Every finding on record at Aviata at University Hills

Based on observations, interviews, and record reviews, the facility failed to maintain resident call lights in 8 out of 67 rooms. (Rooms 101, 127, 151, 201, 204, 209, 231, and 252)The findings include: On 12/1/2025, a walkthrough of the building was performed with the Maintenance Director. Every resident's room was checked for functioning call lights in the beds and bathrooms. During the walkthrough, rooms 204A and B, 209A and B, 201A and B, 231A and B, 252A and B, 151A and B, 127A, and 101A and B were observed with nonfunctioning call lights.On 12/1/2025 at 10:30 am, Resident # 3 was interviewed. She stated she needs to have a bell at the bedside to make sure she can call the nurses but stated she cannot because the call light sometimes does not work.On 12/1/2025 at 10:40 am, Resident #1 was interviewed. She explained that, for a long time, her call light was not working, and the nurses gave her a bell to call for assistance. She stated the nursing aides appear irritated when she uses the bell and ask her why she keeps ringing the bell. She added that the call light is working now but is not reliable and that is why she keeps the bell at bed side.On 12/1/2025 at 10:50 am, the Maintenance Director was interviewed. He stated that he has been working in the facility for 4 months. He explains the process of placing a request for service in the facility through a program the nurses use to report on any broken equipment. This program will alert him when an order comes through. He explained the process he would follow to find outside repair services for any call light issues. He stated that the call lights malfunction so often because of electrical malfunctions in the building. He stated that the nurses give bells to the patients to make sure they are going to be able to call the nurses if they need assistance. He stated that residents that cannot use the bell are moved closer to the nursing station to be watched. He stated that, at this time, there were no broken call lights reported in the building.At the 100 and 200 hall nurse stations, Staff N, a Certified Nursing Aide, reported that the call light panel does not always illuminate when a resident activates their call light. When room [ROOM NUMBER] Bed B was tested, the call light did not illuminate in the panel at the nurse's station. The Maintenance Director explained that he reported this to the Administration. He stated that they acknowledged the issue and explained that the system uses outdated bulbs that cannot be replaced. Staff N stated that when they hear a call alert at the nurse's station, they must often go to the hallway to identify which room light is on. Staff N stated that many times the lights do not illuminate, so they provide bells to use when the call lights do not work.

Based on observations, staff interview, and policy review, the facility failed to provide housekeeping and maintenance services neccessary to maintain a sanitary and orderly interior for 11 of 32 sampled rooms and 2 common areas observed. (Rooms 106, 110, 123, 129, 131, 208, 226, 227, 228, 232, 234, the unit one hallway, and the locked unit day room) The findings include: During a tour of the locked memory care unit with the Administrator and Employee B (Regional Maintenance Director) on 9/18/24 at 3:58 PM, the following was observed: room [ROOM NUMBER]B had blinds in disrepair. room [ROOM NUMBER] had a dark stain on the bathroom floor and an unlabeled wash basin on the back of the toilet. room [ROOM NUMBER] had two fire dampers bulging from the ceiling tile near the door. room [ROOM NUMBER] had one door that was missing from the armoire. room [ROOM NUMBER] had no curtains or blinds on the window and had a partially patched hole in the wall. The locked unit day room had a cove base missing from the wall near the exit door. Photographic evidence was obtained of all of the above. During the tour, the Administrator stated the former Maintenance Director was supposed to audit the blinds last week and she was not sure if this happened. She stated the brown stain in room [ROOM NUMBER] looked like rust and the basin should be labeled and stored in the resident's cabinet. She was not sure why the cove base was removed in the day room of the locked unit or why the door was missing from the armoire in room [ROOM NUMBER]. The Administrator confirmed the wall was not fully repaired in room [ROOM NUMBER]. 30584 room [ROOM NUMBER] On 09/17/24 at 4:17 PM, an observation of the privacy curtain in room [ROOM NUMBER] revealed several dark brownish/[NAME] spots on the curtain. Interview with the two residents living in this room revealed the curtain has always been stained like this since they each arrived in this room. On 09/18/24 at 9:11 AM and 12:29 PM, follow up observations of the privacy curtain in room [ROOM NUMBER] revealed it to be the same stained/soiled curtain. (photographic evidence obtained) 50082 During a tour of the 100 hallway on 9/17/24 at approximately 12:30 PM, the following issues were observed: room [ROOM NUMBER]'s mini blinds on the window were broken and twisted, not allowing for total privacy from the outside. room [ROOM NUMBER]'s mini blinds were broken with paper taped to the glass to cover the area not covered by the blinds. room [ROOM NUMBER] had 2 large gashes in the drywall on the wall nearest the bathroom door. On 09/18/24 at approximately 4:26 PM, during a tour with the Regional Maintenance Director and the Executive Director (ED), the ED acknowledged the environmental deficiencies in rooms 129, 131 and 123. 50783 room [ROOM NUMBER] During an observation of room [ROOM NUMBER] on 09/16/24 at 11:13 AM, there was noted a black colored film in the ceiling area. The bathroom towel rack and glove box holder were observed to have raised flaky and rusted areas across the bar. The ceiling tiles were noted with a dark grey dust on them. There were broken blinds in the room window with a privacy curtain tacked across the window. The dresser sitting by the B bed has the bottom drawer missing. The safety floor mat was observed to be dirty and torn. (photographic evidence obtained) room [ROOM NUMBER] During an observation of room [ROOM NUMBER] on 09/16/24 at 11:20 PM, dark green and blackish circular spots were noted on the ceiling tiles of the doorway. Brownish color areas observed beind the entry door. (photographic evidence obtained) Unit One During an observation of the unit one hallway on 9/16/23 at approximately 11:00 AM, there was observed multiple areas in the ceiling tiles with greenish and black colored spots. (photographic evidence obtained) Review of the facility policy for Maintenance (effective 11/30/14) revealed the facility's physical plant and equipment will be maintained through a program of preventitive maintenance and prompt action to identify areas/items in need of repair.

Based upon interviews, observations, and record reviews the facility failed to implement the care plan to meet the nursing and physical needs to maintain the highest functional well-beingfor 1 of 22 residents reviewed for care plans. (Resident #95) The findings include: On 09/16/24 at approximately 01:30 PM Resident #95 was observed attempting to feed herself with her family present. Despite repeated attempts, she was unsuccessful using silverware and used her hands to feed herself, dropping much of the food in the process. On 09/17/24 at 12:36 PM, the resident was observed laying in bed with a bedside tray table positioned next to the bed with a lunch tray positioned on it with tray positioned at chin level. Resident #95 was observed having difficulty feeding herself. Resident #95's milk was not opened and Resident #95 was observed unsuccessfully attempting to open it. Resident #95 was observed with food debris down the front of her clothing and on her chin where she attempted to feed herself. On 09/18/24 at approximately 08:45 AM, Resident #95 was observed sitting up in bed with breakfast tray sitting on bedside table. Resident #95 had a towel placed on her chest area for protection but food debris was observed on the front side of her shirt. A staff member entered room to pick up meal trays. I asked the staff member who identified herself as a CNA but did not give her name if the resident required any assistance with eating her breakfast this morning. The staff member responded no, she feeds herself and left the room carrying the breakfast tray to the dietary cart. Resident #95's brother was interviewed on 9/16/24 concerning this issue. He stated, They don't always come in here and check on her. They keep her curtain pulled and can't see her if she is having trouble swallowing or starts to choke on her food. He stated he had spoke to the Administrator about this and he was assured it would be addressed, but he cannot see that it has been corrected for the past three weeks. The grievance log showed a grievance was written on 09/04/24 regarding Resident #95 not being assisted with meals. The grievance submitted on 9/4/24 indicated that the facility would initiate therapy to screen resident for speech therapy. The Director of Nursing (DON) would review the care plan and update as needed. Staff would be educated on the resident's status for eating meals. Resident #95's physician order states that she has a dietary order for a regular, no added salt diet with Dysphagia Advanced texture, Regular with Thin Liquids consistency, Chopped Meats and fortified foods and Milk with meals. A physician's order dated 4/8/24 stated the resident was to be up in her wheelchair for all meals. An order dated 9/5/24 also states that Resident #95 is to be assisted for meals and to cue resident and assist with feeding with every meal. The record review states that Resident #95 is care planned for the potential nutritional problems related to hemiparesis / hemiplegia hindering her ability to feed herself. This care plan was initiated on 4/15/23. Current interventions include monitor and document any signs of dysphagia, pocketing, choking, coughing, drooling, or holding food in her mouth. Resident will be provided a divided plate and adaptive equipment / utensil with each meal. On 6/19/2024, a care plan was initiated for Resident #95, who is at high risk for aspiration related to swallowing assessment results. Current interventions include: all staff is to be informed of residents dietary and safety needs. Resident is to alternate small bites of food and small sips of fluid, use a teaspoon for eating, do not use straws. Staff is to check mouth after meal for pocketed food and debris. Resident #95's Minimum Data Set (MDS) assessment on 3/27/24 states the resident requires set up and clean up assistance for eating, oral hygiene, partial to moderate assistance for toileting, shower/ bathing, dressing, and personal hygiene, and transfers. The MDS assessment on 5/20/24 reveals she needs partial / moderate assistance required for eating, oral hygiene, dressing, and transfers. dependent assistance for toileting and bathing. A MDS assessment dated [DATE] stated the resident did not have a swallowing disorder or an issue with loss of liquids from mouth when eating or drinking or an issue with holding food in mouth/cheek. On 9/17/24 at approximately 02:00 PM, during an interview with CNA staff N, she stated she cares for Resident #95 consistently and is familiar with Resident #95's care needs. When asked about where the resident eats her meals, CNA N responds Mostly in her room, she will refuse to get up out of bed. When asked how much assistance the resident needs with eating meals, CNA N responds she doesn't need to be assisted with meals. When asked if the resident requires any special equipment to eat or requires to be queued to eat her meals or feed herself, CNA N responds that the resident doesn't have any special adaptive equipment and does not need to be queued to eat her meals. CNA N stated the resident usually eats about 40-50% of her meals. CNA N stated the only time she refused to eat was when she was on a puree diet. When CNA N was asked if Resident #95 has lost any weight, she responded, I don't see any difference in her weight. The DON was interviewed on 09/17/24 at approximately 04:15 PM about Resident #95. She was asked why the resident does not have any weights documented for the months of June, July, and August 2024. The DON stated that she did not know but did state that the resident will refuse to be weighed at times. The DON also acknowledged, per physician orders, that a CNA or any staff member had to be present for all mealtimes. That clinical staff is to stay with resident while Resident #95 is eating to assist as needed and cue resident to eat her meals. On 9/18/24 at approximately 11:58 AM, an interview was conducted with the DON and Administrator regarding the grievance initiated for Resident #95 on 09/04/24.The Administrator and DON agreed that the resident was care planned and has a physician order to be assisted with meals. When asked why, on three separate observations, Resident #95 was feeding herself and no staff member present during mealtimes, the DON responded that there should be a staff member present during meals. They agreed that she uses a divided plate and built up utensils so the food won't slide off the plate. When asked why she had not been using specialized equipment during the observations, the Administrator stated that she did not know but she will follow up with dietary regarding the adaptive equipment as it is their responsibility to insure that the correct plate and adaptive equipment is sent on the meal trays.

Based on observations, interviews, and review of the electronic medical records (EMR), the facility failed to provide necessary range of motion services for 1 of 4 residents sampled for range of motion. (Resident #68) The findings include: A review of Resident #68's medical record revealed an order dated 4/03/2024 stating Resident up to wheelchair every meal, every shift. Further review of the EMR revealed that staff had signed off on Resident #68 being up in her wheelchair for meals on 9/16/2024, 9/17/2024 (evening and night shift), 9/18/2024 and 9/19/2024 (day shift). However, on four separate observations on 09/16/24 at approximately 11:56 AM and 03:10 PM and on 09/17/2024 at approximately 08:35 AM and 03:59 PM, Resident #68 was observed to be in her bed. On 09/17/24 at approximately 12:45 PM, Resident #68 was observed semi-reclined in bed, leaning to the right side. The lunch tray was delivered by Staff Member P, a certified nursing assistant (CNA), who proceeded to reposition the resident and began to feed resident #68 her lunch. An interview was conducted with Staff Member P, who indicated that fluids were offered with meals and medications but that the resident is unable to request or drink on her own. When asked if the resident is put in her wheelchair, CNA P responded No, she can't sit in that because she is too stiff, we can't put her legs up. She slides forward, she's too stiff. On 09/17/2024, a telephone interview was conducted with Resident #68's daughter, who stated that the resident has never been observed to be out of bed on her visits. She stated that her visits occur primarily on weekends or after work. On 09/18/24 at approximately 09:35 AM, an interview was conducted with Staff Member O, Registered Nurse (RN), who indicated Resident #68 is fully dependent for care. She acknowledged that the resident has not been getting out of bed for every meal and that this has been something that has needed to be updated.

Based on staff interviews, record review, and the facilities' policy and procedures, the facility failed to maintain ongoing communication and collaboration with the dialysis center regarding dialysis care and services for 1 of 1 residents reviewed for dialysis care. (Resident #43) The findings include: A review of Resident #43's dialysis communication binder on 9/19/2024 revealed the last dialysis communication form was completed on 8/9/2024, even though Resident #43 had been receiving dialysis care from an outside facility every Monday, Wednesday, and Friday. On 09/18/24 at approximately 11:47 AM, the director of nursing (DON) indicated the residents have their own dialysis binders that are used to communicate with the dialysis center which should be kept at the nurses' station. The unit managers check the dialysis binders weekly to ensure the dialysis communication sheets are being completed. A concurrent interview with Staff C, unit manager, confirmed she did not follow up on these. On 09/18/24 at approximately 02:23 PM, during a follow-up interview with the DON, she stated that the expectation is that the 11:00 pm-7:00 am shift nurse was to initiate the communication sheet and place it in the dialysis communication binder that is sent with the resident to the dialysis center. The dialysis center is then asked to communicate a summary of the residents' dialysis treatment. The facility nurse receiving the resident then reviews and acknowledges the communication from dialysis to ensure continuum of care. If the dialysis center does not complete their portion, it is the facilities responsibility to fax it to or contact the dialysis center by phone and get the communication of care. The DON acknowledged the last communication between the facility and the dialysis center was on 8/9/24. A review of the facilities policy and procedure named Coordination of hemodialysis services, N-1359 effective 11/30/2014, revised 07/02/2019 (page 1 of 1) states residents requiring an outside ESRD facility will have services coordinated by the facility. There will be communication between the facility and the ESRD facility regarding the resident. the facility will establish a dialysis agreement/arrangement if there are any residents requiring dialysis services. the agreement shall include how the residents care is managed. 1) the dialysis communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. 2) Nursing will collect and complete the information regarding the resident to send to the ESRD center. 3)The ESRD facility is to review the dialysis communication form and either: a) complete the communication form and return with the resident OR b) provide treatment information to the facility. 4) upon the residents return to the facility, nursing will review the dialysis communication for and information completed by the dialysis center OR the information sent by the dialysis center; communicate with the residents physician and other ancillary department as needed, implement interventions as appropriate. 5) Nursing will complete the post dialysis information on the dialysis communication form and file the completed form in the residents clinical record.

