Every finding on record at Edgefield Post-Acute

Based on observation, interview, and facility policy review, the facility failed to maintain food service equipment and food storage areas in a clean and sanitary condition and failed to ensure sanitizing solutions were maintained at an effective concentration. Specifically, the facility failed to maintain kitchen equipment (including walk in refrigerators and freezers, reach in refrigerators, ice machine, handwashing sinks, and dish room drainage) in good repair and free from rust, mold, food debris, and leaks; and failed to ensure sanitizers were maintained at appropriate concentrations for effective sanitation. These deficient practices had the potential to affect 100 of 104 residents (excluding four residents on tube feedings) and had the potential to result in food contamination and foodborne illness.Findings include:Review of the facility's undated policy titled Sanitization . All . equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. 3. All equipment, food contact surfaces . are cleaned and sanitized using heat or chemical sanitizing solutions. 9. Service area wiping cloths are drained, cleaned, and sanitized per manufactures instructions. 10. Ice machines and ice storage containers are drained, cleaned, and sanitized per manufactures instructions .During an initial kitchen tour on 04/15/26 at 8:53 AM, revealed the handwashing sink in the kitchen lacked a nearby trash receptacle for paper towels, requiring staff to walk across the cooking area to dispose of dirty paper towels after handwashing.During observation on 04/15/26 at 9:02 AM, the walk in refrigerator floor was observed to be rusted due to a leaking drainpipe from the cooling unit. The rusted area measured approximately five feet by six feet. The threshold into the walk in refrigerator was loose, and the floor surface was uneven with a noticeable dip.During an observation on 04/15/26 at 9:02 AM, the second reach in refrigerator (Traulsen brand) had multiple red, pink, and brown food debris stains on the bottom interior surface.A follow up observation on 04/16/26 at 11:41 AM, with the Dietary Manager (DM) and Certified Dietary Manager (CDM), confirmed the food debris remained and had not been cleaned.During an observation on 04/15/26 at 9:05 AM, the reach in ice machine was observed to have rust measuring approximately eight inches along the door hinge. Continued observation confirmed the ice machine remained in use.During an observation on 04/15/26 at 9:08 AM, the walk in freezer door and surrounding surfaces were observed to have a splotchy gray substance on both sides of the door, extending from ceiling to floor. The substance measured approximately two feet wide at the bottom narrowing to six inches at the top on the left side, three feet on the right side, and 36 inches across the base of the door.During an observation on 04/15/26 at 9:14 AM, dish machine logs reflected quaternary ammonium sanitizer readings of 100 parts per million (PPM) (standard for sanitation is 200 PPM). At the same time, the dish room sink drain was observed backing up with soap suds measuring approximately two feet wide, one foot long, and three inches deep due to improper drain placement.During an observation of sanitizer buckets on 04/15/26, the DM tested the sanitizer concentration using test strips and obtained a reading of 100 PPM, which the DM indicated was not sufficient for proper sanitation.During an interview on 04/15/26 at 9:19 AM., Dietary Aide 1 stated, I don't know what the chemical concentration should be. I'm new. I've been here two weeks.During an interview on 04/16/26 at 11:23 AM, the CDM stated the gray substance in the walk-in freezer was mold and had been present since I've been here, approximately 12 years. The CDM further stated the rusted and deteriorated freezer flooring could contaminate food. The CDM concluded sanitizer buckets should be changed every two hours and that dish room sanitizer should be maintained at 100-200 PPM, with 200 PPM being the expected effective concentration.During an interview on 04/17/26 at 9:25 AM, the Minimum Data Set Coordinator (MDSC)1 (acting in the capacity of Director of Nursing) declined to comment when asked about the expectation for continuing use of the rust affected ice machine.During an interview on 04/17/26 at 10:45 AM, the Administrator stated the rusty ice machine should not be used because it could cause illness. The Administrator confirmed the replacement door was approved on 04/13/26, and repairs to the leaking drainpipe were made after being brought to attention during the survey. The Administrator further stated he was aware that the dish room drainpipe did not properly align with the floor drain and had been aware of the issue previously, stating staff would sometimes kick the pipe out of place.

Based on observation and interview, the facility failed to maintain resident rooms and bathrooms in good repair for 5 of 49 resident rooms sampled, (Rooms 129, 200/203, 225, 227, and 224/226). These failures included damaged air conditioning units, chipped and broken furniture, cracked drywall, bathroom fixtures in disrepair, and lack of a formal maintenance system. This resulted in an environment that was not consistently safe or well maintained.1. During an observation on 04/15/26 at 10:51 AM, of room [ROOM NUMBER] revealed the air conditioning unit was broken, the controller was filled with dust, and the metal cover was rusted and falling off with paint flecking. The footboard of the resident's bed had chipped Formica (a durable, heat-resistant composite material made from layers of [NAME] paper impregnated with melamine resin and hardened under high pressure) with exposed particle board. The armoire had chipped surfaces on the top drawer and corner with exposed particle board, and the bottom drawer was chipped approximately one foot long by four inches high, creating rough and damaged surfaces in the resident room.2. During observations on 04/15/26 at 8:51AM until 11:45AM revealed the following:room [ROOM NUMBER] - When entering the bathroom from this room, three floor tiles were broken.room [ROOM NUMBER] - The bathroom floor tiles around the wall near the toilet were cracked and missing pieces of the tiles.room [ROOM NUMBER] - The drywall was cracked above the air conditioning unit. The drywall was cracked around the sink in the bathroom.room [ROOM NUMBER] - In the bathroom, the drywall was damaged around the toilet and the wall across from the toilet was gouged.Rooms 223/225 - In the shared bathroom, the drywall was cracked behind the toilet.Rooms 224/226 - In the shared bathroom, the room smelled of urine, and the sink was scraped along the edges.During an interview on 04/17/26 at 11:08 AM, the Maintenance Director (MD) stated that the air conditioning unit in room [ROOM NUMBER] would require full replacement and indicated that he was not aware of the damage in the room. The MD stated, I need to replace the whole air conditioning unit, and no one told me about the damage in the room.During an interview on 04/17/26 at 10:46 AM, the MD stated that the cracked linoleum needed caulking in the bathroom between rooms 200/203 and he would enter the maintenance request in TELS (a computerized maintenance repair log system) and stated he didn't know about the damage to the door edge. During an interview on 04/17/26 at 10:49 AM, the MD stated that in room [ROOM NUMBER], he was unaware there was cracked drywall above the air conditioner and unaware that in the bathroom of room [ROOM NUMBER] the drywall was cracked around the sink. The MD said it needs clean and repainted and put the repair need into TELS now. The MD they have been on the bathroom since the first of the week, but the cracked drywall around the sink was never addressed. During an interview on 04/17/26 at 10:51 AM, the MD stated that in the bathroom of room [ROOM NUMBER], he was unaware the drywall around the sink was cracked and needed repaired. The MD put the damaged environment into the TELS program. During an interview on 04/17/26 at 10:52 AM, MD stated that the bathrooms between room [ROOM NUMBER] and 226 needed the sink replaced due to the sink was scratched. The MD said he would put the repair need into TELS to replace the sink.In a subsequent interview on 04/17/26 at 10:56 AM, the MD stated that staff could enter maintenance concerns into the TELS system. He stated that he attempted to perform room rounds approximately once per month, primarily to change light bulbs, and acknowledged that he did not have a policy for routine maintenance or repairs, stating the issues observed were items he never would have noticed.

Based on record review, interview, and facility policy review, the facility failed to complete a root cause analysis for a potential unwitnessed fall for 1 of 2 residents (Resident (R)85), reviewed for falls out of a total sample of 49. Without identifying why the resident was found on the floor, the cause of a potential fall (e.g., toileting needs, environmental hazards, medication effects, poor footwear, lack of assistance) was not identified, and the same risk factors remain unaddressed.Findings include:Review of a facility policy titled, Falls - Clinical Protocol, dated 03/2018, indicated, . Falls should be categorized as . Those that occur while trying to rise from a sitting or lying to an upright position . Those that occur while upright and attempting to ambulate . Other circumstances such as sliding out of a chair or rolling from a low bed to the floor . The policy failed to identify the need for a root cause analysis for falls. Review of R85's electronic medical record (EMR) titled admission Record, located under the Profile tab, indicated that the facility admitted the resident on 01/20/26.Review of R85's EMR titled admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/27/26 and located under the MDS tab, indicated that the staff could not determine a Brief Interview for Mental Status (BIMS) score. The assessment indicated that the resident could walk with supervision or touch assistance. The assessment revealed that the resident had a history of falls. Review of R85's EMR titled, Care Plan, located under the Care Plan tab and dated 01/20/26, indicated that the resident was at risk for falls. The care plan identified that the resident had a history of crawling on the floor. Review of R85's EMR titled, Fall Risk Observation/Assessment, located under the Eval (Evaluation) tab and dated 01/20/26, revealed that the resident scored 28, which determined the resident was considered to be at high risk for falls. Review of R85's EMR titled Care Plan, located under the Care Plan tab and dated 01/21/26, indicated that the resident was at risk for psychosocial behaviors of crawling out of bed.Review of R85's EMR titled nursing Progress Notes, located under the Prog (Progress) Note tab and dated 01/22/26, indicated that a nurse was called into the resident's room. The resident was found crawling on the floor (a potential unwitnessed fall) towards the door. The nurse assessed the resident, and the resident sustained no injuries. Review of R85's EMR titled Fall Risk Observation/Assessment, located under the Eval tab and dated 01/22/26, revealed that the resident scored 28 which determined the resident was considered to be at high risk for falls. Review of R85's EMR failed to contain evidence of a root cause analysis of R85's crawling on the floor (a potential unwitnessed fall). During an interview on 04/16/26 at 3:35 PM, the Administrator stated that the facility did not complete a fall investigation since the family shared that the resident had a history of placing herself on the ground. During an interview conducted on 04/17/26 at 8:40 AM, the MDS Coordinator (MDSC)2, who was the acting Director of Nursing (DON), and the Regional Director of Clinical Services (RDCS) stated that a fall investigation was to be completed after a fall. MDSC2 stated a fall investigation was not completed since the crawling was a typical behavior for R85, and the facility did not consider the resident's crawling (a potential unwitnessed fall) a fall.

Based on record review, and interview, the facility failed to ensure 1 of 3 residents (Resident (R)12) and their resident representatives (RR), reviewed for emergent hospital transfer out of a total sample of 49 residents, were provided with a written bed hold policy and transfer notice that contained the appeal process. This failure had the potential to affect the resident and their RR by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following hospitalization for residents transferred to the hospital.Findings include:Review of R12's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE]. Review of R12's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/26, and located under the MDS tab of the EMR, revealed R12 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated R12 was cognitively intact.Review of R12's Progress Note, dated 01/17/26 and located under the Progress Note tab of the EMR, revealed R12 had a change in condition. An order was received to send the resident to the hospital for urgent evaluation and treatment. Review of R12's Notice of Proposed Transfer/Discharge, dated 01/19/25 and provided by the facility, revealed that the document did not include the appeal process or entity information that handled appeals. During an interview on 04/17/26 at 1:55 PM, the Social Services Director (SSD) stated she was unsure which agency handled appeals, but she believed it was in [NAME], SC. She was unaware the facility transfer form did not include this information. She stated she just used the form that was provided by their corporate office. During an interview on 04/17/2026 at 8:46 AM, Minimum Data Set Coordinator (MDSC)1 (in DON absence) stated she was unsure of the process and did not comment but stated she expected the facility to be in compliance with regulations.

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 2 of 5 residents (Residents (R)94 and R109) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. This practice had the potential to increase the risk for residents to contract pneumonia.Findings include:Review of the facility policy titled Pneumococcal Vaccine with a revision date of October 2023, revealed, Policy Statement All resident are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation . 7. Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.Review of the CDC website titled, PneumoRecs VaxAdvisor App (Application) for Vaccine Providers, dated 01/09/25, indicated, . Give one dose of PCV15, PCV20, or PCV21 at least 1 year after the last does of PPSV23. Regardless of which vaccine is used . their pneumococcal series is complete .1. Review of R94's electronic medical records (EMR) titled, admission Record, located under the Profile tab, indicated that the facility admitted the resident on 11/30/21. Review of R94's EMR titled, Immunizations, located under the Immun (Immunization) tab, indicated the resident received Pneumovax 23 (PPSV23) on 12/03/21. There was no evidence that the resident or her representative was offered the PCV20 or the PCV21 vaccine. 2. Review of R109's EMR titled, admission Record, located under the Profile tab, indicated that the facility admitted the resident to the facility on [DATE]. Review of R109's EMR titled, Immunizations, located under the Immun tab, indicated the resident received PPSV23 on 10/06/22. There was no evidence that the resident or her representative was offered the PCV20 or the PCV21 vaccine. During an interview conducted on 04/17/26 at 8:40 AM, the Minimum Data Set Coordinator (MDSC)1, who was the acting Director of Nursing (DON), and the Regional Director of Clinical Services (RDCS) both stated that they were unaware of the updated CDC recommendations for pneumococcal vaccines. The facility's Infection Preventionist was unavailable to be interviewed while onsite.

Based on interview, record review and facility policy review, the facility failed to ensure an antibiotic was not used without the presence of a diagnosed infection for 1 of 1 resident (Resident (R)9) reviewed for antibiotic stewardship out of a total sample of 49. The failure had the potential to increase the risk of adverse events, including the development of antibiotic-resistant organism, from unnecessary or inappropriate antibiotic use.Findings include:Review of the facility's policy titled, Antibiotic Stewardship, dated 2001, revealed, The antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program . when a culture and sensitivity is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued .Review of R9's electronic medical record (EMR) Face Sheet, under the Profile tab, revealed an admission date of 03/06/26 with diagnoses including but not limited to, uropathy, chronic kidney disease, urinary tract infection (UTI), and retention of urine.Review of R9's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/26 and located under the MDS tab of the EMR, revealed R9 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated R9's cognition was severely impaired. The MDS indicated that R9 had an indwelling urinary catheter.Review of R9's EMR Progress Notes, in the Progress Notes tab, revealed from admission on [DATE] to 04/09/26 when R9 went to the urology appointment, there was no documentation the resident was experiencing signs or symptoms of a UTI. Review of the Progress Notes dated 04/09/25 indicated, resident went to urology appointment.ordered to get U/A [urinalysis] and C&S [culture and sensitivity] .collected and sent to ECH [lab's name]. Review of R9's EMR Documents tab revealed the Urinalysis Report, dated 04/10/26 with the signature of NP1 with the handwritten order for Cipro 250 BID [twice per day] x [times] 5 d [five days]. The urinalysis indicated, Color (A-Abnormal); Clarity Turbid (A); Nitrite Positive (A); Protein 3+ (A); blood 4+ (A); WBC [White Blood Count] innumerable (A); RBD [Red Blood Count] 50-100 (A); Bacteria 2+ (A); and Mucus 1+ (A).Review of R9's EMR Orders, under the Orders tab, revealed, Cipro [antibiotic] Oral Tablet 250 milligram (mg) Give 1 tablet by mouth two times a day for UTI for 5 Days dated 04/10/26.Review of R9's EMR Progress Notes, in the Progress Notes tab and dated 04/11/26, indicated, seen by NP [Nurse Practitioner (NP1)] ordered Cipro [an antibiotic] for UTI, no odor or abd [abdominal pain noted or reported. Review of R9's EMR Progress Notes, in the Progress Notes tab and dated 04/13/26, indicated, Resident remains on Cipro for UTI No c/o [complaint of] burning or abd discomfort.NP1 made aware of the C&S report, NP1 stated don't worry about it he's on Cipro and he has the Urology appt [appointment] coming up.Review of R9's EMR Progress Notes, in the Progress Notes tab and dated 04/14/26, indicated, Resident is afebrile and denies dysuria and burning. No hematuria [blood in urine] noted. Review of the Progress Notes revealed no further documentation that R9 had complaints of dysuria or burning.Review of R9's EMR Medication Administration Record (MAR), under the Orders tab, revealed R9 received the Cipro on 04/10/26 at 8:00PM through 04/15/26 at 9:00AM which no indication for usage.During an interview on 04/17/26 at 2:42 PM, the MDS Coordinator (MDSC)1 stated the facility should follow federal regulation about prescribing an antibiotic. MDSC1 stated that R9's urinalysis was contaminated and that the C&S could not be performed. The MDSC confirmed that there was no follow up after the facility was notified of the urinalysis report was discussed with NP1.During an interview on 04/17/26 at 3:13 PM, NP1 stated that he started the resident on Cipro prophylactically and that he never saw the C&S report. He stated he was not aware that the urine was contaminated.During an interview on 04/17/26 at 3:35 PM, MDSC1 confirmed that after the contaminated urine report was reported to NP1 on 04/11/26, there was no follow-up conducted. MDSC1 stated that there was no evidence in the EMR that R9's urologist was notified and asked if the provider wanted to repeat the urinalysis and obtain a C&S.During an interview on 04/17/26 at 3:56 PM, MDSC1 stated that the facility followed the McGeer's (standardized surveillance definitions used to identify infections in long-term care (LTC) facilities, ensuring consistent reporting and monitoring of infections) criteria. During an interview and review of the facility's Antibiotic Stewardship manual in the presence of MDSC1, revealed no documentation that R9's use of the antibiotic Cipro and the diagnosis of UTI had been reviewed using the McGeer's criteria. MDSC1 confirmed that the facility did not follow the McGeer's criteria for UTI

Based on record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure 2 of 2 residents (Resident (R)94 and R109) out of 49 sampled residents, had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment of the residents.(Cross Reference F883) Findings include:Review of the CDC website titled, PneumoRecs VaxAdvisor App (Application) for Vaccine Providers, dated 01/09/25, indicated . Give one dose of PCV15, PCV20, or PCV21 at least 1 year after the last does of PPSV23. Regardless of which vaccine is used . their pneumococcal series is complete Review of the RAI manual, dated 10/2024 and located in the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual by CMS, revealed, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment .1. Review of R94's electronic medical records (EMR) titled, admission Record, located under the Profile tab, indicated that the facility admitted the resident on 11/30/21. Review of R94's EMR titled quarterly MDS, with an Assessment Reference Date (ARD) of 03/24/26 and located under the MDS tab, indicated that the resident was up to date on her pneumococcal vaccine.Review of R94's EMR titled, Immunizations, located under the Immun (Immunization) tab, indicated the resident received Pneumovax 23 (PPSV23) on 12/03/21. There was no evidence that the resident or her representative was offered the PCV20 or the PCV21 vaccine. 2. Review of R109's EMR titled, admission Record, located under the Profile tab, indicated that the facility admitted the resident to the facility on [DATE]. Review of R109's EMR titled quarterly MDS, with an ARD of 04/02/26 and located under the MDS tab, indicated that the resident was up to date on her pneumococcal vaccine. Review of R109's EMR titled, Immunizations, located under the Immun tab, indicated the resident received PPSV23 on 10/06/22. There was no evidence that the resident or her representative was offered the PCV20 or the PCV21 vaccine. During an interview on 04/17/26 at 8:40 AM, the MDS Coordinator (MDSC)2, who was also the acting Director of Nursing (DON), and the Regional Director of Clinical Services (RDCS) stated that they were unaware of the updated CDC requirements for the pneumococcal vaccines and confirmed that the MDS assessments for R94 and R109 were inaccurate.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; document discussion related to risk versus benefits; and obtain signed informed consent prior to bed rail use for 1 of 3 residents (Resident (R)64), reviewed for side rails out of 49 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to a potential restraint or side rail entrapment. Findings include:Review of the facility policy titled Bed Safety and Bed Rails with a revised date of August 2022, revealed, Policy Statement . The use of bed rails is prohibited unless the criteria for use of bed rails have been met. Policy Interpretation and Implementation . Use of Bed Rails . 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.Review of R64's Face Sheet, in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE], with diagnoses that included but was not limited to, hypertensive heart disease with heart failure.Review of R64's Care Plan, located under the Care Plan tab of the EMR and revised 02/03/26, revealed R64 may use quarter side rails for mobility as clinically indicated. Review of R64's Bed Rail/Entrapment Risk Evaluation, located under Assessments tab in the EMR and dated 02/03/26, revealed no documentation that alternates were explored prior to bed rail/side rail use. Further review revealed no documentation related to risks versus benefits or informed consent, and the assessment indicated that bedrails were not being considered or used. Review of R64's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/26, and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated R64 was severely cognitively impaired.Review of R64's Physician Orders, located under the Orders tab in the EMR and dated 04/2026, revealed no current order for side rail use.During an observation on 04/15/26 at 5:35 PM, R64 was in bed, with the head of the bed upright, and side rails were up on both sides. During an interview on 04/17/26 at 8:06 AM, Licensed Practical Nurse (LPN)6 stated she completed R64's admission bedrail assessment. She stated she could not remember if alternatives were explored prior to bedrail use or if there were a discussion of risk and benefits and informed consent. She stated she was unaware that R64's bedrail assessment indicated he did not have bedrails and they were not being considered.During an observation on 04/17/26 at 8:15 AM with LPN6, R64 was sitting on the edge of the bed. There were side rails on both sides of the bed. During an interview on 04/17/2026 at 8:46 AM, Minimum Data Set Coordinator (MDSC)1 (in DON absence) stated there should not be bedrails on a resident's bed if the assessment indicated they were not in use or being considered.

Based on observation, record review, interview, and facility policy review, the facility failed to: 1. Ensure neurological checks were conducted as ordered by the medical provider after 1 of 2 residents (Resident (R)85) reviewed for falls, was found on the floor crawling (a potential unwitnessed fall) out of a survey sample of 49. This failure to complete neurological checks placed the resident at risk for potential neurological decline; 2.) Follow the facility's policy regarding the assessment and documentation of open areas for 1 of 1 resident (R9) reviewed for open skin areas in the sample of 49 residents. The failure to accurately assess and document the resident's open areas as indicated in the facility's policy had the potential to affect the notification of the provider for treatment when the open areas size increased or the areas showed signs of infection; and 3.) Ensure proper positioning and use of an assistive seating device for 1 of 1 resident (R33). Specifically, the facility failed to ensure the resident's Broda chair (A Broda Chair is a specialized wheelchair designed to provide advanced comfort, support, and safety for individuals with complex mobility or positioning needs) was consistently set up and used according to safe positioning principles. This failure placed the resident at risk for improper positioning, loss of postural support, and potential injury.Findings include:1. Review of a facility policy titled, Neurological Assessment (Routine), dated 10/2023, indicated, . The purpose of this procedure is to provide guidelines for conducting a routine neurological assessment . There was no evidence in the policy that addressed how to monitor a resident after an unwitnessed fall. Review of R85's electronic medical record (EMR) titled admission Record, located under the Profile tab, indicated that the facility admitted the resident on 01/20/26.Review of R85's EMR titled admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/27/26 and located under the MDS tab, indicated that the staff could not determine a Brief Interview for Mental Status (BIMS) score. The assessment indicated that the resident could walk with supervision or touch assistance. The assessment revealed that the resident had a history of falls.Review of R85's EMR titled Care Plan, located under the Care Plan tab and dated 01/20/26, indicated that the resident was at risk for falls. The care plan identified that the resident had a history of crawling on the floor.Review of R85's EMR titled Care Plan, located under the Care Plan tab and dated 01/21/26, indicated that the resident was at risk for psychosocial behaviors of crawling out of bed.Review of R85's EMR titled nursing Progress Notes, located under the Prog (Progress) Note tab and dated 01/22/26, indicated that a nurse was called into the resident's room. The resident was found crawling on the floor (a potential unwitnessed fall) towards the door. The nurse assessed the resident, and the resident sustained no injuries.Review of R85's EMR titled Nurse Practitioner (NP)2 Progress Notes, located under the Prog Note tab and dated 01/22/26, revealed that NP2 was notified of an unwitnessed fall sustained by the resident. NP2 noted that the resident sustained no injuries but directed the staff to conduct neurological checks per facility protocol.Review of R85's EMR titled Physician Orders, located under the Misc (Miscellaneous) tab and dated 01/22/26, revealed, . Neuro checks with VS [vital signs] s/p [status post] fall as follows: q [every] 15min [minutes] x [times] 1 hours, q30 min x 1 hour, hourly x 4 hours, q4h x 24 hours. Notify a clinician of any change in condition . There was no evidence in the clinical record that showed the clinical staff implemented the medical provider's orders.During an interview conducted on 04/17/26 12:25 PM, the Administrator stated that if NP2 ordered neurological checks then the staff should have completed them.During an interview conducted on 04/17/26 at 1:39 PM, the MDS Coordinator (MDSC)2, who was also the acting Director of Nursing (DON), stated that the staff more than likely did not complete the neurological checks since R85 had the behavior of crawling on the floor. MDSC2 stated it was important to do neurological checks after an unwitnessed fall since the facility wanted to monitor the resident's condition.2. Review of the facility's policy titled, Wound Care, dated 2001, indicated, . The following information should be recorded I [sic] the resident's medical record . 6. All assessment data (i.e., wound bed color, size, drainage, obtained when inspecting the wound.Review of the facility's policy titled, Skin Assessment: Best Practice, provided by the MDSC, indicated, Assessment of a resident's skin condition helps define prevention strategies . use the following guidelines: . Weekly skin Assessment, a weekly skin assessment is completed once a week and describes the current condition of the patient's skin.Review of R9's Face Sheet, under the Profile tab, revealed an admission date of 03/06/26, with diagnoses including but not limited to, uropathy, chronic kidney disease, urinary tract infection (UTI), and retention of urine.Review of the EMR Care Plan, under the Care Plan tab, revealed, Skin Risk Resident is at risk for skin breakdown related to Cardiovascular disease, Chronic Obstructive Pulmonary Disease (COPD), cognitive Impairment, Dementia, Diabetes, impaired ADL ability, impaired mobility, incontinence of Bowel Redness to sacrum present on readmission to facility . Revision on: 03/10/26 with intervention of administer treatment as ordered.Review of R9's admission MDS, with an ARD of 03/13/26 and located under the MDS tab of the EMR, revealed R9 had a BIMS score of 7 out of 15, which indicated R9's cognition was severely impaired. The MDS indicated that R9 had no Pressure ulcers (PURs).During an observation on 04/17/26 at 9:24 AM, Licensed Practical Nurse (LPN)1 performed a treatment to R9's sacral area. The left buttock had one open area, and the right buttock had one scabbed area. The sacral area had extremely red/purple excoriation.Review of R9's Nursing Comprehensive Skin Evaluation/Assessment, dated 03/06/26, provided by Medical Records (MR) revealed, skin warm, discoloration to buttocks . coccyx area few small open areas.Review of R9's Nursing Comprehensive Skin Evaluation/Assessment, dated 03/16/26, provided by MR indicated, skin warm, discoloration to buttocks . coccyx area few small open areas.Review of R9's Nursing Comprehensive Skin Evaluation/Assessment, dated 03/23/26, provided by MR indicated, skin warm, discoloration to buttocks . coccyx area few small open areas.Review of R9's EMR Skin Notes in Progress Notes under the Progress Notes tab, dated 03/24/26, indicated, Resident observed with large open area (no measurements) to sacral area, area observed as pink and red and actively bleeding .Review of the Skin Notes dated 03/25/26 indicated, writer assessed sacral region . there were open areas (no measurements or indication how many open areas), sacral area is excoriated .Review of R9's Nursing Comprehensive Skin Evaluation/Assessment, dated 03/30/26 provided by MR, indicated, skin warm, discoloration to buttocks . coccyx area few small open areas.Review of R9's Nursing Comprehensive Skin Evaluation/Assessment, dated 04/06/26, provided by MR indicated, skin warm, discoloration to buttocks . coccyx area few small open areas.Review of R9's Nursing Comprehensive Skin Evaluation/Assessment, dated 04/13/26, provided by MR indicated, skin warm, discoloration to buttocks . coccyx area few small open areas.During an interview on 4/16/25 at 4:25 PM, LPN8/Wound nurse stated that she could not find in the EMR documentation of the measurement of the open areas on R9's sacrum since his admission on [DATE] until 04/16/26 Review of R9's Progress Notes by NP1, under the Progress Notes tab in the EMR, revealed for dates of 04/03/26, 04/10/26, and 04/15/26, NP1 documented in the NP Progress Notes the area was a sacral decubitus ulcer.During an interview on 04/17/26 at 9:04 AM, with MDSC1 and the Regional Director of Clinical Services (RDCS), the RDCS stated that when an open area is found, the wound nurse is to assess the area within 24 hours. MDSC1 stated that the expectation was that the wound nurse would describe the area following the facility's policy regarding documentation with the weekly note. MDSC1 and RDCS were shown documentation in the EMR that indicated R9 had a few open areas with no measurements and other documentation that indicated the area to the sacrum as a large open area, and the NP1 describing the sacrum in the NP1's progress notes as a sacral decubitus ulcer.During an interview with NP1 on 04/17/26 at 1:03 PM, he stated that he had seen the area in the last two weeks. He stated that the excoriation to the sacral area appeared to be a fungal infection. He stated that he did not recall that his progress notes indicated the area was a decubitus ulcer.3. Review of R33's Face Sheet, located under the Profile tab of the EMR revealed R33 was admitted to the facility on [DATE], with diagnoses including but not limited to, seizure disorder, severe intellectual disability, legal blindness, aphasia, and hearing loss, with a history of impaired cognition and severely impaired decision making skills.Review of R33's quarterly MDS, with an ARD of 04/08/26 and located under the MDS tab of the EMR, revealed R33 was rarely or never understood, had short-term and long-term memory problems, was severely impaired for daily decision-making skills, and used a manual wheelchair. R33 was dependent for positioning and mobility.During an observation on 04/15/26 at 12:01 PM, R33 was seated in a Broda chair in the dining room. The left shoulder bolster was loose, barely attached with Velcro, and not touching the resident's shoulder, failing to provide lateral support. The bolster was not readjusted until 45 minutes later.During an observation on 04/15/26 at 3:35 PM, the same left shoulder bolster was again observed hanging off the side of the Broda chair, not positioned to support the resident.During repeated observations on 04/16/26, revealed continued lack of proper positioning. At 11:12 AM, R33 was seated in the Broda chair in the hallway with no shoulder bolsters positioned on either side. At 11:58 AM, R33 remained seated in the Broada chair without shoulder bolsters. At 1:33 PM, R33 was seated in the Broda chair in his bedroom at the foot of the bed, still without shoulder bolsters in place.During an interview on 04/16/26 at 1:37 PM, Certified Nursing Assistant (CNA)2 stated the shoulder cushions were loose and slid down near the resident's bottom due to the resident rocking side to side. The CNA stated she attempted to tighten the straps, but the cushions remained loose at elbow level. She reported therapy had shown her how to position the resident in the Broda chair.During an interview on 04/16/26 at 1:45 PM, CNA3 and the Director of Rehabilitation (DOR) stated the cushions were meant to provide lateral support and should be properly placed each time staff positioned the resident in the chair. The bolsters slipped down because they were not placed or tightened properly.

