Every finding on record at Clarion Wellness and Rehabilitation Center

Based on clinical record review, staff interviews, and policy review, the facility failed to administer medications as ordered by the physician for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 61 residents. Findings include:The Minimum Data Set (MDS) for Resident #1, dated 9/6/25, listed a diagnosis for hypertension (high blood pressure). The Physician's Order dated 10/22/25 directed to change Resident #1's order for amlodipine from 5 milligrams (mg) daily to 2.5 mg two times daily to start on 10/23/25. The Electronic Medication Administration Record (EMAR) indicated Resident #1 received 2.5 mg two times daily from 10/23/25 to 10/26/25 and on the morning of 10/27/25. In addition, the facility held evening dose for 10/27/25. The Electronic Health Record (EHR) indicated on 10/27/25 Staff A, Certified Medication Aide (CMA), informed Staff B, Licensed Practical Nurse (LPN), the medication cart had amlodipine 5 mg daily, when it should have a dose of 2.5 mg two times a day. Staff B contacted and received an order to hold the evening dose and resume 2.5 mg two times daily on 10/28/25. Resident #1 had a blood pressure of 157/96 (average 120/80) at that time. The facility notified Resident #1's sister and the DON of the medication error. In interview on 11/25/25 at 8:24 AM the Director of Nursing (DON) stated the order to change from amlodipine 5 mg daily to 2.5 mg two times daily on 10/23/25 did not get faxed to the pharmacy as their pharmacy is not integrated into their EHR. The nurse should have faxed the medication change to the pharmacy but forgot. They did not have the 2.5mg medication cards in the medication cart until 10/27/25 after catching the medication error. As corrective action, he spoke with all the nurses and CMAs about the 5 rights of medication administration and now prints off the order listing report daily and faxes it to the pharmacy as a double check. They also plan to change to a pharmacy that integrates with their EHR. The DON reported he didn't have documentation of the education as he did it verbally. When asked if the day shift gave the wrong dose of amlodipine 4 times and the evening shift charted, they gave a medication they did not have 4 times, he stated that they had. The Administration of Medications policy dated July 2017 directed all medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. It also indicated that prior to administering the resident's medication, the nurse or medication technician should compare the drug and dosage schedule on the resident's MAR with the drug label. NOTE: If there is any reason to question the dosage or the schedule, the nurse or med tech should check the physician's orders.

Based on facility record review and staff interview, the facility failed to have the minimum required members present at their quarterly Quality Assessment and Performance Improvement (QAPI) meetings as directed by Centers for Medicare and Medicaid Services (CMS). The facility reported a census of 62 residents. Findings include:The facility provide the list of sign-in sheets of the QAPI meetings. The review of the staff sign-in lacked documentation of the Infection Preventionist (IP) presence during the 2/18/25 meeting. An email from the Director of Nursing reflected all people who attended the QAPI meeting, signed the forms the day of the meet.During an interview on 8/28/25 at 9:05 AM the Administrator acknowledged the IP didn't sign the form to indicate attendance on the quarterly February 2025 QAPI meeting as expected. The Administrator added he planned to have QAPI meetings monthly instead of quarterly.

Based on clinical record review, observations, staff interviews, and policy review the facility failed to implement care plan interventions to reduce the risk for falls for 1 out of 20 residents reviewed (Resident #19). The facility reported a census of 62 residents.Findings include: Resident #19's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. Resident #19 required substantial to maximal assistance with bed mobility and all transfers. The MDS included diagnoses of fractures and other multiple traumas, depression, chronic obstructive pulmonary disease (COPD), muscle weakness, wedge compression fracture of the second lumbar vertebrae (a type of spinal fracture where the front portion of the vertebrae in the lumbar area of the spine collapses, creating a wedge shape), COVID-19, cognitive communication deficits, limitation of activities due to disabilities, other reduced mobility and repeated falls.The Care Plan Focus initiated 7/28/25 indicated Resident #19 had an actual fall with no injury. The Intervention created 8/10/25, initiated 8/8/25 directed to put Resident #19's bed a low position.The Nursing Note dated 8/8/25 at 8:38 AM documented 2 Certified Nurse Aides (CNA) summoned the nurse to Resident #19's room. The nurse observed Resident #19 lying on his right side on the floor facing the bed. He had his feet near the dresser next to the bed below the TV. He wore his brief but didn't have on his gown. Resident #19's had his oxygen concentrator on but didn't have the oxygen cannula in place as it laid on the bottom of the bedside table. Resident #19 sustained a skin tear to his right elbow that measured 2.7 centimeters (cm) x 2.7 cm with minimal bleeding. The nurse cleaned the area and applied border gauze (sterile multi-layered absorbent wound dressing). Three staff assisted Resident #19 from sitting position standing position with a gait belt and then into the wheelchair. An additional skin assessment revealed an abrasion to Resident #19's right knee covered with a Mepilex (a padded type dressing). Resident #19 had a small red area to the right shoulder blade. The note indicated Resident #19 could bear his own weight on both lower legs. The staff put oxygen back on Resident #19. The note reflected an immediate nursing intervention have Resident #19's bed in a low position while he's in bed. On 8/25/25 at 2:12 PM, observed Resident #19 lying in bed, not in low position.On 8/27/25 at 1:56 PM, observed Resident #19 lying in bed, not in low position.On 8/27/25 at 3:32 PM, Staff A, CNA reviewed Resident #19's Care Plan and stated it directed the bed be in low position. After going to Resident #19's room, observed him lying supine in bed without the bed low position. Staff A lowered the bed to the lowest position closest to the floor.On 8/27/25 at 4:05 PM, the Director of Nursing (DON) said he expected the staff to follow the Care Plan. On 8/28/25 at 9:00 AM, the Administrator reported the standard of practice is for the staff to follow the Care Plan.The Fall Management policy revised June 2018 directed to provide each resident with an appropriate assessment and intervention to prevent falls and minimize complications if falls occur.

Based on clinical record review, staff interview, hospital record review, and facility policy review, the facility failed to provide adequate nursing supervision to prevent an accident and injuries for 1 of 1 resident reviewed (Resident #23) related to a suicide attempt. Resident #23 voiced he wanted to kill himself and had a plan on 5/17/25 (he attempted to use his fingernails to try to dig out a vein) and 5/18/25 (he placed a pen over his wrist and inner arm bend), the facility sent him to the emergency room (ER) on both dates. Upon return on 5/17/25 the facility implemented temporary one-to-one (1:1) supervision. The facility discontinued the supervision the same day around 9:30 PM without putting any further safety interventions in place. Resident #23 returned to the ER on [DATE] related to suicide ideation and gestures. The facility reported a census of 62 residents. Findings include:Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS identified Resident #23 as independent with bed mobility, transfers, and required partial/moderate assistance with ambulation. The MDS included diagnoses of anxiety, depression, and schizophrenia.The Care Plan Focus revised 10/7/24 indicated Resident #23 took psychotropic medications related to the diagnoses of bipolar, schizoaffective disorder, and auditory hallucinations. The Interventions directed the following:a. Staff to monitor, record, and report to the Provider as needed any side effects and adverse reactions of psychoactive medications that included suicidal ideation.b. Staff to notify psychiatric services via telehealth of increased auditory hallucination, statements of voices telling Resident #23 to do inappropriate things or self-harm. The Care Plan lacked information regarding suicide precautions or a prevention plan.The Nursing Note dated 5/16/25 at 5:03 AM reflected Resident #23 stood at the end of the hallway yelling, Give me my fucking water, give me my fucking water now, I'm going to fuck you up. The note documented Resident #23 threatened to hit the staff with his walker. Resident #23 came down the hallway full force with his walker in his hand and knocked the Registered Nurse (RN) to the ground. Resident #23 stood over the RN and stated, give me fucking water now. The note indicated Resident #23 returned to his room, slammed his door shut and started hitting the walls loudly. The note documented facility called the police and ambulance to transfer Resident #23 to the hospital. The Hospital After Visit Summary dated 5/16/25 documented an altered mental status with diagnosis of agitation as the reason for Resident #23's visit. The summary documented a new order to give hydroxyzine (medication used for anxiety) 50 milligrams (mg) every 6 hours as needed for agitation. The Ambulance Service Report dated 5/17/25 documented the Emergency Medical Services (EMS) received a page to the facility for Resident #23 due to statements of him being suicidal and conducting self-harm with his fingernail. The facility staff reported they couldn't control him. The report documented the facility nurse reported Resident #23 told her he was going to commit suicide and was not going to stay at the facility. The facility nurse reported Resident #23 went to the emergency room (ER) within the last 20-hours for the same thing. The note documented EMS transferred Resident #23 to the ER. A Psychiatric Evaluation assessment dated [DATE] at 9:43 PM revealed Resident #23 completed a suicide risk screening and was considered a positive screen. Resident #23 answered yes to the questions of in the past few weeks, have you wished you were dead? Have you ever tried to kill yourself? In addition, when asked Resident #23 how he tried to kill himself, he reported he wanted to leave the nursing home and so he cut himself superficially to be taken seriously and get out. The Psychiatric Evaluation Reassessment dated [DATE] indicated Resident #23 arrived to the emergency department (ED). The facility nurse reported him as delusional and suicidal. On arrival, he reported suicidal ideations and had superficial scratches on his arms. Resident #23 reported he was trying to dig a vein out. The note documented Resident #23 declared he would kill himself if he had to go back to the facility. The note indicated Resident #23 didn't have any thoughts of hurting himself during the assessment. The Nursing Note dated 5/17/25 at 10:34 AM documented Resident #23 returned to the facility with a new order to start Geodon (antipsychotic medication) 20 mg 1 tablet at bedtime. The indicated Resident #23 rested in his room with his call light in place. Resident #23's clinical record lacked documentation of implementation a formal suicidal prevention plan, suicide precautions and/or interventions upon his return from the ER. The Condition Follow-Up Note dated 5/18/25 at 4:34 AM indicated Resident #23 told the staff to shut the door when they leave after they open his room door.The Behavior Note dated 5/18/25 at 4:53 PM documented Resident #23 refused all medication during the morning (AM) and evening (PM) pass. The note reflected Resident #23 told staff he was suicidal. When the nurse asked Resident #23 if he had a plan, he slammed the door to his room. When the nurse opened the door to visit with Resident #23 regarding his suicidal intentions, he held a pen on his wrist and then moved the pen to his antecubital area (inner arm bend). Resident #23 informed the nurse he would take his medication. When the nurse informed him, they had to crush his medication due to his history of pocketing, regurgitating, and stockpiling the medication in his room, Resident #23 pushed the nurse with the door and attempted to slam the door on the nurse. The note revealed the nurse called 911 and informed police of Resident #23's behaviors and the police directed to send him to the ER. The Nursing Note dated 5/18/25 at 5:00 PM, documented as the nurse filled out paper work to send Resident #23 to the ER, the police officer called for an ambulance due to him becoming increasingly agitated and restless. A Psychiatric Evaluation assessment dated [DATE] at 9:43 PM reflected Resident #23 completed a suicide risk screen, that resulted in a positive screen. Resident #23 answered yes to the following questions of in the past week, have you been having thoughts about killing yourself? Have you ever tried to kill yourself? In addition, when Resident #23 asked how he tried to kill himself, he replied that he tried to put a pen to his arm.The Psychiatric Evaluation Assessment listed Resident #23's chief complaint as suicide. The note reflected Resident #23 reported if he went back, he would try it again. The impression/risk assessment documented Resident #23 may have decompensated psychiatrically and he required inpatient psychiatric hospitalization for safety, medication management, and discharge planning. The Psychiatric Evaluation Reassessment dated [DATE] at 9:41 AM documented the impression/risk assessment indicated when informing Resident #23 he would be returned back to the long-term care facility, he developed conditional suicidal ideation, stating he would poke himself again if he went back. The reassessment treatment/therapy recommendations directed the long-term care facility to remove all sharp objects including pens and utensils (can have plastic utensils) and Resident #23 should be in line of sight at the care facility.The Nursing Note dated 5/20/25 at 4:53 PM documented Resident #23 returned to the facility accompanied by the Administrator and the Director of Nursing (DON). The note documented the facility received new orders for Resident #23 to have no sharp objects could harm the patient or staff in his room. The note indicated the facility faxed the psychiatric evaluation reassessment to the primary provider. Resident #23's clinical record lacked documentation of the implementation of a formal suicidal prevention plan, suicide precautions and/or interventions after he return from the hospital. The clinical record lacked documentation the facility implemented the order for Resident #23 to have no sharp objects, increased supervision, or had him in line of sight. On 8/26/25 at 3:56 PM, the DON reported he didn't feel Resident #23 acted suicidal, but behavioral. He said he knew Resident #23 and felt he tried to find a way to leave the building. He said he talked with Staff D, Licensed Practical Nurse (LPN), about Resident #23's behaviors. He said Resident #23 didn't harm himself but acted like he would. He said the pen didn't actually touch Resident #23's skin. The DON said he didn't have any concerns and didn't think Resident #23 would actually harm himself. When asked what safety measures, they put in place, the DON responded when Resident #23 returned from the ER on [DATE] he asked Staff E, Certified Medication Aide (CMA), to sit with Resident #23. He reported Resident #23 chased Staff E out of his room and down the hallway. He said he spoke to Resident #23 and didn't think he was a continuous risk. The DON reported he didn't recall any scratch marks. He said it must not have broken the skin and he didn't have a huge concern about the incident. When asked if the facility did any suicide assessments, the DON replied no. On 8/27/25 at 9:42 AM, Staff C, RN, reported when she came on duty that night, Resident #23 already went to the ER on ce. She said later that night Resident #23 walked up to the nurses' station and said he would commit suicide if he couldn't go back to the ER. Staff C reported she asked him if he had a plan and he referred to his fingernails. She said Resident #23 dug into his antecubital and described the area as red with scratches but without blood. She said she told Resident #23 he went to the ER. She said Resident #23 said he would go back to his room and keep working at it. She described him as adamant he needed to go to the ER or he would kill himself. She added Resident #23 stated he had his teeth and she didn't know for sure what he planned to do with his teeth. She said she made the decision, Resident #23 needed evaluated. She called the ER and the DON. She said Resident #23 went to sit in the dining room. She went in and out of the nurses' station and could see where he sat. She said she couldn't say 100% if he continued to scratch at his arms but she didn't see any movement with his hands. When asked if anyone, provided supervision in the dining room, she responded no. She said Resident #23 left the dining room to go back to his room when the police officer showed up and knew him. She said the police officer went back to Resident #23's room and stayed with him until the ambulance came. She said Resident #23 walked out of his room and sat on the cot. She described him as not aggressive. When asked if Resident #23 had any history of suicidal ideation, she replied she didn't recall any, just that one week. She said his behaviors reached an all-time high level. She described Resident #23 saying he wanted to die as different for him. She said Resident #23 had strange quirks but reported that as something different. When asked if the facility had a suicide policy and/or an assessment, she said normally if the staff felt a resident had a potential risk they would remove anything from the room that could be used to harm themselves like sharp objects, call light cords, or shoes laces. She didn't think that happened on her shift unless they did it the next day. She said Resident #23 didn't have a lot of stuff in his room.On 8/27/25 at 10:57 AM, Staff D, LPN, reported Staff E, CMA, tried to give Resident #23 his medications. He refused the medications and told Staff E he wanted to kill himself. She said Staff E told her about it, so she went to his room. She said Resident #23 put a pen to his wrist and moved it to his left antecubital area. Staff D said he didn't push the pen into his skin and she didn't think he had the pen out. She said Resident #23 didn't make any marks on his skin. She said Resident #23's incident happened not long after he had an encounter with another nurse he injured. Staff D said she stood in the doorway and Resident #23 tried to slam the door on her. She described the door as really heavy and Resident #23 really had to push the door. She felt Resident #23 tried to crush her with the door. Staff D said she had concerns about his aggressiveness towards her. She said she called his primary care physician and received an order to send Resident #23 to the ER. She said when the officer arrived and after some time passed Resident #23 started to get aggressive with the officer. When asked if the facility had a policy or protocol regarding suicide, she replied she believed the facility did, but couldn't remember what the policy said. She thought the policy directed 15-minute checks, removing objects that could be sharp or used to harm themselves, and to provide a bell as a call light. When asked if the facility put any safety interventions in place, she responded she didn't know of any interventions and no one passed any information about one in report. She acknowledged she didn't put any interventions in place herself, and didn't know if anyone went through his room to look for harmful objects. She reported she didn't really have concerns about him hurting himself. She said Resident #23 didn't like to be in pain and she didn't think he had the means to hurt himself. She said he didn't have much in his room to begin with. She acknowledged Resident #23 spent a lot of time in his room with the door shut and he ambulated independently. She reported he could have the opportunity to obtain something if he wanted. She reported she didn't know how he got the pen. On 8/27/25 at 2:00 PM, the DON reported on 5/17/25 after Resident #23 returned from the hospital he asked Staff E to provide 1:1 care. He said Staff E was scheduled until 2 PM but agreed to stay over. He said he stopped the 1:1 with Resident #23 after Staff E called him. He said he didn't feel Resident #23's needed the 1:1 as Resident #23 didn't voice any suicidal thoughts. When asked if they put any additional safety precautions in place after they stopped the 1:1, he replied no. The DON and Corporate Nurse verified the facility didn't update the Care Plan regarding Resident #23's suicidal ideation, attempts, and interventions. On 8/27/25 at 2:17 PM, Staff E, CMA reported she worked 6 AM to 2 PM on 5/17/25. Staff E said the facility asked her to stay over to provide 1:1 with Resident #23. She said she started the 1:1 around 2 PM and stopped around 9:30 PM. She called the DON and he gave her the okay to leave since Resident #23 acted like his regular self. She said she didn't know if anyone provided supervision prior to 2 PM or after she left. She sat in his room and then moved out into the hallway for his comfort. On 8/27/25 at 3:54 PM, the DON reported he didn't know about the treatment recommendations from the psychiatric reassessment on 5/20/25. He added they didn't provide Resident #23 supervision to keep him within line of sight. He acknowledged Resident #23 had his room at the end of the hallway and he liked to keep his door closed. The Suicidal Precaution and Prevention policy revised October 2024 directed the staff to:a. Identify residents at risk to self-injury.b. To keep the safety of residents as a priority. When a resident expresses the desire to die or states a plan to kill oneself, all staff begin a Suicide Watch.c. Any staff person hearing a resident express things such as life isn't worth living, wishes for death, or attempts to harm himself will report the information to their supervisor, licensed nurse/charge nurse, or DON. The policy instructed to complete the following:a. Nursing to call a primary care physician, responsible party and/or surrogate decision maker. b. Nursing to monitor, via room every 15 minutes and/or 1:1 interaction depending on resident's verbalization of plans to harm themselves.c. Initiate alert charting including, but not limited to such observations as to the nature of the resident's comments, body language, verbal expression, and mood.d. Include residents and type of comments to the 24-hour report.e. Review medical status and/or condition with a medical provider to rule out medical conditions. Notify the crisis line or send the resident to the ER for evaluation. f. Resident's door to remain open at all times. Staff to pull the privacy curtain when giving care.g. All staff keep sharp objects out of reach of the resident (needles, scissors, pens, mirrors, glass picture frames, cords, jewelry, etc.)h. Dietary to provide all meals/snacks on paper/plastic products. i. Social Services will evaluate resident's psychosocial and mood indicators. They will coordinate and communicate with the mental health clinicians and update the plan of care as needed.

Based on clinic record review, staff interviews, and policy review, the facility failed to administer medications per physician orders for 1 out of 1 resident reviewed (Resident #23) for significant medication errors. The facility reported a census of 62 residents. Findings include: Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS listed Resident #23 as independent with bed mobility, transfers. He required partial/moderate assistance with ambulation. The MDS included diagnoses of anxiety, depression, and schizophrenia.The Care Plan Focus revised 10/7/24 reflected Resident #23 took psychotropic medications (antipsychotic medication Haldol and Geodon) related to diagnoses of bipolar (frequent changes in mood), schizoaffective disorder (a mixture of mood and schizophrenic symptoms), and auditory hallucinations (hearing things not there). The Interventions directed staff to administer medications as ordered and give the Haldol Decanoate intramuscular injection (IM) every month as ordered.Resident #23's May 2025 Medication Administration Record included the following orders:a. Started 5/16/24: Fluphenazine HCL (antipsychotic medication) 5 milligrams (mg) administer 1.5 tablets every morning (AM) and at bedtime (HS) related to schizoaffective disorder. The MAR lacked documentation of administration on the following days: i. 5/18 - AM ii. 5/23 - AM, HS iii. 5/24 - AM iv. 5/25 - AM v. 5/27 - AM, HSb. 5/17/25: Geodon - inject 20 mg IM as needed every time Resident #23 refused to take the fluphenazine for 2 weeks related to schizoaffective disorder, bipolar type. The MAR lacked documentation that staff offered and/or Resident #23 received Geodon 20 mg IM on the dates/times he didn't receive or refused his fluphenazine medication. A Physician order dated 6/25/25 directed staff to administer Haldol Decanoate IM - inject 50 mg IM one time every 30 days related to schizoaffective disorder. Resident #23's July 2025 MAR indicated he didn't receive the Haldol Decanoate IM on 7/26/26.The eMAR - Medication Administration Note dated 7/26/25 at 12:58 PM documented Resident #23 refused his medication and care needs. The progress notes lacked documentation staff offered or attempted to give the Haldol Decanoate injection at a later time. The Secure Conversation with the Primary Care Physician Note dated 8/13/25 documented Resident #23 missed his medication. The note identified Resident #23 didn't receive his monthly injection of Haldol on 7/26/25 and was due again on 8/26/25. The Physician directed staff to give the Haldol injection on 8/13/25 or as soon as possible and to complete monthly thereafter. An incident report titled Medication Error dated 8/13/25 documented Resident #23 missed his monthly Haldol injection on 7/26/25. The incident report documented the staff gave the medication and adjusted the MAR. On 8/26/25 at 3:56 PM, the Director of Nursing (DON) acknowledged the facility didn't give Resident #13's Haldol Decanoate IM in July per the Physician order. He said the nurse made an error and identified it. He said the staff gave the Haldol IM when they found the error. On 8/26/25 at 4:21 PM, Staff B, Licensed Practical Nurse (LPN), reported she found the Haldol IM medication error. Staff B said she honestly didn't know how the error occurred. She said Resident #23 had increased behaviors and as she researched his notes/orders, she discovered he didn't receive his Haldol injection in July. She notified the DON and Physician and gave the injection that day she identified the error. On 8/27/25 at 12:04 PM, the DON reported he expected the nursing staff to administer the Haldol Deaconate IM per the Physician's orders. On 8/27/25 at 2:00 PM, the DON acknowledged Resident #23 didn't receive the Geodon IM as ordered by the physician and he expected the staff to follow the order.The Administration of Medications policy dated July 2017 directed to administer medication as prescribed by the resident's physician, nurse practitioner, or physician's assistant. The policy directed staff to administer medication in accordance with the written orders of the attending physician and as recorded on the resident's MAR.

Based on clinical record review and staff interviews, the facility failed to have a complete and accurately documented medical record for 1 of 20 residents reviewed (Resident #23). The facility reported a census of 62 residents.Findings include: Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS listed Resident #23 as independent with bed mobility, transfers. He required partial/moderate assistance with ambulation. The MDS included diagnoses of anxiety, depression, and schizophrenia.A Physician order dated 4/9/24 directed staff to administer benztropine mesylate (Cogentin, medication to treat side effects of other drugs) 1 milligram (mg) at bedtime related to schizoaffective disorder, bipolar type.The Secured Conversations Note dated 5/10/25 at 8:33 PM indicated the nurse sent a message to the primary care physician (PCP) identified the facility didn't have Resident #23's Cogentin medication in stock since the beginning of the month.Resident #23's May 2025 Medication Administration Record (MAR) documented he received his Cogentin medication from 5/1/25 to 5/5/25 and on 5/9/25. On 8/26/25 at 2:05 PM, the Pharmacist reported the pharmacy sent 27 tablets of Cogentin on April 4th to cover until the end of April. She said the pharmacy didn't send any Cogentin again until May 20th when the facility got the order reinstated. She said the pharmacy didn't send the Cogentin medication at the beginning of May as the prior authorization (PA) ran out and the pharmacy didn't receive a new PA. She said the pharmacy received an order to discontinue the Cogentin medication on 5/12/25. She said the pharmacy sent the PA either to the facility or Provider to complete. She said they sent a notice of noncoverage to the facility initially on 4/17/25. She said the notice of noncoverage, and the PA are two separate things. She said the notice of noncoverage provided a list of different options for the facility. She said the facility had the option to authorize the fill until the approval of the PA, requested an alternative medication from the Provider, or asked the provider to hold the medication until the approval of the PA. She said they sent the notice of noncoverage again to the facility on 5/8/25.On 8/27/25 at 12:04 PM, the Director of Nursing (DON) acknowledged the staff signed off the MAR that they administered the Cogentin medication in May when the facility didn't have the medication. The Administration of Medications policy dated July 2017 directed staff to record all current drugs and dosage schedules on the resident's MAR. In addition, the policy directed the staff must indicate the reason and document the appropriate code they withheld a drug with any follow up documentation as appropriate for the situation.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past 2 surveys, and staff interview, the facility failed to correct their own deficiencies for 1 of 1 areas of concern. The facility reported a census of 62 residents. Findings include: The survey identified a concern with infection prevention and control at the current recertification survey and during the last 2 recertification surveys: The undated facility Quality Assurance and Performance Improvement (QAPI) Plan documented the facility will put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also included tracking, investigating, and monitoring adverse events every time they occur, and action plans implemented through the plan, do, study, act (PDSA) cycle of improvement to prevent recurrences.During an interview on 8/28/25 at 1:15 PM, the Administrator acknowledged the facility received a deficiency at F880 on the current recertification survey and the previous 2 recertification surveys.

Based on observation, record review and staff interview, the facility failed to provide wound care in a manner to prevent infection for 1 of 3 residents reviewed with wounds (Resident #3). The facility reported a census of 63 residents.Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental status (BIMS) score of 13, indicating no cognitive impairment. The MDS included diagnoses of diabetes, chronic obstructive pulmonary (lung) disease, and pressure ulcer of the sacral region.The Care Plan Focus dated 7/9/25 identified Resident #3 had an actual skin impairment of a pressure ulcer to her coccyx. The Care Plan identified Resident #3 had a risk for additional pressure ulcers. The Goals listed his ulcers would remain free from infection. The Care Plan Identified Resident #3 had a diabetic ulcer of the right front leg, with a secondary etiology (cause) of a venous (impaired blood flow of the veins) leg ulcer. The Goals indicated Resident #3 wouldn't have complications from the ulcer through the review date.On 8/25/25 at 11:23 AM watched Staff B, Licensed Practical Nurse (LPN), perform Resident #3's wound care. Staff B placed supplies on Resident #3's table without a barrier. Staff B put on a gown and gloves, then removed a dressing from Resident #3's lower leg. Without hand hygiene, Staff B changed her gloves completed Resident #3's wound care and removed her gloves. Staff B washed hands for a few seconds turned off faucet with her bare hand before she removed paper towels to dry her hands. Staff B put on new gloves. Resident #3 stood, and Staff B removed the dressing to their coccyx (area above the buttock). Without hand hygiene, Staff B changed her gloves, cleansed the area, applied ointment, and covered the ulcer. Staff B then washed her hands in the same manner previously described. On 8/27/25 at 4:05 PM the Infection Preventionist (IP) stated the staff should only take the dressing supplies needed to a resident's room and then put on a barrier. She reported the staff should wash their hands for 20 seconds and use a paper towel to shut off the faucet. She stated staff should complete hand hygiene with sanitizer or washing hands between glove changes. The Hand Hygiene policy revised October 2022 instructed to provide the necessary supplies, education, and oversight to ensure healthcare workers performed hand hygiene based on accepted standards. The policy described hand hygiene as one of the most effective measures to prevent the spread of infection. Studies showed that effective hand decontamination could significantly reduce the rate of healthcare associated infection. All personnel should follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:a. Before and after coming on dutyb. Before and after direct contact with residentsc. Before donning sterile glovesd. Before handling clean or soiled dressings, gauze pads, etc.e. Before moving from a contaminated body site to a clean body site during resident caref. After contact with a resident's intact sking. After contact with blood or bodily fluids h. After handling used dressings, contaminated equipment, etc.m. After removing gloves i. After removing and disposing of personal protective equipment.The procedure directed to vigorously lather hands with soap, rubbing them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. The staff should rinse hands thoroughly under running water while holding their hands lower than their wrists without touching their fingertips to the inside of sink. The policy instructed to dry hands thoroughly with paper towels and then turn off the faucets with a clean, dry paper towel.