Based upon record review and interviews, the facility failed to provide scheduled medications for 1 of 20 residents reviewed for medication administration. (Resident #43) The findings include: A review of the medication administration record (MAR) for September 2024 revealed Resident #43 has not been receiving the following medications at 9:00 AM and 1:00 PM on Mondays, Wednesdays, and Fridays, as he is out of the facility at dialysis during those times, resulting in multiple missed doses: 1. Prostat (a protein supplement to aide in wound healing) 2. Vit D-Cholecalciferol Oral Capsule 50 MCG (2000 UT) Give 1 capsule by mouth one time a day for supplement 3. Ciclopirox External Solution 8 % (Ciclopirox) Apply to fingernails topically one time a day (to treat fungal infection of the nail bed) 4. Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day (an antiplatelet drug to prevent blood clots) 5. Clotrimazole Mouth/Throat Troche 10 MG (Clotrimazole) Give 1 lozenge by mouth one time a day for mouth (a medication to treat fungal infections) 6. Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG Give 0.5 tablet by mouth one time a day (a medication used to treat heart failure) 7. [NAME]-Vite Oral Tablet Give 1 tablet by mouth one time a day (a multivitamin for dialysis patients) 8. Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day (a medication used for patients with atrial fibrillation to reduce the risk of stroke and blood clots) 9. Calcium Carbonate Oral Tablet Chewable 500 MG (Calcium Carbonate (Antacid) 10. Nepro 8oz. two times a day (a protein supplement for patient with End Stage Renal Disease (ESRD)) 11. Midodrine HCl Oral Tablet 5 MG Give 2 tablet by mouth three times a day (a medication used to treat low blood pressure) 12. Gabapentin Oral Capsule 100 MG Give 1 capsule by mouth three times a day (a medication used to treat pain) On 09/18/24 at approximately 10:08 AM, Staff I, a licensed practical nurse (LPN), stated anything that is on the MAR to give at 9:00 AM, I put LOA (Leave of Absence) because [Resident #43] is out of the building at dialysis. A review of the medical record revealed Resident #43 has a diagnosis of END STAGE RENAL DISEASE DEPENDENT ON RENAL DIALYSIS, ABNORMAL WEIGHT LOSS, AND PROTEIN-CALORIE MALNUTRITION. Resident #43 has a physician's order for Hemodialysis: Monday, Wednesday, and Friday starting at 7:30 AM. Resident #43 has a care plan for hemodialysis related to renal failure. The quarterly minimum data set (MDS), dated [DATE], reveals Resident #43 receives dialysis. On 09/18/24 at approximately 12:16 PM, an interview was conducted with the family nurse practioner (FNP-C) for Resident #43. He indicated the expectation is that the resident going to dialysis would be getting their medications before they leave the facility. He stated he has not been notified by the facility and was not aware until now that the resident has not been receiving all the medications that are scheduled at 9:00 AM. He stated that the resident should be getting these medications. The expectation is that the facility nurse would notify him if a medication is not able to be given for any reason. On 09/19/24 at approximately 11:48 AM, the DON, she indicates that she was not aware the resident was not receiving 9:00 AM scheduled medications 3 times per week on dialysis days. She stated the expectation is that the resident would have been receiving these medication before they leave for dialysis.

Based on observations, staff interviews, review of the electronic medical record (EMR), and review of the facility policies and procedures, the facility failed to provide safe and secure storage of medications for 1 of 1 residents. (Resident #108) The findings include: On 9/16/24 at approximately 11:45 am, Resident #108 was observed with a Spiriva inhaler (a medication used to prevent wheezing and shortness of breath) positioned at bed side. Resident #108 indicated that the inhaler at bedside was empty; however, another inhaler was visibly stored in a nearby open drawer. On 9/17/24 at approximately 10:00 am, during an interview with Resident #108, he stated the Spiriva inhaler still remains in his drawer. A follow up observation at 2:35 pm verified the Spiriva inhaler was still in an open nightstand drawer. On 9/18/24 at approximately 11:30 am, during an interview with Staff C, a licensed practical nurse (LPN), she stated that the inhaler should not be there. LPN C indicated that she was unaware the Spiriva inhaler was in the resident's possession. On 9/18/24 at approximately 12:00 pm, the Assistant Director of Nursing (ADON) acknowledged Resident #108 does not have a physician's order to store or self-administer medications. A review of the medication administration record (MAR) reveals that Spiriva was administered as ordered. A review of the EMR for Resident #108 reveals no order for self-administration of medication. The care plan initiated on 6/27/24 does not include self-administration of medication. A review of the facilities Policy and Procedure: Medication and medication supply storage and disposal, Effective date: 11/30/2014 states, central storage of medications is required for prescription, prescribed over the counter medications and cam (complementary and alternative medicine). will kept in a locked area, in their original labeled container and may not be remove more than 2 hours prior to the schedule administration. Med will be kept in a medication cart that locks and keys are only accessible to the licensed personnel distributing medications.

Based on observations and interviews, the facility failed to ensure the Resident Call lights were functional to allow residents to call for staff assistance for 1 of 32 rooms observed. (rooms [ROOM NUMBERS]) The findings include: room [ROOM NUMBER]: An observation of room [ROOM NUMBER] was conducted on 9/16/24 at 1:31 PM. The resident call system in the bathroom was not functional. A follow up observation of room [ROOM NUMBER] was conducted on 9/18/24 at 8:41 AM and the call system in the bathroom was still not functional. Employee L (Certified Nursing Assistant) confirmed the call system was not functioning. She stated the resident occupying the room toileted independently. Review of the facility policy for Communication Systems, Maintenance Inspection Testing and Safety (effective 11/30/14) revealed, .communication systems and components will be properly maintained to function reliably and ensure operator safety. In the event of systems or component failure the system operators will notify maintenance personnel. If maintenance is unable to resolve the problem the approved contractor will be notified.

Based on interview and record review, the facility failed to obtain a Level II screening for 3 of 6 residents reviewed for Preadmission Screening and Resident Review (PASARR). (Residents #25, #37, and #96) The findings include: Resident #96 A review of the PASARR form for Resident #96 (admitted on [DATE]) noted an identified diagnosis of Anxiety Disorder and a diagnosis of dementia. Per the PASARR form, the combination of a Serious Mental Disorder (SMI) diagnosis and Dementia or neurocognitive disorder would trigger the requirement for a Level II review. A review of the Admission Diagnosis in the medical record noted a diagnosis of Major Depressive Disorder and Unspecified Dementia, Unspecified Severity with Psychotic Disturbance. A review of the Care Plan for Resident #96 noted that the resident was care planned for antipsychotic therapy for diagnosis of dementia with psychotic features, auditory and visual hallucinations, and antidepressant usage. A review of the physician's progress note dated 6/13/2023 noted a medical history of dementia and depression with a hospital admission related to auditory and visual hallucinations. Past medical histories noted diagnoses of Unspecified dementia of unspecified severity with psychotic disturbance and Major Depressive Disorder. Medications prescribed included Sertraline HCL and Donepezil, both psychotropic medications. A review of the admission Minimum Data Set (MDS) dated [DATE] noted that section A1500 did not acknowledge a Serious Mental Illness and Section A1550 did not acknowledge the submission of a Level II PASARR screening. A review of the complete medical record could not locate a Level II PASARR for resident #96. On 06/15/23 at approximately 11:54 AM, the Director of Nursing (DON) was asked what the PASARR process is for completion and validation. She stated they all residents should come with a PASARR prior to admission. In some cases, the facility will get them done. The DON was advised that a Level II PASARR could not be located on Resident #96 even though the her PASARR form triggered for a Level II. The DON acknowledged that a Level II PASARR was not done. Resident #25 A review of the record for Resident #25 noted that he was admitted on [DATE]. The initial PASARR dated 9/22/2017 noted no SMI Diagnosis or Intellectual Disability (ID) A record review of diagnosis for Resident #25 noted a diagnosis of Dementia with onset of 6/8/2019, Bipolar Disorder wit onset of 2/5/2020, Major Depressive Disorder with onset of 9/22/2017 A review of the Minimum Data Set (MDS) dated [DATE], Section A1500 and 1510 indicated no SMI or ID or Level II PASARR was necessary. A review of Section I noted no Mental Illness diagnosis. A review of the Annual MDS dated [DATE] and the Significant Change MDS dated [DATE] noted Section A1500 and 1510 with no SMI. A review of Section I for both MDS noted active diagnosis of Non-Alzheimer's Dementia and Psychiatric /Mood Disorders of Anxiety Disorder, Depression, Bipolar Disorder, and Psychotic Disorder (other than schizophrenia). A review of the Psychiatric Progress Note dated 6/8/2023 referenced a stable psychiatric history of bipolar disorder and anxiety. Current psychiatric medications listed included Fluoxetine 10 mg by mouth daily. A review of the Nurse Practitioners noted dated 6/8/2023 referenced a history of bipolar disorder, dementia, Major Depressive Disorder, and Anxiety. A review of the care plans noted that Resident #25 was care planned for dementia, mood disorder, antidepressant medications, and diagnoses of bipolar disorder, mood disorder and anxiety disorder. On 06/15/23 at approximately 11:54 AM, the Director of Nursing was asked what the PASARR process is for completion and validation. She was asked what they do if there is a change in diagnosis that may trigger a necessary Level II. She stated that she wasn't sure of the process for that. The DON was informed where Resident #25 had a diagnosis change that would have warranted an updated. She acknowledged this was an oversight. 44730 Resident # 37 A review of Resident #37's electronic medical record revealed that the resident was admitted with a Level I PASARR dated 3/19/21. There was no level II PASARR noted in the residents record, even though she had documented diagnoses of Post Traumatic Stress Disorder, Major Depressive Disorder, and Anxiety Disorder. On 6/15/23 at approximately 1:05 PM, an interview was conducted with the Social Worker. She stated that Nursing does the level II PASARR submissions. On 6/15/23 at approximately 1:25 PM, an interview was conducted with the Director of Nursing (DON), who stated that she is reponsible for submitting for Level II PASARRs. She agreed that a Level II review should have been submitted for Resident #37. The DON further stated that they will be conducting an audit for all residents for Level II submissions.

Based on observations, record reviews, and interviews, the facility failed to implement the care plan for behavior monitoring for psychotropic medications for 1 of 5 residents sampled for unnecessary medication review. (Resident #86) The findings include: A record review was conducted of Resident #86's medical record, which revealed an order for Clonazepam 0.5mg (a medication used to treat anxiety). Further review of the medical record revealed a care plan dated 4/23/23 for monitoring of behavioral symptoms and side effects related to anti-anxiety medication. Review of the Medication Administration Record (MAR) revealed no monitoring for behaviors. On 6/13/23 at approximately 3:26 PM, an interview was conducted with Nurse D, a Registered Nurse (RN), concerning behavior monitoring for resident #86. Nurse D stated that the behavior monitoring is normally located on the MAR, but confirmed there was no behavior monitoring for Resident #86. On 6/13/23 at approximately 3:28 PM, an interview was conducted with the Director of Nursing (DON) concerning behavior monitoring for residents on psychotropic medications. The DON stated that the behavior monitoring is located on the MAR and confirmed that there was no behavior monitoring for Resident #86.

Based on observations, record reviews, and interviews, the facility failed to provide dietary services to meet the needs for 1 of 1 resident selected for food services. (Resident #22) The findings include: On 6/12/23 at approximately 8:30 AM, an observation was conducted of Resident #22's breakfast tray, which revealed one slice of French toast, 2 slices of bacon, a bowl of grits, 4 oz of apple juice, and a carton of milk. However, the accompanying dietary slip revealed the resident's diet to be regular, no added salt, with large portions. A further review of the dietary slip indicated the resident should have received 3 slices of French toast, 2 sausage patties, 6 oz of hot cereal, 4 oz of orange juice, and 8 oz of milk. On 6/14/23 at approximately 12:47 PM, an observation was made of Resident #22's lunch tray which revealed a ham sandwich, 1 scoop of potato salad, 1 plate of lettuce and tomato, and a glass of tea. A review of Resident #22's dietary slip indicated the resident should have received 1.5 ham sandwiches, 2/3 cup of potato salad, lettuce and tomato plate, and 1.5 cups of Caesar salad. (Photographic evidence obtained). A review of Resident #22's medical record confirmed his diet order for Regular diet with No Added Salt diet, regular texture, thin liquids consistency, with large portions dated 1/23/23. On 6/14/23 at approximately 2:15 PM, an interview was conducted with the Certified Dietary Manager (CDM) concerning the breakfast and lunch trays for Resident #22. When shown the photographs of Resident #22's breakfast and lunch trays, the CDM verified that the trays and the dietary tickets did not match. The CDM stated that Resident #22 should have received 3 slices of French toast for breakfast and should have received 1.5 ham sandwiches and a Caesar salad at lunch. The CDM went on to state that they should be following the diet order. On 6/14/23 at approximately 2:31 PM, an interview was conducted with the Director of Nursing (DON), concerning verification of the dietary tickets for the residents. The DON stated that it was her expectation that that the nursing staff should check the tray on the carts to verify that it is correct, if it is not correct, they should return the tray to the kitchen to be corrected. The DON further stated that the resident should never see that the tray was not correct. The DON verified the breakfast and lunch trays for Resident #22 did not match the dietary tickets.

