times. The resident had delusional episodes noted [DATE]st and 2nd, 2017, feeling his roommate wanted to harm him, the resident fell from his wheelchair and had a subsequent emergency room visit. The visit confirmed no acute injury despite bump on head. The resident triggered a CAA for Psychosocial Well-being. Review of the CAA revealed the following: The resident had a [DIAGNOSES REDACTED]. The resident had inappropriate outbursts and delusional thinking noted at times. The resident was generally pleasant, friendly and easily directed. The Mood State triggered a CAA. Review of the CAA revealed: The resident had [DIAGNOSES REDACTED]. The resident was being treated with medications and was able to go get therapy at the outpatient psychiatric center when he needed. The resident had [DIAGNOSES REDACTED]. Resident had noted use of [MEDICAL CONDITION] medications including: [MEDICATION NAME] (antipsychotic), quetiapine (antidepressant), and [MEDICATION NAME] (antianxiolytic) for anxious mood indicators. A CAA for behavioral symptoms triggered. Review of the CAA revealed: Noted episode of combativeness (hitting at staff) on [DATE]. Noted episode of verbally aggressive/abusive behavior towards staff and escalating delusional thoughts that his roommate wanted to harm him. The resident had noted [DIAGNOSES REDACTED]. The resident's behaviors were usually easily redirected. Inappropriate behaviors were discouraged as they occurred. Noted use of multiple [MEDICAL CONDITION] medications to help manage moods and behaviors. Care plan was developed for behaviors secondary to the need for implementation of measures to help decrease the number of episodes of inappropriate behaviors. The CAA for [MEDICAL CONDITION] drug use triggered. The resident's [MEDICAL CONDITION] medications included [MEDICATION NAME], and quetiapine. Management of [MEDICAL CONDITION], anxiety, and depression. Noted evidence of paranoid delusional thinking and having had verbally aggressive behaviors during the assessment period. The resident presented with episodes of delusional behaviors (thought staff was stealing from him, roommate was taking his clothes, etc.) however, there was no documented episodes of delusion behavior noted during assessment period. The resident's inappropriate behaviors were monitored every shift and potential side effects of medications were also monitored. Resident #1's care plan, most recently updated on [DATE], included the resident had depression, poor decision making skills, mood and behavioral problems, [MEDICAL CONDITION], anxiety, hallucinations, delusions, paranoia, combativeness/physically abusive acts, impaired cognition, and poor awareness of safety. The goals of the care plan listed included: The resident would present with decreased episodes of inappropriate behaviors (hallucinations/delusions, combativeness during care, etc.), the resident will accept staff redirection/reorientation in a positive manner at each interaction daily over the next review, and the resident will present with decreased episodes of depressive mood (crying/tearfulness, complaints of feeling sad/down, depressed). The Approaches included: Refer to Mental Health as needed for the evaluation of depressive mood, encourage the resident to express his feelings and provide active listening, refer to mental health as needed for the evaluation of depressive mood and behaviors, monitor for the presence of hallucination/delusions every shift, document and record evidence of hallucinations and delusional behaviors in notes, Notify Medical Doctor (MD) of any increase in delusional thinking or hallucinations, and discourage inappropriate behaviors as they occur explaining the potential negative outcome of his actions. Resident #1's notes revealed the following: A nurses' note dated [DATE] documented the resident told a housekeeper to get out of his room. He then picked up a trash can and threatened to hit the housekeeper with the trash can. The resident complained of anxiety to the nurse and the nurse documented she medicated Resident #1 for anxiety. A nurses' note dated [DATE] documented the resident was arguing with his roommate. The curtain was pulled between the two residents and Resident #1 would peek around the curtain and the roommate would start fussing. No intervention was documented. Review of the Nurses' note from [DATE] for Resident #1 revealed a note documenting an event that took place on [DATE]. Resident #1 was documented as having had issues with the roommate he had at the time, the issues included arguing with his roommate and was concerned his roommate was going to get him. The nurse documented she talked with the roommate and asked that he be nice to Resident #1 and not argue with him. The nurse also documented she asked them to be nice to each other. The nurse informed Resident #1 if he felt threatened he could leave the room and talk to the nurse and the resident agreed. The note further documented the resident was moved to a different room on [DATE]. Resident #1's nurses' notes had documentation on [DATE] the resident was waving his hands, talking in a loud voice and stating his roommate was going to stab him in the leg. An interview conducted with Nurse #1 on [DATE] at 11:47 AM revealed Resident #1 had several room changes and roommates. She stated Resident #1 did not get along with the former roommates. When Resident #1 had a roommate he would say the roommate did not like him or they did not get along. The nurse further added most of the time the resident was calm unless he became upset about something. The nurse stated the resident had gotten upset about his roommates, she did not know if it was some paranoia. The nurse then added she guessed that was why administration kept trying to move him and put him with different people, but he always seemed to do better on his own. An interview conducted with the Regional Operations Manager (ROM) on [DATE] at 2:20 PM revealed Resident #1 had several room changes based on his request. She stated Resident #1 would be in a room for a week or so with a resident and he would get paranoid about his roommate and he would request a room change. In regards to Resident #2, the ROM explained his spouse was transferred to another room in the facility in July due to concerns Resident #2 had become argumentative toward his wife. There was a concern he became aggressive toward his spouse. The ROM added Resident #2 and his spouse had severe cognitive loss. An interview conducted with the facility Social Worker (SW) on [DATE] at 2:12 PM revealed Resident #1 had several room changes due to him not getting along with people, she was not sure if it was him or the roommate. Resident #1 liked being in a room by himself. In regards to the room placement of Resident #1 with Resident #2 she stated she had to put residents together in a room. She added some department heads had some hesitation with the roommate combination but there were no identified specific concerns just general statements of It will not work. The SW stated when compared to other possible room assignment for Resident #1 it was believed to be the best option. She stated she was never alarmed or concerned with the combination of Resident #1 and Resident #2. The SW added Resident #1 was seen by psychiatric services for his behaviors associated with his [MEDICAL CONDITION] including his paranoia. The SW stated she spoke with Resident #1 earlier in the day before the incident on [DATE]. The resident had told her he was worried his roommate was going to hurt him and did not want to go back into his room. The resident was unable to clarify on [DATE] how he thought someone was going to hurt him, she added it was just kind of a fear or paranoia. She explained it was not uncommon for Resident #1 to be paranoid about his roommate and he had a history of [REDACTED]. One time the resident did state he thought his former roommate was going to jump him. In regards to Resident #2 she stated he was very demented and was getting agitated toward his spouse. Resident #2 was starting to show aggression toward her, it was reported to her (the SW) he had been yelling at his spouse. The SW stated when she had to combine residents in rooms she would review the potential roommate combination with the Inter Departmental Team and take into consideration the information that was shared. Per the facility 24 hour report for resident abuse, dated [DATE] revealed on [DATE] at 7:20 PM Resident #1 assaulted Resident #2. Review of the 5 Working Day Report, dated [DATE], revealed Resident #1 was discovered in the room, behind a closed door with Resident #2. Resident #2 was discovered on the floor with blood on his face, head, chest, pants, and floor. Resident #2 was yelling, Get him off of me. Resident #1 was discovered sitting in the room in his wheelchair with a set of keys in his hands with blood present on his hands. An interview conducted with Nursing Assistant (NA) #1 on [DATE] at 3:04 PM revealed she was working the evening of [DATE] at the time of the incident involving Resident #1 and Resident #2. She stated Resident #1 had a history of [REDACTED].