Every finding on record at Foxwood Springs Living Center

Based on observation, interview and record review, the facility failed to ensure the physician's order for a narcotic medication was accurately shown on the narcotic sheet and Medication Administration Record (MAR); failed to ensure the nurse accurately documented narcotic medications administered on the MAR; and failed to ensure the policy and procedure for corrections made on the narcotic sheet were followed for one sampled resident (Resident #4) out of 8 sampled residents. The facility census was 92 residents. Review of the facility's Administering Oral Medication policy and procedure dated October 2010, showed the purpose was to provide guidelines for safe administration of oral medications. The policy showed the staff should:-Verify that there is a physician's order for the medication.-Place the MAR within easy viewing distance.-Unlock the medication cart and select the drug from the unit dose drawer.-Check the label on the medication and confirm the medication name and dose with the MAR.-Check the medication dose. Re-check to confirm the proper dose.-For narcotic medication, check the narcotic record for the previous drug count and compare with the supply on hand. Report any discrepancies to the nurse supervisor.-If the medication falls to the floor, discard and document. Repeat the preparation.-Follow the documentation guidelines.-Notify the supervisor if the resident refuses the procedure.-report other information in accordance with policy and procedure and professional standards of practice. Review of the facility's Documentation of medication Administration policy and procedure dated April 2007, showed the facility shall maintain a medication administration record to document all medications administered. the policy showed:-The Staff shall document all medication administered to each resident on the resident's MAR.-Administration of medication must be documented immediately after it is given.-Documentation must include at a minimum; the name and strength of each drug, date and time of administration, reason why the medication was withheld, not administered or refused; signature and title of the person administering the medication and resident response to the medication if applicable (for as needed medication, pain medication). 1. Review of Resident #4's Face Sheet showed the resident was admitted on [DATE] with diagnoses including gout (a complex form of arthritis that can affect anyone. It's characterized by sudden, severe attacks of pain, swelling, redness and tenderness), kidney failure, history of breast cancer and skin cancer, edema (swelling of the tissues, chronic pain, wounds, heart disease with heart failure, osteoarthritis (joint disease that causes the breakdown of cartilage, the smooth tissue that covers the ends of bones), and physical debility. Review of the resident's undated Physician's Orders Sheet showed physician's orders for:-Oxycodone 5 milligrams (mg), two tablets every two hours as needed for chronic pain (started 10/20/25).-Oxycodone 5 mg two tablets every four hours as needed for chronic pain (started 10/19/25). Review of the resident's MAR dated September 2025 showed:-A physician's order for Oxycodone 5 mg two tablets every two hours as needed for chronic pain (1/20/25).-The MAR showed the resident received Oxycodone on 9/13/25, 9/14/25 and 9/29/25. --NOTE: No documentation the medication was removed from the resident's Narcotic Record MAR on these dates. -The MAR did not show Oxycodone was administered on 9/23/25 or on 9/24/25 to the resident (these dates were left blank). The medication showed removed from the resident's Narcotic Record MAR on these dates. Review of the resident's Narcotic Record MAR showed a physician's order for Oxycodone 5 mg one tablet every four hours as needed for 30 days. It showed 30 tablets were delivered by the pharmacy. The date received showed 12/5/24. Amount received showed 30 tablets, but there was a handwritten 20 over the typed 30 tabs. Documentation showed the nurse documented the following administration:-9/23/25 at 2015 showed 2 was scratched through and 1 was documented beside it, leaving 18 tablets on the card. This was not documented on the MAR.-9/24/25 at 0015 showed 1 tablet was administered leaving 17 tablets on the card. This was not documented on the MAR.-9/25/25 at (no time documented) showed 2 tablets were administered, leaving 15 tablets on the card. This was not documented on the MAR. Review of the resident's medical record showed:-The resident's Narcotic Record showed the physician's orders on the Narcotic Record did not match the physician's orders on the resident's POS or MAR dated September 2025 and October 2025.-On the Narcotic Record, the number of tablets the pharmacy showed as delivered (30) was altered to show 20 tablets.-The MAR dated September 2025 did not show the resident was administered oxycodone on 9/23/25 or 9/24/25. Review of the facility Medication Count Sheet (nursing shift sign off sheets) showed nursing staff was instructed to document the name of the resident, name and strength of the medication, number of cards, number of narcotic count sheets, nurse initials (during the shift) and the verifying nurse initial. The inventory shift count showed the nurse would document the date, shift time/key exchange, nurse signatures (nurse coming on duty and nurse going off duty) total number of cards and the total number of count sheets. Documentation showed:-9/23/25 through 9/25/25 showed the resident's name, medication, number of cards, number of count sheets, or nurse initials (nurse on shift and verifying nurse) were not documented (these areas were left blank).-The nurses documented the date, shift time/key exchange, and showed the total number of cards and count sheets matched at the shift change. There were two nurse signatures on these dates. During an interview on 10/22/25 at 11:04 A.M., CMT A said:-The process for giving a narcotic medication was to open the resident's MAR, (which showed the physician's order) and the narcotic book which also showed the medication order.-He/She was supposed to check the orders to make sure it was the correct medication and order on both the narcotic sheet and the MAR.-He/She then pulled the narcotic card, checked that the medication and order matched the physician's order, Narcotic sheet and MAR, then pop the tablet off of the resident's medication card and put it into a cup and get a cup of water to give to the resident.-He/She was supposed to sign the medication out on the narcotic book showing that they gave it and how many tablets were left on the medication card, then also document on the resident's MAR showing the resident received the medication after they give it.-If they followed the protocol, there would not be a reason why it would not be signed out on both the narcotic sheet or MAR and match with the medication card. -If the physician's orders did not match the orders on the resident's MAR or narcotic sheet, he/she would notify the nurse so it could be changed.-If there was a mistake or discrepancy with the narcotic or documentation, he/she would notify the nurse.During an interview on 10/22/25 at 11:27 A.M., Certified Medication Technician (CMT) A said:-The resident receives Hospice services and has pain management.-The resident had Oxycodone as needed for pain that they can provide and that the resident usually will request that a couple times a week. During an interview on 10/22/25 at 3:08 P.M., Registered Nurse (RN) A said:-He/She had been in-serviced on administering a narcotic medication.-When giving a narcotic, they were to verify the physician's orders on the narcotic sheet, MAR and POS and they should all match.-They document administration of the narcotic on the narcotic sheet and on the resident's MAR.-Documentation should include the medication and strength, date, time given, how many you gave, and how many pills were left on the card. They also had to sign it.-When they give the narcotic medication, they were also supposed to document that it was given on the resident's MAR on the date it was administered to the resident.-He/She reconciles the narcotic book with the narcotics in the cabinet. This is supposed to be done daily on each shift.-At shift change, the nurse coming on shift and the nurse going off shift were supposed to count and verify how many narcotics are in the medication cart, then they are to verify that the correct amount is documented on the narcotic sheet.-There should be no reason why it would not be reconciled daily and it was always supposed to be documented completely and accurately on the narcotic count sheet.-The medication count sheet was supposed to be fully filled out and the nurses then document the number of narcotics and the number of cards and medications on the sheet Once they reconcile the narcotics, both nurses sign the sheet showing that the count is correct.-On occasions where a pill is dropped, they would have to destroy it and any destruction of a narcotic must be done by two nurses.-If a medication is wasted then the nurses also have to sign on the narcotic sheet that it was destroyed. He/She said the protocol does not change for as needed (PRN) medications.-The order on the resident's narcotic sheet and the MAR and the physician's order should be the same and the nurse giving the medication should check to ensure the orders are the same before giving the medication. If the orders are not the same, they should clarify the order prior to giving the medication and notify the pharmacy so they can get another narcotic sheet or create a new narcotic sheet with the correct order on it.-Any documentation mistakes on the narcotic sheet should be documented in the nursing notes, but the count should be consistent, and all pills accounted for. During an interview on 10/22/25 at 3:23 P.M., the Director of Nursing (DON) said:-Nurses and CMT staff were supposed to verify the physician's orders on the POS, MAR and Narcotic sheet were the same prior to administering a medication.-If there was a discrepancy with the physician's order, the nurse should verify it and make the change on the MAR and Narcotic sheet.-He/She expected the nurses to accurately document all narcotics administered on the narcotic sheet and on the resident's MAR and if there was a discrepancy or issue, they were supposed to make a note showing what the medication was not administered.-At the end of every shift two nurses were supposed to compete a count of the narcotic medications and verify that with the medication cards and the narcotic sheets to ensure they match up at the beginning and ending of their shift. -When they give a narcotic, the nurse is supposed to document the medication on the narcotic sheet and once its given, document that it was administered on the resident's MAR.-The documentation on the narcotic sheet should show the date, time, quantity given, signature and quantity remaining.-They completed an audit of the narcotics and found the errors on the resident's narcotic sheet. Then when they investigated further, they found that the documentation on the resident's narcotic sheet and MAR did not match. -On 9/23/25 the nurse who worked night shift altered the time and quantity given (changed the amount from 2 tablets to 1 tablet on the resident's narcotic sheet. He/She altered the quantity documented as given.-The physician's orders on the narcotic sheet did not match the MAR. The physician's orders on the resident's MAR showed they should have been giving two tablets of oxycodone every four hours. The documentation on the narcotic sheet showed the nurse gave 1 tablet on 9/23/25 and 9/24/25 then the nurses documented they were giving two tablets thereafter.-The nurse administering oxycodone on 9/23/25 and 9/24/25 did not document that the medication was administered on the resident's MAR.-When he/she interviewed the nurse he/she said that sometimes he/she forgot to sign the resident's MAR after giving his/her medication.-The nurse did not have an explanation for why he/she had altered the resident's narcotic sheet.-He/She said from their investigation, the nurse popped the medication out of the medication card, signed it out on the narcotic sheet but did not sign the MAR on those two dates. -The nurses have to complete the narcotic count at shift change and have to document on the narcotic count sheets that they counted the narcotics and verified it with the narcotic count sheet and medication cards.-The nurses both sign the narcotic count sheet showing they counted the narcotics at shift change, reconciled them to the medication cards. In this case the narcotic count sheet was completed and it showed that both nurses showed the count was compete and was accurate, so the mistake was not immediately caught. During an interview on 10/22/25 4:00 P.M., the Administrator and DON said:-(After looking at the narcotic sheet and MAR) the DON said the orders on the narcotic record and MAR were not the same orders.-The physician's orders on the MAR were the correct orders for giving oxycodone.-The count was 20 pills instead of 30. -They should have ensured the orders on the narcotic sheet and the MAR matched.-They should have started a new narcotic sheet with the correct orders and count.-The Administrator said that they should have ensured that the orders on both the Narcotic Count Sheet and the MAR were correct and were the same order and they should not have written over the count.-They should have started a new narcotic sheet instead of altering the narcotic sheet. Complaint 2634694

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to clean the kitchen floors, preparation table, shelves and drawers, stove, the grill, grill area, ovens, sides and front of the deep fat fryer, refrigerators, and the steamer/convection ovens. Findings include: Review of the undated Sanitization policy read in part: Policy Statement - The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and implementation - 1. All kitchens, kitchen areas and dining areas shall be kept clean . 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . 16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. During the initial tour of the kitchen on 1/7/25 at 11:24 a.m., the following items were not clean in the kitchen. The kitchen floors had food debris, black colored grime and grease under the stove, grill, ovens, steamers and preparation tables. in the kitchen. The food preparation tables, shelves and drawers had food debris and crumbs on and in them; the stove had dried food debris and accumulated grease on the front, sides and back of it; the grill and grill area had food debris and accumulated grime and yellow colored grease on the front and sides of the table to include the wheels of the grill table; the ovens had black food debris built up inside and the outside of the ovens had food debris on the doors and sides; there was yellow grease build up on the sides and front of the deep fat fryer; the refrigerators had dried food substances inside to include dried beverages that had not been cleaned up, and the handles had food sticky debris stuck to them and in the crevices around the handle, the bottoms of the outside of the refrigerators had stains on them; the tilt skillet, and the steamer/convection ovens had black colored food debris inside, and the glass doors were yellowish/brownish in color with gunky handles. There was a sign posted on the steamer that read: Top steamer lunch cook clean after lunch is over. Evening cook check and reclean before leaving if needed. During a second tour of the kitchen on 1/9/25 at 10:04 a.m., the following items were not clean the kitchen. The kitchen floors had food debris, black colored debris, grease under all areas in the kitchen. The preparation tables, shelves and drawers had food debris and crumbs; the stove had dried food debris and accumulated grease on the front, sides and back; the grill and grill area had food debris and accumulated grime and yellow colored grease on the front and sides of the table to include the wheels of the grill table; the ovens had black food debris built up inside and the outside of the ovens had food debris on the doors and sides; there was yellow grease build up on the sides and front of the deep fat fryer; the refrigerators had food debris inside to include beverages that had not been cleaned up, the handles had food debris stuck to them and in the crevices, the bottoms of the outside of the refrigerators had stains on them; the tilt skillet, and the steamer/convection ovens had black colored food debris inside, the glass doors were yellowish / brownish in color. There was a sign posted on the steamer that read: Top steamer lunch cook clean after lunch is over. Evening cook check and reclean before leaving if needed. Observation of the plate warmer revealed it had dried food substances inside and outside to include crevices. During an observation and interview on 1/9/25 at 11:04 a.m., Chef #3 stated that all staff cleaned the kitchen. He/She pointed out a white board on the wall with the dates 12/28 and 12/29 that had a list of staff and items to be cleaned. Chef #3 stated that he/she had been out, and the whiteboard had not been updated. He/she stated that he/she and the Executive Chef were responsible for ensuring the kitchen was cleaned. He/she stated they were also responsible for monitoring to ensure that the tasks were completed. Chef #3 stated it was important to clean the kitchen to prevent illness to the residents and keep rodents and bugs out. During an observation and interview on 1/9/25 at 12:08 p.m., the Director of Dining Services (DDS) agreed the aforementioned items were not clean. He/she said, Just needs to be cleaned. The DDS stated it was important to clean the kitchen to prevent cross contamination, not get people sick, keep bugs out, and not get dirt in the food. He/she also stated he/she had not been in the kitchen as often as he/she should have been.

Based on interviews and record review, the facility failed to maintain a Quality Assessment and Performance Improvement (QAPI) Committee with the participation of the Medical Director and Infection Control Preventionist (or designee) for three (3) out of six (6) quarterly meetings. Findings include: Review of the facility's Quality Assurance and Performance Improvement policy, dated 3/15/24, noted, Policy Interpretation and Implementation . 5 . The following individuals serve on the committee: Administrator, or designee who is in a leadership role; Director of Nursing Services; Medical Director; Infection Preventionist . Review of QAPI committee meeting attendance sheets revealed all required committee members signed the attendance sheets for meetings held on 9/21/23, 3/21/24, and 6/20/24. On 12/21/23, the signature of the Medical Director was not present on the sign-in sheet for this quarterly meeting. On 9/19/24, the signature of the Infection Control Preventionist was not present on the sign-in sheet for this quarterly meeting. On 12/19/24, the signatures for both the Medical Director and the Infection Control Preventionist were not present for this quarterly meeting. In an interview on 1/10/25 at 10:16 a.m., the Assistant Director of Nursing (ADON) verified the sign-in sheets and identified the roles of the committee members. It was revealed that neither the Medical Director nor a designee participated in the 12/21/23, and 12/19/24 meetings and the Infection Control Preventionist did not participate in the 9/19/24 and 12/19/24 meetings. The ADON stated that he/she was new to the role of coordinating the QAPI Committee Meetings and he/she was not aware of required attendance of members.