Based on observation, interviews, clinical record review and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 7 residents reviewed for elopement risk. (Resident #1) On 3/2/23, an elopement risk evaluation form identified Resident #1, a cognitively impaired vulnerable resident, as at risk for elopement, however, no care plan for elopement risk was initiated. Resident #1 subsequently eloped from the facility on 3/11/23 unbeknownst to staff, placing the resident at risk for serious injury, harm, or death. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of J, isolated. The facility's Administrator and the Director of Nursing were notified of the findings of Immediate Jeopardy on 4/5/23 at 4:35 PM. Immediate Jeopardy was removed on 4/6/23 at 5:00 PM and the the scope and severity of the Immediate Jeopardy deficiencies was reduced from a J level to an D level. Cross reference F689 and F867 The findings include: A record review was conducted of Resident #1, which revealed the resident was originally admitted to the facility on [DATE] with diagnoses of Dementia, Psychosis, need for assistance with personal care, Type 2 Diabetes, Difficulty in walking, and muscle weakness. On 3/2/23, an elopement risk evaluation form was completed by Staff member L, a Licensed Practical Nurse (LPN). This form identified an elopement risk score of 3.0, which indicated that the resident was at risk for elopement. Further review of the elopement risk evaluation form revealed the following directions: Complete quarterly and with significant change. If the resident is deemed at risk, a prevention protocol should be initiated immediately and documented in the care plan. The following questions were included on the form: 1. Is the resident cognitively impaired? 2. Is the resident independently mobile (ambulatory or wheelchair)? 3. Does the resident have poor decision-making skills? 4. Has the resident demonstrated exit seeking behaviors? 5. Does the resident wander oblivious to safety needs? 6. Does the resident have a history of elopement? 7. Does the resident have the ability to exit the facility? 8. Based on potential risk factors above, resident is determined to be AT RISK for elopement LPN L marked Yes to questions 1 through 8. The forms states Yes, to questions 4,5 or 6 automatically place the resident AT RISK The form further stated, If it is determined that the resident has eloped, implement care plan immediately to ensure resident's safety. Report all residents AT RISK to the Director of Clinical Services and on the 24-hour report. Review of Resident #1's care plan revealed he had the potential to be aggressive in his behavior as evidenced by aggressively moving in his wheelchair throughout the hallways. Other issues include poor impulse control, plundering his roommates' personal items, eating his roommate's food, and going into others' rooms. No care plan was initiated for his elopement risk, and no interventions were put in to place to ensure the Resident #1's safety. Further review of the record revealed that Resident #1 was discharged to the hospital on 3/2/23, with a return to the facility on [DATE]. The elopement risk evaluation was not completed for the re-admission for 3/5/23, which resulted in a care plan not being updated for elopement risk and interventions were not put in place to ensure the resident's safety. A review of the facility's investigation revealed that Resident #1 was last seen at approximately 3:30 PM in the hallway by Staff Member B, a Certified Nursing Assistant (CNA). At approximately 4:00 PM Staff Member A, a Licensed Practical Nurse (LPN), observed Staff Member D, another CNA, standing at the therapy door exit shutting off the door alarm. LPN A clocked out for the day and exited through the therapy door. LPN A reported that, when she reached the canopy area outside the building, she noticed Resident #1 propelling himself in his manual wheelchair backwards up the East driveway exit hill. LPN A called out to Resident #1, who then rolled down the hill to LPN A. The staff member returned Resident #1 to the facility nurses' station and reported the resident being found in the parking lot to LPN M and the weekend supervisor. On 4/3/23 at approximately 3:30 PM, an interview was conducted with the Director of Clinical Services (DCS) and Staff Member K, a Care Plan Coordinator. When asked why the care plan for Resident #1 was not updated on 3/2/23, Care Plan Coordinator K responded the only reason she could think of was that she did not get to his care plan by the time the resident went out to the hospital on 3/2/23. The DCS stated that when residents are gone from the facility for over 24 hours, they are considered a re-admission upon return, with new assessments completed, including an elopement risk evaluation. The DCS stated that Resident #1 should have had an elopement risk evaluation completed upon re-admission on 3/5/23 and could not explain why it was not completed. The DCS further stated that, if it had been completed, it would have triggered the Minimum Data Set (MDS) and care plan to be updated and the resident would have been placed in the elopement risk binders that are kept on each nurses station and the receptionist's desk at the front entrance to alert staff regarding residents who are considered elopement risks. When asked if the care plan for Resident #1 would have changed upon re-admission, Care Plan Coordinator K stated it would not have changed much unless there was a significant change in condition. Care Plan Coordinator K confirmed that the elopement risk evaluation on 3/2/23 with a score of 3.0, when the previous elopement risk evaluation dated 8/13/21 was score was a 0 (which is not considered a risk for elopement), should have triggered the care plan to have been updated. Both the DCS and Care Plan Coordinator K confirmed that Resident #1's care plan was not updated for elopement risk until 3/12/23, which is the day after the resident had exited the building into the parking lot. A review was conducted of the Policy and Procedure titled N-1031, Subject: Elopement/Wandering Risk Guidelines (effective date of 9/21/2016 last revised 8/01/2020), which stated, Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain a photograph. Initiate individualized interventions based on Patient/Residents' at risk. Document individualized interventions in the patient/resident Care Plan and Kardex. Review of the Policies and Procedures document name N-1015, Subject: Plans of Care (effective date 11/30/2014 last revised 9/25/2017) revealed, Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Develop and implement an individualized Person-Centered baseline plan of care within 48 hours of admission. Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA (Omnibus Reconciliation Act) MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. Under Note: The resident plan of care encompasses many documents that are part of the resident's clinical record including, but not limited to, structured care plan documents, MARS (Medication Administration Records), TARS (Treatment Administration Records), physician orders, flow records, and/or legal documents that would drive the plan of care for the individual resident. The Immediate Jeopardy was removed onsite on 04/06/2023 after receipt of an acceptable removal plan and verification of corrective actions. On 04/06/2023 at approximately 5:03 PM, the removal plan was verified after staff interviews to determine knowledge of elopement policy, education on the importance of completing the elopement risk evaluation on admissions and re-admissions, physician notification of change in condition with emphasis on new or increased behaviors of wandering or exit seeking and the importance of developing a care plan and implementing interventions to include the appropriate level of supervision at the time of the residents change in behavior. Interviews were conducted with 20 staff members representing all 3 shifts. All responded with confirmation of training and were able to verbalize when assessments are to be completed as well as the updating of the care plan with implementation of appropriate interventions. The training sign-in sheet was verified, along with the documentation of training covered. On 3/11/23, Resident #1's elopement evaluation and care plan were reviewed and updated. The Director of Clinical Services, Assistant Director of Clinical Services, MDS/care plan coordinators and Executive Director were educated by the Regional Director of Clinical Services on 4/04/2023 regarding the process to review admission and readmission charts for accuracy of elopement evaluations and responsibility to provide appropriate interventions and supervision for residents with wandering and exit seeking behaviors through the care planning process. On 4/6/2023, review of the education was verified, the sign-in sheet for training and the documentation of training covered were also verified. On 4/6/23, an interview with the MDS RN coordinator verified the education training. Immediately post event on 3/11/23, the facility reviewed 100% of resident records to verify current elopement assessments and care plans developed as indicated. The removal plan documented this was updated on 4/5/23 with a review of current residents admitted or readmitted since 3/11/23 to ensure an elopement risk assessment was completed and appropriate care plan interventions were in place for those at risk for elopement. Six residents were identified as not having an assessment. The survey team verified that elopement assessments were completed. The facility added a new section to the morning clinical meeting checklist to verify completion and accuracy of elopement evaluation and the development of a care plan with implementation of appropriate interventions, verified on 4/6/2023.

Based on observation, staff interviews, resident interview, responsible party interview, clinical record review and policy review, the facility failed to provide adequate supervision of a vulnerable resident and identify the resident as an elopement risk due to exit seeking and wandering behaviors for 1 of 7 residents sampled for accidents and supervision. (Resident #1) On 3/11/23, Resident #1, a cognitively impaired vulnerable resident, was able to exit the facility unbeknownst to staff. A facility staff member responded to a door alarm, looked out the window instead of exiting the facility and checking the surrounding grounds, shut the alarm off when no residents were observed, and returned to work. Resident #1 was able to propel himself in his wheelchair approximately 245 feet from the exit door. The resident was found by another staff member who had clocked out at approximately 4:00 PM for the day and noted the resident propelling himself backward in his wheelchair up the east exit, which is approximately at a 45 degree slope and only 32 feet from a major 2-lane highway, and 528 feet downhill to a major 4-lane highway intersection. This failure allowed the resident, who had a documented diagnosis of dementia to exit the facility into the parking lot, placing the resident at risk for serious injury, harm, abduction, or death. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of J, isolated. The facility's Administrator and the Director of Nursing were notified of the findings of Immediate Jeopardy on 4/5/23 at 4:35 PM. Immediate Jeopardy was removed on 4/6/23 at 5:00 PM and the scope and severity of the Immediate Jeopardy deficiencies was reduced from a J level to a D level. Cross reference F656 and F867 The findings include: A record review was conducted of Resident #1, which revealed the resident was originally admitted to the facility on [DATE] with diagnoses of Dementia, Psychosis, need for assistance with personal care, Type 2 Diabetes, Difficulty in walking, and muscle weakness. On 3/2/23, an elopement risk evaluation form was completed by Staff member L, a Licensed Practical Nurse (LPN). This form identified an elopement risk score of 3.0, which indicates that the resident was at risk for elopement. Further review of the elopement risk evaluation form revealed the following directions: Complete quarterly and with significant change. If the resident is deemed at risk, a prevention protocol should be initiated immediately and documented in the care plan. The following questions were included on the form: 1. Is the resident cognitively impaired? 2. Is the resident independently mobile (ambulatory or wheelchair)? 3. Does the resident have poor decision-making skills? 4. Has the resident demonstrated exit seeking behaviors? 5. Does the resident wander oblivious to safety needs? 6. Does the resident have a history of elopement? 7. Does the resident have the ability to exit the facility? 8. Based on potential risk factors above, resident is determined to be AT RISK for elopement Staff L marked Yes to questions 1 through 8. The forms stated Yes, to questions 4,5 or 6 automatically place the resident AT RISK The form further stated, If it is determined that the resident has eloped, implement care plan immediately to ensure resident's safety. Report all residents AT RISK to the Director of Clinical Services and on the 24-hour report. A review of Resident #1's care plan revealed he had the potential to be aggressive in his behavior as evidenced by aggressively moving in his wheelchair throughout the hallways. His care plan also identified poor impulse control, stealing his roommates' personal items, eating his roommate's food, and going into others' rooms uninvited. No care plan was initiated for elopement risk, and no interventions were put in to place to ensure the residents' safety. A further review of the clinical record revealed that Resident #1 was discharged to the hospital on 3/2/23, with a return to the facility on [DATE]. The elopement risk evaluation was not completed for the re-admission for 3/5/23, which resulted in a care plan not being updated for elopement risk and interventions were not put in place to ensure the resident's safety. A review of the resident's most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely impaired for daily decision making (worsened from moderately impaired on both the 2/24/23 discharge assessment and the 12/9/22 quarterly MDS Assessment). His balance was not steady, and he required extensive assistance with dressing, toilet use and personal hygiene. His prior MDS on 2/22/23 revealed he was independent with toilet use and required limited assistance with dressing. The MDS identified the diagnosis of non-Alzheimer's dementia and psychotic disorder. An interview with Resident #1 on 4/3/23 at 11:15 AM found Resident #1 up and dressed and sitting in a wheelchair on the memory care (Serenity) unit. Resident #1 stated that he wanted to go home. In an interview on 4/5/23 at 9:35 AM, Resident #1's Responsible Party stated that Resident #1 is an outside person and he likes to be outside more than inside. A review of the facility's investigation revealed that Resident #1 was last seen on 3/11/23 at approximately 3:30 PM in the hallway by Staff Member B, a Certified Nursing Assistant (CNA). At approximately 4:00 PM, Staff Member A, a Licensed Practical Nurse (LPN) observed Staff Member D, another CNA, standing at the therapy door exit shutting off the door alarm. LPN A clocked out for the day and exited through the same therapy door. LPN A reported that when she reached the outside canopy area, she noticed Resident #1 propelling himself in his manual wheelchair backwards up the driveway exit hill. LPN A called out to Resident #1, who then rolled down the hill to LPN A. The staff member returned Resident #1 to the facility nurses' station and reported to Staff Member M, an LPN and weekend supervisor, of the resident being found in the parking lot. CNA D was suspended pending investigation on 3/11/23, and later terminated by the facility on 3/20/23. On 4/3/23 at approximately 2:53 PM, a telephone interview was conducted with former CNA D who stated that she went down to the private hall with another CNA to give the shift report. CNA D stated that she heard the alarm but assumed that someone else would answer it, but when she returned back toward the nurses station, the alarm was still going off. CNA D further stated that she went to the therapy door exit, looked out the window but did not see anything, so she turned the alarm off and returned to work. CNA D stated she did not exit the facility and check the surrounding grounds, and denied having any training on elopement prior to 3/11/23. She stated that, if she did have training during her orientation, she did not remember doing so, until the Administrator re-educated her on elopement procedure after the incident. On 4/3/23 at approximately 3:30 PM, an interview was conducted with the Director of Clinical Services (DCS) and Staff Member K, a Care Plan Coordinator. When asked why the care plan for Resident #1 was not updated on 3/2/23, Care Plan Coordinator K responded the only reason she could think of was that she did not get to his care plan by the time the resident went out to the hospital on 3/2/23. The DCS stated that when residents are gone from the facility for over 24 hours, they are considered a re-admission upon return, with new assessments completed, including an elopement risk evaluation. The DCS stated that Resident #1 should have had an elopement risk evaluation completed upon re-admission on 3/5/23 and could not explain why it was not completed. The DCS further stated that, if it had been completed, it would have triggered the MDS and care plan to be updated and the resident would have been placed in the elopement risk binders that are kept on each nurses station and the receptionist's desk at the front entrance to alert staff regarding residents who are considered elopement risks. When asked if the care plan for Resident #1 would have changed upon re-admission, Care Plan Coordinator K stated it would not have changed much unless there was a significant change in condition. Care Plan Coordinator K confirmed that the elopement risk evaluation on 3/2/23 with a score of 3.0, when the previous elopement risk evaluation dated 8/13/21 was score was a 0 (which is not considered a risk for elopement), should have triggered the care plan to have been updated. Both the DCS and Care Plan Coordinator K confirmed that Resident #1's care plan was not updated for elopement risk until 3/12/23, which is the day after the resident had exited the building into the parking lot. On 4/4/23 at approximately 8:40 AM, an observation was made with the Maintenance Director and the Administrator in the parking lot for station 1, where LPN A located the resident after he exited. The Maintenance Director measured with tape-measure the distance from the area the resident was located to the Therapy Exit door, which measured approximately 245 feet. On 4/4/23 at approximately 9:58 AM, an interview was conducted with LPN A who stated that right after shift change she stayed over to complete her charting on nurses' station 2. She remembered hearing a faint beeping noise while completing her charting. LPN A stated she went to clock out for the day and noticed CNA D at the therapy door exit inputting the code to shut the alarm off. LPN A stated at this point she was not aware that a resident had exited the facility. LPN A stated she clocked out for the day at approximately 4:00 PM and exited out of the facility through the Therapy Exit door after inputting the code. When she reached the canopy area while walking to her car, she looked up and noticed Resident #1 propelling himself backwards up the hill of the east parking lot exit. She stated she called out to him by name and he lifted his feet up and let go of the wheels with his hands and proceeded to roll back toward her down the driveway hill. LPN A further stated that she took off running toward the resident and caught him at the base of the hill right where the first cars were parked to slow him down. LPN A went on to state that she returned the resident into the facility through the laundry room exit door and notified the Weekend Nurse Supervisor. LPN A identified the exact area where she found Resident #1 in the parking lot, and an observation was made in the presence of LPN A and the Administrator that the resident was located approximately 32 feet via measuring tape from a busy 2-lane highway with a speed limit of 30 miles per hour. LPN A further stated that Resident #1 would wander around the facility in his wheelchair and would try and go out to the courtyard to smoke even when the door was locked, but she had not observed him trying to exit the facility. On 4/4/23 at approximately 5:30 PM, an interview was conducted with the DCS. The DCS stated that Resident #1 would not have been able to sustain himself outside of the facility without supervision. The DCS also stated that they were unable to locate the last elopement drill conducted prior to the event, stating that it was the previous Assistant Director of Clinical Services' responsibility, and they have had some difficulties locating her documents since she quit without notice. On 4/5/23 at approximately 9:00 AM, a follow-up interview was conducted with the DCS. She stated that they were able to elopement find training conducted in an all staff meeting on 11/30/22 that included the policy and procedure but were still unable to locate any documentation of any drills conducted prior to the 3/11/23 incident. A review was conducted of the Policy and Procedure titled N-1031, Subject: Elopement/Wandering Risk Guidelines (effective date of 9/21/2016 last revised 8/01/2020), which stated, Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain a photograph. Initiate individualized interventions based on Patient/Residents' at risk. Document individualized interventions in the patient/resident Care Plan and Kardex. Review of the Policies and Procedures document name N-1015, Subject: Plans of Care (effective date 11/30/2014 last revised 9/25/2017) revealed, Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Develop and implement an individualized Person-Centered baseline plan of care within 48 hours of admission. Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA [Omnibus Reconciliation Act] MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. Under Note: The resident plan of care encompasses many documents that are part of the resident's clinical record including, but not limited to, structured care plan documents, MARS (Medication Administration Records), TARS (Treatment Administration Records), physician orders, flow records, and/or legal documents that would drive the plan of care for the individual resident. The Immediate Jeopardy was removed onsite on 04/06/2023 after receipt of an acceptable removal plan and verification of corrective actions. On 04/06/2023 at approximately 5:03 PM, the removal plan was verified after staff interviews to determine knowledge of elopement policy, education on the importance of completing the elopement risk evaluation on admissions and re-admissions, physician notification of change in condition with emphasis on new or increased behaviors of wandering or exit seeking and the importance of developing a care plan and implementing interventions to include the appropriate level of supervision at the time of the residents change in behavior. Interviews were conducted with 20 staff members representing all 3 shifts. All responded with confirmation of training and were able to verbalize when assessments are to be completed as well as the updating of the care plan with implementation of appropriate interventions. The training sign-in sheet was verified, along with the documentation of training covered. The removal plan indicated resident #1 was placed on 1:1 observation on the day of occurrence, 3/11/23. Resident #1 was subsequently moved to the memory care secure unit, and the observation level was reduced to every 15 minute safety checks. The survey team verified that the 15 minute checks were being conducted through observation, review of logs and interviews with staff on the Serenity Unit. The Director of Clinical Services, Assistant Director of Clinical Services, MDS/care plan coordinators and Executive Director were educated by the Regional Director of Clinical Services on 4/04/2023 regarding the process to review admission and readmission charts for accuracy of elopement evaluations and responsibility to provide appropriate interventions and supervision for residents with wandering and exit seeking behaviors through the care planning process. On 4/6/2023, review of the education was verified, the sign-in sheet for training and the documentation of training covered were also verified. On 4/6/23, an interview with the MDS RN coordinator verified the education training. The facility added a new section to the morning clinical meeting checklist to verify completion and accuracy of elopement evaluation and the development of a care plan with implementation of appropriate interventions, verified on 4/6/2023. The survey team verified that all exit doors were secure and safety features and alarms functioning properly as documented in the removal plan. Immediately post event on 3/11/23, the facility reviewed 100% of resident records to verify current elopement assessments. The removal plan documented this was updated on 4/5/23 with a review of current residents admitted or readmitted since 3/11/23 to ensure an elopement risk assessment was completed and appropriate care plan interventions were in place for those at risk for elopement. Six residents were identified as not having an assessment. The survey team verified that elopement assessments were completed. The removal plan documented that by 4/6/23, 97 out of 136 employees had participated in an elopement drill post event. Elopement drills will continue every shift weekly until 100% of all staff have participated with 9 unplanned drills conducted as of 4/6/23. The survey team verified elopement drills via staff interview and documentation.

