Every finding on record at Capitol House Nursing and Rehab Center

Based on record review and interviews, the facility failed to ensure each resident's drug regimen was free of unnecessary medications. The facility failed to ensure direct care nursing staff documented monitoring results of psychotropic medications for side effects and effectiveness for 1 (#10) of 6 residents reviewed for unnecessary medications. Findings:Review of the facility's policy titled Use of Psychotropic Medication with a revision date of 02/2025 revealed the following, in part:Policy Explanation and Compliance Guidelines:13. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as:d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice. and the resident's comprehensive plan of care. 14. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. Review of Resident #10's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Unspecified Depression, Schizophrenia, and Panic Disorder. Review of Resident #10's Quarterly MDS with an ARD of 04/28/2026 revealed the following, in part: Resident #10 was taking an antidepressant for Depression and anti-anxiety medication for Anxiety. Review of Resident #10's current Physician Orders revealed the following, in part:01/19/2026 Buspirone HCl 5 mg tablet give two tablets by mouth three times a day for Anxiety; 01/19/2026 Remeron 30 mg tablet give one tablet by mouth one time a day for Depression and Insomnia. Further review revealed no orders pertaining to monitoring for effectiveness or monitoring for side effects of psychotropic medications. Review of Resident #10's current Care Plan revealed the following, in part:Problem: The resident uses antianxiety medications related to Anxiety Disorder.Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift.Problem: The resident uses antidepressant medications related to Depression.Interventions: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Review of Resident #10's Medication Administration Record dated 06/02/2026 through 07/22/2026 revealed the following, in part:01/19/2026 Buspirone HCl 5 mg tablet give two tablets by mouth three times a day was administered at 8:00 a.m., 12:00 p.m., and 8:00 p.m.; and 01/19/2026 Remeron 30 mg tablet give one tablet by mouth one time a day was administered at 8:00 p.m. Further review revealed no documentation pertaining to monitoring for effectiveness or monitoring for side effects of psychotropic medications. Review of Resident #10's Nurses Notes dated 06/02/2026 through 07/22/2026 revealed no documentation pertaining to monitoring for effectiveness or monitoring for side effects of psychotropic medications. On 07/22/2026 at 8:40 a.m., an interview was conducted with S17LPN. She reviewed Resident #10's Physician Orders and MAR and verified the resident received Remeron for depression daily and Buspirone three times a day for anxiety. She stated for any resident on a psychotropic medication, the computer prompts the nurse during medication administration to sign off monitoring for and documentation of any abnormal side effects and behaviors. She stated if there was a behavior or side effect, the computer prompts the nurse to document a progress note. She stated she monitored Resident #10 for side effects and behaviors of the antidepressant and antianxiety medications. She confirmed she could not find any documentation of monitoring for Resident #10 for behaviors or side effects related to the antidepressant and antianxiety medications, but there should have been. On 07/22/2026 at 8:50 a.m., an interview was conducted with S15MR. She stated she was responsible for reviewing and entering new admission and readmission residents' physician orders into the computer system. She stated for psychotropic medication orders, a monitor was attached to each individual medication which alerts the nurse during medication administration to sign off monitoring and to document any behaviors or side effects of the psychotropic medications. She stated Resident #10's physician orders changed several times due to his hospitalizations and the requirement for the nurses to monitor the medications would fall off the order. She reviewed and confirmed there was no physician ordered task assigned to the nurses to document monitoring of Resident #10's antidepressant and antianxiety medications for behaviors or side effects and there should have been. She confirmed all residents on psychotropic medications should be monitored every shift for side effects and behaviors. On 07/22/2026 at 10:50 a.m., an interview was conducted with S16NP. She stated she relied on the nurse's documentation of any resident's mood, sedation and side effects of the psychotropic medications to determine the response and effectiveness of the medications. On 07/22/2026 at 9:20 a.m., an interview was conducted with S2DON. She confirmed residents on psychotropic medications should have a Physician's Order entered with a task assigned to the nurses to document the monitoring of behaviors and monitoring of side effects of psychotropic medications. She stated S15MR was responsible for entering resident's psychotropic medication monitoring orders and responsible for ensuring the orders were entered correctly. She reviewed Resident #10's Physician orders, MAR and Nurses Notes and confirmed he was prescribed Remeron for Depression and Buspirone for Anxiety. She confirmed there was no documented monitoring by the nurses administering Resident #10's psychotropic medications and there should have been.

Based on observations, interviews, and record review, the facility failed to ensure drugs used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure medication carts were free of expired multi-dose insulin which was available for resident use. This deficient practice was observed on 1 (Cart 1) of 3 medication carts reviewed. Findings: Review of the facility's policy last revised on 04/2021 and titled Multiple-Dose Vials revealed the following, in part:Policy: It is the policy of the facility to ensure proper and safe use of multi-dose vials of medication. Policy Explanation and Compliance Guidelines: B.) if a multi-dose has been opened or accessed (needle punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.Review of [NAME]-Lilly manufacturer guidelines for Humulin R revealed the following, in part:Preparing the Dose: Do not use Humulin R past the expiration date printed on the label or 31 days after first use. Review of Norvo Nordisk manufacturer guidelines for Novolin R revealed the following, in part: Open multi-dose vials must be discarded 42 days after the first puncture.An observation was conducted on [DATE] at 9:18 a.m. of Cart 1 with S4LPN. Cart 1 revealed the following:1 opened and punctured multi-dose vial of Humulin R dated [DATE] with [NAME]-Lilly as manufacturer; and1 opened and punctured multi-dose vial of Humulin R dated [DATE] with [NAME]-Lilly as manufacturer. An interview was conducted on [DATE] at 9:20 a.m. with S4LPN. S4LPN stated multi-dose insulin should only be available for administration on the medication cart for a maximum of 30 days after the labeled open date. S4LPN confirmed the two vials were opened longer than 30 days and should not be available for resident administration after more than 30 days past the opened date. An interview was conducted on [DATE] at 10:05a.m. with S2DON. S2DON confirmed multi-dose vials of insulin should not be kept on the medication carts longer than 30 days after the labeled open date and should be disposed of after 30 days. A second observation was conducted on [DATE] at 12:20 p.m. of Cart 1 with S4LPN. Cart 1 revealed the following: 1 opened and punctured multi-dose vial of Novolin R dated [DATE] with Norvo Nordisk as manufacturer. An interview was conducted on [DATE] at 12:20 p.m. with S4LPN. S4LPN confirmed the above named multi-dose vial of insulin was opened longer than 30 days and should not be available for resident administration after more than 30 days past the opened date. An interview was conducted on [DATE] at 1:00 p.m. with S2DON. S2DON confirmed the above multi-dose insulin vials were expired per the manufacturer guidelines and should not have been available for resident administration on the medication cart.

Based on interviews and record review, the facility failed to develop and implement an individualized, resident-centered Care Plan with interventions which included the appropriate level and number of staff required for safe bed mobility and ADL care performed while in bed for 1 (#101) of 4 residents reviewed for ADLs. Findings: Review of Resident #101's Clinical Record revealed an initial admission date of 03/27/2026 with diagnoses which included, in part, the following; Functional Quadriplegia; Debility; Acute and Chronic Respiratory Failure with Hypercapnia; Tracheostomy Status; Dependence on Respirator (Ventilator); and a History of Repeated Falls. Further review revealed on 05/28/2026 Resident #101 weighed 263 pounds. Review of Resident #101's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 05/30/2026, indicated she was assessed to have a Brief Interview of Mental Status score of 04, which indicated she was severely cognitively impaired. Further review revealed she had Bilateral Upper and Lower Extremity Impairment; and was Totally Dependent on staff for all mobility, ADLs and care needs. Review of Resident #101's Fall Risk Assessment, dated 05/29/2026, indicated she was assessed to have a Fall Risk Score of 15, which indicated she was a high risk for falls. Review of Resident #101's Physician's Orders and Therapy Plans of Care revealed no documented evidence to indicate the appropriate level and number of staff assistance required for safe bed mobility and ADL care performed while in bed. Review of Resident #101's Care Plan revealed, in part, the following: Focus Areas including: ADL Self-Care Deficit related to Anoxic Brain Damage and Impaired Mobility; and At Risk for Falls related to Impaired Mobility. Further review revealed no documented evidence to indicate the appropriate level and number of staff assistance required for safe bed mobility and ADL care performed while in bed. Review of the facility's Incident Report for Resident #101, dated 05/30/2026 at 9:18 a.m., revealed, in part, the following: Incident Type: Fall.Incident Description: S6LPN was called to Resident #101's room by S7CNA. S7CNA stated Resident #101 fell off of her bed while he was turning her during resident care. An interview was conducted on 07/21/2026 at 1:56 p.m. with S7CNA. S7CNA confirmed he was Resident #101's assigned CNA on 05/30/2026 when she fell. S7CNA confirmed he was in Resident #101's room changing her by himself when her weight shifted as he rolled her over and he was unable to prevent her from falling to the floor. S7CNA stated at the time of Resident #101's fall, the facility did not have a place he could look to determine how much assistance she required for safe bed mobility and ADL care performed in bed because the facility left it up to the CNA who was assigned to the resident to determine if they should ask for help or not. An interview was conducted on 07/21/2026 at 9:28 a.m. with S6LPN. S6LPN confirmed Resident #101 was non-verbal, unresponsive, unable to assist with any of her care, and weighed over 200 pounds. S6LPN confirmed given Resident #101's status, she would need at least 2 person assistance to safely perform bed mobility and ADL care while in bed. S6LPN confirmed she was Resident #101's nurse when she fell on [DATE]. S6LPN confirmed on 05/30/2026, S7CNA was in Resident #101's room providing her care independently when she fell from her bed to the floor. S6LPN confirmed at the time of Resident #101's fall on 05/30/2026, the facility left it up to the CNA who was assigned to a resident to determine how much assistance they needed to safely perform bed mobility and ADL care while she was bed and did not include this information in any of the resident's Care Plans. An interview was conducted on 07/21/2026 at 11:42 p.m. with S14PTA. S14PTA confirmed he was the facility's Director of Therapy Services and was familiar with Resident #101's capabilities and care needs. S14PTA confirmed Resident #101 would require a minimum of 2 person assistance to safely perform bed mobility and ADL care while in bed. An interview was conducted on 07/21/2026 at 10:10 a.m. with S10MDS. S10MDS confirmed she was responsible for creating Care Plans for all of the resident's in the facility. S10MDS confirmed Resident #101's Care Plan did not indicate the appropriate level and number of staff required to safely perform bed mobility and ADL care while in bed and the facility did not require her to include this information in any of the resident's Care Plans. An interview was conducted on 07/21/2026 at 9:47 a.m. with S3ADON. S3ADON confirmed Resident #101's care plan did not indicate the appropriate level and number of staff required to safely perform bed mobility and ADL care while she was bed and the facility did not require this information to be included in any of their resident's Care Plans. S3ADON stated at the time of Resident #101's fall on 05/30/2026, the facility left it up to the CNA who was assigned to a resident to determine how much assistance they needed to safely perform bed mobility and ADL care in bed. An interview was conducted on 07/21/2026 at 10:21 a.m. with S2DON. S2DON confirmed she was present in the facility when Resident #101 fell on [DATE] and interviewed S7CNA immediately following the fall to determine what happened. S2DON confirmed S7CNA was in Resident #101's room providing ADL care for her by himself when her weight shifted and he was unable to prevent her from falling to the floor. S2DON stated at the time of Resident #101's fall on 05/30/2026, the facility left it up to the CNA who was assigned to a resident to determine how much assistance they needed to safely perform bed mobility and ADL care while she was bed and the facility did not require this information to be included in any of their resident's Care Plans.

Based on observation, interviews, and record review, the facility failed to ensure services provided met professional standards of quality by failing to ensure nursing staff verified, accurately administered, and accurately documented enteral feedings for 1 (#7) of 2 residents reviewed for enteral feeding.Findings: Review of the facility's policy titled, Care and Management of Feeding Tubes last revised 10/2025 revealed the following, in part:It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.Policy Explanation and Compliance Guidelines:1. Feeding tubes will be utilized according to physician/nurse practitioner's orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. Review of the facility's policy titled, Documentation in Medical Record dated 10/2020 revealed the following, in part:Policy: Each patient/resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Policy Explanation and Compliance Guidelines:3. Principles of documentation include, but are not limited to:a. Documentation shall be factual.i. False information shall not be documented. Review of Resident #7's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction, Dysphagia, and Gastrostomy Status. Review of Resident #7's current Physician Orders revealed the following, in part:Start date: 06/08/2026 - Three times a day enteral feeding of Glucerna 1.5 bolus 300 mL per PEG at 8:00 a.m., 12:00 p.m., and 4:00 p.m.; andStart date: 02/23/2026 - Continuous enteral feeding of Glucerna 1.5 at 65 mL/hr per PEG from 6:00 p.m. to 6:00 a.m. Review of Resident #7's MAR dated 07/19/2026 revealed a check mark with initials, which indicated S5LPN administered/acknowledged the enteral feeding orders at the following times:Three times a day enteral feeding of Glucerna 1.5 bolus 300 mL per PEG at 12:00 p.m. and 4:00 p.m.; andStart date: 02/23/2026 - Continuous enteral feeding of Glucerna 1.5 at 65 mL/hr per PEG from 6:00 p.m. to 6:00 a.m. on day shift and evening shift. An observation was made of Resident #7 on 07/19/2026 at 12:08 p.m. Resident #7 was lying in bed with enteral feeding of Glucerna 1.5 infusing continuously via pump at 65 mL/hr. A telephone interview was conducted with S5LPN on 07/20/2026 at 1:49 p.m. She confirmed she was assigned to Resident #7 from 6:00 a.m. to 6:00 p.m. on 07/19/2026. She confirmed Resident #7 received continuous enteral feedings of Glucerna 1.5 at 65mL/hr during her shift on 07/19/2026. She stated she did not administer any bolus enteral feedings to Resident #7 on 07/19/2026. She stated she thought Resident #7 was ordered to receive continuous tube feeding 24/7. She confirmed Resident #7 should have received tube feeding as ordered by the physician. She confirmed she should have verified the enteral feeding order, accurately administered, and accurately documented administration of enteral feedings. An interview was conducted with S2DON on 07/20/2026 at 2:01 p.m. She stated enteral feedings should have been administered as ordered by the physician. She confirmed Resident #7 was ordered to receive bolus enteral feedings during the day and continuous enteral feedings overnight. She sated the nurse should have reviewed, administered and accurately documented Resident #7's enteral feeding as ordered by the physician.

Based on interviews and record review, the facility failed to provide each resident with adequate supervision and assistance in order to prevent accidents by failing to ensure each resident was assessed to determine the appropriate level and number of staff required for safe bed mobility and ADL care performed while in their bed for 1 (#101) of 4 residents reviewed for ADLs. Findings: Review of the facility's ADL Policy and Procedure, revised 04/2022, revealed, in part, the following: Policy Explanation and Compliance Guidelines:3. A resident who is unable to carry out ADLs will receive the necessary services to maintain good. personal hygiene. Review of the facility's Turning and Repositioning Policy and Procedure, revised 07/2023, revealed, in part, the following: 6. Use the appropriate number of staff to perform the tasks safely. Review of the facility's Incident Report for Resident #101, dated 05/30/2026 at 9:18 a.m., revealed, in part, the following: Incident Type: Fall.Incident Description: S6LPN was called to Resident #101's room by S7CNA. S7CNA stated Resident #101 fell off her bed while he was turning her for resident care. Review of Resident #101's Clinical Record revealed an initial admission date of 03/27/2026 with diagnoses which included, in part, the following; Functional Quadriplegia; Debility; Acute and Chronic Respiratory Failure with Hypercapnia; Tracheostomy Status; Dependence on Respirator (Ventilator); and a History of Repeated Falls. Further review revealed on 05/28/2026 Resident #101 weighed 263 pounds. Review of Resident #101's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 05/30/2026, indicated she was assessed to have a Brief Interview of Mental Status Score of 04, which indicated she was severely cognitively impaired. Further review revealed she had Bilateral Upper and Lower Extremity Impairment; and was Totally Dependent on staff for all mobility, ADLs and care needs. Review of Resident #101's Fall Risk Assessment, dated 05/29/2026, indicated she was assessed to have a Fall Risk Score of 15, which indicated she was at a high risk for falls. Review of Resident #101's Physical and Occupational Therapy Evaluations, Assessments and Treatment Plans revealed no documented evidence to indicate she was assessed to determine the appropriate level and number of staff assistance required for safe mobility, ADLs and care needs performed while in bed. Review of Resident #101's Care Plan revealed no documented evidence to indicate she was assessed to determine the appropriate level and number of staff assistance required for safe mobility, ADLs and care needs performed while in bed. Review of Resident #101's Physician Orders revealed no documented evidence to indicate she was assessed to determine the appropriate level and number of staff assistance required for safe mobility, ADLs and care needs performed while in bed. An interview was conducted on 07/21/2026 at 1:56 p.m. with S7CNA. S7CNA confirmed he was Resident #101's assigned CNA on 05/30/2026 when she fell. S7CNA confirmed on 05/30/2026, he was in Resident #101's room changing her by himself when her weight shifted as he rolled her over and he was unable to prevent her from falling to the floor. S7CNA confirmed at the time of Resident #101's fall, the facility left it up to the CNA assigned to a resident to determine how much assistance they needed when performing bed mobility and ADL care in bed. S7CNA confirmed he thought he would be able to safely perform the task without the assistance of another staff member. An interview was conducted on 07/21/2026 at 9:28 a.m. with S6LPN. S6LPN confirmed Resident #101 was non-verbal, unresponsive, unable to assist with any of her care, and weighed over 200 pounds. S6LPN confirmed the nurses were not responsible for assessing the level of assistance a resident required for safe bed mobility and ADL care performed in bed; however, given Resident #101's status, she felt she needed at least 2 person assistance to safely perform these tasks. S6LPN confirmed she was Resident #101's nurse when she fell on [DATE]. S6LPN stated at the time of Resident #101's fall, the facility left it up to the CNA assigned to a resident to determine how much assistance they needed when performing bed mobility and ADL care in bed. S6LPN confirmed on 05/30/2026, S7CNA was in Resident #101's room providing her care independently when she fell from her bed to the floor. An interview was conducted on 07/21/2026 at 10:59 a.m. with S8CNA. S8CNA stated Resident #101 was obese and unable to control her own body weight so she would never feel safe performing her care in bed with any less than 3 people. An interview was conducted on 07/21/2026 at 10:10 a.m. with S10MDS. S10MDS confirmed she was not responsible for assessing the level of assistance a resident required for safe bed mobility and ADL care performed in bed. An interview was conducted on 07/21/2026 at 11:42 p.m. with S14PTA. S14PTA confirmed he was familiar with Resident #101 and in his opinion she required a minimum of 2 person assistance to safely perform bed mobility and in bed incontinence care. S14PTA confirmed he was the facility's Director of Therapy Services and his department was not responsible for assessing the level of assistance a resident required for safe bed mobility and ADL care performed in bed. An interview was conducted on 07/21/2026 at 9:47 a.m. with S3ADON. S3ADON confirmed she was the facility's CNA Supervisor and confirmed the facility did not assess the level of assistance a resident required for safe bed mobility and ADL care performed in bed. S3ADON confirmed at the time of Resident #101's fall on 05/30/2026, the facility left it up to the CNA who was assigned to a resident to determine how much assistance they needed to safely perform a resident's bed mobility and ADL care in bed. An interview was conducted on 07/21/2026 at 10:21 a.m. with S2DON. S2DON confirmed she was present in the facility when Resident #101 fell on [DATE] and interviewed S7CNA immediately following the fall to determine what happened. S2DON confirmed S7CNA was in Resident #101's room providing her ADL care by himself when her weight shifted and he was unable to prevent her from falling to the floor. S2DON stated at the time of Resident #101's fall on 05/30/2026, the facility left it up to the CNA who was assigned to a resident to determine how much assistance they needed to safely perform a resident's bed mobility and ADL care in bed. S2DON confirmed the facility did not ensure each resident was assessed for the level of staff assistance required to safely complete these resident care tasks.

Based on observation, interviews, and record review, the facility failed to ensure a resident fed by enteral means received treatment and services to prevent complications by failing to administer enteral feedings as ordered by the physician for 1 (#7) of 2 residents reviewed for enteral feeding.Findings: Review of the facility's policy titled, Care and Management of Feeding Tubes last revised 10/2025 revealed the following, in part:It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.Policy Explanation and Compliance Guidelines:1. Feeding tubes will be utilized according to physician/nurse practitioner's orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. Review of Resident #7's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction, Dysphagia, and Gastrostomy Status. Review of Resident #7's Significant Change MDS with an ARD of 05/04/2026 revealed he had an enteral feeding tube and received 51% or more of nutrition and 501 mL/day or more of hydration through his enteral feeding tube. Review of Resident #7's current Care Plan revealed the following, in part:Problem: The resident requires tube feeding related to Dysphagia.Interventions: The resident needs assistance from staff with enteral feeding and water flushes. See Medical Doctor's orders for current feeding order. Review of Resident #7's current Physician Orders revealed the following, in part:Start date: 06/08/2026 - Three times a day enteral feeding of Glucerna 1.5 bolus 300 mL per PEG at 8:00 a.m., 12:00 p.m., and 4:00 p.m.; andStart date: 02/23/2026 - Continuous enteral feeding of Glucerna 1.5 at 65 mL/hr per PEG from 6:00 p.m. to 6:00 a.m. An observation was made of Resident #7 on 07/19/2026 at 12:08 p.m. Resident #7 was lying in bed with an enteral feeding of Glucerna 1.5 infusing continuously via pump at 65 mL/hr. A telephone interview was conducted with S5LPN on 07/20/2026 at 1:49 p.m. She confirmed she was assigned to Resident #7 from 6:00 a.m. to 6:00 p.m. on 07/19/2026. She confirmed Resident #7 received a continuous enteral feeding of Glucerna 1.5 at 65mL/hr during her shift on 07/19/2026. She stated she did not administer any bolus enteral feedings to Resident #7 on 07/19/2026. She stated she thought Resident #7 was ordered to receive continuous enteral feedings 24/7. She confirmed Resident #7 should have received enteral feedings as ordered by the physician. An interview was conducted with S2DON on 07/20/2026 at 2:01 p.m. She confirmed Resident #7 was ordered to receive bolus enteral feedings during the day and continuous enteral feedings overnight. She stated enteral feedings should have been administered as ordered by the physician.

Based on record review, observation and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#5) of 3 residents reviewed for Pressure Ulcers. The facility failed to ensure nursing staff accurately documented physician orders and wound care provided for Resident #5's Left Heel Pressure Ulcer. Findings: Review of the facility's policy dated 10/2020, titled Documentation in Medical Record revealed the following, in part:Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through . accurate . documentation.Policy Explanation and Compliance Guidelines:1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.3. Principles of documentation include, but are not limited to:b. Documentation shall be accurate. Review of Resident #5's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Stage 4 Pressure Ulcer of Left Heel. Review of Resident #5's Physician Orders dated July 2026 revealed the following, in part:Start Date: 07/10/2026 Right Heel Pressure Ulcer clean with wound cleanser, pat dry, paint with betadine, and cover with dry dressing every other day until resolved. Review of Resident #5's Treatment Administration Record dated July 2026 revealed the following, in part:Start date: 07/10/2026 Right Heel Pressure Ulcer clean with wound cleanser, pat dry, paint with betadine, and cover with dry dressing every other day until resolved was documented as performed on 07/10/2026, 07/12/2026, 07/14/2026, 07/16/2026, 07/18/2026 and 07/20/2026. Review of Resident #5's Wound Care Assessments dated July 2026 revealed no documented evidence of a Right Heel Pressure Ulcer. On 07/20/2026 at 8:52 a.m., an observation was made of wound care for Resident #5 with S18WC. S18WC performed wound care to Resident #5's Left Heel Pressure Ulcer. Further observation revealed Resident #5 did not have a Right Heel Pressure Ulcer. On 07/20/2026 at 9:15 a.m., an interview was conducted with S18WC. She reviewed Resident #5's clinical record and confirmed she entered the wound care order for a Right Heel Pressure Ulcer on 07/10/2026. She stated the wound care order should have been entered for Resident #5's Left Heel Pressure Ulcer. She confirmed she inaccurately documented Resident #5's wound care order and wound care. On 07/21/2026 at 11:50 a.m., an interview was conducted with S2DON. She reviewed Resident #5's clinical record and confirmed Resident #5 had a Left Heel Pressure Ulcer. She confirmed Resident #5's wound care orders and wound care were not accurately documented and should have been.

Based on observations and interviews, the facility failed to store and prepare food under sanitary conditions by failing to ensure: 1. Ceiling vents in the kitchen were clean, free of rust and debris; 2. Ceiling tiles (6) in the kitchen and (2) in the adjacent Dining areas were free from water stains. The deficiency had the potential to affect 64 residents who were served meals from the kitchen. Findings: On 06/09/2025 at 8:13 a.m., the initial tour of the facility's kitchen was conducted with S4DM. The following observations were made in the presence of S4DM during the initial tour: Main Kitchen/cooking Area: Rusty orange and dirty brown large ceiling vent coverings above serving steam table; Rust stains and flakey black debris noted on large ceiling vent covering in dishwashing room; Ceiling tiles (6), ranging from baseball to softball size, contained stains in main kitchen. On 06/09/2025 at 8:40 a.m., an interview was conducted with S4DM. She verified the ceiling vent coverings were dirty, rusty, and needed cleaning in the main kitchen, dining, and dishwasher room areas. She stated she did not know date of last cleanings performed. She stated S5MS was responsible for cleaning and replacements of all kitchen ceiling vent covers and ceiling tiles. On 06/11/2025 at 8:05 a.m., an observation was made of ceiling tiles in kitchen and above steam serving table with baseball size stain and 2 appromimate16X20 vents with large amount of rust covering entire surface; ceiling tiles (6) in main cooking area of kitchen observed with water stains in size ranging from baseball to softball size. S4DM confirmed aforementioned findings. S4DM stated she did not think areas could be cleaned at this point in time. She stated S5MS was aware of current condition of vents and ceiling tiles. On 06/11/2025 an interview with S5MS was conducted at 8:45 a.m. He stated he was aware of the water stained ceiling tiles (6) and ventilation coverings in the kitchen locations. He further stated the issues were caused by the air condition system, which was located right above the main kitchen area. S5MS confirmed he was responsible for monitoring and cleaning all ventilation coverings and ceiling tiles. He stated he had painted over ceiling vent covering in dishwashing room and had not replaced with a new covering. He confirmed the tiles and covering should have been maintained under sanitary conditions. On 06/11/2025 an interview with S1ADM was conducted at 8:45 a.m. S1ADM confirmed there was rust on the ventilation coverings in the kitchen areas and six ceiling tiles contained water stains. S1ADM confirmed the ceiling tiles and vent coverings should have been replaced to maintain sanitary conditions in the kitchen and dining room areas, and were not.

Based on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of discharges in writing for 1 (Resident #97) of 1 (Resident #97) sampled residents reviewed for transfer and discharge requirements. Findings: Review of the facility's policy titled Transfer and Discharge (including AMA) revealed in part: Policy: It is the policy of the facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited circumstances. This policy applies to all residents regardless of their payment source. Definitions: Transfer and Discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical place or not. Transfer and discharge does not refer to movement of a resident to a bed within the same facility. 5. The facility will maintain evidence that the notice was sent to the Ombudsman. Review of Resident #97's Electronic Medical Record (EMR) revealed, in part, Resident #97 was admitted to the facility on [DATE] and was transferred from the facility to the local hospital on [DATE]. Review of the facility's Emergency Transfer Log dated 05/01/2025-05/30/2025 revealed no documentation of Resident #97's transferred to the hospital on [DATE]. Review of Resident #97's Nurse's note dated 05/07/2025 at 6:06 p.m. revealed, in part, Resident #97 was transferred on 05/07/2025 at 3:48 p.m. to a local hospital for treatment. On 06/11/25 at 2:26 p.m., an interview was conducted with S1ADM. S1ADM confirmed the facility had not issued a written notice to the facility's assigned Ombudsman when Resident #97 transferred to a local hospital as required.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan which met the needs of 2 (#26 and #84) of 24 residents reviewed in the final sample. The facility failed to: 1. Ensure Resident #26 was care planned for his preference of a daily bath; and 2. Ensure Resident #84's soft mitt or splint was in place on right hand at all times This deficient practice had the potential to affect a current census of 97 residents. Findings: Review of the facility's policy titled Care Planning Special Needs, with a revision date of 09/2020 revealed the following: Policy: To address special needs, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. This policy pertains to the following needs: .respiratory care, prostheses . Policy Explanation and Compliance Guidelines: 1. Comprehensive care plans will be developed based on resident assessments, goals, and preferences in accordance with assessment and care plan procedures. 6. The person-centered care plan will be developed, based on specific factors identified in assessments and physician orders, and in accordance with the resident's goals and preferences. 7. Medical conditions will be monitored and managed to prevent complications. b. RNs and LPNs will participate in the management of medical conditions by following physician orders . 1. Review of Resident #26's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #26's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/28/2025, revealed a Brief Interview of Mental Status (BIMS) of 13, which indicated he was cognitively intact. Further review revealed he was dependent on staff assistance for bathing. Review of Resident #26's ADL (Activities of Daily Living) Flowsheet, dated June 2025, revealed Resident #26 should receive a bath on Mondays, Wednesdays, and Fridays. Further review revealed no evidence of his preference for a daily bath. Review of the C.N.A. (Certified Nursing Assistant) Assignment Sheet, dated June 2025, revealed no documentation of Resident #26's preference for a daily bath. Review of Resident #26's current Care Plan revealed the following: Problem: Date initiated 05/12/2025- The resident has an ADL self-care performance deficit related to Cerebrovascular Accident with Residual Effects. Interventions: Bathing/Showering: The resident is totally dependent on staff to provide as scheduled and as necessary. Further review revealed no documentation of the resident's preference for daily baths. On 06/09/2025 at 10:15 a.m., an interview was conducted with Resident #26. He stated he preferred daily bed baths, and he confirmed he informed staff of him wanting daily baths. On 06/10/2025 at 12:25 p.m., an interview was conducted with S15CNA. She stated Resident #26 preferred a daily bath. She stated his bath days on the ADL Flowsheet were scheduled for Monday, Wednesday, and Friday. She stated it was not documented anywhere Resident #26 preferred a daily bath. She stated staff who did not usually work with Resident #26, like agency staff, would not know he preferred a daily bed bath as it was not documented anywhere. On 06/10/2025 at 1:02 p.m., an interview was conducted with S14CNA. She stated Resident #26 preferred a daily bath. She stated his bath days on the ADL Flowsheet were scheduled for Monday, Wednesday, and Friday. She stated she knew Resident #26 was a daily bed bath because the resident and the staff who trained her informed her of this. She confirmed there was no documentation of the resident's preference for daily baths. On 06/10/2025 at 3:32 p.m., an interview was conducted with S16CNA. She stated she was assigned to Resident #26 on 06/08/2025, but was not normally assigned to him. She stated she was unaware of Resident #26's preference for a daily bath as it was not documented on the C.N.A. Assignment Sheet or the ADL Flowsheet. On 06/11/2025 at 12:00 p.m., an interview was conducted with S3ADON. She stated Resident #26 was to receive a daily bed bath per his preference. She confirmed Resident #26's preference for a daily bath was not documented on his care plan, the C.N.A. Assignment Sheet, or ADL Flowsheet and should have been. On 06/11/2025 at 12:22 p.m., an interview was conducted with S10MDS. She stated she was responsible for resident care plans. She stated she would care plan a resident's ADL preferences. She stated she would be notified of a resident's preferences during care plan meetings. She stated she was not aware Resident #26 preferred daily baths. She reviewed Resident #26's current care plan and confirmed Resident #26's care plan did not reflect his preference of a daily bed bath and should have. On 06/11/2025 at 1:06 p.m., an interview was conducted with S2DON. She stated Resident #26 preferred a daily bed bath. She stated he should be care planned for his preference of a daily bath. She reviewed Resident #26's care plan, C.N.A. Assignment Sheet, and ADL Flowsheet and confirmed he was not care planned for his preference of daily baths and should have been. 2. Review of Resident #84's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction, Gastrostomy Status, and Tracheostomy Status. Review of Resident #84's quarterly MDS with an ARD of 05/15/2025, revealed a BIMS was not conducted due to resident being rarely or never understood, indicating severe cognitive impairment. Further review revealed the resident was totally dependent on staff for all self-care activities. Review of Resident #84's current Physician's Orders revealed the following: Start date: 01/09/2025 - Soft mitt to right hand with every 30 minute checks due to pulling tubing. Review of Resident #84's current Care Plan revealed the following: Problem: Date initiated 04/02/2025-Resident has an alteration in musculoskeletal status related to right hand contracture. Resident wears right hand splint usually during the day. Resident wears right hand soft mitt when splint not in use. Interventions Problem: Date initiated 01/08/2025-Resident uses physical restraints (Right hand soft mitt/guard) related to pulling of tubing. On 06/10/2025 at 8:38 a.m., an observation was made of Resident #84 lying in bed with no soft mitt or splint noted on the resident's right hand. On 06/10/2025 at 11:39 a.m., an observation was made of Resident #84 lying in bed with no soft mitt or splint noted on the resident's right hand. On 06/10/2025 at 1:50 p.m., an observation was made of Resident #84 lying in bed with no soft mitt or splint noted on the resident's right hand. On 06/10/2025 at 3:24 p.m., an interview was conducted with S8LPN. She reviewed Resident #84's current Physician's Orders, and stated Resident #84 should always have either a soft mitt or a splint on her right hand due to the possibility of the resident pulling on her tubes. S8LPN observed and confirmed Resident #84 did not have a mitt or splint in place on her right hand and should have. On 06/10/2025 at 3:35 p.m., an interview was conducted with S3ADON. She reviewed Resident #84's Physician's Orders and confirmed Resident #84 should have a soft mitt or splint on her right hand at all times.

