Every finding on record at Belen Meadows Healthcare and Rehabilitation Center

Based on record review and interviews, the facility failed to notify the resident for several weeks about a significant health-related test result for 1 (R #1) of 1 (R #1) resident. Failure to provide timely notification of a significant health related finding is likely to result in delayed awareness, frustration, and may contribute to delayed or inadequate treatment. The findings are: A. Record review of R #1's face sheet revealed an admission date of 01/18/26 with the following diagnoses: Ileostomy (a surgical procedure in which the last part of the small intestine (ileum) is connected to the abdominal wall and an opening (stoma) is created in the abdominal wall created to allow waste to leave the body).Scoliosis (abnormal side-to-side curvature of the spine).Fibromyalgia (chronic muscle pain).[NAME] disease (autoimmune disorder that attacks the thyroid). B. Record review of R #1's nursing progress notes, dated 04/27/26, revealed R #1 was discharged to the hospital on [DATE] after experiencing a change in condition (CIC; any noticeable alteration in a resident's physical, mental, or functional status that may indicate a new or worsening health issue and requires timely assessment and reporting), including abnormal vital signs (body temperature, pulse rate, respiration rate, oxygen saturation, and blood pressure). R #1 was diagnosed with pneumonia (infection and inflammation of the lung) at the hospital and returned to the facility on [DATE]. C. Record review of R #1's provider follow up note, dated 05/05/26, revealed the facility nursing staff was instructed to obtain a stool sample for Clostridium difficile (C-diff; a spore-forming bacterium that causes diarrhea and inflammation of the colon, often triggered by antibiotic use) because R #1 had recently been treated with antibiotics for pneumonia and diarrhea. D. Record review of R #1's physician orders, dated 05/05/26, revealed an order for nursing staff to collect a stool sample from R #1 for a fecal occult blood test (FOBT; a diagnostic test used to detect hidden blood in the stool, which may indicate underlying gastrointestinal conditions) for C diff. E. Record review of R #1's laboratory test results (medical procedures in which a sample of blood, urine, saliva, or other bodily fluids is collected and analyzed in a laboratory to evaluate a person's health), dated 05/06/26, revealed the FOBT was positive, indicating blood was present in R #1's stool. F. Record review of R #1's provider follow up note, dated 06/09/26, did not indicate that R #1 was notified of the positive FOBT, which showed blood in her stool. G. Record review of R #1's provider encounter note, dated 06/17/26, revealed R #1 was notified of the positive FOBT collected on 05/05/26, with a recommendation for a gastrointestinal evaluation (a series of tests and examinations used to determine the causes of gastrointestinal symptoms) and a colonoscopy (a procedure using a flexible fiber optic instrument inserted through the anus to examine the colon). R #1 reported frustration because she was not notified of the FOBT results sooner than 06/17/26. H. On 07/01/26 at 11:20 am, during an interview, R #1 stated she was not notified for a long time of the FOBT results collected on 05/05/26. R #1 stated she is not always notified of important changes in her care, and she should be. I. On 07/02/26 at 10:58 am, during an interview, the Director of Nursing (DON) stated residents should be informed in a timely manner of important changes in their care. The DON stated R #1 was not informed of the FOBT results collected on 05/05/26 until 06/17/26.

Based on observation, record review, and interviews, the facility failed to provide care consistent with professional standards for 1 (R #1) of 1 (R #1) resident who requires colostomy (a surgical procedure in which the colon is connected to the abdominal wall and an opening (stoma) is created in the abdominal wall created to allow waste to leave the body) care, when the facility nursing staff were unaware of the expectations for colostomy bag (a pouch attached to the body that collects fecal waste) care and insisted R #1 could perform her own colostomy care. If the facility does not provide care consistent with professional standards for a resident with a colostomy, residents are likely to experience frustration from not receiving the care they need. The findings are: A. Record review of R #1's face sheet revealed an admission date of 01/18/26 with the following diagnoses: Ileostomy (a surgical procedure in which the last part of the small intestine (ileum) is connected to the abdominal wall and an opening (stoma) is created in the abdominal wall created to allow waste to leave the body).Scoliosis (abnormal side-to-side curvature of the spine).Fibromyalgia (chronic muscle pain).[NAME] disease (autoimmune disorder that attacks the thyroid). B. Record review of R #1's physician orders, dated 01/20/26, revealed the facility nursing staff are required to change R #1's colostomy appliance (the entire containment system used to collect waste) one time a day, every three days, and as needed. R #1's physician order required the facility nursing staff to perform colostomy care during both day and night shifts, and as needed. C. Record review of R #1's grievance, dated 06/23/26, revealed R #1 reported she was not receiving assistance with her colostomy bag. D. Record review of R #1's care plan, dated 06/24/26, revealed the facility nursing staff are required to monitor the skin around R #1's colostomy stoma to ensure it remains clean and free of irritation, and to change the appliance as needed. E. Record review of R #1's nursing progress notes, dated 06/24/26 at 7:01 am, revealed on 06/23/26 a Certified Nursing Assistant (CNA) reported R #1 might file a grievance against her because R #1 had repeatedly complained about needing help emptying her colostomy bag. The CNA stated R #1 should empty the bag herself because she was independent and able to do so. The CNA was told R #1 has tremors (an involuntary quivering movement) and could not empty the bag by herself. The CNA insisted R #1 could perform the task and stated she had witnessed R #1 emptying the colostomy bag. The CNA was reminded that R #1 has episodes of shaking, which is why she requests assistance. R #1 was upset because she and the CNA argued about emptying the colostomy bag. F. On 07/01/26 at 11:20 am, during an interview, R #1 stated the facility nurses do not help her with her colostomy bag. She stated she used to manage it independently, but she shakes now, and the tremors make it difficult. R #1 was observed shaking due to tremors. G. On 07/02/26 at 11:30 am, during an interview, the Speech Therapist (ST) stated R #1 has complained to her about not receiving help with her colostomy bag. The ST stated R #1 told her there have been times when the colostomy bag was full and needed to be emptied, but the nurses did not assist her. H. On 07/02/26 at 11:45 am, during an interview, the Director of Nursing (DON), stated when the facility received R #1's grievance on 06/23/26, the CNA was suspended immediately. She stated she reviewed the nursing progress note dated 06/24/26 regarding R #1 performing her own colostomy care. The DON stated the nurse who wrote the progress note should have reported the issue to management instead of documenting it in a nursing progress note that was not reviewed for an extended period of time. She stated when she spoke with the nurse and the CNA mentioned in the nursing progress note, there was confusion about what CNAs can and cannot do regarding colostomy care. The DON stated CNAs should empty colostomy bags for residents who use them. I. On 07/02/26 at 11:55 am, during an interview, the Unit Manager (UM) #1 stated it does not matter whether R #1 previously performed her own colostomy care, because colostomy care must be provided by the facility's nursing staff.

Based on record review and interview, the facility failed to ensure an alleged incident involving an unwitnessed fall with potential injury was reported to the State Agency (SA) for 1 (R #1) of 1 (R #1) resident reviewed for incidents. This failure compromised the State Agency's ability to triage and investigate allegations promptly, which may impact the overall effectiveness of the facility's abuse prevention system.The findings are:A. Record review of the facility's Abuse Prohibition policy revised on 11/14/25, revealed the facility prohibits neglect and requires immediate reporting, investigation, documentation, and follow-up of alleged injuries including injuries of an unknown source. The policy defines neglect as failing to provide care or services necessary to prevent harm and directs the center to: Initiate an investigation within twenty-four hours when the facility receives information about an injury or suspected neglect,Document interviews and findings in the facility tracking system,Notify the physician and resident representative, Submit findings of completed investigations within five days to the State Agency. B. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following diagnoses:Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),Muscle weakness (reduction in the power exerted by muscles),Major Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).\C. Record review of R #3's progress notes dated 01/03/26 revealed R #3 had an unwitnessed fall in her room in the morning, resulting in a swollen left hand. R #3 had a Telehealth appointment with a provider, and the provider ordered an x-ray (a picture taken inside the body to check for broken bones or injuries) for R #3's swollen left hand. D. Record review of R #3's x-ray report dated 01/05/26 revealed R #3's hand did not have breaks or a dislocation present.E. On 02/10/26 at 10:13 a.m., during an interview with the Director of Nursing (DON), she stated staff completed a head-to-toe assessment on R #3 and notified the provider following R #3's fall. The DON stated an unwitnessed fall with R #3's left hand swelling, with an X-ray to rule out injury, would require reporting to the State Agency due to the potential for injury.F. On 02/10/26 at 11:36 a.m., during an interview with the Administrator (ADM), she stated she was aware of R #3's unwitnessed fall. The ADM stated the facility should have reported R #3's fall with injury to the SA, but that did not happen.

Based on observation and interview, the facility failed to ensure the filters on the ice machine were replaced timely. This failure had the potential to affect all residents at the facility. This deficient practice could likely cause pollutants to enter the water causing contamination and illness. The findings are: A. On 09/16/25 at 9:29 am, an observation revealed the filters of the ice machine had a replacement date of 04/24/25. There were two filters, and they had the same change by date. The instructions on the filters recommended changing the filters at least once per year. B. On 09/16/25 at 9:31 am, during an interview, the District Manager stated the Maintenance Director was responsible for changing and ordering the filters. C. On 09/19/25 at 11:45 am, an observation revealed the ice machine had the same filters with a replacement date of 04/24/25. D. On 09/19/25 at 11:56 am, during an interview, Maintenace Director stated the filters needed to be changed.

Based on observations, record reviews and interviews, the facility failed to:-Follow proper infection control practices for handling laundry when staff failed to ensure- laundry was free from used sharps. If staff fail to handle used laundry, then residents could be at risk of development and transmission of disease and infections.- Demonstrate its measures to minimize the risk of Legionella (bacteria naturally found in water that can cause a severe type of lung infection called legionnaires' disease when people inhale tiny water droplets containing the bacteria) in the building's water system, when the Water Management Program (WMP) team failed to develop and implement an adequate LWMP. This deficient practice is likely to lead to outbreaks of legionellosis (legionnaires' disease and Pontiac fever, a milder flu-like illness).These failures had the potential to affect all residents in the facility. The findings are: Sharps in the Laundry A. Record review of the facility's Needle Handling and Sharps Injury Prevention policy, last revised on 04/15/23, showed shaving razors must be placed in sharps disposal containers (a rigid, puncture-proof plastic container designed to safely hold used needles, syringes, and other sharp medical objects). The policy did not mention the possibility of contaminating linen with sharps or how to prevent such incidents. B. On 09/19/25 at 1:12 pm, during an observation and interview, a sharps disposal container located in the laundry room contained multiple shaving razors. Laundry Technician #1 stated the shaving razors were in the sharps container, because she found razors in dirty residents' towels when staff brought towels in the laundry room. She stated she reported the incidents but did not recall when or to whom she reported the incidents. C. On 09/19/25 at 1:20 pm, during an interview, the facility's Infection Control Preventionist stated she was not aware laundry staff found razors in dirty linen. She stated staff did not report the incidents to her. The ICP stated leaving used shaving razors in towels could put laundry staff at risk of blood-porn pathogens (germs live in blood). D. On 09/19/25 at 1:50 pm, during an observation and interview, sharps disposal containers were mounted in the shower rooms in 100, 200, 300, and 400 halls. Certified Nurse Aide (CNA) #1 stated staff should dispose of used razors in sharps disposal containers located in the shower rooms. E. On 09/16/25 at 3:21 pm, during an interview, the Director of Nursing (DON) stated she was not aware laundry staff found used razors in dirty towels. The DON stated staff did not report the incidents to her. She stated staff should discard used razors in the sharp disposal containers located in shower rooms. The DON stated such incidents put laundry staff at risk of infections. Water Management Plan F. Record review of the facility's WMP, last revised on 09/13/25, showed the following: - The policy did not have a procedure on how to use the control measures to control the introduction and/or spread of Legionella in the building water system. - The policy did not include control limits (the maximum value, minimum value, or range of values that are acceptable for the control measures that you are monitoring to reduce the risk for legionella growth and spread) and parameters. - The policy did not have monitoring procedures to include specified and documented environmental testing protocols for legionella and established control limits acceptable for the control measures the facility monitored to reduce the risk for Legionella growth and spread. - The policy did not have established ways to intervene when control limits were not met or when there was a case of healthcare-associated legionellosis in the facility. G. On 09/19/25 at 10:00 am, during an interview with the facility's Administrator, Director of Nursing, Maintenance Director, and the Infection Control Preventionist, they stated the WMP team reviewed the WMP yearly, and the last time they reviewed the plan was on 09/13/25. They stated they were not aware the WMP was inadequate to prevent the growth and spread of legionella in the building water system. They stated they were not aware the plan did not have procedures to explain how to use the control measures, what were the acceptable control limits and parameters, what were the monitoring procedures, what were the testing protocols, and what were the established ways to intervene when control limits were not met or when there was a case of healthcare-associated legionellosis in the facility.

Based on record and interview, the facility failed to allow a resident to choose the time wound care would take place for 1 (R #123) of 1 (R #123) resident. This deficient practice could likely contribute to the resident not receiving wound care, which could cause the wound to worsen or become infected. The findings are:A. Record review of R #123's medical record indicated R #123 was admitted to the facility on [DATE] with the following diagnoses:-Quadriplegia (paralysis of all four limbs),-Chronic pain,-Anxiety,- Depression,- Chronic sacral (the portion of the spine between the lower back and the tailbone) pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin). B. Record review of R #123's physician orders, dated 08/12/25, revealed an order for wound care to the coccyx (tail bone). Apply triad paste (helps with wound care) mixed with Collagen particles (collagen particles are effective in promoting wound healing by enhancing tissue regeneration) to wound. Do not scrub to remove paste. Wipe away soiled layer of paste and then apply a fresh layer, two times per day every day and night shift. C. Record review R #123's Treatment Administration Record (TAR), dated 08/12/25 to 08/23/25, indicated staff administered wound care to R #123 eight out of 11 opportunities on the day shift and three out of 11 opportunities on the night shift. D. Record review of R #123's nursing progress notes revealed the following:- Dated 08/13/25 at 2:15 am, Certified Nursing Assistant (CNA) and the Nurse went to change R #123 and to turn him. The CNA and Nurse were going to perform wound care for the resident at the same time. R #123 refused to have the wound care done and stated, That's very unprofessional to do the wound care at 2:00 am. R #123 stated he would talk to the Supervisor in the morning, because it was unprofessional for wound care to be done at 2:00 am. - Dated 08/14/25 at 3:17 am, wound care to the coccyx was refused. R #123 requested wound care to be done twice per day during the morning hours to 6 pm. - Dated 08/15/25 at 3:57 am, wound care to the coccyx was refused. R #123 requested wound care to be done in the a.m. - Dated 08/15/25 at 9:35 am, R #123 was seen today to discuss recent refusals of wound care. Per resident, the wound was fine and did not require wound care as often as currently ordered. Education was provided on the current treatment plan. Triad paste was currently ordered two times per day (BID) and as needed (PRN). Education was provided to the resident on the importance of keeping the skin well lubricated with the Triad to prevent further injury to the skin.- Staff did not document a progress note on 08/16/25 to indicate why wound care did not take place on day shift or why wound care was refused by R #123 on the night shift. - Dated 08/17/25 at 1:01 am, R #123 refused wound care to the coccyx as ordered. - Dated 08/18/25 at 2:31 am, R #123 refused wound care to the coccyx multiple times and wanted it to be done during day shift only. - Dated 08/19/25 at 2:21 am, R #123 refused wound care to the coccyx multiple times and wanted it to be done during day shift only. - Dated 08/20/25 at 12:05 am, R #123 refused wound care to the coccyx multiple times and wanted it to be done during day shift only. - Dated 08/21/25 at 1:30 am, R #123 refused wound care to the coccyx multiple times and wanted it to be done during day shift only. E. On 09/19/25 at 10:00 am, during an interview, the Director of Nursing (DON) stated R #123 was difficult and refused care a lot. She stated if a resident verbalized they did not want wound care done at a certain time, then staff should get a hold of team lead, the wound care nurse, or the physician to tell them. The DON stated if the wound dressing was missing or soiled, then wound care would have to be done. She stated if it was the resident's preference to change the wound care time, then her expectation would be to accommodate the resident and have it done earlier, not at night. The DON stated some residents did not mind receiving wound care during the evening or night shift. F. On 09/19/25 at 10:15 am, during an interview, Unit Manager (UM) #2 stated R #123 was non-compliant with wound care and did not want it done at night. She stated they addressed the issue with the resident, but she could not remember how they addressed it. G. Record review of R #123's electronic medical record revealed the record did not contain any documentation in the progress notes, care plan, or in the orders regarding a discussion or a completion of a change in the time of R #123's wound care.

Based on observations and interviews, the facility failed to maintain a safe, comfortable, and homelike environment when staff failed to: - Maintain the dining room in a homelike manner.- Maintain resident rooms and bathrooms in good repair.-Maintain a resident bathroom free of flies.This failure had the potential to affect all residents who utilized the dining room and all residents in eight resident rooms. If the facility does not ensure resident rooms and common areas are clean, free from pests, and maintained in good repair, then residents are at risk of decreased quality of life, pest infestation, and injury due to unsafe environmental conditions. The findings are: Dining Room A. On 09/15/25 at 8:25 am, observations revealed the following: - Seven fluorescent light bulbs located around the walls were burnt out. - One chandelier bulb was burnt out. - All four walls had scuff marks with missing paint. - Several slats were missing from the wooden blinds in the windows. B. On 09/19/25 at 1:30 PM, during an interview, the Maintenance Director stated he was responsible for maintaining the dining room. He stated the lights in the dining area should be operational, the walls should not be scuffed, and the blinds should be fixed. Resident Rooms and Bathrooms C. On 09/15/25 at 10:00 am, observations revealed the following: – Resident occupied room [ROOM NUMBER]: The hot water at the bathroom faucet did not turn on when the faucet was turned. Further observation revealed a white towel on the floor and pushed up under the air conditioner unit. – Resident occupied room [ROOM NUMBER]: The floor in the bathroom had broken tiles. The sink was filled with water and drained slowly. Standing water and discolored tiles on the floor near the toilet. The walls were scuffed with missing paint. – Resident occupied room [ROOM NUMBER]: Large cracks extended across the floor into the bathroom shared with room [ROOM NUMBER]. The bathroom sink filled with water and drained slowly. The bathroom had a foul odor. – Resident occupied room [ROOM NUMBER]: The bathroom door was difficult to open due to the floor crack. Multiple tiles were risen off the floor and created an uneven walking surface. D. On 09/15/25 at 10:25 AM, during an interview, the resident in room [ROOM NUMBER] stated she placed towels under her air conditioning unit because water leaked into her room when it rained and created a slipping hazard. E. On 09/15/25 at 10:45 AM, during an interview, the residents in rooms [ROOM NUMBERS] stated they shared the bathroom. They reported the sink did not drain properly, standing water was present around the toilet, and the bathroom had a persistent foul odor. They stated they reported the concerns to maintenance, but the repairs were not completed. F. On 09/16/25 at 9:34 am, during an observation, the bathroom faucet located in resident occupied room [ROOM NUMBER] was broken, and the water ran continuously. Further observations on 09/17/25 at 10:18 am, 09/18/25 at 9:00 am, and 09/19/25 at 11:55 am, revealed the water ran continuously in the resident's bathroom. G. On 09/17/25 at 10:20 am, during an observation, room [ROOM NUMBER] had a broken window with a horizontal crack, and tape covered the crack. H. On 09/18/25 at 9:11 am, during an observation, a bed located in room [ROOM NUMBER] had a broken footboard on the bed. Further observation revealed the window screen was half detached from the frame, and the window was open. I. On 09/19/25 at 11:18 am, during interview, Certified Nurse Aide (CNA) #1 stated if a hazard was in a resident's room, then she would report it to maintenance staff right away by completing a work order. CNA #1 stated she did not observe or receive any complaints regarding broken faucets, broken footboard, or partially detached window screen. She stated the hazards could result in an uncomfortable environment for residents. J. On 09/19/25 at 1:30 PM, during an interview, the Maintenance Director stated he was responsible for maintaining the resident rooms. He stated he was aware of the concerns in some of the resident rooms, but the repairs were not completed. He stated room [ROOM NUMBER] experienced water intrusion during a rainstorm, and the resident placed a towel under the air conditioner. He stated the issues should have been corrected. Flies K. On 09/16/25 at 9:34 am, observation of R #55's room revealed eight flies in the restroom. L. On 09/17/25 at 10:18 am, observation of R #55's room revealed 12 flies in the restroom. M. On 09/18/25 at 9:00 am, observation of R #55's room revealed 12 flies in the restroom. N. On 09/19/25 at 11:55 am, observation of R #55's room revealed eight flies in the restroom. O. On 09/18/25 at 9:04 am, during an interview, R #55 stated she used the restroom, and there were always flies present. R #55 stated she once counted 15 flies in her restroom. She stated she preferred not to have flies in her bathroom. P. On 09/19/25 at 11:18 am, during interview, Certified Nurse Aide (CNA) #1 stated she did not observe any flies in R #55's room, and she did not receive any complaints regarding flies. She stated the flies could create an uncomfortable environment for resident. Q. On 09/19/25 at 1:30 PM, during an interview, the Maintenance Director stated he was responsible for maintaining resident rooms. He stated he was not aware of the flies in R #55's room. He stated the issue should have been corrected.

Cross reference to F755 Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate did not exceed 5 percent (%) for 2 (R #55 and R #73) of 2 (R #55, and R #73) residents. Staff administered 26 medications with three errors resulting in a medication error rate of 8.6%. If staff administer medications in error, then residents are likely to experience less than optimal results from their medication regimen (a prescribed systematic form of treatment for a course of drugs).The findings are: R #73 A. Record review of the facility's Medication Administration Policy, dated [DATE], showed the following: - Medications were administered in accordance with written orders of the prescriber. - Medications to be given on an empty stomach or before meals were to be scheduled for administration thirty minutes to two hours prior to meals. - Medications were administered within sixty minutes of scheduled time unless otherwise specified by the prescriber. B. Record review of R #73's Face Sheet showed R #73 was admitted to the facility on [DATE] with diagnoses of history of venous thrombosis and embolism (blood clot) and hypothyroidism (the thyroid is not making enough thyroid hormone). C. Record review of R #73's Provider Orders showed the following: - Dated [DATE], an active order to administer levothyroxine (a medication prescribed to manage hypothyroidism) oral tablet 75 microgram (mcg). Give one tablet by mouth one time a day, 30 to 60 minutes before breakfast, for hypothyroidism. - Dated [DATE], an active order to administer apixaban (blood thinner) oral tablet 5 milligrams (mg). Give one tablet by mouth two times a day at 8:00 am and 8:00 pm for blood clots. D. On [DATE] at 9:24 am, during observation, Certified Medication Aide (CMA) #1 prepared, poured, and administered the levothyroxine and apixaban to R #73. E. On [DATE] at 9:26 am during an interview, CMA #1 stated he should have administered the levothyroxine 30 to 60 minutes before breakfast and administered the apixaban within a two-hour period, one hour before to one hour after the scheduled time specified by the provider. He stated he was assigned to two resident halls, and that made him administer R #73's medications late. CMA #1 stated R #73 ate her breakfast before she received her morning medications. F. On [DATE] at 10:28 am during an interview, the Director of Nursing (DON) stated she expected CMA #1 to administered R #73's medications at the scheduled times as ordered by the prescribing provider. The DON stated the facility had a medication administration policy to administer medications within one hour before to one hour after the scheduled time, unless otherwise specified by the provider. R #55 G. Record review of the facility's Non-controlled Medications Orders Policy, last revised [DATE], revealed medications were administered only upon the receipt of a clear, complete, and signed order by a person lawfully authorized to prescribe. H. Record review of the facility's Medication Administration Policy, dated [DATE], revealed staff should review and confirm medication orders for each individual resident on the Medication Administration Record prior to administration. I. Record review of R #55's Face Sheet showed R #55 was admitted to the facility on [DATE]. J. Record review of R #55's Provider Orders, dated [DATE], showed an order for Artificial Tears. Instill one drop of Artificial Tears Ophthalmic Solution in both eyes every two hours, as needed, for itchiness/dryness for seven days. The order had an end date of [DATE]. K. On [DATE] at 9:14 am, during an observation, R #55 had visible redness around eyes and irritation, as evidenced by R #55 rubbing her eyes. L. On [DATE] at 9:15 am, CMA #2 administered Artificial Tears to R #55. M. On [DATE] at 9:01 am, during interview, R #55 stated she could request Artificial Tears from nurses whenever she needed them. R #55 stated she last requested and received Artificial Tears on [DATE]. N. On [DATE] at 11:40 am, during an interview, the DON stated the CMAs completed weekly medical cart audits. The DON stated CMAs go through medications in medical carts and take out any medications that are expired or discontinued. The DON stated medications should not be given to a resident without an active order. The DON stated it was the responsibility of the CMAs completing cart audits and whoever was administering medications at the time to make sure orders were active and up to date. The DON stated it was her expectation nurses and CMAs would not give any medications to residents without an active order. O. On [DATE] at 12:15 pm, during a phone interview, CMA #2 stated she administered Artificial Tears to R #55 on [DATE]. CMA #2 stated she thought R #55 had an active order for Artificial Tears. CMA #2 stated all medications must have an order prior to administering to the resident. CMA #2 stated it was primarily the responsibility of the doctor to make sure orders were up to date. CMA #2 stated potential hazards of administering medications without active order could result in a resident having an allergic reaction or interaction with other medications.

