Every finding on record at Calera Manor

Based on record review and interview, the facility failed to ensure an RN was on duty for 8 consecutive hours per day. The DON identified 74 residents who resided in the facility. Findings: A PBJ Staffing Data Report, dated 01/01/25 through 03/31/25 (the second quarter of fiscal year 2025), showed the facility did not have RN coverage on 44 of the 90 days in that quarter. Below are the dates identified as not having RN coverage in January, February, and March 2025. a. January 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 30th, and 31st. b. February 2nd, 8th, 9th, 15th, 22nd, and 23rd. c. March 2nd, 15th, 16th, 22nd, 23rd, 29th, and 30th. On 06/10/25 at 1:46 p.m., the DON stated the facility did not have documentation of RN coverage for the dates listed on the facility's PBJ report. They stated the facility did not have registered nurses available to cover on those dates.

Based on record review and interview, the facility failed to ensure residents did not receive antipsychotic medications for the diagnosis of dementia for 2 (#14 and #25) of 6 sampled residents reviewed for unnecessary medications. The DON stated 22 residents were prescribed antipsychotic medications at the facility. 1. A significant change MDS assessment, dated 03/09/25, showed in section C Res #14 had a BIMS score of 3 [this indicated the resident's cognition was severely impaired]. A policy titled Antipsychotic Medication Use, dated April 2007, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. A prescription order, dated 03/04/25, showed Res #14 had been prescribed one tablet of Seroquel [an antipsychotic medication] 50 mg every day for dementia with mood disturbance. A prescription order, dated 05/16/25, showed Res #14 had been prescribed one tablet of Risperdal [an antipsychotic medication] 1 mg each day for dementia with mood disturbance. On 06/11/25 at 2:42 p.m., the ADON stated it was their understanding antipsychotic medications could be used for the diagnosis of dementia with behaviors. On 06/11/25 at 2:43 p.m., MDS coordinator #1 stated it was also their understanding that antipsychotic medications could be used for the diagnosis of dementia with behaviors. 2. A prescription order, dated 02/26/24, showed Res #25 had been prescribed two tablets of Seroquel [an antipsychotic medication]100 mg each night at 8:00 p.m. for dementia with agitation. An annual MDS assessment, dated 05/12/25, showed in section C Res #25 had a BIMS score of 3 [the score of 3 on the BIMS assessment indicated the resident's cognition was severely impaired]. Section N of the MDS assessment showed Res #25 had received antipsychotic medications on a routine basis. On 06/10/25 at 11:29 a.m., the DON was asked about Res #14 and #25's use of the antipsychotic medications. They stated Risperdal and Seroquel were medications used for people with hallucinations and such. They stated the medications were not approved by the FDA for treating dementia and they believed the orders showing Res #14 and #25 were using it for dementia was a clerical error. They stated the facility did not use antipsychotic medication for dementia. They stated Res #14 and #25 had not experienced hallucinations or delusions of which they were aware. On 06/10/25 at 11:48 a.m., LPN #1 stated they had worked with Res #25 for about three months. They stated the reason the resident had been prescribed Seroquel was for them yelling out and saying things that did not make sense. They stated the Res #25 was confused at times, but they had not seen or heard of the resident hallucinating or experiencing delusions. When asked about what Seroquel was, they stated it was an antipsychotic medication. LPN #1 was asked about monitoring Res #25 for psychotic symptoms such as hallucinations and delusions. LPN #1 stated no one had instructed them to monitor for those.

Based on record review and interview, the facility failed to report an allegation of physical abuse to local law enforcement for 1 (#80) of 1 sampled resident reviewed for abuse. The assistant administrator reported the census in the facility was 74. Findings: A facility policy titled Abuse - Reportable Events, dated 08/19, read in part, All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. The policy further read in part, Local law enforcement will be notified of any reportable crime against a resident. An admission assessment, dated 05/11/24, showed Res #80 had a BIMS score (a test of cognitive function) of 15, which is indicative of intact cognition. An incident report form, dated 05/17/24, showed Res #80 reported an allegation of physical abuse to facility staff. The report also showed the physician, the resident's legal representative and adult protective services were notified. The report did not show local law enforcement had been notified. On 06/11/25 at 2:49 p.m., the DON stated they could not locate any documentation law enforcement had been contacted regarding this allegation.

Based on record review and interview, the facility failed to implement a comprehensive care plan intervention regarding smoking safety assessments for 1 (#25) of 18 sampled residents reviewed for care plans. The DON stated there were 74 residents resided in the facility. Findings: A facility policy titled Smoking Policy, undated, read in part, The nursing staff will conduct an assessment upon admission to establish guidelines for each resident who wished to smoke. The policy further read in part, Assessments will continue to be completed upon admission, quarterly and change in condition. A facility policy titled Care Plans - Comprehensive, dated 2010, read in part, Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. A care plan problem, dated 12/27/24, showed Res #25 was a smoker and at risk for injury. A correlated care plan intervention, dated 12/27/24, showed the nursing department was to conduct smoking assessments on Res #25 according to facility policy. On 06/10/25 at 1:01 p.m., LPN #1 was asked about Res #25's smoking routine. They stated Res #25 continued to smoke but only occasionally. The LPN was asked about smoking safety assessments. They stated those were done by the DON and ADON. On 06/10/25 at 1:12 p.m., the DON was asked about Res #25's smoking routine. They stated the resident did smoke occasionally. On 06/10/25 at 1:14 p.m., the DON stated they had checked with the ADON and found out the resident had never been assessed for smoking safety. DON stated they were supposed to have been done on admission and then quarterly. On 06/10/25 at 1:25 p.m., the ADON was asked about Res #25's smoking assessments. They stated Res #25 would smoke occasionally and sometimes go months without smoking then suddenly smoke every week. They stated because of the resident's smoking routine they may not been aware Res #25 was a smoker. They stated they had looked in Res #25's records and could not find any smoking safety assessments for them. They stated they should have been done on admission and quarterly.

Based on record review and interview, the facility failed to ensure a resident that smoked cigarettes was assessed for the ability to safely smoke for 1 (#25) of 4 sampled residents reviewed for accidents. The DON stated 15 residents at the facility smoked tobacco products. Findings: A facility policy titled, Smoking Policy, undated, read in part, The nursing staff will conduct an assessment upon admission to establish guidelines for each resident who wished to smoke. Any restrictions will be noted in the resident's record. The policy also read in part, Assessment will continue to be completed upon admission, quarterly, and change of condition, A care plan problem, dated 12/27/24, showed Res #25 was a smoker and at risk for injury. A correlated care plan intervention, dated 12/27/24, showed the nursing department was to conduct smoking assessments on Res #25. An annual MDS assessment for Res #25, dated 05/12/25, showed in section C, the resident had a BIMS score of 3 which indicated Res #25's cognition was severely impaired. On 06/10/25 at 1:01 p.m., LPN #1 was asked about Res #25's smoking routine. They stated Res #25 continued to smoke but only occasionally. The LPN was asked about smoking safety assessments. They stated those were done by the DON and ADON. On 06/10/25 at 1:12 p.m., the DON was asked about Res #25's smoking routine. They stated the resident did smoke occasionally. They were asked about how they ensure residents smoke safely. DON stated they assess the residents that smoke when they are admitted . They stated they were not sure how often they were assessed after the initial assessment. On 06/10/25 at 1:14 p.m., the DON stated they had checked with the ADON and found out the resident had never been assessed for smoking safety. DON stated they were supposed to have been done on admission and then quarterly. On 06/10/25 at 1:25 p.m. the ADON stated any resident who smoked was to be assessed for safety on admission and quarterly. They stated in the case of Res #25, they may not have been aware they were a smoker. They stated Res #25 would smoke occasionally and sometimes go months without smoking and then suddenly smoke every week. They stated because of the residents inconsistent pattern of smoking, they may not have known Res #25 was smoking. They stated they had looked in their records and could not find a smoking safety assessment for Res #25. They stated they should have been done.

Based on record review and interview, the facility failed to notify the physician of a significant weight change for 1 (#71) of 3 sampled residents reviewed for nutrition. A weight variance report, dated 06/09/25, showed 4 residents with significant weight loss. Findings: An undated facility policy titled Weight and Height Measurement, read in part, Notify the charge nurse or physician of all weight changes of five pounds (or 5%) or more in a 30-day period or ten percent in a 180-day period or per state requirement. Review of the vital sign records for Res #71 showed their weight on: - 05/02/25 - 126.1 pounds, - 05/14/25 - 114.2 pounds, and - 05/27/25 - 109.4 pounds. A care plan intervention, implemented on 05/05/25, read in part. Monitor vital sign and weight as ordered, notify physician if there is a significant weight change. A Dietitian's Recommendations for Primary Care Provider form, dated 05/30/25, showed Res #71's weight had decreased from 126.1 pounds on 05/02/25 to 109.4 pounds in one month. The form also recommended 60 milliliters of TwoCal HN (a liquid nutritional supplement) three times a day and to consider adding Vitamin B12 and Omega 3. This form was not signed by the physician. On 06/11/25 at 2:30 p.m., LPN #1 stated the dietician was responsible for notifying the physician of significant weight loss. On 06/12/25 at 8:46 a.m., the DON stated they were unable to locate any documentation the physician had been made aware of Res #71's weight loss. They also stated they received the resident weights after the CNA's take them. They stated they had never contacted the physician regarding Res #71's weight loss.

Based on record review and interview, the facility failed to ensure sufficient staff to provide supervision for one (#35) of 17 sampled residents reviewed for sufficient staffing. The administrator identified 67 residents resided in the facility and 23 resident were dependent on staff for assistance with activities of daily living. Findings: Resident #35 had diagnoses which included pain, dysphagia following cerebral infarction, and need for assistance with personal care. A Physician Order, dated 11/21/23, documented Resident #35 was to have nectar thick liquids. An admission assessment, dated 11/24/23, documented Resident #35 had no cognitive impairment, needed substantial assistance with toileting, showers, dressing, and personal hygiene, and had upper and lower extremity impairment. A Timecard Editor, dated 12/30/23, documented three staff clocked in on 10 p.m.-6 a.m. shift. A Timecard Editor, dated 01/05/24, documented three staff clocked in on 10 p.m.-6 a.m. shift. A Timecard Editor, dated 01/06/23, documented four staff clocked in on 10 p.m. -6 a.m. shift. On 01/10/24 at 2:37 p.m., Resident #35 was asked if there was an issue with staffing. Resident #35's family member was present and stated, They don't have any staff. They identified the weekends as being short staffed. Resident #35 stated they asked for thickened water around five in the morning on Sunday, 01/06/24, and was told by a staff member I don't have time to get water. On 01/11/24 at 8:15 a.m., the Adm. Asst. was asked to review 12/30/23, 01/05/24 and 01/06/24 staffing timecards for 10 p.m.-6 a.m. shift and asked if there was sufficient staff on these dates. They stated on 01/05/24 facility census was 68 residents and there should have been five staff. On 01/06/24 the facility census was 68 and there should have been five staff. On 12/30/23 the census was 74 and there should have been five staff. They were asked if staffing had been met for these dates. They stated, No.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours per day. The administrator identified 67 residents resided in the facility. On 01/09/24 at 2:56 pm., RN coverage time sheets were reviewed with the Adm. Asst. from 10/01/23 through 10/31/23. There was no RN coverage for eight consecutive hours per day for the following dates: 10/03/23, 10/04/23, 10/05/23, 10/07/23, and 10/09/23 through 10/14/23. The Administrator acknowledged there was no RN coverage. A staff schedule, dated 12/25/23 through 01/13/24 did not have a Registered Nurse scheduled on 01/07/24. On 01/09/24 at 3:22 p.m., the Adm. Asst. was shown the staff schedule dated 12/25/23 through 01/13/23 and asked if there had been registered nurse coverage on 01/07/24. They reviewed the the payroll time on the computer and stated no RN had clocked in on that date. No further information was provided.