#1 stated she heard someone calling faintly, help. She stated she left the break room and went down the hall and by the time she got to the room of Resident #1 and Resident #2 other staff had responded to the incident prior to her arrival. The nurses were around Resident #2 and he was bleeding from his mouth, his head, had a bruise on his arm, and a bruise on his back. Resident #1 was taken out of the room and put into the nurses' station with NA#2. An interview conducted with NA #2 on [DATE] at 3:29 PM revealed she was working the evening of [DATE] at the time of the incident involving Resident #1 and Resident #2. She stated she had been working with Resident #1 for ,[DATE] weeks. She stated he spent most of his time in his room with the door closed. NA #2 stated the evening of the incident she heard someone calling. On her way to investigate who was calling she was informed to stay at the nurses' station with Resident #1 by a nurse. While NA #2 was providing 1:1 with Resident #1, he explained to her he went into the room and Resident #2 had his privacy curtain closed. Resident #1 stated he wanted it opened so he opened the privacy curtain. Resident #2 closed the privacy curtain. Resident #1 stated when he opened the privacy curtain Resident #2 had a pistol in his hand and came at Resident #1. Resident #1 took the keys from around his neck and hit Resident #2 in the head ,[DATE] times, Resident #2 fell to the floor, and then Resident #1 started kicking Resident #2. An interview conducted with the Unit Manager (UM) on [DATE] at 3:52 PM revealed she was working the evening of [DATE] at the time of the incident involving Resident #1 and Resident #2. The UM described Resident #1 as a resident who liked to stay to himself, he was difficult to get along with, he wanted things his way, he often stayed in his room, he liked to have the door closed when he was in his room, and he had room changes because of his behaviors. The resident's behaviors included having the television too loud and wanting to have the door closed. In regards to Resident #2 she stated he often stayed in his room, and his spouse had to be moved out of the room they shared because of an altercation Resident #2 had with his wife. She stated she heard a resident calling for help the evening of [DATE] and when she heard where it was coming from (the room of Resident #1 and Resident #2) the sound was muffled because the door was closed. She arrived to the room after other staff members had responded to the incident and the door was opened. Other staff members were assisting Resident #2 off of the floor, he was provided first aid to his wounds, and they started assessing his injuries. Resident #1 was taken out of the room and he was stating he wanted his belongings out of the room. An interview conducted with Nurse #2 on [DATE] at 4:10 PM revealed she worked on [DATE] when Resident #1 was placed in the room with Resident #2 and she felt both residents were displeased about being roommates and did not really talk to each other. Resident #2 asked where his spouse was going to sleep and the nurse explained his spouse was going to sleep in another room and Resident #1 would be in the room now. She said Resident #2 said OK and went back to looking out the window. Nurse #2 stated she was present at the facility at the time of the incident on [DATE]. Nurse #2 stated Resident #1 spent most of the day out of the room he shared with Resident #2 on [DATE]. She explained Resident #1 had a history of [REDACTED]. She stated she heard someone calling for help the evening of the incident involving Resident #1 and Resident #2. She added when she opened the door to the room she observed Resident #2 to be lying on the floor, in front of his bed. He was laying sideways, on one elbow. Resident #1 was sitting in his wheelchair and was calm. She assessed Resident #2 and found he had quite a bit of blood on him. When they attempted to assist him into a sitting position Resident #2 continued to holler. He was saying he was [AGE] years old (the resident was [AGE] years old) and keep him, referring to Resident #1, out of here. Resident #2 also stated if he were to get his hands on him, he would kill him, referring to Resident #1. Review of the emergency room documentation dated [DATE] revealed Resident #2 complained of right hip pain and had [MEDICAL CONDITION]. The physical exam revealed the resident blood pressure was ,[DATE] and had 1 centimeters (cm) laceration to the right parietal (top of the head) scalp with hematoma and 0.5 cm laceration to the right upper lip. There was a contusion to the left shoulder. The resident was awake, alert, and conversive. The result of the radiology study of the right hip showed impacted right femoral neck fracture, osteopenia and [MEDICAL CONDITION] findings. The CT (computed tomography, a diagnostic medical test that produces images of the head) scan of the head did not show bleeding or mass. A CT scan of the face did not show any fractures. The wounds were cleaned and irrigated. Two staples were placed in the right scalp laceration. Two sutures were placed in the right upper lip. Review of the hospital medical record revealed Resident #2 was moved to a different hospital on [DATE]. He underwent surgery to repair the broken hip. Postoperatively, the resident had [MEDICAL CONDITION] requiring overnight intubation (mechanical respiration through a breathing tube). The resident was extubated (removal of the breathing tube) on [DATE]. The resident was agitated so they could not place a nasogastric tube to provide hydration and nutrition. Palliative (end of life) care was consulted due to the resident's declining clinical condition. His sodium level worsened due to dehydration and inability to eat. The palliative care note revealed the health care power of attorney (HCPOA) was interviewed. He stated the resident had no difficulty swallowing prior to this hospital admission, but now the resident has minimal verbal communication and was exhibiting signs of difficulty swallowing after prolonged use of the breathing tube after surgery. The resident was scheduled for a swallowing exam for the evaluation of swallowing difficulty. The health care power of attorney told Palliative care that in the event the resident was unable to pass the swallowing evaluation, the resident would not want a permanent feeding tube and the resident would not want to be resuscitated in the event he experienced [MEDICAL CONDITION] or respiratory arrest. The resident did not pass the swallowing exam. The resident had labored breathing and died at 1:52 AM on [DATE] likely due to aspiration according to the discharge summary. Resident #2's discharge [DIAGNOSES REDACTED]. Review of Resident #2's Certificate of Death revealed a date of injury of [DATE]. The date of death was listed as [DATE]. The resident's immediate cause or condition that resulted in death was listed as complications of a right femoral neck (hip) fracture. The description as to how the [MEDICAL CONDITION] occurred was listed as a ground level fall after assault by another resident. The manner of death listed was homicide. Review of the Incident/Investigation report from the local Police Department with a date of [DATE] and a time of 7:38 PM revealed a crime of aggravated assault on handicapped person and murder. The victim was listed as Resident #2. The crimes listed were aggravated assault on a handicapped person and number. The description of the incident was the suspect hit, kicked, and otherwise assaulted victim, causing injuries that led to the death of the victim. The injury listed was severe lacerations Several unsuccessful attempts were made to interview law enforcement regarding the incident between Resident #1 and Resident #2. An interview conducted with the ROM on [DATE] at 2:20 PM revealed Resident #1 was placed under one to one supervision with NA#2 upon discovery of the assault until he was transported by the local Police Department to the local emergency room . The ROM further clarified Resident #1 did not currently reside at the facility and was incarcerated without bond. An interview conducted with the Licensed Clinical Social Worker (LCSW) with the consult psychiatric services on [DATE] at 4:28 PM revealed she was seeing Resident #1 since February of 2017. She stated he was very paranoid and delusional. She said he thought other people wanted to hurt him. She also stated she thought other residents were Satanist and thought others were out to get him because they worshipped Satan. During their visits Resident #1 had talked about his previous roommate being a Satanist. The LCSW added the resident had expressed hallucinations to her in the past including thoughts that his roommate had a gun or weapon and thought his roommate was going to kill him. The LCSW clarified he had made these comments about residents who were bedbound and did not represent a threat to Resident #1. The LCSW saw the resident on [DATE] and he told her he thought his roommate and the other resident who lived next door to him were going to jump him. The LCSW asked Resident #1 on [DATE] if he felt so overwhelmed he felt he was going to hurt himself or someone else and he responded no. Resident #1's behavior, delusions, and paranoia were lessened when the resident did not have a roommate. When Resident #1 did not have a roommate he was able to make progress about his delusions and paranoia. When Resident #1 had a roommate he would not allow the LCSW to visit him in the room and they would have to conduct their visit in another location in the facility. When he had a roommate, Resident #1 would sit outside the room at times and not enter the room. In regards to Resident #2 the LCSW explained he was very demented. On one occasion he had asked where his spouse was and he was looking for his car keys so he could take her home. An interview conducted with the psychiatrist with the consult psychiatric services on [DATE] at 2:38 PM revealed she had visited Resident #1 on [DATE]. She stated she had seen him due to a concern about the resident reaching out and touching staff, visitors, and other residents. She added he had chronic paranoia but it seemed managed and controlled by his medications regime. Despite attempts made via phone from [DATE] through [DATE] and request to facility staff to interview Resident #2's medical doctor from regarding his decline and death, Resident #2's medical doctor did not come to the facility or return calls to be interviewed. Calls were made on [DATE] to the hospital where Resident #2 died and attempts were made to interview the medical doctor who provided care resulted in no interviews. A call was made and a message was left at the medical doctor's office on [DATE] in regards to interview Resident #2's hospital medical doctor and no response was received. The Administrator, DON, Director of Clinical Services, Clinical Consultant and Regional Operations Manager were notified of the Immediate Jeopardy on [DATE] at 7:20 PM.

Based on record review, staff, Licensed Clinical Social Worker (LCSW) and psychiatrist interviews, the administration failed to recognize potential harmful effects of paranoia and delusions and failed to implement a system of thoughtful decision making with roommate assignments. In addition the facility failed to create and maintain a safe environment for the residents. The result of the previous listed failures resulted in injuries and subsequent death to one of three sampled residents (Resident #2) who were investigated for abuse. The findings included: Immediate jeopardy began on [DATE] at 7:20 PM Resident #1 assaulted Resident #2. Resident #2 was discovered on the floor with blood on his face, head, chest, pants, and floor. Resident #1 was discovered sitting in the room in his wheelchair with a set of keys in his hands with blood present on his hands. The immediate jeopardy is present and ongoing. Cross Refer to F 223: Based on record review, staff, Licensed Clinical Social Worker (LCSW) and psychiatrist interviews, the facility failed to protect 1 (Resident # 2) of 3 sampled residents from abuse. Resident #1, who was exhibiting behaviors of paranoia assaulted Resident #2, who was cognitively impaired. Resident #2, was admitted to the hospital on [DATE] and died on [DATE].