Based on observations, interviews, and review of the facility's cleaning checklist, the facility failed to maintain the physical environment in a safe, clean, comfortable and homelike manner on 200 Hall for two (2) residents who resided on this hall (Resident #48 and Resident #53), and failed to maintain in a safe, clean manner a lounge area and ice machine shared by residents from both 100 and 200 Halls. The combined census on the 100 and 200 Halls on 1/7/25, the first day of the survey, was 45. Findings include: During the initial tour of 200 Hall on 1/7/25, beginning at 12:55 p.m., observation found the carpeting on the hall was not clean, with small pieces of paper trash, small fragments of gauze, and debris noted throughout the length of the hallway from one (1) end of the residential corridor to the other. The carpeting on this hall was found to be in the same state when observed throughout the rest of the afternoon on 1/7/25 and throughout the day on 1/8/25. An observation was made of Resident #48's semi-private room in the presence of a visiting family member at 1:01 p.m. on 1/7/25. At the time of the observation, Resident #48 was sitting upright in a specialty chair at bedside facing the TV as the visitor sat on the edge of Resident #48's bed. When asked if he/she had any concerns regarding care and/or services, Resident #48 shook his/her head no. When asked if the visitor had any concerns, the visitor pointed to trash on the floor (including cotton balls), expressed concern about the cleanliness of the room, and stated he/she would usually just pick up the trash himself. Further observation found trash under the center of Resident #48's bed and several pillows under the head of Resident #48's bed by the wall. An observation was also made of the other half of Resident #48's semi-private room, which was occupied by Resident #53, who was out of the room at the time of this observation. This observation found trash on the floor in front of the foot of Resident #53's bed, as well as a cushion (labeled with Resident #53's name) on the floor under a wooden armchair positioned next to the sink and across from the foot of Resident #53's bed. At 10:36 a.m. on 1/8/25, a repeat observation was made of the room shared by Resident #48 and Resident #53. This observation found the floor on Resident #53's side of the room was not clean, with trash, equipment (including the seat cushion labeled with Resident #53's name), and debris on floor under the sink and furniture. Trash was also observed on the floor at the foot of Resident #48's bed (including cotton balls) and pillows and paper trash under Resident #48's bed. Beginning at 9:15 a.m. on 1/10/25, a tour was conducted of the shared lounge located across from the nursing station and at the juncture of 100 Hall and 200 Hall. This tour was conducted in the company of the Assistant Director of Nursing (ADON). When asked what this space was called, the ADON stated he/she always referred to as the common area. The common area was divided into a living room area (with a TV, tables, and chairs on vinyl plank flooring) and a sunroom area (with potted plants, floor-to-ceiling window panels, [NAME] tile flooring, and a door to an outside courtyard). During this tour, the following concerns were noted: - A disposable exam glove was under rear wheel of the medication cart parked by the piano; in the living room area; - Accumulations of dirt were seen in the corners of walls and behind the potted plants in the sunroom area; - Heavy accumulations of dust were found along the top surfaces of wooden chair rail molding along the walls of the perimeter of the common area; the dust was easily removed with rubbing by a finger; - The wooden baseboards around the perimeter of the common area, including in the sunroom area, had heavy accumulations of dust; the dust was easily removed with rubbing by a finger; - The [NAME] tile flooring in the sunroom area was generally clean, except within about two (2) inches of the wooden baseboard, where the tile was noticeably discolored; - Multiple cobwebs were noted in the corners of the frames of the floor-to-ceiling windows in the sunroom area, in the corners of the walls and floors, and stringing from a wall-mounted light sconce to the frame and the automatic closing device on the adjacent door leading into a courtyard, which was marked with signage stating: NO PUBLIC USE and THIS IS NOT AN EXIT; - Dust build-up was on the bottom rungs of all the chairs placed around two (2) tables in the common area, which was easily removed with rubbing by a finger; - Pieces of paper trash was found on the open floor, as was a bottle cap under an end table in the living room area; and - The doorknob to a door labeled HOSPICE SUPPLIES ONLY was loose from the door and missing one (1) of two (2) screws intended to secure the doorknob to the door. The above findings were verified by the ADON at the time of the observations, after which the observations were halted to allow the ADON to invite supervisors for the Housekeeping and Facilities (Maintenance) departments to join the tour. A tour of the 200 Hall began at approximately 9:35 a.m. on 1/10/25, in the company of the ADON, the Facilities Director (who was supervisory over Housekeeping and Facilities), the Facilities Supervisor, and Housekeeping Supervisor #5, with the following concerns noted: - The left-hand leaf of the double doors going from the Health Care Center to the Administrative Offices, which had been held open by a magnetic holder, was closed, and the surveyor pointed to heavy accumulations of dark-colored dust, debris and webbing in the corner of the floor behind the door as well as on all three (3) door hinges. - The ice machine located across from the nursing station was noted to be dripping water into the collection tray. On the front of the ice machine and on the collection tray were heavy accumulations of a white substance consistent in appearance with lime build-up, which was easily removed by scrapping with a fingernail. The vent on the left side of the ice machine was coated with an accumulation of dust. The polyvinyl chloride (PVC) piping leading from the left side of the machine to an air-gapped drain in the wall beside the machine was coated with a heavy accumulation of dust. The floor under the machine was not clean. When interviewed at the time of the observation, the Facilities Director confirmed it was the responsibility of Facilities staff to maintain the cleanliness of the ice machines. - As the group traveled down the 200 Hall from the nursing station, accumulations of dust and debris were observed along the top edge of the wooden baseboards, the top edge of the backboard to the wooden handrails, and inside the wells of the handrails lining both sides of the hall. - The surveyor commented to the accompanying staff that the carpets looked clean today, but they were visibly soiled with pieces of trash and debris on Days 1 and 2 of the survey. The Housekeeping Supervisor confirmed the expectation that the carpets in the hallways were to be vacuumed daily. At 9:39 a.m. on 1/10/25, the surveyor released the left-hand leaf of the double doors between rooms [ROOM NUMBERS] to examine the carpeting behind the previously closed door. On the carpeting were multiple pieces of debris which were yellow-orange in color with an appearance consistent with food particles. - Examination of a resident room whose occupant was not present (room [ROOM NUMBER]) found the open floor of the room to be generally clean, but the floor between the wall and the wardrobe near the window was found to have debris and a large particle of food (possibly a cookie) visible just inside the opening to that space. Examination of the vent to the packaged terminal air conditioner (PTAC) unit found an accumulation of debris inside the unit. The bottom rung of a wooden armchair (identical to the chairs seen in the common area) was found to have a heavy accumulation of dust easily removed with rubbing by a finger. - A framed picture in the hallway outside of room [ROOM NUMBER] was tested for cleanliness, by running a finger across the top of the frame. This resulted in finding a heavy accumulation of dust. - Debris, including a piece of medical tape with writing on it, was noted within the well of the handrail outside of room [ROOM NUMBER]. - The left-leaf of the double doors across from a door labeled HOUSEKEEPING CENTRAL STORAGE was released from the magnetic hold-open device. Examination of the carpeted flooring behind where the door had been held open against the wall found the carcass of a large, winged insect on the floor, as well as a heavy accumulation of debris in the corner behind the door. All the above findings were verified by all staff members accompanying the surveyor at the time of the observations. At 9:51 a.m. on 1/10/25, the surveyor asked the Facilities Director and Housekeeping Supervisor #5 about expectations for cleaning residents' rooms. They reported that at a minimum, on a DAILY basis, the residents' rooms were to be dusted, sinks cleaned, and floor swept and mopped (including under beds, sinks, and easily movable furniture, such as an armchair). When asked about routine cleaning of the hallways, they reported that the carpeting in the hallways was to be vacuumed daily and the handrails dusted/wiped down daily, including inside the wells of the handrails. At approximately 9:55 a.m. on 1/10/25, the surveyor knocked on the door to Resident #48's room and obtained permission from his/her to enter and examine his/her room in the company of the same facility staff. Upon entering the room, the surveyor noted the open floor of the room had been swept and mopped, but on the floor under the head of Resident #48's bed were three (3) bed pillows. Under the wooden armchair beside the sink across from the foot of Resident #53's bed was the seat cushion labeled with Resident #53's name. The surveyor reported to the facility staff having observed pillows under Resident #48's bed on Day 1 and Day 2 for the survey, as well as trash on the floor around Resident #48's bed, including paper trash and cotton balls. Upon exiting Resident #48's room, the ADON reported the cotton balls were likely used to obtain the resident's capillary blood glucose levels, and the ADON re-entered the room to remove the pillows from the floor. At approximately 10:00 a.m. on 1/10/25, the surveyor asked the Facilities Director and Housekeeping Supervisor #5 for the facility's policies and procedures for cleaning the resident rooms and common areas, as well as any cleaning schedules, cleaning checklists that had been completed during the current week, and the schedule as worked for the Housekeeping Department for the week of the survey (1/7/25 through 1/10/25). The Facilities Director stated he/she was not sure whether such policies and procedures existed, but they did have a sheet on each housekeeper's cart that provided direction to staff on what was to be cleaned and how often. At 10:24 a.m. on 1/10/25, the Facilities Director presented a two-page document titled Health Center and stated, These tasks are to be done daily. No policies or procedures, completed cleaning checklists, or a copy of the Housekeeping Department's schedule as worked for the current week were provided. Review of the document titled Health Centered contained the following (quoted verbatim): Clean and disinfect all high touch surfaces to include door knobs, key pads hand rails, faucets, crash carts etc. 100 Hall __ Clean Nurses Stations Daily (Sweep, Mop, Trash & Clean Counters) __ Clean Med-Room Daily (Sweep, Mop, Clean Counters & Sink) __ Clean Both Offices Daily (Sweep, Mop, Trash & Clean Counters) __ Clean Soil Utility Room Daily (Sweep & Mop & Clean Sink) __ Clean Linen Room Daily (Sweep & Mop) NOTHING ON TOP SHELVES! __ Clean Supply Room (Sweep & Mop) Daily 200 Hall __ Clean Beauty Shop Daily (Sweep, Mop, Trash, Clean All Counters, Bathroom, & Mirrors) __ Clean Soil Utility Room Daily (Sweep, Mop & Clean Sink) __ Clean Ice Maker 2X [twice] A Daily __ Clean Linen Room Daily (Sweep & Mop) NOTHING ON TOP SHELVES! __ Clean HCC [Health Care Center] Lounge Daily (Sweep, Trash, Wipe Down Tables & Chairs, MOP 3X [three times] A Week) __ Clean Restorative Therapy 2X A Week (Vacuum, Wipe Down Table, Trash) __ Clean Chaplains Office 1X A Week (Vacuum, Wipe Down Tables, Trash, Dust) __ Deliver Morning & Afternoon Personals (11AM & 2PM) Clean and disinfect all high touch surfaces to include door knobs, key pads hand rails, faucets, crash carts etc. Monday - Clean handrails on beds, overhead lights & glove boxes Tuesday - Pull out nightstands and beds, sweep & mop behind them. Wednesday - Dust all furniture and sprinkler heads and vents. Thursday - Clean blinds & window sills Friday - Clean janitor cart & closet. Clean floor sink, sweep & mop. When interviewed again at 3:20 p.m. on 1/10/25, the Facilities Director confirmed there were no policies or procedures for cleaning the resident rooms or common areas and that a copy of the checklist identified above was kept on each housekeeping cart as a reference tool only. The Facilities Director confirmed that the checklist was not actually filled out by housekeeping staff each day, turned in, or retained. When asked how the facility verified that the tasks identified on the checklist were being completed at the frequencies specified, the Facilities Director stated it was the responsibility of the Housekeeping Supervisor to do spot checks daily. According to the Facilities Director, [He/She, referring to Housekeeping Supervisor #5] is supposed to 'spot check' at least one (1) room on every hall every day. The Facilities Director acknowledged that additional monitoring was indicated in view of the findings made during a tour of 200 Hall and the lounge or common area shared by the residents on 100 Hall and 200 Hall.

Based on observation, interview and record review, the facility staff failed to ensure an environment free from accident hazards. Staff failed to secure the contents of an unattended treatment cart stored in a lounge used by residents on the 100 and 200 Halls. The cart contained medicated creams, ointments, and topical sprays, as well as bandage scissors. The unlocked treatment cart presented a potential hazard to all residents residing on 100 and 200 Halls. Findings include: Review of the facility policy titled Security of Medication Cart, revised April 2007, noted: Policy Interpretation and Implementation . 4. Medication carts must be securely locked at all times when out of the nurse's view. On 1/7/25 at 12:41 p.m., the surveyor observed an unlocked treatment cart in which were stored band aids, bandages, gauze, gauze tape, lidocaine pain spray, medicated ointments and creams, and bandage scissors. The cart was stored in an open lounge area, and multiple residents were observed to be within six (6) feet of the treatment cart. In an interview on 1/7/25 at 12:42 p.m., Registered Nurse (RN) Charge Nurse #4 stated he/she accidentally left the cart unlocked after being called away to assist someone. RN Charge Nurse #4 stated he/she should have secured the cart by locking it before leaving it unattended.

Based on interviews and record review, the facility failed to ensure a resident, who was not determined by a physician to lack the ability to make informed healthcare decisions, was provided with opportunities to make decisions in their best interest for the Care Plan process. This was evidenced by one (1) of three (3) residents sampled for participation in the Care Plan process (Resident #64). Findings include: Review of the facility's Advance Directives policy with a revision date of December 2016 revealed: Policy Statement - Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation . 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 4. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information. Review of Resident #64's Durable Power of Attorney (DPOA) for Health Care Decisions document revealed, I appoint the person named below to be my agent to make health care decisions for me when and only when I cannot make decisions or communicate what I want done. Review of Resident #64's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated moderate cognitive impairment. In an interview on 1/10/25 at 4:25 p.m., Social Worker #1 stated that Resident #64 was determined by his/her physician to lack the capacity to make informed healthcare decisions. Social Worker #1 stated that they did not document a decline in the resident's decision-making capacity, nor could they provide the physician's documentation about such a change. In an interview on 1/10/25 at 4:30 p.m., Social Worker #2 stated that Resident #64 had a Durable Power of Attorney (DPOA) representative who was notified of healthcare concerns and asked to acknowledge changes in care and services. The surveyor asked Social Worker #2 why Resident #64 was not asked to participate in planning his/her care and to acknowledge changes in his/her care and services. Social Worker #2 stated that the resident was not able to participate in the planning of his/her care at the time, due to his/her cognitive status. Social Worker #2 stated that the decision-making authority of the DPOA representative was placed into effect upon the date of the resident's signature on the DPOA document and not after the resident's physician determined that he/she was no longer able to make informed healthcare decisions.

Based on interviews and record review, the facility failed to ensure the Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage were acknowledged by the resident. This was evidenced for one (1) of three (3) residents sampled for Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Resident #64). Findings include: Review of Resident #64's Durable Power of Attorney (DPOA) for Health Care Decisions documents revealed, I appoint the person named below to be my agent to make health care decisions for me when and only when I cannot make decisions or communicate what I want done. Review of Resident #64's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated moderate cognitive impairment. In an interview on 1/10/25 at 4:25 p.m., Social Worker #1 stated that Resident #64 was not notified of the determination of non-coverage, because the resident was determined by his/her physician to lack capacity to make informed healthcare decisions. Social Worker #1 stated they did not document that a decline had occurred in the resident's cognitive status, nor could they provide documentation that Resident #64's physician determined the resident was no longer able to make his/her own informed healthcare decisions - to include acknowledging the receipt of the Beneficiary Notice of Non-Coverage. In an interview on 1/10/25 at 4:30 p.m., Social Worker #2 stated that Resident #64 had a Durable Power of Attorney (DPOA) representative who was making healthcare decisions on behalf of the resident. The surveyor asked Social Worker #2 why Resident #64 was not asked to participate in his/her own healthcare decision-making - to include being informed of and acknowledging receipt of the Beneficiary Notice of Non-Coverage. Social Worker #2 stated that Resident #64 was not able to do so at the time due to his/her cognitive condition. Social Worker #2 stated that the decision-making authority of the DPOA representative was placed into effect upon the date of the resident's signature on the DPOA document and not after the resident's physician determined that he/she was no longer able to make informed healthcare decisions.

Based on interviews and record review, the facility failed to develop a Comprehensive Care Plan after a significant change in the status/condition of a resident. This was evidenced by Resident #10 having had an unwitnessed fall with major injury resulting in a right hip replacement and pubic bone fracture on 7/24/24. The Care Plan was not revised within seven (7) days to ensure timeliness of a person-centered comprehensive assessment to address the resident's needs for one (1) of one (1) resident sampled for Comprehensive Care Plan timeliness (Resident #10). Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of March 2022, noted: Policy Interpretation and Implementation . 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set] assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. Review of Resident #10's face sheet documented an admitted [DATE]. Medical diagnoses included Senile Degeneration of Brain, Major Depressive Disorder, Hypertension, Dementia and Type II Diabetes. Review of Resident #10's significant change status/condition Care Plan dated 8/19/24 documented the resident had sustained a pubic bone fracture on 7/24/24. An interview with the Assistant Director of Nursing (ADON), on 1/10/25 at 10:16 a.m., revealed Resident #10's Care Plan was not updated within the seven (7) day timeframe. The ADON stated the Care Plan, which reflected the fall on 7/24/24, was updated on 8/19/24.

Based on interview and record review, the facility failed to notify the resident's responsible party to obtain consent prior to starting a new medication for one sampled resident (Resident #2) out of three sampled residents. The facility census was 88 residents. The Director of Nurses (DON) and the Administrator were notified on 7/9/24 of Past Non-Compliance which occurred on 5/10/24. All nursing staff were in-serviced on notification of responsible parties on 6/21/24. The deficiency was corrected on 6/21/24. Review of the facility's policy titled Charting and Documentation dated July 2017 showed: -Any changes in the resident's condition shall be documented in the resident's medical record. -Documentation should include notification of the family. 1. Review of Resident #2's undated admission record showed the resident had a Durable Power of Attorney (DPOA) and had a diagnosis of dementia (a progressive mental disorder characterized by memory problems, impaired reasoning, and personality changes). Review of the resident's care plan dated 2/10/23 showed: -The resident had dementia. -Special instructions the resident's DPOA wanted to be contacted for any medication changes. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/3/24 showed the following staff assessment of the resident: -Severely cognitively impaired. -Had a diagnosis of dementia. Review of the resident's psychiatry/medication progress note dated 5/7/24 showed: -The visit was for follow-up on the resident's behaviors. -The resident had a diagnosis of dementia. -New orders included: --Add Memantine (cognition-enhancing medication used to treat dementia by decreasing abnormal activity in the brain, which can slow down the decline of one's thinking, memory and reasoning) 5 milligrams (mg) every morning for one week, then increase to 5 mg twice a day, then increase to 10 mg every morning and 5 mg at bedtime and then 10 mg twice a day for behaviors related to dementia. Review of the resident's psychiatry/medication progress note dated 5/15/24 showed: -The visit was for follow-up on the resident's behaviors. -New orders included: --Increase Memantine to 5 mg twice a day the next week and weekly thereafter. --Increase Memantine to 10 mg every morning, 5 mg at bedtime and then 10 mg twice a day for behaviors related to dementia. Review of the resident's Medication Administration Record (MAR) dated May 2024 showed the resident received: -Memantine 5 mg at bedtime for dementia 5/10/24-5/15/24. -Memantine 5 mg at bedtime for dementia 5/30/24-5/31/24. -Memantine 5 mg twice a day for dementia 5/16/24-5/29/24. -Memantine 5 mg in the morning for dementia on 5/30/24. -Memantine 10 mg in the morning for dementia on 5/31/24. Review of the resident's MAR dated June 2024 showed the resident received: -Memantine 10 mg in the morning for dementia 6/1/24-6/17/24. -Memantine 5 mg at bedtime for dementia 6/1/24-6/16/24. Review of the resident's communicate note dated 6/17/24 showed: -The resident's DPOA was notified of a new order for Memantine and one other medication. -The resident's DPOA did not approve of the recommended medications. Review of the resident's communication note dated 6/21/24, documented by the DON showed: -A conference call was held with the resident's DPOA. -They discussed the DPOA's grievance filed regarding not being notified when medication changes were made. Review of the facility's in-service education form dated 6/21/24 showed the facility's nurses were educated on notifying families of changes. During an interview on 7/9/24 at 11:19 A.M., Licensed Practical Nurse A said: -The charge nurse should have notified the resident's DPOA when a new physician's order was given for a new medication. -The resident's DPOA usually declined any recommendations for new medications. During an interview on 7/9/24 at 11:50 P.M., the Administrator said (with the DON present): -The resident's DPOA notified him/her that the resident was prescribed and administered a medication without notifying him/her. -The charge nurses were in-serviced on 6/21/24 of their responsibility for notifying DPOAs of recommended medication changes. During an interview on 7/9/24 at 12:23 P.M., the DON said: -The psychiatrists did not enter their orders into the electronic health record but gave verbal orders to the charge nurses. -The charge nurse at the time of the verbal order was responsible for contacting the resident's DPOA. -The ADON in-serviced all the charge nurses on 6/21/24 that they should contact the DPOA regarding any medication changes. -They also developed a form to obtain consent for an evaluation by the psychiatry group and to receive treatment recommendations. During an interview on 7/9/24 at 2:00 P.M., the resident's DPOA said: -The facility did not notify him/her prior to administering Memantine, which was a new medication for the resident. -He/She found out about the new medication when he/she received the resident's pharmacy bill on 6/17/24. -He/She informed facility staff at that time that he/she had not approved the administration of Memantine and wanted it discontinued. MO00237772