Based on observations, resident interview, facility records review, staff interview, and policy review, the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility (Residents #6 and #7) for 2 of 5 resident reviewed for call lights. The facility reported a census of 56 residents. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The Census listed Resident #6 resided in private room [ROOM NUMBER]. On 7/8/25 at 3:23 PM, observed Resident #6's call light on. At 3:50 PM observed someone answer the call light. The observation revealed Resident #6 had his call light on for 27 minutes. On 7/9/25 at 8:36 AM, Resident #6 reported his call lights can be on for half an hour or more. He reported the long call lights happened a lot and was his biggest concern. Resident #6 reported he kept track of the call light times with his phone and his clock. He said he planned ahead and pushed the call light early when he has to go to the bathroom as he knew he would have to wait. He said the facility didn't have a specific shift when the call lights were worse. He reported in general the facility had long call lights. Review of Resident #6's Call Light report for room [ROOM NUMBER] from 7/2/25 to 7/9/25 listed call lights on for 15 minutes or more on the following dates and times:7/2 - 5:19 AM - 16 minutes7/2 - 6:55 AM - 17 minutes7/3 - 12:32 AM - 20 minutes7/3 - 6:50 AM - 16 minutes7/4 - 6:19 AM - 21 minutes7/4 - 8:31 AM - 20 minutes7/4 - 9:24 AM - 16 minutes7/4 - 12:36 PM - 17 minutes7/4 - 1:56 PM - 17 minutes7/5 - 8:55 AM - 24 minutes7/5 - 5:45 PM - 28 minutes7/7 - 10:00 PM - 18 minutes7/8 - 2:51 PM - 27 minutes7/8 - 3:23 PM - 26 minutes and 48 seconds7/8 - 6:16 PM - 17 minutes7/8 - 8:42 PM - 18 minutes2. Resident #7's MDS assessment dated [DATE] identified a BIMS score of 5, indicating severe cognitive impairment. The Census revealed Resident #7 resided in private room [ROOM NUMBER]. On 7/8/25 at 3:17 PM, observed Resident #7's call light on. At 3:49 PM witnessed someone answered their call light. The observation revealed Resident #7 had their call light on for 32 minutes. Review of Resident #7's Call Light report for room [ROOM NUMBER] from 7/2/25 to 7/9/25 reflected they had their call light on 15 minutes or more on the following dates and times:7/2 - 4:42 AM - 16 minutes7/2 - 12:54 PM - 23 minutes7/2 - 7:04 PM - 16 minutes7/3 - 12:04 AM - 40 minutes7/3 - 10:44 PM - 16 minutes7/4 - 1:12 AM - 20 minutes7/4 - 5:22 AM - 25 minutes7/4 - 6:04 AM - 27 minutes7/4 - 5:23 PM - 33 minutes7/4 - 6:50 PM - 16 minutes7/4 - 8:46 PM - 21 minutes7/5 - 2:41 AM - 19 minutes7/5 - 8:47 AM - 45 minutes7/5 - 9:51 AM - 16 minutes7/5 - 12:24 PM - 20 minutes7/5 - 1:30 PM - 36 minutes7/5 - 5:53 PM - 17 minutes7/6 - 3:53 AM - 32 minutes7/6 - 5:35 PM - 18 minutes7/6 - 5:56 PM - 17 minutes7/6 - 6:32 PM - 20 minutes7/7 - 3:44 AM - 31 minutes7/7 - 3:32 PM - 20 minutes7/7 - 5:23 PM - 50 minutes7/7 - 8:52 PM - 22 minutes7/8 - 3:17 PM - 31 minutes7/8 - 5:42 PM - 27 minutes7/8 - 10:08 PM - 31 minutes and 34 seconds7/9 - 5:22 AM - 20 minutesOn 7/9/25 at 9:07 AM, the Administrator reported he expected the staff to answer call lights within 15 minutes. He reported the facility had 2 staff members called in the afternoon of 7/8/25. A facility policy titled Call Light/Bell revised May 2007 directed staff to answer the light/bell within a reasonable time of 10 - 15 minutes.

Based on clinical record review, hospital record review, policy review, resident and staff interviews, the facility failed to provide care and services to promote healing of pressure wounds for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 56 residents.Finding include:The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) which may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar.Unstageable Ulcer: inability to see the wound.Other staging considerations include:Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent skin. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 required substantial/maximal assistance with bed mobility and depended on staff for transfers. Resident #1's MDS included diagnoses of hypertension (high blood pressure), anemia (low blood iron), diabetes mellitus, malnutrition (not enough nutrition), and orthopedic aftercare following surgical amputation. The MDS documented Resident #1 had a risk for developing pressure ulcers/injuries. The MDS identified Resident #1 had 2 venous/arterial ulcers and surgical wounds. The MDS documented Resident #1 received the following skin and ulcer/injury treatments: pressure reducing device to chair/bed, nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care, applications of nonsurgical dressing, and applications of ointment/medications. The Care Plan with a goal date of 4/22/25 documented Resident #1 had a pressure ulcer to the coccyx (area near the buttocks) and right knee related to disease process, history of ulcers, immobility (lack of movement), peripheral vascular disease (impaired blood vessels in the legs and arms) and diabetes mellitus. The care plan directed the following interventions:- Staff to administer medications/treatments as ordered and monitor/document for side effects and effectiveness.- Staff to assess, record, and monitor wound healing including measuring the wound (length, width, depth), status of the wound perimeter (area around the wound) and wound bed. The intervention directed staff to report improvements and declines to the Physician. - Staff to monitor, document, and report to the Physician as needed changes in the skin status including appearance, color, wound healing, wound size, wound stage, signs and symptoms of infection.- Staff complete a weekly head-to-toe skin at risk assessment. The Braden Scale for Predicting Pressure Sore Risk documented the following scores:1/3/25 - 14 - Moderate Risk3/11/25 - 11 - High Risk4/5/25 - 9 - Very High [NAME] Progress Note dated 1/24/25 documented Resident #1 had a new wound to his coccyx. The note documented the area as open and described the skin around the wound as red/purple in color. The note documented the nurse requested a treatment order for Triad paste (treatment used to keep wound bed moist and facilitate autolytic debridement body does the work) to the area and the Physician responded ok. The progress note lacked documentation of measurements, type and staging of the wound.A Progress Note dated 1/31/25 documented Resident #1 received new orders to discontinue the Triad paste and clean the sacral (tailbone) wound with wound cleanser, pat dry, apply skin prep to peri-wound and apply Allevyn sacrum dressing (foam dressing) every 3 days and as needed. A Skin Pressure Ulcer Weekly assessment dated [DATE] documented Resident #1 had a stage 2 pressure wound to his coccyx that measured 1.0 cm (centimeters/length) x 0.7 cm (width). The assessment documented the wound bed had granulation (new tissue and small blood vessels that develop on a wound as it starts to heal) with no drainage or odor present. A Progress Note dated 2/18/25 at 4:07 PM documented Resident #1 left the facility via ambulance and went to the local hospital. A Progress Note dated 2/18/25 at 8:08 PM documented Resident #1 remained in the emergency room waiting for admission to another hospital. Review of the clinical record lacked documentation of skin assessments for the coccyx wound from 2/6/25 to 2/18/25. The clinical record documented Resident #1 returned to the facility on 3/11/25. The form titled After Visit Summary dated 3/11/25 directed staff to apply hydrophilic wound dressing topical paste (Triad paste) to Resident #1's sacral wound 2 times a day and as needed if soiled (dirty).The form titled Initial admission Record dated 3/11/25 lacked documentation a skin assessment was completed of the coccygeal sacral region upon return from the hospital. Review of the clinical record lacked documentation of skin assessments for the coccygeal sacral (area above the tailbone and the lower back) region from 3/11/25 to 3/26/25.A Progress Note dated 3/26/25 at 11:34 AM documented Resident #1 admitted to the hospital due to low blood pressure and wounds. A Hospital Wound Consultation note dated 3/26/25 documented the hospital evaluated Resident #1 due to pressure ulcer/injury management. The note revealed Resident #1 had known sacral and right knee pressure wounds. The note revealed the following wound assessments for the sacrum and right knee:A. Sacrum Primary wound type: PressureLength: 1.3 cmWidth: 0.8 cmStage: healing full thicknessWound description: clean with granulationWound edges: definedDrainage: serous (thin, watery, clear or pale yellow), scant amount, wound bed moistOdor: absentB. Anterior Right Knee Pressure InjuryPrimary wound type: PressureLength: 6 cmWidth: 5 cmStage: unstageableWound description: eschar, sloughWound edges: definedDrainage: serous Odor: absentThe clinical record documented Resident #1 returned to the facility on 4/4/25. The form titled Initial admission Record dated 4/4/25 documented Resident #1 had a superficial wound to his coccyx area that measured 1.9 cm x 0.8 cm. The assessment lacked documentation regarding the characteristics or staging of the wound to the coccyx. In addition, the readmission assessment documented Resident #1 had a pressure area to the right knee that measured 3.5 cm x 3.8 cm. The assessment documented the right knee wound bed as 100% slough (a form of dead tissue that prevents healthy tissue from developing) and well-defined edges (distinct with a smooth outline).The form titled Discharge summary dated [DATE] directed staff to administer the following wound care/treatments:A. Coccyx - clean the area with soap and water, rinse, pat dry, apply liberal (large amount) layer of Triad paste to entire coccygeal and sacral regions twice a day and as needed for all incontinent episodes. Ensure all of the Triad paste was thoroughly removed from the area at least once daily.B. Right Knee - cleanse the area with soap and water, rinse, pat day, apply a thin layer of Normilgel ag (antimicrobial hydrogel used to assist with debridement and removal of slough in dry necrotic dead tissue wounds) to the wound, ensuring the ointment stay within the wound edges, cover the wound with dry gauze then secure with wrap gauze daily and as needed for soiling or dislodgment. The April 2025 Treatment Administration Records (TAR) revealed the treatment order for Resident #1's right knee was not transcribed to the TAR indicating the treatment was not completed from 4/4/24 to 4/16/24. Review of the Discharge summary dated [DATE] revealed the facility Wound Nurse noted the treatments orders on 4/4/25. Review of the clinical record lacked documentation of skin assessments for the coccygeal sacral region from 4/6/25 to 4/16/25.A Progress Note on 4/16/25 documented the hospital admitted Resident #1. On 7/8/25 at 11:30 AM, Staff A, Licensed Practical Nurse (LPN)/Wound Nurse, verified being present during Resident #1's readmission skin assessment on 4/4/25. She said Resident #1 had a superficial (near the surface) open area on his coccyx that measured 1.9 cm x 0.8 cm with a 3 cm x 3 cm area of redness around the open area. She described the area as an abrasion with the top layer of skin missing. When asked about noting the readmission physician orders on 4/4/25, Staff A reported not being responsible for putting the physician orders in the computer. She said the Director of Nursing (DON) or the MDS Coordinator took care of the orders. She said when she noted the orders, she didn't see the treatment order included the right knee.On 7/8/25 at 11:42 AM, the DON acknowledged the lack of skin assessments for Resident #1 related to the coccygeal sacral region. He verified he couldn't locate documented treatments for Resident #1's right knee from 4/4 to 4/16. He reported he expected the staff to complete at admission or readmission complete a full head-to-toe skin assessment and document any areas of concern. He reported he expected the documentation included the wound measurements and characteristics. In addition, he expected the staff to put treatment orders in place immediately. The DON said he expected the staff to follow the Physician orders and document the completion of the treatments on the TAR. A facility policy titled Skin and Wound Monitoring and Management revised April 2025 directed the following:1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individua's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and2. A resident with pressure injury(s) received the necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing.The policy documented that a licensed nurse must assess/evaluate a resident's skin on admission. The policy instructed to document all areas of breakdown, excoriation, or discoloration, or other unusual findings, on the Initial admission Record. The assessment/evaluation should align with the scope of practice and include but not be limited to:1) Measuring the skin injury2) Staging the skin injury (when the cause is pressure)3) Describing the nature of the injury (e.g., pressure, stasis, surgical incision)4) Describing the location of the skin alteration5) Describing the characteristics of the skin alterationIn addition, the policy directed a licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, that existed on the resident. The assessment/evaluation should include but not be limited to:1) Measuring the skin injury2) Staging the skin injury (when the cause is pressure)3) Describing the nature of the injury (e.g., pressure, stasis, surgical incision)4) Describing the location of the skin alteration5) Describing the characteristics of the skin alteration6) Describing the progress with healing, and any barriers to healing which may exist7) Identifying any possible complications or signs/symptoms consistent with the possibility ofinfectionIn addition, the policy instructed to monitor the skin daily via medication and treatment administration records. The policy directed staff to confirm the implementation of all orders as ordered.

Based on clinical record review, facility policy review, residents and staff interviews the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of their quality of life for 3 out of 6 residents reviewed. (Residents #1, #2 and #4). The facility identified a census of 66 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating no memory impairments. able to be understood and understand by others, no behaviors and supervision with all activities of daily living (ADL). The MDS included diagnoses of heart failure, diabetes mellitus, anxiety, bipolar and the need for assistance with personal cares. The MDS reflected Resident #1 received an antianxiety medication in the lookback period. The Care Plan Focus initiated 1/1/25 indicated Resident #1 had a potential for a psychosocial well-being problem related to a verbal abuse incident. The Interventions included: *Allow time to answer questions and to verbalize feelings perceptions, and fears. *Increase communication between resident/family/caregivers about care and living environment: explain all procedures and treatments, medications, results of labs/tests, condition, all changes, rules, options. *Provide emotional support as needed *Provide opportunities for family to participate in care. *Social Services to check on resident periodically to see how she is coping and needs any further assistance/follow up. The Incident Note dated 1/1/25 at 4:00 PM reflected Resident #1 stated she put on her call light to have a Certified Nursing Assistant (CNA) staff make bed. A CNA went into Resident #1's room and turned off light stating, she didn't have any time. Resident #1 watched the CNA staff go up and down the hall for the next two hours, without stopping at her room. After about 2 hours, Resident #1 pressed her call light again. The same CNA returned to Resident #1's room and turned off her light yelling I am answering 'fucking' call lights, I don't have time. When leaving the room, Resident #1 stated she wanted the door left open. The CNA instead slammed the door shut. Immediate Intervention: The facility notified the Director of Nursing (DON) immediately and immediately walked the CNA out of facility. The Social Services Note dated 1/2/25 at 10:31 AM indicated a staff member talked with Resident #1 regarding the Incident on 1/1/25 with the CNA she talked to about making her bed. Resident #1 said, I pulled the call light and asked her to make my bed, the CNA stated she would when she finished answering call lights. Resident #1 said, I had my door opened and I kept seeing her go back and forth. I pulled the light again and she came in stating, 'I told you when I have time, I will make your bed' and then she walked out. Resident #1 stated, When I used the call light for a 3rd time, she came in and yelled at me saying, 'she will get to my bed when she can.' I was scared because she was so angry and yelling at me. Resident #1 said she didn't see her for the rest of the night. This staff person asked her about how long she did the call lights to ask for her bed to be made and resident stated at least 45 minutes. Resident #1 said that she never felt this upset with a staff person and she felt safe at the facility, all the girls there are good to me except this time. The Condition Follow-up Note dated 1/3/25 at 2:44 AM, for the condition that started 1/1/25, regarding the abuse allegation by a CNA to Resident #1. Resident #1 rested quietly with no change in mood or sleep pattern, no tearfulness, and no vocalization regarding incident with the CNA. The Condition Follow-up Note dated 1/3/25 at 2:08 PM for the condition that started 1/1/25, regarding the abuse allegation by a CNA to Resident #1. Resident #1 didn't voice any concerns regarding the abuse allegation with the CNA. Resident #1 rested in the recliner with no distress noted. Call light within reach. The Condition Follow-up Note dated 1/3/25 at 10:41 PM, for the condition that started 1/1/25, regarding the abuse allegation by a CNA to Resident #1. Resident #1 didn't voice any concerns regarding abuse allegation with the CNA. Resident #1 rested in bed with no distress noted, with her call light within reach. The Condition Follow-up Note dated 1/4/25 at 5:44 PM, for the condition that started 1/1/25, regarding the abuse allegation by a CNA to Resident #1. Resident #1 voiced no complaints of the current caregivers and reported, I feel better now that she doesn't work down this hall. Interview on 2/10/25 at 5:15 PM, Resident #1 verified Staff A, CNA, didn't treat her very nice being very rude and disrespectful when she only wanted her bed made. Resident #1 stated she hasn't seen Staff A since the incident and she felt safe at the facility. 2. Resident #2's MDS assessment dated [DATE], identified a BIMS score of 15, indicating intact cognition. The MDS indicated Resident #2 didn't have behaviors. The MDS listed Resident #2 as dependent on staff for toilet use, personal hygiene, and transfers. The MDS included diagnoses of anemia (low blood iron level), hypertension (high blood pressure), diabetes mellitus, arthritis, anxiety, depression, and bipolar. The MDS reflected Resident #2 used antianxiety medication within the lookback period. The Care Plan Focus initiated 1/1/25 identified Resident #2 had a potential for psychosocial well-being problem related to a verbal abuse incident with a CNA. The Interventions include: *Allow time to answer questions and to verbalize feelings perceptions, and fears. *Increase communication between resident/family/caregivers about care and living environment: explain all procedures and treatments, medications, results of labs/tests, condition, all changes, rules, options. *Provide emotional support as needed *Provide opportunities for family to participate in care. *Social services to check on resident periodically to see how she is coping a needs any further assistance/follow up. The Follow-up Condition Note dated 1/1/25 at 8:45 PM, for the condition that started 1/1/25, regarding emesis and the abuse allegation by a CNA to Resident #2. Resident #2 stated her upset stomach went away when she took the as needed Zofran (anti-nausea) medication. Resident #2 verbalized being slightly upset about the CNA staff. The writer made sure to tell Resident #2 she is safe. Resident #2 appeared alert and oriented to person, place, and time with no other concerns or complaints noted. The Incident Note dated 1/1/25 at 10:33 PM, the writer received notification that Resident #2 complained of verbal abuse from a CNA. Resident #2 stated she didn't feel well that morning and throughout the afternoon. She requested to go to bed to a CNA. The CNA yelled at Resident #2 stating nobody told me you didn't feel well, why didn't first shift put you to bed. Resident #2 reported the CNA as very rude to her. The Immediate Intervention indicated the facility notified the DON immediately and management team. The facility walked the CNA out immediately. The Follow-up Condition Note dated 1/2/25 at 5:35 AM, follow-up for the condition that started 1/1/25, regarding emesis and the abuse allegation by a CNA to Resident #2. Resident #2 rested quietly throughout the night with no tearfulness or verbalization regarding the incident the day before. The Social Services Note dated 1/2/25 at 9:36 AM, reflected the writer talked with Resident #2 about the incident on 1/1/2025 with the CNA. Resident #2 stated, I have not been feeling well the last 3-4 days which I know because the last 2 holidays have been hard for me due to the loss of my daughter. I had my bed raised with my 2 pillows next to my head and I laid over the bed with my top half. I had asked to use the bathroom and then go to bed. The CNA told her that she didn't hear that in report and why didn't she tell the staff about being sick. Resident #2 replied it's not my fault if you didn't know. The CNA continued being rude and short tempered with her. A staff person came in and the CNA left, and I didn't see her again. Resident #2 said reported that CNA as the only one that talked to her like that. She gets along with other people there on staff and she felt safe there. The Nursing Note dated 1/5/25 at 8:57 PM, reflected Resident #2 had her call light on. When the agency CNA answered the call light, Resident #2 stated that it's 8:30 PM. The CNA replied yes, it is. Is there something that I can help you with? Resident #2 said I need to be put to bed. Resident #2 was already lying in bed. The same agency staff member stated, you are in bed. Is there a routine you would like me to do? Resident #2 became visibly upset, and repeated Goodnight. Give me my blanket. Goodnight. At the time, the writer helped the roommate in Resident #2's room. The writer nurse stated to agency CNA to reproach at a later time. When Resident #2's light came on again, the writer answered the call light. The writer asked Resident #2 what she could assist her with, and she stated, going to bed. The writer asked her to tell her routine, she became visibly upset again. The writer educated Resident #2 on the importance of communication with staff to ensure the best care. Resident #2 verbalized understanding and had no further complaints that shift. Interview on 2/10/25 at 4:15 PM, Resident #2 reported Staff A as very rude and disrespectful to her. Resident #2 stated the staff treat her with dignity and respect except for Staff A. Since the incident, Resident #2 explained she hasn't seen Staff A at the facility. 3. Resident #4's MDS assessment dated [DATE], identified a BIMS score of 14, indicating intact cognition. The MDS reflected Resident #4 didn't have behaviors. Resident #4 required substantial to maximum assistance with activities of daily living (ADLs). The MDS listed Resident #4 as dependent with transfers. The MDS indicated Resident #4 always had incontinence of bladder and bowel. The MDS included diagnoses of heart failure, depression, muscle weakness, and unsteadiness of gait. The Care Plan Focus initiated 12/4/24, reflected Resident #4 had the potential for a psychosocial well-being problem related to a verbal abuse incident with an agency CNA. The Interventions include: *Allow time to answer questions and to verbalize feelings perceptions, and fears. *Increase communication between resident/family/caregivers about care and living environment: explain all procedures and treatments, medications, results of labs/tests, condition, all changes, rules, options. *Provide emotional support as needed *Provide opportunities for family to participate in care. *Social Services to check on resident periodically to see how he is coping and needs any further assistance/follow up. The Social Services Note dated 12/17/24 at 4:11 PM indicated the write talked with Resident #4 that day. He said he felt safe there and got good care. He voiced no concerns at that time. The clinic record had two progress notes with the same information on 12/19/24 at 10:52 AM one titled Nursing labeled as late entry and one titled Social Services. The notes reflected Resident #4 reported to the staff that morning that during the night, he had an aide larger in size, with dark hair, tall and with glasses come into his room to do care and poked him in the chest. He described the poking as annoying but it didn't really hurt. Resident #4 said he was awake, so he didn't know why she did that. He said, she was frustrated with me because I couldn't roll like she wanted me too. She was rude, and I didn't want her to take care of me again. No noted bruising to his chest noted at that time. Resident #4 verified I like all the caregivers. This one wasn't a regular staff person. The Condition Follow-up Note dated 12/20/24 at 3:48 AM, for the condition that started 12/19/24, regarding an agency CNA verbally aggressive to Resident #4. Resident #4 rested quietly, with no change in mood and sleep pattern. No tearfulness noted. Resident #4 cooperated with positioning changes with some agitation, per his normal. The Condition Follow-up Note dated 12/20/24 at 9:48 PM, for the condition that started 12/19/24, regarding an agency CNA verbally aggressive to Resident #4. Resident #4 reported he is very much over and not bothered any longer about the rude CNA. The Condition Follow-up Note dated 12/21/24 at 5:23 PM, for the condition that started 12/19/24, regarding an agency CNA verbally aggressive to Resident #4 and poked him in the chest. No concerns voiced over reports of CNA being verbally and physically aggressive. The Social Services Note dated 1/9/25 at 8:38 AM indicated the writer visited with Resident #4 that morning and he stated his care has been good, and the staff answer his call light in a timely manner. He added he felt safe there. Interview on 2/10/25 at 2:00 PM, Resident #4 verified that an agency CNA was not happy to do his care, treated him rude, and not with respect. Resident #4 explained the CNA took a finger and poked him in the chest to wake him up, it didn't hurt, it was just annoying because he was already awake. Resident #4 stated he felt safe at the facility. Interview on 2/11/25 at 3:00 PM, the facility administrator and DON, verified they expected all staff to treat residents with dignity and respect per the policy/procedure. The Resident Rights document dated October 2016, instructed as a resident of the nursing facility, they have the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. They have the right to exercise their rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States. The section regarding Respect and Dignity, indicated they have the right to be treated with respect and dignity.

Based on resident's record review, staff interviews, facility investigation review, time card detail, employee files, and policy review, the facility failed to separate staff members accused of alleged physical and verbal abuse from dependent residents in a timely manner for 2 of 2 residents reviewed (Residents #47 and #316). 1. Resident #47 reported an allegation of physical abuse on 3/20/24 to a Certified Nurse Aide (CNA). The CNA failed to report the allegation to Administration, which allowed the alleged abuser to work multiple days after the allegation. In addition, one dietary staff member learned of the allegation in the morning of 3/26/24, but failed to report the allegation until 5:00 PM that evening. This allowed the staff member to continue to work their entire shift on 3/26/24. 2. A CNA witnessed another CNA swear at a behavioral resident on 6/16/24. The CNA didn't report the incident to Administration until 6/20/24, their next scheduled day to work. Due to the lack of the CNA reporting the incident to Administration, the alleged abuser continued to work multiple days until 6/20/24. The Department notified the facility of the immediate jeopardy (IJ) on 10/16/24 of the IJ that began on 3/20/24. The facility removed the immediacy on 10/16/24 after implementing the following: a. The facility educated all staff on 10/16/24 regarding the abuse policy and reporting of alleged abuse to their supervisor immediately. The facility would notify the as needed (PRN) staff prior to them working their next shift. b. The facility terminated the employment of the 2 alleged perpetrators. The facility lowered the scope and severity from a level K to an E prior to the survey exit after ensuring the facility implemented their removal plan. The facility reported a census of 61 residents. Findings include: 1. Resident #47's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. The assessment reflected a Resident Mood Interview (PHQ 9) score of 6, indicating mild depression. The MDS reflected Resident #47 didn't have evidence of acute changes in mental status, indicators of psychosis including hallucinations or delusions, no behaviors such as physical, verbal, wandering or rejection of cares. The MDS included diagnoses of heart failure, diabetes mellitus, and depression. Resident #47 received Hospice services during the lookback period. The Care Plan Focus dated 3/28/24 indicated Resident #47 had a potential problem with her psychosocial well being problem related to an incident with a staff member. The Intervention dated 6/4/24 directed Staff B, Dietary, not to enter Resident #47's room alone. The Care Plan lacked documentation of delusions, hallucinations, or making false statements. Review of the facility's investigation reflected Staff C, CNA, completed their employee statement by phone on 3/26/24 at 6:00 PM. Staff C stated she went into Resident #47's room on 3/20/24 with an agency CNA, to put her to bed. While they provided her care, Resident #47 asked them if she told them something, could they promise not to tell anyone? Resident #47 then told them Staff B from dietary brought her meal to her room, visited with her for a little bit, and when he went to leave he kissed her on the neck prior to leaving the room. He also told her his wife didn't understand his sense of humor. Staff C reported she told Resident #47 she needed to tell someone. The facility immediately reeducated Staff C on timely reporting of allegations of abuse and they voiced understanding. Review of the facility's investigation dated 3/26/24, listed the facility's corrective action as suspending Staff B pending the outcome of the investigation. The facility re-educated all staff on the current procedure for reporting any suspected adult abuse. Review of Staff B's time cards dated 3/20/24 to 4/10/24, reflected he continued to work on 3/20/24, 3/22/24, 3/23/24, 3/25/24, and 3/26/24 with access to vulnerable residents. The facility placed Staff B, on suspension during the investigation process and allowed him to return to work on 4/4/24. On 10/16/24 at 8:28 AM, observed Staff B push a cart from the kitchen to Resident #47's room with a room tray. Staff B entered Resident #47's room delivering a breakfast tray. Interview on 10/16/24 at 11:30 AM, Staff J, Dietary, reported she often saw Staff B go into Resident #47's room. Staff J stated Staff B is part of the kitchen staff and didn't understand why he needed to go in there so often. Interview on 10/16/24 at 11:40 AM, Staff K, CNA, revealed she often saw Staff B go in and out of Resident #47's room. Interview on 10/16/24 at 11:50 AM, Staff C explained Resident #47 told her Staff B would bring her meals and always tell her it was nice to have her to talk to because his wife didn't understand. On that day after saying that Staff B, bent down and kissed her before leaving the room. Interview on 10/16/24 at 11:58 AM, Staff L, CNA, revealed Staff B went in Resident #47's room a lot. Staff L explained at times, they had to ask Staff B to leave Resident #47's room to provide cares. Staff L, CNA, stated they didn't know Staff B couldn't be in Resident #47's room alone. 2. Resident #316's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of neurocognitive disorder with Lewy bodies (disorder that affects memory), cognitive communication deficit (difficulty talking due to memory), anxiety disorder, abnormalities of gait and mobility, muscle weakness, and need for assistance with personal care. Resident #316 used antipsychotic medication, antianxiety medication, and antidepressant medication within the lookback period. The Care Plan Focus dated 6/21/24 indicated Resident #316 had a terminal prognosis related to Lewy body dementia. The Intervention instructed the staff to encourage him to express his feelings and listen with non judgmental acceptance and compassion. Review of facility's investigation, the DON's statement dated 6/20/24, reflected they received a phone call from Staff I, Human Resources (HR), reporting Staff F, CNA, told her Staff C, CNA, used profanity when caring for Resident #316. The event occurred on 6/16/24 during the graveyard shift and Staff F didn't report it until 6/20/24, her next scheduled day to work. Review of the facility's investigation, Staff I's, CNA, statement indicated on 6/16/24 they each watched Resident #316 for 30 minutes. Staff I sat with Resident #316 while Staff C sat at the other end of the table. When Staff I returned from break, she started answering call lights. Staff C started yelling and screaming at Staff I for not sitting with Resident #316. Staff I told the nurse that if she screamed at her like that again, she would go home. After that Staff C sat with Resident #316. Staff C talked very mean to Resident #316, and told him, he is going to sit his fucking ass down. Then she asked him where do you think you are going? You are not going anywhere. This went on until Staff I sat with Resident #316 again. The night nurse suggested Staff I take Resident #316 to the back desk and chart to keep things mellow for the night. Review of the facility's investigation dated 6/20/24, listed the corrective action as Staff C immediately suspended from working pending investigation. Review of time cards dated 6/16/24 to 6/20/24, Staff C continued to work the rest of her overnight shift on 6/16/24 6/17/24 and an overnight shift on 6/19/24 6/20/24. Review of a disciplinary notice dated 7/2/24 for Staff C identified due to gross misconduct - suspicion of verbal or emotional abuse of a resident. On 6/20/24 a staff member reported that Staff C spoke to Resident #316 on 6/16/24 using profanity. The facility immediately placed Staff C on leave until 7/2/24. Following the completion and outcome of the investigation, the facility terminated Staff C's employment immediately. On 10/17/24 at 1:07 PM the Administrator stated they expected any staff who witness any form of abuse is to separate the victim and alleged abuser, making sure the victim is safe. Then immediately report the allegation to administration staff including the Administrator and the DON. Review of facility provided policy Abuse Prevention and Prohibition revised September 2017 indicated that each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but not limited to freedom from corporal punishment, involuntary seclusion, any physical or chemical restraints not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends or other individuals. The section labeled Prevention indicated all personnel, residents, visitors etc. are encouraged to report incidents and grievances without the fear of retribution. The facility will provide feedback regarding concerns. The facility employees will take action to protect, prevent abuse, and neglect from occurring within the facility by: Staff having knowledge of the individual residents' care needs. Supervision of staff to identify inappropriate behaviors (i.e. derogatory language, rough handling, ignoring residents while giving care etc.). Assess, Care Plan and monitor residents' rooms, self injurious behaviors, communication disorders, totally dependent on staff. Protection If a resident incident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, the facility will take the following steps to prevent further potential abuse while the investigation is in progress; if the suspected perpetrator is an employee: Remove employee immediately from the care of any resident; suspend the employee during the investigation.

