Every finding on record at Central Guest House Healthcare & Rehabilitation Ce

Based on observations, interviews, and record review, the facility failed to ensure residents received their dietary supplements with each meal for 1 (Resident #1) of 3 residents reviewed for nutrition. Resident #1Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Quadriplegia, Unspecified Level of Spinal Cord Injury, and Unspecified Protein-Calorie Malnutrition. Review of Resident #1's most recent MDS with an ARD of 03/22/2026, revealed a BIMS of 5, which indicated severe cognitive impairment. Review of Resident #1's current Physician Orders revealed the following, in part:Start date 03/16/2026- Magic cup with meals. Review of Resident #1's most recent Registered Dietician Assessment Summary revealed, in part, the following:Current Diet Order: NAS (No Added Salt) diet. Regular texture, Regular/Thin consistency, double portion meats. Magic cup with meals three times a day. Liquid protein three times a day. House supplement four times a day. Glucerna in the evening with supper.Malnutrition Plan: Provide resident with meals, snacks, and supplements to meet nutrient needs. On 04/20/2026 at 9:25 a.m., an observation was made of Resident #1's breakfast tray and meal ticket with documentation noted for a Magic cup with meals. This item was not noted on Resident #1's breakfast tray. On 04/20/2026 at 9:34 a.m., an observation was made of Resident #1's breakfast tray and meal ticket with S2LPN. She confirmed Resident #1's breakfast tray did not have the ordered magic cup and should have. On 04/20/2026 at 8:22 a.m., an interview was conducted with S3DS. S3DS stated magic cups came from the kitchen. S3DS stated kitchen staff should prepare resident trays according to the resident's meal ticket. She stated if magic cups were on the meal tickets they should be on the resident's tray. On 04/21/2026 at 11:10 p.m., an interview was conducted with S1DON. S1DON stated if a resident had dietary supplements ordered with meals, they should be on the resident's tray as ordered.

Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety. There were 166 residents in the facility who ate food from the kitchen.Findings:On 03/23/2026 at 8:50 a.m., an initial tour of the kitchen was conducted with S2DM, who confirmed the following observations:Freezer:The following items were observed in unsealed bags in open cardboard boxes:-1 10 pound bag of fully cooked sausage patties-1.2 ounce plastic bag of cheese and garlic biscuit dough-1.5 pound plastic bag of diced ham-10.35 pound plastic bag of fully cooked chicken breast patties-10 pound plastic bag of fish fingers-1 pound bag of egg rollsOn 03/23/26 at 8:55 a.m., an interview was conducted with S2DM. S2DM confirmed the aforementioned items were open, and not sealed. S2DM stated all foods stored in the freezer should have been sealed and not left open to air.On 03/24/2026 at 4:18 p.m., an interview was conducted with S1ADM. S1ADM was notified of the aforementioned findings. S1ADM stated opened food items should have been sealed and not open to air in the freezer. S1ADM stated the above food items were not stored in accordance with professional standards for food service safety, and should have been.

Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#135) of 4 residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing care to a resident who was on Enhanced Barrier Precautions (EBP).Review of the facility's policy titled Enhanced Barrier Precautions Policy & Procedure dated 04/2024, revealed the following, in part: Procedure:1. EBP are indicated for residents with any of the following: b. Indwelling medical devices even if the resident is not known to be infected or colonized with and MDRO. ii. Indwelling medical device examples include urinary catheters4. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: b. Providing hygiene g. Device care or use (urinary catheter)5. Personal Protective Equipment (PPE) is to be applied prior to performing the high-contact resident activity according to below and before moving on to another resident: b. Put on gown and glovesEquipment 2. Gown and gloves Review of Resident #135's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses including Retention of Urine, Overactive Bladder, Urinary Incontinence, and Neuromuscular Dysfunction of Bladder. Review of Resident #135's current Physician Orders revealed the following, in part:Enhanced Barrier Precautions: utilize gown and gloves during high-contact care activities for residents with chronic wounds or indwelling medical devices. Every shift for presence of foley catheter (Start date: 10/10/2024) Review or Resident #135's current Care Plan revealed the following:Problem: The resident has a clinical condition and or medical device (i.e. urinary catheter) that warrants enhanced barrier precautions.Interventions: Utilize gloves and gown when performing high-contact resident care activities (i.e., providing hygiene) and when providing care to medical devices (i.e., urinary catheter) On 03/25/2026 at 9:10 a.m., an observation of the Enhanced Barrier Precautions sign posted outside of Resident #135's door revealed the following, in part: Providers and staff must:Wear gloves and a gown for the following high-contact resident care activities.Device care or use On 03/25/2026 at 9:15 a.m., an observation was made of S7CNA performing catheter care and peri care for Resident #135. S7CNA was not wearing a gown while performing high contact care to Resident #135. On 03/25/2026 at 9:30 a.m., an interview was conducted with S7CNA. S7CNA confirmed Resident #135 was on EBP due to having a urinary catheter. She further confirmed she did not wear a gown when performing catheter care and peri care for Resident #135 and should have. On 03/25/2026 at 2:13 p.m., an interview was conducted with S3DON. S3DON confirmed she expected staff to follow EBP guidelines when providing high contact care to residents with an indwelling medical device such as a urinary catheter.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#59) of 3 residents reviewed for ADL's. The facility failed to shampoo Resident #59's hair.Findings:Review of Resident #59's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Abnormalities of Gait and Mobility, Generalized Muscle Weakness, Anxiety Disorder, Idiopathic Progressive Neuropathy, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, and Acute on Chronic Respiratory Failure with Hypoxemia. Review of Resident #59's Quarterly MDS with an ARD of 02/19/2026 revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed she required partial/moderate assistance with personal hygiene. Review of Resident #59's Care Plan revealed the following, in part:Problem: The resident requires staff assistance with ADL care.Intervention: Resident prefers morning showers. Review of Resident #59's ADL documentation revealed she was scheduled to receive baths on Mondays, Wednesdays, and Fridays. Further review of ADL Documentation for bathing dated 02/25/2026 through 03/24/2026 revealed no documentation Resident #59's hair was washed after 03/02/2026. On 03/23/2026 at 9:39 a.m., an interview was conducted with Resident #59. She stated her bath days were on Mondays, Wednesdays and Fridays. She stated Resident #59 used to go to the whirlpool before her fall last month and have her hair washed every week. She stated now she took bed baths and her hair had not been washed in 3 weeks. She stated her scalp was itching and her hair felt oily and dirty. She stated on either Wednesday or Friday of last week she asked S9CNA to wash her hair during her bath. She stated S9CNA did not wash her hair and told her she can go to the salon and have her hair washed. On 03/24/2026 at 12:48 p.m., an interview was conducted with S9CNA. She stated Resident #59's bath days were on Mondays, Wednesdays and Fridays. She stated the CNA's on the hall were responsible for the resident's showers and baths. She stated Resident #59 required assistance with her ADL's and had been getting bed baths since she came back from the hospital last month. She stated she was assigned to Resident #59 last Friday, 03/20/2026, and Resident #59 requested her hair to be washed during the bed bath. She stated she told Resident #59 it might be best for her to go to the beauty shop to have her hair washed so they can lean her head back in the bowl. She stated she had not washed Resident #59's hair in about one month since she got back from the hospital. She confirmed washing a resident's hair was part of a bath and if the resident asked to have their hair washed, she was supposed to do it. She stated she had not notified the nurse Resident #59 wanted her hair washed and she had not done it. On 03/24/2026 at 1:10 p.m., an observation and interview was conducted with Resident #59. She was in her room seated in a wheelchair. She stated her hair still felt dirty, oily and her scalp itched. Resident #59's hair was observed pulled back in ponytail, stray hairs sticking up, and the hair by her temples and ears was observed slightly oily and stuck to the side of her head. On 03/24/2026 at 1:22 p.m., an interview was conducted with S6LPN. She stated Resident #59 used to bathe in the whirlpool, but had been receiving bed baths since she returned from the hospital last month. She confirmed if a resident requested their hair to be washed then the CNA's should absolutely perform it. She stated no staff had reported not being able to wash Resident #59's hair. On 03/24/2026 at 3:35 p.m., an observation was made of Resident #59 with S10CNA. S10CNA stated Resident #59's baths were done on Mondays, Wednesdays, and Fridays on the 6:00 a.m. to 2:00 p.m. shift. She stated washing a resident's hair was part of the bath and should be done on bath days. She observed Resident #59's hair, ran her fingers through the resident's hair, and stated it felt greasy and needed to be washed. On 03/25/2026 at 10:06 a.m., an interview was conducted with S3DON. She confirmed washing a resident's hair was part of a bath. She confirmed if a resident wanted their hair washed on their bath day it should be washed. She stated it was difficult to submerge a resident's hair to clean it well while doing a bed bath. She stated had staff notified her or the nurse they were unable to wash Resident #59's hair during a bed bath, she would have brought Resident #59 to the salon and washed her hair.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident. The facility failed to ensure medications were administered as ordered for 1 (#162) of 7 residents reviewed for medication administration.Findings: Review of the facility's policy titled, Medication Administration with an effective date of 10/04/2024, revealed the following, in part:Policy: Nursing personnel shall ensure the safe and effective administration of medications.Procedure:1. Medication Administration:g. Administer the medication as ordered .4. Missing Medication:a. Notify the Pharmacy immediately to fill the order during regular pharmacy hours. After hours, retrieve the medication from the emergency medication kit. Review of Resident #162's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Pneumonia, Obstructive Sleep Apnea, Cough, Shortness Of Breath, Acute Upper Respiratory Infection, Unspecified Diastolic Congestive Heart Failure, Tobacco Use, Hypoxemia, Chronic Obstructive Pulmonary Disease, and Acute On Chronic Respiratory Failure. Review of Resident #162's Quarterly MDS with an ARD of 01/23/2026 revealed she had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #162's Physician Orders dated March 2026 revealed the following, in part:Order date: 03/19/2026, Start date: 03/20/2026, End date: 03/24/2026- Prednisone oral tablet 20 mg give 2 tablets by mouth one time a day for 4 days. Review of Resident #162's Medication Administration Record dated March 2026 revealed, in part, S5LPN documented Prednisone as not administered on 03/21/2026 and 03/22/2026. Review of Resident #162's Nurses Notes dated March 2026 and signed by S5LPN revealed the following, in part:03/21/2026 at 10:10 a.m. Prednisone oral tablet 20 mg give 2 tablets by mouth one time a day for 4 days not administered. Waiting on pharmacy.03/22/2026 at 9:46 a.m. Prednisone oral tablet 20 mg give 2 tablets by mouth one time a day for 4 days not administered. Waiting on pharmacy. On 03/23/2026 at 9:12 a.m., an observation was made of Resident #162. Resident #162 was coughing up light, tan colored phlegm into a cup. An interview was conducted with Resident #162 at that time. Resident #162 stated she had been coughing up a lot of phlegm and was supposed to be started on a steroid over the weekend and was not. On 03/24/2026 at 1:50 p.m., an interview was conducted with S6LPN. She stated she was assigned to Resident #162 on 03/19/2026 from 7:00 a.m. to 3:00 p.m. She stated, on 03/19/2026, S11NP ordered Prednisone 20 mg take 2 tablets once a day for 4 days for Resident #162 due to cough and congestion. She reviewed Resident #162's clinical record and verified she entered the order for the Prednisone on 03/19/2026 at 1:57 p.m. with a start date of 03/20/2026 at 8:00 a.m. On 03/24/2026 at 3:05 p.m., an interview was conducted with S5LPN. She verified she was assigned to Resident #162 from 07:00 a.m. to 11:00 p.m. on 03/21/2026 and 03/22/2026. She stated Resident #162 had a cough and an order to administer Prednisone. She stated Resident #162's Prednisone was not delivered from the pharmacy. She confirmed she did not administer Resident #162's Prednisone on 03/21/2026 and 03/22/2026. On 03/25/2026 at 8:50 a.m., an interview was conducted with S11NP. She stated, on 03/19/2026, Resident #162 complained of a cough and congestion. She stated she prescribed Prednisone 20 mg tablets take once a day for 4 days for Resident #162's COPD. She confirmed she expected Resident #162's Prednisone to be administered as ordered. On 03/25/2026 at 9:04 a.m., an observation was made of the facility's two emergency medication kits with S12ADON. S12ADON reviewed the list of medications contained in the emergency medication kits and stated each kit contained 6 tablets of Prednisone 10 mg tablets. She confirmed the drawers containing the Prednisone tablets were sealed and no tablets had been removed. On 03/25/2026 at 10:13 a.m., an interview was conducted with S3DON. She stated if Resident #162's Prednisone dose was not delivered and available to administer, the nurse should have looked in the emergency medication kits to see if the medication was available and then utilized the medication from the kit. She stated she had reviewed Resident #162's MAR and nurses' notes dated 03/21/2026 and 03/22/2026 and confirmed S5LPN did not administer Resident #162's Prednisone and documented she was waiting on pharmacy. She confirmed Resident #162's Prednisone should have been administered as ordered.

Based on observations, interviews, and record review, the facility failed to implement a resident's person centered plan of care for 1 (#114) of 7 sampled residents reviewed. The facility failed to ensure Resident #114's shrinker sock was applied to his right below the knee amputation (BKA) as identified in his plan of care.Review of Resident #114's Clinical Record revealed he admitted to the facility on [DATE] with diagnoses, which included Acquired Absence of Right Leg Below Knee. Review of Resident #114's Annual MDS with ARD of 02/04/2026 revealed a BIMS of 06, which indicated severe cognitive impairment. Review of Resident #114's current Physician's Orders revealed the following, in part:Shrinker sock to be applied to right BKA anytime prosthetic leg and silicone liner with screw is removed. On 03/23/2026 at 9:45 a.m., an observation and interview was conducted with Resident #114. He was lying in bed with no shrinker sock in place to right BKA with a sign above his bed, stating gray shrinker sock to be worn while in bed. Resident #114 stated he had not refused staff to apply shrinker sock. On 03/24/2026 at 8:20 a.m., an observation and interview was conducted with Resident #114. He was lying in bed with no shrinker sock in place to right BKA with a sign above his bed, stating gray shrinker sock to be worn while in bed. Resident #114 stated he had not refused staff to apply shrinker sock. On 03/24/2026 at 8:25 a.m., an interview and observation was conducted with S8CNA. She confirmed Resident #114's shrinker sock was not in place and should have been. She further confirmed she was assigned to Resident #114 and had not attempted to apply Resident #114's shrinker sock to his right BKA. On 03/24/2026 at 2:00 p.m., an interview was conducted with S13CNA. S13CNA stated CNAs were responsible for applying Resident #114's shrinker sock to his right BKA. She further stated Resident #114 should have his shrinker sock on when he was in bed. S13CNA stated he had never refused to let her put the shrinker sock on his right BKA. On 03/25/2026 at 12:23 p.m. an interview was conducted with S4LPN. She stated Resident #114 had never refused care from her. S4LPN confirmed Resident #114 had an order to wear a shrinker sock while in bed and it should have been in place if he was in bed. On 03/25/2026 at 3:00 p.m., an interview was conducted with S15CNA. S15CNA stated she had applied Resident #114's shrinker sock in the past with no issues regarding resident refusal. She stated he had never refused care when she worked with him. On 03/25/2026 at 2:13 p.m., an interview was conducted with S3DON. She verified Resident #114's Physician's Order for shrinker sock to be applied to right BKA if prosthetic was not in place. S3DON confirmed Resident #114 should have shrinker sock on his right BKA while in bed unless he refused. S3DON further confirmed staff were expected to follow physician's orders.

Based on observations, interviews, and policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure staff with facial hair wore a beard restraint while preparing to serve food. This deficient practice had the potential to affect any of the 155 residents who received food from the facility's kitchen. Findings: Review of the facility's policy titled, Medical Nutrition Therapy and Food Systems Management with a revision date of 10/2018 revealed the following, in part: 3. Proper Work Attire b. The food service employee observes the following dress standards: i. Employees with facial hair wear a beard restraint. An observation was made in the facility's kitchen on 02/10/2025 at 11:26 a.m. The dietary staff were preparing to serve lunch. There were three male dietary aides with beards preparing drinks and placing lids on the cups. None of the three male dietary aides had on a facial hair restraint. An interview was conducted with S5DM on 02/11/2025 at 11:33 a.m. She confirmed the male dietary aides had facial hair, did not have on a beard restraint while preparing food and drinks, and should have. An interview was conducted with S1ADM on 02/12/2025 at 8:49 a.m. He confirmed facial hair should have been restrained while dietary staff prepared food and drinks.

Based on record review and interviews, the facility failed to ensure a Significant Change in Status Minimum Data Set (MDS) Assessment was completed within 14 days of a resident admitted to hospice for 1 (#136) of 3 (#76, #136, and #159) sampled residents who received hospice services. Findings: Review of Resident #136's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #136's Physicians Orders revealed Resident #136 was admitted to Hospice on 04/30/2024. Review of Resident #136's MDS assessments from 04/30/2024 to present revealed no Significant Change MDS was submitted to reflect Hospice services were provided. On 02/12/2025 at 10:54 a.m., an interview was conducted with S3MDS. She stated an admission to Hospice services required a Significant Change MDS assessment. She reviewed Resident #136's MDS assessments and confirmed a Significant Change MDS was not completed after being admitted to Hospice on 04/30/2024 and should have. On 02/12/2025 at 2:04 p.m., an interview was conducted with S2DON. She confirmed Resident #136 was admitted to Hospice services on 04/30/2024. S2DON reviewed Resident #136's MDS assessments and confirmed a Significant Change MDS was not completed after being admitted to Hospice and should have.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of infection by failing to ensure staff donned proper Personal Protective Equipment (PPE) when performing high-contact resident care for 1 (#18) of 8 (#18, #28, #33, #55, #67, #136, #154 and #362) residents reviewed on Enhanced Barrier Precautions (EBP). This deficient practice had the potential to affect any of the 33 residents residing in the facility who had Enhanced Barrier Precautions implemented. Findings: Review of the facility's policy which had an effective date of 04/01/2024, and titled Enhanced Barrier Precautions Policy and Procedure revealed the following, in part: Purpose: To prevent the spread of potential infection by implementing Enhanced Barrier Precautions when contact precautions do not apply. This approach recommends the use of EBP during high-contact care activities for residents with chronic wounds . Procedure: EBP are indicated for residents with any of the following: 1 b. Wounds and/or indwelling medical devices even if the resident is not known to be infected. 5. PPE is to be applied prior to performing the high- contact resident activity according to below and before moving on to another resident: Perform hand hygiene, put on a gown and gloves, after resident care throw away gown and gloves in trash receptacle, and perform hand hygiene. Review of Resident #18's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer of Sacral Region and Resistance to Multiple Antibiotics. Review of Resident #18's current Physician Orders revealed the following, in part: Enhanced Barrier Precautions: utilize gown and gloves during high contact care activities for resident with chronic wounds. An observation of Resident #18's a brief change and wound care was conducted on 02/11/2025 at 9:05 a.m. An EBP sign was noted on Resident #18's door which read providers and staff must wear gloves and gowns for the following high- contact resident care activities: changing brief and wound care. S11CNA was observed to change the residents brief and assist with wound care. S10LPN was observed to perform wound care. Neither S11CNA nor S10LPN were observed to wear a gown during the care provided. An interview was conducted on 02/11/2025 at 9:22 a.m. with S10LPN. She stated EBP was used for any resident with chronic open wounds which required a dressing. She confirmed Resident # 18 was on EBP and she did not wear a gown for wound care, but should have. An interview was conducted on 02/11/2025 at 9:25 a.m. with S11CNA. She stated EBP was used for any resident with open wounds. She confirmed Resident #18 was on EBP and she did not wear a gown to change Resident #18's brief or assist with wound care, but should have. An interview was conducted on 02/11/2025 at 3:43 p.m. with S2DON. She reported EBP are used for resident's who have wounds or open areas of the skin that required a dressing. She confirmed Resident #18 was on EBP. She further confirmed staff were expected to wear gowns when changing a brief or performing wound care on Resident #18.

Based on observations, interviews, and policy review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 (Cart A and Cart B) of 3 (Cart A, Cart B, and Cart C) medication carts observed. The facility failed to ensure: 1. Insulin vials were labeled with the date opened and discarded 28 days after the date opened; and 2. Medications were discarded by their expiration date. Findings: Review of the facility's policy titled, Medication Administration dated [DATE] revealed the following, in part: Purpose: To define responsibility and delineate processes for safe administration of medications by nursing personnel. Procedure: 7. Multi-dose vials: b. All multi-dose vials shall be labeled with the initials of the person opening the vial and an expiration date that is 28 days after opening. c. Opened multi-dose vials that lack dates or initials shall be discarded. Cart A An observation was made of Cart A on [DATE] at 2:24 p.m. with S7LPN present. The following was observed: One bottle of Mucus Relief 400 mg with an expiration date of ,d+[DATE]. An interview was conducted with S7LPN following the above observation. She confirmed the above medication was expired and available for use. She stated medications should have been discarded by the manufacture's expiration date. Cart B An observation was made of Cart B on [DATE] at 2:15 p.m. with S6LPN present. The following was observed: One vial of Resident #65's Novolin R 100 unit/mL insulin with a fill date of [DATE] was opened and not labelled with the open date; One vial of Resident #107's Novolin R 100 unit/mL insulin with a fill date of [DATE] was opened and not labelled with the open date; One vial of Resident #107's Novolin R 100 unit/mL insulin with a fill date of [DATE] was opened and not labelled with the open date; One vial of Resident #123's Novolin R 100 unit/mL insulin with a fill date of [DATE] was open and labelled with an open date of [DATE]; and One tube of Resident #56's Premarin Vaginal Cream 30 grams was available for use with an expiration date of [DATE]. An interview was conducted with S6LPN following the above observation. She confirmed the above observations. She stated insulin vials should have been labelled with the open date and discarded 28 days after opening. She confirmed all medications should have been discarded by the manufacturer's expiration date. An interview was conducted with S2DON on [DATE] at 10:23 a.m. She confirmed insulin vials should have been labelled with the open date and discarded 28 days after opening. She stated medications should have been discarded by the manufacturer's expiration date.

Based on interviews and record reviews, the facility failed to ensure MDS assessments accurately reflected the residents' status by failing to ensure: 1.Discharge dispositions were accurately coded for 1 (#161) of 4 (#159, #161, #312, and #412) discharged resident records reviewed; and 2. Hospice services were accurately coded for 1 (#136) of 3 (#76, #136 and #159) residents reviewed who received hospice services. Findings: Review of the facility's policy titled, MDS Policy and Procedure dated 06/25/2015 revealed the following, in part: Policy: All Minimum Data Set (MDS) are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual. 1. Resident #161 Review of Resident #161's Clinical Record revealed an admitted [DATE] and a discharge date of [DATE]. Further review of the Clinical Record revealed she was a planned discharge home with Home Health Services. Review of Resident #161's Discharge MDS assessment with an ARD of 11/12/2024 revealed her discharge from the facility was unplanned. An interview was conducted with S4SW on 02/12/2025 at 11:28 a.m. She stated Resident #161's discharge from the facility was a planned discharge. An interview was conducted with S3MDS on 02/12/2025 at 11:34 a.m. She confirmed Resident #161's discharge from the facility was a planned discharge. She confirmed Resident #161's discharge MDS with an ARD of 11/12/2024 was coded as her discharge was unplanned. She confirmed Resident #161's MDS was coded inaccurately. An interview was conducted with S2DON on 02/12/2025 at 12:19 p.m. She confirmed Resident #161's discharge from the facility was planned, and her discharge MDS should have been coded accurately to reflect her planned discharge. 2. Resident #136 Review of Resident #136's Clinical Record revealed an admitted [DATE]. Further review of the Clinical Record revealed Resident #136 was admitted to Hospice services on 04/30/2024. Review of Resident #136's Quarterly MDS assessment with an ARD of 12/18/2024 revealed the following: Section O0110: Special Treatments, Procedures and Programs: K1- Hospice Care- No An interview was conducted with S9MDS on 02/12/2025 at 10:52 a.m. She confirmed Resident #136 received hospice services. She reviewed Resident #136's MDS with an ARD of 12/18/2024 and confirmed it was inaccurately coded to reflect the hospice services provided. An interview was conducted with S2DON on 02/12/2025 at 11:08 a.m. She confirmed Resident #136 began receiving hospice services on 04/30/2024. She reviewed Resident #136's MDS with an ARD of 12/18/2024 and confirmed it was inaccurately coded to reflect the hospice services provided. 47191

Based on observations and interviews, the facility failed to ensure nurse staffing data was posted in a prominent place readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 157 residents residing in the facility. Findings: A tour was conducted of all facility common areas on 02/10/2025 at 9:50 a.m. Observations revealed there was no nurse staffing data posted. An interview was conducted with S8UC on 02/10/2025 at 10:03 a.m. She stated she was responsible for writing the nurse staffing data on the facility's form. She stated she kept the form in a binder behind the nurses' station. She confirmed a resident or family member would have to ask to view the nurse staffing data. She confirmed the nurse staffing data was not posted in a prominent area readily accessible to residents and visitors. An interview was conducted with S1ADM on 02/10/2025 at 10:07 a.m. He confirmed the facility's nurse staffing data was not posted in a prominent area readily accessible to residents and visitors.

Based on record review and interviews, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted timely for 1 (#1) of a total of 16 sampled residents reviewed for Resident Assessment. Findings: Review of the facility policy titled, MDS Policy and Procedure, with an effective date of 06/25/2015, revealed the following, in part: All Minimum Data Set (MDS) are to be completed and transmitted according to the most current Resident Assessment Instrument manual. Resident #1 Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE]. On 10/14/2024, review of Resident #1's Admission MDS with an ARD of 08/30/2024 revealed the MDS was incomplete and had a status of in progress. On 10/14/2024, review of Resident #1's Quarterly MDS with an ARD of 09/11/2024 revealed the MDS assessment was incomplete and had a status of in progress. On 10/15/2024 at 1:10 p.m., an interview was conducted with S4MDS. She reviewed the above MDS assessments and confirmed they were not completed within the required 14 days after the ARD date and had not been transmitted to CMS. On 10/15/2024 at 1:27 p.m., an interview was conducted with S2DON. She reviewed the above MDS assessments and confirmed they were not completed within the required 14 days after the ARD date and had not been transmitted to CMS.

Based on record reviews and interviews, the facility failed to ensure alleged violations involving verbal abuse were reported immediately, but not later than 2 hours after the allegation was made to the administrator and to the state survey agency for 1 (#8) of 4 (#4, #6, #7, and #8) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse Prevention and Prohibition Policy, dated 03/25/2023, revealed, in part: Policy: If you suspect verbal abuse of a resident or mistreatment of a resident contact the Administrator immediately. Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/2024 revealed a Brief Interview for Mental Status (BIMS) of 15, indicating he was cognitively intact. Review of the facility's Investigative Reports submitted to the state survey agency dated May 2024 to October 2024 revealed there were no reports filed for Resident #8. On 10/18/2024 at 12:48 p.m., an interview was conducted with Resident #8. He stated a few weeks ago S8CNA came up to him, waved her finger in his face and cursed at him. Resident #8 stated he felt angry after this incident. On 10/18/2024 at 3:10 p.m., an interview was conducted with S9LPN. She confirmed she was the nurse present during an incident involving S8CNA and Resident #8 in September 2024. She stated Resident #8 was yelling and cursing at the resident. She stated S8CNA pointed her finger at Resident #8 and called him a racist. She confirmed yelling and cursing was verbal abuse. She stated she did not report this incident to anyone and should have. On 10/18/2024 at 2:52 p.m., an interview was conducted with S1ADM. He stated he was not aware of the incident involving S8CNA and Resident #8 in September 2024. He stated he would have expected staff to report any allegation of abuse immediately. He confirmed the allegation of verbal abuse should have been reported to the state survey agency within 2 hours.

Based on interviews and record reviews, the facility failed to ensure services were provided to meet quality professional standards. The facility failed to ensure physicians orders were obtained and clarified upon readmission from the hospital for 2 (#64, and #500) of 4 (#49, #64, #149, and #500) residents reviewed for hospitalization s. This deficient practice resulted in an Immediate Jeopardy situation on 03/16/2024 at 9:00 p.m., when Resident #500 returned to the facility without hospital discharge orders. Resident #500 was admitted to the hospital on 03/15/2024 with symptoms including facial edema, tongue swelling, disoriented, and difficulty breathing. The hospital diagnoses was anaphylactic allergic reaction to Amiodarone. The facility failed to obtain records and orders from the hospital upon readmission on 03/16/2024 and Amiodarone 200 mg BID remained on the eMAR. On 03/18/2024 at 8:00 a.m., S20LPN administered Amiodarone to Resident #500. S1ADM was notified of the Immediate Jeopardy situation on 03/19/2024 at 5:55 p.m. The Immediate Jeopardy was removed on 03/20/2024 at 2:12 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for any resident in the facility that returned from the hospital with new diagnoses and/or orders. Findings: Resident #500 Review of Resident #500's clinical record revealed a facility admitted [DATE]. On 03/15/2024, Resident #500 was admitted to the hospital and diagnosed with an allergic reaction to Amiodarone and returned to the facility on [DATE]. Review of Resident #500's quarterly MDS with an ARD of 12/20/2023 revealed a BIMS of 15, which indicated she was cognitively intact. Review of Resident #500's Physician Orders dated March 2024 revealed an active order for Amiodarone 200 mg BID with a start date of 03/06/2024. Review of Resident #500's Nurses' Notes dated March 15, 2024 revealed, in part: 03/15/2024 at 6:45 a.m., S21LPN noted resident was stating that she could not breathe. Resident #500 had her O2 concentrator as high as it could go and was also on her portable tank set at 4 liters. BP 194/149, Pulse ranged from 88-127, Temperature 97.7, Respirations 32, O2 Saturation ranged from 78%-92%. Resident #500 continued stating I can't breathe! Gave resident a breathing treatment with the solution and she stated that it was not working. At 6:55 a.m. call placed to on call NP and verbal order was given to send resident to the hospital. Resident #500 refused to go to the hospital at that time. 03/15/2024 at 11:40 a.m., S22LPN entered room. Resident #500 found sitting in bed with facial edema. Upon assessment, Resident #500's tongue was swollen and she was disoriented. O2 Sats were 66% on room air. Resident #500's O2 Sats 86% on 3L. NP was called and notified of change. Resident #500 agreed to go to hospital. Review of Resident #500's hospital records dated 03/15/2024 to 03/16/2024 revealed the following, in part: Reason for hospitalization was facial edema and tongue swelling. Anaphylaxis likely secondary to Amiodarone. Discharge instructions included to use Epipen as needed for anaphylactic reactions and Do not take Amiodarone. Review of Resident #500's Nurses' Notes dated 03/16/2024 at 10:15 p.m.: Resident #500 returned from local hospital via ambulance at approximately 9:00 p.m. S23LPN received a prescription for an epi-pen from local hospital, which was faxed to the facility contracted pharmacy. Signed by S23LPN Review of Resident #500's eMAR dated March 2024, revealed Amiodarone 200 mg tablet BID was not discontinued upon readmission to the facility at 9:00 p.m. on 03/16/2024. Further review revealed the medication was documented as administered on 03/18/2024 at 8:00 a.m. An interview was conducted with Resident #500 on 03/18/2024 at 10:51 a.m. She reported she went to the hospital for having an allergic reaction to a medicine. She stated the hospital discontinued Amiodarone. An interview was conducted with S20LPN on 03/19/2024 at 2:18 p.m. She stated when a resident was readmitted to the facility, the receiving nurse was responsible for obtaining and entering new orders into the system. S20LPN reviewed Resident #500's physician's orders and eMAR and confirmed Amiodarone 200 mg BID was not discontinued on 03/16/2024 when the resident returned from the hospital. After further review of the eMAR, S20LPN she stated S23LPN attempted to administer Amiodarone 200 mg to Resident #500 on 03/17/2024 at 8:00 a.m. and 4:00 p.m., but the resident refused to take the Amiodarone. S20LPN stated on 03/18/2024 at 8:00 a.m., she put all of Resident #500's pills, including Amiodarone 200 mg, into one pill cup prior to entering the resident's room. She stated Resident #500 took all the medications in the pill cup at that time. She stated after the resident consumed the medications, Resident #500 asked if the Amiodarone was in the pill cup. S20LPN said she told the resident yes, and Resident #500 stated she did not want to take that medication again. S20LPN confirmed she did not know Resident #500 had an allergic reaction to Amiodarone 200 mg and the medication should have been discontinued upon return from the hospital on 03/16/2024. An interview was conducted with S23LPN on 03/19/2024 at 2:56 p.m. S23LPN confirmed he readmitted Resident #500 to the facility on [DATE] and did not contact the hospital or facility physician to obtain or clarify orders for Resident #500. An interview was conducted with S8NP on 03/19/2024 at 2:29 p.m. S8NP reviewed Resident #500's discharge orders and stated Resident #500 had an allergic reaction to Amiodarone on 03/15/2024 that required hospital admission. S8NP stated the facility staff should have followed the discharge orders from the hospital and discontinued Amiodarone upon the resident's return on 03/16/2024. An interview was conducted with S24RPH on 03/20/2024 at 3:40 p.m. S24RPH stated the facility should notify the pharmacy when a medication was discontinued. She stated if a resident had an allergic/anaphylactic reaction to a medication it should be immediately discontinued, he confirmed that the half-life of Amiodarone was 26 to 107 days, and a resident could have a reaction at any time to a medication. S24RPH confirmed a medication reaction could occur within the first dose or 24 hours or at any time after the medication is administered. Resident #64 Review of clinical record for Resident #64 revealed was readmitted to the facility on [DATE] with an indwelling urinary catheter. Review of Resident #64's Quarterly MDS with an ARD of 01/31/2024 revealed Resident #64 was incontinent of bladder with an indwelling catheter. Review of Resident #64's local hospital discharge records dated 01/22/2024 revealed no orders for catheter care. Review of Resident #64's current Physician Orders revealed no orders for an indwelling catheter from 01/22/2024 until 03/19/2024. On 03/18/2024 at 9:30 a.m., an observation was made of Resident #64 lying in bed with an indwelling catheter. On 03/19/2024 at 2:45 p.m., an interview was conducted with S18LPN. S18LPN stated a physician's order was required for resident catheter changes and care. S18LPN stated S3WNC was responsible for changing resident's catheters. After reviewing Resident #64's active orders, S18LPN confirmed there was not an order for catheter care and catheter changes prior to 03/19/2024. On 03/20/2024 at 9:06 a.m., an interview was conducted with S3WCN. She stated she was responsible for completing catheter changes. She stated she was not aware Resident #64 had a catheter. After reviewing Resident #64's active orders, S3WCN confirmed there was not an order for indwelling catheter changes or daily catheter care. On 03/20/2024 at 10:45 a.m., an interview was conducted with S30LPN. She stated she was the nurse on duty when Resident #64 returned from the hospital on 01/22/2024. S30LPN stated Resident #64 had a catheter when he returned to the facility. She stated Resident #64 did not return to facility with discharge paperwork. S30LPN stated she did not call the on call nurse practitioner to obtain or clarify orders related to the urinary catheter. On 03/20/2024 at 11:58 a.m., an interview was conducted with S2ADON. She stated an order was required for catheter changes and catheter care. After reviewing Resident #64's current orders January to March 2024, S2ADON confirmed there was not an order for catheter care and catheter changes prior to 03/19/2024. She stated if a resident did not have orders for needed care she expected her staff to call the on call nurse practitioner to obtain orders. 48912

Based on record review, observations, and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 158 residents who were served from the kitchen. Findings: Review of the 10/2018 revised facility's policy titled Storage of Refrigerated Food on 03/20/2024 revealed the following, in part: Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: 3. Food taken out of original containers is put in a clean sanitized container with a tight fitting lid. No food is left uncovered. 4. All non-hazardous, opened foods are labeled with name of food and date stored. 5. All hazardous foods are labeled with name of food and date to be discarded or the date stored. Cooked foods are held no longer than 48 hours. Review of the 10/2018 revised facility's policy titled Storage of Frozen Food on 03/20/2024 revealed the following, in part Policy: The facility ensures the quality and safety of frozen foods through accepted storage practices. Procedure: 5. Food taken out of original containers is put in a clean sanitized container with a tight fitting lid. No food is left uncovered. 6. Frozen foods that are stored in open containers or packages are labeled with name of food and date stored. 7. Opened boxes with liners should be closed and sealed tightly with packing tape. Review of the 10/2018 revised facility's policy titled Storage of Canned and Dry Food on 03/20/2024 revealed the following, in part: Policy: The facility ensures the quality and safety of canned and dry foods through accepted storage practices. Procedure: 6. Opened packages are stored in tightly covered containers. Zip lock bags may be used. 7. Opened packages are labeled with name of product and date opened. 8. Bins may be used for bulk foods. Remove the food from packaging and store in clean sanitized bins. Store scoop separately in clean, covered container. On 03/18/2024 at 8:20 a.m., an initial tour of the kitchen was conducted with S11DW. The following observations were made and confirmed: Refrigerator -A package of Ham was opened, unsealed, and undated. -A jug of Cultured Low Fat Buttermilk with an expiration date of 03/13/2024. -A pack of tortillas wrapped in cellophane with no date. -A clear plastic container of scrambled eggs not labeled or dated. -A clear plastic container of beets with no date. Freezer -8 blue cups of frozen lemonade without lids. -A bag of seasoning opened and unsealed. -A bag of biscuits opened and unsealed. On 03/18/2024 at 8:34 a.m., a tour of the kitchen was conducted with S10DM. The following observations were made and confirmed -A bulk container contained a bag of opened unsealed rice, the container lid was open and a clear plastic pitcher was stored in the rice. -22 bowls of dry cereal were covered with cellophane with no dates. On 03/18/2024 at 8:34 a.m., an interview was conducted with S10DM. She was notified of the aforementioned findings made with S11DW. She confirmed all opened items should be labeled and dated. She confirmed the frozen lemonade should have had lids. On 03/18/2024 at 11:13 a.m., a follow-up visit was conducted to the kitchen. On a silver metal table, stacks of bowls were observed along with a tray of silverware wrapped in napkins. There were 5 cups with lids located between the bowls and wrapped silverware. On 03/18/2024 at 11:13 a.m. an interview was conducted with S10DM. She confirmed the bowls and wrapped silverware were intended for resident use. She confirmed the five lidded cups belonged to staff. She confirmed staff cups should not be placed with resident dishes. On 03/19/2024 at 3:21 p.m., an interview was conducted with S1ADM. He was notified of the aforementioned findings. He confirmed opened food items should be labeled, dated, and sealed. He confirmed staff cups should be stored in the breakroom and not with resident dishes.

Based on record review, observations, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 (Cart A and Cart B) of 3 (Cart A, Cart B, and Cart C) medication carts observed. The facility failed to ensure: 1. Insulin pens were labeled with the date opened; 2. Insulin pens were discarded 28 days after the date opened; and 3. Insulin pens were labeled with resident identification. Findings: Review of the updated 04/2023 facility's policy titled PCSA - Medications with Shortened Expiration Dates, on 03/18/2024, revealed, in part: Review of the Lantus (Insulin Glargine) revealed the following, in part: Expiration time after puncturing or placing at room temperature - 28 days. Review of Novolog Flexpen revealed the following, in part: Expiration time after puncturing or placing at room temperature - 28 days. Review of Levimir Flexpen revealed the following, in part: Expiration time after puncturing or placing at room temperature - 42 days. Cart A: An observation was made of Cart A on 03/18/2024 at 1:25 p.m. with S18LPN who confirmed the below observation: Resident # 9 - Novolin R insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. Resident #21 - Novolin R insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. Resident #21 - Lantus insulin pen was open, in use and not dated to indicate when the insulin pen was opened. Resident #32 - Novolin R insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. Resident # 35 - Novolin R insulin pen was open, in use and not dated to indicate when the insulin pen was opened. Resident #48 - Lantus insulin pen was open, in use and not dated to indicate when the insulin pen was opened. Resident #112 - Levimir insulin pen was open, in use and not dated to indicate when the insulin pen was opened. An interview was conducted with S18LPN following the above observation. S18LPN stated insulin pens should have been labeled with the open date and discarded 28 days after opening and they were not. Cart B: An observation was made of Cart B on 03/18/2024 at 1:45 p.m. with S6LPN who confirmed the below observation: Resident #105 - Lantus insulin pen was open, in use and did not have any label indicating it was for Resident #105, or when it was opened. An interview was conducted with S6LPN following the above observation. S6LPN stated insulin pen should be labeled with the resident ID, open date and discarded 28 days after opening and it was not. An interview was conducted with S2ADON on 03/18/2024 at 2:10 p.m. She confirmed the facility uses the PCSA - Medications with Shortened Expiration Dates guideline. She stated insulin pens should be labeled with the resident ID, open date and discarded per this guideline and were not.

48912 Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 2 (#64, #113) of 4 (#64, #80, #113 and #116) residents reviewed for ADL's. The facility failed to trim fingernails for Resident #64 and #113. Findings: Review of the facility's policy, Bath, Bed Policy and Procedure, dated 08/01/2017, revealed the following, in part: Procedure: 16. Care of fingernails and toenails are part of the bath. Be certain nails are clean. Inform the charge nurse if a resident needs his/her toenails cut if they are diabetic or have poor circulation. 17. Fingernails and toenails of diabetic residents are cut by the licensed nurse or podiatrist. Resident #64 Review of the Medical Record for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness and Need for Assistance with Personal Care. Review of the most recent MDS (Minimum Data Set) for Resident #64 with an ARD (Assessment Reference Date) of 01/31/2024 revealed Resident #64 had a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident was cognitively intact. Further review revealed Resident #64 required substantial assistance for ADLs. Review of the current Physician Orders for Resident #64 revealed no orders for nail care. On 03/18/2024 at 12:32 p.m., an observation and interview was conducted of Resident #64. His fingernails were long, jagged and approximately 0.5 cm past the tip of all 10 fingers. Resident #64 stated his nails were too long and he wanted them trimmed. On 03/19/2024 at 8:35 a.m., an observation was made of Resident #64. His fingernails were long, jagged and approximately 0.5 cm past the tip of all 10 fingers. Resident #113 Review of the Medical Record for Resident #113 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Orthopedic aftercare following Surgical Amputation and Rheumatoid Arthritis. Review of the most recent MDS for Resident #113 with an ARD of 02/21/2024 revealed Resident #113 had a BIMS of 15, which indicated the resident was cognitively intact. Further review revealed Resident #113 required substantial assistance for ADLs. Review of the current Physician Orders for Resident #113 revealed no orders for nail care. On 03/18/2024 at 9:31 a.m., an observation and interview was conducted of Resident #113. Resident #113's fingernails were long, jagged and approximately 1-2 cm past the tip of all 10 fingers with black substance noted underneath. Resident #113 stated she did not like her nails long because they got dirty and wanted them trimmed. On 03/19/2024 at 8:53 a.m., an observation was made of Resident #113. Her fingernails were long, jagged and approximately 1-2 cm past the tip of all 10 fingers with black substance noted underneath. On 03/19/2024 at 9:16 a.m., an interview was conducted with S4CNA. She stated the wound care nurse was responsible for nail care for the residents. On 03/19/2024 at 1:02 p.m., an interview was conducted with S3WCN. She stated the wound care nurse was responsible for nail care and all residents should have an order for monthly nail care. She reviewed Resident #113's current physician orders and confirmed Resident #113 did not have any nail care orders and should have. An observation was made at this time of Resident #113 with S3WCN. S3WCN confirmed Resident #113's nails were long, jagged, approximately 1-2 cm past the tip of all 10 fingers with black substance noted underneath and needed to be trimmed. On 03/19/2024 at 1:21 p.m., an interview was conducted with S3WCN. She reviewed Resident #64's current physician orders and confirmed Resident #64 did not have any nail care orders and should have. An observation was made at this time of Resident #64 with S3WCN. S3WCN confirmed Resident #64's nails were long, jagged, approximately 0.5 cm past the tip of all 10 fingers and needed to be trimmed. On 03/19/2024 at 1:29 p.m., an interview was conducted with S2ADON. She confirmed all residents should have monthly nail care orders, and she would expect resident's nails to be trimmed and cleaned.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 2 (#64, #113) of 4 (#64, #80, #113 and #116) residents reviewed for ADL's. The facility failed to trim fingernails for Resident #64 and #113. Findings: Review of the facility's policy, Bath, Bed Policy and Procedure, dated 08/01/2017, revealed the following, in part: Procedure: 16. Care of fingernails and toenails are part of the bath. Be certain nails are clean. Inform the charge nurse if a resident needs his/her toenails cut if they are diabetic or have poor circulation. 17. Fingernails and toenails of diabetic residents are cut by the licensed nurse or podiatrist. Resident #64 Review of the Medical Record for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness and Need for Assistance with Personal Care. Review of the most recent MDS (Minimum Data Set) for Resident #64 with an ARD (Assessment Reference Date) of 01/31/2024 revealed Resident #64 had a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident was cognitively intact. Further review revealed Resident #64 required substantial assistance for ADLs. Review of the current Physician Orders for Resident #64 revealed no orders for nail care. On 03/18/2024 at 12:32 p.m., an observation and interview was conducted of Resident #64. His fingernails were long, jagged and approximately 0.5 cm past the tip of all 10 fingers. Resident #64 stated his nails were too long and he wanted them trimmed. On 03/19/2024 at 8:35 a.m., an observation was made of Resident #64. His fingernails were long, jagged and approximately 0.5 cm past the tip of all 10 fingers. Resident #113 Review of the Medical Record for Resident #113 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Orthopedic aftercare following Surgical Amputation and Rheumatoid Arthritis. Review of the most recent MDS for Resident #113 with an ARD of 02/21/2024 revealed Resident #113 had a BIMS of 15, which indicated the resident was cognitively intact. Further review revealed Resident #113 required substantial assistance for ADLs. Review of the current Physician Orders for Resident #113 revealed no orders for nail care. On 03/18/2024 at 9:31 a.m., an observation and interview was conducted of Resident #113. Resident #113's fingernails were long, jagged and approximately 1-2 cm past the tip of all 10 fingers with black substance noted underneath. Resident #113 stated she did not like her nails long because they got dirty and wanted them trimmed. On 03/19/2024 at 8:53 a.m., an observation was made of Resident #113. Her fingernails were long, jagged and approximately 1-2 cm past the tip of all 10 fingers with black substance noted underneath. On 03/19/2024 at 9:16 a.m., an interview was conducted with S4CNA. She stated the wound care nurse was responsible for nail care for the residents. On 03/19/2024 at 1:02 p.m., an interview was conducted with S3WCN. She stated the wound care nurse was responsible for nail care and all residents should have an order for monthly nail care. She reviewed Resident #113's current physician orders and confirmed Resident #113 did not have any nail care orders and should have. An observation was made at this time of Resident #113 with S3WCN. S3WCN confirmed Resident #113's nails were long, jagged, approximately 1-2 cm past the tip of all 10 fingers with black substance noted underneath and needed to be trimmed. On 03/19/2024 at 1:21 p.m., an interview was conducted with S3WCN. She reviewed Resident #64's current physician orders and confirmed Resident #64 did not have any nail care orders and should have. An observation was made at this time of Resident #64 with S3WCN. S3WCN confirmed Resident #64's nails were long, jagged, approximately 0.5 cm past the tip of all 10 fingers and needed to be trimmed. On 03/19/2024 at 1:29 p.m., an interview was conducted with S2ADON. She confirmed all residents should have monthly nail care orders, and she would expect resident's nails to be trimmed and cleaned.

Based on record review and interviews, the facility failed to initiate and resolve grievances voiced for 1 (#114) of 34 sampled residents reviewed for grievances. Findings: Review of the facility's policy titled, Grievance Policy and Procedure, reviewed on 03/19/2024, and dated 10/10/2022 revealed the following, in part: Policy: The resident, family member, visitor, volunteer individual or employee has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Documentation: 1. Document grievances made by a resident, resident's family member . the grievance shall include: a. Date the grievance was received. b. A summary statement of the grievance. c. Steps taken to investigate the grievance. d. A summary of the pertinent findings or conclusions regarding the concerns. i. Record the grievance on the facility's Grievance log. Follow Up/Resolution: 1. The grievance official/compliance liaison or designee will follow up with the complainant with a resolution within 5 business days of the date that the grievance was filed. Review of the Quarterly MDS with an ARD of 03/13/2024 revealed Resident #114 had a BIMS of 9 which indicated moderate impairment. Review of the facility's Grievance Log from 10/01/2023 to current revealed no grievances were filed for Resident #114. On 03/18/2024 at 11:19 a.m., an interview was conducted with Resident #114 and his niece. Resident #114's niece stated she made multiple complaints about missing clothing and they have not been replaced. She stated she last reported missing clothing in January 2024 to S1ADM and laundry department. On 03/20/2024 at 4:00 p.m., an interview was conducted with S1ADM. He stated the social services directors were responsible for completing grievances. S1ADM stated he was not aware of Resident #114 ever missing any clothing items. On 03/21/2024 at 8:11 a.m., an interview was conducted with S18LPN. She stated family did report to her Resident #114 was missing some clothing a couple months ago and she reported it to the laundry department. S18LPN stated family member also went to laundry department to report Resident #114 was missing some clothing. On 03/21/2024 at 8:36 a.m. an interview was conducted with S27HKS. She stated there were reports made to her about Resident #114 missing some clothing. On 03/21/2024 at 8:45 a.m., an interview was conducted with S28SSD. She confirmed social services was responsible for completing grievances. She stated no one informed her Resident #114 was missing any clothing. She stated staff should have reported it to her. S28SSD confirmed a grievance should have been completed and S1ADM should have been informed for Resident #114 missing clothing.