Based on observation, record review, and interview, the facility failed to ensure: a. staff did not carry two resident's medications (#126 and #59) to administer at the same time, b. staff counted controlled medications every shift per policy, and c. controlled medications had accurate narcotic count sheets for two (#70 and #46) of four sampled residents reviewed for medications. The administrator identified 67 residents resided in the facility. The DON identified 35 residents received narcotics. Findings: An undated Narcotic Count policy, read in parts .To complete a physical inventory of narcotics at change of each shift by two licensed nurses to identify discrepancies and need for reconciliation and accountability .To assure controlled drugs are handled, stored .properly .To assure proper record keeping for controlled drugs .Narcotic records are reconciled by a physical count of the remaining narcotics supply at the change of each shift by the oncoming and outgoing licensed nurse .If the count is not accurate, the nurse going off duty is to remain on duty until the count is reconciled . 1. On 01/09/24 at 6:54 a.m., CMA #1 was observed to have a cup of medications on top of the medication cart. They were asked to start medication pass when they were ready. CMA #1 stated they were ready and began to prepare medications for Resident #126. After the medications were prepared for Resident #126, CMA #1 was observed to pick up Resident #126's medications, nasal spray, water cup, and Resident #59's medication cup and water and enter the residents room. CMA #1 handed the medications and nasal spray to Resident #126. After Resident #126 took their medications CMA #1 then went to the restroom, washed their hands, took the nasal spray to the cart, sanitized their hands, then returned to the room and administered Resident #59's medications. On 01/09/24 at 2:37 a.m., the ADON was informed of the observation with CMA #1 during medication observation. They were asked what the policy was for passing medications to two residents at a time and what could the outcome be to the resident. The ADON stated, they should only pass one resident at a time and the possible outcome could be the wrong medication is given to the wrong patient. On 01/10/24 at 10:59 a.m., CMA #1 was asked why had they took two medications cups into the resident's room at the same time. They stated they were running late on medication pass and knew that should not have done that. 2. On 01/10/24 at 10:04 a.m., the CONTROLLED DRUGS-COUNT RECORD, for the following months were reviewed: a. from 12/01/23 through 12/31/23, the sign out sheet did not contain documentation of staff signatures for 130 of 186 opportunities, and b. from 01/01/24 through 01/10/24, the sign out sheet did not contain documentation of staff signatures for 47 of 56 opportunities. On 01/10/24 at 11:30 a.m., the DON was shown the count sheets for December 2023 and January 2024 with missing staff signatures and asked when should the count be completed. They stated every shift, but they had not been completed. 3. Resident #70 did not have narcotic count sheets completed for an unopened bottle of Lorazepam 2 mg/ml and Morphine 20/ml that was observed in the refrigerator in the medication room. Resident #46 did not have a narcotic count sheet completed for an unopened bottle of Morphine 10 mg/5 ml that was observed in the refrigerator in the medication room. Resident #70's medication count sheet, dated 12/22/23 through 01/01/24, documented there was six milliliters of Morphine 20 mg/ml in an opened bottle. On 01/10/24 at 10:04 a.m., LPN #3 was asked who was responsible for the narcotic count. They stated the nurse checks all the narcotics in from hospice services that are in the refrigerator. They were asked where the count sheets were for Resident #46's unopened bottle of morphine and for Resident #70's unopened bottles of Morphine and Lorazepam. They stated there were not any. LPN #3 was unable to determine the amount in Resident #70's opened bottle of morphine. On 01/10/24 at 10:28 a.m., the DON used a syringe to count Resident #70's remaining morphine and stated there was probably about one milliliter in the bottle. They were asked if the count was correct that documented six milliliters remained. They stated, No.

Based on record review and interview, the facility failed to ensure snacks were offered to one [#8] of three sampled residents reviewed for snacks. The administrator identified 67 residents resided in the facility. Findings: The Snacks (Between Meal and Bedtime) policy, revised October 2010, read in part, .The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the snack was served. 2. The name and title of the individual(s) who served the snack. 3. The amount of the snack eaten by the resident(i.e., 50%, 75%, etc.). 4. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure. 5. Any special special request(s) made by the resident concerning his or her eating time or food likes and dislikes. 6. Any difficulty the resident had in feeding himself of herself, chewing or swallowing. 7. If the resident refused the snack, the reason(s) why and the intervention taken. 8. The signature and title of the person recording the data. On 1/10/24 at 1:27 p.m., Resident #8 reported they usually did not get offered snacks at night. Resident #8's clinical health record did not contain documentation that bedtime snacks had been offered since 12/19/23 at 7:13 p.m. On 01/10/24 at 2:15 p.m., the Regional Director stated, I don't see any documentation on snacks for Resident #8 in the electronic health records and medication administration records. On 0/10/24 at 2:16 p.m. the Regional Director stated, Snacks are to be offered according to physician orders and company policy.

Based on observation, record review, and interview, the facility failed to maintain infection control during wound care for one (#19) of one sampled resident reviewed for wound care. The administrator identified 67 residents resided in the facility. The DON identified eight residents received wound care. Findings: An undated Dressing Change Guidelines, read in parts .The following is meant to be used as a guideline only and to promote the safe-and-effective use of the wound care products .ointments or medications should be placed in a clean contained (plastic med cup) which is to be brought into the room .Position resident .Don gloves, remove soiled dressings .Remove gloves wash hands .Don gloves .clean wound .Remove gloves wash hands .Don gloves for topical/dressing .apply with clean cotton tipped applicator . Resident #19 had diagnoses which included muscle wasting and atrophy, osteoarthritis, and depression. A Physician Order, dated 12/27/23, documented to cleanse the coccyx with normal saline, pat dry, apply medihoney and calcium alginate and cover with a dry dressing every day. A Physician Order, dated 12/27/23, documented to cleanse the left heel with normal saline, pat dry, apply Iodosorb and calcium alginate cover with foam and wrap with Kerlix every day. A Physician Order, dated 12/27/23, documented to cleanse the right heel with normal saline, pat dry, apply Iodosorb and calcium alginate cover with foam and wrap with Kerlix every day. On 01/10/24 at 4:29 p.m., LPN #4 was observed to perform wound care on Resident #19. LPN #4 donned gloves and removed a border dressing from the resident's coccyx, removed their gloves, sanitized their hands and donned clean gloves. LPN #4 used normal saline and gauze sponges to clean the wound, removed their gloves, did not sanitize their hands, and donned clean gloves. LPN #4 then cut dressings to size, applied medihoney with their gloved finger to the wound, applied calcium alginate dressing and secured it with a bordered dressing. Then they removed their gloves, sanitized their hands, donned clean gloves, and assisted the resident to dress. LPN #4 was then observed to cut the gauze dressings from both feet. LPN #4 then removed the dressing from the right heel, removed their gloves, but did not sanitize their hands. LPN #4 donned gloves, cleansed the right wound with normal saline and gauze sponges, picked up the tube of Iodosorb with dirty gloves, applied ointment to the wound using a q-tip, then applied the dressings and Kerlix wrap. LPN #4 then removed the cut dressing from the left heel, took off their gloves but did not sanitize their hands. LPN #4 donned gloves, cleansed the wound, removed their gloves, but did not sanitize their hands. Then they donned clean gloves used a q-tip to apply Iodosorb ointment, applied the ointment, covered with dressings, and secured with Kerlix wrap. LPN #4 removed their gloves, sanitized their hands, donned gloves, and secured both dressings with tape. On 01/10/24 at 5:15 p.m., LPN #4 acknowledged they had not sanitized their hands after glove changes and had touched the medication tube with dirty gloves during the dressing change. On 01/11/24 at 9:49 a.m., the DON was asked how should wound care be performed related to changing gloves. They stated staff should sanitize after every glove removal/change. , No.

Based on observation, record review, and interview, the facility failed to ensure supervision for a resident who was on a mechanically altered diet for one (#60) of 17 sampled residents. The administrator identified 67 residents resided in the facility and the DON reported four residents received a pureed diet and nineteen residents received a mechanical soft diet. Findings: A Safety and Supervision of Residents policy, revised December 2007, read in parts, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Implementing interventions to reduce accident risks and hazards shall include the following .ensuring that interventions are implemented . Resident #60 had diagnoses that included traumatic brain injury and dysphagia. Resident #60's care plan, dated 10/05/22, read in part, .was at risk for weight loss due to dysphagia .[Resident #60] must be removed after each meal and monitored by staff to prevent him from eating off of other resident's trays . The care plan had not been updated to contain any current interventions had been put into place to prevent Resident #60 from eating food off other resident's trays. An annual assessment, dated 10/08/23, documented Resident #60's cognitive skills for daily decision making was severely impaired. A Physician Order, dated 04/12/23, documented Resident #60's diet was mechanical soft with pureed meat and nectar thick liquids. On 01/04/24 at 1:24 p.m., Resident #60 was observed to roll themselves in the dining room and began to eat off of a plate of food sitting on a table. No staff were observed in the dining room. The plate of food was not Resident #60's plate. Resident #60 was observed drinking from a cup with ice and thin liquids and eating shaved meat with their hands. CMA #2 was in the hallway near the dining room and was asked if the resident should be eating that food. CMA #2 stated the resident should not be eating the food. On 01/04/24 at 2:15 p.m., Resident #60 was observed sitting at the dining table eating a piece of bread. Activities staff were observed to put dots of paint on a plate for activities. CNA #2 was observed in the hallway near the dining room and was asked what the was resident eating. CNA #2 approached Resident #60 and removed the bread from the resident's hand. Resident #60 had dipped the bread into some of the blue paint on the plate and was attempting to take a bite when staff intervened. On 01/05/24 at 11:10 a.m., the DON was asked if staff had informed them about Resident #60 eating off another resident's tray. They stated yes, and it was in the care plan to redirect the resident and remove the resident from the dining room after meal time was over. They were asked if staff had notified them the Resident was observed eating bread during activities. They stated no. The DON stated Resident #60 is not one on one, staff did checks every 2 hours and would redirect.

Based on record review and interview, the facility failed to ensure showers were provided for one (#8) of two sampled residents reviewed for ADL assistance. The administrator identified 67 residents resided in the facility. Findings: Resident #8 had diagnoses that included Parkinson's disease, was wheelchair dependent, and required supervision and touch assistance for showers. On 01/09/24 at 12:15 p.m., Resident #8 reported they had not received a shower for the past three weeks. No showers were documented for Resident #8 for the following dates: 12/23/23, 12/26/23, 12/29/23, 01/01/24, 01/03/24, and 01/05/24. The last week of December for the bathing sheets, 3 out of 3 opportunities were missed. According the first week of January 2024 bathing sheets schedule, 3 out of 3 opportunities were missed. A facility shower list documented Resident #8 was to receive showers Monday, Wednesday, and Friday of each week. On 01/09/24 at 12:16 p.m., the ADON reviewed the showers that were documented for Resident #8 and acknowledged that showers had not been given as scheduled.

