Every finding on record at Haviland Operator, LLC

The facility reported a census of 45 residents and one kitchen. Based on record review, observation and interview, the facility failed to store and prepare food under sanitary conditions for the residents of the facility.Findings included:- On 10/13/25 at 01:26 PM, during the initial tour of the kitchen with Dietary Staff BB, the following concerns were identified:1. The kitchen refrigerator had an opened three-pound bag of shredded lettuce not labeled with the opened date; an opened three-pound bag of [NAME] slaw not labeled with the opened date; six unlabeled one-ounce plastic containers of ketchup and a one-gallon plastic container of Italian dressing approximately one-half full without a label for the date opened.2. The kitchen had an unsanitizable countertop with exposed wood at the corner measuring approximately two inches by three inches 3. The metal kitchen entrance door had missing paint around the handle of the door.4. The handwashing sink, which was behind the kitchen entrance door, had loose caulking at the junction of the sink to the wall, and brown staining noted in the area behind the loose caulking adjacent to the wall5. Observation of a stack of ten large cookie sheets revealed baked-on brown grime inside on the cooking surface and outside of the sheet and one small cookie sheet with baked-on brown grime which came in direct contact with the food6. Observation of the gas stove hood revealed grease build-up on the outer ridge around the hood above the gas stove.On 10/13/25 at 01:46 PM, Dietary Staff BB confirmed the above findings were a concern and repairs needed to enable the staff to handle and serve food in a sanitary and safe manner.On 10/14/25 at 11:22 AM, Dietary Staff CC opened the oven to check the temperature of the food for the lunch meal. Observation of the inside of the oven revealed baked-on grime and grease over two oven racks and throughout the inside of the stove. Dietary Staff CC reported there was not a safe time to clean the oven because it was old and required the staff to turn the oven on at 05:30 AM at the setting of 500 degrees Fahrenheit (F) to get it hot enough to thoroughly cook the food in time to serve the residents meals. She stated the oven remained on all day to maintain the temperature and staff left at 06:00 PM after supper so they could not cool the oven down to clean it. On 10/14/25 at 11:24 AM, Dietary Staff BB confirmed the concern regarding the cleanliness of the oven. She stated the staff should clean the oven with oven cleaner at least weekly. Upon reviewing the cleaning schedule Dietary Staff BB verified cleaning the oven with oven cleaner was not on the dietary staff schedule as she thought.On 10/14/25 at 11:29 AM, Certified Nurse Aide (CNA) M and CNA P entered the food preparation area approximately 12 feet into the kitchen where dishes and utensils for food service were present on two metal tables without washing their hands. They walked to the steam table, picked up plates of food from the top of the steam table, then reached into a box of condiments which included packets of Mayonnaise, salt, and pepper. They placed the packets of condiments on top of the food, in direct contact with the food. Further observation revealed CNA P left the kitchen and delivered the plates of food to several residents, touching one resident's back and then returned to the kitchen without performing hand hygiene and repeating the process including picking up condiments and placing them directly on top of plated food. On 10/14/25 at 11:29 AM, Dietary Staff BB confirmed she had observed nursing staff place the condiment packets directly on the food and was aware of the concern with the potential of the spread of bacteria but said that was how the facility had provided condiments since she had been serving the residents. Additionally, she reported the residents did not have condiments available at the tables because the residents would pick them up and hoard them but agreed the packets should not be in direct contact with the food as it was not sanitary. The facility policy Food Safety Requirements F812, dated 10/2025, documentation included all s stored in the refrigerator or freezer will be covered, labeled and dated. The policy did not address of the maintaining the kitchen in good repair to ensure sanitary conditions.

The facility reported a census of 45 residents. Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for residents in the facility. Findings included: - Observation during initial tour of the facility on 6-20-18 at 9:30 a.m., and during environmental tour on 6-26-18 at 10:00 a.m., with maintenance staff D, revealed the following areas/items noted to be in need of repair, replacement, and/or cleaning: 1) The handrails of both hallways had several areas of gouged wood, and lacked paint/stain in several areas. 2) The beauty shop had a heavy build-up of loose hair in the drain of the hair-washing sink. 3) The shower room on one hall lacked tile on the wall at the foot of the tub and behind the toilet. 4) Two resident rooms on one hall lacked paint where repairs had been made on the walls. 5) One resident room lacked paint on the base boards and the wall above the base board was damaged. 6) One room lacked paint on the corner piece by the sink. 7) Seventeen of 28 vinyl chairs contained rips or tears on the seat. On 6-25-18 at 1:04 p.m., administrative staff A stated, the chairs had not been repaired/replaced due to the facility putting in a new air conditioning unit. The facility had a bid from a nearby business to repair the chairs. On 6-26-18 at 10:00 a.m., maintenance staff D stated, the handrails are in need of repair. The housekeeping staff were responsible for cleaning the beauty shop. The missing tile on the shower room floor was due to not being able to find matching tile. The facility policy for Cleaning and Disinfection of Environment Surfaces, revised (MONTH) 2009, included: Surfaces will be disinfected with disinfectant according to the label's safety precautions and use directions. The facility failed to provide maintenance and housekeeping services to maintain the environment of the facility in a sanitary and homelike manner.

The facility reported a census of 45 residents. Based on observation, and interview the facility failed to store, prepare, and serve food under sanitary conditions for the residents of this facility. Findings including: - During a tour of the dietary department of the facility, on 6/20/18 at 10:49 AM, with dietary staff C revealed the following areas in need of cleaning: 1.) The inside of one toaster contained a layer of crumbs in the bottom, and contained a layer of a sticky substance on the outside of the toaster. 2.) Three work tables contained a layer of dust and food particles on the bottom shelf. 3.) On the inside base of the freezer, contained a layer of crumbs and food substance. 4.) Two plastic food carts wheels with a layer of grime, and the shelves lacked the protective plastic coating. 5.) On the inside of twenty-eight blue plastic coffee cups contained a brown discoloration. 6.) The three storage shelve in the storage room contained a heavy layer of dust build-up. 7.) The floor mat under the dishwasher had a layer of grime. On 6/25/18 at 10:20 A.M., dietary staff C stated he/she did not like to bleach the coffee cups because it removed the finish of the cups. The floor mat was difficult to remove to be cleaned because it goes underneath the dishwasher. The facility policy for sanitization, revised (MONTH) (YEAR), included: the food service area shall be maintained in a clean and sanitary manner. The facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

The facility census totaled 46 residents. All of the residents received meals prepared in the kitchen. Based on observation, interview and record review the facility failed to serve meals from prepared menus planned for the residents and approved by the registered dietician for all meals served. This had the potential to affect all 46 residents served from the kitchen. Findings included: - Observation on 6/8/16 at 11:10 a.m. revealed the serving of the noon meal was the same food served on 6/7/16 as noted during dining observation on 6/7/16 at 11:30 a.m. The meal consisted of chicken tenders, chicken fried steak, potato wedges, mashed potatoes and gravy and baked beans. During an interview on 6/8/16 at 11:10 a.m., dietary staff H reported the kitchen served lunch restaurant style and if he/she had to have a different menu every day he/she would not have the room to store the food. He/she did say they cooked a special menu on Fridays that the residents requested. The cooks used a corporate menu for the breakfast and supper meals. He/she also said dietary did not follow the menus and substituted and picked and chose what they cooked based on resident likes and dislikes. Dietary staff H reported the registered dietician approved the changes to the menu and he/she needed to look for the menus in his/her office. During an interview on 6/8/16 at 11:20 a.m. administrative staff C reported the registered dietician came to the facility just a couple of days prior and he/she spoke to the dietician by phone at approximately 11:15 on 6/8/16. Administrative staff C reported the dietician had approved the menus on that day but had not signed the sheet with his/her approval. Administrative staff C was going to fax the menus to the registered dietician for his/her signature. Review of the dietician consult report dated 5/25/16 revealed no documentation of the registered dietician reviewing the menus or approving them. The report did state the facility planned to offer special options each week and to add some variance to the menus. Review of the revised menu had no documentation from the registered dietician stating his/her review or approval. On 6/8/16 at 3:00 p.m. Administrative staff C brought a copy of the menus he/she had faxed to the registered dietician. The menu had a signature of the registered dietician on it and stated he/she had reviewed the menus and dated the day of his/her last visit on 5/25/16 though the menu dates were for 5/5/16 thru 5/11/16. The dietician did not approve the menus until 3 weeks after the implementation of the menus. During an interview on 6/8/16 at 4:20 p.m. dietary staff H reported the menu for that week of May was the only menu he/she had. When asked about the dates and the RD signature he/she reported he/she did not even remember when he/she was there. When asked if this was the only menu he/she had and if he/she repeated the same menu week after week, he/she reported again that was the only menu he/she had. Dietary staff H was working on another menu but that it was not complete at this time. The surveyor made attempts to contact the registered dietitian. Several attempts were made to contact the registered dietician by phone, twice on 6/8/16 at 1:30 p.m. and 4:00 p.m. and again on 6/9/16 at 8:35 a.m. The registered dietician did not reply to any of the calls. Review of the facility's undated policy called Menus revealed: Menus for regular and therapeutic diets are written at least 2 weeks in advance. The dated menus are posted at least 1 week in advance. The Dietician will review and approve all menus. Menus will be varied for the same day of consecutive weeks. When a cycle menu is used, the cycle shall be of no less than 3 weeks duration. The facility failed to serve meals from prepared menus planned for the residents and approved by the registered dietician for all meals served. This had the potential to affect all 46 residents served from the kitchen.

The facility census totaled 46 residents. The facility prepared and served meals for all 46 residents. Based on observation, interview and record review the facility failed to store and serve foods in a sanitary manner by having undated open food items in the refrigerator and the freezer, a scoop in the bin containing brown sugar and by the inappropriate handling of glassware by the drinking surface. This had the potential to affect all 46 residents. Findings included: - The initial tour of the kitchen on 6/6/16 at 7:50 a.m. revealed the freezer contained 4 pizzas in an open undated bag with no use by date or open date. The refrigerator contained a large bag of chopped onions. The bag was not closed and there was no date on the bag. A large bin marked brown sugar sat in the dry storage area. The scoop sat down in the sugar stored in the bin. During an interview on 6/6/16 at 8:10 a.m., dietary staff H, revealed staff received instructions that all food items needed to be dated before returning the items to the freezer or refrigerator. Staff H also acknowledged there should be no scoop left in the dry goods bins. Staff H removed all food items from the refrigerator and freezer and disposed of them. Review of the policy for Food Receiving and Storage dated January 2016 revealed all food items stored in the refrigerator or freezer must be covered, labeled and dated. The freezer must keep food items frozen solid. Items removed from the original box or packaging must be stored airtight, dated, and contents clearly labeled. The facility failed to store food in a sanitary manner by having undated open food items in the refrigerator and the freezer, and a scoop in the bin containing brown sugar. - Observation on 6/7/16 at 8:10 a.m. revealed dietary staff N serving glasses in the dining room by the drinking surface of the top rim. Staff N reported he/she received training on how to handle glassware and cups by the lower part of the cup he/she just got in a hurry. During an interview on 6/7/16 dietary staff H reported there was no policy for staff handling of glassware. Staff H reported he/she just trained hands on with all staff. The facility failed to serve drinks in a sanitary manner by the failure to handle drinkware properly in the dining room.

The facility census totaled 46. The facility had 2 halls where residents resided. The facility employed one housekeeper who cleaned both halls potentially effecting the entire resident population. Based on observation, interview and record review, the facility failed to provide a sanitary environment to prevent the development and transmission of disease and infection when housekeeping staff failed to properly sanitize resident's rooms, failed to cover the linen cart while distributing clean blankets, and failed to change gloves when finished cleaning one resident room and before starting to clean a different resident room. The facility also failed to ensure dietary staff properly covered open wounds on hands prior to preparing meals for all residents. Findings included: - Observation on 6/8/16 at 9:09 AM revealed housekeeping staff I replenished the clean linen closet on the south hall with blankets. The laundry cart staff I used to transport the blankets was not covered with a sheet to protect clean items during transport in the hallway. Observation on 6/8/16 at 9:13 AM revealed housekeeping staff I donned a pair of disposable gloves before starting to clean a resident room. Staff I sprayed orange oil surface cleaner on the sink area. At 9:23 AM staff I started to wet mop the tile floor with water that had Ecolab Oasis 100 floor cleaning product added to it, and finished mopping at 9:24 AM. At 9:25 AM staff I went to the adjacent resident room to start cleaning without changing his/her gloves after finishing with the original room. At 9:28 AM staff I sprayed disinfectant on the toilet bowl and surrounding surfaces. At 9:32 AM staff I wiped down the surface of the toilet with a dry cleaning rag. At 9:33 AM staff I changed gloves. After staff I finished cleaning the resident room, he/she was asked about the wet time (time determined by the manufacture where the product must stay wet in order to work as indicated) for the disinfectant cleaner. Staff I stated he/she thought the wet time was about 5 minutes. During an interview on 6/9/16 at 7:44 AM maintenance supervisor staff J stated staff should use disinfectant cleaner on any surface residents touched and believed the product needed to stay wet for 5 minutes. Staff J stated the facility utilized Keystone Disinfectant Cleaner 2.0 and provided information from the manufacturer which listed a wet time for disinfection effectiveness as being 10 minutes. Staff J stated he/she expected staff to change gloves after the toilet was cleaned and before starting on a different resident room. Review of the Cleaning and Disinfection of Environmental Surfaces policy (Revised August 2010) revealed: Environmental surfaces should be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. Non-critical environmental surfaces include bedside tables, furniture and floors. Non-critical surfaces should be disinfected with an EPA (Environmental Protection Agency)-registered intermediate or low-level hospital disinfectant according to the label's safety precaution and use directions. The facility failed to prevent the development and transmission of infection when staff failed to properly sanitize resident rooms, change gloves between resident rooms and cover clean linens while transporting in the hallway. - Observation on 6/6/16 at 7:50 a.m. dietary staff H had open, partially scabbed wounds to the back of his/her right hand and the upper left wrist. No dressings or bandages were present on the wounds. Dietary staff H worked in the kitchen assisting the cook in preparing food for the breakfast meal. During an interview on 6/6/16 at 8:05 a.m., dietary staff H reported the policy for open wounds included to keep them covered with a bandage at all times. Observation on 6/6/16 at 8:20 a.m. revealed staff H had all wounds covered with bandages. The facility failed to provide a policy regarding open wounds on staff as requested on 6/6/16. The facility failed to prevent the spread of infections by allowing staff H to work in the kitchen with open wounds.

