Every finding on record at Hill Top Home of Comfort Inc

Based on observation, review of the medical record, and review of facility policy, the facility failed to ensure that each resident receives the necessary respiratory care and services in accordance with professional standards of practice for 1 of 1 sampled resident (Resident #29) observed with oxygen. Failure to follow physician's orders regarding oxygen tubing changes at scheduled intervals has the potential to cause respiratory infections or adverse effects. Findings include: Review of the facility policy, Oxygen Administration occurred on 08/28/25. This policy, dated 03/28/25, stated, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans . Review of Resident #29's medical record occurred on all days of survey. Physician's orders, dated 11/18/23 stated, Change oxygen tubing weekly and wash concentrator filter at NOC [night]. Once A Day on Fri [Friday]. Review of the care plan identified oxygen use and to keep oxygen saturations (level of oxygen in the blood) above 90%. Observations on all days of the survey showed Resident #29 wore oxygen per nasal cannula and tape on the tubing labeled with a date of 08/15/25. Review of the Treatment Administration Record (TAR) showed staff signed the TAR on 08/22/25 indicating staff changed the oxygen tubing however, date on the tubing identified 08/15/25. The facility failed to ensure staff changed the oxygen tubing according to the physician's orders.

Based on record review, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from resident to resident abuse for 1 of 2 sampled residents (Resident #48), 1 supplemental resident (Resident #34), and 1 of 2 closed records (Resident #210). Failure to identify physical or sexual abuse placed residents at risk for possible mental and emotional distress, and/or physical injury. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 08/16/23. The IJ was identified when nurse's notes in Resident #34's and #210's medical records, dated 08/16/23, identified the residents had engaged in kissing and touching. A second nurse's note in Resident #48's medical record, dated 10/26/23, identified he led a female resident (Resident #34) into his room and barricaded the door with a chair. This finding placed residents in immediate danger due to the potential for mental and emotional distress and/or physical injury. *07/11/24 at 10:05 a.m. The survey team notified the administrator of the IJ situation, provided the IJ template, and requested a plan for removal of the immediate jeopardy. *07/12/24 at 1:37 p.m. The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: *Conducted interviews with Resident #34 and Resident #48 in regards to the resident to resident altercations. *Reviewed care plans for Resident #34 and Resident #48 to ensure resident behaviors were identified and interventions implemented. *Implemented behavior logs to be filled out by nurses to identify potential behaviors/abuse situations. *Education provided to all staff on 07/11/24 by the Director of Nursing (DON) and the Social Services Designee (SSD). Staff not available for education will complete education prior to their next scheduled shift. Education specifically focused on how to identify what constitutes resident to resident abuse or the potential of such abuse and the importance of implementing procedures to ensure the safety of the resident involved as well as the potential for all residents in the facility. *Implemented monitoring of the behavior logs by the SSD to ensure all behaviors are addressed and assessed for potential abuse. *07/16/24 at 11:40 a.m. The survey team verified the implementation of the removal plan as of 07/11/24 and the IJ removal. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 06/26/24. This policy, dated October 2019, stated, . to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse . 'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 'Sexual Abuse' is non-consensual sexual contact of any type with a resident. 'Physical Abuse' includes, but is not limited to hitting, slapping, punching, biting, and kicking. The components of the facility abuse prohibition plan are . Screening . Prospective residents will be screened . An assessment of the individual's functional and mood/behavioral status, medical acuity, and special needs will be reviewed prior to admission.The facility will implement policies and procedures to prevent and prohibit all types of abuse . that achieves: . Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the [sic] identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded . Identifying, correcting and intervening in situations in which abuse . is more likely to occur . The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict . The facility will have [sic] assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse . An immediate investigation is warranted when suspicion of abuse . or reports of abuse . occur . The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: . increased supervision of the alleged victim and residents . Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator . - Review of Resident #34's medical record occurred on all days of survey. Diagnoses included dementia, anxiety, and post traumatic stress disorder. An annual Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. The care plan stated, . A history of trauma affects me negatively. I had an abusive husband and will talk about at times. Triggers that have the potential to re-traumatize me include: Sound . Smell . Touch . Once I have experienced a trigger, I may display these signs/symptoms: . Anxiety/Edginess . Overwhelming fear . Anger/Irritability . Changes in mood state . Confusion/Disorientation . The frequency or severity of my trauma-related signs and symptoms will not increase through next review. The care plan failed to address the resident's wishes for engaging in physical contact with other residents. Nursing progress notes for Resident #34 included the following: * 08/16/23 at 10:57 a.m., [Resident #34] was found in the room of [Resident #210]. [Resident #34] was discovered halfway undressed, pants and brief were on the floor, socks thrown on opposite sides of the room, and was engaged in physical contact with [Resident #210]. Both were kissing/touching, [Resident #210] was in the process of pulling down his pants when staff walked in. Both residents were assisted with putting their clothes back on and [Resident #34] was guided out of the room. * 08/16/23 at 2:15 p.m., Son . was called and notified of situation that occurred earlier with another male resident. Son appreciative of call and indicated his mother has always been drawn to companionship. He expressed no concern about the situation as long as resident is showing happiness . - Review of Resident #210's medical record occurred on all days of survey, and included a diagnoses of dementia. An admission MDS, dated [DATE], identified severely impaired cognition. The care plan stated, I have the following behavior problem . physically abusive . verbally abusive . wandering . sexually inappropriate . The care plan failed to address the resident's wishes for engaging in physical contact with other residents. Nursing progress notes for Resident #210 included the following: * 08/15/23 at 5:01 p.m., Resident seen today by [physician name] on routine rounds for admit appointment. Assessment completed, chart and VS [vital signs] reviewed. Reported occasional behaviors/outbursts. Reported resident will be seen . on psych rounds next Wednesday. [Physician name] gave orders to increase Seroquel [antipsychotic medication] to 75 mg [milligrams] . BID [two times daily]. Orders faxed to pharmacy. * 08/16/23 at 10:56 a.m., [Resident #34] was found in the room of [Resident #210]. [Resident #34] was discovered halfway undressed, pants and brief were on the floor, socks thrown on opposite sides of the room, and was engaged in physical contact with [Resident #210]. Both were kissing/touching, [Resident #210] was in the process of pulling down his pants when staff walked in. Both residents were assisted with putting their clothes back on and [Resident #34] was guided out of the room. During an interview on 06/26/24 at 12:45 p.m., two administrative nurses (#1 and #2) confirmed they did not identify the actions between Resident #34 and Resident #210 as sexual abuse. - Review of Resident #48's medical record occurred on all days of survey. Diagnoses included dementia, Alzheimer's disease, and anxiety. A discharge MDS, dated [DATE], identified moderately impaired cognition. Nursing progress notes for Resident #48 included the following: * 10/26/23 at 2:45 p.m., Resident was seen leading another female resident [Resident #34] . into his room. Redirection was unsuccessful . Resident then started to be aggressive and screaming.while walking towards this writer with a fist closed. Resident then brought the female resident [Resident #34] to his room, closed the door, and barricaded it using another chair. This writer tried to knock on the door and asked if he could let the female resident [Resident #34] out as she looks frantic. Resident started yelling and screaming . DON was told of the incident on the unit and came right away. * 10/26/23 at 4:00 p.m., . When entered unit [Resident #48] had barricaded his room door with a chair with another female resident in the room. began to verbally scream and yell at staff outside of the room in the hallway. Administrator of facility was able to get door open a small amount and could see female resident sitting on [Resident #48's] bed . After many attempts [Resident #48] continued to refuse to open the door . Administrator pushed door open. [Resident #48] stepping backwards from door fell on to right knee and buttock. He quickly stood up and refused to have anyone enter his room and would not allow to have female resident leave the room. staff assisted female resident away from [Resident #48's] room. [Resident #48] began to follow staff and female resident down the hallway screaming and swung at face of staff member. He is placing residents. at risk to be hurt. [Resident #48's] wife indicated.has a hx [history] of getting very upset and aggressive. Call placed to 911 with police presence to send [Resident #48] into ER [emergency room ] for evaluation. During interviews on 06/26/24 at 9:08 a.m. and 9:20 a.m., two administrative staff members (#2 and #3) confirmed they did not identify the actions of Resident #48 towards Resident #34 as physical abuse. The facility failed to have a system and policy and procedures in place for assessing all residents' needs, desires, and usual preferences to determine how to care plan according to the assessment. 47896

Based on record review, review of facility policy, and staff interview, the facility failed to report potential abuse to the State Survey Agency (SSA) for 1 of 2 sampled residents (Resident #48), 1 supplemental resident (Resident #34), and 1 of 2 closed records (Resident #210). Failure to report potential abuse between cognitively impaired residents to the SSA, placed Resident #34, #48, #210, and other residents at risk for possible abuse and/or injury. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 08/16/23. The IJ resulted from facility staff failing to report physical and sexual abuse between Resident #34, Resident #48, and Resident #210 to the SSA. These findings placed residents in immediate danger due to the potential for mental and emotional distress and or/physical injury. *07/11/24 at 10:05 a.m. The survey team notified the administrator and director of nursing of the IJ situation, provided the IJ template, and requested a plan for removal of the immediate jeopardy. *07/12/24 at 1:37 p.m. The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: *Conducted interviews with Resident #34 and Resident #48 in regards to the resident to resident altercations. *Reviewed care plans for Resident #34 and Resident #48 to ensure resident behaviors were identified and interventions implemented. *Implemented behavior logs to be filled out by nurses to identify potential behaviors/abuse situations. *Education provided to all staff on 07/11/24 by the Director of Nursing (DON) and the Social Service Designee (SSD). Staff not available for education will complete education prior to their next scheduled shift. Education specifically focused on identifying abuse or potential for abuse, how and who to report abuse to, including administration, physician's, resident representatives and the SSA, and the timeframes for reporting allegations of abuse. *Implemented monitoring of the behavior logs by the SSD to ensure all behaviors are addressed and assessed for potential abuse. *07/16/24 at 11:40 a.m. The survey team verified the implementation of the removal plan as of 07/11/24 and the IJ removal. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: Review of a policy titled Abuse, Neglect and Exploitation occurred on 06/26/24. This policy, dated October 2019, stated, . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies . within specified timeframes . not later than 2 hours after the allegation is made, if the event that cause allegation involve abuse . or . Not later than 24 hours if the events that cause allegation do not involve abuse and do no result in serious bodily injury. - Review of Resident #34's medical record occurred on all days of survey. Diagnoses included dementia, post-traumatic stress disorder and anxiety. An annual Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. Nursing progress notes for Resident #34 included the following: * 08/16/23 at 10:57 a.m., [Resident #34] was found in the room of [Resident #210]. [Resident #34] was discovered halfway undressed, pants and brief were on the floor, socks thrown on opposite sides of the room, and was engaged in physical contact with [Resident #210]. Both were kissing/touching, [Resident #210] was in the process of pulling down his pants when staff walked in. Both residents were assisted with putting their clothes back on and [Resident #34] was guided out of the room. * 08/16/23 at 2:15 p.m., Son . was called and notified of situation that occurred earlier with another male resident. Son appreciative of call and indicated his mother has always been drawn to companionship. He expressed no concern about the situation as long as resident is showing happiness . - Review of Resident #210's medical record occurred on all days of survey, and included a diagnosis of dementia. An admission MDS, dated [DATE], identified severely impaired cognition. Nursing progress notes for Resident #210 included the following: * 08/15/23 at 5:01 p.m., Resident seen today by [physician name] on routine rounds for admit appointment. Assessment completed, chart and VS [vital signs] reviewed. Reported occasional behaviors/outbursts. Reported resident will be seen . on psych rounds next Wednesday. [Physician name] gave orders to increase Seroquel [antipsychotic medication] to 75 mg [milligrams] . BID [two times daily]. Orders faxed to pharmacy. * 08/16/23 at 10:56 a.m., [Resident #34] was found in the room of [Resident #210]. [Resident #34] was discovered halfway undressed, pants and brief were on the floor, socks thrown on opposite sides of the room, and was engaged in physical contact with [Resident #210]. Both were kissing/touching, [Resident #210] was in the process of pulling down his pants when staff walked in. Both residents were assisted with putting their clothes back on and [Resident #34] was guided out of the room. The record lacked evidence the facility reported the above incident to the SSA as possible abuse. During an interview on 06/26/24 at 12:45 p.m., two administrative nurses (#1 and #2) confirmed the facility failed to report the interaction between Resident #34 and Resident #210 to the SSA. - Review of Resident #48's medical record occurred on all days of survey. Diagnoses included dementia, Alzheimer's disease, and anxiety. A discharge MDS, dated [DATE], identified moderately impaired cognition. Nursing progress notes for Resident #48 included the following: * 10/26/23 at 2:45 p.m., Resident was seen leading another female resident [Resident #34]. into his room. Redirection was unsuccessful . Resident then started to be aggressive and screaming.while walking towards this writer with a fist closed. Resident then brought the female resident [Resident #34] to his room, closed the door, and barricaded it using another chair. This writer tried to knock on the door and asked if he could let the female resident [Resident #34] out as she looks frantic. Resident started yelling and screaming . DON was told of the incident on the unit and came right away. * 10/26/23 at 4:00 p.m., . When entered unit [Resident #48] had barricaded his room door with a chair with another female resident in the room. began to verbally scream and yell at staff outside of the room in the hallway. Administrator of facility was able to get door open a small amount and could see female resident sitting on [Resident #48's] bed . After many attempts [Resident #48] continued to refuse to open the door . Administrator pushed door open. [Resident #48] stepping backwards from door fell on to right knee and buttock. He quickly stood up and refused to have anyone enter his room and would not allow to have female resident leave the room. staff assisted female resident away from [Resident #48's] room. [Resident #48] began to follow staff and female resident down the hallway screaming and swung at face of staff member. He is placing residents. at risk to be hurt. [Resident #48's] wife indicated.has a hx [history] of getting very upset and aggressive. Call placed to 911 with police presence to send [Resident #48] into ER [emergency room ] for evaluation. The record lacked evidence the facility reported the above incident to the SSA as possible abuse. During interviews on 06/26/24 at 9:08 a.m. and 9:20 a.m., two administrative staff members (#2 and #3) confirmed the facility failed to report the interaction between Resident #34 and Resident #48 to the SSA. 47896