Based on record review and interviews, the facility failed to be administered in a manner which enabled the effective and efficient use of resources to ensure an effective system was in place to ensure Advance Directives would be followed appropriately for 4 (#81, #112, #143, and #136) of the 30 sampled and 3 random residents reviewed for Advanced Directives. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:45 a.m., when S8LPN stopped performing CPR on Resident #143 due to a discrepancy in the resident's code status. S8LPN performed CPR for 5 minutes before stopping after a facility staff discovered Resident #143 had conflicting advance directive wishes that designated both DNR and full code status. Death was pronounced for Resident #143 on [DATE] at 6:30 a.m. Further record review revealed Resident #81, Resident #112, and Resident #136 had discrepancies with their documented code statuses and interviews confirmed staff did not know which code status to follow in case of an emergency. S1ADM was notified of the Immediate Jeopardy on [DATE] at 4:00 p.m. The Immediate Jeopardy Plan of Removal included the following information: 1. Corrective actions for alleged deficient practice were accomplished for Resident #81, Resident #112, Resident #136, Resident #394, by the following: a. Resident #81, order clarification written for DNR to match Advance Directive, completed [DATE] b. Resident #112, order clarification written for DNR to match Advance Directive, completed [DATE] c. Resident #136, order clarification written for DNR to match Advance Directive, completed [DATE] d. Resident #394, order clarification written for DNR to match Advance Directive, completed [DATE] e. Staff Developer, will In-service Nursing staff regarding CPR policy, initiated [DATE], to be completed by [DATE]. Staff will not be allowed to work until signed off. f. Regional Director or Corporate QI Nurse will in-service Staff Developer, who will be presenting in-services to nursing staff, completed [DATE]. g. Corporate QI Nurse, will in-service Social Services that Advanced directives must be changed in the event of a change in physician order, initiated [DATE], completed [DATE]. h. Staff Developer, will in-service Nursing Staff to contact MD or NP for termination of CPR, initiated [DATE], to be completed [DATE]. Staff will not be allowed to work until signed off. i. Corporate QI Nurse will in-service Administrator and Assistant Administrator regarding Advanced Directive policy and procedure and CPR policy and procedure. j. Audit of all Code Status orders to ensure they match what is in resident chart, completed [DATE]. k. Audit of all Code Status orders to ensure they match Advance Directives, [DATE]. 2. All residents have the potential to be affected by this alleged deficient practice 3. The measures put into place to prevent this alleged deficient practice from re-occurring a. Staff Developer, will In-service Nursing staff regarding CPR policy, initiated [DATE], to be completed by [DATE]. Staff will not be allowed to work until signed off. b. Corporate QI Nurse, will in-service Social Services that Advanced directives must be changed in the event of a change in physician order, initiated [DATE], completed [DATE]. c. Staff Developer, will in-service Nursing Staff to contact MD or NP for termination of CPR, initiated [DATE], to be completed [DATE]. Staff will not be allowed to work until signed off d. Corporate QI Nurse will in-service Administrator and Assistant Administrator regarding Advanced Directive policy and procedure and CPR policy and procedure. e. Audit of all Code Status orders to ensure they match what is in resident chart, completed [DATE] f. Audit of all Code Status orders to ensure they match Advance Directives, completed [DATE] g. Follow up CPR and Code Status test for nursing staff to review understanding, initiated [DATE] and to be completed [DATE]. h. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each new admission and ensure physician orders match advance directive, beginning [DATE], to be completed [DATE], expected 100% compliance. i. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident hospital return and ensure physician orders match advance directive beginning [DATE], to be completed [DATE], expected 100% compliance. j. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident quarterly care plan and ensure physician orders match advance directive beginning [DATE] to be completed [DATE], expected 100% compliance. k. Administrator or designee will review discharged residents charts and ensure resident code status was carried out according to policy and procedure, twice per week, ending [DATE]. 4. Facility will monitor its performance to ensure sustained compliance by the following a. Follow up CPR and Code Status test for nursing staff to review understanding, initiated [DATE] and to be completed [DATE]. b. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each new admission and ensure physician orders match advance directive, beginning [DATE], to be completed [DATE], expected 100% compliance. c. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident hospital return and ensure physician orders match advance directive beginning [DATE], to be completed [DATE], expected 100% compliance. d. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident quarterly care plan and ensure physician orders match advance directive beginning [DATE] to be completed [DATE], expected 100% compliance e. Administrator or designee will review discharged residents charts and ensure resident code status was carried out according to policy and procedure, twice per week, ending [DATE]. f. Administrator of designee will review advance directive audit twice per week for compliance, ending [DATE]. g. Regional Director or Corporate QI Nurse will review audits once per week for compliance, ending [DATE]. g. Additional in-servicing and or progressive disciplinary action will occur if further non-compliance is noted. Through interviews and record reviews, the surveyor confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The Immediate Jeopardy was removed on [DATE] at 3:26 p.m. The deficient practice continued at a potential for more than minimum harm for all 149 residents currently residing in the facility. Findings: Review of facility's Advance Directive Policy and Procedure revealed the following: Procedure: Upon admission, the facility will: IV. Determine whether the resident has an advanced directive, and if not determine whether the resident wishes to formulate an advanced directive. a. If the resident or resident's legal representative has executed one or more advance directives, or executes upon admission, the facility will incorporate and maintain a copy in the residents medical record readily retrievable by any facility staff and desired wishes be communicated to the resident's direct care staff and physician. Quarterly as needed the facility will: II. Identify, clarify, and periodically review, as part of the comprehensive care planning process, the existing care instructions on whether the resident wishes to change or continue these instructions. Review of the facility's Cardiopulmonary Resuscitation (CPR) Policy and Procedure reveals: 7. If the resident is unresponsive, apneic, and or only gasping and has elected CPR on his/her advanced medical directives begin basic life support. 8. Continue uninterrupted basic life support measures until you are relieved by another person knowledgeable about CPR, emergency life medical personnel (paramedics, EMT's, etc.) arrives to assume emergency medical care, or a physician pronounces the resident expired. On [DATE] at 10:25 a.m., an interview was conducted with S8LPN. She stated she was called to Resident #143's room where she found her unresponsive on [DATE] at 5:30 a.m. She stated she reviewed Resident #143's paper chart, noted the resident was a Full Code then began CPR. She stated while performing CPR, S5LPN brought an Advanced Directive indicating the resident was a DNR. She explained after the second advance directive was brought in and indicated the resident was a DNR, she and S5LPN made the determination to terminate CPR efforts on [DATE] at 5:35 a.m. She confirmed the coroner arrived on [DATE] at 6:15 a.m., and called time of death at 6:30 a.m. On [DATE] at 2:24 p.m., an interview was conducted with S16LPN. She confirmed she responded to a code for Resident #143 on [DATE]. She explained she was in the room with S8LPN when CPR was initiated. She stated while S8LPN was performing CPR, S5LPN entered the room with an Advanced Directives which indicated Yes to CPR and Yes to DNR. S16LPN She confirmed CPR was stopped at that time. On [DATE] at 2:09 p.m., an interview was conducted with Resident #143's daughter. She stated prior to admission, she completed and electronic advanced directive for the resident which should have indicated a Full Code status. She confirmed she had filled out a second Advance Directive on [DATE] over the phone with S9AC. She confirmed S9AC was made aware Resident #143 was to be a Full Code with CPR initiated in the event of cardiac or respiratory arrest. On [DATE] at 1:05 p.m., an interview was conducted with S17NP. She confirmed she never gave a telephone/verbal order to discontinue CPR for Resident #143. On [DATE] at 2:32 p.m., an interview was conducted with S1ADM. S1ADM reviewed both versions of Resident #143's Advanced Directives and stated he interpreted both to mean Resident #143 was a full code status and staff should have continued CPR until further clarification could be made. He confirmed staff began CPR on Resident #143 and then stopped prior to the resident being pronounced dead by an appropriate entity. On [DATE] at 11:27 a.m. and interview was conducted with S15RCN. S15CRN reviewed both of Resident #143's Advance Directive Consents. S15RCN stated the Resident #143's daughter marked both CPR and DNR on the form. She confirmed the resident's wishes were unclear and she would expect staff to refer to the physician's order for further clarification. On [DATE] at 9:24 a.m., an interview was conducted with S9AC. She stated upon admission, either the resident or their responsible party would fill out the Advance Directive Consent. She stated she would then scan the completed consent email it to S3ADON, S8LPN, S7LPN and S12AADM. She stated S7LPN was responsible for entering the order into the resident's medical record. She confirmed any changes made to a resident's code status should have been updated immediately throughout their medical record. On [DATE] at 9:43 a.m., an interview was conducted with S7LPN. She stated Advanced Directives were completed by S9AC upon admission then emailed to her to enter as Physician's Orders into the EHR. She stated for current residents, any changes made to their Advanced Directives or Physician's orders would be brought to her to update the EHR. She confirmed she was the only person responsible for entering a residents' Advance Directive and Code Status into their medical record as a Physician's Order. She also confirmed she had been expected to perform chart audits weekly to ensure accuracy of Advanced Directives but had not conducted them. She then confirmed she was directed by S1ADM to change the Physician's orders for Resident #112 and Resident #136 to DNR on the morning of [DATE] to match their signed Advanced Directive. She stated prior to making those changes, both Resident #112 and Resident #136 had a physician's order for a full code in their EHR. She further confirmed Resident #81's February 2023 Physician's Order for Full Code status was incorrect because the resident signed an Advanced Directive indicating DNR status. On [DATE] at 2:41 p.m., an interview was conducted with S14CQIN. She confirmed S1ADM made her aware of the discrepancies with Resident #143's Advanced Directive on [DATE] after she expired. She confirmed the facility swapped to an electronic Advanced Directive several months ago and family members had difficulty understanding and completing the new form to correctly reflect their wishes regarding code status. S14CQIN reviewed both of Resident #143's Advance Directive consents and stated she interpreted both to mean Resident #143 was a full code status and staff should have continued CPR until further clarification could be made. On [DATE] at 12:58 p.m., an interview was conducted with S1ADM. He confirmed following Resident #143's death on [DATE], he found discrepancies regarding her Advanced Directive. He stated he also identified CPR had been initiated for her then stopped without a physician's order or the presence of EMS assuming her care. He confirmed the facility opened the QA process for Advance Directives as of [DATE] and all charts were audited by S12AADM to ensure accuracy. He then confirmed there were current discrepancies present for Resident #81, Resident #112 and Resident #136. Cross Reference 678 47732

46642 47732 Based on interviews and record reviews, the facility failed to ensure an effective system was in place for advanced directives. The facility failed to ensure: 1. Advanced directives were correctly implemented for 1 (#143) of 4 (#143, #344, #345, and #346) residents reviewed that expired; and 2. Resident's medical records accurately reflected the residents' wishes for emergency basic life support for 3 (#81, #112, and #136) of the 30 sampled and 3 random residents reviewed for Advanced Directives. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:45 a.m., when S8LPN stopped performing CPR on Resident #143 due to a discrepancy in the resident's code status. S8LPN performed CPR for 5 minutes before stopping after a facility staff discovered Resident #143 had conflicting advance directive wishes that designated both DNR and full code status. Death was pronounced for Resident #143 on [DATE] at 6:30 a.m. Further record review revealed Resident #81, Resident #112, and Resident #136 had discrepancies with their documented code statuses and interviews confirmed staff did not know which code status to follow in case of an emergency. S1ADM was notified of the Immediate Jeopardy situation on [DATE] at 4:00 p.m. The Immediate Jeopardy Plan of removal included the following information: 1. Corrective actions for alleged deficient practice were accomplished for Resident #81, Resident #112, Resident #136, Resident #394, by the following: a. Resident #81, order clarification written for DNR to match Advance Directive, completed [DATE] b. Resident #112, order clarification written for DNR to match Advance Directive, completed [DATE] c. Resident #136, order clarification written for DNR to match Advance Directive, completed [DATE] d. Resident #394, order clarification written for DNR to match Advance Directive, completed [DATE] e. Staff Developer, will In-service Nursing staff regarding CPR policy, initiated [DATE], to be completed by [DATE]. Staff will not be allowed to work until signed off. f. Regional Director or Corporate QI Nurse will in-service Staff Developer, who will be presenting in-services to nursing staff, completed [DATE]. g. Corporate QI Nurse, will in-service Social Services that Advanced directives must be changed in the event of a change in physician order, initiated [DATE], completed [DATE]. h. Staff Developer will in-service Nursing Staff to contact MD or NP for termination of CPR, initiated [DATE], to be completed [DATE]. Staff will not be allowed to work until signed off. i. Corporate QI Nurse will in-service Administrator and Assistant Administrator regarding Advanced Directive policy and procedure and CPR policy and procedure. j. Audit of all Code Status orders to ensure they match what is in resident chart, completed [DATE]. k. Audit of all Code Status orders to ensure they match Advance Directives, [DATE]. 2. All residents have the potential to be affected by this alleged deficient practice 3. The measures put into place to prevent this alleged deficient practice from re-occurring a. Staff Developer will in-service Nursing Staff regarding CPR policy, initiated [DATE], to be completed by [DATE]. Staff will not be allowed to work until signed off. b. Corporate QI Nurse will in-service Social Services that Advanced directives must be changed in the event of a change in physician order, initiated [DATE], and completed [DATE]. c. Staff Developer will in-service Nursing Staff to contact MD or NP for termination of CPR, initiated [DATE], to be completed [DATE]. Staff will not be allowed to work until signed off. d. Corporate QI Nurse will in-service Administrator and Assistant Administrator regarding Advanced Directive policy and procedure and CPR policy and procedure. e. Audit of all Code Status orders to ensure they match what is in resident chart, completed [DATE] f. Audit of all Code Status orders to ensure they match Advance Directives, completed [DATE] g. Follow up CPR and Code Status test for nursing staff to review understanding, initiated [DATE] and to be completed [DATE]. h. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each new admission and ensure physician orders match advance directive, beginning [DATE], to be completed [DATE], expected 100% compliance. i. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident hospital return and ensure physician orders match advance directive beginning [DATE], to be completed [DATE], expected 100% compliance. j. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident quarterly care plan and ensure physician orders match advance directive beginning [DATE] to be completed [DATE], expected 100% compliance. k. Administrator or designee will review discharged residents charts and ensure resident code status was carried out according to policy and procedure, twice per week, ending [DATE]. 4. Facility will monitor its performance to ensure sustained compliance by the following a. Follow up CPR and Code Status test for nursing staff to review understanding, initiated [DATE] and to be completed [DATE]. b. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each new admission and ensure physician orders match advance directive, beginning [DATE], to be completed [DATE], expected 100% compliance. c. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident hospital return and ensure physician orders match advance directive beginning [DATE], to be completed [DATE], expected 100% compliance. d. Administrator, DON, Admissions, Data Entry and SSD will utilize an audit tool (See Attached) to review each resident quarterly care plan and ensure physician orders match advance directive beginning [DATE] to be completed [DATE], expected 100% compliance. e. Administrator or designee will review discharged residents charts and ensure resident code status was carried out according to policy and procedure, twice per week, ending [DATE]. f. Administrator of designee will review advance directive audit twice per week for compliance, ending [DATE]. g. Regional Director or Corporate QI Nurse will review audits once per week for compliance, ending [DATE]. h. Additional in-servicing and or progressive disciplinary action will occur if further non-compliance is noted Through interviews and record reviews, the surveyor confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The Immediate Jeopardy was removed on [DATE] at 3:26 p.m. The deficient practice continued at a potential for more than minimum harm for all 149 residents currently residing in the facility. Findings: Review of facility's Advance Directive Policy and Procedure revealed the following: Upon admission, the facility will: IV. Determine whether the resident has an advanced directive, and if not determine whether the resident wishes to formulate an advanced directive. a. If the resident or resident's legal representative has executed one or more advance directives, or executes upon admission, the facility will incorporate and maintain a copy in the residents medical record readily retrievable by any facility staff, and desired wishes be communicated to the resident's direct care staff and physician. Quarterly as needed the facility will: II. Identify, clarify, and periodically review, as part of the comprehensive care planning process, the existing care instructions on whether the resident wishes to change or continue these instructions. Review of the facility's Cardiopulmonary Resuscitation (CPR) Policy and Procedure revealed, in part, the following: 7. If the resident is unresponsive, apneic, and or only gasping and has elected CPR on his/her advanced medical directives begin basic life support. 8. Continue uninterrupted basic life support measures until you are relieved by another person knowledgeable about CPR, emergency life medical personnel (paramedics, EMT's, etc.) arrives to assume emergency medical care, or a physician pronounces the resident expired. Resident #143 Review of Resident #143's Clinical Record revealed she was admitted to the facility on [DATE] and expired on [DATE]. Review of Resident #143's Advanced Directives revealed, in part, the following: On [DATE], the resident's daughter indicated Resident #143 should be a Full Code. On [DATE], the resident's daughter indicated Resident #143 should be both a Full Code and DNR. Review of Resident #143's Physician Orders revealed, in part, the following: [DATE] - Code Status: Full Code. Review of Resident #143's Nurses Notes revealed [DATE] at 5:30 a.m., S8LPN had been called to Resident #143's room where she found her unresponsive and began CPR. Another nurse was getting paperwork together when she noticed DNR was marked on Advanced Directive Consent. CPR was stopped. Resident's daughter was notified and arrived at the facility. Coroner arrived at 6:15 a.m., assessed resident and called 6:30 a.m. as time of death. On [DATE] at 8:55 a.m., an interview was conducted with S6LPN. She confirmed in the event a resident coded, a nurse would be expected to locate and confirm the resident's code status. She then confirmed the Code status could be found in multiple locations; the hard chart and the physician's orders. She stated she would look in the EHR on the resident's face sheet or MAR to find the code status. She stated if she were in the nurse's station, she would look in the resident's hard chart. On [DATE] at 9:24 a.m., an interview was conducted with S9AC. She stated upon admission, either the resident or their responsible party would fill out the Advance Directive Consent. She stated the completed consent would then be scanned and emailed to S3ADON, S8LPN, S7LPN and S12AADM. She stated S7PN was responsible for entering the order into the resident's medical record. She confirmed any changes made to a resident's code status should be updated immediately throughout the medical record. On [DATE] at 9:43 a.m., an interview was conducted with S7LPN. She stated Advanced Directives were completed by S9AC upon admission then emailed to her to enter as Physician's Orders into the EHR. She stated for current residents, any changes made to their Advanced Directives or Physician's orders would be brought to her to update them in the EHR. She confirmed she was the only person responsible for entering a resident's Advance Directive and Code Status into their medical record as a Physician's Order. She also confirmed she had been expected to perform chart audits weekly to ensure accuracy of Advanced Directives but had not conducted them as she should have. She confirmed she was directed by Administration to change the Physician's Orders for Resident #112 and Resident #136 to a DNR on the morning of [DATE] to match their signed Advanced Directive. She then confirmed prior to making those changes, both Resident #112 and Resident #136 had a Physician's Order for Full code status. She then confirmed Resident #81's February 2023 Physician's Order for Full Code status was incorrect based on the presence of a signed Advanced Directives indicating DNR status. On [DATE] at 10:25 a.m., an interview was conducted with S8LPN. She stated she was called to Resident #143's room where she found her unresponsive. She stated she reviewed Resident #143's paper chart, noted the resident was a Full Code then began CPR. She stated while performing CPR, S5LPN brought an Advanced Directive indicating the resident was a DNR. She explained after the second advance directive was brought in and indicated the resident was a DNR, she and S5LPN made the determination to terminate CPR efforts on [DATE] at 5:35 a.m. She confirmed the coroner arrived on [DATE] at 6:15 a.m., and called time of death at 6:30 a.m. On [DATE] at 2:18 p.m., an interview was conducted with S5LPN. She confirmed she responded to the code for Resident #143 on [DATE]. She denied locating or entering the resident's room with an Advanced Directive of DNR. She also confirmed she did not receive an order from S17NP to stop the CPR efforts for Resident #143. On [DATE] at 2:24 p.m., an interview was conducted with S16LPN. She confirmed she responded to a code for Resident #143 on [DATE]. She explained she was in the room with S8LPN when CPR was initiated. She stated while S8LPN was performing CPR, S5LPN entered the room with an Advanced Directives which indicated Yes to CPR and Yes to DNR. S16LP confirmed CPR was stopped at that time. On [DATE] at 2:09 p.m., an interview was conducted with Resident #143's daughter. She stated prior to admission, she completed and electronic advanced directive consent for her mother which should have indicated a Full Code status. She confirmed she had filled out a second Advance Directive on [DATE] over the phone with S9AC. She confirmed S9AC was made aware Resident #143 was to be a Full Code with CPR initiated in the event of cardiac or respiratory arrest. On [DATE] at 1:05 p.m., an interview was conducted with S17NP. She confirmed she was familiar with Resident #143. She explained the residents advanced directive should indicate CPR should be initiated or not in the event of cardiac arrest or respiratory arrest. She confirmed she never gave a telephone/verbal order to discontinue CPR for Resident #143. She then confirmed she would never give a telephone order to discontinue CPR on any resident. On [DATE] 01:45 p.m. an interview was conducted with S3ADON. She stated that S2DON would review all resident's code status prior to S9AC submitting to the electronic chart. She stated the code status could be located under the code status tab in the paper chart or on the face sheet of the electronic chart. On [DATE] at 2:32 p.m., an interview was conducted with S1ADM. S1ADM reviewed both versions of Resident #143's Advanced Directives and stated he interpreted both to mean Resident #143 was a full code status and staff should have continued CPR until further clarification could be made. He confirmed staff began CPR on Resident #143 and then stopped prior to the resident being pronounced dead by an appropriate entity. On [DATE] at 2:41 p.m., an interview was conducted with S14CQIN. She confirmed S1ADM made her aware of the discrepancies with Resident #143's Advanced Directive on [DATE] after she expired. She confirmed the facility swapped to an electronic Advanced Directive several months ago and family members had difficulty understanding and completing the new form to correctly reflect their wishes regarding code status. S14CQIN reviewed both of Resident #143's Advance Directive consents and stated she interpreted both to mean Resident #143 was a full code status and staff should have continued CPR until further clarification could be made. On [DATE] at 11:27 a.m. and interview was conducted with S15RCN. S15CRN reviewed both of Resident #143's Advance Directive Consents. S15RCN stated the Resident #143's daughter marked both CPR and DNR on the form. She confirmed the resident's wishes were unclear and she would expect staff to refer to the physician's order for further clarification. Resident #81 Review of Resident #81's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #81's LaPOST, signed by the resident on [DATE], revealed the resident indicated she would like to be a DNR. Review of Resident #81's Physician Orders revealed, in part, the following: [DATE] - Code Status: Full Code. On [DATE] at 8:55 a.m., an interview was conducted with S6LPN. She reviewed Resident #81's EHR and confirmed their code status per physician's orders was a Full Code and CPR should be initiated in the events of an emergency. Resident #112 Review of Resident #112's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #112's Advanced Directives, signed by the resident's daughter on [DATE], revealed the resident indicated she would like to be a DNR. Review of Resident #112's current Physician Orders revealed, in part, the following:[DATE] - Code Status: Full Code. Review of Resident #112's Physician Progress Notes, dated [DATE], [DATE], and [DATE], indicated the resident was Full Code status. Resident #136 Review of Resident #136's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #136's most recent MDS, with an ARD of [DATE], revealed the resident was assessed to have a BIMS of 10, which indicated the resident had moderate cognitive impairment. Review of Resident #136's LaPOST, signed by the resident on [DATE], revealed the resident indicated he would like to be a DNR. Review of Resident #136's current Physician Orders revealed both of the following active orders: An order for Code Status: Full Code; and An order for Code Status: Do Not Resuscitate DNR. Review of Resident #136's Hospice Records Binder with the local hospice company indicated, in part, Resuscitation Status: DNR per LaPOST. On [DATE] at 11:30 a.m., an interview was conducted with Resident #136. He confirmed he signed the paperwork to become a DNR in [DATE] and his wishes had not changed since that time. On [DATE] at 12:58 p.m., an interview was conducted with S1ADM. He confirmed the facility opened the QA process for Advance Directives as of [DATE] and all charts were audited by S12AADM following the incident to ensure accuracy. He then confirmed there were current discrepancies present for Resident #81, Resident #112 and Resident #136.

Based on observations, interviews, and record reviews, the facility failed to ensure there was a system in place to protect residents from sexual abuse for 3 (#1, R2, and R3) cognitively impaired female residents out of a total of 9 (#1, #2, #3, #6, #7, #8, R1, R2, R3) sampled residents reviewed for abuse. The facility failed to ensure: 1. Staff recognized all types of sexual abuse; and 2. Staff protected female residents (#1, R2, and R3) from two aggressive male residents (#2 and #3) who displayed continued sexual aggression. The deficient practice resulted in an immediate jeopardy situation for Resident #1 on 11/26/2020, when S8LPN found Resident #1, who was incapable of consenting to a sexual relationship, lying in Resident #2's bed. Resident #2 was laying on top of Resident #1. Resident #2 continued to direct sexually inappropriate behaviors towards Resident #1 on 12/16/2020, 01/14/2021, 02/02/2021, and 02/03/2021. On 02/09/2021, Resident #1 was lying in her bed completely unclothed, while Resident #2 was lying on top of her humping her with his pants slightly down. On 02/23/2021, Resident #3, a cognitively impaired resident, with known sexually inappropriate behaviors, was observed kissing resident R3 and trying to grab resident R2's buttocks. The facility failed to recognize the sexually inappropriate behaviors exhibited by the two aggressive male residents as sexual abuse. Therefore, the facility failed to implement interventions to protect the female residents on the Hall A from aggressive sexual actions of Resident #2 and Resident #3, who also resided on the Hall A. S1ADM was notified of the Immediate Jeopardy on 03/03/2021 at 6:57 p.m. The Immediate Jeopardy was removed on 03/04/2021 at 2:30 p.m. when the facility submitted an acceptable Plan of Removal which included: 1. Corrective actions for alleged deficient practice were accomplished for Resident #2 and Resident #3 by the following: a. Resident #2, discharged from the facility effective 02/09/2021 b. Resident #3, placed on 1:1supervision effective 03/03/2021 c. Root Cause Analysis (RCA) and Performance Improvement Project initiated 02/11/2021 d. All female residents, residing on Hall A, relocated to one side of the hall effective 02/09/2021 e. CNA assigned to sit on Hall A each shift to ensure female residents residing on the hall are free from sexual abuse effective 03/03/2021 f. Increased CNA staffing on the 10:00 p.m. - 6:00 a.m. shift for Hall A from 2 to 3 effective 03/03/2021 g. In-service all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 h. Testing all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 2. All residents have the potential to be affected by this alleged deficient practice 3. The measures put into place to prevent this alleged deficient practice from re-occurring a. RCA and PIP initiated and completed as above (with in-service listed above) b. CNA assigned to sit on Hall A each shift to ensure female residents residing on the hall are free from sexual abuse effective 03/03/2021 c.Increased CNA staffing on the 10:00 p.m. - 6:00 a.m. shift for Hall A from 2 to 3 effective 03/03/2021 d. In-service all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 e. Testing all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 4. Facility will monitor its performance to ensure sustained compliance by the following a. DON and or designee will observe by direct visual observation three times a week to ensure CNA assigned to sit on Hall A is indeed meeting the assignment to ensure female residents residing on the hall are free from sexual abuse initiated on 02/11/2021. b. DON and or designee will conduct audits by questioning staff regarding Abuse, Prevention and Prohibition Policy and Procedure three times a week for one 1 month, twice a week for 1 month, then once a week for one month to ensure female residents residing on Hall A are free from sexual abuse initiated on 02/11/2021 c. Additional in-servicing and or progressive disciplinary action will occur if further non-compliance is noted The deficient practice had the potential for more than minimal harm for the other 13 female residents residing on Hall A. Findings: Review of the facility's policy entitled Abuse- Prevention and Prohibition Policy and Procedure included: Purpose: Each resident has the right to be free from abuse. No one shall abuse a resident. This policy applies to facility staff, other residents, family members or resident representatives, and anyone else present in our facility. Policy: To provide a safe, abuse-free environment for all residents. If you suspect verbal, sexual, physical or mental abuse of a resident, misappropriation of resident property, corporal punishment or involuntary seclusion of a resident, exploitation or mistreatment of [REDACTED]. Sexual Abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual Abuse is non-consensual sexual contact of any type with a resident. There may be some situations in which the resident is unable to express him/herself due to a medical condition and/or cognitive impairment (e.g., stroke, coma, [MEDICAL CONDITION]), cannot relate what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by the resident does not mean that mental abuse did not occur. Sexual Abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual Abuse is non-consensual sexual contact of any type with a resident. Definitions: Willful - means the individual must have acted deliberately, not that he/she must intended to inflict injury or harm. Resident #1: Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, which included: [MEDICAL CONDITION], Anxiety Disorder, Restlessness, and Agitation. Review of the MDS with an ARD of 01/26/2021 revealed Resident #1 had a BIMS of 3, which indicated she was severely cognitively impaired. Review of Resident #1's current Care Plan revealed the following, in part: I have cognitive loss related to [DIAGNOSES REDACTED]. I have impaired decision making skills and I need assistance with decision making. Resident #2: Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, which included: Major [MEDICAL CONDITION], Anxiety Disorder, Unspecified [MEDICAL CONDITION], Cerebral Infarction, and Spondylosis. Review of the MDS with an ARD of 10/23/2020 revealed Resident #2 had a BIMS of 13, which indicated he was cognitively intact. Review of Resident #2's current Care Plan revealed the following, in part: I have cognitive loss related to [MEDICAL CONDITION]; I am forgetful; I have modified decision making skills and require assistance with decision making. I am an elopement risk related to I am a wanderer; I reside on Hall A. I am at risk for altered moods; I have no abnormal moods or behaviors noted at this time. 01/22/21 I was involved in an altercation Review of the Physicians Progress Note for Resident #2 dated 11/23/2020 revealed, in part: Staff reported increased sexually inappropriate behaviors of trying to touch female staff, luring to his room, and increased masturbating. Review of the Nurse's Note for Resident #2 dated 11/26/2020 revealed, in part: S8LPN enters Resident #2's room and was noted to have a female resident lying in his bed. Resident #2 was found on top of a female with clothes on. S8LPN and CNAs separated the residents and the female resident was taken out of room. S1ADM was notified at this time. Review of the Physician's Progress Notes for Resident #2 dated 11/30/2020 revealed, in part: Resident #2 has had inappropriate behavior with other female residents. Overview: Continues with excessive wandering and invading others' personal space. He is inappropriate and impulsive. Review of the hospital records dated 12/16/2020 revealed, in part: Resident #2 attempted to stab S16CNA and was sexually inappropriate towards a female peer. Review of the Nurse's Note dated 01/11/2021 revealed, in part: S18CNA reported Resident #2 was attempting to touch S18CNA inappropriately. S18CNA tried to distance self from Resident #2. Resident #2 was persistent and began to bang on the door to get S18CNA. Resident #2 followed S18CNA to Hall A's entrance door where S18CNA was able to get away. Resident #2 was unable to be redirected, will continue to monitor. Review of the Nurse's Note for Resident #2 dated 01/14/2021 revealed, in part: Resident #2 was sexually and physically aggressive towards staff and residents on several occasions throughout the shift. All attempts by CNAs and S10LPN to redirect Resident #2 was unsuccessful. At 3:00 p.m., Resident #2 was seen attempting to swing at a CNA. Resident told CNA suck my d**k b***h and I'm going to beat your a*s when the nurse leaves. Resident was escorted to his room. Resident did not stay there. Verbal order given to S3ADON for [MEDICATION NAME] 2MG/ML x1 dose now. Review of the Physician's Progress Note for Resident #2 dated 01/15/2021 revealed, in part: Staff reports increased sexual aggression. Review of the Physician's Progress Notes for Resident #2 dated 01/18/2021 revealed, in part: on 01/14/2021 Resident #2 required IM [MEDICATION NAME] due to attempting to physically assault staff and unable to be redirected. Overview: Patient with increased sexually inappropriate behavior with staff. Review of the Nurse's note for Resident #2 dated 02/02/2021 revealed, in part: Resident #2 standing in dining room trying to get to the female residents. Review of the Nurse's notes for Resident #2 dated 02/03/2021 revealed, in part: Received reports from CNAs that resident was seen with his tongue down another resident's throat on yesterday's evening shift. Reported immediately to S2DON. Review of Nurse's note dated 02/03/2021 revealed, in part: Resident #2 was seen rubbing a female resident on her arm this morning. Resident #2 was asked by CNAs to go to the other end of the hallway away from the female resident. Several minutes later S10LPN was called by a CNA to look towards him. I observed resident #2 attempting to hit a staff member with a broomstick. Resident #2 was aggressive at the time and not willing to let go of the stick. S10LPN immediately went to assist. As staff were able to remove the stick from residents #2 hand, S10LPN escorted resident into his room and asked him to stay there. Resident #2 sat down on his bed and told us to move out of his way. S10LPN asked resident to stay in his room and calm down. Resident #2 then punched S10LPN in the chest and said I'm not calming down. I'm going beat y'all's a***s today. Resident encouraged to not come out of room with aggressive behavior. Resident declined to cooperate. As staff exited the room, resident began to follow. A few minutes later S10LPN was called by staff out loud. S10LPN looked down the hallway to see resident #2 holding a stick while attempting to swing at staff. Resident was resisting while staff tried to take the stick away from him. Resident #2 was then seen punching S20CNA. Call placed to S4NP. Verbal order given to send resident out to the hospital. S2DON and S3ADON notified of incident. Review of the hospital records dated 02/04/2021 revealed, in part: Resident #2 was admitted to this hospital for combativeness, [MEDICAL CONDITION], and increased anxiety. Recent admission here on 12/16/2020 for attempting to stab a CNA and behaving in a sexually inappropriate manner towards a female peer. Patient reportedly hit a staff person at the nursing home and is described as hypersexual. Review of the Nurse's Note for Resident #2 dated 02/09/2021 revealed, in part: S2DON was summoned to the facility because Resident #2 was found in a female resident's bed. Resident #2 was clothed. S19CNA redirected him out of the resident's room and summoned S7LPN to room. Resident #2 was trying again to get back into the female resident's room. Resident #2 was immediately removed off of Hall A and placed in one on one observation. Review of the hospital records dated 02/09/2021 at 2:44 p.m. revealed, in part: Neurostatus: Alert and oriented to person, place, time, and reason. Summary: Resident #2 presents to the hospital from the nursing home because he keeps performing unwanted sexual advances towards the female residents. Resident #2 seen here for the same several days ago and released. Review of the Police Report dated 02/09/2021 at 9:02 a.m. revealed, in part: S1ADM stated earlier that day the facility found Resident #2 and Resident #1 in the same bed together. S1ADM informed that Resident #1 was completely nude and Resident #2 was fully dressed. S1ADM stated that both Resident #1 and Resident #2 are mentally impaired. S1ADM stated the facility did an internal investigation required by state law. The investigation showed no sexual intercourse or foul play. An observation was made of Hall A on 02/26/2021 at 4:36 a.m. Hall A was observed to have a set of double doors that were opened with no staff on the hall. Surveyor observed 3 male residents wandering in and out of rooms on Hall A. Staff noted on Hall A at 4:54 a.m. An interview was conducted on 02/26/2021 at 4:55 a.m. with S14CNA. She confirmed she worked on Hall A and was familiar with Resident #1 and Resident #2. She stated Resident #1 was cognitively impaired and unable to consent to a sexual relationship. She stated Resident #2 was a wanderer and would go into other resident's rooms. She stated Resident #2 was cognitive enough to consent to sexual acts and he knew what was going on. She confirmed she worked Shift C on 02/08/2021. She stated on 02/09/2021 around 4:30 a.m., S19CNA told her Resident #2 was in bed on top of Resident #1. She stated she went to Resident #1's room after the residents were separated, and Resident #1 looked shocked and had watery eyes. She stated the facility recently separated the male and the female resident's rooms on Hall A. She explained the female residents' rooms were before the double doors and the male residents' rooms were after the double doors. She stated she was unsure why the male and female residents were separated. She stated the doors on Hall A were supposed to be closed and confirmed they were not. An interview was conducted on 02/26/2021 at 5:05 a.m. with S24CNA. She stated that a couple of weeks ago the female residents were moved to the front of the hall, and the male residents were moved to the back. She stated the double doors on Hall A separated the male and female residents' rooms. She stated she was not sure why the male and female residents were moved. She stated the doors on Hall A were supposed to remain closed, but sometimes the staff would prop them open. She stated she wasn't sure why the double doors were supposed to be closed. An interview was conducted on 02/26/2021 at 5:35 a.m. with S7LPN. She confirmed she worked on Hall A and was familiar with Resident #1 and Resident #2. She stated Resident #1 was cognitively impaired and unable to consent to a sexual relationship. She stated she was not sure if Resident #2 could consent because he was usually sleeping when she worked. She stated she worked Shift C on 02/08/2021 and around 4:30 a.m. Resident #2 wandered into Resident #1's room. She stated S19CNA went to check on Resident #1 and saw Resident #2 in bed with Resident #1. She stated Resident #2 was on top of Resident #1. She stated Resident #2 had on pants and underwear and Resident #1's brief was opened exposing her lower body. She stated Resident #1 was alert to person. She stated when she entered the room to assess Resident #1, she was at her baseline. She explained Resident #1's baseline consisted of a flat affect. She stated she examined her external vagina and did not observe any signs of trauma. An interview was conducted on 02/26/2021 at 6:18 a.m. with S15CNA. She confirmed that she worked on Hall A and was familiar with Resident #1. She stated Resident #1 could not hold a conversation and did not have the capability to consent to sexual acts. She stated the facility separated the male and female residents' rooms on Hall A 2-3 weeks ago, but she did not know why. An interview was conducted on 02/26/2021 at 6:31 a.m. with S16CNA. He confirmed he worked on Hall A and was familiar with Resident #1 and Resident #2. He stated Resident #1 was cognitively impaired and unable to consent to a sexual relationship. He stated Resident #2 was aware of his actions and knew what he was doing. He stated Resident #2 should not have been placed on Hall A because he knew right from wrong. He reported Resident #2 had told him he was sexually frustrated. He stated 02/09/2021 was not the first time Resident #2 was found in bed with Resident #1. He said in November 2020 Resident #1 was found in Resident #2's bed. He said he was told Resident #2 was humping Resident #1. He stated Resident #2 frequently grabbed Resident #1's hand, popped her butt, or grabbed her when he was passing by her. He stated he had witnessed Resident #2 fondling himself and masturbating in the halls on multiple occasions. He stated he was present for an incident with S18CNA where Resident #2 was trying to kick down the door to get to S18CNA. He stated he tried to redirect Resident #2 and when he asked him what he was doing Resident #2 stated, I am horny and need some vagina. He stated he often reported behaviors to the nurse on duty, but nothing was done. He stated he knew Resident #2 was going to harm someone. An interview was conducted on 02/26/2021 at 6:48 a.m. with S17CNA. She confirmed she worked on Hall A and cared for Resident #1 and Resident #2. She stated Resident #1 was cognitively impaired and unable to consent to a sexual relationship. She stated Resident #2 was aware of and intentional with his actions. She stated Resident #2 exhibited sexual behaviors towards herself and Resident #1. She stated if she were sitting in a chair on Hall A Resident #2 would try to lean over her and put his genitals near her face. She stated Resident #2 would try to grope her and would tell her to suck his penis. She stated Resident #2 targeted Resident #1. She stated Resident #2 didn't show any of the other female resident's attention. She explained Resident #2 would always touch Resident #1 when she wandered on Hall A. She stated Resident #2 would pull Resident #1 close by grabbing her hand and tell her to come here. She stated Resident #2 was not easily redirected. She stated they would separate Resident #1 and Resident #2, but Resident #2 would always find a way to get back to Resident #1. An interview was conducted on 02/26/2021 at 8:40 a.m. with S18CNA. She confirmed she worked on Hall A and cared for Resident #1 and Resident #2. She stated Resident #1 was cognitively impaired and unable to consent to a sexual relationship. She stated Resident #2 was well aware of what he was doing. She stated Resident #2 would follow her into other resident's rooms. She stated if she shut the door to the room Resident #2 would bang on the door and tell her to come out of the f*****g room. She stated there was an incident where she was in a female resident's room and Resident #2 came in behind her. She explained she redirected him out of the room, but he came back in. She stated when she turned around Resident #2's pants were unzipped and he was masturbating behind her. She stated a few months ago Resident #1 was found in Resident #2's bed with him on top of her. She stated after that the CNAs would try and sit on the hall to monitor the residents, but Resident #2 would wait until they went to assist another resident and would sneak and go into all the rooms. She stated she observed Resident #2 fondling himself outside of his room on numerous occasions and would expose himself while in the hallway. She stated Resident #2 told her he was horny and wanted sex. She stated she reported the sexual behaviors to the nurses, CNA supervisor, and other CNA's, but nothing was ever done. An interview was conducted on 03/01/2021 at 11:26 a.m. with S8LPN. She confirmed she worked on Hall A and cared for Resident #1 and Resident #2. She stated Resident #1 was severely cognitively impaired and unable to consent to a sexual relationship. She stated Resident #2 was not impaired cognitively, and was able to knowingly engage in a sexual relationship. She stated on 11/26/2020 she found Resident #1 in Resident #2's bed. She explained Resident #1 was lying on her back and Resident #2 was lying on top of her. She stated she was the nurse assigned to Hall A on 02/09/2021, Shift A. She explained when she reported to work that morning she was informed in report that Resident #2 was found in Resident #1's room and Resident #1's brief was undone. She stated she was told Resident #2 was on top of Resident #1. She stated she and S4NP assessed Resident #1's body for any signs of redness, trauma, or discharge around the exterior vaginal area. She stated Resident #1 did not say anything when S4NP examined her upper body, but when S4NP began to examine her lower body Resident #1 told them not to touch her and then told them to stop when S4NP examined her vagina. An interview was conducted on 03/01/2021 at 11:51 a.m. with S4NP. She stated she was aware of Resident #2's sexual behaviors. She stated Resident #2 had no boundaries and she was aware Resident #2 had a history of [REDACTED]. She stated the facilities hands were tied because you can't restrain the residents and we can't put them all on 1:1 supervision. She denied being aware of Resident #1 being found in Resident #2's bed in November of 2020 or that he was found kissing Resident #1 on 02/02/2021. She stated she was informed of the incident with Resident #1 and Resident #2 while she was on her way to the facility the morning of 02/09/2021. She stated she examined Resident #1's exterior vagina and did not see anything that made her think there had been forced entry. She confirmed she did not internally examine the resident or complete a rape kit. She stated Resident #1 was cognitively impaired and unable to consent to a sexual relationship. She stated Resident #1 was at her baseline when she examined her. She stated she asked Resident #1 if she was in pain and the resident responded no. She stated based on her response and the exterior vaginal exam she did not think Resident #1 needed to be sent to the hospital for further examination. An interview was conducted on 03/01/2021 at 12:13 p.m. with Resident #1. She was observed sitting quietly at a table in the dining area. Resident #1 was unable to say her name or hold a conversation due to her cognitive impairment. An interview was conducted on 03/01/2021 at 12:32 p.m. with S10LPN. She confirmed she had worked on Hall A and was familiar with Resident #1 and Resident #2. She stated Resident #1 was cognitively impaired and unable to consent to a sexual relationship. She stated Resident #2 was able to consent to a sexual relationship and was not appropriate to be on Hall A. She explained Resident #2 appeared to know exactly what he was doing. She stated she was aware of an incident on 01/14/2021 where Resident #2 was trying to grab and kiss female residents and CNAs, but mostly Resident #1. She stated attempts by CNAs and herself to redirect Resident #2 was unsuccessful. She stated that same day Resident #2 told S20CNA suck my d**k b***h and I'm going to beat you're a*s when the nurse leaves. She stated she tried to escort Resident #2 to his room. She stated S4NP was notified multiple times. She stated on 02/03/2021 a CNA reported Resident #2 had his tongue down Resident #1's throat the day before to S9LPN. She stated she looked for the documentation of the incident and could not find it so she reported it to S2DON. She said S2DON instructed her to document what the CNA reported in Resident #2's clinical record. She confirmed she worked on 02/03/2021 and observed Resident #2 rubbing Resident #1's arm. She stated she asked Resident #2 to stop and tried to separate him from Resident #1. She stated Resident #2 always targeted Resident #1. She reported she spoke with S2DON about Resident #2's behavior and explained he should not reside on Hall A, but S2DON disagreed with her, and nothing was done about the sexually inappropriate behaviors. An interview was conducted on 03/01/2021 at 2:16 p.m. with S11LPN. She stated she was responsible for Resident #1 and Resident #2's care plans. She stated she was only aware of 2 incidents involving Resident #2's inappropriate sexual behavior on 11/26/2020 and 02/09/2021. She explained both involved Resident #2 being on top of Resident #1 in bed. She stated on 11/26/2020, the team discussed increasing supervision for Resident #1, but she was unsure if it was implemented. She confirmed she had not been made aware of any other incidents involving Resident #2's inappropriate sexual behaviors and should have been. An interview was conducted on 03/01/2021 at 3:25 p.m. with S13LPN. She stated she was familiar with Hall A and Resident's #1 and #2. She stated none of the CNA's reported any behavioral issues with Resident #2 because they were supposed to report behavioral issues to the nurse. She stated on 02/09/2021, 2 CNAs told her Resident #2 was found in Resident #2's room. She stated she was told Resident #1 had her brief off and Resident #2 was standing by the bed. She stated she was not informed that Resident #2 was on top of Resident #1. She confirmed she should have been made aware of the nature of the incident so she could appropriately train her CNA staff. An interview was conducted on 03/02/2021 at 8:40 a.m. with S19CNA. She confirmed she worked on Hall A and was familiar with Resident #1 and Resident #2. She stated Resident #1 was cognitively impaired and unable to consent to a sexual relationship. She stated Resident #2 knew what he was doing and should not have been on Hall A. She stated she worked on 02/09/2021 Shift C. She stated around 4:15 a.m., She could hear Resident #1 talking. She stated she entered Resident #1's room and saw both residents in the bed with Resident #2 on top of Resident #1, humping her. She stated she could see that Resident #2 had his pants on, but they were pulled down a little. She stated Resident #2 appeared shocked and was verbally aggressive towards her when she instructed him to get off of Resident #1. She stated he told her to move, and get out. She stated she had to ask him twice to get off of Resident #1 before he complied. She stated when he stood up she should could see that his pants were down a little with his boxer shorts exposed. She stated his penis was not exposed, but she could see that he was erect. She stated Resident #1's brief was pulled down and her lower body was exposed. She stated Resident #1's face was flat and she appeared to be at her baseline. She stated S7LPN assessed Resident #1 and then called S1ADM and S2DON. She stated she sat at Resident #1's door and Resident #2 kept trying to get into the room with Resident #1. She stated he kept saying, Let me go back in there. She stated Resident #2 knew exactly where Resident #1's room was and waited until the CNA staff were busy to go in. An interview was conducted on 03/02/2021 at 9:24 a.m. with S20CNA. She confirmed she had worked on Hall A and was familiar with Resident #1 and Resident #2. She stated Resident #2 was always aggressive towards her and would tell her suck my penis and then grab his penis through his pants and shake it at her. She stated she reported this to the nurse, but nothing was ever done. She stated on 02/03/2021, she witnessed Resident #2 trying to enter the day room to get to Resident #1. She stated he had already been redirected and asked to leave the day room for touching Resident #1 and he kept trying to come back in to her. An interview was conducted on 03/02/2021 at 10:06 a.m. with S9LPN. She confirmed she had worked on Hall A and was familiar with Resident #1 and Resident #2. She stated she felt like Resident #1 didn't know what was going on, and could not consent to any sexual behaviors. She stated she felt like Resident #2 could consent to sexual behaviors. She stated Resident #2 knew what he was doing. She stated on 01/11/2021, S18CNA, reported Resident #2 was cornering the CNAs and trying to touch them inappropriately. She stated she observed Resident #2 banging on the doors to resident rooms and trying to get inside with S18CNA. She stated she reported this to S2DON and S2DON responded S18CNA had never submitted a witness statement regarding that incident. She stated on 02/02/2021 she observed Resident #2 grabbing Resident #1's breast, putting his tongue down her throat, and touching her inappropriately all day long. Resident #1 would keep telling Resident #2 no, but he would still do it without Resident #1's consent. She confirmed this was considered sexual abuse and reported this to S1ADM, but he did not do anything to resolve the situation until after 02/09/2021 when Resident #2 was found in Resident #1's bed. She stated Resident #2 had been found in bed with Resident #1 a few months ago as well. She stated Resident #2 always went after Resident #1 and he should not have resided on Hall A. She stated on 11/26/2020, she saw Resident #2 pulling Resident #1 into his room. She stated she and S8LPN went into Resident #2's room he was on top of Resident #1, humping her. She said Resident #1 was agitated when she found them. She stated resident #1 was the only Resident #2 would go after. An interview was conducted on 03/02/2021 at 10:54 a.m. with S6SW. She confirmed she was familiar with Resident #1 and Resident #2. She stated Resident #1 was cognitively impaired and unable to consent to a sexual relationship. She stated Resident #2's cognitively abilities were higher and he was able to consent to a sexual act. She stated Resident #2 appeared to understand what he was doing and that his actions were wrong. She explained S18CNA spoke with her about the incident on 01/11/2021, where Resident #2 touched her inappropriately. S6SW stated she met with Resident #2, and he confirmed the incident and his behavior was inappropriate. An interview was on conducted on 03/02/2021 at 11:13 a.m. with S23CNA. She confirmed she worked in Hall A on occasions. She stated department heads would meet each morning and discuss any problems that needed to be addressed with residents. She stated she knew Resident #2 was aggressive towards other residents but was never informed he had sexual behaviors. She stated the sexual behaviors were not discussed in the morning meetings she attended. An interview was conducted on 03/02/2021 at 11:35 a.m. with S2DON. She stated Resident #1's cognitive abilities were on the lower end of the spectrum and the resident was not capable of consenting to a sexual relationship. She stated she felt Resident #2 was unable to consent to a sexual relationship. She said sexual abuse was sexual intercourse, kissing, or groping with a resident who was not cognitive or who was unwilling. She stated her staff were instructed to report any suspicion of sexual abuse immediately. She stated staff would report to her verbally as well as document in the clinical records. She stated each morning she would review all the notes entered on each resident from the day before. She explained if her staff did not communicate with her she had no way of knowing when incidents happened. She stated she was never made aware of a CNA having to lock themselves in rooms to get away

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent sexual abuse for 3 (#1, R2, and R3) of 9 (#1, #2, #3, #6, #7, #8, R1, R2, R3) residents reviewed. The facility failed to implement written policies by failing to: 1. Identify behaviors as sexual abuse when 2 (#2 and #3) residents exhibited sexually inappropriate behaviors towards female residents; 2. Investigate reported incidents involving allegations of sexual abuse by 2 (#2 and #3) male residents; 3. Protect 3 (#1, R2, and R3) cognitively impaired female residents from sexual abuse; and 4. Identify staff responsible for the investigation. The deficient practice resulted in an immediate jeopardy situation for Resident #1 on 11/26/2020, when Resident #1, who was incapable of consenting to a sexual relationship, was found lying in Resident #2's bed by S8LPN. Resident #2 was laying on top of Resident #1. Resident #2 continued to direct sexually inappropriate behaviors towards Resident #1 on 12/16/2020, 01/14/2021, 02/02/2021, and 02/03/2021. On 02/09/2021, Resident #1 was lying in her bed completely unclothed, while Resident #2 was lying on top of her humping her with his pants slightly down. On 02/23/2021, Resident #3, a cognitively impaired resident, with known sexually inappropriate behaviors, was observed kissing resident R3 and trying to grab resident R2's buttocks. S1ADM was notified of the Immediate Jeopardy on 03/03/2021 at 6:57 p.m. The Immediate Jeopardy was removed on 03/04/2021 at 2:30 p.m. when the facility submitted an acceptable Plan of Removal which included: 1. Corrective actions for alleged deficient practice were accomplished for Resident #2 and Resident #3 by the following: a. Resident #2, discharged from the facility effective 02/09/2021 b. Resident #3, placed on 1:1supervision effective 03/03/2021 c. Root Cause Analysis (RCA) and Performance Improvement Project initiated 02/11/2021 d. All female residents, residing on Hall A, relocated to one side of Hall A effective 02/09/2021 e. CNA assigned to sit on the Hall A each shift to ensure female residents residing on Hall A are free from sexual abuse effective 03/03/2021 f. Increased CNA staffing on the 10p-6a shift for Hall A from 2 to 3 effective 03/03/2021 g. In-service all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 h. Testing all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 2. All residents have the potential to be affected by this alleged deficient practice 3. The measures put into place to prevent this alleged deficient practice from re¿ occurring a. RCA and PIP initiated and completed as above (with in-service listed above) b. CNA assigned to sit on Hall A each shift to ensure female residents residing on Hall A are free from sexual abuse effective 03/03/2021 c. Increased CNA staffing on the 10p-6a shift for Hall A from 2 to 3 effective 03/03/2021 d. In-service all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 e. Testing all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 4. Facility will monitor its performance to ensure sustained compliance by the following a. DON and or designee will observe by direct visual observation three times a week to ensure CNA assigned to sit on Hall A is indeed meeting the assignment to ensure female residents residing on the hall are free from sexual abuse initiated on 02/11/2021. b. DON and or designee will conduct audits by questioning staff regarding Abuse, Prevention and Prohibition Policy and Procedure three times a week for one 1month, twice a week for 1month, then once a week for one month to ensure female residents residing on the hall are free from sexual abuse initiated on 02/11/2021 c. Additional in-servicing and or progressive disciplinary action will occur if further non-compliance is noted The deficient practice had the potential for more than minimal harm for the other 13 female residents residing on Hall A. Findings: Review of the facility's policy entitled Abuse- Prevention and Prohibition Policy and Procedure revealed in part: Purpose: Each resident has the right to be free from abuse. No one shall abuse a resident. Policy: To provide a safe, abuse-free environment for all residents. Sexual Abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual Abuse is non-consensual sexual contact of any type with a resident. There may be some situation in which the resident is unable to express him/herself due to a medical condition and /or cognitive impairment (e.g., stroke, coma, [MEDICAL CONDITION]), cannot relate what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by the resident does not mean that mental abuse did not occur. Abuse Prohibition Practice Each resident has the right to be free from mistreatment. The facility takes steps to identify residents whose personal histories render them at risk for abusing other residents, and develops interventions strategies to prevent occurrences, monitors for changes that would trigger abusive behavior, and reassesses interventions on a regular basis. Identification: The facility Administrator proactively identifies events such as suspicious bruises, trends, patterns, and occurrences that may constitute abuse and determines the direction of the investigation. We use grievances, verbal reports, incident/accident report, and Quality Assurance to identify possible abuse. Investigation: Administrator completes a thorough investigation, including interviews of employees who were working in resident's room during the time in question and obtaining signed statements from these employees. Protection: Resident to resident altercations: When another resident is the alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's mental status and notify the physician for a determination regarding treatment and/or discharge options. The safety of other residents and employees of the facility is of primary concern. Resident #2 Review of the Nurse's Notes for Resident #2 revealed the following, in part: 11/26/2020 - S8LPN enters Resident #2's room and was noted to have a female resident lying in his bed. Resident #2 was found on top of a female with clothes on. S8LPN and CNAs separated the residents and the female resident was taken out of room. S1ADM was notified at this time. 01/14/2021 - Resident #2 was sexually and physically aggressive towards staff and residents on several occasions throughout the shift. 02/03/2021 - Received reports from CNAs that resident was seen with his tongue down another resident's throat on yesterday's evening shift. Reported immediately to S2DON. 02/03/2021 - Resident #2 was seen rubbing a female resident on her arm this morning. Call placed to S4NP. Verbal order given to send resident out to the hospital. S2DON and S3ADON notified of incident. Review of the Physician's Progress Notes for Resident #2 dated 11/30/2020 revealed, in part: Resident #2 has had inappropriate behavior with other female residents. Overview: Continues with excessive wandering and invading others personal space. He is inappropriate and impulsive. An interview was conducted on 02/26/2021 at 5:35 a.m. with S7LPN. She stated she worked Shift C on 02/08/2021 and around 4:30 a.m. Resident #2 wandered into Resident #1's room. She stated S19CNA went to check on Resident #1 and saw Resident #2 in bed with Resident #1. She stated Resident #2 was on top of Resident #1. She stated Resident #2 had on pants and underwear and Resident #1's brief was opened exposing her lower body. She stated Resident #1 was alert to person. She stated when she entered the room to assess Resident #1, she was at her baseline. She explained Resident #1's baseline consisted of a flat affect. She stated she examined her external vagina and did not observe any signs of trauma An interview was conducted on 02/26/2021 at 6:31 a.m. with S16CNA. He reported Resident #2 had told him he was sexually frustrated. He stated 02/09/2021 was not the first time Resident #2 was found in bed with Resident #1. He said in November 2020 Resident #1 was found in Resident #2's bed. He said he was told Resident #2 was humping Resident #1. He stated Resident #2 frequently grabbed Resident #1's hand, popped her butt, or grabbed her when he was passing by her. He stated he had witnessed Resident #2 fondling himself and masturbating in the halls on multiple occasions. An interview was conducted on 03/02/2021 at 8:40 a.m. with S19CNA, she stated she worked on 02/09/2021 Shift C. She stated around 4:15 a.m., She could hear Resident #1 talking. She stated she entered Resident #1's room and saw both residents in the bed with Resident #2 on top of Resident #1, humping her. She stated she could see that Resident #2 had his pants on, but they were pulled down a little. She stated Resident #2 appeared shocked and was verbally aggressive towards her when she instructed him to get off of Resident #1. She stated he told her to move, and get out. She stated she had to ask him twice to get off of Resident #1 before he complied. She stated when he stood up she should could see that his pants were down a little with his boxer shorts exposed. She stated his penis was not exposed, but she could see that he was erect. She stated Resident #1's brief was pulled down and her lower body was exposed. She stated Resident #1's face was flat and she appeared to be at her baseline. She stated S7LPN assessed Resident #1 and then called S1ADM and S2DON. She stated she sat at Resident #1's door and Resident #2 kept trying to get into the room with Resident #1. She stated he kept saying, Let me go back in there. An interview was conducted on 03/02/2021 at 10:06 a.m. with S9LPN. She stated on 02/02/2021 she observed Resident #2 grabbing Resident #1's breast, putting his tongue down her throat, and touching her inappropriately all day long. Resident #1 would keep telling Resident #2 no, but he would still do it without Resident #1's consent. She stated on 11/26/2020, she saw Resident #2 pulling Resident #1 into his room. She stated she and S8LPN went into Resident #2's room he was on top of Resident #1, humping her. She said Resident #1 was agitated when she found them. She stated resident #1 was the only one Resident #2 would go after. An interview was conducted on 03/02/2021 at 11:35 a.m. with S2DON. She stated S1ADM and herself would investigate incidents of resident behaviors. She stated CNA's are expected to report resident behaviors to the nurse, and the nurse then, reports the behaviors to her. She stated if the nurse reported to her that the behavior was addressed she would not investigate the incident any further. She confirmed she would not investigate and speak with all staff and/or residents involved in an incident if the nurse reported to her it was no longer a problem and the behavior was addressed. She said sexual abuse was sexual intercourse, kissing, or groping with a resident who was not cognitive or who was unwilling. She stated she knew of the incident on 11/26/2020 where a female resident was found in Resident #2's bed, but she did not know who the female resident was. She confirmed she did not investigate the incident to identify who the female resident was. She reviewed the nurse's note dated 02/03/2021, and stated Resident #2 was sent to the hospital after he stuck his tongue down Resident #1's throat. She confirmed she did not investigate this incident any further because Resident #2 was sent out of the facility. She stated Hall A had one male resident, Resident #3, residing on it that currently exhibits inappropriate sexual behaviors towards female residents. An interview was conducted on 03/02/2021 at 1:08 p.m. with S1ADM. He stated he and S2DON were responsible for investigating incidents with resident behaviors. He stated abuse was a willful intent to harm and sexual abuse was any unwanted sexual acts that both parties do not consent to. He confirmed CNAs had come to him and reported Resident #2's sexually inappropriate behaviors. He stated on 11/26/2020, a female resident was found in Resident #2's bed. He stated both residents had clothes on and he did not know who the female resident was. He confirmed no investigation was done to identify the female resident. He stated he was also aware of incidents where Resident #2 had touched a female residents arm and tried to kiss a female resident. He stated he did not investigate either incidents because he did not think it was sexual abuse. He stated he did not think residents on Hall A could act intentionally so he did not consider it to be sexual abuse. He stated Hall A had one male resident, Resident #3, residing on it that currently exhibited inappropriate sexual behaviors towards female residents. Resident #3 Review of Physicians' Notes for Resident #3 dated 10/02/2020 revealed, in part: Resident #3 seen by S5NP for hyper sexuality and [MEDICAL CONDITION]. Resident #3 remained sexually inappropriate behavior towards other female resident and aggressive behaviors toward staff. Review of Nurses' Notes for Resident #3 dated 02/23/2021 revealed, in part: 02/23/2021 at 5:05 p.m., Resident #3 seen grabbing other female residents inappropriately. Redirected resident back into room. Will continue to monitor. An interview was conducted on 03/02/2021 at 5:15 p.m. with S17CNA. She stated on 02/23/2021 she saw Resident #3 kissing R3 in the mouth. She stated she told Resident #3 to stop. She stated she reported the incident to the nurse on duty. An interview was conducted on 03/02/2021 at 5:20 p.m. with S1ADM and S2DON. The Communication Binder was reviewed with S1ADM and S2DON. S1ADM stated he was notified of the incident that occurred with Resident #3 kissing R3 on 02/23/2021. S2DON stated she was not aware of any of the incidents related to Resident #3 that were documented in Hall A's Communication Binder. S2DON confirmed no specific changes in measures or interventions were made for Resident #3 since his hospitalization on [DATE]. A telephone interview was conducted on 03/03/2021 at 1:07 p.m. with S9LPN. She verified she was the nurse working on Hall A on 02/23/2021, Shift B. She verified she witnessed Resident #3 grab Resident R1 sexually inappropriately. She stated she documented the incident, but did not report it because she was able to redirect Resident #3. She stated she would have reported the incident if she was not able to interrupt the behavior and redirect the resident. An interview was conducted on 03/03/2021 at 1:47 p.m. with S2DON. S2DON reviewed Resident #3's Care Plan and stated Resident #3 was referred to Psychiatric Services after the incident on 02/23/2021. She confirmed facility staff did not implement any interventions at that time to prevent sexually inappropriate behaviors towards female residents.