Based on observation, record reviews and staff interviews, the facility failed to prevent 1 of 7 cognitively impaired residents from exiting the facility by failing to follow wanderguard manufacturer instructions in regard to placement of the wanderguard, resulting in the resident being admitted to the hospital with [REDACTED].(Resident #1) The Immediate Jeopardy began on 1/10/2015 when Resident #1 exited the facility unattended by the facility staff, and was found beside the storage building. The Immediate Jeopardy was removed on 1/23/2015 at 3:45 PM when the facility provided an acceptable Credible Allegation of Compliance. The facility will remain out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action and monitoring for Resident #1. The findings included: The manufacturer's instruction on wanderguards was reviewed. The instruction indicated under warning "Do not place the signaling device on or next to metal such as wheelchair frames, jewelry, watches, etc (etcetera) or allow it to come in contact with a door or associated hardware, such as crash bar, push bar, etc. Metal could interfere with the signal sent to the door module." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#1 was implemented due to increased wandering. The order was changed on November 2014 indicating the wanderguard was to be placed on the wheelchair of the resident ' s wrist. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had long and short term memory problems, required assistance of one person with mobility, dressing and hygiene. The assessment also indicated the resident needed supervision with ambulation in the room and corridor. The MDS further indicated the resident needed limited assist with locomotion on and off the unit. The resident was not coded for wandering behavior. The resident initially was care planned for wandering behaviors on 4/12/2014. The care plan was updated on 6/11/2014, 9/10/2014 and 12/3/2014. The resident was identified with wandering behaviors creating the potential for elopement and needed continual monitoring for attempts at elopement. The goal stated for this problem was that the resident would not present with any episodes of elopement daily over the next review. The interventions listed for this problem included: 1- "Monitor resident for behaviors (attempts at elopement, wandering) every shift record any incident of elopement in nurse's note. Notify physician of any increased moods or behaviors." 2- "Apply wanderguard for safety." 3- "Provide redirection when wandering." Review of the nurse's note dated 1/8/2015 at 9:00 PM, read "Resident #1 sitting up in wheelchair in hallway. Refuse to go to bed. Blanket is over his head. Stated, "I'm ok right here, I don't want to go to bed." Review of the nurse's note date 1/10/2015 at 5:00 AM indicated "Resident continue to sit up in wheelchair near front door all night. Encourage several times to go to bed. Refuse." Review of the nurse's note date 1/10/2015 at 10:35 PM read "Resident has been sitting in wheelchair in front of heater all day. He has refused all attempts to clean or change him today." Review of the nurse note dated 1/10/2015 at 11:20 PM revealed "When doing rounds found resident w/c (wheelchair) empty sitting beside heater in hallway, search of building completed by all staff and resident not found on call RN (Registered Nurse) (Assistant Director of Nursing) phoned, emergency services notified." Review of the nurse note's dated 1/11/2015 at 3:00 AM documented "Resident found and transferred to the hospital." Review of Resident #1's facility's timeline dated 1/11/2015 revealed on Saturday, 1/10/205 between 10:30 PM-10:50 PM, the resident was last seen sitting by heater (preferred area for patient). At 11:00 PM, Nurse #1 saw an empty wheelchair, assumed patient was in the bathroom. Between 11:30PM- 11:35PM, a Missing patient code was activated Assistant Director of Nursing (ADON) who was on call was notified and staff started searching building and grounds for patient. At 11:40 PM, police department was called and they arrived immediately. At 11:40PM, ADON called Director of Nursing (DON) and administrator (both arrived shortly thereafter). At 11:45PM, police and emergency management "search term" instructed the staff to go in building (Interfering with (a dog) scent/ hunt). At 12:00 Midnight, the Administrator called and notify the Medical Director. At 2:50 AM, Emergency Management Director entered facility and stated resident had been found and being transported to the hospital. Hospital History and physical dated 1/11/2015 documented "apparently this patient wandered out of nursing home and was found under a building outside, this being January of a particular cold week. He was treated for [REDACTED]. They had him on warming blanket and given warm IV (intravenous) fluids and warm bladder irrigation and warm oxygen. His temperature increased to 99.3 and was admitted to the hospital for environmental hypothermia." Doctor's progress note dated 1/15/2015 documented "resident of nursing home who wandered out of the facility and he was found outside and he was sent to the hospital and he was treated for [REDACTED]. They had him on warming blanket and given warm IV fluids and warm bladder irrigation and warm oxygen. His temperature increased to 99.3 and was admitted to the hospital for environmental hypothermia. Initially he was placed in ICU (Intensive Care Unit) but once he improved he was transferred out. He was also treated for [REDACTED]. He was also treated for [REDACTED]." During an interview on 1/21/2015 at 12:10 PM, Nurse Assistant (NA)#1 reported that she was sitting with the resident every day since he came back. NA #1 stated that the resident sometimes resisted care and refused to go to bed. She added Resident #1 was very unsteady when walking. NA #1 also reported that the wanderguard that the resident had on before was not placed around the wrist, it was placed on the wheelchair and clothes. She further stated that the wanderguard was too small to go around the resident's foot. The interview with Resident #1 on 1/21/2015 at 12:25 PM revealed that he was trying to go home the day he eloped from the building. Observation of the resident on 1/21/2015 at 12:30 PM revealed the resident appeared to be weak. Resident #1 had wanderguard applied on his arm and a body alarm attached to his wheelchair. The sitter was observed with the resident. During an interview on 1/21/2015 at 2:03 PM, the third shift NA #2 who was assigned to Resident # 1 when he eloped stated that she came to work at 11:00 PM, and the resident was already missing. She also stated the second shift nurse mentioned that the resident must have been missing from 10:45 PM because that was the time they thought he had gone to the bathroom. NA #2 further reported that the staff began to look for the resident throughout the building at 11:30 PM and they could not find him. She added the staff called the police immediately. NA #2 also stated before the resident eloped from the building, for 3 days he had refused to get out of his wheelchair and go to bed. She stated the resident sat beside the exit door next to the heater everyday. NA #2 also mentioned that the resident had refused to be cleaned up and just wanted to sit beside the heater the days before he eloped from the facility. During an interview with Director of Nursing (DON) on 1/21/2015 at 2:30PM, she stated the staff was not checking to make sure the wanderguard was present on the resident's wrist or ankle. She further stated that the staff began checking the placement as a plan of correction after the resident came back from the hospital. The DON also reported that the resident used the exit door which is beside the office to exit the building. The DON further reported the resident had not been himself since he came back from the hospital. She also stated that Resident #1 had been in bed since the incident happened on 1/10/2015. The DON further reported the day the resident eloped, he was found after 4 hours by the emergency and search rescue team. She added the rescue team found the resident at 3 AM. DON also reported that the resident had crossed the road and was found under a storage building across the street. The DON also reported that she was not aware that the wanderguard was being placed on the wheelchair by staff on the unit. The DON added that she just became aware that wanderguard was being placed on the resident ' s wheelchair. She also stated the staff had been in serviced that they are not to place the wanderguard on the wheelchair. During an interview with Nurse#1 on 1/21/2015 at 3:38PM, who was assigned to work second shift on 1/10/2015, revealed she saw the resident at 10:30 PM sitting beside the heater by the exit door. She added the resident had resisted going to bed stating to the second shift NA #3 that he was just fine sitting by the heater and did not want to go to bed. Nurse #1 reported that she did not see the resident again until she was called on the phone while on her way home that the resident was missing. Nurse #1 also indicated that the resident's wanderguard was on the wheelchair because the resident was able to remove the wanderguard from the wrist and the resident's feet were swollen so the wanderguard could not fit the resident's ankle. During the interview with NA#3 on 1/21/2015 at 3:45 PM, who was assigned to Resident #1 second shift on 1/10/2015, she stated she saw the resident shortly before shift change and she did not recall what time the resident went missing. NA#3 further stated when she saw the resident around 10:45 PM, he was not agitated and recalled seeing the wanderguard on wheelchair. NA#3 also reported that the resident was dressed in khaki pants, a blue hoodie and black tennis shoes. She further stated the resident had resisted the effort to get him to go to bed for at least 3 days before his elopement. During an interview with Nurse # 2 on 1/21/2014 at 4:43 PM, who was assigned to Resident #1 third shift on 1/10/2015, she reported that when she came on her shift, the resident was missing from his wheelchair after she looked at the monitor. She added that she thought that the resident had gone to the bathroom but after 15 minutes she became concerned as to the reason he had not come back to sit in his wheelchair. Nurse #2 also reported as soon as she realized the resident was not back in 15 minutes they began to search for him in all the rooms in the