Based on clinical records review, staff interview, facility investigation review, and policy review, the facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) of 2 of 2 allegations of physical and verbal abuse within 24-hours of staff learning of the incidents. 1. On 3/20/24 around 11:30 PM, Resident #47 notified a Certified Nursing Aide (CNA) of alleged physical abuse. On 3/26/24 around 5:50 AM a Dietary Aide learned of Resident #47's allegation of physical abuse by a second CNA. No one reported the allegation of abuse until the Dietary Aide reported it to the Director of Nursing (DON) on 3/26/24 around 6:00 PM. The facility began their investigation of the alleged abuse on 3/26/24 and reported the incident to that evening at 10:08 PM. 2. On 6/16/24 around 11:30 PM a CNA documented they witnessed alleged verbal abuse towards Resident #316. The CNA reported the alleged verbal abuse to the DON on 6/20/24 around 3:30 PM. The DON called the DIAL abuse hotline on 6/20/24 around 3:40 PM to report the alleged abuse. The facility failed to provide the completed investigation findings and results within 5 days to the DIAL. The Facility filed their Self-Report with the DIAL on 7/1/24 at 9:14 PM. The Department notified the facility of the immediate jeopardy (IJ) on 10/16/24 of the IJ that began on 3/20/24. The facility removed the immediacy on 10/16/24 after implementing the following: a. The facility educated all staff on 10/16/24 regarding the abuse policy and reporting of alleged abuse to their supervisor immediately. The facility would notify the as needed (PRN) staff prior to them working their next shift. b. The facility terminated the employment of the 2 alleged perpetrators. The facility lowered the scope and severity from a level K to an E prior to the survey exit. The facility reported a census of 61 residents. Findings include: 1. Resident #47's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. The assessment reflected a Resident Mood Interview (PHQ 9) score of 6, indicating mild depression. The MDS reflected Resident #47 didn't have evidence of acute changes in mental status, indicators of psychosis including hallucinations or delusions, no behaviors such as physical, verbal, wandering or rejection of cares. The MDS included diagnoses of heart failure, diabetes mellitus, and depression. Resident #47 received Hospice services during the lookback period. The Care Plan Focus dated 3/28/24 indicated Resident #47 had a potential problem with her psychosocial well being problem related to an incident with a staff member. The Intervention dated 6/4/24 directed Staff B, Dietary, not to enter Resident #47's room alone. The Care Plan lacked documentation of delusions, hallucinations, or making false statements. The Nursing Note dated 3/26/24 at 6:40 PM identified Staff C, CNA, reported Resident #47 told her as she provided care of an incident on 3/20/24 at approximately 11:30 PM. Resident #47 reported that previous to 3/20/24, as Staff B, Dietary, brought a meal to her room, he visited with her for a while, and then kissed her on the neck prior to leaving her room. The Director of Nursing (DON) interviewed Resident #47 immediately, she reported Staff B kissed her on the cheek prior to leaving the room. She didn't remember exactly which day it occurred but stated she knew it happened prior to the day she said something to the girls. She denied feeling unsafe or afraid of Staff B and stated he's a nice man. The DON continued the investigation. Resident #47 had a BIMS score of 13, indicating intact cognition. Review of facility Self-Report indicated the incident approximately occurred on 3/20/24 at 11:30 PM. The facility submitted the report on 3/26/24 at 10:08 PM. Review of the facility's investigation reflected Staff C, CNA, completed their employee statement by phone on 3/26/24 at 6:00 PM. Staff C stated she went into Resident #47's room on 3/20/24 with an agency CNA, to put her to bed. While they provided her care, Resident #47 asked them if she told them something, could they promise not to tell anyone? Resident #47 then told them Staff B from dietary brought her meal to her room, visited with her for a little bit, and when he went to leave he kissed her on the neck prior to leaving the room. He also told her his wife didn't understand his sense of humor. Staff C reported she told Resident #47 she needed to tell someone. The facility immediately reeducated Staff C on timely reporting of allegations of abuse and they voiced understanding. Staff D's, Dietary Aide, statement on 3/26/24 at 6:00 PM, reflected Staff E, CNA, notified her around 5:50 AM that Staff C mentioned Resident #47 let her know when Staff B took her room tray, he set it down on the table, and then gave her a kiss on the neck. No one mention what day it happened. In an interview on 10/15/24 at 1:32 PM, Staff D reported on 3/26/24 at 5:50 AM, Staff E told her that Staff C told her about the incident with Resident #47 and Staff B. Staff D stated she reported it to the Administration at approximately 6:00 PM on 3/26/24. Review of the facility's investigation dated 3/26/24, listed the facility's corrective action as suspending Staff B pending the outcome of the investigation. The facility re-educated all staff on the current procedure for reporting any suspected adult abuse. 2. Resident #316's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of neurocognitive disorder with Lewy bodies (disorder that affects memory), cognitive communication deficit (difficulty talking due to memory), anxiety disorder, abnormalities of gait and mobility, muscle weakness, and need for assistance with personal care. Resident #316 used antipsychotic medication, antianxiety medication, and antidepressant medication within the lookback period. The Care Plan Focus dated 6/21/24 indicated Resident #316 had a terminal prognosis related to Lewy body dementia. The Intervention instructed the staff to encourage him to express his feelings and listen with non judgmental acceptance and compassion. The Care Plan Focus dated 4/19/24 reflected Resident #16 had a risk for elopement and wandering related to disorientation to place. The Interventions directed the following: a. Identify patterns of wandering and intervene as appropriate. b. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. The Change of Condition Note dated 6/16/24 at 6:04 PM indicated Resident #316 received an order to increase his lorazepam (antianxiety medication) due to his increased restlessness and anxiety. Review of the facility's Self-Report indicated an allegation of abuse occurred on 6/16/24 at 12:30 AM. The report listed the date knew as 6/20/24, with the Self-Report filed 7/1/14 at 9:14 PM. Review of facility's investigation, the DON's statement dated 6/20/24, reflected they received a phone call from Staff I, Human Resources (HR), reporting Staff F, CNA, told her Staff C, CNA, used profanity when caring for Resident #316. The event occurred on 6/16/24 during the graveyard shift and Staff F didn't report it until 6/20/24, her next scheduled day to work. Review of the facility's investigation, Staff I's, CNA, statement indicated on 6/16/24 they each watched Resident #316 for 30 minutes. Staff I sat with Resident #316 while Staff C sat at the other end of the table. When Staff I returned from break, she started answering call lights. Staff C started yelling and screaming at Staff I for not sitting with Resident #316. Staff I told the nurse that if she screamed at her like that again, she would go home. After that Staff C sat with Resident #316. Staff C talked very mean to Resident #316, and told him, he is going to sit his fucking ass down. Then she asked him where do you think you are going? You are not going anywhere. This went on until Staff I sat with Resident #316 again. The night nurse suggested Staff I take Resident #316 to the back desk and chart to keep things mellow for the night. Review of the facility's investigation dated 6/20/24, listed the corrective action as Staff C immediately suspended from working pending investigation. On 10/17/24 at 1:07 PM the Administrator stated they expected any staff who witness any form of abuse is to separate the victim and alleged abuser, making sure the victim is safe. Then immediately report the allegation to administration staff including the Administrator and the DON. Review of facility provided policy, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment revised 11/28/17 indicated in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property, are reported immediately but not later than 2-hours after the allegation is made if the events that cause the allegation involve abuse or resulted in serious bodily injury. Not later than 24-hours if the events that cause the allegation didn't involve abuse and didn't result in serious bodily injury. Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the facility, the State Survey Agency, and the Adult Protective Services (as appropriate). Ensure that after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s). Review of facility provided policy Abuse Prevention and Prohibition revised September 2017 instructed the following: a. Training Orientation program will include review of facility's policy on: i. What constitutes abuse, neglect, exploitation and misappropriation of resident property. ii. Care of the cognitively impaired/appropriate interventions to deal with aggressive and/or catastrophic reactions of resting; iii. Dementia Management and Resident Abuse Prevention; iv. How staff should report their knowledge related to allegations without fear of reprisal. v. How to recognize signs of burnout, frustration and stress that may lead to abuse. The Department of Justice information regarding Your Legal Duty . Reporting Elder and Dependent Adult Abuse. Elder Justice Act Reporting Reporting/Response All alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days.

Based on clinic record review, staff interviews, resident interview, Nurse Practitioner interview, and policy review, the facility failed to administer medications per physician orders for 2 out of 2 residents reviewed (Resident #25 and #2) for significant medication errors. 1. The facility failed to provide Resident #25 their ordered Revlimid (anticancer medication that slows the progression of multiple myeloma and various types of cancer) from 4/25/24 to 6/5/24. 2. Resident #2 received medications not prescribed to her. Resident #2 received her roommates' medications (Resident #10) instead of her own. The facility reported a census of 61 residents. The State Agency informed the facility of the Immediate Jeopardy on 10/16/24 at 2:47 PM that began on 4/25/24. The facility staff removed the Immediate Jeopardy on 10/16/24 through the following actions: a. The facility educated all nurses and certified medication aides (CMAs) on following the physician orders policy on 10/16/24. As needed (PRN) staff members will complete education prior to working the next shift. b. The DNS (Director Nursing Services)/designee will audit all missing/omitted MAR (Medication Administration Records) and TAR (Treatment Administration Record) entries daily for the next 4 weeks. They will educate nursing when needed on following physician orders, correct order entry, and the process for medication errors. c. Two nurses will double note all orders. This is a permanent systemic change. The DNS/designee will run missing entries report in the electronic medical record (EMR) daily for omissions on the MAR/TAR. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented their removal plan. The facility identified a census of 61 residents. Findings include: 1. Resident #25's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. Resident #25 required partial/moderate assistance with bed mobility, transfers, and toileting. The MDS included diagnoses of cancer, anemia (low blood iron), hypertension (high blood pressure), and renal (kidney) disease. The Care Plan Focus dated 2/5/24 reflected Resident #25 had an alteration in hematological (affecting the blood) status related to cancer. Resident #25 received treatments in [NAME] City. The Care Plan directed staff to administer medication as ordered, monitor for side effects, and effectiveness. A Physician order dated 3/27/24 directed staff to restart Revlimid (Lenalidomide) 5 milligrams (mg) by mouth on days 1-21 every 28 days. The Oncology Report dated 3/27/24 indicated Resident #25's care facility wasn't completely sure if he received his Revlimid or not. They believe he last received it February 24 through March 16, which put him due to restart on March 24, 2024. They reported they had a complete cycle worth of Revlimid for him in their facility. Orders placed to restart Revlimid 5 mg that day. A Physician order dated 4/10/24 directed staff to administer Revlimid (Lenalidomide) 5 mg by mouth on days 1-21 followed by 7 days off. The order directed to start the Revlimid on 4/25/24 to 5/15/24 with no dose from 5/16/24 to 5/22/24. The Advance Registered Nurse Practitioner (ARNP) signed the order and the facility faxed the order to the pharmacy on 5/8/24. The Oncology Report dated 4/10/24 indicated Resident #25's care facility wasn't completely sure if he received his Revlimid or not. They believe he last received it February 24 through March 16, which put him due to restart on March 24, 2024. They reported they had a complete cycle worth of Revlimid for him in their facility. Orders placed to restart Revlimid 5 mg on 3/27/24. Next cycle to start 4/25/24. A Physician order dated 6/5/24 directed staff to continue Revlimid 5 mg by mouth on days 1-21, followed by 7 days off. The order directed the staff to start the Revlimid on 6/5/24 to 6/25/24 with no dosing from 6/26/24 to 7/2/24. The order listed the Revlimid order as ongoing. The Oncology Report dated 6/5/24 reflcted Resident #25's care facility wasn't completely sure as to whether he received his Revlimid or not, but they believe he last received it February 24 through March 16, which would have put him due to restart on March 24, 2024. Once again, Resident #25 didn't receive Revlimid since April 17th, 2024. The provider contacted the DON of Resident #25's care facility who advised the nurse believed they discontinued Resident #25's medication, so they didn't give Revlimid to the him. The provider provided information on Revlimid dosing and the importance of proper administration. The DON reported they had a complete cycle worth of Revlimid for him in the facility and could restart Revlimid that day. Review of the March and April 2024 MAR reflected Resident #25 received Revlimid 5 mg from 3/28/24 to 4/17/24. Review of the April, May, and June 2024 MAR lacked documentation of Resident #25 receiving Revlimid as ordered by the physician from 4/25/24 to 5/15/24. In addition, the forms lacked documentation Resident #25 restarted their Revlimid on 5/23/24 as order. A Physician Progress note dated 6/5/24 from the cancer center indicated they restarted Resident #25 on Revlimid 5 mg for 21 days every 28 days in the latter part of February 2024. The note identified Resident #25 didn't receive his Revlimid since 4/17/24. The ARNP contacted the Director of Nursing (DON) who advised the nurse believed they discontinued the medication, so they didn't give Resident #25 the Revlimid. The note documented the ARNP provided information on Revlimid dosing and the importance of proper administration. The note documented the facility reported they had a complete cycle worth of Revlimid for Resident #25 in the facility and would restart his Revlimid on 6/5/24. A Cancer Center note titled Missed Revlimid Cycles dated 6/5/24 documented the facility nurse and the DON reported Resident #25 didn't receive his Revlimid medication since 4/17/24. The note included Resident #25 brought a medication list with him that didn't have Revlimid listed. The note documented Resident #25 missed one complete cycle and a part of the following cycle of the Revlimid medication. The note documented the facility DON verbalized the facility had two cycles of the Revlimid medication on hand. The DON didn't provide an explanation on why Resident #25 didn't receive the Revlimid medication. The note documented written physician orders on 4/10/24 instructed the facility staff to start the next cycle of Revlimid on 4/25/24. The facility didn't administer the medication starting on 5/23/24. The facility received instructions to have Resident #25 start the Revlimid on 6/5/24 for 21 days then off for 7 days per the 28 day cycle and resume next cycle after the 7-day break. A graph labeled M Protein IgG Lambda (a type of paraprotein that is produced by myeloma cells) dated 4/1/24 to 10/28/24 documented elevated M Protein IgG Lambda levels in May 2024 when Resident #25 didn't receive their Revlimid medication. The graph documented the M Protein IgG Lambda levels consistently decreased since June 2024. Review of the clinical record lacked documentation of the facility notifying Resident #25's Primary Care Physician and/or family regarding Resident #25 not receiving the Revlimid medication per the Physician's order. The facility didn't complete an investigation and medication error form regarding the omission of the Revlimid. On 10/14/24 11:40 AM, Resident #25 reported he had his cancer medication screwed up at one time. He stated he thought it happened about a month ago or so. He stated the facility told him about it. When asked if he received the medication now, he reported he didn't know for sure. On 10/15/24 at 3:23 PM, The DON acknowledged she couldn't locate documentation that Resident #25 received the Revlimid medication from 4/25/24 to 5/15/24 and restarted the order on 5/23/24. The DON reported she was still looking into it. She thought maybe a nurse didn't know how to transcribe the medication onto the MAR with 21 days on and 7 days off. She stated the Revlimid came from an outside pharmacy set up by the cancer center. The DON stated the cancer center would contact her regarding medication concerns. On 10/15/24 at 10:10 AM, the Cancer Center Operation Manager, MSN (Master of Science in Nursing), reported the Cancer Center called the facility regarding concerns with the administration of the Revlimid medication. She stated the cancer center nurse talked to a facility nurse and the DON. She reported Revlimid as a medication used to help control Resident #25's multiple myeloma (cancer). She stated not receiving the medication could contribute to the progression of the multiple myeloma and could be potentially fatal. She stated Resident #25's had an elevation in his lab (M spike) (lab to measure the amount of M protein in the blood) in May. She reported the Cancer Center sent the physician orders for the Revlimid to the specialty pharmacy. She reported she didn't know of any issue with the facility receiving the medication. On 10/16/24 at 12:35 PM, the Cancer Center ARNP reported she had concerns with Resident #25 missing cycles of the Revlimid medication. The ARNP reported Resident #25 restarted the Revlimid in February 2024. She sent specific orders on when to dose the medication and when to stop it. She stated to give the Revlimid for 21 days and then stop for 7 days. She stated the treatment was ongoing. She had concerns for Resident #25's health as multiple myeloma could be a life-threatening illness. She reported the facility didn't have to refill his medication as they had so much on hand. The ARNP reported she called the DON on 6/5/24 as she was concerned Resident #25 could relapse and could die. She stated the DON blamed the problem on a new nurse. She stated the cancer center didn't typically call the facility ahead of time to get the resident's MAR but they did for Resident #25, as they wanted to check to see if he received his Revlimid. She reported they had a hard time getting information from the facility. She stated at the last appointment they requested the MAR ahead of time and didn't get the MAR until he came to the appointment. The ARNP stated not administering the Revlimid to Resident #25 consistently could lead to his demise and he could die. She stated if he didn't get the appropriate treatment it could lead to a relapse. She stated Resident #25 already had 2 stem-cell transplants in the past and she didn't want him to have to go through that again. She described Resident #25 as currently stable, with his lab counts improved. On 10/16/24 at 1:04 PM, the DON reported she received a call from a nurse at the Cancer Center at the beginning of the summer. She stated the nurse was checking to ensure Resident #25's Revlimid orders were put in the computer correctly. She stated the cancer center feared Resident #25 missed a cycle of his Revlimid. She stated the Cancer Center ordered to give the Revlimid for 21 days and then off for 7 days. She stated the nurse wanted to make sure they gave it correctly. The DON reported she didn't give the medication, her nurses did. On 10/17/24 at 9:15 AM, the Nurse Consultant reported she expected the staff to follow physician orders and the 6 rights of administering medications. A facility policy titled Physician Orders revised May 2019 instructed all drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. The policy further documented that the charge nurse or DON shall place the order for all prescribed medications. A facility policy titled Medication Errors and Adverse Reactions reviewed May 2023 directed the facility needed to report medication errors and adverse drug reactions the resident's attending physician. The policy directed to complete a medication error form and the nursing service would implement/follow any new physician's orders. The policy instructed to record the resident's condition and response to any ordered treatment. 2. Resident #2's MDS assessment dated [DATE] identified a BIMs score of 15, indicating intact cognition. Resident #2 required partial/moderate assistance with bed mobility, transfers, and toileting. The MDS included diagnoses of coronary artery disease (impaired blood circulation), hypertension (high blood pressure), hyperlipidemia (elevated cholesterol), thyroid disorder, anxiety disorder, depression, schizophrenia (mental health disorder that can cause hallucinations and delusions), and cognitive communication deficit. The clinical census report identified Resident #2 and Resident #10 resided in room [ROOM NUMBER]. An incident reported titled Medication Error dated 10/13/24 documented a CMA gave Resident #2 Resident #10's medications by accident. The incident report identified Resident #2 received the following unprescribed medications: Oxycodone (opioid) 5 mg (milligrams), Baclofen (muscle relaxer) 10 mg, Gabapentin (anticonvulsant) 100 mg, Lexapro (antidepressant) 10 mg, Melatonin (hormone to help with sleep) 6 mg and Topamax (anticonvulsant) 100 mg. The incident report documented immediate action taken included notifying the Physician, monitoring Resident #2 throughout the night, and reviewing the 6 rights of giving medications with the CMA. The incident report documented the facility notified Resident #10's family of the error. On 10/16/24 at 11:52 AM, Staff G, RN (Registered Nurse), verified she worked the evening of 10/13/24. Staff G reported Resident #10 called for a nurse. Staff G reported Resident #10 showed her a cup of pills and stated they weren't hers. Staff G looked at the cups of pills and verified they weren't Resident #10's medications. Staff G stated she took the cup of pills to Staff H, CMA, and asked her whose pills they were. Staff G stated Staff H reported she mixed up the pills and gave Resident #2's pills to Resident #10 and Resident #10 pills to Resident #2. Staff G reported she destroyed the cups of pills that Resident #10 gave her in the drug buster and dispensed the correct medications to Resident #10. Staff G stated she notified the doctor of Resident #2's medication error. She stated she checked on Resident #2 every hour throughout the night to make sure she was alert and would wake up. Staff G stated she educated Staff H on never taking two medication cups in the room at the same time, as she was asking for trouble. Staff G reported she educated Staff H regarding leaving medications in the room unattended. Staff G reported Staff H took both residents' medication cups in the same room at the same time and got them mixed up. On 10/17/24 at 9:15 AM, the Nurse Consultant reported she expected the staff to follow the 6 rights of administering medications. A facility policy titled Medication Administration reviewed May 2021 instructed to accurately prepare, administer, and document oral medications. The policy directed staff to identify the resident when administering medications by the photo on the MAR or by asking their name. The policy documented they must identify the resident before administering medications. The person administering the medication must remain with the resident until all they swallowed all of their medications.

