Every finding on record at Avir at Keeneland

Based on observation, interview and record review the facility failed to store, prepare, distribute and in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure floors were not soiled with food, grease, and white dried substances. 2. The facility failed to ensure food items in the refrigerator were dated and not opened to air. 3. The facility failed to ensure appliances were not greasy and did not contain food particles. 4. The facility failed to ensure food items were stored properly per the manufacturer. These failures could place residents at risk for foodborne illness and a decline in health status.The findings include: Observation of the kitchen on 03/17/2026 at 9:00 AM, with the DM revealed the floors were dirty with food particles, a white dried flaky substance and a greasy film. Observation on 03/17/2026 at 9:10 AM of the 1st commercial refrigerator, with the DM revealed the bottom shelf was soiled with a brown sticky substance, and 2 forks laid underneath the refrigerator. Observation on 03/17/2026 at 9:15 AM of the 3rd commercial refrigerator with the DM revealed a cup of a purple gel substance opened to the air, had no cover, no label, and no date. Inside there were 2 large white plastic containers labeled as potato salad without an open or expiration date. Observation on 03/17/2026 at 9:30 AM revealed the fryer was covered on all sides with grease and fried food crumbs were in the oil and on the surfaces of the fryer. The floor around the fryer and next to the stove had dried orange food particles and other brown greasy substances. Observation on 03/17/2026 at 9:50 AM of the spice rack revealed a large brown container of chocolate syrup, dated opened on 02/25/2026. The manufacturer label stated to refrigerate after opening. In a follow up observation on 03/19/2026 at 9:30 AM, revealed a fork remained underneath the 1st refrigerator and dried greasy substances under and around the fryer. In an interview on 03/19/2026 at 09:32 AM, the Dietary Aide stated the cleaning responsibilities were on all kitchen staff. The Dietary Aide stated there were 2 shifts and each shift was responsible for sweeping and moping the floors at the end of each shift. The Dietary Aide stated the fryer oil was changed weekly and the fryer thoroughly cleaned after they cooked fish on Fridays. The Dietary Aide stated they scraped it clean and was not sure why it looks like it did. In an interview on 03/19/2026 at 9:40 AM, the DM stated she had just recently fired an entire shift for not completing tasks and the remaining staff were working to catch up on all the deep cleaning. She stated it was ultimately her responsibility to make sure the staff were cleaning per the policy and schedules, her expectations were for all staff to help in keeping the kitchen clean, storage and labeling done correctly, and everything kept in order. The DM stated the fryer was deep cleaned every Friday after they fry fish and she was working on having the floors pressure washed. The DM stated at this time she was not sure what the brown substance was in the refrigerator, that the cup in the refrigerator was Jello, but she wasn't sure when it was placed in the refrigerator or what it was not labeled or dated and wasn't sure when the potato salad containers were opened then threw them away. The DM stated she was not aware the chocolate syrup required refrigeration and threw the container out. The DM further that they'd done the best they could with cleaning the fryer. She stated a negative outcome would be; the residents could become ill if cleaning, storage, and labeling were not done properly. In an interview on 03/19/2026 at 11:45 AM with the DON it was revealed the dietary manager was responsible for keeping the kitchen clean and in order. She stated her expectation for the kitchen would be to follow the policy and cleaning log schedules. She stated all kitchen staff were responsible for making sure when an item was opened it should be labeled with the open date and leftovers were properly labeled and covered. She further stated a negative outcome for the residents could be food borne illnesses. In an interview on 03/19/2026 at 12:00 PM with the ADMN, she stated the dietary manager was responsible for making sure staff cleaned the kitchen appropriately. She stated her expectation for the kitchen would be for all staff to follow the daily, weekly and monthly cleaning schedules. She further stated a negative outcome for the residents could be food borne illness issues, sanitary issues, and not having a clean environment. She stated the facility had not had any recent viruses or foodborne illness outbreaks. Record review and interview on 03/19/2026 at 10:43 AM the DM provided a copy of the Dietary Aide job description and orientation competency checklist, as well as the most recent kitchen staff in-service, completed on 2/22/2026, regarding kitchen cleaning, sanitation, job duties, dating and labeling, and following cleaning schedules. The DM stated she was not aware the competency checklist was available to complete for new hires but would be using them from then on. She said the fryer was not listed on the current weekly cleaning schedule list but would add it. Record review of the policy provided titled General Sanitation of Kitchen, dated 2023, revealed [in part]:Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule.Tasks will be assigned to be the responsibility of specific positions.Frequency of cleaning for each task will be defined.5.0 Employees will be trained in how to perform cleaning tasks.6.0 On the cleaning schedule, employees will initial and date tasks when completed. (Refer to Chapter 5: Cleaning instructions for sample cleaning schedule and forms) Record Review of policy provided, titled Sample Cleaning Schedule, dated 2023Weekly:Refrigerators Monthly:Clean behind and under major appliances Daily:FloorsExterior of.and other appliances Record review of the policy provided titled Cleaning Instructions: Refrigerators, dated 2023, revealed [in part]:The refrigerators will be cleaned thoroughly inside and outside with a detergent followed by a sanitizer at least once every month or as needed. Spills and leaks will be cleaned as they occur. 8. Spills should be cleaned at the time they occur. Record review of the policy provided titled Cleaning Instructions: Deep Fat Fryer ,dated 2023, revealed [in part]:Fryers will be cleaned after each use.2. Wipe down the exterior of the fryer. Wipe down areas around the fryer including the walls.5. Remove food particles from the oil after each use. Record review of the policy titled Cleaning Instructions: Floors, dated 2023, revealed [in part]:Kitchen and dining room floors, tables and chairs will be cleaned and sanitized regularly.Sweep and clean kitchen floors after each meal. Sanitize at least once daily. Move major appliances at least once a month in order to facilitate cleaning behind and underneath them. Record review of the policy titled Food Safety and Sanitation dated 2023 revealed [in part]:C. The food and nutrition services department will follow regulations as outlined by other official health agencies and organizations with jurisdiction over the facility.4. Food Storagea. Stored food is handled to prevent contamination and growth of pathogenic organisms.All time and temperature control for safety foods (including leftovers) should be labeled, covered, and dated when stored.Perishable ingredients should be refrigerated when they are not being used.When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. Record review of the policy titled Food Storage, dated 2023, revealed [in part]:12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code.13. Refrigerated food storage:f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen, or discarded. Record review of the policy titled Food Safety - Director of Food and Nutrition Services' Responsibilities, dated 2023, revealed [in part]:The director of food and nutrition services will be responsible for providing safe foods to all individuals.Regulatory requirements for food safety and sanitation will be met.Sanitary conditions will be maintained in the food storage, preparation, and serving areas.All refrigerated and frozen foods will be stored and handled properly. 6. Employees will follow proper cleaning and sanitizing instructions for all kitchen equipment.10. Cleaning schedules will be posted and followed. Record review of the policy titled Training/Orientation, dated 2023, revealed [in part]:Food and nutrition services staff will be adequately trained to perform assigned duties and are required to participate in regularly scheduled in-service training sessions. Upon completion of initial mandatory facility training, each employee will be trained in all food service areas that are related to the job. The director of food and nutrition services will be responsible for department orientation and competency training of new staff.Staff will be trained on the following:1.Overview of Food ServiceGoal: To introduce work and the general responsibilities of the employee.B. Job descriptionC. Reference materials (policy manual). 2. Introduction to food serviceGoal: To provide proper procedures for maintaining an efficient operation, practicing mechanical safety an performing general cleaning duties.C. StoringD. EquipmentE. Cleaning 3. SanitationGoal: To understand the importance of maintaining a clean and sanitary environment. To give specific information on food protection and cleaning of dishes and equipment.b. Equipmente. Cleaning schedules and procedures 5. Food Preparation and Food SafetyGoal: To explain methods of safe food preparatione. Proper food handling and storage, including leftover food. 9. Review of Policies and ProceduresGoal: To provide a basic overview of department's policies and procedures.e. Sanitation and infection controlf. Cleaning instructionsh. Food safety Record review of recent in-service, dated 02/22/2026, with topics which included kitchen cleaning and sanitation, job duties, dating, labeling, and following cleaning schedule book. This in-service was attended by 4 kitchen staff members and the DM. Record review of job description titled Dietary Aide dated [DATE] revealed [in part]:Dietary Aides assist in preparing the dining rooms and tables, provide meal service to residents, and maintain cleanliness and sanitation of dining and kitchen areas.Essential Functions:Ensure compliance with sanitation.Other duties as assigned, with or without reasonable accommodation, to assist in maintaining quality standards and maintaining the facility as a viable and successful entity. Record review of the, undated, checklist titled Dietary Orientation/Competency Checklist revealed [in part]:Training:Food handlingStoring foodHow to clean kitchen equipment

Based on observation, interview and record review the facility failed to determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 4 residents (Resident #13, 20, 30) reviewed for pharmacy services. 1. The facility failed to accurately and timely complete documentation of controlled drug administration for Resident #13, #20 and #30). 2.The facility failed to monitor controlled medications stored on 1 of 2 medication carts checked for narcotic reconciliation and the narcotic locked box in the refrigerator. 3. The facility failed to ensure medications were not missing. These failures could place residents at risk of medication overdose, medication under-dose, and ineffective therapeutic outcomes.During an observation on 03/19/2026 at 8:33 AM revealed the March 2026 controlled count reconciliation sign off sheet for the south hall was not signed at shift change with both oncoming and off-going nursing staff on 3/18/2026 at 6PM or at shift change for 3/19/2026 6AM. During an observation on 03/19/2026 at 9:35 AM revealed the pharmacy blister card for pregabalin medication for Resident #20 contained 24 capsules and the controlled substance count sheet for said medication reflected 25 available. During an interview on 03/19/2026 at 9:36 AM with LVN-C regarding the discrepancy of the pregabalin count for Resident #20, she stated the other nurse hasn't signed it yet. She quickly stated it was the other nurse training her who administered the medication. This medication was administered by LVN-C and observed during the morning medication administration. During the interview with LVN-C she stated that she did indeed administer the pregabalin. She stated a negative outcome for residents could be it could cause a medication error and possibly harm the residents, and the expectation was the medication be signed out as administered. During an observation and interview on 3/19/2026 at 9:38 AM, of the south medication cart narcotic logbook revealed Hydrocodone/Acetaminophen 10-325 mg for resident #30. Observation of narcotic count sheet revealed 72 available and observation of medication blister pack in the narcotic lock box revealed 73. Interview with LVN-B revealed she must not have given the medication, so she voided the entry and asked LVN-C who she was training to co-sign the sheet for her, and did signed the sheet. When LVN-B was asked about best practice when administering narcotics and what could be a negative outcome. Her response was my bad, I guess it could hurt someone. During an observation on 03/19/2026 at 9:40 AM of Resident #13's narcotic medication log sheet for lorazepam 2 milligram per milliliter topical rub , it revealed there were 7 available The narcotic lock box in the refrigerator of the locked medication room revealed there were 4 syringes available. During an observation and interview on 03/19/2026 at 9:43 AM, LVN-B signed the narcotic sheet for Resident #13 and dated it 3/18/2026 at 4PM which resulted in 6 available. In an interview with LVN-B regarding the late signature and the discrepancy, LVN-B stated honestly no about counting the refrigerator medications. She reported they were not counted yesterday for her shift either. LVN-B was unable to recall the last time she counted the refrigerator medications. She stated it should be completed everyday but that it does not always happen. She stated that negative outcome might be the resident could run out. During an interview on 03/19/2026 at 11:45 AM with the ADON she stated she expected all nursing staff to sign the controlled substance log book. out immediately and there were no exceptions . During an interview on 03/09/2026 at 4:50 PM with the DON, she stated her expectations of shift change counting and signing the controlled count book was it needed to happen. She stated the staff were expected to sign out all medications that required a signature and to document appropriately. She stated an adverse outcome could be a medication error, or too much medication for the resident which may result in an illness or death. Record review for Resident #13, #20 and #30 to include face sheets, MDS, care plans and physician orders for the identified residents. Record review of the facility's policy titled Controlled Substances revised November 2022. Policy Statement The facility complies with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976).Dispensing and Reconciling Controlled Substances states1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection /follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. records of personnel access and usage; b. medication administration records; c. declining inventory records; and d. destruction, waste and return to pharmacy records. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. 7. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet.

Based on interview and record review, the facility failed to ensure the resident had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative option he or she preferred for 1 of 5 residents (Resident #3) reviewed for resident rights.1.The facility failed to ensure Resident #3 had a signed consent form for Trazadone, an antidepressant medication, which was ordered by her physician on 12/23/2025.2.The facility failed to ensure Resident #3 had a signed consent form for Alprazolam, an antianxiety medication, which was ordered by her physician on 01/29/2026.3.The facility failed to ensure Resident #3 had a signed consent form for Effexor, an antidepressant medication, which was ordered by her physician on 03/17/2026.4.The facility failed to ensure Resident #3 had a signed consent form for Depakote, an anticonvulsant medication, which was ordered by her physician on 03/17/2026. These failures could place residents at risk for adverse reactions from receiving medications that altered brain activity associated with mental processes and behaviors.The findings include: Record review of Resident #3's Face Sheet, dated 3/18/2026, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. The Face Sheet information included the name of the resident's responsible family member. The resident's diagnoses included dementia (decline in cognitive function affecting memory, thinking, and behavior), Parkinsonism (condition with impaired physical movements including rigidity, tremors, slowness of motion), bipolar disorder (mental health condition with wide mood swings form manic/high to depressed/low), schizoaffective disorder (mix of mental illness with schizophrenia - psychosis, hallucinations - and a major mood disorder), major depressive disorder (condition with symptoms of persistent low mood, profound sadness, or a sense of despair), anxiety, and insomnia (difficulty sleeping). Record review of Resident #3's current Order Summary, dated 3/18/2026, indicated the following medication orders:12/23/2025 - Order for Trazodone 50 mg tablet by mouth in the evening related to major depressive disorder, recurrent.1/29/2026 - Order for Alprazolam (Xanax) tablet 0.5 mg by mouth three times a day for anxiety.3/17/2026 - Order for Effexor Capsule Extended Release 24 Hour 150 mg - Give 1 capsule by mouth at bedtime related to major depressive disorder, recurrent, combine with 75 mg for total dose of 225 mg of Effexor.3/17/2026 - Order for Effexor Capsule Extended Release 24 Hour 75 mg - Give 1 capsule by mouth at bedtime related to major depressive disorder, recurrent, combine with 150 mg for total dose of 225 mg of Effexor. 3/17/2026 - Order for Depakote Sprinkles Oral Capsule Delayed Release 125 mg 2 capsules (to equal 250 mg) by mouth one time a day for bipolar disorder. Record review of Resident #3's Psychoactive Medication Consent forms indicated the following:- The form dated 2/17/2026 documented the medication order for Trazodone 50 mg tablet once a day for the condition of depression. The form was not completed and did not document the beneficial effects expected from the medication, potential risks and side effects, proposed course of the medication (duration), consent and education, type of consent obtained - telephone or verbal, the name and date of the person obtaining permission, or the name and date of the resident, guardian, or legal representative (who consented to the administration of the medication).- The form dated 2/17/2026 documented the medication order for Alprazolam 0.5 mg tablet three times daily for the condition of anxiety. The documented beneficial effects expected from the medication was reduced adverse behaviors. The form was not completed and did not document the potential risks and side effects, proposed course of the medication (duration), consent and education, type of consent obtained - telephone or verbal, the name and date of the person obtaining permission, or the name and date of the resident, guardian, or legal representative (who consented to the administration of the medication).- The form dated 2/17/2026 documented the medication order for Effexor Extended Release 24 Hour 75 mg capsule once a day for the condition of depression. The form was completed and documented verbal consent was obtained, except for the name and date of the person obtaining permission, and the name and date of the resident, guardian, or legal representative (who consented to the administration of the medication).- The form dated 2/17/2026 documented the medication order for Effexor Extended Release 24 Hour 150 mg capsule once a day. The form was not completed and did not document the condition to be treated, the beneficial effects expected from the medication, potential risks and side effects, proposed course of the medication (duration), consent and education, type of consent obtained - telephone or verbal, the name and date of the person obtaining permission, or the name and date of the resident, guardian, or legal representative (who consented to the administration of the medication).- The form dated 2/17/2026 documented the medication order for Depakote Delayed Release 250 mg once a day for the other condition of Parkinson's. The documented beneficial effects expected from the medication was improved function ability. The form was not completed and did not document the potential risks and side effects, proposed course of the medication (duration), consent and education, type of consent obtained - telephone or verbal, the name and date of the person obtaining permission, or the name and date of the resident, guardian, or legal representative (who consented to the administration of the medication). Record review of Resident #3's annual MDS assessment, dated 11/07/2025, indicated a Brief Interview for Mental Status was not conducted, memory problem and severely impaired decision making skills; inattention and disorganized thinking; no mood state indicators; no behavioral symptoms; diagnoses included progressive neurological conditions, non-Alzheimer's dementia, anxiety, depression, bipolar disorder, schizophrenia; and medications included anti-anxiety and anti-depression medications with indication for use. Record review of Resident #3's quarterly MDS assessment, dated 3/07/2026, indicated a Brief Interview for Mental Status was not conducted, memory problem and severely impaired decision making skills; mood indicators of depressed, appetite change, trouble concentrating, slow speech/movements; no behavioral symptoms; diagnoses included progressive neurological conditions, non-Alzheimer's dementia, anxiety, depression, bipolar disorder, schizophrenia; and medications included anti-anxiety and anti-depression medications with indication for use. During an interview and record review on 3/19/2026 at 4:09 PM, the RNC reviewed Resident #3's psychoactive medication consent forms in the resident's electronic health record. She stated the Corporate MDS Coordinator was doing electronic health record audits and had started the psychoactive medication consent forms. The RNC stated the Corporate MDS Coordinator's intent probably was to start the forms and have one of the facility nurses to complete the follow-up and ensure the consent was obtained from the resident's responsible family member or representative and complete the form. In an interview on 3/19/2026 at 4:17 PM, the DON stated the expectation was to obtain consent prior to the psychoactive medication initial dose being administered. The DON stated an adverse effect of not providing information and education and obtaining informed consent could be upset family members and adverse side effects for residents including sedation, tardive dyskinesia (involuntary movement disorder), and other risk factors. The DON stated consent was needed for Depakote when the indication for use was mood stabilization. The DON stated Resident #3 received Depakote for the diagnosis of schizoaffective disorder. In an interview on 3/19/2026 at 4:23 PM, the RNC stated there was not a specific written facility policy for obtaining informed consent for psychoactive medications. She stated the facility followed the federal and state guidelines for obtaining informed consent. The RNC printed and provided a copy of the facility policy for Psychotropic Medication Use for review.Record review of the facility policy for Psychotropic Medication Use, dated 2001, specified [in part]:Policy StatementResidents will not receive medications that are not clinically indicated to treat a specific condition.Policy Interpretation and Implementation1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior .3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes:a. indications for use;b. dose (including duplicate therapy);c. duration;d. adequate monitoring for efficacy and adverse consequences; ande. preventing, identifying and responding to adverse consequences .7. Categories of medications which affect brain activity such as antihistamines, anti-cholinergic medications, and central nervous system medications that are prescribed as a substitute for or and adjunct to a psychotropic medication are monitored and managed as psychotropic medications.Resident Evaluations3. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether:c. a particular medication is clinically indicated to manage the symptoms or condition, andd. the actual or intended benefit of the medication is understood by the resident/representative.4. Residents (and/or representatives) have the right to decline treatment with psychotropic medications. a. The staff and physician will review with the resident/representative the risks related to taking the medication as well as appropriate alternatives.

Based on interview and record review the facility failed to ensure conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 4 residents (Resident #13) reviewed for assessments. The MDS Coordinator did not complete Resident #13's Annual Minimum Data Set (MDS) Assessment. This deficient practice could place residents at risk of not meeting the residents needs with inaccurate and incomplete MDS assessments.The findings were: Record review of Resident #13's face sheet, dated 3/19/2026, revealed an admission date of 02/10/2025, and a readmission date of 08/01/2025. Resident #13 had diagnoses which included: Vascular dementia with agitation (decreased blood flow to areas of the brain with behaviors), hypertension (high blood pressure), depression (persistent sadness), anxiety (stress response), cardiac pacemaker (implanted device for slow heart rate that monitors and sends small electrical impulses to regulate its rhythm), and atherosclerotic heart disease (hardening of the arteries in the heart). Record review of Resident #13's electronic MDS record, on 03/19/2026, revealed an Annual MDS, dated [DATE], the Assessment Reference Date (ARD), was in progress and not completed making it 36 days overdue at 402 days. The most recent Quarterly MDS was accepted on 11/11/2025, made Resident #13's next quarterly assessment 36 days overdue at 128 days. In an interview on 03/19/2026 at 2:50 PM with the RNC, she stated she needed to call the remote MDS nurse who was currently taking care of the MDS' as the new ADON nurse in training would be taking that over soon. In an interview on 03/19/2026 at 3:35 PM with RNC, she stated the MDS for Resident #13 had fallen through the cracks and not followed up on. She stated it was her expectation for all MDS assessments to be completed and transmitted in a timely manner according to policy and regulations. The RNC further stated she did not feel the resident was placed in any harm by the assessment being incomplete, the only issue would be the facility was not being paid correctly for care given and that the DON would ultimately be responsible for the accuracy and timely reporting of the MDS. Record review of the policy titled Resident Assessments, dated revised March 2022, revealed [in part]:The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements.(3) Annual Assessment (Comprehensive) 2. The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. Record review of Center for Medicare and Medicaid (CMS) RAI User's Manual dated October 2025 revealed [in part]; Chapter 2.6 Required Omnibus Budget Reconciliation Act (OBRA) Assessments for the MDS 02. Annual Assessment (A0310A = 03)The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an Significant Correction in Status Assessment (SCSA) or a Significant Correction to Prior Assessment (SCPA) has been completed since the most recent comprehensive assessment was completed. The ARD (item A2300) must be set within 366 days after the ARD of the previous OBRA comprehensive assessment (ARD of previous comprehensive assessment + 366 calendar days) AND within 92 days since the ARD of the previous OBRA Quarterly or Significant Change of Quarterly Assessment (SCQA) (ARD of previous OBRA Quarterly assessment + 92 calendar days).

Based on observation, interview and record review the facility failed to ensure drugs and biological used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory cautionary instructions, and the expiration date when applicable for 1 of 1 medication rooms reviewed for medication storage and 1 of 2 medication carts reviewed for medication storage. The facility failed to ensure the Medication Room did not have expired medication and biologicals.The facility failed to ensure that medications were stored properly in the medication carts. This failure could place residents who at risk of receiving expired medications. During an observation on 03/19/2026 9:25 AM, of the medication cart for South Hall, revealed several loose pills in the second drawer. During an interview on 03/19/2026 at 9:32 AM, LVN-C reported it was her first day in training and she did not look through the cart like she should have. She immediately began to remove all loose medications found and placed them in the sharps box on the side of the medication cart. During an observation on 03/19/2026 at 9:45 AM of the medication room revealed several bottles of medications on a shelf. Among these bottles were 3 sealed bottles of sodium bicarbonate (325milligram tablets with 100 tablets each). The expiration date on each of these bottles reflected 10-25. During an interview on 03/19/2026 at 11:45 AM with the ADON, regarding her expectations for the medication carts, revealed she expected the nurse scheduled to administer medications to keep the cart tidy and free from loose medications. Her expectation for medications in the medication room was to ensure expired medications were destroyed properly. She reported it would be her responsibility for ordering and checking the stock in the medication room but she has not been able to complete this task yet. During an interview on 03/19/2026 at 4:50 PM with the DON, regarding her expectation of expired medications and loose pills in the medication cart, revealed she expected the nurses to keep the medication carts cleaned and free from spills and loose pills being in the bottom of the drawers. Record review of the facility's policy titled Medication Labeling and Storage (revised February 2023)Policy Heading The facility stores all medications and biologicals in locked compartments under [NAME] temperature, humidity, and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation Medication Storage Medications and biological are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 (Resident #7) of 4 residents reviewed for medical records. The facility failed to document Resident #7's weekly skin assessments. These failures place residents at risk of health and safety due to inaccurate assessments. Findings included: Record review of Resident #7's face sheet dated 3/27/25 revealed, a [AGE] year-old female admitted on [DATE] with the following diagnoses: Cerebral palsy (group of movement disorders), cerebral infraction (stroke), vascular dementia (brain damage), type 2 diabetes, schizophrenia, muscle wasting (loss of muscle mass and strength). Record review of Resident #7's quarterly MDS dated [DATE] revealed, Section C-Cognitive Behavior BIMS score of 00 (severe cognitive impairment), Section GG-Extensive assist (means helper did all the effort for rolling left to right in bed, dressing, toileting, transferring). Section M-Skin Condition revealed the resident was at risk for pressure ulcers. Record review of Resident #7's care plan dated 3/4/25 revealed, Resident #7 was at risk for skin break down and ulcers, approach to care: Monitor for incontinent every 2 hours and PRN, change promptly, monitor for skin break down, assess skin weekly and record findings, apply moisturizing lotion. Record review of Resident #7's weekly skin assessment documentation revealed no evidence that skin assessments were performed on: 03/11/2025 and 03/18/2025. During an interview on 3/23/25 at 4:30pm. LVN N stated that she is one of Resident #7's nurses, and that charge nurses were responsible for weekly skin assessments. LVN N stated that the facility's computer documentation system would high-light the day each resident was due for a skin assessment. LVN N stated the skin assessment was probably done but that the nurse failed to document in the resident's chart. LVN N stated the skin assessments should have been documented weekly in a resident's chart. During an interview on 3/25/25 at 3:58 p.m., the DON stated his expectation would be that skin assessments be performed weekly by the charge nurse. The DON stated that himself and the ADON monitored that skin assessments were being done by performing random chart audits. The DON stated charge nurses were responsible for performing weekly skin assessments. The DON stated he was unaware why skin assessments had not been documented. The DON stated that weekly skin assessments were an important measure to help prevent skin issues and catching any issues early. Review of the facility policy titled Skin Integrity Monitoring System dated 2/2021, Assessment and Monitoring, 3.) All residents will be assessed weekly using the (Weekly Skin Assessment) form for any type of skin integrity complications, this will include pressure injury and non-pressure related complications. The (Weekly Skin Assessment) will be documented on the (Weekly Skin Assessment) in clinical software.

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services for 2 of 2 residents (Residents #8 and #23) reviewed for tube feeding management. 1. The facility failed to ensure that Resident #8 and Resident #23 had properly labeled formula and water for their tube feedings on 12/17/24 and 12/18/24. 2. The facility failed to ensure that Resident #8's head of bed was elevated while her tube feeding was infusing on 12/18/24. These failures could place residents at risk of aspiration and not receiving adequate nutrition by way of enteral feeding. The findings included: Review of Resident #8's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, dysphagia (difficulty swallowing) following stroke, and protein-calorie malnutrition. Review of Resident #8's Annual MDS Assessment, dated 11/21/24, revealed: she scored a 5 on her mental status exam, indicating severe cognitive impairment. She was dependent on staff for all ADLs. She had loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual in food in mouth after meals, coughing or choking during meals or when swallowing medications, and complaints of difficulty or pain with swallowing. She had a feeding tube and received 51% or more of her total calories from tube feeding and 501 cc/day or more of her fluid intake from tube feeding. Review of Resident #8's Care Plan, most recent edit date 12/18/24, revealed the following: Problem - Resident was at nutritional risk and fluid alteration as she requires enteral tube feeding, Isosource 1.5 continuous feeding with water flushes. (Resident is NPO related to stroke associated dysphagia. Goal - Resident will not exhibit signs of complications from feeding tube or enteral feeding solution. Approach (interventions) - Administer medications via tube; evaluate/record/report effectiveness/adverse side effects. Check placement and patency of feeding tube before each feeding or medication administration. Monitor for signs of malnutrition (pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with [NAME] or magenta hue, poor skin turgor, cachexia (a general state of ill health involving weight loss and muscle loss), bilateral edema, muscle wasting). NPO (nothing by mouth) status. Provide flushes/additional fluids as ordered. Provide frequent oral care, lubricate lips. Review of Resident #8's Physician Order Report on 12/18/24 revealed the following orders: Change irrigation set every day (Start Date: 12/28/23) Diet - NPO (nothing by mouth) every shift (Start Date: 8/6/24) Elevate head of bed 30 degrees every shift (Start Date: 8/14/23) Monitor feeding tube site and change dressing daily, cleanse site with normal saline and gauze, place a new dressing over the site daily and as needed for soiled dressing (Start Date: 9/4/24) Isosource 1.5 at 85 ml/hour for 20 hours - flush to be 350 ml of water every 4 hours while pump is running, every day at 2:00 pm (Start Date: 9/5/24) Check feeding tube placement by auscultating (listening with stethoscope) air passage before medication administration and every shift (Start Date: 11/26/24) Observation on 12/17/24 at 12:51 pm revealed Resident #8 in bed with tube feeding disconnected. The resident's tube feeding formula and water were hanging on a pole at bedside. The prefilled bag of formula had no label on the bag indicating resident information or date the feeding was prepared. The bag of water hanging with formula had a label with only the date (12/16/24) and resident's name legible. Observation on 12/18/24 at 5:10 pm revealed Resident #8 in bed, the head of the bed was elevated approximately 15-20 degrees with tube feeding connected and infusing at 85 ml/hr. Review of Resident #23's Face Sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including stroke, dysphagia (difficulty swallowing), gastrostomy (feeding tube) status, and protein-calorie malnutrition. Review of Resident #23's Quarterly MDS Assessment, dated 11/5/14, revealed: he scored a 15 on his mental status exam, indicating he was cognitively intact. He was dependent on staff for all ADLs. He had loss of liquids/solids when eating or drinking, and coughing or choking during meals or when swallowing medications. He had a feeding tube. He had a mechanically altered diet. He received 51% or more of his total calories from tube feeding and 501cc/day or more of his fluid intake from tube feeding. Review of Resident #23's Physician Order Report revealed the following orders: Check feeding tube placement by aspirating stomach contents prior to feedings and flushes every shift - if residual is greater than 100 cc, hold feeding for 1 hour and recheck, if still greater than 100 cc notify physician (Start Date: 9/24/20) Elevate head of bed 30 degrees every shift (Start Date: 3/1/21) Cleanse feeding tube site every day with normal saline and gauze (Start Date: 3/9/23) Change irrigation set and feeding bad every day, 6 pm - 6 am (Start Date: 8/27/24) Flush feeding tube with 5-10 ml of water between each medication when administering medications, every shift (Start Date: 10/5/23) Start tube feeding with Isosource 1.5 at 90 cc/hour for 12 continuous hours, 225 cc water every 4 hours, every day at 5:00 pm (Start Date: 10/7/24) Stop tube feeding at 5:00 am every day (Start Date: 10/7/24) Pleasure feedings, regular diet, mechanical soft texture, thin liquids, must be sitting up in wheelchair for pleasure feedings (Start Date: 12/17/24) A record review of Resident #23's care plan was completed on 12/19/24. The care plan contained proper documentation of the resident's tube feeding, goals, and interventions. The saved copy of the resident's care plan was erased and unable to be referenced at the time the citation was written. Observation on 12/18/24 at 5:05 pm revealed Resident #23's tube feeding hanging on pole with bag of water. The resident was not in the room at the time, and the tube feeding set up was hanging but not connected to the resident. Neither bag (formula or water) had a label indicating date prepared or resident information. In an interview on 12/19/24 at 5:26 pm with the ADON and DON, the DON stated that Resident #8 and Resident #23 were the only tube residents in the facility with feeding tubes. The DON stated that the nurses should ensure that the HOB was elevated to 30 to 45 degrees during a tube feeding, the resident should remain with HOB elevated throughout the feeding and then for at least 30 minutes after the feeding is disconnected. The DON and ADON both stated that the formula and water bags should have a label including the date, nurse initials, flow rate for feeding, resident name, resident room number, and the time the bag was hung. The DON stated that annual competencies were done for feeding tubes for all nursing staff. The ADON stated there were newly hired nurses in the facility that might need refreshing on the training and policy/procedure. The DON stated there was no excuse for the failures. The ADON stated the failures were an educational issue with the nursing staff. In an interview on 12/19/24 at 6:17 pm, the Administrator stated that she had nothing further to add regarding the failures and that she agreed with everything the ADON and DON had stated. She stated that the formula and water bags not being labeled occurred on 2 different staff rotations and that indicated it was an educational issue across the board that needed to be addressed. She stated that the head of the bed not being elevated was also an educational issue. Review of facility policy titled Enteral Formula Via: Feeding Tube, Bolus, Gravity, Pump (Closed/Open) Administration effective date 10/2020 revealed, in part: The syringe and bag (if used) should be changed every 24 hours. The ready-to-hang bottles should be changed according to the manufacturer recommendation or when total amount infused is less than the manufacturer recommendation . The syringe, bag, and/or bottle should be labeled with the resident name, room number, date changed, and the nurse's signature/initials. The bag or bottle should also specify the physician order for formula, rate, route, and means of administration. Elevate the head of the bed at least 30 degrees or more before starting the feeding and for at least 30-40 minutes after the feeding. It is policy that the head of the bed is elevated at least 30 degrees or more during the administration of the tube feeding and 1 hour after the feeding is completed.