building. She added after they could not find him, they called the administration staff and also called the police. Nurse #2 further reported that the resident had been sitting next to the heater with hands in front of the heater for about five days. She added the resident did not want to be bothered. Nurse #2 also reported that the resident ' s wanderguard was not placed on his wrist because the resident was able to remove it. She reported that the wanderguard was placed on wheelchair because the resident had edema in his ankle. During an interview on 1/22/2015 at 11:00 AM, the administrator reported that after it was found that the resident was missing at the facility, she was notified immediately. She further reported that the rescue team was also notified and the search for the resident was started immediately. She further stated it took long, about 4 hours to find the resident because the rescue dog was having hard time finding a scent. The Administrator further stated the staff was asked to go back into the building for the rescue team to continue with search outside with facility. The Administrator reported the resident exited the facility using the exit door near the front office. The door did not alarm when the resident exited the facility. The administrator also reported she just became aware that the wanderguard was being placed on the resident's wheelchair instead of the wrist. The Administrator further reported after the resident came back from the hospital the interventions put in place was to have one on one sitter to make sure he was safe and a wander guard was placed on the resident's wrist. The Administrator also indicated the facility had 5 main doors and all of them were equipped with wanderguard. She further stated that the doors alarms when a resident with a wanderguard approaches the door. On 1/10/2015, the night the resident went missing according to the metrological website channel the weather was fair and 19 degrees at 11:00 PM and 15 degrees on 1/11/2015 at 3:00 AM when the resident was found. During a drive between the facility and the storage building, revealed the distance was 0.2 miles. An observation on 1/22/2015 at 5: 00 PM revealed the road that the resident crossed to reach storage building was a two way street and it had several houses and trees beside it. A vacant parking lot was observed between the storage building and the facility. The pavement from the facility to the storage building was uneven. One street light and one stop sign were also observed beside the street. The Administrator was notified of the Immediate Jeopardy on 1/22/2015 at 1:41 PM. The facility provided the following Credible Allegation on 1/23/2015 at 3:45 PM. Credible Allegation of Compliance: Corrective action which will be accomplished for those residents found to be affected by the deficient practice: The Resident #1 was put on one to one monitoring 24 hours per day immediately upon his return to the facility on [DATE]. A wanderguard bracelet was applied to the left ankle of resident #1 upon his return to the facility on [DATE]. It was changed to his left wrist by the Assistant Director of Nursing on 1/22/15 and applied according to the manufacturer's recommendations. An additional alarm was added by the Maintenance Director on 1/22/15 to the door where the resident exited that will sound any time the door is opened regardless as to whether a person is wearing a wanderguard bracelet. In the event a resident that is wearing a wanderguard bracelet attempts to exit through the door, both alarms will sound. Resident # 1 will remain on one to one monitoring until 1/24/15 and then will be placed on hourly visual checks for a period of three (3) months and will be reevaluated at that time for need of hourly checks An audit of each door leading to outside the facility was completed on 1/22/15 by the Maintenance Director to determine if the door is alarmed and if the alarm is in working order. As of 1/23/15 every exit door is equipped with a wanderguard monitor and an additional alarm that will sound any time the door is opened regardless as to whether a person is wearing a wanderguard bracelet. The main entrance is manned with a receptionist from 8am to 8pm. The receptionist is relieved for breaks by the Business Office Manager Monday through Friday and the Manager on Duty on weekends.The additional alarm on the main entrance that will be armed from 8pm to 8am when the receptionist leaves that will sound any time the door is opened regardless as to whether a person is wearing a wanderguard bracelet.The receptionist will be responsible for arming and disarming the alarm. An alarm log was developed by the Director of Clinical Services on 1/23/15 to be filled out daily by the receptionist to document arming and disarming the alarm. All facility staff regardless of position or title was in-serviced by Director of Nursing and/or Administrative nursing team regarding all staff members are responsible for responding to any alarm sounding in the facility on 1/22/13 and 1/23/15. Any facility staff that was not in-serviced on these dates will not be allowed to work until the in-service is completed. How the facility will identify other residents having the potential to be affected by the same deficient practice: A one hundred percent head count was completed on all residents on 1/11/15 at 12:30 a.m. by the Administrator, Director of Nursing, Assistant Director of Nursing, and two police officers to verify each resident's presence and location in the facility. A one hundred percent chart audit was completed by the Director of Nursing, Assistant Director of Nursing, and Unit Managers on 1/11/15 of all residents to determine which residents are identified to be at risk for elopement/wandering. All residents that were identified to be at risk for wandering/elopement were checked for placement and function of their wanderguard bracelets with the wanderguard wand by the Director of Nursing. All residents that were identified to be at risk for wandering/elopement were rechecked by Administrative Nursing Team on 1/22/15 to ensure all wanderguard bracelets were placed according manufacturer's recommendation. Any resident that was found with an improperly placed bracelet was corrected at that time to be in adherence with manufacturer's recommendations. The facility doors were also checked with the wandergaurd wand according to the manufacturer's recommendations by the Director of Nursing for functionality of the wandergaurd door alarm. All doors were functioning properly. The nurse on duty determined the resident to be missing between 11:30 and 11:35 pm 1/10/15 and activated the Missing Person Policy. The nurse on call (Assistant Director of Nursing) was notified at that time and a search of the building and grounds was initiated. The Assistant Director of Nursing instructed the nurse on duty to notify the Police Department at that time and called to notify the Administrator and Director of Nursing. The Police Department was dispatched at 11:41 p.m. and arrived at approximately 11:44 p.m. The Director of Nursing and the Administrator arrived to the building within approximately five minutes of being called. The Police Officer, Administrator and Director of Nursing completed a one hundred percent head count of the residents in the building and activated a city and county unit search of perimeter of the building. The facility staff was asked by the Police Department to remain inside the building due to the K9 unit being utilized and not wanting the scent trail to be contaminated. The external search was wholly turned over to the city/county Police Departments at that time. Resident #1 was located at approximately 2:51 a.m. on 1/11/15. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. A wanderguard bracelet flow sheet to be completed by the staff nurses each shift on each resident identified to be at risk for elopement/wandering, was developed and implemented by the Director of Nursing on 1/12/15 to document the nurse checking placement according to manufacturer's recommendation and function of the wandergaurd bracelet and if the resident was displaying any elopement behavior for the month of January and will be transcribed to the Treatment Record thereafter. A list of residents identified to be at risk for elopement/wandering was placed at the front of each Medication Administration book by the Assistant Director of Nursing on 1/21/15 to alert the staff nurses as to which residents will require documentation on the wandergaurd bracelet flow sheet/Treatment Administration Record. The Assistant Director of Nursing will be responsible for updating and replacing the list and updating the Care Plans and Care Cards as changes occur. An elopement/wandering risk notebook to be kept at each nursing station and front desk, was implemented on 1/21/15 by the Director of Nursing with names and pictures of each resident that has been identified to be at risk for elopement/wandering. The notebook will be updated by the Assistant Director of Nursing as changes occur. The nursing staff was in-service was started on 1/12/15 by the Director of Nursing regarding elopement policy and procedure, missing resident policy and procedure, policy and procedure regarding checking the wanderguard bracelets and doors. All facility staff was educated regarding the elopement policy and procedure, missing resident policy and procedure, it being the responsibility of all staff members to respond to any alarm sounding, by the Assistant Director of Nursing on 1/21/15 to 1/23/15. Any facility staff that was not in-serviced on these dates will not be allowed to work until the in-service is completed. The nursing staff was re-in serviced by the Assistant Director of Nursing on 1/22/15 and 1/23/15 regarding the process for placing a wanderguard bracelet, placing the bracelet according to manufacturer's recommendation, checking for placement and function, documenting wandering/elopement behaviors and checking the door monitors according to manufacturer's recommendations. Any facility staff that was not in-serviced on these dates will not be allowed to work until the in-service is completed. On 1/23/2015 at 5:15 PM, verification of the Credible Allegation was evidenced by interview of all staff related to identifying residents at risk for elopement, ensuring placement and function of the wanderguard. The staff was also aware of whom to report the elopement behaviors.

