Every finding on record at Edisto Post Acute

Based on record review, observation and interview, the facility failed to ensure accurate posting of licensed staff with hours worked for multiple dates. Reviewed staffing as posted from 10/01/24 through 09/14/25.Findings include: Review of the daily staffing posted as worked from 10/01/24 - 09/14/25 revealed 9 days a Registered Nurse (RN) was not listed for the required 8 consecutive hours in each 24-hour period. During an interview on 09/17/25 at 11:55 AM the Staffing Coordinator revealed the staffing for the dates in question were reviewed. The Staffing Coordinator confirmed that the postings were inaccurate and/or incomplete. The Staffing Coordinator stated, The central supply clerk and I put in the numbers on the staff postings. Human resources verifies that the postings are correct. During an interview on 09/17/25 at 12:24 AM the Regional Director of Quality Assurance and the Director of Nursing confirmed that a registered nurse was not listed on the posted staffing for the above-mentioned days and stated they were not aware that the hours were inaccurate and/or incomplete on the daily posting. During an interview on 09/17/25 at approximately 1:00 PM the Human Resources Director revealed that, The staffing coordinator posts the staffing sheets daily. The staffing coordinator makes any corrections regarding staffing to the staffing sheets throughout the day and as needed to denote staffing changes. I do the calculations the next day.

Based on observation, interview and review of the facility policy, the facility failed to store and prepare food in accordance with professional standards for food service safety in 1 of 1 main kitchen and 3 of 3 nourishment rooms, placing all residents who eat from the kitchen at risk for foodborne illness.Findings include:Review of a facility policy titled, Food Receiving and Storage last revised July 2014, states, Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: . 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. All foods stored in the refrigerator or freezer will be covered, labeled and dated . 12. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods. 13. Food items and snacks kept on the nursing units must be maintained as indicated below: b. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. c. Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines. d. Beverages must be dated when opened and discarded after twenty-four (24) hours. e. Other opened containers must be dated and sealed or covered during storage. f. Partially eaten food may not be kept in the refrigerator.During an observation on 09/16/25 at 7:37 AM of the main kitchen revealed the following:In the Walk-in Cooler: One container of lemons with no expiration date. One box of lettuce with no open/expiration date; the lettuce appeared slimy with a red hue. One sheet of premade pears and peaches in serving cups, with no open/expiration date and unlabeled. One container of unsweet tea, undated and unlabeled. Four bottles of salad dressing: two bottles of Thousand Island, one bottle of Catalina, and one bottle of Creamy French, all with no open/expiration date. Two open and thawed bags of raw chicken stored on the shelf above the potatoes.In the Walk-in Freezer: Two open and used plastic bags containing white round cheese slices with no open/expiration date. One open and used bag of tater tots with no open/expiration date. Two bags of tuna with no open/expiration date. One open and used bag of potato wedges, dated 06/26/25.During an interview on 09/16/25 at 7:50 AM, the Certified Dietary Manager confirmed the findings, stated that staff were aware that items needed to be labeled and dated, and instructed them to remove the items from the cooler and freezer.During an interview on 09/16/25 after speaking with the Certified Dietary Manager, the Kitchen Manager (KM) stated that the freezer and cooler had been taken care of and the items were removed.During an observation on 09/17/25 at 3:07 PM of the Southwest nourishment room refrigerator revealed staff food stored with resident foods and an unlabeled plastic bag of an unidentified item.During an observation and interview on 09/17/25 at 3:14 PM of the North Hall nourishment room refrigerator with Licensed Practical Nurse (LPN)2 revealed: One open, half-eaten Hershey's candy bar. Two open, unlabeled bottles of water. One open, unlabeled bottle of [NAME]. Two open, unlabeled bottles of flavored syrup (caramel and strawberry). One open, unlabeled bottle of Torani vanilla syrup. A thermometer was not observed.LPN2 was unable to locate the thermometer as well and placed a call to kitchen staff for a replacement. LPN2 stated the kitchen staff was responsible for maintaining the refrigerators.During an observation on 09/17/25 at 3:37 PM of the East Hall nourishment refrigerator revealed: Three plastic bags of unlabeled, unidentified food items. One unlabeled plastic container filled with an unidentified brown substance. One unlabeled plastic jug of an unidentified drink. No thermometer was found in the fridge.During a follow-up interview on 09/18/25 at 10:33 AM, the KM stated that housekeeping is responsible for the daily cleaning of the refrigerators. The KM also stated that staff food items should not be stored in those refrigerators. Lastly, he stated that they found the thermometer in one of the refrigerators, behind a drawer, and that both fridges now have thermometers.During an interview on 09/18/25 at 12:05 PM, the Director of Nursing (DON) stated that dietary is responsible for maintaining the temperature logs and that they add or remove nourishments for the residents as needed. The DON stated that staff have their own separate break room and should not be storing their items with resident food items.

Based on observations, interviews, and review of facility policy, the facility failed to ensure that the lids on trash containers were kept closed when not in use. During an observation, one trash container lid remained open due to a tree branch obstructing closure.Review of the facility policy titled Food-Related Garbage and Refuse Disposal last revised on October 2017, states: Food-related garbage and refuse are disposed of in accordance with current state laws. The Policy Interpretation and Implementation, states, 1. All food waste shall be kept in containers. 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. 5. Garbage and refuse containing food wastes will be stored in manner that is inaccessible to pests. 6. Storage areas will be kept clean at all times and shall not constitute a nuisance. 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.During an observation and interview with the Kitchen Manager (KM) on 09/16/25 from 8:25 AM to 8:30 AM revealed the dumpster container area, located at the rear entrance of the facility, the dumpster container had two separate top lids. The lid on the right side of the container was not closed. The KM attempted to close the top right lid but was unable to due to a tree branch. The KM stated that he would have to come back to cut the branch andclose the lid and indicated dumpster lids were to be kept closed when not in use.

Based on observation, interview, record review, and review of facility policy, the facility failed to assess and provide Resident (R)101 with activities to meet her interests and needs for 1 of 2 residents reviewed for activities. Findings include:Review of the facility policy titled Activity Programs last revised on June 2018 revealed, Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Policy interpretation and implementation include the activities program is provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities.Review of R101's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to cognitive communication deficit, dementia without behaviors, muscle weakness, and epilepsy. Review of R101's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/20/25 revealed that R101 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated that she had severe cognitive impairment. During an interview on 09/16/25 at 9:09 AM, R101 revealed that staff do not provide her with activities in her room. Review on 09/17/25 of R101's Activity Notes revealed no documentation related to activities.Review on 09/18/25 of R101's Activity Notes with a creation date of 09/18/25 at 1:22 PM and effective date of 09/08/25 revealed, Resident participated in Bingo for a while before wandering out.Review on 09/18/25 of R101's Activity Notes with a creation date of 09/18/25 at 1:23 PM and effective date of 09/09/25 revealed, Resident wandered through the hall socializing with other residents. Review on 09/18/25 of R101's Activity Notes with a creation date of 09/18/25 at 1:24 PM and effective date of 09/10/25 revealed, Resident attended bible study and observed in Bingo. Review on 09/18/25 of R101's Activity Notes with a creation date of 09/18/25 at 1:25 PM and effective date of 09/11/25 revealed, Resident sat and listed [sic] to music in the activity room. Resident also conversed with another resident in the activity room.Review on 09/18/25 of R101's Activity Notes with a creation date of 09/18/25 at 1:27 PM and effective date of 09/12/25 revealed, Resident wandered in and out of Bingo, resident attended social hour afterwards.Review on 09/18/25 of R101's Activity Notes with a creation date of 09/18/25 at 1:32 PM and effective date of 09/15/25 revealed, Resident observed in Bingo while helping another resident with Bingo.Review of R101's admission Activity assessment dated [DATE] revealed when assessed for activity pursuit patterns and preferences. R101 stated that it was somewhat important that she be provided with books, newspapers, and magazines to read. Review of R101 Assessments revealed no other Activity assessments for R101 after admission. During an interview on 09/18/25 at 3:00 PM, the Activity Director (AD) revealed she documents residents' activities on paper on an Attendance Participation Record. The AD further stated that she was informed today by facility Administration that she should be documenting resident activities in the Electronic Medical Record (EMR). The AD revealed that all activity notes for the resident in the EMR were completed today (09/18/25). The AD was able to provide Attendance Participation Record sheets for June, July, and August 2025. The AD concluded that at this time they are unable to locate September 2025 Attendance Participation Record.During a follow up interview with the AD on 09/18/25 at 3:39 PM, revealed the last activity was completed on 01/16/25; during the admission process for R101, the AD was unable to locate quarterly activity assessments for R101 at this time.

Based on interviews, record reviews, and review of facility policy, the facility failed to report an allegation of abuse involving Resident (R)121, to the state agency in the required time frame, for 1 of 3 residents reviewed for alleged abuse.Findings include:Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating with a revision date of September 2022 revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services ( where state law provides jurisdiction in long - term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. 'Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.Review of R121's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, cognitive communication deficit, Type 2 diabetes mellitus with hyperglycemia, morbid (severe) obesity due to excess calories, other specified disorders of thyroid and pain.Review of R121's Five - Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/25 revealed R121 had a Brief Interview for Mental Status (BIMS) of 15 of 15, suggesting that she was cognitively intact. Further review of the MDS revealed R121 requires setup/cleanup assistance with eating and oral care. Resident is dependent with toileting hygiene, lower body dressing, putting on and taking off footwear, showering/bathing and personal hygiene. Resident requires substantial/maximal assist with upper body dressing.During an interview on 09/16/25 at 10:24 AM R121 revealed, The Certified Nursing Assistants (CNAs) wipe back to front. That is not right. On last Thursday or Friday during day shift, a CNA dug my rectum and p***y out so hard with a rough washcloth. It caused pain. I was sore down there the next day. I did not know who to tell on Friday or over the weekend. I told my therapist on Monday, and she told her boss, and he questioned me about it. I do not know names. Their badges are flipped over. We do not know which staff is agency and which staff is not. He was going to take it to the department heads. During an interview on 09/16/25 at 12:55 PM, the Director of Therapy confirmed that he was made aware of the resident's care concerns yesterday. He spoke with [staff member] and then notified the DON of the resident's concerns. During an interview with the Director of Nursing (DON) on 09/16/25 at 1:05 PM, revealed that she was unaware of the resident's concerns. The Director of Therapy was in the room and stated that he was mistaken and he intended to tell the DON about the resident's concerns yesterday, but he was pulled away and was not able to tell her. The DON stated that she would start an investigation immediately. During an interview with the DON on 09/17/25 at 9:00 AM, revealed that she spoke with R121 about her care concerns. An investigation was initiated, and a 24-hour report was faxed to DHEC. The employee in question was identified and suspended pending the outcome of the investigation. During an interview with the Administrator on 09/17/25 at 9:35 AM, revealed he expects staff to notify him immediately of any abuse concerns. He stated that he is always available 24/7.During an interview with the DON on 08/18/25 at approximately 12:24 PM, revealed that all staff are in-serviced on hire, annually, and as needed for abuse. If any form of abuse is detected, they should notify the DON or ED, whether it is verbal, physical or injury of unknown origin. She states her expectation is for staff to be educated enough to identify signs of abuse and report it immediately.

Based on observation, interview, and review of facility policy, the facility failed to provide dignity and respect for Resident (R)80 and his personal space/room, when a staff member was taking a break in R80's room.Findings include:Review of the facility policy titled Dignity last revised on February 2021, revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy interpretation and implementation include residents are treated with dignity and respect at all times. Resident's private space and property are respected at all times. Staff do not handle or move a resident's personal belonging without the resident's permission.Review of R80's Face Sheet revealed he was admitted to the facility on [DATE] with the diagnoses including but not limited to cerebral pasly, bipolar disorder, muscle spasm, and lack of coordination.Review of R80's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/15/25 revealed that he had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that he is cognitively intact.During an observation and interview on 09/16/25 at 9:02 AM, revealed Certified Nursing Assistant (CNA)1 sitting on resident's bed and using her cellphone while he was out of his room taking a break. CNA1 stated that she normally does not take breaks in resident rooms and the facility has a break room further down the hall. CNA1 revealed that she was not on a designated break but taking a break between resident care.During an interview on 09/16/25 at 9:22 AM R80 revealed that he was not aware that CNA1 was sitting on his bed and taking a break. R80 further stated that he has seen other CNAs doing similar things in other resident rooms.During an interview on 09/18/25 at 5:12 PM the Director of Nursing (DON) revealed that staff should not be on their cellphones during work hours and staff should treat resident rooms/spaces with respect.

Based on interview, record review, and review of facility policy, the facility failed to revise/update Resident (R)80's Care Plan in a timely manner, after R80 expressed suicidal idealizations, a significant change in the resident's mood status, for 1 of 3 residents reviewed for mood/behavior. Findings include:Review of the facility's policy titled Care Planning - Interdisciplinary Team last revised on March 2022 revealed, The interdisciplinary team is responsible for the development of resident care plans. Policy interpretation and implementation include resident care plans are developed according to the timeframes and criteria established by federal guidelines. Comprehensive, person-centered care plans are based on resident assessment and developed by an interdisciplinary team (IDT). The IDT includes but is not limited to: the resident's attending physician; a registered nurse with responsibility for the resident; a nursing assistant with responsibility for the resident; a member of the food and nutrition services staff; to the extent practicable, the resident and/or resident representative; and other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Review of R80's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral palsy, bipolar disorder, muscle spasm, and lack of coordination.Review of R80's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/15/25 revealed that he had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that he is cognitively intact.Review of R80's Electronic Medical Record (EMR) Social Services Note dated 09/11/25 revealed, Patient left out of the facility via stretcher related to suicidal ideations. Patient received orders from Medical Doctor to get re-evaluated. Nurse Practitioner notified, paperwork sent with patient to hospital.Review of R80's EMR Social Services Note dated 09/11/25 revealed, Social Services Director (SSD) reached out to resident representative and notified her that the resident was being sent out the hospital for evaluation. Resident representative voiced understanding.Review of R80's EMR Social Services Note dated 09/11/25 revealed, Resident met with this writer in office and expressed concerns regarding his family, stating they often say they will visit but do not follow through. R80 further shared that he feels the need to speak with a mental health professional about his emotions. SSD provided support and encouragement, and resident appeared receptive. Resident Representative (RR) was notified of resident feelings and RR voiced she will try to visit once a week. SSD gave an option if family isn't able to visit in person facility with Zoom/Facetime. Both [R80] and his RR were in agreement; this writer notified the Director of Nursing (DON) who subsequently informed the Medical Doctor (MD). After discussion, a decision was made to send the resident to the hospital for further psychiatric evaluation. The resident agreed with the plan of care, RR was notified accordingly.Review of R80's Hosptial Discharge summary dated [DATE] revealed, [R80] with a past medical history of cerebral palsy, high blood pressure, and bipolar disorder presents the emergency room (ER) today complaining of being depressed. Patient is depressed now for a few days and has had suicidal ideation for a few days. Thoughts were to cut his wrist, no formal plan formalized. Denies drugs or alcohol; patient has cerebral palsy and is wheelchair bound. R80 states he has been seeing things and hearing voices as well, no command hallucinations. Review of R80's Care Plan revealed no care plan interventions related to the resident's recent thoughts of suicidal ideations. During an interview on 09/18/25 at 3:50 PM, the SSD revealed that R80's Care Plan had not yet been revised to reflect his significant change in mood status, and there are no interventions in place related to suicidal ideations. During an interview on 09/18/25 at 5:12 PM, the Director of Nursing (DON) revealed that R80's Care Plan should have been revised after his most recent changes in mood/suicidal ideations.

Based on observation, interview, and record review, and review of facility policy, the facility failed to provide Resident (R)89 the right to privacy, by failing to adequately secure her Electronic Medical Record (EMR), for 1 of 2 reviewed for resident rights. Findings include:Review of the facility policy titled Dignity last revised on February 2021 revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff protect confidential clinical information. Examples include the following: verbal staff-to-staff communication; signs indicating the resident clinical status or care needs are not openly posted in the resident's room unless specifically requested by the resident or family member.Review of the facility policy titled Health Insurance Portability and Accountability Act (HIPAA) Training Program, last revised on April 2007, revealed, All facility personnel, including business associates, are required to attend our facility's HIPAA compliance training program. Policy interpretation and implementation include, . to ensure the confidentiality of our resident's Protected Health Information (PHI) and facility information, a HPAA and data security training program will be provided for all employees and business associates who have access to protected health and facility information.Review of R89's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to contracture of left hand, type 2 diabetes, weakness, and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/25 revealed that she had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated that she was not cognitively intact.During an observation on 09/16/25 at 10:11 AM, the South Unit revealed R89's EMR, specifically her Face Sheet information, was visible on the laptop mounted to a medication cart. Further observation revealed there were no staff members present at this time. During an observation and interview on 09/16/25 at 10:13 AM of the South Unit with Licensed Practical Nurse (LPN)1 revealed that they had stepped away to provide R89 with her morning medication. LPN1 further stated that they believed that they secured R89 because they pulled the laptop screen out of line of sight. LPN1 further stated that because she is taller, the laptop appeared to be secured. LPN1 finally stated that they should have used the privacy screen in the EMR.During an interview on 09/18/25 at 5:16 PM, the Director of Nursing (DON) revealed that their expectation is for staff to provide privacy when handling resident's PHI. The DON further stated that the EMR has a feature built in the program for a privacy screen when staff need to step away from their medication cart/laptop.During an interview on 09/18/25 at 7:24 PM, the Administrator revealed that their expectation is for staff to provide privacy when handling residents' PHI and to follow HIPAA guidelines.

Based on review of the facility policy, record review, and interviews, the facility failed to complete fall risk assessments in a timely manner for 1 of 1 resident (Resident (R)1). Findings include: Review of facility policy titled, Quarterly Assessments revealed, 2. Three Quarterly assessments are completed in each 12-month period, assuming the resident does not have a Significant Change in Status Assessment (SCSA) or Significant Correction to Prior Comprehensive Assessment (SCPA) completed and was not discharged from the nursing home. Record review of R1's Face Sheet revealed, R1 was admitted to the facility on [DATE] with diagnoses including but not limited to; fracture of right femur, subsequent encounter for closed fracture with routine healing, repeated falls, osteoarthritis, and abnormalities of gait and mobility. Record review of R1's Care Plan dated 12/20/24 revealed, Focus: Resident is at risk for falls related to medication regimen, anxiety, Depression, HX falls. Fall 12/5/2024. Revision on 1/15/2025. GOAL- Resident will not have any major injuries with falls. Resident will not have any major injuries with falls and resident will be compliant with fall interventions through next review. INTERVENTIONS-Cancelled:12/5/2024 two people assist with bed mobility. Cancelled 12/5/2024: Two staff members present for all bed mobility . Record review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/24 revealed, under section J1700- A. Did the resident have a fall any time in the last month prior to admission/entry or reentry? YES C. Did the resident have any fracture related to a fall in 6 months prior to admission/entry or reentry? Yes. J2510. Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot). Record review of R1's Quarterly Fall Risk assessment dated [DATE] revealed, a score of 12 indicating she was a moderate risk for assessment. No other Fall risk assessment in EHR (Electronic Health Record). During an interview on 02/20/25 at 2:50 PM, Registered Nurse (RN)1 stated, she was familiar with the resident. RN1 stated, Assessments are done quarterly and confirmed R1 missed 2 assessments in 2024. Floor nurses are responsible for conducting those assessments. RN1 states, She is not sure why the resident didn't have it done. Orders are to be put in for 3 days prior to charting. [Another order would get put in the day of the assessment id to be done], and it would then populate on the [Electronic Medication Administration Record] EMAR when it was due. RN1 Stated, Her expectation is for residents to have assessments done within the required time frame. During an interview on 2/25/25 at 4:45 PM, the Assistant Director of Nursing (ADON) confirmed, There was no updated assessments found for R1.

Based on observation, interviews, and facility policy review, the facility failed to treat residents with respect and dignity for two sampled residents (Resident (R)28 and R64) as evidence by staff standing over the residents while assisting them with eating their meals. Findings include: Review of the facility's policy titled Assistance with Meals revealed: 2. 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; b. keeping interactions with other staff to minimum while assisting residents with meals; c. avoiding the use of labels when referring to residents (e.g., feeders); and d. avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident. Observation during lunch meal on 6/18/24 at 12:34 PM showed Certified Nurse Aide (CNA)1 was observed feeding R64, while she was standing over the resident. Further observations on 06/18/24 at 12:39 PM showed CNA1 was then observed feeding a second resident, R28, in addition to R64, and was standing up in between the residents, while feeding both of them. On 6/20/24 at 12:4 PM, during an interview with the Director of Nursing (DON), the DON stated, The protocol for just somebody that needs assistant with feeding, they have to feed the patient. They deliver the tray. They've used their hands; of course, they should have already used their hand sanitizer. They, you know, shouldn't touch the food. If they have to cut it up or anything like that after they're done, they need to wash their hands before they move on to the next person. They need to sit down when they're feeding the resident. On 6/20/24 at 12:51 PM, the DON further stated, Training? The last time was probably today, but I guess yesterday they did, but probably today. Now they know they need to wash their hands before and after helping a resident. The training probably didn't go in depth with not feeding two patients at the same time, but as far as standing while feeding the residents, they (the staff) know they need to sit down.

Based on record review and interview with facility staff the facility failed to ensure a comprehensive person-centered care plan for each resident identified services to be provided to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being by not initiating a care plan for the use of antipsychotic medications for one (1) of 21 residents whose care plans were reviewed (Resident (R)77). The findings include: Review of the medical record for R77 revealed an admitted [DATE]. Diagnoses included Metabolic Encephalopathy, Dementia and Depression. Review of the Physician's Orders for R77 revealed Physician's Orders for Quetiapine Fumarate (Seroquel-an antipsychotic) 25 mg (milligrams) at bedtime, and Escitalopram Oxalate (Lexapro-an antidepressant) 10 mg by mouth daily. Review of the Medication Administration Record for R77 for the months of May 2024 and June 2024 revealed R77 received Seroquel and Lexapro from 5/28/24 through 6/18/24. Review of the Admission Minimum Data Set (MDS) assessment for R77, with an Assessment Reference Date (ARD) of 6/4/24, revealed that R77 had not been coded for the use of antipsychotic and antidepressant medications. Review of the Care Plan for R77 revealed no Care Plan for the use of the antipsychotic medication, Seroquel. On 6/19/24 at 1:35 PM, during an interview with the MDS Coordinator 5, s/he stated s/he must have missed coding those medications and the MDS would need a modification. The MDS Coordinator 5 stated since R77 had not been coded on the Admission MDS for the use of antipsychotic medications, a Care Plan for the use of Seroquel had not been developed as it should have been.

Based on observations, interviews, and facility policy review, the facility failed to ensure that food was served to residents in a manner that would ensure the prevention and spread of disease or potential infection for two (2) sampled residents (R28 and R64) during meals observation. The findings include: Review of the facility's policy titled Handwashing/Hand Hygiene revealed: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The policy further revealed, Administrative Practices to Promote Hand Hygiene 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Observation during lunch meal on 6/18/24 at 12:34 PM showed Certified Nursing Assistant (CNA)1 was observed feeding R64. Observed CNA2 setting up R28 meal on the food tray while he/she was still feeding R64 without washing his/her hands. On 6/18/24 at 12:39 PM, CNA1 was observed to simultaneously feeding two residents, R28 and R64, without performing any hand hygiene in between assisting one to the other. On 6/18/24 at 3:15 PM, Licensed Practical Nurse (LPN)1, stated that the facility is definitely under staffing. LPN1 then stated, They have at least 15 Feeders (residents who need assistant with eating) and only three (3) CNAs to help. LPN1 then stated that the CNAs were doing the best they could to attend all of the residents. S/he stated, You know, now we have more residents and less staffing. On this wing right now, we have 2 CNAs I think, but we have several feeders. How can they attend all of them . On 6/20/24 at 12:49 PM, during an interview with the Director of Nursing (DON), the DON stated, Every delivery of trays, they have to wash their hands with hand sanitizer. Of course, they already wash their hands before delivery of trays. They can use hand sanitizer three times, and they have to wash their hands if they're going to feed a patient, you know. They should wash their hands after even before they go to the next person not hand sanitizer. No, not washing their hands and helping 2 patients at the same time, that will not be appropriate. They should wash their hands before they move to the next person . On 6/20/24 at 12:51 PM, the DON further stated, Training? The last time was probably today, but I guess yesterday they did but probably today. Now they know they need to wash their hands before and after helping a resident. The training probably didn't go in depth with not feeding two patients at the same time, but as far as standing while feeding the residents, they (the staff) know they need to sit down.