48593 Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Resident #26, Resident #32) reviewed for infection control. The facility failed to ensure staff followed infection control policies and procedures while providing Resident #26 and Resident #32 with wound care. This failure could place residents at risk for cross contamination and infection. The findings include: Record review of Resident #26's admission record dated 12/19/24 revealed Resident #26 was a [AGE] year-old female with an admitted to the facility of 01/03/2023. Admission record revealed Resident #26 had diagnoses that included muscle weakness, type 2 diabetes, transient cerebral ischemic attack (stroke), and anxiety. Record review of Resident #26 's MDS (minimum data set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) of 6 indicating the resident had severe cognitive impairment. Under section M1200 the skin and ulcer/injury treatment, revealed the resident to had a pressure injury and needed applications of ointments/medication. Record review of Resident #26 's Care plan dated 11/12/2024 revealed Problem: Resident has a stage 3 right medial shin pressure ulcer related to immobility. Goal: Resident's ulcer will heal without complications. Approach: keep clean and dry as possible. Minimize skin exposure to moisture. Record review of Resident #26 's order summary revealed an order of pressure wound of the left medial shin: cleanse with normal saline and gauze. Apply alginate calcium and santyl to wound bed. Cover with a bordered island dressing. And pressure wound of the right medial shin: cleanse with normal saline and gauze. Apply alginate calcium and santyl to wound bed. Cover with a bordered island dressing During an observation of wound care on 12/19/24 at 09:54 AM with the DON for Resident #26, the DON used shears that were not cleaned prior to use, to cut the dressing that was placed on Resident #26's wounds on her left shin and right shin. Record review of Resident #32's admission record dated 12/19/24 revealed Resident #32 was a [AGE] year-old female with an admitted to the facility of 06/04/2024. Admission record revealed Resident #32 had diagnoses that included Cerebral infarction due to thrombosis of right middle cerebral artery (stroke), hearing loss, contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) of muscle right upper arm, contracture of muscle left upper arm, and contracture right hand. Record review of Resident #32 's MDS dated [DATE] revealed the resident was unable to obtain a BIMS score due to being rarely or never understood. Section M1200 the skin and ulcer/injury treatment, revealed the resident to have a have a pressure injury and needing of applications of ointments/medication. Under section M1040 other ulcers, wounds and skin problems, D. open lesion(s) other than ulcers, rashes, cuts. Record review of Resident #32 's order summary revealed orders of Right hand: Apply alginate calcium once daily wrap with island gauze with border for 30 days ordered on 10/18/24 and pressure wound of the right ring finger: cleanse w/ NS and gauze. Apply alginate calcium and santyl. Cover with bordered island dressing ordered on 12/06/24. During an observation of wound care on 12/19/24 at 09:54 AM with the DON for Resident #32, the DON cleansed the resident's wound to the inside of her right hand, then set the resident's hand down on the resident's gown with no barrier in place. During an interview on 12/19/24 at 01:53 PM, the DON stated that he normally had someone holding Resident #32's hand during wound care due to pain, but since she was not in pain, he did not think to have someone hold the hand to prevent contaminating the wound. The DON stated he recognized how that was cross contamination. The DON stated the shears he used were cleaned after the last wound care was performed and was placed in his office. The DON acknowledges that he could not guarantee the shears were clean by the time he used them since they had been out of his sight. The DON stated he recognized how that could be a chance for cross contamination. Record review of facility policy titled infection control - cleaning and disinfecting resident care items and equipment stated in part reusable items are to be cleaned and disinfected or sterilized between residents.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to conduct the functions of the food and nutrition service for 1 of 1 (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility's DM met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses. Findings included: Record review of the DM's employee file revealed a hire date on 1/20/21. There was no documented evidence of a Dietary Manager Certificate found in the file. In an interview on 12/17/24 at 10:30AM, the DM stated she did not have her dietary manager certification. The DM stated she stated her employment at the facility was in Housekeeping then as the Dietary Manager at the facility for the past 2 years. The DM stated she was planning on starting online classes after the New Year. She stated she did have a current food handlers' certificate. In an interview on 12/19/24 at 2:00 PM, the Administrator stated her expectation was that the Dietary Manager would have completed a food service manager's course and have a current certification as a Dietary manager. She stated the failure could result in the resident's not having their nutritional needs met and place them at risk for foodborne illness. Review of the Job description of the Dietary Manager not dated, revealed in part: Job summary - Manage the operations of the dietary department to include staffing, food ordering and preparation, food delivering and clean up, in accordance with facility policies, physician orders, care plans, and appropriate regulations. Successful completion of Certified Dietary Manager exam.

Based on interviews, the facility failed to ensure residents had a right to organize and participate in resident groups in the facility and provide 7 out of 7 Residents private space to conduct group meetings without facility staff present or continued interruptions by facility staff walking through the meeting to and from the kitchen and outside breakroom. The facility failed to provide a private area for confidential resident group meeting. This failure placed all residents that could participate in a resident council at risk of not having the right to voice their concerns without staff being present or overhearing their concerns and to conduct resident council meetings without interference. Findings included: During a confidential group interview on 10/24/2023 at 2:00 p.m., 7 residents stated that staff cut through area during resident council meetings. During an interview on 10/24/2023 at 3:30 p.m., AD stated that the facility had to move council meetings from conference room to therapy room then from therapy room to dining room due to resident council growing. AD stated that residents have complained about staff walk through the dining room during the resident council meeting. She stated that she reported the complaint over to management. She felt that residents should have the right to have privacy during the council meetings. She stated that since the meetings were for one hour a month, staff should be able to walk around the building to get to their breakroom opposed to walking through dining room for convenience. During an interview on 10/24/2023 at 3:44 p.m., ADMN stated that the facility does not have a policy for resident council. Admin stated that the facility goes off the TAC (Texas Administrative Code) requirements. She stated that she was aware in the past that it was an issue with staff walking through resident council. Admin felt the failure was because the facility did not have signage telling staff not to enter the dining room during resident council meeting. She stated her expectation was for staff to not enter resident council meeting. She stated the negative effect would be that the residents would not be able to speak freely during their meetings with staff present.

Based on interview, and record review the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 2 (Resident #31 & Resident #36) residents reviewed for individual activities. The facility failed to provide one-on-one visits to Resident #31 & Resident #36 as care planned. This failure could result in residents having a diminished quality of life. Findings included: Record review of Resident #31's face sheet dated 10/24/2023 revealed an [AGE] year-old female who was admitted on [DATE] (initial) and 09/10/2023 (most recent) with diagnoses of adult failure to thrive (state of decline), cognitive communication deficit (difficulty with thinking and how someone uses language), weakness, dysphagia following nontraumatic subarachnoid hemorrhage (difficulty swallowing after brain bleed not caused by trauma), reduced mobility, and hemiplegia (inability to move one side of the body). Record review of Resident #31's quarterly MDS dated [DATE] revealed BIMS of 15 meaning cognitively intact. Resident #31 needs extensive one person assistance with bed mobility, self-performance, and toilet use. Resident #31 was not observed to transfer or walk at the time of the assessment. Resident #31 needed supervision / setup with eating at the time of the assessment. Received medications for anxiety, depression, fluid retention, and infection. Record review of Resident #31's care plan revealed problem start date: 04/12/2023 category: activities . is a one on one in room. She likes to have her nails done and reminisce. Her Husband visits her every day. She likes to read and watch television. She is a bed bound resident. But enjoys our visits. Intervention: Resident will have one on one room visits 3 times per week through the review date. The resident will maintain involvement in cognitive stimulation, social activities as desired through review date. During an interview on 10/24/2023 at 12:07 p.m., Resident #31 stated there was a man that comes to visit her some but doesn't know when he was here. She stated that she thought he was a chaplain. She stated that she had care plan meetings in her room since she did not like to get out of bed. She stated that the activities director did not come into room three times a week. Resident #31 stated that she was not lonely as she had Jesus. Record review of Resident #36's face sheet dated 10/24/2023 revealed an [AGE] year-old female who was admitted on [DATE] with diagnoses of pain, open-angle glaucoma (disease that affects vision), cerebral infarction due to thrombosis of infarction (stroke caused by blood clot), aphasia (difficulty swallowing), hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side (inability to move or weakness of left side that is not dominant as person is right handed), cognitive communication deficit (difficulty with thinking and how someone uses language), weakness, and depression. Record review of Resident #36's comprehensive MDS dated [DATE] revealed BIMS of 11 meaning moderately impaired cognition. Resident is dependent on staff to perform oral hygiene (clean teeth), toileting, bathing, dressing, putting on and taking off footwear, and transferring from bed to chair. Record review of Resident #36's care plan revealed problem start date: 10/01/2023 category: activities . needs one on one in room social interactions AD visits 2x a week for stimulating conversations about news and tv shows the weather current events in the work. Sometimes refuses visits do to pain or family visitors. During an interview on 10/24/2023 at 10:23 a.m., Resident #36 stated she did not get to participate in activities much. She stated she uses a hoyer lift (machine that allows staff to transfer someone that cannot assist with transfer). During an interview on 10/25/2023 at 9:50 a.m., AD stated that she had been doing activities. She will provide print out of documentation for the residents' one on one activities. She revealed she had not been good with documenting activities in facility's electronic system. Record review of the facility's one on one documentation dated 08/25/2023 provided revealed that both Resident #31 and Resident #36 had two 1:1 observation in the month of October. During an interview on 10/25/2023 at 1:30 p.m., AD stated that the observations were the only documented. She stated that she has 7 days to document activities. During an interview on 10/25/2023 at 1:48 p.m., ADMN stated that documentation should occur within 24 hours of activity being performed. She stated that staff members should not be documenting anything on a note pad, it should be completed in electronic documentation. She stated that all staff had been trained on documentation. Record review of the policy titled ONE-ON-ONE PROGRAM dated 01/01/2023 revealed Policy One-on-one wellness visits will be provided for those residents whose physical or intellectual impairments prohibit their active involvement in group programs and/or those residents wo prefer not to attend group programs and/or for identified short term rehab patients. Procedure Wellness staff will utilize the One-on-One Tracking form to maintain an up to date list of residents identified for one-on-one programming each month. When visits are completed the date of intervention is noted and the appropriate documentation information is completed in the wellness activity participation documentation (form or EMR depending on facility) .The resident's individual care plan must include identified need and interventions as well as the number of visits he/she is to receive per week. The wellness staff are responsible for documenting each one-on-one session according to the facility documentation process (see Home Office Forms for paper log and refer to EMR as identified) and should include: Date, Duration of visit, Intervention(s), Response(s). If a one-on-one intervention is offered but the resident refuses, it must also be documented with reason for refusal. 48883 Based on interview, and record review the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 2 (Resident #31 & Resident #36) residents reviewed for individual activities. The facility failed to provide one-on-one visits to Resident #31 & Resident #36 as care planned. This failure could result in residents having a diminished quality of life. Findings included: Record review of Resident #31's face sheet dated 10/24/2023 revealed an [AGE] year-old female who was admitted on [DATE] (initial) and 09/10/2023 (most recent) with diagnoses of adult failure to thrive (state of decline), cognitive communication deficit (difficulty with thinking and how someone uses language), weakness, dysphagia following nontraumatic subarachnoid hemorrhage (difficulty swallowing after brain bleed not caused by trauma), reduced mobility, and hemiplegia (inability to move one side of the body). Record review of Resident #31's quarterly MDS dated [DATE] revealed BIMS of 15 meaning cognitively intact. Resident #31 needs extensive one person assistance with bed mobility, self-performance, and toilet use. Resident #31 was not observed to transfer or walk at the time of the assessment. Resident #31 needed supervision / setup with eating at the time of the assessment. Received medications for anxiety, depression, fluid retention, and infection. Record review of Resident #31's care plan revealed problem start date: 04/12/2023 category: activities . is a one on one in room. She likes to have her nails done and reminisce. Her Husband visits her every day. She likes to read and watch television. She is a bed bound resident. But enjoys our visits. Intervention: Resident will have one on one room visits 3 times per week through the review date. The resident will maintain involvement in cognitive stimulation, social activities as desired through review date. During an interview on 10/24/2023 at 12:07 p.m., Resident #31 stated there was a man that comes to visit her some but doesn't know when he was here. She stated that she thought he was a chaplain. She stated that she had care plan meetings in her room since she did not like to get out of bed. She stated that the activities director did not come into room three times a week. Resident #31 stated that she was not lonely as she had Jesus. Record review of Resident #36's face sheet dated 10/24/2023 revealed an [AGE] year-old female who was admitted on [DATE] with diagnoses of pain, open-angle glaucoma (disease that affects vision), cerebral infarction due to thrombosis of infarction (stroke caused by blood clot), aphasia (difficulty swallowing), hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side (inability to move or weakness of left side that is not dominant as person is right handed), cognitive communication deficit (difficulty with thinking and how someone uses language), weakness, and depression. Record review of Resident #36's comprehensive MDS dated [DATE] revealed BIMS of 11 meaning moderately impaired cognition. Resident is dependent on staff to perform oral hygiene (clean teeth), toileting, bathing, dressing, putting on and taking off footwear, and transferring from bed to chair. Record review of Resident #36's care plan revealed problem start date: 10/01/2023 category: activities . needs one on one in room social interactions AD visits 2x a week for stimulating conversations about news and tv shows the weather current events in the work. Sometimes refuses visits do to pain or family visitors. During an interview on 10/24/2023 at 10:23 a.m., Resident #36 stated she did not get to participate in activities much. She stated she uses a hoyer lift (machine that allows staff to transfer someone that cannot assist with transfer). During an interview on 10/25/2023 at 9:50 a.m., AD stated that she had been doing activities. She will provide print out of documentation for the residents' one on one activities. She revealed she had not been good with documenting activities in facility's electronic system. Record review of the facility's one on one documentation provided on 10/25/2023 revealed that both Resident #31 and Resident #36 had two 1:1 observation in the month of October of 2023. During an interview on 10/25/2023 at 1:30 p.m., AD stated that the observations were the only documented. She stated that she has 7 days to document activities. During an interview on 10/25/2023 at 1:48 p.m., ADMN stated that documentation should occur within 24 hours of activity being performed. She stated that staff members should not be documenting anything on a note pad, it should be completed in electronic documentation. She stated that all staff had been trained on documentation. During an interview on 10/25/2023 at 1:48 p.m., AD stated she had not documented activities. She stated that she was unsure of how many times each resident required one on one. Record review of the policy titled ONE-ON-ONE PROGRAM dated 01/01/2023 revealed Policy One-on-one wellness visits will be provided for those residents whose physical or intellectual impairments prohibit their active involvement in group programs and/or those residents wo prefer not to attend group programs and/or for identified short term rehab patients. Procedure Wellness staff will utilize the One-on-One Tracking form to maintain an up to date list of residents identified for one-on-one programming each month. When visits are completed the date of intervention is noted and the appropriate documentation information is completed in the wellness activity participation documentation (form or EMR depending on facility) .The resident's individual care plan must include identified need and interventions as well as the number of visits he/she is to receive per week. The wellness staff are responsible for documenting each one-on-one session according to the facility documentation process (see Home Office Forms for paper log and refer to EMR as identified) and should include: Date, Duration of visit, Intervention(s), Response(s). If a one-on-one intervention is offered but the resident refuses, it must also be documented with reason for refusal.

Based on observation, interview and record review the facility failed to accurately assess each resident's status for 1 of 4 Residents (Resident #36) reviewed for assessment accuracy in that: Resident #36's Admission MDS dated [DATE] did not have Section H (bowel and bladder) coded correctly. This failure could place residents at risk of not receiving the proper care and services due to inaccurate records. Finding included: Record review of Resident #36's face sheet dated 08/25/2023 revealed she was [AGE] year-old female. She was admitted to the facility on [DATE] with a diagnosis of Cerebral infarction due to thrombosis of unspecified cerebral artery (disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of Resident #36's Admission MDS dated [DATE] revealed the following: Section C (BIMS) revealed a score of 11 out 15, reveals that the resident had moderate cognitive impairment. Section H (bowel and bladder) revealed the resident did not have an indwelling catheter, did have an ostomy. Record review Resident #36's orders revealed that the resident had a Foley Catheter, start date of 08/07/2023. Record review of Resident #36 orders from 08/07/2023 to 08/25/2023 revealed that the resident did not have an Ostomy. Record review of Resident #36's care plan dated 08/25/2023 revealed that the resident did not have an ostomy and did have a catheter. During an observation and interview on 10/23/2023 beginning at 3:16 PM, Resident #36 was in her room lying in bed. Resident had a catheter bag hanging from bedside that was covered by a privacy bag. She revealed that she had a catheter before she was admitted into the facility. She revealed that she has never had an ostomy and was unsure what it even was. Observation revealed that the resident did not have an ostomy and did have a catheter. During an interview on 10/25/23 at 09:56 AM, the MDS Coordinator, revealed the Admission MDS dated [DATE] was coded inaccurately under the bowel and bladder section. She revealed that Resident #36 has had a catheter since admission and has not had an ostomy since admission. She revealed that the failure could cause an inaccurate care plan and confusion with the floor staff in the care areas. The MDS coordinator revealed that they use the RAI manual for guidance, she was unsure of they had a policy covering it. Record review of the facility's policy and procedures regarding resident assessments dated October 2010 revealed: The purpose of this assessment is to describe the resident's capabilities to perform daily life functions and to identify significant impairments in functional capacity derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. A copy of the facilities policy on Accuracy of Assessments was requested on 08/25/2023 and was not received at the time of exit.

Based on interview and record review, the facility failed to develop the comprehensive care plan with the participation of the resident and the IDT (Interdisciplinary Team) for 2 of 6 residents (Resident #36 and #37) reviewed for care plans. The facility's failure could affect residents by placing them at risk for individual needs not being identified and addressed in the IDT meeting and decreased feelings of self-determination and psychosocial well-being within their living environment. The findings included: Record review of Resident #36's face sheet dated 10/25/2023 revealed resident was a [AGE] year-old female. She was admitted to the facility on [DATE] with a diagnosis of Cerebral infarction due to thrombosis of unspecified cerebral artery (disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of Resident #36's Admission MDS dated [DATE] revealed the following: Section C (BIMS) revealed a score of 11 out 15, reveals that the resident had moderate cognitive impairment. Record review in Resident #36's electronic record revealed there was a Care Conference completed on 08/10/2023, but it was before the Admission MDS assessment containing Section V (CAAS) and the Care Plan was completed. The resident was not included or invited to the meeting. In an interview on 10/23/23 at 3:16 PM, Resident #36 revealed that she has not been included or attended a care plan conference or meeting. She revealed that she had some things she would like to discuss concerning her care. Record review of Resident #37's face sheet dated 10/25/2023 revealed resident was a [AGE] year-old male. He was admitted to the facility on [DATE] with a diagnosis of end stage renal disease (kidney failure), gangrene (tissue death), hypertension (high blood pressure) and symbolic dysfunctions (language deficit). Record review of Resident #37's Admission MDS dated [DATE] revealed the following: Section C (BIMS) revealed a score of 15 out 15, reveals that the resident was cognitively intact. Record review in Resident #37's electronic record revealed there was a Care Conference completed on 09/26/2023, but it was before the Admission MDS assessment containing Section V (CAAS) and the Care Plan was completed. A RN was not included in the IDT meeting. In an interview on 10/23/2023 at 3:13 PM, Resident #37 stated he had never been invited or attended a care plan conference meeting. In an interview on 10/25/2023 at 09:56 AM the MDS Coordinator revealed from electronic record review that the IDT meeting was not conducted at all on Resident #36. She revealed that what was captured before the MDS was completed was a care conference that was requested by the family. She revealed that the care plan was not discussed, since it was not completed yet. She revealed for Resident #37, she did not have a RN or the full IDT present. She revealed that was not doing them correctly. She revealed that Resident #37 did not even have his CAAS completed or the care plan when they had a meeting on 09/26/2023. The MDS Coordinator revealed that she forgot to do it. The MDS Coordinator revealed that the care plan failure could cause the residents to receive improper care. She revealed that she uses the RAI for guidance and for their policy and procedure. Record review of the facility policy Care Plans, dated 02/2021, reflected the following [in part]: 1. Concerns and Problems a. Review CAA (Care Area Assessment) triggers on the MDS. If the interdisciplinary Team (IDCPT) decides to proceed with care planning, list the problem. 1. The specific problem as well as the underlying cause should be listed. 2. If the home is using nursing diagnoses for problem statements, the underlying condition must be identified. This may be done by following the nursing diagnoses with a statement beginning Due to . or Related to . b. Sources are, but are not limited to: 1. Problems relating to diagnoses. 2. Problems relating to physician's orders. (Remember, all orders for care should correspond to a diagnosis.) 3. Dietary problems - including the need for feeding assistance. 4. Psychosocial problems. 5. Activity problems. 6. Rehabilitation problems. 7. Behavior control problems. 8. Problems related to preventive care. 9. Problems related to provision of safety. 10. All problems identified on all assessments. 11. Specialized services related to PASRR and RT 2. Resident Goals (Short-Term Goals) a. List a measurable, reasonable goal for each problem identified. Goals should be stated in terms of what the resident will or will not accomplish. b. It may be difficult for the staff to think in these terms for gravely ill residents. However, specific goals such as, Skin intact, No weight loss, No further contractures, etc. are measurable. However, the IDCPT must be sure to state a reasonable goal. c. Although each discipline may have a unique goal to accomplish for each problem, all disciplines should work as a team and coordinate efforts to accomplish care plan goals. 3. Approach / Plan a. List care to be provided for the problem listed. The care must be NECESSARY AND APPROPRIATE to accomplish the goal stated. b. Coordinate care to be provided to the resident for the most effective, efficient utilization of resources. c. Individualize care to ensure the care plan is person centered for the unique needs of the resident. d. Communicate vital information to staff providing direct resident care. e. List infection control measures. f. List safety measures. g. Each discipline should list approaches for the care it will provide. Coordinating care by all disciplines, working toward a common or similar goal, will improve efficiency. 4. Involved Service or Responsible Discipline a. The following persons are to be involved in the development of the care plan: Licensed nurses (LVN/RN) Registered Nurse (RN) Nursing assistants (C N A responsible for resident). Restorative nursing assistant (RNA). Dietary supervisor (FSS). Social Service Designee (SSD). Activity Director (AD). Therapists (RPT, ST, OT, RRT). Attending Physician Any other professional needed

Based on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 2 medication carts reviewed for pharmacy services. The facility did not ensure medications carts were secured and locked. This failure could place the residents who resided in the facility at risk of a drug diversion. Findings included: During an observation on 10/24/2023 at 4:36 PM, LVN A left a medication cart unlocked and unattended. She did not have visual of the medication cart. There were 3 residents that were in close range to the medication cart. The medication cart contained medications that were perscribed to the residents. During an interview on 10/25/2023 at 9:32 AM with LVN A, she revealed that she walked away after she found out she was going to have to work a different area than she normally does. She stated she stepped away and wasn't paying attention to the cart and if she locked it. She revealed the failure could cause the resident to gain access to medications that would be bad for them. She revealed she has received training on locking the medication carts. She revealed that it was a one-time failure, and she has since been in-serviced on it. During an interview on 10/25/2023 at 10:00 AM with the DON, revealed that her expectations are for the medication carts to be locked anytime a nurse walks away from it. She revealed that she has provided training to LVN A. A policy and procedure titled: Medication storage dated 02/2021 was received on 10/25/2023 at 10:03 AM, revealed the following: Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (i.e., medication aides, etc.) are allowed access to medications. Medication rooms, carts, and medications supplies are locked or attended by persons with authorized access.

Based on observation and interview, the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift in a place readily accessible to residents and visitors, in that: 1. The facility failed to update and post the daily nurse staffing information on 10/25/2023. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. The findings included: Observation on 10/25/2023 at 2:30 PM revealed the daily nurse staffing pattern was not posted on the wall in the location designated for it. In an interview on 10/25/2023 at 2:35 PM, ADON stated, I'm sorry I failed to change the staffing today because I've been working ever since last night. In an interview on 10/25/23 at 2:40 PM DON stated, We post the staffing daily today it was just an oversight on our part, and she said failure to post the daily staffing would give the public inaccurate information regarding the facility staffing, and census. In an interview on 10/25/23 at 2:53 PM Administrator stated, we don't have a policy on nurse staff posting but the staff posting is posted daily by the ADON and I check it on a daily basis but with everything that's going on I failed to check it today. She said not posting the information would give the public inaccurate information.

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including the State Survey Agency in accordance with the State law through established procedures for Residents (Resident #7) reviewed for reportable incidents in that: The facility did not report to HHSC (State Agency) within the required timeframe after Resident #1 choked to death in the dining room. This failure placed residents at risk for neglect and incidents involving resident safety not being reported to the State Agency by the facility. The findings included: Record review of Resident #7's face sheet, revealed a [AGE] year old female admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Advanced Directive indicated Full Code (Full Code allows for all interventions, CPR, chest compressions, defibrillator and breathing tube). Record review of Resident #7's initial MDS started [DATE] revealed a BIMS score of 10, which indicated cognitively impaired. (Scores closer to 0 indicate severe cognitive impact whilst scores closer to 15 indicate an intact cognitive response: 08 - 12: moderately impaired.) Record review of Nursing notes dated[DATE] ,and witness statements from ADON and LVN #1 reavealed on [DATE] at approximately 12:45pm Resident #7 was eating lunch in dining room when resident began to choke. LVN #1 performed the [MEDICATION(S)] maneuver on resident #7. ADON and DON responded to situation and came to dining room to help. [MEDICATION(S)] maneuver was able to cause resident #7 to vomit but resident had stopped breathing, DON began CPR. EMT arrived and continued CPR with no response and Resident #7 expired. Record review of HHSC computerized program for tracking facilities Self-Reports revealed the Administrator, DON or designee did not Self-Report to HHSC that Resident #7 Death to HHSC. Record review of resident #7 Care Plan, Dated [DATE], revised [DATE], Risk of Aspiration Pneumonia, check for Ausculate lung sounds, Crackles, wheezing. Elevate head of bed for lung expansion, monitor/Document/report to MD the following, aspiration, Pneumonia, fever, cough, trachypnea and [CONDITION(S)]. Record review of waivers Against Medical Advice, signed by resident # 7 dated [DATE], resident was informed of risks for: Recurrent Lung infection, choking/coughing, Pain during swallowing, aspiration Pneumonia, Fluid Overload. Resident was informed of risks. During interview on [DATE] at 1:39 pm with the facily's Administrator and Director of Nursing said that they consulted with their corporate office, and it was decided that the incident was not a reportable incident. When asked what was the reasoning for determining not to report the incident the Administrator stated she did not know. During interview on [DATE] at 3:00 pm with Administrator and DON said they did not report because the facility had Care Planned that Resident #7 was at risk for aspiration, Resident #7 was informed of risks by facility, Resident #7's personal physician, facility's Social worker, facility's Ombudsman and family. Resident #7 reserved the right to eat normal textured food and had signed waivers from the facility that Resident #7 knew the risks but it was her choice to eat regular textured food and staff monitors resident's in the dining room. Review of Facility's policy of Reporting Abuse, Neglect, Exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator or designee will report the allegation to HHSC. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of allegation. Neglect, Is the failure of the facility, its employees or Services to a resident that are necessary to avoid physical harm, pain Neglect, Is the failure of the facility, its employees or Services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress., mental anguish or emotional distress.

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property, are thoroughly investigated for one of one reportable incidents (Resident #7) reviewed for investigations. The facility failed to thoroughly investigate when Resident #7 choked to death in the dining room. This failure placed residents at risk for neglect and incidents involving resident safety not being reported to the State Agency by the facility. The findings included: Record review of Resident #7's face sheet, revealed a [AGE] year old female admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Advanced Directive indicated Full Code (Full Code allows for all interventions, CPR, chest compressions, defibrillator and breathing tube). Record review of Resident #7's initial MDS started [DATE] revealed a BIMS score of 10, which indicated cognitively impaired. (Scores closer to 0 indicate severe cognitive impact whilst scores closer to 15 indicate an intact cognitive response: 08 - 12: moderately impaired.) Record review of Nursing notes dated[DATE] ,and witness statements from ADON and LVN #1 reavealed on [DATE] at approximately 12:45pm Resident #7 was eating lunch in dining room when resident began to choke. LVN #1 performed the [MEDICATION(S)] maneuver on resident #7. ADON and DON responded to situation and came to dining room to help. [MEDICATION(S)] maneuver was able to cause resident #7 to vomit but resident had stopped breathing, DON began CPR. EMT arrived and continued CPR with no response and Resident #7 expired. Record review of HHSC computerized program for tracking facilities Self-Reports revealed the Administrator, DON or designee did not Self-Report to HHSC that Resident #7 Death to HHSC. Record review of resident #7 Care Plan, Dated [DATE], revised [DATE], Risk of Aspiration Pneumonia, check for Ausculate lung sounds, Crackles, wheezing. Elevate head of bed for lung expansion, monitor/Document/report to MD the following, aspiration, Pneumonia, fever, cough, trachypnea and [CONDITION(S)]. Record review of waivers Against Medical Advice, signed by resident # 7 dated [DATE], resident was informed of risks for: Recurrent Lung infection, choking/coughing, Pain during swallowing, aspiration Pneumonia, Fluid Overload. Resident was informed of risks. During interview on [DATE] at 1:39 pm with the facily's Administrator and Director of Nursing said that they consulted with their corporate office, and it was decided that the incident was not a reportable incident. When asked what was the reasoning for determining not to report the incident the Administrator stated she did not know. During interview on [DATE] at 3:00 pm with Administrator and DON said they did not report because the facility had Care Planned that Resident #7 was at risk for aspiration, Resident #7 was informed of risks by facility, Resident #7's personal physician, facility's Social worker, facility's Ombudsman and family. Resident #7 reserved the right to eat normal textured food and had signed waivers from the facility that Resident #7 knew the risks but it was her choice to eat regular textured food and staff monitors resident's in the dining room. Review of Facility's policy of Reporting Abuse, Neglect, Exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator or designee will report the allegation to HHSC. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of allegation. Neglect, Is the failure of the facility, its employees or Services to a resident that are necessary to avoid physical harm, pain Neglect, Is the failure of the facility, its employees or Services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress., mental anguish or emotional distress. Investigation: Comprehensive investigations will be the responsibility of the Administrator and/or Abuse Preventionist. All allegations of Abuse, Neglect, Exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review the facility failed to ensure residents/resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's Responsible Party was informed when Resident #1 had changes to his [MEDICATION(S)] 125 mg order on 06/14/2022. This deficient practice could place residents at risk for not being informed about care and treatments that may affect the resident's well-being. The findings were: Record review of Resident #1's face sheet, dated 09/01/2022, revealed Resident #1 was a 41-yearl old male, with his latest admission to the facility being on 06/27/2022 and the original admitted was 09/22/2021. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's initial Admission MDS, dated [DATE], revealed Resident #1 had an intellectual disability. Section C revealed a BIMS score of 12 , which signified moderate cognitive impairment. Section E indicated Resident #1 had verbal behavior symptoms directed toward others. Section I indicated he had a [CONDITION(S)] Disorder and a [CONDITION(S)] along with anxiety disorder and Impulse Disorder. Record review of Resident #1's most recent admission MDS, dated [DATE], revealed Resident #1 had an intellectual disability. Section C revealed a BIMS score of 07, which indicated severe cognitive impairment. Section E indicated Resident #1 did not exhibit any behaviors physical or verbally. Record review of Resident #1's signed physician orders, dated 05/13/2022, revealed Resident #1 had the following orders: - [MEDICATION(S)] Sprinkles ([MEDICATION(S)]) capsule delayed release sprinkle; (a medication used to treat seizures and mood disorders) 125 MG PO [by mouth] QD [daily], At Bedtime, Start date: 09/30/2021, End date: Open Ended. Record review of FDA.gov (Federal Drug Administration), revealed .[MEDICATION(S)] is an anti-epileptic drug indicated for: o treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Accessed on 09/08/2022 https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/ 3s037lbl.pdf Record review of Resident #1's Pharmacy Review Note to Attending Physician/Prescriber, dated 06/12/2022, revealed the following: [Resident #1] [Physician A] .This Resident has been taking [MEDICATION(S)] 125 mg HS (at bedtime) since 09-2021. Please evaluate the current dose and consider a dose reduction . Further review of this note revealed in handwritten ink the words per psych and next to the medication hand written letters D/C. The Signature line on the note revealed a stamped signature with hand written initials from [NP A] and was dated 06/14/2022. Record review of Resident #1's progress notes, dated from 06/12/2022 thru 06/27/2022, revealed no progress note describing Resident #1's responsible party was informed of the medication changes, but did reflect the following entry: .06/15/2022 14:48 (2:48pm) [MEDICATION(S)] DC' d per [contracted pharmacy] recommendation and [Physician B] approval .electronically signed by the DON. In a telephone interview on 09/01/2022 at 9:30 a.m., Resident #1's responsible party indicated he had medical power of attorney for the resident and he made all the medical decisions for Resident #1. The Responsible Party for Resident #1 indicated in mid-June he learned the resident's [MEDICATION(S)] 125 mg had been discontinued and he was not notified or included in the decision to discontinue the medication. Resident #1's Responsible Party indicated the facility should have included him in that decision and was concerned it was abruptly discontinued rather than weaned off. In an interview on 09/01/2022 at 1:34 p.m., the DON said Physician A deferred the recommendation to reduce the dose of [MEDICATION(S)] to Physician B and NP A, who oversaw Resident #1's psychiatric services because the [MEDICATION(S)] 125 mg was given for mood stabilization rather than for [CONDITION(S)] control. The DON said he recalled getting the signed note that gave the order to discontinue the [MEDICATION(S)] 125 mg and made the changes to Resident #1's orders but the DON said he did not recall calling the Responsible Party for Resident #1, who oversaw and made decisions for Resident #1`s care. The DON said it was an oversight on his part and the responsible party for Resident #1 should have been contacted regarding the decision to discontinue the medication to ensure the understanding and communicate any concerns with discontinuing the medication with Physician A, Physician B or NP A. In a telephone interview on 09/01/2022 at 3:03 p.m., NP A said he was the nurse practitioner for Physician B, who performed the psychiatric services for the facility. NP A said he managed Resident #1's psychiatric care and had just evaluated Resident #1 on 05/31/2022 and had diagnosed him with [CONDITION(S)] I disorder, intermittent explosive disorder, [CONDITION(S)] disorder and [CONDITION(S)]. NP A said he recalled discontinuing the dose of [MEDICATION(S)] at 125 mg Resident #1 received after a pharmacy review was performed on 06/12/2022. NP A said initially the recommendation from the pharmacy consultant A had been sent to Physician A, however due to the medication being given for a psychiatric diagnosis, Physician A wrote per psych and deferred the recommendation to NP A and Physician B to review. NP A stated after she reviewed the recommendation; it was determined the [MEDICATION(S)] was on a non-therapeutic dose for both managing his [CONDITION(S)] and Impulsive Disorder and a non-therapeutic dose to manage any seizures, which NP A indicated Resident #1 received two other [CONDITION(S)] medications to effectively manage his [CONDITION(S)] control and felt the [MEDICATION(S)] was not ordered to assist with his [CONDITION(S)] control but more so for mood stabilization. NP A said Resident #1 had not exhibited any increased behaviors and was doing well, therefore the decision to discontinue the [MEDICATION(S)] was agreed and NP A signed the recommendation. In a telephone interview on 09/01/2022 at 3:30 p.m., Pharmacy Consultant A said she made the recommendation to reduce the dose of [MEDICATION(S)] 125 mg for Resident #1 on 06/12/2022 and due to that being such a low dose, there was no need to gradually reduce and her recommendation would have been to just discontinue the dose. In a telephone interview on 09/01/2022 at 3:56 p.m., Physician A said he oversaw Resident #1's medical care while he was a resident at the facility and had in fact, overseen his care for many years at previous facilities. Physician A recalled that Resident #1 received the [MEDICATION(S)] 125 mg for psychiatric issues and indicated when he received the pharmacy consultant recommendation to reduce the [MEDICATION(S)] 125 mg, he referred the recommendation to psychiatric services and acknowledged the had written per psych on the recommendation note. Physician A said Resident #1 received an entry level low dose and it was the lowest dose you could start someone on and it was in no way being used to manage his [CONDITION(S)] disorder. In a telephone interview on 09/01/2022 at 5:45 p.m., Physician B said she provided psychiatric services for Resident #1 and NP A worked under her and assisted her with providing psychiatric evaluations and services for the long-term care facilities and specifically for Resident #1. Physician B said she reviewed Resident #1's recommendation from the Pharmacy Consultant A and agreed with the decision to discontinue the [MEDICATION(S)] 125 mg due to it being a non-therapeutic dose for his [CONDITION(S)] disorder and Impulse Disorder and indicated it was not being used to manage his [CONDITION(S)] disorder nor was there a need to taper the dose. Record review of Resident #1's signed Statement of Resident Rights by Resident #1's Responsible Party on 09/24/2021, revealed the following: .You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. You have all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States .Any violation of these rights is against the law .You have a right to: .2. Make your own choices regarding personal affairs, care, benefits, and services . 11. To be fully informed about your total medical condition, in a language you understand, and to be notified whenever there is a significant change in their medical condition, by the person providing services. The person should explain the change, recommended treatment, and the expected results of the treatment, including reasonably expected effects, side effects, and risks . Record review of the facility's policy entitled Change of Condition, observing, reporting and recording, dated 02/2021, revealed the following: .Policy It is the policy of this home to inform the resident, the resident's physician and if indicated the resident's responsible party of the following .4. A need to alter treatment significantly .7. A change in resident rights under federal or State law or regulations pertaining to care of the resident.

