Every finding on record at Avir at Elkhart

Based on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for residents for 4 of 8 residents (Resident #2, Resident #33, Resident #40, and Resident #44) observed for resident environment.1.The facility failed to ensure the room of Resident #2 and Resident #44 did not have a baseboard that was detached from the wall from 6/1/2026 to 6/3/2026. 2. The facility failed to ensure hot water was available in resident bathroom for Resident #33 on 6/1/26 and 6/2/26. 3. The facility failed to ensure the room of Resident #40 did not have a hole in the wall behind the door from 6/1/2026 to 6/3/2026. These failures could place residents at risk for an unsanitary and uncomfortable environment. Findings include:1.Record review of a face sheet for Resident #2 dated 6/3/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COPD (a group of lung diseases that affect breathing), PVD (a conditions that causes decreased blood flow to the legs and feet), and vascular dementia (a decrease in blood flow in the brain that can lead to damaged brain tissue).Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated he had severe impairment in thinking with a BIMS score of 6. He used a wheelchair for mobility.Record review of a care plan for Resident #2 dated 12/9/2025 indicated he had impaired cognitive function/dementia or impaired thought processes related to prior CVA (stroke) and unaware of safety. Interventions included to encourage resident to ask for help or assistance.Record review of a face sheet for Resident #44 dated 6/3/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Parkinson's disease (a disorder that affects the nervous system that worsen over time that control many parts of the body) and Alzheimer's disease (a progressive disorder that affects memory, thinking, and behavior).Record review of a Quarterly MDS Assessment for Resident #44 dated 3/5/2026 indicated he was rarely/never understood with a BIMS score of 0 indicating severe cognitive impairment. He was dependent on staff for all ADLs.Record review of a care plan for Resident #44 dated 5/5/2026 indicated he was at risk of falls related to confusion. Interventions included to anticipate and meet the resident needs.During an observation on 6/1/2026 at 10:31 am, the room of Resident #2 and Resident #44 had a baseboard that was not attached to the wall that was approximately about a foot in length that was not attached. Resident #20 was in the room sitting in a wheelchair, but his speech was very difficult to understand. Resident #44 was not in the room.During an observation on 6/2/2026 at 8:40 am, the room of Resident #2 and Resident #44 still had the baseboard that was not attached to the wall. Neither resident was in the room at the time of the observation.During an observation on 6/3/2026 at 8:40 am, the room of Resident #2 and Resident #44 still had the baseboard that was not attached to the wall.2. Record review of a facility face sheet dated 6/2/26 for Resident #33 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of hepatic failure (liver failure).Record review of a quarterly MDS assessment dated [DATE] for Resident #33 indicated a BIMS score of 11, which indicated he had moderately impaired cognition. He was independent with personal and oral hygiene.Record review of a comprehensive care plan for Resident #33 indicated it did not address his ADL status.During an interview on 6/1/26 at 11:30 am Resident #33 said he did not have hot water in his bathroom sink.During an observation on 6/1/26 between 3:12 pm and 3:17 pm the water was turned on at bathroom sink for Resident #33. Hot water was allowed to run for 5 minutes, and water remained cold to touch.During an observation and interview on 6/2/26 between 10:52 am and 10:57 am hot water was turned on and ran in Resident #33's bathroom sink, and after running for 5 minutes, water remained cold to touch. Resident #33 was in his room and said, It's always like that; I don't want to wash my hands in cold water.3. Record review of a face sheet for Resident #40 dated 6/3/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia affective left non dominant side (paralyzed on the left side), dementia (a decline in the mental abilities you need for daily living), and major depressive disorder (persistent sadness or loss of interest in doing things).Record review of a Quarterly MDS Assessment for Resident #40 dated 3/2/2026 indicated he had moderate impairment in thinking with a BIMS score of 12. During an observation and interview on 6/1/2026 at 10:46 am, Resident #40 was in bed awake. He said he had been at the facility for a while. There was a large hole in the wall behind the door.During an observation on 6/2/2026 at 8:44 am, Resident #40 was asleep in bed. The hole was still present on the wall behind his door.During an observation and interview on 6/3/2026 at 8:50 am, Resident #40 was in bed awake. He said he noticed the hole in the wall behind his door a while ago but was not sure how long it had been there. He said no one said anything to him about fixing it. He said it did not bother him one way or another.During an interview on 6/3/2026 at 8:52 am, HSK C said she had been employed at the facility for a year. She was cleaning on the hall of Resident #44, Resident #2 and Resident #40. She said she noticed the hole on the wall behind the door in Resident #40's room but forgot to report it and could not remember how long it had been there. She said she did report the detached baseboard in Resident #44 and Resident #2's room to her supervisor. She said she would not like living in a facility that was not repaired.During an interview on 6/3/2026 at 8:59 am, the HSK Supervisor said the issues in the rooms of Resident #44, Resident #2, and Resident #40 were reported to her by the housekeeping staff of areas that needed repair. She said when maintenance issues were reported to her by the staff she would enter them in TELS and it would go directly to the Maintenance Supervisor.During an interview on 6/3/2026 at 9:02 am, the Maintenance Supervisor said requests for repairs were reported to him verbally and through TELS. He said he was made aware of the baseboard in Resident #44 and Resident #2's room. He said the HSK Supervisor told him about the baseboard last Thursday (5/28/2026). He said he planned to repair the rooms that day (6/3/2026). He said in Resident #40's room he was aware of the hole in the wall that needed repair and he had the sheetrock to repair it. He said those issues were not reported in TELS. He said there could be risk of moisture coming from the wall that had the detached baseboard and could be a slip/trip hazard. He said the hole in the wall would not be pleasing to look at.During an interview on 6/3/26 at 9:40 am the Maintenance Director said sometimes the pilot light would get blown out on the water heater that supplied water to the resident room. He said he would check it. He said he would not want to wash his hands or brush his teeth with cold water.Record review of a TELS work order for the facility undated indicated no work orders for the rooms of Resident #44, Resident #2, and Resident #40.During an interview on 6/3/2026 at 2:10 pm, the Administrator said all staff were responsible for reporting maintenance requests and had access in TELS. She said TELS was a system they had in place to report maintenance issues that were reported to the Maintenance Supervisor. She said each resident in the facility was assigned a staff member that were supposed to check their rooms daily. She said she was not made aware that Resident #33 did not have hot water in his bathroom, nor was she aware the room of Resident #2 and Resident #44 had a baseboard that was detached from the wall; nor was she aware that Resident #40 had a hole in his wall. She said cold water would not feel good to someone's hands and the look in the rooms might feel uncomfortable to the residents if there were holes in the walls or baseboards that were not attached. Record review of a facility policy titled Homelike Environment dated February 2021 read: .Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .

Based on interviews and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 15 out of 15 anonymous residents during a confidential meeting who were reviewed for resident rights.The facility failed to ensure the resident council grievances were promptly resolved.This failure could place residents at risk for a decreased quality of life. The findings included: Record review of Resident council minutes dated 5/21/2026 indicated new business: need the Activity Director back and off the floor because she makes them happy. Staff in attendance was the Activity Director.Record review of Resident council minutes dated 4/16/2026 indicated new business: they run out of tea, having water for all meals, running out of everything; need more money for activities. Residents want meal of the month again. Old business: running out of milk on Mondays, never have juice, no salt, still no alternates. running out of grease and they cannot make fries. Residents said it is not the dietary staff it's the company. Want to know if they can start making meals of the month again. Staff members in attendance were the Activity Director. [sic]During an interview on 6/1/2026 at 2:00 pm, the Activity Director said she was assigned to work as a nurse aide that day for 2 of 5 halls in the facility. She said for the past 2 weeks she had been working on the halls as a nurse aide and had not been able to help with activities. She said if the facility was short a nurse aide when someone called in to work, then they would pull her to work on the floor to cover the shift. During a confidential interview on an undisclosed date and time, there were 15 Anonymous residents who attended the confidential interview. All 15 Anonymous residents indicated they felt their grievances were not being considered and were not given any resolutions. The residents complained about activities and wanted the Activity Director back to assist with activities. They said she had been working on the floor for the past 2 months, but she was not to blame, all fault was on the facility. They said they talked about the meal of the month and were told they did not have the budget for it but were told it would return next month (July 2026). The residents had concerns about having the same menu over and over and were tired of macaroni. They said the facility told them they did not have the funds for the food and were concerned that a new company took over and the facility has gone to shit and things have gotten worse. They voiced concerns about being served meals on paper plates for over a month due to hot water concerns in the kitchen. They said activities such as bingo were called about four times a week, but it was called by the residents currently and some residents choose not to attend because they are not giving out any prizes which does not make it fun anymore. There were not any resolutions to the grievances or concerns when they notified the facility. During a follow up interview on 6/3/2026 at 10:17 am, the Activity Director said she had been the Activity Director for the facility since 2022. She said they had meetings once a month in the facility. She said the residents voiced concerns and she would take notes and put them on the minutes and would get the President of resident council to sign them and then would give the minutes to the Administrator. She said the Administrator has not attended a resident council meeting since she started at the facility. She said since the new company took over her budget for activities has dropped and she was not able to provide prizes or snacks for bingo like she used to. She said there have not been any staff that worked in the facility that have been willing to help out with the activities in the facility. She said she hated it for the residents, and they deserved happiness and their concerns should be heard and something done. She said the residents have not had their meal of the month since October 2025. She said she tried to help the residents with activities as much as she could between providing care for residents in the facility.During an interview on 6/3/2026 at 10:31 am, the Administrator said she had been employed at the facility since 12/9/2025. She said she was the grievance officer and would talk to residents verbally when grievances came to her and then would put the resolution on the grievance form. She said the Activity Director had been pulled to the floor to work and helped out with activities as she could. She said she would not like it if activities were not being done daily and would expect the person responsible to do the activities in the facility. She said activities were to keep the residents engaged. She said the residents have complained about activities to her and the residents agreed to call bingo. She said she reviewed the minutes after each resident council meeting and tried to resolve them but had not formally gone to the meeting after to provide the group with any resolutions. She said grievances were for concerns in the facility and they helped to find a solution and increase quality of life. She said she planned to continue to work with the residents, document and follow-up with resident council with the findings and solutions.Record review of a facility policy titled Grievances/Complaints, Filing revised April 2017 indicated, .The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. 3. All grievances, complaints or recommendations stemming from residents or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response . Record review of a facility policy titled Resident Right revised February 2021 indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: v. have the facility respond to his or her grievances .

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessments for 6 of 12 residents reviewed for care plans. (Resident #23, Resident #24, Resident #26, Resident #31, Resident #33, and Resident #53,).1.The facility failed to include in Resident #23's care plan activities of daily living and transfer status. 2. The facility failed to include in Resident #24's care plan activities of daily living and transfer status. 3. The facility failed to include in Resident #26's care plan activities of daily living, urinary and bowel incontinence and his PASRR status. 4. The facility failed to include in Resident #31's care plan activities of daily living and transfer status. 5. The facility failed to include in Resident #33's care plan activities of daily living. 6. The facility failed to include in Resident #53's care plan activities of daily living and her urinary and bowel incontinence. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.Findings included:1.Record review of a facility face sheet dated 6/2/26 for Resident #23 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis following a stroke).Record review of a quarterly MDS assessment dated [DATE] for Resident #23 indicated resident was rarely/never understood and had severely impaired cognition. He was dependent with transfers.Record review of a comprehensive care plan for Resident #23 indicated he did not have a care plan for ADLs addressing transfers.2.Record review of a facility face sheet dated 6/2/26 for Resident #24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Alzheimer's disease.Record review of a comprehensive MDS assessment dated [DATE] for Resident #24 indicated he was rarely/never understood and had severe cognitive impairment. He was dependent for transfers.Record review of a comprehensive care plan for Resident #24 indicated it did not address ADL status or transfers.3.Record review of a Face Sheet for Resident #26 dated 6/3/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of autistic disorder (a condition related to brain development that impacts how a person perceives and socialized with others), hypertension (high blood pressure) and legal blindness (blind in both eyes).Record review of an admission MDS Assessment for Resident #26 dated 4/15/2026 indicated he was rarely/never understood with a BIMS score of 0. He was dependent on staff for personal hygiene and showering/bathing. He was frequently incontinent of urine/bowel.Record review of a care plan for Resident #26 indicated he admitted to the facility on [DATE], his care plan did not reflect his activities of daily living and the assistance he required from staff present; he did not have urinary/bowel incontinence on the care plan with interventions; it did not reflect his PASRR status.Record review of a PL1 screening for Resident #26 dated 4/2/2026 indicated he had an intellectual disability and a developmental disability.Record review of PE for Resident #26 dated 4/10/2026 indicated he was evaluated for his intellectual disability and developmental disability for PASRR services.4.Record review of a facility face sheet dated 6/2/26 for Resident #31 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of epilepsy (seizure disorder).Record review of a quarterly MDS assessment dated [DATE] for Resident #31 indicated a BIMS score of 6, which indicated she had severely impaired cognition. She was dependent with transfers.Record review of a comprehensive care plan for Resident #31 indicated she did not have an ADL care plan.5.Record review of a facility face sheet dated 6/2/26 for Resident #33 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of hepatic failure (liver failure).Record review of a quarterly MDS assessment dated [DATE] for Resident #33 indicated a BIMS score of 11, which indicated he had moderately impaired cognition. He was independent with personal and oral hygiene.Record review of a comprehensive care plan for Resident #33 indicated it did not address his ADL status.6.Record review of a Face Sheet for Resident #53 dated 6/3/2026 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of malignant neoplasm of lung (lung cancer), hypertension (high blood pressure) and COPD (a group of breathing diseases that affect breathing).Record review of an admission MDS Assessment for Resident #53 dated 2/5/2026 indicated she had moderate impairment in thinking with a BIMS score of 12. She was dependent on staff for toileting hygiene, and substantial/maximal assistance was needed for showering/bathing. She was always incontinent of urine/bowel.Record review of a care plan for Resident #53 dated 1/31/2026 did not indicate a care plan for her activities of daily to indicate what type of assistance was needed along with urinary and bowel incontinence.During an interview on 6/2/2026 at 11:30 am, the Regional Reimbursement Consultant said that the care plans were triggered from the MDS assessment, but the previous MDS Coordinator was not going into the electronic system correctly to check the care areas that needed to be addressed on the care plan. She said in December 2025 the DON noticed the care plans were not comprehensive and complete and she along with the DON worked on them but had not completed them all for the facility. She said the facility had started a PIP in April 2026 and was not sure why they had not been able to get the care plans updated at this time. She said incomplete care plans and care plans that were not comprehensive could cause a delay in resident care.During an interview on 6/3/2026 at 2:00 pm, the DON said the MDS Coordinator was responsible for updating and revising the care plans in the facility. She said the facility had been without a MDS Coordinator for about a month and a new one was hired 6/1/2026. She said care plans should include the residents' diagnoses, wounds if they had them, weights, medications, special considerations, ADLs, etc. and should be individualized for each resident. She said the care plans should be reviewed quarterly and as needed. She said if the care plans were not accurate then the staff would not know how to properly care for the residents.During an interview on 6/3/2026 at 2:10 pm, the Administrator said the nurses and MDS Coordinator were responsible for the care plans. She said the care plan should be implemented initially on admission, quarterly, annually, and any time there after with changes. She said the care plan should include diet orders, activities of daily living, pain, etc. She said if the care plan were not accurately reflected, the residents might not get the care needed. She said she expected to have more accurate care plans in the facility for the residents.Record review of a facility policy titled Comprehensive Assessments dated March 2022, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including 2. any specialized services to be provided as a result of PASRR recommendations .

Based on observation, interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or the resident preferences indicated otherwise for 1 of 6 residents (Resident #7) reviewed for nutrition status. The facility failed to follow facility policy and dietary recommendations for Resident #7. Resident # 7 lost 29 lbs. from 3/26/2026 to 05/05/2026 which was a significant weight loss of 20.7%. These failures could place residents at risk for loss of weight and inadequate nutrition. Findings include: Record review of Resident #7's face sheet, dated 06/02/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included Type 2 Diabetes Mellitus (a problem in the way the body regulates and uses sugar as a fuel), hypertension, (high blood pressure), cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), and cerebral aneurysm (a localized dilation or ballooning of a blood vessel in the brain due to a weakness in the vessel wall). Record review of Resident #7's admission comprehensive MDS, dated [DATE], revealed BIMS score of 99, which indicated severe cognitive impairment. Section K: Nutritional Approaches revealed resident receives 51% or more of calories from tube feeding. Resident recorded height 68 inches and weight 163 lbs. Record review of Resident #7's vital sign flowsheet indicated weights obtained on 3/26/2026- 163.0 lbs; 4/7/2026- 163.0 lbs; 4/8/2026- 130.8 lbs; 5/5/2026 134.0 lbs. Body Mass Index at 134.0 lbs. equals 20.4 with healthly range of 18.5 - 25.0 for Resident #7 age and height. Record review of Resident #7's Nutrition/Dietary note dated 05/5/2026 at 1:36 p.m. by the Registered Dietician, revealed resident weight 143.4 lbs with a mechanical lift. no visible signs of 13% weight loss. recommendation of weekly weights, continue current enteral feeding order, and registered dietician to evaluate monthly. Record review of Resident #7's hospital after care visit summary dated 3/16/2026 indicated that discharge recommendations for enternal nutrition via tube feeding was Osmolite 1.2 at 65 ml/hr. Record review of Resident #7's clinical notes indicated resident was assessed by primary care physician on 4/21/2026 and 5/19/2026 with no new orders. Record review of Resident #7's physician orders for March, April, May, and June 2026 has a diet order of nothing by mouth diet, Osmolite 1.2 at 65 cc/hr via gastronomy tube (g-tube) stationary pump. Record review of Resident #7's care plan initiated 3/30/2026 of impaired nutrition related to g-tube feeding. Intervention included consult dietician. During an observation on 6/02/2026 at 9:20 AM, Resident #7 was lying in bed with head of bed elevated 30 degrees. Resident was clean and well groomed. Observation of personal care by staff revealed resident well nourished in appearance and without any skin alterations. Resident with tube feeding running on feeding pump of Osmolite 1.2 at a rate of 65 cc/hr. During an interview with the Director of Nurses on 6/3/2026 at 9:30 AM, she stated she was responsible for reviewing residents' weights and making sure residents who required weekly weights were done every week. She stated she was aware of the weight discrepancy with Resident #7. She said she believed the weight that the resident was currently at was an accurate weight and that weekly weights should have been obtained upon admission to establish a baseline for the resident due to the initial weight of 163.0 lb not being an accurate weight. She stated a resident is re-weighed if a significant difference is noted during monthly weights. She said Resident #7 should have been re-weighed and that weekly weights should have been done upon admission, but it was overlooked. She said she also failed to put Resident #7 on the weekly weights list in May after the dietician recommended weekly weights. The DON stated staffing has been challenging, and she overlooked placing resident on weekly weights and obtaining a reweight. She stated she tracks all residents' weights, monthly and weekly weights using a spreadsheet and that she will print off a list of residents needing to be weighed weekly. She stated orders for weekly weights are not put into the current system due to if recorded in electronic medical record it will alter monthly, 3 month and 6 month weight loss calculations. She stated she keeps weekly weights in a separate binder. The DON said moving forward she will review weights weekly and obtain any reweighs within 24-48 hours. She stated she will ensure that all new admissions are weighed weekly to establish a baseline weight. She said that if weights are not rechecked or if weekly weights are not done, weight gains and/or losses are not identified promptly. During an interview with the Administrator on 6/3/2026 at 10:00 AM she said the Director of Nurses is responsible for the weight program. She stated all nursing staff are responsible for obtaining accurate weights on residents in the building. She stated moving forward, all new admissions and dietary recommendations would be reviewed during the morning meeting. She said a standard of care meeting occurs every Thursday and that follow ups to dietary recommendations and weight loss/gain concerns would be discussed in detail at that time. She stated not weighing residents per recommendations or policy could result in a delay in identifying resident weight loss or weight gain. Record review of the facility's policy titled, Weight Assessment and Intervention revised March 2022, revealed the following: 1. Residents are weighed upon admission or readmission and weekly for four weeks, as determined by the Interdisciplinary Team (IDT) and monthly thereafter .3. Any weight change of 5 pounds or more since the last weight assessment will be reweighed for confirmation.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the residents' status for 1 of 6 residents reviewed for assessments. (Resident #15) The facility failed to ensure Resident #15's quarterly MDS assessment, dated 3/03/2026, was coded correctly. This failure could place residents at risk of not having individual needs met.Findings include: Record review of Resident #15's facility face sheet dated 6/02/2026, indicated Resident #15 was a [AGE] year-old male that admitted on [DATE] with a diagnosis of traumatic brain injury. Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated Resident #15 had a wound, wound infection and insulin. Record review of Resident #15's order summary report dated 6/02/2026 indicated Resident #15 did not have a current nor a discontinued order in the last 6 months for a wound, infection or insulin. During an interview on 6/02/2026 at 11:30 am the Regional Reimbursement Consultant said that the previous MDS nurse was not accurately completing the MDS assessments and was no longer in that position as of a month ago. She said the facility had a new MDS nurse that started yesterday and she would be training the new MDS nurse on proper completion of MDS assessments. She said she was responsible for the oversight of the MDS assessments and was not aware that Resident #15's was inaccurate. She said that when the facility changed electronic charting systems the MDS assessments began to be incorrect, but it wasn't until a few months ago they realized it. She said that inaccurate MDS assessments affect the resident care areas and could result in incomplete care of the resident. During an interview on 6/03/2026 at 1:00 pm the DON said that she was not sure how Resident #15's MDS was coded incorrectly and where the MDS nurse at the time got her information. She said that Resident #15 had never had a wound, wound infection or used insulin that she was ever aware of. She said that miscoded assessments could cause inaccuracy of the care plans and inaccurate resident care. During an interview on 6/03/2026 at 1:34 pm the Administrator said that the previous MDS nurse was not completing the MDS assessments accurately and was no longer in that position. She said the Regional Reimbursement Consultant was monitoring the MDS assessments monthly and had not realized that Resident #15's assessment was inaccurate. She said the facility had hired a new MDS nurse and she was currently being trained and audits would occur weekly to ensure accuracy of assessments. She said inaccurate assessments could result in a delay of resident care. Record review of a facility policy titled Resident assessment dated 2001 indicated, . A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. 8.All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information .

Based on observation, interview and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing for 1 of 6 residents (Resident #6) reviewed for pressure ulcers.The facility failed to provide wound care for a pressure ulcer to his left heel for Resident #6 for 10 of 31 days in May of 2026 which could have caused pressure ulcers to deteriorate.The facility failed to ensure a wound care treatment order was in place for Resident #6 for 10 days between the dates of 5/25/26 and 6/3/26.This failure could place residents with pressure ulcers at risk for wound deterioration and decline in existing pressure ulcers.Findings included:Record review of a facility face sheet dated 6/3/26 for Resident #6 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness following a stroke), and hypertension (high blood pressure).Record review of an MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 10, which indicated he had moderately impaired cognition. He was dependent with most ADLs. He had 2 stage 3 pressure ulcers and was receiving pressure ulcer/injury care.Record review of Medication and Treatment Administration Records dated May 1-31, 2026 indicated he had the following treatment order: Cleanse wound to left heel with wound cleanser, pat dry and apply calcium alginate, cover with gauze island dressing, may change prn for soiling or dislodgement every day shift related to pressure ulcer of left heel, stage 3. Order had a start date of 4/18/26 and a discontinued date of 5/25/26. There was no documentation of treatment being administered from 5/25/26 until 5/31/26.Record review of an electronic medical record on 6/3/26 for Resident #6 indicated there was no wound care order for pressure ulcer to left heel.Record review of a Physicians Order Summary Report dated 6/3/26 for Resident #6 indicated the following order dated 6/3/26: .Cleanse left heel with normal saline, pat dry, apply calcium alginate and Medi honey prn if saturated, soiled, or dislodged secure island dressing daily every day shift . which was obtained after surveyor intervention.Record review of a Braden Scale for Predicting Pressure Ulcer Risk dated 5/13/26 for Resident #6 indicated a score of 12, which indicated he was at high risk for developing pressure ulcers. Record review of a wound care physician evaluation dated 5/22/26 for Resident #6 indicated a stage 3 pressure injury to left heel with the following measurements: 1 x 0.6 x 0.1 cm. Record review of a wound care physician evaluation dated 5/29/26 for Resident #6 indicated a stage 3 pressure injury to left heel with the following measurements: 0.8 x 0.6 x 0.1 cm. Wound progress showed improvement as evidenced by decreased necrotic tissue and decreased surface area and wound showed no signs of infection.During an observation on 06/02/2026 at 1:45 pm DON was observed to perform wound care to Resident #6's pressure ulcer to his left heel with no infection control issues observed. Wound was pink in appearance with no drainage observed, there was no odor detected. No visible signs and symptoms of infection were observed. During an interview on 6/3/26 at 2:20 pm DON said if wound care orders were not put in the system appropriately, the orders would not show up on the Medication Administration Record or Treatment Administration Record for the nurses to know to perform the wound care and the wounds could possibly get worse. She said she was the one most of the time doing the wound care and she had been performing it because she knew to do it, and she was unsure how she missed noticing the order was not on the TAR the last week. She said it was possible the order was obtained when the old one was discontinued and that she possibly may have been interrupted because they have been short staffed, and maybe forgot to go back and the put the order in. During an interview on 6/3/26 at 2:35 pm Administrator said she expected her staff to put orders in when received or changed so that residents would receive the ordered care. She said if treatments were not provided as ordered, wounds could get worse.Record review of a facility policy titled Physician Orders dated February 2025 read: .Physician orders are essential for the comprehensive care of the residents. Record review of a facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 2001 read: .The physician/physician extender will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 3 of 10 residents reviewed for quality of care. (Resident #23, Resident #24, and Resident #31)The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #23, #24, and #31.This failure could result in a loss of quality of life due to injuries.Findings include:Record review of a facility face sheet dated 6/2/26 for Resident #23 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis following a stroke).Record review of a quarterly MDS assessment dated [DATE] for Resident #23 indicated resident was rarely/never understood and had severely impaired cognition. He was dependent with transfers. Record review of a comprehensive care plan for Resident #23 indicated he did not have an ADL care plan addressing transfer status.Record review of a facility face sheet dated 6/2/26 for Resident #24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Alzheimer's disease.Record review of a comprehensive MDS assessment dated [DATE] for Resident #24 indicated he was rarely/never understood and had severe cognitive impairment. He was dependent with transfers. Record review of a comprehensive care plan for Resident #24 indicated he did not have an ADL care plan addressing transfer status.Record review of a facility face sheet dated 6/2/26 for Resident #31 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of epilepsy (seizure disorder). Record review of a quarterly MDS assessment dated [DATE] for Resident #31 indicated a BIMS score of 6, which indicated she had severely impaired cognition. She was dependent with transfers. Record review of a comprehensive care plan for Resident #31 indicated she did not have an ADL care plan addressing transfer status.During an observation on 6/1/26 at 11:20 am Resident #24 was observed in common area in a geri-chair with a blue mesh mechanical lift sling observed underneath him. There was no tag on the sling, it appeared to have been ripped off, and the loops on the sling were faded in color. During an observation on 6/1/26 at 11:42 am Resident #31 was observed up in dining room with a solid blue mechanical lift sling observed underneath her. There was a tag observed on the back of the sling, it was torn and illegible.During an observation on 6/2/26 at 11:50 am Resident #23 was observed up in the dining room with a blue mesh mechanical lift sling underneath him and there was no tag observed on the sling, it appeared to have been ripped off.During an interview on 6/2/26 at 11:52 am DON said she did not know why the tags were getting messed up on the slings unless it was because of the dryer. During an interview on 6/3/36 at 10:45 am Laundry Aide said she might use bleach on the slings, but she was unsure and could not remember which setting they were washed on. She said she did dry them in the dryer. She said she did not know they were supposed to be air dried. During an interview on 6/3/26 at 1:10 pm Housekeeping/Laundry Supervisor said slings were dried in the dryer. She said she did not know they should be air dried and they did not have an appropriate place to hang them to dry. She said she would talk to administration to find a solution.During an interview on 6/3/26 at 2:20 pm DON said if slings were laundered inappropriately, it could weaken them and they could break, causing accidents. She said she would be ordering new slings and ensure they were air dried going forward.During an interview on 6/3/26 at 2:35 pm Administrator said if the slings were weakened, they could break down and cause accidents. She said they would be putting a system in place to air dry the slings so they would not be dried in the dryer going forward. Record review of a facility policy titled Safe Lifting and Movement of Residents dated July 2017 read: .staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order .Record review of a manufacturer guideline for use obtained at www.medline.com on 6/3/26 indicated: .Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use.