Based on observation, interview, and record review the facility failed to protect one sampled resident (Resident #3) out of 10 sampled residents from intimidation and physical abuse. On 1/25/24 at about 10:00 A.M., Licensed Practical Nurse (LPN) A, Certified Nurses Aide (CNA) A, CNA B, and CNA C forcibly made the resident shower. The resident said no and struck out at staff. The resident reported having a fear of water and doesn't like water on his/her face. The resident was visibly tearful and upset while recounting the event. The resident had a thumb size dark purple bruise with a green ring around it on the back of his/her right upper arm, thumb size dark purple bruise on the left lower arm below the elbow, and finger size dark purple bruise on the right upper outer arm. The facility had 87 residents. On 2/5/24 at 2:35 P.M., the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 1/25/24. On 1/30/24, facility administration was notified of the incident, an investigation immediately began, and corrective actions were implemented. The IJ was corrected by the facility, prior to DHSS' investigation beginning on 1/31/24. Review of the facility Abuse policy, dated April 2021, showed the resident has the right to be free from abuse, including physical abuse and physical restraint. Review of the facility policy Requesting, Refusing and/or Discontinuing Care or Treatment revised 2/2021 showed: -Residents had the right to refuse nursing care provided to maintain or restore health and wellbeing, improve functional level, or relieve symptoms. -Residents were informed of his or her right to refuse treatment. -The resident would not be forced to accept any care. -The resident could refuse care. -If a resident refused care an appropriate member of the interdisciplinary team (IDT) would meet with the resident to: --Determine why he or she was refusing care. --Try to address his of her concerns and discussed alternative options; --Discuss the potential outcomes or consequences of the decision. -During the meeting, the IDT team member would reiterate the right to refuse care at any time. -The resident would not, under any circumstances, be coerced, intimidated, manipulated, or threatened for refusing care. -The IDT would have assessed the resident's needs and offered the resident alternative treatments. -If the decision to refuse or discontinue treatment resulted in a significant change of condition, a reassessment would have occurred, and appropriate changes would be made to the resident's care plan. -Detailed information related to the refusal were documented in the resident's medical record. -Documentation pertaining to resident's requested refusal included at least the following: --The date and time the care was attempted. --The type of care. --The resident's response and stated reason(s) for refusal. --The name of the person who attempted to administer the care. -That the resident was informed of the purpose of the treatment and potential outcome of not receiving the treatment. -The resident's condition and any adverse effects due to the request. -The date and time the practitioner was notified as well as practitioner's response. -All other pertinent observations. -The signature and title of the person that recorded the data. Review of Resident #3's Admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Morbid (severe) obesity; -Unspecified Osteoarthritis (a degenerative disease of the bones and joints); -Low back pain; -Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety); and -Need for assistance with personal cares. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 11/3/23, showed: -The resident was cognitively intact. -The resident had not exhibited any refusal of cares during the look-back period. -The resident had no behaviors documented during the look-back period. -The resident needed partial/moderate assistance, staff person does less than half the effort for bathing. -The resident needed partial/moderate assistance, staff person does less than half the effort for transfers. Review of the resident's care plan, dated 11/13/23, showed: Focus: The resident was resistive to cares and made false allegations at times Interventions: -Encourage as much participation/interaction by the resident as possible during care activities. -Give clear explanation of all care activities, prior to and as the activities occur, during each contact. -If possible, negotiate a time for activities of daily living (ADLs) so the resident participates in the decision-making process. Return at the agreed upon time. -If the resident resisted with the ADLs, reassure resident, leave, and return five to 10 minutes later and try again. -Praise the resident when behavior is appropriate. -Provide resident with opportunities for choice during care provision. -Resident rights and dignity will be respected during and care options. Focus: The resident has an ADL self-care performance deficit related to musculoskeletal impairment, pain low back. Interventions: -The resident preferred to wash him/herself up in the sink in his/her room and will most often refuse a shower or bath. -Bathing/showering the resident required assistance by (2) staff with showering twice a week and as necessary Review of facility form Skin Monitoring: Comprehensive Certified Nurses Aide (CNA) Shower Review, dated 1/25/24, showed the resident received a shower with no skin issues reported. Review of facility form Skin Monitoring: Comprehensive Certified Nurses Aide (CNA) Shower Review, dated 1/30/24, showed the resident had a bruise on the left lower arm below the elbow. Review of the resident's Progress notes, dated 1/30/24 at 5:59 P.M., showed the Director of Nursing (DON) spoke to Nurse Practitioner (NP) B regarding the resident's claim of staff showering the resident after he/she refused his/her shower on 1/25/24. Nurse Practitioner (NP) B ordered a psychiatric evaluation to be completed. NP B would be in on 1/31/24 to see the resident. Family, Administrator, and DON aware and family and resident spoke to Administrator, DON, Social Worker around 4:00 P.M. on 1/30/24. Review of the facility investigation that was started on 1/30/24 showed the resident stated to nursing administration during a family meeting on 1/30/24 that he/she was given a shower after telling the staff he/she did not want to take a shower on 1/25/24. During interview and observation on 2/2/24 at 9:05 A.M., the resident said: -On 1/25/24 about 10:00 A.M., he/she was given a shower by four staff after he/she refused the shower. -Licensed Practical Nurse (LPN) A came and got the resident from the activity room telling the resident that he/she needed to go somewhere. -Once he/she turned down the hall headed to the shower room he/she told the LPN he/she did not want a shower. -The LPN said the resident was getting a shower. -When the LPN propelled the resident's wheelchair into the shower room three other staff were waiting. -He/She told the staff again no. -The staff started to disrobe the resident. -Staff got hold of his/her arm and forced him/her up. -He/she tried to fight the staff then gave up. -He/She had a fear of water from never learning to swim and doesn't like water on his/her face. -The resident was visibly tearful and upset while recounting the event. -The resident had a thumb size dark purple bruise, with a green ring around it, on the back of his/her right upper arm. A thumb size dark purple bruise on the left lower arm below the elbow and a finger size dark purple bruise on the right upper outer arm. -He/She was not afraid to be in the facility and had a family meeting scheduled for 1/30/24 that was why he/she waited to report the incident. -The meeting was with the Social Worker and the resident wanted to wait to tell him/her at the appointed time and date. During a phone interview on 2/2/24 at 11:07 A.M., LPN A said: -He/She was asked to give the resident a shower on 1/25/24, because the resident had not had a shower in over a month. -The charge nurse asked his/her help in getting the resident showered. -He/She made the decision to the get the shower done. -He/She took the resident out of the activity room in his/her wheelchair and took the resident to the shower room. -The resident raised his/her voice and screamed at the staff. -The resident said no and said he/she bathed him/herself. -He/She explained to the resident the need for a shower and the need to have skin assessed. -The resident hit LPN A. -Then the resident calmed down and stood up. -Staff touched the resident's arms and used the resident's arms to lift the resident up. -The resident needed assistance with standing. -The LPN helped the resident by grabbing the waist band of the resident's pants. -He/She was not trying to abuse the resident just wanted to get him/her clean. -He/She was unsure what the resident's care plan said about showers since he/she usually did not work that hall. During a phone interview on 2/2/24 at 11:20 A.M., CNA A said: -It was the resident's shower day (1/25/24) and when he/she asked the resident to shower, the resident said no. -He/She told LPN A and was told to go to the shower room. -LPN A went and got the resident and wheeled the resident to the shower room. -The resident was not upset or tearful when he/she entered the shower room with LPN A. -The resident said he/she was not going to shower. -He/She stood in front of the resident. -LPN A and CNA C stood the resident up. -The resident was fighting the staff. -The resident hit the CNA in the face. -The resident then seemed to comply and calmed down. -The resident used his/her legs to stand up with the staff standing him/her with arms around the resident's arms. -The resident was showered and assisted in getting dressed. -No staff held the resident down and scrubbed the resident. -While the resident was being showered, he/she did not fight the staff and seemed to go along with it. -When you ask the resident to shower the resident would usually start crying. --He/She was unsure what the care plan said about the resident refusing to shower and what interventions should have been tried. -All the staff came to the shower room to get the shower done. -He/She had never seen a a care plan on a resident. During a phone interview on 2/2/24 at 11:32 A.M., CNA B said: -LPN A asked him/her to help give the resident a shower. -He/She went to the shower room. -LPN A brought the resident to the shower room in his/her wheelchair. -He/She was standing behind the wheelchair holding the wheelchair since the resident kept unlocking the brakes. -The resident was hitting the staff and saying no. -LPN A and CNA C helped the resident stand up by holding the resident's arms (arms looped around the resident's arms and under the resident's arms) to prevent the resident from falling. -The resident was one assist for all cares. -The resident was known to refuse cares. -He/She would educate the resident on the importance of showers. -He/She would usually come back and try multiple times on shower days. -LPN A said the shower had to be done and given that day. During an interview on 2/2/24 at 1:32 P.M., Registered Nurse (RN) A said: -He/She asked LPN A to shower the resident. -It was the resident's shower day. -He/She did not tell LPN A to shower the resident even if the resident refused. During an interview on 2/2/24 at 1:45 P.M., CNA G said: -The resident had a history of refusing showers and preferred to bathe at his/her sink; -He/She was unsure what the residents care plan said about showers; -If a resident said no- you should reeducate the resident and try to come up with a way to get the care taken care of- but not to force; and -If a resident still refused you would inform the Charge Nurse. During an interview on 2/2/24 at 2:12 P.M., CNA H said: -When a resident refused baths, you document it and tell the Charge Nurse. -He/She would not force a resident to do anything, that would be wrong. During an interview on 2/5/24 at 12:11 P.M., LPN B said: -He/she completed the resident skin assessment after the resident reported on 1/30/24 the facility staff had forced him/her to shower. -When he/she did the skin assessment on the resident, he/she could not see the resident's upper arms, because the resident refused. -When he/she tried to assess the resident's skin the resident said he/she was fine and to leave him/her alone. The resident was educated on why the skin assessment needed to be done and the resident agreed. -He/She respected the resident wishes and did not force the resident to complete a skin assessment. -This was why he/she did not find the bruises the surveyor did. -The resident should not have been forced to have a shower when the resident said no. During an interview on 2/6/24 at 12:00 P.M., the Administrator and DON said: -No staff reported that a resident refused a shower and staff went ahead and showered the resident. -This was not appropriate. -This was abuse. -The facility found out about this incident on 1/30/24 during the family meeting. During an interview on 2/2/24 at 10:34 A.M., NP A said: -It was his/her expectation that a if a resident refused a shower, it would not be given. -It was his/her expectation that a resident would not be forced to take a shower. -Forcing a resident to take a shower/bath against his/her consent would be abuse. MO0231226

Based on interview and record review, the facility failed to provide safe transfer assistance for one sampled resident (Resident #3). On 1/25/24 the resident was transferred by four staff from his/her wheelchair to a shower chair without the use of a gait belt, while the resident physically resisted. Staff grabbed the resident by his/her arms and lifted him/her up from the wheelchair, resulting in bruising on the back of his/her right upper arm, left lower arm below the elbow, and on the right upper outer arm. The facility census was 87 residents. Review of facility policy Safe Lifting and Movement of Residents, revised 7/2017, showed: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility used appropriate techniques and devices to lift and move residents. -Residents safety would be incorporated into goals and decisions regarding the safe lifting and moving of residents. -Nursing staff, in conjunction with the rehabilitation staff, would have assessed the individual residents' needs for transfer assistance. -Staff documented the residents transferring and lifting needs in the care plan. -Staff responsible for direct resident care would be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. A policy on gait/transfer belts was requested from the facility and not provided. 1. Review of Resident #3's Admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Morbid (severe) obesity; -Unspecified Osteoarthritis (a degenerative disease of the bones and joints); -Low back pain; and. -Need for assistance with personal cares. Review of the resident's care plan, revised 5/12/22, showed: -The resident required assistance by two staff to move between surfaces and necessary. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 11/3/23, showed: -The resident was cognitively intact. -The resident had not exhibited any refusal of cares during the look-back period. -The resident needed partial/moderate assistance, staff person does less than half the effort for transfers. During interview and observation on 2/2/24 at 9:05 A.M., the resident said: -On 1/25/24 about 10:00 A.M., he/she was given a shower by four staff after he/she refused the shower; -He/she tried to fight the staff then gave up; -The staff did not use a gait belt. -The staff grabbed him/her by his/her arms and lifted him/her up from the wheelchair. -The resident had a thumb size dark purple bruise with a green ring around it on the back of his/her right upper arm. A thumb size dark purple bruise on the left lower arm below the elbow and a finger size dark purple bruise on the right upper outer arm. During a phone interview on 2/2/24 at 11:07 A.M., Licensed Practical Nurse (LPN) A said: -He/She was asked to give the resident a shower on 1/25/24, because the resident had not had a shower in over a month. -He/She took the resident to the shower room. -The resident said no; -The resident hit LPN A; -Staff touched the resident's arms and used the resident's arms to lift the resident up. -The resident needed assistance with standing. -He/She helped the resident by grabbing the waist band of the residents' pants, and did not use a gait belt. -The resident was supposed to be assisted by two staff for transfers. -He/she did not say whether the resident needed a gait belt or not. During a phone interview on 2/2/24 at 11:20 A.M., Certified Nurse Aide (CNA) A said: -It was the resident's shower day (1/25/24). -He/She stood in front of the resident. -LPN A and CNA C stood the resident up without a gait belt. -The resident used his/her legs to stand up with the staff steadying him/her with arms around the resident's arms. -No gait belt was used during the transfer to the shower chair or back to wheelchair. -The resident was to be assisted by two staff for transfers. -He/She has never seen a a care plan on a resident. -He/she did not think the resident needed a gait belt. During a phone interview on 2/2/24 at 11:32 A.M., CNA B said: -LPN A asked him/her to help give the resident a shower. -He/She went to the shower room. -LPN A brought the resident to the shower room in his/her wheelchair. -He/She was standing behind the wheelchair holding the wheelchair. -LPN A and CNA C helped the resident stand up, by holding the resident's arms (arms looped around the residents arms and under the residents arms) to prevent the resident from falling. -The resident was fighting the staff. -The resident hit the CNA in the face. -The resident was an assist of one staff for all cares. -The resident did not have a gait belt on. -He/she did not know if the resident required a gait belt for transfers. During an interview on 2/6/24 at 10:41 A.M., CNA F said gait belts were to be used for all residents anytime a resident was transferred without using a mechanical lift. During an interview on 2/6/24 at 10:46 A.M., Registered Nurse (RN) B said gait belts were to be used for all transfers unless the resident was a mechanical lift. During an interview on 2/6/24 at 10:55 A.M., Certified Occupational Therapist Assistant A said a gait belt was to be used for all transfers. It was the safest way to transfer a resident. During an interview on 2/6/24 at 10:58 A.M., Physical Therapy Assistant A said a gait belt was to be used with all manual transfers. During an interview on 2/6/24 at 11:00 A.M., the Director of Rehab said it was his/her expectation gait belts be used for all transfers when the resident was moved, unless the resident required a mechanical lift. During an interview on 2/6/24 at 11:04 A.M., Certified Medication Technician (CMT) B said gait belts were to be used for all transfers. During an interview on 2/6/24 at 11:06 A.M., CMT A said gait belts were to be used anytime a resident was stable and transferred, and if a resident was unstable a mechanical lift was to be used. During an interview on 2/6/24 at 11:08 P.M., LPN E said anytime a resident is transferred a gait belt should be used. During an interview on 2/6/24 at 11:09 A.M., CNA J said a gait belt would be used for all transfers. During an interview on 2/6/24 at 11:10 A.M., CNA I said a gait belt should be used during all transfers. During an interview on 2/6/24 at 11:11 A.M., CMT C said a gait belt should be used for all transfers. During an interview on 2/6/24 at 12:00 P.M., the Administrator and Director of Nursing said: -It was both their expectation a gait belt would be used unless it was care planned that the resident was self-transfer or the resident used a mechanical lift. -All staff were trained on the use of gait belts.

Based on observation and interview, the facility failed to place the date on the tray of when the turkey breasts and chicken pieces were taken from the freezer for defrosting; to remove encrusted deposits of burnt-on debris from the stove top; to refrigerate items (dessert toppings, steak sauce, grape jelly); to protect several glasses of juice and plates of apple crisp from a dusty fan in the [NAME] Bridge dining room; to maintain the fans the [NAME] Bridge Kitchenette free from a heavy buildup of dust; failed to measure the temperature of non-pasteurized eggs before they were placed on a plate for service; and to remove debris from the nozzles of the spray wand of the automated dishwasher. This practice potentially affected 80 residents who ate food from the kitchen. The facility census was 80 residents. 1. Observation on 6/26/23 at 8:52 A.M., during the initial kitchen observation showed two turkey breasts and a bin of frozen chicken pieces were taken from the freezer and did not have a date that showed when they were taken from the freezer for defrosting. 2. Observation on 6/29/23 from 6:13 A.M. during breakfast meal preparation showed: -The same two packages of turkey breasts which were taken from the freezer with no date, were taken from the freezer for defrosting. -The presence of encrusted deposits on the stove top. -Open containers of dessert topping, steak sauce and beef base, which were not refrigerated even though label stated refrigerate after opening. -The presence of debris in the nozzles of the spray wand of the automated dishwasher. Observation on 6/29/23 at 6:46 A.M. showed: -Open steak sauce and beef base not refrigerated after opening even though label states -A fan with a heavy buildup of dust that was on and blowing towards the steam table in the [NAME] Bridge kitchenette. -A wall mounted fan with a heavy buildup of dust that was on and blowing towards a table with several glasses of juice and water and containers of apple crisps which were not covered in the [NAME] Bridge dining room. -An open container of grape jelly in the [NAME] Bridge kitchenette which was not refrigerated, even though the label stated refrigerate after opening. Observation on 6/29/23 in the main kitchen showed Dietary Cook (DC) B cooked a non-pasteurized egg and failed to check the temperature of the egg before placing it on a plate for service at 8:16 A.M., and again at 8:24 A.M. During interviews on 6/29/23, the following was said: -At 7:43 A.M., Dining Room Server A said he/she did not even notice the fan in the [NAME] Bridge was dusty before he/she was asked about the fan. -At 10:04 A.M., Housekeeper B said he/she started employment at the facility about 1 month ago and in the month he/she had worked at the facility, he/she had not cleaned the fan in the [NAME] Bridge dining room. -At 10:05 A.M., Housekeeper C said it had been about two weeks since he/she cleaned the fan in the [NAME] Bridge dining room. -At 10:06 A.M., the Assistant Director of Dining Services said they have been asking housekeeping to clean the fans because dietary staff get accused of breaking the fans. During interviews about the food service on 6/29/23 from 10:12 A.M. through 10:29 A.M., the Assistant Dining services Director said: -At 10:12 A.M., he/she expected the staff to follow the label recommendations on the containers of condiments. -At 10:20 A.M. he/she understood why the dietary staff needed to place a pull date on the food from the freezer. -At 10:23 A.M., the night shift dietary staff should drain and clean the dishwasher and that cleaning should include removing all the nozzles. -At 10:25 A.M. he/she had been working with the vendors to obtain pasteurized eggs because he/she understood that at times, the temperature of the eggs may not be measured after they were cooked. -At 10:28 A.M., he/she said the stove top grates should be cleaned weekly.

