Every finding on record at Carlyle Senior Care of Fork

Based on observation and interview, the facility failed to ensure staff served resident meals in a clean and safe manner and utilized proper hand hygiene during meal service in one (1) of two (2) dining rooms and for one (1) of one (1)1 resident observed during tray set up. (Resident (R)15) Findings include: During midday meal service on 4/15/25 from 12:10 p.m. to 12:55 p.m., Certified Nursing Assistant (CNA) HH was observed assisting multiple unidentified residents throughout the dining room with tray set up, getting additional drinks, getting and opening a resident's sandwich, clearing tables and removing trays. Additionally, CNA HH touched multiple residents on the arm, shoulder or back to prompt or encourage them to finish the meal. During the observation, CNA HH failed to use any hand hygiene between residents or after clearing the tables. Observation on 4/15/25 revealed the dietary staff delivered the cart with the room trays at approximately 12:50 p.m. to the nursing unit. CNA HH opened the cart and removed the tray for Resident #15. When this surveyor arrived at the door of R15's room, CNA HH was observed using his/her bare hands to tear the pork chop served into smaller pieces. In an interview on 4/15/25 at 3:50 p.m., the Director of Nursing (DON) verified that CNA HH was not available due to leaving early. The DON confirmed that staff knew hand hygiene should be done between residents and while serving in the dining room. The DON also confirmed staff was trained to use utensils and not hands to cut up a resident's food. In an interview on 4/16/25 at 2:00 p.m., CNA HH acknowledged using his/her bare hands to hand the pork chop. She/he stated that she/he knew better, as it was not the proper way to handle a resident's food. She/he also acknowledged that that hand hygiene should be used between residents when serving meals.

Based on observation, interview and review of facility policy, the facility failed to ensure foods that are stored in the walk-in refrigerator and freezer, and unit refrigerators were labeled and discarded after manufacturer's expiration date. These deficiencies had the potential to affect all the residents who reside in the facility. Findings include: Review of the facility policy titled, Dietary-Food Safety Requirements-Policy with an approval date of 05/21/19 revealed under policy explanation and compliance guidelines, (1) b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms; (3)c iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by it use-by date, or frozen (where applicable) discarded. Review of the facility policy titled, Use and storage of food brought in by family and visitors policy with an approval date of 11/23/16 revealed under policy explanation and compliance guidelines, (2) a. The facility may refrigerate label and date prepared items in the nourishment refrigerator. 2 (b) The prepared food must be consumed by the resident within 3 days. 2 (c) If not consumed within 3 days, food will be thrown away by facility staff. During a kitchen observation, of the [NAME] refrigerator and freezer, on 08/20/23 at 10:18 AM revealed the following: 4 plastic containers of strawberries, which appeared to be covered in a mold like substance. 6 cantaloupes the were soft to the touch and appeared to be rotten. 1 crate of cabbages which was not dated. 3 individual salads in white styrofoam containers, which were not labeled and dated. 2 apples which appeared to be rotten. 1 pint of ice cream with an expiration date of 01/20/23. During an interview on 08/20/23 at approximately 10:18 AM, the Kitchen Supervisor stated the items should have a label with date. The Kitchen Supervisor proceeded to remove and discard the items. During an observation of the Unit Nourishment Refrigerator on 08/23/23 at 10:33 AM, revealed the following: 1 12-pack box of [NAME] Beer Non-alcoholic opened containing one beer which was not labeled or dated. 2 individual packed lunches, which was not labeled or dated. During an interview on 08/23/23 at approximately 10:40 AM, Licensed Practical Nurse (LPN)1 confirmed that one of the lunches was hers. LPN1 was unaware of which resident the [NAME] Beer belonged to. LPN1 acknowledged that items in unit refrigerator should be labeled and dated. During an interview on 08/23/23 at 11:56 AM, the Administrator revealed his expectations for the process for storing foods in the kitchen and unit refrigerators are to ensure meats, and other items are properly stored, items are up-to-date and discarded in a timely manner.

Based on review of facility policy, observations, record reviews and interviews, the facility failed to ensure the dignity was maintained for 3 of 16 residents. Specifically, Resident (R)3, (R33) and R84 were observed in bed and wearing hospital gowns for multiple days. Findings include: Review of the undated facility policy titled, Dignity - Promoting ad Maintaining, states under Policy, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, the maintains or enhances resident's quality of life by recognizing each resident's individuality. Under the section titled Compliance Guidelines states, 1. All staff members are involved in providing care to resident's to promote and maintain resident dignity and respect resident rights. 4. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. 9. Groom and dress residents according to resident preference. Review of R3's Face Sheet revealed R3 was admitted to the facility with diagnoses including, but not limited to, aphasia, vascular dementia, pressure ulcers, and muscle wasting. During observations on 08/20/23, 08/21/23, 08/22/23 and 08/23/23 revealed R3 in bed and dressed daily in a hospital gown. No documentation could be found in the medical record for R3 to ensure she or her personal representative had made a request as their choice for her to wear hospital gowns daily. Review of R33's Face Sheet revealed R33 was admitted to the facility with diagnoses including, but not limited to, age related physical debility, abnormal posture, lack of coordination, muscle weakness, functional quadriplegia, cerebrovascular accident, spastic hemiplegia affecting right dominant side, and cognitive communication deficit. During observations on 08/20/23, 08/21/23 revealed R33 in bed wearing a hospital gown. During an interview on 08/22/23 at 2:00 PM, the Unit Manager Licensed Practical Nurse (LPN)3 stated that some of the residents choose to wear hospital gowns daily and if they do it is on the resident's plan of care. During an interview on 08/22/23 at approximately 2:03 PM, the Social Services Director (SSD) agreed with LPN3 and confirmed that some residents choose to wear hospital gowns daily and if that is their preference then it is on the care plan. Review of R33's Care Plan on 08/22/23 at 1:20 PM, did not include a care plan or interventions regarding R33 wearing a hospital gown daily. No documentation could be found in R33's medical record that R33 had as a preference to wear a hospital gown daily. Review of R84's Face Sheet revealed R84 was admitted to the facility with diagnoses including, but not limited to, dementia, physical debility, malaise, protein calorie malnutrition, muscle wasting and atrophy, lack of coordination and unsteadiness on feet. During observations on 08/20/23, 08/21/23, 08/22/23, R84 was in bed wearing a hospital gown. Review of R84's Care Plan revealed no documentation that R84 preferred to wear a hospital gown daily. During an interview on 08/23/23 at 10:50 AM, the Minimum Data Set Care Plan Coordinator provided a copy of the care plan for R84, and stated she has added the documentation to include R84 wearing a hospital gown daily.