Based on observation, interview, and record review the facility failed to ensure all medications were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts (Nurse Cart) reviewed for medication storage.The facility failed to ensure injectable medications were labeled with an open and use by date on 6/3/26.This failure could put residents at risk for adverse reactions to medications and decreased quality of life.Findings included:During an observation on 6/3/26 at 7:40 am an opened multi-dose injector pen of Ozempic for Resident # 22 was observed on the nurse medication cart without an opened date or use by date; and an opened multi-dose Novolog Flex Pen for Resident # 4 was observed with no opened date or use by date. Label indicated Ozempic had been filled on 2/20/26, and Novolog had been filled on 5/5/26.During an interview on 6/3/26 at 7:45 LVN B said she normally always dated medications when she opened them, she said she was unsure why those medications were not dated, she said another nurse must have opened them. She said residents should not be given medications that may be old or outdated, it could make them sick.During an interview on 6/3/26 at 2:20 pm DON said if medications were not labeled with an open date, they could go bad. She said you should not give medications that are old because they may not work as well. She said she would provide more education to nurses to ensure medications were appropriately dated when opened and orders were put in as ordered.During an interview on 6/3/26 at 2:35 pm Administrator said she expected her nursing staff to date medications once they were opened. She said if medications were used past the date the efficacy could be compromised. She said going forward, the facility would provide further education to the nurses and audit the medication carts periodically. Record review of a facility policy titled Medication Labeling and Storage dated February 2023 read: .multi-dose vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial .Record review of safety information for Ozempic retrieved from www.ozempic.com on 6/3/26 indicated medication should be stored at room temperature for 56 days once opened and then discarded.Record review of safety information for Novolog Flex Pen retrieved from https://diabeteseducation.novocare.com/ on 6/3/26 indicated medication should be stored at room temperature or refrigerated for up to 28 days and should be discarded after 28 days even if there was insulin left in the pen.

Based on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 2 of 12 residents (Residents #3 and #33) reviewed for call lights. The facility failed to ensure Resident #3 had a call light in the bathroom that was functional on 06/01/2026 and 06/02/2026. The facility failed to ensure Resident #33's bathroom had a call light pull cord on 6/1/26. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings included: 1.Record review of facility face sheet dated 6/2/2026 for Resident #3 indicated he was a [AGE] year-old male admitted to facility on 4/29/2025. Diagnosis included chronic obstructive pulmonary disease (a condition that limits airflow into and out of the lungs), schizoaffective disorder (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), polyneuropathy (a nerve damage condition), and acquired absence of right leg below the knee (surgical removal of portion of leg below the knee). Record review of a quarterly MDS dated [DATE] for Resident #3 indicated a BIMSscore of 11, indicating moderate cognitive impairment. He was always continent of bowel and bladder. He was independent with toileting transfers. Record review of Resident #3's comprehensive care plan initiated 2/3/2026 indicated resident was at risk for falls with interventions that included .ensure call light is available to resident . During observations on 6/1/2026 at 10:00 AM and 6/2/2026 at 8:00 am revealed the emergency call light located in Resident #3's bathroom without a cover and a black and red plastic-coated wire protruding from the uncovered area of the call light. During an interview on 6/2/2026 at 8:00 AM, Resident #3 stated he used his bathroom daily and was able to transfer himself from his wheelchair to the toilet without assistance. He stated he was unsure how long the cover to the emergency call light in his bathroom had been missing. He denied having a need to utilize the call light while in the bathroom. He stated he has not experienced any delay of care or assistance related to not having a call light available in the bathroom. He said he had not told any staff about the missing call light cover in his bathroom 2.Record review of a facility face sheet dated 6/2/26 for Resident #33 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of hepatic failure (liver failure). Record review of a quarterly MDS assessment dated [DATE] for Resident #33 indicated a BIMS score of 11, which indicated he had moderately impaired cognition. He was independent with personal and oral hygiene. Record review of a comprehensive care plan for Resident #33 indicated it did not address his ADL status. During an observation on 06/01/2026 at 11:05 am Resident #33's bathroom call light was observed with no call light cord connected to the call light box. During an interview on 6/2/26 at 8:45 am Maintenance Director said he had been out sick yesterday, but he was putting a new string on the call light now. He said residents needed to be able to call for help in the event of a fall. During an interview on 6/2/26 at 10:52 am Resident #33 said He (maintenance director) put a string on my call light for me. Thank you. Resident #33 denied having suffered any falls. During an interview on 6/3/26 at 2:20 pm DON said she expected call lights to be available to all residents in their bathrooms. She said they should be available in the event of a fall. She said residents might not be able to call for help if call lights were not available. During an interview on 6/3/26 at 2:35 pm Administrator said she expected all bathrooms to have a functioning call light for residents to use in the event of an emergency. She said a resident might not be able to call for help if strings were not attached to the call lights. Record review of a facility policy titled Call System, Residents dated January 2025 read: .Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor .

Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 2 smoking areas. The facility failed to keep paper and plastic trash out of the designated ashtrays and fire can on 6/02/2026. This failure could place residents at risk for injury, burns, and an unsafe smoking environment.Findings include: During an observation on 6/02/2026 at 11:48 am the smoking area located off the secured unit had 2 ashtrays and 1 red fire can. 1 ashtray had 3 empty cigarette boxes in it and the red fire can had 4 plastic cups and 1 plastic bottle in it. During an interview on 6/02/2026 at 12:03 pm CNA A said that the staff assist the residents to smoke and only take the lighter and cigarette outside. She said the trash was probably put there by staff. She said maintenance or housekeeping were responsible for cleaning out the ashtrays and fire can, but if she saw the trash she would remove it herself. She said they had been told not to place trash in the ashtrays or red fire can because it could cause a fire. During an interview on 6/02/2026 at 12:55 pm Housekeeping/Laundry Supervisor said she and the Maintenance Director had to clean the smoking areas daily because staff often put trash in the ashtrays and fire can. She said the staff had been educated on fire risk, but some still did not listen. During an interview on 6/03/2026 at 1:34 pm the Administrator said that the smoking area was to be monitored with each smoke break and cleaned daily by the Housekeeper or Maintenance Director. She said there should not be any paper or plastic trash in the ashtrays or fire can because of the risk of fire. She said the staff had been told the ashtrays and fire can were for cigarette butts only and she would provide further education to them regarding fire safety in the smoking areas. Record review of a facility policy titled Smoking Policy dated October 2022 indicated, This facility shall establish and maintain safe resident smoking practices. Metal containers, with self-closing cover devices, are available in smoking areas. Ashtrays are emptied only into designated receptacles .

Based on observation, interview, and record review, the facility failed to provide residents a safe, clean, comfortable and homelike environment for 1 of 5 showers (Shower A) and 1 of 5 residents (Resident #1) reviewed for environment. The facility failed to ensure when a torn shower curtain and broken shower head holders were observed in a shared facility shower.This failure could place all residents at risk of diminished quality of life.Findings included: Review of an admission Record dated 1/21/26, for Resident #1 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Parkinson's Disease (neurological disorder that affects movement), Type 2 Diabetes Mellitus, and muscle wasting and atrophy (weakness). Record review of a quarterly MDS, dated [DATE], indicated Resident #1 had moderately impaired cognition with a BIMS of 11. Record review of a comprehensive care plan, dated 3/19/23, indicated Resident #1 required supervision to set-up assistance for all ADLs. Care planned appropriate interventions were in place including allow extra time to complete ADLs, monitor for pain/intolerance during self-care, and provide supervision to set-up assistance for all ADLs. During an interview on 1/20/26 at 8:50 a.m., Resident #1 said she did not like taking showers in the shared showers because they were always dirty. Resident #1 said the showers were not cleaned regularly between residents. Resident #1 said she complained about the showers for four months, but nothing was corrected. Resident #1 said the shower head holders were broken and she had to hang the shower head on the grab bars in the shower. Resident #1 said the shower head often slipped from the grab bars to the floor. Resident #1 said the showers were unsanitary. During an observation on 1/20/26 at 2:15 p.m., Shower A, a shared shower room for Halls 1 and 2, was noted to have a ripped/torn shower curtain, missing or broken shower head holders, and disposable gloves on the floor. During an interview on 1/20/26 at 4:00 p.m., Resident #1 said the shower curtain was ripped and the shower head holders were broken for over a month. Resident #1 said a CNA always stayed to provide shower assistance, if needed, but she never saw them clean or sanitize the shower between residents. During an interview on 1/21/25 at 9:12 a.m., the Maintenance Supervisor said the staff reported to him verbally, by phone, or through a computerized maintenance system for facility maintenance needs. The Maintenance Supervisor said he recently replaced the shower head holders in Shower A, approximately 1.5 weeks ago. The Maintenance Supervisor said there was no work order for the repair because he was informed verbally by staff. The Maintenance Supervisor said there was no invoice for parts available because parts used in repair were on hand. The Maintenance Supervisor said he was unaware of the shower curtain being torn. During an interview on 1/21/26 at 9:20 a.m., LVN A said CNAs were expected to clean and sanitize the showers between residents. LVN A said housekeeping also cleaned the showers daily, but not between each resident. LVN A said she ensured CNAs were cleaning the showers by going into the showers with them to perform visual inspections and reminded CNAs to take out dirty linens. During an interview on 1/21/26 at 10:00 a.m., LVN B said it was the CNAs responsibility to clean showers between residents use. LVN B said housekeeping was responsible for daily cleaning. LVN B said she ensured CNAs were performing their job duties by good communication and following behind CNAs to ensure tasks were completed. During an interview on 1/21/26 at 10:30 a.m., CNA C said CNAs were expected to clean the showers after residents use, but not to sanitize them. CNA C said cleaning included picking up dirty linens and clothing. CNA C said the shower head holders were broken for several months. CNA C said the hole in the shower curtain was there for a few weeks. CNA C said she was unable to report the issues to maintenance because she didn't know how to use the electronic reporting system. CNA C said she could have reported the issues to maintenance verbally. During an interview on 1/21/26 at 10:45 a.m., CNA D said CNAs were responsible for cleaning and sanitizing showers between users. CNA D said CNAs were expected to clean the shower and pick up dirty linens and place them in the linen barrel. CNA D said she reported the broken shower heads and the torn shower curtain to maintenance verbally two weeks ago. During an interview on 1/21/26 at 11:00 a.m., CNA E said it was housekeeping's job to clean and sanitize the shower between residents use. CNA E said CNAs were only responsible for collecting dirty clothes and linens. During an interview on 1/21/26 at 11:10 a.m., the Floor Tech said housekeeping was responsible for cleaning the showers once per shift. The Floor Tech said to his knowledge housekeeping was not responsible for cleaning the shower after every resident. Floor Tech said it was the CNAs responsibility for cleaning/sanitizing the shower after every resident. During an interview on 1/21/26 at 11:30 a.m., the DON said CNAs were responsible for cleaning and disinfecting showers between residents so it would be safe for the next resident. The DON said housekeeping cleaned the showers once in the morning and once in the evening. The DON said she planned to in-service staff regarding cleaning/sanitizing showers between residents. During an interview on 1/21/26 at 1:15 p.m., the ADM said she was responsible for oversight of the nursing department. The ADM said CNAs were expected to clean and sanitize the shower between residents. The ADM said housekeeping cleaned daily but not between every resident. The ADM said risks to residents from improperly cleaned showers could include skin infections or slips and falls. The ADM said she planned to in-service staff going forward to ensure showers were cleaned properly between residents. Record review of a facility policy titled Homelike Environment, dated revised February 2021, indicated .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment.

Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 6 of 6 resident hallways (Halls #1, #2, #3, #4, #5, and #6) reviewed for sufficient staffing in that:The facility failed to ensure sufficient nursing staff when multiple residents and family members reported slow or no call light response.The facility failed to provide an additional support nurse to assist the charge nurse on 8/4/25, 8/5/25, and 8/6/25.This failure could place all residents who required assistance from staff at risk for loss of dignity, injury, and hospitalization. Findings included: 1.Review of an undated admission Record for Resident #1 indicated she was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of Unspecified Dementia (altered cognition), Macular Degeneration (loss of vision), and muscle wasting. Record review of a significant change MDS dated [DATE] indicated she had moderately impaired cognition with a BIMS score of 12. She required moderate assistance with toileting hygiene; lower body dressing, putting on/taking off footwear, and personal hygiene; she required supervision with oral hygiene; she required setup/cleanup assistance with eating. She was frequently incontinent of bowel and bladder.Record review of a comprehensive care plan dated 11/17/23 indicated Resident #1 had an ADL deficit and required varying assistance with ADLs as needed. Appropriate interventions were in place including do not rush resident, instruct in use of walker/wheelchair, and provide setup cueing assistance for bed mobility, toileting, and eating.Review of an undated admission Record for Resident #2 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of coronary artery disease (heart disease), fracture of left humerus (upper arm bone), repeated falls, and osteoarthritis (loss of bone density). Record review of a significant change MDS dated [DATE] indicated Resident #2 had a BIMS score of 10 which indicated moderate cognitive impairment. She required total assistance for putting on/taking off footwear, toileting hygiene, and lower body dressing; she required maximum assistance with upper body dressing, shower/bathing; she required supervision for oral hygiene; she required setup/cleanup assistance with eating. She was always incontinent of bowel and bladder. Record review of a comprehensive care plan dated 2/12/25 indicated Resident #2 was at high risk for falls related to diagnosis of peripheral vascular disease (affects blood flow to lower extremities), muscle weakness, and lack of coordination. Appropriate interventions were in place including reporting changes in endurance, ambulation, and transfers, monitor frequently, reposition for comfort and safety, encourage call light usage, place call light within reach and answer promptly, assess for medication contributing factors, and assess for proper fitting clothing.Review of an undated admission Record for Resident #3 indicated she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of senile degeneration of the brain (age-related cognitive decline), Chronic Kidney Disease, and Metabolic encephalopathy (altered cognition related to metabolic imbalances). Record review of a significant change MDS dated [DATE] indicated Resident #3 had a BIMS score of 3 which indicated severe cognitive impairment. She required total assistance with toileting hygiene and showering/bathing; she required maximum assistance with lower body dressing and taking off/putting on footwear; she required moderate assistance with upper body dressing; she required supervision with oral hygiene and personal hygiene; she required setup/cleanup assistance with eating. She was always incontinent of bowel and bladder. Record review of a comprehensive care plan dated 2/27/24 indicated Resident #3 had an ADL functional deficit related to unsteady gait and confusion. Appropriate interventions were in place including assistance with dressing, grooming, bathing, and bed mobility.During an interview on 8/4/25 at 10:40 a.m., Resident #1's RP said she had concerns about slow call light response times. She said she put a camera in Resident #1's room and saw her on several occasions, dates unknown, banging on the wall to get staff attention because no one was answering her call light. She said she thought the new ADM would resolve the issues.During an observation on 8/4/25 at 10:45 a.m. of a photograph taken from the camera in Resident #1's room Resident #1 appeared to be banging on the wall. The photograph was dated 4/30/25 at 7:43 a.m.During an interview on 8/4/25 at 11:10 a.m., Resident #1 said call lights were always answered slowly. She said she usually did not use her call light because staff never answered it. She said she had to bang on the walls and yell for help on multiple occasions, dates unknown. She said staff responded quickly when she banged on the walls and hollered for help.During an observation and interview on 8/4/2025 at 11:34 a.m., Resident #2 was sitting in her wheelchair in her room beside her bed. She appeared to be clean and well-groomed with no offensive odors. There were no visible marks, skin tears, or bruises. Her call light cord was sticking out from under the fitted sheet on her mattress. She said a CNA came in and made her bed in a rush. Resident #2 said it typically took an estimated 20 to 30 minutes for staff to respond to call lights. Resident #2 said both she and her roommate have had to yell for staff assistance (dates unknown) due to slow staff response times to call lights. She said staff responded faster when she yelled out for assistance.During an observation and interview on 8/4/25 at 11:45 a.m., Resident #4 , who was Resident #2's roommate, was lying in her bed in her room. She appeared clean and well-groomed with no offensive odors. She had no visible skin tears, marks, or bruising. She was receiving supplemental oxygen via nasal canula at 2L . Resident #4 said she frequently used her call light for assistance and staff response time was an estimated average 15-20 minutes. Resident #4 said she has had to yell for assistance once before, unknown date, due to slow staff response. She said staff came quickly when she yelled for help.During an interview on 8/4/25 at 12:24 p.m., CNA D said she did not always have time to complete all resident care timely when she was the only CNA assigned to work on the memory care unit.During an interview on 8/4/25 at 2:05 p.m., LVN B said CNAs were expected to round on residents at least every 2 hours and part of that rounding was to include making sure the resident's call lights were left within reach and accessible. She said CNAs were expected to answer call lights timely to address resident needs. LVN B said she monitored for staff compliance with policies and care planned interventions by rounding frequently.During an anonymous interview on., Anonymous said the facility was short staffed. Anonymous said they did not have enough time in the day to perform all their duties and frequently had to stay late to ensure adequate resident care.During an interview on 8/6/25 at 9:20 a.m., the DON said she was aware of the staffing concerns at the facility. The DON said she was trying to hire additional CNAs by posting on a job board with a starting pay of $15.00 per hour and sign-on bonus of $2,000.00. The DON said applicants were not showing up for interviews or were working one shift and then quitting. The DON said the facility had been in talks with corporate who had informally agreed to conduct a wage analysis to increase pay to attract and retain staff. During an interview on 8/6/25 at 9:30 a.m., the ADON said she was aware of the staffing concerns at the facility and had been in discussions with corporate regarding a wage analysis to increase pay. During an interview on 8/6/25 at 9:40 a.m. Resident #3's RP said she visited Resident #3 every day and recorded staff interaction in a notebook. The RP said on 7/29/25 at approximately 7:30 a.m. Resident #3 had an incontinent episode, and no staff responded to the call light to change her until approximately 9:00 a.m. The RP said on 8/1/25 staff checked on Resident #3 at approximately 2:00 p.m. and did not come back to check on her again until approximately 6:00 p.m.An observation of a hand-written note on 8/6/25 at 9:45 p.m. written by Resident #3's RP indicated .7/29 [Resident #3] needs changing no help it's 7:30 in the morning.8:30 no one has come yet to change [Resident #3]. Over an hr.9:00 [CNA] came to change [Resident #3].8/1 [Resident #3] last changed at 2:00 it is now 6:00 no one has come to check her. 4 hrs??? .During an observation and attempted interview on 8/6/25 at 9:50 a.m., Resident #3 was observed in her room lying in bed. Resident was covered up by a blanket and only her head was visible. There were no visible marks, skin tears, or bruising and no offensive-odors were detected. Resident #3 did not respond to interview questions.During an interview on 8/6/25 at 9:55 a.m., the AD said she was regularly placed on the schedule as a CNA and was expected to perform all duties as an AD in addition to working on the floor as a CNA. The AD said there was not enough time in the day to perform all CNA duties adequately.During an attempted interview on 8/6/25 at 9:58 a.m., the DON said ADM was out sick today. ADM was not interviewed as part of this investigation.Review of a facility policy titled Answering the Call Light dated 9/21/22 indicated .Answer the resident's call light as soon as possible.2. During an observation on 8/4/25 at 10:00 a.m., a Daily Assignment Sheet dated 8/4/25 indicated there was no support nurse scheduled to work that day. During an interview on 8/4/25 at 12:24 p.m., CNA D said if she needed the charge nurse, she would have to leave the secured memory care unit and look for them or ask another staff member to. CNA D said the charge nurse was usually in a resident room and not at the nurse's station.During an interview on 8/4/25 at 2:05 p.m., LVN B said she worked 6:00 a.m. to 6:00 p.m. as the charge nurse and was expected to cover all 6 resident halls. LVN B said she was supposed to have the help of a support nurse during the daytime, but usually didn't. LVN B said the ADON and DON provided some support during daytime hours but there was no support on other shifts. During an interview on 8/6/25 at 9:20 a.m., the DON said she was aware of the staffing concerns at the facility. The DON said corporate only allowed for one charge nurse position to cover 6 resident halls. The DON said one charge nurse for 6 halls was not an adequate staffing ratio, but corporate would not allow for a second nurse unless the facility census was 56 or more residents, and the current census was 54. The DON said the ADON lived three minutes from the facility and came in on-call to assist the charge nurse when needed during nights and weekends. The DON said the charge nurse who worked 6:00 a.m. to 6:00 p.m. received assistance from a support nurse which was usually herself or the ADON. The DON said there was no support nurse for evening hours after 5:00 p.m. or overnight from 6:00 p.m. to 6:00 a.m. The DON said she was trying to hire another LVN for the support nurse position and advertising on a job board with a sign-on bonus of $3,000.00. The DON said applicants were not showing up for interviews or not accepting the position so she and the ADON were serving as support nurse in addition to their administrative duties.During an interview on 8/6/25 at 9:30 a.m., the ADON said she was aware of the staffing concerns at the facility and had been in discussions with corporate regarding only allowing for a second charge nurse. The ADON said during the day administrative nurses supported the charge nurse, but in the evening and overnight, there was no additional support. The ADON said on 7/20/25 a resident had a fall with injury during the evening and the charge nurse on duty had to spend approximately 45 minutes assessing the resident and dressing wounds. The ADON said she had to come into the facility on-call because the charge nurse was unable to provide care to the other residents while completing post-fall protocols.During an interview on 8/6/25 at 9:55 a.m., the AD said the facility only staffed one charge nurse for all 6 resident hallways. The AD said she did not feel this was an adequate staffing ratio because nurses were often busy with one resident for up to 45 minutes at a time leaving other resident needs unattended in a timely manner. During an anonymous interview, Anonymous #2 said the facility's expectation was for one nurse to cover all 6 resident hallways. Anonymous #2 said the charge nurse who worked from 6:00 a.m. through 6:00 p.m. was supposed to have help from a support nurse, but they usually did not. Anonymous #2 said the administrative nurses assisted, but typically came in after 8:00 a.m. and left by 4:00 p.m. which did not cover the busiest times of the day which was around shift change. Anonymous #2 said they felt the nurses had to sacrifice quality of care to accomplish all their responsibilities. Review of staffing assignment sheets indicated no support nurse worked on 8/4/25, 8/5/25, or 8/6/25.Review of a facility assessment tool dated 5/28/25 indicated if the DON had other responsibilities another RN must be added as an ADON.Review of employee timesheets indicated the ADON worked the following hours: 8/4/25 from 10:09 a.m. to 3:37 p.m., and 8/5/25 from 8:11 a.m. to 3:47 p.m., (there was no time sheet data available for 8/6/25), leaving no additional support nurse for the remainder of the 6:00 a.m. to 6:00 p.m. shifts and no ADON to allow for the DON to take on additional responsibilities of a support nurse per the facility assessment.In an email from the ADM received on 8/7/25 at 12:45 p.m., the ADM said the support nurse position was to be an extra LVN who acted as a second nurse due to the facility's growth in census and to assist with wound treatments. The ADM said there was no specific policy associated with this position as tasks required would fall under LVN job description other duties as assigned.Review of an LVN job description indicated .ESSENTIAL JOB FUNCTIONS:.Other duties as assigned.

Based on observation, interview, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to store and label foods in accordance with professional standards. 2. The facility failed to ensure there were no gaps under the air conditioning unit beside the handwashing sink. 3. The facility failed to maintain clean air vents on the air conditioner located near the clean dish station. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and/or transmission-based infections. Findings include: During an observation on 04/07/25 at 09:20 AM revealed the dry storage area had clear plastic bins of bulk granulated sugar, breadcrumbs, bulk powdered sugar, flour, and corn meal with no best by date or expiration dates on the bins. A box of dry pinto beans was open to air, not sealed. During an observation interview on 04/07/2025 at 09:30 AM revealed a gap approximately 1 inch x 18 inches at the bottom of a window unit , located beside the employee handwashing station, with the outside visible. The window AC unit located above the clean dish station was noted to have dirty lint and black buildup on the vents. The DM said the prior maintenance man was aware of the gap but she had not reported the gap to the new maintenance man that started working at the facility two weeks ago. During an observation and interview on 04/07/2025 at 09:35 AM revealed containers of spiked/opened juice concentrate connected to the juice dispenser (apple, pink lemonade, fruit punch, orange, cranberry) on the bottom shelf with no open dates. The DM said the juice was delivered every other week and had a shelf life of 7 days after being opened. During an interview on 04/07/24 at 9:45 AM the DM stated she was responsible for training all dietary staff and dietary staff were trained on kitchen sanitation to include cleaning vents on the air conditioners, reporting the gap underneath the air conditioner, dating items when they were opened and use by dates, when to discard those items per the guidelines of that item. She stated she would begin retraining all staff because of the sanitary risks and expected all staff to follow all kitchen sanitation rules. During an interview on 04/08/25 08:16 AM the Registered Dietician said the bulk granulated sugar, bulk powdered sugar, flour, and corn meal stored in bins in the dry storage should be dated with the use by date as well as the open date. She said she was not sure when the 5 boxes of concentrated juices expire but all items should be labeled when opened. She said that if cleaning, sanitation, and proper storage measures were not followed in the kitchen, it could cause resident illness and contamination. During an interview on 04/08/24 at 11:30 AM the Administrator said the DM was responsible for oversight of kitchen sanitation, cleanliness, labeling and storage, as well as the training for the dietary staff. He said that if cleaning, sanitation, and proper storage measures were not followed in the kitchen, it could cause resident illness and contamination. He stated he expected all dietary staff to follow the regulations for cleaning the kitchen, maintaining sanitation and proper storage of all foods. Record review of a facility policy dated 4/18/2022 titled Food Safety in Receiving and Storage indicated, .Food will be received and stored by methods to minimize contamination and bacterial growth; 7. check expiration dates and use by dates to assure the dates are within acceptable parameters . Record review of a facility policy dated 10/01/2018 titled General Kitchen Sanitation indicated, .The facility recognizes that food borne illness has the potential to harm the elderly and frail residents. All nutrition and service employees will maintain clean, sanitary kitchen . Record review of https://www.fda.gov/media/164194/download, accessed 04/08/2025 indicated .Labeling 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 4 of 4 (Resident #6, Resident #28, Resident #40, and Resident #41) residents reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Residents #6, Resident #28, Resident #40, and Resident #41. This failure could place residents who received pureed meat and vegetables at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes. Findings included: Record review of face sheet dated 04/08/25 for Resident #6 indicated she admitted to the facility on [DATE] and was a [AGE] year-old female with diagnoses of diabetes (high glucose levels in the blood) and muscle weakness. Record review of a physician's order summary dated 04/08/25for Resident #6 indicated an order for regular pureed diet and thin liquids dated 11/23/20. Record Review of face sheet dated 04/08/25 for Resident #28 indicated she admitted to the facility on [DATE] and was [AGE] year-old female with diagnoses of dysphagia (difficulty swallowing) and dementia unspecified (decline in cognitive abilities) Record review of a physician's order summary dated 04/08/25 for Resident #28 dated 04/08/25 indicated an order for enhanced regular diet, pureed texture dated 12/02/2024. Record review of face sheet dated 04/08/25 for Resident #40 indicated he admitted to the facility on [DATE] and was [AGE] year-old male with diagnoses of dysphagia (difficulty swallowing) and muscle wasting. Record review of a physician's order summary dated 04/08/25 for Resident #40 dated 04/08/25 indicated an order for pureed double portion enhanced with nectar thick liquids dated 01/02/2025. Record review of face sheet dated 04/08/25 for Resident #41 indicated she admitted to the facility on [DATE] and was [AGE] year-old female with diagnoses of dysphagia (difficulty swallowing) and muscle weakness. Record review of a physician's order summary dated 04/08/25 for Resident #41 indicated an order for enhanced regular pureed diet with thin liquids dated 02/04/2025. During an observation on 04 /08/25 at 12:00 PM the [NAME] pureed the meat loaf, green beans, roasted potatoes and roll without a recipe. She added milk to all items and then added thickener to obtain a pudding consistency. The [NAME] did not taste test the items for consistency. The [NAME] said she did not routinely check to see if the foods fully blended . All foods were plated for lunch service to resident#6, Resident #28, Resident #40, and Resident #41. During an observation on 04 /08/25 at 12:20 PM revealed a sample test tray from the pureed meal for lunch of meat loaf, green beans, roasted potatoes, and roll. The meatloaf and roasted potatoes contained chunks and was not at pudding consistency as required. The DM tested the puree tray along with surveyors and agreed the meal contained chunks, not pudding consistency. The DM said the Robot Coupe had stopped working over a year ago and they had been blending the puree foods with a blender. She said certain foods were hard to process with the blender the facility was using. The DM said the risk to the residents was possible choking and a decreased dining experience. During an interview on 04/08/25 at 2:30 PM the RD said that she had started working for the facility as a consultant the end of February 2025 and she watched puree processes while she was at the facility but did not sample the pureed foods to determine if the texture was smooth. The RD said pureed foods should be nutritional and palatable and a smooth consistency. She said the risk to the residents was choking if the puree diet was not at the required consistency. During an interview on 04/09/25 09:37 AM the Administrator said he had obtained a bid for a new Robot Coupe and would be replacing the blender. The Administrator said pureed foods should be nutritional and palatable and a smooth consistency. He said if the foods were not blended to pudding consistency there could be a risk of choking. He said if the pureed foods were not prepared correctly the resident would not get the full nutritional value of the food. Record review of an undated Lifestyle Diet Manual . Page 9 .Based on the foods served on the Regular Diet plan blended to a consistency of mashed potatoes or pudding. The Pureed Diet may be used for residents with oral, esophageal, or stomach disorders that are unable to tolerate solid food. Conditions such as dysphasia (difficulty swallowing), stroke, cancer of the head or neck, or lack of chewing ability may warrant this diet prescription.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 (Resident #43) reviewed for pharmacy services. The facility failed to provide Resident #43's naproxen (anti-inflammatory medication) 250 mg tablet ordered to be given two times a day from 1/4/2025-4/8/2025 per physician's orders. This failure could place residents who received administered medications at risk of not receiving the intended therapeutic benefit of their medications. Findings included: Record review of a face sheet for Resident #43 dated 4/8/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of heart failure (heart is not able to pump enough blood to the body), ankylosing spondylitis in spine (anti-inflammatory disease that causes pain and stiffness in the spine), and spinal stenosis (narrowing of the spine). Record review of a Quarterly MDS assessment dated [DATE] for Resident #43 indicated she had moderate impairment in thinking with a BIMS of 12. She required substantial/maximal assistance with eating, oral hygiene and upper body dressing and was dependent with all other ADL's. She received scheduled pain medication regimen during the 5 day look back period and had pain frequently with pain intensity of a 5 (moderate pain) out of 10 on a 1-10 pain scale. Record review of a care plan for Resident #43 dated 3/24/2025 indicated she had pain in right shoulder. Interventions included to administer medications per MD order. Record review of a MAR for Resident # 43 dated 4/1/2025-4/8/2025 indicated an order for naproxen 250 mg twice a day to be given at 8 am and 8 pm with a start date of 1/4/2025 revealed from April 1-April 8, 2025, the medication was given as ordered with initials present. Record review of active physician orders for Resident #43 dated 4/8/2025 indicated an order for naproxen 250 mg twice a day to be given at 8 am and 8 pm with a start date of 1/4/2025. During an observation and interview on 4/8/2025 at 8:58 AM, revealed MA C was in the process of administering medications to Resident #43. MA C pulled a bottle of OTC naproxen that was 220 mg from the medication cart and said all the facility had available was for 220 mg tablets and the MAR for Resident #43 had an order that started on 1/4/2025 for naproxen 250 mg to be given twice daily. He said he had been giving naproxen 220 mg since the order was given by the physician in January 2025. He said he did not notice the order being incorrect until being observed by the Surveyor that day (4/8/2025). He did not give the medication and said he would notify the charge nurse. He said he was instructed to look at the medication before administering to be sure it was for the right person, the right dosage, the right time, the right medication, the right site, and the right route. He said if they did not follow those things, it could cause sickness, or a possible reaction and they would have to let the family and physician know. He said a resident could have a reaction to the medicine. He said he should have paid more attention. He immediately called for the charge nurse who came to the medication cart and told her that the order in the chart for Resident #43's naproxen was 250 mg and all available in the facility was an over-the-counter supply of 220 mg tablets. LVN D said she would contact the physician. Record review of clinical competency: medication pass for MA C dated 11/1/2024 indicated he was satisfactory with observing the seven rights of administration that included the right dose/dosage form. During an interview on 4/8/2025 at 9:09 AM, LVN D said she was the charge nurse for that day. She said she was not aware of the order for naproxen 250 mg for Resident #43 before being notified by MA C and all that was available in the cart was naproxen 220 mg tablets. She said staff should verify the medication with the order for the milligrams before administering. She said if they did not then it was a medication error, and residents could have side effects of an overdose or not get enough of the medication that was needed. LVN D said she contacted the NP and received an order for naproxen 220 mg to be given twice daily. She said the order was a data entry error as the facility only had 220 mg of naproxen OTC available. Record review of a MAR for Resident #43 dated 4/1/2025-4/8/2025 indicated an order for Aleve (naproxen) OTC 220 mg twice a day with a start date of 4/8/2025. Record review of active physician orders for Resident #43 dated 4/8/2025 indicated an order for Aleve (naproxen) OTC 220 mg twice a day with a start date of 4/8/2025. During an interview on 4/9/2025 at 8:43 AM, the DON said she was not aware of Resident #43's order for naproxen not matching what was in the medication cart. She said staff should look at the order and compare to the bottle of medication and if not correct it should be reported. She said with each medication to be administered they should check the order against the MAR. She said if they did not check, there could be a medication error. She planned to in-service staff to make sure they checked to make sure orders were entered correctly. She said there was health risk to the residents if staff did not follow the physician orders for medications. Record review of an in-service dated 4/8/2025 conducted at the facility on Medication Administration and MA C was in attendance with his signature present. During an interview on 4/9/2025 at 9:40 AM, the Administrator said the DON was responsible for ensuring physician's orders were entered correctly. He said dosages could be mistaken and residents could receive the wrong medications if they were not accurate. He said he expected all medications to be entered correctly and accurately. Record review of a facility policy titled Administering Medications dated April 22, 2022, indicated, .Medications shall be administered in a safe and timely manner as prescribed. 8. The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 3 resident's (Resident #2) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure a plastic bag of sliced cheese and sandwich meat was labeled and dated in a personal refrigerator on [DATE] and [DATE] for Resident #2. These failures could place residents at risk for food borne illnesses. Findings include: Record review of a face sheet for Resident #2 dated [DATE] indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of PVD (narrowing or blockage in the blood vessels), disorganized schizophrenia (impairment in daily activities and communication), and acute ischemic heart disease (heart damage caused by narrowed heart arteries). Record review of an Annual MDS Assessment for Resident #2 dated [DATE] indicated she had moderate impairment in thinking with a BIMS score of 12. She required set up or clean up assistance with eating. Record review of a care plan dated [DATE] for Resident #2 indicated she was at risk for nutritional deficit related to her IDD. Interventions included to provide set up assistance with meals. During an observation on [DATE] at 9:36 AM, revealed Resident #2 was not in her room. A personal refrigerator was present that had a plastic bag of sliced cheese and sandwich meat that was not labeled or dated. During an observation on [DATE] at 10:00 AM, revealed Resident #2 was not in her room. The plastic bag of sliced cheese and sandwich was still in her personal refrigerator not dated or labeled. During an interview on [DATE] at 10:03 AM, the HSK Supervisor said all housekeeping staff were responsible for checking the temperatures of the personal refrigerators in the resident rooms. She said the nursing staff were to check them daily for expired foods. During an observation and interview on [DATE] at 10:05 AM, revealed the HSK Supervisor observed the refrigerator in the room of Resident #2 and said the plastic bags of sliced cheese and sandwich meat should have dates on them. She said the Administrator would purchase Resident #2 meat and cheese from the local market sometimes but was not sure when he bought them. She said she would remove them. During an interview on [DATE] at 10:07 AM, the Administrator said he did purchase meat and cheese for Resident #2 one day last week but did not put the dates that they were purchased on them. He said he would start putting dates on the items if he purchased them for the resident. During an interview on [DATE] at 8:42 AM, CNA E said the nurse aides were not responsible for checking the personal refrigerators. She said the housekeeping staff were. During an interview on [DATE] at 8:43 AM, the DON said housekeeping staff were responsible for checking the personal refrigerators for unlabeled and expired foods. She said staff were in-serviced on [DATE] and instructed them if food was brought in by family or visitors to make sure the foods were labeled and dated. She said residents could get sick if they ate foods that were not labeled or dated because they would not be aware of how long they had been in the refrigerator. During an interview on [DATE] at 9:42 AM, the Administrator said the facility currently had the housekeeping staff check to make sure temperatures were correct in the personal refrigerators. He said they also had other staff that included guardian angels (staff assigned to resident rooms) and himself to check. He said he was not sure when the foods were put in the refrigerator of Resident #2, and they should be labeled and dated. He said the refrigerators should be checked daily and residents could get sick if they ate old food. Record review of a facility policy titled Resident Refrigerators dated ,d+[DATE] indicated, .For safe and sanitary storage, handling, and consumption of food items purchased by residents from an outside vendor or other food items brought to residents by non-facility employees. 3. Food stored in a residents' room refrigerator will be labeled with a date. 4. A facility employee will inspect resident refrigerators on a weekly basis to ensure there are no expired foods and cleanliness is maintained. Housekeeping may discard food, drink, and perishables .