Based on interview and record review, the facility failed to ensure a bed-hold form was completed and sent for three sampled residents who were discharged to the hospital (Resident #3, #7 and #328) out of 19 sampled residents. The facility census was 80 residents. Review of the facility's policy titled Bed-Holds and Returns dated March 2022 showed: -All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). -Residents are provided written information about these policies at least twice: --Well in advance of any transfer (in the admission packet). --At the time of transfer (or, if the transfer was an emergency, within 24 hours). 1. Review of Resident #328's face sheet showed he/she admitted to the facility with the following diagnoses of Diabetes Mellitus Type Two (DMII- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/15/23 showed the resident discharged the facility on 6/15/23 with return-anticipated. Review of the resident's bed-hold form received 6/29/23 showed: -The bed-hold agreement that was signed by the resident was dated 4/4/23. -A copy of the notice of bed-hold policy and rights was dated 6/15/23 but did not include a resident or staff signature. During an interview on 6/30/23 at 8:48 A.M. Licensed Practical Nurse (LPN) D said: -He/she thought Administration was responsible for sending out the bed-hold forms. -He/she had never transferred a resident out of the facility without Administration being present in the building. -He/she would call the supervisor on duty if Administration was not able to send out the bed-hold form at the time of transfer. During an interview on 6/30/23 at 9:13 A.M. LPN E said: -He/she was unsure if a bed-hold form needed to be sent out with the resident during transfer out of the facility. -He/she new the form existed, but was not educated on the process of what needed to be done with the form. -He/she thought that the admissions person would be the person to complete the bed-hold forms. During an interview on 6/30/23 at 10:21 A.M. Registered Nurse (RN) B said: -He/she needed more education on the bed-hold process. -He/she knew there were rules regarding bed-holds that needed to be followed. -He/she would check with the admissions person to see if a bed-hold needed to be sent out with the resident upon transfer out of the facility. During an interview on 6/30/23 at 1:18 P.M. the Director of Nursing (DON) said: -He/she expected the nurses to complete the bed-hold forms and social services was the back-up to ensure completion of the bed-hold forms. -Bed-holds needed to be sent out regardless if social services was in the building. -He/she would expect the nurses to complete a nurses note upon transfer of a resident that included if the bed-hold form was sent with the resident. -He/She was not aware that the bed-hold forms were being completed improperly before survey. 21003 2. Review of Resident #3's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including heart failure, seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain), high blood pressure, falls, pain and low iron level. Review of the resident's Bed Hold Form dated 3/16/22, showed the resident elected to hold his/her bed should he/she be discharged from the facility. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented with minimal cognitive impairment. -Needed limited assistance with bathing, dressing, hygiene, and needed extensive assistance with toileting. Review of the resident's MDS Record showed the resident discharged from the facility, on 4/26/23, to the hospital and re-entered the facility on 4/29/23. Review of the resident's Nursing Notes showed: - On 4/26/23 the resident reported to the nurse that he/she believed he/she was having signs and symptoms of atrial fibrillation (irregular heartbeat) after breakfast. The resident requested to go to the hospital and the nurse notified his/her family and physician. The nurse documented that the resident did not take his/her morning medications prior to leaving. The emergency services staff escorted the resident to the hospital at 9:00 A.M. At 9:08 A.M., the nurse called the hospital emergency room and the hospital nurse reported the resident was being admitted for heart exacerbation and respiratory failure. -On 4/29/23 The resident arrived at the facility at 7:10 P.M., via personal vehicle accompanied by his/her daughter and other family. His/her daughter provided the resident's medication list and staff welcomed the resident back. He/she showed no signs of pain, no skin changes no added concerns. The nurse obtained his/her vital signs. Assessments were in progress, the nurse made the resident's physician aware of the resident's re-admission and management. Review of the resident's Medical Record showed there was no documentation showing the facility staff explained the bed hold procedure or provided the resident with a bed hold form upon his/her discharge to the hospital. There was no documentation showing the bed hold form was provided to the resident's responsible party upon the resident's hospitalization . 3. Review of Resident #7's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including bladder cancer, kidney failure, urinary track infection, high blood pressure, muscle weakness, pain and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Review of the resident's Bed Hold Form dated 1/17/23, showed the resident elected to hold his/her bed should he/she be discharged from the facility. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented with minimal cognitive impairment. -Needed limited assistance with toileting and one person assistance with bathing, but was independent with transfers, mobility, dressing, hygiene, and eating. Review of the resident's MDS Record showed the resident discharged from the facility, on 5/12/23, to the hospital and re-entered the facility on 5/17/23. Review of the resident's Nursing Notes showed: -On 5/12/23 the resident's family stated the edema (fluid in the tissues) had been going on for too long and requested that the resident be sent to the hospital. The nurse left notification for the physician and the resident left to go to the hospital. -On 5/13/23 the emergency room nurse called and reported this resident was admitted to the hospital for a blood clot, and the final report was pending. They administered medication to treat it and the resident's family was at his/her bedside. -On 5/18/23 the resident was readmitted to the facility on the day shift. The resident denied pain, and his/her vital signs were within normal limits. The resident has been resting with his/her eyes closed, call light within reach as well as personal items on bedside table. Continue to monitor during the rest of this shift. -There was no documentation showing the nurse notified the resident or family of the bed hold procedure or that the bed hold form was provided and signed by the resident or family prior to discharging to the hospital. Review of the resident's MDS Record showed the resident discharged from the facility, on 5/26/23, to the hospital and re-entered the facility on 5/31/23. Review of the resident's Social Services Progress Note dated 6/1/23, showed: -The resident was in the hospital from 5/26/23 to 5/31/23. -The resident was readmitted to the facility on [DATE] with a diagnosis of Hematuria (the presence of blood in the urine). -The Social Worker would continue to follow the resident and provide assistance where needed. Social Service to follow and assist as needs arise. Review of the resident's Medical Record showed there was no documentation showing the facility staff provided the resident with the bed hold form or explained the procedure to the resident or family/responsible party prior to or upon discharge to the hospital. 4. During an interview on 6/28/23 at 2:26 P.M., the DON said: -All residents are asked to sign the Bed Hold Agreement upon admission. -Since Resident #3 and #7 were both private pay, he/she did not think that they had to provide the bed hold form upon hospitalization for residents who were private pay. -They only provided the bed hold form upon hospitalization with residents who were insured through Medicaid/Medicare. During an interview on 6/28/23 at 2:58 P.M., the Administrator said: -They have all residents sign the Bed Hold Agreement upon admission. -Residents #3 and #7 were both in certified and licensed beds even though they were private pay. -Residents who were private pay did not receive a bed hold form for signature upon each hospitalization , but they would hold the resident's bed. -For those residents on Medicaid/Medicare, the nurses were supposed to complete the bed hold form and get the resident or responsible party's signature upon sending the resident out to the hospital. The nurse completing the form should make a copy and send the original with the resident to the hospital. -Often the family was notified of the resident's hospitalization by phone, but there should be a copy of the bed hold form in the resident's medical record. During an interview on 6/30/23 at 12:55 P.M., Registered Nurse (RN) C said: -When they send a resident to the hospital, the nurse had the bed hold form that they were supposed to explain to the resident and responsible party and complete. -They were supposed to give the bed hold form to the resident or responsible party to sign and they were to send it with the resident to the hospital. -If the resident was unable to sign, and the responsible party was unavailable at the time, they would notify the responsible party by phone. -They did not usually keep a copy of the signed bed hold form for their records. During an interview on 6/30/23 at 1:18 P.M., the DON said: -They had not been completing bed holds correctly. -They were developing a new process for completing the bed hold forms. -Social Services would ensure the bed hold form was signed by the resident or responsible party. -The nursing staff would issue the bed hold form upon hospitalization if it was an emergent situation. They would make a nursing note and make a copy of the bed hold form so they could have it for their records. -Social Services would complete the follow up (notifying the responsible party) or getting the signatures to acknowledge the form was completed with each hospitalization for all residents who were sent to the hospital.

Based on observation, interview, and record review, the facility failed to maintain hot foods at or close to 120 F (degrees Fahrenheit) for two sampled residents (Residents #35 and #43) who received room trays on 6/29/23. This practice potentially affected at least four residents who received room trays on that date. The facility census was 80 residents. 1. Review of Resident #43's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 5/24/23, showed the resident had moderate cognitive impairment. During an interview on 6/29/23 at 8:58 A.M., Certified Nursing Assistant (CNA) A said he/she worked 3 to 4 days per week and had not seen anyone from the dietary department go out to the hallways to measure the food temperatures. Observation on 6/29/23 at 9:12 A.M., showed: -A room tray was delivered to the nurse's station for the resident. -At 9:17 A.M. CNA A took the resident's tray to his/her room. Observation on 6/29/23 at 9:18 A.M during a temperature check of the hot foods on the resident's tray showed: -The eggs were 110.4 F -The sausage was 108.2 F During an interview on 6/29/23 at 9:20 A.M., the resident said: -He/she did not like his/her food cold. -No dietary staff had come and measured the temperature of food. -He/she always got his/her food after 9:00 A.M. 2. Review of Resident #35's quarterly MDS dated [DATE] showed the resident was cognitively intact. Observation on 6/29/23 at 9:12 A.M., showed: -A room tray was delivered to the nurse's station for the resident. -At 9:14 A.M., CNA A took the resident's tray to his/her room. During an interview on 6/29/23 at 9:24 A.M., the resident said: -The food had not been very good recently. -Sometimes the food got cold. -He/she said his/her food was cold that day. 3. During an interview on 6/29/23 at 11:07 A.M., the Assistant Director of Dining Services said at that time, there was not a process in place to test the food temperatures of room trays. During an interview on 6/30/23 at 9:35 A.M., the Registered Dietitian (RD) said the food should be palatable when it got to the residents.

Based on observation, interview, the facility failed to do or maintain the following area in a clean, sanitary or comfortable manner: maintain the ceiling vents in the employee breakroom, free of a buildup of dust; ensure the screen over the outdoor vent in the laundry room was completely secured to the wall to prevent the entrance of pests; to maintain the commode seat in resident room [ROOM NUMBER], without any indentations; to ensure there was negative air flow in the shower rooms and the restrooms of the resident rooms on the 600 Hall; to maintain the ceiling vent without a heavy buildup of dust in the 800 Hall shower room; and to maintain the [NAME] Bridge kitchenette at a comfortable temperature during the breakfast meal preparation on 6/29/23. This practice affected no-resident areas (the employee breakroom and the [NAME] Bridge Kitchenette) and at least 4 residents on the 600 Hall. The facility census was 80 residents. 1. Observation on 6/27/23 at 10:59 A.M., with Maintenance Worker B showed a heavy buildup of dust on three ceiling vents in the employee breakroom. During an interview on 6/27/23 at 11:02 A.M., Maintenance Worker B said he/she did not know the last time the ceiling vents were cleaned. 2. Observation on 6/27/23 at 11:55 A.M., with Maintenance Worker B showed a 3 and 1/4 inch (in.) gap between the wall and the screen over the outdoor vent, which could potentially let pests into the laundry area. During an interview on 6/27/23 at 11:58 A.M., the Housekeeping Supervisor said he/she had not noticed that gap before. During an interview on 6/27/23 at 11:59 A.M., Maintenance Worker B said he/she could repair that screen to be securely attached to the wall. 3. Observation on 6/27/23 at 1:45 P.M., with Maintenance Worker B showed the commode seat in the restroom of resident room [ROOM NUMBER], with two indentations, which caused the commode seat to not be easily cleanable. During an interview on 6/27/23 at 1:47 P.M., Maintenance Worker B said the commode seat needed to be changed. 4. Observation on 6/28/23 from 8:54 A.M. through 9:21 A.M., with Maintenance Worker B showed the absence of negative air flow from the shower room and resident rooms 601, 606 and 605, as evidenced by the negative air flow vents not being able to provide suction to a tissue paper that was held to those vents. 5. Observation on 6/28/23 a 10:08 A.M., with Maintenance Worker B showed a heavy buildup of dust in and on the ceiling vent in the 800 Hall shower room. During an interview on 6/28/223 at 10:09 A.M., Maintenance Worker B said he/she needed to clean that shower vent. 6. Observation on 6/29/23 at 7:59 A.M., during the breakfast preparation showed: -The ambient air temperature of the kitchenette was 93.3 F (degrees Fahrenheit). -Note: The temperature was taken some distance away from the steam table and appliances. Observation on 6/29/23 at 10:15 A.M., after the breakfast preparation showed; -The ambient air temperature of the kitchenette without any appliances operating was 90.9 F. -Note: The temperature was taken some distance away from the steam table and appliances. During an interview on 6/29/23 at 10:11 A.M. Maintenance Person B said they may have to install another vent in the ACC kitchenette. During an interview on 6/29/23 at 10:13 A.M., the Assistant Dining Services Director, said opening another vent in the past had not been discussed. During an interview on 7/3/23 at 10:16 AM., the Maintenance Director said the motor of the vent which assists in drawing out the hot air out of the kitchenette, was clogged with vegetative matter including seeds and leaves.

Based on observation, interview and record review, the facility failed to provide supporting documentation for the use of a wandering type bracelet (are monitoring devices that are attached to patients and electronically notify nurses when the patient attempts to leave the ward or unit to which the patient is assigned) safety device to include changes in resident behavior, or exit seeking behaviors for one sampled resident who was his/her own responsible person and who's Brief Interview for Mental Status (BIMS) score was 15 (A score of 13 to 15 would indicate the resident was cognitively intact); and to document the resident's right to consent either verbal or written consent, for the use of a wandering safety device for one sampled resident (Resident #16); and to allow one sampled resident (Resident #37) who was cognitively intact the ability to make decisions for himself/herself out of 19 sampled residents. The facility resident census was 80 residents. Review of the facility Wander and Elopements Policy revised on 3/19 showed: -The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the resident. -If a resident identified at risk for wandering, elopement , or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident safety. Review of the facility Resident Right's policy revised on 2/21 showed: -The resident has the right to be treated with respect, kindness and dignity. -To be free from corporal punishment or involuntary seclusion, and physicals restrains not required to treat the resident's symptoms. -The right to choose to participate in, decision-making regarding his or her care. 1. Review of Resident #16's Admission Face Sheet showed: -The resident was his/her own responsible party. -Had diagnoses of Major Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living) and Parkinson's Disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). Review of the resident's Psychiatric Services Visit Summary dated 3/17/23 showed: -The resident believed he/she was a werewolf and would howl like a wolf at times. -He/she believed the facility staff were injecting people with fertility drugs. -The resident was very sensitive to new medications and often had adverse reactions to Antipsychotic medication. -Note: There was no documentation related to any wandering or exit seeking behaviors. Review of the resident's Social Services (SS) Progress note dated 3/24/23 at 3:30 P.M. showed -SS staff were visiting with the resident on 3/23/23 and he/she began to get angry with SS during their visit. -Staff tried to redirect him/her, the resident got upset and put his/her fist up out of frustration. -Nursing staff came to assist the resident out of the SS office. -There was no documentation related to any wandering behaviors or being at risk for elopement. Review of the resident's SS Progress Note dated 4/27/23 at 11:09 A.M. showed: -SS met with the resident for his/her quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) review. -The resident was sitting in his/her room at the time of the visit. -The resident said he/she was feeling down, tired, and having trouble concentrating at times. -SS suggested that he/she see the facility psychologist, the resident was agreeable to seeing the psychologist. -The resident signed a consent form to see the psychologist the next time the psychologist visited the facility. -Note: There was no documentation related to exit seeking behavior or wandering off the unit. Review of the resident's Quarterly MDS dated [DATE] showed he/she: -Had a BIMS score of 15 (a score between 13 to 15 would indicate the resident cognitively intact). -Was able to make his/her needs known and able to understand others. -Had no documentation related to having wandering behaviors or being at risk for elopement. Review of the resident's Psychiatric Services Consult dated 4/29/23 showed the resident: -Was depressed due to his/her diagnosis of Parkinson's. -Was alert and oriented times four (oriented to person, place, time and to circumstance) -Thought process was logical and goal directed. -Had no evidence of any perceptual disturbance, paranoia or delusional thinking during the assessment. -Note: There was no documentation related to having wandering or exit seeking behaviors. Review of the resident's hand written Care Plan Conference Summary dated 5/4/23 showed: -The resident was having frequent paranoid situations. --There was no detailed behavioral documentation of what the paranoid situation included. -The resident and two family members were present during the Care Plan meeting. -No documentation related to the resident having wandering or exit seeking behaviors. Review of the resident's BIMS interview and assessment for MDS dated [DATE] showed the resident: -Was able to understand and express ideas, and wants both verbally and non-verbally. -Had a BIMS score of 15 which indicated he/she was cognitively intact. Review of the resident's Elopement Evaluation assessment dated [DATE] at 9:13 A.M. showed: -The resident did not have a history of elopement while at home. -He/she did not have wandering behavior and had goal directed activity. -The resident would wander aimlessly or non-goal-directed. -The resident did have wandering behaviors and would likely affect the safety or well-being of himself/herself or others. -His/Her wandering behavior was likely to affect the privacy of others. -He/she was not recently admitted or readmitted (within past 30 days). -The final elopement score of four indicated the resident was at risk for elopement. -Had no supporting documentation of any safety interventions that were put in place. -Did not have any supporting documentation for the need of or for the use of a wandering safety device. Review of the resident's Health Status Note dated 6/23/23 at 4:51 P.M., showed: -The resident's wandering safety device was placed on his/her left ankle for safety. -Nursing staff had placed a call to the resident's family member to inform him/her of the wandering safety device placement. -The family member said he/she was ok with resident's wandering safety device placement. -Note: There was no documentation of the resident (who was his/her own responsible person) having consented to the use of a wandering safety device or that his/her physician had been notified prior to use of the wandering safety device. Review of the resident's Treatment Administration Record (TAR) dated 6/2023 showed a new physician order dated 6/23/23 at 11:00 P.M., for a wandering safety device to be placed on the resident's left ankle, nursing staff were to check the wandering safety device placement every shift and replace the wandering safety device as needed. Review of the resident's Physician Order Sheet (POS) dated 6/2023 showed: -A new physician order for a wandering safety device to be placed on his/her left ankle, nurse staff were to check the wandering safety device placement every shift and replace the device if needed (ordered on 6/23/23 at 11:00 P.M.). -Nursing staff were to monitor the resident's skin integrity at the site of the wandering safety device every shift (ordered on 6/25/23 at 3:00 P.M.). Review of the resident's Personalized Care Plan updated on 6/26/23 showed; -The resident was an elopement risk related to his/her impaired safety awareness. -The resident wandered aimlessly related to his/her cognitive impairment. -Interventions included placement of a wandering safety device to his/her left ankle, nursing staff were to check placement of the wandering safety device every shift. Observation on 6/26/23 at 9:18 A.M. of the resident in his/her room showed: -He/she was sitting in his/her recliner chair, with a wandering safety device on his/her left ankle. -The resident was able to make his/her needs known. Observation on 6/27/23 at 10:28 A.M., showed the resident: -Was in a low wheelchair able to propel self in room. -Had a wandering safety device on his/her left ankle. Review of the resident's electronic Medical Record on 6/28/23 at 9:48 A.M., showed: -The resident did not have supporting documentation for the use or need of a wandering safety deviceto include any wandering or, exit seeking behaviors or having a change in his/her mental status related to paranoia. -The resident did not have any documentation that written or verbal consent was obtained by the facility staff for the use of the wandering safety device. During an interview on 6/28/23 at 9:32 A.M., Certified Nursing Assistant (CNA) H said: -The resident had a diagnosis of Parkinson's and his/her symptoms of Parkinson's had increasingly got worse. He/she had episodes of confusion at times. -The nursing staff were responsible for the resident's Elopement Assessment and monitoring of safety devices such as a wandering safety device. -He/she was not aware of the resident having wandering or exit seeking behaviors. Observation on 6/28/23 at 11:23 A.M., of the resident in the main dining area showed he/she was sitting at a table in his/her wheelchair with a wandering safety device placed on his/her left ankle. During an interview on 6/29/23 at 8:58 A.M., the resident said: -He/she had a safety monitor on his/her left ankle because he/she had wandered over to his/her old apartment, and did not inform facility staff he/she was leaving the unit. -He/she would not always notify facility staff when leaving the unit. -Since the placement of the wandering safety device, he/she had not attended any off unit activities. He/she said had no place to go this week. -A wandering safety device was placed on his/her left ankle so facility staff would be able to locate him/her. -The resident did not feel offend or discouraged by having to wear the wandering safety device. It did not affect his/her ability to move freely within the facility. -Facility staff did not ask permission of him/her before the placement of the wandering safety device. During an interview on 6/29/23 at 9:11 A.M., CNA A said: -The resident was able to propel himself/herself around the facility and would leave the unit without telling staff. -It was like playing hide and seek with the resident. -The resident liked to visit with peers. During an interview on 6/29/23 at 11:42 A.M., Licensed Practical Nurse (LPN) C said: -The facility recently completed new elopement assessments on 6/23/23 for any residents who were at risk for or had the potential for wandering and if they had a BIMS score below nine (moderately cognitively impaired) they were given a wandering safety device. -The resident had a history of thinking he/she was a werewolf and would howl at times. -He/she had not seen the resident have wandering behaviors, exit seeking behaviors, packing up personal items or stating he/she wanted to go home or leave the facility. -The resident did like to attend activities off the unit on the assisted living side. -He/she would document any wandering behaviors, wanting to leave the facility, or exit seeking in the resident medical records. -Elopement assessments for wandering were to be completed quarterly by the nursing staff and he/she would expect to have supporting documentation of the resident's behaviors of wandering or exit seeking noted in the resident's medical record. During an interview on 6/29/23 at 12:04 P.M., LPN A said: -The resident's wandering safety device was put in place for his/her safety and to let facility staff know by alarm where the resident was at and to ensure he/she was not wandering out facility doors. -The resident had a mental health consult that documented the resident had a delusion of believing he/she was a werewolf. -On 6/23/23 the resident had a BIMS assessment completed, he/she thought it was nine or below, but after review of the documentation he/she noticed the resident's BIMS score was 15. -The residents Elopement Evaluation Assessment would include any noted behavioral changes in the resident. -The resident had a past behavior of thinking he/she was a werewolf and he/she was teaching other residents how to howl like a wolf. -He/she had a diagnosis of Parkinson's with behavioral changes. -The resident was able to make his/her own decisions and choices. -The resident was able to propel himself/herself throughout the facility. -The resident's wandering safety device would alarm if the resident got close to an exit and that was how staff monitored the whereabouts of the resident. -Review of the resident's medical record with LPN A showed the resident's last behaviors were documented in 3/23. The resident did not have any supporting documentation related to why the resident was at risk for wandering or if he/she had any wandering behaviors. -He/she would expect to have documentation of any wandering behaviors or when the resident did not notify the facility staff when leaving the unit. During an interview on 6/30/23 at 10:50 A.M., Infection Control Preventionist (ICP) said: -If residents were at risk for wandering, then an assessment would be completed to see if safety devices such as a wandering safety device was needed. -The facility staff had notified the resident's family member and noted in the medical record. -The resident was able to make needs known and if he/she did not want the wandering safety device he/she could let staff known or could cut the wander guard bracelet off. -The resident had Parkinson's which caused hallucinations at times, the resident thought he/she was a werewolf. During an interview on 6/30/23 at 11:40 A.M., Director of Nursing (DON) said: -The facility did not have any written consents for use of a wandering safety device. -The assessment for use was the elopement assessment that was completed on 6/23/23, and use of a wandering safety device was dependant on the score. -They facility had notified the resident's family member and documented in his/her nursing notes. -He/she would expect nursing staff to document the resident being notified of the use of the wandering safety device and had agreed to the safety measure. -The resident's family member was notified of placement of the wandering safety device. -The resident was his/her own responsible person, he/she was able to make his/her needs known and had a BIMS of 15. -After completing the Elopement Evaluation Assessment, the resident scored at risk for wandering and the facility placed the wandering safety device on the resident due to the finding of the evaluation. During an interview on 6/30/23 at 1:18 P.M., the DON and Assistance Director of Nursing (ADON) said: -On 6/23/23, the facility nursing staff had completed an Elopement Evaluation Assessment on all residents, due to a prior incident of a resident exiting the facility. -Any resident who had the potential for at risk of wandering or exit seeking and had a BIMS, lower than nine had an Elopement Assessment completed by facility nursing staff. -On 6/23/23 any resident with a score that indicated they were at risk was given a wandering safety device. -The resident had shown no behaviors of exit seeking, of wanting to leave the facility or wandering. -He/she had no current behaviors documented related to delusions of being a werewolf. -The facility had past documentation by mental health specialist showing the resident had delusions of being a werewolf. -The resident had a BIMS score of 15. -During the day the resident was not confused, during the night the resident was more confused. -The facility did not have documentation of the night time confusion. -The residents with an elopement assessment score of 3 or more were at risk for elopement or wandering. And the facility had placed wandering safety devices on those residents at risk for wandering or elopement. -He/She would expect facility nursing staff to have documentation of the residents being educated and accepted the use of the wandering safety device. -The resident's family was called and agreed to the use of the wandering safety device. -He/she would expect nursing staff to have supporting documentation for the use of the wandering safety device to include any wandering behaviors, exit seeking behaviors or change in mental status. -The resident's care plan should be comprehensive and personalized to include any current wandering behaviors or incidents and any delusional behaviors noted. 45623 2. Review of Resident #37's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity). -Dysphagia (difficulty swallowing). Review of the resident's Admission Note, dated 1/16/23, showed LPN A documented: -The resident had no teeth. -Broken or ill-fitting dentures were not assessed. -Abnormal mouth tissue was not assessed. -Lack of natural teeth was not assessed. Review of the resident's Durable Power of Attorney (DPOA) for Health Care, dated 1/18/23, showed the resident had named an agent to have full authority over healthcare decision making when he/she was incapacitated as certified by one physician. Review of the resident's Significant Change MDS dated [DATE], showed staff assessed the resident and documented the resident: -Had a BIMS of 13, which indicated he/she was cognitively intact. -Required set-up assistance for meals and oral hygiene. -Had no dental issues. -Had unclear speech. -Had difficulty communicating. -Had a poor appetite several days during the look-back period. Observation on 6/26/23 at 12:55 P.M. showed the resident had no teeth. During an interview on 6/26/23 at 12:55 P.M., the resident said: -He/she had lost his/her dentures a few years ago. -No one had ever asked him/her if he/she was interested in getting new dentures. Review of the resident's care plan, last revised 6/28/23, showed: -Staff were to clean the resident's gums multiple times a day. -Staff documented the resident had communication problems related to dentition problems. During an interview on 6/28/23 at 1:00 P.M., the DON said: -He/she could not find any dental notes for the resident. -He/she did not believe the resident had seen the dentist since admitting to the facility. During an interview on 6/28/23 at 2:24 P.M., the DON said: -The resident had not had dentures in [AGE] years. -The resident was admitted without dentures or teeth. -He/she was unsure if anyone had asked the resident if he/she was interested in dentures. Review of the resident's SS Note, dated 6/28/23 at 2:25 P.M., showed SS A documented: -He/she had met with the resident regarding dentures. -The resident stated interest in obtaining dentures. -The SS explained to the resident that it might be difficult given how long the resident had not had teeth. -The resident stated he/she would like to pursue dentures, regardless of possible difficulties. During an interview on 6/29/23 at 8:15 A.M., CNA A said: -He/she was aware the resident didn't have any teeth but thought it was the resident's choice. -He/she guessed the resident wasn't interested based on the resident's life story, so he/she had never asked about the resident's desire for dentures. During an interview on 6/29/23 at 8:42 A.M., Registered Nurse (RN) A said he/she expected staff to ask any resident without teeth if they were interested in obtaining dentures. During an interview on 6/29/23 at 9:35 A.M., the resident said: -He/she wasn't able to eat a lot of foods because he/she didn't have any teeth. -He/she was bothered that he/she couldn't eat what he/she wanted but no one had ever offered to help. During an interview on 6/29/23 at 11:14 A.M., LPN A said: -The resident had a family member that worked at the facility. -He/she had asked the family member working at the facility about the resident's teeth and the family member said the resident hadn't had teeth for a long time. -He/she normally ask residents about dentures on admission but since the resident's family member worked there, he/she had spoken with him/her instead. -He/she believed the resident would refuse dental appointments that were not furnished within the facility's building and a denture consult would require the resident to see an outside dentist. -He/she was unsure if the resident had been declared incapacitated. During an interview on 6/29/23 at 1:05 P.M., the DON said the resident had not been declared incapacitated by a physician or the courts. During an interview on 6/30/23 at 8:34 A.M., Social Worker A said: -The resident hadn't had teeth in over [AGE] years so his/her family probably hadn't thought about it. -The staff were aware the resident didn't have teeth but the resident didn't like leaving the building for appointments so he/she assumed the resident would not be interested and did not ask. During an interview on 6/30/23 at 9:03 A.M., the resident said the staff kept telling him/her getting dentures would be a big ordeal but he/she still wanted to try. During an interview on 6/30/23 at 1:17 P.M., the DON said: -The resident had never been offered dentures because his/her family member worked in the facility and said the resident wouldn't want them. -He/she had discussed dentures with the resident's family member and that family member decided the resident wouldn't benefit from dentures. -The resident was able to make choices for himself/herself. -The resident had never mentioned he/she wanted dentures. -During recent discussions with the resident's family, the family said to follow the resident's choices but they did not believe it would be beneficial. -He/she didn't realize the resident was able to make his/her own choices because the resident had signed a DPOA.