Based on interviews, and record reviews the facility failed to ensure assessments accurately reflected the resident's status for 1of 2 residents (Resident #' 21) reviewed for PASSR Evaluation. 1. Resident #21's Admission MDS dated [DATE] inaccurrately documented the resident did not have serious mental illness despite having diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents at risk of inadequate care and services based on inaccurate assessment and place residents at risk of inaccurate information being transmitted to CMS which uses the data to shape future regulations and improve the quality of life and care for residents who live in nursing facilities. The findings included: Record review of Resident #21's face sheet, not dated, revealed a [AGE] year-old male with a re-admitted [DATE] and the latest return date of 07/03/2022. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #21'correction MDS dated [DATE] revealed a BIMS of 3 which indicated severe cognitive impairment Record reviews of Resident #21 's EMR and the long-term care portal documentation on 08/11/22, revealed the resident's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), and was dated 1/11/22 and, indicated yes for mental illness. His PE section for mental Illness was documented as completed on 01/28/22. Section C, (the section of the PE pertaining to Mental Illness) documented the resident had the following Mental Illness Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21's admission MDS dated [DATE] Section A 1500 indicated no, the resident had not been evaluated by level 2 PASRR and determined to have a serious mental illness. A 1510 Level 2 PASRR conditions did not indicate that the had a serious mental illness or other related condition. During an interview with MDS Regional Consultant on 08/11 /22 at 10:35 AM she stated Resident 21's Admission MDS dated [DATE], section A1500 and A1510 were marked no for Mental illness, and this would be an inaccuracy. MDS nurse stated she was unaware this was an MDS inaccuracy and confirmed the resident did have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 08/11/2022 at 10:30 AM, the MDS nurse she was responsible for the accuracy of the MDS sections she completed. She did not state how the residents could be affected by these inaccuracies. The Regional MDS Consultant stated in an interview on 8/11/22 at 11:40 AM the facility followed the RAI (Resident Assessment Instrument Manual Manual) for information on completion of the MDS and there was not another written policy.

Based on observation, interview, and record review the facility failed to ensure a medication error rate was not 5 percent or greater. The medication error rate was 26 percent with 8 errors in 30 opportunities involving one staff, LVN A and 1 of 1 resident (Resident # 83) reviewed for medication errors. Resident ID # 83 's medications were combined in a bolus dose and administered through her gastrostomy feeding tube instead of administering the medications separately. This failure could place residents receiving medication by gastrostomy tube at risk of not receiving the intended therapeutic benefit of their medication, or blockage of the feeding tube. The findings include: Review of resident # 83's face sheet, not dated, revealed she was admitted to the facility on [DATE]. She was [AGE] years of age. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #83's orders dated 08/10/2022 revealed the following medications scheduled for administration: [MEDICATION(S)] 10 mg 1 tablet by g-tube (term used to describe a tube in the stomach) one time a day, Guaifenesin 400 mg 3 tablets per g-tube every 12 hours to equal 1200 mg every 12 hour , [MEDICATION(S)] 50 mg 1 tablet per g-tube, every day, [MEDICATION(S)] 400 mg 1 tablet every day, [MEDICATION(S)] 10 mg one tablet a day, [MEDICATION(S)] 10 mg 1 tablet once a day, vitamin C 500 mg 1 tablet daily, B12 100 mcg 1 tablet every day, Vitamin D3 10/400 1 daily, and zinc 50 mg 1 daily. During an observation of medication pass on 08/11/2022 at 09:17 AM LVN A prepared 1 crushed a bolus dose of medications which contained: [MEDICATION(S)] 10 mg 1 tablet, Guaifenesin 400 mg 3 tablets to equal 1200 mg, [MEDICATION(S)] 50 mg 1 tablet [MEDICATION(S)] 400 mg, [MEDICATION(S)] 10 mg 1 tablet, Vitamin D3 1 tablet, Vitamin B12 100 mcg 1 tablet, Zinc 50 mg 1po and entered the resident's room. LVN A administered the medications to resident # 83 mixed together in one medicine cup through her gastrostomy tube. In an in interview at 9:30 AM on 08/10/2022 LVN A stated it was her normal practice to combine and administer the medications in a bolus dose. She stated she routinely administered gastrostomy tube (tube for feeding and medications inserted into the stomach) medications in a bolus dose. She stated that the consequences of administering the meds in the bolus dose was that the tube could become clogged. In interview at 10:30:AM on 08/10/2022 the DON stated that his expectation was that g- tube medications should be crushed and given individually in separate cups, and meds should be followed by at least 15 ml of water before and between each medication. He stated the resident did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he would Inservice the nurses on the proper technique for administering the medications. Review of the facility's policy titled Medication Administration, dated 202/2021, revealed in part: 1. Check placement of tube in stomach by insertion of air into tube and listening to the epigastric area with a stethoscope for a bubbling sound or aspirate contents of stomach with a catheter syringe. 2. Attach the barrel of the syringe to the tube and pour water into the syringe per physician order; instill and add liquids or diluted medication to the syringe; allow to flow into the tube by gravity or administer gentle boosts with the plunger (approximately 1 inch down) if the medication will not flow by gravity: Each medication should be administered separately Liquid dosage forms should be used when available and if appropriate Verify that the medication can be crushed (If not crushable ask physician to change to a crushable form) Grind simple compressed tablets to a fine powder and mix with water Open hard gelatin capsules and mix powder with water Dilute liquid medication as appropriate Review of article titled Drug Administration Through an Enteral Feeding Tube revealed: Avoid mixing medications intended for administration through an enteral feeding tube .when more than one drug is administered at the same time, predicting stability and compatibility becomes even more difficult. Thus, when more than one drug is scheduled for administration, they must be given separately. https://www.nursingcenter.com/ce_articleprint?an= 446- 0000- accessed 08/11/2022.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were free from any chemical restraints imposed for staff convenience and not required to treat the resident's medical symptoms for three (Residents #13, #10, and #12) of 11 residents reviewed for chemical restraints. 1) LVN A administered Resident #13 [MEDICATION NAME] (antianxiety medication) Gel, without an order, [MEDICATION NAME] (antipsychotic medication) IM without using non-pharmological interventions first, threatened Resident #13 with an injection if she did not "calm down," and administered Sterile Water for injections after threatening Resident #13 with a "shot." 2) Resident #10 was administered [MEDICATION NAME] Gel and a [MEDICATION NAME] (antipsychotic medication) injection after she became upset when she was not allowed to have peanut butter crackers. Staff did not offer her another snack and did not call her husband prior to administering the [MEDICATION NAME] and [MEDICATION NAME]. 3) Resident #12 was administered [MEDICATION NAME] on several occasions for staff convenience to control or manage Resident #12's behavior, even though he was easily redirected. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could affect the other eight residents who exhibited behaviors by placing them at risk of sedation, medical complications [REDACTED]. Findings included: 1) Resident #13 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] for Resident #13 revealed she did not have any behaviors, [MEDICAL CONDITION] or hallucinations. She did not have any signs of [MEDICAL CONDITION]. Review of a Comprehensive Plan of Care for Resident #13 initiated on [DATE] revealed, "Resident is on a Therapeutic Diet...Reg LCS diet...small portions...Approaches: ...2) DM to monitor/discuss food preferences...Resident noncompliant (with) diet @ all meals...." Review of a Comprehensive Plan of Care for Resident #13 initiated on [DATE] revealed, "Resident has cognitive impairment AEB (as evidenced by) [MEDICAL CONDITION] Disorder-she tells staff members what to do & how to do it. She tells housekeepers how to clean d/t used to be a worker in a cafe AEB HOH (hard of hearing)-appears bossy @ times...Approaches: 1) Resident may sit close to D/R (dining room) while D/R is being cleaned as resident request. 2) Gentle reminders if resident is being inappropriate. 3) Redirect as needed...." A review of a Cognitive/Behavior Data Collection dated [DATE] for Resident #13 revealed she required daily intervention for orientation/memory. The form indicated Resident #13 exhibited the following behaviors daily: yelling, cursing, and crying. The interventions included: 1) Calm, gentle approach, 2) Distract to another activity, 3) Stop activity and reassure if upset, 4) Anticipate needs, 5) Assist/remind to bathroom, 6) Quiet area to limit stimuli, 7) Rest periods and 8) Receives psych services. A review of the [DATE] consolidated physician's orders [REDACTED]. A review of a physician's telephone order dated [DATE] for Resident #13 revealed she was receiving [MEDICATION NAME] (used to treat [MEDICAL CONDITION] or [MEDICAL CONDITION]) 20 mg by mouth every a.m. This dose was increased from 15 mg. A review of a nurse's note dated [DATE] at 10:00 a.m. for Resident #13, revealed, ",[DATE] Escorted out of dining room at supper time because she got into an argument (with) another resident. Stopped once removed from situation...." A review of a nurse's note dated [DATE] at 10:00 a.m. for Resident #13, revealed, "Alert to staff...very rude & (and) argumentative (with) staff & resident. In room yelling @ (at) staff to come in there... 5:30 p.m. Resident in dining room, yelling, cursing, throwing @ staff & residents. 2 staff unable to calm resident. Took to room (with) staff...hitting, kicking, attempting to bite staff. Med IM (left) arm. 20 mg [MEDICATION NAME] for severe agitation... 6:00 p.m. Still very aggressive & yelling... 7:00 p.m. In room. Quieter but still non-compliant & argumentative... 9:00 p.m. In room in w/c sleeping. This nurse & CNA attempted to change her & get her ready for bed. Woke up yelling, 'I'm not changing I'm not ready for bed. Resident stopped yelling & staff left room. (authored by LVN A)." A review of the [DATE] MAR for Resident #13 revealed there was no documentation of the [MEDICATION NAME] being administered on [DATE], or for the entire month through [DATE]. Review of the February 2011 MAR indicated [REDACTED]. A review of the Behavior Monitoring logs for [DATE] for Resident #13 revealed she had three behavior (yelling) incidents prior to [DATE]. All three incidents were treated with redirection and/or one-on-one, which meant the staff would sit with the resident. On [DATE] the logs reflected she had one episode of behaviors and the intervention was, "Refer to nurse's notes." A review of the incident and accident reports on [DATE] revealed no reports regarding Resident #13's behavior on [DATE]. A review of a physician's telephone order dated [DATE] for Resident #13 revealed she was receiving [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 50 mg by mouth at bedtime for anxiety [MEDICATION NAME](used to treat [MEDICAL CONDITION]) 5 mg by mouth at bedtime for [MEDICAL CONDITION]. An interview on initial tour with LVN A on [DATE] at 9:45 a.m. revealed Resident #13 was hard of hearing, had Dementia, behaviors and was not interviewable. LVN A stated Resident #13 sometimes "acted out" by yelling and appeared confused. An observation of Resident #13 on [DATE] at 9:45 a.m. revealed Resident #13 was asleep in bed with two side rails in the up position. LVN A was not able to awaken Resident #13. An observation on [DATE] at 12:05 p.m. revealed Resident #13 was up in the dining room in her wheelchair. She was alert and not exhibiting any behaviors. An observation on [DATE] at 2:22 p.m. revealed Resident #13 was sleeping in her bed. A confidential interview on [DATE] revealed he/she observed Resident #13 asking for buttermilk during the evening meal on [DATE]. He/she stated Resident #13 was told she could only have buttermilk one time a day. He/she stated Resident #13 became upset and was throwing food and 'choking' herself. He/she stated he/she heard LVN A and LVN I state, "Just let her do it." An interview on [DATE] at 3:22 p.m. with DA J revealed she was asked by LVN A to help get Resident #13 to her room during the incident. DA J stated LVN A rubbed the yellow gel ([MEDICATION NAME]) on Resident #13's neck. DA J stated LVN A then administered a "shot" in Resident #13's right shoulder. DA J stated LVN A then gave Resident #13 another shot in the left shoulder. When asked how much time had passed, from the "yellow gel" to the time of the second shot, DA J stated 10 minutes. An interview on [DATE] at 3:55 p.m. with LVN A revealed she was the charge nurse for Resident #13 on Sunday, [DATE]. She stated she heard screaming coming from the dining room and went to see what was happening. She stated Resident #13 wanted buttermilk and was told she could only have it one time a day. When asked why Resident #13 was not allowed to have the buttermilk, LVN A stated the facility only bought enough for her to have it once a day. LVN A stated she removed Resident #13 from the dining room and took her to her room, with the assistance of DA J and Cook K. LVN A stated she gave Resident #13 [MEDICATION NAME] gel. LVN A denied trying any additional interventions before administering the [MEDICATION NAME] gel, other than removing Resident #13 from the dining room. The MAR indicated [REDACTED]. There was no entry on the MAR for [MEDICATION NAME] gel. LVN A stated she was not aware Resident #13 did not have an order for [REDACTED].#13. She stated she told Resident #13, "I'm gonna have to give you another shot (if she did not calm down)." LVN A stated Resident #13 said, "Go ahead!" LVN A stated she then withdrew 3 cc of N/S in a syringe and administered it to Resident #13 in the opposite arm. When asked if she obtained an order for [REDACTED]." When asked if she notified the physician of what she had done, LVN A stated she did tell the physician she administered [MEDICATION NAME] and an injection of Saline. LVN A stated Resident #13 calmed down and was taken back to the dining room. http://www.drugs.com/[MEDICATION NAME].html. "[MEDICATION NAME] is used to treat anxiety disorders... Seek emergency medical attention if you think you have used too much of this medicine. An overdose of [MEDICATION NAME] can be fatal. [MEDICATION NAME] overdose symptoms may include extreme drowsiness, confusion, muscle weakness, [MEDICAL CONDITION], or coma...." An interview on [DATE] at 4:15 p.m. with the ADM and the DON revealed they were not aware of Resident #13 being threatened with a shot for behaviors until today. When asked who did have knowledge of the incident prior to today, the ADM stated the licensed nurses on [DATE] (LVN A and LVN I) knew. (Note: LVN A was working on [DATE] from 2:00 p.m. to 10:00 p.m.) A review of an incident report dated [DATE] (provided to the survey team on [DATE]) for Resident #13 revealed, "...Incident date: [DATE]...Time: 5:30 p.m....State Facts Observed at scene: Resident in dining room yelling, cussing, throwing @ staff. Hitting, kicking & attempting to bite staff. Grabbed staff hand & twisted her finger...." This report was completed by Regional Nurse C. The second page of the incident report was, "Incident Investigation." It reflected it was not an abuse allegation. The section of the report titled "List Interventions in Place to Prevent Incident" reflected, "Redirection, removing resident from area & talking calmly to her. [MEDICATION NAME] 20 mg IM if other steps are not successful. Treatment @ (local behavior unit)...." A statement included with the Incident Report regarding Resident #13, dated [DATE] by the DM, revealed, "(Cook K) called (DM) on Sunday evening. (Cook K) stated that (Resident #13) was in the dining room upset... (LVN A) came into the dining room. (Resident #13) was upset and (LVN A) took (Resident #13) to her room. (Cook K) went down to (Resident #13's) room, saw (LVN A) put something on (Resident #13's) neck and gave her 2 shots. I told (Cook K) to call (ADM) she said she already did. I then reported it to (DON) on Monday [DATE] morning." The statement was signed by the DM. An interview on [DATE] at 8:57 p.m. with Cook K revealed she was working on [DATE]. She stated Resident #13 wanted buttermilk and she told her she was only allowed to have it once a day. Cook K stated Resident #13 became upset, began to yell, and LVN A stated to Resident #13, "You're going to your room!" She stated Resident #13 began to choke herself. Cook K stated LVN A told Resident #13, "That's it!" Cook K stated LVN A, LVN I, DA J and herself escorted Resident #13 to her room. She stated LVN A put the yellow gel on Resident #13's neck. Cook K stated she and DA J were sitting on each side of Resident #13, holding the resident by her arms. Resident #13 was stating she wanted to go back to the dining room because she was hungry. Cook K stated LVN A administered a "shot" in Resident #13's right arm and then another shot in the left arm. She stated Resident #13 was then allowed to go back to the dining room. Cook K stated LVN A brought in a vial and "mixed" the medication for the first shot. She stated LVN A brought in the second shot from the hall and she did not see if she mixed it or not. Cook K stated once Resident #13 was brought back to the dining room, "She was out of it." Cook K stated Resident #13 was not able to talk or eat. Cook K stated Resident #16 asked staff, "Will you see if she is ok? (talking about Resident #13)." Cook K stated Resident #17 also checked on Resident #13 and asked if she was ok. A review of a confidential, handwritten witness statement, provided to the survey team regarding Resident #13 revealed, "...(LVN I) pushed her & (LVN A) went to get her a paste & put it on her neck. Then gave her a shot...(Resident #13) grabbed (a person) and started hitting...(LVN A) got another shot and gave it to (Resident #13). The whole time (Resident #13) is wanting to go back to dining area to eat. (LVN A) told her 'No.'...(Resident #13) threw it (grilled cheese sandwich) across floor. (LVN A) went to get another shot and gave it to her...then (Resident #13) came back to dining area & sat at her table & was out. (Resident #17) felt of her to see if she was ok cause it upset (Resident #16)...(Regional Nurse C) the nurse for corp (corporation) came to me & asked for a Incident report & I told her about the shots. She said that two of the shots was sayleen (sic) & it was to make the first shot to start to work faster...." A review of a Provider Investigation [DATE] for Resident #13 (provided to the survey team on [DATE]) revealed the report was called to the State agency on [DATE] at 10:00 p.m. The Incident Category was, "Escalating behaviors around other residents & staff." The incident date was [DATE] at 5:30 p.m. The Provider Investigation Report reflected the "Alleged Perpetrator" was, "(Resident #13)." The witnesses listed on the Report were, "(LVN A, DA J and LVN I)." The Report reflected, "Resident in dining room asking for buttermilk. She became very agitated & started yelling, cussing, hitting, trying to kick and grabbed the Dietary staff members hand & twisted her fingers. Resident removed from area, received PRN medication & became calmer (with) decreased stimuli in room." The Provider Investigation Report reflected the provider response was, "...Notified residents (family member)...PCP...& psychiatrist. Identify when resident is having an increase in anxiety/agitation so that interventions can be started to try to prevent escalation of behaviors. Interventions are remove from area causing an increase in behaviors, redirection, talking to her calmly. [MEDICATION NAME] 20 mg IM PRN for behaviors that do not respond to the other interventions. Resident has prior history of treatment @ (facility behavior unit) and will be re-evaluated if behaviors cont. staff inserviced...Investigation Summary: During investigation, (LVN A) stated she went into dining room when resident became verbally & physically agitated. She removed resident from area and applied [MEDICATION NAME] topical get & [MEDICATION NAME] 2 (sic) mg IM (left) deltoid. (LVN A) then stated that resident continued (with) behavior & was told she would get another shot. Resident Stated, 'I don't care if you give me another shot.' (LVN A) stated she gave the resident a shot of Normal Saline in (right) deltoid. The resident did not have a current order for [MEDICATION NAME] or for Normal Saline as a placebo...Provider Action Taken Post-Investigation: Statements obtained from staff. (LVN A) suspended [DATE] pending investigation completion....Resident is being monitored for adverse effects. Resident condition & behaviors have been stable from [DATE] @ 8 pm to current. No adverse reactions to [MEDICATION NAME] or normal saline IM Placebo. Staff have been inserviced...." An interview on [DATE] at 9:00 a.m. with the DM revealed she was first made aware of the incident on Sunday [DATE], after Cook K called her to report the incident. The DM stated she instructed Cook K to call the ADM. When asked who she reported the incident to, the DM stated she talked to the DON about it on Monday ([DATE]). An interview on [DATE] at 9:06 a.m. with the DON revealed she was first made aware of the incident with Resident #13 on "Monday." She added she reviewed the 24-hour report and it indicated Resident #13 had escalating behaviors. She stated "a girl" (staff member) told her on Monday during the time she was handing out checks that, "I've got a bunch of stuff to tell you." The DON stated she asked, "Like what?" The staff member asked the DON if she had about 30 minutes. The DON stated the staff member never came back and she never went to the staff member to have the discussion. The DON stated she thought the staff member was upset about a personal issue and stated she was going to quit. The DON stated she was not trained on how to conduct an investigation. She added she was "too tired" to continue with the interview and it was stopped. A telephone interview on [DATE] at 12:05 p.m. with LVN I revealed she heard screams from the dining room on [DATE] and went to see what was happening. She stated she assisted getting Resident #13 back to her room, because she had become upset that she was not allowed to have buttermilk. She stated she was holding the wheelchair from the handles on the back of the chair. She stated LVN A came into the room and stated to Resident #13, "Calm down or I'm gonna have to give you a shot." LVN I stated LVN A then administered an injection. LVN I stated the medication came from a vial that LVN A was mixing as she entered the room. LVN I stated LVN A exited the room and re-entered moments later with a syringe (unknown contents). LVN I stated Resident #13 continued to yell, and LVN A administered a second injection in her other arm. LVN I stated LVN A stated to Resident #13, "(Resident #13) you got to calm down or I'm going to have to give you another shot." When asked how much time had elapsed between the first and second injection, LVN I stated seven to ten minutes. When asked what the facility policy was for residents who exhibited behaviors, LVN I stated they were to protect the residents and give them what they wanted if possible. When asked if LVN A acted appropriately in administering two injections to Resident #13, LVN I stated she was unsure if the timeframe of the two injections being given was appropriate. LVN I confirmed she did not discuss the timeframe with LVN A or anyone else after the incident. LVN I added she was interviewed about the incident last evening ([DATE]), by the ADM. When asked what she would do, if a resident exhibited severe behaviors, she administered a [MEDICATION NAME] injection, and the behaviors continued, LVN I stated she would notify the physician. When asked how many times she had observed staff administer sterile water as an injection to a resident, LVN I stated she had never seen that before. When asked if she completed an incident report regarding the incident, LVN I stated she had not. When asked what the policy was for completing incident reports, LVN I stated since she worked the weekends, she would complete the report and place it under the DON's office door. An interview on [DATE] at 1:20 p.m. with the facility's only ADON revealed she was first made aware of the incident with Resident #13 on [DATE]. She stated someone (was not able to state whom) mentioned on [DATE] (Monday) that Resident #13 had behaviors, but did not mention any medications. The ADON stated LVN A came to her on [DATE] and told her she administered a sterile water injection to Resident #13. The ADON stated LVN A told her she also administered the [MEDICATION NAME] gel to Resident #13, but did not realize she did not have an order for [REDACTED]. The ADON denied LVN I informed her of the administration of the sterile water injection immediately after the [MEDICATION NAME] injection. A review of the "All Disciplines To Use Progress Notes" for Resident #13 revealed, "[DATE]: Very anxious. Her room mate not doing well..XXX[DATE]: In wheelchair. Depressed. Her room mate died two nights ago...." An interview was conducted on [DATE] at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member. When asked what had been done since [DATE], regarding Resident #13 being threatened with a shot for behaviors, the ADM stated LVN A was suspended. When asked if any inservices on identifying abuse had been conducted with any staff, the ADM stated there had not been. The ADM was informed of the following: Neither the DM nor Cook K reported what they observed as abuse on [DATE] to the Abuse Coordinator (ADM); LVN I did not intervene, nor did she report the two injections being administered within seven to ten minutes of each other, and did not recognize the threat of an injection as abuse on [DATE]; and LVN A threatened Resident #13 with an injection if she did not "calm down," falsely documented what she had administered to Resident #13 on [DATE], and did not complete an incident report regarding Resident #13. During the same interview conducted on [DATE] at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member, they were notified that an IJ situation had been identified in the area of Resident Behavior/Facility Practices. An observation on [DATE] at 12:05 p.m. revealed Resident #13 was up in the dining room. She was not exhibiting any behaviors. An interview on [DATE] at 12:25 p.m. with Regional Nurse C revealed she was not able to locate any previous orders for Resident #13 to be administered [MEDICATION NAME] gel. An observation on [DATE] at 12:10 p.m. revealed Resident #13 was up in the dining room eating lunch. She was alert and did not exhibit any behaviors. A telephone interview on [DATE] at 2:50 p.m. with the Medical Director revealed Resident #13 was one of his residents. He stated no staff member notified him of the behaviors, nor did they call him for an order to administer a placebo injection. He added, "I would not have allowed that." Review of the Plan of Removal, originally provided on [DATE], revised on [DATE] and accepted on [DATE], revealed: All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) were being in-serviced on Reporting Abuse/Neglect and Mistreatment, including: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention and Resident rights. The in-service was initiated by the Administrator. To ensure understanding the facility was administering a post test on the in-services. The in-services would continue each shift to ensure all staff received the training and validation testing. That was initiated on [DATE] and the completion date was [DATE], The Administrator was in-serviced on the topic of Abuse, including Abuse Definitions, Abuse Policies and Procedures, Freedom from Abuse, Resident Rights, Behavior Intervention, Behavior Crisis, and Abuse Prevention by corporate personnel on [DATE] and reviewed again on [DATE]. The Administrator and Regional Nurse Consultant, thoroughly investigated the incidents, which occurred over the past weekend. The employees, who did not respond appropriately and per facility policy were appropriately disciplined by the Administrator. The employees included the following: 1) DON suspended pending investigation on [DATE] and terminated on [DATE], 2) LVN A suspended pending investigation on [DATE] and terminated on [DATE], 3) LVN I) who witnessed the incident on [DATE] involving Resident #13 received a one-on-one in-service on abuse, which included the following: definitions, behavior interventions, behavior crisis, freedom from abuse, abuse prevention; and resident rights, and 4) Dietary staff Cook K, DA J and DM received an in-service on the topic Reporting Abuse/Neglect and Mistreatment, which included the following: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention, Resident rights and written disciplinary notice. For employees who were unable to come to the facility on [DATE] or [DATE] for the in-services listed on the Plan of Removal, the ADM or ADON conducted the in-service over the phone with the employee. The oral in-service conducted over the phone would be documented on the in-service record and included Review of the POS [REDACTED]. All newly hired staff (licensed nurses, certified nurses assistants, medication aides, dietary, housekeeping, laundry, activity director, business office manager, social worker, maintenance) would be in-serviced on Reporting Abuse/Neglect and Mistreatment by the Administrator/designee prior to working their first shift. Validation of understanding would be accomplished by administering a post test. This was initiated on [DATE] and the completion date was ongoing. A QA Meeting would be held on [DATE] with members of the QA team, including the Administrator, Housekeeping/Laundry Supervisor, ADON, Business Office Manager, Activity Director, FSS, Maintenance staff member, and the Medical Director via telephone conference. The QA Committee, which included the Medical Director, would monitor for the next 90 days to ensure the system was effective. The QA Committee would review Incident/Accident Reports, investigation of incidents/accidents, in-services and Post Tests. This was initiated on [DATE] and the completion date was on-going for 90 days. To ensure all incidents were investigated and appropriately reported, the DON/ADON/Designee would review the 24 hour Report and the Incident/Accident Reports daily for compliance. The Incident/Accident Reports, which had not been completed and thoroughly investigated would be completed, investigated immediately and reported to DADS appropriately. The results of their review would be reported to the QA Committee each month for the next 90 days. This was initiated on [DATE] and was ongoing. All licensed nurses, including the ADON, are being in-serviced by the Regional Nurse Consultant on the topics of: 1. The Twenty Four Hour Report form and the Guidelines for Nursing Report Policy & Procedure. 2. Incident/Accident Reporting Policies & Procedures. Initiated [DATE] Completion Date: [DATE] All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on the topic of intimidation and threats toward residents. The in-service has been initiated by the Regional Nurse Consultant. Validation of understanding is being accomplished by administering a post test on the subject in-serviced. The in-service will continue each shift to ensure all staff has the training and validation testing. Initiated [DATE] Completion date: [DATE] All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) were being in-serviced on the topic of Behaviors, which included Behavior Crisis Policy and Procedure and Behavior Assessment/Management/Interventions Policies and Procedures. The in-service was initiated by the Regional Nurse Consultant. This in-service would continue on each shift to ensure all staff had the training. The interviews on [DATE] from 10:00 a.m. to 10:50 a.m. with CNA D, CNA N, Housekeeping/Laundry Supervisor O, DA P, Business Office Manager (BOM), LVN I, HK/LA Q and CNA R, revealed they knew what to do regarding residents' behaviors and abuse. The interviews on [DATE] from 10:05 a.m. to 10:28 a.m. with CNA G, LVN B, DA S, DM, CNA F and LVN T, revealed they knew what to do regarding residents' behaviors and abuse. The interviews on [DATE] from 10:35 a.m. to 11:00 a.m. with DM, SA S, ADON, CNA E, CNA D, LVN T, DA P, Housekeeping/Laundry Supervisor O, Physical Therapist Assistant (PTA) U and CNA F, revealed they knew what to do regarding residents' behaviors and abuse. The Administrator was advised via telephone the IJ was lowered on [DATE] at 3:37 p.m. A review of a "Notice Of Disciplinary Action" dated [DATE] revealed LVN A was terminated on [DATE] for, "Allegation of abuse...Abuse confirmed...Injection of normal saline & application of [MEDICATION NAME] gel, both without a physicians order...." LVN A signed a "Freedom From Abuse, Neglect and Mistreatment of [REDACTED]. The form was found in her employee file. A review of an Abuse Policy Pre-Post Test, completed by LVN A on [DATE], revealed there were 20 questions. LVN A answered seven of the questions incorrectly. 2) Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a significant change MDS assessment dated [DATE] for Resident #10 revealed she was able to recall the current season, location of her room, staff members names/faces and that she was in a nursing home. She had modified independence in cognitive skills for decision making. She had behaviors of inattention and disorganized thinking, which fluctuated. She also had [MEDICAL CONDITION]. A review of a physician's telephone order dated [DATE] for Resident #10 revealed, "Resident is restricted to eating in presence of nursing personal only." Review of a Cognitive/Behavior Data Collection dated [DATE] for Resident #10 revealed a handwritten note on the back that reflected, "Res wanted a snack. Demanded peanut butter sandwich then peanut butter crackers. When explained that both foods are not indicated in her diet...She began a loud temper tantrum. Threw full juice cup at the nurse, spilling it on floor. Screaming, yelling, stomping, off w/o wheelchair. Ruffles hair wildly. Finally calmed once some peanut butter crackers were crushed and mixed into a milkshake...which she ate and remained calm along with very apologetic afterwards." Review of a Nurse's Note dated [DATE] timed at 6:00 p.m. authored by LVN A for Resident #10 revealed, "Resident going out front door via w/c & yelling. 2nd nurse went to talk (with) her attempted to stop w/c & talk (with) her. Resident yelling jumped up & ran down side walk. Other nurse going quickly trying to talk (with) resident. This nurse got [MEDICATION NAME] gel 2 mg/ml 1 cc. When got out side resident on ground slapping, scratching, kicking staff. [MEDICATION NAME] gel applied. Took several minutes to get resident to w/c. Then trying to kick, scratch, slap and bite staff. Med IM (with) [MEDICATION NAME] injection 5 mg/ml IM (left) deltoid. CNA sat (with) resident 10 minutes resident settled down...." A review of a Comprehensive Plan of Care initiated [DATE] for Resident #10 revealed she had episodes of inappropriate behaviors. The approaches included the following: a) Monitor for early warning signs, b) Explain all procedures, c) Provide Psych consult, d) Courage to attend social activities, e) Monitor and chart behaviors and f) give meds per order. A review of the [DATE] consolidated physician's orders [REDACTED]. 1) [MEDICATION NAME] (antianxiety) 0.5 mg one by mouth three times a day 2) [MEDICATION NAME] 1 mg one by mouth daily 3) [MEDICATION NAME] gel 2 mg/ml 1 cc to wrist or neck every 8 hours as needed for agitation 4) [MEDICATION NAME] 5 mg by mouth two times a day 5) [MEDICATION NAME] Injection 5 mg/ml IM every 8 hours as needed for severe agitation 6) [MEDICATION NAME] 400 mg one by mouth at bedtime The orders also indicated she was on a "Pure