Based on observation, interview, and facility policy review, the facility failed to promote and maintain dignity during dining services for 3 of 21 Residents (R)61, R33, and R37, reviewed who ate in the Main Dining Room. This failure resulted in residents experiencing prolonged waits for meals and being assisted in a manner that did not preserve dignity.Findings include:Review of the facility policy titled, Assistance with Meals revealed, . Facility staff will serve resident trays and will help residents who require assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals; . c. avoiding the use of labels when referring to residents (e.g., feeders) .During an observation on 04/15/26 at 11:56 AM, R33 and R37 were brought to the dining room and placed at a table together. They were not provided their meal trays. Staff served the other 19 residents, while R33 and R37 remained without food. At 12:45 PM, R33 was moved to a different table, provided a meal tray, and was assisted with his meal. At 12:50 PM, R37 was moved to a different table and assisted with his meal. During an observation on 04/15/26 at 12:27 PM, the Infection Preventionist (IP) was observed standing while assisting R61 with his meal. The IP fed the resident from a bowl while standing beside him and telling him, You don't have to be afraid. There was an empty chair next to the resident. Review of R33's admission Record found under the Profile tab of the electronic health record (EMR) revealed R33 was admitted on [DATE], with diagnoses including but not limited to, convulsions, intellectual disabilities, legal blindness, aphasia, hearing loss, cataract, protein-calorie malnutrition, dysphagia, oral phase, cognitive communication deficit and type 2 diabetes mellitus. Review of R33's Quarterly Minimum Data Set (MDS) found under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 04/08/26, revealed R33 was dependent for eating (meaning helper does all of the effort to complete the activity). Review of R33's Care Plan, revealed R33 requires staff assist with Activities of Daily Living (ADL) and mobility due to cognitive, communication, and physical impairments and the goal was to assist resident with all meals and snacks. Review of R37's admission Profile found under the Profile tab of the EMR revealed R37 was admitted on [DATE] with diagnoses including but not limited to, anemia, hip fracture, non-Alzheimer's dementia, seizure disorder, and malnutrition. Review of R37's Quarterly MDS found under the MDS tab of the EMR with an ARD of 01/16/26, revealed his Brief Interview for Mental Status (BIMS) score was coded as 99 indicating R37 was unable to answer the questions and the staff assessment had to be completed. R37 had short-term and long-term memory loss and severely impaired decision-making skills - never/rarely made decisions and was dependent on staff for eating (meaning Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity.) During an interview on 04/15/26 at 12:53 PM, the IP stated, They [R33 and R37] are feeders and we serve them last. The IP further explained that usually there wasn't another Certified Nursing Assistant (CNA) available, so residents did not have to wait as long. The IP stated staff should sit down while assisting residents with meals.During an interview on 04/17/26 at 12:00 PM, the Minimum Data Set Coordinator (MDSC)1 confirmed that staff should sit while assisting residents with meals.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were not left at the bedside for a resident who was not assessed as able to self-administer medications, for 1 of 1 Resident (R)11. This failure placed the resident at risk for unsafe medication use and improper self administration.Findings include:Review of the facility policy titled Self-Administration of Medications revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 3. If it is deemed safe and appropriate for the resident to self-administer medications, this is documented in the medical record and the care plan . 8. Self-administered medications are stored in a safe and secured place, which is not accessible by other residents. 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge.Review of the admission Record located in the electronic medical record (EMR) under the Profile tab revealed R11 was admitted on [DATE], with diagnoses including but not limited to, dependence on respirator [ventilator] status, tracheostomy status, type 2 diabetes mellitus without complications, morbid (severe) obesity with alveolar hypoventilation, anxiety disorder, obesity, class 3, anemia in chronic kidney disease, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, dyskinesia of esophagus, chronic kidney disease, stage 3a, and mood disorder due to known physiological condition with manic features.Review of R11's Quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date of 04/13/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R11 was cognitively intact. Further review of the MDS revealed R11 was taking antibiotics.Review of R11's Care Plans section of the EMR revealed there were no care plans related to R11's ability to self-administer medications and did not state resident was on antibiotics.Review of R11's Physician Orders located in the EMR under the Orders revealed no physician orders authorizing self administration of medications and no physician orders allowing medications to be kept at the bedside.Review of R11's Assessments tab did not reveal any assessments evaluating the resident's ability to safely self administer medications.During an observation and interview on 04/16/26 at 4:07 PM, Azithromycin (macrolide antibiotic effective against bacterial infections) was observed stored in a three drawer plastic container in R11's room. At 4:10 PM, R11 stated the facility had not organized her tracheostomy supplies since she moved in the prior year. During this time, the resident displayed a blood glucose glucometer kept on her bed, indicating she was conducting blood sugar testing independently. R11 stated the Azithromycin was with her trach supplies since she moved in on 04/15/25 and the doctor at home had her testing her blood sugar and that was her meter from home. During an observation and interview with Licensed Practical Nurse (LPN)7 on 04/16/26 at 4:28 PM, a box of Azithromycin 250 mg tablets, labeled with directions to take twice daily for four days from CVS, was found in the bottom drawer of R11's tracheostomy supply container. LPN7 stated the medication was not supposed to be kept at the bedside. A few minutes later, the resident again presented her blood glucose monitor kept at the bedside. LPN7 stated the resident should not have a glucometer on her bed or bedside table and that it should not be kept in the room.Despite identifying the medication as unauthorized, at 4:45 PM on 04/16/26, LPN7 left the CVS medication in the resident's room.During an observation with LPN6 on 04/17/26 at 8:47 AM, revealed a personal use blood glucose glucometer was located in the R11's room. LPN6 stated the resident was not allowed to have the device in her room or self administer blood sugar testing.During an interview on 04/17/26 at 8:47 AM, LPN6 verified there was no physician order for R11 to keep medications at the bedside or to self administer medications. LPN6 stated she was unaware of the resident being authorized to have medications in her room, or assessed to have medications at the bedsideDuring an interview on 04/17/26 at 8:48 AM, LPN6 stated that if staff find medications in a resident's room, the medication should be removed, verified, and not left at the bedside. She added that staff would need to determine whether a resident is appropriate for self administration before allowing medications in the room.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that 1 of 1 resident (Resident (R)85), reviewed for restraints out of a total sample of 49, was properly assessed for the use of positioning devices (pillows used as a restraint) intended to reduce the risk of rolling, crawling, or falling out of bed. In addition, the facility failed to ensure that informed consent was obtained and documented for the use of a chair alarm. (Cross Reference F684 and F689) Findings include:Review of a facility policy titled, Use of Restraints dated 12/2007, indicated, . Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . 'Physical Restraints' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body . The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition . and this restricts his/her typical ability to change position or place, that device is considered a restraint . Restraints may only be used when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restrain is required to . Treat the medical symptom . Protect the resident's safety; and . Help the resident attain the highest level of his/her physical or psychological well-being . Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following . The specific reason for the restraint (as it relates to the resident's medical symptom) . How the restraint will be used to benefit the resident's medical symptom; and . The type of restraint, and period of time for the use of the restraint Review of R85's electronic medical record (EMR) titled admission Record, located under the Profile, indicated that the facility admitted the resident on 01/20/26, with a diagnosis including but not limited to, Alzheimer's disease. Further review revealed R85 was receiving hospice services.Review of R85's EMR titled admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/27/26 and located under the MDS tab, indicated the staff could not determine the resident's Brief Interview for Mental Status (BIMS) score. The assessment indicated that the resident was able to ambulate with supervision or touching of staff. The assessment revealed that she was totally dependent on staff for all activities of daily living. The assessment indicated that the facility used no restraints with R85, including a chair alarm. Review of R85's EMR titled, Care Plan, located under the Care Plan tab and dated 01/20/26, revealed the resident was care planned for being at risk for falls due to a history of falls and crawling out bed. In addition, the resident's care plan identified that the resident was at risk for psycho-social behaviors of crawling out of bed, disrobing, and combativeness with staff, all related to her diagnosis of dementia. Review of R85's EMR titled, Progress Notes, located under the Prog (Progress) Note tab, failed to contain evidence of informed consent for the use of a chair alarm. Review of R85's EMR titled physician Orders, located under the Orders tab, failed to contain an order for an assessment authorizing the use of positioning devices that could restrict the resident's movement, nor was there an order for a chair alarm. During an observation on 04/16/26 at 10:44 AM, R85 was in bed, and her bed was in a low position. During this observation, an interview was conducted with Restorative Nurse Aide (RNA)1 who stated there were times that the resident would dangle her legs off the bed. During an observation and interview on 04/16/26 at 4:22 PM, Licensed Practical Nurse (LPN)1/Unit Manager for Peach entered R85's room. LPN1 stated that the resident would attempt to roll out of bed. During this interview, the resident was observed in bed. There was a pillow on the left side of her head, positioned under the flat sheet. Observed another pillow on the left side of the bed under the flat sheet positioned on the side of the resident's feet. The bed faced the resident's door. LPN1 confirmed the positioning of the pillows and stated that the facility did not use side rails, and the pillows were not restraints. LPN1 stated that there was currently no bed alarm for the resident since the resident would destroy the bed alarm. LPN1 stated that the resident used a chair alarm currently. Observed the chair alarm attached to the back of the resident's wheelchair during this interview. LPN1 stated that the resident did attempt to roll out of bed. LPN1 confirmed the pillows located under the flat sheet were not directly under the resident and prevented the resident from rolling or falling out of bed. During an interview on 04/16/26 at 4:34 PM, Certified Nurse Aide (CNA)1 stated that R85 did try to roll out of bed, and the pillows were placed under the flat sheet to prevent the resident from rolling out. CNA1 confirmed the chair alarm was placed on the resident's wheelchair to prevent the resident from getting out of her wheelchair. CNA1 stated that the resident could walk but was not to walk. Observed the resident in bed and her legs were dangling off the side of her bed. During an observation on 04/16/26 at 5:16 PM, R85 had two pillows under the flat sheet.During an interview on 04/17/26 at 8:21 AM, Registered Nurse (RN)1, who was a hospice nurse, stated that hospice did not provide the facility with a chair alarm for R85.During an interview on 04/17/26 at 8:40 AM, MDS Coordinator (MDSC)2, who was the acting Director of Nursing (DON), and Regional Director of Clinical Services, stated a restraint was a device that a resident cannot easily remove. A request was made for informed consent for the use of positioning pillows and a chair alarm, and this was not provided by the end of the survey.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure proper personal protective equipment (PPE), specifically ex-large disposable gloves were available for staff use prior to entering into a contact/droplet transmission-based precaution (TBP) room and/or failed to post proper TBP signage for contact/droplet precautions for 2 of 2 residents (Resident (R)87 and R75), reviewed for TBP out of a total sample of 49. This increased the likelihood that infectious organisms could be transmitted from residents to staff, other residents, or the environment.Findings include:Review of a facility policy titled, Isolation - Categories of Transmission-Based Precautions, dated 09/2022, indicated, . Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents . When a resident is placed on transmission - based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .The signage informs the staff of the type of CDC (Centers for Disease Control) precaution(s), instructions for use of PPE .1. Review of R87's electronic medical record (EMR) titled, admission Record, located under the Profile tab, indicated that the facility admitted the resident on 03/19/26.Review of R87's EMR titled Encounter progress notes, located under the Prog (Progress) Note tab and dated 04/15/26, indicated the resident tested positive for respiratory syncytial virus (RSV).Review of R87's EMR titled physician Orders, located under the Orders tab and dated 04/15/26, indicated that the medical provider ordered that the resident be placed under contact/droplet precautions.During an observation on 04/15/26 at 1:29 PM, of R87's room, there was signage on the outside of door indicating Enhanced Barrier Precautions (EBP) were required. Licensed Practical Nurse (LPN)6 donned gown and gloves and entered the room. During an observation on 04/15/26 at 4:45 PM, the signage outside R87's door indicated R87 was on Droplet and Contact precautions. During an observation and interview conducted on 04/16/26 at 2:24 PM, the Housekeeper was observed to don (put on) a gown and a pair of bright green and black work gloves prior to entering into R87's room. Posted was a contact/droplet precaution sign. The Housekeeper was immediately interviewed after this observation and confirmed he was ready to enter the resident's room. The Housekeeper stated that he has worn the gloves before he enters a TBP room and takes the gloves home to wash them. The Housekeeper stated that the facility does not provide extra-large gloves. The top drawer of the three-drawer container was opened and there were only medium and large sized disposable gloves. During an interview on 04/16/26 at 2:26 PM, the Housekeeping Supervisor stated that the facility did have extra-large gloves, but there were not in the drawers for staff to use.During an interview on 04/17/2026 at 8:06 AM, Licensed Practical Nurse (LPN)6 stated she did not don eye protection when she entered room R87's room on 04/15/26 at 1:29 PM to assist the resident. She stated the EBP sign was not accurate, and the room should have had contact and droplet precautions in place due to the resident testing positive for influenza. She stated she was aware prior to entering the room on 04/15/26 at 1:29 PM that the resident in Bed A had tested positive for influenza on 04/14/26, and the signage should have been changed to contact and droplet precautions. LPN6 stated she should have donned eye protection when providing care.2. Review of R75's EMR titled admission Record, located under the Profile tab, indicated that the facility admitted the resident on 10/03/22.Review of R75's EMR titled physician Orders, located under the Orders tab and dated 04/15/26, indicated that the medical provider ordered to place the resident on contact/droplet precautions for being positive for RSV. During an observation conducted on 04/15/26 at 12:05 PM, R75's room had EBP sign posted on the outside. EBP signage does not meet contact/droplet TBP requirements. During an observation and interview conducted on 04/15/26 at 12:26 PM, several staff were observed to enter into R75's room without PPE, such as a gown and gloves. The Minimum Data Set Coordinator (MDSC) 1 was observed to instruct the staff to don proper PPE prior to entering R75's room. An interview was conducted with MDSC1, who was the acting Director of Nursing (DON), and confirmed that the incorrect sign was posted on the resident's room and stated a contact/droplet precaution sign was not posted to alert the staff of the PPE required prior to entering the resident's room. During an interview conducted on 04/17/26 at 8:40 AM, MDSC1 and Regional Director of Clinical Services (RDCS) both stated that staff needed to follow the policies for infection control. RDCS stated that the process was for a resident to be tested for a disease process and once the information comes in to alert the staff. Both stated that there were extra-large gloves in stock.During an interview conducted on 04/17/26 at 11:53 AM, MDSC1 stated that the expectation for TBP and staff included the appropriate sign and then the appropriate PPE to be donned and doffed (take off).

Based on observations, interviews, record review, and facility policy review, the facility failed to provide services to residents who were unable to carry out activities of daily living (ADLs) that were necessary to maintain good grooming and personal hygiene for 2 (Resident #59 and Resident #8) of 3 sampled residents reviewed for ADL care. Specifically, Resident #59 and Resident #8 had fingernails that were long, jagged, and dirty. Findings included: A review of a facility policy titled Fingernails/Toenails, Care of, revised in February 2018, indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Further review revealed, 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 5. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc. 6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. 1. A review of Resident #59's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/26/2023, revealed the resident was admitted to the facility on [DATE]. Per the MDS, Resident #59 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS revealed the resident was totally dependent on staff for dressing, personal hygiene, and bathing. During this assessment period, Resident #59 had an active diagnosis to include cerebral palsy. A review of Resident #59's care plan, initiated on 12/12/2021, indicated the resident required assistance with ADLs related to communication problems and limited range of motion due to spastic quadriplegic CP and weakness. A review of Resident #59's Progress Notes dated from 09/27/2022 to 09/06/2023, revealed no evidence of documentation which indicated the resident's fingernails were checked or if any nail care was provided to the resident. A review of Resident #59's Documentation Survey Report for September 2023 revealed the resident received a bed bath on 09/05/2023, 09/06/2023, 09/08/2023, 09/11/2023, 09/12/2023, 09/13/2023, 09/14/2023, 09/15/2023, 09/16/2023, 09/17/2023, 09/19/2023, 09/20/2023. 09/21/2023, 09/23/2023, 09/24/2023, 09/26/2023, and 09/27/2023. During an observation on 09/26/2023 at 10:15 AM, Resident #59 was observed lying in their bed in their room. The resident smiled when spoken to but could not answer questions. The resident's hands were contracted, with fingernails that were long and jagged with a brown substance underneath them. During an interview on 09/26/2023 at 1:37 PM, Resident Representative (RR) #9 stated they would, at times, assist Resident #59 with ADL care when they visited the resident at the facility. RR #9 stated they visited weekly and would provide nail care to the resident during visits and were unsure if the certified nurse aides (CNA) provided nail care to the resident. During an observation on 09/27/2023 at 11:43 AM, Resident #59's fingernails were long and jagged and had a brown substance underneath the nails. During an interview on 09/27/2023 at 2:18 PM, CNA #4 stated she assisted residents with bed baths or showers, meal assistance, and dressing and would take residents outside. CNA #4 stated she did not provide nail care to residents during ADLs. She stated the activity department held a nail group every Friday that residents could attend to have their nails cared for. CNA #4 stated she assisted Resident #59 with bed baths, oral care, and feeding assistance. She stated the resident did not refuse care from staff. CNA #4 stated she did not provide nail care to Resident #59. During an interview on 09/27/2023 at 2:41 PM, CNA #5 stated CNAs assisted residents with ADLs, including nail care, which should be provided during bed baths. She stated activities held a nail group weekly. She stated Resident #59 attended the nail activity group every Friday for nail care. CNA #5 stated if the nail group was not held weekly, the CNAs would trim and clean the resident's nails. During a telephone interview on 09/28/2023 at 9:52 AM, Licensed Practical Nurse (LPN) #6 stated Resident #59 was very pleasant and required total assistance from staff for ADLs. He stated the resident's fingernails were long the last time he saw them on 09/25/2023 during the night shift. LPN #6 stated day shift CNAs should provide nail care to the residents, keeping them trimmed and cut. He stated Resident #59 was not a diabetic, so the CNAs should provide nail care to the resident. LPN #6 stated the resident had contractures but could open and stretch out their hand. During an observation on 09/28/2023 at 10:36 AM, Resident #59's fingernails were long and jagged and had a brown substance underneath the nails. During an interview on 09/28/2023 at 1:05 PM, the Activity Assistant (AA) #8 stated the activities department held a nail group every Friday, but they only removed nail polish and repainted residents' nails in the group. She stated they did not trim or file the residents' nails in the group. AA #8 stated Resident #59 received one-on-one activities in their room and had frequent visitors. She stated the activity associates did not provide nail care to Resident #59; their CNAs were to provide nail care to the resident. During an interview on 09/28/2023 at 1:33 PM, the Assistant Director of Nursing (ADON) stated resident nail care should be provided by the CNAs and that the weekly nail group was just polishing of nails. She stated the CNAs should check residents' fingernails during baths and showers, which were provided at least three times a week. The ADON stated fingernails should be checked for cleanliness, trimmed, and filed for safety. She stated Resident #59 had frequent visitors who assisted them with nail care, but the CNAs should check their nails on bath days and providing nail care on bath days if needed. During an observation on 09/28/2023 at 1:35 PM with the ADON, Resident #59 was lying in bed in their room. The ADON went to the resident and asked to see their fingernails, and the resident offered their hand. As the ADON examined Resident #59's fingernails, the ADON stated the resident's fingernails were jagged and needed to be filed or trimmed. During an interview on 09/29/2023 at 9:47 AM, the Director of Nursing (DON) stated fingernail care should be provided by the CNAs on bath days. She stated nails should be checked, trimmed, and cleaned, especially if residents scratched or dug at themselves. The DON stated CNAs provided nail care to residents who were not diabetic. She stated diabetic residents received nail care from nurses or podiatrist. The DON stated Resident #59 received bed baths and required total assistance from staff with ADLs, and she expected CNAs to evaluate the resident's fingernails and hands every bath day. The DON stated the resident had contractures but could open their hand. She stated the resident's fingernails should be short and trimmed to protect the resident's skin and hands. During an interview on 09/29/2023 at 12:15 PM, the Administrator stated non-diabetic nail trimming and filing should be provided by the CNAs. He stated the activity department held a nail polishing group every week, but nail trimming and filing were not provided during that group. He stated nail care could be provided at bedside for residents, but the beauty shop could also be used. The Administrator stated nail care needed to be an assignment for the CNAs and was a good task for CNAs on light duty. He stated Resident #59 did have contractures, so their fingernails should be short and filed to prevent injury. 2. A review of Resident #8's Admission Record revealed the facility admitted the resident on 08/18/2017. Per the Admission Record, on 08/23/2017, Resident #8 was diagnosed with type 2 diabetes mellitus. A review of Resident #8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/17/2023, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident required extensive assistance from staff for personal hygiene and total assistance from staff with bathing. The MDS revealed the resident did not refuse care during the MDS assessment period. A review of Resident #8's care plan, revised on 08/02/2021, indicated the resident had a self-care deficit related to generalized weakness, decreased mobility, obesity, altered mood, bowel and bladder incontinence, and chronic pain. Interventions specified the resident preferred bed baths, required assistance from staff with bath/showers as needed, and required staff assistance with personal hygiene as needed. A review of Resident #8's Progress Notes dated from 09/29/2022 to 09/26/2023, revealed no evidence of documentation the resident refused assistance with their activities of daily living (ADLs). A review of Resident #8's Documentation Survey Report for September 2023, revealed the resident received a bed bath on 09/02/2023, 09/05/2023, 09/06/2023, 09/09/2023, 09/11/2023, 09/12/2023, 09/13/2023, 09/14/2023, 09/15/2023, 09/18/2023, 09/19/2023, 09/20/2023, 09/21/2023, 09/23/2023, 09/24/2023, 09/26/2023, and 09/27/2023. During an observation on 09/26/2023 at 9:03 AM, Resident #8 was observed in bed in their room. The resident's fingernails were long, jagged, and had a brown substance under the fingernails and around their cuticles. During an observation and interview on 09/27/2023 at 2:02 PM, Resident #8 was observed in bed in their room. The resident's fingernails were long, jagged, and had a brown substance under the fingernails and around their cuticles. Resident #8 stated the brown substance under their nails could have been from when they scratched a scab they had on their arm. Resident #8 stated no one helped them trim their nails at the facility. Resident #8 stated they had not requested their nails be trimmed, and no staff had offered. Resident #8 stated it would be nice to have their nails trimmed. During an interview on 09/27/2023 at 2:41 PM, Certified Nurse Aide (CAN) #5 stated CNAs assisted residents with ADLs, including nail care, which should be provided during bed baths. She stated activities held a nail group weekly. She stated if the resident were a diabetic, their nail care would be done by the nurse. CNA #5 stated she did not provide nail care to Resident #8 as they were diabetic but would assist the resident with their bed baths. During an observation and interview on 09/28/2023 at 10:39 AM, Resident #8 was observed in bed playing on their tablet. The resident's fingernails were long and jagged with a brown substance underneath. Resident #8 stated the nurses had not offered them nail care during their visits or when they were assessed and did not offer nail care on bath days. During an observation and interview on 09/29/2023 at 8:32 AM, Resident #8 was observed in bed in their room. Licensed Practical Nurse (LPN) #7 knocked on the door and approached the resident and asked to see their fingernails. The resident obliged, and after examination, LPN #7 stated the resident's nails needed to be trimmed as they were not jagged and long. LPN #7 stated the resident's fingernails also needed to be cleaned. She stated the nurses should check residents' nails during skin assessments, and CNAs should check and report any concerns to the nurses on bath days. LPN #7 stated Resident #8 picked at their skin, so their fingernails should be short to prevent injury and infection. LPN #7 stated the nurses assisted with fingernail care for diabetic residents, but toenail care was usually referred to the podiatrist. She stated she did trim and tended to the fingernails of the diabetic residents because it was important to protect the resident's skin and prevent infections, especially if residents picked at their skin. LPN #7 stated she worked with Resident #8, and the resident had never requested nail care from her, but the resident did pick at their skin, and the resident was a diabetic. During an interview on 09/29/2023 at 9:47 AM, the Director of Nursing (DON) stated fingernail care should be provided by the CNAs on bath days. She stated nails should be checked, trimmed, and cleaned, especially if residents scratched or dug at themselves. The DON stated CNAs provided nail care to residents who were not diabetic. She stated diabetic residents received nail care from nurses or podiatrist. She stated Resident #8 received bed baths and required total assistance from staff with ADLs and would refuse care and be argumentative with staff. The DON stated the resident would also dig and pick at their skin and would also be found scratching their skin in their sleep, so it was important to offer nail care to the resident and encourage their participation in care. The DON stated the resident's nails should be short and trimmed, and the nurses should offer nail care frequently in the event the resident accepted care. During an interview on 09/29/2023 at 12:15 PM, the Administrator stated non-diabetic nail trimming and filing should be provided by the CNAs, unless the resident was a diabetic, then finger and toenail care should be provided by the podiatrist. He stated Resident #8 would be found scratching their skin while they slept. The Administrator stated he witnessed this sleep scratching as he passed by the resident's room. He stated Resident #8 accepted care on their own terms. The Administrator stated since the resident was a diabetic and their name would be placed on the podiatrist list for nail care.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure that a glucose meter (a device used to monitor blood glucose levels) was cleaned with an approved disinfectant wipe. This affected 1 (Resident #2) of 2 residents observed for blood glucose testing during the medication pass observation. Findings included: A review of a facility policy titled Blood Sampling - Capillary (Finger Sticks), revised in September 2014, revealed, The purpose of this procedure is to provide guidelines for cleaning a glucometer used for blood sugars [glucose] and to prevent the introduction of bacteria. Further review revealed Steps in the procedure included 1. Wash hands with soap and water, dry thoroughly. 2. Apply gloves. 3. To clean and disinfect the meter, clean the meter with an approved disinfecting wipe (bleach wipe) before and after use. 4. Wipe all external areas of the meter including both front and back surfaces until visibly clean. 5. Allow the surface of the meter to remain wet at room temperature for the contact time of five minutes by leaving wipe wrapped around meter. 6. Allow the meter to air dry. 7. Discard disinfecting wipe. 8. Remove gloves. 9. Wash hands with soap and water, dry thoroughly. A review of the blood glucose monitoring system operator's manual, undated, revealed one of the products recommended for use for cleaning the glucose meter was bleach germicidal wipes. A review of Resident #2's Admission Record indicated the facility admitted Resident #2 on 06/28/2017. On 11/01/2017, Resident #2 was diagnosed with type 2 diabetes mellitus. On 06/09/2020, Resident #2 was diagnosed with long-term use of insulin. A review of Resident #2's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2023, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident had received insulin injections seven days during the seven-day lookback period. A review of Resident #2's care plan, revised 08/09/2023, revealed the resident had a potential for hypoglycemia or hyperglycemia related to diabetes mellitus and a history of pancreatitis. Interventions included to obtain blood glucose levels as ordered. A review of Resident #2's physician's orders revealed an order revised on 04/05/2021 for blood glucose checks to be completed four times daily for diabetes mellitus. During an observation on 09/27/2023 at 11:20 AM, Registered Nurse (RN) #1 was observed as she prepared to check Resident #2's blood glucose level. RN #1 used a 70% isopropyl alcohol swab to clean the glucose meter before entering the resident's room. After the blood glucose check was completed, RN #1 again used a 70% isopropyl alcohol swab to clean the glucose meter. During an interview on 09/27/2023 at 2:32 PM, the Director of Nursing (DON) stated RN #1 had come to them after the surveyor had left the medication cart following the observation of the blood glucose check for Resident #2 and admitted they had used the wrong wipe to disinfect the glucose meter. During an interview on 09/27/2023 at 3:21 PM, RN #1 stated the facility's policy for disinfection of a glucose meter was to use bleach germicidal wipes that were located in the bottom drawer of the medication cart. RN #1 acknowledged she had used alcohol wipes to clean the glucose meter before and after checking Resident #2's blood glucose level. During an interview on 09/27/2023 at 5:06 PM, RN #1 stated she always used bleach wipes to clean a glucose meter and did not know why she used alcohol swabs to clean the glucose meter earlier in the day. During an interview on 09/27/2023 at 5:55 PM, RN #1 stated the glucose meter used for Resident #2 was used only for Resident #2. The RN stated all residents who received blood glucose checks had their own glucose meter, which was stored in separate plastic bags in the bottom drawer of the medication cart. During an interview on 09/28/2023 at 10:40 AM, the DON stated she expected staff to disinfect a glucose meter with the bleach germicidal wipes that were in the bottom drawer of each medication cart. During an interview on 09/28/2023 at 10:47 AM, the Administrator stated he expected staff to disinfect a glucose meter with the bleach germicidal wipes.