Based on observations, interviews, and facility policy review, the facility failed to ensure 2 rooms (room [ROOM NUMBER], room [ROOM NUMBER]) on 2 of 4 units were in good repair. Findings include: A review of an undated facility policy titled, Maintenance Request Form revealed, Policy Statement: The Maintenance Director and maintenance staff shall respond to all maintenance requests in a prompt and efficient manner and keep a record of all work performed. The policy included, Policy Interpretation and Implementation: 1. Employees may initiate a maintenance request by completing a Maintenance Request form (i.e., noting the person requesting the order, the date of the request, the location of the needed repair, and a brief description of the work needed) and place maintenance requests in the appropriate location. 2. The Maintenance Director should review all work requests received, prioritize the requests if needed, and schedule the tasks to be performed. Whenever possible, the maintenance requests will be completed within 24 hours from the date of the request. 1. On 08/20/23 at 11:46 AM, an observation of room [ROOM NUMBER]'s wall to the left of the window revealed the wall had tears, scratches, and lines scribbled on the wall covering an area measuring approximately 3 feet (ft.) by 2 ft. Additional observations on 08/20/23 at 3:02 PM and 08/21/23 at 1:38 PM revealed the wall's condition had not changed. An interview on 08/22/23 at 10:01 AM, Certified Nurse Assistant (CNA)1 said the wall in room [ROOM NUMBER] had been in that condition for approximately two months. CNA1 said they had not reported it to anyone and was unaware if anyone else had reported it. CNA1 said the procedure for letting maintenance know if something in a resident's room needed to be repaired was to fill out a report and put it in a slot kept at the nurses' station or to tell maintenance staff. An interview on 08/22/23 at 10:23 AM, the Maintenance Director said they had been aware of the condition of the wall in room [ROOM NUMBER] for about two weeks, which was scheduled to be repaired after completing needed repairs on the 300 Hall. An interview on 08/22/23 at 2:50 PM, the Maintenance Director said they did not have a work order for room [ROOM NUMBER] because it was verbally reported by Licensed Practical Nurse (LPN) 4. 2. On 08/22/23 at 8:52 AM, an observation of room [ROOM NUMBER] of the windowsill and the wall beneath the windowsill revealed both the windowsill and an area of the wall measuring approximately 3 inches (in) by 12 in had peeling paint. Additional observations on 08/22/23 at 9:53 AM revealed the windowsill and the wall's conditions had not changed. An interview on 08/22/23 at 10:07 AM, Certified Nurse Assistant (CNA)2 said they had not noticed the condition of the windowsill in room [ROOM NUMBER] because they usually kept the curtain pulled over it and they usually floated and was only assigned to this room occasionally. CNA2 also said usually if they saw something that needed repair, they would let maintenance know. An interview on 08/22/23 at 10:16 AM, LPN2 said they had not noticed the condition of the windowsill but would fill out a maintenance form to request repair. An interview on 08/22/23 at 10:18 AM, the Maintenance Director said they were not aware of the condition of the windowsill in room [ROOM NUMBER]. The Maintenance Director said that it needed to be painted and that he was normally made aware of these types of maintenance issues by staff completing a maintenance work order and placing it in the slot at the nurses' station that they checked daily every morning, at noon, and at 3:00 PM. An interview on 08/22/23 at 3:10 PM, the Director of Nursing (DON) said that if their staff saw something in a resident's room that needed to be fixed or repaired, they needed to fill out a maintenance work order form and put it in the maintenance box. The DON also said that maintenance staff checked the boxes daily and she expected them to fix the problem as soon as possible. The DON also said that recently maintenance staff had been dealing with a plumbing problem that had taken precedence over some of the other maintenance issues. An interview on 08/22/23 at 3:37 PM, Registered Nurse (RN)2, acting as the Administrator in the Administrator's absence, said that if staff saw an issue that needed to be fixed or repaired in a resident's room, they should complete a repair slip and put it in the maintenance slot. RN2 also said that maintenance staff checked the slots every day and maintenance staff came to the morning meetings as well. Depending on the extent of the repair, maintenance staff prioritized maintenance issues, and they should be addressed as soon as possible.

Based on review of facility policy, record review, and interviews the facility failed to accurately assess Resident (R)45 after a fall for 1 out of 3 residents reviewed for falls. Findings include: Review of facility policy titled, MDS-conducting an accurate resident assessment with an approval date of 09/25/19 revealed, the purpose of this policy is to assure that all resident's receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Review of the section titled policy explanation and compliance guidelines revealed, Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths and areas of decline. The assessment will be documented in the medical record. Review of R45's Face Sheet revealed R45 was admitted to the facility on [DATE] and diagnoses including but not limited to, dementia, major depressive disorder, dysphagia, acid reflux, alcohol dependence, and mood disorder. Review of R45's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating R45 had severe cognitive impairment. Further review of the MDS revealed the assessment was not revised/updated to reflect a fall with injury on 05/10/23. Review of R45's Care Plan with a start date of 09/29/21 revealed care plan goal for falls and potential for falls related to contracture of lower extremities, history of previous fall, history of closed head injury, and history of dementia. Review of R45's Progress Note dated 05/10/23 at 9:30 PM, revealed [R45] fell out of bed onto floor reaching for a bag of Cheeze-it chips. [R45] landed face down hitting his forehead causing an app. 1 inch cut center his forehead. No other injury noted. Family member notified and 911 called at 9:40 PM for transport. EMS arrived at 9:55 PM and [R45] was placed on stretcher and taken to [local hospital]. On 05/11/23 [R45] returned to the facility with stitches to forehead and no discharge paper work. Paperwork to be faxed over by hospital. An interview with the MDS Coordinator on 08/22/23 at 2:47 PM revealed when a resident has had a fall with injury, the MDS Coordinator will update the plan and assessment and if it is within the look back period or within the 3 months review it would be listed on the assessment. Upon review of R45's MDS, the MDS Coordinator acknowledged the fall with injury which occurred on 05/10/23 was not updated on the 07/16/23 Quarterly MDS assessment.

Based on review of the facility policy, observations, record reviews and interviews the facility failed to ensure the Comprehensive Care Plan was reviewed and revised to reflect Resident (R)84's preference to wear hospital gowns daily, and change back and forth to hospital gowns and street clothes as she prefers for 1 of 3 residents reviewed for Dignity. Findings include: Review of the undated facility policy titled, Care Plan Revision Upon Status Change, states, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those resident's experiencing a status change. The, Policy Explanation and Compliance Guidelines: states, 1. The comprehensive care plan will be reviewed and revised as necessary . The procedure for reviewing and revising the care plan, states, h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plan have been updated to reflect current residing needs. Review of R84's Face Sheet revealed R84 was admitted to the facility with diagnoses including, but not limited to, dementia, physical debility, malaise, protein calorie malnutrition, muscle wasting and atrophy, lack of coordination and unsteadiness on feet. During observations on 08/20/23, 08/21/23, and 08/22/23, R84 was in bed wearing a hospital gown. Review of R84's Care Plan revealed no documentation that R84 prefers to wear a hospital gown daily. Review of R84's medical records revealed no documentation to address the resident's choice to wear a hospital gown daily, or that it is her preference to change from a gown to street clothes or from street clothes to a gown multiple times during the day. During an interview on 08/22/23 at 2:00 PM, the Unit Manager Licensed Practical Nurse (LPN)3 stated that some of the residents choose to wear hospital gowns daily and if they do it is on the resident's plan of care. During an interview on 08/22/23 at approximately 2:03 PM, the Social Services Director confirmed that some residents choose to wear hospital gowns daily and if that is their preference then it is on the care plan.