Based on observation, interview, and record review the facility failed to ensure the privacy of one sampled resident (Resident #4) during a blood glucose test (a test that measures the amount of glucose (sugar) levels in the blood) and when receiving insulin (a hormone produces in the pancreas which regulates the amount of sugar in the blood) out of 19 sampled residents. The facility census was 80 residents. Review of the facility's policy titled Dignity dated February 2021 showed staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of Resident #4's face sheet showed he/she admitted to the facility with the following diagnoses: -Alzheimer's Disease (a progressive mental deterioration that can occur in middle or old age due to degeneration of the brain) with Early Onset (having an age of onset of Alzheimer's younger than [AGE] years old). -Diabetes Mellitus Type Two (DMII- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 4/24/23 showed the resident had severely impaired cognition. Review of the resident's Physician Order Sheet (POS) dated June 2023 showed the resident received Levemir (long-acting insulin) FlexTouch Solution Pen-Injector 100 Units (U)/ milliliters (ml) (Insulin Detemir): Inject 18 U subcutaneously two times a day for DMII. Observation on 6/29/23 at 7:23 A.M. of a blood glucose test and insulin administration performed by Certified Medication Technician (CMT) A showed: -He/she gathered all supplies needed and walked from the medication cart to the resident sitting in a common area adjacent to the dining room. -He/she introduced himself/herself and told the resident that he/she was going to perform a blood glucose test. -He/she did not ask the resident if he/she wanted to go into his/her room or provide a private setting to perform the test. -He/she completed the test and walked back to the medication cart. -He/she then gathered all of the supplies needed to perform insulin administration on the resident. -He/she walked back to the resident and told him/her that he/she needed insulin. -He/she asked the resident if he/she could lift up his/her shirt to inject the insulin into the resident's abdomen. -He/she did not ask the resident if he/she consented to perform the procedure in the common area. -The resident lifted up his/her shirt just below the chest and pulled his/her pants down just below his/her navel exposing the resident's skin and part of his/her brief. -After completing the insulin administration he/she walked back to the medication cart, disposed appropriate supplies, and charted the insulin administration. During an interview on 6/29/23 at 7:36 A.M. CMT A said: -He/she thought the procedure went okay. -He/she would not have done anything differently. -He/she would be able to receive appropriate consent from the resident in order to perform procedures in common areas. -He/she could have given the resident more options for the insulin administration instead of just asking the resident to expose his/her stomach for the administration. During an interview on 6/30/23 at 8:43 A.M. Licensed Practical Nurse (LPN) D said: -Blood sugar tests and insulin administration should not be performed in common areas unless the resident refused to leave the area. -If a resident refused to leave the common area for a test or procedure the resident would need to consent to the procedure being performed in the common area or be pulled aside to a more private area. -Care staff should always ask for consent from a resident before any procedure. -Residents with a diagnosis of dementia would be able to consent to procedures performed in any common area or dining room. -If a resident in a common area needed to receive insulin the care staff should pull the resident aside and see if the insulin could go into the arm instead of the abdomen. During an interview on 6/30/23 at 9:01 A.M. LPN E said: -When performing a blood glucose test or insulin administration it should not be done in the dining room or common area. -He/she always attempted to have any resident go into their room before a procedure was completed, but if the resident refused, he/she would try to provide privacy as best possible. -A resident with dementia can consent to certain procedures as long as the procedure is explained to the resident. -If a resident is adamant about staying in the common area for insulin administration he/she would give the insulin into the resident's arm. -It is not appropriate to give insulin into the abdomen or stomach area in a non-private setting. -The CMT should have given the resident a choice of where to receive the insulin and should have provided more privacy. -When certain cares are not provided in privacy it is a dignity issue for the resident. -If he/she saw a CMT or nurse perform a blood glucose test or insulin administration in a non-private setting he/she would pull the staff person aside after the procedure was completed and educate them on resident privacy and dignity. During an interview on 6/30/23 at 10:26 A.M. Registered Nurse (RN) B said: -He/she was unsure if a blood glucose test or insulin administration could be performed in a common area and would need to see the facility policy. -He/she would think that it would be a privacy issue if performed in a common area. -Residents with a diagnosis of dementia would not be able to give consent for how a procedure was performed. -If a resident refused or was unable to leave the common area for insulin administration he/she would give the resident the insulin in the arm. If he/she saw a CMT or nurse try to perform a blood glucose test or insulin administration in a non-private setting he/she would walk over to the resident and assist in providing privacy and once the procedure was completed he/she would educate them to be more mindful of the resident's privacy. During an interview on 6/30/23 at 1:18 P.M. the Director of Nursing (DON) said: -He/she would expect staff to take a resident to their room when performing a test or procedure. -A resident with dementia would be able to consent for procedures and should be asked how they would like it done. -Any person receiving insulin would want privacy and would expect staff to give options of where and how the procedure was completed. -Regardless if a resident refused or did not want to leave the common area privacy should be given in some shape or form.

Based on observation, interview, and record review, the facility failed to follow professional standards by not aspirating (draw fluid by suction) or flushing an peripheral intravenous catheter (PIVC or IV-a thin plastic tube inserted into a vein using a needle) prior to administering medication for one sampled resident (Resident #278) out of 19 sampled residents. The facility census was 80 residents. Review of the facility's policy, titled Dispensing and Administration of Saline and Heparin Flushes for IV Catheters dated February 2017, showed staff were required to flush any type of IV catheter: -With 10 milliliters (ml) of Normal Saline (a sterile solution that is a mixture of sodium chloride and water) prior to administering medication through the IV. -With 10 ml of Normal Saline after administration of any medication through the IV. Review of the facility's policy titled Peripheral Intravenous Catheter Flushing dated 2021 showed: -Staff were to obtain, document, and submit to the pharmacy, orders for a PIVC to be flushed. -Staff were required to flush a PIVC to ensure and maintain catheter patency (the state of being unobstructed). -A prescriber's order, to include flushing agent, volume, and frequency, was required to flush a PIVC. -Catheter patency was required to be verified prior to each use. This required aspirating the catheter to obtain positive blood return. -Staff were to flush the catheter after aspirating blood and observe for signs of complications. -If resistance was met when flushing, staff were not to attempt any further flushes, but were to remove the catheter and insert a new peripheral catheter. 1. Review of Resident #278's face sheet showed he/she was admitted with the following diagnoses: -Sepsis (a life-threatening complication of an infection). -Cellulitis (a serious bacterial skin infection) of the right lower limb. -Acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). Review of the resident's Treatment Administration Record (TAR), dated 6/29/23, showed: -An order for Ceftazidime (an antibiotic) two grams to be given daily via IV entered on 6/23/23 and discontinued 6/26/23. This medication was documented as given on 6/24/23, 6/25/23, and 6/26/23. -An order for Ceftriaxone (an antibiotic) two grams to be given daily via IV entered 6/28/23 to be given until 7/3/23. This medication was documented as given on 6/28/23 and 6/29/23. -An order for a Normal Saline flush to be given via IV once a shift (three times a day) for patency. This medication was documented as given as ordered. Observation on 6/29/23 at 8:49 A.M. showed: -Licensed Practical Nurse (LPN) A entered the resident's room and prepared the IV medication. -LPN A pulled up the resident's sleeve and exposed the insertion port of the IV catheter. -LPN A wiped the insertion port of the IV catheter with alcohol, attached the IV medication tubing, opened the IV tubing clamps, and started the IV medication pump. -LPN A removed his/her gloves and promptly left the resident's room. -NOTE: LPN A did not aspirate or flush the line prior to starting the IV medication, and did not observe the resident's IV site for complications such as infiltration (when the catheter goes through or comes out of a vein) or phlebitis (inflammation of the vein as noted by redness, warmth, and pain in the affected area). During an interview on 6/29/23 at 8:49 A.M., LPN A said: -There was nothing he/she would have done differently. -He/she did not aspirate or flush the IV line prior to administering the IV medication because there was no order to do so. During an interview on 6/29/23 at 9:22 A.M., LPN B said: -He/she was IV certified. -IV lines were to be flushed before IV medication was started. -If there was no order to flush before administering the IV medication, he/she would call the doctor to obtain an order. During an interview on 6/29/23 at 10:52 A.M., LPN C said: -He/she was IV certified. -IV lines must be flushed prior to giving IV medication to ensure the line was patent. -If there was no order to flush prior to giving IV medication, he/she would call the doctor to obtain an order. During an interview on 6/30/23 at 1:17 P.M., the Director of Nursing (DON) said: -IV lines were to be aspirated and flushed with Normal Saline prior to starting IV medication. -If there was no order to flush an IV line before giving IV medications, he/she expected the staff to call and get an order.

Based on observation, interview, and record review, the facility failed to ensure the wheels on all mobile devices were locked prior to transferring and repositioning one sampled resident (Resident #278) out 19 sampled residents. The facility census was 80 residents. A copy of the facility's policy on accidents and transferring of residents was requested and not received at the time of exit. 1. Review of Resident #278's face sheet showed he/she was admitted with the following diagnoses: -Abnormalities of gait and mobility. -Muscle Weakness. -Fall from chair. Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 5/25/23, showed: -The resident had a Brief Interview for Mental Status (BIMS) of six, indicating the resident had severe cognitive impairment. -Extensive staff assistance was required for bed mobility. -Extensive staff assistance was required for transferring from one surface to another. Review of the resident's care plan, last revised 6/28/23, showed: -Staff documented that the resident was at risk for falls. -Staff documented on 4/22/21 that the resident had fallen while attempting to transfer and that the wheelchair brakes were not working properly. Observation on 6/26/23 at 9:57 A.M. showed: -Certified Nurse Assistant (CNA) D and CNA E were performing peri-care for the resident in his/her bed, while Licensed Practical Nurse (LPN) A performed a skin assessment. -As CNA D and CNA E rolled the resident to his/her other side to continue peri-care, the bed moved approximately 15 centimeters (cm) which resulted in the top right side of the headboard hitting the wall. -LPN A put his/her leg against the bottom half of the bed and the bed stopped moving. -The wheels on the bed were observed to be in the unlocked position. -All staff continued with their duties. -CNA D and CNA E placed the brief under the resident and again turned him/her to finish placing the brief. -Staff stood directly against the bed to prevent it from moving. -When the cares were complete, CNA D, CNA E, and LPN A covered the resident, lowered the bed, and left the room. -NOTE: No staff member locked the wheels to the bed prior to leaving the room. During an interview on 6/26/23 at 10:09 A.M., CNA D said: -He/she did see the bed move when the resident was rolled to his/her side. -He/she had looked at the lock on the bed and it appeared locked so he/she wasn't sure how the bed had moved. During an interview on 6/26/23 at 10:10 A.M., CNA E said: -He/she saw the bed move when the resident was rolled to his/her side. -He/she was not sure why the bed had moved. -The locking levers on some of the beds didn't work well so they appear locked but actually are not. During an interview on 6/29/23 at 8:15 A.M., CNA A said: -He/she expected the bed and wheelchair to be locked prior to moving a resident. -He/she checked the locks on all mobile devices before transferring a resident. During an interview on 6/29/23 at 9:38 A.M., CNA B said: -All wheels on all mobile devices were to be locked before transferring a resident. -He/she ensured all mobile devices were locked before transferring a resident. -If a bed moved while he/she was providing cares, he/she would lock it immediately before resuming cares. During an interview on 6/29/23 at 10:54 A.M., CNA C said: -He/she had found beds unlocked on occasion. -If a bed moved while he/she was providing cares, he/she would immediately stop and lock the bed before continuing with cares. During an interview on 6/29/23 at 11:14 A.M., LPN A said: -All mobile devices were to have the wheels checked to ensure they are locked before transferring a resident. -If a bed moved while he/she was providing cares, he/she would lock the wheels before continuing with cares. -He/she had not noticed the bed move while providing cares to the resident on 6/26/23. During an interview on 6/30/23 at 1:17 P.M., the Director of Nursing (DON) said: -Any items with wheels were to be verified as locked before attempting a transfer. -If a bed moved during cares and multiple care givers were present, he/she expected one staff member to stop and lock the bed before continuing cares. -No staff had reported difficulty with locking the wheels on any beds.