Based on interviews and record reviews, the facility failed to ensure a resident's discharge assessment was completed and transmitted for 1 (#82) of 2 (#82 and #88) residents reviewed for Resident Assessment. Findings: Review of the facility's policy titled, MDS (Minimum Data Set) 3.0 Completion and dated 05/2023 revealed the following, in part: Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop and interdisciplinary care plan. Policy Explanation and Compliance Guidelines: 2. Types of Omnibus Budget Reconciliation Act Assessments i. Death Tracking i. Complete when a resident expires in the facility no later than discharge (death) date plus seven calendar days. 7. Transmission Requirements: a. All assessments shall be transmitted to the designated CMS (Centers for Medicare and Medicaid Services) system within 14 days of completion. Review of Resident #82's Clinical Record revealed she was admitted to the facility on [DATE] and was pronounced deceased in the facility on [DATE]. Review of Resident #82's MDS assessments revealed no discharge assessment was completed. An interview was conducted with S10MDS on [DATE] at 1:07 p.m. She confirmed Resident #82 was admitted to the facility on [DATE] and expired in the facility on [DATE]. She confirmed a discharge MDS assessment should have been completed for Resident #82's and was not. An interview was conducted with S2DON on [DATE] at 1:29 p.m. She reviewed Resident #82's MDS assessments and confirmed a discharge assessment should have been completed and was not.

Based on observations, interviews, and record review, the facility failed to ensure a resident with a Pressure Ulcer and at high risk for Pressure Ulcer development received care consistent with professional standards of practice and based on the comprehensive assessment by failing to ensure an air mattress was properly implemented for 1 (#54) of 3 (#45, #54, #150) residents reviewed with Pressure Ulcers. Findings: Review of the facility's policy titled, Pressure Injury Prevention and Management with a revision date of 07/2024 revealed the following, in part: Policy: This facility is committed to the prevention of avoidable pressure injuries, to provide treatment and services to heal the pressure ulcer/injury, and the development of additional pressure ulcers/injuries. Policy Explanation and Compliance Guidelines: Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Provide appropriate, pressure-distributing support surfaces. Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Chronic Respiratory Failure, Anoxic Brain Damage, Muscle Wasting and Atrophy, and History of Pressure Ulcers. Review of Resident #54's Quarterly MDS with an ARD of 04/15/2025 revealed a Brief Interview for Mental Status (BIMS) was unable to be conducted, which revealed she was severely cognitively impaired. Further review revealed Resident #54 was at risk for Pressure Ulcer development and was dependent on staff for turning and repositioning. Review of Resident #54's Braden Scale for Predicting Pressure Ulcer Risk dated 04/15/2025 revealed a score of 11, which indicated she was at high risk for Pressure Ulcer development. Review of Resident #54's current Physician Orders revealed, in part: A Low Air Loss Mattress on her bed. Review of Resident #54's current Care Plan revealed the following, in part: History of Pressure Ulcers Problem: 06/04/2025 Stage 1 Pressure Ulcer to Right Hip. Interventions: Low Air Loss Mattress on bed. An observation was made of Resident #54 on 06/09/2025 at 8:36 a.m. She was lying in bed. Her air mattress pump was not on. An observation was made of Resident #54 on 06/09/2025 at 12:40 p.m. She was lying in bed. Her air mattress pump was not on. An observation was made of Resident #54 on 06/09/2025 at 1:40 p.m. She was lying in bed. Her air mattress pump was not on. An observation was made of Resident #54 on 06/10/2025 at 8:50 a.m. She was lying in bed. Her air mattress pump was not on. An interview was conducted with S6LPN on 06/10/2025 at 10:16 a.m. She stated Resident #54 had a history of Pressure Ulcers and was at risk for Pressure Ulcer development. She stated Resident #54 had an air mattress in place. She stated the mattress pump should have been turned on at all times. An observation was made of Resident #54 with S2DON on 06/10/2025 at 8:52 a.m. An interview was conducted with S2DON at that time. S2DON confirmed the air mattress pump was not on, which meant the mattress was not alternating pressure as intended. She confirmed the air mattress pump should have been on at all times. She confirmed Resident #54's air mattress was an intervention to prevent Pressure Ulcers since the resident was high risk for Pressure Ulcer development.

Based on observation, interviews, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice for 1 of 1 (#300) resident reviewed for IV (Intravenous) therapy. The facility failed to monitor and flush a vascular device according to professional standards. The deficient practice had the potential to affect all residents who may require IV antibiotic or fluid therapy. Findings: Review of the facility's Policy dated 09/2024 titled, Intravenous Therapy-LTC revealed, in part: Policy: The facility will adhere to accepted standards of practice regarding infusion practices. Compliance Guidelines: 11. IV sites are checked per facility protocol . 13. IV documentation is recorded in the nurses' notes and/or Medication Administration Record (MAR). Intermittent Medication Infusion: 1. Review and verify practitioner's order for infusion solution or medication . 13. Attach 10ml (milliliter) syringe and confirm patency of vascular access device as per protocol. Review of Resident #300's Medical Record revealed resident was admitted to the facility on [DATE] with diagnoses which included Quadriplegia, Acute and Chronic Respiratory Failure with Hypoxia, Pneumonia, and Tracheostomy. Review of Resident #300's Physician Orders, dated 06/10/2025, revealed an order on 06/09/2025 for Midline placement today, and Meropenem Solution Reconstituted 1 GM (gram), use 1 gram intravenously every twelve hours for Klebsiella Pneumoniae for 14 days. Further review revealed no physician orders for an assessment daily, dressing changes, or flushing schedule for Resident #300's maintenance of the Midline venous access device. Review of Resident #300's Medication Administration Record (MAR), dated 06/10/2025, revealed no documented evidence of an assessment daily or flushing schedule for Resident #300's Midline device. On 06/10/2025 at 9:00 a.m., an observation was made of Resident #300's Midline vascular access site in the left, upper arm, during medication administration. S7LPN scrubbed the hub with alcohol for 20 seconds, connected a NS (normal saline) syringe and flushed the Midline device. On 06/10/2025 an interview was conducted with S7LPN, after medication infusion was started. SLPN stated that she knew the device was patent because she observed it being inserted into Resident's left arm yesterday. On 06/10/2025 at 4:25 p.m., an interview was conducted with S2DON. S2DON stated all nurses were responsible for ensuring appropriate orders for each resident are documented. S2DON stated she expected nurses to flush a Midline access device in between medication administration with saline and heparin to maintain patency. She reviewed Resident #300's current physician orders and confirmed there was not an order for daily assessment of or flushing her Midline IV device and should have been. She confirmed the nurse should have notified the Practitioner for missing flush orders and documented on MAR.

Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#26) of 3 (#10, #19, and #26) residents reviewed for Activities of Daily Living (ADL). The facility failed to ensure nursing staff accurately documented Resident #26's baths. Findings: Review of Resident #26's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #26's Quarterly MDS with an ARD of 04/28/2025 revealed he was dependent on staff assistance for bathing. Review of the C.N.A. (Certified Nursing Assistant) Assignment Sheet dated June 2025 revealed Resident #26 should receive a bath Monday through Saturday. Review of Resident #26's ADL (Activities of Daily Living) Flowsheet dated 06/01/2025 to 06/11/2025 revealed no documentation a bath was given on 06/03/2025, 06/05/2025 or 06/07/2025. Review of Resident #26's Nurses' Notes dated June 2025 revealed no documented evidence of refusals of baths. On 06/10/2025 at 3:22 p.m., a telephone interview was conducted with S13CNA. She verified she was assigned to Resident #26 on 06/07/2025 and gave him a bed bath. She confirmed she did not document his bed bath on 06/07/2025, and should have. On 06/11/2025 at 11:52 a.m., an interview was conducted with S14CNA. She verified she was assigned to Resident #26 on 06/03/2025 and 06/05/2025 and gave Resident #26 a bed bath. She reviewed Resident #26's ADL Flowsheet dated June 2025 and confirmed she did not document the baths were given. She confirmed Resident #26's baths were not accurately documented and should have been. On 06/11/2025 at 12:00 p.m., an interview was conducted with S3ADON. She stated Resident #26 was to receive a daily bed bath. She reviewed Resident #26's ADL Flowsheet dated June 2025 and confirmed the CNAs were not documenting the daily baths. She confirmed the documentation did not show a bath was performed on the above mentioned dates and should have. On 06/11/2025 at 1:06 p.m., an interview was conducted with S2DON. She stated Resident #26 preferred a daily bed bath. She reviewed Resident #26's ADL Flowsheet dated June 2025 and confirmed there was no documentation Resident #26 received a bath on the above mentioned dates. She confirmed Resident #26's baths were not accurately documented and should have been.

Based on interviews and record reviews, the facility failed to meet Hospice requirements by failing to maintain a system to ensure a hospice resident's Clinical Binder contained documentation of Hospice Nurse Visit notes for 1 (#81) of 1 resident reviewed for hospice care. This deficient practice had the potential to affect any of the residents receiving hospice services in the facility. Findings: Review of the facility's policy titled Hospice Services Facility Agreement, with a revision date of 10/2020 revealed the following: Policy: It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. A review of Resident #81's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #81 was a patient of a local hospice agency with a Certification Period of 04/03/2025 through 07/01/2025. A review of Resident #81's hospice binder revealed resident was admitted to the hospice agency on 04/03/2025. Further review revealed no Hospice Nurse Visit notes were contained in the binder. On 06/10/25 at 3:52 p.m. an interview was conducted with the Hospice Liaison. She reviewed Resident #81's hospice binder and confirmed there were no hospice progress notes in the binder. On 06/10/25 at 4:37 p.m. an interview was conducted with S8LPN. She reviewed Resident #81's hospice binder and confirmed there were no hospice progress notes in the binder. On 06/11/25 at 11:42 a.m. an interview was conducted with hospice nurse. She confirmed she had not placed documentation with resident #81's weekly assessments in the facility's hospice binder. On 06/11/25 at 2:10 p.m. an interview was conducted with S9CRN. She confirmed hospice progress notes should be updated and kept in the resident's hospice binder. On 6/11/25 at 2:10 p.m. an interview was conducted with S2DON. She confirmed hospice progress notes should be updated and kept in the resident's hospice binder.

Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable infection by failing to ensure staff performed appropriate infection control practices during and after incontinence care for 1 (#61) of 3 (#19, #37, and #61) residents observed for incontinence care. Findings: Review of the facility's policy titled, Catheter Care revealed the following, in part: Policy: It is the policy of this facility to ensure residents with indwelling catheters receive appropriate catheter care. Compliance Guidelines: Female Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). Review of the facility's policy titled, Hand Hygiene revealed the following, in part: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, patients, residents, and visitors. Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene may be performed by using both soap and water or alcohol based hand rub. Hand hygiene should be performed during resident care when moving from a contaminated body site to a clean site. Review of Resident #61's current Physician Orders revealed, in part, to cleanse her catheter daily and as needed with soap and water. On 06/11/2025 at 9:00 a.m., an observation was made of S11LPN performing catheter and incontinence care on Resident #61. S11LPN donned clean gloves and used clean perineal wipes to remove bowel movement off of Resident #61's buttocks. S11LPN then, without changing gloves or performing hand hygiene, placed a clean sheet over Resident #61's torso with her soiled gloves. S11LPN removed her soiled gloves and applied clean gloves without performing hand hygiene. S11LPN obtained a clean wash cloth with soap and water, removed bowel movement off of Resident #61's catheter tubing and then used a perineal wipe to clean bowel movement off of Resident #61's catheter tubing. S11LPN removed her soiled gloves and applied clean gloves without performing hand hygiene. S11LPN then used five wash cloths to clean Resident #61's perineum and each time, placed the soiled wash cloths on the floor. S11LPN obtained a perineal wipe and cleaned bowel movement off of Resident # 61's buttocks, wiping toward the catheter tubing and vaginal area. Then without changing her gloves or performing hand hygiene, S11LPN opened a clean incontinence pad and placed it under Resident #61 with her soiled gloves. S11LPN, without changing gloves or performing hand hygiene, touched Resident #61's right arm and torso to turn Resident #61 toward S11LPN, touched the inside of Resident #61's clean brief, fastened Resident #61's brief, pulled Resident #61's gown down, and placed the sheets and blankets on Resident #61 with soiled gloves. S11LPN opened Resident #61's room door, removed her gown and gloves and exited Resident #61's room without performing hand hygiene. S11LPN went to another hall in the facility, retrieved a linen cart, placed a clean trash bag in the linen cart and put the lid down. Then without performing hand hygiene and using her soiled hands, S11LPN opened the Personal Protective Equipment cart drawer and put on a gown. S11LPN used her soiled hands to tie the gown around her waist and behind her neck. On 06/11/2025 at 9:40 a.m., an interview was conducted with S11LPN. S11LPN confirmed she should have removed her soiled gloves and applied clean gloves after removing bowel movement form Resident #61 and prior to moving to a clean area. S11LPN confirmed she did not perform hand hygiene between glove changes and after removing soiled gloves, and should have. S11LPN confirmed she placed soiled linen on the floor, and should not have. S11LPN confirmed she exited Resident #61's room and retrieved a soiled linen cart from another hallway without sanitizing her hands. S11LPN confirmed she should have wiped away from Resident #61's catheter tubing and vaginal area when removing bowel movement. On 06/11/2025 at 10:57 a.m., an interview was conducted with S2DON. S2DON confirmed staff should change their gloves when soiled and when moving from a contaminated to a clean area during resident care. S2DON confirmed staff should sanitize their hands between glove changes. S2DON confirmed staff should wipe from front to back in a female and should wipe away from catheter tubing while performing incontinence care. S2DON confirmed staff should place dirty linens into the dirty linen basin. S2DON confirmed soiled linen should not have been placed onto the floor.

Based on observations and interviews, the facility failed to ensure maintenance services were provided to maintain a safe, clean, comfortable, and homelike environment for 4 of 4 (#R1, #R2, #R3 and #R4) residents' rooms observed for environmental concerns. The facility failed to ensure A/C (air conditioning) window units were clean, free of debris, and received regular maintenance Findings: Resident #R1 Review of Resident #R1's Clinical Record revealed she was admitted to the facility on [DATE] with a BIMs of 15, which indicated cognitively intact. An observation was made on 12/23/2024 at 10:30 a.m. of Resident #R1's room A/C window unit. The right and left adjustable louvers of the A/C window unit were covered throughout with a buildup of black substances, spotted flat black stains and a blue glove stuffed into a crevice of one of the louvers. Further observation of the A/C window unit revealed the front panel grill had a buildup of gray dust. An interview was conducted on 12/23/2024 at 10:30 a.m. with Resident #R1. Resident #R1 stated she had her A/C window unit running all the time. Resident #R1 observed the A/C window unit, and she confirmed there were multiple black spots that looked like mold on the adjustable louvers and gray dust buildup on the front panel grill of the A/C window unit. She stated the A/C window unit needed to be cleaned. She stated she had trouble with allergies and was worried the state of the A/C window unit could have caused an increase in her allergy symptoms. Resident #R2's An observation was made of on 12/23/2024 at 10:38 a.m. of Resident #R3's A/C window unit in her room. Observed the right and left adjustable louvers of the A/C window unit were spotted with a buildup of black substances and spotted, flat, black stains. Further observation of the A/C window unit revealed the front panel grill had a buildup of gray dust. Resident #R3 and Resident #R4 An observation was made on 12/23/2024 at 10:40 a.m. of Room c's A/C window unit. Observed the right and left adjustable louvers of the A/C window unit were spotted with a buildup of black substances and spotted, flat, black stains. Further observation of the A/C window unit revealed the front panel grill had a buildup of gray dust. Review of facility's documentation of Central A/C Filter Monthly Log revealed the following: November: Inspected- maintenance Replaced- cleaned/replaced December: Inspected-blank Replaced-blank A facility tour and interview was conducted on 12/23/2024 at 2:00 p.m. with S2MnD. S2MnD stated he monitored and was responsible for the monthly cleaning and maintenance of the A/C window units in the facility. During the tour, S2MnD observed the aforementioned Resident #R1, Resident #R2, Resident #R3 and Resident #R4's A/C window units, and he confirmed they were covered with black spots which looked like mildew. S2MnD confirmed the A/C window units were usually cleaned and maintenance completed once a month on the 15th and 16th day. He stated the A/C window units were due to be cleaned and filter replaced on 12/15/2024 and 12/16/2024, but had not completed the services. A facility tour and interview was conducted on 12/23/2024 at 2:45 p.m. with S1ADM. S1ADM observed the aforementioned A/C window units, and she confirmed they were covered with black spots and were due to be cleaned and maintenance.

Based on observation, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect 78 residents who were served meals from the kitchen. Findings: Review of the facility's policy titled, Food Safety Requirements, dated 08/2022, revealed in part: Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. 3. Facility staff shall inspect all food, food products, and beverages upon receipt and ensure proper storage a. Refrigerated storage-foods that require refrigeration shall be refrigerated immediately upon receipt. On 06/10/2024 at 9:00 a.m., an initial tour of the kitchen was conducted with S7DM. The following items were found opened on a shelf instead of in the refrigerator: 1. Soy Sauce, 1 gallon bottle, half empty. Manufacture's label read Refrigerate After Opening. 2. Lemon Juice, 1 quart bottle, half empty. Manufacture's label read Refrigerate After Opening. On 06/10/2024 at 9:02 a.m., an interview was conducted with S7DM. She confirmed the soy sauce and lemon juice were open. She confirmed both the soy sauce and lemon juice should have been refrigerated upon opening and was not. On 06/11/2024 at 10:00 a.m., an interview was conducted with S1ADM. She stated she expected all opened food items which require refrigeration would be stored in the refrigerator.

Based on observation, interviews, and record review, the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#82) of 2 (#59 and #82) sampled residents reviewed for dignity. The facility failed to ensure staff communicated with the resident, and explained the care to be provided. Findings: Review of Resident #82's Clinical Record revealed he was admitted on [DATE] with diagnoses, which included Cerebral Infarction, Tracheostomy, and Need for Assistance with Personal Care. Review of Resident #82's admission assessment MDS with an ARD of 05/21/2024 revealed the provider assessed the resident as having a BIMS of 0, indicating the resident was severely cognitively impaired. Further review revealed he was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. On 06/10/2024 at 10:20 a.m., an observation was conducted of Resident #82. S9CNA walked into Resident #82's room, pulled the curtain, and pulled the sheet to turn Resident #82 without explaining the care to be provided. On 06/12/2024 at 3:09 p.m., an interview was conducted with S3ADON. She confirmed she would expect all staff to greet residents when entering the room and explain the care to be provided. On 06/12/2024 at 3:30 p.m., an interview was conducted with S2DON. She confirmed she would expect all staff to greet residents when entering the room and explain care to be provided.

Based on interviews and record review, the facility failed to ensure alleged violations involving neglect were reported immediately to the Administrator and within 24(twenty four) hours after the allegations were made to the state agency for 1of 1 (#70) residents reviewed for neglect. Findings: A review of the facility's policy titled, Reporting Alleged Violations revealed, in part, the following: Policy: The purpose of this policy is to assure that all alleged violations are reported immediately to the facility administrator and other officials. Compliance Guidelines: 2. If the alleged violation involves abuse or results in serious bodily injury, it must be reported immediately but no later than 2 hours after the allegation is made. 4. The alleged violations must be reported to the administrator of the facility and to other officials (including to the State Agency and Adult Protective Services where state law provides jurisdiction in long term care facilities) in accordance with state law through established procedures. A review of the clinical record revealed Resident #70 was admitted to the facility on [DATE]. Resident #70's diagnosis included Encounter for Attention to Tracheostomy. A review of Resident #70's Nurse's Notes from 05/17/2024 revealed: 05/17/2024 at 4:00a.m.- Signed by S10LPN- Summoned to room by charge nurse while assisting with care of resident. Upon entering resident room, resident lying with head turned to right side. Condition stable. Resident noted to have large amount of larvae exiting from mouth area. Ambulance called to transport resident out of facility. A review of the facility's Investigative Report turned in to state agency revealed the incident with Resident #70 having maggots coming from his mouth was discovered on 05/17/2024 at 5:00 a.m. Further review revealed an investigative report was not entered into the system until 05/20/2024 at 12:18 p.m. On 06/12/2024 at 3:05 p.m., an interview was conducted with S1ADM. She confirmed she did not report the incident within 24 hours to the state agency. She confirmed she reported the incident on 05/20/2024 and it should have been reported within 24 hours of the incident.

Based on review of the medication package insert, record reviews and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, including excessive doses, for 1(#296) of 7 (#31, #39, #85, #86, #92, #295, and #296) residents reviewed for hospitalization s. The facility failed to ensure: 1.) Clinically significant medications were administered as ordered by the physician, 2.) Medications were transcribed correctly from the physician's orders [REDACTED]. 3.) Preventative and/or corrective measures were identified and implemented when medications were not administered as ordered by the physician. An Immediate Jeopardy occurred for Resident #296 on [DATE] at 4:00 p.m. when the resident was administered an excessive dose of Xarelto. Resident #296 had been hospitalized and was readmitted to the facility on [DATE] with physician orders [REDACTED]. The medication was transcribed incorrectly to the MAR and on [DATE] through [DATE], the Resident received Xarelto 15 mg BID and Xarelto 20 mg at 4:00 p.m. On [DATE], the resident received Xarelto 15 mg at 8:00 a.m. and Xarelto 20 mg at 4:00 p.m. On [DATE], the resident experienced excessive bleeding from the mouth, nose and [MEDICAL CONDITION] site. The resident was transferred to the hospital at approximately 9:00 a.m. and she was pronounced dead at 10:10 a.m. S1ADM was notified of the Immediate Jeopardy on [DATE] at 4:08 p.m. The Immediate Jeopardy was removed on [DATE] at 12:40 p.m. when an acceptable plan of removal was received from the provider and implemented. Through interviews and record reviews, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Review of the Plan of Removal revealed the following: [DATE] Nurse Practitioner contacted to verify accurate dosage orders for all 22 residents currently residing in the facility on anticoagulants. On [DATE], all 22 residents currently residing in the facility on an anticoagulant assessed for signs and symptoms of abnormal bleeding. Nurse Practitioner will be contacted immediately for any concerns noted. Effective [DATE], new admit and readmit medication orders to be verified by nurse and on call nurse practitioner prior to facility printing return or new admit orders. For after hour readmissions, admitting nurse to contact on call Nurse Practitioner for verification of accurate dosage of anticoagulants and all medications. Beginning [DATE], all nurses on 2p-10p and 10p-6a shifts to be inserviced on signs and symptoms of abnormal bleeding. Beginning [DATE], all nurses on 2p-10p and 10p-6a shifts and medical records personnel to be inservices on facility policy for nurse practitioner verification of new and readmission orders [REDACTED]. Beginning [DATE], all nurses on 2p-10p and 10p-6a shifts and medical record personnel, to be inserviced on medication order clarification for discrepancies. Orders that are incomplete, illegible, or otherwise unclear shall not be initiated until all orders are verified or clarified. If there is any question regarding a medication prescribed, dose, or strength (e.g., very high or very low), administration frequency, or dosage interval, all nurses shall contact the prescriber. Questionable orders shall be verified /clarified prior to initiating the order. Inservice to be completed no later than [DATE]. All weekend nurses to be inserviced by phone on [DATE]. Weekend nurses to be inserviced in person no later than [DATE]. This deficient practice continued at a potential for more than minimal harm for the 22 residents residing in the facility on an anticoagulant medication. Findings: Review of the Xarelto (Rivaroxaban) prescription package insert, revised ,[DATE], revealed there was not a recommended daily dose that exceeded 30 mg per day. Dosage and Administration included: Nonvalvular [MEDICAL CONDITION] Fibrillation: For patients with CrCl >50 mL/min: 20 mg orally, once daily with the evening meal. For patients with CrCl ?50 mL/min: 15 mg orally, once daily with the evening meal. treatment of [REDACTED]. Reduction in the Risk of Recurrence of [MEDICAL CONDITION] and/or PE in patients at continued risk for [MEDICAL CONDITION] and/or PE: 10 mg once daily with or without food, after at least 6 months of standard anticoagulant treatment. [MEDICATION NAME] of [MEDICAL CONDITION] Following Hip or Knee Replacement Surgery: 10 mg orally once daily with or without food. Reduction of Risk of Major Cardiovascular Events (CV Death, MI, and Stroke) in chronic CAD or PAD: 2.5 mg orally twice daily, with or without food, in combination with aspirin (,[DATE] mg) once daily. Resident #296 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Readmission orders [REDACTED] Rivaroxaban (Xarelto) 15 mg tablet 1 tablet by PEG tube route 2 (two) times daily with meals for 21 days. Then switch to Xarelto 20 mg daily afterward for 2.5 more months. Review of the hospital discharge instructions revealed the following in part: We are starting higher dose Xarelto for upper extremity [MEDICAL CONDITION]. Take Xarelto 15 mg twice daily for 21 days, then transition to Xarelto 20 mg daily for another 2.5 months (total 3 months). Review of the Facility's Re-Admit Orders for (MONTH) of 2019 revealed: Order Date: [DATE] Start Date: [DATE] Rivaroxaban 20 mg, take 1 tablet per PEG Q evening, Sub for Xarelto Order Date: [DATE] Start Date: [DATE] Rivaroxaban 15 mg, take 1 tablet per PEG BID X 21 days, Sub for Xarelto Order Date: [DATE] Start Date: [DATE] Rivaroxaban 20 mg, take 1 tablet per PEG QD X 2.5 months, Sub for Xarelto Review of the (MONTH) 2019 MAR revealed S2DON's signature with a date of [DATE] which indicated she had reviewed the MAR and all orders were transcribed correctly. Review of Telephone Orders revealed an order dated [DATE] at 1600: DC all previous Xarelto orders Xarelto 20 mg per PEG Q Day Signed: S15LPN7 Signature of Physician: S7NP [DATE] Review of the Medication Administration Record for (MONTH) 2019 revealed: Rivaroxaban 20 mg, take 1 tablet per PEG Q Evening, Sub for Xarelto Order Date: [DATE] Start Date: [DATE] 4:00 p.m. The entries for [DATE], [DATE], [DATE], and [DATE] were initialed with a circle around it, which indicated the medication was not given. The entries for [DATE], [DATE], and [DATE] were initialed, which indicated the medication was administered. Rivaroxaban 15 mg, take 1 tablet per PEG BID X 21 days, Sub for Xarelto Order Date: [DATE] Start Date: [DATE] 8:00 a.m. and 8:00 p.m. The entries for [DATE] starting at 8:00 p.m. through [DATE] at 8:00 a.m. were initialed, which indicated the medication was administered. Handwritten Entry: Rivaroxaban 20 mg, take 1 tablet per PEG Q Day, Xarelto [DATE] 8:00 a.m. The entry for [DATE] was initialed, which indicated the medication was administered Review of the Medication Administration Record for (MONTH) 2019 revealed: Rivaroxaban 20 mg, give 1 tablet per Peg Q Day Order Date: [DATE] Start Date: [DATE] 8:00 a.m. The entries for [DATE] through [DATE] were initialed, which indicated the medication was administered. Review of the Nurses Note dated [DATE] revealed: Summoned to Room by RT and CNA at 9 am. Resident bleeding profusely from nose and mouth. Signed by: S13LPN5 Review of the Respiratory Therapist Note Dated [DATE] at 9:30 a.m. revealed: Called to patient room by CNA. Patient continuously bleeding nasally, orally, and through trach. O2 increased. Patient saturation 94%. Patient trying to talk and still actively bleeding. Suctioned patient orally and nasally until EMT arrived and transferred patient out. Signed by: S16RT Review of the emergency room Documentation dated [DATE] revealed Resident #296 expired in the emergency room at 10:10 a.m. The clinical impression was [MEDICAL CONDITION] and blood loss. An interview was conducted with S13LPN5 on [DATE] at 8:24 a.m. She reported Resident #296 had died yesterday. She reported, you know she was on a blood thinner. She stated the CNA was changing the resident and noticed some blood. S13LPN5 further explained when the CNA sat Resident #296 up she just starting to bleed everywhere. She reported the CNA called her into the room and she went in and started to suction Resident #296. She stated she continued until EMS arrived. An interview was conducted with S21CNA5 on [DATE] at 8:45 a.m. She reported on the morning of [DATE] she entered Resident #296's room and was about to start bathing her. She reported the resident was at her baseline upon entering the room and was communicating as normal with her. She reported she turned away to get something and heard what sounded like Resident #296 starting to vomit. She reported when she turned back around the resident was vomiting blood. She reported she called for help and by the time someone had gotten to the room blood was coming from Resident #296's nose, mouth, and [MEDICAL CONDITION] site. She denied ever seeing Resident #296 bleeding like that. An interview was conducted with S28MR on [DATE] at 11:30 a.m. She reported S2DON would give her the readmission orders [REDACTED]. She explained once the orders were in the system S2DON would review them for accuracy, sign the facility orders, and then fax it to the pharmacy. She stated she only transcribed the orders, and it was up to S2DON and the nurses to check for accuracy. She stated she was of a nonclinical background. She confirmed she transcribed the orders for Resident #296 upon readmission to the facility on [DATE]. An interview was conducted with S13LPN5 on [DATE] at 1:10 p.m. She reported she worked at the facility Monday through Friday from 6:00 a.m. to 2:00 p.m. She reported upon Resident #296's return to the facility on [DATE] there was a discrepancy with the medication order for Xarelto. She explained Resident #296 had three separate orders for this medication. She explained the orders were discontinued and corrected on [DATE]. She reviewed the (MONTH) 2019 MAR and confirmed all three orders had been transcribed to the MAR on [DATE]. She also confirmed the nurses had access to administer the 15 mg twice a day dose and the 20 mg evening dose. S13LPN5 confirmed Resident #296 received 15 mg at 8:00 a.m. and 8:00 p.m. as well as 20 mg at 4:00 p.m. on [DATE] and [DATE]. S13LPN5 also confirmed Resident #296 received 15 mg at 8:00 a.m. and 20 mg at 4:00 p.m. on [DATE]. S13LPN5 reported Xarelto was a blood thinner and could cause excessive bleeding. An interview was conducted with S15LPN7 on [DATE] at 2:29 p.m. She reported she worked Monday through Friday from 2:00 p.m. to 10:00 p.m. S15LPN7 reported upon return from the hospital Resident #296 had too many orders for Xarelto. She stated the orders were all initiated on [DATE] and the pharmacy delivered the 15 mg dose that evening to her while she was working. She stated the pharmacy delivered the 20 mg dose the next day. She stated the way the order was written from the hospital was confusing. She denied contacting the hospital doctor to clarify the order. She denied contacting the facility's doctor to clarify the discrepancy. She reported she knew the medication entry was wrong so she held the 20 mg 4:00 p.m. dose on [DATE]-[DATE]. She confirmed she did not contact the physician and communicate that the medication was being held due to a concern for the order being wrong. She denied knowing if she communicated her concern for a medication discrepancy with any of the other staff nurses or S2DON. S15LPN7 stated Xarelto was a blood thinner and a side effect could be bleeding. She reported on [DATE] S7NP happened to be in the facility later in the day and she was able to talk to her about the Xarelto order. She reported S7NP discontinued all previous orders for the medication and ordered Xarelto 20 mg daily. She stated she gave the 20 mg daily Xarelto at 4:00 p.m. that day even though 15 mg had been given that morning. She confirmed she did not contact the nurse practitioner to clarify if she should have given that dose or not. An interview was conducted with S16RT on [DATE] at 8:19 a.m. She reported she checked Resident #296 on [DATE] at 7:50 a.m. and the resident was at her baseline and all was within normal limits. She denied any signs of bleeding at that time. She reported she did suction the resident and the secretions were thick yellow as normal for this resident. She reported S21CNA5 called her into the room after 9:00 a.m. on [DATE], and when she walked in Resident #296 had bright red thick blood gushing from her nose, mouth, and [MEDICAL CONDITION] site. She reported the staff were unable to get the blood to slow down, and Resident #296 was transferred out to the hospital with blood pouring out. She reported it was like something just burst inside of her. She denied being aware Resident #296 was on a blood thinner. An interview was conducted with S13LPN5 on [DATE] at 9:20 a.m. She reported she saw Resident #296's readmission orders [REDACTED]. She confirmed Xarelto was ordered three separate times, and she thought the order was incorrect. She confirmed she did not contact the hospital physician to clarify the order. She confirmed she did not contact the facility's physician to clarify the order. She confirmed she did not communicate with the other staff nurses or S2DON in regards to the discrepancy. She also confirmed the pharmacy had delivered the Xarelto 15 mg BID dose and the Xarelto 20 mg evening dose to the hall for administration to Resident #296. She stated the nurses communicate between shifts verbally and stated she was not able to communicate with the weekend shift because she never saw them. She confirmed she should have contacted the doctor in regards to a medication discrepancy and communicated with the other nurses. She denied knowing if anyone at the facility had realized the resident had received extra doses of the medications. She confirmed no extra interventions were put into place once the order was changed on [DATE]. An interview was conducted with S2DON on [DATE] at 9:40 a.m. She confirmed S28MR was non-clinical personnel and was responsible for entering the orders into the computer system. She stated once the orders were entered either she, the ADON, or the staff nurse would review them and then fax it to pharmacy. She confirmed she reviewed the readmission orders [REDACTED]. She stated she did review the orders and she did not see anything wrong with it so she signed it and sent it to pharmacy. She reported the nurses should have immediately contacted the physician if they suspected the order was wrong. She confirmed the nurse should have contacted the physician to clarify the medication order and should not have held the medication without communicating with anyone. S2DON denied being aware S13LPN5 and S15LPN7 had identified a medication discrepancy and had not contacted the physician to clarify and correct it. S2DON confirmed she was unaware Resident #296 had received extra doses of Xarelto prior to [DATE]. She confirmed Resident #296 had received excessive doses of Xarelto on [DATE], [DATE], and [DATE]. A telephone interview was conducted with a pharmacy technician for the facility's contracted pharmacy on [DATE] at 12:40 p.m. She confirmed Xarelto 15 mg BID was delivered to the facility on [DATE] and Xarelto 20 mg daily was delivered to the facility on [DATE]. An interview was conducted with S7NP on [DATE] at 8:57 a.m. She reported she was made aware of an issues with the order for Xarelto for Resident #296 on [DATE]. She reported she reviewed the hospital discharge orders and the transcribed facility orders and they were not the same. She confirmed the orders were not transcribed correctly. S7NP confirmed she was not aware Resident #296 had received extra doses of Xarelto when she changed the order on [DATE]. She also confirmed this was a medication error and that Resident #296 received extra doses of Xarelto that were not ordered.