Based on observation, record reviews, interviews, and review of facility policy, the pharmacy failed to dispense a medication for Resident (R)96 in a timely manner pursuant to the facility having faxed the required lab results to dispense, for 1 of 25 medication pass observations. Findings include: Review of the facility policy titled Emergency Pharmacy Service with a revised date of 7/15/2019 states, It is the policy of [Pharmacy] that emergency pharmacy service is available on a 24-hour basis . Emergency needs for medication are met . by special order from the provider pharmacy . Review of R96's Face Sheet revealed R96 was admitted to the facility on [DATE] with diagnoses including, but not limited to schizophrenia. During Medication Administration observation on 08/21/23 at approximately 9:09 AM, Licensed Practical Nurse (LPN)1, after administering medications to R96, stated that all medication had been administered to R96. Review of the medication pass reconciliation dated August 2023, revealed a physicians order dated 12/12/22 for Clozapine 100 mg (milligram) 1-1/2 tablets (150 mg) BID by mouth twice daily at 9:00 AM and 9:00 PM. Review of the August 2023 Medication Administration Record (MAR) revealed that the medication had been charted as not given by LPN1. An interview on 08/22/23 at approximately 10:29 AM, LPN1 stated that she had not administered the medication because it was not available and that in order for the pharmacy to dispense Clozapine, there must be proof of lab results and that these had been faxed to the pharmacy, but the drug did not arrive in time. LPN1 provided a copy of the lab results (CBC with differential) which had been faxed to [local pharmacy] on 08/15/23 at 10:39 AM. LPN1 further stated the Consultant Pharmacist, had called [local pharmacy] and determined that there was a new pharmacist who failed to dispense the medication. LPN1 stated the Clozapine arrived on 08/21/23 at approximately 2:30 PM and she administered according to the physician's new order. During a telephone interview on 08/22/23 at approximately 11:25 AM, the Consultant Pharmacist confirmed the Clozapine was part of the Risk Evaluation and Mitigation Strategies (REMS) program and that a new pharmacist had not dispensed it in time for the 08/21/23 9:00 AM dose to be administered.

Based on record review and interview, the facility failed to assure each resident is afforded the required 80 square feet per resident for their living space, for 12 of 12 resident rooms with an occupancy of 2 to 3 residents each. Findings include: Based on record review the facility provided a list of rooms that did not meet the required 80 square feet per resident. The following rooms did not meet the requirement: room [ROOM NUMBER] measures 11' 9 x 19' 6 = 233 square feet and houses 3 residents for 78 square feet per resident. room [ROOM NUMBER] measures 13' 11 x 10' 11 = 133 square feet and houses 2 residents for 67 square feet per resident. room [ROOM NUMBER] measures 13' 10 x 10' 10 = 131 square feet and houses 2 residents for 66 square feet per resident. room [ROOM NUMBER] measures 13' 11 x 11' 0 = 144 square feet and houses 2 residents for 72 square feet per resident. room [ROOM NUMBER] measures 11' 0 x 14' 0 = 154 square feet and houses 2 residents for 77 square feet per resident. room [ROOM NUMBER] measures 13' 11 x 11' 0 = 144 square feet and houses 2 residents for 72 square feet per resident. room [ROOM NUMBER] measures 10' 11 x 13' 10 = 132 square feet and houses 2 residents for 66 square feet per resident. room [ROOM NUMBER] measures 14' 0 x 10' 11 = 142 square feet and houses 2 residents for 71 square feet per resident. room [ROOM NUMBER] measures 13' 10 x 10' 11 = 132 square feet and houses 2 residents for 66 square feet per resident. room [ROOM NUMBER] measures 13' 11 x 10' 11 = 131 square feet and houses 2 residents for 66 square feet per resident. room [ROOM NUMBER] measures 13' 11 x 10' 11 = 131 square feet and houses 2 residents for 66 square feet per resident. room [ROOM NUMBER] measures 13' 11 x 11' 0 = 144 square feet and houses 2 residents for 66 square feet per resident. During an interview with the Administrator he provided a Room Waiver Request which states: Please accept this request to incorporate the dimensions of these rooms for compliance. They have been in place for many years as this building has been in operation since the 1950's.

.Based on record review, interview, and review of policy titled, updated 09/04/19, Abuse, Neglect, and Exploitation Policy the facility failed to ensure 1 of 3 (Resident (R)1) residents were free from abuse. This failure has the potential to have a negative effect on the resident ' s psychosocial and physical functioning. Findings Include: Based on review of R1s Quarterly Minimum Data Set (MDS), dated [DATE], R1 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was admitted with a Brief Interview for Mental Status (BIMS) score of 15, noting intact cognition. In R1 ' s MDS, in Section E- Behavior, physical behavioral symptoms directed toward others . occurring one to three days and verbal behavioral symptoms directed toward others .occurred one to three days. A review of R1 ' s electronic medical chart (EMC) in the notes section a progress note on 11/09/21, written by Licensed Practical Nurse (LPN) 1 at 8:33 PM, read R1 has been noted to having episodes of screaming throughout the shift and using inappropriate language to staff this shift . I asked CNA to go see why the resident was screaming .Resident asked for soda. CNA went to vending machine and got resident a cold can of Coke, placed straw in it and left the room. CNA came to commons area . resident started to scream her name again, CNA and myself walked back down to room, resident noted to being agitated and cursing when staff entered room. While assisting CNA with care, resident became combative and swinging above her left eye in the eye brow area. Bleeding noted to area. Resident does take a blood thinner as ordered by MD. Residents glassed noted on the floor and bent. Resident has blood under her nails on her right hand where she scratched her left eyebrow area. CNA called out for assistance, I immediately exited the room and came down the hall to notify another nurse. CNA x2 provided first aid to resident ' s eye area. Bleeding controlled . A review of R1 ' s EMC in the Notes section a progress note on 11/09/21, written by LPN 1 at 10:54 PM, read on-call Nurse Practitioner called to notify of skin tear on left eyebrow area. LPN 1 added first aide was administers to resident and bleeding is under control. A review of R1 ' s EMC in the notes section a progress note on 11/09/21, written by LPN1 at 11:31 PM, read R1 is being sent to [NAME] emergency room for suspected [CONDITION(S)]. A review of EMC in the Care Plan section revealed a Care Plan, dated 12/15/20, noting a potential for behavior problems related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Approaches for this behavior includes, but not limited to, redirect resident if the R1 is aggressive or combative; assist resident to maintain control of her feelings; provide a stable and supportive environment .; remove from situations that increase agitation or combativeness and approach in a calm non-threatening manner. A Progress Note from Elite Patient Care- South Carolina, dated 11/11/21 and signed 11/12/21, under Chief Complaint/Reason for this Visit, a laceration is noted. Under the section History Present Illness (HPI) Relating to this Visit revealed R1 was seen for a laceration .R1 ' s laceration noted above left eyebrow. Staff reported R1 had increased agitation on night shift. R1 reported there was a physical altercation with a nurse and subsequently sent to the Emergency Department (ED). R1 was diagnosed with a [CONDITION(S)] Proper authorities were notified and procedures in place. An interview with Certified Nurse Assistant (CNA) 1 at 11:50 AM on 12/06/21 revealed LPN 1 told CNA 1 she hit R1. LPN 1 added, she (R1) hit me, I hit her back. CNA 1 saw R1 with blood running down her face, from above her eyebrow to her chin. R1 was visibly upset. CNA 1 proceeded to notify the Director of Nursing (DON). CNA 1 confirmed she had abuse prevention training. An interview with CNA 2 at 11:55 AM on 12/06/21 revealed, after hearing a commotion in R1 ' s room, CNA 2 and CNA 1 approached R1 ' s room. LPN 1 was leaving the room, as LPN 1 left the room she said she (R1) hit me, I hit her back. CNA 2 assisted CNA 1 in helping clean up the R1. CNA 1 added R1 was upset, shaking, and crying. CNA 2 confirmed she did have abuse prevention training. An interview with the DON and Administrator at 11:45 PM on 12/06/21 revealed, during a conversation with R1, R1 confirmed LPN 1 hit her. Both the Administrator and the DON spoke with CNA 1 and CNA 2 as well as LPN 1. Ultimately, LPN 1 was terminated after their investigation. An interview at 12:45 on 12/06/21 with LPN 2 and LPN 3 revealed they did not witness any behaviors from R1 for awhile. An interview with R1 on 12/06/21 at 11:30 PM, R1 stated LPN 1 hit her with a closed fist leading to a scratch above her eye and bending her glasses. A review of a document, updated 09/04/19, titled Abuse, Neglect and Exploitation-Policy revealed in the Policy section It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. In the Definitions section read ' Physical Abuse ' includes, but is not limited to hitting, slapping, punching In the section titled Employee Training revealed, A. New employees will be educated on abuse In the section Prevention of Abuse, Neglect, and Exploitation read The facility will implement policies and procedures to prevent and prohibit all types of abuse .B. Identifying, correcting and intervening in situations in which abuse .is more likely to occur with the deployment of trained and qualified . staff . and assure that the staff assigned have knowledge of the individual residents ' care needs and behavioral symptoms. Several attempts were made via telephone to contact LPN 1 with no success.

