Every finding on record at Immanuel Campus Of Care

Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the right to be free from physical abuse for two residents (Residents #170, #171). The deficient practice could lead to additional resident-to-resident altercations, creating an unsafe environment. Findings include:-Resident #170 (alleged victim) was admitted to the facility on [DATE], with diagnoses that included Borderline Personality Disorder, Major Depressive Disorder, Hereditary idiopathic nervous system, and degenerative disease of the nervous System.The care plan focus problem initiated on January 21, 2019, revealed that resident #170 has a behavior problem related to personality disorder like staff splitting, making false accusations toward staff, being verbally abusive toward staff, and using manipulation to get what she wants.The annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a Brief interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. Review of skin assessment dated [DATE], revealed no skin breakdowns, open areas of concern.-Resident #171 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses that included Mood disorder due to known physiological condition, schizophrenia, borderline personality disorder, Suicidal Ideation and Paraplegia.The care plan focus problem initiated on March 27, 2024, revealed that the resident has a psychosocial well-being problem related to borderline personal disorder. Further review of the resident's care plan indicated that resident has been screened for traumatic history and is positive for domestic violence, elder abuse, child sexual abuse, stalking, driving under the influence, and mental health disorder.The annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the residents has a BIMS Score of 14, indicating cognitively intact. A review of the resident's medication record dated on May 27, 2024, revealed that resident was prescribed Desvenlafaxine 50mg (an antidepressant), and Ziprasidone 20mg (an antipsychotic medication), Lorazepam 1mg (anti-anxiety medication).Further review of the resident's medication record dated on April 22, 2024, indicated that resident's behavior was being monitored daily.Review of skin assessment dated [DATE], revealed no skin breakdowns, open areas of concern.The facility report dated on May 1, 2024, revealed that two residents (Resident #171 and #170) of Desert Cove in room [ROOM NUMBER] were arguing over the TV volume. Resident #171 said that resident #170 came to her bedside, which made her afraid, so she scratched resident #170 on her arm. Resident #171 said that resident #170 took her glasses and broke them. The residents were separated. Resident #170 indicated that she was trying to get resident #171's remote to turn her TV volume down. Resident #170 says that is when resident #171 scratched her right forearm area. Resident #171 said that resident #170 broke her glasses. Resident #170 denies breaking resident #171's glasses. Resident #171 was placed on one-on-one supervision until a room and unit change could happen.The behavioral note for Resident #171 dated May 01, 2024, revealed that while Licensed Practical nurse (LPN/ staff #129) was assessing roommate's arm for injury, resident #171 stated loudly, Yes, I scratched her, she was going to take my TV remote. The resident was placed on one-on-one before she was transferred to the other room.Review of Resident #170's change of condition progress note, included in the facility incident report, revealed that the resident #170 stated, My roommate scratched me, please have the nurse come take care of it. The nurse assessed the resident and resident #170 stated that, Her volume was too loud, so I went to turn it down and she scratched me. The assessment revealed three one-inch abrasions to the underside of the forearm and one approximately one-inch abrasion to the posterior forearm. On May 20, 2026 at 9:40 a.m., during a phone interview with the Certified Nursing Assistant (CNA/ Staff #115 ), she stated that she heard residents yelling at each other when passing out snacks. The CNA added that she remembered resident #170 saying that a resident scratched her. She stated that she didn't witness a physical fight, but resident #170 tends to instigate or pick at the other resident (#171), which led to an argument or fight.On May 20, 2026, at 10:02 a.m., during a phone interview with a LPN (Staff #129), she stated residents #170 and #171 were in the same room when the incident happened. She added that resident #170 came to the nursing station and reported that the resident refused to be in her room with resident #171. She added that resident #170 reported that she didn't want to go back to her room because resident #171 yelled at her. The LPN added that she remembered telling the resident to call staff if she needed anything. Staff #129 stated that she didn't witness resident #171 scratch resident #170, but resident #171 told her that she scratched resident #170 because of the TV remote. She stated that she remembers the facility interviewing her regarding the incident as part of the investigation.On May 22, 2026, at 11:38 a.m., the Administrator (Staff #48) was interviewed. After review of incident report she stated that she remembered placing the resident on one-on-one care until she was transferred to a different unit and substantiated the incident. She added that, based on current practice, if there's a resident-to-resident altercation, the alleged resident receives one-on-one care until transfer to a different room or unit. She stated that the risks could lead to further fighting if there's no intervention.Review of the policy titled, Abuse Program Policy and Procedure, revealed, that residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.

Based on observation, record review, interviews, and facility policy review the facility failed to ensure one of thirty-three sampled residents (#36) was free from physical restraint related to bed rails. The universe was one hundred and seventy-eight. The deficient practice could cause a resident to suffer physical injury from entrapment or psychosocial harm related to restraint use. Findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder, dementia, and anxiety disorder. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. The MDS also included that no form of restraints, including bed rails, and/or alarms were coded as in use. The MDS further indicated impairment on both sides for lower extremities, dependent for mobility, and is dependent for all self-care activities. The comprehensive care plan reviewed/revised on March 28, 2026 revealed no evidence that use of the bed rails or concave mattress were addressed with interventions implemented. The care plan identified that the resident had an Activities of Daily Living (ADL) self-care performance deficit and required total assistance in all areas. During an observation on May 19, 2026 at 11:39 AM, the resident was lying in bed with eyes closed and both half-length bed rails raised. A blue fall mat was noted on the floor to the side of the bed. During an observation on May 20, 2026 at 1:03 PM, the resident was lying in bed with eyes closed on a concave mattress, with both half-length bed rails raised and a blue fall mat was noted on the floor to the side of the bed. During this observation the resident had just received care from a Certified Nursing Assistant (CNA) (staff #250). Following the observation, Staff #250 was interviewed and staff #250 stated that the resident was a high fall risk, that is why there is a fall mat and bed rails are up. The current physician orders on May 21, 2026 revealed no evidence of any orders regarding use of bed rails on her bed. Further review of the physician's orders revealed an order for concave mattress to bed due to the resident's poor safety awareness, was ordered April 13, 2021. The Treatment Administration Record (TAR) on May 21, 2026 for May 2026 revealed no intervention or monitoring for use of resident's bed rails. The clinical record on May 21, 2026 revealed no evidence that the resident was assessed for the use of bed rails.The clinical record on May 21, 2026 revealed no evidence that signed consent was given by the guardian regarding use of bed rails. During an observation on May 21, 2026 at 9:31 AM, the resident was lying in bed with eyes closed on a concave mattress with half-length bed rails up on both sides of the bed and a blue fall mat was observed on the floor to the side of the bed. During an observation on May 22, 2026 at 12:02 PM, the resident was lying in bed on a concave mattress, her eyes were open and she was making eye contact but would not respond to questions. The bed was in the lowest position, a blue fall mat was to the side of the bed, and bed rails were up on both sides of the bed. During an interview on May 22, 2026 at 12:05 PM, the CNA (staff #250) stated she was unaware of any restraints or concave mattress currently in use. Staff #250 stated that the resident is a fall risk per her care plan and the bed rails prevent her from rolling off the side of the bed. Staff #250 further stated that she had previously rolled off the side of the bed and that she hadn't noticed any risks other than hurting herself by hitting a body part on the bed rails, but that the resident uses the rails mostly for mobility. In an interview on May 22, 2026 at 12:41 PM, a licensed practical nurse (LPN/staff #101) stated that the bed rails are connected to the bed, one bar on each side of the bed, and the bed rails are used for turning. The LPN stated that the bed rails have always been in place. Staff #101 also stated that she does not consider it a restraint because the resident already had the concave mattress and the mattress was for her very high fall risk. Staff #101 looked into the resident's electronic health record and saw the concave mattress order but did not see an order for the bed rails and also did not see any indication of bed rail use in the resident's care plan. Staff #101 further stated that in her point of view that the resident has a bed rail not a grab bar, a grab bar is half the size of the bed rail. In an interview on May 22, 2026 at 1:50 PM with the Director of Nursing (DON/staff #12), the DON stated the facility process for bed rails is to get a physician order for the bed rail and enter it into the care plan prior to implementation. The DON additionally stated that concave mattresses are used for significant risk for falling out of the bed and the facility process is to get an physician order and enter it into the care plan prior to implementation. The DON reviewed the resident's electronic health record and stated there was an order for a concave mattress. The DON stated he did not see an order for the bed rails. He further stated he found no indication of bed rail use or concave mattress use in the resident's care plan. The DON stated that bed rails in use with a concave mattress would be considered a restraint. He stated that the risk would be psychological harm and/or getting stuck in between the concave mattress and the bed rail. Review of facility policy on Bed Safety and Bed Rails revealed that bed rails were defined as adjustable metal or rigid plastic bars that attach to the bed and the term bed rails includes side rails, safety rails, and grab/assist bars. The facility policy defined physical restraints as any manual method, device, or equipment that is attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement. The facility's policy further stated that the use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Review of facility policy on Physical Restraint Application revealed that preparation for application of physical restraints includes verification of physician's order for the use of restraints, review of the resident's care plan to assess for any special needs of the resident, and assemble equipment and supplies needed.

Based on observations, record review, interviews, and facility policy review the facility failed to ensure a comprehensive care plan with interventions was developed, revised, and implemented related to safety and prevention for two of thirty-three sampled residents (#36 and #30) regarding use of bed rails, concave mattress and use of nicotine. The universe was one hundred and seventy-eight. The deficient practice could result in the resident's needs not being met. Findings include:Regarding resident #36-Resident #36 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder, dementia, and anxiety disorder. Review of the Morse Fall Scale dated November 11, 2025, completed post fall, revealed the resident was assessed as a high risk for falling with a score of 60.0. Further review of the assessment revealed the resident had a history of falls.The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. The MDS also included that no form of restraints, including bed rails, and/or alarms were coded as in use. The MDS further indicated impairment on both sides for lower extremities, dependent for mobility, and is dependent for all self-care activities. A review of the comprehensive care plan last reviewed/revised on March 28, 2026 revealed no evidence that use of the bed rails on her bed, concave mattress on her bed, and being a fall risk were addressed with interventions implemented. The care plan further revealed that the resident has an ADL self-care performance deficit and requires total assist in all areas. The care plan mentioned falls as side effects to anti-anxiety medication and antipsychotic medication. During an observation on May 19, 2026 at 11:39 AM, the resident was lying in bed with eyes closed and both half-length bed rails raised. A blue fall mat was noted on the floor to the side of the bed. During an observation on May 20, 2026 at 1:03 PM, the resident was lying in bed with eyes closed on a concave mattress, with both half-length bed rails raised and a blue fall mat was noted on the floor to the side of the bed. During this observation the resident had just received care from a Certified Nursing Assistant (CNA) (staff #250). Following the observation, an interview was conducted with Staff #250 who stated that the resident was a high fall risk, that is why there is a fall mat and bed rails are up. The current physician orders on May 21, 2026 revealed no evidence of orders regarding use of bed rails on her bed or use of fall mat. Further review of the current physician's orders revealed an order for concave mattress to bed due to the resident's poor safety awareness that was ordered April 13, 2021. The Treatment Administration Record (TAR) on May 21, 2026 for May 2026 revealed no intervention or monitoring for use of resident's bed rails or for falls. The clinical record on May 21, 2026 there was no evidence that the resident was assessed or informed consent was given by the guardian for the use of bed rails.During an observation on May 21, 2026 at 9:31 AM, the resident was lying in bed with eyes closed on a concave mattress with half-length bed rails up on both sides of the bed and a blue fall mat was observed on the floor to the side of the bed. During an observation on May 22, 2026 at 12:02 PM, the resident was lying in bed on a concave mattress, her eyes were open and she was making eye contact but would not respond to questions. The bed was in the lowest position, a blue fall mat was to the side of the bed, and bed rails were up on both sides of the bed. During an interview on May 22, 2026 at 12:05 PM, the CNA (staff #250) stated she was unaware of any restraints or concave mattress currently in use. Staff #250 stated that the resident is a fall risk per her care plan and the bed rails prevent her from rolling off the side of the bed. Staff #250 further stated that she had previously rolled off the side of the bed and that she hadn't noticed any risks other than hurting herself by hitting a body part on the bed rails, but that the resident uses the rails mostly for mobility. In an interview on May 22, 2026 at 12:41 PM, a licensed practical nurse (LPN/staff #101) stated that the bed rails are connected to the bed, one bar on each side of the bed, and the bed rails are used for turning. The LPN stated that the bed rails have always been in place. Staff #101 also stated that she does not consider it a restraint because the resident already had the concave mattress and the mattress was for her very high fall risk. Staff #101 looked into the resident's electronic health record and saw the concave mattress order but did not see an order for the bed rails and also did not see any indication of bed rail use in the resident's care plan. Staff #101 further stated that in her point of view that the resident has a bed rail not a grab bar, a grab bar is half the size of the bed rail. In an interview on May 22, 2026 at 1:50 PM with the Director of Nursing (DON/staff #12), the DON stated the facility process for bed rails is to get a physician order for the bed rail and enter it into the care plan prior to implementation. The DON additionally stated that concave mattresses are used for significant risk for falling out of the bed and the facility process is to get an physician order and enter it into the care plan prior to implementation. The DON reviewed the resident's electronic health record and stated there was an order for a concave mattress. The DON stated he did not see an order for the bed rails. He further stated he found no indication of bed rail use or concave mattress use in the resident's care plan. The DON stated that bed rails in use with a concave mattress would be considered a restraint. He stated that the risk would be psychological harm and/or getting stuck in between the concave mattress and the bed rail. Regarding resident #30-Resident #30 was admitted to the facility on [DATE] with diagnoses including quadriplegia, injury at C3 level of cervical spinal cord, and nicotine dependence. The progress notes from October 23, 2025 revealed that the resident does have quadriplegia, no edema noted, and can use his arms and hands. The Safe Smoking Assessment Form dated April 15, 2026 revealed the resident smokes vapes, resident is an independent smoker, supervision would be required during designated smoking times, and the evaluation would be utilized to the residents smoking care plan on admission and as indicated. Further review revealed that the question regarding a smoking care plan being in place was indicated as yes. The Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognitive function. The comprehensive care plan last reviewed/revised May 12, 2026 revealed no evidence of nicotine dependence or safe smoking interventions. Further review revealed smoking as an activity he enjoys. During an observation on May 19, 2026 at 9:59 AM and 11:20 AM a container of 6mg peppermint nicotine pouches was observed on the table next to the resident's bed. During an interview conducted on May 19, 2026 at 11:25 AM with a licensed practical nurse (LPN/staff #241), staff #241 confiscated the container of nicotine pouches from the resident and counted nine nicotine pouches in the container. Staff #241 stated that nicotine pouches are part of the medication orders and they are kept in the medication cart for the nurse to dispense the pouches to the resident. Staff #241 looked at the residents orders in the electronic health record and stated that there were no orders for nicotine pouches. Staff #241 also stated the risks of having the nicotine pouches without an order would be the resident possibly overdosing. Staff #241 further stated she would let her supervisor know so they could request a physician's order.During an interview conducted on May 21, 2026 at 11:20 AM, smoking aid (staff #281) stated that resident #30 had quit smoking cigarettes about a year ago and had started vaping. Staff #281 also stated that resident #30 had a vape and had given it to another resident (resident #64) to use when it was confiscated but he had not seen resident #30 lately and was unsure about the nicotine pouches being used. Staff #281 further stated that all smoking articles go into the old locked medication cart on the smoking patio for the smoking aid to sign out to the residents to use, but certain residents have pass to leave the facility and there is a smoke shop down the street they can go to whenever the residents want to obtain nicotine products. During an interview conducted on May 22, 2026 at 1:02 PM, the Certified Nursing Assistant (CNA) (staff #131) stated that nicotine products should not be in the residents rooms, if the residents are seen with nicotine products in their rooms, she would report it to the nurse and the nurse would talk with the resident. Staff #131 also stated that resident #30 had been previously seen vaping in his shared room and that it is very dangerous because if they start coughing they could choke or other people could be exposed to second-hand smoke. Staff #131 further stated that she was not sure what the smoking policy is. During an interview conducted on May 22, 2026 at 1:50 PM, the director of nursing (DON/staff #12) stated that smoking must be supervised by activities and the risk of residents having vapes and nicotine pouches would be that the facility staff could not monitor the use of those items. The DON also stated that the residents do not need a physician's order for vapes and nicotine pouches and they did not need to include smoking in the care plan. The DON further stated that the facility must do a smoking assessment and did see a smoking assessment for resident #30 completed April 5th, 2026.A review of the current physician orders on May 22, 2026 revealed no evidence of any orders regarding use of nicotine products. Review of the facility's policy on Smoking Guidelines, that includes vaping devices and nicotine pouches under the definition of smoking, revealed that any resident with smoking-related privileges, restrictions, or safety concerns, including the need for close monitoring, shall have these issues documented in the resident's care plan, and staff shall be made aware of these concerns.