Based on observations, interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 (#32) residents reviewed for accidents. This had the potential to affect all 13 residents identified by the facility as requiring a mechanical lift for transfers. This deficient practice resulted in an actual harm for Resident #32 on 10/05/2018 when S30CNA11 attempted to transfer the resident, who required two person assistance, from her bed to a Geri Chair with a mechanical lift. During the transfer, the straps on one side came off and the resident fell to the floor. The resident was transferred to the hospital and diagnosed with [REDACTED]. Findings: Review of the policy titled Hoyer lift transfer revealed the following, in part: Hoyer Lift All Hoyer lift transfers to be used with 2 staff member assist only. Review of the Manufacturer User Manual for the gray mechanical lift revealed the following, in part: 5 Operation 5.2 Closing/Opening Legs Warning! Risk of Injury The lift could tip and endanger the patients and assistants. -The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to maximum open position -The shifter handle must be locked in place for optimum stability and safety Closing/Opening Manual Legs The shifter handle is used to open or close the legs of the base for stability when lifting a patient The shifter handle must lock into its mounting slot to lock the legs in full closed position. Warning! Risk of Injury The lift could tip and endanger the patient and assistance. -If the shifter handle is not positioned completely into its mounting slot, do not use the patient lift until the shifter handle is properly seated and the legs of the patient lift are locked in place. 8 Maintenance 8.4 Detecting Wear and Damage .Replace any defective parts immediately and ensure that the lift is not used until repairs are made. Review of Resident #32's clinical revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #32's Quarterly MDS with an ARD of 11/28/2018 revealed the resident had a BIMS score of 5 indicating severe cognitive impairment. Resident #32 required extensive Two+ person physical assistance with transfers. Section J- Health Conditions revealed the resident had one fall with major injury since admission. A review of the Care Plan revealed the following, in part: Problem: (on-set 08/09/2016) At risk for falls - 10/05/2018 Resident was being transferred with lift from bed to chair when the straps came off the lift and resident fell on to her right side c/o pain to arm. Sent to ER Goal: Decreasing Number of Falls 05/20/2019 Intervention: 10/05/2018 Return from ER with fracture clavicle and arm in sling. Review of the Nurse's Note revealed the following, in part: 10/05/2018 at 4:20 p.m. Aide called to nurse's station for help. Upon walking into the room, noted resident lying on the floor on her right side c/o pain upon assessment, stated my arm hurt. Review of the Physician's Telephone Orders revealed the following, in part: 10/05/2018 3:10 p.m. Send to ER Eval and Treat R.B.T.O. per NP/S14LPN6. Review of the emergency room Note revealed the following, in part: Patient: Resident #32 DOS: 10/05/2018 4:15 p.m. Chief Complaint: hurt all over Attending Note: I reviewed triage note. Pt notes she hurt's all over and points to R Shoulder. Pt is not able to give more information. Radiology: Type of study: X-ray Impression Clinical Indication: Unspecified fall, initial encounter, with injury to the right shoulder. Pain in right shoulder Findings: . There is a slightly displaced distal clavicle fracture. Impression: 1. Slightly displaced clavicle fracture Orders: 10/05/2018 Arm Sling-Apply Attending Note: X-ray as above. Fracture is displaced and closed. Pt given sling. Pt counseled on results of test. She is bed bound. Will discharge back to NH. Diagnosis: [REDACTED].>Review of the Discharge Orders from the local hospital revealed the following, in part: Clavicle Fracture - Aftercare Instructions (ER/ED), English Special Instructions: Sling as directed. Tylenol for pain. Ice for swelling . Review of the Nurse's Note revealed the following, in part: 10/06/2018 at 12:30 a.m. Resident c/o of having pain at this time. Tylenol 650 mg tabs given PO 10/06/2018 at 8:00 a.m.c/o pain (Rt) shoulder. Pain #3 on pain scale, relieved with medication 10/08/2018 at 9:00 a.m., Resident c/o rt arm pain and will not keep sling on to rt arm. Adm 2-500mg Tylenols for pain PO 10/16/2018 at 8:00 a.m., . Pain #3 in pain scale relieved with medication 10/28/2018 at 9:00 a.m., . Pain #3 on pain scale relieved with medication . On 05/08/2019 at 12:03 p.m., an observation was made of S19CNA3 and S26CNA10 transferring Resident #32 from a Geri Chair to a bed using a gray mechanical lift. On 05/09/2019 at 10:05 a.m., an interview was conducted with S2DON. S2DON stated there was only one CNA present when Resident #32 fell from the mechanical lift. On 05/09/2019 at 11:01 a.m., a telephone interview was conducted with S30CNA11. S30CNA11 stated she was present and caring for Resident #32 when she fell from a mechanical lift. S30CNA11 stated the bar the sling straps hang on had flipped over and Resident #32 launched forward from her chair. On 05/09/2019 at 1:24 p.m., an observation was made of the gray mechanical lift used to transfer Resident #32 on 05/08/2019 at 12:03 p.m. On the back of the lift, near the base, a short metal hollow tube was present and appeared to be removed and/or broken. On 05/09/2019 at 1:51 p.m., an observation of the gray mechanical lift was made with S2DON, S4CNASUP, and S6MAINSUP. S6MAINSUP stated the hollow metal tube was the lever/handle used to spread the legs of the lift. S6MAINSUP stated the legs could not be spread without the bar and should not be like that. S6MAINSUP stated he did not know the handle was broken. S6MAINSUP stated no maintenance was performed on the lifts other than battery or control changes. S6MAINSUP stated he had no documentation of maintenance performed for the lifts. On 05/09/2019 at 1:58 p.m., an interview was conducted with S4CNASUP. S4CNASUP stated S30CNA11 was transferring Resident #32 by herself when she fell from the mechanical lift. S4CNASUP stated S30CNA11 had used a mechanical lift for the transfer. S4CNASUP stated Resident #32 had called out and she reported to the room. S4CNASUP stated one side of the sling was attached to the lift and the other side was off. S4CNASUP stated S30CNA11 should have had a second staff member present for the transfer. On 05/09/2019 at 3:37 p.m., an interview was conducted with S2DON. S2DON stated S30CNA11 had placed the lift pad/sling wrong on the lift and was the reason Resident #32 fell . S2DON stated she did not know if S6MAINSUP ever evaluated the equipment after Resident #32's fall from the lift. On 05/09/2019 at 5:22 p.m., an interview was conducted with S4CNASUP. S4CNASUP stated the gray mechanical lift would be ok to use for certain transfers because not all transfers require the lift legs to be spread. S4CNASUP stated the broken handle controlled the legs of the lift and the legs would not be able to spread to open, but it is okay for residents to be transferred via the lift. On 05/10/2019 at 9:06 a.m., an observation of the gray mechanical lift was made with S6MAINSUP. S6MAINSUP stated the legs of the lift were not operational without the handle/lever. S6MAINSUP attempted to open the legs with the remaining portion of the handle/lever. S6MAINSUP stated the legs would not open. On 05/10/2019 at 1:22 p.m., an interview was conducted with S19CNA3. S19CNA3 stated after Resident #32 fell from the mechanical lift she did not want to get up in her chair for a few days. On 05/10/2019 at 1:31 p.m., an interview was conducted with S20CNA4. S20CNA4 stated she worked with Resident #32 after she fell from the mechanical lift. She stated she had to wear a sling and staff had to be careful when transferring her because she leaned toward that side. S20CNA4 stated Resident #32 would state her arm hurt after the accident.

Based on interview, and record review the facility failed to ensure each resident received and was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by failing to clarify an order for [REDACTED].#5, #6, #7) sampled residents. The deficient practice resulted in an actual harm for Resident #3 on 11/1/17 while waiting to receive a CT of the head at an out-patient clinic. Resident #3 had two [MEDICAL CONDITION] and was subsequently admitted to a local hospital with a [DIAGNOSES REDACTED]. On 9/27/17 at 6:30 p.m. the resident returned to the facility following a Neurologist appointment with a written prescription for [MEDICATION NAME] 750 mg twice a day that had an end date of 10/27/17 and eleven refills. Review of the October 2017 MAR, revealed Resident #3 was administered the last of [MEDICATION NAME] 750mg at 8 p.m. on 10/27/17. An initial [MEDICATION NAME] level dated 11/1/17 done while in the Hospital's emergency room revealed a level of <10 mcg/ml; the therapeutic level is 50 - 100 mcg/ul. Finding: Review of the record revealed Client #3 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the yearly MDS with 10/11/17 ARD revealed a BIMS of 3 which indicated severe cognitive impairment. He required total dependence with all ADLs. An observation of the resident was not done due to him being out of the facility during the survey and readmitted to the hospital for an elevated temp. Review of a Neurology Progress Note dated 9/27/17 revealed in part Assessment and Plan 1. Will increase [MEDICATION NAME] 750 mg BID for [MEDICAL CONDITION] ppx. 2. CMP, [MEDICATION NAME] level day of next appt. before coming to clinic. 3. RTC in 3 months. Review of a Neurosurgery Progress Note dated 10/4/17 revealed in part [MEDICATION NAME] Acid Level- 53.6 mcg/ml (normal range- 50.0-100.0 mcg/ml) Review of facility Physician order [REDACTED]. 9/27/17- [MEDICATION NAME] Sprinkle 250mg, give 3 capsules per peg every 12 hours. (substitute for [MEDICATION NAME]) until 10/27/17; 9/27/17 -[MEDICATION NAME] Acid Level Prior to MD appt. on 10/27/17 Review of the Nurse's Notes revealed the following: 9/27/17 1830 - completed by S4LPN- Resident returned to facility via stretcher from MD Appt. accompanied by mother.[MEDICAL CONDITION]. Skin w/d (warm/dry) to touch. Resp even/unlabored. PEG Tube intact and patent. Resident has new orders as follows: [MEDICATION NAME] 250mg DR; take 3 tablets (750mg total) p.p. q 12 hours with end date 10/27/17. [MEDICATION NAME] Acid level prior to appt. on 10/27/17. NP notified via communication binder mother aware. Appears confused on return appt. date. Paperwork positive. Info faxed to pharmacy. 9/29/17 a.m. - completed by S3LPN- Resident resting in bed. Eyes closed. He is non-verbal. All needs met by staff. He has 2 upcoming doctor/clinic appts. on October 4, 2017 and October 27, 2017. Appointment given to transportation. Review of the Nurse's Notes revealed the following: 10/4/17 12:15 p.m. and completed by S4LPN- Resident returned to facility. No new orders given at this time; no new appointment dates noted.[MEDICAL CONDITION]; PEG intact. Will monitor. 10/5/17 11:30 a.m. and completed by S4LPN- Resident mother showed paper work from doctor's office. Paper given with doctor's appointment, 11/1/17 @ 1 p.m., 11/15/17 @ 8:30 a.m., and 12/27/17 no time noted at this time. Will monitor. Review of the chart revealed a [MEDICATION NAME] Level ([MEDICATION NAME] and [MEDICATION NAME] are the same medication). The value was 91.0 ug/ml. The therapeutic range was 50-100 ug/ml. A review of the October 2017 MAR indicated [REDACTED] [MEDICATION NAME] Sprinkle 250mg, give 3 capsules per peg every 12 hours. Sub for [MEDICATION NAME]. Order date: 9/27/17; Start Date: 9/27/17: Stop Date: 10/27/17. Review of the documented initials revealed the last dose was administered on 10/27/17 at 8:00 p.m. Review of a local hospital H&P dated 11/1/7 revealed in part History of Present Illness: Patient is a [AGE] year old male with history of right hemicrani s/p GSW 9/2016 that is now bedbound, nonverbal, and depending on gtube/trach. Care is at a nursing home. After GSW, patient developed subsequent [MEDICAL CONDITION] disorder and a [DIAGNOSES REDACTED] (VP shunt in place). Present to ED after 2 witnessed [MEDICAL CONDITION] in outpatient CT. [MEDICAL CONDITION] were tonic-clonic in nature. The first one resolved within 5 minutes but patient had another witnessed [MEDICAL CONDITION] in elevator on way to ER. No further witnessed [MEDICAL CONDITION] activity but found to be Hypertensive and [MEDICAL CONDITION] in the 150s-160s, currently in 120s. Has received 4 mg of [MEDICATION NAME] and 2 grams of [MEDICATION NAME] in ED. MICU was consulted for admission for further evaluation of [MEDICAL CONDITION] and concerns for non-convulsive [DIAGNOSES REDACTED], and a continuous EEG has been ordered. Of note, patient's [MEDICAL CONDITION] medication was recently increased to [MEDICATION NAME] 750 mg BID. [MEDICATION NAME] levels returned in ED <10. Mother states that she then called the nursing home and patient has not been receiving the [MEDICATION NAME]. Review of the local hospital ED laboratory report dated 11/1/17 revealed a [MEDICATION NAME] Acid Level of < 10 MCG/ML. The therapeutic range was 50.0 - 100 MCG/ML. An interview was conducted with S3LPN on 11/20/17 at 11:15 a.m. She stated Resident #3 was a nonresponsive and received total care. She stated he had a [MEDICAL CONDITION] collar with oxygen and received continuous tube feedings via a PEG tube. She stated the resident had just returned on 11/17/17 after a two and half week stay at a local hospital. She stated the resident went for a Neurology appointment on 11/1/17, had two [MEDICAL CONDITION] and was admitted to the hospital. An interview was conducted with S3LPN on 11/20/17 at 3:30 p.m. She stated he had a lengthy hospitalization in July 2017 and returned on [MEDICATION NAME] 500 mg twice a day. She stated the resident's [MEDICATION NAME] had been increased following a Neurology appointment in September 2017. After reviewing Resident #3's nurse's notes, she stated on his 9/27/17 appointment with the Neurologist, his medication was increased to 750 mg twice a day. She stated he had orders for the [MEDICATION NAME] 750 mg to end on 10/27/17. She stated she was aware the resident's [MEDICATION NAME] ended on 10/27/17 but she thought the client's physician wanted to stop the medication and didn't think anything of it. On 11/21/17 at 9:03 a.m., S2MDS presented this surveyor with a written prescription from Resident #3's Neurologist dated 9/27/17. She stated the prescription had been filed away in medical records. The prescription read: [MEDICATION NAME] ([MEDICATION NAME]) 250 MG DR ([MEDICATION NAME] coated) tablet, Take 3 tables (750 mf total) by mouth every 12 (twelve) hours. End Date: Oct. 27, 2017. Refills: 11. A telephone interview was conducted with Resident #3's mother on 11/21/17 at 9:25 a.m. She stated she scheduled Resident #3's Neurology and Neurosurgeon appointments. She stated after he returned back to the facility, she would provide the nurse's with a copy of any appointments and prescriptions. She stated on 11/1/17, Resident #3 had an appointment for a CT of the Head. She stated after they arrived for the appointment, Resident #3 started having [MEDICAL CONDITION] back to back and was sent to a local ER. She stated she informed the ER doctor that Resident #3's [MEDICATION NAME] had recently been increased to 750 mg by his Neurologist. She stated the ER doctor informed her that Resident #3's [MEDICATION NAME] level was real low. She stated she called the facility and spoke to a nurse about Resident #3's [MEDICATION NAME] medication. She stated the nurse informed her Resident #3's [MEDICATION NAME] had been discontinued. A telephone interview was conducted with S6Pharm on 11/21/17 at 10:51 a.m. She stated she received a written order on 9/28/17 from Resident #3's facility physician for [MEDICATION NAME] 250mg, 3 tablets, twice a day with an end dated on 10/27/17. She stated the [MEDICATION NAME] order was an ongoing prescription with 11 refills and was last refilled on 10/26/17. She stated refills are not automatically generated. She stated a facility staff member requested the refill on 10/26/17. A telephone interview was conducted with S6NP on 11/21/17 at 11:13 a.m. She stated she becomes aware of new orders from an outside doctor by either receiving the admission packet of information for review, a copy of the physician's orders [REDACTED]. She stated if she had received any new orders for Resident #3, she would not have changed or altered the order because the resident's mother has told her to stay out of his business. She stated his mother does not provide her with a copy of outside doctor visits/progress notes for her to review. When questioned regarding the Neurologist prescription written for Resident #3 on 9/27/17 for [MEDICATION NAME] 250 mg that included an end dated of 10/27/17 and eleven refills, she stated she did not recall seeing the order. She stated had she seen the order, she would have made sure the nurse's clarified the order. An interview was conducted with S7CNA on 11/21/17 at 11:25 a.m. She stated she was the assigned CNA to care for Resident #3 on the 6 a.m. to 2 p.m. shift. She stated he required total assistance with ADLs, had a trache, and received feedings through his PEG tube. She stated she had been instructed by the nurse to report to her immediately if she witnessed Resident #3 having a [MEDICAL CONDITION]. S7CNA stated she had never witnessed Resident #3 having a [MEDICAL CONDITION]. An interview was conducted with S1DON on 11/21/17 at 12:28 p.m. She stated she became aware of the Neurologist prescription dated 9/27/17 for [MEDICATION NAME] for Resident #3 on yesterday. She stated she found the prescription in the resident's file in the medical room. After reviewing the order, she stated the order should have been clarified because the order contained an end date and eleven refills. When asked about any checks and balances to ensure accuracy of outside doctor's orders, she stated she reviewed all physician orders. She stated the nurse was supposed to place any new orders in one of two boxes for her review. She stated her review boxes are located on her door or in the nurse's station. An interview was conducted with S4LPN on 11/21/17 at 2:33 p.m.-She stated she worked the 2 p.m. to 10 p.m. shift Monday thru Friday. She stated she was the assigned nurse to care for Resident #3. After reviewing her nurse's note dated 9/27/17, she stated the resident's mother returned with a prescription for [MEDICATION NAME], orders for lab work, and a return appointment on 10/27/17. She stated based on paperwork she reviewed, she thought the resident had a return appointment on 10/27/17. She stated the resident's mother seemed confused about the dates of his return appointments. When questioned about the orders for the medication [MEDICATION NAME], S4LPN stated she remembered the resident had a hard prescription for the medication. After reviewing the Neurologist prescription dated 9/27/17 for [MEDICATION NAME], she stated the order should have been clarified because of the end date of 10/27/17 and eleven refills.