The facility census totaled 46 residents with 15 residents sampled. Of those, 15 were reviewed for comprehensive care plans. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for resident #50 to ensure staff provided the special services according to the level II PASRR (Preadmission Screening and Resident Review- a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) letter recommendations and for resident # 46 related to rejection of cares. Findings included: - Review of resident #50's signed physician order [REDACTED]. Review of the admission MDS (minimum data set) dated 3/28/16 revealed a BIMS (brief interview for mental status) score of 14, indicating cognitively intact. The resident had a level II PASRR (Preadmission Screening and Resident Review- a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) for serious mental illness. The resident had no signs of [MEDICAL CONDITION] (sudden severe confusion, disorientation and restlessness) and had a mood score of 5, indicating mild depression. The resident had no delusions, hallucinations, or behaviors. The resident required supervision with set up assistance for all ADLs (activities of daily living). The resident did not receive scheduled pain medication but received as needed (PRN) pain medications and the resident denied pain. The resident received an antipsychotic, antianxiety, and antidepressant medication daily for 7 days of the observation period. Review of the [MEDICAL CONDITION] drug CAA (care area assessment) dated 3/28/16 revealed the resident received [MEDICAL CONDITION] medications for management of major [MEDICAL CONDITION], anxiety disorder and [MEDICAL CONDITION] disorder. The resident had a potential for drug toxicity due to long-term [MEDICAL CONDITION] drug use. Staff monitored the resident for abnormal extremity movements per the AIMS (abnormal involuntary movement scale- used to measure movement abnormalities due to [MEDICAL CONDITION] drug use side effects) quarterly. The psychiatrist assessed the resident monthly and reviewed the medication regimen. The pharmacy consultant reviewed medications monthly and made recommendations for dosage reduction and/or discontinuation of unnecessary medications PRN. Review of the care plan last reviewed on 3/28/16 revealed the following interventions/plans related to the recommendations for specialized training in the PASRR letter: The resident will participate in the job program by mopping the floors. Staff will prompt the resident PRN to complete his/her job and give verbal praise when completed. The resident will at least partially complete 1-3 scheduled activities a month. If the resident refused to complete scheduled activities, staff will remind/encourage the resident complete a different activity in his/her free time. The resident will work on his/her goal to move out by completing ADLs independently. Staff will educate the resident to complete his/her ADLs routinely. Staff will encourage the resident to attend at least the amount of activities per his/her goal. Staff will encourage/educate the resident on the need for labs to evaluate medication levels. Staff needed to evaluate the effectiveness of pain interventions. If the resident stated his/her back hurt, he/she lay down at times because it helped with pain relief. If the resident reported pain, staff were to offer PRN [MEDICATION NAME] to alleviate his/her pain. The resident had a [DIAGNOSES REDACTED]. The resident will comply with his/her medication regimen through the review date. The resident will accept his/her medications at the medication cart and/or in the dining room. If the resident refused his/her medications staff would notify the physician. Staff needed to remind the resident to see the psychiatrist when he/she came to the facility. Staff needed to administer medication as ordered and monitor/document for side effects and effectiveness. The care plan lacked any specific education related to the resident's medication regimen, need for each medication and the impact it had on his/her physical and mental health and what could happen if not taken as prescribed. Review of the PASRR determination letter dated 3/18/16 revealed the nursing facility would provide the following: Education about the resident's medication regimen, need for each medication and the impact it had on the resident's health and mental health and what occurred when medications were not taken as prescribed. Review of the care plan meeting notes dated 4/6/16 revealed staff reviewed the initial care plan with the resident but lacked evidence the facility educated the resident on his/her medications, what they were for, and his/her need to follow the medication regimen. Observation on 6/7/16 at 12:44 PM revealed the resident placed wet floor signs down the south hallway and he/she stated that he/she was going to mop the hallway floor. During an interview on 6/7/16 at 10:54 AM the resident reported staff had not taught him/her about the medications he/she took. The resident stated he/she did not know what medications he/she took or why. During an interview on 6/7/16 at 1:12 PM direct care staff D reported the staff had notebooks at the nurse's station that gave them information on what kind of care the resident needed and things the staff needed to monitor for. Staff D also stated he/she got a shift report so if there was anything different the nurse told him/her. During an interview on 6/8/16 at 12:41 PM direct care staff E reported the facility had medications classes where the residents were taught about their medications. Staff E did not know for sure if the resident attended the classes or not. Staff E also reported he/she looked at the mini care plan at the nurse's station to know what kind of care the resident needed and if the staff needed more information they could look at the care plan in administrative nursing staff A's office. During an interview on 6/8/16 at 1:15 PM administrative nursing staff A reported stated he/she looked at the PASRR letter to develop a plan for the resident and he/she did not know if the resident would be giving his/her own medications or if his/her family member would be setting them up. Staff A stated he/she could see where the care plan did not address the need to educate the resident regarding his/her medications, what they were for, and the importance of taking them as prescribed. Review of the care planning policy dated 9/2012 revealed the development of an individualized comprehensive care plan would be completed by the community care planning/interdisciplinary team responsible for each resident. The facility failed to develop an individualized care plan that included providing the resident education related to his/her medications, their purpose, and the need to take them as prescribed as recommended by the PASRR letter. - Review of resident #46's June 2016 POS (Physician order [REDACTED]. Review of resident #46's Admission MDS (Minimum Data Set) dated 11/20/15 revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition. No behaviors were present or exhibited. Review of the ADLs (Activities of Daily Living)/Functional Status CAA (Care Area Assessment) dated 11/20/15 revealed the resident was able to complete ADLs with prompting/cueing from staff. The resident had long-standing mental illness and presented with potential for self-care deficit as the resident was noted to refuse to bathe 2 days during look back period Review of the resident's Quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognition. The resident had psychomotor [MEDICAL CONDITION] behavior present that fluctuated as well as daily rejection of care. Review of the resident's care plan revealed the resident had a potential for self-care deficit due to staff needing to supervise or provide set-up assistance to complete ADLs as related to the resident'S [DIAGNOSES REDACTED]. Interventions included staff to document if resident completed ADLs or refused. Staff to assist resident with bathing by prompting resident to bathe and to provide needed supplies. Review of a nursing note dated 4/8/16 revealed the resident refused to bathe or shower and staff educated the resident as to the importance of good personal hygiene to assist with the prevention of skin breakdown. Review of a nursing note dated 6/5/16 revealed the resident continued to refuse to bathe/shower; was educated on the importance of maintaining good personal hygiene; and asked to then take a sponge bath in sink and to change clothes; refuses; will continue to monitor. An observation on 6/8/16 at 4:43 PM revealed the resident in the hallway by the nurse's station. The resident wore the same red shirt and gray sweats he/she wore during the stage 1 interview 2 days prior. During an interview on 6/8/16 at 8:57 AM direct care staff E stated staff regularly encouraged the resident a lot to perform ADLs such as showers but he/she did not always agree with staff. Staff encouraged the resident daily to take showers and gave him/her what he/she needed to take a shower but the resident refused quite often. When he/she refused staff would notify the nurse and try to re-approach him/her at a later time and with a different staff member. During an interview on 6/9/16 at 7:30 AM the resident stated he/she believed the staff allowed him/her choices with bathing and he/she preferred to have a bath every 4-5 days. During an interview on 6/8/16 at 12:51 PM licensed nursing staff F stated the resident mainly required verbal cues and coaching for ADLs. He/she required more cueing for bathing, and refused. Staff even offer to help him/her with a sink or sponge bath, get him/her towels or whatever he/she needs but politely refused or stated he/she will do it later. During an interview on 6/9/16 at 7:32 AM, administrative nursing staff A stated staff tried to encourage residents to bathe at least three times a week and then see what the resident's pattern was. Staff A acknowledged there were not any interventions included in the care plan that dealt with refusal to take a bath. During an interview on 6/9/16 at 11:18 AM, administrative nursing staff B stated he/she expected staff to keep trying interventions to get the resident to comply with bathing and expected interventions used to be included in the care plan. The facility failed to revise the resident's care plan to include interventions for behaviors associated with rejection of care dealing with bathing.

The facility census totaled 46 residents with 15 residents sampled and reviewed for revision of care plans. Based on observation, interview, and record review the facility failed to revise the care plan for 1 of 15 residents. (#9- behavior management ) Findings included: - Review of resident #9's signed physician order [REDACTED]. Review of the quarterly MDS (minimum data set) dated 1/15/16 revealed resident #9 had a BIMS (brief interview for mental status) of 7 indicating severe cognitive impairment. The resident had signs and symptoms of [MEDICAL CONDITION] which included difficulty focusing and disorganized thinking, had trouble concentrating on things, and presented to staff feeling down or depressed with little interest or pleasure in doing things. The resident had hallucinations but no behavioral issues including rejection of care. The resident required set up and supervision with activities of daily living (ADL) and had good balance. The resident received an antipsychotic, antianxiety, and an antidepressant three out of the seven observation days. Review of the annual MDS dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. The resident had delusions and hallucinations, behavioral symptoms not directed toward others, and rejection of cares 1-3 days during the 7 day observation period. The resident required the same assistance as he/she did on 1/15/16 with ADLs. Review of cognitive loss CAA (care area assessment) dated 4/28/16, the resident had long standing displays of inattention, changing subjects often, moving slowly, display at times of shadow boxing in hallways , hallucinations, and delusions as part of his/her behaviors/[DIAGNOSES REDACTED]. The resident also refused bathing 2 days during the 7 day observation period. Review of the care plan last reviewed on 4/28/16 revealed the following interventions regarding ADLs (activities of daily living) and what staff needed to do if a resident refused care: The resident required staff prompting, supervision or set-up assistance to complete his/her ADLs. The resident will complete bathing at least 3 times a week. The resident could complete bathing after staff prompted him/her and provided supplies needed. Staff will encourage the resident to complete ADLs as independently as possible and will provide assistance as needed. The care plan lacked interventions to identify what the staff needed to do if the resident refused care, such as bathing. Review of the nurse's notes dated 4/20/16 at 4:05 PM revealed the resident was compliant in medication/treatment administration with some reminders, comes to dining room for meals; personal hygiene is with staff assistance/reminders. review of the resident's medical record revealed [REDACTED]. From the time period of 3-16-16 to 4-16-16 the resident has been bathed 5 times. Observation on 6/7/16 at 4:24 PM revealed the resident in line for a cigarette. The resident's hair was stringy and his/her clothing was the same as he/she had on yesterday. Interview with direct care staff D on 6/7/16 at 1:12 PM revealed the staff had notebooks at the nurses' station that gave them information on what kind of care the resident needed and things the staff needed to monitor for. Staff D also stated he/she got a shift report so if there was anything different the nurse told him/her. Staff D stated he/she would report to the nurse if the resident rejected any cares. Staff D also stated he/she documented in the computer if the resident refused to change his/her clothing, bathe, or fluids and then the nurse followed up on it. Staff D stated the aides try to offer assistance throughout the day if the resident refuses or may ask the resident the next day if they wanted to bathe. Interview with direct care staff E on 6/8/16 at 12:26 PM revealed there is a mini care plan in the nurses station that tell direct care staff what care is needed for the resident. Staff E stated the resident did not always like to take his/her baths but he/she is pretty good at it. Staff E stated he/she would ask the resident throughout the day to take a shower and if he/she wouldn't staff would then tell the nurse and make sure to ask the resident again the next day. Staff E reported the resident took at least one bath per week but staff try 3 times and the resident can choose to bathe or not. Interview with licensed nursing staff G on 6/8/16 at 2:31 PM revealed the resident was more friendly and social in the morning. Staff G stated resident did not usually refuse showers and the staff had a tracking sheet to monitor and make sure the resident completed the care, staff would ask the resident if there is anything he/she needed. Interview on 6/9/16 at 1:38 PM with administrative nursing staff A revealed the resident refused to bathe 2 days during the look back period. If a resident refused a shower the staff tried different avenues and if the resident still refused the staff may try different rewards if the resident would refuse a bath or other cares such as labs. Administrative staff A stated if a resident refused the care system triggered an alert for the nurse that something needed to be addressed. Staff A reported the care plan should have had alternative interventions in it as to what staff needed to do if the resident refused care. Review of the facility's Care Planning policy dated September 2012 revealed the Community Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The policy did not address how often or what would trigger staff to revise a resident's care plan. The facility failed to update the resident's care plan to include directions as to what staff needed to do for resident #9 when he/she refused bathing care.