Number of residents sampled: 3Number of residents cited: 1The facility failed to protect resident right to make informed decisions and choices for one resident.Based on review of clinical and administrative records, resident and staff interviews, and review of facility policy, the facility failed to protect one out of three resident's right (#20) to make informed decisions and choices. The deficient practice could lead to a vulnerable resident not understanding their legal rights.Findings include:Resident #20 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, schizoaffective disorder, major depressive disorder, recurrent, anxiety disorder, heart failure, chronic obstructive pulmonary disease, unspecifiedThe annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a Brief interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment.The care plan problem focus date initiated on July 01, 2024, revealed that resident has used an anti-anxiety medication related to anxiety disorder. Initial interventions initiated on July 01, 2024 included observation for side effects such as increased risk of confusion, amnesia, and cognitive impairment that looks like dementia.Additional review of the resident care plan problem focus date initiated on April 19, 2024, revealed that the resident has a chronic Hemiplegia and neuropathy pain related to neuropathy and hemiparesis. Initial interventions initiated on April 29, 2024, and revised on January 15, 2026, revealed to be observed for side effects are increased agitation, restlessness, confusion, and hallucination, dysphoria.Review of the resident signed arbitration agreement dated on April 24, 2024, revealed that the document was signed by the resident. During further review of the resident arbitration agreement, there were no resident representative signatures.Review of the resident admission packet that was signed on April 24, 2024, and arbitration agreement is included in the resident's admission packet and signed the same day. Additional review of the resident's most recent annual Minimum Data Set (MDS), the MDS dated [DATE], revealed that the resident has a Brief interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment.An interview with the resident on May 21 at 8:48 a.m. found that she didn't know what arbitration is and didn't remember signing an arbitration agreement. When asked during the interview, she didn't know her current location, date, or time. During the interview, the resident appeared confused.On May 21, 2026, at 3:00 p.m., an interview with the Director of admission (staff #286) found that an arbitration agreement is a contract stating that future disputes-such as claims of neglect, abuse, or injury-will be resolved through private, binding arbitration rather than through the traditional court system. The staff added that the facility must present the contract in plain, accessible language and clearly explain what it means to the resident or their legal representative. The staff added that the arbitration agreement is included in the resident's admission Agreement Packet. The staff added that during admission, she makes sure to go through all the documents in the resident's admission packet with the resident and their family. She added that with an arbitration agreement, she makes sure the resident or their representative understands what arbitration is before they sign it. The staff added that a resident with a low Brief Interview for Mental Status (BIMS) must have a legal representative present who understands arbitration before signing the document. The admission staff reviewed resident #20's signed arbitration agreement and her annual Minimum Data Set (MDS). Staff #286 stated that, based on the resident's Brief Interview for Mental Status (BIMS) dated April 24, 2024, the resident should have a legal representative present.An interview with the administrator (staff #48) was conducted on May 22, 2026, at 11:38 a.m. During the interview, the administrator reviewed the resident #20 arbitration agreement in the resident's admission packet and stated that the resident signed the arbitration agreement. The administrator stated she didn't see a signature from the resident's legal representative on the arbitration agreement. The administrator stated that, with the resident's low BIMS score, the resident is required to have a legal representative with her who can understand arbitration before signing the agreement.Review of the policy titled, Binding Arbitration Agreements, revealed that the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. And the resident or his or her representative acknowledges that he or she understands the agreement because the risks can be denial of a vulnerable resident's legal rights without their true consent.

Based on clinical record review, staff and resident interviews, and facility policy, the facility failed to protect the rights of one Resident (#6) out of the five sampled residents to be free from abuse by another resident (#10). The deficient practice could result in other residents being abused.The facility census was 168. Finding include--Regarding Resident #6 (Alleged Victim)Resident #6 was admitted to the facility on [DATE], with diagnoses that included anoxic brain damage, mood disorder, depression, post-traumatic stress disorder (PTSD), and speech disturbance.A care plan initiated on May 20, 2025, revealed that the Resident #6 had been screened for traumatic history and is positive for adult sexual abuse, child physical abuse, domestic violence, and other vehicular victimization. The intervention included Resident #6 will be encouraged to socialize with other residents that have a similar history as opportunity allows and staff members would seek to avoid re-traumatization by minimizing resident triggers.A quarterly MDS (minimum data set) dated February 11, 2026, revealed that the resident had a BIMS (brief interview for mental status) score of 9, which indicated moderately cognitive impaired.A nursing note dated March 14, 2026, revealed that the Licensed Practical Nurse (LPN, staff #253) observed Resident #6 on the floor and crying. Per document, Resident #6 was non-verbal but admitted being pushed to the floor by another Resident #10. Per note, Resident #6 was assessed and no injury was noted but Resident #6 had pain on the head due to hitting head and knee.A weekly skin assessment dated [DATE], revealed that the Resident #6 had no breakdowns, open areas or areas of concerns.An interview was conducted on March 20, 2026, at 11:58 a.m., with Resident #6 and she responded to the answer by giving a thumbs-up sign. Resident #6 then stated that she recalled the incident between her and Resident #10 and the incident happened in the activity room. Resident #6 then stated that Resident #10 hurt her, and she got injured on her left head and it made her feel scared at the time of the incident.-Regarding Resident #10 (Alleged Perpetrator)Resident #10 was admitted to the facility on [DATE], with diagnoses that included anoxic brain damage, bipolar disorder, anxiety, seizures, and cognitive communication deficit.A care plan initiated on February 7, 2025, revealed that Resident #10 had been screened for traumatic history and is positive for substance abuse, and diagnosed with mental health disorder. The interventions included Resident #10 would be monitored for increased signs and symptoms of depression and reporting to the psychological provider as needed.A quarterly MDS (minimum data set) dated February 3, 2026, revealed that the resident was a BIMS (brief interview for mental status) score of 15, which indicated intact cognition.A nursing note dated March 14, 2026, revealed that the Licensed Practical Nurse (LPN, staff #176) was on the unit when yelling and commotion were heard coming from the activities area. Per note, the LPN observed a female resident seated on the floor and Resident #10 in his wheelchair yelling that she had been talking to another man. Resident #10 was re-directed back to his room and encouraged to remain calm. Per note, Resident #10 was advised that aggressive behavior toward others was not permitted, even when feeling upset. The psychiatric provider was notified, and Resident #10 was transferred to hospital for further evaluation of increased physical aggression.An interview was conducted on March 20, 2026, at 10:12 a.m. with an LPN (Staff #253). The LPN stated that there are different types of abuse, including physical, verbal, and emotional. Per Staff #253, the facility process for a resident-to-resident altercation would be to separate both residents, notify the abuse coordinator immediately, and assess both residents for injuries. The LPN stated that she recalled the incident between Resident #6 and Resident #10. LPN then stated that on March 14, 2026, around 2 or 3 p.m., two staff members Activity and CNA (certified nursing assistance) came to her unit and stated that Resident #10 pushed Resident #6 and she was on the floor in the activity room. The LPN went to activity room and found Resident #6 on the floor and crying. The LPN stated that Resident #6 was non-verbal and can respond only by typing on her phone. Staff #253 stated another resident, Resident #4 witnessed the incident and informed her that Resident #6, #10, and #4 were playing karaoke in the activity room. Resident #6 was observed on her phone and Resident #10 thought Resident #6 was chatting with someone. Resident #10 then tried to grab Resident #6's phone and she refused to give her phone to him. Resident #10 then got angry, screamed, and grabbed Resident #6 from her neck area and both residents fell. Resident #10 stood up after fall but Resident #6 couldn't do so and started crying. Resident #10 was redirected to his room and Resident #6 was assessed for any injuries. The LPN further stated that she will consider the incident as resident to resident physical abuse Because Resident #10 was the one who put his hand on Resident #6.An interview was conducted on March 20, 2026, at 11:05 a.m. with a Life Enrichment Associate (Staff #215). Per Staff #215, physical abuse could be either hitting someone or unwanted touch. Staff #215 stated that she recalls the incident between Resident #6 and #10 and it happened on Saturday March 14, 2026, around 3 p.m. The 3 residents #6, #10, and #4 were in the activities room when Resident #10 saw Resident #6 was watching a video on her phone and got upset. Resident #10 then started yelling and using F and B' words at Resident #6, then dragged her down to the floor. The Resident #10 also stated to Staff #215 that resident #6 hit the left side of her head on the table before falling on the floor. Staff #215 further stated that she would consider this as a physical and emotional assault then an abuse because abuse is ongoing and assault is a one-time thing.An interview was conducted on March 20, 2026, at 11:36 a.m., with Resident #4. She stated that she knew Resident #6 and she is her best friend. Resident #4 then stated that she knew Resident #6 and #10 were dating at one point. Resident #4 further stated that the incident between Resident #6 and #10 happened last week on Saturday, March 14, 2026, in the activity room. The three residents were playing karaoke in the activity room. Resident #6 was observed watching a video on her phone and Resident #10 leaned his head on Resident #6 to look over her phone and then tried to grab her phone and Resident #6 stated No. Resident #10 then started yelling F and B words to Resident #6 and then stood up, leaning on her, using both of his arms to scoop her neck into his armpit and force her up from the wheelchair. Resident #6's head landed on the table first and then both Resident #6 and #10 landed on the floor. Resident #10 then started yelling, I hate you, f b, I will kill you, you cheated on me. Resident #6 then started crying and appeared scared and told Resident #4 not to leave her alone. Resident #6 then called the police. Resident #4 further stated that she considers this as a physical and verbal abuse.An interview was conducted on March 20, 2026, at 12:06 p.m., with Resident #10 who stated that he thinks the incident happened either on March 13 or 14, 2026. Resident #10 further stated that he was trying to take Resident #6's phone and she reacted to him by saying No. Resident #10 then pulled Resident #6 from her wheelchair because she was cheating on him. Resident #10 further stated that he was not sure whether Resident #6 got hurt or not. Resident #10 also stated that he did not get hurt during the incident.An interview was conducted on March 20, 2026, at 2:32 p.m., with a Director of Nursing (DON, staff #141). He stated that there are different types of abuse including physical, verbal, and sexual. DON then stated, as per facility process for physical abuse, residents are separated, making sure they are safe, notify the family, Arizona Department of Health services (AZDHS), Adult Protected Services (APS), and Ombudsman within 2 hours, and continue to do the investigation. The DON then stated that the incident between Resident #6 and #10 happened on March 14, 2026, and was reported to him by LPN (staff #176). The LPN stated that Resident #6 was on her phone when Resident #10 approached her. LPN then stated that Resident #10 grabbed Resident #6 and pulled her out of her wheelchair. Resident #6 expressed that she was scared and called 911 from her phone. Resident #10 was assisted back to his room and staff sat with him one-on-one. Resident #6's skin was assessed and denied any injury but was in pain. The DON further stated that he will consider this as physical abuse due to a report of one resident being pulled from a wheelchair by another resident.Review of the facility policy titled, Resident Rights, revised in December 2016, revealed that all residents would be free from abuse, neglect, misappropriation of property, and exploitation.Review of the facility policy titled, Abuse Program Policy and Procedure, revised in December 2016, revealed that physical abuse included hitting, slapping, pinching, and kicking. It also included controlling behavior through corporal punishment.

Based on a closed record review, staff interviews, review of facility documentation, policy, and procedures, the facility failed to ensure that the resident's representative was notified of an injury for one resident (#222). The deficient practice could result in resident representatives not being informed of resident's injuries. Findings included:Resident #222 was re-admitted on [DATE] with a diagnosis that included Senile degeneration of brain, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic chronic kidney disease, major depressive disorder, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.A review of the electronic health record progress notes dated from October 19, 2025 to October 24, 2025 revealed discoloration observed at multiple places on the resident's body, along with the Physician's orders for X-ray for the resident #222; however, the progress notes revealed no documentation that the family had been notified subsequent to the injury or incident.A review of the MDS (minimum data set) dated October 14, 2025, revealed a BIMS (Brief Interview of Mental Status) score of 00, which indicated severe cognitive impairment. Resident #222 requires one-person maximum assistance.An interview was conducted on October 24, 2025, at 10:01 AM, with Licensed Practical Nurse (LPN/Staff #260). Staff #260 stated that LPN responsibilities included administering medications, monitoring patient conditions, and performing regular skin assessments. Staff #260 confirmed a bruise on the resident's right shoulder while assisting her for breakfast. Staff #260 stated that when hospice arrived for resident's shower, they called me (Staff #260) to assess the area since hospice employee had noted the discoloration. Staff #260 stated had observed a bruise on the right shoulder (approx. 1 cm x 2-3 cm), and a yellow discoloration on the left inner thigh (approx. 0.5 cm x 1 cm); and that, the weekend and night nurses had also noted the shoulder bruise. Staff #260 stated that hospice visits the resident twice weekly for showers and clothing changes.An interview was conducted on October 24, 2025, at 02:17 PM. with a Certified Nursing Assistant (CNA/staff #250). Staff #250 stated that for unwitnessed falls, the nurse is notified immediately to assess for injuries, assist the resident, report to the family and DON/ADON, and document the incident. Moderate-risk residents have fall mats and are kept within sight; high-risk residents receive one-on-one monitoring, fall mats, and low bed positioning. For Resident #222, the CNA reported bruising on her right shoulder and hip on Monday. No falls were reported; however, fall mats are in place, as she sometimes crawls out of bed.An interview was conducted on October 24, 2025, at 2:30 PM with LPN (staff #245). Staff #245 stated that fall risk assessments are completed upon admission and reviewed weekly, biweekly, monthly, or annually based on the resident's condition. For unwitnessed falls, neuro checks are performed, an incident report is completed, and the nurse must immediately notify the family, physician, and supervisors after the assessment, even if no injuries are observed. All falls, whether witnessed or unwitnessed, must be documented. Resident #222, experienced an unwitnessed fall on Friday, October 17th, around 9 PM. Staff #245 stated had found the resident sitting on the floor and assessed her thoroughly; her skin was intact with no bruising or injuries noted. She was calm and comfortable, showing no signs of pain or distress. I did not notify the family or supervisors at that time, as it was near the end of my shift and I was off over the weekend. I acknowledge this was an error on my part for not reporting the incident promptly.A telephonic interview was conducted on October 24, 2025 at 3:21 PM with the resident's representative, RR #200 who stated that the resident had been injured at the facility; and that, she had received no notification from the facility. RR #200 stated was later notified by the Hospice staff on October 20, 2025.An interview was conducted on October 24, 2025, at 3:36 PM with the Director of Nursing (DON# #230). Staff #230 stated that for an unwitnessed fall, the resident is assessed immediately, injuries are treated, and safety is ensured. If needed, the resident is sent to the hospital. When no injuries are found, neuro checks are done, and the doctor, family, guardian, and case manager are notified. The nurse must document the incident, complete a risk report, and inform supervisors. Regarding resident #100, the staff # 230 was notified two days after her fall, which occurred on Friday but was initially reported as Saturday. The family was informed once it was confirmed on Monday. This delay did not meet facility expectations, and the staff # 245 was reeducated on the importance of timely reporting and communication.A review of the facility policy entitled Assessing falls and their causes, revised March 2018 revealed that the facility shall notify the resident's physician and family in an appropriate time frame. The policy further revealed that notification of the physician and family, as indicated, should be recorded in the resident's medical records.