Based on Record Review and Interview, the facility failed to ensure care and services were provided to 1 (#6) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9), which included residents who were at risk for self extubation related to tracheostomies and/or mechanical ventilation in accordance with professional standards of quality by failing: 1. ensure resident #6 who required mechanical ventilation received proper treatment and care when the resident pulled her [MEDICAL CONDITION] out on [DATE], 2. ensure that resident #6 was re-evaluated, and new interventions were implemented on [DATE] to prevent Resident #6 from pulling the [MEDICAL CONDITION] out again on [DATE]; 3. ensure that there were communication and coordination of services between the nursing staff and the respiratory staff in order to implement an interdisciplinary approach to the resident ' s plan of care; 4. establish a policy/procedure that address what the facility staff must do when residents extubate themselves. The Immediate Jeopardy situation began on [DATE] at 9:55 PM when Resident #6, who had a [MEDICAL CONDITION] and required mechanical ventilation, self-extubated and there was no re-evaluation of the resident to address the problem. A second occurrence of self-extubation occurred on [DATE] which resulted in a critical event for Resident #6. On [DATE] at 7:10 PM, the facility's respiratory therapist identified the resident disconnecting her ventilator tubing from her [MEDICAL CONDITION] and failed to communicate this incident to nursing or the physician. On [DATE] at 8:00 PM, the resident was found unresponsive in her room with her [MEDICAL CONDITION] out and on the floor. CPR (Cardiopulmonary Resuscitation) was initiated. The [MEDICAL CONDITION] was replaced and EMS (Emergency Medical Services) was activated. The resident exited the facility per ambulance at 8:30 PM with rescue breathing being provided by ambulance personnel. The resident was transported to the hospital and she was diagnosed with [REDACTED]. On [DATE] at 3:00 PM, the survey team notified S1ADM (Administrator) and S2 DON (Director of Nurses) of the IJ (Immediate Jeopardy) situation that currently existed in the facility. The IJ situation ended for Resident #6 on [DATE] at 8:30 PM when Resident #6 exited the facility with emergency personnel. The deficient practice remained in place for residents (#7 and #9) who were identified by the facility as having the potential for accidental extubation. The facility's plan of removal was accepted on [DATE] at 11:30 AM and included the following: 1. All [MEDICAL CONDITION] were reviewed using an Accidental Extubation Risk Factor Evaluation tool and 2 residents (#7 and #9) were identified as at risk for accidental extubation. 2. Increased supervision initiated for each resident with nurses assessing the at risk residents and documenting every 30 minute monitoring on the resident's Medication Administration Record. 3. Respiratory Therapy would monitor and document every 30 minute monitoring on the resident's medical record. 4. Both residents would be monitored with a continuous pulse oximeter. 5. All [MEDICAL CONDITION] to the facility would be assessed and documented using the Accidental Extubation Risk Factor Evaluation tool within 24 hours of admit and at quarterly assessment. 6. Facility updated respiratory therapy flow sheet to assess for accidental extubation risk factors at each shift for [MEDICAL CONDITION]. 7. Facility will utilize Accidental Extubation Prevention and Assessment policy in the event of a resident identified as a risk for accidental extubation. 8. Director of Nursing, Respiratory Director, or designee will perform 10 random chart audits and risk assessments per week until 100 % compliance is met consistently for 8 weeks. Then will perform 10 random audits per month. Results of audit will be reported to Quality Assurance team quarterly. 9. Director of Nursing or designee will utilize audit tool to review all incidents of accidental extubation and facility will review all incidents of accidental extubation quarterly with Quality Assurance team. 10. Facility updated Accident/Incident Investigating and Reporting Policy to include instances of accidental extubation, updating care plans to include interventions, as well as communication between staff. The facility initiated respiratory policy on accidental extubation. All staff was in-serviced regarding new policies. The deficient practice remains at an actual harm. Findings: Title 46 Professional and Occupational Standards Part XLVII. Nurses. Subpart 2. Registered Nurses. Chapter 39. Legal Standards of Nursing Practice. 3901. Legal Standards. A. The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the registered nurse in the practice of nursing. The standards of nursing practice provide a means of determining the quality of care which an individual receives regardless of whether the intervention is provided solely by a registered nurse or by a registered nurse in conjunction with other licensed or unlicensed personnel as provided in LAC 46:XLVII.3703 Review of the facility's policy titled Director of Nursing Services revealed in part: Policy Statement: The Nursing Services department is under the direct supervision of a Registered Nurse. Policy Interpretation and Implementation: 1. The Nursing Services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experience in nursing administration, rehabilitative and geriatric nursing. 2. The Director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: .Develop standards of nursing practice; .Developing methods for coordination of nursing services with other resident services; .Assuring that nursing care personnel are administering care and services in accordance with the resident ' s assessment and care plan. Record review revealed that resident #6 was admitted to the facility on [DATE] with admit [DIAGNOSES REDACTED]. Resident #6 was admitted with a #8 extra-long Shiley [MEDICAL CONDITION] and required continuous mechanical ventilation support. Review of the Physical Restraint Informed Consent for Resident #6 dated [DATE] revealed the family requested soft wrist restraints d/t (due to) resident attempting to disconnect her tubing from the ventilator and attempting to get out of the bed. Restraint Intervention Recommended - soft wrist restraints prn (as needed); Specific Target Behavior - pulling at tubing and trying to get out of bed; Medical Symptoms - [MEDICAL CONDITION] - vent (ventilator). This consent was signed by the resident's responsible party on [DATE] and was witnessed by staff. On [DATE] at 1:20 PM, an investigation dated [DATE] done by S3RRTD (Registered Respiratory Therapist Director) for Resident #6 was reviewed and it read as follows: Date: [DATE]; Resident Name: (Resident #6); Nature of Concern: self-extubation-see attached; Department Responsible- RT (Respiratory Therapy); Date Assigned: [DATE]; Investigation: see attached; Findings: unable to verify was checked; Resolution: see attached; Date Resolved: [DATE]; Department Supervisor: S3RRTD; Administrator was blank; Social Service Director was blank; Attached read: (Resident #6) has made several attempts to self-extubate. [DATE]: (Resident #6) was educated about the dangers of pulling on trach/vent circuit due to making several attempts of disconnecting herself from the ventilator. [DATE]: (Resident #6) self-extubated.[MEDICAL CONDITION] without difficulty and restrained. [DATE]: (Resident #6) was found self-extubated.[MEDICAL CONDITION] reinserted and sent to hospital. (Resident #6) was found unresponsive by RT (Respiratory Therapist). Unable to verify (Resident #6's) reason for self-extubation. The attached form was signed by S3RRTD. There were no witness statements attached to this investigation and no indications that witness statements were obtained. On [DATE], the review of the Physician's Communication Problem Binder revealed no documentation that Resident #6's physician was notified when she pulled her [MEDICAL CONDITION] out on [DATE]. Review of the Nurse's Notes for Resident #6 revealed: [DATE] at 4:45 a.m. - attempting to get out of bed during the night. Disconnecting herself from the vent, RT (Respiratory Therapist) and staff monitoring and redirecting that vent (ventilator) must stay on. Constant redirection. Call NP (Nurse Practitioner) made aware of this behavior .and gave orders to monitor. Notified RP (Responsible Party) and she requested restraints be used. [DATE] at 5:00 a.m. - NP (Nurse Practitioner) notified again with orders to apply soft wrist restraints for safety prn (as needed) and they were applied. [DATE] at 9:50 p.m. - resident pulled [MEDICAL CONDITION] RT (Respiratory Therapy) at bedside and replaced trach. O2 sat 100%. Restraints applied. Resident awake and aware. Review of the Respiratory Flow Sheet for Resident #6 dated [DATE], timed 21:55 revealed that the resident pulled [MEDICAL CONDITION]. Further review revealed that pt. sats (patient ' s oxygen saturation) down to 77%,[MEDICAL CONDITION] replaced and sats (oxygen saturation) up to 99%. Pt. (patient) is now restrained and resting well. A review of the care plan and clinical record for Resident #6 revealed no revisions or new interventions after the resident pulled her [MEDICAL CONDITION] out on [DATE]. During an interview on [DATE] at 9:32 AM, S9LPN/MDS (Licensed Practical Nurse/Minimum Data Set) confirmed she was the nurse responsible for assessments, the development of the care plan, and revisions to the care plan for Resident #6. S9LPN/MDS stated she was aware of Resident #6's behavior of pulling out tubes and disconnecting the ventilator tubing. S9LPN/MDS stated that there was a new order for restraints on [DATE] due to pulling and disconnecting tubes and that revision was made to the care plan. S9LPN/MDS stated that if Resident #6 had other incidents of pulling out or disconnecting tubing, pulling out her [MEDICAL CONDITION], or getting out of bed to disconnect tubing then she would have made revisions to the plan of care with new interventions. S9LPN/MDS reviewed the care plan for Resident #6 and stated that she was only aware of the [DATE] incident when the resident pulled her feeding tube out. S9LPN/MDS stated that she was not aware of Resident #6 pulling her [MEDICAL CONDITION] out on [DATE]. S9LPN/MDS stated new interventions should have been put into place and floor nurses should have communicated this incident to her for revision of the plan of care. Review of the nurse's notes dated [DATE] revealed that the first entry was timed at 8:00 p.m. and read: Summoned to pt. (patient) room, pt. (patient) unresponsive with ashy pale color. RT (Respiratory Therapist) at bedside [MEDICAL CONDITION] by RT (Respiratory Therapist) immediately. After rescue breathing was started by RT (Respiratory Therapist) and nurse, faint pulse but unable to obtain BP (Blood Pressure) and O2 sat (Oxygen Saturation). Ambulance called. Fire Department arrived, rescue breathing continued by fire department, RP (Responsible Party) notified and NP (Nurse Practitioner) notified. 8:30 p.m. -pt. (patient) exit facility in route to (hospital), pulse 54/minute, 100% O2 (oxygen) and bagging. RP (responsible party) notified of pt. (patient) in route and said she would meet at hospital. Report was called into the hospital by staff nurse. Review of the Respiratory Flow Sheet for Resident #6 dated [DATE], timed 1910 - [MEDICAL CONDITION] site read: well, no irritation noted. Further review of the Respiratory Flow Sheet for Resident #6 dated [DATE] revealed the following entry timed 2000: Pt (patient) was found unresponsive, no respirations, no pulses, [MEDICAL CONDITION] out. Reinserted a [MEDICAL CONDITION]#[MEDICATION NAME][MEDICAL CONDITION] difficulty and secured it in place. Breath sounds equal bilateral and coarse. Initiated CPR and manually bagged with 100% O2 (oxygen) activated EMS (Emergency Medical Service). Pt. (patient) was sent out to hospital with palpable pulses and 100% oxygen manually bagged per EMS. A review of the hospital records revealed she was diagnosed with [REDACTED]. Per EMS (Emergency Medical Service) the patient was found unresponsive in her bed with [MEDICAL CONDITION]. [MEDICAL CONDITION] immediately replaced and her initial rhythm was PEA (Pulseless Electrical Activity). Further review of the hospital records revealed the EKG (electrocardiogram) dated [DATE] timed 9:10 PM revealed: no acute ischemic changes. According to the discharge summary, Out of hospital [MEDICAL CONDITION], which was felt likely to be due to her respiratory arrest due to airway obstruction with a dislodged trach. On [DATE], the resident still had no improvement, family was informed of brain death determination, and the resident was pronounced dead at 11:08 AM. On [DATE] at 3:30 p.m., S2DON (Director of Nursing) stated that the respiratory department did their own incident investigations and that she had none to provide for Resident #6. On [DATE] at 3:40 p.m., S3RRTD (Registered Respiratory Therapist Director) stated that there were no incident reports for Resident #6 and that if any investigation was done, it would have been documented by the therapist who was on shift at the time of the incident. He stated that the therapist would just write what happened on the back of the respiratory flow sheet. On [DATE] at 11:30 AM an interview was conducted with S2DON, and S3RRTD. During the interview, S2DON reviewed the closed clinical record for Resident #6 and stated the resident required total care from staff and was admitted to one of the respiratory rooms. When asked what respiratory care the resident required, S2DON stated that she could not answer that and the Respiratory Department could better answer questions about her respiratory needs. S3RRTD (Registered Respiratory Therapist Director) entered the conference room at this time ([DATE] at 11:33 AM) and joined this interview regarding Resident #6. S3RRTD stated the resident had [MEDICAL CONDITION], connected to a ventilator and she was ventilator dependent. S3RRTD stated that he did not provide care for her because the respiratory therapist provided the actual care. S3RRTD reviewed the respiratory flow sheets and stated that she was on continuous ventilator support which was set to deliver a tidal volume (TV) of 360 milliliters of air combined with 30% oxygen (FiO2) at a respiratory rate (AC- assist control) of at least 22 times per minute. S2DON stated that sometimes residents were agitated and required the use of restraints. S2DON then stated that Resident #6 was confused. S3RRTD stated that all disciplines were notified when the resident pulled [MEDICAL CONDITION] and notification included the cause. S3RRTD verified that the notifications of disciplines he was referring to was the physician and nursing. S3RRTD stated that the respiratory therapist investigated to determine the cause and there was no form that was filled out showing the investigation into the cause or circumstances. S3RRTD stated the nurse on duty was notified then and there. S2DON reviewed the Nurse's Notes for Resident #6 dated [DATE] and stated that the nurse caring for Resident #6 on [DATE] when the resident self-extubated was S4LPN (Licensed Practical Nurse). S2DON revealed that S4LPN did not document the cause and did not document notification of the resident's family or physician. S3RRTD reviewed the Respiratory Flow Sheet dated [DATE] and confirmed there was no indication that the respiratory therapist investigated to determine reason the resident pulled [MEDICAL CONDITION] and there was no documentation that the physician was notified. When asked if he had any further documentation regarding Resident #6 regarding the incident on [DATE], S3RRTD stated no. S2DON confirmed there were no new interventions put in place after Resident #6 pulled her [MEDICAL CONDITION] out on [DATE]. She stated that according to the [DATE] Nurse's Notes, the restraints that were previously ordered were applied. S3RRTD stated that there is an audible and visual alarm that goes off as well as an external alarm that is located on the ledge outside of the door that connected to the back of the vent. S3RRTD stated that no one would silence alarms except for respiratory; that all staff could check on residents with alarms but respiratory was responsible for vent settings, tubing, trach's, resetting alarms, etc. S3RRTD and S2DON confirmed that they were both aware of Resident #6 being found unresponsive by staff after pulling her [MEDICAL CONDITION] out on [DATE], which led to her transfer from the facility to the hospital. When asked if there was a written incident investigation regarding the [DATE] incident, S3RRTD stated if respiratory investigated to determine cause, it would be documented on the flow sheet. S3RRTD confirmed there was no documentation of an investigation on the [DATE] Respiratory Flow Sheet. S2DON stated that nursing would not have an incident investigation for respiratory issues. S2DON then told S3RRTD that he had documentation of the [DATE] investigation on his desk. During an interview on [DATE] at 3:15 PM, S7RT (Respiratory Therapist) stated she worked as a respiratory therapist at this facility since [DATE] and became full time in October of 2014. S7RT ensured external alarms were functioning correctly and knew it was working correctly when it alarmed. There was also a green light that showed it was functioning properly. All respiratory staff was responsible when alarms sounded. S7RT stated there were usually 3 respiratory therapists assigned to work from 7 AM-7 PM, and usually 3 respiratory therapist until 11 PM and then 2 respiratory therapists scheduled to work from 11 PM until 7 AM. S7RT stated there were usually ,[DATE] residents who were dependent on the ventilators. S7RT stated that currently there were ,[DATE] residents who required continuous mechanical ventilation and were dependent on the ventilator to live. S7RT stated that only the respiratory therapists would silence alarms and the CNA (Certified Nursing Assistant) and nursing staff were aware that the respiratory therapists were to be called if a resident was disconnected from the vent or if high pressure alarms went off when residents coughed. S7RT confirmed that she cared for Resident #6 and stated the resident could communicate verbally by trying to mouth her words and most of the time staff understood what she said. S7RT stated the resident was able to understand and voice her needs. S7RT stated that her family visited daily. S7RT stated that staff did not document the response time to answer alarms and the only documentation she was aware of was when she checked the box indicating if the resident had an external back-up alarm. S7RT stated that if Resident #6 seemed anxious then it should be communicated to the nurse. S7RT revealed that the day the [MEDICAL CONDITION] came out and the resident was found unresponsive ([DATE]), she and S5RT observed Resident #6 disconnecting herself from the ventilator and S5RT told her not to disconnect herself from the vent. S7RT stated S5RT was referring to not disconnecting the ventilator tubing from the [MEDICAL CONDITION] and she stated that Resident #6 nodded yes to indicate that she understood his instructions. S7RT stated that this occurred shortly after S5RT began his shift, probably a little after 7 PM. S7RT stated she did not notify S4LPN that the resident disconnected herself from the ventilator because she considered it normal behavior for the resident. S7RT stated that she and S5RT were aware that she disconnected the ventilator tubing because the external alarm sounded. S7RT stated that it alarmed for only seconds so they did not feel that it was necessary to document the incident or to notify the nurse of the behavior. S7RT confirmed that it was less than an hour later that the resident was found unresponsive with her [MEDICAL CONDITION] out. S7RT stated she was not sure if there was an order for [REDACTED]. S7RT confirmed that Resident #6 did not have soft wrist restraints applied when she disconnected her ventilator tubing from her [MEDICAL CONDITION] on [DATE] around 7:00 PM and she did not notify S4LPN or any other nursing staff that the resident pulled on her tubing and disconnected it. S7RT stated she was in another room when someone said that S5RT was working on the resident and when she entered Resident #6's room, S5RT was bagging the resident with an ambu bag connected to the [MEDICAL CONDITION]. S5RT stated that Resident #6 pulled her [MEDICAL CONDITION] out prior to the [DATE] incident. S5RT stated that if she discovered [MEDICAL CONDITION] then she would notified the nurse to determine what could be done to ensure that the resident did not pull [MEDICAL CONDITION] again. S7RT stated that she was not involved in any investigations and was not asked to provide any witness statements when residents self-extubated. S7RT stated that S4LPN worked the respiratory unit often and she would think that she would ensure that something was done to ensure the resident did not do this again and the nurse would notify the doctor and get an order for [REDACTED]. S7RT stated that she would have only notified the nurse if she thought the resident seemed anxious and she did not feel like the resident was anxious. During an interview on [DATE] at 10:05 AM, S4LPN confirmed she cared for Resident #6 and was her nurse when she self extubated [DATE] and [DATE]. S4LPN stated that when resident #6 pulled her [MEDICAL CONDITION] out [DATE], one of the respiratory therapist was in the room with the resident and she heard them yelling no Mrs. (Resident #6) no. S4LPN stated the resident was a large woman and she (S4LPN) and the respiratory therapist tried to stop her but she overpowered them and pulled it out with the respiratory therapist's hands on it. S4LPN stated that either S5RT or S6RT replaced the [MEDICAL CONDITION] immediately and she applied the soft wrist restraints. S4LPN stated that she should have notified the family and the physician of Resident #6 pulling her [MEDICAL CONDITION] out. S4LPN stated that she could not recall if she called the physician or the nurse practitioner regarding the July incident and stated that documentation of the notification would be in her nurse's notes or on the problem list for doctors. S4LPN stated that no new interventions were put in place that she was aware of to prevent another incident after the [DATE] incident. S4LPN stated that the incident on [DATE] happened after supper time and she remembered going into the room and S5RT was fumbling around looking for supplies and the [MEDICAL CONDITION] was on the floor. S4LPN stated that Resident #6's hands were not restrained and Resident #6 was unresponsive, with no respirations, and no pulse. S4LPN stated that she started CPR (Cardiopulmonary Resuscitation) and S5RT found his supplies at bedside and inserted another [MEDICAL CONDITION]. S4LPN stated that 911 was called, they were able to obtain a faint pulse and rescue breathing continued. S4LPN stated that they were unable to obtain a blood pressure and or oxygen saturation. When asked how she became aware that the resident was unresponsive, S4LPN stated that she was sitting at the nurse's station and one of the CNAs approached her at the nurse's station and told her that they found Resident #6 unresponsive. S4LPN confirmed that the respiratory alarms were able to be heard from the nurse's station. S4LPN stated that she did not recall if she heard a continuous alarm or not. S4LPN stated that after the incident, she asked S8CNA about Resident #6 and S8CNA told her that she and another CNA were going to change Resident #6 and both left the room to get supplies. S4LPN stated that according to the CNA the resident was stable but when they returned, they noticed she looked different and [MEDICAL CONDITION] was out. S4LPN stated that one of the CNAs got S5RT and the other CNA approached her at the nurse's station. S4LPN stated she was not told that Resident #6 had disconnected her ventilator tubing from her [MEDICAL CONDITION] earlier in the shift on [DATE]. S4LPN stated that Resident #6 was dependent on the ventilator for breathing and she could not breathe without it. S4LPN stated that the resident was seen several times other than [DATE] and [DATE] attempting to [MEDICAL CONDITION] and pull tubing. S4LPN stated that was the reason for the restraints and they were used when nursing was aware she was pulling at tubes or trach. S4LPN denied being asked to complete a witness statement. S4LPN stated that the only reason she knew what the CNA staff was doing was because she asked. S4LPN denied knowledge of an investigation being done after the [DATE] incident or the [DATE] incident. During an interview on [DATE] at 3:15 PM, S8CNA (Certified Nursing Assistant) stated that she cared for Resident #6 on the day that she pulled out her own [MEDICAL CONDITION], and was transferred to a hospital and later died . S8CNA stated that the resident had a history of [REDACTED]. S8CNA added that the resident was on soft restraints all of the time. S8CNA stated that if Resident #6 would pull her tube out the alarm would go off. S8CNA confirmed that on the day Resident #6 pulled her [MEDICAL CONDITION] out her restraints were off and she heard the alarm and went into the room. S8CNA stated the resident had just pulled the tube out and she used the intercom in the room to call the respiratory therapist. S8CNA revealed that she stayed in the room and performed CPR with the nurse, and respiratory therapist until the EMS arrived and they took over and transported her to the hospital. On [DATE] at 10:00 AM, a phone interview was conducted with S6RT (Respiratory Therapist). S6RT stated that he cared for Resident #6 on [DATE] and that she pulled out her whole [MEDICAL CONDITION]. S6RT stated that he heard the ventilator alarm and went into the room to find S5RT in the room. S6RT stated that S5RT replaced the [MEDICAL CONDITION] and reported the event to S4LPN, who put her in restraints at that time. S6RT stated that the resident did not have any kind of bad outcome because S5RT was at the bedside when it happened and he was able to replace the tube immediately. S6RT stated that he did not call the doctor because the nurses usually called the doctor. S6RT stated that he does not notify the doctor if a resident pulls the [MEDICAL CONDITION] out unless there is some serious consequence to the resident. S6RT stated that since they were able to put [MEDICAL CONDITION] right back in, he did not call the physician and did not know if the nurse called the physician. S6RT stated that he wrote what happened on the back of the respiratory flow sheet but did not do any investigation or document any kind of an incident report. S6RT stated that respiratory never applied or removed restraints, it was nursing function. S6RT stated that Resident #6 was ventilator dependent and could not tolerate being off of the ventilator at all. S6RT stated that Resident #6 was frequently agitated and disconnected the tubing; he knew this because he heard the nurses talking about those issues and witnessed her agitation at times after her family left. S6RT stated that the resident was coherent and visited with her large family often. She was able to follow some commands but when she was more agitated she may accidentally disconnect the tubing or pull out the trach. On [DATE] at 10:30 AM, a phone interview was conducted with S5RT (Respiratory Therapist). S5RT stated that the respiratory therapists respond to all ventilator alarms and all respiratory needs and that the nurses took care of everything else that was going on with the residents. S5RT stated that on [DATE] during shift change at 7:10 p.m., he heard Resident #6's alarm sound. S5RT stated that he went in the room to find that she was agitated and that she had disconnected her ventilator tubing from the [MEDICAL CONDITION]. S5RT replaced the ventilator circuit and told the resident not to pull on the tubing because she may accidentally pull her tube out and she nodded that she understood. S5RT stated that he was not assigned to Resident #6 that evening but that whoever heard a ventilator alarm first just went to take care of the problem. S5RT stated that S7RT and the nurse (name unknown) were in the room at the end of his conversation with her so he assumed they both knew what happened. S5RT stated that around 8:00 p.m. on [DATE], he was working with another resident across the hall from Resident #6. S5RT stated that he heard a CNA (Certified Nursing Assistant) call for him and he heard the ventilator alarm sounding. S5RT stated that he finished what he was doing with the resident he was working with, then he went to Resident #6's room. S5RT found her unresponsive, the [MEDICAL CONDITION] tie undone on one side, and the whole [MEDICAL CONDITION] was out on her right shoulder. S5RT stated that she was not breathing and he found another [MEDICAL CONDITION] in her room and replaced the tube without difficulty. They began using a bag to ventilate her with oxygen and the nurses began doing chest compressions because they could not find a pulse. S5RT stated that he did not know where S7RT was when the resident extubated herself and stated that she may have been caring for another resident because there were only 2 respiratory therapists working and they had to care for around 20 ventilator residents that evening. S5RT verified that she pulled out her [MEDICAL CONDITION] on [DATE] and he had replaced it without a problem at the time. During an interview on [DATE] at 10:16 AM, S3RRTD (Registered Respiratory Therapist Director) confirmed he was director of the respiratory department and stated that the respiratory department handled all ventilators, [MEDICAL CONDITION] care, breathing treatments, etc. and the nurse handled everything else. S3RRTD revealed that the respiratory therapist would notify the nurse if they found a problem not related to respiratory. S3RRTD stated that he was not aware of the respiratory therapist documenting when they notify nurses of problems. When asked how the respiratory therapist would know if nurses followed up on problems, he stated, I am not sure. S3RRTD reviewed the Policy/Procedure: Guidelines for the Care of Ventilator Residents in a Skilled Nursing Facility and confirmed that the policy stated nursing and/or respiratory therapy was responsible for care of Ventilator Residents, but does not specifically indicate which discipline was responsible for what. During an interview on [DATE] at 10:30 AM, S3RRTD (Registered Respiratory Therapist Director) stated that a respiratory therapist would call the doctor if a resident were having respiratory problems, and would notify the nurse. S3RRTD stated the physician notification would be documented on a respiratory flow sheet. S3RRTD further stated that the respiratory therapist would not document each time a nurse was notified. S3RRTD stated the nurse would probably notify the physician unless it was a respiratory related problem. When asked who would notify the physician when a resident pulled a tube, S3RRTD stated it would probably be the nurse after we (respiratory therapy staff) notified her. During an interview on [DATE] at 11:38 AM, S3RRTD (Registered Respiratory Therapist Director) stated the facility did not have a policy that addressed specifically communication between n

Based on Record Review and Interview, the Facility failed to ensure that a resident with a [MEDICAL CONDITION] received proper care and treatment for 1 (#6) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) sampled residents, which included residents who were at risk for self extubation related to tracheostomies and/or mechanical ventilation. The facility failed to: 1. ensure that the frequency of staff monitoring was increased for Resident #6 after the [DATE] when it was discovered that the resident self extubated. 2. ensure there was communication and coordination of care between the nursing staff and the respiratory staff for a resident known to disconnect and/or pull her [MEDICAL CONDITION] out (#6). 3. ensure that all staff notified nursing on each occurrence when resident #6 was seen attempting to or had disconnected her [MEDICAL CONDITION] tubing from the ventilator. 4. ensure soft wrist restraints were used on [DATE] at 7:10 p.m. as ordered for Resident #6 after the resident disconnected her ventilator tubing from her [MEDICAL CONDITION]. The Immediate Jeopardy situation began on [DATE] at 9:55 PM when Resident #6, who had a [MEDICAL CONDITION] and required mechanical ventilation, self-extubated, and the resident was not re-evaluated concerning new approaches to address the problem. A second occurrence of self-extubation occurred on [DATE] which resulted in a critical event for Resident #6. On [DATE] at 7:10 PM, the facility's respiratory therapist identified the resident disconnecting her ventilator tubing from her [MEDICAL CONDITION] and failed to communicate this incident to nursing or the physician. On [DATE] at 8:00 PM, the resident was found unresponsive in her room with her [MEDICAL CONDITION] out and on the floor. CPR (Cardiopulmonary Resuscitation) was initiated. The [MEDICAL CONDITION] was replaced and EMS (Emergency Medical Services) was activated. The resident exited the facility per ambulance at 8:30 PM with rescue breathing being provided by ambulance personnel. The resident was transported to the hospital and she was diagnosed with [REDACTED]. On [DATE] at 3:00 PM, the survey team notified S1ADM (Administrator) and S2 DON (Director of Nurses) of the IJ (Immediate Jeopardy) situation ended for her on [DATE] at 8:30 PM when Resident #6 exited the facility with emergency personnel. The deficient practice remained in place for residents (#7 and #9) who were identified by the facility as having the potential for accidental extubation. The facility's plan of removal was accepted on [DATE] at 11:30 AM and included the following: 1. All [MEDICAL CONDITION] were reviewed using Accidental Extubation Risk Factor Evaluation tool and 2 residents (#7 and #9) were identified as at risk for accidental extubation. 2. Increased supervision initiated for each resident with nurses assessing the at risk residents and documenting every 30 minute monitoring on the resident's Medication Administration Record. 3. Respiratory Therapy would monitor and document every 30 minute monitoring on the resident's medical record. 4. Both residents would be monitored with a continuous pulse oximeter. 5. All [MEDICAL CONDITION] resident admissions to the facility would be assessed and documented using the Accidental Extubation Risk Factor Evaluation tool within 24 hours of admit and at quarterly assessment. 6. Facility updated respiratory therapy flow sheet to assess for accidental extubation risk factors at each shift for [MEDICAL CONDITION]. 7. Facility will utilize Accidental Extubation Prevention and Assessment policy in the event of a resident identified as a risk for accidental extubation. 8. Director of Nursing, Respiratory Director, or designee will perform 10 random chart audits and risk assessments per week until 100 % compliance is met consistently for 8 weeks. Then will perform 10 random audits per month. Results of audit will be reported to Quality Assurance team quarterly. 9. Director of Nursing or designee will utilize audit tool to review all incidents of accidental extubation and facility will review all incidents of accidental extubation quarterly with Quality Assurance team. 10. Facility updated Accident/Incident Investigating and Reporting Policy to include instances of accidental extubation, updating care plans to include interventions, as well as communication between staff. Facility initiated respiratory policy on accidental extubation. All staff was in-serviced regarding new policies. The deficient practice remains at an actual harm. Findings: Record review revealed that resident #6 admitted to the facility on [DATE] with admit [DIAGNOSES REDACTED]. Resident #6 was admitted with a #8 extra-long Shiley [MEDICAL CONDITION] and required continuous mechanical ventilation support. Review of the Physical Restraint Informed Consent for Resident #6 dated [DATE] revealed the family requested soft wrist restraints d/t (due to) resident attempting to disconnect her tubing from the ventilator and attempting to get out of the bed. Restraint Intervention Recommended - soft wrist restraints prn (as needed); Specific Target Behavior - pulling at tubing and trying to get out of bed; Medical Symptoms - [MEDICAL CONDITION] - vent (ventilator). This consent was signed by the resident's responsible party on [DATE] and was witnessed by staff. Review of the Nurse's Notes for Resident #6 revealed: [DATE] at 4:45 a.m. - attempting to get out of bed during the night. Disconnecting herself from the vent, RT (Respiratory Therapist) and staff monitoring and redirecting that vent (ventilator) must stay on. Constant redirection. Call NP (Nurse Practitioner) made aware of this behavior .and gave orders to monitor. Notified RP (Responsible Party) and she requested restraints be used. [DATE] at 5:00 a.m. - NP (Nurse Practitioner) notified again with orders to apply soft wrist restraints for safety prn (as needed) and they were applied. [DATE] at 4:00 p.m. - J (jejunostomy) tube leaking, resident using abdominal muscles to constrict the tube and causing the tube to disconnect. Counseled the resident about tubing and therapeutic regimen and displayed understanding per head nod. Will monitor [DATE] at 9:50 p.m. - resident pulled [MEDICAL CONDITION] RT (Respiratory Therapy) at bedside and replaced trach. O2 sat 100%. Restraints applied. Resident awake and aware. This entry was signed by S4LPN. Review of the Respiratory Flow Sheet for Resident #6 dated [DATE], timed 21:55 revealed that the resident pulled [MEDICAL CONDITION]. Further review revealed that pt. sats (patient ' s oxygen saturation) down to 77%,[MEDICAL CONDITION] replaced and sats (oxygen saturation) up to 99%. Pt. (patient) is now restrained and resting well. This entry was written by S6RT (Respiratory Therapist). A review of the care plan and clinical record for Resident #6 revealed no revisions or new interventions after the resident pulled her [MEDICAL CONDITION] out on [DATE]. During an interview on [DATE] at 9:32 AM, S9LPN/MDS (Licensed Practical Nurse/Minimum Data Set) confirmed she was the nurse responsible for assessments, the development of the care plan, and revisions to the care plan for Resident #6. S9LPN/MDS stated she was aware of Resident #6 ' s behavior of pulling out tubes and disconnecting the ventilator tubing. S9LPN/MDS stated that there was a new order for restraints on [DATE] due to pulling and disconnecting tubes and that revision was made to the care plan. S9LPN/MDS stated that if Resident #6 had other incidents of pulling out or disconnecting tubing, pulling out her [MEDICAL CONDITION], or getting out of bed to disconnect tubing then she would have made revisions to the plan of care with new interventions. S9LPN/MDS reviewed the care plan for Resident #6 and stated that she was only aware of the [DATE] incident when the resident pulled her feeding tube out. S9LPN/MDS stated that she was not aware of Resident #6 pulling her [MEDICAL CONDITION] out on [DATE]. S9LPN/MDS stated new interventions should have been put into place and floor nurses should have communicated this incident to her for revision of the plan of care. Review of the nurse's notes dated [DATE] at 8:00 p.m. - Summoned to pt. (patient) room, pt. (patient) unresponsive with ashy pale color. RT (Respiratory Therapist) at bedside [MEDICAL CONDITION] by RT (Respiratory Therapist) immediately. After rescue breathing was started by RT (Respiratory Therapist) and nurse, faint pulse but unable to obtain BP (Blood Pressure) and O2 sat (Oxygen Saturation). Ambulance called. Fire Department arrived, rescue breathing continued by fire department, RP (Responsible Party) notified and NP (Nurse Practitioner) notified. 8:30 p.m. - pt. (patient) exit facility in route to (hospital), pulse 54/min, 100% O2 (oxygen) and bagging. RP (responsible party) notified of pt. (patient) in route and said she would meet at hospital. Report was called into the hospital by staff nurse. This entry was signed by S4LPN (Licensed Practical Nurse). Review of the Respiratory Flow Sheet for Resident #6 dated [DATE], timed 1910 - [MEDICAL CONDITION] site read: well, no irritation noted. This entry was initialed by S7RT. Further review of the Respiratory Flow Sheet for Resident #6 dated [DATE] revealed the following entry timed 2000: Pt (patient) was found unresponsive, no respirations, no pulses, [MEDICAL CONDITION] out. Reinserted a [MEDICAL CONDITION]#[MEDICATION NAME][MEDICAL CONDITION] difficulty and secured it in place. Breath sounds equal bilateral and coarse. Initiated CPR and manually bagged with 100% O2 (oxygen) activated EMS (Emergency Medical Service). Pt. (patient) was sent out to hospital with palpable pulses and 100% oxygen manually bagged per EMS. This entry was signed by S5RT. A review of the hospital records revealed she was diagnosed with [REDACTED]. Per EMS (Emergency Medical Service) the patient was found unresponsive in her bed with [MEDICAL CONDITION]. [MEDICAL CONDITION] immediately replaced and her initial rhythm was PEA (Pulseless Electrical Activity). Further review of the hospital records revealed the EKG (electrocardiogram) dated [DATE] timed 9:10 PM revealed: no acute ischemic changes. According to the discharge summary, Out of hospital [MEDICAL CONDITION], which was felt likely to be due to her respiratory arrest due to airway obstruction with a dislodged trach. On [DATE], the resident still had no improvement, family was informed of brain death determination, and the resident was pronounced dead at 11:08 AM. During an interview with S2DON (Director of Nursing) on [DATE] at 11:30 AM, she reviewed the closed clinical record for Resident #6 and stated the resident required total care from staff and was admitted to one of the respiratory rooms. When asked what respiratory care the resident required, S2DON stated that she could not answer that and the Respiratory Department could better answer questions about her respiratory needs. S3RRTD (Registered Respiratory Therapist Director) entered the conference room at this time ([DATE] at 11:33 AM) and joined this interview regarding Resident #6. S3RRTD stated the resident had [MEDICAL CONDITION], connected to a ventilator and she was ventilator dependent. S3RRTD stated that he did not provide care for her because the respiratory therapist provided the actual care. S3RRTD reviewed the respiratory flow sheets and stated that she was on continuous ventilator support which was set to deliver a tidal volume (TV) of 360 milliliters of air combined with 30% oxygen (FiO2) at a respiratory rate (AC- assist control) of at least 22 times per minute. S2DON stated that sometimes residents were agitated and required the use of restraints. S2DON then stated that Resident #6 was confused. S3RRTD stated that all disciplines were notified when the resident pulled [MEDICAL CONDITION] and notification included the cause. S3RRTD verified that the notifications of disciplines he was referring to was the physician and nursing. S3RRTD stated that the respiratory therapist investigated to determine the cause and there was no form that was filled out showing the investigation into the cause or circumstances. S3RRTD stated the nurse on duty was notified then and there. S2DON reviewed the Nurse's Notes for Resident #6 dated [DATE] and stated that the nurse caring for Resident #6 on [DATE] when the resident self-extubated was S4LPN (Licensed Practical Nurse). S2DON revealed that S4LPN did not document the cause and did not document notification of the resident ' s family or physician. S2DON confirmed there were no new interventions put in place after Resident #6 pulled her [MEDICAL CONDITION] out on [DATE]. S2DON stated that according to the [DATE] Nurse's Notes, the restraints that were previously ordered were applied. S3RRTD stated that there is an audible and visual alarm that goes off as well as an external alarm that is located on the ledge outside of the door that connected to the back of the vent. S3RRTD stated that no one would silence alarms except for respiratory; that all staff could check on residents with alarms but respiratory was responsible for vent settings, tubing, trach's, resetting alarms, etc. S3RRTD and S2DON confirmed that they were both aware of Resident #6 being found unresponsive by staff after pulling her [MEDICAL CONDITION] out on [DATE], which led to her transfer from the facility to the hospital. When asked if there was an incident report or investigation regarding the [DATE] incident, S3RRTD stated if respiratory investigated to determine cause, it would be documented on the flow sheet. S3RRTD confirmed there was no documentation of an investigation on the [DATE] Respiratory Flow Sheet. S2DON stated that nursing would not have an incident report or investigation for respiratory issues. S2DON then told S3RRTD that he had documentation of the [DATE] investigation on his desk. This information was requested. On [DATE] at 1:20 PM, an investigation dated [DATE] done by S3RRTD (Registered Respiratory Therapist Director) for Resident #6 was reviewed and it read as follows: Date: [DATE]; Resident Name: (resident #6); Nature of Concern: self-extubation-see attached; Department Responsible-RT (Respiratory Therapy); Date Assigned: [DATE]; Investigation: see attached; Findings: unable to verify was checked; Resolution: see attached; Date Resolved: [DATE]; Department Supervisor: S3RRTD; Administrator was blank; Social Service Director was blank; Attached read: (Resident #6) has made several attempts to self-extubate. [DATE]: (Resident #6) was educated about the dangers of pulling on trach/vent circuit due to making several attempts of disconnecting herself from the ventilator. [DATE]: (Resident #6) self-extubated.[MEDICAL CONDITION] without difficulty and restrained. [DATE]: (Resident #6) was found self-extubated.[MEDICAL CONDITION] reinserted and sent to hospital. (Resident #6) was found unresponsive by RT (Respiratory Therapist). Unable to verify (Resident #6's) reason for self-extubation. The attached form was signed by S3RRTD. During an interview on [DATE] at 3:15 PM, S7RT (Respiratory Therapist) stated she worked as a respiratory therapist at this facility since [DATE] and became full time in October of 2014. S7RT revealed that the day the [MEDICAL CONDITION] came out and the resident was found unresponsive ([DATE]), she and S5RT observed Resident #6 disconnecting herself from the ventilator and S5RT told her not to disconnect herself from the vent. S7RT stated S5RT was referring to not disconnecting the ventilator tubing from the [MEDICAL CONDITION] and she stated that Resident #6 nodded yes to indicate that she understood his instructions. S7RT stated that this occurred shortly after S5RT began his shift, probably a little after 7 PM. S7RT stated she did not notify S4LPN that the resident disconnected herself from the ventilator because she considered it normal behavior for the resident. S7RT stated that she and S5RT were aware that she disconnected the ventilator tubing because the external alarm sounded. S7RT stated that it alarmed for only seconds so they did not feel that it was necessary to document the incident or to notify the nurse of the behavior. S7RT confirmed that it was less than an hour later that the resident was found unresponsive with her [MEDICAL CONDITION] out. S7RT stated she was not sure if there was an order for [REDACTED]. S7RT confirmed that Resident #6 did not have soft wrist restraints applied when she disconnected her ventilator tubing from her [MEDICAL CONDITION] on [DATE] around 7:00 PM and she did not notify S4LPN or any other nursing staff that the resident pulled on her tubing and disconnected it. S7RT stated she was in another room when someone said that S5RT was working on the resident and when she entered Resident #6's room, S5RT was bagging the resident with an ambu bag connected to the [MEDICAL CONDITION]. S5RT stated that Resident #6 pulled her [MEDICAL CONDITION] out prior to the [DATE] incident. S5RT stated that if she discovered [MEDICAL CONDITION] then she would notified the nurse to determine what could be done to ensure that the resident did not pull [MEDICAL CONDITION] again. S7RT stated that she would have only notified the nurse if she thought the resident seemed anxious and she did not feel like the resident was anxious. During an interview on [DATE] at 10:05 AM, S4LPN confirmed she cared for Resident #6 and was her nurse when she self extubated [DATE] and [DATE]. S4LPN stated that when resident #6 pulled her [MEDICAL CONDITION] out [DATE], one of the respiratory therapist was in the room with the resident and she heard them yelling no Mrs. (Resident #6) no . S4LPN stated the resident was a large woman and she (S4LPN) and the respiratory therapist tried to stop her but she overpowered them and pulled it out with the respiratory therapist's hands on it. S4LPN stated that either S5RT or S6RT replaced the [MEDICAL CONDITION] immediately and she applied the soft wrist restraints. S4LPN stated that no new interventions were put in place that she was aware of to prevent another incident after the [DATE] incident. During continued interview, S4LPN confirmed that she was working [DATE] when resident #6 pulled her [MEDICAL CONDITION] out and was found unresponsive by the CNAs. S4LPN stated that the incident happened after supper time and she remembered going into the room and S5RT was fumbling around looking for supplies and the [MEDICAL CONDITION] was on the floor. S4LPN stated that Resident #6 ' s hands were not restrained and Resident #4 was unresponsive, with no respirations, and no pulse. S4LPN stated that she started CPR (Cardiopulmonary Resuscitation) and S5RT found his supplies at bedside and inserted another [MEDICAL CONDITION]. S4LPN stated that 911 was called, they were able to obtain a faint pulse and rescue breathing continued. S4LPN stated that they were unable to obtain a blood pressure and or oxygen saturation. When asked how she became aware that the resident was unresponsive, S4LPN stated that she was sitting at the nurse's station and one of the CNAs approached her at the nurse ' s station and told her that they found Resident #6 unresponsive. S4LPN confirmed that the respiratory alarms were able to be heard from the nurse's station. S4LPN stated that she did not recall if she heard a continuous alarm or not. S4LPN stated that after the incident, she asked S8CNA about Resident #6 and S8CNA told her that she and another CNA were going to change Resident #6 and both left the room to get supplies. S4LPN stated that according to the CNA the resident was stable but when they returned, they noticed she looked different and [MEDICAL CONDITION] was out. S4LPN stated that one of the CNAs got S5RT and the other CNA approached her at the nurse's station. S4LPN stated she was not told that Resident #6 had disconnected her ventilator tubing from her [MEDICAL CONDITION] earlier in the shift on [DATE]. S4LPN stated that Resident #6 was dependent on the ventilator for breathing and she could not breathe without it. S4LPN stated that the resident was seen several times other than [DATE] and [DATE] attempting to [MEDICAL CONDITION] and pull tubing. S4LPN stated that was the reason for the restraints and they were used when nursing was aware she was pulling at tubes or [MEDICAL CONDITION]. During an interview on [DATE] at 3:15 PM, S8CNA (Certified Nursing Assistant) stated that she cared for Resident #6 on the day that she pulled out her own [MEDICAL CONDITION], and was transferred to a hospital and later died . S8CNA stated that the resident had a history of [REDACTED]. S8CNA added that the resident was on soft restraints all of the time. S8CNA stated that if Resident #6 would pull her tube out the alarm would go off. S8CNA confirmed that on the day Resident #6 pulled her [MEDICAL CONDITION] out her restraints were off and she heard the alarm and went into the room. S8CNA stated the resident had just pulled the tube out and she used the intercom in the room to call the respiratory therapist. S8CNA revealed that she stayed in the room and performed CPR with the nurse, and respiratory therapist until the EMS arrived and they took over and transported her to the hospital. On [DATE] at 10:00 a.m., a phone interview was conducted with S6RT (Respiratory Therapist). S6RT stated that he cared for Resident #6 on [DATE] and that she pulled out her whole [MEDICAL CONDITION]. S6RT stated that he heard the ventilator alarm and went into the room to find S5RT in the room. S6RT stated that S5RT replaced the [MEDICAL CONDITION] and reported the event to S4LPN, who put her in restraints at that time. S6RT stated that respiratory never applied or removed restraints, it was nursing function. S6RT stated that Resident #6 was ventilator dependent and could not tolerate being off of the ventilator at all. S6RT stated that Resident #6 was frequently agitated and disconnected the tubing; he knew this because he heard the nurses talking about those issues and witnessed her agitation at times after her family left. S6RT stated that the resident was coherent and visited with her large family often. She was able to follow some commands but when she was more agitated she may accidentally disconnect the tubing or pull out the trach. On [DATE] at 10:30 a.m., a phone interview was conducted with S5RT (Respiratory Therapist). S5RT stated that the respiratory therapists respond to all ventilator alarms and all respiratory needs and that the nurses took care of everything else that was going on with the residents. S5RT stated that on [DATE] during shift change at 7:10 p.m., he heard Resident #6's alarm sound. S5RT stated that he went in the room to find that she was agitated and that she had disconnected her ventilator tubing from the [MEDICAL CONDITION]. S5RT replaced the ventilator circuit and told the resident not to pull on the tubing because she may accidentally pull her tube out and she nodded that she understood. S5RT stated that he was not assigned to Resident #6 that evening but that whoever heard a ventilator alarm first just went to take care of the problem. S5RT stated that S7RT and the nurse (name unknown) were in the room at the end of his conversation with her so he assumed they both knew what happened. S5RT stated that around 8:00 p.m. on [DATE], he was working with another resident across the hall from Resident #6. S5RT stated that he heard a CNA (Certified Nursing Assistant) call for him and he heard the ventilator alarm sounding. S5RT stated that he finished what he was doing with the resident he was working with, then he went to Resident #6 ' s room. S5RT found her unresponsive, the [MEDICAL CONDITION] tie undone on one side, and the whole [MEDICAL CONDITION] was out on her right shoulder. S5RT stated that she was not breathing and he found another [MEDICAL CONDITION] in her room and replaced the tube without difficulty. They began using a bag to ventilate her with oxygen and the nurses began doing chest compressions because they could not find a pulse. S5RT stated that he did not know where S7RT was when the resident extubated herself and stated that she may have been caring for another resident because there were only 2 respiratory therapists working and they had to care for around 20 ventilator residents that evening. S5RT verified that she pulled out her [MEDICAL CONDITION] on [DATE] and he had replaced it without a problem at the time. During an interview on [DATE] at 10:16 AM, S3RRTD (Registered Respiratory Therapist Director) confirmed he was director of the respiratory department and stated that the respiratory department handled all ventilators, [MEDICAL CONDITION] care, breathing treatments, etc. and the nurse handled everything else. S3RRTD revealed that the respiratory therapist would notify the nurse if they found a problem not related to respiratory. When asked how the respiratory therapist would know if nurses followed up on problems, he stated, I am not sure. S3RRTD reviewed the Policy/Procedure: Guidelines for the Care of Ventilator Residents in a Skilled Nursing Facility and confirmed that the policy stated nursing and/or respiratory therapy was responsible for care of Ventilator Residents, but does not specifically indicate which discipline was responsible for what. During an interview on [DATE] at 11:38 AM, S3RRTD (Registered Respiratory Therapist Director) stated the facility did not have a policy that addressed specifically communication between nurses and respiratory. S3RRTD stated the facility did not have a policy for staff in emergency situations when residents extubate themselves. S3RRTD stated the Emergency Equipment policy only listed the equipment to be available at the bedside.