Based on observations, interviews, and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure 3 (#1, R2, and R3) of 9 (#1, #2, #3, #6, #7, #8, R1, R2, and R3) residents reviewed were free from sexual abuse by failing to: 1. Protect 3 (#1, R2, and R3) cognitively impaired female residents from sexual abuse from two male residents (#2 and #3), with known sexually inappropriate behaviors, who all resided on Hall A; 2. Identify two male residents' (#2 and #3) inappropriate sexual behaviors towards female residents as sexual abuse; 3. Act upon reported allegations of sexually inappropriate actions of Resident #2 and Resident #3; 4. Communicate interventions to staff and reevaluate its effectiveness in order to protect cognitively impaired female residents from sexual abuse; 5. Investigate the allegations of sexual abuse; and 6. Identify staff responsible for the investigation. S1ADM was notified of the Immediate Jeopardy on 03/03/2021 at 6:57 p.m. The deficient practice resulted in an immediate jeopardy situation for Resident #1 on 11/26/2020, when S8LPN found Resident #1, who was incapable of consenting to a sexual relationship, in Resident #2's bed. Resident #2 was laying on top of Resident #1. Resident #2 continued to direct sexually inappropriate behaviors towards Resident #1 on 12/16/2020, 01/14/2021, 02/02/2021, and 02/03/2021. On 02/09/2021, Resident #1 was lying in her bed completely unclothed, while Resident #2 was lying on top of her humping her with his pants slightly down. On 02/23/2021, Resident #3, a cognitively impaired resident, with known sexually inappropriate behaviors, was observed kissing resident R3 and trying to grab resident R2's buttocks. The facility failed to recognize the sexually inappropriate behaviors exhibited by the two aggressive male residents as sexual abuse. Therefore, the facility failed to implement their policy to protect the female residents on Hall A from aggressive sexual actions of Resident #2 and Resident #3, who also resided on Hall A. The Immediate Jeopardy was removed 03/04/2021 at 2:30 p.m. when the facility submitted an Immediate Jeopardy Plan of Removal which included: Plan of Removal Included the Following: 1. Corrective actions for alleged deficient practice were accomplished for Resident #2 and Resident #3 by the following: a. Resident #2, discharged from the facility effective 02/09/2021 b. Resident #3, placed on 1:1 supervision effective 03/03/2021 c. Root Cause Analysis (RCA) and Performance Improvement Project initiated 02/11/2021 d. All female residents, residing on Hall A, relocated to one side of Hall A effective 02/09/2021 e. CNA assigned to sit on Hall A each shift to ensure female residents residing on Hall A are free from sexual abuse effective 03/03/2021 f. Increased CNA staffing on the 10:00 p.m. - 6:00 a.m. shift for Hall A from 2 to 3 effective 03/03/2021 g. In-service all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 h. Testing all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 i. Regional Director in-serviced NFA and DON on investigating allegation(s) of abuse and if the allegation(s) of abuse meets the requirements to be reported, a SIMS will be initiated effective 03/04/2021 2. All residents have the potential to be affected by this alleged deficient practice 3. The measures put into place to prevent this alleged deficient practice from re-occurring a. RCA and PIP initiated and completed as above (with in-service listed above) b. CNA assigned to sit on Hall A each shift to ensure female residents residing on Hall A are free from sexual abuse effective 03/03/2021 c. Increased CNA staffing on the 10:00 p.m. and 6:00 a.m. shift for Hall A from 2 to 3 effective 03/03/2021 d. In-service all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 e. Testing all staff regarding Abuse, Prevention and Prohibition Policy and Procedure initiated on 02/11/2021 to be completed by 03/12/2021 f. Regional Director in-serviced NFA and DON on investigating allegation(s) of abuse and if the allegation(s) of abuse meets the requirements to be reported, a SIMS will be initiated effective 03/04/2021 4. Facility will monitor its performance to ensure sustained compliance by the following a. DON and or designee will observe by direct visual observation three times a week to ensure CNA assigned to sit on Hall A is indeed meeting the assignment to ensure female residents residing on Hall A are free from sexual abuse initiated on 02/11/2021. b. DON and or designee will conduct audits by questioning staff regarding Abuse, Prevention and Prohibition Policy and Procedure three times a week for 1 month, twice a week for 1 month, then once a week for one month to ensure female residents residing on Hall A are free from sexual abuse initiated on 02/11/2021 c. Regional Director or designee will conduct an audit once a week to ensure SIMS are being completed effective 03/04/2021. d. Additional in-servicing and or progressive disciplinary action will occur if further non-compliance is noted The deficient practice continued at a potential for more than minimal harm for the residents residing on Hall A. Findings: Cross Reference: F600 and F607 Review of the facility's policy entitled Abuse- Prevention and Prohibition Policy and Procedure included: Purpose: Each resident has the right to be free from abuse. No one shall abuse a resident. This policy applies to facility staff, other residents, family members or resident representatives, and anyone else present in our facility. Policy: To provide a safe, abuse-free environment for all residents. If you suspect verbal, sexual, physical or mental abuse of a resident, misappropriation of resident property, corporal punishment or involuntary seclusion of a resident, exploitation or mistreatment of [REDACTED]. Sexual Abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual Abuse is non-consensual sexual contact of any type with a resident. There may be some situation in which the resident is unable to express him/herself due to a medical condition and /or cognitive impairment (e.g., stroke, coma, [MEDICAL CONDITION]), cannot relate what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by the resident does not mean that mental abuse did not occur. Sexual Abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual Abuse is non-consensual sexual contact of any type with a resident. Definitions: Willful - means the individual must have acted deliberately, not that he/she must intended to inflict injury or harm. Abuse Prohibition Practice Each resident has the right to be free from mistreatment. The facility takes steps to identify residents whose personal histories render them at risk for abusing other residents, and develops interventions strategies to prevent occurrences, monitors for changes that would trigger abusive behavior, and reassesses interventions on a regular basis. Identification: The facility Administrator proactively identifies events such as suspicious bruises, trends, patterns, and occurrences that may constitute abuse and determines the direction of the investigation. We use grievances, verbal reports, incident/accident report, and Quality Assurance to identify possible abuse. An interview was conducted on 03/01/2021 at 2:16 p.m. with S11LPN. She confirmed she was responsible for Resident #1 and Resident #2's care plans. She stated incidents and behaviors were discussed each morning in the morning meetings. She stated the facility's interdisciplinary team would have a meeting every morning. She stated the team would discuss behaviors and incidents. She stated the incident on 11/26/2020 with Resident #2 being found in bed with Resident #1 was discussed in the meeting and the team discussed increasing supervision for Resident #1 She stated she did not know of any other incidents with Resident #1 and Resident #2 from 11/26/2020 to 02/09/2021. An interview was conducted on 03/02/2021 at 11:13 a.m. with S23CNA. She explained each morning the staff had a meeting and would discuss any behaviors or incidents regarding residents. She stated Resident #2's sexual behaviors were not discussed in the morning meetings. An interview was conducted on 03/02/2021 at 5:20 p.m. with S1ADM and S2DON. The Communication Binder was reviewed with S1ADM and S2DON. S1ADM stated he was not notified of the incident that occurred with Resident #3 kissing R3 on 02/23/2021. S2DON stated she was not aware of any of the incidents related to Resident #3 that were documented in Hall A's Communication Binder. S2DON confirmed no specific changes in measures or interventions were made for Resident #3 since his hospitalization on [DATE]. An interview was conducted on 03/02/2021 at 11:35 a.m. with S2DON. She said sexual abuse was sexual intercourse, kissing, or groping with a resident who was not cognitive or who was unwilling. She stated her staff were instructed to report any suspicion of sexual abuse immediately. She stated the CNA would report to the nurse, the nurse would report to the DON, and the DON would report to S1ADM. She stated staff would report to her verbally as well as document in the clinical records. She stated a disciplinary team meets every morning and discusses resident's behaviors. She stated MDS is in the meeting, and they are responsible for updating the care plan. She stated it is then put in as a task for the nurses that pops up. She stated the CNA supervisor is responsible for telling the CNAs if an intervention has been implemented or the care plan has changed. She stated each morning she would review all the notes entered on each resident from the day before so was aware of all that had happened. She confirmed she did not see some of the nurses notes that had Resident #2's behaviors in it. She stated the CNA staff were instructed not to use the communication binder. She confirmed no one was reviewing the binder at this time. She reviewed the clinical record for Resident #2. She stated she knew of the incident on 11/26/2020 where a female resident was found in Resident #2's bed, but she did not know who the female resident was. She stated they discussed increased supervision for Resident #1, but she was unsure if it was implemented. After reviewing Resident #2's clinical record she revealed she was only aware of incidents occurring between Resident #1 and Resident #2 on 11/26/2020, 02/03/2021 and 02/09/2021. She stated she did not know Resident #2 had exhibited inappropriate sexual behaviors towards Resident #1 because the notes only stated a female resident and did not specify Resident #1. She stated S18CNA never reported to her that she was touched inappropriately and had to lock herself in a room to get away from Resident #2. She stated Resident #2 was sent to the hospital after he stuck his tongue down Resident #1's throat on 02/03/2021. She stated he returned to the facility on [DATE] and the staff were supposed to increase supervision at that time. She stated the nursing staff should have known about the increased supervision, but she was unsure who told them. She stated prior to the return on 02/08/2021, the facility addressed Resident #2's behaviors with redirection, medication adjustments, and sending him out of the facility to a behavioral hospital. She stated the interventions were ineffective because on 02/09/2021 Resident #2 was found in bed with Resident #1. She stated after the incident on 02/09/2021 the facility separated the male and female residents on Hall A. She stated the doors on the hallway were to have a staff member monitoring them at all times. She confirmed when surveyors entered Hall A on 02/26/2021 there should have been a CNA monitoring the hall and the double doors should have been closed. She confirmed the staff should have known the reason for the separation of male and female residents. She stated the CNA staff should not be utilizing the communication binder to report sexual behaviors. She stated she does not know if Resident #2 was aware of his sexual behaviors. She stated Hall A currently had one male resident, Resident #3, who exhibited inappropriate sexual behaviors towards female residents. An interview was conducted on 03/02/2021 at 1:08 p.m. with S1ADM. He stated abuse was a willful intent to harm and sexual abuse was any unwanted sexual acts that both parties did not consent to. He explained staff were to report concerns of sexual abuse immediately to him. He confirmed CNAs had come to him and reported Resident #2's sexually inappropriate behaviors. He stated on 11/26/2020, a female resident was found in Resident #2's bed. He stated both residents had clothes on and he did not know who the female resident was. He stated at that time staff implemented redirection as an intervention for Resident #2. He stated he was also aware of incidents where Resident #2 had touched a female residents arm and tried to kiss a female resident. He stated he did not think residents on Hall A could act intentionally, so he did not consider the behaviors of Resident #2 or Resident #3 to be sexual abuse. He stated due to their mental status it was not rape, nor was it sexual abuse. He stated, once a behavior is exhibited, a behavior note goes in the chart. After review, if the facility feels it is necessary, an incident report would be made. He stated the facility would send residents to the behavioral hospital to find out why they had the behaviors and the hospital would address it. He stated once the residents return, they are supposed to be better, so they do not add interventions. He confirmed the facility did not increase supervision of Resident #2 until after the incident on 02/09/2021. He stated Hall A currently had one male resident, Resident #3, who exhibited inappropriate sexual behaviors towards women.

Based on interviews and record review, the facility failed to ensure that one (#4) of six residents (#1, #2, #3, #4, #5, and #6) reviewed for accidents did not receive a [MEDICAL CONDITION] medication prior to being evaluated by a physician and prior to determining the underlying cause of the resident's change in condition. An Immediate Jeopardy occurred for Resident #4 on 01/16/2019 at 10:44 a.m., when Resident #4 was administered an injection of [MEDICATION NAME] 5mg/1ML prior to being evaluated by a physician and prior to determining the underlying cause for the resident's change in condition. Later in the day, on 01/16/2019 at approximately 12:00 p.m., the resident was found on the floor in his room. The resident was administered a second injection of [MEDICATION NAME] 10mg/2ML between 1:00 p.m. and 1:30 p.m. The Facility staff acknowledged there was a change in the resident's condition when the resident was observed experiencing auditory/visual hallucinations and weakness with the inability to stand, however, the nursing staff did not look for an underlining cause for the change in condition. On 01/17/2019 at 6:30 a.m., Resident #4 was transferred to the emergency room and admitted to ICU. Resident #4 was diagnosed with [REDACTED]. The resident returned to the facility on [DATE] under Hospice care. S1ADMIN was notified of the Immediate Jeopardy situation on 03/14/19 at 3:23 p.m. The Immediate Jeopardy was removed for Resident #4 at 4:45 p.m. on 03/15/19 when an acceptable plan of removal was received from the provider and observation and interviews revealed the immediacy had been removed. Plan of Removal Unnecessary Medications 1. Corrective action for situation 1 was corrected by: *Notification of the physician and having the residents medication reviewed occurred on 03/15/2019 at 11:10 a.m. with new recommended changes. *In-service with nursing staff by DON or designee regarding the implementation of a new tool to utilize Administering PRN Antipsychotic medication to ensure proper assessment of the resident's condition prior to medication administration and follow-up. In-service began on 03/14/2019 at 4:04 p.m. and will completed on 03/19/2019 at 4:04 p.m. *The anti-[MEDICAL CONDITION] in the emergency drug kit was removed and will be held securely by the by the DON or designee to improve control of administration. This measure was completed 03/14/2019 at 4:04 p.m. *The new assessment includes Assessment for use of PRN Antipsychotics including a pre assessment and post administration assessment. This measure was implemented on 03/14/2019 at 4:04 p.m. and will continue as protocol. 2. Other residents that have the potential to be effected by the deficient practice will be identified by: *Pharmaceutical consultant audit completed by consultant pharmacist. Other residents identified will have a pharmacy consultant letter submitted to the physician identifying resident specific need for a a dose reduction. There was no finding for PRN anti-psychotic. This measure was started on 03/14/2019 at 9:00 p.m. and recommendations were received 03/14/2019 at 11:43 p.m. The recommendations have been sent residents MD possible reductions on 03/15/2019 at 10:00 a.m. All will be completed and returned to the facility by 03/19/2019 at 12:00 p.m. *The anti-[MEDICAL CONDITION] in the emergency drug kit was removed and will be held securely by the DON or designee to improve control of administration. This measure was completed on 03/14/2019 at 4:04 p.m. 3. Measures put into place to ensure the alleged deficient practice does not recur is by: *In-service with nursing staff by DON or designee regarding the implementation of a new tool to utilize when administering PRN Antipsychotic medication to ensure proper assessment of the resident's condition prior to medication administration and follow-up. Competency check In-service began on 03/14/2019 at 12:00 p.m. The assessment tool was implemented on 03/14/2019 at 4:04 p.m. and will continue as protocol. *Implemented a new form to utilize prior to the administration of a PRN anti-[MEDICAL CONDITION]. The new form titled Assessment for use of PRN Antipsychotics including a pre assessment and post assessment was implemented on 03/14/2019 at 4:04 a.m. *The DON or designee will complete an immediate review of all PRN anti-[MEDICAL CONDITION] medications and review with each resident's primary physician. This measure was initiated on 03/15/2019 at 11:30 a.m. and will be completed by 03/19/2019 at 12:00 p.m. *The DON or designee will complete monthly PRN Anti-[MEDICAL CONDITION] medications review and review monthly with primary care physician for recommendations for change. This measure was implemented on 03/15/2019 at 11:30 a.m. and will continue monthly. *All staff nurses will complete an online Relias training course. [MEDICAL CONDITION] Treatments: A Neuropsychological Approach which concludes with a post test that evaluates the learner's retention and requires an 80% score to pass. These trainings will be assigned as of 2:30 p.m. on 03/15/2019 and will be completed by 03/19/2019 by 12:00 p.m. 4. Corrective actions will be monitored to ensure the alleged deficient practice will not recur by: *The DON or designee will review all PRN Anti-[MEDICAL CONDITION] medications monthly and review monthly with primary care physician for recommendations for change. This measure was implemented on 03/15/2019 at 11:30 a.m. and will continue monthly. *In-service with nursing staff by DON or designee regarding the implementation of a new tool to utilize when administering PRN Anti-psychotic medication to ensure proper assessment of the resident's condition prior to medication administration and follow-up. In-service began 03/14/2019 at 4:04 p.m. and will be completed on 03/19/2019 at 12:00 p.m. The assessment tool was implemented on 03/14/2019 at 4:04 p.m. and will continue as protocol. *The DON or designee will monitor by completing monthly monitoring PRN Anti-[MEDICAL CONDITION] medications review and review monthly with primary care physician for recommendation for change. This measure was implemented by 03/14/2019. After staff in-services are complete, monitoring will continue until 04/26/2019 at 4:00 p.m. *The DON or designee will complete chart audits on random residents weekly with PRN anti-[MEDICAL CONDITION] orders to ensure proper completion and follow-up of the new assessment tool protocol related to administration of PRN anti-[MEDICAL CONDITION] medication. During in-service training, the DON or designee will monitor competency by return demonstration. This measure was implemented on 03/14/2019. After staff in-services are complete, audits will continue until 04/26/2019 at 4:00 p.m. *The anti-psychotic in the emergency drug kit was removed and will be held securely by the DON or to improve control of administration. This measure was completed on 03/14/2019 at 4:04 p.m. and will continue as protocol. *The ID team will meet weekly to review data. If further issues are identified progressive disciplinary a action will be taken. This deficient practice continued at a potential for more than minimal harm for other residents, in the facility, who may have experienced a change in condition and were administered a [MEDICAL CONDITION] medication prior to being evaluated by a physician and prior to determining the underlining cause for the change in condition. Findings: Review of the Facility's [MEDICAL CONDITION] Medications Policy and Procedure revealed in part the following: Purpose: To maintain the resident's highest practicable level of physical, mental, and psychosocial well-being and to prevent or minimize adverse consequences related to [MEDICAL CONDITION] medication therapy to the extent possible. Definitions: Unnecessary Drug: An unnecessary drug is any drug when used: in excessive dose, for excessive duration, without adequate monitoring, without adequate indications for its use, in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or any combination stated above. [MEDICAL CONDITION] Drug: Any drug that affects brain activities associated with mental processes and behavior. Review of the Facility's Change in Condition Policy and Procedure Policy: Resident change in condition will be assessed and reported promptly. A follow up will occur as appropriate. Review of the clinical record revealed Resident #4 was a [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Quarterly MDS with an ARD of 12/11/2018 revealed Resident #4 had a BIMS of 3 which indicated severe cognitive impairment. Review of Section D-Mood Status revealed a mood severity score of 0 which indicated Resident #4 did not exhibit any altered moods. Section E-Behavior Status revealed no behavioral symptoms were exhibited. Section G-Functional Status revealed Resident #4 required limited assistance and 1 person physical assist for transfers, walking, and locomotion. Review of Resident #4's Care Plan revealed: Problem Onset: 12/06/2017, Resident refused a.m. care this morning resident became combative with staff. Stated When Ask why cause I don't want a bath that's why. 12/15/2017, I have no recent refusals of care noted. 07/18/2018, I was found groping a female resident's breast. Review of Resident #4's (MONTH) 2019 Medication Administration Record [REDACTED]. Review of Resident #4's Hospital Record revealed: HOSPITAL Admission Record: 01/17/2019 Admitting Complaint: Altered Mental Status Patient Narrative: Pt with a fall on 01/14/2019. It was reported there was no head injury but patient has been increasingly combative and more altered than normal. History of dementia but usually oriented to person and place. HOSPITAL Discharge Record: 01/24/2019 Discharge Diagnosis: [REDACTED]. Review of the Facility's Nurse Practitioners Progress Note dated 01/25/2019 revealed: Pt has a history of sexual inappropriateness with staff members on multiple occasions. Pt had a fall and began to exhibit atypical behaviors. He was transferred to the hospital. He was in a confused and agitated state. Review of (MONTH) 2019 Nurses Noted revealed: Late Entry for 01/14/2019, documented on 01/16/2019 at 11:28 a.m.: CNA reported to the nurse's station and stated that resident was sitting on the floor on his buttocks next to the bed. Upon entry of room resident was sitting in a chair on the side of his bed. Patient put in chair by CNA. Asked patient how did he get on the floor. Patient did not respond. Neuro checks in place. Notified NP and Resident Representative. Will continue to monitor. Signed By: S22LPN Late Entry for 01/15/2019 11P-7AM: documented on 1/19/2019 at 7:16 a.m.: Resident remained in bed. Breathing non-labored. Awake and Alert. Appears weak and unable to stand and ambulate with walker. Will continue to monitor. Signed By: S17LPN 01/16/2019 at 10:44 a.m.: Upon entry of residents room had a bible in his hand. CNA reported that resident was trying to hit her with it. I tried to administer medication resident said if you touch me you will die. Resident then picked up the lamp off his bed and began swinging it. I stepped away .The CNA and I then got the lamp out of his hand. Resident stated I'm a die I'm a soldier in the army of the lord. Called S13NP and was ordered to give 5mg/1ML of [MEDICATION NAME]. S12CC and I went in the room to administer it. The resident then pulled the cord from the air conditioner and started swinging it. After the cord was removed from the residents hand he grabbed the night stand and began trying to pick it up. S12CC and I then got the resident a little calmer so we could administer medication. Signed By: S22LPN 01/16/2019 at 1:24 p.m.: Resident received [MEDICATION NAME] 10 mg/1 ML IM Injection x 1 dose now in upper left arm. Resident tolerated procedure well, resident is having visual and auditory hallucinations at this time. Resident is being physically aggressive towards the nursing staff. Resident refused vital signs. Will continue to monitor throughout shift. Signed by: S24LPN 01/16/2019 at 1:43 p.m.: Resident in bed screaming loudly at this time still refuses to let nursing staff get vital signs on him. Still having visual hallucinations at this time, will continue to monitor. Signed By: S24LPN 01/17/2019 at 6:25 a.m.: Resident has been agitated and confused throughout shift with weakness that required observation and assistance. Resident continued to attempt to get out of bed while being weak. Transferred resident from bed to wheelchair with assistance. Resident was very aggressively resistant with pulling and grabbing of our clothes, hands, and wheelchair while assisting. Resident cut hand on wheelchair during transfer. Applied pressure, cleaned, and dressed site. NP on call notified. Signed By: S17LPN 01/17/2019 at 7:51 a.m.: Report called to ER nurse about transfer due to altered mental status and previous fall on the 14th of January. Since fall resident status has changed. Signed By: S22LPN 01/17/2019 at 10:20 a.m.: Report called per ER. Resident has [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. 01/16/2019 1 p.m. [MEDICATION NAME] 5 MG/ML [MEDICATION NAME], Give [MEDICATION NAME] 10 MG/ML x 1 dose now. Entered by S24LPN Review of the Facility's Emergency Kit medication removal form revealed: On 01/16/2019 at 9:10 [MEDICATION NAME] was removed by S12CC for Resident #4. Directions: Give 5 MG/Ml IM x 1 dose Stat. Used for: Agitation An interview was conducted with S22LPN 03/12/2019 at 1:45 p.m. She verified Resident #4 fell on [DATE] and on 01/16/2019. She stated prior to those falls Resident #4 was ambulatory with his walker. She reported during the time of 01/14/2019 to 01/17/2019 Resident #4 had increasing behavioral issues. She reported Resident #4 grabbed a lamp and pointed it at her. She reported Resident #4 had not exhibited behavior like that before. An interview was conducted with S22LPN on 03/13/2019 at 9:40 a.m. She verified she was working on 01/14/2019 when Resident #4 had an unobserved fall. She reported she went into Resident#4's room and he was sitting on his buttocks on the floor with his head resting on the side of his wheelchair. She explained Resident #4's baseline was alert and oriented to person and place, but he was never fully oriented. She also reported Resident #4 was able to ambulate with his walker. She stated there was an entry in the nursing notes from the night of 01/15/2019 that reported a change in Resident #4. She reported she came back to work on 01/16/2019 and Resident #4 was becoming more combative with staff. She also reported Resident #4 was weaker and not able to ambulate like he used to anymore. She denied contacting the doctor once the change was observed. She reported contacting S13NP on 01/16/2019 when Resident #4 had exhibited escalating aggressive behaviors and received an order to administer [MEDICATION NAME] 5mg/1ML to the resident. She stated the resident had a fall on 01/16/2019 after the [MEDICATION NAME] was administered. S22LPN reported this fall was similar to the fall on 01/14/2019, and Resident #4 was found in the same position as the previous fall. An interview was conducted with S13NP on 03/13/2019 at 10:29 a.m. She reported Resident #4 had 2 falls in (MONTH) 2019 and she was contacted after both of those falls. She reported after the first fall Resident #4 had some changes in behavior, and staff thought the resident had a urinary tract infection. She reported the results from the urinalysis were negative. She reported being notified of aggressive behaviors on 01/16/2019 and ordered a one-time dose of 10mg/2ML of [MEDICATION NAME] to be administered. S13NP did not mention staff communicating Resident #4 had been having auditory and visual hallucinations on 01/16/2019. She reported she was notified on 01/17/2019 of Resident #4's behaviors continuing to worsen and said he was atypical and combative. She reported he was then sent to the ER due to his behaviors continuing to escalate. She described Resident #4's baseline as confused at times and sexual. An interview was conducted with S5ADON on 03/13/2019 at 1:15 p.m. She reported Resident #4 was ambulatory with a walker before going into the hospital on [DATE]. She explained after a resident had an unwitnessed fall the staff were supposed to implement neurological checks for the next 72 hours. She explained the nurses are supposed to assess for any changes in the residents status. She then reviewed the (MONTH) 2019 nurses notes. She verified behavioral changes could be a sign of a neurological change. She reported she would have expected the staff to contact the doctor about any changes the resident exhibited. She confirmed the behaviors documented were abnormal. She confirmed the nurses should have recognized the change in condition for Resident #4. She reported a resident with a brain bleed should not be given [MEDICATION NAME] for behaviors. An interview was conducted with S17LPN on 03/13/2019 at 2:30 p.m. She reported she had worked with Resident #4 during the times between 01/14/2019 and 1/16/2019. She reported the agitation was very unusual for Resident #4. She reported weakness and difficulty standing as being unusual and explained Resident #4 could normally stand and balance alone with his walker. She reported Resident #4 was normally accepting of assistance or would come get help if needed, but at that time he didn't want to be touched. He said things like, 'Oh, no you are going to make me fall. She denied contacting the doctor at that point. S17LPN confirmed and acknowledged a mental status change in Resident #4 but thought it was from a urinary tract infection. An interview was conducted with S12CC on 01/13/2019 at 3:10 p.m. He also reported the facility would use [MEDICATION NAME] in the event a resident was very agitated and tried to hit someone. He verified being present when Resident #4 received [MEDICATION NAME] and confirmed he assisted S24LPN with administering the medications. He reported a [MEDICATION NAME] injection would not normally be the first intervention to treat behaviors but Resident #4 was on guard and trying to hit you with a cane and said things like I'm the Lord of Kings. S12CC reported he thought Resident #4 had a fall on 01/14/2019 and staff were trying to stop him from getting out of the bed again and having another fall. An interview was conducted with S4DON on 03/13/2019 at 3:35 p.m. She explained after an unwitnessed fall neurological checks are implemented for 72 hours. She said nurses would assess for vital signs, range of motion, check for a difference in concentration, whether the resident was able to answer questions as usual, light sensitivity, hand grasp, moving limbs, and pain. She stated if staff noticed any change they are to contact the doctor immediately. She reported a behavioral change such as aggression or combativeness would have to be assessed on an individualized basis. She reported if a behavioral change was noted after an unwitnessed fall it would really depend on how marked the change was on whether or not it would be concerning. She reported Resident #4 had some confusion and episodes of aggressive and sexually inappropriate behavior. She denied the aggressive behavior as being a daily or routine occurrence. She explained the resident was independently ambulatory with a walker and would go into the dining room for meals prior to falling in (MONTH) 2019. She verified Resident #4 had fallen on 01/14/2019 and 01/16/2019. She verified there was a late entry on 01/15/2019 that reported Resident #4 was weakened and unable to stand. She verified increased behaviors on 01/16/2019 and reported Resident #4 was trying to hit staff members and was swinging a lamp at them. She explained these behaviors resulted in the [MEDICATION NAME] injection being given to Resident #4. She also confirmed Resident #4 was being monitored for neurological changes at that time due to the falls. She explained the nurse would contact the doctor, receive an order for [REDACTED].#4 received. She was able to provide an electronic physicians order entered by S24LPN for one of the doses received. She then reviewed the notes and reported it appeared Resident #4 fell a second time. She again repeated [MEDICATION NAME] was not a routine medication that was given to residents. An interview was conducted with S12CC on 03/13/2019 at 5:45 p.m. He confirmed he was the one that removed the [MEDICATION NAME] from the emergency kit to administer to Resident #4. He reviewed the medication removal slip and confirmed the [MEDICATION NAME] was removed from the kit on 01/16/2019 at 9:10 a.m. He confirmed 1 5 ML [MEDICATION NAME] was removed. He then reported S22LPN told him there was a doctor's order for the medication administration and he went and got it. He reported the medication was administered around 10:44 a.m. per the nurse's notes. When asked if it was routine practice to remove a medication prior to a doctor's order he stated, No. He stated when this type of medication was removed it was normally administered immediately. He reported Resident #4 was very combative and was trying to hit the staff with the nightstand. He confirmed knowing Resident #4 had a fall on 01/14/2019. He verified there was an entry on the MAR indicated [REDACTED]. An interview was conducted with S24LPN on 03/13/2019 at 6:37 p.m. She described Resident #4 as ambulatory with a walker prior to falling in (MONTH) 2019. She also stated he was normally oriented to person and place with episodes of confusion at times. She verified she had worked with Resident #4 on 01/16/2019 starting at 1:00 p.m. She confirmed she was aware Resident #4 had fallen and was being monitored for neurological changes. She reported Resident #4 was really agitated that day. He was threatening to hit staff and said things like don't touch me and get away from me. She also stated Resident #4 was having auditory and visual hallucinations. She explained Resident #4 did not seem to want staff to be near him. She stated we had to get an order for [REDACTED].#4 had received another dose of [MEDICATION NAME] earlier in the day. When asked if it was a normal to administer medication for behaviors to Resident #4 she stated, No. She explained in past if Resident #4 had behaviors he was easily redirected and no other interventions were needed. On 3/14/19 at 8:38 AM, an interview was conducted with S22LPN on 03/14/2019 at 8:38 a.m. She confirmed she gave the dose of [MEDICATION NAME] 5Mg/Ml on 01/16/2019 at 9:40 a.m. or something. She stated she got an order from S13NP and then S12CC removed the medication from the emergency kit and assisted her with administration to Resident #4. She confirmed Resident #4 fell after the dose of [MEDICATION NAME] was administered. She reported she wrote an order for [REDACTED]. She also confirmed she could not find the order she wrote for the [MEDICATION NAME] in the chart. An interview was conducted with S6ADON on 03/14/2019 at 8:54 a.m. She verified the facility could not find the two orders for the [MEDICATION NAME] that was administered on 01/16/2019. She reported she did not remember assisting S24LPN with administration of the medication. She denied contacting S13NP for the order and denied removing the medication from the emergency kit. S6ADON denied knowing Resident #4 had received two separate doses of [MEDICATION NAME] on 01/16/2019 until she started reviewing the record trying to find the order. She confirmed two separate nurses had documented administration of 2 different doses of [MEDICATION NAME] in Resident #4's record.