Based on staff interviews, clinical record review, review of the quality assurance performance improvement plan, and policy review, the facility failed to implement their corrective action plan for monitoring of new admissions and re-admissions for elopement risk assessments for 6 of 20 residents reviewed. (Residents #6, 9, 12, 14, 19, and 20). On 3/11/23, Resident #1, a cognitively impaired vulnerable resident, was able to exit the facility unbeknownst to staff. The facility developed an implemented an immediate corrective action plan which included reviewing 100% of new admissions to ensure a complete and accurate elopement assessment and interventions initiated as indicated. On 4/3/23, the survey team identified 6 residents admitted after 3/11/23 whom had not had an elopement risk assessment completed since admission. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of J, isolated. The facility's Administrator and the Director of Nursing were notified of the findings of Immediate Jeopardy on 4/5/23 at 4:35 PM. Immediate Jeopardy was removed on 4/6/23 at 5:00 PM and the scope and severity of the Immediate Jeopardy deficiencies was reduced from a J level to an D level. Cross reference F689 and F656 The findings include: A review was conducted of the facility Quality Assurance Performance Improvement (QAPI) plan which revealed under Plan: Director of Clinical Services (DCS) that the agency will conduct Quality Monitoring of newly admitted residents exhibiting exit seeking behaviors daily in clinical meetings weekly for 4 weeks. A review of the Risk Management Quality Improvement Data Collection Form revealed that the DCS failed to ensure that all readmitted residents received an updated elopement risk assessment upon re-admission. The Risk Management/Quality Improvement Data Collection Form, dated 3/28/23, revealed that Residents #6, 9, 12, 14, 19, and 20 had all been discharged and readmitted to the facility but none of them received a new elopement risk evaluation upon re-admission. On 4/4/23, an interview was conducted with the DCS at approximately 1:00 PM. The DCS stated she ran a report from Point Click Care (the facility's Electronic Medical Records software application) and was able to generate a list of residents that triggered as elopement risk and that is what she used for the weekly monitoring of all the current residents at risk for elopement. The daily monitoring is for new or re-admissions that have been gone for over 24 hours. The surveyor asked the DCS, If the assessment for elopement risk was not completed on return, then how do you know if the resident had a change in condition and are now at risk for elopement? The DCS replied, I cannot know for sure unless it was redone. A review was conducted of the document titled Policies and Procedures document subject: Quality Assurance Performance Improvement Program (QAPI) Document name: PI-215, (Effective date 11/30/2014, last revised 10/24/2022). The policy states The center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The center's QAPI program is an on-going comprehensive review of care and services provided to residents. Including but not limited to a. Medical Care, b. Clinical care, j. Admissions, l. Medical Records. 2. Important functional areas may include but are not limited to b. Admission process, c. Resident assessment, d. Quality of care, e. Quality of Life, f. Potential Adverse Events. 3. Review of activities may include but not limited to: b. Incident/accident reports, d. Interdisciplinary care planning, f. Environment of care/safety, i. Staff orientation, in-service and competence. Under Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: a.) implementation, d.) Ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities. e.) Ensures corrective actions are implemented to address identified problems in systems. f.) Evaluates the effectiveness of actions. g.) Establishes expectations for safety, quality, rights and choice and respect. Under Data Collection Systems and Monitoring: The center will collect and monitor data from different departments reflecting its performance. 8. The center will identify data sources and timeframe for collection. Data sources may include but are not limited to: a.) Direct observation tools. b.) Audit tools g.) Quality measures. 9. The center will develop a schedule for routine data collection. Under Performance indicators: The center will establish performance indicators for data collected. 10. The center will utilize performance indicator to establish goals, identify opportunities for improvement, and evaluate progress towards goals. Under Identifying Quality Deficiencies and Corrective Action: The center will monitor department performance systems to identify issues or adverse events. 15. If a quality deficiency is identified, the committee will oversee the development of corrective action(s). 16. The center may choose the method of corrective action i.e., Plan, Do, Study, Act or Performance Improvement Project. The Immediate Jeopardy was removed onsite on 04/06/2023 after receipt of an acceptable removal plan and verification of corrective actions. On 04/06/2023 at approximately 5:03 PM, the removal plan was verified after staff interviews to determine knowledge of elopement policy, education on the importance of completing the elopement risk evaluation on admissions and re-admissions, physician notification of change in condition with emphasis on new or increased behaviors of wandering or exit seeking and the importance of developing a care plan and implementing interventions to include the appropriate level of supervision at the time of the residents change in behavior. Interviews were conducted with 20 staff members representing all 3 shifts. All responded with confirmation of training and were able to verbalize when assessments are to be completed as well as the updating of the care plan with implementation of appropriate interventions. The training sign-in sheet was verified, along with the documentation of training covered. The Director of Clinical Services, Assistant Director of Clinical Services, MDS/care plan coordinators and Executive Director were educated by Regional Director of Clinical Services on 4/04/2023 regarding the process to review admission and readmission charts for accuracy of elopement evaluations and responsibility to provide appropriate interventions and supervision for residents with wandering and exit seeking behaviors through the care planning process. On 4/6/2023, review of the education was verified. On 4/6/23, an interview with the MDS Registered Nurse coordinator verified the education training. The facility added a new section to the morning clinical meeting checklist to verify completion and accuracy of elopement evaluation and the development of a care plan with implementation of appropriate interventions, verified on 4/6/2023. On 4/6/23, staff re-education was verified via 20 staff interviews conducted and review of education sign in sheet that staff nurses were educated on 4/4/23 regarding the accuracy of elopement evaluations and the importance of providing appropriate supervision for residents with wandering or exit seeking behaviors. It was verified via interviews and review of the in-service dated 4/6/23 that QAPI committee training provided by the ED was conducted on 4/6/23. Inservice training for the ED and DCS on QAPI policy and procedures was verified via record review 4/6/23. Immediately post event on 3/11/23, the facility reviewed 100% of resident records to verify current elopement assessments and care plans developed as indicated. The removal plan documented this was updated on 4/5/23 with a review of current residents admitted or readmitted since 3/11/23 to ensure an elopement risk assessment was completed and appropriate care plan interventions were in place for those at risk for elopement. Six residents were identified as not having an assessment. The survey team verified that elopement assessments were completed.

Based on interviews and record reviews the facility failed to ensure residents were free from significant medication errors for 2 of 3 residents sampled (resident #1 and # 2). Resident #1's blood sugar was not monitored per order which resulted in the resident becoming unresponsive and being transferred to the hospital with a blood sugar of 1711. Resident #2's INR (international normalized ratio) was not monitored daily as ordered which resulted in his blood clotting factor being below therapeutic range of 2-3. The findings include: Resident #1 On 12/21/22 a record review was conducted of resident # 1, which revealed that resident #1 had a history of being a brittle (severe) diabetic. A review of the Electronic Record revealed an order written by the Nurse Practitioner on 11/21/22 for blood sugar checks before meals and at bedtime. A review of the Electronic Medication Administration Record (EMAR) for the month of November failed to reveal the order or that the facility was checking the resident's blood sugar. Review of the nurse progress note dated 11/23/22 at 15:06 (3:06 PM) the resident was sent to the emergency room after being found unresponsive with an elevated blood sugar of 482. A review of the hospital record revealed a physician progress note dated 11/24/22 at 16:57 (4:57 PM) indicating that the resident was admitted with a blood sugar of 1711 (normal blood sugar range of 80-130) and a diagnosis of diabetic Ketoacidosis (is a serious complication of diabetes that can be life threatening and develops when your body does not have enough insulin to allow blood sugar into your cells for use as energy). On 12/21/22 at approximately 2:00 PM, an interview was conducted with the Director of Nursing (DON) who stated that he became aware of resident #1 being transferred to the hospital on 11/23/22, and upon investigating the incident noted that the order for blood sugars was not entered into the Electronic Records correctly and the Nurse Practitioner was counseled on entering orders correctly. The DON went on to state that since that time they are pulling all the orders from the Electronic Records every weekday morning from the previous day/and or weekend, including new admissions and make sure they are entered into the EMR correctly. The DON stated that since the cyber attack we have been on paper charting and we have been pulling the charts and double checking the handwritten orders for accuracy, including the new admissions. Resident #2: A review of resident #2 medical record was conducted, which revealed that resident #2 was admitted to the facility on [DATE] with a diagnosis of Osteomyelitis, (an infection in the bone). A review of the admitting orders revealed that the resident was admitted with an order for Warfarin 5mg (milligrams) one tablet by mouth daily (a medication used to prevent blood clots), and to monitor INR (a lab test to check the blood clotting factor) daily and adjust accordingly for goal INR of 2-3. A review of the resident's Medication Administration Record (MAR) for the month of December failed to reveal the INR order. On 12/21/22 at approximately 6:00 PM, an interview was conducted with the DON, who stated that he could not find an order for resident #2's INR in the lab book. He went on to state that the Nurse Practitioner had been notified and the lab would be drawn tonight (12/21/22) as a stat (done right away) lab, and an order for daily INR labs was placed. The DON went on to state that he was not sure how that order was missed. On 12/22/22 at approximately 9:00 AM, a follow up interview was conducted with the DON who stated that upon further investigation they found an INR lab result for resident #2 dated 12/16/22 with the result of 1.3, however no other labs were found, and the lab that was drawn last night the result was 1.0 (therapeutic range is 2-3). A review of article titled International Normalized Ratio (INR) written by Sufan Shikdar; Rishik Vasisht; Priyanka T. [NAME]. Last updated May 8, 2022. Located at https://www.ncbi.nlm.nih.gov/books/NBK507707/ Revealed under Indications: INR monitoring is most commonly required for the patients who are on warfarin, a vitamin K antagonist. The dose of warfarin is adapted based on INR scores so that it remains in the therapeutic range to prevent thrombosis from subtherapeutic INR or hemorrhagic complications from supratherapeutic INR. The anticoagulant effect of warfarin indicated by an INR in the target range also guides us when to discontinue heparin.

Based on observations and interviews the facility failed to maintain a safe and homelike environment for 1 of 3 areas observed (the kitchen). The findings include: On 12/20/22 an observation was made of the facility kitchen area which revealed the ceiling with peeling paint above the tray service line, and through out the kitchen. (Photographic evidence obtained). On 12/20/22 at approximately 12:29 PM, an interview was conducted with the Administrator who stated no, the paint peeling on the ceiling above the tray line is not safe. The Administrator went on to state that the Maintenance Director was terminated in November, and that they have hired a replacement, the Maintenance Directors from two of the facility's other buildings have been filling in until the new director starts.

Based on observations, interviews and facility policy review the facility failed to provide food preparation in a safe manner for 1 of 2 meal preparations observed (dinner meal). The findings include: On 12/20/22 an observation was made of staff member E, a dietary aide, standing at a food preparation table putting on gloves, staff member E was noted to have false acrylic nails that were painted. On 12/20/22 at approximately 1:37 PM, an interview was conducted with staff member E, who confirmed that her nails were acrylic and went on to state that she had them done for the holidays but that she knows she is not to have polish or nails on in the kitchen. On 12/20/22 at approximately 2:30 PM an interview was conducted with the Dietary District Manger who stated that employee E, was sent home for the day and informed that she could not have acrylic or painted nails in the kitchen. The Dietary District Manager went on to state that the kitchen staff would be re-in-serviced on the policy for nails. On 12/20/22 a review was conducted on the policy Titled Staff Attire last revised 9/2017, which revealed under Procedures: 6. Fingernails will be kept clean and neat. Nail polish and/or acrylic nails are not permitted.

Based on observations, interviews, quality assurance performance improvement plan review, and policy review the facility failed to implement their corrective action plan for monitoring of the kitchen for a safe/clean/homelike environment for 1 of 1 Corrective Actions Plans reviewed. The findings include: A review was conducted of the facility's corrective action plan concerning the environment of the kitchen, which stated that the facility repaired/painted the kitchen ceiling and that dietary staff were in-serviced on the components of the regulation with emphasis on maintaining the kitchen in a safe/homelike environment. The plan further stated that the Executive Director and Dietary Manager would conduct rounds in the kitchen 3 times weekly for 4 weeks, then 2 times weekly for 4 weeks, then monthly thereafter to ensure the kitchen is maintained in a safe/homelike manner. The plan goes on to state, The findings of these rounds will be reported to the QA/PI (Quality Assurance / Performance Improvement) committee monthly until compliance has been met, the completion date for this plan was 1/26/23. A review was conducted of the Quality Assurance (QA) audit tool revealed that the dates of 1/30/23, 2/01/23, and 2/03/23 were signed off by the Administrator, Director of Nursing (DON), and the Kitchen Manger, however the questionnaire portion of the tool was not filled out for all three days of the rounds. On 2/6/23 at approximately 10:20 AM, an observation was made of the kitchen area which revealed the ceiling with peeling paint noted above the food preparation table located in front of the stove, and an area located next to the kitchen office. Further observation revealed that there was a black biomaterial substance noted on the ceiling tile next to the kitchen office, and water stain area noted around the sprinkler system tile. (Photographic evidence obtained.) On 2/6/23 at approximately 9:45 AM, an interview was conducted with the Administrator. The Administrator confirmed the area above the food preparation table and beside the kitchen office had peeling paint. The Administrator also confirmed that the ceiling tile beside the kitchen office had black biomaterial substance. The Administrator stated that they did remove the peeling paint and re-painted the ceiling metal structure and they had been conducting the rounds of the kitchen but had not noticed these areas. On 2/6/23 at approximately 11:15 AM, a follow up interview was conducted with the Administrator who stated that she did the walking rounds on 1/30/23, but was on vacation for 2/01/23 and 2/03/23. She stated that on those days the DON and Dietary Manager conducted the rounds. The Administrator stated that she did not notice these areas on the 30th, that she was paying attention to the areas above the tray line and the stove. The Administrator went on to state that she was not sure why they had not filled out the QA form, and stated that had she filled in the questionnaire the others may have followed suit. She stated that if it was not documented it was not done. On 2/7/23 at approximately 3:40PM an interview was conducted with the Director of Nursing (DON) who stated that she did the rounds in the kitchen on February 1st and 3rd paying attention to the area above the tray line, stated that she did not fill out the questionnaire on the QA tool, just signed to the side that they were completed. The DON went on to state that she should have completed the questionnaire. On 2/7/23 a review was conducted of the document titled Policies and Procedures document subject: Quality Assurance Performance Improvement Program (QAPI) Document name: PI-215, Effective date: 11/30/2014, last revised 10/24/2022. Under Policy: The center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Under Procedure: 1. The center's QAPI program is on-going comprehensive review of care and services provided to residents. Including but not limited to: i.) Environmental Services 2. Important functional areas may include but are not limited to: i.) Plant technology and safety management. 3. Review of activities may include but not limited to: f.) Environment of care/safety. Under Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: a.) implementation, d.) Ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities. e.) Ensures corrective actions are implemented to address identified problems in systems. f.) Evaluates the effectiveness of actions. g.) Establishes expectations for safety, quality, rights and choice and respect. Under Data Collection Systems and Monitoring: The center will collect and monitor data from different departments reflecting its performance. 8. The center will identify data sources and timeframe for collection. Data sources may include but are not limited to: a.) Direct observation tools. b.) Audit tools g.) Quality measures. 9. The center will develop a schedule for routine data collection. Under Performance indicators: The center will establish performance indicators for data collected. 10. The center will utilize performance indicator to establish goals, identify opportunities for improvement, and evaluate progress towards goals. Under Identifying Quality Deficiencies and Corrective Action: The center will monitor department performance systems to identify issues or adverse events. 15. If a quality deficiency is identified, the committee will oversee the development of corrective action(s). 16. The center may choose the method of corrective action i.e., Plan, Do, Study, Act or Performance Improvement Project.