Based on record review, policy review, and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest physical, mental, and psychosocial well-being for a resident with a [MEDICAL CONDITION] for 1 (#6) of 9 (#1 - #9) sampled residents with tracheostomies in a total sample of 9. The facility failed to: 1. ensure resident #6 who required mechanical ventilation received proper treatment and care when the resident pulled her [MEDICAL CONDITION] out on [DATE]; 2. ensure that resident #6 was re-evaluated, and new interventions were implemented on [DATE] to prevent Resident #6 from pulling the [MEDICAL CONDITION] out again on [DATE]; 3. ensure that there were communication and coordination of services between the nursing staff and the respiratory staff in order to implement an interdisciplinary approach to the resident ' s plan of care; 4. establish a policy/procedure that address what the facility staff must do when residents extubate themselves. 5. ensure that the facility is tracking and trending incidents of self extubation for resident that are ventilator dependent. The Immediate Jeopardy situation began on [DATE] at 9:55 PM when Resident #6, who had a [MEDICAL CONDITION] and required mechanical ventilation, self-extubated and the facility failed to ensure professional standards of care was followed by not re-evaluating the resident and developing new interventions to address the problem. A second occurrence of self-extubation occurred on [DATE] which resulted in a critical event for Resident #6. On [DATE] at 7:10 PM, the facility's respiratory therapist identified the resident disconnecting her ventilator tubing from her [MEDICAL CONDITION] and failed to communicate this incident to nursing or the physician. On [DATE] at 8:00 PM, the resident was found unresponsive in her room with her [MEDICAL CONDITION] out and on the floor. CPR (Cardiopulmonary Resuscitation) was initiated. The [MEDICAL CONDITION] was replaced and EMS (Emergency Medical Services) was activated. The resident exited the facility per ambulance at 8:30 PM with rescue breathing being provided by ambulance personnel. The resident was transported to the hospital and she was diagnosed with [REDACTED]. On [DATE], the resident still had no improvement, her family was informed of brain death determination, and the resident was pronounced dead at 11:08 AM. On [DATE] at 3:00 PM, the survey team notified S1ADM (Administrator) and S2 DON (Director of Nurses) of the IJ (Immediate Jeopardy) situation ended for her on [DATE] at 8:30 PM when Resident #6 exited the facility with emergency personnel. The deficient practice remained in place for residents (#7 and #9) who were identified by the facility as having the potential for accidental extubation. The facility's plan of removal was accepted on [DATE] at 11:30 AM and included the following: 1. All [MEDICAL CONDITION] were reviewed using Accidental Extubation Risk Factor Evaluation tool and 2 residents (#7 and #9) were identified as at risk for accidental extubation. 2. Increased supervision initiated for each resident with nurses assessing the at risk residents and documenting every 30 minute monitoring on the resident's Medication Administration Record. 3. Respiratory Therapy would monitor and document every 30 minute monitoring on the resident's medical record. 4. Both residents would be monitored with a continuous pulse oximeter. 5. All [MEDICAL CONDITION] to the facility would be assessed and documented using the Accidental Extubation Risk Factor Evaluation tool within 24 hours of admit and at quarterly assessment. 6. Facility updated respiratory therapy flow sheet to assess for accidental extubation risk factors at each shift for [MEDICAL CONDITION]. 7. Facility will utilize Accidental Extubation Prevention and Assessment policy in the event of a resident identified as a risk for accidental extubation. 8. Director of Nursing, Respiratory Director, or designee will perform 10 random chart audits and risk assessments per week until 100 % compliance is met consistently for 8 weeks. Then will perform 10 random audits per month. Results of audit will be reported to Quality Assurance team quarterly. 9. Director of Nursing or designee will utilize audit tool to review all incidents of accidental extubation and facility will review all incidents of accidental extubation quarterly with Quality Assurance team. 10. Facility updated Accident/Incident Investigating and Reporting Policy to include instances of accidental extubation, updating care plans to include interventions, as well as communication between staff. Facility initiated respiratory policy on accidental extubation. All staff was inserviced regarding new policies. The deficient practice remains at a potential for more than minimal harm. Findings: Cross reference finding at tag F157 Cross reference finding at tag F281 Cross reference finding at tag F328 Cross reference finding at tag F520 Review of the hospital records revealed the EKG (electrocardiogram) dated [DATE] timed 9:10 PM revealed: no acute ischemic changes. According to the discharge summary, Out of hospital [MEDICAL CONDITION], which was felt likely to be due to her respiratory arrest due to airway obstruction with a dislodged trach. On [DATE], the resident still had no improvement, family was informed of brain death determination, and the resident was pronounced dead at 11:08 AM. On [DATE] at 2:30 p.m., S1ADM (Administrator) stated that there were no grievances filed on her behalf and that he had no incidents or investigations to provide for the resident. During an interview with S2DON (Director of Nursing) on [DATE] at 11:30 AM, she reviewed the closed clinical record for Resident #6 and stated the resident required total care from staff and was admitted to one of the respiratory rooms. S2DON reviewed the Nurse's Notes for Resident #6 dated [DATE] and stated that the nurse caring for Resident #6 on [DATE] when the resident self-extubated was S4LPN (Licensed Practical Nurse). S2DON revealed that S4LPN did not document the cause and did not document notification of the resident's family or physician. S2DON confirmed there were no new interventions put in place after Resident #6 pulled her [MEDICAL CONDITION] out on [DATE]. She stated that according to the [DATE] Nurse's Notes, the restraints that were previously ordered were applied. S2DON stated that nursing would not have an incident report or investigation for respiratory issues. During an interview on [DATE] at 3:15 PM, S7RT (Respiratory Therapist S7RT confirmed that Resident #6 did not have soft wrist restraints applied when she disconnected her ventilator tubing from her [MEDICAL CONDITION] on [DATE] around 7:00 PM and she did not notify S4LPN or any other nursing staff that the resident pulled on her tubing and disconnected it. S7RT stated she was in another room when someone said that S5RT was working on the resident and when she entered Resident #6's room, S5RT was bagging the resident with an ambu bag connected to the [MEDICAL CONDITION]. S5RT stated that Resident #6 pulled her [MEDICAL CONDITION] out prior to the [DATE] incident. S5RT stated that if she discovered [MEDICAL CONDITION] then she would notified the nurse to determine what could be done to ensure that the resident did not pull [MEDICAL CONDITION] again. S7RT stated that she was not involved in any investigations and was not asked to provide any witness statements when residents self-extubated. S7RT stated that S4LPN worked the respiratory unit often and she would think that she would ensure that something was done to ensure the resident did not do this again and the nurse would notify the doctor and get an order for [REDACTED]. During an interview on [DATE] at 10:16 AM, S3RRTD (Registered Respiratory Therapist Director) confirmed he was director of the respiratory department and stated that the respiratory department handled all ventilators, [MEDICAL CONDITION] care, breathing treatments, etc. and the nurse handled everything else. S3RRTD revealed that the respiratory therapist would notify the nurse if they found a problem not related to respiratory. S3RRTD stated that he was not aware of the respiratory therapist documenting when they notify nurses of problems. When asked how the respiratory therapist would know if nurses followed up on problems, he stated, I am not sure. S3RRTD reviewed the Policy/Procedure: Guidelines for the Care of Ventilator Residents in a Skilled Nursing Facility and confirmed that the policy stated nursing and/or respiratory therapy was responsible for care of Ventilator Residents, but does not specifically indicate which discipline was responsible for what. During an interview on [DATE] at 10:30 AM, S3RRTD (Registered Respiratory Therapist Director) stated that a respiratory therapist would call the doctor if a resident were having respiratory problems, and would notify the nurse. S3RRTD stated the physician notification would be documented on a respiratory flow sheet. S3RRTD further stated that the respiratory therapist would not document each time a nurse was notified. S3RRTD stated the nurse would probably notify the physician unless it was a respiratory related problem. When asked who would notify the physician when a resident pulled a tube, S3RRTD stated it would probably be the nurse after we (respiratory therapy staff) notified her. During an interview on [DATE] at 11:38 AM, S3RRTD (Registered Respiratory Therapist Director) stated the facility did not have a policy that addressed specifically communication between nurses and respiratory. S3RRTD stated the facility did not have a policy for staff in emergency situations when residents extubate themselves. S3RRTD stated the Emergency Equipment policy only listed the equipment to be available at the bedside. During a phone interview on [DATE] at 3:18 PM, S10 MD (Medical Doctor) stated she or the nurse practitioner should be notified when a resident self-extubated themselves and she would still expect to be notified if the respiratory therapist was able to replace the trach. On [DATE] at 9:10 AM, S1ADM confirmed that the facility's Accident/Incident Investigating and Reporting Policy did not include incidents of accidental extubation prior to the notification of Immediate Jeopardy on [DATE].

Based on record review and interviews the facility failed to ensure Social Service consult/intervention was done on a resident admitted with a [DIAGNOSES REDACTED]. The facility failed to have a process in place to implement social service interventions for a resident admitted with [DIAGNOSES REDACTED].#70) of 2 residents (#70, #52) with depression, mental, and psychosocial difficulties reviewed from a total Stage 2 sample of 31 (#36, #127, #58, #29, #108, #147, #52, #88, #145, #137, #135, #100, #110, #146, #91, #9, #18, #102, #20, #30, #11, #45, #61, #47, #129, #131, #103, #126, #17, #70, #28). This resulted in an immediate jeopardy situation for Resident #70 beginning on 2/19/11 when the resident was noted staying for long periods of time in the bathroom insisting he was bathing and exhibiting bizarre behavior. The resident remained in immediate jeopardy when he continued to exhibit escalating aggressive, threatening and bizarre behavior and facility failed to assess for causative factors and care plan approaches and continued to not have social services involved. The Immediate Jeopardy was lifted on 06/23/2011 at 10:05 p.m. when he was transferred to a local hospital. The deficient practice continued at scope and severity level II, potential for more than minimal harm, for a resident who exhibit aggresisve and threatening behaviors towaed other residents. Findings: Resident # 70 Resident #70 was a [AGE] year old black male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment for Resident #70 dated 2/14/11 revealed the resident was admitted to the facility from the psychiatric unit of a local hospital at 5:00 p.m. Review of the Nurses Notes revealed the following in part: 2/14/11 at 5:00 p.m. Resident #70 admitted to the facility from a psychiatric unit of a local hospital. 2/14/11 at 5:30 p.m. Resident #70 asked could he have a disposable razor so he could shave PRN, refused at this time due to history from admit at local hospital dated 1/26/11 when Resident #70 was evaluated due to agitation/paranoia and homicidal thoughts. Razor removed from resident's possession. 2/19/11 at 12:10 a.m. Resident #70 staying long time in bathroom insisting he is bathing when CNA inquired behavior bizarre. Monitor for elopement, remains quiet and isolative at this time. 2/21/11 at 2:00 p.m. Resident refuses 2pm medication - states "I do not need any more medication" - attempted to encourage resident to take meds - refused reported by day nurse S8LPN resident refused all A.M. meds, DON notified to speak with resident. 2/21/11 at 8:00 p.m. Resident refused Seroquel 300 mg - States "I keep telling the doctors I don't want this I am not going to take it ". DON notified. 3/23/11 at 5A Frown noted to face. Refused to allow nurse to give Haldol injection. Resident stated "I don't need that anymore, I feel good " . Nurse informed that the doctor has ordered the medication to be taken once a month. Resident replied, "the doctor might have ordered it but I do not need it, I am fine. I am on cloud nine. Get out and close the door " . 3/23/11 at 8AM Resident awake, oriented X 3 appears guarded offered Haldol D that he refused earlier. Took P.O. medications without problems. Refused injection, states "the doctor took me off of that over 6 months ago. Informed resident that he received this injection a month ago "No I didn't" frowning "where is the lady who drives the transportation van? I'm leaving here because this place is associated with Church. I'm not staying here. Informed resident that he said just yesterday he liked it here. "Oh no it's associated with the church", when told that it wasn't "oh yes I saw the pictures, the lady told me. Appears to becoming agitated allowed to be alone. 3/23/11 at 10:35 pm Resident in room, ambulating, picking up belongings. Frowning at anyone entering room. Talking to self stating "I need to get my things, I need to go to the social workers office". Explained to resident that all Social Service business are closed. Non compliant monitoring required. 3/24/11 at 1:00 pm Resident arrives back to the nursing home in back of EBRP vehicle. Officer stated they were called because he was exhibiting bizarre behavior at Chase Bank. Patient is agitated using profanity states he wasn't causing a disturbance he was trying to use their phone to call the FBI because people were stealing from him, putting nude pictures of him on the internet. 3/24/11 at 1:30 pm New Order received to administer Haldol 5mg IM Now. DON administered Haldol 5mg/IM to the right gluteal. 3/29/11 at 7:20 A.M Resident refused Haldol D injection stating the DON already gave me my monthly shot...... Nurse tried to explain to the resident that Haldol D injection was a maintenance injection that lasted once a month. Resident insisted that he didn't take Haldol D and was not going to take it again resident very adamant. Nurse Practitioner notified of residents refusal to allow monthly injection. Nurse Practitioner stated that DON should be notified in order that they might get together to discuss options. Resident is his own responsible party. DON notified per 24 hour nursing report. 4/13/11 at 11P resident very possessive of room blocking hallway door and locking bathroom door to keep staff out. Nurse having to call out to resident to assure herself of his well being. 4/14/11 at 5A when hospice CNA attempted to enter room to get roommate personal items to give bath/hygiene care, Resident opened door, but butter knife noted in hand resident then told staff to get all roommate possessions out of room. Nurse closed door without comment. 4/18/11 at 3:30 p.m. Ambulating throughout the facility ad lid. Oriented X3. Episodes of anxiety, redirecting by staff required. Supervision by staff required due to possible elopement risk. 4/25/11 at 2:15 p.m. Supervision required by staff due to possible elopement and episodes of anxiety and anger. 4/28/11 at 3:20 p.m. This nurse was walking down the hallway when I heard resident #70 yelling in room 31. Upon entering the room I observed Resident #70 standing over Resident #58 who was lying in bed talking on his phone, Resident #70 was yelling with a knife in his hand saying "say something, I'll stab you m----- f-----, you killed my brother and I'm going to kill you". Lots of cueing and coaxing done to redirect resident to his room. Director of Nurses and social services notified to come to room. 4/29/11 at 12 a.m. Resident remains isolated in room with both doors blocked. Refuses to allow nurse/staff in room. Will continue to monitor. 5/1/11 at 10:15 a.m. Received report from Ms. ----- that she was approached by the resident at the dollar general store and asked for some money. Stated that when she refused to give him any money resident began threatening her stating "I'll stab you in your head" and also called her numerous vulgar names. Spoke with the resident about the above stated incident, he denies asking for money and stated that she was cursing at him. Resident is very agitated at this time, attempted to redirect, success after several attempts instructed resident to go have a seat, he complied. 5/1/11 at 10:30 a.m. Placed a call to Nurse Practitioner to notify of the incident, received an order for [REDACTED]. Spoke with resident and encouraged him to stay on the premises today. He verbalized understanding and stated that he would remain on the premises today. No further agitation noted at this time. Will continue to observe. 5/1/11 at 10:50 a.m. City police entered the facility. Spoke with resident regarding the above incident. No charges filed at this time. Resident remains calm. 5/3/11 at 2:15 p.m. Notified by S1SSD resident to be PEC'd to the behavioral hospital this p.m. 5/20/11 at 2:00 p.m. readmitted from Behavioral Health Hospital. 5/22/11 at 2:00 a.m. Noted resident ambulating thru halls, in the dining room eating off different people trays that was left over. Earlier threatened 2 different residents, told one resident "I'll break your neck", told another resident "move get out my way". Seen also scraping some kind of food particle off the floor. 5/23/11 at 1 a.m. Appears a little calmer, but I did see him going into another residents room. When asked, he said "the television was too loud I turned it down". 5/27/11 at 3:30 pm Episodes of anxiety/anger redirecting by staff required. Paces constantly cleaning different areas. 5/27/11 at 9:30 p.m. Resident had verbal confrontation with another resident in hall. Was threatening resident with stabbing him with a knife. Nurses times 3 intervened Resident #70 returned to his room no weapons of any sort found. Instructed that type of behavior unacceptable, verbalized understood, shut door in my face. Director of Nursing (DON) notified. 5/28/11 at 2 a.m. Resident pacing in room and ambulating in hall slightly agitated. Returned to room and shut door will continue to monitor. 6/2/11 at 8 p.m. Resident refused Risperdal 3 mg p.o. states it gives him a headache. DON notified. 6/2/11 at 10:30 p.m. Resident sitting on bed with clothes on staring in space. No agitation noted at this time. Will continue to monitor. 6/3/11 at 8 a.m. Knocked on door to administer a.m. medication no answer. Returned 30 minutes later door ajar resident observed in bed in prone position. Respiration regular and unlabored will not answer. Didn't eat breakfast. 6/3/11 at 10:30 p.m. Keeps obstruction behind door during the night. Wood handle object noted in hand when nurse enters room to check on resident no aggression exhibited at this time. Released wood object returned it to hiding place. 6/5/11 at 8:30 am Resident standing in hallway cursing and using various obscenities while speaking to the housekeeper due to his refusal to allow the housekeeper to clean his room. Resident was redirected with a lot of difficulty but returned to his room and closed the door. Will continue to observe. 6/6/11 at 11 p.m. Resident remains up and ambulating around main nurse's station. Observed resident cleaning off and wiping off tables. Will continue to monitor. 6/6/11 at 11:45p.m. Resident sitting on bed in room with clothes on refusing to get ready for bed at this time. Observed murmuring to self. 6/7/11 at 1:10 p.m. Remains awake sitting on bed criticizing roommate inability to remain continent. Resident was reprimanded and redirected. 6/7/11 at 6:10 a.m. Resident walking toward CNAs gathered in front of nurse ' s station very aggressively, demanding which one of you m----- f----- called me a b-----, one of you b------ called me a b----. Nurse observed a razor in hand, resident chased CNAs into main nurses station after CNAs denied that anyone called him a b----. Nurse attempted to intercept resident, holding on to his left arm which held the razor. Resident chased CNA ' s into break room with razor in hand using extreme profanity. CNAs locked themselves in the break room bathroom. Resident refused to listen to nurse repeated statement that no one called him a [***] . Resident # 70 met another male resident in the hallway near nurses station and proceeded to threaten him, standing over resident in his wheelchair, holding his wheelchair handle and daring resident to tell him to let his wheelchair go. Shouting to other resident "I will cut your m----- f------ neck off, you m----- f-----". Nurse holding resident's raised hand with razor in it to keep him from attempting to strike at other resident. Nurse repeatedly reassuring Resident #70 that the other male resident will not tell him anything. Nurse told other male resident to self propel away from resident #70. Resident #70 proceeded to ambulate down hall shouting obscenities at other male resident. Nurse remained behind resident holding onto hand carrying razor. Nurse able to redirect resident to room. 6/7/11 at 6:15 a.m. DON notified of resident's behavior, directed nurse to call police. Police contacted arrival pending. 6/7/11 at 6:20 a.m. Resident going in and out of his room asking nurse the where abouts of another male resident. Requesting that he return to his room repeatedly. 6/7/11 at 6:28 a.m. Police arrived, met resident on hall, resident carrying small garden rake and razor. Police, after some resistance on resident's par,t was able to persuade resident to voluntarily hand over small yard rake and razor. Body search performed, no other weapons found on resident. Resident somewhat calm, no further threats verbalized. Resident returned to his room. 6/7/11 at 6:36 a.m. Police stated that since he did not harm himself or anyone else they could take him. Police stated the resident had to be PEC'd. The police exited the facility. 6/7/11 at 6:45 a.m. Administrator contacted and informed of resident's behavior and police intervention. 6/7/11 at 9 a.m. S46NursePractitioner informed of residents behavior and police intervention. 6/7/11 at 11:15 a.m. New order for resident to be sent to a local hospital for PEC per nurse practitioner, transported per police. 6/16/11 at 4:00 p.m. readmitted to the facility from local hospital's geri-psych unit. 6/21/11 at 2:35 p.m. Resident verbal altercation with another resident. Resident #70 and sister notified of initiation of 30 day discharge process. Nursing Home Psychological Services contacted for on site evaluation of Resident #70. 6/21/11 at 4:10 p.m. Resident #70 walking up hall S36DON behind him, resident #70 passes a resident in her w/c and calls her a [***] and a dog without provocation. S36DON confronted resident and asked why he said that to her. He replied that he had not said anything. S36DON told him that he heard him say it. "Okay, I did" . Escorted Resident #70 back to his room and attempted to counsel him without success, very agitated. Phoned S46NursePractioner and received order for haldol 5mg IM now and to administer meds as ordered. 6/23/11 at 9:50 p.m. PEC'd to the emergency room of a local hospital. Review of the Medical Record for Resident #70 and the Facility LOG - Nursing Home Psychological Services from revealed: No entry/documented evidence of a consult, initial evaluation or re-evaluation for Resident # 70 prior to 6/22/11. On 6/23/11 at 8:30 a.m. S36DON in an interview stated the first and only psychiatric consult for Resident #70 was on 6/22/11. He further stated that the S49Physician and S46NursePractictioner dealt with Resident #70's behavior issues. After review of Resident #70's medical record S36DON verified there were no medication adjustments made by the S49Physician or S46NursePractioner they only continued his meds except for now doses of Haldol when Resident #70 had an incident/acted out. Review of the social services notes written by S1SSD revealed only the following entries: 2/18/11 SSD visited with resident to complete Initial Social Service history. No concerns or complaints noted. Resident is his own responsible party. SSD will continue to visit resident to ensure social needs are addressed as outlined on care plan. 2/23/11 SSD visited with resident to complete BIMS assessment. See MDS section B, E and Q for cognitive functioning. No concerns or complaints noted at this time. SSD will continue to visit resident to ensure social needs are addressed as outlined on care plan. 3/24/11 SSD spoke with resident regarding the behavior he exhibited at the drug store and the local bank resident was escorted back to the facility by the police. Police reported that the resident created a disturbance at drug store stating he was robbed. He then exited the local drug store and went to the local bank where he told the employees that he needed to contact the FBI regarding his money. The SSD and DON spoke to resident and tried to get him to calm down. Resident took his medicine from the DON. SSD will continue to monitor resident and his behavior. No other SSD documentation was noted in Resident#70 medical record. On 6/23/11 at 9:35 a.m. S1SSD stated Resident #70 will threaten staff and residents usually occurs on weekends or at night. She said when it happens during the day, I can usually calm him down. S1SSD stated that Resident #70's behavior is normally good, but he has episodes were he explodes. Resident #70 can be passing someone in the hall and starts cussing them out. S1SSD further stated Resident #70 is verbal with female residents, but physical with male residents. S1SSD stated that she has not been able to locate a day program for him or any other placement. S1SSD stated that she only documents if the incident occurs when she is present and she was involved with it. On 6/23/11 at 3:45 pm in an interview with S1SSD she further stated meetings are held for care planning or if something occurs and we need to have a meeting to address any new or ongoing problems of a resident. S1SSD stated the only meetings held for Resident #70 were for care planning. S1SSD stated there were no care plan/IDT meetings for Resident #70 to address his behavior issues. Behaviors are documented only if /when they occur and then we try and locate the proper facility to address whatever concerns we are having at the time. S1SSD verified there was no documented evidence Resident #70's behavior issues/problems had been addressed.