Based on observations, resident interviews, staff interviews, clinical record review, facility investigation, police report, and facility policy, the facility failed to provide a safe environment free from physical, verbal, and psychosocial abuse for 2 of 2 residents reviewed (Residents #47 and #316). 1. Despite Resident #47 reported alleged physical abuse on 3/20/24, the alleged abuser continued to work until the Director of Nursing (DON) learned of the allegations and started an investigation on 3/26/24. The facility allowed the alleged abuser to return to work on 4/3/24 and he continued to work at the facility. Resident #47 reported the alleged staff member on multiple occasions entered and stayed in her room alone. Resident #47's Care Plan updated on 3/28/24 instructed the alleged staff member to not enter her room alone. Interviews with CNAs revealed the alleged staff member often came in and out of Resident #47's room throughout the day. Observations revealed the alleged staff member entering and exiting Resident #47's room alone. Resident #47 reported while crying about being afraid of the alleged staff member and being afraid to tell anyone about the situation. 2. A witnessed event on 6/16/24 around 11:30 PM of verbal abuse towards Resident #316 didn't get reported to the DON until 6/20/24 around 3:30 PM. The alleged abuser continued to work with vulnerable residents until the DON learned of the allegations on 6/20/24 around 3:40 PM. The facility's lack of action for multiple days, allowing the alleged perpetrators to continue to work with vulnerable residents resulted in an immediate jeopardy situation to the residents. The Department notified the facility of the immediate jeopardy (IJ) on 10/16/24 of the IJ that began on 3/20/24. The facility removed the immediacy on 10/16/24 after implementing the following: a. The facility educated all staff on 10/16/24 regarding the abuse policy and reporting of alleged abuse to their supervisor immediately. The facility would notify the as needed (PRN) staff prior to them working their next shift. b. The facility terminated the employment of the 2 alleged perpetrators. The facility lowered the scope and severity from a level K to a G prior to the survey exit after ensuring the facility implemented their removal plan. The facility reported a census of 61 residents. Findings include: 1. Resident #47's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. The assessment reflected a Resident Mood Interview (PHQ 9) score of 6, indicating mild depression. The MDS reflected Resident #47 didn't have evidence of acute changes in mental status, indicators of psychosis including hallucinations or delusions, no behaviors such as physical, verbal, wandering or rejection of cares. The MDS included diagnoses of heart failure, diabetes mellitus, and depression. Resident #47 received Hospice services during the lookback period. The Care Plan Focus dated 3/28/24 indicated Resident #47 had a potential problem with her psychosocial well being problem related to an incident with a staff member. The Intervention dated 6/4/24 directed Staff B, Dietary, not to enter Resident #47's room alone. The Care Plan lacked documentation of delusions, hallucinations, or making false statements. Review of the facility's investigation reflected Staff C, CNA, completed their employee statement by phone on 3/26/24 at 6:00 PM. Staff C stated she went into Resident #47's room on 3/20/24 with an agency CNA, to put her to bed. While they provided her care, Resident #47 asked them if she told them something, could they promise not to tell anyone? Resident #47 then told them Staff B from dietary brought her meal to her room, visited with her for a little bit, and when he went to leave he kissed her on the neck prior to leaving the room. He also told her his wife didn't understand his sense of humor. Staff C reported she told Resident #47 she needed to tell someone. The facility immediately reeducated Staff C on timely reporting of allegations of abuse and they voiced understanding. Interview on 10/16/24 at 11:50 AM, Staff C explained Resident #47 told her Staff B would bring her meals and always tell her it was nice to have her to talk to because his wife didn't understand. On that day after saying that Staff B, bent down and kissed her before leaving the room. Review of facility's investigation, statement taken by the Director of Nursing (DON), for Resident #47 dated 3/26/24 at 7:00 PM stated The DON asked Resident #47 if she had any problems with her care or treatment by the staff. Resident #47 paused for approximately 30 seconds and then asked if she meant Staff B from the kitchen? The DON asked her if she could tell her what happened. Resident #47 replied, it's no big deal, she didn't want anyone to get in trouble. The DON reassured her that she just needed Resident #47 to tell her what occurred to ensure she is safe and cared for. Resident #47 responded, Oh she is definitely safe and she isn't afraid of anyone there. Resident #47 then stated, one-night last week they brought her the wrong drinks. Staff B brought her the correct one. He visited with her for a few minutes and kissed her on the cheek when he left. Again, adding it wasn't a big deal. Resident #47 remarked she felt perfectly safe with everyone there and not scared of anyone. Review of the facility's investigation statement by Staff B on 3/27/24 reflected he didn't recall the incident with Resident #47. He added he always been nice to her as she reminds him of his grandma. She jokingly called him her boyfriend in front of other staff members a few times that he could recall, while delivering trays. He reported he worked in healthcare for 7 years and never had an accusation such as that. Staff B explained he never kissed a resident even on the cheek and knew it would be inappropriate. He added he tried his best to be nice with all of the residents and go out of his way to help them. Review of the Police Department Report dated 3/26/24 at 8:59 PM, indicated Resident #47 appeared of sound mind. The police officers conducted an interview of the suspect. The interview of Staff B, concluded he was simply trying to be nice, he had no sexual intent or intent to harm. Interview on 10/15/24 at 4:33 PM, Resident #47 revealed she did not want to discuss the incident much. If she knew it would have blown up so much she wouldn't have told the girls (Staff C, CNA). Resident #47 reported the police came there, making it a whole big thing. Resident #47 stated after the incident, Staff B, talked to her but not like before, he just said hi. That lasted for a couple weeks, then Staff B came into her room and checking on her often. It started as Staff B, being nice and pushing her in the wheelchair to the dining room. Resident #47 stated Staff B, now came in her room and sits in her recliner uninvited. He came to Resident #47's room [ROOM NUMBER] 8 times a day and it made her uncomfortable. Resident #47 explained a time in the dining room, Staff B sat by her. He started rubbing her arm and back, Resident #47 asked Staff B to stop. Resident #47, repeatedly stated how uncomfortable Staff B made her when he came in her room so often. Resident #47 explained she made up excuses for him to leave, earlier that day (10/15/24) after lunch Staff B, came and sat in her recliner. When Resident #47 told him she was going to nap, Staff B responded with did that mean he had to leave? Resident #47 became tearful and said she couldn't directly tell Staff B that he made her uncomfortable or to tell him to stop coming to her room. Resident #47 hadn't told him the reason she wanted him to leave and just continued to make excuses. While tearful, Resident #47 stated she denied being afraid or uncomfortable with Staff B to the staff for fear of what would happen. Since the last time she had told Staff C what happened and the police showed up. Resident #47 expressed she had fear of the staff and Administration finding out what she said in the interview. The Hospice Residential Communication Form completed by the Hospice Social Worker on 6/18/24 indicated Resident #47 reported increased feelings of depression. The Hospice Nurse on 6/24/24 left a note that order sent to the primarcy care provider (PCP) to increase/add an antidepressant. The Hospice Physician Orders dated 6/25/24 reflected Resident #47 reported an increase in depression. The Provider replied if history of seizures, begin Wellbutrin XL (antidepressant) 150 MG by mouth everyday for 2 weeks then 300 MG everyday by mouth. On 10/16/24 at 8:28 AM, observed Staff B push a cart from the kitchen to Resident #47's room with a room tray. Staff B entered Resident #47's room delivering a breakfast tray. Interview on 10/16/24 at 11:30 AM, Staff J, Dietary, reported she often saw Staff B go into Resident #47's room. Staff J stated Staff B is part of the kitchen staff and didn't understand why he needed to go in there so often. Interview on 10/16/24 at 11:40 AM, Staff K, CNA, revealed she often saw Staff B go in and out of Resident #47's room. Interview on 10/16/24 at 11:58 AM, Staff L, CNA, revealed Staff B went in Resident #47's room a lot. Staff L explained at times, they had to ask Staff B to leave Resident #47's room to provide cares. Staff L, CNA, stated they didn't know Staff B couldn't be in Resident #47's room alone. Interview on 10/16/24 at 11:12 AM, Staff I, Human Resources (HR), stated she didn't know of Resident #47 making any allegations towards other residents or staff, other than the investigated incident on 3/26/24. Staff I, also denied any knowledge of Resident #47 having any negative feeling towards Staff B that may have led to a false accusation. Interview on 10/16/24 at 11:15 AM, Staff M, Social Services, stated other than the investigated incident with Resident #47 and Staff B, she didn't know of any other accusations towards staff or residents made by her. Staff M, denied knowing of any ill feelings Resident #47 may have towards Staff B that may have led to a false accusation. Staff M, met with Resident #47 routinely after the incident, Resident #47 didn't communicate to Staff M that she felt uncomfortable around Staff B. In an interview on 10/16/24 at 1:55 PM, the DON and Facility Administrator acknowledged the intervention that Staff B was not to enter Resident #47's room alone, on her Care Plan. They stated Resident #47's Care Plan shouldn't have that and they put it there as a precaution. In an interview on 10/17/24 at 1:07 PM, Facility Administrator acknowledged they expected residents' Care Plans get updated appropriately, timely, and followed as indicated. Review of Comprehensive Person Centered Care Planning Policy revised date December 2023 directed the interdisciplinary team (IDT) shall develop a comprehensive person centered Care Plan for each resident that included measurable objective and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 2. Resident #316's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of neurocognitive disorder with Lewy bodies (disorder that affects memory), cognitive communication deficit (difficulty talking due to memory), anxiety disorder, abnormalities of gait and mobility, muscle weakness, and need for assistance with personal care. Resident #316 used antipsychotic medication, antianxiety medication, and antidepressant medication within the lookback period. The Care Plan Focus dated 6/21/24 indicated Resident #316 had a terminal prognosis related to Lewy body dementia. The Intervention instructed the staff to encourage him to express his feelings and listen with non judgmental acceptance and compassion. The Care Plan Focus dated 4/19/24 reflected Resident #16 had a risk for elopement and wandering related to disorientation to place. The Interventions directed the following: a. Identify patterns of wandering and intervene as appropriate. b. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. The Change of Condition Note dated 6/16/24 at 6:04 PM indicated Resident #316 received an order to increase his lorazepam (antianxiety medication) due to his increased restlessness and anxiety. The Condition Follow-Up Note dated 6/17/24 at 4:25 AM reflected Resident #316 didn't sleep that night, he moved his feet and legs constantly. He attempted to stand by himself, closes his eyes briefly then has an entire body jerk, waking himself. Resident #316 hallucinated and talked to himself. He occasionally answered questions correctly but frequently had word salad (confused nonsensical speech). He scratched his entire body but mostly his arms and legs. He had hydroxyzine without relief. Resident #316 required one-on-one (1:1) assistance for safety. Resident #316 had neurological checks within his normal limits. He received a recent increase in Aricept and Ativan the day before. Difficult to ascertain if restlessness and itching are medication related. Review of the facility's investigation, Staff I's, CNA, statement indicated on 6/16/24 they each watched Resident #316 for 30 minutes. Staff I sat with Resident #316 while Staff C sat at the other end of the table. When Staff I returned from break, she started answering call lights. Staff C started yelling and screaming at Staff I for not sitting with Resident #316. Staff I told the nurse that if she screamed at her like that again, she would go home. After that Staff C sat with Resident #316. Staff C talked very mean to Resident #316, and told him, he is going to sit his fucking ass down. Then she asked him where do you think you are going? You are not going anywhere. This went on until Staff I sat with Resident #316 again. The night nurse suggested Staff I take Resident #316 to the back desk and chart to keep things mellow for the night. Review of the facility's investigation dated 6/20/24, listed the corrective action as Staff C immediately suspended from working pending investigation. Review of time cards dated 6/16/24 to 6/20/24, Staff C continued to work the rest of her overnight shift on 6/16/24 6/17/24 and an overnight shift on 6/19/24 6/20/24. On 10/17/24 at 1:07 PM the Administrator stated he expected a staff who witnessed any form of abuse to separate the victim and alleged abuser. They need to make sure the victim is safe and immediately report the incident to the administration staff including himself and the DON. Review of facility provided policy Abuse Prevention and Prohibition revised September 2017 indicated that each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but not limited to freedom from corporal punishment, involuntary seclusion, any physical or chemical restraints not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends or other individuals. The section labeled Prevention indicated all personnel, residents, visitors etc. are encouraged to report incidents and grievances without the fear of retribution. The facility will provide feedback regarding concerns. The facility employees will take action to protect, prevent abuse, and neglect from occurring within the facility by: Staff having knowledge of the individual residents' care needs. Supervision of staff to identify inappropriate behaviors (i.e. derogatory language, rough handling, ignoring residents while giving care etc.). Assess, Care Plan and monitor residents' rooms, self injurious behaviors, communication disorders, totally dependent on staff. Protection If a resident incident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, the facility will take the following steps to prevent further potential abuse while the investigation is in progress; if the suspected perpetrator is an employee: Remove employee immediately from the care of any resident; Suspend employee during the investigation. Reporting/Response All alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days. The Facility will report to the State Nurse Aide Registry or Licensing authorities any knowledge it has of any action by a court of law which would indicate an employee is unfit for service. The facility will analyze occurrences and determine what changes are needed, if any, to the policies and procedures to prevent further occurrences. The Administrator/Designee will inform the resident and his/her representative of the results of the investigation and corrective action taken.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 resident reviewed for catheter care (Resident #363). The facility reported a census of 61 residents. Findings include: Resident #363 lacked a completed Minimum Data Set (MDS) assessment due to recent admission to the facility on [DATE]. The Care Plan Focus dated 10/2/24 reflected Resident #363 had an indwelling urinary catheter related to urinary retention and benign prostatic hyperplasia (BPH enlarged prostate that blocks the passage of urine). The Care Plan directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. On 10/14/24 at 12:12 PM, observed Resident #363's catheter drainage bag lying on the floor without a privacy cover next to the low bed behind the fall mat. Observed Staff A, CNA (certified nursing assistant), pick up the uncovered catheter bag off the floor and hanged it on the side of the bed, visible from the entrance door of the room. On 10/15/24 at 3:31 PM, observed Resident #363's catheter drainage bag with a privacy cover hanging on the side of a trash can containing garbage. On 10/16/24 at 8:30 AM, observed Resident #363's catheter drainage bag hanging on the side of a trash can containing garbage. On 10/16/24 at 8:55 AM, observed Resident #363's catheter drainage bag continuing to hang on the side of the trash can. The ADON (Assistant Director of Nursing) completed a wound treatment to the right heel and threw garbage in the trash can while the catheter drainage bag hanged on the side. On 10/17/24 at 9:15 AM, the Nurse Consultant verified the catheter drainage bag shouldn't hang on the side of a dirty trash can. A facility policy titled Indwelling Urinary Catheter revised December 2023 instructed to provide each resident with an indwelling catheter daily and as needed catheter care to prompt hygiene, comfort, and decrease the risk of infection. The policy directed staff to cover the drainage bag with a privacy bag to maintain dignity.

Based on review of employee file, facility policy, and staff interview, the facility failed to provide a valid Dependent Adult Abuse Mandatory Reporter Certificate, for the time of an alleged abuse (3/20/24) for Staff C, Certified Nursing Assistant (CNA). The facility reported a census of 61 residents. Findings include: Review of the facility's abuse investigation dated 3/26/24, identified Resident #47 told Staff C, CNA, of an alleged abuse incident that happened to her. Staff C failed to report this to the Administrative Staff in the facility. On 10/15/24, the review of Staff C's employee file included a current completed Dependent Adult Abuse Mandatory Reporter Certificate dated 3/27/24. An Email date 10/16/24 at 1:57 PM, Staff I, Human Resources, indicated she couldn't find a Dependent Adult Abuse Mandatory Reporter Certificate with a date prior to 3/27/24. On 10/17/24 at 3:15 PM, the Director of Nursing (DON) stated, Staff C was obtaining a copy of this certification and bringing it to the facility. The facility failed to provide the document prior to exit of the facility on 10/17/24 at 5:00 PM. The Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment policy revised 11/28/17 instructed in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility would ensure all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately but: not later than 2 hours after the allegation is made if the events that cause the allegation involved abuse or resulted in serious bodily injury. The facility wouldn't report later than 24-hours if the events related to the allegation didn't involve abuse and didn't result in serious bodily injury. The facility would ensure all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the facility, the State Survey Agency, and the Adult Protective Services (as appropriate). The facility would make sure to take immediate steps after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, to protect the identified resident(s). The Abuse Prevention and Prohibition policy revised September 2017 directed the facility to provide a training orientation program. The program would include a review of the facility's policy on: a. What constitutes abuse, neglect, exploitation and misappropriation of resident property. b. Care of the cognitively impaired/appropriate interventions to deal with aggressive and/or catastrophic reactions of resting. c. Dementia Management and Resident Abuse Prevention. d. How staff should report their knowledge related to allegations without fear of reprisal. e. How to recognize signs of burnout, frustration and stress that may lead to abuse. f. Department of Justice information regarding Your Legal Duty . Reporting Elder and Dependent Adult Abuse. g. Elder Justice Act Reporting Reporting/Response All alleged violations will be reported via phone or in writing within 24-hours to the State Licensing Agency. h. The facility shall follow up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days.

Based on observation and staff interviews, the facility failed to ensure staff used proper food handling procedures to prevent possible contamination of food during lunch service with food uncovered. The facility reported a census of 61 residents. Findings include: During an observation on 10/16/24 at 12:30 PM, the facility delivered the room trays to residents in the 100 hallway, 200 hallway, 300 hallway and 400 hallways. The trays contained uncovered food of the desserts on all of the room trays brought to residents, a bowl of chips, and a bowl of crackers. During an interview 10/16/24 at 12:50 PM, Staff D, Cook, reported they should cover all food when transported down the hallways. Staff D acknowledged they didn't cover the dessert placed in bowls for residents eating in their rooms, as well as a bowl of chips, and a bowl of crackers. Staff D stated they expected food be covered. During an interview 10/16/24 at 2:04 PM, the Administrator stated they expected the staff to cover all food when food is transported in hallways when serving residents their meals, for infection control purposes. The Administrator stated the facility didn't have a policy specific to food service, stated the facility followed professional standards for food service safety and infection control.

Based on observation and staff interviews, the facility's Dietary Staff failed to perform the proper functions of food and nutrition services for the pureed food process for 3 of 3 residents requiring a pureed diet. The facility reported a census of 61 residents. Findings include: During an observation 10/16/24 at 11:20 AM, Staff D, Cook, began the puree process for turkey and wild rice casserole for 3 residents on a puree diet. Staff D used the 5 1/3-ounce scoop to scoop out 3 servings of the casserole. Staff D placed the servings in the Robot Coupe (brand name machine used to puree food). Staff D added an unmeasured amount of thickener and chicken broth to the Robot Coupe. Staff D pureed this in the Robot Coupe, and added more unmeasured chicken broth. Without measuring the puree or using the graph to determine what size to use, Staff D placed the total pureed casserole into a container. Staff D used the 5 1/3-ounce scoop to plate the food for the 3 residents with a puree diet. During an interview 10/16/24 at 11:35 AM, Staff D stated she pureed the food for approximately a year and had no training on the process. Staff D stated she googled and asked the Dietitian how to puree. She didn't receive training on the texture pureed servings. Some have told her the texture is a little too thick, which she will thin it out. She never received training on the consistency for pureed food. Staff D stated she didn't know how to use the puree graph (on the wall in the kitchen), she stated she never used the graph. Staff D looked at the book and menu from the food distributor for the food served for that day, and used the scoop size listed in the book. Staff D stated she never measured the pureed food after pureeing to determine the scoop size using the graph. She has added thickener and liquid to the mixture, altering the original volume. During an interview 10/16/24 at 1:56 PM, the Administrator stated they expected the staff to measure the pureed food after it is pureed and use the graph to determine the scoop size to use. The Administrator stated the facility didn't have a specific puree policy, however the Administrator stated they expected staff to follow the therapeutic diets and use the graph to determine the scoop size for pureed food, to ensure the residents received the appropriate portion size.

Based on clinical record review, policy review and staff interview, the facility failed to ensure a consistent code status between the Iowa Physician's for Scope of Treatment (IPOST), Care Plan, and the Electronic Health Record (EHR) for 1 of 1 resident reviewed for advanced directives (Resident #16). The facility reported a census of 61 residents. Findings include: The Care Plan Focus dated [DATE] indicated Resident #16 desired to have cardiopulmonary resuscitation (CPR) per his IPOST. The Goal reflected the staff would honor his advanced directive. The Intervention directed the staff to review the IPOST document with each care conference and update as needed (PRN). The Clinical Physician Orders reviewed on [DATE] included an order dated [DATE] for Resident #16 to have cardiopulmonary resuscitation (CPR)/Full Code. Resident #16's IPOST dated [DATE] reflected he desired a do not resuscitate (DNR) status. The Advanced Directives policy, revised [DATE] instructed changes or revocations of a directive must be submitted to the facility, in writing. The Care Plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment, Care Plan, or elsewhere in the clinical record. During an interview [DATE] at 1:10 PM the Director of Nursing (DON) acknowledged Resident #16's IPOST didn't match his Care Plan or his orders in the EHR. The DON added they expected the advanced directives match between the IPOST, the Care Plan and the orders in the EHR.