Based on clinical record review, resident and staff interviews, and review of facility policy, the facility failed to protect the rights of one resident (#16) to be free from abuse from another resident (#3). The deficient practice could result in residents being physically or emotionally harmed.Findings include:-Resident #16 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, paraplegia, and obesity.Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.Review of the progress notes revealed a nurses' note, dated July 7, 2025 at 11:15AM, which revealed that Resident #16 was experiencing increased hallucinations, delusions, and false allegations towards staff and peers.Further review of the progress notes revealed a room change notice, dated July 7, 2025 at 1:57PM, which revealed that Resident #16 had his room moved to another hall. The reason listed was prevention.Review of the nurses note, dated July 7, 2025 at 8:17PM, revealed that police had called the facility unit wishing to speak to Resident #16, as he had requested to file a report against another resident for assault. The staff who wrote the note indicated that they had no knowledge of the alleged event. The note also indicated that Resident #16 declined to talk to police at the time.Review of the facility self-report investigation revealed that Resident #16 reported to his insurance case manager on July 7, 2025 that he was struck on the left side of his face by another resident. Resident #16 did not identify the resident at first, but later stated that it was Resident #3 who struck him.Interview was conducted on July 15, 2025 at 09:55AM with Resident #16, who confirmed that another resident had punched him in the face and attempted to choke him. When asked where exactly he had been hit, the resident pointed to his face, under his left eye. The resident reported that this incident occurred when he was on his previous unit and that the incident had occurred on a Thursday. The resident explained that the incident occurred in the hallway, as staff was pushing his wheelchair into a room. He also stated that staff and residents had seen the incident occur, and named a Life Enrichment Associate who saw it. Resident #16 stated that following the event, the staff took the other resident away, and staff assisted Resident #16 to go outside to smoke.-Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic systolic heart failure, dementia with other behavioral disturbance, and anemia.Review of the MDS dated [DATE] revealed a BIMS score of 0, indicating severe cognitive impairment.Review of the progress notes revealed an order administration note, dated July 3, 2025 at 6:00PM, which indicated that Resident #3 was administered Ativan for aggressive behavior. The note indicated that the resident was very aggressive and agitated.Interview was conducted on July 15, 2025 at 10:01AM with Resident #3, who denied recalling ever being involved in or witnessing any fights between residents.Interview was conducted on July 15, 2025 at 10:06AM with a Licensed Practical Nurse (LPN/Staff #4), who stated that she did not witness the altercation between Resident #16 and Resident #3, but had heard about it from a case worker. The LPN explained that Resident #16 had claimed that Resident #3 had choked him.Interview was conducted on July 15, 2025 at 11:00AM with a Life Enrichment Associate (Staff #7), who stated that on July 3, 2025, she was gathering the residents to watch a movie, when she witnessed Resident #3 hit Resident #16. She explained that this incident occurred as she was assisting Resident #16 toward the day room. The staff stated that Resident #3 approached Resident #16 and hit him in the face. The staff stated that the two residents were separated. When asked if this incident had been reported to anyone, including facility management, the staff stated that she was not sure if the incident had been reported, but stated that there was a nurse and Certified Nursing Assistants (CNAs) who had also seen the event occur. Staff #7 stated that an incident like this should typically be reported, and confirmed that this could be potential abuse.Further review of the facility self-report investigation revealed that three staff interviews were conducted from the staff that were working on July 3, 2025, who all denied witnessing the alleged altercation. However, there was no evidence that Staff #7, who directly saw the incident, was interviewed or provided a statement.Interview was conducted on July 15, 2025 at 12:22PM with the Executive Director (ED/Staff #35), who confirmed that she is the abuse officer for the facility. The ED confirmed that all staff receive annual and ongoing training on abuse, including the types of abuse, reporting, and who to notify. The ED stated that she would expect staff to notify their supervisor of potential abuse, who would then report to her, so that abuse can be reported to the appropriate agencies within two hours. The ED also stated that her process for investigating abuse included to interview the alleged victim, the alleged perpetrator, and then to interview ten percent of the residents on the unit and ten percent of the staff working. The ED stated that the risk of abuse not being reported would be that the facility cannot act to prevent further harm. When asked about the altercation between Resident #16 and Resident #3, the ED stated that she first became aware of the incident through Resident #16's insurance case manager. The ED then explained that when interviewed, Resident #16 could not tell them the date the incident occurred, only that it was a Thursday, and the resident also did not name any witnesses. The ED stated that her investigation included interviewing some of the staff working the previous Thursday, though she could not verify that any staff witnessed the altercation or that abuse had occurred.Review of the facility policy titled, Abuse Program Policy and Procedure, revealed that residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. The policy revealed that employees must immediately report any suspected abuse or incidents of abuse to the Administrator and/or designee. The policy also indicated that all alleged violations involving abuse, neglect, exploitation or mistreatment should be reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on clinical record review, resident and staff interviews, facility documentation, and policy review, the facility failed to develop and implement policies and procedures for documenting and reporting alleged violations involving abuse, in accordance with federal and state laws and regulations. The deficient practice resulted in an alleged violation concerning abuse (involving Resident #16 and Resident #3) not being investigated timely and reported within the mandatory two-hour timeframe to Adult Protective Services (APS) and the State Agency. This deficient practice could result in further allegations not being documented or reported in a timely manner, which could impact residents' quality of life and care.Findings include:Regarding Resident #16Resident #16 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, paraplegia, and obesity.Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.Review of Resident #16's progress notes revealed no evidence that any altercations or potential abuse situations had occurred on the night of July 3, 2025.Review of the nurses note, dated July 7, 2025 at 8:17PM, revealed that police had called the unit wishing to speak to Resident #16, as he had requested to file a report against another resident for assault. The staff who wrote the note indicated that they had no knowledge of the alleged event. The note also indicated that Resident #16 declined to talk to police at the time.Review of the facility self-report investigation revealed that Resident #16 reported to his insurance case manager on July 7, 2025 that he was struck on the left side of his face by another resident. Resident #16 did not identify the resident at first, but later stated that it was Resident #3 who struck him.Interview was conducted on July 15, 2025 at 09:55AM with Resident #16, who confirmed that another resident had punched him in the face and attempted to choke him. The resident reported that this incident occurred when he was on his previous unit and that the incident had occurred on a Thursday. The resident stated that staff and residents had seen the incident occur, and named a Life Enrichment Associate who saw it. Resident #16 stated that following the event, the staff took the other resident away, and staff assisted Resident #16 to go outside to smoke.Regarding Resident #3Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic systolic heart failure, dementia with other behavioral disturbance, and anemia.Review of Resident #3's progress notes revealed no evidence that any altercations or potential abuse situations had occurred on the night of July 3, 2025.Interview was conducted on July 15, 2025 at 11:00AM with a Life Enrichment Associate (Staff #7), who stated that on July 3, 2025, she was gathering the residents to watch a movie, when she witnessed Resident #3 hit Resident #16. She explained that this incident occurred as she was assisting Resident #16 toward the day room. The staff stated that there was no sign of escalation, but that Resident #3 approached Resident #16 and hit him in the face. The staff stated that the two residents were separated. When asked if this incident had been reported to anyone, including facility management, the staff stated that she was not sure if the incident had been reported, but stated that there was a nurse and Certified Nursing Assistants (CNAs) who had also seen the event occur. Staff #7 stated that an incident like this should typically be reported, and confirmed that this could be potential abuse.Further review of the facility self-report investigation revealed that three staff interviews were conducted from the staff that were working on July 3, 2025, who all denied witnessing the alleged altercation. However, there was no evidence that Staff #7, who directly saw the incident, was interviewed or provided a statement. There was no evidence found that all witnesses and staff who worked with the residents were interviewed, as instructed in the facility policy. Interview was conducted on July 15, 2025 at 12:22PM with the Executive Director (ED/Staff #35), who confirmed that she is the abuse officer for the facility. The ED confirmed that all staff receive annual and ongoing training on abuse, including the types of abuse, reporting, and who to notify. The ED stated that she would expect staff to notify their supervisor of potential abuse, who would then report to her, so that abuse can be reported to the appropriate agencies within two hours. The ED also stated that her process for investigating abuse included to interview the alleged victim, the alleged perpetrator, and then to interview ten percent of the residents on the unit and ten percent of the staff working. The ED stated that the risk of abuse not being reported would be that the facility cannot act to prevent further harm. When asked about the altercation between Resident #16 and Resident #3, the ED stated that she first became aware of the incident through Resident #16's insurance case manager. The ED then explained that when interviewed, Resident #16 could not tell them the date the incident occurred, only that it was a Thursday, and the resident also did not name any witnesses. The ED stated that her investigation included interviewing some of the staff working the previous Thursday, though she could not verify that any staff witnessed the altercation or that abuse had occurred.Review of the facility policy titled, Abuse Program Policy and Procedure, revealed that employees must immediately report any suspected abuse or incidents of abuse to the Administrator and/or designee. The policy also indicated that all alleged violations involving abuse, neglect, exploitation or mistreatment should be reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. The policy listed the minimum steps the individual conducting the investigation should take, which included to interview the person reporting the incident, interview any witnesses to the incident, interview the resident, and interview staff members who have had contact during the period of the alleged incident. There was no evidence found that these steps were taken as instructed in the facility policy.

Based on clinical record reviews, facility documentation, and staff interviews, the facility failed to ensure that an alleged violation involving abuse (involving Resident #16 and Resident #3) was reported to the State Agency and Adult Protective Services (APS) within the required timeframe of two hours. The deficient practice could cause a delay in response to potential abuse, putting residents at risk.Findings include:Regarding Resident #16Resident #16 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, paraplegia, and obesity.Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Review of the facility self-report investigation revealed that Resident #16 reported to his insurance case manager on July 7, 2025 that he was struck on the left side of his face by another resident. Resident #16 did not identify the resident at first, but later stated that it was Resident #3 who struck him.Interview was conducted on July 15, 2025 at 09:55AM with Resident #16, who confirmed that another resident had punched him in the face and attempted to choke him. When asked where exactly he had been hit, the resident pointed to his face, under his left eye. The resident reported that this incident occurred when he was on his previous unit and that the incident had occurred on a Thursday. The resident explained that the incident occurred in the hallway, as staff was pushing his wheelchair into a room. He also stated that staff and residents had seen the incident occur, and named a Life Enrichment Associate who saw it. Resident #16 stated that following the event, the staff took the other resident away, and staff assisted Resident #16 to go outside to smoke.Regarding Resident #3Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic systolic heart failure, dementia with other behavioral disturbance, and anemia.Interview was conducted on July 15, 2025 at 11:00AM with a Life Enrichment Associate (Staff #7), who stated that on July 3, 2025, she was gathering the residents to watch a movie, when she witnessed Resident #3 hit Resident #16. She explained that this incident occurred as she was assisting Resident #16 toward the day room. The staff stated that there was no sign of escalation, but that Resident #3 approached Resident #16 and hit him in the face. The staff stated that the two residents were separated. When asked if this incident had been reported to anyone, including facility management, the staff stated that she was not sure if the incident had been reported, but stated that there was a nurse and Certified Nursing Assistants (CNAs) who had also seen the event occur. Staff #7 stated that an incident like this should typically be reported, and confirmed that this could be potential abuse.Further review of the facility self-report investigation revealed that three staff interviews were conducted from the staff that were working on July 3, 2025, who all denied witnessing the alleged altercation. However, there was no evidence that Staff #7, who directly saw the incident, was interviewed or provided a statement.Interview was conducted on July 15, 2025 at 12:22PM with the Executive Director (ED/Staff #35), who confirmed that she is the abuse officer for the facility. The ED confirmed that all staff receive annual and ongoing training on abuse, including the types of abuse, reporting, and who to notify. The ED stated that she would expect staff to notify their supervisor of potential abuse, who would then report to her, so that abuse can be reported to the appropriate agencies within two hours. The ED also stated that her process for investigating abuse included to interview the alleged victim, the alleged perpetrator, and then to interview ten percent of the residents on the unit and ten percent of the staff working. The ED stated that the risk of abuse not being reported would be that the facility cannot act to prevent further harm. When asked about the altercation between Resident #16 and Resident #3, the ED stated that she first became aware of the incident through Resident #16's insurance case manager. The ED then explained that when interviewed, Resident #16 could not tell them the date the incident occurred, only that it was a Thursday, and the resident also did not name any witnesses. The ED stated that her investigation included interviewing some of the staff working the previous Thursday, though she could not verify that any staff witnessed the altercation or that abuse had occurred.Review of the facility policy titled, Abuse Program Policy and Procedure, revealed that employees must immediately report any suspected abuse or incidents of abuse to the Administrator and/or designee. The policy also indicated that all alleged violations involving abuse, neglect, exploitation or mistreatment should be reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of one resident #222 to be free from abuse by another resident #333. The deficient practice could result in further abuse.Findings include:-Resident #222 was admitted on [DATE] with diagnoses that included unspecified intracranial injury with loss of consciousness.An MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 04, which indicated that the resident was severely cognitively impaired.Progress note dated April 14, 2024 revealed that Resident #222 was observed sitting outside during a smoke break when Resident #333 stood up, turned around, hit Resident #222 in the face. Further, the progress note revealed that Resident #222 had been immediately separated from the location of the incident, and assessed for any pain and injuries. The progress note also revealed that mild redness was observed on Resident #222's face. The progress note also revealed that Resident #222 was moved to a different unit following that incident. A skin assessment with the completion date of April 14, 2024 confirmed documentation of mild redness on the face of Resident #222.- -Resident #333 was admitted on [DATE] with diagnoses that included schizoaffective disorder, bipolar type.MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 06, which indicated resident was severely cognitively impaired.Progress note dated April 14, 2024 revealed that Resident #222 had been observed sitting outside during a smoke break when Resident #333 stood up, turned around, hit Resident #222 in the face. Further, the progress note revealed that Resident #333 had been immediately separated from the location of the incident, and assessed for any pain and injuries. An interview was conducted Licensed Practical Nurse (LPN/Staff #88) on July 3, 2025 at 11:10AM, who stated that abuse can be in the form of verbal, physical, misappropriation of property, emotional; and, as well as neglect. Staff #88 stated that although they did not witness the incident between Resident #222 and Resident #333, if a resident to resident incident occurred in a common area, such as the designated smoking area, that it can be identified as abuse, and if not addressed per professional standards and facility protocol, may place residents and staff into immediate danger.An interview was conducted with a Certified Nursing Assistant (CNA/Staff #77) on July 3, 2025 at 12:13PM, who stated that abuse can be in the form of verbal, physical, emotional, sexual, and as well as misappropriation of property. Staff #77 stated that although they did not witness the incident between Resident #222 and Resident #333, if a resident to resident incident occurred in a common area, such as the designated smoking area, that it can be identified as abuse, and can subject a resident to the risk of further abuse and effect their wellbeing if the facility's abuse policy was not implemented.An interview was conducted with a CNA (Staff #22) on July 3, 2025 at 1:28PM, who stated that although they did not witness the incident between Resident #222 and Resident #333, if a resident to resident incident occurred in a common area, such as the designated smoking area, that it can be identified as abuse, if a resident harmed the other resident physically, mentally, verbally or emotionally.An interview was conducted with Resident #333 on July 3, 2025 at 1:40PM who recalled that residents have been a part of altercation that took place in the area that was designated for smoking.An interview was conducted with the Administrator (Staff #66) on July 3, 2025 at 2:26PM who stated that Resident #222 and Resident #333 were located in the designated smoking area when Resident #333 stood up from their seat and hit Resident #222 in the face, which had resulted in mild redness to Resident #222's face. Staff #66 stated that both residents had been separated; and that, Resident #222 had been placed in a room in which they felt safe in. Staff #66 also stated that both residents underwent assessments to determine further injuries. Staff #66 also stated that within their investigation, interviews were conducted with witnesses who confirmed the incident did occur.A facility policy titled Abuse Program Policy and Procedure revealed that abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. The policy also defined physical abuse to include hitting, slapping, pinching and kicking.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#32) did not abuse another resident (#121). The deficient practice could result in residents being physically harmed. Findings include: -Resident #32 was admitted on [DATE] with diagnoses that included pityriasis versicolor, bipolar disorder, aphasia, mild neurocognitive disorder, psychoactive substance abuse, history of traumatic brain injury, and schizoaffective disorder bipolar type. Review of a care plan initiated on May 4, 2023 revealed no evidence of physical behaviors or the incident that occurred between the two residents. An Annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated the resident was severely cognitively impaired. The assessment also indicated no behaviors were exhibited. A progress note dated June 1, 2024 at 3:58 p.m. revealed that the resident was being physically and verbally aggressive with staff and trying to hit them while attempting to leave. The progress note revealed that three staff members attempted to contain the aggressive behaviors, but ultimately the police were called. The progress note further revealed that the resident hit another resident before he was placed on 1:1 supervision. An Interdisciplinary Team note dated June 3, 2024 at 12:06 p.m. revealed that the resident had an episode of physical aggression on June 1, 2024 with another resident, and the interventions were to separate the residents, place the resident on a 1:1 supervision until a unit change was completed. -Resident #121 was admitted on [DATE] with diagnoses that included dementia with agitation, type 2 diabetes, bipolar disorder, anxiety, altered mental status, adjustment disorder, conduct disorder, major depressive disorder, post-traumatic stress disorder, and psychosis. A progress note dated June 1, 2024 at 2:42 p.m. revealed that the resident was in the dining room attempting to ambulate around another resident when the aggressor pulled the resident down to the floor. The progress note revealed that the resident was first on his knees, then he fell to the ground before he was assessed for pain and injuries. An Admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Review of a care plan initiated on June 7, 2024 revealed a focus on physically aggressive behaviors related to dementia. Review of the facility investigation dated June 4, 2024 revealed that Resident #121 was attempting to ambulate near Resident #32 in the dayroom when Resident #32 grabbed Resident #121 ' s leg and pulled him to the ground. The investigation revealed that Resident #121 fell on to his knees, was assessed for pain and injuries, and no injuries were found. The investigation further revealed that the two residents were separated immediately, and Resident #32 was put on 1:1 supervision until a unit change could be completed. The investigation revealed that the facility substantiated resident to resident abuse. An interview was conducted on May 27, 2025 at 2:12 p.m. with a Certified Nursing Assistant (CNA/Staff#52) who stated that he recalled observing the incident between Resident #32 and Resident #121. The CNA stated that Resident #32 grabbed Resident #121 ' s ankle; and then, escorted Resident #32 back to his room after getting assistance from the nurse to assess Resident #121. A telephonic interview was attempted with no response on May 27, 2025 at 2:21 p.m. with a Licensed Practical Nurse (LPN/Staff#170) who witnessed the incident. An interview was conducted on May 27, 2025 at 2:28 p.m. with the administrator and Abuse Coordinator (Administrator/Staff#43) who stated that there was an incident between two residents in which one resident grabbed another resident's leg and pulled him to the ground. The administrator stated that the staff separated the residents, placed Resident #32 on 1:1 supervision, and completed a unit change for Resident #32. The administrator stated that they usually do a good job of preventing altercations like this, but this incident they did not prevent because the resident just grabbed at the other resident, which resulted in the facility substantiating their investigation of resident to resident abuse. Review of a policy titled, Resident Rights, was revised in December of 2016 and revealed that residents should be free from abuse, neglect, misappropriation of property, and exploitation. Review of a policy titled, Abuse Program Policy and Procedure, was revised in November of 2017 and revealed that residents had the right to be free from abuse, and furthermore the facility would ensure that residents were not subjected to abuse by anyone, including other residents. The policy revealed that the facility would prevent and prohibit all types of abuse, and it also defined physical abuse as hitting, slapping, pinching, and kicking.