Based on record review, observation and staff interview, the facility failed to develop a care plan with measurable goals and interventions to prevent further injuries for 1 (Resident #68) of 2 sampled residents with known self injurious behavior. Resident had bitten her fingers causing the right index finger to be necrotic and infected. The findings include: The immediate jeopardy (IJ) for Resident # 68 began on June 2, 2012 when the fingers were injured from biting. The administrator was notified of the immediate jeopardy (IJ) on August 2, 2012 at 2:45 PM. The IJ was removed on August 3, 2012 at 7:15 PM after the Credible Allegation was validated through staff interview and record review. The facility was left out of compliance at no actual harm with the potential for more than minimal harm that is not IJ (D) to allow completion of the employee training. Resident #68 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #68 had no behavioral symptoms. Resident #68 had a doctor's order dated 04/03/12 for a hand mitten to the right hand to prevent her from removing the wound vac dressing from the stage IV pressure ulcers on the right and left hip. The hand mitten was discontinued on 06/04/12 when the wound vac was discontinued. On 07/16/12, the hand mitten was restarted to prevent self injury, removal of dressing, foley catheter and gastrostomy tube. The significant change in status MDS assessment dated [DATE] indicated that Resident #68 had behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds) which occurred 4-6 days but less than daily during the review period. The Care Area Assessments (CAAs) for behavioral symptoms dated 04/19/12 revealed " resident is a (age) year old who triggered for a behavioral assessment due to displaying behavior such as hitting herself with soft mitten and shaking side rails. She has recently started receiving services from hospice. She has a [DIAGNOSES REDACTED]. She also has a history of [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. She also displays behaviors when she was currently going to the wound center. Staff noticed a major change in her behavior when she returned back to the facility. Her family support is good. Resident is here for long term placement. " The assessment also indicated that referral to another discipline was not warranted and care plan will be developed to monitor resident's behavioral symptoms. The care plan dated 04/25/12 was reviewed. The care plan problem was " name of the resident) needs monitoring of mood (crying/tearfulness, repetitive verbalizations, anxiousness, sad/anxious appearance) and behaviors (yelling/screaming out, resistive with care) associated with [MEDICAL CONDITION] disorder requiring the use of multiple [MEDICAL CONDITION] medications. " The goal was " mood and behaviors will be better controlled while on [MEDICAL CONDITION] medications as evidenced by decreased episodes of anxiety/restlessness and decreased episodes of yelling/screaming out weekly over the next review. " The approaches included " monitor resident's mood and behavior status daily (e.g resistive with care, repetitive verbalizations, crying/tearfulness, etc.) on behavior flow sheet and or in notes. Notify physician of any increased behaviors or mood, administer [MEDICATION NAME] (anti-depressant)as ordered, administer [MEDICATION NAME] as ordered routinely for the treatment of [REDACTED]. " Resident #68 was on psychoactive medications to control her behaviors. The physician's orders [REDACTED]. The nurse's notes were reviewed. The notes dated 06/02/12 at 7:30 AM, revealed that Resident #68 was biting her right index finger trying to remove the hand mitten. A small amount of blood was noted on the mitten. After the hand mitten was removed and the finger was cleaned with warm water, cuts were noted on the dorsal and posterior area of the index finger. There were no changes made to the care plan to address the self injurious behavior. On 08/02/12 at 1:45 PM, the MDS/care plan nurse was interviewed. She stated that she did not make changes to the care plan because she was not aware of the 06/02/12 incident when Resident #68 had bitten her fingers. On 06/04/12 at 10:00 AM, the nurse's notes revealed that Resident #68 was in bed, she had several scratches to the neck, chest and arms. On 06/08/12 at 11 PM, resident had self inflicted scratches on her body. On 07/08/12 at 10:30 PM, resident noted to have multiple areas of scratches to chest and left arm, resident was observed scratching self with right hand and displayed signs and symptoms of agitation. There were no changes made to the care plan to prevent Resident #68 from repeated self injurious behavior. On 06/04/12, the wound vac and the hand mitten were discontinued. There was no doctor's order to discontinue the hand mitten, it was per the request of the administration. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #68 had memory and decision making problems and had behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds) which occurred 1-3 days during the review period. The nurse's notes on 07/14/12 at 5:35 AM revealed that the resident was found with profuse bleeding coming from her right hand related to chewing on hand. Large amount of blood in the mouth, face and clothing was observed. The notes further indicated that the attending physician was notified and the resident was sent to the emergency room . At 7:45 AM, Resident #68 was back to the facility from the emergency room . On 07/16/12 at 11:30 AM, the notes indicated that an order was written to clarify use of untied mitten. Resident has harmed self over the weekend by chewing on hand. She had history of continually removing fully inflated foley, gastrostomy tube and dressing to wound. The emergency room records dated 07/14/12 were reviewed. The notes revealed under the chief complaint was " bleeding fingers right hand, patient found chewing flesh from hand by staff. " On physical examination, the resident was noted to have deep abrasions on right hand fingers. The clinical impression was self inflicted abrasions right hand from patient biting. The notes further revealed multiple wounds on right hand due to patient chewing on first 2 fingers and thumb. On 07/16/12, there was a doctor's order to wear mitten (untied) to right hand to prevent self injury, removal of dressing, foley catheter, and [DEVICE], remove every shift to provide care, monitor status. On 07/16/12, the utilization of the hand mitten to prevent self injurious acts was added to the care plan problem. On 07/17/12, " [MEDICATION NAME] as ordered to aide with agitation " was added to the approaches. There were no changes made to the care plan to prevent the self injurious acts from happening again aside from [MEDICATION NAME] and hand mitten. The care plan dated 07/18/12 (review date) was reviewed. The care plan problems included " (name of resident) utilizes a hand mitten to prevent her from self injurious acts and " (name of resident) needs monitoring of mood (crying/tearfulness, repetitive verbalizations, anxious complaints, sad/anxious appearance and behaviors (yelling/screaming out, resistive with care, self abusive acts, etc.) associated with [MEDICAL CONDITION] disorder requiring the use of multiple [MEDICAL CONDITION] medications. " The care plan did not have a measurable goal and interventions to address the care and treatment related to the self injurious behavior of Resident #68. On 08/02/12 at 1:45 PM, the MDS/care plan nurse was interviewed. She was aware of the incident when Resident #68 had chewed her fingers on 07/14/12. She updated the care plan on 07/18/12 by incorporating the use of the hand mitten to prevent her from self injurious acts to the mood/behavior and use of [MEDICAL CONDITION] medication care plan problem. She indicated that she did not develop a care plan with goals and approaches specific to the self injurious behavior. She added that Resident #68 was on hand mitten to prevent her from self injurious acts and her medications were adjusted after the 07/14/12 incident. On 08/01/12 at 9:45 AM, Nurse # 11 was observed during the dressing change to the right hand of Resident #68. The right index finger was observed to be necrotic, swollen and with odor. The wound had yellowish wound bed. The thumb was macerated. Nurse #5 was observed to clean the fingers with [MEDICATION NAME], xeroform was applied and covered with dry dressing. On 08/01/12 at 10:15 AM, Nurse #11 was interviewed. She indicated that hand mitten and socks were tried for Resident #68 to prevent her from biting her fingers. On 08/01/12 at 11:20 AM, administrative staff #2 was interviewed. She stated that she was aware of the 2 incidents where Resident #68 had chewed her fingers. She indicated that she had not tried other measures aside from a hand mitten to prevent her from biting her fingers. On 08/01/12 at 3:40 PM, Nurse #4 was interviewed. She stated that she was with the physician when he saw Resident #68 on 07/30/12. She found the finger to be macerated with slough tissue and with yellowish drainage. The physician had ordered surgical consult for debridement of the right index finger. On 08/01/12 at 5:05 PM, Nurse #3 was interviewed. She stated that she was the nurse on 07/28/12 when she found maggots on the right index finger wounds. She added that she had removed four maggots from the wound. She further stated that hand mitten and socks were tried to prevent her from biting her fingers but they did not work, Resident #68 was able to remove them. On 08/02/12 at 9:00 AM, Resident #68 was scheduled for debridement of the right index finger at the hospital. She came back to the facility after lunch. Debridement was not performed to the resident's finger. At 2:20 PM, the hospital staff was interviewed. She stated that she was a surgical service supervisor who worked with the surgeon. She indicated that because of the extensive tissue loss, debridement was not of benefit so the surgeon had referred Resident #68 to the orthopedic doctor for amputation of the right index finger. The surgical consultation report dated 08/02/12 was reviewed. The report revealed examination of the right index finger. The debridement was unlikely to be of benefit considering extensive tissue loss. Recommend