Based on record review, review of facility policy, and staff interviews, the facility failed to investigate resident to resident abuse for 1 of 2 sampled residents (Resident #48), 1 supplemental resident (Resident #34), and 1 of 2 closed records (Resident #210). Failure to investigate alleged violations of resident to resident abuse, ensure residents were protected during each investigation, and implement corrective actions/evaluate their effectiveness following each investigation, placed Resident #34, #48, #210, and other residents at risk for possible mental and emotional distress and/or physical injury. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 08/16/23. The IJ resulted from facility staff failing to investigate physical and sexual abuse for resident to resident altercations between Resident #34, Resident #48, and Resident #210. The IJ was identified when nurse's notes in Resident #34's and #210's medical record, dated 08/16/23, identified the residents had engaged in kissing and touching. A second nurse's note in Resident #48's medical record, dated 10/26/23, identified he led a female resident (Resident #34) into his room and barricaded the door with a chair. Failure to investigate incidents of potential abuse may result in unwanted physical and/or sexual contact and my cause residents mental and emotional distress and/or physical injury. *07/11/24 at 10:05 a.m. The survey team notified the administrator and director of nursing of the IJ situation, provided the IJ template, and requested a plan for removal of the immediate jeopardy. *07/12/24 at 1:37 p.m. The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: *Conducted interviews with Resident #34 and Resident #48 in regards to the resident to resident altercations. *Reviewed care plans for Resident #34 and Resident #48 to ensure resident behaviors were identified and interventions implemented. *Implemented behavior logs to be filled out by licensed nurses to identify potential behaviors/abuse situations. *Education provided to all staff on 07/11/24 by the Director of Nursing (DON) and the Social Worker Designee (SSD). Staff not available for education will complete education prior to their next scheduled shift. Education specifically focused on identifying abuse or potential abuse, and conducting and documenting an investigation in order to ensure resident safety and appropriate interventions are put in place. *Implemented monitoring of the behavior logs by the SSD to ensure all behaviors are addressed and assessed for potential abuse. *07/16/24 at 11:40 a.m. The survey team verified the implementation of the removal plan as of 07/11/24 and the IJ removal. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: Review of a policy titled Abuse, Neglect and Exploitation occurred on 06/26/24. This policy, dated October 2019, stated, . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse . occur. Written procedures for investigations include . Investigating different types of alleged violations . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations . Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause, and . Providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: . Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed . Increased supervision of the alleged victim and residents . - Review of Resident #34's medical record occurred on all days of survey. Diagnoses included dementia. An annual Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. Nursing progress notes for Resident #34 included the following: * 08/16/23 at 10:57 a.m., [Resident #34] was found in the room of [Resident #210]. [Resident #34] was discovered halfway undressed, pants and brief were on the floor, socks thrown on opposite sides of the room, and was engaged in physical contact with [Resident #210]. Both were kissing/touching, [Resident #210] was in the process of pulling down his pants when staff walked in. Both residents were assisted with putting their clothes back on and [Resident #34] was guided out of the room. * 08/16/23 at 2:15 p.m., Son . was called and notified of situation that occurred earlier with another male resident. Son appreciative of call and indicated his mother has always been drawn to companionship. He expressed no concern about the situation as long as resident is showing happiness . - Review of Resident #210's medical record occurred on all days of survey. Diagnoses included dementia. An admission MDS, dated [DATE], identified severely impaired cognition. Nursing progress notes for Resident #210 included the following: * 08/15/23 at 5:01 p.m., Resident seen today by [physician name] on routine rounds for admit appointment. Assessment completed, chart and VS [vital signs] reviewed. Reported occasional behaviors/outbursts. Reported resident will be seen . on psych rounds next Wednesday. [Physician name] gave orders to increase Seroquel [antipsychotic medication] to 75 mg [milligrams] . BID [two times daily]. Orders faxed to pharmacy. * 08/16/23 at 10:56 a.m., [Resident #34] was found in the room of [Resident #210]. [Resident #34] was discovered halfway undressed, pants and brief were on the floor, socks thrown on opposite sides of the room, and was engaged in physical contact with [Resident #210]. Both were kissing/touching, [Resident #210] was in the process of pulling down his pants when staff walked in. Both residents were assisted with putting their clothes back on and [Resident #34] was guided out of the room. The facility lacked evidence they started and/or completed an investigation into the incident between Resident #34 and #210. During an interview on 06/26/24 at 12:45 p.m., two administrative nurses (#1 and #2) confirmed the facility failed to complete and document an investigation of the interaction between Resident #34 and Resident #210. - Review of Resident #48's medical record occurred on all days of survey. Diagnoses included dementia, Alzheimer's disease, and anxiety. A discharge MDS, dated [DATE], identified moderately impaired cognition. Nursing progress notes for Resident #48 included the following: * 10/26/23 at 2:45 p.m., Resident was seen leading another female resident [Resident #34]. into his room. Redirection was unsuccessful . Resident then started to be aggressive and screaming.while walking towards this writer with a fist closed. Resident then brought the female resident [Resident #34] to his room, closed the door, and barricaded it using another chair. This writer tried to knock on the door and asked if he could let the female resident [Resident #34] out as she looks frantic. Resident started yelling and screaming . DON was told of the incident on the unit and came right away. * 10/26/23 at 4:00 p.m., . When entered unit [Resident #48] had barricaded his room door with a chair with another female resident in the room. began to verbally scream and yell at staff outside of the room in the hallway. Administrator of facility was able to get door open a small amount and could see female resident sitting on [Resident #48's] bed . After many attempts [Resident #48] continued to refuse to open the door . Administrator pushed door open. [Resident #48] stepping backwards from door fell on to right knee and buttock. He quickly stood up and refused to have anyone enter his room and would not allow to have female resident leave the room. staff assisted female resident away from [Resident #48's] room. [Resident #48] began to follow staff and female resident down the hallway screaming and swung at face of staff member. He is placing residents. at risk to be hurt. [Resident #48's] wife indicated . has a hx [history] of getting very upset and aggressive. Call placed to 911 with police presence to send [Resident #48] into ER [emergency room ] for evaluation. The facility lacked evidence they started and/or completed an investigation into the incident between Resident #34 and #48. During interviews on 06/26/24 at 9:08 a.m. and 9:20 a.m., two administrative staff members (#2 and #3) confirmed the facility failed to document an investigation of the interaction between Resident #34 and Resident #48. 47896

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 15 sampled residents (Resident #20 and #51). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages N-6 to N-8 stated, . N0415: High-Risk Drug Classes: Use and Indication . Coding Instructions . N0415J1 Hypoglycemic (including insulin): Check if a hypoglycemic medication was taken by the resident any time during the observation period. Review of Resident #51's medical record occurred on all days of survey. A physician's order, dated 01/24/24, stated, Metformin 500mg [milligrams] daily with breakfast. The quarterly MDS, dated [DATE], showed staff failed to identify Resident #51 received a hypoglycemic medication. During an interview on the afternoon of 06/25/24, an administrative nurse (#1) confirmed staff failed to document a hypoglycemic medication on the MDS. SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages O-3 an O-4 stated, . Steps for Assessment . Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period . O0110C1, Oxygen therapy . Code continuous or intermittent oxygen administered . Review of Resident #20's medical record occurred on all days of survey. The medication administration record (MAR) showed Resident #20 received two liters of oxygen on all shifts daily from 03/25/24 - 04/08/24. A quarterly MDS, dated [DATE], lacked documentation of Resident #20's continuous oxygen use. During an interview on the afternoon of 06/25/24, an administrative nurse (#1) confirmed staff failed to document Resident #20's oxygen use on the MDS. 46964