Based on record review, interview with facility staff and review of facility policy, the facility failed to ensure the comprehensive assessment for one (1) of 21 residents reviewed was completed accurately (Resident (R)77). Findings include: Review of facility policy titled Electronic Transmission of the MDS revealed the Policy Interpretation and Implementation stated 8. The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking. Review of the medical record for R77 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, dementia and depression. Review of the Physician's Orders for R77 revealed Physician's Orders for Quetiapine Fumarate (Seroquel-an antipsychotic) 25 mg (milligrams) at bedtime, and Escitalopram Oxalate (Lexapro-an antidepressant) 10 mg by mouth daily. Review of the Medication Administration Record for R77 for the months of May 2024 and June 2024 revealed R77 received Seroquel and Lexapro from 5/28/24 through 6/18/24. Review of the Admission MDS assessment for R77, with an Assessment Reference Date of 6/4/24, revealed that R77 had not been coded for the use of antipsychotic and antidepressant medications. On 6/19/24 at 1:35 PM, during an interview with the MDS Coordinator 5, s/he stated s/he must have missed coding those medications and the MDS would need a modification.

Based on record reviews, interviews, and review of the facility's policy, the facility failed to provide Resident (R)2 with appropriate care to her percutaneous endoscopic gastronomy (PEG) tube. This failure resulted in the development of maggots at the site of the PEG tube. On 06/12/23 at approximately 4:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 06/13/23 at 1:15 PM, the Administrator was notified that the failure to provide appropriate care to the site of R2's PEG tube , resulting in the development of maggots, constituted Immediate Jeopardy (IJ) at F693 with a start date of 05/21/23. On 06/14/23 at 9:40 AM the facility presented an acceptable plan of removal for the IJ at F693. The survey team validated the removal of immediacy following the facility's implementation of the plan of removal. However, the facility remained out of compliance at a lower scope and severity level of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F693, constituting substandard quality of care. Findings include: Facility policy titled Enternal Feedings - Safety Precautions, last revised November 2018 documents: Observe for signs of skin breakdown, infection and irritation. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] from an acute care hospital, with diagnosis that included but was not limited to; muscle weakness, dysphagia, dementia, and bacterial infection. Review of R2's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/22 revealed, R2 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating R2 was not cognitively intact. Review of R2's undated Care Plan revealed, .at nutritional risk due to NPO, CHF, dementia, significant dysphagia, weight loss, abnormal labs, weight loss, need for PEG tube to meet 100% of Est needs, and malnutrition. [R2] at high risk for nutritional decline due to failure to thrive and overall decline. R2's goal was to, . maintain her weight once edema is resolved, she will have improved skin integrity, her skin integrity, and she will tolerate her tube feeding through the next review date. Further review of R2's Care Plan revealed an intervention, Administer medications as ordered. Monitor/Document for side effects and effectiveness. However, there were no interventions that included maintaince/cleaning of the PEG tube. Review of R2's Physician Orders revealed an order dated 05/21/23, Clean stoma area with hydrogen peroxide and apply BID [twice a day] for 7 days 5/21/23 -5/28/23 every shift for Monitoring for 7 days. Note Text: Mupirocin External Ointment 2%. Review of R2's Discharge Progress Note dated 05/26/23 revealed, 5/24/2023, Follow-up scheduled due to noted maggot infestation on the stoma of the PEG. I was called by the nurse on Sunday at home that this was noted during a dressing change. I immediately ordered hydrogen peroxide twice daily to kill the maggots and Bactroban ointment to apply twice daily. RN notified family. I sent an email to the admin and DON that we needed to review protocols on Monday. We had a meeting Monday to review cleaning and possible initiation of blood lights in the area. There have been flies noted in the halls and it is summertime so they are coming through the doors on occasion. 5/26 - [R2] is medically cleared for discharge on hospice with stable vital signs on exam today. Note Text: This nurse met with MD concerning new orders for treatment of maggots. this nurse also spoke with hospice nurse who provided care for [R2] today and states no issues noted at this time. [R2] assessed by this nurse at this time, no issues noted. no distress noted at this time. will continue to follow up with IDT team and resident's family. During an interview on 06/12/23 at 1:15 PM, the former Director of Nursing (DON) revealed, he had received a call from Licensed Practical Nurse (LPN)1 and another nurse who stated that R2 had maggots in her G-tube. The former DON revealed the facility has a lot of flies and further revealed that LPN1 did not describe or say how many maggots she saw but she did tell him that R2 did not have any orders in the system to care for her G-tube. The former DON concluded that he was working on a quality improvement audit to ensure that all residents in the facility get an order to receive G-tube care. During an interview on 06/12/23 at 1:29 PM, LPN1 revealed, during a body audit on R2, the Friday before, LPN1 removed R2's G-tube dressing. The dressing contained an abnormal discharge that was dark brown, with a moderate amount of fluid, and no odor. On this day LPN1 further revealed that R2 did not have orders for peg tube care. LPN1 stated the next day the g-tube dressing was saturated, and upon removal of the dressing, there was a ball of maggots under the dressing. Some of the maggots were trying to get into her G-tube. It looked like they had just hatched, so I cleaned the g-tube and some were on me. During a phone interview on 06/12/23 at 3:50 PM, Registered Nurse (RN)1 revealed R2 would get wound care from hospice when in the building and for facility staff to provide wound care the other times. RN1 further revealed she was notified that R2 had maggots on 05/21/23 and she called the family to notify them. During an interview on 6/12/23 at 4:43 PM, RN2 revealed that R2 was not care planned for the maggots in her wound because, It is not something I encountered before. We care plan infections. We handled this in a grievance form. During an interview on 6/14/23 at 8:30AM, the DON stated, all staff are supposed to follow all physician orders for wound care and the same for infection control. The facility's removal plan with a included the following: MD notified and new orders obtained and initiated. Site was cleaned per order and all maggots were removed. Local Pest Control notified numerous times and treatments discussed and initiated. 100% Audit complete on 6-13-23 on all residents with ostomy/stomas/ feeding tube sites to ensure that all stoma sites are clean and bug free. 100% Audit complete on 6-13-23 on all residents with ostomy/stomas/feeding tube sites to ensure that all of these residents have orders to cleanse site Q shift and to monitor site q shift. Education provided to all licensed nurses in person or via phone by RDCS and DON/designees on 6-13-23 related to non-sterile dressing change procedure and orders for cleansing and monitoring of all ostomy/stoma and feeding tube sites q shift. Education will be provided to all newly hired staff and or agency staff as well as facility staff not reached by phone prior to next shift scheduled. AdHoc QA Meeting Held 6-13-23 Root cause of issue related to maggots noted on resident R2 identifed as flies in facility and lack of orders for monitoring and cleansing the gtube site qshift. Audits of all residents with Stomas/ostomies/feeding tube sites complete to ensure all sites are clean and maggot free. Audits of all residents with Stomas/ostomies/feeding tube sites complete to ensure all of the residents with these sites have orders in place for monitoring and cleansing sites q shift. Education initiated for all licensed nurses to include monitoring all stoma/ostomy/feeding tube sites q shift as well as cleansing q shift. Education provided as well for non-sterile dressing change procedure. The above components have been implemented as of 6-13-23 by 8pm.

Based on interviews and record review, the facility failed to provide sufficient staffing to its residents, resulting in deficient quality of care for 6 of 10 residents. Resident (R)5 was left soiled for several hours waiting for staff, and R6 fell trying to use the restroom after waiting for staff to come help her. Findings include: R5 was admitted to the facility on [DATE] with diagnoses including, but not limited to, nontraumatic intracerebral hemorrhage, type 2 diabetes mellitus, and hemiplegia and hemiparesis. Review of R5's 5 day Minimum Data Set (MDS) with an assessment reference date (ARD) on 03/23/2023 revealed R5 scored a 12 out of15 on his Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition. R6 was admitted to the facility on [DATE] with diagnoses including, but not limited to, pneumonia, malignant neoplasm, muscle weakness, and repeated falls. Review of R6's admission MDS with an ARD of 03/07/2023 revealed R6 scored an 11 out of 15 on her BIMS indicating moderately impaired cognition. R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, epileptic seizures, contractures, and legal blindness. R8 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarct and gait abnormalities. R9 was admitted to the facility on [DATE] with diagnoses including, but not limited to, end stage renal dialysis, hyperlipidemia, and requiring dialysis. R10 was admitted to the facility on [DATE] with diagnoses including, but not limited to, cerebral infarction, muscle weakness, and type 2 diabetes mellitus. Review of facility grievances revealed a 03/20/2023 grievance from R7 that staff did not get her out of bed daily as she preferred. Review of facility grievances revealed a 03/20/2023 grievance from R8 that staff do not check on her often enough. Review of facility grievances revealed a 03/21/2023 grievance from R9 indicating that she had not been changed since the previous evening. The Director Of Nursing followed up on the grievance, and review of his email revealed that she was left soiled for some time but could not remember the specific length of the time. Staff would be educated on rounding and anticipating resident needs. Review of facility grievances revealed a 03/22/2023 grievance from R6 that staff did not respond to her call light in a timely manner. Review of facility grievances revealed a 03/24/2023 grievance from R10 that he had not been changed since 3 AM, and he fell trying to get up to go to the bathroom. Interview with Licensed Practical Nurse (LPN)1 on 05/08/2023 at 2:02 PM revealed the nursing aides often had to ask for help, and that management would have to assist them during resident meals. During an interview with Certified Nursing Aide (CNA)1 on 05/08/2023 at 2:10 PM, she revealed she usually works 7 AM - 7 PM. She stated, The number of residents she has had on her assignment is 14. There is not enough time to complete her tasks. The other day she, and an unnamed coworker, couldn't assist R5 in a timely manner. His lights had been ringing from 8-11, and he hadn't been touched at all. The staffing is terrible because the aides are overworked. They have too many residents for too few workers. During an interview with Registered Nurse (RN)1 on 05/08/2023 at 2:19 PM, she revealed the facility had staffing concerns -- specifically relating to the patient to CNA ratio. She stated she often had to assist CNAs with their tasks. During an interview with CNA2 on 05/08/2023 at 2:26 PM, she revealed she had 13 residents that shift. She stated she usually has 13-14 residents on day shift. She also indicated there is not enough time to complete all tasks, and she will routinely pass what could not be done to the next CNA. During an interview with CNA3 on 05/08/2023 at 2:29 PM, she revealed she had 12-13 residents to care for on her 7 AM-7 PM shift. Because of staffing concerns, some residents don't get changed when they should, or they don't get the wash care (bath/shower) they should get. R6 slipped because she was trying to get to the bathroom after waiting for someone to respond to her call light. During an interview with CNA4 on 05/08/2023 at 2:33 PM, she revealed she had 14 residents on the day shift. There is not enough time to complete all tasks, and CNAs need help badly. During an interview with CNA5 on 05/08/2023 at 2:36 PM, she revealed she had 14 residents on her 7 AM-7 PM shift. She stated, There is not enough time to complete all her tasks. Often, staff can't wash or bathe the residents as they should and just do perineal care and go to the next resident. On weekends, it's possible for CNAs to have 18-20 residents during the day shift. She believed that increasing staff would cut down on falls and fall injuries because if a resident falls at the bottom of the hall, she might not realize until the next hour. It's also impossible to meet the 2 hour rounds standard because there are too many residents she has to provide care for. During an interview with LPN2 on 05/08/2023 at approximately 2:40 PM, she revealed that she was the wound nurse. She stated, Even as the facility's wound nurse, she often had to help CNAs because there weren't enough nursing aides. Furthermore, she has had trouble finding an aide to assist with wound care. She has mentioned the staffing concerns to the facility several times, and they say that they're coming up with an action plan but have yet to present one. During an interview with the DON on 05/08/2023 at 2:48 PM, she revealed the facility had no plans to correct staffing concerns. The DON stated, the facility uses central supply, the schedular, and activities assistants to assist when callouts occur. Department heads do compliance rounds where they round and check on residents. They might assist with resident meals, but this is usually only lunch since department heads are not usually present for breakfast or dinner. During an interview with CNA6 on 05/08/2023 at 3 PM, she revealed she usually has 14-15 residents on her 7 AM-7 PM shifts. She stated, There is not enough time to complete tasks with such a workload, especially activities of daily living (ADLs), showers, hygiene, and toileting. During an interview with R5 on 05/08/2023 at approximately 3:24 PM, he confirmed the incident where he waited several hours soiled before staff came to answer his call light. During an interview with R6 on 05/08/2023 at approximately 4 PM, she confirmed concerns with delayed staffing. R6 stated, There are not enough CNAs to provide care. She did confirm an incident where she waited a long time for someone to help her after pushing her call light before getting up and falling - resulting in a broken tooth. Observation confirmed that R6 had a broken tooth. Review of R6's Change in Condition Evaluation with effective date 4/12/2023 revealed the resident had a change in condition related to a fall on 04/12/2023. The resident was found on the floor of the bathroom sitting on buttocks. The call light near the shower was on. The resident fell while getting up off the commode and fell on her face, resulting in a broken tooth. Review of February staff postings revealed that the facility assigned more than 9 residents to a CNA on a first shift (defined as 7 AM - 3 PM) for 21 days. Review of March staff postings revealed that the facility assigned more than 9 residents to a CNA on a first shift (defined as 7 AM - 3 PM) for 23 days. Review of April staff postings revealed that the facility assigned more than 9 residents to a CNA on a first shift (defined as 7 AM - 3 PM) for 30 days.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that a resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice placed the resident at risk for respiratory distress. Findings include: Review of the facility's policy titled [CONDITION(S)] Care revised 08/13 revealed, .A replacement [CONDITION(S)] tube must be available at the bedside at all times . Review of R45's Admission Record found in the electronic medical record (EMR) under the Profile tab, revealed R45 was originally admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R45's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/13/21 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating resident had moderate cognitive impairment. R45's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R45 required special treatments and programs to include [CONDITION(S)] care. Review of R45's undated Care Plan located in the EMR under the Care Plan tab revealed the resident had a communication deficit related to a history of cognitive communication deficit with laryngectomy (portion of larynx/throat surgically removed) and aphonia (without voice). Resident noted with a history of removing laryngeal tube and sitting it in a cup of water .Resident was also at risk for altered respiratory status related to having larynx tube (larytube)/[CONDITION(S)] related to [CONDITION(S)] obstruction, absence of larynx, history of shortness of breath, and history of swelling to larynx tube. Nursing staff to provide .Larytube care as ordered and as needed .Resident is to use the Heat and Moisture Exchanger (HME) Cassette in Larytube as ordered . Review of R45's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 05/10/22 at 12:44 PM revealed R45 with [CONDITION(S)]/larytube (artificial opening to larynx). An interview and observation on 05/11/22 at 11:21 AM with Licensed Practical Nurse (LPN)8 confirmed she was assigned to the care of R45 on 05/11/22. When asked where the emergency [CONDITION(S)]/inner cannula was located for R45's larytube, LPN8 stated she did not know where the replacement inner cannula was located other than at the bottom of the nursing cart or in the supply room. Additionally, LPN8 stated if R45 were to go into respiratory arrest she would call 911(emergency services) and use the ambu bag to provide artificial respirations and the resident would be sent to the emergency department (ED) due to not being able to locate a replacement laryngeal tube. An interview on 05/11/22 at 11:44 AM with LPN9 revealed she worked at the facility through a staffing agency. LPN9 confirmed she had been assigned to the care of R45 on 05/10/22. LPN9 further revealed she was unable to locate a 10mm laryngeal tube, and the only cannula she was able to find was a 7.6mm 8DIC replacement tube located in the supply storage room on the South wing. An interview on 05/11/22 at 12:10 PM with the Unit Manger (UM) revealed she checked R45's room daily and just replaced the resident's laryngeal tube yesterday. The UM showed this surveyor a box labeled Atos provox larytube 10/155 brand laryngeal tube that she stated she keeps in her office. The UM confirmed that a replacement tube should be at R45's bedside at all times and she was not aware that the resident did not have one available or that LPN8 was unable to locate one.

Based on document review, interview, and review of facility policy, the facility failed to ensure two Licensed Practical Nurses (LPN8 and LPN9) were completely trained on tracheal care and safety measures for one of one (Resident (R) 45) reviewed for [CONDITION(S)] status. Findings include: Review of the facility's undated policy titled Edisto Post Acute Facility Assessment 2021 revealed §483.95 Training Requirements. A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified at §483.70(e) . Review of an undated document titled Long Term Care Essential Clinical Assessment provided by the facility indicated LPN8 and LPN9 did not receive [CONDITION(S)] care training. An interview on 05/11/22 at 11:21 AM with LPN8 revealed she worked at the facility through a staffing agency and was not sure when she last had [CONDITION(S)] care training. When asked where the emergency [CONDITION(S)]/inner cannula was located for R45's larytube (laryngeal tube in place related to history of [CONDITION(S)] and collapse). LPN8 stated she did not know where the replacement inner cannula was located other than at the bottom of the nursing cart or in the supply room. LPN8 reviewed R45's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, LPN8 was not able to state what was meant by the order reading Change HME [heat moisture exchanger] on cannula .check and confirm HME is in place every shift related to encounter for attention to [CONDITION(S)]. An interview on 05/11/22 at 11:44 AM with LPN9 revealed she worked at the facility through a staffing agency was not sure when she last had [CONDITION(S)] care training. LPN9 further stated she was unable to locate a 10mm laryngeal tube, and the only cannula she was able to find was a 7.6mm 8DIC replacement tube located in the supply storage room on the South wing. An interview on 05/12/22 at 11:39 AM with the Director of Staff Development (DSD) confirmed that LPN8 and LPN9 had not received [CONDITION(S)] care training by the staffing agency or the facility but should have. During the interview the surveyor requested a copy of [CONDITION(S)] care training required by the facility. The document was not provided to the surveyor. An interview on 05/12/22 at 11:54 AM with the Assistant Director of Nursing (ADON) revealed it was the expectation of the facility that all nurses providing care to residents with a [CONDITION(S)] appliance receive [CONDITION(S)] care education. ADON confirmed LPN8 and LPN9 had not received [CONDITION(S)] care training from the staffing agency or the facility but should have. ADON further stated that LPN8 told her she had not received formal [CONDITION(S)] care training from the staffing agency or the facility; ADON was unable to get in touch with LPN9 to obtain a statement.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide an individualized activity program for two Resident (R) 88 and R296 of 29 sampled residents. This had the potential for the residents to feel isolated and not promote their quaility of life. Findings include: Review of the facility policy titled Activity Programs revised 08/06 revealed 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs .6. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g., bed bound or visually impaired residents) . 7. Individualized and group activities are provided that: a. reflect the schedules, choices and rights of the residents; b. Are offered at hours convenient to the residents, including evenings, holidays and weekends . 1. Review of R88's undated Admission Record found in R88's electronic medical record (EMR) under the Profile tab indicated he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R88's document Baseline Care Plan Person-Centered Care Planning dated 04/27/22, located in the EMR under the Evaluations tab revealed the resident and/or Resident Representative (RR) participated in Baseline Care Plan Meeting .Section V: Activities: A.1. Daily Routine N/A 2. Activities and Hobbies: Resident enjoys watching television . Review of R88's document titled Activity Assessment - V2.1 dated 04/27/22 located in the EMR under the evaluations tab stated resident was not able to communicate and an interview for daily and activity preferences should not be conducted. The document also revealed activities should be done in R88's room. Review of R88's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/22, found in the resident's EMR under the MDS tab revealed R88 did not have a Brief Interview for Mental Status (BIMS) assessment. The MDS section F revealed staff were interviewed regarding R88's daily and activity preferences to reflect the resident had no preferences and he should not be evaluated individually. Review of R88's Activities and Activities Participation Note located in EMR under the Progress Notes tab was empty as of 05/12/22. Observation and interview on 05/10/22 at 9:08 AM with R88 revealed the resident said he could not see. Signs were posted to the bedroom door indicating droplet and contact precautions were in place. R88 stated he did not participate in any activities. Interview on 05/11/22 at 1:25 PM with R88's daughter revealed her sister came to visit at least one to two times per day and she came to visit daily. She said she was concerned that she had not seen her father participating in any activities since he was admitted on [DATE]. The daughter stated he loved to talk to people and have interaction with them. She further revealed the only interaction staff had with R88 was noted to be nursing assessments and the Certified Nursing Assistants (CNAs) providing care. Interview on 05/11/22 at 1:30 PM with CNA1 revealed she had not seen R88 participating in or being offered any activities. Interview on 05/11/22 at 3:58 PM with the Activities Director (AD) revealed R88 liked watching TV, reading books, and music therapy. The AD confirmed neither himself nor the Activities Assistant (AA) had performed one to one activities with R88 since he was admitted to the facility on [DATE]. Interview on 05/11/22 at 4:28 PM with Licensed Practical Nurse (LPN)8 revealed she had not seen R88 participating in activities and that he was primarily in his bed either eating, sleeping, or just sitting there. Interview on 05/11/22 at 4:33 PM with CNA4 revealed she was not sure what activities R88 liked to participate in because he stays to himself, liked his door closed, liked it quiet, and calm. CNA4 also stated that R88 had no difficulties communicating with staff. 2. Review of R296's undated Admission Record found in R296's EMR under the Profile tab indicated he was admitted to the facility on [DATE]. Review of R296's quarterly MDS with an ARD of 05/01/22, found in the resident's EMR under the MDS tab revealed the resident had a BIMS score of eight out of 15 indicating the resident was moderately cognitively impaired. Review of R296's document Baseline Care Plan Person-Centered Care Planning dated 05/04/22, located in the EMR under the Evaluations tab revealed the resident and/or Resident Representative (RR) participated in Baseline Care Plan Meeting .A. Activity Preferences 1. Daily Routine patient will participate in therapy program and attend activities of choice .2. Activities and Hobbies: tbd [to be determined] 3. Other notes: pt [patient] to be provided w [with] activity schedule; all activities held with any isolation protocol in place . Review of R296's document Care Plan dated 05/09/22, located in the EMR under the Care Plan tab revealed the resident had an alteration in psychosocial well-being related to visitor restrictions to limit risk for exposure to Coronavirus per protocol .Allow resident to voice feelings and frustrations as indicated .assist resident to communicate with family and friends via alternative methods such as: phone calls, video calls, and email . Review of R296's documents located in the EMR under the evaluations tab revealed he did not have an activity assessment performed upon admission. Review of R296's Activities and Activities Participation Note located in EMR under the Progress Notes tab was empty as of 05/12/22. Observations on 05/10/22 at 9:00 AM, 1:31 PM, and 5:13 PM revealed R296 was resting in bed with his eyes closed. Interview on 05/10/22 at 9:00 AM with LPN9 confirmed R296 was on contact precautions and resting in bed with his eyes closed. LPN9 stated she had not seen R296 participating in any activities or the activities department in his room during any of her shifts. Interview on 05/11/22 at 4:15 PM with the AD revealed he was not aware that R296 was located downstairs and on transmission-based precautions (TBP). AD stated he met the resident at the end of his admission care conference and had limited information about R296 and had not created an individualized baseline care plan reflecting the resident's activity preferences. AD confirmed no formal activities had been offered to the resident and that neither himself, nor the AA had visited with R296. Interview on 05/11/22 at 4:30 PM with LPN8 revealed she had not seen anyone from the activities department visiting with R296. Interview on 05/11/22 at 4:33 PM with CNA4 revealed R296 liked to watch TV and occasionally had visitors on the evening shift. CNA4 stated she had not seen anyone from the activities department conducting visits on the West hall. Interview on 05/11/22 at 5:01 PM with the Director of Nursing (DON) revealed it was her expectation and understanding that the AD performs an assessment upon admission and then develops a baseline care plan related to activities. The DON stated she was not aware that R88 or R296 did not have an individualized care plan or that they had not been provided activities while on TBP.