Based on review of facility policy, record review, and interviews, the facility failed to ensure resident property was kept safe from loss or theft for 1 resident (R)1 of 1 resident reviewed for misappropriation of property. Specifically, the facility failed to ensure $750.00 of R1's personal money was kept safe from loss or theft. Findings include: Review of the facility's policy titled, Investigating Incident of Theft and/or Misappropriation of Resident Property last revised April 2021 revealed: Residents have the right to be free from exploitation, theft and/or misappropriation of personal property. Our facility exercises reasonable care to protect the resident from property loss or theft, including a. implementing policies that strictly prohibit, and pursue to the full extent of the law, staff or employee theft or misappropriation of resident property; b. providing measures to safeguard resident valuables from easy public access. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, bipolar disorder, anxiety, hypertensive heart disease with heart failure, and depression. Review of R1's Scheduled 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/17/23 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. A review of R1's Discharge Summary from the local hospital dated 03/01/23 revealed, Here is a [AGE] year-old lady who was brought in through ambulance from the skilled nursing facility when she was in ER she was obtunded, unable to communicate she is in septic shock with altered mental status. She has been unresponsive and diaphoretic. An interview with R1 on 7/19/23 at 12:22 PM in R1's Room revealed that R1 went out to the hospital in late February due to Septic Shock. R1 stated that she asked for her phone while at the hospital and the hospital told her she did not come with her cell phone. R1 stated upon return to the facility, she asked for her phone and the staff did not know where her phone was.The Social Services Director tried to convince her that she had taken the cellphone with her to the hospital. R1 stated that the phone had been lost for approximately a month and the facility Administrator convinced R1's mother to purchase a new phone, which she did from Amazon. R1 stated that 2 weeks later after having her new phone, a CNA (Certified Nursing Aide) asked her if she had found her phone and asked her what the phone looked like. R1 stated the CNA told her she would be right back and returned with the resident's missing phone, which was a Samsung Galaxy and the phone was dead. CNA told R1 that the phone was located on the other side of the facility at the nurse's station on the counter. R1 stated that she put the phone on the charger and when the phone cut on she checked the phone to see if it had been messed with and noticed three $250.00 transactions totaling the amount of $750 that was sent to a lady named (XXX) on 02/28/23, while she was hospitalized . R1 stated that the only person with that name is the housekeeper that used to clean her room daily, and the housekeeper quit before R1 returned from a hospital stay. R1 stated that the same day she got her phone back, the Housekeeper called her asking if she had found her phone which R1 stated she found strange and asked her(housekeeper) if she sent herself money from her phone and housekeeper hung up the phone and changed her number. R1 stated that she told the Facility Administrator and she is still awaiting reimbursement. An interview with Social Services (SS) on 07/19/23 at 12:55 PM revealed the SS stated that R1 went out to the hospital in late February, and stated that R1 told her that staff could not locate her phone upon return to the facility. SS stated that R1's mother purchased the phone from Amazon and returned the phone a week or two later because the resident's missing phone was located. SS stated that the facility did not pay for the phone because the phone was returned and R1's mother had received a refund from Amazon. SS stated that when R1 regained access to her phone she notified staff that she had three (3) $250.00 charges equaling to 750 dollars during the time she was hospitalized . SS stated the Ombudsman and police were notified and that the police sent the case up to the Attorney General's office. SS stated that she is not sure if the facility reimbursed R1 the total amount of $750.00, and that's a question for the Administrator. An interview with CNA1 on 07/19/23 at 1:15 PM revealed that R1 is a patient of hers and she provides daily ADL care. CNA1 stated that R1 mentioned to her that she was missing her phone when R1 returned from the hospital. CNA1 stated that after approximately a month she saw a phone in the Peach unit on top of a med cart that matched the description of the resident's phone after asking R1 what her phone looked like and the phone was dead. CNA1 asked the staff who the phone belonged to and since nobody claimed the phone, CNA1 brought the R1 which confirmed it was her phone and put the phone on the charger for her. CNA1 stated that once the phone turned on, the resident unlocked it, and stated that her money was missing. CNA1 stated that she and the resident reported to Facility Administrator and Social Services, and they stated they would Take care of it. In an interview with the Facility Administrator (FA) on 07/19/23 at 1:58 PM in the conference room, FA stated that R1 went out to the hospital on 02/23/23, and returned on 03/01/23. FA stated that upon return from the hospital, R1 told staff and FA that she could not locate her phone. FA stated that staff assumed that R1 had taken her phone with her, however, she had not. The search did not locate the phone and R1's mother replaced the phone. FA stated on 04/19/23 the facility located the old phone in a drawer at the nurse's station and it was returned to R1. FA stated that once the resident charged the phone, R1 informed staff that she got on her mobile banking app and there had been a few withdrawals from R1's account on 02/28/23 totaling $750.00 ,which R1 was hospitalized during those transactions, and Police were notified and R1 notified her bank that she did not make those transactions because she had been in the hospital and the phone was not with her. FA stated bank refused to refund the money to R1 and he typed a letter stating R1 did not have the phone in her possession during hospitalization for the resident's bank. FA stated that he is unsure who would have been able to access R1's account as her phone was locked and at the time it was found it was dead. FA stated that all staff who had been working were interviewed and had no knowledge of when the phone was put at the nurse's station or any knowledge that it had not been with R1. FA stated that the facility could not substantiate the allegation and he did not feel it was his obligation to refund the resident her money back. FA stated that he encouraged R1 to obtain a lock box at her bedside for personal belonging and valuables. FA stated that he uses agency staff for housekeeping duties and confirmed that the housekeeper in question's middle name is XXX, and that the housekeeper quit on her own prior to the resident's return which was odd, she had given no reason why she just quit, so FA discontinued the contract with the agency. Interview with FA also revealed that there was no schedule or sign-in sheets for housekeeping the day the transactions were made, only nursing staff. Multiple attempts for a phone interview with Housekeeper on 07/19/23 were unsuccessful.

Based on observations, interviews, and review of facility policies the facility failed to store food in accordance with professional standards for food service safety; food items were not dated and labeled on two (2) of two (2) units. The findings include: Review of the facility policy entitled Food: Safe Handling for Foods from Visitors dated 7/2019 revealed facility staff will 4. Ensure that foods are in a sealed container to prevent cross contamination. Label foods with the resident's name and the current date. 5. Refrigerators/freezers for storage of foods brought in by visitors will be properly maintained . During an observation on 8/26/21 at 12:10 p.m. in the kitchen on the 200 Unit revealed an open box of doughnuts with no label, three (3) frozen meals with no labeling, crumbs in bins of refrigerator, dried brown substance covering bottom of refrigerator, pitcher of ice in freezer with no cover and no labeling. The observation was confirmed by the Registered Nurse (RN) Supervisor for the 200 Unit and the Kitchen Manager (KM). During an observation on 8/26/21 at 12:25 p.m. in the kitchen on the 100 Unit revealed a gallon-sized plastic bag with a disposable ice pack with no labeling, a partial drink from a restaurant on the counter with no labeling, juice box drink in the refrigerator with no label, and crumbs in the bins of the refrigerator. Licensed Practical Nurse (LPN) #1 confirmed the observation. In an interview on 8/26/21 at 12:30 p.m. the KM stated the refrigerators should not had any unlabeled, uncovered items that were observed as well as no food belonging to employees. The KM reported that s/he had checked the refrigerators that day, They should have not been in the condition in which they were observed.

Based on record review, interview and policy review, the facility failed to ensure one (1) of 23 sampled residents (Resident #101) was treated with dignity and respect during the provision of care. Staff did not include Resident #101 in conversation when providing care to her, resulting in the resident feeling disrespected. Findings include: Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact (Brief Interview for Mental Status score of 13 out of 15). Under the Mood section, the resident was assessed as feeling down/depressed. Under the Behavior section, the resident was assessed as exhibiting no behavioral concerns. The resident was impaired in range of motion (ROM) on one side for the upper extremities and on both sides for the lower extremities. She required extensive assistance with activities of daily living (ADLs) such as: bed mobility, dressing, toilet use, and hygiene. The resident was assessed as frequently incontinent of bowel and bladder. Review of the care plan dated 6/3/19 revealed the resident had a self-care deficit related to Spastic [DIAGNOSES REDACTED], muscle weakness, and lack of coordination. The care plan goal was for the resident to have her ADL needs met and to participate in care as her limitations allowed. Interventions in pertinent part were: assist with ADLs as needed; allow sufficient time to complete care; provide incontinence care after each incontinent episode; and explain all procedures prior to providing care. During an interview on [DATE] at 10:51 AM, the resident stated she was not treated with respect and explained she wore disposable incontinence briefs and stated two nurse aides worked together when changing her briefs. The resident stated, They talk back and forth to each other. They have their own conversation, like I am a mannequin. It is rude . If I chime in, they give me a dirty look. It happens about once a day. During the interview, the resident was observed lying in the bed with the head of the bed slightly elevated while wearing a hospital gown. The resident was writing on paper positioned on the over bed table. During an interview on [DATE] at 11:45 AM Certified Nurse Assistant (CNA) KK stated she had been frequently assigned to the resident and was familiar with her care. CNA KK stated the resident was telling the truth and that she had observed CNAs working with the resident, while having a conversation with each other that did not include the resident. CNA KK stated the CNAs were overlooking the fact that the behavior was rude. CNA KK stated she had no problems providing care to the resident; however, the resident had made accusations about staff that were not true and that was why there were always two (2) staff providing care to her. During an interview on [DATE] at 9:48 AM Registered Nurse (RN) DD stated both facility staff and agency staff provided care to residents while having conversations with each other and not with the residents. RN DD stated she had talked with the staff about this, but it still occurred. She stated there were a lot of agency nursing staff, indicating there were more agency staff today than regular staff. She stated this required continued education because different agency staff came to the facility. During an interview on at [DATE] at 10:42 AM the Director of Nursing (DON) stated staff should not be having conversations with each other that excluded residents when providing care. The DON stated staff were trained about this during orientation and during abuse training that occurred at least annually. The DON stated they had provided dignity inservices but could beef up the education and training to make it more interactive for staff. Policies and procedures related to dignity were requested; the document titled, Residents Rights (undated) was provided and revealed: You have the right to be treated with dignity and respect in a manner that promotes or enhances your quality of life.

Based on observation, record review, interview, and policy review, the facility failed to ensure one (1) of 23 sampled residents who received tube feeding (Resident #45), was administered tube feeding properly and in accordance with physician's orders [REDACTED].#45 to aspirate (accidental ingestion of a fluid or solid into the trachea and lungs). Findings include: Resident #45 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was moderately impaired in cognition with a Brief Interview for Mental Status (BI[CONDITION]) score of nine (9) out of 15. The resident was assessed with [REDACTED]. The resident required extensive assistance with bed mobility, dressing and toilet use. The resident was dependent on one (1) staff for eating and received nutrition via a feeding tube. The resident was 61 inches tall and weighed 337 pounds. Review of physician's orders [REDACTED]. -[MEDICATION NAME] Cal tube feeding formula at [AGE] ml. (milliliters)/hour continuously via [MEDEQUIP] (G) tube; -Flush G tube with 30 ml. water before and after medications per shift initiated on 3/28/18 -Flush G tube with 320 ml. water every 4 hours; -Make sure the Head of the Bed (HOB) is elevated during feeding; -The resident was not prescribed a diet or foods to be taken orally. Review of a Physician's Progress Note dated 12/12/19 revealed the resident was not oriented to time, place or person and her recent memory was abnormal. The resident received oxygen administered at three (3) liters per nasal cannula with good air exchange noted. The resident received nutrition via the feeding tube due to dysphagia. Review of the care plan initiated on [DATE] revealed the resident received enteral nutrition which placed her at risk for aspiration. The goal was to be free of complications from use of enteral nutrition and to maintain her weight. Care plan interventions directed staff to administer the tube feeding and water flushes in accordance with physician's orders [REDACTED]. Observations on [DATE] revealed the HOB was not elevated to a minimum of 30 degrees while the resident was being administered the tube feeding formula: -On [DATE] at 1:15 PM the resident was lying in a large bariatric bed, with an air mattress in place, with the HOB minimally elevated at less than 30 degrees (approximately 20 - 25 degrees). Oxygen was being administered via a nasal cannula. The tube feeding pump indicated the tube feeding formula ([MEDICATION NAME]) was being administered at a rate of [AGE] ml. per hour. The resident tossed her head back and forth intermittently, appearing agitated, and did not respond to the surveyor's introduction or attempt at conversation. -On [DATE] at 3:29 PM the HOB continued to be elevated minimally at approximately 20 - 25 degrees. The resident was lying with her torso slightly crossways on the mattress. The resident took gasping breaths and her eyes were closed; oxygen was being administered via the nasal cannula. The tube feeding formula continued to be administered at [AGE] ml. per hour. -On [DATE] at 4:10 PM the resident continued lying in the same position, slightly crossways in the bed elevated at approximately 20 - 25 degrees. The formula was being administered at [AGE] ml. per hour. The resident tossed her head back and forth several times, appearing agitated and gasping for breath. Registered Nurse (RN) II was asked to evaluate the resident and she came into the room. RN II stated the HOB was supposed to be elevated to 45 degrees and agreed it was elevated less than it should have been. RN II raised the HOB to greater than 30 degrees. The resident did not say anything or indicate she was uncomfortable, until RN II asked her after raising the bed if the height of the bed, if it was ok. The resident mumbled she liked the bed lower. RN II stated the resident generally preferred the HOB be kept lower; however, she kept the bed raised to approximately 30 degrees. -Observations on 1[DATE] and [DATE] revealed the resident was out of the facility, having been sent to the hospital. Review of a Health Status Note dated 1[DATE] at 8:48 AM revealed, Resident presents with labored breathing with congestion/rattling in lung fields via auscultation. [MEDICATION NAME] was given at 8:00 am for air hunger. Vital signs were obtained and the resident was sent to the hospital for evaluation as instructed by the Nurse Practitioner. Review of the hospital Emergency Department report dated 1[DATE] revealed the resident presented in the hospital with hypoxic [MEDICAL CONDITION] and critical laboratory results which required admission to the hospital. The resident remained in the hospital as of the survey exit on [DATE]. During an interview on [DATE] at approximately 10:30 AM Licensed Practical Nurse (LPN) JJ stated she sent the resident to the hospital on [DATE] due to breathing issues. She stated the resident required intubation due to labored breathing. She stated the facility had not received a full report on the resident's condition. During an interview on [DATE] at 11:41 a.m. Certified Nurse Assistant (CNA) KK stated Resident #45's HOB was supposed to be at 45 degrees when the tube feeding was being administered. She stated the nurses and CNAs were responsible to make sure it was at the correct angel (45 degrees). CNA KK stated the resident preferred the HOB be lower than 45 degrees; however, once she explained the reason the resident accepted the HOB of 45 degrees and did not continue to complain. CNA KK stated, Everyone is to make sure it is at 45 degrees. During an interview on [DATE] at 2:27 PM The Director of Therapy stated the HOB should be elevated to at least 30 degrees during tube feeding administration. She stated the resident had been on the Speech Therapy caseload in July of 2019 to attempt feeding trials, but the resident did not want to continue and was discharged from therapy on tube feeding. During an interview on 2/18/19 at 3:03 PM the Speech Therapist stated she was relatively new to the facility and had not worked with the resident in July 2019. She stated the HOB should be a minimum of 30 degrees while the tube feeding was being administered. She stated if the HOB was at less than 30 degrees, this could result in backflow of the formula and potential aspiration. During an interview on [DATE] at 9:36 AM RN DD stated there was no measuring device on the resident's bed and staff had to eye ball it when adjusting the HOB to achieve the correct angle. RN DD stated the resident was picky how she was positioned in the bed and did not always want her head elevated. RN DD stated the resident could not adjust the HOB herself and was dependent on staff to do this. RN DD stated the resident was not oriented and was frequently confused. RN DD stated staff tried to educate the resident about the need for the HOB to be elevated; however, they went by what the resident wanted. During an interview on [DATE] at 10:32 AM the Director of Nursing (DON) stated the resident had been admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The DON stated safety came first and the HOB should be elevated to the minimum safe level of 30 degrees when the tube feeding was being administered. She stated the resident was cognitively impaired and did not always understand the implications of care and treatment. Review of the facility's Tube Feeding Systems policy dated November 2019, revealed the purpose of the policy was to provide guidelines for the safe administration of tube feedings. For continuous feeding, staff were to elevate the head of the bed between 30 - 45 degrees for the duration of the feeding and for one (1) hour after administration.

Based on record review, policy review and staff interview, the facility failed to ensure that the medical records were complete and accurately documented for one (1) Resident out of twenty-three (23) sampled Residents with nutritional and hydration risks. (Resident #22) Findings Include: Review of Resident #22's Activities of Daily Living (ADL) Record Sheets for October, November and December 1st-15th,2019 revealed several incomplete areas for meal and fluid intake. An interview conducted on [DATE] at 9:46 AM with (CNA) Certified Nursing Assistant AA, the aide said we are responsible for recording all meal and fluid intakes on the Monthly Activity of Daily Living sheets. If there are blanks on the sheet staff did not fill them out. When ask if there were any blanks on the sheets, CNA AA stated yes. An interview conducted on [DATE] at 10:24 AM with Registered Nurse (RN) BB and revealed the Certified Nursing Assistant Activity of Daily Living sheet should be filled out daily. When there are blank areas on the sheets it's mostly agency staff. I agree there are days that are not filled out with missing information, the Director of Nursing is aware, and I think she has been working on that. An interview conducted on [DATE] at 11:03 AM with Nurse Practitioner (NP) CC revealed the NP made rounds in the facility 3-4 days a week working under the direction of the Medical director. I review Activity of Daily Living Sheets to determine adequate fluid intake for the residents; I agree there are a lot of blank areas not filled out daily. I like to look at them to determine adequate fluid intake for the residents. An Interview conducted on [DATE] at 9:57 AM with the Director of Nursing (DON) who stated she is aware of the missing documentation on the Activity of Daily Living Sheet and further acknowledged the missing areas on the charts. We had meetings and in-services about the importance of documenting on the resident's sheets. My expectation is that staff fill out the ADL sheets daily. We are starting a program called the ADL Champion that includes the required charting and expectations from our staff. The Agency staff have been included in the meetings as well. Things have gotten better, but we are not there yet. Review of the facility's Policy titled Medical Records dated November 2019, revealed the medical records are primarily in electronic format. The facility's vendor for electronic medical records is Point Click Care (PCC), which is a web-based computer system that relies on internet access. Includes the following: 1. Certified Nursing Assistant Activities of Daily Living Records are on Paper. S/S=D