Based on interviews, record review, policy review, and review of manufacturer recommendations, the facility failed to assess the risk of resident entrapment and/or obtain informed consent for the use of bed rails/grab bars for one (Resident #148) of two residents reviewed for entrapment from bed rails. In addition, the facility failed to conduct ongoing evaluations of risks and ongoing assessments to ensure a grab bar was meeting Resident #148's needs. Staff placed a grab bar (also known as an assistance handle, bed bar, and transfer aide) on Resident #148's bed on [DATE] without assessing the risks/benefits of the grab bar for the resident and without obtaining the resident/resident responsible party's consent. When Resident #148 began climbing out of bed, the facility failed to evaluate the risks of ongoing usage of the grab bar. On [DATE], Resident #148 was found with his/her upper body between the headboard and grab bar, hanging off the side of the bed. According to the Medical Examiner, Resident #148 died from positional asphyxiation (a form of asphyxia or deficient supply of oxygen to the body arising from abnormal breathing which occurred when someone's position prevented them from breathing adequately). This had the potential to affect 22 residents in the facility with bed rails. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, S483.25(n)(1)(2) Bedrails at a scope and severity of J. The IJ began on [DATE] when Resident #148 was found to be entrapped between the headboard and bed bar and died from positional asphyxiation. The Administrator and Staff V, MDS Resource, were notified of the IJ on [DATE] at 6:52 PM and were provided the IJ template at that time. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency (SSA) on [DATE] at 4:17 PM. The IJ was removed on [DATE] after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of isolated harm that was not immediate jeopardy for F700. Findings included: A review of the facility's policy titled, Bedrail Assessment, last revised ,d+[DATE], indicated, If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails. 1. After the facility has attempted alternatives to bed rails and determined that these alternatives failed to meet the resident's assessed needs, the facility IDT [Interdisciplinary Team] will assess the resident for risks of entrapment and possible benefits of using bed rail. The risks and benefits of side rails will be considered for each resident. 2. If the use of bedrail is recommended by the IDT, the facility must obtain informed consent from the resident or if applicable, the resident representative for the use of bed rails prior to installation. Further review of the policy revealed 6. Assuring the correct use of an installed bed rail, and maintenance of bed rails is an essential component in reducing the risk of injury. After the installation of bed rails, it is expected that the facility will continue to provide necessary treatment and care, in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's record, and include the following components, but are not limited to: a.The type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation of the monitoring; b.The identification of how needs will be met during use of the bed rails, such as for repositioning, hydration, meals, use of the bathroom and hygiene; c.Ongoing assessment to assure that the bed rail is used to meet the resident's needs; d.Ongoing evaluation of risks; e.The identification of who may determine when the bed rail will be discontinued; and f.The identification and interventions to address any residual effects of the bed rail (e.g., generalized weakness, skin breakdown). 7. If the side rail is associated with symptoms of distress, such as screaming or agitation, the resident's needs and use of side rails will be reassessed. A review of a User-Service Manual Joerns Deluxe Assist Handle [grab bar/bed bar/transfer aide] dated 2012, indicated Warning: An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of restraint and bed system entrapment guidance. Entrapment zones involve the relationship of components often directly assembled by the healthcare facility rather that the manufacturer. Therefore, compliance is the responsibility of the facility. While the guidelines apply to all healthcare settings, long term care facilities have particular exposure since serious entrapment events typically involve frail, elderly or dementia patients. A review of the facility's Bed Safety Evaluation dated [DATE] revealed the facility was required to measure the distance of the Headboard/footboard to mattress, horizontal measurement and the Rail to bed end (board), both ends. The evaluation indicated a. Place bed in flat position, elevate side rails b. With tape measure, measure the minimum and maximum distance between the side rail and bed end at the head and foot end of the bed. The Definition of Pass was if the Distance is less than 2-,d+[DATE] inches or greater than 12-,d+[DATE] inches. According to the evaluation, If measurement does not meet criteria, bed with side rails should not be used. There was no documented evidence the facility completed a Bed Safety Evaluation for Resident #148. A review of the Admission Record indicated Resident #148 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #148's 5-day Prospective Payment System (PPS) Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had no cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Per the MDS, the resident had behaviors of rejecting of care and wandering that occurred one to three days during the assessment period. The MDS noted the resident required extensive assistance of one person with bed mobility, transfers, dressing, toilet use, and bathing, limited assistance of one person for walking in the corridor and personal hygiene, and supervision with walking in their room, locomotion on and off the unit, and eating. The resident's height was noted to be 62 inches and weight was 226 pounds. According to the assessment, a bed rail was not being utilized as a restraint. A review of Resident #148's Care Plan, dated [DATE], indicated the resident had sustained falls and was at risk for further falls related to polypharmacy (multiple medications to treat a condition). The care plan's stated goal was for the resident not to sustain serious injury. Further review of the care plan revealed the facility developed interventions that included the following: - On [DATE], the facility revised Resident #148's Care Plan to include Resident has a history of placing self on the floor. Per the plan, if the resident wanted to sit on the floor, the resident should request assistance to sit on the floor and staff should stay with the resident to ensure safety and to ultimately assist the resident off the floor. - On [DATE], a floor mat was placed beside the resident's bed and the bed was lowered to its lowest position. - On [DATE], the facility revised the resident's care plan indicating Resident #148 had a tendency to rock to the side of bed and roll onto his/her hands/knees at the side of the bed. Staff were directed to provide the resident support and assist the resident to an upright position and to the safety of the bed, if allowed. The care plan revealed a floor mat was in place at the resident's bedside. - On [DATE], the facility developed an intervention to place Resident #148's bed to the right side of the door by a closet with a half rail/grab bar applied to both sides of the bed to establish boundaries. - On [DATE], the facility developed an intervention for a half rail/transfer aid (grab bar) applied to the outer edge of the bed to establish boundaries and to aid in transferring. - On [DATE], an intervention to place a mat/mattress between the wall and bed to help protect the resident from being on the floor was added to the care plan. A review of Resident #148's medical record revealed no documented evidence the facility's Interdisciplinary Team (IDT) assessed the resident for risk of entrapment or the risks and benefits of side rail/grab bar usage, as required by the facility's policy, prior to placing side rails on the resident's bed on [DATE]. In addition, there was no documented evidence the facility reviewed the risks and benefits of bed rails and obtained informed consent from the resident/resident's representative for the use of bed rails prior to their installation. Further, there was no documented evidence the facility ensured the bed's dimensions were appropriate for the resident or confirmed that the bed rails installed were appropriate for the size and weight of the resident. Further review of the Care Plan revealed the facility developed a care plan for Resident #148's psychosocial well-being related to a history of purposefully leaning or appearing as though the resident was [CONDITION(S)]. The facility revised the care plan on [DATE] to include an intervention to conduct visual checks on the third shift every hour and converse with the resident to prevent behaviors. However, there was no documented evidence staff conducted visual checks of Resident #148 hourly on the third shift. A review of Resident #148's Progress Notes dated [DATE] at 5:30 AM, [DATE] at 5:30 AM, [DATE] at 5:30 AM, and [DATE] at 5:30 AM revealed the resident has a history of falls and falls are a behavior for this resident. Further review of Progress Notes dated [DATE] at 12:11 PM revealed Resident #148 was noted to have behaviors today with trying to roll onto the floor. During an interview on [DATE] at 10:52 AM, Staff G, Certified Nurse Aide (CNA), revealed the type of grab bar Resident #148 had on his/her bed was part of the bed and could be moved from side to side, but not up and down. Staff G stated Resident #148 used the grab bar sometimes to sit up on the side of the bed. Further interview revealed the resident would crawl into and out of bed (on all sides of the bed) onto his/her hands and knees. Staff G stated Resident #148 had a mattress behind the bed leaning against the wall to keep the resident from falling between the bed and the wall. During an interview on [DATE] at 8:43 AM, Staff I, Licensed Practical Nurse (LPN), revealed Resident #148 barrel-rolled out of the side of the bed, then used the grab bar to pull him/herself up. She stated Resident #148 was able to get up from a kneeling position. During an interview on [DATE] at 10:00 AM, the MDS Coordinator revealed Resident #148 would roll or flop him/herself off the side of the bed. According to the MDS Coordinator, Resident #148 exhibited this behavior and others for attention. During an interview on [DATE] at 6:07 PM, Staff B, Registered Nurse (RN), stated Resident #148 had severe mental illness and had behaviors that included being combative and coming out of his/her room with no pants on. Staff B noted staff were also monitoring the resident for putting him/herself on the floor. A review of nursing Progress Notes dated [DATE] at 11:46 PM revealed Staff B documented, After repeated episodes of staff observing resident putting [him/herself] on the floor, a safety intervention has been put into place. Mattress lowered to the floor and metal bedframe removed from the room. DON [Director of Nursing] notified. Continued review of Resident #148's care plan revealed that, on [DATE], staff revised the care plan to include After repeated episodes of staff observing the resident putting [him/herself] on the floor intentionally, along with additional multiple behaviors noted, safety intervention of lowering mattress to the floor and removing the bedframe to prevent injury, has been put in place. An interview with the Director of Nursing (DON) on [DATE] at 2:31 PM revealed the intervention of putting Resident #148's mattress on the floor was never implemented and should have been removed from the care plan. She stated a night nurse initiated it and when the interdisciplinary team (IDT) reviewed it the following morning, they did not believe it was appropriate. The DON stated she had stated she was not going to put the mattress on the floor and make the resident sleep on the floor like a dog. There was no documented evidence provided by the facility denoting the facility assessed the safety of the resident's bed or implemented interventions to keep Resident #148 safe. There was no documented evidence the facility conducted an ongoing assessment to assure that the bed rail was meeting Resident #148's needs, conducted an ongoing evaluation of risks, or identified who could determine when the bed rail could be discontinued as required per the facility's Bedrail Assessment policy/procedure. A review of the facility's Logbook Documentation dated [DATE] revealed staff should Inspect Bed and Rails and Mattresses for damage and repair or replace as necessary. Further review of the log revealed no documented evidence Resident #148's bed/side rails were inspected for areas of possible entrapment or proper fit. During an interview on [DATE] at 11:48 AM with the Maintenance Supervisor, he stated he had been working at the facility for two months and had never worked in a long-term care facility before. He stated he had been given paperwork with instructions on how to check mattresses and bed rails but had only looked at a few beds. He also stated the computer system that the facility used to keep track of work orders issued a monthly reminder to do bed checks, but he had not been doing them. He stated he was scheduled to do his first checks on all the beds during the current month. He stated he had marked the task as being completed because he did quick visual checks on the beds to make sure they were safe but did not realize there was more to the inspection and paperwork to be completed. A review of a nurse's Progress Notes, authored by Staff B and dated [DATE] at 5:25 AM, indicated a CNA notified her that Resident #148 was on the floor. The note indicated that upon entering the room, Staff B observed the resident face down, hanging off the side of the bed between the bed and a dresser. The resident's lower body from the hips down was on the mattress with the resident's shins and feet suspended slightly above the surface of the bed. The note indicated the resident's torso was between the headboard and the grab bar. According to the note, Resident #148's head was tucked towards the chest and right shoulder, and the right side of the resident's head was resting on the floor. The note indicated the resident's right arm was tucked under the resident and the left arm was beside the resident bent at the elbow and wrist. Further review of the note revealed that, after moving the dresser, the resident's legs had to be lifted over the half side rail (grab bar) and rolled onto his/her back for assessment by the nurse. The note indicated the resident had lividity to his/her entire face (reddish to bluish-purple discoloration of the skin due to the settling and pooling of blood following death) and rigor mortis had started (rigor mortis was stiffening of the joints and muscles of a body a few hours after death). According to the note, Resident #148 had no pulse and no respirations. Cardiopulmonary resuscitation (CPR) was not performed related to lividity and rigor mortis. The note indicated the resident was last seen during rounds at 2:00 AM when the resident refused to be toileted but was given a chicken salad sandwich. The note indicated the bed was 16 inches from the floor and the nightstand was 18 inches from the bed. The distance between the headboard and the grab bar was not documented. According to the note, a medical examiner, physician, and Director of Nursing (DON) were notified and the DON and physician came to the facility. During an interview with the County Medical Examiner on [DATE] at 4:09 PM, he stated Resident #148 died from positional asphyxiation. A review of Resident #148's electronic medical record (EMR) revealed the last time staff documented any interaction with the resident was on [DATE] at 11:23 PM, when a CNA documented the resident was independent with walking in the room with no help or staff oversight at any time. During an interview on [DATE] at 6:07 PM with Staff B, the RN on duty at the time of the incident, revealed Staff C, CNA, came to her and warned Staff B to be prepared when she entered Resident #148's room. Staff B entered Resident #148's room and stated the resident's legs were on the bed and the rest of his/her body was hanging off the side of the bed. She stated the resident's legs were partially elevated off the bed from being stiff from rigor mortis. Staff B stated Resident #148's left shoulder and cheek were on the floor with their left arm out beside him/her, facing the wall. Staff B stated full lividity had set in and the resident's color was completely purple and black. Staff B stated it was a horrible sight. Staff B stated the bed was up approximately 18 inches off the floor, but she could not remember if the floor mat was down or not. She stated she had to have one of the CNAs move the nightstand and move the bottom part of the resident's body off the bed over the grab bar so she could assess the resident. Staff B stated Resident #148 was known to crawl around the bed and off the bed. She stated the resident broke his/her ankle several months prior and had started climbing out of bed and crawling on the floor and had continued to do it. She stated she felt the resident did it for attention. Staff B stated the resident used the positioning (grab) bar when in bed to assist him/her to sit up on the side of the bed. She said she had not thought of the positioning (grab) bar as a hazard since it was positioned far enough down that the resident's head could not get trapped, but the resident obviously got caught between the headboard and the grab bar. She stated she had completed bed rail assessments before because the facility had night shift staff complete them, but she could not recall if she had done a side rail assessment for Resident #148. Staff B stated she could not recall exactly the last time she saw the resident during the night in question but stated staff checked to make sure the resident was in their room and not trying to go out one of the facility doors. She stated the CNA saw Resident #148 during 2:00 AM rounds and gave the resident a chicken salad sandwich to eat. Staff B stated the CNAs found the resident when they were doing their final rounds that started at 4:00 AM. During a follow-up interview with Staff B on [DATE] at 8:20 AM, she stated she was not aware of the care plan intervention to check on the resident hourly and had not been monitoring the resident hourly. Staff B stated Resident #148 was independent in his/her room, and staff monitored when the resident came out of his/her room to make sure he/she was dressed and not going to other resident doors. During an interview on [DATE] at 8:48 AM, Staff C stated that on the night of the incident, she came into work at 2:00 AM. She stated if Resident #148 was asleep, she would usually not wake the resident, but on the night of the incident, during 4:00 AM rounds, for some reason she felt like she needed to wake Resident #148. She stated when she entered the room, she pulled the curtain back and the resident's legs were on the bed and his/her head was between the bed and the nightstand. Staff C stated she immediately went out of the room, told another CNA (Staff E), and went to get the nurse. She stated she walked back in the room when Staff E turned the resident over, and the resident was purple and black. Staff C stated she knew she could not go back in the room after that because she was close with the resident. Staff C stated she did not remember the grab bar or the floor mat and did not remember the height of the bed. She stated Resident #148 only needed assistance occasionally and had often put him/herself on the floor intentionally. During an interview on [DATE] at 9:53 AM with Staff E, she stated she was an agency CNA, and at the time of the incident she was working with Staff C. She stated when she started the shift at 6:00 PM the previous evening, she did a walk through with the CNA from the previous shift who told her that Resident #148 was independent and continent of urine. She stated she interpreted that to mean she should check on the resident but not wake them to check for incontinence. She stated she was down the hall answering a call light from approximately 3:45 AM to 4:00 AM and poked her head in Resident #148's room and the resident was lying in bed. She stated at approximately 4:30 AM, she and the other CNA started doing rounds and passing ice water. She stated Staff C went in to check on Resident #148 and came out of the room stating the resident had fallen. She stated when she went into the room, the resident's body was hanging off the side of the bed. Staff E stated she touched the resident, and the resident was cold. Staff E stated the nurse asked her to move the resident so the resident could be assessed. She stated the nurse moved the nightstand and she pulled the resident's legs over the bed rail. She stated the resident's face was completely purple, and the nurse stated the resident had passed. She stated she left the resident and finished rounds with Staff C. She stated she heard Staff B on the phone with the Director of Nursing (DON), and Staff B asked her and Staff C if the resident was in a low bed and if the bed was in a low position. Staff E stated she did not know Resident #148 was occasionally incontinent and would crawl out of bed. During an interview on [DATE] at 10:39 AM with Staff F, CNA, revealed she came in at 6:00 PM on [DATE] and worked until 2:00 AM on [DATE], noting she was not at the facility when the incident in question occurred. Staff F stated Resident #148 wandered and did what he/she wanted. She stated the resident asked her for a sandwich around midnight, though she was not sure of the stated time. Staff F stated Resident #148 was in bed lying down at 2:00 AM when she did rounds with Staff C at the shift change. She stated the resident's bed was at a normal height, but she did not remember a fall mat. Staff F stated the resident had a grab bar on one side of the bed. She stated she did not think the resident used the grab bar but may have used it to get up from a lying position. During an interview on [DATE] at 9:28 AM, Staff D, Physical Therapy Assistant (PTA), stated he had worked at the facility for ten years. He stated therapy staff should assess residents to see if side rails/grab bars were appropriate for the resident and make sure paperwork was in place. He stated if a grab bar/side rail needed to be replaced, he had been replacing them due to the facility not having a maintenance person for a couple of months. Staff D stated when he visited with Resident #148, he tried to make sure the resident was using the grab bar to get to the edge of the bed. He stated Resident #148 was a good-sized person and used to be able to get themself up once they were on the floor, but their ability had declined. Staff D stated he was not aware Resident #148 was crawling off the bed. Staff D stated if he had known Resident #148 was crawling off the bed, he would have recommended to have the grab bar removed and developed other interventions to keep the resident safe. During an interview on [DATE] at 2:53 PM, the Rehabilitation Director stated he had been at the facility for three to four years. He stated the facility tried not to use side rails, but when a resident was admitted to the facility for therapy and was assessed to have difficulty with bed mobility, then a positioning bar/grab bar would be appropriate. He stated therapy's involvement with side rails/bed rails was to work with residents on how to use them appropriately. He stated if therapy did not see a functional need for a side rail/bed bar, they would bring it to the team for discussion. He stated a resident crawling in and out of bed would need an individualized assessment to determine the risks and benefits of the grab bar device. However, the Rehabilitation Director then stated he was aware Resident #148 was putting themself on the floor and stated that, depending on the reason for the action, which was usually for attention, he felt that checking on the resident more frequently was an appropriate intervention to keep the resident safe. During an interview on [DATE] at 12:12 PM, the DON revealed when she was doing an investigation for Resident #148's incident, she realized the resident did not have a consent or an assessment for grab bar usage. She stated the facility did not use bed or side rails, only grab bars, which were used for positioning or identifying boundaries. The DON stated Resident #148 had a grab bar to identify boundaries because the resident would get too close to the edge of the mattress, and the bar let the resident know to scoot over. She stated the resident would also use the grab bar to push themself away from the edge of the bed. A follow-up interview with the DON on [DATE] at 2:31 PM revealed at the time of the incident, Resident #148 was independent and needed to be able to get out of bed; otherwise, the bed would have been considered a restraint for the resident. She stated it looked like the resident got up and was trying to crawl out the top of the bed between the headboard and bed/grab bar. The DON stated it looked like the resident put his/her hand on the nightstand, and either the resident's hand slipped, or the nightstand moved, and the resident fell to the floor. She stated it appeared that the resident tucked his/her head to roll but the nightstand kept the resident from going all the way over. The DON further stated the resident had small legs and a larger torso/upper body with extra skin under their chin, so when the resident fell forward, the resident was caught between the bed and the nightstand. The DON stated the resident crawled into bed like a child on his/her hands and knees onto the mattress and then laid flat on his/her stomach or rolled on his/her side. She stated the resident used the bed/grab bar to sit up on the side of the bed or to reposition. According to the DON, she did not believe the bed/grab bar was a danger because there was plenty of room between the headboard and the grab bar so that the resident's head would not get stuck. The DON stated she did not feel that the bed/grab bar impeded the resident from being able to move when the incident occurred. However, the DON was unable to answer how the facility was keeping the resident safe when they were crawling in and out of bed. She stated she believed if the resident had a roommate or if there had been a resident room on the other side of the wall where the resident was (there was a shower room next door), then someone might have heard the resident. She stated she could not remember if there was a mat beside or behind the bed against the wall. During an interview on [DATE] at 1:57 PM with the Administrator, he stated he was aware Resident #148 had [CONDITION(S)] behaviors and put him/herself on the floor, noting he believed it was for attention. The Administrator stated he did not know what interventions were in place to keep the resident safe related to crawling in and out of bed. He stated the DON would know the safety interventions for Resident #148. According to the Administrator, the nurse should complete a side rail assessment and then have maintenance staff put the rail in place. He stated consents for the bed/grab bars should be obtained upon admission. Further interview with the Administrator revealed the facility's maintenance director left abruptly in April of 2022, and they were in the process of training a new maintenance director. In the meantime, he stated a maintenance person from one of the other facilities was supposed to be completing necessary bed/grab bar checks. Removal Plan: Removal of Immediacy Plan F700 Date/Time Presented to Surveyors: [DATE] at 9:30 AM Identified here are the steps and immediate action(s) the facility will take to address the reported non-compliance, keep residents safe and free from serious harm or death, and prevent serious harm from occurring or recurring. STEPS/IMMEDIATE ACTION: 1. Medical Director was notified on [DATE] of IJ. 2. On [DATE] all residents with grab bar/positioning enabling devices in use were evaluated by the Director of Nursing (DON)/designee for continued need utilizing the Point Click Care Electronic Medical Record Bed Rail Safety Evaluation UDA (user defined assessment) prior to implementation and at least quarterly for continued use. The Bed Rail Safety Evaluation is an Interdisciplinary Team (IDT) evaluation that assesses the residents physical and mental characteristics and abilities, the type and appropriateness of bed being utilized, documentation of resident/resident representative education of risk factors, education on use of equipment, and the risk factors involved in utilizing the equipment, as well as documentation of equipment safety via inspection by Maintenance Director/Designee prior to use. Nursing staff/designee assessed residents bed mobility to determine appropriate alternative devices needed for resident bed mobility. Nursing staff evaluated 100% of the beds with grab bar/positioning enabling devices and found no concerns. 3. Medical Director notified of resident requiring continued use of grab bars. 4. Recommendations reviewed with the resident/and or representative and implemented as ordered including revisions to care plans as indicated by Minimum Data Set/IDT nursing staff. Continued compliance will be audited as outlined below. 5. As of [DATE], all residents with grab bars have the appropriate consents in place as verified through electronic and hard copy medical record review. Consents must be in place prior to implementation of side rail use and will be a part of each residents nursing admission packet and implemented before any side rails are placed for a resident. Continued compliance will be audited as outlined below. 6. All staff will be in-serviced by the Director of Nursing/designee regarding the facility's process for evaluating side rail need and implementing side rails, including assessing the resident for risk of entrapment prior to installation, review of risk/benefits & obtaining consent prior to installation, and ensuring that the bed dimensions are appropriate for the resident's size and weight Staff education initiated [DATE] with all IDT staff recalled to the building to assist in completing this education. Individuals present on the evening and night shifts of [DATE] and the AM shift of [DATE] were educated by the DON/IDT. Policy sent to multiple staff members not present in the building with DON/IDT educating and receiving verbal verification of understanding via phone. All employees we were unable to reach will be educated on their next scheduled shift by the DON/Designee All new staff will be trained on the bed rail safety policy and procedure during new hire orientation. 7. Facility Maintenance Director in-serviced by the Administrator regarding the faci[TRUNCATED]

Based on observation, record review, and staff interview, the facility failed to prevent AN avoidable pressure ulcer and provide necessary treatment and services to promote healing and prevent infection of A pressure ulcer for 1 of 2 residents with pressure ulcers (Resident #3). The facility reported a census of 49 residents. Resident #3 developed an ulcer to the great toe on 10/8/16. The facility identified the area as open, draining and red, but failed to document a complete assessment. The facility asked for treatment of [REDACTED]. On 10/28/16 the facility received orders for antibiotic for the toe, indicating decline, but lacked any assessment of the area and failed to address the treatment. On 11/3/16 the physician saw Resident #3 and ordered a podiatrist consult. The facility completed assessment of the area on 11/4/16. In November 2016, the podiatrist diagnosed the ulcer as pressure, related most likely to a sock rolled up in the shoe causing irritation. The Director of Nursing confirmed the resident did not put socks and shoes on him/herself or take them off him/herself. The podiatrist debrided the ulcer 3 times in November of necrotic tissue, and changed the treatment. The bone was visible at the base of the ulcer, and the podiatrist documented high suspicion of bone erosion related to osteo[DIAGNOSES REDACTED]. Findings include: 1. Resident #3 had a Minimum Data Set (MDS) assessment, with a reference date of 9/23/16, Resident #3 scored 9 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. Resident #3 required extensive assistance of 2 people with activities of daily living (ADL's) including bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Resident #3's [DIAGNOSES REDACTED]. Resident #3 had no pressure ulcers but identified at risk for the development of pressure ulcers. The MDS defined a Stage IV pressure ulcer as full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed, and often included undermining and tunneling. The Care Plan dated 6/20/16 identified Resident #3 with actual skin impairment, history of left heel pressure wound and right great toe wound. The interventions included to identify potential causative factors and eliminate/resolve when possible, and monitor/document location, size and treatment of [REDACTED]. to the physician. The Progress Notes dated 10/8/16 at 11:14 AM documented Resident #3 noted with right great toe redness, warmth to touch, denied any discomfort, and noted yellow discharge from site. Staff cleansed the area and left open to air dry. They applied no shoe, bilateral TED (improves circulation and reduced risk of blood clots) stockings, and gripper socks. Staff faxed the physician, updating on right great toe and requesting treatment until resolved. At 12:04 PM, the facility received a signed fax back from the physician with orders for treatment with [MEDICATION NAME] 2 times a day to the right great toe until resolved. A facsimile dated 10/8/16 notified the physician Resident #3 had a right great toe open area with yellow discharge, warm to touch. The fax questioned if the physician would recommend [MEDICATION NAME] 2 times a day until the area resolved, no shoe, transfer with gripper on, and continue with TED stockings. The physician responded okay. The clinical record lacked an assessment including size, ulcer bed and surrounding skin appearance, extent of redness, or cause of the ulcer. The Progress Notes dated 10/9/16 at 6:46 a.m. documented treatment completed to right great toe, no redness or drainage noted. The Progress Notes dated 10/10/16 at 11:22 p.m. documented Resident #3 continued with the reddened area to his/her great toe. The Progress Notes dated 10/11/16 at 12:05 a.m. documented Residents #3 denied pain to his/her right great toe. The toe was red with no swelling, increased warmth, or drainage. A Weekly Nursing Summary dated 10/12/16 documented Resident #3 free of any open areas. The summary lacked any documentation of the status of the toe. A Weekly Nursing Summary dated 10/19/16 documented Resident #3 free of any open areas. The summary lacked any documentation of the status of the toe. The Progress Notes dated 10/28/16 at 3:25 p.m. documented a new verbal order from a Physician for [MEDICATION NAME] 2 times a day for 5 days. At 5:45 p.m. antibiotic initiated for right great toe. The clinical record lacked any assessment of the right great toe. A Weekly Nursing Summary dated 10/26/16 documented Resident #3 had a treatment to the right great toe. The summary lacked any documentation of the status of the toe. A Weekly Nursing assessment dated [DATE] documented Resident #3 had a red right toe, on antibiotic. The summary lacked any documentation of the status of the toe. A clinic visit dated 11/3/16 documented Resident #3 had infection in his/her right foot finishing antibiotic, and ulcer of the right 1st toe. The right first toe had a 5 mm ulcer with some drainage. The plan included a podiatry consult and physical therapy consult for ulcer treatment. A Weekly Skin Ulcer Non-Pressure report dated 11/04/16 documented an initial review with an unknown start date of the right great toe. The area measured 0.9 by 0.8 cm. The area was scabbed with 0.2 cm diameter dark area central to the outer reddened area. The area was tender to touch, with no drainage or odor, and treated with [MEDICATION NAME]. A Weekly Skin Pressure Ulcer report dated 11/08/16 documented the right toe area measured 0.8 by 0.7 cm, with serous drainage. A Weekly Skin Pressure Ulcer report dated 11/15/16 documented the right toe measured 1.1 by 0.8 cm and unstageable due to slough/eschar. A Weekly Skin Pressure Ulcer report dated 11/22/16 documented the right toe measured 0.8 by 0.9 cm and unstageable due to slough/eschar. A Weekly Skin Pressure Ulcer report dated 11/29/16 documented the right toe measured 0.8 by 0.8 cm and unstageable due to slough/eschar. A Weekly Skin Pressure Ulcer report dated 12/6/16 documented the right toe measured 0.8 by 0.7 cm and unstageable due to slough/eschar. Then podiatry consult dated 11/8/16 at 8:32 AM documented Resident #3 seen for right foot ulcer, stating pain at three out of 10 on the pain scale. The family thought the cause of the ulcer most likely a sock rolled up in his/her shoe causing irritation. It had been open for the past couple of weeks and quite painful. Resident #3 had one short course of antibiotics which consisted of [MEDICATION NAME]. Pre-debridement measurements of the wound at 0.4 by 0.2 cm with anatomic depth probes to the bone. The wound base and edges with fibrous necrosis in the base and hyper [DIAGNOSES REDACTED] around the edges. Probing of the base of the wound showed no undermining and no exposed tendon, but there was exposed bone directly in the base of the wound. The surrounding tissue showed mild [DIAGNOSES REDACTED] and [MEDICAL CONDITION], and mild [MEDICAL CONDITION]. The x-ray and clinical findings were suggestive of bone erosion secondary to osteo[DIAGNOSES REDACTED] (inflammation/infection of bone). The wound was debrided of all abnormal tissue. A podiatry note dated 11/16/16 at 2:38 p.m. documented Resident #3 returned for follow-up of the ulcer on the right great toe with pre-debridement measurements of 0.4 by 0.3 cm. There was a large flood of fibrous necrosis well adhered to the base of the ulceration. Probing of the base of the wound showed no undermining and no exposed tendon but there was exposed bone in the base of the ulceration. There was mild surrounding [DIAGNOSES REDACTED] and [MEDICAL CONDITION] which was markedly improved from the previous visit. Culture report was reviewed with the family which showed [MEDICAL CONDITION] (MRSA) which was sensitive to his/her current antibiotics. The ulcer was sharply debrided of all abnormal tissue using a combination of a scalpel, sharp curette, and tissue nipper to remove all abnormal tissue. The debridement carried to healthy bleeding tissue at the base of the ulceration and the edges. Excision of both subcutaneous and fascial (connective) tissue was carried out. The post procedure dimensions measured at 0.5 by 0.6 cm with anatomical death of 0.4 cm into the fascial space. They extended the course of antibiotics due to the high likelihood of osteo[DIAGNOSES REDACTED] with exposed bone. The podiatry follow-up dated 11/30/16 at 2:13 p.m. documented Resident #3 returned for follow-up of the ulcer with pre-debridement measurements of 0.2 by 0.2 cm with an atomic death indeterminate with a complete covering of fibrous necrosis in the base of the ulceration. The ulcer was sharply debrided of all abnormal tissue. Post procedure dimensions measured 0.4 by 0.4 cm with an atomic death of 0.3 cm. During an observation on 12/6/16 at 8:45 a.m. Staff A Certified Nursing Assistant (CNA) and Staff B CNA assisted Resident #3 with a.m. cares. Resident #3 had a small ulcer to the right big toe, with no redness. Staff put Resident #3's TED socks on and Resident #3's right shoe had cut out (open) for toes. During an interview on 12/6/16 at 2:10 p.m. the Director of Nursing (DON) stated initially they thought the ulcer was venous because the family member stated Resident #3 had a venous ulcer on the 2nd toe, but the family member also stated they had found a TED stocking in the shoe which may have caused pressure. The Podiatrist diagnosed a pressure ulcer. The DON started doing skin assessments in November. She could not say what the toe looked like before that. She did not know why they did not complete wound assessments before then; normally they did wound assessments weekly. She could not find documentation of the area for 10/28/16 when they 1st started the antibiotic. She could not say how big the ulcer was when 1st discovered because no one documented it. During an interview on 12/7/16 at 3:30 p.m. the DON stated Resident #3 would/could not put on or take off his/her own TED socks or shoes. Someone had to do that for him/her. The facility policy and procedures titled Wound Management, reviewed 7/2016, documented a resident having pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. The policy indicated in order prevent existing pressure ulcers from worsening, nursing staff should implement approaches including monitoring the impact of interventions and modifying interventions as appropriate based on any identified changes. They should review and/or re-evaluate existing treatment regimens in connection with the resident's clinical presentation, to include interventions and care plan considerations, if any wound was non-healing or not showing signs of improvement after a given time or any time a wound worsened.