Based on observation, interview and record review, the facility failed to ensure necessary transmission-based precautions were implemented for 16 of 16 residents who tested positive for COVID-19; and who resided on the COVD-19 unit to include three (3) sample residents residing on that unit (Resident #1, Resident #2 and Resident #3). The findings included: Review of the facility's Emergency Preparedness Plan COVID-19 Standard Operating Guideline dated 3/12/2020 noted Contact and droplet precautions are implemented during care of residents with suspected COVID-19 and continued for 14 days or until 24 hours after the resolution of fever and respiratory symptoms .Facility to comply with CDC (Center for Disease Control) updated PPE (personal protective equipment) recommendations for the care of patients with known or suspected COVID-19 that stated: 3. Eye protection, gown and gloves continue to be recommended. Review of the facility's Isolation - Categories of Transmission-Based Precautions revised 10/2018 noted Contact precautions directed to place resident in private room, if possible and use gloves and gowns when entering room. Droplet precautions directed to place resident in private room and use masks when entering room. Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. Review of Resident #1's clinical record revealed an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #1's COVID-19 laboratory results report date of 6/16/2020 revealed the resident tested positive for [MEDICAL CONDITION]. According to the residents COVID-19 care plan initiated 6/13/2020, transmission-based precautions for COVID-19 were initiated on 6/16/2020. Review of Resident #2's clinical record revealed an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #2's COVID-19 laboratory results report date of 6/13/2020 revealed the resident tested positive for [MEDICAL CONDITION]. According to the residents COVID-19 care plan initiated 6/13/2020, transmission-based precautions for COVID-19 were initiated on 6/13/2020. Review of Resident #3's clinical record revealed an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #3's COVID-19 laboratory results report date of 6/8/2020 revealed the resident tested positive for [MEDICAL CONDITION]. According to the residents COVID-19 care plan initiated 6/8/2020, transmission-based precautions for COVID-19 were initiated on 6/8/2020. Review of information obtained from www.cdc.gov on 6/18/2020 noted Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown .Because of higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP (healthcare providers) is newly identified in the facility . Observation on the COVID-19 unit on 6/18/2020 at 12:35 p.m. with the facility's Director of Nursing (DON) present, revealed there were 16 residents residing on the unit, and the unit was staffed with one (1) Licensed Practical Nurse (LPN) and two (2) Certified Nursing Aides (CNAs). All staff were wearing gowns, head coverings, shoe coverings, and goggles. The residents' meal cart was stationed at the end of the hallway and one CNA was observed passing meal trays into residents' rooms. The aide performed hand hygiene before entering three (3) residents' rooms; however, the aide did not don gloves before entering the rooms. Interview on 6/18/2020 at 10:47 a.m. with CNA #1 (who was not the aide delivering meal trays on the COVID-19 unit) revealed when a resident presented with signs or symptoms of COVID-19, this information was reported to the supervising nurse and precautions were put into place. The aide said a resident with known or suspected COVID-19 was placed in isolation and staff had to utilize the appropriate PPE to enter their room which included the use of gloves. Interview on 6/18/2020 at 12:40 p.m. with the facility's DON confirmed the facility was using CDC recommendations for the use of PPE. The DON also confirmed that contact precautions and droplet precautions were to be in place in accordance with the facility's policy; and confirmed the aide should have donned & doffed gloves between delivering resident meal trays. Continued interview revealed the aide was responsible for delivering the meal trays to all 16 residents on the COVID-19 unit. During a follow-up interview with the DON on 6/19/2020 at 7:17 a.m., the nurse again confirmed the facility's policy coincided with CDC recommendations and gloves should be worn and changed in between delivering meal trays to residents. During a telephone interview on 6/19/2020 at 9:28 a.m. with the Registered Nurse (RN) in the Epidemiology Department of the local Department of Health and Environmental Control (DHEC) office, the nurse confirmed that gloves should be donned when entering a resident's room and changed in between entering residents' rooms.

Based on record review, interview, and review of the facility's policy on Abuse and Neglect, the facility failed to implement its policies related to obtaining a background check for staff prior to hire, reporting allegations of Abuse, and investigating allegations of abuse for 4 of 6 residents reviewed for abuse (Residents #21, #99, #606, and #607). The findings included: The facility admitted Resident #21 on 2/10/15 with [DIAGNOSES REDACTED]. Record review revealed the facility submitted an Initial 24-Hour Report of an allegation of verbal abuse concerning Resident #21. Review of the report indicated the reportable event occurred on 11/8/18. Review of the facility's Investigative File revealed the Initial Report was not faxed and reported to the State Agency until 11/9/18 at 11:16 AM. The facility admitted Resident #99 on 9/28/18 with [DIAGNOSES REDACTED]. Record review revealed the facility submitted an Initial 24-Hour Report of an allegation of mental abuse concerning Resident #99. Review of the report indicated the reportable event occurred on 10/08/18 on the evening shift. Review of the facility's Investigative File revealed the Initial Report was not faxed and reported to the State Agency until 10/09/18 at 11:37 AM. Review of the facility's policy on Abuse and Neglect revealed that the section entitled Abuse Investigation and Reporting stated under Reporting 2., An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The facility admitted Resident #606 on 10/09/18 with [DIAGNOSES REDACTED]. During review of a Facility-Reported Incident, the personnel file for a Physical Therapy Assistant (PTA) revealed no background check and no copy of the PTA's license. The PTA's employee file was requested from the Director of Nursing (DON) on 04/17/19. The DON stated the assistant was a contracted employee and that his employee file was at the contracting vendor's office. The background check was again requested on 04/18/19 and the DON confirmed the PTA was now an employee of the facility. No documentation of a background check was provided by the facility at the time of exit. Review of the facility's Abuse Prevention Program, revised (MONTH) (YEAR), revealed As part of the resident abuse prevention, the administration will: .2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law: . The facility admitted Resident #607 on 10/13/18 with [DIAGNOSES REDACTED]. During the investigation of a Facility-Reported Incident, review of the 24-Hour Report revealed the incident occurred on 10/19/18 at 07:20 PM. Further review revealed the 24-Hour Report was dated 10/20/18 and faxed to the State Agency at 01:14 PM and was not reported to the State Agency within the required 2 hours for an allegation of abuse. During an interview on 04/18/19 at 02:15 PM, the DON neither confirmed nor denied that the incident was not reported timely, was not thoroughly investigated or the that the facility failed to follow their policy related to reporting and investigating. Review of the facility's Five-Day Follow-Up Report revealed a statement from the alleged perpetrator. No staff statements, other than the alleged perpetrator, were obtained by the facility. Review of the assignment sheet dated 10/19/18 revealed the alleged perpetrator was listed on the schedule from 3:00 PM until 11:00 PM on that date. The assignment sheet also showed another Certified Nursing Assistant (CNA) was also listed and assigned to the same group. On 10/22/18 at 13:36 (01:36 PM) Social Services documented in the Progress notes SSA (Social Services Assistant) follow-up with resident in reference to reportable. Resident roommate stated the resident was in his/her bed and reached for the call light. When the CNA entered the room s/he yelled. The roommate stated s/he heard the resident crying. The resident stated s/he felt scared at the time. SSA asked the resident did she feel safe? resident stated Yes. Staff made aware and reported to licensure for further investigation. SSA will continue to follow-up if any issues arise. There was no written statement from either the resident or the resident's roommate. During an interview at approximately 03:10 PM, the DON confirmed the report of the allegation was not timely. The DON further stated that she needed to look further for any additional investigation. At approximately 4:00, the DON confirmed there was no additional information related to an investigation and that the policy had not been followed. Review of the policy Abuse Investigation and Reporting revealed, Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: Review the completed documentation; Review the resident's medical record to determine events leading up to the incident; Interview the person(s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors; Interview other residents to whom the accused employee provides care or services; and Review all events leading up to the alleged incident.

Based on record review and interview the medical director failed to be responsible for the coordination of medical care in the facility. Resident #158 was noted to have self-injury behaviors and was prescribed Risperadone for behaviors. Resident #158 went to the hospital from 5/4-5/13/15. Review of the hospital paperwork revealed the Risperadone was to be continued. Resident #158 did not receive the medication until 5/20/15. On 5/17/15 Resident #158 bit his/her own finger causing a fracture which led to the finger being amputated. One of two residents reviewed for self injury behaviors. On 9/11/15 at approximately 6:25 PM, the Administrator and Director of Nursing were notified that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility since 5/13/2015. Resident #158 was readmitted to the facility on [DATE]. The facility failed to develop a comprehensive plan of care that addressed the needs of the residents related to his behaviors and [MEDICAL CONDITION] medications. The facility failed to identify and accurately assess Resident #158, a cognitively impaired resident with known self-injurious behaviors. The facility failed to administer antipsychotic medications in accordance with the physician's orders [REDACTED]. The resident was known to have self-injurious behaviors including biting his fingers to the point of fracturing the digit. The facility failed to implement interventions to prevent or monitor for these behaviors. Resident #158 was not given the antipsychotic medication for his self-injurious behaviors from 5/13/15 through 5/20/15 resulting in a serious injury on 5/17/15 to his hand. Resident #158 bit his finger causing a severe fracture and subsequent amputation of that digit. The findings included: Cross refer to F 272, F 279, F 309, F 319, F 323, F 333 and F 490 as it related to the facility's failure to accurately assess the resident, the failure provide the necessary care and services to a resident that severely injured themselves with a bite wound, the facility failure to provide the necessary care services to treat, monitor and care for self-inflicted wounds for a cognitively impaired resident with self-injurious behaviors, the failure of the facility to provide psychosocial care and services to meet the needs of the resident, the facility failed to provide adequate supervision to prevent injuries, the failure of the facility to administer medications in accordance with physician orders [REDACTED]. Review of Resident #158's medical record revealed an SBAR Communication Form dated 5/17/15. Review of the form revealed the resident had increased agitation. The behavioral evaluation included Resident #158 bites self and tries to bite at others. Resident #158 was observed biting his/her right hand middle finger at 4:00 AM. The skin evaluation included bite puncture wounds to the middle 2nd finger on the right hand. The description of the appearance indicated the nurse saw Resident #158 biting his/her right hand 2nd middle finger. The nurse removed the resident's hand from their mouth and noted the finger to have deep bite marks and chewed up tissue. Resident #158 was sent to the emergency room for evaluation and treatment. Additional information included the nurse heard Resident #158 making loud, agitated noises. The nurse responded to the room and found the resident lying in bed with his/her right hand in their mouth biting down on the middle finger. The nurse removed the resident's hand when the resident opened his/her mouth. There was a moderate amount of blood oozing from the punctures. The SBAR Communication Form noted transport arrived to the facility at 5:10 AM to transport Resident #158 to the hospital. In a telephone interview with the surveyor on 9/15/15 at approximately 3:10 PM, LPN #9 stated s/he knew about Resident #158's biting behavior from the hospital and that s/he had worked with the resident since s/he was admitted [DATE]. LPN #9 stated that s/he was told in report that Resident #158's Risperadone was discontinued in the hospital because the resident had pneumonia for the hospital stay 5/4-5/13/15. LPN #9 stated s/he was told the medication sedated him/her and caused the pneumonia. LPN #9 stated Resident #158 often has his/her mouth open trying to bite. The resident becomes agitated when staff touches him/her. LPN #9 stated Resident #158 bites on the mitt on his/her right hand. LPN #9 stated that on 5/17/15 s/he made rounds and went into the resident's room. The resident was in bed with his/her eyes closed. LPN # 9 left the room and continued to make rounds. LPN #9 stated approximately 10 minutes later s/he heard grunting. LPN #9 started looking to see where the noise was coming from and tracked it back to Resident #158. When s/he entered the room Resident #158 had leaned up and over to where his/her hand was. The resident had not lifted his/her hand to their mouth. LPN #9 stated Resident #158's eyes were wide open and s/he had a wild look in their eyes. LPN # stated s/he could hear the resident's bone cracking and the resident did not seem like s/he felt any pain. LPN #9 stated s/he had never seen the resident like that before. LPN #9 stated s/he could not get the resident's hand out of his/her mouth until the resident opened his/her mouth and she was able to pull the fingers out. LPN #9 stated that when s/he called the physician that night s/he told the physician's nurse that the resident's Risperadone had been discharged and the nurse asked why. LPN #9 told the physician's nurse what s/he was told in report about the medication being discharged at the hospital because the resident was diagnosed with [REDACTED].#9 to put Resident #158 back on Risperadone. In a telephone interview with the surveyor on 9/15/15 at approximately 3:30 PM, the Medical Director ( Resident #158's attending physician) stated the Risperadal 0.25 mg BID was on Resident #158's discharge paperwork from the hospital and on the Re-admission Physician order [REDACTED]. The Medical Director stated that Resident #158 could have an increase in behavior because s/he was not receiving the Risperadal. The Medical Director stated s/he thinks it was a transcription error. The Medical Director stated s/he was not aware of any follow-up to the incident related to the medication error. Review of Resident #158's medical record revealed a copy of the Discharge Summary of the resident's hospitalized from [DATE]-4/14/15. The Discharge Summary indicated Resident #158 had [MEDICAL CONDITIONS] status with behavioral issues. The discharge [DIAGNOSES REDACTED]. The Discharge Summary indicated the resident suffered frontal lobe injuries such that his/her behavioral control appeared to be very much impaired. Psychiatry was consulted to help control the patient's behavioral issues. The patient had developed a tendency to attempt to bite nearby objects. The patient's PEG was bit off on one occasion in the patient's confused state. On March 9, 2015 the patient actually bit his/her fingers on the right hand injuring his/her third digit. With the assistance of psychiatry the best medical regimen that could be determined was Risperadone 0.5 milligrams twice a day with reasonable behavioral control without successfully inhibiting the patient's ability to interact with surroundings. To protect his/her hand, a mitten was placed as appeared to be the most humane form of protection that can be offered without restraining the patient. The resident's discharge medications included Risperadone 0.5 mg twice a day. Review of the Infectious Disease/Wound Care physician progress notes [REDACTED].#158 had multiple open wounds to the hands that were self-inflicted. The documentation of the area to the right hand self-inflicted bite wounds noted the dorsal 3rd finger had an opening that measured 0.5 cm x 0.4 cm x 0.1 cm. The resident's 4th finger was discolored without openings noted. Review of the hospital Nurse Progress Notes dated 4/8/15 indicated the nurse reinforced the resident's dressing on his/her right hand to prevent him/her from biting self. The Nurse Progress Note dated 4/9/15 indicated the resident was noted chewing on his/her right hand dressing. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #158 was admitted on Risperadone 0.5 mg(milligrams) BID (twice a day) for behaviors. Review of Resident #158's Initial Plan of Care dated 4/16/15 revealed there was no care plan initiated for the resident's behavior or use of [MEDICAL CONDITION] medication. Review of Resident #158's Care Plan dated 5/8/15 revealed a care plan for aggressive behavior with ADL's (Activities of Daily Living), but the behavior of biting his/her hand was not noted. Further review of the 5/8/15 Care Plan revealed at risk for adverse effects related to use of [MEDICAL CONDITION] medications was identified as a problem area. Interventions and approaches were listed on the care plan and included to monitor and record target behaviors and inform the physician of increase in frequency for possible medication adjustments. Review of Resident #158's Medication Administration Record and Treatment Administration Record revealed no documentation of behavior monitoring in April 2015 or May 2015. Review of Resident #158's Admission Report sheet revealed notes that indicated the resident had self inflicted hand lacerations to two fingers (3rd/4th). The resident was noted to have behaviors issues of combativeness and biting. The resident's skin issues included hydrogel to fingers. Review of the New Admission History and Physical completed 4/23/15 indicated Resident #158 had a human bite on the right hand third digit on 3/9/15. The assessment indicated the resident's right hand was bandaged. Review of Resident #158's Wound Care Record for April 2015 and May 2015 revealed a treatment to cleanse the 2nd and 3rd fingers on the right hand with wound cleanser- apply hydrogel impregnated gauze dressing. Change daily and as needed. The April 2015 Wound Care Record revealed the treatment was provided to the resident form 4/17-4/30/15. The May 2015 Wound Care Record revealed the treatment was provided to the resident until s/he went out to the hospital on [DATE]. Review of the resident's May 2015 Treatment Record upon return from the hospital on [DATE] revealed there was no treatment order for a dressing to the resident's right hand. Review of the resident's May 2015 Psycho-Pharmacological Record for May 2015 revealed the resident received Risperadone 0.25 mg twice a day for behaviors from 5/1-5/4/15 when the resident was sent out to the hospital. Review of the Nursing Evaluation/Data Collection form for Resident #158's readmission on 5/13/15 revealed the resident's behavior included biting per the nurse at the hospital. review of the resident's medical record revealed [REDACTED]. The facility was not able to produce the Physician's Monthly Orders for 5/13-5/31/15. Review of Resident #158's Medication Administration Record for May 2015 upon return from the hospital on [DATE] revealed [MEDICATION NAME] 0.25 mg twice a day was started on 5/20/15. There was no documentation that the resident received [MEDICATION NAME] between 5/13/15 and 5/20/15. Review of the MD/NP (Physician/Nurse Practitioner) Readmission Progress Note dated 5/15/15 revealed the plan for Resident #158 included to continue all current orders and medications. Review of the MD/NP Progress Note dated 5/19/15 revealed the plan for Resident #158 included to start back on [MEDICATION NAME]. Review of the hospital Patient Summary dated 5/17/15 indicated Resident #158's Medications to Continue with No Changes included Risperadone 0.25 mg 1 tablet twice a day. The hospital paperwork indicated the resident had a human bite and a [MEDICAL CONDITION] with a nearby cut, puncture or deep scrape. Review of the x-ray report for Resident #158 dated 5/17/15 indicated the resident had a laceration and comminuted fracture with involvement of the distal aspect of the third middle phalanx as well as the third distal phalanx. The distal phalanx is angulated and displaced. Review of Resident #158's Patient Discharge Summary dated 5/20/15 from the hospital's Same Day Surgery Center indicated the resident's medication list included Risperadone 0.25 mg 1 tablet twice a day. Review of the Physician's Telephone Orders dated 5/28/15 indicated to discharge the dressing to Resident #158's right hand. The sutures will dissolve. Further review of the Physician's Telephone Orders revealed and order dated 6/4/15 for a posey hand control mitt to the resident's right hand to prevent self inflicted wounds to the right hand by biting. Review of the Nurses' Notes dated 4/16/15 at 10:30 PM revealed the dressing to the resident's right hand was intact and dry. There was no documentation in the Nurses Notes on 4/16/15 that indicated the size or condition of the wounds to the resident's right hand. Nurses' Notes were reviewed from 4/16-5/16/15 with no documentation noted related to the resident's behavior of biting self. There was also no documentation related to the size or condition of the wounds to the resident's right hand. Review of the Nurses' Notes dated 4/23/15 revealed the resident was reviewed in PAR meeting related to being a new admission to the facility. There was no documentation related to the resident's behavior or condition of the resident's right hand. Review of the Nurses' Notes dated 5/13/15 revealed no documentation related to the resident's medications or communication with the physician. Review of the Nurses' Notes revealed an entry with a date that was not legible. The previous note was dated 5/18/15 at 11:30 PM and the next legible date was 5/19/15 at 11:30 PM. The Nurses' Note indicated the physician visited with new orders to start [MEDICATION NAME] and physical therapy to evaluate the resident for a hand mitt. In an interview with the surveyor on 9/10/15 at approximately 12:10 PM, the North/East UM stated when Resident #158 went out to the hospital on [DATE] they stitched his/her finger, x-rayed the finger and found the fracture. When the resident returned from the hospital on [DATE] s/he had an appointment to see the orthopedic physician. Resident #158 went to the appointment on 5/20/15 and was sent to the same day surgery center at the hospital and had his/her finger amputated. The North/East UM thinks the resident had his/her finger amputated because of how the fracture was and how bad the skin was. The finger was amputated at the joint. The North/East UM stated Resident #158 would put his/her hand up to their mouth and suck on their fingers at times. In an interview with the surveyor on 09/11/2015 at approximately 1:32 PM the North/East UM(Unit Manager) stated she was the unit manager when Resident #158 bit his/her finger. The North/East UM was not aware of hospital information related to Resident #158 biting his/her fingers prior to admission. The North/East UM stated Admissions usually alerts staff to a resident's history during the morning meeting. The North/East UM could not remember if that happened with Resident #158. The nurse on duty also gets report from the nurse at the hospital when a resident is admitted from the hospital. The nurse on duty also reviews the discharge paperwork from the hospital. The nurse on duty should have reviewed the paperwork and contacted the physician or hospital to see if the facility should continue the order (for mitt from hospital). The nurse should document that they clarified the information. The nurse should pass on the information to the UM so it can be addressed. Chart checks are done in morning meeting for new admissions to make sure all information is there. The staff will discuss the resident and any history at that time. That information is not documented. The North/East UM stated s/he was a nurse on the floor in April so s/he would not have been at the morning meeting when Resident #158 was admitted . The North/East UM stated that if a resident is on a behavior medicine they will start behavior monitoring. Behavior monitoring is documented on the resident's Medication Administration Record. In an interview with the surveyor on 09/11/2015 at approximately 4:17 PM, the DON (Director of Nursing) stated s/he and the nurse on duty look at hospital information for behaviors, history, etc. The Assistant DON will also review the information at times. Unit Managers also review the information. The DON also stated the History/Physical and Discharge Summary come with the resident and that is what they track. The DON stated that in morning clinical meeting they look to make sure that all information that is needed is in the chart. The Discharge Summary is usually faxed over and the nurse on duty looks at that before the resident arrives. The DON stated the nurse on duty should have noted there was a biting problem and made sure there was something in place to prevent. The nurse also should have talked to the physician about the behavior and documented the conversation in the Nurses Notes. The wound to Resident #158's fingers was noted on the admission sheet. The DON reviewed the Nurses Notes dated 4/16/15 and confirmed the wound was not noted in the admission Nurses Notes. The DON reviewed the body audit form from admitted d 4/16/15 and confirmed the wound to Resident #158's fingers was not documented there. The DON confirmed there was no Non-Pressure Skin Condition form in the resident's chart for the area to Resident #158's fingers. The DON confirmed that a Non-Pressure Condition Form should have been completed that documented the size of the area and the condition of the skin. The DON stated the wound to the resident's fingers should have been documented on weekly if a treatment was ordered. The DON reviewed Resident #158's medical record and thinned medical record and confirmed there was no order for treatment to the resident's fingers on the admission orders [REDACTED]. Further review of the resident's medical record revealed [REDACTED]. The DON reviewed Resident #158's TAR (Treatment Administration Record) and did not see on April or May any behavior monitoring documentation. The DON stated that since the resident had previous behavior and was receiving an antipsychotic medication behavior monitoring should have been documented on the TAR. The DON stated Resident #158 came back from the hospital on [DATE] with an order for [REDACTED]. The DON confirmed that the Risperadal 0.25 mg BID was not documented on the MAR as administered until May 20th. The DON stated the nurse should verify what is on the discharge summary and talk with the physician. The nurse should also tell the physician what medications the resident was on before. The nurse should make a note on the Nurses Note about the conversation and what should be continued or discontinued. The DON stated the next morning the chart is reviewed in morning meeting. In morning meeting the medical record is reviewed for physician orders [REDACTED]. The DON verified Risperadal 0.25 mg was ordered. The DON reviewed the Nurse Notes dated 5/13/15 and confirmed there was no documentation related to the order. The DON stated the nurse initiates the initial care plan for new admission residents. Minimum Data Set staff completes the Care Plan on residents after the assessment is completed. Care Plan updates are a combined effort. The resident's medical record is brought to morning meeting and Care Plans are updated there. The nurses on duty may updated the care plan but it is verified in the morning meeting. The DON reviewed Resident #158's initial care plan and confirmed the resident's behavior and antipsychotic medication were not on the initial care plan and stated that they should have been on the initial care plan. In an interview with the surveyor on 9/11/15 at approximately 4:20 PM the ADON (Assistant Director of Nursing) stated Resident #158's behavior was discussed when s/he was admitted to the facility. Resident #158 had self inflicted biting and s/he was combative with staff. The ADON could not remember if they discussed interventions for the resident at the time of admission. In an interview with the surveyor on 09/11/2015 at approximately 4:41 PM, the DON reviewed Resident #158's medical record and thinned record. The DON could not locate the May Physician orders [REDACTED]. The DON stated the nurse should have written readmission orders [REDACTED]. In an interview with the surveyor on 09/11/2015 at approximately 5:49 PM, the ADON and South/West Unit Manager reviewed the resident's medical record and thinned chart. The South/West UM and ADON were at the facility at the time of the incident. The South/West UM was covering the North/East unit during the time of the resident's admission to the facility. The South/West UM and ADON did not remember completing any type of medication error report related to Resident #158 and Risperadal. Neither the South/West UM or ADON remember having any discussion or investigation into what happened with Resident #158 not receiving the Risperadal medication as ordered. Both the South/West UM and ADON were not aware Resident #158 did not receive the medication as ordered. The Immediate Jeopardy identified at the facility on 9/11/15 had not been removed at the time of completion of the recertification and complaint survey on 9/15/15.