Based on observations, interviews, clinical and closed record reviews, and review of facility policy, the facility's administration failed to thoroughly investigate four (4) alleged incidents of potential abuse/neglect related to injuries of unknown origins and sexual assault as required for five (5) of 34 sampled residents (Resident #7, #8, #13, #20 and #21). 1. Resident #13's alleged incident of injury of unknown origin (right femur fracture) that occurred on 9/18/18. 2. Resident #20's alleged injury of unknown origin (left ankle fracture) that occurred on 9/2/19. 3. Resident #21's alleged injury of unknown origin (right-hand fracture) that occurred on 10/12/19. 4. Resident #7 sexually assaulted Resident #8 on 8/23/18. The facility did not interview other residents as part of their investigation to determine if Resident #7 has assaulted any other resident. Therefore, this deficiency is cited at a harm level. The findings included: Review of the facility's Reporting of Alleged Abuse to Facility Management policy revised 8/19, defines an injury of unknown source as an injury that meets both of the following conditions: 1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and 2) The injury is suspicious because of: a) The extent of the injury; or b) The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma; or c) The number of injuries observed at one (1) point in time; or d) The incidence of injuries over time. Review of the facility's Abuse Investigations policy revised 8/19, noted All reports of alleged resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Guidelines: 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2. The individual conducting the investigation will, as a minimum: a. Review the resident's medical record to determine events leading up to the alleged incident; b. Interview the person (s) reporting the incident; c. Interview any witnesses to the incident; d. Interview the resident (as medically appropriate); e. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; f. Interview the roommate (as medically appropriate). Family members and visitors; g. Interview the resident's attending physician as needed to determine the resident's level current level of cognitive function and medical condition; h. Interview other residents with whom the individual provides care or services and/or interacts; and i. Review all events leading up to the alleged incident. 3. Witness reports will be obtained in writing. Witnesses will be required to sign and date reports. 1. Review of Resident #13's clinical record reveled an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. According to the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #13 was severely cognitively impaired, having scored zero (0) out of 15 on the Brief Interview for Mental Status (BI[CONDITION]) assessment. The MDS noted the resident was assessed to be totally dependent on two (2) person staff assist for activities of daily living (ADLs) such as bed mobility, eating, transfer, dressing, eating, toilet use, personal hygiene and bathing. Resident #13 required the supervision of one staff person for locomotion when off the unit as resident requires two (2) person mechanical lift to be up in wheelchair for short periods of time. Review of Resident #13's care plan addressing Staff Assistance with all Activities of Daily Living (ADLs) related to Impaired Cognition and Left-Sided Weakness initiated 7/1/18, revealed the resident has a history of aggression with staff during provision of ADL care. Some of the interventions in place to address this focus area were, as follows: - Give clear explanation of all care activities prior to and as they occur during each contact. - If resident resists with ADLs, reproach later to offer care. - Praise the resident when behavior is appropriate. - Frequent observation for safety. - Allow enough time to complete tasks. Review of Resident #13's Progress Notes revealed on 9/18/18, During morning report, Licensed Practical Nurse (LPN) #9 was made aware of swollen right inner thigh and that an x-ray had been obtained during 1st shift for Resident #13. LPN #9 was unaware of anything had happened to Resident #13 other than what was given in report. Later that day, LPN #9 obtained a report from x-ray with abnormal results. The x-ray indicated a fractured deformity of right proximal femoral shaft of unknown age with no dislocation. LPN # 9 informed the Director of Nursing (DON) who informed the Administrator. The Nurse Practitioner (NP) as well as Resident #13's Responsible Party (RP) were also notified. The NP gave an order to send Resident #13 to the hospital for evaluation. Review of Resident #13's Progress Note on 9/18/18, that morning (6:39 AM), indicated Nurse called from the hospital to give report for resident to return to the facility and confirmed [MEDICAL CONDITION] leg and not recent due to significant amount of [DIAGNOSES REDACTED] around area. Hospital staff, physician and nurse spoke with RP and NP regarding x-ray and information obtained at this time and family agrees no reason for surgery considering resident (#13) is not weight bearing. Review of Resident #13's x-ray results dated 9/17/18, indicated a fracture deformity of the right proximal femoral shaft of unknown age. On 12/11/19 at 10:15 AM, Resident #13 was observed lying in bed and did not respond when called by name. The resident was not able to respond to simple conversation related to his cognitive status. During an interview on 12/11/19 at 11:47 AM, LPN #8 stated she was the nurse on the medication cart. She was asked by Certified Nursing Assistant (CNA) #10 to come and assess Resident #13. CNA #10 stated while she and another CNA (#12) were turning Resident #13 to his left side, he cried out in pain. CNA #10 stated she had also noticed bruising to the right hip. During an interview on 12/11/19 at 1:47 PM, CNA #10 stated she and CNA #12 went into Resident #13's room on 9/18/19 around 10 p.m. to provide care. When I turned the resident to his left side, he let out a scream and had bruising to his right hip. I got the nurse to look at him. During an interview on 12/11/19 at 1:58 PM, CNA #12 confirmed she had gone in Resident #13's room to help CNA #10 provide care to the resident. The resident (#13) shouted out in pain when we turned him. On 12/12/19 at 8:55 AM an interview was conducted with the CNA (#13) who provided care to Resident #13 during the night shift on 9/18/18. CNA #13 stated I do not remember anything, don't know anything. Review of the Investigative File which contained the Initial 24 Hour (dated 9/18/18) and Five-Day Follow-Up (dated 9/21/18) Reports indicated the following summary: Resident (#13) noted to have pain to his right leg during ADL (Activities of Daily Living) care and an x-ray was obtained. X-ray revealed a subacute right femur fracture. Resident was assessed and sent to the emergency room (ER). MD (Doctor of Medicine), RP and police notified. At the conclusion of the investigation to include staff interviews and medical review the injury was most likely caused by resident's combative behavior during care. Staff educated to include two (2) person assist with ADL care. Care plan reviewed and revised to include pain management as resident is not an operative candidate. Included in the file were numerous staff statements stating no knowledge of how Resident #13 obtained his right leg fracture. The file contained no interviews of follow-up interviews with other residents, family, visitors, physician Resident #13's roommate or a listing of staff who worked shifts prior to the finding along with who might have additional information to determine how the incident occurred. The staff statements in the file did not contain times and locations of the interviews. On 12/12/19 at 2:10 PM, an interview was conducted with the Administrator, who was the Abuse Coordinator, to try and establish a timeframe for the series of events leading up to Resident #13's right leg fracture. When asked the Administrator provided the following timeline: - CNA #10 alerted the nurse during 1st shift that resident (#13) yelling during care on 9/17/18. - Nurse #8 (no longer employed) received an order for [REDACTED]. - Mobilex obtained report and results sent to facility on 9/17/18 at time of 19:26 (7:26 PM) - Order obtained to send resident to the hospital for further evaluation on 9/18/18. - Interact (change in condition form) completed on 9/18/18 by Nurse #8. - Staff statements acquired on 9/8/18 to include 11-7 shift on 9-17-18 and 3-11 shift 9/18/18. The administrator, during the interview, was unable to provide any documentation of events and interviews prior to the reporting of Resident #13's fracture. The administrator did state there had been a Risk Manager (RM) who conducted most of the of the investigations at that time and no longer was employed at the facility. During an interview with the RM (no long employed) on 12/12/19 at 2:45 PM, she stated she had filled the position of RM from 8/18 through 10/18 and reported all documentation directly to the Administrator. She was unable to provide specific details regarding Resident #13's injury of unknown origin investigation. 2. Review of Resident #20's closed record indicated the resident's original admitted was 8/26/11 and readmitted [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #20 passed away on 12/3/19, related to [MEDICAL CONDITION]. According to the resident's Quarterly MDS assessment dated [DATE], Resident #20 was severely cognitively impaired, having scored three (3) out of 15 on the BI[CONDITION] assessment. The MDS noted the resident was assessed to be totally dependent on two (2) person staff assist for ADLs such as bed mobility, eating, transfer, dressing, eating, toilet use, personal hygiene and bathing. Resident #20 required the supervision of one staff person for locomotion when off the unit. The resident was coded to be incontinent of bowel and bladder and was mostly bed bound. Review of Resident #20's care plan addressing Alteration in Comfort/Pain related to pain, discoloration and swelling of left foot. Some of the interventions in place to address this focus area were, as follows: - Administer pain medication as ordered. - Adjust daily schedule as needed related to degree of pain. - Assist with repositioning for increased comfort. - Frequent observation for safety. - Observe for signs/symptoms of pain or discomfort. Review of Resident #20's Progress Notes revealed on 9/1/19, indicated LPN #31 Called to resident's (#20) room by CNA (#30) to look at resident's left foot. Upon assessment the resident (#20) was in tears and wheezing. Resident's left foot was swollen, blue in color around the outside of the left ankle, and inside of the left ankle. Resident is pointing at foot and crying then pointing at the wheelchair. When asked if she hit her foot on the wheelchair, resident responded by nodding her head yes. Review of Resident #20's Progress Note dated 9/1/19, indicated LPN #31 had notified the NP who ordered an X-ray of left ankle scheduled with Mobile-X for 9/1/19. Review of Resident #20's Progress Note dated 9/2/19, indicated the DON had reviewed the results of the x-ray to be a fracture to the left ankle. Resident #20 returned to the facility the same day with a splint in place to her left leg/foot and continued to be up in her wheelchair. Review of Resident #20's X-ray results dated 9/2/19, indicated a [MEDICAL CONDITION] left fibula with no displacement. Resident #20 could not be interviewed due to passing away on 12/3/19, related to [MEDICAL CONDITION]. During an interview on 12/11/19 at 3:10 PM, CNA #40 indicated she and another CNA (#41) were providing care for Resident #20. The resident was able to turn and did not express any indication of discomfort. Before we left the room, Resident #20 asked me to find her nurse as she needed pain medication. I found the nurse on duty at the time and relayed Resident #20's request to her. I don't remember who that nurse was. During an interview on 12/11/19 at 3:47 PM, CNA #41 confirmed that she did assist CNA #40 with Resident #20's care. The resident asked us to get her nurse as she needed pain medication. I am not sure who that nurse was. On 12/12/19 at 2:10 PM, during an interview regarding Resident #20's injury, the Administrator provided the following timeline: - 9/2/19, Resident (#20), complained of leg pain, after nurse assessment (no name provided). - 9/2/19, MD notified, and an order received for x-ray due to leg pain. - 9/2/19, Results obtained from x-ray-Left Leg Ankle Fracture. - Resident #20 sent to the hospital for further evaluation and treatment. - 9/2/19, Police notified of injury and 24-Hour Report initiated. - 9/3/19, Skin assessment done upon return from the hospital. - 9/3, 4, and 5/19, Psychosocial follow-up. During the interview, the Administrator was unable to explain why there had not been any documentation of a thorough investigation including interviews and review of events leading up to nursing receiving a report that Resident #20 had already been injured. Review of the Investigative File which contained the Initial 24 Hour (dated 9/2/19) and Five-Day Follow-Up (dated 9/6/19) Reports indicated the following summary: Resident (#20) complained of left leg pain. Upon assessment of the x-Ray revealed a left ankle fracture with leg swelling and discoloration noted. After x-Ray results, RP and police notified. Resident (#20) was sent to the hospital for further evaluation. Psychosocial support provided to the resident. Upon completion of the investigation, including staff resident statements and record review, it was determined that during transfer the resident's leg may have twisted or gotten tangled while staff was assisting. Full lift transfer and therapy to evaluate and treat as needed. No additional documentation was provided to substantiate the above conclusion. 3. Review of resident #21's record indicated the resident's original admitted was 4/5/18. The resident's [DIAGNOSES REDACTED]. According to the resident's Quarterly MDS assessment dated [DATE], Resident #21 was severely cognitively impaired, having scored three (3) out of 15 on the BI[CONDITION] assessment. The MDS noted the resident was assessed to be totally dependent on two (2) person staff assist for ADLs such as bed mobility, eating, transfer, dressing, eating, toilet use, personal hygiene and bathing. Resident #21 required the supervision of one staff person for locomotion when off the unit. The resident was coded to be incontinent of bowel and bladder and was mostly bed bound. Review of Resident #21's Care Plan dated 9/2/19, titled Self-Care Deficit related to Dementia, Generalized Weakness and Pain. addressed the resident's need for total care. along with pain, discoloration and swelling of the right hand. Some of the interventions in place to address this focus area were, as follows: - Administer pain medication as ordered. - Adjust daily schedule as needed related to degree of pain. - Assist with repositioning for increased comfort. - Frequent observation for safety. - Observe for signs/symptoms of pain or discomfort. Review of Resident #21's Progress Notes dated 10/10/19, indicated staff alerted RN #50 that the resident was seizing. Two (2) minutes of [MEDICAL CONDITION] activity noted. Review of Resident #21's Progress Note dated 10/10/19, indicated the resident was sent out to the hospital for evaluation following the [MEDICAL CONDITION]. Review of Resident #21's Progress Note dated 10/10/19, indicated Resident #21 returned from the hospital the same day with no new orders. She was assessed by nursing to have a bandage on her right wrist from a blood draw at the hospital. The bandage was removed by nursing as the resident's (#21) right wrist was red and swollen. Review of Resident #21's Progress Note dated 10/11/19, indicated Resident #21 was grimacing (nonverbal) from pain and a x-ray was ordered. Review of Resident #21's x-ray results dated 10/12/19, indicated an impacted radial fracture to the right hand/arm. Resident #21 was sent to the hospital for casting and returned to the facility on [DATE]. On 12/11/19 at 1:15 PM, Resident #21 was observed lying in bed. The resident was not able to respond to simple conversation related to her cognitive status. She was only able to make grunting sounds. During an interview on 12/11/19 at 4:10 PM, CNA #51 indicated when she came to work (not sure of the date) the resident's right arm (#21) was already splinted. On 12/11/19, several CNA's were interviewed regarding Resident #21's injury. None of the CNA's interviewed were able to provide additional information. On 12/11/19 at 5:01 PM, an interview was with Resident #21's roommate, who was alert and oriented and, in the room, when the [MEDICAL CONDITION] occurred. The roommate confirmed the resident (#21) had a [MEDICAL CONDITION] and was sent out to the hospital. When she returned there was a bandage around her right wrist which was removed by nursing. Sometime after that, she (Resident #21) began to scream in pain, received an X-ray and was sent to the hospital for casting. The roommate provided vital information regarding Resident #21's injury. Her interview statement was not in the investigation file as part of the fact-finding evidence to substantiate what exactly had happened During an interview on 12/12/19 at 3:45 PM, the Medical Director stated, It is very important that the facility conducts a complete and thorough investigation to ensure the safety of all residents. Sometimes accidents happen when care is provided and there should be the understanding that all staff is to report any incidents as mandated reporters. On 12/12/19 at 1:35 PM, during an interview regarding Resident #21's injury, the Administrator provided the following timeline: 9:03 AM, [MEDICAL CONDITION] activity noted on 10/10/19. - Sent out at 9:24 AM, and returned 3:26 PM, on 10/10/19, with an Ace bandage on her wrist from the hospital with no discharge instructions as it relates to care. - Resident returned to the facility on [DATE] at 9:33 PM, with no new orders. - 10/11/19 at 8:07 AM, bandage removed per resident's complaint it was too tight. - 10/11/19 at 6:50 PM, noted redness and swelling to right hand. Nurse notified NP and order of x-ray. - At 9:59 PM, administrator notified police via email of the injury on 10/12/19. - X-Ray that was on 10/12/19, that revealed acute fracture involving right distal radius. 23:11 (11:11 PM), results sent to facility. Verbally notified by DON at 9:30 PM - Transferred to hospital per MD order on 10/13/19 at 12:26 PM. - 10/13/19 at 3:40 AM, returned with soft cast noted to right forearm, with follow-up with ortho 3-4 day - 10/17/19, Roommate interview by social services indicated the resident (#21) was fine when transported to the hospital. Review on 12/12/19, of the timeline, record review and interviews reflect discrepancies in the investigation of Resident #21's injury. Review of the Investigative File which contained the Initial 24 Hour (dated 10/12/19) and Five-Day Follow-Up (dated 10/17/19) Report including staff and residents indicated the following summary: During resident assessment (#21) observed resident wrist swollen, X-Ray revealed fracture involving the distal radius. X-Ray results right wrist fracture. Notified RP, MD and police. Upon completion of investigation most likely cause was during a [MEDICAL CONDITION], the resident's (#21) right wrist may have twisted or gotten tangled while staff was assisting. Care plan was reviewed and updated to include padded side rail and therapy to evaluate and treat as needed. No additional documentation was provided as part of the investigation to substantiate the above conclusion. In an interview on 12/12/19 at 11:15 AM, the Administrator indicated he follows the abuse policy 8/19/19, but may have not completed all documentation and interviews to arrive at the root cause of the above resident injuries. 4. A review of Resident #7's face sheet dated 12/12/19 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's face sheet dated 12/12/19 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility reported incident dated 8/23/18 revealed CNAs #4 and #12 witnessed Resident #7 wheel up to Resident #8, who was in her wheelchair in the television area. CNAs #4 and #12 witnessed Resident #7 stroke Resident #8's thigh and groin area. CNA #12 wrote in her statement that Resident #7 was patting between his legs and saying he wanted some (name for female genitalia). The investigation did not include evidence of any interviews with other residents on Resident #7's unit to see if any other incidents had occurred. In an interview on 12/11/19 at 5:04 PM, the administrator stated there were no interviews done with other residents on Resident #7's unit, that it had not occurred to them to do the interviews. 5. Review on 12/12/19, of sexual abuse and injuries of unknown origin for Resident #'s 7, 8, 13, 20, and 21 were incomplete regarding guidelines listed above for Abuse Investigations per facility policy that include: Review of medical records for events leading up to injury, interviews with person reporting incident, any witnesses, resident(s) (if medically feasible), staff on all shifts, roommate, family, visitors and the physician along with a timeline to determine who, what, where, when and why the injuries occurred.

Based on record review and interviews, the facility failed to implement abuse policy for 2 of 6 residents reviewed for behaviors and 1 of 5 reportable incidents reviewed. Resident #28, #86 and #94. The findings included: Cross refer to F223 related to resident #86 with repeated abuse of roommates. Resident with long history of Paranoid [MEDICAL CONDITION] with repeated hospitalization s for behaviors, was allowed to return to facility and continued to room with other residents. Resident #86 abusive behaviors continued towards roommates. The findings included: The facility reported an allegation of physical abuse for Resident #28 on 2/6/17. The facility's Five-Day Follow-Up Report indicated on 2/5/17 at 6:28 PM CNA #4 pushed the chair that the resident was sitting in down the hallway and let it go. The chair was moving at a quick rate of speed and hit the wall. Further review of the medical record revealed the Significant Change Minimum Data Set ((MDS) dated [DATE] coded Resident #28 as having a Brief Interview for Mental Status score of 12. The Significant Change MDS coded Resident #28 as totally dependent for transfers, dressing, hygiene and bed mobility with no behaviors coded as occurring during the assessment period. Review of Resident #28's care plan revealed alteration in behavior due to dementia with behavioral disturbance was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to maintain a calm, unhurried environment. LPN #6's facility-obtained statement dated 2/5/17 indicated s/he was in the hallway with LPN #8 and LPN #9. CNA #4 was pushing Resident #28 in his/her wheelchair toward them. CNA #4 stated the resident had called him/her a black [***] and that they needed to do something with the resident. LPN #6 told CNA #4 that s/he needed to take the resident to his/her nurse because they were passing medications. In an interview with the surveyor on 4/25/17 at approximately 4:15 PM, LPN #6 stated s/he was training LPN #8 and LPN #9 and they were doing the last medication pass around 5:30 PM. They were in the hallway in the area of Rms 101-106. CNA #4 was pushing Resident #28 down the hall. CNA #4 said y'all need to get him/her. LPN #6 told CNA #4 s/he needed to take the resident to his/her nurse since they were doing medication pass. CNA #4 let go of the wheelchair, but LPN #6 was turning away at the time and didn't see what happened. LPN #6 heard LPN #9 yell out, thought the resident had hit him/her. Resident #28 had made a derogatory statement toward CNA #4 and s/he was mad about what the resident said. LPN #6 said it had something to do with race but s/he can't remember exactly what. CNA #4 came up and said you need to take the resident because of what s/he said. LPN #6 stated s/he never heard Resident #28 say anything derogatory to staff. LPN #7's facility-obtained statement dated 2/5/17 indicated s/he witnessed the incident, as much as s/he could see. LPN #7 was at the nurses' desk charting. CNA #4 got Resident #28 and pulled his/her rock-n-glide wheelchair down to the other nurse and 2 orientees. When CNA #4 let go of the chair it turned and bumped the wall with the foot of the chair. Resident #28 did not have his/her feet on that part of the chair and s/he didn't express any harm or injury. LPN #7 went and got the resident and put him/her at the nurses' desk. LPN #8's facility-obtained statement dated 2/5/17 indicated s/he heard CNA #4 say something such as Get (him/her) away from me or Keep (him/her) away from me. LPN #8 was standing at the medication cart, CNA #4 was pushing Resident #28 down the hall. CNA #4 stopped walking and Resident #28 kept rolling down the hall unassisted at a pretty quick rate of speed. Resident #28's wheelchair veered right towards the wall and spun around and crashed into the wall. It was a pretty hard impact, but LPN #8 didn't believe the resident was injured. Resident #28 seemed kind of scared. LPN #8 continued passing medications. An interview with LPN #8 was documented on his/her facility-obtained statement. The interview indicated LPN #6 told CNA #4 to take Resident #28 to LPN #7, his/her nurse. Then s/he came back pushing Resident #28 and let the wheelchair go. Resident #28 grabbed the wheel and the chair spun around to the right hitting the wall. Resident #28 appeared very scared of what happened. LPN #9's facility-obtained statement dated 2/5/17 indicated s/he was at the medication cart when CNA #4 pushed Resident #28 down the hall and his/her wheelchair spun around and hit the wall. CNA #4 walked away and the resident said help me. Then LPN #7 came and pushed the resident to sit at the nurses' desk. CNA #4's facility-obtained statement indicated s/he went to get Resident #28 from his/her room and pushed him/her to LPN #6. Resident #28 hit another nurse in the leg. LPN #6 told CNA #4 to take Resident #28 to his/her nurse, LPN #7. CNA #4 walked away. CNA #4 indicated Resident #28 called him/her a stupid black [***] . In an interview with the surveyor on 4/27/17 at approximately 4:22 PM, the DON (Director of Nursing) stated Resident #28 calls out for help a lot, wants to get up and then down. Resident #28 is endstage Alzheimer's. Resident #28 is combative with staff at times. S/he is repetitive - help me/help, take me to my room. When you don't do what the resident wants you to do, s/he becomes mean with staff. When Resident #28 becomes mean, s/he reverts to 1960's language that is not appropriate. CNA #4 had worked with the resident before. S/he was his/her 1:1 sitter. The DON received a call about the incident, thinks it was in the evening. The DON was told that CNA #4 had gotten mad because Resident #28 said something inappropriate and s/he pushed him/her into the wall. CNA #4 had lost his/her cool, s/he pushed the wheelchair and let it go. CNA #4 said y'all need to take him/her to a nurse and 2 trainees who were passing medications. The nurse who CNA #4 went to responded can you take him/her to the nurses' station to his/her nurse. Review of the facility's Abuse Prevention Program revealed physical abuse of the resident is prohibited. The policy indicated staff receives orientation and on-going training on appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, how to recognize signs of burnout, frustration and stress that may lead to abuse. The facility reported an allegation of resident to resident physical abuse involving Resident #94 on 2/14/17 for an incident that occurred on 2/13/17 at 7:55 PM. Review of the facility's Five-Day Follow-Up Report dated 2/16/17 revealed Resident #94 approached Resident #12 in the hall and hit him/her on the shoulder. After completion of the investigation the event did occur. Resident #94 placed on 1:1 staff observation. Care plan reviewed and updated. The facility also previously reported Resident #94 to the State Agency for abuse of Resident C (12/16/16) and Resident B (1/12/17). Each time the resident was care planned for 1:1 supervision. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the care plan revealed alteration in behavior as evidenced by verbal and physical aggression towards others was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included 1:1 supervision as ordered, and psych consult as ordered (2/22/17). The date initiated for the care plan was 12/5/16 with revision date of 3/2/17. On 2/13/17 the care plan indicated to separate from Resident #12, 1:1 supervision. The care plan did not include Resident #94's other incidents. Review of Resident #94's Nurse's Notes revealed no entry for Resident #94 between 10/25/16 and 11/17/16. Review of the Nurses' Notes dated 11/17/16 indicated resident without behavior. Sitter on 1st and 3rd shift discontinued. Sitter on 2nd shift will continue. On 1/12/17 at 2200 another resident approached the nurses' station stating (Resident #94) came into my room through the bathroom and grabbed my arm and twisted it. Resident removed from the room by staff. 1:1 sitter stated that the resident had went into the bathroom and then went into the neighboring room. On 2/13/17 at 7:55 PM resident was seen approaching another resident and hitting him/her on the shoulder. Resident was put on 1:1 with a sitter. Review of the resident's Physician Telephone Order dated 2/22/17 revealed an order for [REDACTED]. The resident was noted to still have periods of combative behaviors. The plan was to continue medications and behavior management. Will request psych consult as well for any additional input. Continue 1:1 observation. Review of Resident #94's medical record revealed only 3 physician progress notes [REDACTED]. The resident was seen on 10/27/16 and no visit reason was noted. The resident was seen on 4/26/17 for significant weight loss. Noted resident still has periods of aggressive behavior. Review of Resident #94's Social Progress Notes from 11/9/16-4/28/17 revealed an entry dated 12/16/16 that indicated the resident was observed punching another resident in the dining room. Resident was redirected with no further aggressive behavior noted. There were no additional social service notes related to the other incidents the resident was involved in. Review of the Incident Report dated 11/12/16 revealed it was reported to the nurse by a CNA that Resident #94 struck Resident A on 11/11/16. The note on 11/15/16 indicated communication with Resident A, no injury to hand. Resident #94 patted him/her on the hand but didn't hit him/her. Review of the Incident Report dated 12/4/16 revealed it was reported that Resident #94 went into Resident B's room and the resident asked him/her to leave. The resident's sitter tried redirecting him/her and s/he then punched the sitter in the chin. The nurse entered the room and the resident punched him/her 3 times in the arm. The note on 12/5/16 indicated 1:1 sitter. Review of the Incident Report dated 12/16/16 revealed Resident #94 punched another resident in the face while in the dining room. The note on 12/28/16 indicated resident to remain 1:1 with education to sitter to ensure the resident is within arms reach and resident will not be allowed in the dining room during meals. Resident #94 was noted to be on 1:1 supervision at the time of the incident. Review of the Incident Report dated 1/12/17 revealed Resident B approached the nurses' station and stated that another resident had come into his/her room through the bathroom. Resident B stated that Resident #94 grabbed his/her right arm and twisted it. Resident #94 was on 1:1 supervision at the time of the incident. Review of the Incident Report dated 2/13/17 revealed Resident #94 hit Resident #12 on the right arm. The note dated 2/14/17 indicated Resident #94 was placed on 1:1 staff supervision. Resident was noted to already be on 1:1 supervision at the time of the incident. CNA #5's facility-obtained statement dated 2/13/17 indicated Resident #94 was walking around on Peach wing and hit Resident #12 in his/her shoulder. Resident #94 was agitated. CNA #3's facility-obtained statement dated 2/13/17 indicated Resident #94 walked up to Resident #12 and punched him/her in the arm and kept walking. In an interview with the surveyor on 4/25/17 at approximately 4:25 PM, CNA #3 stated Resident #94 was walking by and s/he threw his/her hand and hit Resident #12 on his/her shoulder. Resident #12 was standing in the common area near the nurses' station, Resident #94 was walking by. CNA #3 stated Resident #94 will try to hit staff and residents. CNA #3 stated Resident #94 has been that way since s/he has been at the facility. CNA #3 stated you never know when the resident is going to strike out. In an interview with the surveyor on 4/25/17 at approximately 12:10 PM, LPN #1 stated s/he is usually assigned to Resident #94. LPN #1 stated you have to monitor him/her and watch him/her closely. LPN #1 stated sometimes Resident #944 can be hard to redirect. When trying to redirect him/her, sometimes s/he will swing. LPN #1 stated Resident #94 has hit residents and staff. Sometimes s/he will hit residents, comes out of nowhere. LPN #1 stated you can't always tell when the resident is about to hit someone. LPN #1 stated s/he was at the facility when the resident hit Resident #12, but did not witness it. Resident #94 was roaming around, the CNA from the other hall came and told LPN #1 that Resident #94 walked up to Resident #12 and hit him/her. The CNA brought Resident #94 back to the unit to LPN #1. Resident #94 had a 1:1 sitter to monitor him/her. LPN #1 stated Resident #94 doesn't have a sitter on 1st shift, but does have one on 2nd shift. LPN #1 stated Resident #94 tends to get up more in the evening. In an interview with the surveyor on 4/27/17 at approximately 4:30 PM, the DON (Director of Nursing) stated Resident #94 wanders around the whole facility. The DON stated if you approach the resident calmly s/he is fine. If aggressive, he lashes out. The DON stated Resident #94 hit Resident B, Resident C, and Resident #12. The DON stated Resident #94 was on 1:1 when some of the incidents occurred. The DON stated Resident #94 had been on 1:1 since s/he got to the facility almost a year ago. He is on 1:1 more than he is off. The DON stated they did reeducation with staff on 1:1 and what the criteria is for 1:1. The DON stated 1:1 is documented in the nurses notes. The DON stated 1:1 is a nurse driven initiation and not a physician's orders [REDACTED].>In an interview with the surveyor on 4/27/17 at approximately 5:05 PM, the facility administrator stated Resident #94 did not have any psych notes that s/he could find. The facility administrator stated that s/he called the psychiatrist and they have no documentation of seeing Resident #94. In an interview with the surveyor on 4/27/17 at approximately 5:25 PM, the DON stated s/he is not sure why the psych consult wasn't done. The DON stated usually the Social Services Director puts the consult on the psych list and the psychiatrist will see on their next visit. The DON confirmed the psychiatrist has been in the building since the physician order [REDACTED].#94 to have a psych consult. The surveyor requested multiple times during the survey any policies related to how to handle combative residents and staff inservicing on 1:1. The information was not provided to the surveyor prior to exit on the last day of the survey. Review of the facility's Abuse Prevention Program revealed if a resident is observed exhbiting any form of abuse towards another resident, staff will intervene immediately. Residents will be closely monitored. Social services will be notified for follow up and continued monitoring. Care plans will be updated as needed. If the alleged abuse involves another resident, there may be restrictions on the accused resident's ability to visit other resident's rooms unattended.

Based on review of facility files and interview, the facility failed to provide medically-related social services to maintain the highest practicable physical, mental and psychosocial well-being of each resident. Resident #94 was noted to have behaviors of hitting other residents. The social worker did not document all of the incidents and the social interventions for the resident. The social worker did not follow-up with Resident #12 after s/he was hit by Resident #94. The social worker failed to ensure that Resident #94 was seen by psych per the resident's physician order. Two of three residents reviewed for social services. The findings included: The facility reported an allegation of resident to resident physical abuse involving Resident #94 on 2/14/17 for an incident that occurred on 2/13/17 at 7:55 PM. Review of the facility's Five-Day Follow-Up Report dated 2/16/17 revealed Resident #94 approached Resident #12 in the hall and hit him/her on the shoulder. After completion of the investigation the event did occur. Resident #94 placed on 1:1 staff observation. Care plan reviewed and updated. The facility also previously reported Resident #94 to the State Agency for abuse of Resident C (12/16/16) and Resident B (1/12/17). Each time the resident was care planned for 1:1 supervision. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's Physician Telephone Order dated 2/22/17 revealed an order for [REDACTED]. Review of the physician progress notes [REDACTED]. The resident was noted to still have periods of combative behaviors. The plan was to continue medications and behavior management. Will request psych consult as well for any additional input. Continue 1:1 observation. Review of Resident #94's Social Progress Notes from 11/9/16-4/28/17 revealed an entry dated 12/16/16 that indicated the resident was observed punching another resident in the dining room. Resident was redirected with no further aggressive behavior noted. There were no additional social service notes related to the other incidents the resident was involved in. Review of the Incident Report dated 11/12/16 revealed it was reported to the nurse by a CNA that Resident #94 struck Resident A on 11/11/16. The note on 11/15/16 indicated communication with Resident A, no injury to hand. Resident #94 patted him/her on the hand but didn't hit him/her. Review of the Incident Report dated 12/4/16 revealed it was reported that Resident #94 went into Resident B's room and the resident asked him/her to leave. The resident's sitter tried redirecting him/her and s/he then punched the sitter in the chin. The nurse entered the room and the resident punched him/her 3 times in the arm. The note on 12/5/16 indicated 1:1 sitter. Review of the Incident Report dated 12/16/16 revealed Resident #94 punched another resident in the face while in the dining room. The note on 12/28/16 indicated resident to remain 1:1 with education to sitter to ensure the resident is within arms reach and resident will not be allowed in the dining room during meals. Resident #94 was noted to be on 1:1 supervision at the time of the incident. Review of the Incident Report dated 1/12/17 revealed Resident B approached the nurses' station and stated that another resident had come into his/her room through the bathroom. Resident B stated that Resident #94 grabbed his/her right arm and twisted it. Resident #94 was on 1:1 supervision at the time of the incident. Review of the Incident Report dated 2/13/17 revealed Resident #94 hit Resident #12 on the right arm. The note dated 2/14/17 indicated Resident #94 was placed on 1:1 staff supervision. Resident was noted to already be on 1:1 supervision at the time of the incident. Review of Resident #12's Social Progress Notes revealed there was no documentation that social services followed up with the resident after the incident. In an interview with the surveyor on 4/27/17 at approximately 4:30 PM, the DON (Director of Nursing) stated Resident #94 wanders around the whole facility. The DON stated if you approach the resident calmly s/he is fine. If aggressive, he lashes out. The DON stated Resident #94 hit Resident B, Resident C, and Resident #12. The DON stated Resident #94 was on 1:1 when some of the incidents occurred. The DON stated Resident #94 had been on 1:1 since s/he got to the facility almost a year ago. He is on 1:1 more than he is off. The DON stated they did reeducation with staff on 1:1 and what the criteria is for 1:1. The DON stated 1:1 is documented in the nurses notes. The DON stated 1:1 is a nurse driven initiation and not a physician's orders [REDACTED].>In an interview with the surveyor on 4/27/17 at approximately 5:05 PM, the facility administrator stated Resident #94 did not have any psych notes that s/he could find. The facility administrator stated that s/he called the psychiatrist and they have no documentation of seeing Resident #94. In an interview with the surveyor on 4/27/17 at approximately 5:25 PM, the DON stated s/he is not sure why the psych consult wasn't done. The DON stated usually the Social Services Director puts the consult on the psych list and the psychiatrist will see on their next visit. The DON confirmed the psychiatrist has been in the building since the physician order [REDACTED].#94 to have a psych consult. Review of the facility's Abuse Prevention Program revealed follow-up of abuse allegations. Social Service will follow up with the resident to monitor resident's emotional well-being following the incident. Referrals to Psychological/Psychiatric services will be made as needed. On April 27, 2017 the Administrator was notified the facility was in Immediate Jeopardy and/or Substandard Quality of Care. The Immediate Jeopardy existed in the facility as of December 16, 2016 related to the following citation: 483.40 (d) F250 Medically related Social Services - As it relates to the failure of the facility to ensure a resident with aggressive behaviors was seen for a psychiatric evaluation ordered by the physician and other residents abused by this same resident were followed up for any issues resulting from the aggressive behaviors. An Allegation of Compliance (AOC) was provided by the facility to the survey team with a completion date of 4/28/2017. The AOC included the following: 1. Residents #86 and #94 were ordered by the physician to be sent out for psychiatric evaluation. Resident #86 was sent out on 4/27/17 and Resident #94 was sent out in the AM of 4/28/17. 2. The facility Social Services Director completed resident interviews on 4/27/17 to ensure no evidence of abuse had occurred or was observed including resident to resident altercations. 3. Nursing Administration completed resident observations on 4/27/17 for non-interviewable residents to ensure no signs of abuse were observed. 4. 100% audit was initiated on 4/27/17 and completed by Nursing Administration and the Social Services Director to ensure residents with behaviors are monitored and interventions implemented per the resident's needs. 5. 100% audit was completed for the past 60 days by Social Services to ensure psych consults were completed as required. No additional residents were identified during this audit. 6. 100% licensed and non-licensed staff received re-education by the Staff Development Coordinator, RN Supervisor and Director of Nursing beginning on 4/27/17 related to abuse to include reporting and recognizing signs and symptoms; including resident to resident. 7. 100% of Facility's Licensed Nurses received re-education by the Facility's Staff Development Coordinator, RN Supervisor and Director of Nursing beginning 4/27/17 related to the requirements of monitoring residents with aggressive behaviors and implementing interventions for the behaviors. Staff will be required to complete this education prior to returning to work. New hire and agency nurses will receive this training during orientation. 8. The Social Services Director and Social Service Assistant were re-educated by the Administrator related to requirements of ensuring psych consults are completed per physician's orders [REDACTED]. Observations, record reviews, and interviews revealed the plan submitted by the facility on 4/27/17 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice as of 4/28/17. The citation at F250 will continue at a lower scope and severity level of E.