Based on record review and staff interviews, the facility failed to coordinate an assessment for Resident #20 for the level II PASARR after a change in [DIAGNOSES REDACTED]. The findings included: Per record review on 11/12/19, the resident was seen by LifeSource on 10/23/19, due to a referral by staff for behavior outbursts. Seen by psychotherapy via telemedicine. The psychotherapy consult listed the [DIAGNOSES REDACTED]. Care plan in record to monitor for behaviors with guidance for redirection and medication monitoring. [MEDICAL CONDITION] was not included on admission list of diagnoses. Level 1 PASARR noted no further intervention needed on admission. A level II PASARR was not in the record for the change in behavior and the new [DIAGNOSES REDACTED]. On 11/12/19 at 11:20 AM, interview with the Director of Nursing revealed that the facility just started the telemedicine psychotherapy in 2019. She stated they decided which residents to sign up for the therapy and they (facility staff) chose Resident #20 for the psychotherapy program. She stated, the doctor did not complete a level 2 PASARR on any of the patients in therapy that were referred for therapy by the facility staff. When Social Services (SS) was asked on 11/13/19 at 10:20 AM if there was any PASARR level II referral completed for Resident #20, SS stated, not to her knowledge and that she does not know anything about it.

Based on record review and staff interviews, the facility failed to notify the state mental health authority after a significant change in mental condition for 1 of 2 residents reviewed for Preadmission Screening and Resident Review (PASARR) referrals (Resident #20). The findings included: Per record review on 11/12/19, the resident was seen by LifeSource on 10/23/19, due to a referral by staff for behavior outbursts. Seen by psychotherapy via telemedicine. The psychotherapy consult listed the [DIAGNOSES REDACTED]. A level II PASARR was not in the record for the change in behavior and the new [DIAGNOSES REDACTED]. In an interview on 11/12/19 at 11:20 interview with Director of Nursing (DON), she stated, the doctor did not complete a level 2 PASARR on the resident. When Social Services (SS) was asked on 11/13/19 at 10:20 AM if there was any PASARR level II referral completed for resident, SS stated, not to her knowledge and that she does not know anything about it. Social Services stated she was not informed that there was a need for a PASARR. On 11/15/19 at 11:45 AM, interview with DON revealed that resident's doctor who was treating her prior to being in the facility stated she has had [MEDICAL CONDITION] the whole time he has seen her. The DON stated, the [DIAGNOSES REDACTED].

Based on observation, record review, and staff interviews, the facility failed to provide hydration via the enteral tube as ordered for 1 of 1 resident reviewed for enteral feedings (Resident #95). The findings included: The facility admitted Resident #95 on 02/08/19 with [DIAGNOSES REDACTED]. Observation of Resident #95 on 11/12/19 at 09:54 AM revealed Novosource Renal infusing at 60 ml/hr (milliliters per hour) and Water flush infusing at 30 ml/hr. At 12:53 PM, review of the monthly cumulative orders revealed an order for [REDACTED].>Observation at 08:55 AM on 11/13/19 revealed the flush infusing at 30 ml/hr. At 08:55, review of the Medication Administration Record [REDACTED]. Review of the Nutrition assessment dated [DATE] revealed the flush at 35 ml/hr from 05:00 PM to 11:00 AM provided 630 ml. On 11/13/19 at 09:26 AM, observation of Resident #95 revealed the Outsource Renal infusing at 60 ml/hr and Water flush at 30 ml/hr. During an interview on 11/13/19 09:26 AM, Licensed Practical Nurse (LPN) #1 confirmed the water flush was infusing at 30 ml/hr. The LPN #1 further confirmed the order for the flush was 35 ml/hr.

Based on observation, interview, and record review, the facility failed to ensure the shower room was maintained in safe and sanitary condition. This deficient practice affected 21 of 24 residents residing on the 200 Hall who were showered in the room. Findings include: Observation on 08/14/18 at 12:10 PM of the Shower Room in Hall 200 revealed the following: The hallway tiles adjoining the threshold to the shower floor included three broken tiles with missing portions, exposing the underlying subfloor. The outside of the shower room door revealed there were three tiles located across the doorway opening. The first tile from the right had a missing piece of tile measuring 4 inches by 1 1/2 in size, the second tile had a missing piece of tile measuring 1 inch by 1 inch, and the third tile had a missing piece of tile measuring 5 inches by 3 inches in size. The floor of the shower room had two missing tiles where the two floor drains were located exposing the underlying grout over concrete subfloor. Three broken floor tiles were located on lower right shower room wall with four of five tiles broken where the right wall met the back wall. These breaks resulted in large gaps where black, soft matter was visible. Grout was missing from between floor tiles with standing water and black debris visible in the vacant spaces. The back wall was covered with sheets of pressed wood that had been painted. There were cracks in the wood running from the floor to near the top of the wood. A soft, black matter was visible in the cracks. Calk was missing from around the wood covering and moisture was evident in all cracks in the partially tiled and wooden surfaces. During an interview on 08/17/18 at 2:00 PM, Housekeeper 1, stated she was responsible for keeping the Shower Room in Hall 200 clean. She described this procedure as clearing any debris that might be in the shower area, mopping the floor, and disinfecting the walls, shower controls, spray heads and shower chairs with a substance used at the facility called Good Spray. She stated, she tried to disinfect the shower room but couldn't get into all the cracks in the tiles, gaps in the grout, and cracks/holes in the wood paneling. She stated there was black mold growing in the cracks and holes and she tried everything she and her supervisor could think of to stop the mold from growing but nothing really worked. She stated, she tried cleaning the cracks and holes with a long stick to scrape up the mold but it didn't work well. She stated, she tried her best, but she just couldn't get the broken surfaces clean. On 08/17/18 at 2:15 PM, Certified Nursing Assistant (CNA) 2 stated she preferred not to use the Shower Room in the 200 Hall because of the poor condition of the room. She stated the maintenance man had recently installed a metal threshold piece along the doorway floor to cover most of the broken tiles in the doorway but the missing tile which was still present in front of the new threshold still posed problems with moving residents who used wheelchairs into the shower room. The added threshold was supposed to make is safer to wheel residents into the shower room. She stated she used the shower room to give baths and to clean people up who needed some extra cleaning during the shift. She stated she preferred taking residents to the 300 Hall, but that wasn't always possible. On 08/17/18 at 2:30 PM, CNA3 stated the shower room was in poor repair and she hated to use it. She stated the surfaces were in such bad shape that they were uncleanable. On 08/16/18 at 9:25 AM, the Maintenance Supervisor stated he was unaware of how long the 200 Hallway Shower Room had been in that condition because he had only worked at the facility for two months. He confirmed the Shower Room has been in the same condition for the two months he had been on duty. He added he was aware the shower room had been identified for repair/remodeling by the facility administration. The Maintenance Supervisor confirmed the cracks in the tiles, the missing grout between tiles and the gaps in the walls created unsealed surfaces that could not be effectively sanitized. On 08/16/18 at 10:00 AM, the Administrator explained environmental rounds were conducted weekly by key personnel including the himself (Administrator), the Director of Nursing, and the Social Worker, among others. The purpose of these rounds, is to identify any issues in need of maintenance attention. He stated he had documented something on the 200 Shower Room and would provide that. On 08/16/18 at 11:00 AM, the Administrator provided a document labeled, 07/30/18 Hall 2 Group Rounds. The document included 15 items requiring maintenance attention. Among those items was listed, Shower - Fix broken tile in shower ASAP (as soon as possible)! Esp (especially) at drain. On 08/18/18 at 2:00 PM, during a follow up interview with the Administrator. He reported a belief that the facility does a really good job of identification of issues but stated, we need to do better at getting the system to assure the things identified get fixed. He added, We may need a better filing system or computer system which identifies when identified concerns actually are resolved. Review of the facility's policy titled, Resident Environmental Quality, effective 11/23/16, indicated, The facility should be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. The policy was not specific to shower rooms beyond that and instead focused on equipment bedrooms, water pest control, etc. Additional documentation provided by the Administrator described as the instructions to staff for the cleaning the bathroom, indicated, scrubbing ceramic tile, mopping and rinsing the entire shower room.