Based on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: The facility did not ensure the gas stove was in working order. Two of six gas stove burners (rear middle and font middle) did not light automatically, when the knob was turned, the pilot light on the burners would not light and both burners had black hard carbon buildup from spilled foods. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings include: During an observation and interview on 04/07/25 at 9:15 am the Dietary Manager demonstrated both middle burners on the gas stove did not light and were noted to have black hard carbon build up from spilled foods from spill foods on them The Dietary Manager stated the kitchen staff were responsible for cleaning the stove burners and the burners had not worked in a long time. The Dietary Manager said the previous maintenance director and the Administrator were aware of the middle burners not staying lit. She said the burners not working correctly could be a fire hazard. She said she had not notified the current Maintenance Director to look at the stove. During an interview on 04/07/24 at 1:01 PM the Maintenance Director said he had been employed at the facility for two weeks. He said the kitchen staff were responsible for cleaning the stove burners and he performed maintenance to the gas stove if needed. He stated he was not aware of the burners not lighting, there was no request in the maintenance request book but would clean the burners and ensure the stove would light properly. During an interview on 04/08/24 at 10:45 AM the Administrator stated the dietary staff were responsible for everyday cleaning of the stove and the maintenance director was responsible for maintaining the equipment from carbon buildup and ensuring the equipment was working fully. He stated if equipment was not maintained it could cause an adverse event or be a fire hazard. He stated he expected all essential equipment to be maintained in proper working order. Record review of the maintenance request binder revealed no entry's found for the burners not lighting on the gas stove from the dietary department staff for the last 3 months. Record review of a facility policy dated 10/01/2018 titled Range and Grill indicated, .the facility will maintain the range in a clean manner to minimize the risk of food hazard; 2. scrape off burned particles and grease .

Based on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 2 of 9 residents (Residents #4 and #6) reviewed for call lights. The facility failed to ensure Residents #4 and #6's bathrooms had a call light pull cord on 04/07/2025. This failure could place residents at risk of injury, pain, hospitalization , and a diminished quality of life. Findings included: 1. Record review of a facility face sheet revealed Resident #4 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of traumatic brain injury. Record review of a Quarterly MDS assessment dated [DATE] revealed Resident #4 had a BIMS of 6 indicating moderately impaired cognition and was dependent on staff for toileting and supervision of staff for toilet transfers. Record review of a comprehensive care plan dated 11/4/2024 revealed Resident #4 was at risk for injuries related to falls and to provide toileting assistance, resident to call for assist and keep call light in reach. During an observation and interview on 04/07/25 at 9:33 am revealed Resident #4's bathroom call light box was not attached to the wall. The light would activate with the touch of the button, but the pull cord did not work. Resident #4's best friend said he used his bathroom and would pull on the cord breaking the box. She said the Maintenance Director fixed the box last week, but it broke again sometime after she left on Friday 04/04/25. Resident # 4 said he would yell if he needed help. 2. Record review of a facility face sheet revealed Resident #6 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of heart failure. Record review of a Quarterly MDS assessment dated [DATE] revealed Resident #6's BIMS was not completed. Further review revealed a SAMS was completed and indicated severely impaired cognitive skills for daily decision-making. Record review of a comprehensive care plan dated 10/24/2023 revealed Resident #6 was at risk for injuries related to falls and would remain free from injuries. During an observation on 04/07/25 at 9:45 am revealed Resident #6's bathroom call light box was not attached to the wall. The light would activate with the touch of the button, but the pull cord did not work. Resident #6 was not able to be interviewed. During an interview on 04/07/25 at 9:47 am CNA A said she worked on Saturday 4/05/25. She said Resident #4's and Resident #6's lights were not broken but noticed them being broken this morning. She said Resident #4 sometimes used his bathroom and Resident #6 used her bathroom daily. She said there was a maintenance log to notify the supervisor of broken things, but she had not put it in the log yet today. She said if the call light was broken, residents could not call for help, and they could get hurt. During an observation on 04/07/25 at 10:00 am revealed Resident #6 was in the bathroom toileting. During an interview on 04/07/25 at 10:18 am the Maintenance Director said he was responsible for broken call lights. He said he was not aware of Resident #6's call light box being off the wall and the pull cord not working. He said he fixed Resident #4's bathroom call light on 04/04/25 and it must have broken again over the weekend. He said there was a log, but the staff usually verbally reported to him, and he would fix the problem. He said a broken call light cord could result in a resident not getting help if they need it. During an observation on 04/07/2025 at 11:25 am revealed large bells were in Resident #4's and Resident #6's bathrooms. During an interview on 04/07/2025 at 11:30 am the Maintenance Director said he could not fix the pull cords on the bathroom lights for Resident #4 and Resident #6 until the parts were delivered. He said each resident was provided a bell to use for emergencies. During an interview on 04/09/25 at 9:44 am the Administrator said the call lights should be checked by all staff each shift and by maintenance as needed to ensure they are in full working order. He said the staff should be reported immediately any broken call lights to the maintenance director or himself. He said there was a maintenance log, and they could report verbally. He said if a call light was not in full working order and the cord did not work the resident could have a delayed response in care. Record review of a facility policy dated September 21, 2022 titled Answering the Call Light revealed, .6. report all defective call lights to the nurse supervisor promptly .

Based on observations, interviews, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for the 1 of 2 (secured unit smoking area) smoking areas reviewed. The facility failed to ensure the paper trash and cigarette butts were disposed of separately in the ashtrays and red fire can on 04/07/25. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. Findings include: During an observation on 04/07/25 at 9:57 AM revealed the smoking area located outside the secured unit had one ashtray with cigarette butts and empty cigarette boxes and the red fire can had paper trash and cigarette butts. The paper trash was observed as burned ash. During an interview on 04/07/25 at 10:03 AM CNA A said that there should not be any paper in the ashtrays or cans because of fire. She said housekeeping was responsible for cleaning out the ashtrays and red fire can daily. She said that residents were supervised when smoking and staff supervising should also make sure paper trash was not disposed of in the ashtrays and red can to prevent fires. During an interview on 04/07/25 at 10:15 am Housekeeper B said she was not aware the smoking area outside the secured unit was her responsibility to clean. She said she started a month ago and was only cleaning inside the facility. She said she would see that the smoking area trash was removed from the cans, so a fire did not happen. During an interview on 04/07/25 at 10:30 AM the Housekeeping Supervisor said the housekeeping department was responsible for the smoking area and should be checking the area daily. She said there should not be any paper trash in the ashtrays or red fire can because of fires. She said she had a turnover of staff and will retrain staff maintaining the smoking area to prevent fires. During an interview on 04/07/25 at 9:55 am the Administrator said the smoking areas were to be maintained by housekeeping and maintenance. He said the areas should be checked daily and the supervising staff with each smoke break should ensure the area was clean, maintained, and no paper trash was mixed with cigarette butts. He said that not properly disposing of cigarette butts and trash could result in a fire. Record review of an undated facility document titled Smoking Area Monitoring Schedule revealed .daily schedule of responsible department to include maintenance and housekeeping schedule to ensure all ash trays are emptied, ensure trash and cigarette butts are being kept in separate containers and red cans are emptied daily . Record review of an undated facility policy titled Smoking Policy - Residents revealed, .this facility shall establish and maintain safe smoking practices .

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 11 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free of abuse from HSK-A. On 06/25/24 HSK A yelled and cursed at Resident #1. The noncompliance was determined to be PNC. The noncompliance began on 06/25/24 and ended on 06/26/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of verbal abuse. Findings included: Record review of Resident #1's undated face sheet reviewed on 03/06/25 indicated he was a [AGE] year-old male, admitted on [DATE], and his diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary),. schizophrenia (chronic mental disorder), and hypertension (high blood pressure). Record review of Resident #1's annual MDS assessment dated [DATE] indicated he was independent in performing most ADLS and needed supervision and verbal cues with showering. He was able to make himself understood and understood others, and he had severe cognitive impairment (BIMS-5). Record review of Resident #1's care plan dated 06/26/24 indicated behavioral problems started on 08/24/23. He had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). On 06/25/24 Resident #1 struck staff twice on the back while in his room. Interventions included asking permission before providing care, attempt to clean his room or address maintenance issues when he is not in his room. If he becomes agitated, notify the charge nurse or nursing management to assist, maintain a professional demeanor with resident to avoid reacting defensively or escalating the situation, Record review of progress note dated 06/25/24 at 8:42 a.m. LVN A indicated she heard an altercation coming from the hall. On investigation, she saw HSK A standing at Resident #1's doorway arguing with Resident #1. LVN A immediately intervened. LVN A escorted HSK A to the nurse's station. Resident #1 was placed on one-on-one observation and skin and pain assessment was completed. Administrator was notified and HSK A was escorted out of the building by the administrator. Resident #1 had no RP to notify. Record review of a skin assessment dated [DATE] at 11:51 AM, conducted by LVN B, showed a scratch to the back of right shoulder. Record review of progress notes dated 06/25/24 at 12:04 PM, DON documented a telehealth call with counselor at psychiatric facility. New orders to increase Seroquel to 100 mg BID and to monitor Resident #1 one-on-one until tomorrow morning. May remove Resident #1 from one-on-one supervision if no other behaviors. Medical Director (PCP) was notified of the recommendation for medication change and agreed. Record review of progress notes dated 06/25/24 at 12:34 PM LVN B indicated Resident #1 complained of pain to his right shoulder. Resident was given Tylenol. Record review of progress notes dated 06/26/24 at 8:10 AM, DON documented Resident #1 was removed from one-on-one. Will continue to monitor for 72-hours. Seroquel 100 mg BID yesterday. Resident #1 was smiling and self-propelling in wheelchair in the AM. Record review of a Resident Monitoring Checks form dated 06/25/24 to 06/26/24 showed Resident #1 was monitored every 15 minutes from 8:45 AM on 06/25/24 till 6:00 AM on 06/26/24. No behaviors were noted. Record review of consolidated physician orders dated 06/01/24 to 06/30/25 showed on 06/25/24, Resident #1's Seroquel was changed from 50 mg, BID, to 100 mg, BID for Schizophrenia. Record review of facility investigation dated 06/25/24 indicated on 06/25/24 HSK A went to clean Resident #1's room. Resident #1 allegedly hit HSK A after he asked HSK A to leave his room and HSK A refused. HSK A alleged Resident #1 hit him in his back two times. There were no witnesses to the incident inside Resident #1's room. Staff reported hearing yelling and cursing as HSK A left the room and headed down the hallway to the nurse's station. Staff reported HSK A was angry and threatening to hurt Resident #1. HSK A was removed from the facility by the administrator. HSK A was terminated. Staff was in-serviced on Abuse/Neglect, Dementia/Behaviors, and how to approach Resident #1. Record review of a written statement dated 06/25/24, the administrator indicated, at approximately 9:00 AM, he heard loud yelling from the back door of his office. He said he saw HSK A in front of Resident #1's room, saying, I am going to whoop your ass to Resident #1. HSK A's housekeeping cart was outside of Resident #1's room and he was in the hallway speaking to Resident #1. HSK A said Resident #1 hit him twice in the back. The administrator drew HSK A way from the situation toward the nurse's station. HSK A continued to maintain a loud voice and threatened to get him back in whatever way he could-out on the street, etc. to return the hurt. HSK A continued to yell and administrator asked HSK A to come to his office. HSK A was advised he could not continue to make verbal treats toward Resident #1, and yet he continued to say he would. The administrator told HSK A he was terminated and was escorted off the property. Record review of a written statement dated 06/25/24 by CNA A indicted she was at the nurse's station when she heard and saw HSK A at the end of Hall 1 yelling and cursing at Resident #1. HSK A came to the nurse's station and was yelling derogatory things regarding Resident #1. Record review of a written statement dated 06/25/24 by LVN C indicated she was in the conference room and heard yelling. She stepped out of the room and saw HSK A grab a glass off his housekeeping cart and walk to the front of the facility. The administrator intervened and met with HSK A at the front door. LVN C did not witness anything between Resident #1 and HSK A inside Resident #1's room. Record review of a written statement dated 06/25/24 by LVN A indicated she was at the nurse's station when she saw and heard HSK A hollering in the hallway. HSK A was walking down the hall toward the nurse's station. HSK A said Resident #1 hit him. HSK A was cursing and threatening to beat up Resident #1. The administrator intervened, but HSK A continued to holler about what he wanted to do to Resident #1. The administrator asked HSK A to leave the facility. Record review of a written statement dated 06/25/24 by LVN B indicated HSK A was upset with Resident #1 and started yelling, cursing, and making treats toward Resident #1. The administrator immediately intervened and HSK A left the facility. Record review of a written statement dated 06/25/24 by Receptionist A said HSK A came to the front office cursing about Resident #1. HSK A was irate and kept making comments about what he wanted to do to Resident #1. HSK A met with the administrator and was asked to leave the building. Record review of a witness statement dated 06/25/24 at 9:00 AM of HSK A, taken by RN A over the telephone showed, I got to work like normal and started cleaning. When I got to Resident #1's hall he was sitting at the front of the hall and when I made my way to his room he came in shortly after. He started making comments about the tile in his bathroom, so I went in there and started looking at it. I had my back turned to him, and he had gotten up out of his wheelchair and started punching me in the back about three times before I could turn around. When I turned around, I pushed him off me and he was trying to hit me in the head. I started yelling for someone to come help me. After I got out of his room, I went to the nurse's station and talked to the administrator and told him what happened, and he walked me outside. Record review of HSK A's employee records showed he was terminated on 06/25/24 for inappropriate behavior. Two attempts were made on 03/06/25 at 12:50 PM and 03/07/25 at 11:20 AM to interview HSK A via telephone. There was no answer. An automated recording said, The mailbox is full and cannot receive messages. Unable to contact AP. During an attempted interview on 03/06/25 at 10:50 a.m., Resident #1 was not able to recall or answer questions regarding the incident with HSK A on June 25, 2024. Unable to interview due to cognitive ability. Review of In-service records dated 01/01/2024 showed HSK A received training on Resident Abuse. During an interview on 03/07/25 at 10:10 a.m., CNA A said on 06/25/24, she was working the morning shift on 06/25/24. CNA A said she heard HSK A, yelling and cursing as he was walking up hall 1 toward the nurses' station. She said HSK A said Resident #1 hit him, and he was not going to Fucking put his hands on me, and I will hurt him. CNA A said Resident #1 was not in the hallway. CNA A said Resident #1 was in his room. CNA A said she had been trained on identifying abuse and neglect and to report any abuse or neglect to the administrator, who is the abuse coordinator. CNA A said she had also been trained on how to handle behaviors of residents and to give them space when they are upset and report the behavior to the nurse immediately. CNA A said the yelling and cursing from HSK A on that day was verbal abuse. During an interview on 03/07/25 at 10:19 a.m., LVN C said she was working on 06/25/24 around 9:00 a.m. she said she was in the conference room and heard someone yelling and cursing. LVN C said she went out into the hall and saw HSK A, grab a personal cup off the housekeeping cart and walk to the front, yelling and cursing as he came up the hall. LVN C said she did not see Resident #1 in the hallway. LVN C said she backed up when HSK A walked past her, because she did not know what he was going to do. LVN C said HSK A went to the front door, where the administrator stopped him. LVN C said she did not remember anything HSK A said but that he was yelling and cursing. LVN C said she had been trained on how to handle behaviors of residents and to give them space when they are to report the behavior to the charge nurse immediately. During an interview on 03/07/25 at 10:57 a.m., the Administrator said on 06/25/24 around 9:00 AM, he was in his office when he heard yelling in the hall. He said his office has a door that goes into Hall-1. He said he looked out of the door into the hall to see what the yelling was about, and he saw HSK A coming out of Resident #1's room. He said HSK A was in the hallway yelling toward Resident #1's room. He was yelling Get the F away from me. He said HSK A walked up the hallway toward the nurse's station. He said he told HSK A to come inside his office. He said HSK A said that he was cleaning the bathroom inside Resident #1's room when Resident #1 started hitting him in his back. He said HSK A said he pushed Resident #1 away from him and left the room. He said HSK A said he did not remember if Resident #1 fell when his pushed him, but he was just trying to get out of the room. He said HSK A was immediately terminated and escorted out of the facility. He said he interviewed Resident #1, but due to his cognitive ability was not a good historian. He said when he asked him if the white man pushed him, he nodded his head up and down, indicating Yes. He said the allegation of Resident Abuse was confirmed and the police were contacted. He said staff received In-service training on Abuse/Neglect, behaviors, Resident Rights and Approaching Resident #1. He said Resident #1 was placed on watch to insure there were no other incidents and he was referred to psych services for evaluation. He said the issue was discussed in the QAPI meeting and the DON and Medical Director attended the QAPI Meeting. He said there have not been any other incidents involving Resident #1. During an interview on 03/07/25 at 11:27 a.m., LVN B said she was working on the morning of 06/25/24. She said she was at the nurse's station when she heard yelling from down the hall. LVN said she witnessed HSK A yelling and cursing toward Resident #1's room. LVN B said the HSK A came up the hall yelling very loudly and cursing. LVN B said she conducted a skin assessment of Resident #1 and there was a small abrasion on his back. LVN B said Resident #1 was not able to say what caused the abrasion. LVN B said she does not know if Resident #1, fell , but if so, he would have been able to get himself up. LVN B said since there were no witnesses to the incident, and Resident #1 was not able to say what happened to cause the abrasion on his back, she could not determine what caused the abrasion. LVN B said she had received training on abuse and resident behaviors and had received specialized training on approaching Resident #1. During an interview on 03/07/25 at 11:34 a.m., RN A said she no longer works for the facility, but was employed as a Regional Nurse on 06/25/24, the date of the incident between Resident #1 and HSK A. She said she was not at the facility at the time of the incident but did contact HSK A via telephone to get a statement. She said when she spoke with HSK A, he was very hostile to her on the phone. RN A said she read HSK A's statement to him over the phone, and he agreed that what she recorded was accurate. She said HSK A was terminated on the day of the incident. RN A said since she was not at the facility at the time of the incident, she had no firsthand knowledge of what happened. During an interview on 03/07/25 at 11:38 a.m., DON said she was not at the facility at the time of the incident in June between Resident #1 and HSK-A. DON said she assisted in the investigation after the fact. She said HSK A was terminated, and staff received training on abuse, neglect, Dealing with Resident #1, and Resident Rights. DON said the incident was discussed at the QAPI meeting in June and Resident #1's care plan was updated to include interventions when dealing with Resident #1. During all interviews with staff on 03/06/25 and 03/07/25, including 2-RN's 3 LVN's and 5 CNA's. staff were able to give examples of abuse and were able to identify interventions when dealing with behaviors for Resident #1. They said they had received training on identifying and reporting abuse to the abuse coordinator, which was the administrator. Review of the facility's Abuse and Neglect Policy dated 04/08/2021 indicated It is the policy of this facility that rights will be protected of alleged victims of abuse, neglect, misappropriation or mistreatment, as well as the rights of staff who are accused of abuse, neglect, misappropriation or mistreatment-as well as those who report it.A corrective action plan will be developed, and an internal investigation will be conducted for findings. Review of safe surveys showed safety surveys were conducted on 06/25/24 by the ADON showing there were no concerns with other residents and residents felt safe at the facility. Review of QAPI minutes showed a QAPI meeting was conducted with Administrator, DON, ADON, Dietary Manager, Maintenance Director, and Medical Director on 07/22/2024. Concerns addressed at the meeting included incident between Resident #1 and HSK A on 06/25/24. Review of In-services records showed on 06/25/24 and 06/26/24, all staff received In-service training on Abuse/Neglect, behaviors, and approaching Resident #1. All education was completed with all staff that were working 06/26/2024. The noncompliance was determined to be PNC. The noncompliance began on 06/25/24 and ended on 06/26/24. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (Resident #1 and Resident #242) reviewed for adequate supervision. 1. The facility failed to transfer Resident #1 with a mechanical lift and 2 staff member assistance, resulting in a laceration to her right lower extremity requiring 16 sutures. 2. The facility did not ensure the brakes were engaged when Resident #242 was lifted and lowered with the Hoyer device (an assistive lift device that allows for transfer using electrical power). These failures could place residents at risk for injury, harm,or impairment. Findings included: 1. Record review of Resident #1's Admission Record indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included senile degeneration of the brain (the mental loss of intellectual ability that is associated with old age), repeated falls, abnormalities in gait (when a person is unable to walk in the usual way), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should, and anxiety (Intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's MDS dated [DATE] revealed a BIMS with a score of 4, which indicated severely impaired cognition. The MDS also revealed, Resident #1, required extensive assistance with 2 staff members for transfers. Record review of Resident #1's Care Plan, completed by the DON, revealed a problem initiation on 12/05/2022 for a laceration to right lower posterior leg from a wheelchair transfer by hospice aide. The laceration measured 6.0cm X 4.0cm X 0.5cm and required 16 sutures in the emergency room . Care plan titled ADL assistance revealed Resident #1 required extensive assistance of 2 staff members for transfer. Record review of Resident #1's accident and injury report completed by LVN G, indicated on 12/05/2022 Resident #1, sustained an injury to her right lower extremity measuring 6.0cm X 4.0cm X 0.5cm. The accident report revealed Resident #1 was in moderate pain, there was a large amount of blood, the accident occurred during transfer, first aid was administered, and Resident #1 was sent to the emergency room . The accident report revealed the injury was a large laceration with jagged edges that needed sutures. Record review of Resident #1's nursing notes dated 12/05/2022 revealed the following: LVN G wrote: This nurse called to resident's room (Resident #1). Resident received laceration to RLE (right lower extremity) 6.0cm X 4.0cm X 0.5cm. First aid performed to stop bleeding. EMS (emergency medical service called for transfer to a local emergency room for further evaluation. NP (nurse practitioner) and family aware. Record review of a hospital exam dated 12/05/2022 indicated Resident #1 came to the emergency room after suffering a laceration to right calf area measuring 6.0cm X 3.8cm. The laceration required sutures to approximate the skin and stop the bleeding. Procedure completed and Resident #1 was sent back to the nursing facility. During observation and interview on 01/09/2023 at 2:30 p.m., Resident #1's family stated on 12/05/2022 she was called and informed that Resident #1 was being sent to the ER because she had a skin tear to her leg. Resident #1's family stated she met Resident #1 in the ER and she had more than a skin tear. She stated it was a huge laceration that required 16 sutures. She stated she stayed with Resident #1 until the sutures were completed, and the ER (emergency room ) sent her back to the facility. Resident #1 was well-groomed lying-in bed with family at bedside. During an interview on 01/10/2023 at 9:40 a.m., CNA B said she had worked at the facility for several years and was the full time CNA for 100 hall (the hall Resident #1 resided on). CNA B stated she remembered the incident in which Resident #1 sustained a laceration to her right lower extremity. CNA B stated that was the day the Hospice CNA F reported to her she had transferred Resident #1 by herself with no assistance. CNA B stated she remembered it because it was a huge deal that she transferred Resident #1 alone and Resident #1 was injured in the process. CNA B explained that Resident #1 was always a 2-person mechanical lift transfer. CNA B further explained that Resident #1 was too unpredictable to attempt any kind of stand pivot transfer and for the safety of the resident and the CNA she must be transferred by mechanical lift and always have 2 staff. CNA B stated, Hospice CNA F knew Resident #1 was a mechanical lift with 2 staff because Hospice CNA F had assisted her with the mechanical lift transfer of Resident #1 several times before. During an interview on 01/10/2023 at 2:00 p.m., LVN G stated she recalled the incident that occurred on 12/05/2022 with Resident #1 and Hospice CNA F. LVN #G stated she was called down to Resident 1's room and noted a large amount of blood pooled beneath her wheelchair. She noted a large laceration to Resident #1's right posterior calf area. LVN G stated, Hospice CNA F told her she was not sure how it happened but Resident #1 had to have scratched her leg on the wheelchair during transfer. Hospice CNA F stated she did transfer Resident #1 alone. LVN G stated Hospice CNA F called her supervisor and told her the laceration occurred and the facility was sending Resident #1 to the hospital. LVN G was not aware of any education or disciplinary action for Hospice CNA F. LVN G stated the care plan, as well as the CNA kiosk had the information for each resident's care needs. LVN G stated the hospice CNAs generally asked the nurse or another CNA if they were unsure of how to transfer a resident. LVN G stated Hospice CNA F had been to the building dozens of times and was the assigned hospice CNA to Resident #1. LVN G stated Hospice CNA F had transferred Resident #1 with the assistance of herself and other staff members by mechanical lift multiple times prior to the incident. During an interview on 01/10/2023 at 3:00 p.m., Hospice CNA F stated she transferred Resident #1 alone at least once per week. Hospice CNA F stated on 12/05/2022 around 4:00 p.m., she transferred Resident #1 with a stand pivot transfer. She got ready to leave the room wheeling Resident #1 and noted a small pool of blood beneath Resident #1's wheelchair. She stated she immediately called for help, the nurse came, and first aid was administered. Hospice CNA F stated she did not have access to the facilities records to know how they had Resident #1's care planned for transfer. Hospice CNA F stated she believed hospice had Resident #1 care planned as a 1-person transfer. Hospice CNA F stated she had not reviewed the facility or hospice care plan. Hospice CNA F further explained she was tall and had not had any problem transferring Resident #1 alone in the past. Hospice CNA F stated she knew the facility used a mechanical lift to transfer Resident #1. She stated she felt the facility used a mechanical lift because the CNAs were short, and Resident #1 was tall, and they could not handle her. Hospice CNA F stated she had not received any further training on transfers by the facility of the hospice company, nor had she received any direction on how to communicate with the facility about the amount of care each resident required. Hospice CNA F stated she had been back in the facility and cared for other hospice resident's a dozen times since 12/05/2022 with no further education on transfer. Record review of hospice plan of care with a start date of 07/18/2022, revealed Resident # 1 was always a 2-person mechanical lift transfer. Hospice provided the mechanical lift and the sling required for transfer on 07/18/2022. During an interview on 01/10/2023 at 3:30 p.m., the DON revealed she was informed on 12/05/2022, that Resident #1 had sustained a laceration to her right calf during the improper transfer and was being sent to the ER for evaluation. The DON stated she reviewed the accident report and questioned Hospice CNA F. The DON stated Hospice CNA F had a horrible attitude and was loud with her when she attempted to educate her on communicating with the staff about how many people should be assisting with transfers. The DON stated she attempted to educate Hospice CNA F, but Hospice CNA F called her manager and told her the facility was demanding Resident #1's care plan be changed to 2-person mechanical lift transfer. The DON stated she told the Hospice Nurse Manager not to send the CNA back into the facility and that the facility and hospice care plans had to be the same. The DON stated she attempted to educate Hospice CNA F to ask staff, look at the hospice care plan, or look at the CNA kiosk before providing care to ensure she was giving proper safe care. The DON stated the hospice staff had to ask the facility staff for access to the facility care plan and the kiosk which contained the CNA care plan for each resident The only way for the hospice staff to know the resident's plan of care was to ask the staff to see it or look at the hospice care plan. The DON was not aware of how many times Hospice CNA F had been back to the building following the 12/05/2022 incident. No paperwork was located showing documentation of education for any CNA after the improper transfer with a laceration occurred. During an interview on 01/10/2023 at 4:40 p.m., Hospice RN manager E revealed she was called by Hospice CNA F and informed Resident #1 was being sent to the ER following an incident in which Resident #1 was injured during a transfer. Hospice RN E stated Hospice CNA F thought Resident #1 was a one-person pivot transfer and requested that Resident #1's hospice care plan be changed to reflect the 2-person mechanical lift transfer. Hospice RN manager E revealed she did not change the care plan to a 2-person mechanical transfer. She stated when she looked at it, hospice was already providing a mechanical lift and sling for the transfer of Resident #1. Hospice RN manager E stated she did not do further education with Hospice CNA F ensuring resident safety and continuity of care. Hospice RN manager E stated the hospice company educated the CNAs to always speak the nurse and CNA prior to care to ensure no changes in the resident care status had occurred. Hospice RN manager E stated the hospice CNAs were educated to follow the hospice care plan which was located in the hospice book at each nurses station. During an interview on 01/11/2023 at 10:15 a.m., the DON stated the incident from 12/05/2022 with Resident #1, could have been prevented if the Hospice CNA F had followed the plan of care set forth by the facility and transferred Resident #1 with a mechanical lift with 2 staff members present. The failure to do so resulted in a laceration to her right calf requiring 16 sutures. The DON stated she attempted to do education with Hospice CNA F, and she was not receptive to the education. The DON stated she talked to the Hospice RN E and requested Hospice CNA F not take care of Resident #1 and that all hospice care plans match facility care plans for continuity of care. The DON stated failure to provide adequate supervision for ADLs will result in injury and could result in serious injury. During an interview on 01/11/2023 at 10:30 a.m., the Administrator stated He stated that hospice should have educated their staff on following the care plan and safe transfers. The Administrator stated he knew the facility was responsible for resident safety no matter who was caring for them. The Administrator stated not providing the proper supervision during care can result in serious injury and harm. The Administrator stated the facility had monthly in services and following resident care plans was discussed at least quarterly and upon hire with each staff member. 2.Record review of the Resident #242's physician order report indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including, epilepsy (a brain disorder that causes recurring, unprovoked seizures), Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and muscle spasm. Record review of the active physician order dated 1/6/23 indicated Resident #242 was to have fall precautions in place. Record review of the care plan reviewed by the facility on 1/10/22 indicated Resident #242's environment would be monitored to decrease risk for falls. During an observation on 1/10/23 at 11:40 a.m., CNA H had positioned the Hoyer net under Resident #242 in her wheelchair. CNA H left the room and returned with LVN G to complete the transfer. CNA H moved the mechanical lift into place in front of the wheelchair. CNA H then lowered the device (brought the cradle into appropriate position to secure the mechanical lift net). LVN G and CNA H secured the mechanical lift net to the cradle. CNA H did not lock the brakes of the mechanical lift. CNA H raised Resident #242 up in the mechanical lift. CNA H and LVN G moved the lift and positioned Resident #242 over her bed. CNA H, without locking the brakes, lowered Resident #242 onto her bed. During an interview on 1/10/23 at 11:49 a.m., CNA H said she should have locked the brakes before she lifted or lowered Resident #242. CNA H said she did not lock the brakes because she forgot. CNA H said it was important to lock the brakes of the mechanical lift before a resident was lifted or lowered because the lift could move which might cause the resident to bang into something or fall. During an interview on 1/10/23 at 11:50 a.m., LVN K said staff should always make sure the brakes are applied on the mechanical lift before a resident was lifted/lowered. LVN K said leaving the brakes unlocked while a resident was lifted/lowered could cause the lift to jerk or slide, which could startle the resident. LVN K elaborated, the Resident could fall out of the lift or the lift could fall over with the Resident in the lift. During an interview on 1/11/23 at 10:36 a.m., LVN G said she did not realize CNA H had not locked the brakes of the mechanical lift before lifting/lowering Resident #242 yesterday (1/10/22). LVN G said it was very important to lock the brakes of the mechanical lift before a resident was lifted/lowered because the resident could fall out or the lift could tip over. During an interview on 1/11/23 at 1:45 p.m., the DON said she expected staff to ensure brakes were applied on the mechanical lift before a resident was lifted/lowered. The DON said she expected staff to ensure brakes were applied on the device (bed or chair) the Resident was lifted from, the device the Resident was lowered to (bed or chair) and the mechanical lift brakes were locked before lifting or lowering the Resident. She said these safety mechanisms (locking the brakes) were in place to prevent injury. The DON said failure to ensure the brakes were locked on the mechanical lift device could have resulted in significant injury. During an interview on 1/11/23 at 2:06 p.m., the Administrator said staff should have locked the brakes on the Mechanical lift before lifting/lowering Resident #242. The Administrator said he expected staff to utilize all approaches to safety. Record review of an undated policy entitled Accidents and Supervision revealed, Avoidable Accident means that an accident occurred because the facility failed to: * identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or * Evaluate and analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; and/or * Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice to eliminate the risk, if possible, and, if not, reduce the risk of an accident; and/or * Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. Record review of the undated facility policy titled, General Safety Policy stated, In general, all employees will maintain a safe environment and report any issues immediately. Procedure: 1. Employees will report all unsafe or potentially hazardous acts or conditions to the supervisor immediately. Supervisors/managers will be responsible for implementing protocol to resolve the unsafe or potentially hazardous condition immediately .8. Any incident (e.g., any unusual occurrence that is not consistent with routine facility activity) must be reported immediately. Reporting incidents will assist in providing a safe and secure environment for residents, visitors, and employees. An Incident Report form must be completed within one hour of the occurrence and submitted to your supervisor as soon as possible after completing the report form. 9. The supervisor must investigate the incident report immediately. After the investigation is complete, the supervisor will complete a follow-up report, attach it to the original incident report and submit both reports to the DON before the end of the shift. 10. If the incident involves an employee or resident injury, first aid and subsequent medical evaluation as needed will be provided first. The incident reports will reflect the delay in submitting the report to the DON. 41093