Based on record review and interviews, the facility failed to provide an accurate update of care plan interventions to depict the residents' actual care needs for 2 of 6 residents reviewed for behaviors. Residents #86 and #94 with abusive behavior care plans did not show review and revised updates of interventions for changes. The findings included: The facility admitted resident #86 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Annual Minimum Data Set (MDS) of 1/23/17. The resident's Brief Interview for Mental Status (BIMS) score was 3 out of 15. Behaviors were coded of delusions with no behaviors. A Quarterly MDS of 3/20/17 revealed the resident was not coded for delusions. Review of the care plan revealed an identified problem history of physical and verbal aggression toward staff and other residents. History of refusing medications, history of refusing staff assistance with ADL's and mobility tasks, hygiene and bathing. Interventions included to administer medication. Divert attention when possible and attempt to refocus behavior on something else. The interventions were updated for each emergency room Visit for evaluation. Although the problem was identified of the residents aggression towards staff and other residents, there were no interventions to prevent aggression towards other residents. The interventions in place were after the aggression occurred. The facility reported an allegation of resident to resident physical abuse involving Resident #94 on 2/14/17 for an incident that occurred on 2/13/17 at 7:55 PM. Review of the facility's Five-Day Follow-Up Report dated 2/16/17 revealed Resident #94 approached Resident #12 in the hall and hit him/her on the shoulder. After completion of the investigation the event did occur. Resident #94 placed on 1:1 staff observation. Care plan reviewed and updated. The facility also previously reported Resident #94 to the State Agency for abuse of Resident C (12/16/16) and Resident B (1/12/17). Each time the resident was care planned for 1:1 supervision. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the care plan revealed alteration in behavior as evidenced by verbal and physical aggression towards others was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included 1:1 supervision as ordered, and psych consult as ordered (2/22/17). The date initiated for the care plan was 12/5/16 with revision date of 3/2/17. On 2/13/17 the care plan indicated to separate from Resident #12, 1:1 supervision. The care plan did not include Resident #94's other incidents. Review of Resident #94's Nurse's Notes revealed no entry for Resident #94 between 10/25/16 and 11/17/16. Review of the Nurses' Notes dated 11/17/16 indicated resident without behavior. Sitter on 1st and 3rd shift discontinued. Sitter on 2nd shift will continue. On 1/12/17 at 2200 another resident approached the nurses' station stating (Resident #94) came into my room through the bathroom and grabbed my arm and twisted it. Resident removed from the room by staff. 1:1 sitter stated that the resident had went into the bathroom and then went into the neighboring room. On 2/13/17 at 7:55 PM resident was seen approaching another resident and hitting him/her on the shoulder. Resident was put on 1:1 with a sitter. Review of the resident's Physician Telephone Order dated 2/22/17 revealed an order for [REDACTED]. The resident was noted to still have periods of combative behaviors. The plan was to continue medications and behavior management. Will request psych consult as well for any additional input. Continue 1:1 observation. Review of Resident #94's medical record revealed only 3 physician progress notes [REDACTED]. The resident was seen on 10/27/16 and no visit reason was noted. The resident was seen on 4/26/17 for significant weight loss. Noted resident still has periods of aggressive behavior. Review of the Incident Report dated 11/12/16 revealed it was reported to the nurse by a CNA that Resident #94 struck Resident A on 11/11/16. The note on 11/15/16 indicated communication with Resident A, no injury to hand. Resident #94 patted him/her on the hand but didn't hit him/her. Review of the Incident Report dated 12/4/16 revealed it was reported that Resident #94 went into Resident B's room and the resident asked him/her to leave. The resident's sitter tried redirecting him/her and s/he then punched the sitter in the chin. The nurse entered the room and the resident punched him/her 3 times in the arm. The note on 12/5/16 indicated 1:1 sitter. Review of the Incident Report dated 12/16/16 revealed Resident #94 punched another resident in the face while in the dining room. The note on 12/28/16 indicated resident to remain 1:1 with education to sitter to ensure the resident is within arms reach and resident will not be allowed in the dining room during meals. Resident #94 was noted to be on 1:1 supervision at the time of the incident. Review of the Incident Report dated 1/12/17 revealed Resident B approached the nurses' station and stated that another resident had come into his/her room through the bathroom. Resident B stated that Resident #94 grabbed his/her right arm and twisted it. Resident #94 was on 1:1 supervision at the time of the incident. Review of the Incident Report dated 2/13/17 revealed Resident #94 hit Resident #12 on the right arm. The note dated 2/14/17 indicated Resident #94 was placed on 1:1 staff supervision. Resident was noted to already be on 1:1 supervision at the time of the incident. CNA #5's facility-obtained statement dated 2/13/17 indicated Resident #94 was walking around on Peach wing and hit Resident #12 in his/her shoulder. Resident #94 was agitated. CNA #3's facility-obtained statement dated 2/13/17 indicated Resident #94 walked up to Resident #12 and punched him/her in the arm and kept walking. In an interview with the surveyor on 4/25/17 at approximately 4:25 PM, CNA #3 stated Resident #94 was walking by and s/he threw his/her hand and hit Resident #12 on his/her shoulder. Resident #12 was standing in the common area near the nurses' station, Resident #94 was walking by. CNA #3 stated Resident #94 will try to hit staff and residents. CNA #3 stated Resident #94 has been that way since s/he has been at the facility. CNA #3 stated you never know when the resident is going to strike out. In an interview with the surveyor on 4/25/17 at approximately 12:10 PM, LPN #1 stated s/he is usually assigned to Resident #94. LPN #1 stated you have to monitor him/her and watch him/her closely. LPN #1 stated sometimes Resident #944 can be hard to redirect. When trying to redirect him/her, sometimes s/he will swing. LPN #1 stated Resident #94 has hit residents and staff. Sometimes s/he will hit residents, comes out of nowhere. LPN #1 stated you can't always tell when the resident is about to hit someone. LPN #1 stated s/he was at the facility when the resident hit Resident #12, but did not witness it. Resident #94 was roaming around, the CNA from the other hall came and told LPN #1 that Resident #94 walked up to Resident #12 and hit him/her. The CNA brought Resident #94 back to the unit to LPN #1. Resident #94 had a 1:1 sitter to monitor him/her. LPN #1 stated Resident #94 doesn't have a sitter on 1st shift, but does have one on 2nd shift. LPN #1 stated Resident #94 tends to get up more in the evening. In an interview with the surveyor on 4/27/17 at approximately 4:30 PM, the DON (Director of Nursing) stated Resident #94 wanders around the whole facility. The DON stated if you approach the resident calmly s/he is fine. If aggressive, he lashes out. The DON stated Resident #94 hit Resident B, Resident C, and Resident #12. The DON stated Resident #94 was on 1:1 when some of the incidents occurred. The DON stated Resident #94 had been on 1:1 since s/he got to the facility almost a year ago. He is on 1:1 more than he is off. The DON stated they did reeducation with staff on 1:1 and what the criteria is for 1:1. The DON stated 1:1 is documented in the nurses notes. The DON stated 1:1 is a nurse driven initiation and not a physician's orders [REDACTED].>In an interview with the surveyor on 4/27/17 at approximately 5:05 PM, the facility administrator stated Resident #94 did not have any psych notes that s/he could find. The facility administrator stated that s/he called the psychiatrist and they have no documentation of seeing Resident #94. In an interview with the surveyor on 4/27/17 at approximately 5:25 PM, the DON stated s/he is not sure why the psych consult wasn't done. The DON stated usually the Social Services Director puts the consult on the psych list and the psychiatrist will see on their next visit. The DON confirmed the psychiatrist has been in the building since the physician order [REDACTED].#94 to have a psych consult. On April 27, 2017 the Administrator was notified the facility was in Immediate Jeopardy and/or Substandard Quality of Care. The Immediate Jeopardy existed in the facility as of December 16, 2016 related to the following citations: 483.10 (C)(2)(i-ii,iv,v)(3) 483.21(b)(2) F280 Revise Care Plans - As it relates to the failure of the facility to adequately care plan 2 residents with aggressive behaviors toward other residents. Both residents had care plans developed due to behaviors but no evidence of interventions added or revised after ongoing resident to resident abuse occurred. An Allegation of Compliance (AOC) was provided by the facility to the survey team with a completion date of 4/28/2017. The AOC included the following: 1. Residents #86 and #94 were ordered by the physician to be sent out for psychiatric evaluation. Resident #86 was sent out on 4/27/17 and Resident #94 was sent out in the AM of 4/28/17. 2. The facility Social Services Director completed resident interviews on 4/27/17 to ensure no evidence of abuse had occurred or was observed including resident to resident altercations. 3. Nursing Administration completed resident observations on 4/27/17 for non-interviewable residents to ensure no signs of abuse were observed. 4. 100% audit was initiated on 4/27/17 and completed by Nursing Administration and the Social Services Director to ensure residents with behaviors are monitored and interventions implemented per the resident's needs. 5. 100% audit was completed for the past 60 days by Social Services to ensure psych consults were completed as required. No additional residents were identified during this audit. 6. 100% licensed and non-licensed staff received re-education by the Staff Development Coordinator, RN Supervisor and Director of Nursing beginning on 4/27/17 related to abuse to include reporting and recognizing signs and symptoms; including resident to resident. 7. 100% of Facility's Licensed Nurses received re-education by the Facility's Staff Development Coordinator, RN Supervisor and Director of Nursing beginning 4/27/17 related to the requirements of monitoring residents with aggressive behaviors and implementing interventions for the behaviors. Staff will be required to complete this education prior to returning to work. New hire and agency nurses will receive this training during orientation. 8. The Social Services Director and Social Service Assistant were re-educated by the Administrator related to requirements of ensuring psych consults are completed per physician's orders [REDACTED]. Observations, record reviews, and interviews revealed the plan submitted by the facility on 4/27/17 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice as of 4/28/17. The citations at F280 will continue at a lower scope and severity level of E.

Resident #86 had numerous behaviors including refusal of medications, verbal, mental and physical abuse of roommates. The resident had repeated hospital transfers for behaviors with repeated returns to the facility exhibiting the same behaviors. Resident #86 was sent to the hospital from 12/30/16 through 1/9/17, 1/31/17 through 2/1/17, 2/22/17 through 2/23/17, and 2/26/17 through 3/9/2017 for behaviors. During this time period the resident had five (5) different roommates. The facility admitted resident #86 with [DIAGNOSES REDACTED]. On 4/24/2017 at approximately 3:50 PM the resident was observed, up in wheel chair, propelling self in hallways. The surveyor attempted to speak to resident. Resident was looking at this surveyor, no verbal response and no attempts at conversation. On 4/25/17 at approximately 11:30 AM the surveyor attempted to interview the resident. Resident #86 continued to look when the surveyor attempted to talk with resident. Attempts to interview were unsuccessful. Review of the medical record revealed an Annual Minimum Data Set (MDS) of 1/23/17. The resident's Brief Interview for Mental Status (BIMS) score was 3 out of 15. Behaviors were coded of delusions with no behaviors. A Quarterly MDS of 3/20/17 revealed the resident was not coded for delusions. Review of the care plan revealed an identified problem history of physical and verbal aggression toward staff and other residents. History of refusing medications, history of refusing staff assistance with ADL's and mobility tasks, hygiene and bathing. Interventions included to administer medication, divert attention when possible and attempt to refocus behavior on something else. Further review of the medical record revealed a Behavioral Health Discharge Summary 3/9/2017, History of Chronic [MEDICAL CONDITION], the patient was admitted on court papers for refusing medications and refusing the pill and we started [MEDICATION NAME] 234 mg IM given on 2/27/17. Having paranoid and threatening behavior towards staff. The patient is very agitated and paranoid and psychotic, refusing to take medications. Review of the Nurses Notes (NN) from August 2016 through 4/24/17 revealed the resident had many behaviors towards others, behaviors of voiding and having BM's on floor, yelling, cursing, throwing liquid (water/soda) on roommates. Resident frequently refused medications including antipsychotics and insulin. S/he paced in her wheelchair and talked to herself/himself. NN 12/22/16: Roommate stated resident (#86) hit me in the mouth and poured water and soda on my face Resident (Res) admitted s/he poured what was in his/her cup on the roommate. Ice cream was noted on the wall and a water/ice cup was on the floor. Beside roommate's bed. Res. admitted s/he had thrown things in the room. 12/23/16: 1:1 care provided 12/24/16: Resident blocked door with bedside table to prevent staff from entering room to check on roommate. Roommate reports resident turning his/her TV to cartoons when s/he finds a show to watch. The res turns TV down so roommate can't hear. Res. turns off roommate's light. Res stated s/he wanted res (roommate) out of his/her room. 12/30/2016: 4:30 AM- Roommate states Res took his/her phone and tried to pour water on me. Res keeps turning light off. 6:30 AM: On 1:1 supervision. 11:28 AM: New order to transfer to hospital for evaluation and treatment. 10:00 (?) AM Remains on 1:1. Complained of (c/o) person following him/her, wanted sitter out. Resist to redirect. 12:30 PM transferred to ____(psychiatric hospital unit) Director of Nursing (DON), Assistant DON (ADON), Deputy Sheriff, Social Worker (SW) and Nurse Practitioner (NP) present during transfer. 1/4/17: PAR Meeting Note: Res (resident) to Res abuse. 1/9/17: Returned from hospital. Refused body audit. 5:00 PM Already refusing care. Refusing meds. Urinating on floor. Refused vital signs and weight. Pants saturated with urine. 1/11/17 11:00 AM Continues to have paranoia and hallucinations. 6:00 PM Continues with paranoia and hallucinations. Cursing out loud in room. Urinated in middle of hallway. 1/14/17 6:00 PM: S/he told another resident s/he was going to get away out the door first chance s/he gets. S/he doesn't want people to live in his/her room. 1/18/17: Res. Roommate yelling, I saw you do that. I know its you that's been doing things to my stuff and stealing . 1/22/17 Ref meds 1/26/17: Refused all AM meds. 7:00 PM refused all meds, 1/28/17 Refused all PM meds. 1/31/17: Threatening roommate, refused meds. Orders to transfer to hospital for evaluation. 6:10 PM: Transferred to hospital. Res still refusing to eat and take medications. Threatening roommate with doing anything to get him/her out of his/her room. 2/1/17: Call from hospital, [DIAGNOSES REDACTED]. Returned to the facility. Urine noted on floor by res. Bed. Refused shower. PAR Meeting- Refused meds, incontinent throughout facility. Episodes of harassing roommate. Returned with antibiotic for UTI. 2/11/17: Standing on stumps in wheel chair cussing at window and door. Telling them to shut up, Refused meds and vital signs. 2/15/17: Cursing at other residents and staff. 2/19/17: Told nurse that TV in room cussed out his/her TV and now the preacher won't come on his/her TV. Resident in the Hospital for behaviors 2-22-17 through 2-23-17 and 2-26-17 through 3/9/17. 4/13/17: CNA reported to nurse this resident arguing with roommate about TV in his/her room, using much profanity. Resident was telling roommate that s/he doesn't like him/her and wants him/her to stop watching him/her and stop talking to him/her. 4/15/17: Refused vital signs, ADL's and Insulin. 4/18/17: Resident had a episode of verbal aggression toward roommate. Review of Physician's Progress Notes revealed a progress note of 1/11/17. readmitted from (psychiatric hospital) where had been sent for increased agitation, abuse against other residents, refusal to take medication . Has been rolling self around hall, talking to self, cursing, acting strangely. Review of monthly psychiatric visits from 8/25/16 through 4/18/17 revealed on each visit ( 8/25/16, 10/18/16, 11/23/16, 1/10/17, 2/10/17, 3/21/17 and 4/18/17) the resident was documented to have had active hallucinations and delusional thinking. Continued challenges related to yelling, non-compliance with medications. This non-compliance continues and has only gotten minimally better with medications because s/he variably refuses. Recommend at this point legal guardianship/power of attorney be pursued with patient being declared by a judge to be unable to make appropriate treatment decisions, legally protecting facility should administration of meds against the patient's will become necessary. Currently calm inspite of [MEDICAL CONDITION]. On 4/26/17 at approximately 10:35 AM, the Administrator and Director of Nurses were interviewed by the surveyor. The Administrator and DON were asked what was being done to protect other residents from resident #86. They stated they were not aware of the resident hitting another resident. They have moved roommates. S/he has had 5 roommates. 1:1 has been provided. We have considered a private room On April 27, 2017 the Administrator was notified the facility was in Immediate Jeopardy and/or Substandard Quality of Care. The Immediate Jeopardy existed in the facility as of December 16, 2016 related to the following citations: 483.40 (b)(1) Treatment/Services for Mental/Psychosocial F319 - As it relates to the failure of the facility to address aggressive behaviors of 2 residents and protect other residents from resident to resident abuse. An Allegation of Compliance (AOC) was provided by the facility to the survey team with a completion date of 4/28/2017. The AOC included the following: 1. Residents #86 and #94 were ordered by the physician to be sent out for psychiatric evaluation. Resident #86 was sent out on 4/27/17 and Resident #94 was sent out in the AM of 4/28/17. 2. The facility Social Services Director completed resident interviews on 4/27/17 to ensure no evidence of abuse had occurred or was observed including resident to resident altercations. 3. Nursing Administration completed resident observations on 4/27/17 for non-interviewable residents to ensure no signs of abuse were observed. 4. 100% audit was initiated on 4/27/17 and completed by Nursing Administration and the Social Services Director to ensure residents with behaviors are monitored and interventions implemented per the resident's needs. 5. 100% audit was completed for the past 60 days by Social Services to ensure psych consults were completed as required. No additional residents were identified during this audit. 6. 100% licensed and non-licensed staff received re-education by the Staff Development Coordinator, RN Supervisor and Director of Nursing beginning on 4/27/17 related to abuse to include reporting and recognizing signs and symptoms; including resident to resident. 7. 100% of Facility's Licensed Nurses received re-education by the Facility's Staff Development Coordinator, RN Supervisor and Director of Nursing beginning 4/27/17 related to the requirements of monitoring residents with aggressive behaviors and implementing interventions for the behaviors. Staff will be required to complete this education prior to returning to work. New hire and agency nurses will receive this training during orientation. 8. The Social Services Director and Social Service Assistant were re-educated by the Administrator related to requirements of ensuring psych consults are completed per physician's orders [REDACTED]. Observations, record reviews, and interviews revealed the plan submitted by the facility on 4/27/17 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice as of 4/28/17. The citations at F319 will continue at a lower scope and severity level of E. Based on review of facility files and interview, the facility failed to ensure a resident with mental disorders received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Resident #94 was noted to have several incidents of hitting other residents while on 1:1 observation. The facility failed to ensure the resident was evaluated by the psychiatrist per a physician order. Resident #86 had numerous behaviors including refusal of medications, verbal, mental and physical abuse of roommates. The resident had repeated hospital transfers for behaviors with repeated returns to the facility exhibiting the same behaviors; two of six residents reviewed for behaviors. The findings included: The facility reported an allegation of resident to resident physical abuse involving Resident #94 on 2/14/17 for an incident that occurred on 2/13/17 at 7:55 PM. Review of the facility's Five-Day Follow-Up Report dated 2/16/17 revealed Resident #94 approached Resident #12 in the hall and hit him/her on the shoulder. After completion of the investigation the facility substantiated the event occurred. Resident #94 was placed on 1:1 staff observation and the care plan was reviewed and updated. The facility previously reported Resident #94 to the State Agency for abuse of Resident C (12/16/16) and Resident B (1/12/17). Each time the resident was care planned for 1:1 supervision. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 12.05.2016 and updated 03/02/2017 revealed that alteration in behavior as evidenced by verbal and physical aggression towards others was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included 1:1 supervision as ordered, and psych consult as ordered (2/22/17). On 2/13/17 the care plan indicated to separate from Resident #12, 1:1 supervision. The care plan did not include Resident #94's other incidents. Review of Resident #94's Nurse's Notes revealed no entry for Resident #94 between 10/25/16 and 11/17/16. Review of the Nurses' Notes dated 11/17/16 indicated resident without behavior. Sitter on 1st and 3rd shift discontinued. Sitter on 2nd shift will continue. On 1/12/17 at 2200 another resident approached the nurses' station stating (Resident #94) came into my room through the bathroom and grabbed my arm and twisted it. Resident removed from the room by staff. 1:1 sitter stated that the resident had went into the bathroom and then went into the neighboring room. On 2/13/17 at 7:55 PM resident was seen approaching another resident and hitting him/her on the shoulder. Resident was put on 1:1 with a sitter. Review of the resident's Physician Telephone Order dated 2/22/17 revealed an order for [REDACTED]. The resident was noted to still have periods of combative behaviors. The plan was to continue medications and behavior management. Will request psych consult as well for any additional input. Continue 1:1 observation. Review of Resident #94's medical record revealed only 3 physician progress notes [REDACTED]. The resident was seen on 10/27/16 and no visit reason was noted. The resident was seen on 4/26/17 for significant weight loss. Noted resident still has periods of aggressive behavior. Review of Resident #94's Social Progress Notes from 11/9/16-4/28/17 revealed an entry dated 12/16/16 that indicated the resident was observed punching another resident in the dining room. Resident was redirected with no further aggressive behavior noted. There were no additional social service notes related to the other incidents the resident was involved in. Review of the Incident Report dated 11/12/16 revealed it was reported to the nurse by a Certified Nurse Aide (CNA) that Resident #94 struck Resident A on 11/11/16. The note on 11/15/16 indicated communication with Resident A, no injury to hand. Resident #94 patted him/her on the hand but didn't hit him/her. Review of the Incident Report dated 12/4/16 revealed it was reported that Resident #94 went into Resident B's room and the resident asked him/her to leave. The resident's sitter tried redirecting him/her and s/he then punched the sitter in the chin. The nurse entered the room and the resident punched him/her 3 times in the arm. The note on 12/5/16 indicated 1:1 sitter. Review of the Incident Report dated 12/16/16 revealed Resident #94 punched another resident in the face while in the dining room. The note on 12/28/16 indicated resident to remain 1:1 with education to sitter to ensure the resident is within arms reach and resident will not be allowed in the dining room during meals. Resident #94 was noted to be on 1:1 supervision at the time of the incident. Review of the Incident Report dated 1/12/17 revealed Resident B approached the nurses' station and stated that another resident had come into his/her room through the bathroom. Resident B stated that Resident #94 grabbed his/her right arm and twisted it. Resident #94 was on 1:1 supervision at the time of the incident. Review of the Incident Report dated 2/13/17 revealed Resident #94 hit Resident #12 on the right arm. The note dated 2/14/17 indicated Resident #94 was placed on 1:1 staff supervision. Resident was noted to already be on 1:1 supervision at the time of the incident. CNA #5's facility-obtained statement dated 2/13/17 indicated Resident #94 was walking around on Peach wing and hit Resident #12 in his/her shoulder. Resident #94 was agitated. CNA #3's facility-obtained statement dated 2/13/17 indicated Resident #94 walked up to Resident #12 and punched him/her in the arm and kept walking. In an interview with the surveyor on 4/25/17 at approximately 4:25 PM, CNA #3 stated Resident #94 was walking by and s/he threw his/her hand and hit Resident #12 on his/her shoulder. Resident #12 was standing in the common area near the nurses' station, Resident #94 was walking by. CNA #3 stated Resident #94 will try to hit staff and residents. CNA #3 stated Resident #94 has been that way since s/he has been at the facility. CNA #3 stated you never know when the resident is going to strike out. In an interview with the surveyor on 4/25/17 at approximately 12:10 PM, LPN #1 stated s/he is usually assigned to Resident #94. LPN #1 stated you have to monitor him/her and watch him/her closely. LPN #1 stated sometimes Resident #944 can be hard to redirect. When trying to redirect him/her, sometimes s/he will swing. LPN #1 stated Resident #94 has hit residents and staff. Sometimes s/he will hit residents, comes out of nowhere. LPN #1 stated you can't always tell when the resident is about to hit someone. LPN #1 stated s/he was at the facility when the resident hit Resident #12, but did not witness it. Resident #94 was roaming around, the CNA from the other hall came and told LPN #1 that Resident #94 walked up to Resident #12 and hit him/her. The CNA brought Resident #94 back to the unit to LPN #1. Resident #94 had a 1:1 sitter to monitor him/her. LPN #1 stated Resident #94 doesn't have a sitter on 1st shift, but does have one on 2nd shift. LPN #1 stated Resident #94 tends to get up more in the evening. In an interview with the surveyor on 4/27/17 at approximately 4:30 PM, the DON (Director of Nursing) stated Resident #94 wanders around the whole facility. The DON stated if you approach the resident calmly s/he is fine. If aggressive, he lashes out. The DON stated Resident #94 hit Resident B, Resident C, and Resident #12. The DON stated Resident #94 was on 1:1 when some of the incidents occurred. The DON stated Resident #94 had been on 1:1 since s/he got to the facility almost a year ago. He is on 1:1 more than he is off. The DON stated they did reeducation with staff on 1:1 and what the criteria is for 1:1. The DON stated 1:1 is documented in the nurses notes. The DON stated 1:1 is a nurse driven initiation and not a physician's orders [REDACTED].>In an interview with the surveyor on 4/27/17 at approximately 5:05 PM, the facility administrator stated Resident #94 did not have any psych notes that s/he could find. The facility administrator stated that s/he called the psychiatrist and they have no documentation of seeing Resident #94. In an interview with the surveyor on 4/27/17 at approximately 5:25 PM, the DON stated s/he is not sure why the psych consult wasn't done. The DON stated usually the Social Services Director puts the consult on the psych list and the psychiatrist will see on their next visit. The DON confirmed the psychiatrist has been in the building since the physician order [REDACTED].#94 to have a psych consult.