Based on observation and interview, the facility failed to protect a treatment cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) from unauthorized access when staff failed to lock the treatment cart while staff were away from the cart. This deficient practice had the potential to affect all residents on the 200 Unit. If staff fails to lock an unsupervised treatment cart, then residents could obtain medical equipment which could result in injury or death.The findings are:A. On 09/18/25 at 9:01 AM, during an observation of the 200 Unit, the treatment cart top drawer was opened, and the contents were exposed. Staff were not present in the area near the treatment cart. Further observations revealed the treatment cart had wound care dressing, wound cleanser, tweezers, barrier cream, irrigation solution, and scissors. B. On 09/19/25 at 9:10 AM, during an interview, Registered Nurse (RN)#1 stated he was responsible for the unlocked and opened treatment cart. RN #1 stated he stepped away to assist a resident and left the top drawer of the cart open, which exposed the contents of the treatment cart. He stated it was his expectation to lock the treatment cart when it was unattended. RN #1 stated if a resident had accessed the open treatment cart, the resident could have ingested something. C. On 09/19/25 at 2:15 PM, during an interview, the Director of Nursing (DON) stated staff were never to leave a treatment cart open and unattended. The DON stated it was her expectation for staff to lock all treatment and medication carts when staff were not attending them. She stated if a treatment cart was unlocked, then residents could ingest an item.

Based on record reviews, observation, and interviews, the facility failed to honor a resident's dietary preference for 1 (R #12) of 1 (R #12) resident. If the facility failed to serve a resident a vegetarian diet, then resident might receive meat and feel unheard and unimportant.The findings are: A. Record review of R #12's admission Record, dated 09/16/25, revealed an admission date of 05/02/2022 with the following diagnoses:-Type II diabetes mellitus. (DM; a disease in which the body cannot make or properly use insulin).-Morbid obesity. (severely overweight).-Legally blind (a significant and permanent loss of vision). B. Record review of R #12's admission Diet Order, dated 05/22/22, revealed regular diet, vegetarian, no eat eggs, and no meat. C. Record review of R #12's Care Plan, dated 09/02/25, revealed the following:- Consistent carbohydrate diet (a consistent amount of carbohydrates to help manage blood glucose levels).- The care plan did not address a vegetarian diet, no meat, and no eggs. D. Record review of R #12's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 09/08/25, revealed a diabetic diet (a meal plan that helps manage blood sugar levels). E. On 09/15/25 at 11:26 AM, during an interview, R #12 stated she was a vegetarian but received meat with every meal. R #12 stated the facility did not provide her with an alternative meal. She stated she was hungry, because she could only eat the salad. F. On 09/18/25 at 1:30 PM, during an observation and interview, R #12's lunch consisted of a pork sandwich and coleslaw. R #12 stated she received salad and meat, which she believed was pork. She stated she did not eat the meat, and she needed a snack. R #12 stated she consistently reminded staff of her dietary preference but continued to receive meals with meat. G. Record review of R #12's lunch ticket, dated 09/18/25, revealed a regular diet, and staff were to serve the resident a pork sandwich for lunch. H. On 09/19/25 at 1:43 PM, during an interview, the Dietary Director stated R #12 had several diet orders in the system: a regular diet, a CCHO diet, and a vegetarian diet. He stated the residents were currently on a regular liberalized diet (a modified therapeutic diet in which previous dietary restrictions are reduced or removed to promote better intake and quality of life). The Dietary Manager stated R #12's lunch ticket was incorrect, and R #12 should be on a CCHO and vegetarian diet. The Dietary Director stated his expectation was for staff to serve all residents the correct diet to avoid an adverse reaction. I. On 09/19/25 at 2:26 PM, during an interview, the Director of Nursing (DON) stated she was not aware R #12 received the incorrect diet. The DON stated it was her expectation for all residents to receive the correct diet. She stated if a resident received the incorrect diet, then it could lead to an allergic reaction or sickness.

Based on record review and interview, the facility failed to keep accurate and complete resident records for 2 (R #97 and #123) of 2 (R #97 and #123) residents. This deficient practice could likely cause confusion about the resident's care the resident based on the documentation presented in the resident's electronic medical record. The findings are: R #97 A. Record review of R #97's face sheet revealed an admission date of 04/19/24 with the following diagnoses:- Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),-Osteoarthritis (condition caused by wear and tear of the joints causing loss of range of motion and pain with movement),-Chronic pain,-Left femur (long bone that connects the hip to the knee) fracture. B. Record review of R #97's After-Hour Encounter note (a note written by the provider not during regular business hours) revealed the following:- Dated 06/10/25 at 9:00 am, R #97 had a fall sometime between 06/10/25 at 9:00 pm and 06/11/25 at 1:00 am. - Dated 06/11/25 at 1:00 am, R #97 had a fall with complaint of pain to the left shoulder and the left side groin area. Plan: X-ray on the left shoulder and left hip and pelvis. C. Record review of the facility's documentation of after-hours provider notification regarding R #97's fall, and provided by the Corporate Nurse, revealed the following:-After Hours Encounter Note in R #97's electronic medical record documented a call occurred on 06/10/25 at 9:00 pm, but the facility's after-hours provider notification documentation stated the call occurred on 06/11/25 at 7:20 am.- After Hours Encounter Note in R #97's electronic medical record documented a call occurred on 06/11/25 at 1:00 am, but the facility's after-hours provider notification documentation stated the call occurred on 06/11/25 at 7:26 am. D. On 09/19/25 at 2:30 pm, during an interview, the Corporate Nurse stated he was not sure why the times on R #97's After-Hour Encounter notes in the electronic medical record were different than the list of times he pulled from the provider record. The Corporate Nurse stated there was a problem, but he was not clear on why the documentation was not accurate. R #123E. Record review of R #123's face sheet indicated an admission date of 08/12/25 with the following diagnoses:- Quadriplegia (paralysis of all four limbs),-Chronic pain,-Anxiety (feelings of fear or apprehension),-Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). F. Record review of R #123's Activities of Daily Living (ADL; activities related to personal care such as bathing, dressing, hygiene, toileting, and eating) flow sheet (a document on which Certified Nursing Assistants document care), dated 08/12/25 to 08/23/25, indicated the record did not have documentation for the following areas:-Bathing, 2 out of 4 entries were missing.-Bed mobility, 30 out of 35 entries were missing.-Dressing, 30 out of 35 entries were missing.-Hygiene, 30 out of 35 entries were missing.-Toileting, 30 out of 35 entries were missing.-Eating, 21 out of 31 entries were missing. G. On 09/19/25 at 2:57 pm, during an interview, the Director of Nursing (DON) stated the documentation for R #123 was not acceptable. She stated sometimes agency staff did not have access to the electronic medical record to document the care they provided to the residents. She stated R #123 was not at the facility very long, and that might be why management did not notice the lack of documentation.

Based on record review and staff interview, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected the resident's diagnosis of major depressive disorder for 1 (R #9) of 1 (R #9) resident. If the facility does not ensure PASARR screenings are completed accurately, then residents with serious mental illness may not receive required evaluations or specialized services, placing them at risk for unmet mental health needs and a decline in psychosocial well-being.The findings are: A. Record review of the facility's Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients policy, revised 02/16/24, revealed the Social Worker or designated staff will assure all patients with mental disorders and intellectual disability received appropriate pre-admission screenings according to Federal and State regulations. The policy stated if a PASARR was not completed or was incorrect, then Social Services would coordinate with the appropriate agency to conduct the evaluation, review PASARR results to determine care needs, and incorporate recommendations into the patient's assessment and care planning. B. Record review of R #9's face sheet revealed he was admitted to the facility on [DATE] with diagnoses of liver disease, dementia, and major depressive disorder. C. Record review of R #9's Minimum Data Set (MDS; a federally mandated comprehensive assessment completed by facility staff), dated 08/26/25, revealed the following:- The resident had little interest or pleasure in doing things, felt down or depressed, had poor appetite, low energy, trouble concentrating, changes.- The resident had impaired memory recall and impaired decision-making.- A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score 11, moderate impairment.-Psychiatric/Mood Disorder revealed depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). D. Record review of R #9's PASRR Level I Identification Screening, dated 09/16/25, revealed staff documented the resident did not have a diagnosis of or a suspected mental illness. E. On 09/18/25 at 2:25 p.m., during an interview, the Social Services Director stated R #9's PASARR Level I Identification Screen was incorrect. She stated staff should have documented the resident had a diagnosis of a mental illness, because the resident had a diagnosis of major depressive disorder.

Based on record review and interview the facility failed to send a resident out to the hospital in a timely manner after the resident had a fall with pain and possible injury for 1 (R #97) of 1 (R #97) resident. This deficient practice could likely cause the resident to be in pain longer than necessary. The findings are: A. Record review of R #97's face sheet revealed she was admitted on [DATE] with the following diagnoses.-Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),-Osteoarthritis (condition caused by wear and tear of the joints causing loss of range of motion and pain with movement),-Chronic pain,-Left femur (long bone that connects the hip to the knee) fracture. B. Record review of R #97's After-Hour Encounter note (a note written by the provider not during regular business hours) revealed the following:- Dated 06/10/25 at 9:00 am, R #97 had a fall sometime between 06/10/25 at 9:00 pm and 06/11/25 at 1:00 am. - Dated 06/11/25 at 1:00 am, R #97 had a fall with complaint of pain to the left shoulder and the left side groin area. Plan: X-ray on the left shoulder and left hip and pelvis. C. Record review of R #97's pain documentation revealed the following:- Dated 06/10/25 at 7:31 pm was a 2 (scale 1-10, 1 was the least amount of pain and 10 was the most amount of pain).- Dated 06/10/25 at 11:28 pm was a 2. - Dated 06/11/25 at 7:15 am, was a 5. D. Record review of R #97's nursing progress notes, dated 06/11/25 at 7:48 am, indicated R #97 was transferred to the hospital due to an abnormal x-ray. E. Record review R #97's physician orders revealed the following:- Dated 06/11/25 at 8:54 am, x-ray of the left shoulder minimum of two views, one time only for pain. This order indicated it was waiting to be sent.-Dated 06/11/25 at 8:54 am, x-ray of the left hip with or without pelvis 2 to 3 views. This order indicated that it was waiting to be sent. F. Record review of R #97's nursing progress note, dated 06/11/25 at 3:15 pm, revealed R #97 pain level was noted to be a 7 out of 10. G. Record review of R #97's X-rays Report revealed the following:- Completed on 06/11/25 at 6:21 pm and read on 06/11/25 6:36 pm, x-ray to the left shoulder did not show an acute fracture or dislocation.- Completed on 06/11/25 at 6:22 pm and read on 06/11/25 at 6:36 pm, x-ray to the left hip showed a fracture to the left femoral neck (connects femoral head to the femoral shaft) with displacement of the distal fragment (portion of fractured bone that is farthest from center of the body). H. Record review of R #97's progress note, dated 06/11/25 at 7:48 pm, revealed R #97 was sent out to the hospital for hip fracture. I. On 09/18/25 at 9:57 am, during an interview, Unit Manager (UM) #2 stated staff entered the R #97's fall into the system at 7:15 am on 06/11/25. The UM #2 stated she was not clear why it took so long for R #97 to go out to the hospital. UM #2 stated she did not remember being notified of this fall for R #97. The UM #2 said sometimes non-emergent ambulance can take a while, but she never saw it take up to 12 hours to pick up a resident. J. On 09/18/25 at 10:42 am, during an interview, the Licensed Practical Nurse (LPN) #5 stated she remembered R #97 fell, but she was not working on the hall on 06/11/25 during the day shift. She stated she recalled being upset about how the nurse handled R #97's care around the fall. LPN #5 stated she went down the 100 hall for something and saw R #97 slumped over in her wheelchair and leaning to one side. She stated R #97 complained and told her that her left side hurt. LPN #5 stated she could tell R #97 was in pain. LPN #5 stated she asked the nurse working the 100 hall to assist her with putting R #97 to bed. She stated they assisted R #97 into bed, and R #97 immediately rolled to her right side, saying it hurt, to indicate her left side hurt. LPN #5 stated R #97's nurse told the resident that she was fine. LPN #5 stated she told R #97's nurse R #97 was not fine, and she needed to call the provider. LPN #5 stated she did not know when R #97's nurse called the provider, but it was already a delay in getting R #97 treatment. LPN #5 stated she was very upset about the care for R #97, because you could tell something was wrong with R #97's hip. She stated the resident's hip did not look right. LPN #5 stated she did not know when R #97 fell, because she was not her nurse. K. On 09/18/25 at 11:43 am, during an interview, the Director of Nursing (DON) stated she did not recall being notified of R #97's fall. The DON stated sometimes it took a while for x-ray technicians to come out to do an x-ray. She stated if the resident fell after-hours, then the nurse would likely enter the orders instead of the provider. The DON stated the timeframe of the fall, getting the x-rays, and R #97 being sent out should have been faster, especially if R #97 was in pain.

Based on observations, interviews, and record reviews, the facility failed to ensure a residents specialized air mattress was properly inflated for 1 (R #12) of 1 (R #12) resident. If the facility fails to ensure the residents' air mattress was properly inflated, then the resident could be at risk of entrapment or of development or worsening of a resident's pressure ulcers.The findings are:A. Record review of R #12's admission Record, dated 09/16/25, revealed an admission date of 05/02/22 with the following diagnoses:-Reduced mobility (decreased ability to move the body independently).-Legally blind.-Type 2 diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin).-Morbid obesity (severely overweight). B. Record review of R #12's Provider Orders, dated 07/22/25, revealed the following:-Specialty mattress. (a mattress designed to prevent or treat pressure injuries (bedsores) by reducing or redistributing pressure on the skin) -Alternating air mattress (a therapeutic or specialty mattress that contains air cells which automatically inflate and deflate in a programmed cycle to regularly shift pressure from one area of the body to other) to the resident's bed. C. Record review of R #12's Care Plan, dated 07/23/25, revealed the resident had an alternating air mattress (a therapeutic or specialty mattress that contains air cells which automatically inflate and deflate in a programmed cycle to regularly shift pressure from one area of the body to other). D. On 09/17/25 at 9:10 AM, during an observation, the resident slept in her bed. The alternating air mattress was off, deflated, and did not have any power lights. E. On 09/17/25, at 9:18 AM, during an interview, the Licensed Practical Nurse (LPN) #1 stated R #12's air mattress was deflated. LPN #1 stated the deflated mattress could cause entrapment or additional pressure wounds for the residents. LPN #1 stated all nursing staff were responsible to check resident care equipment. F. On 09/19/25 at 2:17 PM, during an interview, the Director of Nursing (DON) stated it was her expectation for nursing staff to check resident care equipment during their daily rounds. The DON said if resident care equipment did not function properly, then it could lead to a negative outcome for the resident. She stated a deflated mattress could become an entrapment hazard if the resident was asleep in bed.

Based on observation, interview, and record review, the facility failed to properly maintain respiratory care equipment for 1 (R #6) of 1 (R #6) residents when staff failed to date R #6's oxygen humidifier (to moisturize dry oxygen). If staff fail to date oxygen humidifiers, then residents could be at risk of serious infections. The findings are:A. Record review of the facility's Oxygen Policy, last revised on 08/07/23, showed the following:- If oxygen humidifier was used, staff should label with date.- Staff should replace disposable oxygen setup (equipment used for oxygen administration) every seven days. B. Record review of R #6's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnosis of congestive heart failure (CHF; impaired heart function) and anemia (low red blood cell count). C. Record review of R #6's Provider Orders showed the following:- Dated 07/28/25, an active order to administer oxygen at two liter/minute through a nasal cannula to keep oxygen above 90 percent (%), when the resident lay down. as needed for hypoxia (insufficient oxygen in the body's tissues).- Dated 09/11/25, an active order to change oxygen components and label them with date and initials as needed and every Monday for Infection Control. D. On 09/16/25 at 9:35 am, during an observation, R #6 's oxygen humidifier bottle was attached to his oxygen concentrator (oxygen supply machine) and undated. E. On 09/16/25 at 10:00 am, during an interview, Nurse #1 stated she was not aware R #6's oxygen humidifier was undated. She stated she should have dated the resident's oxygen humidifier and replaced it as needed, and every week as ordered. F. On 09/16/25 at 12:28 PM, during an interview, the Director of Nursing (DON) stated staff changed oxygen humidifiers and oxygen tubing as needed and every week. She stated undated oxygen humidifiers could put residents at risk of infection.

Cross reference to F759. Based on record review, observation, and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met when staff failed to dispose of medication after it was completed for 1 (R #55) of 1 (R #55) resident. If staff fail to dispose of completed medications, then residents could be at increased risk of medication errors, receive unnecessary treatments, and medication could be diverted. The findings are:A. Record review of the facility's Disposal of Medications Policy, dated January 2024, showed the following:- If a prescriber discontinued a medication, the medication container was removed from the medication cart as soon as practicable according to State and Federal regulations in a timely manner.- Medications awaiting disposal or return were stored in a locked secure area designated for that purpose and separated from active orders until destroyed or picked up by the pharmacy staff.- Medications awaiting destruction that cannot be disposed of immediately should be recorded on a log to include the name of the individual storing the medication, resident name, the prescription number is applicable, the quantity of the medication, the strength of the medication, and the date of disposition. B. Record review of R #55's Face Sheet showed R #55 was admitted to the facility on [DATE]. C. Record review of R #55's Provider Orders, dated 08/19/25, showed an order for Artificial Tears. Instill one drop Artificial Tears ophthalmic solution in both eyes every two hours, as needed, for itchiness/dryness for seven days. The order had an end date of 08/26/25. D. Record review of the facility's Medication Disposal Form, dated 08/27/25, revealed staff did not document R #55's completed artificial tears eye drops (used to relieve dry eyes and provide temporary lubrication). E. On 10/18/25 at 10:19 am, observation of the 100-hall medication cart showed an opened and used artificial tears eye drops bottle. Certified Medication Aide (CMA) #1 stated the eye drops belonged to R #55. He stated he should have disposed of the bottle, because R #55's order was completed on 08/26/25. F. On 09/18/25 at 11:00 am, during an interview, Nurse #2 stated he received completed and discontinued medications from nurses and CMAs, and he destroyed them. Nurse #2 stated he prepared a monthly report of destroyed medications in a Medication Disposal Form. Nurse #2 stated he did not receive R #55's completed eye drops. G. On 09/18/25 at 11:20 am during an interview, the Director of Nursing (DON) stated she expected Licensed Nurses and CMAs to dispose of completed medications and not to keep the completed medications in medication carts.

Based on record reviews and interviews, the facility failed to ensure residents obtained routine dental care for 1 (R #6) of 1 (R #6) resident reviewed for dental services, when the facility failed to provide documentation to show R #6 received routine dental services at least annually. If staff fail to arrange for residents' dental services, then it could lead to untreated tooth decay (damage to tooth surface), gum disease, and other oral health issues like bad breath, tooth sensitivity, and tooth loss. The findings are:A. Record review of the facility's Dental Services policy, dated 11/28/17 and last revised on 09/15/25, showed the following:- The facility provided or obtained, from an outside resource, routine and emergency dental services, to meet the needs of each resident.- Routine dental services meant an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental x-rays as needed, dental cleaning, and fillings (a treatment to repair a damaged tooth).- When necessary or if requested, the facility assisted residents in making dental appointments and arranged transportation to and from the dental service location.- The policy did not state staff roles in arranging those appointments. B. Record review of R #6's Face Sheet showed the resident was admitted into the facility on [DATE]. C. Record review of R #6's Provider Orders, dated 07/15/24, showed an order to send R #6 for a dental appointment on 7/22/24 at 10:30 am. Transportation staff to provide transportation. The provider discontinued the order on 09/17/24. D. Record review of R #6's Electronic Health Record (EHR), undated, showed staff did not document R #6 saw a dentist after the 07/15/24 provider order. Further review revealed R #6 last saw a dentist on 11/21/22. E. On 19/16/25 at 9:31 am, during observation and interview, R #6 stated she did not have any dental services in a while. She stated she had pain in several teeth and pointed at her mouth. R #6 stated she had her natural teeth. F. On 09/16/25 at 1:40 pm during an interview, the Social Services Director (SSD) stated the facility sent R #6 to her dental appointment on 11/21/22. She stated the facility's driver kept track of residents' routine dental appointments. She stated she occasionally helped the driver and let him know when new residents needed dental appointments. SSD stated she was not aware R #6 did not go to dental appointments annually. G. On 09/16/25 at 2:15 pm, during an interview, Nurse Manager #1 stated the facility's driver kept track of residents' routine dental appointments. She stated she occasionally let the driver know when she wanted him to schedule new dental appointments. Nurse Manager #1 stated she was not aware R #6 did not go to dental appointments annually. H. On 09/19/25 at 9:47 am, during an interview, the facility driver stated he kept track of residents' routine dental appointments and their due dates. He stated social services staff and nurse managers alerted him when they needed him to schedule new dental appointments. The driver stated he was responsible for keeping track of and scheduling routine dental appointments. The driver stated he was responsible for driving residents to their appointments when they were due. I. On 09/19/25 at 11:47 am during an interview, the Director of Nursing (DON) stated the facility's driver was not supposed to be solely responsible for arranging residents' dental appointments. She stated the Interdisciplinary Team (IDT; includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, resident or resident representative, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident) was supposed to collaborate in arranging those appointments.

Based on observation, interview, and record review, the facility failed to ensure a resident's wheelchair was maintained in safe operating condition for 1 (R #62) of 1 (R #62) resident. If staff do not maintain resident equipment, then residents are at risk of injury. The findings are: A. Record review of R #62's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 07/03/25, identified diagnoses of repeated falls, generalized muscle weakness, and need for assistance with personal care. B. Record review of R # 62's comprehensive care plan, revised on 09/12/25, showed interventions for assistance with activities of daily living (ADL; personal care tasks such as bathing, dressing, eating, toileting, and mobility), transfers, locomotion, and mobility due to limited mobility. C. On 09/16/25 at 12:29 a.m., during an observation and interview, R # 62 sat in his wheelchair in the common area. The back bar across the wheelchair was not attached and hung on the left side. R # 62 stated his wheelchair was broken for an extended period of time. D. On 09/19/25 at 10:01 a.m., during an interview, Licensed Practical Nurse (LPN) stated she noticed R # 62's wheelchair was broken. She stated she told the night nurse to notify the therapy staff, but she did not document the broken wheelchair in the resident's progress notes. E. On 09/26/25 at 12:12 p.m., during an interview, the Physical Therapist (PT) stated her expectation was for staff to submit a workorder in TELS (a computerized maintenance reporting system) for R #62's wheelchair to get the back of the wheelchair fixed. She stated the wheelchair was unsafe for the resident. She stated R #62's wheelchair was missing the back bar that went across the back of the chair, and they could not find the knob that secured the bar. She stated her expectation was for staff to place the resident into a different wheelchair until staff completed the repairs to his wheelchair.