Based on record review, staff and resident interviews, facility documentation, and facility policy and procedure, the facility failed to ensure adequate supervision to prevent a non-prescribed medication overdose for one resident (#12). The deficient practice could result in an avoidable accidental overdose of residents. Findings Include: -Regarding Resident #24: -Resident #24 was admitted to the facility on [DATE] with diagnoses that included asthma, major depressive disorder, and opioid use with unspecified opioid induced disorder. A care plan-initiated [DATE] revealed no focus related to substance abuse or dependency. A quarterly Minimum Data Set (MDS) assessment dated on [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated resident was cognitively intact. Review of a Nurse Practioner (NP) progress note dated [DATE] at 4:14 PM revealed that the resident reported recent methamphetamine abuse, and reported trying to refrain from use. An interview was conducted on [DATE] at 1:29 PM with Resident #24 who stated that he did give fentanyl to Resident #12, but could not remember the exact date, only that it occurred around the end of February 2025 or beginning of [DATE]. Resident #24 also stated that he believed it was the reason why Resident #12 went to the hospital. In a follow up interview with resident #24 conducted on [DATE] at 2:49 PM, the resident stated that he obtained the fentanyl from outside the facility. He further stated that the individual that he obtained the fentanyl from was not a staff member or associated with the facility. -Regarding Resident #12 Resident #12 was admitted to the facility on [DATE] with diagnoses that included esophageal obstruction, anxiety disorder, and long-term use of opiate analgesic. A quarterly MDS assessment dated on [DATE] revealed a BIMS score of 14 which indicated that the resident was cognitively intact. The resident's care plan revealed a focus for a known history of substance abuse related to poisoning by other opioids, accidental. Interventions included administering medications as ordered, monitor for side effects, report to the physician as needed, and encourage the resident to communicate triggers as needed. A nurse's progress note dated [DATE] at 1:02 PM revealed Resident #12 was found in bed unresponsive around 12:15 PM, oxygen and cardiopulmonary resuscitation (CPR) were initiated. The note revealed that there was mouth foaming and some residual at the nose noted. Upon ambulance arrival the resident was responsive to some questions and was then transferred to the hospital. A nurse's note dated [DATE] at 6:43 PM revealed that the resident was admitted to the hospital for observation. A hospital visit summary dated [DATE] revealed that a urine drug screen for Resident #12 was positive for oxycodone, fentanyl, and benzodiazepines. Review of physician's orders revealed no evidence of an order for fentanyl. An interview was conducted on [DATE] at 1:31 PM with resident #12 who stated he went to the hospital on [DATE] due to a fentanyl drug overdose. The resident stated that he obtained the fentanyl from outside the facility from an individual who is not affiliated with the facility. The resident further stated that he did not receive any medications that were not prescribed to him from anyone in the facility. Resident #12 further stated that Resident #24 was his previous roommate in the facility. An interview was conducted on [DATE] at 2:56 PM with a Licensed Practical Nurse (LPN/Staff #27) who stated that residents were not allowed to keep medications in their room unless specifically indicated. The LPN also stated that if observed that a resident had illicit drugs or prescriptions that were not prescribed to them that she would alert the supervisor. The Staff #27 stated that she was not aware of any interventions that were in place to prevent a resident from obtaining non-prescribed medications or other illicit substances. Staff #27 also stated that she was aware of the incident that occurred on [DATE] regarding Resident #12 and stated that it was suspected that the resident, got something and overdosed on it. Staff #27 stated that she was not aware of what Resident #12 had taken or where he had obtained the substance from. An interview was conducted on [DATE] at 3:26 PM with an LPN (Staff #3) who stated that he was usually assigned to the locked units of the facility so it was not an issue with resident's bringing in illicit substances or non-prescribed medications because the residents do not leave the unit. Staff #3 also stated that he had heard of residents who are not on the locked units bringing things into the facility. Staff #3 stated that an intervention to prevent residents from bringing in non-prescribed medications or illicit substances included searching the resident's room if they are suspected of using illicit drugs or behaving differently. Staff #3 stated that he was aware of the incident that occurred on [DATE] regarding Resident #12, and stated that the resident was found in his room unresponsive so cardiopulmonary resuscitation (CPR) was initiated and 911 was called. Staff #3 further stated that Resident #12 was suspected to have overdosed on a substance and that there was residual powder around the resident's nose. Staff #3 stated that staff did find some substance in Resident #12's room but were not sure what it was. In an interview conducted on [DATE] at 3:46 PM with the Assistant Director of Nursing (ADON/ Staff #42), the ADON stated that interventions to ensure there are no illicit substances in the facility included: asking the residents if they had illicit substances, drug screenings, and room searches. The ADON stated that the facility would need to obtain consent prior to administering a drug screen or searching the resident's room. The ADON also stated that they educate residents about the dangers of using illicit substances, especially if the resident is currently taking a narcotic. The ADON stated that interventions were in place to prevent a resident from obtaining outside non-prescribed medications or illicit substances which included: the physician could limit the resident going outside the facility on a pass, counseling, and outpatient rehabilitation or other services other than what the facility can provide. The ADON stated that there was one suspected incident of a resident sharing a non-prescribed medication with another resident. However, no residents have stated that they had shared a non-prescribed medication with another resident. The ADON further stated that Resident #12 told the facility he had obtained the non-prescribed medication from outside of the facility and would not tell the facility what the substance was. The ADON confirmed that the hospital records revealed a urine drug screen that was positive for fentanyl, and a suspected drug overdose for Resident #12. Review of the facility policy, Safety and Supervision of Residents, revised [DATE], revealed that resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy indicated that the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. The policy also revealed that resident supervision is a core component of the systems approach to safety.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#1 and #2) were free from physical abuse. The deficient practice could result in further incidents of staff to resident abuse. Findings include: - Regarding resident#1: Resident #1 was admitted to the facility on [DATE] with diagnosis including conduct disorder, unspecified, personal history of traumatic brain injury, unspecified mood [affective] disorder, violent behavior, anxiety disorder, unspecified. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood or behaviors and dependent for activities of daily living and substantial/maximal assist for mobility. A review of the care plan initiated on November 25, 2024 revealed a focus area indicating that the resident has a psychosocial wellbeing problem related to traumatic brain injury. Interventions included allowing the resident time to answer questions and to verbalize feelings, perceptions and fears. Further review of the care plan revealed a focus area that the resident has a behavior problem related to verbal aggression. Interventions included intervening as to protect the rights and safety of others, approaching and speaking to the resident in a calm manner, diverting their attention, remove from situation and take to alternate location as needed. If reasonable, discuss the resident's behavior and explain or reinforce why the behavior is inappropriate and/or unacceptable to the resident. A review of the progress notes for March 9, 2025 revealed no documentation regarding the alleged abuse of staff to resident. A review of the Weekly Skin Evaluation dated March 10, 2025 revealed no breakdowns, open areas or areas of concern for resident #1. An attempt to conduct a telephonic interview was conducted March 20, 2025 at 11:30am with certified nursing assistant (CNA/Staff #5). There was no response. Message left for a return phone call. An interview was conducted on conducted on March 20, 2025 at 2:30 p.m. with Licensed Practical Nurse (LPN/Staff #11). Staff #11 stated resident #1 was seated in his wheelchair in the far in of the community room and was trying to go to the side of the room where there were other residents and CNA #5 were seated. Staff #11 stated CNA #5 did not want the resident in the area she was seated at and CNA#5 pushed the resident roughly and resident #1 was resistant. Staff #11 stated he was concerned with what he saw and told CNA #5 to stop and that CNA #5 stated I don't care. Staff #11 stated I told her to be careful pushing resident #1. Staff #11 stated the CNA#5 did not explain to the resident #1 what she was going to do as she pulled the resident back to the far corner of the room. Staff #11 stated he told CNA#5 to keep serving the residents their meals. Staff #11 stated he continued with his med pass believing CNA #5 had listened to his directive. Staff #11 stated he noticed CNA #5 went to the nurse's station and grabbed a desk chair and went towards resident #1 who was propelling himself towards the table she did not want him to sit at, and purposely tipped the desk chair behind resident #1 and aggressively and with force pushed the desk chair against the back of the resident's wheelchair hitting resident #1 on his upper back. Staff #11 stated Staff #5 displayed abusing behavior I told her repeatedly to stay away from the resident due to her anger that was directed towards the resident- the resident had not done anything to her. Staff #11 stated CNA #5 had a temper and had been aggressive with resident #1 before and used to pull him back and she would take the bib and used it to pull the resident back forcefully- jerking the resident. Staff #11 stated he did not report the prior incident because I talked to her about what she did and thought it would not happen again. An attempt to interview was conducted on March 20, 2025 at 2:48 pm with resident #1. Due to the resident's cognition and BIMS score of 00, the interview could not be completed. The resident was unable to follow line of questioning or remembrance of the alleged event. A review of the facility reportable event report with discover date of March 10, 2025 revealed both resident #1 and Staff #5 were interviewed. Interview with resident #1 was unable to be completed due to level of cognition, but the resident answered yes to fell ing safe in the facility. Staff #5 reported that she felt the need to defend herself by pushing her chair into the resident's wheelchair and could have handled her frustration differently and stopped when told to by the nurse. Staff #5 was immediately suspended and resident #1 was assessed revealing no injuries. Staff #5 was terminated and Stated Board of Nursing notified of the abuse. -Regarding Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, recurrent, unspecified, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, mood disorder due to known physiological condition, unspecified. Review of the Care Plan initiated on August 17, 2024 revealed and area of focus for physically aggressive behaviors related to depression by spitting at staff. Interventions included staff will observe behavior occurrences, cause, interventions and effect and report as needed. Further review of the care plan revealed a focus for smoking. Interventions included instructing on facility policy regarding smoking times, locations and safety concerns. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. Further review of the MDS revealed no indicators for mood and behavioral symptoms directed towards others. Review of the behavior charting dated March 19, 2025 for resident #2 revealed resident was redirected when cussing and name calling to staff and going on nursing station without permission. The charting stated the resident #2. attends supervised smoke break, and able to let needs be known. Further review revealed resident compliant with medication, participated in the last supervised smoke break of the day, no negative behavior and resident is sleeping comfortably through the night. Review of the progress notes revealed no documentation regarding alleged staff to resident abuse. An interview as conducted on March 20, 2025 at 2:52 pm with resident #2. Resident #2 stated he had come from his shower and wanted to be shaved. Resident #2 stated CNA/Staff#7 told him to go to his room. Resident #2 stated Staff #7 said go to your room like I was a little kid. Resident #2 stated I told her to go f**k herself. Resident #2 stated CNA #7 said f*** you mother****** go to your room mother******. Resident #2 stated it made me feel very mad when she spoke to me in that language. Resident #2 stated he has had no further problems since and that staff #7 has not been back. A telephonic interview was conducted on March 20, 2025 at 12:21 pm with CNA/Staff #7. Staff #7 said she was assisting with resident #2. Staff #7 stated she has been employed with the facility since May 2024 and received CPI training as part of the new hire process and had refresher training November 2024. Staff #7 stated resident #2 wanted his head shaved and wanted CNA/Staff#22 to shave his head bald. Staff #7 stated resident #2 had followed her and staff#22 and behind the red line at the nursing station and was yelling and screaming at Staff #22 to have his head shaved. Staff #7 stated Staff #22 explained to him she could not do it at that time due to completing rounds, but that she could do it later. He started swing his arms as if to hit someone, I got around him to pull the resident out of the red line area as he was swinging at staff #22. Staff #7 stated she told the resident that if staff #22 did not have time to shave his head, she would since she was staying until 4:30pm. Staff #7 stated resident #2 started screaming using the Mother***(MF) and B word. Staff #7 stated she explained to the resident he could not use that language. Staff #7 stated additional staff came to assist and tried to calm the resident down. Staff #7 stated Registered Nurse/ Staff # 32 asked that she finish her rounds. Staff #7 denied using inappropriate language directed at the resident, that she just kept telling him to not use the MF or B word. Staff #7 stated that she did tell resident #2 that she would not take him for his smoke break. Staff #7 stated she told the resident this because he was already upset with her, not to punish the resident, but because he was already upset with her. Staff #7 stated I did not tell him correctly. An interview was conducted on March 20, 2025 at 12:53 pm with Registered Nurse (RN/ Staff # 32). Staff #32 stated she worked for the facility since 2016 and worked on the unit the date of the alleged incident. Staff #32 stated she is familiar with resident #2 and staff #7. Staff #32 stated resident #2 has a history of being verbally and physically abusive towards staff, attention seeking, and demanding with care. Staff #2 stated she was not present at the actual incident and was told by CNA/Staff #7 that the resident was following another staff member and had crossed the red line. Staff #32 stated staff #7 told her that she and staff #22 were telling resident #2 to go back and he tried to hit one of them, calling them names using the word b****, and m*****f***** and f***y**. Staff #32 stated I am surprised because she is our go-to CNA, a hard worker and very good with the residents. An interview was conducted on March 20, 2025 at 1:12 pm with (CNA/Staff #22). Staff #22 stated she has worked for the facility for [AGE] years and has worked with staff #7. Staff #22 stated she is good with the residents, but has an aggressive tone. I have heard her speaking to the CNA's with who she has a problem or with some of the residents. Staff #22 stated she was assigned resident #2 on the date of the alleged incident. Staff #22 stated he asked me to shave, I told him when lunch is done I will come and find you- he said ok. Staff #22 stated she went to lay down another resident and when she came out of the room she saw staff #7 taking resident #2 to the soiled laundry. Staff #22 stated staff #7 told her she was bringing him to staff#22 to shave. Staff #22 stated she told staff #7 that she had already spoken to him and that she would take care of him after lunch. Staff #22 stated Staff #7 told the resident he would have to wait and started taking him to the dining room. Staff #22 stated when the resident became upset and started using foul language, she walked away. Staff #22 stated staff #7 got mad and came back and said what did you say?. Staff #22 stated staff #7 told resident#2 that you have to respect me and if you keep talking to me that way I'm not taking you to smoke. Staff #22 stated there were other words that were said but she did not hear them, but that she was yelling and screaming at the resident, Staff #22 stated I have heard her speak to another resident like that, she does not know how to control her anger. An attempt was made to interview (CNA/Staff#30) on March 20, 2025 at 1:42 pm, Message was left for a return phone call. A review of the facility reportable event report with discover date of March 19, 2025 revealed multiple staff witnesses reporting staff #7 yelling and curing at resident #2. Interview with staff #7 revealed staff #7 stated I got loud with resident #2. An interview as conducted on March 10, 2025 at 4:18 pm with Director of Nursing (DON/Staff#15). Staff #15 stated all new hires are provided with Crisis Prevention Intervention (CPI) training and at annual renewal classes. Staff #15 stated the trainings involve real life scenarios and mock drill. Staff # 15 stated if there are any outbursts from residents, the staff will have a huddle and will reflect for prevention instead of reaction. Staff #15 stated the expectation for alleged staff to resident abuse is to remove the person hat is named- interview, suspend immediately, interview all staff that work the unit and staff off the unit and based on the results of the investigation will terminate their employment or have them return to work. Staff #15 stated CNA #5 admitted to the incident involving resident #1 and the facility has substantiated their investigation. Staff #15 stated in regards to resident #2, the facility will also substantiate and that both CNA #5 and CNA#7 will be reported to the State Board of Nursing. Staff #15 stated that it is her expectation that any suspected abuse is reported right away and has been discussed in abuse and that Staff should not make the decision when to report. Staff #15 stated it has never been the facility's practice to record allegations of staff to resident abuse, only resident to resident abuse. Review of the abuse policy tilted Abuse Program Policy and Procedure revised November 2017 states Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms.

Based on review of clinical records and policy, and staff interviews the facility failed to ensure that the medication administration records accurately reflected targeted behavior monitoring as specified within physician orders for residents (# 118, # 123). The deficient practice may result in administering unnecessary medication and/or undesirable medication-induced harm. Findings include: -Resident # 118 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder, bipolar disorder, and insomnia. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 11, which indicated the resident was moderately cognitively impaired. Review of electronic medical records (EMR) revealed a physician order initiated on October 25, 2024 as follows: trazadone hydrochloride oral tablet 100 milligram, give 1 tablet by mouth at bedtime for depression as evidenced by inability to sleep. -Resident # 123 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder, bipolar disorder, Parkinson's disease, and personality disorder. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 04, which indicated the resident was severely cognitively impaired. Review of electronic medical records (EMR) revealed a physician order initiated on March 12, 2024 as follows: Lexapro oral tablet 10 milligram, give 1 tablet by mouth one time a day for depression as evidenced by verbalizing sadness. An interview was conducted on January 29, 2025 PM with Licensed Practical Nurse (LPN/Staff # 768) who confirmed that nurses administered medications daily to residents in the facility based on physician orders. Staff #768 stated that medication orders have the name of the medication, dosage, frequency; and that, medication orders may have additional parameters or instructions that require documentation or communication with the physician. Staff # 768 specified when providing psychiatric medication the order will include the specific behaviors that should be monitored for each medication. Staff #768 stated if a written order has 'a.e.b.' or 'as evidenced by', it means those behaviors should be monitored per the order. Moreover, Staff # 768 stated that this additional behavior observation would be documented on the medication administration record (MAR). Staff # 768 stated that the risks are that the facility would not know if the medication is working or not because they won't be able to track it. An interview was conducted on January 29, 2025 at 02:28 PM with Licensed Practical Nurse (LPN/Staff # 111) who confirmed that as a nurse in the facility she administered medications to the residents. Staff # 111 confirmed that whenever psychotropic medication are administered there are certain behaviors that are required to be monitored. Staff # 111 stated if residents continue with the behaviors the doctor is notified because sometimes they will reevaluate the order and see if it needs to be adjusted. Staff # 111 stated that the assessment is documented then staff go back and reassess to see the behavior change; but that, the resident has to exhibit the behavior to administer the medication. Staff # 111 stated if this were not documented we would not be able to determine if the medication is needed or not or its effectiveness to treat the diagnosis or why the meds are given. Staff # 111 stated if behavior is not monitored, the medication can trigger something else different than the purpose it was given. On January 29, 2025 at 02:35 PM Staff # 111 reviewed the medication administration records for Resident # 118. Staff # 111 confirmed that trazadone medication had been administered as ordered daily December 01 through December 31, 2024 and January 01 through January 28, 2025. Moreover, Staff # 111 confirmed that the ordered specified 'a.e.b.' inability to sleep, therefore Resident # 118 should have been monitored for sleep. Staff # 111 stated that based on the order, she would have monitored if resident is waking due to insomnia. Staff # 111 stated that the way the order was written the medication would not be administered if the resident had no insomnia. Staff # 111 confirmed that the inability to sleep was not monitored for this resident on the electronic medical records, but it should have been monitored. Staff # 111 stated prior to administering medication, she would call doctor and ask why is the medication given. On January 29, 2025 at 02:44 PM Staff # 111 reviewed the medication administration records for Resident # 123. Staff # 111 confirmed that Lexapro medication had been administered as ordered daily December 01 through December 31, 2024 and January 01 through January 28, 2025. Moreover, Staff # 111 confirmed that the ordered specified 'a.e.b.' verbalizing sadness, therefore Resident # 123 should have been monitored for verbalized sadness. Staff # 111 stated that based on the order, she would have asked the resident if something is making them sad. Staff # 111 stated that the way the order was written the medication would not be administered if the resident was not sad. Staff # 111 confirmed that the verbalization of sadness was not monitored for this resident on the electronic medical records, but it should have been monitored. Staff # 111 stated prior to administering medication, she would call doctor and ask why is the medication given. An interview was conducted on January 29, 2025 at 03:39 PM with the Director of Nursing (DON/Staff # 405 ). DON stated that a medication order had the name of medication, the diagnoses, the route, the frequency, and parameter if necessary. DON stated that parameters could be in both, as needed medication, as well as for scheduled medication orders. DON stated that the purpose of a parameter is that it gives directions within certain situations. DON stated that the parameter can be both before or after the medication is administered. DON stated if the medication is given outside the parameter, anything outside of the parameter would require the nurse to call the doctor and would not meet the expectation. DON stated only measuring side effects would not be enough; and that, it is usually documented separately; and that, the behaviors for any psychotropic medication should still be monitored if it is a parameter within the order. DON reviewed medication administration records for Residents (# 118 and # 123) and confirmed that the 'as evidenced by' or 'a.e.b.' indicated behavior in the orders for trazadone and lexapro were not monitored. DON stated that monitoring the behavior meets the facility's expectations; and that, if 'a.e.b.' were not documented it would not meet the facility's expectations. DON confirmed that the behavior specified on the order was not monitored on the medication administration records, progress notes, or electronic medical records and did not meet the facility's expectations. Review of the facility's Policy titled, Administering Medications, (revised April 2019) revealed, medications are administered in accordance with prescriber orders; as required or indicated for a medication, the individual administering the medication records in the resident's medical record: any results achieved and when those results were observed; and the signature and title of the person administering the drug.