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans for 2 of 15 sampled residents (Resident #48 and #56). Failure to review and revise the care plan limited staff's ability to communicate needs, ensure continuity of care, and may negatively impact the care provided to residents. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 06/26/24. This policy, revised 10/2021, stated, .care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment and PRN [as needed] with changes. - Review of Resident #48's medical record occurred on all days of survey. Diagnosis included Alzheimer's disease, anxiety disorder, delusional disorders, and dementia with psychotic disturbance. Review of progress notes from October 2023 to May 2024 identified Resident #48 exhibited verbal and physical behaviors on the following dates: *10/20/2023 at 8:48 p.m. stated, Incident. Staff reported resident initiated an argument with [another resident]. *10/26/23 at 2:45 p.m. stated, Resident was seen leading another female resident. into his room. Resident then started to be aggressive and screaming. while walking towards this writer with a fist closed. Resident then brought female resident to his rooms, closed the door, and barricaded it using another chair. Resident started yelling and screaming. *10/26/23 at 4:00 p.m. stated, .began to verbally scream and yell at staff outside of the room in the hallway. very upset swung to punch administrator of facility.began to follow staff and female resident down the hallway screaming and swung at face of staff member. *12/17/23 at 6:14 p.m. stated, Behavior. [another resident's spouse] was standing in hallway by her husband's closed room. This resident got close to her and shook his fist in her face without being instigated. *05/10/24 at 10:00 p.m. stated, Behavior Charting.started following around the 2 CNAs and would square up and/or swing fists at them but did not make contact. *05/13/24 at 7:06 p.m. stated, . Staff observed [Resident #48] yelling, screaming, and pushing against the wall. A discharge MDS, dated [DATE], identified physical and verbal behavioral symptoms directed towards others occurred 1 to 3 days. The current care plan stated, .Behavioral symptoms. I am at risk for elopement as evidenced by: my exit seaking [sic] and wandering. The care plan failed to identify behavioral symptoms related to verbal and physical behavioral symptoms directed towards others. -Review of Resident #56's medical record occurred on all days of survey. Diagnosis included chronic obstructive pulmonary disease (COPD) and wheezing. A physician's order, dated 04/18/24, stated, Oxygen per NC [nasal cannula] to maintain O2 [oxygen] sat >90% [saturation greater than 90 percent]. In an interview on 06/24/24 at 12:36 p.m., Resident #56 confirmed she should have oxygen on continuously and placed nasal cannula on. The facility failed to update Resident #56's care plan regarding oxygen use. During an interview on 06/25/24 at 3:40 p.m., an administrative staff member (#1) confirmed the facility failed to update Resident 56's care plan related to oxygen use and resident's refusal to wear at times.

Based on staff interview, the facility failed to ensure 1 of 1 nutrition and food services supervisor (#1) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 07/26/23 at 3:31 p.m., the nutrition and food services supervisor (#1) and an administrative staff member (#2) confirmed the necessary courses required for the director of food and nutrition services are not completed. The facility failed to ensure the supervisor (#1) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body.

Based on observation and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment on 3 of 4 units (Meadow Lane, Northern, and Spring). Failure to maintain a safe, clean, and sanitary environment does not provide a comfortable/homelike environment and places residents at risk for injury. Findings include: Observations of the environment on all days of the survey showed the following: - Meadow Lane Rooms 1101 - personal fan soiled with dust and heat register with broken piece hanging off the register 1103 - wall near the bed with scuffed/scraped areas 1104 - wall near the bed with scuffed/scraped areas 1106 - wall in the bathroom with scuffed/scraped areas 1109 - wall in the bathroom with two areas of missing paint 1110 - wall near the bed with scuffed/scraped areas and an open cable TV outlet box with exposed cable cords 1111 - two open cable TV outlet boxes with exposed cable cords 1112 - an open cable TV outlet box with exposed cable cords - Northern Rooms 1201 - wall behind the bed scuffed/scraped 1202 - wall behind the bed scuffed and scraped 1205 - broken outlet on the wall and some of the heat register pieces broken 1206 - wall behind the bed scuffed/scraped, holes in wall where previous items hung, open cable TV box with exposed cable cords, heat register smashed in at the end, and wall under window with dark dirty spots 1211 - wall behind the bed scuffed/scraped. - Spring Rooms 1403 - scratches in the paint on 3 of the walls. 1404 - scrapes and gouges in the wall behind the bed and recliner, and patched unpainted areas under the TV 1405 - large patched, unpainted area by the bathroom 1406 - large gouges in the wall by the video game table 1407 - gouges behind the head of bed 1408 - patched unpainted area behind the bathroom door 1409 - multiple scrapes on the wall and gouges beneath the TV mount A wall at the end of Spring unit's hallway with gouged, scuffed/scraped areas, a wooden box in the hallway with computer hookup wires from old electronic health system During an environmental tour on 06/23/22 at 8:20 a.m., an administrative staff (#1) stated he expected nursing staff to submit work orders and maintenance staff to cover the cable TV outlets.

INSULIN ADMINISTRATION 1. Based on observation, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #40) and two supplemental residents (Residents #18 and #36) observed receiving insulin. Failure to administer insulin as instructed may result in residents receiving an inaccurate dose of insulin. Findings include: Review of the facility policy titled Insulin Pen occurred on 06/22/22. This policy, revised 10/2021, stated, . Injecting the insulin: . While still pressing the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin. Observation of insulin administration showed the following: * 06/22/22 at 9:30 a.m., a staff nurse (#4) administered 3 units of insulin via pen to Resident #18. After injecting the insulin, the staff nurse (#4) failed to keep the needle in the skin for 6-10 seconds. * 06/22/22 at 11:27 a.m., a staff nurse (#4) administered 2 units of insulin via pen to Resident #40. After injecting the insulin, the staff nurse (#4) failed to keep the needle in the skin for 6-10 seconds. * 06/22/22 at 11:37 a.m., a staff nurse (#4) administered 10 units of insulin via pen to Resident #36. After injecting the insulin, the staff nurse (#4) failed to keep the needle in the skin for 6-10 seconds. During an interview on 06/23/22 at 9:07 a.m., two administrative nurses (#2 and #3) confirmed they expected staff to follow the facility policy regarding insulin administration. TRANSCRIBING ORDERS 2. Based on record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sample resident (Resident #37) reviewed with a dietary order change. Failure to transcribe Resident #37's dietary order when received placed the resident at risk for adverse consequences. Findings include: Review of the facility policy titled Medication Orders occurred on 06/23/22. This policy, revised 09/20/21, stated, .Verbal orders should be received only by licensed nurses, and confirmed in writing by the physician, on the next visit to the facility. All medication orders are documented into Matrix Care [electronic health record system] under current orders. Review of Resident #37's medical record occurred all days of survey. The record showed a physician's order, dated 11/18/21, for a regular diet. A progress note, dated 12/09/21, stated, Received telephone order from speech therapist stating, NDD3 [National Dysphagia Diet] diet with all foods cut into small pieces, gravy/sauce added to meat, thin liquids ok via cup/straw, line of sight supervision, [sit at] 90 degree for all meals. The resident's current care plan identified a mechanically altered NDD3 diet matching the progress note documented on 12/09/21. During an interview on 06/23/22 at 8:39 a.m., two administrative nurses (#2 and #3) confirmed staff failed to transcribe Resident #37's dietary order into the medical record. Failure to transcribe the order at the time received has the potential for a negative consequence to the resident.

Based on observation and staff interview, the facility failed to ensure staff discarded expired medications and laboratory supplies for 4 of 5 storage areas (Meadow Lane and Carus Court medication carts, a medication room, and a laboratory tray) observed. Failure to discard expired medications, vacutainers (blood specimen collection tubes), and other resident medical supplies increased the risk of residents receiving outdated medications with reduced efficacy and/or staff utilizing outdated laboratory and medical supplies. Findings include: - Observation of the Meadow Lane medication cart on 03/02/21 at 12:10 p.m. with a medication assistant (MA) (#3) identified a tube of [MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME] 1% ointment expired on 09/27/20. The MA (#3) stated, Resident #26 is no longer on that medication. - Observation of the Carus Court medication cart on 03/02/21 at 12:40 p.m. with a staff nurse (#4) identified one [MEDICATION NAME] 25G (gauge) x1 (one inch) safety needle expired on 03/2019. - Observation of the medication room on 03/02/21 at 1:00 p.m. with a staff nurse (#5) and MA (#3) identified the following expired medications and laboratory/medical supplies: *Four Vacutainer Safety-Lok infusion sets (23Gx3/4) expired 06/30/20 *Forty-five Alcohol Prep Pads with expiration dates of 06/2020, 06/2019, and 08/2020 *Three [MEDICATION NAME] Zinc packets expired 01/2018 *One Smart Site Needle Free Valve expired 01/25/20 *Three green top vacutainers expired 05/31/20 *Five blue top vacutainers expired 11/30/19 and 12/31/19 *Two Yellow top vacutainers expired 12/31/20 *One Purple top vacutainer expired 09/30/20 *Three Red top vacutainers expired 08/31/20 *One bottle of [MEDICATION NAME] ear drops expired 06/2019 *Two NG (nasogastic) Sample Kits expired 10/2019 and 01/2021 *Three Copan culture tubes expired 02/2020 *Thirty male sterile caps (sterile caps for intravenous tubing) expired 03/01/20 - Observation of a laboratory tray on 03/02/21 at 1:31 p.m. with an administrative nurse (#6) identified four blue top vacutainers expired 05/31/20. During interview on 03/02/21 at 1:31 p.m., an administrative nurse (#6) confirmed the above items had expired and staff needed to discard the items. During interview on 03/02/21 at 3:00 p.m. with an administrative nurse (#1) identified the facility had no policy/procedure for review and destruction of expired medications/medical supplies. The administrative nurse (#1) agreed all nurses are responsible to ensure expired medications and medical supplies are discarded.

Based on observation and staff interview, the facility failed to serve food under sanitary conditions and kitchen equipment kept clean in 1 of 1 kitchens used to prepare food and wash dishware. Failure to change gloves before touching ready-to-eat foods and to effectively clean kitchen equipment has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: Observation during a kitchen tour on 03/04/21 at 7:38 a.m., showed several areas of corrosion on the edges of the dishwasher and a layer of corrosion particles and dirt on its top. Observation of the breakfast meal on 03/04/21 showed an unidentified kitchen staff member touched serving counters, meal tickets, and the handle on a steamer/oven to retrieve hot plates. Without changing gloves, he repeatedly reached into a container of toast and placed it onto resident meal trays. During an interview on 03/04/21 at 8:43 a.m., administrative staff members (#1, #6, and #9) agreed falling debris from the outside of the unclean dishwasher could fall onto/contaminate clean dishes and kitchen staff (#7) should have changed gloves and utilized a utensil to serve the toast. During an interview on 03/04/21 at 9:34 a.m., an administrative staff member (#8) stated he assumed the dishwasher servicing company was responsible for cleaning/descaling the outside of the dishwasher when they come.