Based on observation, record review and interview, the facility failed to conduct a periodic comprehensive, accurate, assessment and provide appropriate care and services for 7 (#9, #11, #52, #70, #91, #100, #135) of a total stage 2 sample of 31 (#36, #127, #58, #29, #108, #147, #52, #88, #145, #137, #135, #100, #110, #146, #91, #9, #18, #102, #20, #30, #11, #45, #61, #47, #129, #131, #103, #126, #17, #70, #28). The facility failed to: 1) to obtain a psychological evaluation on 1 of 1(#70) sampled resident with a psychiatric [DIAGNOSES REDACTED]. 2) accurately assess a resident (#70) admitted with psychiatric [DIAGNOSES REDACTED]. 3) accurately assess a resident (#70) admitted with psychiatric [DIAGNOSES REDACTED]. 4) Assess 1 (#52) of 3 sampled residents (#70, #52, #9) who displayed mental and psychosocial adjustment difficulty, 5) Assess 2 (#11, #91) of 3 sampled residents (#11, #91, #131) with dental concerns, 6) Assess 2 of 2 sampled residents reviewed for elopement risk (#70, #9) 7) Assess 1 (#91) of 4 sampled residents (#91, #147, #131, #70) reviewed for activities and, 8) Assess 1 (#100) of 3 sampled residents (#100, #102, #129) reviewed for falls and the use of the wanderguard (#100) 9) Have social worker assess 1 of 1 (#70) residents for escalating agressive and threatening behaviors. This resulted in an immediate jeopardy situation for Resident #70 beginning on 2/19/11 when the resident was noted staying for long periods of time in the bathroom insisting he was bathing and exhibiting bizarre behavior. The resident was in immediate jeopardy at this time when the facility failed to obtain a psychiatric evaluation, assess for causative factors, failed to have the social worker assess the resident. The resident remained in immediate jeopardy when he continued to exhibit aggressive, threatening, bizarre behavior. The facility allowed the resident to sign himself out without determining if this was a safe practice. The facility did not obtain a psychological consult after the resident continued to display escalating behaviors. The Immediate Jeopardy was removed on 06/23/11 at 10:05 p.m. when Resident #70 was transferred from the facility to the hospital under a PEC (Physician's Emergency Commitment). The deficient practice continued at scope and severity level II, potential for more than minimal harm, for any resident exhibiting increasing incidents of aggrerssive and threatening behaviors toward other residents. . Findings: Resident # 70 Resident #70 was a [AGE] year old black male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #70 was admitted from a psychiatric unit of a local hospital where he had been evaluated for agitation/paranoia and homicidal thoughts. Review of the admission nursing assessment for Resident #70 dated 2/14/11 revealed the resident was admitted to the facility from the psychiatric unit of a local hospital at 5:00 p.m. Review of the Minimal Data Set (MDS) assessments for Resident #70 revealed the following in part: Admission MDS assessment dated [DATE] A1800 Entered from - 03 (Acute Hospital) A2300 Assessment reference date: Observation end date: 2/23/11 Section C - Cognitive Patterns: C0500 Summary Score - 13 (13-15 cognitively intact) Section D - Mood D0300 Summary Score - 08(5-9 mild depression) Section E - Behavior E0100 [MEDICAL CONDITION] - None of the above E0200 Behavior symptoms presence and frequency: Physical and verbal behavior symptoms directedtoward others and behavior symptoms not directed toward others all coded 0. E0300 were any behavior symptoms in question E0200 coded 1,2 or3? Enter code was 0 which indicated skip to E0800, rejection of care. Discharge return not anticipated MDS assessment dated [DATE] A1800 Entered from - 03 (Acute Hospital) A2300 Assessment reference date: Observation end date: 6/7/11 Section C - Cognitive Patterns: C0500 Summary Score - 13 (13-15 cognitively intact) Section D - Mood D0300 Summary Score - 07 (5-9 mild depression) Section E - Behavior E0100 [MEDICAL CONDITION] - None of the above Review of the Elopement Risk Assessment Form for Resident #70 dated 2/14/11 revealed: A. Mental Status - 0 (not disoriented) B. Emotional Status - 0 (Complacent/Cooperative) C. Activity - 4 (Ambulatory) D. Mobility - 4 (Full) E. Medication - (Medications that alter mental status or [MEDICAL CONDITION]) F. Elopement History - 5 (Wanders the facility but does not try to leave Total score of 15 (Score as elopement risk if score is 10 or greater) Interventions Implemented to Attempt to prevent Elopement: Resident signs in and out of facility to walk to store independently. Review of the medial revealed no other elopement risk assessment was conducted after the 2/14/11 assessment. Review of the Nurses Notes revealed the following in part: 2/14/11 at 5:00 p.m. Resident #70 admitted to the facility from a psychiatric unit of a local hospital. 2/14/11 at 5:30 p.m. Resident #70 asked could he have a disposable razor so he could shave PRN, refused at this time due to history from admit at local hospital dated 1/26/11 when Resident #70 was evaluated due to agitation/paranoia and homicidal thoughts. Razor removed from resident's possession. 2/19/11 at 12:10 a.m. Resident #70 staying long time in bathroom insisting he is bathing when CNA inquired behavior bizarre. Monitor for elopement, remains quiet and isolative at this time. 2/21/11 at 2:00 p.m. Resident refuses 2pm medication - states "I do not need any more medication" - attempted to encourage resident to take meds - refused reported by day nurse, S8LPN, resident refused all A.M. meds, DON notified to speak with resident. 2/21/11 at 8:00 p.m. Resident refused [MEDICATION NAME] 300 mg - States "I keep telling the doctors I don't want this, I am not going to take it ". DON notified. 3/23/11 at 5A Frown noted to face. Refused to allow nurse to give [MEDICATION NAME] 100mg IM injection. Resident stated "I don't need that anymore, I feel good ". Nurse informed that the doctor has ordered the medication to be taken once a month. Resident replied, "the doctor might have ordered it but I do not need it, I am fine. I am on cloud nine. Get out and close the door". 3/23/11 at 8AM Resident awake, oriented X 3, appears guarded, offered [MEDICATION NAME] D that he refused earlier. Took P.O. medications without problems. Refused injection, states "the doctor took me off of that over 6 months ago. Informed resident that he received this injection a month ago "No I didn't" (frowning) "where is the lady who drives the transportation van? I'm leaving here because this place is associated with Church. I'm not staying here. Informed resident that he said just yesterday he liked it here. "Oh no it's associated with the church", when told that it wasn't "oh yes I saw the pictures, the lady told me". Appears to becoming agitated allowed to be alone. 3/23/11 at 10:35 pm Resident in room, ambulating, picking up belongings. Frowning at anyone entering room. Talking to self stating "I need to get my things, I need to go to the social workers office". Explained to resident that all Social Service business is closed. Non compliant monitoring required. 3/24/11 at 1:00 pm Resident arrives back to the nursing home in back of EBRP vehicle. Officer stated they were called because he was exhibiting bizarre behavior at a local bank. Patient is agitated using profanity, states he wasn't causing a disturbance he was trying to use their phone to call the FBI because people were stealing from him, putting nude pictures of him on the internet. 3/24/11 at 1:30 pm New Order received to administer [MEDICATION NAME] 5mg IM Now. DON administered [MEDICATION NAME] 5mg/IM to the right gluteal. 3/29/11 at 7:20 A.M Resident refused [MEDICATION NAME] D injection stating the DON already gave me my monthly shot...... Nurse tried to explain to the resident that [MEDICATION NAME] D injection was a maintenance injection that lasted once a month. Resident insisted that he didn't take [MEDICATION NAME] D and was not going to take it again, resident very adamant. Nurse Practitioner notified of residents refusal to allow monthly injection. Nurse Practitioner stated that DON should be notified in order that they might get together to discuss options. Resident is his own responsible party. DON notified per 24 hour nursing report. 4/13/11 at 11P resident very possessive of room blocking hallway door and locking bathroom door to keep staff out. Nurse having to call out to resident to assure herself of his well being. 4/14/11 at 5A when hospice CNA attempted to enter room to get roommate personal items to give bath/hygiene care. Resident opened door, but butter knife noted in hand, resident then told staff to get all roommate possessions out of room. Nurse closed door without comment. 4/18/11 at 3:30 p.m. Ambulating throughout the facility ad lid. Oriented X3. Episodes of anxiety, redirecting by staff required. Supervision by staff required due to possible elopement risk. 4/25/11 at 2:15 p.m. Supervision required by staff due to possible elopement and episodes of anxiety and anger. 4/28/11 at 3:20 p.m. This nurse was walking down the hallway when I heard resident #70 yelling in room [ROOM NUMBER]B. Upon entering the room I observed Resident #70 standing over Resident #58 who was lying in bed talking on his phone, Resident #70 was yelling with a knife in his hand saying "say something, I'll stab you m----- f-----, you killed my brother and I'm going to kill you". Lots of cueing and coaxing done to redirect resident to his room. Director of Nurses and social services notified to come to room. 4/29/11 at 12 a.m. Resident remains isolated in room with both doors blocked. Refuses to allow nurse/staff in room. Will continue to monitor. 5/1/11 at 10:15 a.m. Received report from Ms. ----- that she was approached by the resident at the dollar general store and asked for some money. Stated that when she refused to give him any money resident began threatening her stating "I'll stab you in your head" and also called her numerous vulgar names. Spoke with the resident about the above stated incident, he denies asking for money and stated that she was cursing at him. Resident is very agitated at this time, attempted to redirect, success after several attempts, instructed resident to go have a seat, he complied. 5/1/11 at 10:30 a.m. Placed a call to Nurse Practitioner to notify of the incident, received an order for [REDACTED]. He verbalized understanding and stated that he would remain on the premises today. No further agitation noted at this time. Will continue to observe. 5/1/11 at 10:50 a.m. City police entered the facility. Spoke with resident regarding the above incident. No charges filed at this time. Resident remains calm. 5/3/11 at 2:15 p.m. Notified by S1SSD resident to be PEC'd to the behavioral hospital this p.m. 5/20/11 at 2:00 p.m. readmitted from Behavioral Health Hospital. 5/22/11 at 2:00 a.m. Noted resident ambulating thru halls, in the dining room eating off different people's trays that was left over. Earlier threatened 2 different residents, told one resident "I'll break your neck", told another resident "move get out my way". Seen also scraping some kind of food particle off the floor. 5/23/11 at 1 a.m. Appears a little calmer, but I did see him going into another residents room. When asked, he said "the television was too loud, I turned it down". 5/27/11 at 3:30 pm Episodes of anxiety/anger, redirecting by staff required. Paces constantly, cleaning different areas. 5/27/11 at 9:30 p.m. Resident had verbal confrontation with another resident in hall. Was threatening resident with stabbing him with a knife. Nurses times 3 intervened Resident #70 returned to his room no weapons of any sort found. Instructed that type of behavior unacceptable, verbalized understood, shut door in my face. Director of Nursing (DON) notified. 5/28/11 at 2 a.m. Resident pacing in room and ambulating in hall slightly agitated. Returned to room and shut door, will continue to monitor. 6/2/11 at 8 p.m. Resident refused [MEDICATION NAME] 3 mg p.o., states it gives him a headache. DON notified. 6/2/11 at 10:30 p.m. Resident sitting on bed with clothes on staring in space. No agitation noted at this time. Will continue to monitor. 6/3/11 at 8 a.m. Knocked on door to administer a.m. medication, no answer. Returned 30 minutes later, door ajar, resident observed in bed in prone position. Respiration regular and unlabored, will not answer. Didn't eat breakfast. 6/3/11 at 10:30 p.m. Keeps obstruction behind door during the night. Wood handle object noted in hand when nurse enters room to check on resident, no aggression exhibited at this time. Released wood object, returned it to hiding place. 6/5/11 at 8:30 am Resident standing in hallway cursing and using various obscenities while speaking to the housekeeper due to his refusal to allow the housekeeper to clean his room. Resident was redirected with a lot of difficulty but returned to his room and closed the door. Will continue to observe. 6/6/11 at 11 p.m. Resident remains up and ambulating around main nurse's station. Observed resident cleaning off and wiping off tables. Will continue to monitor. 6/6/11 at 11:45p.m. Resident sitting on bed in room with clothes on refusing to get ready for bed at this time. Observed murmuring to self. 6/7/11 at 1:10 p.m. Remains awake sitting on bed criticizing roommate inability to remain continent. Resident was reprimanded and redirected. 6/7/11 at 6:10 a.m. Resident walking toward CNAs gathered in front of nurse's station, very aggressively demanding which one of you m----- f----- called me a b-----, one of you b-------called me a b----. Nurse observed a razor in hand, resident chased CNAs into main nurses station after CNAs denied that anyone called him a b----. Nurse attempted to intercept resident, holding on to his left arm which held the razor. Resident chased CNAs into break room with razor in hand using extreme profanity. CNAs locked themselves in the break room bathroom. Resident refused to listen to nurse repeated statement that no one called him a b----. Resident #70 met another male resident in the hallway near nurses station and proceeded to threaten him, standing over resident in his wheelchair, holding his wheelchair handle and daring resident to tell him to let his wheelchair go. Shouting to other resident "I will cut your m----- f------ neck off, you m------f-----". Nurse holding resident's raised hand with razor in it to keep him from attempting to strike at other resident. Nurse repeatedly reassuring Resident #70 that the other male resident will not tell him anything. Nurse told other male resident to self propel away from Resident #70. Resident #70 proceeded to ambulate down hall shouting obscenities at other male resident. Nurse remained behind resident holding onto hand carrying razor. Nurse able to redirect resident to room. 6/7/11 at 6:15 a.m. DON notified of resident's behavior, directed nurse to call police. Police contacted, arrival pending. 6/7/11 at 6:20 a.m. Resident going in and out of his room asking nurse the where abouts of another male resident. Requesting that he return to his room repeatedly. 6/7/11 at 6:28 a.m. Police arrived, met resident on hall, resident carrying small garden rake and razor. Police after some resistance on resident's part was able to persuade resident to voluntarily hand over small yard rake and razor. Body search performed, no other weapons found on resident. Resident somewhat calmer no further threats verbalized. Resident returned to his room. 6/7/11 at 6:36 a.m. Police stated that since he did not harm himself or anyone else, they could not take him. Police stated the resident had to be PEC'd. The police exited the facility. 6/7/11 at 6:45 a.m. Administrator contacted and informed of resident's behavior and police intervention. 6/7/11 at 9 a.m. S46NursePractitioner informed of resident's behavior and police intervention. 6/7/11 at 11:15 a.m. New order for resident to be sent to a local hospital for PEC per nurse practitioner, transported per police. 6/16/11 at 4:00 p.m. readmitted to the facility from local hospital's geri-psych unit. 6/21/11 at 2:35 p.m. Resident verbal altercation with another resident. Resident #70 and sister notified of initiation of 30 day discharge process. Psychological services contacted for on site evaluation of resident #70. 6/21/11 at 4:10 p.m. Resident #70 walking up hall S36DON behind him, resident #70 passes a resident in her w/c and calls her a b---- and a dog without provocation. S36DON confronted resident and asked why he said that to her. He replied that he had not said anything. S36DON told him that he heard him say it. "Okay, I did". Escorted Resident #70 back to his room and attempted to counsel him without success, very agitated. Phoned S46NursePractioner and received order for [MEDICATION NAME] 5mg IM now and to administer meds as ordered. 6/23/11 at 9:50 p.m. PEC'd to the emergency room of a local hospital. Review of the Medical Record for Resident #70 and the Facility LOG - Nursing Home Psychological Services from revealed: No entry/documented evidence of a consult, initial evaluation or re-evaluation for Resident # 70 prior to 6/22/11. 6/23/11 at 8:30 a.m. S36DON in an interview stated the first and only psych consult for Resident #70 was on 6/22/11. 6/23/11 at 12:30 p.m. S2MDSCoordinator reports that a significant change is done when there is a change in 2 or more care areas. Behavior monitoring is done on the MAR indicated [REDACTED]. Reports Resident #70 came directly from a local hospital ' s behavioral health unit with only the hospital paperwork. Review of the social services notes written by S1SSD revealed only the following entries: 2/18/11 SSD visited with resident to complete Initial Social Service history. No concerns or complaints noted. Resident is his own responsible party. ... 2/23/11 SSD visited with resident to complete BIMS assessment. See MDS section B, E and Q for cognitive functioning. No concerns or complaints noted at this time. 3/24/11 SSD spoke with resident re: the behavior he exhibited at the drug store and the local bank resident was escorted back to the facility by the police. Resident took his medicine from the DON. SSD will continue to monitor resident and his behavior. No other SSD documentation was noted in Resident#70 medical record. 6/23/11 at 9:35 a.m. S1SSD stated Resident #70's behavior is normally good, but he has episodes were he explodes. Resident #70 can be passing someone in the hall and starts cussing them out. S1SSD further stated Resident #70 is verbal with female residents but physical with male residents. S1SSD stated that she has not been able to locate a day program for him or any other placement. S1SSD stated that she only documents if the incident occurs when she is present and she was involved with it. S1SSD stated there were no care plan/IDT meetings for Resident #70 to address his behavior issues. Behaviors are documented on if /when they occur and then we try and locate the proper facility to address whatever concerns we are having at the time. S1SSD verified there was no documented evidence that Resident #70's behavior issues/problems had been addressed. Resident #100 Resident #100 was [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation was made of the resident on 6/21/11 at 12:30 p.m. Resident was up in wheelchair in her room reading a book. She was alert and oriented to place but could not remember how long she had been a resident of the facility. She was later seen propelling herself in the wheelchair down the hall to the dining room. Review of the most current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/11 revealed the following: Section C Cognitive Pattern C0600was coded 0 which indicated no(resident was able to complete interview)--> skip to C1300, Signs and Symptoms of [MEDICAL CONDITION] C1300 was coded 0 in all areas. Section G-Functional Status revealed Resident #100 was Independent in bed mobility, transfer walk in room, walk in corridor, locomotion on unit, locomotion off unit and eating. The MDS further revealed the resident required limited assistance for dressing and toilet use and Physical help limited to transfer only with bathing. Under Section G0600-Mobility Devices revealed she used a wheelchair. Review of the Medical Record revealed Resident #100 had Fall Risk Assessments done on 10/13/10 and 12/29/10. The resident's total score was greater than 10 and she was deemed High Risk for falls on all assessments done. Review of the Incident/Accident Log from 7/1/10 to present revealed the following documented falls: 10/26/10-fell in room 2/7/11-fell in room 3/4/11-fell in room 3/15/11-fell in bathroom 6/8/11-fell in common area 6/16/11-fell in room Review of the Incident/Accident Report for the above dates revealed the following: 10/26/11-Time of incident: 3:00 p.m. Resident verbalized she slipped and fell while trying to stand up from seated position in wheelchair. Complained of headache pain. No other apparent injury at present. Neuro checks initiated. Will monitor. Unwitnessed fall. There was no documentation of the investigation of causative factors for the resident falling. Neuro checks were initiated but done for that one time. 1/27/11-Time of Incident: 8:40 a.m. Upon entering room resident sitting on floor on buttocks. Resident reports she was about to get in bed-soft lap belt hooked on wheelchair Additional comments and/or steps to prevent recurrence: Advised to seek assistance prior to any attempted transfers. 3/4/11-Time of Incident: 12:55 p.m. Upon passing by room resident sitting on floor in front of wheelchair. Resident reports "I sat here". Additional comments and/or steps to prevent recurrence: Educated to seek assistance prior to any transfer attempts. 3/5/11-Time of incident: 1:47 p.m. Called to room by S21CNA who found resident on floor in bathroom. Soft lap belt was connected to wheelchair. Additional comments and/or steps to prevent recurrence: Educated on the importance of seeking assistance prior to any transfers. 6/8/11-Time of incident: 2:45 p.m. Place of Incident: main dining area. Resident reports she was bending down to pick up another resident's Bingo chips off floor and landed on buttocks on floor. Additional comments and/or steps taken to prevent recurrence: Resident educated to avoid bending over while in wheelchair due to risk of fall/injury. 6/16/11-Time of incident: 10:33 p.m. Resident stated she was attempting to change her clothes and while attempting to stand-up she lost her balance and fell to the floor landing on her buttock. Denies hitting head. Additional comments and/or steps taken to prevent recurrence: Instructed CNA to assist resident with changing her clothes every day. An interview was conducted with S36DON on 6/27/11 at 2:30 p.m. He reviewed the above incident reports and the follow-up documented there in and stated the incident report given was all he had for the reports. He verified there was no further follow-up for any of the incidents of the falls for Resident #100. An interview was conducted with S36DON on 6/23/11 at 8:30 a.m. He was asked how the staff and any one who came in contact with the residents knew which residents were at risk for falls in the facility. He stated that when a resident falls, it is discussed in the morning supervisor meeting and the CNA supervisor or the nurse make the rest of the staff aware of the residents who are at risk for falls. He stated there was no written fall protocol or no indication on the resident's door or wheelchair or room that they are at risk for falls. An interview was conducted with S34CNA on 6/27/11 at 10:45 a.m. She was asked how she knew which residents of her hall were at risk for falls. She said that the residents who are at risk for falls have a leaf or flower on their doors or have an arm band on them. When asked what color the arm band was, she was unclear and did not really know. She said that all of her residents that she was responsible for are bedbound and she does not have to worry about them getting up and falling. An interview was conducted with S28CNA on 6/27/11 at 1:45 p.m. She stated she has only been employed for 2 weeks but she worked the hall where Resident #100 lived.. When asked how she knew if the resident was high risk for falls, she said the resident should have a rose over their bed or an armband. When asked what color the arm band was, she said either yellow or white. When asked how the staff knew which one was fall risk, she said it was written on the armband if the resident was at risk for falls. An observation was made with S28CNA on 6/27/11 at 1:50 p.m. of Resident #100's room and arm for an armband. The room was examined for a rose over the bed or an armband of any color on the resident. There was no rose on the door, over the bed or anywhere in the room and no armband on the resident. S28CNA verified that none of the above signs of a resident at risk for falls was present in the resident's room. She admitted that she was not sure if Resident #100 was a fall risk or not as there was nothing to identify her as a fall risk. An interview was conducted with S32LPN on 6/27/11 at 2:00 p.m. regarding high risk fall residents. She said that there was usually a fallen leaf or some sort of flower over the resident's bed to identify him/her as a fall risk. She said she was not sure which one. An observation was made with S32LPN of Resident #47's room on 6/27/11 at 2:05 p.m. She stated that he was a fall risk so she was going to show surveyor the leaf or flower to identify the resident as high risk for falls. The room was examined for a leaf or any flower and neither was present. S32LPN verified there was nothing in the resident's room to let the rest of the staff know that he was high risk for falls. She was not sure how the CNA's know which residents are at risk for falls. Review of the Incident/Accident Reports revealed the following incident: 4/30/11 at 9:30 a.m. Location of the incident/accident: Facility yard Resident's condition before incident/accident: Disoriented Description of what happened: Patient found in facility front yard by CNA. Wanderguard in place on ankle-No injury. Type of injury: None apparent Additional comments: MD notified-Obtain urinalysis in am to assess increase confusion, evaluation for placement on secure unit. There was no documentation that an assessment of how the resident wandered out of the facility and if at the time the wanderguard was working. An interview was conducted with S36DON on 6/24/11 at 9:45 a.m. regarding the above incident and the follow-up done by the facility. He reviewed the incident report and the medical record and could not find any investigation as to what happened or how the resident got out of the facility with the wandgerguard and none of the staff knew. Resident #9 Resident #9 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation was made of Resident #9 on 6/23/11 at 1:44 p.m. He was dressed in blue jeans, white tee shirt and a light/dark blue winter jacket. He was sitting at the dining table, falling asleep. He has been ambulatory about the facility all day, talking to himself and to anybody that will respond to him-some of the conversation made sense and some of it was not understandable. The resident was seen several times during the dates 6/20/11 to 6/24/11 and 6/27/11 and 6/28/11 sitting in the front of the facility without staff attendance when the surveyors arrived at the facility. Review of the Elopement Risk Assessment done 5/24/11 revealed resident with score of 17 which is High Risk. An interview was conducted with S1SSD on 6/28/11 at 8:15 a.m. She said that when residents are admitted to the facility and are at risk for elopement, a wanderguard is placed immediately. When asked why Resident #9 did not have a wanderguard, she said she was never informed that he was high risk for elopement. She said that was the first time she heard that Resident #9 was an elopement risk. The S1SSD was not aware that Resident #9 was an elopement risk so that she could continue to assess the resident for wandering. Resident #91 On 06/21/2011 at 1:29 p.m., the daughter and responsible party of Resident #91 was interviewed. She stated that her mother liked to play bingo, but the staff sometimes tell her that they don't have enough people to help her play bingo. She stated that after her mother had a stroke she reverted back to her former language and now does not speak English very well. She stated that when they told her they did not have enough people to help her play bingo, she just told them don't worry about it. The resident's daughter stated that if they could provide assistance for some residents, they should provide assistance for all the residents. The resident's daughter also stated that she thought her mother had a gum problem or a tooth problem. She stated that when she flossed her mother's teeth, her mother's gums bled. She stated that her mother has complained of pain in her mouth. The resident's daughter stated that her mother was seen by a dentist at the facility, but the dentist just looked in her mouth and wasn't very thorough. Review of the record revealed that the resident's [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set) dated 03/09/11 revealed the following: BIMS (Brief Interview for Mental Status) = 10 (8-12 score is moderately impaired). Section F; Preference for Customary routine and Activities FO500. Interview for Activity Preference A. - 3 not very important to have books, newspapers, and magazines to read B. - 3 not very important to listen to music C. - 3 not very important to be around animals such as pets. D. 2 Somewhat important to keep up with the news. E. - 2 Somewhat important to do things with groups of people F. 2 Somewhat important to do your favorite activities G. 2 Somewhat important to go outside to get fresh air when the weather is good. H. 3 not very important to participate in religious services or practices. F0600 Daily and Activity Preferences Primary Respondent 2 - Family or significant other. Section L: Dental None of the above. Review of the Resident's Interest Form documented by S37Activity Director, revealed that the resident was admitted to the facility on [DATE] and was assessed with [REDACTED]. Previous hobbies or activities: Jazzercise Would you rather take part in activities with a group or by yourself: Group In the morning or afternoon: Afternoon What kind of music do you like? All Kind Do you like to sing? Yes The following were listed as likes: Movies, plays, watching T.V., Listening to Radio, Taking part in plays, fishing, gardening, Picnic, walks, shopping, riding, church services, going to sports events, wash and set (hair), manicures, hair cut, entertainment, banquet, dinners, parties, visit, visitors. There was no documented evidence of any assessment of the resident's language barrier. There was no documented evidence of any assessment for special adaptations needed for the resident to