Based on interview, the facility failed to inform residents and resident representatives in writing of a room change, including the reason for the change, when residents changed rooms due to a flooding event. for 8 (R #1-8) of 8 (R #1-8) residents that were moved. This deficient practice is likely to result in frustration and confusion for residents. The findings are: A. On 01/07/25 at 10:20 am during an interview with Nurse Manager (NM) #1, she stated the Managers were called into the facility because of the flooding on the 200 wing on 01/06/25. She stated the Managers were asked to assist in moving residents. She stated she assisted moving residents R #5 and R #3. She stated she did not call the residents' families or the resident representatives to inform them of the move or of the flooding issue. NM #1 states she was not aware if any staff called the families or resident representatives of R #1-8 to inform them of the move and flooding. B. Record Review of R #6's medical record revealed staff documented the following: - Dated 1/7/2025 at 11:15 am, due to water/ plumping issue, the resident was moved to another hall for safety. Staff notified the resident's POA/son on this date. No further questions or concerns at this time. - The record did not contain documentation that staff notified the POA in writing of the room change to include the reason for the change. C. On 01/07/25 at 11:57 am during an interview with R #6's family member, he stated the facility notified him about R #6's room change on 01/07/25 at 10:00 am. D. Record Review of R #3's medical record revealed the record did not contain documentation staff notified the resident or resident representative in writing regarding the room change to include the reason for the change. E. On 01/07/25 at 12:28 pm during a phone interview with R #3's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care), she stated the facility did not notify her of R #3's room change, and she would have liked to know what was going on with R #3. F. Record Review of R #4's medical record revealed the record did not contain documentation staff notified the resident or resident representative in writing regarding the room change to include the reason for the change. G. On 01/07/25 at 12:45 pm during interview with R #4, she stated staff asked her to move rooms, but the did not tell her why she was moving. H. Record Review of R #1's medical record revealed the record did not contain documentation staff notified the resident or resident representative in writing regarding the room change to include the reason for the change. I. Record Review of R #2's medical record revealed staff documented the following: - Dated 1/7/2025 at 10:59 am, due to water/ plumping issue, staff attempted to move the resident to a room that did not have a water issue. The resident refused to move rooms. Staff re-attempted on this date, and the resident agreed to move. - The record did not contain documentation that staff notified the POA in writing of the room change to include the reason for the change. J. Record Review of R #5's medical record revealed staff documented the following: - Dated 1/7/2025 at 11:12 am, due to water/ plumping issue, the resident was moved to another hall for safety. Staff notified the resident's POA on this date, but she was not available at this time. Staff left a message for a call back. - The record did not contain documentation that staff notified the POA in writing of the room change to include the reason for the change. K. Record Review of R #7's medical record revealed the record did not contain documentation staff notified the resident or resident representative in writing regarding the room change to include the reason for the change. L. Record Review of R #8's medical record revealed the record did not contain documentation staff notified the resident or resident representative in writing regarding the room change to include the reason for the change. M. On 01/07/25 at 1:38 pm during an interview with the Director of Nursing (DON), she stated 18 residents resided on the 200 wing. She stated seven residents were able to ambulate on their own, and those were the residents that moved to other units of the facility.The DON stated staff notified the families of all the residents that were moved on 01/07/25 by 1:00 pm by phone, but staff did not provide documentation in writing. The DON stated the flooding issue started on 01/06/25, and residents were moved on 01/06/25. The DON stated the families for R #1-8 were not notified in writing at that time.

Based on record review, observation and interviews, the facility failed to ensure staff documented the medication refrigerator temperatures in the medication storage room. This deficient practice is likely to result in all residents living in the facility, as identified on the census list provided by the Executive Director (ED) on 06/24/24, receiving medication that has lost their potency or effectiveness due to not being stored at the proper temperature. The findings are: A. Record review of the medication storage room temperature log book for the medication #1 refrigerator, the medication #2 refrigerator, and the specimen refrigerator revealed staff did not document temperature recordings for the following dates: 1. 06/21/24 pm. 2. 06/22/24 am and pm. 3. 06/23/24 am and pm. B. On 06/24/24 at 10:28 am during observation of the medication storage room, the medication #1 refrigerator, the medication #2 refrigerator, and the specimen refrigerator contained insulin and other medications that required refrigeration. C. On 06/28/24 at 12:23 pm, during an interview with the Director of Nursing (DON), she stated staff must check all medication storage room's refrigerator and freezer temperatures twice a day (am and pm) and document the temperatures on the temperature log. She stated staff checked to make sure the refrigerators maintained a temperature range of 36 to 46 degrees Fahrenheit, which preserved temperature-controlled medications and specimens.

Based on record review and interview, the facility failed to notify the resident's guardian and the physician of blood sugar fluctuations for 1 (R #298) of 2 (R #34 and R #298) residents reviewed for insulin use and blood sugar management. If the facility is not monitoring for blood sugar fluctuations, then residents are likely at risk of serious harm or death. The findings are: A. Record review of the facility's policy Change in Condition: Notification of, last revised 06/01/21, revealed A center must immediately inform the resident/patient (hereinafter patient), consult with the patient's physician, and notify, consistent with his/her authority, the patient's Health Care Decision Maker (HCDM), where there is: . A significant change in the patient's physical, mental, or psychosocial status . A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). B. Record review of R #298's face sheet revealed that he was admitted to the facility on [DATE] with the following diagnosis: unspecified dementia with behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), type 1 diabetes mellitus with hypoglycemia (a chronic condition in which the pancreas produces little or no insulin accompanied by low blood sugars), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) , schizoaffective disorders (mood disorders associated with a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), and depression (conditions associated with the elevation or lowering of a person's mood) C. On 03/07/23 at 2:05 pm, during an interview, R #298 explained that he has been a type 1 diabetic since he was 8 years old and feels like he is having issues with the management of his blood sugar levels, as he does not feel well in the mornings. D. Record review of Blood Glucose Testing and Management Hypoglycemia (Low Blood Glucose) which can be found at the American Diabetes Association website https://diabetes. org revealed the following: Low blood glucose [less than 70 mg/dL (milligrams per decilitre- one-thousandth (1/1000) of a gram per fluid volume that is one-tenth (1/10) liter)] is when your blood glucose levels have fallen low enough that you need to take action to bring them back to your target range [When fasting, a normal blood sugar range is 70-100 mg/dl). When not fasting, a normal reading is 125 mg/dl]. A low blood glucose level triggers the release of epinephrine (adrenaline), the fight-or-flight hormone. Epinephrine is what can cause the symptoms of hypoglycemia such as thumping heart, sweating, tingling, and anxiety. If the blood sugar glucose continues to drop, the brain does not get enough glucose and stops functioning as it should. This can lead to blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. If blood glucose stays low for too long, starving the brain of glucose, it may lead to seizures, coma, and very rarely death. Treatment- The 15-15 Rule [hypoglycemic protocol]- have 15 grams of carbohydrate to raise your blood glucose and check it after 15 minutes. If it's still below 70 mg/dl, have another serving. Repeat these steps until your blood glucose is at least 70 mg/dl . E. Record review of R #298's nursing notes revealed the following: Nursing note dated 01/24/23, Res [resident] initial CBG [Capillary Blood Glucose- the sugar in your blood] was 224 mg/dl, insulin given as per sliding scale (The dosage of insulin based on blood glucose level. The higher the blood glucose the more insulin is given). About 3 hours after res (resident) CBG went down suddenly to 57 mg/dl. Res was symptomatic and had sweating a lot with urinary incontinence. Increased jerking movements but still a bit responsive. Insta glucose [a medication that is a concentrated carbohydrate that is used to treat low blood sugar levels before unconsciousness occurs] 24 g (grams) administered as ordered but [his CBG was] still 64 mg/dl. At this time, resident had seizure like activity and became stupor [a state of near-unconsciousness or insensibility]. Immediately administered glucagon IM [intramuscular- directly into the muscle], 1 mg and called 911 for possible emergency transfer. Checked again sugar level and went up to 72 mg/dl. Few minutes after rechecked again noted 79 mg/dl . Physician on call was informed and the DON. Transferred to [name of hospital] at 0055H [12:55 am] F. Record review of R #298's Electronic Health Record (EHR) revealed that he returned to the facility on [DATE]. While he was at the hospital on 01/24/23, he was treated for seizure secondary to hypoglycemia [a condition in which your blood sugar (glucose) level is lower than the standard range of 70]. His glucose level was found to be in the 40's upon admission which increased to 100 after the administration of intramuscular glucagon. G. Record review of physician orders revealed the following: - Physicians order, dated 02/24/23, Insulin Glargine-yfgn [insulin is a hormone that lowers blood glucose levels. Insulin Glargine-yfgn is a long-acting type of insulin that works slowly, over about 24 hours] Subcutaneous Solution Pen-injector (a short needle is used to inject a drug into the tissue layer between the skin and the muscle) 100 unit/ml (milliliters), Inject 20 unit subcutaneously two times a day for diabetic management - Physician order, dated 02/23/23, Insulin Lispro [short acting insulin which is able to absorb quickly after injection] (1 unit dial) Subcutaneous Solution Pen-injector 100 unit/ml Inject as per sliding scale [subcutaneously before meals and at bedtime for screening of diabetes]: if 151 - 200 = 2 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units greater than 401 notify provider - Physician PRN [as needed] order, dated 02/23/23, Hypoglycemia Protocol [method of raising blood sugar by following the 15-15 rule [have 15 grams of carbs and check your blood sugar after 15 minutes until it reaches the normal range]: Observe sign/symptoms of hypoglycemia as needed if blood glucose is less than 70 mg/dl or ordered low parameter follow hypoglycemia protocol - Physician PRN order, dated 02/23/23, Insta-glucose gel 77.4% (Glucose) [a concentrated carbohydrate that is used to treat low blood sugar levels before unconsciousness occurs] Give 1 dose by mouth as needed for BG (Blood Glucose) less than 70. Pt (patient) arousable conscious and able to swallow. Hold all medications until provider authorizes resumption. Remain with pt. Keep pt in bed/chair for safety. Repeat blood glucose in 15 min. - Physician PRN as needed order, dated 02/23/23, Glucagon Emergency kit 1 MG (Glucagon (rDNA)) [A hormone that triggers the liver to release stored sugar, which raises blood sugar when it is below healthy ranges- hypoglycemic], Inject 1 mg intramuscularly as needed for BG less than 70. Not arousable conscious or able to swallow. If repeat blood glucose is below 70 mg/dl and pt is NOT arousal, conscious or able to swallow. Continue to hold all diabetic medications until provider authorizes resumption. Remain with pt. Keep pt in bed/chair for safety. H. Record review of R #298's Blood Sugar Summary revealed the following blood sugars readings that were out of normal limits (below 70 or above 400): 02/24/23 at 2:50 am- 405.0 02/27/23 at 7:53 am- 60.0 03/01/23 at 7:41 am- 69.0 03/02/23 at 10:48 am- 58.0 03/05/23 at 6:05 pm- 400.0 03/09/23 at 7:04 am- 62.0 03/09/23 at 4:35 pm- 68.0 03/12/23 at 3:24 pm- 66.0 03/13/23 at 12:30 pm- 46.0 03/13/23 at 4:37 pm- 501.0 I. Record review of R #298's nursing notes revealed the following: - Nursing note, dated 02/24/23, BS [Blood Sugar] 405.0 - 2/24/2023 02:50 [2:50 am] No note indicating that the physician was notified of high blood sugar. - Nursing note, dated 02/26/23, Res came over to nurses station requesting to have his blood sugar level to be checked. An hour before this, I did my rounds but res appears he's just fine and I asked him he said 'I'm fine'. But now he seems no energy and he felt his blood sugar is low. Checked his blood sugar noted 51 mg/dl. Hypoglycemic protocol initiated, give something sweet strawberry jelly and rechecked after 15 minutes noted went up to 78 mg/dl and res stated he feels better. Gave biscuits also, needs attended. Will continue to monitor. No note indicating that the physician was notified of low blood sugar. - Nursing noted, dated 02/28/23, Around 2030 [8:30 pm] of 2/27/23 the patient blood sugar was checked and it was 376 [mg/dl] all due [ordered] insulin was given as ordered according to the sliding scale. The nurse advised the pt to eat something after few hours of receiving insulin. Then around 0000 [12:00 am] of 2/28/23 the CNA (Certified Nurse Assistant) went to nurse station and stated that pt was talking on his dream and sweating a lot. The nurse on duty went to pt room and decided to checked his blood sugar and it was just 34. The patient was lethargic [a state of low energy and sleepiness] at 0010 [12:10 am] IM [intramuscular] Glucagon [emergency kit] was given after 15 minutes blood sugar was rechecked and it was 44, The nurse on duty decided to gave a 2nd dose of IM glucagon at 0030 [12:30 am], After 30 mins the blood sugar went up to 60. 1 lnsta glucose was given at 0045 [12:45 am], After 15 mins blood sugar was rechecked and went up to 77. At 0200 [2:00 am] the blood sugar was rechecked and it was 120 at 0130 [1:30 am]. The patient verbalized that he felt better than earlier. Kept monitored. No note indicating that the physician was notified of low blood sugar and/or the initiation of hypoglycemic protocol. - Nursing note, dated 03/01/23, At 0240H [2:40 am], res (resident) reported to the CNAs on duty that he's not feeling better suspecting having a low blood sugar. This nurse immediately assessed the CBG noted 43 mg/dL, noted shaking but still alert and conscious. Hypoglycemic protocol initiated, administered IM [intramuscular- directly into the muscle] glucagon as ordered and lnsta-glucose by mouth. Rechecked after 15 mins noted CBG level went up to 168 mg/dl. Comfort rendered, needs attended. Appears stable at this time. Res stated I'm feeling better now ready to sleep back. Will cont. to monitor No note indicating that the physician was notified of low blood sugar and/or the initiation of hypoglycemic protocol. - Nursing note, dated 03/05/23, Around 0000H [12:00 am], the CNA on duty reported to this nurse that this resident wanted to check his blood sugar suspecting low blood glucose. Assessed immediately and CBG taken noted 56 mg/dl. Noted res alert and oriented and still able to make needs known. Hypoglycemic protocol rendered, checked after 15 mins noted went up to 68 mg/dl. Another food given, yogurt and strawberry shake given then rechecked after noted 98 mg/dL and this res stated 'I'm feeling great now I need to go back to sleep'. Comfort rendered, needs attended. Will continue to monitor. No note indicating that the physician was notified of blood sugar level fluctuations. -Nursing note, dated 03/09/23, no notes documented related to the blood sugar readings: 03/09/23 at 7:04 am- 62.0 and 03/09/23 at 4:35 pm- 68.0. - Nursing note, dated 03/12/23, Resident CBG @ [at] 0650 [6:50 am] was 34, hence the hypoglycemic protocol was commenced immediately. 1 mg Glucagon IM and lnstaGlucose Gel administered. At 0730 [7:30 am], CBG was 54, breakfast was served and he ate 100% with about 3 glasses of orange juice. CBG @ 0845 [8:45 am] was 288, had insulin as per order. No note indicating that the physician was notified of low blood sugar. - Nursing note, dated 03/13/23, BS (blood Sugar) 46 at approx. 1225 [12:25 am]. Res symptomatic with confusion and staggered gait. Gave Three Musketeers candy bar and 1/2 coke. Recheck was at approx. 1324 [1:24 pm] with result 191. Res asymptomatic and states feels much better. Will cont. (continue) to monitor for complications this shift. No note indicating that the physician was notified of low symptomatic low blood sugar and/or the initiation of hypoglycemic protocol. J. On 03/15/23 at 1:21 pm during an interview with the Director of Nursing (DON) and ADM, the DON stated that there is no Policy on Diabetic Management because each resident's physicians orders is what they follow because each resident has different orders and different parameters [regarding what is considered high blood sugar and what is considered low blood sugar]. He stated that they have contact with the guardian for stuff like changes in condition, etc. K. On 03/15/23 at 3:52 pm during an interview with Court Appointed Guardian (CAG) for R #298, he stated that the facility contacts him when there is a change in condition for R #298. He stated that he was called twice regarding blood sugar levels and thinks that R #298 was sent out to the hospital due to his blood sugar being too low, but he is not sure. L. On 03/13/23 at 1:57 pm, during an interview with License Practical Nurse (LPN) #1, when asked if R #298 is compliant with medications, he explained that If his sugars appear low, he will ask you to hold his insulin. He does that because he knows his body. He asks to hold his insulin, until he says he wants it. When asked what happens after R #298 asks to hold his insulin, he explained I wait until he wants it. When asked if holding medication is the same as a refusal he explained that he didn't consider it as a refusal but after discussing it, he realizes that it is a refusal since it is not being administered as ordered by the doctor. When asked if he has notified the physician of R #298's refusal, he confirmed no. M. On 03/14/23 at 2:07 pm, during interview with LPN #1, when asked to explain what happens if a resident's blood sugar extends out of normal limits, he explained If the blood sugar reading reaches the 400 parameter then you call the doctor. When asked if the resident's blood sugar is low, he explained I don't think they have parameters for low blood sugar. If its low, like below 60, you give them something to eat to bring their sugar up. If its consistently low and bottoming out, then I would notify the doctor. If I put the hypoglycemia protocol in place then yes, I would call the doctor N. On 03/14/23 at 2:24 pm, during an interview with the facility's physician, when asked if she was made aware of R #289's blood sugar fluctuations, she explained We have parameters when they [nursing staff] are supposed to let me know. I'm sure they notify whoever is covering the on-call. When asked if she has a log of the on-call notifications, she stated, no. When asked why she would expect to be notified, she explained This is standard practice and we might hold another dose [of glucose or insulin medications]. I noticed that he (R #289) has had some lows. When asked if she was made aware of his low blood sugar occurrences, for example the low blood sugar on 03/05/23, she confirmed no and explained I was planning on changing his night time insulin. I wanted to decrease it and leave the morning dose the same. It's something that we have to follow [track and trend]. When asked why the change in night time insulin has not been implemented, she explained His sugars are not consistently dangerously low. When asked what is considered dangerously low, she confirmed a reading in the 20's. She then explained Brittle diabetics will often go low but you have to balance the highs with the lows. I meant to do it last night but he's not emergent. When he was at [name of other LTC facility], he was high. Since he has been at [name of current facility], he has been low and I am in the middle of managing his diabetes. O. On 03/14/23 at 2:48 pm, during an interview with the DON, when asked what is expected of staff if a resident's blood sugar drops below 70, she explained per the order, they are supposed to call the provider and obtain orders. They should do a 15 min check, 30 min check and then notify the provider She then confirmed, per nursing notes, that the physician was not notified on 03/01/23, 03/05/23, 03/09/23, 03/12/23, and 03/13/23. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J which was announced in-person on 03/15/23 at 4:09 pm to the Center Executive Director. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 03/16/23 at 11:34 am. Implementation of the POR was verified onsite on 03/16/23 at 3:23 pm by conducting record reviews and staff interviews. This resulted in the scope and severity being reduced to E. Plan of Removal: All residents with diabetes have the potential to be affected by this alleged deficient practice, if the facility fails to monitor and notify the provider of residents for a change in condition related to diabetes. The following identification/corrections will be completed by 03/16/23: - Licensed nurses will complete assessments on current diabetic residents residing in center to determine presence of a medical change in condition. Identified issues will be reported to provider for further direction and medical orders and documented. - Registered nurse reviewed current resident's blood glucose for the past 30-days for trending to determine presence of a medical change in condition with steps taken to provide care related to identified medical need. Identified changes in condition not reported to MD (Medical Doctor) will be reported and medical orders will be followed, with monitoring and then documented. - Licensed nurse will review current diabetic orders to ensure order set includes notification of a provider when outside of a noted range (this could vary per resident needs). - The elnteract change in condition documentation needs to be completed, with the notification noted. It also needs to include all abnormal findings in each system within the form, vital signs, neurological status, blood glucose etc. The nurse needs to include a narrative note about what happen before, during and after the event, and the provider orders and interventions that were put into place. - Range for the orders are below 70 to initiate hypoglycemic protocol and the higher end varies per patient's sliding scale and is indicated in their orders. - When patients are on the boarder, nurse to follow provider order unless patient is symptomatic for hypoglycemia or hyperglycemia. If symptomatic for hypoglycemia or hyperglycemia, notify provider immediately for specific instructions on whether to hold order or proceed with orders. Education: The Director of Nursing/designee will begin education 03/16/23. As of 03/16/23, 100% of currently scheduled Direct Care staff will be educated on this policy. Any direct care staff member that is not on the current schedule as of 03/16/23, is on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. New hires/agency staff will be educated on the above during orientation. The Director of Nursing/designee will review diabetic resident progress notes, orders and nursing dashboard during morning clinical meeting to determine if residents noted change in condition identified, process followed, and monitoring occurred. Quality Assurance and Monitoring: - The Director of Nursing/designee will audit 5 random diabetic residents for unmanaged blood glucose levels, and change in condition notification 3 x (times) per week for 1 month, then weekly for 2 months. - Administrator and/or designee will bring results of audits to QAPI [Quality Assurance and Performance Improvement- a committee tasked with the responsibilities of identifying faults and improving them] committee for further recommendations based on tracking and trending presented monthly for the next 3 months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator. 40671

Based on interview and record review the facility failed to meet professional standards of practice by not changing one (R #193) of one (R #193) residents wound vac (or a negative-pressure wound therapy, is a therapeutic technique using a suction pump, tubing and a dressing to remove excess exudate and promote healing in acute or chronic wounds) per physician orders [REDACTED]. This deficient practice caused harm to the resident by not performing wound care for two to three weeks and by not changing out the foam in the wound as ordered. The resident was sent out to the emergency room so the foam could be surgically debrided (to remove debris or infected/dead tissue from a wound). The findings are: A. Record review of a nursing progress note dated 05/06/20 reveled that R #193 was admitted to the facility with a surgical wound that measured approximately 27 cm length, 6 cm width and 6 cm depth. B. Record review of the Physician orders [REDACTED]. Set unit to 125 mmHg (mmHg stands for millimeters of mercury and it indicates the level of pressure or compression) continuously. Cleanse with wound cleanser. Place black foam into wound. Apply skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) to intact skin around the wound cover with occlusive transparent dressing (means that no air or moisture can penetrate in or out) and secure tubing per manufacturer guide every day shift Monday, Wednesday and Friday. C. Record review of the Skin Integrity Report (SIRS) indicated that the first date of wound measurement was on 05/11/20. There are no other measurements on the SIRS. D. Record review of the Treatment Administration Record (TAR) indicated that wound care was completed on 05/08/20, 05/11/20, 05/13/20. The TAR indicated that no wound care was completed on the 15th and to see the nursing notes on the 18th. There is no nursing note on the 18th that indicated why the wound care had not been done. E. Record review of the nursing progress notes dated 5/21/20 indicated the following: on this day the nurse on the floor requested help to do this residents wound care including wound vac change. Resident had already been medicated to reduce pain during wound care with Oxy PO (pain pill by mouth) and [MEDICATION NAME] (is used to temporarily numb and relieve pain) injected onto black sponge over abdomen to reduce pain. When ready this nurse and the Registered Nurse (RN) (unknown nurse) on the floor went into the residents room, removed the transparent dressing, cleansed around the black sponge, soaked with NS (normal saline), but black sponge was difficult to remove. At that time nursing felt that the resident should be assessed in the emergency room (ER). PA (Physician's assistant) was notified and had resident sent to ER for further evaluation. At that time nursing covered the area with ABD (for wounds requiring high absorbency pads) and secured with a transparent dressing as residents request to remain free and clear of infection. F. Record review of the nursing progress notes dated 5/21/20 indicated the following: Late entry: Patient sent to ER after wound assessment, noted sponge from wound vac difficult to remove from wound bed, physician notified and orders to send patient to ER for evaluation. All existing wound care removed and new temp (temporary) wound care done for transfer to ER. No s/s (signs/symptoms) of infection noted, no odor, patient VS (vital signs) stable. G. On 11/18/20 at 8:47 am, during an interview with the Certified Executive Director (CED) he stated that for wound care his Director of Nursing and his two Unit Managers are doing wound rounds twice per week. He stated that the two Unit Managers are responsible for doing wound care. He stated that they expectation is that wounds get documented on the SIRS every week. He stated that one of his unit managers was COVID positive around the time that the wounds stopped being documented and measured in the wound book. He did not have any other information about wound care. H. On 11/19/20 at 9:32 am, during an interview with Unit Manager #1, she stated that the nurses working the floor are responsible for wound care at this time. Before this outbreak occurred the unit managers would go with the nurses to evaluate the wounds and update the SIRS. The UN#1 agreed that the SIRS sheets were not being completed. She stated that now due to COVID and the staffing issues they are having, the nurses are responsible to do the wounds but it depends on which nurse is working on whether or not the treatments are going to get done. UM #1 stated that for R #193 they went to do rounds and the nurse was having a hard time getting the sponge out of the wound. R #193 told them that the last time the wound had been changed, the foam was left in and not changed. UN #1 stated that this is not acceptable. The foam should have been changed per the order that was written. They only changed the transparent dressing and put the date on it but didn't do anything else. She stated that she is aware of some supplies not being available at one point as well. She stated that 6 to 9 days passed before the dressing was changed per physician orders. She stated that they had to send him out to the emergency room , because his skin was growing around the foam and it needed to be surgical debrided.