Based on interviews and record reviews, the facility failed to be administered in a manner which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by failing to: 1. Ensure staff accurately determined the required number of persons needed to safely transfer 4 (#3, #7, #8, #9) of 4 (#3, #7, #8, #9) residents sampled for transfers. 2. Staff did not administer unnecessary anti-[MEDICAL CONDITION] medications to 1 (#4) of 6 (#1, #2, #3, #4, #5, #6) residents sampled for accidents. This deficient practice resulted in an Immediate Jeopardy situation for Resident #3 on 2/18/2019 after the resident complained of left hip pain when being transferred and an x-ray revealed an Acute Fracture to the left femoral neck. On 2/18/2019, the resident, who required two person assistance with transfers, was transferred by one CNA from the bed to his chair. After the discovery of the left femoral neck fracture, the resident was transferred to the hospital and had a left hip hemi arthroplasty performed on 2/20/2019. The CNAs working with the residents did not know how to find out the functional statuses for the residents who required assistance with transfers in the facility. An Immediate Jeopardy occurred for Resident #4 on 01/16/2019 at 10:44 a.m., when Resident #4 was administered an injection of [MEDICATION NAME] 5mg/1ML prior to being evaluated by a physician and prior to determining the underlying cause for the resident's change in condition. Later in the day, on 01/16/2019 at approximately 12:00 p.m., the resident was found on the floor in his room. The resident was administered a second injection of [MEDICATION NAME] 10mg/2ML between 1:00 p.m. and 1:30 p.m. The Facility staff acknowledged there was a change in the resident's condition when the resident was observed experiencing auditory/visual hallucinations and weakness with the inability to stand, however, the nursing staff did not look for an underlining cause for the change in condition. On 01/17/2019 at 6:30 a.m., Resident #4 was transferred to the emergency room and admitted to ICU. Resident #4 was diagnosed with [REDACTED]. The resident returned to the facility on [DATE] under Hospice care. S1ADMIN was notified of the Immediate Jeopardy situation on 03/14/19 at 3:23 p.m. The Immediate Jeopardy was removed for Resident #3 and #4 at 4:45 p.m. on 03/15/19 when an acceptable plan of removal was received from the provider and the immediacy had been removed. The plan of removal included the following: Plan of Removal Unnecessary Medications 1. Corrective action for situation 1 was corrected by: *Notification of the physician and having the residents medication reviewed occurred on 03/15/19 at 11:10 a.m. with new recommended changes. *In-service with nursing staff by DON or designee regarding the implementation of a new tool to utilize Administering PRN Antipsychotic medication to ensure proper assessment of the resident's condition prior to medication administration and follow-up. In-service began on 03/14/19 at 4:04 p.m. and will completed on 03/19/19 at 4:04 p.m. *The anti-[MEDICAL CONDITION] in the emergency drug kit was removed and will be held securely by the by the DON or designee to improve control of administration. This measure was completed 03/14/19 at 4:04 p.m. *The new assessment includes Assessment for use of PRN Antipsychotics including a pre assessment and post administration assessment. This measure was implemented on 03/14/19 at 4:04 p.m. and will continue as protocol. 2. Other residents that have the potential to be effected by the deficient practice will be identified by: *Pharmaceutical consultant audit completed by consultant pharmacist. Other residents identified will have a pharmacy consultant letter submitted to the physician identifying resident specific need for a a dose reduction. There was no finding for PRN anti-psychotic. This measure was started on 03/14/19 at 9:00 p.m. and recommendations were received 03/14/19 at 11:43 p.m. The recommendations have been sent residents MD possible reductions on 03/15/19 at 10:00 a.m. All will be completed and returned to the facility by 03/19/19 at 12:00 p.m. *The anti-[MEDICAL CONDITION] in the emergency drug kit was removed and will be held securely by the DON or designee to improve control of administration. This measure was completed on 03/14/19 at 4:04 p.m. 3. Measures put into place to ensure the alleged deficient practice does not recur is by: *In-service with nursing staff by DON or designee regarding the implementation of a new tool to utilize when administering PRN Antipsychotic medication to ensure proper assessment of the resident's condition prior to medication administration and follow-up. Competency check In-service began on 03/14/19 at 12:00 p.m. The assessment tool was implemented on 03/14/19 at 4:04 p.m. and will continue as protocol. *Implemented a new form to utilize prior to the administration of a PRN anti-[MEDICAL CONDITION]. The new form titled Assessment for use of PRN Antipsychotics including a pre assessment and post assessment was implemented on 03/14/19 at 4:04 a.m. *The DON or designee will complete an immediate review of all PRN anti-[MEDICAL CONDITION] medications and review with each resident's primary physician. This measure was initiated on 03/15/19 at 11:30 a.m. and will be completed by 03/19/19 at 12:00 p.m. *The DON or designee will complete monthly PRN Anti-[MEDICAL CONDITION] medications review and review monthly with primary care physician for recommendations for change. This measure was implemented on 03/15/19 at 11:30 a.m. and will continue monthly. *All staff nurses will complete an online Relias training course. [MEDICAL CONDITION] Treatments: A Neuropsychological Approach which concludes with a post test that evaluates the learner's retention and requires an 80% score to pass. These trainings will be assigned as of 2:30 p.m. on 03/15/19 and will be completed by 03/19/19 by 12:00 p.m. 4. Corrective actions will be monitored to ensure the alleged deficient practice will not recur by: *The DON or designee will review all PRN Anti-[MEDICAL CONDITION] medications monthly and review monthly with primary care physician for recommendations for change. This measure was implemented on 03/15/19 at 11:30 a.m. and will continue monthly. *In-service with nursing staff by DON or designee regarding the implementation of a new tool to utilize when administering PRN Anti-psychotic medication to ensure proper assessment of the resident's condition prior to medication administration and follow-up. In-service began 03/14/19 at 4:04 p.m. and will be completed on 03/19/19 at 12:00 p.m. The assessment tool was implemented on 03/14/19 at 4:04 p.m. and will continue as protocol. *The DON or designee will monitor by completing monthly monitoring PRN Anti-[MEDICAL CONDITION] medications review and review monthly with primary care physician for recommendation for change. This measure was implemented by 03/14/19. After staff in-services are complete, monitoring will continue until 04/26/19 at 4:00 p.m. *The DON or designee will complete chart audits on random residents weekly with PRN anti-[MEDICAL CONDITION] orders to ensure proper completion and follow-up of the new assessment tool protocol related to administration of PRN anti-[MEDICAL CONDITION] medication. During in-service training, the DON or designee will monitor competency by return demonstration. This measure was implemented on 03/14/19. After staff in-services are complete, audits will continue until 04/26/19 at 4:00 p.m. *The anti-psychotic in the emergency drug kit was removed and will be held securely by the DON or to improve control of administration. This measure was completed on 03/14/19 at 4:04 p.m. and will continue as protocol. *The ID team will meet weekly to review data. If further issues are identified progressive disciplinary a action will be taken. Education and monitoring/Staff Knowledge of resident change and transfer needs: 1. Other residents that have the potential to be effected by the deficient practice will be identified by: *Review of the historical MDS for residents that require assistance with transfers and reviewed care plan to ensure it reflects the current resident transfer needs. This audit was started on 03/14/19 at 4:04 p.m. and will be completed by 03/15/19 at 12:00 p.m. *CNA staff was in-serviced on residents need to be a 2 person assist and where to access the information. In-service began on 03/14/19 at 4:04 p.m. and will be completed on 03/19/19 at 12:00 p.m. The task care plans were reviewed to ensure it reflected the residents current transfer needs which started on 03/14/19 at 4:04 p.m. and was completed by 03/19/19 at 12:00 p.m. 2. Corrective action for situation 2 was corrected by: *CNA staff was in-serviced on residents need to be a 2 person assist and where to access the information. In-service began on 03/14/19 at 4:04 p.m. and will be completed by 03/19/19 at 12:00 p.m. The task care plans were reviewed to ensure it reflected the residents current transfer needs. This audit was started on 03/14/19 at 4:04 p.m. and will be completed by 03/15/19 at 12:00 p.m. 3. Measures put into place to ensure the alleged deficient practice does not recur is by: *DON or designee in-serviced CNA staff on residents that need to be a 2 person assistance with transfers and where to access the information. In-service began on 03/14/19 at 4:04 p.m. will be completed by 03/15/19 at 12:00 p.m. *Completed audit of task care plan to ensure it reflects an accurate plan of each resident transfer needs status, This audit was started on 03/14/19 at 4:04 p.m. and will be completed by 03/15/19 at 12:00 p.m. 4. Corrective actions will be monitored to ensure the alleged deficient practice will not recur by: *DON or designee in-serviced CNA staff on residents that require a 2 person assistance with transfers and where to access the information. The task care plans were reviewed to ensure it reflected the residents current transfer needs. In-service and the audit of task care plans began on 03/14/19 at 4:04 p.m. and will be completed on 03/19/19 at 12:00 p.m. *Additional qualified nursing staff member was added to the staffing pattern to assist with transfer only. This staff member was added to the staffing pattern to assist with transfers only. This staff member's sole duty is to be available to assist when needed with 2 person transfers. This measure was implemented on 03/14/19 at 4:04 p.m. and will be completed by 03/19/19 at 12:00 p.m. *CNA competency will be assessed and if staff is unable to properly demonstrate correct method of transfer further in-servicing will immediately occur per DON or designee. *The DON or designee will audit random task care plans weekly to ensure it reflects the current resident transfer status. This measure was implemented on 03/14/19. After staff in-services are complete, auditing will continue until 04/26/19 at 4:00 p.m. *The DON or designee will complete visual observations weekly of random residents being transferred and review their transfer status to ensure proper transfer technique is completed according to the residents task care plan. Visual observations will be documented on quality of care forms. If proper transfer is observed the CNA will be retrained. During in-service training, the DON or designee will monitor competency by return demonstration. This measure was implemented on 03/14/19. After staff in-services are complete, observations will continue until 04/26/19 at 4:00 p.m. *The DON or designee will complete random staff interview weekly to ensure staff is knowledgeable about resident transfer status, how to access information in the task care plan and daily care guides for residents. DON or designee will document interviews on quality care forms. CNAs will do return demonstration for the kiosk to identify where the residents care guide is located. If CNA is not showing proficiency, the CNA will be retrained. This measure was implemented on 03/14/19. After staff in-services are complete, interviews will continue until 04/26/2019 at 4:00 p.m. *The ID team will meet weekly to review data. If further issues are identified progressive disciplinary action will be taken. This deficient practice continued at a potential for more than minimal harm for all 58 residents in the facility who required 2+ person assistance with transfers. This deficient practice continued at a potential for more than minimal harm for other residents, in the facility, who may have experienced a change in condition and were administered a [MEDICAL CONDITION] medication prior to being evaluated by a physician and prior to determining the underlining cause for the change in condition. Findings: Cross Reference F689 Cross Reference F758 1. On 03/13/2019 at 12:47 p.m., an interview was conducted with S5ADON. S5ADON stated CNAs should report off to each other about residents and refer to the kiosk for resident transfer needs and requirements. S5ADON stated she expected staff to get help when a resident was identified as a 4 for Total Dependence. S5ADON stated S32CNA transferred Resident #3 many times without assistance and never had an issue. On 03/13/2019 at 3:32 p.m., an interview was conducted with S4DON. S4DON stated the amount of people required to transfer a resident would be dependent on the aide's ability. S4DON stated she expected staff to follow the kiosk, request assistance when needed, and communicate with each other. On 03/14/2019 at 8:19 a.m., an interview was conducted with S2ADMIN. S2ADMIN stated she knew S32CNA transferred Resident #3 with one person. On 03/14/2019 at 11:40 a.m., an interview was conducted with S1ADMIN. S1ADMIN confirmed S32CNA had been transferring Resident #3 by himself for a long time and never had any issues. On 03/15/2019 at 9:41 a.m., an interview was conducted with S3DCO in the presence of 4 surveyors. S3DCO stated if resident is extensive or total assist it will be a two + person support. In the kiosk, the aide has the choice to pick if the person had limited or extensive assistance. S3DCO stated the aide decides what the resident needs are and the assistance needed. She stated they are certified, trained, and they make those assessments. She stated the aide drives the assessment for ADL care. S3DCO stated this is not the first time they have heard the CNAs did not know what type of assistance the residents needed. S3DCO stated the ADL legend is in the kiosk, she cannot understand why there is confusion over transfer requirements because it is in the kiosk and they can use it if they can read-and they screen for that. 2 An interview was conducted with S5ADON on 03/13/2019 at 1:15 p.m. She explained after a resident had an unwitnessed fall the staff were supposed to implement neurological checks for the next 72 hours. She explained the nurses were supposed to assess for any changes in the residents status. When asked how staff nurses are tested for competency in neurological assessments she replied, If you are a nurse you should know how to assess. She verified behavioral changes could be a sign of a neurological change. She reported she would have expected the staff to contact the doctor about any changes the resident exhibited. She confirmed the behaviors documented were abnormal. She confirmed the nurses should have recognized the change in condition for Resident #4. She reported a resident with a brain bleed should not be given [MEDICATION NAME] for behaviors. An interview was conducted with S4DON on 03/13/2019 at 3:35 p.m. She verified Resident #4 had fallen on 01/14/2019 and 01/16/2019. She verified there was a late entry on 01/15/2019 that reported Resident #4 was weakened and unable to stand. She verified increased behaviors on 01/16/2019 and reported Resident #4 was trying to hit staff members and was swinging a lamp at them. She explained that was when the [MEDICATION NAME] injection was given to Resident #4. She also confirmed Resident #4 was being monitored for neurological changes at that time due to the falls. She then reviewed the notes and reported it appeared Resident #4 fell a second time. She again repeated [MEDICATION NAME] was not a routine medication that was given to residents. She denied completing any in-services educating her nurses on identifying changes in conditions because she did not think there was a reason to. She was asked if hospice was an anticipated need for Resident #4 in the near future and she stated, no. She was asked if the need for hospice resulted from the falls sustained in (MONTH) and she stated, yes, probably so. An interview was conducted with S6ADON on 03/14/2019 at 8:54 a.m. She verified the facility could not find two orders for [MEDICATION NAME] to be administered on 01/16/2019. S6ADON denied knowing Resident #4 had received two separate doses of [MEDICATION NAME] on 01/16/2019 until she had started reviewing the record trying to find the order. She confirmed two separate nurses had documented administration of 2 different doses of [MEDICATION NAME] in Resident #4's record. She reported she was not sure if the behavioral changes documented on Resident #4 could have been a sign of a neurological change resulting from an unobserved fall.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 4 of 4 (#3, #7, #8, #9) residents reviewed for transfers. The facility failed to use a two-person transfer, as determined necessary by the comprehensive plan of care, during a transfer from the resident's wheelchair to bed (Resident #3). This deficient practice resulted in an Immediate Jeopardy situation for Resident #3 on 2/18/2019 after the resident complained of left hip pain when being transferred and an x-ray revealed an Acute Fracture to the left femoral neck. On 2/18/2019, the resident, who required two person assistance with transfers, was transferred by one CNA from the bed to his chair. After the discovery of the left femoral neck fracture, the resident was transferred to the hospital and had a left hip hemi arthroplasty performed on 2/20/2019. The CNAs working with the residents did not know how to find out the functional statuses for the residents who required assistance with transfers in the facility. The Immediate Jeopardy was removed at 4:45 p.m. on 03/15/2019 when an acceptable plan of removal was received from the provider and observation and interview revealed the immediacy had been removed. The plan of removal included the following: Plan of Removal Education and monitoring/Staff Knowledge of resident change and transfer needs: 1. Other residents that have the potential to be effected by the deficient practice will be identified by: *Review of the historical MDS for residents that require assistance with transfers and reviewed care plan to ensure it reflects the current resident transfer needs. This audit was started on 03/14/2019 at 4:04 p.m. and will be completed by 03/15/2019 at 12:00 p.m. *CNA staff was in-serviced on residents need to be a 2 person assist and where to access the information. In-service began on 03/14/2019 at 4:04 p.m. and will be completed on 03/19/2019 at 12:00 p.m. The task care plans were reviewed to ensure it reflected the residents current transfer needs which started on 03/14/2019 at 4:04 p.m. and was completed by 03/19/2019 at 12:00 p.m. 2. Corrective action for situation 2 was corrected by: *CNA staff was in-serviced on residents need to be a 2 person assist and where to access the information. In-service began on 03/14/2019 at 4:04 p.m. and will be completed by 03/19/2019 at 12:00 p.m. The task care plans were reviewed to ensure it reflected the residents current transfer needs. This audit was started on 03/14/2019 at 4:04 p.m. and will be completed by 03/15/2019 at 12:00 p.m. 3. Measures put into place to ensure the alleged deficient practice does not recur is by: *DON or designee in-serviced CNA staff on residents that need to be a 2 person assistance with transfers and where to access the information. In-service began on 03/14/2019 at 4:04 p.m. will be completed by 03/15/2019 at 12:00 p.m. *Completed audit of task care plan to ensure it reflects an accurate plan of each resident transfer needs status, This audit was started on 03/14/2019 at 4:04 p.m. and will be completed by 03/15/2019 at 12:00 p.m. 4. Corrective actions will be monitored to ensure the alleged deficient practice will not recur by: *DON or designee in-serviced CNA staff on residents that require a 2 person assistance with transfers and where to access the information. The task care plans were reviewed to ensure it reflected the residents current transfer needs. In-service and the audit of task care plans began on 03/14/2019 at 4:04 p.m. and will be completed on 03/19/2019 at 12:00 p.m. *Additional qualified nursing staff member was added to the staffing pattern to assist with transfer only. This staff member was added to the staffing pattern to assist with transfers only. This staff member's sole duty is to be available to assist when needed with 2 person transfers. This measure was implemented on 03/14/2019 at 4:04 p.m. and will be completed by 03/19/2019 at 12:00 p.m. *CNA competency will be assessed and if staff is unable to properly demonstrate correct method of transfer further in-servicing will immediately occur per DON or designee. *The DON or designee will audit random task care plans weekly to ensure it reflects the current resident transfer status. This measure was implemented on 03/14/2019. After staff in-services are complete, auditing will continue until 04/26/2019 at 4:00 p.m. *The DON or designee will complete visual observations weekly of random residents being transferred and review their transfer status to ensure proper transfer technique is completed according to the residents task care plan. Visual observations will be documented on quality of care forms. If proper transfer is observed the CNA will be retrained. During in-service training, the DON or designee will monitor competency by return demonstration. This measure was implemented on 03/14/2019. After staff in-services are complete, observations will continue until 04/26/2019 at 4:00 p.m. *The DON or designee will complete random staff interview weekly to ensure staff is knowledgeable about resident transfer status, how to access information in the task care plan and daily care guides for residents. DON or designee will document interviews on quality care forms. CNAs will do return demonstration for the kiosk to identify where the residents care guide is located. If CNA is not showing proficiency, the CNA will be retrained. This measure was implemented on 03/14/2019. After staff in-services are complete, interviews will continue until 04/26/2019 at 4:00 p.m. *The ID team will meet weekly to review data. If further issues are identified progressive disciplinary action will be taken. This deficient practice continued at a potential for more than minimal harm for all 58 residents in the facility who required 2+ person assistance with transfers. Findings: Resident #3 Review of the policy titled Transferring a Resident Policy and Procedure was reviewed. The purpose of the policy was to provide the most effective means of moving a resident with diminished lower body sensation, weakness, immobility or injury. The policy stated that resident's would be transferred as safely as possible. Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set, dated dated dated of 01/15/2019 revealed Resident #3 had a Brief Interview for Mental Status score of 0, which indicated severe cognitive impairment, total dependence and 2+ person assistance with transfers, unsteady balance, and wheelchair use. Review of the Care Plan was modified on 01/19/2019 and noted the following in part: required extensive to total assistance with ADLs, required assistance with transfers, and staff to transfer Resident #3 on his strong side. Review of the ADL Coding Legend stationed in the care kiosk revealed Resident #3 was coded as 4 for transfers, which indicated that resident was totally dependent on staff and required 2+ person physical assist for transfers. Review of the General Notes entered by S5ADON at 2:48 p.m. on 02/18/2019 revealed the following: S32CNA reported Resident #3 was unable to put weight down on left leg. States he act as if he is in pain. Resident nodded head up and down when asked was he experiencing pain in his left leg. Asked did he fall nodded head from side to side no but nodded head about pain from hip to lower leg. S13NP notified and orders for x-ray left hip and lower extremity. Review of the General Note entered by S4DON at 10:28 a.m. on 02/19/2019 revealed the following, in part: Late entry 02/18/2019. Xray results reviewed. Results as follows: Left hip x-ray unilateral 2-3 views. Impression: Acute fracture left femoral neck. S13NP notified. Order received to send resident out for ER evaluation. Ambulance called resident transported to HOSPITAL2 for evaluation. Review of the hospital records revealed Resident #3 was transported to the emergency room via ambulance on 02/18/2019. Resident #3 was admitted to the hospital from the emergency department with [DIAGNOSES REDACTED]. He was admitted for pain control and operative evaluation, and subsequently taken to the operating room for a left hip hemiarthroplasty on 02/20/2019. The discharge summary revealed the following Diagnoses: [REDACTED]. X-ray of the left hip revealed a subcapital impacted and angulated [MEDICAL CONDITION] femur. The Operative Report noted the resident was found to have a displaced femoral neck fracture and extensive discussion with resident and his family was done regarding his [DIAGNOSES REDACTED]. Review of the written statement provided by S32CNA on 02/19/2019 revealed the following in part: On Monday (MONTH) 18, 2019, when I got upstairs with the carts, I started passing out the trays so the patients can eat. I seen Resident #3 ripping his brief like he normally does when he needs to be changed. I told my nurse S11SD that he was ripping his brief and that I will change him after the trays were taking downstairs because we can not have dirty barrels out during lunch. That's called cross contamination. After the trays were taking down, I preceded to assist Resident #3 with his transfer to be changed and noticed that he didn't help in the transfer. So I went and reported my concerns to the S5ADON. She told me thank you and that she will get him checked out, so that they can have him x-ray. Review of the written statement provided by S32CNA on 02/24/2019 revealed the following: On Monday, (MONTH) 18, 2019, I went to transfer Resident #3 in the bed. When I went to transfer him, he put his arm around my neck and I assisted him in standing. Then I pivoted him and sat him down on the bed. After that I changed his brief and helped him get back up. That's what I reported what I observed during the transfer. Review of the Physical Therapy Plan of Care revealed a start date of 03/01/2019. Medical [DIAGNOSES REDACTED]. The initial assessment revealed, in part, that Resident #3 required maximum assistance x2 (76-99% assist with 2 people) with sit to stand transfers. An interview was conducted with S32CNA at 1:46 p.m. on 03/11/2019. He stated Resident #3 was a one person assist when he worked with him. He stated Resident #3 could do for himself. He stated he noticed something was not right with Resident #3 on 02/18/2019. He stated he normally transferred Resident #3 by himself as Resident #3 could normally assist him with transfers, but, on 02/18/2019, Resident #3 couldn't help like he normally did. He stated he knew something was wrong with Resident #3's leg and he reported this to S5ADON. An interview was conducted with S25CNA at 12:52 p.m. on 03/12/2019. She stated, when she worked with Resident #3, he was able to be assisted by one or two person assist. She stated he could pivot a little and help when transferring, but he could not stand up or transfer without assistance. An interview was conducted with S21LPN at 1:26 p.m. on 03/12/2019. She stated Resident #3 could currently be transferred with one person assist for transfers. She stated Resident #3's injury was due to a fall. She stated she had not done any training or in-services following Resident #3's injury. An interview was conducted with S33CNA at 2:20 p.m. on 03/12/2019. She was asked how she would identify a resident's transfer needs and she stated, she would notice their ability to transfer and walk. She stated some residents may be wobbly and need more help. She stated residents in wheelchairs were usually a two person assist, but it depended on the resident. An interview was conducted with S14REHAB at 3:22 p.m. on 03/12/2019. He stated Resident #3 began therapy after surgery. He stated Resident #3 was cleared for weight bearing as tolerated status last week. He stated Resident #3 was a fall risk, and he would recommend that he be transferred with two person assist for safety. An interview was conducted with S34CNA at 10:18 a.m. on 03/13/2019. She stated Resident #3 could assist with transfers before surgery, but could not help as much now. She stated she was not sure where you could find what a resident's transfer needs were in the chart or care kiosk. She stated resident's transfer needs were verbally reported by the nurse. An observation was made of the care kiosk during the interview. S34CNA accessed the resident's care tasks and confirmed that the type of assistance used must be documented as a one person or two person assist for Resident #3. An interview was conducted with S32CNA at 10:26 a.m. on 03/13/2019. He stated Resident #3 could help him during transfers. He stated he transferred Resident #3 from his wheelchair to his bed, changed his brief, and then transferred the resident back to his wheelchair from his bed. He stated he heard Resident #3 whimpered when he got him out of bed. He stated that he could tell the resident was in pain. He stated Resident #3 did a little jackknife move and shook his head when he touched his leg, which indicated he was in pain. He stated S5ADON was the first nurse that he saw, so he told her something was not right with the resident. He stated the nurse would tell him if a resident needed two person or lift assistance with transfers, but also stated the size of the resident sometimes determined the need for one person versus two person assist. He stated that Resident #3 was a smaller person and could help him transfer, so he used one person assist with him. An interview was conducted with S20LPN at 11:14 a.m. on 03/13/2019. She stated that Resident #3 was transferred via two person assist with a lift prior to his fall. She stated that CNA staff could view his transfer needs on the kiosk. She stated that she could access the kiosk to look up transfer requirements for a resident. She stated that one person could probably transfer him. An interview was conducted with S11SD at 11:40 a.m. on 03/13/2019. She confirmed S32CNA reported something was not right with Resident #3 during a transfer and brief change, and he had reported this to S5ADON on 02/18/2019. She stated Resident #3 was totally dependent on staff for transfers; however, later in the interview, she stated Resident #3 could stand and pivot to assist with transfers and was an extensive assist. She stated extensive assist meant he could be transferred with one to two person assist. She stated, since Resident #3 could assist with transfer, S32CNA could transfer him by himself, but two person assist was required with female CNAs. She was asked how a CNA would determine a resident's transfer needs. She stated the MDS nurses would determine the assistance required, the care plan would generate the triggered care tasks, and the scheduled care tasks located in the care kiosk should tell the CNAs what type of assistance a resident needed. She confirmed the care plan noted to transfer the resident on his strong side, but did not reflect the number of people required. She confirmed the level of assistance was not in the care plan and should have been. She confirmed the quarterly MDS dated [DATE] was coded as Resident #3 requiring total dependence on staff and 2+ person assistance with toileting and transferring and two people should assist Resident #3 with such needs. An interview was conducted with S5ADON at 12:47 p.m. on 03/13/2019. She stated that S32CNA stopped her on 02/18/2019 and reported that something was not right with Resident #3. She stated that Resident #3 normally assisted S32CNA with transfers, but could not pivot to help at that time. She stated that she spoke with Resident #3 and he indicated that he had pain in his left hip and leg. She stated she reported this to S13NP and an order was obtained for an x-ray. She stated she assessed Resident #3 following his x-ray and noted his hip and leg were swollen at that time. She stated S32CNA transferred Resident #3 many times without assistance and had not had any issues. She stated she would expect staff to get assistance if a resident was identified as total dependence required, or 4. An interview was conducted with S34CNA at 1:37 p.m. on 03/13/2019. She stated she would assess a resident's needs based on their situation. She stated some residents are smaller than others and could be lifted or transferred by one person, even if they are totally dependent on staff; however, other residents may be bigger and require the use of two person assist or lift assist. She stated that nurses inform CNAs of resident needs, but the information received was often inconsistent. An interview was conducted with S8MDS at 2:56 p.m. on 03/13/2019. She confirmed she conducted the quarterly MDS assessment dated [DATE] for Resident #3. She confirmed she updated the Resident's plan of care, unless the update was related to a fall. She confirmed Resident #3's quarterly MDS dated [DATE] was coded as total dependence and 2+ person physical assist with transfers. She confirmed needs assistance with transfers was noted in the care plan. She was asked how a resident's transfer needs were assessed, and she stated she interviewed CNAs to see what type of transfers were performed during the 7-day lookback period. She stated physical therapy and nursing staff determined a resident's functional status and needs during assessment, but the resident's needs change daily and the CNAs should determine the resident's needs for the day based on their training. She stated S10CNASUP was responsible for training CNAs on functional assistance and transfers. She stated Resident #3's needs changed daily. She stated he sometimes required two person assist and other days he required one person assist. She stated that some staff may need help and others may not. An interview was conducted with S10CNASUP at 3:37 p.m. on 03/13/2019. She confirmed she was responsible for training CNAs. She stated CNAs receive in-person training on transfers and resident's care plans before going out on the floor. She stated that most bedbound people require lift assist with two people, especially if they are heavy. She stated that if a resident is smaller, they may be able transfer with one person assist. She stated that staff should always get two people to perform transfers with residents who are totally dependent. She confirmed the kiosk contained a code and a picture of the resident, and CNAs could check the kiosk to verify the resident's ADLs if they need a refresher. An interview was conducted with S12CC at 3:31 p.m. on 03/13/2019. He stated he was responsible for clinical data entry, such as fall precautions, and ensuring all data was correct in the system. He stated Resident #3 was a one person assist because he could bear weight on one of his legs and pivot. He stated Resident #3 could not bear weight on his contracted leg and required some assistance with transfers. He stated CNAs could ask him, or the resident's nurse to determine a resident's transfer requirements. He stated he would check therapy orders or the ADL requirements in the chart to determine a resident's transfer needs. He verified Resident # 3's care plan noted transfer with assistance and stated he would tell a CNA to perform his transfers with one person assist based on the care plan. An interview was conducted with S19LPN at 9:26 a.m. on 03/14/2019. She stated Resident #3 was not steady on his feet and required total staff assistance for all ADLs. She stated the level of assistance needed depended on the staff member and method of transfer used. An interview was conducted with S6ADON in the presence of S37CN at 9:32 a.m. on 03/14/2019. She confirmed that S32CNA noticed Resident #3 had discomfort during a transfer and reported this to S5ADON. S37CN stated, if a resident is total dependent or coded as 4, that indicated the resident could not help at all and the resident was unable to assist in transfers. S37CN confirmed that S32CNA transferred Resident #3 multiple times without assistance. S6ADON stated that physical therapy collaborated with MDS nursing staff to a determination of the resident's needs. S6ADON contacted S14REHAB via telephone during the interview, at which time S14REHAB confirmed he would recommend Resident #3 be transferred with two person assist for safety. An interview was conducted with S4DON at 4:40 p.m. on 03/13/2019. She confirmed Resident #3 sustained a [MEDICAL CONDITION]. She confirmed S32CNA and S30CNA transferred Resident #3 via one person assist. She stated S32CNA worked with Resident #3 so long and never needed assistance transferring him. She stated that ladies would pair up with two people to transfer Resident #3. She stated the amount of people needed to transfer a resident would be dependent on the CNAs ability to transfer the resident. She confirmed total dependence and 2+ person physical assistance was coded for Resident #3 on the quarterly MDS dated [DATE]. She confirmed the care plan did not note how many people were required for transfer. She stated she was not sure why there were inconsistencies between the MDS and Care Plan. She stated if Resident #3 was coded as a 4 and required total assistance with transfers, then staff should carry out the task with two person assist. An interview was conducted with S2ADMIN at 8:19 a.m. on 03/14/2019. She confirmed that she conducted an investigation in regard to Resident #3's [MEDICAL CONDITION]. She stated she determined the cause of injury was the resident transfer with S32CNA on 02/18/2019. She confirmed the level of transfer assistance varied amongst staff and residents. She stated the care plan indicated to transfer with assistance and she determined the resident was transferred according to his care plan. An interview was conducted with S1ADMIN at 11:40 a.m. on 03/14/2019. He confirmed S32CNA had been transferring Resident #3 for a long time by himself and had never had any issues. An interview was conducted with S3DCO at 9:41 a.m. on 03/15/2019. She stated 2+ person support would be done with transfers if a resident was extensive or total assist. She confirmed CNAs could determine whether the resident required more or less assistance at any given time. She stated resident's needs change and CNAs are certified to make decisions about resident's ADL needs. She stated that CNAs make the determination on what level of care is needed based on the resident's needs at the time of care. She confirmed that resident's coded as a 3-Extensive Assistance or a 4-Total Dependence required two plus person assist and the CNAs have a choice in the kiosk to chart the level of assistance used for transfer, such as one person or two person assist. She stated the information charted by the CNAs drives the assessment of resident ADL care. She stated this is not the first time she had heard the CNAs did not know what type of assistance the residents needed. She reviewed the kiosk for Resident #3 and confirmed the care guide listed the following: Transfer 4. She reviewed the SC MDS dated [DATE] and confirmed Resident #3 was coded as 4. Total Dependence for transfer self-performance and 3. Two+ persons physical assist for transfer support provided. She stated the ADL legend was in the kiosk and she could not understand why there was confusion over transfer requirements. She stated they (staff) can use it if they can read, and they screened for that. Resident #7 Review of the clinical record revealed Resident #7 was admitted to the facility on [DATE] and had the following diagnoses, in part: Unspecified Lack of Coordination, Pneumonia, Abnormal Weight Loss, Abnormalities of Gait and Mobility, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of the quarterly MDS dated [DATE] revealed that Resident #7 had a Brief Interview of Mental Status score of 03, indicating severe cognitive impairment, and required total dependence on staff and 2+ persons physical assist for transfers. Review of the care plan revealed the following, in part: Staff assistance required for ADLs, extensive to total assistance with ADLs, and assist with bed mobility and transfers as needed. An interview was conducted with S32CNA at 1:59 p.m. on 03/13/2019. He stated he would determine a resident's transfer needs by their size and ability to assist with transfers. He stated he could lift Resident #7 by himself, but ladies were working, they would need two people to transfer him. On 03/15/2019 at 9:41 a.m., S3DCO reviewed the care kiosk for Resident #7. S3DCO stated Resident #7 was coded as 4 for transfers indicating Total Dependence. She reviewed the MDS with an ARD of 12/25/19 and confirmed Resident #7 was coded as a 4 indicating Total Dependence. She stated if resident was extensive or total assist, transfers would be done with two + person support. Resident #8 Review of the clinical record revealed Resident #8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Care Plan revealed Resident #8 required limited to total staff assistance for ADLs related to [MEDICAL CONDITION]. Review of the Quarterly MDS dated [DATE] revealed Resident #8 had a BIMS score of 04, indicating severe cognitive impairment, and required extensive/2+ persons physical assist with transfers. An interview was conducted with S34CNA at 1:37 p.m. on 03/13/2019. She stated she would assess a resident's needs based on their situation. She stated some residents are smaller than others and could be lifted or transferred by one person, even if they are totally dependent on staff. She stated one resident she cared for was able to do that with was Resident #8. She stated Resident #8 was totally dependent on staff, but was small enough for her to transfer on her own. On 03/15/2019 at 9:41 a.m., S3DCO reviewed the care kiosk for Resident #8 and confirmed she was coded as a 3 for transfers and required extensive assistance. She reviewed the Quarterly MDS dated [DATE] and confirmed Resident #8 was coded as a 3 for transfers and required extensive assistance. She stated if a resident was coded as extensive or total assist, transfers would be done with two + person support. Resident #9 Review of the clinical record revealed Resident #9 was admitted to the facility on [DATE]. Other [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed that Resident #9 had a BIMS of 06, indicating severe cognitive impairment, and required extensive assistance/2+ person physical assist for transfers. Review of the Care Plan revealed Resident #9 required staff assistance for ADL's related to the hypertension, [MEDICAL CONDITION], and depression, and noted the following intervention: assist with bed mobility and transfers as needed. An interview was conducted S32CNA at 1:59 p.m. on 03/13/2019. He stated he would determine a resident's transfer needs by their size and ability to assist with transfers. He stated Resident #9 was mostly independent and he just needed to supervise him while transferring. On 03/15/2019 at 9:41 a.m., S3DCO reviewed the care kiosk for Resident #9. She stated Resident #9's kiosk scheduled care for transfers was coded as 3 for extensive assistance. She reviewed the SC MDS dated [DATE] and confirmed Resident #9 for transfers indicating he did some performance and required extensive assistance, thus coded as a 3. She stated if a resident was extensive or total assist, transfers would be done with two + person support.

Based on observations, interviews and record reviews, the facility failed to ensure residents that were cognitively impaired and at risk for falls received adequate supervision and assistive devices to prevent accidents for 1 (#3) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents that had a history of [REDACTED]. This failed practice resulted in an actual harm for Resident #3 on [DATE], when the resident, who had a history of [REDACTED]. Resident #3's daughter found the resident on the floor in his room with the dresser on top of him and the television by his head. Resident #3 was bleeding from the forehead. The resident was transferred to a local hospital on [DATE] where he had a CT (computerized tomography) scan that revealed he had minimal traumatic fracture to the left low frontal bone extending through the inner and outer table of frontal sinus, orbital roof/medial orbital wall, traumatic fracture also extends through the left inferior orbital rim and anterior wall maxillary sinus. There were also adjacent fractures of nasal bones. Findings: Resident #3 Review of the clinical record for Resident #3 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] for Resident #3 revealed the resident had a BIMS (Brief Interview for Mental Status) of 6 which indicated the resident was severely impaired for cognition. Further review of the MDS revealed the resident was coded to require one person assist for bed mobility and transfers and balance from a seated to standing position not steady, only able to stabilized with staff assistance. Review of Resident #3's Fall Risk assessment dated [DATE] revealed: Level of Consciousness/Mental Status: Intermittent confusion History of Falls (Past 3 months): No falls in past 3 months Ambulation/Elimination Status: Chair bound - and/or assist with elimination Gait Status: Requires use of assistive devices Score: 11 (score of 10 or above is High Risk) Review of Incident Report dated [DATE] for Resident #3: Type: Fall with head injury Location: Hallway on unit Date [DATE] Activity at time: Unknown Narrative: Resident sitting in wheelchair, flipped backward, hit his head. Hematoma to back of head. Resident would not respond to verbal stimuli or tactile, unresponsive for a while, perform sternal rub and still no response. Call to doctor with report. Send to ER (emergency room ) for evaluation and treatment. Daughter notified, said she will call her brother to meet him at the hospital and ADON aware. Immediate action taken: Vital taken. ROM (range of motion) to extremities, neuro assess, pain assess, sternal rub. Physician Notified: [DATE] at 11:20 a.m.; responded [DATE] at 11:25 a.m. Review of Incident Report dated [DATE] provided by the facility revealed the following incident for Resident #3: Type: Fall/no head injury Location: Resident room Date: [DATE] Activity at time: From bed without assist Narrative: Nurse and daughter entered room. Resident on fall mat on floor at bedside. Darkened color sputum noted on side of resident face by mouth. Resident able to move all extremities within his limits. Denied hitting head. Resident is confused often. Resident was attempting to move self. Moving from side to side. Bed in lowest position. Immediate action taken: Vital signs, Head to toe assessment, EMS (Emergency Medical Services) notified for transfer to local hospital per daughter's request. Physician notified: [DATE] at 6:10 p.m. Review of Incident Report dated [DATE] for Resident #3: Type: Fall with head injury Location: Resident room Date: [DATE] Activity at time: From bed without assist Narrative: Staff noted resident lying on floor on his back in room with dresser turned over on him and television next to his head on the floor. Moderate bleeding noted to forehead with hematoma/laceration, also a skin tear to left forearm and abrasion to right knee. Bleeding ceased as towels applied. Resident is orient to name only with confusion daily and is unable to explain what happened. Resident daughter also here visiting at bedside. Ambulance called and in route. Sent to local hospital for evaluation. Immediate actions taken: First aid applied and resident transported to hospital for evaluation. Physician notified: [DATE] at 6:13 p.m. Review of the Plan of Care for Resident #3 revealed the following, in part: [DATE] - I require staff assistance for ADLs (activities of daily living) related to generalized weakness; I need limited to extensive assist with ADLs and transfers; I use a wheelchair for mobility. Interventions included, in part, assistance with ambulation, bed mobility, and transfers. [DATE] - I have cognitive loss related to my [DIAGNOSES REDACTED]. Interventions include, in part, report any changes to my doctor and family, give me verbal cues/reminders when I cannot remember. [DATE] - I had a fall out of my wheelchair; I flipped my chair backwards; I hit my head. Interventions: Initial neuro checks. Provide me with anti-tippers to the back of my wheelchair. [DATE] - Provide me with a fall mat at my bedside. [DATE] - I had a fall in my room; I was found lying on the fall mat beside my bed; I have no injuries noted. Interventions: Send to ED (Emergency Department) for evaluation and treatment. [DATE] - I had a fall in my room; I was found on the floor with my dresser lying on top of me and my television at my head; I was unable to explain what happened; I have a hematoma/laceration to my forehead, skin tear to my left forearm and an abrasion to my right knee. Interventions: Secure dresser and television to wall. Move closer to nurses station. Send to ED for evaluation and treatment. Review of the Quality Assurance Form dated [DATE] presented by S1DON revealed the following: Identifiable Problem: Television and chests not mounted to wall. Television placement on top of chest. Recommended Plan of Action: 1. Report findings to administrator. 2. Administrator to investigate. 3. 100% audit of each room for safety. 4. Resident room to be moved closer to nurses station. Follow-up: Date of Follow-up: [DATE] 1. Administrator notified [DATE]. 2. Administrator and regional completed inspection of room with incident [DATE]. 3. Room inspections being rounded on this a.m. 4. Room move completed. Recurring problems: 1. [DATE] mid-day - 76 rooms identified as having chests in need of mount. 2. Maintenance obtaining supplies to secure chests. 3. Ordering 24 inch television and scheduling wall mounts. Follow-up: 1. [DATE] Maintenance repairs being done. 2. [DATE] Television ordered and to be mounted. On [DATE] at 2:56 p.m., an interview was conducted with S1DON. She stated prior to the fall on [DATE] there was constant redirection to get Resident #3 up and in bed because he seemed to want to be on the floor. S1DON stated on [DATE], S1DON and S3ADON were preparing to leave the facility for the day. They were on the third floor when Resident #3's daughter came to the nurse's station and said he was on the floor. S1DON stated that when she got to the room the resident was on the floor on his back. The dresser was on his body. He had a gash on the left arm. The television was on the floor. He had a cut on his forehead that was bleeding. Staff immediately got the dresser off Resident #3. EMS took Resident #3 to a local hospital for evaluation. The hospital contacted the facility on [DATE] at around 11:00 p.m. and informed the nurse the resident had expired. They were not given a specific reason for the expiration. On [DATE] at 3:45 p.m., an interview was conducted with S3ADON. She stated on [DATE] she was about to get on the elevator when Resident #3's daughter came up and said he was on the floor. S3ADON and nursing staff went to the resident's room. A dresser was on top of the resident, so staff removed it. He had a cut on his arm. He also had a cut on his head and the television was on the floor above his head. On [DATE] at 3:54 p.m., an interview was conducted with S4LPN. She stated Resident #3 was in a low bed. She stated he was confused and kept getting out of bed. On [DATE] at 4:30 p.m., an interview was conducted with S5MDS. After reviewing Resident #3's MDS with an ARD of [DATE], she verified that the resident had a BIMS of 6 which she verified means cognitive impairment. S5MDS verified that after the fall on [DATE], no new interventions were put in place upon return from the ED. S5MDS also verified that, according to the MDS, Resident #3 required one person assist for bed mobility and transfers. On [DATE] at 4:40 p.m., an interview was conducted with S2ADON. After reviewing Resident #3's care plan, S2ADON verified upon coming back from the ED after the fall on [DATE], she should have added something else as an intervention, however she had not. On [DATE] at 8:37 a.m., an interview was conducted with S6CNA. She stated Resident #3 had started getting confused and she did not think he realized he could not do certain things for himself. She would remind him not to get up on his own, but he would still do it. Even in a low bed he would get out and lie on the floor. On [DATE] at 9:05 a.m. an interview was conducted with S7LPN. She stated she came back to work the first of November after being off on leave, and the resident seemed more confused and more combative. S7LPN stated she was not told to monitor the resident more frequently. On [DATE] at 9:15 a.m. an interview was conducted with S8CNA. She stated Resident #3 was put in a low bed and he would roll off onto the fall mat. She stated there were no other fall interventions implemented besides put the resident in bed and monitor him. On [DATE] at 10:15 a.m. an interview was conducted with S9CNA. She stated the resident seemed confused and said things that did not make sense. S9CNA stated that telling the resident to stay in bed was not working. The resident would still find a way to get out of bed. She stated Resident #3 needed assistance with transfers and most of the time it took 3 people, sometimes 2 people. On [DATE] when she came on her shift Resident #3 was on his fall mat, so she and the nurse got him back in bed. S9CNA was told the resident had been getting out of bed all day. When she brought his meal tray to his room, he was back on the fall mat. She stated she went to let the nurse know he was on the fall mat again. Since Resident #3's nurse was downstairs passing medications, S9CNA stated she told S14LPN that the resident was on the mat. S9CNA stated S14LPN told her to leave him there. S9CNA found Resident #3's nurse and informed her the resident was on the fall mat. The nurse and S9CNA came back up to the third floor. At that time the resident's daughter was there saying he had fallen in his room. When S9CNA went in the resident's room, the television was on the floor. The ambulance service was called and the nurses were checking the resident. On [DATE] at 10:39 a.m. an interview was conducted with S1DON. She verified that Resident #3 had a fall on [DATE] and was sent to the ED. S1DON reviewed the care plan and verified the intervention for the [DATE] fall was to send the resident to the ED for evaluation and treatment. After review of the care plan, she verified no new interventions had been put into place after the fall on [DATE]. S1DON verified a QA (Quality Assurance) was opened the night of the accident on [DATE] and identified the problem was dressers and televisions. On [DATE] at 12:25 p.m. an interview was conducted with S12Main. He stated there were dressers in rooms that need to be mounted to the wall. He also stated televisions are being ordered and will be mounted after delivery. On [DATE] at 4:00 p.m. an interview was conducted and observation was made of Rooms b and c with S12Main and S11Adm. Both rooms had dressers with 3 drawers. S11Adm stated that dressers with 3 drawers were considered night stands and would not be mounted, but dressers with 4 drawers would be mounted to the wall.

Based on observation, interview, record review and review of the Infection Control Policy, the facility failed to establish and maintain an infection control program designed to provide a sanitary environment and to prevent the development and transmission of disease and infection to 104 other facility residents after 1 sampled residents (#5) diagnosed with [REDACTED]. The facility failed to: 1) ensure staff correctly followed appropriate contact and isolation precautions for a resident with[DIAGNOSES REDACTED] infection (#5); 2) follow the policy and procedures regarding isolation precautions during house keeping of rooms (#5); 3) be administered in a manner that prevents possible transmission of highly infectious[DIAGNOSES REDACTED] to residents that reside in the facility (total of 105 residents); 4) have staff use the proper cleaning solution for equipment (Hoyer lift and Glucometer) used in an isolation room and then used in other residents' rooms in the facility; and 5) have soap and paper towels available in a resident's bathroom at all times (#66). An Immediate Jeopardy situation began on 10/16/13 when resident #5 was diagnosed with [REDACTED]. On 12/12/13 at 4:05PM, the survey team notified S2 Administrator and S1 DON of the IJ (Immediate Jeopardy) situation that currently existed in the facility. The IJ situation began on 10/16/13 when sampled resident #5 was diagnosed with [REDACTED]. The facility submitted a plan of removal to the survey team on 12/12/13 at 5:37 PM for the IJ situation. The plan of removal included the following: 1. Facility staff to be inserviced on Contact Isolation Precautions according to facility Policy. 2. EPA-approved spore-killing disinfectant (Dispatch Towels with bleach and bleach 1:10 solution) to be utilized in rooms where [DIAGNOSES REDACTED]icle patients are treated. 3. Housekeeping staff will be inserviced on proper cleaning of resident room while in isolation. 4. Identified room to be cleaned according to facility policy with spore- killing disinfectant daily. 5. Administrator/designee will perform daily review to ensure compliance of staff following contact isolation precautions and cleaning of the resident room while in isolation according to policy. On 12/12/13 at 5:37 PM, the IJ situation was removed after the facility implemented their plan. The deficient practice was lowered to a Level 2 pattern for the other 104 residents potentially exposed to [DIAGNOSES REDACTED]. Findings: On 12/11/13 review of the record for resident #5 revealed admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed a stool sample collected for resident #5 on 10/15/13 tested positive for Toxigenic Clostridium Difficile. Further review of the record revealed on 10/31/13 resident #5 was re-tested for[DIAGNOSES REDACTED] and returned positive again for active[DIAGNOSES REDACTED]. Review of the laboratory report from 10/31/13 revealed written documentation resident #5 was on Questran, one packet three times a day (for diarrhea), [MEDICATION NAME] completed, and on [MEDICATION NAME] 875mg twice a day for 30 days started on 10/03/13. Further review of the laboratory results from 10/31/13 revealed the MD did not make a notation on the record until 11/26/13, which stated 'on [MEDICATION NAME] by mouth'. Review of a physician's telephone order dated 11/01/13 at 12:00 PM revealed to restart [MEDICATION NAME] 500mg by mouth 4 times a day for 14 days due to [DIAGNOSES REDACTED]. On 11/10/13, resident #5 was transferred to local hospital per family request due to the continuation of[DIAGNOSES REDACTED]. Further review of the record revealed resident #5 returned to the facility on [DATE] at 4:30 PM with [DIAGNOSES REDACTED]. Further review of the orders revealed resident #5 was to be placed on [MEDICATION NAME] 250mg by mouth every 6 hours for 14 days. Review of the physician's telephone orders dated 11/19/13 at 8:30 AM revealed an order for [REDACTED]. On 11/20/13 an order was written for [MEDICATION NAME] 250mg every 6 hours for total of 21 days. On 11/20/13 a progress note was written by S23 MD(GI Associate). Resident with history of[DIAGNOSES REDACTED]icile, [MEDICATION NAME]. Suggest 21 days [MEDICATION NAME] 250mg 4 times a day, [MEDICATION NAME] granules one packet in milk twice a day. Follow up 10 days with MD. Review of the Physician's Telephone Orders written on 11/22/13 which was 2 days after S23 MD examined resident #5 revealed the order for the [MEDICATION NAME] 250mg every 6 hours for total of 21 days, [MEDICATION NAME] Granules 1 packet in milk twice a day, follow up with S23 MD in 10 days was finally written. On 12/12/13 the surveyor requested information regarding resident #5's follow up appointment with S23 MD. According to the MD order, the appointment should have been made for 12/02/13. The record revealed an attempt to make the follow up appointment was not made until 12/04/13, at which time the facility was told S23 MD was booked until January. The appointment was made for 01/06/14 at 2:30 PM, which is over 1 month after the S23 MD wanted a follow up visit with resident #5. Review of the Physician's telephone orders written on 11/26/13 revealed an order for [REDACTED]. Further review of another Physician's telephone order written on 12/06/13 revealed another order for stool for[DIAGNOSES REDACTED] in 1 week. (Due 12/13/13) On 12/12/13 review of resident #5's bowel movements for 12/08/13 - 12/11/13 revealed: On 12/08/13 resident #5 had 2 watery liquid stool, on 12/09/13 resident #5 had a large watery liquid stool, on 12/10/13 resident #5 had 2 soft formed stools, on 12/11/13 resident #5 had 2 watery liquid stools. On 12/11/13 at 10:00AM observation of S24 Housekeeper revealed she came out of resident #5's room with gloves on, reached into her shirt pocket to retrieve the housekeeping cart key. S24 Housekeeper then picked up the broom and dust pan with the same contaminated gloves and took the items into the resident's room. Further observation revealed the housekeeper brought the broom and dust pan back out into the hallway and set them on the floor. The housekeeper further placed the bucket of liquid cleaner on top of the housekeeping cart without disinfecting it. S24 Housekeeper then retrieved the mop, came back out of resident #5's room with no gloves on, placed the mop back into the mop water outside of the resident's room, then pushed the cart down the hallway. On 12/11/13 at 3:30 PM, resident #5 was weighed using the only Hoyer lift used to weight residents in the facility. Further observation revealed the Hoyer lift was not disinfected after use by resident #5, who was in isolation for[DIAGNOSES REDACTED]. On 12/11/13 at 5:10 PM, further observation revealed S21 CNA was called out of resident #5's room by the S11 ADON to move the food cart on the hallway. Further observation revealed S21 CNA entered the resident's room without gloves and came back out of the resident's room without washing her hands, closed the door on the food cart, pushed the cart down the hall without washing her hands, after being in the isolation room. On 12/12/13 at 10:00 AM, observation of S24 Housekeeper during the cleaning of resident #5's isolation room revealed: S24 Housekeeper carried all cleaning supplies into resident's room. Further observation revealed S24 Housekeeper cleaned the bathroom first. Observation revealed S24 Housekeeper sprayed the sink, toilet, lifted the toilet lid with gloved hand, set the spray cleaner on the floor, then sprayed the shower with citrus disinfectant and set the cleaning supplies on the shower bench. Further observation of S24 Housekeeper revealed she knelt down on the floor with her uniform touching the bathroom floor. S24 Housekeeper wiped around the toilet on the floor, then wiped the hand rail next to the toilet, paper towel dispenser, and then wiped the shower. S24 Housekeeper picked up the glass cleaner and cleaned the mirror and then set the bottle on the floor and picked up a partial roll of paper towel from the floor to dry the mirror. Observation of S24 Housekeeper cleaning resident #5's room revealed that she put the Lemon Luster furniture polish can on the floor. S24 Housekeeper reached into her shirt pocket to unlock the toilet paper dispenser and then put her keys back into her pocket without taking her contaminated gloves off and washing her hands. Further observation revealed S24 Housekeeper wiped the dresser, night table, over bed table, bed, with lemon luster furniture polish. S24 Housekeeper then touched the door knob with her contaminated gloves. S24 Housekeeper used the broom and dustpan from the housekeeping cart without changing her contaminated gloves. S24 Housekeeper went out into the hall without taking her gloves off or washing her hands and brought a bucket of cleaner into the room and sat the bucket on the floor. On 12/12/13 at 10:20 AM, an interview with S24 Housekeeper revealed Pine Sol cleaner was in the bucket. Further review revealed S24 Housekeeper never took off her gloves, then took the broom and dustpan out into the hallway and sat them on the floor without disinfecting the items. S24 Housekeeper then got the mop and mopped the resident's floor, went out into the hallway again without changing her gloves or washing her hands, got a roll of toilet paper from her housekeeping cart then tore the paper off of the roll with the same contaminated gloves and threw the paper away in the trash can on her housekeeping cart. S24 Housekeeper put all of the rags and mop head into a regular trash bag that was on her cart. Further observation revealed S24 Housekeeper never washed her hands after cleaning the resident #5's room and never cleaned the mop handle, broom handle, or dust pan after using them in the resident's room. On 12/12/13 at 10:22 AM, an interview with S24 Housekeeper revealed she mopped with neutral cleaner and wiped with Lysol cleaner. Further interview revealed she obtains the Lysol cleaner from the Housekeeping Supervisor. Further interview with S24 Housekeeper as she was taking the items to the laundry in a regular trash bag revealed she does not always take the cleaning items directly to the laundry. She was asked if there was a specific reason for taking the items at this time and she revealed she will take the items when there is a bad odor, but she was taking these items because there was a lot of coffee spilled on the floor that she had to clean up and there was no other special reason. On 12/12/13 at 11:15AM, an interview with S25 Housekeeping Supervisor revealed they use citrus cleaner and Lysol with Pine-Sol in it. Review of the labels on the bottles of the citrus cleaner and Lysol cleaner revealed neither killed the[DIAGNOSES REDACTED]icile spore. Further interview with S25 Housekeeping Supervisor revealed every now and then she will give the housekeepers bleach to clean with but at this time there is no one that needs to have their room cleaned with bleach. On 12/12/13 at 10:25 AM, S5 Dietary Manager confirmed that resident #5's disposable breakfast meal tray was brought back into the kitchen along with the other resident trays. She confirmed that the tray should not be brought back into the kitchen because resident #5 is on isolation. Review of the facility's isolation policy and procedures regarding food service revealed that all disposable items used and left over food shall be placed in isolation trash can, lined with red biohazard bag located in the resident room. On 12/12/13 at 3:17 PM, interview with S2 Administrator confirmed that resident's #5's disposable breakfast tray should not have been brought back into the kitchen with the other resident's trays. On 12/12/13 at 4:00 PM, interview with S1 DON confirmed she spoke with resident #5's physician and he wants resident #5 to remain on isolation until after the recheck of the stool culture to be obtained on 12/13/13. Review of the Isolation Policy and Procedure revealed: Purpose: To prevent the spread of infection. Policy: When the infection control program determines that a resident needs isolation to prevent the spread of infection the facility must isolate the resident. Procedure: To be utilized on all residents in isolation: 1. Any resident suspected or diagnosed as having a communicable disease shall be placed in the appropriate type of isolation. The resident will be isolated only to the degree necessary to isolate the infecting organism. a. Isolation Categories include: i. Contact ii. [MEDICATION NAME] iii. Drainage/Secretion iv. Droplet 2. If the resident is suspected of having a communicable disease, the physician or designee will be notified promptly. a. A Physician order [REDACTED]. 3. Isolation precautions will be implemented according to CDC guidelines. 4. The resident and responsible party will be notified of the need to implement isolation precautions. 5. Appropriate staff will be notified of the isolation precautions. a. Sign to notify staff and visitors will be placed on the resident's door. 6. Resident will be moved to isolation room. a. Resident shall only co-hort with same infectious disease. 7. Social worker and activities will implement room bound visits and activities when applicable. 8.. PPE ( Personal Protective Equipment) will be kept available outside of resident room when applicable. 9. Hand washing is required before and after contact with the infected resident or contaminated articles. Contact Isolation: 1. These infections are transmitted via contact or indirect contact with the resident or the resident's environment. a. Example: [DIAGNOSES REDACTED]icile, Shingles 2. Gowns and gloves are to be utilized for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. 3. Mask and goggles to be utilized if applicable. PPE: ( Personal Protective Equipment) 1. Use of gowns: a. When the use of gowns is necessary for isolation precautions, disposable gowns shall be worn by all personnel entering the room. b. Disposable gowns shall be used only one and discarded. c. Gowns are to be put on prior to entering resident's room. d. Gowns are to be placed in isolation trash can lined with red biohazard bag locate in the resident room. 2. Gloves: a. To be utilized at all times. 3. Mask: a. To be utilized for droplet precautions, resident excretions when applicable. b. To be utilized for contact, [MEDICATION NAME], and drainage/secretion isolation when applicable. 4. Goggles: a. To be utilized for droplet precautions, resident excretions when applicable. b. To be utilized for contact, [MEDICATION NAME], and drainage/secretion isolation when applicable. Disposal of Infectious Materials: 1. All disposable such as dressings, tissue, dishes, etc shall be placed in the isolation trash can line with red biohazard bag located in room. Laundry and Linen Services: 1. A plastic laundry melt-away bag shall be placed into a hamper stand with/wheels or barrel with/wheels in the isolation room for placement of soiled linen. Soiled linen shall be handled as little and as gently as possible to prevent the spread of infection. 2. When the melt away beg is full, not overflowing, the bag will be sealed and then transported to laundry department for removal and washing. 3. All isolation laundry and linen shall be washed separately. Food Service: 1. Residents placed in isolation shall be served all meals on disposable trays, dishes and utensils if applicable. 2. Disposable cups shall be used to serve drinking water to the resident throughout the isolation procedure. 3. All disposable items used and left over food shall be placed in isolation trash can, lined with red biohazard bag located in the resident room. Concurrent Cleaning of the Isolation Room: 1. Housekeeping will put on PPE as precautions indicate and take only needed supplies into the isolation room. 2. Clean room thoroughly: a. Use disinfectants spray or wipes according to the manufacturer recommendation. b. Use disinfectant cleaner to mop floors. c. Wipe down bed rails, mattresses, over bed tables, toilet seat and rim, toilet flushing handle, faucet levers, furniture handles, doorknobs, etc. 3. To remove mop and bucket: a. Empty liquid in toilet. b. Wipe mop handle and outside of bucket with disinfectant spray or wipes according to the manufacturer recommendation. c. Place contaminated mop head and cleaning rag ( if disposable wipe not used) in a melt-away bag and take to laundry to be washed separately. 4. Remove protective equipment apparel according to instructions and dispose of it in the room. 5. Wash hands thoroughly. Discharge from isolation: Dispose of bedpans, washbasins, emesis basin, and urinals in red bag. Wipe down large equipment with disinfectant wipe or spray according to manufacture label. On 12/12/13, review of the Center for Disease Control website (www.CDC.gov) revealed guidelines to prevent the spread of Clostridium Difficile. The CDC states to isolate the patients with [DIAGNOSES REDACTED]icile immediately, wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. Clean the room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there. Resident #66 Resident #66 was admitted with [DIAGNOSES REDACTED]. Review of the care plan revealed that the resident is at risk for infection related to the use of a foley catheter, colostomy and stasis ulcers. On 12/12/13 at 9:48 AM, an observation of resident #66 was made with S19 CNA and S15 ADON. Resident #66's covers were pulled down to the end of the bed leaving the resident uncovered and dressed only in a hospital gown and heel boots. S15 ADON left the room and S19 CNA disconnected the continuous feeding tubing at the connector site and turned off the feeding pump to the resident's percutaneous endoscopic gastrostomy site. S19 CNA then laid the tubing of the continuous feeding over the top of the infusion pump and left the connector uncovered and open to air. S19 CNA lowered the head of the bed and resident #66 was laying flat on her back in the bed. S15 ADON re-entered the room and the resident was dressed in a loose fitting dress. S19 CNA emptied the foley catheter urine collection bag into a clear measuring container. S19 CNA handed the container of urine to S15 ADON and she took the container of urine to the bathroom and emptied the urine into the toilet. When surveyor walked to the bathroom for an observation, S15 ADON was washing her hands with water only. There was no soap or soap dispenser in the resident's bathroom and the paper towels were not accessible. S19 CNA and S15 ADON confirmed that the soap dispenser was gone and no paper towels were accessible. Resident #66 had a roommate that used the bathroom for toileting. In addition, there was no hand-sanitizer available in the room or nearby in the hallway. On 12//12/13 at 9:59 AM, S15 ADON told S19 CNA that she had to go take care of something and told the S19 CNA to get someone to help transfer resident #66 to her geri-chair. On 12/12/13 at 10:01 AM, resident #66's urine collection bag was laid onto the resident's legs and the resident was lifted by the Hoyer lift and transferred into the geri-chair. On 12/12/13 at 10:07 AM, S19 CNA hung the resident's foley collection bag under her geri-chair. Without removing or changing her gloves, S19 CNA placed a blanket over the resident's legs and feet and brushed the resident's hair. On 12/12/13 at 10:10 AM, the surveyor asked S19 CNA if she normally disconnected the continuous feeding from resident #66 while she was providing care for the resident. S19 CNA confirmed that she disconnects and turns off resident #66's feeding pump when she is getting the resident up into her geri-chair. S19 CNA went on to say "sometimes I hook it back up and then I get the nurse to come check it". On 12/12/13 at 10:11 AM, S19 CNA removed her gloves and rinsed off her hands with water only and dried her hands on her scrubs in resident #66's bathroom. After that, S19 CNA pushed resident #66, who was in her geri-chair, out into the hall toward the nurses' station. On 12/12/13 at 1:20 PM, an observation was made with S15 ADON of resident #66's bathroom. S15 ADON confirmed that there was still no soap in the resident #66's bathroom. S15 ADON stated there should be soap available for use in the resident's bathroom at all times. Of note, resident #66 had a roommate that used the bathroom for toileting. On 12/12/13 at 3:26 PM, S1 DON confirmed that S19 CNA should not stop, start disconnect or reconnect the continuous percutaneous endoscopic gastrostomy continuous tube feeding. S1 DON also confirmed that resident #66's bathroom should have had soap and paper towels available at all times. She went on to say that S19 CNA should change gloves after handling a foley collection bag and before touching the resident's clean blanket and brushing the resident's hair. Fourth Floor: On 12/09/13 at 11:55 AM, observations during medication pass revealed S13 LPN was going in and out of resident's rooms on the fourth floor performing accuchecks. Further observations revealed S13 LPN did not clean the glucometer machine after using it with each resident. After performing all of the accuchecks, S13 LPN then proceeded to place the contaminated glucometer into the drawer on the medication cart. On 12/11/13 at 3:50 PM, observation revealed S22 LPN was checking accuchecks on several residents on the fourth floor. Further observations revealed the S22 LPN was not cleaning the glucometer between residents. At 3:55 PM, the surveyor asked S22 LPN how she would check the blood sugar for sampled resident #5 (a diabetic), who was in isolation for [DIAGNOSES REDACTED]icile infection. S22 LPN stated that she would use an alcohol wipe to clean the glucometer after using it on him. Review of CDC information revealed that alcohol does not kill the spores associated with [DIAGNOSES REDACTED]icile.