Based on observations and interview the facility failed to ensure each resident's bedroom had a window to the outside. Two of 56 facility rooms did not meet that requirement. No actual harm resulted from the limited square footage. Findings include: Observation during a resident interview on 08/13/18 at 4:23 PM, revealed the only window in room [ROOM NUMBER]'s looked into the therapy room. During an interview on 08/14/18 at 9:45 AM, the Administrator stated he was not aware that room [ROOM NUMBER] did not have a window to the outside. Additional observation on 08/14/18 at 10:58 AM, revealed the only window in room [ROOM NUMBER] looked into an office. In an interview on 08/14/18 at 2:15 PM, the Maintenance Supervisor stated he was not aware that there were two resident rooms that did not have a window to the outside.

Based on record review, observation, interview and review of facility policies titled Food Storage and Proper Use of Thermometers, the facility failed to follow proper food storage and food handling practices for 1 of 1 kitchen. During observation of the kitchen undated/unlabeled items and opened foods not sealed properly were observed. During the temping of the foods, staff could not accurately state how to calibrate a thermometer nor could correctly read the thermometer. The findings included: During the initial kitchen observation on 4/17/17 at 11:20 AM the following was observed: (1) partial pack of hamburger buns; (1) partial pack of rolls; (1) partial pack of hot dog buns; all items opened with no open date. Observation of the reach in freezer revealed (1) partial bag of peas and (1) partial bag of greens opened with no open date. Observation of the dry storage area revealed an opened bag of black eye peas not sealed completely. Observation of the box freezer revealed a thermometer with a reading of 30 degrees. The seal of the freezer was not tight. All items in the freezer were frozen solid. The above observations were confirmed by the Dietary Manager during the initial tour of the kitchen. Observation of the box freezer on 4/19/17 at 5:15 PM revealed the freezer thermometer again had a reading of 30 degrees. All items in the freezer were frozen solid. A second thermometer was placed and when observed within ten minutes the new thermometer read 10 degrees. Review of the temperature log for the freezer revealed the temperatures were taken every day in April 2017 with a reading of minus 10 degrees Fahrenheit. Prior to temping of the food items on 4/19/17 at 4:45 PM, the evening cook was asked what was the accepted temperature for calibration of the thermometer He/she stated the thermometer should be calibrated to 30 degrees and then changed his/her answer to 40 degrees. During the temping of the food temperatures for the evening meal the evening cook incorrectly read the thermometer at times with a difference of 10 degrees. Dietary staff #2 was asked to calibrate a thermometer prior to obtaining the temperature of the milk. He/she stated the thermometer should be calibrated to 20 degrees and then stated 30 degrees. At that time the Dietary Supervisor cued the staff member that the proper calibration temperature was 32 degrees. Review of the facility policy titled Food Storage revealed under the procedure section the following: 15b.-Frozen foods must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times each day. 15c.- All foods should be covered, labeled and dated. Review of the facility policy titled Proper Use of Thermometers revealed under the procedure section the following: 3- .Place the thermometer in ice water and wait three minutes stirring occasionally. After three minutes the thermometer should read 32 degrees Fahrenheit.

Based on record review, observation, interview and review of facility policy titled Resident Environment Quality, the facility failed to provide an environment as free from accident hazards as possible. During observation of resident rooms, a regular extension cord was used to operate resident equipment for 2 of 2 residents observed utilizing oxygen concentrators. The findings included: The facility admitted Resident #144 with [DIAGNOSES REDACTED]. The facility admitted Resident #41 with [DIAGNOSES REDACTED]. During room observations on 4/18/17 at 3:21 PM, a regular extension cord was noted in Resident #144 and 41's room with items plugged into the cord. During environmental rounds on 4/20/17 at 9:45 AM, with the Director of Operations, the Administrator and the Maintenance Director, the extension cord was observed. The Maintenance Director confirmed two oxygen concentrators had been plugged into the extension cord. Review of the facility policy titled Resident Environment Quality under Policy Explanation and Compliance Guidelines revealed the following: 2. Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.

Based on observation, interview and facility review of facility policy titled, Dignity During Meal Time, the facility staff failed to ask residents prior to putting on clothing protectors. The findings included: During observation prior to the dinner meal service on 04/19/17 at 4:35 pm a Certified Nursing Assistant (CNA) was observed placing clothing protectors on residents without asking if the resident wished to have one, in the dining room on the 300/200 unit. CNA #1 was observed telling the CNA putting on the protectors to ask the residents first if they wanted a protector. The CNA was then observed asking a resident if s/he wanted a protector. The resident stated s/he did No. The CNA told the resident s/he had to put the protector on. The resident agreed to take the protector in her hand. In an interview on 04/19/17 at 4:35 pm CNA #1 confirmed that the CNA had gone into the cabinet, took out the protectors and started putting them on the residents. CNA #1 stated the proper procedure was to offer a clothing protector and allow residents to choose whether to accept. Review of facility policy titled, Dignity During Meal Times on 04/21/17 at 1:54 pm revealed that It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life. Recognizing each resident's individuality and protecting the rights of each resident.

Based on record review, interviews and review of the facility policy titled, Room And/Or Roommate Change, the facility failed to ensure Resident #144 was notified of a room change on 2 different occasions while out of the facility for 1 of 1 resident reviewed for Admission,Transfer and Discharge. The findings included: The facility admitted Resident #144 with [DIAGNOSES REDACTED]. During an interview on 4/18/2017 at approximately 10:39 AM with Resident #144 he/she stated, I went to [MEDICAL TREATMENT] and came back and they had moved me to another room. Resident #144 had been asked if he/she had had a room or roommate change in the last nine months and if he/she was given notice prior to the change. Review on 4/21/2017 at approximately 10:37 AM of the nurses notes dated 3/13 2017 until 3/18/2017 Resident #144 was out of the facility and in the hospital. When he/she returned he/she was moved to another room which was the facility's decision to do so. No documentation could be found in the nurses notes nor the social service notes to indicate that Resident #144 was informed of the room change prior to the change. During an interview on 4/21/2017 at approximately 10:45 AM with the Social Service worker he/she stated, Resident #144 was moved again due to the resident being unable to see outside of the facility. No documentation could be found in the nurses notes nor the social service notes to indicate that Resident #144 was notified of the room change. Per Resident #144 when he/she returned from [MEDICAL TREATMENT] he/she had been moved to another room without prior notification. Review on 4/21/2017 at approximately 11:40 AM of the facility policy titled, Room And/Or Roommate Change, states under Policy: A resident and/or family have the right to refuse a transfer to another room within the facility. In addition, the resident and/or family have the the right to be informed in advance and in writing, to include the reason for the change, before the room or roommate in the facility is changed.