Based on record review and interview, the facility failed to investigate allegations of inappropriate sexual behavior for two (#36 and #63) of three sampled residents reviewed for abuse. The Administrator identified there were 67 residents residing in the facility. Findings: An Abuse - Reportable Events policy, dated 08/2019, read in parts, .The facility administration will conduct and investigate allegations of .suspected abuse .Investigation .b. Begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family, and/or residents . Resident #63 had diagnoses that included hyperlipidemia and chronic kidney disease. A quarterly MDS for Resident #63, dated 10/11/23, documented they had BIMS of 10. A Nurses Note, written by LPN #2, dated 12/17/23, documented staff had to continuously separate Resident #63 from rubbing on a female resident. On 01/08/24 at 10:18 a.m., LPN #2 acknowledged reporting incidents of a somewhat sexual nature between Resident #63 and Resident #36 to the charge nurse on duty at the time, but did not complete any incident reports. A review of Resident #63's medical record revealed no incident reports had been created for these continuous incidents and no investigations had initiated. On 01/08/24 at 10:19 a.m., the DON denied being aware of any reports of inappropriate sexual behavior involving Resident #63 and acknowledged that if incidents had occurred, an investigation should have been initiated. 46653 2. Resident #36 had diagnosis that included unspecified dementia and cognitive communication deficit. On 01/08/24 at 1:23p.m., the DON stated LPN #2 reported the incident between Resident #36 and #63 and was aware of the families request to keep the two residents away from each other. The DON stated they did not see anything wrong and the incident should have been documented and investigated. There was no documentation the allegation had been investigated.

Based on record review and interview, the facility failed to report allegations of abuse to the State agencies for two (#36 and #63) of three sampled residents reviewed for abuse. The Administrator reported there were 67 residents residing in the facility. Findings: An Abuse - Reportable Events policy, dated 08/2019, read in parts, .1. The Charge nurse will: If a resident to resident incident occurs, staff should immediately intervene. Separate residents and take them to areas away from each other until the situation has subsided .Notify the repsonsible party/guardian and physician of each resident .2. The administrator will: Notify state agency as required . 1. A quarterly MDS for resident #63, dated 10/11/23, documented they had diagnoses that included hyperlipidemia and chronic kidney disease with a BIMS of 10. 2. A significant change MDS for resident #36, dated 01/03/23, documented they had diagnoses that included dementia and cognitive communication deficit with a BIMS of 02. A Nurse's Note, written by LPN #2 on 12/17/23, documented staff had to continuously separate Resident #63 from rubbing Resident #36. On 01/08/24 at 10:18 a.m., LPN #2 was asked if they felt the rubbing referred to in their note, written 12/17/23, was of a sexual nature. LPN #2 stated, Well, sort of, yes. LPN #2 acknowledged reporting this incident to LPN #1. On 01/08/24 at 2:15 p.m., LPN #1 acknowledged receiving report of the above-mentioned incident and speaking with MDS Coordinator #1 and the Adm. Asst. about it. There was no documentation that the allegation of inappropriate touching of a sexual nature was reported to the proper authorities. On 01/08/24 at 10:20 a.m., the DON acknowledged the incident had not been reported per facility policy.

Based on record review, observation, and interview, the facility failed to ensure privacy by preventing wandering residents from going in other residents' rooms uninvited for two (#23 and #25) of three sampled residents reviewed for privacy. The administrator identified 67 residents resided in the facility and the ADON identified seven residents that wandered. Findings: A 'Resident Rights' document, revised 08/2013, read in parts, .Privacy and confidentiality. The resident has the right to personal privacy .Personal privacy includes accommodations . 1. Resident #25 had diagnoses which included hypertension. On 01/04/24 at 2:22 p.m., Resident #25 reported there was a male resident that walks in their room all the time unwanted and drips snot everywhere. When asked what the facility had done to stop this from happening Resident #25 stated nothing, I tell them, and they just keep coming and getting him out. 2. Resident #23 had diagnoses which included hypothyroidism. On 01/04/24 at 2:57 p.m., Resident #23 reported there were unwanted residents that walked into their room all the time and they had to call for staff to get them out. When asked what the facility had done to stop this from happening Resident #23 stated nothing, they just come and get them. On 01/08/24 at 3:15 p.m., a staff member was observed walking out of Resident #25's room holding a male resident's hand and leading him down the hall. I went into Resident #25's room and asked the resident what happened. They stated, He was in here again. I wish they would do something about that. On 01/09/24 at 9:11 a.m., the ADON was asked if they received complaints from Resident #23 or #25 about residents roaming into their rooms uninvited. The ADON stated yes, but we remove them. On 01/10/24 at 9:53 a.m., the ADON acknowledged there were interventions that could have been initiated to prevent wandering residents from entering other residents' rooms and that the facility had not effectively protected the resident's right to privacy.

Based on record review and interview, the facility failed to ensure informed consent was obtained for the use of an antipsychotic medication for one (#47) of five sampled residents reviewed for unnecessary meds. The Administrator identified 67 residents resided in the facility and the DON identified 22 residents who received psychotropic medications. Findings: Resident #47 had diagnoses which included saddle embolus of pulmonary artery, high blood pressure, and dementia. A five day assessment, dated 11/18/23, documented Resident #47 had severe cognitive impairment. The clinical health record did not contain documentation an informed consent had been signed for the use of Risperdal. A medication flowsheet, dated 11/01/23 through 11/30/23, documented to administer Risperidone one milligram in the am and two milligrams at hour of sleep. A Physician Order, dated 12/11/23, documented an increase for Risperidone to two milligrams in the morning. A medication flowsheet, dated 12/01/23 through 12/21/23, documented a dose change on 12/11/23 to two milligrams in the morning. On 01/09/24 at 12:15 p.m., the Corp. Nurse Consult. #1 was asked the policy for obtaining informed consent prior to the use of psychotropic medications. They stated a consent should be obtained before the medication is administered. They were asked if a consent form had been obtained. The Corp. Nurse Consult. #1 stated there was not a consent form in the EHR but they would look in Resident #47's hard chart. No further documentation was provided by the facility.

Based on record review and interview, the facility failed to update a care plan after falls for one (#1) of four residents reviewed for care plans. The Resident Census and Conditions of Residents, dated 04/12/23, documented a census of 69. Findings: Res #1 was admitted with diagnoses which included dementia and below the knee amputation. The Care Planning - Interdisciplinary Team policy, revised 12/08, documented in parts, .develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning .care plans are revised as information about the resident and resident's condition change. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans . The Quarterly Fall Risk, dated 02/23/23, documented Res #1 had diminished safety awareness and impaired mobility. It documented the resident had a history of falls within the past three months and rated the resident at a high risk for falls. Res #1's fall care plan was last updated on 02/26/23. A quarterly assessment, dated 03/30/23, documented Res #1 had severe cognitive impairment, was non-ambulatory, and required total assistance with activities of daily living. A progress note, dated 04/08/23 at 4:23 p.m., documented Res #1 was found in the floor on a fall mat. A progress note, dated 04/12/23 at 7:13 p.m., documented Res #1 was found in the floor. On 04/13/23, at 3:15 p.m., the ADON stated the care plan for Res #1 should have been updated after the falls on 04/08/23 and 04/12/23. On 04/13/23 at 3:30 p.m., the Administrator stated the care plan for Res #1 should have been updated after the falls on 04/08/23 and 04/12/23.

Based on record review and interview, the facility failed to: a. identify residents at risk for falls for four (#1, 2, 3 and #5) of five residents reviewed for falls b. implement interventions to prevent falls for two (#1, and #2) of five residents reviewed for falls. The All Falls for Facility report dated, 09/13/22 through 12/13/22, identified 39 residents with falls. A Falls - Evaluation and Prevention policy last revised 12/19 read in parts, POLICY: It is the policy of this facility to assess/evaluate each resident for the potential for falls and fall risk and implement interventions for fall prevention as indicated .RESIDENTS SHOULD BE EVALUATED FOR THEIR FALL RISK: On admission/re-admission to the facility, following any change of condition ., following a fall or near-fall whether witnessed or unwitnessed, quarterly .upon admission, the nursing staff/interdisciplinary care team should determine if a resident it at risk for falls and develop appropriate interventions based on the evaluation .Interventions will be implemented based on the fall risk assessment score and evaluation of other risk factors .New interventions will be implemented following subsequent falls should they occur . Res #1 was admitted on [DATE] with diagnoses which included muscle wasting/atrophy, debility and difficulty walking. There were no fall risk assessments completed for Res #1 between their admission on 09/23/22 and their discharge on 11/14/22. A progress note, dated 11/06/22 at 11:00 p.m., read in parts, Pt. heard hollering out for help. Found pt. lying on her backside in the floor. Pt. c/o pain to top of head but not sure if she hit it. No noted hematoma or laceration. Pt. states she was trying to get into her w/c and fell back onto bottom .Pt does c/o pain to their bottom . A fall care plan, dated 10/06/22, did not have a fall intervention for the fall on 11/06/22 for Res #1. Res #2 was admitted with diagnoses which included muscle wasting/atrophy, debility and difficulty walking. Fall risk assessments were not completed after each fall for seven of seven falls between 09/14/22 through 12/13/22. Fall risk assessments were not completed quarterly between 03/04/22 and 12/14/22. A progress note, dated 11/29/22 at 11:00 a.m., read in parts, Pt heard hollering out for help. Found pt. lying on her backside in the floor. Pt c/o pain to top of head but not sure if she hit it. No noted hematoma or laceration .Pt c/o pain to her bottom . A fall care plan, dated 07/02/21, last revised on, 12/08/22, did not have a fall intervention for the fall on 11/29/22 for Res #2. Res #3 was admitted with diagnoses which included weakness and lack of coordination. There were no fall risk assessments completed for Res #3 since admission on 09/30/22. Res #5 was admitted with diagnoses which included weakness, muscle wasting/atrophy, and difficulty in walking. There was no fall risk assessment completed for Res #5 upon admission. On 12/14/22 at 9:45 a.m., the ADON reported interventions should have been developed and fall risk assessments completed with every fall.