Based on interview, observation, and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *The facility failed to ensure CPR was provided to Resident #1 who was a full code. On [DATE] CPR was not initiated by facility staff after Resident #1 was found not breathing, without a pulse, and unresponsive. EMS was notified by facility upon arrival that Resident #1 was expired and did not initiate CPR or transport to hospital. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] at 8:48 AM to [DATE] at 11:59 PM. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings included: Record review of the face sheet, dated [DATE], indicated Resident #1 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] from acute hospital. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's face sheet indicated a directive in place for full code (in the event of [CONDITION(S)], CPR will be initiated). Record review of Resident #1's physician orders, dated [DATE], indicated order for full code. Record review of Resident #1's advance directive in his electronic health record indicated a selection for Applied Full Code. Record review of Resident #1's care plan dated [DATE] indicated Resident #1 code status: Resident code status is: FULL CODE. Approaches for Resident #1 included Staff will honor Code Status preference for resident and/or responsible agent as indicated. Record review of facility Advances Directives and Code Status Report, dated [DATE], revealed Resident #1 was a Full Code. Record review of Resident #1's MDS, dated [DATE], indicated a BIMS score of 04 and revealed no indication for DNR advance directive. Record review for Resident #1's SBAR Communication Form, dated [DATE] completed by LVN A, revealed a change in respiratory status on [DATE]. NP was notified at 8:41 am and representative was notified at 8:50 am. Full Code was selected under Advance Care Planning information section. Record review of Resident #1's nursing note completed by DON, dated [DATE] at 12:34 p.m., indicated LVN A called 911 at 8:40 a.m. after finding resident unresponsive with abnormal breathing and fever at 8:39 a.m. NP was notified at 8:41 am by LVN A that resident was being sent to ER by EMS. Resident #1 was found with no heartbeat, no respirations, and no eye touch reflex at 8:48 and RP was notified by LVN A at 8:50 a.m. DON assessed Resident #1 for 5 minutes and pronounced at 8:53 a.m. Ambulance arrived at facility at 8:54 a.m. and LVN A notified EMS that resident expired. EMS stated, since being dismissed, no need to come in and departed from facility without initiating CPR. During an interview on [DATE] at 10:30 a.m., the ADM said the DON notified him that CPR was not initiated on Resident #1 and that the Director of Clinical Services was at the facility yesterday and conducted in-services and additional CPR training with all staff. During an interview on [DATE] at 10:30 a.m., the DON and ADON said they did not initiate CPR on Resident #1 on [DATE]. DON said Resident #1 was found with no breathing, no heart rate, and no pupil response at 8:48 AM. DON told LVN A to notify the RP of his condition. DON said she pronounced him at 8:53 after assessing for five (5) minutes with no signs of life. At 8:54 AM the ambulance arrived. LVN A was instructed by DON to notify EMS that resident had expired. DON said LVN A then called funeral home and notified provider. DON said she realized she forgot the CPR procedure and CPR was not initiated on Resident #1 per full code status approximately two (2) hours after he expired. DON said she notified attending physician and NP of the failure to follow code status at approximately 10:00 AM. Attending physician and NP said the full code order should have been followed. DON said she was ultimately responsible for ensuring CPR was initiated on Resident #1. DON said the incident had been QA'd (Quality Assurance Program) to ensure that code status was followed which included the Administrator, Social Services, herself, ADON, and the Director of Clinical Services. DON said the Director of Clinical Services conducted in-services and training on [DATE] on CPR, an audit was conducted CPR training to ensure staff had current certification, Code Blue was implemented for the facility, mock drills were conducted along with an AED device proficiency test and training. DON said she ensured code status was placed in the front of resident charts and in nursing carts, completed safe surveys, and written warnings were issued for nursing staff involved in Resident #1's incident. DON said the facility's policy and procedures when a resident was not breathing and unresponsive would be to follow physician orders/code status and initiate CPR when a resident a is a full code. DON said code status can be found in paper charts, nursing carts, and the electronic health record. During an interview on 11:14 a.m., the ADON said she had received CPR training on [DATE] and had current certification. ADON said she responded to Resident #1 after being informed by CNA A that he needed to be assessed. ADON said she was aware Resident #1 was a full code and did not initiate CPR because she was following the lead of the DON. She said LVN A notified 911, physician, and RP. ADON said EMS arrived at the facility after Resident #1 expired and did not enter the facility or initiate CPR. During an interview on [DATE] at 11:15 a.m., the DON said she admitted full responsibility for CPR not being initiated on Resident #1 when it should have been. DON said there was no malice and that she was not thinking about the procedure. She said she had been working at the facility for three weeks and that Resident #1 was her first resident to expire rapidly after significant decline. During an interview on [DATE] at 11:50 a.m., LVN A said she did not initiate CPR on Resident #1 on [DATE] because she was following the lead of the DON. LVN A said all licensed personnel were responsible for initiating CPR on residents but that the DON was in charge. LVN A said she had received CPR training and has used the AED device on a prior occasion. LVN A said CPR should be initiated when a resident was a full code and was going into [CONDITION(S)]. She said it was important to provide basic life support to all residents with a full code status to respect residents wishes and prevent possible death. LVN A said that CNA A and CNA B notified her of Resident #1 declining on [DATE] and instructed them to notify the DON and ADON. LVN A said the ADON, and DON had responded by the time she entered Resident #1's room. During an interview on [DATE] at 12:09 p.m., CNA A said that she notified LVN A she was needed in Resident #1's room after finding him with abnormal breathing. CNA A said LVN A was passing medication and the DON came to Resident #1's room. She said there was no discussion about CPR being initiated. She said she had received training on CPR provided by in-services and that CPR should be initiated if a resident stop breathing. She said the DON and nurses were usually responsible for ensuring code status was followed. CNA A said she could verify code status by reviewing resident face sheet in the electronic health record system. During an interview on [DATE] at 12:27 p.m., CNA B said that she had received training on CPR via in-services and drills. She said CPR would be initiated on a resident after they stopped breathing if they did not have a DNR in place and that she had access to code status in Matrix. She said that the DON was ultimately responsible for initiating CPR on Resident #1. During an interview and observation on [DATE] at 1:10 pm, the DON said she had reviewed Resident #1's code status when reviewing charts before the incident on [DATE]. She said she was aware that Resident #1 was a full code and did not initiate CPR due to making a mistake and not following protocol. DON opened AED device container located on wall near nurse station and battery indicator light indicated power was functioning. AED device pads and batteries were not expired, and crash cart supplies were available and readily accessible. DON said AED maintenance log and crash cart checklists for ,d+[DATE] - ,d+[DATE] revealed daily checks conducted with no corrective actions. DON said the AED device had been functioning and that the pads and battery were not expired. DON said in the event of an emergency response for CPR on a full code resident she would obtain or instruct someone to obtain what was needed on the crash cart and AED device. DON said the AED device was not obtained for Resident #1 on [DATE]. DON said she accepts full responsibility for not initiating CPR per code status and not following policy and procedure for emergency response on Resident #1. DON said it was important for basic life support to be provided on all residents without a DNR to prevent possible injury or death. The administrator was notified of the Immediate Jeopardy (IJ) past-noncompliance on [DATE] at 2:30 pm. IJ pas non-compliance was verified by: staff interviews related to CPR, CPR initiation, honoring code status, following physician orders, what to do when finding an unresponsive resident, where to find emergency supplies and code status, and checking AED pads weekly for expiration. Observations of residents were conducted, review of in-services related to CPR, advance directives, change in condition, and AED inspection was completed. During a telephone interview on [DATE] at 2:50 p.m., physician said he was notified that Resident #1's code status was not followed a couple hours following his death on [DATE]. He said that CPR should have been initiated and that the DON apologized and admitted her mistake. He was concerned that orders were not followed and informed the DON it was very important to make sure CPR orders were followed for resident safety. Physician said he instructed the DON to ensure code status was readily available and reviewed procedure to administer CPR when there is no DNR order. During a telephone interview on [DATE] at 3:00 p.m., NP said she was notified that code status was not followed on Resident #1 soon after he expired on [DATE]. She said the DON admitted that she made a mistake by not initiating CPR on Resident #1. NP said that CPR should have been initiated on a full code resident and that she has never had this happen before at this facility. During a telephone interview on [DATE] at 4:30 p.m., Resident #1's RP said she was notified by the facility on [DATE] that CPR was not initiated per physician orders. RP said she was aware Resident #1 was a full code and that the facility failed to initiate CPR on Resident #1. During an interview on [DATE] at 5:07 p.m., ADM said the potential risks to residents if physician orders/code status were not followed would be death. He said if code status was not followed for resident it would impact all parties involved including staff, residents, and representatives. ADM said CPR not being initiated on Resident #1 was an isolated incident since being employed at the facility for six months and that he was aware of CPR being initiated appropriately with previous DON and that the current DON was a new employee. ADM said it was important for staff to follow code status to ensure the safety and rights of residents and that a failure to do so could result in death or injury. ADM said the DON did not conduct CPR because she drew a blank. ADM said the DON was a trauma nurse and had experience in emergency situations. He said that the ADON, DON, or LVN could have initiated CPR on Resident #1 in that situation, but ultimately the DON was the highest-ranking nurse and should have initiated CPR. ADM said all staff was responsible for ensuring code status is followed. ADM said the facility was ensuring that code status is followed by administering a Code Blue, conducting mock drills and closely monitoring code status, proficiency, and related training. Review of facility CPR Certification Log, undated, revealed the DON, ADON, and LVN A were CPR certified. Review of In-service Training Records, dated [DATE], revealed the DON, ADON, and LVN A received training that reviewed printing code status to put in crash cart and compare with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Provider Investigation Report, revealed an Associate Memorandum for a written warning issued on [DATE] to DON, ADON, and LVN A with a date of violation on [DATE] for failure to follow policy and procedure when resident was unresponsive. The written warnings were signed by the DON, ADON, LVN A, ADM, Director of Clinical Services and included the following: Describe in detail information you have available which supports taking the above course of action. State the action that will be taken if the problem persists. Nurse pronounced resident expired, did not perform CPR and did not check code status. Nurse failed to follow physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . State the corrective action the individual may take to eliminate the above problem area: Employee has been in-services by the Director of Clinical Services on proper procedures, including Emergency Procedure - Cardiopulmonary Resuscitation, Automatic External Defibrillator, Change in Resident Condition/Status, Mock Code Proficiency, Skill Proficiency AED, and where to locate Code Status in Matrix. Failure to follow policy and procedure will result in further disciplinary action, up to and including termination. Record review of Provider Investigation Report, dated [DATE], revealed a table titled Mock Code Proficiency with correct critical actions to include: 1) Assess patient establish stability - Assess airway, breathing, circulation, determine instability and assess vital signs 2) Call for help - CALL 911 Delegate GET assistance - Call out for help, Delegate staff for help, stay with patient 3) Time patient becomes pulseless - List time: ____ 4) Staff establish unresponsiveness - <30 seconds 5) Code status verified - Full Code or DNR 6) Delegate someone to bring CPR Cart and AED to resident room - CPR Cart in room, AED cart in room 7) Patient positioned/backboard placed - Patient in a flat and supine position 8) Chest compressions started - Time to compress <1 min, no pause for ventilations, compression at rate of 100 per minute, compression hand positioning at the middle-Nipple line on sternum, Recoil, Performs 2 minutes uninterrupted CPR. 9) BLS/CPR - Proper sequence of compressions 10) Bag-Valve Mask - Head/chin tile for jaw thrust, mask positioned correctly, adequate seal, establishes a chest rise, oxygen available if needed 11) Power on AED - Turn On AED MODE, Leave on AED 12) PADS placed - Proper Placement, No interruptions in CPR, proper adult pads 13) Connect pads to defibrillator - No interruptions in CPR, Efficient Connection, Equipment properly working 14) Shock delivered safely - Visual ALL CLEAR check, Verbalize ALL CLEAR Statement 15) Resume CPR CYCLE - 30:2 16) Continued until EMT TEAM arrives - Yes or No Review of Provider Investigation Report, dated [DATE], revealed a table titled, Skill Validation Checklist - AUTOMATED EXTERNAL DEFIBRILLATOR (AED) and included the following: Referenced Procedure: AUTOMATED EXTERNAL DEFIBRILLATOR SKILL The Licensed Staff Member 1. Identify the purpose and protocol for use of AED 2. Verbalizes appropriate and inappropriate situations for use of AED 3. Demonstrates daily maintenance check (green light, pad expiration) 4. Document's equipment check (Emergency Cart Checklist Signature Sheet) .NOTE: Current CPR certification is recommended Review of facility policy, titled Emergency Procedure - Cardiopulmonary resuscitation, revised ,d+[DATE], revealed the following: Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden [CONDITION(S)]. General Guidelines 1. Sudden [CONDITION(S)] is a loss of heart function due to abnormal heart rhythms (arrhythmias). [CONDITION(S)] occurs soon after symptoms appear. It is a leading cause of death among adults. 2. A heart attack refers to impaired blood flow to the heart. Which leads to damage of the heart muscle. A heart attack can cause sudden [CONDITION(S)]. Typically, heart attacks are less sudden than SCA. 3. Victims of [CONDITION(S)] may initially have gasping respirations or may appear to be having a [CONDITION(S)]. Training in BLS. 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) 7. If the resident's DNR status in unclear, CPR will be initiated until it is determined that there is a SNR or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 8. If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. Preparation for Cardiopulmonary Resuscitation 1. Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitation efforts, including non-licensed personnel. 2. 2. The facility's procedure for administering CPR shall incorporate the steps covered in 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. 3. Provide periodic Mock Codes (simulations of an actual [CONDITION(S)]) for training purposes. 4. Provide information on CPR/BLS policies and advance directives to each resident/representative upon admission. Emergency Procedure - Cardiopulmonary Resuscitation 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [CONDITION(S)] is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events. 2. Initial BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. All rescuers, trained or not, should provide chest compressions to victims of [CONDITION(S)]. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 4. When the AED arrives, assess for need and follow AED protocol as indicated. 5. Continue with CPR/BLS until emergency medical personnel arrive. Review of facility policy, titles Advance Directives, dated [DATE], revealed the following: Policy: Advance directives will be respected in accordance with state law and facility policy. Procedure: .7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive . 18. The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). 19. Changes or revocations of a directive must be submitted in writing to the Director of Nursing or designee. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. 20. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. 21. The Nurse Supervisor will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. Review of facility policy, dated [DATE], titled Change in Resident Condition or Status revealed the following: Policy: Our facility shall notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. (e.g. changes in level of care, billing/payments, resident rights, etc.) Procedure: 1. The nurse will notify the resident's Attending Physician, or physician on call when there has been a(an): a. Accident or incident involving the resident Review of facility policy, no date, titled Automatic External Defibrillator, Use and Care of revealed the following: Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR), including defibrillation, for victims of sudden [CONDITION(S)]. Policy Interpretation and Implementation 1. During a sudden [CONDITION(S)] event, follow guidelines outlines in the procedure for Cardiopulmonary Resuscitation. 2. If an individual (resident, visitor, staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR immediately unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis). 3. The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected. Recognizing the signs and symptoms of arrhythmia (and when to use the AED) is part of the CPR/BLA training. Record review of A publication by the American Heart Association at https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_ 6.pdf, accessed [DATE] at 2:50 p.m., indicated .Immediate cardiopulmonary resuscitation (CPR) and early defibrillation, with and automated external defibrillator (AED), can more than double a victim's chance of survival. In fact, early defibrillation, along with CPR, is the only way to restore the victim's heart rhythm to normal in a lot of cases of [CONDITION(S)]. For every minute that passes without CPR and defibrillation, however, the chances of survival decrease by ,d+[DATE] percent. The 2020 update of AHA's Heart Disease and Stroke Statistics show that 23% of out-of-hospital cardiac arrests are shockable.