Based on observation, interview and record review, the facility failed to be administered in a manner that enables it to use its resources to effectively and efficiently maintain an infection control program designed to provide a sanitary environment and to prevent the development and transmission of disease and infection for 1 of 1 (#5) sampled resident diagnosed with [REDACTED]. The facility failed to be administered in a manner which: 1) ensured staff correctly followed appropriate contact and isolation precautions(#5); 2) ensured staff followed the policy and procedures regarding isolation precautions during house keeping of rooms(#5); 3) prevented possible transmission of highly infectious [MEDICAL CONDITION] (#5) to all residents who reside in the facility (total of 105 residents); and 4) ensured that proper cleaning solution for equipment (Hoyer lift and Glucometer) that was used in an isolation room and then on other residents in the facility. The failed practice resulted in an IJ (Immediate Jeopardy) situation which began on 10/16/13 when resident #5 was diagnosed with [REDACTED]. As a result of the administration failing to ensure implementation of infection control precautions, resident #5 continued to have active [MEDICAL CONDITION] infection on 12/12/13 which was 59 days after the initial diagnoses. A total of 104 other residents in the facility were in an Immediate Jeopardy situation due to the improper infection control practices and possible exposure to the [MEDICAL CONDITION] infection. On 12/12/13 at 4:05PM, the survey team notified S2 Administrator and S1 DON of the IJ (Immediate Jeopardy) situation that currently existed in the facility. The IJ situation began on 10/16/13 when sampled resident #5 was diagnosed with [REDACTED]. The facility submitted a plan of removal to the survey team on 12/12/13 at 5:37 PM for the IJ situation. The plan of removal included the following: 1. Facility staff to be inserviced on Contact Isolation Precautions according to facility Policy. 2. EPA-approved spore-killing disinfectant (Dispatch Towels with bleach and bleach 1:10 solution) to be utilized in rooms where [DIAGNOSES REDACTED]icile patients are treated. 3. Housekeeping staff will be inserviced on proper cleaning of resident room while in isolation. 4. Identified room to be cleaned according to facility policy with spore- killing disinfectant daily. 5. Administrator/designee will perform daily review to ensure compliance of staff following contact isolation precautions and cleaning of the resident room while in isolation according to policy. On 12/12/13 at 5:37 PM, the IJ situation was removed after the facility implemented their plan. The deficient practice was lowered to a Level 2 pattern for the other 104 residents potentially exposed to [DIAGNOSES REDACTED]. Findings: Resident #5 On 12/11/13 review of the record for resident #5 revealed admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed a stool sample collected for resident #5 on 10/15/13 tested positive for Toxigenic [MEDICAL CONDITION]. Further review of the record revealed on 10/31/13 resident #5 was re-tested for [MEDICAL CONDITION] and returned positive again for active [MEDICAL CONDITION]. Review of the laboratory report from 10/31/13 revealed written documentation resident #5 was on Questran, one packet three times a day (for diarrhea), [MEDICATION NAME] completed, and on [MEDICATION NAME] 875mg twice a day for 30 days started on 10/03/13. Further review of the laboratory results from 10/31/13 revealed the MD did not make a notation on the record until 11/26/13, which stated 'on [MEDICATION NAME] by mouth'. Review of a physician's telephone order dated 11/01/13 at 12:00 PM revealed to restart [MEDICATION NAME] 500mg by mouth 4 times a day for 14 days due to [DIAGNOSES REDACTED]. On 11/10/13, resident #5 was transferred to local hospital per family request due to the continuation of [MEDICAL CONDITION]. Further review of the record revealed resident #5 returned to the facility on [DATE] at 4:30 PM with [DIAGNOSES REDACTED]. Further review of the orders revealed resident #5 was to be placed on [MEDICATION NAME] 250 mg by mouth every 6 hours for 14 days. Review of the physician's telephone orders dated 11/19/13 at 8:30 AM revealed an order for [REDACTED]. On 11/20/13 an order was written for [MEDICATION NAME] 250 mg every 6 hours for total of 21 days. On 11/20/13 a progress note was written by S23 MD(GI Associate). Resident with history of [MEDICAL CONDITION], [MEDICATION NAME]. Suggest 21 days [MEDICATION NAME] 250 mg 4 times a day, [MEDICATION NAME] granules one packet in milk twice a day. Follow up 10 days with MD. Review of the Physician's Telephone Orders written on 11/22/13 which was 2 days after S23 MD examined resident #5 revealed the order for the [MEDICATION NAME] 250 mg every 6 hours for total of 21 days, [MEDICATION NAME] Granules 1 packet in milk twice a day, follow up with S23 MD in 10 days was finally written. On 12/12/13 the surveyor requested information regarding resident #5's follow up appointment with S23 MD. According to the MD order, the appointment should have been made for 12/02/13. The record revealed an attempt to make the follow up appointment was not made until 12/04/13, at which time the facility was told S23 MD was booked until January. The appointment was made for 01/06/14 at 2:30 PM, which is over 1 month after the S23 MD wanted a follow up visit with resident #5. Review of the Physician's telephone orders written on 11/26/13 revealed an order for [REDACTED]. Further review of another Physician's telephone order written on 12/06/13 revealed another order for stool for [MEDICAL CONDITION] in 1 week. (Due 12/13/13) On 12/12/13 review of resident #5's bowel movements for 12/08/13 - 12/11/13 revealed: On 12/08/13 resident #5 had 2 watery liquid stool, on 12/09/13 resident #5 had a large watery liquid stool, on 12/10/13 resident #5 had 2 soft formed stools, on 12/11/13 resident #5 had 2 watery liquid stools. On 12/11/13 at 10:00AM observation of S24 Housekeeper revealed she came out of resident #5's room with gloves on, reached into her shirt pocket to retrieve the housekeeping cart key. S24 Housekeeper then picked up the broom and dust pan with the same contaminated gloves and took the items into the resident's room. Further observation revealed the housekeeper brought the broom and dust pan back out into the hallway and set them on the floor. The housekeeper further placed the bucket of liquid cleaner on top of the housekeeping cart without disinfecting it. S24 Housekeeper then retrieved the mop, came back out of resident #5's room with no gloves on, placed the mop back into the mop water outside of the resident's room, then pushed the cart down the hallway. On 12/11/13 at 3:30 PM, resident #5 was weighed using the only Hoyer lift used to weight residents in the facility. Further observation revealed the Hoyer lift was not disinfected after use by resident #5, who was in isolation for [MEDICAL CONDITION]. On 12/11/13 at 5:10 PM, further observation revealed S21 CNA was called out of resident #5's room by the S11 ADON to move the food cart on the hallway. Further observation revealed S21 CNA entered the resident's room without gloves and came back out of the resident's room without washing her hands, closed the door on the food cart, pushed the cart down the hall without washing her hands, after being in the isolation room. On 12/12/13 at 10:00 AM, observation of S24 Housekeeper during the cleaning of resident #5's isolation room revealed: S24 Housekeeper carried all cleaning supplies into resident's room. Further observation revealed S24 Housekeeper cleaned the bathroom first. Observation revealed S24 Housekeeper sprayed the sink, toilet, lifted the toilet lid with gloved hand, set the spray cleaner on the floor, then sprayed the shower with citrus disinfectant and set the cleaning supplies on the shower bench. Further observation of S24 Housekeeper revealed she knelt down on the floor with her uniform touching the bathroom floor. S24 Housekeeper wiped around the toilet on the floor, then wiped the hand rail next to the toilet, paper towel dispenser, and then wiped the shower. S24 Housekeeper picked up the glass cleaner and cleaned the mirror and then set the bottle on the floor and picked up a partial roll of paper towel from the floor to dry the mirror. Observation of S24 Housekeeper cleaning resident #5's room revealed that she put the Lemon Luster furniture polish can on the floor. S24 Housekeeper reached into her shirt pocket to unlock the toilet paper dispenser and then put her keys back into her pocket without taking her contaminated gloves off and washing her hands. Further observation revealed S24 Housekeeper wiped the dresser, night table, over bed table, bed, with lemon luster furniture polish. S24 Housekeeper then touched the door knob with her contaminated gloves. S24 Housekeeper used the broom and dustpan from the housekeeping cart without changing her contaminated gloves. S24 Housekeeper went out into the hall without taking her gloves off or washing her hands and brought a bucket of cleaner into the room and sat the bucket on the floor. On 12/12/13 at 10:20 AM, an interview with S24 Housekeeper revealed Pine Sol cleaner was in the bucket. Further review revealed S24 Housekeeper never took off her gloves, then took the broom and dustpan out into the hallway and sat them on the floor without disinfecting the items. S24 Housekeeper then got the mop and mopped the resident's floor, went out into the hallway again without changing her gloves or washing her hands, got a roll of toilet paper from her housekeeping cart then tore the paper off of the roll with the same contaminated gloves and threw the paper away in the trash can on her housekeeping cart. S24 Housekeeper put all of the rags and mop head into a regular trash bag that was on her cart. Further observation revealed S24 Housekeeper never washed her hands after cleaning the resident #5's room and never cleaned the mop handle, broom handle, or dust pan after using them in the resident's room. On 12/12/13 at 10:22 AM, an interview with S24 Housekeeper revealed she mopped with neutral cleaner and wiped with Lysol cleaner. Further interview revealed she obtains the Lysol cleaner from the Housekeeping Supervisor. Further interview with S24 Housekeeper as she was taking the items to the laundry in a regular trash bag revealed she does not always take the cleaning items directly to the laundry. She was asked if there was a specific reason for taking the items at this time and she revealed she will take the items when there is a bad odor, but she was taking these items because there was a lot of coffee spilled on the floor that she had to clean up and there was no other special reason. On 12/12/13 at 11:15AM, an interview with S25 Housekeeping Supervisor revealed they use citrus cleaner and Lysol with Pine-Sol in it. Review of the labels on the bottles of the citrus cleaner and Lysol cleaner revealed neither killed the [MEDICAL CONDITION] spore. Further interview with S25 Housekeeping Supervisor revealed every now and then she will give the housekeepers bleach to clean with but at this time there is no one that needs to have their room cleaned with bleach. On 12/12/13 at 10:25 AM, S5 Dietary Manager confirmed that resident #5's disposable breakfast meal tray was brought back into the kitchen along with the other resident trays. She confirmed that the tray should not be brought back into the kitchen because resident #5 is on isolation. Review of the facility's isolation policy and procedures regarding food service revealed that all disposable items used and left over food shall be placed in isolation trash can, lined with red biohazard bag located in the resident room. On 12/12/13 at 3:17 PM, interview with S2 Administrator confirmed that resident's #5's disposable breakfast tray should not have been brought back into the kitchen with the other resident's trays. On 12/12/13 at 4:00 PM, interview with S1 DON confirmed she spoke with resident #5's physician and he wants resident #5 to remain on isolation until after the recheck of the stool culture to be obtained on 12/13/13. Review of the Isolation Policy and Procedure revealed: Purpose: To prevent the spread of infection. Policy: When the infection control program determines that a resident needs isolation to prevent the spread of infection the facility must isolate the resident. Procedure: To be utilized on all residents in isolation: 1. Any resident suspected or diagnosed as having a communicable disease shall be placed in the appropriate type of isolation. The resident will be isolated only to the degree necessary to isolate the infecting organism. a. Isolation Categories include: i. Contact ii. [MEDICATION NAME] iii. Drainage/Secretion iv. Droplet 2. If the resident is suspected of having a communicable disease, the physician or designee will be notified promptly. a. A Physician order [REDACTED]. 3. Isolation precautions will be implemented according to CDC guidelines. 4. The resident and responsible party will be notified of the need to implement isolation precautions. 5. Appropriate staff will be notified of the isolation precautions. a. Sign to notify staff and visitors will be placed on the resident's door. 6. Resident will be moved to isolation room. a. Resident shall only co-hort with same infectious disease. 7. Social worker and activities will implement room bound visits and activities when applicable. 8.. PPE ( Personal Protective Equipment) will be kept available outside of resident room when applicable. 9. Hand washing is required before and after contact with the infected resident or contaminated articles. Contact Isolation: 1. These infections are transmitted via contact or indirect contact with the resident or the resident's environment. a. Example: [DIAGNOSES REDACTED]icile, Shingles 2. Gowns and gloves are to be utilized for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. 3. Mask and goggles to be utilized if applicable. PPE: ( Personal Protective Equipment) 1. Use of gowns: a. When the use of gowns is necessary for isolation precautions, disposable gowns shall be worn by all personnel entering the room. b. Disposable gowns shall be used only one and discarded. c. Gowns are to be put on prior to entering resident's room. d. Gowns are to be placed in isolation trash can lined with red biohazard bag locate in the resident room. 2. Gloves: a. To be utilized at all times. 3. Mask: a. To be utilized for droplet precautions, resident excretions when applicable. b. To be utilized for contact, [MEDICATION NAME], and drainage/secretion isolation when applicable. 4. Goggles: a. To be utilized for droplet precautions, resident excretions when applicable. b. To be utilized for contact, [MEDICATION NAME], and drainage/secretion isolation when applicable. Disposal of Infectious Materials: 1. All disposable such as dressings, tissue, dishes, etc shall be placed in the isolation trash can line with red biohazard bag located in room. Laundry and Linen Services: 1. A plastic laundry melt-away bag shall be placed into a hamper stand with/wheels or barrel with/wheels in the isolation room for placement of soiled linen. Soiled linen shall be handled as little and as gently as possible to prevent the spread of infection. 2. When the melt away beg is full, not overflowing, the bag will be sealed and then transported to laundry department for removal and washing. 3. All isolation laundry and linen shall be washed separately. Food Service: 1. Residents placed in isolation shall be served all meals on disposable trays, dishes and utensils if applicable. 2. Disposable cups shall be used to serve drinking water to the resident throughout the isolation procedure. 3. All disposable items used and left over food shall be placed in isolation trash can, lined with red biohazard bag located in the resident room. Concurrent Cleaning of the Isolation Room: 1. Housekeeping will put on PPE as precautions indicate and take only needed supplies into the isolation room. 2. Clean room thoroughly: a. Use disinfectants spray or wipes according to the manufacturer recommendation. b. Use disinfectant cleaner to mop floors. c. Wipe down bed rails, mattresses, over bed tables, toilet seat and rim, toilet flushing handle, faucet levers, furniture handles, doorknobs, etc. 3. To remove mop and bucket: a. Empty liquid in toilet. b. Wipe mop handle and outside of bucket with disinfectant spray or wipes according to the manufacturer recommendation. c. Place contaminated mop head and cleaning rag ( if disposable wipe not used) in a melt-away bag and take to laundry to be washed separately. 4. Remove protective equipment apparel according to instructions and dispose of it in the room. 5. Wash hands thoroughly. Discharge from isolation: Dispose of bedpans, washbasins, emesis basin, and urinals in red bag. Wipe down large equipment with disinfectant wipe or spray according to manufacture label. On 12/12/13, review of the Center for Disease Control website (www.CDC.gov) revealed guidelines to prevent the spread of [MEDICAL CONDITION]. The CDC states to isolate the patients with [DIAGNOSES REDACTED]icile immediately, wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. Clean the room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there. Fourth Floor: On 12/09/13 at 11:55 AM, observations during medication pass revealed S13 LPN was going in and out of resident's rooms on the fourth floor performing accuchecks. Further observations revealed S13 LPN did not clean the glucometer machine after using it with each resident. After performing all of the accuchecks, S13 LPN then proceeded to place the contaminated glucometer into the drawer on the medication cart. On 12/11/13 at 3:50 PM, observation revealed S22 LPN was checking accuchecks on several residents on the fourth floor. Further observations revealed the S22 LPN was not cleaning the glucometer between residents. At 3:55 PM, the surveyor asked S22 LPN how she would check the blood sugar for sampled resident #5 (a diabetic), who was in isolation for [DIAGNOSES REDACTED]icile infection. S22 LPN stated that she would use an alcohol wipe to clean the glucometer after using it on him. Review of CDC information revealed that alcohol does not kill the spores associated with [DIAGNOSES REDACTED]icile.

I. Based on observation, record review, and interview the facility failed to ensure 2 (#6, 11) of 2 (#6, 11) residents who were bolus fed per PEG tube were comprehensively assessed for a significant weight loss, out of a total of 10 residents that exceeded the QCLI threshold for Nutrition (Significant Weight Loss). This deficient practice resulted in an actual harm of significant weight loss to resident #6 and #11 by the facility not: 1.) accurately weighing and documenting the weights for a resident (#6); 2.) not notifying timely the resident ' s physician and / or responsible party of a significant weight loss (#6, 11); and 3.) not having appropriate approaches in the plan of care for the residents that are fed by PEG tube and who have had a significant weight loss (#6, 11). Findings: Resident #6 Review of the medical record revealed resident #6 had [DIAGNOSES REDACTED]. Review of the current care plan for resident #6 revealed the facility had identified on 10/08/12 that the resident required a PEG tube for adequate nutritional intake, that the resident was currently NPO (nothing by mouth), and at risk for weight loss. Review of the December 2013 physician orders [REDACTED]. Review of the December 2013 MAR indicated [REDACTED]. On 12/11/13 at 10:30AM, review of the electronic medical record for resident #6 revealed the following weights were recorded in the computer: 6/13/13 - 196 7/18/13 - 197 8/15/13 - 197 9/12/13 - 198 10/10/13 - 198 11/14/13 - 196 12/05/13 - 184 On 12/12/13 at 10:00AM, S21 Nurse Consultant was questioned regarding whether resident #6 had been re-weighed after the 12 pound weight loss between 11/14/13 (196 pounds) and 12/05/13 (184 pounds). She was unaware of the significant weight change on 12/05/13, but stated she would look into the matter. 12/12/13 at 11:10AM, the S1 DON provided a computerized list of the resident ' s weights. Review of the list revealed handwritten documentation of resident #6 being re-weighed on 12/06/13 with a lift and the weight being 195 pounds. The handwritten documentation was initialed by S15 ADON. At this time, S1 DON confirmed the Registered Dietician (RD) saw the 195 pound weight on 12/06/13 when she was here reviewing records. On 12/12/13 at 1:20PM, the surveyor requested that resident #6 be re-weighed due to the discrepancy in weights. Observation at this time revealed S1 DON and S15 ADON reweighed resident #6 with a Hoyer lift. The resident's weight was 185.8. S15 ADON confirmed that the facility had only one Hoyer lift they used to weigh all residents needing a lift to be weighed. On 12/12/13 at 1:30PM, an interview S15 ADON confirmed she had re-weighed resident #6 on 12/06/13 because there was weight loss since November 2013 weight of 196 pounds. S15 ADON confirmed that she did not document the re-weighed weight of 196 pounds in computer until today (12/12/13). S15 ADON confirmed that when she put the 12/06/13 weight of 195 pounds in the computer system, she replaced the 12/05/13 computer weight of 184 pounds; but she left the 12/05/13 date which was inaccurate. S15 ADON also stated that resident #6 was re-weighed this morning (12/12/13) around 10AM by her and S17 CNA. S15 ADON stated the resident weighed 182 pounds and she confirmed she failed to report this weight to anyone. On 12/12/13 at 1:35PM, an interview with S17 CNA confirmed she was present earlier today when S15 ADON re-weighed resident #6. S17 CNA confirmed the resident weighed 182 pounds. She also confirmed they only have one lift used to weigh residents and they used the Hoyer lift this morning to weigh resident #6. Review of the 12/06/13 RD notes revealed that the flushes and feedings per PEG tube for resident #6 provided 1500 calories, 68gm protein, 1780ml fluid weight, 2000ml total fluid volume. The RD assessment notes did not address the weight loss of 12 pounds from 11/14/13 to 12/05/13. There was no documentation that the RD addressed the weight loss or had the resident re-weighed. Review of the Physcian Progress Note dated 12/06/13 for resident #6 revealed there was no documentation regarding the resident's weight loss during the period of 11/14/13 - 12/05/13. On 12/12/13 at 3:30PM, S1 DON confirmed that resident #6 had a significant weight loss in the past month, but was unable to determine exactly how much weight loss due to discrepancy with documentation by S15 ADON. She also confirmed there were no recent protein levels obtained for resident #6. S1 DON stated there were no interventions for weight loss initiated in the resident ' s plan of care because she was unaware of any weight loss until today (12/12/13), due to the discrepancies regarding the documentation of weights. She also confirmed the resident's physician was not notified until today (12/12/13) of the significant weight loss. Resident #11 On 12/11/13 review of the record for resident #11 revealed the following census weights. Weight closest to survey start date: 159 on 12/05/2013 Weight 30 days ago (11/06/2013): 170 (which is 11 lbs. less than on the first date or a 6.9% loss) Weight 90 days ago (09/18/2013): 171 (which is 12 lbs. less than on the first date or a 7.5% loss) Weight 180 days ago (06/05/2013): 173 (which is 14 lbs. less than on the first date or a 8.8% loss) On 12/11/13 at 10:22AM record review revealed resident #11 receives tube feeding as the only source of nutrition. Resident #11 recieves Fibersource HN- One carton via peg 5 times a day bolus feedings (Tube feedings to provide 1500 KCAL's, 68gm protein and 2250ml total fluid volume daily). Flush peg with 250ml of water via peg 5 times a day. Promod 30ml PT (per tube) TID (three times a day) On 8/8/13- registered dietician (RD) recommended add promod 30 ml BID due to low [MEDICATION NAME] lab value. A low [MEDICATION NAME] lab value is an indicator of poor nutritional state. 8/13/13- Promod 30ml BID was added On 9/11/13 registered dietician Nutrition Assessment revealed: Ideal Body Weight: 130 BMI- 28 [MEDICATION NAME]: 2.7 low Weight status: ht: 66 inches, IBW- 117-143#- BMI overweight- weight stable Dietician Recommended Nutrition Prescription 1500-1600Kcals, 60-80gm pro and 1950-2200 ml/day fluid Fibersource HN 1 carton 5 times a day H2O flush 250cc QID TF + flush provide: 1500 dal, 66 gms pro, 2013 FW, 2250 TV meeting needs, protein supplement added to improve protein status. 10/4/13- RD- recommended tube feeding flush and supplement per orders. TF monitoring, protein supplement added to improve protein level next lab draw, weight stable, tolerating feeding well, stable. RD Nutritional assessment dated [DATE] revealed: Weight status:10/2/13-- 170# weight stable 10/16/13- 171 lbs. 10/21/13- Weight Evaluation done 10/23/13- 171 lbs. 10/23/13 alb- 2.5 low Registered Dietician Recommendations: 1500-1600 kcal, 60-80 gm pro and 2200 ml/day fluid Fibersource HN 1 carton 5 X day H2O flush 250 QID TF + flush provide: 1500 cal, 66gm pro, 2013FW, 2250 TV Promod 30ml per tube twice a day Registered Dietician Evaluation on 10/23/13 revealed: resident meeting needs, will recommend to increase protein supplements to TID (three times a day) due to decreased [MEDICATION NAME] lab last draw, weight loss noted with suspected error in previous weights with new baseline weight established and monitored weekly, BMI-WNL, tolerating feeding well, TF+flush provide: 1500 cal, 66 gm protien, 2013 FW, 2250TV Nutritional Goals- stable weight, intact skin, improved alb lab next draw, TF tolerance. 10/30/13- 171 lbs. 11/6/130- 170 11/13/13- 170 11/20/13- 160 11/21/13- 160 11/25/13- 160 11/25/13 MD Notified of weight loss- No New Orders (This was 5 days after the resident showed a 10 pound weight loss in 7 days). Review of the notes in resident #11 record revealed on: 11/26/13 6:28PM- Resident's PCP (primary care physician) was notified of resident's weight loss on 11/25/13 when MD was in the facility. No new orders given. Unable to reach resident's responsible party. Will try again at a later time. Further review of the record revealed there was no other attempt to contact the family regarding the weight loss. On 11/26/13 a late entry from weight evaluation done 10/21/13 revealed the resident's weight was reviewed in high risk meeting and noted to have a 10 pund weight loss. The resident was re-weighed times 2 with S11ADON present to assure accuracy and resident's current weight is 160 punds. The resident was weighed with the hoyer life. The resident has a pe[DEVICE] and currently receives fibersource HN one carton PP (per peg) 5 times daily with 250ml water flush QID (4 times a day) to equal 1500 Kcals, 68 grams protein, and 2250 ml TFV (total fluid volume) daily. Resident is NPO (nothing by mouth) current supplements are promod 30ml PT BID (twice a day). Resident is above IBW of 130. RD last saw resident on 10/24/13. Resident will be weighed weekly with ADON present. Will continue to monitor until stable. On 12/5/13 resident #11 weighed- 159 pounds. On 12/6/13- registered dietician recommended to increase promod to 30ml TID due to decreased [MEDICATION NAME] lab last draw. Weight loss noted with suspected error in previous weights with new baseline weight established and monitored weekly. BMI (body mass index) -WNL(within normal limits) tolerating feeding well TF plus flush provided: 1500 cal. 66 gm protein. 2013 FW, 2250 total volume. RD Assessment 12/6/13 revealed: Orders: Fibersource HN 1 carton 5 times a day, peg flush 250ml QID TF + flush provide: 1500 cal, 66 gm protein, 2013 ml FW, 2250 TV IBW (ideal body weight): 130 BMI: 26 Weight status: 11/25/13- 160# Weight changes: Advantageous to remain @ lower wt level On 12/10/13 Increased promod 30ML to three times a day for Low [MEDICATION NAME]. On 12/11/13 at 3:00PM interview with S17 Restorative CNA revealed resident #11 has weekly weights. At this time observation of S17Restorative CNA weighed resident #11 using the hoyer lift and the resident's weight is now down to 156.8 which is another 2.2 pound weight loss in one week. Review of the plan of care revealed: At risk for weight loss related to resident has peg tube due to dysphagia on 11/21/13 resident has had weight loss. Approaches: take meds as ordered by physician, remind me or encourage me to eat meals in the dining room , offer bedtime snack I need my current food likes and dislikes maintained by dietary, Have the dietician re-evaluate my nutritional status as needed. Provide me with an attractive setting with socialization opportunity for my meals. I need my meals served as ordered by my physician. Weigh me as appropriate, and administer my Promod as ordered. 12/12/13 4:40PM interview with S1DON revealed she is not sure why the registered dietician has not recommended the resident for continuous tube feeding instead of bolus feedings. Further interview with S1DON confirmed resident #11 has had a significant weight loss since 11/13/13 resident #11 has lost a total of 13.2 pounds. S1DON confirmed the plan of care was not appropriate approaches regarding the weight loss since the resident has a peg tube and is unable to have any feedings by mouth. II. Based on observation, record review, and interview, the facility failed to conduct an accurate ongoing dental assessment for 2 (#6, 11) of 3 (#6, 11, 72) residents who met the QCLI criteria for dental status and services from a total of 33 Stage 2 sampled residents. Findings: Resident #6 On 12/10/13 at 11:24AM, an observation of resident #6 revealed she had multiple missing, dark, discolored teeth. On 12/11/13 review of the record for resident #11 revealed the resident was totally dependant on staff for all activities of daily living. Observation of resident #11 revealed she was bedridden and unable to perform her own activities of daily living. Review of the Admission assessment dated [DATE] for resident #6 revealed there was no documentation in the dental section indicating obvious or likely cavity or broken natural teeth. On 12/12/13 at 9:30AM, an interview with S12LPN revealed she had worked with the resident for 1 1/2 years. She stated the resident's teeth have been in poor condition ever since she began working with her. On 12/12/13 at 4:00PM, an interview with S1DON confirmed resident #6 ' s teeth are in poor condition. She also confirmed the MDS assessment of resident #6's dental problems was not correct. Resident #11 On 12/11/13 review of the record for resident #11 revealed the resident was totally dependant on staff for all activities of daily living. Observation of resident #11 revealed she was bedridden and unable to perform her own activities of daily living. Review of the plan of care revealed requires staff assistance for ADLs. Left side weakness, extensive to total care with my ADLs. 12/09/2013 11:16 AM obs. of res. revealed large amount of build up on residents teeth. Res. states they don't brush her teeth. Several teeth are broken. 12/11/13 9:45AM observation revealed resident's teeth were not cleaned and resident's breath had strong foul odor. 12/11/13 10:15AM observation of resident's mouth revealed it remains with large amount of plaque buildup and with a foul odor coming from her mouth. Observation of res. revealed she is unable to perform own oral care. 12/11/13 2:00PM observation revealed resident's teeth were not cleaned and resident's breath had strong foul odor. 12/11/13 4:30PM observation revealed resident's teeth were not cleaned and resident's breath had strong foul odor. 12/12/13 9:08AM obs. of RN tx nurse during peg tube care revealed resident was requesting juice dry saliva noted running down side of face. RN told res. she could only have feedings through her peg tube. Res. constantly licking tongue, mouth very dry, strong breath odor. RN never wiped dried saliva. Review of the annual MDS assessment dated [DATE] revealed documentation of resident #11 having no dental problems. On 12/12/13 at 4:30PM interview with S1DON confirmed the MDS assessment of resident #11's dental problems was not correct.

Based on observation, record review and interview the facility failed to ensure that 2 (#6, 11) of 2 residents maintained acceptable parameters of body weight and protein levels to prevent significant weight loss for 2 (#6, #11) of 2 residents who were bolus tube fed and had significant weight loss in a total sample of 2 residents with bolus tube feedings and a facility with 11 tube feeders and 10 residents with unplanned weight loss according to the resident census and condition report. This deficient practice resulted in an actual harm to resident #6 and #11 by not accurately assessing and acting on the significant weight loss for bolus tube feeders to ensure the residents did not have significant weight loss. Findings: Resident #6: Review of the medical record revealed resident #6 had [DIAGNOSES REDACTED]. Review of the current care plan for resident #6 revealed the facility had identified on 10/08/12 that the resident required a PEG tube for adequate nutritional intake, that the resident was currently NPO (nothing by mouth), and at risk for weight loss. Review of the December 2013 physician orders [REDACTED]. Review of the December 2013 MAR indicated [REDACTED]. On 12/11/13 at 10:30AM, review of the electronic medical record for resident #6 revealed the following weights were recorded in the computer: 6/13/13 - 196 7/18/13 - 197 8/15/13 - 197 9/12/13 - 198 10/10/13 - 198 11/14/13 - 196 12/05/13 - 184 On 12/12/13 at 10:00AM, S21 Nurse Consultant was questioned regarding whether resident #6 had been re-weighed after the 12 pound weight loss between 11/14/13 (196 pounds) and 12/05/13 (184 pounds). She was unaware of the significant weight change on 12/05/13, but stated she would look into the matter. 12/12/13 at 11:10AM, the S1 DON provided a computerized list of the resident ' s weights. Review of the list revealed handwritten documentation of resident #6 being re-weighed on 12/06/13 with a lift and the weight being 195 pounds. The handwritten documentation was initialed by S15 ADON. At this time, S1 DON confirmed the Registered Dietician (RD) saw the 195 pound weight on 12/06/13 when she was here reviewing records. On 12/12/13 at 1:20PM, the surveyor requested that resident #6 be re-weighed due to the discrepancy in weights. Observation at this time revealed S1 DON and S15 ADON reweighed resident #6 with a Hoyer lift. The resident's weight was 185.8. S15 ADON confirmed that the facility had only one Hoyer lift they used to weigh all residents needing a lift to be weighed. On 12/12/13 at 1:30PM, an interview S15 ADON confirmed she had re-weighed resident #6 on 12/06/13 because there was weight loss since November 2013 weight of 196 pounds. S15 ADON confirmed that she did not document the re-weighed weight of 196 pounds in computer until today (12/12/13). S15 ADON confirmed that when she put the 12/06/13 weight of 195 pounds in the computer system, she replaced the 12/05/13 computer weight of 184 pounds; but she left the 12/05/13 date which was inaccurate. S15 ADON also stated that resident #6 was re-weighed this morning (12/12/13) around 10AM by her and S17 CNA. S15 ADON stated the resident weighed 182 pounds and she confirmed she failed to report this weight to anyone. On 12/12/13 at 1:35PM, an interview with S17 CNA confirmed she was present earlier today when S15 ADON re-weighed resident #6. S17 CNA confirmed the resident weighed 182 pounds. She also confirmed they only have one lift used to weigh residents and they used the Hoyer lift this morning to weigh resident #6. Review of the 12/06/13 RD notes revealed that the flushes and feedings per PEG tube for resident #6 provided 1500 calories, 68gm protein, 1780ml fluid weight, 2000ml total fluid volume. The RD assessment notes did not address the weight loss of 12 pounds from 11/14/13 to 12/05/13. There was no documentation that the RD addressed the weight loss or had the resident re-weighed. Review of the Physcian Progress Note dated 12/06/13 for resident #6 revealed there was no documentation regarding the resident's weight loss during the period of 11/14/13 - 12/05/13. On 12/12/13 at 3:30PM, S1 DON confirmed that resident #6 had a significant weight loss in the past month, but was unable to determine exactly how much weight loss due to discrepancy with documentation by S15 ADON. She also confirmed there were no recent protein levels obtained for resident #6. S1 DON stated there were no interventions for weight loss initiated in the resident ' s plan of care because she was unaware of any weight loss until today (12/12/13), due to the discrepancies regarding the documentation of weights. She also confirmed the resident's physician was not notified until today (12/12/13) of the significant weight loss. Resident #11 On 12/11/13 review of the record for resident #11 revealed the following census weights. Weight closest to survey start date: 159 on 12/05/2013 Weight 30 days ago (11/06/2013): 170 (which is 11 lbs. less than on the first date or a 6.9% loss) Weight 90 days ago (09/18/2013): 171 (which is 12 lbs. less than on the first date or a 7.5% loss) Weight 180 days ago (06/05/2013): 173 (which is 14 lbs. less than on the first date or a 8.8% loss) On 12/11/13 at 10:22AM record review revealed resident #11 receives tube feeding as the only source of nutrition. Resident #11 recieves Fibersource HN- One carton via peg 5 times a day bolus feedings (Tube feedings to provide 1500 KCAL's, 68gm protein and 2250ml total fluid volume daily). Flush peg with 250ml of water via peg 5 times a day. Promod 30ml PT (per tube) TID (three times a day) On 8/8/13- registered dietician (RD) recommended add promod 30 ml BID due to low [MEDICATION NAME] lab value. A low [MEDICATION NAME] lab value is an indicator of poor nutritional state. 8/13/13- Promod 30ml BID was added On 9/11/13 registered dietician Nutrition Assessment revealed: Ideal Body Weight: 130 BMI- 28 [MEDICATION NAME]: 2.7 low Weight status: ht: 66 inches, IBW- 117-143#- BMI overweight- weight stable Dietician Recommended Nutrition Prescription 1500-1600Kcals, 60-80gm pro and 1950-2200 ml/day fluid Fibersource HN 1 carton 5 times a day H2O flush 250cc QID TF + flush provide: 1500 dal, 66 gms pro, 2013 FW, 2250 TV meeting needs, protein supplement added to improve protein status. 10/4/13- RD- recommended tube feeding flush and supplement per orders. TF monitoring, protein supplement added to improve protein level next lab draw, weight stable, tolerating feeding well, stable. RD Nutritional assessment dated [DATE] revealed: Weight status:10/2/13-- 170# weight stable 10/16/13- 171 lbs. 10/21/13- Weight Evaluation done 10/23/13- 171 lbs. 10/23/13 alb- 2.5 low Registered Dietician Recommendations: 1500-1600 kcal, 60-80 gm pro and 2200 ml/day fluid Fibersource HN 1 carton 5 X day H2O flush 250 QID TF + flush provide: 1500 cal, 66gm pro, 2013FW, 2250 TV Promod 30ml per tube twice a day Registered Dietician Evaluation on 10/23/13 revealed: resident meeting needs, will recommend to increase protein supplements to TID (three times a day) due to decreased [MEDICATION NAME] lab last draw, weight loss noted with suspected error in previous weights with new baseline weight established and monitored weekly, BMI-WNL, tolerating feeding well, TF+flush provide: 1500 cal, 66 gm protien, 2013 FW, 2250TV Nutritional Goals- stable weight, intact skin, improved alb lab next draw, TF tolerance. 10/30/13- 171 lbs. 11/6/130- 170 11/13/13- 170 11/20/13- 160 11/21/13- 160 11/25/13- 160 11/25/13 MD Notified of weight loss- No New Orders (This was 5 days after the resident showed a 10 pound weight loss in 7 days). Review of the notes in resident #11 record revealed on: 11/26/13 6:28PM- Resident's PCP (primary care physician) was notified of resident's weight loss on 11/25/13 when MD was in the facility. No new orders given. Unable to reach resident's responsible party. Will try again at a later time. Further review of the record revealed there was no other attempt to contact the family regarding the weight loss. On 11/26/13 a late entry from weight evaluation done 10/21/13 revealed the resident's weight was reviewed in high risk meeting and noted to have a 10 pund weight loss. The resident was re-weighed times 2 with S11ADON present to assure accuracy and resident's current weight is 160 punds. The resident was weighed with the hoyer life. The resident has a pe[DEVICE] and currently receives fibersource HN one carton PP (per peg) 5 times daily with 250ml water flush QID (4 times a day) to equal 1500 Kcals, 68 grams protein, and 2250 ml TFV (total fluid volume) daily. Resident is NPO (nothing by mouth) current supplements are promod 30ml PT BID (twice a day). Resident is above IBW of 130. RD last saw resident on 10/24/13. Resident will be weighed weekly with ADON present. Will continue to monitor until stable. On 12/5/13 resident #11 weighed- 159 pounds. On 12/6/13- registered dietician recommended to increase promod to 30ml TID due to decreased [MEDICATION NAME] lab last draw. Weight loss noted with suspected error in previous weights with new baseline weight established and monitored weekly. BMI (body mass index) -WNL(within normal limits) tolerating feeding well TF plus flush provided: 1500 cal. 66 gm protein. 2013 FW, 2250 total volume. RD Assessment 12/6/13 revealed: Orders: Fibersource HN 1 carton 5 times a day, peg flush 250ml QID TF + flush provide: 1500 cal, 66 gm protein, 2013 ml FW, 2250 TV IBW (ideal body weight): 130 BMI: 26 Weight status: 11/25/13- 160# Weight changes: Advantageous to remain @ lower wt level On 12/10/13 Increased promod 30ML to three times a day for Low [MEDICATION NAME]. On 12/11/13 at 3:00PM interview with S17 Restorative CNA revealed resident #11 has weekly weights. At this time observation of S17Restorative CNA weighed resident #11 using the hoyer lift and the resident's weight is now down to 156.8 which is another 2.2 pound weight loss in one week. Review of the plan of care revealed: At risk for weight loss related to resident has peg tube due to dysphagia on 11/21/13 resident has had weight loss. Approaches: take meds as ordered by physician, remind me or encourage me to eat meals in the dining room , offer bedtime snack I need my current food likes and dislikes maintained by dietary, Have the dietician re-evaluate my nutritional status as needed. Provide me with an attractive setting with socialization opportunity for my meals. I need my meals served as ordered by my physician. Weigh me as appropriate, and administer my Promod as ordered. 12/12/13 4:40PM interview with S1DON revealed she is not sure why the registered dietician has not recommended the resident for continuous tube feeding instead of bolus feedings. Further interview with S1DON confirmed resident #11 has had a significant weight loss since 11/13/13 resident #11 has lost a total of 13.2 pounds. S1DON confirmed the plan of care was not appropriate approaches regarding the weight loss since the resident has a peg tube and is unable to have any feedings by mouth.

Based on observation, record reviews and interviews the facility failed to to be administered in a manner to ensure their resources were used effectively to maintain the resident's highest practical, physical, mental and psychosocial well-being for 1 (#75) of 10 (#75, #61, #116, #133, #130, #79, #84, #26, #12) sampled residents receiving pain medication regimens by failing to a system in place to: 1). Prevent residents (#75) from experiencing break through pain during the period of 10/31/12-12/12/12. 2). To clarify a physician's orders [REDACTED]. 3). Confirmed the hospice written physician order [REDACTED]. 4). Communicate with hospice to ensure that the resident was free of break through pain and the effectiveness of the pain management orders. This resulted in an actual harm when Resident #75 had continuous break through pain and did not received the hospice physician ordered pain medication of [MEDICATION NAME] 10mg give 20cc per Tube q 6 hours as needed for pain between 10/31/12 and 12/12/12 and had prior pain scale levels averaging from 6 to 10 on a pain scale of 1-10 with 10 being the worse pain. The resident was no longer sitting up in chair, became bedbound and unable to swallow over the last month. Also the resident stop participated in room activities around the end of October, 2012 to the 1st week of November, 2012. Findings: Review of verbal order for Resident #75 taken and written per hospice admit nurse stated as follow: 10/31/12 at 3:05 p.m., [MEDICATION NAME] 7.5/500/15cc give 10ml q 6 hours prn. Review of the Hospice Physician order [REDACTED].#75 read, [MEDICATION NAME] 10mg per tube q 6 hours prn pain. On 12/10/12 at 12:35 p.m., a resident interview was held with Resident #75. He said that he experiences pain on a daily basis especially to his hands and just all over. He also said that he get pain medication, but it only last for a short period of time and then he has to wait until he could get more. Resident #75 said that his pain got worse about 2 months ago around the time he was put on hospice. He said that he does not leave his room at all. He also said he no longer get out of bed, sit up in a chair or participate in room activities anymore which was his choice. Resident #75 said the pain intensity varies from sharp to dull. He said he get relief usually for a short time after getting the pain medication, but it does not last until the next dose. During an interview with S10LPN on 12/11/12 at 11:32 a.m., she revealed that Residents #75's [MEDICATION NAME] label had been written as a 20cc dose. She said that there was a written order from the Hospice Nurse which read [MEDICATION NAME] 10cc. S10LPN said that someone crossed the 20ccs out and hand wrote 10 cc on the bottle label. S10LPN said this was the way all of Resident #75's [MEDICATION NAME] medication bottles were done, beginning with first bottle delivered on 10/31/12. She also said that she nor any of the other nurses had contacted the pharmacy or the hospice physician for clarification of the order since they had a written order on Resident #75's chart which read, [MEDICATION NAME] 7.5/500/15cc give 10ml q 6 hours prn. She also confirmed said that Resident #75 was receiving 1/2 the dosage of what the pharmacy had been sending for his pain. S10LPN said it was not protocol for them to write on the pharmacy labels. She said that when something like this happen they are to notify the pharmacy for clarification and to get a new label, if the label was mislabeled On 12/11/12 at 11:50 a.m., a medication pass observation was done of S10LPN and administering Resident #75 his [MEDICATION NAME]. Prior to the actual medication pass a review of the resident's [MEDICATION NAME] medication bottle was made. The label on the bottle revealed Resident #75's name and the date of 11/23/12. The label also revealed 20cc per tube every 6 hours as needed for pain; [MEDICATION NAME]-APAP. Review of the label revealed that there was a line was crossed through the 20 cc on the label and 10cc was hand written on the label in black ink. S10LPN asked the resident to rate his pain and he stated "7." She also asked him was it still in his hands this time and he said "yes." S10LPN proceeded to administer the [MEDICATION NAME] 10 cc per tube, as well as the scheduled tube feedings. An interview was held with S13Corporate Nurse on 12/11/12 at 12:40 p.m. in the 4th floor nurses' station. She said that she had just spoken the Hospice Administrator. She also said that the administrator said that the hospice admit nurse may had intended to write [MEDICATION NAME] 10 mg, but wrote 10 ml on Resident #75 pain medication order dated 10/31/12. S13Corporate Nurse did not present any clarification regarding Resident #75 [MEDICATION NAME] order from the hospice physician nor the facility's pharmacy. Another interview was held with S10LPN on 12/11/12 at 1:45 p.m. She said she had contacted Resident #75's Hospice Nurse for clarification of the resident's pain medication. She said that the hospice nurse told her that the resident was to receive [MEDICATION NAME] 7.5/500/15ml 20 cc q 6 hours prn pain. During another observation of Resident #75 on 12/11/12 at 2:00 p.m., resident was laying in bed with eyes wide-open and staring out in space. When he was asked if his pain was decreased or better he stated, "somewhat." He explained that most of the times he has some degree of pain throughout the day and night. On the same day, 12/11/12 at 2:30 p.m., an observation was made with the S13Corporate Nurse and S14Corporate Administration of Resident #75. The resident was asked was his pain any better by S13Corporate Nurse. The resident said "somewhat." S13Corporate Nurse asked the resident how long has he been having this type of pain. The resident responded" almost 2 months." An interview was held with S12LPN on 12/12/12 at 6:45 a.m. She said that Resident #75 had been experiencing a lot of break through pain throughout the night for over a month or so. She said that last night was one of his rougher nights, because he was requesting pain medication every 2 hours on at least (2) occasions. She said they did start the order to increase the [MEDICATION NAME] to 20cc q6 hours yesterday evening and Resident #75 received a dose at 6:50 p.m. and on 12/12/12 at 06:37 a.m. S12LPN said at 6:57 a.m., he was complaining of more pain and wanting pain medication again. She also said that Resident #75 had been asking for pain medication for the past month or so before he could have his next dose. An interview was held with S8CNA on 12/12/12 at 8:45 a.m. She said that she totally assist with all of Resident #75 morning care and his bed baths. She said that prior to giving him a bed bath each morning the nurse has to give him pain medication or he would not make it through the bath comfortably, because he was always in pain. She also said once he was medicated he was able to enjoy his morning care. S8CNA said she cannot remember exactly when his pain level change, but it had been at least a month. An interview was held with Resident #75's hospice admit nurse on 12/12/12 at 10:15 a.m. She said that she had taken a verbal order from the hospice physician on 10/31/12 for pain medication for Resident #75. She also said she was not aware that the pharmacy was sending pain medication that was different from the verbal order she had written. She also said that she may have written 10ml instead of 10mg, but it was the facility's responsibility to get a clarification of the order either from the hospice physician or from the pharmacy. An interview was held with Resident #75's scheduled hospice nurse on 12/12/12 at 10:50 a.m. She said that a couple of weeks ago the resident's day nurse had mentioned to her that Resident #75 was having break through pain between his pain medication administration. She also said that when she made his visits, sometimes he would say his pain level was an "8" and she would go out the room and come back later and it would be a "6" or vice versa. She said that she would assess Resident #75's pain levels at different times and ways and many times he would contradict himself. The hospice nurse said eventually she had decided to get an increase in his pain medication, because the nurse told her that the resident was having chronic and increasing pain. She said that on 12/05/12 she contacted the hospice physician and got a faxed copy of a prescription order which read, [MEDICATION NAME] 10mg per tube q 4 hours prn pain. She also said she faxed the order directly to the facility's pharmacy and intended to send a copy of the order to the facility. During an interview with S10LPN on 12/12/12 at 11:15 a.m., she said that she had received the new [MEDICATION NAME] from the pharmacy on 12/05/12, but she never received a copy of the prescription from the hospice nurse. She also said that she had received a call from the hospice nurse a few minutes ago and the hospice nurse said she will be faxing a copy of the 12/05/12 order to them shortly for their records. S10LPN said that she did not contact the physician regarding the resident's break through pain, because she told the hospice nurse. She also said that she did contact the hospice physician on 12/11/12 and got clarification of the 10/31/12 order. S10LPN said that the order did read that Resident #75 was to get [MEDICATION NAME] 7.5/500/15ml/20cc q 6hours prn pain. An interview was held with the facility's pharmacist on 12/12/12 at 11:25 a.m. He said that on 10/31/12 he had received a hard copy from the hospice physician's office for pain medication for Resident #75. He also said that the copy read [MEDICATION NAME] 10mg per tube q 6 hours. The pharmacist said in order for the resident to receive 10mg of the [MEDICATION NAME] 20cc must be administered to the resident. He said that he filled the order and delivered the medications to the facility on [DATE] and 11/23/12. The Pharmacist said he received a new pain medication order on 12/05/12 from the hospice physician office. He said the hard copy read [MEDICATION NAME] 20cc q 4hours which was filled and delivered to the facility on the same day (12/05/12). The pharmacist said that he was never contacted or questioned about either of the hospice physician's orders [REDACTED]. An interview was held with Resident #75's hospice physician on 12/13/12 at 8:15 a.m.. He said that he admitted Resident #75 to hospice on 10/31/12. He said that he was told by the hospice nurse that the resident was having pain. He also said that he ordered [MEDICATION NAME] 20cc/10mg per tube q 6 hours to assist with pain control and the resident's comfort. The Hospice Physician said his office sent the prescription directly to the facility pharmacy. He also said about two weeks ago he was contacted by the hospice nurse informing him that Resident #75 was having break through pain, so he ordered [MEDICATION NAME] 20cc/10mg per tube q 4 hours in hopes this will give him faster and more relief and he would not have to wait q 6 hours for pain medications. The hospice physician said that this second pain order was also written on a prescription and sent to the pharmacy and that the hospice nurse/agency received a copy also. He also said that the hospice nurse usually get the order to the facility on ce he gives them an order on a resident. Review of Resident #75 Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Description- [MEDICATION NAME] 7.5/500/15ml Give 10ml q 6 hours per peg prn pain. Start Date: 11/01/12 [MEDICATION NAME] Bit/[MEDICATION NAME] 338.29 Chronic Pain Nec (Pain scale level was prior to pain medication administration)Time Codes Date Pain Scale Time Codes Date Pain Scale 12:15am. 11/25/12 8 10:22am. 11/18/12 4 12:28am. 11/23/12 9 12:01.m. 11/24/12 8 12:28am. 11/24/12 8 12:04pm. 11/10/12 9 12:32am. 11/10/12 8 12:20pm. 11/22/12 8 12:39am. 11/11/12 6 2:56pm. 11/15/12 8 12:46am. 11/16/12 6 3:42pm. 11/17/12 4 1:09am 11/08/12 5 4:42pm. 11/04/12 8 1:13am 11/22/12 5 5:05pm. 11/07/12 4 4:51am. 11/06/12 6 5:06pm. 11/25/12 8 5:49am. 11/29/12 7 5:07pm. 11/29/12 5 8:55am 11/13/12 5 5:19pm. 11/28/12 5 9:11am. 11/19/12 8 5:23pm. 11/20/12 6 9:19am 11/14/12 8 5:28pm. 11/27/12 5 9:23am. 11/25/12 8 5:38pm. 11/23/12 5 9:30am 11/28/12 9 6:15pm. 11/21/12 6 9:37am. 11/26/12 8 December 2012 12:44am. 12/10/12 10 12:20p.m. 12/2/12 8 1:45am. 12/09/12 5 12:20p.m. 12/10/12 8 4:44am. 12/03/12 5 12:27p.m. 12/01/12 8 5:01am 12/02/12 5 4:28p.m. 12/09/12 9 5:27am. 12/06/12 6 5:00p.m. 12/08/12 8 8:57am. 12/05/12 9 5:24p.m. 12/07/12 6 9:18am. 12/09/12 8 6:29p.m. 12/06/12 5 9:23am. 12/08/12 8 6:48p.m 12/10/12 6 9:31am. 12/07/12 8 Review of Resident #75's Activities Progress Notes dated 10/03/12 written by S11Activity Director(AD) stated Resident #75 was doing well. He remained in bed all day. S11AD visits the resident 1-3 times a week providing activities such as one/one conversation, memory enhancement (twice) and sensory-stimulation (Balloon Volley). Resident also enjoyed watching TV; talk shows. Resident participate 15-30minutes of each activity provided. An interview was held with S11Activity Director on 12/13/12 at 11:45 a.m. She said that around the end of October or maybe the 1st of November, 2012. Resident #75 stopped participating in his room activities. She said he did not verbally say he was in pain, but she could tell many times he was because she had spend a lot of time with him. S11Activity Director said that Resident #75 would become less focus, quiet and stares off in another direction when he was in pain. She also said she started reading books and magazines to him, but he would no longer participate in balloon volley or any kind of movement exercises.