Based on record review and interview, the facility failed to develop a baseline care plan regarding falls for two (#1 and #3) of five residents reviewed for falls. The Admit/Discharge Report dated, 09/13/22 through 12/13/22, identified 35 residents as new admissions in the last three months. Findings: A Care Plans - Preliminary policy revised 12-22, documented in parts, A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission .To assure that the resident's immediate care needs are met and maintained .the preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. Res #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 09/23/22 at 6:00 p.m., read in parts, CN-called down to room by CMA - (name withheld) D/T resident was in the floor. Upon arrival was sitting up on her bed, said she got up and is ok, that she falls all the time. No apparent injuries noted at this time . A progress note, dated 09/25/22 at 6:16 p.m., read in parts, Called (name withheld) NP, on call for Dr. (name withheld), notified resident had a fall .orders for resident to be sent to the ER . A baseline care plan regarding falls was not developed for Res #1. Res #3 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 10/01/22 at 6:21 p.m., read in parts, Heard someone yelling; went to resident room and noticed resident sitting in the floor with legs under the bed. Resident stated she couldn't get up . A progress note, dated 10/02/22 at 7:30 a.m., read in parts, Resident was ambulating in hallway with wheeled walker lost her balance and fell . A baseline care plan regarding falls was not developed for Res #3. On 12/14/22 at 9:45 a.m., the ADON reported there was no baseline care plans for falls developed for Res #1 and #3.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 03/03/22 related to the facility's failure to thoroughly investigate an allegation of abuse and prevent further potential abuse for all residents while the investigation was in progress for Res #1. On 03/03/22 family member #1 reported observing CNA #1 slap Res #1 across the face. The facility did not provide abuse training upon hire for CNA #1. CNA #1was allowed to return to work before the abuse investigation was completed. Residents were not questioned regarding abuse until four days after the allegation of abuse was made. Family member #1 was not questioned about what they witnessed nor was a statement obtained from them. On 10/14/22 at 6:00 p.m., the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to thoroughly investigate an allegation of abuse and prevent further potential abuse while the investigation was in progress. The past noncompliance IJ was removed, effective 03/10/22 at 6:56 p.m., once the facility concluded their abuse investigation and put measures in place to ensure that residents were protected from abuse and the facility staff received abuse training. An in-service regarding abuse was conducted on 03/04/22 for all facility staff and newly hired employees received abuse training prior to working the floor. Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for one (#1) of one resident reviewed for abuse and prevent further potential abuse for all residents while the investigation was in progress. The Residents Census Conditions of Residents, dated 10/12/22, documented 69 residents resided in the facility. The Abuse - Reportable Events policy dated 08/19 read in parts, Training: .All new employees will receive in-service training pertaining to all aspects of abuse prohibition before working a shift .Investigation: Begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family and/or residents .Ask any witness to wait for the Administrator or the person on-call to arrive at the facility. If an employee is involved, the employee will be detained and removed from their assigned duties until they are interviewed by the Administrator .Assess all residents who may have been affected or suspicion of abuse with head to toe assessments and completion of Safe Survey Questionnaires .All allegations involving staff will necessitate suspension without pay, pending investigation . Resident #1 was admitted with diagnoses which included Parkinson's disease, dementia, and cognitive communication deficit. An Incident/Accident Report, completed by the MDS Coordinator, dated, 03/03/22 at 9:00 p.m., read in parts, Family member #1 .stated she witnessed CNA #1 slap Res #1 in the face .also stated CNA #2 was in the room .skin assessment complete. No noted injuries. A final Incident Report Form was submitted to OSDH on 03/10/22 and read in part, .CNA #1 was suspended immediately pending investigation. CNA #1 was hired on 02/17/22, did not complete abuse training until 03/11/22, eight days after an allegation of abuse was made regarding them. A Timecard Editor dated, 02/27/22 - 03/19/22, documented on 03/03/22 CNA #1 clocked out at 9:12 p.m., 12 minutes after the allegation of abuse. A Timecard Editor dated, 02/27/22 - 03/19/22, documented on 03/04/22 CNA #1 clocked in at 2:02 p.m., 17 hours after the allegation of abuse, 6 days prior to the investigation being concluded. The was no documentation to show Family Member #1 was neither interviewed by the administrator regarding abuse allegation, nor was their witness statement obtained. A witness statement was obtained from CNA #1 and #2 on 03/04/22, one day after the allegation of abuse. The Resident Safe Survey Questionnaire was not given to residents until 03/08/22, four days after the allegation of abuse. On 10/13/22 at 2:00 p.m., the administrator stated CNA #1 was allowed to return to work before the investigation was completed because both CNA #1 and CNA #2 denied the allegation. The administrator reported he should have followed the facility's abuse policy and made sure CNA #1 completed their abuse training before working the floor and remained suspended until the investigation was completed. The administrator stated the Resident Safe Survey Questionnaire should have been started at the time of the abuse allegation, not four days later.

Based on record review, observation and staff interview, it was determined the facility failed to ensure: a) Skin assessments were completed weekly per the facility policy and procedure for one (#3) of one sampled resident with pressure sores. b) Two newly identified unstageable pressure sores were reported to the physician and treatment orders obtained for one (#3) of two sampled residents with pressure sores. This had the potential to affect three residents identified by the DON as having pressure sores. This was actual harm to resident #3. Findings: The facility's policy and procedure documented: "Pressure Ulcer, Care and Prevention of: ...If a pressure ulcer is present, the licensed nurse is responsible to record condition of the skin, including stage, size, depth, color, drainage and odor as well as the treatment provided. Notification of the physician is required when a new pressure ulcer is identified as well as when treatment is not effective... Skin Assessments: ...known pressure ulcer assessments are to be completed on Fridays. If a resident develops, or is admitted /readmitted with a pressure ulcer, move the paper work to the Friday divider for the designated shift..." Resident #3 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/15/13, documented the resident had moderately impaired cognition, required extensive assistance with bed mobility, transferring between surfaces, hygiene and bathing. The assessment documented the resident required supervision with eating, was always incontinent of bowel and bladder, was at risk for pressure sores, but did not have any pressure sores at the time of the assessment. On January 2013, April 2013 and July 2013, the 'Braden Pressure Ulcer Risk Assessment', for resident #3, documented a score of 15. The form documented, "15 or 16= low risk of developing pressure ulcers." On 02/12/13, a care plan documented, "Problem: (Name deleted resident #3) is at risk for pressure ulcers related to frequent incontinence and decreased mobility...Approach: ...Skin will be assessed weekly. Staff will contact the physician as needed for any areas of concern." On 05/15/13, a care plan revision documented, "She does cont to be at risk for pressure ulcers 0 pressure ulcers @ this time. Cont current POC." On 06/24/13, 07/01/13 and 07/08/13, the 'Skin Assessment Flowsheet', documented the resident's skin was warm, dry and intact. On 07/13/13, an admission nursing evaluation, documented, "Arrived to facility...Skin assessment completed see skin book..." On 07/13/13, a 'Skin Assessment Flowsheet', documented, "readmitted from (Name deleted) hosp. Possible DTI (deep tissue injury) noted to coccyx deep purple in color. No other skin issues noted." On 07/13/13, a telephone physician's orders [REDACTED]." On 07/13/13, a care plan revision, documented, "Resident has a pressure area: Location: coccyx...Approach: Perform treatment per order, if no improvement with in two weeks- report to M.D...Keep family/responsible party and M.D. informed of resident's progress...Cleanse area to coccyx c DWC pat dry. Apply Meplex bordered to sacrum qod until healed x 14 days & re-eval." On 07/13/13, a 'Skin Assessment Flowsheet- Pressure Sore', documented, "Stage- UTS (unable to stage), Dimensions (cm)- L: 5 1/2, W: 7 1/2, Code: DTI." The pressure area was not assessed until 07/26/13, when a 'Skin Assessment Flowsheet- Pressure Sore', documented, "Stage- UTS (unable to stage), Dimensions (cm)- L (length): 5.5, W (width) : 7.5, Code: DTI." LPN #2 was the nurse that completed the assessment. On 07/31/13 at 9:45 a.m., the ADON, who was an LPN, was observed providing pressure sore treatment for [REDACTED]. The ADON was observed to clean the area with DWC with 4x4 gauze. The LPN was then asked to measure and stage the open area. The LPN reported the pressure sore on the right upper buttocks measured 1.5 x 0.6 cm and was unstageable due to slough in the bed of the wound. The LPN then measured the pressure sore on the middle section of the left buttock. She report the sore measured 3 x 1 and was unstageable due to the wound bed containing slough. The LPN then covered the pressure sores with Meplix boarder foam. The LPN reported the Meplix foam was just for cushion on the pressure sores. On 07/31/13 at 1:00 p.m., LPN #2 was interviewed. The LPN was asked if the resident had any open pressure sores when she had completed the wound assessment on 07/26/13. The LPN reported the area did not have any open areas, only the purple of the DTI. On 07/31/13 at 2:00 p.m., LPN #1 was interviewed. The LPN had administered the last pressure sore treatment for [REDACTED]. LPN #1 was asked what the pressure sore had looked like when observed two days ago. The LPN reported the area had been purple in color when the resident first came back to facility from the hospital. She reported when she had provided the pressure sore treatment two days ago there had been two stage II pressure sores. The LPN was asked what treatment she had provided. She reported the same treatment that had been started when the resident had come back from the hospital. The LPN was asked if she had contacted the physician due to the two new opened areas. She reported she had not. Two days after the two pressure sores had opened and the physician had been contacted, the following new orders were written: On 07/31/13 at 4:30 p.m., a telephone physician's orders [REDACTED]. Apply Santyl & collagen cover c non bordered foam drsg & secure c transparent film qd x 14 days & re-eval or until healed and, Cleanse open area to (L) buttocks c DWC, pat dry. Apply [MEDICATION NAME], cover c collagen, non bordered foam drsg & secure c transparent film qd x 14 days & re eval or until healed. Decubvite 1 cap po QD for promotion of wound healing."