The facility census totaled 46 residents. Based on observation, interview and record review the facility failed to ensure residents remained free of unnecessary medications by the failure to monitor behaviors for 2 of 5 residents reviewed for unnecessary medications. (#33, #50) Findings included: - Review of resident #33's signed physician orders [REDACTED].(current) drug therapy and drug induced subacute dyskinesia (an impairment of the ability to execute voluntary movements). Review of the annual MDS dated [DATE] revealed a BIMS (brief interview on mental status) of 14 indicating normal cognition. The resident had hallucinations and delusions. The resident had improved and had no behaviors. The resident required supervision and set up with his/her daily cares. Medications included an antipsychotic medication, antianxiety, and an antidepressant. Review of the care plan with a revision date of 3/15/15 revealed: The resident received [MEDICAL CONDITION] medications to treat the resident's anxiety disorder, [MEDICAL CONDITION] disorder and major [MEDICAL CONDITION]. The resident was at risk for potential drug toxicity. Approaches included; Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/record occurrence of target behavior symptoms (isolation, delusional statements) and document per facility protocol. Review of the physician orders [REDACTED]. Aripiprazole Lauroxil ER prefilled syringe 662 mg (milligrams) /2.4 ml (milliliter) Inject 2.4 ml intramuscularly 1 time every 28 days for [MEDICAL CONDITION] disorder- ordered on [DATE] [MEDICATION NAME] HCL 20 mg tab 1 by mouth daily for major [MEDICAL CONDITION]- ordered on [DATE] [MEDICATION NAME] 1 mg tab by mouth at bedtime for anxiety disorder -ordered on [DATE] [MEDICATION NAME] tablet 2 mg by mouth twice a day for [MEDICAL CONDITION] disorder- ordered on [DATE] [MEDICATION NAME] tablet 0.5 mg by mouth 1 tab twice daily for anxiety disorder. - ordered on [DATE] Review of the psychoactive behavioral monitoring revealed: Target behavior for the use of [MEDICATION NAME] was delusions. Note the number of episodes for every shift. No behaviors noted during the months of April, May and June 2016 Target behavior for use of [MEDICATION NAME] (Aripiprazole Lauroxil ER) was delusions. Note the number of episodes per shift. No episodes noted during the month of April, May and June 2016. The TAR (treatment administration record (where behaviors are documented) failed to have specific targeted behaviors for the use of [MEDICATION NAME] and [MEDICATION NAME]. Review of consulting pharmacist recommendations dated 3/14/16 for a gradual dose reduction for [MEDICATION NAME] and [MEDICATION NAME]. The physician replied to keep same medications with a statement reading I feel the benefits of using this drug outweigh the risk to the resident, and I have no changes regarding these medications. Patient would likely decompensate if changed. Observation on 6/7/16 at 9:55 a.m. revealed the resident lay in bed resting with the TV on. The resident answered questions readily when spoken to. No distress noted. Observation on 6/7/16 at 12:30 p.m. revealed the resident sat on the side of his/her bed visiting with another resident. The resident was calm and smiling while talking to the resident. Observation on 6/7/16 at 1:10 p.m. revealed the resident with a group of residents for an outing. The resident was in good spirits. Observation on 6/7/16 at 4:00 p.m. revealed the resident resting in bed covered with a blanket. Observation on 6/8/16 at 7:10 a.m. the resident sat in the TV area waiting for breakfast. The resident was quiet and interacted with other residents in the room. During an interview on 6/7/16 at 9:55 a.m., the resident reported he/she was going to stay in bed all day. It made him/her comfortable. The resident denied pain but reported he/she was having twins today. During a conversation on 6/7/16 at 4:30 p.m., the resident informed the surveyor that he/she had some babies while he/she was lying down but could not remember where he/she put them now. The resident reported he/she was going to have twins later. During an interview on 6/7/16 at 1:24 p.m., direct care staff E reported the resident liked (gender) and thought he/she was married and having a baby. The resident was delusional and often talked about having twins. If the resident had behaviors or was not him/herself, he/she would report the behaviors to the charge nurse. During an interview on 6/8/16 at 8:33 a.m. direct care staff D reported the resident had trouble with delusions mostly about (gender) as his/her lover or child. Sometimes he/she needed someone to sit with him/her during delusions and hallucinations that scared him/her. If staff D noted the resident having any different behaviors or not acting right, he/she charted the behavior and could mark a special alert with the charting informing the nurse of the behavior and what was going on. Also, he/she reported it verbally to the nurse. During an interview on 6/8/16 at 3:32 p.m., direct care staff L reported the resident was not much trouble. The resident bathed on his/her shift and needed coaxing and encouragement because he/she would refuse to bathe. The resident needed reassurance when delusional. During an interview on 6/8/16 at 1:30 p.m. licensed nurse G reported the resident was delusional and thought he/she was pregnant all the time. The physician had worked his/her up even doing a pregnancy test to assure the resident he/she was not pregnant. The physician had adjusted the resident's medications and he/she was less delusional. The nurse reported charting on the resident frequently but did not chart specific targeted behaviors for every medication. There was some behavior monitoring for delusions. During an interview on 6/8/16 at 10:30 a.m. administrative nurse B reported there was no behavior monitoring for all the psychoactive medications the resident received. Nurse B reviewed the resident's TAR and did not locate behavior monitoring for specific targeted behaviors for [MEDICATION NAME] and [MEDICATION NAME]. Review of the facility's policy named Behavior Assessment and Monitoring dated 2/2014 revealed: Problematic behavior would be identified and managed appropriately. If a resident received treatment for [REDACTED]. The staff will document either in progress notes, behavior assessment forms, or other comparable approaches the following information about specific problem behaviors: number and frequency of episodes, preceding or precipitating factors, interventions attempted and outcomes associated with interventions. The facility failed to ensure resident #33 was free of unnecessary medications by the failure to accurately monitor specific targeted behaviors for psychoactive medications received. - Review of resident #50's signed physician order [REDACTED]. Review of the admission MDS (minimum data set) dated 3/28/16 revealed a BIMS (brief interview for mental status) score of 14, indicating cognitively intact. The resident had a level II PASRR (Preadmission Screening and Resident Review- a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) for serious mental illness. The resident had no signs of [MEDICAL CONDITION] (sudden severe confusion, disorientation and restlessness) and had a mood score of 5, indicating mild depression. The resident had no delusions, hallucinations, or behaviors. The resident required supervision with set up assistance for all ADLs (activities of daily living). The resident did not receive scheduled pain medication but received as needed (PRN) pain medications and the resident denied pain. The resident received an antipsychotic, antianxiety, and antidepressant medication daily for 7 days of the observation period. Review of the [MEDICAL CONDITION] drug CAA (care area assessment) dated 3/28/16 revealed the resident received [MEDICAL CONDITION] medications for management of major [MEDICAL CONDITION], anxiety disorder and [MEDICAL CONDITION] disorder. The resident had a potential for drug toxicity due to long-term [MEDICAL CONDITION] drug use. Staff monitored the resident for abnormal extremity movements per the AIMS (abnormal involuntary movement scale- used to measure movement abnormalities due to [MEDICAL CONDITION] drug use side effects) quarterly. The psychiatrist assessed the resident monthly and reviewed the medication regimen. The pharmacy consultant reviewed medications monthly and made recommendations for dosage reduction and/or discontinuation of unnecessary medications PRN. Review of the care plan last reviewed on 3/28/16 revealed the following interventions/goals related to medications: Monitor/record medication side effects and report to the physician as necessary. Be aware the resident had the potential for an activity deficit due to major depressive order. Know the resident had the potential for ineffective coping due to staying at the facility until the resident's family member could find a home. Staff will prompt/encourage the resident to display manageable behaviors. (Talking with staff if the resident felt depressed instead of isolating him/herself) Monitor/record occurrences of target behavior symptoms (isolation, depression) and document per facility protocol. Monitor behavior episodes and attempt to redirect. Nurses will notify the psychiatrist of any new, continuing/worsening behaviors. Review of the physicians order sheet dated 5/16/16 included the following medication orders: [MEDICATION NAME] 2 mg (milligram) tablet three times a day for anxiety disorder. [MEDICATION NAME] 10 mg daily for major [MEDICAL CONDITION] [MEDICATION NAME] 100 mg at bedtime for difficulty sleeping [MEDICATION NAME] XL 24 hour 150 mg daily for major [MEDICAL CONDITION] [MEDICATION NAME] Sodium ER (extended release) 500 mg 2 tablets daily for major [MEDICAL CONDITION] [MEDICATION NAME] ER 50 mg daily for major [MEDICAL CONDITION] Review of the March, April, May 2016 MAR, (Medication administration record) and TAR (treatment administration record) lacked evidence of monitoring medication effectiveness related to specific targeted behaviors for antipsychotic medications. An observation on 6/8/16 at 9:42 AM the resident mopped the floor down the north hall and another male resident stopped and visited with the resident. The conversation appeared appropriate with no inappropriate interaction noted. During an interview on 6/7/16 at 10:54 AM the resident stated he/she did not really know much about his/her medications but knew he/she needed to take them. During an interview on 6/7/16 at 1:12 PM direct care staff D reported if the resident had a behavior staff documented it in the computer. Staff D stated a special alert came up with different behaviors and if the one the resident exhibited on was not listed, then staff could put in a custom alert like if the resident refused a shower or something like that. Staff D stated the nurse then got the alert and the nurse followed up on it. During an interview on 6/8/16 at 12:42 PM direct care staff E stated he/she had not witnessed any behaviors from the resident. Staff E stated if the resident did anything out of the normal routine he/she would notify the charge nurse. During an interview on 6/8/16 at 2:25 PM licensed nursing staff G reported the resident did not have behaviors but staff monitored the resident for self-isolation and withdrawal. Staff G stated he/she watched the resident a little closer on Monday and Tuesday after returning from a weekend home with his/her family member. Staff G reported there were different ways of monitoring for the behaviors; they could be in a progress note or on the TAR. Staff G stated each medication had an attached behavior specifically for that medication on the TAR. During an interview on 6/8/16 at 9:59 AM administrative nursing staff B reported each resident had specific behaviors on the TAR that he/she expected the nurse to use to monitor the behaviors. If it were anything out of the ordinary the computer popped up an alert that the nurse had to document on to clear prior to leaving for the day. Staff B reviewed the resident's TAR and MAR and stated staff had initiated the behavior monitoring in a different area of the computer instead of on the TAR. Staff B stated he/she did audits but had not caught that staff were not monitoring behaviors for this resident. Review of the behavior assessment and monitoring policy dated 2/2014 revealed if staff treated the resident for problematic behavior or mood; the staff would obtain and document ongoing reassessments of changes (positive or negative) in the individual's behavior, mood, and functions. The staff would document either in progress notes, behavior assessment forms, or other comparable approaches the following information about specific problem behaviors: a. number and frequency; b. preceding or precipitating factors c. Interventions attempted; and d. outcomes associated with interventions. The facility failed to monitor specifically identified behaviors for a resident who received [MEDICAL CONDITION] medications.

The facility census totaled 46 residents with 15 residents sampled. Of those, 1 resident was reviewed for PASRR (Preadmission Screening and Resident Review- a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care). Based on observation, interview, and record review the facility failed to ensure staff provided medication education and training as recommended in the PASRR letter. (#50) Findings included: - Review of resident #50's signed physician order [REDACTED]. Review of the admission MDS (minimum data set) dated 3/28/16 revealed a BIMS (brief interview for mental status) score of 14, indicating cognitively intact. The resident had a level II PASRR (Preadmission Screening and Resident Review- a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) for serious mental illness. The resident had no signs of [MEDICAL CONDITION] (sudden severe confusion, disorientation and restlessness) and had a mood score of 5, indicating mild depression. The resident had no delusions, hallucinations, or behaviors. The resident required supervision with set up assistance for all ADLs (activities of daily living). The resident did not receive scheduled pain medication but received as needed (PRN) pain medications and the resident denied pain. The resident received an antipsychotic, antianxiety, and antidepressant) medication daily for 7 days of the observation period. Review of the [MEDICAL CONDITION] drug CAA (care area assessment) dated 3/28/16 revealed the resident received [MEDICAL CONDITION] medications for management of major [MEDICAL CONDITION], anxiety disorder and [MEDICAL CONDITION] disorder. The resident had a potential for drug toxicity due to long-term [MEDICAL CONDITION] drug use. Staff monitored the resident for abnormal extremity movements per the AIMS (abnormal involuntary movement scale- used to measure movement abnormalities due to [MEDICAL CONDITION] drug use side effects) quarterly. The psychiatrist assessed the resident monthly and reviewed the medication regimen. The pharmacy consultant reviewed medications monthly and made recommendations for dosage reduction and/or discontinuation of unnecessary medications PRN. Review of the psychosocial CAA dated 3/28/16 revealed the resident had a recent admission to the State hospital. The resident had a long-standing history of depression and history of suicide attempts while living on his/her own in the community. Review of the care plan last reviewed on 3/28/16 revealed the following interventions/plans related to the recommendations for specialized training in the PASRR letter: The resident will participate in the job program by mopping the floors. Staff will prompt the resident PRN to complete his/her job and give verbal praise when completed. The resident will at least partially complete 1-3 scheduled activities a month. If the resident refused to complete scheduled activities, staff will remind/encourage the resident complete a different activity in his/her free time. The resident will work on his/her goal to move out by completing ADLs independently. Staff will educate the resident to complete his/her ADLs routinely. Staff will encourage the resident to attend at least the amount of activities per his/her goal. Staff will encourage/educate the resident on the need for labs to evaluate medication levels. Staff needed to evaluate the effectiveness of pain interventions. If the resident stated his/her back hurt, he/she lay down at times because it helped with pain relief. If the resident reported pain, staff were to offer PRN [MEDICATION NAME] to alleviate his/her pain. The resident had a [DIAGNOSES REDACTED]. The resident will comply with his/her medication regimen through the review date. The resident will accept his/her medications at the medication cart and/or in the dining room. If the resident refused his/her medications staff would notify the physician. Staff needed to remind the resident to see the psychiatrist when he/she came to the facility. Staff needed to administer medication as ordered and monitor/document for side effects and effectiveness. The care plan lacked any specific education related to the resident's medication regimen, need for each medication and the impact it had on his/her physical and mental health and what could happen if not taken as prescribed. Review of the PASRR determination letter dated 3/18/16 revealed the nursing facility would provide the following: Education about the resident's medication regimen, need for each medication and the impact it had on the resident's health and mental health and what occurred when medications were not taken as prescribed. Review of the care plan meeting notes dated 4/6/16 revealed that staff reviewed the initial care plan with the resident but lacked evidence that the facility educated the resident on his/her medications, what they were for and his/her need to follow the medication regimen. Review of the medication class dated 5/23/16 that reviewed medications for [MEDICAL CONDITION] and their side effects revealed the resident did not attend the class. Observation on 6/7/16 at 12:44 PM revealed the resident placed wet floor signs down the south hallway and he/she stated that he/she was going to mop the hallway floor. On 6/8/16 at 9:36 AM the resident mopped the north hallway. During an interview on 6/7/16 at 10:54 AM the resident reported staff had not taught him/her about the medications he/she took. The resident stated he/she did not know what medications he/she took or why. During an interview on 6/7/16 at 1:12 PM direct care staff D reported the resident needed prompting to accomplish ADLs otherwise the resident asked staff for things he/she needed During an interview on 6/8/16 at 12:41 PM direct care staff E reported the facility had medications classes where the residents were taught about their medications. Staff did not know for sure if the resident attended the classes or not. During an interview on 6/8/16 at 1:15 PM administrative nursing staff A reported the resident had a move out goal to be able to move out with his/her family. Staff A stated he/she did not know if the resident would have someone else help him/her set up the medications or if the resident would do it him/herself and had would wait until he/she found that information out to provide education. Staff A stated he/she agreed the care plan did not identify the education need of the resident related to his/her medications. During an interview on 6/8/16 at 2:21 PM licensed nursing staff G reported he/she taught the medication class and discussed specific types of medications and PRN medications not each resident's specific medications. Review of the admissions to the facility policy dated 3/2/15 revealed residents admitted to the facility would have a level 2 PASRR completed prior to admission based upon State and federal guidelines. The facility would follow guidelines listed in the level 2 letter. The facility failed to provide medication education as recommended according to the level 2 PASRR letter for resident #50.

The facility census totaled 46 residents with 15 residents included in the sample. Based on observation, interview and record review the pharmacy failed to ensure the facility staff were administering medications for specific targeted behaviors and monitoring for specific targeted behaviors for 2 of 5 residents reviewed for unnecessary medications. (#33, #50) Findings included: - Review of resident #33's signed physician orders [REDACTED].(current) drug therapy and drug induced subacute dyskinesia (an impairment of the ability to execute voluntary movements). Review of the annual MDS dated [DATE] revealed a BIMS (brief interview on mental status) of 14 indicating normal cognition. The resident had hallucinations and delusions. The assessment indicated the resident had improved and had no behaviors. Medications included an antipsychotic medication, antianxiety, and an antidepressant. Review of the care plan with a revision date of 3/15/15 revealed: The resident received psychotropic medications to treat the resident's anxiety disorder, schizoaffective disorder and major depressive disorder. The resident was at risk for potential drug toxicity. Approaches included; Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/record occurrence of target behavior symptoms (isolation, delusional statements) and document per facility protocol. Review of the physician orders [REDACTED]. Aripiprazole Lauroxil ER prefilled syringe 662 mg (milligrams) /2.4 ml (milliliter) Inject 2.4 ml intramuscularly 1 time every 28 days for schizoaffective disorder- ordered on [DATE] Fluoxetine HCL 20 mg tab 1 by mouth daily for major depressive disorder- ordered on [DATE] Lorazepam 1 mg tab by mouth at bedtime for anxiety disorder -ordered on [DATE] Haloperidol tablet 2 mg by mouth twice a day for schizoaffective disorder- ordered on [DATE] Lorazepam tablet 0.5 mg by mouth 1 tab twice daily for anxiety disorder. - ordered on [DATE] Review of the psychoactive behavioral monitoring revealed: Target behavior for the use of Geodon was delusions. Note the number of episodes for every shift. No behaviors noted during the months of April, May and June 2016 Target behavior for use of Invega Sustenna (Aripiprazole Lauroxil ER) was delusions. Note the number of episodes per shift. No episodes noted during the month of April, May and June 2016. The TAR (treatment administration record- where behaviors are documented) failed to have specific targeted behaviors for the use of Haldol, Lorazepam and Fluoxetine. Review of consulting pharmacist recommendations dated 3/14/16 for a gradual dose reduction for Invega, Fluoxetine, Lorazepam and Haldol. The physician replied to keep same medications with a statement reading I feel the benefits of using this drug outweigh the risk to the resident, and I have no changes regarding these medications. Patient would likely decompensate if changed. Review of the pharmacy consultant monthly medication review revealed: 5/19/15- medication review. no irregularities 6/15/15- medication review. no irregularities 7/16/16- medication review. no irregularities 8/19/15- medication review. no irregularities 9/16/15- medication review. no irregularities 10/15/15- medication review. no irregularities 11/17/15- medication review. no irregularities 12/16/15- medication review. no irregularities 1/19/16- medication review. no irregularities 2/15/16- Consider changing Mobic to Acetaminophen, and Loratadine to 10 mg daily as needed. 3/18/16- No irregularities noted, multiple behavior medication changes. 5/16/16- No irregularities noted During an interview on 6/7/16 at 9:55 a.m., the resident reported he/she was going to stay in bed all day. It made him/her comfortable. The resident denied pain but reported he/she was having twins today. During a conversation on 6/7/16 at 4:30 p.m., the resident informed the surveyor that he/she had some babies while he/she was lying down but could not remember where he/she put them now. The resident reported he/she was going to have twins later. During an interview on 6/7/16 at 1:24 p.m., direct care staff E reported the resident liked (gender) and thought he/she was married and having a baby. The resident was delusional and often talked about having twins. When the resident had behaviors or was not him/herself, he/she would report the behaviors to the charge nurse. During an interview on 6/8/16 at 1:30 p.m. licensed nurse G reported the resident was delusional and thought he/she was pregnant all the time. The physician had worked his/her up even doing a pregnancy test to assure the resident he/she was not pregnant. The physician had adjusted the resident's medications and he/she was less delusional. The nurse reported charting on the resident frequently but did not chart specific targeted behaviors for every medication. There was some behavior monitoring for delusions in the TAR but not for every medication. No behavior monitoring for Haldol During an interview on 6/8/16 at 10:30 a.m. administrative nurse B reported there was no behavior monitoring for all the psychoactive medications the resident received. Nurse B reviewed the resident's TAR and did not locate behavior monitoring for specific targeted behaviors for Haldol, Fluoxetine and Lorazepam. During an interview on 6/13/16 at 8:41 AM pharmacy consultant O reported he/she did look at the TAR for behavior monitoring as well as the computer documentation for any holes in the documentation. Consultant O stated the facility had a good system in place and he/she had just missed identifying the two residents surveyors identified without specific targeted behaviors. Review of the facility's policy named Pharmacy Services Overview dated 4/2007 revealed: The facility shall accurately and safely provide or obtain pharmacy services including the provision of routine and emergency medications, and biologicals, and the services of a licensed Pharmacist. The facility shall contract with a licensed pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. The pharmacy failed to ensure the facility staff were administering medications for specific targeted behaviors and monitoring for specific targeted behaviors for 3 residents reviewed for unnecessary medications. - Review of resident #50's signed physician order [REDACTED]. Review of the admission MDS (minimum data set) dated 3/28/16 revealed a BIMS (brief interview for mental status) score of 14, indicating cognitively intact. The resident had a level II PASRR (Preadmission Screening and Resident Review- a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) for serious mental illness. The resident had no signs of delirium (sudden severe confusion, disorientation and restlessness) and had a mood score of 5, indicating mild depression. The resident had no delusions, hallucinations, or behaviors. The resident received an antipsychotic, antianxiety, and antidepressant medication daily for 7 days of the observation period. Review of the psychotropic drug CAA (care area assessment) dated 3/28/16 revealed the resident received psychotropic medications for management of major depressive disorder, anxiety disorder and bipolar disorder. Review of the care plan last reviewed on 3/28/16 revealed the following interventions/goals related to medical record review: Monitor/record occurrence of for target behavior symptoms (isolation, depression) and document per facility protocol. The pharmacy consultant needed to review medications monthly and recommend dosage reduction and/or discontinuation of unnecessary medications. Review of the physicians orders dated 5/16/16 included the following medications: [REDACTED] Clonazepam 2 mg (milligram) tablet three times a day for anxiety disorder Olanzapine 10 mg daily for major depressive disorder Trazodone 100 mg at bedtime for difficulty sleeping Wellbutrin XL 24 hour 150 mg daily for major depressive disorder Divalproex Sodium ER (extended release) 500 mg 2 tablets daily for major depressive disorder Pristiq ER 50 mg daily for major depressive disorder Review of the March, April, and May 2016 MAR (Medication administration record) and TAR (treatment administration record) lacked evidence of monitoring medication effectiveness related to specific targeted behaviors for antipsychotic medications. Review of the pharmacy review April and May of 2016 failed to identify the facility had not monitored the resident for specific targeted behaviors related to psychotropic medications. An observation on 6/8/16 at 9:42 AM the resident mopped the floor down the north hall and another male resident stopped and visited with the resident. The conversation appeared appropriate with no inappropriate interaction noted. During an interview on 6/7/16 at 10:54 AM the resident stated he/she did not really know much about his/her medications but knew he/she needed to take them. During an interview on 6/7/16 at 1:12 PM direct care staff D reported if the resident had a behavior, staff documented it in the computer. Staff D stated a special alert came up with different behaviors and if the one the resident exhibited on was not listed, then staff could put in a custom alert like if the resident refused a shower or something like that. Staff D stated the nurse then got the alert and followed up on it. During an interview on 6/9/16 at 1:15 PM administrative nursing staff B reported the pharmacist did look at the behavior monitoring on the TAR but he/she must have missed that staff were not monitoring behaviors. During an interview on 6/13/16 at 8:41 AM consultant pharmacist staff O reported he/she looked at the TAR for behavior monitoring. Staff O stated he/she must have just missed identifying staff had not monitored for the targeted behaviors for the resident. Review of the pharmacy services policy dated 4/2007 revealed the facility would contract with a licensed pharmacist to help establish procedures for conducting the monthly medication regimen review for each resident in the facility. The facility failed to ensure the consultant pharmacist identified irregularities related to the lack of monitoring of specific targeted behaviors.