Based on observation, record review and staff interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 8 of 9 residents. Resident #1 had resident to resident incidents with Resident #9 on 2 occasions. Resident #2 and Resident #3 both abused Resident #5 on 2 separate occasions. Resident #2, who was involved in a previous unprovoked incident with Resident #5, slapped Resident #3 across the face unprovoked leaving red marks. From [DATE] to present, Resident #8 received 7 skin injuries during care or transfers. Interventions following all the incidents were educating and reeducating staff. Resident #4 was a high fall risk and entered the facility with alarms. Documentation identified the resident's prior facility provided one to one supervision due to the resident's fall risk. The facility discontinued the resident's alarms after 2 weeks without providing additional supervision knowing the alarm assistance device was no longer in use. Staff stated prior to alarm discontinuation, the resident was known to self- transfer. The resident fell after 3 days without the alarm and hit his/her head and remained unresponsive until he/she expired on [DATE]. Staff tipped Resident #6's wheelchair backwards to the floor when they lifted the resident's legs to place the legs on a footstool. The resident hit his/her head on the floor and sustained a bump and abrasion to the back of the head. The facility identified a census of 59 residents and 15 of the 59 residents resided in the CCDI (Chronic Confusion and Dementing Illness). The sample consisted of 9 residents. Findings include: 1. Resident #3 had a MDS (Minimum Data Set) assessment with a reference date of [DATE]. The MDS indicated Resident #3 had a BIMS (brief interview for mental status) score of 1. A score of 1 identified the resident had a severe cognitive impairment. The MDS identified the resident with the following indicators of delirium: disorganized thinking and inattention. The resident had the following behavior symptoms identified: physical behaviors directed towards others and other behaviors directed towards others 1 to 3 days out of 7 days. The resident wandered and rejected care 4 to 6 days out of 7 days. The resident required supervision with ambulation and personal hygiene. The MDS indicated the resident had an admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 resided on the CCDI (Chronic Confusion and Dementing Illness) unit. Nursing progress notes identified the following information: Background information: [DATE] at 8:49 p.m. The resident repeatedly held another resident's hand. [DATE] at 2:51 p.m. The resident entered another resident's room while that resident used the rest room. At 8:30 p.m. the resident held another resident's hand. [DATE] at 5:15 a.m. The resident attempted to hold another resident's hand. [DATE] at 6 p.m. The resident wanted to enter the room of other resident. [DATE] at 8:01 p.m. The resident attempted to hold another resident's hand. At 8:46 p.m. of the same date the resident made inappropriate comments. [DATE] The resident required frequent redirection to stay away from other resident. An encounter telehealth note from the psychiatric DNP (doctor of nursing practice) identified the resident with an incident on [DATE]. The resident grabbed another resident's wheelchair and tried to take the other resident to his/her room. It took 4 staff to redirect the resident. Incident: [DATE] at 11 a.m. revealed staff observed the resident with both hands on the left wrist of another resident. The resident and other resident sat in recliners in the lounge area of the CCDI unit. Staff redirected Resident #3 and moved the other resident. An incident report dated [DATE] at 11 a.m. revealed Resident #3 twisted the other resident's left wrist with his/her hands. On [DATE] the DNS (director of nursing service) assessed the other resident's left wrist. Observation showed an approximate 1 centimeter (cm.) red/purple area on the radial left wrist. The DNS documented that the area was not consistent with a finger print and the right wrist had a similar area. Fifteen minute check sheets identified the resident on 15 minute checks at the time of the incident. On [DATE] at 12:05 p.m. the Administrator identified the other resident as Resident #5. Review of Resident #5's nursing progress notes dated [DATE] at 11 a.m. identified the incident. Progress notes indicated the staff applied ice to the resident's wrist and did not observe swelling or deformity. A MDS with assessment reference date of [DATE] assessed Resident #5 with a BIMS score of 6 (severe cognitive impairment). The MDS identified the resident with physical and verbal behaviors directed towards others and rejection of care 1 to 3 days a week. The resident required extensive staff assistance with transfers and toileting. The resident ambulated once or twice with the assistance of 2 staff. The resident had [DIAGNOSES REDACTED].#5 resided on the CCDI (chronic confusion and dementing illness) unit. A facsimile (fax) to the physician dated [DATE] at 3 p.m. reported Resident #3 got agitated when another resident yelled out and Resident #3 grabbed the other resident's arm with a twisting motion. The other resident had a 1 cm (centimeter) by 1 cm. dark purple area resembling purpura to the left wrist. Observation showed on [DATE] at 11:57 a.m. the resident sitting at the dining room table in a wheelchair. The resident complained about the meal and stated he/she didn't like anything he/she received. The resident stated he/she would rather have a piece of pie. 2. A MDS with an assessment reference date of [DATE] assessed Resident #2 with short and long term memory impairments and severely impaired decision making ability. The resident had the following indicator of delirium: disorganized thinking. The resident had physical behavior symptoms directed towards others 1 to 3 days a week. The resident required supervision with ambulation. The resident had [DIAGNOSES REDACTED]. Resident #2 resided on the CCDI (chronic confusion and dementing illness) unit. A Care Plan dated [DATE], revealed the resident used anti- anxiety medications related to PTSD (post- traumatic stress disorder). The resident exhibited anxiety with loud noises. The resident kicked a female resident and staff noted thunder before the incident. The resident made statements about bombs following the incident. The resident was physically aggressive with another resident and the resident made sexual comments to staff. The written Care Plan identified 15 minute checks starting on [DATE]. Nursing progress notes identified the following information: [DATE] at 7:06 a.m. revealed staff observed the resident upset related to another resident shouting out. Resident #2 threatened other residents with clenched fists. Staff identified the incident as an episode of PTSD. [DATE] at 8:33 p.m. revealed staff witnessed Resident #2 walk up to Resident #5 and kick the resident in the left knee. The [DATE] care plan revealed the intervention following the incident was a urine dip and 15 minute checks. A fax to Resident #2's physician dated [DATE] at 3 p.m. revealed staff informed the physician that Resident #2 walked out of the room and walked up to Resident #5 and kicked the resident in the knee. Resident #2 then walked away and sat at the table. The fax identified staff placed the resident on 15 minute checks and would obtain a UA (urinalysis) and set up an appointment with the psychiatric DNP (doctor of nursing practice). A fax to Resident #5's physician regarding the incident dated [DATE] at 3 p.m. revealed Resident #5 sat in the CCDI lobby when Resident #2 came out of his/her room and kicked Resident #5 in the left lateral knee. The resident stated, Oh that hurt. No injuries observed. Review of Resident #5's nursing progress notes, dated [DATE] at 9:35 a.m. revealed Resident #2 kicked Resident #5 in the left knee. Assessment showed the resident did not sustain an injury. The nursing progress notes dated [DATE] at 9:45 p.m. identified the UA as negative per urine dip. On [DATE] at 1:32 p.m. Staff A CNA (certified nurse aide) stated she observed the [DATE] incident. Resident #3 walked up and kicked Resident #5 in the knee without warning. Resident #5 let out a yell. Staff A stated it was a pretty hard kick. [DATE] at 11:20 a.m. revealed staff observed the resident walk into the common area of the CCDI with a CNA (certified nurse aide). The resident then walked up to Resident #3 and struck Resident #3 across the left side of the face with an open hand. The CNA then grabbed Resident #2's left arm and Resident #3's left arm. Resident #3 grabbed Resident #2's right wrist. Staff intervened and separated the residents. An incident report dated [DATE] at 11:20 a.m. revealed Resident #3 had dispersed redness under the left eye and lateral left side of the face. Staff applied ice to the area. The resident did not complain of pain or discomfort. On [DATE] at 12:25 p.m. a visitor stated he witnessed the [DATE] incident. He stated Resident #2 came over to Resident #3 and smacked Resident #3 hard on the head. The visitor stated he thought the hit would have caused a concussion. He stated the staff was right there to intervene. View of video of the [DATE] incident showed Staff B walked a couple feet ahead of Resident #2. Staff B turned and Resident #2 put his arm out to keep Staff B away and then slapped Resident #3 full force by pulling his enter arm out and then slapping Resident #3 with an open hand on the head/face. Resident #3 put his/her arms up to defend self and Resident #2 grabbed the other resident's arms with more attempts to strike the resident. On [DATE] at 10:06 a.m., Staff B CNA stated she walked Resident #2 to the table for lunch. Resident #2 stated, I got this and went over and struck Resident #3. Staff B stated she stepped in and held Resident #3. The ADON (assistant director of nursing) also stepped in and helped. They applied ice to Resident #3's eye. Staff B stated the incident occurred without warning. On [DATE] at 10:05 a.m. the ADON stated Resident #3 sat at a table waiting for lunch between 11:30 a.m. and 12 p.m. She heard Resident #2 say I got this and then Resident #2 smacked Resident #3 in the face with an open hand. Staff B got between the residents and the ADON walked Resident #2 into another room. Resident #2 said Resident #3 stole from him/her. Intervention dated [DATE] was to keep staff between residents involved in physical aggression when ambulating, activities and meals. [DATE] at 11:40 a.m. revealed Resident #1 threw a bed pad over Resident #2's head and Resident #2 responded by swinging his/her arm with no physical contact made between residents. On [DATE] at 1:43 p.m. the ADON stated there was not a new intervention following the [DATE] incident because the intervention in place was effective. On [DATE] at 12:12 p.m. observation showed Resident #2 seated in the dining room with Resident #5 seated in a wheelchair at Resident #2's right. On [DATE] at 9:50 a.m. Resident #2 stated he/she had an argument or 2 but the resident couldn't remember what it was about. The resident denied getting in fights. The resident stated he/she gets along with people and didn't have any trouble with anyone but you never know. An encounter telehealth note dated [DATE] identified the resident saw the psychiatric DNP per video conferencing. The DNP wrote Resident #2 was doing well with no aggressive behaviors. The DNP increased Resident #2's sertraline from 25 milligrams (mg.) to 50 mg for anxiety. 3. A MDS with assessment reference date of [DATE] assessed Resident #1 with impaired short and long term memory and severely impaired decision making skills. The resident admitted to the facility on [DATE]. The resident had the following indicators of delirium: disorganized thinking and inattention. The resident had delusions and physical behaviors directed towards others 1 to 3 days out of 7. The behaviors put others at significant risk of physical injury. The resident required supervision with ambulation. The resident had [DIAGNOSES REDACTED]. Resident #1 resided on the CCDI (Chronic Confusion and Dementing Illness) unit. Nursing progress notes dated [DATE] at 7:01 a.m. revealed the nurse visited with the resident who suddenly removed his/her brooch and stated he/she could use it to stab those [***] es. Staff started 15 minute checks. An incident report dated [DATE] at 11:30 a.m. and completed by Staff E RN (registered nurse) revealed the resident threw a stuffed bear at Resident #9 who sat in a recliner. Resident #9 then hit the other resident in the face with the bear. Resident #1 then hit the other resident in the stomach with the back of the hand. Nursing progress notes dated [DATE] at 11:30 a.m. and documented by Staff E revealed staff observed Resident #1 approach a table of residents and throw a stuffed bear at Resident #9. Resident #9 took the stuffed bear and hit the resident in the face with it. The resident then jerked his/her hand toward the other resident's abdomen and struck the back of staff that attempted to intervene. Nursing progress notes dated [DATE] at 11:46 a.m. and documented by Staff F CMA (certified medication aide) revealed staff administered Alprazolam (antianxiety) for the resident's appearance of being very upset hitting staff and others with bear and hands. Nursing progress notes dated [DATE] at 3:54 p.m. and documented by the ADON contained an interdisciplinary team review of the [DATE] incident. Resident #1 picked up a stuffed bear and threw it at Resident #9. Resident #9 picked up the bear and threw it back at Resident #1. Resident #9 then walked over to Resident #1 and lifted his/her leg and kicked Resident #1 in the abdomen. A psychiatric DNP dated [DATE] revealed an encounter telehealth note identified the ADON informed the DNP of the [DATE] incident. The DNP documented the other resident made fun of Resident #1 and pulled Resident #1's chair out while Resident #1 stood so he/she would fall. The other resident pushed the chair against Resident #1's legs. When Resident #1 turned around, he/she almost fell . Resident #1 threw a bear at the other resident and the other resident threw the bear back. The other resident kicked Resident #1 in the abdomen. There was no injury. The DNP documented the resident's mood changed quickly. The resident turns aggressive after being nice. Yesterday the resident got a butter knife and staff took it away. The resident was very restless and touched other residents when they did not want to be touched. On [DATE] at 9:17 a.m. the surveyor asked the ADON about the information she informed the DNP of but was not documented. The ADON stated she spoke with a lot people about the incident including dietary and that is what she was told when she conducted interviews. She didn't recall who told her the information. Video of the incident showed Resident #1 throwing a stuffed bear at Resident #9 who threw it right back at Resident #1. Resident #1 caught the bear and then went to Resident #9 and attempted to hit the resident. Resident #3 put her foot up as defense to keep Resident #1 away and Resident #1 grabbed the other resident's leg, then let go and walked away. Nursing progress notes dated [DATE] at 8:45 p.m. and written by Staff C CMA (certified medication aide) revealed Resident #1 hit another resident on the back of the head. Staff C documented she witnessed the incident, the hit was not too hard' and she stepped between the two residents. Staff C identified she informed Staff D LPN (licensed practical nurse) about the incident. On [DATE] at 2:16 p.m. Staff D LPN confirmed Staff C informed him of the incident. He stated he got swamped and never filled out an incident report. On [DATE] at 3:08 p.m. Staff C stated she saw Resident #1 raise his/her hand and the other resident (Resident #9) bent his her head and grabbed it stating don't hit me. Staff C stated she was unable to view if contact was made between the residents due to the angle in which Resident#1 stood. She confirmed she wrote the [DATE] nursing progress entry to indicate she saw the incident and Resident #1 struck the other resident on the back of the head but not very hard. Staff C stated Resident #9 later repeatedly warned others to keep away from Resident #1 because Resident #1 would hit and/or kill them. Video of the incident showed Resident #1 standing and partially blocking the view of Resident #9, Resident #1 raised his her hand and brought it down appearing to strike the other resident in the head. Resident #9 reacted by appearing to strike Resident #1's arm. Since Resident #1's body blocked the view so the actual connections could not be viewed. Observation showed, on [DATE] at 11 a.m. Resident #1 in the CCDI unit. The resident wore pajamas and his/her feet were bare. The resident was combative with staff and attempting to hit staff with a towel. Staff attempted to give the resident a medication in sauce and the resident spit the pill out. Staff asked the resident to wash his/her hands due to the resident having bowel movement (BM) on them. The resident refused. Staff got the resident in the shower room at 11:18 a.m. The resident remained agitated and yelled during the shower. When staff completed care, the resident exited the shower fully dressed and staff followed the resident one to one. At 11:40 a.m. staff remained one to one with the resident. At 12:20 p.m. staff remained one to one with the resident. At 3:04 p.m. staff remained one to one with the resident. At 4:23 p.m. staff remained one to one with the resident. Resident #1's care plan dated [DATE] revealed the resident with a potential to demonstrate physical behaviors hitting, pinching, kicking related to dementia. Throwing stuffed bear at another resident, throwing clothing on floor and struck female resident on arm. An intervention dated [DATE] and initiated [DATE] directed frequent checks. Interventions dated [DATE] included to call family in times of increased behaviors and referral to a psychiatric hospital. Nursing progress notes dated [DATE] at 10:32 a.m. revealed the facility consulted with the psychiatric provider about behaviors. Staff received an order to increase Haldol (antipsychotic) to 1 mg. at 11 a.m. and 4 p.m. Nursing progress notes contained an entry written by the corporate nurse and dated [DATE] at 6:51 p.m., that revealed staff would place an alarmed floor mat beside the resident's bed to alert staff the resident is awake and ambulating. Resident is to be within staff line of sight when resident awake. A MDS with assessment reference date of [DATE] assessed Resident #9 with a BIMS score of 4 (severe cognitive impairment). The resident had fluctuating episodes of disorganized thinking. The resident had behaviors of rejection of care 1 to 3 days out of 7. The resident was independent with ambulation. The resident had [DIAGNOSES REDACTED].#9 resided on the CCDI (chronic confusion and dementing illness) unit. Nursing progress notes contained a late entry dated [DATE] at 12:34 p.m. for [DATE] at 8:46 p.m. and written by Staff D LPN revealed he was called to the CCDI and informed one resident had their arm raised and the other resident grabbed the side of the head. Staff D documented staff said they did not see if the resident made contact. Staff separated the residents. On [DATE] at 3:48 p.m. observation showed Resident #9 in his her room seated on the bed. The resident stated someone hit him/her on the upper arm once but denied anyone hit him/her anywhere else. The resident did not know the month, year or president's name. The resident did know he/she was in Clarion. 4. A MDS with assessment reference date of [DATE] assessed Resident #8 with a BIMS score of 3 (severe cognitive impairment). The resident required extensive assistance of staff for bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and bathing. A balance during transitions and walking test revealed the resident as not steady and only able to stabilize with staff assistance in all areas of testing. The resident was frequently incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The MDS did not identify the resident with any behavior symptoms including rejection of care. A Care Plan dated [DATE] identified the resident with a potential for skin injury. The resident used anticoagulants with a history of bruises and skin tears secondary to physical aggression. The Care Plan identified staff should ensure the resident wore long sleeves or geri-sleeves prior to transfers and padding added to bed mobility bar and arms of dining room chair. Staff should reproach the resident with geri-sleeves if the resident refuses. Reproach resident when signs of agitation were present. A skin alteration report dated [DATE] at 9:32 p.m. identified the resident as combative with cares and received a 5.5 cm. by 0.1 cm. to the right anterior forearm. The skin report identified the skin tear occurred when staff tried to hold the resident's hand to prevent the resident from hitting staff. The intervention was to reeducate staff to reproach resident with a different staff when agitated. A skin alteration report dated [DATE] at 2:36 p.m. revealed staff observed bruises to the resident's right knee measuring 2 cm. by 2 cm. and 2 cm. by 3 cm. right lower calf and 0.5 cm. by 0.5 cm. to the right lower calf. Nursing progress notes dated [DATE] at 10:04 a.m. identified the intervention after the discovery of bruises was to educate staff to use caution during transfers and ambulation. Reminded to monitor placement if legs as to not strike against hard surfaces. A skin alteration report dated [DATE] at 12:25 p.m. revealed the resident received a 7.3 c.m. long by 0.3 cm. wide skin tear. Staff stated they attempted to transfer the resident from the wheelchair to the bathroom. The resident attempted to pinch staff between the legs and staff moved the resident's hand out of the way and sat the resident on the toilet. Nursing progress notes dated [DATE] at 12:25 p.m. identified the intervention following the incident as educated staff regarding precautions with transfers. Encourage safety of residents and staff. A skin alteration report dated [DATE] at 8:25 p.m. revealed staff pulled the resident's sweatshirt off and then observed a skin tear to the upper right arm. Staff reported the resident was cooperative and there was no blood on the shirt. Nursing progress notes dated [DATE] at 11:15 p.m. identified the area measured 4.5 cm. by 5 cm. Nursing progress notes identified the intervention after the incident as reeducate staff on being careful when removing clothes as the resident's skin is fragile. On [DATE] at 3:27 p.m. Staff J CNA stated she was with the resident when the resident got the skin tear to the upper arm. Staff J stated the resident gets aggressive with cares. Staff J stated she started to change the resident's shirt and when she pulled it up partway, the resident started freaking out. When she completed pulling it off, she observed a skin tear to the right upper arm. Staff stated the resident has fragile skin and wore rings. A skin alteration report dated [DATE] at 10 p.m. revealed during care the resident hit and slapped at staff and received a 4.5 cm. c-shaped skin tear to the back of the right hand. The report identified the resident has geri-sleeves but refuses them at times. The writer discussed importance of geri-gloves to protect skin and the importance to apply them prior to care. The intervention following the incident was reeducated staff to keep nails trimmed and remove rings before performing care. A skin alteration report dated [DATE] at 2:17 a.m. revealed staff got the resident ready for bed and the resident swung his/her hands around and caught the skin of the left hand on his/her ring and received a 5.5 cm. by 0.1 cm. c-shaped skin tear to left hand. The intervention following the incident was to check placement of geri-sleeve before providing care. The report stated staff tried to hold the resident's hands but the resident swung them away and received the skin tear. On [DATE] at 3:08 p.m. Staff C CMA stated she worked when the resident received a skin tear on the left hand from a ring. Staff came out of the resident's room and said the resident had a skin tear. Staff C stated the resident held his/her hand with the other hand and when he/she moved it, it caused a larger skin tear. Staff said the resident fought with the staff. She stated after the resident received the skin tear, staff let the resident be and came back later and put the resident in bed. A skin alteration report dated [DATE] at 5:41 a.m. revealed the resident received a 4.5 cm. by 0.1 cm. skin tear to the left forearm just above the wrist when staff removed the resident's sweatshirt, The intervention following the incident was to reeducate staff to ensure the resident wears geri-sleeves before cares. Observation showed, on [DATE] at 11:30 a.m. the resident seated in a wheelchair with a large white bandage protruding from the bottom of his/her left arm sleeve. At that time, Staff G CNA stated the resident wore the bandage because of a skin tear. Observation showed no padding on the wheelchair or dining room table. The resident wore a sweatshirt with long sleeves but not geri sleeves. On the same date at 1:10 p.m. Staff F CMA approached the resident about using the toilet and the resident said yes. Once in the bathroom, staff attempted to transfer the resident but the resident refused. Staff did not attempt to apply geri-sleeves prior to the transfer attempt. Staff then took the resident to the lounge and transferred the resident from the wheelchair to the recliner without attempting to apply geri-sleeves. The resident cooperated with the transfer. After the transfer to the recliner the resident stated he/she loved everybody. On [DATE] at 2:10 p.m. Staff F CMA stated the resident refused geri-sleeves that morning. Observation showed on [DATE] at 2:35 p.m., the resident in a recliner in the lounge. The resident wore long sleeves. At that time, Staff H CMA checked for geri-sleeves and the resident did not have them on the right arm. Staff could not check the left arm due to the resident's protectiveness of the arm. Staff H stated she applied the geri-sleeves that morning and the resident must have taken them off. Interviews: On [DATE] at 1:45 p.m. Staff I CNA stated the resident gets combative. When the resident gets combative, staff are supposed to step away and reproach at another time. On [DATE] at 2:10 p.m. Staff F CMA stated the resident receives skin tears during transfers. If the resident is combative he/she pinches staff and could rub his/her arm against something. If the resident is combative, Staff F walks away and reproaches the resident with a smile. On [DATE] at 2:01 p.m. Staff E RN stated the resident gets combative. If the resident is combative, staff leaves and comes back later. The resident wears geri-sleeves if allowed. The resident does wear long sleeves. 5. A MDS with assessment reference date of [DATE] assessed Resident #4 with a BIMS score of 7 (severe cognitive impairment). The resident was admitted to the facility on [DATE]. The resident had verbal and other behavior symptoms 1 to 3 days out of 7. The resident required extensive staff assistance with bed mobility, transfers, ambulation in and out of the room, dressing, toileting and personal hygiene. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance. The resident required a walker and wheelchair for mobility. The resident was frequently incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The MDS did not identify the resident with falls since admission to the facility. Hospice notes dated [DATE] revealed that while residing at another facility, prior to transfer to this facility, the resident had a staff with him/her at all times due to fall risk. The resident tried to get up by self and move on his/her own. A fall risk assessment dated [DATE] revealed the resident was a high risk for falls. A Care Plan dated [DATE] identified the resident at risk for falls related to gait/balance problems, psychoactive drug use, unaware of safety needs. The Care Plan did not identify that the resident used a bed and chair alarm from [DATE] to [DATE]. The only time the Care Plan identified bed/chair alarm use was after a fall and dated [DATE]. The Care Plan did not identify the resident's transfer needs. On [DATE] at 12:39 p.m. the Care Plan nurse confirmed the alarms were not on the Care Plan until post fall. She checked the medication administration records and treatment administration records and stated the alarms were not on them either. She responded via email dated [DATE] at 12:52 p.m. and stated the nurse ' s note on admit indicated the alarm was in place. She did not see it on the Care Plan until post fall. The comprehensive Care Plan was due [DATE] and the alarm was in place and on the Care Plan by then. On the same date at 1:57 p.m. she emailed and said the alarms were not on the initial Care Plan due to oversight. Nursing progress notes dated [DATE] at 5 p.m. contained an admission note that revealed the resident needed a personal alarm in place at all times. Nursing progress notes dated [DATE] at 3:46 p.m. revealed the resident ambulated with one staff and a walker. The resident's gait was slow and unsteady at times. Hospice notes dated [DATE] revealed the resident as very confused and tried to get up without assistance. Staff offered the resident dessert and the resident sat back down. Hospice documented the resident was more anxious the past day or so. A change of condition form, dated [DATE] identified the facility discontinued the resident's bed and chair alarm and would conduct a 72 hour monitor. The record lacked evidence there was any type of safety assessment prior to the discontinuation of the alarms or any interventions in place to replace the alarm assistance device. Nursing progress notes dated [DATE] at 8:39 p.m. revealed staff observed the resident lying in the prone position in the bathroom doorway. The resident was unresponsive with bloody drainage coming from the nose. Staff initiated neurological checks. Staff used a bath blanket with total assist to transfer the resident from the floor. The resident remained unresponsive and staff positioned the resident on the right side. Staff placed a bed alarm and floor mat with the bed in low position. Review of subsequent nursing progress notes dated [DATE] at 10:15 p.m. through [DATE] at 11:20 p.m. revealed the resident remained unresponsive until the resident expired on [DATE] at 11:20 p.m. A certificate of death revealed the physician identified the immediate cause of death as syncope of 1 week due to or as a consequence of advanced Alzheimer's disease. Interviews: On [DATE] at 3:08 p.m. Staff C CMA stated she worked when the resident fell . The resident's call light came on as Staff C worked with another resident that she couldn't leave. Resident #4 wasn ' t supposed to walk by self. Staff C assisted the other resident 5 to 8 minutes when she heard a thud. She went to Resident #4's room and found the resident on the floor with blood coming from the resident's nose. She observed bruising around the resident's

Based on observation, record review, resident and staff interviews, the facility failed to ensure each resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion for 3 residents. Resident #1 abused Resident #9 on 2 occasions. Resident #2 and Resident #3 both abused Resident #5 on 2 separate occasions. Resident #2 who was involved in a previous unprovoked incident with Resident #5 slapped Resident #3 across the face unprovoked leaving red marks. The facility reported a census of 59 residents and the sample consisted of 9 residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 8/25/16, assessed Resident #3 with a brief interview for mental status (BIMS) score of 1 (severe cognitive impairment). The MDS identified the resident had the following indicators of [MEDICAL CONDITION]: disorganized thinking and inattention. The resident had the following behavior symptoms identified: physical behaviors directed towards others and other behaviors directed towards others 1 to 3 days out of 7. The resident wandered and rejected care 4 to 6 days out of 7. The resident required supervision with ambulation and personal hygiene. The resident admitted to the facility 1/8/16 with [DIAGNOSES REDACTED]. Resident #3 resided on the CCDI (chronic confusion and dementing illness) unit. Nursing progress notes identified the following information: Incident: 7/9/16 at 11 a.m. revealed staff observed the resident with both hands on the left wrist of another resident. The resident and other resident sat in recliners in the lounge area of the CCDI unit. Staff redirected Resident #3 and moved the other resident. An incident report dated 7/9/16 at 11 a.m. revealed Resident #3 twisted the other resident's left wrist with his/her hands. On 7/9/16 the DNS (director of nursing service) assessed the other resident's left wrist. Observation showed an approximate 1 centimeter (cm.) red/purple area on the radial left wrist. The DNS documented that the area was not consistent with a finger print and that the right wrist contained a similar area. 15 minute check sheets identified the resident on 15 minute checks at the time of the incident. On 10/20/16 at 12:05 p.m. the Administrator identified the other resident as Resident #5. Review of Resident #5's nursing progress notes dated 7/9/16 at 11 a.m. identified the incident. Progress notes revealed staff applied ice to the resident's wrist and did not observe swelling or deformity. A MDS with assessment reference date of 6/9/16 assessed Resident #5 with a BIMS score of 6 (severe cognitive impairment). The MDS identified the resident with physical and verbal behaviors directed towards others and rejection of care 1 to 3 days a week. The resident required extensive staff assistance with transfers and toileting. The resident ambulated once or twice with the assistance of 2 staff. The resident had [DIAGNOSES REDACTED].#5 resided on the CCDI (chronic confusion and dementing illness) unit. A facsimile (fax) to the physician dated 7/9/16 at 3 p.m. reported Resident #3 got agitated when when another resident yelled out and Resident #3 grabbed the other resident's arm with a twisting motion. The other resident had a 1 cm. by 1 cm. dark purple area resembling purpura to the left wrist. Observation showed on 10/18/16 at 11:57 a.m. the resident sitting at the dining room table in a wheelchair. The resident complained about the meal and stated he/she didn't like anything he/she received. The resident stated he/she would rather have a piece of pie. 2. A MDS with assessment reference date 9/3/16, assessed Resident #2 with short and long term memory impairments and severely impaired decision making ability. The resident had the following indicator of [MEDICAL CONDITION]: disorganized thinking. The resident had physical behavior symptoms directed towards others 1 to 3 days a week. The resident required supervision with ambulation. The resident had [DIAGNOSES REDACTED]. Resident #2 resided on the CCDI (chronic confusion and dementing illness) unit. A care plan dated 5/20/16, revealed the resident used anti anxiety medications related to [MEDICAL CONDITIONS]. The resident exhibited anxiety with loud noises. The resident kicked a female resident and staff noted thunder before the incident. The resident made statements about bombs following the incident. The resident was physically aggressive with another resident and the resident made sexual comments to staff. The written care plan identified 15 minute checks starting on 7/24/16. Nursing progress notes identified the following information: 7/23/16 at 8:33 p.m. revealed staff witnessed Resident #2 walk up to Resident #5 and kick the resident in the left knee. The 5/20/16 care plan revealed the intervention following the incident was a urine dip and 15 minute checks. A fax to Resident #2's physician dated 7/23/16 at 3 p.m. revealed staff informed the physician that Resident #2 walked out of the room and walked up to Resident #5 and kicked the resident in the knee. Resident #2 then walked away and sat at the table. The fax identified staff placed the resident on 15 minute checks, would obtain a UA and set up an appointment with the psychiatric DNP (doctor of nursing practice). A fascimilie to Resident #5's physician regarding the incident dated 7/23/16 at 3 p.m. revealed Resident #5 sat in the CCDI lobby when Resident #2 came out of his/her room and kicked Resident #5 in the left lateral knee. The resident stated, oh that hurt. No injuries observed. Review of Resident #5's nursing progress notes, dated 7/23/16 at 9:35 a.m. revealed Resident #2 kicked Resident #5 in the left knee. Assessment showed the resident did not sustain injury. Nursing progress notes dated 7/23/16 at 9:45 p.m. identified the UA as negative per urine dip. On 10/19/16 at 1:32 p.m. Staff A CNA (certified nurse aide) stated she observed the 7/23/16 incident. Resident #3 walked up and kicked Resident #5 in the knee without warning. Resident #5 let out a yell. Staff A stated it was a pretty hard kick. 9/1/16 at 11:20 a.m. revealed staff observed the resident walk into the common area of the CCDI with a CNA (certified nurse aide). The resident then walked up to Resident #3 and struck Resident #3 across the left side of the face with an open hand. The CNA then grabbed Resident #2's left arm and Resident #3's left arm. Resident #3 grabbed Resident #2's right wrist. Staff intervened and separated the residents. An incident report dated 9/1/16 at 11:20 a.m. revealed Resident #3 had dispersed redness under the left eye and lateral left side of the face. Staff applied ice to the area. The report revealed resident did not complain of pain or discomfort. View of video of the 9/1/16 incident showed Staff B walk a couple feet ahead of Resident #2. Staff B turned and Resident #2 put his arm out to keep Staff B away and then slapped Resident #3 full force by pulling his enter arm out and then slapping Resident #3 with an open hand on the head/face. Resident #3 put his/her arms up to defend self and Resident #2 grabbed the other resident's arms with more attempts to strike the resident. On 9/26/16 at 12:25 p.m. a visitor stated he witnessed the 9/1/16 incident. He stated Resident #2 came over to Resident #3 and smacked Resident #3 hard on the head. The visitor stated he thought the hit would have caused a concussion. He stated the staff was right there to intervene. On 10/19/16 at 10:06 a.m., Staff B CNA stated she walked Resident #2 to the table for lunch. Resident #2 stated, I got this and went over and struck Resident #3. Staff B stated she stepped in and held Resident #3. The ADON (assistant director of nursing) also stepped in and helped. They applied ice to Resident #3's eye. Staff B stated the incident occurred without warning. On 10/18/16 at 10:05 a.m. the ADON stated Resident #3 sat at a table waiting for lunch between 11:30 a.m. and 12 p.m. She heard Resident #2 say I got this and then Resident #2 smacked Resident #3 in the face with an open hand. Staff B got between the residents and the ADON walked Resident #2 into another room. Resident #2 said Resident #3 stole from him/her. Intervention dated 9/26/16 was to keep staff between residents involved in physical aggression when ambulating, activities and meals. On 9/26/16 at 12:12 p.m. observation showed Resident #2 seated in the dining room with Resident #5 seated in a wheelchair at Resident #2's right. On 10/18/16 at 9:50 a.m. Resident #2 stated he/she had an argument or 2 but the resident couldn't remember what it was about. The resident denied getting in fights. The resident stated he/she gets along with people and didn't have any trouble with anyone but you never know. An encounter telehealth note dated 10/14/16 identified the resident saw the psychiatric DNP per video conferencing. The DNP wrote Resident #2 was doing good with no aggressive behaviors. The DNP increased Resident #2's [MEDICATION NAME] from 25 milligrams (mg.) to 50 mg for anxiety. 3. A MDS with assessment reference date of 10/11/16 assessed Resident #1 with impaired short and long term memory and severely impaired decision making skills. The resident admitted to the facility on [DATE]. The resident had the following indicators of [MEDICAL CONDITION]: disorganized thinking and inattention. The resident had delusions and physical behaviors directed towards others 1 to 3 days out of 7. The behaviors put others at significant risk of physical injury. The resident required supervision with ambulation. The resident had [DIAGNOSES REDACTED]. Resident #1 resided on the CCDI (chronic confusion and dementing illness) unit. Nursing progress notes dated 10/6/16 at 7:01 a.m. revealed the nurse visited with the resident who suddenly removed his/her brooch and stated he/she could use it to stab those [***] es. Staff started 15 minute checks. An incident report dated 10/6/16 at 11:30 a.m. and completed by Staff E RN (registered nurse) revealed the resident threw a stuffed bear at Resident #9 who sat in a recliner. Resident #9 then hit the other resident in the face with the bear. Resident #1 then hit the other resident in the stomach with the back of the hand. Nursing progress notes dated 10/6/16 at 11:30 a.m. and documented by Staff E revealed staff observed Resident #1 approach a table of residents and throw a stuffed bear at Resident #9. Resident #9 took the stuffed bear and hit the resident in the face with it. The resident then jerked his/her hand toward the other resident's abdomen and struck the back of staff that attempted to intervene. Nursing progress notes dated 10/6/16 at 11:46 a.m. and documented by Staff F CMA (certified medication aide) revealed staff administered [MEDICATION NAME] (antianxiety) for the resident's appearance of being very upset hitting staff and others with bear and hands. Nursing progress notes dated 10/7/16 at 3:54 p.m. and documented by the ADON contained an interdisciplinary team review of the 10/6/16 incident. Resident #1 picked up a stuffed bear and threw it at Resident #9. Resident #9 picked up the bear and threw it back at Resident #1. Resident #9 then walked over to Resident #1 and lifted his/her leg and kicked Resident #1 in the abdomen. A psychiatric DNP dated 10/7/16 revealed telecommunication was made and the ADON informed the DNP of the 10/6/16 incident. The DNP reported the other resident made fun of Resident #1 and pulled Resident #1's chair out while Resident #1 stood so he/she would fall. The other resident pushed the chair against Resident #1's legs. When Resident #1 turned around, he/she almost fell . Resident #1 threw a bear at the other resident and the other resident threw the bear back. The other resident kicked Resident #1 in the abdomen. There was no injury. The DNP documented the resident's mood changed quickly. The resident turns aggressive after being nice. Yesterday the resident got a butter knife and staff took it away. The resident was very restless and touched other residents when they did not want to be touched. On 10/25/16 at 9:17 a.m. the surveyor asked the ADON about the information she informed the DNP of but was not documented. The ADON stated she spoke with a lot people about the incident including dietary and that is what she was told when she conducted interviews. She didn't recall who told her the information. Video of the incident showed Resident #1 throwing a stuffed bear at Resident #9 who threw it right back at Resident #1.Resident #1 caught the bear and then went to Resident #9 and attempted to hit the resident. Resident #3 put her foot up as defense to keep Resident #1 away and Resident #1 grabbed the other resident's leg, then let go and walked away. Nursing progress notes dated 10/17/16 at 8:45 p.m. and written by Staff C CMA (certified medication aide) revealed Resident #1 hit another resident on the back of the head. Staff C documented she witnessed the incident, the hit was not too hard' and she stepped between the two residents. Staff C identified she informed Staff D LPN (licensed practical nurse) about the incident. On 10/18/16 at 2:16 p.m. Staff D LPN confirmed Staff C informed him of the incident. He stated he got swamped and never filled out an incident report. On 10/18/16 at 3:08 p.m. Staff C stated she saw Resident #1 raise his/her hand and the other resident (Resident #9) bent his her head and grabbed it stating don't hit me. Staff C stated she was unable to view if contact was made between the residents due to the angle in which Resident#1 stood. She confirmed she wrote the 10/17/16 nursing progress entry indicating she saw the incident and that Resident #1 struck the other resident on the back of the head but not very hard. Staff C stated Resident #9 later repeatedly warned others to keep away from Resident #1 because Resident #1 would hit and/or kill them. Video of the incident showed Resident #1 standing and partially blocking the view of Resident #9, Resident #1 raised his her hand and brought it down appearing to strike the other resident in the head. Resident #9 reacted by appearing to strike Resident #1's arm. Since Resident #1's body blocked the view so the actual connections could not be viewed. Observation showed, on 10/18/16 at 11 a.m. Resident #1 in the CCDI unit. The resident wore pajamas and his/her feet were bare. The resident was combative with staff and attempting to hit staff with a towel. Staff attempted to give the resident a medication in sauce and the resident spit the pill out. Staff asked the resident to wash his/her hands due to the resident having bowel movement (BM) on them. The resident refused. Staff got the resident in the shower room at 11:18 a.m. The resident remained agitated and yelled during the shower. After staff completed care, the resident exited the shower fully dressed and staff followed the resident one to one. At 11:40 a.m. staff remained one to one with the resident. At 12:20 p.m. staff remained one to one with the resident. At 3:04 p.m. staff remained one to one with the resident. At 4:23 p.m. staff remained one to one with the resident. Resident #1's care plan dated 10/6/16 revealed the resident with a potential to demonstrate physical behaviors hitting, pinching, kicking related to dementia. Throwing stuffed bear at another resident, throwing clothing on floor and struck female resident on arm. An intervention dated 10/6/16 and initiated 10/11/16 directed frequent checks. Interventions dated 10/18/16 included to call family in times of increased behaviors and referral to a psychiatric hospital. A MDS with assessment reference date of 7/22/16, assessed Resident #9 with a BIMS score of 4 (severe cognitive impairment) and fluctuating episodes of disorganized thinking. The resident had behaviors of rejection of care 1 to 3 days out of 7. The resident was independent with ambulation. The resident had [DIAGNOSES REDACTED].#9 resided on the CCDI (chronic confusion and dementing illness) unit. Nursing progress notes contained a late entry dated 10/19/16 at 12:34 p.m. for 10/17/6 at 8:46 p.m. and written by Staff D LPN revealed he was called to the CCDI and informed one resident had their arm raised and the other resident grabbed the side of the head. Staff D documented staff said they did not see if the resident made contact. Staff separated the residents. On 10/18/16 at 3:48 p.m. observation showed Resident #9 in his her room seated on the bed. The resident stated someone hit him/her on the upper arm once but denied anyone hit him/her anywhere else. The resident did not know the month, year or president's name. The resident did know he/she was in Clarion.