Based on record review, interview and review of the facility policy titled MDS/Care Plans, the facility failed to afford the opportunity to Resident #144 to participate in the care plan process for 1 of 1 resident reviewed for care plan participation. The findings included: The facility admitted Resident #144 with [DIAGNOSES REDACTED]. Record review on 4/19/17 revealed the Admission Minimum Data Set((MDS) dated [DATE] listed Resident #144's Brief Interview for Mental Status(BIMS) as12 with a current BIMS dated 4/1/17 of 14. During an interview with Resident #144 on 4/18/17 at 10:34 AM, he/she stated the facility did not talk to him/her about medications, therapy or other treatments. Review of the Care Plan Review Form on 4/19/17 revealed the care plan dated 4/3/17 did not indicate the resident had been invited to the care plan nor did it indicate the care plan had been discussed with the resident at a later date. A second copy of the Care Plan Review Form was provided on 4/20/17 which stated the resident had been invited but declined. During an interview with Social Service Director on 4/20/17 at 1:34 PM, he/she stated the resident had been in the hospital and the family member wanted to have the care plan meeting on 4/3/17. He/she continued by stating an invitation was probably not sent to him/her due to the request. The Social Service Director reviewed both copies of the sign in sheet and stated he/she did not check the box on the second copy indicating the resident had been invited but declined the invitation to the care plan meeting. After reviewing a book which contained information related to when a resident is sent a care plan invitation, the Social Service Director stated there was no documentation an invitation had been sent. Review of the facility policy titled MDS/Care Plans states under the Policy Interpretation and Implementation #7 the following: The resident and responsible party are encouraged to actively participate in the development and review of the care plan. Each resident and responsible party will be notified of the date and time for each interdisciplinary care plan team meeting,

Based on record review, interview and review of the facility policy titled Assessment of Unconscious Resident, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being. Resident #144 with an episode of unresponsiveness with no documented monitoring or reassessments. (1 of 1 reviewed for change in condition) The findings included: The facility admitted Resident #144 with [DIAGNOSES REDACTED]. Record review on 4/20/17 of the nurse's notes revealed on 3/13/17 at 8:05 AM, Resident #144 was non responsive to verbal stimuli and not responsive to touch. Only slight facial grimacing was observed during firm sternal rub. The resident's oxygen saturation level was 98% on 2 liters of oxygen and the pulse rate was 99, blood pressure of 100/60 and respirations were documented at 24. No shortness of breath, congestion, or diaphoresis were observed. The right upper chest tunnel catheter was dry and intact. At that time the physician was notified. At 8:20 AM, the physician called back and gave an order to transfer to the hospital. At 8:50 AM, Resident #144 was transported to the hospital and continued to be non responsive to verbal stimuli and sternal rub. The nurse's notes documented at the time of transfer the vital signs were stable. No documentation was presented to indicate what the vital signs were at the time of transfer. Further record review revealed no documentation of reassessing the resident from 8:05 AM to 8:50 AM at the time of transfer. During an interview with the Licensed Practical Nurse(LPN) #2 on 4/20/17 at 1:00 PM, after reviewing the documentation, he/she confirmed there was no documentation related to reassessing the resident. He/she continued by stating if a resident had an episode of unresponsiveness, he/she would assess the resident which included vital signs and a blood sugar check. The resident would be sent out immediately and he/she would not wait on the phone call from the physician. During an interview on 4/20/17 at 1:15 PM with LPN #3, he/she stated if a resident's vital signs were normal but the resident is not responsive, he/she would use nursing judgement and call the physician. If vital signs were not stable and the resident was unresponsive, he/she would transport to the hospital immediately. He/she continued by stating someone was in the room with the resident and confirmed he/she should have documented the incident better. Review of the facility policy titled Assessment of Unconscious Resident states under Policy Interpretation and Implementation states the following: 2. If the resident is unconscious but breathing on his/her own, check vital signs and monitor blood pressure, pulse and respirations as needed, depending on resident assessment. 3. During resident assessment, inspect the tongue for signs of biting, which may indicate a [MEDICAL CONDITION]. The policy also states a nurse or assistant should remain with the resident until emergency services arise for transport.

Based on record review and interview, the facility failed to ensure care and services were provided in regards to following physician's orders for 1 of 4 residents reviewed for accidents. Resident #24 had a fall with an injury in the facility, upon return from the hospital recommendations were not followed up with or acted upon. The findings include: The facility admitted Resident #24 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes on 3/18/15 at approximately 10:00 AM revealed an entry on 1/31/15 at 11:30 AM which stated. "Called to room per CNA (Certified Nursing Assistant). Resident sitting on buttocks on floor beside bed. CNA states 'She didn't hit her head.' Tabs alarm in resident's hand. No abrasions or lacerations. Upon PROM (Passive Range of Motion) facial grimacing and moaning noted when L(eft) leg moved...PA (Physician's Assistant) notified...911 notified..." Per the Nurses Notes, when the family member was notified, s/he stated "Mom has metal plates in left leg + arm near wrist." Review of the 1/31/15 hospital History and Physical on 3/18/15 at approximately 9:25 AM revealed that the resident had sustained a contusion on his/her leg after falling. Discharge instructions included: "Follow up with MD (Medical Doctor), When: 2-3 days, Reason: recheck today's complaint." Review of the resident's record did not provide any indication that the facility had followed up with the resident's physician related to the fall with injury to the resident's left leg. The 2/21/15 1:25 PM Nurses Notes stated: "Spoke with (physician) regarding L knee. Green--Discolored. Warm and tender to touch--Any attempt to flex/ext(end) the L leg (s/he) becomes agitated, yells out 'Oh my leg ' When staff..touches the knee, (s/he) guards it." An x-ray was done as ordered at 2:30 PM. At 11:49 PM, "X-ray report received. Results show acute proximal tibial fx (fracture)..." During an interview on 3/20/15 at approximately 11:00 AM, the Unit Manager stated the resident did not have an x-ray at the hospital and s/he did not come back with any new orders related to injuries. During an interview on 3/20/15 at approximately 2:00 PM, the Director of Nursing (DON) confirmed the discharge instructions were in the medical record. The DON stated the nurses were responsible to complete a physician order for [REDACTED]. as required.