Based on observation, record review, review of facility policy and procedure, and staff interview, the facility failed to follow infection control standards on 2 of 4 days (03/01/21 and 03/02/21) of survey. Failure of the facility to ensure appropriate transmission based precautions were followed may result in resident and staff exposure to COVID-19 (a [MEDICAL CONDITION] infection) or other healthcare-associated infections. Findings include: Review of the facility policy titled, Nebulizer Treatments during covid-19 pandemic occurred on 03/02/21. This policy, dated 09/18/20, stated, 1) Must be fit tested with n95 (sic) to administer neb (nebulizer). 4) If only set up and resident can turn on and off, the staff member can set up, close door and rotate sign and keep track of time to open door again. 5) Door must be kept closed for the period of the neb and 30 minutes after neb. Sign on door need (sic) to be rotated back so (sic) staff goes into room. Review of the facility policy titled, Transmission-Based Precautions occurred on 3/03/21. This policy, revised November 2020, stated, . Place residents with suspected or confirmed infectious agents on isolation precautions empirically while awaiting confirmation . as recommended by the CDC (Center for Disease Control) . will be documented in the medical record . communicated through in house communication forms . signage. Review of the Centers for Disease Control and Prevention (CDC) guidance for PPE use, found at: https://www.cdc.gov, stated, . Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/23/21, stated . The PPE (personal protective equipment) recommended when caring for a patient with suspected or confirmed COVID-19 includes the following . Put on an N95 respirator . Put on eye protection . Put on clean, non-sterile gloves . Put on a clean isolation gown upon entry into the patient room . - Observation on 03/01/21 at 10:45 a.m., showed Resident #303 sitting at the bedside in the room with a nebulizer treatment in progress. The resident's door remained open with no nebulizer signage displayed. During an interview on 03/02/21 at 11:24 a.m., a medication aide (MA) (#3) stated, Staff wear N95 masks, face shield, gown, and gloves in residents' rooms while a nebulizer treatment is in progress. The resident's door must have a nebulizer in progress sign and must remain closed for 30 minutes following the completion of the treatment. -Observation on 03/02/21 at 7:10 a.m., showed three separate Enhanced Precautions signs and an isolation cart outside of a resident room on enhanced precautions with the door wide open. At 7:11 a.m., a certified nursing assistant (CNA) (#10), wearing a surgical mask and face shield, entered the room, turned off the call light, moved the bedside table, touched blankets, socks, a dresser, chair and door. The CNA failed to hand sanitize and don appropriate PPE when entering and exiting the room. During an interview on 03/03/21 at 5:06 p.m., two administrative nurses (#1and #6) agreed the staff should follow facility policy and CDC guidelines and wear the appropriate PPE and close the residents door.

Based on record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 2 of 2 sampled residents (Resident #47 and #50) with skin wounds. Failure to follow physician's orders, and failure to complete weekly documentation regarding wound measurements may result in worsening skin wounds and delayed treatment changes as needed. Findings include: Review of the facility policy titled, Documentation of Wound Treatments occurred on 03/04/21. This policy, reviewed/revised February 2020, stated, Policy: The purpose of this guideline is to provide a consistent process for accurate and complete wound treatment documentation. The facility must maintain clinical records on each resident in accordance with professional standards and practices that are: Complete, Accurately documented . Treatment Documentation Guidelines: Type of wound (pressure injury, surgical, etc. ), Stage if pressure injury . or wound depth if non-pressure . Measurements: height, width, depth, undermining, tunneling. Description of wound characteristics: Color of the wound bed, type of tissue in the wound bed (i.e. granulation), Temperature of the peri -wound (warm, inflamed, macerated), Drainage/Exudate, Odor, Pain. Frequency of Wound Documentation: Weekly. PRN (as needed) with any resident change in condition or change in wound status. - Review of Resident #47's medical record occurred on all days of the survey and included [DIAGNOSES REDACTED]. A significant change Minimum Data Set ((MDS) dated [DATE], identified the application of a nonsurgical dressing other than to feet. Resident #47's current treatment administration record (TAR) showed Change dressing to left shin wound: apply dry dressing to area daily. Resident #47's current care plan stated, . I am at risk for potential skin integrity impairment due to aging, health problems, and limited mobility. Goal: My skin will remain intact through the next review. Review of Resident #47's progress notes from 12/28/20 - 03/03/21 identified the following: * 12/28/20 at 9:14 a.m.: Call placed to (physician) in regards to left shin wound not improving, orders received to send to ER (emergency room ) for wound evaluation. * 01/28/21 at 2:51 p.m.: With open area on left shin, with whitish tissue covering the wound, small amount of brownish discharges (sic) noted, non-foul smelling. * 02/01/21 at 7:24 a.m.: Weekly skin assessment. Open area noted on left shin, with tissue covering the wound, small amount of brownish discharges (sic) noted, non-foul smelling. * 02/08/21 at 6:51 a.m.: Weekly skin assessment. Continuous (sic) to have open area to left shin with small amount of brownish discharges (sic) noted, non-foul smelling * 02/15/21 at 5:29 a.m.: Weekly skin Assessment. Continuous (sic) to have ope (sic) area on left shin with small amount of brownish discharges (sic) noted, non-foul smelling T * 03/01/21 at 7:47 a.m.: Skin Assessment. Continuous (sic) to have open area on left shin with yellowish tissue covering the wound bed with small amount of brownish discharges (sic) noted. The facility failed to provide documentation of weekly wound assessments including wound measurements. - Review of Resident #50 medical record occurred on all days of survey. A quarterly MDS dated [DATE] identified application of nonsurgical dressing other than to feet. An Event, dated 12/26/20, stated, . Wound measuring 9 cm x 6 cm noted to left lower leg (shin). Type of Injury: Laceration. Deep . Resident #50's current TAR identified Clean wound to left lower leg with normal saline. Apply wet to dry dressing . Cover gently with ACE wrap. On in AM (morning). Off in PM (evening). The current care plan stated, . I am at risk for skin breakdown related to incontinence and fragile skin. Goal: My skin will remain intact through the next review. Review of resident #50's progress notes 12/18/20- 02/27/01 identified the following: * 01/01/21 at 10:04 p.m.: Weekly skin assessment. Resident continues to have abrasion to left shin. No bleeding or drainage noted form scab or abrasion to shin. Denies pain. * 01/07/21 a 6 8:25 p.m.: . Dressing change to left lower leg done. Does look more red around edges of wound this evening. Denies pain in area. * 01/15/21 at 10:06 p.m.: Weekly skin assessment. Resident continues to have abrasion to left shin, has no bleeding or drainage noted. * 02/19/21 at 10:31 p.m.: Weekly skin Assessment. 0.5 cm open area on left shin, area is moist, with white tissue covering the wound bed, slight redness noted on the surrounding area. Area left open to air. * 02/27/21 at 03:01 a.m.: Skin Assessment: . Wound to left leg is healing good, slightly red due to granulation, no open area noted, left open to air. The facility failed to provide documentation of weekly wound assessments including wound measurements. During an interview on 03/03/21 at 3:00 p.m., an administrative nurse (#6) clarified the facility nursing staff should document on all skin concerns as per facility policy.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure staff provided appropriate/timely treatment and services to monitor/prevent the possible deterioration/healing of pressure ulcers for 3 of 3 sampled residents (Resident #2, #42, and #47) with pressure ulcers. Failure to identify and consistently monitor/assess may have resulted in delayed identification and treatment of [REDACTED]. Findings include: Review of the facility policy titled Wound Treatment Guidelines occurred on 03/04/21. This policy, dated October 2019, stated, . Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. 6. Treatments will be documented on the Treatment Administration Record (TAR) 7. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Review of the facility policy titled Documentation of Wound Treatments occurred on 03/04/21. This policy, dated February 2020, stated, The purpose of this guideline is to provide a consistent process for accurate and complete wound treatment documentation . 2. Type of wound (pressure injury, surgical, etc.) 2. Stage, if pressure injury (I, II, III, IV, unstageable) or wound depth, if non-pressure (partial or full thickness) 3. Measurements: height, width, depth, undermining, tunneling 4. Description of wound characteristics a. Color of wound bed b. Type of tissue in the wound bed (i.e. granulation) c. Temperature of the peri-wound (warm, inflamed, macerated) d. Drainage/Exudate e. Odor f. Pain 5. Current treatment 6. Weekly progress towards healing, effectiveness of current interventions 7. Any treatment for [REDACTED]. Modifications of interventions 9. Notifications to physician and/or responsible party regarding wound or treatment changes. Frequency of Wound Documentation: 1. Weekly 2. PRN (as needed) with any resident change in condition or change in wound status. -Review of Resident #2's medical record occurred on all days of the survey and included [DIAGNOSES REDACTED]. Resident #2 current care plan stated, . Pressure Ulcer. I am at risk for potential skin integrity impairment due to aging, health problems, and limited mobility. I currently have an unstageable pressure ulcer to right heel . upon return (10/29/2020 . stage 2 on admission) . 12/04/2020 unstageable/Diabetic ulcer . Goal: My skin will remain intact through next review . Approach: Heel protection/Blue boots 24/7 . assist me to avoid skin to skin contact as possible . complete skin assessment of my body weekly and as needed if I have an area of concern. See (EMR) and Progress notes for updates . Resident #2's physician orders and current TAR identified the following: -Resident to wear heel protector to both heels 24/7. Special instructions: for unstageable decubitus right heel ulceration. Every shift 7:00 a.m. - 3:00 p.m., 3:00 p.m. - 11:00 p.m., 11:00 p.m. - 7:00 a.m. RIGHT HEEL: cleanse open area; apply [MEDICATION NAME], and change dressing DAILY. Special instructions treatment to right heel DAILY. Once a Day. 7:00 a.m. - 3:00 p.m. ULCER: Weekly Ulcer Report (Document measurements, color of wound bed, drainage amount and color, odor, tunneling and surrounding tissue. Describe progress and effectiveness of treatment) Once a day on Thursday evenings . Review of Resident #2's progress notes showed the following: -11/05/20 at 9:41 p.m.: Weekly skin assessment failed to assess/measure right heel wound. -11/12/20 at 9:11 a.m.: Weekly skin assessment failed to assess/measure right heel wound. -11/19/20 at 10:53 p.m.: Weekly skin assessment failed to assess/measure right heel wound. -11/26/20 at 10:23 p.m.: MDS Charting/skin assessment: right heel is black in color. The facility failed to measure right heel wound. -12/03/2020 at 9:39 p.m.: Weekly skin assessment . wound to right heal is covered with black eschar. The facility failed to assess right heel wound. -02/11/21 at 10:40 p.m.: Weekly skin assessment failed to assess/measure right heal wound. The facility failed to follow physician orders for weekly or PRN skin assessments and provide consistent documentation of Resident #2's wounds and follow facility policy, which may have resulted in delayed identification and treatment of [REDACTED]. - Review of Resident #42's medical record occurred on all days of survey and included [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], identified one stage 2 pressure ulcer present on admission/reentry, extensive assist of two staff for bed mobility, transfer, toileting, and dressing, and high cognitive function. The current care plan, updated 02/08/21, stated, . I currently have open areas to coccyx present upon return. I frequently refuse to allow staff to treat. I also refuse to lay down in bed . I desire my wounds to exhibit signs of healing evidenced by decrease in size, improved appearance, and be free from signs & symptoms of infection by next review date. Resident #42's current physician's orders identified the following: - Rash/Lesion: Daily monitoring, [MEDICATION NAME] to right upper buttocks daily til (sic) healed. Special Instructions: THREE OPEN AREAS TO GLUTEAL AREA: Cleanse with soap and warm water, barrier cream, and dressing Twice A Day 07:00 AM - 03:00 PM, 03:00 PM - 11:00 PM. Start date: 2-8-21 - Weekly skin assessment completed Once A Day on Mon (Monday) 07:00 AM - 03:00 PM Start date: 12-1-2019 Review of the progress notes showed the following: - 12/28/19 - .25 cm (centimeter) R (right) buttock. [MEDICATION NAME] per T.O. (telephone order) til (sic) healed. (no follow-up documentation on this area noted) - 01/06/21 - Assessment after returning from the hospital. Has open area (approx (approximately) 1cm) on left buttock near coccyx. After cleansing [MEDICATION NAME] applied. - 01/11/21 - . meplix ([MEDICATION NAME]) placed to coccyx area, area remains 0.5 cm open with no drainage to site nor discoloration. No other bruising, ST's (skin tears), rashes nor lacerations noted throughout the body. - 01/24/21 - Left superficial area to buttock. - 01/25/21 - Weekly skin assessment. Right buttock open area .5 cm and left buttock with shearing - 02/08/21 - From top of coccyx and downward assessment. First area: 1.6 cm x 1.6 cm open on right gluteal cheek. Second area: 1.4 cm x 3 cm. Third area .5 cm x .5 cm left lower coccyx area. The progress notes failed to follow physician orders for weekly or PRN skin assessments and follow facility policy to identify the type of wound, the Stage or wound depth, color, temperature, drainage, odor, pain or pain treatment, dressing/treatment type, treatment effectiveness/modification, or physician notification for treatment update/changes on a consistent basis. During an interview on 03/03/21 at 3:45 p.m., an administrative nurse (#1) agreed the facility failed to follow physician orders and facility policy to assess/monitor the resident's wounds on a consistent basis. The nurse (#1) identified the wound as a Stage II pressure ulcer on the MDS, dated [DATE], by reading the progress notes/medical record but agreed the nursing staff failed to identify wound type or stage the wounds in the documentation. - Review of Resident #47's medical record occurred on all days of the survey and included [DIAGNOSES REDACTED]. Resident #47's current care plan, stated, . Pressure Ulcer. I am at risk for potential skin integrity impairment due to aging, health problems, and limited mobility. Goal: My skin will remain intact through the next review. Approach: Please place blue boots at all times. No shoes. Monitor left heel daily and notify MD (medical doctor) and family if worsens. Complete skin assessment of my body weekly and as needed if I have any area of concern. See Event and Progress notes for updates. Resident #47's physician orders and current TAR identified the following: - Apply [MEDICATION NAME] dressing to blister to left heel every 3 days until healed. Once A Day Every 3 Days 11:00 p.m. - 7:00 a.m., dated 02/27/20. - Weekly skin assessment completed. Special Instructions: Do on Monday morning bath days. Once a day on Sunday 11:00 p.m. - 7:00 a.m., dated 02/27/20. - OPEN AREA TO LEFT HEEL: Cleanse wound with wound cleanser spray, apply [MEDICATION NAME] and [MEDICATION NAME] dressing, once a day 11:00 p.m. - 7:00 a.m., dated 02/23/21. - Contact precautions for draining wound, every shift 7:00 a.m. - 3:00 p.m., 3:00 p.m. - 11:00 p.m., and 11:00 p.m. - 7:00 a.m., dated 02/24/21. Review of Resident #47's progress notes showed the following: - 12/28/20 at 7:01 a.m.: Weekly skin assessment . Bilateral heels are dry and intact; with 1 cm elevated lesion on left heel, denies pain. Applied [MEDICATION NAME] for protection. - 01/04/21 at 6:24 a.m.: The weekly skin assessment failed to assess heel wound. - 01/18/21 at 7:29 a.m.: The weekly skin assessment failed to assess heel wound. - 01/28/21 at 2:51 p.m.: .With 0.5 cm open area on left heel and raised lesion on left lateral side of the heel, area is covered with [MEDICATION NAME]. - 02/01/21 at 7:24 a.m.: Weekly skin assessment . Open area on left heel and raised lesion on left lateral side of the heel, covered with [MEDICATION NAME] . - 02/08/21 at 6:51 a.m.: Weekly skin assessment . Open area on left heel and raised lesion on left lateral side of the heel, [MEDICATION NAME] applied . - 02/15/21 at 5:29 a.m.: Weekly skin Assessment . Open area on left heel and raised lesion on left lateral side of the heel, [MEDICATION NAME] applied . - 02/21/21 at 7:21 a.m.: .With 4 x 3 cm open area on left heel, with black eschar, whitish tissue in some area, macerated with foul-smelling brownish discharges (sic). - 02/22/21 at 6:34 a.m.: Weekly Skin Assessment. With 4 x 3 cm open area on left heel, with black eschar, macerated with foul-smelling. [MEDICATION NAME] applied . - 02/24/21 at 4:53 a.m.: Wound dressing done to open are (sic) to left heel as ordered. Area noted with black eschar, dry and non-foul smelling. Complained tolerable pain during dressing change. - 02/25/21 at 4:47 a.m.: . An open ulcer remains (approx. 5 cm width x 5 cm length) on the L (left) -heel. Perimeter of wound is macerated w/dk (white/dark) pink tissue. Interior of wound has combination of white/dk. brown flesh. No odor detected. - 02/28/21 at 7:19 a.m.: (Recorded as Late Entry on 03/01/21 2:22 PM) . Left heel wound appears macerated, moist, with black eschar, whitish and red tissues noted on the wound bed, non-foul smelling . - 03/01/21 at 7:47 a.m.: Weekly Skin Assessment . Continuous (sic) to have 4 x 3 cm open area on left heel, with black eschar, dry and no discharges (sic) and non-odorous . The facility failed to provide consistent monitoring of Resident #42 and Resident 47's wounds, including staging and measuring of the area which limited the facility's ability to identify the type of wound, treatment effectiveness, and if the wound was healing or worsening for physician follow-up and orders for proper treatment.