Based on observation, record review, resident and staff interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 4 residents reviewed for accidents. Resident #1 and #4 fell when staff was busy with residents they could not leave. Resident #3 did not have his/her alarm in place when observed during the investigation. The CCDI (chronic confusion and dementing illness) unit had 16 residents on the unit when Resident #1's fall occurred. 10 of the 16 residents used alarms. 6 of 16 residents required two staff for assistance with an additional 3 residents sometimes requiring 2 staff for assistance totaling a potential 9 of 16 residents that required 2 staff to assist them. The facility reported a census of 59 resident. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment, with a reference date of 5/5/15. The MDS reflected the resident had a BIMS (Brief Interview for Mental Status score of 4. A score of 4 represented the resident as severely cognitively impaired. The resident required extensive assistance of staff with bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and bathing. The resident used a walker and wheelchair for mobility. A balance during transitions and walking test identified the resident as unsteady and only able to stabilize with staff assistance in all areas of testing. The resident experienced frequent bowel and bladder incontinent episodes. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with 2 falls without injury since the prior assessment. History of Falls: A fall report dated 2/1/15 at 1 p.m. identified the resident fell in the dining room. When the nurse arrived to the CCDI (Chronic Confusion and Dementing Illness) unit, she observed the resident on the floor next to the dining table lying on his/her back. The resident stated his/her walker hit something causing the resident to fall. According to the fall report, the intervention following the incident was to have staff place all walkers by the wall away from dining tables. An x-ray report dated 2/3/15 identified the resident with a nondisplaced acute right superior and inferior pubic rami fracture. An ADL (activity of daily living) report from 1/7/15 to 1/13/15 identified the resident as independent with ambulation. A handwritten note sent via facsimile on 6/23/15 to the State Agency and written by the Director of Nursing Services (DNS) identified the resident ambulated independently prior to the 2/1/5 fall. A fall report form dated 3/3/15 at 8:05 p.m., revealed the resident fell in the bathroom. When found, the resident only wore a brief. A personal alarm was in place and connected to a night gown that the resident self- removed. The resident did not sustain an injury. According to the fall form, the intervention following the incident was a pressure alarm on the bed. A fall report dated 4/9/15 at 7:20 a.m. reflected the resident fell in the common area when the resident ambulated with staff from the shower room to the dining area in the CDDI unit. The resident ambulated unsteadily and when the resident arrived at the table, there was another resident's walker in the way. Staff stood in front of the resident to push the walker out of the way. The resident pushed his/her walker into the other walker and stumbled with his/her knees buckling and the resident sat on the floor. The resident did not sustain injury. According to the fall report, the intervention following the incident was staff education. A fall report dated 5/27/15 at 12:30 a.m. reflected the resident fell in his/her room. Staff found the resident sitting on the floor by the bed with back against the bed and legs drawn up. The resident stated the doorbell rang (alarm) and he/she shut it off. The resident did not sustain injury. According to the fall report, the intervention following the incident was to change the pressure alarm to a TAB alarm. Major Injury Incident: A fall report dated 6/17/15 at 8:45 p.m. reflected the resident fell in the dining room. Staff called the charge nurse (Staff A) licensed practical nurse (LPN) to the unit. Staff A documented she observed the resident lying on the floor on the left side. The resident received a 1 centimeter (cm.) by 0.1 cm. skin tear to the top of the right ear. The resident would not bear weight on the left leg so staff sent the resident to the hospital for examination. The report identified the resident ambulated without assistance and fell . The report reflected Staff B witnessed the incident. On the fall report, Staff B stated she walked with another resident when she observed the resident start to get up. Staff B stated she tried to get the resident she was with to sit down so she could help Resident #1 but it was too late. A hospital history and physical dated 6/18/15 identified the resident fell at the care center and could not bear weight afterwards. The resident came to the emergency room (ER) and diagnosed with [REDACTED]. The resident underwent [REDACTED]. The hospital x-ray report dated 6/18/15 at 8:54 a.m. reflected the resident had an acute fracture of the left hip with cephalad (inn or into a position nearer the head or front) and lateral displacement of the shaft fragment, subacute healing fractures of the right superior and inferior pubic rami (pelvis) and osteopenia, probable osteoporosis. The hospital x-ray report dated 6/18/15 at 2:34 p.m. identified an acute fracture of the left hip with advanced osteoarthritis of the right hip joint. The resident has late subacute healing fractures of the right superior and inferior pubic rami (pelvis). Staff Interviews: On 7/21/15 at 7:34 p.m. Staff B (certified medication aide), stated there were two staff working on the unit. Staff C left the unit to get gripper socks and leaving Staff B alone on the unit. During the shift prior to the fall, Resident #1 exhibited extremely antsy behavior and repeatedly said he/she could walk. After supper the resident got up and down so one staff stayed in the common area. When Staff C left the unit, Staff B observed Resident #1 with eyes closed and feet up in the common area so she took Resident #5 and when they got to the corner to turn to the hallway, she heard Resident #1's alarm sound. On 7/22/15 at 2:15 p.m. Staff B stated Resident #5 was ready for bed. She observed Resident #1 laid back in a recliner with eyes closed so she thought it was safe to leave Resident #1 and help Resident #5 to bed. Staff B ambulated Resident #5 to his/her bedroom and as they went to turn a corner to the hallway, she heard Resident#1's alarm activate. Staff B stated she let go of Resident #5 after she ensured Resident #5 seemed steady. She ran to try and catch Resident #1 and got within 2 to 3 feet of the resident and the resident fell . The resident moved fast. The resident first grabbed a walker and then a chair and then a table to keep him/herself steady as he/she ambulated but when the resident got to the cupboard/bookcase, the resident fell . Staff B called for Staff A to come to the unit to help on the Walkie call device. At that time, Staff C (certified medication aide) heard the call for help and entered the unit. Staff C then assisted Resident #5 to sit down. On 7/22/15 at 2:30 p.m. Staff B identified where the recliner was that Resident #1 sat in prior to getting up and then where the resident fell . At that time, the Maintenance Director measured the distance between the recliner and point of the fall. The area measured 8 feet. On 7/22/15 at 2:05 p.m. Staff C (certified medication aide) stated she stepped out of the unit to get gripper socks. She was about 10 feet outside the CCDI unit door when she heard Staff B ask for help over the Walkie call device. Staff C stated when she entered after hearing the call for assistance to the unit, she observed Resident #1 on the floor and Resident #5 standing with a walker alone by the medication cart. On 7/21/15 at 2:18 p.m. Staff A (licensed practical nurse) stated Staff B assisted another resident and tried to get that resident to sit down but by the time Staff B got to Resident #1, the resident already fell . Staff C just stepped out and walked right back in when she heard Staff B needed help. When asked if she thought the incident could have been prevented, Staff A stated maybe if Staff C had not left the unit. On 7/21/15 at 9:45 a.m. the Director of Nursing (DON) identified 16 residents in the CCDI unit, on the time of the incident. On the same date, the DON provided the surveyor with a listing of residents in the CCDI unit that used alarms when Resident #1's incident occurred. The list identified 10 of 16 residents in the CCDI used alarms. The list identified Resident #5 (the resident left standing alone when Staff B ran to Resident #1) used a bed/chair alarm. On 7/22/15 at 10:25 a.m., the DON identified 6 residents on the CCDI required 2 staff to assist them with an additional 3 requiring 2 at times it just depended on the day, totaling a potential 9 residents in the units that may require assistance of 2 staff. The CCDI staffing policy identified the facility would provide at least one nursing personnel on the CCDI unit at all times. Care Plan: The Care Plan submitted to the State Agency when the self- report was made and dated 5/4/15 (according to the computer) identified the resident as at risk for falls related to cognitive deficits and decreased safety awareness and confusion. The resident had impaired mobility and used a front wheeled walker as an assistive device. The resident had a history of [REDACTED]. The care plan did not identify the resident used an alarm. The current Care Plan, dated 6/23/15 and printed for the surveyor on 7/21/15 did not contain a directive for alarms. The Care Plan also directed staff to walk to dine with the resident as tolerated with a front wheeled walker. The resident returned to the facility on that date with an order for [REDACTED]. The Kardex with current interventions listed for the nurse aides, also printed on 7/21/15, did not identify alarm usage and directed staff to walk to dine with the resident. Observation on 7/21/15 at 11 a.m. identified the resident in a recliner with feet up and pressure alarm in place. The alarm functioned when staff pivot transferred the resident to the wheel chair. Staff did not ambulate the resident to the meal. On 7/22/15 at 1:22 p.m. the Director of Nursing stated the walk to dine intervention was reactivated when the resident returned. She stated she talked to restorative and they did not ambulate the resident. On 7/24/15 at 7:40 p.m., the Director of Nursing stated she received a call from the service center regarding the discrepancy of the Kardex. The Director of Nursing stated the service center informed her they had to make a change in the settings and the problem should be resolved. 2. Resident #4 had a MDS assessment with a reference date of 5/5/15. The MDS reflected the resident had a BIMS score of 5 (severe cognitive impairment). The resident had physical and verbal behaviors and rejected care. The resident required extensive staff assistance with bed mobility, transfers, ambulation, dressing, toileting and personal hygiene. A balance during transitions and walking test identified the resident as unsteady and only able to stabilize with staff assistance in all areas of testing. The resident utilized a walker and wheelchair for mobility. The resident had functional limitations in range of motion on one side of the lower extremities. The resident frequently experienced bladder incontinence. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with 2 falls without injury since the previous assessment. Fall History: A fall report dated 3/11/15 at 11:15 p.m. reflected the resident fell out of bed in the resident's room. The resident stated he/she needed the bathroom. The resident did not sustain an injury. The fall report did not identify an intervention following the incident. The Care Plan identified a pressure alarm to bed/wheelchair started on 3/12/15. A fall report dated 3/23/15 at 10:32 a.m. revealed the resident fell in the common area of the CCDI unit. Staff observed the resident scooting down to the foot rest of the recliner causing the recliner to tip forward. Staff lowered the resident to the floor. The resident did not sustain an injury. The intervention listed on the fall report after the incident was a urinalysis dipstick check and place fall mats on the sides of the recliner. A fall report dated 3/23/15 at 11 p.m. reflected the resident fell in the resident's room. Staff observed the resident lying on their right side on the floor mat. The resident pulled the floor lamp upon self and pulled dresser scarf off and all the dresser objects went on the floor. No glass broke. The alarm did not sound when the fall occurred. Observation showed the resident's bedding wet and the resident's brief dry. The resident received a bruise to the right front of the iliac crest (pelvis). The report identified the intervention following the incident was: Alarm replaced. Bed in low position. Pillow bolsters replaced under sheet on both sides of the bed and fall mats continued on both sides of the bed. A fall report dated 3/24/15 at 11:10 a.m. reflected the resident fell in the common area. The report identified the resident sat in the recliner with a pressure alarm in place. Staff assisted other residents and heard the alarm sound. When they arrived, they observed the resident climbing out of the recliner. Staff attempted to reposition the resident and lowered the resident to the floor. The resident did not sustain an injury. The report did not identify an intervention following the incident on the form. The care plan identified the following intervention started on 3/25/15: Encourage resident to rest in bed when able. If resident chooses to lie on floor, provide floor mat for safety and comfort. A fall report dated 4/1/15 at 8:05 a.m. reflected the resident fell in the common area. Staff observed the resident climbing out of the recliner and lowered the resident to the floor. The resident did not sustain an injury. Review of the fall report and Care Plan did not identify an intervention following the fall incident. A fall report dated 4/1/15 at 9:40 a.m. reflected the resident slid out of the recliner to his/her knees and then onto left side. The resident did not sustain an injury. The fall report and Care Plan did not identify an intervention following the incident. A fall report dated 4/6/15 at 6:30 a.m. reflected the resident fell in the common area of the CCDI unit. The resident did not sustain an injury. The intervention listed after the fall on the fall report was: back of wheelchair seat lowered for positioning. A fall report dated 4/23/15 at 7:10 a.m. reflected the resident fell in the common area. Staff found the resident lying on the floor by the recliner. The resident did not sustain an injury. Following this incident, the facility sent a facsimile for a referral to Hope Harbor (psychiatric facility). The fall report and care plan did not identify any other action taken after the fall incident. A fall report dated 4/23/15 at 8:26 p.m. reflected the resident fell in the common area. Staff observed the resident sitting on the floor with his/her back against the recliner. The resident did not sustain an injury. Following this incident, the facility sent a facsimile for a referral to Hope Harbor (psychiatric facility). The fall report and Care Plan did not identify any other action taken after the fall incident. A fall report dated 5/11/15 at 3:17 p.m. reflected the resident fell in the resident's room. Staff observed the resident on the floor mat next to the bed about 6 inches from the side of the bed on his/her hands and knees. The form did not identify injury or pain. The intervention listed on the fall report following the incident was: toilet resident prior to and following completion of therapy. The physician ordered an x-ray of the hip. An x-ray report dated 5/13/15 identified an avulsion fracture of the tip of the left greater trochanter (upper part of thigh bone) with slight medial displacement. A 5/18/15 physician order [REDACTED]. A major injury determination form dated 5/15/15 at 2:30 p.m. revealed the injury as not a major injury. A fall report dated 5/25/15 at 4:33 a.m. revealed the resident fell in the resident's room. Staff observed the resident by the bed on his/her knees. The intervention following the incident was: obtain urinalysis and staff education to have all supplies available when providing care. The care plan identified on 5/28/15 an intervention to position the bed in the lowest position. A fall report dated 5/30/15 at 6:47 a.m. revealed the resident fell in the resident's room at 1:40 a.m. The resident laid on his/her back with feet against the bed and head towards the east wall. The resident identified self as rolling in bed and then being on the floor. The intervention was: apply a concave mattress to the bed. The Nursing Progress Notes, dated 6/5/15 at 10:34 a.m. identified the resident left the facility for Hope Harbor. The Nursing Progress Notes dated 6/19/15 at 4:12 p.m. revealed the resident returned to the facility from Hope Harbor. A fall report dated 6/24/15 at 6 a.m. and written by Staff D (licensed practical nurse) revealed staff found the resident on the floor in the resident's room. The nurse aide responded to the alarm but could not reach the room in time. The resident did not sustain an injury. The intervention listed on the fall form was: toilet the resident at midnight and 4 a.m. A facsimile (fax) to the physician dated 7/1/15, identified the resident received a skin tear to the left elbow (no size documented). The physician signed the fax agreeing to the geriatric glove usage. The Care Plan identified an intervention for geriatric sleeves at all times started on 6/29/15. On 7/21/15 at 7:07 p.m. Staff D stated the nurse aide called her to the resident's room on 6/24/15. Staff D stated there was one nurse aide on duty in the CCDI unit when the fall occurred. The nurse aide was with another alarmed resident and by the time she got to the resident's room, the resident already rolled out of bed. Staff D stated it was shift change too, so staff could have been at report, also delaying response time. A fall report dated 7/9/15 at 3:04 a.m. identified the resident rolled out of bed onto the floor mat. The resident did not sustain an injury. The intervention listed on the fall form after the incident was: floor mat removed and a standard mattress placed in place of floor mat. A facsimile to the physician dated 7/9/15 regarding the incident revealed staff recommended a tab alarm and hourly checks. The physician responded and directed staff to perform a urinalysis (UA) and signed the form. The TAB alarm and hourly checks were not on the Kardex or Care Plan. A fall report dated 7/10/15 at 5:26 a.m. revealed staff found the resident on the fall mat next to his/her bed in the resident's room at 11:45 a.m. on 7/9/15. The resident stated he/she was asleep and when he/she woke up the resident was on the floor. The resident did not sustain an injury. The intervention was: mattress in place of fall mat from intervention earlier in the day. A fall report dated 7/12/15 at 4:25 p.m. revealed the resident fell out of his/her wheelchair in the dining room. The nurse aide stated she just turned her back on the resident 2 to 3 minutes earlier. The resident did not sustain an injury. The fall report identified the new intervention as Dycem (non sliding material) to (the seat of the) wheelchair. A fall report dated 7/12/15 at 10:10 p.m. and written by Staff E (registered nurse) revealed the resident fell in the common area of the CCDI unit. Staff found the resident lying on his/her left side in front of the recliner. The resident complained of discomfort to the left elbow. The resident received a skin tear to the left elbow during the fall. A facsimile to the physician revealed the left elbow skin tear measured 5 centimeters (cm.) On 7/21/15 at 3:09 p.m. Staff E (registered nurse) stated when the incident occurred she was going to the rest room off the unit. She heard Staff C (nurse aide) page for assistance for the CCDI unit. Staff E did not hear a reply to the page so as soon as she finished in the rest room, she went to the CCDI unit. When she entered the CCDI unit, the resident's alarm was still sounding and the resident was on the floor. Both staff on the CCDI were in rooms with other residents. The care plan identified the intervention of Dycem to wheelchair and recliner on 7/13/15. Observation showed, on 7/21/15 at 11 a.m., the resident in a recliner with a geriatric sleeve on the left arm and no geriatric sleeve on the right arm. There was no geriatric sleeve lying in the area to indicate one had been in place and the resident removed it. The resident sat on a pressure alarm with no Dycem in place. After the surveyor questioned the geriatric sleeve and the Dycem not in place, staff obtained a geriatric sleeve for the right arm and took Dycem from another chair in the common area and placed it in the resident's chair. The Care Plan, dated 6/19/15 identified the resident had a problem of falls. The Care Plan contained an intervention dated 7/8/15 for a concave mattress. The concave mattress intervention was listed as the intervention following the 5/30/15 fall. The Care Plan identified a 7/13/15 intervention for Dycem to the wheelchair and recliner, a 7/10/15 intervention for a mattress by the bed, a 3/12/15 intervention for a pressure alarm to bed and wheelchair, a 6/29/15 intervention for geriatric sleeves at all times and a 6/24/15 intervention for toilet during 10 p.m. to 6 a.m. shift. The care plan did not identify the specific toileting directive for midnight and 4 a.m. listed as the intervention following the 6/24/15 fall. The facility provided documentation that identified the concave mattress was in place prior to 7/8/15 listing on the Care Plan. 3. Resident #3 had a MDS assessment with a reference date of 4/28/15. The MDS reflected the resident had a BIMS score of 14. A score of 14 identified the resident had no problems with cognition. The MDS identified the resident as independent with transfers, ambulation and toileting. The resident did not have falls since the previous assessment. The resident had an admission date of [DATE]. History of Falls: A fall report form dated 5/22/15 at 1:45 a.m., revealed the resident fell in the bathroom without injury. The resident wore one shoe and stated he/she could not find the other one. The fall form listed the intervention following the incident as: leave the resident's shoes on the table for easy access. A fall report form dated 5/28/15 at 6:11 p.m. reflected the resident fell on the floor with back leaning against the recliner. The resident complained of discomfort to the right side of the gluteal cleft and a skin tear to the right posterior arm. The skin tear measured 4 centimeters (cm.) by 1 cm. The intervention was: pad the recliner front legs and educate resident to call for assistance. Care Plan: The current Care Plan dated 5/27/15, identified a history of falls related to cognitive deficits, anorexia, depression, anxiety and ambulation with a front wheeled walker. The Care Plan and Kardex with current interventions printed on 7/21/15, directed staff to ensure the resident used an alarm in the bed and chair. An email from the Director of Nursing dated 7/27/15 at 12:50 p.m. identified the alarm intervention was started on 5/28/15. Observation on 7/21/15 at 11:08 a.m. identified the resident in his/her room sitting in the recliner. The resident stated when he/she fell in the bathroom that he/she was trying to kill a spider. The resident stated when he/she fell from the recliner that he/she tried to reach something. Observation identified the resident as not seated on an alarm. The surveyor summoned Staff F (nurse aide) who found the alarm pad beside the recliner by the trash can and the alarm box on the counter by the sink. At that time, Staff F applied the alarm.