Based on record review and interview, the facility failed to prevent physical and verbal abuse of 1 of 1 resident reviewed for allegations of abuse. Resident #1 was threatened with discharge and forcibly held down after refusing a flu shot. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurse's Notes on 12/3/14 at approximately 10:00 AM, "Resident approached by myself and administrator re (regarding): taking flu shot. 'Resident stated hell no get the hell out.' Administrator continued to talk to resident. Resident became more agitated and stood up in front of the administrator. I left the room to call 911 as administrator requested and when I got back was reported that resident had grabbed admin (administrator) by the tie and nurse had to get it loose then resident was lying on bed with arms pinned down and admin laying on him/her. Resident then bit administrator as was reported to me. Resident was checked for injuries per nurse. None noted..." Review of the resident's care plan revealed a problem with behaviors, "curses at staff, refuses care combative with staff, [DIAGNOSES REDACTED]. On 12/3/14 the care plan was updated to include, "Res (resident) was approached by administrator about getting flu vaccine. Started No, and to get the hell out. Became agitated. Reported to me that s/he grabbed administrator by the tie, admin (administrator) had res (resident) on bed lying on him/her with arms down. Reported to DON (director of nurses), and assist admin." An approach was added, "MD started new med (medicine). Res should be given a calm environment to calm down after being agitated." On 12/10/14 at approximately 1:05 PM the surveyor interviewed the New Administrator. S/he stated that s/he was on hall 4 at the nurse's station talking to a resident, therapist and social worker. Licensed Practical Nurse (LPN) #1 came down the hall and told me I needed to go to (Resident #1's) room. I entered the room; the administrator was over the top of the resident holding him/her down by his/her arms. The resident was in bed and the administrator was holding him/her by his/her forearms. No other body parts of administrator were touching the resident. They were arguing when I entered the room. I came in at the tail end. The Director of Nursing (DON) and I went back and talked to the resident. S/he said s/he wasn't injured but to keep his/her big ass away from him/her." On 12/10/14 at approximately 1:40 PM Licensed Practical Nurse (LPN) #2 was interviewed by the surveyor. The LPN stated, "About 10:30 AM ____ (LPN #1) came and said Resident #1 refused flu shot again. The administrator said lets go see. They walked down the hall and I heard the resident screaming and cursing and said no. I thought I heard a table fall. When I got down to the room ___ (floor tech) had picked up table and walked back out. LPN #1 had walked down the hall and said, 's/he (administrator) wants him/her (resident) sent to the ____(psych hospital). When I walked in the room the administrator was laying over the bed, feet toward bottom on floor with head and waist up across bed. I didn't know if resident had a hold of administrator. Then I saw the resident had the administrators tie. I pulled the tie but it was tight. I said ____(resident) let go and s/he eased and I was able to get the tie out. I put my hands on resident's forearms and told the administrator s/he could get up. The administrator continued to lay on the resident and told me to go call 911." At approximately 2:20 PM Licensed Practical Nurse (LPN) #1 was interviewed by the surveyor. The LPN stated on the morning of December 3, 2014, the resident had been on a list of residents that refused the flu shot. The LPN reported to the administrator the resident refused the flu shot. The administrator and the nurse went to the resident's room. The resident was told s/he needed to take the flu shot. The resident said no. "The resident was in the bed, s/he was cussing the administrator, telling us to get the hell out of his/her room. I told the administrator I could document his/her refusal and his/her behavior and it would be fine. The administrator stated the resident could go to _____ (psych hospital) or be discharged ."

Based on facility files, record review and interviews, the facility failed to follow their policy on Abuse/Neglect for 1 of 3 investigations for allegations of abuse. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurse's Notes on 12/3/14 at approximately 10:00 AM, "Resident approached by myself and administrator re (regarding): taking flu shot. 'Resident stated hell no get the hell out.' Administrator continued to talk to resident. Resident became more agitated and stood up in front of the administrator. I left the room to call 911 as administrator requested and when I got back was reported that resident had grabbed administrator by the tie and nurse had to get it loose then resident was lying on bed with arms pinned down and administrator laying on him/her. Resident then bit administrator as was reported to me. Resident was checked for injuries per nurse. None noted..." Review of the facility's Abuse Policy revealed the policy was to provide a safe, secure, quiet, homelike environment for all residents and to provide a safe workplace for all employees. The procedure included: 1. Monitor behavior of all residents closely and be alert for any signs, which may indicate that a resident is becoming upset. 2. Should a resident resist care or become combative, get the resident to safety, use a soft tome of voice and stop attempting care. Never force any resident. Pull back and allow the resident to calm down. Protection Abuse Policy stated, "Immediately respond to the needs of the injured party. The accused or suspected employee is immediately suspended pending an investigation. The individual must be counseled, terminated and/or denied visiting privileges to the center during the investigation." On 12/10/14 the surveyor interviewed the Company Executive Officer (CEO) at approximately 5:40 PM. The CEO stated on the 3rd (December) the President of the company met with the administrator and told him/her not to be in the building. On December the 8th, Monday, the administrator was given a hand delivered letter/agreement to sign. The letter/agreement dated December 8th and signed by the administrator indicated, "... In our conversation the afternoon of the incident you stated to me that you would leave the facility and not go back until the investigation was conducted. It was my understanding that you entered the building at least three times the following day. I went to the facility at approximately 11:00 AM after learning that you were there and passed you on road leaving the facility. You were observed by the Ombudsman entering the facility after this. S/he was not pleased with this. As an experienced administrator I know that you know it is standard procedure for an individual accused of resident abuse not to reenter the facility after an accusation is made until the accusation is investigated..." The suspended facility Administrator was interviewed over the phone on 12/11/14 at approximately 10:06 AM by the surveyor. During the interview the administrator confirmed that s/he had re-entered the building and talked to the resident. "I left facility and then came back. I left my checkbook. I went and asked ______ (Resident #1) if s/he was ok. I didn't know anything about being accused of abuse."

Based on record review and interviews, the facility failed to provide social services intervention for 1 of 1 resident with mental illness that was allegedly abused. Resident #1 diagnosed with [REDACTED]. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurse's Notes on 12/3/14 at approximately 10:00 AM, "Resident approached by myself and administrator re (regarding): taking flu shot. 'Resident stated hell no get the hell out.' Administrator continued to talk to resident. Resident became more agitated and stood up in front of the administrator. I left the room to call 911 as administrator requested and when I got back was reported that resident had grabbed admin (administrator) by the tie and nurse had to get it loose then resident was lying on bed with arms pinned down and admin laying on him/her. Resident then bit administrator as was reported to me. Resident was checked for injuries per nurse. None noted..." Review of the resident's care plan revealed a problem with behaviors, "curses at staff, refuses care combative with staff, [DIAGNOSES REDACTED]. On 12/3/14 the care plan was updated to include, "Res (resident) was approached by administrator about getting flu vaccine. Started No, and to get the hell out. Became agitated. Reported to me that s/he grabbed administrator by the tie, admin had res on bed lying on him/her with arms down. Reported to DON (director of nurses), and assist admin. " An approach was added, "MD started new med (medicine). Res should be given a calm environment to calm down after being agitated." Review of the Social Services (SS) Notes revealed the last Social Services note was dated 10/31/14. There was no Social Services Note documenting the allegation of abuse or the resident's response or condition following the incident. There were no social services notes depicting the resident's behaviors towards other residents. The SS Note dated 10/31/14 stated, "...Dx (diagnoses) Dementia, Agitation. S/he receives ATIVAN (agitation). Resident is oriented to name - disoriented to place and time. Resident requires assistance with ADL (Activities of Daily Living) care... s/he refuses to participate with interview. S/he refuses and becomes agitated with staff at times when care is provided..." On 12/10/14, the Social Services Director (SSD) was interviewed by phone at approximately 5:15 PM by the surveyor. The Social Services Director stated s/he had talked to the resident later in the afternoon, after the incident. "S/he said s/he was OK. I asked if s/he had any problems and s/he said no. I have not put anything in the chart. I didn't write anything. I go around to each resident every morning, but s/he is usually in bed. I have not talked to any of the other residents. I don't know if any other residents are aware."