Based on record review and interview, the facility failed to provide care for 1 (R #1) of 5 (R #s 1, 2, 3, 4, and 5) residents reviewed for falls, by not initiating neuro checks after R #1 fell hitting his head and failed to implement preventitive interventions when R #1 continued to experience injuries from falls. This deficienct practice resulted in R #1 sustaining a brain bleed and broken ribs following 3 falls in 4 days. The findings are: A. On 08/06/20 at 3:45 pm a family member of R#1 stated, Originally my father went to the (name of hospital) on the 6th (07/06/20) for a broken hip. He was there for about 2 weeks. He was then admitted to (name of facility) on 07/22/20. During the time that he was there, I received a call on a Tuesday, early in the morning, that he had fallen. They found him in good spirits and he was ok. They called me consecutively for 3 days to tell me that he had fallen. I went to see him through the gate outside and we were about 20-30 feet apart. I received a call on Friday that he had fallen again that he had a laceration on his left arm and that he had bumped his ear and that he had a small bruise. On Saturday they called me at 2 am to let me know he had fallen again but that he was fine. My family then went to go see him. His left ear was black and blue. The laceration on his arm was bad. We didn't know anything about the broken ribs. We decide to send him to the hospital. We called the ambulance and asked them to send him to the (name of hospital). He was not able to go to the (name of hospital), so they sent him to (name of hospital). They admitted him to the neuro ICU (Intensive Care Unit) and we received a report back that he was bleeding in his brain, broken ribs on his left side, and bruising all over his body. He was not himself, not responsive, and totally dazed. While we pulled him out of (name of facility), we had to sign a form for him to leave Against Medical Advice (AMA). That was then sent over to Adult Protective Services. I was questioned why I pulled him out of the facility and I told them to' save his life '. They (the facility) didn't want to let him go to the hospital. He suffers from dementia and Alzheimer's. He has worsened, and he is very fidgety and high anxiety. He gets up and he needs something to protect him or to watch him. They also received that directive from the (name of hospital). I was called 3 times to notify me of the falls. They called me each time very early in the morning, one at 2 am, 5 am, and 6 am. They were calls form the nurse on her private phone. They said that they found him on the floor. On the first time when he fell , I asked that they do something, they said they would put mats and I asked that he get 1-on-1 services. They were not able to provide 1-on-1 so I told them to do what they can . When they called me on that Friday or Thursday, they told me that he had fallen; he had a bruised left ear and a laceration on his upper forearm. When I asked how bad, she said 'oh, it's not bad, we bandaged him up '. I didn't realize that the trauma to his head led to bleeding in his brain. His physician said that if there are any bruising, he needs to have an MRI (Magnetic resonance imaging is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body) because he is on [MEDICATION NAME] (an anticoagulant medicine used to prevent and treat the symptoms of blood clots). B. Record review of hospital documentation reveals that R#1 was admitted on [DATE] at 2:15 pm (after his stay at the Long Term Care Facility). Upon evaluation, he was found to have bilateral subdural hemorrhages (A pool of blood between the brain and its outermost covering)- R SAH (Right Subarachnoid hemorrhage: Bleeding in the space between the brain and the tissue covering the brain)/subdural hematoma and rib fractures on the 9th and 10th ribs. C. Record review of the facility progress notes dated 07/21/20 indicates that the patient was admitted for the following reasons: Teaching and Training, Therapy fracture, status [REDACTED]. Needs assistance of 1-2 people to get out of bed . D. Record review of the Treatment Administration Record indicates that R#1 was ordered to receive [MEDICATION NAME] Sodium Solution 40 mg/0.4 ML (an anticoagulant medicine used to prevent and treat the symptoms of blood clots) by injecting 1 syringe subcutaneously one time a day for anticoagulant, until 07/26/20. This medicine was administered daily, as ordered on [DATE] to 07/24/20. E. Record review of assessments indicate that there were 3 incidents where R#1 experienced a Change in Condition on the following dates: 07/22/20, 07/24/20, and 07/25/20. F. Record review of the progress notes indicate that on 07/22/20, R#1 experienced an unwitnessed fall where no injuries were observed, and floor mats were then implemented. G. Record review of the Risk Management System (RMS) report, dated 07/22/20, indicates that R#1 was found where a Level of consciousness is 1X (oriented to self), resident baseline is confused. Patient found on floor by CNA (Certified Nursing Assistant). Patient potentially rolled out of bed. H. When asked if a Neurological Assessment of the fall on 07/22/20 was completed, the document was unable to be locate by facility staff. I. Record review of the progress notes indicate that on 07/24/20, R#1 occasionally tries to get out of bed/wheel chair on his own. He sustained a minor skin tear to his left hand (rear) from his wheel chair while trying to get out of his bed. It was immediately cleansed and [MEDICATION NAME] dressing applied. No complaint for pains or discomfort. Will continue to monitor. J. Record review of the progress notes indicate that on 07/25/20, R#1 was found on the floor in his room around 3:30 am. Denies any pain or discomfort at time of report. Further review reveals that the resident obtained a scratch on his left upper back. K. When asked if a RMS report and a Neurological Assessment of the fall on 07/25/20 was completed, the Unit Manager stated that a neurological assessment was not initiated. When asked why it was not initiated, she stated that the resident left the facility that same day. L. Record review of the Care Plan for R#1 did not include any updates or entries related to the resident's falls, fall risk or medication regimen. M. On 08/11/20 at 4:05 pm, during an interview with the facility Center Nurse Executive (CNE), when asked to discuss R#1, the CNE stated We have been the only center that has been open to admissions. We have had many people come in who are substance abusers or alcohol dependent. At this time, we got a large influx of residents. They would come, like 7 at a time. Some just didn't want to be here. They would tell us that they didn't want to be here . In this case, we let them know that if they leave AMA, it's a different process. His case was different, he didn't want to be here form the get go. He sustained a fall and then he left. Typically, those who leave AMA, they are unhappy when they get here, they have high expectations. With COVID, they have to have the same staff on the halls. They told me that the son came over here, and they did a window visit that day and he said he wanted to take him home. He wasn't satisfied with the process- he fell , and he didn't want him to have falls. When asked to explain the process of what should happen when someone falls, the CNE stated Typically, if the CNA finds them, they do not move the resident for C-spine precautions. The nurse should assess them. They have 2 hours to report that to me. They should also accompany the fall with an RMS report, neuro checks, then contact the provider and the family. They should also provide a nurse's note. When asked who would send the resident to the hospital, the CNE stated the provider would make the discretion to send a resident to the hospital. The provider is receiving information from the nurse and what the nurse tells the provider would warrant a trip to the hospital. N. On 08/11/20 at 4:12 pm, during an interview with the Unit Manager, when asked to explain what she can recall about R#1, the Unit Manager stated there was a window visit, the grandson called R#1's son. The grandson said he had a fall but that he nicked his ear. His ear was large and purple. His reasoning to take him out of the building was that he wanted to take him somewhere where he would not fall as much. The day he left, he had a gash in his ear, and a laceration on his arm. When asked what should be considered if a resident who was prescribed an anticoagulant had fallen and was later found to have bruising, the Unit Manger stated they would consider sending him out. If he was on blood thinner, they should monitor. Look for more bruising. I would have called to report the bruised ear. O. Record review of a statement from the facility physician states In response to (name of R#1) family's allegations of neglect of patient at (name of facility)- Patient was admitted to (name of hospital) for a fall on 07/06/20 resulting in a right intertrochanteric (bony protrusions on the femur where the muscles of the thigh and hip attach) [MEDICAL CONDITION] which required surgical intervention. Patient has a history of falls at home. He was admitted to (name of LTC facility) on 07/21/20. On 07/22/20 patient sustained a fall out of bed, the bed was in the lowest position and a fall mat was in place. The nurse notified me, the provider at the facility, and I assessed the patient after getting report from the nurse. Patient appeared to be at baseline confusion due to dementia and had no physical signs of the fall, such as scratches, bruising bleeding, ect. I determined that a transfer to the hospital may be more risky to patient's health as I felt he had no indication to go out and given the risk of COVID-19. I again saw the patient on 07/23/20, he was again seen in bed which was at the lowest position with a fall mat in place. Patient again had a fall on 07/25/20 from bed in the lowest position onto the fall mat at 5:10 am. On call provider was notified and determined this fall did not warrant a trip to the hospital due to nursing assessment, which found a small non-bleeding scratch on patient's left upper back. No other injuries were noted. The family of the patient was notified after each fall and on 07/25/2020 they decided to take patient out of the facility to take home against medical advice- they believed that since we would not restrain patient that he was not safe at the facility. After being taken out of the facility, Ombudsman was contacted and informed of the situation, in turn they contacted Adult Protective Services due to concerns for patient safety. It is my opinion that an injury that (name of R#1) has sustained after 07/25/2020 at 1:00 pm (when resident was discharged ) is not the responsibility of (name of facility). P. Record review of the facility policy titled Falls Management, dated 02/18/20, indicates that the purpose of the policy is to reduce risk for falls and minimize the actual occurrence of falls and to address injury and provide care for a fall. Further review of the policy indicates that Practice Standards include the flowing: 1. Identify patient's fall risk by reviewing the Electronic Medical Record Systems and Non-electronic Medical Records Systems. 2. Communicate patient's fall risk status to caregivers. 3. Develop individualized plan of care. 4. Review and revise care plan regularly. 5. If patient falls: 5.1. Follow 'Guidelines for Managing a Fall' if a staff member is present when the fall occurs. 5.2. Utilize the 'Fall Response Protocol ' for both witnessed and unwitnessed falls. 5.2.1 Perform Neurological Evaluation for all unwitnessed falls and witnessed falls with injury to the head or face. 5.3. Document accident/incident: 5.3.1. As a new event in the Risk Management System (RMS) 5.3.2. On a Change of Condition Note 5.3.3. On the 24-Hour Report 5.3.4. Investigation using the Fall Investigation/QA and other appropriate tools in RMS. 5.4. Update care plan to reflect new interventions. 5.5. Conduct interdisciplinary team meeting within 72 hours of fall. 5.6. The Center Executive Director and Center Nurse executive will conduct a post fall review. Q. Record review of the facility policy titled Neurological Evaluation, dated 12/20/19, indicates that the Neurological evaluation will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluation will be performed: every 15 minutes x (for) two hours, then every 30 minutes x (for) two hours, then every 60 minutes x (for) four hours, then every 8 hours until at least 72 hours has lapsed.

Based on record review and interview, the facility failed to ensure that the environment for 3 (R #s 1, 3 and 4) of 5 (R #s 1, 2, 3, 4 and 5) residents reviewed for falls remained as free from accident hazards as possible by failing to identify probable causes of the fall, failing to disseminate safety concerns to staff members, and failing to identify and implement new interventions to prevent future falls. If resident falls are not adequately evaluated and new interventions are not implemented, residents may experience avoidable falls and injuries. The findings are: Findings related to R #1: A. Record review of the Risk Management Summary (RMS) Event Report dated 03/03/16, revealed R #1 was Found on floor in room .resident stated she was trying to get in her wheelchair and slipped on floor. B. Record review of R #1's Care Plan dated 03/13/16, revealed interventions were not updated after R #1's fall on 03/03/16 to include new interventions to prevent future falls and injury. The intervention for using nonskid socks HS (at night) was initiated on 05/10/16, two months after R #1's fall and other interventions were initiated on 09/11/15. C. Record review of Admission Progress Notes dated 05/19/16, indicated R #1 is a high fall risk, with a Fall Risk score of 16.0. D. Record review of the RMS Event Reports revealed the following: 1. On 05/09/16, R #1 fell in her bathroom. Interventions added immediately after fall and care plan updated: non skid socks. Report stated R #1 had on regular socks. R #1 has a history of unsteady gait. 2. On 05/10/16, R #1 fell in room. Interventions added and care plan updated, Orders for UA (urine analysis) C & S (culture and sensitivity) due to increased confusion in last 24 hours, PT/OT (physical therapy/occupational therapy) to evaluate and treat. 3. On 05/24/16, R #1 fell in room, with cut/laceration. Preventative measures: non skid socks, has electric hi-low bed; rolled in her sleep. Interventions added and care plan updated: a mat placed to left side of bed at HS. E. Record review of R #1's Current Care Plan dated 05/27/16, revealed Resident is at risk for falls: Impaired mobility. Interventions are: Medication evaluation as needed and assist resident getting in and out of bed with 2 person assistance. Interventions were created on 05/20/16. R #1 fell on [DATE], 05/10/16, and 05/24/16. Interventions do not include non skid socks, high low bed, and mat to left side of bed. F. On 06/14/16 at 2:50 pm, during interview the Director of Nursing (DON) stated that after R #1's fall on 05/24/16 they put a mat at the side of the bed and put R #1 in a bed that goes down to the floor. The DON stated, I would say she was considered a high fall risk due to the recent hospitalization she just had. Her fall risk is 16, so high risk. The interventions put in place for residents identified as high risk are an electric bed that goes into a low position and non skid socks. Regarding R #'s care plan, the DON confirmed that it was not updated stating, I am not seeing the interventions, I'm seeing the goals were updated. G. On 06/14/16 at 3:35 pm, during interview the Administrator confirmed R #1's care plan was not updated with new interventions. H. On 06/15/16 at 10:07 am, during interview Certified Nursing Assistant (CNA) #1 confirmed R #1 has not had a fall mat in her room. I. On 06/15/16 at 10:25 am, during interview and observation of R #1's room, the DON stated that putting R #1's bed in the lowest position is not care planned, staff pass it on in report. The DON also stated, After a fall we put it (low bed in lowest position) specifically in the care plan. She confirmed after the falls in May, putting the bed in the lowest position should have been care planned. She also confirmed there was not a fall mat in R #1's room. J. On 06/16/16 at 9:57 am, during interview the Director of Rehabilitation Services stated R #1 was not motivated and resistant with therapy. She stated, She (R #1) is not safe to transfer or go to the restroom without assistance, but she thinks she can so she does. Findings for R#3: K. Record review of R #3's medical record History and Physical (H&P) dated 01/19/16 revealed, R #3 was admitted [DATE] from an outside Skilled Nursing facility and her medical history included dementia without behaviors, difficulty walking, muscle weakness, adult failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction, and low cholesterol), moderate protein- calorie malnutrition, and a history of falls. R #3 is unable to stand or walk without assistance and was unable to cooperate with a neurological or psychiatric exam due to her dementia. L. Record review of the Admission Resident Data Set form for R #3 revealed a fall risk assessment score of 16, noting a score of 10 or above indicates risk of falls is high. M. Record review of the Fall Risk Evaluation dated 2016 for R #3 revealed assessment was completed on 1/15/16, 1/27/6, 1/29/16 and 2/5/16 all noted with a fall risk assessment score of 10, noting a score of 10 or above represents HIGH RISK. Note, there was a second sheet attached with the dates of 2/12/16 and 2/19/16 but the assessment was blank and not completed. N. Record review of the Nursing progress notes dated 1/25/16 at 11:00 stated, R #3 Found on floor next to bed/wc (wheel chair). No injury seen. O. Record review of the RMS (risk management system) log revealed no record of an ' Event Summary ' being completed on R #3 for the above incident that had occurred on 1/25/16. P. Record review of the Car Plan for R #3 revealed cares in place addressing R #3s risk for falls due to her impaired mobility, cognitive loss and lack of safety awareness. Reminding R #3 to use her call light was listed as one of the interventions in place. However, this measure may be inappropriate due to mental status and degree of cognitive loss. There was no documentation in the care plan indicating the use of non-skid socks as a preventative measure. Q. Record review of the Resident Data Set Monthly Summary dated 4/2016 revealed a fall risk score of 11 for R #3 indicating a continued high risk for falls to occur. R. Record review of the RMS- Event Summary Report dated 6/12/16 indicated R #3 was in her room sitting in her wheel chair when another resident walking in the hallway saw R #3 on the floor. Per the event summary R #3 had been wearing shoes at time of fall and preventative measure that were in place per report was non skid socks. S. On 6/15/16 at 9:35 am, observed R #3 sitting in a wheel chair in the day area by the nurse's station. R #3 was noted to have no physical restraints in place, no chair alarm, no shoes and no fall preventing non-skid socks. During this observation R #3 was wearing regular cotton socks. T. On 6/15/16 at 2:48 pm, during interview with the DON stated that any resident who is at risk for falls would have an electric bed that goes to a low position and non- skid socks. U. On 6/16/16 at 9:39 am during interview with the Director of Rehabilitation stated, she would expect a resident like R #3 to have shoes and socks on or non skid socks. Director of rehabilitation then stated that R #3 was discharged from PT (physical therapy) in February to restorative care. When asked if it was PT that recommends non skid socks, Director of rehab stated , No, nursing will as well. Findings for R #4: V. Record review of the medical record revealed R #4 was admitted [DATE] and his medical history includes Parkinson's disease, [DIAGNOSES REDACTED](a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications) enlarged prostate with urinary symptoms, dementia, abnormalities of gait and mobility, osteoarthritis of knee and a history of falling. W. Record review of the H&P dated 1/26/16 for R #4 indicated R #4 is not receiving any anticoagulants (Blood thinners) for chronic A-fib because of frequent falls and the associated risk of severe head injury outweighs the risk of suffering from a stroke. X. Record review of the Admission Resident Data Set assessment for R #4 revealed R #4 was assessed as having a fall risk sore of 10 indicating resident is at risk for falls. Y. Record review of the Monthly Resident Data Set records for R #4 revealed; 1. Record dated February 2016 - no fall risk assessment completed. 2. Record dated (not dated) revealed a fall risk score of 15. 3. Record dated April 2016 revealed a fall risk score of 18. Z. Record review of the nursing progress notes date 01/28/16 through 03/01/16 revealed R #4 is confused, is wheel chair bound, though was noted on 02/02/16 to be walking towards facility double doors stating he was going home. R #4 self-propels himself in his wheel chair. On 02/22/16, R #4 was reported as complaining of hip pain and a small scrape was noted on his right temple. There was no possible explanation documented for either change in condition. On 02/23/16 nursing documentation stated R#4 was complaining of sacral (lower back) pain, again with no possible explanation, and was given Tylenol for pain. On 03/01/16, it was documented R #4 was found in the dining room on his knees. AA. Record review of the Incident and Accident IDT (interdiction team) notes dated 03/11/16 stated, R #4 had experienced four falls this review on 03/01/16, twice on 03/07/16 and on 03/09/16. Further review revealed on 03/01/16 R #4 stated he was getting up from his wheel chair and it moved from under him and he fell . On 03/07/16 at 3:20 am it was documented R #4 was calling out for help and was found on floor next to his bed. On 03/07/16 at 1:00 pm R #4 was found on the floor in his room and his wheel chair across the room. On 03/09/16 at 12:45 pm R #4 was found on the floor in the hallway of the 400 unit. Fall was documented as unwitnessed but this information was not included in the notes in regards to the other three falls noted above. BB. Record review of the ADL (Activities of Daily Living) record for R #4 dated February 2016 through May 2016 revealed, R #4 consistently required extensive assistance or total dependence for areas of bed mobility, transfers, toilet use, dressing, locomotion and personal hygiene. CC. Record review of Restorative notes dated April 2016 revealed R #4 was discharged from Restorative services due to R #4's inability to performed mobility tasks per plan and poor concentration. DD. Record review of the RMS Event Summary report for R #4 revealed the following; 1. On 03/01/16 at 5:50 pm: Fall, found on floor with his knees and wheel chair behind him- no injuries found. No interventions initiated. 2. On 03/07/16 at 3:20 am: Fall, found on floor seated beside bed. Resident complained of pain. Interventions put in place -non-skid socks. 3. On 03/07/16 at 1:00 pm: Fall, found on floor next to residents ' room. Wheel chair across the room. No interventions initiated. 4. On 03/09/16 at 12:45 pm: Fall, found on floor in 400 unit hallway with no injuries reported. No further interventions noted. 5. On 4/7/16 at 5:00 PM: Fall, found on floor in dining room with wheel chair next to him. No injuries seen. No further interventions noted. 6. On 4/10/16 at 1:45 pm: Fall, found on floor in room near bed. No injuries. No further interventions in place. 7. On 5/22/16 at 5:00 pm: resident got up in dining room, tried to walk then to sit and missed chair. Another resident slowed is fall to the floor. Immediate interventions and plan; anti-roll back brakes to wheel chair. EE. Record review of the Care Plan for R #4 dated 05/23/16 revealed anti-roll back brakes to wheel chair initiated on 05/26/16. There was no intervention stating the use of anti-skid socks as stated above as being initiated on 03/07/16. FF. On 06/15/16 at 1:17 pm, observed R #4 in his room in bed sleeping with bed low to floor and call bell was hanging off side of bed and out of reach. Also noted R #4 was wearing regular cotton socks on and no indications of non-skid socks in residents room or at bedside. GG. On 06/15/16 at 2:35 pm, observed R #4 attempting to get out of bed on his own with half his body hanging off bed. Call bell was still hanging off side of bed. When asked resident to use call light he just looked around but could not locate it. This surveyor called for help and CNA (Certified Nurse Aide) #2 (activities assistant) came to assist R #4. CNA #2 then confirmed R #4's wheelchair did not have an anti-roll back device on it. HH. On 06/16/16 at 9:52 am, Observed R #4 in his room awake watching TV, his wheel chair by the foot of his bed. There were still no anti-roll back device attached to his chair as stated was initiated on 05/22/16 on the event investigation and on the care plan dated 5/26/16. II. Record review of Care Plan Policy dated 01/02/14, indicated The care plan will include measurable objectives to meet patient needs and goals as identified by the assessment process. The comprehensive care plan is: reviewed and revised a minimum of quarterly and as needed to reflect response to care and changing needs and goals. The care plan must be customized to each individual patient's needs. JJ. Record review of Falls Care Delivery Process dated 06/01/13, revealed the following: 1. Identify patients with scores of 12 and above as high risk for falls, 2. Develop a plan of care including general and specific interventions to reduce fall risk, 3. Implement immediate interventions after the fall, 4. Update care plan with new interventions as appropriate, 5. Re-evaluate the care plan regularly for appropriate falls risk interventions, 6. Update care plan 1-7 days after fall. KK. Record review of Falls Management Policy dated 03/15/16, revealed Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause.

Based on interview and record review, the facility failed to provide in a timely manner, or obtain from an outside resource, emergency dental services to meet the needs of one (#40) of four (#s 12, 40, 55 and 122) sampled resident. This deficient practice likely resulted in a decreased quality of life for the resident during two months of living with dental pain. The findings are: A. During an interview with Resident #40 on 07/08/14 at 10:28 am he stated, "I have a toothache. I've been telling them about 3 months about my toothache. I haven't seen a dentist. They said they were going to have people come down to work on my teeth, but I've never seen anyone walk in. My teeth kill me all day and all night. I have to put Oragel on my teeth, but it dries out my mouth." B. Physician's Telephone Orders for Resident #40 reviewed. An order dated 05/18/14 states, "Urgent dental pain left lower mouth." C. Resident #40's medical record reviewed. Notation dated 06/05/14 stated, " Appt with (name of dental clinic) scheduled 07/21/14 at 9:40 am." The signature on this notation was illegible. D. During an interview with the Director of Nursing on 07/14/14 at 4:00 pm, he was asked about the two month time lapse between the, "Urgent" dental order and the scheduled appointment. He stated, "That is a long wait." When asked about the process for acquiring dental services, he stated, "It would go through Social Services or through our driver, who helps set up appointments too. Normally we would go back and ask the resident if that would be okay. Worse comes to worse, we could send him to an ER."