Based on onsite investigation, interviews, review of facility documentation and policy, the facility failed to ensure that one resident # 64 was treated with dignity and respect and that the resident was cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing the resident 's individuality. The deficient practice could result in a lower quality of life for residents in the facility. Findings include: Resident #64 was admitted on [DATE] with diagnosis including schizoaffective disorder, bipolar type, major depressive disorder, single episode, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the quarterly MDS dated [DATE] revealed a BIMS score of 04, which indicated resident was severely cognitively impaired. A review of the care plan revealed a focus for mood problems related to dementia. Interventions included monitor and record mood and report to provider for mood patterns or signs or symptoms of depression, anxiety or sad mood. Moreover, the care plan revealed resident required extensive assist with ADL care related to dementia, generalized weakness and pain. Interventions included total assist with dressing and hygiene. Observations: An observation conducted on January 28, 2025 at 12:11 AM, revealed Resident #64 with her breast exposed in the dining room with other residents present. An observation conducted on January 29, 2025 at 11:01 AM, revealed Resident #64 with her top clothing raised while in the hallway with breast exposed. Other residents were present. An interview was conducted on January 31, 2025 at 11:01 A.M. with a Certified Nursing Assistant (CNA/staff # 736). Staff # 736 stated that the staff were the ones who choose the residents clothing; and that, Resident #64 does not own any undergarments. Staff #736 stated she had observed resident #64 with her clothing up and happens 1-2 times per week with other residents present, and this is why the staff do not dress the resident in a dress. Staff #736 stated this is part of the resident's behavior and when it happens staff will take the resident to her room and place her in bed. Staff #736 stated the resident requires constant re-direction with pulling her clothing up. Staff #736 stated she has not reported the incidents to the nurse and stated, it is bad that I have not. Staff #736 stated activities staff have also returned the resident to her room due to trying to undress. An interview was conducted on January 31, 2025 at 11:01 A.M. with Licensed Practical Nurse (LPN/# 723). Staff # 723 stated Resident #64 is a max assist with ADL's with dressing, with no significant changes in the resident's behaviors. Staff #723 stated she was not informed that the resident was exposing herself, and had concerns with the resident's dignity and exposing her breasts with other residents present. An interview was conducted on January 31, 2025 at 12:13 P.M. with Director of Nursing (DON/Staff #405). Staff # 405 stated if a resident has a history of exposing themselves, or have been made aware that they have exposed themselves, that they would need to meet and decide what to do for that resident. Staff #405 stated it is her expectation that staff would report the incidents as soon as they are aware of them; and that, the risks for not reporting these behaviors of exposing themselves would be a dignity concern for those residents that have exposed themselves and for the residents who would observe it. Staff #405 further stated that dependent on the resident; there could be possible harm to the resident's emotional stability. A review of the facility policy titled Dignity states each resident shall be cared for in the manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on clinical record reviews, staff and resident interviews, facility documentation and policies, the facility failed to ensure that two residents (#137, #12) were free from abuse. The deficient practice could lead to further abuse of residents. Findings include: -Regarding Resident #137 Resident #137 was admitted at the facility April 17, 2024 with diagnoses of traumatic hemorrhage of cerebrum, bipolar disorder, major depressive disorder, anxiety disorder, and insomnia. A review of the Quarterly Minimum Date Set (MDS) dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score section was 00/15 which indicated was severely cognitively impaired. In addition, MDS revealed resident #137 had short and long-term memory problems, cognitive skills for daily decision making was severely impaired, is rarely understood, rarely understands, physical and verbal behavioral symptoms directed towards others were not exhibited, and has no physical impairment in upper extremity range of motion (ROM), and has impairment on both sides of lower-extremity range of motion (ROM). A review of behavior charting documentation dated July 07, 2024, revealed resident #137 as, increased mood swings which involve crying then immediately yelling out angry and is difficult to redirect and has poor safety related to trying to stand up unassisted. In section-3 of behavior charting document, the selected interventions are redirection, acknowledged appropriate behaviors, promoted healthy boundaries, reduced emotional stimuli, promoted environmental safety, verbally de-escalated outburst, and safety checks. The box for intervention 1:1 one on one was not checked as an intervention. A review of clinical records Change of Condition progress-note July 07, 2024, by a licensed practical nurse #770 revealed that resident #137 was, sitting in w/c, verbalizing non-sensible verbiage, approached by peer-who raised his right closed hand and brought into contact with right side of patient's mouth. Patients separated and assessed for injury. Cold pack applied to right side of mouth. -Regarding Resident #105 Resident #105 was admitted to the facility on [DATE] with diagnoses schizoaffective disorder, delusional disorders, fetal alcohol syndrome, lack of expected normal physiological development in childhood. A review of Reportable Event Record July 7, 2024 resident to resident abuse, revealed resident #105 is alert with Brief Interview of Mental Status (BIM) score of 00/15 which indicated was severely cognitively impaired. The Reportable Event Record noted, two male residents (#137 and #105) were in dayroom. Resident #137 wandered and approached resident #105. The CNA redirected #137. As resident #137 and CNA were moving away from resident #105 when thereafter #105 reached, and hit resident #137 on the right side of his mouth. Both residents were immediately separated. Resident #105 was placed on one-on-one supervision until a room and unit change could be completed with one of the men. The nurse performed first aid and applied ice to #137's mouth as a preventative measure. No injuries noted. It was noted that the allegation of resident-to-resident abuse was substantiated. A review of behavior charting documentation dated July 07, 2024 revealed, resident #105, has increased yelling out, cursing, laughing and crying at times, he yells out Big Fat Pig and other inappropriate phrases, he is verbally and physically aggressive. In section-3 of behavior charting document, the selected interventions are redirection, acknowledged appropriate behaviors, promoted healthy boundaries, reduced emotional stimuli, promoted environmental safety, verbally de-escalated outburst, and safety checks. The box for intervention 1:1 one on one was not checked as an intervention. A review of clinical records progress-note July 7, 2024 revealed, resident #105 rose from geri-chair, approached peer in w/c, raised his closed right hand and came in contact with peer right-side of mouth. Residents separated, one on one provided, no injuries seen. Resident #105's guardian and emergency contacts notify. Management notified, Physicians notified-no new orders. A review of clinical records progress-note July 8, 2024, revealed that resident #105 s/p (status/post) physical aggression initiated. Intervention placed as residents involved immediately separated until other resident moved to different unit for prevention of further incident. Resident tolerating intervention well at this time. An interview was conducted on January 29, 2025 with Behavioral Unit certified nursing assistant (CNA/Staff #762) who revealed the process and procedures. Staff #762 stated they all monitor the units activity and try to redirect residents and prevent altercations. If resident to resident abuse occurs, we immediately separate the residents, inform Nurse, whom informs the manager and we write out a witness statement. On orientation we had training on abuse reporting, and we have abuse course training, and cross training in the units. Staff #762 stated that the CNAs had access to care plans on each resident. Staff #762 recalled that resident #105 was on this unit July 2024 and resident #137 was moved to the other secured unit where resident #105 could not enter. All moving or room changing decisions are carried through management and care plans are updated by a nurse. Resident #105 actions was stated as, he can move very fast. An interview was conducted on January 29, 2025 with certified nursing assistant (CNA/Staff #315). Staff #315 stated having access to care plans and that resident #137 can answer simple-basic yes and no questions with head motion but verbally he is difficult to understand. Staff #315 stated that resident #137 had a short attention span and the team consistently been able to redirect resident #137 with snacks like applesauce, yogurt, and pudding. Staff #315 reviewed her training for resident to resident altercations procedures in reporting immediately to nurse, after both involved residents were safely separated. An interview was conducted on January 31, 2025 with Behavioral Unit licensed practical nurs (LPN/Staff #30). Staff #30 stated he was working on the unit in July 2024, but was not on site for that incident between resident #137 and resident #105 yet heard about the incident. Staff #30 recalled that resident #137 got moved right away off this unit Behavioral Unit to a secured unit. Staff #30 stated that resident #105 cannot communicate nor carry a conversation; and that, resident #105 is easily annoyed. Moreover, resident #105 stated that back in July 2024, resident #105 was a fast mover. Resident #137 was new to the unit in 2024 and the medical doctor was adjusting his medication, because he was agitated and noisy. An interview was conducted on January 31, 2025 with DON staff #405. Staff #405 stated procedure regarding escalating behaviors between residents is that the staff redirect, and remove the residents from the situation. If behavior continues and is resident to resident type, the residents are separated. The aggressor receive one on one care and move one of the residents to another unit. Staff #405 stated that nurses do a skin assessment, provide first aid. Staff #405 stated that at times, residents may be sent to the hospital. Staff #405 stated that abuse is reported to management immediately, and within two hours, make sure reported to all the related parties, and the team will call to all the required agencies reporting the incident. Staff #405 stated that the process involves retraining after interviewing the staff that are present at scene, and interview the residents that are interviewable. Staff #405 stated that abuse is always reported within 2-hours; and that, the risk of not doing so is that there would be serious harm or something broken, or become unconscious. Staff #405 stated that they have daily discussions on identified concerns. Staff #405 stated that resident #105 approached resident #137 and hit resident #137. They were separated. Nursing staff called and informed all the related parties and then made agency contacts. All the behavioral unit staff have specialized training, but in this case, it appeared that (resident #105) just stepped up and hit him (resident #137). An interview was conducted January 31, 2025 with the Abuse Coordinator/Administrator (Staff #28). Staff #28 stated, we make sure residents are separated, placed on one on one, and nurse do skin checks and provide first aid. Staff #28 stated that the team reported incident within 2-hours to state agencies, police, Ombudsman, and appropriate parties. 51158 -Regarding Resident #12: Resident #12 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, bipolar disorder, major depressive disorder, and auditory hallucinations. A care plan revised November 24, 2020 revealed that resident #12 had a potential to be verbally abusive. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15 which indicated that the resident was cognitively intact. -Regarding Resident #400 Resident #400 was admitted to the facility on [DATE] with diagnoses that included paraplegia, paranoid personality disorder, restlessness and agitation. A quarterly MDS dated [DATE] included a BIMS score of 15 which indicated that the resident was cognitively intact. On January 29, 2025 at 10:58 a.m. a phone interview attempt was made with resident #12, however resident did not answer the phone call. An interview was conducted with resident #12's representative on January 29, 2025 at 11:01 a.m., the resident's representative stated that the facility made her aware of the altercation when it occurred and knew that it was physical. The resident's guardian stated that the facility intervened and separated the residents immediately. The resident's representative stated that there were no injuries as a result of the altercation, and that, the resident stated he felt safe at the facility. On January 29, 2025 at 12:06 p.m. a phone interview attempt was made with resident #400, however resident did not answer the phone call. An interview was conducted with resident #400's representative on January 29, 2025 at 12:07 p.m., the residents representative stated that the facility made her aware of the altercation when it occurred. An interview was conducted with a licensed practical nurse (LPN/Staff #95) on January 31, 2025 at 8:30 a.m., the LPN stated that resident #400 was in the kitchen and resident #12 was in the hallway in front of the kitchen. Staff #95 stated that the residents began exchanging words and resident #400 rolled out of the kitchen and punched resident #12 twice in the face. Staff #95 stated that she intervened and attempted to block resident #12 from further hits until additional staff helped separate the two residents. Staff #95 stated that she immediately notified the Director of Nursing (DON) and the physician regarding the altercation. An interview was conducted with a Certified Nursing Assistant (CNA/Staff #150) on January 31, 2025 at 9:44 a.m., the CNA stated that she was not directly involved when the residents began physically fighting. Staff #150 stated that she was made aware of the two residents beginning talking negatively with each other; and that resident #400 turned around and began punching resident #12. An interview was conducted with a licensed practical nurse (LPN/Staff #854) on January 31, 2025 at 10:06 a.m., the LPN stated that she was not directly involved in the incident but did hear that it was a physical altercation between resident #12 and #400; and that, the nursing staff attempted to intervene but resident #12 did get hit by resident #400. An interview was conducted with the DON (Staff #405) on January 31, 2025 at 11:58 a.m., the DON stated that the facilities process regarding abuse is to educate the staff to report any suspicion or knowledge of abuse. Staff #405 stated that the administrator is the abuse coordinator and they are to report any alleged abuse to the Arizona Department of Health Services, Adult Protective Services, the Ombudsman and the local police department within 2 hours of being informed. The DON stated that she was familiar with the altercation that occurred between resident #12 and #400. She stated that she was made aware that the two residents were arguing and it became physical where a nurse intervened to attempt to break up the physical altercation. The DON stated that both residents were assessed for injury and resident #400 was placed on 1:1 care until he was moved to another unit. Staff #405 stated that notifications were made to the resident ' s representatives and the physician as well. An interview was conducted with the Administrator (Staff #28) on January 31, 2025 at 12:10 p.m., the Administrator stated that any time alleged abuse occurs education is provided to all staff as well as several times a year. Administrator stated that education involves observing for verbal or nonverbal cues to help protect the residents and prevent any abuse from occurring. Staff #28 stated that she was made aware on June 20, 2024 that resident #400 hit resident #12 twice in the face. Additionally, administrator stated that resident #400 was placed on 1:1 care until his unit switch; and that, no injuries were noted to resident #12. The administrator confirmed her role as the facility's abuse coordinator; in her investigation she was able to substantiate the allegation of resident-to-resident physical abuse due to staff witnessing it and both residents admitting to it. The administrator stated that the risks could result in someone getting seriously hurt leading to a higher level of care. Staff #28 stated that the actions of staff were to her expectations it was unfortunate the incident occurred. Review of facility policy titled, Abuse Program Policy and Procedure, identified that residents have the right to be free from abuse, and residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Further review of the policy under subsection, Resident to Resident Altercations, identified that staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#77) was provided the supervision needed to maintain her health and safety. The deficient practice could result in residents being harmed physically and psychologically. Findings included: Resident #77 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included borderline personality disorder, schizoaffective disorder, major depression, and generalized anxiety. The behavior psychiatric evaluation dated September 21, 2024 revealed that the chief complaint was depressed mood and suicidal thoughts. The patient was admitted with depressed mood and suicidal attempt. As per the clinical and multidisciplinary team (MDT) assessment, the patient is functionally impaired due to influence of symptoms and is risky to get discharged from the inpatient unit. The Approach Plan/behavior plan date May 9, 2023 revealed that the resident had a self-harming/suicidal history. Interventions included to be aware of history of self-harm, suicidal ideation and/or prior attempted suicides and ensure the resident knows she is a valued person. If observing an increase in mood or harm is being expressed, contact the psych provider. The minimum data set (MDS) dated [DATE] included a brief interview mental status score of 15 indicating the resident was cognitively intact. Review of the care plan dated November 4, 2024 revealed that the resident had a history of suicidal ideations/attempts. Interventions included to see the behavior plan. A behavior note dated December 18, 2024 revealed that the resident was transferred to a unit to be monitored for suicidal safety reason. The resident was to remain on one-to-one supervision care. Review of the 5-day written investigation dated December 20, 2024 revealed that prior to the resident being left unsupervised, one staff had left the unit to assist with an emergency in another area, adding to the strain on staff. A progress note dated December 18, 2024 revealed that at approximately 7:10 p.m. staff went into the resident's room and noted that the resident had a sheet wrapped around her neck. The resident was pink in color and responsive. The sheet was removed from her neck and she was taken to the nurses station. She verbalized that she was depressed and wanted to harm herself. The resident was assessed for injury and vital signs (VS) were taken. VS: 127/104, 155, 99% RA, 98 F, 24. Crisis line was called and advised to call the fire department. The Director of Nursing (DON), Administrator, nurse practitioner (NP), power of attorney (POA), and the assistant director of nursing (ADON) were notified. The emergency medical services (EMS) arrived at approximately 7:30 p.m. and the resident left the facility at approximately 7:40 p.m. An interview was conducted on December 20, 2024 at 10:51 p.m. with the Director of Nursing (DON/staff #1), who stated that resident #77 was supposed to have a one-to-one staffing ratio because she was having a hard time. She stated that the one-to-one left resident #77 to assist staff with another resident. Resident #77 was found standing on her bed with a sheet wrapped around her neck and 911 was called. She was transferred to the hospital because she stated that she wanted to harm herself. Staff #1 stated that since then, the staff are being retrained not to leave a resident if staff is assigned as the one-to-one even if there is a situation with another resident. An interview was conducted on December 20, 2024 at 2:29 p.m. with a licensed practical nurse (LPN/staff #12), who stated that the resident had just transferred to the unit and was supposed to have a one-to-one staff. The one-to-one was the only male staff on the unit and when another male resident was trying to break through the locked door, the male staff was the only one strong enough to handle him. The male resident was kicking and screaming. When the male staff went to help with the male resident, resident #77 was left unsupervised. Resident #77 went into her room and was found with a sheet wrapped around her neck trying to hang herself from the ceiling. Staff #12 pointed and identified the male resident #99 as the resident who was trying to break down the doors to get out. The facility policy, Safety and Supervision of Residents states that the resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on observation, documentation, resident and staff interviews, and the facility policy and procedures, the facility failed to ensure that residents (#55 and #33) were allowed to leave their rooms during a COVID-19 outbreak. The deficient practice could result in residents not being treated with dignity and respect or afforded their rights. Findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses that included dementia in other diseased classified, traumatic brain injury, adjustment disorder, schizoaffective disorder, and bipolar disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 9 indicating the resident had a moderate cognitive impairment. The COVID-19 line listing documentation revealed that resident #55 tested positive for COVID-19 on December 2, 2024 and was asymptomatic. Note: resident #55 remained quarantined on December 20, 2024, which was a total of 18 days. -Resident #33 was admitted to the facility on [DATE] with diagnoses that included major depression, general anxiety, and borderline personality disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. The COVID-19 line listing documentation revealed that resident #33 tested positive for COVID-19 on December 2, 2024 and was asymptomatic. Note: resident #33 remained quarantined on December 20, 2024, which was a total of 18 days. An interview was conducted on December 19, 2024 at 4:15 p.m. with resident #55, who stated that he is not allowed to go out of his room because of COVID-19. He stated that he is not sick and has not been allowed to go for a cigarette. The resident was upset as evidenced by the increased volume and irritated tone of his voice. During the interview, resident #66 called out from across the hall and wanted to report that he was told that he can't come out of his room, but he did have COVID-19. During this time, another resident #33 ambulated in her wheelchair to the door of her room and stated that she is not allowed out of her room and no one answered her call light. Then, a certified nursing assistant (CNA/staff #6) was observed carrying a food tray towards resident #33's room and heard telling resident #33 to get back in her room, your not supposed to be out of your room in an unwelcoming tone. Staff #6 went into resident #33's room to deliver the food tray and resident #33 was heard saying, don't you like me to staff #6 and staff #6 said, don't talk like that, in an unfriendly and gruff voice, and walked out of the resident's room. The surveyor stopped staff #6 and asked for an interview. Staff #6's tone and general demeanor softened and she stated that there is COVID-19 on the unit and this is why residents are not supposed to come out of their rooms and why she is delivering food trays to the residents' rooms. During an interview was conducted on December 20, 2024 at 8:30 a.m. with the Nursing Administrator Staff (LPN/staff 17), staff reviewed the COVID-19 Line List and stated that resident #55 and #33 tested positive for COVID-19 on December 2, 2024, so they should have been able to come out of their room as of December 10, 2024. She stated that residents out of quarantine and residents who are COVID-19 negative should have been allowed to come out of their rooms, eat meals and do activities in the public area. She stated that if staff are telling residents that they can't come out of their rooms, it is a violation of resident rights and seclusion is a form of abuse. She stated that if she heard a staff telling a resident to get back in his or her room, she would consider a dignity and respect issue. She stated that she never told staff the the residents could not come out of their rooms because COVID-19 was spreading. An interview was conducted on December 20, 2024 at 9:16 a.m. with the Quality Assurance and Performance Improvement (QAPI) nurse, who identified herself as the Infection Control Preventionist (staff #20). She stated that after the seven days, she notifies the staff that the resident can come out of his or her room. She reviewed the COVID-19 Line List and stated that resident #55 and #33 tested positive for COVID-19 on December 2, 2024, so they should have been able to come out of their rooms as of December 10, 2024 and meals and activities should have been offered in the dining room. She stated that staff cannot tell residents to get back in their rooms because it is a form of seclusion and is a matter of dignity and respect. She stated that if she witnessed a staff telling a residents to get back in their rooms, she would remove the resident from the unit, re-educate the staff, and write the staff up if this was a pattern of behavior and seclusion if a form of abuse. She stated that she never told staff that the residents had to stay in their rooms, but may have told staff to encourage the residents to stay in their rooms because COVID-19 is spreading. Then, (staff #20) stated that this never applied to all the residents, just the residents who were COVID-19 positive. She also stated that the Nursing Administrator Staff (LPN/staff 17) never assisted her with implementing procedures or monitoring the COVID-19 outbreak. An interview was conducted on December 20, 2024 at 4:35 p.m. with a licensed practical nurse (LPN/staff #14), who stated that she was told by the nursing administrator staff (LPN/staff #17) and the QAPI nurse (LPN/staff #20) that none of the residents are allowed to come out of their rooms because people keep getting sick. The facility policy, Resident Rights states that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include to be treated with respect, kindness, and dignity, and to be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms.