Based on observation, interview and record review, it was determined the facility failed to ensure two (Residents #13 and #15) of eight residents reviewed for abuse were free from verbal, physical, and mental abuse. 1) LVN A threatened Resident #13 with another injection if she did not stop. LVN A gave #13 an injection of sterile water, while Cook K and DA J held her arms. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. 2) Resident #15 was cursing and talking loudly, when CNA V went to assist him to bed. She told him to stop and then told him he could stay in his wheelchair all night. CNA V told him that twice. Resident #15 then backed his w/c into his room and CNA V closed his door. A few seconds later, CNA V opened his door, went in, and closed his door. This was witnessed by CNA R, but no one intervened to protect the resident. These failures could affect the other 9 residents in the facility, with behaviors, by placing them at risk of verbal, physical and mental abuse. Findings included: 1) Resident #13 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] for Resident #13 revealed she did not have any behaviors, [MEDICAL CONDITION] or hallucinations. She did not have any signs of [MEDICAL CONDITION]. A review of a Cognitive/Behavior Data Collection dated [DATE] for Resident #13 revealed she required daily intervention for orientation/memory. The form indicated Resident #13 exhibited the following behaviors daily: yelling, cursing, and crying. The interventions included: 1) Calm, gentle approach, 2) Distract to another activity, 3) Stop activity and reassure if upset, 4) Anticipate needs, 5) Assist/remind to bathroom, 6) Quiet area to limit stimuli, 7) Rest periods and 8) Receives psych services. A review of the [DATE] consolidated physician's orders [REDACTED]. A review of a physician's telephone order dated [DATE] for Resident #13 revealed she was receiving [MEDICATION NAME] (used for [MEDICAL CONDITION] and [MEDICAL CONDITION]) 20 mg by mouth every a.m. This dose was increased from 15 mg. A review of a nurse's note dated [DATE] at 10:00 a.m. for Resident #13, revealed, ",[DATE] Escorted out of dining room at supper time because she got into an argument (with) another resident. Stopped once removed from situation...." A review of a nurse's note dated [DATE] at 10:00 a.m. for Resident #13, revealed, "Alert to staff...very rude & (and) argumentative (with) staff & resident. In room yelling @ (at) staff to come in there... 5:30 p.m. Resident in dining room, yelling, cursing, throwing @ staff & residents. 2 staff unable to calm resident. Took to room (with) staff...hitting, kicking, attempting to bite staff. Med IM (left) arm. 20 mg [MEDICATION NAME] for severe agitation... 6:00 p.m. Still very aggressive & yelling... 7:00 p.m. In room. Quieter but still non-compliant & argumentative... 9:00 p.m. In room in w/c sleeping. This nurse & CNA attempted to change her & get her ready for bed. Woke up yelling, 'I'm not changing I'm not ready for bed. Resident stopped yelling & staff left room (authored by LVN A)." A review of the [DATE] MAR for Resident #13 revealed there was no documentation of the [MEDICATION NAME] being administered on [DATE], or for the entire month through [DATE]. Review of the February 2011 MAR indicated [REDACTED]. A review of the Behavior Monitoring logs for [DATE] for Resident #13 revealed she had three behavior (yelling) incidents prior to [DATE]. All three incidents were treated with redirection and/or one-on-one, which meant the staff would sit with the resident. On [DATE] the logs reflected she had one episode of behaviors and the intervention was, "Refer to nurse's notes." A review of the incident and accident reports on [DATE] revealed no reports regarding Resident #13's behavior on [DATE]. A review of a physician's telephone order dated [DATE] for Resident #13 revealed she was receiving [MEDICATION NAME] 50 mg by mouth at bedtime for anxiety [MEDICATION NAME] mg by mouth at bedtime for [MEDICAL CONDITION]. An interview on initial tour with LVN A on [DATE] at 9:45 a.m. revealed Resident #13 was hard of hearing, had Dementia, behaviors and was not interviewable. LVN A stated Resident #13 sometimes "acted out" by yelling and appeared confused. An observation of Resident #13 on [DATE] at 9:45 a.m. revealed Resident #13 was asleep in bed with two side rails in the up position. LVN A was not able to awaken Resident #13. An observation on [DATE] at 12:05 p.m. revealed Resident #13 was up in the dining room in her wheelchair. She was alert and not exhibiting any behaviors. An observation on [DATE] at 2:22 p.m. revealed Resident #13 was sleeping in her bed. A confidential interview on [DATE] revealed he/she observed Resident #13 asking for buttermilk during the evening meal on [DATE]. He/she stated Resident #13 was told she could only have buttermilk one time a day. He/she stated Resident #13 became upset and was throwing food and 'choking' herself. He/she stated he/she heard LVN A and LVN I state, "Just let her do it." An interview on [DATE] at 3:22 p.m. with DA J revealed she was asked by LVN A to help get Resident #13 to her room during the incident. DA J stated LVN A rubbed the yellow gel ([MEDICATION NAME]) on Resident #13's neck. DA J stated LVN A then administered a "shot" in Resident #13's right shoulder. She stated LVN A then gave Resident #13 another shot in the left shoulder. When asked how much time had passed, from the "yellow gel" to the time of the second shot, DA J stated 10 minutes. An interview on [DATE] at 3:55 p.m. with LVN A revealed she was the charge nurse for Resident #13 on Sunday, [DATE]. She stated she heard screaming coming from the dining room and went to see what was happening. She stated Resident #13 wanted buttermilk and was told she could only have it one time a day. When asked why Resident #13 was not allowed to have the buttermilk, LVN A stated the facility only bought enough for her to have it once a day. LVN A stated she removed Resident #13 from the dining room and took her to her room, with the assistance of DA J and Cook K. LVN A stated she gave Resident #13 [MEDICATION NAME] gel. LVN A denied trying any additional interventions before administering the [MEDICATION NAME] gel, other than removing Resident #13 from the dining room. The MAR indicated [REDACTED]. There was no entry on the MAR for [MEDICATION NAME] gel. LVN A stated she was not aware Resident #13 did not have an order for [REDACTED].#13. She stated she told Resident #13, "I'm gonna have to give you another shot (if she did not calm down)." LVN A stated Resident #13 said, "Go ahead!" LVN A stated she then withdrew 3 cc of N/S in a syringe, and administered it to Resident #13 in the opposite arm. When asked if she obtained an order for [REDACTED]." When asked if she notified the physician of what she had done, LVN A stated she did tell the physician she administered [MEDICATION NAME] and an injection of Saline. LVN A stated Resident #13 calmed down and was taken back to the dining room. http://www.drugs.com/[MEDICATION NAME].html. "[MEDICATION NAME] is used to treat anxiety disorders... Seek emergency medical attention if you think you have used too much of this medicine. An overdose of [MEDICATION NAME] can be fatal. [MEDICATION NAME] overdose symptoms may include extreme drowsiness, confusion, muscle weakness, [MEDICAL CONDITION], or coma...." An interview on [DATE] at 4:15 p.m. with the ADM and the DON revealed they were not aware of Resident #13 being threatened with a shot for behaviors until today. When asked who did have knowledge of the incident prior to today, the ADM stated the licensed nurses on [DATE] (LVN A and LVN I) knew. (Note: LVN A was working on [DATE] from 2:00 p.m. to 10:00 p.m.) A review of an incident report dated [DATE] (provided to the survey team on [DATE]) for Resident #13 revealed, "...Incident date: [DATE]...Time: 5:30 p.m....State Facts Observed at scene: Resident in dining room yelling, cussing, throwing @ staff. Hitting, kicking & attempting to bite staff. Grabbed staff hand & twisted her finger...." This report was completed by Regional Nurse C. The second page of the incident report was, "Incident Investigation." It reflected it was not an abuse allegation. The section of the report titled "List Interventions in Place to Prevent Incident" reflected, "Redirection, removing resident from area & talking calmly to her. [MEDICATION NAME] 20 mg IM if other steps are not successful. Treatment @ (local behavior unit)...." A statement included with the Incident Report regarding Resident #13, dated [DATE] by the DM, revealed, "(Cook K) called (DM) on Sunday evening. (Cook K) stated that (Resident #13) was in the dining room upset... (LVN A) came into the dining room. (Resident #13) was upset and (LVN A) took (Resident #13) to her room. (Cook K) went down to (Resident #13's) room, saw (LVN A) put something on (Resident #13's) neck and gave her 2 shots. I told (Cook K) to call (ADM) she said she already did. I then reported it to (DON) on Monday [DATE] morning." The statement was signed by the DM. An interview on [DATE] at 8:57 p.m. with Cook K revealed she was working on [DATE]. She stated Resident #13 wanted buttermilk and she told her she was only allowed to have it once a day. Cook K stated Resident #13 became upset, began to yell, and LVN A stated to Resident #13, "You're going to your room!" She stated Resident #13 began to choke herself. Cook K stated LVN A told Resident #13, "That's it!" Cook K stated LVN A, LVN I, DA J and herself escorted Resident #13 to her room. She stated LVN A put the yellow gel on Resident #13's neck. Cook K stated her and DA J were sitting on each side of Resident #13, holding the resident by her arms. Resident #13 was stating she wanted to go back to the dining room because she was hungry. Cook K stated LVN A administered a "shot" in Resident #13's right arm and then another shot in the left arm. She stated Resident #13 was then allowed to go back to the dining room. Cook K stated LVN A brought in a vial and "mixed" the medication for the first shot. She stated LVN A brought in the second shot from the hall and she did not see if she mixed it or not. Cook K stated once Resident #13 was brought back to the dining room, "She was out of it." Cook K stated Resident #13 was not able to talk or eat. Cook K stated Resident #16 asked staff, "Will you see if she is ok? (talking about Resident #13)." Cook K stated Resident #17 also checked on Resident #13 and asked if she was ok. A review of a confidential, handwritten witness statement, provided to the survey team regarding Resident #13 revealed, "...(LVN I) pushed her & (LVN A) went to get her a paste & put it on her neck. Then gave her a shot...(Resident #13) grabbed (a person) and started hitting...(LVN A) got another shot and gave it to (Resident #13). The whole time (Resident #13) is wanting to go back to dining area to eat. (LVN A) told her 'No.'...(Resident #13) threw it (grilled cheese sandwich) across floor. (LVN A) went to get another shot and gave it to her...then (Resident #13) came back to dining area & sat at her table & was out. (Resident #17) felt of her to see if she was ok cause it upset (Resident #16)...(Regional Nurse C) the nurse for corp (corporation) came to me & asked for a Incident report & I told her about the shots. She said that two of the shots was sayleen (sic) & it was to make the first shot to start to work faster...." A review of a Provider Investigation [DATE] for Resident #13 (provided to the survey team on [DATE]) revealed the report was called to the State agency on [DATE] at 10:00 p.m. The Incident Category was, "Escalating behaviors around other residents & staff." The incident date was [DATE] at 5:30 p.m. The Provider Investigation Report reflected the "Alleged Perpetrator" was, "(Resident #13)." The witnesses listed on the Report were, "(LVN A, DA J and LVN I)." The Report reflected, "Resident in dining room asking for buttermilk. She became very agitated & started yelling, cussing, hitting, trying to kick and grabbed the Dietary staff members hand & twisted her fingers. Resident removed from area, received PRN medication & became calmer (with) decreased stimuli in room." The Provider Investigation Report reflected the provider response was, "...Notified residents (family member)...PCP...& psychiatrist. Identify when resident is having an increase in anxiety/agitation so that interventions can be started to try to prevent escalation of behaviors. Interventions are remove from area causing an increase in behaviors, redirection, talking to her calmly. [MEDICATION NAME] 20 mg IM PRN for behaviors that do not respond to the other interventions. Resident has prior history of treatment @ (facility behavior unit) and will be re-evaluated if behaviors cont. staff inserviced...Investigation Summary: During investigation, (LVN A) stated she went into dining room when resident became verbally & physically agitated. She removed resident from area and applied [MEDICATION NAME] topical get & [MEDICATION NAME] 2 (sic) mg IM (left) deltoid. (LVN A) then stated that resident continued (with) behavior & was told she would get another shot. Resident Stated, 'I don't care if you give me another shot.' (LVN A) stated she gave the resident a shot of Normal Saline in (right) deltoid. The resident did not have a current order for [MEDICATION NAME] or for Normal Saline as a placebo...Provider Action Taken Post-Investigation: Statements obtained from staff. (LVN A) suspended [DATE] pending investigation completion....Resident is being monitored for adverse effects. Resident condition & behaviors have been stable from [DATE] @ 8 pm to current. No adverse reactions to [MEDICATION NAME] or normal saline IM Placebo. Staff have been inserviced...." An interview on [DATE] at 9:00 a.m. with the DM revealed she was first made aware of the incident on Sunday [DATE], after Cook K called her to report the incident. The DM stated she instructed Cook K to call the ADM. When asked who she reported the incident to, the DM stated she talked to the DON about it on Monday ([DATE]). An interview on [DATE] at 9:06 a.m. with the DON revealed she was first made aware of the incident with Resident #13 on "Monday." She added she reviewed the 24-hour report and it indicated Resident #13 had escalating behaviors. She stated "a girl" (staff member) told her on Monday during the time she was handing out checks that, "I've got a bunch of stuff to tell you." The DON stated she asked, "Like what?" The staff member asked the DON if she had about 30 minutes. The DON stated the staff member never came back and she never went to the staff member to have the discussion. The DON stated she thought the staff member was upset about a personal issue and stated she was going to quit. The DON stated she was not trained on how to conduct an investigation. She added she was "too tired" to continue with the interview and it was stopped. A telephone interview on [DATE] at 12:05 p.m. with LVN I revealed she heard screams from the dining room on [DATE] and went to see what was happening. She stated she assisted getting Resident #13 back to her room, because she had become upset that she was not allowed to have buttermilk. She stated she was holding the wheelchair from the handles on the back of the chair. She stated LVN A came into the room and stated to Resident #13, "Calm down or I'm gonna have to give you a shot." LVN I stated LVN A then administered an injection. LVN I stated the medication came from a vial that LVN A was mixing as she entered the room. LVN I stated LVN A exited the room and re-entered moments later with a syringe (unknown contents). LVN I stated Resident #13 continued to yell, and LVN A administered a second injection in her other arm. LVN I stated LVN A stated to Resident #13, "(Resident #13) you got to calm down or I'm going to have to give you another shot." When asked how much time had elapsed between the first and second injection, LVN I stated seven to ten minutes. When asked what the facility policy was for residents who exhibited behaviors, LVN I stated they were to protect the residents and give them what they wanted if possible. When asked if LVN A acted appropriately in administering two injections to Resident #13, LVN I stated she was unsure if the timeframe of the two injections being given was appropriate. LVN I confirmed she did not discuss the timeframe with LVN A or anyone else after the incident. LVN I added she was interviewed about the incident last evening ([DATE]), by the ADM. When asked what she would do, if a resident exhibited severe behaviors, she administered a [MEDICATION NAME] injection, and the behaviors continued, LVN I stated she would notify the physician. When asked how many times she had observed staff administer sterile water as an injection to a resident, LVN I stated she had never seen that before. When asked if she completed an incident report regarding the incident, LVN I stated she had not. When asked what the policy was for completing incident reports, LVN I stated since she worked the weekends, she would complete the report and place it under the DON's office door. An interview on [DATE] at 1:20 p.m. with the facility's only ADON revealed she was first made aware of the incident with Resident #13 on [DATE]. She stated someone (was not able to state whom) mentioned on [DATE] (Monday) that Resident #13 had behaviors, but did not mention any medications. The ADON stated LVN A came to her on [DATE] and told her she administered a sterile water injection to Resident #13. The ADON stated LVN A told her she also administered the [MEDICATION NAME] gel to Resident #13, but did not realize she did not have an order for [REDACTED]. The ADON denied LVN I informed her of the administration of the sterile water injection immediately after the [MEDICATION NAME] injection. A review of the "All Disciplines To Use Progress Notes" for Resident #13 revealed, "[DATE]: Very anxious. Her room mate not doing well..XXX[DATE]: In wheelchair. Depressed. Her room mate died two nights ago...." An interview was conducted on [DATE] at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member. When asked what had been done since [DATE], regarding Resident #13 being threatened with a shot for behaviors, the ADM stated LVN A was suspended. When asked if any inservices on identifying abuse had been conducted with any staff the ADM stated there had not been. The ADM was informed of the following: Neither the DM, nor Cook K reported what they observed as abuse on [DATE] to the Abuse Coordinator (ADM); LVN I did not intervene, nor did she report the two injections being administered within seven to ten minutes of each other, and did not recognize the threat of an injection as abuse on [DATE]; and LVN A threatened Resident #13 with an injection if she did not "calm down," falsely documented what she had administered to Resident #13 on [DATE], and did not complete an incident report regarding Resident #13. During the same interview conducted on [DATE] at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member, they were notified that an IJ situation had been identified in the area of Resident Behavior/Facility Practices. An observation on [DATE] at 12:05 p.m. revealed Resident #13 was up in the dining room. She was not exhibiting any behaviors. An interview on [DATE] at 12:25 p.m. with Regional Nurse C revealed she was not able to locate any previous orders for Resident #13 to be administered [MEDICATION NAME] gel. An observation on [DATE] at 12:10 p.m. revealed Resident #13 was up in the dining room eating lunch. She was alert and did not exhibit any behaviors. A telephone interview on [DATE] at 2:50 p.m. with the Medical Director revealed Resident #13 was one of his residents. He stated no staff member notified him of the behaviors, nor did they call him for an order to administer a placebo injection. He added, "I would not have allowed that." A review of a "Notice Of Disciplinary Action" dated [DATE] revealed LVN A was terminated on [DATE] for, "Allegation of abuse...Abuse confirmed...Injection of normal saline & application of [MEDICATION NAME] gel, both without a physicians order...." LVN A signed a "Freedom From Abuse, Neglect and Mistreatment of [REDACTED]. The form was found in her employee file. A review of an Abuse Policy Pre-Post Test, completed by LVN A on [DATE], revealed there were 20 questions. LVN A answered seven of the questions incorrectly. 2) Resident #15 was a [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15's admission MDS assessment dated [DATE] reflected he had unclear speech and he had limited ability to make himself understood. The MDS assessment also reflected he had short and long-term memory problems, he was "short-tempered, easily annoyed," he had [MEDICAL CONDITION], verbal behavioral symptoms daily, and physical symptoms such as hitting or scratching self, pacing, verbal/vocal symptoms like screaming, disruptive sounds. The assessment reflected Resident #15 required "limited" to "extensive" assistance with all ADLs and he required "total assistance" for toileting. Care plans addressing Resident #15's behavior included the following: [DATE] behaviors exhibited were pushing other resident's w/c and scratched resident and anger management; [DATE] refused medications and increased behavior problems; [DATE] episodes of resistance to ADL care mood state; [DATE] episodes of inappropriate behaviors cursing, anger problem, yelled at others, and delusional; and [DATE] total assist with ADLs due to right-sided weakness. At 11:00 a.m. on Sunday [DATE], the Administrator informed the surveyors she had suspended a CNA the previous evening for "what she had said to __ (Resident #15)." She stated she was still working on the report. Review of nurse's notes for Resident #15 on [DATE] at "945" revealed, "Report to Chg. (Charge) Nurse that ____ (CNA V) was verbally abusive to this resident. Stating until you stop cursing, talking loud I'am (sic) not going to put you to bed. ,[DATE] min later ___ (CNA V) went and put resident to bed. Report to Abuse Coord (Coordinator) ___ (Administrator's name) Adm." Resident #15 was interviewed on [DATE] at 11:15 a.m. He did not remember any incident of abuse. During the end-of-day meeting with facility staff on [DATE] at 11:50 a.m., the surveyors asked if the Administrator would provide the investigation for review the next day. On [DATE] the investigation of the incident with CNA V and Resident #15 was reviewed. The Provider Investigation Report dated [DATE] reflected the incident between Resident #15 and CNA V was observed by CNA R, who was across the hall. The Report also reflected, "Per witness, employee __ (CNA V) told resident __ (Resident #15) that if he did not want to stay up all night he needed to stop. Emp (employee) (CNA V) repeated this statement again to resident. Res wheeled into his room, CNA V closed the door to the room." The "Provider Response" section reflected, "Employee __ (CNA V) immediately suspending (sic) pending investigation. ... Investigation immediately initiated." CNA V's statement dated [DATE] reflected, "__ (Resident #15) was yelling down the hall for me to hurry-up come-on, hurry up and using foul language towards me. I stated that Im (sic) not going to put you to bed when your (sic) acting like that you need to be patient. Until you stop screaming and cussing @ (at) me and slamming your door you will stay-up. Then I asked him if he was done? He said yes Dxxnit (Damn it) and did not say another word as I put him to bed." CNA R's Witness Statement dated [DATE] reflected, "I __(CNA R) heard CNA __(CNA V) tell resident He was talking loud to the CNA she told him if he did not wont (sic) to stay up all night he needed to stop. CNA made the statement twice to him he backed his self into his room and CNA closed his door. Then (CNA V) went into room to put him to bed. A few seconds later." CNA R was interviewed via telephone on [DATE] at 11:24 a.m. She stated she and CNA V were going to lay another resident down. Resident #15 had his light on. She told CNA V to lay Resident #15 down. CNA V approached him at the doorway to his room. CNA R stated she was in the hallway across from Resident #15's room and Resident #15 was cursing and talking loudly. She stated CNA V told him to "Stop." CNA R stated she told him he could stay in the wheelchair all night and she said it two times to the resident. CNA R said the resident backed his wheelchair back into the room and CNA V closed the door. CNA R stated, "In a few seconds she opened the door and went in and closed his door." CNA R said she reported the incident right away to LVN I, who was "passing pills" on that hallway, and told her CNA V had gone into Resident #15's room. She stated LVN I told her to go report the incident to the Administrator and continued passing pills. She said she went right away to the Administrator's office. CNA R reported she told the Administrator the story. CNA R stated when she and the ADM started down the hallway toward Resident #15's room, she saw CNA V coming up the hall with Resident #15's dirty clothes in a bag. On [DATE] at 11:50 a.m. the surveyor asked the Administrator if LVN I had gone down to Resident #15's room after CNA R reported the incident between Resident #15 and CNA V to her first. The Administrator said she did know LVN I was on the hall. At 2:45 p.m. on [DATE] LVN I was interviewed. The surveyor asked if she had gone down to Resident #15's room right after she had been informed of the incident by CNA R, when CNA V was in Resident #15's room. She stated she did not think CNA V would hurt Resident #15. The surveyor asked if she thought the statement CNA V made to the resident was abusive. She said, "Yes." LVN I stated they had been talking about this (abuse) for a long time. LVN I said she saw Resident #15 later when he was in bed and he was still agitated. During the end-of-day meeting on [DATE] at 3:20 p.m., the surveyors expressed concerns about residents not being "immediately protected" after an allegation of abuse by a staff member was made. The Provider Action Taken Post-Investigation section of the investigation report was modified on [DATE] to include: "Employees __ (CNA R) and (LVN I) to be educated by Administrator on immediate protection provided to resident at time of alleged abuse. This education (in-service) will also be included for all staff." The Notice of Disciplinary Action attached to the investigation reflected the allegation of abuse was confirmed and CNA V was terminated. 3) Review of the Plan of Removal, originally provided on [DATE], and revised on [DATE] and accepted on [DATE], revealed: All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) were being in-serviced on Reporting Abuse/Neglect and Mistreatment, including: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention and Resident rights. The in-service was initiated by the Administrator. To ensure understanding the facility was administering a post test on the in-services. The in-services would continue each shift to ensure all staff received the training and validation testing. That was initiated on [DATE] and the completion date was [DATE]. The Administrator was in-serviced on the topic of Abuse, including Abuse Definitions, Abuse Policies and Procedures, Freedom from Abuse, Resident Rights, Behavior Intervention, Behavior Crisis, and Abuse Prevention by corporate personnel on [DATE] and again reviewed on [DATE]. The Administrator and Regional Nurse Consultant, thoroughly investigated the incidents, which occurred over the past weekend. The employees, who did not respond appropriately and per facility policy were appropriately disciplined by the Administrator to include. The employees included the following: 1) DON suspended pending investigation on [DATE] and terminated on [DATE], 2) LVN A suspended pending investigation on [DATE] and terminated on [DATE], 3) LVN I) who witnessed the incident on [DATE] involving resident (Resident #13) received an one on one in-service on abuse, which included the following: definitions, behavior interventions, behavior crisis, freedom from abuse, abuse prevention; and resident rights, and 4) Dietary staff Cook K, DA J and DM received an in-service on the topic Reporting Abuse/Neglect and Mistreatment, which included the following: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention, Resident rights and written disciplinary notice. For employees who were unable to come to the facility on [DATE] or [DATE] for the in-services listed on the Plan of Removal, the ADM or ADON conducted the in-service over the phone with the employee. The oral in-service conducted over the phone would be documented on the in-service record and included Review of the POS [REDACTED]. All newly hired staff (licensed nurses, certified nurses assistants, medication aides, dietary, housekeeping, laundry, activity director, business office manager, social worker, maintenance) would be in-serviced on Reporting Abuse/Neglect and Mistreatment by the Administrator/designee prior to working their first shift. Validation of understanding would be accomplished by administering a post test. This was initiated on [DATE] and the completion date was ongoing. A QA Meeting would be held on [DATE] with members of the QA team, including the Administrator, Housekeeping/Laundry Supervisor, ADON, Business Office Manager, Activity Director, FSS, Maintenance staff member, and the Medical Director via telephone conference. The QA Committee, which included the Medical Director, would monitor for the next 90 days to ensure the system was effective. The QA Committee would review Incident/Accident Reports, investigation of incidents/accidents, in-services and Post Tests This was initiated on [DATE] the completion date was on-going for 90 days. To ensure all incidents were investigated and appropriately reported, the DON/ADON/Designee would review the 24 hour Report and the Incident/Accident Reports daily for compliance. The Incident/Accident Reports, which had not been completed and thoroughly investigated would be completed, investigated immediately, and reported to DADS appropria