The facility census totaled 46 residents. Based on interview and record review the facility failed to ensure residents had the right to review the past state inspections (survey results) which had the potential to affect all residents. Findings included: - Review of the admission information shared with residents and families/legal representative revealed the residents had the right to review survey results. During an interview on 6/8/16 at 3:48 PM resident #45 reported he/she did not know he/she could see the results of the previous State inspections. The resident stated he/she did not remember anyone talking to the residents in resident council or talking to him/her personally about it. During an interview on 6/8/16 at 3:52 PM resident #24 reported he/she did not know where the survey results were or that he/she could look at them. During an interview on 6/8/16 at 4:00 PM resident #41 reported he/she did not know what or where the survey results were or that he/she could look at them. During an interview on 6/8/16 at 4:10 PM resident #14 reported he/she did not know where the survey results were or that he/she could look at them. During an interview on 6/8/216 at 4:23 PM administrative staff C reported the facility told the residents and their families on admission where the past survey results were and reviewed the results with the residents after each survey. Staff C stated the facility did not normally think about the residents knowing where the results were and that they could look at them. Staff C stated the facility focused on whether or not the resident had any concerns the facility needed to work on. Review of the resident rights policy revised on 8/2009 revealed the residents had a right to examine survey results. The facility failed to ensure residents knew they had a right to review the past survey results and failed to make sure residents knew where those survey results were kept.