Based on observation, record review and interview, the facility failed to provide the necessary care and services to maintain the highest practical physical, mental and psychosocial well-being in accordance with the plan of care for 1(#75) of 10(#75, 61, 116, 133, 130, 79, 110, 84, 26, 12) residents receiving pain medication regimens by failing to: 1) Keep resident free from break through pain (10/31/12-12/12/12). 2) Clarify the physician's orders [REDACTED]. Confirmed the hospice nurse written order with the Hospice Physician and/or the prescription sent to the pharmacy. 3). Administer the Hospice physician's orders [REDACTED].#75 received 10cc each time the pain medication was administered which was 1/2 of the dose ordered. 4). Communicate with hospice to ensure that the resident was free of break through pain and the effectiveness of the pain management orders. This resulted in an actual harm when Resident #75 had continuous break through pain and did not received the hospice physician ordered pain medication of [MEDICATION NAME] 10mg give 20cc per Tube q 6 hours as needed for pain between 10/31/12 and 12/12/12 and had prior pain scale levels averaging from 6 to 10 on a pain scale of 1-10 with 10 being the worse pain. The resident was no longer sitting up in chair, became bedbound and unable to swallow over the last month. Also the resident stop participated in room activities around the end of October, 2012 to the 1st week of November, 2012. Findings: Resident #75 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. On 10/31/12 Resident #75 was admitted to hospice with [DIAGNOSES REDACTED]. On 12/10/12 at 11:30a.m., an observation was made of Resident #75 with S10LPN at his bedside. During the the observation Resident #75 was lying in bed covered with blankets to his shoulders and staring off into space. S10LPN asked the resident to rate his pain and he said it was "8." (The facility pain scale rated pail levels from 1 to 10 with 10 being the worse pain level). According to the Hospice Initial Certification dated 10/31/12 and signed 11/02/12, Resident #75 was admitted for Adult failure to thrive. It also revealed in the last month he has become bedbound, no longer sitting up in chair and unable to swallow. His admission pain assessment dated [DATE] revealed the following: Area: bilateral Location: Hand Present pain: 10 Acceptable pain: 0 Physician Notified: Yes, Modified order written. Comment: new order [MEDICATION NAME] 10ml q6 hours prn. Review of verbal order taken and written per hospice admit nurse stated as follow: 10/31/12 at 3:05 p.m., [MEDICATION NAME] 7.5/500/15cc give 10ml q 6 hours prn. Review of the Hospice Physician order [REDACTED]. On 12/10/12 at 12:35 p.m., a resident interview was held with Resident #75. He said that he experiences pain on a daily basis especially to is hands and just all over. He also said that he get pain medication but it only last for a short period of time and then he has to wait until he could get more. Resident #75 said that his pain got worse about 2 months ago around the time he was put on hospice. He said that he does not leave his room at all. He also said he does not get out of bed, sit up in a chair or participate in room activities anymore which was his choice. Resident #75 said the pain intensity varies from sharp to dull. He said he get relief usually for a short time after getting the pain medication but it does not last until the next dose. During an interview with S10LPN on 12/11/12 at 11:32 a.m., she revealed that Residents #75's [MEDICATION NAME] label had been written as a 20cc dose. She said that there was a written order from the Hospice Nurse which read [MEDICATION NAME] 10cc. S10LPN said that someone crossed the 20ccs out and hand wrote 10 cc on the bottle label. S10LPN said this was the way all of Resident #75's [MEDICATION NAME] medication bottles were done, beginning with first bottle delivered on 10/31/12. She also said that she nor any of the other nurses had contacted the pharmacy or the hospice physician for clarification of the order since they had a written order on Resident #75's chart which read, [MEDICATION NAME] 7.5/500/15cc give 10ml q 6 hours prn. She also confirmed said that Resident #75 was receiving 1/2 the dosage of what the pharmacy had been sending for his pain. S10LPN said it was not protocol for them to write on the pharmacy labels. She said that when something like this happen they are to notify the pharmacy for clarification and to get a new label, if the label was mislabeled On 12/11/12 at 11:50 a.m., a medication pass observation was done of S10LPN and administering Resident #75 his [MEDICATION NAME]. Prior to the actual medication pass a review of the resident's [MEDICATION NAME] medication bottle was made. The label on the bottle revealed Resident #75's name and the date of 11/23/12. The label also revealed 20cc per tube every 6 hours as needed for pain; [MEDICATION NAME]-APAP. Review of the label revealed that there was a line was crossed through the 20 cc on the label and 10cc was hand written on the label in black ink. S10LPN asked the resident to rate his pain and he stated "7." She also asked him was it still in his hands this time and he said "yes." S10LPN proceeded to administer the [MEDICATION NAME] 10 cc per tube, as well as the scheduled tube feedings. An interview was held with S13Corporate Nurse on 12/11/12 at 12:40 p.m. in the 4th floor nurses' station. She said that she had just spoken the Hospice Administrator. She also said that the administrator said that the hospice admit nurse may had intended to write [MEDICATION NAME] 10 mg, but wrote 10 ml on Resident #75 pain medication order dated 10/31/12. S13Corporate Nurse did not present any clarification regarding Resident #75 [MEDICATION NAME] order from the hospice physician nor the facility's pharmacy. Another interview was held with S10LPN on 12/11/12 at 1:45 p.m. She said she had contacted Resident #75's Hospice Nurse for clarification of the resident's pain medication. She said that the hospice nurse told her that the resident was to receive [MEDICATION NAME] 7.5/500/15ml 20 cc q 6 hours prn pain. During another observation of Resident #75 on 12/11/12 at 2:00 p.m., resident was laying in bed with eyes wide-open and staring out in space. When Resident #75 was asked if his pain was decreased or better he stated "somewhat." He explained that most of the times he has some degree of pain throughout the day and night. On the same day 12/11/12 at 2:30 p.m. an observation was made with the S13Corporate Nurse and S14Corporate Administration of Resident #75. S13Corporate Nurse asked the resident if his pain was any better, the resident said "somewhat." When she asked the resident how long has he been having this type of pain, the resident stated" almost 2 months." An interview was held with S12LPN on 12/12/12 at 6:45 a.m. She said that Resident #75 had been experiencing a lot of break through pain throughout the night for over a month or so. She said that last night was one of his rougher nights because he was requesting pain medication every 2 hours on at least (2) occasions. She said they did start the order to increase the [MEDICATION NAME] to 20cc q6 hours yesterday evening and Resident #75 received a dose at 6:50 p.m. and on 12/12/12 at 06:37 a.m. S12LPN said at 6:57 a.m., he was complaining of more pain and wanting pain medication again. She also said that Resident #75 had been asking for pain medication for the past month or so, before he could have his next dose. An interview was held with S8CNA on 12/12/12 at 8:45 a.m. She said that she totally assist with Resident #75 morning care and complete bed baths. She said that prior to giving him a bed bath each morning the nurse has to give him pain medication or he would not make it through the bath comfortably, because he was always in pain. She also said once he was medicated he was able to enjoy his morning care. S8CNA said she cannot remember exactly when his pain level change, but it had been at least a month. An interview was held with Resident #75's hospice admit nurse on 12/12/12 at 10:15 a.m. She said that she had taken a verbal order from the hospice physician on 10/31/12 for pain medication for Resident #75. She also said she was not aware that the pharmacy was sending pain medication that was different from the verbal order she had written. She also said that she may have written 10ml instead of 10mg, but it was the facility's responsibility to get a clarification of the order either from the hospice physician or from the pharmacy. An interview was held with Resident #75's hospice nurse on 12/12/12 at 10:50 a.m. She said that a couple of weeks ago the resident's day nurse had mentioned to her that Resident #75 was having break through pain between his pain medication administration. She also said that when she made his visits sometimes he would say his pain level was an "8" and she would go out the room and come back later and it would be a "6" or vice versa. She said that she would assess Resident #75's pain levels at different times and ways and many times he would contradict himself. The hospice nurse said eventually she had decided to get an increase in his pain medication, because the nurse told her that the resident was having chronic and increasing pain. She said that on 12/05/12 she contacted the hospice physician and got a faxed copy of a prescription order which read, [MEDICATION NAME] 10mg per tube q 4 hours prn pain. She also said she faxed the order directly to the facility's pharmacy and intended to send a copy of the order to the facility. During an interview with S10LPN on 12/12/12 at 11:15 a.m., she said that she had received the new [MEDICATION NAME] from the pharmacy on 12/05/12, but she never received a copy of the prescription from the hospice nurse. She also said that she had received a call from the hospice nurse a few minutes ago and the hospice nurse said she will be faxing a copy of the 12/05/12 order to them shortly for their records. S10LPN said that she did not contact the physician regarding the resident's break through pain, because she told the hospice nurse. She also said that she did contact the hospice physician on 12/11/12, to get clarification of the 10/31/12 order. S10LPN said that the order did state that Resident #75 was to get [MEDICATION NAME] 7.5/500/15ml/20cc q 6hours prn pain. An interview was held with the facility's pharmacist on 12/12/12 at 11:25 a.m. He said that on 10/31/12 he had received a hard copy from the hospice physician's office for pain medication for Resident #75. He also said that the copy read [MEDICATION NAME] 10mg per tube q 6 hours. The pharmacist said in order for the resident to receive 10mg of the [MEDICATION NAME] 20cc must be administered to the resident. He said that he filled the order and delivered the medications to the facility on [DATE] and 11/23/12. The pharmacist said he received a new pain medication order on 12/05/12 from the hospice physician office. He said the hard copy stated [MEDICATION NAME] 20cc q 4hours which was filled and delivered to the facility on the same day (12/05/12). The pharmacist said that he was never contacted or questioned about either of the hospice physician's orders [REDACTED]. An interview was held with Resident #75's hospice physician on 12/13/12 at 8:15 a.m.. He said that he admitted Resident #75 to hospice on 10/31/12. He said that he was told by the hospice nurse that the resident was having pain. He also said that he ordered [MEDICATION NAME] 20cc/10mg per tube q 6 hours to assist with pain control and the resident's comfort. The hospice physician said his office sent the prescription directly to the facility pharmacy. He also said about two weeks ago he was contacted by the hospice nurse informing him that Resident #75 was having break through pain, so he ordered [MEDICATION NAME] 20cc/10mg per tube q 4 hours in hopes this will give him faster and more relief and he would not have to wait q 6 hours for pain medications. The hospice physician said that this second pain order was also written on a prescription and sent to the pharmacy and the hospice nurse/agency received a copy also. He also said that the hospice nurse usually get the order to the facility on ce he gives them an order on a resident. Review of Resident #75 Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Description- [MEDICATION NAME] 7.5/500/15ml Give 10ml q 6 hours per peg prn pain. Start Date: 11/01/12 [MEDICATION NAME] Bit/[MEDICATION NAME] 338.29 Chronic Pain Nec (Pain scale level was prior to pain medication administration)Time Codes Date Pain Scale Time Codes Date Pain Scale 12:15am. 11/25/12 8 10:22am. 11/18/12 4 12:28am. 11/23/12 9 12:01.m. 11/24/12 8 12:28am. 11/24/12 8 12:04pm. 11/10/12 9 12:32am. 11/10/12 8 12:20pm. 11/22/12 8 12:39am. 11/11/12 6 2:56pm. 11/15/12 8 12:46am. 11/16/12 6 3:42pm. 11/17/12 4 1:09am 11/08/12 5 4:42pm. 11/04/12 8 1:13am 11/22/12 5 5:05pm. 11/07/12 4 4:51am. 11/06/12 6 5:06pm. 11/25/12 8 5:49am. 11/29/12 7 5:07pm. 11/29/12 5 8:55am 11/13/12 5 5:19pm. 11/28/12 5 9:11am. 11/19/12 8 5:23pm. 11/20/12 6 9:19am 11/14/12 8 5:28pm. 11/27/12 5 9:23am. 11/25/12 8 5:38pm. 11/23/12 5 9:30am 11/28/12 9 6:15pm. 11/21/12 6 9:37am. 11/26/12 8 December 2012 12:44am. 12/10/12 10 12:20p.m. 12/2/12 8 1:45am. 12/09/12 5 12:20p.m. 12/10/12 8 4:44am. 12/03/12 5 12:27p.m. 12/01/12 8 5:01am 12/02/12 5 4:28p.m. 12/09/12 9 5:27am. 12/06/12 6 5:00p.m. 12/08/12 8 8:57am. 12/05/12 9 5:24p.m. 12/07/12 6 9:18am. 12/09/12 8 6:29p.m. 12/06/12 5 9:23am. 12/08/12 8 6:48p.m 12/10/12 6 9:31am. 12/07/12 8 Review of Resident #75's Activities Progress Notes dated 10/03/12 written by S11Activity Director(AD) stated Resident #75 was doing well. He remained in bed all day. S11AD visits resident 1-3 times a week providing activities such as one/one conversation, memory enhancement (twice) and sensory-stimulation (Balloon Volley). Resident also enjoyed watching TV; talk shows. Resident participate 15-30 minutes of each activity provided. An interview was held with S11ActivityDirector on 12/13/12 at 11:45 a.m. She said that around the end of October or maybe the 1st of November, 2012. Resident #75 stopped participating in his room activities. She said he did not verbally say he was in pain, but she could tell many times he was because she had spend a lot of time with him. S11Activity Director said that Resident #75 would become less focus, quiet and stares off in another direction when he was in pain. She also said she started reading books and magazines to him, but he would no longer participate in balloon volley or any kind of movement exercises.

Based on observation, record review, interviews the facility failed to ensure the nurses do not draw a line through the pharmacy label on medication ([MEDICATION NAME]) dispensed to the facility for 1(#75) of 10 (#75, #61, #116, #133, #130, #79, #110, #84, #26, #120) residents observed during the medication pass,. This resulted in an actual harm when Resident #75 had continuous break through pain and did not received the hospice physician ordered pain medication of [MEDICATION NAME] 10mg give 20cc per Tube q 6 hours as needed for pain between 10/31/12 and 12/12/12 and had prior pain scale levels averaging from 6 to 10 on a pain scale of 1-10 with 10 being the worse pain. The resident was no longer sitting up in chair, became bedbound and unable to swallow over the last month. Also the resident stop participated in room activities around the end of October, 2012 to the 1st week of November, 2012. Findings: Review of the Fundamental of Nursing, Standards and Practice, Third Edition, S.C. Delaune and P.K. Ladner, 2006, revealed in part on page 788, Guidelines for Medication Administratin...."To protect the client from medications errors, nurses have traditionally used as a guide the "five rights" of drug administration: 1. Right drug 2. Right dose 3. Right client 4. Right route 5. Right time... Review of verbal order taken and written per hospice admit nurse stated as follow: 10/31/12 at 3:05 p.m., [MEDICATION NAME] 7.5/500/15cc give 10ml q 6 hours prn. Review of the Hospice Physician order [REDACTED]. During an interview with S10LPN on 12/11/12 at 11:32 a.m., she revealed that Residents #75's [MEDICATION NAME] label had been written as a 20cc dose. She said that there was a written order from the Hospice Nurse which read [MEDICATION NAME] 10cc. S10LPN said that someone crossed the 20ccs out and hand wrote 10 cc on the bottle label. S10LPN said this was the way all of Resident #75's [MEDICATION NAME] medication bottles were done, beginning with first bottle delivered on 10/31/12. She also said that she nor any of the other nurses had contacted the pharmacy or the hospice physician for clarification of the order since they had a written order on Resident #75's chart which read, [MEDICATION NAME] 7.5/500/15cc give 10ml q 6 hours prn. She also confirmed said that Resident #75 was receiving 1/2 the dosage of what the pharmacy had been sending for his pain. S10LPN said it was not protocol for them to write on the pharmacy labels. She said that when something like this happen they are to notify the pharmacy for clarification and to get a new label, if the label was mislabeled On 12/11/12 at 11:50 a.m., a medication pass observation was done of S10LPN and administering Resident #75 his [MEDICATION NAME]. Prior to the actual medication pass a review of the resident's [MEDICATION NAME] medication bottle was made. The label on the bottle revealed Resident #75's name and the date of 11/23/12. The label also revealed 20cc per tube every 6 hours as needed for pain; [MEDICATION NAME]-APAP. Review of the label revealed that there was a line was crossed through the 20 cc on the label and 10cc was hand written on the label in black ink. S10LPN asked the resident to rate his pain and he stated "7." She also asked him was it still in his hands this time and he said "yes." S10LPN proceeded to administer the [MEDICATION NAME] 10 cc per tube, as well as the scheduled tube feedings. An interview was held with S13Corporate Nurse on 12/11/12 at 12:40 p.m. in the 4th floor nurses' station. She said that she had just spoken the Hospice Administrator. She also said that the administrator said that the hospice admit nurse may had intended to write [MEDICATION NAME] 10 mg, but wrote 10 ml on Resident #75 pain medication order dated 10/31/12. S13Corporate Nurse did not present any clarification regarding Resident #75 [MEDICATION NAME] order from the hospice physician nor the facility's pharmacy. An interview was held with the facility's Pharmacist on 12/12/12 at 11:25 a.m. He said that on 10/31/12 he had received a hard copy from the hospice physician's office for [MEDICATION NAME] for Resident #75. He also said that the copy read [MEDICATION NAME] 10mg per tube q 6 hours. The Pharmacist said in order for the resident to receive 10mg of the [MEDICATION NAME], 20cc must be administered to the resident. He said that he filled the order and delivered the medications to the facility on [DATE] and 11/23/12. The Pharmacist said he received a new pain medication order on 12/05/12 from the hospice physician office. He said the hard copy stated [MEDICATION NAME] 20cc q 4hours, which was filled and delivered to the facility on the same day (12/05/12). The pharmacist said that he was never contacted or questioned about either of the hospice physician's orders [REDACTED]. An interview was held with Resident #75's Hospice Physician on 12/13/12 at 8:15 a.m.. He said that he admitted Resident #75 to hospice on 10/31/12. He said that he was told by the hospice nurse that the resident was having pain. He also said that he ordered [MEDICATION NAME] 20cc/10mg per tube q 6 hours to assist with pain control and the resident's comfort. The Hospice Physician said his office sent the prescription directly to the facility's pharmacy. He also said about two weeks ago he was contacted by the hospice nurse informing him that Resident #75 was having break through pain, so he ordered [MEDICATION NAME] 20cc/10mg per tube q 4 hours in hopes this will give him faster and more relief and he would not have to wait q 6 hours for pain medications. The Hospice Physician said that this second pain order was also written on a prescription and sent to the pharmacy and the hospice nurse/agency received a copy also. He also said that the hospice nurse usually get the order to the facility on ce he gives them an order on a resident.

Based on interviews and record review the facility failed to ensure that there was adequate supervision/monitoring and assistive devices in place for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents to prevent falls for a cognitively impaired resident. The facility failed to ensure that fall interventions for a cognitively impaired resident were appropriately modified to meet her needs and understanding by failing to: 1. Ensure that supervision/monitoring was increased for a resident with a history of falls on 5/1/12, 9/13/12 and 10/20/12. (#2) 2. Reassess a cognitively impaired resident's level of understanding once instruction/reminders were given not to get up out of the chair without assistance, and the resident fell while trying to get out of the wheelchair on 9/13/12 and 10/20/12 . (#2) 3. Ensure that Resident #2 was assessed and monitored after a fall on 10/20/12. 4. Identify and implement appropriate fall interventions for a cognitively impaired resident who was known to unbuckle her wheelchair seatbelt after falls on 5/1/12, 9/13/12, and 10/20/12. (#2) 5. Ensure that the registered nurse conducted a complete physical assessment including an assessment of the lower extremities on a resident who fell from her wheelchair on 10/20/12. (#2) 6. Continue to monitor a resident (#2) on 10/20/12 after 8:40 p.m. after it was noted at that time that her right leg was swollen and warm to touch following a fall from her wheelchair. Resident #2 had the [DIAGNOSES REDACTED]. The immediate jeopardy began on 9/13/12 at 8:00 a.m. when Resident #2 fell out of her wheelchair and her seatbelt was not fastened. As a result she hit her forehead on the dresser. The interventions after the fall consisted of the following: encouraged resident to keep seatbelt on, encouraged resident to use call light, and encouraged resident to use her reacher. Review of the plan of care revealed Resident #2 was at risk for falls related to impaired cognition, and it also revealed that she was forgetful. Review of the quarterly minimum data set (MDS) with assessment reference date (ARD) of 9/11/12 revealed she had a Brief Interview for Mental Status (BIMS) score of 10 which revealed she was moderately cognitively impaired, and she required extensive assistance of 2 persons for transfers. The facility failed to update the plan of care with cognitively appropriate interventions to prevent her from falling from the wheelchair. On 10/20/12 at 3:07 p.m. Resident #2 was found on the bathroom floor with her wheelchair in the bathroom doorway by S7CNA. S6RNSupervisor failed to complete an assessment of Resident #2's bilateral lower extremities. S8LPN failed to continue to monitor Resident #2 after 8:40 p.m. at which time she had noted Resident #2's right leg was swollen and warm to touch. S3ADON observed Resident #2 at 11:00 p.m. and noted her right leg was swollen with a deformity above the knee. Review of the hospital's radiology results dated 10/21/12 revealed Resident #2 had a distal shaft right femur with acute, displaced, comminuted fracture. The Immediate Jeopardy (IJ) ended on 10/20/12 at 11:22 p.m. when she was transferred to the hospital. The Assistant Administrator was informed of the IJ for Resident #2 on 11/7/12 at 8:10 a.m. The deficient practice remained at a scope and severity of Isolated Actual Harm for Resident #2. Findings: Resident #2 Review of the clinical record revealed Resident #2 had the following Diagnoses: [REDACTED]. Review of the quarterly MDS with ARD of 9/11/12 revealed the following: Usually makes self understood; Understands others; BIMS score of 10 (cognitive impairment); transfer - extensive assistance of 2 persons; personal hygiene - extensive assistance of one person; toilet use - extensive assistance of 2 persons; bathing - extensive assistance of 1 person; always incontinent of bowel and bladder. Review of Resident #2's Incident Report revealed the following: Date: 11/8/11 Time: 6:50 p.m. Incident Type: Fall no Head injury Type of injury: Fracture Activity at Time: Other Narrative of incident and description of injuries: E... H..., summoned to room by other nurse upon entering the room it was reported that Resident #2 had unfastened her seat belt in an attempt to take her shirt off. While attempting to do this she fell out of her wheelchair. Dr. S ... present and x-ray ordered. X-ray results are abnormal showing fracture to the left hip. Resident sent to ER for further treatment; Immediate Actions Taken: Dr. S ... here at the time of the incident and new orders obtained for x-ray. When results came ordered Resident #2 go to ER for further evaluation. Physician notified: M ... S ... 11/8/11 at 6:50 p.m. Family notified: M ... B ... 11/8/11 at 9:30 p.m. Medical risk factors possibly r/t incident: fall history, arthritis / osteoporosis, fracture, and incontinency. Immediate Post- Incident Action: Resident returned from ER with orders for bed rest and Physical Therapy (PT)/Occupation Therapy (OT) to evaluate and treat as indicated. Narrative of Investigation: On 11/8/11 Resident #2 had a fall from her wheelchair in which resulted in a fracture of her left hip. Resident #2 reports that she unfastened her seatbelt and attempted to take her shirt off. Due to her poor trunk control she fell out of the wheelchair onto the floor causing a fracture to her left hip. Dr. S ... was present at the time of the incident and ordered the x-ray and when the results came back she then ordered resident to go to the ER. She returned from ER with orders for bed rest and for PT/OT to evaluate. Date: 5/1/12 Time: 2:51 p.m. Incident Type: Fall with Head injury Type of injury: Hematoma Activity at Time: Reaching Narrative of incident and description of injuries: Resident wheeled herself into bathroom. Her watch band broke; she leaned over to pick it up, lost her balance falling to floor. Patient (Pt) hit head on floor. Hematoma to right forehead. Immediate Actions Taken: Assessment, range of motion (ROM), ice pack to right forehead, notified MD and family. Physician notified: M ... S ... 5/1/12 at 3:00 p.m. Family notified: M ... B ... 5/1/12 at 3:01 p.m. Medical risk factors possibly r/t incident: fall history, arthritis / osteoporosis, sensory limitations, incontinency, confusion/disorientation, and bowel & bladder (B&B) urgency. Immediate Post- Incident Action: Given a reacher. Narrative of Investigation: Resident had just been transferred from toilet to wheelchair by CNA. The CNA went back into the bathroom to retrieve something and while she did Resident #2 bent over to get her watch that had fallen to the floor. She fell while reaching for her watch. Resident given a reacher. After speaking with son, decided to add lap tray and discontinue (d/c) seatbelt. Date: 9/13/12 Time: 8:00 a.m. Incident Type: Fall with Head injury Type of injury: none apparent Activity at Time: Reaching Narrative of incident and description of injuries: Resident was up in wheelchair. She was reaching down to get towel and fell out of wheelchair. She hit her forehead on the dresser. No bumps or bruising noted on her head. ROM done to all extremities. No complaint of pain or discomfort voiced or noted. Seatbelt was not fastened. Immediate Actions Taken: Seatbelt applied and reacher given to resident. Call light in place. Physician notified: M ... S ... 9/13/12 at 8:31 a.m. Family notified: M ... B ... 9/13/12 at 8:53 a.m. Medical risk factors possibly r/t incident: fall history, arthritis / osteoporosis, failure to thrive. Immediate Post- Incident Action: Encouraged resident to keep seatbelt on. Encouraged resident to use call light when she needs something and not to reach down. She has a reacher so she doesn't have to bend over. Encouraged resident to use it. Resident verbalized understanding and return demonstrated using the reacher; call light, and fastening seatbelt. Incident Investigation: Seatbelt applied and reacher given to resident. Call light in place. Date: 10/20/12 Time: 3:07 p.m. Incident Type: Fall / no head injury Type of Injury: Fracture Location: Resident room Activity at time: To / from bathroom alone Narrative of incident and description of injures: Resident was in the bathroom to clean up (stated she felt like she needed to be cleaned). Was reaching for washcloth, fell out of wheelchair. Found lying on L side on floor. Resident awake, alert, confused at times. Upon initial assessment no visible injury observed. Resident with no complaints of pain. CNA reported swelling to right knee at 7 p.m. Upon assessment, noted swelling to right knee and warm to touch. Resident with no complaints of pain. MD notified of findings and new orders received. Family notified as well. Immediate Actions Taken: Resident assessed and placed back into wheelchair with assistance X 2. Self release seatbelt applied. Vital signs obtained. No complaints of pain at this time. CNA assisted resident with ADL needs. Actions Taken: First Aid by S6RNSupervisor on 10/20/12 at 3:07 p.m. temperature (T) 97.4, pulse (P) 95, respirations (R) 18, blood pressure (B/P) 105/64, pain scale = 0; Physician notified - M ... S ... on 10/20/12 at 7:15 p.m. Family notified - M ... B ... on 10/10/12 at 7:15 p.m. Taken to Hospital: Local Hospital...; Disposition: ER / return to facility Meds taken during last 8 hours - cardiovascular / antihypertensives, analgesics / narcotics, laxatives/ cathartics; Medical Risk Factors possibly related to incident: fall history, inability to understand directions, arthritis / osteoporosis, confusion / disorientation, and incontinency. Immediate Post- Incident Action: Resident assessed and placed back into wheelchair with assistance x 2. Explained to resident that she needs to call for assistance when she wants to be cleaned. Resident verbalized understanding. Bathroom items placed within reach. Incident Investigation: 1. Resident uses self-release seatbelt as safety device. Resident is non-compliant with seatbelt. 2. Resident currently being treated for [REDACTED]. 3. X-ray of R knee ordered = femur fracture. 4. Resident with history of osteoarthrosis and failure to thrive. Review of the Departmental Notes revealed the following: 9/13/12 9:19 a.m. Resident was sitting in her room in her wheelchair. She was reaching over trying to get a towel and fell out of wheelchair. Seatbelt was not on. Resident was assisted back to her chair after exam. ROM to all extremities. She stated she hit her head on dresser on L forehead no redness bumps or bruising noted on head or any part of body. Called placed to Dr. S ... concerning fall. Waiting for return call. Left message on son's, M ..., answering machine. Resident has zero complaint of pain or discomfort. Will monitor. 9/13/12 10:16 a.m. Returned call about resident fall. She states observe resident with neuro checks for at least 24 hours. I explained we were doing 72 hour neuro checks already. She states OK. No other orders. 9/14/12 10:08 a.m. Resident has zero complaint of pain or discomfort from fall. Up in wheelchair. Can propel self. Takes medications with water. Can feed self. Appetite is OK. Oriented times three. Can recall cat, bat, ball after 5 minutes. Needs assist with transfers and changing brief. Incontinent of bowel and bladder. Will continue to monitor. No acute distress (NAD). No bumps or bruising from fall. Can make needs known. Family visits weekly. 10/20/12 11:46 p.m. Late entry for 10/20/12 at 3 p.m. - Resident lying in bed, neuro checks begun. 10/20/12 11:48 p.m. Late entry for 10/20/12 at 7 p.m. - CNA reported swelling to resident's R knee to LPN. Site immobile, enlarged, warm to touch. Resident denied pain. Call to MD, New order noted. 10/21/12 12:02 a.m. Late entry for 10/20/12 at 7:15 p.m. - Call to resident's family. 10/22/12 2:33 a.m. Late entry for 10/20/12 at 7:15 p.m. - Call to MD's office. The initial call placed to MD's office regarding incident. 10/22/12 3:12 a.m. Late entry for 10/20/12 at 8:40 p.m. - Dr. S ... notified, and spoken to regarding resident's swollen, warm knee. New order noted. 10/22/12 3:58 a.m. Late entry for 10/20/12 at 8:40 p.m. - CNA reported swelling to resident's R knee, to LPN. Site immobile, enlarged, warm to touch. Resident denied pain. 10/22/12 3:15 p.m. I was called to room ... by S7CNA who found Resident #2 on the bathroom floor. Resident was not in distress at that time. S7CNA and I moved the wheelchair that was blocking the doorway so we could get in and put Resident #2 back in her chair. Resident #2 denied pain before the transfer back to her chair. She didn't cry out in distress during the lift, and she stated she was not in pain after she was securely sitting in the wheelchair, seatbelt fastened. S7CNA remained with resident while I got the V.S. machine, and when I returned, she went to notify S8LPN about her resident. Vitals at 14:45 were: 97.4, 95, 105/64, 18, 95% oxygen (O2) saturation. I wrote these vital signs (VS) on a piece of paper and handed them to S8LPN when she arrived in Resident #2's room and filled her in on what happened. On 10/21/12 at 11:22, I notified C ... Hospice of Resident #2's subsequent hospitalization . 10/22/12 4:17 p.m. The following note dated 10/22/12 is a late entry from an occurrence on 10/20/12. 10/23/12 9:54 a.m. Late entry for 10/20/12 11:00 p.m. Upon arriving to work and getting report from S8LPN she reported that Resident #2 had a fall in the bathroom and that her knee had begun swelling and she had obtained an order for [REDACTED]. S .... At this point the x-ray tech arrived to obtain the x-ray. I accompanied the x-ray tech to the room to assist him. Upon observation of her right, leg swelling was noted and a deformity above the knee was also noted. X-ray tech obtained x-ray. I asked Resident #2 if she was any pain and she denied pain I then notified Dr. S ... of the swelling and deformity. She gave an order to send to ER for eval. I then called M ... B ... (son) and notified him of her being transferred to ER for evaluation of her leg. He stated that he would meet her there. A ... ambulance was notified for transfer. Review of the Physician order [REDACTED]. 10/9/12 1014 a.m. D/C ? side rails (order clarification); Full side rails X 2 for repositioning r/t right sided hemiparesis and per family request and per resident request; Self-release seat belt while up in w/c to remind resident not to get up without assistance 10/20/12 8:40 p.m. May x-ray right knee; Ice to site as needed (PRN). 10/20/12 11:21 p.m. Send to ER for evaluation Review of the hospital's radiology results dated 10/21/12 revealed distal shaft right femur with acute, displaced, comminuted fracture. Review of the physician's exam performed at the hospital revealed the following: tender to palpation over right anterior thigh; exam over the right anterior thigh demonstrates a mild to moderate amount of swelling /effusion; exam reveals significant deformity and angulation of the right anterior thigh of approximately 25 degrees; and obvious deformity of distal femur. Review of the Fall Risk assessment dated [DATE] revealed the following: Alert; 1-2 falls in past 3 months; Chair Bound - and/or assist with elimination; vision status adequate; Group Total: 10; Resident added to program; 10 or above = high risk; Added to fall prevention program. Therapy to screen. Staff in-serviced resident on using her reacher. Review of the Care Plan revealed the following in part: Problem Onset: 1/10/12 I am incontinent of urine and bowel. I need extensive assistance with bed mobility. Goal & Target Date: I will not experience any skin conditions from incontinence 12/25/12. Approaches: Provide me incontinence pads as needed. Watch me for environmental factors that may contribute to incontinence. Assist me with perineal cleansing as needed. Provide me verbal cueing. Problem Onset: 1/10/12 I am at risk for falls r/t history of falls, impaired cognition, psychotropic medication use, requiring assistance with transfers. I need extensive assistance with transfers. Some time I will try to get up without assistance. I have a seatbelt to cue me for safety awareness due to my dx of [DIAGNOSES REDACTED]. 9/13/12 Actual fall Resident was reaching down to get a towel and fell out of wheelchair. She hit the front of her head. 10/20/12 Fall in bathroom from w/c reaching down to get washcloth. Goal & Target Date: Will assist resident to eliminate falls thru 12/25/12. Approaches: Encourage to use the reacher 9/13/12. Encourage to use the call light 9/13/12. Seatbelt while in wheelchair. Remind me to ask for assist for all transfers. Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician. I need my pathway in my room free of clutter. Fall mat at side of bed. 4/14/11 full side rail on the left side per my request. 9/13/12 Encourage to keep seatbelt on. 10/21/12 Encouraged to call for assistance with ADL needs. Resident verbalized understanding. 10/20/12 Placed bathroom items within reach. Problem Onset: 1/10/12 I experience the presence of pain r/t inoperable left hip fracture and osteoarthritis. 9/11/12 My pain is being controlled with my medication. Goal & Target Date: I will verbalize decreased frequency / intensity of pain 12/25/12. Approaches: Evaluate my pain daily using 1-10 scale. Administer my pain medication as ordered. Problem Onset: 1/10/12 I require staff assistance for ADL's. I require total care to extensive assistance with ADL's r/t dx of CVA with [DIAGNOSES REDACTED] and right lower extremity contracture. Goal & Target Date: I will increase independence with ADL's. 12/25/12 Approaches: Assist me to the sink to perform hygiene and grooming tasks. I require assistance with transfers. Problem Onset: 1/10/12 I have cognitive loss r/t BIMS score and I am forgetful I have trouble recalling what I ate 5 minutes after meals. Goal & Target Date: I will maintain my cognitive function without decline. 12/25/12. Approaches: Give verbal cues / reminders when I cannot remember. Problem Onset: 1/10/12 I require staff assistance for ADL's. I require total care to extensive assistance with ADL's r/t dx of CVA with [DIAGNOSES REDACTED] and right lower extremity contracture. Goal & Target Date: I will increase independence with ADL's. 12/25/12. Approaches: I prefer morning bed baths. Give me verbal cues to help prompt me. Break my tasks up into smaller steps. Allow me rest breaks between tasks. Assist me with bathing. Place my supplies on the bedside table within reach. Assist me to the sink to perform hygiene and grooming tasks. I require assistance with bed mobility. I use a wheelchair for long distance mobility. Assist me by placing my selected clothing on the bed. I need help with the buttons, zippers, and snaps. I require assistance with transfers. Transfer me on my strong side. Assist me with adjusting my clothing. Help me open up container and cut up food. Problem Onset: 1/10/12 I am at high risk for skin breakdown r/t incontinence and requiring assistance with bed mobility. . Goal & Target Date: I will remain free of skin breakdown. 12/25/12. Approaches: Reposition me every 2 hours while in bed and as needed. Problem Onset: Task Care Plan Goal & Target Date: Tasks Complete. Approaches: Bowel, bladder, am/pm care, bath M-W-F on 6-2 shift, meals, snack, pain, skin, sleep, pain assessment, dehydration monitoring, nursing summary and body audit every Monday on 2-10 shift, vital signs every 4 weeks on Tuesday on 6-2 shift, weight every 4 weeks on Tuesday on 6-2 shift, a low bed with fall mat (monitor q shift). Review of the urinalysis dated 10/17/12 revealed white blood cells (WBC) too numerous to count (TNTC) (normal 0-5), red blood cells (RBC) 5-10 (normal 0-2), bacteria 3+ (normal none). Review of the Therapy Screening Forms revealed the following: 2/15/12 - status: care plan update; OT therapy not indicated and Pt on hospice; PT not indicated, Pt recently d/c from PT. 3/12/12 - status: care plan update; OT not indicated and Pt on hospice; PT not indicated. 6/1/12 - status: care plan update; OT not indicated; PT not indicated. 10/22/12 - Status: fall; OT - currently in hospital, will re-screen upon return; PT - at hospital. Review of the OT evaluation & plan of treatment revealed the following: Certification period - 11/10/11 - 1/8/12 Short-term goals - Patient will increase BUE strength to 4/5 to facilitate patient's ability to perform functional activities for 20 minutes. Patient will perform functional problem solving with minimal/close supervision and 35% verbal cues in order to increase safety during daily living tasks and safely participate with functional activities. Long-term goals - Patient will have good activity tolerance to complete safe stand by assistance activities of daily living/independent activities of daily living tasks from w/c height. Review of the PT evaluation & plan of treatment revealed the following: Certification period - 11/11/11 - 1/9/12 Short-term goals - Patient will increase dynamic sitting balance to Poor + spontaneously righting self when needed in order to prepare for transfers. Patient will safely perform bed mobility tasks with max assistance without use of side rails for safety awareness in order to get in/out bed. Long-term goals - Patient will safely perform bed mobility tasks with contact guard assistance without use of side-rails for safety awareness in order to get in/out of bed Review of the PT discharge summary revealed ...Patient Response - Progress & Response to treatment (tx): Patient made very minimal progress, tolerated tx fairly and is discharged at this time due to enrollment with hospice services. An interview was held with S22RehabDirector on 11/7/12 at 9:15 a.m. After reviewing Resident #2's clinical record, she verified that Resident #2 had the following therapy screening referrals: 2/15/12 for care plan update referral - OT not indicated, patient recently d/c from PT on 12/15/11.; 3/12/12 for care plan update referral - therapy not indicated because she was hospice; 6/1/12 for care plan update referral - therapy not indicated due to hospice; 10/22/12 for fall screen referral - did not screen because never came back from hospital. She said that Resident #2's certification period for therapy was 11/11/11 until discharge on [DATE]. She said according to the PT notes, Resident #2 was discharged because she was picked up by hospice and she made very minimal progress. She said the notes did not reveal why she made minimal progress, and she said the therapist no longer worked at the facility. An interview was held with S24ActivityDirector on 11/8/12 at 11:00 a.m. She said that she would make room visits to Resident #2 two to three times a week. She said that staff did not direct her to visit her more often. An interview was held with Dr. S ... on 10/23/12 at 2:40 p.m. She said she had a non urgent message on 10/20/12 around 5 p.m. that Resident #2 had a fall with no injuries. She said that she did not remember who it was from. She said it was described as a nontraumatic fall with no injuries. She said that she got an urgent call at 9:15 p.m. from S8LPN, and she said now it looked like the right knee was swelling and warm. Dr. S ... said she ordered an x-ray. She said S3ADON called her around 11:15 p.m. and said it looked like Resident #2 had an obvious fracture. Dr. S ... said she told S3ADON to send Resident #2 to the emergency room for an evaluation. An interview was held with S3ADON on 10/23/12 at 2:50 p.m. She said S8LPN gave her report on 10/20/12 and told her Resident #2 had fallen and her right knee was swollen. She said at the end of report the x-ray technician arrived, and she assisted him with the x-ray. She said that she observed the right leg, and it was swollen and looked deformed. An interview was held on 10/24/12 at 9:16 a.m. with S5MDSCoordinator. After reviewing Resident #2's MDS, she verified that Resident #2 is usually understood and understands others, has adequate vision with no corrective lenses, can repeat 3 words with cueing, knew correct year, and had a BIMS score of 10 which meant moderate cognitive impairment. After reviewing Resident #2's care plan, S5MDSCoordinator explained that Resident #2 had a fall on 9/13/12. She said that Resident #2 fell out of the wheelchair while reaching down to get a towel. She said there were no injuries. She said that after the fall Resident #2 was encouraged to keep her seatbelt on and use her call light and reacher. She said that resident #2 had another fall on 10/20/12 in the bathroom while reaching for a wash cloth and fell out of the wheelchair. S5MDSCoordinator said Resident#2 was encouraged to call for assistance with ADLs, and she was able to verbalize understanding. She said they also placed her bathroom items within reach. She also verified that the care plan revealed that Resident #2 was forgetful and had trouble recalling. S5MDSCoordinator said that on 10/16/12 Resident #2 was also diagnosed with [REDACTED]. She explained that the UTI messes up her cognition and she may not be as alert and sharp as would be. She said when they have UTIs the elderly will do things that are not normal for them. After reviewing the care plan she verified that it did not reveal to increase supervision. An interview was held with S6RNSupervisor on 10/24/12 at 9:31 a.m. She said around 3 p.m. on 10/20/12 S7CNA told her Resident #2 was on the floor. She said Resident #2 was found in the bathroom on her left side with the wheelchair in the bathroom also. S6RNSupervisor said Resident #2 said she was okay and denied hurting. She said Resident #2 did not know how long she had been down on the floor. S6RNSupervisor said that Resident #2 did not grimace or complain of (c/o) pain when they put her back in her w/c. She said that she obtained her vital signs, and they were perfect. S6RNSupervisor explained that S8LPN, Resident #2's assigned nurse, came into Resident #2's room, and she gave Resident #2's vital signs to S8LPN and left the room. S6RNSupervisor said she did not assess Resident #2's lower extremities, because she thought S8LPN would do that, and she got called away from the room. She said that she was called away to a routine task, and it was not another emergency. S6RNSupervisor explained there was a spoon on the floor in the bathroom and Resident #2 may have been trying to pick it up. She said that Resident #2 knew how to undo her seatbelt; she had a history of [REDACTED]. S6RNSupervisor explained that Resident #2 had a previous fall while reaching for something. She said that she was the weekend supervisor. S6RNSupervisor said that her responsibility was to assist the staff nurse when a resident had a fall. She explained the LPNs could assess a resident unless it was a new admit or a new skin issue, and then she had to assess the resident. An interview was held on 10/24/12 at 10:08 a.m. with S7CNA. She said that she had been employed at the facility for almost 2 years, and she usually took care of Resident #2. She explained that at times Resident #2 was confused and other times she was alert and oriented. She explained that Resident #2 would undo her seatbelt and get up without assistance at times. She said that she had not had any falls this year other than the one in October. She said that Resident #2 wore a seatbelt while she was in her wheelchair. S7CNA explained that she had to go see Resident #2 every 2 hours. S7CNA verified that she found Resident #2 lying on her left side about 2:30 p.m. on 10/20/12 on the bathroom floor, and she reported it to the supervisor. She explained that the supervisor came in, and Resident #2 told her she was not hurting. S7CNA explained that she and S6RNSupervisor put Resident #2 back in her wheelchair and got her vital signs. S7CNA said that Resident #2 never complained of pain. She said there was a spoon on the bathroom floor and Resident #2 may have been trying to get it. S7CNA said she could not understand what Resident #2 said when she asked what happened and how she got on the floor. She said that S9CNA and she placed Resident #2 in bed after they got her vital signs. She explained that Resident #2 was a high risk for falls because she would unbuckle the seatbelt. She said that she told S8LPN at 8:35 p.m. that she needed to check Resident #2 because her leg was big like it was artificial. S7CNA said that Resident #2 had a reacher to get stuff off the floor, but she did not have it with her when she found her on the bathroom floor on 10/20/12. An interview was held with S3ADON on 10/24/12 at 10:34 a.m. She said that she arrived around 11:00 p.m. on 10/20/12 to work, and she received report from S8LPN. She explained that S8LPN told her that Resident #2 had a fall around 3 p.m., her knee began to swell, and she got order for x-ray. S3ADON said after report the x-ray technician arrived which was around 11:05 p.m., and she assisted him with the x-ray. S3ADON said that Resident #2's knee was swollen, and there was a deformity above knee on the right femur. S3ADON said that Resident #2 denied pain. S3ADON said she called Dr. S ... and told her what she saw and asked if they could send Resident #2 to the ER. She said Dr. S ... gave an order to send her to the ER. S3ADON described the leg as being swollen, warm to touch, without bruising, and the femur appeared detached. S3ADON said Resident #2 never c/o pain, moaned, or cried out. S3ADON explained that Resident #2 was a fall risk, and she had a history of [REDACTED]. She said that Resident #2 had a history of [REDACTED]. S3ADON said when she asked Resident #2 what happened to her leg that Resident #2 told her that she wanted to go to the bathroom. S3ADON explained that Resident #2 was incontinent. S3ADON said S8LPN told her that Resident #2 said she wanted to clean herself up. S3ADON said prior to this fall, Resident #2 was packing her clothes and wanted to go home. She said the doctor ordered a urinalysis (UA), and Resident #2 was started on Bactrim. S3ADON said the UA results revealed increased leukocytes and indicated a UTI. An interview was held with S2DON on 10/24/12 at 11:00 a.m. in the presence of S1Administrator and S2ADON. S2DON explained the fall prevention program is initiated if have a resident has a fall. She said the fall prevention program cues the CNAs as to which residents are at risk for falls. She described Resident #2's cognitive status as awake, alert, and confused at times. She said that she did not know her well enough to tell about her memory. S3ADON said that Resident #2's BIMS score was a 10. She said the score of 10 means that she had moderate cognitive impairment. S2DON said that Resident #2 was able to recall after cueing. After reviewing the clinical record, S2DON explained that on 9/13/12 Resident #2 was up in her w/c and reached down to get a towel and fell out of her w/c. She said that she hit her head, but there were no bumps or bruising. She said it also revealed that Resident #2's seatbelt was not fastened. She said after the fall they encouraged the resident to keep the seatbelt on and gave her a reacher after the fall. After reviewing the incident report, she said that Resident #2 already had the reacher, and they encouraged her to use it and encouraged her to use the call light, and encouraged her to keep the seatbelt on. S2DON said on 10/20/12 Resident #2 had anoth