Based on observation, interview and record review, it was determined the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were reported immediately to the administrator of the facility and to other officials in accordance with State law; to have evidence that all alleged violations were thoroughly investigated; and to prevent further potential abuse while the investigation was in progress for three (Residents #3, #13, and #15) of eight residents who were reviewed for abuse. 1) Neither the DM, nor Cook K, reported to the Abuse Coordinator (ADM), what they observed, and did not identify the incident as abuse, when LVN A threatened Resident #13 with a shot if she did not calm down. LVN I did not intervene, nor did she report the two injections (for behaviors) being administered within seven to ten minutes of each other, and did not recognize the threat of an injection as abuse. LVN A threatened Resident #13 with an injection if she did not "calm down," she injected Resident #13 with sterile water, and she falsely documented what she had administered to Resident #13. LVN A did not complete an incident report regarding Resident #13. The ADM became aware of the incident four days due to surveyor inquiry. As of five days later, no staff had been inserviced regarding the identification of abuse or reporting abuse immediately to the Abuse Coordinator. 2) CNA V verbally abused Resident #15 and then went into his room and closed the door. CNA R witnessed the exchange and saw CNA V go into Resident #15's room. CNA R immediately told LVN I about the allegation and CNA V going in the resident's room. LVN I told CNA R to report the allegation to the ADM. LVN I did not go to Resident #15's room to check on him or prevent further abuse from CNA V. 3) Resident #3 was found, face down in a pool of blood. No staff witnessed the incident wheelchair, no statements were obtained, and not all of the staff were interviewed to determine if Resident #3's lap buddy was in place prior to the fall. Resident #3 was sent to the hospital where she received 15 sutures to the forehead above the left eye. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the plan or removal. These failures could have affected the 41 residents in the facility by placing them at risk of verbal, physical and mental abuse. Findings included: 1) Resident #13 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] for Resident #13 revealed she did not have any behaviors, [MEDICAL CONDITION] or hallucinations. She did not have any signs of [MEDICAL CONDITION]. A review of a Cognitive/Behavior Data Collection dated [DATE] for Resident #13 revealed she required daily intervention for orientation/memory. The form indicated Resident #13 exhibited the following behaviors daily: yelling, cursing, and crying. The interventions included: 1) Calm, gentle approach, 2) Distract to another activity, 3) Stop activity and reassure if upset, 4) Anticipate needs, 5) Assist/remind to bathroom, 6) Quiet area to limit stimuli, 7) Rest periods and 8) Receives psych services. A review of the [DATE] consolidated physician's orders [REDACTED]. A review of a physician's telephone order dated [DATE] for Resident #13 revealed she was receiving [MEDICATION NAME] (used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION]) 20 mg by mouth every a.m. This dose was increased from 15 mg. A review of a nurse's note dated [DATE] at 10:00 a.m. for Resident #13, revealed, ",[DATE] Escorted out of dining room at supper time because she got into an argument (with) another resident. Stopped once removed from situation...." A review of a nurse's note dated [DATE] at 10:00 a.m. for Resident #13, revealed, "Alert to staff...very rude & (and) argumentative (with) staff & resident. In room yelling @ (at) staff to come in there... 5:30 p.m. Resident in dining room, yelling, cursing, throwing @ staff & residents. 2 staff unable to calm resident. Took to room (with) staff...hitting, kicking, attempting to bite staff. Med IM (left) arm. 20 mg [MEDICATION NAME] for severe agitation... 6:00 p.m. Still very aggressive & yelling... 7:00 p.m. In room. Quieter but still non-compliant & argumentative... 9:00 p.m. In room in w/c sleeping. This nurse & CNA attempted to change her & get her ready for bed. Woke up yelling, 'I'm not changing I'm not ready for bed. Resident stopped yelling & staff left room (authored by LVN A)." A review of the [DATE] MAR for Resident #13 revealed there was no documentation of the [MEDICATION NAME] being administered on [DATE], or for the entire month through [DATE]. Review of the February 2011 MAR indicated [REDACTED]. A review of the Behavior Monitoring logs for [DATE] for Resident #13 revealed she had three behavior (yelling) incidents prior to [DATE]. All three incidents were treated with redirection and/or one-on-one, which meant the staff would sit with the resident. On [DATE] the logs reflected she had one episode of behaviors and the intervention was, "Refer to nurse's notes." A review of the incident and accident reports on [DATE] revealed no reports regarding Resident #13's behavior on [DATE]. A review of a physician's telephone order dated [DATE] for Resident #13 revealed she was receiving [MEDICATION NAME] (used to treat Schizophrenai) 50 mg by mouth at bedtime for anxiety [MEDICATION NAME](used to treat [MEDICAL CONDITION]) 5 mg by mouth at bedtime for [MEDICAL CONDITION]. An interview on initial tour with LVN A on [DATE] at 9:45 a.m. revealed Resident #13 was hard of hearing, had Dementia, behaviors and was not interviewable. LVN A stated Resident #13 sometimes "acted out" by yelling and appeared confused. An observation of Resident #13 on [DATE] at 9:45 a.m. revealed Resident #13 was asleep in bed with two side rails in the up position. LVN A was not able to awaken Resident #13. An observation on [DATE] at 12:05 p.m. revealed Resident #13 was up in the dining room in her wheelchair. She was alert and not exhibiting any behaviors. An observation on [DATE] at 2:22 p.m. revealed Resident #13 was sleeping in her bed. A confidential interview on [DATE] revealed he/she observed Resident #13 asking for buttermilk during the evening meal on [DATE]. He/she stated Resident #13 was told she could only have buttermilk one time a day. He/she stated Resident #13 became upset and was throwing food and 'choking' herself. He/she stated he/she heard LVN A and LVN I state, "Just let her do it." An interview on [DATE] at 3:22 p.m. with DA J revealed she was asked by LVN A to help get Resident #13 to her room during the incident. DA J stated LVN A rubbed the yellow gel ([MEDICATION NAME]) on Resident #13's neck. DA J stated LVN A then administered a "shot" in Resident #13's right shoulder. She stated LVN A then gave Resident #13 another shot in the left shoulder. When asked how much time had passed, from the "yellow gel" to the time of the second shot, DA J stated 10 minutes. An interview on [DATE] at 3:55 p.m. with LVN A revealed she was the charge nurse for Resident #13 on Sunday, [DATE]. She stated she heard screaming coming from the dining room and went to see what was happening. She stated Resident #13 wanted buttermilk and was told she could only have it one time a day. When asked why Resident #13 was not allowed to have the buttermilk, LVN A stated the facility only bought enough for her to have it once a day. LVN A stated she removed Resident #13 from the dining room and took her to her room, with the assistance of DA J and Cook K. LVN A stated she gave Resident #13 [MEDICATION NAME] gel. LVN A denied trying any additional interventions before administering the [MEDICATION NAME] gel, other than removing Resident #13 from the dining room. The MAR indicated [REDACTED]. There was no entry on the MAR for [MEDICATION NAME] gel. LVN A stated she was not aware Resident #13 did not have an order for [REDACTED].#13. She stated she told Resident #13, "I'm gonna have to give you another shot (if she did not calm down)." LVN A stated Resident #13 said, "Go ahead!" LVN A stated she then withdrew 3 cc of N/S in a syringe, and administered it to Resident #13 in the opposite arm. When asked if she obtained an order for [REDACTED]." When asked if she notified the physician of what she had done, LVN A stated she did tell the physician she administered [MEDICATION NAME] and an injection of Saline. LVN A stated Resident #13 calmed down and was taken back to the dining room. An interview on [DATE] at 4:15 p.m. with the ADM and the DON revealed they were not aware of Resident #13 being threatened with a shot for behaviors until today. When asked who did have knowledge of the incident prior to today, the ADM stated the licensed nurses on [DATE] (LVN A and LVN I) knew. (Note: LVN A was working on [DATE] from 2:00 p.m. to 10:00 p.m.) A review of an incident report dated [DATE] (provided to the survey team on [DATE]) for Resident #13 revealed, "...Incident date: [DATE]...Time: 5:30 p.m....State Facts Observed at scene: Resident in dining room yelling, cussing, throwing @ staff. Hitting, kicking & attempting to bite staff. Grabbed staff hand & twisted her finger...." This report was completed by Regional Nurse C. The second page of the incident report was, "Incident Investigation." It reflected it was not an abuse allegation. The section of the report titled "List Interventions in Place to Prevent Incident" reflected, "Redirection, removing resident from area & talking calmly to her. [MEDICATION NAME] 20 mg IM if other steps are not successful. Treatment @ (local behavior unit)...." A statement included with the Incident Report regarding Resident #13, dated [DATE] by the DM, revealed, "(Cook K) called (DM) on Sunday evening. (Cook K) stated that (Resident #13) was in the dining room upset... (LVN A) came into the dining room. (Resident #13) was upset and (LVN A) took (Resident #13) to her room. (Cook K) went down to (Resident #13's) room, saw (LVN A) put something on (Resident #13's) neck and gave her 2 shots. I told (Cook K) to call (ADM) she said she already did. I then reported it to (DON) on Monday [DATE] morning." The statement was signed by the DM. An interview on [DATE] at 8:57 p.m. with Cook K revealed she was working on [DATE]. She stated Resident #13 wanted buttermilk and she told her she was only allowed to have it once a day. Cook K stated Resident #13 became upset, began to yell, and LVN A stated to Resident #13, "You're going to your room!" She stated Resident #13 began to choke herself. Cook K stated LVN A told Resident #13, "That's it!" Cook K stated LVN A, LVN I, DA J and herself escorted Resident #13 to her room. She stated LVN A put the yellow gel on Resident #13's neck. Cook K stated her and DA J were sitting on each side of Resident #13, holding the resident by her arms. Resident #13 was stating she wanted to go back to the dining room because she was hungry. Cook K stated LVN A administered a "shot" in Resident #13's right arm and then another shot in the left arm. She stated Resident #13 was then allowed to go back to the dining room. Cook K stated LVN A brought in a vial and "mixed" the medication for the first shot. She stated LVN A brought in the second shot from the hall and she did not see if she mixed it or not. Cook K stated once Resident #13 was brought back to the dining room, "She was out of it." Cook K stated Resident #13 was not able to talk or eat. Cook K stated Resident #16 asked staff, "Will you see if she is ok? (talking about Resident #13)." Cook K stated Resident #17 also checked on Resident #13 and asked if she was ok. A review of a confidential, handwritten witness statement, provided to the survey team regarding Resident #13 revealed, "...(LVN I) pushed her & (LVN A) went to get her a paste & put it on her neck. Then gave her a shot...(Resident #13) grabbed (a person) and started hitting...(LVN A) got another shot and gave it to (Resident #13). The whole time (Resident #13) is wanting to go back to dining area to eat. (LVN A) told her 'No.'...(Resident #13) threw it (grilled cheese sandwich) across floor. (LVN A) went to get another shot and gave it to her...then (Resident #13) came back to dining area & sat at her table & was out. (Resident #17) felt of her to see if she was ok cause it upset (Resident #16)...(Regional Nurse C) the nurse for corp (corporation) came to me & asked for a Incident report & I told her about the shots. She said that two of the shots was sayleen (sic) & it was to make the first shot to start to work faster...." A review of a Provider Investigation [DATE] for Resident #13 (provided to the survey team on [DATE]) revealed the report was called to the State agency on [DATE] at 10:00 p.m. The Incident Category was, "Escalating behaviors around other residents & staff." The incident date was [DATE] at 5:30 p.m. The Provider Investigation Report reflected the "Alleged Perpetrator" was, "(Resident #13)." The witnesses listed on the Report were, "(LVN A, DA J and LVN I)." The Report reflected, "Resident in dining room asking for buttermilk. She became very agitated & started yelling, cussing, hitting, trying to kick and grabbed the Dietary staff members hand & twisted her fingers. Resident removed from area, received PRN medication & became calmer (with) decreased stimuli in room." The Provider Investigation Report reflected the provider response was, "...Notified residents (family member)...PCP...& psychiatrist. Identify when resident is having an increase in anxiety/agitation so that interventions can be started to try to prevent escalation of behaviors. Interventions are remove from area causing an increase in behaviors, redirection, talking to her calmly. [MEDICATION NAME] 20 mg IM PRN for behaviors that do not respond to the other interventions. Resident has prior history of treatment @ (facility behavior unit) and will be re-evaluated if behaviors cont. staff inserviced...Investigation Summary: During investigation, (LVN A) stated she went into dining room when resident became verbally & physically agitated. She removed resident from area and applied [MEDICATION NAME] topical get & [MEDICATION NAME] 2 (sic) mg IM (left) deltoid. (LVN A) then stated that resident continued (with) behavior & was told she would get another shot. Resident Stated, 'I don't care if you give me another shot.' (LVN A) stated she gave the resident a shot of Normal Saline in (right) deltoid. The resident did not have a current order for [MEDICATION NAME] or for Normal Saline as a placebo...Provider Action Taken Post-Investigation: Statements obtained from staff. (LVN A) suspended [DATE] pending investigation completion....Resident is being monitored for adverse effects. Resident condition & behaviors have been stable from [DATE] @ 8 pm to current. No adverse reactions to [MEDICATION NAME] or normal saline IM Placebo. Staff have been inserviced...." An interview on [DATE] at 9:00 a.m. with the DM revealed she was first made aware of the incident on Sunday [DATE], after Cook K called her to report the incident. The DM stated she instructed Cook K to call the ADM. When asked who she reported the incident to, the DM stated she talked to the DON about it on Monday ([DATE]). An interview on [DATE] at 9:06 a.m. with the DON revealed she was first made aware of the incident with Resident #13 on "Monday." She added she reviewed the 24-hour report and it indicated Resident #13 had escalating behaviors. She stated "a girl" (staff member) told her on Monday during the time she was handing out checks that, "I've got a bunch of stuff to tell you." The DON stated she asked, "Like what?" The staff member asked the DON if she had about 30 minutes. The DON stated the staff member never came back and she never went to the staff member to have the discussion. The DON stated she thought the staff member was upset about a personal issue and stated she was going to quit. The DON stated she was not trained on how to conduct an investigation. She added she was "too tired" to continue with the interview and it was stopped. A telephone interview on [DATE] at 12:05 p.m. with LVN I revealed she heard screams from the dining room on [DATE] and went to see what was happening. She stated she assisted getting Resident #13 back to her room, because she had become upset that she was not allowed to have buttermilk. She stated she was holding the wheelchair from the handles on the back of the chair. She stated LVN A came into the room and stated to Resident #13, "Calm down or I'm gonna have to give you a shot." LVN I stated LVN A then administered an injection. LVN I stated the medication came from a vial that LVN A was mixing as she entered the room. LVN I stated LVN A exited the room and re-entered moments later with a syringe (unknown contents). LVN I stated Resident #13 continued to yell, and LVN A administered a second injection in her other arm. LVN I stated LVN A stated to Resident #13, "(Resident #13) you got to calm down or I'm going to have to give you another shot." When asked how much time had elapsed between the first and second injection, LVN I stated seven to ten minutes. When asked what the facility policy was for residents who exhibited behaviors, LVN I stated they were to protect the residents and give them what they wanted if possible. When asked if LVN A acted appropriately in administering two injections to Resident #13, LVN I stated she was unsure if the timeframe of the two injections being given was appropriate. LVN I confirmed she did not discuss the timeframe with LVN A or anyone else after the incident. LVN I added she was interviewed about the incident last evening ([DATE]), by the ADM. When asked what she would do, if a resident exhibited severe behaviors, she administered a [MEDICATION NAME] injection, and the behaviors continued, LVN I stated she would notify the physician. When asked how many times she had observed staff administer sterile water as an injection to a resident, LVN I stated she had never seen that before. When asked if she completed an incident report regarding the incident, LVN I stated she had not. When asked what the policy was for completing incident reports, LVN I stated since she worked the weekends, she would complete the report and place it under the DON's office door. An interview on [DATE] at 1:20 p.m. with the facility's only ADON revealed she was first made aware of the incident with Resident #13 on [DATE]. She stated someone (was not able to state whom) mentioned on [DATE] (Monday) that Resident #13 had behaviors, but did not mention any medications. The ADON stated LVN A came to her on [DATE] and told her she administered a sterile water injection to Resident #13. The ADON stated LVN A told her she also administered the [MEDICATION NAME] gel to Resident #13, but did not realize she did not have an order for [REDACTED]. The ADON denied LVN I informed her of the administration of the sterile water injection immediately after the [MEDICATION NAME] injection. A review of the "All Disciplines To Use Progress Notes" for Resident #13 revealed, "[DATE]: Very anxious. Her room mate not doing well..XXX[DATE]: In wheelchair. Depressed. Her room mate died two nights ago...." An interview was conducted on [DATE] at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member. When asked what had been done since [DATE], regarding Resident #13 being threatened with a shot for behaviors, the ADM stated LVN A was suspended. When asked if any inservices on identifying abuse had been conducted with any staff, the ADM stated there had not been. The ADM was informed of the following: Neither the DM nor Cook K reported what they observed as abuse on [DATE] to the Abuse Coordinator (ADM); LVN I did not intervene, nor did she report the two injections being administered within seven to ten minutes of each other, and did not recognize the threat of an injection as abuse on [DATE]; and LVN A threatened Resident #13 with an injection if she did not "calm down," falsely documented what she had administered to Resident #13 on [DATE], and did not complete an incident report regarding Resident #13. During the same interview conducted on [DATE] at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member, they were notified that an IJ situation had been identified in the area of Resident Behavior/Facility Practices. An observation on [DATE] at 12:05 p.m. revealed Resident #13 was up in the dining room. She was not exhibiting any behaviors. An interview on [DATE] at 12:25 p.m. with Regional Nurse C revealed she was not able to locate any previous orders for Resident #13 to be administered [MEDICATION NAME] gel. An observation on [DATE] at 12:10 p.m. revealed Resident #13 was up in the dining room eating lunch. She was alert and did not exhibit any behaviors. A telephone interview on [DATE] at 2:50 p.m. with the Medical Director revealed Resident #13 was one of his residents. He stated no staff member notified him of the behaviors, nor did they call him for an order to administer a placebo injection. He added, "I would not have allowed that." Review of the Plan of Removal, originally provided on [DATE], and revised on [DATE] and accepted on [DATE], revealed: All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) were being in-serviced on Reporting Abuse/Neglect and Mistreatment, including: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention and Resident rights. The in-service was initiated by the Administrator. To ensure understanding the facility was administering a post test on the in-services. The in-services would continue each shift to ensure all staff received the training and validation testing. That was initiated on [DATE] and the completion date was [DATE]. The Administrator was in-serviced on the topic of Abuse, including Abuse Definitions, Abuse Policies and Procedures, Freedom from Abuse, Resident Rights, Behavior Intervention, Behavior Crisis, and Abuse Prevention by corporate personnel on [DATE] and again reviewed on [DATE]. The Administrator and Regional Nurse Consultant, thoroughly investigated the incidents, which occurred over the past weekend. The employees, who did not respond appropriately and per facility policy were appropriately disciplined by the Administrator to include. The employees included the following: 1) DON suspended pending investigation on [DATE] and terminated on [DATE], 2) LVN A suspended pending investigation on [DATE] and terminated on [DATE], 3) LVN I) who witnessed the incident on [DATE] involving resident (Resident #13) received an one on one in-service on abuse, which included the following: definitions, behavior interventions, behavior crisis, freedom from abuse, abuse prevention; and resident rights, and 4) Dietary staff Cook K, DA J and DM received an in-service on the topic Reporting Abuse/Neglect and Mistreatment, which included the following: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention, Resident rights and written disciplinary notice. For employees who were unable to come to the facility on [DATE] or [DATE] for the in-services listed on the Plan of Removal, the ADM or ADON conducted the in-service over the phone with the employee. The oral in-service conducted over the phone would be documented on the in-service record and included Review of the POS [REDACTED]. All newly hired staff (licensed nurses, certified nurses assistants, medication aides, dietary, housekeeping, laundry, activity director, business office manager, social worker, maintenance) would be in-serviced on Reporting Abuse/Neglect and Mistreatment by the Administrator/designee prior to working their first shift. Validation of understanding would be accomplished by administering a post test. This was initiated on [DATE] and the completion date was ongoing. A QA Meeting would be held on [DATE] with members of the QA team, including the Administrator, Housekeeping/Laundry Supervisor, ADON, Business Office Manager, Activity Director, FSS, Maintenance staff member, and the Medical Director via telephone conference. The QA Committee, which included the Medical Director, would monitor for the next 90 days to ensure the system was effective. The QA Committee would review Incident/Accident Reports, investigation of incidents/accidents, in-services and Post Tests This was initiated on [DATE] the completion date was on-going for 90 days. To ensure all incidents were investigated and appropriately reported, the DON/ADON/Designee would review the 24 hour Report and the Incident/Accident Reports daily for compliance. The Incident/Accident Reports, which had not been completed and thoroughly investigated would be completed, investigated immediately, and reported to DADS appropriately. The results of their review would be reported to the QA Committee each month for the next 90 days. This was initiated on [DATE] and was ongoing. All licensed nurses, including the ADON, are being in-serviced by the Regional Nurse Consultant on the topics of: 1. The Twenty Four Hour Report form and the Guidelines for Nursing Report Policy & Procedure. 2. Incident/Accident Reporting Policies & Procedures. Initiated [DATE] Completion Date: [DATE] All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on the topic of intimidation and threats toward residents. The in-service has been initiated by the Regional Nurse Consultant. Validation of understanding is being accomplished by administering a post test on the subject in-serviced. The in-service will continue each shift to ensure all staff has the training and validation testing. Initiated [DATE] Completion date: [DATE] All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) were being in-serviced on the topic of Behaviors, which included Behavior Crisis Policy and Procedure and Behavior Assessment/Management/Interventions Policies and Procedures. The in-service was initiated by the Regional Nurse Consultant. This in-service would continue on each shift to ensure all staff had the training. The interviews on [DATE] from 10:00 a.m. to 10:50 a.m. with CNA D, CNA N, Housekeeping/Laundry Supervisor O, DA P, Business Office Manager (BOM), LVN I, HK/LA Q and CNA R, revealed they knew what to do regarding residents' behaviors and abuse. The interviews on [DATE] from 10:05 a.m. to 10:28 a.m. with CNA G, LVN B, DA S, DM, CNA F and LVN T, revealed they knew what to do regarding residents' behaviors and abuse. The interviews on [DATE] from 10:35 a.m. to 11:00 a.m. with DM, SA S, ADON, CNA E, CNA D, LVN T, DA P, Housekeeping/Laundry Supervisor O, Physical Therapist Assistant (PTA) U and CNA F, revealed they knew what to do regarding residents' behaviors and abuse. The Administrator was advised via telephone the IJ was lowered on [DATE] at 3:37 p.m. A review of a "Notice Of Disciplinary Action" dated [DATE] revealed LVN A was terminated on [DATE] for, "Allegation of abuse...Abuse confirmed...Injection of normal saline & application of [MEDICATION NAME] gel, both without a physicians order...." LVN A signed a "Freedom From Abuse, Neglect and Mistreatment of [REDACTED]. The form was found in her employee file. A review of an Abuse Policy Pre-Post Test, completed by LVN A on [DATE], revealed there were 20 questions. LVN A answered seven of the questions incorrectly. 2) Resident #15 was a [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15's admission MDS assessment dated [DATE] reflected he had unclear speech and he had limited ability to make himself understood. The MDS assessment also reflected he had short and long-term memory problems, he was "short-tempered, easily annoyed," he had [MEDICAL CONDITION], verbal behavioral symptoms daily, and physical symptoms such as hitting or scratching self, pacing, verbal/vocal symptoms like screaming, disruptive sounds. The assessment reflected Resident #15 required "limited" to "extensive" assistance with all ADLs and he required "total assistance" for toileting. Care plans addressing Resident #15's behavior included the following: [DATE] behaviors exhibited were pushing other resident's w/c and scratched resident and anger management; [DATE] refused medications and increased behavior problems; [DATE] episodes of resistance to ADL care mood state; [DATE] episodes of inappropriate behaviors cursing, anger problem, yelled at others, and delusional; and [DATE] total assist with ADLs due to right-sided weakness. At 11:00 a.m. on Sunday [DATE], the Administrator informed the surveyors she had suspended a CNA the previous evening for "what she had said to __ (Resident #15)." She stated she was still working on the report. Review of nurse's notes for Resident #15 on [DATE] at "945" revealed, "Report to Chg. (Charge) Nurse that ____ (CNA V) was verbally abusive to this resident. Stating until you stop cursing, talking loud I'am (sic) not going to put you to bed. ,[DATE] min later ___ (CNA V) went and put resident to bed. Report to Abuse Coord (Coordinator) ___ (Administrator's name) Adm." Resident #15 was interviewed on [DATE] at 11:15 a.m. He did not remember any incident of abuse. During the end-of-day meeting with facility staff on [DATE] at 11:50 a.m., the surveyors asked if the Administrator would provide the investigation for review the next day. On [DATE] the investigation of the incident with CNA V and Resident #15 was reviewed. The Provider Investigation Report dated [DATE] reflected the incident between Resident #15 and CNA V was observed by CNA R, who was across the hall. The Report also reflected, "Per witness, employee __ (CNA V) told resident __ (Resident #15) that if he did not want to stay up all night he needed to stop. Emp (employee) (CNA V) repeated this statement again to resident. Res wheeled into his room, CNA V closed the door to the room." The "Provider Response" section reflected, "Employee __ (CNA V) immediately suspending (sic) pending investigation. ... Investigation immediately initiated." CNA V's statement dated [DATE] re

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for three (Residents #3, #13, and #15) of eight residents who were reviewed for abuse. 1) Neither the DM, nor Cook K, reported to the Abuse Coordinator (ADM), what they observed, and did not identify the incident as abuse, when LVN A threatened Resident #13 with a shot if she did not calm down. LVN I did not intervene, nor did she report the two injections (for behaviors) being administered within seven to ten minutes of each other, and did not recognize the threat of an injection as abuse. LVN A threatened Resident #13 with an injection if she did not "calm down," she injected Resident #13 with sterile water, and she falsely documented what she had administered to Resident #13. LVN A did not complete an incident report regarding Resident #13. The ADM became aware of the incident four days due to surveyor inquiry. As of five days later, no staff had been inserviced regarding the identification of abuse or reporting abuse immediately to the Abuse Coordinator. 2) CNA V verbally abused Resident #15 and then went into his room and closed the door. CNA R witnessed the exchange and saw CNA V go into Resident #15's room. CNA R immediately told LVN I about the allegation and CNA V going in the resident's room. LVN I told CNA R to report the allegation to the ADM. LVN I did not go to Resident #15's room to check on him or prevent further abuse from CNA V. 3) Resident #3 was found, face down in a pool of blood. No staff witnessed the incident wheelchair, no statements were obtained, and not all of the staff were interviewed to determine if Resident #3's lap buddy was in place prior to the fall. Resident #3 was sent to the hospital where she received 15 sutures to the forehead above the left eye. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because not all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could have affected all 41 residents in the facility by placing them at risk of verbal, physical and mental abuse. Findings included: 1) A review of the current facility's abuse policy entitled, "Abuse Policy" dated [DATE], revealed, "...It is the policy of this facility to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Definition: Abuse: Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental pr physical injury or harm or death to a resident. This includes financial, verbal, sexual, metal/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition...Mental/psychological Abuse: Mistreatment within the definition of 'abuse' not resulting in physical harm, including, but not limited to, humiliation, harassment, threats of punishment, deprivation, or intimidation...PROCEDURE:...Training: ...it is the Responsibility of every employee to report immediately anything that could adversely affect the health and welfare of any resident...PREVENTION: a)...All current employees will receive inservice training pertaining to all aspects of reporting abuse, concerns, incidents and grievances without fear of retribution...IDENTIFICATION: a) Administration and licensed staff will be aware of potential situations of abuse during rounds and contact with staff, residents and resident family members. b) Incident/Accident reports will be reviewed by the Administrator and Director of Nurses or designee to identify possible incidents of abuse...c) All incident/accidents of unknown origin will be investigated. d) Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident or misappropriation of a resident's property immediately to their supervisor or Senior Staff Member. The Senior Staff Member is defined as the 'highest ranking person in the building at the time of the incident.' a. Administrator, b. Director of Nurses, c. Assistant Director of Ruses, d. Charge Nurse. E. The supervisor or Senior Staff Member shall immediately report to the Administrator or person on call. INVESTIGATION: a. When an employee becomes aware of an allegation or suspicion of abuse the employee should: Immediately report the allegation or suspicion to the charge nurse on the unit which the resident resides immediately. b. The charge nurse will assess the resident...Notify the Administrator or the person on-call...The person on call will notify the Administrator...Begin taking written statements from the person reporting the allegation...If an employee is involved, the employee will be detained and removed from their assigned duties until they are interviewed by the Administrator...c. The person on call will notify the Administrator...come to the facility to continue the investigation...d. The Abuse Coordinator will review all aspects of the investigation as soon as possible. Ensure that all reports are complete and appropriate authorities have been notified...PROTECTION: a. All residents will be immediately protected from harm. b. All allegations involving staff will necessitate suspension...If the allegation is substantiated, the employee will be terminated...REPORTING: a. All alleged allegations of abuse will be reported to the appropriate state agency...." 2) Resident #13 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] for Resident #13 revealed she did not have any behaviors, [MEDICAL CONDITION] or hallucinations. She did not have any signs of [MEDICAL CONDITION]. A review of a Cognitive/Behavior Data Collection dated [DATE] for Resident #13 revealed she required daily intervention for orientation/memory. The form indicated Resident #13 exhibited the following behaviors daily: yelling, cursing, and crying. The interventions included: 1) Calm, gentle approach, 2) Distract to another activity, 3) Stop activity and reassure if upset, 4) Anticipate needs, 5) Assist/remind to bathroom, 6) Quiet area to limit stimuli, 7) Rest periods and 8) Receives psych services. A review of the [DATE] consolidated physician's orders [REDACTED]. A review of a physician's telephone order dated [DATE] for Resident #13 revealed she was receiving [MEDICATION NAME] (used for treating Scnizophrenia and [MEDICAL CONDITION]) 20 mg by mouth every a.m. This dose was increased from 15 mg. A review of a nurse's note dated [DATE] at 10:00 a.m. for Resident #13, revealed, ",[DATE] Escorted out of dining room at supper time because she got into an argument (with) another resident. Stopped once removed from situation...." A review of a nurse's note dated [DATE] at 10:00 a.m. for Resident #13, revealed, "Alert to staff...very rude & (and) argumentative (with) staff & resident. In room yelling @ (at) staff to come in there... 5:30 p.m. Resident in dining room, yelling, cursing, throwing @ staff & residents. 2 staff unable to calm resident. Took to room (with) staff...hitting, kicking, attempting to bite staff. Med IM (left) arm. 20 mg [MEDICATION NAME] for severe agitation... 6:00 p.m. Still very aggressive & yelling... 7:00 p.m. In room. Quieter but still non-compliant & argumentative... 9:00 p.m. In room in w/c sleeping. This nurse & CNA attempted to change her & get her ready for bed. Woke up yelling, 'I'm not changing I'm not ready for bed. Resident stopped yelling & staff left room (authored by LVN A)." A review of the [DATE] MAR for Resident #13 revealed there was no documentation of the [MEDICATION NAME] being administered on [DATE], or for the entire month through [DATE]. Review of the February 2011 MAR indicated [REDACTED]. A review of the Behavior Monitoring logs for [DATE] for Resident #13 revealed she had three behavior (yelling) incidents prior to [DATE]. All three incidents were treated with redirection and/or one-on-one, which meant the staff would sit with the resident. On [DATE] the logs reflected she had one episode of behaviors and the intervention was, "Refer to nurse's notes." A review of the incident and accident reports on [DATE] revealed no reports regarding Resident #13's behavior on [DATE]. A review of a physician's telephone order dated [DATE] for Resident #13 revealed she was receiving [MEDICATION NAME] 50 mg by mouth at bedtime for anxiety [MEDICATION NAME] mg by mouth at bedtime for [MEDICAL CONDITION]. An interview on initial tour with LVN A on [DATE] at 9:45 a.m. revealed Resident #13 was hard of hearing, had Dementia, behaviors and was not interviewable. LVN A stated Resident #13 sometimes "acted out" by yelling and appeared confused. An observation of Resident #13 on [DATE] at 9:45 a.m. revealed Resident #13 was asleep in bed with two side rails in the up position. LVN A was not able to awaken Resident #13. An observation on [DATE] at 12:05 p.m. revealed Resident #13 was up in the dining room in her wheelchair. She was alert and not exhibiting any behaviors. An observation on [DATE] at 2:22 p.m. revealed Resident #13 was sleeping in her bed. A confidential interview on [DATE] revealed he/she observed Resident #13 asking for buttermilk during the evening meal on [DATE]. He/she stated Resident #13 was told she could only have buttermilk one time a day. He/she stated Resident #13 became upset and was throwing food and 'choking' herself. He/she stated he/she heard LVN A and LVN I state, "Just let her do it." An interview on [DATE] at 3:22 p.m. with DA J revealed she was asked by LVN A to help get Resident #13 to her room during the incident. DA J stated LVN A rubbed the yellow gel ([MEDICATION NAME]) on Resident #13's neck. DA J stated LVN A then administered a "shot" in Resident #13's right shoulder. She stated LVN A then gave Resident #13 another shot in the left shoulder. When asked how much time had passed, from the "yellow gel" to the time of the second shot, DA J stated 10 minutes. An interview on [DATE] at 3:55 p.m. with LVN A revealed she was the charge nurse for Resident #13 on Sunday, [DATE]. She stated she heard screaming coming from the dining room and went to see what was happening. She stated Resident #13 wanted buttermilk and was told she could only have it one time a day. When asked why Resident #13 was not allowed to have the buttermilk, LVN A stated the facility only bought enough for her to have it once a day. LVN A stated she removed Resident #13 from the dining room and took her to her room, with the assistance of DA J and Cook K. LVN A stated she gave Resident #13 [MEDICATION NAME] gel. LVN A denied trying any additional interventions before administering the [MEDICATION NAME] gel, other than removing Resident #13 from the dining room. The MAR indicated [REDACTED]. There was no entry on the MAR for [MEDICATION NAME] gel. LVN A stated she was not aware Resident #13 did not have an order for [REDACTED].#13. She stated she told Resident #13, "I'm gonna have to give you another shot (if she did not calm down)." LVN A stated Resident #13 said, "Go ahead!" LVN A stated she then withdrew 3 cc of N/S in a syringe, and administered it to Resident #13 in the opposite arm. When asked if she obtained an order for [REDACTED]." When asked if she notified the physician of what she had done, LVN A stated she did tell the physician she administered [MEDICATION NAME] and an injection of Saline. LVN A stated Resident #13 calmed down and was taken back to the dining room. An interview on [DATE] at 4:15 p.m. with the ADM and the DON revealed they were not aware of Resident #13 being threatened with a shot for behaviors until today. When asked who did have knowledge of the incident prior to today, the ADM stated the licensed nurses on [DATE] (LVN A and LVN I) knew. (Note: LVN A was working on [DATE] from 2:00 p.m. to 10:00 p.m.) A review of an incident report dated [DATE] (provided to the survey team on [DATE]) for Resident #13 revealed, "...Incident date: [DATE]...Time: 5:30 p.m....State Facts Observed at scene: Resident in dining room yelling, cussing, throwing @ staff. Hitting, kicking & attempting to bite staff. Grabbed staff hand & twisted her finger...." This report was completed by Regional Nurse C. The second page of the incident report was, "Incident Investigation." It reflected it was not an abuse allegation. The section of the report titled "List Interventions in Place to Prevent Incident" reflected, "Redirection, removing resident from area & talking calmly to her. [MEDICATION NAME] 20 mg IM if other steps are not successful. Treatment @ (local behavior unit)...." A statement included with the Incident Report regarding Resident #13, dated [DATE] by the DM, revealed, "(Cook K) called (DM) on Sunday evening. (Cook K) stated that (Resident #13) was in the dining room upset... (LVN A) came into the dining room. (Resident #13) was upset and (LVN A) took (Resident #13) to her room. (Cook K) went down to (Resident #13's) room, saw (LVN A) put something on (Resident #13's) neck and gave her 2 shots. I told (Cook K) to call (ADM) she said she already did. I then reported it to (DON) on Monday [DATE] morning." The statement was signed by the DM. An interview on [DATE] at 8:57 p.m. with Cook K revealed she was working on [DATE]. She stated Resident #13 wanted buttermilk and she told her she was only allowed to have it once a day. Cook K stated Resident #13 became upset, began to yell, and LVN A stated to Resident #13, "You're going to your room!" She stated Resident #13 began to choke herself. Cook K stated LVN A told Resident #13, "That's it!" Cook K stated LVN A, LVN I, DA J and herself escorted Resident #13 to her room. She stated LVN A put the yellow gel on Resident #13's neck. Cook K stated her and DA J were sitting on each side of Resident #13, holding the resident by her arms. Resident #13 was stating she wanted to go back to the dining room because she was hungry. Cook K stated LVN A administered a "shot" in Resident #13's right arm and then another shot in the left arm. She stated Resident #13 was then allowed to go back to the dining room. Cook K stated LVN A brought in a vial and "mixed" the medication for the first shot. She stated LVN A brought in the second shot from the hall and she did not see if she mixed it or not. Cook K stated once Resident #13 was brought back to the dining room, "She was out of it." Cook K stated Resident #13 was not able to talk or eat. Cook K stated Resident #16 asked staff, "Will you see if she is ok? (talking about Resident #13)." Cook K stated Resident #17 also checked on Resident #13 and asked if she was ok. A review of a confidential, handwritten witness statement, provided to the survey team regarding Resident #13 revealed, "...(LVN I) pushed her & (LVN A) went to get her a paste & put it on her neck. Then gave her a shot...(Resident #13) grabbed (a person) and started hitting...(LVN A) got another shot and gave it to (Resident #13). The whole time (Resident #13) is wanting to go back to dining area to eat. (LVN A) told her 'No.'...(Resident #13) threw it (grilled cheese sandwich) across floor. (LVN A) went to get another shot and gave it to her...then (Resident #13) came back to dining area & sat at her table & was out. (Resident #17) felt of her to see if she was ok cause it upset (Resident #16)...(Regional Nurse C) the nurse for corp (corporation) came to me & asked for a Incident report & I told her about the shots. She said that two of the shots was sayleen (sic) & it was to make the first shot to start to work faster...." A review of a Provider Investigation [DATE] for Resident #13 (provided to the survey team on [DATE]) revealed the report was called to the State agency on [DATE] at 10:00 p.m. The Incident Category was, "Escalating behaviors around other residents & staff." The incident date was [DATE] at 5:30 p.m. The Provider Investigation Report reflected the "Alleged Perpetrator" was, "(Resident #13)." The witnesses listed on the Report were, "(LVN A, DA J and LVN I)." The Report reflected, "Resident in dining room asking for buttermilk. She became very agitated & started yelling, cussing, hitting, trying to kick and grabbed the Dietary staff members hand & twisted her fingers. Resident removed from area, received PRN medication & became calmer (with) decreased stimuli in room." The Provider Investigation Report reflected the provider response was, "...Notified residents (family member)...PCP...& psychiatrist. Identify when resident is having an increase in anxiety/agitation so that interventions can be started to try to prevent escalation of behaviors. Interventions are remove from area causing an increase in behaviors, redirection, talking to her calmly. [MEDICATION NAME] 20 mg IM PRN for behaviors that do not respond to the other interventions. Resident has prior history of treatment @ (facility behavior unit) and will be re-evaluated if behaviors cont. staff inserviced...Investigation Summary: During investigation, (LVN A) stated she went into dining room when resident became verbally & physically agitated. She removed resident from area and applied [MEDICATION NAME] topical get & [MEDICATION NAME] 2 (sic) mg IM (left) deltoid. (LVN A) then stated that resident continued (with) behavior & was told she would get another shot. Resident Stated, 'I don't care if you give me another shot.' (LVN A) stated she gave the resident a shot of Normal Saline in (right) deltoid. The resident did not have a current order for [MEDICATION NAME] or for Normal Saline as a placebo...Provider Action Taken Post-Investigation: Statements obtained from staff. (LVN A) suspended [DATE] pending investigation completion....Resident is being monitored for adverse effects. Resident condition & behaviors have been stable from [DATE] @ 8 pm to current. No adverse reactions to [MEDICATION NAME] or normal saline IM Placebo. Staff have been inserviced...." An interview on [DATE] at 9:00 a.m. with the DM revealed she was first made aware of the incident on Sunday [DATE], after Cook K called her to report the incident. The DM stated she instructed Cook K to call the ADM. When asked who she reported the incident to, the DM stated she talked to the DON about it on Monday ([DATE]). An interview on [DATE] at 9:06 a.m. with the DON revealed she was first made aware of the incident with Resident #13 on "Monday." She added she reviewed the 24-hour report and it indicated Resident #13 had escalating behaviors. She stated "a girl" (staff member) told her on Monday during the time she was handing out checks that, "I've got a bunch of stuff to tell you." The DON stated she asked, "Like what?" The staff member asked the DON if she had about 30 minutes. The DON stated the staff member never came back and she never went to the staff member to have the discussion. The DON stated she thought the staff member was upset about a personal issue and stated she was going to quit. The DON stated she was not trained on how to conduct an investigation. She added she was "too tired" to continue with the interview and it was stopped. A telephone interview on [DATE] at 12:05 p.m. with LVN I revealed she heard screams from the dining room on [DATE] and went to see what was happening. She stated she assisted getting Resident #13 back to her room, because she had become upset that she was not allowed to have buttermilk. She stated she was holding the wheelchair from the handles on the back of the chair. She stated LVN A came into the room and stated to Resident #13, "Calm down or I'm gonna have to give you a shot." LVN I stated LVN A then administered an injection. LVN I stated the medication came from a vial that LVN A was mixing as she entered the room. LVN I stated LVN A exited the room and re-entered moments later with a syringe (unknown contents). LVN I stated Resident #13 continued to yell, and LVN A administered a second injection in her other arm. LVN I stated LVN A stated to Resident #13, "(Resident #13) you got to calm down or I'm going to have to give you another shot." When asked how much time had elapsed between the first and second injection, LVN I stated seven to ten minutes. When asked what the facility policy was for residents who exhibited behaviors, LVN I stated they were to protect the residents and give them what they wanted if possible. When asked if LVN A acted appropriately in administering two injections to Resident #13, LVN I stated she was unsure if the timeframe of the two injections being given was appropriate. LVN I confirmed she did not discuss the timeframe with LVN A or anyone else after the incident. LVN I added she was interviewed about the incident last evening ([DATE]), by the ADM. When asked what she would do, if a resident exhibited severe behaviors, she administered a [MEDICATION NAME] injection, and the behaviors continued, LVN I stated she would notify the physician. When asked how many times she had observed staff administer sterile water as an injection to a resident, LVN I stated she had never seen that before. When asked if she completed an incident report regarding the incident, LVN I stated she had not. When asked what the policy was for completing incident reports, LVN I stated since she worked the weekends, she would complete the report and place it under the DON's office door. An interview on [DATE] at 1:20 p.m. with the facility's only ADON revealed she was first made aware of the incident with Resident #13 on [DATE]. She stated someone (was not able to state whom) mentioned on [DATE] (Monday) that Resident #13 had behaviors, but did not mention any medications. The ADON stated LVN A came to her on [DATE] and told her she administered a sterile water injection to Resident #13. The ADON stated LVN A told her she also administered the [MEDICATION NAME] gel to Resident #13, but did not realize she did not have an order for [REDACTED]. The ADON denied LVN I informed her of the administration of the sterile water injection immediately after the [MEDICATION NAME] injection. A review of the "All Disciplines To Use Progress Notes" for Resident #13 revealed, "[DATE]: Very anxious. Her room mate not doing well..XXX[DATE]: In wheelchair. Depressed. Her room mate died two nights ago...." An interview was conducted on [DATE] at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member. When asked what had been done since [DATE], regarding Resident #13 being threatened with a shot for behaviors, the ADM stated LVN A was suspended. When asked if any inservices on identifying abuse had been conducted with any staff, the ADM stated there had not been. The ADM was informed of the following: Neither the DM nor Cook K reported what they observed as abuse on [DATE] to the Abuse Coordinator (ADM); LVN I did not intervene, nor did she report the two injections being administered within seven to ten minutes of each other, and did not recognize the threat of an injection as abuse on [DATE]; and LVN A threatened Resident #13 with an injection if she did not "calm down," falsely documented what she had administered to Resident #13 on [DATE], and did not complete an incident report regarding Resident #13. During the same interview conducted on [DATE] at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member, they were notified that an IJ situation had been identified in the area of Resident Behavior/Facility Practices. An observation on [DATE] at 12:05 p.m. revealed Resident #13 was up in the dining room. She was not exhibiting any behaviors. An interview on [DATE] at 12:25 p.m. with Regional Nurse C revealed she was not able to locate any previous orders for Resident #13 to be administered [MEDICATION NAME] gel. An observation on [DATE] at 12:10 p.m. revealed Resident #13 was up in the dining room eating lunch. She was alert and did not exhibit any behaviors. A telephone interview on [DATE] at 2:50 p.m. with the Medical Director revealed Resident #13 was one of his residents. He stated no staff member notified him of the behaviors, nor did they call him for an order to administer a placebo injection. He added, "I would not have allowed that." Review of the Plan of Removal, originally provided on [DATE], and revised on [DATE] and accepted on [DATE], revealed: All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) were being in-serviced on Reporting Abuse/Neglect and Mistreatment, including: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention and Resident rights. The in-service was initiated by the Administrator. To ensure understanding the facility was administering a post test on the in-services. The in-services would continue each shift to ensure all staff received the training and validation testing. That was initiated on [DATE] and the completion date was [DATE]. The Administrator was in-serviced on the topic of Abuse, including Abuse Definitions, Abuse Policies and Procedures, Freedom from Abuse, Resident Rights, Behavior Intervention, Behavior Crisis, and Abuse Prevention by corporate personnel on [DATE] and again reviewed on [DATE]. The Administrator and Regional Nurse Consultant, thoroughly investigated the incidents, which occurred over the past weekend. The employees, who did not respond appropriately and per facility policy were appropriately disciplined by the Administrator to include. The employees included the following: 1) DON suspended pending investigation on [DATE] and terminated on [DATE], 2) LVN A suspended pending investigation on [DATE] and terminated on [DATE], 3) LVN I) who witnessed the incident on [DATE] involving resident (Resident #13) received an one on one in-service on abuse, which included the following: definitions, behavior interventions, behavior crisis, freedom from abuse, abuse prevention; and resident rights, and 4) Dietary staff Cook K, DA J and DM received an in-service on the topic Reporting Abuse/Neglect and Mistreatment, which included the following: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention, Resident rights and written disciplinary notice. For employees who were unable to come to the facility on [DATE] or [DATE] for the in-services listed on the Plan of Removal, the ADM or ADON conducted the in-service over the phone with the employee. The oral in-service conducted over the phone would be documented on the in-service record and included Review of the POS [REDACTED]. All newly hired staff (licensed nurses, certified nurses assistants, medication aides, dietary, housekeeping, laundry, activity director, business office manager, social worker, maintenance) would be in-serviced on Reporting Abuse/Neglect and Mistreatment by the Administrator/designee prior to working their first shift. Validation of understanding would be accomplished by administering a post test. This was initiated on [DATE] and the completion date was ongoing. A QA Meeting would be held on [DATE] with members of the QA team, including the Administrator, Housekeeping/Laundry Supervisor, ADON, Business Office Manager, Activity Director, FSS, Maintenance staff member, and the Medical Director via telephone conference. The QA Committee, which included the Medical Director, would monitor for the next 90 days to ensure the system was effective. The QA Committee would review Incident/Accident Reports, investigation of incidents/accidents, in-services and Post Tests This was initiated on [DATE] the completion date was on-going for 90 days. To ensure all incidents were investigated and appropriately reported, the DON/ADON/Designee would review the 24 hour Report and the Incident/Accident Reports daily for compliance. The Incident/Accident Reports, which had not been completed and thoroughly investigated would be completed, investigated immediately, and reported to DADS appropriately. The results of their review would be reported to the QA Committee each month for the next 90 days. This was initiated on [DATE] and was ongoing. All licensed nurses, including the ADON, are being in-serviced by the Regional Nurse Consultant on the topics of: 1. The Twenty Four Hour Report form and the Guidelines for Nursing Report Policy & Procedure. 2. Incident/Accident Reporting Policies & Procedures. Initiated [DATE] Completion Date: [DATE] All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on the topic of intimidation and threats toward residents. The in-service has been initiated by the Regional Nurse Consultant. Validation of understanding is being accomplished by administering a post test on the subject in-serviced. The in-service will continue each shift to ensure all staff has the training and validation testing. Initiated [DATE] Completion date: [DATE] All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) were being in-serviced on the topic of Behaviors, which included Behavior Crisis Policy and Procedure and Behavior Assessment/Management/Interventions Policies and Procedures. The in-service was initiated by the Regional Nurse Consultant. This in-service would continue on each shift to ensure all staff had the training. The interviews on [DATE] from 10:00 a.m. to 10:50 a.m. with CNA D, CNA N, Housekeeping/Laundry Supervisor O, DA P, Business Office Manager (BOM), LVN I, HK/LA Q and CNA R, revealed they knew what to do regarding residents' behaviors and abuse. The interviews on [DATE] from 10:05 a.m. to 10:28 a.m. with CNA G, LVN B, DA S, DM, CNA F and LVN T, revealed they knew what to do regarding residents' behaviors and abuse. The interviews on [DATE] from 10:35 a.m. to 11:00 a.m. with DM, SA S, ADON, CNA E, CNA D, LVN T, DA P, Housekeeping/Laundry Supervisor O, Physical Therapist Assistant (PTA) U and CNA F, revealed they knew what to do regarding residents' behaviors and abuse. The Administrator was advised via telephone the IJ was lowered on [DATE] at 3:37 p.m. A review of a "Notice Of Disciplinary Action" dated [DATE] revealed LVN A was terminated on [DATE] for, "Allegation of abuse...Abuse confirmed...Injection of normal saline & application of [MEDICATION NAME] gel, both without a physicians order...." LVN A signed a "Freedom From Abuse, Neglect and Mistreatment of [REDACTED]. The form w