Based on observation, interview and record review, the facility failed to ensure personnel had the ability to provide basic life support care prior to the arrival of emergency medical personnel. The facility did not maintain a working automated external defibrillator (AED - used during sudden [MEDICAL CONDITION]) for use in the administration of CPR. The facility did not have a staff who was CPR certified available at all times. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:35 p.m. While the IJ was removed on [DATE] at 4:25 p.m., the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents who had a full code status at risk of death. Findings included: An Advance Directives and Code Status Report dated [DATE] indicated 36 residents wished to be resuscitated in the event of [MEDICAL CONDITION]. During an observation on [DATE] at 11:00 a.m., the only available AED for the facility did not display a green illuminated light indicating readiness for use. The surveyor did not hear the AED alarming at this time. The owner's manual for the Philips HeartStart AED, the facility's AED, dated [DATE], recommended routine maintenance, including: .periodically checking the green Ready light . if the green Ready light is not blinking see Troubleshooting Tips . Replace any used, damaged, or expired supplies and accessories . Record each periodic check in an inspection log .If the Ready light is off, the Onsite (AED) is emitting a series of single chirps, and the i-button is flashing, a self-test error has occurred, there is a problem with the pads or the battery power is low. Press the i-button for instructions . During an observation and interview on [DATE] at 11:15 a.m., the DON removed the AED from the case. The AED was showing a blue illuminated light labeled i and emitting a chirping noise at regular intervals. The DON said she was not sure why the blue i light was illuminated and did not know who was responsible for conducting readiness checks on the AED or documenting those checks. The DON said she was not aware that the AED was not ready for use. During an interview on [DATE] at11:20 a.m., the administrator said the maintenance department was responsible for checking the AED and documenting the results. During an observation and interview on [DATE] at 11:30 a.m., the DON pressed the blue information button and the AED emitted a verbal prompt to insert fresh battery. The green light indicating operational readiness did not illuminate. The DON and administrator said after consulting with their corporate representatives they learned that checking the AED was the responsibility of the nursing department, and they were looking for the spare battery. The DON said there were no records indicating the AED was being checked for operational readiness. The DON said she did not know how long the AED battery had been low. During an interview on [DATE] at11:40 a.m. the administrator said the facility did not have an extra battery and provided a purchase order indicating the replacement battery for the AED would be delivered [DATE]. During an interview on [DATE] at 11:45 a.m., the DON said the AED should be checked daily by the 10p-6a nursing staff. During an observation on [DATE] at 1:50 p.m., the AED was hanging on the wall; the green light indicating operational readiness was not illuminated. During an interview on [DATE] at 2:08 p.m., LVN A said she had not received instruction from the facility about how to check the AED, although she had received training from other places she worked. LVN A said if the green light was not on, that usually meant the AED was not functional. During an interview on [DATE] at 3:10 p.m., the DON said the administrator was traveling to a nearby town to get a replacement battery for the AED. During an observation on [DATE] at 3:45 p.m. the AED displayed an illuminated green light indication operational readiness. During a telephone interview on [DATE] at 5:10 p.m., LVN E said she worked the 10p-6a shift. She said she had not received instruction on checking the AED or any type of check off sheet to ensure the AED was operational. During a telephone interview on [DATE] at 5:11 p.m., LVN F said she worked the 10p-6a shift. She said she had never used the AED, and the facility had not instructed her on required checks of the AED. During an interview on [DATE] at 9:30 a.m., the DON said CPR included the use of the AED. She said if a resident experienced [MEDICAL CONDITION] during the time the AED was not functional, the facility would not have been able to provide full and complete CPR. The DON said the facility did not have documentation of any AED checks for operational readiness being completed. A purchase order dated [DATE] (after surveyor intervention) indicated the facility ordered a replacement battery for the AED and the projected delivery date was [DATE]. The owners manual for the Philips HeartStart AED, used by the facility, dated [DATE] indicated: .The Ready Light (green) tells you the readiness of the HeartStart. If the light is off the AED needs attention . The Information Button (blue, labeled I) flashes when it has information you can access by pressing it . The beeper chirps to alert you when it needs attention . The battery is non-rechargeable . The only effective treatment for [REDACTED]. During a telephone interview on [DATE] at 3:30 p.m., LVN G said she had responded to an unresponsive resident at the facility on [DATE]. She said she had initiated CPR and used the AED but was unable to revive the resident. LVN G said the AED seemed to work fine, although she had never used it before. During an interview on [DATE] at 10:58 a.m., the DON said there was no record of CPR certification for LVN G, and she no longer worked at the facility. The DON said LVN H and LVN I's CPR certifications had expired but had been renewed after surveyor intervention. During an interview on [DATE] at 1:35 p.m., the administrator said the facility did not require all charge nurses be CPR certified, and that a couple of people (unnamed) had expired CPR certifications. The administrator said CPR certifications were supposed to be checked by the Human Resources manager and the ADON when hired and annually. The administrator was unable to provide a system regarding how the facility ensured there were CPR certified staff assigned on each shift. Detail Time Reports Dated [DATE] through [DATE] indicated there was no staff on duty certified to perform CPR on [DATE] from 6:09 p.m. through 9:00 p.m., and on [DATE] from 9:11 p.m. through 9:43 p.m. A policy titled ,[DATE] Charge Nurse Duties dated [DATE] indicated the AED should be checked on the night shift. An undated policy titled Emergency Procedure - Cardiopulmonary Resuscitation indicated early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival but did not include instructions to utilize the AED. The policy indicated if an individual was found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR except in the case of a known Do Not Resuscitate order or obvious signs of irreversible death (e.g., rigor mortis). The policy indicated if the first responder is not CPR certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. The policy indicated in preparation for cardiopulmonary resuscitation: .The facility would select and identify a CPR Team for each shift in the case of an actual [MEDICAL CONDITION] . The CPR Team in this facility shall include at least one nurse, one LVN and two CNAs, all of whom have received training and certification in CPR/BLS . During an interview on [DATE] at 9:58 a.m., Philips AED Technical Support was contacted at 800.263.3342. The Philips representative indicated the Philips Heartstart AED used a battery that was not rechargeable and required replacement once the battery was depleted. The Philips representative said once the battery was low there was no indicator to confirm there was enough power in the battery to deliver therapy. A publication by the American Heart Association at https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_ 6.pdf , accessed [DATE] at 1:50 p.m., indicated .Immediate cardiopulmonary resuscitation (CPR) and early defibrillation, with and automated external defibrillator (AED), can more than double a victim's chance of survival. In fact, early defibrillation, along with CPR, is the only way to restore the victim's heart rhythm to normal in a lot of cases of [MEDICAL CONDITION]. For every minute that passes without CPR and defibrillation, however, the chances of survival decrease by ,[DATE] percent. The 2013 update of AHA's [MEDICAL CONDITION] and Stroke Statistics show that 23% of out-of-hospital [MEDICAL CONDITION] are shockable. The administrator and DON were notified on [DATE] at 4:35 p.m. that an Immediate Jeopardy was identified due to the above failures and the template was provided via email at 5:06 p.m. The facility's plan of removal was accepted on [DATE] at 6:15 p.m., and included: Maintaining Automatic External Defibrillator (AED) *The AED will be monitored daily by the ,[DATE] shift to validate the green light is on, showing the AED is ready for use. *This monitoring will be documented on the AED daily check off form. *If the green light is not solid, then the staff will check the battery or correct placement. Facility will have a backup battery in the AED case to replace if needed. If replacing the battery does not correct the problem, staff will contact the DON or the administrator for further instruction. Education *Staff will be educated during this shift or prior to the start of their next shift on AED daily check off form. *DON or administrator will provide this training today and will ensure all staff nurses are educated by [DATE]. Staff that are on leave or not currently working in the facility will be rained on this process prior to returning to work. *New employees will be educated during orientation of this process and prior to assuming duties. Monitoring *The DON or designee will check documentation daily for two weeks, weekly for two weeks and then monthly until the Quality Assurance Performance Committee deems it no longer necessary. Medical Director *The Medical Director has been notified of the Immediate Jeopardy The DON or designee will present findings to the Quality Assurance Performance Committee monthly for 3 months and then quarterly until the Quality Assurance Performance Committee deems it no longer necessary. Any recommendations will be implemented and monitored until compliance is achieved. Corrective actions will be completed [DATE]. The POR was updated on [DATE] to include: 1. HR will ensure that all patient care nurses are CPR certified upon hire and will monitor monthly for expiration dates. 2. All current nurses will be educated on the importance of current CPR certification and keeping it current. 3. HR and Nursing Administration will ensure that CPR certifications are current and will alert the DON within 30 days of expiration. 4. RN Hobson will not assume a charge nurse role until she is CPR certified. 5. All nurses who serve in a patient care role are currently certified and any new nurses will be required to show certification prior to assuming the floor. 6. A QAPI tool was created to monitor the HR and Nursing Administration portion of this issue. 7. Corrective actions are in place as of [DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on [DATE] at 3:36 p.m., the administrator said the HR manager had gone home ill. The administrator said CPR certifications had been checked for all nurses who provide patient care, and they were current. The administrator said it would be the facility practice to check all CPR certifications for licensed staff upon hire, and that all licensed staff would be required to maintain CPR certification. The administrator said CPR certifications had been entered into the payroll database. The administrator said this would allow the HR manager to run a report monthly to monitor CPR certifications that were nearing expiration. During an interview on [DATE] at 3:53 p.m., RN D said she currently was not CPR certified and would not work on the floor as a charge nurse without a current CPR certification. During an interview on [DATE] at 4:00 p.m., LVN A said she had received an in-service regarding the importance of maintaining a current CPR certification. She said her CPR certification was current at this time. LVN A said she had received an in-service on the AED regarding the requirements for checking the AED, how to tell if the AED was ready to use, and what to do if the green light signaling operational readiness was not illuminated. During an interview on [DATE] at 4:05 p.m., LVN C said she had received an in-service regarding the importance of maintaining a current CPR certification. She said her CPR certification was current at this time. LVN C said she had received an in-service on the AED regarding the requirements for checking the AED, how to tell if the AED was ready to use, and what to do if the green light signaling operational readiness was not illuminated. During an interview on [DATE] at 4:10 p.m., LVN B said she had received an in-service regarding the importance of maintaining a current CPR certification. She said her CPR certification was current at this time. LVN B said she had received an in-service on the AED regarding the requirements for checking the AED, how to tell if the AED was ready to use, and what to do if the green light signaling operational readiness was not illuminated. On [DATE] at 4:25 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent accidents was provided for 1 of 1 resident reviewed for accident (Resident #3). The facility did not implement effective interventions to prevent an elopement for Resident #3 who had a history of [REDACTED]. The facility did not have all alarms on the doors turned on, resulting in Resident #3 eloping without staff knowledge from the facility on 7/24/20. Resident #3 was missing for at least one hour before he was found outside at 11:50 p.m. in his wheelchair, stuck in the mud, and drenched in sweat. This was determined to be past non-compliance that existed from 7/24/20 and was corrected on 7/28/20 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for injury and elopement. Findings included: Physician orders [REDACTED].#3 was a [AGE] year-old male, admitted [DATE], and had [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 had severe cognitive impairment. Resident #3 was independent with locomotion on and off the unit, required limited assistance with eating, toileting, and personal hygiene, required extensive assistance with bathing and dressing and had wandering episodes 1-3 times. An Event Report dated 12/31/2019 at 4:46 a.m. indicated Resident #3 successfully eloped in the past, no interventions were taken, and no interventions were necessary. Nurse documentation indicated Resident #3 went down hall 1 and opened the back door sounding the alarm in an attempt to leave the facility. When asked where he was going, he said he was leaving. It was noted that Resident #3 was fairly easy to redirect resident at this time. The report indicated Resident #3 did manage to get half of his wheelchair outside of the exit door. An evaluation note on the report indicated Resident #3 was evaluated for the need for placement on the secured unit. During an interview on 8/4/2020 at 10:00 a.m., the Social Worker said Resident #3 went to the doors and attempted to exit the facility occasionally and was easily redirected. The Social Worker said she was not sure if Resident #3 had been evaluated for the secured unit because he was easily redirected. During an interview on 7/31/2020 at 9:45 a.m., the administrator said Resident #3 had a TBI ([MEDICAL CONDITION]) from a previous car accident. She said Resident #3 He has attempted to elope maybe twice. She said she did not want to move Resident #3 to the secured unit, as wheeling around the facility was all he did, and she did not want to take that away from him. The administrator said Resident #3 would not fit in well on their small unit and would have to be moved to a bigger unit. A care plan initiated 1/14/19 indicated Resident #3 wandered throughout the facility and would open the exit doors. The care plan interventions included re-direct him as needed. He knows where his room is and will usually easily go to his room instead of other resident' room or outside. This care plan was updated on 7/27/20 to reflect a new intervention of will assess for new alarms on exit doors. An Event Report dated 7/24/2020 at 11:50 p.m. indicated Resident #3 was found behind the laundry building at 11:50 p.m. The report indicated Resident #3 had a history of [REDACTED]. A resident progress note dated 7/25/2020 at 12:05 a.m., indicated Resident #3 was not in his room when LVN K made rounds to check on the residents. The note indicated all staff assisted in searching for Resident #3 inside the facility for approximately 1 hour. Resident #3 was found outside behind the laundry building at approximately 11:50 p.m. Resident #3 was sitting in his wheelchair, which was stuck in the mud. The progress note indicated LVN K helped the resident out of the mud and back inside the building. LVN K then assessed Resident #3, and he was drenched in sweat, with no injuries or pain noted. During an interview on 8/4/2020 at 9:15 a.m., Resident #3 said he had no recollection of the evening he went outside the facility and got his wheelchair stuck in the mud. He said he enjoyed wheeling around the facility. During an interview on 8/3/2020 at 10:30 p.m., LVN K said she was assigned to Resident #3 on 7/24/20 when he was missing and found outside. She said she was making rounds after receiving report at 10:00 p.m. and saw Resident #3 was not in his room. She said she finished making her rounds because she thought he went to the dining room to drink coffee, as he frequently did. She said once she completed her rounds at approximately 10:40 p.m., she saw Resident #3 was not in the dining room. LVN K said she thought it was about 10:40 p.m. when she realized Resident #3 was missing. She said she and CNAs L and M spent an hour inside the facility searching for Resident #3. LVN K said when Resident #3 was not found inside, LVN K went outside to look for the resident. LVN K said, she saw Resident # 3 was sitting in his wheelchair and had his leg raised, and the resident said, I'm stuck. LVN K said she pulled Resident #3's chair out of the mud and assisted him back into the facility. She said she assessed him from head to toe. She said the resident was sweating, but had no visible injuries. LVN K said she did not hear any alarms go off while Resident #3 was missing. She was not aware of Resident #3 having any previous elopement attempts. LVN K said Resident #3 often told the staff he wanted to go home, and he wanted to get in his truck, which was not at the facility. LVN K said she had previously mentioned to someone that Resident #3 needed to be screened for the secured unit, but nothing was ever done. LVN K did not recall who she mentioned this to During an interview on 8/4/2020 at 9:15 a.m., CNA L said on 7/24/2020, LVN K asked her for help looking for Resident #3. She did not recall the time LVN K came to her to ask her for help. CNA L said Resident #3 wandered around the facility in his wheelchair and in the dining room. CNA L said she did not remember Resident #3 eloping from the facility prior to this incident CNA L said CNA M helped the resident bathe and changed his clothes after the elopement incident. Said she could not remember what time he was last seen in his room, or what time he went missing. During an interview on 8/4/2020 at 9:33 a.m. CNA M said on 7/24/20 she thought she was the one who noticed Resident #3 was not in his room, but she did not recall what time that was. She said her, CNA L, and LVN K looked in all the rooms and the bathrooms. She said CNA L and LVN K went outside and found the resident. She said Resident #3 seemed fine when he came back inside. Said she helped the resident bathe and changed his clothes after the elopement incident. CNA M said she was not sure what door Resident #3 exited. She said Resident #3 had set the door alarms off before a couple of times and tried to get out of the facility, but she was not aware of the resident eloping prior to this incident. Said she could not remember what time he was last seen in his room, or what time he went missing. During an observation on 8/3/20 at 10:45 a.m., the back door in the dining room (the door the facility suspected Resident #1 eloped from) lead to an uneven cemented area with numerous cracks. The area led to a short gravel road which had to be crossed to get to the laundry area which was approximately 50 yards from the facility. The area around the laundry had dirt for the covering with small patches of grass. During a telephone interview on 8/17/20 at 3:22 p.m., the maintenance director said the laundry room was approximately 50 yards from the dining room door. During an interview on 7/31/2020 at 9:45 a.m., the administrator said Resident #3 eloped from the facility on 7/24/20 and was missing for approximately an hour. The administrator said Resident #3 was moved to Hall 3 on 8/2/2020 after he wandered onto hall 3 (a unit designated for quarantined residents due to possible COVID exposure). The administrator said alarms are on all the units to notify staff of residents leaving. She said the one in the dining room was found to have been shut off after Resident #3's elopement, but no one knew who shut the alarm off or how long it had been shut off. The administrator said the LVN working was not sure of the time Resident #3 was last seen in his room, and the CNA thought it was around 9:45 p.m. The administrator did not specify which CNA gave him that timeframe. The administrator said Resident #3 was found around midnight. She said the resident's wheelchair was stuck in the mud by the laundry facility. She said this will be going to the Quality Assurance for review on August 23, 2020. During an interview on 8/4/2020 at 10:00 a.m. the Social Worker said she was not aware of any previous elopement involving Resident #3. An undated Missing Resident policy stated, . the charge nurse shall be responsible for documenting the incident in the nurses notes of the resident's chart. All documentation must be concise and reflect the actual facts as they relate to the incident including: times, persons contacted condition of resident upon return to the facility, physician notification and orders, treatment indication and any other pertinent information. It was determined these failures placed Resident #3 in an Immediate Jeopardy situation from 7/24/20 to 7/28/20. The facility took the following actions to correct the non-compliance on 7/28/20: During an interview on 8/4/2020 at 3:00 p.m. The administrator said the maintenance man checked the dining room alarm on 7/28/20 and the alarm was not working. He discovered it had been shut off, but then he turned it on and it worked fine. The Record of Alarm testing dated 08/4/2020 indicated all alarms were working on the following days: 7/3, 7/9, 7/16 and 7/31/2020. Observations of facility door alarms on 8/4/2020 at 9:00 a.m. indicated the alarms on halls 1-4 and the dining room alarms were functioning. The door to hall 5 (the secured unit) would not open unless a code was put into the keypad on the wall. The facility's provider investigation report (PIR) dated 8/1/2020 indicated the incident occurred on and was reported to the state on 7/25/2020. The facility performed a prompt investigation of the incident, including obtaining statements from all available witnesses and took appropriate action to protect the residents during the investigation. The PIR indicated the administrator assessed the physical environment and noted that there were 2 different types of alarms on the hallway exit doors which made it difficult to determine which type of alarm was sounding. Maintenance staff checked the doors on 7/28/2020 and found the dining room door alarm to be disarmed. Due to the location of this door and the patterns of Resident #3 (he drinks a lot of coffee and snacks in the dining room a lot,) it is presumed this could be the door he exited from. It is the closest exit to the laundry area that may have allowed him to get to a muddy area. This resident pushes himself backwards most of the time which would reasonably conclude why he was not aware of where he was going. The PIR indicated maintenance has purchased and received the replacement alarms to allow for all alarms to operate the same and use the same key to activate, and to allow for nursing to better be able to locate the key and to have an alarm that is more user friendly. It was noted the alarm is simple to tell if it is activated or not. The PIR indicated actions taken after the facility's investigation included the following: Staff will be trained on what to do in the event of a missing resident, go on walking rounds at the end of each shift to allow for all residents to be accounted for at the end of shift changeover, trained on the new door alarms and how to ensure that they are always on. Maintenance will monitor the alarms once a day Monday-Friday and RN supervisor or designee will monitor on Saturday and Sunday. Additional barriers will be placed as a visual cue for this particular resident as he has frequent behaviors at which time he is looking for his car. An employee sign in sheet dated 7/31/2020 showed staff had training on exit seeking vs elopement, using the correct terminology, what to do when unable to locate a resident, and upon return of the resident. Staff was also trained on the new alarms, and informed that they have to stay on all the time. During an interview on 8/4/2020 at 3:45 p.m., the facility was asked for additional information at exit, no additional information was provided.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 6 residents reviewed for accidents. (Residents #1, #2, #3, #4, #5, and #6). The facility did not adequately intervene to prevent an accident, when Resident #1, who had a history of [REDACTED].#2 out of his wheelchair. As a result of Resident #1's uncontrolled aggression, Resident #2 sustained multiple acute lumbar compression fractures. Residents #3, #4, #5 and #6 were fearful of Resident #1. An Immediate Jeopardy situation was identified that existed from 9/21/17 to 9/25/17. The Immediate Jeopardy was identified on 10/10/17 and was removed on 10/11/17. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective measures. This failure could place the census of 55 residents at risk of injuries due to residents with mental illness not being properly supervised when displaying behaviors. Findings included: A history and physical from the local hospital dated 06/08/17, indicated the local police found Resident # 1 on the street in urine and stool, and exhibiting behaviors of paranoia and hallucinations. The police took him to the hospital. The note indicated he had a history of [REDACTED]. The note indicated Resident #1 was combative, paranoid and having hallucinations. The note indicated the resident tested positive for cocaine, marijuana and phencyclidine (PCP), and would be transferred to an inpatient psychiatric hospital. A note from the local behavioral hospital dated 6/16/17 indicated Resident #1 was admitted to the behavioral hospital on [DATE] and discharged to the local nursing facility on 06/16/17. A discharge summary from the local behavioral hospital dated 06/16/17 indicated Resident #1's [DIAGNOSES REDACTED]. The discharge note indicated Resident #1 received a referral for addiction treatment. Discharge medications included Seroquel 150 mg at bedtime, and to discontinue Geodon 20 mg twice daily. A face sheet dated 06/29/17 indicated Resident #1 was admitted on [DATE] from a local behavioral hospital. He was a [AGE] year old male, with [DIAGNOSES REDACTED]. Electronic nursing notes dated 06/18/17 at 11:23 a.m. indicated Resident #1 was talking to non-existent people, and removed his clothing. All attempts to redirect the resident were ineffective. The resident exhibited explosive behavior, and threatened staff and residents with kitchen utensils, and pointed a knife at residents in a threatening manner. The NP was notified, and new orders received. A telephone order dated 06/18/17 indicated Resident #1's physician ordered Seroquel (antipsychotic) 50 mg to be given daily at 8 a.m. and 2 p.m., and Geodon (antipsychotic) 20 mg twice daily with meals. Electronic nursing notes dated 06/18/17 at 2:02 p.m. indicated Resident #1 had explosive outbursts toward other residents and staff, and he threatened to kill everyone here. Multiple attempts to calm Resident #1 were ineffective. Resident #1 told staff he wanted to leave, and his behaviors continued. Law enforcement was notified. The note indicated Resident #1 was to be placed on one on one monitoring, to protect the residents' safety. There was no further documentation regarding the 1:1 monitoring. Electronic nursing notes dated 06/18/17 at 2:20 p.m. indicated the local police arrived, and were given information regarding Resident #1's mental status, and his hostile, aggressive, combative behavior, and threats to kill staff. The note indicated the police notified the local mental health authority, who advised the facility they would need to obtain an emergency mental health warrant. The note indicated the facility was given the contact information for a local judge to secure the warrant. The DON and administrator were notified concerning Resident #1's situation, and given instructions for obtaining the mental health warrant. The note indicated the administrator would contact the social worker for completion of paperwork. Electronic nursing notes dated 06/18/17 at 4:23 p.m. indicated Resident #1 became polite and courteous when the local police arrived, and denied any issues. The note indicated the charge nurse on duty asked Resident #1 if something was wrong, and Resident # 1 became irritated. The police spoke with the charge nurse and said You are not going to get him riled up so he can hit you. We are not going to play that game. The paperwork needed to secure the emergency mental health warrant was not completed. A nursing note dated 06/19/17 at 12:58 p.m. indicated Resident # 1 grabbed a fork and threatened an aide, saying he was going to stab her. The resident was re-directed by a male staff member. A PASRR Level 1 screening, dated 06/19/17 was completed by the local behavioral hospital, and indicated Resident # 1 had mental illness. During an interview on 10/10/17 at 10:06 a.m., the social worker said the PASRR Level 1 was done at the local behavioral hospital, and Resident #1 did not trigger for a Level 2 PASRR evaluation, although he was positive for mental illness. A care plan initiated on 06/23/17 indicated Resident # 1 exhibited alterations in mood and behaviors as evidenced by his making animal sounds, fidgeting, yelling, cursing, drinking his own urine, and urinating in inappropriate places due to his schizophrenia. Interventions included referrals to psychiatric services as needed with exacerbation or inability to redirect behavior, remove from common areas during times of unacceptable behaviors, social service visits as needed, and 1:1 supervision as needed. A telephone order dated 06/23/17 required an increase of Resident #1's Geodon dose to 40 mg by mouth twice daily. A telephone order dated 06/29/17 indicated Resident # 1 was to have a psychiatric evaluation and treatment by the local psychologist. A nursing note dated 07/04/17 at 6:22 p.m. indicated another resident notified staff Resident # 1 was cursing, and accusing everyone of stealing his cigarettes on his smoke break. The note indicated staff tried to talk with Resident # 1. The resident became extremely agitated and continued cursing. Resident # 1 refused to come inside. The staff could not redirect the resident. A staff member was able to get Resident # 1 to come into the facility, and noted Resident #1 made threatening throat cutting gestures towards the staff and other residents, scaring the residents. The administrator was notified. A physician order [REDACTED].#1 had psychotic symptoms, delusions, hallucinations, and incoherence. A response notification dated 7/21/17 at 12:23 p.m. indicated Resident # 1's referral for psychological services was denied because Resident #1's Medicare coverage did not include coverage for psychiatric services. During a telephone interview on 10/10/17 at 12:07 p.m., the local psychologist said he attempted to see Resident # 1 when he learned the facility was seeking a psychological referral, but was unable to speak to him because Resident # 1 was uncooperative. He said after the referral was denied, he did not attempt to see Resident # 1 anymore. The psychologist said he notified the DON and social worker that he was unable to see Resident # 1. He said he did not document his attempt to visit with Resident #1 because there was nothing to document. During an interview on 10/10/17 at 10:46 a.m., the social worker said the facility did not keep a list of residents who received in-house psychiatric services. The social worker said she was responsible for processing the referrals. She said she was unaware Resident # 1 was denied psychiatric services. She said she did not follow up on referrals. The social worker said there were no systems in place to ensure there was follow-up on referrals. During an interview on 10/10/17 at 11:14 a.m., the DON said she was unaware that Resident # 1 was not seen by psychiatric services. She said the social worker was responsible for following up with referrals. The DON said the facility did not have a policy on monitoring residents with behaviors, and said there was no additional documentation concerning supervision and monitoring of Resident # 1. During an interview on 10/10/17 at 11:30 a.m., the administrator said she was unaware Resident # 1 was not seen by psychiatric services. An update to Resident #1's care plan, dated 08/2017 indicated Resident #1's inappropriate behaviors had decreased and he was doing well, with no change in interventions noted. The most recent MDS dated [DATE] indicated Resident #1 was moderately cognitively intact (BIMS 11). The MDS indicated he was independent with activities of daily living. The MAR for 09/08/17 indicated Resident #1 missed his antipsychotic medications at 4:00 p.m. - Geodon 40 mg., and Seroquel 50 mg (one tablet), and 8:00 p.m. - Seroquel XR 150 mg (one tablet). A nursing note dated 09/21/17 at 4:42 pm indicated Resident #1 had increased agitation that day, and was calling names and starting arguments with others. The note indicated Resident #1 had delusional thinking. Resident #1 said he was Jesus and was marking his arms for drug use with a pen. All attempts to redirect the resident were unsuccessful. The note indicated the NP was contacted and new orders received. Resident #1 was calmer after 1-2 hours. A telephone order for Resident #1 dated 09/21/17 indicated he was to receive Klonopin (for seizure disorders or panic disorder) 1 mg twice daily and every six hours as needed due to his increased agitation. A nursing note dated 09/21/17 at 8:35 p.m. indicated Resident #1 was outside the facility at the picnic table, was yelling out, throwing a trash can and the cigarette ashtray into the road. The note indicated Resident #1 lay on the ground, hitting his forearms and said it is time for my medication. The note indicated the resident was assisted into a wheelchair, back into the facility. Resident #1 then began rolling through the hallways, touching door knobs, carts, and knocking on walls. CNAs were doing rounds on halls and reported Resident #1 was putting trash can lids on his head. Staff redirection was not effective, and Resident #1's PRN medication was administered. During an interview on 10/09/17 at 2:33 p.m., LVN D said on 09/21/17 Resident # 1 was outside the facility, and was throwing ashtrays, chairs and trash cans. She said Resident # 1 then rolled down the hallways, knocking on other residents' doors. She said another resident reported Resident # 1 was outside throwing things. She said Resident # 1 was redirected to his room. LVN D said no special monitoring was started for Resident #1. There was no incident report for Resident #1's behaviors on 09/21/17. The MAR for 09/21/17 indicated Resident #1 did not receive his antipsychotic medications at 4:00 p.m. (Geodon 40 mg., and Seroquel 50 mg) and at 8:00 p.m. - Seroquel XR 150 mg. A note, signed by the ADON, dated 09/22/17 indicated he (the ADON) was called to Resident # 2's room due to an argument between two residents. The ADON redirected the two residents, and asked Resident # 1 to leave Resident #2's room. The administrator was contacted. During an interview on 10/09/17 at 4:25 p.m., the ADON said he worked the night of 09/22/17 on the night shift. He said when he arrived at the facility, Resident #1 was in Resident # 2's room, yelling at Resident # 2. The ADON said he redirected Resident #1 to his room. He said Resident #1 came back out of his room between 2:00 a.m. and 3:00 a.m., and was staring at another resident, trying to provoke the other resident. The ADON said he did not know why Resident # 1 was not on 1:1 monitoring. The MAR for 09/22/17 indicated Resident #1 did not receive his antipsychotic medications at 8:00 p.m. (Seroquel XR 150 mg). A nursing note dated 09/23/17 at 12:02 a.m. for a late entry for 5:00 p.m. indicated Resident # 1 continued to exhibit behaviors, was cursing at other residents and staff, hallucinating, and accusing other residents of taking his belongings. The note indicated Resident #1's routine Klonopin was given. A nursing note dated 09/23/17 at 12:07 a.m. indicated Resident #1 walked into Resident #2's room and began arguing with him, threatened other residents, and said he did not give a damn about anyone calling the cops on him. The note indicated Resident #1 was redirected to his room, and calmed down. A nursing note dated 09/23/17 at 1:45 p.m. indicated Resident #1 was in the facility in his wheelchair, both inside and outside the facility. The note indicated Resident #1 was very talkative with staff and residents about drugs and drug use. The note indicated Resident #1 was gathering things such as trash to give to staff as presents, was tapping on walls, and exhibiting obsessive compulsive behavior ((NAME)D). An incident report dated 09/23/17 at 2:30 p.m. indicated Resident # 1 was in the smoking area and had an altercation with another resident. The report indicated Resident # 1 pushed the other resident over, causing him to fall from his wheelchair. The incident follow up report indicated there was no injury. Edema was noted to Resident #1's left lower extremity (ankle). Resident #1 was transferred to a local hospital at 5:00 p.m. and was diagnosed with [REDACTED].# 1 was monitored for behaviors during smoke breaks and in the dining area. The report indicated on 09/25/17, Resident #1 discharged to the local behavioral hospital. According to the clinical records Resident # 2 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident # 2 was moderately impaired for decision making and he required extensive assistance with ADLS, including locomotion on and off the unit by one staff member. During an interview on 10/09/17 at 10:34 a.m. Resident # 2 said Resident # 1 was outside making animal sounds, then Resident # 1 stood up and hit him, causing him to fall out of his wheelchair, and break his back. He said the incident was unprovoked, and no staff were present during the incident. He said Resident # 1 would often yell and curse, and he tried to just stay away from Resident # 1. An incident report dated 09/23/17 at 2:30 p.m. indicated Resident # 2 was sitting in his wheelchair in the smoking area when Resident #1 pushed Resident # 2 out of his wheelchair on to the ground. The report indicated the residents were separated and EMS was called to transfer Resident # 2 to the local hospital for evaluation. The report indicated Resident #2 had abrasions to his right hand, knuckles, and elbow. The report indicated Resident # 2 was transported to local hospital at 3:00 p.m., the physician and family were notified. A care plan update on 09/23/17 indicated Resident #1 assaulted another resident, and the intervention included to transfer Resident #1 to a local hospital for psychiatric evaluation. A provider investigation report dated 09/29/17 indicated Resident # 2 was sitting outside in his wheelchair when Resident #1 started a verbal altercation with him, and pushed Resident # 2 from his wheelchair, causing Resident #2 to hit his head on the concrete. The response indicated Resident # 1 was transported to the local hospital, and when Resident #1 returned to the facility, staff monitored Resident # 1 at all times until he was admitted to the local behavioral hospital on [DATE]. During a telephone interview on 10/09/17 at 11:48 a.m., CNA F said on 9/23/17, she was going on break with Resident # 3. She said as she approached the smoking area with Resident #3, she heard Resident # 1 yelling at Resident # 2. She said she told Resident # 3 to go get the nurse. CNA F said before she could get out of the doors, she saw Resident # 1 push Resident # 2 out of his wheelchair. She said had not heard Resident # 2 say anything to Resident # 1 prior to the incident. CNA F said Resident # 2 was at a table with his head lying on the table. CNA F said she checked on Resident # 2, and Resident # 1 said Resident # 2 had fallen out of his chair, and said he must be drunk. CNA F said she only worked weekends. She said Resident # 1 displayed aggressive behaviors prior to the incident on 9/23/17. She said the prior weekend before the incident, Resident # 1 was in the dining area, throwing silverware at other residents. She said staff called the police on Resident # 1 prior to the incident. CNA F said staff tried to redirect Resident # 1 when he acted out, and other residents were afraid of Resident # 1, and said he would try to bully staff and other residents. CNA F said she had no knowledge of any special supervision requirements or increased monitoring for Resident # 1. CNA F said she was never instructed to provide increased supervision for Resident #1. During a telephone interview on 10/10/17 at 11:41 a.m., LVN G said she was the nurse on duty on 9/23/17, the day of the incident between Resident #1 and Resident #2. She said CNA F and Resident # 3 were screaming that Resident # 1 had pushed Resident # 2 out of his wheelchair. She said upon arriving outside to the smoking area, Resident # 2 was lying on the concrete ground, and Resident # 1 was sitting by him. She said she asked Resident # 1 to go inside the facility at that time. She said Resident # 2 was assessed and sent to a local hospital. She said Resident # 2 told her that Resident # 1 starting screaming at him and pushed him over. She said she noticed swelling to Resident # 1 left foot, and he agreed to go to the hospital for evaluation. She said staff tried to keep a visual watch on him. LVN G said she was told in report that if Resident # 1 had any behaviors, she was to call the local police. LVN G said she only worked the weekends at this facility. She said she had not been instructed to provide any special monitoring or supervision for Resident # 1 due to his behaviors. A face sheet dated 10/11/17 indicated Resident # 3 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident # 3 was cognitively intact with a BIMS of 15 and was independent with ADLs. During an observation and interview on 10/09/17 at 11:30 a.m., Resident # 3 appeared visibly anxious and tearful when she talked about Resident # 1, and said he was a time bomb. She said about a week prior to the incident, Resident # 1 threw an ashtray at her and called her a [***] . She said she asked LVN C to watch her hall where both she and Resident #1 lived. Resident #3 said she was afraid of Resident # 1 and felt she was in danger, and said Resident # 1 was going to hurt someone. She said she also reported the incident to the social worker and the social worker offered Resident #3 an opportunity to move to another hall. She said Resident # 1 was on a tear on 9/23/17, the day of the incident. Resident #3 said she and CNA F were going out to the smoking area the day of the incident. She said Resident # 1 and Resident # 2 were in the smoking area. No staff were present. Resident #3 said she could hear Resident # 1 yelling and cursing at Resident # 2 as they approached the area. She said CNA F asked her to go get the nurse, as CNA F was rushing to get to Residents #1 and #2. She said CNA F yelled that Resident # 1 had pushed Resident # 2 out of the wheelchair. She said the same night after the incident, at some time after 10:00 p.m., Resident # 1 came out to the smoking area while she was there. Resident #3 said no staff was present. Resident #3 said Resident # 1 told her he was going to kill her and cut her throat. She said she immediately started trying to wheel herself inside of the building and Resident # 1 was behind her yelling and cursing at her. She said she did not feel safe, and felt she was in danger during the time Resident # 1 was in the facility. She said she reported the incident to staff, but she did not feel anything was done after she reported it. A local hospital report dated 09/30/17, indicated on 09/23/17, Resident # 2 was at the nursing facility and a man took him out of his wheelchair and beat him up. The report indicated Resident # 2 got hit and knocked out of his wheelchair. An MRI was done on 09/24/17 and showed multiple acute compression fractures of the L3 and L4 vertebrae, with a burst fracture at L2. A SBAR (Situation, Background, Assessment, Recommendation) communication form dated 09/23/17 at 5:00 p.m. indicated Resident # 1 assaulted another resident. The communication form noted Resident #1 had edema to his left lower extremity. The document indicated Resident #1 would be transferred to a local hospital. A hospital report dated 09/23/17 indicated Resident #1 was admitted with complaints of ankle injury and psychiatric problems. The document indicated Resident #1 had an altercation with another resident. Resident #1 denied any suicidal or homicidal ideations, and answered questions appropriately. There was concern with Resident #1's previous history of drug use. The report indicated there was no indication for emergent intervention or admission. The MAR for 09/23/17 indicated Resident #1 did not receive his antipsychotic medications at 4:00 p.m. (Geodon 40 mg.). Discharge orders from the hospital dated 09/23/17 at 10:45 p.m. indicated Resident #1 had DVT with orders to follow up with primary care physician in 1 to 2 days. The MAR for 09/24/17 indicated Resident #1 did not receive his 10:00 a.m. dose of Klonopin 1 mg. A nursing note dated 09/24/17 at 8:59 p.m. indicated Resident #1 continued aggressive behaviors throughout the shift. Resident #1 yelled out threats, threw water, and hit himself in his head and face. Staff assisted with 1:1 as much as possible to keep Resident #1 calm and safe. A social worker's note dated 09/25/17 at 10:26 a.m. indicated the social worker contacted the local behavioral hospital for admission due to Resident #1's current behaviors. He was accepted for admission to the behavioral hospital. A nursing note dated 09/25/17 at 4:30 p.m. indicated Resident #1 was on 15 minute monitoring for behaviors and was discharged to the local behavioral hospital at 3:30 p.m. A 15 minute surveillance log indicated Resident #1 was monitored every 15 minutes on 09/25/17 from 6:00 a.m. to 3:30 p.m., but no entries were made at 6:45 a.m., 9:30 a.m., 10:15 a.m., 12:45 p.m., or 1:15 p.m. During an interview on 10/10/17 at 10:51 a.m., LVN A said she started the every 15 minutes monitoring sheets on 09/25/17. She said no one had instructed her to do so, but due to her experience as a nurse, she just knew to do it. She said prior to the incident on 09/23/17 Resident # 1 said he was Jesus and was asking for drugs. LVN A said she notified the NP, but no special monitoring was put in place. During an interview on 10/09/17 at 1:10 p.m., LVN C said Resident # 1 had episodes of bizarre behavior. He said residents were afraid of Resident # 1 because he was very intimidating, threatened he would kick your ass, expose himself, and was loud and hostile. He said Resident # 1 could present a danger to others, was over 6 feet tall, and said some female residents said they were afraid of Resident # 1. During a telephone interview on 10/09/17 at 1:14 p.m., the social worker said a female resident expressed concerns about Resident # 1, saying she felt uncomfortable around him. She said Resident # 1 agreed to go to the local behavioral hospital after the incident. She was not aware of any special precautions or monitoring for Resident # 1 prior or after the incident. During an interview on 10/09/17 at 2:14 p.m., the DON said she was notified on 09/22/17 that Resident # 1 that on 09/21/17 Resident # 1 was throwing things. She said from the time Resident #1 was admitted to the facility, he had outbursts where he yelled and cursed at staff. She said the behavior was not directed toward anyone. During an interview on 10/10/17 at 1:37 p.m., the NP said she reviewed the clinical records from the local behavioral hospital prior to Resident #1's admission in June, and did not see anything that was cause for alarm. She said she, and the administrator agreed to accept Resident # 1 in the facility. She said Resident # 1 was on a minimal amount of medication. She said when Resident # 1 started having behaviors, she changed his medication and Resident # 1 appeared to be improving. She said she was not aware the psychologist was not seeing Resident # 1. A face sheet for Resident # 4 dated 10/11/17 indicated she was a [AGE] year old female admitted to facility on 12/22/15. Her [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #4 was cognitively intact with a BIMS of 14. The MDS indicated she was independent in all ADLs. During an interview on 10/09/17 Resident # 4 said Resident # 1 would constantly threaten people. She said she was afraid of Resident # 1 and did not feel safe while he was in the facility. She said she had spoken with staff about her concerns and they would just say they were working on his medications. She said Resident # 1 would yell and curse during smoke breaks. She said she would just try and stay away from Resident # 1. She said she felt she was in danger because of the way Resident # 1 would act. She said Resident had acted up since he came to the facility. A face sheet for Resident # 5 dated 10/11/17 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. An MDS dated [DATE] for Resident # 5 MDS indicated she was cognitively intact with a BIMS of 15. The MDS indicated she required supervision with her ADLs. During an interview on 10/09/17 at 12:20 p.m. Resident # 5 said she would try and stay away from Resident # 1 due to she was afraid of him. She said he would constantly yell and curse at staff and other residents. She said she did not feel safe while Resident # 1 was in the facility and felt she was in danger. She said she could not enjoy her smoke break due to Resident # 1 because you never knew what he was going to do. She said she had voiced concerns with staff and was just told they were working on his medication. She said Resident # 1 had been acting out since he came to the facility. A face sheet for Resident # 6 dated 10/11/17 indicated she was [AGE] years old, admitted on [DATE]. Her [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident # 6 was cognitively intact with a BIMS of 13. The MDS indicated she required limited assistance with ADLs. During an interview on 10/09/17 at 12:28 p.m., Resident # 6 said Resident # 1 would threaten residents a lot. She said everyone was afraid of Resident # 1. She said Resident # 1 would curse, yell and spit at people. She said staff would never do anything. She said she felt threatened by Resident # 1 and that she was in danger as long as he was around. Resident # 6 said Resident # 1 would throw silverware at Residents. She said Resident # 1 had been acting up since he came to facility. During an interview on 10/09/17 at 4:49 p.m., the administrator said the facility was aware Resident # 1 had behaviors. She said the NP along with the facility felt Resident # 1 could be managed. She said she was unsure of the monitoring provided to Resident # 1 concerning his behaviors. On 10/10/17 at 4:35 p.m., the administrator, DON, and ADON were notified an Immediate Jeopardy was identified. On 10/10/17 at 6:52 p.m. a Plan of Removal was accepted and included: . 1. All staff will have an in-service on Identifying, Preventing and Managing Aggressive Behaviors before they are allowed to clock in for their next shift. New staff will complete the training before starting to work and it will be repeated quarterly for all staff and as needed. 2. Nurses will be in-serviced by the DON or her designee on Monitoring Aggressive Behaviors, and documenting the behaviors on the 24-hour report, initiating Q 15 minute checks and in the nurse's notes. 3. ( name of local psychiatric services provider ) and the Social Worker have developed a system in which the Client Service Director will e-mail a list each Monday of the residents they have on services and the Social Worker can ensure it is every resident we have with an order for [REDACTED]. All orders for referral to psych service will be discussed in the morning meeting and referrals will be placed on a log to ensure all residents with referrals receive services timely. 4. All residents will be assessed for behaviors and if there are any noted behaviors MD and RP will be notified immediately and interventions will be put in place. The Interdisciplinary Team will discuss any behaviors in the morning meeting 5. All potential admissions will be reviewed by the IDT for appropriate placement into the facility and the administrator / or designee will make the final decision regarding admission. On 10/11/17 it was confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on 10/11/17 at 12:45 p.m., the RQC (Regional Quality Manager) said staff were in-serviced on dealing with aggressive residents, documentation on 24 hour report sheet, initiating monitoring and use of monitoring sheet. She said staff that had not been in-serviced would not be allowed to return to work until they had been in-serviced. She said the DON or designee would audit charts daily for any documented behaviors and record on daily audit sheets. She said administrative staff had been in-serviced on all potential admissions to be reviewed by the IDT team for appropriate placement. She said a social worker kept a log of all referrals made to psych services and follow up. She said the local psych services will fax over list of current residents being seen by the psychologist weekly to ensure residents with orders are being seen. Four LVNs said they had been in serviced on 10/10/17 and 10/11/17 on dealing with aggressive residents, when to implement monitor and documentation. They could identify warning signs of a resident becoming agitated or aggressive. They were able to identify what the new protocol was for implementing monitoring where to document and whom to report it to. Seven CNAs said they had been in serviced on dealing with aggressive residents and when to report to charge nurses and how to monitor. They could identify signs of agitation and aggression and how to attempt to redirect. The RQM (Regional Quality Manager) at 2:50 p.m. provided documentation of staff training. She said all charts were reviewed 10/11/17 for documented behaviors by the DON and provided a daily audit for resident behaviors and monitors. She said there were no pending admission and provided signed in service by administrative staff on process for potential admissions. She said all current referrals and orders to the in house physiologist were audited to ensure services were provided. During an interview on 10/11/17 at 2:55 p.m. the administrator said she would monitor to ensure all corrective measures were f(TRUNCATED)