Based on record reviews, observations and staff interviews, it was determined the facility failed to: a.) Ensure pressure sores were assessed weekly, with staging and measurements documented for six (#1, 4, 5, 6, 7, and #11) of eight sampled residents identified with pressure sores. Resident #6 had actual harm. This had the potential to affect all eight sampled residents identified with pressure sores during the survey process. The facility had identified only three residents with pressure sores at the beginning of the survey per the 'Resident Census and Conditions of Residents' form. b) Ensure pressure sore treatments had been provided without contaminating the pressure sores for four (#1, 5, 6 and #7) of four sampled residents observed during pressure sore treatment. This affected four residents and had the potential to affect eight sampled residents identified with pressure sores during the survey. The facility had identified only three residents with pressure sores at the beginning of the survey per the 'Resident Census and Conditions of Residents' form. c) Ensure Protein Powder, ordered by the residents' physicians, to promote pressure sore healing, had been administered for two (#5 and #6) of two sampled residents. This affected two of eight residents identified with pressure sores during the survey process. The facility had identified only three residents with pressure sores at the beginning of the survey per the 'Resident Census and Conditions of Residents' form. d) Ensure a pressure sore treatment had been ordered by the residents' physicians for two (#6 and #9) of eight sampled residents identified with pressure sores. This had the potential to affect the other six residents with pressure sores identified during the survey. The facility had identified only three residents with pressure sores at the beginning of the survey per the 'Resident Census and Conditions of Residents' form. e) Ensure pressure relieving devices were being utilized for three (#1, 5 and #11) of eight sampled residents identified with pressure sores. This had the potential to affect all eight residents identified with pressure sores during the survey. The facility had identified only three residents with pressure sores at the beginning of the survey per the 'Resident Census and Conditions of Residents' form. Findings: On 02/08/12, the nursing policy and procedures book was reviewed to locate a policy on pressure sores. No policy could be located. On 02/08/12, at 3:00 p.m., the ADON (assistant director of nursing) was asked for a pressure sore policy and procedure. The ADON looked in the nursing policy and procedures book and could not find one. She then said she would look in the other policy and procedure book. The ADON came back, a short time later, with a policy and procedure for pressure sores. She asked the surveyor if this was okay. The ADON was asked where she had found the policy. She said the previous corporate RN had typed up the policy, but the policy had never been okayed to put into the policy book. The facility's policy and procedure for 'Incontinent Care' documented, "...Inspect skin and report all irritated areas to charge nurse. The charge nurse is to notify a physician when a decubitus first occurs or when treatment is not effective..." 1. Resident #6 had [DIAGNOSES REDACTED]. An order signed by the physician on 01/20/11, documented, "...Protein Powder 1 scoop at meals." A 'Braden Pressure Ulcer Risk Assessment', dated 09/13/11, for the resident, documented a score of '15'. The form documented a total score of '16' or less are considered a high risk of developing pressure ulcers. A 'Weekly Skin Integrity Review', dated 11/08/11, documented, "Stage II to right gluteal." The weekly assessment did not document measurements or a description of the pressure sore. Seven days later, a 'Weekly Skin Integrity Review', dated 11/15/11, documented, "Tx (treatment) to right gluteal cont. (continue)." The weekly assessment did not document measurements or a description of the pressure sore. Seven days later, a 'Weekly Skin Integrity Review', dated 11/22/11, was left blank and did not address the resident's skin. The form had just been signed by a LPN (licensed practical nurse). Seven days later, a 'Weekly Skin Integrity Review', dated 11/29/11, documented the resident's skin was intact and dry. Nine days later, a 'Weekly Skin Integrity Review', dated 12/08/11, documented the resident's skin was intact and dry. Two weeks later, a 'Weekly Skin Integrity Review', dated 12/22/11, documented, "Tx to Stage II on right gluteal." The assessment did not document measurements or a description of the pressure sore. A 'Weekly Skin Integrity Review', dated 12/27/11, documented, "Tx to Stage II on right gluteal." The assessment did not document measurements or a description of the pressure sore. An annual assessment, dated 12/28/11, documented she had inadequate short and long term memory, severely impaired cognition, was totally dependent on staff for bed mobility, required extensive assistance with transferring between surfaces, was not ambulatory, required extensive assistance with dressing, eating, hygiene, was occasionally incontinent of bladder and always incontinent of bowel, was at risk for developing a pressure sore, but did not have a pressure sore at the time of the assessment. On 12/22/11, a stage II pressure sore had been found on the resident's 'right gluteal' and should have been identified on the annual assessment dated [DATE]. A care plan, dated 12/28/11, documented, "Problem: (Name deleted resident #6) is at risk for pressure ulcers due to incontinence and decreased mobility. She depends on staff for transfers, incontinent care & positioning... Interventions: Staff will perform a body/skin audit at least weekly...(Name deleted resident #6) will be offered a bath 3 times weekly as ordered...Staff will monitor (Name deleted resident #6) skin daily for reddened areas and report them to the doctor as needed.... Problem: (Name deleted resident #6) is at risk for impaired nutrition less than body requirements AEB (as evidenced by) she requires the use of a mechanically altered diet. She also requires total assist with her meals. She is at risk for oral pain due to she has her own teeth. She is missing some of her teeth and some are in poor condition... Interventions: ...Pureed with one scoop of protein powder added to each meal... Problem: Resident requires hospice as evidence by terminal illness of : [MEDICAL CONDITION]'s chorea... Approach: ...Monitor for decreased appetite, weight loss, skin break down, n/v (nausea and vomiting), report to hospice... Problem: Stage II right gluteal... Approach: Cleanse c (with) DWC, pat dry, apply think layer of [MEDICATION NAME], cover c collagen & border foam drsg (dressing) qd (everyday) X 21 days & re-valuate..." A 'Weekly Skin Integrity Review', dated 01/06/12, documented, "0.1 x 0.1 x 0.2, tx to Stage II cont." The diagram of the body, documented the pressure sore on the resident's right buttocks. The assessment did not document a description of the pressure sore. A 'Weekly Skin Integrity Review', dated 01/13/12, documented, "0.1 x 0.1 x 0.2, open area, old." The assessment did not document the location of the pressure sore or document a description of the pressure sore. On 01/13/12, hospice documented, "Skin: Stage II to coccyx c tx in place..." On 01/28/11, the resident's physician had faxed the facility a form titled, 'Guidelines for Clinically Unavoidable Pressure Sores'. The form documented, "...Resident is thin, frequent movements due to [MEDICAL CONDITION]'s. Has developed Stg II pressure ulcer, on coccyx. Supplements are Med Pass 2.0 60 mls (milliliters) QID (four times a day) & Protein Powder 1 scoop TID (three times a day)..." The February 2012, physician's orders [REDACTED]. Pat dry. Apply thin layer of [MEDICATION NAME] & cover c collagen & non stick [MEDICATION NAME] & secure c [MEDICATION NAME] q day X 21 days & re-eval...DIET: PUREED WITH ONE SCOOP OF PROTEIN POWDER ADDED TO EACH MEAL.." On 02/09/12, at 9:30 a.m., LPN (licensed practical nurse) #1 was observed providing pressure sore treatment for [REDACTED]. The resident was repositioned to her side with the assistance of a CNA (certified nurse aide). The resident was observed to have four open areas on her coccyx. The LPN was asked what he would stage the four pressure sores. The LPN reported stage II's. The LPN was asked to measure the pressure sores. He reported there were four Stage II pressure sores with the following measurements: 1 cm (centimeter) x 1 cm on the far right, .5 x .9 in the middle, 2 cm x 1 cm on the top center and .5 cm x 1.5 cm in the bottom center. The LPN was asked which of the open areas had been identified on the last skin assessment. He reported the bottom center had been identified as being open at that time. The LPN was observed to obtain a 4 x 4 gauze. The LPN wet the 4 x 4 with DWC (Dermal wound cleanser) and cleaned all the stage II pressure sores at the same time, using a circular motion. Using the same 4 x 4 gauze promoted cross contamination. The LPN then obtained a second 4 x 4 gauze and patted the areas dry. (Using the same 4x4 to dry the four separate pressure sores also caused cross contamination of the pressure sores) The LPN never changed gloves or washed his hands between the treatment of [REDACTED]. The LPN had a plastic medication cup containing [MEDICATION NAME] ointment. Using one Q-tip, the LPN applied the ointment on all four of the stage II pressure sores. This again, cross contaminated the four pressure sores. After the [MEDICATION NAME] had been applied, the four pressure sores were covered with Collagen and a clear adhesive dressing. The LPN was observed to treat all the areas with the same 4 x 4 gauzes and the same Q-tip and never changed gloves or washed his hands during the entire treatment. At 10:20 a.m., the ADON was interviewed. She was asked what the facility's policy and procedures were related to skin assessments and pressure sores. The ADON reported a head-to-toe assessment was to be completed weekly. All pressure sores were supposed to be assessed on Fridays and the assessments should contain measurements. On 02/09/12, at 1:30 p.m., cook #1 was interviewed. Cook #1 was asked which food or drink item on the lunch meal she had added the resident's protein powder. She reported she had not put the protein powder in anything, because the facility was out of the protein powder. The cook was asked how long she had been cooking for the facility. She reported one month. The cook was then asked how long the facility had been out of the protein powder. She reported the facility had some when she first started, but she had never used it since she had worked at the facility. At 1:35 p.m., the DM (dietary manager) was asked where the protein powder was kept. She reported the protein powder was stored in the stock room. The DM pointed to an empty shelf and reported that was where the protein powder would be, if they had any. The DM then reported she was new to the position and had not been aware the facility had been out of protein powder. She said they would order some protein powder tomorrow. She said it would be next week before any protein powder would be delivered. 2. An annual assessment, dated 11/21/11, for resident #7, documented the resident had adequate short and long term memory, was cognitively intact, required supervision with bed mobility, required assistance from staff with transferring between surfaces and ADLs, was occasionally incontinent of bowel and bladder, was at risk for developing pressure sores and had one Stage II pressure sore at the time of the assessment. A 'Weekly Skin Integrity Review', dated 01/09/12, documented, "Skin intact, dry." A 'Weekly Skin Integrity Review', dated 01/17/12, documented, "3.0 x 3.0 x 0.1 Stage II (R) gluteal tx in place." There were no more weekly skin assessments since 01/17/12. A care plan, dated 01/31/12, documented the following: "Problem: Resident has current skin concerns: Stage II left gluteal... Approach: ...Perform treatments per order, if no improvement x 2 weeks. Report to MD (medical doctor). Monitor areas for increase breakdown, s/s (signs and symptoms) of infection, report to M.D. Cleanse c (with) DWC, pat dry, apply thin layer of TAO (Triple Antibiotic Ointment) over c adhesive bandage qd (everyday)X 14 days & re-eval." The February 2012, physician's orders [REDACTED]. On 02/08/12, at 4:00 p.m., the ADON (assistant director of nursing) was interviewed. She was asked if the resident's skin had been assessed since 01/17/12. The ADON reported the DON (director of nursing) had told the wound nurse to get the assessments caught up, but it did not look like it had been done. On 02/09/12, at 10:45 a.m., LPN (licensed practical nurse) #1 was observed providing a pressure sore treatment for [REDACTED]. The LPN washed his hands and donned gloves. The supplies were already set-up in the resident's room on the bedside table. The resident stood up from his W/C (wheelchair) and held onto a table, while the LPN provided the care per the resident's choice. First the LPN removed the dirty dressing and then realized he needed something to measure the pressure sore from the treatment cart which was setting outside the resident's room. The LPN removed his gloves and went out to the treatment cart without washing his hands or using alcohol gel. The LPN came back into the room and without washing his hands, donned another pair of gloves and proceeded to measure the resident's pressure sore. The last time the pressure sore had been measured was on 01/17/12, and measured 3.0 x 3.0 x 0.1. The LPN measured the pressure sore as 4 x 2 cm (centimeters). With the same gloves on, the LPN proceeded to clean the pressure sore with NS (normal saline) and 4x4s. The LPN then realized the [MEDICATION NAME] was in the treatment cart. He removed his gloves and without washing his hands, went back out to the treatment cart to obtain the [MEDICATION NAME]. The LPN came back into the room, and without washing his hands, donned gloves and proceeded to apply the [MEDICATION NAME] to the pressure sore, then applied Alginate dressing, an ABD (abdominal pad) and secured the dressing with paper tape. On 02/09/12, at 1:00 p.m., the DON was informed of the lack of handwashing. She said, he knows better. 3. A care plan, dated 03/17/11, for resident #9, documented the following: "Problem: Resident is at risk for skin breakdown related to: incontinence, immobility, fragile skin, cognitive impairment, physical impairment... Approach: ...Monitor for skin break down, report to M.D. (medical doctor) and R. P (responsible party)..." The last 'Braden Pressure Ulcer Risk Assessment', was dated 09/04/11, and documented a score of '20'. The form documented a score of 16 or less represented a high risk of developing pressure ulcers. The form did not document what a score of '20' represented. A quarterly assessment, dated 12/10/11, documented the resident had inadequate short and long term memory, moderately impaired cognition, required assistance from the staff with bed mobility, transferring between surfaces, ADLs (activities of daily living), was occasionally incontinent of bowel and bladder, was at risk for developing pressure sores, but did not have any pressure sores at the time of the assessment. The February 2012, physician's orders [REDACTED]. On 02/08/12, at 4:00 p.m., the resident's 'Weekly Skin Integrity Review' sheets were reviewed. The last documented skin assessment had been completed on 01/18/12, and documented the resident's skin was intact and dry. On 02/09/12, at 3:30 p.m., the ADON (assistant director of nursing) was assisting with the assessment of the resident's skin. The resident was observed lying in her bed. The ADON was observed to reposition the resident onto her side. The resident reported to the ADON that her buttocks had been hurting. When the resident was uncovered she was observed naked from the waist down and had an open area on her coccyx. The ADON measured the area as 1 cm (centimeter) x 1.5 cm and reported the area as a Stage II pressure sore. On 02/09/12, at 4:00 p.m., the ADON was interviewed. The ADON was asked if the resident was continent or incontinent. She reported the resident was incontinent at times. The ADON was asked if she would have expected the CNAs (certified nurse aide) who had provided care to the resident that day, to have seen the pressure sore on the resident's coccyx. She reported someone should have seen the area when they toileted her or provided incontinent care. The ADON said the pressure sore should have been reported to the charge nurse and an order obtained from the physician to treat the pressure sore. 4. Resident #4 had been admitted to the facility on [DATE], and had been discharged to home on 09/27/11. The afternoon of 02/08/12, the closed medical record for the resident was obtained. The records were still in the original binder they had been placed in while the resident was residing in the facility. The resident's [DIAGNOSES REDACTED]. The admission assessment, dated 09/01/11, documented the resident was at risk for pressure sores and had one Stage II pressure sore. The care plan, dated 08/19/11, documented, "...Number present on admission/reentry: 1 Stage II to coccyx..." The admission nursing evaluation, dated 08/19/11, documented a small stage II pressure sore to the buttocks. There were no measurements for the pressure sore or the location, either the left or right buttocks. A physician's telephone order, dated 08/19/11, documented, "...Cleanse open area to coccyx c (with) DWC (Dermal Wound Cleanser), pat dry, apply thin layer of TAO (Triple Antibiotic Ointment), cover c Derma-gel transparent Drsg (dressing) Qd (every day) x 14 days and re-eval." The August, 2011, treatment sheet documented a treatment had been completed on a 'coccyx' pressure sore, August 20th through the 30th, 2011, when the word 'healed' had been hand-written in below the '30th'. The skin assessment book was reviewed for assessments of the pressure sore which had been identified on admission. No assessments could be located for the pressure sore. On 02/08/12, at 5:30 p.m., the ADON (assistant director of nursing) was asked if she would look for any skin assessments completed for the resident on the pressure sore identified on admission. On 02/09/12, the ADON was asked if she had located any pressure sore assessments for the resident. She said she had looked everywhere. She said there had been no assessments completed. 5. Resident #5 had been admitted to the facility on [DATE]. The 14-day admission assessment, dated 01/17/12, documented the resident had good cognition, had one Stage II pressure sore and was frequently incontinent of bowel and bladder. The care plan documented a Stage II to the buttocks: Cleanse with DWC, pat dry, apply TAO and cover with bordered foam dressing qd (everyday) x 14 days & reevaluate. "2/1/12 Continue tx (treatment) x 14 days & reeval." A physician's orders [REDACTED]. The skin assessment book was reviewed on 02/08/11. The resident did not have any completed skin assessments in the skin book. The skin assessment book was to contain the assessments for any resident identified with pressure sores. On 02/08/12, at 5:10 p.m., the ADON (assistant director of nursing) was asked if she could locate any skin assessments for the resident. After looking, she said there were no pressure sore assessments in the skin book. The ADON said she would call the Director of Nursing (DON), who was out of town, to see if she knew any place else the assessments were located. The ADON called the DON and reported back to the surveyors. The ADON said the DON had previously told the charge nurse to 'get the book caught up'. On 02/09/12, at 10:00 a.m., LPN (licensed practical nurse) #1 was observed providing pressure sore treatment for [REDACTED]. The LPN washed his hands and donned gloves. The LPN cleaned the pressure sore with normal saline, patted the area dry with 4x4's, applied TAO with a Q-tip and then covered the pressure sore with bordered foam. The LPN wore the same gloves during the entire treatment and never washed his hands between dirty to clean. The LPN was asked the size of the pressure sore just treated. The LPN said 'about 2 x 2'. The resident's wheelchair (W/C) was observed. The W/C had an incontinent pad in the seat. There was not a cushion to relieve pressure off the resident's buttocks. The resident had been observed in the W/C during the day and until bedtime. On 02/09/12, at 1:00 p.m., the dietary staff was interviewed. Cook #1 was asked which food or drink item on the lunch meal she had added the resident's protein powder. She reported she had not put the protein powder in anything, because the facility was out of protein powder. The cook was asked how long she had been cooking for the facility. She reported one month. The cook was then asked how long the facility had been out of the protein powder. She reported she didn't know, but she had never used it since she had worked at the facility. At 1:15 p.m., the DM (dietary manager) was asked where the protein powder was stored. She reported the protein powder should be in the stock room. On going into the storage room, the DM pointed to an empty shelf. She said that is where the protein powder should be. The DM then reported she was new to the position and had not been aware the facility had been out of protein powder. She said they would order some protein powder tomorrow and the powder would be in the next week. 6. The medical record for resident #1, documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. An admission assessment, dated 04/21/11, documented the resident had severely impaired cognition, required extensive assist with transfers, ambulation, total assist with bathing and hygiene and was always incontinent of bowel and bladder. The assessment identified the resident as being at risk for developing pressure sores, had no identified pressure sores and had a pressure reducing device in chair and bed. The resident's care plan, dated 04/21/11, documented the resident required extensive assist with ADLs (activities of daily living) and was dependent on the staff for personal hygiene. Weekly skin sheets documented her skin was intact and dry on the following dates: October 2011: 6th, 13th, 20th and 27th. November 2011: 3rd, 10th, 17th and 24th. December 2011: 1st, 8th, 15th, 22nd and 28th. The resident's care plan documented, "1/10/12 Resident has current skin concerns: (redness buttocks)...Keep M.D. (medical doctor) and R.P. (responsible party) informed of residents progress. Cleanse c DWC, pat dry, apply thin layer of diaper rash 40% zinc BID (twice a day)..." The January 2012, treatment sheet documented, "Diaper rash cream c 40% Zinc apply to buttocks, BID X 14 d then re-eval 1/10/12." Weekly skin sheets for the resident documented the resident's skin was intact and dry on 01/12/12. The skin sheet did not identify the redness to the resident's buttocks. There were no skin assessments after the one dated 01/12/12. An entry on the resident's care plan documented,"1/24/12 Resident has current skin concerns; Excoriation... Keep M.D. and R.P. (responsible party) informed of residents progress. Cleanse c DWC, pat dry, apply generous amount of [MEDICATION NAME] cream BID..." The February 2012, treatment sheet documented, "Cleanse excoriated area to buttocks with DWC, pat dry. Apply generous amount of [MEDICATION NAME] cream BID X 14 days and re eval. 01/24/2012." There were no skin assessments identifying the excoriation to the resident's buttocks. A nurse's note, dated 02/08/12, at 7:00 p.m., documented, "Res toileted X 2 assist, Stage II to coccyx...N.O. (new order) for tx..." The nurse's note was signed by RN (registered nurse) #1. A telephone order, dated 02/08/12, documented, "Cleanse open area to coccyx c DWC, pat dry apply thin layer of TAO (triple antibiotic ointment) cover c (with) bordered dressing q d (everyday) and prn (as needed)..." The resident's skin had not been assessed on a weekly basis to monitor for breakdown. On 02/08/12, at 7:20 p.m., RN (registered nurse) #1 was observed preparing to provide a wound treatment to the resident's pressure sore on her coccyx. The RN was observed to remove her supplies from the treatment cart. The RN gloved her hands and then opened the bottom drawer of the treatment cart. The RN removed several 4X4 gauze pads from the drawer. The RN was observed to shut the drawer with the 4X4 gauze pads touching the drawer. The RN entered the resident's room. The resident was in her recliner. The RN and a CNA attempted to assist the resident to a standing position. The resident was unable to stand due to her sock feet slipping on the floor. The resident was returned to the chair and the RN reported they would have to place her shoes on her. The RN was observed to put the resident's shoe on her foot by pushing on the sole of the foot with her gloved hand. The RN did not remove her soiled gloves. The resident was then assisted to stand. The RN, without changing her gloves, sprayed a wound cleanser onto the 4X4 gauze pads and placed TAO onto the dressing. The RN took the 4X4 gauze and wiped over the pressure sore. The RN then patted the area dry and placed the dressing over the pressure sore. The RN did not change her gloves at any time during the wound care. The RN removed her gloves after applying the dressing to the pressure sore. On 02/09/12, at 11:05 a.m., the RN was asked if she had done an assessment and measured the resident's pressure sore. The RN reported she had not. She reported she thought the wound was about .5 cm (centimeter) X .5 cm. She reported she would get the measurements. At 11:20 a.m., the resident was observed in her room, in her W/C (wheelchair). LPN #1 was observed to provide a treatment to the resident's pressure sore on her coccyx. RN #1 assisted the LPN with the treatment. The RN and LPN reported they were going to take the resident to the bathroom, so she could hold onto the grab bar, which made it easier for the resident to stand. The resident was pushed into the bathroom in her W/C. The LPN donned gloves. The LPN and RN assisted the resident to a standing position. The back of the resident's pants were observed wet. The resident had been sitting on an alarm pad in the W/C. There was no cushion in the resident's W/C to provide pressure relief. The RN and LPN were asked why the resident didn't have a W/C cushion to reduce the pressure. The RN reported the resident should have had a W/C cushion in her W/C, especially since she had a new pressure sore. The LPN was observed to pull the resident's wet pants and brief down. The LPN, without changing gloves, removed the old dressing from the coccyx, took 4X4 gauze pads from a cup and wiped the pressure sore. The LPN reported the gauze pads had the wound cleanser on them. The LPN, without changing his gloves, measured the pressure sore. The LPN reported the pressure sore measured 1 cm (centimeter) X 1 cm. After completing the measurements, the LPN placed the TAO on the pressure sore, using a q-tip. The LPN then placed the padded foam dressing over the pressure sore. The LPN did not change his gloves during the entire procedure. On 02/09/12, at 4:50 p.m., the ADON was interviewed regarding the lack of skin assessments since 01/12/12, and the resident having a stage II pressure sore. The ADON was informed of the treatment orders for skin problems after the 01/12/12, date and no assessments to address the skin problems. The ADON reported there should have been weekly skin assessments for the resident. She reported the policy was to assess every resident's skin weekly. She reported there should be a head-to-toe assessment on everyone at risk, especially if the resident had a skin issue. The ADON was then informed of the observations of two different staff providing wound care without changing soiled gloves. The ADON reported the gloves should have been changed between clean and dirty and hands should be washed with each glove change. The ADON was also informed the resident was sitting in her W/C without a cushion. She reported there should have been a cushion to prevent pressure. The ADON reported she would inservice the nursing staff. 7. The medical record for resident #11, documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. An annual assessment, dated 08/24/11, documented the resident had severely impaired cognition, required extensive assist with transfers, total assist with grooming/ hygiene, was frequently incontinent of bowel and bladder, was at risk for pressure sores, and had a stage II pressure sore. The resident's care plan, dated 08/24/11, documented the resident was at risk for pressure sores due to incontinence. The goal documented the resident would have no pressure sores greater than a stage II during the next quarter. Interventions included weekly skin assessments, repositioning q (every) 2 hours and to pressure relieving devices in place. An entry on the care plan, dated 08/29/11, documented the resident had a stage II on her spine. Weekly skin assessments, dated 10/07/11, 10/14/11, 10/21/11, 10/28/11, 11/04/11 and 11/11/11, documented the resident had a stage II to the spine which was healing well. There was no description or measurement of the pressure sore on any of the assessments. There was no documentation the wound had closed on the assessments. The next assessment, dated 11/18/11, documented the skin was intact and dry. The weekly skin assessments from 11/18/11 through 01/12/12, documented the resident had dry, intact skin. There were no assessments after 01/12/12, in the skin book. A quarterly assessment, dated 11/24/11, documented the resident had severely impaired cognition, required extensive assist with transfers, total assist with eating, bathing, hygiene, was frequently incontinent of bowel and bladder, was at risk for pressure sores, and did not have a pressure sore. On 02/09/12, at 3:10 p.m., the resident was observed in her bed. RN #1 assisted with an observation of the resident's skin. The resident had a round, red area on her right hip. The resident's upper back, along her spine, had an area of redness with scar tissue in the center. The resident was thin and the spine was protruding. The resident's right leg was resting on her left leg. When separated a red area 5 cm long and 1 cm wide was observed just below her knee. A similar area was observed on the left leg. The areas were non-blanchable. There was no pressure reducing device between the resident's legs to prevent pressure. A red area was observed on the resident's left shoulder where the resident's chin rested on the shoulder. There was no pressure relieving device to prevent pressure on the shoulder. A red area was observed on the left ankle. The area had a white center. RN #1 was asked to observe the area. The RN reported it looked like a healed pres