The facility had a census of 46 residents with 3 residents selected for sample. Based on observation, interview and record review, the facility failed to ensure each resident had the right to be free from physical abuse. Resident #1 entered resident #4's room and beat the resident on the face and head, pulled the resident to the floor, and then repeatedly hit the resident's head against the floor. Facility staff witnessed the event and did not physically intervene. After approximately 5 minutes, resident #1 stopped beating resident #4 and left the room. Resident #4 experienced severe injuries that necessitated transfer to a specialty hospital. Resident #4 expired on [DATE] from injuries inflicted by resident #1. The facility's failure to develop/implement specific individualized interventions to address resident #1's recent hospitalization for management of physical aggression, facility failure to ensure all staff received training in how to deal with unmanageable, violent residents, and failure to intervene appropriately when a resident physically attacked another resident, placed all facility residents in immediate jeopardy. Based on observation, interview and record review, the facility failed to take sufficient action to prevent abuse when Resident #2 developed increasingly agitated/aggressive behaviors after he/she refused antipsychotic medications for several weeks, and after staff failed to notify the physician in a timely manner of those refusals. After his/her behaviors escalated, resident #2 initiated two physical altercations (shoving/hitting) with residents within a 48 hour time period which resulted in his/her transfer to a mental health hospital. Findings included: - Resident #1's clinical record included [DIAGNOSES REDACTED]. The [DATE] Quarterly MDS (Minimum Data Set) identified resident #1 with no cognitive impairment, no acute onset of mental status change, no hallucinations or delusions, rejection of care ,[DATE] days within the 7 day observation period, no wandering behaviors, and use of antipsychotic, antianxiety and antidepressant medication daily. The [DATE] Annual MDS identified resident #1 with no cognitive impairment, no acute onset mental status change, the presence of hallucinations and delusions, no physical behaviors directed toward others, the presence of other behaviors which did not put the resident or others at significant risk for physical illness or injury ,[DATE] days during the 7 day observation period, improved behaviors compared to the prior assessment, and use of antipsychotic, antianxiety and antidepressant medication daily. CAAs (Care Area Assessments) completed on [DATE] included: o Behaviors: Resident with long standing displayed behaviors of having difficulty focusing on conversations and resident changes subjects often with [DIAGNOSES REDACTED]. Resident's behaviors do not place (him/her) or peers in immediate threat at this time. Facility staff trained to deal with behaviors and de-escalation of behaviors. o Moods: Resident with long standing behavior of keeping to self and attending few activities. [MEDICAL CONDITION] and [MEDICAL CONDITION]. o [MEDICAL CONDITION] drug use; Resident is on long term [MEDICAL CONDITION] medication for treatment of [REDACTED]. Resident #1's [DATE] care plan included the following: o I take antipsychotic medications due to my mental illness of paranoid [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. If I continue to display behavior or my behavior worsens, the staff will contact the psychiatrist. o Staff will check on me at least every two hours and document on the clipboard ([DATE]) o I have behaviors of threatening peers/staff, urinating/defecating on floor, eating/taking food to my room, ignoring staff, going from staff to staff until getting my way, bumming cigs and money and drinks. Staff to document behaviors as they are seen. Staff to redirect behaviors as they occur. (Family member) to be notified of increase in behaviors. Psychiatrist to be notified of new/worsening behaviors. ([DATE]) o I had a physical altercation with a (male/female) peer on previous night. I will have no further physical altercations with peers over the next 90 days. I will talk with staff if I feel anger/upset at anyone over the next 90 days. Attempt to redirect if noted to be getting upset (pacing more, clenching fists, statements; notify screener for resident to be screened if see increased escalation anger/behaviors. Encourage resident to stay away from (male/female) peer who had resident altercation. Screened to (mental health hospital) due to increased anger/physical with another peer. ([DATE]). o I readmitted from (mental health hospital) due to I became upset and had physical aggression with 2 peers and was screened to (mental health hospital) on [DATE]. I will continue to display no anger/aggression or cause physical harm to my peers as this was (mental health hospital's) discharge goal. I will continue this for the next 90 days. Resident continued with previously listed interventions. Res. reminded that if (he/she) had another physical altercation, screener would be contacted. ([DATE]) The care plan lacked evidence that staff reviewed and revised it with specific interventions upon resident #1's return from the mental health hospital on [DATE] to address the recent history of increased physical aggression/physical contact directed at peers. Progress Notes included the following: o [DATE] at 5:45 p.m.: This entry described an incident that occurred when another resident walked by resident #1 and tapped/hit him/her on the right side of the body. Resident #1 then ran after the other resident, grabbed his/her hair, and pulled the resident to the floor. The facility notified the guardian and physician of the incident. o [DATE] at 12:49 p.m.: This entry described an incident between resident #1 and another resident that occurred when resident #1 yelled a profanity and then attempted to punch the other resident. The facility notified the guardian and then contacted a mental health screener to evaluate the resident's recent behavior changes. o [DATE] at 4:25 p.m.: This entry described the completion of a mental health screen by a qualified mental health professional and subsequent transfer to mental health hospital for treatment of [REDACTED]. Resident #1 returned from the mental health hospital on [DATE]. A Nursing Admission Evaluation on the resident's return to the facility on [DATE] described the resident as alert and oriented, verbally appropriate, pleasant and content. The assessment also noted the resident's history of depression, history of physical aggression, history of being verbally abusive, the presence of hallucinations, and use of antipsychotic, antianxiety, and antidepressant medications. Discharge notes dated [DATE] from the mental health hospital noted resident #1 reported no hallucinations or delusions at the time of discharge and no homicidal or suicidal ideation. Discharge instructions included: * Utilize free time by doing healthy, meaningful activities * Participate in therapy to learn and practice healthy coping skills for various issues and effective stress management. Review of resident #1's care plan after readmission to the facility on [DATE] revealed no evidence staff reviewed/revised the care plan with the previously described discharge instructions. Additional Progress Notes after resident #1's readmission included: o [DATE] at 1:00 a.m.: This entry described resident #1's refusal of vital signs and refusal of an assessment of an infected foot/toe. o [DATE] at 10:17 a.m.: This entry described the resident's compliance with taking medications and eating a meal in the dining room with other residents without incident. o [DATE] at 12:51 p.m.: This entry described episodes of urinary incontinence that morning, and described the resident as walks around in a daze. The note also described how resident #1 packed out his/her room that morning and took all of his/her clothing and room items into the hallway and then returned them to his/her room. According to the note, (He/she) is not responding to staff interaction . o [DATE] at 1:40 a.m.: This entry described the resident's compliance with taking medications on the evening shift and described him/her as walking in hall laughing loudly. Then, on [DATE] at 8:45 p.m., a Progress Note included the following: Call received from nursing on duty at facility that resident (resident #1) attacked (another resident). Resident in custody of LE (law enforcement) and transported to jail. Contacted screener who will complete screen (mental health screen) in jail. A later Progress Note in resident #1's clinical record dated [DATE] at 2:44 p.m. described the [DATE] incident as follows: Resident was having a routine evening, walking in halls and outside, going to smoke breaks. After resident ate supper, nurse reminded resident to stop at medication cart for supper meds. Resident ignored nurse and walked on to room to lay down. After several minutes of walking around facility, resident came to med cart for HS (hour of sleep/bedtime) meds at 1945 (7:45 p.m.). 1700 (5:00 p.m.) meds given at this time along with HS meds. At 2015 (8:15 p.m.) nurse at med cart heard an unusual clanging sound. Upon investigation, observed this resident (resident #1) in (resident #4's) room, standing over (him/her) in bed, hitting (him/her) repeatedly in the face and head wouldn't stop, nurse called 911. This resident threw (resident #4) off the bed head first and continued hitting (him/her) and banging (his/her) head against the floor Another resident intervened and got this resident away. The facility completed an investigation into the previously described incident which described how resident #1 walked into resident #4's room and began hitting him/her in the face with both hands. According to the facility's investigation, Licensed Nurse D heard an unusual noise and went to investigate the origin. Nurse D found resident #1 standing over resident #4's bed, striking the resident in the head. Nurse D yelled at Resident #1 to stop and then called for assistance of other staff. Resident #1 then pulled resident #4 off the bed, repeatedly struck him/her in the face and head, and then banged the resident's head against the floor. While the altercation between resident #1 and resident #4 took place, Licensed Nurse D called emergency responders for assistance. Resident #1 eventually stopped beating resident #4 after another resident intervened and held resident #1 from doing more damage to resident #4. Emergency medical staff stabilized resident #4 and sent him/her to an outlying hospital via a helicopter. As of [DATE], the date of the facility investigation, resident #4 remained at the hospital in critical condition, and resident #1 remained at a mental health hospital. Behavior monitoring completed by licensed nurses on [DATE], the day prior to the incident between resident #1 and #4, noted that resident #1 experienced auditory hallucinations on the day shift. According to the schedule for [DATE], the day of the incident between resident #1 and #4, nursing staff for the afternoon/evening shift consisted of two staff members, Licensed Nurse D and Direct Care Staff E. Staffing schedules for the entire month of [DATE] included assignment of 1 nurse aide and one licensed nurse to the evening shift routinely throughout the month. During an interview on [DATE] at 2:00 p.m., Administrative Nurse C reported resident #4 expired on [DATE] from injuries received in the [DATE] incident with resident #1. During an interview on [DATE] at 8:40 a.m., Office Staff F reported staff must recertify in CPI (Crisis Prevention Interventions) training each year. Staff F also reported a contracted CPI instructor provided the classes, and conducted them when several people needed the class. According to Staff F, newly hired employees do not take the CPI class prior to starting work at the facility, but are enrolled in the first available class after they are hired. During an interview on [DATE] at 8:50 a.m., Administrative Nurse C reported all staff received CPI training in order to know how to deal with resident behaviors and de-escalation techniques. According to the CPI (Crisis Prevention Interventions) participant workbook dated 2005 with a reprint date of 2014, The philosophy of the CPI program is to provide the best care, welfare, safety and security for the individuals in your charge, even in violent moments has been proven effective in potentially violent situations. The CPI workbook included Preventive Techniques, Nonviolent Crisis Intervention and team intervention. Objectives for trainees, included: 1) Training staff with effective techniques in approaching and reducing the tension of an agitated person. 2) Focusing on the alternatives if a person loses control and becomes violent. 3) Instructing staff members in techniques to control their own anxieties during interventions and maintain the best possible professional attitude. 4) Providing nonverbal, paraverbal (the messages that we transmit through the tone, ptich and pacing of our voices), verbal and physical intervention skills to allow the staff to maintain the best possible care and welfare, as well as safety and security, for all involved - even during the most violent moments. The workbook directed staff to avoid overreaction or under-reaction. Use verbal intervention skills to intervene with a verbally acting out person. However, when the aggression becomes physical, you must also have in your repertoire of skills safe physical intervention techniques to control the physical acting-out behavior. During a telephone interview on [DATE] at 4:00 p.m., Administrative Staff A reported he/she contacted the facility's CPI trainer and learned the trainer did not teach facility staff the methods to physically intervene when a resident is violent as taught in the CPI manual. According to Staff A, the facility decided 3, 4 or 5 years ago to stop training staff how to intervene physically because there was concern with the size and strength of the residents. Staff A could not verbalize what policies the facility put into place to handle violent residents when they stopped providing CPI training that covered that area. According to Staff A, staff should call 911 if a resident became violent and should not intervene physically while they awaited response from law enforcement. During an interview on [DATE] at 4:10 p.m., Administrative Nurse B reported a mental health screener determined resident #1 required admission to a mental health hospital in early [DATE] after he/she had two physical altercations with other residents within a 24 hour time period. According to Nurse B, resident #1 behaved normally for him/her upon readmission to the facility and on [DATE], the day of the incident, did not exhibit any signs of aggression after readmission until the time of the beating incident with resident #4. Nurse B reported, There were no warning signs. (He/she) just attacked (resident #4). Upon review of the clinical record, Nurse B reported the facility completed charting every shift for 72 hours for resident #1 upon readmission on [DATE] which is the facility's standard process for all readmissions. Nurse B also reported staff monitored resident #1's whereabouts every 2 hours upon readmission, which is also the process for all facility residents. Nurse B could not verbalize any additional interventions implemented upon resident #1's [DATE] readmission to address the recent history of physical aggression toward other residents. During an interview on [DATE] at 9:46 a.m., Licensed Nurse D confirmed he/she worked the evening shift on [DATE], the night of the incident between resident #1 and resident #4. Nurse D reported resident #1 acted normally for him/her through the early hours of the shift. After resident #1 took his/her medications, he/she went to lay down for awhile. A short time later the resident went out to smoke with other residents and a staff member and had no behaviors during that outing. Nurse D saw resident #1 return to his/her room after smoking. A short time later Nurse D heard a strange noise coming from somewhere in the South hallway and went to investigate. Nurse D reported he/she stopped outside of resident #4's room where the noise came from, and observed resident #1 beating resident #4 on the face/head with clenched fists. According to Nurse D, he/she did not enter the room but yelled at resident #1 to stop. In response to that request, resident #1 stopped beating resident #4 for just a second, stared blankly at Nurse D, and then resumed the beating. Nurse D called out for help from the other staff member working that shift, Direct Care Staff E. As Nurse D turned to go to the Nurses Station to call 911, he/she saw resident #1 throw resident #4 onto the floor and start beating his/her head against the floor. After he/she called 911, Nurse D went back to the scene of the incident where Direct Care Staff E and several residents also stood at the doorway. Nurse D recalled that he/she and Staff E repeatedly told resident #1 to stop, but the resident did not respond to their requests and kept beating resident #4. Nurse D estimated the continual beating lasted a good 5 minutes before another resident called out to resident #1 from the doorway and convinced him/her to stop beating resident #4. At that time resident #1 left resident #4's room and went back to his/her own room. Nurse D recalled that neither staff members or any residents ever entered resident #4's room during the previously described incident, until after resident #1 returned to his/her room. Nurse D estimated it took law enforcement approximately 10 minutes to get to the facility after he/she placed the 911 call because they had to drive from another town several miles away. Nurse D reported he/she did not physically intervene during the incident because of fear resident #1 would hurt him/her, and that would leave only one staff member to deal with the situation and take care of the residents. Nurse D stated, All my instincts told me it would make things worse for more people if I did (attempt to intervene physically). Although the facility's initial investigation into this incident included a statement that another resident physically removed resident #1 from resident #4's room in order to stop the beating, Nurse D reported that no one, neither residents or staff, entered resident #4's room during the entire incident. Licensed Nurse D reported he/she completed CPI training annually for many years, but failed to complete the training when the facility offered it in [DATE]. Nurse D confirmed he/she lacked current CPI certification. As requested, the facility provided a list of current employees (as of [DATE]) as well as dates of CPI and ANE (abuse, neglect, exploitation) training for all staff. According to the list provided, 8 of 32 current staff members lacked CPI training within the last year, including Licensed Nurse D, the nurse who worked on [DATE] when resident #1 beat resident #4. Also according to the list, 14 of 32 current staff lacked ANE training within the past year, including Licensed Nurse D. Direct Care Staff E, the other staff member on duty at the time of the incident, completed CPI and ANE training within the past 12 months. According to the facility's current, undated Unmanageable Residents policy, Crisis Prevention Intervention physical control positions may only be used if a resident becomes physically aggressive. Verbal crisis prevention skills must be used at all other times. The facility's Abuse Prevention Program policy with a revision date of [DATE] included, The facility administration and employees are committed to protecting resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual The abuse prevention program provides policies and procedures that govern .mandated staff training/orientation programs that includes abuse prevention, identification and reporting of abuse The facility failed to ensure each resident had the right to be free from physical abuse when staff failed to develop and implement specific, individualized interventions related to aggression for resident #1 upon his/her readmission to the facility from a mental health hospital where he/she underwent evaluation and treatment for [REDACTED]. These facility failures placed all residents in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 3:15 p.m. by implementing the following measures: 1) Revised admission screening polices to include special assessment of prospective resident's histories of previous violent behaviors and [DIAGNOSES REDACTED]. 2) Review of all current resident's clinical records in order to identify current residents with histories of violent behaviors and/or aggression, and them development and implementation of individualized care plans/interventions to address those behaviors. 3) Completed CPI training for all but two staff members who were unavailable for training. The two staff members will receive CPI training on [DATE]. 4) Evaluated staffing levels to ensure that two CPI certified staff remain on duty at all times, around the clock, with plans for additional staff support when resident behaviors/needs require increased staffing levels. 5) Revised the facility policy for how to handle unmanageable residents. After abatement of the immediate jeopardy, the deficient practice remained at a scope/severity of G. - Resident #2's clinical record included multiple medical [DIAGNOSES REDACTED]. characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The [DATE] Annual MDS (Minimum Data Set) identified resident #2 with no cognitive impairment, no acute onset of mental status change, the presence of behavioral symptoms not directed toward others 1 to 3 days during the 7 day observation period, the presence of hallucinations and delusions, behaviors not directed toward others ,[DATE] days during the 7 day observation period, behaviors did not put resident or others at risk for physical illness/injury. CAAs (Care Area Assessments) completed after [DATE] Annual MDS included the following: o Behaviors: Resident with long standing displays of inattention, disorganized thinking and staring into space as part of behavior displayed with mental illness of [MEDICAL CONDITION] disorder. Resident with behaviors of yelling, laughing and crying loudly when pacing in hallways at times. Resident with long standing refusal to have labs drawn and at times refusing to bathe. Resident's behaviors do not place resident or peers in immediate threat at this time. The [DATE] Admission MDS identified resident #2 with no cognitive impairment, the presence of moods, the presence of hallucinations and delusions, the presence of behaviors not directed toward others, behaviors did not put the resident or others at risk for physical illness or injury, and use of antipsychotic and antidepressant medication daily. CAAs (Care Area Assessments) completed on [DATE] included: o Behaviors: 'Resident with long-standing behaviors displayed of pacing in hallway, talking to self/unseen persons, yelling/crying loudly, refusing medications, hallucinations and voicing delusional statements. Resident's behaviors do not place self or others in immediate threat at this time. Resident with long-standing displays of listed behaviors and have become part of residents usual routine. At times behaviors are purposeful such as when refusing medications or bathing. At times behaviors without any noted reason. Resident with long-standing mental illness and displays behaviors associated with illness. Resident's behaviors unable to be controlled when outside facility as not accepted as normal in community. Resident's peers with similar behaviors and this allows resident to not feel embarrassed. Facility staff trained to deal with behaviors and techniques for de-escalation of behaviors. Will continue to care plan for resident's behaviors. Staff to monitor for behaviors, attempt to redirect and document behaviors when they occur. Psychiatrist to be notified of new or worsening behaviors occurring to determine if medication adjustment is warranted. At this time no referral indicated, however IDT (interdisciplinary team) will continue to monitor and will consult with healthcare professional as needed.' The [DATE] care plan for resident #2 included: o Inappropriate behavior related to [MEDICAL CONDITION] disorder and [MEDICAL CONDITION] document behaviors in soon as occurs, remind resident of need to take medication and comply with careplan to work towards move out goal. Try different staff to try to get resident to take medications, bathe or allow lab to be drawn. The care plan lacked specific interventions related to physical aggression directed toward other residents. MARs (Medication Administration Records) directed staff to provide multiple medications to resident #2, including: o [MEDICATION NAME], an antipsychotic medication, 6 mg (milligrams) 2 tablets daily for unspecified [MEDICAL CONDITION] ([DATE] order) According to the [DATE] MAR, resident #2 refused the [MEDICATION NAME] 1 time during the month. According to the [DATE] MAR, resident #2 refused the [MEDICATION NAME] 4 times during the month. According to the [DATE] MAR, resident #2 refused the medication 4 times in the first 4 days of the month. o [MEDICATION NAME], an antidepressant medication, 15 mg daily for [MEDICAL CONDITION] According to the [DATE] MAR, resident #2 refused the medication 1 time during the month. According to the [DATE] MAR, resident #2 refused the medication 17 times during the month. According to the [DATE] MAR, resident #2 refused the medication 3 times in the first 4 days of the month. o [MEDICATION NAME], a medication used to lower blood cholesterol levels, 20 mg. daily for [MEDICAL CONDITION] (elevated blood cholesterol), According to the [DATE] MAR, resident #2 refused the medication 1 time during the month. According to the [DATE] MAR, resident #2 refused the medication 14 times during the month. According to the [DATE] MAR, resident #2 refused the medication 3 times in the first 4 days of the month. o [MEDICATION NAME] 1 mg, a medication used to treat involuntary movements due to the side effects of certain psychiatric drugs, twice daily for pseudobulbar affect According to the [DATE] MAR, resident #2 refused the medication 12 times during the month. According to the [DATE] MAR, resident #2 refused the medication 34 times during the month. According to the [DATE] MAR, resident #2 refused the medication 6 times in the first 4 days of the month. o [MEDICATION NAME], a medication used to treat a [MEDICAL CONDITION] disorder, 25 mcg (micrograms) daily for [MEDICAL CONDITION] (an underactive [MEDICAL CONDITION]) According to the [DATE] MAR, resident #2 refused the medication 3 times during the month. According to the [DATE] MAR, resident #2 refused the medication 2 times in the first 4 days of the month. Review of resident #2's clinical record (progress notes, physician's orders [REDACTED]. Progress notes dated from [DATE] to [DATE] included frequent documentation by licensed nurses related to resident #2's refusal of medications and increasing behaviors, including: refusals of medications on [DATE], 18, 21, 22, 23, 24, 25, 27, 28, 29 and 30, 2015. Resident #2 also refused medications [DATE], 3 and 4, 2015. According to the progress notes, resident #2 exhibited behaviors as follows: o [DATE]: The resident packed clothing and placed the items in a trash bin o [DATE]: The resident paced and yelled on the second shift and talked loudly with an agitated voice to him/herself on the 3rd shift. o [DATE] at 11:28 a.m. and 3:54 p.m.: The resident refused medications and reported There are snakes in them. o [DATE]: The resident paced the hallways and laughed. o [DATE]: Staff noted resident #2 sat in his/her bedroom crying. o [DATE]: Staff noted resident #2 had periods of crying loudly and then had occasional laughing. The resident also refused medications because There's snakes in them. o [DATE]: Resident #2 paced the hallways and made random statements. o [DATE]: Staff found resident #2 laying naked on his/her bed with the door open to the main corridor. Later, staff noted the resident paced the halls and laughed. o [DATE]: Resident #2 refused medications because they had snakes in them. o [DATE]: Resident #2 paced the hallways and made loud, quick statements that staff could not understand. o [DATE]: Staff noted resident #2 paced and stood and stared and again refused medications due to snakes in them. o [DATE]: Resident #2 paced the hallways while crying and cursing. At other times the resident paced and laughed. o [DATE] at 9:31 p.m.: At approximately 1955 (7:55 p.m.) this resident violently shoved/pushed (another resident) to get out of my (expletive) way. (Other resident) went approximately ,[DATE] feet away. Continued yelling for (him/her)to get out of her way Writer notified RN (registered nurse) on duty. (Parent) of resident notified and in agreement for placement in another facility for med adjustments. Contracted screener who then instructed this nurse to fax information on resident to (acute psychiatric unit) no bed available contacted (another acute psychiatric facility) and waiting on return call. The clinical record lacked evidence of increased supervision/monitoring of resident #2 after he/she demonstrated physical aggression against another resident as previously described. Additional progress notes included: o [DATE] at 10:04 a.m.: Resident #2 paced and was tearful. o 5.7.15 at 12:16 a.m.: This entry described an incident which happened on [DATE] at 5:45 p.m. when resident #2 approached another resident and struck that resident without provocation. According to the Progress Notes dated [DATE] at 4:55 p.m., a mental health screener evaluated resident #2 and determined he/she required hospitalization at a