Based on record review and interview, the facility failed to ensure each resident received the necessary care and services to maintain the highest practicable physical and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Resident #158 was admitted to the facility with wounds to the right hand related to self biting. There was no documentation of the size or condition of the wounds in the resident's medical record. Resident #158 received treatment to the areas through 5/4/15 but there was no documentation of monitoring the areas. On 9/11/15 at approximately 6:25 PM, the Administrator and Director of Nursing were notified that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility since 5/13/2015. Resident #158 was readmitted to the facility on [DATE]. The facility failed to develop a comprehensive plan of care that addressed the needs of the residents related to his behaviors and [MEDICAL CONDITION] medications. The facility failed to identify and accurately assess Resident #158, a cognitively impaired resident with known self-injurious behaviors. The facility failed to administer antipsychotic medications in accordance with the physician's orders [REDACTED]. The resident was known to have self-injurious behaviors including biting his fingers to the point of fracturing the digit. The facility failed to implement interventions to prevent or monitor for these behaviors. Resident #158 was not given the antipsychotic medication for his self-injurious behaviors from 5/13/15 through 5/20/15 resulting in a serious injury on 5/17/15 to his hand. Resident #158 bit his finger causing a severe fracture and subsequent amputation of that digit. Additionally, Resident #94's treatments were not done as ordered and Resident #94 did not recieve his medications as ordered. Resident #51's PICC line dressings were not done. Resident #164 had no bowel movement for 7 days with no documentation of physician notification or intervention. Resident #61 had no hospice documentation in the facility. Five of thirty-five residents reviewed for care and services. The findings included: Cross refer to F 272, F 279, F 319, F 323, F 333, F 490 and F 501 as it related to the facility's failure to accurately assess the resident, the failure to develop and implement a care plan for behaviors, the facility failure to meet the psychosocial needs of a cognitively impaired resident with self-injurious behaviors, the failure of the facility to provide adequate supervision to prevent injury, the failure of the facility to administer medications in accordance with physician orders, the failure of the facility to administer it's resources effectively to keep residents safe from injury and the failure of the Medical Director to coordinate care and to assure resident care policies were implemented. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #158's medical record revealed a copy of the Discharge Summary of the resident's hospitalized from [DATE]-4/14/15. The Discharge Summary indicated Resident #158 had [MEDICAL CONDITIONS] status with behavioral issues. The discharge [DIAGNOSES REDACTED]. The Discharge Summary indicated the resident suffered frontal lobe injuries such that his/her behavioral control appeared to be very much impaired. Psychiatry was consulted to help control the patient's behavioral issues. The patient had developed a tendency to attempt to bite nearby objects. The patient's PEG was bit off on one occasion in the patient's confused state. On March 9, 2015 the patient actually bit his/her fingers on the right hand injuring his/her third digit. With the assistance of psychiatry the best medical regimen that could be determined was Risperadone 0.5 milligrams twice a day with reasonable behavioral control without successfully inhibiting the patient's ability to interact with surroundings. To protect his/her hand, a mitten was placed as appeared to be the most humane form of protection that can be offered without restraining the patient. Review of the Infectious Disease/Wound Care physician progress notes [REDACTED].#158 had multiple open wounds to the hands that were self-inflicted. The documentation of the area to the right hand self-inflicted bite wounds noted the dorsal 3rd finger had an opening that measured 0.5 cm x 0.4 cm x 0.1 cm. The resident's 4th finger was discolored without openings noted. Review of the hospital Nurse Progress Notes dated 4/8/15 indicated the nurse reinforced the resident's dressing on his/her right hand to prevent him/her from biting self. The Nurse Progress Note dated 4/9/15 indicated the resident was noted chewing on his/her right hand dressing. Review of Resident #158's Admission Report sheet revealed notes that indicated the resident had self inflicted hand lacerations to two fingers (3rd/4th). The resident was noted to have behaviors issues of combativeness and biting. The residents skin issues included hydrogel to fingers. Review of the New Admission History and Physical completed 4/23/15 indicated Resident #158 had a human bite on the right hand third digit on 3/9/15. The assessment indicated the resident's right hand was bandaged. Review of Resident #158's Wound Care Record for April 2015 and May 2015 revealed a treatment to cleanse the 2nd and 3rd fingers on the right hand with wound cleanser- apply hydrogel impregnated gauze dressing. Change daily and as needed. The April 2015 Wound Care Record revealed the treatment was provided to the resident form 4/17-4/30/15. The May 2015 Wound Care Record revealed the treatment was provided to the resident until s/he went out to the hospital on [DATE]. Review of the resident's May 2015 Treatment Record upon return from the hospital on [DATE] revealed there was no treatment order for a dressing to the resident's right hand. Review of the Nurses' Notes dated 4/16/15 at 10:30 PM revealed the dressing to the resident's right hand was intact and dry. There was no documentation in the Nurses Notes on 4/16/15 that indicated the size or condition of the wounds to the resident's right hand. Nurses' Notes were reviewed from 4/16-5/16/15 with no documentation noted related to the resident's behavior of biting himself. There was also no documentation related to the size or condition of the wounds to the resident's right hand. Review of the Nurses' Notes dated 4/23/15 revealed the resident was reviewed in PAR meeting related to being a new admission to the facility. There was no documentation related to the resident's behavior or condition of the resident's right hand. In an interview with the surveyor on 09/11/2015 at approximately 4:17 PM, the DON (Director of Nursing) stated s/he and the nurse on duty look at hospital information for behaviors, history, etc. The Assistant DON will also review the information at times. Unit Managers also review the information. The DON also stated the History/Physical and Discharge Summary come with the resident and that is what they track. The DON stated that in morning clinical meeting they look to make sure that all information that is needed is in the chart. The Discharge Summary is usually faxed over and the nurse on duty looks at that before the resident arrives. The wound to Resident #158's fingers was noted on the admission sheet. The DON reviewed the Nurses Notes dated 4/16/15 and confirmed the wound was not noted in the admission Nurses Notes. The DON reviewed the body audit form from admitted d 4/16/15 and confirmed the wound to Resident #158's fingers was not documented there. The DON confirmed there was no Non-Pressure Skin Condition form in the resident's chart for the area to Resident #158's fingers. The DON confirmed that a Non-Pressure Condition Form should have been completed that documented the size of the area and the condition of the skin. The DON stated the wound to the resident's fingers should have been documented on weekly if a treatment was ordered. The DON reviewed Resident #158's medical record and thinned medical record and confirmed there was no order for treatment to the resident's fingers on the admission orders [REDACTED]. Further review of the resident's medical record revealed [REDACTED]. Review of Resident #61's medical record revealed an order dated 7/27/15 for hospice to evaluate and admit the resident if appropriate. Review of the Hospice Nursing Facility Notification of Hospice Admission for Resident #61 revealed the resident was admitted to hospice on 7/27/15. review of the resident's medical record revealed [REDACTED]. There was a Hospice Nursing Focus Notes form that had one entry dated 7/27/15. There was a Hospice Social Work Notes form that had three entries 7/27/15, 8/3/15 and 8/28/15. The 7/27/15 entry had only IV-Admission, the 8/3/15 entry had only RV and the 8/28/15 entry had only PRN/PRC documented. There was also a Hospice Chaplain Notes form that had three entries dated 7/31/15, 8/12/15 and 8/27/18. There was no other Hospice documentation in Resident #61's medical record. The nurse on duty looked for additional hospice documentation but was not able to locate any information at the nurses station. In an interview with the surveyor on 09/10/2015 at approximately 3:47 PM the North/ East Unit Manager stated s/he had talked with the Hospice nurse and s/he would bring Resident #61's hospice notes to the facility. The North/East Unit Manager confirmed the hospice notes were not at the facility. The North/East Unit Manager stated the notes are usually under a hospice tab in the resident's chart. After reviewing the chart the North/East UM stated there was no hospice tab in Resident #61's medical record. The North/East UM stated hospice staff comes to the nurses desk and asks if there have been any changes or concerns with a hospice resident. When the hospice staff finish with the resident they come back to the nurses station and let staff know how the visit was. Hospice CNAS make a note and give it the facility nurse who signs it. The North/East UM thought they were putting the CNA notes in the chart or in some kind of book. The North/East UM stated the Hospice is new to the facility and they usually use a different Hospice. The facility nurse does not document that the Hospice nurse/CNA have been in to see a resident because they usually keep their own notes and put in the resident's medical record to document their visit and what was done. The North/East UM confirmed the only information in Resident #61's medical record was the initial paperwork for admission to hospice. On 09/10/2015 at approximately 4:02 PM the Medical Records staff stated Resident #61's hospice documentation may be in his/her office waiting to be filed. The Medical Records staff looked for Resident #61's hospice notes in his/her office and stated that the notes were not there. The Medical Records staff did provide a copy of the Hospice Care Plan that was in his/her office. The Hospice Care Plan had a print date of 8/31/15. On 9/10/15 at approximately 4:30 PM the Hospice nurse came to the surveyor and stated s/he could not print out the hospice notes from his/her computer because it was not working today. The Hospice nurse stated that the surveyor could review his/her computer to see Resident #61's hospice documentation. The surveyor asked if the hospice notes could be printed out at the hospice office to review since there was no documentation in the facility. No hospice documentation was provided to the surveyor prior to exit of the recertification and complaint survey on 9/12/15. The facility admitted Resident #51 with [DIAGNOSES REDACTED]. Review of Resident #51's medical record on 9/11/2015 at approximately 2:13 PM revealed a Nurse's Note dated 6/15/2015 at 2:55 PM which states, Resident readmitted .resident has a double lumen PICC line to upper left arm, dressing dry and intact. There was no mention of the PICC line dressing change found in the nurses notes or on the Treatment Record for Resident #51. Further review of Resident #51's medical record on 9/11/2015 at approximately 2:15 PM revealed a form titled,Central Venous Catheter - Physician/Licensed Independent Practitioner Order Sheet, states under, Change Catheter Site Dressing: and checked is, 24 hours post PICC insertion, and On admission, Q (every) week and PRN (as needed) with a transparent dressing. An interview on 9/12/105 at approximately 5:00 PM with the Director of Nurses (DON) confirmed that the PICC line dressing was not changed by the facility since the insertion on 6/16/2015 until the PICC line was discontinued on 7/24/2015. The facility admitted Resident #94 with [DIAGNOSES REDACTED]. Review on 9/12/2015 at approximately 10:43 AM of a quarterly Bowel and Bladder Evaluation did not include a date a signature of the per completing the form or the findings from the evaluation. Review on 9/12/2015 at approximately 10:45 AM of the Treatment Record for Resident #94 revealed a treatment to his/her right great toe and second toe of left foot which stated to cleanse areas with wound cleanser and apply triple antibiotic ointment, and apply a Band-Aid and change daily until resolved. Further review of the treatment record on 9/12/2015 at approximately 10:45 PM revealed that Resident #94 did not receive the dressing change and ointment on 3/20/2015, 3/22/2015 and 3/30/2015 and 3/31/2015. Review on 9/12/2015 at approximately 10:45 AM of the Medication Administration Record [REDACTED]. He/she did not receive [MEDICATION NAME] 2 mg on 5/20/2015, 5/22/2015, 5/25/2015, 5/27/2015 and 5/29/2015. Nor did he/she receive [MEDICATION NAME] 1 mg on 5/19/2015, 5/21/2015, 5/23/2015. 5/24/2015, 5/26/2015, 5/28/2015, 5/30/2015, 5/31/2015 as ordered by the physician. Review on 9/12/2015 at approximately 10:45 AM of the MAR for Resident #94 dated June 2015 revealed pain was not monitored on the PM shift for 5/9/2015 nor was it monitored on 6/25/2015 on the AM shift. Further review of the MAR for June 2015 on 9/12/2015 at approximately 10:45 AM for Resident #94 revealed the medication [MEDICATION NAME] 40 mg was not given on 6/10/2015 nor did he/she receive it on 6/15/2015. Resident #94 did not receive the Levothyroxin 25 micrograms (mcg) on 6/10/2015 nor did he/she receive it on 6/15/2015. Resident #94 did not receive the [MEDICATION NAME] Sol 0.5% at bedtime on 6/25/2015, 6/29/2015 and 6/30/2015. This resident did not receive the Carvedilol 12.5 mg as ordered at 9:00 PM on 6/21/2015, 6/24/2015 and 6/30/2015. Further review of Resident #94's medical record on 9/12/2015 at approximately 10:45 AM revealed a MAR indicated [REDACTED]. He/she did not receive the Levothyroxin 25 mcg on 7/15/2015 at 6:00 AM as ordered. [MEDICATION NAME] was ordered for 7/16/2015 and he/she did not receive it. His/her finger stick blood sugar was not done on 7/9/2015 at 4:30 PM, or 7/17/2015 at 4:30 PM nor 7/26/2015 at 4:30 PM. Resident #94 was ordered to have 8 units of [MEDICATION NAME] 70/30 at 5:00 PM. He/she did not receive the 8 units of [MEDICATION NAME] on 7/9/2015 at 5:00 PM and 7/16/2015 at 5:00 PM nor did he/she receive it on 7/23/2015, 7/24/2015 and 7/26/2015. During an interview on 9/12/2015 at approximately 1:00 PM with the Director of Nurses, he/she confirmed that the bowel and bladder assessments were not dated and completed correctly. He/she also verified that the MARs and the Treatment sheets had days when the medicationss were not given and the treatments were not done. The facility admitted Resident #164 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) revealed that the resident had both short- and long-term memory problems with moderately impaired cognitive skills for daily decision making. The resident required extensive assistance of one person for transfers and toileting. According to the assessment, the resident had functional limitations in both lower extremities and was frequently incontinent of bowel. Review of the 5-27-15 Nutritional Therapy Assessment on 9-11-15 at 3:30 PM revealed that Resident #164 had an intake of 75-100%. Review of Certified Nursing Assistant (CNA) computerized records at 5 PM on 9-11-15 revealed that the resident had no bowel movements documented from 5-23-15 to 5-31-15. During an interview on 9-12-15 at 8:40 AM, the Director of Nurses (DON) was unaware if the facility had a protocol or standing orders to address residents with constipation. The DON stated s/he would have to check. During an interview on 9-12-15 at 8:50 AM, when asked about treatment for constipation, Licensed Practical Nurse (LPN) #10 stated s/he would give a 'PRN (as needed)' (laxative) or notify the doctor if the resident complained of constipation or exhibited symptoms of constipation. The LPN stated s/he had been employed approximately six months and had no resource available to check when a resident had their last BM. S/he did not access computerized data. S/he was unaware of any established protocol to address constipation. On 9-12-15 at 9:13 AM during an interview, the Assistant Director of Nursing (ADON) stated s/he was unaware of facility protocols to address constipation. S/he stated, I will check. At 10:43 AM, the ADON stated that each morning in a managers' meeting, staff reviewed a report showing residents who had no BM in the previous 3 days. S/he stated that nurses did have access to the CNA documentation because they were responsible to check that CNA's completed their daily documentation of care provided. However, s/he did not know if they reviewed BM's. The Immediate Jeopardy identified at the facility on 9/11/15 had not been removed at the time of completion of the recertification and complaint survey on 9/15/15.

Based on record review and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical and psychosocial well-being of each resident. One of two residents reviewed for self injurious behaviors. On 9/11/15 at approximately 6:25 PM, the Administrator and Director of Nursing were notified that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility since 5/13/2015. Resident #158 was readmitted to the facility on [DATE]. The facility failed to develop a comprehensive plan of care that addressed the needs of the residents related to his behaviors and [MEDICAL CONDITION] medications. The facility failed to identify and accurately assess Resident #158, a cognitively impaired resident with known self-injurious behaviors. The facility failed to administer antipsychotic medications in accordance with the physician's orders [REDACTED]. The resident was known to have self-injurious behaviors including biting his fingers to the point of fracturing the digit. The facility failed to implement interventions to prevent or monitor for these behaviors. Resident #158 was not given the antipsychotic medication for his self-injurious behaviors from 5/13/15 through 5/20/15 resulting in a serious injury on 5/17/15 to his hand. Resident #158 bit his finger causing a severe fracture and subsequent amputation of that digit. The findings included: Cross refer to F 272, F 279, F 309, F 319, F 323, F 333 and F 501 as it related to the facility's failure to accurately assess the resident, the failure provide the necessary care and services to a resident that severely injured themselves with a bite wound, the facility failure to provide the necessary care services to treat, monitor and care for self-inflicted wounds for a cognitively impaired resident with self-injurious behaviors, the failure of the facility to provide psychosocial care and services to meet the needs of the resident, the facility failed to provide adequate supervision to prevent injuries, the failure of the facility to administer medications in accordance with physician orders, and the failure of the Medical Director to coordinate care and to assure resident care policies were implemented. In an interview with the surveyor on 09/11/2015 at approximately 4:17 PM, the DON (Director of Nursing) stated s/he and the nurse on duty look at hospital information for behaviors, history, etc. The Assistant DON will also review the information at times. Unit Managers also review the information. The DON also stated the History/Physical and Discharge Summary come with the resident and that is what they track. The DON stated that in morning clinical meeting they look to make sure that all information that is needed is in the chart. The Discharge Summary is usually faxed over and the nurse on duty looks at that before the resident arrives. The DON stated the nurse on duty should have noted there was a biting problem and made sure there was something in place to prevent. The nurse also should have talked to the physician about the behavior and documented the conversation in the Nurses Notes. The wound to Resident #158's fingers was noted on the admission sheet. The DON reviewed the Nurses Notes dated 4/16/15 and confirmed the wound was not noted in the admission Nurses Notes. The DON reviewed the body audit form from admitted d 4/16/15 and confirmed the wound to Resident #158's fingers was not documented there. The DON confirmed there was no Non-Pressure Skin Condition form in the resident's chart for the area to Resident #158's fingers. The DON confirmed that a Non-Pressure Condition Form should have been completed that documented the size of the area and the condition of the skin. The DON stated the wound to the resident's fingers should have been documented on weekly if a treatment was ordered. The DON reviewed Resident #158's medical record and thinned medical record and confirmed there was no order for treatment to the resident's fingers on the admission orders [REDACTED]. Further review of the resident's medical record revealed [REDACTED]. The DON reviewed Resident #158's TAR (Treatment Administration Record) and did not see on April or May any behavior monitoring documentation. The DON stated that since the resident had previous behavior and was receiving an antipsychotic medication behavior monitoring should have been documented on the TAR. The DON stated Resident #158 came back from the hospital on [DATE] with an order for [REDACTED]. The DON confirmed that the Risperadal 0.25 mg BID was not documented on the MAR as administered until May 20th. The DON stated the nurse should verify what is on the discharge summary and talk with the physician. The nurse should also tell the physician what medications the resident was on before. The nurse should make a note on the Nurses Note about the conversation and what should be continued or discontinued. The DON stated the next morning the chart is reviewed in morning meeting. In morning meeting the medical record is reviewed for physician orders [REDACTED]. The DON verified Risperadal 0.25 mg was ordered. The DON reviewed the Nurse Notes dated 5/13/15 and confirmed there was no documentation related to the order. The DON stated the nurse initiates the initial care plan for new admission residents. Minimum Data Set staff completes the Care Plan on residents after the assessment is completed. Care Plan updates are a combined effort. The resident's medical record is brought to morning meeting and Care Plans are updated there. The nurses on duty may updated the care plan but it is verified in the morning meeting. The DON reviewed Resident #158's initial care plan and confirmed the resident's behavior and antipsychotic medication were not on the initial care plan and stated that they should have been on the initial care plan. In an interview with the surveyor on 9/11/15 at approximately 4:20 PM the ADON (Assistant Director of Nursing) stated Resident #158's behavior was discussed when s/he was admitted to the facility. Resident #158 had self inflicted biting and s/he was combative with staff. The ADON could not remember if they discussed interventions for the resident at the time of admission. In an interview with the surveyor on 09/11/2015 at approximately 4:41 PM, the DON reviewed Resident #158's medical record and thinned record. The DON could not locate the May Physician orders [REDACTED]. The DON stated the nurse should have written readmission orders [REDACTED]. In an interview with the surveyor on 09/11/2015 at approximately 5:49 PM, the ADON and South/West Unit Manager reviewed the resident's medical record and thinned chart. The South/West UM and ADON were at the facility at the time of the incident. The South/West UM was covering the North/East unit during the time of the resident's admission to the facility. The South/West UM and ADON did not remember completing any type of medication error report related to Resident #158 and Risperadal. Neither the South/West UM or ADON remember having any discussion or investigation into what happened with Resident #158 not receiving the Risperadal medication as ordered. Both the South/West UM and ADON were not aware Resident #158 did not receive the medication as ordered. In an interview with the surveyor on 09/11/2015 at approximately 1:32 PM the North/East UM(Unit Manager) stated she was the unit manager when Resident #158 bit his/her finger. The North/East UM was not aware of hospital information related to Resident #158 biting his/her fingers prior to admission. The North/East UM stated Admissions usually alerts staff to a resident's history during the morning meeting. The North/East UM could not remember if that happened with Resident #158. The nurse on duty also gets report from the nurse at the hospital when a resident is admitted from the hospital. The nurse on duty also reviews the discharge paperwork from the hospital. The nurse on duty should have reviewed the paperwork and contacted the physician or hospital to see if the facility should continue the order (for mitt from hospital). The nurse should document that they clarified the information. The nurse should pass on the information to the UM so it can be addressed. Chart checks are done in morning meeting for new admissions to make sure all information is there. The staff will discuss the resident and any history at that time. That information is not documented. The North/East UM stated s/he was a nurse on the floor in April so s/he would not have been at the morning meeting when Resident #158 was admitted . The North/East UM stated that if a resident is on a behavior medicine they will start behavior monitoring. Behavior monitoring is documented on the resident's Medication Administration Record. In a telephone interview with the surveyor on 9/15/15 at approximately 3:10 PM, LPN #9 stated s/he knew about Resident #158's biting behavior from the hospital and that s/he had worked with the resident since s/he was admitted [DATE]. LPN #9 stated that s/he was told in report that Resident #158's Risperadone was discontinued in the hospital because the resident had pneumonia for the hospital stay 5/4-5/13/15. LPN #9 stated s/he was told the medication sedated him/her and caused the pneumonia. LPN #9 stated Resident #158 often has his/her mouth open trying to bite. The resident becomes agitated when staff touches him/her. LPN #9 stated Resident #158 bites on the mitt on his/her right hand. LPN #9 stated that on 5/17/15 s/he made rounds and went into the resident's room. The resident was in bed with his/her eyes closed. LPN # 9 left the room and continued to make rounds. LPN #9 stated approximately 10 minutes later s/he heard grunting. LPN #9 started looking to see where the noise was coming from and tracked it back to Resident #158. When s/he entered the room Resident #158 had leaned up and over to where his/her hand was. The resident had not lifted his/her hand to their mouth. LPN #9 stated Resident #158's eyes were wide open and s/he had a wild look in their eyes. LPN # stated s/he could hear the resident's bone cracking and the resident did not seem like s/he felt any pain. LPN #9 stated s/he had never seen the resident like that before. LPN #9 stated s/he could not get the resident's hand out of his/her mouth until the resident opened his/her mouth and she was able to pull the fingers out. LPN #9 stated that when s/he called the physician that night s/he told the physician's nurse that the resident's Risperadone had been discharged and the nurse asked why. LPN #9 told the physician's nurse what s/he was told in report about the medication being discharged at the hospital because the resident was diagnosed with [REDACTED].#9 to put Resident #158 back on Risperadone. In an interview with the surveyor on 9/10/15 at approximately 12:10 PM, the North/East UM stated when Resident #158 went out to the hospital on [DATE] they stitched his/her finger, x-rayed the finger and found the fracture. When the resident returned from the hospital on [DATE] s/he had an appointment to see the orthopedic physician. Resident #158 went to the appointment on 5/20/15 and was sent to the same day surgery center at the hospital and had his/her finger amputated. The North/East UM thinks the resident had his/her finger amputated because of how the fracture was and how bad the skin was. The finger was amputated at the joint. The North/East UM stated Resident #158 would put his/her hand up to their mouth and suck on their fingers at times. In a telephone interview with the surveyor on 9/15/15 at approximately 3:30 PM, the Medical Director ( Resident #158's attending physician) stated the Risperadal 0.25 mg BID was on Resident #158's discharge paperwork from the hospital and on the Re-admission Physician order [REDACTED]. The Medical Director stated that Resident #158 could have an increase in behavior because s/he was not receiving the Risperadal. The Medical Director stated s/he thinks it was a transcription error. The Medical Director stated s/he was not aware of any follow-up to the incident related to the medication error. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #158 was admitted on Risperadone 0.5 mg(milligrams) BID (twice a day) for behaviors. Review of Resident #158's medical record revealed a copy of the Discharge Summary of the resident's hospitalized from [DATE]-4/14/15. The Discharge Summary indicated Resident #158 had [MEDICAL CONDITIONS] status with behavioral issues. The discharge [DIAGNOSES REDACTED]. The Discharge Summary indicated the resident suffered frontal lobe injuries such that his/her behavioral control appeared to be very much impaired. Psychiatry was consulted to help control the patient's behavioral issues. The patient had developed a tendency to attempt to bite nearby objects. The patient's PEG was bit off on one occasion in the patient's confused state. On March 9, 2015 the patient actually bit his/her fingers on the right hand injuring his/her third digit. With the assistance of psychiatry the best medical regimen that could be determined was Risperadone 0.5 milligrams twice a day with reasonable behavioral control without successfully inhibiting the patient's ability to interact with surroundings. To protect his/her hand, a mitten was placed as appeared to be the most humane form of protection that can be offered without restraining the patient. The resident's discharge medications included Risperadone 0.5 mg twice a day. Review of the Infectious Disease/Wound Care physician progress notes [REDACTED].#158 had multiple open wounds to the hands that were self-inflicted. The documentation of the area to the right hand self-inflicted bite wounds noted the dorsal 3rd finger had an opening that measured 0.5 cm x 0.4 cm x 0.1 cm. The resident's 4th finger was discolored without openings noted. Review of the hospital Nurse Progress Notes dated 4/8/15 indicated the nurse reinforced the resident's dressing on his/her right hand to prevent him/her from biting self. The Nurse Progress Note dated 4/9/15 indicated the resident was noted chewing on his/her right hand dressing. Review of Resident #158's Initial Plan of Care dated 4/16/15 revealed there was no care plan initiated for the resident's behavior or use of [MEDICAL CONDITION] medication. Review of Resident #158's Care Plan dated 5/8/15 revealed a care plan for aggressive behavior with ADL's (Activities of Daily Living), but the behavior of biting his/her hand was not noted. Further review of the 5/8/15 Care Plan revealed at risk for adverse effects related to use of [MEDICAL CONDITION] medications was identified as a problem area. Interventions and approaches were listed on the care plan and included to monitor and record target behaviors and inform the physician of increase in frequency for possible medication adjustments. Review of Resident #158's Medication Administration Record and Treatment Administration Record revealed no documentation of behavior monitoring in April 2015 or May 2015. Review of Resident #158's Admission Report sheet revealed notes that indicated the resident had self inflicted hand lacerations to two fingers (3rd/4th). The resident was noted to have behaviors issues of combativeness and biting. The residents skin issues included hydrogel to fingers. Review of the New Admission History and Physical completed 4/23/15 indicated Resident #158 had a human bite on the right hand third digit on 3/9/15. The assessment indicated the resident's right hand was bandaged. Review of Resident #158's Wound Care Record for April 2015 and May 2015 revealed a treatment to cleanse the 2nd and 3rd fingers on the right hand with wound cleanser- apply hydrogel impregnated gauze dressing. Change daily and as needed. The April 2015 Wound Care Record revealed the treatment was provided to the resident form 4/17-4/30/15. The May 2015 Wound Care Record revealed the treatment was provided to the resident until s/he went out to the hospital on [DATE]. Review of the resident's May 2015 Treatment Record upon return from the hospital on [DATE] revealed there was no treatment order for a dressing to the resident's right hand. Review of the resident's May 2015 Psycho-Pharmacological Record for May 2015 revealed the resident received Risperadone 0.25 mg twice a day for behaviors from 5/1-5/4/15 when the resident was sent out to the hospital. Review of Resident #158's medical record revealed an SBAR Communication Form dated 5/17/15. Review of the form revealed the resident had increased agitation. The behavioral evaluation included Resident #158 bites self and tries to bite at others. Resident #158 was observed biting his/her right hand middle finger at 4:00 AM. The skin evaluation included bite puncture wounds to the middle 2nd finger on the right hand. The description of the appearance indicated the nurse saw Resident #158 biting his/her right hand 2nd middle finger. The nurse removed the resident's hand from their mouth and noted the finger to have deep bite marks and chewed up tissue. Resident #158 was sent to the emergency room for evaluation and treatment. Additional information included the nurse heard Resident #158 making loud, agitated noises. The nurse responded to the room and found the resident lying in bed with his/her right hand in their mouth biting down on the middle finger. The nurse removed the resident's hand when the resident opened his/her mouth. There was a moderate amount of blood oozing from the punctures. The SBAR Communication Form noted transport arrived to the facility at 5:10 AM to transport Resident #158 to the hospital. Review of the Nursing Evaluation/Data Collection form for Resident #158's readmission on 5/13/15 revealed the resident's behavior included biting per the nurse at the hospital. review of the resident's medical record revealed [REDACTED]. The facility was not able to produce the Physician's Monthly Orders for 5/13-5/31/15. Review of Resident #158's Medication Administration Record for May 2015 upon return from the hospital on [DATE] revealed [MEDICATION NAME] 0.25 mg twice a day was started on 5/20/15. There was no documentation that the resident received [MEDICATION NAME] between 5/13/15 and 5/20/15. Review of the MD/NP (Physician/Nurse Practitioner) Readmission Progress Note dated 5/15/15 revealed the plan for Resident #158 included to continue all current orders and medications. Review of the MD/NP Progress Note dated 5/19/15 revealed the plan for Resident #158 included to start back on [MEDICATION NAME]. Review of the hospital Patient Summary dated 5/17/15 indicated Resident #158's Medications to Continue with No Changes included Risperadone 0.25 mg 1 tablet twice a day. The hospital paperwork indicated the resident had a human bite and a [MEDICAL CONDITION] with a nearby cut, puncture or deep scrape. Review of the x-ray report for Resident #158 dated 5/17/15 indicated the resident had a laceration and comminuted fracture with involvement of the distal aspect of the third middle phalanx as well as the third distal phalanx. The distal phalanx is angulated and displaced. Review of Resident #158's Patient Discharge Summary dated 5/20/15 from the hospital's Same Day Surgery Center indicated the resident's medication list included Risperadone 0.25 mg 1 tablet twice a day. Review of the Physician's Telephone Orders dated 5/28/15 indicated to discharge the dressing to Resident #158's right hand. The sutures will dissolve. Further review of the Physician's Telephone Orders revealed and order dated 6/4/15 for a posey hand control mitt to the resident's right hand to prevent self inflicted wounds to the right hand by biting. Review of the Nurses' Notes dated 4/16/15 at 10:30 PM revealed the dressing to the resident's right hand was intact and dry. There was no documentation in the Nurses' Notes on 4/16/15 that indicated the size or condition of the wounds to the resident's right hand. Nurses' Notes were reviewed from 4/16-5/16/15 with no documentation noted related to the resident's behavior of biting self. There was also no documentation related to the size or condition of the wounds to the resident's right hand. Review of the Nurses' Notes dated 4/23/15 revealed the resident was reviewed in PAR meeting related to being a new admission to the facility. There was no documentation related to the resident's behavior or condition of the resident's right hand. Review of the Nurses' Notes dated 5/13/15 revealed no documentation related to the resident's medications or communication with the physician. Review of the Nurses' Notes revealed an entry with a date that was not legible. The previous note was dated 5/18/15 at 11:30 PM and the next legible date was 5/19/15 at 11:30 PM. The Nurses' Note indicated the physician visited with new orders to start [MEDICATION NAME] and physical therapy to evaluate the resident for a hand mitt. The Immediate Jeopardy identified at the facility on 9/11/15 had not been removed at the time of completion of the recertification and complaint survey on 9/15/15.