Based on observation, interview and record review, it was determined the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were reported immediately to the administrator of the facility and to other officials in accordance with State law; to have evidence that all alleged violations were thoroughly investigated; and to prevent further potential abuse while the investigation was in progress for three (Residents #3, #13, and #15) of eight residents who were reviewed for abuse. 1) Neither the DM, nor Cook K, reported to the Abuse Coordinator (ADM), what they observed, and did not identify the incident as abuse, when LVN A threatened Resident #13 with a shot if she did not calm down. LVN I did not intervene, nor did she report the two injections (for behaviors) being administered within seven to ten minutes of each other, and did not recognize the threat of an injection as abuse. LVN A threatened Resident #13 with an injection if she did not "calm down," she injected Resident #13 with sterile water, and she falsely documented what she had administered to Resident #13. LVN A did not complete an incident report regarding Resident #13. The ADM became aware of the incident four days due to surveyor inquiry. As of five days later, no staff had been inserviced regarding the identification of abuse or reporting abuse immediately to the Abuse Coordinator. 2) CNA V verbally abused Resident #15 and then went into his room and closed the door. CNA R witnessed the exchange and saw CNA V go into Resident #15's room. CNA R immediately told LVN I about the allegation and CNA V going in the resident's room. LVN I told CNA R to report the allegation to the ADM. LVN I did not go to Resident #15's room to check on him or prevent further abuse from CNA V. 3) Resident #3 was found, face down in a pool of blood. No staff witnessed the incident wheelchair, no statements were obtained, and not all of the staff were interviewed to determine if Resident #3's lap buddy was in place prior to the fall. Resident #3 was sent to the hospital where she received 15 sutures to the forehead above the left eye. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the plan or removal. These failures could have affected the 41 residents in the facility by placing them at risk of verbal, physical and mental abuse. Findings included: 1) Resident #13 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] for Resident #13 revealed she did not have any behaviors, [MEDICAL CONDITION] or hallucinations. She did not have any signs of [MEDICAL CONDITION]. A review of a Cognitive/Behavior Data Collection dated [DATE] for Resident #13 revealed she required daily intervention for orientation/memory. The form indicated Resident #13 exhibited the following behaviors daily: yelling, cursing, and crying. The interventions included: 1) Calm, gentle approach, 2) Distract to another activity, 3) Stop activity and reassure if upset, 4) Anticipate needs, 5) Assist/remind to bathroom, 6) Quiet area to limit stimuli, 7) Rest periods and 8) Receives psych services. A review of the [DATE] consolidated physician's orders [REDACTED]. A review of a physician's telephone order dated [DATE] for Resident #13 revealed she was receiving [MEDICATION NAME] (used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION]) 20 mg by mouth every a.m. This dose was increased from 15 mg. A review of a nurse's note dated [DATE] at 10:00 a.m. for Resident #13, revealed, ",[DATE] Escorted out of dining room at supper time because she got into an argument (with) another resident. Stopped once removed from situation...." A review of a nurse's note dated [DATE] at 10:00 a.m. for Resident #13, revealed, "Alert to staff...very rude & (and) argumentative (with) staff & resident. In room yelling @ (at) staff to come in there... 5:30 p.m. Resident in dining room, yelling, cursing, throwing @ staff & residents. 2 staff unable to calm resident. Took to room (with) staff...hitting, kicking, attempting to bite staff. Med IM (left) arm. 20 mg [MEDICATION NAME] for severe agitation... 6:00 p.m. Still very aggressive & yelling... 7:00 p.m. In room. Quieter but still non-compliant & argumentative... 9:00 p.m. In room in w/c sleeping. This nurse & CNA attempted to change her & get her ready for bed. Woke up yelling, 'I'm not changing I'm not ready for bed. Resident stopped yelling & staff left room (authored by LVN A)." A review of the [DATE] MAR for Resident #13 revealed there was no documentation of the [MEDICATION NAME] being administered on [DATE], or for the entire month through [DATE]. Review of the February 2011 MAR indicated [REDACTED]. A review of the Behavior Monitoring logs for [DATE] for Resident #13 revealed she had three behavior (yelling) incidents prior to [DATE]. All three incidents were treated with redirection and/or one-on-one, which meant the staff would sit with the resident. On [DATE] the logs reflected she had one episode of behaviors and the intervention was, "Refer to nurse's notes." A review of the incident and accident reports on [DATE] revealed no reports regarding Resident #13's behavior on [DATE]. A review of a physician's telephone order dated [DATE] for Resident #13 revealed she was receiving [MEDICATION NAME] (used to treat Schizophrenai) 50 mg by mouth at bedtime for anxiety [MEDICATION NAME](used to treat [MEDICAL CONDITION]) 5 mg by mouth at bedtime for [MEDICAL CONDITION]. An interview on initial tour with LVN A on [DATE] at 9:45 a.m. revealed Resident #13 was hard of hearing, had Dementia, behaviors and was not interviewable. LVN A stated Resident #13 sometimes "acted out" by yelling and appeared confused. An observation of Resident #13 on [DATE] at 9:45 a.m. revealed Resident #13 was asleep in bed with two side rails in the up position. LVN A was not able to awaken Resident #13. An observation on [DATE] at 12:05 p.m. revealed Resident #13 was up in the dining room in her wheelchair. She was alert and not exhibiting any behaviors. An observation on [DATE] at 2:22 p.m. revealed Resident #13 was sleeping in her bed. A confidential interview on [DATE] revealed he/she observed Resident #13 asking for buttermilk during the evening meal on [DATE]. He/she stated Resident #13 was told she could only have buttermilk one time a day. He/she stated Resident #13 became upset and was throwing food and 'choking' herself. He/she stated he/she heard LVN A and LVN I state, "Just let her do it." An interview on [DATE] at 3:22 p.m. with DA J revealed she was asked by LVN A to help get Resident #13 to her room during the incident. DA J stated LVN A rubbed the yellow gel ([MEDICATION NAME]) on Resident #13's neck. DA J stated LVN A then administered a "shot" in Resident #13's right shoulder. She stated LVN A then gave Resident #13 another shot in the left shoulder. When asked how much time had passed, from the "yellow gel" to the time of the second shot, DA J stated 10 minutes. An interview on [DATE] at 3:55 p.m. with LVN A revealed she was the charge nurse for Resident #13 on Sunday, [DATE]. She stated she heard screaming coming from the dining room and went to see what was happening. She stated Resident #13 wanted buttermilk and was told she could only have it one time a day. When asked why Resident #13 was not allowed to have the buttermilk, LVN A stated the facility only bought enough for her to have it once a day. LVN A stated she removed Resident #13 from the dining room and took her to her room, with the assistance of DA J and Cook K. LVN A stated she gave Resident #13 [MEDICATION NAME] gel. LVN A denied trying any additional interventions before administering the [MEDICATION NAME] gel, other than removing Resident #13 from the dining room. The MAR indicated [REDACTED]. There was no entry on the MAR for [MEDICATION NAME] gel. LVN A stated she was not aware Resident #13 did not have an order for [REDACTED].#13. She stated she told Resident #13, "I'm gonna have to give you another shot (if she did not calm down)." LVN A stated Resident #13 said, "Go ahead!" LVN A stated she then withdrew 3 cc of N/S in a syringe, and administered it to Resident #13 in the opposite arm. When asked if she obtained an order for [REDACTED]." When asked if she notified the physician of what she had done, LVN A stated she did tell the physician she administered [MEDICATION NAME] and an injection of Saline. LVN A stated Resident #13 calmed down and was taken back to the dining room. An interview on [DATE] at 4:15 p.m. with the ADM and the DON revealed they were not aware of Resident #13 being threatened with a shot for behaviors until today. When asked who did have knowledge of the incident prior to today, the ADM stated the licensed nurses on [DATE] (LVN A and LVN I) knew. (Note: LVN A was working on [DATE] from 2:00 p.m. to 10:00 p.m.) A review of an incident report dated [DATE] (provided to the survey team on [DATE]) for Resident #13 revealed, "...Incident date: [DATE]...Time: 5:30 p.m....State Facts Observed at scene: Resident in dining room yelling, cussing, throwing @ staff. Hitting, kicking & attempting to bite staff. Grabbed staff hand & twisted her finger...." This report was completed by Regional Nurse C. The second page of the incident report was, "Incident Investigation." It reflected it was not an abuse allegation. The section of the report titled "List Interventions in Place to Prevent Incident" reflected, "Redirection, removing resident from area & talking calmly to her. [MEDICATION NAME] 20 mg IM if other steps are not successful. Treatment @ (local behavior unit)...." A statement included with the Incident Report regarding Resident #13, dated [DATE] by the DM, revealed, "(Cook K) called (DM) on Sunday evening. (Cook K) stated that (Resident #13) was in the dining room upset... (LVN A) came into the dining room. (Resident #13) was upset and (LVN A) took (Resident #13) to her room. (Cook K) went down to (Resident #13's) room, saw (LVN A) put something on (Resident #13's) neck and gave her 2 shots. I told (Cook K) to call (ADM) she said she already did. I then reported it to (DON) on Monday [DATE] morning." The statement was signed by the DM. An interview on [DATE] at 8:57 p.m. with Cook K revealed she was working on [DATE]. She stated Resident #13 wanted buttermilk and she told her she was only allowed to have it once a day. Cook K stated Resident #13 became upset, began to yell, and LVN A stated to Resident #13, "You're going to your room!" She stated Resident #13 began to choke herself. Cook K stated LVN A told Resident #13, "That's it!" Cook K stated LVN A, LVN I, DA J and herself escorted Resident #13 to her room. She stated LVN A put the yellow gel on Resident #13's neck. Cook K stated her and DA J were sitting on each side of Resident #13, holding the resident by her arms. Resident #13 was stating she wanted to go back to the dining room because she was hungry. Cook K stated LVN A administered a "shot" in Resident #13's right arm and then another shot in the left arm. She stated Resident #13 was then allowed to go back to the dining room. Cook K stated LVN A brought in a vial and "mixed" the medication for the first shot. She stated LVN A brought in the second shot from the hall and she did not see if she mixed it or not. Cook K stated once Resident #13 was brought back to the dining room, "She was out of it." Cook K stated Resident #13 was not able to talk or eat. Cook K stated Resident #16 asked staff, "Will you see if she is ok? (talking about Resident #13)." Cook K stated Resident #17 also checked on Resident #13 and asked if she was ok. A review of a confidential, handwritten witness statement, provided to the survey team regarding Resident #13 revealed, "...(LVN I) pushed her & (LVN A) went to get her a paste & put it on her neck. Then gave her a shot...(Resident #13) grabbed (a person) and started hitting...(LVN A) got another shot and gave it to (Resident #13). The whole time (Resident #13) is wanting to go back to dining area to eat. (LVN A) told her 'No.'...(Resident #13) threw it (grilled cheese sandwich) across floor. (LVN A) went to get another shot and gave it to her...then (Resident #13) came back to dining area & sat at her table & was out. (Resident #17) felt of her to see if she was ok cause it upset (Resident #16)...(Regional Nurse C) the nurse for corp (corporation) came to me & asked for a Incident report & I told her about the shots. She said that two of the shots was sayleen (sic) & it was to make the first shot to start to work faster...." A review of a Provider Investigation [DATE] for Resident #13 (provided to the survey team on [DATE]) revealed the report was called to the State agency on [DATE] at 10:00 p.m. The Incident Category was, "Escalating behaviors around other residents & staff." The incident date was [DATE] at 5:30 p.m. The Provider Investigation Report reflected the "Alleged Perpetrator" was, "(Resident #13)." The witnesses listed on the Report were, "(LVN A, DA J and LVN I)." The Report reflected, "Resident in dining room asking for buttermilk. She became very agitated & started yelling, cussing, hitting, trying to kick and grabbed the Dietary staff members hand & twisted her fingers. Resident removed from area, received PRN medication & became calmer (with) decreased stimuli in room." The Provider Investigation Report reflected the provider response was, "...Notified residents (family member)...PCP...& psychiatrist. Identify when resident is having an increase in anxiety/agitation so that interventions can be started to try to prevent escalation of behaviors. Interventions are remove from area causing an increase in behaviors, redirection, talking to her calmly. [MEDICATION NAME] 20 mg IM PRN for behaviors that do not respond to the other interventions. Resident has prior history of treatment @ (facility behavior unit) and will be re-evaluated if behaviors cont. staff inserviced...Investigation Summary: During investigation, (LVN A) stated she went into dining room when resident became verbally & physically agitated. She removed resident from area and applied [MEDICATION NAME] topical get & [MEDICATION NAME] 2 (sic) mg IM (left) deltoid. (LVN A) then stated that resident continued (with) behavior & was told she would get another shot. Resident Stated, 'I don't care if you give me another shot.' (LVN A) stated she gave the resident a shot of Normal Saline in (right) deltoid. The resident did not have a current order for [MEDICATION NAME] or for Normal Saline as a placebo...Provider Action Taken Post-Investigation: Statements obtained from staff. (LVN A) suspended [DATE] pending investigation completion....Resident is being monitored for adverse effects. Resident condition & behaviors have been stable from [DATE] @ 8 pm to current. No adverse reactions to [MEDICATION NAME] or normal saline IM Placebo. Staff have been inserviced...." An interview on [DATE] at 9:00 a.m. with the DM revealed she was first made aware of the incident on Sunday [DATE], after Cook K called her to report the incident. The DM stated she instructed Cook K to call the ADM. When asked who she reported the incident to, the DM stated she talked to the DON about it on Monday ([DATE]). An interview on [DATE] at 9:06 a.m. with the DON revealed she was first made aware of the incident with Resident #13 on "Monday." She added she reviewed the 24-hour report and it indicated Resident #13 had escalating behaviors. She stated "a girl" (staff member) told her on Monday during the time she was handing out checks that, "I've got a bunch of stuff to tell you." The DON stated she asked, "Like what?" The staff member asked the DON if she had about 30 minutes. The DON stated the staff member never came back and she never went to the staff member to have the discussion. The DON stated she thought the staff member was upset about a personal issue and stated she was going to quit. The DON stated she was not trained on how to conduct an investigation. She added she was "too tired" to continue with the interview and it was stopped. A telephone interview on [DATE] at 12:05 p.m. with LVN I revealed she heard screams from the dining room on [DATE] and went to see what was happening. She stated she assisted getting Resident #13 back to her room, because she had become upset that she was not allowed to have buttermilk. She stated she was holding the wheelchair from the handles on the back of the chair. She stated LVN A came into the room and stated to Resident #13, "Calm down or I'm gonna have to give you a shot." LVN I stated LVN A then administered an injection. LVN I stated the medication came from a vial that LVN A was mixing as she entered the room. LVN I stated LVN A exited the room and re-entered moments later with a syringe (unknown contents). LVN I stated Resident #13 continued to yell, and LVN A administered a second injection in her other arm. LVN I stated LVN A stated to Resident #13, "(Resident #13) you got to calm down or I'm going to have to give you another shot." When asked how much time had elapsed between the first and second injection, LVN I stated seven to ten minutes. When asked what the facility policy was for residents who exhibited behaviors, LVN I stated they were to protect the residents and give them what they wanted if possible. When asked if LVN A acted appropriately in administering two injections to Resident #13, LVN I stated she was unsure if the timeframe of the two injections being given was appropriate. LVN I confirmed she did not discuss the timeframe with LVN A or anyone else after the incident. LVN I added she was interviewed about the incident last evening ([DATE]), by the ADM. When asked what she would do, if a resident exhibited severe behaviors, she administered a [MEDICATION NAME] injection, and the behaviors continued, LVN I stated she would notify the physician. When asked how many times she had observed staff administer sterile water as an injection to a resident, LVN I stated she had never seen that before. When asked if she completed an incident report regarding the incident, LVN I stated she had not. When asked what the policy was for completing incident reports, LVN I stated since she worked the weekends, she would complete the report and place it under the DON's office door. An interview on [DATE] at 1:20 p.m. with the facility's only ADON revealed she was first made aware of the incident with Resident #13 on [DATE]. She stated someone (was not able to state whom) mentioned on [DATE] (Monday) that Resident #13 had behaviors, but did not mention any medications. The ADON stated LVN A came to her on [DATE] and told her she administered a sterile water injection to Resident #13. The ADON stated LVN A told her she also administered the [MEDICATION NAME] gel to Resident #13, but did not realize she did not have an order for [REDACTED]. The ADON denied LVN I informed her of the administration of the sterile water injection immediately after the [MEDICATION NAME] injection. A review of the "All Disciplines To Use Progress Notes" for Resident #13 revealed, "[DATE]: Very anxious. Her room mate not doing well..XXX[DATE]: In wheelchair. Depressed. Her room mate died two nights ago...." An interview was conducted on [DATE] at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member. When asked what had been done since [DATE], regarding Resident #13 being threatened with a shot for behaviors, the ADM stated LVN A was suspended. When asked if any inservices on identifying abuse had been conducted with any staff, the ADM stated there had not been. The ADM was informed of the following: Neither the DM nor Cook K reported what they observed as abuse on [DATE] to the Abuse Coordinator (ADM); LVN I did not intervene, nor did she report the two injections being administered within seven to ten minutes of each other, and did not recognize the threat of an injection as abuse on [DATE]; and LVN A threatened Resident #13 with an injection if she did not "calm down," falsely documented what she had administered to Resident #13 on [DATE], and did not complete an incident report regarding Resident #13. During the same interview conducted on [DATE] at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member, they were notified that an IJ situation had been identified in the area of Resident Behavior/Facility Practices. An observation on [DATE] at 12:05 p.m. revealed Resident #13 was up in the dining room. She was not exhibiting any behaviors. An interview on [DATE] at 12:25 p.m. with Regional Nurse C revealed she was not able to locate any previous orders for Resident #13 to be administered [MEDICATION NAME] gel. An observation on [DATE] at 12:10 p.m. revealed Resident #13 was up in the dining room eating lunch. She was alert and did not exhibit any behaviors. A telephone interview on [DATE] at 2:50 p.m. with the Medical Director revealed Resident #13 was one of his residents. He stated no staff member notified him of the behaviors, nor did they call him for an order to administer a placebo injection. He added, "I would not have allowed that." Review of the Plan of Removal, originally provided on [DATE], and revised on [DATE] and accepted on [DATE], revealed: All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) were being in-serviced on Reporting Abuse/Neglect and Mistreatment, including: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention and Resident rights. The in-service was initiated by the Administrator. To ensure understanding the facility was administering a post test on the in-services. The in-services would continue each shift to ensure all staff received the training and validation testing. That was initiated on [DATE] and the completion date was [DATE]. The Administrator was in-serviced on the topic of Abuse, including Abuse Definitions, Abuse Policies and Procedures, Freedom from Abuse, Resident Rights, Behavior Intervention, Behavior Crisis, and Abuse Prevention by corporate personnel on [DATE] and again reviewed on [DATE]. The Administrator and Regional Nurse Consultant, thoroughly investigated the incidents, which occurred over the past weekend. The employees, who did not respond appropriately and per facility policy were appropriately disciplined by the Administrator to include. The employees included the following: 1) DON suspended pending investigation on [DATE] and terminated on [DATE], 2) LVN A suspended pending investigation on [DATE] and terminated on [DATE], 3) LVN I) who witnessed the incident on [DATE] involving resident (Resident #13) received an one on one in-service on abuse, which included the following: definitions, behavior interventions, behavior crisis, freedom from abuse, abuse prevention; and resident rights, and 4) Dietary staff Cook K, DA J and DM received an in-service on the topic Reporting Abuse/Neglect and Mistreatment, which included the following: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention, Resident rights and written disciplinary notice. For employees who were unable to come to the facility on [DATE] or [DATE] for the in-services listed on the Plan of Removal, the ADM or ADON conducted the in-service over the phone with the employee. The oral in-service conducted over the phone would be documented on the in-service record and included Review of the POS [REDACTED]. All newly hired staff (licensed nurses, certified nurses assistants, medication aides, dietary, housekeeping, laundry, activity director, business office manager, social worker, maintenance) would be in-serviced on Reporting Abuse/Neglect and Mistreatment by the Administrator/designee prior to working their first shift. Validation of understanding would be accomplished by administering a post test. This was initiated on [DATE] and the completion date was ongoing. A QA Meeting would be held on [DATE] with members of the QA team, including the Administrator, Housekeeping/Laundry Supervisor, ADON, Business Office Manager, Activity Director, FSS, Maintenance staff member, and the Medical Director via telephone conference. The QA Committee, which included the Medical Director, would monitor for the next 90 days to ensure the system was effective. The QA Committee would review Incident/Accident Reports, investigation of incidents/accidents, in-services and Post Tests This was initiated on [DATE] the completion date was on-going for 90 days. To ensure all incidents were investigated and appropriately reported, the DON/ADON/Designee would review the 24 hour Report and the Incident/Accident Reports daily for compliance. The Incident/Accident Reports, which had not been completed and thoroughly investigated would be completed, investigated immediately, and reported to DADS appropriately. The results of their review would be reported to the QA Committee each month for the next 90 days. This was initiated on [DATE] and was ongoing. All licensed nurses, including the ADON, are being in-serviced by the Regional Nurse Consultant on the topics of: 1. The Twenty Four Hour Report form and the Guidelines for Nursing Report Policy & Procedure. 2. Incident/Accident Reporting Policies & Procedures. Initiated [DATE] Completion Date: [DATE] All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on the topic of intimidation and threats toward residents. The in-service has been initiated by the Regional Nurse Consultant. Validation of understanding is being accomplished by administering a post test on the subject in-serviced. The in-service will continue each shift to ensure all staff has the training and validation testing. Initiated [DATE] Completion date: [DATE] All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) were being in-serviced on the topic of Behaviors, which included Behavior Crisis Policy and Procedure and Behavior Assessment/Management/Interventions Policies and Procedures. The in-service was initiated by the Regional Nurse Consultant. This in-service would continue on each shift to ensure all staff had the training. The interviews on [DATE] from 10:00 a.m. to 10:50 a.m. with CNA D, CNA N, Housekeeping/Laundry Supervisor O, DA P, Business Office Manager (BOM), LVN I, HK/LA Q and CNA R, revealed they knew what to do regarding residents' behaviors and abuse. The interviews on [DATE] from 10:05 a.m. to 10:28 a.m. with CNA G, LVN B, DA S, DM, CNA F and LVN T, revealed they knew what to do regarding residents' behaviors and abuse. The interviews on [DATE] from 10:35 a.m. to 11:00 a.m. with DM, SA S, ADON, CNA E, CNA D, LVN T, DA P, Housekeeping/Laundry Supervisor O, Physical Therapist Assistant (PTA) U and CNA F, revealed they knew what to do regarding residents' behaviors and abuse. The Administrator was advised via telephone the IJ was lowered on [DATE] at 3:37 p.m. A review of a "Notice Of Disciplinary Action" dated [DATE] revealed LVN A was terminated on [DATE] for, "Allegation of abuse...Abuse confirmed...Injection of normal saline & application of [MEDICATION NAME] gel, both without a physicians order...." LVN A signed a "Freedom From Abuse, Neglect and Mistreatment of [REDACTED]. The form was found in her employee file. A review of an Abuse Policy Pre-Post Test, completed by LVN A on [DATE], revealed there were 20 questions. LVN A answered seven of the questions incorrectly. 2) Resident #15 was a [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15's admission MDS assessment dated [DATE] reflected he had unclear speech and he had limited ability to make himself understood. The MDS assessment also reflected he had short and long-term memory problems, he was "short-tempered, easily annoyed," he had [MEDICAL CONDITION], verbal behavioral symptoms daily, and physical symptoms such as hitting or scratching self, pacing, verbal/vocal symptoms like screaming, disruptive sounds. The assessment reflected Resident #15 required "limited" to "extensive" assistance with all ADLs and he required "total assistance" for toileting. Care plans addressing Resident #15's behavior included the following: [DATE] behaviors exhibited were pushing other resident's w/c and scratched resident and anger management; [DATE] refused medications and increased behavior problems; [DATE] episodes of resistance to ADL care mood state; [DATE] episodes of inappropriate behaviors cursing, anger problem, yelled at others, and delusional; and [DATE] total assist with ADLs due to right-sided weakness. At 11:00 a.m. on Sunday [DATE], the Administrator informed the surveyors she had suspended a CNA the previous evening for "what she had said to __ (Resident #15)." She stated she was still working on the report. Review of nurse's notes for Resident #15 on [DATE] at "945" revealed, "Report to Chg. (Charge) Nurse that ____ (CNA V) was verbally abusive to this resident. Stating until you stop cursing, talking loud I'am (sic) not going to put you to bed. ,[DATE] min later ___ (CNA V) went and put resident to bed. Report to Abuse Coord (Coordinator) ___ (Administrator's name) Adm." Resident #15 was interviewed on [DATE] at 11:15 a.m. He did not remember any incident of abuse. During the end-of-day meeting with facility staff on [DATE] at 11:50 a.m., the surveyors asked if the Administrator would provide the investigation for review the next day. On [DATE] the investigation of the incident with CNA V and Resident #15 was reviewed. The Provider Investigation Report dated [DATE] reflected the incident between Resident #15 and CNA V was observed by CNA R, who was across the hall. The Report also reflected, "Per witness, employee __ (CNA V) told resident __ (Resident #15) that if he did not want to stay up all night he needed to stop. Emp (employee) (CNA V) repeated this statement again to resident. Res wheeled into his room, CNA V closed the door to the room." The "Provider Response" section reflected, "Employee __ (CNA V) immediately suspending (sic) pending investigation. ... Investigation immediately initiated." CNA V's statement dated [DATE] re