The facility had a census of 46 residents, with 3 residents selected for sample. Based on interview and record review, the facility failed to provide 2 of 3 residents with adequate assessment, supervision and interventions to prevent accidents/hazards. Resident #1 and #2 had two incidents each of aggression/violence against other residents which necessitated their hospitalization at hospitals which treated residents with mental illness. Upon both resident's discharges from the hospital and return to the facility, the facility failed to develop and implement appropriate individualized, specific interventions related to recent aggression/violence directed at other residents, including increased supervision in an attempt to protect all residents. Resident #1 attacked resident #4 within three days of his/her readmission. Resident #4 experienced significant physical injury in the attack and later expired from those injuries. This deficient practice placed resident #4 in immediate jeopardy. Findings included: - Resident #1's clinical record included [DIAGNOSES REDACTED]. The [DATE] Quarterly MDS (Minimum Data Set) identified resident #1 with no cognitive impairment, no acute onset of mental status change, no hallucinations or delusions, rejection of care ,[DATE] days within the 7 day observation period, no wandering behaviors, and use of antipsychotic, antianxiety and antidepressant medication daily. The [DATE] Annual MDS identified resident #1 with no cognitive impairment, no acute onset mental status change, the presence of hallucinations and delusions, no physical behaviors directed toward others, the presence of other behaviors which did not put the resident of others at significant risk for physical illness or injury ,[DATE] days during the 7 day observation period, improved behaviors compared to the prior assessment, and use of antipsychotic, antianxiety and antidepressant medication daily. CAAs (Care Area Assessments) completed on [DATE] included: o Behaviors: Resident with long standing displayed behaviors of having difficulty focusing on conversations and resident changes subjects often with [DIAGNOSES REDACTED]. Resident's behaviors do not place (him/her) or peers in immediate threat at this time. Facility staff trained to deal with behaviors and de-escalation of behaviors. o Moods: Resident with long standing behavior of keeping to self and attending few activities. Schizophrenia and traumatic brain injury. o Psychotropic drug use: Resident is on long term psychotropic medication for treatment of [REDACTED]. Resident #1's [DATE] care plan included the following: o I take antipsychotic medications due to my mental illness of paranoid schizophrenia and schizoaffective disorder. If I continue to display behavior or my behavior worsens, the staff will contact the psychiatrist. o Staff will check on me at least every two hours and document on the clipboard ([DATE]) o I have behaviors of threatening peers/staff, urinating/defecating on floor, eating/taking food to my room, ignoring staff, going from staff to staff until getting my way, bumming cigs and money and drinks. Staff to document behaviors as they are seen. Staff to redirect behaviors as they occur. Father to be notified of increase in behaviors. Psychiatrist to be notified of new/worsening behaviors. ([DATE]) o I had a physical altercation with a (male/female) peer on previous night. I will have no further physical altercations with peers over the next 90 days. I will talk with staff if I feel anger/upset at anyone over the next 90 days. Attempt to redirect if noted to be getting upset (pacing more, clenching fists, statements; notify screener for resident to be screened if see increased escalation anger/behaviors. Encourage resident to stay away from female peer who had resident altercation. Screened to (mental health hospital) due to increased anger/physical with another peer ([DATE]). o I readmitted from (mental health hospital) due to I became upset and had physical aggression with 2 peers and was screened to (mental health hospital) on [DATE]. I will continue to display no anger/aggression or cause physical harm to my peers as this was (mental health hospital's) discharge goal. I will continue this for the next 90 days. Resident continued with previously listed interventions. Res. reminded that if (he/she) had another physical altercation, screener would be contacted ([DATE]) Progress Notes included the following: o [DATE] at 5:45 p.m.: This entry described an incident that occurred when another resident walked by resident #1 and tapped/hit him/her on the right side of the body. Resident #1 then ran after the other resident, grabbed his/her hair, and pulled the resident to the floor. o [DATE] at 12:49 p.m.: This entry described an incident between resident #1 and another resident that occurred when resident #1 yelled a profanity and then attempted to punch the other resident. o [DATE] at 4:25 p.m.: This entry described the completion of a mental health screen by a qualified mental health professional and subsequent transfer to mental health hospital for treatment of [REDACTED]. Resident #1 returned from the mental health hospital on [DATE]. A Nursing Admission Evaluation on the resident's return to the facility on [DATE] described the resident as alert and oriented, verbally appropriate, pleasant and content. The assessment also noted the resident's history of depression, history of physical aggression, history of being verbally abusive, the presence of hallucinations, and use of antipsychotic, antianxiety, and antidepressant medications. Discharge notes dated [DATE] from the mental health hospital noted resident #1 reported no hallucinations or delusions at the time of discharge and no homicidal or suicidal ideation. Review of resident #1's care plan after readmission to the facility on [DATE] revealed no evidence staff reviewed/revised the care plan to include increased supervision due to the recent history of aggression/violence against other residents. Additional Progress Notes after resident #1's readmission included: o [DATE] at 8:45 p.m.: Call received from nursing on duty at facility that resident (resident #1) attacked (another resident). Resident in custody of LE (law enforcement) and transported to jail. Contacted screener who will complete screen (mental health screen) in jail. A later Progress Note in resident #1's clinical record dated [DATE] at 2:44 p.m. described the [DATE] incident that involved #1 as follows: Resident was having a routine evening, walking in halls and outside, going to smoke breaks. After resident ate supper, nurse reminded resident to stop at medication cart for supper meds. Resident ignored nurse and walked on to room to lay down. After several minutes of walking around facility, resident came to med cart for HS (hour of sleep/bedtime) meds at 1945 (7:45 p.m.). 1700 (5:00 p.m.) meds given at this time along with HS meds. At 2015 (8:15 p.m.) nurse at med cart heard an unusual clanging sound. Upon investigation, observed this resident (resident #1) in (another resident's) room, standing over (him/her) in bed, hitting (him/her) repeatedly in the face and head wouldn't stop, nurse called 911. This resident threw (other resident) off the bed head first and continued hitting (him/her) and banging (his/her) head against the floor Another resident intervened and got this resident away. The facility completed an investigation into the previously described incident which described how resident #1 walked into resident #4's room and began hitting him/her in the face with both hands. According to the facility's investigation, Licensed Nurse D heard an unusual noise and went to investigate the origin. Nurse D found resident #1 standing over resident #4's bed, striking the resident in the head. Nurse D yelled at Resident #1 to stop and then called for assistance of other staff. Resident #1 then pulled resident #4 off the bed, repeatedly struck him/her in the face and head, and then banged the resident's head against the floor. While the altercation between resident #1 and resident #4 took place, Licensed Nurse D called emergency responders for assistance. Resident #1 eventually stopped beating resident #4 after another resident intervened and held resident #1 from doing more damage to resident #4. Emergency medical staff stabilized resident #4 and sent him/her to an outlying hospital via helicopter. As of [DATE], the date of the facility investigation, resident #4 remained at the hospital in critical condition, and resident #1 remained at a mental health hospital. Behavior monitoring completed by licensed nurses on [DATE], the day prior to the incident between resident #1 and #4, noted the resident resident #1 had auditory hallucinations on the day shift. The clinical record lacked evidence of additional supervision of resident #1 upon his/her return from the mental health hospital on [DATE] as related to the recent history of aggression/violence against other residents and hospitalization for treatment of [REDACTED]. According to Administrative Staff B, staff who initialed the boxes were required to actually see the residents when they placed their initials on that form. Although requested, the facility could not provide any other documentation that staff monitored/supervised resident #1 more closely after his/her readmission to the facility on [DATE]. During an interview on [DATE] at 2:00 p.m., Administrative Nurse C reported resident #4 expired on [DATE] from injuries received in the [DATE] incident with resident #1. During an interview on [DATE] at 4:10 p.m., Administrative Nurse B reported a mental health screener determined resident #1 required admission to a mental health hospital in early [DATE] after he/she had two physical altercations with other residents within a 24 hour time period. According to Nurse B, resident #1 behaved normally for him/her upon readmission to the facility and on [DATE], the day of the incident, did not exhibit any signs of aggression after readmission until the time of the beating incident with resident #4. Nurse B reported, There were no warning signs. (He/she) just attacked (resident #4). Upon review of the clinical record, Nurse B reported the facility completed charting every shift for 72 hours for resident #1 upon readmission on [DATE] which is the facility's standard process for all readmissions. Nurse B also reported staff monitored resident #1's whereabouts every 2 hours upon readmission, which is also the process for all facility residents. Nurse B could not verbalize any additional interventions implemented upon resident #1's [DATE] readmission to address the recent history of physical aggression toward other residents and verified increased supervision of the resident. The facility's Abuse Prevention Program policy with a revision date of [DATE] included, The facility administration and employees are committed to protecting resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individuals This deficient practice placed resident #4 in immediate jeopardy when the facility failed to prevent resident to resident altercations. Resident #1 had two incidents of aggression/violence against other residents which necessitated his/her hospitalization at a mental health hospital. Upon resident #1's readmission to the facility on [DATE], the facility failed to develop and implement appropriate individualized, specific interventions related to recent aggression/violence directed at other residents, including increased supervision in an attempt to protect all residents. Resident #1 attacked resident #4 within three days of his/her readmission. Resident #4 experienced significant physical injury in the attack and later expired from those injuries. The facility abated the immediate jeopardy on [DATE] at 3:15 p.m. by implementing the following measures: 1) Revised admission screening polices to include special assessment of prospective resident's histories of previous violent behaviors and [DIAGNOSES REDACTED]. 2) Review of all current resident's clinical records in order to identify current residents with histories of violent behaviors and/or aggression, and them development and implementation of individualized care plans/interventions to address those behaviors. 3) Completed CPI training for all but two staff members who were unavailable for training. The two staff members will receive CPI training on [DATE]. 4) Evaluated staffing levels to ensure that two CPI certified staff remain on duty at all times, around the clock, with plans for additional staff support when resident behaviors/needs require increased staffing levels. 5) Revised the facility policy for how to handle unmanageable residents. After abatement of the immediate jeopardy, the deficient practice remained at a scope/severity of G. - Resident #2's clinical record included multiple medical [DIAGNOSES REDACTED]. characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The [DATE] Annual MDS (Minimum Data Set) identified resident #2 with no cognitive impairment, no acute onset of mental status change, the presence of behavioral symptoms not directed toward others 1 to 3 days during the 7 day observation period, the presence of hallucinations and delusions, behaviors not directed toward others ,[DATE] days during the 7 day observation period, behaviors did not put resident or others at risk for physical illness/injury. CAAs (Care Area Assessments) completed after [DATE] Annual MDS included the following: o Behaviors: Resident with long standing displays of inattention, disorganized thinking and staring into space as part of behavior displayed with mental illness of schizoaffective disorder. Resident with behaviors of yelling, laughing and crying loudly when pacing in hallways at times. Resident with long standing refusal to have labs drawn and at times refusing to bathe. Resident's behaviors do not place resident or peers in immediate threat at this time.: The [DATE] Admission MDS identified resident #2 with no cognitive impairment, the presence of moods, the presence of hallucinations and delusions, the presence of behaviors not directed toward others, behaviors did not put the resident or others at risk for physical illness or injury, and use of antipsychotic and antidepressant medication daily. CAAs (Care Area Assessments) completed on [DATE] included: o Behaviors: Resident with long-standing behaviors displayed of pacing in hallway, talking to self/unseen persons, yelling/crying loudly, refusing medications, hallucinations and voicing delusional statements. Resident's behaviors do not place self or others in immediate threat at this time. Resident with long-standing displays of listed behaviors and have become part of residents usual routine. At times behaviors are purposeful such as when refusing medications or bathing. At times behaviors without any noted reason. Resident with long-standing mental illness and displays behaviors associated with illness. Resident's behaviors unable to be controlled when outside facility as not accepted as normal in community. Resident's peers with similar behaviors and this allows resident to not feel embarrassed. Facility staff trained to deal with behaviors and techniques for de-escalation of behaviors. Will continue to care plan for resident's behaviors. Staff to monitor for behaviors, attempt to redirect and document behaviors when they occur. Psychiatrist to be notified of new or worsening behaviors occurring to determine if medication adjustment is warranted. At this time no referral indicated, however IDT (interdisciplinary team) will continue to monitor and will consult with healthcare professional as needed. The [DATE] care plan for resident #2 included: o Inappropriate behavior related to schizoaffective disorder and depressive disorder document behaviors in soon as occurs, remind resident of need to take medication and comply with careplan to work towards move out goal. Try different staff to try to get resident to take medications, bathe or allow lab to be drawn. The care plan lacked specific interventions related to physical aggression directed toward other residents. Progress Notes for resident #2 included: o [DATE] at 9:31 p.m.: At approximately 1955 (7:55 p.m.) this resident violently shoved/pushed (another resident) to get out of my (expletive) way. (Other resident) went approximately ,[DATE] feet away. Continued yelling for (him/her)to get out of her way Writer notified RN (registered nurse) on duty. (Parent) of resident notified and in agreement for placement in another facility for med adjustments. Contracted screener who then instructed this nurse to fax information on resident to (acute psychiatric unit) no bed available contacted (another acute psychiatric facility) and waiting on return call. o [DATE] at 1321: Contact (psychiatrist) .meds changed agrees to evaluation for inpatient stay at another facility to adjust medications. o 5.7.15 at 12:16 a.m.: described incident which happened on [DATE] at 1745 where resident #2 approached another resident and struck that resident without provocation. A subsequent progress note documented resident #2's transfer to a mental health hospital on [DATE] for evaluation and treatment of [REDACTED]. An interim care plan dated [DATE], the date of resident #2's readmission to the facility after hospitalization at a mental health hospital for treatment of [REDACTED]. o 3 day charting due to readmission o Monitor Vital Signs every shift o Behaviors and medication compliance o Physician to be notified of any adverse or physical aggressive behavior due to history. If physical aggression occurs, placed resident on 1:1 immediately, notify psychiatrist, notify law enforcement. The care plan developed upon resident #2's readmission lacked measurable goals and individualized, specific interventions related to increased monitoring/supervision of the resident due to the recent history of aggression, and interventions to prevent additional aggression before it occurred. The revised care plan included only interventions to address aggression once it occurred and lacked preventative interventions including the need for increased supervision to protect other residents. The clinical record lacked evidence of additional supervision of resident #2 upon his/her return from the mental health hospital on [DATE] as related to the recent history of aggression/violence against other residents and hospitalization for treatment of [REDACTED]. According to Administrative Staff B, staff who initialed the boxes were required to actually see the residents when they placed their initials on that form. Although requested, the facility could not provide any documentation that staff monitored/supervised resident #2 more closely after his/her readmission to the facility on [DATE]. During observations on [DATE] at 2:25 p.m. and [DATE] at 8:00 a.m., resident #2 continuously paced the hallways. The resident did not initiate conversation with others during the observations and did not exhibit signs of aggression/violence. During an interview on [DATE] at 4:10 p.m., Administrative Nurse C reported a mental health screener determined resident #2 required admission to a mental health hospital in early [DATE] after he/she had two physical altercations with other residents within a short time period. According to Nurse C, resident #2 returned to the facility from the mental health hospital on [DATE]. The facility's Abuse Prevention Program policy with a revision date of [DATE] included, The facility administration and employees are committed to protecting resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individuals. The facility failed to provide resident #2 with adequate supervision to prevent accidents/hazards Resident #2 had two incidents of aggression/violence against other residents which necessitated his/her hospitalization at a mental health hospital. Upon resident #2's readmission to the facility on [DATE], the facility failed to develop and implement appropriate individualized, specific interventions related to recent aggression/violence directed at other residents, including increased supervision in an attempt to protect all residents.

br>The facility had a census of 46 residents. Based on interview and record review, the facility failed to ensure nurse aide competency when 5 of 9 certified nurse aides/certified medication aides failed to participate in ANE (abuse, neglect, exploitation) training upon hire and/or every 12 months. Findings included; - As requested on 7/14/15 the facility provided a list of all staff members, including certified nurse aides and certified medication aides. The list also included the dates the aides last received ANE training. According to that list, the facility employed 9 nurse aides. Of the 9 aides, 5 lacked evidence of training at the time of hire and/or training within the past 12 months as follows: o Direct Care Staff G: Hired on 4/6/15 and no evidence of ANE training o Direct Care Staff H: no evidence of ANE training since 3/8/14 o Direct Care Staff K: no evidence of ANE training since 3/4/14 o Direct Care Staff I: Hired on 6/23/15 and no evidence of ANE training o Direct Care Staff J: Hired on 7/2/12 and no evidence of ANE training During a telephone interview on 7/14/15 at 5:15 p.m., Administrative Staff A reported the facility changed ANE training methods within the past year. Prior to the change, staff did Silver Chair training on ANE at the time of hire and then annually thereafter. According to Staff A, the facility lacked current ANE training documentation on some staff, and reported, We think more staff have had the training but we can't find the documentation of it. The facility's Abuse Prevention Program policy with a revision date of September 2012 included, The facility administration and employees are committed to protecting residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual The abuse prevention program provides policies and procedures that govern .mandated staff training/orientation programs that includes abuse prevention, identification and reporting of abuse The facility failed to ensure nurse aide competency when 5 of 9 certified nurse aides/certified medication aides failed to participate in ANE (abuse, neglect, exploitation) training upon hire and/or every 12 months.