Based on observation, record review and interview, the facility failed to ensure residents attained the highest level of well-being for 2 of a total stage 2 sample of 31 (#36, #127, #58, #29, #108, #147, #52, #88, #145, #137, #135, #100, #110, #146, #91, #9, #18, #102, #20, #30, #11, #45, #61, #47, #129, #131, #103, #126, #17, #70, #28). The facility failed to: 1.) assess for causative factors that trigger resident #70's aggressive threatening behaviors and implement interventions addressing the causative factors; 2.) obtain a psychiatric consult with a psychiatrist for resident #70 when he was admitted to the facility and after altercations and threatening behaviors with citizens, staff, and other residents; 3.) increase monitoring of a resident with aggressive, bizarre, and threatening physical and verbal behaviors after he threatened a hospice aide and other residents (#70); 4.) assess if it was safe to allow a resident to sign himself out after the police returned him to the facility (#70); 5.) failed to consult with a psychiatrist regarding the resident refusing his monthly doses of [MEDICATION NAME] IM and using one time doses of [MEDICATION NAME] in an attempt to control his behaviors (#70). 6.) Ensure the social worker reassessed a resident for escalating behaviors (#70); 7.) Ensure the activity director assessed for and implemented individualized meaningful activities to met a resident'sneeds (#70); 8.) Assess a resident who displayed adjustment difficulty (#52); 9.) Ensure that resident #52's hygiene and grooming was maintained. Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted from a psychiatric unit of a local hospital where he had been evaluated for agitation/paranoia and homicidal thoughts. Resident #70 was in Immediate Jeopardy beginning 3/24/11 after the police brought the resident back to the facility after the resident was exhibiting aggressive, bizarre, threatening behavior at a local bank and the facility failed to obtain a psychiatric consult with a psychiatrist and failed to reassess the resident to determine if it was safe for him to leave the facility alone. The resident continues aggressive, bizarre, threatening behaviors and the facility failed to assess for causative factors of the residents behaviors and plan interventions for the causative factors. On 5/1/11, the resident threatened a shopper at a store. On 6/7/11, the resident threatened a resident with a razor. On 6/21/11, the resident had a verbal altercation with another resident and cursed at another resident. The facility's only interventions were to give one time dose of [MEDICATION NAME], to redirect the resident, and to PEC (Physician's Emergency Committment) the resident to the hospital on [DATE], 6/7/11, and 6/23/11.. The social worker failed to reassess the resident's aggressive, threatening and bizarre behaviors. The resident was not assessed for individualized meaningful activities. The facility continued to fail to obtain a psychiatric evaluation as the behaviors continued to escalate. The Immediate Jeopardy was removed on 06/23/11 at 10:05 p.m. when Resident #70 was transferred from the facility to the hospital under a PEC (Physician's Emergency Commitment). The deficient practice continued at scope and severity level II, potential for more than minimal harm, for any resident exhibiting threatening physical and verbal behaviors toward other residents. Findings: Resident # 70: Resident #70 was a [AGE] year old black male admitted to the facility on [DATE] from a psychiatric unit of a local hospital where he had been evaluated for agitation/paranoia and homicidal thoughts and had threatened someone at the psych hospital with a razor. He was admitted with [DIAGNOSES REDACTED]. Review of the Minimal Data Set (MDS) assessments for Resident #70 revealed the following in part: Admission MDS assessment dated [DATE] A1800 Entered from - 03 (Acute Hospital) A2300 Assessment reference date: Observation end date: 2/23/11 Section C - Cognitive Patterns: C0500 Summary Score - 13 (13-15 cognitively intact) Section D - Mood D0300 Summary Score - 08(5-9 mild depression) Section E - Behavior E0100 [MEDICAL CONDITION] - None of the above EO200 Behavioral Symptom - none EO600 Impact on others - none Review of the Elopement Risk Assessment Form for Resident #70 dated 2/14/11 revealed: A. Mental Status - 0 (not disoriented) B. Emotional Status - 0 (Complacent/Cooperative) C. Activity - 4 (Ambulatory) D. Mobility - 4 (Full) E. Medication - (Medications that alter mental status or [MEDICAL CONDITION]) F. Elopement History - 5 (Wanders the facility but does not try to leave Total score of 15 (Score as elopement risk if score is 10 or greater) Interventions Implemented to Attempt to prevent Elopement: Resident signs in and out of facility to walk to store independently. Review of the medial revealed no other elopement risk assessment was conducted after the 2/14/11 assessment. Review of the Nurses Notes revealed the following, in part: 2/14/11 at 5:30 p.m. Resident #70 asked could he have a disposable razor so he could shave PRN, refused at this time due to history from admit at local hospital dated 1/26/11 when Resident #70 was evaluated due to agitation/paranoia and homicidal thoughts. Razor removed from resident's possession. 2/19/11 at 12:10 a.m. Resident #70 staying long time in bathroom, insisting he is bathing when CNA inquired, behavior bizarre. Monitor for elopement, remains quiet and isolative at this time. 2/21/11 at 2:00 p.m. Resident refuses 2 pm medication - states "I do not need any more medication"- attempted to encourage resident to take meds - refused, reported by day nurse S8LPN, resident refused all A.M. meds, DON notified to speak with resident. 2/21/11 at 8:00 p.m. Resident refused [MEDICATION NAME] 300 mg - States "I keep telling the doctors I don't want this I am not going to take it". DON notified. 3/23/11 at 5:00 a.m. Frown noted to face. Refused to allow nurse to give [MEDICATION NAME] 100mg IM injection. Resident stated "I don't need that anymore, I feel good". Nurse informed that the doctor has ordered the medication to be taken once a month. Resident replied, "the doctor might have ordered it but I do not need it, I am fine. I am on cloud nine. Get out and close the door". 3/23/11 at 8:00 a.m. Resident awake, oriented X 3, appears guarded, offered [MEDICATION NAME] D that he refused earlier. Took P.O. medications without problems. Refused injection, states "the doctor took me off of that over 6 months ago. Informed resident that he received this injection a month ago "No I didn't" frowning "where is the lady who drives the transportation van? I'm leaving here because this place is associated with Church. I'm not staying here. Informed resident that he said just yesterday he liked it here. "Oh no it's associated with the church", when told that it wasn't "oh yes I saw the pictures, the lady told me. Appears to becoming agitated allowed to be alone. 3/23/11 at 10:35 p.m. Resident in room, ambulating, picking up belongings. Frowning at anyone entering room. Talking to self stating "I need to get my things, I need to go to the social workers office". Explained to resident that all Social Service business are closed. Non compliant monitoring required. 3/24/11 at 1:00 p.m. Resident arrives back to the nursing home in back of EBRP vehicle. Officer stated they were called because he was exhibiting bizarre behavior at a local bank. Patient is agitated using profanity, states he wasn't causing a disturbance, he was trying to use their phone to call the FBI because people were stealing from him, putting nude pictures of him on the internet. 3/24/11 at 1:30 p.m. New Order received to administer [MEDICATION NAME] 5mg IM Now. DON administered [MEDICATION NAME] 5mg/IM to the right gluteal. 3/29/11 at 7:20 a.m. Resident refused [MEDICATION NAME] D intra muscular injection stating the DON already gave me my monthly shot...... Nurse tried to explain to the resident that [MEDICATION NAME] D was a maintenance injection that lasted once a month. Resident insisted that he didn't take [MEDICATION NAME] D and was not going to take it again resident very adamant. Nurse Practitioner notified of resident's refusal to allow monthly injection. Nurse Practitioner stated that the DON should be notified in order that they might get together to discuss options. Resident is his own responsible party. DON notified per 24 hour nursing report. 4/13/11 at 11:00 p.m. resident very possessive of room blocking hallway door and locking bathroom door to keep staff out. Nurse having to call out to resident to assure herself of his well being. 4/14/11 at 5:00 a.m. A when hospice CNA attempted to enter room to get roommate's personal items to give bath/hygiene care, Resident opened door. but butter knife noted in hand, resident then told staff to get all roommate's possessions out of room. Nurse closed door without comment. 4/18/11 at 3:30 p.m. Ambulating throughout the facility ad lid. Oriented X3. Episodes of anxiety, redirecting by staff required. Supervision by staff required due to possible elopement risk. 4/25/11 at 2:15 p.m. Supervision required by staff due to possible elopement and episodes of anxiety and anger. 4/28/11 at 3:20 p.m. This nurse was walking down the hallway when I heard resident #70 yelling in room [ROOM NUMBER]B. Upon entering the room I observed Resident #70 standing over Resident #58 who was lying in bed talking on his phone, Resident #70 was yelling, with a knife in his hand, saying "say something, I' ll stab you m----- f-----, you killed my brother and I'm going to kill you". Lots of cueing and coaxing done to redirect resident to his room. Director of Nurses and social services notified to come to room. 4/29/11 at 12 a.m. Resident remains isolated in room with both doors blocked. Refuses to allow nurse/staff in room. Will continue to monitor. 5/1/11 at 10:15 a.m. Received report from Ms. ----- that she was approached by the resident at the dollar general store and asked for some money. Stated that when she refused to give him any money, resident began threatening her stating "I'll stab you in your head" and also called her numerous vulgar names. Spoke with the resident about the above stated incident, he denies asking for money and stated that she was cursing at him. Resident is very agitated at this time, attempted to redirect, success after several attempts, instructed resident to go have a seat, he complied. 5/1/11 at 10:30 a.m. Placed a call to Nurse Practitioner to notify of the incident, received an order for [REDACTED]. He verbalized understanding and stated that he would remain on the premises today. No further agitation noted at this time. Will continue to observe. 5/1/11 at 10:50 a.m. City police entered the facility. Spoke with resident regarding the above incident. No charges filed at this time. Resident remains calm. 5/3/11 at 2:15 p.m. Notified by S1SSD, resident to be PEC'd to the behavioral hospital this p.m. 5/20/11 at 2:00 p.m. readmitted from Behavioral Health Hospital. Readmission MDS assessment dated [DATE] A1800 Entered from - 03 (Acute Hospital) A2300 Assessment reference date: Observation end date: 6/7/11 Section C - Cognitive Patterns: C0500 Summary Score - 13 (13-15 cognitively intact) Section D - Mood D0300 Summary Score - 07 (5-9 mild depression) Section E - Behavior E0100 [MEDICAL CONDITION] - None of the above Review of nurses notes revealed the following in part: 5/22/11 at 2:00 a.m. Noted resident ambulating thru halls, in the dining room eating off different people trays that was left over. Earlier threatened 2 different residents, told one resident "I'll break your neck", told another resident "move get out my way". Seen also scraping some kind of food particle off the floor. 5/23/11 at 1 a.m. Appears a little calmer, but I did see him going into another residents room. When asked, he said "the television was too loud I turned it down". 5/27/11 at 3:30 p.m. Episodes of anxiety/anger redirecting by staff required. Paces constantly cleaning different areas. 5/27/11 at 9:30 p.m. Resident had verbal confrontation with another resident in hall. Was threatening resident with stabbing him with a knife. Nurses times 3 intervened, Resident #70 returned to his room, no weapons of any sort found. Instructed that type of behavior unacceptable, verbalized understood, shut door in my face. Director of Nursing (DON) notified. 5/28/11 at 2:00 a.m. Resident pacing in room and ambulating in hall slightly agitated. Returned to room and shut door, will continue to monitor. 6/2/11 at 8:00 p.m. Resident refused [MEDICATION NAME] 3 mg p.o. states it gives him a headache. DON notified. 6/2/11 at 10:30 p.m. Resident sitting on bed with clothes on staring in space. No agitation noted at this time. Will continue to monitor. 6/3/11 at 8:00 a.m. Knocked on door to administer a.m. medication, no answer. Returned 30 minutes later, door ajar, resident observed in bed in prone position. Respiration regular and unlabored, will not answer. Didn't eat breakfast. 6/3/11 at 10:30 p.m. Keeps obstruction behind door during the night. Wood handle object noted in hand when nurse enters room to check on resident, no aggression exhibited at this time. Released wood object returned it to hiding place. 6/5/11 at 8:30 a.m. Resident standing in hallway cursing and using various obscenities while speaking to the housekeeper due to his refusal to allow the housekeeper to clean his room. Resident was redirected with a lot of difficulty but returned to his room and closed the door. Will continue to observe. 6/6/11 at 11 p.m. Resident remains up and ambulating around main nurse's station. Observed resident cleaning off and wiping off tables. Will continue to monitor. 6/6/11 at 11:45 p.m. Resident sitting on bed in room with clothes on refusing to get ready for bed at this time. Observed murmuring to self. 6/7/11 at 1:10 p.m. Remains awake sitting on bed criticizing roommate inability to remain continent. Resident was reprimanded and redirected. 6/7/11 at 6:10 a.m. Resident walking toward CNAs gathered in front of nurse's station very aggressively, demanding which one of you m----- f----- called me a b----, one of you b------ called me a b----. Nurse observed a razor in hand, resident chased CNAs into main nurses station after CNAs denied that anyone called him a b----. Nurse attempted to intercept resident, holding on to his left arm which held the razor. Resident chased CNAs into break room with razor in hand using extreme profanity. CNAs locked themselves in the break room bathroom. Resident refused to listen to nurse repeated statement that no one called him a [***] . Resident # 70 met another male resident in the hallway near nurses station and proceeded to threaten him, standing over resident in his wheelchair, holding his wheelchair handle and daring resident to tell him to let his wheelchair go. Shouting to other resident "I will cut your m----- f------ neck off, you m----- f-----". Nurse holding resident's raised hand with razor in it to keep him from attempting to strike at other resident. Nurse repeatedly reassuring Resident #70 that the other male resident will not tell him anything. Nurse told other male resident to self propel away from resident #70. Resident #70 proceeded to ambulate down hall shouting obscenities at other male resident. Nurse remained behind resident holding onto hand carrying razor. Nurse able to redirect resident to room. 6/7/11 at 6:15 a.m. DON notified of resident's behavior, directed nurse to call police. Police contacted, arrival pending. 6/7/11 at 6:20 a.m. Resident going in and out of his room asking nurse the where abouts of another male resident. Requesting that he return to his room repeatedly. 6/7/11 at 6:28 a.m. Police arrived, met resident on hall, resident carrying small garden rake and razor. Police after some resistance on resident's part, was able to persuade resident to voluntarily hand over small yard rake and razor. Body search performed, no other weapons found on resident. Resident somewhat calm, no further threats verbalized. Resident returned to his room. 6/7/11 at 6:36 a.m. Police stated that since he did not harm himself or anyone else they could not take him. Police stated the resident had to be PEC'd. The police exited the facility. 6/7/11 at 6:45 a.m. Administrator contacted and informed of resident's behavior and police intervention. 6/7/11 at 9 a.m. S46NursePractitioner informed of resident's behavior and police intervention. 6/7/11 at 11:15 a.m. New order for resident to be sent to a local hospital for PEC per nurse practitioner, transported per police. 6/16/11 at 4:00 p.m. readmitted to the facility from local hospital's geri-psych unit. 6/21/11 at 2:35 p.m. Resident verbal altercation with another resident. Resident #70 and sister notified of initiation of 30 day discharge process. Nursing home psychological services contacted for on site evaluation of resident #70. 6/21/11 at 4:10 p.m. Resident #70 walking up hall, S36DON behind him, resident #70 passes a resident in her w/c and calls her a b---- and a dog without provocation. S36DON confronted resident and asked why he said that to her. He replied that he had not said anything. S36DON told him that he heard him say it. "Okay, I did". Escorted Resident #70 back to his room and attempted to counsel him without success, very agitated. Phoned S46NursePractioner and received order for [MEDICATION NAME] 5mg IM now and to administer meds as ordered. 6/23/11 at 9:50 p.m. PEC'd to the emergency room of a local hospital. Review of the Incident report QA/CQI Log revealed only one entry for Resident #70: 4/28/11 Resident #70 - Verbal Threat Review of the Medical Record for Resident #70 and the Facility LOG - Nursing Home Psychological Services form revealed: No entry/documented evidence of a consult, initial evaluation or re-evaluation for Resident # 70 prior to 6/22/11. 6/23/11 at 8:30 a.m. S36DON in an interview stated the first and only psych consult for Resident #70 was on 6/22/11. He further stated that the S49Physician and S46NursePractictioner dealt with Resident #70. After review of Resident #70's medical record, S36DON verified there were no medication adjustments made by the S49Physician or S46NursePractioner, they only continued his meds except for doses of [MEDICATION NAME] ordered when Resident #70 had an incident/acted out. S36DON further stated that when Resident #70 acts out, the staff talks to him and he calms down and is all right. When he is aggressive and "I" step in and defuse the situation he calms down quickly, but most of my staff is afraid of him. S36DON stated that he spoke with the resident's family on 6/21/11 and they were made aware the resident would receive a 30 day notice of discharge. S36DON stated Resident #70's sister will not accept the resident secondary to threats, but his brother will. S36DON stated the resident is not appropriate for the facility and would have never been accepted had the previous facility been honest. S36DON said Resident #70 will be receiving a 30 day discharge notice and he has spoken with S49Physician about this resident's behavior. S36DON stated that if we increase monitoring we remind each other verbally to monitor the resident, increased monitoring is not officially documented anywhere. S36DON reported the facility did not initiate a wander guard for Resident #70 because it is his right to leave the facility. He stays outside the facility most of the time. He will sign himself out most of the time to go to the dollar store. S36DON stated when Resident #70 was PEC'd to the behavioral health unit of a local hospital he did not refuse to take the resident back, but spoke with the social worker at the hospital and stated he didn't feel comfortable accepting him back into the building because he was a known threat. S36DON further stated the Social Worker reported that they were trying to find him placement and S36DON stated that he requested they keep the resident at the behavior health facility until they found out where he would be going. Review of the Physician order [REDACTED]. [MEDICATION NAME] 2 mg PO QD [MEDICATION NAME] 100mg PO Q Night [MEDICATION NAME] 3 mg PO Q HS [MEDICATION NAME] 3 mg PO BID [MEDICATION NAME] D 100 mg IM Q Month Trazadone 50 mg PO Q HS Regular Diet Review of Physician's Telephone orders for Resident #70 revealed: 3/24/11 [MEDICATION NAME] 5 mg IM Now 5/1/11 [MEDICATION NAME] 5 mg IM X 1 dose if agitation persist MD to evaluate medication regimen next week. 6/7/11 OK to PEC to ER of a local hospital 6/21/11 [MEDICATION NAME] 5mg IM Now (agitation) 6/22/11 at 11:50 a.m. S3MedicareCoordinator stated the residents discharge on 6/7/11 was a discharge return not anticipated, but the resident was readmitted to the facility on [DATE]. Review of the Care Plan dated 3/2/11 for Resident #70 revealed, in part, the following: A. Problem/Need: [DIAGNOSES REDACTED]. Problem Onset: 3/2/2011 Goal: Show at least one physical sign that stress is being alleviated Goal Date: 6/2/11 Approaches: 1. Observe for change in mental status and document. Report any decline to physician 2. Monitor and document behavior and report any abnormal observations to the physician 3. Social Services to evaluate and visit with resident 4. Administer medications as ordered by physician. 5. Approach resident warmly and positively at all times 6. Provide consistent caregivers on all shifts 7. Convey acceptance of resident to resident 8. Provide structured care routine for resident 9. Provide opportunity for resident to vent feelings. Listen in a non-judgmental manner 10. Offer reassurance to resident as necessary B. Problem/Need: Risk for increasing confusion, mood changes and disordered thoughts secondary to [MEDICAL CONDITION] and paranoid state. Problem Onset: 3/2/11 Goal: Will know person, place, and time Goal Date: 6/2/11 Approaches: 1. Reality orientation if needed 2. Explain all procedures 3. Involve in enjoyable activities which orient to reality 4. Medications as ordered 5. Allow resident to vent his feelings to staff, listen in non-judgmental manner 6. Meds as ordered Problem: 4/28/11 per incident report: Resident in room [ROOM NUMBER]B standing over resident yelling, cursing and hollering, threatening another resident with a pair of scissors in his hand. Approaches: 4/28/11 1. Phoned M.D. 2. [MEDICATION NAME] 5mg IM now 3. Social Services and Director of Nurses to talk calmly with resident. Problem: 6/7/11 Resident sent to Local Hospital emergency room per Physicians Emergency Certificate. Problem: 6/21/11 Resident cursing and threatening another resident Approaches: 6/21/11 1. 5mg IM [MEDICATION NAME] now for agitation. Further review of the Care Plan dated 3/2/11 for Resident #70 revealed there were no listed problems, goals or interventions to address the resident's behavior issues. On 6/23/11 at 8:00 a.m. in an interview with S2MDSCoordinator after reviewing Resident #70's medical record and care plan verified the care plan was not updated after each behavioral incident of Resident #70. She further stated the nurses complete an incident report and send the yellow copy to MDS, so the care plan can be updated appropriately. If it is a new order we get the pink copy of the telephone order. If the staff does not complete an incident report and forward the yellow copy to us, then we have no way of knowing about any new incident to update the care plan. On 6/23/11 at 12:30 p.m. S2MDSCoordinator reports that a significant change is done when there is a change in two or more care areas. Behavior monitoring is done on the MAR indicated [REDACTED]. Review of the Initial Social Services History for Resident #70 completed by S1SSD revealed in part: Date of admission 2/14/11 Source of information - Self Siblings - 0 (none) living Review of the residents Face Sheet for resident #70 revealed information for a Second Contact listing the name and contact telephone number for the resident's sister. Review of the social services notes written by S1SSD revealed only the following entries: 2/18/11 SSD visited with resident to complete Initial Social Service history. No concerns or complaints noted. Resident is his own responsible party. SSD will continue to visit resident to ensure social needs are addressed as outlined on care plan. 2/23/11 SSD visited with resident to complete BIMS assessment. See MDS section B, E and Q for cognitive functioning. No concerns or complaints noted at this time. SSD will continue to visit resident to ensure social needs are addressed as outlined on care plan. 3/24/11 SSD spoke with resident regarding the behavior he exhibited at the drug store and a local bank, resident was escorted back to the facility by the police. Police reported that resident created a disturbance at drug store stating he was robbed. He then exited drug store and went to the bank where he told the employees that he needed to contact the FBI regarding his money. SSD and DON spoke to resident and tried to get him to calm down. Resident took his medicine from the DON. SSD will continue to monitor resident and his behavior. No other SSD documentation was noted in Resident #70 medical record. On 6/23/11 at 9:35 a.m. S1SSD stated Resident #70 will threaten staff and residents, this usually occurs on weekends or at night, usually when it happens during the day "I" can calm him down. S1SSD stated Resident #70 came from another long term care facility because they didn't want him back after a stay in the hospital. She further stated Resident #70 has not received a 30 day discharge notice letter, but we have discussed giving him a one. S1SSD stated that Resident #70's behavior is normally good, but he has episodes were he explodes. Resident #70 can be passing someone in the hall and starts cussing them out. S1SSD further stated Resident #70 is verbal with female residents, but physical with male residents. S1SSD stated that she has not been able to locate a day program for him or any other placement. S1SSD stated that she only documents if the incident occurs when she is present and she was involved with it. On 6/23/11 at 12:25 p.m. S1SSD reports that Resident #70's intake information on his initial social service history is incomplete secondary to the information not received from family and possible inaccurate information from the resident. On 6/23/11 at 3:45 pm Interview with S1SSD reports the members of the Care Plan/IDT team are as follows: Social Services Nursing (for the resident) Dietary Manager Recreation MDS Nurse (For the resident) Respiratory (vent resident) CNA Supervisor CNA (for the resident only if needed) S1SSD further stated meetings are held for care planning or if something occurs and we need to have a meeting. S1SSD stated the only meetings held for Resident #70 were for care planning only. S1SSD stated there were no care plan/IDT meetings for Resident #70 to address his behavior issues. Behaviors are documented only if /when they occur and then we try and locate the proper facility to address whatever concerns we are having at the time. S1SSD reported Resident # 70 room changes were due to the resident being out of the facility more than 7 days, not for problems with him and his roommates. S1SSD stated the first conversation she had with Resident #70's sister was on a conference call with S36DON on 6/21/11. S1SSD further stated she had no contact with Resident #70's family until 6/21/11. S1SSD further stated she was not aware of the family members listed on the face sheet. Reports Resident #70 indicated during the initial Social Service evaluation that he had no family. When new admits come into the facility the information pertaining to the [DIAGNOSES REDACTED]. Review of the resident Interest/Activity dated 2/15/11 for Resident #70 completed by the Activity Director revealed the following in part: Would you rather take part in activities with a group or by yourself? Self In the morning or afternoon? Both What kind of music do you like? Classic soul Music Do you like to sing? Yes Information obtained from: Resident #70 - himself Likes: Literary - Newspaper, Magazines, Watching TV, Listening to radio Religious activities - Bible reading Personal Grooming - Wash and set, Manicures, Hair Cut Review of the Activity Directors Notes for Resident #70 revealed only one entry: Resident #70 was admitted to the facility on [DATE] from a local hospital. He is awake, alert, verbal, oriented X 3. RAD will continue to follow up. On 6/24/11 at 8:10 a.m.,during an interview with S37ActivityDirector she reported Resident #70 did not participate in scheduled activities for the most part. She said he would participate in the birthday parties, but he did not participate in bingo, card games or table games. S37ActivityDirector reported that Resident #70 mostly sat outside and talked with other residents, read books and magazines. S37ActivityDirector further stated Resident #70 had no behavior issues with her, but that she has seen him get agitated at times. S37ActivityDirector stated that she attempted to find out other things Resident #70 might like, but he was not interested in participating in activities. S37ActivityDirector stated that she did not document any of her interactions with Resident #70 to re-asses his likes and dislikes and types of activities he was interested in. On 6/23/11 at 9:00 a.m. in an interview Resident #70 reports that he has lived here a couple of months now, but have gone to the hospital a couple of times. Resident stated,"but I am all right now." He said he had a few bad days, and gets a little crazy when he doesn't take his medicine. The resident said they gave him a shot and that he is all right now. He stated "we all have good days and bad days, ups and downs." The resident said he likes living at the facility, but "if they tell me I have to leave it will be O.K." On 6/23/11 at 9:10 a.m. in an interview S52LPN reported that Resident #70 will act out if provoked. S52LPN stated that she had never witnessed any of his behaviors, but that she had been told about them. S52LPN stated everyone monitors his behavior and watches out for any problems, but increased monitoring is not documented anywhere. S52LPN stated we don't have a form or anything to document that we are monitoring a patient every hour or anything like that. On 6/23/11 at 9:20 a.m. in an interview S6LPN stated that she just recently started to take care of Resident #70 when he returned to the facility last week. S6LPN stated since she has been taking care of him, his behavior has been OK. Resident #70 will leave the facility to go to the store and return. S6LPN further stated that Resident #70 will tell "us" when he leaves to go to the store most of the time. S6LPN stated if any resident refuses medications "we" are to call the doctor to let them know per policy and procedure. On 6/23/11 at 10:05 a.m. in an interview S32LPN stated that Resident #70 has had some behavior issues. He has had episodes when he barricades himself in his room and had verbal altercations with people inside and outside of the facility. S32LPN stated that increased monitoring is not documented. If Resident #70 refuses any medication we circle it and document on the back of the medication administration record. S32LPN stated incident reports are done when a resident hurts themselves or someone else and should be done for any occurrence out of the ordinary including verbal confrontations. On 6/23/11 at 1:10 p.m. in an interview S36DON stated the admission paperwork for Resident #70 came from the hospital with no information from the previous nursing home. He reported the interventions used with Resident #70 for his behavior problems were: 1. Resident # 70 was PEC'd to behavioral health units at local facilities twice. 2. The Staff redirected Resident #70's behavior as appropriate. 3. Resident #70 was to be monitored more closely 4. A

Based on observation, record review and interview, the facility failed to ensure the resident's environment remained as free of accidents as possible for 3 (#58, #100, #102) of a total stage 2 sample of 31 (#36, #127, #58, #29, #108, #147, #52, #88, #145, #137, #135, #100, #110, #146, #91, #9, #18, #102, #20, #30, #11, #45, #61, #47, #129, #131, #103, #126, #17, #70, #28). The facility failed to: 1.) increase monitoring of a resident (#70)with aggressive, bizarre, and threatening physical and verbal behaviors toward another resident (#58); 2.) assess for causative factors that trigger resident #70's aggressive threatening behaviors; 3.) obtain a psychiatric consult for resident #70 after he threatened a hospice aide and other residents; 4.) Investigate the causative factors contributing to a resident with multiple falls for 2 of 2 residents (#100, #102 ); 5.) Implement interventions/approaches to reduce falls for residents determined to be high risk for falls for 2 of 2 residents reviewed for accidents (#100, #102) 6.) Identify residents at risk for falls (#100, #102) 7.) Educate staff on the facility system for identifying residents at risk for falls for 2 of 2 residents reviewed with falls (#100, #102) 8.) Initiate an investigation when a resident with a wandergard was found outside the facility wandering in the courtyard. Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted from a psychiatric unit of a local hospital where he had been evaluated for agitation/paranoia and homicidal thoughts. On 4/28/11 at 3:20 p.m., resident #70 went into room 31 and was found standing over Resident # 58 yelling with a knife in his hand that he would stab and kill resident #58. Resident #58 was placed in Immediate Jeopardy at this time. The facility failed to immediately increase supervision and obtain a consult with a psychiatrist. The facility failed to assess for causative factors that triggered resident #70s aggression. The Immediate Jeopardy ended for resident #58 on 06/23/2011 at 10:05 p.m. when resident #70 was transferred to a local hospital. The deficient practice continues at scope and severity level II, potential for more than minimal harm, for all the residents in the facility as the facility failed to put a system in place to prevent the deficient practice from reoccurring if another resident is admitted with a psychiatric [DIAGNOSES REDACTED]. Findings: Resident # 70: Resident #70 was a [AGE] year old black male admitted to the facility on [DATE] from a psychiatric unit of a local hospital where he had been evaluated for agitation/paranoia and homicidal thoughts and had threatened someone at the psych hospital with a razor. He was admitted with [DIAGNOSES REDACTED]. Review of the Minimal Data Set (MDS) assessments for Resident #70 revealed the following in part: Admission MDS assessment dated [DATE] A1800 Entered from - 03 (Acute Hospital) A2300 Assessment reference date: Observation end date: 2/23/11 Section C - Cognitive Patterns: C0500 Summary Score - 13 (13-15 cognitively intact) Section D - Mood D0300 Summary Score - 08(5-9 mild depression) Section E - Behavior E0100 Psychosis - None of the above EO200 Behavioral Symptom - none EO600 Impact on others - none Review of the Elopement Risk Assessment Form for Resident #70 dated 2/14/11 revealed: A. Mental Status - 0 (not disoriented) B. Emotional Status - 0 (Complacent/Cooperative) C. Activity - 4 (Ambulatory) D. Mobility - 4 (Full) E. Medication - (Medications that alter mental status or psychotropics) F. Elopement History - 5 (Wanders the facility but does not try to leave Total score of 15 (Score as elopement risk if score is 10 or greater) Interventions Implemented to Attempt to prevent Elopement: Resident signs in and out of facility to walk to store independently. Review of the medial revealed no other elopement risk assessment was conducted after the 2/14/11 assessment. Review of the Nurses Notes revealed the following in part: 3/23/11 at 8: a.m.- Resident awake, oriented X 3 appears guarded offered Haldol D that he refused earlier. Took P.O. medications without problems. Refused injection, states "the doctor took me off of that over 6 months ago. Informed resident that he received this injection a month ago "No I didn't" frowning "where is the lady who drives the transportation van? I'm leaving here because this place is associated with Church. I'm not staying here. Informed resident that he said just yesterday he liked it here. "Oh no it's associated with the church", when told that it wasn't "oh yes I saw the pictures, the lady told me. Appears to becoming agitated allowed to be alone. 3/24/11 at 1:00 p.m. Resident arrives back to the nursing home in back of EBRP. Officer stated they were called because he was exhibiting bizarre behavior at a local bank. Patient is agitated using profanity states he wasn't causing a disturbance he was trying to use their phone to call the FBI because people were stealing from him, putting nude pictures of him on the Internet. 4/13/11 at 11:00 p.m. resident very possessive of room blocking hallway door and locking bathroom door to keep staff out. Nurse having to call out to resident to assure herself of his wellbeing. 4/14/11 at 5:00 a.m. when hospice CNA attempted to enter room to get roommate personal items to give bath/hygiene care, Resident opened door but butter knife noted in hand resident then told staff to get all roommate possessions out of room. Nurse closed door without comment. 4/28/11 at 3:20 p.m. This nurse was walking down the hallway when I heard resident #70 yelling in room 31. Upon entering the room I observed Resident#70 standing over Resident # 58 who was lying in bed talking on his phone, Resident # 70 was yelling with a knife in his hand saying " say something, I'll stab you m----- f-----, you killed my brother and I'm going to kill you " . Lots of cueing and coaxing done to redirect resident to his room. Director of Nurses and social services notified to come to room. 4/29/11 at 12 a.m. Resident remains isolated in room with both doors blocked. Refuses to allow nurse/staff in room. Will continue to monitor. 4/29/11 at 12 a.m. Resident remains isolated in room with both doors blocked. Refuses to allow nurse/staff in room. Will continue to monitor. 5/1/11 at 10:15 a.m. Received report from Ms. ... that she was approached by the resident at the dollar general store and asked for some money. Stated that when she refused to give him any money resident began threatening her stating "I'll stab you in your head" and also called her numerous vulgar names. Spoke with the resident about the above stated incident, he denies asking for money and stated that she was cursing at him. Resident is very agitated at this time, attempted to redirect, success after several attempts instructed resident to go have a seat, he complied. 5/1/11 at 10:30 a.m. Placed a call to Nurse Practitioner to notify of the incident, received an order for [REDACTED]. Spoke with resident and encouraged him to stay on the premises today. He verbalized understanding and stated that he would remain on the premises today. No further agitation noted at this time. Will continue to observe 5/1/11 at 10:50 a.m. City police entered the facility. Spoke with resident regarding the above incident. No charges filed at this time. Resident remains calm. 5/1/11 at 10:30 a.m. Placed a call to Nurse Practitioner to notify of the incident, received an order for [REDACTED]. Spoke with resident and encouraged him to stay on the premises today. He verbalized understanding and stated that he would remain on the premises today. No further agitation noted at this time. Will continue to observe. 5/1/11 at 10:50 a.m. City police entered the facility. Spoke with resident regarding the above incident. No charges filed at this time. Resident remains calm. 5/3/11 at 2:15 p.m. Notified by S1SSD, resident to be PEC'd to the behavioral hospital this p.m. 5/20/11 at 2:00 p.m. readmitted from Behavioral Health Hospital. Readmission MDS assessment dated [DATE] A1800 Entered from - 03 (Acute Hospital) A2300 Assessment reference date: Observation end date: 6/7/11 Section C - Cognitive Patterns: C0500 Summary Score - 13 (13-15 cognitively intact) Section D - Mood D0300 Summary Score - 07 (5-9 mild depression) Section E - Behavior E0100 Psychosis - None of the above Review of nurses notes revealed the following in part: 5/22/11 at 2:00 a.m. Noted resident ambulating thru halls, in the dining room eating off different people trays that was left over. Earlier threatened 2 different residents, told one resident " I'll break your neck " , told another resident " move get out my way " . Seen also scraping some kind of food particle off the floor. 5/27/11 at 9:30 p.m. Resident had verbal confrontation with another resident in hall. Was threatening resident with stabbing him with a knife. Nurses times 3 intervened Resident #70 returned to his room no weapons of any sort found. Instructed that type of behavior unacceptable, verbalized understood, shut door in my face. Director of Nursing (DON) notified. 6/3/11 at 10:30 p.m. Keeps obstruction behind door during the night. Wood handle object noted in hand when nurse enters room to check on resident no aggression exhibited at this time. Released wood object returned it to hiding place. 6/5/11 at 8:30 a.m. Resident standing in hallway cursing and using various obscenities while speaking to the housekeeper due to his refusal to allow the housekeeper to clean his room. Resident was redirected with a lot of difficulty but returned to his room and closed the door. Will continue to observe. 6/7/11 at 6:10 a.m. Resident walking toward CNAs gathered in front of nurse ' s station very aggressively, demanding which one of you m----- f-----called me a b----, one of you b----es called me a b----. Nurse observed a razor in hand, resident chased CNAs into main nurses station after CNAs denied that anyone called him a b----. Nurse attempted to intercept resident, holding on to his left arm which held the razor. Resident chased CNA's into break room with razor in hand using extreme profanity. CNAs locked themselves in the break room bathroom. Resident refused to listen to nurse repeated statement that no one called him a [***] . Resident # 70 met another male resident in the hallway near nurses station and proceeded to threaten him, standing over resident in his wheelchair, holding his wheelchair handle and daring resident to tell him to let his wheelchair go. Shouting to other resident "I will cut your m----- f---ing neck off, you m----- f---er " . Nurse holding resident's raised hand with razor in it to keep him from attempting to strike at other resident. Nurse repeatedly reassuring Resident #70 that the other male resident will not tell him anything. Nurse told other male resident to self propel away from resident #70. Resident #70 proceeded to ambulate down hall shouting obscenities at other male resident. Nurse remained behind resident holding onto hand carrying razor. Nurse able to redirect resident to room. 6/7/11 at 6:28 a.m. Police arrived, met resident on hall, resident carrying small garden rake and razor. Police after some resistance on resident's part was able to persuade resident to voluntarily hand over small yard rake and razor. Body search performed, no other weapons found on resident. Resident somewhat calm no further threats verbalized. Resident returned to his room. 6/21/11 at 4:10 p.m. Resident #70 walking up hall S36DON behind him, resident #70 passes a resident in her w/c and calls her a b---- and a dog without provocation. S36DON confronted resident and asked why he said that to her. He replied that he had not said anything. S36DON told him that he heard him say it. "Okay, I did". Escorted Resident #70 back to his room and attempted to counsel him without success, very agitated. Phoned S46 Nurse Practicing and received order for Haldol 5mg IM now and to administer meds as ordered. On 6/23/11 at 8:30 a.m. S36DON in an interview stated the first and only psych consult for Resident #70 was on 6/22/11. He further stated that the S49 Physician and S46 Nurse Practitioner dealt with Resident #70. After review of Resident #70's medical record S36DON verified there were no medication adjustments made by the S49 Physician or S46 Nurse Practitioner they only continued his meds except for doses of Haldol ordered when Resident #70 had an incident/acted out. S36DON further stated that when Resident #70 acts out the staff talks to him and he calms down and is all right. When he is aggressive and I step in and defuse the situation he calms down quickly, but most of my staff is afraid of him. S36DON stated that he spoke with the resident's family on 6/21/11 and they were made aware the resident would receive a 30 day notice of discharge. S36DON stated Resident #70's sister will not accept the resident secondary to threats, but his brother will. S36DON stated the resident is not appropriate for the facility and would have never been accepted had the previous facility been honest. The DON said Resident #70 will be receiving a 30 day discharge notice and he has spoken with S49 Physician about this resident behavior. S36DON stated that if we increase monitoring we remind each other verbally to monitor the resident, increased monitoring is not officially documented anywhere. S36DON reported the facility did not initiate a wander guard for Resident #70 because it is his right to leave the facility. He stays outside the facility most of the time he will sign himself out most of the time to go to the dollar store. S36DON stated when Resident #70 was PEC'd to the behavioral health unit of a local hospital he did not refuse to take the resident back, but spoke with the social worker at the hospital and stated he didn't feel comfortable accepting him back into the building because he was a known threat. S36DON further stated the Social Worker reported that they were trying to find him placement and S36DON stated that he requested they keep the resident at the behavior health facility until they found out where he would be going. On 6/23/11 at 8:30 a.m. S36DON in an interview stated the facility did not initiate a wander guard for Resident #70 because it is his right to leave the facility. He stays outside the facility most of the time. He will sign himself out most of the time to go to the store. S36DON verified the only elopement risk assessment for Resident #70 was the one dated 2/14/11. On 6/23/11 at 8:00 a.m. in an interview with S2MDS Coordinator after reviewing Resident #70's medical record and care plan verified the care plan was not updated after each behavioral incident of Resident #70. She further stated the nurses complete an incident report and send the yellow copy to MDS so the care plan can be updated appropriately. If it is a new order we get the pink copy of the telephone order. If the staff does not complete an incident report and forward the yellow copy to us, then we have no way of knowing about any new incident to update the care plan. On 6/23/11 at 9:35 a.m. S1SSD stated Resident #70 will threaten staff and residents, this usually occurs on weekends or at night, usually when it happens during the day I can calm him down. S1SSD stated Resident #70 came from another long term care facility because they didn't want him back after a stay in the hospital. She further stated Resident #70 has not received a discharge letter, but we have discussed giving him a discharge letter. S1SSD stated that Resident #70's behavior is normally good, but he has episodes were he explodes. Resident #70 can be passing someone in the hall and starts cussing them out. S1SSD further stated Resident #70 is verbal with female residents, but physical with male residents. S1SSD stared that she has not been able to locate a day program for him or any other placement. S1SSD stated that she only documents if the incident occurs when she is present and she was involved with it. On 6/23/11 at 10:05 a.m. S32LPN stated that Resident #70 has had some behavior issues. She said he had episodes when he barricades himself in his room and had verbal altercations with people inside and outside of the facility. S32LPN stated that increased monitoring is not documented. 6/23/11 at 5:00 p.m. in an interview with S36DON stated that comprehensive assessments for safety are not done. He said there is no official form or policy; safety issues are identified through observation. S36DON stated with increased monitoring there is no form for that, the staff is constantly monitoring the resident as part of the nursing process. Every morning we have a meeting with the department heads and we discuss any problems with any resident. S36DON further stated the meetings are very informal and not necessarily documented. S36DON stated that he felt more than safe to say that all staff is aware of the issues with Resident #70 and we all monitor him and most of the time he is easily redirected. Resident #100: Resident #100 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation was made of the resident on 6/21/11 at 12:30 p.m. The resident was up in a wheelchair in her room reading a book. She was alert and oriented to place, but could not remember how long she had been a resident of the facility. She was later seen propelling herself in the wheelchair down the hall to the dining room. Review of the most current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/11 under Section G-Functional Status revealed Resident #100 was Independent in bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, locomotion off unit and eating. The MDS further revealed the resident required limited assistance for dressing and toilet use and Physical help limited to transfer only with bathing. Under Section G0600-Mobility Devices revealed she used a wheelchair. Review of the Medical Record revealed Resident #100 had Fall Risk Assessments done on 10/13/10 and 12/29/10. The resident's total score was greater than 10 and she was deemed High Risk for falls on all assessments done. Review of the Incident/Accident Log from 7/1/10 to present revealed the following documented falls: 10/26/10-fell in room 2/7/11-fell in room 3/4/11-fell in room 3/15/11-fell in bathroom 6/8/11-fell in common area 6/16/11-fell in room Review of the Incident/Accident Report for the above dates revealed the following: 10/26/11-Time of incident: 3:00 p.m. Resident verbalized she slipped and fell while trying to stand up from seated position in wheelchair. Complained of headache pain. No other apparent injury at present. Neuro checks initiated. Will monitor. Unwitnessed fall. There was no documentation of an investigation of this fall. Neuro checks were initiated, but were done for that one time. 1/27/11-Time of Incident: 8:40 a.m. Upon entering room resident sitting on floor on buttocks. Resident reports she was about to get in bed-soft lap belt hooked on wheelchair Additional comments and/or steps to prevent recurrence: Advised to seek assistance prior to any attempted transfers. 3/4/11-Time of Incident: 12:55 p.m. Upon passing by room resident sitting on floor in front of wheelchair. Resident reports "I sat here". Additional comments and/or steps to prevent recurrence: Educated to seek assistance prior to any transfer attempts. 3/5/11-Time of incident: 1:47 p.m. Called to room by S21CNA who found resident on floor in bathroom. Soft lap belt was connected to wheelchair. Additional comments and/or steps to prevent recurrence: Educated on the importance of seeking assistance prior to any transfers. 6/8/11-Time of incident: 2:45 p.m. Place of Incident: main dining area. Resident reports she was bending down to pick up another resident's Bingo chips off floor and landed on buttocks on floor. Additional comments and/or steps taken to prevent recurrence: Resident educated to avoid bending over while in wheelchair due to risk of fall/injury. 6/16/11-Time of incident: 10:33 p.m. Resident stated she was attempting to change her clothes and while attempting to stand-up she lost her balance and fell to the floor landing on her buttock. Denies hitting head. Additional comments and/or steps taken to prevent recurrence: Instructed CNA to assist resident with changing her clothes every day. An interview was conducted with S36DON on 6/27/11 at 2:30 p.m. He reviewed the above incident reports and the follow-up documented there in and stated the incident report given was all he had for the reports. He verified there was no further follow-up for any of the incidents of the falls for Resident #100. Review of the Care Plan revealed the following under the area of Fall: Potential for falls r/t impaired mobility. Actual fall 3/15/11 on floor in bathroom with soft lap belt attached to wheelchair. Per 6/8/11: Resident reports she was bending down to pick-up another resident bingo chips off the floor and landed on buttock on floor. Approaches: -Place call light within reach and instruct resident to call for any assistance. -Give resident verbal reminders not to ambulate or transfer without assistance. -Place items frequently used by the resident within easy reach, to avoid resident reaching for items -Follow facility protocol for falls -Notify MD/RP PRN falls An interview was conducted with S2MDS Coordinator on 6/22/11 at 1:30 p.m. She reviewed the medical record and reviewed the Care Plan under the fall section and could not find an update for the falls the resident had. She verified that there were no new interventions/approaches added to the care plan each time the resident fell . An interview was conducted with S36DON on 6/23/11 at 8:30 a.m. He was asked how the staff and any one who came in contact with the residents knew which residents were at risk for falls in the facility. He stated that when a resident falls, it is discussed in the morning supervisor meeting and the CNA supervisor or the nurse makes the rest of the staff aware of the residents who are at risk for falls. He stated there was no written fall protocol or no indication on the resident's door or wheelchair or room that they are at risk for falls. An interview was conducted with S34CNA on 6/27/11 at 10:45 a.m. She was asked how she knew which residents on her hall were at risk for falls. She said that the residents who are at risk for falls have a leaf or flower on their doors or have an arm band on. When asked what color the arm band was, she was unclear and did not really know. She said that all of the residents that she was responsible for are bedbound and she does not have to worry about them getting up and falling. An interview was conducted with S28CNA on 6/27/11 at 1:45 p.m. She stated she has only been employed for 2 weeks, but she worked the hall where Resident #100 lived. When asked how she knew if the resident was high risk for falls, she said the resident should have a rose over their bed or an armband. When asked what color the arm band was, she said either yellow or white. When asked how the staff knew which ones were a fall risk, she said it was written on the armband if the resident was at risk for falls. An observation was made with S28CNA on 6/27/11 at 1:50 p.m. of Resident #100's room and arm for an armband. The room was examined for a rose over the bed or an armband of any color on the resident. There was no rose on the door, over the bed or anywhere in the room and no armband on the resident. S28CNA verified that none of the above signs of a resident at risk for falls was present in the resident's room. She admitted that she was not sure if Resident #100 was a fall risk or not, as there was nothing to identify her as a fall risk. An interview was conducted with S32LPN on 6/27/11 at 2:00 p.m. regarding high risk fall residents. She said that there was usually a fallen leaf or some sort of flower over the resident's bed to identify him/her as a fall risk. She said she was not sure which one. An observation was made with S32LPN of Resident #47's room on 6/27/11 at 2:05 p.m. She stated that he was a fall risk, so she was going to show the leaf or flower to identify the resident as high risk for falls. The room was examined for a leaf or any flower and neither was present. S32LPN verified there was nothing in the resident's room to let the rest of the staff know that he was high risk for falls. She was not sure how the CNA's know which residents are at risk for falls. The facility failed to have a system in place to identify residents at risk for falls and a system to educate the staff on which residents were fall risks. Review of the Incident/Accident Reports revealed the following incident: 4/30/11 at 9:30 a.m. Location of the incident/accident: Facility yard Resident's condition before incident/accident: Disoriented Description of what happened: Patient found in facility front yard by CNA. Wanderguard in place on ankle-No injury. Type of injury: None apparent Additional comments: MD notified-Obtain urinalysis in am to assess increase confusion, evaluation for placement on secure unit. There was no documentation of an investigation of the incident or increased supervisor for the resident found outside with a wanderguard. An interview was conducted with S36DON on 6/24/11 at 9:45 a.m. regarding the above incident and the investigation done by the facility. He reviewed the incident report and the medical record and could not find any additional information for the incident or any investigation as to what happened or how the resident got out of the facility with the wanderguard. He did not find any documentation about the staff having knowledge of the incident. He stated that the wanderguards locks the door when the person wearing it comes in contact with it. He further stated that some family member must have held the door open for the resident to go out of the door without the wanderguard being activated. He said the wanderguards are checked every month by social services. A review of the wanderguard check list was presented by S1SSD on 6/24/11 at 1:00 p.m. Review of the report for dates of service January 2011 to June 2011 revealed the following checks for Resident #100: 1/21/11 2/16/11 3/29/11 4/15/11 5/16/11 6/17/11 There was no documentation in the comments section to say if the appliance worked or not. There was no check done after the incident on 4/30/11 until 5/16/11. An interview was conducted with S1SDD on 6/28/11 at 8:10 a.m. She stated that the day Resident #100 was found in the front yard she was easily directed back in the building. She said the resident just wanted to sit outside for a while. When asked if she checked the wanderguard for workability the day she got outside, she stated no, but she did do her next monthly check when due. An observation was made of how the wanderguard was checked with Resident #100 and Resident #79 on 6/28/11 at 8:15 a.m. Neither resident was taken to the door to see if the door would lock as it was supposed to. A machine was placed next to the wanderguard and a green light went off and S1SDD stated that's how she knows that the wanderguard is working. Review of the Care Plan for Resident #100 did not reveal an entry regarding the wanderguard the resident was wearing. There was no written documentation as to the use or any maintenance of the wanderguard. An interview was conducted with S2MDS Coordinator on 6/28/11 at 10:00 a.m. She reviewed the medical record and the Care Plan for Resident #100 and verified that the care plan did not have an entry regarding the wanderguard. She was not sure why it was not care planned. Surveyor: Sylve, Lori A. Resident #102: A review of the facility's Falls and Fall Risk , Managing policy revealed the following : Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff with the input of the attending physician,will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions, (i.e., to try one or a few at a time, rather than many at once). MDS staff will conduct a fall risk assessment upon admit and update quarterly . Therapy will screen residents in the event a fall occurs, if applicable. 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. A review of the clinical record revealed the Resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the Resident's annual MDS (Minimum Data Set), dated 03/25/2011 revealed the following: BIMS (Brief Interview Mental Status) as 15 (cognitive). G 0300. Balance During Transitions and Walking The resident scored a (2) Not Steady ,only able to stabilize with human assistance in the following areas: A. Moving from seated to standing position B. walking (with assistive device if used) C. Turning around and facing the opposite direction while walking. (only able to stabilize with human assistance). Review of the Resident's clinical record revealed the following: Fall Risk Assessment: Total Score of 10 or above represents High Risk For Falls 12/08/2010 S2MDS Coordinator assessed Resident's score as 15 03/07/2011 S3Medicare Coordinator assessed Resident's score as 15 05/23/2011 S3Medicare Coordinator assessed Resident's score as 15 A review of the care plan revealed the following: Problem: Potential for falls related to impaired immobility and psychotropic medication use. History of multiple falls. Last fall: 02/04/2011 Attempt to transfer to wheelchair without assistance and fell to floor. 04/10/2011 fell from wheel chair 04/11/2011 fell from toilet 05/05/2011 fell attempting to transfer from wheelchair to bed, sustained a small laceration to forehead. 05/12/2011 Found on floor in shower room on stomach, attempting to transfer to wheelchair sustained small abrasion to head, 2 scratches to (L) knee. 06/3/2011 fell in dining area ambulating with walker without assistance, no injuries noted 06/23/2011 Resident reported he fell in early am and did not report it. No injuries sustained Approaches:Assist with transfers as needed. Resident can stand and pivot to aid in transfers. Give Resident verbal reminders not to ambulate without assistance PT, OT as ordered Observe resident for adverse side effects/toxicity of medications in current drug regime. Contact physician with abnormal findings Follow facility protocol for falls Notify MD(Medical Doctor) and responsible party PRN (as needed) all falls Wheel chair for mobility Continue to encourage resident to call for assistance for transfers 02/01/2011 PT, OTC as ordered 02/08/2011 Out to inpatient rehab. 02/22/2011 Returned to facility with orders to continue PT, OT 04/10/2011 Encourage resident to call for assistance 04/11/2011 Reminded to use call light for assistance for toileting 05/05/2011 Remind resident to call for assistance 05/12/2011 Remind resident to call for assistance when