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as possible and four (Residents #10, #12, #15 and #18) each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #10) of 16 residents reviewed for hazards. 1) On 03/13/11, Resident #10, who was identified as a high risk for elopement, was not wearing her physician-ordered Wanderguard when she eloped from the facility and had to be brought back physically into the facility. On 03/17/11, the ADM and the DON were unaware Resident #10 had eloped from the facility. On 03/17/11, Resident #10 was not wearing the physician-ordered Wanderguard. 2) The facility had four residents (Residents #10, #12, #15, and #18), who had Wanderguards, and were determined to be a "high risk" for elopement. The front door was not operating properly by locking when a Wanderguard device was in the immediate vicinity on 03/15/11, 03/16/11, and 03/19/11. The Administrator said the Maintenance Director failed to advise staff that the door was not functioning properly. An Immediate Jeopardy(IJ) was identified on 03/17/11. While the IJ was lowered on 03/22/11, the facility remained out of compliance at a scope of "pattern" and a severity of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because all staff had not been trained, and the facility was still monitoring the implementation of the plan of removal. This could affect the other three residents, who were identified as risk for elopement by placing them at risk for exiting the facility undetected by staff and suffering injuries such as lacerations, fractures, and death. Non-Immediate Jeopardy Deficiencies: 3) Shower rooms on south hall were unlocked and there was an unlocked cabinet above the commode which contained: 1 spray bottle of Heavy Duty Bathroom Cleanser, 1 container of Equate Deep Moisture Lotion, 1 container of Perfect Purity Advanced Lubricating Skin Lotion, 1 container of moisture barrier ointment, Heavy Duty Bathroom Cleanser, soothe and cool body lotion, 2 cans of shaving cream and 5 tubes of toothpaste. The Central Supply closet was unlocked and contained Excel Gel, Silver Med., Silversorb, Polysporin, Safe Gel, Stomahesive, eight boxes of syringes with needles attached and two cans of shaving cream. Two linen carts had baby powder on them. All of the items indicated to keep out of the reach of children/keep away from young children. These failures could affect the facility's four residents (Residents #10, #12, #15 and #18) identified with wandering behaviors, and placed them at risk for exposing them to hazards causing them harm and the need for immediate medical attention. The facility identified four residents who had behaviors of wandering. Findings included: 1) Resident #10 was a [AGE] year-old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a significant change MDS assessment dated [DATE] for Resident #10 revealed she was able to recall the current season, location of her room, staff members' names/faces and that she was in a nursing home. She had modified independence in cognitive skills for decision-making. She had behaviors of inattention and disorganized thinking, which fluctuated. She also had delusions. A review of a Wandering Risk Assessment Tool dated 09/14/10 for Resident #10 revealed she was at high risk for wandering. A review of a physician's telephone order dated 02/08/11 for Resident #10 revealed, "Clarification: May have Wanderguard QS (each shift) due to poor safety awareness." This order was completed by the DON. A review of the March 2011 consolidated physician's orders [REDACTED]." A review of the facility's incident/accident reports for March 2011 revealed no reports of any unusual occurrences for Resident #10. A review of the March 2011 facility investigations, which were reported to the state agency, revealed no investigations for Resident #10. A review of the Cognitive/Behavior Data Collection dated 03/12/11 for Resident #10 revealed a handwritten note on the back that reflected, "Res wanted a snack. Demanded peanut butter sandwich then peanut butter crackers. When explained that both foods are not indicated in her diet... She began a loud temper tantrum. Threw full juice cup at the nurse, spilling it on floor. Screaming, yelling, stomping, off w/o wheelchair. Ruffles hair wildly. Finally calmed once some peanut butter crackers were crushed and mixed into a milkshake... which she ate and remained calm along with very apologetic afterwards." A review of a Nurse's Note dated 03/13/11 timed at 6:00 p.m. authored by LVN A for Resident #10 revealed, "Resident going out front door via w/c & (and) yelling. 2nd nurse went to talk (with) her attempted to stop w/c & talk (with) her. Resident yelling jumped up & ran down side walk. Other nurse going quickly trying to talk (with) resident. This nurse got Ativan gel 2 mg/ml 1 cc. When got out side resident on ground slapping, scratching, kicking staff. Ativan gel applied. Took several minutes to get resident to w/c. Then trying to kick, scratch, slap and bite staff. Med IM (with) Haldol injection 5 mg/ml IM (left) deltoid. CNA sat (with) resident 10 minutes resident settled down...." An observation and interview on the initial tour on 03/16/11 at 9:30 a.m. with LVN A revealed Resident #10 had behaviors of fighting with staff, screaming and "throwing fits." She was ambulatory but used a wheelchair due to a poor gait. There was no mention of any recent incidents during initial tour. Resident #10 was observed asleep in her bed. An interview on 03/17/11 at 3:22 p.m. with DA J revealed on 03/13/11 she observed Resident #10 grab a package of peanut butter crackers off a tray and take off with them. DA J stated she knew Resident #10 was on a pureed diet and told her she was not allowed to have the crackers. DA J stated she found the charge nurse and informed her Resident #10 had the crackers. DA J stated Resident #10 became upset and went out the front door. DA J confirmed there was no wander guard bracelet on Resident #10 as the door did not alarm when she went through it. DA J stated she was never asked to write a statement, and no staff member had interviewed her about the incident. She stated she talked to the DON on 03/14/11 about the incident. An interview on 03/17/11 at 4:15 p.m. with the ADM and the DON revealed they were not aware of the incident, which occurred on 03/13/11 with Resident #10. They confirmed there was no incident report for this incident. An observation on 03/17/11 at 5:10 p.m. revealed the DON wheeled Resident #10 to the front door where the wanderguard system was. The door never alarmed. The DON was not able to locate a wanderguard on Resident #10 at that time. An observation on 03/17/11 at 6:00 p.m. on the front lawn of the facility revealed 65 cars passed on the busy street in front of the facility within five minutes. The posted speed limit was 40 miles per hour. A telephone interview on 03/17/11 at 8:40 p.m. with CNA/MA V revealed she was working as a CNA on 03/13/11. She stated she heard an overhead page help was needed, "now." CNA/MA V stated Resident #10 was outside on the lawn. She stated Resident #10 was halfway to the street when she arrived outside. A telephone interview on 03/17/11 at 8:57 p.m. with Cook K revealed she was working on 03/13/11. She stated she had been to the dumpster when she heard screams from staff they needed help. She stated LVN A and LVN I were behind the wheelchair. DA J and CNA/MA V were on the ground with Resident #10 trying to stop her from getting into the street. Cook K stated when they finally got Resident #10 back inside the building LVN A administered the yellow paste (Ativan Gel) and a shot to Resident #10. A telephone interview on 03/18/11 at 12:05 p.m. with LVN I revealed she was working on 03/13/11 and was the charge nurse for Resident #10. She stated she was passing medications when she was approached by DA J and was told Resident #10 had crackers. LVN I stated she was told Resident #10 was not to have the crackers. LVN I stated at a later time, she was told Resident #10 was allowed to have the crackers in the presence of a nurse. She stated when Resident #10 exited the facility, she went out with her and was talking with her. She stated Resident #10 was walking on the sidewalk, talking calmly. LVN I stated Resident #10 was asking for the crackers. LVN I stated at that time, "I got the crackers from her." She then stated DA J approached, and Resident #10 became agitated and began to kick and scream. LVN I stated she observed LVN A apply Ativan gel to Resident #10, and she began to calm down. LVN I denied seeing LVN A administer an injection. However, LVN I stated, "I said she should have got an injection." She stated she was under the impression Resident #10 was allowed to go on the front porch unassisted. When asked if Resident #10 was injured, LVN I stated she did have stickers (grass burrs) all over her, but it was because "staff agitated her." When asked if she reported the staff's actions, which agitated Resident #10 to the point of needing PRN medications for behavior, LVN I stated she did not. An interview on 03/18/11 at 1:20 p.m. with the facility's only ADON revealed she was informed on 03/14/11 of the incident with Resident #10. She added the staff blew everything out of proportion. When asked what had been done to prevent that from happening again, the ADON stated she was not aware. The ADON added she thought the ADM was inservicing staff on that. A review of a psychiatry note dated 03/18/11 for Resident #10 revealed, "Pt had a meltdown over the weekend. Became agitated & ran outside. Several PRNs (medication) were given. Was wanting crackers (is able to eat in front of LVN) - dietary wasn't sure & checked (with) nurse. Pt knew could have - didn't realize need nurse... Required PRN when ran outside & was agitated. Pt did not have (Wanderguard) bracelet on... Pt got angry b/c dietary wanted to (check) (with) nurse before pt ate crackers b/c on pureed... Pt has taken bracelet off... but is back on now... All staff will be inserviced that (Resident #10) can eat crackers...." A review of the incident report (completed on 03/17/11 after surveyor inquiry) for Resident #10, revealed the incident occurred on 03/13/11 at 6:00 p.m. Under "State facts," was, "Resident became upset in dining room concerning peanut butter crackers. Dietary staff not aware resident can have them since she is on puree diet (with) honey thick liquids. Res became very agitated rolled w/c out door & got out of w/c placed self on ground kicking, screaming, hitting, biting... Incident Investigation: Resident became very agitated concerning peanut butter crackers & staff knowledge of diet... POTENTIAL CONTRIBUTING FACTORS... (increased) agitation r/t diet & snack of peanut butter crackers that she was not given to eat... LIST INTERVENTIONS IN PLACE TO PREVENT INCIDENT: Inservice staff that resident has MD order to allow her to have a snack of peanut butter crackers...." Review of the Cognitive/Behavior Data Collection dated 03/13/11 for Resident #10 revealed "Interventions," were, "Calm, gentle approach, Offer food or drink...." 2) As surveyors exited the facility on 03/16/11 at 3:10 p.m., two maintenance staff were observed to be working on the closure on the front door. On 03/17/11 at 9:15 a.m., the Maintenance Director advised the surveyors yesterday (03/16/11), they replaced the key pad. He said a new system was installed last year. On 03/17/11 at 4:00 p.m., the Life Safety Code surveyor advised the surveyors the facility's Wanderguard system was not locking properly. He reported the locking mechanism on the front door did not lock; however, the aural alarm did work when a Wanderguard device was in the immediate vicinity. An observation on 03/17/11 at 5:00 p.m. revealed the front door did not lock, when approached by the surveyor with a spare Wanderguard device. The alarm did sound. During the end-of-day meeting with the Administrator and the DON on 03/17/11 at 5:17 p.m., the surveyors asked for documentation to show when the facility had ordered the part to fix the Wanderguard system and asked when the facility was aware the system was not locking properly. The surveyors also asked for a list of residents, who were at risk for elopement. A review of a policy entitled, "Wandering Resident," dated January 2008 and provided as the current policy by the ADON revealed, "Policy: It is the policy of this facility that residents at risk for wandering will be identified and monitored for safety. Procedure: 1) Residents will be assessed for wandering risk factors upon admission, quarterly and with any change in condition. 2) Residents considered at risk will be assessed for the secure unit, if located in the facility of use of a wander guard if facility is equipped with a wander guard type system. 3) The IDCPT (Interdisciplinary Care Plan Team) will be responsible to develop a care plan to assure that the resident receives the appropriate monitoring to assure safety...7) Staff will be trained upon hire and at least annually on the procedure for a missing resident, as well as the appropriate method to deter a wandering resident." On 03/17/11 at 5:17 p.m., the Administrator and the DON were notified of the IJ in the area of Quality of Care and Administration with Substandard Quality of Care (SQC) due to the malfunctioning of the Wanderguard system, Resident #10 going out the front door without it alarming on 03/13/11, and the Administrator and DON having no knowledge of the incident until 03/17/11. Surveyors requested a Plan of Removal for the IJ from the Administrator and the DON. An interview on 03/17/11 at 5:21 p.m. with the ADM and the DON revealed the ADM was not aware there was an order for [REDACTED]. At 5:52 p.m. on 03/17/11, the surveyors reviewed the facility's Wanderguard Book. Sheets were found for Residents #10, #12, #15, and #18, who were identified as a "high" elopement risks. The Administrator provided a parts invoice for the Wanderguard system to the surveyors on 03/18/11 in the morning. The invoice was dated 03/16/11 and reflected a Magnetic Solution De Lock, a bracket mounting, and a cover were ordered. The same list of residents, Residents #10, #12, #15, and #18, who the facility identified as a "high" elopement risk, was provided by the Administrator on 03/18/11 at 10:09 a.m. to the surveyors. On 03/18/11 at 9:50 a.m., the surveyor interviewed the Maintenance Director via telephone. He said he had been suspended, because he had not informed the DON about the front door lock not working. He said he told the DON on Wednesday (03/16/11) afternoon. He said he had also told the nurse, who was on the south side. He said he "thought" he had told the Administrator. He said he also called the Maintenance Supervisor on Tuesday (03/15/11), who was going to get the part and be there on Wednesday. Review of the facility's revised Plan of Removal for the IJ dated and accepted on 03/18/11 revealed the following: All staff were to be in-serviced on their response to door alarms and reporting malfunctioning of the wanderguard system. The plan reflected all new staff would be trained on the personal response procedure. Random tests would be done to assure compliance. Additionally, a daily check was established for each wanderguard "bracelet" on each resident. Door alarms would also be checked daily. Any malfunctions of the system were to be immediately reported to the Administrator and the Maintenance Director. The plan included ensuring the Nurse Aide Care Plans identified residents at "high risk for wandering and indicate the appropriate approaches to address such behavior...." Safety measures included posting a staff member by a malfunctioning door to ensure safety of wandering residents. The surveyors found an additional resident at risk for elopement. The facility's 03/19/11 24-hour report reflected Resident #17 was on 15-minute checks because of his attempts to elope. Logbook Documentation of the "operation of door monitors and patient wandering system" reflected the new system's alarms were activated on 11/24/10 on the Break Room and Patio doors. Documentation reflected, "Waiting on parts to complete the 2 fire doors and front door." This documentation was on a sheet dated 11/29/10 to 12/03/10. The sheet dated for 11/24/10 was not provided to the surveyors. Documentation on the sheet dated 12/02/10 reflected, "New alarm system installed and finished 12-2-2010." The front door closer was replaced as noted on the 02/07/11 sheet. All other sheets reflected the system was working "as expected." An interview on 03/19/11 at 11:21 a.m. with the ADM revealed Resident #10 had been transferred to another facility. The ADM stated during the Wanderguard checks on 03/18/11, Resident #10 did not have hers on. It was located in the trashcan. The ADM stated they were not able to keep her safe in the facility. Resident #10's family agreed to move her to a more secure facility. A review of a physician's telephone order dated 03/18/11 for Resident #10 revealed, "May release w/ meds for transfer to (new facility)." When surveyors entered the facility on 03/20/11 at 9:15 a.m., two maintenance staff were working on the front door. They reported they were "putting a part on the door that had come in." During an interview with the ADM on 03/20/11 at 9:55 a.m., she reported the magnet for the front door was working yesterday (Saturday, 03/19/11) when she left at 11:00 p.m. She said it was not locking that morning when she arrived at work at 7:00 a.m. The ADM advised the surveyors she had posted staff at the door to monitor and provided the appropriate documentation. At 11:15 a.m. on 03/20/11, the surveyor went out to the patio area outside the dining room. The door had not closed and when the surveyor re-entered the dining room a minute later, the aural alarm was buzzing. The surveyor waited in the dining room for two minutes before a staff person came into the room wheeling a resident. She saw the surveyor; walked over and opened the patio door, ascertained a staff person was with the resident on the patio, and reset the alarm. On 03/21/11 at 9:00 a.m., the Maintenance Director was interviewed via telephone. He reported he had been terminated. He stated the front door magnet (lock) had not been changed when the new system was installed in November 2010. He reported having re-occurring problems with it since December 2010. He stated he had to work on the door two to three times a week. He stated he had advised the Maintenance Supervisor and the ADM. He said he had called the Maintenance Supervisor last Tuesday (03/15/11) at 11:30 a.m., because the magnet and the key board were not working. The ADM was interviewed on 03/21/11 at 10:05 a.m. about the Wanderguard system. She said the new system, which was installed in August or September 2010 was working. She reported the only trouble she knew about was the closure to the front door. She said the closure was replaced about six weeks ago. She stated she was aware the key pad had been changed. She also advised she was aware the magnet was replaced on 03/20/11. She denied any knowledge the Maintenance Director had told her there were on-going problems with the magnet on the front door. She stated she would provide documentation about maintenance for the door. The interviews on 03/21/11 10:05 a.m. to 10:28 a.m. with four (CNA G, LVN B, DA S and DM) revealed they all responded appropriately when questioned about the wanderguard system. On 03/23/11 at 1:40 p.m., the Maintenance Supervisor was interviewed via telephone. He confirmed the door magnet was defective on the front door. He stated the ADM had called him Wednesday (03/16/11) morning to advise him surveyors were in the building. He stated the facility Maintenance Director had called him at 1:00 p.m. on 03/16/11 and said he was having problems with the front door. He denied the Maintenance Director had advised him he was having problems with the lock on the front door. He stated the coil on the door was burnt up, and was replaced on 03/16/11 in the evening, and he had ordered another one. The magnet was replaced on Sunday (03/20/11). Review of the Post Test, completed by fifteen staff (Housekeeping/Laundry Supervisor O, ADON, DM, DON, BOM, LVN T, Cook K, CNA W, LVN X, CNA/MA V, CNA E, LVN B, DA S, LVN Y and CNA Z) after the Inservice regarding the Wanderguard system was conducted, revealed they all answered the test questions correctly. The ADM was advised via telephone the IJ was lowered on 03/22/11 at 3:37 p.m. In addition to the IJ, the following deficient practices were identified concerning items that should be secured: 1) An observation on 03/16/11 at 9:45 a.m. of the shower room on South hall revealed the door was unlocked, and there was an unlocked cabinet above the commode which contained: one spray bottle of "Heavy Duty Bathroom Cleanser," which had a label reflected, "keep away from young children;" one container of "Equate Deep Moisture Lotion;" one container of "Perfect Purity Advanced Lubricating Skin Lotion;" and one container of "moisture barrier ointment" None of the items had resident names on them. 2) An observation on 03/16/11 at 9:50 a.m. of the shower room directly across the hall revealed the door was unlocked, and there was an unlocked cabinet above the commode, which contained: one spray bottle of "Heavy Duty Bathroom Cleanser," which had a label reflected, "keep away from young children;" one container of "soothe and cool body lotion;" two cans of shaving cream; and five tubes of toothpaste None of the items had resident names on them. In an interview with CNA E on 03/18/11 at 2:30 p.m., CNA E stated, "We use all that stuff for everyone." 3) On 03/16/11 at 11:07 a.m., the door to the south side shower on the right side of the hall was not latched. The door handle was locked, but the door had not completely closed. The cabinet in the shower was not locked, and the following items were found: a full spray bottle of cleaner spray; a bottle of barrier ointment lotion with a warning to keep out of reach of children; a vinyl bag had a bottle of nail polish; and body scrub. 4) On 03/16/11 at 11:17 a.m. in the linen cart by Room 11, two small bottles of baby powder were found, which had a warning to keep out of reach of children. 5) On 03/16/11 at 11:24 a.m., the facility's only ADON was observed taking the North linen cart into Room 22. When the surveyor asked what was on the cart, she showed the surveyor the linen cart, which had the following items: shampoo, four bottles of lotion, a peri-care bottle, one deodorant container, and one bottle of after shave in a pillow case. 6) An observation on 03/17/11 at 11:01 a.m. revealed the Central Supply closet, just south of the restroom near the nurse's station, was not locked. Inside, the following was found: a. Excel Gel b. Silver Med c. Silversorb d. Polysporin e. Safe Gel f. Stomahesive g. eight boxes of syringes with needles attached h. two cans of shaving cream All of the items' labels indicated to keep out of the reach of children. 7) An interview on 03/17/11 at 11:07 a.m. with the ADM revealed the door to the Central Supply storage should always be locked. She was informed of the observation at 11:01 a.m. on that date.

Based on observation, interview and record review, it was determined the facility failed to ensure each resident's drug regimen was free from any unnecessary drugs for three (Residents #13, #10, and #12) of 11 residents reviewed for chemical restraints. 1) LVN A administered Resident #13 [MEDICATION NAME] Gel, without an order, [MEDICATION NAME] IM without using non-pharmological interventions first, and administered sterile water for injections without a physician's orders [REDACTED]. 2) Resident #10 was administered [MEDICATION NAME] Gel and a [MEDICATION NAME] injection after she became upset when she was not allowed to have peanut butter crackers. Staff did not offer her another snack, and did not call her family member, prior to administering the [MEDICATION NAME] and the [MEDICATION NAME]. 3) Resident #12 did not receive non-pharmacological interventions (such as behavioral interventions), instead of, or in addition to, medication even though he was easily redirected. An Immediate Jeopardy (IJ) was identified on 03/18/11. While the IJ was removed on 03/22/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could affect the other eight residents with identified behaviors by placing them at risk of being over-medicated, drowsy, unable to participate in care, unable to eat, or suffering from adverse drug reactions. Findings included: 1) Resident #13 was a [AGE] year-old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] for Resident #13 revealed she did not have any behaviors, [MEDICAL CONDITION] or hallucinations. She did not have any signs of [MEDICAL CONDITION]. A review of the March 2011 consolidated physician's orders [REDACTED]. A review of a nurse's note dated 03/13/11 at 10:00 a.m. for Resident #13, revealed, "Alert to staff... very rude & (and) argumentative (with) staff & resident. In room yelling @ (at) staff to come in there... 5:30 p.m. Resident in dining room, yelling, cursing, throwing @ staff & residents. 2 staff unable to calm resident. Took to room (with) staff...hitting, kicking, attempting to bite staff. Med IM (left) arm. 20 mg [MEDICATION NAME] for severe agitation... 6:00 p.m. Still very aggressive & yelling... 7:00 p.m. In room. Quieter but still non-compliant & argumentative... 9:00 p.m. In room in w/c sleeping. This nurse & CNA attempted to change her & get her ready for bed. Woke up yelling, 'I'm not changing I'm not ready for bed. Resident stopped yelling & staff left room.(authored by LVN A)." A review of the March 2011 MAR for Resident #13 revealed there was no documentation of the [MEDICATION NAME] being administered on 03/13/11, or for the entire month through 03/19/11. Review of the February 2011 MAR indicated [REDACTED]. A review of the Behavior Monitoring logs for March 2011 for Resident #13 revealed she had three behavior (yelling) incidents prior to 03/13/11. All three incidents were treated with redirection and/or one-on-one, which meant the staff would sit with the resident. On 03/13/11, the logs reflected she had one episode of behaviors and the intervention was, "Refer to nurse's notes." A review of a physician's telephone order dated 03/17/11 for Resident #13 revealed she was receiving [MEDICATION NAME] 50 mg by mouth at bedtime for anxiety [MEDICATION NAME] mg by mouth at bedtime for [MEDICAL CONDITION]. An interview on initial tour with LVN A on 03/16/11 at 9:45 a.m. revealed Resident #13 was hard of hearing, had Dementia, behaviors and was not interviewable. LVN A stated Resident #13 sometimes "acted out" by yelling and appeared confused. An observation of Resident #13 on 03/16/11 at 9:45 a.m. revealed Resident #13 was asleep in bed with two side rails in the up position. LVN A was not able to awaken Resident #13. An observation on 03/16/11 at 12:05 p.m. revealed Resident #13 was up in the dining room in her wheelchair. She was alert and not exhibiting any behaviors. An observation on 03/17/11 at 2:22 p.m. revealed Resident #13 was sleeping in her bed. An interview on 03/17/11 at 3:22 p.m. with DA J revealed she was asked by LVN A to help get Resident #13 to her room during the incident. DA J stated LVN A rubbed the yellow gel ([MEDICATION NAME]) on Resident #13's neck. DA J stated LVN A then administered a "shot" in Resident #13's right shoulder. She stated LVN A then gave Resident #13 another shot in the left shoulder. When asked how much time had passed, from the "yellow gel" to the time of the second shot, DA J stated 10 minutes. An interview on 03/17/11 at 3:55 p.m. with LVN A revealed she was the charge nurse for Resident #13 on Sunday, 03/13/11. She stated she heard screaming coming from the dining room and went to see what was happening. She stated Resident #13 wanted buttermilk and was told she could only have it one time a day. When asked why Resident #13 was not allowed to have the buttermilk, LVN A stated the facility only bought enough for her to have it once a day. LVN A stated she removed Resident #13 from the dining room and took her to her room, with the assistance of DA J and Cook K. LVN A stated she gave Resident #13 [MEDICATION NAME] gel. LVN A denied trying any additional interventions before administering the [MEDICATION NAME] gel, other than removing Resident #13 from the dining room. The MAR indicated [REDACTED]. There was no entry on the MAR for [MEDICATION NAME] gel. LVN A stated she was not aware Resident #13 did not have an order for [REDACTED].#13. She stated she told Resident #13, "I'm gonna have to give you another shot (if she did not calm down)." LVN A stated Resident #13 said, "Go ahead!" LVN A stated she then withdrew 3 cc of N/S in a syringe, and administered it to Resident #13 in the opposite arm. When asked if she obtained an order for [REDACTED]." When asked if she notified the physician of what she had done, LVN A stated she did tell the physician she administered [MEDICATION NAME] and an injection of Saline. LVN A stated Resident #13 calmed down and was taken back to the dining room. http://www.drugs.com/[MEDICATION NAME].html. "[MEDICATION NAME] is used to treat anxiety disorders... Seek emergency medical attention if you think you have used too much of this medicine. An overdose of [MEDICATION NAME] can be fatal. [MEDICATION NAME] overdose symptoms may include extreme drowsiness, confusion, muscle weakness, [MEDICAL CONDITION], or coma...." An interview on 03/17/11 at 4:15 p.m. with the ADM and the DON revealed they were not aware of Resident #13 being threatened with a shot for behaviors until today. When asked who did have knowledge of the incident prior to today, the ADM stated the licensed nurses on 03/13/11 (LVN A and LVN I) knew. (Note: LVN A was working on 03/17/11 from 2:00 p.m. to 10:00 p.m.) A review of an incident report dated 03/17/11 (provided to the survey team on 03/18/11) for Resident #13 revealed, "...Incident date: 03/13/11 ...Time: 5:30 p.m. ...State Facts Observed at scene: Resident in dining room yelling, cussing, throwing @ staff. Hitting, kicking & attempting to bite staff. Grabbed staff hand & twisted her finger...." This report was completed by Regional Nurse C. The second page of the incident report was, "Incident Investigation." It reflected it was not an abuse allegation. The section of the report titled "List Interventions in Place to Prevent Incident" reflected, "Redirection, removing resident from area & talking calmly to her. [MEDICATION NAME] 20 mg IM if other steps are not successful. Treatment @ (local behavior unit)...." An interview on 03/17/11 at 8:57 p.m. with Cook K revealed she was working on 03/13/11. She stated Resident #13 wanted buttermilk and she told her she was only allowed to have it once a day. Cook K stated Resident #13 became upset, began to yell, and LVN A stated to Resident #13, "You're going to your room!" She stated Resident #13 began to choke herself. Cook K stated LVN A told Resident #13, "That's it!" Cook K stated LVN A, LVN I, DA J and herself escorted Resident #13 to her room. She stated LVN A put the yellow gel on Resident #13's neck. Cook K stated she and DA J were sitting on each side of Resident #13, holding the resident by her arms. Resident #13 was stating she wanted to go back to the dining room because she was hungry. Cook K stated LVN A administered a "shot" in Resident #13's right arm and then another shot in the left arm. She stated Resident #13 was then allowed to go back to the dining room. Cook K stated LVN A brought in a vial and "mixed" the medication for the first shot. She stated LVN A brought in the second shot from the hall and she did not see if she mixed it or not. Cook K stated once Resident #13 was brought back to the dining room, "She was out of it." Cook K stated Resident #13 was not able to talk or eat. Cook K stated Resident #16 asked staff, "Will you see if she is ok? (talking about Resident #13)." Cook K stated Resident #17 also checked on Resident #13 and asked if she was ok. A review of a confidential, handwritten witness statement, provided to the survey team regarding Resident #13 revealed, "...(LVN I) pushed her & (LVN A) went to get her a paste & put it on her neck. Then gave her a shot... (Resident #13) grabbed (a person) and started hitting... (LVN A) got another shot and gave it to (Resident #13). The whole time (Resident #13) is wanting to go back to dining area to eat. (LVN A) told her 'No.'... (Resident #13) threw it (grilled cheese sandwich) across floor. (LVN A) went to get another shot and gave it to her... then (Resident #13) came back to dining area & sat at her table & was out. (Resident #17) felt of her to see if she was ok cause it upset (Resident #16)... (Regional Nurse C) the nurse for corp (corporation) came to me & asked for a Incident report & I told her about the shots. She said that two of the shots was sayleen (sic) & it was to make the first shot to start to work faster...." A review of a Provider Investigation 03/17/11 for Resident #13 (provided to the survey team on 03/18/11) revealed the report was called to the State agency on 03/17/11 at 10:00 p.m. The Incident Category was, "Escalating behaviors around other residents & staff." The incident date was 03/13/11 at 5:30 p.m. The Provider Investigation Report reflected the "Alleged Perpetrator" was, "(Resident #13)." The witnesses listed on the Report were, "(LVN A, DA J and LVN I)." The Report reflected, "Resident in dining room asking for buttermilk. She became very agitated & started yelling, cussing, hitting, trying to kick and grabbed the Dietary staff members hand & twisted her fingers. Resident removed from area, received PRN medication & became calmer (with) decreased stimuli in room." The Provider Investigation Report reflected the provider response was, "...Notified residents (family member) ...PCP ...& psychiatrist. Identify when resident is having an increase in anxiety/agitation so that interventions can be started to try to prevent escalation of behaviors. Interventions are remove from area causing an increase in behaviors, redirection, talking to her calmly. [MEDICATION NAME] 20 mg IM PRN for behaviors that do not respond to the other interventions. Resident has prior history of treatment @ (facility behavior unit) and will be re-evaluated if behaviors cont. staff inserviced... Investigation Summary: During investigation, (LVN A) stated she went into dining room when resident became verbally & physically agitated. She removed resident from area and applied [MEDICATION NAME] topical get & [MEDICATION NAME] 2 (sic) mg IM (left) deltoid. (LVN A) then stated that resident continued (with) behavior & was told she would get another shot. Resident Stated, 'I don't care if you give me another shot.' (LVN A) stated she gave the resident a shot of Normal Saline in (right) deltoid. The resident did not have a current order for [MEDICATION NAME] or for Normal Saline as a placebo... Provider Action Taken Post-Investigation: Statements obtained from staff. (LVN A) suspended 03/17/11 pending investigation completion.... Resident is being monitored for adverse effects. Resident condition & behaviors have been stable from 03/13/11 @ 8 pm to current. No adverse reactions to [MEDICATION NAME] or normal saline IM Placebo. Staff have been inserviced...." An interview on 03/18/11 at 9:06 a.m. with the DON revealed she was first made aware of the incident with Resident #13 on "Monday." She added she reviewed the 24-hour report and it indicated Resident #13 had escalating behaviors. She stated "a girl" (staff member) told her on Monday (during the time she was handing out checks) that, "I've got a bunch of stuff to tell you." The DON stated she asked, "Like what?" The staff member asked the DON if she had about 30 minutes. The DON stated the staff member never came back and she never went to the staff member to have the discussion. The DON stated she thought the staff member was upset about a personal issue and stated she was going to quit. The DON stated she was not trained on how to conduct an investigation. She added she was "too tired" to continue with the interview and it was stopped. A telephone interview on 03/18/11 at 12:05 p.m. with LVN I revealed she heard screams from the dining room on 03/13/11 and went to see what was happening. She stated she assisted getting Resident #13 back to her room, because she had become upset that she was not allowed to have buttermilk. She stated she was holding the wheelchair from the handles on the back of the chair. She stated LVN A came into the room and stated to Resident #13, "Calm down or I'm gonna have to give you a shot." LVN I stated LVN A then administered an injection. LVN I stated the medication came from a vial that LVN A was mixing as she entered the room. LVN I stated LVN A exited the room and re-entered moments later with a syringe (unknown contents). LVN I stated Resident #13 continued to yell, and LVN A administered a second injection in her other arm. LVN I stated LVN A stated to Resident #13, "(Resident #13) you got to calm down or I'm going to have to give you another shot." When asked how much time had elapsed between the first and second injection, LVN I stated seven to ten minutes. When asked what the facility policy was for residents who exhibited behaviors, LVN I stated they were to protect the residents and give them what they wanted if possible. When asked if LVN A acted appropriately in administering two injections to Resident #13, LVN I stated she was unsure if the timeframe of the two injections being given was appropriate. LVN I confirmed she did not discuss the timeframe with LVN A or anyone else after the incident. LVN I added she was interviewed about the incident last evening (03/17/11), by the ADM. When asked what she would do, if a resident exhibited severe behaviors, she administered a [MEDICATION NAME] injection, and the behaviors continued, LVN I stated she would notify the physician. When asked how many times she had observed staff administer sterile water as an injection to a resident, LVN I stated she had never seen that before. When asked if she completed an incident report regarding the incident, LVN I stated she had not. When asked what the policy was for completing incident reports, LVN I stated since she worked the weekends, she would complete the report and place it under the DON's office door. An interview on 03/18/11 at 1:20 p.m. with the facility's only ADON revealed she was first made aware of the incident with Resident #13 on 03/17/11. She stated someone (was not able to state whom) mentioned on 03/14/11 (Monday) that Resident #13 had behaviors, but did not mention any medications. The ADON stated LVN A came to her on 03/17/11 and told her she administered a sterile water injection to Resident #13. The ADON stated LVN A told her she also administered the [MEDICATION NAME] gel to Resident #13, but did not realize she did not have an order for [REDACTED]. The ADON denied LVN I informed her of the administration of the sterile water injection immediately after the [MEDICATION NAME] injection. An interview was conducted on 03/18/11 at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member. When asked what had been done since 03/17/11, regarding Resident #13 being threatened with a shot for behaviors, the ADM stated LVN A was suspended. When asked if any inservices on identifying abuse had been conducted with any staff, the ADM stated there had not been. The ADM was informed of the following: Neither the DM nor Cook K reported what they observed as abuse on 03/13/11 to the Abuse Coordinator (ADM); LVN I did not intervene, nor did she report the two injections being administered within seven to ten minutes of each other, and did not recognize the threat of an injection as abuse on 03/13/11; and LVN A threatened Resident #13 with an injection if she did not "calm down," falsely documented what she had administered to Resident #13 on 03/13/11, and did not complete an incident report regarding Resident #13. During the same interview conducted on 03/18/11 at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member, they were notified that an IJ situation had been identified. Review of the Plan of Removal, originally provided on 03/18/11, revised on 3/19/11 and accepted on 3/20/11, revealed: All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) were being in-serviced on Reporting Abuse/Neglect and Mistreatment, including: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention and Resident rights. The in-service was initiated by the Administrator. To ensure understanding the facility was administering a post test on the in-services. The in-services would continue each shift to ensure all staff received the training and validation testing. That was initiated on 03/18/11 and the completion date was 03/19/11, The Administrator was in-serviced on the topic of Abuse, including Abuse Definitions, Abuse Policies and Procedures, Freedom from Abuse, Resident Rights, Behavior Intervention, Behavior Crisis, and Abuse Prevention by corporate personnel on 03/18/11 and reviewed again on 03/19/11. The Administrator and Regional Nurse Consultant, thoroughly investigated the incidents, which occurred over the past weekend. The employees, who did not respond appropriately and per facility policy were appropriately disciplined by the Administrator. The employees included the following: 1) DON suspended pending investigation on 03/18/11 and terminated on 03/19/11, 2) LVN A suspended pending investigation on 03/17/11 and terminated on 03/19/11, 3) LVN I) who witnessed the incident on 03/13/11 involving Resident #13 received a one-on-one in-service on abuse, which included the following: definitions, behavior interventions, behavior crisis, freedom from abuse, abuse prevention; and resident rights, and 4) Dietary staff Cook K, DA J and DM received an in-service on the topic Reporting Abuse/Neglect and Mistreatment, which included the following: Abuse Definitions, Behavior interventions, Behavior crisis, Freedom from abuse, Abuse prevention, Resident rights and written disciplinary notice. For employees who were unable to come to the facility on [DATE] or 03/19/11 for the in-services listed on the Plan of Removal, the ADM or ADON conducted the in-service over the phone with the employee. The oral in-service conducted over the phone would be documented on the in-service record and included Review of the POS [REDACTED]. All newly hired staff (licensed nurses, certified nurses assistants, medication aides, dietary, housekeeping, laundry, activity director, business office manager, social worker, maintenance) would be in-serviced on Reporting Abuse/Neglect and Mistreatment by the Administrator/designee prior to working their first shift. Validation of understanding would be accomplished by administering a post test. This was initiated on 03/18/11 and the completion date was ongoing. A QA Meeting would be held on 03/19/11 with members of the QA team, including the Administrator, Housekeeping/Laundry Supervisor, ADON, Business Office Manager, Activity Director, FSS, Maintenance staff member, and the Medical Director via telephone conference. The QA Committee, which included the Medical Director, would monitor for the next 90 days to ensure the system was effective. The QA Committee would review Incident/Accident Reports, investigation of incidents/accidents, in-services and Post Tests. This was initiated on 03/19/11 and the completion date was on-going for 90 days. To ensure all incidents were investigated and appropriately reported, the DON/ADON/Designee would review the 24 hour Report and the Incident/Accident Reports daily for compliance. The Incident/Accident Reports, which had not been completed and thoroughly investigated would be completed, investigated immediately and reported to DADS appropriately. The results of their review would be reported to the QA Committee each month for the next 90 days. This was initiated on 03/18/11 and was ongoing. All licensed nurses, including the ADON, are being in-serviced by the Regional Nurse Consultant on the topics of: 1. The Twenty Four Hour Report form and the Guidelines for Nursing Report Policy & Procedure. 2. Incident/Accident Reporting Policies & Procedures. Initiated 03/19/11 Completion Date: 03/19/11 All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on the topic of intimidation and threats toward residents. The in-service has been initiated by the Regional Nurse Consultant. Validation of understanding is being accomplished by administering a post test on the subject in-serviced. The in-service will continue each shift to ensure all staff has the training and validation testing. Initiated 03/18/11 Completion date: 03/19/11 All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) were being in-serviced on the topic of Behaviors, which included Behavior Crisis Policy and Procedure and Behavior Assessment/Management/Interventions Policies and Procedures. The in-service was initiated by the Regional Nurse Consultant. This in-service would continue on each shift to ensure all staff had the training. The interviews on 03/20/11 from 10:00 a.m. to 10:50 a.m. with CNA D, CNA N, Housekeeping/Laundry Supervisor O, DA P, Business Office Manager (BOM), LVN I, HK/LA Q and CNA R, revealed they knew what to do regarding residents' behaviors and abuse. The interviews on 03/21/11 from 10:05 a.m. to 10:28 a.m. with CNA G, LVN B, DA S, DM, CNA F and LVN T, revealed they knew what to do regarding residents' behaviors and abuse. The interviews on 03/22/11 from 10:35 a.m. to 11:00 a.m. with DM, SA S, ADON, CNA E, CNA D, LVN T, DA P, Housekeeping/Laundry Supervisor O, Physical Therapist Assistant (PTA) U and CNA F, revealed they knew what to do regarding residents' behaviors and abuse. An interview on 03/19/11 at 12:25 p.m. with Regional Nurse C revealed she was not able to locate any previous orders for Resident #13 to be administered [MEDICATION NAME] gel. A telephone interview on 03/22/11 at 2:50 p.m. with the Medical Director revealed Resident #13 was one of his residents. He stated no staff member notified him of the behaviors, nor did they call him for an order to administer a placebo injection. He added, "I would not have allowed that." The Administrator was advised via telephone the IJ was lowered on 03/22/11 at 3:37 p.m. 2) Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a significant change MDS assessment dated [DATE] for Resident #10 revealed she was able to recall the current season, location of her room, staff members names/faces and she was in a nursing home. She had modified independence in cognitive skills for decision making. She had behaviors of inattention and disorganized thinking, which fluctuated. She also had [MEDICAL CONDITION]. A review of a Nurse's Note dated 03/13/11 timed at 6:00 p.m. authored by LVN A for Resident #10 revealed, "Resident going out front door via w/c & yelling. 2nd nurse went to talk (with) her attempted to stop w/c & talk (with) her. Resident yelling jumped up & ran down side walk. Other nurse going quickly trying to talk (with) resident. This nurse got [MEDICATION NAME] gel 2 mg/ml 1 cc. When got out side resident on ground slapping, scratching, kicking staff. [MEDICATION NAME] gel applied. Took several minutes to get resident to w/c. Then trying to kick, scratch, slap and bite staff. Med IM (with) [MEDICATION NAME] injection 5 mg/ml IM (left) deltoid. CNA sat (with) resident 10 minutes resident settled down...." A review of a Comprehensive Plan of Care initiated 01/13/11 for Resident #10 revealed she had episodes of inappropriate behaviors. The approaches included the following: a) Monitor for early warning signs, b) Explain all procedures, c) Provide Psych consult, d) Encourage to attend social activities, e) Monitor and chart behaviors and f) give meds per order. A review of the March 2011 consolidated physician's orders [REDACTED]. 1) [MEDICATION NAME] (antianxiety) 0.5 mg one by mouth three times a day 2) [MEDICATION NAME] 1 mg one by mouth daily 3) [MEDICATION NAME] gel 2 mg/ml 1 cc to wrist or neck every 8 hours as needed for agitation 4) [MEDICATION NAME] 5 mg by mouth two times a day 5) [MEDICATION NAME] Injection 5 mg/ml IM every 8 hours as needed for severe agitation 6) [MEDICATION NAME] 400 mg one by mouth at bedtime A review of the March 2011 MAR for Resident #10 revealed no documentation [MEDICATION NAME] gel was administered on 03/13/11. The MAR indicated [REDACTED]. A review of the Behavior Intervention Monthly Flow Record for March 2011 for Resident #10 revealed the following: 1) on 03/02/11 she had one episode on the evening shift of anxiety, which was treated with redirection. (Note: per the March 2011 MAR indicated [REDACTED].) 2) on 03/06/11 on the day shift, she had two episodes of "cries/yells," which was treated with redirection and one-on-one. 3) on 03/09/11 on the night shift, she had two episodes of anxiety, which was treated with redirection, one-on-one and PRN medications. She also had one episode on the night shift of '"cries/yells," which was treated with redirection, one-on-one, and PRN medications. She had one episode on the night shift of severe agitation, which was treated with redirection, one-on-one, and PRN medications. 4) on 03/11/11 she had one episode on the night shift of anxiety, which was treated with redirection, one-on-one, and PRN medications. 5) on 03/12/11 she had one episode on the night shift of anxiety, which was treated with redirection, one-on-one, and PRN medications. She also had one episode on the night shift of "cries/yells," which was treated with redirection, one-on-one, and PRN medications. She then had two episodes on the evening shift of "cries/yells," which was treated with redirection and one-on-one. (Note: per the March 2011 MAR indicated temper tantrum."). She had two episodes on the evening shift of severe agitation, that was treated with redirection and one-on-one. 6) on 03/13/11 she had one episode on the night shift of anxiety, that was treated with redirection, one-on-one, and PRN medications. She then had three episodes on the evening shift of "cries/yells," that was treated with redirection. She had one episode on the night shift of severe agitation, which was treated with redirection, one-on-one, and PRN medications. She had three episodes on the evening shift of severe agitation, that was treated with redirection. 7) on 03/17/11 she had one episode on the evening shift of "cries/yells." There was no documentation of the treatment. An observation and interview on the initial tour on 03/16/11 at 9:30 a.m. with LVN A revealed Resident #10 had behaviors of fighting with staff, screaming, and throwing "fits." She was ambulatory, but used a wheelchair due to a poor gait. There was no mention of any recent incidents. Resident #10 was observed asleep in her bed. An interview on 03/17/11 at 3:22 p.m. with DA J revealed on 03/13/11 she observed Resident #10 grab a package of peanut butter crackers off a tray and take off with them. DA J stated she knew Resident #10 was on a pureed diet and told her she was not allowed to have them. DA J stated she found the charge nurse and informed her that Resident #10 had the crackers. DA J stated Resident #10 became upset and went out the front door. DA J stated Resident #10 was not able to get the wheelchair completely through the door, so she got up and started walking. DA J stated they (her and LVN A) stopped Resident #10 in the grass and were talking with her. DA J stated she asked Resident #10, "Do you want the crackers?" Resident #10 then began to calm down. DA J stated at that time, LVN I "snatched" the crackers from Resident #10 and said to her, "You can't have them!" DA J stated Resident #10 became very upset and was dragging her (DA J) by her hand towards the road. DA J stated after they got Resident #10 back inside the facility, LVN A applied the "yellow" paste to her and gave her a shot in the arm. She confirmed the two medications were immediately given together. An interview on 03/17/11 at 4:15 p.m. with the ADM and the DON revealed they were not aware of the incident, which occurred on 03/13/11 with Resident #10. They confirmed there was no incident report for this incident. A telephone interview on 03/17/11 at 8:40 p.m. with CNA/MA V revealed she was working as a CNA on 03/13/11. She stated she heard an overhead page that help was needed, "now." She stated Resident #10 was outside on the lawn. She stated Resident #10 was half way to the street when she arrived outside. CNA/MA V stated it took both nurses and two other staff members to get Resident #10 back inside the facility. CNA/MA V stated if someone had told her Resident #10 wanted the peanut butter crackers, she would have sat with her while she ate them. A telephone interview on 03/17/11 at 8:57 p.m. with Cook K revealed she was working on 03/13/11. She stated she had been to the dumpster when she heard screams from staff that they needed help. She stated LVN A and LVN I were behind the wheelchair, DA J and CNA/MA V were on the ground with Resident #10 trying to stop her from getting into the street. Cook K stated when they finally got Resident #10 back inside the building, she observed LVN A administer a shot in the resident's right arm. A telephone interview on 03/18/11 at 12:05 p.m. with LVN I revealed she was working on 03/13/11 and was the charge nurse for Resident #10. Sh