Based on record review and interview, the facility failed to notify 1 (R #99) of 1 resident's family member when the resident's psychoactive medication was discontinued and restarted. This failed practice resulted in a significant change in the resident's mental condition in which the resident began seeing imaginary things and was hallucinating. The family member was not made aware until one month later. The facility also failed to notify 1 (R #63) of 1 resident's family members and physician of medication changes, falls, and skin condition changes. The Resident Census and Condition Report received from the Director of Nursing (DON) identified 4 residents with skin rashes, and 7 residents receiving antibiotics. This failed practice resulted in a significant change in the resident's physical condition in which the family member was not aware. The findings are: A. Record review and interviews for R #99 revealed the following: 1. Medical Record review indicated: a. "Face Sheet" (not dated) indicated, [DIAGNOSES REDACTED]. b. "Physicians Order" dated 12/01/10 indicated: [MEDICATION NAME] (an antipsychotic medication) 100 mg (milligrams) amp ([MEDICATION NAME]) IM (Intramuscular) q (every) 3 weeks on Mondays for Visual Hallucinations. c. "Physicians Order" dated 03/ /12 (date unclear) indicated: Discontinue [MEDICATION NAME]. d. "Physicians Order" dated 03/27/12 indicated: "Please renew [MEDICATION NAME] Deconate. Continue current dose due to [DIAGNOSES REDACTED]. e. "Physicians Order" dated 06/26/12 indicated: "Renew order for [MEDICATION NAME] Deconate as currently ordered, continue current dose due to [DIAGNOSES REDACTED]. 2. Interviews indicated: a. On 08/15/12 at 2:40 pm, family member #4 stated, regarding R #99, "They didn't even tell me that they were taking her off of it ([MEDICATION NAME]). I found out about a month later when her behaviors changed. She was acting really weird and going crazy. She started having hallucinations all over again." b. On 8/15/12 at 3:10 pm, Staff #3 Licensed Practical Nurse (LPN) stated, "The family should be notified whenever there is a change in the resident's condition. After reviewing the medical record. There was no documentation to indicate that the resident's daughter was notified when the [MEDICATION NAME] was discontinued and restarted." B. Record review and interviews for R #63 revealed the following: 1. Medical Record review indicated: a. "Face Sheet" dated 05/04/12 indicated [DIAGNOSES REDACTED]. b. "Nurses Notes" dated 10/01/11 indicated, "Currently being followed for Upper Respiratory Infection with antibiotics in place." c. No documentation that the family had been notified of Upper Respiratory Infection or antibiotic treatment. d. "Nurses Notes" dated 11/29/11 indicated, "Patient has slight rash on left side." e. "Physician Telephone Order" dated 11/30/11 indicated, "Left lateral (pertaining to the side) abdomen rash. New order to apply Lotriasone cream twice a day time 3 weeks for rash." f. No documentation that the family was notified of the rash or medication order. g. "Nurses Notes" dated 01/27/12 indicated, "Resident found on floor." h. No documentation that the family or physician was notified. i. "Nurses Notes" dated 04/14/12 indicated, "Resident's daughter noticed that resident had rash on shoulders and back." j. No documentation that the family was notified of skin condition prior to 04/14/12. k. "Nurses Notes" dated 04/15/12 indicated, "New order for [MEDICATION NAME] for rash." l. No documentation that the family was notified of [MEDICATION NAME] order. 2. Interviews identified: a. On 08/07/12 10:23 am, family member #5 stated, regarding R #63, "I am the person who would be notified of changes. There have been changes to my mom's care that I was not notified of such as, a rash and some other skin issue. When I notice changes, I go and ask the staff why didn't you tell us?" b. On 08/13/12 at 8:43 am, the DON stated, "Notification of changes should be documented in the nurses notes."

Based on record review and interview the facility failed to implement the written policies and procedures for Investigating allegations of abuse and neglect, Protection of residents from abuse and neglect, Reporting requirements, as well as Prevention of abuse and neglect. This deficient practice presents a risk of alleged abuse not being investigated and reported to the state agency. This failed practice of not investigating and reporting allegations of abuse and neglect had the potential to cause harm to 99 residents identified on the Census List provided by the DON on 08/06/12. The findings are: A. Review of the facility's "Abuse Prevention Policy" dated 08/31/2007 indicated: 1. "It is the policy...to maintain the resident's right to be free from verbal, sexual, physical and mental abuse, involuntary seclusion, and neglect..." 2. "The center shall take the following steps to prevent, detect, and report allegations of abuse, and neglect." 3. Prevention: "Encouraging reporting of concerns without fear of retribution. Analysis of physical environment that may make abuse or neglect more likely to occur...Supervision of staff to identify inappropriate behaviors such as using derogatory language, rough handling...Assessment, care planning, and monitoring of residents with needs and behaviors which may lead to conflict, residents who have aggressive behaviors such as entering residents' rooms, and self-injurious behaviors." 4. Identification: "Intervention in situation in which abuse, neglect...is more likely to occur." 5. Investigation: "The Administrator is responsible for coordinating and completing the investigation...Investigation to include...reporting of results to the proper authorities...The Investigation will include witness statements..." 6. Protection: "Protection of residents...Separation of resident alleged to be a perpetrator from other residents who may be at risk...Additional supervision of residents found to be perpetrators of abuse..." 7. Reporting: "Alleged violations...will be reported to the State Agency immediately...The results of investigations will be reported to officials...within five working days of the incident." B. Review of the facility's "Incident/Accident Management Policy and Procedure" revised 10/01/10 indicated: 1. "It is the policy... to investigate incidents and report them as required by law." 2. "To ensure the safety of our residents...To meet the requirements...that incidents are investigated, documented and reported..." 3. Investigation: "The Administrator will ...determine the cause of the incident...and take corrective action...to eliminate any on-going dangers to the resident...The Administrator/designee is responsible for submitting written investigation within 5 days...Appropriate steps will be taken to prevent reoccurrence of the incident." C. Review of the "Incident/Accident Log" for the past six months (March 2012-August 2012) revealed the following incidents of abuse that were either not reported to the State agency or did not have evidence of a thorough investigation conducted within five working days of the incident: 1. "Incident Report" dated 02/02/12 indicated, "Resident (identified as R #98) became upset and started to use a loud voice and foul language towards resident (identified as R #14). (Name of R #98) reached and grabbed (name of R #14's) collar and began to shake him violently while was still in his wheelchair." A "Follow up Investigation" conducted by the Director of Nursing (DON) dated 02/13/12 indicated it was not submitted to the State Survey Agency until 11 days after the incident between R #98 and R #14 occurred. 2. "Incident Report of resident to resident abuse" dated 06/15/12 indicated R #95 propelled his wheelchair behind R #127 and slapped R #127 in the head. R #95 said, "This is for hitting me this morning." The five day follow-up investigation dated 06/22/12 was not sent to the State Survey Agency. 3. "Incident Report of resident to resident abuse" dated 06/15/12 indicated R #95 rammed his wheelchair into R #7. R #7 then slapped R #95. There was no initial Incident report completed. The five day follow up investigation dated 06/22/12 was not sent to the State Survey Agency. 4. "Incident Report of resident to resident abuse" dated 06/15/12 indicated R #95 took a drink belonging to R #127. R #127 hit R #95 in the face. The five day follow up investigation dated 06/22/12 was not submitted to the State Survey Agency. 5. "Incident Report of resident to resident abuse" dated 08/03/12 indicated R #95 struck R #25 between the shoulder blades on her back." The five day follow up investigation was not completed and faxed to the State Survey Agency until 08/14/12 (11 days after the incident occurred). D. On 08/14/12 at 10:30 am, the DON stated, "I don't know where the two missing DHI reports are. I don't have proof that they were done." E. On 08/14/12 at 10:35 am, the Administrator stated, referring to the incident on 08/03/12 between R #95 and R #25 "I have not completed the five day investigation." F. On 08/14/12 at 11:00 am, the Administrator stated, "If there is a resident to resident altercation, then (name of the DON) is responsible for the five day follow up investigation to be submitted within five working days of the allegation. It was recently identified that there were issues with the five day follow up investigations not being done and being submitted to the Department of Health. The five day follow up is completed by me, unless it is resident to resident abuse, then the DON does it. The follow-up needs to be completed in five working days." G. On 08/14/12 at 11:30 am, the DON stated that she was aware there was no copy or documentation to prove the five day follow up investigations were submitted to the State Survey Agency. H. On 08/15/12 at 3:45 pm, the DON stated, With the incident that occurred between (name of R #14 and R #98) on 02/03/12, "Unfortunately at the time our Assistant Director of Nursing (ADON) did not get it done so yes, I realize this follow up investigation was really late."

The facility failed to ensure the wanderguard system was properly functioning to alert staff of residents exiting the facility into the smoking and back patio areas which had open gates with direct unsecured access leading to a ditch and a busy street. A non-functioning door bell on the door leading from the main dining room to the smoking area, and key pad on the door in the small dining room which did not have a code posted for resident use, resulted in residents not being able to re-enter the facility from the back smoking area/patio area and small dining room. This resulted in an Immediate Jeopardy to the residents safety. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 08/07/12 at 7:51 pm. The facility took corrective action by providing a plan of removal on 08/07/12. Based on documentation provided on the plan of removal, actions taken by the facility were: 1. Head count of all residents completed and all are accounted for. 2. Staff members have been posted at Solarium exit off the Restorative dining room and back porch exit off the main dining room immediately to prevent unaccompanied residents from being in these areas. 3. Staff members will continue to be scheduled and posted at these two exits 24 hours/day until patios can be secured for resident use. 4. All gates on outside fence have been secured with combination locks. The combination to locks has been posted on locks in case of emergency. 5. Staff currently present in center will be in-serviced on: a. Closure of Solarium patio off the Restorative dining room for resident use at this time. b. Residents who use the back patio off the main dining room will need to be accompanied by a staff member until area is secure. c. Implementation of gate locks on outside fencing for safety of residents. Staff members will be advised that combination to locks is posted on gate locks. d. Staff members will be educated on changes to fire safety plan that requires assigned staff member to unlock gates in event of a fire or other emergency requiring evacuation. Door monitors will be responsible for disengaging gate locks when required. 6. Staff members will be in-serviced on the above prior to the start of their shift. 7. Securement of the two patio areas will be attained with 6 foot fencing that will be installed. Once areas are secured, key pads will be discontinued and areas will be open for resident use. 8. Mag locks will also be installed for fencing gates that will automatically disengage with fire alarm. The Immediate Jeopardy was lifted on 08/07/12 at 9:35 pm. This resulted in the scope and severity of the deficiency being lowered to a Level 2, Scope E. While the Immediate Jeopardy was removed on 08/07/12, the facility remained out of compliance at the lower severity level. Based on observations, record review and interviews, the facility failed to ensure resident safety for 4 (R #'s 95, 107, 117, and 127) of 4 residents for the following reasons: 1. The wanderguard system was not functioning properly to alert staff of residents exiting the facility into the smoking and back patio areas which had open gates with direct unsecured access leading to a ditch and nearby busy street. 2. Residents were able to wander out of the facility into the parking lot near a busy street. 3. Residents were not able to re-enter the facility from the back smoking area/patio area and small dining room. This deficient practice had the potential to cause harm to 99 residents identified on the "Resident Nurses Report Sheet" provided by the Assistant Director of Nursing (ADON) on 08/08/12, by causing the residents to be locked outside for long periods of time near a busy street and a ditch. The findings are: A. Review of the "Resident Nurses Report Sheet" identified the census was 99. There were 18 residents identified with Dementia, 19 residents identified with Dementia with Behaviors, 9 residents identified with Alzheimer's, 8 residents identified with Traumatic Brain Injury, 2 residents identified with Intracranial Injury, 1 resident identified with Mild Mental Retardation, 5 residents identified with Mental disorder, 1 resident identified with Anoxic (pertaining to or caused by a general lack of oxygen) Brain Damage, 1 resident identified with Bipolar/Dementia, 1 resident identified with Intellect Disability, 1 resident with Metastatic Brain Cancer and 33 Cognitively intact residents. B. Review of the "Elopement Policy and Procedure" revised 05/09/08 indicated: 1. "It is the policy of this facility to protect residents from wandering away from the facility..." 2. "Elopement, is defined as that situation where a resident with impaired decision making ability who is obviously unaware of his/her own safety needs and therefore at risk for injury outside the confines of the facility has left the facility without knowledge of staff." 3. "The resident will be assessed for risk of elopement upon admission. Residents on the secured unit will be deemed at risk for elopement." C. Observations and interviews for R #117 revealed the following: 1. On 08/07/12 observations identified: a. At 2:54 pm, R #117 walked out the main dining room door leading to an outside smoking area. He then lifted the handle of a outer perimeter gate that leads directly to a nearby street and exited the gate. As he exited, he walked pass two unidentified staff members, who didn't acknowledge the resident. He proceeded to walk towards a small bench located near the street with heavy traffic. b. At 2:54 pm, one of the two unidentified staff stated, "Oh yeah, he (referring to R #117) does this all the time." The two unidentified staff members did not attempt to redirect the resident back into the enclosed gated area. 2. Interview indicated: a. On 08/07/12 at 2:55 pm R #117 stated, "I just lift the handle and walk right out. I know the code to get outside. I come out here all the time. I have the run of the mill around here." D. On 08/07/12 at 4:00 pm, observations were made of the entire outer perimeter gates of the facility. Outside the small dining room there was an unlocked gate. Immediately outside the gate was a large ditch. There was a small key pad on the outside of the exit door in the small dining room but there was no code posted to get back into the building. There was another unlocked gate near the smoking area/outside patio (located off the main dining room) which lead directly towards a nearby street with heavy traffic. On the outside was a bell to ring for staff to let residents back into the building but the bell was not functioning. All gates of the outer perimeter of the facility were easily accessible and it was easy lift the handle and walk through. E. On 08/07/12 at 5:45 pm, the Administrator stated, "The codes are posted on top of the key pads." F. On 08/07/12 at 6:35 pm, observation of the exit door leading outside from the main dining room to the smoking area revealed the bell located on the outer wall to ring for assistance was still not working and there was no code posted for the key pad. If a resident did not know the code they could not re-enter the building. Also there was no way to alert staff that someone was locked out and could not re-enter the building because the door bell was not working. G. Interview, observation and record review for R #107 revealed the following: 1. On 08/07/12 at 6:30 pm, family member #1 stated, regarding R #107, "My biggest concern is when she (referring to R #107) was admitted to the facility they never explained to me anything about an elopement risk. She would not know how to use to door key pad code to get out of the building or back in even if she wanted to because she is confused. When I try to leave at the front entrance, she does try to follow me. I know of an incident where my mom got out of the building by herself. I did witness a resident last Saturday who was by himself in the back outside smoking patio area around 3:00 pm, in the afternoon. He could not get back into the building. It was so hot outside and he looked so flushed. He was outside by himself and could not get back into the building. When I asked him what are you doing out here he said 'I can't get back in the building. The bell is not working.' He did not know the code to get back into the building and the bell to ring for someone to let him in was not working." 2. Observations identified: a. On 08/13/12 at 7:00 am, the resident (R #107) was seen walking around the facility. She was first seen in the large dining room then began to wander down the halls. There was no staff re-direction at this time. b. 08/14/12 at 7:15 am, the resident was again seen wandering around the facility by herself. She was also noted to have a wanderguard in place. c. On 08/14/12 at 7:38 am, the resident was again seen walking towards the outside door leading to the smoking area/back patio by herself. There was no staff re-direction at this time. d. On 08/16/12 at 6:45 am, the resident was seen walking down 200 hall, towards the main dining room. 3. Medical Record review identified: a. "Face Sheet" dated 05/04/12 indicated, [DIAGNOSES REDACTED]. b. "History and Physical Form" dated 04/24/12 indicated, "Suffering from End Stage Dementia." 3. "Physician Order" dated 05/08/12 indicated, "Wanderguard due to decreased safety awareness and increased risk for elopement." 4. "Long Term Care admission orders Resident does not have decisional capacity." 5. "Physical Restraint/Device Assessment" dated 05/08/12 indicated, "Wanders, and paces. At risk for elopement. Pt. (patient) has dementia with behaviors. Paces non-stop. Unaware of surroundings. Enters any open door. No safety awareness noted." 6. "Elopement Risk Assessment" dated 04/22/12 indicated, the resident is at risk for elopement. 7. "Comprehensive Care Plan" dated 04/27/12 indicated, "At times will exit seek looking for family. Wanderer/elopement risk evidenced by wanders, leaves unit, verbalized intent of going home, looking for her mother." H. Review of the "Alleged Incident/Accident Report" dated 05/09/12, indicated, (name of R #107) "Followed another family member through the double doors on to the parking lot after removing her wanderguard. Condition prior to incident was confused...location was to an outside parking lot. She stood by the locked door and when the visitor opened the door she followed him to the parking lot." I. On 08/09/12 at 2:45 pm, the Admissions Director stated, "Residents and families are only informed of the security code verbally, prior to admission. All residents must have a code to enter and exit the facility." J. On 08/09/12 at 3:05 pm, the Administrator stated, "Prior to a resident being admitted , our admissions person talks with the families and lets them know there will be a code to get in and out. The only area that the wanderguards will alert is in the front area. As far as the back patio leading to the smokers and the small dining room, there is no wanderguard system." K. Record review, observations and interviews of R #95 revealed the following: 1. "Incident/Accident Report" dated 07/26/12 indicated, "Nurse found (name of R #95) in the back parking lot. Resident found exit door ajar as an independent smoker was going outside. Continued through door onto patio, into parking area." 2. Observations identified: a. On 08/08/12 at 10:30 am, the resident was rolling himself down the 200 hallway telling the staff, "I want to go out." He was then seen rolling himself backwards in his wheelchair down the hallway to the main dining room by the exit door leading to the outside smoking area. There was no staff re-direction at this time. b. On 08/08/12 at 10:40 am, he was seen wheeling himself to the nurses station again saying, "I want to go outside." He was also telling the staff, "No I don't want to wait." 3. Medical Record review indicated: a. "Face Sheet" dated 05/27/12 indicated, admitting [DIAGNOSES REDACTED]. b. "Resident Transfer Form" (no date) (from the previous facility) indicated, "Resident observed to be exiting building. States, "I'm doing this so I can be thrown out of here." c. "Physical Restraint Assessment" dated 07/26/12 indicated, "History of Elopement, wanderguard placed on wheelchair (w/c) due to decreased safety awareness. d. " Incident/Accident Interdisciplinary (IDT) Notes" indicated, "On 07/26/12 (name of R #95) found the exit door in main dining room to be ajar when following a independent smoker towards the door. He pushed the door open, went through the patio, opened the outside gate and exited to the parking area. e. "Licensed Nurses Notes" dated, 07/26/12 indicated, "Resident was found in the back parking lot with out any supervision of any employee." f. "Elopement Care Plan" dated 07/26/12 indicated, "Resident is a wanderer as evidenced by verbalizing his intent to leave the building/facility. Wanders and leaves the unit. Memory Impairment, Impaired cognition, poor judgement." g. "Elopement Risk Assessment" dated 05/24/12 indicated, "Resident exhibits anxious behavior, wandering with no purpose, watches others go out, and history of elopement attempts." It also identified the resident at risk for Elopement. 4. Interview identified: a. On 08/09/12 at 12:55 pm, Staff #3 Licensed Practical Nurse (LPN) stated, "He thought he could just go outside by himself. I've seen him attempt to go outside when the smokers are outside. He would just wait and then rush through the door and head outside. If he had his mind set on something you were not going to change it. We never had a 24-hour person right there with him. I did find him out in the parking lot that leads directly to the street. I went to take trash out and there he was. He was by himself at that time. I didn't see anyone else out there with him. In order to get out to that area, you have to go through the exit door to the smoking area, then lift the handle to the gait. At that time, the gait was open." L. Interview and record review of R #127 revealed the following: 1. Interview identified: a. On 08/10/12 at 1:35 pm, family member #2 stated regarding R #127, "Initially I would have expected this place to be safe for my dad. We were told by staff (don't remember who) there was a code to keep patients in. If you need to come and go you have to enter the code on the key pad. He (referring to R #127) would not know the code to get in or out of the building. People come and go in and out of this place. He does have a wanderguard and even then, he went outside several times right out the front entrance. He would be able to follow anyone leaving the building and walk right out. Initially when he was admitted here to the facility we were told this was a locked unit because of the code that you have to punch in. When we placed him here, we felt it was a safe environment. We were told it was a locked unit with a key pad so he couldn't get out. There is no security here to keep the patients safe with Alzheimer's. People can just come and just go." 2. Medical Record review indicated: a. "Face Sheet" dated 06/01/12 indicated, admitting [DIAGNOSES REDACTED]. b. "Physician Telephone Orders" dated 06/07/12 indicated, "Wanderguard placement related to Elopement Risk." c. "Long Term Care admission orders Resident does not have decisional capacity." d. "Elopement Comprehensive Care Plan" (no date indicated) indicated "Resident wanders. Memory Impairment and Impaired cognition." e. "Elopement Risk Assessment" dated 08/05/12 indicated, "Resident is disoriented/confused. Oblivious to needs or safety, exhibits searching behavior, or looking for exit doors, watching others go out, wanting to leave the facility, and history of elopement attempts. Resident is at risk for Elopement." M. Interview and record review for R #68 revealed the following: 1. Interview identified: a. On 08/13/12 at 1:15 pm R #68 stated, "I don't like staying in the building. I like to go outside to get air whenever I want to. I feel like I am in a prison here. Because the door is always locked, I can't get outside because of my condition (quadriplegia). It doesn't matter that I know the door code, because I am physically unable to operate the key pad to open the door. I have to wait for someone to unlock the door so I can get out. Sometimes when I tell the nurses I want out, they will just ignore me." 2. Medical Record review indicated: a. Admitting [DIAGNOSES REDACTED]. b. "History and Physical" dated 06/12/12 indicated, R #68 has Quadriplegia (paralysis of all four extremities and trunk) and fracture of the cervical spine. c. "Social Work Progress Notes" dated 07/17/12 indicated, "Resident is alert and oriented to person, place, time and situation. Resident is also able to make needs known." N. On 08/14/12 at 7:45 am, Staff #5 Certified Nursing Assistant (CNA) stated, "The only place I'm aware of that the wanderguards work is at the front entrance. I'm required to check the wanderguard system to make sure it's working properly, but there are no other exits with a wanderguard system that works. I don't think the wanderguard system works for the back patio smoking area." O. On 08/15/12 at 8:25 am, the Human Resource/Payroll Manager stated, "With (name of R #107), I saw her outside in the front parking lot. She was wandering outside. I'm not sure how she got outside of the building." P. On 08/15/12 at 2:05 pm, Staff #6 Certified Medication Aide (CMA) stated, "I remember the day she (R #107) got out into the front parking lot. I had seen her walking out in the front parking lot. I do know that she is exit seeking a lot and sometimes she does not do good with redirection."