Based on observation, record review, and interviews, the facility failed to be administered in a manner that used its resources effectively and efficiently to attain and maintain the physical, mental and psychosocial well-being of 1 (#70) of 3 (#9, #52, and #70) sampled residents with psychiatric disorders and behavioral symptoms out of a Stage 2 sample of 31. The Administration failed to: 1. Have a process in place to ensure that residents admitted with psychiatric disorders received psychiatric evaluations when they began to exhibit aggressive threatening behaviors directed toward other residents (#70). 2. Ensure that accurate assessments regarding behavioral issues were documented on the MDS for a resident admitted with a [DIAGNOSES REDACTED].#70). 3. Ensure interventions were identified to prevent endangerment of other residents from a resident exhibiting aggressive, threatening behaviors (#70). 4. Ensure that the resident exhibiting aggressive threatening behaviors was assessed for causative factors that triggered the resident's aggressive threatening behaviors (#70). 5. Identify and care plan approaches to address and control the resident's aggressive, threatening behaviors (#70). 6. Assess, care plan, and implement meaningful activities (#70). 7. Involve the social worker in assessing and intervening to control the resident's aggressive, threatening behaviors (#70). 8. Determine the resident's ability to sign himself out of the facility and safely interact in the community (#70). 9. Monitor the resident to prevent abuse to other residents (#70). 10. Have an effective Quality Assurance Program that identified problem areas in assessment, monitoring, and provision of services for residents with aggressive, threatening behaviors (#70). (Refer to F272, F309, F323) 11. Have a system in place to identify residents at risk for falls (Refer to F323). 12. Have a system in place to educate the staff on which residents were fall risks (Refer to F323). Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted from a psychiatric unit of a local hospital where he had been evaluated for agitation/paranoia and homicidal thoughts. Resident #70 was in Immediate Jeopardy beginning 03/24/11 after the police brought the resident back to the facility after the resident was exhibiting aggressive, bizarre, threatening behavior at a local bank and the facility failed to obtain a psychiatric consult with a psychiatrist and failed to reassess the resident to determine if it was safe for him to leave the facility alone. The resident continued aggressive, bizarre, threatening behaviors and the facility failed to assess for causative factors of the resident's behaviors and plan interventions for the causative factors. On 04/28/11, the resident threatened another resident with a knife. On 05/01/11, the resident threatened a shopper at a store. On 06/07/11, the resident threatened a resident with a razor. On 06/21/11, the resident had a verbal altercation with another resident and cursed at another resident. The facility's only interventions were to give one time doses of [MEDICATION NAME], to redirect the resident, and to PEC (Physician's Emergency Commitment) the resident to the hospital on [DATE], 06/07/11, and 06/23/11. The Social Worker failed to reassess the resident's aggressive, threatening, and bizarre behaviors. The resident was not assessed for individualized meaningful activities. The facility continued to fail to obtain a psychiatric evaluation as the behaviors continued to escalate. The Immediate Jeopardy was removed on 06/23/11 at 10:05 p.m., when Resident #70 was transferred from the facility to the hospital under a PEC (Physician's Emergency Commitment). The deficient practice continued at scope and severity level II potential for more than minimal harm for any resident with exhibiting aggressive, threatening behaviors toward other residents. Findings: 1. Failure to obtain a psychiatric evaluation for a resident with threatening, aggressive, and bizarre behavior: The Administration failed to ensure that residents admitted to the facility with psychological [DIAGNOSES REDACTED]. Cross reference to F272, F309, and F323. 2. Failure to asses the resident for causative factors that triggered the resident's behavior: The Administration failed to ensure that the staff assessed residents with aggressive and threatening behavior to determine any causative factors or triggers for their behaviors. Cross reference to F272, F309, and F323. 3. Failure to identify and care plan approaches to address and control the resident's behavior: The Administration failed to ensure that the facility staff identified and care planned approaches to address and control the resident's behavior. Cross reference to F272, F309, and F323. 4. Failure to assess, care plan, and implement meaningful activities: The Administration failed to ensure that facility staff assessed the resident for meaningful activities and failed to ensure that meaningful activities were implemented for the resident with aggressive, threatening, and bizarre behavior. 5. Failure to involve the social worker in assessing and intervening to control the resident's behavior: The Administration failed to ensure that the facility's social worker assessed the resident's behavior and intervened with the resident. Cross reference to F272, F309, and F323. 6. Failure to determine the resident's ability to sign himself out of the facility and safely interact in the community: The Administration failed to ensure that the resident was assessed to determine if he was able to safely sign himself out of the facility and interact in the community. Cross reference to F272, F309, and F323. 7. Failure to monitor the resident to prevent abuse to other residents: The Administration failed to ensure that the staff monitored the resident to prevent abuse to other residents. Cross reference to F272, F309, and F323. 8. Failure to have an effective Quality Assurance Program that identified problem areas in assessment, monitoring, and provision of services for residents with behaviors: The Administration failed to have an effective Quality Assurance Program that; identified problem areas in resident behavior and prevention of abuse, implemented interventions to address the problems, and monitored to ensure the problem was corrected. Cross reference to F272, F309, and F323.

Based on observation, record review, and interviews, the facility failed to be administered in a manner that used its resources effectively and efficiently to attain and maintain the physical, mental and psychosocial well-being of 1 (#70) of 3 (#9, #52, and #70) sampled residents with psychiatric disorders and behavioral symptoms out of a Stage 2 sample of 31. The Administration failed to: 1. Have a process in place to ensure that residents admitted with psychiatric disorders received psychiatric evaluations when they began to exhibit aggressive threatening behaviors directed toward other residents (#70). 2. Ensure that accurate assessments regarding behavioral issues were documented on the MDS for a resident admitted with a [DIAGNOSES REDACTED].#70). 3. Ensure interventions were identified to prevent endangerment of other residents from a resident exhibiting aggressive, threatening behaviors (#70). 4. Ensure that the resident exhibiting aggressive threatening behaviors was assessed for causative factors that triggered the resident's aggressive threatening behaviors (#70). 5. Identify and care plan approaches to address and control the resident's aggressive, threatening behaviors (#70). 6. Assess, care plan, and implement meaningful activities (#70). 7. Involve the social worker in assessing and intervening to control the resident's aggressive, threatening behaviors (#70). 8. Determine the resident's ability to sign himself out of the facility and safely interact in the community (#70). 9. Monitor the resident to prevent abuse to other residents (#70). 10. Have an effective Quality Assurance Program that identified problem areas in assessment, monitoring, and provision of services for residents with aggressive, threatening behaviors (#70). (Refer to F272, F309, F319, F323) 11. Have a system in place to identify residents at risk for falls (Refer to F323). 12. Have a system in place to educate the staff on which residents were fall risks (Refer to F323). Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted from a psychiatric unit of a local hospital where he had been evaluated for agitation/paranoia and homicidal thoughts. Resident #70 was in Immediate Jeopardy beginning 03/24/11 after the police brought the resident back to the facility after the resident was exhibiting aggressive, bizarre, threatening behavior at a local bank and the facility failed to obtain a psychiatric consult with a psychiatrist and failed to reassess the resident to determine if it was safe for him to leave the facility alone. The resident continued aggressive, bizarre, threatening behaviors and the facility failed to assess for causative factors of the resident's behaviors and plan interventions for the causative factors. On 04/28/11, the resident threatened another resident with a knife. On 05/01/11, the resident threatened a shopper at a store. On 06/07/11, the resident threatened a resident with a razor. On 06/21/11, the resident had a verbal altercation with another resident and cursed at another resident. The facility's only interventions were to give one time doses of [MEDICATION NAME], to redirect the resident, and to PEC (Physician's Emergency Commitment) the resident to the hospital on [DATE], 06/07/11, and 06/23/11. The Social Worker failed to reassess the resident's aggressive, threatening, and bizarre behaviors. The resident was not assessed for individualized meaningful activities. The facility continued to fail to obtain a psychiatric evaluation as the behaviors continued to escalate. The Immediate Jeopardy was removed on 06/23/11 at 10:05 p.m., when Resident #70 was transferred from the facility to the hospital under a PEC (Physician's Emergency Commitment). The deficient practice continued at scope and severity level II potential for more than minimal harm for any resident with exhibiting aggressive, threatening behaviors toward other residents. Findings: 1. Failure to obtain a psychiatric evaluation for a resident with threatening, aggressive, and bizarre behavior: The Administration failed to ensure that residents admitted to the facility with psychological [DIAGNOSES REDACTED]. Cross reference to F272, F309, and F323. 2. Failure to asses the resident for causative factors that triggered the resident's behavior: The Administration failed to ensure that the staff assessed residents with aggressive and threatening behavior to determine any causative factors or triggers for their behaviors. Cross reference to F272, F309, and F323. 3. Failure to identify and care plan approaches to address and control the resident's behavior: The Administration failed to ensure that the facility staff identified and care planned approaches to address and control the resident's behavior. Cross reference to F272, F309, and F323. 4. Failure to assess, care plan, and implement meaningful activities: The Administration failed to ensure that facility staff assessed the resident for meaningful activities and failed to ensure that meaningful activities were implemented for the resident with aggressive, threatening, and bizarre behavior. 5. Failure to involve the social worker in assessing and intervening to control the resident's behavior: The Administration failed to ensure that the facility's social worker assessed the resident's behavior and intervened with the resident. Cross reference to F272, F309, and F323. 6. Failure to determine the resident's ability to sign himself out of the facility and safely interact in the community: The Administration failed to ensure that the resident was assessed to determine if he was able to safely sign himself out of the facility and interact in the community. Cross reference to F272, F309, and F323. 7. Failure to monitor the resident to prevent abuse to other residents: The Administration failed to ensure that the staff monitored the resident to prevent abuse to other residents. Cross reference to F223, F272, F309, and F323. 8. Failure to have an effective Quality Assurance Program that identified problem areas in assessment, monitoring, and provision of services for residents with behaviors: The Administration failed to have an effective Quality Assurance Program that; identified problem areas in resident behavior and prevention of abuse, implemented interventions to address the problems, and monitored to ensure the problem was corrected. Cross reference to F223, F272, F309, and F323.

Based on observations, interviews, and record reviews, the Director of Nurses failed to develop and implement policy and procedures and a system of clinical supervision to ensure reconciliation of [MEDICATION NAME] (controlled medication) for 1 of 2 sampled residents (#2) receiving [MEDICATION NAME] out of 5 sampled residents and 3 random residents (R10, R15, & R19) out of a total of 28 residents with an order for [REDACTED]. Review of the Controlled Substances Policy revealed " ...2. Controlled substance must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together. The nurse must sign the receipt acknowledging receipt of the narcotic medication. 3. If the count is correct, a control sheet must be made for each substance. Do not enter more than one (1) prescription per page. This record must contain: a. Name of the resident; b. Name and strength of the drug; c. Quantity received; d. Number on hand; e. Name of physician; f. Prescription number; g. Name of issuing pharmacy; h. Date and time received; i. Time of administration; j. Method of administration; k. Signature of nurse administering medication. ... 5. Controlled substances must be stored in a separately locked container in the medication room. This container must remain locked when not in use. ...9. Controlled drugs must be counted at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. Discrepancies must be documented and reported to the director of nursing services. 10. The director of nursing services is responsible for investigating discrepancies to determine the cause of such occurrences and to provide the administrator with a written report of such findings ... " Resident #2 Review of the clinical record revealed resident #2 had the following Diagnoses: [REDACTED]. Review of the March 2011 Physician order [REDACTED]. Review of the Physician ' s Telephone Orders dated 3/29/11 revealed discontinue (d/c) current [MEDICATION NAME] order. [MEDICATION NAME] 10/500 per [DEVICE] every 4 hrs prn pain. Review of the April 2011 Physician order [REDACTED]. Review of the Physician ' s Telephone Orders dated 4/6/11 at 3 p.m. revealed give 7.5mg/500mg per peg every 4 hrs for pain till 10/500 comes in. Review of the May 2011 Physician order [REDACTED]. Review of the Physician ' s Telephone Orders revealed 5/24/11 at 8:50 a.m. - Clarification [MEDICATION NAME] order on 4/6/11 at 3 p.m. Give [MEDICATION NAME] 7.5mg - 500 mg till 10/500 mg [MEDICATION NAME] pills come in. Review of the prescription dated 4/7/11 revealed [MEDICATION NAME] 10 mg #120, refill 3 times. Review of the pharmacy deliver sheets dated 4/7/11 revealed that 120 [MEDICATION NAME] 10/500 mg were delivered to the facility on [DATE] for resident #2. It also revealed that S14LPN signed that she received the 120 [MEDICATION NAME]. Review of the pharmacy deliver sheets dated 4/20/11 revealed that 120 [MEDICATION NAME] 10/500 mg were delivered to the facility on [DATE] for resident #2. It also revealed that S7LPN signed that she received the 120 [MEDICATION NAME]. Review of the pharmacy deliver sheets dated 5/2/11 revealed that 7 [MEDICATION NAME] 10/500 mg were delivered to the facility on [DATE] for resident #2. It also revealed that S13LPN signed that she received the 7 [MEDICATION NAME]. Review of resident #2 ' s Individual Resident ' s Narcotic Sheets was not able to account for 205 [MEDICATION NAME] 10/500 mg delivered on the following dates: 4/7/11, 4/20/11, and 5/2/11. Review of resident #2 ' s Individual Resident ' s Narcotic Sheets revealed the date of 4/13/11 at 12 a.m. there were 32 [MEDICATION NAME] 10/500 mg on hand. It also revealed the last [MEDICATION NAME] of the 32 [MEDICATION NAME] was administered on 4/18/11 at 8 p.m. which left the remaining count of 0 [MEDICATION NAME]. Review of resident #2 ' s Individual Resident ' s Narcotic Sheets revealed the date of 4/29/11 at 4 a.m. there were 10 [MEDICATION NAME] 10 mg on hand. It also revealed the last [MEDICATION NAME] of the 10 [MEDICATION NAME] was administered on 5/1/11 at 12 a.m. which left the remaining count of 0 [MEDICATION NAME]. An interview was held with H ...C ..., pharmacist, on 5/25/11 at 12:45 p.m. He said that he had to dispense 7 more [MEDICATION NAME] on 5/2/11 because they could not find the 120 pills that were dispensed on 4/20/11. An interview was held with S2DON and S15QANurse on 5/25/11 at 12:55 p.m. regarding accounting for the 120 [MEDICATION NAME] dispensed on 4/20/11. They said they were not aware that the 120 [MEDICATION NAME] dispensed on 4/20/11 were missing. S15QANurse said that 120 [MEDICATION NAME] 10/500 mg were delivered to the facility on [DATE]. S15QANurse said that 60 of the [MEDICATION NAME] were sent to the unit and the other 60 [MEDICATION NAME] were locked in the file cabinet in the director of nurses ' (DON) office. She said the 60 [MEDICATION NAME] locked in the DON office were not counted each shift. She said they were counted before being locked in the file cabinet in his office. S2DON said that in February 2011 he turned in a nurse for stealing liquid [MEDICATION NAME] and forging another nurse ' s name. An interview was held with S2DON on 5/25/11 at 1:15 p.m. After reviewing the CDS Narcotic Log book, S2DON said the missing 205 [MEDICATION NAME] 10/500 mg were not destroyed. He said the policy is for the [MEDICATION NAME] to be returned to him when they were d/c ' d. An interview was held with S2DON on 5/25/11 at 1:45 p.m. He verified that he could only account for 42 [MEDICATION NAME] 10/500 mg out of the 247 pills dispensed since 4/7/11. An interview was held with S2DON on 5/25/l1 at 2:04 p.m. He explained when narcotics come in they are signed in by nurse and placed on cart. He said the nurses are supposed to do shift counts. He said if they are off by one pill the nurse is to call him immediately, and no one goes home. He also explained that the nurse that receives the narcotics is to initiate individual resident narcotic sheet. An observation was made of the following medications that were located in the DON ' s file cabinet in his office along with S2DON on 5/25/11 at 2:15 p.m.: R26 - 2 boxes of 25 mcg [MEDICATION NAME]es (total of 10 patches) R27 - 1 box of 25 mcg [MEDICATION NAME]es (total of 5 patches); 473 cc of [MEDICATION NAME] 7.5 [MEDICATION NAME] R21 - 2 vials of [MEDICATION NAME] 2 mg/ ml; [MEDICATION NAME] 1 mg 4 injections R18 - [MEDICATION NAME] 1 mg 168 pills R28 - [MEDICATION NAME] 1mg 60 pills R29 - 463 cc of [MEDICATION NAME] R30 - 473 cc of [MEDICATION NAME] R31 - 473 cc [MEDICATION NAME] 7.5 [MEDICATION NAME] S2DON explained that these were maintained in his office so they did not have to be kept on the unit. He said the unit kept one order and he kept the refills. An interview was held with S15QAnurse on 5/26/11 at 10:30 a.m. She said that she did contact the pharmacy and tell them that they needed more [MEDICATION NAME] for resident #2. She said she did not remember telling them that she couldn ' t find the [MEDICATION NAME]. She said that she called on 4/20/11 and 5/2/11 and told them the same thing. She said that S2DON was out of town on 5/2/11. She said she looked in S2DON ' s office, but there were no [MEDICATION NAME] either time. She said that S2DON was the only person with a key to the file cabinet with the narcotics, but since he was out of town he had left her the key. An interview was held with H ...C ..., pharmacist, on 5/26/11 at 1:45 p.m. He said that S15QANurse was the nurse that called both times to report that they could not find the resident #2 ' s [MEDICATION NAME]. He said that he did not do an investigation on the [MEDICATION NAME] that the facility could not find. He said that he just told them that he could not send more because the time was not up. He said that he had not noticed that facility having a problem with a shortage of [MEDICATION NAME] except for resident #2. He said that he was not aware that the DON was storing narcotics in his office. An interview was held with S15QA nurse, on 5/26/11 on 2:15 p.m. She said that on 5/2/11 S16LPN reported to her that he only had either 4 or 9 [MEDICATION NAME] left for resident #2 for the weekend, and they were going to run out before the weekend was over. S15QANurse explained that she was on call that weekend because the DON was out of town so she had the key to his office and file cabinet. She said that she remembered that S7LPN had brought resident #2 ' s 60 of the 120 [MEDICATION NAME] of pills to be locked in the DON ' s office on 4/20/11 when they were delivered. S15QANurse said that she looked in the file cabinet on 5/2/11 but the second card of [MEDICATION NAME] with 60 pills was not in the file cabinet so she assumed that they had already been put on the cart. She said at this time she and S16LPN searched the medicine cart but there were no more [MEDICATION NAME] in it for resident #2. She said that she called the pharmacy, but she did not remember who she talked to. She told them that they were out of [MEDICATION NAME] for resident #2, and S2DON was out of town. She asked them to send 7 pills until S2DON was back. She said they asked to make sure that S2DON did not have the second card of 60 [MEDICATION NAME]. She said that pharmacy knew that S2DON was storing some narcotics in his office because the pharmacy was sending the prescription along with all the refills written on the prescription. She said that S2DON called the pharmacy to let them know that it was too much liquid to be stored on the carts. S15QANurse said on 4/20/11 she could not remember which nurse reported to her that [MEDICATION NAME] was needed for resident #2. She said the nurse told her they were getting low on [MEDICATION NAME] for resident #2. She said that she called the Pharmacy and talked with a pharmacist. She said that she told him that they were out of [MEDICATION NAME] 10s for resident #2. She said that he said that he would have to see if he was eligible for a refill and if he was not eligible he would call her back. She said that she reported both occurrences to the DON about running out of [MEDICATION NAME] for resident #2. She said she told him on 4/20 and 5/3. An interview was held with the S2DON on 5/26/11 at 2:55 p.m. He said that he was not told on 4/20/11 that resident #2 was out of [MEDICATION NAME]. He said that he did not give approval for medicine to be ordered on [DATE]. He said that no nurse contacted him to let him know that they were running out of [MEDICATION NAME] for resident #2. He said he was gone 5/2/11 and was not informed that the [MEDICATION NAME] had to be filled again for resident #2. During the meeting S1Administrator said that he was aware that narcotics were being stored in the DON office. S2DON said the pharmacist was not aware. S2DON explained that when medications are brought to his office to be stored the nurse makes an inventory sheet reflecting the medication name, resident name, and how much medication is present. S1Administrator said that he has a key to the DON ' s office, but not to the file cabinet with the narcotics. S2DON said that S15QANurse has a key to his office also. S2DON said that no one is allowed to have a key to the file cabinet with the narcotics. He said that he does not leave a key with anyone when he goes out of town. An interview was held with S14LPN on 5/27/11 at 7:59 a.m. She said that the count had been incorrect with the liquid [MEDICATION NAME] when she came on before. She could not remember when this occurred, the resident ' s name, or how many cc ' s were missing. She explained that she and the other nurse signed on the count sheet the corrected count. She said that she did not know what happened to the missing liquid [MEDICATION NAME]. She said that she called S2DON, and he looked into it. An interview was held with S18PharmacyConsultant on 5/27/11 at 8:33 a.m. He verified that he was the pharmacy consultant for the facility. He said he had been the consultant for the past 2 or 3 years. He said that he completed monthly drug regimen reviews. He said that he had not noticed a problem with a shortage of [MEDICATION NAME] at this facility. He explained that each month he checks a hall and reconciles the narcotics. He said that he checks the math on the sheets to see if the dose administered is the correct amount. He explained that if he would have noticed a problem that the [MEDICATION NAME] counts were not correct, he would check out the problem and if it was a systemic problem then he would report it to the DON. He explained that there is a weak link in the system. He said the nurse can order the medicine, steal the count sheet and [MEDICATION NAME], and it is impossible to detect. He said that he was not sure if the pharmacy or the facility initiated the individual narcotic count sheet. He said he checks to make sure there is a count sheet with the cards of narcotics. He said that he has never received a call from this facility that they were having a problem with missing [MEDICATION NAME]. He said if they suspect that someone is stealing [MEDICATION NAME], there are ways to set traps and catch them. An interview was held with S2DON on 5/27/11 at 10:57 a.m. He said that he was not aware on 5/14/11 of R10 ' s [MEDICATION NAME] count was corrected from 308 ml to 205 ml with no explanation. He said no investigation was done because he was not aware. He said that S14LPN had never called him to tell him that the count was off on " a " hall for [MEDICATION NAME]. He said there was no policy about keeping narcotics in his office. He said the new medication carts would not hold all of the narcotics. He said that he has got new drawers on the cart so what ' s in the office will be given out when needed. He said that he was the only key holder for the file cabinet which contains the narcotics. S2DON explained that the supervision in place to make ensure narcotics are accounted for consisted of the following: the nurse signs the delivery sheet and DON keeps a copy for 30 days, and the nurse completes the count sheet and placed it on the medication cart. S2DON said the only time he is involved is if narcotics didn ' t come in or was about to run out. He explained that each day he reviewed the delivery sheets to see what comes in and ask the nurse if she has all her meds to see if he has to call the pharmacy. He said beginning now every Monday the pharmacy will fax the DON all schedule IIs, IIIs, IV, and V drugs delivered for the previous week and the DON will personally go to each medication cart and validate that the scheduled medications are accounted for. He explained the supervision that was in place to make sure narcotics were given as ordered consisted of the DON and QA nurse auditing MARS every month. He explained if it was a PRN medication they were checking to make sure it was documented on the back of the MAR. He said in the future he will take the narcotic sheet as well and reconcile the count. He said that he also randomly looks at the shift to shift nurses ' signatures accounting for accuracy of narcotics on a weekly basis. He was not aware of missing narcotics. He also verified there was no system in place to ensure that individual narcotic records were completed when narcotics were received from pharmacy. He said that he had not been auditing these sheets because the nurses were signing that counts were correct. An interview was held with S15QANurse on 5/27/11 at 12:30 p.m. She said that she could not locate resident #2 ' s individual resident ' s narcotic sheets for 2/10/11 and 2/15/11 when 473 cc of [MEDICATION NAME] 7.5mg/15 milliliters were delivered to the facility. She verified that she could not account for the 946 cc of [MEDICATION NAME] 7.5mg/15 milliliters. Resident R10 Review of the Dispensary Monthly Audit Log revealed R10 received liquid [MEDICATION NAME]. The facility received 473 ml on 3/15/11 and 473 ml on 3/28/11. Review of the Individual Resident ' s Narcotic Sheet revealed 10 ml off on the count on 3/14/11. The count should have been 128 ml not 138ml. S8MDSNurse verified the discrepancy. This bottle was received in February. S8MDSNurse said 13 ml were usually wasted each month. During the month of March 3 ml were recorded as wasted at the end of the month. There was a 10 ml discrepancy on bottle received 3/15/11 on the date of 3/18/11. The count was 388ml. It should have been 398ml. S8MDSNurse verified difference. A bottle received on 3/28/11 was started on 3/31. On 4/3 at 8 a.m. the count was 368 ml. 15 ml were given at 8 pm on 4/3/11. The count was recorded as 313 ml, which was a 40 ml discrepancy. S8MDSNurse verified S19LPN gave all doses that had a discrepancy. A bottle was started on 4/16/11. On 5/3 the count was 188ml. On 5/3 at 12 pm, 15 ml were given and the count was listed at 103 ml which was an 85 ml discrepancy. These discrepancies were verified by S8MDSNurse. She stated this resident was on " d " hall. She also said S19LPN (nurse gave all doses) quit on 5/21/11. An observation was made of R10 ' s individual narcotic count sheet along with S8MDSNurse on 5/26/11 at 4:30 p.m. It revealed 5/14/11 1 a.m. amount remaining of 308ml of [MEDICATION NAME]. The next entry revealed correct count on 5/14/11 of 250 ml. On 5/17/11 at 12 pm the count equaled 190 ml. Then S20LPN administered 15 ml on 5/17/11 at 6 p.m. and the count equaled 165 ml. S8MDSNurse verified 25 ml was subtracted from the count instead of 15 ml that was ordered. Resident R15 An observation was made of R15 ' s individual narcotic count sheet along with S8MDSNurse on 5/26/11 at 4:30 p.m. On 3/9/11 at 12 pm the count of [MEDICATION NAME] equaled 443 ml. Then S20LPN administered 15 ml on 3/9/11 at 4 p.m. and the count equaled 368 ml. S8MDSNurse verified 75 ml was subtracted from the count instead of 15 ml that was ordered. An observation was made of R15 ' s individual narcotic record with date of 3/19/11 at 4 p.m. It revealed that 8ml were administered and the balance was 0. The next nurse signed that she administered 8 ml from the 0 balance. S15QANurse verified this finding on 5/27/11 at 8:20 a.m. Resident R19 An interview was held with S15QANurse on 5/27/11 at 12:30 p.m. Review of the Dispensary Monthly Audit Log revealed that 37 [MEDICATION NAME] were delivered to the facility on [DATE] for R19. S15QANurse verified that she could not account for the 37 pills of [MEDICATION NAME] 7.5 delivered on 3/3/11 because she could not locate the individual narcotic count sheet.