treatment by orthopedic, hand surgeon and wound care. On 08/02/12 at 10:39 AM, the administrative staff #1 was interviewed. She stated that Resident #68 was wearing a hand mitten when she chewed her finger on 06/02/12. She indicated that the hand mitten was ordered because she was pulling the wound vac, [DEVICE] and foley catheter out. She also stated that when the wound vac was discontinued, the use hand mitten was also discontinued. The hand mitten was restarted when she chewed her fingers again. She added that she could not think of other measures that were tried to prevent her from biting her fingers aside from the hand mitten. The administrator was notified of the immediate jeopardy on 08/02/12 at 2:45 PM. The facility provided a credible allegation of compliance on 08/03/12 at 7:08 PM. The allegation of compliance indicated: ? On August 3, 2012, Resident #68 was transferred to (name of the hospital) for unrelated medical issues. Following hospitalization , Resident #68 will be transferred to Hospice House due to multiple medications, and very complex medical situation which includes [MEDICAL CONDITION], severe Altered Mental Status, & [MEDICAL CONDITION] disorder, long history of rash, itching, pain, agitation, & multiple infections. Hospice House was recommended by (name of the doctor), Chief Medical Officer for (name of the hospice care network) for medication management to control [MEDICAL CONDITION] & behaviors. ? Because all residents with behaviors have the potential to be affected by the cited deficiency, all medical records (52 total) and care plans for residents with documented behaviors were re-evaluated by Administrator, Director of Nursing, and (3) RN Supervisors, on August 2, 2012 to assure appropriate behavior interventions were in place. No additional residents with unaddressed behaviors were identified during the reviews. ? The MDS Coordinator will be educated by (name of the management group) Post Acute Care Director of Quality on August 3, 2012. The MDS Coordinator educated the IDT (interdisciplinary team) on August 3, 2012. Education included care plan development, individualization of goals and interventions and updating procedures. The team will also participate in education resident behavior and intervention offered by (name of the psychologist) on August 6, 2012 or August 7, 2012. ? The Acuity Intervention Team, which consist of the Administrator, Director of Nursing, 3 RN Supervisors, Dietary, Social Worker, Admissions Coordinator, & Therapy, on a weekly basis, will audit five medical records to ensure that appropriate intervention, assessment, & care planning are in place. New admissions will be reviewed weekly at the Acuity Intervention Team meeting to ensure that appropriate behavioral intervention, assessment, & care planning are in place. Family and staff involved in resident care are offered an opportunity to provide input into the care plan process to assure resident centered care. ? Results of the monitoring will be shared with the Director of Nursing weekly and with the facility Quality Assurance and Assessment Committee monthly. Monitoring will continue a minimum of ninety days at which time the Quality Assurance and Assessment Committee will determine if the deficiency has been resolved. If it has been determined that the deficiency has been resolved, monitoring will be conducted on a quarterly basis. Corrective Action Date: August 3, 2012 The credible allegation was verified on 8/03/12 at 7:10 PM as evidenced by staff interviews and review of the in-service signed in sheets on care plan development, individualization of goals and interventions and how to update the care plan. The care plans of residents identified with behavior poblems were reveiwed. The care plan had goals and interventions in place for behaviors.

Based on record review, observation and staff interview, the facility failed to implement effective interventions to prevent repeated self inflicted injuries for 1 (Resident # 68) of 2 sampled residents with known self injurious behavior. Resident #68 had bitten her fingers causing the right index finger to be necrotic and infected. The facility also failed to implement interventions to prevent falls as care planned for 1 (Resident #11) of 3 sampled residents. The findings include The immediate jeopardy (IJ) for Resident # 68 began on June 2, 2012 when the fingers were injured from biting. The administrator was notified of the immediate jeopardy (IJ) on August 2, 2012 at 2:45 PM. The IJ was removed on August 3, 2012 at 7:15 PM after the Credible Allegation was validated through staff interview and record review. The facility was left out of compliance at no actual harm with the potential for more than minimal harm that is not IJ (D) to allow completion of the employee training. Example #2 (Resident 11) was cited at no actual harm with the potential for more than minimal harm that is not IJ (D). 1. Resident #68 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#68 had no behavioral symptoms. The significant change in status MDS assessment dated [DATE] indicated that Resident #68 had behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds) which occurred 4-6 days but less than daily during the review period. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #68 had memory and decision making problems and had behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming, disruptive sounds) which occurred 1-3 days during the review period. The care plan dated 07/18/12 was reviewed. The care plan problems included " (name of resident) utilizes a hand mitten to prevent her from self injurious acts and " (name of resident) needs monitoring of mood (crying/tearfulness, repetitive verbalizations, anxious complaints, sad/anxious appearance and behaviors (yelling/screaming out, resistive with care, self abusive acts, etc.) associated with bipolar disorder requiring the use of multiple psychotropic medications. " The care plan did not have a measurable goal and interventions to address the care and treatment related to the self injurious behavior. On 04/03/12, there was a doctor's order to apply mitten to right hand to prevent resident from removing the wound vac (vacuum) dressing from the stage IV pressure ulcers of the left and right hip. The physician's orders [REDACTED]. Resident #68 was on Valium 5 mgs (milligram) 1 tablet daily for anxiety disorder, Geodon 40 mgs daily for bipolar disorder and Ativan 1 mgs every 8 hours for anxiety disorder. On 07/17/12, Ativan 1 mgs every 8 hours was changed to Ativan 2 mgs twice a day and Valium was discontinued. The nurse's notes were reviewed. The notes dated 06/02/12 at 7:30 AM, revealed that Resident #68 was biting her right index finger trying to remove the hand mitten. A small amount of blood was noted on the mitten. After the hand mitten was removed and the finger was cleaned with warm water, cuts were noted on the dorsal and posterior area of the index finger. The attending physician was notified and had ordered Rocephin (an antibiotic) 1 gm (gram) IM (intramuscular) times one with Lidocaine (local anesthetic) and to treat the wounds to the right index finger with betadine wash with dry dressing daily until healed. The notes at 8:30 PM revealed that the dressing to the right index finger was intact and no drainage was noted. Resident #68 was agitated and Ativan (use for the management of anxiety disorder) was administered. There was no evidence in the records that non pharmacological interventions were implemented or tried to prevent the self injurious behavior from happening again other than Ativan. Review of the psychoactive medication monthly flow records for June and July, 2012, there was no self injurious behavior listed under target behavioral symptoms. On 08/01/12 at 5:05 PM, Nurse #3 was interviewed. She stated it should have been listed under target behavior but it was not. The notes dated 06/04/12 at 10:00 AM revealed that Resident #68 was in bed, she had several scratches to the neck, chest and arms. On 06/08/12 at 11 PM notes, resident had self inflicted scratches on her body, Ativan was administered as scheduled. There was no evidence in the records that non pharmacological interventions were implemented or tried to prevent the self injurious behavior from happening again other than Ativan. On 06/04/12 at 2:28 PM, the nurse's notes indicated that the hand mitten was discontinued. There was no doctor's order to discontinue the hand mitten, it was per the request of the administration due to no behaviors noted. The nurse's notes dated 07/08/12 at 10:30 PM, resident noted to have multiple areas of scratches to chest and left arm, resident was observed scratching self with right hand and displayed signs and symptoms of agitation. There was no evidence in the records that non pharmacological interventions were implemented or tried to prevent the self injurious behavior from happening again. On 07/10/12, there was a doctor's order to discontinue the treatment to the right index finger, the area had healed. On 08/01/12 at 3:10 PM, Nurse #1 was interviewed. She stated that she was the treatment nurse on 07/10/12 and when she looked at the right index finger, the area was healed so she discontinued the treatment. The nurse's notes dated 07/14/12 at 5:35 AM revealed " found resident with profuse bleeding coming from left hand related to resident chewing on hand. Large amount of blood in the mouth, face and clothing. " The notes further indicated that the attending physician was notified and the resident was sent to the emergency room . At 7:45 AM, Resident #68 was back to the facility from the emergency room . On 08/01/12 at 10:10 PM, Nurse #2 was interviewed by phone. She stated that she was the night nurse on 07/14/12. She clarified that the affected hand was the right hand and not the left. She revealed that Resident #68 was on bolus tube feeding every 2 hours during her shift (12 AM, 2 AM and 4 AM). She went to the room to give Resident #68 her 4:00 AM bolus feeding. She found large amount of bright red blood in her mouth, face and clothing. Her right hand was in her mouth and when she removed her hand from her mouth she became agitated. After she cleaned the hand, she noticed that the bleeding