Based on observation and interview, the facility failed to ensure residents had a safe environment free from hazards and prevent accidents for 3 of 3 dryers during a tour of the laundry room. Failure to monitor and clean the buildup of lint in the dryers may create a hazard which poses a potential risk to the residents. During a tour of the laundry room on 03/04/21 at 9:11 a.m., observation showed three large dryers with lint collected on the lint screens. Each lint screen showed approximately two inches or more of lint buildup on the screens with the lint sagging and hanging down into the collection area. During an interview on 03/04/21 at 9:11 a.m., when asked questions regarding policy and cleaning schedule, an administrative staff (#11) stated he is not aware of a policy, daily or weekly log documentation of cleaning of the lint screens and assumed staff cleaned on a regular basis. During an interview on 03/04/21 at 9:15 a.m. two administrative staff members (#11 and #12) agreed of a need to have a policy addressing the cleaning and maintenance of the dryer lint screens.

Based on observation, record review, and staff interview, the facility failed to provide respiratory care consistent with physician's orders for 1 of 4 sampled residents (Resident #47) with oxygen orders. Failure to provide oxygen as ordered has the potential for residents to experience complications related to inadequate/excessive oxygen saturation levels. Findings include: Review of Resident #47's medical record occurred on all days of survey. A physician's order, dated 07/06/20, stated Oxygen at 2LPM (liter(s) per minute) at night. Observations of Resident #47 on 03/01/21 at 9:30 a.m. and 2:22 p.m., 03/02/21 at 7:50 a.m. and 2:04 p.m., 03/03/21 at 9:51 a.m., and 03/04/21 at 7:43 a.m. showed the resident wore a nasal cannula attached to an oxygen concentrator set at 2 LPM. These observations showed facility staff failed to follow the physician order. During an interview on 03/01/21 at 2:22 p.m., a certified nurse aide (#2) stated Resident #47 received comfort cares and wore oxygen all the time. During an interview on 03/03/21 at 3:45 p.m., an administrative nurse (#1) stated staff failed to clarify physician orders for the current oxygen use. The facility failed to follow the physician orders for Resident #47.

Based on observation and resident/staff interviews, the facility failed to treat residents with dignity/respect during 4 of 4 meals observed (noon/evening meals on 04/29/19 and morning/noon meals on 04/30/19). Failure to speak to/feed residents in a dignified manner and/or serve all residents at the same table at once does not enhance residents' dignity or quality of life. Findings include: The facility failed to provide a copy of their policy addressing treating residents in a dignified manner as requested by the survey team. Observation of the noon meal on 04/29/19 showed the following: * At 11:39 a.m. - Table #1 consisted of five residents sitting at the table, with only one of the five residents receiving their meal. The last resident was served his/her meal at 11:47 a.m., eight minutes later. * At 11:41 a.m. - Table #2 consisted of four residents sitting at the table, with only one of the four residents receiving their meal. The last resident was served his/her meal at 12:03 p.m., 22 minutes later. * At 11:45 a.m. - Table #3 consisted of one resident who received her meal. At 11:52 a.m. another resident joined the table and received his/her meal at 12:06 p.m., 14 minutes later. * At 11:48 p.m. - Table #4 consisted of three residents sitting at the table, with only two of the residents receiving their meals. The last resident received his/her tray at 11:59 p.m., eleven minutes later. * Throughout the observation, staff randomly delivered trays to residents seated at different tables. * Throughout the noon meal three unidentified certified nursing assistants (CNAs) spoke to staff members seated at other tables versus the residents they were feeding. * An unidentified CNA reclined Resident #31's Broda chair (reclining wheelchair) to an approximate 120 degree angle. The unidentified CNA then pushed Resident 31's head back with one hand and attempted to feed her with the other hand even though her mouth was closed. The CNA scrapped saliva/food off the resident's lower lip. Observation of the evening meal on 04/29/19 showed the following: * At 5:10 p.m. - Table #1 consisted of four residents sitting at the table, with only three of the residents receiving their meals. The last resident was served his/her meal at 5:20 p.m., ten minutes later. * Throughout the observation, staff randomly delivered trays to residents seated at different tables. * Throughout the evening meal two unidentified CNAs spoke to staff members seated at other tables versus the residents they were feeding. Observation during the morning meal on 04/30/19 showed the following: * A CNA (#3) provided feeding assistance to Resident #3. The CNA (#3) looked on as Resident #3 chewed the end of a strip of bacon for over a minute, with the remainder of strip hanging from his lips. The CNA (#3) then attempted to remove the bacon strip with a fork, dropping it onto Resident #3's clothing protector. The CNA (#3) scraped food from Resident #33's clothing protector, broke the bacon strip into pieces, mixed it with the food on his plate, and re-fed it to him. * A CNA (#12) provided feeding assistance to Resident #33. The CNA (#12) scraped food off of Resident #33's clothing protector, mixed the food scraped from his clothing protector with the food on his plate, and re-fed the food to him. Observation of the noon meal on 04/30/19 showed the following: * A CNA (#3) provided feeding assistance to Resident #3. The CNA (#3) scraped food off of Resident #3's clothing protector, mixed the food scraped from his clothing protector with the food on his plate, and re-fed the food to him. * A CNA (#12) provided feeding assistance to Resident #33. The CNA (#12) scraped food off of Resident #33's clothing protector, mixed the food scraped from his clothing protector with the food on his plate, and re-fed the food to him. During an interview on 05/02/19 at 10:45 a.m., two administrative nurses (#1 and #2) confirmed staff should use a napkin to remove food from the residents' faces and/or clothing protectors and should not mix the dropped food with the remaining food on their plates and/or re-feed the food to them.