Based on record reviews and interviews, 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 practicable physical well-being for 1 (#2) of 5 (#1, #2, #3, #4, & #5) sampled residents after a fall. Administration failed to: 1. Have a system in place to ensure that nursing staff assessed and implemented protective measures for cognitively impaired residents who had been assessed as being at risk for falls.(#2) 2. Have a system in place to ensure that supervision/monitoring was increased for a resident with a history of falls on 5/1/12, 9/13/12, and 10/20/12. (#2) 3. Have a system in place to ensure a cognitively impaired resident's level of understanding was reassessed once instruction/reminders were given not to get up out of the chair without assistance, and the resident fell while trying to get out of the wheelchair on 9/13/12 and 10/20/12 . (#2) 4. Have a system in place to ensure that a resident was assessed and monitored after a fall on 10/20/12. (#2) 5. Have a system in place to ensure that appropriate fall interventions were identified and implemented for a cognitively impaired resident who was known to unbuckle her wheelchair seatbelt after falls on 5/1/12, 9/13/12, and 10/20/12. (#2) Resident #2 had the [DIAGNOSES REDACTED]. The immediate jeopardy began on 9/13/12 at 8:00 a.m. when Resident #2 fell out of her wheelchair and her seatbelt was not fastened. As a result she hit her forehead on the dresser. The interventions after the fall consisted of the following: encouraged resident to keep seatbelt on, encouraged resident to use call light, and encouraged resident to use her reacher. Review of the plan of care revealed Resident #2 was at risk for falls related to impaired cognition, and it also revealed that she was forgetful. Review of the quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/11/12 revealed she had a Brief Interview Mental Status (BIMS) score of 10 which revealed she was moderately cognitively impaired, and she required extensive assistance of 2 persons for transfers. The facility failed to update the plan of care with cognitively appropriate interventions to prevent her from falling from the wheelchair. On 10/20/12 at 3:07 p.m. Resident #2 was found on the bathroom floor with her wheelchair in the bathroom doorway by S7CNA. S6RNSupervisor failed to complete an assessment of Resident #2's bilateral lower extremities. S8LPN failed to continue to monitor Resident #2 after 8:40 p.m. at which time she had noted Resident #2's right leg was swollen and warm to touch. S3ADON observed Resident #2 at 11:00 p.m. and noted her right leg was swollen with a deformity above the knee. Review of the Local Hospital's radiology results dated 10/21/12 revealed Resident #2 had a distal shaft right femur with acute, displaced, comminuted fracture. The Immediate Jeopardy (IJ) ended on 10/20/12 at 11:22 p.m. when she was transferred to the hospital. The Assistant Administrator was informed of the IJ for Resident #2 on 11/7/12 at 8:10 a.m. The deficient practice remained at a scope and severity of Isolated Actual Harm for Resident #2. Findings: Resident #2 Review of the clinical record revealed Resident #2 had the following Diagnoses: [REDACTED]. Review of the quarterly MDS with ARD of 9/11/12 revealed the following: Usually makes self understood; Understands others; BIMS score of 10 (cognitive impairment); transfer - extensive assistance of 2 persons; personal hygiene - extensive assistance of one person; toilet use - extensive assistance of 2 persons; bathing - extensive assistance of 1 person; always incontinent of bowel and bladder. Review of Resident #2's Incident Report revealed the following: Date: 11/8/11 Time: 6:50 p.m. Incident Type: Fall no Head injury Type of injury: Fracture Activity at Time: Other Narrative of incident and description of injuries: E... H..., summoned to room by other nurse upon entering the room it was reported that Resident #2 had unfastened her seat belt in an attempt to take her shirt off. While attempting to do this she fell out of her wheelchair. Dr. S ... present and x-ray ordered. X-ray results are abnormal showing fracture to the left hip. Resident sent to ER for further treatment; Immediate Actions Taken: Dr. S ... here at the time of the incident and new orders obtained for x-ray. When results came ordered Resident #2 go to ER for further evaluation. Physician notified: M ... S ... 11/8/11 at 6:50 p.m. Family notified: M ... B ... 11/8/11 at 9:30 p.m. Medical risk factors possibly r/t incident: fall history, arthritis / [MEDICAL CONDITION], fracture, and incontinency. Immediate Post- Incident Action: Resident returned from ER with orders for bed rest and Physical Therapy (PT)/Occupation Therapy (OT) to evaluate and treat as indicated. Narrative of Investigation: On 11/8/11 Resident #2 had a fall from her wheelchair in which resulted in a fracture of her left hip. Resident #2 reports that she unfastened her seatbelt and attempted to take her shirt off. Due to her poor trunk control she fell out of the wheelchair onto the floor causing a fracture to her left hip. Dr. S ... was present at the time of the incident and ordered the x-ray and when the results came back she then ordered resident to go to the ER. She returned from ER with orders for bed rest and for PT/OT to evaluate. Date: 5/1/12 Time: 2:51 p.m. Incident Type: Fall with Head injury Type of injury: Hematoma Activity at Time: Reaching Narrative of incident and description of injuries: Resident wheeled herself into bathroom. Her watch band broke; she leaned over to pick it up, lost her balance falling to floor. Patient (Pt) hit head on floor. Hematoma to right forehead. Immediate Actions Taken: Assessment, range of motion (ROM), ice pack to right forehead, notified MD and family. Physician notified: M ... S ... 5/1/12 at 3:00 p.m. Family notified: M ... B ... 5/1/12 at 3:01 p.m. Medical risk factors possibly r/t incident: fall history, arthritis / [MEDICAL CONDITION], sensory limitations, incontinency, confusion/disorientation, and bowel & bladder (B&B) urgency. Immediate Post- Incident Action: Given a reacher. Narrative of Investigation: Resident had just been transferred from toilet to wheelchair by CNA. The CNA went back into the bathroom to retrieve something and while she did Resident #2 bent over to get her watch that had fallen to the floor. She fell while reaching for her watch. Resident given a reacher. After speaking with son, decided to add lap tray and discontinue (d/c) seatbelt. Date: 9/13/12 Time: 8:00 a.m. Incident Type: Fall with Head injury Type of injury: none apparent Activity at Time: Reaching Narrative of incident and description of injuries: Resident was up in wheelchair. She was reaching down to get towel and fell out of wheelchair. She hit her forehead on the dresser. No bumps or bruising noted on her head. ROM done to all extremities. No complaint of pain or discomfort voiced or noted. Seatbelt was not fastened. Immediate Actions Taken: Seatbelt applied and reacher given to resident. Call light in place. Physician notified: M ... S ... 9/13/12 at 8:31 a.m. Family notified: M ... B ... 9/13/12 at 8:53 a.m. Medical risk factors possibly r/t incident: fall history, arthritis / [MEDICAL CONDITION], failure to thrive. Immediate Post- Incident Action: Encouraged resident to keep seatbelt on. Encouraged resident to use call light when she needs something and not to reach down. She has a reacher so she doesn't have to bend over. Encouraged resident to use it. Resident verbalized understanding and return demonstrated using the reacher; call light, and fastening seatbelt. Incident Investigation: Seatbelt applied and reacher given to resident. Call light in place. Date: 10/20/12 Time: 3:07 p.m. Incident Type: Fall / no head injury Type of Injury: Fracture Location: Resident room Activity at time: To / from bathroom alone Narrative of incident and description of injures: Resident was in the bathroom to clean up (stated she felt like she needed to be cleaned). Was reaching for washcloth, fell out of wheelchair. Found lying on L side on floor. Resident awake, alert, confused at times. Upon initial assessment no visible injury observed. Resident with no complaints of pain. CNA reported swelling to right knee at 7 p.m. Upon assessment, noted swelling to right knee and warm to touch. Resident with no complaints of pain. MD notified of findings and new orders received. Family notified as well. Immediate Actions Taken: Resident assessed and placed back into wheelchair with assistance X 2. Self release seatbelt applied. Vital signs obtained. No complaints of pain at this time. CNA assisted resident with ADL needs. Actions Taken: First Aid by S6RNSupervisor on 10/20/12 at 3:07 p.m. temperature (T) 97.4, pulse (P) 95, respirations (R) 18, blood pressure (B/P) 105/64, pain scale = 0; Physician notified - M ... S ... on 10/20/12 at 7:15 p.m. Family notified - M ... B ... on 10/10/12 at 7:15 p.m. Taken to Hospital: Local Hospital; Disposition: ER / return to facility Meds taken during last 8 hours - cardiovascular / antihypertensives, [MEDICATION NAME] / narcotics, laxatives/ cathartics; Medical Risk Factors possibly related to incident: fall history, inability to understand directions, arthritis / [MEDICAL CONDITION], confusion / disorientation, and incontinency. Immediate Post- Incident Action: Resident assessed and placed back into wheelchair with assistance x 2. Explained to resident that she needs to call for assistance when she wants to be cleaned. Resident verbalized understanding. Bathroom items placed within reach. Incident Investigation: 1. Resident uses self-release seatbelt as safety device. Resident is non-compliant with seatbelt. 2. Resident currently being treated for [REDACTED]. 3. X-ray of R knee ordered = femur fracture. 4. Resident with history of [MEDICAL CONDITION] and failure to thrive. Review of the Departmental Notes revealed the following: 9/13/12 9:19 a.m. Resident was sitting in her room in her wheelchair. She was reaching over trying to get a towel and fell out of wheelchair. Seatbelt was not on. Resident was assisted back to her chair after exam. ROM to all extremities. She stated she hit her head on dresser on L forehead no redness bumps or bruising noted on head or any part of body. Called placed to Dr. S ... concerning fall. Waiting for return call. Left message on son's, M ..., answering machine. Resident has zero complaint of pain or discomfort. Will monitor. 9/13/12 10:16 a.m. Returned call about resident fall. She states observe resident with neuro checks for at least 24 hours. I explained we were doing 72 hour neuro checks already. She states OK. No other orders. 9/14/12 10:08 a.m. Resident has zero complaint of pain or discomfort from fall. Up in wheelchair. Can propel self. Takes medications with water. Can feed self. Appetite is OK. Oriented times three. Can recall cat, bat, ball after 5 minutes. Needs assist with transfers and changing brief. Incontinent of bowel and bladder. Will continue to monitor. No acute distress (NAD). No bumps or bruising from fall. Can make needs known. Family visits weekly. 10/20/12 11:46 p.m. Late entry for 10/20/12 at 3 p.m. - Resident lying in bed, neuro checks begun. 10/20/12 11:48 p.m. Late entry for 10/20/12 at 7 p.m. - CNA reported swelling to resident's R knee to LPN. Site immobile, enlarged, warm to touch. Resident denied pain. Call to MD, New order noted. 10/21/12 12:02 a.m. Late entry for 10/20/12 at 7:15 p.m. - Call to resident's family. 10/22/12 2:33 a.m. Late entry for 10/20/12 at 7:15 p.m. - Call to MD's office. The initial call placed to MD's office regarding incident. 10/22/12 3:12 a.m. Late entry for 10/20/12 at 8:40 p.m. - Dr. S ... notified, and spoken to regarding resident's swollen, warm knee. New order noted. 10/22/12 3:58 a.m. Late entry for 10/20/12 at 8:40 p.m. - CNA reported swelling to resident's R knee, to LPN. Site immobile, enlarged, warm to touch. Resident denied pain. 10/22/12 3:15 p.m. I was called to room ... by S7CNA who found Resident #2 on the bathroom floor. Resident was not in distress at that time. S7CNA and I moved the wheelchair that was blocking the doorway so we could get in and put Resident #2 back in her chair. Resident #2 denied pain before the transfer back to her chair. She didn't cry out in distress during the lift, and she stated she was not in pain after she was securely sitting in the wheelchair, seatbelt fastened. S7CNA remained with resident while I got the V.S. machine, and when I returned, she went to notify S8LPN about her resident. Vitals at 14:45 were: 97.4, 95, 105/64, 18, 95% oxygen (O2) saturation. I wrote these vital signs (VS) on a piece of paper and handed them to S8LPN when she arrived in Resident #2's room and filled her in on what happened. On 10/21/12 at 11:22, I notified C ... Hospice of Resident #2's subsequent hospitalization . 10/22/12 4:17 p.m. The following note dated 10/22/12 is a late entry from an occurrence on 10/20/12. 10/23/12 9:54 a.m. Late entry for 10/20/12 11:00 p.m. Upon arriving to work and getting report from S8LPN she reported that Resident #2 had a fall in the bathroom and that her knee had begun swelling and she had obtained an order for [REDACTED]. I accompanied the x-ray tech to the room to assist him. Upon observation of her right, leg swelling was noted and a deformity above the knee was also noted. X-ray tech obtained x-ray. I asked Resident #2 if she was any pain and she denied pain I then notified Dr. S ... of the swelling and deformity. She gave an order to send to ER for eval. I then called M ... B ... (son) and notified him of her being transferred to ER for evaluation of her leg. He stated that he would meet her there. A ... ambulance was notified for transfer. Review of the Physician order [REDACTED]. 10/9/12 1014 a.m. D/C ? side rails (order clarification); Full side rails X 2 for repositioning r/t right sided [MEDICAL CONDITION] and per family request and per resident request; Self-release seat belt while up in w/c to remind resident not to get up without assistance 10/20/12 8:40 p.m. May x-ray right knee; Ice to site as needed (PRN). 10/20/12 11:21 p.m. Send to ER for evaluation Review of the Local Hospital's radiology results dated 10/21/12 revealed distal shaft right femur with acute, displaced, comminuted fracture. Review of the physician's exam performed at the hospital revealed the following: tender to palpation over right anterior thigh; exam over the right anterior thigh demonstrates a mild to moderate amount of swelling /effusion; exam reveals significant deformity and angulation of the right anterior thigh of approximately 25 degrees; and obvious deformity of distal femur. Review of the Fall Risk assessment dated [DATE] revealed the following: Alert; 1-2 falls in past 3 months; Chair Bound - and/or assist with elimination; vision status adequate; Group Total: 10; Resident added to program; 10 or above = high risk; Added to fall prevention program. Therapy to screen. Staff in-serviced resident on using her reacher. Review of the Care Plan revealed the following in part: Problem Onset: 1/10/12 I am incontinent of urine and bowel. I need extensive assistance with bed mobility. Goal & Target Date: I will not experience any skin conditions from incontinence 12/25/12. Approaches: Provide me incontinence pads as needed. Watch me for environmental factors that may contribute to incontinence. Assist me with perineal cleansing as needed. Provide me verbal cueing. Problem Onset: 1/10/12 I am at risk for falls r/t history of falls, impaired cognition, [MEDICAL CONDITION] medication use, requiring assistance with transfers. I need extensive assistance with transfers. Some time I will try to get up without assistance. I have a seatbelt to cue me for safety awareness due to my dx of [MEDICAL CONDITION]. 9/13/12 Actual fall Resident was reaching down to get a towel and fell out of wheelchair. She hit the front of her head. 10/20/12 Fall in bathroom from w/c reaching down to get washcloth. Goal & Target Date: Will assist resident to eliminate falls thru 12/25/12. Approaches: Encourage to use the reacher 9/13/12. Encourage to use the call light 9/13/12. Seatbelt while in wheelchair. Remind me to ask for assist for all transfers. Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician. I need my pathway in my room free of clutter. Fall mat at side of bed. 4/14/11 full side rail on the left side per my request. 9/13/12 Encourage to keep seatbelt on. 10/21/12 Encouraged to call for assistance with ADL needs. Resident verbalized understanding. 10/20/12 Placed bathroom items within reach. Problem Onset: 1/10/12 I experience the presence of pain r/t inoperable left [MEDICAL CONDITION] and [MEDICAL CONDITION]. 9/11/12 My pain is being controlled with my medication. Goal & Target Date: I will verbalize decreased frequency / intensity of pain 12/25/12. Approaches: Evaluate my pain daily using 1-10 scale. Administer my pain medication as ordered. Problem Onset: 1/10/12 I require staff assistance for ADL's. I require total care to extensive assistance with ADL's r/t dx [MEDICAL CONDITIONS] and right lower extremity contracture. Goal & Target Date: I will increase independence with ADL's. 12/25/12 Approaches: Assist me to the sink to perform hygiene and grooming tasks. I require assistance with transfers. Problem Onset: 1/10/12 I have cognitive loss r/t BIMS score and I am forgetful I have trouble recalling what I ate 5 minutes after meals. Goal & Target Date: I will maintain my cognitive function without decline. 12/25/12. Approaches: Give verbal cues / reminders when I cannot remember. Problem Onset: 1/10/12 I require staff assistance for ADL's. I require total care to extensive assistance with ADL's r/t dx [MEDICAL CONDITIONS] and right lower extremity contracture. Goal & Target Date: I will increase independence with ADL's. 12/25/12. Approaches: I prefer morning bed baths. Give me verbal cues to help prompt me. Break my tasks up into smaller steps. Allow me rest breaks between tasks. Assist me with bathing. Place my supplies on the bedside table within reach. Assist me to the sink to perform hygiene and grooming tasks. I require assistance with bed mobility. I use a wheelchair for long distance mobility. Assist me by placing my selected clothing on the bed. I need help with the buttons, zippers, and snaps. I require assistance with transfers. Transfer me on my strong side. Assist me with adjusting my clothing. Help me open up container and cut up food. Problem Onset: 1/10/12 I am at high risk for skin breakdown r/t incontinence and requiring assistance with bed mobility. . Goal & Target Date: I will remain free of skin breakdown. 12/25/12. Approaches: Reposition me every 2 hours while in bed and as needed. Problem Onset: Task Care Plan Goal & Target Date: Tasks Complete. Approaches: Bowel, bladder, am/pm care, bath M-W-F on 6-2 shift, meals, snack, pain, skin, sleep, pain assessment, dehydration monitoring, nursing summary and body audit every Monday on 2-10 shift, vital signs every 4 weeks on Tuesday on 6-2 shift, weight every 4 weeks on Tuesday on 6-2 shift, a low bed with fall mat (monitor q shift). Review of the urinalysis dated 10/17/12 revealed white blood cells (WBC) too numerous to count (TNTC) (normal 0-5), red blood cells (RBC) 5-10 (normal 0-2), bacteria 3+ (normal none). Review of the Therapy Screening Forms revealed the following: 2/15/12 - status: care plan update; OT therapy not indicated and Pt on hospice; PT not indicated, Pt recently d/c from PT. 3/12/12 - status: care plan update; OT not indicated and Pt on hospice; PT not indicated. 6/1/12 - status: care plan update; OT not indicated; PT not indicated. 10/22/12 - Status: fall; OT - currently in hospital, will re-screen upon return; PT - at hospital. Review of the OT evaluation & plan of treatment revealed the following: Certification period - 11/10/11 - 1/8/12 Short-term goals - Patient will increase BUE strength to 4/5 to facilitate patient's ability to perform functional activities for 20 minutes. Patient will perform functional problem solving with minimal/close supervision and 35% verbal cues in order to increase safety during daily living tasks and safely participate with functional activities. Long-term goals - Patient will have good activity tolerance to complete safe stand by assistance activities of daily living/independent activities of daily living tasks from w/c height. Review of the PT evaluation & plan of treatment revealed the following: Certification period - 11/11/11 - 1/9/12 Short-term goals - Patient will increase dynamic sitting balance to Poor + spontaneously righting self when needed in order to prepare for transfers. Patient will safely perform bed mobility tasks with max assistance without use of side rails for safety awareness in order to get in/out bed. Long-term goals - Patient will safely perform bed mobility tasks with contact guard assistance without use of side-rails for safety awareness in order to get in/out of bed Review of the PT discharge summary revealed ...Patient Response - Progress & Response to treatment (tx): Patient made very minimal progress, tolerated tx fairly and is discharged at this time due to enrollment with hospice services. An interview was held with S22RehabDirector on 11/7/12 at 9:15 a.m. After reviewing Resident #2's clinical record, she verified that Resident #2 had the following therapy screening referrals: 2/15/12 for care plan update referral - OT not indicated, patient recently d/c from PT on 12/15/11.; 3/12/12 for care plan update referral - therapy not indicated because she was hospice; 6/1/12 for care plan update referral - therapy not indicated due to hospice; 10/22/12 for fall screen referral - did not screen because never came back from hospital. She said that Resident #2's certification period for therapy was 11/11/11 until discharge on [DATE]. She said according to the PT notes, Resident #2 was discharged because she was picked up by hospice and she made very minimal progress. She said the notes did not reveal why she made minimal progress, and she said the therapist no longer worked at the facility. An interview was held with S24ActivityDirector on 11/8/12 at 11:00 a.m. She said that she would make room visits to Resident #2 two to three times a week. She said that staff did not direct her to visit her more often. An interview was held with Dr. S ... on 10/23/12 at 2:40 p.m. She said she had a non urgent message on 10/20/12 around 5 p.m. that Resident #2 had a fall with no injuries. She said that she did not remember who it was from. She said it was described as a nontraumatic fall with no injuries. She said that she got an urgent call at 9:15 p.m. from S8LPN, and she said now it looked like the right knee was swelling and warm. Dr. S ... said she ordered an x-ray. She said S3ADON called her around 11:15 p.m. and said it looked like Resident #2 had an obvious fracture. Dr. S ... said she told S3ADON to send Resident #2 to the emergency room for an evaluation. An interview was held with S3ADON on 10/23/12 at 2:50 p.m. She said S8LPN gave her report on 10/20/12 and told her Resident #2 had fallen and her right knee was swollen. She said at the end of report the x-ray technician arrived, and she assisted him with the x-ray. She said that she observed the right leg, and it was swollen and looked deformed. An interview was held on 10/24/12 at 9:16 a.m. with S5MDSCoordinator. After reviewing Resident #2's MDS, she verified that Resident #2 is usually understood and understands others, has adequate vision with no corrective lenses, can repeat 3 words with cueing, knew correct year, and had a BIMS score of 10 which meant moderate cognitive impairment. After reviewing Resident #2's care plan, S5MDSCoordinator explained that Resident #2 had a fall on 9/13/12. She said that Resident #2 fell out of the wheelchair while reaching down to get a towel. She said there were no injuries. She said that after the fall Resident #2 was encouraged to keep her seatbelt on and use her call light and reacher. She said that resident #2 had another fall on 10/20/12 in the bathroom while reaching for a wash cloth and fell out of the wheelchair. S5MDSCoordinator said Resident#2 was encouraged to call for assistance with ADLs, and she was able to verbalize understanding. She said they also placed her bathroom items within reach. She also verified that the care plan revealed that Resident #2 was forgetful and had trouble recalling. S5MDSCoordinator said that on 10/16/12 Resident #2 was also diagnosed with [REDACTED]. She explained that the UTI messes up her cognition and she may not be as alert and sharp as would be. She said when they have UTIs the elderly will do things that are not normal for them. After reviewing the care plan she verified that it did not reveal to increase supervision. An interview was held with S6RNSupervisor on 10/24/12 at 9:31 a.m. She said around 3 p.m. on 10/20/12 S7CNA told her Resident #2 was on the floor. She said Resident #2 was found in the bathroom on her left side with the wheelchair in the bathroom also. S6RNSupervisor said Residen t#2 said she was okay and denied hurting. She said Resident #2 did not know how long she had been down on the floor. S6RNSupervisor said that Resident #2 did not grimace or complain of (c/o) pain when they put her back in her w/c. She said that she obtained her vital signs, and they were perfect. S6RNSupervisor explained that S8LPN, Resident #2's assigned nurse, came into Resident #2's room, and she gave Resident #2's vital signs to S8LPN and left the room. S6RNSupervisor said she did not assess Resident #2's lower extremities because she thought S8LPN would do that, and she got called away from the room. She said that she was called away to a routine task, and it was not another emergency. S6RNSupervisor explained there was a spoon on the floor in the bathroom and Resident #2 may have been trying to pick it up. She said that Resident #2 knew how to undo her seatbelt; she had a history of [REDACTED]. S6RNSupervisor explained that Resident #2 had a previous fall while reaching for something. She said that she was the weekend supervisor. S6RNSupervisor said that her responsibility was to assist the staff nurse when a resident had a fall. She explained the LPNs could assess a resident unless it was a new admit or a new skin issue, and then she had to assess the resident. An interview was held on 10/24/12 at 10:08 a.m. with S7CNA. She said that she had been employed at the facility for almost 2 years, and she usually took care of Resident #2. She explained that at times Resident #2 was confused and other times alert oriented. She explained that Resident #2 would undo her seatbelt and get up without assistance at times. She said that she had not had any falls this year other than the one in October. She said that Resident #2 wore a seatbelt while she was in her wheelchair. S7CNA explained that she had to go see Resident #2 every 2 hours. S7CNA verified that she found Resident #2 lying on her left side about 2:30 p.m. on 10/20/12 on the bathroom floor, and she reported it to the supervisor. She explained that the supervisor came in, and Resident #2 told her she was not hurting. S7CNA explained that she and S6RNSupervisor put Resident #2 back in her wheelchair and got her vital signs. S7CNA said that Resident #2 never complained of pain. She said there was a spoon on the bathroom floor and Resident #2 may have been trying to get it. S7CNA said she could not understand what Resident #2 said when she asked what happened and how she got on the floor. She said that S9CNA and she placed Resident #2 in bed after they got her vital signs. She explained that Resident #2 was a high risk for falls because she would unbuckle the seatbelt. She said that she told S8LPN at 8:35 p.m. that she needed to check Resident #2 because her leg was big like it was artificial. S7CNA said that Resident #2 had a reacher to get stuff off the floor, but she did not have it with her when she found her on the bathroom floor on 10/20/12. An interview was held with S3ADON on 10/24/12 at 10:34 a.m. She said that she arrived around 11:00 p.m. on 10/20/12 to work, and she received report from S8LPN. She explained that S8LPN told her that Resident #2 had a fall around 3 p.m., her knee began to swell, and she got order for x-ray. S3ADON said after report the x-ray technician arrived which was around 11:05 p.m., and she assisted him with the x-ray. S3ADON said that resident #2's knee was swollen, and there was a deformity above knee on the right femur. S3ADON said that Resident #2 denied pain. S3ADON said she called Dr. S ... and told her what she saw and asked if they could send Resident #2 to the ER. She said Dr. S ... gave an order to send her to the ER. S3ADON described the leg as being swollen, warm to touch, without bruising, and the femur appeared detached. S3ADON said Resident #2 never c/o pain, moaned, or cried out. S3ADON explained that Resident #2 was a fall risk, and she had a history of [REDACTED]. She said that Resident #2 had a history of [REDACTED]. S3ADON said when she asked Resident #2 what happened to her leg that Resident #2 told her that she wanted to go to the bathroom. S3ADON explained that Resident #2 was incontinent. S3ADON said S8LPN told her that Resident #2 said she wanted to clean herself up. S3ADON said prior to this fall, Resident #2 was packing her clothes and wanted to go home. She said the doctor ordered a urinalysis (UA), and Resident #2 was started on Bactrim. S3ADON said the UA results revealed increased leukocytes and indicated a UTI. An interview was held with S2DON on 10/24/12 at 11:00 a.m. in the presence of S1Administrator and S2ADON. S2DON explained the fall prevention program is initiated if have a resident has a fall. She said the fall prevention program cues the CNAs as to which residents are at risk for falls. She described Resident #2's cognitive status as awake, alert, and confused at times. She said that she did not know her well enough to tell about her memory. S3ADON said that Resident #2's BIMS score was a 10. She said the score of 10 means that she had moderate cognitive impairment. S2DON said that Resident #2 was able to recall after cueing. After reviewing the clinical record, S2DON explained that on 9/13/12 Resident #2 was up in her w/c and reached down to get a towel and fell out of her w/c. She said that she hit her head, but there were no bumps or bruising. She said it also revealed that Resident #2's seatbelt was not fastened. She said after the fall they encouraged the resident to keep the seatbelt on and gave her a reacher after the fall. After reviewing the incident report, she said that Resident #2 already had the reacher, and they encouraged her to use it and encouraged her to use the call light, and encouraged her to keep the seatbelt on. S2DON said on 10/20/12 Resident #2 had another fall. S2DON said she was in the bathroom trying to clean up and was reaching for a washcloth and fell out of wheelchair. S2DON said that Resident #2 was found lying o

Based on record reviews and interviews, the facility failed to ensure services provided met professional standards of quality for 1 (#2) of 5 (#1, #2, #3, #4, & #5) sampled residents reviewed for falls by failing to: 1. Ensure that a resident was assessed and monitored after a fall on 10/20/12 at which time the resident sustained [REDACTED].(#2) 2. Ensure that the registered nurse conducted a complete physical assessment including an assessment of the lower extremities on a resident who fell from her wheelchair on 10/20/12. (#2) 3. Continue to monitor a resident (#2) on 10/20/12 after 8:40 p.m. after it was noted at that time that her right leg was swollen and warm to touch following a fall from her wheelchair. Resident #2 had the [DIAGNOSES REDACTED]. The immediate jeopardy began on 10/20/12 at 3:07 p.m. when Resident #2 was found on the bathroom floor with her wheelchair in the bathroom doorway by S7CNA. S6RNSupervisor failed to complete an assessment of Resident #2's bilateral lower extremities. S8LPN failed to continue to monitor Resident #2 after 8:40 p.m. at which time she had noted Resident #2's right leg was swollen and warm to touch. S3ADON observed Resident #2 at 11:00 p.m. and noted her right leg was swollen with a deformity above the knee. Review of the hospital's radiology results dated 10/21/12 revealed Resident #2 had a distal shaft right femur with acute, displaced, comminuted fracture. The Immediate Jeopardy (IJ) ended on 10/20/12 at 11:22 p.m. when she was transferred to the hospital. The Assistant Administrator was informed of the IJ for Resident #2 on 11/7/12 at 8:10 a.m. The deficient practice remained at a scope and severity of Isolated Actual Harm for Resident #2. Findings: Review of the Louisiana State Board of Nursing website revealed the Delegation Decision-Making Process from the Registered Nurse to the Licensed Practical Nurse (http://www.lsbn.state.la.us/Portals/1/Documents/DelegationTree.pdf) with the following information: In Louisiana, R.S. 37:913(14)(f) provides that registered nursing includes delegating nursing interventions to qualified nursing personnel in accordance with criteria established by the Board of Nursing. LAC 46:XLVII.3703 sets the standards for the implementation of the statutory mandate. The term "delegating nursing interventions" is defined and criteria are provided for all delegatory activities, for delegation to licensed practical nurses, and for delegation to unlicensed nursing personnel. The registered nurse who delegates nursing interventions retains the responsibility and accountability to assure that the delegated intervention is performed in accord with established standards of practice, policies and procedures. Appropriate assessment, planning, implementation and evaluation are integral activities in the fulfillment of the registered nurse's responsibility and accountability. Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses Subpart, I. Practical Nurse, under subchapter E.Curriculum Requirements revealed in part ..."3. development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgment, prudence, ethical thinking and behaviors, problem solving and critical thinking abilities...7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and working as a member of the interdisciplinary health care team..." Resident #2 Review of the clinical record revealed Resident #2 had the following Diagnoses: [REDACTED]. Review of the quarterly MDS with ARD of 9/11/12 revealed the following: Usually makes self understood; Understands others; BIMS score of 10 (cognitive impairment); transfer - extensive assistance of 2 persons; personal hygiene - extensive assistance of one person; toilet use - extensive assistance of 2 persons; bathing - extensive assistance of 1 person; always incontinent of bowel and bladder. Review of the Incident Report dated 10/20/12 revealed the following: Time: 3:07 p.m. Incident Type: Fall / no head injury Type of Injury: Fracture Location: Resident room Activity at time: To / from bathroom alone Narrative of incident and description of injures: Resident was in the bathroom to clean up (stated she felt like she needed to be cleaned). Was reaching for washcloth, fell out of wheelchair. Found lying on L side on floor. Resident awake, alert, confused at times. Upon initial assessment no visible injury observed. Resident with no complaints of pain. CNA reported swelling to right knee at 7 p.m. Upon assessment, noted swelling to right knee and warm to touch. Resident with no complaints of pain. MD notified of findings and new orders received. Family notified as well. Immediate Actions Taken: Resident assessed and placed back into wheelchair with assistance X 2. Self release seatbelt applied. Vital signs obtained. No complaints of pain at this time. CNA assisted resident with ADL needs. Actions Taken: First Aid by S6RNSupervisor on 10/20/12 at 3:07 p.m. temperature (T) 97.4, pulse (P) 95, respirations (R) 18, blood pressure (B/P) 105/64, pain scale = 0; Physician notified - M ... S ... on 10/20/12 at 7:15 p.m. Family notified - M ... B ... on 10/10/12 at 7:15 p.m. Taken to Hospital: local hospital Disposition: ER / return to facility Meds taken during last 8 hours - cardiovascular / antihypertensives, [MEDICATION NAME] / narcotics, laxatives/ cathartics; Medical Risk Factors possibly related to incident: fall history, inability to understand directions, arthritis / [MEDICAL CONDITION], confusion / disorientation, and incontinency. Immediate Post- Incident Action: Resident assessed and placed back into wheelchair with assistance x 2. Explained to resident that she needs to call for assistance when she wants to be cleaned. Resident verbalized understanding. Bathroom items placed within reach. Incident Investigation: 1. Resident uses self-release seatbelt as safety device. Resident is non-compliant with seatbelt. 2. Resident currently being treated for [REDACTED]. 3. X-ray of R knee ordered = femur fracture. 4. Resident with history of [MEDICAL CONDITION] and failure to thrive. Review of the Departmental Notes revealed the following: 10/20/12 11:46 p.m. Late entry for 10/20/12 at 3 p.m. - Resident lying in bed, neuro checks begun. 10/20/12 11:48 p.m. Late entry for 10/20/12 at 7 p.m. - CNA reported swelling to resident's R knee to LPN. Site immobile, enlarged, warm to touch. Resident denied pain. Call to MD, New order noted. 10/21/12 12:02 a.m. Late entry for 10/20/12 at 7:15 p.m. - Call to resident's family. 10/22/12 2:33 a.m. Late entry for 10/20/12 at 7:15 p.m. - Call to MD's office. The initial call placed to MD's office regarding incident. 10/22/12 3:12 a.m. Late entry for 10/20/12 at 8:40 p.m. - Dr. S ... notified, and spoken to regarding resident's swollen, warm knee. New order noted. 10/22/12 3:58 a.m. Late entry for 10/20/12 at 8:40 p.m. - CNA reported swelling to resident's R knee, to LPN. Site immobile, enlarged, warm to touch. Resident denied pain. 10/22/12 3:15 p.m. I was called to room ... by S7CNA who found Resident #2 on the bathroom floor. Resident was not in distress at that time. S7CNA and I moved the wheelchair that was blocking the doorway so we could get in and put Resident #2 back in her chair. Resident #2 denied pain before the transfer back to her chair. She didn't cry out in distress during the lift, and she stated she was not in pain after she was securely sitting in the wheelchair, seatbelt fastened. S7CNA remained with resident while I got the V.S. machine, and when I returned, she went to notify S8LPN about her resident. Vitals at 14:45 were: 97.4, 95, 105/64, 18, 95% oxygen (O2) saturation. I wrote these vital signs (VS) on a piece of paper and handed them to S8LPN when she arrived in Resident #2's room and filled her in on what happened. On 10/21/12 at 11:22, I notified C ... Hospice of Resident #2's subsequent hospitalization . 10/22/12 4:17 p.m. The following note dated 10/22/12 is a late entry from an occurrence on 10/20/12. 10/23/12 9:54 a.m. Late entry for 10/20/12 11:00 p.m. Upon arriving to work and getting report from S8LPN she reported that Resident #2 had a fall in the bathroom and that her knee had begun swelling and she had obtained an order for [REDACTED]. I accompanied the x-ray tech to the room to assist him. Upon observation of her right, leg swelling was noted and a deformity above the knee was also noted. X-ray tech obtained x-ray. I asked Resident #2 if she was any pain and she denied pain I then notified Dr. S ... of the swelling and deformity. She gave an order to send to ER for evaluation. I then called M ... B ... (son) and notified him of her being transferred to ER for evaluation of her leg. He stated that he would meet her there. A ... ambulance was notified for transfer. Review of the Physician order [REDACTED]. 10/20/12 8:40 p.m. May x-ray right knee; Ice to site as needed (PRN). 10/20/12 11:21 p.m. Send to ER for evaluation Review of the local hospital's radiology results dated 10/21/12 revealed distal shaft right femur with acute, displaced, comminuted fracture. Review of the physician's exam performed at the hospital revealed the following: tender to palpation over right anterior thigh; exam over the right anterior thigh demonstrates a mild to moderate amount of swelling /effusion; exam reveals significant deformity and angulation of the right anterior thigh of approximately 25 degrees; and obvious deformity of distal femur. Review of the Care Plan revealed the following in part: Problem Onset: 1/10/12 I am at risk for falls r/t history of falls, impaired cognition, [MEDICAL CONDITION] medication use, requiring assistance with transfers. I need extensive assistance with transfers. Some time I will try to get up without assistance. I have a seatbelt to cue me for safety awareness due to my diagnosis (dx) of [MEDICAL CONDITION]. 9/13/12 Actual fall Resident was reaching down to get a towel and fell out of wheelchair. She hit the front of her head. 10/20/12 Fall in bathroom from w/c reaching down to get washcloth. Goal & Target Date: Will assist resident to eliminate falls thru 12/25/12. Approaches: Encourage to use the reacher 9/13/12. Encourage to use the call light 9/13/12. Seatbelt while in wheelchair. Remind me to ask for assist for all transfers. Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician. I need my pathway in my room free of clutter. Fall mat at side of bed. 4/14/11 full side rail on the left side per my request. 9/13/12 Encourage to keep seatbelt on. 10/21/12 Encouraged to call for assistance with ADL needs. Resident verbalized understanding. 10/20/12 Placed bathroom items within reach. An interview was held with Dr. S ... on 10/23/12 at 2:40 p.m. She said she had a non urgent message on 10/20/12 around 5 p.m. that Resident #2 had a fall with no injuries. She said that she did not remember who it was from. She said it was described as a nontraumatic fall with no injuries. She said that she got an urgent call at 9:15 p.m. from S8LPN, and she said now it looked like the right knee was swelling and warm. Dr. S ... said she ordered an x-ray. She said S3ADON called her around 11:15 p.m. and said it looked like Resident #2 had an obvious fracture. Dr. S ... said she told S3ADON to send Resident #2 to the emergency room for an evaluation. An interview was held with S3ADON on 10/23/12 at 2:50 p.m. She said S8LPN gave her report on 10/2012 and told her Resident #2 had fallen and her right knee was swollen. She said at the end of report the x-ray technician arrived, and she assisted him with the x-ray. She said that she observed the right leg, and it was swollen and looked deformed. An interview was held with S6RNSupervisor on 10/24/12 at 9:31 a.m. She said around 3 p.m. on 10/20/12 S7CNA told her Resident #2 was on the floor. She said Resident #2 was found in the bathroom on her left side with the wheelchair in the bathroom also. S6RNSupervisor said Resident#2 said she was okay and denied hurting. She said Resident #2 did not know how long she had been down on the floor. S6RNSupervisor said that Resident #2 did not grimace or complain of (c/o) pain when they put her back in her w/c. She said that she obtained her vital signs, and they were perfect. S6RNSupervisor explained that S8LPN, Resident #2's assigned nurse, came into Resident #2's room, and she gave Resident #2's vital signs to S8LPN and left the room. S6RNSupervisor said she did not assess Resident #2's lower extremities because she thought S8LPN would do that, and she got called away from the room. She said that she was called away to a routine task, and it was not another emergency. She said that she was the weekend supervisor. S6RNSupervisor said that her responsibility was to assist the staff nurse when a resident had a fall. She explained the LPNs could assess a resident unless it was a new admit or a new skin issue, and then she had to assess the resident. An interview was held on 10/24/12 at 10:08 a.m. with S7CNA. She said that she had been employed at the facility for almost 2 years, and she usually took care of Resident #2. She explained that at times Resident #2 was confused and other times alert oriented. S7CNA verified that she found Resident #2 lying on her left side about 2:30 p.m. on 10/20/12 on the bathroom floor, and she reported it to the supervisor. She explained that the supervisor came in, and Resident #2 told her she was not hurting. S7CNA explained that she and S6RNSupervisor put Resident #2 back in her wheelchair and got her vital signs. S7CNA said that Resident #2 never complained of pain. She said that she told S8LPN at 8:35 p.m. that she needed to check Resident #2 because her leg was big like it was artificial. An interview was held with S3ADON on 10/24/12 at 10:34 a.m. She said that she arrived around 11:00 p.m. on 10/20/12 to work, and she received report from S8LPN. She explained that S8LPN told her that Resident #2 had a fall around 3 p.m., her knee began to swell, and she got order for x-ray. S3ADON said after report the x-ray technician arrived which was around 11:05 p.m., and she assisted him with the x-ray. S3ADON said that Resident #2's knee was swollen, and there was a deformity above knee on the right femur. S3ADON said that Resident #2 denied pain. S3ADON said she called Dr. S ... and told her what she saw and asked if they could send Resident #2 to the ER. She said Dr. S ... gave an order to send her to the ER. S3ADON described the leg as being swollen, warm to touch, without bruising, and the femur appeared detached. S3ADON said Resident #2 never c/o pain, moaned, or cried out. S3ADON said when she asked Resident #2 what happened to her leg that Resident #2 told her that she wanted to go to the bathroom. S3ADON explained that Resident #2 was incontinent. S3ADON said S8LPN told her that Resident #2 said she wanted to clean herself up. S3ADON said prior to this fall, Resident #2 was packing her clothes and wanted to go home. She said the doctor ordered a urinalysis (UA), and Resident #2 was started on Bactrim. S3ADON said the UA results revealed increased leukocytes and indicated a UTI. An interview was held with S2DON on 10/24/12 at 11:00 a.m. in the presence of S1Administrator and S2ADON. S2DON said on 10/20/12 Resident #2 had another fall. S2DON said she was in the bathroom trying to clean up and was reaching for a washcloth and fell out of wheelchair. S2DON said that Resident #2 was found lying on her left side on the floor. She said then at 7 p.m. the CNA reported swelling to Resident #2's right knee. S2DON said that Resident #2 was diagnosed with [REDACTED]. After reviewing Resident #2's care plan, S2DON verified that it revealed that Resident #2 had cognitive loss, had trouble recalling, and was forgetful. She also verified that it revealed Resident #2 had dementia. After reviewing the nurse's notes, she explained the first nursing assessment on 10/20/12 related to the fall was at 3:00 p.m., and it revealed lying in bed and neuro checks begun. She verified there was no assessment documented by S8LPN or S6RNSupervisor at 3:00 p.m. when Resident #2 was found on the floor. S2DON explained that S6RNSupervisor charted a late entry on 10/22/12 at 3:15 for the occurrence on 10/20/12, but there is no time. S2DON explained that the late entry revealed vital signs were obtained at 1445. She verified that a complete assessment was not documented in the note. S2DON explained that the RN supervisor was responsible for assessing a resident after a fall. She said on 10/20/12 at 7 p.m. S8LPN documented immobile, enlarged, warm to touch, denies pain. She said S8LPN had another entry at 8:40 p.m. which revealed Resident #2's leg was enlarged and warm. S2DON verified there was no other assessment of Resident #2 from 8:40 p.m. to 11:00 pm. She said that the resident should have been assessed and monitored for pain more frequently than every 2 hours. S2DON said that no other measures were taken because S8LPN and S6RNSupervisor were the only 2 employees involved. An interview was held with S2DON and S1Administrator on 10/15/12 at 12:15 p.m. After reviewing the in-services held since 10/20/12, S2DON explained that she had conducted in-services regarding the following topics: making nurse's note with every incident, how to chart on echart, neuro checks as applicable, notifying the director of nurses (DON) of all falls, assessments performed immediately after a fall and document in the nurse's notes, and notification of MD and responsible party timely. She explained that staff were in-serviced on the following topics on 10/24/12 (note complaint survey conducted 10/23/12 - 10/25/12): after fall a full body assessment, pain assessment, ROM, skin assessment, neuro status assessment, vital signs, injuries, neuro checks initiated as applicable, notification of MD and responsible party after assessment, notify DON of falls, complete nurse's notes of findings, and complete incident report. After reviewing the current lists of nurses employed at the facility she verified the following nurses had not received the in-service training regarding falls and assessments: S10LPN, S11LPN, S13LPN, S14LPN, S15LPN, S16LPN, S17LPN, S18LPN, S19LPN, S20LPN, S21LPN, and S6RNSupervisor.

Based on record review and interview, the facility failed to ensure that all alleged violations of abuse were reported immediately to the administrator of the facility and other officials in accordance with state law through established procedure for 2 (#1, #R1) of 8 (#1, #2, #3, #4, #5, #6, #7, and R1) residents reviewed for alleged physical abuse. The facility failed to: 1) Report an incident of alleged resident to resident physical abuse to the Administrator for a residents (#1) 2) Ensure a CNA who had knowledge of alleged staff to resident (R1) physical abuse reported it to the Administrator immediately. Resident #1 was a [AGE] year old male resident admitted to the facility on [DATE] as a transfer from another nursing home facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/30/11 revealed the resident's skills for decision making as Severely Impaired-never/rarely made decisions. Resident #2 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS with an Assessment Reference Date of 8/30/11 revealed the resident was admitted from another nursing home. It further revealed his cognitive skills for daily decision making was Moderately Impaired-decisions poor; cues/supervision required. On 9/25/11 at 8:45 p.m., Resident #2 called nurse to the room that was occupied by he and Resident #1. Resident #1 was found on the floor and stated he was beat up by his roommate (Resident #2). Resident #2 was sitting in bed holding his fist and pointing to the TV remote control. When asked if they were fighting over the remote control, he stated yes. Resident #1 was placed in an Immediate Jeopardy situation on 9/25/11 at 8:45 p.m. when it was discovered that he was beaten by Resident #2. The residents were not separated, but remained in the same room, and the facility failed to immediately increase supervision/monitoring, assess resident #2's mental status or obtain a psychiatric consult for Resident #2. The facility failed to assess for causative factors that triggered Resident #2's abusive behavior. The Immediate Jeopardy ended for Resident #1 on 9/26/11 at 1:45 a.m. when he was transferred to a local hospital emergency room . The deficient practice continues at a scope and severity level II, potential for more than minimal harm, for all the residents of the facility, as the facility failed to increase supervision/monitoring, assess Resident #2 for causative factors that triggered his behavior and have him psychologically evaluated. Findings: Review of the facility's Policy/Procedure entitled: Prevention and Prohibition of Abuse revealed the following in part: 7. Reporting/Response The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or director of nurses... All employees are required by law to report any suspected abuse or neglect. Any employee who knows or has reason to believe that abuse occurred and does not immediately report will face possible termination... Review of the Client Incident Report dated 9/30/11 revealed the following: Events: Discovered: 9/25/2011 8:45 p.m. Occurred: 9/25/2011 8:45 p.m. Entered: 9/26/2011 7:10 p.m. Findings: Substantiated Accused/Allegation: Resident #2 Abuse: Physical Victim: Resident #1 Case Notes: On September 25, 2011 at 8:45 p.m. S5LPN was called to room --- by Resident #2. She found Resident #1 (Resident #2's roommate) on the floor. Resident #2 was waving a remote control in the air, hold his fist up. S5LPN completed a nurse assessment on Resident #1 and assisted him into his bed.... Resident #1 had bruising to right outer eye and inner eye and raised area to right brow. Bruising to right temple was also noted...An assessment was completed for Resident #2 also. He did not complain of pain at the time of the incident. A scratch was noted to under right eye. Residents were counseled and supervision was increased for both residents. There was no documentation in the medical record that supervision was increased for either resident. An interview was conducted with S5LPN on 10/4/11 at 1:45 p.m. When asked if she reported this incident to the Administrator or DON, she stated, "No". She said she attempted to call the Administrator and did not get an answer and she did not attempt to call any other Administrative staff. She further stated that she had never been involved with the situation of two residents fighting and was not sure what she was supposed to do. She was unable to say how supervision was increased as the next time she made an entrance into the room was when Resident #1 called for assistance to the bathroom. An interview was conducted with S1Administrator on 10/4/11 at 8:30 a.m. She stated she did not learn about the altercation of Resident #1 and Resident #2 until the afternoon of 9/26/11 when she was called by the floor nurse because the daughter of Resident #1 had come to the facility and demanded that Resident #1 be sent to the emergency room . S1Administrator said that the numbers of the Administrative staff are posted in the nurses' station and are(take out) available to all staff in case of emergency situations. She verified that she did not get a call immediately about the incident. An interview was conducted with S2Director of Nursing on 10/4/11 at 9:00 a.m. She said she was informed of the incident when she returned to work on 9/27/11. She said she was out on 9/26/11 for a workshop and was not contacted about the altercation between Resident #1 and Resident #2. Review of the facility's OTIS reports dated 8/20/11 at 8:00 p.m. S7CNA witnessed S8CNA hit random Resident #1 in the head with her hand. The incident was not reported by S7CNA to S4Assistant Director of Nursing until 8/25/11 at 2:15 p.m. The acknowledgement of the policy and procedure for the prevention and prohibition of abuse was signed by S7CNA on 8/11/11. In an interview with S1Administrator on 10/4/11 at 4:15 p.m., she stated S7CNA had just been hired and trained recently. She stated S7CNA had signed a copy of the facility's policy and procedure stating she was aware of the facility's policy and procedure for reporting abuse. She stated S7CNA should have notified administration immediately after the incident with the resident occurred. She also verified the OTIS report had a discovery date of 8/20/11 and an entry date of 8/25/11.

Based on observation, interviews and record review, the facility failed to ensure each resident's right to be free from neglect for 1 (#1) of 7 sampled residents (#1, #2, #3, #4, #5, #6, #7). The facility failed to ensure: 1) Resident #1 was immediately separated from Resident #2 after a physical altercation that caused bodily injury to Resident #1 2) The Physician was notified immediately of the altercation and injuries to Resident #1 inflicted by Resident #2 3) Supervision/monitoring of Resident #2 was increased to prevent further injury to Resident #1 and/or other residents in the facility 4) That Administration was notified of the altercation and injuries inflicted on Resident #1 by Resident #2 5) That law enforcement was notified of the physical attack and resulting injuries to Resident #1 by Resident #2 6) Staff followed and implemented the facility's policy/procedure to prohibit neglect of Resident #1 and 7) Immediate assessment of Resident #2's mental status was done and that the physician was notified for a determination regarding treatment options. On 9/25/11 at 8:45 p.m., Resident #2 called nurse to the room that was occupied by he and Resident #1. Resident #1 was found on the floor and stated he was beaten up by his roommate (Resident #2). Resident #2 was sitting in bed holding his fist and pointing to the TV remote control. When asked if they were fighting over the remote control, he stated "yes." Resident #1 was placed in an Immediate Jeopardy situation on 9/25/11 at 8:45 p.m. when it was discovered that he was assaulted by Resident #2. The residents were not separated immediately after the altercation and the facility failed to immediately increase supervision or obtain a psychiatric consult for Resident #2. The facility failed to assess for causative factors that triggered Resident #2's abusive behavior. The Immediate Jeopardy ended for Resident #1 on 9/26/11 at 1:45 a.m. when he was transferred to a local hospital emergency room . The deficient practice continues at a scope and severity level II, potential for more than minimal harm, for all the residents of the facility, as the facility failed to increase supervision/monitoring, assess Resident #2 for causative factors that triggered his behavior and have him psychologically evaluated. Findings: Review of the facility's policy/procedure entitled: Prevention and Prohibition of Abuse revealed the following in part: Purpose: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy: To provide a safe environment for all residents free of abuse. Types of Abuse... 3. Physical Abuse includes hitting, slapping, pinching, biting, shoving, and kicking. It also includes controlling behavior through corporal (physical) punishment... 6. Neglect means failure to provide adequate medical care, goods and services which results in physical harm, mental anguish, or mental illness... III. Abuse Prohibition Practice Each resident has the right to be free from mistreatment, neglect, and misappropriation of property. This includes the facility's identification of residents' whose personal histories render the at risk for abusing other residents and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. 6. Protection: Resident to resident altercations: When another resident is alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's mental status and notify the physician for a determination regarding treatment and/or discharge options. The safety of other residents and employees of the facility is of primary concern. 7. Reporting/Response The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or director of nurses. The Administrator or designee will notify the regional director and corporate nurse... All employees are required by law to report any suspected abuse or neglect... Resident #1 Resident #1 was a [AGE] year old male resident admitted to the facility on [DATE] as a transfer from another nursing home facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/30/11 revealed the resident's skills for decision making as(were) Severely Impaired-never/rarely made decisions. Review of section G-Functional Status revealed the following: The resident was independent with bed mobility and eating, and required supervision with transfers, locomotion on and off the unit, dressing, toilet use, bathing, and personal hygiene. Under the section G0300-Balance During Transitions and Walking: 1) Moving from seated to standing position and Walking-Not steady, but able to stabilize without human assistance 2) Turning around, Moving on and off toilet and Surface-to-surface transfer-Steady at all times. Resident #2 Resident #2 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS with an Assessment Reference Date of 8/30/11 revealed the the following: Section C-Cognitive Patterns C1000-Cognitive Skills for Daily Decision Making Moderately Impaired -decisions poor; cues/supervision required C1300-Signs and Symptoms of [MEDICAL CONDITION] A. Inattention-behavior continuously present, does not fluctuate B. Disorganized thinking-behavior continuously present, does not fluctuate Section D0500-Staff Assessment of Resident Mood Over the last 2 weeks, did the resident have any of the following problems or behaviors? H. Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that he has been moving around a lot more than usual Symptom presence-Yes Symptom Frequency-12-14 days (nearly every day) Review of the Client Incident Report dated 9/30/11 revealed the following: Events: Discovered: 9/25/2011 8:45 p.m. Occurred: 9/25/2011 8:45 p.m. Entered: 9/26/2011 7:10 p.m. Findings: Substantiated Accused/Allegation: Resident #2 Abuse: Physical Victim: Resident #1 Case Notes: On September 25, 2011 at 8:45 p.m. S5LPN was called to room ___ by Resident #2. She found Resident #1 (Resident #2's roommate) on the floor. Resident #2 was waving a remote control in the air holding his fist up. S5LPN completed an assessment on Resident #1 and assisted him into his bed.... Resident #1 had bruising to right outer eye and inner eye and raised area to right brow. Bruising to right temple was also noted... An assessment was completed for Resident #2 also. He did not complain of pain at the time of the incident. A scratch was noted under right eye. Residents were counseled and supervision was increased for both residents.. There was no documentation in the medical record that supervision was increased for either Resident #1 or Resident #2. Review of the medical record revealed there was no indication in the medical record that supervision was increased for either of the residents. The Client Incident Report dated 9/30/11 stated the following in part: On September 26, 2011 at 1:40 a.m. S5LPN entered room Resident #1's room and noted red emesis on floor next to his bed. Resident #1's mouth was also bloody. He was assisted to the bathroom per his request. Resident #1's gait was unsteady and resident complained of pain "down there". Physician notified and instructed to send Resident #1 to emergency room (ER). Family notified. Resident transported to ER via ambulance. Resident #1 returned to facility at 6:13 a.m. and placed in another room. Hospital paperwork stated a sprained hip joint was found. Left hip was negative for fracture and pelvis is negative for fracture. Review of the Nurse's Notes dated 9/26/11 at 1:40 a.m. revealed the following: Called to room by resident, in bed and wet. About 100-200cc's of red emesis noted on floor. Abrasion noted to face and mouth filled with blood. Resident #1 asking to go to restroom. Assisted to restroom with assistance of CNA's x 3. Resident gait unsteady, unable to hold head up. States he is hurting. He hit me down there. MD's office called and informed of patient's status-order received to send to ER. Review of the Emergency Department Chart dated 9/26/11 revealed the following: Arrival Date: 9/26/11 2:19 a.m. Visit Date: 9/26/11 2:20 p.m. Chief Complaint: Assault Vital Signs/Data: Temperature: 97.6 Fahrenheit, Pulse: 92, Respiration 20, Blood Pressure: 137/75, Pain 6/10. Triage: History comes from patient, was supplied by the patient's nursing home record and supplied by patient's ambulance record. Nursing Assessment: Mental Status: Alert. Oriented to person, Cooperative and fully verbal. Skin: Skin is warm, dry and intact with normal color and turgor. There is a superficial but contaminated and dirty abrasion located on the right side of the forehead. The right side of forehead area of trauma which had been bleeding has now stopped. Clinical History of Present Illness Summary: Patient involved in altercation at nursing home. Staff found him lying on floor with the other guy waving a remote control at him. Patient states his roommate hit him in the groin and head. Patient has pain in his groin and head. He has blood in his mouth. Per nursing home staff he normally ambulates well but is not walking as good as he usually does. Review of the medical record revealed there is no clear documentation in the medical record that Resident #1 was assaulted more than the one time. Review of Nurse's Notes dated 9/26/11 at 6:13 a.m. revealed the following: Returned from hospital via cab in wheelchair with assistance x 3. Awake and alert... Bandage to right cheek with mild bruising under right eye, right lower check/jaw swollen, right arm has red bruise down forearm. Resident moved to another room for safety/separation. An observation was made of the Resident #1's room on 10/3/11 at 1:45 p.m. His room was directly across from the nurses' station and the room that he was transferred from was almost at the end of the hallway. An observation of Resident #2 was not possible as he had been transferred to another facility on 9/30/11. There was no documented evidence that supervision occurred for Resident #2 from 9/26/11 to 9/30/11 when he was transferred out of the facility. Review of the Nurse's Notes dated 9/26/11 at 7:00 p.m. revealed the following: Resident #1's family here wanting to know if police had been called about the incident yesterday. "Explained to her I wasn't here yesterday but was reported to me that the MD had been notified and was sent to ER and resident and roommate in separate rooms and are being kept apart." Family refused to speak with Administrator and called the police. She also called the ambulance service...Police demanding to see resident's chart-informed him that I would have to check with Administrator to see if he could see chart due to Hippa laws-he stated "this is a criminal case and I want to see the chart to see the record when he was sent to ER". I told him when I get permission from the Administrator to let him see the ER record I would let him and until I talked with the Administrator he would not see the record. Review of the Nurse's Notes dated 9/27/11 at 6:00 p.m. revealed the following in part: Resident #1's daughter here at this time wanting resident to go to hospital. Explained to her that resident had CT head ordered, she did not want to hear it. Order received to send resident to hospital. Review of the emergency room Chart dated 9/28/11 at 7:31 p.m. revealed the following: Triage and Nursing History: Patient involved in altercation 2 days ago and now has right eye ecchymosis and bruising to right thigh. Patient states got punched in face. Nursing Assessment: Patient was sent from local nursing home 2-3 days ago for check up after assault, states patient was feeling worse today so staff wanted to have patient rechecked. Patient complained of bilateral hip pain, ecchymosis noted to right orbit. A medium sized area of ecchymosis is noted over the right orbit. MD Assessment 9/28/11 at 7:30 p.m.: Primary Diagnosis 1) Alzheimer's Dementia 2) Altercation 3) Injury in a health care facility Chief Complaint: Injury to upper portion of face History of Present Illness: Patient was in altercation 2 days ago with another resident at the nursing home. His major complaint being left groin pain. Small bruise on face and thigh. No altered mental status, no headache, no nausea/vomiting. Today continues to deny these things and feels better except some mild left groin pain. Vital Signs: Blood Pressure: 100/62, Pulse: 72, Respirations: 20/min, Pain: 6/10. Review of the Nurse's Note dated 9/28/11 at 9:30 p.m. revealed the following: Resident returned to facility per private vehicle...Transferred to bed per CNA. Review of the Nurse's Notes dated 9/28/11 at 10:50 a.m. revealed the following: Resident awake and alert, general weakness noted, leans to right side and unable to sit/stand alone. Notified Nurse Practitioner. New order for CT of head without contrast, [MEDICATION NAME] 75 mg every 6 hour PRN (as necessary), and Orthostatic B/P every shift x 48 hours. Orders noted, resident aware of new orders, up in chair in dining room with assistance x 2. Review of the medical record revealed there was no other documentation in the medical record of Resident #1 until 9/29/11 at 6:15 p.m. Review of the Nurse's Notes dated 9/29/11 without a time revealed the following: Send to ER-recent head injury-new onset incontinence, ataxia. Review of the Nurse's Notes dated 9/29/11 at 6:15 p.m. revealed the following: Notified ER nurse that resident would be transported to local hospital for recent head injury, incontinence, ataxia. Ambulance arrived at 8:20 p.m. Review of the Emergency Department Chart dated 9/29/11 at 6:55 p.m. revealed the following: Nursing Assessment: Mental Status: Patient back to Emergency Department via EMS with reported unable to ambulate and incontinence both bowel and bladder as per patient's daughter. Patient with right eye periorbital bruising and right hip bruising from altercation 4 days ago. Patient states has pain to his suprapubic area and states is unable to void. Pt currently wearing adult brief. Lethargic, poorly responsive. Oriented to person, Cooperative. Fully verbal, Cannot bear weight to walk. Skin: There is pain noted over the following areas: face and right hip and iliac crest. A small area of ecchymosis is noted over the following areas: face and right hip and iliac crest. Clinician History of Present Illness Incontinent of bowel and bladder since altercation at nursing home 2 days ago. Patient was hit in head and fell to ground. He was seen here with negative head CT and pelvis x-ray. He presents today with lower back pain, pelvis pain, may be more confused than baseline, and can't make it to the bathroom without urinating on self. Primary Diagnosis: [REDACTED]. Results: CT Lumbar Without Contrast: Films of the spine show: patient with L1 compression fracture Disposition: Patient admitted to hospital Review of the History and Physical dated 9/29/11 revealed the following: The patient was in an altercation with his roommate at a local nursing home approximately 4 to 5 days ago in which the patient was hit multiple times in the head and pelvic/back. The patient initially was evaluated in the emergency room , was negative for any fractures or acute changes on CAT scan of the head. The patient continued to complain of pain; In addition, the patient developed some new onset ataxia and bowel and bladder incontinence that was not present before the altercation. The patient is therefore admitted to the hospital for further evaluation and treatment. Review of Systems: HEENT (head, eye, ear, nose, and throat): The patient does complain of a headache, but is not present at the present time. GASTROINTESTINAL: Recent onset of bowel incontinence [MEDICAL CONDITION]: Recent onset of urinary incontinence NEUROLOGICAL: The patient complains of some generalized weakness and difficulty walking. SKIN: Patient with notable bruises to the right orbital, temporal, and right ear. In addition, he also has right lower abdomen and flank pelvic area bruising, all from recent altercation ORTHOPEDICS: Some muscular pain, mostly to the right hip/pelvic area. ASSESSMENT/Diagnoses: [REDACTED]. 2. New onset urinary and bowel incontinence 3. Ataxia 4. Recent head injury Review of the Hospital Discharge Instructions dated 10/2/11 revealed the following: Discharge Diagnosis: [REDACTED]. Appointment: Follow-up with physician in 3 weeks Activity Level/Special Instructions: Up out of bed (OOB) with TLSO brace only An observation was made and interview conducted with Resident #1 on 10/3/11 at 8:45 a.m. The resident was awake and alert sitting in the wheelchair on his way to get a shower. He stated he was not having any pain at the moment. The resident had a small raised area noted above the right eyebrow. There was a discolored area under his right eye and some discoloration to the outer ear area. In an interview with the resident, he stated that Resident #2 was upset about some candy. He said he gave Resident #2 his candy back, but he still jumped on him. He said Resident #2 hit him with his fist and then kicked him in the groin. He stated that he hollered for help, but nobody heard him or came to see what was happening. He said that when he came to the facility, he was walking, but since the fight he has had to use the wheelchair for mobility. An interview was conducted with S5LPN on 10/4/11 at 1:45 p.m. She said that she did not separate the two residents when the altercation happened because she was able to calm Resident #2 down and he turned over in the bed and went to sleep. When asked if she knew what caused Resident #2 to get angry and hit Resident #1, she stated, "no". She said she had never had two residents fight in the nursing home before and she was unsure of what she should have done. When asked if she notified the Administrator or DON, she said, no. She stated she attempted to call the Administrator, but got no answer to her phone. She admitted she did not attempt to call any of the other Administrative staff to report the incident. An interview was conducted with S2DON on 10/14/11 at 9:10 a.m. She said that it was reported to her that the residents were not separated when the incident happened, but when Resident #1 returned to the facility from the emergency room , he was placed in another room. She verified that Resident #2 was not sent out for a Psychiatric evaluation until 9/30/11, five days after the altercation. She verified that the nurse writing the incident report did not following the facility's policy and procedure for reporting abuse. She said she did not learn of the incident until she returned to the facility on [DATE]. She said that both residents were on the same floor in different rooms and far apart from one another. Resident #1 was placed in the room across the nurse's station. An interview was conducted with S1Administrator on 10/4/11 at 8:30 a.m. She stated she did not learn about the altercation of Resident #1 and Resident #2 until the afternoon of 9/26/11 when she received a call from the nurse working the floor after the daughter came to the facility and demanded that Resident #1 be sent to the emergency room . She said that the numbers of the Administrative staff are posted in the nurses' station and are available to all staff to contact in an emergency situation. She verified that she did not get a call immediately about the incident.