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures to prohibit abuse and neglect for 1 of 6 residents reviewed for abuse. (Residents #1, #2, #3, #4, #5, #6) The facility did not implement one on one supervision or prevent Resident #1 from pushing Resident # 2 out of his wheelchair, after Resident #1 demonstrated increased violent behaviors, threatening staff and other residents prior to the incident. Resident #2 sustained multiple acute lumbar compression fractures as a result of Resident #1's actions. Residents #3, #4, #5 and #6 were fearful of Resident #1. An Immediate Jeopardy situation was identified that existed from 9/21/17 to 9/25/17. The Immediate Jeopardy was identified on 10/10/17 and was removed on 10/11/17. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective measures. This failure could place the census of 55 residents at risk of injuries due to residents with mental illness not being properly supervised when displaying behaviors. Findings included: The facility's undated Abuse and Neglect policy stated a purpose of to prohibit abuse of residents from any source .to promote the well-being of residents by providing a safe and supportive environment . to maintain the resident's right to be free from verbal, sexual, physical, mental abuse . In the prevention section of the policy, it said observe resident behavior and their reaction to other residents . place residents in accommodations and environments that keep them calm . and assess, monitor, and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict . such as residents with a history of aggressive behaviors In the protection section of the policy, it listed temporary one on one supervision of a resident as an intervention. A history and physical from the local hospital dated 06/08/17, indicated the local police found Resident # 1 on the street in urine and stool, and exhibiting behaviors of paranoia and hallucinations. The police took him to the hospital. The note indicated he had a history of [REDACTED]. The note indicated Resident #1 was combative, paranoid and having hallucinations. The note indicated the resident tested positive for cocaine, marijuana and phencyclidine (PCP), and would be transferred to an inpatient psychiatric hospital. A note from the local behavioral hospital dated 6/16/17 indicated Resident #1 was admitted to the behavioral hospital on [DATE] and discharged to the local nursing facility on 06/16/17. A discharge summary from the local behavioral hospital dated 06/16/17 indicated Resident #1's [DIAGNOSES REDACTED]. The discharge note indicated Resident #1 received a referral for addiction treatment. Discharge medications included [MEDICATION NAME] 150 mg at bedtime, and to discontinue [MEDICATION NAME] 20 mg twice daily. A face sheet dated 06/29/17 indicated Resident #1 was admitted on [DATE] from a local behavioral hospital. He was a [AGE] year old male, with [DIAGNOSES REDACTED]. Electronic nursing notes dated 06/18/17 at 11:23 a.m. indicated Resident #1 was talking to non-existent people, and removed his clothing. All attempts to redirect the resident were ineffective. The resident exhibited explosive behavior, and threatened staff and residents with kitchen utensils, and pointed a knife at residents in a threatening manner. The NP was notified, and new orders received. A telephone order dated 06/18/17 indicated Resident #1's physician ordered [MEDICATION NAME] (antipsychotic) 50 mg to be given daily at 8 a.m. and 2 p.m., and [MEDICATION NAME] (antipsychotic) 20 mg twice daily with meals. Electronic nursing notes dated 06/18/17 at 2:02 p.m. indicated Resident #1 had [MEDICAL CONDITION] toward other residents and staff, and he threatened to kill everyone here. Multiple attempts to calm Resident #1 were ineffective. Resident #1 told staff he wanted to leave, and his behaviors continued. Law enforcement was notified. The note indicated Resident #1 was to be placed on one on one monitoring, to protect the residents' safety. There was no further documentation regarding the 1:1 monitoring. Electronic nursing notes dated 06/18/17 at 2:20 p.m. indicated the local police arrived, and were given information regarding Resident #1's mental status, and his hostile, aggressive, combative behavior, and threats to kill staff. The note indicated the police notified the local mental health authority, who advised the facility they would need to obtain an emergency mental health warrant. The note indicated the facility was given the contact information for a local judge to secure the warrant. The DON and administrator were notified concerning Resident #1's situation, and given instructions for obtaining the mental health warrant. The note indicated the administrator would contact the social worker for completion of paperwork. Electronic nursing notes dated 06/18/17 at 4:23 p.m. indicated Resident #1 became polite and courteous when the local police arrived, and denied any issues. The note indicated the charge nurse on duty asked Resident #1 if something was wrong, and Resident # 1 became irritated. The police spoke with the charge nurse and said You are not going to get him riled up so he can hit you. We are not going to play that game. The paperwork needed to secure the emergency mental health warrant was not completed. A nursing note dated 06/19/17 at 12:58 p.m. indicated Resident # 1 grabbed a fork and threatened an aide, saying he was going to stab her. The resident was re-directed by a male staff member. A PASRR Level 1 screening, dated 06/19/17 was completed by the local behavioral hospital, and indicated Resident # 1 had mental illness. During an interview on 10/10/17 at 10:06 a.m., the social worker said the PASRR Level 1 was done at the local behavioral hospital, and Resident #1 did not trigger for a Level 2 PASRR evaluation, although he was positive for mental illness. A care plan initiated on 06/23/17 indicated Resident # 1 exhibited alterations in mood and behaviors as evidenced by his making animal sounds, fidgeting, yelling, cursing, drinking his own urine, and urinating in inappropriate places due to his [MEDICAL CONDITION]. Interventions included referrals to psychiatric services as needed with exacerbation or inability to redirect behavior, remove from common areas during times of unacceptable behaviors, social service visits as needed, and 1:1 supervision as needed. A telephone order dated 06/23/17 required an increase of Resident #1's [MEDICATION NAME] dose to 40 mg by mouth twice daily. A telephone order dated 06/29/17 indicated Resident # 1 was to have a psychiatric evaluation and treatment by the local psychologist. A nursing note dated 07/04/17 at 6:22 p.m. indicated another resident notified staff Resident # 1 was cursing, and accusing everyone of stealing his cigarettes on his smoke break. The note indicated staff tried to talk with Resident # 1. The resident became extremely agitated and continued cursing. Resident # 1 refused to come inside. The staff could not redirect the resident. A staff member was able to get Resident # 1 to come into the facility, and noted Resident #1 made threatening throat cutting gestures towards the staff and other residents, scaring the residents. The administrator was notified. A physician order [REDACTED]. A response notification dated 7/21/17 at 12:23 p.m. indicated Resident # 1's referral for psychological services was denied because Resident #1's Medicare coverage did not include coverage for psychiatric services. During a telephone interview on 10/10/17 at 12:07 p.m., the local psychologist said he attempted to see Resident # 1 when he learned the facility was seeking a psychological referral, but was unable to speak to him because Resident # 1 was uncooperative. He said after the referral was denied, he did not attempt to see Resident # 1 anymore. The psychologist said he notified the DON and social worker that he was unable to see Resident # 1. He said he did not document his attempt to visit with Resident #1 because there was nothing to document. During an interview on 10/10/17 at 10:46 a.m., the social worker said the facility did not keep a list of residents who received in-house psychiatric services. The social worker said she was responsible for processing the referrals. She said she was unaware Resident # 1 was denied psychiatric services. She said she did not follow up on referrals. The social worker said there were no systems in place to ensure there was follow-up on referrals. During an interview on 10/10/17 at 11:14 a.m., the DON said she was unaware that Resident # 1 was not seen by psychiatric services. She said the social worker was responsible for following up with referrals. The DON said the facility did not have a policy on monitoring residents with behaviors, and said there was no additional documentation concerning supervision and monitoring of Resident # 1. During an interview on 10/10/17 at 11:30 a.m., the administrator said she was unaware Resident # 1 was not seen by psychiatric services. An update to Resident #1's care plan, dated 08/2017 indicated Resident #1's inappropriate behaviors had decreased and he was doing well, with no change in interventions noted. The most recent MDS dated [DATE] indicated Resident #1 was moderately cognitively intact (BIMS 11). The MDS indicated he was independent with activities of daily living. The MAR for 09/08/17 indicated Resident #1 missed his antipsychotic medications at 4:00 p.m. - [MEDICATION NAME] 40 mg., and [MEDICATION NAME] 50 mg (one tablet), and 8:00 p.m. - [MEDICATION NAME] XR 150 mg (one tablet). A nursing note dated 09/21/17 at 4:42 pm indicated Resident #1 had increased agitation that day, and was calling names and starting arguments with others. The note indicated Resident #1 had delusional thinking. Resident #1 said he was Jesus and was marking his arms for drug use with a pen. All attempts to redirect the resident were unsuccessful. The note indicated the NP was contacted and new orders received. Resident #1 was calmer after 1-2 hours. A telephone order for Resident #1 dated 09/21/17 indicated he was to receive Klonopin (for [MEDICAL CONDITION] disorders or panic disorder) 1 mg twice daily and every six hours as needed due to his increased agitation. A nursing note dated 09/21/17 at 8:35 p.m. indicated Resident #1 was outside the facility at the picnic table, was yelling out, throwing a trash can and the cigarette ashtray into the road. The note indicated Resident #1 lay on the ground, hitting his forearms and said it is time for my medication. The note indicated the resident was assisted into a wheelchair, back into the facility. Resident #1 then began rolling through the hallways, touching door knobs, carts, and knocking on walls. CNAs were doing rounds on halls and reported Resident #1 was putting trash can lids on his head. Staff redirection was not effective, and Resident #1's PRN medication was administered. During an interview on 10/09/17 at 2:33 p.m., LVN D said on 09/21/17 Resident # 1 was outside the facility, and was throwing ashtrays, chairs and trash cans. She said Resident # 1 then rolled down the hallways, knocking on other residents' doors. She said another resident reported Resident # 1 was outside throwing things. She said Resident # 1 was redirected to his room. LVN D said no special monitoring was started for Resident #1. There was no incident report for Resident #1's behaviors on 09/21/17. The MAR for 09/21/17 indicated Resident #1 did not receive his antipsychotic medications at 4:00 p.m. ([MEDICATION NAME] 40 mg., and [MEDICATION NAME] 50 mg) and at 8:00 p.m. - [MEDICATION NAME] XR 150 mg. A note, signed by the ADON, dated 09/22/17 indicated he (the ADON) was called to Resident # 2's room due to an argument between two residents. The ADON redirected the two residents, and asked Resident # 1 to leave Resident #2's room. The administrator was contacted. During an interview on 10/09/17 at 4:25 p.m., the ADON said he worked the night of 09/22/17 on the night shift. He said when he arrived at the facility, Resident #1 was in Resident # 2's room, yelling at Resident # 2. The ADON said he redirected Resident #1 to his room. He said Resident #1 came back out of his room between 2:00 a.m. and 3:00 a.m., and was staring at another resident, trying to provoke the other resident. The ADON said he did not know why Resident # 1 was not on 1:1 monitoring. The MAR for 09/22/17 indicated Resident #1 did not receive his antipsychotic medications at 8:00 p.m. ([MEDICATION NAME] XR 150 mg). A nursing note dated 09/23/17 at 12:02 a.m. for a late entry for 5:00 p.m. indicated Resident # 1 continued to exhibit behaviors, was cursing at other residents and staff, hallucinating, and accusing other residents of taking his belongings. The note indicated Resident #1's routine Klonopin was given. A nursing note dated 09/23/17 at 12:07 a.m. indicated Resident #1 walked into Resident #2's room and began arguing with him, threatened other residents, and said he did not give a damn about anyone calling the cops on him. The note indicated Resident #1 was redirected to his room, and calmed down. A nursing note dated 09/23/17 at 1:45 p.m. indicated Resident #1 was in the facility in his wheelchair, both inside and outside. The note indicated Resident #1 was very talkative with staff and residents about drugs and drug use. The note indicated Resident #1 was gathering things such as trash to give to staff as presents, was tapping on walls, and exhibiting obsessive compulsive behavior ((NAME)D). An incident report dated 09/23/17 at 2:30 p.m. indicated Resident # 1 was in the smoking area and had an altercation with another resident. The report indicated Resident # 1 pushed the other resident over, causing him to fall from his wheelchair. The incident follow up report indicated there was no injury. [MEDICAL CONDITION] was noted to Resident #1's left lower extremity (ankle). Resident #1 was transferred to a local hospital at 5:00 p.m. and was diagnosed with [REDACTED].# 1 was monitored for behaviors during smoke breaks and in the dining area. The report indicated on 09/25/17, Resident #1 discharged to the local behavioral hospital. According to the clinical records Resident # 2 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident # 2 was moderately impaired for decision making and he required extensive assistance with ADLS, including locomotion on and off the unit by one staff member. During an interview on 10/09/17 at 10:34 a.m. Resident # 2 said Resident # 1 was outside making animal sounds, then Resident # 1 stood up and hit him, causing him to fall out of his wheelchair, and break his back. He said the incident was unprovoked, and no staff were present during the incident. He said Resident # 1 would often yell and curse, and he tried to just stay away from Resident # 1. An incident report dated 09/23/17 at 2:30 p.m. indicated Resident # 2 was sitting in his wheelchair in the smoking area when Resident #1 pushed Resident # 2 out of his wheelchair on to the ground. The report indicated the residents were separated and EMS was called to transfer Resident # 2 to the local hospital for evaluation. The report indicated Resident #2 had abrasions to his right hand, knuckles, and elbow. The report indicated Resident # 2 was transported to local hospital at 3:00 p.m., the physician and family were notified. A care plan update on 09/23/17 indicated Resident #1 assaulted another resident, and the intervention included to transfer Resident #1 to a local hospital for psychiatric evaluation. A provider investigation report dated 09/29/17 indicated Resident # 2 was sitting outside in his wheelchair when Resident #1 started a verbal altercation with him, and pushed Resident # 2 from his wheelchair, causing Resident #2 to hit his head on the concrete. The response indicated Resident # 1 was transported to the local hospital, and when Resident #1 returned to the facility, staff monitored Resident # 1 at all times until he was admitted to the local behavioral hospital on [DATE]. During a telephone interview on 10/09/17 at 11:48 a.m., CNA F said on 9/23/17, she was going on break with Resident # 3. She said as she approached the smoking area with Resident #3, she heard Resident # 1 yelling at Resident # 2. She said she told Resident # 3 to go get the nurse. CNA F said before she could get out of the doors, she saw Resident # 1 push Resident # 2 out of his wheelchair. She said had not heard Resident # 2 say anything to Resident # 1 prior to the incident. CNA F said Resident # 2 was at a table with his head lying on the table. CNA F said she checked on Resident # 2, and Resident # 1 said Resident # 2 had fallen out of his chair, and said he must be drunk. CNA F said she only worked weekends. She said Resident # 1 displayed aggressive behaviors prior to the incident on 9/23/17. She said the prior weekend before the incident, Resident # 1 was in the dining area, throwing silverware at other residents. She said staff called the police on Resident # 1 prior to the incident. CNA F said staff tried to redirect Resident # 1 when he acted out, and other residents were afraid of Resident # 1, and said he would try to bully staff and other residents. CNA F said she had no knowledge of any special supervision requirements or increased monitoring for Resident # 1. CNA F said she was never instructed to provide increased supervision for Resident #1. During a telephone interview on 10/10/17 at 11:41 a.m., LVN G said she was the nurse on duty on 9/23/17, the day of the incident between Resident #1 and Resident #2. She said CNA F and Resident # 3 were screaming that Resident # 1 had pushed Resident # 2 out of his wheelchair. She said upon arriving outside to the smoking area, Resident # 2 was lying on the concrete ground, and Resident # 1 was sitting by him. She said she asked Resident # 1 to go inside the facility at that time. She said Resident # 2 was assessed and sent to a local hospital. She said Resident # 2 told her that Resident # 1 starting screaming at him and pushed him over. She said she noticed swelling to Resident # 1 left foot, and he agreed to go to the hospital for evaluation. She said staff tried to keep a visual watch on him. LVN G said she was told in report that if Resident # 1 had any behaviors, she was to call the local police. LVN G said she only worked the weekends at this facility. She said she had not been instructed to provide any special monitoring or supervision for Resident # 1 due to his behaviors. A face sheet dated 10/11/17 indicated Resident # 3 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident # 3 was cognitively intact with a BIMS of 15 and was independent with ADLs. During an observation and interview on 10/09/17 at 11:30 a.m., Resident # 3 appeared visibly anxious and tearful when she talked about Resident # 1, and said he was a time bomb. She said about a week prior to the incident, Resident # 1 threw an ashtray at her and called her a [***] . She said she asked LVN C to watch her hall where both she and Resident #1 lived. Resident #3 said she was afraid of Resident # 1 and felt she was in danger, and said Resident # 1 was going to hurt someone. She said she also reported the incident to the social worker and the social worker offered Resident #3 an opportunity to move to another hall. She said Resident # 1 was on a tear on 9/23/17, the day of the incident. Resident #3 said she and CNA F were going out to the smoking area the day of the incident. She said Resident # 1 and Resident # 2 were in the smoking area. No staff were present. Resident #3 said she could hear Resident # 1 yelling and cursing at Resident # 2 as they approached the area. She said CNA F asked her to go get the nurse, as CNA F was rushing to get to Residents #1 and #2. She said CNA F yelled that Resident # 1 had pushed Resident # 2 out of the wheelchair. She said the same night after the incident, at some time after 10:00 p.m., Resident # 1 came out to the smoking area while she was there. Resident #3 said no staff was present. Resident #3 said Resident # 1 told her he was going to kill her and cut her throat. She said she immediately started trying to wheel herself inside of the building and Resident # 1 was behind her yelling and cursing at her. She said she did not feel safe, and felt she was in danger during the time Resident # 1 was in the facility. She said she reported the incident to staff, but she did not feel anything was done after she reported it. A local hospital report dated 09/30/17, indicated on 09/23/17, Resident # 2 was at the nursing facility and a man took him out of his wheelchair and beat him up. The report indicated Resident # 2 got hit and knocked out of his wheelchair. An MRI was done on 09/24/17 and showed multiple acute compression fractures of the L3 and L4 vertebrae, with a burst fracture at L2. A SBAR (Situation, Background, Assessment, Recommendation) communication form dated 09/23/17 at 5:00 p.m. indicated Resident # 1 assaulted another resident. The communication form noted Resident #1 had [MEDICAL CONDITION] to his left lower extremity. The document indicated Resident #1 would be transferred to a local hospital. A hospital report dated 09/23/17 indicated Resident #1 was admitted with complaints of ankle injury and psychiatric problems. The document indicated Resident #1 had an altercation with another resident. Resident #1 denied any suicidal or homicidal ideations, and answered questions appropriately. There was concern with Resident #1's previous history of drug use. The report indicated there was no indication for emergent intervention or admission. The MAR for 09/23/17 indicated Resident #1 did not receive his antipsychotic medications at 4:00 p.m. ([MEDICATION NAME] 40 mg.). Discharge orders from the hospital dated 09/23/17 at 10:45 p.m. indicated Resident #1 had [MEDICAL CONDITION] with orders to follow up with primary care physician in 1 to 2 days. The MAR for 09/24/17 indicated Resident #1 did not receive his 10:00 a.m. dose of Klonopin 1 mg. A nursing note dated 09/24/17 at 8:59 p.m. indicated Resident #1 continued aggressive behaviors throughout the shift. Resident #1 yelled out threats, threw water, and hit himself in his head and face. Staff assisted with 1:1 as much as possible to keep Resident #1 calm and safe. A social worker's note dated 09/25/17 at 10:26 a.m. indicated the social worker contacted the local behavioral hospital for admission due to Resident #1's current behaviors. He was accepted for admission to the behavioral hospital. A nursing note dated 09/25/17 at 4:30 p.m. indicated Resident #1 was on 15 minute monitoring for behaviors and was discharged to the local behavioral hospital at 3:30 p.m. A 15 minute surveillance log indicated Resident #1 was monitored every 15 minutes on 09/25/17 from 6:00 a.m. to 3:30 p.m., but no entries were made at 6:45 a.m., 9:30 a.m., 10:15 a.m., 12:45 p.m., or 1:15 p.m. During an interview on 10/10/17 at 10:51 a.m., LVN A said she started the every 15 minutes monitoring sheets on 09/25/17. She said no one had instructed her to do so, but due to her experience as a nurse, she just knew to do it. She said prior to the incident on 09/23/17 Resident # 1 said he was Jesus and was asking for drugs. LVN A said she notified the NP, but no special monitoring was put in place. During an interview on 10/09/17 at 1:10 p.m., LVN C said Resident # 1 had episodes of bizarre behavior. He said residents were afraid of Resident # 1 because he was very intimidating, threatened he would kick your ass, expose himself, and was loud and hostile. He said Resident # 1 could present a danger to others, was over 6 feet tall, and said some female residents said they were afraid of Resident # 1. During a telephone interview on 10/09/17 at 1:14 p.m., the social worker said a female resident expressed concerns about Resident # 1, saying she felt uncomfortable around him. She said Resident # 1 agreed to go to the local behavioral hospital after the incident. She was not aware of any special precautions or monitoring for Resident # 1 prior or after the incident. During an interview on 10/09/17 at 2:14 p.m., the DON said she was notified on 09/22/17 that Resident # 1 that on 09/21/17 Resident # 1 was throwing things. She said from the time Resident #1 was admitted to the facility, he had outbursts where he yelled and cursed at staff. She said the behavior was not directed toward anyone. During an interview on 10/10/17 at 1:37 p.m., the NP said she reviewed the clinical records from the local behavioral hospital prior to Resident #1's admission in June, and did not see anything that was cause for alarm. She said she, and the administrator agreed to accept Resident # 1 in the facility. She said Resident # 1 was on a minimal amount of medication. She said when Resident # 1 started having behaviors, she changed his medication and Resident # 1 appeared to be improving. She said she was not aware the psychologist was not seeing Resident # 1. A face sheet for Resident # 4 dated 10/11/17 indicated she was a [AGE] year old female admitted to facility on 12/22/15. Her [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #4 was cognitively intact with a BIMS of 14. The MDS indicated she was independent in all ADLs. During an interview on 10/09/17 Resident # 4 said Resident # 1 would constantly threaten people. She said she was afraid of Resident # 1 and did not feel safe while he was in the facility. She said she had spoken with staff about her concerns and they would just say they were working on his medications. She said Resident # 1 would yell and curse during smoke breaks. She said she would just try and stay away from Resident # 1. She said she felt she was in danger because of the way Resident # 1 would act. She said Resident had acted up since he came to the facility. A face sheet for Resident # 5 dated 10/11/17 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. An MDS dated [DATE] for Resident # 5 MDS indicated she was cognitively intact with a BIMS of 15. The MDS indicated she required supervision with her ADLs. During an interview on 10/09/17 at 12:20 p.m. Resident # 5 said she would try and stay away from Resident # 1 due to she was afraid of him. She said he would constantly yell and curse at staff and other residents. She said she did not feel safe while Resident # 1 was in the facility and felt she was in danger. She said she could not enjoy her smoke break due to Resident # 1 because you never knew what he was going to do. She said she had voiced concerns with staff and was just told they were working on his medication. She said Resident # 1 had been acting out since he came to the facility. A face sheet for Resident # 6 dated 10/11/17 indicated she was [AGE] years old, admitted on [DATE]. Her [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident # 6 was cognitively intact with a BIMS of 13. The MDS indicated she required limited assistance with ADLs. During an interview on 10/09/17 at 12:28 p.m., Resident # 6 said Resident # 1 would threaten residents a lot. She said everyone was afraid of Resident # 1. She said Resident # 1 would curse, yell and spit at people. She said staff would never do anything. She said she felt threatened by Resident # 1 and that she was in danger as long as he was around. Resident # 6 said Resident # 1 would throw silverware at Residents. She said Resident # 1 had been acting up since he came to facility. During an interview on 10/09/17 at 4:49 p.m., the administrator said the facility was aware Resident # 1 had behaviors. She said the NP along with the facility felt Resident # 1 could be managed. She said she was unsure of the monitoring provided to Resident # 1 concerning his behaviors. On 10/10/17 at 4:35 p.m., the administrator, DON, and ADON were notified an Immediate Jeopardy was identified. On 10/10/17 at 6:52 p.m. a Plan of Removal was accepted and included: . 1. All staff will have an in-service on Identifying, Preventing and Managing Aggressive Behaviors before they are allowed to clock in for their next shift. New staff will complete the training before starting to work and it will be repeated quarterly for all staff and as needed. 2. Nurses will be in-serviced by the DON or her designee on Monitoring Aggressive Behaviors, and documenting the behaviors on the 24-hour report, initiating Q 15 minute checks and in the nurse's notes. 3. ( name of local psychiatric services provider ) and the Social Worker have developed a system in which the Client Service Director will e-mail a list each Monday of the residents they have on services and the Social Worker can ensure it is every resident we have with an order for [REDACTED]. 4. All residents will be assessed for behaviors and if there are any noted behaviors MD and RP will be notified immediately and interventions will be put in place. The Interdisciplinary Team will discuss any behaviors in the morning meeting 5. All potential admissions will be reviewed by the IDT for appropriate placement into the facility and the administrator / or designee will make the final decision regarding admission. On 10/11/17 it was confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on 10/11/17 at 12:45 p.m., the RQC (Regional Quality Manager) said staff were in-serviced on dealing with aggressive residents, documentation on 24 hour report sheet, initiating monitoring and use of monitoring sheet. She said staff that had not been in-serviced would not be allowed to return to work until they had been in-serviced. She said the DON or designee would audit charts daily for any documented behaviors and record on daily audit sheets. She said administrative staff had been in-serviced on all potential admissions to be reviewed by the IDT team for appropriate placement. She said a social worker kept a log of all referrals made to psych services and follow up. She said the local psych services will fax over list of current residents being seen by the psychologist weekly to ensure residents with orders are being seen. Four LVNs said they had been in serviced on 10/10/17 and 10/11/17 on dealing with aggressive residents, when to implement monitor and documentation. They could identify warning signs of a resident becoming agitated or aggressive. They were able to identify what the new protocol was for implementing monitoring where to document and whom to report it to. Seven CNAs said they had been in serviced on dealing with aggressive residents