Based on documentation, resident and staff interviews, and the facility policy and procedures, the facility failed to ensure that residents (#55 and #33) were offered activities when they were COVID-19 positive and the residents on their unit were not allowed to attend activities in the common area. The deficient practice could impact the psychosocial well being of residents. Findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses that included dementia in other diseased classified, traumatic brain injury, adjustment disorder, schizoaffective disorder, and bipolar disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 9 indicating the resident had a moderate cognitive impairment. The COVID-19 line listing documentation revealed that resident #55 tested positive for COVID-19 on December 2, 2024 and was asymptomatic. Note: resident #55 remained quarantined on December 20, 2024, which was a total of 18 days. -Resident #33 was admitted to the facility on with diagnoses that included The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. The COVID-19 line listing documentation revealed that resident #33 tested positive for COVID-19 on December 2, 2024 and was asymptomatic. Note: resident #55 remained quarantined on December 20, 2024, which was a total of 18 days. An interview was conducted on December 19, 2024 at 4:15 p.m. with resident #55, who stated that he is not allowed to go out of his room because of COVID-19. He stated that he is not sick and has not been allowed to go for a cigarette. The resident was upset as evidenced by the increased volume and irritated tone of his voice. During the interview, resident #66 called out from across the hall and wanted to report that he was told that he can't come out of his room, but he did have COVID-19. During this time, another resident #33 ambulated in her wheelchair to the door of her room and stated that she is not allowed out of her room. Then, a certified nursing assistant (CNA/staff #6) was observed carrying a food tray towards resident #33's room and heard telling resident #33 to get back in her room, your not supposed to be out of your room in an unwelcoming tone. Staff #6 went into resident #33's room to deliver the food tray and resident #33 was heard saying, don't you like me to staff #6 and staff #6 said, don't talk like that, in an unfriendly and gruff voice, and walked out of the resident's room. The surveyor stopped staff #6 and asked for an interview. Staff #6's tone and general demeanor softened and she stated that there is COVID-19 on the unit and this is why residents are not supposed to come out of their rooms and why she is delivering food trays to the residents' rooms. During an interview conducted on December 20, 2024 at 8:30 a.m. with the Nursing Administrator Staff (LPN/staff 17), she reviewed the COVID-19 Line List and stated that resident #55 and #33 tested positive for COVID-19 on December 2, 2024, so they should have been able to come out of their rooms as of December 10, 2024. She stated that residents out of quarantine and residents who are COVID-19 negative should have been aloud to come out of their rooms, eat meals and do activities in the public area. She stated that she told the staff that residents are allowed to come out of their rooms to attend activities and staff could encourage residents to wear masks. An interview was conducted on December 20, 2024 at 9:16 a.m. with the the Quality Assurance and Performance Improvement (QAPI) nurse, who identified herself as the Infection Control Preventionist (staff #20). She stated that the quarantine time for COVID-19 is seven days. She stated that after the seven days, she notifies the staff that the resident can come out of his or her room. She reviewed the COVID-19 Line List and stated that resident #55 and #33 tested positive for COVID-19 on December 2, 2024, so they should have been able to come out of their rooms as of December 10, 2024 and meals and activities should have been offered in the dining room. An interview was conducted on December 20, 2024 at 10:05 a.m. with the activity assistant/Life Enrichment Associate (staff #26) and the Life Enrichment Director (staff #35). Staff #26 stated that the purpose of activities is to keep the residents entertained, out of bed, and happy. She stated that each resident is assessed and asked what he or she likes to do and if a resident is not attending activities, she would assume that something is wrong, such as the resident is sad, and would report it to the nurse. Then, she stated that she doesn't document the types of activities or the number of times any resident attends activities, so she guesses that she wouldn't really know if a resident had a change of condition. She stated that during the COVID-19 outbreak, she did not offer any of the residents who were COVID-19 positive any activity materials and did not want to put on the personal protective equipment (PPE) to enter their rooms, but it was her understanding that she was supposed to offer them activity packets. She thought that the quarantine was ten days and stated that she was told by a nurse when the quarantine ended for a resident. She stated that the COVID-19 outbreak made her nervous and she didn't offer any activities to the residents on the unit who tested positive for ten days. She stated that there is a risk of residents not having anything to do and she was not following the activity care plan when she didn't offer activities to the residents. She stated that she had been offering activities to a few of the residents in the dining room. During the interview, (staff #35) stated that the purpose of activities is to improve lives, help with depression, physical and emotional well being, and it creates a sense of community. She stated that she reviews the residents quarterly and when their is a change in condition or concern regarding activity participation, but didn't have any documentation for any of these residents. An interview was conducted on December 20, 2024 at 10:51 a.m. with the Director of Nursing (DON/staff #1), who stated that all residents who were COVID-19 free, were allowed to move around on the unit. She stated that one-to-one activities were offered to the residents who were COVID-19 positive in their rooms and the other residents were allowed to attend regular activities. It was her expectation that activities are documented: attended, not attending, passive and self-directed for each resident. The activity assistant/Life Enrichment Associate (staff #26) should be following the activity care plan for each resident and the purpose of activities is keep the residents engaged, happy, and to decrease behaviors. She stated that the risk of not offering activities is that residents may experience depression, self-isolation, and anxiety sometimes. An interview was conducted on December 20, 2024 at 4:35 p.m. with a licensed practical nurse (LPN/staff #14), who stated that she was told by the nursing administrator staff (LPN/staff #17) and the QAPI nurse (LPN/staff #20) that none of the residents are allowed to come out of their rooms because people keep getting sick. Review of the facility policy, Resident Rights revealed that employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: communication with and access to people and services.

Based on clinical record reviews, facility documentation, staff interviews, policy review, and the State Agency (SA) complaint tracking system, the facility failed to ensure that a resident (resident #1) was free from verbal abuse from staff members. The deficient practice could lead to further abuse of residents. Findings include: Resident #1 was admitted on [DATE] with diagnoses of bipolar disorder, essential hypertension, paraplegia, other neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, personal history of sudden cardiac arrest, chronic pain syndrome, obesity and anxiety. A review of the MDS (Minimum Data Set) assessment revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident was cognitively intact. Review of the reported incident submitted on August 29, 2024, revealed that the Administrator was informed by a staff member of unprofessional conduct when trying to redirect a resident not to smoke unattended. On August 28, 2024, resident #1 became argumentative with staff member #4. Staff member #4 admitted that he had called the resident, bitch ass and if he were not in a wheelchair, he would put his hands on him and fuck him up after being called a bitch. Staff member #4 was suspended pending investigation. During an entrance conference held with the Administrator (staff #7) on September 5, 2024 at 08:58 AM, administrator confirmed that staff member #4 had been terminated. Review of the facility's 5-day investigation report revealed that staff #4 had a written and signed statement of being unprofessional. Review of resident's care plan revealed that resident #1 had a behavior problem as evidenced by (AEB) history of verbal and physical aggression, delusions, sleeplessness. Interventions were in place to help decrease situations. Review of resident's Medication Administration Record (MAR) did not show any documentation for behaviors on August 28 and 29, 2024. Staff in-service for abuse training held on July 19, 2024 at 11:30 AM and list of attendees with signatures were reviewed, and Staff member #4 was not on the list. Administrator stated that staff member #4 was likely missing from the list and not in attendance due to already having abuse training at orientation. Review of staff #4 prior orientation abuse training was dated May 01, 2024. Review of the facility's Identifying Types of Abuse policy (revised September 2022) was revealed Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Abuse toward a resident can occur as staff-to-resident abuse. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to resident within hearing distance, regardless of age, ability to comprehend, or disability.