Based on observations, interviews, quality assurance performance improvement plan review, and policy review the facility failed to implement their corrective action plan for monitoring of the kitchen for a safe/clean/homelike environment for 1 of 1 Corrective Actions Plans reviewed. The findings include: A review was conducted of the facility's corrective action plan concerning the environment of the kitchen, which stated that the facility repaired/painted the kitchen ceiling and that dietary staff were in-serviced on the components of the regulation with emphasis on maintaining the kitchen in a safe/homelike environment. The plan further stated that the Executive Director and Dietary Manager would conduct rounds in the kitchen 3 times weekly for 4 weeks, then 2 times weekly for 4 weeks, then monthly thereafter to ensure the kitchen is maintained in a safe/homelike manner. The plan goes on to state, The findings of these rounds will be reported to the QA/PI (Quality Assurance / Performance Improvement) committee monthly until compliance has been met, the completion date for this plan was 1/26/23. A review was conducted of the Quality Assurance (QA) audit tool revealed that the dates of 1/30/23, 2/01/23, and 2/03/23 were signed off by the Administrator, Director of Nursing (DON), and the Kitchen Manger, however the questionnaire portion of the tool was not filled out for all three days of the rounds. On 2/6/23 at approximately 10:20 AM, an observation was made of the kitchen area which revealed the ceiling with peeling paint noted above the food preparation table located in front of the stove, and an area located next to the kitchen office. Further observation revealed that there was a black biomaterial substance noted on the ceiling tile next to the kitchen office, and water stain area noted around the sprinkler system tile. (Photographic evidence obtained.) On 2/6/23 at approximately 9:45 AM, an interview was conducted with the Administrator. The Administrator confirmed the area above the food preparation table and beside the kitchen office had peeling paint. The Administrator also confirmed that the ceiling tile beside the kitchen office had black biomaterial substance. The Administrator stated that they did remove the peeling paint and re-painted the ceiling metal structure and they had been conducting the rounds of the kitchen but had not noticed these areas. On 2/6/23 at approximately 11:15 AM, a follow up interview was conducted with the Administrator who stated that she did the walking rounds on 1/30/23, but was on vacation for 2/01/23 and 2/03/23. She stated that on those days the DON and Dietary Manager conducted the rounds. The Administrator stated that she did not notice these areas on the 30th, that she was paying attention to the areas above the tray line and the stove. The Administrator went on to state that she was not sure why they had not filled out the QA form, and stated that had she filled in the questionnaire the others may have followed suit. She stated that if it was not documented it was not done. On 2/7/23 at approximately 3:40PM an interview was conducted with the Director of Nursing (DON) who stated that she did the rounds in the kitchen on February 1st and 3rd paying attention to the area above the tray line, stated that she did not fill out the questionnaire on the QA tool, just signed to the side that they were completed. The DON went on to state that she should have completed the questionnaire. On 2/7/23 a review was conducted of the document titled Policies and Procedures document subject: Quality Assurance Performance Improvement Program (QAPI) Document name: PI-215, Effective date: 11/30/2014, last revised 10/24/2022. Under Policy: The center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Under Procedure: 1. The center's QAPI program is on-going comprehensive review of care and services provided to residents. Including but not limited to: i.) Environmental Services 2. Important functional areas may include but are not limited to: i.) Plant technology and safety management. 3. Review of activities may include but not limited to: f.) Environment of care/safety. Under Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: a.) implementation, d.) Ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities. e.) Ensures corrective actions are implemented to address identified problems in systems. f.) Evaluates the effectiveness of actions. g.) Establishes expectations for safety, quality, rights and choice and respect. Under Data Collection Systems and Monitoring: The center will collect and monitor data from different departments reflecting its performance. 8. The center will identify data sources and timeframe for collection. Data sources may include but are not limited to: a.) Direct observation tools. b.) Audit tools g.) Quality measures. 9. The center will develop a schedule for routine data collection. Under Performance indicators: The center will establish performance indicators for data collected. 10. The center will utilize performance indicator to establish goals, identify opportunities for improvement, and evaluate progress towards goals. Under Identifying Quality Deficiencies and Corrective Action: The center will monitor department performance systems to identify issues or adverse events. 15. If a quality deficiency is identified, the committee will oversee the development of corrective action(s). 16. The center may choose the method of corrective action i.e., Plan, Do, Study, Act or Performance Improvement Project.

Based on observations and interviews the facility failed to ensure the provision of sufficient clean linen for 2 of 2 clean linen storage rooms, (100 and 200 halls). The findings include: On 8/15/22 beginning at approximately 2:00 PM, a tour was conducted of the laundry room and the clean linen storage rooms, with staff member G, laundry supervisor. The tour of the laundry revealed no employee currently in the laundry washing linens, at this time staff member G stated that the employee scheduled to come in this afternoon called and said they would be late due to a family emergency. Accompanied staff member G to the linen rooms on hall 100 and hall 200, both of the clean linen storage rooms revealed storage shelves contained no towels or wash clothes available for second shift. Staff member G, stated that the staff pull the linens from the closets and horde them in the residents' rooms for use. On 8/15/22 at approximately 2:30 PM, an interview was conducted with staff member D, a Licensed Practical Nurse (LPN), who stated that the linens were not being washed enough to have enough towels and wash clothes for resident baths. On 8/15/22 at approximately 4:00PM, a follow-up observation was made of the 100 and 200 hall linen closets; the shelves were still without towels or washcloths and very few sheets available. The Assistant Director of Nursing (ADON) was asked to view both linen closets, the ADON stated, No, this is not sufficient linens to care for the residents. (Photographic evidence obtained) On 8/15/22 at approximately 4:30 PM, an interview was conducted with the Administrator. The Administrator was shown the photographs of the clean linen closets of 100 and 200 hall. The Administrator viewed the photographs and stated, No, that is not enough linens for the residents. When asked what his expectation was for sufficient linens, he stated that there should be 3 of each available for each resident, one in use one on the shelf and one in the wash.

Based on observation, record reviews, and interviews the facility failed to implement the plan of care for 1 of 4 residents (#24) sampled for nutrition and for 1 of 1 resident sampled for skin condition other than pressure injuries (#77). The findings include: Resident #24 A record review was conducted for resident #24 which revealed a care plan, dated 8/27/20, for Nutritional problem or potential problem related to moderate protein calorie malnutrition with the goal Resident to comply with recommended diet daily and the interventions included RD (Registered Dietician) will evaluate and make diet changes to recommendations as needed and to provide and serve diet as ordered. A review of the physician orders [REDACTED]. The record review failed to reveal a dietary assessment, or any other assessment conducted by the Registered Dietician (RD) regarding nutritional needs for Resident #24 or any Dietary progress notes. A review of the Medication Administration Record [REDACTED]. On 1/13/21 at approximately 2:01 PM, an interview was conducted with the Unit Manager during which she was asked if Resident #24 received the Ensure pudding supplement ordered on [DATE]. After reviewing the Medication Administration Record [REDACTED]. No there is no documentation that it is given. The resident failed to receive the supplement from October 21, 2020 until January 12, 2021. On 1/14/21 at approximately 10:19 AM, a follow up interview was conducted with the Unit Manager during which she stated she was told about weight loss when dietary reports during the weekly weight meetings. She confirmed that Resident #24 was identified as having weight loss and stated, We initiated the Ensure after the meeting in October. She was asked if the RD was present for weight meeting in December and she said, No, I assumed the RD got the information since it is provided by dietary. Resident #77 A record review was conducted for resident #77 which revealed a plan of care that included the intervention for the resident to have a skin inspection head to toe by nurse weekly. A review of the assessments showed there were no weekly skin assessments since 9/22/20 in the electronic or hard copy record. On 1/13/21 at approximately 2:30 PM, an interview was conducted with the Director of Nursing (DON) who was asked what her expectation was for the nurses to complete the Skin Evaluation form for the weekly skin evaluations. The DON stated her expectation was for the nurses to conduct the weekly skin checks and document them in the resident's record.

Based on staff interview and clinical record review, the facility failed to maintain acceptable parameters of nutritional status for 1 of 4 residents sampled for nutrition (Resident #24). The findings include: A review of resident #24's record revealed the resident had a significant weight loss from the first weight recorded in the electronic record on September 7, 2020 of 184.8 pounds and recorded weight January 06, 2021 of 161 pounds. The percentage of weight loss was 12.97 % for 4 months. A review of the physician orders [REDACTED]. The Admission MDS (Minimum Data Set) documented a Brief interview of Mental Status (BIMS) score of 3 indicating cognitive impairment with other [DIAGNOSES REDACTED]. Section V- Care Area Assessment (CAA) Summary identified Nutritional Status as a concern. A record review was conducted for resident #24 which revealed a care plan, dated 8/27/20, for Nutritional problem or potential problem related to moderate protein calorie malnutrition with the goal Resident to comply with recommended diet daily and the interventions included RD (Registered Dietician) will evaluate and make diet changes to recommendations as needed and to provide and serve diet as ordered. A search of the dietary assessments failed to find any assessment by the Registered dietician regarding nutritional needs for Resident #24 or any progress notes from dietary. A review of the Medication Administration Record [REDACTED]. A review of the weight loss meeting progress note dated 10/20/2020 found the interdisciplinary team (IDT) indicated resident #24 was on a dysphagia puree diet and He is a - 3% weight loss times 1 week and -5.41% weight loss. Will give Ensure pudding twice daily related to weight loss. The IDT meeting notes documented on 12/18/2020 Resident is on puree dysphagia diet. Has a poor appetite. Will initiate 60 ml med pass three times daily related to weight loss. Family aware of concern. Gave consent for COVID vaccine. Will continue weekly weights. On 1/13/21 at approximately 10:02 AM, an interview was conducted with the Registered Dietician (RD) during which he stated that he was responsible for admission assessments and annual assessments on residents in the facility. He was asked if he completed an admission assessment or any review for weight loss on resident #24. He replied, There is no admission assessment for (resident #24). On 1/13/21 at approximately 11:27 AM, a follow-up interview was conducted with the RD at which time he provided the Weight Change Report which verified on the December weights a 11.69% weight loss for resident #24. Upon verification of this the RD stated, Yes I should have completed an assessment when I got the results of the weight loss in December. No, there is not an assessment completed on (Resident #24). On 01/13/21 at approximately 2:01 PM, an interview was conducted with Employee D, Unit Manager, during which she was asked if Resident #24 had received the Ensure pudding supplement ordered on [DATE]. After reviewing the Medication Administration Record [REDACTED]. No, there is no documentation that it is given. On 01/14/21 at approximately 10:19 AM, a follow up interview was conducted with Employee D, during which she stated that she finds out about weight loss concerns by the weights reported by dietary during weekly weight meetings. She verified that Resident #24 had been identified as having significant weight loss. We initiated the Ensure after the meeting in October. She was asked if the RD was present for weight meeting for the significant weight loss in December and she said, No. I assumed the RD got the information since it is provided by dietary. She further provided The nurse practitioner was notified of the weight loss to get new orders which was to include the med pass three times daily.

Based on facility record review, hospital record review, resident representative interview, and staff interviews, the facility failed to develop and implement an effective bowel management plan, to include consistent monitoring of bowel elimination resulting in constipation/fecal impaction for 1 of 3 residents reviewed for bowel incontinence. (resident #1) The findings include: Resident #1 was admitted to the facility on [DATE] and transferred to the hospital on [DATE] due to fever and respiratory concerns. The hospital records reveal on 7/4/19, the resident had an abdominal/pelvic and chest computed tomography (CT) scan without contrast with an impression of fecal impaction and constipation, with a very large amount of stool in the rectum. The CT scan report documented the stomach was mildly distended; large amount of stool throughout the colon including a very large stool ball in the rectum. Review of resident #1's facility medical record revealed the resident was incontinent of bowel. The resident had a physician order [REDACTED]. The resident did not have an as needed laxative ordered by a physician. The resident received [MEDICATION NAME] 100 mg (stool softener) by mouth twice daily since 5/15/19. Review of the Medication Administration Record [REDACTED]. The record revealed no documented communication to the physician regarding the resident not having a BM every 3 days. A BM was not recorded (MONTH) 1 through 4 2019, (MONTH) 9 through 16 2019, and (MONTH) 27 through (MONTH) 1, 2019. Review of the clinical order alerts listing report for (MONTH) 2019 and (MONTH) 2019 revealed the electronic record system created an alert for no BM in a 3-day period on the following dates: 6/2/2019 6/3/2019 6/4/2019 6/5/2019 6/6/2019 6/12/2019 6/13/2019 6/14/2019 6/15/2019 6/16/2019 6/17/2019 6/30/2019 7/1/2019 7/2/2019 7/3/2019 The admission minimum data set with an assessment reference date of 5/14/2019 revealed the resident had a score of 6 for the brief interview of mental status indicating severe cognitive impairment. Review of the activities of daily living (ADL) documentation survey report for (MONTH) and (MONTH) 2019 revealed no documentation for bowel movement (BM) entered on the ADL form for 7 AM-3 PM shift on 6/1, 6/12, 6/15, 6/21, 6/25, 6/26, 6/27, 6/29, 6/30; no documentation of BM entered on the ADL form for 3 PM-11 AM shift on 6/1, 6/11, 6/25, 6/27, 6/29, 6/30 and no documentation of BM entered on the ADL form for 11 PM-7 AM on 6/15/19. The legend on the documentation survey report indicates staff should enter each shift for the resident if the resident is continent, incontinent, had no BM, or continence not rated due to ostomy, the size of the BM, and the consistency of the BM. Several entries for the resident only indicated that the resident was continent or incontinent and no other information was documented regarding whether the resident had a BM during the shifts. A telephone interview was conducted with the resident #1's daughter on 9/18/19 at 12:36 PM. The daughter stated she brought prune juice to the facility and spoke with employee C (licensed practical nurse unit manager) on (MONTH) 21, 2019. She informed employee C of her mother's history of constipation and requested the facility give her mother the prune juice every day. Employee C assured her the facility would provide the prune juice to her mother daily. The daughter stated her mother's abdomen was swollen when she was taken to the hospital and it took days for the hospital to clear the fecal impaction. An interview was conducted with employee F (licensed practical nurse) on 9/17/19 at 8:30 AM. Employee F stated the certified nursing assistants (CNAs) check for BM and document in the computerized system, nurses check for documentation of BM every few days. She was not sure exactly how often. She indicated that if it had been more than three days since the resident had a BM, the nursing staff should obtain an order for [REDACTED]. An interview was conducted with employee G (licensed practical nurse) on 9/17/19 at 8:36 AM. Employee G stated the CNAs chart the BM in the electronic medical record. The nurses should check the system at the end of each shift to be sure no BM was missed. She stated if there was no documentation, she would ask the CNA if it was correct and try to determine if the resident had a BM in 3 days. If the resident is alert and oriented, she will ask resident if they have had a BM. If no BM is documented, she must assume no BM occurred. She would then administer a physician ordered laxative; if no laxative is ordered call the physician. An interview was conducted with employee C (licensed practical nurse unit manager) on 9/17/19 at 8:45 AM. Employee C stated the CNAs are to chart every shift in the electronic record system if the resident had a BM or not. She did not know if the documentation required in the system included size of BM. If the resident does not have a BM in 3 days, she receives an alert in the computer system. She makes a list of residents with the BM alert and provides the list to the floor nurse. The floor nurse will then ask the CNA and the resident if the resident is alert. She was not aware resident #1 did not have a BM documented for 5 days. She stated at times resident #1 had diarrhea and confirmed it would be possible for a resident to have diarrhea with a fecal impaction. Further interview was conducted with employee C on 9/17/19 at 12:45 PM. She stated the facility had no formal process to ensure the nurses are checking for BMs and administering laxatives if needed or notifying the physician. An interview was conducted with the Director of Nursing (DON) on 9/17/19 at 4:11 PM. The DON stated the unit manager would pull the BM alerts and disperse them to the nurses. The nurses would find out if the residents listed on the alert had a BM or if they needed a laxative. She was not aware if a nurse followed up on the BM alerts for resident #1. She stated the facility had no formal process in place to ensure CNAs complete the ADL documentation.