Based on observation, record review and interview the facility administration failed to use its reources effectively to attain the highest physical, mental and psychosocial well-being of each resident. Two of 6 residents identified as having aggressive physical behaviors toward other residents in the facility were not adequately care planned and their behaviors not consistently addressed to ensure the safety and well-being of other residents. Residents #86 and #94 continued to physically abuse other residents. Cross refer to F250, F280 and F319 as it relates to the abusive behaviors of Residents #86 and #94. The findings included: Resident #86 had numerous behaviors including refusal of medications, verbal, mental and physical abuse of roommates. The resident had repeated hospital transfers for behaviors with repeated returns to the facility exhibiting the same behaviors. Resident #86 was sent to the hospital from 12/30/16 through 1/9/17, 1/31/17 through 2/1/17, 2/22/17 through 2/23/17, and 2/26/17 through 3/9/2017 for behaviors. During this time period the resident had five (5) different roommates. The facility admitted resident #86 with [DIAGNOSES REDACTED]. On 4/24/2017 at approximately 3:50 PM the resident was observed, up in wheel chair, propelling self in hallways. The surveyor attempted to speak to resident. Resident was glaring at this surveyor, no verbal response and no attempts at conversation. On 4/25/17 at approximately 11:30 AM the surveyor attempted to interview the resident. Resident #86 continued to glare when the surveyor attempted to talk with resident. Attempts to interview, were unsuccessful. Review of the medical record revealed an Annual Minimum Data Set (MDS) of 1/23/17. The resident's Brief Interview for Mental Status (BIMS) score was 3 out of 15. Behaviors were coded of delusions with no behaviors. A Quarterly MDS of 3/20/17 revealed the resident was not coded for delusions. Review of the care plan revealed an identified problem history of physical and verbal aggression toward staff and other residents. History of refusing medications, history of refusing staff assistance with ADL's and mobility tasks, hygiene and bathing. Interventions included to administer medication, divert attention when possible and attempt to refocus behavior on something else. Review of monthly psychiatric visits from 8/25/16 through 4/18/17 revealed on each visit ( 8/25/16, 10/18/16, 11/23/16, 1/10/17, 2/10/17, 3/21/17 and 4/18/17) the resident was documented to have had active hallucinations and delusional thinking. Continued challenges related to yelling, non-compliance with medications. This non-compliance continues and has only gotten minimally better with medications because s/he variably refuses. Recommend at this point legal guardianship/power of attorney be pursued with patient being declared by a judge to be unable to make appropriate treatment decisions, legally protecting facility should administration of meds against the patient's will become necessary. Currently calm inspite of [MEDICAL CONDITION]. On 4/26/17 at approximately 10:35 AM, the Administrator and Director of Nurses were interviewed by the surveyor. The Administrator and DON were asked what was being done to protect other residents from resident #86. They stated they were not aware of the resident hitting another resident. They have moved roommates. S/he has had 5 roommates. 1:1 has been provided. We have considered a private room. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the care plan revealed alteration in behavior as evidenced by verbal and physical aggression towards others was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included 1:1 supervision as ordered, and psych consult as ordered (2/22/17). The date initiated for the care plan was 12/5/16 with revision date of 3/2/17. On 2/13/17 the care plan indicated to separate from Resident #12, 1:1 supervision. The care plan did not include Resident #94's other incidents. The facility reported an allegation of resident to resident physical abuse involving Resident #94 on 2/14/17 for an incident that occurred on 2/13/17 at 7:55 PM. Review of the facility's Five-Day Follow-Up Report dated 2/16/17 revealed Resident #94 approached Resident #12 in the hall and hit him/her on the shoulder. After completion of the investigation the event did occur. Resident #94 placed on 1:1 staff observation. Care plan reviewed and updated. The facility also previously reported Resident #94 to the State Agency for abuse of Resident C (12/16/16) and Resident B (1/12/17). Each time the resident was care planned for 1:1 supervision. Review of Resident #94's Nurse's Notes revealed no entry for Resident #94 between 10/25/16 and 11/17/16. Review of the Nurses' Notes dated 11/17/16 indicated resident without behavior. Sitter on 1st and 3rd shift discontinued. Sitter on 2nd shift will continue. On 1/12/17 at 2200 another resident approached the nurses' station stating (Resident #94) came into my room through the bathroom and grabbed my arm and twisted it. Resident removed from the room by staff. 1:1 sitter stated that the resident had went into the bathroom and then went into the neighboring room. On 2/13/17 at 7:55 PM resident was seen approaching another resident and hitting him/her on the shoulder. Resident was put on 1:1 with a sitter. Review of the resident's Physician Telephone Order dated 2/22/17 revealed an order for [REDACTED]. The resident was noted to still have periods of combative behaviors. The plan was to continue medications and behavior management. Will request psych consult as well for any additional input. Continue 1:1 observation. Review of Resident #94's medical record revealed only 3 physician progress notes [REDACTED]. The resident was seen on 10/27/16 and no visit reason was noted. The resident was seen on 4/26/17 for significant weight loss. Noted resident still has periods of aggressive behavior. Review of Resident #94's Social Progress Notes from 11/9/16-4/28/17 revealed an entry dated 12/16/16 that indicated the resident was observed punching another resident in the dining room. Resident was redirected with no further aggressive behavior noted. There were no additional social service notes related to the other incidents the resident was involved in. In an interview with the surveyor on 4/27/17 at approximately 4:30 PM, the DON (Director of Nursing) stated Resident #94 wanders around the whole facility. The DON stated if you approach the resident calmly s/he is fine. If aggressive, he lashes out. The DON stated Resident #94 hit Resident B, Resident C, and Resident #12. The DON stated Resident #94 was on 1:1 when some of the incidents occurred. The DON stated Resident #94 had been on 1:1 since s/he got to the facility almost a year ago. He is on 1:1 more than he is off. The DON stated they did reeducation with staff on 1:1 and what the criteria is for 1:1. The DON stated 1:1 is documented in the nurses notes. The DON stated 1:1 is a nurse driven initiation and not a physician's orders [REDACTED].>In an interview with the surveyor on 4/27/17 at approximately 5:05 PM, the facility administrator stated Resident #94 did not have any psych notes that s/he could find. The facility administrator stated that s/he called the psychiatrist and they have no documentation of seeing Resident #94. In an interview with the surveyor on 4/27/17 at approximately 5:25 PM, the DON stated s/he is not sure why the psych consult wasn't done. The DON stated usually the Social Services Director puts the consult on the psych list and the psychiatrist will see on their next visit. The DON confirmed the psychiatrist has been in the building since the physician order [REDACTED].#94 to have a psych consult. On April 27, 2017 the Administrator was notified the facility was in Immediate Jeopardy and/or Substandard Quality of Care. The Immediate Jeopardy existed in the facility as of December 16, 2016 related to the following citations: 483.70 Administration F490 - As it relates to the failure of the facility Administration to ensure residents are protected against resident to resident abuse and residents with mental health issues are provided the care and services to meet their needs. An Allegation of Compliance (AOC) was provided by the facility to the survey team with a completion date of 4/28/2017. The AOC included the following: 1. Residents #86 and #94 were ordered by the physician to be sent out for psychiatric evaluation. Resident #86 was sent out on 4/27/17 and Resident #94 was sent out in the AM of 4/28/17. 2. The facility Social Services Director completed resident interviews on 4/27/17 to ensure no evidence of abuse had occurred or was observed including resident to resident altercations. 3. Nursing Administration completed resident observations on 4/27/17 for non-interviewable residents to ensure no signs of abuse were observed. 4. 100% audit was initiated on 4/27/17 and completed by Nursing Administration and the Social Services Director to ensure residents with behaviors are monitored and interventions implemented per the resident's needs. 5. 100% audit was completed for the past 60 days by Social Services to ensure psych consults were completed as required. No additional residents were identified during this audit. 6. 100% licensed and non-licensed staff received re-education by the Staff Development Coordinator, RN Supervisor and Director of Nursing beginning on 4/27/17 related to abuse to include reporting and recognizing signs and symptoms; including resident to resident. 7. 100% of Facility's Licensed Nurses received re-education by the Facility's Staff Development Coordinator, RN Supervisor and Director of Nursing beginning 4/27/17 related to the requirements of monitoring residents with aggressive behaviors and implementing interventions for the behaviors. Staff will be required to complete this education prior to returning to work. New hire and agency nurses will receive this training during orientation. 8. The Social Services Director and Social Service Assistant were re-educated by the Administrator related to requirements of ensuring psych consults are completed per physician's orders [REDACTED]. Observations, record reviews, and interviews revealed the plan submitted by the facility on 4/27/17 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice as of 4/28/17. The citations at F490 will continue at a lower scope and severity level of E.

Based on review of facility files and interview, the facility failed to ensure services provided by the facility were provided by qualified persons in accordance with each resident's written plan of care. Resident #94 was noted to have several incidents that involved him/her hitting other residents. The physician wrote an order for [REDACTED]. One of six residents reviewed for behaviors. The findings included: The facility reported an allegation of resident to resident physical abuse involving Resident #94 on 2/14/17 for an incident that occurred on 2/13/17 at 7:55 PM. Review of the facility's Five-Day Follow-Up Report dated 2/16/17 revealed Resident #94 approached Resident #12 in the hall and hit him/her on the shoulder. After completion of the investigation the event did occur. Resident #94 placed on 1:1 staff observation. Care plan reviewed and updated. The facility also previously reported Resident #94 to the State Agency for abuse of Resident C (12/16/16) and Resident B (1/12/17). Each time the resident was care planned for 1:1 supervision. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the care plan revealed alteration in behavior as evidenced by verbal and physical aggression towards others was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included 1:1 supervision as ordered, and psych consult as ordered (2/22/17). The date initiated for the care plan was 12/5/16 with revision date of 3/2/17. On 2/13/17 the care plan indicated to separate from Resident #12, 1:1 supervision. The care plan did not include Resident #94's other incidents. Review of Resident #94's Nurse's Notes revealed no entry for Resident #94 between 10/25/16 and 11/17/16. Review of the Nurses' Notes dated 11/17/16 indicated resident without behavior. Sitter on 1st and 3rd shift discontinued. Sitter on 2nd shift will continue. On 1/12/17 at 2200 another resident approached the nurses' station stating (Resident #94) came into my room through the bathroom and grabbed my arm and twisted it. Resident removed from the room by staff. 1:1 sitter stated that the resident had went into the bathroom and then went into the neighboring room. On 2/13/17 at 7:55 PM resident was seen approaching another resident and hitting him/her on the shoulder. Resident was put on 1:1 with a sitter. Review of the resident's Physician Telephone Order dated 2/22/17 revealed an order for [REDACTED]. The resident was noted to still have periods of combative behaviors. The plan was to continue medications and behavior management. Will request psych consult as well for any additional input. Continue 1:1 observation. Review of Resident #94's medical record revealed only 3 physician progress notes [REDACTED]. The resident was seen on 10/27/16 and no visit reason was noted. The resident was seen on 4/26/17 for significant weight loss. Noted resident still has periods of aggressive behavior. Review of Resident #94's Social Progress Notes from 11/9/16-4/28/17 revealed an entry dated 12/16/16 that indicated the resident was observed punching another resident in the dining room. Resident was redirected with no further aggressive behavior noted. There were no additional social service notes related to the other incidents the resident was involved in. Review of the Incident Report dated 11/12/16 revealed it was reported to the nurse by a CNA that Resident #94 struck Resident A on 11/11/16. The note on 11/15/16 indicated communication with Resident A, no injury to hand. Resident #94 patted him/her on the hand but didn't hit him/her. Review of the Incident Report dated 12/4/16 revealed it was reported that Resident #94 went into Resident B's room and the resident asked him/her to leave. The resident's sitter tried redirecting him/her and s/he then punched the sitter in the chin. The nurse entered the room and the resident punched him/her 3 times in the arm. The note on 12/5/16 indicated 1:1 sitter. Review of the Incident Report dated 12/16/16 revealed Resident #94 punched another resident in the face while in the dining room. The note on 12/28/16 indicated resident to remain 1:1 with education to sitter to ensure the resident is within arms reach and resident will not be allowed in the dining room during meals. Resident #94 was noted to be on 1:1 supervision at the time of the incident. Review of the Incident Report dated 1/12/17 revealed Resident B approached the nurses' station and stated that another resident had come into his/her room through the bathroom. Resident B stated that Resident #94 grabbed his/her right arm and twisted it. Resident #94 was on 1:1 supervision at the time of the incident. Review of the Incident Report dated 2/13/17 revealed Resident #94 hit Resident #12 on the right arm. The note dated 2/14/17 indicated Resident #94 was placed on 1:1 staff supervision. Resident was noted to already be on 1:1 supervision at the time of the incident. CNA #5's facility-obtained statement dated 2/13/17 indicated Resident #94 was walking around on Peach wing and hit Resident #12 in his/her shoulder. Resident #94 was agitated. CNA #3's facility-obtained statement dated 2/13/17 indicated Resident #94 walked up to Resident #12 and punched him/her in the arm and kept walking. In an interview with the surveyor on 4/25/17 at approximately 4:25 PM, CNA #3 stated Resident #94 was walking by and s/he threw his/her hand and hit Resident #12 on his/her shoulder. Resident #12 was standing in the common area near the nurses' station, Resident #94 was walking by. CNA #3 stated Resident #94 will try to hit staff and residents. CNA #3 stated Resident #94 has been that way since s/he has been at the facility. CNA #3 stated you never know when the resident is going to strike out. In an interview with the surveyor on 4/25/17 at approximately 12:10 PM, LPN #1 stated s/he is usually assigned to Resident #94. LPN #1 stated you have to monitor him/her and watch him/her closely. LPN #1 stated sometimes Resident #944 can be hard to redirect. When trying to redirect him/her, sometimes s/he will swing. LPN #1 stated Resident #94 has hit residents and staff. Sometimes s/he will hit residents, comes out of nowhere. LPN #1 stated you can't always tell when the resident is about to hit someone. LPN #1 stated s/he was at the facility when the resident hit Resident #12, but did not witness it. Resident #94 was roaming around, the CNA from the other hall came and told LPN #1 that Resident #94 walked up to Resident #12 and hit him/her. The CNA brought Resident #94 back to the unit to LPN #1. Resident #94 had a 1:1 sitter to monitor him/her. LPN #1 stated Resident #94 doesn't have a sitter on 1st shift, but does have one on 2nd shift. LPN #1 stated Resident #94 tends to get up more in the evening. In an interview with the surveyor on 4/27/17 at approximately 4:30 PM, the DON (Director of Nursing) stated Resident #94 wanders around the whole facility. The DON stated if you approach the resident calmly s/he is fine. If aggressive, he lashes out. The DON stated Resident #94 hit Resident B, Resident C, and Resident #12. The DON stated Resident #94 was on 1:1 when some of the incidents occurred. The DON stated Resident #94 had been on 1:1 since s/he got to the facility almost a year ago. He is on 1:1 more than he is off. The DON stated they did reeducation with staff on 1:1 and what the criteria is for 1:1. The DON stated 1:1 is documented in the nurses notes. The DON stated 1:1 is a nurse driven initiation and not a physician's orders [REDACTED].>In an interview with the surveyor on 4/27/17 at approximately 5:05 PM, the facility administrator stated Resident #94 did not have any psych notes that s/he could find. The facility administrator stated that s/he called the psychiatrist and they have no documentation of seeing Resident #94. In an interview with the surveyor on 4/27/17 at approximately 5:25 PM, the DON stated s/he is not sure why the psych consult wasn't done. The DON stated usually the Social Services Director puts the consult on the psych list and the psychiatrist will see on their next visit. The DON confirmed the psychiatrist has been in the building since the physician order [REDACTED].#94 to have a psych consult.

Based on observation, record review and interview the facility failed to maintain the residents highest level of functioning to prevent minimum adverse consequences related to medication therapy. Resident #86 was ordered an antipsychotic to promote the resident's best quality of life. The facility was unable to obtain the medication from the pharmacy. One of six residents sampled for behaviors/ medications. The findings included: Cross Refer to F329 as it relates to the facility having an order for [REDACTED]. The facility admitted resident #86 with [DIAGNOSES REDACTED]. On 4/24/2017 at approximately 3:50 PM the resident was observed, up in wheel chair, propelling self in hallways. The surveyor attempted to speak to the resident. S/he looked at the surveyor, s/he made no verbal response and made no attempt at conversation. On 4/25/17 at approximately 11:30 AM the surveyor attempted unsuccessfully to interview the resident. Review of Resident #86's medical record revealed a Discharge Summary 3/9/2017 that stated, .Hospital Course: .The patient very agitated and paranoid and psychotic, refusing to take medications and needed a shot of Zyprexa IM (intramuscularly). Doctor has been asked to do a second opinion for evaluation for capacity and forced medication protocol . So we started her/him on Invega since she is constantly refusing the pill and we started the Invega Sustenna 234 mg (milligrams) IM given on 02/27/17.S/he was more compliant with her/his medication by mouth and the shots. A 2nd dose was given of Invega Sustenna 156 mg IM on 03/06/17. We designated examinations and we were able to get her scheduled for court hearing on 03/09/17.Her/his behavior gradually showed improvement. S/he was more cooperative with the care here.S/he is also not yelling and screaming anymore and not agitated and s/he is able to answer our questions and s/he has been more cooperative.During the court hearing it is deemed that the patient has achieved maximum benefit from inpatient psychiatric stabilization.We finally got a court dismissal on 03/09/17 and we will then proceed with discharge back to the nursing home.Please note that s/he is now court-ordered to get the Invega Sustenna shot 117 mg IM every 4 weeks and next shot is due on 04/03/17 by the nurse in the nursing home. They have to give the shot though the patient refuses because this is now court ordered.Prognosis is fair as long as patient remains compliant with medications and diet . Review of the March 2017 Order Summary Report indicated under the Pharmacy section Invega Sustenna Suspension 117 mg/0.75ml (Paliperidone Palmitate) inject 117 mg intramuscularly one time a day every 30 day(s) related to unspecified psychosis not due to a substance or known physiological condition. The report indicated the order date as 03/09/2017 and a start date of 04/03/2017. Review of the facility progress notes documented the resident back at the facility on 03/09/2017. A Psychosocial note, signed by the facility social worker dated 03/27/2017 stated, Resident returned from the hospital on [DATE]. Resident has not exhibited any inappropriate behaviors since return. Resident is out of room daily. Resident continues to voice needs appropriately. No problems with new roommate as of 03/10/2017. Will continue to provide psychosocial support as appropriate to resident. On 04/01/2017 at 16:08 a note stated, Resident was found urinating in the dining room when nobody was in the room. S/he became verbally aggressive when caught and confronted saying s/he didn't do it and they don't know what they were talking about. A Late Entry note dated 04/03/2017 at 14:14 stated, Resident is ordered Invega IM monthly, medication is not available from pharmacy, it is out of stock and will be sent as soon as the stock is repleted. MD aware. The notes included entries on 04/05/2017 of the resident roaming the facility in her/his wheelchair, refusing vital signs and medications. A Late Entry dated 04/07/2017 at 14:15 stated, Pharmacy called to check status of Invega, medication remains out of stock at this time. On 04/10/2017 at 14:19 a noted stated, Invega is still out of stock. MD notified. The documentation for 04/13/2017 and 04/18/2017 indicated the resident was arguing and verbally aggressive toward her roommate. Resident redirected, will continue to monitor. A note dated 04/25/2017 at 13:43 stated, Resident has an order for [REDACTED]. Will continue to follow up with pharmacy weekly to check on progress of receiving medication. On 04/27/2017 the progress note stated, Residents Invega is not available, thus resident is being transferred to hospital for evaluation r/t receiving court ordered medication and pharmacy's inability to give date it will be available. Review of the Pharmacy Medication Regimen Review dated 03/29/2017 indicated the resident was a re-admit, that Depakote was reduced, Risperdal and as needed Ativan were discontinued. The review showed that Invega had been added to the resident's drug regimen. In an interview with the surveyor on 04/26/2017 at 10:35 AM the Director of Nursing and the Administrator confirmed the medication was not available, that the facility had called the pharmacy/ physician and documented the calls. The Administrator and Director of Nursing confirmed that the pharmacy was responsible for providing the medications. In an interview with the surveyor on 04/27/2017 at 12:00 PM the physician stated s/he was aware there was no Invega available. S/he stated if the resident's behaviors deteriorates s/he would change medication.

Based on observation, record review and interview the facility failed to manage and monitor the medication regimen for Resident #86. Resident #86 was ordered an antipsychotic to promote the resident's best quality of life. The facility was unable to obtain the medication and had no plan in place to address the lack of medication. One of six residents sampled for behaviors/ medication. The findings included: Cross Refer to F428 as it relates to failure of the facility to obtain an ordered medication for a resident and no plan in place to obtain the drug. The facility admitted resident #86 with [DIAGNOSES REDACTED]. On 4/24/2017 at approximately 3:50 PM the resident was observed, up in wheel chair, propelling self in hallways. The surveyor attempted to speak to the resident. S/he looked at the surveyor, s/he made no verbal response and made no attempt at conversation. On 4/25/17 at approximately 11:30 AM the surveyor attempted unsuccessfully to interview the resident. Review of the medical record revealed an Annual Minimum Data Set ((MDS) dated [DATE] indicating a Brief Interview for Mental Status (BIMS) score 3 out of 15; behaviors of delusions were coded. The Quarterly MDS dated [DATE] revealed the resident was not coded for delusions. Review of the care plan revealed a history of physical and verbal aggression toward staff and other residents; refusing medications, refusing staff assistance with ADL's and mobility tasks, hygiene and bathing. Interventions included to administer medication, divert attention when possible and attempt to refocus behavior on something else. Further review of the medical record revealed a Discharge Summary 3/9/2017 that stated, .Hospital Course: .The patient very agitated and paranoid and psychotic, refusing to take medications and needed a shot of [MEDICATION NAME] IM (intramuscularly). Doctor has been asked to do a second opinion for evaluation for capacity and forced medication protocol . So we started her/him on [MEDICATION NAME] since she is constantly refusing the pill and we started the [MEDICATION NAME] 234 mg (milligrams) IM given on 02/27/17.S/he was more compliant with her/his medication by mouth and the shots. A 2nd dose was given of [MEDICATION NAME] 156 mg IM on 03/06/17. We designated examinations and we were able to get her scheduled for court hearing on 03/09/17.Her/his behavior gradually showed improvement. S/he was more cooperative with the care here.S/he is also not yelling and screaming anymore and not agitated and s/he is able to answer our questions and s/he has been more cooperative.During the court hearing it is deemed that the patient has achieved maximum benefit from inpatient psychiatric stabilization.We finally got a court dismissal on 03/09/17 and we will then proceed with discharge back to the nursing home.Please note that s/he is now court-ordered to get the [MEDICATION NAME] shot 117 mg IM every 4 weeks and next shot is due on 04/03/17 by the nurse in the nursing home. They have to give the shot though the patient refuses because this is now court ordered.Prognosis is fair as long as patient remains compliant with medications and diet . Review of the March 2017 Order Summary Report indicated under the Pharmacy section [MEDICATION NAME] Suspension 117 mg/0.75ml (Paliperidone [MEDICATION NAME]) inject 117 mg intramuscularly one time a day every 30 day(s) related to unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. The report indicated the order date as 03/09/2017 and a start date of 04/03/2017. Review of the physician's readmission note dated 03/10/2017 noted the monthly court ordered [MEDICATION NAME] Review of the facility progress notes documented the resident back at the facility on 03/09/2017. A Psychosocial note, signed by the facility social worker dated 03/27/2017 stated, Resident returned from the hospital on [DATE]. Resident has not exhibited any inappropriate behaviors since return. Resident is out of room daily. Resident continues to voice needs appropriately. No problems with new roommate as of 03/10/2017. Will continue to provide psychosocial support as appropriate to resident. On 04/01/2017 at 16:08 a note stated, Resident was found urinating in the dining room when nobody was in the room. S/he became verbally aggressive when caught and confronted saying s/he didn't do it and they don't know what they were talking about. A Late Entry note dated 04/03/2017 at 14:14 stated, Resident is ordered [MEDICATION NAME] IM monthly, medication is not available from pharmacy, it is out of stock and will be sent as soon as the stock is [MEDICATION NAME]. MD aware. The notes included entries on 04/05/2017 of the resident roaming the facility in her/his wheelchair, refusing vital signs and medications. A Late Entry dated 04/07/2017 at 14:15 stated, Pharmacy called to check status of [MEDICATION NAME], medication remains out of stock at this time. On 04/10/2017 at 14:19 a noted stated, [MEDICATION NAME] is still out of stock. MD notified. The documentation for 04/13/2017 and 04/18/2017 indicated the resident was arguing and verbally aggressive toward her roommate. Resident redirected, will continue to monitor. A note dated 04/25/2017 at 13:43 stated, Resident has an order for [REDACTED]. Will continue to follow up with pharmacy weekly to check on progress of receiving medication. On 04/27/2017 the progress note stated, Residents [MEDICATION NAME] is not available, thus resident is being transferred to hospital for evaluation r/t receiving court ordered medication and pharmacy's inability to give date it will be available. Review of the Pharmacy Medication Regimen Review dated 03/29/2017 indicated the resident was a re-admit, that [MEDICATION NAME] was reduced, [MEDICATION NAME] and as needed [MEDICATION NAME] were discontinued. The review showed that [MEDICATION NAME] had been added to the resident's drug regimen. In an interview with the surveyor on 04/26/2017 at 10:35 AM the Director of Nursing and the Administrator confirmed the medication was not available, that the facility had called the pharmacy/ physician and documented the calls. The Administrator and Director of Nursing confirmed that the pharmacy was responsible for providing the medications. In an interview with the surveyor on 04/27/2017 at 12:00 PM the physician stated s/he was aware there was no [MEDICATION NAME] available. S/he stated if the resident's behaviors deteriorates s/he would change medication.