Based on record review and interview, the facility failed to ensure that residents are free of any significant medication errors. Resident #158 was noted to have self-injury behaviors and was prescribed Risperadone for behaviors. Resident #158 went to the hospital from 5/4-5/13/15. Review of the hospital paperwork revealed the Risperadone was to be continued. Resident #158 did not receive the medication until 5/20/15. On 5/17/15 Resident #158 bit his/her own finger causing a fracture which led to the finger being amputated. One of eight residents reviewed for medications. On 9/11/15 at approximately 6:25 PM, the Administrator and Director of Nursing were notified that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility since 5/13/2015. Resident #158 was readmitted to the facility on [DATE]. The facility failed to develop a comprehensive plan of care that addressed the needs of the residents related to his behaviors and [MEDICAL CONDITION] medications. The facility failed to identify and accurately assess Resident #158, a cognitively impaired resident with known self-injurious behaviors. The facility failed to administer antipsychotic medications in accordance with the physician's orders [REDACTED]. The resident was known to have self-injurious behaviors including biting his fingers to the point of fracturing the digit. The facility failed to implement interventions to prevent or monitor for these behaviors. Resident #158 was not given the antipsychotic medication for his self-injurious behaviors from 5/13/15 through 5/20/15 resulting in a serious injury on 5/17/15 to his hand. Resident #158 bit his finger causing a severe fracture and subsequent amputation of that digit. The findings included: Cross refer to F 272, F 279, F 309, F 319, F 323, F 490 and F 501 as it related to the facility's failure to accurately assess the resident, the failure provide the necessary care and services to a resident that severely injured themselves with a bite wound, the facility failure to provide the necessary care services to treat, monitor and care for self-inflicted wounds for a cognitively impaired resident with self-injurious behaviors, the failure of the facility to provide psychosocial care and services to meet the needs of the resident, the facility failed to provide adequate supervision to prevent injuries, the failure of the facility to administer medications in accordance with physician orders, the failure of the facility to administer it's resources effectively to keep residents safe from injury and the failure of the Medical Director to coordinate care and to assure resident care policies were implemented. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #158 was admitted on Risperadone 0.5 mg(milligrams) BID (twice a day) for behaviors. Review of the resident's Physician's Telephone Orders dated 4/30/15 revealed an order to discontinue Risperadone 0.5 mg BID and start Risperadone 0.25 mg BID. Review of Resident #158's Medication Administration Record for May 2015 upon return from the hospital on [DATE] revealed Risperadone 0.25 mg twice a day was started on 5/20/15. There was no documentation that the resident received Risperadone between 5/13/15 and 5/20/15. Review of the MD/NP (Physician/Nurse Practitioner) Readmission Progress Note dated 5/15/15 revealed the plan for Resident #158 included to continue all current orders and medications. Review of the MD/NP Progress Note dated 5/19/15 revealed the plan for Resident #158 included to start back on Risperadone. Review of the Nurses' Notes dated 5/13/15 revealed no documentation related to the resident's medications or communication with the physician. Review of Resident #158's medical record revealed an SBAR Communication Form dated 5/17/15. Review of the form revealed the resident had increased agitation. The behavioral evaluation included Resident #158 bites self and tries to bite at others. Resident #158 was observed biting his/her right hand middle finger at 4:00 AM. The skin evaluation included bite puncture wounds to the middle 2nd finger on the right hand. The description of the appearance indicated the nurse saw Resident #158 biting his/her right hand 2nd middle finger. The nurse removed the resident's hand from their mouth and noted the finger to have deep bite marks and chewed up tissue. Resident #158 was sent to the emergency room for evaluation and treatment. Additional information included the nurse heard Resident #158 making loud, agitated noises. The nurse responded to the room and found the resident lying in bed with his/her right hand in their mouth biting down on the middle finger. The nurse removed the resident's hand when the resident opened his/her mouth. There was a moderate amount of blood oozing from the punctures. The SBAR Communication Form noted transport arrived to the facility at 5:10 AM to transport Resident #158 to the hospital. The DON stated Resident #158 came back from the hospital on [DATE] with an order for [REDACTED]. The DON confirmed that the Risperadone 0.25 mg BID was not documented on the MAR as administered until May 20th. The DON stated the nurse should verify what is on the discharge summary and talk with the physician. The nurse should also tell the physician what medications the resident was on before. The nurse should make a note on the Nurses Note about the conversation and what should be continued or discontinued. The DON stated the next morning the chart is reviewed in morning meeting. In morning meeting the medical record is reviewed for physician orders [REDACTED]. The DON verified Risperadone 0.25 mg was ordered. The DON reviewed the Nurse Notes dated 5/13/15 and confirmed there was no documentation related to the order. In a telephone interview with the surveyor on 9/15/15 at approximately 3:30 PM, the Medical Director ( Resident #158's attending physician) stated the Risperadone 0.25 mg BID was on Resident #158's discharge paperwork from the hospital and on the Re-admission Physician order [REDACTED]. The Medical Director stated that Resident #158 could have an increase in behavior because s/he was not receiving the Risperadone. The Medical Director stated s/he thinks it was a transcription error. The Medical Director stated s/he was not aware of any follow-up to the incident related to the medication error. Review of Resident #158's medical record revealed a copy of the Discharge Summary of the resident's hospitalized from [DATE]-4/14/15. The Discharge Summary indicated Resident #158 had [MEDICAL CONDITIONS] status with behavioral issues. The discharge [DIAGNOSES REDACTED]. The Discharge Summary indicated the resident suffered frontal lobe injuries such that his/her behavioral control appeared to be very much impaired. Psychiatry was consulted to help control the patient's behavioral issues. The patient had developed a tendency to attempt to bite nearby objects. The patient's PEG was bit off on one occasion in the patient's confused state. On March 9, 2015 the patient actually bit his/her fingers on the right hand injuring his/her third digit. With the assistance of psychiatry the best medical regimen that could be determined was Risperadone 0.5 milligrams twice a day with reasonable behavioral control without successfully inhibiting the patient's ability to interact with surroundings. To protect his/her hand, a mitten was placed as appeared to be the most humane form of protection that can be offered without restraining the patient. The resident's discharge medications included Risperadone 0.5 mg twice a day. Review of the Nursing Evaluation/Data Collection form for Resident #158's readmission on 5/13/15 revealed the resident's behavior included biting per the nurse at the hospital. review of the resident's medical record revealed [REDACTED]. The facility was not able to produce the Physician's Monthly Orders for 5/13-5/31/15. Review of the New Admission History and Physical completed 4/23/15 indicated Resident #158 had a human bite on the right hand third digit on 3/9/15. The assessment indicated the resident's right hand was bandaged. Review of the resident's May 2015 Psycho-Pharmacological Record for May 2015 revealed the resident received Risperadone 0.25 mg twice a day for behaviors from 5/1-5/4/15 when the resident was sent out to the hospital. Review of the hospital Patient Summary dated 5/17/15 indicated Resident #158's Medications to Continue with No Changes included Risperadone 0.25 mg 1 tablet twice a day. The hospital paperwork indicated the resident had a human bite and a [MEDICAL CONDITION] with a nearby cut, puncture or deep scrape. Review of the x-ray report for Resident #158 dated 5/17/15 indicated the resident had a laceration and comminuted fracture with involvement of the distal aspect of the third middle phalanx as well as the third distal phalanx. The distal phalanx is angulated and displaced. Review of Resident #158's Patient Discharge Summary dated 5/20/15 from the hospital's Same Day Surgery Center indicated the resident's medication list included Risperadone 0.25 mg 1 tablet twice a day. Review of the Nurses' Notes revealed an entry with a date that was not legible. The previous note was dated 5/18/15 at 11:30 PM and the next legible date was 5/19/15 at 11:30 PM. The Nurses' Note indicated the physician visited with new orders to start Risperadone and physical therapy to evaluate the resident for a hand mitt. In an interview with the surveyor on 9/10/15 at approximately 12:10 PM, the North/East UM stated when Resident #158 went out to the hospital on [DATE] they stitched his/her finger, x-rayed the finger and found the fracture. When the resident returned from the hospital on [DATE] s/he had an appointment to see the orthopedic physician. Resident #158 went to the appointment on 5/20/15 and was sent to the same day surgery center at the hospital and had his/her finger amputated. The North/East UM thinks the resident had his/her finger amputated because of how the fracture was and how bad the skin was. The finger was amputated at the joint. The North/East UM stated Resident #158 would put his/her hand up to their mouth and suck on their fingers at times. In an interview with the surveyor on 09/11/2015 at approximately 1:32 PM the North/East UM(Unit Manager) stated she was the unit manager when Resident #158 bit his/her finger. The North/East UM was not aware of hospital information related to Resident #158 biting his/her fingers prior to admission. The North/East UM stated Admissions usually alerts staff to a resident's history during the morning meeting. The North/East UM could not remember if that happened with Resident #158. The nurse on duty also gets report from the nurse at the hospital when a resident is admitted from the hospital. The nurse on duty also reviews the discharge paperwork from the hospital. The nurse on duty should have reviewed the paperwork and contacted the physician or hospital to see if the facility should continue the order (for mitt from hospital). The nurse should document that they clarified the information. The nurse should pass on the information to the UM so it can be addressed. Chart checks are done in morning meeting for new admissions to make sure all information is there. The staff will discuss the resident and any history at that time. That information is not documented. The North/East UM stated s/he was a nurse on the floor in April so s/he would not have been at the morning meeting when Resident #158 was admitted . The North/East UM stated that if a resident is on a behavior medicine they will start behavior monitoring. Behavior monitoring is documented on the resident's Medication Administration Record. In an interview with the surveyor on 09/11/2015 at approximately 4:17 PM, the DON (Director of Nursing) stated s/he and the nurse on duty look at hospital information for behaviors, history, etc. The Assistant DON will also review the information at times. Unit Managers also review the information. The DON also stated the History/Physical and Discharge Summary come with the resident and that is what they track. The DON stated that in morning clinical meeting they look to make sure that all information that is needed is in the chart. The Discharge Summary is usually faxed over and the nurse on duty looks at that before the resident arrives. The DON stated the nurse on duty should have noted there was a biting problem and made sure there was something in place to prevent. The nurse also should have talked to the physician about the behavior and documented the conversation in the Nurses Notes. The DON reviewed Resident #158's TAR (Treatment Administration Record) and did not see on April or May any behavior monitoring documentation. The DON stated that since the resident had previous behavior and was receiving an antipsychotic medication behavior monitoring should have been documented on the TAR. In an interview with the surveyor on 09/11/2015 at approximately 4:41 PM, the DON reviewed Resident #158's medical record and thinned record. The DON could not locate the May Physician orders [REDACTED]. The DON stated the nurse should have written readmission orders [REDACTED]. In an interview with the surveyor on 09/11/2015 at approximately 5:49 PM, the ADON and South/West Unit Manager reviewed the resident's medical record and thinned chart. The South/West UM and ADON were at the facility at the time of the incident. The South/West UM was covering the North/East unit during the time of the resident's admission to the facility. The South/West UM and ADON did not remember completing any type of medication error report related to Resident #158 and Risperadone. Neither the South/West UM or ADON remember having any discussion or investigation into what happened with Resident #158 not receiving the Risperadone medication as ordered. Both the South/West UM and ADON were not aware Resident #158 did not receive the medication as ordered. In a telephone interview with the surveyor on 9/15/15 at approximately 3:10 PM, LPN # stated s/he knew about Resident #158's biting behavior from the hospital and that s/he had worked with the resident since s/he was admitted [DATE]. LPN # stated that s/he was told in report that Resident #158's Risperadone was discharged in the hospital because the resident had pneumonia for the hospital stay 5/4-5/13/15. LPN # stated s/he was told the medication sedated him/her and caused the pneumonia. LPN # stated Resident #158 often has his/her mouth open trying to bite. The resident becomes agitated when staff touches him/her. LPN # stated Resident #158 bites on the mitt on his/her right hand. LPN # stated that on 5/17/15 s/he made rounds and went into the resident's room. The resident was in bed with his/her eyes closed. LPN # left the room and continued to make rounds. LPN # stated approximately 10 minutes later s/he heard grunting. LPN # started looking to see where the noise was coming from and tracked it back to Resident #158. When s/he entered the room Resident #158 had leaned up and over to where his/her hand was. The resident had not lifted his/her hand to their mouth. LPN # stated Resident #158's eyes were wide open and s/he had a wild look in their eyes. LPN # stated s/he could hear the resident's bone cracking and the resident did not seem like s/he felt any pain. LPN # stated s/he had never seen the resident like that before. LPN # stated s/he could not get the resident's hand out of his/her mouth until the resident opened his/her mouth and she was able to pull the fingers out. LPN # stated that when s/he called the physician that night s/he told the physician's nurse that the resident's Risperadone had been discharged and the nurse asked why. LPN # told the physician's nurse what s/he was told in report about the medication being discharged at the hospital because the resident was diagnosed with [REDACTED].# to put Resident #158 back on Risperadone. The Immediate Jeopardy identified at the facility on 9/11/15 had not been removed at the time of completion of the recertification and complaint survey on 9/15/15.