The facility failed to ensure that residents (both cognitive and cognitively impaired) were free from physical and verbal abuse such as hitting, kicking, yelling, punching, slapping, and being run over by a resident in a wheelchair with a known history of physical and verbal abuse. The facility also failed to protect residents from being physically and verbally abused on an ongoing basis. This resulted in Immediate Jeopardy to the resident's safety. This deficient practice had the potential to affect all 99 residents. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 08/08/12 at 6:15 pm. The facility took corrective action by providing a plan of removal on 08/08/12. Based on documentation provided in the plan of removal, actions taken by the facility were: 1. (Name of resident R #95) was placed on one-on-one observation and removed from dining room for meals. 2. Incident/Accident logs for the past 6 months were reviewed to identify other residents who also have demonstrated repeated behaviors that are dangerous to others. Another resident, identified was (name of resident R #127). No other residents were identified as displaying repeated behaviors that were dangerous to others. 3. (Name of resident R #127) was placed on one-on-one observation. 4. Medical Director (MD) notified by the DON that despite the interventions in place, the above residents continue to be a risk to the safety of others in the center and requested assistance in obtaining immediate alternate placement. a. Medical Director gave verbal orders to transport (name of resident R #95) to (Name of facility) Behavorial Health emergency room (ER) for evaluation and alternate placement related to (r/t) danger to self and others. Instructions sent to call (Name of Doctor) upon arrival in ER for further details. b. Medical Director gave verbal orders to transport (name of resident R #127) to (Name of Facility) Behavorial ER for evaluation and alternate placement related to (r/t) danger to self and others. Instructions sent to call (Name of Doctor) upon arrival in ER for further details. 5. Transfers of both residents will be completed per MD order, responsible parties have been notified and both residents will remain on one-on-one observation until transfers are completed. 6. (Name of Doctor) states he will be working with the physicians at these two hospitals to find alternate placement for both residents and they will not be returned to center. The Immediate Jeopardy was lifted on 08/08/12 at 8:15 pm. This resulted in the scope and severity of the deficiency being lowered to a Level 3, Scope H. While the Immediate Jeopardy was removed on 08/08/12, the facility remained out of compliance at the lower severity level. Based on observation, record review and interviews the facility failed to ensure that 9 (R #s 7, 11, 25, 29, 45, 68, 79, 92, and 172) of 9 residents were free from physical, and verbal abuse such as hitting, kicking, yelling, punching, slapping, and being run over by 2 (R #s 95 and 127) of 2 residents in wheelchairs with a known history of physical and verbal abuse. This failed practice was likely to have caused injury to all 99 residents identified on the Census List provided by the DON on 08/06/12. The findings are: A. Observations, record review and interviews for R #95 revealed the following: 1. On 08/08/12 observations identified: a. At 9:35 am, the resident was seen running into another resident who uses a wheelchair (R #11) with his wheelchair (w/c). b. At 10:30 am, the resident wheeled himself out of the activity room backwards into the hallway without looking behind him. c. At 10:40 am, he was seen wheeling himself to the nurses station demanding to go outside. He seemed upset when the staff told him he needed to wait 15 minutes and stated in an angry tone, "I don't want to wait 15 minutes." d. At 10:45 am, as the resident wheeled himself away from the nurses station, a female resident (R #25) was seated in her w/c near the nurses station. R #95 wheeled himself towards R #25 and grabbed the left wheel of R #25's wheelchair and forcibly pushed her w/c forward. e. At 10:50 am, R #95 was observed going backwards in his w/c towards the dining room. He barely missed hitting residents with his wheelchair. The resident did not look behind him. 2. Medical Record review indicated: a. "Face Sheet" dated 05/27/12 identified [DIAGNOSES REDACTED]. b. "Diagnostic Interview & Behavioral Treatment Plan" dated 04/30/12 (from the previous facility) indicated, "Poor anger and impulse control. Aggressive behaviors, yelling, shouting and unable to calm self. Increased agitation. Presents as very angry and agitated c/o (complains of) other residents. Verbally aggressive towards staff and other residents. Resorts to yelling and lashing out." c. "Progress Notes" dated 05/07/12 (from previous facility) indicated, "Resident up in w/c propelling self through hall and he spanked the bottom of the housekeeping staff. When the resident was asked (about the incident) he said "Yeah I smacked her ass 'cause it's big." d. "Progress Notes" dated 05/14/12 (from previous facility) indicated, "Resident observed to be exiting building. States, 'I'm doing this so I can be thrown out of here.'" e. "Emergency Mental Health Evaluation for Psychiatric hospitalization " dated 05/07/12 (from previous facility) indicated, "Physical aggression towards staff and other residents. Throws objects at staff and other residents. Verbal aggression continues when around others and when by himself. Has caused physical injury to another resident. Mental Status has increased/agitated. Attitude is hostile. Mood is irritable, and angry." f. "physician progress notes [REDACTED]. (patient) seen for evaluation of increased behaviors. Pt. with agitation. Today seen self propelling self very quickly and wandering." g. "Physical Restraint/Device Assessment" dated 07/26/12 indicated, "Behavior patterns: Curses, hits, and is sexually inappropriate. Pt. propels self without regards for safety." h. "Psychological Examination" dated 05/07/12 indicated, "He has a known history of physical and verbal aggression to staff and other residents and has caused physical injuries to other residents. He requires constant redirection regarding inappropriate contact (i.e. "grabbing the buttocks of female staff") and deliberate crashing into other residents then awaiting their response. He has almost constant outbursts of vulgarity and profanity towards other residents. He waits for a larger group and then begins the disruptions." 3. "Incident/Accident Interdisciplinary (IDT) Notes" identified: a. On 05/30/12, "This resident punched another resident in the left cheek." b. On 06/07/12, "He continues with both verbal and physically aggressive behaviors and intimidation techniques, towards staff and residents, that require constant redirection." c. On 06/11/12, "This resident, without provocation, rolled his wheelchair into the dining area and struck resident R #127. He (R #95) was not able to be redirected from behaviors being repeated." d. On 06/15/12, "Resident ran into the back of another resident's chair, (R #7) angering that resident. e. On 06/15/12, "Resident slapped another resident (R #127) in the face. He continues to be erratic with disregard of resident safety in wheelchair." f. On 06/28/12, "Occasional verbal outbursts towards residents." g. On 07/05/12, "Continues with verbal outbursts. Continues to require constant redirection and displays inappropriate verbal outbursts." h. On 07/27/12, "Bumped into the w/c of another resident." i. On 08/03/12, "This morning (name of R #95) approached female resident (identified as R #25) from behind and punched her in the back." j. On 08/08/12, "Was rapidly propelling w/c through common area and bumped into another resident." 4. "Resident Council Meeting minutes" dated 07/31/12 indicated that residents (identified as R #11, 29, 79 and 92) complain that (name of R #95) runs into them with his wheelchair. "Residents fear he will injure someone someday." 5. "Concern/Grievance Report" dated 08/01/12 indicated that R #172 complained to the DON that R #95 grabbed his wife. "Resident and spouse demanded that police be called and criminal charges be filed." 6. Interviews indicated: a. On 08/07/12 at 11:50 am, R #79 stated, (name of R #95) hit (name of R #25) in the back. "He doesn't even let you use the phone. He bumps into residents with his wheelchair and he goes around backwards. He pokes people that go into the family room, like me. I was trying to get ahold of my son and he wouldn't let me use the phone. He kept hitting me on the back of my head with his hand. He was telling me I couldn't use the phone." b. On 08/07/12 at 2:15 pm, R #172 stated that R #95 is a problem. "He sexually assaulted my wife twice, about 2 weeks ago then again after he was reported. We made a report with the social worker. He shouldn't be here. He's done it to other females, too." c. On 08/08/12 at 9:40 am, R #11 stated "He (name of R #95) is always running his wheelchair into everyone. He just ran into me again and it hurt. He has done this many times. Somebody is going to get hurt." d. On 08/08/12 at 10:40 am, Staff #1 Certified Nursing Assistant (CNA) stated regarding R #95, "We try to re-direct him. Sometimes he cooperates and sometimes he just doesn't. He is very set in his ways. He tells us "No" a lot, when we want him to do things. He does bump into other residents a lot and says things like 'Oh well it didn't matter.' Sometimes he will say bad words when he is impatient with us and to the other residents." e. On 08/08/12 at 10:45 am, Staff #2 (CNA) stated, "He (R #95) always goes real fast in his w/c. It's really bad. He runs into other residents all the time. We just can't control him." f. On 08/08/12 at 11:30 am, R #25 stated, "(name of R #95) came and hit me in the back by the nurses station. The nurse knew because she saw him hit me. I guess 'cause he didn't like me. I was just sitting at the nurses station and he hit me really hard in the back. I'm afraid of (name of R #95 and R #127). Those two don't belong here. The staff don't do anything. (Name of R #95) runs right into you with his wheelchair. I'm just sitting around and here he comes and hits me with his chair. Nobody ever checked my back when he hit me. No one came and asked me if I was ok. (Name of the Administrator) told me not to speak to you (Surveyors). She told me she could have me transferred out of here because I complained. It makes me feel so depressed. I'm afraid to tell anybody because you get in trouble for it. Please don't tell her (Administrator) because she will jump all over me. I talk to the staff but it doesn't do any good. No one does anything." g. On 08/08/12 at 11:30 am, R #68 stated, "He runs into me all the time. I told the staff, but he still does it. He runs into everybody." h. On 08/08/12 at 3:20 pm, Staff #3 Licensed Practical Nurse (LPN) stated, "(name of R #95) has what is known as an impulsive disorder. He acts impulsively. He has ran his wheelchair into several residents. We try to keep him engaged in activities but that hasn't worked. He has struck other residents in the past. His behavior has always been this way." i. On 08/08/12 at 3:30 pm, the Activities Director stated, "His attention span in activities is about 10 to 15 minutes. At a birthday party, he came up behind another resident and slapped him in the head." j. On 08/08/12 at 3:45 pm, R #172's wife stated, "I've had several incidents with (Name of resident #95). The first time, I was sitting in the solarium. He entered the room and grabbed my pelvic bone. I yelled at him to get his hands off me. He said to me 'Bad hands good fingers.' I was really upset. I told the Activity Assistant and she told me to tell the nurse. I told the nurse. Nothing was done. (Name of Social Services Director) called me and apologized. She said they would keep him busy but he takes off on them." Then on Wednesday evening last week (08/01/12), I was standing at the nurses station when (Name of husband R #172) said 'Watch out.' All of a sudden (Name of R #95) was right on me. He put his hands on my waist and I yelled at him to get his hands off me. I told the DON what happened. My husband said to her (referring to DON) 'You need to keep him away from my wife.' (Name of DON) said 'That's not an assault.' I said, It is too. I did not give him permission to touch my body. I was really upset. My husband told him (referring to R #95) 'You better keep your hands off my wife.'" On Tuesday about a week ago (07/31/12), (Name of husband R #172) and I were in the solarium for communion service when (Name of R #95) came in and ran into a resident sitting in a chair. That resident whispered that she was very scared of that guy. He's gonna knock me over one day and hurt me. He also ran over another resident's toes. She can't speak but you could see he hurt her. I told the nurse. She (the nurse) said that he has a right to be in there. I told her, He's going to hurt one of your residents one day." k. On 08/08/12 at 4:30 pm, the DON stated, "He gets agitated after about 45 minutes. He is not an easy person to work with." l. On 08/08/12 at 4:50 pm, the Social Services Director stated, "He has a known history of behaviors. There has been nothing done consistently to control his impulses to ensure that residents are free from abuse. We have not been monitoring the effectiveness of his treatment plan. There have been numerous occasions where he is running into others or near miss. He continues to have other incidents with other residents. It has been a challenge getting him to stay still." m. On 08/09/12 at 8:45 am, R #92 stated, "I've had some problems with (name of R #95). He has come into my room without my permission. Once I was here in my room reading my bible and I noticed he was in here sitting right behind me just rocking in his wheelchair. I asked him to get out of here. It really scared me. Then another time he grabbed my wheelchair really hard and pushed me out of the way. I don't understand why they let him do that to us." n. On 08/09/12 at 9:00 am, R #29 stated, "I've had problems with (Name of R #95). He is so disruptive. He just goes up and down the halls and yells at people. He has crashed his wheelchair into people before in the hallway. He has also bumped into me with his wheelchair and it hurts. He propels himself super fast and all of the staff know about it. He comes into my room and I don't like it. I'm afraid he is going to run into me and hurt my leg. I have brought up my concerns before and all I was told was 'We'll keep a watch on him'" o. On 08/09/12 at 10:45 am, the Clinical Psychiatrist stated, "Because of his stroke, he was having behaviors with personality problems. My recommendation was that the nurses contact me if he had outburst but I did not receive any phone calls from the nursing staff regarding his outbursts." p. On 08/09/12 at 11:22 am, R #11 stated, regarding R #95 "He has hit me with his wheelchair before. He has also tried to hit me and has told me to shut up for no reason. This happens almost every day. He drives his wheelchair backwards and he hits other people with it. He has been lucky no-one has been hurt. I feel afraid of him and it's just awful. He is going to hurt somebody someday. I don't have use of my right arm or hand and that scares me even more. The staff know about him." q. On 08/09/12 at 12:55 pm, Staff #3 LPN stated, "(name of R #95) slapped (name of R #25) and then hit her and took off. He hit (name of R #25) on the left cheek and in between her shoulder blades. He is very aggressive when he is in the w/c. He will get you cornered between the wall and the chairs. I've seen him swing and miss other residents. I believe these were reported to the DON. If he had his mind set on something, you were not going to change it." r. On 08/09/12 at 4:35 pm, the Physical Therapist stated, "I'm glad he is gone because he was extremely dangerous with his wheelchair. He was running into people." s. On 8/15/12 at 10:00 am, Staff #4 CNA stated, "We have so many problems with him. He even hit me as well. I was telling the nurses about him, but they really didn't do anything. I had to try to redirect him all the time from going into residents rooms then after 5 minutes he would go into another residents room. Nothing happened when I told the nurses. He would keep doing the same thing over and over. I thought he was going to hurt someone really soon. If I had to go to someone to report anything, I would not feel comfortable talking to the DON because she doesn't acknowledge us. I would try to avoid her if I could." t. On 08/15/12 at 3:35 pm, R #7 stated, "He hit me in the neck and then he hit me in the back. I hit him back. I did not tell anyone. He still runs his wheelchair into me. He hurt my toe and my arm. He also hit me in my room two weeks ago." B. Record review and interviews for R #127 revealed the following: 1. Medical Record review indicated: a. "Face Sheet" dated 06/01/12 indicated, admitting [DIAGNOSES REDACTED]. b. "physician progress notes [REDACTED]." c. "history and physical examination Pt. was combative and hitting other residents and staff..." 2. "Incident/Accident IDT Notes" indicated, a. On 05/31/12, "Had multiple episodes of striking staff and other residents." b. On 06/04/12, "Resident (identified as R #95) ran into (name of R #127)'s chair. (Name of R #127) then punched (Name of R #95) in the face." c. On 06/18/12, "Hit a resident in the face." d. On 06/20/12, "As (name of R #127) was watching TV, another resident entered the room and he (R #127) slapped him behind the head." e. On 07/12/12, "Continues to demonstrate verbal/physical aggression towards staff." f. On 07/18/12, "Resident (identified as R #29) reported to staff that (name of R #127) entered her room. When she told him to leave, he hit her in the face. He was unable to be redirected." g. On 08/08/12, "(Name of R #127) was passing resident (identified as R #29) and struck her on the left cheek and back of the head." 3. Interviews indicated: a. On 08/08/12 at 11:30 am, R #25 stated, "There is another resident here (name of R #127) who comes in my room. The other day he came at me with his fist like he was going to hit me. It was while I was in my room. I'm afraid of (name of R #95 and R #127). Those two don't belong here. b. On 08/09/12 at 9:00 am, R #29 stated, "Yesterday (name of resident # 127) punched me in the head and the left cheek bone. This is not the first time. All I said to him was this is not your room. My cheek bone is still a little tender today. Sometimes he barges into my room. One time I found him in my room and I told him to get out. He hit me on the cheek again. I have brought up my concerns before about him and all I was told was 'We'll keep a watch on him.'" c. On 08/09/12 at 12:55 pm, Staff #3 LPN stated, "I heard the slap between (name of R #127) and (name of R #29). (Name of R #29) told (name of R #127) that was not his room and he hit her in the back of the head and slapped on her on the right cheek. When I assessed her she had a faint red mark on her cheek. d. On 8/15/12 at 10:00 am, Staff #4 CNA stated, "We had problems with (name of R #127) as well. He hit me. He was always hitting people. Just last week, I know he hit a female resident (identified as R #29). I heard her yelling out. I went to see what was going on. I did see him hit her in the back of the head. She (R #29) told me that he just punched her in the face because she was trying to tell him where his room was and he hit her in the head." Based on observation, record review and interview the facility failed to ensure 1 (R #14) of 1 residents was free from physical abuse. R #98 (who was identified with known behaviors) pulled R #14 from behind in his wheelchair causing him to hit his head on the floor. This failed practice was likely to cause injury to all 99 residents identified on the Census List provided by the DON on 08/06/12. The findings are: A. Observations, record review and interviews for R #14 revealed the following: 1. On 08/08/12, at 7:30 am, R #14 was seen sitting in his wheelchair in the restorative dining room. He had some small red bruises on his right elbow. 2. On 08/16/12 at 6:15 am, the resident's right elbow was observed to have a very large bright purple bruise on it. 3. Medical record review indicated: a. "Face Sheet" dated 05/15/12 indicated, [DIAGNOSES REDACTED]. b. "history and physical examination Resident has dementia." c. "physician progress notes [REDACTED]." d. "Care Plan" dated 05/08/12 indicated, "Cognitive loss/dementia as well as short term memory and long term memory problems. His cognitive skills for daily decision making are impaired. The resident also has impaired physical mobility and requires extensive assistance for transferring and all activities of daily living." 4. "Incident & Accident IDT Notes" indicated: a. On 02/03/12, "Resident (identified as R #14) was passing another resident (identified as R #98) in the hallway. R #98 began yelling at R #14 and reached over and grabbed R #14 by the collar and began violently shaking him. b. On 03/10/12, "(name of R #98) grabbed (name of R #14) and overturned his wheelchair." c. On 03/15/12, "Bruising to top of left hand and right wrist (of R #14)." d. On 03/22/12, "Bruising has faded to yellow/green." 5. "Alleged Incident Accident Report" dated 03/11/12 indicated, "Client (identified as R #14) was sitting in the dining room "not doing a thing" was found on back still in sitting position in w/c. (Name of R #98) grabbed (name of R #14) and tipped him over and dropped him on the floor. Before the incident, (name of R #14) was sitting in the dining room waiting for breakfast. During the incident, Staff #7 LPN stated, "I heard (name of R #98) yelling and saw (name of R #98)grab (name of R #14's) wheelchair and pull him backwards and drop him on the floor." 6. Interviews indicated: a. On 08/15/12 at 11:20 am, family member #3 stated, regarding R #14 "I was told a man walked up to the back of my dads wheelchair and pulled him on the back. It was also the same person who was picking on my dad a lot. I was told the nurses saw my dad on the floor and he hit his head hard. My concern was that there was a man who was picking on my dad. I do not feel there was any monitoring going on. I don't know how someone could have pulled him back in his wheelchair hard like that. To this day, I don't know how hard he was hit." b. On 08/15/12 at 2:47 pm, Staff #8 LPN stated, "I didn't see the incident, but I went in the dining room to assist in picking him (R #14) up off the floor." c. On 08/15/12 at 2:00 pm, Staff #9 Certified Medication Aide (CMA) stated, "I was standing at the medication cart and I heard yelling. I saw (name of R #14's) wheelchair turned over. He (R #14) said 'He (referring to R #98) threw me down.' He would try to grab peoples wheelchairs when residents were trying to pass by. He would also try to swing at people." B. Record review for R #98 revealed: 1. Medical record review indicated: a. "Face Sheet" dated 08/09/12 indicated [DIAGNOSES REDACTED]." b. "Psychoactive Medication Acknowledgement Form" dated 05/29/12 indicated, the resident is receiving [MEDICATION NAME] (a anti-anxiety medication) for verbal and physical abuse. An additional Psychoactive Medication form dated 03/16/12 indicated the resident is also receiving [MEDICATION NAME] (a antipsychotic medication) for physical aggression towards others. c. "Behavioral Management/Psychoactive Medication Review" dated 04/12/12 indicated, (name of R #98) "Is aggressive with staff and other residents." d. "Comprehensive Care Plan" dated 12/08/11 indicated, "Behavioral symptoms manifested by physically abusive behavior towards others. Verbally abusive behaviors such as yelling and threatening." The facility failed to ensure the wanderguard system was properly functioning to alert staff of residents exiting the facility into the smoking and back patio areas which had open gates with direct unsecured access leading to a ditch and a busy street. A non-functioning door bell on the door leading from the main dining room to the smoking area, and key pad on the door in the small dining room which did not have a code posted for resident use, resulted in residents not being able to re-enter the facility from the back smoking area/patio area and small dining room. This resulted in Immediate Jeopardy to the residents safety. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 08/07/12 at 7:51 pm, which was cited at a Level K. The facility took corrective action by providing a plan of removal on 08/07/12. Based on documentation provided on the plan of removal, actions taken by the facility were: 1. Head count of all residents completed and all are accounted for. 2. Staff members have been posted at Solarium exit off the Restorative dining room and back porch exit off the main dining room immediately to prevent unaccompanied residents from being in these areas. 3. Staff members will continue to be scheduled and posted at these two exits 24 hours/day until patios can be secured for resident use. 4. All gates on outside fence have been secured with combination locks. The combination to locks has been posted on locks in case of emergency. 5. Staff currently present in center will be in-serviced on: a. Closure of Solarium patio off the Restorative dining room for resident use at this time. b. Residents who use the back patio off the main dining room will need to be accompanied by a staff member until area is secure. c. Implementation of gate locks on outside fencing for safety of residents. Staff members will be advised that combination to locks is posted on gate locks. d. Staff members will be educated on changes to fire safety plan that requires assigned staff member to unlock gates in event of a fire or other emergency requiring evacuation. Door monitors will be responsible for disengaging gate locks when required. 6. Staff members will be in-serviced on the above prior to the start of their shift. 7. Securement of the two patio areas will be attained with 6 foot fencing that will be installed. Once areas are secured, key pads will be discontinued and areas will be open for resident use. 8. Mag locks will also be installed for fencing gates that will automatically disengage with fire alarm. The Immediate Jeopardy was lifted on 08/07/12 at 9:35 pm. While the Immediate Jeopardy was removed on 08/07/12, the facility remained out of compliance at the lower severity level. Based on observations, record review and interviews, the facility failed to ensure resident safety for 4 (R #'s 95, 107, 117, and 127) of 4 residents for the following reasons: 1. The wanderguard system was not functioning properly to alert staff of residents exiting the facility into the smoking and back patio areas which had open gates with direct unsecured access leading to a ditch and nearby busy street. 2. Residents were able to wander out of the facility into the parking lot near a busy street. 3. Residents were not able to re-enter the facility from the back smoking area/patio area and small dining room. This deficient practice had the potential to cause harm to 66 cognitively impaired residents and 33 cognitively intact residents identified on the "Resident Nurses Report Sheet" provided by the Assistant Director of Nursing (ADON) on 08/08/12, by causing the residents to be locked outside for long periods of time near a busy street and a ditch. The findings are: A. Review of the "Resident Nurses Report Sheet" identified the census was 99. There were 18 residents identified with Dementia, 19 residents identified with Dementia with Behaviors, 9 residents identified with Alzheimer's, 8 residents identified with [MEDICAL CONDITION], 2 residents identified with Intracranial Injury, 1 resident identified with Mild Mental [MEDICAL CONDITION], 5 residents identified with Mental disorder, 1 resident identified with [MEDICAL CONDITION] (pertaining to or caused by a general lack of oxygen) Brain Damage, 1 resident identified with [MEDICAL CONDITION]/Dementia, 1 resident identified with Intellect Disability, 1 resident with Metastatic [MEDICAL CONDITION] and 33 Cognitively intact residents. B. Observations and interviews for R #117 revealed the following: 1. On 08/07/12 observations identified: a. At 2:54 pm, R #117 walked out the main dining room door leading to an outside smoking area. He then lifted the handle of a outer perimeter gate that leads directly to a nearby street and exited the gate. As he exited, he walked pass two unidentified staff members, who didn't acknowledge the resident. He proceeded to walk towards a small bench located near the street with heavy traffic. b. At 2:54 pm, one of the two unidentified staff stated, "Oh yeah, he (referring to R #117) does this all the time." The two unidentified staff members did not attempt to redirect the resident back into the enclosed gated area. 2. Interview indicated: a. On 08/07/12 at 2:55 pm R #117 stated, "I just lift the handle and walk right out. I know the code to get outside. I come out here all the time. I have the run of the mill around here." C. On 08/07/12 at 4:00 pm, observations were made of the entire outer perimeter gates of the facility. Outside the small dining room there was an unlocked gate. Immediately outside the gate was a large ditch. There was a small key pad on the outside of the exit door in the small dining room but there was no code posted to get back into the building. There was another unlocked gate near the smoking area/outside patio (located off the main dining room) which lead directly towards a nearby street with heavy traffic. On the outside was a bell to ring for staff to let residents back into the building but the bell was not functioning. All gates of the outer perimeter of the facility were easily accessible and it was easy lift the handle and walk through. D. On 08/07/12 at 5:45 pm, the Administrator stated, "The codes are posted on top of the key pads." E. On 08/07/12 at 6:35 pm, observation of the exit door leading outside from the main dining room to the smoking area revealed the bell located on the outer wall to ring for assistance was still not working and there was no code posted for the key pad. If a resident did not know the code they could not re-enter the building. Also there was no way to alert staff that someone was locked out and could not re-enter the building because the door bell was not working. F. Interview, observation and record review for R #107 revealed the following: 1. On 08/07/12 at 6:30 pm, family member #1 stated, regarding R #107, "My biggest concern is when she (referring to R #107) was admitted to the facility they never explained to me anything about an elopement risk. She would not know how to use to door key pad code to get out of the building or back in even if she wanted to because she is confused. When I try to leave at the front entrance, she does try to follow me. I know of an incident where my mom got out of the building by herself. I did witness a resident last Saturday who was by himself in the back outside smoking patio area around 3:00 pm, in the afternoon. He could not get back into the building. It was so hot outside and he looked so flushed. He was outside by himself and could not get back into the building. When I asked him what are you doing out here he said 'I can't get back in the building. The bell is not working.' He did not