Based on clinical record reviews, resident and staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of 21 residents (#34, #183, 164, #104, #128, #156, #169, #144, #28, #184, #170, #77, #172, #182, #1, #47, #98, #196, #134, #142 and #86) to be free from abuse by another resident. The sample size was 77. The deficient practice could result in further abuse and resident(s) sustaining injury from resident to resident abuse. Findings include: Regarding residents #34 and #190 -Resident #34 was admitted to the facility on [DATE], with diagnoses that included schizophrenia, fracture of left radius, acute post hemorrhagic anemia, acute osteomyelitis left hand, psychosis, acquired absence of right upper limb below elbow, and open wound of right upper arm. The care plan dated March 29, 2023 included that the resident used anti-psychotic medication related to behavior Lewy bodies, violent behavior, psychosis, psychoactive substance abuse, stimulant abuse, schizoaffective disorder-bipolar type, bipolar disorder, suicidal ideations, anxiety disorder, major depressive disorder, and mood disorder. A review of a progress note dated December 24, 2023 revealed that resident #34 was brought to the dining room and was assessed by a registered nurse (RN/staff #186). The documentation included that the resident had small lacerations to his face and a small one to the chest; and that, the RN cleansed all lacerations with wound cleanser and patted dry. Another progress note dated December 24, 2023 revealed that resident #34 complained of pain to the face and left wrist area; and that, the resident had discoloration marks, scratches to his face and had a clean bandage intact to his left wrist. Per the documentation, the resident showed the RN (staff #183) that he was not able to move his left hand or hold a cup or spoon. It also included that the resident was administered with pain medications; and that, the physician was notified. Further, the documentation included that the resident was sent to the hospital; and, the resident returned from the hospital. According to the documentation, the resident had a fracture of the left arm and had a splint on left arm and a sling in place. -Resident #190 was admitted on [DATE] with diagnoses of Huntington's disease, violent behavior, psychoactive substance abuse, stimulant abuse, schizoaffective disorder-bipolar type, suicidal ideations, anxiety disorder and major depressive disorder. A review of resident #190's care plan dated November 2, 2022, revealed the resident had behavior problems related to a psychiatric diagnosis. A review of behavioral health plan dated December 1, 2022, revealed the resident had behaviors of striking out, hitting, and throwing things. A review of another care plan for resident #190 dated December 14, 2022, revealed the resident had physically aggressive behaviors related to anger. The progress notes dated December 23, 2023 included that resident #190 came to the dining room area to get a drink of water and asked the RN (staff #186) if he could get some medicine for his headache. Per the documentation, while the RN was getting his medication, resident #190 picked up a dining chair and hit the RN on the left posterior shoulder and left side of head with it. The RN tried to grab the chair while backing away from resident #190; and, two CNAs (Certified Nursing Assistant) and a second RN intervened. According to the documentation, resident #190 ran to his room where the door was open and started hitting his roommate (resident #34). It also included that the CNAs removed resident #190 from the room and escorted him to the courtyard; and, the RN then administered as needed medication for aggression to resident #190. On December 24, 2023, the facility submitted a self-report to the SA (State Agency) that residents #190 hit resident #34. An eInteract form dated December 27, 2023 revealed the police sent resident #190 to a behavioral facility on December 24, 2023 at 9:22 a.m. for behavior issues and interventions related to anger. Review of the facility's investigative report dated December 28, 2023, revealed the police were called and when the police arrived, resident #190 was hand-cuffed and removed from the facility. The report included an interview conducted by the facility on December 24, 2023 with resident #34 reported that he wished he could have defended himself when his roommate (resident #190) was hitting him. The report also included an interview conducted by the facility on December 4, 2023 with resident #190 who told the facility that he was because he wanted to go home; and, he was sorry to hit his roommate (resident #34). Continued review of the facility investigative report included a witness statement dated December 24, 2023 by a CNA (staff #146) who reported that resident #190) came out to the dining area, requested for a cup to drink water from staff and after drinking water resident #190 said he wanted to go home. Per the documentation, the nurse told resident #190 that it was late and he cannot go home; and that, resident #190 became aggravated and picked up a chair and attempted to throw it at the nurse. The documentation also included that the CNA reported that she and another CNA (staff #267) ran over to resident #190 and took the chair away from him; and the nurse told the both CNAs to take resident #190 back in his room while the nurse prepared the resident's medication. According to the documentation the two CNAs were standing with resident #190 him at the courtyard; and the resident kept saying he wanted to go home. It also included that both CNAs tried redirecting the resident and told him that will talk with the management in the morning. The documentation included that resident #190 then ran to his room and the two CNAs ran after him. Further, the documentation included that the resident #190 was found on top of his roommate (resident #34) on the bed and his roommate was struggling with him. The two CNAs pulled him out from his roommate, took him roommate to the dining room and resident #190 remained in his room and was given a shot by the nurse. The facility investigation also included another witness statement dated December 24, 2023, by another CNA (staff #267) who reported that resident #190 came to the dining room, drank water, and told the nurse that he wanted to go home; and, the nurse told him that he cannot go home and it was late. The documentation included that the resident got upset, picked a chair, attempted to hit the nurse, the CNA and another CNA (staff #146) ran and took the chair away and the nurse asked both CNAs to take the resident to his room and that the nurse was going to give the resident a shot. Per the documentation, the two CNAs and the resident were at the yard and the resident continued to say he wanted to go home and that the nurse did not want him to go. It also included that the two CNAs attempted to calm the resident to stay as the nurse will let the manager know in the morning; and that, a few minutes later, the resident ran to his room. The documentation included that the two CNAs went to the resident's room immediately and found the resident on his roommate's (resident #34) bed and his roommate (resident #34) was trying to get out of bed. Further, the documentation included that resident #34 had blood and was taken to the dining room for first aid treatment. Both CNAs were in the room with resident #190. Continued review of the facility investigation revealed a witness statement dated December 24, 2023 by an RN (staff #281) who reported that the RN saw resident #190 was asking his nurse for water and then pain medication; and that, the nurse proceeded to the med cart and was attempting to open cart. The RN said that resident #190 raised a chair and attempted to hit his nurse; and that, the RN and two CNAs intervened and separated nurse from resident #190. The RN reported that resident #190 was taken to the middle courtyard by the two CNAs; and that, the two CNAs reported that while they were in the courtyard, resident #190 ran to his room and jumped on the roommate (resident #34) and was hitting his roommate on the face. Per the documentation, the roommate was removed from the room and taken to the day room; and, resident #190 was administered with his as needed IM (intramuscular) injection. Further, the two CNAs stayed in the room with resident #190 him while the RN notified management and administered first aid to the roommate. Further, the documentation included that resident #190 threatened that he will continue to assault people until the facility discharge him. The witness statement by another RN (staff #186) included that on December 23, 2023 at 11:55 p.m., resident #190 came to the dining room area to get a drink of water and asked staff #186 if he could get some medicine because he had a headache. Per the documentation, staff #186 got up to check on the computer what PRN medication the resident had and as staff #186 proceeded to open the medication cart, the resident attacked staff #186 with one of the brown dining room chairs and hit staff #186 on the left posterior shoulder and to the left side of the head. Per the documentation, staff #186 tried to grab the chair and at the same time walking backwards away from the resident; and that, the coworkers of staff #186 intervened separated the resident from staff #186 and took the away to the unit's court yard area. It also included that staff #186 proceeded to obtain the resident's medication from the medication room and upon coming out of the medication room, the roommate (resident #34) of resident #190 was sitting in the unit's dining room with other licensed staff who was assessing him since resident #190 had injured the roommate as well. Regarding residents #31 and #183 -Resident #31 was admitted to the facility on [DATE] with diagnoses of anxiety disorder, persistent mood disorders, major depressive disorder, disorder of psychological development, bipolar disorder, hearing loss, and schizoaffective disorder-bipolar type. The behavioral plan dated May 23, 2021 revealed the resident was physically aggressive. Interventions included that staff were to attempt to anticipate needs to prevent escalation, keep things out of reach, and offer alternative solutions to express anger such as hitting a pillow, ripping up newspaper, or using soft objects to squeeze. A review of the BIMS score dated February 3, 2023 revealed a score of 15 indicating the resident was cognitively intact. -Resident #183 was admitted to the facility on [DATE] with diagnoses disruptive mood dysregulation disorder, major depressive disorder, unspecified psychosis, adjustment disorder, and borderline personality disorder. A review of the BIMS score dated March 8, 2023 revealed a score of 15 indicating the resident was cognitively intact. The behavior plan dated March 29, 2023 revealed the resident was physically aggressive. Interventions included that staff were to attempt to anticipate needs to prevent escalation, avoid having them around targeted person, and if aggression continues, leave and return in 10 minutes and re-approach until behavior stops. A progress note dated March 10, 2023 7:28 p.m. revealed that resident #183 was sitting at nursing station when another resident (#31) walked up to her, pulled her hair and open handedly hit her three times with light force to the head. Per the documentation, both residents were separated and placed on one on one supervision; and, at 9:55 p.m., resident #183 was transferred to another room on a different unit. It also included that there were no signs or symptoms of injury to both residents. On March 10, 2023, the facility submitted a self-report to the SA regarding an incident where resident #31 hit and pulled the hair of resident #183. A review of facility documentation included that an interview with residents #31 and #183 was conducted by the facility on March 13, 2023. Per the documentation, resident #31 admitted to hitting and grabbing the hair of resident #183; and that she was sorry and did not mean to do that. The documentation included that resident #183 stated that she was not doing anything when resident #31 grabbed her hair and hit her. Regarding resident #164 and #185 -Resident #164 was admitted on [DATE] with diagnoses that included hypertension, unspecified psychosis, and schizophrenia. The BIMS score dated April 28, 2023 revealed a score of 15 indicating the resident had intact cognition. A review of the care plan and behavioral plan revealed that resident #164 did not have any aggressive physical behaviors. The progress note dated June 6, 2023 included that resident #164 was assessed post event with no injury and no redness or discoloration noted to the head; and that, resident #164 said she was fine. -Resident #185 was admitted on [DATE] with diagnoses of schizoaffective disorder - bipolar type, personal history of traumatic brain injury, altered mental status, other psychoactive substance abuse with psychoactive substance-induced mood disorder, and psychosis The behavior plan dated August 29, 2022, revealed the resident had a history of striking out or hitting. The care plan dated March 1, 2023 revealed the resident had the potential to be physically aggressive related to poor impulse control. Interventions included that when the resident become agitated, staff were to intervene before agitation escalated and guide the resident away from the source of distress, engage calmly in conversation, and if the resident was aggressive, staff were to walk calmly away and approach later. The BIMS score dated April 28, 2023 included a score of 13 indicating the resident had mild cognitive impairment. A progress note dated June 6, 2023 included that resident #185 punched resident #164 in the back of the head. The documentation included that the CNA reported that the CNA was speaking to resident #164 when resident #185 walked by and just punched resident #164 in the back of the head. Per the documentation, both Residents were escorted to their rooms; and, resident #185 had a 1:1 with CNA outside her room. At 6:58 p.m., LPN/staff #245 contact the psychiatrist and received an order for resident #185 to be sent to the emergency room . The facility self-report dated June 6, 2023 revealed that resident #185 hit resident #164 in the back of the head. A review of the facility's investigative report dated June 12, 2023 revealed that resident #185 approached and hit resident #164 on the back of her head twice. It also included a written witness statement by a CNA (staff #198) who reported that the CNA was talking with resident #164 when resident #185 walked past them, turned around, reached up and punched resident #164 in the back of the head two times. per the documentation, another CNA walked resident #185 back to her room and the CNA (staff #198) walked resident #164 back to her room. Regarding residents #121 and #104 -Resident #121 was admitted on [DATE] with the diagnoses of paranoid schizophrenia, mixed obsessional thoughts and acts, bipolar disorder, borderline intellectual functioning, auditory hallucinations, visual hallucinations, dementia with mood disturbance, major depressive disorder, generalized anxiety disorder, traumatic brain injury, disruptive mood dysregulation disorder, borderline personality disorder, suicidal ideations, and schizoaffective disorder- bipolar type. A review of the care plan dated March 7, 2023 revealed that the resident had behavior problems. Another care plan dated March 14, 2023, revealed that the resident used antipsychotic medications related to behavior management. The behavioral health plan dated March 24, 2023 revealed the resident had physical aggression. The BIMS score dated June 7, 2023 was 11 indicating the resident had moderate cognitive impairment. The progress note dated July 8, 2023 at 11:30 a.m. included that the LPN (staff #64) saw resident #121 punched another resident (#104) in the doorway of the dining room: and that, resident #121 lost his balance. It also included that there were no injuries were noted; and, resident #121 was moved to another room on a different unit. An interdisciplinary note dated July 12, 2023 revealed that resident #121 was placed on one on one supervision until resident #121 was moved to another room. -Resident #104 was admitted on [DATE], with diagnoses of impulse disorder, traumatic brain injury, personality disorder, extrapyramidal and movement disorder, paranoid schizophrenia and disorganized schizophrenia A review the care plan revealed the resident was physically aggressive and was striking residents and staff. Another care plan dated September 18, 2017 included the resident had impaired cognitive function/dementia or impaired thought processes related to dementia and schizophrenia. A review of resident #104's behavioral health plan dated March 4, 2021 revealed the resident had physical and verbal aggressive behaviors. A review of the BIMS score dated June 24, 2023 revealed a score of 3 indicating the resident had severe cognitive impairment. A progress note dated July 8, 2023 revealed that resident #104 was playing with the light switches in the hallway when another resident #121 came out of the dining room to ask resident #104 to stop playing with the lights. Per the documentation, both residents started punching each other and was separated from each other; and that, resident #104 had a scratch on the right elbow. An interdisciplinary note dated July 12, 2023 revealed that on July 8, 2023 resident #104 was placed on one on one supervision until the other resident #121 was moved to another room. The facility self-report dated July 8, 2023 revealed an altercation between residents #104 and #121. The report included a written statement dated July 8, 2023 from the LPN who saw the incident. The LPN wrote that resident #104 was playing with the light switches and the LPN asked resident #104 to stop. Per the documentation, resident #121 then approached resident #104 and began speaking to resident #104; and that, both residents began hitting each other. It also included that the LPN got between the two residents, separated them and directed resident #104 to go back to his room. The documentation included that both residents were placed on a one on one supervision until a room and unit change was done. Further review of the report included an interview with resident #121 and resident #104 conducted by the facility on July 9, 2023. Per the documentation, resident #121 was sorry for hitting the other resident; and, resident #104 was unable to recall the altercation with resident #121. Regarding residents #128 and #167 -Resident #128 was admitted on [DATE], with diagnoses of delusional disorders, psychosis, major depressive disorder, schizophrenia, and vascular dementia with other behavioral disturbance. A review of the BIMS score dated June 16, 2023 revealed a score of 6 indicating the resident had severe cognitive impairment. The progress note dated July 30, 2023 revealed that a CNA reported that resident #128 was in the room of resident #167; and that, resident #167 struck resident #128 on the face. Per the documentation, resident #128 was removed from the room and taken to his own room; and that, resident #128 had no injury noted, was confused and was unable to verbalize the incident and is confused. A progress note dated August 3, 2023 included that residents (#128 and #167) were immediately separated and placed on one on one supervision until resident #167 was moved to a different room and unit. -Resident #167 was admitted on [DATE], with diagnoses of mild neurocognitive disorder, major depressive disorder, anxiety disorder, borderline personality disorder, vascular dementia with other behavioral disturbance, and disruptive mood dysregulation disorder. The BIMS score dated June 14, 2023 was 13 indicating the resident had intact cognition. A review of a progress note dated July 30, 2023 revealed that resident #128 entered the room of resident #167 room after lunch; and that, resident #167 yelled at resident #128 to get out of the room. Per the documentation, a CNA heard resident #167 yelling and responded by trying to remove resident #128 from the room when resident #167 struck resident #128 on the face in the right eye. It also included that resident #167 was immediately placed on a one on one. A progress note dated July 31, 2023 revealed resident #167 was moved to another room and unit due to a higher acuity. A physician note dated July 31, 2023 revealed the physician ordered a psychiatric consult for behavior and medication management. Review of the facility investigative report included interviews with resident #167 and #128 conducted by the facility on July 30, 2023. Per the documentation, resident #167 was sick of resident #128 coming into his room so he hit resident #128; and, resident #128 did not have any recollection of the incident. The facility investigation also included a written witness statement dated July 30, 2023 by a by CNA (staff #163) who reported that she was looking for resident #128 when she heard resident #167 screaming; and, when the CNA went into the room of resident #167, she grabbed a wheelchair to get resident #128 out. It also included that resident #167 swung at resident #128 hitting resident #128 in the right eye. Further review of the facility investigation included a written statement from an LPN (staff #279) who reported that during an interview the LPN conducted with resident #167 on July 30, 2023, resident #167 reported that I'm (referring to resident #167) just sick of him (referring to resident #128). Per the documentation, resident #167 continued to yell, was placed on one to one supervision until the unit manager came to assist with moving the resident and was then moved to another room and unit. Regarding residents #156 and #17 -Resident #156 was admitted on [DATE] with diagnoses of alcohol dependence with alcohol-induced persisting dementia, violent behavior, and dementia with other behavioral disturbance. The behavioral health plan dated May 7, 2021 revealed the resident had delusions and had a behavior of striking out and hitting. The care plan dated November 21, 2022, revealed the resident had an actual history to demonstrate physical aggressive behaviors and struck out at staff and peers. A review of the BIMS score dated September 18, 2023 revealed a score of 3 indicating the resident had severe cognitive impairment. The progress notes dated November 4, 2023 included that the doorway of the dining room was blocked by the wheelchair of resident #156 and was not allowing other residents to pass through so another resident #17 hit resident #156 in the face with his hand. Per the documentation, both residents were separated, assessed for injuries and were placed on one to one supervision until one of the residents was moved. It also included that there were no injuries noted. The progress note dated November 6, 2023 revealed that resident #156 was moved to another room and unit. A progress note dated November 7, 2023 revealed resident #156 was seen by psychiatry. -Resident #17 was admitted on [DATE] with diagnoses of persistent mood [affective] disorder, focal traumatic brain injury, generalized anxiety disorder, blindness right eye category 3, bipolar disorder, psychosis, and dementia. A review of the BIMS score dated November 3, 2023 revealed a score of 3 indicating the resident had severe cognitive impairment. The facility investigation included interviews with residents #156 and #17 conducted by the facility on November 8, 2023. Per the documentation, resident #156 did not remember getting hit; and, resident #17 denied hitting anybody. The investigation also included an interview conducted on November 9, 2023 with the LPN (staff #64) who witnessed the incident. Per the documentation, the LPN reported that the doorway of the dining room was blocked by resident #156's wheelchair; and that, resident #17 hit resident #156 open handed in his face. It also included that there were no injuries noted; and, both residents were immediately separated and resident #17 was placed on one on one supervision. Regarding residents #168 and #169 -Resident #168 was admitted on [DATE], with diagnoses of bipolar disorder, Asperger's, mood disorder, moderate intellectual disabilities, metabolic syndrome, anxiety disorder, attention deficit hyperactivity disorder, pervasive developmental disorder, and autistic. The behavioral health plan dated June 16, 2021 revealed the resident had physically aggressive behaviors. The care plan dated December 14, 2022 revealed the resident had physically aggressive behaviors. -Resident #169 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, traumatic brain injury, violent behavior, hallucinations, schizophrenia, bipolar, paranoid personality disorder, generalized anxiety disorder, TIA and cerebral infarction, major depressive disorder, and blindness one eye. The resident was discharged on [DATE]. A review of resident #169's clinical record revealed a BIMS score of 13 on October 14, 2022 that indicated the resident was cognitively intact. A review of resident #169's behavioral health plan dated March 4, 2021, revealed the resident had physically aggressive behavior. On January 24, 2023, the facility submitted a self-report to the SA regarding an incident between residents #169 and #168 where one resident hit the other resident causing the other resident to hit the initial resident back. A progress note dated January 24, 2023 revealed that the LPN (staff #270) witnessed resident #169 backed her wheelchair up and bumped into resident #168 who then pointed in resident #169's face. Per the documentation, resident #169 then grabbed the arm of resident #168 to get the finger of resident #168 out of her face. It also included that resident #168 then grabbed the arm of resident #169; and before the LPN could get to the residents, resident #168 punched resident #169 in the face. Further, the documentation included that when resident #169 moved her wheelchair back to get away, resident #168 lost her balance and fell . The two residents were immediately separated and put on one to one supervision; and, resident #169 had a bruise on her right cheek with a small bump. According to the documentation, resident #169 was moved to a new room. Review of the facility documentation included that an interview with residents #168 and #169 was conducted by the facility on January 26, 2023. Per the documentation, resident #169 reported that she was backing up in her chair and accidentally bumped into resident #168 who then started telling her to watch where she was going and put finger in her face. It also included that resident #169 reported that she grabbed the arm of resident #168 to move it away and resident #168 grabbed her arm back and then punched her face on her right cheek. According to documentation, resident #168 reported that resident #169 bumped into her when resident #169 was backing up in her chair. It also included that resident #168 reported that she pointed at the face of resident #169 and told resident #169 to watch where she was going. Further, resident #168 reported that resident #169 grabbed her arm; and that resident #168 then grabbed the arm and punched resident #169 in the face. Regarding residents #144 and #49 -Resident #144 was admitted on [DATE] with diagnoses of mood affective disorder, major depressive disorder, and schizoaffective disorder. A review of the BIMS score dated July 9, 2023 revealed a score of 5 that indicated the resident had severe cognitive impairment. The behavior plan dated August 8, 2022 revealed the resident had behaviors of striking out and hitting, throwing things, and hallucinations. A review of the progress note dated July 15, 2023 included that resident #144 was attacked by his peer (resident #49) because resident #144 destroyed the posters on the door of resident #49. Per the documentation, resident #144 was removed to a safe area. -Resident #49 was admitted on [DATE] with diagnoses of focal traumatic brain injury, dementia, anorexia, suicidal ideations, bipolar disorder, persistent mood affective disorder and adjustment disorder with mixed disturbance of emotions and conduct. The BIMS score dated on May 26, 2023 included a score of 4 indicating the resident had severe cognitive impairment. A review of the care plan dated March 20, 2022 revealed the resident had a potential to be physically aggressive with a history of harming others. The behavioral plan dated September 9, 2022, revealed the resident had a history of striking out and hitting. On July 15, 2023, the facility submitted a self-report to the SA regarding resident #49 hitting resident #144. A review of a progress note dated July 15, 2023 revealed that resident #49 got upset and attacked his peer (resident #144) because resident #144 destroyed his posters. Per the documentation, both residents were separated immediately and resident #49 went back to his room and slept. The care plan dated July 17, 2023 revealed the resident had behavior problems, was not interviewable and was not reliable. Review of facility documentation revealed a written statement dated July 15, 2023 by a CNA (staff #280) who stated that on July 15, 2023 at about 9:55 p.m. the CNA asked and offered to take resident #144 to go to his room; but resident #144 refused and told the CNA that he will go by himself. Per the documentation, the CNA said okay and started organizing the chairs when the CNA heard commotion in the room of resident #144 but the CNA was informed by another staff that the commotion was in the room of resident #49. The documentation included that the CNA rushed into the room of resident #49 and found resident #49 over resident #144; and resident #49 was hitting resident #144 and was struggling to take his paper from resident #144 who had blood on his face. Further, it also included that the CNA separated both residents and sent resident #144 back to his room. The facility documentation also included an interview with residents #144 and #49 conducted by the facility on July 16, 2023. Per the documentation, resident #144 reported that resident #49 hit him so he tried to hit resident #49 back. It also included that resident #49 reported that resident #144 made him mad by pulling his pictures off his door; and that, he scratched resident #144. Regarding residents #28 and #49 -Resident #28 was admitted to the facility on [DATE] with diagnoses that included disorder of psychological development, traumatic brain injury, and schizoaffective disorder- bipolar type. A review of the care plan dated March 31, 2022 revealed the resident had behavior problems, was not interviewable and was not reliable. The behavioral plan dated April 14, 2022 revealed the resident had physical aggressive behavior. The progress note dated August 16, 2023 revealed that resident #28 was shoved by resident #49 causing resident #28 to fall to the ground. The progress note dated August 17, 2023 included that resident #28 was status post fall due to a resident to resident altercation; and, had an abrasion was noted to the left side of his lip. It also included that the resident denied pain or discomfort. Another progress note dated August 17, 2023 revealed that resident #28 was involved in a physical altercation and was immediately separated from the aggressor. It also included that the aggressor was placed on one-to-one supervision until the aggressor was move [TRUNCATED]