Based on observation, interview, and record review, the facility failed to ensure a suprapubic (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) catheter (flexible tube) was monitored, cleaned as ordered, and that an assessment of the resident's ability to perform the task had been completed, for one sample resident (Resident #20) out of 19 sampled residents. The facility census was 80 residents. The facility's policy for self-care of catheters was not received at time of exit. Review of the facility's policy, dated October 2010, titled Suprapubic Catheter Care showed staff were to: -Observe urine for any unusual appearance. -Check the resident frequently to ensure tubing was free of kinks. -Empty the collection bag. -Observe the stoma (a surgically made hole) for redness or skin breakdown. -Document the characteristics of the urine and skin after care was performed. Review of the facility's policy, dated February 2021, titled Self-Administration of Medications showed: -The Interdisciplinary Team (IDT) was to assess each resident's cognitive and physical ability to determine whether self-administration was safe and clinically appropriate. -If it was deemed safe for a resident to self-administer medication, it was to be documented in the medical record and care plan. -Self-administration of medication was to be reassessed periodically. Review of Drugs.com article, dated 7/2/23, titled How to Care for Your Suprapubic Catheter showed the insertion site was to be cleaned twice a day. 1. Review of Resident #20's face sheet showed he/she was admitted with the following diagnoses: -Urinary Tract Infection (UTI). -Retention of urine. -Encounter for fitting and adjustment of a urinary device. Review of the resident's Urologist's note from the hospital, dated 2/9/23, showed: -The urologist noted that the resident was able to plug the catheter during the day as the resident was able to void the majority of the urine but did not completely empty his/her bladder. -The physician did not indicate the resident was able to perform any of these cares independently. Review of the resident's Care Plan, last revised 5/4/23, showed: -The resident required one staff to assist with showering. -The resident required one staff to assist with dressing. -The resident had limited physical mobility. -The resident had impaired cognitive function due to short term memory loss. -The resident was at risk for infection related to the suprapubic catheter. -Staff were to check the tubing for kinks each shift. -Staff were to monitor the urine output and characteristics. -The resident was to change from a drainage bag to a leg bag (a drainage bag that straps to the leg for discretion) every morning and wear the leg bag throughout the day. -The resident was to change from the leg beg to a drainage bag at night independently. During an interview on 6/26/23 at 1:10 P.M., the resident said: -Staff applied a urine drainage bag to his/her catheter at bedtime. -He/she disconnected the drainage bag in the morning. -Staff changed the catheter tubing once a month. -He/she used the same urine drainage bag for approximately 10 days. -He/she did not use a new drainage bag every day but staff did give him/her a new one every once in a while. Observation on 6/27/23 at 10:06 A.M. showed: -The resident's catheter drainage bag was tied to the hand rail in the bathroom and had nothing covering the end that attached to the resident's urinary catheter. -The resident had a solid plastic cone inserted into the opening of his/her catheter. -The resident was not wearing a leg bag. During an interview on 6/27/23 at 10:08 A.M., the resident said: -He/she removed the urine drainage bag every morning and placed a cap into the urinary catheter to prevent leaking. -The cap he/she currently had in his/her catheter tubing wasn't actually for the catheter but the staff couldn't find the right thing so he/she had been told to use a plastic cone. -Staff did not give the resident a new cap every day, he/she used the same one until he/she requested a new one. Review of the resident's Order Report Summary, dated 6/28/23, showed: -The physician ordered an abdominal ultrasound due to pain and swelling. -Staff were to check the level of the drainage bag each shift to ensure it was below the bladder. -Staff were to clean the suprapubic site every eight hours as needed. -An additional physician's order requesting the catheter to be changed monthly. -An order for the resident to change to a leg drainage bag every morning and wear it throughout the day. -An order for the resident to change from a leg drainage bag to a regular drainage bag at night. -Staff were to confirm securement of the catheter tubing every shift. Review of the resident's Treatment Administration Record (TAR), dated 6/28/23, showed: -Staff documented each shift that the placement of the drainage bag had been checked. -Staff documented each shift that they ensured the securement of catheter. -No catheter care had been documented by staff for the month of June 2023. During an interview on 6/28/23 at 1:11 P.M., the resident said: -Staff had never told him/her that a leg bag was to be used during the day. -He/she had a leg bag but only used it when he/she was running errands. -When staff attached the urine drainage bag at night, sometimes the entire bag would fill and have to be drained immediately. -He/she would occasionally remove the cap on his/her urinary catheter during the day to see if anything would drain but usually only a small amount of urine came out. -He/she had significant abdominal bloating that staff had said was gas. During an interview on 6/28/23 at 1:56 P.M., the resident said: -Staff had never watched him/her connect or disconnect either drainage bags. -Staff had never watched him/her drain the drainage bag. -He/she cleaned the insertion site of the suprapubic catheter when he/she showered twice a week. -Staff cleaned the insertion site of the suprapubic catheter once a month when the catheter was replaced. During an interview on 6/29/23 at 7:24 A.M., Licensed Practical Nurse (LPN) C said: -The resident was independent with cares. -The resident managed all catheter care including capping the catheter and attaching his/her own drainage bag at night. -Staff ask the resident each morning about the resident's urine output. -Nurses were responsible for changing the catheter tubing each month. -He/she gave the resident the end of a syringe to cap the urinary catheter. -He/she gave the resident a new cap to place on the drainage bag, when not in use, approximately weekly. -The resident cleaned his/her insertion site independently. -He/she did not believe the facility assessed the resident to ensure the resident was competent to perform the catheter care. -He/she did not know the resident was supposed to wear a leg bag during the day. -He/she expected the physician's orders to be followed. Observation on 6/29/23 at 8:08 A.M. showed the resident's urine drainage bag tubing was wrapped around the hand rail in the bathroom, with the end exposed to air. During an interview on 6/29/23 at 8:15 A.M., Certified Nursing Assistant (CNA) A said: -He/she was aware the resident drained his/her drainage bag independently. -He/she did not believe it was appropriate to reuse the drainage bag but, if it was to be reused, it should be capped and not left open to air. -Nurses were responsible for ensuring the resident had all necessary supplies for the catheter. -He/she expected the care plan to be followed. -He/she believed the resident cleaned the insertion site independently but was not sure. During an interview won 6/29/23 at 8:42 A.M., Registered Nurse (RN) A said: -All drainage bags were to be visualized by staff every shift. -Nurses were responsible for cleaning catheter insertion sites. -Any resident who wanted to provide their own catheter care was to be watched by staff to ensure they were capable of managing it correctly and that the activity was completed. -If a resident complained of abdominal distention and had a urinary catheter, he/she would attempt to drain it to see if that was the problem. -He/she expected the physician's orders to be followed. -If a resident refused to wear a leg bag, it was to be documented on the TAR. -Once a drainage bag was detached it could not be used again. During an interview on 6/29/23 at 9:38 A.M., CNA B said: -Nurses were responsible for cleaning the catheter insertion sites. -If a resident completed the insertion site cleaning themselves, staff should watch to ensure it was done correctly. -Once a drainage bag was removed it should not be reused due to possible contamination. -He/she expected the care plan to be followed. During an interview on 6/29/23 at 10:54 A.M., CNA C said: -He/she did not observe or chart on the resident's catheter or urine because the resident did everything himself/herself. -Nurses were responsible for cleaning the insertion site. -He/she expected the physician's orders and care plan to be followed. -He/she wasn't sure if the resident used a leg bag because the resident did his/her own cares. -Drainage bags could not be reused once detached from the catheter. During an interview on 6/29/23 at 11:14 A.M., Licensed Practical Nurse (LPN) A said: -The resident cleaned his own catheter insertion site. -The resident was to notify the staff if he/she had any problems with the catheter. -The resident was to clean the insertion site daily. -He/she knew the resident washed the insertion site daily because when he/she entered the room the resident would be at the sink washing himself/herself. -He/she expected an assessment of the resident's ability to perform cares before being deemed independent. -The resident was to be assessed quarterly to ensure proper technique for any procedure performed independently. -He/she was aware the resident removed the drainage bag in the mornings. -The resident was to place a blue cap over the catheter tubing and was given a new cap weekly. -It was okay to reconnect a drainage bag as long as the tip was cleaned before being reconnected. -He/she had never seen the resident cap the catheter tubing with anything but a blue cap. -The resident's abdominal distention was due to gas. -If the resident needed his/her catheter drained, he/she would do it themselves. -The physician's orders and care plan were to be followed. -He/she was aware the resident did not usually wear the leg drainage bag during the day. -He/she expected an order for the catheter to be capped if that was something the facility allowed. -He/she had never known the resident to refuse cares. Observation on 6/30/23 at 8:24 AM. showed: -The urine drainage bag tubing was wrapped around the hand rail in the bathroom, with the end exposed to air, with approximately 300 mililiters (ml) of clear yellow urine in the bag. During an interview on 6/30/23 at 1:17 P.M., the Director of Nursing (DON) said: -Catheter drainage bags were to be visualized by staff every day. -Nurses were to provide/observe catheter care and sign off that it was completed on the TAR. -The resident's catheter was cleaned by the nurses. -He/she knew the resident provided some of his/her own cares, believed both the resident and nurses cleaned the resident's insertion site. -The insertion site was to be cleaned daily or more often and documented on the TAR. -The resident was an exception because he/she provided some of their own cares. -The resident's insertion site was to be cleaned per the order, which was as needed only, because the resident completed his/her own cares. -Staff should have assessed the resident for competency in completing insertion site cleaning before allowing him/her to perform the task independently. -He/she believed the urologist had assessed the resident's ability to perform catheter care and therefore the facility did not need to complete an assessment for self-care. -He/she was unsure how often the resident should be reassessed for providing self-cares. -If the urologist ordered the catheter to be capped, there should have been an order. -Staff supplied the resident with supplies when he/she asked for them. -The resident knew what he/she needed and knew what to ask for. -A drainage bag that had been detached from the catheter and left open to air should not be reused. -Every time the resident detached the drainage bag from the catheter, a new drainage bag should be given to him/her for that night. -He/she did not know if nursing staff told the resident how often to clean the insertion site.