Based on observation, record review, and staff interview, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 5 of 20 sampled residents (Resident #23, #28, #31, #34, and #43) requiring staff assistance for transfers/transport. Failure to ensure the appropriate level of assistance (Resident #31) and/or proper use of assistive devices (Resident #23, #28, #34, and #43) placed the residents at risk of accidents with/without injury. Findings include: The facility failed to provide copies of their policies addressing the appropriate level of assistance and/or proper use of assistive devices during transfers/transport as requested by the survey team. - Review of Resident #28's medical record occurred on all days of survey. The current care plan/card identified, . All staff will monitor for proper use of my adaptive devices . Wheelchair use due to weakened state. Observation on 04/29/19 at 11:22 a.m., showed an Activity staff member (#9) transported Resident #28 in her wheelchair down the hall towards her unit. A few minutes later a second Activity staff member (#10) transported Resident #28 from her unit to the Activity room. One or both of Resident #28's shoes slid along the surface of the floor, making an audible noise whenever they made contact with the floor. Resident #28 did not lift her feet. The Activity staff members (#9 and #10) failed to place foot pedals on Resident #28's wheelchair and/or cue the resident to lift her feet. - Review of Resident #23's medical record occurred on all days of survey. The current care plan/card identified, . All staff will monitor for proper use of my adaptive devices . Wheelchair use due to weakened state. Observation on 04/29/19 at 11:41 a.m., showed a certified nursing assistance (CNA) (#4) transported Resident #23 from the resident lounge to the dining room. One or both of Resident #23's shoes slid along the surface of the floor, making an audible noise whenever they made contact with the floor. Resident #23 did not lift her feet. The CNA (#4) failed to place foot pedals on Resident #23's wheelchair and/or cue the resident to lift her feet. During an interview on 05/02/19 at 10:45 a.m., two administrative nurses (#1 and #2) stated they would expect staff to cue (Resident #23 and #28) as each resident is able to lift her feet. - Review of Resident #31's medical record occurred on all days of survey. The current care plan/card identified, . Toilet use: E2 (assist of 2) . I require to be checked and changed due to my incontinence . Observation on 04/29/19 at 3:35 p.m. showed a CNA (#3) completed Resident #31's check and change cares without the assistance of another CNA. - Review of Resident #34's medical record occurred on all days of survey. The current care plan/card identified, . Transfer: E1 (assist of 1) stand up lift . Observation on 04/29/19 at 5:00 p.m. showed a CNA (#3) utilized a mechanical sit-to-stand lift to transfer Resident #34 from his bed to the wheelchair. The CNA (#3) applied the sling under the axilla (underarms) area. The CNA (#3) failed to place leg straps and tighten the belt after starting to lift the resident. - Review of Resident #43's medical record occurred on all days of survey. The current care plan/card identified, . Transfer: E1 stand up lift . Observation on 04/29/19 at approximately 5:20 p.m. showed a CNA (#3) utilized a mechanical sit-to-stand lift to transfer Resident #43 from his bed to the wheelchair. The CNA (#3) applied the sling under the axilla (underarms) area. The CNA (#3) failed to place leg straps and tighten the belt after starting to lift the resident. During an interview on 05/02/19 at 10:00 a.m., an administrative nurse (#1) stated she would expect staff to use the stand lift per manual.

Based on record review, review of facility policy, and staff interviews, the facility failed to develop a comprehensive care plan for 3 of 20 sampled residents (Resident #5, #12, and #36). Care planning drives the type of care/services a resident receives and failure to develop a care plan that includes the care/services to be provided to the resident may negatively impact their quality of life. Finding include: Review of the facility policy titled Careplan occurred on 05/02/19. This policy, revised 10/2018, stated, . Plan must identify problems/needs, list goals . approaches and evaluation . care plans are to be updated as problems/needs change or new problems/needs arise . care plan will be updated and/or reviewed with any quarterly, annual or significant change MDS, or more frequently if needed . - Review of Resident #5's medical record occurred on all days of survey. The record identified a [DIAGNOSES REDACTED]. The care plan failed to reflect Resident #5's need for physician prescribed medications and/or the signs/symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. During an interview on 05/01/19 at 1:37 p.m., an administrative nurse (#2) confirmed Resident #5's current care plan fails to address her [DIAGNOSES REDACTED]. - Review of Resident #12's medical record occurred on all days of survey. The record identified a [DIAGNOSES REDACTED]. The care plan failed to identify signs/symptoms of an adverse reaction (such as bruising) secondary to anti-coagulant/anti-platelet drug use. The record also identified a [DIAGNOSES REDACTED]. The care plan failed to reflect Resident #12's need for physician prescribed medications and/or the signs/symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. - Review of Resident #36's medical record occurred on all days of survey. The record identified a history of venous [MEDICAL CONDITION]/embolism and a prescribed medication to reduce the risk of forming blood clots. The care plan failed to identify signs/symptoms of an adverse reaction (such as bruising) secondary to anti-coagulant/anti-platelet drug use. During an interview on 05/01/19 at 1:37 p.m., an administrative nurse (#2) confirmed Resident #36's current care plan fails to address her history of venous [MEDICAL CONDITION]/embolism and need for prescribed medications.

Based on observation, record review, review of professional literature, and staff interview, the facility failed to ensure safe positioning during meals for 1 of 6 sampled residents (Resident #13) observed being fed in the dining room. Failure to ensure proper positioning prior to giving food and liquids placed Resident #13 at risk of aspiration and choking. Findings include: Nancy B. Swigert, The Source for Dysphagia: Third Edition, LinguiSystems, Inc (2007), pages 9 and the educational handouts, identified, . Signs and symptoms of dysphagia . coughing . During the oral intake of . liquids, it is optimal for a patient to be seated at a 90 degree angle, whether in a bed or in a chair. Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue . Review of Resident #13's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. I am currently being monitored by OT (occupational therapy) for swallowing due to having occasionally (sic) coughing episodes during feeding. Review of Resident #13's swallowing evaluation completed on 02/28/19, stated, . position as close to 90 degree during meals. Requires 100% assistance with meals including setup and feeding. dysphagia. Observations showed the following: * On 04/29/19 at 12:02 p.m., an unidentified certified nursing assistant (CNA) assisted Resident #13 with the noon meal while the resident sat in a broda chair, (multi positional wheelchair) reclined to a 120 degrees. * On 04/29/19 5:12 p.m., an unidentified CNA assisted Resident #13 with a drink of water at the supper meal while the resident sat in a broda chair reclined to a 130 degrees. * On 04/29/19 at 5:20 p.m., an unidentified CNA reclined Resident #13's broda chair to 115 degrees and started assisting the resident with supper meal. * On 05/01/19 at 11:53 a.m., an unidentified CNA assisted Resident #13 with the noon meal while the resident sat in the broda chair, reclined to 130 degrees. The CNAs failed to position Resident #13 as close to 90 degrees as possible prior to offering foods or liquids. During an interview on 05/02/19 at 9:55 a.m., an administrative nurse (#1) agreed staff should position residents as close to 90 degrees as possible prior to being offered food or liquids.