The facility failed to ensure that residents (both cognitive and cognitively impaired) were free from physical and verbal abuse such as hitting, kicking, yelling, punching, slapping, and being run over by a resident in a wheelchair with a known history of physical and verbal abuse. This resulted in an Immediate Jeopardy to the resident's safety. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 08/08/12 at 6:15 pm. The facility took corrective action by providing a plan of removal on 08/08/12. Based on documentation provided in the plan of removal, actions taken by the facility were: 1. (Name of resident R #95) was placed on one-on-one observation and removed from dining room for meals. 2. Incident/Accident logs for the past 6 months were reviewed to identify other residents who also have demonstrated repeated behaviors that are dangerous to others. Another resident identified was (name of resident R #127). No other residents were identified as displaying repeated behaviors that were dangerous to others. 3. (Name of resident R #127) was placed on one-on-one observation. 4. Medical Director (MD) notified by the DON that despite the interventions in place, the above residents continue to be a risk to the safety of others in the center and requested assistance in obtaining immediate alternate placement. a. Medical Director gave verbal orders to transport (name of resident R #95) to (Name of facility) Behavorial Health emergency room (ER) for evaluation and alternate placement related to (r/t) danger to self and others. Instructions sent to call (Name of Doctor) upon arrival in ER for further details. b. Medical Director gave verbal orders to transport (name of resident R #127) to (Name of Facility) Behavorial ER for evaluation and alternate placement. Instructions sent to call (Name of Doctor) upon arrival in ER for further details. 5. Transfers of both residents will be completed per MD order, responsible parties have been notified and both residents will remain on one-on-one observation until transfers are completed. 6. (Name of Doctor) states he will be working with the physicians at these two hospitals to find alternate placement for both residents and they will not be returned to center. The Immediate Jeopardy was lifted on 08/08/12 at 8:15 pm. This resulted in the scope and severity of the deficiency being lowered to a Level 3, Scope H. While the Immediate Jeopardy was removed on 08/08/12, the facility remained out of compliance at the lower severity level. Based on observation, record review and interviews the facility failed to ensure that 9 (R #s 7, 11, 25, 29, 45, 68, 79, 92, and 172) of 9 residents were free from physical, and verbal abuse such as hitting, kicking, yelling, punching, slapping, and being run over by 2 (R #s 95 and 127) of 2 residents in wheelchairs with a known history of physical and verbal abuse. This failed practice caused injury to 9 residents identified on the Census List provided by the DON on 08/06/12. The facility also failed to ensure 1 (R #14) of 1 residents was free from physical abuse. R #98 (who was identified with known behaviors) pulled R #14 from behind in his wheelchair causing him to hit his head on the floor. This failed practice caused injury to 1 resident identified on the Census List provided by the DON on 08/06/12. The findings are: A. Observations, record review and interviews for R #95 revealed the following: 1. On 08/08/12 observations indicated: a. At 9:35 am, the resident was seen running into another wheelchair bound resident (R #11) with his wheelchair (w/c). b. At 10:30 am, the resident wheeled himself out of the activity room backwards into the hallway without looking behind him. c. At 10:40 am, he was seen wheeling himself to the nurses station demanding to go outside. He seemed upset when the staff told him he needed to wait 15 minutes and stated in an angry tone, "I don't want to wait 15 minutes." There was no staff re-direction at this time. d. At 10:45 am, as the resident wheeled himself away from the nurses station, a female resident (R #25) was seated in her w/c near the nurses station. R #95 wheeled himself towards R #25, grabbed the left wheel of R #25's wheelchair and forcibly pushed her w/c forward. e. At 10:50 am, R #95 was observed going backwards in his w/c towards the dining room. He barely missed hitting residents with his wheelchair. The resident did not look behind him. There was no staff re-direction at this time. 2. Medical Record review indicated: a. "Face Sheet" dated 05/27/12 indicated [DIAGNOSES REDACTED]. b. "Diagnostic Interview & Behavioral Treatment Plan" dated 04/30/12 (from the previous facility) indicated, "Poor anger and impulse control. Aggressive behaviors, yelling, shouting and unable to calm self. Increased agitation. Presents as very angry and agitated c/o (complains of) other residents. Verbally aggressive towards staff and other residents. Resorts to yelling and lashing out." c. "Progress Notes" dated 05/07/12 (from previous facility) indicated, "Resident up in w/c propelling self through hall and he spanked the bottom of the housekeeping staff. When the resident was asked (about the incident) he said "Yeah I smacked her ass 'cause it's big." d. "Progress Notes" dated 05/14/12 (from previous facility) indicated, "Resident observed to be exiting building. States, 'I'm doing this so I can be thrown out of here.'" e. "Emergency Mental Health Evaluation for Psychiatric hospitalization " dated 05/07/12 (from previous facility) indicated, "Physical aggression towards staff and other residents. Throws objects at staff and other residents. Verbal aggression continues when around others and when by himself. Has caused physical injury to another resident. Mental Status has increased/agitated. Attitude is hostile. Mood is irritable, and angry." f. "physician progress notes [REDACTED]. (patient) seen for evaluation of increased behaviors. Pt. with agitation. Today seen self propelling self very quickly and wandering." g. "Physical Restraint/Device Assessment" dated 07/26/12 indicated, Behavior patterns: Curses, hits, and is sexually inappropriate. Pt. propels self without regards for safety." h. "Psychological Examination" dated 05/07/12 indicated, "He has a known history of physical and verbal aggression to staff and other residents and has caused physical injuries to other residents. He requires constant redirection regarding inappropriate contact (i.e. "grabbing the buttocks of female staff") and deliberate crashing into other residents then awaiting their response. He has almost constant outbursts of vulgarity and profanity towards other residents. He waits for a larger group and then begins the disruptions." 3. "Incident/Accident Interdisciplinary Notes (IDT) Notes" indicated: a. On 05/30/12, Resident punched another resident in the left cheek. b. On 06/07/12, Resident continues with both verbal and physically aggressive behaviors and intimidation techniques, towards staff and residents, that require constant redirection. c. On 06/11/12, Resident, without provocation, rolled his wheelchair into the dining area and struck a resident (R #127). He (R #95) was not able to be redirected from behaviors being repeated. d. On 06/15/12, Resident ran into the back of another resident's chair, (R #7) angering that resident. e. On 06/15/12, Resident slapped another resident (R #127). He continues to be erratic with disregard of resident safety in wheelchair." Where do the quotes begin? f. On 06/28/12, "Occasional verbal outbursts towards residents." g. On 07/05/12, "Continues with verbal outbursts. Continues to require constant redirection and displays inappropriate verbal outbursts." h. On 07/27/12, "Bumped into the w/c of another resident." i. On 08/03/12, "This morning (name of R #95) approached female resident (identified as R #25) from behind and punched her in the back." j. On 08/08/12, "Was rapidly propelling w/c through common area and bumped into another resident." 4. "Resident Council Meeting minutes" dated 07/31/12 indicated that residents (identified as R #11, 29, 79 and 92) complain that R #95 runs into them with his wheelchair. "Residents fear he will injure someone someday." 5. "Concern/Grievance Report" dated 08/01/12 indicated that R #172 complained to the DON that R #95 grabbed his wife. "Resident and spouse demanded that police be called and criminal charges be filed." 6. Interviews indicated: a. On 08/07/12 at 11:50 am, R #79 stated, "(name of R #95) hit (name of R #25) in the back. He doesn't even let you use the phone. He bumps into residents with his wheelchair and he goes around backwards. He pokes people that go into the family room, like me. I was trying to get ahold of my son and he wouldn't let me use the phone. He kept hitting me on the back of my head with his hand. He was telling me I couldn't use the phone." b. On 08/07/12 at 2:15 pm, R #172 stated that R #95 is a problem. "He sexually assaulted my wife twice, about 2 weeks ago then again, after he was reported. We made a report with the Social Worker. He shouldn't be here. He's done it to other females too." c. On 08/08/12 at 9:40 am, R #11 stated "(name of R #95) is always running his wheelchair into everyone. He just ran into me again and it hurt. He has done this many times. Somebody is going to get hurt." d. On 08/08/12 at 10:40 am, Staff #1 Certified Nursing Assistant (CNA) stated regarding R #95, "We try to re-direct him. Sometimes he cooperates and sometimes he just doesn't. He is very set in his ways. He tells us "No" a lot, when we want him to do things. He does bump into other residents a lot and says things like 'Oh well it didn't matter.' Sometimes he will say bad words when he is impatient with us and to the other residents." e. On 08/08/12 at 10:45 am, Staff #2 CNA stated, "He (R #95) always goes real fast in his w/c. It's really bad. He runs into other residents all the time. We just can't control him." f. On 08/08/12 at 11:30 am, R #25 stated, "(name of R #95) came and hit me in the back by the nurses station. The nurse knew because she saw him hit me. I guess 'cause he didn't like me. I was just sitting at the nurses station and he hit me really hard in the back. I'm afraid of (name of R #95 and R #127). Those two don't belong here. The staff don't do anything. (Name of R #95) runs right into you with his wheelchair. I'm just sitting around and here he comes and hits me with his chair. Nobody ever checked my back when he hit me. No one came and asked me if I was ok. (Name of the Administrator) told me not to speak to you (Surveyors). She told me she could have me transferred out of here because I complained. It makes me feel so depressed. I'm afraid to tell anybody because you get in trouble for it. Please don't tell her (Administrator) because she will jump all over me. I talk to the staff, but it doesn't do any good. No one does anything." g. On 08/08/12 at 11:30 am, R #68 stated, "He runs into me all the time. I told the staff, but he still does it. He runs into everybody." h. On 08/08/12 at 3:20 pm, Staff #3 Licensed Practical Nurse (LPN) stated, "(name of R #95) has what is known as an impulsive disorder. He acts impulsively. He has ran his wheelchair into several residents. We try to keep him engaged in activities but that hasn't worked. He has struck other residents in the past. His behavior has always been this way." i. On 08/08/12 at 3:30 pm, the Activities Director stated, "His attention span in activities is about 10 to 15 minutes. At a birthday party, he came up behind another resident and slapped him in the head." j. On 08/08/12 at 3:45 pm, R #172's wife stated, "I've had several incidents with (Name of resident #95). The first time, I was sitting in the solarium. He entered the room and grabbed my pelvic bone. I yelled at him to get his hands off me. He said to me 'Bad hands good fingers.' I was really upset. I told the Activity Assistant and she told me to tell the nurse. I told the nurse. Nothing was done. (Name of Social Services Director) called me and apologized. She said they would keep him busy but he takes off on them. Then on Wednesday evening last week (08/01/12), I was standing at the nurses station when (Name of husband R #172) said 'Watch out.' All of a sudden (Name of R #95) was right on me. He put his hands on my waist and I yelled at him to get his hands off me. I told the DON what happened. My husband said to her (referring to DON) 'You need to keep him away from my wife.' (Name of DON) said 'That's not an assault.' I said, It is too. I did not give him permission to touch my body. I was really upset. My husband told him (referring to R #95) 'You better keep your hands off my wife. On Tuesday about a week ago (07/31/12), (Name of husband R #172) and I were in the solarium for communion service when (Name of R #95) came in and ran into a resident sitting in a chair. That resident whispered that she was 'very scared of that guy.' He's gonna knock me over one day and hurt me. He also ran over another resident's toes. She can't speak but you could see he hurt her. I told the nurse. She (the nurse) said that he has a right to be in there. I told her, he's going to hurt one of your residents one day." k. On 08/08/12 at 4:30 pm, the DON stated, "He gets agitated after about 45 minutes. He is not an easy person to work with." l. On 08/08/12 at 4:50 pm, the Social Services Director stated, "He has a known history of behaviors. There has been nothing done consistently to control his impulses to ensure that residents are free from abuse. We have not been monitoring the effectiveness of his treatment plan. There have been numerous occasions where he is running into others or near miss. He continues to have other incidents with other residents. It has been a challenge getting him to stay still." m. On 08/09/12 at 8:45 am, R #92 stated, "I've had some problems with (name of R #95). He has come into my room without my permission. Once, I was here in my room reading my bible and I noticed he was in here sitting right behind me just rocking in his wheelchair. I asked him to get out of here. It really scared me. Then another time he grabbed my wheelchair really hard and pushed me out of the way. I don't understand why they let him do that to us." n. On 08/09/12 at 9:00 am, R #29 stated, "I've had problems with (Name of R #95). He is so disruptive. He just goes up and down the halls and yells at people. He has crashed his wheelchair into people before in the hallway. He has also bumped into me with his wheelchair and it hurts. He propels himself super fast and all of the staff know about it. He comes into my room and I don't like it. I'm afraid he is going to run into me and hurt my leg. I have brought up my concerns before and all I was told was 'We'll keep a watch on him.'" o. On 08/09/12 at 10:45 am, the Clinical Psychiatrist stated, "Because of his stroke, he was having behaviors with personality problems. My recommendation was that the nurses contact me if he had outbursts, but I did not receive any phone calls from the nursing staff regarding his outbursts." p. On 08/09/12 at 11:22 am, R #11 stated, regarding R #95 "He has hit me with his wheelchair before. He has also tried to hit me and has told me to shut up for no reason. This happens almost every day. He drives his wheelchair backwards and he hits other people with it. He has been lucky no-one has been hurt. I feel afraid of him and it's just awful. He is going to hurt somebody someday. I don't have use of my right arm or hand and that scares me even more. The staff know about him." q. On 08/09/12 at 12:55 pm, Staff #3 LPN stated, "(name of R #95) slapped (name of R #25) and then hit her and took off. He hit (name of R #25) on the left cheek and in between her shoulder blades. He is very aggressive when he is in the w/c. He will get you cornered between the wall and the chairs. I've seen him swing and miss other residents. I believe these were reported to the DON. If he had his mind set on something, you were not going to change it." r. On 08/09/12 at 4:35 pm, the Physical Therapist stated, that she was glad the resident had been discharged because he was extremely dangerous with his wheelchair. s. On 8/15/12 at 10:00 am, Staff #4 CNA stated, "We have so many problems with him. He even hit me as well. I was telling the nurses about him, but they really didn't do anything. I had to try to redirect him all the time from going into residents rooms, then after five minutes he would go into another residents room. Nothing happened when I told the nurses. He would keep doing the same thing over and over. I thought he was going to hurt someone really soon. If I had to go to someone to report anything, I would not feel comfortable talking to the DON because she doesn't acknowledge us. I would try to avoid her if I could." t. On 08/15/12 at 3:35 pm, R #7 stated, "He hit me in the neck and then he hit me in the back. I hit him back. I did not tell anyone. He still runs his wheelchair into me. He hurt my toe and my arm. He also hit me in my room two weeks ago." B. Record review and interviews for R #127 revealed the following: 1. Medical Record review indicated, a. "Face Sheet" dated 06/01/12 indicated admitting [DIAGNOSES REDACTED]. b. "physician progress notes [REDACTED]." c. "history and physical examination Pt. was combative and hitting other residents and staff..." 2. "Incident/Accident IDT Notes" indicated, a. On 05/31/12, "Had multiple episodes of striking staff and other residents." b. On 06/04/12, "Resident (identified as R #95) ran into (name of R #127's) chair. R #127 then punched R #95 in the face." c. On 06/18/12, "Hit a resident in the face." d. On 06/20/12, "As (name of R #127) was watching TV, another resident entered the room and he (R #127) slapped him behind the head." e. On 07/12/12, "Continues to demonstrate verbal/physical aggression towards staff." f. On 07/18/12, "Resident (identified as R #29) reported to staff that (name of R #127) entered her room. When she told him to leave, he hit her in the face. He was unable to be redirected." g. On 08/08/12, "(name of R #127) was passing resident (identified as R #29) and struck her on the left cheek and back of the head." 3. Interviews indicated: a. On 08/08/12 at 11:30 am, R #25 stated, "There is another resident here (name of R #127) who comes in my room. The other day he came at me with his fist like he was going to hit me. It was while I was in my room. I'm afraid of (name of R #95 and R #127). Those two don't belong here. b. On 08/09/12 at 9:00 am, R #29 stated, "Yesterday (name of resident #127) punched me in the head and the left cheek bone. This is not the first time. All I said to him was this is not your room. My cheek bone is still a little tender today. Sometimes he barges into my room. One time I found him in my room and I told him to get out. He hit me on the cheek again. I have brought up my concerns before about him and all I was told was 'We'll keep a watch on him.'" c. On 08/09/12 at 12:55 pm, Staff #3 LPN stated, "I heard the slap between (name of R #127) and (name of R #29). (Name of R #29) told (name of R #127) that was not his room and he hit her in the back of the head and slapped on her on the right cheek. When I assessed her she had a faint red mark on her cheek." d. On 8/15/12 at 10:00 am, Staff #4 CNA stated, "We had problems with (name of R #127) as well. He hit me. He was always hitting people. Just last week, I know he hit a female resident (identified as R #29). I heard her yelling out. I went to see what was going on. I did not see him hit her in the back of the head. She (R #29) told me that he just punched her in the face because she was trying to tell him where his room was and he hit her in the head." C. Observations, record review and interviews for R #14 revealed the following: 1. On 08/08/12, at 7:30 am, R #14 was seen sitting in his wheelchair in the restorative dining room. He had some small red bruises on his right elbow. 2. On 08/16/12 at 6:15 am, the resident's right elbow was observed to have a very large bright purple bruise on it. 3. Medical Record review indicated: a. "Face Sheet" dated 05/15/12 indicated [DIAGNOSES REDACTED]. b. "history and physical examination Resident has dementia." c. "physician progress notes [REDACTED]." d. "Care Plan" dated 05/08/12 indicated, "Cognitive loss/dementia as well as short term memory and long term memory problems. His cognitive skills for daily decision making are impaired. The resident also has impaired physical mobility and requires extensive assistance for transferring and all activities of daily living." 4. "Incident & Accident IDT Notes" indicated: a. On 02/03/12, "Resident (identified as R #14) was passing another resident (identified as R #98) in the hallway. (Name of R #98) began yelling at (name of R #14) and reached over and grabbed him by the collar and began violently shaking him. b. On 03/10/12, "(Name of R #98) grabbed (name of R #14) and overturned his wheelchair." c. On 03/15/12, "Bruising to top of left hand and right wrist of (name of R #14)." d. On 03/22/12, "Bruising has faded to yellow/green." 5. "Alleged Incident Accident Report" dated 03/11/12 indicated, "Client (identified as R #14) was sitting in the dining room "not doing a thing" was found on back still in sitting position in w/c. (Name of R #98) grabbed (Name of R #14) and tipped him over and dropped him on the floor. Before the incident, (name of R #14) was sitting in the dining room waiting for breakfast. During the incident, (name of Staff #7- LPN) stated, "I heard (name of R #98) yelling and saw (name of R #98) grab (name of R #14's) wheelchair and pull him backwards and drop him on the floor." 6. Interviews indicated: a. On 08/15/12 at 11:20 am, family member #3 stated, regarding R #14 "I was told a man walked up to the back of my dads wheelchair and pulled him on the back. It was also the same person who was picking on my dad a lot. I was told the nurses saw my dad on the floor and he hit his head hard. My concern was that there was a man who was picking on my dad. I do not feel there was any monitoring going on. I don't know how someone could have pulled him back in his wheelchair hard like that. To this day, I don't know how hard he was hit." b. On 08/15/12 at 2:47 pm, Staff #8 LPN stated, "I didn't see the incident, but I went in the dining room to assist in picking him (R #14) up off the floor." c. On 08/15/12 at 2:00 pm, Staff #9 Certified Medication Aide (CMA) stated, "I was standing at the medication cart and I heard yelling. I saw (name of R #14's) wheelchair turned over. He (R #14) said 'He (referring to R #98) threw me down.' He would try to grab peoples wheelchairs when residents were trying to pass by. He would also try to swing at people." B. Record review for R #98 revealed: 1. Medical Record review indicated: a. "Face Sheet" dated 08/09/12 indicated [DIAGNOSES REDACTED]." b. "Psychoactive Medication Acknowledgement Form" dated 05/29/12 indicated the resident is receiving [MEDICATION NAME] (an anti-anxiety medication) for verbal and physical abuse. An additional Psychoactive Medication form dated 03/16/12 indicated the resident is also receiving [MEDICATION NAME] (an antipsychotic medication) for physical aggression towards others. c. "Behavioral Management/Psychoactive Medication Review" dated 04/12/12 indicated, (Name of R #98) "Is aggressive with staff and other residents." d. "Comprehensive Care Plan" dated 12/08/11 indicated, "Behavioral symptoms manifested by physically abusive behavior towards others. Verbally abusive behaviors such as yelling and threatening."

Based on record review and interview the facility failed to ensure 5 of 5 allegations of resident abuse were reported immediately to the State Survey and Certification Agency. The facility failed to ensure there was evidence that all alleged allegations were thoroughly investigated to prevent further abuse. The facility also failed to ensure the results of all investigations were reported to the State Survey and Certification Agency within 5 (five) working days of the incident. This deficient practice presents a risk of potential harm to residents. This deficient practice presents a risk of potential harm to resident safety. If allegations of abuse are not investigated, the facility is unable to determine what happened in order to prevent it from re-occurring. If the five day follow-up investigation is not submitted, the State Survey and Certification Agency is not able to determine whether or not a thorough investigation was completed to ensure resident safety. The findings are: A. Review of the "Incident/Accident Log" for the past six months (March 2012-August 2012) revealed the following incidents of abuse that were either not reported to the State Agency or did not have evidence of a thorough investigation conducted within five working days of the incident: 1. "Incident Report" dated 02/02/12 indicated, "Resident (identified as R #98) became upset and started to use a loud voice and foul language towards resident (identified as R #14). R #98 reached and grabbed R #14's collar and began to shake him violently while was still in his wheelchair." A "Follow up Investigation" conducted by the Director of Nursing (DON) dated 02/13/12 indicated it was not submitted to the State Survey Agency until 11 days after the incident between R #98 and R #14 occurred. 2. "Incident Report of resident to resident abuse" dated 06/15/12 indicated R #95 propelled his wheelchair behind R #127 and slapped R #127 in the head. R #95 said "This is for hitting me this morning." The five day follow-up investigation dated 06/22/12 was not sent to the State Survey Agency. 3. "Incident Report of resident to resident abuse" dated 06/15/12 indicated R #95 rammed his wheelchair into R #7. R #7 then slapped R #95. There was no initial Incident report completed. The five day follow up investigation dated 06/22/12 was not sent to the State Survey Agency. 4. "Incident Report of resident to resident abuse" dated 06/15/12 indicated R #95 took a drink belonging to R #127. R #127 hit R #95 in the face. The five day follow up investigation dated 06/22/12 was not submitted to the State Survey Agency. 5. "Incident Report of resident to resident abuse" dated 08/03/12 indicated that R #95 struck R #25 between the shoulder blades on her back. The five day follow up investigation was not completed and faxed to the State Survey Agency until 08/14/12 (11 days after the incident occurred). B. On 08/14/12 at 10:30 am, the DON stated, "I don't know where the two missing DHI reports are. I don't have proof that they were done." C. On 08/14/12 at 10:35 am, the Administrator stated, referring to the incident on 08/03/12 between R #95 and R #25, "I have not completed the five day investigation." D. On 08/14/12 at 11:00 am, the Administrator stated, "If there is a resident to resident altercation, then (name of the DON) is responsible for the five day follow up investigation to be submitted within five working days of the allegation. It was recently identified that there were issues with the five day follow up investigations not being done and being submitted to the Department of Health. The five day follow up is completed by me unless it is resident to resident abuse, then the DON does it. The follow-up needs to be completed in five working days." E. On 08/14/12 at 11:30 am, the DON stated that she was aware there was no copy or documentation to prove the five day follow up investigations were submitted to the State Survey Agency. F. On 08/15/12 at 3:45 pm, the DON stated, "With the incident that occurred between (name of R #14 and R #98) on 02/03/12, unfortunately at the time our Assistant Director of Nursing (ADON) did not get it done so yes, I realize this follow up investigation was really late."