Based on record review, observation, resident, visitors, and staff interviews, it was determined the facility failed to ensure effective measures and monitoring were being implemented for a resident (#6) who was being aggressive towards another resident (#2). Resident #6 had two documented incidents of being both verbally and physically abusive towards resident #2. There was only one sampled resident that was exhibiting signs of aggression. This had the potential to affect all 41 residents. Findings: The facility's policy and procedure "Abuse Prohibition Policy, Resident to Resident Abuse" documented, "...Staff observations, resident family interviews, RAI assessment, resident council meetings, internal quality assurance and Behavior Risk Assessment will identify residents that develop behavior problems while in the facility... Nursing will complete a behavior risk assessment for any resident identified at risk for behavioral episodes. Residents exhibiting behavior problems will have a behavior monitor completed. The behavior monitor will be individualized with specific interventions and behavior modifications identified for each resident needs..." Facility staff will immediately intervene to halt abusive behavior and initiate appropriate actions to ensure the safety of all residents based on individual occurrence. These actions may include, but not be limited to the following: Remove abusive resident from other residents. Licensed nurse will assess residents and treat injury if minor. If injury requires medical attention, notify attending physician and resident's responsible party... Details of any abusive incidents will be documented in the resident's clinical record...Identifying procedures: Resident will be identified for behavioral problems that may result in potential for and/or actual harm to other residents on admission to the facility by review of history, any previous documented behavioral problems, current medication, family interviews and physician consultation. A licensed nurse will complete review on day of admission." 1. Resident #6 had been admitted to the facility on [DATE]. On 05/28/11, a "Cornell Scale for Depression in Dementia" documented the resident had irritability was annoyed and short tempered. On 06/14/11, an incident report (IR) documented: "(Name deleted resident #2) was in her W/C in Nursing Home Lobby and (Name deleted resident #6) was also in her W/C in the lobby. (Name deleted resident #6) came up behind (Name deleted resident #2), kicked her W/C when (Name deleted resident #2) attempted to leave area (Name deleted resident #6) followed her and pulled her hair and kicked her chair again, yelling 'get out of here.' When a staff member intervened (Name deleted resident #6) attempted to hit her also. (Name deleted resident #6's) aggressive behavior has escalated over last 2 days. Until yesterday (Name deleted resident #6) was easily re-directed. She has been monitored closely since incident occurred...Contacted (Name deleted psych unit) for referral, information provided, resident was accepted by facility and transportation was arranged, and resident was transferred to...via van in stable condition (on 06/15/11 at 6:10 p.m.)...relevant resident history...Resident is non-ambulatory, uses W/C for mobility, is able to propel self...Resident is oriented to person only...Is normally easily re-directed with 1:1 interaction until this incident. Behaviors are monitored and documented..." The care plan, documented, "(Name deleted resident #6) has a [DIAGNOSES REDACTED]. She is oriented to person only...She will get agitated at times. She has to have frequent redirection and diversional activities. Update 6/15/11 Cont current POC new order for geri psych eval for med adjustment due to ^ behaviors awaiting bed availability @ this time. Returned 6/27/11 p (after) med adjustment." The July 2011, physician's orders [REDACTED]. The resident was on [MEDICATION NAME] 0.25 mg one tablet twice a day and [MEDICATION NAME] 0.5 mg one tablet at bedtime. The [MEDICATION NAME] had been adjusted while in the geri psych unit. On 07/26/11 at 4:15 p.m., an IR documented: "(Name deleted resident #2) was sitting in the TV room in her wheelchair, (Name deleted resident #6) wheeled herself into the TV room and kicked (Name deleted resident #2) on the left shin without provocation. No injury occurred. Skin was intact. (Name deleted resident #2) was removed from the TV area and taken to the nurse's station. Incident was reviewed on security cameras. (Name deleted resident #6) was redirected by the nurse and no further negative behaviors were noted. This incident was witnessed by another residents daughter...final report...Staff has been counseled to observe both residents closely by visual and security cameras and to keep resident as least 10 feet apart to avoid further incidents. Residents reside on different halls, and sit across the dining room from each other..." The abused resident (#2) had been removed from watching TV while the abusive resident (#6) was redirected in some way. On 07/26/11, a nurse's note documented, "Resident (#6) up in W/C in TV room. Confused, disoriented (Name deleted resident #6) in TV room went up to (Name deleted resident #2) and kicked her in shin- left leg, no injury observed...up in W/C in constant attendance until bedtime since incident. Finally put to bed resting quietly @ end of shift." On 07/27/11, a comprehensive assessment, documented the resident was sometimes able to make her needs known, sometimes able to understand others, had inadequate short and long term memory with severely impaired cognition, with signs and symptoms of delusion and disorganized thinking that comes and goes with a change in severity. The assessment also documented the resident did not have any physical behavioral symptoms directed toward others. The MDS coordinator was interviewed. She was asked if she knew the resident had been abusive on 07/26/11, a day before the MDS was finalized. She reported she had not been aware of the resident exhibiting any abusive behavior since the first incident in June 2011, when the resident had been sent to a Geri-psych unit. The behavior monitoring sheet dated for July and August 2011, documented the resident's behaviors as kicking, banging on door and yelling. There were no behaviors being monitored of being verbally and physically abusive towards other residents. There was no information on the behavior sheet that the staff has been counseled to observe both residents closely by visual and security cameras and to keep resident as least 10 feet apart to avoid further incidents On 08/11/11 at 11:30 a.m., LPN #1 who was the charge nurse was interviewed. He was asked what activities he would watch for on the monitors. He reported he would watch to ensure the staff were doing their jobs and that no one had fallen in the hallways or lobbys. The LPN did not mention the two residents were to be monitored. On 08/11/11 at 1:20 p.m., resident #6 was observed in her W/C. The resident had been sitting by the front door. She was observed to propel her W/C across the lobby and down the hallway where resident #2 resided. Resident #2 was observed lying in her bed. Resident #6 was observed to propel herself to the end of resident #2's hallway and back. No staff were observed monitoring resident #6's location during this time. Several staff were observed standing around the nurses' station talking. On 08/11/11 at 2:30 p.m., CNA #1 was observed providing care for resident #2. The resident was asked if she had problems with any of the residents in the facility. The resident reported one of the residents had kicked her and pulled her hair a couple of times. She then stated the last time had been two weeks ago. The resident was then asked if she was frightened by the resident. She reported she was afraid of her. CNA #1 reported resident #2 had told her about the incidents several times. The CNA had observed resident #2 becoming frightened when she saw resident #6 coming down the hall or being in the lobby. At 3:00 p.m., friends of the resident had come to visit. The friends were interviewed. They reported the resident had mentioned to them several times of a resident pulling her hair, kicking her, yelling at her and that she was frightened by her. On 08/11/11 at 3:15 p.m., an unidentified alert and oriented resident was interviewed. The resident was asked if she had been aware of any resident being aggressive toward other residents. The resident identified resident #6 as being confrontational with other residents. The resident reported there had been an incident of a verbal confrontation between this resident and another resident the previous evening. On 08/11/11 at 3:30 p.m., the DON was interviewed. The DON was informed regarding resident #6 propelling herself down the hallway where resident #2 resided. She was informed no staff had been observed monitoring resident #6's location. The DON reported she really didn't feel it was a problem. At 3:45 p.m., the ADM was interviewed. The ADM was informed regarding (Resident #2's Name deleted) being frightened of (Resident #6's Name deleted) that had attacked her. The ADM reported she had been aware of the incidents.