Based on record review, interviews with staff and physician, the facility failed to plan nursing provisions to effectively monitor anticoagulant medication levels according to physician's orders [REDACTED]. Resident #1's physician directed staff to recheck his/her blood clothing test INR (International Normalized Ratio) and the resident continued to receive [MEDICATION NAME] medication without monitoring the impact of anticoagulant (blood thinning) medication. Resident #1's INR elevated to 11 with a therapeutic INR range between1.0-3.0. The findings established an immediate jeopardy to residents health and safety. In addition, the facility failed to obtain INR testing as ordered by the physician for Resident #10 and Resident #12. The facility identified a census of 51 current residents. Findings included: 1. A Minimum Data Set (MDS) assessment tool dated August 7, 2012 documented Resident #1 with moderately impaired cognition, required extensive staff assistance with bed mobility, transfers, ambulation, toilet use, and personal hygiene. An undated [DIAGNOSES REDACTED]. Resident #1's Care Plan with an initiated date of January 13, 2012 had a Focus area that documented the resident with thin fragile skin and received [MEDICATION NAME], a blood thinner/anticoagulant, that caused the resident to bruise easily. Interventions directed staff the resident with multiple bruises most of the time due to [MEDICATION NAME] and remember how thin and fragile resident's skin during cares, padded foot pedals on wheel chair, center bar of bedside table padded, and use a padded gait belt during transfers. Prior to Resident #1's admission to the nursing home, a Hospital Consult dated 12/28/11 revealed the resident had sustained a left femur fracture at his/her home. The cardiologist completed a pre-op (operation) risk assessment prior to surgery. The surgery was canceled due to the resident's elevated INR (International Normalized Ratio). A hospital Patient Discharge & Transfer Form in the resident's record documented the resident with a hospital admission from December 28, 2011 to January 5, 2012 and directed the staff to see the [MEDICATION NAME] order and instruction sheet. A [MEDICATION NAME] Orders and Instructions sheet dated January 5, 2012 documented the resident received [MEDICATION NAME] Anticoagulation for [MEDICAL CONDITION], [MEDICATION NAME] a continuation of pre-hospital treatment, and the resident's last INR (International Normalized Ratio) on January 5, 2012 resulted in 1.8. The sheet directed staff to administer [MEDICATION NAME] three milligrams (mg.) orally on Monday, Wednesday, and Friday, [MEDICATION NAME] two mg. on Saturday, Sunday, Tuesday, and Thursday, and the next INR due January 9, 2012 at the facility. Record review revealed the following related to INR results, physician orders, and interviews: a) A Facsimile Transmittal (fax) sent to the physician January 14, 2012 documented the resident received [MEDICATION NAME] therapy, requested an order date to obtain an INR/PT ([MEDICATION NAME] Time), and the physician directed staff to obtain an INR monthly. Record review lacked any documentation of an INR completed January 9, 2012. During interview October 17, 2012 at 2:20 p.m. Staff SS verified the INR not completed on January 9, 2012. b) A hospital Laboratory Report dated, January 19, 2012 (ten days later than original order date) documented an INR test with a greater than 11 result (High Critical), normal range 1.00 to 3.00, and directed staff to view the critical value flow sheet/INR. A Family Practice Clinic Laboratory Notification Form, dated January 19, 2012 (Thursday), documented a Critical Value INR result of 15.92 and normal range 1.00 to 3.00. The form documented the facility notified of physician orders [REDACTED]. c) A hospital Laboratory Report, dated January 23, 2012, documented an INR test result of 3.76. The same sheet documented a physician order [REDACTED]. d) A hospital Laboratory Report, dated January 31, 2012, documented an INR test result of 3.59, high. The same sheet documented a physician order [REDACTED]. on Monday and Thursday, and [MEDICATION NAME] two mg. on Sunday, Tuesday, Thursday, and Saturday, recheck the INR on February 8, 2012, and then obtain INR's weekly. e) A hospital Laboratory Report, dated February 8, 2012, documented an INR test with a greater than 11 result, High Critical. A Family Practice Clinic Laboratory Notification Form, dated February 8, 2012, documented the resident with a Critical Value INR result greater than 11. The form documented physician orders [REDACTED]. by subcutaneous route, hold the [MEDICATION NAME]/[MEDICATION NAME] until further notice, and recheck the INR February 13, 2012. f) An Interdisciplinary Progress Notes (IDPN) entry, dated February 10, 2012 at 2:30 p.m., documented a physician order [REDACTED]. daily Monday (February 13, 2012), and recheck the resident's INR Thursday (February 16, 2012). During interview October 18, 2012 at 11:05 a.m. Staff JJ stated she placed a call to the resident's primary physician on February 10, 2012 to inquire about the resident's [MEDICATION NAME] injection. Staff JJ stated the resident's primary physician saw the resident's critical INR value from February 8, 2012 and called the facility with the orders documented in the IDPN's February 10, 2012 at 2:30 p.m. Staff JJ stated the initial orders obtained on February 8, 2012 came from a different physician at the clinic. g) A hospital Laboratory Report, dated February 16, 2012, documented an INR test result of 2.33. The report documented a physician note "OK" and recheck the INR in one month. h) A hospital Laboratory Report, dated March 8, 2012, documented an INR test with a greater than 11 result, High Critical. Facility electronic physician order [REDACTED]. March 12, 2010. i) A hospital Laboratory Report, dated March 10, 2012, documented an INR test with a greater than 11 result, High Critical. An IDPN sheet, with a late entry dated March 11, 2012 at 6:15 a.m., documented a verbal physician order [REDACTED]. intramuscular to the resident, hold the [MEDICATION NAME] until Monday, March 12, 2012, and recheck the INR March 12, 2012. An IDPN sheet, with a late entry dated March 11, 2012 at 6:15 a.m. documented the nurse administered Vitamin K five mg. per left ventrogluteal March 10, 2012 at 1:20 p.m. j) A hospital Laboratory Report, dated March 12, 2012 documented an INR test with a result of 7.59, High Critical. A Family Practice Clinic Laboratory Notification Form sheet, dated March 12, 2012 documented the 7.59 Critical Value result and directed staff to continue to hold the resident's [MEDICATION NAME] and recheck the INR Thursday (March 15, 2012). k) A hospital Laboratory Report, dated March 15, 2012, documented an INR test with a result of 4.20, High. The report documented a physician order [REDACTED]. l) A hospital Laboratory Report, dated March 20, 2012 documented an INR test with a result of 1.83. The report documented a physician's note "Ok", check on the resident's previous [MEDICATION NAME] dose, and restart [MEDICATION NAME]. The report had a hand written note that documented [MEDICATION NAME] five mg. daily. An IDPN entry dated March 22, 2012 at 1:30 p.m. documented the resident's physician saw the resident at the facility and ordered an INR for Friday, March 23, 2012. m) A hospital Laboratory Report, dated March 24, 2012 (not March 23, 2012) documented an INR test result of 7.91, High Critical. An IDPN entry, dated March 24, 2012 at 2:35 p.m. documented telephone physician's orders [REDACTED]. During interview October 19, 2012 at 9:00 a.m. Staff QQ stated she was unsure why the resident had an INR drawn on March 24, 2012 instead of March 23, 2012 as directed by the physician. Staff QQ stated the nurse possibly tried to draw the INR on March 23, 2012, unable to obtain the specimen, and another staff obtained the INR on March 24, 2012. Staff QQ stated she expected the nurse to document the failed attempt in the IDPN. Record review revealed no record of an attempted INR draw on March 23, 2012 or INR draw on March 24, 2012. The record documented an INR drawn and physician order's for [MEDICATION NAME] and the INR obtained March 24, 2012. n) A hospital Laboratory Report, dated March 26, 2012, documented an INR test result of 7.43, High Critical. The report documented physician orders [REDACTED]. o) A hospital Laboratory Report, dated March 28, 2012, documented an INR test result of 2.70. The report documented physician orders [REDACTED]. p) Record review revealed the next INR test completed June 26, 2012 with a result of 1.80 after a physician order [REDACTED]. The record lacked any new orders for [MEDICATION NAME] dose and repeat INR's between March 28, 2012 and the order obtained June 21, 2012. Electronic nursing Progress Notes entry dated June 23, 2012 at 1:11 p.m. documented an INR test drawn drawn from the resident. Review of the resident's record and hospital INR reports lacked any INR test results for June 23, 2012. q) A hospital Laboratory report dated June 26, 2012 documented an INR result of 1.80. The record lacked any documentation of follow up for this INR test. r) A hospital Laboratory report, dated June 28, 2012, documented an INR test result of 1.80. The report documented a physician comment, Ok, and repeat the INR in one month. During interview October 17, 2012 at 3:40 p.m. Staff SS verified an INR not obtained for Resident #1 between March 28, 2012 and June 26, 2012. s) Record review revealed INR tests completed July 26, 2012, August 30, 2012, and September 27, 2012. During interview October 18, 2012 at 7:00 a.m. Staff QQ stated the facility lacked a policy/procedure to obtain INR tests and obtained INR tests as ordered by the physician. Staff QQ unsure if facility had a policy/procedure to note physician orders. During interview October 18, 2012 at 9:05 a.m. Staff SS stated Staff QQ kept a laboratory calendar to document orders for laboratory tests. During interview October 18, 2012 at 9:15 a.m. Staff JJ stated staff wrote INR orders for April 2, 2012 and other dates on a calendar, the nurse filled out a laboratory requisition, and the order entered into the electronic record system for the physician to sign. During interview October 18, 2012 at 9:20 a.m. Staff QQ stated when a nurse obtained physician orders [REDACTED]. Staff QQ stated the night nurse wrote all laboratory tests and physician appointments on a sheet for the day nurse and the day nurse responsible for follow up. During interview October 18, 2012 at 9:40 a.m. a physician's office nurse verified the physician's office [MEDICATION NAME] flow sheet documented a physician order [REDACTED]. daily. The nurse stated the resident's physician allowed INR's to remain 1.5 to 1.6 at times, instead of 2.0 to 3.0, especially after a resident had high results. The nurse stated the physician normally ordered monthly INR's. During interview October 18, 2012 at 11:20 a.m. Staff SS stated the facility kept a [MEDICATION NAME] Flow Sheet with each resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Staff SS presented a copy of the Careage (former facility name) Lab Guidelines and stated the sheet only a guideline, and the facility needed physician orders [REDACTED]. During interview October 18, 2012 at 12:15 p.m. Staff QQ had the laboratory calendar and verified the calendar lacked documentation to obtain INR tests for Resident #1 on January 9, 2012 and April 2, 2012. During interview October 18, 2012 at 12:20 p.m. a physician's office nurse verified a physician order [REDACTED]. daily. During interview October 18, 2012 at approximately 12:30 p.m. Staff SS presented [MEDICATION NAME] Flow Sheets for all the residents in the facility that received [MEDICATION NAME] and verified the flow sheets not up to date. The resident's [MEDICATION NAME] Flow Sheet lacked documentation of INR's draw in 2012 for the following dates: January 23, February 16 and 18, March 10, 12, 15, 20, 26, and 28, June 26 and 28, and July 26, 2012. During interview October 18, 2012 at 12:50 p.m. Staff QQ stated the laboratory staff needed to check with the facility nurse on a daily basis to find out if all laboratory tests completed before left the facility. Staff QQ stated she would check with facility staff to find out if done. During interview October 18, 2012 at 1:00 p.m. Staff QQ stated she remembered the facility had a separate laboratory calendar for resident's that resided in the Angel's Wing. Staff QQ stated Resident #1 not in the Angel's unit when admitted to the facility January 5, 2012. The Angel's unit calendar had the April 2, 2012 INR documented. Staff QQ stated she would find out where the breakdown in communication happened when a laboratory test written on the calendar and not completed. Staff QQ stated she planned to ask the nurse's if the laboratory staff checked with the nurse before left the facility to make sure all laboratory draws completed as ordered. During interview October 18, 2012 at 2:20 p.m. the resident's physician stated he/she expected stable INR's checked monthly. The physician stated the concern greater when orders given for an INR on a specific date and the INR not completed. The physician verified facility staff had responsibility to make sure INR's checked according to the physician's orders [REDACTED]. During a meeting with the facility staff October 18, 2012 at 3:30 p.m. Staff QQ stated she had not checked with nursing staff to find out if the laboratory staff checked with the nurses to make sure all the laboratory draws completed as ordered. During interview October 18, 2012 at 5:20 p.m. Staff SS stated a meeting held for all nursing staff and the staff instructed on new [MEDICATION NAME] policy and procedure. The procedure directed nurses to use the INR tracking sheet before [MEDICATION NAME] administration, check the tracking sheet to ensure labs and orders current before [MEDICATION NAME] administration, when the INR not up to date, hold [MEDICATION NAME] and obtain an order for [REDACTED]. Staff SS presented written documentation the staff reviewed documentation for all current residents on [MEDICATION NAME], INR orders reviewed, and the physician notified to obtain orders when needed. Any resident without up to date INR's had Stat (immediate) INR's drawn and [MEDICATION NAME] held until results obtained. The INR tracking sheets updated for all residents and printed on bright colored paper to ensure visibility in the MAR (Medication Administration Record). During interview October 19, 2012 at 8:05 a.m. Staff QQ stated she became aware of INR's not being completed as ordered and the facility combined laboratory tests into one calendar instead of two. Staff QQ stated parts of the electronic record implemented periodically during the last year and nurses possibly failed to print orders entered into the electronic record. During interview October 19, 2012 at 8:20 a.m. Staff QQ stated staff nurses reported laboratory staff checked with the nurses to make sure all blood draws completed before they left the facility. Staff QQ unable to answer how blood draws missed when on the calendar and not drawn. During interview October 19, 2012 at 9:30 a.m. Staff QQ stated the facility lacked a policy for staff to note physician laboratory orders including INR's and followed Standard Practice. Standard practice meant the nurse filled out a laboratory requisition for the hospital, placed the order on the calendar, entered the order into the electronic record, printed a copy of the order for the physician to sign, and when INR ordered monthly, gave Staff QQ a copy of the order. Staff QQ stated facility staff met with all nurses the evening of October 18, 2012 and instructed the nurses to give a copy of all physician orders [REDACTED]. Staff QQ stated the Angel ' s Wing calendar (where the resident resided) lacked documentation for the March 23, 2012 INR. Staff QQ stated staff wrote the INR on the South wing March 23, 2012 calendar because the facility in transition process to one calendar for both wings during March 2012. During interview October 19, 2012 at 9:45 a.m. Staff FF stated when a new physician order [REDACTED]. During interview October 19, 2012 at 9:55 a.m. Staff QQ stated Resident #1 did not have any signs of active bleeding when his/her INR tests was elevated. Staff QQ stated the resident had a history of [REDACTED]. During telephone interview October 22, 2012 at 12:30 p.m. Staff QQ stated inability to remember the exact date the facility noticed missed INR's. Staff QQ stated the facility combined the Angel's Wing (north) calendar with the south wing calendar because the facility noticed INR tests missed on residents in the Angel's Wing. During previous interview October 19, 2012 at 9:30 a.m., Staff QQ stated the facility began the transition to one calendar during March 2012. 2. The MDS dated [DATE] documented Resident #10 with severely impaired cognition and [DIAGNOSES REDACTED]. The resident's Care Plan with an initiated date of March 10, 2012 had a Focus that documented the resident received [MEDICATION NAME] to thin blood and caused bruising. The care plan documented the resident had the left arm rest of wheel chair padded. Record review revealed the resident admitted to the facility February 27, 2012. A hospital Laboratory Report, dated March 6, 2012, documented an INR result of 1.66 (1.00-3.00 normal range) and the physician wrote "OK" on the report. The record lacked further follow up on INR tests until June 19, 2012 when the facility requested a physician order, via facsimile, to obtain monthly INR's. The physician signed an order June 20, 2012 for staff to obtain monthly INR's. Record review revealed an INR not completed until June 28, 2012 with a 4.80 result. The physician directed staff to skip [MEDICATION NAME] for two days and then administer [MEDICATION NAME] 2.5 mg. on Tuesday, Thursday, Saturday, and Sunday, [MEDICATION NAME] 5 mg. on Monday, Wednesday, and Friday, and obtain another INR in one week (July 5, 2012). The July 2012 calendar documented the resident needed an INR test on July 5, 2012. Record review revealed a Laboratory Report dated July 19, 2012, three weeks later instead of one week later, with an INR result of 3.94, high. The report documented a physician order [REDACTED]. daily and recheck the INR in two weeks (August 2, 2012). The August 2012 calendar documented the resident needed an INR test on August 2, 2012. Record review revealed a Laboratory Report dated August 23, 2012, four weeks later instead of two weeks later, with an INR result of 1.82 and the physician wrote "OK". During interview October 18, 2012 at 1:00 p.m. Staff QQ verified the calendar documented the resident needed INR's drawn July 5, 2012 and August 2, 2012 and the facility failed to obtain the tests until later dates. During interview October 18, 2012 at 2:20 p.m. the resident's physician stated he/she expected stable INR's checked monthly. The physician stated the concern greater when orders given for an INR on a specific date and the INR not completed. The physician verified facility staff had responsibility to make sure INR's checked according to the physician's orders [REDACTED]. Record review revealed the resident's [MEDICATION NAME] Flow Sheet lacked documentation of INR's drawn March 6, 2012 and June 19, 2012. 3. Resident #12's October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident's June 18, 2012 admission orders [REDACTED]. A May 22, 2012 Laboratory Report (prior to admission) documented the resident's INR 2.34, directed to continue the same dose of [MEDICATION NAME] and to recheck the INR in one month. A July 25, 2012 Facsimile Transmittal to the Physician stated the Pharmacy Consultant wanted the physician to consider a monthly INR to manage the [MEDICATION NAME]. Again, the Physician ordered an INR monthly. The resident's record lacked any documentation indicating staff obtained an INR until August 30, 2012. During interview on October 18, 2012 Staff SS, Registered Nurse and Staff QQ, Registered Nurse confirmed no INR had been obtained until August 30, 2012. The facility abated the immediate jeopardy situation on October 18, 2012 by completing the following: The facility educated nurses on the use of the INR tracking sheet. The nurses were education that prior to passing any [MEDICATION NAME] medication the nurse must look at the INR tracking sheet to ensure that the labs and (physician's) orders are current. Nurses were instructed that when the INR was not up to date they must hold the [MEDICATION NAME] and obtain an order for [REDACTED]. The facility developed a [MEDICATION NAME] Protocol to be followed whenever staff administered [MEDICATION NAME] ([MEDICATION NAME], Jantoven). The facility educated the nursing staff on October 18, 2012 of the [MEDICATION NAME] policy and procedure. The policy informed the nursing staff that when the PT/INR is in the critical range (greater than 3.5) and to hold the [MEDICATION NAME] until the physician can be notified and new order/s received the day the INR was received. The protocol directed staff to communicate the following to the physician: the PT/INR lab value obtained, the current [MEDICATION NAME] dose, and request any changes and the date of the next PT/INR (and directed the nursing staff to avoid general dates like 2 weeks, etc.) The nurse would also assess the resident for bleeding or bruising and document their findings. The facility educated the nursing management on entering the lab orders into the computer. The nursing management will provide a list of labs to be drawn weekly to the Hospital lab department. The nursing management have been educated on reviewing all new residents charts within 24-48 hours to ensure all incoming order have been transcribed correctly and labs (test) have been ordered. The nursing management was educated to review the lab sheet weekly and to ensure all labs have been drawn and results were obtained back to the facility. On October 18, 2012 the facility also reviewed all residents receiving [MEDICATION NAME] medication and all INR (lab) orders were reviewed. Any resident that did not have a current order for INR the physician was notified to obtain current orders. Any INR labs that were not up to date were ordered immediately for laboratory results and the [MEDICATION NAME] medication was held until the laboratory results were obtained. All residents receiving [MEDICATION NAME] were reviewed to ensure a INR tracking sheet was in place and up to date. These actions taken by the facility lowered the immediate jeopardy from a "J" severity level to a "D" severity level as the facility would need to monitor staff 's implementation of their policy/procedure.

Based on observation, record review, staff, resident and family interviews, the facility failed to plan services to ensure residents received adequate supervision from hazard in the environment and assistance to prevent accidents for two (2) of (5) residents (Resident #1 and Resident #6). The facility reported a census of 40 (forty) residents. Findings Include: 1. A Minimum Data Set (MDS) with observation end date of 11/30/10, assessed Resident #1 with a Brief Interview for Mental Status score of 4. A score of 4 identifies severe cognitive impairment. The MDS identified the resident as independent with bed mobility, transfers, ambulation, eating and toileting. The resident required supervision with dressing and personal hygiene and extensive staff assistance with bathing. The MDS identified the resident to use assistive devices of walker and cane. The MDS identified the resident with [DIAGNOSES REDACTED]. The MDS identified the resident with falls since the last assessment. A fall risk assessment dated [DATE] identified the resident with a fall risk score of "13". A score of 10 or above indicates high risk. A change in condition report dated 10/14/10 at 1:40 p.m. identified the resident as up ad lib in the CCDI (chronic confusion dementing illness) unit. The resident attempted to sit in the merry walker and fell . Staff did not identify injury when they assessed the resident after the fall. The physician saw the resident on 12/8/10 and assessed the resident with a decline due to dementia related to transient ischemic attack/cerebral vascular accident. The physician signed a form that contained the statement, "May do trial in 300 hall". Interdisciplinary progress notes identified the following information on the following dates: On 12/12/10 7:30 p.m. Resident ambulating with one assist. Gait weak and unsteady. On 12/13/10 at 3:45 a.m. the resident ambulated with assistance of one and front wheeled walker. The resident tires easily. Later that day (no time given) the resident moved to room 306. The entry documented the resident's family member "requested the move and is aware of increased risk of falls and decreased supervision". Observation of room 306 on 2/9/10 showed room 306 at the end of a hallway. The hallway was between 2 dining areas with no nursing station nearby. A baby monitor was placed above a large picture mid-length of the hall. The following Interdisciplinary progress notes identified the resident did not use the call lights or wait for staff assistance when the alarm sounded: On 12/14/10 at 8:30 a.m. the resident's alarms on and functional. The resident " noncompliant with alarms " and using the call light. Stand by assistance of one staff and front wheeled walker needed with ambulation. On 12/18/10 at 9 p.m. the resident " noncompliant with alarms " . In hallway without walker. Alarm sounding. The document revealed the resident ' s confusion as the resident stated, "I do not know where I am". The resident was redirected to room 306. On 12/20/10 at 10:30 a.m. the resident noncompliant with alarms. Does not use call light for assistance. Up with assistance of one staff. The note documented the resident ' s gait slow and unsteady. Alert with confusion. A change in condition report dated 12/21/10 at 12:10 p.m. identified the resident ambulating with staff when the resident became weak and staff lowered the resident to the floor. The resident sustained [REDACTED]. purple discoloration on the middle finger of the right hand. Interdisciplinary progress notes identified the following information on the following dates: On 12/21/10 at 9:30 p.m., the resident required assistance of 2 staff for transfers. On 12/22/10 at 10 a.m., the resident as noncompliant with alarms. Up with assistance of one. Gait slow and weak. On 12/23/10 at 10:30 a.m. Up with assistance of 2. Gait slow and unsteady. Speech slow and slurred at times. Complained of being very tired. A change in condition report dated 1/5/11 at 2:55 p.m. stated Staff D, RN observed the resident lying on back with legs extended and head against wall with walker 3 to 4 feet away. Alarm in room sounding. The resident identified pain in the left hip at a pain level of 10. (Ten is the highest pain rating identifying the worst pain.) The facility called for an ambulance and the resident transported to the emergency room (ER) for evaluation. Interdisciplinary progress notes dated 1/5/11 at 5 p.m. documented the facility placed a call to the Medical Center regarding the resident's condition. The Medical Center personnel informed the facility the resident sustained [REDACTED]. A hospital discharge summary dated 1/14/11 identified the resident as undergoing surgical repair of the left hip. The postop course was complicated by pneumonia which resolved with Levaquin (antibiotic) therapy. The resident takes oral intake poorly and was weak. Family considered hospice before fracture but has now decided with resident's declining condition to proceed with comfort measures at the care center. The care plan dated 12/7/10 identified the resident with [DIAGNOSES REDACTED]. The care plan contained an addendum dated 12/13/10 directing staff to utilize a pressure alarm for the resident at all times until stronger. Observation showed, on 2/9/11 at 1 p.m. 2 staff transfer the resident to his/her bed using a mechanical lift. When the lift raised the resident from the chair, the pressure alarm sounded. Staff Interviews: On 2/9/11 at 12:05 p.m., Staff C, Director of Nursing (DON) stated she investigated the incident. Staff observed the resident on the floor. She identified the 300 hall as a hall with less supervision than the CCDI unit (where the resident resided prior to the move to room306). The resident used an alarm. In order for staff to hear the alarms there is a baby monitor in the hallway that transmits to a baby alarm in the closed CCDI unit. The day of the incident, the MDS nurse (Staff D) heard the alarm as she worked in her office. Staff C did not know if anyone on the CCDI heard the alarm. One staff worked on the CCDI unit when the incident occurred. If there is one staff on the unit, they cannot leave to answer 300 hall alarms. They are to call staff on the 100 or 200 halls to come and answer the alarm if it is sounding. On 2/10/10 Staff C documented when she completed the accident/fall reporting flow-sheet she thought the facility was culpable for the accident because it happened at the facility and the staff could not reach the resident in time. On 2/9/10 at 12:32 p.m., Staff D stated as she sat in her office on the day of the incident (1/5/11) when she heard alarm go off. She waited a bit to see if anyone got it but no one did so she answered it. She estimated the alarm sounded less than a minute-"just long enough to realize someone was not with her". Staff D stated she found the resident on the floor in the hallway. She used the walkie talkie to summon Staff G. Staff G then took over and assessed the resident and sent the resident to the ER. Staff D stated the 300 hall is not the hall she would have chosen for the resident. Staff D identified the 300 hall as "no mans land". Staff D stated the resident's family wanted the resident to move to 306 due to construction in the CCDI unit On 2/9/11 at 3:15 p.m. the Administrator stated the resident's family insisted on moving the resident to room 306. The facility discouraged it but the family did not want any other room. They chose the room because it had a bathroom that the resident did not have to share with anyone. At 4 p.m., the Director of Nursing identified 5 residents on the 300 hall when the resident fell . On 2/9/11 at 2:13 p.m., Staff G stated her shift started at 3 p.m. but she punched in early to assist with physician rounds and orders. Staff D paged her. At that time, she was at the south station noting orders. Staff G stated at the time of the incident one staff worked in the CCDI unit. Staff G identified the resident as on the floor in the 300 hallway. The resident immediately complained of hip pain so Staff G sent the resident to the ER for examination. Staff G stated the resident was not a good candidate for the 300 hall but that is what the family wanted. On 2/9/10 at 2:31 p.m., Staff F identified herself as in the CCDI when she heard the alarm over the baby monitor. She could not leave the unit because she was the only staff in the unit. She stated she radioed someone from the other halls and stated those staff get to the alarm as soon as they have the time. She estimated she heard the alarm sounding for less than 5 minutes. On 2/9/11 at 2:38 p.m. the maintenance man measured the distance from the resident's bed to the hallway area where Staff G identified she found the resident. The resident ambulated 9 feet from the bed to the doorway and 11 feet down the hall way. The distance totaled 20 feet. The resident returned to the facility on [DATE] with no weight bearing to the left leg for 3 weeks and Hospice care. On 2/10/11 at 1:30 p.m., the resident's responsible party stated the day before the incident she arrived and a dietary staff was standing in the resident's doorway. The dietary aide told the responsible party she was waiting for a C.N.A. (certified nursing assistant). The responsible party stated the dietary aide left and a C.N.A. never came. 2. A Minimum Data Set (MDS) with an assessment reference date of 2/23/10 assessed Resident #6 with impaired long and short term memory and moderately impaired decision making skills. The resident had communication difficulty and was sometimes understood by others. The resident is sometimes understandable by others. The MDS identified the resident to require limited assistance of staff with transfers and eating. The resident was independently ambulatory. The MDS identified [DIAGNOSES REDACTED]. The resident had falls in the past 31 to 180 days and resided in the CCDI dementia unit. A change in condition report dated 5/7/10 at 9:10 p.m. stated Staff A heard a thud and investigated. Staff B entered Resident #6's room and observed the resident on the floor. The resident screamed and cried when the nurse (Staff B) touched the resident's right leg. The resident transported to the emergency room (ER) for evaluation. An ER report dated 5/7/10 identified the resident with a pelvic fracture. The resident admitted to the hospital for further ortho consult and pain control. The resident returned to the facility on [DATE] with an order for [REDACTED]. Following this injury, the care plan identified initiation of a pressure alarm at all times. A change in condition report dated 6/29/10 at 8:20 p.m. and written by Staff B identified staff in another resident's room when Resident #6's alarm sounded. Staff found the resident on the floor leaning on the left hip. No injury assessed. On 2/10/10 at 11:57 a.m., Staff B stated she thought there was one staff on the unit when the 6/29/10 incident occurred. She stated she thought there should be more than one staff on the unit and possibly that fall "may have been prevented". A change in condition report dated 12/9/10 at 5:30 p.m., identified a fall on the CCDI unit. The alarm sounded and when the nurse entered the dining room, she observed the resident fall to the right side. The resident transported to the ER and returned on the same date at 8:45 p.m. The x-rays did not identify injury and the physician ordered bedrest through the night. A change in condition report, dated 1/18/11 at 6:15 p.m. and written by Staff B identified the resident lying on the floor. Staff A identified herself as in another room with an alarmed resident and heard Resident #6's alarm sound. Staff A could not leave the resident she was with and ultimately found Resident #6 on the floor lying on the left side. The resident began to cry out in pain when staff touched either the left lower extremity or the left hip. The resident transported to the ER for evaluation. An x-ray report dated 1/18/11 showed a triangular shaped bony fragment projecting medial to the left femoral neck and below the left femoral head which was not present previously. Site of origin uncertain. An acute avulsion fracture off the acetabular rim "cannot be excluded. Clinical correlation is advised". On 2/10/10 at 11:57 a.m., Staff B stated when the incident occurred, the nurse for the CCDI unit was passing medications on the 300 hall, leaving only Staff A in the CCDI unit. Staff A was with another resident. Staff B stated she thought the fall could have been prevented with more staff on the unit. On 2/10/10 at 11:35 a.m. Staff A identified herself as the only staff present on the unit when the resident's alarm sounded. At that time, another C.N.A. fed residents off the unit and the nurse was in the 300 hall passing medications. Staff A assisted another resident who also used alarms and could not leave that resident. Staff A thought the fall could have been prevented if there was another staff in the unit. The resident returned to the facility on [DATE] at 8:50 p.m. with no new orders. On 1/19/11 at 11 a.m., the physician phoned the facility and informed them of a "chip" off of the acetabulum (an avulsion fracture). Observation showed, on 2/9/11 at 5:03 p.m., the resident in the CCDI unit with 2 alarms in use. Observation showed two staff present in the CCDI unit when the resident observation was made.