Based on record review, staff interviews and policy review the facility failed to maintain a complete and accurate medical record for 3 of 3 residents reviewed for bowel elimination (residents #1, 2 and 3). Cross reference F690. The findings include: Review of resident #1's medical record revealed the resident was incontinent of bowel. Review of the activities of daily living (ADL) documentation survey report for (MONTH) and (MONTH) 2019 revealed no documentation for bowel movement (BM) entered on the ADL form for 7 AM-3 PM shift on 6/1, 6/12, 6/15, 6/21, 6/25, 6/26, 6/27, 6/29, 6/30; no documentation of BM entered on the ADL form for 3 PM-11 PM shift on 6/1, 6/11, 6/25, 6/27, 6/29, 6/30 and no documentation of BM entered on the ADL form for 11 PM-7 AM on 6/15/19. Review of resident #2's medical record revealed the resident was frequently incontinent of bowel. Review of the ADL documentation survey report for (MONTH) 2019 revealed no documentation of BM entered on the ADL form for 7 AM-3 PM shift on 7/2 and 7/11, and for 3 PM-11 PM shift on 7/2, 7/3, 7/6 and 7/10. Review of resident #3's medical record revealed the resident was incontinent of bowel. Review of the ADL documentation survey report for (MONTH) 2019 revealed no documentation for bowel movement entered on the ADL form for 7 AM-3 PM shift on 7/2, 7/5, 7/15, 7/16; no documentation of BM entered for 3 PM-11 PM shift on 7/3, 7/7, 7/13, 7/15; no documentation of BM entered on the ADL form for 11 PM-7 AM shift on 7/7, 7/11, 7/12, 7/14, 7/15 and 7/16. The legend on the documentation survey report indicates staff should enter each shift for the resident if the resident is continent, incontinent, had no BM, or continence not rated due to ostomy, the size of the BM, and the consistency of the BM. Several entries for the sampled residents only indicate if the resident is continent or incontinent and no other information is provided regarding whether or not the residents had a BM. An interview was conducted with employee C (licensed practical nurse unit manager) on 9/17/19 at 8:45 AM. Employee C stated the certified nursing assistants (CNAs) are to chart whether or not the resident had BM every shift in the electronic computer system. An interview was conducted with the Director of Nursing (DON) on 9/17/19 at 4:11 PM. The DON stated she was not aware of the incomplete ADL documentation prior to the survey. She stated there was no formal process in place to ensure the CNAs were completing the required ADL documentation. Review of the facility policy for Clinical/Medical Records (MR-195 effective 11/30/14, revised 8/25/17) revealed clinical records are maintained in accordance with professional practice standards to provide complete and accurate information on each resident for continuity of care. The purpose of the clinical record is to document the course of the resident's plan of care and to provide a medium of communication among health care professionals involved in this care.

Based on closed record review, interview and policy review, the facility failed to ensure that immediate facility-initiated discharges only occurred to meet health, safety or welfare needs of residents for 1 of 3 residents sampled for discharge (#267). The facility issued a same day discharge notice, without indicating the reason, and subsequently discharged the resident despite the family stating they were unable to care for the resident at home. The findings include: On [DATE], a closed record review was conducted for resident #267 which revealed the resident was admitted to the facility on [DATE] for short term rehabilitation, and had a history of [REDACTED]. The record also revealed that on [DATE] he was discharged home with Hospice services. Review of the Nursing Home Transfer and Discharge Notice revealed that both the 'Date Notice Given' and the 'Effective Date' were documented as [DATE]. The 'Reason for Discharge or Transfer' was not identified. Documented under the section, 'Brief explanation to support this action', was Home with Hospice and information provided verbally over the phone as wife (name listed) and responsible party declines to come to facility to sign paperwork with a notation date of [DATE]. A review of the admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed under section G, Functional Status, that Resident #267 required extensive assistance with 2+ persons for bed mobility, and transfer, extensive assistance with 1 person physical assist for eating, dressing and personal hygiene, and was totally dependent with 1 person physical assist for toileting. Review of the Social Services note dated [DATE] titled Discharge Planning demonstrated that the resident's spouse had stated to the Social Services Director (SSD) that she desired for the resident to stay in the facility for long term care, but was informed by the SSD the that the facility does not have bed availability. The note further stated that the resident's wife then contacted a local Hospice provider to request admission and refused to sign the Notice of Medicare Non-Coverage (NOMNC) form. On [DATE] the Social Services Director (SSD) documented that the spouse requested wheelchair transportation because she could not physically carry the resident in her car. The SSD further documented that the discharge paperwork, to include the Nursing Home Transfer and Discharge Notice, was sent home with the resident. Review of a letter submitted to the Agency for Health Care Administration (AHCA) by the spouse of resident #267 stated that she was informed on [DATE] that the resident would be discharged on [DATE] for refusing therapy 3 times. She went on to say that when she accompanied him to therapy he did quite well. She states that she was given a copy of the NOMNC while visiting her husband on [DATE]; however, it was not explained to her and that she did not refuse to sign the form. She also stated in the letter that she had stressed to them that I was physically unable to care for him on my own. She states she was never given a thirty days notice of discharge but was given three days to find alternative placement which she was unable to do. She stated that her husband was a difficult patient who required [MEDICATION NAME] for his behaviors related to dementia and a stroke he had in (MONTH) 2019. Hospice Skilled Nursing notes, from a meeting prior to discharge on [DATE] at 9:00am, were reviewed. The Hospice nurse met with Resident #267 and his wife. The Hospice nurse documented, Since being in rehab, he has been combative and unable to participate in physical therapy. The facility has notified (the wife) that Resident #267 will be discharged on [DATE]. (The wife) feels she cannot take care of him at home and is seeking long term placement. The SSD at University Hills is assisting with finding placement. Review of Hospice notes from [DATE] until the resident's death on [DATE] revealed that Resident #267 remained at home until his death. On [DATE] at approximately 10:26 AM, an interview was conducted with the Social Services Director in which she stated that resident #267 was discharged on [DATE]. She stated that the wife had requested he stay in the facility, but there were no beds available in the locked unit so he could not stay. She reported that prior to discharge, the resident had been in a private room on a non-locked unit but his behaviors were such that he required a locked unit. She reported he was sent home via a wheelchair taxi. When asked if anyone attended the resident on his way home she stated no. At this time she was asked if it was customary to send a resident with behavior issues, severe enough that he required a locked unit, home unattended via taxi, she stated the driver had the skills to deal with it. She further stated that there were no beds in the facility despite the census on the day of discharge of 115 (of 120 possible beds). On the day prior to discharge, (MONTH) 6th, the facility census was 116 including the resident. She stated she remembers the wife stating she did not want to take him home because she could not take care of him and that if there had been a bed available he would have stayed, but there were no beds. On [DATE] at approximately 11:37 AM, an interview was conducted with the driver of the taxi that transported the resident home on the day of discharge. He stated that it is against their policy to assist with transferring residents out of the wheelchair and that if there was a concern with the caregiver not being able to transfer a resident they would call for emergency services to come and assist. He stated he has not had a need to call for this is a few months. He did not recall transferring the resident but stated he transfers many residents. On [DATE] at approximately 1:36 PM, an interview was conducted with the Administrator. During the interview she was asked about the discharge for resident #267. She reported that the resident was discharged for refusing therapy and because the facility did not have beds in the locked unit, therefore his needs could not be met. She reported that the capacity in the Serenity Unit, the locked unit, was 16 however one room is private therefore it is currently 15. She stated that resident #267 had been housed in a traditional room while he was at the facility, but this was a Medicare bed and he needed a long term care bed which was not available. She stated that the resident had been in restraints in the hospital prior to admission and had a history of [REDACTED]. She further stated that the facility would not have discharged him unless Hospice was scheduled to be at the house when the resident arrived because the wife needed assistance transferring him. When asked about a taxi being used to transport the resident home she stated that if there are behaviors they would send a CNA (certified nursing assistant) with the resident, but on the day he was discharged he was up eating crackers and not having issues, so they just sent him alone. When asked about the discharge related to refusing therapy, she reviewed the record and stated that the nursing notes do not support his refusal with multiple documented entry's as up in therapy. She further stated that therapy should have documented the times he refused in their notes. She stated that if there was a bed on the secured unit he would still be in the facility today, but there was not a bed. When asked why he couldn't stay in a traditional bed until an opening in the locked unit, she stated that the wife did not ask to fill out the paperwork. She was unable to demonstrate that the spouse was aware that paperwork could be completed that would allow him to stay. On [DATE] at approximately 10:46 AM, an interview was conducted with the Director of Therapy, in which he stated the resident had refused therapy on (MONTH) 1st and 2nd and had ended treatment 15 minutes early on (MONTH) 3rd. He stated that when a resident refuses therapy 3 times they are discharged after the Power of Attorney and the resident are educated on the need to continue and participate. The surveyor requested copies of the notes in which the resident or the family were offered education to which he stated he was unable to find evidence of education. The Director stated that the resident's last day of therapy as well as his discharge date from therapy was [DATE]. Review of the plan of care dated [DATE] revealed that Resident #267 required extensive assist with transfers and bed mobility and had issues with behaviors that included aggression, risk for elopement and resistive to care at times; however, there was no mention of the resident refusing physical therapy. Review of the facility assessment revealed that the facility is licensed for 120 beds and that they accept residents with [MEDICAL CONDITION] (hallucinations, Delusions, Etc) impaired cognition, mental disorder, depression, [MEDICAL CONDITION] disorder (i.e Mania/depression) [MEDICAL CONDITION], post-traumatic stress disorder, anxiety disorder behaviors that needs intervention. It states that their highest volume of admissions are related to psych. The assessment further states that the facility provides care to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairments, care of individuals with depression, trauma/[MEDICAL CONDITIONS], other psychiatric diagnoses, intellectual or developmental disabilities. Review of the facility policy Transfer/Discharge Notification & Right to Appeal dated [DATE] revealed documentation must be made by the resident's physician when the discharge is necessary due to the resident's welfare and the resident's needs cannot be met in the center. Timing of the notice discharge must be made 30 days prior to residents discharge except when there are safety or health concerns. Orientation for transfer or discharge the center must provide and document sufficient preparation and orientation, in a form and manner that the resident understands, to ensure safe and orderly transfer or discharge. The policy and procedures for transfer and discharge and provision of services will be equal for all individuals regardless of payor source.

Based on closed record review, interview and policy review, the facility failed to ensure the written notice for discharge included a reason for discharge, the discharge notice was issued as soon as practicable before discharge and that there was physician documentation justifying the reason for discharge for 1 of 3 residents reviewed (resident #267). The findings include: On 4/18/19, a closed record review was conducted for resident #267 which revealed the resident was admitted to the facility on [DATE] for short term rehabilitation and had a history of [REDACTED]. The record also revealed that on 3/7/19 he was discharged home with Hospice services. Review of the Nursing Home Transfer and Discharge Notice revealed that both the 'Date Notice Given' and the 'Effective Date' were documented as 3/7/19. The 'Reason for Discharge or Transfer' was not identified. Documented under the section, 'Brief explanation to support this action', was Home with Hospice and information provided verbally over the phone as wife (name listed) and responsible party declines to come to facility to sign paperwork with a notation date of 3/7/19. A review of the Physician/Advanced Registered Nurse Practitioner (ARNP) documentation failed to find justification for the discharge. There was an order dated 3/5/19 to Consult Hospice, anticipate Hospice services at discharge if okay with family. Evaluate and treat if appropriate. On 3/7/19 the ARNP wrote an order that simply said, discharge. On the Physician's Progress Notes form, on 3/5/19 the ARNP documented, Hospice at discharge versus other. Leaning towards Hospice. Patient's wife cannot take care of him by herself in his current condition. Discharge plans ongoing, to be determined soon. On 3/7/19 the ARNP documented the resident was improving overall. Hospice planning to follow at home. Review of the Social Services note dated 3/6/19 titled Discharge Planning demonstrated that the resident's spouse had stated to the Social Services Director (SSD) that she desired for the resident to stay in the facility for long term care, but was informed by the SSD the that the facility does not have bed availability. The SSD further documented that the discharge paperwork, to include the Nursing Home Transfer and Discharge Notice, was sent home with the resident Review of a letter submitted to the Agency for Health Care Administration (AHCA) by the spouse of resident #267 stated that she was informed on 3/4/19 that the resident would be discharged on [DATE] for refusing therapy 3 times. She also stated in the letter that she had stressed to them that I was physically unable to care for him on my own. She states she was never given a thirty days notice of discharge but was given three days to find alternative placement which she was unable to do. She stated that her husband was a difficult patient who required [MEDICATION NAME] for his behaviors related to dementia and a stroke he had in (MONTH) 2019. On 4/19/19 at approximately 1:36 PM, an interview was conducted with the Administrator. During the interview she was asked about the discharge for resident #267. She reported that the resident was discharged for refusing therapy and because the facility did not have beds in the locked unit, therefore his needs could not be met. She stated that if there was a bed on the secured unit he would still be in the facility today, but there was not a bed. Review of the facility policy Transfer/Discharge Notification & Right to Appeal dated 3/26/18 reveled documentation must be made by the resident's physician when the discharge is necessary due to the resident's welfare and the resident's needs cannot be met in the center. Timing of the discharge notice must be made 30 days prior to residents discharge except when there are safety or health concerns. Orientation for transfer or discharge the center must provide and document sufficient preparation and orientation, in a form and manner that the resident understands, to ensure safe and orderly transfer or discharge. The policy and procedures for transfer and discharge and provision of services will be equal for all individuals regardless of payor source.