Based on record review, observation and staff interview, it was determined the facility failed to ensure their abuse policy and procedure was followed to protect one (#2) of one sampled resident who had been assaulted on two different occasions by another sampled resident (#6). This had the potential to affect all 41 residents. Findings: The facility's policy and procedure "Abuse Prohibition Policy, Resident to Resident Abuse" documented, "Abuse is defined as the willful infliction of injury, unreasonable anguish or deprivation by an individual, including a caregiver, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, pain or mental anguish...Physical abuse includes hitting, slapping, pinching and kicking... Protection: This facility will provide residents, families and staff information on how and whom to report concerns, incidents and grievances without fear of retribution and provide feedback regarding the concerns that have been expressed...Staff observations, resident family interviews, RAI assessment, resident council meetings, internal quality assurance and Behavior Risk Assessment will identify residents that develop behavior problems while in the facility...Nursing will complete a behavior risk assessment for any resident identified at risk for behavioral episodes. Residents exhibiting behavior problems will have a behavior monitor completed. The behavior monitor will be individualized with specific interventions and behavior modifications identified for each resident needs...Facility staff will immediately intervene to halt abusive behavior and initiate appropriate actions to ensure the safety of all residents based on individual occurrence. These actions may include, but not be limited to the following: Remove abusive resident from other residents. Licensed nurse will assess residents and treat injury if minor. If injury requires medical attention, notify attending physician and resident's responsible party...Details of any abusive incidents will be documented in the resident's clinical record... Identifying procedures: Resident will be identified for behavioral problems that may result in potential for and/or actual harm to other residents on admission to the facility by review of history, any previous documented behavioral problems, current medication, family interviews and physician consultation. A licensed nurse will complete review on day of admission." On 04/26/11, resident #2 was admitted to the facility. On 06/03/11, a care plan documented: "Problems: Anxiety. Goals: Will demonstrate reduced anxiety as evidenced by response to proper medication X 90 days. Approaches:... Minimize contact with other stressful stimuli, i.e. other anxious residents, group settings. Use calm reassuring voice when approaching..." On 06/14/11 at 10:30 a.m., an IR documented: "(Name deleted resident #2) was in her W/C in Nursing Home Lobby and (Name deleted resident #6) was also in her W/C in the lobby. (Name deleted resident #6) came up behind (Name deleted resident #2), kicked her W/C when (Name deleted resident #2) attempted to leave area (Name deleted resident #6) followed her and pulled her hair and kicked her chair again, yelling 'get out of here.' When a staff member intervened (Name deleted resident #6) attempted to hit her also. (Name deleted resident #6's) aggressive behavior has escalated over last 2 days. Until yesterday (Name deleted resident #6) was easily re-directed. She has been monitored closely since incident occurred. She attempted to kick another resident this morning but did not make contact. Her physician was notified and order received for psych. eval. We had attempted to contact resident's POA on 06/14/11 when incident occurred but telephone number on file was not longer good. Contacted POA's sister and she said she would get a message to him to call me, which he finally did, today (06/15/11). He gave telephone consent for psych at (Name deleted psych unit) where she had been a patient previously for the same problems. Contacted (Name deleted psych unit) for referral, information provided, resident was accepted by facility and transportation was arranged, and resident was transferred to ..... via van in stable condition (on 06/15/11 at 6:10 p.m.). ...relevant resident history... Resident is non-ambulatory, uses W/C for mobility, is able to propel self. Dx: Dementia w/Behavior Disturbances, HTN, [MEDICAL CONDITION], Osteopenia & [MEDICAL CONDITION]. Resident is oriented to person only, is incontinent of B&B, requires assistance with all ADL's except is independent for eating. Resident is high risk for falls due to debility/muscle weakness but has personal alarm and has had no falls for quite some time. Is normally easily re-directed with 1:1 interaction until this incident. Behaviors are monitored and documented. On return from this Hospital stay will have PT/OT evaluate resident for safety/strengthening." On 06/14/11, the nurse's note did not contain documentation or details of the abusive incident with the other resident. The facility did not follow their policy and procedure to ensure abusive incidents were documented in the resident's clinical record. On 06/15/11 at 9:00 a.m., the nurse's note documented, "Alert, oriented to self... Crying this a.m. increased anxiety noted. [MEDICATION NAME] 0.5 mg given @ 0800. Assisted to lay down in room. Decreased anxiety noted @ 0900..." The resident returned to the facility on [DATE], at 4:05 p.m. On 07/25/11, a 14 day assessment documented the resident usually made herself understood, usually understood others, had inadequate short and long term memory, had moderately impaired cognition, did not have any behaviors, required limited assistance with bed mobility, transferring between surfaces, required extensive assistance with ambulation, dressing and toilet use and utilized a W/C as her mobility device. On 07/26/11 at 4:15 p.m., an IR documented: "(Name deleted resident #2) was sitting in the TV room in her wheelchair, (Name deleted resident #6) wheeled herself into the TV room and kicked (Name deleted resident #2) on the left shin without provocation. No injury occurred. Skin was intact. (Name deleted resident #2) was removed from the TV area and taken to the nurse's station. Incident was reviewed on security cameras. (Name deleted resident #6) was redirected by the nurse and no further negative behaviors were noted. This incident was witnessed by another residents daughter...final report...Staff has been counseled to observe both residents closely by visual and security cameras and to keep resident as least 10 feet apart to avoid further incidents. Residents reside on different halls, and sit across the dining room from each other..." On 07/26/11, a nurse's note documented, "Resident up in W/C in TV room. Confused, disoriented (Name deleted resident #6) in TV room went up to (Name deleted resident #2) and kicked her in shin- left leg, no injury observed. Color pale, skin W/D/I, resp easy, LCTAB, abd soft c 0 BS, up in W/C in constant attendance until bedtime since incident. Finally put to bed resting quietly @ end of shift." The August 2011, physician's orders [REDACTED]. On 08/11/11 at 11:30 a.m., LPN #1 who was the charge nurse was interviewed. He was asked what activities he would watch for on the monitors. He reported he would watch to ensure the staff were doing their jobs and that no one had fallen in the hallways or lobbys. The LPN did not mention the two residents were to be monitored. On 08/11/11 at 1:20 p.m., resident #6 was observed in her W/C. The resident had been sitting by the front door. She was observed to propel her W/C across the lobby and down the hallway where resident #2 resided. Resident #2 was observed lying in her bed. Resident #6 was observed to propel herself to the end of resident #2's hallway and back. No staff were observed monitoring resident #6's location during this time. Several staff were observed standing around the nurses' station talking. On 08/11/11 at 2:30 p.m., CNA #1 was observed providing care for resident #2. The resident was asked if she had problems with any of the residents in the facility. The resident reported one of the residents had kicked her and pulled her hair a couple of times. She then stated the last time had been two weeks ago. The resident was then asked if she was frightened by the resident. She reported she was afraid of her. CNA #1 reported resident #2 had told her about the incidents several times. The CNA had observed resident #2 becoming frightened when she saw resident #6 coming down the hall or being in the lobby. At 3:00 p.m., friends of the resident had come to visit. The friends were interviewed. They reported the resident had mentioned to them several times of a resident pulling her hair, kicking her, yelling at her and that she was frightened by her. On 08/11/11 at 3:15 p.m., an unidentified alert and oriented resident was interviewed. The resident was asked if she had been aware of any resident being aggressive toward other residents. The resident identified resident #6 as being confrontational with other residents. The resident reported there had been an incident of a verbal confrontation between this resident and another resident the previous evening. On 08/11/11 at 3:30 p.m., the DON was interviewed. The DON was informed regarding resident #6 propelling herself down the hallway where resident #2 resided. She was informed no staff had been observed monitoring resident #6's location. The DON reported she really didn't feel it was a problem. At 3:45 p.m., the ADM was interviewed. The ADM was informed regarding (Resident #2's Name deleted) being frightened of (Resident #6's Name deleted) that had attacked her. The ADM reported she had been aware of the incidents.