The facility had a census of 46 residents, with 3 residents selected for sample. Based on observation, interview and record review, the facility failed to review/revise the care plans for 2 of 3 residents upon their return from the hospital to include specific and individualized interventions related to the aggression/violence that necessitated the residents' hospitalization s and/or to include hospital discharge instructions. (Residents #1 and #2) Findings included: - Resident #1's clinical record included [DIAGNOSES REDACTED]. The 1/14/15 Quarterly MDS (Minimum Data Set) identified resident #1 with no cognitive impairment, no acute onset of mental status change, no hallucinations or delusions, rejection of care 4-6 days within the 7 day observation period, no wandering behaviors, and use of antipsychotic, antianxiety and antidepressant medication daily. The 4/6/15 Annual MDS identified resident #1 with no cognitive impairment, no acute onset mental status change, the presence of hallucinations and delusions, no physical behaviors directed toward others, the presence of other behaviors which did not put the resident or others at significant risk for physical illness or injury 4-6 days during the 7 day observation period, improved behaviors compared to the prior assessment, and use of antipsychotic, antianxiety and antidepressant medication daily. CAAs (Care Area Assessments) completed on 4/8/15 included: o Behaviors: Resident with long standing displayed behaviors of having difficulty focusing on conversations and resident changes subjects often with [DIAGNOSES REDACTED]. Resident's behaviors do not place (him/her) or peers in immediate threat at this time. Facility staff trained to deal with behaviors and de-escalation of behaviors. o Moods: Resident with long standing behavior of keeping to self and attending few activities. [MEDICAL CONDITION] and [MEDICAL CONDITION]. o [MEDICAL CONDITION] drug use; Resident is on long term [MEDICAL CONDITION] medication for treatment of [REDACTED]. Resident #1's 4/23/14 care plan included the following: o I take antipsychotic medications due to my mental illness of paranoid [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. If I continue to display behavior or my behavior worsens, the staff will contact the psychiatrist. o Staff will check on me at least every two hours and document on the clipboard (4/23/14) o I have behaviors of threatening peers/staff, urinating/defecating on floor, eating/taking food to my room, ignoring staff, going from staff to staff until getting my way, bumming cigs and money and drinks. Staff to document behaviors as they are seen. Staff to redirect behaviors as they occur. Father to be notified of increase in behaviors. Psychiatrist to be notified of new/worsening behaviors (2/18/15) o I had a physical altercation with a (male/female) peer on previous night. I will have no further physical altercations with peers over the next 90 days. I will talk with staff if I feel anger/upset at anyone over the next 90 days. Attempt to redirect if noted to be getting upset (pacing more, clenching fists, statements; notify screener for resident to be screened if see increased escalation anger/behaviors. Encourage resident to stay away from (male/female) peer who had resident altercation. Screened to (mental health hospital) due to increased anger/physical with another peer (5/6/15). o I readmitted from (mental health hospital) due to I became upset and had physical aggression with 2 peers and was screened to (mental health hospital) on 5/7/15. I will continue to display no anger/aggression or cause physical harm to my peers as this was (mental health hospital's) discharge goal. I will continue this for the next 90 days. Resident continued with previously listed interventions. Res. reminded that if (he/she) had another physical altercation, screener would be contacted (5/14/15) The care plan lacked evidence of newly developed individualized, specific interventions upon resident #1's return from the mental health hospital on [DATE] to address the recent history of physical aggression/physical contact directed at peers. Progress Notes included the following: o 5/6/15 at 5:45 p.m.: This entry described an incident that occurred when another resident walked by resident #1 and tapped/hit him/her on the right side of the body. Resident #1 then ran after the other resident, grabbed his/her hair, and pulled the resident to the floor. The facility notified the guardian and physician of the incident. o 5/7/15 at 12:49 p.m.: This entry described an incident between resident #1 and another resident that occurred when resident #1 yelled a profanity and then attempted to punch the other resident. The facility notified the guardian and then contacted a mental health screener to evaluate the resident's recent behavior changes. o 5/7/15 at 4:25 p.m.: This entry described the completion of a mental health screen by a qualified mental health professional and subsequent transfer to mental health hospital for treatment of [REDACTED]. Resident #1 returned from the mental health hospital on [DATE]. A Nursing Admission Evaluation on the resident's return to the facility on [DATE] described the resident as alert and oriented, verbally appropriate, pleasant and content. The assessment also noted the resident's history of depression, history of physical aggression, history of being verbally abusive, the presence of hallucinations, and use of antipsychotic, antianxiety, and antidepressant medications. Discharge notes dated 5/14/15 from the mental health hospital noted resident #1 reported no hallucinations or delusions at the time of discharge and no homicidal or suicidal ideation. Discharge instructions included: * Utilize free time by doing healthy, meaningful activities * Participate in therapy to learn and practice healthy coping skills for various issues and effective stress management. Review of resident #1's care plan after readmission to the facility on [DATE] revealed no evidence staff reviewed/revised the care plan with the previously described discharge instructions. Additional Progress Notes after resident #1's readmission included: o 5/17/15 at 8:45 p.m.: Call received from nursing on duty at facility that resident (resident #1) attacked (another resident). Resident in custody of LE (law enforcement) and transported to jail. Contacted screener who will complete screen (mental health screen) in jail. A later Progress Note in resident #1's clinical record dated 5/19/15 at 2:44 p.m. described the 5/17/15 incident as follows: Resident was having a routine evening, walking in halls and outside, going to smoke breaks. After resident ate supper, nurse reminded resident to stop at medication cart for supper meds. Resident ignored nurse and walked on to room to lay down. After several minutes of walking around facility, resident came to med cart for HS (hour of sleep/bedtime) meds at 1945 (7:45 p.m.). 1700 (5:00 p.m.) meds given at this time along with HS meds. At 2015 (8:15 p.m.) nurse at med cart heard an unusual clanging sound. Upon investigation, observed this resident (resident #1) in (another resident's) room, standing over (him/her) in bed, hitting (him/her) repeatedly in the face and head wouldn't stop, nurse called 911. This resident threw (other resident) off the bed head first and continued hitting (him/her) and banging (his/her) head against the floor Another resident intervened and got this resident away. During an interview on 6/9/15 at 4:10 p.m., Administrative Nurse B reported a mental health screener determined resident #1 required admission to a mental health hospital in early May 2015 after he/she had two physical altercations with other residents within a 24 hour time period. According to Nurse B, resident #1 behaved normally for him/her upon readmission to the facility and on 5/17/15, the day of the incident, did not exhibit any signs of aggression after readmission until the time of the beating incident with resident #4. Nurse B reported, There were no warning signs. (He/she) just attacked (resident #4). Upon review of the clinical record, Nurse B reported the facility completed charting every shift for 72 hours for resident #1 upon readmission on 5/14/15 which is the facility's standard process for all readmissions. Nurse B also reported staff monitored resident #1's whereabouts every 2 hours upon readmission, which is also the process for all facility residents. Nurse B could not verbalize any additional interventions developed/implemented upon resident #1's 5/14/15 readmission to address the recent history of physical aggression toward other residents. The facility failed to review/revise resident #1's care plan at the time of readmission to the facility on [DATE] to include appropriate measurable goals/specific, individualized interventions related to recent episodes of aggression against other residents that necessitated hospitalization in a mental health hospital. The facility also failed to review/revise resident #1's care plan upon readmission to include discharge instructions from the mental health hospital. - Resident #2's clinical record included multiple medical [DIAGNOSES REDACTED]. characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The 3/26/15 Annual MDS (Minimum Data Set) identified resident #2 with no cognitive impairment, no acute onset of mental status change, the presence of behavioral symptoms not directed toward others 1 to 3 days during the 7 day observation period, the presence of hallucinations and delusions, behaviors not directed toward others 1-3 days during the 7 day observation period, behaviors did not put resident or others at risk for physical illness/injury. CAAs (Care Area Assessments) completed after 3/26/15 Annual MDS included the following: o Behaviors: Resident with long standing displays of inattention, disorganized thinking and staring into space as part of behavior displayed with mental illness of [MEDICAL CONDITION] disorder. Resident with behaviors of yelling, laughing and crying loudly when pacing in hallways at times. Resident with long standing refusal to have labs drawn and at times refusing to bathe. Resident's behaviors do not place resident or peers in immediate threat at this time. The 6/15/15 Admission MDS identified resident #2 with no cognitive impairment, the presence of moods, the presence of hallucinations and delusions, the presence of behaviors not directed toward others, behaviors did not put the resident or others at risk for physical illness or injury, and use of antipsychotic and antidepressant medication daily. CAAs (Care Area Assessments) completed on 6/16/15 included: o Behaviors: 'Resident with long-standing behaviors displayed of pacing in hallway, talking to self/unseen persons, yelling/crying loudly, refusing medications, hallucinations and voicing delusional statements. Resident's behaviors do not place self or others in immediate threat at this time. Resident with long-standing displays of listed behaviors and have become part of residents usual routine. At times behaviors are purposeful such as when refusing medications or bathing. At times behaviors without any noted reason. Resident with long-standing mental illness and displays behaviors associated with illness. Resident's behaviors unable to be controlled when outside facility as not accepted as normal in community. Resident's peers with similar behaviors and this allows resident to not feel embarrassed. Facility staff trained to deal with behaviors and techniques for de-escalation of behaviors. Will continue to care plan for resident's behaviors. Staff to monitor for behaviors, attempt to redirect and document behaviors when they occur. Psychiatrist to be notified of new or worsening behaviors occurring to determine if medication adjustment is warranted. At this time no referral indicated, however IDT (interdisciplinary team) will continue to monitor and will consult with healthcare professional as needed.' The 5/29/13 care plan for resident #2 included: o Inappropriate behavior related to [MEDICAL CONDITION] disorder and [MEDICAL CONDITION] document behaviors in soon as occurs, remind resident of need to take medication and comply with careplan to work towards move out goal. Try different staff to try to get resident to take medications, bathe or allow lab to be drawn. The care plan lacked specific interventions related to physical aggression directed toward other residents. An interim care plan upon resident #2's return from the mental health hospital dated 6/2/15 included: o 3 day charting due to readmission o Vital signs every shift o Behaviors and medication compliance o Physician to be notified of any adverse or physical aggressive behavior due to history. If physical aggression occurs, place resident on 1:1 immediately, notify psychiatrist, notify law enforcement. The care plan developed upon resident #2's readmission lacked measurable goals and individualized, specific interventions related to increased monitoring of the resident due to the recent history of aggression, and interventions to prevent additional aggression before it occurred. The revised care plan included only interventions to address aggression once it occurred and lacked preventative interventions. During observations on 6/9/15 at 2:25 p.m. and 6/10/15 at 8:00 a.m., resident #2 continuously paced the hallways. The resident did not initiate conversation with others during the observations and did not exhibit signs of aggression/violence. During an interview on 7/16/15 at 10:00 a.m., Administrative Staff C confirmed the care plan reviewed/revised after resident #2's readmission on 6/2/15 lacked other interventions related to the resident's recent history of aggression directed toward other residents. The facility failed to review/revise resident #2's care plan at the time of readmission to the facility on [DATE] to include appropriate measurable goals/specific, individualized interventions related to recent episodes of aggression against other residents that necessitated hospitalization in a mental health hospital.

The facility census totaled 46 with 12 included in the sample. Based on observation, interview, and record review, the facility failed to provide sufficient fluids to maintain adequate hydration for 1 of 2 residents reviewed for hydration. Resident #25 required hospitalization for treatment of [REDACTED]. Findings included: - Review of resident #25's annual MDS (minimum data set) dated 10/13/14 revealed the resident had a BIMS (brief interview for mental status) score of 15 indicating the resident was cognitively intact. The resident required supervision for bed mobility, transfers, locomotion on the unit, dressing and toilet use and did not use any mobility devices. The resident was always continent of bowel and bladder. Review of the ADL (activities of daily living) CAA (care area assessment) dated 10/13/14 revealed the resident was at risk for potential self-care deficit due to requiring prompting to complete his/her ADLs The care plan instructed staff to encourage the resident to complete ADLs independently and assist the resident as needed. The care plan also directed staff to document when the resident completed ADLs and the amount of assistance needed. Review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14 indicating the resident was cognitively intact. The resident required supervision with one assist for bed mobility, transfers, walk in room, locomotion on unit, toilet use, and personal hygiene and required the use of a walker for mobility. The resident was frequently incontinent of bowel and always continent of bladder. The MDS also indicated the resident was dehydrated. Review of the 12/9/14 care plan revealed staff failed to update the care plan after returning the resident had diarrhea starting on 1/1/15, and failed to add interventions to address the [DIAGNOSES REDACTED]. The resident admitted to a hospital from 12/11/14 to 12/30/14 for unrelated issues. Review of the lab values at the hospital dated 12/24/14 revealed the resident had a normal potassium serum level of 3.8 mmol/L (the measurement unit used for indicating the concentration in the blood), and normal potassium level is between 3.5 - 5.1 mmol/L. Review of the patient transfer form from the hospital revealed the resident was concerned about his/her bowels. Review of the telephone order dated 12/30/15 revealed the resident readmitted to the facility. The resident may use the walker for stability and labs were to be drawn weekly for 6 months. Review of the nursing note dated 1/1/15 at 3:22 p.m. revealed the resident stayed in his/her room all shift. His/her temperature was down to 98.3 degrees Fahrenheit. The resident didn't have any more episodes of diarrhea. The facility failed to document and to monitor the resident's temperatures. Review of the nursing note dated 1/2/15 at 10:42 a.m. revealed the facility notified consultant physician D regarding the resident's loose stools. He/she ordered to continue to isolate the resident and to treat with symptomatic care. Nursing note dated 1/2/15 at 2:15 p.m. revealed the resident had numerous loose stools this shift. Review of the nursing note dated 1/3/15 at 11:48 p.m. revealed the resident had 4 loose stools this shift. Upon arriving on the shift the nurse took the resident's vital signs which revealed the resident's oxygen level was at 85% and 86% on room air (normal oxygen level on room air is above 90%). The resident was lethargic (sluggish), incontinent, and was drooling on his/her chest. The nurse notified the on call physician, who recommended the resident to be seen in the emergency room . The resident was taken to the local hospital where later returned due to his/her oxygen level was above 90% and within normal limits. The resident had a loose bowel movement in his/her brief and staff administered [MEDICATION NAME] (medication for diarrhea) was administered per the physician orders. The [MEDICATION NAME] was given one time dose. Review of nursing note dated 1/4/15 at 8:04 a.m. the nursing staff administered [MEDICATION NAME] per physician orders. Direct care staff assisted the resident to sit up and take the medication. Nursing staff also assisted with eating the breakfast meal of scrambled eggs, toast, and 8 ounces of Gatorade. The resident appeared to be very weak and lethargic. Review of the untimed nursing note dated 1/4/15 revealed the resident continued to have very loose stools and was very lethargic. The resident required assistance with his/her evening meal. The vitals were taken and revealed a blood pressure of 85/55 (a low blood pressure for the resident), temperature of 96.7, pulse of 81, respirations of 18, and oxygen level of 97% on room air. Review of fax cover sheet dated 1/4/15 revealed the resident was seen the emergency roiagnom on [DATE] for diarrhea and lethargy. Physician D decreased [MEDICATION NAME] (a medication for anxiety) from 1 mg (milligram) four times a day to 0.5 mg four times a day for lethargy and continue to monitor. Review of the nursing note dated 1/5/15 at 2:32 a.m. revealed the resident was very drowsy and did not want to do his/her own ADLs. The resident was sick with intestinal problems. Review of the nursing note dated 1/5/15 at 4:31 a.m. revealed the resident used the call light and was found in the bathroom. His/her brief was on the floor full of feces. The resident also urinated all over the floor by the bed. The resident's speech was hard to understand and he/she had trouble walking with the walker. Review of the Bladder retraining recorded dated between 1/6/15 and 1/9/15 revealed the resident had 12 episodes of bowel incontinence along with several hours of undocumented bowel and bladder record. Review of Physician signed note dated 1/8/15 revealed the resident had 1 dose of [MEDICATION NAME] on 1/7/15 and the resident's abdomen had hyperactive bowel sounds. Review of the nursing note dated 1/9/14 revealed the resident had 4 loose stools at the local hospital while doing lab tests. Review of nursing note dated 1/10/15 at 2:18 p.m. revealed the resident left the facility at 9:00 a.m. for lab at the hospital. The resident admitted to the hospital for fluids and potassium replacement with a critical low potassium level of 2.5 mmol/L. (Because fat tissue contains less water than lean tissue, the total amount of water in the body tends to decrease with age. The common cause of dehydration is diarrhea and vomiting resulting in a loss of electrolytes (especially sodium and potassium), even more water is lost, so the concentration of sodium in the blood rises. Review of the hospital History and Physical dated 1/10/15 revealed the resident had severe diarrhea for the past 12 days. He/she had labs drawn and revealed to have significantly low potassium of 2.4mmol/L and a normal potassium level was between 3.4 -5.3 mmol/L. According to the History and Physical, the resident went to the emergency roiagnom on [DATE] with instructions to take [MEDICATION NAME] with minimal improvements. Review of the hospital History and Physical dated 1/13/15 revealed the resident had improvement with the diarrhea, although not entirely gone. The resident was hydrated over the course of 3 days and the hospital was aggressive with the potassium replacement. His/her potassium on dismissal was 4.2 mmol/L. The resident's magnesium was still low on 1/13/15 at 1.7 MG/DL this is within the normal limits (milligrams per deciliter) with a normal value of magnesium 1.6 to 2.3 MG/DL and was started on supplemental magnesium. At the time of dismissal the resident's weight increased since he/she was no longer dehydrated with slowing of the diarrhea. Review of the physician signed note dated 1/23/15 the resident continued to have large loose bowel movement this morning. The resident finished the Methronidazole (an antibiotic used to treat gastro-intestinal infections). The physician ordered to continue the Acidophilus (a medication to help maintain gastrointestinal health) for two more weeks and then discontinue and also decrease the Simethecone (gas relieving medication) to four times a day and at bedtime. review of the resident's medical record revealed [REDACTED]. Review of the bowel monitoring documentation for the month of December 2014 and January 2015 for resident #25's revealed the facility failed to document how many stools the resident had. Review of the fluid intake from the resident's return from the hospital on [DATE] to 1/10/15 when he/she admitted to the hospital for dehydration revealed the resident's average fluid intake a day was 1480 cc (cubic centimeter). Review of blood pressures taken between 12/30/14 and 1/10/15 revealed the resident's average blood pressure was 112/71 and inconsistently documented from the time the resident came back from the hospital and was admitted to the hospital for dehydration. An observation on 1/29/15 at 2:55 p.m. revealed the resident was lying down on his/her bed resting. The resident showed no signs of distress or dehydration An interview on 1/29/15 at 2:53 p.m. with resident #25 revealed he/she continued to have loose stools. He/she reported the night nurse assisted him/her when he/she was unable to make it to the bathroom on time. Resident #25 revealed he/she continued to be worried about why he/she continued to have the diarrhea. An interview on 2/2/15 at 9:13 a.m. with direct care staff E revealed the resident returned from the hospital in December of 2014 and he/she came back confused, incontinent, and using a walker. He/she also returned with diarrhea. The resident required assistance with his/her ADLs. The resident then went to the hospital for low potassium and dehydration. The diarrhea has continued for an extended period of time. An interview on 2/2/15 at 3:27 p.m. with direct care staff F revealed the resident used the walker for ambulation along with cueing after his/her return from the hospital in December. The resident was admitted to the local hospital for an electrolyte problem in January. He/she also reported the resident had become lethargic and was falling. Staff F reported unless the resident used the call light staff was unaware of when or how much diarrhea the resident had due to being independent with toileting. Direct care staff F reported the only monitoring of hydration for the resident was at meal and snack times. He/she also reported the staff did not monitor the output for the resident. Interview on 2/2/15 at 2:12 p.m. with licensed nursing staff G revealed the resident required a walker to ambulate and was independent with ADLs after returning from the hospital. Staff G reported the resident was incontinent of bowel when she came back from the hospital. The resident admitted to the hospital for low potassium and dehydration. The resident continued to have loose stools. He/she reported the facility did not monitor the output for the resident. Nurse G reported the resident's skin was intact with no redness; the staff did not assess his/her bowels, or skin turgor (the expected resiliency of the skin caused by the outward pressure of the cells and interstitial fluid) for dehydration after coming back from the hospital or the emergency visit on 1/3/15. Interview on 2/2/15 at 3:41 p.m. with licensed nursing staff H reported the resident went to the behavioral unit and returned with diarrhea. Nurse H reported the resident became dehydrated and he/she requested the resident be seen by the physician. The resident's oxygen level was low at 85% room air. He/she was taken to the local hospital to the emergency room per the on-call physician orders. The resident was then brought back to the facility after his/her vitals were within normal limits and no lab work was drawn. The next day the resident was lethargic and required assistance with eating. On Friday January 9th the resident was taken back to the hospital and was admitted with a critically low potassium level of 2.4 mmol/L. The resident continued to have diarrhea and was incontinent of bowel. Interview on 2/2/15 at 5:23 p.m. with dietary manager I reported he/she was unaware of the resident's change in condition or his/her new [DIAGNOSES REDACTED]. Interview on 2/2/15 at 6:04 p.m. with administrative nurse B revealed the facility failed to inform the dietary staff of the resident's new [DIAGNOSES REDACTED]. Nurse B also reported the facility failed to recognize the resident was at risk for dehydration after returning from the behavioral unit with the diarrhea first started. Interview on 2/3/15 at 9:55 a.m. with physician D revealed the resident started the diarrhea when returning to the facility from the hospital. He/she reported the resident became dehydrated, had a low potassium level, and needed to be admitted to the hospital. He/she reported they expected the facility to be monitoring accurately the resident's fluid intake and output, along with daily assessments after returning with the new [DIAGNOSES REDACTED]. Physician D continued that he/she expected the facility to be more aware of the resident's condition, monitor and assess him/her and communicate with him/her. Review of the facility Water Policy and procedures dated 6/2013 revealed the policy was created to promote a healthier and higher quality of life for our residents, while preventing the incidence of dehydration. The targeted population included residents who had a decline in ADLs along with other risk factors or diarrhea. A schedule will be developed by the Director of Nursing/designee to coordinate focused rounds on the targeted population. The facility failed to ensure resident #25 had sufficient fluid intake to maintain proper hydration and health after returning from the hospital with chronic diarrhea until the admitted to the hospital for treatment of [REDACTED].