Based on record review and interview, the facility failed to provide aggressive treatment for 1 of 2 residents reviewed for pressure sores. Resident #125 was admitted with pressure sores, did not have pressure sores assessed or orders for treatment of [REDACTED]. The findings included: The facility admitted Resident #125 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Admission Minimum Data Set (MDS). The resident was coded to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The resident's functional status was coded for the need of extensive assist with bed mobility, transfers, dressing, toilet use and hygiene. Non ambulatory, total assist with locomotion and bathing. Supervision was required with eating. Resident had a catheter for urinary elimination. He was frequently incontinent with bowels. S/he weighed 157 lbs. The resident was coded to have unhealed pressure sores, 3 Stage II pressure sores and 2 unstageable, slough/eschar, present on admission. 3.0 x 3.0 with Eschar pressure ulcer care. Resident with pressure reducing device for chair and bed. Pressure ulcer care and surgical wound care. Review of the Hospital Admission Notes from 10/12/16 through 10/26/16 revealed Wound Care Reports including: 10/12/16- Behind ears is noted slight red, cannula padding placed to 02 tubing. Backside is noted to have redness. Bilateral (Bil) heels is noted to have dry patches of brown skin. Petroleum jelly applied. 2 protruding areas to his/her mid back. Areas was noted to have duoderm dressings. Dressings removed. Areas with appearance of friction areas. [MEDICATION NAME] applied. Both areas have red wound beds. 10/21/16- [MEDICATION NAME] dressings changed to his back (2) areas. Areas are noted to have protruding appearance, with upper dressing noted to have small amount of serosangangeous drainage. Behind ears noted without redness or breakdown. Bil heels is noted to have dry scaly appearance. 10/24/16- Red raised area to left side of back and surrounding tissue swollen. [MEDICATION NAME] gentle dressing in place. Dressings to both arms with mod. Serous drainage on dressing. Both plantar dry and peeling. Buttock, elbows and heels intact. Weekly Body Audit: 10/26/16 Open sores to back on spine. Permacath to right chest, bruising to both arms. Skin tear upper left arm and upper right arm, Redness to bottom. MD Progress Notes: 10/28/16- He mentions he has diarrhea. 11/1/16: 2 X 2 cm decubitus. Review of physician's orders [REDACTED]. There were no admission orders [REDACTED]. The initial body audit of 10/26/16 noted open sores to back on spine. No orders for treatment of [REDACTED]. At the time of the orders, the pressure ulcers had worsened and were unstageable. 10/28/16: Stool for Culture and [MEDICAL CONDITION]. 11/1/16: Wound Care Center for debridement of eschar mid back. 11/3/16: Right foot- clean with wound cleanser, pat dry, apply antibiotic ointment. Xeroform between toes, cover with non-adhered dressing, wrap with kling and tape in place, every day shift every Mon-Wed-Fri. Left foot clean with wound cleanser, pat dry, cover with [MEDICATION NAME] gentle wrap entire foot with kling and tape in place every day shift Mon and Thurs. Back clean with wound cleanser, pat dry, apply sureprep, cover with abd pad and tape in place. Every day shift every Mon-Wed-Fri. 11/8/16: Send to ER for eval and treat one time only for decreased B/P and 02 Sats. Review of Nurses Notes revealed a note on 10/30/16 at 8:00 PM. CNA (Certified Nursing Assistant) reported bandage on back and toes. Wife said he had wounds. Spoke with Doctor, states s/he will have wound nurse check on areas tomorrow. Cleaned with wound cleaner and dressed bandage on back and Rt (right) great toe. 11/1/16 at 1:45 PM Primary Physician in to see resident. New order noted for the resident to see the wound clinic for debridement to the eschar to the middle of the resident's back. Review of the wound reports revealed there was no assessment of the pressure sores until 11/3/17. Top of mid back, unstageable pressure ulcer. 3 x 3 -wound bed- black/brown eschar. Mid back- unstageable pressure ulcer. 3 x 2.5 black-brow eschar, black-brown surrounding skin, hardness and induration. Review of the resident's medical record with the Director of Nursing (DON) on 4/28/17. The DON confirmed the resident did not have admission orders [REDACTED]

Based on observation, record review and interview, the facility staff failed to ensure appropriate treatment for 1 of 1 resident observed for enteral feedings and 3 of 6 residents observed with behaviors and receiving medication. During Resident #113's gastric tube ([DEVICE]) medication administration, the nurse failed to follow established procedures to aspirate stomach content prior to instillation of the prescribed medication. In addition, the staff failed to always follow physician's orders [REDACTED]. The facility failed to honor residents rights regarding refusal of medications for 3 of 6 residents reviewed for behaviors. It was reported by a staff member that Residents #86, #112 and #71 were administered medications they had refused. The findings included: On 04/24/2017 a complaint survey was conducted in conjunction with the recertification survey in response to substantiated facility reported incident alleging that resident's were held down and given medications; the physician's orders [REDACTED]. The facility staff involved was terminated and reported to the appropriate agencies. Resident #113 was given enteral feedings by bolus instead of the ordered gravity feeding. Residents #71, #86 and #112 had a history of [REDACTED]. The facility admitted Resident #113 with [DIAGNOSES REDACTED]. On 4/26/17 at approximately 8:27 AM, a review of Resident #113 physicians orders revealed the resident was to receive Levetiracetam solution 100 mg/ML via [DEVICE] every 12 hours and [MEDICATION NAME] 100 mg every 12 hours via [DEVICE]. On 4/26/17 at approximately 8:30 AM, an observation of Resident #113's medication administration on the 100 Magnolia hall with Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 the staff development coordinator revealed that LPN #1 donned gloves, attached a syringe to the residents [DEVICE], and pushed 10 milliliters(ml) of air into the tube. LPN #1 then disconnected the syringe and removed the plunger without checking stomach contents/ residual. LPN #1 reconnected the syringe and proceeded to administer the residents' medications (Levetiracetam and [MEDICATION NAME]). On 4/26/17 at approximately 8:45 AM, during an interview following Resident #113's medication administration observation, LPN #1 and RN #1 verified LPN #1 did not check the residents' residual prior to administration. RN #1 the staff development coordinator stated, I would have expected the nurse to have checked for residual. On 4/26/17 at 11:00 AM, during an interview with the Director of Nursing (DON), the DON was asked if there was a facility policy for [DEVICE] medication administration. The DON stated, No. On 4/24/2017 at 4:10 PM the resident was observed lying in bed, Head of Bed (HOB) elevated. Tube feeding flush hanging, via gravity. Review of the medical record revealed a Quarterly Minimum Data Set (MDS) of 12/13/2016. The MDS had coded the resident with cognitive deficiencies. S/he had no mood or behavior problems. The resident required extensive assist with bed mobility, transfers, and dressing. Total assist was required with locomotion, eating, toilet use, hygiene, and bathing. S/he was always incontinent of bowel and bladder. S/he received nutrition through Gastrostomy Tube Feedings. Review of the medical record revealed the resident's care plan. Risk for infection, aspiration, decreased hydration, decreased nutrition r/t gastric tube. Feedings as ordered, check residual prior to feeding or medication administration. Elevate HOB. Verify tube placement. Risk for pain r/t neoplasm of brain. Impaired cognition and memory impairment with potential for impaired communication. Terminal [DIAGNOSES REDACTED]. Further review of the medical record revealed tube feeding orders: Enteral Feed: 10/27/16 four times a day related to Dietary Counseling and surveillance. Glucerna 1.2 give one can of feeding via tube four times a day, No bolus feedings. 8/15/16 One time a day Tube feeding- 190 cc water every morning. Review of the Five Day facility reported incident included a stated that on 11/03/2016 two witnesses reported that Licensed Practical Nurse (LPN) #9 gave Resident # tube feeding not ordered by the physician. The order was to give feeding by gravity, and it was witnessed given by bolus. On 5/5/2017 at approximately 11:20 AM, Licensed Practical Nurse (LPN) #11, was interviewed by phone. The LPN stated, I did witness the nurse give tube feeding bolus and should have been gravity, it was ---- (LPN #9). On 5/5/17 at 11:30 AM, Licensed Practical Nurse (LPN) #9, was interviewed by phone. The LPN stated s/he fed resident #113's tube feeding by gravity. Tube feedings were placed in a bag. He got it every 6 hours. I don't recall what the order was whether, it was by bag or not. On 5/10/17 at 10:30 AM, LPN #10 was interviewed by the surveyor over the phone. The LPN stated the resident's tube feeding was only to be given by gravity. S/he was to get it while while up in chair or in bed at a 90% angle. S/he had a problem with aspiration. The LPN stated s/he had witnessed the resident receive the tube feeding bolus. The LPN stated s/he had observed the tube feeding to be given bolus quite a few times. I even called the doctor about it. The facility admitted resident #112 with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set (MDS) of 12/6/16 and Annual MDS of 3/3/17 revealed the resident was severely cognitively impaired with Brief Interview for Mental Status (BIMS) score of 2 and 3 out of 15. Review of the Resident's care plan revealed a problem with behaviors. History of verbal and physical aggression with staff and others, refusal to take meds, refusal to allow staff to assist with ADL care and mobility tasks r/t [DIAGNOSES REDACTED], and [MEDICATION NAME] Hemorrhage. 4/24/17 4:20 PM The Surveyor attempted to interview the resident. The resident was sitting in Rock-n-go with alarm at the nurses station. Don't want you around. My name is -------. The resident's speech was slurred and difficult to understand. The resident appeared to be agitated and unable to answer questions. On 4/24/17 at approximately 5:45 PM, Licensed Practical Nurse (LPN) #7 was interviewed by the surveyor. The LPN stated resident #112 reported to me, that the nurse forced him to take his/her medication, her/his name was -----(LPN #8). S/he asked the Certified Nursing Assistants (CNA's) to hold him/her down while s/he gave him/her an injection. I saw him/her do it. The resident was out in the lobby area acting out. I watched the CNA's hold him/her down. They did what they were told to do. I heard him/her say s/he did not want the shot. I reported it to the Director of Nursing (DON). Resident #86 was admitted to the facility with [DIAGNOSES REDACTED]. On 4/24/2017 at approximately 3:50 PM the resident was observed, in wheel chair, propelling self in the hallways. The surveyor attempted to speak to the resident. The resident looked at the surveyor, s/he made no verbal response and no attempt at conversation. On 4/25/17 at approximately 11:30 AM the surveyor attempted unsuccessfully to interview the resident. Review of the medical record revealed an Annual MDS of 1/23/17. The resident's BIMS score was 3 out of 15. Behaviors were coded of delusions with no behaviors. A Quarterly MDS of 3/20/17 revealed the resident was not coded for delusions. Review of the care plan revealed an identified problem history of physical and verbal aggression toward staff and other residents. History of refusing medications, history of refusing staff assistance with ADL's and mobility tasks, hygiene and bathing. Interventions included to administer medication. Divert attention when possible and attempt to refocus behavior on something else. Review of the Nurses Notes from August 2016 through 4/24/17 revealed the resident frequently refused medications. Review of the facility investigation revealed a statement from LPN #10 that stated s/he observed LPN #9 give Resident #86 a [MEDICATION NAME] injection through the resident's clothes, after the resident refused the medication. In a telephone interview with the surveyor on 05/05/2017 at 11:50 AM LPN #9 denied having any problems giving Resident #86 her/him medication. In an interview with the surveyor on 5/10/17 at approximately 10:30 AM LPN #10 stated, I saw her/him (resident #86) get a [MEDICATION NAME] shot by LPN # 9, given straight to the resident through his/her clothes. I was told the resident refused his/her meds. The last time I saw it the resident was bleeding. I think it was his/her right arm. I witnessed LPN #9 several times around May or June of last year give the resident injections when the resident had refused. I had reported to the DON (Director of Nursing). Resident #71 was held down in her/his bed and given a shot. The resident said s/he did not want the [MEDICATION NAME] shot. It made her feel funny and gave him/her knots in his/her arms. I saw the resident given the [MEDICATION NAME] two times. The facility admitted resident #71 with [DIAGNOSES REDACTED]. Review of Nurses Notes revealed the resident had behaviors of hitting staff, cursing and refusing therapy treatments and refused to allow staff to assist. On 4/24/2017 3:40 PM Resident observed lying in bed on back. TV on in room. Alert verbal. Doesn't remember anything about getting a shot through her clothes. Doesn't remember refusing to take [MEDICATION NAME] injection. I take shots all the time.

Based on record review, observations and interviews, the facility failed to protect residents from resident to resident abuse or abuse by a staff member. 5 of 6 residents reviewed for behaviors. Residents #28, #86, #94, #112 and #113 were verbally or physically abused. The findings included: Cross refer to F155 Resident Rights regarding resident #86, #71 and resident #112 given injections against their will. Resident #86 had numerous behaviors including refusal of medications, verbal, mental and physical abuse of roommates. The resident had repeated hospital transfers for behaviors. The resident had repeated returns to the facility and had the same behaviors. The resident was sent to the hospital from 12/30/16 through 1/9/17, 1/31/17 through 2/1/17, 2/22/17 through 2/23/17, and 2/26/17 through 3/9/2017 for behaviors. During the period the resident had five (5) different roommates. The facility admitted resident #86 with [DIAGNOSES REDACTED]. On 4/24/2017 at approximately 3:50 PM the resident was observed, up in wheel chair, propelling self in hallways. The surveyor attempted to speak to resident. Resident glaring at surveyor, no verbal response no attempts at conversation. On 4/25/17 at approximately 11:30 AM the surveyor attempted to interview the resident s/he continued to glare when surveyor attempted to talk with resident. Attempts to interview, were unsuccessful. Review of the medical record revealed an Annual Minimum Data Set (MDS) of 1/23/17. The resident's Brief Interview for Mental Status (BIMS) score was 3 out of 15. Behaviors were coded of delusions with no behaviors. A Quarterly MDS of 3/20/17 revealed the resident was not coded for delusions. Review of the care plan revealed an identified problem history of physical and verbal aggression toward staff and other residents. History of refusing medications, history of refusing staff assistance with ADL's and mobility tasks, hygiene and bathing. Interventions included to administer medication. Divert attention when possible and attempt to refocus behavior on something else. Further review of the medical record revealed a Behavioral Health Discharge Summary 3/9/2017. History of Chronic [MEDICAL CONDITION], the patient was admitted on court papers for refusing medications and refusing the pill and we started [MEDICATION NAME] 234 mg IM given on 2/27/17. Having paranoid and threatening behavior towards staff. The patient is very agitated and paranoid and psychotic, refusing to take medications. Review of the Nurses Notes (NN) from August 2017 through 4/24/17 revealed the resident had many behaviors towards others, behaviors of voiding and having BM's on floor, yelling, cursing, throwing liquid (water/soda) on roommates. Resident frequently refused medications including antipsychotics and insulin. S/he paced in her wheelchair and talked to herself. NN 12/22/16: Roommate stated resident (#86) hit me in the mouth and poured water and soda on my face Resident (Res) admitted s/he poured what was in his/her cup on the roommate. Ice cream was noted on the wall and a water/ice cup was on the floor. Beside roommate's bed. Res. admitted s/he had thrown things in the room. 12/23/16: 1:1 care provided 12/24/16: Resident blocked door with bedside table to prevent staff from entering room to check on roommate. Roommate reports resident turning his/her TV to cartoons when s/he finds a show to watch. The res turns TV down so roommate can't hear. Res. turns off roommate's light. Res stated s/he wanted res (roommate) out of his/her room. 12/30/2016: 4:30 AM- Roommate states Res took his/her phone and tried to pour water on me. Res keeps turning light off. 6:30 AM: On 1:1 supervision. 11:28 AM: New order to transfer to hospital for evaluation and treatment. 10:00 (?) AM Remains on 1:1. Complained of (c/o) person following him/her, wanted sitter out. Resist to redirect. 12:30 PM transferred to ____(psychiatric hospital unit) Director of Nursing (DON), Assistant DON (ADON), Deputy Sheriff, Social Worker (SW) and Nurse Practitioner (NP) present during transfer. 1/4/17: PAR Meeting Note: Res (resident) to Res abuse. 1/9/17: Returned from hospital. Refused body audit. 5:00 PM Already refusing care. Refusing meds. Urinating on floor. Refused vital signs and weight. Pants saturated with urine. 1/11/17 11:00 AM Continues to have paranoia and hallucinations. 6:00 PM Continues with paranoia and hallucinations. Cursing out loud in room. Urinated in middle of hallway. 1/14/17 6:00 PM: S/he told another resident s/he was going to get away out the door first chance s/he gets. S/he doesn't want people to live in his/her room. 1/18/17: Res. Roommate yelling, I saw you do that. I know its you that's been doing things to my stuff and stealing . 1/22/17 Ref meds 1/26/17: Refused all AM meds. 7:00 PM refused all meds, 1/28/17 Refused all PM meds. 1/31/17: Threatening roommate, refused meds. Orders to transfer to hospital for evaluation. 6:10 PM: Transferred to hospital. Res still refusing to eat and take medications. Threatening roommate with doing anything to get him/her out of his/her room. 2/1/17: Call from hospital, [DIAGNOSES REDACTED]. Returned to the facility. Urine noted on floor by res. Bed. Refused shower. PAR Meeting- Refused meds, incontinent throughout facility. Episodes of harassing roommate. Returned with antibiotic for UTI. 2/11/17: Standing on stumps in wheel chair cussing at window and door. Telling them to shut up, Refused meds and vital signs. 2/15/17: Cursing at other residents and staff. 2/19/17: Told nurse that TV in room cussed out his/her TV and now the preacher won't come on his/her TV. Resident in the Hospital for behaviors 2-22-17 through 2-23-17 and 2-26-17 through 3/9/17. 4/13/17: CNA reported to nurse this resident arguing with roommate about TV in his/her room, using much profanity. Resident was telling roommate that s/he doesn't like him/her and wants him/her to stop watching him/her and stop talking to him/her. 4/15/17: Refused vital signs, ADL's and Insulin. 4/18/17: Resident had a episode of verbal aggression toward roommate. Review of Physician's Progress Notes revealed a progress note of 1/11/17. readmitted from (psychiatric hospital) where had been sent for increased agitation, abuse against other residents, refusal to take medication . Has been rolling self around hall, talking to self, cursing, acting strangely. Review of monthly psychiatric visits from 8/25/16 through 4/18/17 revealed on each visit ( 8/25/16, 10/18/16, 11/23/16, 1/10/17, 2/10/17, 3/21/17 and 4/18/17) the resident was documented to have had active hallucinations and delusional thinking. Continued challenges related to yelling, non-compliance with medications. This non-compliance continues and has only gotten minimally better with medications because s/he variably refuses. Recommend at this point legal guardianship/power of attorney be pursued with patient being declared by a judge to be unable to make appropriate treatment decisions, legally protecting facility should administration of meds against the patient's will become necessary. Currently calm inspite of [MEDICAL CONDITION]. On 4/26/17 at approximately 10:35 AM, the Administrator and Director of Nurses were interviewed by the surveyor. The Administrator and DON were asked what was being done to protect other residents from resident #86. They stated they were not aware of the resident hitting another resident. They have moved roommates. S/he has had 5 roommates. 1:1 has been provided. We have considered a private room. Based on record review, observations and interviews, the facility failed to protect residents from abuse by a staff member. One of one resident reviewed for abuse. Resident #28 was abused by a staff member when the resident's wheelchair was pushed and hit a wall. The findings included: The facility reported an allegation of physical abuse for Resident #28 on 2/6/17. The facility's Five-Day Follow-Up Report indicated on 2/5/17 at 6:28 PM CNA #4 pushed the chair that the resident was sitting in down the hallway and let it go. The chair was moving at a quick rate of speed and hit the wall. Further review of the medical record revealed the Significant Change Minimum Data Set ((MDS) dated [DATE] coded Resident #28 as having a Brief Interview for Mental Status score of 12. The Significant Change MDS coded Resident #28 as totally dependent for transfers, dressing, hygiene and bed mobility with no behaviors coded as occurring during the assessment period. Review of Resident #28's care plan revealed alteration in behavior due to dementia with behavioral disturbance was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to maintain a calm, unhurried environment. LPN #6's facility-obtained statement dated 2/5/17 indicated s/he was in the hallway with LPN #8 and LPN #9. CNA #4 was pushing Resident #28 in his/her wheelchair toward them. CNA #4 stated the resident had called him/her a black [***] and that they needed to do something with the resident. LPN #6 told CNA #4 that s/he needed to take the resident to his/her nurse because they were passing medications. In an interview with the surveyor on 4/25/17 at approximately 4:15 PM, LPN #6 stated s/he was training LPN #8 and LPN #9 and they were doing the last medication pass around 5:30 PM. They were in the hallway in the area of Rms 101-106. CNA #4 was pushing Resident #28 down the hall. CNA #4 said y'all need to get him/her. LPN #6 told CNA #4 s/he needed to take the resident to his/her nurse since they were doing medication pass. CNA #4 let go of the wheelchair, but LPN #6 was turning away at the time and didn't see what happened. LPN #6 heard LPN #9 yell out, thought the resident had hit him/her. Resident #28 had made a derogatory statement toward CNA #4 and s/he was mad about what the resident said. LPN #6 said it had something to do with race but s/he can't remember exactly what. CNA #4 came up and said you need to take the resident because of what s/he said. LPN #6 stated s/he never heard Resident #28 say anything derogatory to staff. LPN #7's facility-obtained statement dated 2/5/17 indicated s/he witnessed the incident, as much as s/he could see. LPN #7 was at the nurses' desk charting. CNA #4 got Resident #28 and pulled his/her rock-n-glide wheelchair down to the other nurse and 2 orientees. When CNA #4 let go of the chair it turned and bumped the wall with the foot of the chair. Resident #28 did not have his/her feet on that part of the chair and s/he didn't express any harm or injury. LPN #7 went and got the resident and put him/her at the nurses' desk. LPN #8's facility-obtained statement dated 2/5/17 indicated s/he heard CNA #4 say something such as Get (him/her) away from me or Keep (him/her) away from me. LPN #8 was standing at the medication cart, CNA #4 was pushing Resident #28 down the hall. CNA #4 stopped walking and Resident #28 kept rolling down the hall unassisted at a pretty quick rate of speed. Resident #28's wheelchair veered right towards the wall and spun around and crashed into the wall. It was a pretty hard impact, but LPN #8 didn't believe the resident was injured. Resident #28 seemed kind of scared. LPN #8 continued passing medications. An interview with LPN #8 was documented on his/her facility-obtained statement. The interview indicated LPN #6 told CNA #4 to take Resident #28 to LPN #7, his/her nurse. Then s/he came back pushing Resident #28 and let the wheelchair go. Resident #28 grabbed the wheel and the chair spun around to the right hitting the wall. Resident #28 appeared very scared of what happened. LPN #9's facility-obtained statement dated 2/5/17 indicated s/he was at the medication cart when CNA #4 pushed Resident #28 down the hall and his/her wheelchair spun around and hit the wall. CNA #4 walked away and the resident said help me. Then LPN #7 came and pushed the resident to sit at the nurses' desk. CNA #4's facility-obtained statement indicated s/he went to get Resident #28 from his/her room and pushed him/her to LPN #6. Resident #28 hit another nurse in the leg. LPN #6 told CNA #4 to take Resident #28 to his/her nurse, LPN #7. CNA #4 walked away. CNA #4 indicated Resident #28 called him/her a stupid black [***] . In an interview with the surveyor on 4/27/17 at approximately 4:22 PM, the DON (Director of Nursing) stated Resident #28 calls out for help a lot, wants to get up and then down. Resident #28 is endstage Alzheimer's. Resident #28 is combative with staff at times. S/he is repetitive - help me/help, take me to my room. When you don't do what the resident wants you to do, s/he becomes mean with staff. When Resident #28 becomes mean, s/he reverts to 1960's language that is not appropriate. CNA #4 had worked with the resident before. S/he was his/her 1:1 sitter. The DON received a call about the incident, thinks it was in the evening. The DON was told that CNA #4 had gotten mad because Resident #28 said something inappropriate and s/he pushed him/her into the wall. CNA #4 had lost his/her cool, s/he pushed the wheelchair and let it go. CNA #4 said y'all need to take him/her to a nurse and 2 trainees who were passing medications. The nurse who CNA #4 went to responded can you take him/her to the nurses' station to his/her nurse. Review of the facility's Abuse Prevention Program revealed physical abuse of the resident is prohibited. The policy indicated staff receives orientation and on-going training on appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, how to recognize signs of burnout, frustration and stress that may lead to abuse.