Based on review of facility files and interview, the facility failed to assure that each resident received adequate supervision to prevent accidents and injuries. Resident #158 had a history of [REDACTED]. Resident #158 did not have any monitoring or interventions implemented to prevent injury. Resident #158, a cognitively impaired resident with known self-inflicted bite wounds, bit himself on 5/17/15 that resulted in a fracture of the digit and subsequent amputation of the digit. Two of two residents reviewed for accidents. On 9/11/15 at approximately 6:25 PM, the Administrator and Director of Nursing were notified that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility since 5/13/2015. Resident #158 was readmitted to the facility on [DATE]. The facility failed to develop a comprehensive plan of care that addressed the needs of the residents related to his behaviors and psychotropic medications. The facility failed to identify and accurately assess Resident #158, a cognitively impaired resident with known self-injurious behaviors. The facility failed to administer antipsychotic medications in accordance with the physician's orders [REDACTED]. The resident was known to have self-injurious behaviors including biting his fingers to the point of fracturing the digit. The facility failed to implement interventions to prevent or monitor for these behaviors. Resident #158 was not given the antipsychotic medication for his self-injurious behaviors from 5/13/15 through 5/20/15 resulting in a serious injury on 5/17/15 to his hand. Resident #158 bit his finger causing a severe fracture and subsequent amputation of that digit. Additionally, based on observation and interview the facility failed to ensure fall interventions were put in place after each fall to prevent recurrence. Also, the facility failed to ensure that the residents' environment was free from accident and hazards for 3 of 3 crash carts reviewed. The facilities crash carts were unsecured with sharps available. The findings included: Cross refer to F 272, F 279, F 309, F 319, F 333, F 490 and F 501 as it related to the facility's failure to accurately assess the resident, the failure provide the necessary care and services to a resident that severely injured themselves with a bite wound, the facility failure to provide the necessary care services to treat, monitor and care for self-inflicted wounds for a cognitively impaired resident with self-injurious behaviors, the failure of the facility to provide psychosocial care and services to meet the needs of the resident, the failure of the facility to administer medications in accordance with physician orders, the failure of the facility to administer it's resources effectively to keep residents safe from injury and the failure of the Medical Director to coordinate care and to assure resident care policies were implemented. In a telephone interview with the surveyor on 9/15/15 at approximately 3:10 PM, LPN #9 stated s/he knew about Resident #158's biting behavior from the hospital and that s/he had worked with the resident since s/he was admitted [DATE]. LPN #9 stated that s/he was told in report that Resident #158's Risperadone was discontinued in the hospital because the resident had pneumonia for the hospital stay 5/4-5/13/15. LPN #9 stated s/he was told the medication sedated him/her and caused the pneumonia. LPN #9 stated Resident #158 often has his/her mouth open trying to bite. The resident becomes agitated when staff touches him/her. LPN #9 stated Resident #158 bites on the mitt on his/her right hand. LPN #9 stated that on 5/17/15 s/he made rounds and went into the resident's room. The resident was in bed with his/her eyes closed. LPN # 9 left the room and continued to make rounds. LPN #9 stated approximately 10 minutes later s/he heard grunting. LPN #9 started looking to see where the noise was coming from and tracked it back to Resident #158. When s/he entered the room Resident #158 had leaned up and over to where his/her hand was. The resident had not lifted his/her hand to their mouth. LPN #9 stated Resident #158's eyes were wide open and s/he had a wild look in their eyes. LPN # stated s/he could hear the resident's bone cracking and the resident did not seem like s/he felt any pain. LPN #9 stated s/he had never seen the resident like that before. LPN #9 stated s/he could not get the resident's hand out of his/her mouth until the resident opened his/her mouth and she was able to pull the fingers out. LPN #9 stated that when s/he called the physician that night s/he told the physician's nurse that the resident's Risperadone had been discharged and the nurse asked why. LPN #9 told the physician's nurse what s/he was told in report about the medication being discharged at the hospital because the resident was diagnosed with [REDACTED].#9 to put Resident #158 back on Risperadone. Review of Resident #158's Initial Plan of Care dated 4/16/15 revealed there was no care plan initiated for the resident's behavior or use of psychotropic medication. Review of Resident #158's Care Plan dated 5/8/15 revealed a care plan for aggressive behavior with ADL's (Activities of Daily Living), but the behavior of biting his/her hand was not noted. Further review of the 5/8/15 Care Plan revealed at risk for adverse effects related to use of psychotropic medications was identified as a problem area. Interventions and approaches were listed on the care plan and included to monitor and record target behaviors and inform the physician of increase in frequency for possible medication adjustments. Review of Resident #158's Medication Administration Record and Treatment Administration Record revealed no documentation of behavior monitoring in April 2015 or May 2015. Review of Resident #158's medical record revealed an SBAR Communication Form dated 5/17/15. Review of the form revealed the resident had increased agitation. The behavioral evaluation included Resident #158 bites self and tries to bite at others. Resident #158 was observed biting his/her right hand middle finger at 4:00 AM. The skin evaluation included bite puncture wounds to the middle 2nd finger on the right hand. The description of the appearance indicated the nurse saw Resident #158 biting his/her right hand 2nd middle finger. The nurse removed the resident's hand from their mouth and noted the finger to have deep bite marks and chewed up tissue. Resident #158 was sent to the emergency room for evaluation and treatment. Additional information included the nurse heard Resident #158 making loud, agitated noises. The nurse responded to the room and found the resident lying in bed with his/her right hand in their mouth biting down on the middle finger. The nurse removed the resident's hand when the resident opened his/her mouth. There was a moderate amount of blood oozing from the punctures. The SBAR Communication Form noted transport arrived to the facility at 5:10 AM to transport Resident #158 to the hospital. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #158 was admitted on Risperadone 0.5 mg (milligrams) BID (twice a day) for behaviors. Review of the resident's Physician's Telephone Orders dated 4/30/15 revealed an order to discontinue Risperadone 0.5 mg BID and start Risperadone 0.25 mg BID. Review of Resident #158's medical record revealed a copy of the Discharge Summary of the resident's hospitalized from [DATE]-4/14/15. The Discharge Summary indicated Resident #158 had Anoxic [DIAGNOSES REDACTED] status with behavioral issues. The discharge [DIAGNOSES REDACTED]. The Discharge Summary indicated the resident suffered frontal lobe injuries such that his/her behavioral control appeared to be very much impaired. Psychiatry was consulted to help control the patient's behavioral issues. The patient had developed a tendency to attempt to bite nearby objects. The patient's PEG was bit off on one occasion in the patient's confused state. On March 9, 2015 the patient actually bit his/her fingers on the right hand injuring his/her third digit. With the assistance of psychiatry the best medical regimen that could be determined was Risperadone 0.5 milligrams twice a day with reasonable behavioral control without successfully inhibiting the patient's ability to interact with surroundings. To protect his/her hand, a mitten was placed as appeared to be the most humane form of protection that can be offered without restraining the patient. The resident's discharge medications included Risperadone 0.5 mg twice a day. Review of the Infectious Disease/Wound Care physician progress notes [REDACTED].#158 had multiple open wounds to the hands that were self-inflicted. The documentation of the area to the right hand self-inflicted bite wounds noted the dorsal 3rd finger had an opening that measured 0.5 cm x 0.4 cm x 0.1 cm. The resident's 4th finger was discolored without openings noted. Review of the hospital Nurse Progress Notes dated 4/8/15 indicated the nurse reinforced the resident's dressing on his/her right hand to prevent him/her from biting self. The Nurse Progress Note dated 4/9/15 indicated the resident was noted chewing on his/her right hand dressing. Review of Resident #158's Admission Report sheet revealed notes that indicated the resident had self inflicted hand lacerations to two fingers(3rd/4th). The resident was noted to have behaviors issues of combativeness and biting. The residents skin issues included hydrogel to fingers. Review of the New Admission History and Physical completed 4/23/15 indicated Resident #158 had a human bite on the right hand third digit on 3/9/15. The assessment indicated the resident's right hand was bandaged. Review of the resident's May 2015 Psycho-Pharmacological Record for May 2015 revealed the resident received Risperadone 0.25 mg twice a day for behaviors from 5/1-5/4/15 when the resident was sent out to the hospital. Review of Resident #158's Medication Administration Record for May 2015 upon return from the hospital on [DATE] revealed Risperadone 0.25 mg twice a day was started on 5/20/15. There was no documentation that the resident received Risperadone between 5/13/15 and 5/20/15. Review of the Nursing Evaluation/Data Collection form for Resident #158's readmission on 5/13/15 revealed the resident's behavior included biting per the nurse at the hospital. review of the resident's medical record revealed [REDACTED]. The facility was not able to produce the Physician's Monthly Orders for 5/13-5/31/15. Review of the MD/NP (Physician/Nurse Practitioner) Readmission Progress Note dated 5/15/15 revealed the plan for Resident #158 included to continue all current orders and medications. Review of the MD/NP Progress Note dated 5/19/15 revealed the plan for Resident #158 included to start back on Risperadone. Review of the hospital Patient Summary dated 5/17/15 indicated Resident #158's Medications to Continue with No Changes included Risperadone 0.25 mg 1 tablet twice a day. The hospital paperwork indicated the resident had a human bite and a fracture of the finger with a nearby cut, puncture or deep scrape. Review of the x-ray report for Resident #158 dated 5/17/15 indicated the resident had a laceration and comminuted fracture with involvement of the distal aspect of the third middle phalanx as well as the third distal phalanx. The distal phalanx is angulated and displaced. Review of the Physician's Telephone Orders dated 5/28/15 indicated to discontinue the dressing to Resident #158's right hand. Further review of the Physician's Telephone Orders revealed and order dated 6/4/15 for a posey hand control mitt to the resident's right hand to prevent self inflicted wounds to the right hand by biting. Review of the Nurses' Notes dated 4/23/15 revealed the resident was reviewed in PAR meeting related to being a new admission to the facility. There was no documentation related to the resident's behavior or condition of the resident's right hand. Review of the Nurses' Notes dated 5/13/15 revealed no documentation related to the resident's medications or communication with the physician. Review of the Nurses' Notes revealed an entry with a date that was not legible. The previous note was dated 5/18/15 at 11:30 PM and the next legible date was 5/19/15 at 11:30 PM. The Nurses' Note indicated the physician visited with new orders to start Risperadone and physical therapy to evaluate the resident for a hand mitt. In an interview with the surveyor on 9/10/15 at approximately 12:10 PM, the North/East UM stated when Resident #158 went out to the hospital on [DATE] they stitched his/her finger, x-rayed the finger and found the fracture. When the resident returned from the hospital on [DATE] s/he had an appointment to see the orthopedic physician. Resident #158 went to the appointment on 5/20/15 and was sent to the same day surgery center at the hospital and had his/her finger amputated. The North/East UM thinks the resident had his/her finger amputated because of how the fracture was and how bad the skin was. The finger was amputated at the joint. The North/East UM stated Resident #158 would put his/her hand up to their mouth and suck on their fingers at times. In an interview with the surveyor on 09/11/2015 at approximately 1:32 PM the North/East UM(Unit Manager) stated she was the unit manager when Resident #158 bit his/her finger. The North/East UM was not aware of hospital information related to Resident #158 biting his/her fingers prior to admission. The North/East UM stated Admissions usually alerts staff to a resident's history during the morning meeting. The North/East UM could not remember if that happened with Resident #158. The nurse on duty also gets report from the nurse at the hospital when a resident is admitted from the hospital. The nurse on duty also reviews the discharge paperwork from the hospital. The nurse on duty should have reviewed the paperwork and contacted the physician or hospital to see if the facility should continue the order (for mitt from hospital). The nurse should document that they clarified the information. The nurse should pass on the information to the UM so it can be addressed. Chart checks are done in morning meeting for new admissions to make sure all information is there. The staff will discuss the resident and any history at that time. That information is not documented. The North/East UM stated s/he was a nurse on the floor in April so s/he would not have been at the morning meeting when Resident #158 was admitted . The North/East UM stated that if a resident is on a behavior medicine they will start behavior monitoring. Behavior monitoring is documented on the resident's Medication Administration Record. In an interview with the surveyor on 09/11/2015 at approximately 4:17 PM, the DON (Director of Nursing) stated s/he and the nurse on duty look at hospital information for behaviors, history, etc. The Assistant DON will also review the information at times. Unit Managers also review the information. The DON also stated the History/Physical and Discharge Summary come with the resident and that is what they track. The DON stated that in morning clinical meeting they look to make sure that all information that is needed is in the chart. The Discharge Summary is usually faxed over and the nurse on duty looks at that before the resident arrives. The DON stated the nurse on duty should have noted there was a biting problem and made sure there was something in place to prevent. The nurse also should have talked to the physician about the behavior and documented the conversation in the Nurses Notes. The wound to Resident #158's fingers was noted on the admission sheet. The DON reviewed the Nurses Notes dated 4/16/15 and confirmed the wound was not noted in the admission Nurses Notes. The DON reviewed the body audit form from admitted d 4/16/15 and confirmed the wound to Resident #158's fingers was not documented there. The DON confirmed there was no Non-Pressure Skin Condition form in the resident's chart for the area to Resident #158's fingers. The DON confirmed that a Non-Pressure Condition Form should have been completed that documented the size of the area and the condition of the skin. The DON stated the wound to the resident's fingers should have been documented on weekly if a treatment was ordered. The DON reviewed Resident #158's medical record and thinned medical record and confirmed there was no order for treatment to the resident's fingers on the admission orders [REDACTED]. Further review of the resident's medical record revealed [REDACTED]. The DON reviewed Resident #158's TAR (Treatment Administration Record) and did not see on April or May any behavior monitoring documentation. The DON stated that since the resident had previous behavior and was receiving an antipsychotic medication behavior monitoring should have been documented on the TAR. The DON stated Resident #158 came back from the hospital on [DATE] with an order for [REDACTED]. The DON confirmed that the Risperadone 0.25 mg BID was not documented on the MAR as administered until May 20th. The DON stated the nurse should verify what is on the discharge summary and talk with the physician. The nurse should also tell the physician what medications the resident was on before. The nurse should make a note on the Nurses Note about the conversation and what should be continued or discontinued. The DON stated the next morning the chart is reviewed in morning meeting. In morning meeting the medical record is reviewed for physician orders [REDACTED]. The DON verified Risperadone 0.25 mg was ordered. The DON reviewed the Nurse Notes dated 5/13/15 and confirmed there was no documentation related to the order. The DON stated the nurse initiates the initial care plan for new admission residents. Minimum Data Set staff completes the Care Plan on residents after the assessment is completed. Care Plan updates are a combined effort. The resident's medical record is brought to morning meeting and Care Plans are updated there. The nurses on duty may updated the care plan but it is verified in the morning meeting. The DON reviewed Resident #158's initial care plan and confirmed the resident's behavior and antipsychotic medication were not on the initial care plan and stated that they should have been on the initial care plan. In an interview with the surveyor on 9/11/15 at approximately 4:20 PM the ADON (Assistant Director of Nursing) stated Resident #158's behavior was discussed when s/he was admitted to the facility. Resident #158 had self inflicted biting and s/he was combative with staff. The ADON could not remember if they discussed interventions for the resident at the time of admission. In an interview with the surveyor on 09/11/2015 at approximately 4:41 PM, the DON reviewed Resident #158's medical record and thinned record. The DON could not locate the May Physician orders [REDACTED]. The DON stated the nurse should have written readmission orders [REDACTED]. In an interview with the surveyor on 09/11/2015 at approximately 5:49 PM, the ADON and South/West Unit Manager reviewed the resident's medical record and thinned chart. The South/West UM and ADON were at the facility at the time of the incident. The South/West UM was covering the North/East unit during the time of the resident's admission to the facility. The South/West UM and ADON did not remember completing any type of medication error report related to Resident #158 and Risperadone. Neither the South/West UM or ADON remember having any discussion or investigation into what happened with Resident #158 not receiving the Risperadone medication as ordered. Both the South/West UM and ADON were not aware Resident #158 did not receive the medication as ordered. In a telephone interview with the surveyor on 9/15/15 at approximately 3:30 PM, the Medical Director ( Resident #158's attending physician) stated the Risperadone 0.25 mg BID was on Resident #158's discharge paperwork from the hospital and on the Re-admission Physician order [REDACTED]. The Medical Director stated that Resident #158 could have an increase in behavior because s/he was not receiving the Risperadone. The Medical Director stated s/he thinks it was a transcription error. The Medical Director stated s/he was not aware of any follow-up to the incident related to the medication error. The facility admitted Resident #164 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) revealed that the resident had both short- and long-term memory problems with moderately impaired cognitive skills for daily decision making. S/he had no behavioral symptoms. The resident required extensive assistance of one person for bed mobility, transfers, eating, and tilting. According to the assessment, the resident had functional limitations in both lower extremities, was frequently incontinent of bowel and bladder, and had sustained 2 or more falls since admission. Review of Nurses Notes on 9-11-15 at 2:59 PM revealed that Resident #164 sustained four non-injury falls from 5-20-15 through 5-30-15. There was no evidence of investigation or appropriate interventions implemented to address the underlying cause and prevent recurrence other than application of gripper socks and alarms. There was also no documentation to support that physician-ordered/care planned interventions were in place at the time of the falls. An entry in the Nurses Notes on 5-20-15 (date of admission) at 10:25 PM stated: Walked into resident room, saw resident on the floor on his (her) buttocks at the foot of the bed near the bathroom door. Resident stated he (she) was going to the bathroom . The physician was notified and an order written [REDACTED]. Review of the Interim Care Plan revealed that the use of alarms was not added to the approaches/interventions on the plan to prevent recurrence. Gripper socks were added as an intervention on 5-22-15. An entry on 5-23-15 at 10:30 PM stated: Resident was found on floor as this nurse was making rounds. Resident stated he (she) was trying to use the bathroom . There was no mention of the gripper socks being on or the alarm being in place/sounding. An entry on 5-24-15 at 11:30 AM stated: Res(ident) (up) in w/c (wheelchair) @ nurse station. Res tried to standup and fell in floor . There was no mention of the gripper socks being on or the alarm being in place/sounding. A 6-2-15 MD (Medical Doctor)/NP (Nurse Practitioner) Progress Note documented that the resident had sustained a non-injury fall on 5-30-15. No Nurses Note was found in the record related to the fall. During an interview on 9-12-15 at 12:30 PM, the MDS Coordinator reviewed the medical record and verified there was no mention of alarms in place for the falls on 5-23-15 and 5-24-15 and no documentation in the record about the 5-30-15 fall except what was noted in the MD/NP Progress Note. During an interview on 9-11-15 at 4:05 PM, the corporate representative stated the staff could only locate one of the 4 incident reports (5-20-15) and there were no investigations available for review. On 9-12-15 at 4 PM, the Director of Nursing and Administrator stated they were unable to locate incident/accident reports or fall investigations for falls on 5-23-15, 5-24-15, and 5-30-15. Review of the 5-20-15 interim care plan on 9-11-15 at 4:04 PM revealed that it did not include use of alarms as a fall prevention intervention though they were ordered by the physician on the date of admission. During an interview on 9-12-15 at 9:05 AM, when asked how s/he knew what care/special items residents needed, Certified Nursing Assistant (CNA) #10 stated s/he got report from nurses and looked at the charts. When asked about any other resources of information, the CNA said, No, I just get it from nurses and other CNA's. When asked the same question immediately following the CNA interview, the Unit Manager stated the CNA's had a Care Plan/Kardex which noted individual resident needs/special equipment. During an interview on 9-12-15 at 12:30 PM, the MDS Coordinator was asked who was responsible for initiating and updating the interim care plans. S/he stated that management meetings were held twice daily at which time orders were reviewed and care plans were updated by the Director of Nursing (DON), Assistant DON, Unit Manager, or MDS Coordinator. During the interview, the MDS Coordinator reviewed the interim care plan and confirmed that it did not include the use of alarms as an intervention for fall prevention. When asked how CNA's knew if a resident was to have alarms, s/he referred the surveyor to the CNA Kardex. Review of the closed record on 9-11-15 at 2:54 PM revealed no CNA Care Plan/Kardex with instructions for care of the resident. On 9/10/15 at 9:32 AM, during an observation with the Director of Nursing (DON) of the North Wing, East Wing, and South/West Wing crash carts revealed: North Wing 1.) 2 18 gauge 1 1/2 inch filter needles 2.) 1 hypodermic needle-pro 20 gauge 2 inch needle 3.) 2 BD Insyte Autoguard 22 gauge 1.0 inch needle 4.) 4 BD Nexiva 22 gauge x 1 inch needle IV catheter systems East Wing 1.) 2 18 gauge 1 1/2 inch filter needle 2.) 4 BD Nexiva 22 gauge x 1.0 inch IV catheter systems South/West 1.) 1 pair of scissors 2.) 2 18 gauge 1 1/2 inch filter needles 3.) 3 BD Nexiva 22 gauge x 1.0 inch needle IV catheter systems Following the observations of the North, East and South/West Wing crash carts, the DON verified the needles and scissors were in an unsecured cart. The DON was asked how many residents were cognitively impaired and could have access to the crash carts. S/he indicated 18. The Immediate Jeopardy identified at the facility on 9/11/15 had not been removed at the time of completion of the recertification and complaint survey on 9/15/15.