Based on observation, record review and interview the facility failed to provide the necessary care and services to ensure that 9 (R #s 7, 11, 25, 29, 45, 68, 79, 92, and 172) of 9 residents were free from physical, and verbal abuse such as hitting, kicking, yelling, punching, slapping, and being run over by 2 (R #s 95 and 127) of 2 residents in wheelchairs with a known history of physical and verbal abuse. This failed practice directly affected these residents physical and psychological well being by feeling afraid and in fear. This failed practice was likely to cause injury to 9 residents identified on the Census List provided by the Director of Nursing (DON) on 08/06/12. The findings are: A. Observations, record review and interviews for R #95 revealed the following: 1. On 08/08/12 observations identified: a. At 9:35 am, the resident was seen running into another resident who uses a wheelchair (R #11) with his wheelchair (w/c). b. At 10:30 am, the resident wheeled himself out of the activity room backwards into the hallway without looking behind him. c. At 10:40 am, he was seen wheeling himself to the nurses station demanding to go outside. He seemed upset when the staff told him he needed to wait 15 minutes and stated in an angry tone, "I don't want to wait 15 minutes." d. At 10:45 am, as the resident wheeled himself away from the nurses station, a female resident (R #25) was seated in her w/c near the nurses station. R #95 wheeled himself towards R #25 and grabbed the left wheel of R #25's wheelchair and forcibly pushed her w/c forward. e. At 10:50 am, R #95 was observed going backwards in his w/c towards the dining room. He barely missed hitting residents with his wheelchair. The resident did not look behind him. 2. Medical Record review identified: a. "Face Sheet" dated 05/27/12 indicated, [DIAGNOSES REDACTED]. b. "Diagnostic Interview & Behavioral Treatment Plan" dated 04/30/12 (from the previous facility) indicated, "Poor anger and impulse control. Aggressive behaviors, yelling, shouting and unable to calm self. Increased agitation. Presents as very angry and agitated c/o (complains of) other residents. Verbally aggressive towards staff and other residents. Resorts to yelling and lashing out." c. "Progress Notes" dated 05/07/12 (from previous facility) indicated, "Resident up in w/c propelling self through hall and he spanked the bottom of the housekeeping staff. When the resident was asked (about the incident) he said "Yeah I smacked her ass 'cause it's big." d. "Progress Notes" dated 05/14/12 (from previous facility) indicated, "Resident observed to be exiting building. States, 'I'm doing this so I can be thrown out of here.'" e. "Emergency Mental Health Evaluation for Psychiatric hospitalization " dated 05/07/12 (from previous facility) indicated, "Physical aggression towards staff and other residents. Throws objects at staff and other residents. Verbal aggression continues when around others and when by himself. Has caused physical injury to another resident. Mental Status has increased/agitated. Attitude is hostile. Mood is irritable, and angry." f. "physician progress notes [REDACTED]. (patient) seen for evaluation of increased behaviors. Pt. with agitation. Today seen self propelling self very quickly and wandering." g. "Physical Restraint/Device Assessment" dated 07/26/12 indicated, "Behavior patterns: Curses, hits, and is sexually inappropriate. Pt. propels self without regards for safety." h. "Psychological Examination" dated 05/07/12 indicated, "He has a known history of physical and verbal aggression to staff and other residents and has caused physical injuries to other residents. He requires constant redirection regarding inappropriate contact (i.e. "grabbing the buttocks of female staff") and deliberate crashing into other residents then awaiting their response. He has almost constant outbursts of vulgarity and profanity towards other residents. He waits for a larger group and then begins the disruptions." 3. "Incident/Accident Interdisciplinary (IDT) Notes" identified: a. On 05/30/12, "This resident punched another resident in the left cheek." b. On 06/07/12, "He continues with both verbal and physically aggressive behaviors and intimidation techniques, towards staff and residents, that require constant redirection." c. On 06/11/12, "This resident, without provocation, rolled his wheelchair into the dining area and struck a resident (name of R #127). He (R #95) was not able to be redirected from behaviors being repeated." d. On 06/15/12, "Resident ran into the back of another resident's chair, (R #7) angering that resident. e. On 06/15/12, "Resident slapped another resident (R #127). He continues to be erratic with disregard of resident safety in wheelchair." f. On 06/28/12, "Occasional verbal outbursts towards residents." g. On 07/05/12, "Continues with verbal outbursts. Continues to require constant redirection and displays inappropriate verbal outbursts." h. On 07/27/12, "Bumped into the w/c of another resident." i. On 08/03/12, "This morning (name of R #95) approached female resident (identified as R #25) from behind and punched her in the back." j. On 08/08/12, "Was rapidly propelling w/c through common area and bumped into another resident." 4. "Concern/Grievance Report" dated 08/01/12 indicated, "Resident R #172 approached the Director of Nursing (DON) and stated R #95 "Grabbed my wife." Wife states that "He touched me here (points to waist on right side). Resident and spouse demanded that police be called and criminal charges be filed." 5. Interviews indicated: a. On 08/07/12 at 11:50 am, R #79 stated, "(name of R #95) hit (name of R #25) in the back. "He doesn't even let you use the phone. He bumps into residents with his wheelchair and he goes around backwards. He pokes people that go into the family room, like me. I was trying to get ahold of my son and he wouldn't let me use the phone. He kept hitting me on the back of my head with his hand. He was telling me I couldn't use the phone." b. On 08/07/12 at 2:15 pm, R #172 stated that R #95 is a problem. "He sexually assaulted my wife twice, about 2 weeks ago then again, after he was reported. We made a report with the Social Worker. He shouldn't be here. He's done it to other females, too." c. On 08/08/12 at 9:40 am, R #11 stated "(name of R #95) is always running his wheelchair into everyone. He just ran into me again and it hurt. He has done this many times. Somebody is going to get hurt." d. On 08/08/12 at 10:40 am, Staff #1 Certified Nursing Assistant (CNA) stated regarding R #95, "We try to re-direct him. Sometimes he cooperates and sometimes he just doesn't. He is very set in his ways. He tells us "No" a lot, when we want him to do things. He does bump into other residents a lot and says things like 'Oh well it didn't matter.' Sometimes he will say bad words when he is impatient with us and to the other residents." e. On 08/08/12 at 10:45 am, Staff #2 CNA stated, "He (R #95) always goes real fast in his w/c. It's really bad. He runs into other residents all the time. We just can't control him." f. On 08/08/12 at 11:30 am, R #25 stated, "(name of R #95) came and hit me in the back by the nurses station. The nurse knew because she saw him hit me. I guess 'cause he didn't like me. I was just sitting at the nurses station and he hit me really hard in the back. I'm afraid of (name of R #95 and R #127). Those two don't belong here. The staff don't do anything. (Name of R #95) runs right into you with his wheelchair. I'm just sitting around and here he comes and hits me with his chair. Nobody ever checked my back when he hit me. No one came and asked me if I was ok. (Name of the Administrator) told me not to speak to you (Surveyors). She told me she could have me transferred out of here because I complained. It makes me feel so depressed. I'm afraid to tell anybody because you get in trouble for it. Please don't tell her (Administrator) because she will jump all over me. I talk to the staff but it doesn't do any good. No one does anything." g. On 08/08/12 at 11:30 am, R #68 stated, "He runs into me all the time. I told the staff, but he still does it. He runs into everybody." h. On 08/08/12 at 3:20 pm, Staff #3 Licensed Practical Nurse (LPN) stated, "(name of R #95) has what is known as an impulsive disorder. He acts impulsively. He has ran his wheelchair into several residents. We try to keep him engaged in activities but that hasn't worked. He has struck other residents in the past. His behavior has always been this way." i. On 08/08/12 at 3:30 pm, the Activities Director stated, "His attention span in activities is about 10 to 15 minutes. At a birthday party, he came up behind another resident and slapped him in the head." j. On 08/08/12 at 3:45 pm, R #172's wife stated, "I've had several incidents with (Name of resident #95). The first time, I was sitting in the solarium. He entered the room and grabbed my pelvic bone. I yelled at him to get his hands off me. He said to me 'Bad hands good fingers.' I was really upset. I told the Activity Assistant and she told me to tell the nurse. I told the nurse. Nothing was done. (Name of Social Services Director) called me and apologized. She said they would keep him busy but he takes off on them. Then on Wednesday evening last week (08/01/12), I was standing at the nurses station when (Name of husband R #172) said 'Watch out.' All of a sudden (Name of R #95) was right on me. He put his hands on my waist and I yelled at him to get his hands off me. I told the DON what happened. My husband said to her (referring to DON) 'You need to keep him away from my wife.' (Name of DON) said 'That's not an assault.' I said, It is too. I did not give him permission to touch my body. I was really upset. My husband told him (referring to R #95) 'You better keep your hands off my wife. On Tuesday about a week ago (07/31/12), (Name of husband R #172) and I were in the solarium for communion service when (Name of R #95) came in and ran into a resident sitting in a chair. That resident whispered that she was 'very scared of that guy.' He's gonna knock me over one day and hurt me. He also ran over another resident's toes. She can't speak but you could see he hurt her. I told the nurse. She (the nurse) said that he has a right to be in there. I told her, he's going to hurt one of your residents one day." k. On 08/08/12 at 4:30 pm, the DON stated, "He gets agitated after about 45 minutes. He is not an easy person to work with." l. On 08/08/12 at 4:50 pm, the Social Services Director stated, "He has a known history of behaviors. There has been nothing done consistently to control his impulses to ensure that residents are free from abuse. There have been numerous occasions where he is running into others or near miss. He continues to have other incidents with other residents. It has been a challenge getting him to stay still." m. On 08/09/12 at 8:45 am, R #92 stated, "I've had some problems with (name of R #95). He has come into my room without my permission. Once, I was here in my room reading my bible and I noticed he was in here sitting right behind me just rocking in his wheelchair. I asked him to get out of here. It really scared me. Then another time he grabbed my wheelchair really hard and pushed me out of the way. I don't understand why they let him do that to us." n. On 08/09/12 at 9:00 am R #29 stated, "I've had problems both (names of R #95 and R #127). With (R #95), he is so disruptive. He just goes up and down the halls and yells at people. He has crashed his wheelchair into people before in the hallway. He has also bumped into me with his wheelchair and it hurts. He propels himself super fast and all the staff know about it. He comes into my room and I don't like it. I'm afraid he is going to run into me and hurt my leg. I have brought up my concerns before and all we were told was 'We'll keep a watch on them.'" o. On 08/09/12 at 10:45 am, the Clinical Psychiatrist, stated, "Because of his stroke, he was having behaviors with personality problems. My recommendation was that the nurses contact me if he had outbursts, but I did not receive any phone calls from the nursing staff regarding his outbursts." p. On 08/09/12 at 11:22 am, R #11 stated, regarding R #95 "He has hit me with his wheelchair before. He has also tried to hit me and has told me to 'shut up' for no reason. This happens almost every day. He drives his wheelchair backwards and he hits other people with it. He has been lucky no-one has been hurt. I feel afraid of him and it's just awful. He is going to hurt somebody someday. I don't have use of my right arm or hand and that scares me even more. The staff know about him." q. On 08/09/12 at 12:55 pm, Staff #3 LPN stated, "(Name of R #95) slapped (name of R #25) and then hit her and took off. With (name of R #95) he also struck another resident (identified as R #25). He hit (name of R #25) on the left cheek and in between her shoulder blades. He is very aggressive when he is in the w/c. He will get you cornered between the wall and the chairs. I've seen him swing and miss other residents. I believe these were reported to the DON. If he had his mind set on something, you were not going to change it.' r. On 08/09/12 at 4:35 pm, the Physical Therapist stated, "I'm glad he had been discharged because he was extremely dangerous with his wheelchair. He was running into people." s. On 8/15/12 at 10:00 am, Staff #4 CNA stated, "We have so many problems with him. He even hit me as well. I was telling the nurses about him, but they really didn't do anything. I had to try to redirect him all the time from going into residents rooms then after five minutes he would go into another residents room. Nothing happened when I told the nurses. He would keep doing the same thing over and over. I thought he was going to hurt someone really soon. If I had to go to someone to report anything, I would not feel comfortable talking to the DON because she doesn't acknowledge us. I would try to avoid her if I could." t. On 08/15/12 at 3:35 pm, R #7 stated, "He hit me in the neck and then he hit me in the back. I hit him back. I did not tell anyone. He still runs his wheelchair into me. He hurt my toe and my arm. He also hit me in my room two weeks ago." B. Record review and interviews for R #127 revealed the following: 1. Medical Record review indicated: a. "Face Sheet" dated 06/01/12 indicated, admitting [DIAGNOSES REDACTED]. b. "physician progress notes [REDACTED]. with behaviors and hitting staff, combative and refusing care." c. "history and physical examination Pt. was combative and hitting other residents and staff..." d. "Comprehensive Care Plan" dated 06/05/12 indicated, "Unhappy with others. Staff were to redirect behaviors." e. "Comprehensive Care Plan" dated 06/05/12 indicated, "Behavioral symptoms: Physically abusive behavior, others were hit, socially inappropriate, disruptive behaviors symptoms, resident shows signs of anxiety, resident will strike if someone startles him." Staff are to redirect behaviors and monitor behaviors. f. "Comprehensive Care Plan" dated 06/07/12 indicated, "[MEDICAL CONDITION]: dementia with behavioral dementia, manifested by hitting." Staff are to remove from situation when combative. "Monitor behaviors and assess effective treatment plan." 2. Incident/Accident IDT notes indicated: a. On 05/31/12 "Had multiple episodes of striking staff and other residents." b. On 06/04/12 "Resident (identified as R #95) ran into (name of R #127's) chair. R #127 then punched (name of R #95) in the face." c. On 06/18/12 "He hit a resident in the face." d. On 06/20/12 "As (name of R #127) was watching TV, another resident entered the room and he (R #127) slapped him behind the head." e. On 07/12/12 "Continues to demonstrate verbal/physical aggression towards staff." f. On 07/18/12 "Resident (identified as R #29) reported to staff that (name of R #127) entered her room, when she told him to leave, he then hit her in the face. He was unable to be redirected." g. On 08/08/12 "(name of R #127) was passing resident (identified as R #29). R #127 and struck her on the left cheek and back of the head." 3. Interviews indicated: a. On 08/15/12 at 10:00 am, Staff #4 CNA stated, "With (name of R #127) we had problems with him. He even hit me. He was always hitting people. Just last week, I know he hit a female resident (identified as R #29). I heard her yelling out. I went to see what was going on. I did not see him hit her in the back of the head. She (R #29) told me that he just punched her in the face because she was trying to tell him where his room was and he hit her in the head." b. On 08/09/12 at 12:55 pm, Staff #3 LPN stated, "I heard the slap between (name of R #127) and (name of R #29). (Name of R #29) told (name of R #127 that was not his room and he hit her in the back of the head and slapped on her on the right cheek. When I assessed her, she had a faint red mark on her cheek." C. Review of the "Resident Council Meeting" minutes dated 07/31/12 indicated, that residents (identified as R #11, 29, 79 and 92) complain that (name of R #95) runs into them with his wheelchair. Residents fear he will injure someone someday." D. Review of the following medical records revealed residents that were directly impacted by incidents that occurred either with R #95 or R #127. These residents also specified feeling afraid and in fear of R #95 and R #127. These residents were identified as being vulnerable, both cognitively aware, and in some instances unable to perform activities of daily living without the assistance of staff. 1. Medical Record review of R #25 indicated: a. [DIAGNOSES REDACTED]. b. "Incident/Accident IDT Note" dated 08/03/12 indicated, "On 08/03/12 male resident (identified as R #95) approached her and struck her in the back." c. "Comprehensive Care Plan" dated 04/10/12 indicated, "Cognitive loss/Dementia. Altered cognitive function as manifested by short term memory and long term memory problem. Requires extensive assistance for bed mobility and toilet use." d. "Incident/Accident Report" dated 08/03/12 indicated, "This resident was hit by (name of R #95) on the back at the nursing station. Resident stated (name of R #95) hit me in the back as hard as he could. Witness statement indicated, there is a red mark between her (R #25) shoulder blades. She states "'It stings."' 2. Medical Record review of R #68 indicated: a. [DIAGNOSES REDACTED]. b. "History and Physical" dated 06/12/12 indicated, R #68 has [MEDICAL CONDITION] (paralysis of all four extremities and trunk) and [MEDICAL CONDITION] spine. c. "Social Work Progress Notes" dated 07/17/12 indicated, "Resident is alert and oriented to person, place, time and situation. Resident is also able to make needs known." 3. Medical Record review of R #79 indicated: a. Admitting [DIAGNOSES REDACTED]. b. "Comprehensive Care Plan" dated 03/20/12 indicated, the resident has no cognitive deficits and has impaired physical mobility as manifested by requiring extensive assistance for transfers and toileting. c. "Concern/Grievance Report" dated 08/07/12 indicated, "On August 7, 2012 grievance was filed against (name of R #95). "He kept tapping my shoulder and I had to cut my phone call short." 4. Medical Record review of R #92 indicated: a. Admitting [DIAGNOSES REDACTED]. b. "Comprehensive Care Plan" dated 03/19/12 indicated, the resident has a short term/long term memory problem. Visual function is Impaired. It further indicated the resident has impaired physical mobility and requires extensive assistance with bed mobility, transfers, and dressing. 5. Medical record for R #29 indicated: a. "Face Sheet" dated 05/04/12 indicated, [DIAGNOSES REDACTED]. b. "physician progress notes [REDACTED]. c. "physician progress notes [REDACTED]. d. "Incident/Accident IDT Note" dated 07/18/12 indicated, "On 07/18/12 the resident (R #29) reported to the CNA that another resident (identified as R #127) came into my room and hit me in the face. '"My face is sore.'" e. "Comprehensive Care Plan" dated 05/01/12 indicated, Cognitive loss due to late effect Intracranial injury. The resident also requires extensive assistance with dressing and all activities of daily living." f. "Daily and Q (every) Shift Charting Notes" dated 07/18/12 indicated, "Resident reported to CNA that she was punched in the face by (name of R #127). He came into my room and hit me in the face. My face is just sore." h. "Daily and Q Shift Charting Notes" dated 08/08/12 indicated, "Resident was hit by another resident (identified as R #127) on the left cheek and back of the head. Cheek is reddened. Resident stated, '"I pointed (name of R #127) to his room then he hit me in the cheek and back of the head." i. "Report of Alleged Incident/Accident" document dated 08/08/12 indicated, "(name of R #127) hit (name of R #29) as he passed her in the hall. (Name of R #127) hit (name of R #29) in the face and the back of the head. (Name of R #29) stated, "I told (name of R #127) that was his room and he hit me first on the left cheek then on the back of the head then walked down the hall." 6. Medical Record review for R #11 indicated: a. Admitting [DIAGNOSES REDACTED]. b. "physician progress notes [REDACTED]." c. "Comprehensive Care Plan" dated 03/26/12 indicated, the resident's physical mobility is impaired requiring extensive assistance with bed mobility." 7. Medical Record review for R #45 indicated: a. Admitting [DIAGNOSES REDACTED]. b. "Incident/Accident IDT Note" dated 05/31/12 indicated, "(Name of R #95) punched (name of R #45) in the left cheek." c. "Comprehensive Care Plan" dated 11/14/11 indicated, "Cognitive loss/Dementia." d. "Incident/Accident Report" dated 05/30/12 indicated, "(Name of R #95) punched (name of R #45) in the left cheek." Based on observation, record review and interview the facility failed to provide the necessary care and services to ensure the overall safety of 1 (R #14) of 1 residents was free from physical abuse. R #98 (who was identified with known behaviors) pulled R #14 from behind in his wheelchair causing him to hit his head on the floor. This failed practice was likely to cause injury to all 99 residents identified on the Census List provided by the Director of Nursing (DON) on 08/06/12. The findings are: A. Observations, record review and interviews for R #14 revealed the following: 1. On 08/08/12 at 7:30 am, R #14 was seen sitting in his wheelchair in the restorative dining room. He had some small red bruises on his right elbow. 2. On 08/16/12 at 6:15 am, the resident's right elbow was observed to have a very large bright purple bruise on it. 3. Medical Record review indicated: a. "Face Sheet" dated 05/15/12 indicated, [DIAGNOSES REDACTED]. b. "history and physical examination Resident has dementia." c. "physician progress notes [REDACTED]." d. "Comprehensive Care Plan" dated 05/08/12 indicated, "Cognitive loss/dementia as well as short term memory and long term memory problems. His cognitive skills for daily decision making are impaired. The resident also has impaired physical mobility and requires extensive assistance for transferring and all activities of daily living." 4. "Incident & Accident IDT Notes" indicated: a. On 02/03/12, "Resident (identified as R #14) was passing another resident (identified as R #98) in the hallway. (Name of R #98) began yelling at (name of R #14) and reached over and grabbed (name of R #14) by the collar and began violently shaking him. b. On 03/10/12, "(Name of R #98) grabbed (name of R #14) and overturned his wheelchair." c. On 03/15/12, "Bruising to top of left hand and right wrist (of R #14)." d. On 03/22/12, "Bruising has faded to yellow/green." 5. "Alleged Incident Accident Report" dated 03/11/12 indicated, "Client (identified as R #14) was sitting in the dining room "not doing a thing" was found on back still in sitting position in w/c. (Name of R #98) grabbed (name of R #14) and tipped him over and dropped him on the floor. Before the incident, (name of R #14) was sitting in the dining room waiting for breakfast. During the incident, Staff #7 LPN stated, "I heard (name of R #98) yelling and saw (name of R #98) grab (name of R #14's) wheelchair and pull him backwards and drop him on the floor." 6. Interviews indicated: a. On 08/15/12 at 11:20 am, family member #3 stated, regarding R #14 "I was told a man walked up to the back of my dads wheelchair and pulled him on the back. It was also the same person who was picking on my dad a lot. I was told the nurses saw my dad on the floor and he hit his head hard. My concern was that there was a man who was picking on my dad. I do not feel there was any monitoring going on. I don't know how someone could have pulled him back in his wheelchair hard like that. To this day, I don't know how hard he was hit." b. On 08/15/12 at 2:47 pm, Staff #8 Licensed Practical Nurse (LPN) stated, "I didn't see the incident, but I went in the dining room to assist in picking him (R #14) up off the floor." c. On 08/15/12 at 2:00 pm, Staff #9 Certified Medication Aide (CMA) stated, "I was standing at the medication cart and I heard yelling. I saw (name of R #14's) wheelchair turned over. He (R #14) said 'He (referring to R #98) threw me down.' I do know (name of R #98) would try to grab peoples wheelchairs when residents were trying to pass by. He would also try to swing at people." B. Record review for R #98 revealed: 1. Medical Record review indicated: a. "Face Sheet" dated 08/09/12 indicated [DIAGNOSES REDACTED]." b. "Psychoactive Medication Acknowledgement Form" dated 05/29/12 indicated, the resident is receiving [MEDICATION NAME] (a anti-anxiety medication) for verbal and physical abuse. An additional Psychoactive Medication form dated 03/16/12 indicated the resident is also receiving [MEDICATION NAME] (a antipsychotic medication) for physical aggression towards others. c. "Behavioral Management/Psychoactive Medication Review" dated 04/12/12 indicated, R #98 "Is aggressive with staff and other residents." d. "Comprehensive Care Plan" dated 12/08/11 indicated, "Behavioral symptoms manifested by physically abusive behavior towards others. Verbally abusive behaviors such as yelling and threatening."