was coming from her hand. The skin was removed including the cuticle from the first and second fingers and the fingernails were coming up from the base of the nail. She further indicated that she had to remove a lot of skin tissue from her mouth. She reported that prior to discovering the resident this way the last time she saw the resident was around 2:00 AM when she gave the bolus tube feeding. The emergency room records dated 07/14/12 were reviewed. The notes revealed under the chief complaint was " bleeding fingers right hand, patient found chewing flesh from hand by staff. " On physical examination, the resident was noted to have deep abrasions on right hand fingers. The clinical impression was self inflicted abrasions right hand from patient biting. The notes further revealed multiple wounds on right hand due to patient chewing on first 2 fingers and thumb. The wounds were cleaned with NS (normal saline) and triple antibiotic ointment was applied, covered with 4 x 4 and kling. Pressure dressing was applied to the base of the thumb due to bleeding. Resident #68 was transferred back to the facility with orders to clean the right hand wounds daily with Hibiclens, Neosporin ointment ( an antibiotic), dress fingers with non adhesive dressing and cover with bulky dressing, ace wrap over dressing and Augmentin (an antibiotic) 500 mgs 3 times a day for 10 days. The nurse's notes dated 07/14/12 at 12:30 PM revealed that there was a small amount of bright red blood on the end of the dressing to right hand. When the old dressing was removed, the thumb, first and second fingers were noted to have multiple area of skin missing. The assigned nurse for this date/time was not available for interview. The nurse's notes dated 07/15/12 at 4 AM revealed that the resident's right hand dressing was noted with small amount of bloody drainage, dressing was reinforced. At 10:15 AM, the notes indicated that the dressing was changed and noted multiple areas of skin missing from the thumb, first and second fingers and top of the hand. Moderate amount of bright red blood was noted from the areas. The assigned nurse for this date/time was not available for interview. The nurse's notes dated 07/16/12 at 10 AM indicated that the index finger was red, the dressing was changed. At 11:30 AM, the notes indicated that an order was written to clarify use of untied mitten. Resident has harmed self over the weekend by chewing on hand. She had history of continually removing fully inflated foley, gastrostomy tube and dressing to wound. The ulcer/wound identification and progress records were reviewed. On 07/16/12 (no time), the notes indicated scant amount of bright bloody drainage, very irregularly shaped wound over index finger and thumb. Both were dark like old blood but did not remove with dressing. They were 75 % necrotic and 25 % denuded (outer covering or surface layer of skin is removed). On 07/20/12, the fingers still had 75% necrotic tissue and 25% pink and denuded. No odor and with scant bloody drainage. On 07/28/12, the notes indicated that eschar persisted. The 07/30/12 notes revealed that the doctor was in and requested surgical consult. On 08/01/12 at 10:15 AM, Nurse #5 was interviewed. She stated that she had started as wound care nurse in June, 2012. She also indicated that hand mitten and socks were tried for Resident #68 to prevent her from biting her fingers. On 07/16/12, there was a doctor's order to wear mitten (untied) to right hand to prevent self injury, removal of dressing, foley catheter, and [DEVICE], remove every shift to provide care, monitor status. The nurse's notes dated 07/17/12 at 1:55 PM indicated that the physician was called to report resident's increased agitation by throwing her left arm and biting at her mitten. an order for [REDACTED]. There was no evidence in the records that non pharmacological interventions were implemented or tried to prevent Resident #68 from injuring herself other than Ativan. The nurse's notes dated 07/24/12 at 4:30 PM, Resident #68 was seen and examined by her physician. New orders for treatment to the right index finger, culture and sensitivity of the right index finger wounds and Doxycycline (an antibiotic) 100 mgs for 10 days were received. The physician's progress notes dated 07/24/12 revealed that the resident had finger bites with areas of maceration and mild exudates. The culture and sensitivity report of the right index finger wound dated 07/24/12 was " pseudomonas aeroginosa, heavy growth. " The nurse's notes dated 07/28/12 at 12:45 PM revealed that the nurse was called to Resident #68's room to assess the right index finger. The wound tissue was yellowish, red slough with necrotic tissue mixture. Several maggots were noted imbedded in wound tissue. The wound was noted with bloody yellowish drainage with foul odor. The physician was notified with new orders to clean the right index finger with soap and water, betadine wash and xeroform dressing daily. X-ray of the right hand was also ordered. The notes further revealed that Nurse #3 was called to the room of Resident #68. Nurse #3 had noticed whitish objects around the necrotic tissue. The nurse indicated that she had removed 4 worms (maggots) from the wound. She cleaned the wounds with soap and water and covered with sterile dressing. On 08/01/12 at 5:05 PM, Nurse #3 was interviewed. She stated that she was the nurse on 07/28/12 when she found maggots on the right index finger wounds. She further stated that hand mitten and socks were tried to prevent her from biting her fingers but they did not work, Resident #68 was able to remove them. The x-ray report of the right hand dated 07/28/12 was soft tissue swelling and no fracture or destruction of bone. The nurse's notes dated 07/29/12 at 10 AM indicated that the dressing was changed to the wound on the right index finger. The color remained dull with small section of necrotic tissue. The nurse's notes dated 07/30/12 at 6:10 PM revealed that the physician came to see Resident #68. He ordered Cipro (an antibiotic) 500 mgs twice a day for 10 days and surgical consult for debridement of the right index finger. On 08/01/12 at 3:40 PM, Nurse #4 was interviewed. She stated that she was with the physician when he saw Resident #68 on 07/30/12. She found the finger to be macerated with slough tissue and with yellowish drainage. On 08/01/12 at 9:45 AM, Nurse # 5 was observed during the dressing change to the right hand of Resident #68. The right index finger was observed to be necrotic, swollen and with odor. The wound had yellowish wound bed. The thumb was macerated. Nurse #5 was observed to clean the fingers with Betadine, xeroform was applied and covered with dry dressing. On 08/01/12 at 11:20 AM, administrative staff #1 was interviewed. She stated that she was aware of the 2 incidents when Resident #68 had chewed her fingers. She indicated that she had not tried other measures aside from a hand mitten to prevent her from biting her fingers. On 08/01/12 at 3:30 PM, Nurse #6 was interviewed. She stated that she had observed Resident #68 biting her right hand even with the bulky dressing and a hand mitten on. She further stated that when she changed the dressing on 07/23/12, there was blood on the dressing. On 08/02/12 at 8:30 AM, Resident #68 was sent to the hospital for debridement of the right index finger. On 08/02/12 at 10:39 AM, the administrative staff #2 was interviewed. She stated that Resident #68 was wearing a hand mitten when she chewed her finger the first time. She indicated that the hand mitten was ordered because she was pulling the wound vac, [DEVICE] and foley catheter out. She also stated that when the wound vac was discontinued, the use of the hand mitten was also discontinued. The hand mitten was restarted when she chewed her fingers again. She added that she could not think of other measures that were tried to prevent her from biting her fingers aside from the hand mitten. The nurses should be monitoring her self injurious behavior too and document it on the psychoactive medication monthly flow record every shift. On 08/02/12 at 1:30 PM, Nurse #3 indicated that Resident #68 was back and debridement was not performed. She further stated that the hospital staff stated that the surgeon had referred Resident #68 to an orthopedic doctor for amputation of the right index finger. The surgical consultation report dated 08/02/12 was reviewed. The report revealed examination of the right index finger. The debridement was unlikely to be of benefit considering extensive tissue loss. Recommend treatment by orthopedic, hand surgeon and wound care. On 08/02/12 at 2:20 PM, the hospital staff was interviewed. She stated that she was a surgical service supervisor who worked with the surgeon. She indicated that because of the extensive tissue loss, debridement was not of benefit so the surgeon had referred Resident #68 to the orthopedic doctor for amputation of the right index finger. On 08/03/12 at 1:58 PM, Nurse Aide #1 was interviewed. She stated that she had observed Resident #68 biting her fingers sometime in July prior to having her fingers injured. She added that she was wearing a hand mitten but she was able to remove it. She further stated that the nurses were aware of this behavior. The administrator was notified of the immediate jeopardy on 08/02/12 at 2:45 PM. The facility provided a credible allegation of compliance on 08/03/12 at 7:08 PM. The allegation of compliance indicated: ? On August 3, 2012, Resident #68 was transferred to (name of the hospital) for unrelated medical issues. Following hospitalization , Resident #68 will be transferred to hospice house due to multiple medications, and very complex medical situation which includes Intracranial Hemorrhage, severe Altered Mental Status, & seizure disorder, long history of rash, itching, pain, agitation, & multiple infections. Hospice House was recommended by (name of the doctor), Chief Medical Officer for (name of the hospice care network) for medication management to control seizures & behaviors. ? A: Resident Behaviors: Because all residents with behaviors have the potential to be affected by the cited deficiency, all medical records (52 total) and care plans for residents with documented behaviors were