Based on observation, interview and record review, the facility failed to provide protective oversight and supervision to two residents (Resident #1 and #2) who resided on the secure care unit. On 4/17/17 staff found Resident #1 in Resident #2's room partially unclothed and being inappropriately touched by Resident #2. The facility failed to assess the behaviors, develop interventions and care plans to address the behavior, notify the resident physician of continued behaviors toward the other resident and monitor the residents. On 7/1/17, Resident #1 was found unclothed from the waist down and Resident #2 was inappropriately touching the resident's private area. The facility census was 87 residents. Record review of the facility Incident/Accident Reporting Process revised 10/2016, showed: -When an incident occurred, the nurse should initiate the following: --Evaluate the extent of the injury; --Notify the resident's legal representative and health care provider; --Document the information in the nurses notes including the notification; --Identify approaches to implement if applicable and maintain a worksheet in a separate designated area; --Complete an incident report and provide the report to the Director of Clinical Services; -The Administrator and interdisciplinary team would review the incident report the next business day in the stand up meeting; -The investigation should be completed three business days after the occurrence. Record review of the Behavioral Review and Monitoring policy revised 10/2016, showed: -Behaviors should be identified and managed appropriately; -The charge nurse should identify, document and inform the health care provider about an individual's mental status, behavior and cognition including; --Onset, duration and frequency of the behavior, cognition or mood; -If a resident was being managed for behaviors, the associate and the healthcare provider would obtain and document ongoing re-assessments of changes in behavior; -When a resident exhibits an unusual change in condition, such as a behavior, notify the healthcare provider and legal representative; -Update the care plan. 1. Record review of Resident #1's Admission Record showed he/she was admitted to the facility on [DATE], with the following Diagnosis: [REDACTED]. -Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety); -Major Depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable); -Had a Durable Power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known). Record review of the resident's Care Plan dated 2/7/17, showed he/she: -Had a DPOA; -Had impaired cognitive function or impaired thought processes related to Alzheimer's disease and impaired thought processes; --There was no care plan related to behaviors including removing clothing or inappropriate sexual behaviors. Record review of Resident #1's notes dated 2/18/17 through 3/6/17, showed no documentation regarding sexually inappropriate behaviors. Record review of Resident #1's Physician's Progress Notes dated 3/8/17 showed: -The resident was not capable of understanding his/her rights/responsibilities due to a [DIAGNOSES REDACTED]. Record review of Resident #1's nurses notes dated 3/8/17 through 3/29/17 showed no documentation regarding sexually inappropriate behaviors. Record review Resident #1's General Note dated 3/30/17 at 11:35 A.M., showed: -Resident #1 was in Resident #2's room rubbing Resident #2's knee; -Earlier this morning, Resident #1 was following Resident #2 around and when asked about it Resident #1 said he/she thought it was his/her parent; -Resident #1 was redirected. Record review of Resident #1's nurses notes dated 3/31/17 through 4/6/17, showed no documentation regarding sexually inappropriate behaviors. Record review of Resident #1's Nursing Progress Note dated 4/7/17 at 8:59 A.M., showed: -Resident #1 was in Resident #2's room again helping him/her hang clothes in the closet; -Resident #1 stated Resident #2 was his/her parent; -Resident #1 redirected out of Resident #2's room. Record review of Resident #1's Nursing Progress Note dated 4/7/17 at 5:29 P.M., showed: -Resident #1 was found in Resident #2's room cuddling in bed with him/her; -Resident #1 stated he/she was going to marry Resident #2; -Resident #1 was redirected out of the room; -Resident #1's family member called and talked to the resident; -No investigation was completed by the facility for this incident. Record review of Resident #1's notes dated 4/8/17 through 4/9/17, showed no documentation regarding sexually inappropriate behaviors. Record review of Resident #1's Nursing Progress Note dated 4/10/17 at 11:41 A.M., showed: -Resident #1 was caught in Resident #2's room in his/her bed sleeping three times today; -Resident #1 was redirected out of Resident #2's room. Record review of Resident #1's notes dated 4/11/17 through 5/13/17, showed no documentation regarding sexually inappropriate behaviors. Record review of Resident #1's Minimum Data Set (MDS), a federally mandated tool required to be completed by the facility staff for care planning, dated 5/13/17, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Did not have behaviors; -Required assistance of one staff member with ambulation; -Required limited assistance of two staff members with personal hygiene; -Required extensive assistance of two staff members with dressing; and -Occasionally incontinent of urine and frequently incontinent of bowel. Record review of Resident #1's notes dated 5/14/17 through 5/17/17, showed no documentation regarding sexually inappropriate behaviors. Record review of Resident #1's Resident Programs Progress Note dated 5/17/17 at 12:13 P.M., showed: -A care plan meeting was held for the resident; -There was no documentation showing the behaviors/incidents were discussed during the meeting or that a care plan was developed related to Resident #1's behaviors. Record review of Resident #1's Nurses Notes/Behavior Notes dated 5/18/17 through 6/26/17, showed no documentation regarding sexually inappropriate behaviors. Record review of Resident #1's General Note dated 6/27/17 at 3:48 P.M., showed: -Resident #1 kissed Resident #2 on the forehead; -Redirection was tried but it made Resident #1 angry; -Resident #1 was still angry and wanted to know why he/she could not kiss his/her spouse (Resident #2); -Resident #1 was redirected with a staff member and went outdoors. Record review of Resident #1's Physician's Progress Notes dated 6/28/17, showed the resident: -Was seen per staff concerns; -Had dementia with aggressive behaviors; -Had increased behaviors, becoming aggressive and possessive; -Had been kicking and hitting, rip clothes off of staff members backs which was not documented by the staff in the resident's medical record; -Was unable to be redirected; -A new medication was added: Depakote 125 milligrams (mg) two times per day for dementia with behaviors. Record review of Resident #1's Order Summary Report (OSR) dated 7/2/17 ,showed: -Depakote 125 milligrams (mg) two times per day for dementia with behaviors. Record review Resident #1's Incident Report dated 7/1/17, completed by Licensed Practical Nurse (LPN) A showed: -Date of incident: 7/1/17 at 12:30 P.M.; -An incident involving: Resident #1 and Resident #2; -Witnessed by: Certified Medication Technician (CMT) A; -Alleged: Witnessed resident to resident sexual behavior; -No apparent harm or injury; -The weekend Registered Nurse (RN), House Supervisor A/DPOA was notified at 12:35 P.M. regarding Resident #1; -No documentation staff notified Resident #2's DPOA; -The physician's Nurse Practitioner was notified at 2:00 P.M. 2. Record review of Resident #2's Admission Record showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. --Major depressive disorder; --Had a DPOA. Record review of Resident #2's Care Plan dated 1/3/17, showed he/she: -Had impaired cognitive function or impaired thought processes related to Alzheimer's disease and impaired thought processes; -Had a DPOA; --There was no care plan related to behaviors including sexual behaviors. Record review of Resident #2's admission MDS dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Sometimes understood others; -Did not have behaviors; -Needed the limited assistance of one staff member for transfers and dressing; -Needed the supervision and limited assistance of one staff member for ambulation; -Used a walker and/or a wheelchair for mobility. Record review of Resident #2's Social Services Progress Note dated 1/31/17, showed: -Social Services spoke with the resident's DPOA and let him/her know the resident needed to be moved to the secure care unit; -The resident was having inappropriate behaviors; -The DPOA agreed with the move; --There was no staff documentation related to the type of behaviors the resident was exhibiting. Record review of Resident #2's Nursing Progress Note dated 4/7/17 at 10:26 A.M., showed: -Resident #2 came out of his/her room looking for Resident #1; -Resident #2 continued to look for Resident #1 who was asleep in his/her room. Record review Resident #2's Nursing Progress Note dated 4/7/17 at 1:26 P.M., showed Resident #2 was trying to pull Resident #1 into his/her room, but the nurse stopped them. Record review of Resident #2's Nursing Progress Note dated 4/7/17 at 5:46 P.M., showed: -Resident #2 tried numerous times to get Resident #1 into his/her room; -At one point, the residents were cuddling in Resident #2's bed; -The residents were separated and Resident #1 was removed from the room; --No investigation was completed by the facility for this incident. Record review of Resident #2's Social Services Progress Note dated 4/10/17 at 11:45 A.M., showed: -The Social Services Coordinator (SSC) met with Resident #2 in his/her room for a quarterly review; -Resident #2 was alert, had memory loss and cognitive impairment; -Resident #2 used a wheelchair for mobility; -Resident #2 had recently been making advances towards Resident #1 and was inviting Resident #1 to his/her room; -The staff separated the residents as needed. Record review of Resident #2's Focus Charting-Mood or Behavior Changes Note dated 4/11/17 at 6:00 A.M., showed: -Resident #2 was found in the common area enticing Resident #1 into his/her room; -The nurse removed Resident #2 twice to another area in the common area; -Resident #2 continued to return to Resident #1 who was only alert and oriented to his/her name; -The nurse was interrupted in monitoring this situation for only a few minutes to answer a call light in another room; -When the nurse returned to the common area both residents were missing; -Both residents were found in Resident #2's room; -Resident #1 was removed and was placed in a recliner in the common area; -Communication with Resident #2 by the nurse to leave Resident #1 alone was understood; -Report was given to on-coming staff at shift change. Record review of Resident #2's Nursing Progress Note dated 4/11/17 at 2:22 P.M., showed: -Resident #2 had aggressively been pursuing Resident #1; -Resident #2 spoke to Resident #1 in a controlling tone demanding Resident #1 come to his/her room; -Twice on this shift, Resident #2 grabbed Resident #1's arm and pulled it to the point of Resident #1 stumbling and once almost falling; -Attempts to redirect Resident #2 often do not work. Record review of Resident #2's Focus Charting-Mood or Behavior Changes Note dated 4/12/17 at 10:38 A.M., showed: -Resident #2 had tried pulling Resident #1 to his/her room; -Resident #1 was found in Resident #2's room early this morning and was quickly redirected out of his/her room. Record review Resident #2's Nursing Progress Note dated 4/12/17 at 12:17 P.M., showed: -Resident #2's DPOA was contacted about the resident following and pulling on Resident #1 towards his/her room; -The staff were monitoring the situation and would continue to monitor. Record review of Resident #2's Focus Charting-Mood or Behavior Changes Note dated 4/12/17 at 6:38 P.M., showed: -Resident #2 came out of his/her room stating Where's my supposedly spouse; -The nurse explained Resident #1 was not his/her spouse; -Resident #2 got angry stating I know that he/she is my friend; -Resident #2 was told Resident #1 was in bed; -Resident #2 wanted to know which room and it was explained to him/her this information could not be given, which made him/her very angry; -Resident #2 finally went back to his/her room. Record review Resident #2's Focus Charting-Mood or Behavior Changes Note dated 4/13/17 at 7:15 P.M., showed: -Resident #2 displaying stalker behaviors by seeking out Resident #1; -The nurse was sitting with Resident #1 when Resident #2 came up and told Resident #1 it was time to come home, he/she had been gone to long; -The nurse explained to Resident #2 that Resident #1 was not his/her spouse and was already married which upset him/her; -Resident #2 then looked at Resident #1 angrily and said if that's how you want it; -When the nurse tried to explain again to Resident #2, he/she threw his/her hands up and said Resident #1 was his/her companion; -Resident #2 was taken to his/her room; -Resident #1 then started talking about his/her spouse and family; -Resident #1's family member was called; -Upon putting Resident #1 to bed, the staff had to distract Resident #2 so he/she did not know where the other resident lived. Record review of Resident #2's Focus Charting-Mood or Behavior Changes Note dated 4/14/17 at 1:03 P.M., showed: -Resident #2 has been forcefully attempting to get Resident #1 into his/her room with demanding words and physically trying to pull him/her; -Resident #2 was told Resident #1's spouse would be very upset by his/her behavior and he/she stopped the behavior until later in the afternoon when Resident #2 began the same actions/verbalizations just not as forceful. Record review of the resident's Focus Charting-Mood or Behavior Changes Note dated 4/14/17 at 9:41 P.M., showed: -Resident #2 aggressively telling the Resident #1 Let's go home, NOW; -Resident #2 tried going into the bath house during Resident #1's bath. Record review of Resident #2's Focus Charting-Mood or Behavior Changes Note dated 4/15/17 at 10:04 A.M., showed: -Resident #2 continued to have stalking behaviors toward Resident #1; -Resident #2 continued to grab Resident #1's hand and would try to pull him/her into his/her room; -The residents were separated multiple times; -Staff tried to redirect Resident #2 into other activities such as puzzles, but Resident #2 was not interested. Record review of Resident #2's Focus Charting-Mood or Behavior Changes Note dated 4/15/17 at 5:01 P.M., showed: -Resident #2 continued with behaviors seeking out Resident #1 and attempting to pull Resident #1 with him/her; -Resident #2 was redirected and told he/she could not do that; -Resident #2 did not understand his/her limitations between himself/herself and other resident. Record review of Resident #2's Focus Charting-Mood or Behavior Changes Note dated 4/17/17 at 3:16 P.M., documented by LPN C showed: -Resident #2 had two incidents of aggressive/sexual behaviors with Resident #1; -The first incident, Resident #2 was found inappropriately touching Resident #1 under his/her clothes; -The second behavioral incident, Resident #2 was not allowing Resident #1 to leave his/her room; -Resident #1 was hollering let me go and Resident #2 continued to hold on to Resident #1's arm, pulling the resident back towards him/her; -This nurse was able to free Resident #1's arm and walk him/her out of the room; -Resident #2 then grabbed this nurse's arm and shook it stating the nurse had no right to take the other resident away; -This nurse reported this to the next shift; --Note: No investigation was completed by the facility for this incident. Record review of Resident #2's Physician's Progress Note dated 4/18/17, showed: -Resident #2 presented with sexual, aggressive behaviors per staff; -Resident #2 had a fixed delusion that Resident #1 belongs to him/her; -Resident #2 had told staff I can have any male/female I want; -However, Resident #2 was very fixated on a specific peer; -Fixation was sexual in nature; -Resident #2 was putting his/her hands on Resident #1 and tried to put his/her hands on his/her private lower body parts. Record review Resident #2's Focus Charting-Mood or Behavior Changes Note dated 4/18/17 at 12:10 P.M., showed: -Resident #2 continued to have aggressive and increased hypersexual behaviors with Resident #1; -New physician's orders [REDACTED].#2's DPOA approved; -Resident #2's DPOA was contacted by phone and agreed to the trial of the medication. Record review of Resident #2's OSR showed: -On 4/18/17, Premarin tablet 0.3 mg by mouth at bedtime for hypersexual behavior; and -This medication was still being administered to the resident. Record review of Resident #2's notes from 4/19/17 through 5/15/17, showed no documentation of behaviors. Record review of Resident #2's Physician's Progress Note dated 5/15/17, showed the resident was seen and doing better with his/her behaviors per the staff. Record review of Resident #2's notes from 5/16/17 through 6/12/17, showed no documentation of behaviors. Record review Resident #2's General Note dated 6/13/17 at 6:44 P.M., showed: -Resident #2 has started stalking Resident #1 again; -Redirection was tried numerous times without success; -The staff took Resident #1 to his/her room to get ready for bed and Resident #2 sat outside Resident #1's door. Record review of Resident #2's notes from 6/14/17 through 6/17/17, showed no documentation of behaviors. Record review of Resident #2's Physician's Progress Note dated 6/17/17, showed: -Resident #2 was seen due to a staff concern related to a fall; -Resident #2 was seen in the common areas talking with friend; --There was no documentation showing the resident's behaviors were communicated to the physician. Record review of Resident #2's notes from 6/18/17 through 6/30/17, showed no documentation of behaviors. Record review of Resident #2's Focus Charting-Mood or Behavior Changes note dated 7/1/17 at 1:36 P.M., documented by LPN B showed: -Resident #2 was found before the noon meal in his/her room with Resident #1; -Resident #1 was topless and Resident #2 was groping in a sexually inappropriate manner Resident #1's upper private area; -Resident #1 believed Resident #2 was his/her boyfriend/girlfriend or spouse; -Resident #2 was aware Resident #1 was not his/her spouse and has tried to lure Resident #1 into his/her room on multiple occasions; -Resident #2 had a history of [REDACTED].#1; -Staff attempt to keep the pair out in the common area when they want to be together; -The family member of Resident #1 was notified of the incident; --There was no documentation that showed the residents' physicians or Resident #2's DPOA were notified of the incident, or if interventions were put into place after the incident. Record review of Resident #2's Focus Charting-Mood or Behavior Changes Note dated 7/1/17 at 4:57 P.M., showed: -Resident #2 continued to persist in getting Resident #1 to follow him/her to his/her room; -The staff kept Resident #1 from going to his/her room. During an interview on 7/2/17 at 11:45 A.M., RN House Supervisor A/DPOA said: -On 7/1/17 he/she was told by LPN A, Resident #1 was found with Resident #2 in his/her room; -Resident #1 had no clothing on from the waist up and Resident #2 was fondling Resident #1's upper private area; -Resident #2 was placed on the SCU (MONTH) (YEAR), after being found in another residents' room. -He/she was unaware of any previous sexual contact between Resident #1 and Resident #2; -No other incidents had been reported to him/her between the two residents other than the constant seeking behaviors of Resident #2 towards Resident #1; -He/she did not mind when the residents would sit together, but Resident #2's behaviors had increased towards Resident #1; -Resident #2 would constantly seek out Resident #1; -Resident #2 always stated he/she wanted to marry Resident #1; -There were ongoing issues with Resident #2 seeking Resident #1; -He/she had reported the issues in the past to the management department; -When he/she was informed of the sexually inappropriate behavior of Resident #2 towards Resident #1 on 7/1/17; -He/she called LPN B/Manager on Duty, and reported the sexually inappropriate behavior; -He/she was unsure if the event was reported to the State Agency (SA); -He/she was to report all incidents to LPN B/Manager on Duty who was responsible for investigating and reporting. Observation on 7/2/17 at 12:55 P.M., showed: -Resident #1's room was located across a corner area from Resident #2's room; -The residents' rooms were approximately 20 feet apart. During an interview on 7/2/17 at 1:00 P.M., Certified Nursing Assistant (CNA) A said: -Resident #2 had sexually inappropriate behaviors towards Resident #1; -Resident #2 beckons Resident #1 to come into his/her room; -He/she has seen Resident #1 sitting on Resident #2's bed very closely to him/her; -Resident #2 only had sexually inappropriate behaviors towards Resident #1 and not towards any other residents; -The residents would hold hands and Resident #2 would rub Resident #1's arm; -Resident #2 thought Resident #1 was his/her spouse; -The residents were both confused; -He/she had been working on the SCU since Resident #1 had been admitted to the SCU; -Resident #2 had these constant behaviors towards Resident #1 continually; -The staff tried to keep the residents from going into Resident #2's room; -He/she was working on the SCU during the day on 7/1/17; -He/she had been told of an incident by CMT A that occurred on 7/1/17; -CMT A was coming out of Resident #2's room with the residents; -He/she stated Resident #1 was found with his/her clothes off from the waist down and Resident #2 was inappropriately touching Resident #1's lower private area; -CNA B had assisted with getting Resident #1 dressed; -He/she had been told to always keep an eye on the residents; -He/she had not been told about any other monitoring interventions for the residents after the incident occurred; -During the evening hours on 7/1/17, the two residents were sitting out in the common area together talking; -Resident #2 tried to take Resident #1 into his/her room and he/she stopped him/her; -He/she told Resident #2 to not do that and redirected him/her; -If behaviors occur, he/she would report the behaviors to the charge nurse. During an interview on 7/2/17 at 1:25 P.M., CNA B said: -Resident #2 had sexually inappropriate behaviors towards Resident #1 and towards the staff; -Resident #2 was not alert and oriented and the behaviors were a part of his/her disease process; -Resident #2 did not have sexually inappropriate behaviors towards other residents, only towards Resident #1. -Resident #2 would touch him/her inappropriately during cares; -When he/she would transfer Resident #2, he/she would touch his/her bottom; -Resident #2 would also put his/her hands on his/her front lower private area; -He/she would report all sexually inappropriate behaviors to the charge nurse; -The behaviors of Resident #2 towards Resident #1 were on-going behaviors; -He/she had seen Resident #1 kiss Resident #2 on the couch awhile back; -Resident #2 favored Resident #1 and thought they were married; -Resident #2 did not touch Resident #1 inappropriately when they were out in the common area; -Resident #2 would get upset if the staff tried to separate him/her from Resident #1; -Resident #1 was not alert and oriented; -Resident #2 would try to take Resident #1 into his/her room; -On 7/1/17, CMT A came and asked him/her for help to get Resident #1 dressed; -CMT A stated he/she went to Resident #2's room and found Resident #1 with his/her clothes off from the waist down. Resident #2 was inappropriately touching Resident #1 in his/her lower private area; -CMT A reported the incident to the charge nurse; -He/she had been told to watch the residents and to watch for Resident #2's door to be shut; -He/she was not told about any other additional monitoring or interventions after the incident on 7/1/17, by the charge nurse. During an interview on 7/2/17 at 1:50 P.M., CMT A said: -Resident #2 had behaviors towards Resident #1 and often tried to lure Resident #1 to his/her room; -Resident #2 was fond of Resident #1 in a sexual nature; -Resident #2 did not seek out any other residents; -The residents would often sit together and eat together; -Both residents were confused; -He/she was doing his/her medication pass on 7/1/17 around lunch time and could not locate Resident #1 to give him/her medications; -He/she checked Resident #2's room and found Resident #1 with no clothes on from the waist down standing by the closet; -Resident #2 had his/her hands on the Resident #1's lower private area touching him/her inappropriately; -He/she went and asked CNA B for help to redirect the residents; -CNA B came into the room and they removed Resident #2; -He/she reported the incident to LPN A; -LPN A was responsible for reporting the incident to the Director of Nursing (DON); -LPN A told him/her to watch the residents to make sure they did not go into Resident #2's room; -This was the normal monitoring of the residents; -He/she had not been told of any other additional monitoring for the residents; -Today he/she stopped Resident #2 from taking Resident #1 into his/her room; -These were ongoing behaviors of Resident #2. During an interview on 7/2/17 at 2:00 P.M., LPN A said: -He/she was the weekend day shift charge nurse; -Resident #2 would seek one resident, Resident #1 on the SCU; -Resident #1 was not alert and oriented and would do what Resident #2 said to do; -Resident #2 was more alert than Resident #1 but still confused; -Resident #2 would lure Resident #1 into his/her room often; -Resident #2 always tried to get Resident #1 to go to bed with him/her in a sexual nature; -Resident #2 would make a bee line to Resident #1 as soon as he/she saw Resident #1; -On 7/1/17, CMT A reported Resident #2 was groping Resident #1's upper chest private area and Resident #1's clothing was off from the waist up; -He/she had documented the sexually inappropriate incident in Resident #2's medical record; -Did not notify Resident #2's DPOA; -Did notify RN House Supervisor A/DPOA. -He/she did not notify the residents' physician; -No additional monitoring for the residents put in place after the incident; -Continued the normal monitoring of Resident #2 by watching him/her because of his/her behaviors; -Management was responsible for putting in monitoring interventions; -He/she had been made aware of the correct incident occurrence later on 7/1/17 including Resident #1 had been found with his/her clothes off from the waist down and Resident #2 was inappropriately touching the Resident #1's lower private area; -He/she did not go back and document the new incident details in the medical record or notify anyone of the new incident occurrences. Observation on 7/2/17 at 2:12 P.M., showed: -Resident #2 self propelled to Resident #1 and parked his/her wheelchair approximately seven feet behind the resident; -There was no staff near the area monitoring Resident #2. During an interview on 7/2/17 at 2:22 P.M., RN House Supervisor A/DPOA said: -The charge nurses were responsible for putting residents on one on one monitoring after an incident occurs; -He/she expected the charge nurse to assess the residents after the sexual incident, notify both residents' family and physician and document the incident in both residents' medical records; -He/she had reported to LPN B/Manager on Duty, Resident #1 was found unclothed from the waist up, and was being groped by Resident #2 in the upper private areas; -He/she had not been told by the charge nurse Resident #1's was undressed from the waist down and Resident #2 was inappropriately touching Resident #1's lower private area; -He/she expected the charge nurse to re-report the correct facts of the incident and document the correct incident occurrences in both residents' medical record. During an interview on 7/2/17 at 2:45 P.M., LPN B/Manager on Duty said: -He/she was the manager on duty if something occurred at the facility; -If any incidents occur, the staff would call him/her and report it; -He/she was responsible for reporting to the Administrator; -If you were friendly to Resident #2, he/she would want to hold your hand; -He/she was aware of the ongoing issues with Resident #1 and Resident #2; -Resident #2 thought Resident #1 was his/her spouse; -Resident #1 and Resident #2 buddy up a lot; -He/she had been notified by RN House Supervisor A/DPOA about concerns with Resident #2 towards Resident #1; -RN House Supervisor A/DPOA said Resident #1 had been found with his/her shirt off in Resident #2's room; -He/she was not told Resident #2 was inappropriately touching Resident #1's upper private areas; -He/she did not start an investigation or report this to the Administrator because he/she was unaware of the sexual nature of the incident, so he/she felt it was not a reportable incident; -When an incident did occur, he/she expected the charge nurse to monitor the resident with one on one monitoring; -He/she expected the staff to report the incident to the family and physician; -He/she expected the charge nurse to assess the resident's private areas for injury after the incident occurred; -He/she was unaware the incident was documented incorrectly and Resident #1 had been found with his/her clothing off from the waist down and Resident #2 was inappropriately touching Resident #1's private lower area; -He/she expected the charge nurse to re-document the correct sexually inappropriate behaviors of the incident and re-report the incident. During an interview on 7/2/17 at 3:10 P.M., the Administrator said: -Resident #2 had previous sexual incidents with a resident a long time ago and that was why the resident was moved to the secure care unit; -He/she was unaware of any behaviors for Resident #2 on the SCU; -If an inappropriate sexual incident occurred, he/she expected to be notified immediately; -About one hour ago, LPN B, the manager on call reported Resident #1 was found with his/her shirt off and Resident #2 was grabbing his/her upper private parts; -All staff had a responsibility to report any sexual incidents directly to him/her both LPN B and RN House Supervisor A s