Based on record reviews and interviews, the facility failed to meet the psychosocial needs of Resident #1 allegedly abused by a facility staff member (1 of 1 resident sampled for abuse). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurse's Notes dated 10/23/14 that stated, "5 AM resident refused to let us draw blood tonight. Started yelling very agitated. Stated, your not going to get any more blood." On 10/27/14, "5 AM Resident refused to let nurse draw blood for monthly lab. Patted his/her arm and stated no more blood from me" in loud agitated voice. Resident calm after nurse left out of room..." On 10/28/14, "5:30 AM Resident refused to let us draw blood again this AM. Gets very agitated when we ask him/her. States' I said no more blood from me." Resident calms down afterwards. No acute distress noted." Nurse's Note of 12/3/14 at approximately 10:00 AM, "Resident approached by myself and administrator re (regarding): taking flu shot. 'Resident stated hell no get the hell out.' Administrator continued to talk to resident. Resident became more agitated and stood up in front of the administrator. I left the room to call 911 as administrator requested and when I got back was reported that resident had grabbed admin (administrator) by the tie and nurse had to get it loose then resident was lying on bed with arms pinned down and admin laying on him/her. Resident then bit administrator as was reported to me. Resident was checked for injuries per nurse. None noted..." Review of the resident's Minimum (MDS) data set [DATE] revealed the resident did not receive any [MEDICAL CONDITION] medications. S/he was coded as receiving antianxiety medication. Review of the resident's care plan revealed a problem with behaviors, "curses at staff, refuses care combative with staff, [DIAGNOSES REDACTED]. The care plan was updated on 9/12/14, "another res (resident) entered his/her room, s/he became agitated, scratched res (resident) on R (right) side on neck. The care plan was updated again on 9/13/14, "res yelling and cursing at another res in doorway of his/her room. Res (resident) then hit the other res. on his/her right shoulder-neck area and grabbed his/her shirt, causing the other resident to fall on floor outside door in hallways. Incident witnessed by nurse on hall. Both res. separated immediately-administration and supervisor notified of incident". An approach included psychiatric consult as ordered. On 12/3/14 the care plan was updated to include, "Res was approached by administrator about getting flu vaccine. Started No, and to get the hell out. Became agitated. Reported to me that s/he grabbed administrator by the tie, admin had res on bed lying on him/her with arms down. Reported to DON (director of nurses), and assist admin (administrator). " An approach was added, "MD started new med (medicine). Res should be given a calm environment to calm down after being agitated." Review of the Social Services (SS) Notes revealed the last Social Services note was dated 10/31/14. There was no Social Services Note documenting the allegation of abuse or the resident's response or condition following the incident. There were no social services notes depicting the resident's behaviors towards other residents. The SS Note dated 10/31/14 stated, "...Dx. Dementia, Agitation. S/he receives [MEDICATION NAME] (agitation). Resident is oriented to name- disoriented to place and time. Resident requires assistance with ADL (Activities of Daily Living) care.... s/he refuses to participate with interview. S/he refuses and becomes agitated with staff at times when care is provided..." On 12/10/14, the Social Services Director (SSD) was interviewed by phone at approximately 5:15 PM by the surveyor. The Social Services Director stated s/he had talked to the resident later in the afternoon, after the incident. "S/he said s/he was OK. I asked if s/he had any problems and s/he said no. I have not put anything in the chart. I didn't write anything. I go around to each resident every morning, but s/he is usually in bed. I have not talked to any of the other residents. I don't know if any other residents are aware." On 12/10/14 at approximately 5:00 PM. the facility Medical Director was interviewed via phone by the surveyor. The physician stated, "I have not seen him/her since the incident. I have been in contact with the nurses. I saw him/her before. The plan is we did blood tests for both of them. __ (Resident #1) has some psychiatric issues. S/he has had a few episodes and history. We may have to send to ___(psychiatric hospital). S/he has a few episodes now and then, nothing consistent. We watched him/her, s/he calmed down. Didn't want to do anything further."

Based on record review and interviews the facility failed to respect resident rights for 1 of 1 resident who refused the flu vaccine. Resident #1 refused to receive the flu vaccine. The findings included: On 12/3/14 Resident #1 refused to receive a flu shot. The administrator and a nurse went to the resident to talk the resident into taking the flu shot. The resident refused the flu shot again. The administrator continued to insist the resident take the flu vaccine. The resident began cursing, said no and told the administrator to get out of the room. The administrator did not leave and told the resident the door could not be closed. The resident attempted to push the administrator out of the room. The administrator was observed holding the residents forearms and lying across the resident in the bed. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurse's Notes on 12/3/14 at approximately 10:00 AM, "Resident approached by myself and administrator re (regarding): taking flu shot. 'Resident stated hell no get the hell out.' Administrator continued to talk to resident. Resident became more agitated and stood up in front of the administrator. I left the room to call 911 as administrator requested and when I got back was reported that resident had grabbed administrator by the tie and nurse had to get it loose then resident was lying on bed with arms pinned down and admin (administrator) laying on him/her. Resident then bit administrator as was reported to me. Resident was checked for injuries per nurse. None noted..." On 12/10/14 at approximately 1:25 PM the floor tech was interviewed. S/he stated, "I was buffing hall 4. I heard them fussing and s/he (Resident #1) kept telling the administrator to get out and close the door. The administrator told him/her s/he could not close the door. The resident said s/he would close the door and got up. S/he tried to push the administrator out. S/he could not move the administrator. The administrator kind of like walked the resident back to the bed. Licensed Practical Nurse (LPN) #2 had just walked out. The resident's hands were on the administrators shoulders, neck region. I couldn't see clearly from the angle. The administrator was trying to tell the resident to calm down. S/he laid the resident down on the bed. The administrator had his/her hands on the resident's forearms. On 12/10/14 at approximately 2:20 PM Licensed Practical Nurse (LPN) #1 was interviewed by the surveyor. The LPN stated on the morning of December 3, 2014 the resident had been on a list of residents who refused the flu shot. The LPN reported to the administrator that the resident refused the flu shot. The administrator and the nurse went to the resident's room. The resident was told s/he needed to take the flu shot. The resident said no. "The resident was in the bed, s/he was cussing the administrator, telling us to get the hell out of his/her room. I told the administrator I could document his/her refusal and his/her behavior and it would be fine. The administrator stated the resident could go to _____ (psych hospital) or be discharged . The administrator had talked to another resident that had refused the flu shot. The other resident said no. The administrator told the resident that flu shots were going to become mandatory. The other resident agreed to take the flu shot." In an interview with the surveyor on 12/10/14 at 1:40 PM LPN #2 stated, "About 10:30 AM the LPN #1 came and said _____ (Resident #1) had refused the flu shot again. The administrator said ok lets go see. They walked down the hall and I heard them. The resident screaming and cussing and said no. I though I heard the table fall. When I got down to the room ______ (floor tech) had picked up the table and walked back out. LPN #1 had walked down the hall and said, 'S/he (administrator) wants him/her (resident sent to _____ (psych hospital)'. When I walked in the room, the administrator was laying over the bed. Feet toward bottom, on floor with head-waist up across bed. I didn't know if the resident had a hold of the administrator. Then I saw the resident had the administrators tie. I pulled the tie but it was tight. I said ______ (resident's name) let go and s/he eased and I was able to get the tie out. I put my hands on resident's forearms and told the administrator s/he could get up. Administrator continued to lay on the resident and told me to go call 911.