Based on staff interviews, record review, and quality assurance performance improvement plan review, the facility failed to develop and implement appropriate action plans to address concerns related to facility initiated discharges for 1 of 3 residents sampled for discharge, #267. The findings include: During a previous complaint survey ending on 2/21/2019, concerns were identified at F622 regarding the facility initiated discharge process. The facility had issued a 30 day notice to a resident stating their needs could not be met in the facility due to the resident being found in possession of marijuana on two different occasions. The facility immediately rescinded the discharge and completed a plan of correction (PoC). As part of the corrective action plan, the facility reviewed all transfer and discharge notices issued over the past 6 months through 3/19/19 and documented, No other transfer/discharge notice was found to be inappropriately issued. The Administrator and Social Services Director were re-educated on appropriate reasons to issue transfer/discharge notices. Per the plan of correction, findings of these quality reviews would be reported to the Quality Assurance/ Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Regional Director of Clinical Services. During the current recertification and complaint survey, concerns were identified at F622 regarding inappropriate facility initiated discharges. Resident #267 was issued a same day discharge notice, without indicating the reason, and subsequently discharged despite the family stating they were unable to care for the resident at home. Concerns were also identified at F623 regarding the contents and timing of the written discharge notice and documentation supporting the reasons for discharge for resident #267. The discharge notice for resident #267 was issued on 3/7/19, during the review period identified by the plan of correction. An interview regarding the facility-initiated discharge process was conducted with the Administrator, the head of the Quality Assurance committee, on 04/19/19 at 02:18 PM. The administrator stated that the QA committee had not identified any issues with inappropriate discharge. The committee believed that all discharges had been appropriate. No current action plan regarding facility-initiated discharges was provided for review.

Based on observation, resident interview, staff interview and record review, the facility failed to develop a comprehensive care plan for contractures, wound prevention and wound treatment for 1 of 7 residents sampled (#4). The findings are: Resident #4 was admitted to the facility in October 2016 with contractures and without any documented wounds and transferred to the hospital in November 2016 with wounds to the coccyx (tail bone), heels, and left ear. Record review of the hospital transfer sheet to the nursing home dated 10/14/16 indicated resident #4 did not have any wounds upon admission to the nursing home. Resident #4 was assessed using the Minimum Data Set (MDS) with an assessment reference date of 10/21/17 to be at risk for wounds, needing extensive assistance with daily care, and having limited range of motion to bilateral upper and lower extremities. Review of the admission care plan for resident #4, dated 10/14/16, indicated the resident was at risk for pressure sores with interventions to follow skin care protocol, turn every 2 hours and as needed, and to immediately report redness or skin breakdown. Review of the comprehensive care plan, which follows the admission care plan, and is based on the comprehensive assessment of the resident, lacked plans to address the resident's risk for pressure sores, or limited range of motion. During the resident's stay at the nursing facility, she developed wounds to her coccyx (tail bone), bilateral heels, and her left ear. By the time of her discharge on 11/28/16, resident #4 had a stage IV coccyx wound measuring 5.0 x 7.5 x 2.5 cm with 3 cm undermining, a deep tissue injury (DTI) to bilateral (both) heels that was identified on 11/24/16, and a stage IV pressure wound to the left ear that was also identified on 11/24/16. Review of physical therapy (PT) notes found resident #4 was seen by PT from 10/15/16 through 11/11/16 for positioning. She was assessed for a positioning/orthotic device to be used on bilateral lower extremities for proper body alignment and decreasing pressure areas. She was discharged from PT on 11/11/16 to a nursing restorative program for ankle/foot orthotics and heel boots, alternating each every 2 hours to avoid skin break down and contractures. Therapy in-serviced nursing staff on 11/10/16 for passive range of motion to bilateral upper and lower extremities, hips, knees and ankles, application of foot orthotics for 2 hours then alternate every 2 hours with heel protectors, and placing wedge resident's knee's to avoid contractures. This was signed by staff who attended the in-service on 11/11/16. Review of the medical record for resident #4 lacked documentation that these services were provided. On 11/24/16, bilateral deep tissue injuries to the heels of resident #4 were identified, and the resident was sent to the hospital on [DATE]. Interview with the physical therapist on 2/15/17 at 11:40 AM indicated resident #4 had been discharged from therapy and referred to restorative nursing program. Staff were trained on 11/10/16 to use orthotic boot, wedges and range of motion exercises to avoid contractures and skin break down. Interview with certified nursing assistant (CNA) E on 2/15/17 at 1:10 PM indicated that she cared for resident #4, and the resident was total care and had wounds. She stated staff would turn the resident due to the wounds and the resident had a pressure relief mattress. She stated that the resident had contracted arms which she held close to her chest, and staff gave her a bed bath instead of showers. She said she didn't remember the training from therapy about orthotics boots to prevent further contractures or skin ulcers, but indicated she did see facility soft booties on the resident at times for her heels. Interview with CNA in charge of the restorative program on 2/15/17 at 12:45 PM indicated the resident was never added to the restorative nursing program. Interview with Administrator and Director of Nursing on 2/15/17 at 9:00 am indicated the resident did not receive restorative nursing and the orthotics were not ordered.

Based on observation, resident interview, staff interview and record review, the facility failed to follow the plan of care to prevent pressure to the skin for 1 of 7 residents sampled with wounds. (#2) The findings are: Resident #2 was assessed utilizing a Minimum Data Set (MDS) with an assessment reference date of 12/9/16 as alert and oriented, needing extensive assistance with activities of daily living (ADLs), and being at risk for wounds, but not having wounds at the time of the assessment. Review of the care plan for resident #2, dated 12/27/16, indicated the resident needed total care and needed to have his heels floated and needed to be turned and repositioned. Wound care notes dated 1/26/17 showed a purplish, quarter sized, deep tissue injury (DTI) to the resident's left heel measuring 2.3 centimeters (cm) x 2.9 cm x 0.1 cm. Observation of resident #2 on 2/14/17 at 10:50 am found him lying in bed with heels touching the mattress without heel protectors on, or heels floating off of the mattress. Resident #2 had a dressing on his left heel dated 2/13/17. Interview with the resident indicated his heels were always lying on the bed without pillows or booties (heel protectors). Observation of the resident on 2/14/16 at 2:15 PM found resident lying in bed on his back. His heels did not have heel protectors and they were not floating off of the mattress. An observation of resident care was observed on 2/14/17 at 2:30 PM with certified nursing assistants (CNAs) I and J. After care the CNAs did not turn the resident to either side, and instead, they left the resident positioned on his back. The CNAs indicated resident #2 did not currently have a wound. When questioned about the left heel with the dressing, aide J indicated that was from pressure but he didn't have any wounds. During care his heels were not floating and did not have booties in place, and the CNAs left the room without floating the resident's heels, applying heel protectors, or turning him. Observation on 2/15/17 at 8:00 am revealed resident #2 was in bed, on his back, with his heels not floated and no heel protectors in place. Observation on 2/15/17 at 1:10 pm with the wound nurse showed resident #2 was on his back, heels not floating, and no heel protectors in place. Observation was also conducted of the wound to the resident's left foot. The heel had a deep tissue injury (DTI). A subsequent interview with the nurse indicated the resident should be turned every 2 hours, and his heels should be floated and/or heel protectors applied, and she completed this intervention before she left the resident's room.

Based on observation, resident interview, staff interview, and record review, the facility failed to consistently provide necessary treatment and services to prevent the development and worsening of pressure wounds for 2 of 7 residents sampled with wounds (#2 & #4) which resulted in a finding of harm. The facility failed to float heels off of the bed or consistently apply heel protectors for resident #2 who had bilateral heel wounds. The facility failed to consistently obtain physician orders [REDACTED]. The findings are: Resident #4 Resident #4 was admitted into the facility in October 2016 without any documented wounds and transferred to the hospital in November 2016 with wounds to the coccyx (tail bone), heels, and left ear. Record review of the hospital transfer sheet to the nursing home, dated 10/14/16, indicated resident #4 did not have any wounds upon admission to the nursing home. Resident #4 was assessed using the Minimum Data Set (MDS) with an assessment reference date of 10/21/17 to be at risk for wounds, needing extensive assistance with daily care, and having limited range of motion to her bilateral upper and lower extremities. Review of the admission care plan for resident #4, dated 10/14/16, indicated she was at risk for pressure sores with interventions to follow skin care protocol, turn every 2 hours and as needed, and to immediately report redness or skin breakdown. Review of the comprehensive care plan, which follows the admission care plan, and was based on a comprehensive assessment of the resident lacked plans to address the resident's risk for pressure sores, or her limited range of motion. During the resident's stay at the nursing facility she developed wounds to the coccyx (tail bone), bilateral heels, and left ear as follows: Coccyx- Review of pressure ulcer record dated 10/31/16 indicated resident developed a stage 2 wound to left coccyx measuring 0.6 x 0.5 x 0.1 centimeters (cm) and to right coccyx measuring 1.0 x 0.5 x 0.1. Within 2 weeks on 11/14/16, documentation showed the wounds healed. Two days later on 11/16/16 the right coccyx reopened to a stage III (full thickness skin loss) pressure ulcer measuring 6.1 x 5.9 x 0.2 cm without undermining. On 11/28/16 the wound was 5.0 x 7.5 x 2.5 cm with 3 cm undermining and assessed at a stage IV (full thickness tissue loss with exposed bone, tendon or Muscle). A record review of physician orders [REDACTED]. On 10/31/16 orders were given to cleanse sacrum area (includes coccyx area) with wound cleanser, pat dry and apply skin prep to peri-wound (area surrounding wound), apply foam dressing every 3 days or as needed. Review of the nurse's medication/ treatment record for 10/31/16 does not show the treatment was done. Review of the November 2016 medication/ treatment record revealed treatments were not conducted as ordered, treatments were missed on 11/3, 11/6 and 11/9. Review of pressure ulcer record on 11/16/16 the right coccyx wound re-opened to a stage III. Review of physician orders [REDACTED]. On the medication/treatment record for the month of November 2016 there was an order dated 11/25/16 to cleanse wound, pat dry, pack wound with moistened [MEDICATION NAME], cover with gauze after area has been skin prepped, cover with foam dressing and change every day and as needed. The medication/treatment record was reviewed from the time the coccyx wound was identified on 11/16/16 to when resident #4 transferred to the hospital on [DATE]. Only one treatment was documented as completed, on 11/26/16. The resident's hospital [DIAGNOSES REDACTED]. Ear- Review of pressure ulcer record from 10/14/16- 11/28/16 and wound meeting minutes did not reflect wound to left ear however in wound nurse's progress notes dated 11/24/16 indicated stage IV to left ear. Review of physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. Heels- Review of pressure ulcer record from 10/14/16- 11/28/16 and wound meeting minutes did not reflect wound to heels; however, in wound nurse's progress note dated 11/24/16 there was an indication of a deep tissue injury (DTI) to the resident's bilateral heels. No wound measurements were documented. Review of orders for month of November 2016 found no orders to treat DTI to bilateral heels; however, on the MAR for November 2016 found order dated 11/25/16 to treat bilateral heels with skin prep and cover with foam border heel dressing and change every 7 days. The treatment was not signed as conducted. Resident went out to hospital on [DATE]. Contractures- Review of physical therapy (PT) notes found resident #4 had been seen by PT from 10/15/16 through 11/11/16 for positioning. She was assessed for positioning/orthotic device bilaterally for lower extremities for proper body alignment and to decrease pressure areas. The resident was discharged from PT on 11/11/16 to nursing restorative program for ankle/foot orthotics and heel boots, alternating each every 2 hours to avoid skin break down and contractures. Therapy in-serviced nursing staff on 11/10/16 for passive range of motion to bilateral upper and lower extremities, hips, knees and ankles, to apply foot orthotics for 2 hours then alternate every 2 hours with heel protectors, and to place wedge under the resident's knee's to avoid contractures. This was signed by staff who attended in-service on 11/11/16. Review of chart lacked documentation that this was provided. On 11/24/16, a bilateral deep tissue injury to the heels was identified, and then the resident was sent to the hospital on [DATE]. On 2/15/17 at 1:10 PM, an interview with certified nursing assistant (CNA) E, who cared for resident #4, indicated the resident had been total care and had wounds. Staff would turn her for this and she had a pressure relief mattress. She had contracted arms which she held close to her chest, and staff gave her a bed bath instead of showers. She said she didn't remember the training from therapy about orthotic boots to prevent further contractures or skin ulcers. She indicated she did see facility soft booties on the resident at times for her heels. Interview with the CNA in charge of the restorative nursing program on 2/15/17 at 12:45 pm indicated the resident was never added to the nursing restorative program. Interview with the physical therapist on 2/15/17 at 11:40 am indicated resident #4 was discharged from therapy on 11/10/16 and referred to the restorative nursing program. Staff were trained on 11/10/16 to use orthotic boot and wedges and provide passive range of motion to avoid contractures and skin break down. Interview with the wound care nurse A on 2/15/17 at 11:30 am indicated the resident was admitted without any pressure ulcers. The nurse stated the resident developed an area to her sacrum (coccyx) which healed. About 2 weeks later the area reopened. She then developed an area under her [MEDICAL CONDITION] which healed followed by the development of areas to her ear and heels. During this time, resident #4 was treated by nurses. The nurse indicated she would measure areas weekly and floor nurses would provide the wound care and document on the MAR. She didn't understand why the MAR's did not indicate treatments were done by the nurses. Interview with the Administrator and Director of Nursing on 2/15/17 at 9:00 am indicated resident #4 did not receive restorative nursing, and the orthotics were not ordered. Both confirmed findings of staff not documenting treatments were provided as ordered by the physician and that restorative nursing was not started. Record review of transfer sheet to hospital from facility found on 11/28/16 resident #4 went to emergency room for fever of 103.7 and stage IV wound to coccyx. Review of hospital history and physical dated 11/28/16 indicated resident had fever, grapefruit size sacral decubitus ulcer and maceration of bilateral breasts. Review of hospital progress notes dated 11/29/16 found stage IV ulcer to right coccyx 6 x 5 x 3 cm, Unstageable ulcer to left ear 3 x 1 cm, unstageable ulcer to left heel 3 x 4 cm and right heel 3.8 x 3 cm, stage I to left foot dorsal 3 x 1.4 cm and stage II ulcer to left plantar foot 1.5 x 9 cm intact blister. Review of hospital discharge summary dated 11/28/16-12/29/16 indicated the resident [MEDICAL CONDITION] and Gangrene and [DIAGNOSES REDACTED] of the bone from the sacral decubitus ulcer. The resident had surgery to the wound which resulted in treatment with a [DEVICE]. Resident #2 Resident #2 was assessed utilizing a Minimum Data Set (MDS) with an assessment reference date of 12/9/16 as alert and oriented, needing extensive assistance with activities of daily living (ADLs), and being at risk for wounds, but not having wounds at the time of the assessment. Review of the care plan for resident #2, dated 12/27/16, indicated the resident needed total care and needed to have his heels floated and needed to be turned and repositioned. Wound care notes dated 1/26/17 showed a purplish, quarter sized, deep tissue injury (DTI) to the resident's left heel measuring 2.3 centimeters (cm) x 2.9 cm x 0.1 cm. Observation of resident #2 on 2/14/17 at 10:50 am found him lying in bed with heels touching the mattress without heel protectors on, or heels floating off of the mattress. Resident #2 had a dressing on his left heel dated 2/13/17. Interview with the resident indicated his heels were always lying on the bed without pillows or booties (heel protectors). Observation of the resident on 2/14/16 at 2:15 PM found resident lying in bed on his back. His heels did not have heel protectors and they were not floating off of the mattress. An observation of resident care was observed on 2/14/17 at 2:30 PM with certified nursing assistants (CNAs) I and J. After care the CNAs did not turn the resident to either side, and instead, they left the resident positioned on his back. The CNAs indicated resident #2 did not currently have a wound. When questioned about the left heel with the dressing, aide J indicated that was from pressure but he didn't have any wounds. During care his heels were not floating and did not have booties in place, and the CNAs left the room without floating the resident's heels, applying heel protectors, or turning him. Observation on 2/15/17 at 8:00 am revealed resident #2 was in bed, on his back, with his heels not floated and no heel protectors in place. Observation on 2/15/17 at 1:10 pm with the wound nurse showed resident #2 was on his back, heels not floating, and no heel protectors in place. Observation was also conducted of the wound to the resident's left foot. The heel had a deep tissue injury (DTI). A subsequent interview with the nurse indicated the resident should be turned every 2 hours, and his heels should be floated and/or heel protectors applied, and she completed this intervention before she left the resident's room.