Based on record review, observation, staff and resident interviews, it was determined the facility failed to: a) Ensure indwelling urinary catheter care was provided every shift, as ordered by the physician, for one (#8) of one sampled resident with an indwelling urinary catheter, who had experienced repeated UTI's. This resulted in actual harm. There were no additional indwelling urinary catheters in the facility. b) Ensure a physician notification of blood in a [MEDICAL CONDITION] was followed-up on, to ensure prompt treatment of [REDACTED]. This had the potential to affect two residents identified by the DON as having a [MEDICAL CONDITION]. c) Ensure a laxative was given when there had been no bowel movement for six days, for one (#1) of four sampled residents with a [DIAGNOSES REDACTED]. This had the potential to affect 39 residents identified by the DON as residing in the facility, who could become constipated and require a laxative. Findings: The facility policy and procedure of indwelling catheter care documented: "Purpose...To prevent infection...To reduce irritation...Wash perineum well with soap and warm water...Cleanse area well at catheter insertion site..." 1. The medical record, for resident #8, documented, the resident had been admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. An admission assessment, dated 01/06/11, documented the resident was cognitively intact, required extensive assist with ADLs, and had an indwelling urinary catheter. The assessment documented the resident had not had a UTI in the past 30 days. A care plan entry, dated 01/24/11, documented the resident was transferred to the ER. The next entry was dated 01/28/11, which documented the resident returned with new orders. A care plan entry, dated 01/28/11, documented the resident had an infection. The care plan did not document what kind of infection the resident had. The care plan documented, the resident was to [MEDICATION NAME] mg and Bactrim DS, twice daily, for 10 days. There was no lab available to identify the infection. A urine culture, dated 02/05/11, documented, the resident had a UTI with the bacteria being identified as [MEDICATION NAME] species. An entry, on the resident's care plan, dated 02/07/11, documented, the resident had a UTI and was to receive Bactrim DS, twice daily, for seven days. Another urine culture, dated 03/14/11, documented, the resident had a UTI with the bacteria being identified as Escherichia coli. An entry, on the resident's care plan, dated 03/17/11, documented the resident had a UTI and was to [MEDICATION NAME] mg 1 PO twice daily. A quarterly assessment, dated 04/07/11, documented the resident was cognitively intact, required extensive assist with ADLs and had an indwelling urinary catheter. The assessment, documented, the resident had a UTI in the past 30 days. The resident's treatment sheets documented, "Foley catheter care q shift." The start date was documented as 03/28/11. The treatment sheets for April and May 2011, documented the catheter care had been provided every shift. The May 2011, physician's orders [REDACTED]. May have cath size 18 Fr drain to bedside gravity. Change monthly..." The date ordered was documented as 03/28/11. The May 2011, physician's orders [REDACTED]. On 05/24/11, at 2:50 p.m., the resident was observed in his room in his W/C. There was no evidence the resident had an indwelling urinary catheter. The resident reported, he had a leg bag during the day, which was not visible. He reported, at night, a larger drainage bag was attached. The resident was asked if the nursing staff provided indwelling urinary catheter care every shift, by cleaning around the catheter, at the insertion site, and down the tubing. The resident shook his head and reported no one had ever cleaned around the catheter or down the tubing. The resident was asked if the staff had instructed him on how to clean the indwelling urinary catheter. He shook his head again and reported he would clean it (the catheter) the best he could, when he took a shower, three times weekly. He reported, no one else had ever cleaned the catheter. On 05/24/11 at 3:05 p.m., the DON was interviewed regarding the resident not receiving indwelling urinary catheter care and having repeated UTI's. The DON was informed the resident denied any staff had ever cleaned his indwelling urinary catheter. The DON reported the resident was alert and oriented and if he reported it was not being done, then it was not being done. She reported, he would tell the truth. The DON reported, she would in-service the nursing staff regarding the catheter care. The DON was then informed, the nursing staff were signing on the treatment sheet they were providing the care. The DON reported they should not sign, if it was not done. The DON then called two nurses (LPN #1 and LPN #2) into her office. LPN #1 worked the day shift and LPN #2 worked the evening shift. The two LPN's admitted they had not done the indwelling catheter care, but had checked to see if it was dirty. LPN #1 was asked what catheter care meant. The LPN reported it was cleaning the insertion site and down the tubing. The LPN reported, she always checked the catheter to make sure it was clean. She reported the resident was always up when she arrived and stayed up until she left. She was unable to provide the catheter care. LPN #2 reported, he would just check the catheter and would clean it if it was dirty. The DON reported, she would take care of it. 2. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], acute [MEDICAL CONDITION] and debility. A care plan dated 09/29/10, documented: "Problems: (Name deleted resident #9) has a [DIAGNOSES REDACTED]. He requires some assist with his adl's. He depends on staff to help him... Interventions: ... (Name deleted resident #9) needs assist with toileting. He has [MEDICAL CONDITION] for his bowels. He is continent of urine." The physician's orders [REDACTED]. Change [MEDICAL CONDITION] bag and wafer q 3 days." On 04/08/11, at 4:00 p.m., a fax to the resident's physician documented: "Resident has moderate amount of blood in [MEDICAL CONDITION] bag resident states its happened before and only lasted that one time. Please advise c any orders." This was the only documentation in the resident's record, pertaining to blood in the [MEDICAL CONDITION]. There was no documentation of the physician returning a response to the fax and no evidence the facility had taken further actions related to the bleeding. The next documentation related to the bleeding was on 04/13/11, 5 days after the fax had been sent to the physician. A return fax, from the resident's physician, documented: "(1) hold ASA/ blood thinner. (2) CBC to check. (3) stool for guac. (4) [MEDICATION NAME] 30 mg po qd. (5) call if worse." On 04/13/11, a nurse's note, documented: "New orders received to hold ASA, do CBC, stool for occult blood. Call Dr if resident condition becomes worse." This was the only nurses' note related to the blood in the resident's [MEDICAL CONDITION]. On 04/16/11, a nurse's note documented, "CBC drawn & sent to lab..." The CBC had been ordered by the physician on 04/13/11, due to the resident having blood in his [MEDICAL CONDITION] on 04/08/11. On 04/16/11, a laboratory report of a CBC documented: "RBC- L (low) - 4.07 normal range 4.70-6.10 Hemoglobin L- 12.8 normal range 13.5-18.0 Hematocrit L- 37.4 normal range 42.-52.0" On 04/18/11, a nurse's note documented, "N/O (new order) to resume ASA 325 mg 1 po qd." On 04/18/11, a telephone physician's orders [REDACTED]. "Resume ASA 325 mg 1 qd." On 05/19/11, a quarterly assessment documented the resident had adequate short and long term memory, the resident's cognition was intact, had a [MEDICAL CONDITION] and was always continent of bladder. On 05/22/11, at 3:30 p.m., the DON was interviewed. The DON was shown the documentation, in the resident's record, related to the resident having blood in his [MEDICAL CONDITION]. The DON reviewed the record and reported the staff who had documented the blood should have followed up on it. She then stated, "Someone dropped the ball." On 05/24/11, at 4:03 p.m., the resident was observed sitting in a W/C, in the physical therapy room doing arm exercises. 3. Resident #1 was admitted to the facility on [DATE]. On 07/28/10, a care plan documented: "(Name deleted resident #1) will have a stool softeners/laxatives as ordered: [MEDICATION NAME] 100 mg one cap po BID. [MEDICATION NAME] 30 ml po q day. MOM 30 ml po q hs. (Name deleted resident #1) will be monitored for changes in weight or appetite and the doctor contacted as needed." The February 2011, ADL flow-sheet documented, the resident had not had a bowel movement on the 14th, 15th, 16th, 17th, 18th and 19th. The February 2011, MAR, was reviewed. The resident had not received the PRN Milk of Magnesia (originally ordered on 01-14-11) during the days the resident had been without a bowel movement. The April 2011, physician's orders [REDACTED]. On 04/11/11, a quarterly assessment documented the resident had inadequate short and long term memory, had severely impaired cognitive skills, and was always incontinent of bowel and bladder. On 05/23/11, at 12:40 p.m., the resident was observed sitting in a W/C, in the dining room. The resident was observed eating his lunch meal, of double portions. On 05/25/11, at 9:15 a.m., the DON was interviewed. The DON was asked what the facility's policy was for monitoring bowel movements. She reported the staff would monitor the bowel movement sheets at night, and the residents that had not had a bowel movement in three days, would be given a laxative. The DON reported, he (resident #1) must have been overlooked.