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures to prohibit abuse and neglect for 1 of 6 residents reviewed for abuse. (Residents #1, #2, #3, #4, #5, #6) The facility did not implement one on one supervision or prevent Resident #1 from pushing Resident # 2 out of his wheelchair, after Resident #1 demonstrated increased violent behaviors, threatening staff and other residents prior to the incident. Resident #2 sustained multiple acute lumbar compression fractures as a result of Resident #1's actions. Residents #3, #4, #5 and #6 were fearful of Resident #1. An Immediate Jeopardy situation was identified that existed from 9/21/17 to 9/25/17. The Immediate Jeopardy was identified on 10/10/17 and was removed on 10/11/17. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective measures. This failure could place the census of 55 residents at risk of injuries due to residents with mental illness not being properly supervised when displaying behaviors. Findings included: A history and physical from the local hospital dated 06/08/17, indicated the local police found Resident # 1 on the street in urine and stool, and exhibiting behaviors of paranoia and hallucinations. The police took him to the hospital. The note indicated he had a history of [REDACTED]. The note indicated Resident #1 was combative, paranoid and having hallucinations. The note indicated the resident tested positive for cocaine, marijuana and phencyclidine (PCP), and would be transferred to an inpatient psychiatric hospital. A note from the local behavioral hospital dated 6/16/17 indicated Resident #1 was admitted to the behavioral hospital on [DATE] and discharged to the local nursing facility on 06/16/17. A discharge summary from the local behavioral hospital dated 06/16/17 indicated Resident #1's [DIAGNOSES REDACTED]. The discharge note indicated Resident #1 received a referral for addiction treatment. Discharge medications included [MEDICATION NAME] 150 mg at bedtime, and to discontinue [MEDICATION NAME] 20 mg twice daily. A face sheet dated 06/29/17 indicated Resident #1 was admitted on [DATE] from a local behavioral hospital. He was a [AGE] year old male, with [DIAGNOSES REDACTED]. Electronic nursing notes dated 06/18/17 at 11:23 a.m. indicated Resident #1 was talking to non-existent people, and removed his clothing. All attempts to redirect the resident were ineffective. The resident exhibited explosive behavior, and threatened staff and residents with kitchen utensils, and pointed a knife at residents in a threatening manner. The NP was notified, and new orders received. A telephone order dated 06/18/17 indicated Resident #1's physician ordered [MEDICATION NAME] (antipsychotic) 50 mg to be given daily at 8 a.m. and 2 p.m., and [MEDICATION NAME] (antipsychotic) 20 mg twice daily with meals. Electronic nursing notes dated 06/18/17 at 2:02 p.m. indicated Resident #1 had [MEDICAL CONDITION] toward other residents and staff, and he threatened to kill everyone here. Multiple attempts to calm Resident #1 were ineffective. Resident #1 told staff he wanted to leave, and his behaviors continued. Law enforcement was notified. The note indicated Resident #1 was to be placed on one on one monitoring, to protect the residents' safety. There was no further documentation regarding the 1:1 monitoring. Electronic nursing notes dated 06/18/17 at 2:20 p.m. indicated the local police arrived, and were given information regarding Resident #1's mental status, and his hostile, aggressive, combative behavior, and threats to kill staff. The note indicated the police notified the local mental health authority, who advised the facility they would need to obtain an emergency mental health warrant. The note indicated the facility was given the contact information for a local judge to secure the warrant. The DON and administrator were notified concerning Resident #1's situation, and given instructions for obtaining the mental health warrant. The note indicated the administrator would contact the social worker for completion of paperwork. Electronic nursing notes dated 06/18/17 at 4:23 p.m. indicated Resident #1 became polite and courteous when the local police arrived, and denied any issues. The note indicated the charge nurse on duty asked Resident #1 if something was wrong, and Resident # 1 became irritated. The police spoke with the charge nurse and said You are not going to get him riled up so he can hit you. We are not going to play that game. The paperwork needed to secure the emergency mental health warrant was not completed. A nursing note dated 06/19/17 at 12:58 p.m. indicated Resident # 1 grabbed a fork and threatened an aide, saying he was going to stab her. The resident was re-directed by a male staff member. A PASRR Level 1 screening, dated 06/19/17 was completed by the local behavioral hospital, and indicated Resident # 1 had mental illness. During an interview on 10/10/17 at 10:06 a.m., the social worker said the PASRR Level 1 was done at the local behavioral hospital, and Resident #1 did not trigger for a Level 2 PASRR evaluation, although he was positive for mental illness. A care plan initiated on 06/23/17 indicated Resident # 1 exhibited alterations in mood and behaviors as evidenced by his making animal sounds, fidgeting, yelling, cursing, drinking his own urine, and urinating in inappropriate places due to his [MEDICAL CONDITION]. Interventions included referrals to psychiatric services as needed with exacerbation or inability to redirect behavior, remove from common areas during times of unacceptable behaviors, social service visits as needed, and 1:1 supervision as needed. A telephone order dated 06/23/17 required an increase of Resident #1's [MEDICATION NAME] dose to 40 mg by mouth twice daily. A telephone order dated 06/29/17 indicated Resident # 1 was to have a psychiatric evaluation and treatment by the local psychologist. A nursing note dated 07/04/17 at 6:22 p.m. indicated another resident notified staff Resident # 1 was cursing, and accusing everyone of stealing his cigarettes on his smoke break. The note indicated staff tried to talk with Resident # 1. The resident became extremely agitated and continued cursing. Resident # 1 refused to come inside. The staff could not redirect the resident. A staff member was able to get Resident # 1 to come into the facility, and noted Resident #1 made threatening throat cutting gestures towards the staff and other residents, scaring the residents. The administrator was notified. A physician order [REDACTED]. A response notification dated 7/21/17 at 12:23 p.m. indicated Resident # 1's referral for psychological services was denied because Resident #1's Medicare coverage did not include coverage for psychiatric services. During a telephone interview on 10/10/17 at 12:07 p.m., the local psychologist said he attempted to see Resident # 1 when he learned the facility was seeking a psychological referral, but was unable to speak to him because Resident # 1 was uncooperative. He said after the referral was denied, he did not attempt to see Resident # 1 anymore. The psychologist said he notified the DON and social worker that he was unable to see Resident # 1. He said he did not document his attempt to visit with Resident #1 because there was nothing to document. During an interview on 10/10/17 at 10:46 a.m., the social worker said the facility did not keep a list of residents who received in-house psychiatric services. The social worker said she was responsible for processing the referrals. She said she was unaware Resident # 1 was denied psychiatric services. She said she did not follow up on referrals. The social worker said there were no systems in place to ensure there was follow-up on referrals. During an interview on 10/10/17 at 11:14 a.m., the DON said she was unaware that Resident # 1 was not seen by psychiatric services. She said the social worker was responsible for following up with referrals. The DON said the facility did not have a policy on monitoring residents with behaviors, and said there was no additional documentation concerning supervision and monitoring of Resident # 1. During an interview on 10/10/17 at 11:30 a.m., the administrator said she was unaware Resident # 1 was not seen by psychiatric services. An update to Resident #1's care plan, dated 08/2017 indicated Resident #1's inappropriate behaviors had decreased and he was doing well, with no change in interventions noted. The most recent MDS dated [DATE] indicated Resident #1 was moderately cognitively intact (BIMS 11). The MDS indicated he was independent with activities of daily living. The MAR for 09/08/17 indicated Resident #1 missed his antipsychotic medications at 4:00 p.m. - [MEDICATION NAME] 40 mg., and [MEDICATION NAME] 50 mg (one tablet), and 8:00 p.m. - [MEDICATION NAME] XR 150 mg (one tablet). A nursing note dated 09/21/17 at 4:42 pm indicated Resident #1 had increased agitation that day, and was calling names and starting arguments with others. The note indicated Resident #1 had delusional thinking. Resident #1 said he was Jesus and was marking his arms for drug use with a pen. All attempts to redirect the resident were unsuccessful. The note indicated the NP was contacted and new orders received. Resident #1 was calmer after 1-2 hours. A telephone order for Resident #1 dated 09/21/17 indicated he was to receive Klonopin (for [MEDICAL CONDITION] disorders or panic disorder) 1 mg twice daily and every six hours as needed due to his increased agitation. A nursing note dated 09/21/17 at 8:35 p.m. indicated Resident #1 was outside the facility at the picnic table, was yelling out, throwing a trash can and the cigarette ashtray into the road. The note indicated Resident #1 lay on the ground, hitting his forearms and said it is time for my medication. The note indicated the resident was assisted into a wheelchair, back into the facility. Resident #1 then began rolling through the hallways, touching door knobs, carts, and knocking on walls. CNAs were doing rounds on halls and reported Resident #1 was putting trash can lids on his head. Staff redirection was not effective, and Resident #1's PRN medication was administered. During an interview on 10/09/17 at 2:33 p.m., LVN D said on 09/21/17 Resident # 1 was outside the facility, and was throwing ashtrays, chairs and trash cans. She said Resident # 1 then rolled down the hallways, knocking on other residents' doors. She said another resident reported Resident # 1 was outside throwing things. She said Resident # 1 was redirected to his room. LVN D said no special monitoring was started for Resident #1. There was no incident report for Resident #1's behaviors on 09/21/17. The MAR for 09/21/17 indicated Resident #1 did not receive his antipsychotic medications at 4:00 p.m. ([MEDICATION NAME] 40 mg., and [MEDICATION NAME] 50 mg) and at 8:00 p.m. - [MEDICATION NAME] XR 150 mg. A note, signed by the ADON, dated 09/22/17 indicated he (the ADON) was called to Resident # 2's room due to an argument between two residents. The ADON redirected the two residents, and asked Resident # 1 to leave Resident #2's room. The administrator was contacted. During an interview on 10/09/17 at 4:25 p.m., the ADON said he worked the night of 09/22/17 on the night shift. He said when he arrived at the facility, Resident #1 was in Resident # 2's room, yelling at Resident # 2. The ADON said he redirected Resident #1 to his room. He said Resident #1 came back out of his room between 2:00 a.m. and 3:00 a.m., and was staring at another resident, trying to provoke the other resident. The ADON said he did not know why Resident # 1 was not on 1:1 monitoring. The MAR for 09/22/17 indicated Resident #1 did not receive his antipsychotic medications at 8:00 p.m. ([MEDICATION NAME] XR 150 mg). A nursing note dated 09/23/17 at 12:02 a.m. for a late entry for 5:00 p.m. indicated Resident # 1 continued to exhibit behaviors, was cursing at other residents and staff, hallucinating, and accusing other residents of taking his belongings. The note indicated Resident #1's routine Klonopin was given. A nursing note dated 09/23/17 at 12:07 a.m. indicated Resident #1 walked into Resident #2's room and began arguing with him, threatened other residents, and said he did not give a damn about anyone calling the cops on him. The note indicated Resident #1 was redirected to his room, and calmed down. A nursing note dated 09/23/17 at 1:45 p.m. indicated Resident #1 was in the facility in his wheelchair, both inside and outside. The note indicated Resident #1 was very talkative with staff and residents about drugs and drug use. The note indicated Resident #1 was gathering things such as trash to give to staff as presents, was tapping on walls, and exhibiting obsessive compulsive behavior ((NAME)D). An incident report dated 09/23/17 at 2:30 p.m. indicated Resident # 1 was in the smoking area and had an altercation with another resident. The report indicated Resident # 1 pushed the other resident over, causing him to fall from his wheelchair. The incident follow up report indicated there was no injury. [MEDICAL CONDITION] was noted to Resident #1's left lower extremity (ankle). Resident #1 was transferred to a local hospital at 5:00 p.m. and was diagnosed with [REDACTED].# 1 was monitored for behaviors during smoke breaks and in the dining area. The report indicated on 09/25/17, Resident #1 discharged to the local behavioral hospital. According to the clinical records Resident # 2 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident # 2 was moderately impaired for decision making and he required extensive assistance with ADLS, including locomotion on and off the unit by one staff member. During an interview on 10/09/17 at 10:34 a.m. Resident # 2 said Resident # 1 was outside making animal sounds, then Resident # 1 stood up and hit him, causing him to fall out of his wheelchair, and break his back. He said the incident was unprovoked, and no staff were present during the incident. He said Resident # 1 would often yell and curse, and he tried to just stay away from Resident # 1. An incident report dated 09/23/17 at 2:30 p.m. indicated Resident # 2 was sitting in his wheelchair in the smoking area when Resident #1 pushed Resident # 2 out of his wheelchair on to the ground. The report indicated the residents were separated and EMS was called to transfer Resident # 2 to the local hospital for evaluation. The report indicated Resident #2 had abrasions to his right hand, knuckles, and elbow. The report indicated Resident # 2 was transported to local hospital at 3:00 p.m., the physician and family were notified. A care plan update on 09/23/17 indicated Resident #1 assaulted another resident, and the intervention included to transfer Resident #1 to a local hospital for psychiatric evaluation. A provider investigation report dated 09/29/17 indicated Resident # 2 was sitting outside in his wheelchair when Resident #1 started a verbal altercation with him, and pushed Resident # 2 from his wheelchair, causing Resident #2 to hit his head on the concrete. The response indicated Resident # 1 was transported to the local hospital, and when Resident #1 returned to the facility, staff monitored Resident # 1 at all times until he was admitted to the local behavioral hospital on [DATE]. During a telephone interview on 10/09/17 at 11:48 a.m., CNA F said on 9/23/17, she was going on break with Resident # 3. She said as she approached the smoking area with Resident #3, she heard Resident # 1 yelling at Resident # 2. She said she told Resident # 3 to go get the nurse. CNA F said before she could get out of the doors, she saw Resident # 1 push Resident # 2 out of his wheelchair. She said had not heard Resident # 2 say anything to Resident # 1 prior to the incident. CNA F said Resident # 2 was at a table with his head lying on the table. CNA F said she checked on Resident # 2, and Resident # 1 said Resident # 2 had fallen out of his chair, and said he must be drunk. CNA F said she only worked weekends. She said Resident # 1 displayed aggressive behaviors prior to the incident on 9/23/17. She said the prior weekend before the incident, Resident # 1 was in the dining area, throwing silverware at other residents. She said staff called the police on Resident # 1 prior to the incident. CNA F said staff tried to redirect Resident # 1 when he acted out, and other residents were afraid of Resident # 1, and said he would try to bully staff and other residents. CNA F said she had no knowledge of any special supervision requirements or increased monitoring for Resident # 1. CNA F said she was never instructed to provide increased supervision for Resident #1. During a telephone interview on 10/10/17 at 11:41 a.m., LVN G said she was the nurse on duty on 9/23/17, the day of the incident between Resident #1 and Resident #2. She said CNA F and Resident # 3 were screaming that Resident # 1 had pushed Resident # 2 out of his wheelchair. She said upon arriving outside to the smoking area, Resident # 2 was lying on the concrete ground, and Resident # 1 was sitting by him. She said she asked Resident # 1 to go inside the facility at that time. She said Resident # 2 was assessed and sent to a local hospital. She said Resident # 2 told her that Resident # 1 starting screaming at him and pushed him over. She said she noticed swelling to Resident # 1 left foot, and he agreed to go to the hospital for evaluation. She said staff tried to keep a visual watch on him. LVN G said she was told in report that if Resident # 1 had any behaviors, she was to call the local police. LVN G said she only worked the weekends at this facility. She said she had not been instructed to provide any special monitoring or supervision for Resident # 1 due to his behaviors. A face sheet dated 10/11/17 indicated Resident # 3 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident # 3 was cognitively intact with a BIMS of 15 and was independent with ADLs. During an observation and interview on 10/09/17 at 11:30 a.m., Resident # 3 appeared visibly anxious and tearful when she talked about Resident # 1, and said he was a time bomb. She said about a week prior to the incident, Resident # 1 threw an ashtray at her and called her a [***] . She said she asked LVN C to watch her hall where both she and Resident #1 lived. Resident #3 said she was afraid of Resident # 1 and felt she was in danger, and said Resident # 1 was going to hurt someone. She said she also reported the incident to the social worker and the social worker offered Resident #3 an opportunity to move to another hall. She said Resident # 1 was on a tear on 9/23/17, the day of the incident. Resident #3 said she and CNA F were going out to the smoking area the day of the incident. She said Resident # 1 and Resident # 2 were in the smoking area. No staff were present. Resident #3 said she could hear Resident # 1 yelling and cursing at Resident # 2 as they approached the area. She said CNA F asked her to go get the nurse, as CNA F was rushing to get to Residents #1 and #2. She said CNA F yelled that Resident # 1 had pushed Resident # 2 out of the wheelchair. She said the same night after the incident, at some time after 10:00 p.m., Resident # 1 came out to the smoking area while she was there. Resident #3 said no staff was present. Resident #3 said Resident # 1 told her he was going to kill her and cut her throat. She said she immediately started trying to wheel herself inside of the building and Resident # 1 was behind her yelling and cursing at her. She said she did not feel safe, and felt she was in danger during the time Resident # 1 was in the facility. She said she reported the incident to staff, but she did not feel anything was done after she reported it. A local hospital report dated 09/30/17, indicated on 09/23/17, Resident # 2 was at the nursing facility and a man took him out of his wheelchair and beat him up. The report indicated Resident # 2 got hit and knocked out of his wheelchair. An MRI was done on 09/24/17 and showed multiple acute compression fractures of the L3 and L4 vertebrae, with a burst fracture at L2. A SBAR (Situation, Background, Assessment, Recommendation) communication form dated 09/23/17 at 5:00 p.m. indicated Resident # 1 assaulted another resident. The communication form noted Resident #1 had [MEDICAL CONDITION] to his left lower extremity. The document indicated Resident #1 would be transferred to a local hospital. A hospital report dated 09/23/17 indicated Resident #1 was admitted with complaints of ankle injury and psychiatric problems. The document indicated Resident #1 had an altercation with another resident. Resident #1 denied any suicidal or homicidal ideations, and answered questions appropriately. There was concern with Resident #1's previous history of drug use. The report indicated there was no indication for emergent intervention or admission. The MAR for 09/23/17 indicated Resident #1 did not receive his antipsychotic medications at 4:00 p.m. ([MEDICATION NAME] 40 mg.). Discharge orders from the hospital dated 09/23/17 at 10:45 p.m. indicated Resident #1 had [MEDICAL CONDITION] with orders to follow up with primary care physician in 1 to 2 days. The MAR for 09/24/17 indicated Resident #1 did not receive his 10:00 a.m. dose of Klonopin 1 mg. A nursing note dated 09/24/17 at 8:59 p.m. indicated Resident #1 continued aggressive behaviors throughout the shift. Resident #1 yelled out threats, threw water, and hit himself in his head and face. Staff assisted with 1:1 as much as possible to keep Resident #1 calm and safe. A social worker's note dated 09/25/17 at 10:26 a.m. indicated the social worker contacted the local behavioral hospital for admission due to Resident #1's current behaviors. He was accepted for admission to the behavioral hospital. A nursing note dated 09/25/17 at 4:30 p.m. indicated Resident #1 was on 15 minute monitoring for behaviors and was discharged to the local behavioral hospital at 3:30 p.m. A 15 minute surveillance log indicated Resident #1 was monitored every 15 minutes on 09/25/17 from 6:00 a.m. to 3:30 p.m., but no entries were made at 6:45 a.m., 9:30 a.m., 10:15 a.m., 12:45 p.m., or 1:15 p.m. During an interview on 10/10/17 at 10:51 a.m., LVN A said she started the every 15 minutes monitoring sheets on 09/25/17. She said no one had instructed her to do so, but due to her experience as a nurse, she just knew to do it. She said prior to the incident on 09/23/17 Resident # 1 said he was Jesus and was asking for drugs. LVN A said she notified the NP, but no special monitoring was put in place. During an interview on 10/09/17 at 1:10 p.m., LVN C said Resident # 1 had episodes of bizarre behavior. He said residents were afraid of Resident # 1 because he was very intimidating, threatened he would kick your ass, expose himself, and was loud and hostile. He said Resident # 1 could present a danger to others, was over 6 feet tall, and said some female residents said they were afraid of Resident # 1. During a telephone interview on 10/09/17 at 1:14 p.m., the social worker said a female resident expressed concerns about Resident # 1, saying she felt uncomfortable around him. She said Resident # 1 agreed to go to the local behavioral hospital after the incident. She was not aware of any special precautions or monitoring for Resident # 1 prior or after the incident. During an interview on 10/09/17 at 2:14 p.m., the DON said she was notified on 09/22/17 that Resident # 1 that on 09/21/17 Resident # 1 was throwing things. She said from the time Resident #1 was admitted to the facility, he had outbursts where he yelled and cursed at staff. She said the behavior was not directed toward anyone. During an interview on 10/10/17 at 1:37 p.m., the NP said she reviewed the clinical records from the local behavioral hospital prior to Resident #1's admission in June, and did not see anything that was cause for alarm. She said she, and the administrator agreed to accept Resident # 1 in the facility. She said Resident # 1 was on a minimal amount of medication. She said when Resident # 1 started having behaviors, she changed his medication and Resident # 1 appeared to be improving. She said she was not aware the psychologist was not seeing Resident # 1. A face sheet for Resident # 4 dated 10/11/17 indicated she was a [AGE] year old female admitted to facility on 12/22/15. Her [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #4 was cognitively intact with a BIMS of 14. The MDS indicated she was independent in all ADLs. During an interview on 10/09/17 Resident # 4 said Resident # 1 would constantly threaten people. She said she was afraid of Resident # 1 and did not feel safe while he was in the facility. She said she had spoken with staff about her concerns and they would just say they were working on his medications. She said Resident # 1 would yell and curse during smoke breaks. She said she would just try and stay away from Resident # 1. She said she felt she was in danger because of the way Resident # 1 would act. She said Resident had acted up since he came to the facility. A face sheet for Resident # 5 dated 10/11/17 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. An MDS dated [DATE] for Resident # 5 MDS indicated she was cognitively intact with a BIMS of 15. The MDS indicated she required supervision with her ADLs. During an interview on 10/09/17 at 12:20 p.m. Resident # 5 said she would try and stay away from Resident # 1 due to she was afraid of him. She said he would constantly yell and curse at staff and other residents. She said she did not feel safe while Resident # 1 was in the facility and felt she was in danger. She said she could not enjoy her smoke break due to Resident # 1 because you never knew what he was going to do. She said she had voiced concerns with staff and was just told they were working on his medication. She said Resident # 1 had been acting out since he came to the facility. A face sheet for Resident # 6 dated 10/11/17 indicated she was [AGE] years old, admitted on [DATE]. Her [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident # 6 was cognitively intact with a BIMS of 13. The MDS indicated she required limited assistance with ADLs. During an interview on 10/09/17 at 12:28 p.m., Resident # 6 said Resident # 1 would threaten residents a lot. She said everyone was afraid of Resident # 1. She said Resident # 1 would curse, yell and spit at people. She said staff would never do anything. She said she felt threatened by Resident # 1 and that she was in danger as long as he was around. Resident # 6 said Resident # 1 would throw silverware at Residents. She said Resident # 1 had been acting up since he came to facility. During an interview on 10/09/17 at 4:49 p.m., the administrator said the facility was aware Resident # 1 had behaviors. She said the NP along with the facility felt Resident # 1 could be managed. She said she was unsure of the monitoring provided to Resident # 1 concerning his behaviors. On 10/10/17 at 4:35 p.m., the administrator, DON, and ADON were notified an Immediate Jeopardy was identified. On 10/10/17 at 6:52 p.m. a Plan of Removal was accepted and included: . 1. All staff will have an in-service on Identifying, Preventing and Managing Aggressive Behaviors before they are allowed to clock in for their next shift. New staff will complete the training before starting to work and it will be repeated quarterly for all staff and as needed. 2. Nurses will be in-serviced by the DON or her designee on Monitoring Aggressive Behaviors, and documenting the behaviors on the 24-hour report, initiating Q 15 minute checks and in the nurse's notes. 3. ( name of local psychiatric services provider ) and the Social Worker have developed a system in which the Client Service Director will e-mail a list each Monday of the residents they have on services and the Social Worker can ensure it is every resident we have with an order for [REDACTED]. 4. All residents will be assessed for behaviors and if there are any noted behaviors MD and RP will be notified immediately and interventions will be put in place. The Interdisciplinary Team will discuss any behaviors in the morning meeting 5. All potential admissions will be reviewed by the IDT for appropriate placement into the facility and the administrator / or designee will make the final decision regarding admission. On 10/11/17 it was confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on 10/11/17 at 12:45 p.m., the RQC (Regional Quality Manager) said staff were in-serviced on dealing with aggressive residents, documentation on 24 hour report sheet, initiating monitoring and use of monitoring sheet. She said staff that had not been in-serviced would not be allowed to return to work until they had been in-serviced. She said the DON or designee would audit charts daily for any documented behaviors and record on daily audit sheets. She said administrative staff had been in-serviced on all potential admissions to be reviewed by the IDT team for appropriate placement. She said a social worker kept a log of all referrals made to psych services and follow up. She said the local psych services will fax over list of current residents being seen by the psychologist weekly to ensure residents with orders are being seen. Four LVNs said they had been in serviced on 10/10/17 and 10/11/17 on dealing with aggressive residents, when to implement monitor and documentation. They could identify warning signs of a resident becoming agitated or aggressive. They were able to identify what the new protocol was for implementing monitoring where to document and whom to report it to. Seven CNAs said they had been in serviced on dealing with aggressive residents and when to report to charge nurses and how to monitor. They could identify signs of agitation and aggression and how to attempt to redirect. The RQM (Regional Quality Manager) at 2:50 p.m. provided documentation of staff training. She said all charts were reviewed 10/11/17 for documented behaviors by the DON and provided a daily audit for resident behaviors and monitors. She said there were no pending admission and provided signed in service by administrative staff on process for potential admissions. She said all current referrals and orders to the in house physiologist were audited to ensure services were provided. During an interview on 10/11/17 at 2:55 p.m. the administrator said she would monitor to ensure all corrective measures were followed. She said all behaviors would be d(TRUNCATED)