The facility had a total census of 40 residents. Based on observation, record review and interview, the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 9 of 30 resident rooms and the beauty shop/quiet room.. Findings included: - During environmental tour beginning on 1/26/15 at 7:15 AM, the following maintenance issues were observed in 9 of 30 resident rooms and the beauty shop/quiet room. * chipped paint with rusted metal exposed on the lowest 2 to 3 inches of the bathroom door frames in 6 rooms * rusted caulking surrounding the base of the toilet between the toilet bowl and the floor in 3 bathrooms * heating/air conditioning units with no top grill covering in 2 rooms * the bottom wall trim was missing in 2 rooms with short 3 inch x 4 inch corner pieces and crumbled dirty plaster observed in 1 room * a strip of wall trim approximately 2 -3 feet x 4 inches long missing along the bottom of one wall and approximately 1 foot x 4 inches on the adjacent wall in the beauty shop/quiet room ? multiple areas large and small were previously patched without matching paint on the surfaces in all 9 rooms During an environmental tour and interview on 2/3/15 at 9:02 AM maintenance staff C and Administrative staff A reported the facility made improvements in the environment over the last year with some of the repairs being more recent in the last month. Staff C he/she had a new system in place for routine monthly inspections of the facility and resident rooms. Staff C provided 2 worksheets which included the resident's room numbers, and the type of repair needed. Staff C reported he/she just implemented the program a short time ago and could not provide any further documentation the rooms were being inspected and repairs completed on a regularly scheduled maintenance program. The facility's maintenance service policy revised in December 2009 revealed the maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained. The maintenance director is responsible for maintaining records for the following including inspection of the building, work order requests, and maintenance schedules. The facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 9 of 30 resident rooms and the beauty shop/quiet room.

The facility census totaled 46 residents with 12 included in the sample. Based on observation, interview, and record review, the facility failed to conduct a significant change assessment for resident #25 after he/she returned from the behavioral unit on 12/30/14 and required hospitalization on [DATE] for dehydration and [DIAGNOSES REDACTED] (low potassium in the blood), and declined in the resident's physical and mental condition. (#25) Findings included: - Review of resident #25's annual MDS (minimum date set) dated 10/13/14 revealed the resident had a BIMS (brief interview for mental status) score of 15 indicating the resident was cognitively intact. The resident required supervision for bed mobility, transfers, locomotion on the unit, dressing and toilet use and did not use any mobility devices. The resident was always continent of bowel and bladder. Review of the ADL (activities of daily living) CAA (care area assessment) dated 10/13/14 revealed the resident was at risk for potential self-care deficit due to requiring prompting to complete his/her ADLs The care plan instructed staff to encourage the resident to complete ADLs independently and assist the resident as needed. The care plan also directed staff to document when the resident completed ADLs and the amount of assistance needed. Review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14 indicating the resident was cognitively intact. The resident required supervision with one assist for bed mobility, transfers, walk in room, locomotion on unit, toilet use, and personal hygiene and required the use of a walker for mobility. The resident was frequently incontinent of bowel and always continent of bladder. The MDS also indicated the resident was dehydrated. The facility failed to capture resident #25 decline in bowel incontinence, new [DIAGNOSES REDACTED]. Review of the 12/9/14 revised care plan revealed staff failed to update the care plan after returning from the behavioral unit on 12/30/14, with diarrhea starting on 1/1/15, and a hospitalization for dehydration and [DIAGNOSES REDACTED] ( low potassium in the blood ) from 1/10/15 to 1/13/15. According to the nurse's notes, fluid intake monitoring, bowel and bladder monitoring, physician notes, and review of the history and physical from the behavioral unit and local hospital, resident #25 required hospitalization for treatment of [REDACTED]. The facility failed to revise or update the resident nursing care plan after the hospitalization s to prevent and maintain adequate hydration for the resident. An observation on 1/29/15 at 2:55 p.m. revealed the resident was lying down on his/her bed on the left side, resting. The resident showed no signs of distress or dehydration. His/her legs appeared to be swollen around the ankles and up to his/her calf area. An interview on 2/2/15 at 9:13 a.m. with direct care staff E revealed the resident returned from the behavioral unit in December of 2014 and he/she came back confused, incontinent, and using a walker. He/she also returned with diarrhea. The resident required assistance with his/her ADLs. The resident then went to local hospital for low potassium and dehydration. The diarrhea has continued for an extended period of time. An interview on 2/2/15 at 3:27 p.m. with direct care staff F revealed the resident used the walker for ambulation along with cueing after his/her return from the behavioral unit in December. The resident was admitted to the local hospital for an electrolyte problem in January. Interview on 2/3/15 at 8:31 a.m. with licensed nursing staff J He/she also reported the resident came back to the facility with a decline in ADLs requiring some assistance, required the use of a walker to ambulate, and had diarrhea. The resident was admitted to the local hospital on [DATE] and returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. Nurse J revealed he/she did not update or revise the care plan after the resident returned either time to the facility and he/she did not complete a comprehensive significant change assessment for the resident after the change in the resident's condition in 2 or more areas. Interview on 2/2/15 at 6:04 p.m. with administrative nurse B revealed Nurse B also reported the facility failed to update or revise the care plan after the resident came back from the behavioral unit or the local hospital. Nurse B reported a comprehensive significant change assessment for resident #25 should have been conducted when he/she came back from the behavioral unit and from the hospital. The facility failed to conduct a comprehensive significant change assessment for resident #25 after he/she returned from the behavioral unit on 12/30/14 and required hospitalization on [DATE] for dehydration and [DIAGNOSES REDACTED] (low potassium in the blood), and declined in physical and mental condition. (#25)

The facility census totaled 46 residents with 12 included in the sample. Based on observation, interview, and record review, the facility failed to review and revise resident #25's nursing care plan after he/she returned from the behavioral unit on 12/30/14 and required hospitalization on [DATE] for dehydration and [DIAGNOSES REDACTED] (low potassium in the blood). (#25) Findings included: - Review of resident #25's annual MDS (minimum date set) dated 10/13/14 revealed the resident had a BIMS (brief interview for mental status) score of 15 indicating the resident was cognitively intact. The resident required supervision for bed mobility, transfers, locomotion on the unit, dressing and toilet use and did not use any mobility devices. The resident was always continent of bowel and bladder. Review of the ADL (activities of daily living) CAA (care area assessment) dated 10/13/14 revealed the resident was at risk for potential self-care deficit due to requiring prompting to complete his/her ADLs The care plan instructed staff to encourage the resident to complete ADLs independently and assist the resident as needed. The care plan also directed staff to document when the resident completed ADLs and the amount of assistance needed. Review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14 indicating the resident was cognitively intact. The resident required supervision with one assist for bed mobility, transfers, walk in room, locomotion on unit, toilet use, and personal hygiene and required the use of a walker for mobility. The resident was frequently incontinent of bowel and always continent of bladder. The MDS also indicated the resident was dehydrated. Review of the 12/9/14 revised care plan revealed staff failed to update the care plan after returning from the behavioral unit on 12/30/14, with diarrhea starting on 1/1/15, and a hospitalization for dehydration and [DIAGNOSES REDACTED] ( low potassium in the blood ) from 1/10/15 to 1/13/15. According to the nurse's notes, fluid intake monitoring, bowel and bladder monitoring, physician notes, and review of the history and physical from the behavioral unit and local hospital, resident #25 required hospitalization for treatment of [REDACTED]. The facility failed to revise or update the resident nursing care plan after the hospitalization s to prevent and maintain adequate hydration for the resident. An observation on 1/29/15 at 2:55 p.m. revealed the resident was lying down on his/her bed on the left side, resting. The resident showed no signs of distress or dehydration. His/her legs appeared to be swollen around the ankles and up to his/her calf area. An interview on 1/29/15 at 2:53 p.m. with resident #25 revealed he/she continued to have loose stools. He/she reported the night nurse assisted him/her when he/she was unable to make it to the bathroom on time. Resident #25 revealed he/she continued to be worried about why he/she continued to have the diarrhea. An interview on 2/2/15 at 9:13 a.m. with direct care staff E revealed the resident returned from the behavioral unit in December of 2014 and he/she came back confused, incontinent, and using a walker. He/she also returned with diarrhea. The resident required assistance with his/her ADLs. The resident then went to local hospital for low potassium and dehydration. The diarrhea has continued for an extended period of time. An interview on 2/2/15 at 3:27 p.m. with direct care staff F revealed the resident used the walker for ambulation along with cueing after his/her return from the behavioral unit in December. The resident was admitted to the local hospital for an electrolyte problem in January. He/she also reported the resident had become lethargic and was falling. Staff F reported unless the resident used the call light staff was unaware of when or how much diarrhea the resident had due to being independent with toileting. Direct care staff F reported the only monitoring of hydration for the resident was at meal and snack times. He/she also reported the staff did not monitor the output for the resident. Interview on 2/3/15 at 8:31 a.m. with licensed nursing staff J revealed staff was instructed to assess and monitor the resident daily on all shifts after his/her return from the behavioral unit on 12/30/14. He/she also reported the resident came back to the facility with a decline in ADLs requiring some assistance, required the use of a walker to ambulate, and had diarrhea. The resident was admitted to the local hospital on [DATE] and returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. Nurse J revealed he/she did not update or revise the care plan after the resident returned either time from the facility. Interview on 2/2/15 at 6:04 p.m. with administrative nurse B revealed nursing staff failed to monitor and assess the resident daily for signs and symptoms of dehydration. Nurse B also reported the facility failed to recognize the resident was at risk for dehydration after returning from the behavioral unit with the diarrhea first started. Nurse B also reported the facility failed to update or revise the care plan after the resident came back from the behavioral unit or the local hospital. Interview on 2/3/15 at 9:55 a.m. with physician D revealed the resident started the diarrhea when returning to the facility from the behavioral unit. He/she reported the resident became dehydrated, had a low potassium level, and needed to be admitted to the hospital. He/she reported they expected the facility to be monitoring accurately the resident's fluid intake and output, along with daily assessments after returning with the new [DIAGNOSES REDACTED]. Review of the facility policy on care plan dated 6/2013 revealed the facility will review and revise the resident's care plan after the resident assessment or assessment review. The facility failed to review and revise resident #25's nursing care plan after he/she returned from the behavioral unit on 12/30/14 and required hospitalization on [DATE] for dehydration and [DIAGNOSES REDACTED] (low potassium in the blood). (#25)