Based on observation, record review, review of facility policy and procedure, and resident, staff, and group interview, the facility failed for 4 of 7 sampled residents (Resident #2, #4, #8, and #11) identified with behaviors, including wandering, and one unidentified resident with an incident negatively affecting a cognitively impaired resident (Resident #9) to: 1. Implement the facility's own policy to identify residents and/or situations with potential for the occurrence of injury, prevent resident to resident injury, and protect residents from recurring resident to resident injury. 2. Adequately assess resident behaviors, including monitoring for patterns/trends, causative factors, including time, place, persons involved, happening prior to and at time of behavior, etc, and implement appropriate interventions to prevent behaviors from escalating. 3. Monitor the effectiveness of interventions and revise interventions as appropriate. 4. Implement an interdisciplinary approach to address behaviors which have the potential to result in resident to resident altercation. Failure to adequately assess and monitor residents' behaviors and implement effective interventions to prevent further abusive behaviors resulted in other residents being abused, intimidated, hollered at, harassed, and slapped. Findings include: Review of the facility policy/procedure titled "ABUSE AND NEGLECT PROHIBITION POLICY" occurred on 02/24/11. This policy, revised January 2002, stated, "Hill Top Homes's top priority is to provide a safe, clean comfortable and home like environment . . . Residents must not be subjected to abuse by anyone, including . . . other residents . . . Abuse shall be defined as follows: . . . 'Verbal Abuse' is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again . . . 'Physical Abuse' - includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment . . . ABUSE INVESTIGATION . . . 1. Allegations of mistreatment, neglect, abuse, misappropriation of resident property and injuries of an unknown source will be thoroughly investigated and documented using established procedures. The facility will take necessary steps to prevent further potential abuse while the investigation is in progress. 2. All alleged violations will be investigated thoroughly by a committee including the Administrator, Social Service designee, Director of Nursing, Department Supervisor and other deemed necessary by the Administrator . . . 6. The Administrator, Social Service Designee, Director of Nursing, and Department Supervisor and others as deemed necessary will meet to determine what action is needed to ensure the safety of the residents while the investigation is conducted . . . b. Examples of action for residents could include, but are not limited to, identification of residents whose personal histories render them at risk for abusing other residents, an assessment of appropriate intervention strategies to prevent occurrences, monitoring the resident for any changes that would trigger abuse behavior and reassessment of the strategies on a regular basis through care planning; making a room change; transfer for short term psychiatric assessment or for appropriate permanent alternate placement, or use of chemical or physical restraints as directed by physician order . . . 18. QA (Quality Assurance) monitoring is on-going. . . ." - During a resident interview on 02/23/11 at 8:20 a.m., Resident #3 (identified as interviewable) stated on a daily basis Resident #2 wanders into his room and lies on his roommate's bed. Resident #3 stated "it scares me" when Resident #2 comes into his room because he has witnessed her hitting the staff who retrieve her from his room and he doesn't want her to hit him. He stated she yells at him or says "shut up" when he tries to tell her it isn't her room. - The group interview occurred on 02/23/11 at 1:00 p.m., with six residents in attendance. The residents identified Resident #1, Resident #2, Resident #4, Resident #8, and Resident #11 wandered into residents' rooms and around the facility at all hours of the day. Resident C stated Resident #2 "is a problem" and often wanders into her room and lies in the empty bed. Resident A stated Resident #2 frequently comes into her room both during the day and in the middle of the night and sits in her chair. Resident A explained even though Resident #2 has never hurt her, she is scared of her as she witnessed the resident being abusive to staff and other residents. Resident B identified Resident #2 once wandered into his room and hit him in the chest, causing him soreness for a few days. Resident D stated Resident #2 occasionally comes in his room during the night, sits in his recliner, and will hold her fist up and scream. Resident D indicated if Resident #2 ever hit him he would "hit her so hard he would lay her out on the floor." Resident D explained he has witnessed Resident #8 bumping into other resident's wheelchairs with her own wheelchair. - During a random resident interview on 02/23/11 at 10:05 a.m., Resident #14 stated Resident #2 pushed her in her wheelchair on approximately three separate occasions and the resident stated it scared her as Resident #2 goes too fast. - Observations of Resident #2 identified the following: * 02/22/11 at 1:45 p.m. - Resident #2 laid in Resident #8's bed. A certified nursing assistant (CNA) (#4) stated, "She always does this. She lies in everyone's bed but her own." * 02/23/11 at 8:35 a.m. - Resident #2 laid in Resident #8's bed. * 02/23/11 at 8:50 a.m. - Resident #2 laid in Resident #13's bed. * 02/23/11 at 10:00 a.m. - Resident #2 pushed Resident #14 down the hallway in her wheelchair in a fast pace. Staff intervened. The above observations verified Resident #2 wandered into other residents' rooms, laid in their beds, and pushed residents in their wheelchairs, validating residents' concerns and fears expressed during the group and individual interviews. Review of Resident #2's medical record occurred on February 22-24, 2011. [DIAGNOSES REDACTED]. Current medications for Resident #2 included: [MEDICATION NAME] (an antidepressant) 40 milligrams (mg) daily, [MEDICATION NAME] (an antipsychotic medication) 20 mg daily, [MEDICATION NAME] (used for dementia) 10 mg daily, [MEDICATION NAME] (used for dementia) 10 mg twice daily, and [MEDICATION NAME] (an antianxiety medication) as needed. Resident #2's current Minimum Data Set (MDS), dated [DATE], identified severely impaired daily decision making skills, long-term and short-term memory problems, constant inattention, and a mood interview score of 13 (which indicated moderate depression). Resident #2's MDS showed wandering daily and independent ambulation without the use of assistive devices. Review of the MDS "QUARTERLY STATUS REPORT" for Resident #2, dated 12/08/10, stated, "COGNITIVE: (Resident #2) had difficulty with long/short memory due to dementia secondary to [MEDICAL CONDITION]. (Resident #2) had adequate hearing in quiet settings with some difficulty in noisier settings. (Resident #2) is blind in the right eye . . . (Resident #2's) aggressive behaviors have decreased significantly. (Resident #2) wonders (sic) hallways and into resident's rooms and is redirected by staff. . . ." Resident #2's last comprehensive assessment was an annual MDS, dated [DATE]. This MDS identified moderately impaired daily decision making skills, long-term and short-term memory problems, persistent anger with self or others seen up to five days a week, unpleasant mood in the morning, sad/pained/worried facial expressions, and repetitive physical movements. Review of the "RAP SUMMARY" for Resident #2, dated 06/08/10, stated, ". . . Mood State: Resident will show anger towards others occasionally, including other residents and staff. She has easily been redirected when upset. She is occasionally restless, paces up and down the hallways at times, and has sad expression at times. She is restless during the day, which is when she will pace. . . . Behaviors: Resident will show irritation when staff attempts to do cares with her, and has shown anger. . . ." Review of the "QUARTERLY STATUS REPORT" for Resident #2's annual MDS, dated [DATE], stated, ". . . Social Interaction: . . . Much of her day is spent either in the Badlands Lounge watching TV or in the activities room . . . For the most part, she is pleasant when she is out amongst other residents, except for the 2 following incidents described here. On May 20th, she slapped another resident for no apparent reason. The other resident was not injured. Staff intervened at that time. Then, on May 24th, she was involved in an argument with a male resident where he wanted to sit in the same chair she is used to sitting in. At that time, she swung her foot at him and then stuck her tongue out at him. Staff intervened and diffused the situation . . . Mood State: (Resident #2's) mood has generally been good, with periodic episodes of anger and irritation, particularly during cares. She is restless some days, and will walk up and down the hallways. Eventually, she will find her seat in the Badlands Lounge, where she watches TV and those around her. She has psyche (psychiatric) involvement. . . ." Review of Resident #2's current care plan included the following mood and behavior problems: "Res shows occasional irritation, esp (especially) with cares. She also has shown anger towards other residents, esp (especially) if they try to sit in her favorite chair. Res also is restless often, pacing up and down the hallways," dated 06/08/10; "Aggressive towards other res when angry (slapping)," dated 06/28/10; and "Wandering hallways (and) into other res rooms," dated 12/08/10. The care plan listed the following approaches: acknowledge spiritual concerns; encourage expression; assess for depression; encourage independence with activities of daily living; give frequent reassurance; encourage out-of-room activity; explain all treatments and procedures carefully; observe for changes in mental status; encourage socialization with friends; observe closely around others, particularly when she is sitting in the Badlands Lounge; psychiatric involvement; medication changes; observe closely when in the hallway, especially around other residents and in resident rooms; wanderguard; redirect as needed; move resident to a different area; walk with her and visit; and hold hand out for her to follow." Review of Resident #2's "Interdisciplinary Progress Notes" from May 2010 through February 2011 showed the following: * 05/20/10 at 10:40 p.m. - "Resident (#2) was sitting in TV lounge this (after) noon. Stood up and slapped another resident. (Resident #2) was lead out of area per RN (Registered Nurse). (No) injuries to other resident." * 05/24/10 untimed - "Resident (#2) has a favorite chair she likes to sit in in the Badlands Lounge. A male resident sitting in chair and she told him to get out of the chair. He was upset but got out of chair and told her that it wasn't her chair, it belonged to this place. He shook his finger at her - she stuck her tongue out. He called her a cow (and) she swung her foot at him." * 06/11/10 at 5:00 p.m. - "Resident (#2) slapped the face of another resident in Badlands Lounge. Unknown as to why . . . Told her that's not allowed here (and) if there's trouble to call staff. She giggled. Will watch for addtl (additional) behavior this evening." * 06/28/10 at 10:00 p.m. - "(After) supper, resident (#2) walked up to another (resident) (and) slapped his face. (No) injury to him. Unknown what provoked her." * 07/04/10 at 12:25 p.m. - "Res (resident) attempted to hit another Res in hallway for no observed reason. Res upset today (and) is asking 'to go home.' Irritable with staff. If left alone calms." * 07/27/10 at 5:00 p.m. - "Res had behavior incident . . . Res got mad due to other res yelling at her to 'move, get out of here.' Res then hit other res on arm. Res was educated." * 08/05/10 at 1:00 p.m. - "Res has been wandering often today. Has been in therapy several (times). Res walked by another Res (and) brushed his shoulder as if to hit him (and) kept walking . . ." * 08/28/10 at 1:05 p.m. - "(Resident #2) went to chair in lounge were (sic) another resident was sitting, grabed (sic) onto his arm (and) pulled Res up (and) out of chair (and) other res sat (down) in his w/c. (Resident #2) then walked away as staff member came to assist. No injury noted." * 09/08/10 at 2:00 p.m. - "Resident (#2) wandering; hitting staff and other resident. Staff has attempted to educate resident regarding inappropriate behavior. Resident not expressing understanding. No injuries were received . . ." * 09/11/10 at 3:40 p.m. - "(Resident #2) went into lounge to sit in the chair that another Res was sitting in. She hit a Res X 3 (three times) upset he was sitting in the seat. Quickly got in between the two res (and) removed them from the area. The resident went to her rm (room). No injury noted to either Res." * 09/11/10 at 4:30 p.m. - "Behavior: CNA (certified nursing assistant) reported this resident approached another female resident in a w/c and started stroking her hair . . . Res in (room number) cried out and (Resident #2) struck her across the face. CNAs immediately intervened." * 09/14/10 at 4:30 p.m. - "Activity aide reported combative action. (No) injuries (and) able to redirect." * 10/06/10 at 10:45 p.m. - "Resident (#2) was pacing frequently this evening and would walk in other resident's rooms . . ." * 10/11/10 at 11:00 p.m. - "Wandering. Even went up to Unit I. Impression given that she doesn't know where her room is located." * 10/12/10 at 10:00 a.m. - ". . . Res reported to staff that res wandered into his room (and) hit him in the chest hard on the pm of 10/11/10. Res is wandering more (and) goes into other res rooms. Has angry look on her face at times . . ." * 10/13/10 untimed - ". . . She (Resident #2) wanders into other residents rooms (and) looks irritated or confrontational. OOB (out of bed) pacing all shifts." * 10/17/10 at 11:00 a.m. - "Resident (#2) became upset when staff attempted to redirect her while she was wandering. Resident continues to wander throughout facility." * Late entry for 10/15/10 6:30 a.m. to 11:30 a.m. - "Resident (#2) was in (room number) (and) entered BR (bathroom) where (resident room number) was toileting himself. Later she was in again attempting to lay down in his bed (without) him in it. Later (about) 11:30 a.m. was sitting quietly in (resident room number) rocking chair . . . Also redirected out of (social service) office." * 11/24/10 at 7:30 a.m. - "Resident (#2) wandering halls this am. Into male resident's room and laid down on his bed, resident (male) stated she has done this often." * 11/26/10 at 10:30 a.m. - "Resident (#2) ambulating, wandering throughout facility. Resident will lay in other residents beds . . ." * 01/11/11 at 2:00 p.m. - "Res (#2) wandering halls all shift. Yelled at staff once when attempting to redirect. Res went up behind a res in hall (and) kicked towards his butt, but did not connect. . . ." * 01/11/11 at 8:00 p.m. - "Resident (#2) was asked to leave (name of resident's room). She was holding her pillow (and) went up (and) started hitting RN (with) it. Resident was redirected (and) she marched right up to another resident (and) was going to punch him, RN did catch her arm (and) (no) one was hurt. . . ." * 01/15/11 at 9:20 a.m. - "Behaviors are vary (sic) irratic (sic) (and) irritable . . . 