Based on observation, interview, and record review, it was determined the Administrator and DON failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three (Residents #13, #10, and #12) of 11 residents reviewed for chemical restraints, three (Residents #3, #13, and #15) of eight residents reviewed for abuse and four (Residents #10, #12, #15, and #16) residents' environment were free of accident hazards and one (Resident #10) received adequate supervision to prevent accidents of 16 residents reviewed for accidents/hazards. 1. The Administrator failed to: a) Monitor and supervise the DON to ensure the DON carried out her responsibilities to ensure nursing staff received training and were competent in identifying and protecting residents from abuse; b) Train the DON and test her competency in functioning as the Abuse Coordinator "Designee;" c) Train staff to timely report all allegations of abuse, to investigate allegations of abuse thoroughly, and immediately protect residents during an abuse investigation; and d) Monitor and supervise the Maintenance Director to ensure he carried out his responsibilities to keep the Undergird system functioning properly, to act quickly when the system was not functioning, and to notify facility staff it was not working. 2. The DON failed to follow the facility's policies and procedures. The DON failed to: a) Train nursing staff in identifying abuse; b) Monitor and supervise nursing staff to ensure staff did not use chemical restraints for convenience; c) Train nursing staff to effectively manage residents' behaviors (elopement, cursing, grabbing other people, etc.); and d) Supervise nursing staff to ensure nursing staff were monitoring residents who were identified as high risk for elopement and were wearing their physician ordered Wanderguard bracelets. These failures resulted in the following: 3. Resident #13 was chemically restrained, verbally, and physically abused by LVN A. Resident #13 was taken back to the dining room after the incident, but was too "out of it" to eat or talk. 4. After an Immediate Jeopardy was identified CNA V verbally abused Resident #15 and LVN I did not protect Resident #15 from further abuse by the CNA. 5. Resident #3 was found, face down in a pool of blood and was sent to the hospital where she received 15 sutures to the forehead above the left eye. 6. The front door was locking when a Wanderguard device was in the immediate vicinity on 03/15/11, 03/16/11, and 03/19/11. An Immediate Jeopardy (IJ) was identified on 03/17/11. While the IJ was removed on 03/22/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the implementation of the Plan of Removal. These failures could affect the facility's 41 residents who currently resided in the facility. Findings included: 1) Resident #13 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] for Resident #13 revealed she did not have any behaviors, [MEDICAL CONDITION] or hallucinations. She did not have any signs of [MEDICAL CONDITION]. A review of the March 2011 consolidated physician's orders [REDACTED]. A review of a nurse's note dated 03/13/11 at 10:00 a.m. for Resident #13, revealed, "Alert to staff...very rude & (and) argumentative (with) staff & resident. In room yelling @ (at) staff to come in there... 5:30 p.m. Resident in dining room, yelling, cursing, throwing @ staff & residents. 2 staff unable to calm resident. Took to room (with) staff...hitting, kicking, attempting to bite staff. Med IM (left) arm. 20 mg [MEDICATION NAME] for severe agitation... 6:00 p.m. Still very aggressive & yelling... 7:00 p.m. In room. Quieter but still non-compliant & argumentative... 9:00 p.m. In room in w/c sleeping. This nurse & CNA attempted to change her & get her ready for bed. Woke up yelling, 'I'm not changing I'm not ready for bed. Resident stopped yelling & staff left room (authored by LVN A)." A confidential interview on 03/17/11 revealed he/she observed Resident #13 asking for buttermilk during the evening meal on 03/13/11. He/she stated Resident #13 was told she could only have buttermilk one time a day. He/she stated Resident #13 became upset and was throwing food and 'choking' herself. He/she stated he/she heard LVN A and LVN I state, "Just let her do it." An interview on 03/17/11 at 3:22 p.m. with DA J revealed she was asked by LVN A to help get Resident #13 to her room during the incident. DA J stated LVN A rubbed the yellow gel ([MEDICATION NAME]) on Resident #13's neck. DA J stated LVN A then administered a "shot" in Resident #13's right shoulder. DA J stated LVN A then gave Resident #13 another shot in the left shoulder. When asked how much time had passed, from the "yellow gel" to the time of the second shot, DA J stated 10 minutes. An interview on 03/17/11 at 3:55 p.m. with LVN A revealed she was the charge nurse for Resident #13 on Sunday, 03/13/11. She stated she heard screaming coming from the dining room and went to see what was happening. She stated Resident #13 wanted buttermilk and was told she could only have it one time a day. When asked why Resident #13 was not allowed to have the buttermilk, LVN A stated the facility only bought enough for her to have it once a day. LVN A stated she removed Resident #13 from the dining room and took her to her room, with the assistance of DA J and Cook K. LVN A stated she gave Resident #13 [MEDICATION NAME] gel. LVN A denied trying any additional interventions before administering the [MEDICATION NAME] gel, other than removing Resident #13 from the dining room. The MAR indicated [REDACTED]. There was no entry on the MAR for [MEDICATION NAME] gel. LVN A stated she was not aware Resident #13 did not have an order for [REDACTED].#13. She stated she told Resident #13, "I'm gonna have to give you another shot (if she did not calm down)." LVN A stated Resident #13 said, "Go ahead!" LVN A stated she then withdrew 3 cc of N/S in a syringe and administered it to Resident #13 in the opposite arm. When asked if she obtained an order for [REDACTED]." When asked if she notified the physician of what she had done, LVN A stated she did tell the physician she administered [MEDICATION NAME] and an injection of Saline. LVN A stated Resident #13 calmed down and was taken back to the dining room. An interview on 03/17/11 at 4:15 p.m. with the ADM and the DON revealed they were not aware of Resident #13 being threatened with a shot for behaviors until today. When asked who did have knowledge of the incident prior to today, the ADM stated the licensed nurses on 03/13/11 (LVN A and LVN I) knew. (Note: LVN A was working on 03/17/11 from 2:00 p.m. to 10:00 p.m.) An interview on 03/17/11 at 8:57 p.m. with Cook K revealed she was working on 03/13/11. She stated Resident #13 wanted buttermilk and she told her she was only allowed to have it once a day. Cook K stated Resident #13 became upset, began to yell, and LVN A stated to Resident #13, "You're going to your room!" She stated Resident #13 began to choke herself. Cook K stated LVN A told Resident #13, "That's it!" Cook K stated LVN A, LVN I, DA J and herself escorted Resident #13 to her room. She stated LVN A put the yellow gel on Resident #13's neck. Cook K stated she and DA J were sitting on each side of Resident #13, holding the resident by her arms. Resident #13 was stating she wanted to go back to the dining room because she was hungry. Cook K stated LVN A administered a "shot" in Resident #13's right arm and then another shot in the left arm. She stated Resident #13 was then allowed to go back to the dining room. Cook K stated LVN A brought in a vial and "mixed" the medication for the first shot. She stated LVN A brought in the second shot from the hall and she did not see if she mixed it or not. Cook K stated once Resident #13 was brought back to the dining room, "She was out of it." Cook K stated Resident #13 was not able to talk or eat. Cook K stated Resident #16 asked staff, "Will you see if she is ok? (talking about Resident #13)." Cook K stated Resident #17 also checked on Resident #13 and asked if she was ok. A review of a Provider Investigation 03/17/11 for Resident #13 (provided to the survey team on 03/18/11) revealed the report was called to the State agency on 03/17/11 at 10:00 p.m. The Incident Category was, "Escalating behaviors around other residents & staff." The incident date was 03/13/11 at 5:30 p.m. The Provider Investigation Report reflected the "Alleged Perpetrator" was, "(Resident #13)." The witnesses listed on the Report were, "(LVN A, DA J and LVN I)." The Report reflected, "Resident in dining room asking for buttermilk. She became very agitated & started yelling, cussing, hitting, trying to kick and grabbed the Dietary staff members hand & twisted her fingers. Resident removed from area, received PRN medication & became calmer (with) decreased stimuli in room." The Provider Investigation Report reflected the provider response was, "...Notified residents (family member)...PCP...& psychiatrist. Identify when resident is having an increase in anxiety/agitation so that interventions can be started to try to prevent escalation of behaviors. Interventions are remove from area causing an increase in behaviors, redirection, talking to her calmly. [MEDICATION NAME] 20 mg IM PRN for behaviors that do not respond to the other interventions. Resident has prior history of treatment @ (facility behavior unit) and will be re-evaluated if behaviors cont. staff inserviced...Investigation Summary: During investigation, (LVN A) stated she went into dining room when resident became verbally & physically agitated. She removed resident from area and applied [MEDICATION NAME] topical get & [MEDICATION NAME] 2 (sic) mg IM (left) deltoid. (LVN A) then stated that resident continued (with) behavior & was told she would get another shot. Resident Stated, 'I don't care if you give me another shot.' (LVN A) stated she gave the resident a shot of Normal Saline in (right) deltoid. The resident did not have a current order for [MEDICATION NAME] or for Normal Saline as a placebo...Provider Action Taken Post-Investigation: Statements obtained from staff. (LVN A) suspended 03/17/11 pending investigation completion....Resident is being monitored for adverse effects. Resident condition & behaviors have been stable from 03/13/11 @ 8 pm to current. No adverse reactions to [MEDICATION NAME] or normal saline IM Placebo. Staff have been inserviced...." An interview on 03/18/11 at 9:00 a.m. with the DM revealed she was first made aware of the incident on Sunday 03/13/11, after Cook K called her to report the incident. The DM stated she instructed Cook K to call the ADM. When asked who she reported the incident to, the DM stated she talked to the DON about it on Monday (03/14/11). An interview on 03/18/11 at 9:06 a.m. with the DON revealed she was first made aware of the incident with Resident #13 on "Monday." She added she reviewed the 24-hour report and it indicated Resident #13 had escalating behaviors. She stated "a girl" (staff member) told her on Monday during the time she was handing out checks that, "I've got a bunch of stuff to tell you." The DON stated she asked, "Like what?" The staff member asked the DON if she had about 30 minutes. The DON stated the staff member never came back and she never went to the staff member to have the discussion. The DON stated she thought the staff member was upset about a personal issue and stated she was going to quit. The DON stated she was not trained on how to conduct an investigation. She added she was "too tired" to continue with the interview and it was stopped. A telephone interview on 03/18/11 at 12:05 p.m. with LVN I revealed she heard screams from the dining room on 03/13/11 and went to see what was happening. She stated she assisted getting Resident #13 back to her room, because she had become upset that she was not allowed to have buttermilk. She stated she was holding the wheelchair from the handles on the back of the chair. She stated LVN A came into the room and stated to Resident #13, "Calm down or I'm gonna have to give you a shot." LVN I stated LVN A then administered an injection. LVN I stated the medication came from a vial that LVN A was mixing as she entered the room. LVN I stated LVN A exited the room and re-entered moments later with a syringe (unknown contents). LVN I stated Resident #13 continued to yell, and LVN A administered a second injection in her other arm. LVN I stated LVN A stated to Resident #13, "(Resident #13) you got to calm down or I'm going to have to give you another shot." When asked how much time had elapsed between the first and second injection, LVN I stated seven to ten minutes. When asked what the facility policy was for residents who exhibited behaviors, LVN I stated they were to protect the residents and give them what they wanted if possible. When asked if LVN A acted appropriately in administering two injections to Resident #13, LVN I stated she was unsure if the timeframe of the two injections being given was appropriate. LVN I confirmed she did not discuss the timeframe with LVN A or anyone else after the incident. LVN I added she was interviewed about the incident last evening (03/17/11), by the ADM. When asked what she would do, if a resident exhibited severe behaviors, she administered a [MEDICATION NAME] injection, and the behaviors continued, LVN I stated she would notify the physician. When asked how many times she had observed staff administer sterile water as an injection to a resident, LVN I stated she had never seen that before. When asked if she completed an incident report regarding the incident, LVN I stated she had not. When asked what the policy was for completing incident reports, LVN I stated since she worked the weekends, she would complete the report and place it under the DON's office door. An interview on 03/18/11 at 1:20 p.m. with the facility's only ADON revealed she was first made aware of the incident with Resident #13 on 03/17/11. She stated someone (was not able to state whom) mentioned on 03/14/11 (Monday) that Resident #13 had behaviors, but did not mention any medications. The ADON stated LVN A came to her on 03/17/11 and told her she administered a sterile water injection to Resident #13. The ADON stated LVN A told her she also administered the [MEDICATION NAME] gel to Resident #13, but did not realize she did not have an order for [REDACTED]. The ADON denied LVN I informed her of the administration of the sterile water injection immediately after the [MEDICATION NAME] injection. An interview was conducted on 03/18/11 at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member. When asked what had been done since 03/17/11, regarding Resident #13 being threatened with a shot for behaviors, the ADM stated LVN A was suspended. When asked if any inservices on identifying abuse had been conducted with any staff, the ADM stated there had not been. The ADM was informed of the following: Neither the DM nor Cook K reported what they observed as abuse on 03/13/11 to the Abuse Coordinator (ADM); LVN I did not intervene, nor did she report the two injections being administered within seven to ten minutes of each other, and did not recognize the threat of an injection as abuse on 03/13/11; and LVN A threatened Resident #13 with an injection if she did not "calm down," falsely documented what she had administered to Resident #13 on 03/13/11, and did not complete an incident report regarding Resident #13. During the same interview conducted on 03/18/11 at 3:30 p.m. with the ADM, Regional Nurse C and a corporate staff member, they were notified that an IJ situation had been identified in the area of Resident Behavior/Facility Practices. An interview on 03/19/11 at 12:25 p.m. with Regional Nurse C revealed she was not able to locate any previous orders for Resident #13 to be administered [MEDICATION NAME] gel. A telephone interview on 03/22/11 at 2:50 p.m. with the Medical Director revealed Resident #13 was one of his residents. He stated no staff member notified him of the behaviors, nor did they call him for an order to administer a placebo injection. He added, "I would not have allowed that." 2) Resident #15 was a [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15's admission MDS assessment dated [DATE] reflected he had unclear speech and he had limited ability to make himself understood. The MDS assessment also reflected he had short and long-term memory problems, he was "short-tempered, easily annoyed," he had [MEDICAL CONDITION], verbal behavioral symptoms daily, and physical symptoms such as hitting or scratching self, pacing, verbal/vocal symptoms like screaming, disruptive sounds. The assessment reflected Resident #15 required "limited" to "extensive" assistance with all ADLs and he required "total assistance" for toileting. At 11:00 a.m. on Sunday 03/20/11, the Administrator informed the surveyors she had suspended a CNA the previous evening for "what she had said to __ (Resident #15)." She stated she was still working on the report. Review of nurse's notes for Resident #15 on 03/19/11 at "945" revealed, "Report to Chg. (Charge) Nurse that ____ (CNA V) was verbally abusive to this resident. Stating until you stop cursing, talking loud I'am (sic) not going to put you to bed. 10-15 min later ___ (CNA V) went and put resident to bed. Report to Abuse Coord (Coordinator) ___ (Administrator's name) Adm." Resident #15 was interviewed on 03/20/11 at 11:15 a.m. He did not remember any incident of abuse. On 03/21/11 the investigation of the incident with CNA V and Resident #15 was reviewed. The Provider Investigation Report dated 03/20/11 reflected the incident between Resident #15 and CNA V was observed by CNA R, who was across the hall. The Report also reflected, "Per witness, employee __ (CNA V) told resident __ (Resident #15) that if he did not want to stay up all night he needed to stop. Emp (employee) (CNA V) repeated this statement again to resident. Res wheeled into his room, CNA V closed the door to the room." The "Provider Response" section reflected, "Employee __ (CNA V) immediately suspending (sic) pending investigation. ... Investigation immediately initiated." The Provider Action Taken Post-Investigation section of the investigation report was modified on 03/21/11 to include: "Employees __ (CNA R) and (LVN I) to be educated by Administrator on immediate protection provided to resident at time of alleged abuse. This education (in-service) will also be included for all staff." The Notice of Disciplinary Action attached to the investigation reflected the allegation of abuse was confirmed and CNA V was terminated. CNA V's statement dated 03/19/11 reflected, "__ (Resident #15) was yelling down the hall for me to hurry-up come-on, hurry up and using foul language towards me. I stated that Im (sic) not going to put you to bed when your (sic) acting like that you need to be patient. Until you stop screaming and cussing @ (at) me and slamming your door you will stay-up. Then I asked him if he was done? He said yes Dxxnit (Damn it) and did not say another word as I put him to bed." CNA R was interviewed via telephone on 03/21/11 at 11:24 a.m. She stated she and CNA V were going to lay another resident down. Resident #15 had his light on. She told CNA V to lay Resident #15 down. CNA V approached him at the doorway to his room. CNA R stated she was in the hallway across from Resident #15's room and Resident #15 was cursing and talking loudly. She stated CNA V told him to "Stop." CNA R stated she told him he could stay in the wheelchair all night and she said it two times to the resident. CNA R said the resident backed his wheelchair back into the room and CNA V closed the door. CNA R stated, "In a few seconds she opened the door and went in and closed his door." CNA R said she reported the incident right away to LVN I, who was "passing pills" on that hallway, and told her CNA V had gone into Resident #15's room. She stated LVN I told her to go report the incident to the Administrator and continued passing pills. She said she went right away to the Administrator's office. CNA R reported she told the Administrator the story. CNA R stated when she and the ADM started down the hallway toward Resident #15's room, she saw CNA V coming up the hall with Resident #15's dirty clothes in a bag. On 03/21/11 at 11:50 a.m. the surveyor asked the Administrator if LVN I had gone down to Resident #15's room after CNA R reported the incident between Resident #15 and CNA V to her first. The Administrator said she did know LVN I was on the hall. At 2:45 p.m. on 03/21/11 LVN I was interviewed. The surveyor asked if she had gone down to Resident #15's room right after she had been informed of the incident by CNA R, when CNA V was in Resident #15's room. She stated she did not think CNA V would hurt Resident #15. The surveyor asked if she thought the statement CNA V made to the resident was abusive. She said, "Yes." LVN I stated they had been talking about this (abuse) for a long time. LVN I said she saw Resident #15 later when he was in bed and he was still agitated. 3) Resident #3 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation and interview on 03/16/11 at 9:51 a.m. with LVN A on initial tour revealed Resident #3 had a fall on 03/14/11. She had approximately 16 stitches over her left eye extending up to the hairline. Her left eye was bruised and swollen. A review of an Incident Report dated 03/14/11 at 10:30 a.m. for Resident #3 revealed, "Resident up in w/c (with) lap-buddy in place. Pulled (Pushed) lap-buddy away from w/c. fell out of w/c hitting head on floor obtaining a injury approx 1" long and 1/2" wide." This was completed by LVN I. The DON signed the report on 03/15/11. Review of a witness statement included with the incident report, dated 03/14/11, completed by the DON, revealed, "Interviewed (LVN I) r/t this incident. (LVN I) stated on 03/14/11 @ 10:30 a.m. that resident fell out of w/c d/t she pulled & pushed lap buddy and fell forward out of w/c. She obtained a laceration...Resident returned (with) 15 sutures on left forehead above eye...." A review of a nurse's note dated 03/14/11 for Resident #3 revealed, "10:30 a.m. Resident fell out of w/c obtaining a laceration on fore head. Lt (left) side approx 1" long and 1/2" wide. Confused and disoriented X3." This note was authored by LVN I. A review of a physician's telephone order dated 03/14/11 for Resident #3 revealed, "may transfer to (hospital) to eval & (and) treat head injury." An interview on 03/17/11 at 9:30 a.m. with CNA D revealed she was walking past Resident #3's room, when she observed her on the floor. CNA D stated she did not see her fall. She stated she immediately called the charge nurse. CNA D stated LVN I did talk with her about the incident and CNA D informed LVN I she found Resident #3 on the floor. An interview on 03/17/11 at 9:55 a.m. with LVN T revealed she was called by CNA D to come to the room after Resident #3 was found on the floor. LVN T denied witnessing the fall. LVN T stated no staff member observed her fall. A review of the self-reported incidents, provided by the ADM for the prior year, revealed no report to the state agency of the incident. An interview on 03/17/11 at 10:11 a.m. with the DON revealed she was not aware of Resident #3's fall on 03/14/11. The DON confirmed she was in the building, and was there when Resident #3 was sent out on a stretcher, but denied knowing she had a fall with an injury. She stated she first became aware of the fall on Tuesday (03/15/11). She stated she reviewed the clinical record to determine who may have been present. The DON stated she did not get any witness statements, because she talked with LVN I and was under the impression LVN I witnessed Resident #3 fall. When asked if a resident being sent to the emergency room to get stitches, after a fall, was something she would expect her staff to notify her of, the DON stated they should, but they had not been doing that. The DON denied interviewing the CNA that found Resident #3 on the floor. When asked who was responsible for investigating injuries of unknown origin, the DON stated she was. She added she was not comfortable investigating, and had asked the ADM and Regional Nurse Consultant C for additional training in investigating. An interview on 03/17/11 at 11:44 a.m. with the ADON revealed she worked the 2:00 p.m. to 10:00 p.m. shift on 03/14/11. She stated she was acting as the ADON during the day shift, and provided treatment to the wound on Resident #3's head, prior to her leaving in the ambulance. She stated she informed the DON they had sent Resident #3 out to the hospital. The ADON stated she reported to the DON on the day of the fall (03/14/11) that apparently, Resident #3 had removed her lap buddy and fallen. A telephone interview on 03/18/11 at 12:05 p.m. with LVN I revealed she did not witness Resident #3 fall from her wheelchair. She stated she was notified by a CNA that Resident #3 was on the floor, face down in a pool of blood. She added she "assumed" she fell . She was not aware if the CNA had witnessed the fall. 4) Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a significant change MDS assessment dated [DATE] for Resident #10 revealed she was able to recall the current season, location of her room, staff members' names/faces and that she was in a nursing home. She had modified independence in cognitive skills for decision-making. She had behaviors of inattention and disorganized thinking, which fluctuated. She also had [MEDICAL CONDITION]. A review of the March 2011 consolidated physician's orders [REDACTED]." A review of a Nurse's Note dated 03/13/11 timed at 6:00 p.m. authored by LVN A for Resident #10 revealed, "Resident going out front door via w/c & (and) yelling. 2nd nurse went to talk (with) her attempted to stop w/c & talk (with) her. Resident yelling jumped up & ran down side walk. Other nurse going quickly trying to talk (with) resident. This nurse got [MEDICATION NAME] gel 2 mg/ml 1 cc. When got out side resident on ground slapping, scratching, kicking staff. [MEDICATION NAME] gel applied. Took several minutes to get resident to w/c. Then trying to kick, scratch, slap and bite staff. Med IM (with) [MEDICATION NAME] injection 5 mg/ml IM (left) deltoid. CNA sat (with) resident 10 minutes resident settled down...." An interview on 03/17/11 at 3:22 p.m. with DA J revealed on 03/13/11 she observed Resident #10 grab a package of peanut butter crackers off a tray and take off with them. DA J stated she knew Resident #10 was on a pureed diet and told her she was not allowed to have the crackers. DA J stated she found the charge nurse and informed her Resident #10 had the crackers. DA J stated Resident #10 became upset and went out the front door. DA J confirmed there was not a wander guard bracelet on Resident #10 as the door did not alarm when she went through it. DA J stated she was never asked to write a statement, and no staff member had interviewed her about the incident. She stated she talked to the DON on 03/14/11 about the incident. An interview on 03/17/11 at 4:15 p.m. with the ADM and the DON revealed they were not aware of the incident, which occurred on 03/13/11 with Resident #10. They confirmed there was no incident report for this incident. An observation on 03/17/11 at 5:10 p.m. revealed the DON wheeled Resident #10 to the front door where the Wanderguard system was. The door never alarmed. The DON was not able to locate a Wanderguard on Resident #10 at that time. An observation on 03/17/11 at 6:00 p.m. on the front lawn of the facility revealed 65 cars passed on the busy street in front of the facility within five minutes. The posted speed limit was 40 miles per hour. A telephone interview on 03/17/11 at 8:40 p.m. with CNA/MA V revealed she was working as a CNA on 03/13/11. She stated she heard an overhead page help was needed, "now." CNA/MA V stated Resident #10 was outside on the lawn. She stated Resident #10 was halfway to the street when she arrived outside. A telephone interview on 03/17/11 at 8:57 p.m. with Cook K revealed she was working on 03/13/11. She stated she had been to the dumpster when she heard screams from staff they needed help. She stated LVN A and LVN I were behind the wheelchair. DA J and CNA/MA V were on the ground with Resident #10 trying to stop her from getting into the street. Cook K stated when they finally got Resident #10 back inside the building LVN A administered the yellow paste ([MEDICATION NAME] Gel) and a shot to Resident #10. A telephone interview on 03/18/11 at 12:05 p.m. with LVN I revealed she was working on 03/13/11 and was the charge nurse for Resident #10. She stated she was passing medications when she was approached by DA J and was told Resident #10 had crackers. LVN I stated she was told Resident #10 was not to have the crackers. LVN I stated at a later time, she was told Resident #10 was allowed to have the crackers in the presence of a nurse. She stated when Resident #10 exited the facility, she went out with her and was talking with her. She stated Resident #10 was walking on the sidewalk, talking calmly. LVN I stated Resident #10 was asking for the crackers. LVN I stated at that time, "I got the crackers from her." She then stated DA J approached, and Resident #10 became agitated and began to kick and scream. LVN I stated she observed LVN A apply [MEDICATION NAME] gel to Resident #10, and she began to calm down. LVN I denied seeing LVN A administer an injection. However, LVN I stated, "I said she should have got an injection." She stated she was under the impression Resident #10 was allowed to go on the front porch unassisted. When asked if Resident #10 was injured, LVN I stated she did have stickers all over her, but it was because "staff agitated her." When asked if she reported the staff's actions, which agitated Resident #10 to the point of needing PRN medications for behavior, LVN I stated she did not. An interview on 03/18/11 at 1:20 p.m. with the facility's only ADON revealed she was informed on 03/14/11 of the incident with Resident #10. She added the staff blew everything out of proportion. When asked what had been done to prevent that from happening again, the ADON stated she was not aware. The ADON added she thought the ADM was inse