Based on record review and interview, the facility failed to assure that a resident who displays mental or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem. Resident #158 was noted with self-injurious behaviors prior to admission to the facility. The facility failed to assure the resident received appropriate treatment. Resident #158 bit his finger causing a fracture which subsequently led to the finger being amputated. One of two residents reviewed for self-injury behavior. Resident #158 was noted to have self-injurious behaviors and was prescribed Risperadone for behaviors. Resident #158 went to the hospital from 5/4-5/13/15. Review of the hospital paperwork revealed the Risperadone was to be continued. Resident #158 did not receive the medication until 5/20/15. On 5/17/15 Resident #158 bit his/her own finger causing a fracture which led to the finger being amputated. On 9/11/15 at approximately 6:25 PM, the Administrator and Director of Nursing were notified that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility since 5/13/2015. Resident #158 was readmitted to the facility on [DATE]. The facility failed to develop a comprehensive plan of care that addressed the needs of the residents related to his behaviors and [MEDICAL CONDITION] medications. The facility failed to identify and accurately assess Resident #158, a cognitively impaired resident with known self-injurious behaviors. The facility failed to administer antipsychotic medications in accordance with the physician's orders [REDACTED]. The resident was known to have self-injurious behaviors including biting his fingers to the point of fracturing the digit. The facility failed to implement interventions to prevent or monitor for these behaviors. Resident #158 was not given the antipsychotic medication for his self-injurious behaviors from 5/13/15 through 5/20/15 resulting in a serious injury on 5/17/15 to his hand. Resident #158 bit his finger causing a severe fracture and subsequent amputation of that digit. The findings included: Cross refer to F 272, F 279, F 309, F 323, F 333, F 490 and F 501 as it related to the facility's failure to accurately assess the resident, the failure provide the necessary care and services to a resident that severely injured themselves with a bite wound, the facility failure to provide the necessary care services to treat, monitor and care for self-inflicted wounds for a cognitively impaired resident with self-injurious behaviors, the failure of the facility to provide adequate supervision to prevent injury, the failure of the facility to administer medications in accordance with physician orders, the failure of the facility to administer it's resources effectively to keep residents safe from injury and the failure of the Medical Director to coordinate care and to assure resident care policies were implemented. Review of Resident #158's medical record revealed a copy of the Discharge Summary of the resident's hospitalized from [DATE]-4/14/15. The Discharge Summary indicated Resident #158 had [MEDICAL CONDITIONS] status with behavioral issues. The discharge [DIAGNOSES REDACTED]. The Discharge Summary indicated the resident suffered frontal lobe injuries such that his/her behavioral control appeared to be very much impaired. Psychiatry was consulted to help control the patient's behavioral issues. The patient had developed a tendency to attempt to bite nearby objects. The patient's PEG was bit off on one occasion in the patient's confused state. On March 9, 2015 the patient actually bit his/her fingers on the right hand injuring his/her third digit. With the assistance of psychiatry the best medical regimen that could be determined was Risperadone 0.5 milligrams twice a day with reasonable behavioral control without successfully inhibiting the patient's ability to interact with surroundings. To protect his/her hand, a mitten was placed as appeared to be the most humane form of protection that can be offered without restraining the patient. The resident's discharge medications included Risperadone 0.5 mg twice a day. Review of the Infectious Disease/Wound Care physician progress notes [REDACTED].#158 had multiple open wounds to the hands that were self-inflicted. The documentation of the area to the right hand self-inflicted bite wounds noted the dorsal 3rd finger had an opening that measured 0.5 cm x 0.4 cm x 0.1 cm. The resident's 4th finger was discolored without openings noted. Review of the hospital Nurse Progress Notes dated 4/8/15 indicated the nurse reinforced the resident's dressing on his/her right hand to prevent him/her from biting self. The Nurse Progress Note dated 4/9/15 indicated the resident was noted chewing on his/her right hand dressing. Review of Resident #158's medical record revealed an SBAR Communication Form dated 5/17/15. Review of the form revealed the resident had increased agitation. The behavioral evaluation included Resident #158 bites self and tries to bite at others. Resident #158 was observed biting his/her right hand middle finger at 4:00 AM. The skin evaluation included bite puncture wounds to the middle 2nd finger on the right hand. The description of the appearance indicated the nurse saw Resident #158 biting his/her right hand 2nd middle finger. The nurse removed the resident's hand from their mouth and noted the finger to have deep bite marks and chewed up tissue. Resident #158 was sent to the emergency room for evaluation and treatment. Additional information included the nurse heard Resident #158 making loud, agitated noises. The nurse responded to the room and found the resident lying in bed with his/her right hand in their mouth biting down on the middle finger. The nurse removed the resident's hand when the resident opened his/her mouth. There was a moderate amount of blood oozing from the punctures. The SBAR Communication Form noted transport arrived to the facility at 5:10 AM to transport Resident #158 to the hospital. In a telephone interview with the surveyor on 9/15/15 at approximately 3:10 PM, LPN #9 stated s/he knew about Resident #158's biting behavior from the hospital and that s/he had worked with the resident since s/he was admitted [DATE]. LPN #9 stated that s/he was told in report that Resident #158's Risperadone was discontinued in the hospital because the resident had pneumonia for the hospital stay 5/4-5/13/15. LPN #9 stated s/he was told the medication sedated him/her and caused the pneumonia. LPN #9 stated Resident #158 often has his/her mouth open trying to bite. The resident becomes agitated when staff touches him/her. LPN #9 stated Resident #158 bites on the mitt on his/her right hand. LPN #9 stated that on 5/17/15 s/he made rounds and went into the resident's room. The resident was in bed with his/her eyes closed. LPN # 9 left the room and continued to make rounds. LPN #9 stated approximately 10 minutes later s/he heard grunting. LPN #9 started looking to see where the noise was coming from and tracked it back to Resident #158. When s/he entered the room Resident #158 had leaned up and over to where his/her hand was. The resident had not lifted his/her hand to their mouth. LPN #9 stated Resident #158's eyes were wide open and s/he had a wild look in their eyes. LPN #9 stated s/he could hear the resident's bone cracking and the resident did not seem like s/he felt any pain. LPN #9 stated s/he had never seen the resident like that before. LPN #9 stated s/he could not get the resident's hand out of his/her mouth until the resident opened his/her mouth and she was able to pull the fingers out. LPN #9 stated that when s/he called the physician that night s/he told the physician's nurse that the resident's Risperadone had been discharged and the nurse asked why. LPN #9 told the physician's nurse what s/he was told in report about the medication being discharged at the hospital because the resident was diagnosed with [REDACTED].#9 to put Resident #158 back on Risperadone. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #158 was admitted on Risperadone 0.5 mg (milligrams) BID (twice a day) for behaviors. Review of the resident's Physician's Telephone Orders dated 4/30/15 revealed an order to discontinue Risperadone 0.5 mg BID and start Risperadone 0.25 mg BID. Review of Resident #158's Initial Plan of Care dated 4/16/15 revealed there was no care plan initiated for the resident's behavior or use of [MEDICAL CONDITION] medication. Review of Resident #158's Care Plan dated 5/8/15 revealed a care plan for aggressive behavior with ADL's (Activities of Daily Living), but the behavior of biting his/her hand was not noted. Further review of the 5/8/15 Care Plan revealed at risk for adverse effects related to use of [MEDICAL CONDITION] medications was identified as a problem area. Interventions and approaches were listed on the care plan and included to monitor and record target behaviors and inform the physician of increase in frequency for possible medication adjustments. Review of Resident #158's Medication Administration Record and Treatment Administration Record revealed no documentation of behavior monitoring in April 2015 or May 2015. Review of Resident #158's Admission Report sheet revealed notes that indicated the resident had self inflicted hand lacerations to two fingers (3rd/4th). The resident was noted to have behaviors issues of combativeness and biting. The resident's skin issues included hydrogel to fingers. Review of the New Admission History and Physical completed 4/23/15 indicated Resident #158 had a human bite on the right hand third digit on 3/9/15. The assessment indicated the resident's right hand was bandaged. There was no evidence of on going assessments and monitoring of the wounds. Review of Resident #158's Wound Care Record for April 2015 and May 2015 revealed a treatment to cleanse the 2nd and 3rd fingers on the right hand with wound cleanser- apply hydrogel impregnated gauze dressing. Change daily and as needed. The April 2015 Wound Care Record revealed the treatment was provided to the resident form 4/17-4/30/15. The May 2015 Wound Care Record revealed the treatment was provided to the resident until s/he went out to the hospital on [DATE]. Review of the resident's May 2015 Treatment Record upon return from the hospital on [DATE] revealed there was no treatment order for a dressing to the resident's right hand. Review of the resident's May 2015 Psycho-Pharmacological Record for May 2015 revealed the resident received Risperadone 0.25 mg twice a day for behaviors from 5/1-5/4/15 when the resident was sent out to the hospital. Review of Resident #158's medical record revealed an SBAR Communication Form dated 5/4/15 that indicated the resident was sent to the hospital for chest congestion. Review of the Nursing Evaluation/Data Collection form for Resident #158's readmission on 5/13/15 revealed the resident's behavior included biting per the nurse at the hospital. review of the resident's medical record revealed [REDACTED]. The facility was not able to produce the Physician's Monthly Orders for 5/13-5/31/15. Review of Resident #158's Medication Administration Record for May 2015 upon return from the hospital on [DATE] revealed Risperadone 0.25 mg twice a day was started on 5/20/15. There was no documentation that the resident received Risperadone between 5/13/15 and 5/20/15. Review of the MD/NP (Physician/Nurse Practitioner) Readmission Progress Note dated 5/15/15 revealed the plan for Resident #158 included to continue all current orders and medications. Review of the MD/NP Progress Note dated 5/19/15 revealed the plan for Resident #158 included to start back on Risperadone. Review of the hospital Patient Summary dated 5/17/15 indicated Resident #158's Medications to Continue with No Changes included Risperadone 0.25 mg 1 tablet twice a day. The hospital paperwork indicated the resident had a human bite and a [MEDICAL CONDITION] with a nearby cut, puncture or deep scrape. Review of the x-ray report for Resident #158 dated 5/17/15 indicated the resident had a laceration and comminuted fracture with involvement of the distal aspect of the third middle phalanx as well as the third distal phalanx. The distal phalanx is angulated and displaced. Review of Resident #158's Patient Discharge Summary dated 5/20/15 from the hospital's Same Day Surgery Center indicated the resident's medication list included Risperadone 0.25 mg 1 tablet twice a day. Review of the Physician's Telephone Orders dated 5/28/15 indicated to discontinue the dressing to Resident #158's right hand. The sutures will dissolve. Further review of the Physician's Telephone Orders revealed and order dated 6/4/15 for a posey hand control mitt to the resident's right hand to prevent self inflicted wounds to the right hand by biting. There was no evidence of any intervention between 5/28-6/4/15 to protect the resident from biting his hand/fingers. Review of the Nurses' Notes dated 4/16/15 at 10:30 PM revealed the dressing to the resident's right hand was intact and dry. There was no documentation in the Nurses Notes on 4/16/15 that indicated the size or condition of the wounds to the resident's right hand. Nurses' Notes were reviewed from 4/16-5/16/15 with no documentation noted related to the resident's behavior of biting self. There was also no documentation related to the size or condition of the wounds to the resident's right hand. Review of the Nurses' Notes dated 4/23/15 revealed the resident was reviewed in PAR meeting related to being a new admission to the facility. There was no documentation related to the resident's behavior or condition of the resident's right hand. Review of the Nurses' Notes dated 5/13/15 revealed no documentation related to the resident's medications or communication with the physician. Review of the Nurses' Notes revealed an entry with a date that was not legible. The previous note was dated 5/18/15 at 11:30 PM and the next legible date was 5/19/15 at 11:30 PM. The Nurses' Note indicated the physician visited with new orders to start Risperadone and physical therapy to evaluate the resident for a hand mitt. In an interview with the surveyor on 9/10/15 at approximately 12:10 PM, the North/East UM stated when Resident #158 went out to the hospital on [DATE] they stitched his/her finger, x-rayed the finger and found the fracture. When the resident returned from the hospital on [DATE] s/he had an appointment to see the orthopedic physician. Resident #158 went to the appointment on 5/20/15 and was sent to the same day surgery center at the hospital and had his/her finger amputated. The North/East UM thinks the resident had his/her finger amputated because of how the fracture was and how bad the skin was. The finger was amputated at the joint. The North/East UM stated Resident #158 would put his/her hand up to their mouth and suck on their fingers at times. There was no evidence in the medical record that the resident's wounds were assessed/monitored from 5/17/15-5/20/15. In an interview with the surveyor on 09/11/2015 at approximately 1:32 PM the North/East UM(Unit Manager) stated she was the unit manager when Resident #158 bit his/her finger. The North/East UM was not aware of hospital information related to Resident #158 biting his/her fingers prior to admission. The North/East UM stated Admissions usually alerts staff to a resident's history during the morning meeting. The North/East UM could not remember if that happened with Resident #158. The nurse on duty also gets report from the nurse at the hospital when a resident is admitted from the hospital. The nurse on duty also reviews the discharge paperwork from the hospital. The nurse on duty should have reviewed the paperwork and contacted the physician or hospital to see if the facility should continue the order (for mitt from hospital). The nurse should document that they clarified the information. The nurse should pass on the information to the UM so it can be addressed. Chart checks are done in morning meeting for new admissions to make sure all information is there. The staff will discuss the resident and any history at that time. That information is not documented. The North/East UM stated s/he was a nurse on the floor in April so s/he would not have been at the morning meeting when Resident #158 was admitted . The North/East UM stated that if a resident is on a behavior medicine they will start behavior monitoring. Behavior monitoring is documented on the resident's Medication Administration Record. In an interview with the surveyor on 09/11/2015 at approximately 4:17 PM, the DON (Director of Nursing) stated s/he and the nurse on duty look at hospital information for behaviors, history, etc. The Assistant DON will also review the information at times. Unit Managers also review the information. The DON also stated the History/Physical and Discharge Summary come with the resident and that is what they track. The DON stated that in morning clinical meeting they look to make sure that all information that is needed is in the chart. The Discharge Summary is usually faxed over and the nurse on duty looks at that before the resident arrives. The DON stated the nurse on duty should have noted there was a biting problem and made sure there was something in place to prevent. The nurse also should have talked to the physician about the behavior and documented the conversation in the Nurses Notes. The wound to Resident #158's fingers was noted on the admission sheet. The DON reviewed the Nurses' Notes dated 4/16/15 and confirmed the wound was not noted in the admission Nurses Notes. The DON reviewed the body audit form from admitted d 4/16/15 and confirmed the wound to Resident #158's fingers was not documented there. The DON confirmed there was no Non-Pressure Skin Condition form in the resident's chart for the area to Resident #158's fingers. The DON confirmed that a Non-Pressure Condition Form should have been completed that documented the size of the area and the condition of the skin. The DON stated the wound to the resident's fingers should have been documented on weekly if a treatment was ordered. The DON reviewed Resident #158's medical record and thinned medical record and confirmed there was no order for treatment to the resident's fingers on the admission orders [REDACTED]. Further review of the resident's medical record revealed [REDACTED]. The DON reviewed Resident #158's TAR (Treatment Administration Record) and did not see on April or May any behavior monitoring documentation. The DON stated that since the resident had previous behavior and was receiving an antipsychotic medication behavior monitoring should have been documented on the TAR. The DON stated Resident #158 came back from the hospital on [DATE] with an order for [REDACTED]. The DON confirmed that the Risperadone 0.25 mg BID was not documented on the MAR as administered until May 20th. The DON stated the nurse should verify what is on the discharge summary and talk with the physician. The nurse should also tell the physician what medications the resident was on before. The nurse should make a note in the Nurses' Note about the conversation and what should be continued or discontinued. The DON stated the next morning the chart is reviewed in morning meeting. In morning meeting the medical record is reviewed for physician orders [REDACTED]. The DON verified Risperadone 0.25 mg was ordered. The DON reviewed the Nurses' Notes dated 5/13/15 and confirmed there was no documentation related to the order. The DON stated the nurse initiates the initial care plan for new admission residents. Minimum Data Set staff completes the Care Plan on residents after the assessment is completed. Care Plan updates are a combined effort. The resident's medical record is brought to morning meeting and Care Plans are updated there. The nurses on duty may update the care plan but it is verified in the morning meeting. The DON reviewed Resident #158's initial care plan and confirmed the resident's behavior and antipsychotic medication were not on the initial care plan and stated that they should have been on the initial care plan. In an interview with the surveyor on 9/11/15 at approximately 4:20 PM the ADON (Assistant Director of Nursing) stated Resident #158's behavior was discussed when s/he was admitted to the facility. Resident #158 had self inflicted biting and s/he was combative with staff. The ADON could not remember if they discussed interventions for the resident at the time of admission. In an interview with the surveyor on 09/11/2015 at approximately 4:41 PM, the DON reviewed Resident #158's medical record and thinned record. The DON could not locate the May Physician orders [REDACTED]. The DON stated the nurse should have written readmission orders [REDACTED]. In an interview with the surveyor on 09/11/2015 at approximately 5:49 PM, the ADON and South/West Unit Manager reviewed the resident's medical record and thinned chart. The South/West UM and ADON were at the facility at the time of the incident. The South/West UM was covering the North/East unit during the time of the resident's admission to the facility. The South/West UM and ADON did not remember completing any type of medication error report related to Resident #158 and Risperadone. Neither the South/West UM or ADON remember having any discussion or investigation into what happened with Resident #158 not receiving the Risperadone medication as ordered. Both the South/West UM and ADON were not aware Resident #158 did not receive the medication as ordered. In a telephone interview with the surveyor on 9/15/15 at approximately 3:30 PM, the Medical Director ( Resident #158's attending physician) stated the Risperadone 0.25 mg BID was on Resident #158's discharge paperwork from the hospital and on the Re-admission Physician order [REDACTED]. The Medical Director stated that Resident #158 could have an increase in behavior because s/he was not receiving the Risperadone. The Medical Director stated s/he thinks it was a transcription error. The Medical Director stated s/he was not aware of any follow-up to the incident related to the medication error. The Immediate Jeopardy identified at the facility on 9/11/15 had not been removed at the time of completion of the recertification and complaint survey on 9/15/15.

Based on record review and interview, the facility failed to conduct a comprehensive, accurate assessment of each resident's functional capacity. Resident #158's behavior related to self-biting was not identified and assessed upon admission to the facility. The resident was known to have self-injury from the behavior at the hospital prior to admission to the facility. There was no initial care plan for the behavior or for the [MEDICAL CONDITION] medication the resident was receiving for the behavior. There was no documentation related to continuing or discontinuing interventions that were noted on the hospital Discharge Summary to protect the resident. On 5/17/15, Resident #158 bit his/her own finger causing a fracture which subsequently led to the finger being amputated. There was no documentation of behavior monitoring for Resident #158 for April 2015 or May 2015. One of two residents identified with self-injurious behaviors reviewed for care plans and assessments. On 9/11/15 at approximately 6:25 PM, the Administrator and Director of Nursing were notified that Immediate Jeopardy and /or Substandard Quality of Care existed in the facility since 5/13/2015. Resident #158 was readmitted to the facility on [DATE]. The facility failed to identify and accurately assess Resident #158, a cognitively impaired resident with known self-injurious behaviors. The facility failed to administer antipsychotic medications in accordance with the physician's orders and the plan of care. The resident was known to have self-injurious behaviors including biting his fingers to the point of fracturing the digit. The facility failed to implement interventions to prevent or monitor for these behaviors. Resident #158 was not given the antipsychotic medication for his self-injurious behaviors from 5/13/15 through 5/20/15 resulting in a serious injury on 5/17/15 to his hand. Resident #158 bit his finger causing a severe fracture and subsequent amputation of that digit. The findings included: Cross refer to F 279, F 309, F 319, F 323, F 333, F 490 and F 501 as it related to the facility's failure to develop a comprehensive care plan to meet the needs of the resident, the failure to provide the necessary care and services to a resident that severely injured themselves with a bite wound, the facility failure to meet the psychosocial needs of a cognitively impaired resident with self-injurious behaviors, the failure of the facility to provide adequate supervision to prevent injury, the failure of the facility to administer medications in accordance with physician orders, the failure of the facility to administer it's resources effectively to keep residents safe from injury and the failure of the Medical Director to coordinate care and to assure resident care policies were implemented. Review of Resident #158's medical record revealed a copy of the Discharge Summary of the resident's hospitalized from [DATE]-4/14/15. The Discharge Summary indicated Resident #158 had [MEDICAL CONDITIONS] status with behavioral issues. The discharge [DIAGNOSES REDACTED]. The Discharge Summary indicated the resident suffered frontal lobe injuries such that his/her behavioral control appeared to be very much impaired. Psychiatry was consulted to help control the patient's behavioral issues. The patient had developed a tendency to attempt to bite nearby objects. The patient's PEG was bit off on one occasion in the patient's confused state. On March 9, 2015 the patient actually bit his/her fingers on the right hand injuring his/her third digit. With the assistance of psychiatry the best medical regimen that could be determined was Risperadone 0.5 milligrams twice a day with reasonable behavioral control without successfully inhibiting the patient's ability to interact with surroundings. To protect his/her hand, a mitten was placed as appeared to be the most humane form of protection that can be offered without restraining the patient. The resident's discharge medications included Risperadone 0.5 mg twice a day. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #158 was admitted on Risperadone 0.5 mg (milligrams) BID (twice a day) for behaviors. Review of the Infectious Disease/Wound Care physician progress notes [REDACTED].#158 had multiple open wounds to the hands that were self-inflicted. Review of the hospital Nurse Progress Notes dated 4/8/15 indicated the nurse reinforced the resident's dressing on his/her right hand to prevent him/her from biting self. The Nurse Progress Note dated 4/9/15 indicated the resident was noted chewing on his/her right hand dressing. Review of the resident's Physician's Telephone Orders dated 4/30/15 revealed an order to discontinue Risperadone 0.5 mg BID and start Risperadone 0.25 mg BID. Review of Resident #158's Initial Plan of Care dated 4/16/15 revealed there was no care plan initiated for the resident's behavior or use of [MEDICAL CONDITION] medication. Review of Resident #158's Care Plan dated 5/8/15 revealed a care plan for aggressive behavior with ADL's (Activities of Daily Living), but the behavior of biting his/her hand was not noted. Further review of the 5/8/15 Care Plan revealed at risk for adverse effects related to use of [MEDICAL CONDITION] medications was identified as a problem area. Interventions and approaches were listed on the care plan and included to monitor and record target behaviors and inform the physician of increase in frequency for possible medication adjustments. Review of Resident #158's Medication Administration Record [REDACTED]. Review of Resident #158's Admission Report sheet revealed notes that indicated the resident had self inflicted hand lacerations to two fingers (3rd/4th). The resident was noted to have behavior issues of combativeness and biting. Review of the New Admission History and Physical completed 4/23/15 indicated Resident #158 had a human bite on the right hand third digit on 3/9/15. The assessment indicated the resident's right hand was bandaged. Review of the Nurses' Notes dated 4/23/15 revealed the resident was reviewed in PAR meeting related to being a new admission to the facility. Further review of the nurses' notes from admission through 5/4/2015 (discharge to the hospital), there was no evidence the facility assessed the resident's wounds on his hand. The facility staff was placing a dressing on the resident's hand since admission with no physician's orders for the treatment and no routine assessments or documentation of the wound were located. There was no documentation related to the resident's behavior or condition of the resident's right hand. In an interview with the surveyor on 09/11/2015 at approximately 1:32 PM the North/East UM(Unit Manager) stated she was not aware of hospital information related to Resident #158 biting his/her fingers prior to admission. The North/East UM stated Admissions usually alerts staff to a resident's history during the morning meeting. The North/East UM could not remember if that happened with Resident #158. The nurse on duty also gets report from the nurse at the hospital when a resident is admitted from the hospital. The nurse on duty also reviews the discharge paperwork from the hospital. The nurse on duty should have reviewed the paperwork and contacted the physician or hospital to see if the facility should continue the order (for mitt from hospital). The nurse should document that they clarified the information. The nurse should pass on the information to the UM so it can be addressed. Chart checks are done in morning meeting for new admissions to make sure all information is there. The staff will discuss the resident and any history at that time. That information is not documented. The North/East UM stated s/he was a nurse on the floor in April so s/he would not have been at the morning meeting when Resident #158 was admitted . The North/East UM stated that if a resident is on a behavior medicine they will start behavior monitoring. Behavior monitoring is documented on the resident's Medication Administration Record. In an interview with the surveyor on 09/11/2015 at approximately 4:17 PM, the DON (Director of Nursing) stated s/he and the nurse on duty look at hospital information for behaviors, history, etc. The Assistant DON will also review the information at times. Unit Managers also review the information. The DON also stated the History/Physical and Discharge Summary come with the resident and that is what they track. The DON stated that in the morning clinical meeting they look to make sure that all information that is needed is in the chart. The Discharge Summary is usually faxed over and the nurse on duty looks at that before the resident arrives. The DON stated the nurse on duty should have noted there was a biting problem and made sure there was something in place to prevent the behaviors. The nurse also should have talked to the physician about the behavior and documented the conversation in the Nurses' Notes. The DON reviewed Resident #158's TAR (Treatment Administration Record) and did not see on April 2015 or May 2015 any behavior monitoring documentation. The DON stated that since the resident had previous behavior and was receiving an antipsychotic medication behavior monitoring should have been documented on the TAR. The DON stated the nurse initiates the initial care plan for new admission residents. Minimum Data Set staff completes the Care Plan on residents after the assessment is completed. Care Plan updates are a combined effort. The resident's medical record is brought to morning meeting and Care Plans are updated there. The nurses on duty may update the care plan but it is verified in the morning meeting. The DON reviewed Resident #158's initial care plan and confirmed the resident's behavior and antipsychotic medication were not on the initial care plan and stated that they should have been on the initial care plan. In an interview with the surveyor on 9/11/15 at approximately 4:20 PM the ADON (Assistant Director of Nursing) stated Resident #158's behavior was discussed when s/he was admitted to the facility. Resident #158 had self inflicted biting and s/he was combative with staff. The ADON could not remember if they discussed interventions for the resident at the time of admission. The Immediate Jeopardy identified at the facility on 9/11/15 had not been removed at the time of completion of the recertification and complaint survey on 9/15/15.