Based on observation, interview, and record review, the facility failed to provide care based on the comprehensive assessment to prevent the development and worsening of pressure injuries for 1 of 2 residents reviewed for pressure injuries. (Resident #48) The facility did not provide Resident #48 with pressure redistribution for his feet. The resident developed 3 facility-acquired unstageable pressure injuries. Two of the three pressure injuries worsened in size. This failure could place 37 residents who were in a chair all or most of the time and 2 residents with with pressure injuries at risk of developing pressure injuries and decline in existing pressure injuries. Findings included: Physician orders [REDACTED].#48, admitted [DATE], was a [AGE] year old male with [DIAGNOSES REDACTED]. The care plan initiated 7/8/16 indicated Resident #48 was at risk for impaired skin integrity due to sitting in a geri-chair for long periods, frequent incontinence, dementia, and diabetic status. The care plan did not address pressure injuries. The most recent MDS dated [DATE] indicated Resident #48 had unclear speech. The staff assessment for mental status indicated Resident #48 was moderately impaired. The MDS indicated Resident #48 needed extensive assistance of two or more staff for bed mobility and transfers and extensive assistance from one staff for other ADLs. The MDS indicated Resident #48 was at risk for developing pressure injuries and had one stage 3 pressure injury at the time of assessment. A skin assessment dated [DATE] indicated Resident #48 had intact skin. A Braden risk assessment dated [DATE] indicated Resident #48 was at a mild risk for developing a pressure injury. The care plan updated 12/21/16 indicated Resident #48 had 3 unstageable pressure injuries on his right and left feet. Interventions included .a geri-chair for comfort and positioning, pressure redistributing mattress, incontinent care every two hours, and wound care per physician's orders [REDACTED]. The care plan did not include interventions for providing pressure relief for Resident #48's heels. A progress note dated 12/21/16 indicated Resident #48 had severe deep tissue injury (SDTI) pressure injuries on the bottom of his left foot, on the back of his right heel (foot), and on his right lateral (outer) heel. The note indicated orders were received for wound care and to keep the resident's heels floated. A wound assessment report dated 12/21/16 indicated Resident #48 had the following new pressure injuries: 1) Unstageable on the bottom of his left foot measuring 5 centimeters (cm) x 5.5 cm, 2) Unstageable on his right lateral (outer) heel measuring 2.5 cm x 2.5 cm and, 3) Unstageable on the back of his right heel measuring 2 cm x 2 cm The wound bed was not described for any of the pressure injuries. The report indicated the skin surrounding each wound was normal, his capillary refill was less than 3 seconds, and dorsalis pedis (top of the foot) and posterior tibial (inner ankle) pulses were palpable/strong. The wound healing progress reports dated 1/5/17 indicated Resident #48 had the following pressure injuries: 1) Unstageable on the bottom his of left foot measuring 4 cm x 3.6 cm 2) Unstageable on the bottom of his right heel measuring 1.8 cm x 2 cm 3) Unstageable on his lateral (outer) right foot measuring 2 cm x 1.6 cm The wound healing progress reports dated 1/5/17 for Resident #48 did not include descriptions of the pressure injuries. During an observation and interview on 1/10/17 at 3:15 p.m., Resident #48 was in bed in his room. His feet were resting on a pillow. His heels were not offloaded with the pillow. LVN C said the resident's heels were not offloaded; they were resting on the pillow. LVN C provided wound care and measured Resident #48's pressure injuries as follows: 1) Unstageable bottom of left foot 6.5 cm x 7 cm with black eschar covering the entire wound bed; 2) Unstageable bottom of right foot 2.0 cm x 2.7 cm with black eschar covering the entire wound bed; and 3) Unstageable lateral right foot 1.7 x 0.7 cm with black/brown eschar, which became dislodged during wound care revealing intact skin. After wound care was complete, LVN C said Resident #48's heels should be offloaded at all times. LVN C said it was the first time she had measured Resident #48's wounds. When she documented her measurements in the record, she said the other nurses who measured the wounds prior measured them wrong. During an observation on 1/9/17 at 3:00 p.m., Resident #48 was sitting in his geri-chair in his room with his feet resting on a pillow. His heels were not offloaded off the pillow. During an observation on 1/10/17 at 8:30 a.m., Resident #48 was sitting in his geri-chair in the dayroom with his feet resting on a pillow. His heels were not offloaded off the pillow. During an interview on 1/10/17 at 10:45 a.m., CNA B said she frequently provided care for Resident #48. CNA B said she looked at the ADL book to determine care needs for each resident. CNA B said she did not look at the care plan. During an interview on 1/10/17 at 2:30 p.m., the ADON said Resident #48's pressure injuries were unstageable when identified on 12/21/16. The ADON said Resident #48 was to have his heels offloaded and heel protectors in place. During an interview on 1/11/17 at 2:00 p.m., the ADON said the Braden risk assessment was not completed for 10/17/16 or 11/17/16. An undated policy and procedure indicated .a Braden assessment should occur on admission, weekly x 4, with changes of condition, and then quarterly . A policy and procedure dated 8/14 indicated .residents would not develop a pressure ulcer, and that a resident with a pressure sore receives necessary treatment and services to promote healing and prevent new sores from developing . The National Pressure Ulcer Advisory Panel at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 1/18/17, noted the following pressure ulcer definitions: .The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue . .Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Un-stageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on an ischemic limb or the heel(s) should not be removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Un-stageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions . The CMS 672 dated 1/11/17 indicated 37 residents were in a chair all or most of the time, and two residents had pressure injuries.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent accidents for 1 of 5 residents reviewed for assistance/supervision for eating/drinking (Resident #1). Resident #1 required a sippy cup for the consumption of fluids. The facility did not supervise Resident #1 as he went into the dining area and poured coffee into a regular coffee cup. The resident spilled the coffee into his lap area, sustaining second degree burns to his groin, penis, and inner thighs. An Immediate Jeopardy situation was identified on 05/18/16. The Immediate Jeopardy was removed on 05/19/16. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 2 residents needing supervision and assistive devices with hot liquids at risk of severe burns. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, was admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 is severely cognitively impaired, and required supervision and set-up help with eating. The Care Plan dated 05/12/16, indicated Resident #1 required cueing and supervision by one person for eating, and could feed himself with encouragement. The resident required a sippy cup, and it was noted that the resident would get coffee himself throughout the day and not use the sippy cup. The approaches included getting the sippy cup for him as needed between meals. An Incident Report dated 05/14/16, indicated that at 4:45 p.m. Resident #1 was witnessed with a cup of coffee in his hands and he spilled the coffee onto his lap. The resident was sent to the hospital. The Facility Investigation Report dated 05/14/16, indicated Resident #1 served himself coffee in the dining room and spilled the hot coffee in his lap. The witnesses were a family member and another resident (Resident #2). Resident #1 sustained burns with blisters to his groin area, penis, and inner thighs. He was transported to the hospital. During an interview on 05/19/16 at 8:06 a.m., Resident #2 said she was in the dining room on the evening of 05/14/16 and Resident #1 came into the dining room by himself, poured coffee into a regular coffee cup, and then spilled it on himself. She said there was no staff present. Hospital Records dated 05/14/16, indicated Resident #1 was found to have second degree burns to his penis and the inside of his left and right thighs. During an interview on 05/18/16 at 11:35 a.m., CNA A said Resident #1 needs a sippy cup for liquids. She said the resident prefers to make his own coffee, and when not allowed to, he becomes angry and has behaviors. She said that due to this, prior to the resident burning himself, his coffee was not usually in a sippy cup. During an observation on 05/18/16 at 12:13 p.m., CNA B brought Resident #1 into the dining room and placed him at a table. CNA B then prepared coffee in a regular coffee cup and placed it in front of Resident #1. During an interview on 05/18/16 at 12:21 p.m., CNA B said he was aware Resident #1 needed a sippy cup for liquids, but one of the other CNAs told him that Resident #1 does fine with a regular cup for coffee, so he thought that would be alright. During an observation on 05/18/16 at 11:20 a.m., the coffee service station was located in the dining room on a table adjacent to the kitchen door. The coffee service included two coffee pump canisters (column shaped canisters with a pump at the top for dispensing). The level of the pump was approximately 3.5 feet tall, placing the dispensing area well above the lap area of someone in a wheelchair. At this time, also observed a resident getting coffee, and resident had to reach slightly upward to dispense the coffee (at an approximate 30 degree angle). The Administrator and DON were notified on 05/18/16 at 2:37 p.m., that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was accepted on 05/18/16 at 4:35 p.m. and included: 1. Placing a List in the Nurse Aide Assignment Book of residents who require a sippy cup. 2. Ensuring Resident ADL sheets identify who requires assistive devices. 3. Conduct a review of residents who require assistive devices. 4. In-Service all staff on residents who require assistive devices prior to assuming duties of their next shift. 5. New Employee Orientation will include information about residents who require assistive devices. On 05/19/16, the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: 7 CNAs were interviewed and said they had been trained as to which residents required a sippy cup, and they could identify them. These staff represented all shifts. 2 nurses were interviewed and said they had been trained as to which residents required a sippy cup, and they could identify them. These staff represented all shifts. The Nurse Aide Assignment Book was reviewed and it contained a list of all residents who required assistive devices (including sippy cups). The ADL sheets were reviewed and they identified residents who required assistive devices. An In-service dated 05/18/16, concerning residents who required a sippy cup, was reviewed, and contained the names of 24 staff who attended. A new policy was added to the New Employee Orientation, and this was reviewed and found to address reviewing which residents require assistive devices during this orientation. On 05/19/16 at 11:25 a.m., the Administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm, due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. Assistive Device Assessments dated 05/19/16, indicated there were two residents currently who have a need for an assistive device (sippy cup), and who choose to drink hot liquids.

Based on observation, interview, and record review, the facility failed to implement interventions based on comprehensive assessments to prevent the development of new pressure ulcers for 2 of 2 residents reviewed for pressure ulcers. (Resident #s 10 and 11) 1. Resident #10 was admitted without pressure ulcers, but was at risk for the development of pressure ulcers. He developed a facility - acquired Stage III pressure ulcer with foul odor. The facility did not provide pressure relieving devices. 2. Resident #11had a Stage III pressure ulcer on her right 5th toe that worsened to unstageable. The facility did not have a care plan to address the pressure ulcers to Resident #11's toe. This failure could place the 3 other residents with pressure ulcers at risk for development of new pressure ulcers and decline in existing pressure ulcers. Findings included: 1. Physician orders [REDACTED].#10 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #10 had moderately impaired cognition and was totally dependent for ADLs. The assessment indicated Resident #10 had no pressure ulcers. A weekly skin assessment dated [DATE] indicated Resident #10 had no pressure ulcers. Braden skin risk assessments dated 07/23/14 and 10/21/14 indicated Resident #10 was at risk for developing pressure ulcers. An impaired skin integrity care plan updated 10/01/14 indicated Resident #10 had a Stage III pressure ulcer to his right outer foot. The only intervention on the care plan for prevention of pressure on his feet was, "Appropriate footwear." A hospice nursing note dated 09/30/14 at 9:30 a.m. indicated Resident #10 had a healed abrasion to his right shin. There was no other documentation of other skin problems or pressure ulcers. During a phone interview on 12/03/14 at 10:15 a.m., hospice nurse RN B said she assessed Resident #10 on 09/30/14. RN B said she did not identify a pressure ulcer on Resident #10's right foot during her visit. She said later on 9/30/14, she was notified Resident #10 had a Stage III pressure ulcer on his right outer foot. A nursing note of the weekly skin assessment dated [DATE] at 5:15 p.m., indicated Resident #10 had an "Open area noted to R (right) outer foot 1.5 cm (centimeter) x 1.0 cm clear foul-smelling drainage." A physician order [REDACTED].#10's Stage III pressure ulcer to his right outer foot noted, "...Cleanse wound with wound cleanser, apply triple antibiotic, and cover with a dry dressing daily..." During an observation on 12/03/14 at 2:00 p.m., LVN E provided wound care to Resident #10 ' s right outer foot. He said the pressure ulcer was a healing Stage III. The wound bed was pink and measured 1.5 x 1.9 x less than 0.1 cm. During the following observations, Resident #10 was lying in bed and his heels were not off loaded from the mattress: 12/01/14 at 10:55 a.m., and 2:45 p.m.; 12/02/14 at 7:55 a.m., 11:55 a.m., 9:45 p.m., and 10:20 p.m.; and 12/03/14 at 9:30 a.m. During an interview on 12/03/14 at 11:00 a.m., the DON said she was unaware that Resident #10 had a Stage III pressure ulcer. She said the expectation would be for pressure ulcers to be identified before they reached that stage. 2. Physician orders [REDACTED].#11 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #11 had moderately impaired cognition. Resident #11was identified with1 Stage II and 3 Stage IV pressure ulcers. A care plan for Resident #11 dated 05/05/14 indicated the following: "I have non-healing pressure areas to my left and right buttock and am risk for further skin break down ..." The care plan did not address the wound on her right 5th toe other than one approach which read, "Encourage me to wear the appropriate footwear." A body map assessment for Resident #11 dated 10/27/14 indicated pressure ulcers to her sacrum and right and left buttocks. There was no documentation of a pressure ulcer to her right 5th toe. A body map assessment for Resident #11 dated 10/28/14 indicated pressure ulcers to her sacrum and buttocks and a pressure ulcer to her right 5th toe. A wound assessment report dated 10/28/14 indicated Resident #11 had a Stage III pressure ulcer to her right 5th toe measuring 1.10 cm x 1.30 cm x 0.40 cm. A wound assessment report dated 12/04/14 indicated Resident #11 had a Stage II pressure ulcer to her right 5th toe with 100 % granulation (healing) tissue, and measured 1.10 x 0.90 x 0.03 cm. During an observation and interview on 12/05/14 at 10:03 a.m., LVN E provided wound care to Resident #11. LVN E removed the old dressing to Resident #11's right 5th toe. The wound was purple. LVN E said since the wound bed could not be seen, the wound was unstageable. LVN E said since Resident #11 only wore socks, he was unsure what caused the pressure ulcer. He said Resident #11 sometimes rubbed her feet on the foot pedals of her wheelchair. He said they had not tried foot protectors or padding her wheelchair foot pedals. During the following observations, Resident #11 was sitting in her specialty wheelchair with her feet elevated on the foot pedals and wearing socks. Both feet had foot-drop and were not rubbing on any part of the wheel chair: 12/01/14 at 11:16 a.m.; 12/03/14 at 2:00 p.m. and 7:40 p.m.; 12/04/14 at 11:30 a.m. and 3:00 p.m.; and 12/05/14 at 10:00 a.m. During an interview on 12/04/14 at 2:30 p.m., the DON said the expectation would be for pressure ulcers to be identified before they reached that stage. The National Pressure Ulcer Advisory Panel Website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ accessed 12/09/14 indicated the following: "...International NPUAP-EPUAP Pressure Sore Definition A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Sores Stages/Categories ...Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Additional Categories/Stages for the USA Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as " the body ' s natural (biological) cover " and should not be removed ... " Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The CMS 672 dated 12/01/14 indicated 3 residents had pressure ulcers.

Based on observation, interview, and record review, the facility failed to provide adequate supervision was to prevent falls for 2 of 3 residents reviewed for accidents. (Resident #s 19 and 20) Resident #19 was assessed as being a high risk for falls. Resident #19 fell 5 times between 10/8/14 and 11/26/14. He sustained a laceration to the top of his head and required staples to close the laceration to the top of his head. No interventions were put into place to reduce the resident's risk of falls. Resident #20 fell on [DATE] and on 11/18/14 sustaining a laceration to the left eye, requiring staples. No interventions were put into place to reduce the resident ' s risk of falls. This failure resulted in Resident #s 19 and 20 sustaining lacerations that required staples. This failure could place 10 residents who had falls at risk for injury and neglect. Findings included: 1. Physician orders [REDACTED].#19 was [AGE] year old male, re-admitted [DATE] with [DIAGNOSES REDACTED]. A telephone order dated 09/10/14 indicated Resident #19 required the secured unit. A telephone physician order [REDACTED].#19 was transferred to a psychiatric unit. A face sheet dated 09/09/14 indicated Resident #19's original admitted was 09/09/14. An admission MDS dated [DATE] indicated Resident #19 was moderately impaired in cognition, wandered, used a wheelchair, required supervision for ambulation, and extensive assistance for most other ADLs. Resident #19 was not steady, but able to stabilize without staff assistance during transitions and walking. The assessment indicated no falls, but received occupational therapy 9/13/14 and physical therapy 9/10/14. A fall risk assessment dated [DATE] indicated Resident #19 was a high risk for falls. A fall care plan dated 9/22/14 indicated Resident #19 had: *self-care deficit related to decreased cognitive awareness and dementia with psychosis. Approaches included physical and occupational therapy as ordered. *at risk for falls due to cognitive impairment. Approaches included fall assessment on admission, quarterly, and with changes or falls. A telephone physician order [REDACTED].#19 was readmitted to the facility and physical/occupation therapy was to evaluate and treat resident. An incident/accident report dated 10/28/14 indicated Resident #19 was on the secured unit ambulating out of his bedroom doorway. He fell hitting his buttocks and head. There was no apparent injury. A witness statement Physical Therapist L indicated "It (may be) worth (it) to try putting (resident) in a merry walker where he may walk and sit at any time (with low) fall risk." No other interventions were noted. There were no new fall risk assessments conducted or updates made to Resident # 19 ' s care plan as a result of the fall on 10/28/14. There was no documentation in Resident #19 ' s record to indicate the recommendation for a merry walker was addressed. An incident/accident report dated 11/26/14 indicated Resident #19 was found on the floor by laboratory staff. The post incident action indicated "request bed alarm." There were no new fall risk assessments conducted or updates made to Resident # 19 ' s care plan as a result of the fall on 11/26/14. There was no indication in Resident #19 ' s record the bed alarm was being used. A provider investigation report dated 11/30/14 indicated on 11/29/14 at 11:45 p.m., CNA M found Resident #19 lying on his stomach with the right side of his face on the floor. Blood was noted on the floor at his head. He had a laceration to the top of his head and abrasion to the right side of his head. Resident #19 said he stood up too fast, fell , and hit his head on the floor. He received seven staples to close the laceration to the top of his head. The post-investigation follow-up indicated floor mats were to be beside his bed and staff was in serviced on fall risk. There were no new fall risk assessments conducted or updates made to Resident # 19's care plan as a result of the fall on 11/29/14. Resident #19's fall care plan updated on 11/30/14 indicated resident had a fall while in his room causing a laceration to his head. Approaches included bed/chair alarm. During an observation on 12/04/14 at 5:10 p.m., Resident #19 was sitting in his wheelchair with a staff member present (one-on-one supervision). He had staples to his head. He did not have a fall alarm on his wheelchair. His bed was in the lowest position, but it was still a great distance from the floor. He had a fall mat in place. During an observation and interview on 12/05/14 at 9:07 a.m., Resident #19 was in the dining room with his head down sleeping in his wheelchair. During an observation on 12/05/14 at 2:40 p.m., Resident #19's bed was in the lowest position and his fall mat was in place. Resident was sitting in a recliner in the dining room with his head down. Hospital discharge instructions dated 11/30/14 for Resident #19 indicated he had a head injury. Telephone physician orders [REDACTED]. Neosporin applied to wound twice a day. Tylenol 650 milligram to be given by mouth every six hours as needed. The ADL flow sheets dated November through December 2014 indicated no documentation of fall precautions for Resident #19. During an interview on 12/04/14 at 11:12 p.m., LVN N said Resident #19 was starting to lean forward a lot when in wheelchair. She said fall interventions for Resident #19 included a low bed and supervision. She said they had not tried a merry walker on him. She said he was on every fifteen minute supervision due to an incident he had with another resident (not because he fell ). During an interview on 12/04/14 at 11:21 p.m., CNA H said they now used a fall mat on Resident #19. She said they did not use a fall alarm on Resident #19. She said she was not aware of them trying a merry walker on him. During an interview on 12/05/14 at 9:07 a.m., CNA O said they had not used a chair alarm on Resident #19 because they could not find one. She said Resident #19 tried to use a merry walker, but did not like it and slid under it. She said they just watched Resident #19 closely to ensure he did not fall. She said Resident #19 was monitored every two hours. During an interview on 12/05/14 at 9:10 a.m., LVN E said chair alarms had been on ordered. He said fall alarm (Incident 11/26 referred to bed alarm only) had not been used on Resident #19. LVN E said Resident #19 had a low bed, fall mat and was supervised closely. During an interview on 12/05/14 at 2:44 p.m., CNA P said they did not start using a fall mat for Resident #19 until after his fall with injury, approximately a week ago. She said prior to the fall they were not placing his bed in the lowest position or using a fall mat beside his bed. During an interview on 12/05/14 at 11:30 a.m., the social worker said the only fall risk assessment on Resident #19 was conducted on 10/06/14. During an interview with the MDS coordinator and DON on 12/05/14 at 2:05 p.m., the MDS Coordinator said nurses conducted fall risk assessments upon admission. She said she conducted quarterly fall risk assessments and if residents experience a fall. She said she was unaware of Resident #19 ' s falls and if she had known about the falls, she would have assessed and updated the care plan. Both the MDS Coordinator and the DON said when a resident fell , interventions implemented included fall mats, fall alarms, bolsters for the bed, Palma cushions, and scoop mattresses. They said they checked lighting, referred resident for a therapy screening, and look at all intrinsic and extrinsic factors overall to prevent falls. During an interview on 12/05/14 at 8:40 a.m., the DON said fall risk assessments were completed upon admission, quarterly, and after each falls. She said care plans should be updated with new interventions implemented after each fall. The DON said she was unaware Resident # 19 ' s fall risk assessments not being completed and care plan not been updated. 2. Physician orders [REDACTED].#20 was a [AGE] year old female ,admitted [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #20's cognition was moderately impaired. She required limited assistance of one person with bed mobility and transfers, but had no history of falls. The most recent fall risk assessment dated [DATE] for Resident #20 indicated she had mild- moderate impairment, needed assistance with mobility and transfers. Resident #20 was a high risk for falls. An incident report dated 11/11/14 indicated Resident #20 fell to the floor. No injuries were noted. A fall risk care plan updated on 11/11/14 for Resident #20 noted, she had a fall with no injures noted. Resident #20 was identified as having poor safety awareness and judgment. She resided on the secure unit. Interventions included continue fall precautions and monitoring. An incident reported dated 11/13/14 indicated Resident #20 was found sitting on the floor in the dining room. No injuries were noted. The fall risk care plan was not updated with new interventions after Resident #20 fell on [DATE]. An incident report dated 11/19/14 indicated Resident #20 fell and sustained a laceration above the left eye and required staples. No interventions were listed on the incident report. During an observation on 12/01/14 at 11:10 a.m., Resident #20 was sitting in a geri- chair, eyes closed, with staff present. Resident #20 had no staples to the left eye but had visible bruising. During an interview on 12/03/14 at 10:28 a.m., LVN W said Resident #20 had a history of [REDACTED].#20 could walk but was unsteady. During an interview on 12/05/14 at 8:30 a.m., the DON said no new interventions were implemented to address Resident #20's falls between 11/13/14 and 11/19/14. An assessing falls and their causes policy and procedure revised October 2010 indicated: General Guidelines: "...1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes..." A Fall Risk Assessment policy and procedure revised December 2007 indicated, "...When a resident falls, the following information should be recorded in the resident's medical record: ...5. Completion of a fall risk assessment 6. Appropriate interventions taken to prevent future falls..." The CMS 802 form received 12/01/14 indicated 10 residents had falls.