Based on observation, interview, and record review, the facility staff failed to provide adequate protective oversight, supervision and nursing care in accordance with the resident's condition, by not completing a root cause analysis to determine the cause of a resident's fall, by not putting in place individual interventions to prevent falls, and not completing an individualized care plan related to falls for one sampled resident (Resident #9) who had 22 falls, including falls with injury or suspected injury; for one sampled resident (Resident #12) who fell and sustained a hip fracture (broken hip bone); for one sampled resident (Resident #13) who fell twice within three hours and suffered a left shoulder fracture (broken shoulder bone) and a left arm fracture from two different falls on the same day; for two sampled residents (Resident #2 and #15) who had injury from falls (including lacerations (a cut into the skin) to the resident's head); for two sampled residents (Resident #1 and #4) who had falls with and without injury (including facial lacerations) out of 15 sampled residents. The facility identified 27 resident's who had falls, and six residents who had major injury falls. The facility census was 86 residents. Record review of the facility's Fall Prevention policy revised 3/1/11, showed: -A Fall Risk Assessment Form will be used to assess new admissions for the potential for falls. This assessment will be completed on admission and quarterly (at a minimum) thereafter or with significant change. -Document in the medical record the resident/family education, fall risk program, and specific resident interventions/approaches to reduce the potential for future incidents. -An incident report will be completed at the time of the fall. -A comprehensive nurse's note will be documented and must include that the resident's physician and family were notified. -Initiate the Nursing to Therapy Referral form if this is a repeat fall. -Care plan must be updated and include appropriate and individualized interventions. -Interdisciplinary team members will discuss the findings of fall investigations, collaborate and develop an appropriate plan of care, and re-evaluate a resident's fall risk potential. 1. Record review of Resident #9's Face Sheet dated 12/26/13, showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Personal history of falls. -Difficulty walking. -Generalized muscle weakness. -Hypertension (HTN-high blood pressure). -[DIAGNOSES REDACTED](abnormal heart rhythm). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by the facility staff for care planning purposes) dated 12/26/13, showed he/she: -Was severely cognitively impaired. -Had no behaviors. -Required supervision for bed mobility, transfers, walking, eating, toilet use, and personal hygiene. -Was continent of bowel and bladder. -Had two or more injury falls since admission. Record review of the resident's Fall Investigation Worksheet dated 12/27/13 at 3:45 A.M., showed: -The resident had an un-witnessed fall at his/her bedside while trying to toilet himself/herself. The resident had increased confusion and wandering. -The resident had a reddened area down the left side of his/her back but denied hitting his/her head. -Staff documented the intervention was the resident could benefit from a bed alarm. -This was his/her first fall. Record review of the resident's Nurse's Note dated 12/27/13 at 4:30 A.M., showed he/she was alert and oriented to himself/herself only. The resident attempted to toilet himself/herself. The resident would benefit from a bed alarm. Record review of the resident's Nurse's Notes dated 12/27/13 at 10:40 A.M., showed he/she was alert and oriented to himself/herself and where he/she was. The resident had severe short-term memory loss and could not retain what time it was for more than one minute. Record review of the resident's Fall Investigation Worksheet dated 12/28/13 at 4:30 A.M., showed: -The resident had an un-witnessed fall attempting to toilet himself/herself. The resident was cognitively impaired and had anxiety. -Staff documented the interventions of moving items around in the resident's room, to use the bed alarm at all times, and remind the resident to use his/her call light. Record review of the resident's Nurse's Note dated 12/28/13 at 4:30 A.M., showed the resident was found sitting on his/her buttocks on his/her floor at the bedside. The resident had a two centimeter (cm) skin tear to his/her left forearm. This was the resident's second fall. Record review of the resident's Fall Prevention Checklist dated 12/31/13, showed he/she had a pain management program and a hi-low bed. Record review of the resident's Fall Risk assessment dated [DATE], showed he/she had a score of eight and was not at a high risk for falls. Record review of the resident's first Fall Investigation Worksheet dated 2/2/14 at 6:45 A.M., showed: -The resident had a witnessed fall standing by a recliner. -The staff documented the intervention of an x-ray to the right hip and femur (the leg bone above the knee) which was negative for any injury and laboratory blood draws. -This was resident's third fall. Record review of the resident's Nurse's Note dated 2/2/14 at 6:50 A.M., showed he/she was standing by the recliner in the common area, and stepped back and fell . Record review of the resident's second Fall Investigation Worksheet dated 2/2/14 at 7:30 A.M., showed: -The resident had an un-witnessed fall walking around the common area. The resident was very drowsy. -The resident had a sore hip. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. The resident was assessed and did not have pain. -This was resident's fourth fall. Record review of the resident's Nurse's Notes dated 2/2/14 at 7:30 A.M., showed he/she was standing in the same area by the common area. The resident moved away from the recliner and fell on his/her buttocks. The resident complained of right hip pain. Record review of the resident's Nurse's Notes dated 2/2/14 at 8:00 A.M., showed an x-ray of the resident right hip and laboratory testing was ordered by the resident's physician. Record review of the resident's Nurse's Notes dated 2/2/14 at 10:30 A.M., showed the resident's x-ray reported no broken bones. Record review of the resident's Nurse's Notes dated 2/2/14 at 4:00 P.M., showed some of the resident's medications were not administered to him/her based on the laboratory reports. Record review of the resident's Nurse's Notes dated 2/2/14 at 8:30 P.M., showed the resident could not be left without assistance of staff and required one-on-one supervision. The resident requested to go to bed when he/she was already in bed. Record review of the resident's third Fall Investigation Worksheet dated 2/2/14 at 9:00 P.M., showed: -The resident was in his/her room, coming back from the bathroom and had a non-injury fall. The resident was sluggish, had an unsteady gait and increased agitation. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was the resident's fifth fall. Record review of the resident's Nurse's Notes dated 2/2/14 at 10:00 P.M., showed the resident was in his/her room and had gotten up to use the bathroom and fell . The resident was assessed and had no injuries. Record review of the resident's Fall Investigation Worksheet dated 2/3/14 at 9:45 P.M., showed: -The resident had a un-witnessed fall in his/her room walking to the restroom and had an incontinent episode. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was the resident's sixth fall. Record review of the resident's Nurse's Notes dated 2/3/14 at 10:00 P.M., showed the resident was found sitting on the floor half way between his/her bed and the bathroom with urine on the floor. The resident's alarm was in place on the bed at this time. Record review of the resident's Nurse's Notes dated 2/6/14 at 2:00 P.M., showed he/she was exit seeking, anxious, and pacing on the secure care unit that day. Record review of the resident's Fall Investigation Worksheet dated 2/6/14 at 7:30 P.M., showed: -The resident had an un-witnessed fall in his/her room. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was the resident's seventh fall. Record review of the resident's Nurse's Notes dated 2/6/14 at 10:00 P.M., showed the resident yelled out and staff responded. The resident was found sitting on the floor with a large amount of blood coming from his/her nose. Neurochecks (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs) were completed. The resident's nose had a large amount of swelling and ice was applied. Record review of the resident's Fall Investigation Worksheet dated 2/7/14 at 6:55 A.M., showed: -The resident had an un-witnessed fall in his/her room attempting to walk. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was resident's eighth fall. Record review of the resident's Nurse's Notes dated 2/7/14 showed staff did not document information related to the resident's fall. Record review of the resident's Fall Investigation Worksheet dated 3/10/14 at 7:40 A.M., showed: -The resident was getting up from a recliner in the common area and fell . -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was resident's ninth fall. Record review of the resident's Nurse's Notes dated 3/10/14 at 7:40 A.M., showed the resident was found on the floor after yelling out twice. The resident was sitting in front of his/her recliner on his/her bottom. The resident complained of right hip pain but had no bruising or redness to his/her right hip. The resident was assisted to his/her feet with the assistance of two staff members. Record review of the resident's Fall Investigation Worksheet dated 3/29/14 at 7:40 P.M., showed: -The resident fell while picking up something. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was the resident's tenth fall. Record review of the resident's Nurse's Notes dated 3/29/14 at 11:10 P.M., showed the resident fell while picking something up off the floor. The resident denied any pain or discomfort. Record review of the resident's Fall Risk assessment dated [DATE], showed the resident had a score of ten and was a high risk for falls. Record review of the resident's Fall Investigation Worksheet dated 4/6/14 at 1:20 P.M., showed: -The resident had an un-witnessed fall with an abrasion to the right knee after coming out of another resident's room. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was the resident's eleventh fall. Record review of the resident's Nurse's Notes dated 4/6/14 at 1:44 P.M., showed the resident was up and in another resident's room looking outside to see if his/her family was here. The resident stumbled on his/her way out of the room and fell on to his/her knees. The resident had an abrasion to his/her right knee. Record review of the resident's Quality of Care Progress Notes dated 4/8/14, showed: -The resident had nine falls since he/she was admitted to the facility. -The resident needed to wear non-skid socks at bedtime. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. Record review of the resident's Fall Prevention Checklist dated 4/8/14, showed he/she had a pain management program and a hi-low bed. Record review of the resident's Fall Investigation Worksheet dated 4/21/14 at 4:10 P.M., showed: -The resident had an un-witnessed fall while trying to transfer out of a chair unassisted. -The staff were to supervise the resident during transfers because the resident tried to transfer unassisted most of the time. -This was resident's twelfth fall. Record review of the resident's Nurse's Notes dated 4/21/14 at 5:30 P.M., showed: -The resident was found by a staff member in his/her room on the floor mat. The resident was assessed and complained of right hip pain. The resident was assessed with [REDACTED]. Record review of the resident's Fall Investigation Worksheet dated 4/28/14 at 7:30 P.M., showed: -The resident had a witnessed fall in his/her room. The resident had swelling and bruising to his/her forehead and bruising to his/her right knee. -The staff documented the intervention for this fall was to remind the resident to call for help when needed. -This was the resident's thirteenth fall. Record review of the resident's Nurses Notes dated 4/28/14 at 7:30 P.M., showed the resident's roommate yelled out. The resident was found on the floor in his/her room. The resident was assessed and had swelling and bruising to the medial side of his/her forehead and abrasions with swelling to his/her right shin. Record review of the resident's physician's orders [REDACTED]. -Buspar 15 milligrams (mg): Take one tablet by mouth twice daily for anxiety. -Depakote 250 mg: Take one tablet by mouth twice daily for dementia with behaviors. -Ativan 0.5 mg: Take one tablet by mouth three times daily for anxiety and pacing. -Ativan 0.5 mg: Take one tablet by mouth every four hours as needed for anxiety, agitation, and pacing. Record review of the resident's Fall Investigation Worksheet dated 5/11/14 at 2:20 P.M., showed: -The resident was rummaging through another resident's belongings in another room and was seen by a staff member. The other resident tried to escort Resident #9 out of the room when Resident #9 fell and hit his/her head. Resident #9 had a head laceration to the middle back of his/her head, a knot on the right side of his/her head, and complained of right hip pain. -The staff did not document that a root cause analysis for the resident's fall was completed, or additional individualized interventions were put into place after the fall. -This was the resident's fourteenth fall. Record review of the resident's Nurse's Notes dated 5/11/14 at 3:20 P.M., showed the nurse was notified by a staff member that a loud smack was heard and the resident was found crawling on the floor. Blood ran from the back middle portion of the resident's head, due to a 5 cm deep laceration. The resident was yelling to get him/her out of the room. The resident had a quarter size knot to the left side back of his/her skull and complained of right hip pain. The resident was sent to the emergency room . Record review of the resident's Nurse's Notes dated 5/11/14 at 10:20 P.M., showed the resident returned from the hospital with staples that were intact in the back of his/her head. The resident had new bruising to his/her left hip, left forearm, and left elbow. Record review of the resident's Fall Investigation Worksheet dated 5/29/14 at 11:25 A.M., showed: -The resident had a witnessed fall when he/she was in another resident's room visiting, and caught his/her foot on a walker and fell . -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was the resident's fifteenth fall. Record review of the resident's Nurses Note's dated 5/29/14 at 1:45 P.M., showed the resident was visiting another resident in another room. The resident got his/her feet tangled in a walker and fell . The resident had a small abrasion to his/her right inner forearm. Record review of the resident's Fall Risk assessment dated [DATE], showed the resident had a score of ten and was a high risk for falls. Record review of the resident's POS dated 6/1/14 through 6/30/14, showed physician's orders [REDACTED]. -Buspar 15 mg: Take one tablet by mouth twice daily for anxiety. -Depakote 250 mg: Take one tablet by mouth twice daily for dementia with behaviors. -Seroquel 25 mg: Take one tablet by mouth daily for delusions and behaviors. This medication was discontinued on 6/21/14. -On 6/21/14 a new physician's orders [REDACTED]. This order was discontinued on 6/26/14. -Ativan 0.5 mg: Take one tablet by mouth three times daily for anxiety and pacing. -Ativan 0.5 mg: Take one tablet by mouth every four hours as needed for anxiety, agitation, and pacing. Record review of the resident's Fall Investigation Worksheet dated 6/2/14 at 5:30 P.M., showed: -The resident had a witnessed fall while wandering around in the dining area. The resident stumbled and lost his/her footing. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was the resident's sixteenth fall. Record review of the resident's Nurse's Notes 6/2/14 at 9:45 P.M., showed the resident was walking in the dining room and fell on his/her right side. The resident was assessed with [REDACTED]. Record review of the resident's Physician's Progress Note dated 6/2/14, showed: -The resident was ambulating in the hallway confused and anxious. -The staff reported the resident had increased anxiety and was fearful. -The resident's psychotropic medications were increased. Record review of the resident's Quality of Care Progress Notes dated 6/3/14, showed: -The resident had a total of eight falls over the past three months. -The resident had tried a Merry Walker (a combination walker/chair ambulation restraint device with tubular rectangular gated frame that can be weighted to prevent tipping) PVC (polyvinyl chloride) ambulation device, but the resident would crawl out of it. -The staff did not document that a root cause analysis for the resident's falls was completed or additional individualized interventions were put into place after the falls. Record review of the resident's Physician's Progress Note dated 6/4/14, showed: -The resident's psychotropic medications were changed. Record review of the resident's first Fall Investigation Worksheet dated 6/5/14 at 7:45 A.M., showed: -The resident had a witnessed fall in the dining room. The resident had increased confusion, was anxious and worried. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was the resident's seventeenth fall. Record review of the resident's Nurse's Notes on 6/5/14 at 9:00 A.M., showed he/she was attempting to sit down in the dining room and missed the chair. The resident landed on his/her left hip. The resident was assessed with [REDACTED]. Record review of the resident's second Fall Investigation Worksheet dated 6/5/14 at 11:30 A.M., showed: -The resident was standing and attempting to walk in the dining room. The resident had increased confusion, was anxious and worried. The resident's morning psychotropic medications were not given to the resident. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was the resident's eighteenth fall. Record review of the resident's Nurses Note's dated 6/5/14 at 2:05 P.M., showed the resident was standing by the window and the nurse looked up and the resident was on the floor. The resident had fair range of motion in his/her left knee. The left knee was swollen, bruised, and had an abrasion. Record review of the resident's third Fall Investigation Worksheet dated 6/5/14 at 2:30 P.M., showed: -The resident had an un-witnessed fall in another resident's room while sitting in a chair and had attempted to bend over. Laboratory testing was done and a urinalysis was done to check if the resident had a urinary tract infection (UTI - an infection of one or more structures in the urinary system). The test did not show the resident had a UTI. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was the resident's nineteenth fall, and the third fall on 6/5/14 from 7:45 A.M.-2:30 P.M. Record review of the resident's Nurse's Notes dated 6/5/14 at 3:30 P.M., showed he/she was visiting another resident. He/she bent over while sitting in a chair and fell hitting his/her nose and forehead. The resident's left knee remained swollen and mushy. Record review of the resident's Physician's Progress Note dated 6/5/14, showed: -The resident had three falls that day and all of the resident's medications were not administered to the resident related to the falls. Record review of the resident's Nurse's Notes dated 6/5/14 at 4:00 P.M., showed the nurse ordered an x-ray of the resident's knee. Record review of the resident's Nurse's Notes dated 6/5/14 at 4:30 P.M., showed he/she was agitated, continued to ambulate, and would lean forward during ambulation. Record review of the resident's Nurse's Notes dated 6/5/14, showed the resident may use a self-releasing seatbelt while the resident was in his/her wheelchair during high agitation episodes to reduce falls and prevent injury. The resident's family was notified and gave permission for the use of the seatbelt restraint. Record review of the resident's physician's Telephone Orders Sheet (TOS) dated 6/5/14, showed the following physician's orders [REDACTED]. -The resident may use a self-releasing seatbelt while in his/her wheelchair during high agitation episodes to reduce falls and prevent injury. Record review of the resident's Physician's Progress Note dated 6/6/14, showed: -The resident was on fall precautions and needed close observation after having three falls. Record review of the resident's Nurse's Notes dated 6/6/14 at 2:00 A.M., showed he/she rested quietly in his/her recliner until 1:30 A.M. The resident was assisted to the toilet with the use of a wheelchair. The resident stood up and complained of pain. The resident's left knee remained swollen. The x-ray results showed no injury. Record review of the resident's Physician's Progress Note dated 6/8/14, showed: -The resident was on fall precautions. -The resident was awake and confused. Record review of the resident's Physician's Progress Note dated 6/13/14, showed: -The resident was on fall precautions. Record review of the resident's Fall Investigation Worksheet dated 6/23/14 at 3:25 P.M., showed: -The resident was changing chairs being assisted by two staff members. The resident stood up and lost his/her balance and was lowered to the floor. -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was resident's twentieth fall. Record review of the resident's Nurse's Notes dated 6/23/14 at 4:00 P.M., showed he/she was being assisted by the staff to move from one chair to another. The resident stood up and lost his/her balance. The staff tried to help the resident regain his/her balance and was lowered to the floor. The resident did not have any injuries. Record review of the resident's Fall Prevention Checklist dated 6/23/14, showed he/she had a pain management program, a hi-low bed, a bed and chair alarm, and a seatbelt in his/her wheelchair. Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Was moderately cognitively impaired. -Had no behaviors. -Required the limited assistance of staff for bed mobility, transfers, walking, toilet use, and personal hygiene. -Was occasionally incontinent of bladder and frequently incontinent of bowel. -Had more than two non-injury falls, more than two injury falls, and one major injury fall since the last assessment was completed. -Had a physical restraint. Record review of the resident's Physician's Progress Note dated 6/26/14, showed: -The resident was on fall precautions and had a seatbelt. -The resident was in the dining area very anxious, yelling, and crying. -The resident's psychotropic medications were increased. Record review of the resident's Quality of Care Progress Notes dated 7/1/14, showed: -The resident had a total of 16 falls over the past four months. -The staff did not document that a root cause analysis for the resident's falls was completed or additional individualized interventions were put into place after the falls. Record review of the resident's POS dated 7/1/14 through 7/31/14, showed physician's orders [REDACTED]. -Buspar 15 mg: Take one tablet by mouth twice daily for anxiety. -Depakote 250 mg: Take one tablet by mouth three times daily for dementia with behaviors. -Ativan 0.5 mg: Take one tablet by mouth every four hours as needed for anxiety, agitation, and pacing. -On 6/26/14, a physician's orders [REDACTED].M. and 4:00 P.M. daily; and for Seroquel 25 mg: Take one tablet at 12:00 P.M. daily. -On 6/26/14, a new physician's orders [REDACTED].M. daily. Record review of the resident's Fall Investigation Worksheet dated 7/15/14 at 9:45 P.M., showed: -The resident was attempting to walk and fell . Staff did not document where the resident was at the time of the fall. The resident had insomnia (sleeplessness). -The staff did not document that a root cause analysis for the resident's fall was completed or additional individualized interventions were put into place after the fall. -This was the resident twenty-first fall. Record review of the resident's Nurse's Notes dated 7/15/14 at 10:00 P.M., showed the resident's alarm had sounded just as the resident stumbled and fell to the floor. The resident was assessed and did not have an injury. The resident had been restless during this shift. Record review of the resident's Fall Investigation Worksheet dated 7/20/14 at 7:00 P.M., showed: -The resident had an un-witnessed fall in his/her room attempting to go to the bathroom. -This was the resident's twenty-second fall. Record review of the resident's Nurse's Notes dated 7/20/14 at 8:00 P.M., showed his/her alarm sounded, and when the staff arrived the resident was found on the bathroom floor. The resident stated he/she had hit the left side of his/her head. The resident's upper cheekbone area was red, his/her elbow had multiple bruises, his/her left forearm had an abrasion, and his/her left knee was red. Record review of the resident's Physician's Progress Note dated 7/24/14, showed: -The resident had a history of [REDACTED]. Record review of the resident's Nurses Notes dated 7/28/14 at 1:47 P.M., showed he/she stood up from his/her wheelchair and stumbled. The resident tried to catch himself/herself on the wheelchair but the wheelchair was not locked. The resident fell on his/her buttocks. The resident was assessed with [REDACTED]. -There was no Fall Investigation completed by staff for this fall. -This was the resident's twenty-third fall. Record review of the resident's Short-Term Problem Need List last updated by staff on 7/28/14, showed: -The resident fell on [DATE], 12/28/13, 2/2/14 twice, (the resident fell three times according to the fall investigation reports), 2/3/14, 2/6/14, 2/17/14, 3/10/14, 3/21/14, 3/29/14, 4/6/14, 4/21/14, 4/22/14, 4/28/14, 6/5/14 three times, 6/23/14, 6/24/14, 7/15/14, and 7/28/14. -The staff did not document that a root cause analysis for the resident's falls was completed or additional individualized interventions were put into place after the falls. Record review of the resident's fall Care Plan last reviewed by the staff on 7/31/14, showed: -The resident had a history of [REDACTED]. -The staff were to ensure the resident had proper non-slick footwear and observe the resident's balance while walking. -The staff were to engage the resident in activities that improve strength, balance, and posture. -The staff were to keep areas free of clutter and the resident's call light within reach. -The staff were to toilet the resident routinely. -On 6/6/14, the resident may have a Velcro seatbelt while up in his/her wheelchair. The staff were to check and release the seatbelt every two hours. Record review of the resident's Physician's Progress Note dated 8/21/14, showed: -The resident had a history of [REDACTED]. -The resident had no recent falls. Observation on 8/25/14 at 2:42 P.M., showed the resident in his/her wheelchair by the entrance door of the secure care unit. The resident had a blue Velcro seatbelt around his/her waist and a wheelchair alarm on his/her wheelchair. Observation on 8/26/14 at 6:35 A.M., showed the resident in the dining room seated in a regular chair. The resident stood up independently and asked the staff member to go to the bathroom. Two staff members assisted the resident to his/her wheelchair and took the resident to his/her room. During an interview on 8/27/14 at 12:25 P.M., Certified Nursing Assistant (CNA) B said the resident was a high fall risk. The resident could stand up and walk independently but was unsteady. The resident had a seatbelt on and a wheelchair alarm on to prevent falls. He/she was unsure if the resident was on a restorative walking program. Observations on 8/27/14 showed: -At 12:35 P.M., the resident was by the dining area in his/her wheelchair with his/her seatbelt and wheelchair alarm on. There were two staff members in the dining room assisting other residents with eating. The resident was agitated and repetitively said "help, help" and "ma'am, ma'am." The staff members did not respond to the resident. -At 12:39 P.M., the resident self-propelled his/her wheelchair into room 813 and asked another ambulatory resident to go with him/her. The resident went to the sink and the other resident helped turn the faucet on then left the room. A male resident self-propelled into room 813 and the resident asked how his/her weekend was. The male resident shut the door. -At 12:46 P.M., the male resident opened the door and the resident was self-propelling his/her wheelchair out of the room. A staff member saw the resident in the doorway and said "oh" and moved the resident closer to the dining room area. During an interview on 8/27/14 at 2:56 P.M., the Director of Nursing (DON) and the Administrator said the resident did not have a major injury fall. The resident's MDS that was completed on 6/26/14 was coded incorrectly. The MDS Coordinator was responsible for coding the MDS. During an interview on 8/28/14 at 9:25 A.M., CNA A said the resident was a huge fall risk. The resident could ambulate independently but was very unsteady and stumbled when ambulating. The resident had a wheelchair alarm and a seatbelt used for fall prevention. During an interview on 9/2/14 at 8:32 A.M., MDS Coordinator A said the r