Based on observation, resident interview, staff interview and record review, the facility failed to provide appropriate contracture treatment resulting in harm for 1 of 3 sampled residents ordered to receive services from restorative nursing (#4). The facility failed to initiate a restorative program developed by therapy on 11/11/16 which included passive range of motion, knee wedge, foot orthotics and heel protectors. On 11/24/16, resident #4 developed a deep tissue injury to both heels. The findings are: Review of the admission Minimum Data Set ((MDS) dated [DATE] indicated resident #4 was at risk for wounds, needed extensive assistance with daily care and was assessed to have limited range of motion to bilateral upper and lower extremities. Review of Comprehensive Care Plan based on comprehensive assessment lacked plans to address resident's risk for pressure sores and limited range of motion. Review of Physical Therapy (PT) notes found resident was seen by PT from 10/15/16 through 11/11/16 for positioning. She was assessed for positioning/orthotic device bilaterally for lower extremities for proper body alignment and decrease pressure areas. She was discharged on [DATE] to nursing restorative program for ankle/foot orthotics and heel boots, alternating each every 2 hours to avoid skin break down and contractures. Therapy in-serviced nursing staff on 11/10/16 for passive range of motion to bilateral upper and lower extremities, hips, knees and ankles, to apply foot orthotics for 2 hours then alternate every 2 hours with heel protectors, and to place wedge under her knee's to avoid contractures. This was signed by staff who attended in-service on 11/11/16. Review of chart lacked documentation that these interventions were provided. On 11/24/16, a bilateral deep tissue injury to the heels was identified, and then the resident was sent to the hospital on [DATE]. On 2/15/17 at 1:10 PM, interview with aide E, who cared for resident #4, indicated she was total care and had wounds. Staff would turn her for this and she had a pressure relief mattress. She had contracted arms which she held close to her chest. Staff gave her a bed bath instead of showers. She said she didn't remember the training from therapy about orthotic boots to prevent further contractures or skin ulcers. She indicated she did see facility soft booties at times for her heels. Interview with the certified nursing assistant (CNA) in charge of the restorative nursing program on 2/15/17 at 12:45 pm indicated the resident was never added to the nursing restorative program. Interview with the physical therapist on 2/15/17 at 11:40 am indicated resident #4 was discharged from therapy on 11/10/16 and referred to the restorative nursing program. Staff were trained on 11/10/16 to use orthotic boot and wedges, and to provide range of motion to avoid contractures and skin break down. Record review of hospital transfer sheet to nursing home from hospital dated 10/14/16 indicated resident #4 did not have any wounds upon admission to the nursing home. Interview with the wound care nurse A on 2/15/17 at 11:30 am indicated the resident was admitted without any pressure ulcers. Review of the wound nurse's progress note dated 11/24/16 indicated the resident had a deep tissue injury (DTI) to her bilateral heels. Record review of transfer sheet to hospital from facility found on 11/28/16 resident #4 went to emergency room for fever of 103.7. Review of hospital progress notes dated 11/29/16 found unstageable ulcer to left heel measuring 3 x 4 centimeters (cm), unstageable ulcer to right heel measuring 3.8 x 3 cm, stage I to left foot dorsal (upper part) measuring 3 x 1.4 cm and stage II ulcer to left plantar (sole) foot measuring 1.5 x 9 cm intact blister. Interview with Administrator and Director of Nursing on 2/15/17 at 9:00 AM indicated she did not receive restorative nursing and the orthotics were not ordered. Both confirmed findings of staff not documenting treatments were provided as ordered by the physician and that restorative nursing was not started.

Based on staff interview, and clinical record review the facility failed to provide the necessary staffing on the secured speciality dementia unit to ensure appropriate supervision to prevent inappropriate sexual behavior of 1 male resident (Resident #1) towards 2 vulnerable female residents ( residents #2, and # 3). The findings are: The Serenity Unit of the facility is a locked unit in the facility staffed with 3 Certified Nursing Assistants (CNA) and one Licensed Practical Nurse that floats to the unit for necessary treatments, medication passes, and when called on the 7-3 and 3-11 shifts. The unit has 15 residents. Resident #1's room is next to the day room, Resident #2's room is one room down and across the hall from Resident #1. Resident #3's room is located 3 doors down from the day room. On the day shift 7-3 on 9/30/12 the unit was staffed with 3 CNA's ( one person had a permanent assignment on the unit Employee (B), one CNA was scheduled to work on the unit but normally works on Unit 2 Employee (C), and one CNA was pulled from Unit 1 Employee (D). The Licensed Practical Nurse assigned to Serenity had a family emergency and left about 9:30 am. The RN Supervisor took over her cart at that time. There was a Restorative Aide on and off the unit during the day shift Employee (E) An interview was conducted with Employee (C) on 10/4/12 about 10:40 am. She related that it was her first time to work on the Serenity Unit. She said Resident #3 kept taking her clothes off and getting on the floor scooting saying "I want my chair, I want my chair". An interview with employee E was conducted about 10:50 am on 10/4/12 she relates that Resident #3 was "Frisky on Sunday she kept exposing herself in the day room". The Resident was put to bed about 9:30 am according to Employee (C). She continued to be dressed and she would undress throughout the shift. At the change of shift she was changed into a nightgown with a brief. The curtain was pulled and her door was shut because she began to undress immediately. The Evening shift came in again with 3 CNA's and a LPN who also had duties outside the secured unit. The 3 CNA's were Employee ( B ) who was working a double, Employee (F) who was pulled from Unit 1, and another CNA who was working 3-11 and 11-7. An interview with Employee (B) was conducted about 9:48 am on 10/5/12. She stated, "There was a situation with Resident #1 and Resident #2. He, resident #1 went into resident #2's room alone about 3:15 pm to 3:30 pm. They were separated and the LPN was told when she arrived on the unit". She then said, "Apparently something else happened after that because the LPN went and got the administrator". The Administrator and LPN asked one of the CNA's to take Resident #2 off the unit. This left 2 CNA's on the unit. An interview with Employee (F) was conducted about 5:05 pm on 10/4/12. He says, "I arrived on the unit about 3:30 pm. There was a commotion on the unit. Resident #2 was agitated. The third CNA took her off the unit to calm her down. Resident #2 arrived back on the unit about 4:15 pm and the LPN asked me to take her off the unit and walk her around the facility to calm her down. An interview was conducted with the Administrator about 11:15 on 10/4/12. She said Resident #1 was acting out with Resident #2 about 5:00 pm. Resident #1 had barricaded himself in the room with Resident #2. "I went back to the unit and told the LPN and CNA that Resident #1 needed to be on 1:1"." I went back to the unit about 5:30 pm because Resident #1 was banging and kicking Resident #2's door. I asked CNA to take her off the unit and walk her around, she was brought back to the unit and she swapped with Employee (F). An interview with Employee (C) was conducted on 10/4/12 about 8:50 am. She related, "I was sitting in the hallway observing Resident #1 walking in the hallway and watching the dayroom where other residents were located. Employee (F) was still with Resident #2 in her room still attempting to calm her down, and the third CNA had to take another resident to the toilet. I was sitting there when I observed a resident in the dayroom who cannot stand attempt to get out of his wheelchair". I called to Employee (F) for help and ran to the resident before he could fall. I assisted him into to his chair and went back into the hallway. I did not see Resident #1. An interview with Employee (F) was conducted on 10/4/12 about 5:05 pm. He relates, " I was in Resident #2's room attempting to assist 2 wandering residents out of her room because she was still agitated when I heard Employee (C) call for help. I opened Resident's #2's door and saw Resident #3's door close. I knew that Resident #1 thought Resident #3 was his other girlfriend. I immediately went to Resident #3's room. Employee (C) was a few seconds behind me. I saw the curtain pulled for Resident #3, and as I continued into the room I saw Resident 1 had his finger in her vagina. He saw me and stepped back. I immediately stepped between him and Resident #3. I think Resident #1 understood he needed to leave however he wanted back in the room once we were in the hallway. He became violent and hit me several times in the stomach." On 10/4/12 about 1:17 pm the Administrator was asked you have 2 CNA's, one was on 1:1 supervision with Resident #1 and Resident #2 was being consoled by the second CNA. You did not send any more help to the unit. She was asked how one CNA could begin to observe the day room residents, and Resident #1 with other residents disrobing and acting out while residents needed toileting. She stated, "The LPN was back there giving medication". She was asked "the whole time" she said, "No I do not think so". The administrator was asked again Do you feel that given the situations going on the unit, do you feel you should have staffed more CNA's or help on the unit. She said, " No-- there were 15 residents back there and 3 CNA's -- that is well within the staffing ratios". A review of nurses notes indicate that Resident #1 on 9/22/12 9:45 pm was displaying sexually inappropriate behavior entering into 2 female residents rooms. The resident was put on 1: 1 until he went to sleep. Nurses notes on 9/27/12 dated at 1:00 pm indicates Resident #1 was displaying sexually inappropriate behaviors toward female residents. An interview was conducted with the LPN Employee (H) on 10/5/12 about 8:55 am. She had charted the behaviors on 9/22/12 and 9/27/12 for Resident #1. She stated, "During both incidents Resident #1 directed sexually inappropriate behavior to Resident #2 and #3".

Based on staff interview and clinical record review the facility failed to provide sufficient nursing staff to meet the needs of 3 of 15 residents residing on the secured dementia special care unit. ( Residents #1, #2, #3) The findings are: The Serenity Unit of the facility is a locked unit in the facility staffed with 3 Certified Nursing Assistants (CNA) and one Licensed Practical Nurse that floats to the unit for necessary treatments, medication passes, and when called on the 7-3 and 3-11 shifts. The unit has 15 residents. Resident #1's room is next to the day room, Resident #2's room is one room down and across the hall from Resident #1. Resident #3's room is located 3 doors down from the day room. On the day shift 7-3 on 9/30/12 the unit was staffed with 3 CNA's ( one person had a permanent assignment on the unit Employee (B), one CNA was scheduled to work on the unit but normally works on Unit 2 Employee (C), and one CNA was pulled from Unit 1 Employee (D). The Licensed Practical Nurse assigned to Serenity had a family emergency and left about 9:30 am. The RN Supervisor took over her cart at that time. There was a Restorative Aide on and off the unit during the day shift Employee (E) An interview was conducted with Employee (C) on 10/4/12 about 10:40 am. She related that it was her first time to work on the Serenity Unit. She said Resident #3 kept taking her clothes off and getting on the floor scooting saying "I want my chair, I want my chair". An interview with employee E was conducted about 10:50 am on 10/4/12 she relates that Resident #3 was "Frisky on Sunday she kept exposing herself in the day room". The Resident was put to bed about 9:30 am according to Employee (C). Staff continued to dress resident #3 and she continued to undress throughout the shift. At the change of shift she was changed into a nightgown with a brief. The curtain was pulled and her door was shut because she kept undressing as soon as staff dressed her. The Evening shift came on with 3 CNA's and a LPN who also had duties outside the unit. The 3 CNA's were Employee ( B ) who was working a double, Employee (F) who was pulled from Unit 1, and another CNA who was working 3-11 and 11-7. An interview with Employee (B) was conducted about 9:48 am on 10/5/12. She stated, "There was a situation with Resident #1 and Resident #2. resident #2 went into her room alone about 3:15 pm to 3:30 pm. They were separated and the LPN was told when she arrived on the unit". Employee (B) then said, "Apparently something else happened after that because the LPN went and got the administrator". The Administrator and LPN asked one of the CNA's to take Resident #2 off the unit. This left 2 CNA's on the unit. An interview with Employee (F) was conducted about 5:05 pm on 10/4/12. He says, "I arrived on the unit about 3:30 pm. There was a commotion on the unit. Resident #2 was agitated. The third CNA took her off the unit to calm her down. Resident #2 arrived back on the unit about 4:15 pm and the LPN asked me to take her off the unit and walk her around the facility to calm her down. An interview was conducted with the Administrator about 11:15 on 10/4/12. She said Resident #1 was acting out with Resident #2 about 5:00 pm. Resident #1 had barricaded himself in the room with Resident #2. "I went back to the unit and told the LPN and CNA that Resident #1 needed to be on 1:1"." I went back to the unit about 5:30 pm because Resident #1 was banging and kicking Resident #2's door. I asked CNA to take her off the unit and walk her around, she was brought back to the unit and she swapped with Employee (F). An interview with Employee (C) was conducted on 10/4/12 about 8:50 am. She related, "I was sitting in the hallway observing Resident #1 walking in the hallway and watching the dayroom where other residents were located. Employee (F) was still with Resident #2 in her room still attempting to calm her down, and the third CNA had to take another resident to the toilet. I was sitting there when I observed a resident in the dayroom who cannot stand attempt to get out of his wheelchair". I called to Employee (F) for help and ran to the resident before he could fall. I assisted him into to his chair and went back into the hallway. I did not see Resident #1. An interview with Employee (F) was conducted on 10/4/12 about 5:05 pm. He relates, " I was in Resident #2's room attempting to assist 2 wandering residents out of her room because she was still agitated when I heard Employee (C) call for help. I opened Resident's #2's door and saw Resident #3's door close. I knew that Resident #1 thought Resident #3 was his other girlfriend. I immediately went to Resident #3's room. Employee (C) was a few seconds behind me. I saw the curtain pulled for Resident #3, and as I continued into the room I saw Resident 1 had his finger in her vagina. He saw me and stepped back. I immediately stepped between him and Resident #3. I think Resident #1 understood he needed to leave however he wanted back in the room once we were in the hallway. He became violent and hit me several times in the stomach." On 10/4/12 about 1:17 pm during an interview with the administrator she confirmed there were 2 CNA's, one was providing 1:1 supervision with Resident #1 and Resident #2 was being consoled by another CNA. No additional staff was sent to the unit to assist. The administrator was She was asked how one CNA could begin to observe the day room residents and Resident #1 with other residents disrobing and acting out while other residents needed toileting. She stated, "The LPN was back there giving medications". She was asked "the whole time" she said, "No I do not think so". The administrator was asked do you feel that given the situations on the unit, do you feel more staff was needed to provide care and supervision to the residents? the administrator said, " No-- there were 15 residents back there and 3 CNA's -- that is well within the staffing ratios". A review of nurses notes indicate that Resident #1 on 9/22/12 9:45 pm was displaying sexually inappropriate behavior entering into 2 female residents rooms. The resident was put on 1: 1 until he went to sleep. Nurses notes on 9/27/12 dated at 1:00 pm indicates Resident #1 was displaying sexually inappropriate behaviors toward female residents. An interview was conducted with the LPN Employee (H) on 10/5/12 about 8:55 am. She had charted the behaviors on 9/22/12 and 9/27/12 for Resident #1. She stated, "During both incidents Resident #1 directed sexually inappropriate behavior to Resident #2 and #3".