Based on record review and interview, the facility failed to develop a resident's comprehensive plan of care for one of two residents reviewed for self-injurious behaviors. Resident #158 was noted to have documentation of a behavior related to self-biting prior to admission to the facility. The resident was noted to have injured himself from the behavior at the hospital prior to admission to the facility. There was no initial care plan for the behavior or for the [MEDICAL CONDITION] medication the resident was receiving for the behavior. After Resident #158's initial assessment a comprehensive care plan was developed. Review of the comprehensive care plan revealed there was no care plan for the resident's behavior of self-biting. On 9/11/15 at approximately 6:25 PM, the Administrator and Director of Nursing were notified that Immediate Jeopardy and /or Substandard Quality of Care existed in the facility since 5/13/2015. Resident #158 was readmitted to the facility on [DATE]. The facility failed to develop a comprehensive plan of care that addressed the needs of the residents related to his behaviors and [MEDICAL CONDITION] medications. The facility failed to identify and accurately assess Resident #158, a cognitively impaired resident with known self-injurious behaviors. The facility failed to administer antipsychotic medications in accordance with the physician's orders [REDACTED]. The resident was known to have self-injurious behaviors including biting his fingers to the point of fracturing the digit. The facility failed to implement interventions to prevent or monitor for these behaviors. Resident #158 was not given the antipsychotic medication for his self-injurious behaviors from 5/13/15 through 5/20/15 resulting in a serious injury on 5/17/15 to his hand. Resident #158 bit his finger causing a severe fracture and subsequent amputation of that digit. Additionally, based on record reviews and interviews, the facility failed to develop a comprehensive care plan for Residents #11 and #124 with appropriate individualized interventions for problems identified during the comprehensive assessment. The findings included: Cross refer to F 272, F 309, F 319, F 323, F 333, F 490 and F 501 as it related to the facility's failure to accurately assess the resident, the failure provide the necessary care and services to a resident that severely injured themselves with a bite wound, the facility failure to meet the psychosocial needs of a cognitively impaired resident with self-injurious behaviors, the failure of the facility to provide adequate supervision to prevent injury, the failure of the facility to administer medications in accordance with physician orders, the failure of the facility to administer it's resources effectively to keep residents safe from injury and the failure of the Medical Director to coordinate care and to assure resident care policies were implemented. Review of Resident #158's Initial Plan of Care dated 4/16/15 revealed there was no care plan initiated for the resident's behavior or use of [MEDICAL CONDITION] medication. Review of Resident #158's Care Plan dated 5/8/15 revealed a care plan for aggressive behavior with ADL's (Activities of Daily Living), but the behavior of biting his/her hand was not noted. Review of Resident #158's Admission Report sheet revealed notes that indicated the resident had self inflicted hand lacerations to two fingers (3rd/4th). The resident was noted to have behaviors issues of combativeness and biting. There was no evidence the resident had his behaviors identified on the care plan with appropriate interventions implemented. Review of the New Admission History and Physical completed 4/23/15 indicated Resident #158 had a human bite on the right hand third digit on 3/9/15. The assessment indicated the resident's right hand was bandaged. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #158 was admitted on Risperadone 0.5 mg(milligrams) BID (twice a day) for behaviors. Review of the resident's Physician's Telephone Orders dated 4/30/15 revealed an order to discontinue Risperadone 0.5 mg BID and start Risperadone 0.25 mg BID. Review of Resident #158's medical record revealed a copy of the Discharge Summary of the resident's hospitalized from [DATE]-4/14/15. The Discharge Summary indicated Resident #158 had [MEDICAL CONDITIONS] status with behavioral issues. The discharge [DIAGNOSES REDACTED]. The Discharge Summary indicated the resident suffered frontal lobe injuries such that his/her behavioral control appeared to be very much impaired. Psychiatry was consulted to help control the patient's behavioral issues. The patient had developed a tendency to attempt to bite nearby objects. The patient's PEG was bit off on one occasion in the patient's confused state. On March 9, 2015 the patient actually bit his/her fingers on the right hand injuring his/her third digit. With the assistance of psychiatry the best medical regimen that could be determined was Risperadone 0.5 milligrams twice a day with reasonable behavioral control without successfully inhibiting the patient's ability to interact with surroundings. To protect his/her hand, a mitten was placed as appeared to be the most humane form of protection that can be offered without restraining the patient. The resident's discharge medications included Risperadone 0.5 mg twice a day. Review of the Infectious Disease/Wound Care physician progress notes [REDACTED].#158 had multiple open wounds to the hands that were self-inflicted. Review of the hospital Nurse Progress Notes dated 4/8/15 indicated the nurse reinforced the resident's dressing on his/her right hand to prevent him/her from biting self. The Nurse Progress Note dated 4/9/15 indicated the resident was noted chewing on his/her right hand dressing. In an interview with the surveyor on 09/11/2015 at approximately 4:17 PM, the DON (Director of Nursing) stated s/he and the nurse on duty look at hospital information for behaviors, history, etc. The Assistant DON will also review the information at times. Unit Managers also review the information. The DON also stated the History/Physical and Discharge Summary come with the resident and that is what they track. The DON stated that in morning clinical meeting they look to make sure that all information that is needed is in the chart. The Discharge Summary is usually faxed over and the nurse on duty looks at that before the resident arrives. The DON stated the nurse on duty should have noted there was a biting problem and made sure there was something in place to prevent. The nurse also should have talked to the physician about the behavior and documented the conversation in the Nurses Notes. The DON stated the nurse initiates the initial care plan for new admission residents. Minimum Data Set staff completes the Care Plan on residents after the assessment is completed. Care Plan updates are a combined effort. The resident's medical record is brought to morning meeting and Care Plans are updated there. The nurses on duty may updated the care plan but it is verified in the morning meeting. The DON reviewed Resident #158's initial care plan and confirmed the resident's behavior and antipsychotic medication were not on the initial care plan and stated that they should have been on the initial care plan. In an interview with the surveyor on 9/11/15 at approximately 4:20 PM the ADON (Assistant Director of Nursing) stated Resident #158's behavior was discussed when s/he was admitted to the facility. Resident #158 had self inflicted biting and s/he was combative with staff. The ADON could not remember if they discussed interventions for the resident at the time of admission. The facility admitted Resident #11 with [DIAGNOSES REDACTED]. On 9/12/15 at 10:17 AM review of the Re-admission MDS (Minimal Data Set) dated 6/25/15 revealed Resident #11 had a BIMS (Brief Interview for Mental Status) score of 4 indicating severely impaired cognition, impaired communication with unclear speech, total dependence for all aspects of ADLs (Activities of Daily Living) except eating which was coded as extensive assistant, and ROM (Range of Motion) limitation of the bilateral upper and lower extremities. At 10:31 AM on 9/12/15 review of the care plan revealed a care plan for impaired communication that indicated the resident was able to respond to yes/no questions and to make out some simple phrases in 3-4 word sentences. Further review revealed interventions of Encourage resident to discuss feelings regarding the inability to return to desired place of discharge on a care plan for discharge planning and to encourage resident to express feelings on a care plan for mood disturbance. Review of the care plan revealed multiple inconsistencies related to impaired communication and food restrictions for [MEDICAL CONDITION] Reflux Disease (GERD). Review of the care plan for self-care deficit related to cognition stated the resident was a quadriplegic and had limited ROM at BUE (Bilateral Upper Extremities and was rigid/stiff. Interventions included allow/encourage resident to feed self after tray set-up. The care plan [MEDICAL CONDITION] avoid foods or beverages that tend to irritate [MEDICAL CONDITION] lining (alcohol, chocolate, caffeine, acidic or spicy foods, fried or fatty foods.) On 9/12/15 at 1:20 PM, the MDS RN (Registered Nurse) confirmed that Resident #11 was not feeding self although the MDS RN stated that s/he had observed the resident start to feed self but confirmed the documentation by therapy that the resident was no longer feeding self. The nurse also confirmed the dietary restrictions on the care plan were not listed in the resident diet orders. The MDS RN verified the inconsistencies and inappropriate interventions on the care plan. The facility admitted Resident #124 with [DIAGNOSES REDACTED]. Review of Resident #124's Comprehensive Care Plan revealed that Resident #124 is at high risk for alteration in hydration relating to dysphasia, [MEDICAL CONDITION], and continuous [DEVICE] feedings. Resident is impaired physically and cognitively. Review of the Care Plan on 9/12/15 at approximately 10:30 am, revealed that Resident #124 will continue to self access fluids as needed by 9/23/15, will show no signs of dehydration by 9/23/15, and show no signs of fluid overload AEB no [MEDICAL CONDITION], no SOB daily by 9/23/15. Review of the Care Plan on 9/12/15 at approximately 10:30 am, revealed that Resident #124 required a PEG tube (Percutaneous Endoscopic Gastrostomy Tube). Resident will maintain an acceptable weight by 9/27/15, Resident will have no weight change greater than 5% of current body weight by 9/27/15, and Resident will not experience adverse effects from placement of a PEG tube by 9/27/15. Record review of the Nurses Notes on 9/12/15 at 10:30 am revealed that Resident #124 had a weight loss of 12 pounds. Nurses Notes on 9/12/15 at 10:30 am revealed that weights were 178 lbs. on 6/15/15, 165.8 lbs. on 7/6/15 (6.8% weight loss), 165 lbs. on 7/14/15, 163.2 lbs. on 7/16/15 160.6 lbs. on 7/28/15 163.2 lbs. 164 lbs. on 8/4/15, and 158.5 lbs. on 9/3/15. During an interview on 9/12/15 at 11:50 am with the Administrator and DON (Director of Nursing), the Administrator confirmed that the facility follows all of the doctor's orders relating all of their residents and needs. Both DON and Administrator were not able to confirm that the Care Plan was not individualized for Resident #124. The Immediate Jeopardy identified at the facility on 9/11/15 had not been removed at the time of completion of the recertification and complaint survey on 9/15/15.

Based on review of facility files and interview, the facility failed to prohibit mistreatment and neglect of residents. Review of facility files revealed Resident #61 had an allegation of neglect on 7/4/15 that was not reported or investigated. One of sixteen residents reviewed for neglect. Resident #61 did not have incontinent care provided. The resident's sacral wound worsened. The nurse failed to report and act upon the incident of neglect. The findings included: Review of facility files revealed a One to One Inservice/Counseling Record dated 7/4/15 completed by LPN #8 for CNA #10. The form indicated LPN #8 noticed dark rings and soiled linen for Resident #61. There was blood from the resident's amputation stumps on the bed. Resident #61's head of bed was all the way down while the resident's continuous tube feeding was in place and running. Review of Resident #61's Nurse's Notes revealed an entry dated 7/4/15 at 2:26 PM. Review of the entry revealed documentation the resident's dressing to the sacrum was in place and the wound bed was increasing in red areas. The nurse applied dry dressing to the right stump due to bleeding during repositioning and brief/linen change. There were no other Nurse's Notes on 7/4/15. The next Nurse's Note was dated 7/5/15 at 3:27 PM and indicated the dressing to the resident's sacrum was changed. The area was dry, intact and red in color. Review of Resident #61's Weekly Pressure Ulcer Record revealed a a Stage 2 on the sacrum that developed on 6/28/15. Review of the risk factors section of the form revealed incontinence was checked. On 7/2/15 the area was a Stage 2 that measured 6.5 x 4.5 x 0.1 and the wound bed was pink and moist with dark skin. Further review of the Weekly Pressure Ulcer Record revealed on 7/9/15 the area was unstageable and measured 6.5 x 3 with 100% yellow slough. The wound bed was noted to be boggy with thick yellow slough. There were no additional entries on the Weekly Pressure Ulcer Record between 7/2-7/9/15 to record the condition of the resident's pressure ulcer on the sacrum. Review of Resident #61's Weekly Body Audit revealed an entry dated 7/14/15 that indicated the sacral wound depth had increased. The previous entry on the Weekly Body Audit was dated 6/16/15. Resident #61 was noted to have gone out to the hospital and returned to the facility on [DATE]. Review of the resident's care plan revealed he/she required a PEG tube for adequate nutritional intake was identified as a problem area. Interventions and approaches were listed on the care plan and included to maintain in an upright position after each feeding. Further review of the care plan revealed self care deficit as evidenced by need for extensive to total assist with all Activities of Daily Living. Interventions and approaches were listed on the care plan and included incontinence care every two hours and as needed. In a telephone interview with the surveyor on 9/11/15 at approximately 11:40 AM, Resident #61's Attending Physician stated s/he does not recall if s/he was notified of the incident on 7/4/15. The Attending Physician stated s/he would expect the nurse to look at the resident's sacral wound and redress. In an interview with the surveyor on 9/10/15 at approximately 12:22 PM, the North/East Unit Manager stated s/he was not aware of the incident with CNA #10 and Resident #61 on 7/4/15. In an interview with the surveyor on 09/11/2015 at approximately 9:31 AM, the DON stated there was no incident report completed for the 7/4/15 incident with Resident #61. The DON stated s/he had not seen the counseling statement about the incident. Multiple attempts were made to contact LPN # 8 with no ability to leave a message. In an interview with the surveyor on 09/11/2015 at approximately 9:46 AM, the facility Administrator stated s/he had not seen the counseling statement for CNA #10 dated 7/4/15. The Administrator stated there should be a nurses' note about the incident for Resident #61. The DON stated s/he would expect the incident to be monitored and followed up and the information to be documented in the Nurses' Notes. The DON would also expect a skin assessment to be completed. The DON also would expect acute charting every shift and follow up for at least 72 hours, an incident report, an investigation, and the responsible party and physician to be notified. The nurse should have monitored heart and lung sounds for aspiration. There should also be statements from staff about the incident. Review of the facility's policy and procedures for Abuse Investigations revealed all reports of alleged neglect shall be promptly and thoroughly investigated by facility management. The investigation will include: review the resident's medical record, interview the person reporting the incident, interview any witnesses to the incident, interview the resident, interview the resident's Attending Physician as needed to determine the resident's current medical condition, interview staff members on all shifts who have had contact with the resident during the period of the alleged incident, review all events leading up to the alleged incident. The policy also indicated witness reports will be obtained in writing and witnesses will be required to sign and date reports. The results of the investigation will be recorded on approved documentation forms. The facility's policy and procedures for Abuse Prevention Program included mandated staff training/orientation programs that include topics such as abuse identification and reporting of abuse. Review of the facility's policy and procedures for Reporting of Alleged Abuse to Facility Management revealed it is the responsibility of employees to promptly report any incident or suspected incident of neglect to facility management. The policy defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish or metal illness. Review of facility information for Overview and Assessment of Enteral Feedings revealed procedures included to elevate the head of bed 30 to 45 degrees to prevent aspiration.

Based on review of facility files and interview, the facility failed to assure a resident having pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Review of facility files revealed Resident #61 had an allegation of neglect that included finding the resident in soiled linen with dark rings. The resident had a pressure ulcer on the sacrum at the time of the incident. The pressure ulcer to the sacrum was not monitored after the incident and was noted to worsen on the next Weekly Pressure Ulcer Record assessment. The facility also failed to provide wound care to prevent infection for Resident #119, 1 of 3 residents reviewed for pressure ulcers. The findings included: Review of facility files revealed a One to One Inservice/Counseling Record dated 7/4/15 completed by LPN #8 for CNA #10. The form indicated LPN #8 noticed dark rings and soiled linen for Resident #61. There was blood from the resident's amputation stumps on the bed. Resident #61's head of bed was all the way down while the resident's continuous tube feeding was in place and running. Review of Resident #61's Nurse's Notes revealed an entry dated 7/4/15 at 2:26 PM. Review of the entry revealed documentation the resident's dressing to the sacrum was in place and the wound bed was increasing in red areas. The nurse applied a dry dressing to the right stump due to bleeding during repositioning and brief/linen change. There were no other Nurse's Notes on 7/4/15. The next Nurse's Note was dated 7/5/15 at 3:27 PM and indicated the dressing to the resident's sacrum was changed. The area was dry, intact and red in color. Review of Resident #61's Weekly Pressure Ulcer Record revealed a a Stage 2 on the sacrum that developed on 6/28/15. Review of the risk factors section of the form revealed incontinence was checked. On 7/2/15 the area was a Stage 2 that measured 6.5 x 4.5 x 0.1 and the wound bed was pink and moist with dark skin. Further review of the Weekly Pressure Ulcer Record revealed on 7/9/15 (5 days following the incident of neglect) the area was unstageable and measured 6.5 x 3 with 100% yellow slough. The wound bed was noted to be boggy with thick yellow slough. There were no additional entries on the Weekly Pressure Ulcer Record between 7/2-7/9/15 to record the condition of the resident's pressure ulcer on the sacrum. Review of Resident #61's Weekly Body Audit revealed an entry dated 7/14/15 that indicated the sacral wound depth had increased. The previous entry on the Weekly Body Audit was dated 6/16/15. Resident #61 was noted to have gone out to the hospital and returned to the facility on [DATE]. Review of the resident's care plan revealed self care deficit as evidenced by need for extensive to total assist with all Activities of Daily Living. Interventions and approaches were listed on the care plan and included incontinence care every two hours and as needed. In a telephone interview the surveyor on 9/11/15 at approximately 11:40 AM, Resident# 61's Attending Physician stated s/he does not recall if s/he was notified of the incident on 7/4/15. The Attending Physician stated s/he would expect the nurse to look at the resident's sacral wound and redress. In an interview with the surveyor on 09/11/2015 at approximately 9:46 AM, the facility Administrator stated s/he had not seen the counseling statement for CNA #10 dated 7/4/15. The Administrator stated there should be a nurses note about the incident for Resident #61. The DON stated s/he would expect the incident to be monitored and followed up and the information to be documented in the Nurse Notes. The DON would also expect a skin assessment to be completed. The DON also would expect acute charting every shift and follow up for at least 72 hours, an incident report, an investigation, and the responsible party and physician to be notified. The nurse should have monitored heart and lung sounds for aspiration. There should also be statements from staff about the incident. Multiple attempts were made to contact LPN# 8 with no ability to leave a message and no return phone call. Review of the facility's Skin Management Process revealed identification included skin risk assessment on admission/readmission and significant change. Assessment included to notify the physician for worsening wounds or wounds not responding to treatment. The facility admitted Resident #119 with [DIAGNOSES REDACTED]. On 9/10/15 Wound Care observation was conducted with Licensed Practical Nurse (LPN) #5. The LPN knocked on the door and explained the procedure. The LPN washed her/his bands washed and donned gloves. Resident #119 was positioned on their left side by the CNA for the wound care, the brief was opened and the resident was noted to have feces present at the rectum and on the inner left and right buttock. The LPN tucked the brief over the rectum to cover the feces and proceeded with wound care. During an interview on 9/11/15 at 12:10 PM, the LPN confirmed the presence of feces during the wound care and that s/he had covered it with the brief. When asked if that would be an infection control concern, the LPN stated I see what you're saying. In addition, on 09/11/2015 at 1:44 PM, review of the Weekly Pressure Ulcer Record revealed no measurements done between 5/1/15 and 5/22/15 by facility for the pressure ulcer on the left heel. The sacral and left hip wounds were measured on 5/5 and 5/13/15 at the wound clinic. No measurements were documented by the facility or the wound clinic of the left heel. On 9/11/14 at 2:29 PM, the Corporate Consultant confirmed the lack of measurements.

Based on observation, interview and record review, the facility failed to assure a resident who is fed by gastrostomy tube received the appropriate treatment and services. Observation of Resident #61's tube feeding pump revealed the resident was receiving less tube feeding formula than ordered. Two of four residents reviewed for tube feeding. The findings included: Review of Resident #61's medical record revealed [DIAGNOSES REDACTED]. A PEG (Percutaneous Endoscopic Gastrostomy) was placed on 6/26/15. Resident #61 was noted to have an unstageable area to the sacrum and was receiving a treatment to the surgical area on his/her right above knee amputation. The surgical area to the left above knee amputation had healed. Review of Resident #61's medical record revealed a Physician's Telephone Order dated 8/11/15 to increase [MEDICATION NAME] 1.0 to 60 cc (cubic centimeters)/hour for weight management based on a dietary recommendation. Review of Resident #61's September 2015 Enteral Administration Record revealed an order for [REDACTED]. Resident #61 was noted to have an order for [REDACTED]. Review of Resident #61's Nutrition Services Progress Note revealed an entry dated 8/11/15. Resident #61 was noted to have a 4.4% weight loss x 30 days. The Registered Dietitian recommended to increase [MEDICATION NAME] 1.0 to 60 cc/hr related to weight loss. Review of Resident #61's Yearly Weight Record for 2015 revealed the following: 6/29/15-115# 7/6/15 - 89.8# 7/20/15 - 85# 7/25/15 - 80.6# 7/28/15 - 84.2# 8/4/15 - 84.8# 8/11/15 - 84.2# 8/18/15 - 84.4# 8/25/15 - 84.5 # 9/3/15 - 83# Resident #61 was observed on 9/9/15 at approximately 12:00 PM receiving [MEDICATION NAME] 1.0 @ 55 cc/hr. Resident #61 was observed on 09/10/2015 at approximately 12:45 PM and 3:57 PM receiving [MEDICATION NAME] 1.0 @ 55 cc/hr. On 09/10/2015 at approximately 3:57 PM Registered Nurse #1 confirmed Resident #61's tube feeding rate of [MEDICATION NAME] 1.0 @ 55 cc/hr. The surveyor asked Registered Nurse #1 what Resident #61's tube feeding order was for and s/he went to check the Enteral Administration Record. Registered Nurse #1 stated the order was [MEDICATION NAME] 1.0 @ 60 cc/hr. Review of the Nurses Notes dated 9/4/15 revealed an entry TF (tube feeding) infused at 55 ml/hr as ordered .

Based on review of facility files and interview, the facility failed to implement written polices and procedures that prohibit mistreatment and neglect of residents. Review of facility files revealed Resident #61 had an allegation of neglect on 7/4/15 that was not reported or investigated. One of sixteen residents reviewed for neglect. The findings included: Review of the facility's policy and procedures for Abuse Investigations revealed all reports of alleged neglect shall be promptly and thoroughly investigated by facility management. The investigation will include: review the resident's medical record, interview the person reporting the incident, interview any witnesses to the incident, interview the resident, interview the resident's Attending Physician as needed to determine the resident's current medical condition, interview staff members on all shifts who have had contact with the resident during the period of the alleged incident, review all events leading up to the alleged incident. The policy also indicated witness reports will be obtained in writing and witnesses will be required to sign and date reports. The results of the investigation will be recorded on approved documentation forms. The facility's policy and procedures for Abuse Prevention Program included mandated staff training/orientation programs that include topics such as abuse identification and reporting of abuse. Review of the facility's policy and procedures for Reporting of Alleged Abuse to Facility Management revealed it is the responsibility of employees to promptly report any incident or suspected incident of neglect to facility management. The policy defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish or metal illness. Review of facility files revealed a One to One Inservice/Counseling Record dated 7/4/15 completed by LPN #8 for CNA #10. The form indicated LPN #8 noticed dark rings and soiled linen for Resident #61. There was blood from the resident's amputation stumps on the bed. Resident #61's head of bed was all the way down while the resident's continuous tube feeding was in place and running. Review of Resident #61's Nurse's Notes revealed an entry dated 7/4/15 at 2:26 PM. Review of the entry revealed documentation the resident's dressing to the sacrum was in place and the wound bed was increasing in red areas. The nurse applied dry dressing to the right stump due to bleeding during repositioning and brief/linen change. There were no other Nurse's Notes on 7/4/15. The next Nurse's Note was dated 7/5/15 at 3:27 PM and indicated the dressing to the resident's sacrum was changed. The area was dry, intact and red in color. Review of Resident #61's Weekly Pressure Ulcer Record revealed a a Stage 2 on the sacrum that developed on 6/28/15. Review of the risk factors section of the form revealed incontinence was checked. On 7/2/15 the area was a Stage 2 that measured 6.5 x 4.5 x 0.1 and the wound bed was pink and moist with dark skin. Further review of the Weekly Pressure Ulcer Record revealed on 7/9/15 the area was unstageable and measured 6.5 x 3 with 100% yellow slough. The wound bed was noted to be boggy with thick yellow slough. There were no additional entries on the Weekly Pressure Ulcer Record between 7/2-7/9/15 to record the condition of the resident's pressure ulcer on the sacrum. Review of Resident #61's Weekly Body Audit revealed an entry dated 7/14/15 that indicated the sacral wound depth had increased. The previous entry on the Weekly Body Audit was dated 6/16/15. Resident #61 was noted to have gone out to the hospital and returned to the facility on [DATE]. Review of the resident's care plan revealed requires a PEG tube for adequate nutritional intake was identified as a problem area. Interventions and approaches were listed on the care plan and included to maintain in an upright position after each feeding. Further review of the care plan revealed self care deficit as evidenced by need for extensive to total assist with all Activities of Daily Living. Interventions and approaches were listed on the care plan and included incontinence care every two hours and as needed. In a telephone interview the surveyor on 9/11/15 at approximately 11:40 AM, Resident #61's Attending Physician stated s/he does not recall if s/he was notified of the incident on 7/4/15. The Attending Physician stated s/he would expect the nurse to look at the resident's sacral wound and redress. In an interview with the surveyor on 9/10/15 at approximately 12:22 PM, the North/East Unit Manager stated s/he was not aware of the incident with CNA #10 and Resident #61 on 7/4/15. In an interview with the surveyor on 09/11/2015 at approximately 9:31 AM, the DON stated there was no incident report completed for the 7/4/15 incident with Resident #61. The DON stated s/he had not seen the counseling statement about the incident. In an interview with the surveyor on 09/11/2015 at approximately 9:46 AM, the facility Administrator stated s/he had not seen the counseling statement for CNA #10 dated 7/4/15. The Administrator stated there should be a nurses note about the incident for Resident #61. The DON stated s/he would expect the incident to be monitored and followed up and the information to be documented in the Nurse Notes. The DON would also expect a skin assessment to be completed. The DON also would expect acute charting every shift and follow up for at least 72 hours, an incident report, an investigation, and the responsible party and physician to be notified. The nurse should have monitored heart and lung sounds for aspiration. There should also be statements from staff about the incident.

On the days of the survey based on observations, record review and interviews, the facility failed to provide treatment and services as ordered/needed to prevent further decrease in range of motion (ROM) for 1 of 10 residents reviewed with known contractures. Resident #4 was observed not wearing orthotic device/splint per physicians order and had no services provided to prevent further decline in range of motion. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. The initial observation of Resident #4 on 1/14/13 revealed the resident had contractures of both upper and lower extremities. The surveyor did not observe any devices or splints in place to prevent further decrease in ROM. Review of the 11/21/12 Significant Change Minimum Data Assessment (MDS) on 1/14/13 revealed that the resident had limitations in ROM in both upper and lower extremities. Review of the medical record revealed the resident was recieving Occupational Therapy (OT) and Physical Therapy for contracture management. Further review of the therapy notes indicated Resident #4 was screened and assessed for use of orthotic devices. OT notes dated 10/31/11-11/4/11 revealed he/she had a left elbow extention to 90 degrees and resident was able to tolerate splint. OT notes dated 11/26/11 stated "wrist flexion approximately 80 degrees. Tolerate splint..." Resident #4 was discharged from therapy on 3/13/12 and was able to tolerate the use of wearing the left elbow and wrist/hand orthotic devices. Review of Resident #4's physician's orders [REDACTED]. Review of Resident #4's Care plan related to scheduled care routine tasks, revealed an approach for left palm protectors and left elbow splint. Further review of the resident's care plan indicated nursing was to provide PROM to all extremities during care. Throughout the days of the survey the surveyor observed no orthotic devices on Resident #4 elbow or wrist. During an interview on 1/15/13 with the Certified Occupational Therapy Assistant she stated "the resident had contractures so we put palm guards and elbow splint on resident and he/she was discharged with those devices". During an interview on 1/15/13 at approximately 4 PM Licensed Practical Nurse #3 stated he/she thought the order was discontinued and verified the resident did not have devices on as order. There was also no documentation or information provided to ensure that the Certified Nursing Assistants or nurses were performing PROM for the resident. During an interview on 1/16/13 at approximately 4:15 PM with the Occupational Therapist s/he stated "Since resident was discharged from therapy he/she had a decrease in ROM. The OTR-L assessed resident on 1/16/13 and stated his/her left elbow flexion went from 65 degrees to 111 degrees while recieving therapy and now his/her elbow extension is from 111 degrees to 180 degrees. She/he further stated resident now has no extension in wrist with 35 degrees flexion and we could not get the residents finger out of his/her palm. The resident can no longer wear a wrist splint."