9:10 a.m. Pushed (resident room number) out of the way in hallway by DR (dining room) where feet were rammed into wall. Luckally (sic) Resident wearing shoes. No injury . . . Resident non verbal unless occasional outburst towards other (sic) of 1 to 3 loud words is shut up, what do you want. . . ." * 01/21/11 at 8:00 p.m. - "Wandering most of evening. CNA reported that when she tried to get her out of another resident's room that she slapped the staff member on the face." * 01/22/11 time unknown - ". . . Resident has pushed a male in his w/c. He usually sits between Badlands Lounge (and) Activities Room. Resident then was down on Unit I turned a resident's w/c around (and) started pushing it back towards Nurse's Station I. Resident said, 'I want to go to my room.' Brought (Resident #2) back to Unit II. She has wandered into several rooms. . . ." * 01/23/11 at 10:00 p.m. - ". . . Resident was pushing another resident in a wheelchair . . ." * Late entry for 01/25/11 at 7:05 p.m. - "(Resident #2) walked up to another resident with her hand open like she was going to hit him. Staff intervined (sic) and separated residents. . ." * 01/26/11 at 1:00 p.m. - "Resident (#2) was having increased behavior, pushing other residents in their wheelchair into a wall." * 01/29/11 at 4:30 p.m. - "Res (#2) pushed another Res in hall, other Res w/c bound, (Resident #2) pushed Res into closed door at NS (nurse's station)." * 01/29/11 at 7:50 p.m. - "Res walking in hall in Meadow Lane, another Res sitting in w/c in hallway. (Resident #2) walked past Res in w/c and attempted to strike other Res (with) her hand." * 01/13/11 (sic? 01/31/11?) at 7:10 p.m. - "Another resident told me that (Resident #2) hit her. She said (Resident #2) steals her clothes and jewelry. (No evidence that resident has done this or taking her clothes or jewelry.) Other resident said (Resident #2) came into room (and) when she told her to leave (Resident #2) took the full sling and swung it at her. She then said she hit her on the back and left the room. Instructed her to call if resident comes into room." * 02/10/11 at 3:30 p.m. - "Resident wandering during the day, in and out of other resident rooms. Staff attempted to assist resident out of other resident room and resident kicked her in wrist, no injuries were received . . ." * 02/13/11 at 2:00 p.m. - "Wandering a lot today. Was in (resident room number) bed resting this am. All over facility, in break room. Redirected easily, starts pacing elsewhere . . ." * 02/20/11 at 1:00 p.m. - ". . . Resident is wandering, going in and out of other residents rooms . . ." Review of Resident #2's "Social Service/Behavior Committee Notes" from May 2010 through February 2011 repeatedly identified the following as interventions for Resident #2's wandering and behaviors to other residents: "INTERVENTIONS: Medication (at) Dr's. (doctor's) recommendations. She has psyche (psychiatric) involvement. Staff observes her closely around other residents and their rooms . . ." During an interview on 02/23/11 at 5:15 p.m., an administrative nursing staff member (#5) stated when Resident #2 displayed wandering and aggressive behaviors, staff are instructed to gently lead her out of other residents' rooms as she doesn't understand simple directions. The staff member (#5) stated staff address her basic needs when she is wandering and being aggressive, such as: they check if she is in pain, assist her to the toilet, offer food/beverage, or take her to an activity of her liking if one is going on. Failure of the facility to monitor, track, and trend Resident #2's behaviors and thoroughly assess the causative/precipitating factors leading up to, or resulting in Resident #2's aggressive and abusive behavior, develop and implement effective interventions (proactive approach versus reactive), as well as revise them as necessary; resulted in numerous altercations and harm to other residents. Through resident and group interviews, residents expressed their fear of Resident #2 as they witnessed her abusing other residents and staff members. Record review identified Resident #2 abused other residents and observations during the standard survey identified Resident #2 frequently wandered, lay in other residents' beds (validating residents' concerns and fears expressed during the group and resident interviews), and pushed residents' wheelchairs. Staff often searched for a period of time to locate Resident #2 who ambulated independently throughout the facility. These factors all contribute to the potential for Resident #2 to seriously injure another resident and/or for another resident to cause serious harm to Resident #2. - Review of Resident #4's medical record occurred on February 22-24, 2011. [DIAGNOSES REDACTED]. Current medications for Resident #4 included: [MEDICATION NAME] (used for [MEDICAL CONDITION]/dementia), [MEDICATION NAME] (used for [MEDICAL CONDITION]/behaviors), [MEDICATION NAME] (used for dementia), and [MEDICATION NAME] (used for depression). Resident #4's quarterly MDS, dated [DATE], identified long-term and short-term memory problems and moderately impaired daily decision making skills. The quarterly MDS, dated [DATE], also identified continuous disorganized thinking, fluctuating inattention, [MEDICAL CONDITION], behavioral symptoms not directed at others, wandering, assist with transfers, and supervision needed with walking in room/corridor and locomotion on/off unit. Review of the MDS "QUARTERLY STATUS REPORT" for Resident #4, dated 01/14/11, stated, "Cognitive: . . . When walking through facility hallways, (Resident #4) will at times go into other residents rooms. He requires assist with finding his room and the bathroom much of the time. . . . He . . . needs constant reminding as he forgets quickly. (Resident #4) does have periods in which he gets anxious and upset . . . Social Interaction: . . . he will show upset or anger if he is redirected away from a doorway as he is attempting to leave. . . ." Review of Resident #4's current care plan, dated 10/25/10, stated, " . . . Mood: Resident is frequently restless, wandering or pacing the hallways . . . . Beha (Behaviors): . . . He will also occasionally wander into other resident rooms. In all instances, he is generally easily redirected - annoyed at times. . . . When in another res's (resident's) room, redirect him out to another area. Wanderguard. . . ." Review of Resident #4's "Interdisciplinary Progress Notes" from February 2010 through January 2011 showed the following: * 02/24/10 at 2:45 p.m. - "Resident wandered into another residents room, he did argue with the other resident . . ." * 03/08/10 at 10:40 p.m. - "CNA reported that another resident told her that (Resident #4) came into his room and told him he was going to sleep in his bed tonight, as he bought the place and that this first resident would be the first one out of here." * 03/20/10 at 9:30 p.m. - "Heard voice in room. Resident on roommate's side of the room telling him that he needs to leave (and) to get out of here." * 04/17/10 at 5:12 p.m. - "Resident got up from the table as to leave, but went toward (room number) to talk. Resident (room number) yells out (at) resident "Go sit down (and) eat." (Resident #4) starts yelling back (at) him (and) moving towards (room number) . Nursing escorted him back to his chair (at) the table to continue his meal while another staff member escorted (room number) to (sic) Activity Room where there was less stimulation. . . . As resident (room number) was being taken to (sic) Activity Room, he requested staff members to take him to (Resident #4) to knock his block off." * 05/01/10 at 4:40 p.m. - "Resident went into rm (room number) . He told the resident in the bed to get out of his room. Resident in (room number) said no, that wasn't his room it was his. (Resident #4) told resident that he hated him, turned, and left the room (and) told staff nurse from Unit 1 that he sure took care of that bastard." * 06/04/10 at 4:00 p.m. - "Res. moved to private room . . . Son . . . informed . . . Informed him that res. continues to go into other res's rooms, insisting that their room is his. He has not shown aggression, only verbal . . ." * 06/26/10 at 1:00 p.m. - "Staff reporting that resident wondering (sic) throughout hallways. Going into other residents' rooms. Telling the other residents to leave his room. . . ." * 07/14/10 at 7:30 p.m. - "Resident was aggressive towards another res. verbally, saying didn't like the looks of this other res. Said was going to take res. outside." * 07/17/10 at 6:58 p.m. - "CN (charge nurse) had noted resident going into Badlands Lounge, then very shortly thereafter hearing (room number) calling (Resident #4) an idiot and (Resident #4) challenging him to a fight. . . . I don't know what set him off other than possibly (room number) usually sits in that chair. (Resident #4) was medicated (with) [MEDICATION NAME] . . ." * At 9:00 p.m. - ". . . I gave him [MEDICATION NAME] until 8:00 p.m. So was quite effective in both controling threatening behavior (and) his [MEDICAL CONDITION]/wandering. . . ." * 09/11/10 at 3:50 p.m. - "Res. was sitting in Lounge in chair. Another res. came by (and) hit him x 3 (three times) and (Resident #4's) coffee spilled onto his chest. Res. removed from area. . . ." * 01/01/11 at 11:00 a.m. - "Resident in (room number) (and) was going to BR bathroom) (and) coming over to resident in that room. (Resident #4) resided in this room recently a few nights until ceiling was repaired. Verbal confrontation was loud. CN (charge nurse) removed him from other resident. Both have strong unrelenting personalities." Review of Resident #4's "Social Service/Behavior Committee Notes" from April 2010 through February 2011 repeatedly identified the following symptoms: "SYMPTOMS: . . . He continues to wander throughout facility, and will use other residents' bathrooms for toileting or laying down. He is on a toileting schedule though continues to use other residents' bathrooms and/or continues to attempt to leave facility to toilet. . . . He has also showed anger towards other residents who get too close to him, pushing them in their wheelchairs away from him. : "INTERVENTIONS: Medication (at) Dr's. recommendations. He has psyche (psychiatric) involvement. . . . Res. is given reassurance when particularly anxious. Suggested attendance at activities has been successful at times. . . ." Failure of the facility to assess the precipitating factors leading up to, or resulting in Resident #4's behaviors and/or wandering, develop and implement effective interventions, as well as revise them as necessary; resulted in numerous altercations with other residents. Record review identified Resident #4 has yelled at, threatened other residents and/or challenged them to fight, and has wandered into other residents' rooms. These factors all contribute to the potential for Resident #4 to injure another resident and/or for another resident to cause harm to him. - Review of Resident #8's medical record occurred on February 22-24, 2011. [DIAGNOSES REDACTED]. Current medications for Resident #8 included: [MEDICATION NAME] (used for [MEDICAL CONDITION]/dementia), [MEDICATION NAME] (used for [MEDICAL CONDITION]/behaviors), [MEDICATION NAME] (used for dementia), and [MEDICATION NAME] (used for depression). Resident #8's quarterly MDS, dated [DATE], identified long-term and short-term memory problems and moderately impaired daily decision making skills. The quarterly MDS, dated [DATE], also identified continuous disorganized thinking, fluctuating inattention, [MEDICAL CONDITION], behavioral symptoms not directed at others, assist with transfers and supervision needed with walking in corridor and locomotion on/off unit. Review of the "RAP SUMMARY" for Resident #8, dated 05/17/10, stated, ". . . Behaviors: . . . Resident is frequently inappropriate . . . making repeated, disruptive statements during activities or in the hallways. She is not always easily redirected. . . ." Review of the MDS "QUARTERLY STATUS REPORT" for Resident #8, dated 11/16/10, stated, "Social Interaction: . . . She continues (sic) occasionally argumentative with particular residents . . . Staff intervenes in negative situations when needed. . . . Mood: . . . She continues to show irritability at times and occasionally will become angry when redirected. . . . Activity Plan: . . . . There are times that (Resident #8) will get into it with other residents and staff and can get out of control with name calling and swearing. . . ." Review of Resident #8's current care plan, dated 05/17/10, stated, " . . . Cognition: . . . Apply and maintain wanderguard alarm bracelet. . . . Beha (Behaviors): . . . socially inapropriate, making repeated statements (and) asking repeated questions when in activities or in hallways. . . . When in hallways, use distractions. . . ." Review of Resident #8's "Interdisciplinary Progress Notes" from February 2010 through February 2011 showed the following: * 02/25/10 at 10:00 a.m. - "Staff has continuous reports of resident having several incidents of inappropriate behaviors and disruptive behaviors. . . . Resident is difficult to redirect and can be confrontaitonal when approached by staff. Resident has made inappropriate sexual comments towards other male residents and other residents' male visiting family members. . . ." * 02/28/10 at 10:00 a.m. - ". . . Also made inappropriate advance toward church layman here providing communion . . ." * 03/10/10 at 3:15 p.m. - "Resident became upset at another resident whent (sic) the other resident sat in a chair in (sic) activity room. Resident became rude, attempted to stop (sic) other resident from sitting in the chair. Staff needed to move the other resident to calm resident. . . ." * 05/11/10 at 1:00 p.m. - ". . . Resident is often rude to staff and other residents. Has been reported to be very disruptive during activities, causing other residents to become upset. Activity staff attemps (sic) to redirect resident, often results in increased behaviors from resident. . . . Resident . . . will often attempt to help other residents, and at times risk her safety and the other resident. . . ." * 10/16/10 at 10:00 a.m. - "Resident wandering through out facility in her wheelchair. She will at times ambulate by herself . . . Resident is difficult to redirect. Will go in other residents' rooms at times. . . ." * 10/17/10 at 3:30 p.m. - "CNA said that yesterday resident told another resident to give back her w/c (wheelchair). Resident was upset . . ." * 12/09/10 at 10:30 a.m. - "Resident wandering, following other residents inside their rooms. . . . Staff attemps (sic) to redirect resident, causing her to become upset. . . ." * 02/16/11 at 3:00 p.m. - ". . . Will rock back and forth (with) her feet in w/c to soothe herself, but inadvertently bump into someone from behind (and) not realize her own actions caused this and start name calling until nursing/other staff can intervene. . . ." Review of Resident #8's "Activity Attendance Record" from September 2010 through December 2010 showed the following: * September 2010 - ". . . Yelling at another resident that he's stupid. Upset when I asked her to leave. . . ." * October 2010 - ". . . Disruptive . . . When she sees people holding something or looking at something she's been acusing (sic) them of stealing it from her. . . . Bothering residents . . ." * November 2010 - "Rude, disrupting ppl (people) while talking . . . telling another resident to 'shut up' . . ." * December 2010 - ". . . arguing (with) another resident, ordering her around . . . being very rude to other residents . . . tries to squeeze thru (through) spaces (and) people in her w/c where there is no room even when resident (and) staff ask her to go around . . . backed into a resident and then yelled at them . . . She moves back and forth constantly (and) hits people very often . . ." During an interview on 02/24/11 at 8:20 a.m., an activity staff member (#3) agreed Resident #8 has displayed aggressive behaviors towards others and wandering behaviors, stating, "She does run into others, but we have never had an injury caused by her running into someone." Review of Resident #8's "Social Service/Behavior Committee Notes" from April 2010 through February 2011 repeatedly identified the following symptoms: "SYMPTOMS: . . . Resident continues to attempt to assist other residents and needs reminding not to do this. She can become angry with redirection. She also can be argumentative with other residents." Failure of the facility to asses