re-evaluated by Administrator, Director of Nursing, and (3) RN Supervisors, on August 2, 2012 to assure appropriate behavior interventions were in place. No additional residents with unaddressed behaviors were identified during the reviews. An additional resident with self-injurious behaviors (Resident #51) was evaluated by the primary care physician on August 3, 2012 and no interventions were recommended. B: Wound Evaluation: Because all residents with wounds have the potential to be affected by the cited deficiency, all residents currently receiving wound treatments were evaluated by the Wound Care Coordinator on July 30, 2012 and July 31, 2012. All wounds were found to be clean with no signs or symptoms of infection or maggot infestation. ? A. Resident Behaviors: Initial staff education started on August 3, 2012, via Behavior Educational Sheet, which emphasized the need for staff to report behaviors immediately to the Charge Nurse who will implement interventions as indicated. If resident behaviors pose an immediate serious threat, the resident will be placed on 1:1 monitoring, the physician and family/RP will be notified, and the resident is transferred to the emergency department if needed. The Charge Nurse will document on the 24-Hour report and will be reviewed daily by the Acuity Intervention Team, which consist of the Administrator, Director of Nursing, 3 RN Supervisors, Dietary, Social Worker, Admissions Coordinator, & Therapy, so appropriate interventions could be reviewed and revised as appropriate. This Behavior Education Sheet was provided to 293 employees, which includes all staff and ancillary staff that provide services to the facility. Additional mandatory inservices for all staff on how to handle residents with self injurious behavior and behavior monitoring began on August 3, 2012 and will conclude on August 10, 2012. The inservices will be conducted by the Director of Nursing, Administrator and RN Supervisor. In addition, education on resident behavior and interventions will be conducted for all staff by (name of the psychologist) on August 6, 2012 and August 7, 2012. This inservice will be video taped for additional staff education purposes. Staff unable to attend the inservices will be required to receive education prior to return to work. This education will be incorporated into the facility orientation program for new hires & annually. B. Wound Evaluation: Mandatory inservices for all nursing staff began on August 3, 2012 and will conclude on August 10, 2012. Education will include identification and reporting of wounds, signs and symptoms of infection, and fly and/or maggot infestation. The inservices will be conducted by the Director of Nursing, Administrator and RN Supervisor. At the time a wound is identified, an incident report will be generated and immediate interventions implemented. The intervention will be documented on the 24 hour reported by the Charge Nurse and reported through the Acuity Intervention Team. The Wound Care Coordinator will evaluate all wounds on a weekly basis to assure appropriate treatment/interventions are in place. Staff unable to attend the inservices will be required to receive education prior to return to work. This education will be incorporated into the facility orientation program for new hires & annually. ? A. Resident Behaviors: The Acuity Intervention Team, which consist of the Administrator, Director of Nursing, 3 RN Supervisors, Dietary, Social Worker, Admissions Coordinator, & Therapy, on a weekly basis, will audit five medical records & observe these residents to ensure that appropriate behavioral intervention, assessment, & care planning are in place. If Acuity Intervention Team identifies that behavior issues need an outside expert, a referral will be made to (name of the local county mental health service) for an evaluation. New admissions will be reviewed weekly at the Acuity Intervention Team meeting to ensure appropriate behavioral intervention, assessment, & care planning are in place or if changes need to be made. Family and staff involved in resident care are offered an opportunity to provide input into the care plan process to assure resident centered care. Wound Evaluation: The wound care nurse will assess all bruises, skin tears, wounds and bites weekly and document on the ulcer/wound identification and progress report. The Acuity Intervention Team will monitor the progress report weekly for completeness and progress. ? Results of the monitoring will be shared with the Director of Nursing weekly and with the facility Quality Assurance and Assessment Committee monthly. Monitoring will continue a minimum of ninety days at which time the Quality Assurance and Assessment Committee will determine if the deficiency has been resolved. If it has been determined that the deficiency has been resolved, monitoring will be conducted on a quarterly basis. Corrective Action Date: August 3, 2012 The credible allegation was verified on 8/03/12 at 7:10 PM as evidenced by staff interviews and review of the in-service signed in sheets on reporting behaviors, what type of behavior to report, to whom are you going to report, what would you fill out if behaviors noted and reported and what immediate interventions would you do to prevent resident injury. Interview also with the administrative staff revealed that the charts of residents with behavioral issues were reviewed for appropriate interventions and care planning and wounds were assessed for possible infection/infestation. 2. Resident # 11 was originally admitted to the facility 11/21/08. Cumulative [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 had short term and long term memory impairment and was moderately impaired in decision-making. She required extensive assistance with bed mobility, transfers and toilet use. Ambulation did not occur during the assessment period. Balance was impaired in that she was only able to stabilize with human assistance for moving from a seated to standing position, moving on and off the toilet and surface to surface transfers. Impairment in functional ROM was noted on one side for the lower extremity. A Care Area Assessment (CAA) summary for falls dated 11/11/11 indicated falls since prior assessment occurred on 10/23/11 and 10/24/11 (no injury with falls). Resident #11 was at high risk for falls based on her history of falls, impaired cognition causing a poor awareness of safety needs (dementia), impaired balance and use of psychotrophic medications (Haldol). At the time of the assessment, she was on a low bed with a fall mat and a non-slip pad had been applied to her wheelchair to help prevent further falls. She also wore a body alarm to alert staff when she attempted to transfer unassisted. On 6/2/12 at 6:45 AM., nursing notes revealed Resident # 11 was found on the floor lying on left side. A cut on her left eyebrow was noted. Her physician and family were notified. Resident #11 was sent to the emergency room for treatment. A Confidential Occurrence Report dated 6/2/12 at 6:45 AM. revealed Resident #11 was found on the floor lying on her left side with a noted laceration to the left eyebrow with a small amount of blood. Status before fall: no restraints in place, no side rails, call bell accessible. Resident was confused. A Post Fall Review form dated 6/2/12 indicated Resident #11 was lying in bed at the time of the fall. The fall mat was on the floor and the bed was in the low position. The Care plan was updated to reflect interventions as a result of this fall. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 was moderately impaired in cognition. Resident #11 had one fall without injury and one fall with injury (except major injury) since the last assessment done on 4/19/12. On 7/15/12 at 6:55 PM, nursing notes revealed Resident #11 was found sitting up on floor beside her bed. No acute injury was noted and no further treatment was indicated. A Confidential Occurrence Report dated 7/15/12 at 6:55 PM. indicated Resident #11 was found on the floor in a seated position. No injury was noted. Status before the fall was not completed. A Post Fall Review report dated 7/15/12 revealed assistive devices at the time of the fall included mat on the floor. The care plan was updated. A Care plan reviewed on 7/18/12 included a problem of potential for falls secondary to impaired mobility, history of falls, use of psychotropic medications and mood and behavior problems. The goal read Resident #11 will have no injury as a result of a fall at any time over the next review. Approaches included: "Provide a low bed with fall mat to help reduce the risk of injury from falls from the bed. Antitippers to wheelchair for safety. A non-slip pad to wheelchair " An observation on 8/2/12 at 7:55 AM. revealed Resident #11 lying in her bed in her room. There was not a fall mat on the floor beside the bed. On 8/2/12 at 8:00 AM., Nurse #1 went to Resident #11's room and noted that there was not a fall mat on the floor beside the bed. She stated she expected that all interventions for falls to be in place which included a fall mat to be on the floor. On 8/2/12 at 9:49 AM., Resident #11 was observed sitting in a wheelchair in the hallway. The wheelchair did not have antitippers. There was a noon-slip pad in the wheelchair with a cloth incontinent pad on top of the non-slip pad. On 8/2/12at 9:58AM., Nurse #1 stated the nursing assistant had placed Resident #11 in the wrong wheelchair and she should have been in the wheelchair with the antitippers. During the interview, she instructed nursing staff to take Resident #11 back to her room and put her in the correct wheelchair. On 8/2/12 at 10 AM., nursing assistant (NA) # 2 stated Resident #11 did not have her name on the wheelchair in the room. She said the other resident in the room indicated the wheelchair with the red non-slip pad was hers so she knew the other wheelchair belonged to Resident #11. During the interview, NA # 2 further stated the fall mat was not on the floor when she went in the room around 8:00 AM. On 8/2/12 at 2:13 PM., Administrative staff #2 stated she expected nursing staff to use all of the interventions for falls for Resident #11 which included the fall mat, antitippers on the wheelchair and the non-slip pad.