On the days of the survey, based on observation, record review, and interviews, the facility failed to review and revise the care plans of 2 of 3 sampled residents reviewed for falls. Care plans were not amended to include changes in interventions following falls to prevent recurrence, minimize injury, and maintain the safety of Residents #14 and #109. Failure to implement changes to the plan of care for Resident #109 resulted in harm to the resident. The findings included: Based on record review and interview, the facility failed to implement changes in care plan interventions following multiple falls to prevent recurrence and/or minimize potential injury for Resident #109. Following incidents when the resident fell after having been in her/his chair, the Care Plan was not updated/amended to provide adequate supervision and/or interventions were not added/amended to maintain the resident's safety. After having been left on the toilet unattended in 1-13, adequate supervision was not provided and/or interventions were not implemented to maintain the safety of the resident, resulting in duplicate circumstances recurring in 5-13. Failure to review and revise the Care Plan to implement changes in interventions resulted in harm to this resident. The facility admitted Resident #109 with [DIAGNOSES REDACTED]. During an interview on 7-22-13 at 2:20 PM, the family expressed concerns with staff leaving the resident unattended in the bathroom, resulting in two recent falls. He/she was reticent to discuss the matter further. Review of the Grievance Log revealed that the family had voiced a concern to the facility on [DATE] that "CNA (Certified Nursing Assistant) left resident on toilet." The Resolution was noted as "CNA re-educated on leaving resident unattended in BR (bathroom). Signs placed on door to BR and inside BR that resident not to be left unattended." Review of quarterly fall risk assessment completed on 7-5-13 revealed that Resident #109 was at "medium risk". Observations revealed throughout the survey that, when out of bed, the resident was placed in a rocker/glider wheelchair with a pressure-type alarm and a tabletop restraint, as well as positioning devices for the lower extremities. A bed alarm and an alarmed fall mat were readily visible for use in the resident's room. Review of the 12-26-12 and 6-24-13 Quarterly Minimum Data Set (MDS) Assessments on 7-23-13 at 10 PM revealed that the resident usually understood the spoken word but had unclear speech. Cognitive status was unable to be determined via the Brief Interview for Mental Status. Staff assessment indicated the resident had both short- and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The 12-12 MDS noted the resident with disorganized thinking. Both assessments reviewed noted that the resident was easily annoyed. S/he required extensive assistance of one person for bed mobility. Resident #109 required extensive assistance of one person for transfers and toileting in 12-12 and extensive assistance of two in 6-13. Range of Motion was impaired in one lower extremity. The resident was on a toileting program with occasional incontinence in 12-12 and was noted as continent in 6-13. Resident #109 received routinely administered anti-anxiety and antidepressant medication ([MEDICATION NAME]). Nurse's Notes, Incident Reports, physician's orders [REDACTED]. Additional documentation was requested from the Director of Nurses on 7-25-13 at 1:20 PM . Any additional Nurse's Notes related to the falls, investigations, physician's orders [REDACTED]. The following information was provided, reviewed with, and verified by the Director of Nursing on 7-26-13 beginning at approximately 11 AM. (1) On 6-30-12 at 3:30 PM, the resident was found "sitting on floor in doorway of room". The report noted that first aid was applied but Nurses Notes did not document any injury. The Incident Report noted no witnesses and that a chair alarm and lap tray were in place. "Bed alarm" appeared to be added in a different script. The Investigation noted that a functional alarm was in place at the time of the fall. Statements by two Certified Nursing Assistants (CNAs) noted the resident had last been seen in her/his chair. The Supervisor Follow Up on the Investigation did not reflect the CNA statements as it noted: "Res(ident) had gotten up from nap unassisted & staff unable to reach before fall. Res. had gotten up unassisted & was trying to get in w/c (wheelchair) without help." There was no evidence to substantiate this conclusion. Review of the Care Plan and physician's orders [REDACTED]. (2) On 7-4-12 at 2:15 AM, "Bed alarm and floor pad alarm alerted nsg (nursing) staff" and the resident was found "sitting on floor pad near bed". The Incident Report noted no witnesses. No injuries were sustained. The Investigation noted that Resident #109 "does not use call light." However, the Supervisor Follow Up noted: "Encouraged Resident to use call light." Review of the Care Plan and physician's orders [REDACTED]. (3) On 7-16-12 at 7 AM, a staff member responding to an alarm, noted the resident "sitting on floor" in her/his room. The Incident Report noted no witnesses. No injuries were noted. "Safety devices in place" included only the bed alarm. There was no mention of the fall mat being in place at the time of the incident. The Supervisor Follow Up noted the "Resident transferred self & sat on bottom... did not ask for assistance." Review of the Care Plan and physician's orders [REDACTED]. (4) On 8-14-12 at 5:30 AM, the resident was found "sitting on landing strips...falls alarm on." The Incident Report noted no witnesses. No injuries were noted. Review of the Care Plan and physician's orders [REDACTED]. (5) On 8-16-12 at 1:40 AM, staff responding to an alarm found Resident #109 "sitting on floor by nightstand." The Incident Report noted no witnesses. No injuries were sustained. The Supervisor Follow Up noted the "Resident got up to use restroom; when alarm sounded, resident attempted to turn alarm off; she (he) was found sitting in floor with alarm in hand...reminded to use call light." Review of the Care Plan and physician's orders [REDACTED]. (6) On 8-26-12 at 5:15 PM, the resident was "Found sitting on floor in r(oo)m." The "seat alarm" was in place and functional. First aid was administered, but no record of specific injury could be located. Another resident witnessed the incident. Review of the Care Plan and physician's orders [REDACTED]. (7) On 9-13-12 at 1:30 PM, Resident #109 had been up in a rocker recliner and was found on her/his buttocks in the room. No safety devices were noted in place on the Incident Report. The Incident Report noted no witnesses. The Investigation noted the chair/bed alarm as in use and functional, but "no alarm sound." The Supervisor Follow Up stated: "Resident had to use bathroom- chair alarm and musical mat alarm was off when nurse noticed alarms not sounding when pt. (patient) was found on floor." No injuries were noted, though first aid was documented as administered. Review of the Care Plan and physician's orders [REDACTED]. There was no evidence provided of follow-up regarding the non-functioning alarm. (8) On 9-30-12 at 10:30 PM, "CNA heard alarm sounding. Entered the room, noted Res(ident) crawling on the floor." The Incident Report noted no witnesses. The Supervisor Follow Up stated:"Res got up unassisted." No injuries were noted. Review of the Care Plan and physician's orders [REDACTED]. (9) On 10-4-12 at 6:45 AM, the resident was found "sitting on bathroom floor by toilet...bed alarm not on." The Incident Report noted no witnesses. The CNA statement noted the resident was found "leaning head to r(igh)t in corner of door...moaning loudly." The nurse noted the resident was sitting in urine and upset. S/he sustained a skin tear to the right arm (no dimensions documented).The nurse noted s/he had advised the CNA of a change in the type of bed alarm. No notation was made as to when this occurred as the last fall was noted 5 days previously. Review of the Care Plan and physician's orders [REDACTED]. There was no evidence provided of follow-up with the CNA involved. (10) On 10-14-12 at 11:30 PM, the resident was found "sitting on mat in front of bed" when responding to the bed alarm. A floor pad was in place. The Incident Report noted no witnesses. No injuries were noted. On 10-15-12, the Care Plan was updated for "Staff to check on Res every l hour while in bed. Pull curtain between Residents. Toilet Res. frequently to prevent falls." As the resident was already noted to be on a one-hour bowel and bladder training schedule, this did not represent a change in interventions to prevent recurrence and/or to minimize potential injury. (11) On 10-16-12 at 8 PM, Resident #109 was found "sitting upright in room in front of bathroom door" when staff responded to the wheelchair alarm pad. S/he sustained "a small skin tear" to the lower right arm. The Incident Report noted no witnesses. Review of the Care Plan revealed a 10-18-12 (two days later) entry on the Care Plan that noted "Restorative to ambulate Res to the bathroom." No changes in interventions were implemented to prevent recurrence and/or to minimize potential injury. (12) On 12-16-12 at 7:45 AM, staff responding to an alarm and "resident yelling", found Resident #109 in her/his room, "lying on floor on the right side with feces noted on floor, resident's clothing, and person...Red area noted to right upper forehead ." There was no notation as to whether the resident was in bed or in her/his chair prior to the incident. The Incident Report noted no witnesses. The CNA statements noted the resident was "crying" and "upset". At 9 AM, the resident was moaning and nodded when asked if in pain. Tylenol was given. At 9:25 AM the. resident was "noted to be extreme drowsy...Pupils unequal and not reactive to light." The physician was notified. The resident was sent to the hospital for evaluation and was "admitted for change in LOC (level of consciousness)." Review of the Care Plan and physician's orders [REDACTED]." On 12-20-12, the Care Plan was updated to include an intervention of "PT/0T as ordered." No changes in interventions were implemented to prevent recurrence and/or to minimize potential injury. During the interview, the DON confirmed that this intervention would not keep the resident safe. (13) On 1-24-13 at 1:40 PM, Resident #109 "was taken to BR (bathroom) by nurse + nurse went for add(itiona)l assistance, Res got up + fell ." S/he was found "agitated...on floor" in the bathroom. "Limited (ROM) (L)(eft) side - c/o (complains of) pain (L) hip, (L) trunk, (L) shoulder...EMS called + Res transported to (Hospital) for eval(uation)." The Incident Report noted no witnesses. The resident returned to the facility at 7 PM with a [DIAGNOSES REDACTED]. The State Agency was notified of this incident on 1-24-13 as an "Allegation of neglect." A 1-25-13 physician's orders [REDACTED]. The facility provided documentation that the resident was on a Restorative Bowel and/or Bladder Retraining Program. This program form instructed: "Take to bathroom every hour." According to physician's orders [REDACTED]. (14) On 2-8-13 at 7:45 AM, when responding to an alarm, found Resident #109 "on floor near sensory mat... on (R) (ight) side." Sensory pads were noted in place and functional. The Incident Report noted no witnesses. No injuries were noted. Staff statements noted that the resident had been in her/his chair at the nursing station when last seen prior to the incident. The Care Plan was not updated with a fall notation but an intervention was added on 2-13-13 (five days later): "Staff to redirect resident when trying to go back to room and staff not to leave resident unattended while in room." These instructions do not appear on the CNA Care Card or the Daily Care Guide. (15) On 2-24-13 at 5 AM, "Res found on floor beside bed-Staff heard alarm and respond(ed)...refuses to use call light." S/he had been in bed and was "found lying on landing pad." The Incident Report noted no witnesses. No injuries were noted. The Supervisor Follow Up noted "A good intervention would be move Res. room closer to nurses desk???" A note added in a different script stated: "Family does not want to move resident's room." The Care Plan was updated with the fall and an intervention added of "Staff to cont (inue) to assist with toileting needs and monitor safety. Continue toileting program." Already listed as an approach (undetermined start date) was "toilet resident frequently to prevent falls." No changes in interventions were implemented to prevent recurrence and/or to minimize potential injury. (16) On 3-31-13 at 10:55 PM, staff responding to a bed alarm found the resident "sitting on floor...Resident transferred self without assist." The Incident Report noted no witnesses. No injuries were noted. Nurse's Notes on 4-3-13 (four days later) documented a PAR (patients at risk) meeting related to the fall on 3-31-13. "MD to review meds for urinary urgency + frequency per recommendation of PAR members." Although requested on 7-25-13, there was no evidence provided that the medication review had been done. Review of the Care Plan and physician's orders [REDACTED]. (17) On 4-22-13 at 9 PM, "Resident's alarm sounding, CNAs responded promptly + resident observed kneeling on floor pad" in her/his room. The Incident Report noted no witnesses. No injuries were noted. The Supervisor's Follow Up noted: "Resident attempted to get up out of bed without assistance... Res is reminded to seek ass(is)t with transfers + mobility." Review of the Care Plan and physician's orders [REDACTED]. (18) On 5-12-13 at 1048 PM, Resident #109 was found "lying prone on bathroom floor." The Supervisor's Follow Up stated, "Resident had been sitting on toilet when fall then occurred. CNA was in bedroom....SDC (Staff Development Coordinator) to reeducate CNA on not leaving resident alone in BR". The CNA was noted as a witness to the fall. Nurses Notes documented "Resident has a hematoma to (R) upper forehead d /t (due to) fall. Ice applied to bruise to reduce swelling. Neuro checks started." The Incident Report did not indicate that the resident was sent to the hospital. However, a 5-13-13 Physician's Telephone Order noted: "To ER - fall with trauma to head." 5-13-13 Physician's Progress notes stated, "Today (R) eye + forehead with swelling + bruising. Less active today. To ER for evaluation." An emergency room Report indicated the resident was seen on 5-13-13 at 9:12 PM with a discharge [DIAGNOSES REDACTED]. Signs were placed on the bathroom door and inside the bathroom that resident was not to be left unattended. Incontinent supplies were placed in the bathroom. An in-service was conducted on 5-21-13 (9 days after the fall) to inform staff not to leave the resident unattended in her/his room or in bathroom. Review of the Daily Care Guide noted "Do not leave unattended in bathroom." Review of the CNA Care Card revealed "*DO NOT LEAVE UNATTENDED" entered next to toileting instructions. The DON stated this was added following the 5-12-13 fall. S/he was unable to explain why this information had not been added following the same type incident in 1-13. On the days of the survey, neither the Daily Care Guide nor the CNA Care Card noted that the resident should not be left alone in her/his wheelchair in the room. (19) Review of Nurses Notes on 7-25-13 revealed that Resident #109 was found on the floor on the floor mat at 4 AM on 6-25-13. There was no mention of alarms being in place or sounding. No Incident Report was submitted for review for this incident. There were no noted witnesses. No injuries were noted. Review of the Care Plan and physician's orders [REDACTED]. (20) On 7-7-13 at 10:30 PM, "Bed alarm and floor pad alarms alert nursing staff... Resident found sitting on floor pad near bed with both... alarms functioning... The resident had just been toileted 5 minutes prior to fall...no injuries noted." The Incident Report noted no witnesses. Review of the Care Plan related to falls and physician's orders [REDACTED]. On 7-8-13 Nurses Notes and the Care Plan related to behavior documented a PAR meeting indicating current interventions of: toileting program, floor pad, sensor alarms, lap tray, wing- tip mattress, and review of medication for constipation. The approach noted to "Educate staff on res. behavior + when res. became agitated + squirming staff to take res. to toilet." In-services were completed on 7-8-13 and 7-10-13. Review of the CNA Care Card revealed these instructions had not been added. Review of physician's orders [REDACTED].#109 had the following fall prevention measures implemented on the corresponding dates: -Landing pads on both sides of bed: 6-24-11 (Discontinued on 1-16-13 per Care Plan) -Pad alarm to bed: 7-1-11 -Pad alarm to chair: 7-1-11 -Keep bed in lowest position: 7-1-11 -Rock and Glide chair: 7-1-11 -Lap tray on wheelchair: 7-12-11 -Sensory (floor) mat by the bedside: 2-13-12 -B&B scheduled toileting effective 7-16-12 -Half siderails up X 2 as enablers The facility policy entitled "Accidents and Incidents (Rev. 7/10)" provided by the facility on 7-26 -13 did not address implementation of changes following falls to prevent recurrence and/or minimize resident injury. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. During a record review on 7/24/13 at approximately 10:00 AM, the Nurses Notes revealed the resident fell on [DATE]. Review of the Care Plan revealed that Physical Therapy was ordered as the new intervention for the fall. Review of the CNA (Certified Nursing Assistant) Care Card revealed there was no new intervention implemented after the fall of 7/19/13. During a record review of the "Investigation of Incident/Accident" form on 7/26/13 at 9:47 AM, section E-Intervention/Corrective Action/Supervisor Follow Up verified Resident #14 had a fall and the new intervention to prevent future recurrences of this incident are to: check resident, V/S (Vital Signs) done, and close observation of the resident. During an interview with the Staff Development Nurse at 9:18 AM on 7/26/13 regarding a new intervention implemented after the fall, s/he stated, "The Physical Therapy was the intervention." When asked if that was an intervention or a treatment, s/he acknowledged that Physical Therapy was a treatment and not an intervention to prevent fall recurrence.

On the days of the survey, based on observation, record review, and interviews, the facility failed to provide adequate supervision and/or assistive devices to prevent accidents and/or minimize injury for 2 of 3 sampled residents reviewed for falls. Changes in interventions were not implemented following falls to prevent recurrence, minimize injury, and maintain the safety of Residents #14 and #109. Failure to implement changes in fall prevention measures for Resident #109 resulted in harm to the resident. In addition, based on observation and interview, the facility failed to provide a hazard-free environment. A handrail bracket had a sharp, rough edge and a bottle of sanitizer and disinfectant was noted in a resident room. The findings included: Based on record review and interview, the facility failed to implement changes in interventions following multiple falls to prevent recurrence and/or minimize potential injury for Resident #109. Following incidents when the resident fell after having been in her/his chair, adequate supervision was not provided and/or interventions were not added/amended to maintain the resident's safety. After having been left on the toilet unattended in 1-13, adequate supervision was not provided and/or interventions were not implemented to maintain the safety of the resident, resulting in duplicate circumstances recurring in 5-13. Failure to implement changes in interventions resulted in harm to this resident. The facility admitted Resident #109 with [DIAGNOSES REDACTED]. During an interview on 7-22-13 at 2:20 PM, the family expressed concerns with staff leaving the resident unattended in the bathroom, resulting in two recent falls. He/she was reticent to discuss the matter further. Review of the Grievance Log revealed that the family had voiced a concern to the facility on [DATE] that "CNA (Certified Nursing Assistant) left resident on toilet." The Resolution was noted as "CNA re-educated on leaving resident unattended in BR (bathroom). Signs placed on door to BR and inside BR that resident not to be left unattended." Review of quarterly fall risk assessment completed on 7-5-13 revealed that Resident #109 was at "medium risk". Observations revealed throughout the survey that, when out of bed, the resident was placed in a rocker/glider wheelchair with a pressure-type alarm and a tabletop restraint, as well as positioning devices for the lower extremities. A bed alarm and an alarmed fall mat were readily visible for use in the resident's room. Review of the 12-26-12 and 6-24-13 Quarterly Minimum Data Set (MDS) Assessments on 7-23-13 at 10 PM revealed that the resident usually understood the spoken word but had unclear speech. Cognitive status was unable to be determined via the Brief Interview for Mental Status. Staff assessment indicated the resident had both short- and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The 12-12 MDS noted the resident with disorganized thinking. Both assessments reviewed noted that the resident was easily annoyed. S/he required extensive assistance of one person for bed mobility. Resident #109 required extensive assistance of one person for transfers and toileting in 12-12 and extensive assistance of two in 6-13. Range of Motion was impaired in one lower extremity. The resident was on a toileting program with occasional incontinence in 12-12 and was noted as continent in 6-13. Resident #109 received routinely administered anti-anxiety and antidepressant medication (Wellbutrin, Zoloft, Ativan). Nurse's Notes, Incident Reports, physician's orders [REDACTED]. Additional documentation was requested from the Director of Nurses on 7-25-13 at 1:20 PM . Any additional Nurse's Notes related to the falls, investigations, physician's orders [REDACTED]. The following information was provided, reviewed with, and verified by the Director of Nursing on 7-26-13 beginning at approximately 11 AM. (1) On 6-30-12 at 3:30 PM, the resident was found "sitting on floor in doorway of room". The report noted that first aid was applied but Nurses Notes did not document any injury. The Incident Report noted no witnesses and that a chair alarm and lap tray were in place. "Bed alarm" appeared to be added in a different script. The Investigation noted that a functional alarm was in place at the time of the fall. Statements by two Certified Nursing Assistants (CNAs) noted the resident had last been seen in her/his chair. The Supervisor Follow Up on the Investigation did not reflect the CNA statements as it noted: "Res(ident) had gotten up from nap unassisted & staff unable to reach before fall. Res. had gotten up unassisted & was trying to get in w/c (wheelchair) without help." There was no evidence to substantiate this conclusion. Review of the Care Plan and physician's orders [REDACTED]. (2) On 7-4-12 at 2:15 AM, "Bed alarm and floor pad alarm alerted nsg (nursing) staff" and the resident was found "sitting on floor pad near bed". The Incident Report noted no witnesses. No injuries were sustained. The Investigation noted that Resident #109 "does not use call light." However, the Supervisor Follow Up noted: "Encouraged Resident to use call light." Review of the Care Plan and physician's orders [REDACTED]. (3) On 7-16-12 at 7 AM, a staff member responding to an alarm, noted the resident "sitting on floor" in her/his room. The Incident Report noted no witnesses. No injuries were noted. "Safety devices in place" included only the bed alarm. There was no mention of the fall mat being in place at the time of the incident. The Supervisor Follow Up noted the "Resident transferred self & sat on bottom... did not ask for assistance." Review of the Care Plan and physician's orders [REDACTED]. (4) On 8-14-12 at 5:30 AM, the resident was found "sitting on landing strips...falls alarm on." The Incident Report noted no witnesses. No injuries were noted. Review of the Care Plan and physician's orders [REDACTED]. (5) On 8-16-12 at 1:40 AM, staff responding to an alarm found Resident #109 "sitting on floor by nightstand." The Incident Report noted no witnesses. No injuries were sustained. The Supervisor Follow Up noted the "Resident got up to use restroom; when alarm sounded, resident attempted to turn alarm off; she (he) was found sitting in floor with alarm in hand...reminded to use call light." Review of the Care Plan and physician's orders [REDACTED]. (6) On 8-26-12 at 5:15 PM, the resident was "Found sitting on floor in r(oo)m." The "seat alarm" was in place and functional. First aid was administered, but no record of specific injury could be located. Another resident witnessed the incident. Review of the Care Plan and physician's orders [REDACTED]. (7) On 9-13-12 at 1:30 PM, Resident #109 had been up in a rocker recliner and was found on her/his buttocks in the room. No safety devices were noted in place on the Incident Report. The Incident Report noted no witnesses. The Investigation noted the chair/bed alarm as in use and functional, but "no alarm sound." The Supervisor Follow Up stated: "Resident had to use bathroom- chair alarm and musical mat alarm was off when nurse noticed alarms not sounding when pt. (patient) was found on floor." No injuries were noted, though first aid was documented as administered. Review of the Care Plan and physician's orders [REDACTED]. There was no evidence provided of followup regarding the non-functioning alarm. (8) On 9-30-12 at 10:30 PM, "CNA heard alarm sounding. Entered the room, noted Res(ident) crawling on the floor." The Incident Report noted no witnesses. The Supervisor Follow Up stated:"Res got up unassisted." No injuries were noted. Review of the Care Plan and physician's orders [REDACTED]. (9) On 10-4-12 at 6:45 AM, the resident was found "sitting on bathroom floor by toilet...bed alarm not on." The Incident Report noted no witnesses. The CNA statement noted the resident was found "leaning head to r(igh)t in corner of door...moaning loudly." The nurse noted the resident was sitting in urine and upset. S/he sustained a skin tear to the right arm (no dimensions documented).The nurse noted s/he had advised the CNA of a change in the type of bed alarm. No notation was made as to when this occurred as the last fall was noted 5 days previously. Review of the Care Plan and physician's orders [REDACTED]. There was no evidence provided of followup with the CNA involved. (10) On 10-14-12 at 11:30 PM, the resident was found "sitting on mat in front of bed" when responding to the bed alarm. A floor pad was in place. The Incident Report noted no witnesses. No injuries were noted. On 10-15-12, the Care Plan was updated for "Staff to check on Res every l hour while in bed. Pull curtain between Residents. Toilet Res. frequently to prevent falls." As the resident was already noted to be on a one-hour bowel and bladder training schedule, this did not represent a change in interventions to prevent recurrence and/or to minimize potential injury. (11) On 10-16-12 at 8 PM, Resident #109 was found "sitting upright in room in front of bathroom door" when staff responded to the wheelchair alarm pad. S/he sustained "a small skin tear" to the lower right arm. The Incident Report noted no witnesses. Review of the Care Plan revealed a 10-18-12 (two days later) entry on the Care Plan that noted "Restorative to ambulate Res to the bathroom." No changes in interventions were implemented to prevent recurrence and/or to minimize potential injury. (12) On 12-16-12 at 7:45 AM, staff responding to an alarm and "resident yelling", found Resident #109 in her/his room, "lying on floor on the right side with feces noted on floor, resident's clothing, and person...Red area noted to right upper forehead ." There was no notation as to whether the resident was in bed or in her/his chair prior to the incident. The Incident Report noted no witnesses. The CNA statements noted the resident was "crying" and "upset". At 9 AM, the resident was moaning and nodded when asked if in pain. Tylenol was given. At 9:25 AM the. resident was "noted to be extreme drowsy...Pupils unequal and not reactive to light." The physician was notified. The resident was sent to the hospital for evaluation and was "admitted for change in LOC (level of consciousness)." Review of the Care Plan and physician's orders [REDACTED]." On 12-20-12, the Care Plan was updated to include an intervention of "PT/0T as ordered." No changes in interventions were implemented to prevent recurrence and/or to minimize potential injury. During the interview, the DON confirmed that this intervention would not keep the resident safe. (13) On 1-24-13 at 1:40 PM, Resident #109 "was taken to BR (bathroom) by nurse + nurse went for add(itiona)l assistance, Res got up + fell ." S/he was found "agitated...on floor" in the bathroom. "Limited (ROM) (L)(eft) side - c/o (complains of) pain (L) hip, (L) trunk, (L) shoulder...EMS called + Res transported to (Hospital) for eval(uation)." The Incident Report noted no witnesses. The resident returned to the facility at 7 PM with a [DIAGNOSES REDACTED].The State Agency was notified of this incident on 1-24-13 as an "Allegation of neglect." A 1-25-13 physician's orders [REDACTED]. The facility provided documentation that the resident was on a Restorative Bowel and/or Bladder Retraining Program. This program form instructed: "Take to bathroom every hour." Accoding to physician's orders [REDACTED]. (14) On 2-8-13 at 7:45 AM, when responding to an alarm, found Resident #109 "on floor near sensory mat... on (R) (ight) side." Sensory pads were noted in place and functional. The Incident Report noted no witnesses. No injuries were noted. Staff statements noted that the resident had been in her/his chair at the nursing station when last seen prior to the incident. The Care Plan was not updated with a fall notation but an intervention was added on 2-13-13 (five days later): "Staff to redirect resident when trying to go back to room and staff not to leave resident unattended while in room." These instructions do not appear on the CNA Care Card or the Daily Care Guide. (15) On 2-24-13 at 5 AM, "Res found on floor beside bed-Staff heard alarm and respond(ed)...refuses to use call light." S/he had been in bed and was "found lying on landing pad." The Incident Report noted no witnesses. No injuries were noted. The Supervisor Follow Up noted "A good intervention would be move Res. room closer to nurses desk???" A note added in a different script stated: "Family does not want to move resident's room." The Care Plan was updated with the fall and an intervention added of "Staff to cont (inue) to assist with toileting needs and monitor safety. Continue toileting program." Already listed as an approach (undetermined start date) was "toilet resident frequently to prevent falls." No changes in interventions were implemented to prevent recurrence and/or to minimize potential injury. (16) On 3-31-13 at 10:55 PM, staff responding to a bed alarm found the resident "sitting on floor...Resident transferred self without assist." The Incident Report noted no witnesses. No injuries were noted. Nurse's Notes on 4-3-13 (four days later) documented a PAR (patients at risk) meeting related to the fall on 3-31-13. "MD to review meds for urinary urgency + frequency per recommendation of PAR members." Although requested on 7-25-13, there was no evidence provided that the medication review had been done. Review of the Care Plan and physician's orders [REDACTED]. (17) On 4-22-13 at 9 PM, "Resident's alarm sounding, CNAs responded promptly + resident observed kneeling on floor pad" in her/his room. The Incident Report noted no witnesses. No injuries were noted. The Supervisor's Follow Up noted: "Resident attempted to get up out of bed without assistance... Res is reminded to seek ass(is)t with transfers + mobility." Review of the Care Plan and physician's orders [REDACTED]. (18) On 5-12-13 at 1048 PM, Resident #109 was found "lying prone on bathroom floor." The Supervisor's Follow Up stated, "Resident had been sitting on toilet when fall then occurred. CNA was in bedroom....SDC (Staff Development Coordinator) to reeducate CNA on not leaving resident alone in BR". The CNA was noted as a witness to the fall. Nurses Notes documented "Resident has a hematoma to (R) upper forehead d /t (due to) fall. Ice applied to bruise to reduce swelling. Neuro checks started." The Incident Report did not indicate that the resident was sent to the hospital. However, a 5-13-13 Physician's Telephone Order noted: "To ER - fall with trauma to head." 5-13-13 Physician's Progress notes stated, "Today (R) eye + forehead with swelling + bruising. Less active today. To ER for evaluation." An emergency room Report indicated the resident was seen on 5-13-13 at 9:12 PM with a discharge [DIAGNOSES REDACTED]. Signs were placed on the bathroom door and inside the bathroom that resident was not to be left unattended. Incontinent supplies were placed in the bathroom. An in-service was conducted on 5-21-13 (9 days after the fall) to inform staff not to leave the resident unattended in her/his room or in bathroom. Review of the Daily Care Guide noted "Do not leave unattended in bathroom." Review of the CNA Care Card revealed "*DO NOT LEAVE UNATTENDED" entered next to toileting instructions. The DON stated this was added following the 5-12-13 fall. S/he was unable to explain why this information had not been added following the same type incident in 1-13. On the days of the survey, neither the Daily Care Guide nor the CNA Care Card noted that the resident should not be left alone in her/his wheelchair in the room. (19) Review of Nurses Notes on 7-25-13 revealed that Resident #109 was found on the floor on the floor mat at 4 AM on 6-25-13. There was no mention of alarms being in place or sounding. No Incident Report was submitted for review for this incident. There were no noted witnesses. No injuries were noted. Review of the Care Plan and physician's orders [REDACTED]. (20) On 7-7-13 at 10:30pm, "Bed alarm and floor pad alarms alert nursing staff... Resident found sitting on floor pad near bed with both... alarms functioning... The resident had just been toileted 5 minutes prior to fall...no injuries noted." The Incident Report noted no witnesses. Review of the Care Plan related to falls and physician's orders [REDACTED]. On 7-8-13 Nurses Notes and the Care Plan related to behavior documented a PAR meeting indicating current interventions of: toileting program, floor pad, sensor alarms, lap tray, wing- tip mattress, and review of medication for constipation. The approach noted to "Educate staff on res. behavior + when res. became agitated + squirming staff to take res. to toilet." In-services were completed on 7-8-13 and 7-10-13. Review of the CNA Care Card revealed these instructions had not been added. Review of physician's orders [REDACTED].#109 had the following fall prevention measures implemented on the corresponding dates: -Landing pads on both sides of bed: 6-24-11 (Discontinued on 1-16-13 per Care Plan) -Pad alarm to bed: 7-1-11 -Pad alarm to chair: 7-1-11 -Keep bed in lowest position: 7-1-11 -Rock and Glide chair: 7-1-11 -Lap tray on wheelchair: 7-12-11 -Sensory (floor) mat by the bedside: 2-13-12 -B&B scheduled toileting effective 7-16-12 -Half siderails up X 2 as enablers The facility policy entitled "Accidents and Incidents (Rev.7/10)" provided by the facility on 7-26 -13 did not address implementation of changes following falls to prevent recurrence and/or minimize resident injury. Based on observation and interview, the facility failed to ensure that hazardous chemicals were inaccessible to residents. Room 117 had a 12 ounce container of Purell alcohol-based hand sanitizer (70% ethyl alcohol) on top of the bedside table and a 15 ounce container of Spray Disinfectant on the bathroom sink. No residents other than the one residing in the private room were noted in the immediate vicinity, though the facility did have cognitively impaired self-mobile residents on that hall. The Regional Manager and Housekeeping Supervisor removed the items when brought to their attention during the environmental tour The facility admitted Resident #14 with [DIAGNOSES REDACTED]. During a record review of the "Investigation of Incident/Accident" form on 7/26/13 at 9:47 AM, section E-Intervention/Corrective Action/Supervisor Follow Up verified resident #14 had a fall and the new intervention to prevent future recurrences of this incident are to: check resident, V/S (Vital Signs) done, and close observation of the resident. During a record review on 7/24/13 at approximately 10:00 AM, the Nurses Notes revealed the resident fell on [DATE]. Review of the Care Plan revealed that Physical Therapy was ordered as the new intervention for the fall. Review of the CNA (Certified Nursing Assistant) Care Card revealed there was no new intervention implemented after the fall of 7/19/13. During an interview with the Staff Development Nurse at 9:18 AM on 7/26/13 regarding a new intervention implemented after the fall, s/he stated, "The Physical Therapy was the intervention." When asked if that was an intervention or a treatment, s/he acknowledged that Thysical Therapy was a treatment and not an intervention to prevent recurrence. During an observation on 7/22/13 at approximately 2:00 PM a handrail bracket located on the handrail of the 200 Unit outside Room 210 had a sharp rough edge on the bracket. During an interview with the Administrator on 7/22/13 at 5:15 PM, s/he agreed that the handrail outside Room 210 had a sharp and rough edge on the bracket and stated s/he would have maintenance check it right away. Based on observation and interview, the facility failed to ensure that hazardous chemicals were inaccessible to residents. Room 117 had a 12 ounce container of Purell alcohol-based hand sanitizer (70% ethyl alcohol) on top of the bedside table and a 15 ounce container of Spray Disinfectant on the bathroom sink. No residents other than the one residing in the private room were noted in the immediate vicinity, though the facility did have cognitively impaired self-mobile residents on that hall. The Regional Manager and Housekeeping Supervisor removed the items when brought to their attention during the environmental tour.