Based on record review and interview, the facility failed to be administered in a manner that used resources effectively to maintain the highest practicable, physical and psychological well being for 2 (#1, #2) of 7 sampled residents (#1, #2, #3, #4, #5. #6, #7). The facility failed to: 1) Ensure that two residents involved in a altercation in which bodily harm was inflicted to Resident #1 by Resident #2 were separated from each other or increased supervision/monitoring of the aggressor (#2) was instituted. 2) Staff immediately implement policy/procedure regarding reporting abuse to Administrator, DON, Administrative (#1) 3) Monitor facility staff to ensure the facility's Prevention and Prohibition of Abuse Policy on how to handle a resident with combative behavior was implemented (#2) 4) Have a process in place to ensure that the resident admitted with psychiatric [DIAGNOSES REDACTED].#2). On 9/25/11 at 8:45 p.m., Resident #2 called nurse to the room that was occupied by him and Resident #1. Resident #1 was found on the floor and stated he was beaten up by the roommate. Resident #2 was sitting in bed holding his fist and pointing to the TV remote control. When asked if they were fighting over the remote control, he stated "yes". Resident #1 was placed in an Immediate Jeopardy situation on 9/25/11 at 8:45 p.m. when it was discovered that he was assaulted by Resident #2. The residents were not separated and the facility failed to immediately increase supervision or obtain a psychiatric consult for Resident #2. The facility failed to assess for causative factors that triggered Resident #2's abusive behavior. The Immediate Jeopardy ended for Resident #1 on 9/26/11 at 1:45 a.m. when he was transferred to a local hospital emergency room . The deficient practice continues at a scope and severity level II, potential for more than minimal harm, for all the residents of the facility, as the facility failed to assess Resident #2 for causative factors that triggered his behavior and have him psychologically evaluated. Findings: Review of the facility's policy/procedure entitled: Prevention and Prohibition of Abuse revealed the following in part: Purpose: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy: To provide a safe environment for all residents free of abuse. Types of Abuse... 3. Physical Abuse includes hitting, slapping, pinching, biting, shoving, and kicking. It also includes controlling behavior through corporal (physical) punishment... 6. Neglect means failure to provide adequate medical care, goods and services which results in physical harm, mental anguish, or mental illness... III. Abuse Prohibition Practice Each resident has the right to be free from mistreatment, neglect, and misappropriation of property. This includes the facility's identification of residents' whose personal histories render the at risk for abusing other residents and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. 6. Protection: Resident to resident altercations: When another resident is alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's mental status and notify the physician for a determination regarding treatment and/or discharge options. The safety of other residents and employees of the facility is of primary concern. 7. Reporting/Response The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or director of nurses. The Administrator or designee will notify the regional director and corporate nurse... All employees are required by law to report any suspected abuse or neglect... Resident #1 Resident #1 was a [AGE] year old male resident admitted to the facility on [DATE] as a transfer from another nursing home facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/30/11 revealed the resident's skills for decision making as Severely Impaired-never/rarely made decisions. Review of section G-Functional Status revealed the following: The resident was independent with bed mobility and eating, and required supervision with transfers, locomotion on and off the unit, dressing, toilet use, bathing, and personal hygiene. Under the section G0300-Balance During Transitions and Walking: 1) Moving from seated to standing position and Walking-Not steady, but able to stabilize without human assistance 2) Turning around, Moving on and off toilet and Surface-to-surface transfer-Steady at all times. Resident #2 Resident #2 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS with an Assessment Reference Date of 8/30/11 revealed the the following: Section C-Cognitive Patterns C1000-Cognitive Skills for Daily Decision Making Moderately Impaired -decisions poor; cues/supervision required C1300-Signs and Symptoms of [MEDICAL CONDITION] A. Inattention-behavior continuously present, does not fluctuate B. Disorganized thinking-behavior continuously present, does not fluctuate Section D0500-Staff Assessment of Resident Mood Over the last 2 weeks, did the resident have any of the following problems or behaviors? H. Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that he has been moving around a lot more than usual Symptom presence-Yes Symptom Frequency-12-14 days (nearly every day) An observation was made and interview was conducted with Resident #1 on 10/3/11 at 8:45 a.m. The resident was awake and alert sitting in the wheelchair on his way to get a shower. He stated he was not having any pain at the moment. The resident had a small raised area noted above the right eyebrow. There was a discolored area under his right eye and some discoloration to the outer ear area. In an interview with the Resident, he stated that Resident #2 was upset about some candy. He said he gave Resident #2 his candy back, but he still jumped on him. He said Resident #2 hit him with his fist and then kicked him in the groin. He stated that he hollered for help, but nobody heard him and came to see what was happening. He said that when he came to the facility, he was walking, but since the fight he has had to use the wheelchair for ambulation. He said he had seen Resident #2 one time since the altercation and the transfer from the room, on the elevator, but he did not say anything to him. Review of the Nurse's Notes dated 9/26/11 at 1:40 a.m. revealed the following: Called to room by resident, in bed and wet. About 100-200cc's of red emesis noted on floor. Abrasion noted to face and mouth filled with blood. Resident #1 asking to go to restroom Assisted to restroom with assistance of CNA's x 3. Resident gait unsteady, unable to hold head up. States he is hurting. He hit me down there. MD's office called and informed of patient's status-order received to send to ER. Review of the Emergency Department Chart dated 9/26/11 revealed the following: Arrival Date: 9/26/11 2:19 a.m. Visit Date: 9/26/11 2:20 p.m. Chief Complaint: Assault Vital Signs/Data: Temperature: 97.6 Fahrenheit, Pulse: 92, Respiration 20, Blood Pressure: 137/75, Pain 6/10. Triage: History comes from patient, was supplied by the patient's nursing home record and supplied by patient's ambulance record. Nursing Assessment: Mental Status: Alert. Oriented to person, Cooperative and fully verbal. Skin: Skin is warm, dry and intact with normal color and turgor. There is a superficial but contaminated and dirty abrasion located on the right side of the forehead. The right side of forehead area of trauma which had been bleeding has no stopped. Clinical History of Present Illness Summary: Patient involved in altercation at nursing home. Staff found him lying on floor with the other guy waving a remote control at him. Patient states his roommate hit him in the groin and head. Patient has pain in his groin and head. He has blood in his mouth. Per nursing home staff he normally ambulates well but is not walking as good as he usually does. Review of the medical record revealed there was no clear documentation in the medical record that Resident #1 was assaulted more than the one time. Review of Nurse's Notes dated 9/26/11 at 6:13 a.m. revealed the following: Returned from hospital via cab in wheelchair with assistance x 3. Awake and alert... Bandage to right cheek with mild bruising under right eye, right lower check/jaw swollen, right arm has red bruise down forearm. Resident moved to another room for safety/separation. An observation was made on 10/3/11 at 1:15 p.m. Resident #1 was in the room across from the nurse's station and the room he was moved from was down the hall, almost to the end of the hallway. Resident #2 was in a room by himself, but was unable to be observed as he was out of the facility. Review of the Nurse's Notes dated 9/26/11 at 7:00 p.m. revealed the following: Resident #1's family here wanting to know if police had been called about the incident yesterday. "Explained to her I wasn't here yesterday but was reported to me that the MD had been notified and was sent to ER and resident and roommate in separate rooms and are being kept apart." Family refused to speak with Administrator and called the police. She also called the ambulance service...Police demanding to see resident's chart-informed him that I would have to check with Administrator to see if he could see chart due to Hippa laws-he stated "this is a criminal case and I want to see the chart to see the record when he was sent to ER". I told him when I get permission from the Administrator to let him see the ER record I would let him and until I talked with the Administrator he would not see the record. Review of the Nurse's Notes dated 9/27/11 at 6:00 p.m. revealed the following in part: Resident #1's daughter here at this time wanting resident to go to hospital. Explained to her that resident had CT head ordered, she did not want to hear it. Order received to send resident to hospital. Review of the emergency room Chart dated 9/28/11 at 7:31 p.m. revealed the following: Triage and Nursing History: Patient involved in altercation 2 days ago and now has right eye ecchymosis and bruising to right thigh. Patient states got punched in face. Nursing Assessment: Patient was sent from local nursing home 2-3 days ago for check up after assault, states patient was feeling worse today so staff wanted to have patient rechecked. Patient complained of bilateral hip pain, ecchymosis noted to right orbit. A medium sized area of ecchymosis is noted over the right orbit. MD Assessment 9/28/11 at 7:30 p.m.: Primary Diagnosis 1) Alzheimer's Dementia 2) Altercation 3) Injury in a health care facility Chief Complaint: Injury to upper portion of face History of Present Illness: Patient was in altercation 2 days ago with another resident at the nursing home. His major complaint being left groin pain. Small bruise on face and thigh. No altered mental status, no headache, no nausea/vomiting. Today continues to deny these things and feels better except some mild left groin pain. Vital Signs: Blood Pressure: 100/62, Pulse: 72, Respirations: 20/min, Pain: 6/10. Resident returned from the hospital on [DATE] at 9:30 p.m. Review of the Nurse's Notes dated 9/28/11 at 10:50 a.m. revealed the following: Resident awake and alert, general weakness noted, leans to right side and unable to sit/stand alone. Notified Nurse Practitioner. New order for CT of head without contrast, [MEDICATION NAME] 75mg every 6 hour PRN (as necessary), and Orthostatic B/P q shift x 48 hours. Orders noted, resident aware of new orders, up in chair in dining room with assistance x 2. Review of the medical record revealed there was no other documentation in the medical record of Resident #1 until 9/29/11 at 6:15 p.m. Review of the Nurse's Notes dated 9/29/11 with no documented time revealed the following: Send to ER-recent head injury-new onset incontinence, ataxia. Review of the Nurse's Notes dated 9/29/11 at 6:15 p.m. revealed the following: Notified ER nurse that resident would be transported to local hospital for recent head injury, incontinence, ataxia. Ambulance arrived at 8:20 p.m. Review of the Emergency Department Chart dated 9/29/11 at 6:55 p.m. revealed the following: Nursing Assessment: Mental Status: Patient back to Emergency Department via EMS with reported unable to ambulate and incontinence both bowel and bladder as per patient's daughter. Patient with right eye periorbital bruising and right hip bruising from altercation 4 days ago. Patient states has pain to his suprapubic area and states is unable to void. Pt currently wearing adult brief. Lethargic, poorly responsive. Oriented to person, Cooperative. Fully verbal, Cannot bear weight to walk. Skin: There is pain noted over the following areas: face and right hip and iliac crest. A small area of ecchymosis is noted over the following areas: face and right hip and iliac crest. Clinician History of Present Illness Incontinent of bowel and bladder since altercation at nursing home 2 days ago. Patient was hit in head and fell to ground. He was seen here with negative head CT and pelvis x-ray. He presents today with lower back pain, pelvis pain, may be more confused than baseline, and can't make it to the bathroom without urinating on self. Primary Diagnosis: [REDACTED]. Results: CT Lumbar Without Contrast: Films of the spine show: patient with 1 compression fracture Disposition: Patient admitted to hospital Review of the History and Physical dated 9/29/11 revealed the following: The patient was in an altercation with his roommate at a local nursing home approximately 4 to 5 days ago in which the patient was hit multiple times in the head and pelvic/back. The patient initially was evaluated in the emergency room , was negative for any fractures or acute changes on CAT scan of the head. The patient continued to complain of pain; In addition, the patient developed some new onset ataxia and bowel and bladder incontinence that was not present before the altercation. The patient is therefore admitted to the hospital for further evaluation and treatment. Review of Systems: HEENT (head, eye, ear, nose, and throat): The patient does complain of a headache, but is not present at the present time. GASTROINTESTINAL: Recent onset of bowel incontinence [MEDICAL CONDITION]: Recent onset of urinary incontinence NEUROLOGICAL: The patient complains of some generalized weakness and difficulty walking. SKIN: Patient with notable bruises to the right orbital, temporal, and right ear. In addition, he also has right lower abdomen and flank pelvic area bruising, all from recent altercation ORTHOPEDICS: Some muscular pain, mostly to the right hip/pelvic area. ASSESSMENT/Diagnoses: [REDACTED]. 2. New onset urinary and bowel incontinence 3. Ataxia 4. Recent head injury Review of the Hospital Discharge Instructions dated 10/2/11 revealed the following: Discharge Diagnosis: [REDACTED]. Appointment: Follow-up with physician in 3 weeks Activity Level/Special Instructions: Up out of bed (OOB) with TLSO brace only Review of the Nurse's Note for Resident #2 dated 9/30/11 at 3:00 p.m. revealed the following: Recent physical altercation towards another resident. Resident alert, flat affect with s[DIAGNOSES REDACTED], poor judgement/insight, resist care from staff at intervals. Hostile behavior toward staff and others. Call placed to Nurse Practitioner for psych eval. Review of the Psychological Intake for Resident #2, dated 9/30/11 at 3:45 p.m. revealed the following: Problem (Hx of): Psychiatric [MEDICAL CONDITION] Brief history of the problem: Patient has problems with anyone touching his personal belongings, and his roommate touched his remote control and he made physical contact with roommate to cause harm toward others. Review of Nurse's Note dated 9/30/11 at 5:00 p.m.--Resident was transported to Psych facility. An interview was conducted with S5LPN on 10/4/11 at 1:45 p.m. She said that she did not separate the two residents when the altercation happened because she was able to calm Resident #2 down and he turned over in the bed and went to sleep. When asked if she knew what caused Resident #2 to get angry and hit Resident #1, she stated, no. She said she had never had two residents to fight in the nursing home before and she was unsure of what she should have done. When asked if she notified the Administrator or DON, she said, no. She stated she attempted to call the Administrator but got no answer to her phone. She admitted she did not attempt to call any of the other Administrative staff to report the incident. An interview was conducted with S2DON on 10/4/11 at 9:10 a.m. She said that it was reported to her that the residents were not separated when the incident occurred. She stated that when Resident #1 returned to the facility from the emergency room where he was treated for [REDACTED].#2. She verified that Resident #2 was not sent out for a Psych evaluation until 9/30/11, five days after the altercation. She also said that Resident #2 should have been sent out for a Psych evaluation the day the altercation occurred. She said they received him from another nursing home facility and was not aware of his abusive history. She said that the Administrator or she should have been notified of the incident as soon as it happened but admitted she did not get a report of the incident until she returned on 9/27/11. She said she became aware of the incident and requested a psych evaluation for Resident #2. An interview was conducted with S1Administrator on 10/4/11 at 8:30 a.m. She stated she did not learn about the altercation of Resident #1 and Resident #2 until the afternoon of 9/26/11 she was called when called by the floor nurse because the daughter of Resident #1 came to the facility and demanded that Resident #1 be sent to the emergency room . She said the staff knows that they need to notify the Administrator or other Administrative staff (DON, ADON, or Charge Nurse on Weekend)when a reportable incident occurs. She said that all staff should know what to do. She said that the numbers of all the Administrative staff are posted in the nurses' station and are available to all staff. She verified that she did not get a call immediately about the incident.

Based on obserevation, record review and interview, the facility failed to ensure the resident's environment remained as free of accidents as possible for 1 (#1) of 7 (#1, #2, #3,#4, #5, #6, #7) sampled residents. The facility failed to: 1) Protect resident (#1) who had been assaulted by his roommate (#2) by not seperating them for four and a half hours 2) Increase supervision/monitoring of a resident with aggressive, physical combative behaviors (#2) 3) Assess for causative factors that triggered aggressive, physical combative behavior for the resident (#2) 4) Promptly obtain a psychiatric consult on a resident with psychiatric [DIAGNOSES REDACTED]. assaulted another resident (#2). Review of the Nurse's Note dated 9/25/11 at 8:45 p.m. revealed Resident #2 called the nurse to the room that was occupied by he and Resident #1. Resident #1 was found on the floor and stated he was beat up by the roommate. Resident #2 was sitting in bed holding his fist and pointing to the TV remote control. When asked if they were fighting over the remote control, he stated yes. Resident #1 was placed in an Immediate Jeopardy situation on 9/25/11 at 8:45 p.m. when it was discovered that he was beaten by Resident #2. The residents were not separated and the facility failed to immediately increase supervision or obtain a psychiatric consult for Resident #2. The facility failed to assess for causative factors that triggered Resident #2's abusive behavior. The Immediate Jeopardy ended for Resident #1 on 9/26/11 at 1:45 a.m. when he was transferred to a local hospital emergency room . The deficient practice continues at a scope and severity level II, potential for more than minimal harm, for all the residents of the facility, as the facility failed to assess Resident #2 for causative factors that triggered his behavior and have him psychologically evaluated. Findings: Resident #1 Resident #1 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/30/11 revealed the resident's skills for decision making as Severely Impaired-never/rarely made decisions. Review of section G-Functional Status revealed the following: The resident was independent with bed mobility and eating, and required supervision with transfers, locomotion on and off the unit, dressing, toilet use, bathing, and personal hygiene. Under the section G0300-Balance During Transitions and Walking: 1) Moving from seated to standing position and Walking-Not steady, but able to stabilize without human assistance 2) Turning around, Moving on and off toilet and Surface-to-surface transfer-Steady at times. Resident #2 Resident #2 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS with an Assessment Reference Date of 8/30/11 revealed the resident's cognitive skills for daily decision making was Moderately Impaired-decisions poor; cues/supervision required. Further review of the Admission MDS revealed the following: Section C-Cognitive Patterns C1000-Cognitive Skills for Daily Decision Making Moderately Impaired -decisions poor; cues/supervision required C1300-Signs and Symptoms of Delirium A. Inattention-behavior continuously present, does not fluctuate B. Disorganized thinking-behavior continuously present, does not fluctuate Section D0500-Staff Assessment of Resident Mood Over the last 2 weeks, did the resident have any of the following problems or behaviors? H. Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that he has been moving around a lot more than usual Symptom presence-Yes Symptom Frequency-12-14 days (nearly every day) An observation was made and interview was conducted with Resident #1 on 10/3/11 at 8:45 a.m. The resident was awake and alert sitting in the wheelchair on his way to get a shower. He stated he was not having any pain at the moment. The resident had a small raised area noted above the right eyebrow. There was a discolored area under his right eye and some discoloration to the outer ear area. In an interview with the resident, he stated that Resident #2 was upset about some candy. He said he gave Resident #2 his candy back, but he still jumped on him. He said Resident #2 hit him with his fist and then kicked him in the groin. He stated that he hollered for help, but nobody heard him and came to see what was happening. He said that when he came to the facility, he was walking, but since the fight he has had to use the wheelchair for mobility. He said he had seen Resident #2 one time since the altercation and the transfer from the room, on the elevator, but he did not say anything to him. Review of the Nurse's Notes dated 9/26/11 at 1:40 a.m. revealed the following: Called to room by resident, in bed and wet. About 100-200cc's of red emesis noted on floor. Abrasion noted to face and mouth filled with blood. Resident #1 asking to go to restroom Assisted to restroom with assistance of CNA's x 3. Resident gait unsteady, unable to hold head up. States he is hurting. He hit me down there. MD's office called and informed of patient's status-order received to send to ER. Review of the Emergency Department Chart dated 9/26/11 revealed the following: Arrival Date: 9/26/11 2:19 a.m. Visit Date: 9/26/11 2:20 p.m. Chief Complaint: Assault Vital Signs/Data: Temperature: 97.6 Fahrenheit, Pulse: 92, Respiration 20, Blood Pressure: 137/75, Pain 6/10. Triage: History comes from patient, was supplied by the patient's nursing home record and supplied by patient's ambulance record. Nursing Assessment: Mental Status: Alert. Oriented to person, Cooperative and fully verbal. Skin: Skin is warm, dry and intact with normal color and turgor. There is a superficial but contaminated and dirty abrasion located on the right side of the forehead. The right side of forehead area of trauma which had been bleeding has no stopped. Clinical History of Present Illness Summary: Patient involved in altercation at nursing home. Staff found him lying on floor with the other guy waving a remote control at him. Patient states his roommate hit him in the groin and head. Patient has pain in his groin and head. He has blood in his mouth. Per nursing home staff he normally ambulates well but is not walking as good as he usually does. Review of the medical record revealed there was no clear documentation in the medical record that Resident #1 was assaulted more than the one time. An interview was conducted with S5LPN on 10/4/11 at 1:45 p.m. She said that she did not separate the two residents when the altercation happened because she was able to calm Resident #2 down and he turned over in the bed and went to sleep. When asked if she knew what caused Resident #2 to get angry and hit Resident #1, she stated, "no". She said she had never had two residents to fight in the nursing home before and she was unsure of what she should have done. When asked if she notified the Administrator or DON, she said," no". She stated she attempted to call the Administrator, but got no answer to her phone. She admitted she did not attempt to call any of the other Administrative staff to report the incident. She admitted that there was no documented increased supervision for either resident after Resident #2 settled down. Review of Nurse's Notes dated 9/26/11 at 6:13 a.m. revealed the following: Returned from hospital via cab in wheelchair with assistance x 3. Awake and alert... Bandage to right cheek with mild bruising under right eye, right lower check/jaw swollen, right arm has red bruise down forearm. Resident moved to another room for safety/separation. An observation was made on 10/3/11 at 1:15 p.m. Resident #1 was in the room across from the nurse's station and the room he was moved from was down the hall, almost to the end of the hallway. Resident #2 was in a room by himself, but was unable to be observed as he was out of the facility. Review of the Nurse's Notes dated 9/26/11 at 7:00 p.m. revealed the following: Resident #1's family here wanting to know if police had been called about the incident yesterday. "Explained to her I wasn't here yesterday but was reported to me that the MD had been notified and was sent to ER and resident and roommate in separate rooms and are being kept apart." Family refused to speak with Administrator and called the police. She also called the ambulance service...Police demanding to see resident's chart-informed him that I would have to check with Administrator to see if he could see chart due to Hippa laws-he stated "this is a criminal case and I want to see the chart to see the record when he was sent to ER". I told him when I get permission from the Administrator to let him see the ER record I would let him and until I talked with the Administrator he would not see the record. Review of the Nurse's Notes dated 9/27/11 at 6:00 p.m. revealed the following in part: Resident #1's daughter here at this time wanting resident to go to hospital. Explained to her that resident had CT head ordered, she did not want to hear it. Order received to send resident to hospital. Review of the emergency room Chart dated 9/28/11 at 7:31 p.m. revealed the following: Triage and Nursing History: Patient involved in altercation 2 days ago and now has right eye ecchymosis and bruising to right thigh. Patient states got punched in face. Nursing Assessment: Patient was sent from local nursing home 2-3 days ago for check up after assault, states patient was feeling worse today so staff wanted to have patient rechecked. Patient complained of bilateral hip pain, ecchymosis noted to right orbit. A medium sized area of ecchymosis is noted over the right orbit. MD Assessment 9/28/11 at 7:30 p.m.: Primary Diagnosis 1) Alzheimer's Dementia 2) Altercation 3) Injury in a health care facility Chief Complaint: Injury to upper portion of face History of Present Illness: Patient was in altercation 2 days ago with another resident at the nursing home. His major complaint being left groin pain. Small bruise on face and thigh. No altered mental status, no headache, no nausea/vomiting. Today continues to deny these things and feels better except some mild left groin pain. Vital Signs: Blood Pressure: 100/62, Pulse: 72, Respirations: 20/min, Pain: 6/10. Resident returned from the hospital on [DATE] at 9:30 p.m. Review of the Nurse's Notes dated 9/28/11 at 10:50 a.m. revealed the following: Resident awake and alert, general weakness noted, leans to right side and unable to sit/stand alone. Notified Nurse Practitioner. New order for CT of head without contrast, Antivert 75mg every 6 hour PRN (as necessary), and Orthostatic B/P q shift x 48 hours. Orders noted, resident aware of new orders, up in chair in dining room with assistance x 2. Review of the medical record revealed there was no other documentation in the medical record of Resident #1 until 9/29/11 at 6:15 p.m. Review of the Nurse's Notes dated 9/29/11 with no documented time revealed the following: Send to ER-recent head injury-new onset incontinence, ataxia. Review of the Nurse's Notes dated 9/29/11 at 6:15 p.m. revealed the following: Notified ER nurse that resident would be transported to local hospital for recent head injury, incontinence, ataxia. Ambulance arrived at 8:20 p.m. Review of the Emergency Department Chart dated 9/29/11 at 6:55 p.m. revealed the following: Nursing Assessment: Mental Status: Patient back to Emergency Department via EMS with reported unable to ambulate and incontinence both bowel and bladder as per patient's daughter. Patient with right eye periorbital bruising and right hip bruising from altercation 4 days ago. Patient states has pain to his suprapubic area and states is unable to void. Pt currently wearing adult brief. Lethargic, poorly responsive. Oriented to person, Cooperative. Fully verbal, Cannot bear weight to walk. Skin: There is pain noted over the following areas: face and right hip and iliac crest. A small area of ecchymosis is noted over the following areas: face and right hip and iliac crest. Clinician History of Present Illness Incontinent of bowel and bladder since altercation at nursing home 2 days ago. Patient was hit in head and fell to ground. He was seen here with negative head CT and pelvis x-ray. He presents today with lower back pain, pelvis pain, may be more confused than baseline, and can't make it to the bathroom without urinating on self. Primary Diagnosis: [REDACTED]. Results: CT Lumbar Without Contrast: Films of the spine show: patient with 1 compression fracture Disposition: Patient admitted to hospital Review of the History and Physical dated 9/29/11 revealed the following: The patient was in an altercation with his roommate at a local nursing home approximately 4 to 5 days ago in which the patient was hit multiple times in the head and pelvic/back. The patient initially was evaluated in the emergency room , was negative for any fractures or acute changes on CAT scan of the head. The patient continued to complain of pain; In addition, the patient developed some new onset ataxia and bowel and bladder incontinence that was not present before the altercation. The patient is therefore admitted to the hospital for further evaluation and treatment. Review of Systems: HEENT (head, eye, ear, nose, and throat): The patient does complain of a headache, but is not present at the present time. GASTROINTESTINAL: Recent onset of bowel incontinence GENITOURINARY: Recent onset of urinary incontinence NEUROLOGICAL: The patient complains of some generalized weakness and difficulty walking. SKIN: Patient with notable bruises to the right orbital, temporal, and right ear. In addition, he also has right lower abdomen and flank pelvic area bruising, all from recent altercation ORTHOPEDICS: Some muscular pain, mostly to the right hip/pelvic area. ASSESSMENT/Diagnoses: [REDACTED]. 2. New onset urinary and bowel incontinence 3. Ataxia 4. Recent head injury Review of the Hospital Discharge Instructions dated 10/2/11 revealed the following: Discharge Diagnosis: [REDACTED]. Appointment: Follow-up with physician in 3 weeks Activity Level/Special Instructions: Up out of bed (OOB) with TLSO brace only Review of the Nurse's Note for Resident #2 dated 9/30/11 at 3:00 p.m. revealed the following: Recent physical altercation towards another resident. Resident alert, flat affect with s[DIAGNOSES REDACTED], poor judgement/insight, resist care from staff at intervals. Hostile behavior toward staff and others. Call placed to Nurse Practitioner for psych eval. Review of the Psychological Intake for Resident #2, dated 9/30/11 at 3:45 p.m. revealed the following: Problem (Hx of): Psychiatric psychosis Brief history of the problem: Patient has problems with anyone touching his personal belongings, and his roommate touched his remote control and he made physical contact with roommate to cause harm toward others. Review of Nurse's Note dated 9/30/11 at 5:00 p.m.--Resident was transported to Psych facility. An interview was conducted with S2DON on 10/4/11 at 9:10 a.m. She said that it was reported to her that the residents were not separated when the incident happened, but when Resident #1 returned to the facility from the emergency room where he was treated for [REDACTED].#2 She verified that Resident #2 was not sent out for a Psych evaluation until 9/30/11, five days after the altercation. She also said that Resident #2 should have been sent out for a Psych evaluation the day the altercation occurred because he had never exhibited any behavior of this nature before. She said they received him from another nursing home facility and was not aware of his abusive history. She said that the Administrator or she should have been notified of the incident as soon as it happened, but admitted she did not get a report of the incident until she returned on 9/27/11. She said she was at a workshop on 9/26/11 and did not work that day. She said she became aware of the incident, she requested a psychiatric evaluation for Resident #2. An interview was conducted with S1Administrator on 10/4/11 at 8:30 a.m. She stated she did not learn about the altercation of Resident #1 and Resident #2 until the afternoon of 9/26/11 when she was called when she was called by the floor nurse because the daughter of Resident #1 came to the facility and demanded that Resident #1 be sent to the emergency room . She said the staff knows that they need to notify the Administrator or other Administrative staff (DON, ADON, or Charge Nurse on Weekend)when a reportable incident occurs. She said that all staff should know what to do. She said that the numbers of all the Administrative staff are posted in the nurses' station and are available to all staff. She verified that she did not get a call immediately about the incident.

Based on record review and interviews, the facility failed to ensure residents attained the highest level of well being for 2 (#1, #2) of 7 sampled residents (#1, #2, #3, #4, #5, #6, and #7). The facility failed to: 1) Accurately assess the resident after an altercation to ensure there were no injuries that required emergency room visits and eventual hospitalization (#1) 2) Assess for causative factors that triggered Resident #2's aggressive, physical combative behavior and implement interventions addressing the causative factors. 3) Obtain a consult with a psychiatrist for a resident when he was admitted to the facility with psychiatric [DIAGNOSES REDACTED]. Disorder and after he had an altercation with his roommate. (#2) 4) Increase monitoring of a resident with aggressive, physical combative behavior after an altercation with his roommate (#2) Review of the Nurse's Note dated 9/25/11 at 8:45 p.m. revealed Resident #2 called the nurse to the room that was occupied by he and Resident #1. Resident #1 was found on the floor and stated he was beaten up by the roommate (Resident #2). Resident #2 was sitting in bed holding his fist and pointing to the TV remote control. When asked if they were fighting over the remote control, he stated "yes". Resident #1 was placed in an Immediate Jeopardy situation on 9/25/11 at 8:45 p.m. when it was discovered that he was beaten by Resident #2. The residents were not separated and the facility failed to immediately increase supervision or obtain a psychiatric consult for Resident #2. The facility failed to assess for causative factors that triggered Resident #2's abusive behavior. The Immediate Jeopardy ended for Resident #1 on 9/26/11 at 1:45 a.m. when he was transferred to a local hospital emergency room . The deficient practice continues at a scope and severity level II, potential for more than minimal harm, for all the residents of the facility, as the facility failed to assess Resident #2 for causative factors that triggered his behavior and have him psychologically evaluated. Findings: Resident #1 Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/30/11 revealed the resident's skills for decision making was Severely Impaired-never/rarely made decisions. Review of section G-Functional Status revealed the following: The resident was independent with bed mobility and eating, and required supervision with transfers, locomotion on and off the unit, dressing, toilet use, bathing, and personal hygiene. Under the section G0300-Balance During Transitions and Walking: 1) Moving from seated to standing position and Walking-Not steady, but able to stabilize without human assistance 2) Turning around, Moving on and off toilet and Surface-to-surface transfer-Steady at all times. An observation was made and an interview was conducted with Resident #1 on 10/3/11 at 8:45 a.m. The resident was awake and alert sitting in the wheelchair on his way to get a shower. He stated he was not having any pain at the moment. The resident had a small raised area noted above the right eyebrow. There was a discolored area under his right eye and some discoloration to the outer ear area. In an interview with the resident, he stated that Resident #2 was upset about some candy. He said he gave Resident #2 his candy back, but he still jumped on him. He said Resident #2 hit him with his fist and then kicked him in the groin. He stated that he hollered for help, but nobody heard him and came to see what was happening. He said that when he came to the facility, he was walking, but since the fight he has had to use the wheelchair for mobility. He said he had seen Resident #2 one time since the altercation and the transfer from the room, on the elevator, but he did not say anything to him. Review of the Client Incident Report dated 9/30/11 revealed the following: Events: Discovered: 9/25/2011 8:45 p.m. Occurred: 9/25/2011 8:45 p.m. Entered: 9/26/2011 7:10 p.m. Findings: Substantiated Accused/Allegation: Resident #2 Abuse: Physical Victim: Resident #1 Case Notes: On September 25, 2011 at 8:45 p.m. S5LPN was called to room ___ by Resident #2. She found Resident #1 (Resident #2's roommate) on the floor. Resident #2 was waving a remote control in the air holding his fist up. S5LPN completed an assessment on Resident #1 and assisted him into his bed.... Resident #1 had bruising to right outer eye and inner eye and raised area to right brow. Bruising to right temple was also noted... An assessment was completed for Resident #2 also. He did not complain of pain at the time of the incident. A scratch was noted under right eye. Residents were counseled and supervision was increased for both residents. Review of the medical record revealed there was no indication in the medical record that supervision was increased for either of the residents. Further review of The Client Incident Report dated 9/30/11 stated the following in part: On September 26, 2011 at 1:40 a.m. S5LPN entered room Resident #1's room and noted red emesis on floor next to his bed. Resident #1's mouth was also bloody. He was assisted to the bathroom per his request. Resident #1's gait was unsteady and resident complained of pain "down there". Physician notified and instructed to send Resident #1 to emergency room (ER). Family notified. Resident transported to ER via ambulance. Resident #1 returned to facility at 6:13 a.m. and placed in another room. Hospital paperwork stated a sprained hip joint was found. Left hip was negative for fracture and pelvis is negative for fracture. Review of the Nurse's Notes dated 9/26/11 at 1:40 a.m. revealed the following: Called to room by resident, in bed and wet. About 100-200cc's of red emesis noted on floor. Abrasion noted to face and mouth filled with blood. Resident #1 asking to go to restroom. Assisted to restroom with assistance of CNA's x 3. Resident gait unsteady, unable to hold head up. States he is hurting. He hit me down there. MD's office called and informed of patient's status-order received to send to ER. An interview was conducted with S9CNA on 10/4/11 at 8:30 a.m. She stated that Resident #1 was walking when he came to the facility, but he now has to use the wheelchair. She also stated the resident was going to the bathroom on his own, but was now wearing diapers for incontinence of both urine and bowel. An interview was conducted with S10LPN on 10/4/11 at 1:10 p.m. She said that she had been Resident #1 and Resident #2's nurse since their admission to the facility. She said that neither Resident #1 or Resident #2 had been involved in an altercation that she was aware of. She said they were both very quiet and never caused a confusion. Review of the Emergency Department Chart dated 9/26/11 revealed the following: Arrival Date: 9/26/11 2:19 a.m. Visit Date: 9/26/11 2:20 p.m. Chief Complaint: Assault Vital Signs/Data: Temperature: 97.6, Pulse: 92, Respiration 20, Blood Pressure: 137/75, Pain 6/10. Triage: History comes from patient, was supplied by the patient's nursing home record and supplied by patient's ambulance record. Nursing Assessment: Mental Status: Alert. Oriented to person, Cooperative and fully verbal. Skin: Skin is warm, dry and intact with normal color and turgor. There is a superficial but contaminated and dirty abrasion located on the right side of the forehead. The right side of forehead area of trauma which had been bleeding has no stopped. Clinical History of Present Illness Summary: Patient involved in altercation at nursing home. Staff found him lying on floor with the other guy waving a remote control at him. Patient states his roommate hit him in the groin and head. Patient has pain in his groin and head. He has blood in his mouth. Per nursing home staff he normally ambulates well, but is not walking as good as he usually does. Review of the medical record revealed there was no clear documentation in the medical record that Resident #1 was assaulted more than the one time. An interview was conducted with S5LPN on 10/4/11 at 1:45 p.m. When asked why the residents were left in the same room after the altercation, she stated that she calmed Resident #2 down and he was all right. She further stated that she had never been involved with the situation of two residents fighting and was not sure what she was suppose to do. She admitted that there was no documented increased supervision for either resident after Resident #2 settled down. Review of Nurse's Notes dated 9/26/11 at 6:13 a.m. revealed the following: Returned from hospital via cab in wheelchair with assistance x 3. Awake and alert... Bandage to right cheek with mild bruising under right eye, right lower check/jaw swollen, right arm has red bruise down forearm. Resident moved to another room for safety/separation. An observation was made on 10/3/11 at 1:15 p.m. Resident #1 was in the room across from the nurse's station and the room he was moved from was down the hall, almost to the end of the hallway. Resident #2 was in a room by himself, but was unable to be observed as he was out of the facility. Review of the Nurse's Notes dated 9/26/11 at 7:00 p.m. revealed the following: Resident #1's family here wanting to know if police had been called about the incident yesterday. "Explained to her I wasn't here yesterday but was reported to me that the MD had been notified and was sent to ER and resident and roommate in separate rooms and are being kept apart." Family refused to speak with Administrator and called the police. She also called the ambulance service...Police demanding to see resident's chart-informed him that I would have to check with Administrator to see if he could see chart due to Hippa laws-he stated "this is a criminal case and I want to see the chart to see the record when he was sent to ER". I told him when I get permission from the Administrator to let him see the ER record I would let him and until I talked with the Administrator he would not see the record. Review of the Nurse's Notes dated 9/27/11 at 6:00 p.m. revealed the following in part: Resident #1's daughter here at this time wanting resident to go to hospital. Explained to her that resident had CT head ordered, she did not want to hear it. Order received to send resident to hospital. Review of the emergency room Chart dated 9/28/11 at 7:31 p.m. revealed the following: Triage and Nursing History: Patient involved in altercation 2 days ago and now has right eye ecchymosis and bruising to right thigh. Patient states got punched in face. Nursing Assessment: Patient was sent from local nursing home 2-3 days ago for check up after assault, states patient was feeling worse today so staff wanted to have patient rechecked. Patient complained of bilateral hip pain, ecchymosis noted to right orbit. A medium sized area of ecchymosis is noted over the right orbit. MD Assessment 9/28/11 at 7:30 p.m.: Primary Diagnosis 1) Alzheimer's Dementia 2) Altercation 3) Injury in a health care facility Chief Complaint: Injury to upper portion of face History of Present Illness: Patient was in altercation 2 days ago with another resident at the nursing home. His major complaint being left groin pain. Small bruise on face and thigh. No altered mental status, no headache, no nausea/vomiting. Today continues to deny these things and feels better except some mild left groin pain. Vital Signs: Blood Pressure: 100/62, Pulse: 72, Respirations: 20/min, Pain: 6/10. Resident returned from the hospital on [DATE] at 9:30 p.m. Review of the Nurse's Notes dated 9/28/11 at 10:50 a.m. revealed the following: Resident awake and alert, general weakness noted, leans to right side and unable to sit/stand alone. Notified Nurse Practitioner. New order for CT of head without contrast, [MEDICATION NAME] 75mg every 6 hour PRN (as necessary), and Orthostatic B/P q shift x 48 hours. Orders noted, resident aware of new orders, up in chair in dining room with assistance x 2. Review of the medical record revealed there was no other documentation in the medical record of Resident #1 until 9/29/11 at 6:15 p.m. Review of the Nurse's Notes dated 9/29/11 with no documented time revealed the following: Send to ER-recent head injury-new onset incontinence, ataxia. Review of the Nurse's Notes dated 9/29/11 at 6:15 p.m. revealed the following: Notified ER nurse that resident would be transported to local hospital for recent head injury, incontinence, ataxia. Ambulance arrived at 8:20 p.m. Review of the Emergency Department Chart dated 9/29/11 at 6:55 p.m. revealed the following: Nursing Assessment: Mental Status: Patient back to Emergency Department via EMS with reported unable to ambulate and incontinence both bowel and bladder as per patient's daughter. Patient with right eye periorbital bruising and right hip bruising from altercation 4 days ago. Patient states has pain to his suprapubic area and states is unable to void. Pt currently wearing adult brief. Lethargic, poorly responsive. Oriented to person, Cooperative. Fully verbal, Cannot bear weight to walk. Skin: There is pain noted over the following areas: face and right hip and iliac crest. A small area of ecchymosis is noted over the following areas: face and right hip and iliac crest. Clinician History of Present Illness Incontinent of bowel and bladder since altercation at nursing home 2 days ago. Patient was hit in head and fell to ground. He was seen here with negative head CT and pelvis x-ray. He presents today with lower back pain, pelvis pain, may be more confused than baseline, and can't make it to the bathroom without urinating on self. Primary Diagnosis: [REDACTED]. Results: CT Lumbar Without Contrast: Films of the spine show: patient with 1 compression fracture Disposition: Patient admitted to hospital Review of the History and Physical dated 9/29/11 revealed the following: The patient was in an altercation with his roommate at a local nursing home approximately 4 to 5 days ago in which the patient was hit multiple times in the head and pelvic/back. The patient initially was evaluated in the emergency room , was negative for any fractures or acute changes on CAT scan of the head. The patient continued to complain of pain; In addition, the patient developed some new onset ataxia and bowel and bladder incontinence that was not present before the altercation. The patient is therefore admitted to the hospital for further evaluation and treatment. Review of Systems: HEENT (head, eye, ear, nose, and throat): The patient does complain of a headache, but is not present at the present time. GASTROINTESTINAL: Recent onset of bowel incontinence [MEDICAL CONDITION]: Recent onset of urinary incontinence NEUROLOGICAL: The patient complains of some generalized weakness and difficulty walking. SKIN: Patient with notable bruises to the right orbital, temporal, and right ear. In addition, he also has right lower abdomen and flank pelvic area bruising, all from recent altercation ORTHOPEDICS: Some muscular pain, mostly to the right hip/pelvic area. ASSESSMENT/Diagnoses: [REDACTED]. 2. New onset urinary and bowel incontinence 3. Ataxia 4. Recent head injury Review of the Hospital Discharge Instructions dated 10/2/11 revealed the following: Discharge Diagnosis: [REDACTED]. Appointment: Follow-up with physician in 3 weeks Activity Level/Special Instructions: Up out of bed (OOB) with TLSO brace only An interview was conducted with S5LPN on 10/4/11 at 1:45 p.m. She said that she did not separate the two residents when the altercation happened because she was able to calm Resident #2 down and he turned over in the bed and went to sleep. When asked if she knew what caused Resident #2 to get angry and hit Resident #1, she stated, "no". She said she had never had two residents to fight in the nursing home before and she was unsure of what she should have done. When asked if she notified the Administrator or DON, she said, "no". She stated she attempted to call the Administrator, but got no answer to her phone. She admitted she did not attempt to call any of the other Administrative staff to report the incident. An interview was conducted with S2DON on 10/14/11 at 9:10 a.m. She said that it was reported to her that the residents were not separated when the incident happened, but when Resident #1 returned to the facility from the emergency room , he was placed in another room. She verified that Resident #2 was not sent out for a psychiatric evaluation until 9/30/11, five days after the altercation. Review of the Nurse's Note for Resident #2 dated 9/30/11 at 3:00 p.m. revealed the following: Recent physical altercation towards another resident. Resident alert, flat affect with s[DIAGNOSES REDACTED], poor judgement/insight, resist care from staff at intervals. Hostile behavior toward staff and others. Call placed to Nurse Practitioner for psych eval. Review of the Psychological Intake for Resident #2, dated 9/30/11 at 3:45 p.m. revealed the following: Problem (Hx of): Psychiatric [MEDICAL CONDITION] Brief history of the problem: Patient has problems with anyone touching his personal belongings, and his roommate touched his remote control and he made physical contact with roommate to cause harm toward others. Review of Nurse's Note dated 9/30/11 at 5:00 p.m.--Resident was transported to Psych facility. An interview was conducted with S5LPN on 10/4/11 at 1:45 p.m. She said that she did not separate the two residents when the altercation happened because she was able to calm Resident #2 down and he turned over in the bed and went to sleep. When asked if she knew what caused Resident #2 to get angry and hit Resident #1, she stated, "no". She said she had never had two residents to fight in the nursing home before and she was unsure of what she should have done. When asked if she notified the Administrator or DON, she said, "no". She stated she attempted to call the Administrator, but got no answer to her phone. She admitted she did not attempt to call any of the other Administrative staff to report the incident. An interview was conducted with S2DON on 10/14/11 at 9:10 a.m. She said that it was reported to her that the residents were not separated when the incident happened, but when Resident #1 returned to the facility from the emergency room where he was treated for [REDACTED].#2. She verified that Resident #2 was not sent out for a psychiatric evaluation until 9/30/11, five days after the altercation. She also said that Resident #2 should have been sent out for a psychiatric evaluation the day the altercation occurred because he had never exhibited any behavior of this nature before. She said they received him from another nursing home facility and was not aware of his abusive history. She said that the Administrator or she should have been notified of the incident as soon as it happened, but admitted she did not get a report of the incident until she returned on 9/27/11. She said she was at a workshop on 9/26/11 and did not work that day. She said she became aware of the incident, she requested a psychiatric evaluation for Resident #2. An interview was conducted with S1Administrator on 10/4/11 at 8:30 a.m. She stated she did not learn about the altercation of Resident #1 and Resident #2 until the afternoon of 9/26/11 when she was called by the floor nurse because the daughter of Resident #1 came to the facility and demanded that Resident #1 be sent to the emergency room . She said the staff knows that they need to notify the Administrator or other Administrative staff (DON, ADON, or Charge Nurse on Weekend) when a reportable incident occurs. She said that all staff should know what to do. She said that the numbers of all the Administrative staff were posted in the nurses' station and were available to all staff. She verified that she did not get a call immediately about the incident. Resident #2 Resident #2 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS with an Assessment Reference Date of 8/30/11 revealed the the following: Section C-Cognitive Patterns C1000-Cognitive Skills for Daily Decision Making Moderately Impaired -decisions poor; cues/supervision required C1300-Signs and Symptoms of [MEDICAL CONDITION] A. Inattention-behavior continuously present, does not fluctuate B. Disorganized thinking-behavior continuously present, does not fluctuate Section D0500-Staff Assessment of Resident Mood Over the last 2 weeks, did the resident have any of the following problems or behaviors? H. Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that he has been moving around a lot more than usual Symptom presence-Yes Symptom Frequency-12-14 days (nearly every day) Review of the Nurse's Notes for Resident #2 dated 9/22/11 at 10:30 p.m. revealed resident had a [MEDICAL CONDITION] on the patio while outside smoking. Resident was sent to the hospital and returned at 12:40 a.m. Review of the Nurse's Note after Resident #2 returned from the hospital revealed the following in part: 9/22/11 at 12:40 a.m.--Patient returned to facility accompanied by CNA. Patient escorted per wheelchair to room. Asked patient to lay down, patient refused and non-compliant. 9/22/11 at 12:45 a.m.--Patient on elevator, gait instability. Patient refused to sit down. Continue to exit on elevator. Requesting to smoke. 9/22/11 at 1:28 a.m. --Exited elevator en route to room. 9/22/11 at 1:30 a.m.--Ambulated back to elevator-patient looking for cigarettes. 9/22/11 at 10:32 a.m.--Spoke with Nurse Practitioner regarding recent hospital visit last night and results of [MEDICAL CONDITION], new order for [MEDICATION NAME] 500mg po BID. Orders noted, will monitor.The next documentation in Resident #2's medical record was noted on 9/25/11 at 8:45 p.m. The following Nurse's Note was written: Resident in hall calling for assistance to his room. Upon entering room, roommate found on floor. Resident holding his fist and then points to remote. Roommate admits that they were fighting. Resident calmed down and turned over in bed. Incident report done. Unable to contact family-no long distance code. Resident denies any pain. Scratch noted to face. No drainage or bleeding noted. Will continue to monitor for any signs and symptoms of distress. Review of Nurse's Note dated 9/26/11 at 1:40 a.m. revealed the following: Resident refused vital signs for follow-up incident, attempting to fight. Resident turned over in bed and ignored all encouragement and need for assessment and evaluation. 9/26/11 at 9:00 a.m.--Awake and alert, refusing all care and medications. No apparent harm or physical damage noted. Denies problems, family notified of physical altercation. 9/26/11 at 10:50 p.m.--Asleep-easily awakened. Cooperative, flat affect. Left sided [MEDICAL CONDITION]. Ambulates with unsteady gait. Patient non-compliant with safety at times. Refuses wheelchair assistive device for mobility: no acute distress noted. Review of the Follow-Up Incident/Accident Form for Resident #2 dated 9/25/11-9/27/11 revealed the following: 9/25/11---11-7 Shift--Resident #2 refused-attempting to fight 9/26/11--7-3 Shift---Resident #2 refused all care and meds 9/26/11--3-11 Shift--Resident #2 refused 9/27/11--3-11 Shift--Resident #2 refused Review of the Care Plan for Resident #2 dated 9/2/11 revealed the following: Problem/Need: I am experiencing altered mood state related to I get anxious at times. I love to smoke and get annoyed if I don't have cigarettes. I have a [DIAGNOSES REDACTED]. Approaches: -Evaluate for environmental changes to enhance my mood -Evaluate my effectiveness of medication -Monitor me for target behaviors and or moods Problem dated 9/25/11--Resident holding his fist and pointing to remote with roommate on floor. Resident admits to fighting. Resident has right eye bruise (inner eye) and scratch under right eye lid. The approaches/interventions were not updated for the 9/25/11 incident. There were no interventions to increase supervision or closely monitor the Resident #2's behavior. Review of the medical record revealed Resident #2 had free access whole building (up and down stairs) unattended and went outside and smoked on a regular basis. An interview was conducted with S11MDS Coordinator on 10/4/11 at 3:00 p.m. She reviewed the care plan for Resident #2 and verified that that were no additional interventions added to the care plan when the resident's behavior changed.