Based on clinical record reviews, review of facility documents, staff interviews and review of facility policies and procedures, the facility failed to ensure that one resident (#2) received adequate supervision to prevent resident #2 from assaulting one resident (#1) which resulted in a fractured nasal bone. The deficient practice could result in further incidents of aggression towards additional residents in the facility. Findings include: Resident #2 was admitted on [DATE] with diagnoses that included TBI (Traumatic Brain Injury), dementia with behavioral disturbance, restlessness, agitation, and alcohol dependence. A Quarterly Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 4 which indicated that resident #2 had severe cognitive impairment. The assessment included that resident #2 required supervision for mobility, and had no functional limitations in range of motion. A care plan for behavior problems related to intracranial injury and anxiety was revised on July 21, 2020. The care plan listed multiple interventions including: -Assist the resident to develop more appropriate methods of coping and interacting. -Provide opportunity for positive interaction and to talk with the resident when he passes by. -Intervene as necessary to protect the rights and safety of others. -Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. -Monitor behavior episodes and attempt to determine underlying cause. A Care Plan Focus Summary Note dated August 24, 2020 included that resident #2 used anti-anxiety medication related to [CONDITION(S)] as evidenced by continuous pacing, paranoid behavior, delusional statements, breaking doors and physical aggression. A care plan for the use of Antipsychotic medication related to [CONDITION(S)] initiated on August 24, 2020 included that the resident had the following behaviors: -Continuous pacing -Paranoid behavior -Delusional statements -Breaking doors -Physical aggression. The care plan listed multiple interventions including to monitor and record occurrence for target behavior symptoms and document per facility protocol. A physician order dated August 24, 2020 included monitoring and recording targeted behaviors related to anti-psychotic medication use which included hitting. A physician/psychiatry note dated August 31, 2020 included resident #2 resists care, needs redirection by staff, exit seeking, and is easily agitated. Physician orders dated September 16, 2020 included to monitor for targeted behaviors related to anti-psychotic medication use which included paranoid behavior, physical aggression, and breaking doors. A Nurse Practitioner note dated September 18, 2020 included that resident #2 had been very uncooperative, was having behavioral outbursts, and that nursing had to call the psychiatrist to obtain orders for sedation. A Behavior Note dated October 9, 2020 at 6:54 a.m. included that resident #1 was pacing, intruding into peer's privacy and aggravating peers. A Behavior Note dated October 13, 2020 at 11:05 p.m. included that resident #1 was receiving one to one supervision from staff for a resident to resident altercation hitting a wall, and verbally abusing peers who were concerned about resident #2 creeping into their room and peeping at them, that scares them every time making them unable to sleep. A Health Status Note dated October 13, 2020 at 11:30 p.m. included that resident #2 continued to have exit seeking behavior, setting off alarms at all exit doors and that one to one supervision had been initiated to keep resident #2 safe. The note included that the physician had been notified and medications had been provided to resident #2. Review of the clinical record for October, 2020 did not reveal that the care plan had been updated, to include any additional interventions for abusive, aggressive and threatening behaviors towards peers. There were no additional details in the clinical record regarding the one to one supervision that had been provided on October 13, 2020 that included the duration of the one to one supervision, when it was initiated, and when it was discontinued. A Nurses Note dated January 27, 2021 at 9:47 p.m. included that resident #2 had a verbal altercation with another resident after he trespassed into his neighbor's room. Resident #2 was redirected back to his room and reminded not to enter into other resident's rooms. A Behavior Note dated February 4, 2021 at 10:45 p.m. included that resident #2 had attempted to enter another resident's room through the resident's bathroom and that the other resident had charged towards him and pushed resident #2 back to the common bathroom. The note included that resident #2 was redirected to his room, and re-educated not to pass through the other resident's room while using the bathroom. Review of the clinical record for October, 2020 did not reveal that the care plan had been updated, to include any additional interventions for the resident's intrusive and aggressive behaviors as evidenced by resident #2 instigating a physical altercation with a peer by entering the peer's room through a common bathroom. A Physician/Psychiatry Note dated February 24, 2021 included the resident needed staff encouragement to stay compliant with care, medications, and that the resident was easily agitated at times. A Health Status note late entry dated May 25, 2021 at 2:38 p.m. included that (on May 24, 2021) resident #2 had thrown a small table at a window in the dining room, which broke the glass. A Care Plan Focus Summary Note dated June 14, 2021 included that resident #2 had acted out physical aggression towards peers. A care plan initiated on June 14, 2021 for acting out physical aggression toward peers included to allow resident #2 to let off some steam and for the staff to be aware of proximity. The care plan initiated on June 14, 2021 for acting out physical aggression did not include any additional information that defined let off some steam or the meaning of proximity. The care plan also did not include any additional interventions for increased behavioral supervision in response to the resident's ongoing agitation and physical aggression towards peers. A behavioral approach/plan updated on June 14, 2021 included that resident #2 had anxiety, depression and alcohol abuse. The behavioral plan included that resident #2 had physically aggressive behaviors a few times a month, and listed approaches and interventions that included: -Compromise that after they get cleaned up they can have their favorite snack or activity. -Consider if you must care or can wait. Attempt later. -Assess the environment for too much stimulus. -Avoid large group activities and engage in one to one or small groups. Regarding Resident #1 -Resident #1 was admitted on [DATE] with diagnoses that included traumatic brain injury, extrapyramidal movement disorder, anxiety and migraines. A Quarterly MDS (Minimum Data Set) assessment dated [DATE] included that resident #1 had severe cognitive impairment and had trouble concentrating. Review of resident #1's clinical record revealed the following: -A Health Status Note dated June 14, 2021, at 10:17 pm, which included that at 6:30 p.m. resident #1 was hit by another resident (later identified as resident #2) in the dining room, which caused resident #1 to bleed from his nose. The note included that law enforcement, paramedics, the Director of Nursing (DON), the Behavior Manager, and nurse practitioner were notified, and attempts were made to notify the resident's representative. The note also included the resident was medicated for pain. -A Nurse Practitioner note dated June 15, 2021 included resident #1 was punched in the face last night, no complaints of pain, evident broken nose with bilateral bruising to eye orbits. He does not want to go to the hospital for a CT (computerized tomography) of the head. -A Nurse Practitioner Note dated June 16, 2021, at 7:13 am, included that resident #1 requested to have a CT scan of his face. -A Nurses Note dated June 16, 2021, at 1:04 pm, included that resident #1 had returned from the hospital, and had a nasal bone fracture. A CT) scan report from the hospital dated June 16, 2021 included that resident #1 had a non-depressed nasal bone fracture. A facility investigation summary dated June 18, 2021 included that on June 14, 2021 at approximately 6:30 p.m. residents #1 and #2 were in the dayroom. The summary included that resident #2 walked up to resident #1 and hit him in the back of the neck and in the nose. Resident #1 sustained a nose bleed, discoloration under both eyes and nasal bone fracture. The summary included that staff were unable to get to the resident's in time to prevent the assault, and that both residents were separated immediately by staff. The summary included that neither resident #1, or #2 was able to state what had happened. The facility investigation dated June 18, 2021 included statements from two CNA's (Certified Nursing Assistants/staff #63 and #134) who stated that they were doing rounds outside of the dayroom and observed resident #2 hit resident #1 on the back of the neck and on the nose, and the CNA's separated the residents. During an interview conducted on June 29, 2021 at 10:05 am, with a CNA (staff #14), she stated that resident #1 and resident #2 had never been in an altercation prior to June 14, 2021, and that sometimes resident #2 just lashes out, and when he does that, staff stay out of his bubble or immediate area. Staff #14 stated that in the past resident #2 has required one-to-one staffing (supervision) for safety, and that resident #2 can get aggressive at times but this behavior does not happen very often. Staff #14 stated that the exit seeking and wandering behavior was related to his desire to go home and that the resident gets defiant when redirected by staff, and that is when he gets physical. Staff #14 stated resident #2 has hit windows and walls with his fists and legs or feet. During an interview conducted on June 29, 2021 at 10:12 am with a CNA/RNA (Restorative Nursing Assistant/staff #230), she stated that resident #2 has exhibited wandering and exiting behaviors on many occasions, and that resident #2 only becomes physical with other residents after they (other residents) hit or push him. During an interview conducted on June 29, 2021 at 10:25 am with an LPN (Licensed Practical Nurse/staff #227), she stated that on June 14, 2021 resident #2 seemed worked up and that approximately 20 minutes prior to hitting resident #1, resident #2 made a swinging gesture towards her as though the resident was attempting to hit her. Staff #227 stated that she redirected resident #2 back to his room, and then left resident #2 in his room to cool down. Staff #227 stated that she did not know exactly when resident #2 left his room and entered the dining room but she did see resident #2 hit resident #1 in the back of the neck before reaching around and hitting resident #1 in the nose. Staff #227 stated that resident #2 is very, very stubborn and is non-compliant, and that in the past he has had prescription as needed medications but she does not like giving them because it makes him too sleepy for ADLs (Activities of Daily Living). Staff #227 stated the resident had kicked a glass door and broke a window with a table in the past, and that when the resident is aggressive it is out of the blue. Staff #227 stated that she did not know what the care plan intervention letting off steam meant but the proximity intervention meant keeping an eye on resident #2 in relation to other residents. Staff #227 stated she could not explain why there is no documentation in the clinical record for resident #2 that included that incident on June 14, 2021. During an interview conducted on June 30, 2021 at 1:05 pm with an RN (Registered Nurse/staff #114), he stated that resident #2 has a history of enjoying irritating other residents until they react to him, and that the resident does have wandering behaviors but he does not recall him ever physically attacking anyone. Staff #114 stated the resident does have a history of flipping tables, punching walls, and breaking things. During an interview conducted on June 30, 2021 at 1:20 pm with the Behavior Health Manager (staff #214), he stated that resident #2 is ambulatory, takes his medication, wanders, has a bad memory, is exit seeking, and is physically aggressive at times. Staff #214 stated that resident #2 is not necessarily aggressive with other residents but he has hit walls with his fists or head, broke a window, flipped tables, and kicked doors. Staff #214 stated that the behavioral plan is part of the care plan and is kept at the nursing station and that there were no specific care interventions added to the resident's care plan to address the resident's physical aggression. During an interview conducted on June 30, 2021 at 2:25 pm with the DON (Director of Nursing/staff #58), she stated she does not know if the staff were monitoring resident #2 prior to the hitting of resident #1, and that she thinks (resident #2) was being monitored but the staff were too far away and couldn't get to him fast enough. The DON stated that when the staff separated the two residents, resident #2 was returned to his room, and that her expectation is that if a resident has a change in behavior, the resident will be assessed and monitored until the behavior is corrected. The DON stated that to her knowledge the change in behavior for resident #2 was not documented as reported to the provider and that resident #2 was not assessed by the nurse on June 14, 2021. The DON stated that when the resident is in his room with his roommate, he is not consistently monitored, and that the resident did have a history of hitting walls, throwing things, and being verbally aggressive with other residents and that the interventions for the care plan did not include measurable goals or interventions for physical abuse. The DON stated the resident was moved on the evening of June 29, 2021 to a unit for higher acuity and that the resident was not moved until 15 days after the abuse because of bed availability. A facility policy titled Abuse Program Policy and Procedure, included that residents have the right to be free from abuse and that residents must not be subjected to abuse by anyone including but not limited to other residents. The policy included that an alleged violation is a situation or occurrence that is observed or reported by staff or others, has not yet been investigated and if verified could be non-compliance with federal requirements related to mistreatment, exploitation, neglect or abuse. The policy included that physical abuse includes hitting, slapping, pinching, and kicking, and that employees, facility consultants and/or Attending Physician's must immediately report any suspected abuse or incidents of abuse to the Administrator and/or designee (such as Director of Nursing Services, Social Services Director etc.). The policy included that staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff, and that if two residents are involved in an altercation, staff will consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team. The policy included that if two residents are involved in an altercation to make any necessary changes in the care plan approaches to any or all the involved individuals and to document in the resident's clinical record all interventions and their effectiveness. A facility policy titled Care Planning - Interdisciplinary Team, revised September 2013, included the facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team.

Based on staff interviews, record reviews, review of medical sources and review of policies and procedures, the facility failed to ensure that services provided to one resident (#3) for a change in condition that included mental status change and respiratory distress met professional standards of quality. The deficient practice resulted in a delay in emergency medical treatment and oxygen was incorrectly provided to the resident who was experiencing respiratory distress. Findings include: Resident #3 was admitted on (MONTH) 4, 2019 with [DIAGNOSES REDACTED]. An Admission Nursing Data Collection dated (MONTH) 5, 2019 included the resident had [MEDICAL CONDITION], history of [MEDICAL CONDITION], congestion and wheezing, had lung sounds that were clear bilaterally but were diminished bilaterally in the lower lobes, had shortness of breath or trouble breathing with exertion, and when lying flat. The assessment included that the resident's respiratory rate was 18, and O2 (Oxygen) sat's (Saturation) was 98%, and that the resident used oxygen via nasal cannula at 2 L (Liters). A comprehensive plan of care for altered respiratory status and difficulty breathing related to [MEDICAL CONDITION] was initiated on (MONTH) 5, 2019 (revised on (MONTH) 13, 2019). The plan of care included a goal that the resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate and pattern, and included multiple interventions, including to administer medication/puffers as ordered, and monitor for effectiveness and side effects, and monitor/document/report abnormal breathing patterns to the MD (medical doctor). Review of the comprehensive plan of care, revealed an incomplete focused plan that read The resident has altered cardiovascular status related to Dx which was initiated on (MONTH) 5, 2019, (revised on (MONTH) 11, 2019). The plan of care had a goal which included the resident will be free from cardiac problems. The plan of care included two interventions, the first of which read Assess for shortness of breath and cyanosis every (specify). The second intervention which had been revised on (MONTH) 12, 2019 read OXYGEN SETTINGS: O2 via (SPECIFY: nasal prongs/mask) @ (Specify) L (Specify Freq) Humidified (Specify). Continued review of the comprehensive plan of care for altered cardiovascular status revealed the following missing details: -The actual [DIAGNOSES REDACTED]. -The plan of care did not include how often to assess the resident for shortness of breath and cyanosis. -The plan of care did not include whether to use nasal prongs or a mask, how much oxygen to administer, how frequently the resident was to receive oxygen, or whether the oxygen was to be humidified. Review of the clinical record revealed a flow record titled O2 sat's Summary, which included entries for (MONTH) 1, 3, 4, 6, 7, 8, 9, 10, and 11, 2019. The entries included that the resident's O2 saturation's ranged 94% to 99% and the resident received oxygen via nasal cannula. An admission MDS (Minimum Data Set) assessment dated (MONTH) 11, 2019 included that the resident had a BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact, used a walker or wheelchair, and received oxygen therapy. Continued review of the O2 sat's Summary flow record revealed entries dated (MONTH) 15, 16, 17, 18, 2019 and (MONTH) 3, 2019 which all included that the resident continued to receive oxygen via nasal cannula and the O2 saturation's ranged 94% to 99%. An entry dated (MONTH) 4, 2019 included the resident's O2 sat. was 94% on room air, and an entry dated (MONTH) 12, 2019 included the O2 sat was 96% on room air. Entries dated (MONTH) 18, 19, and 21, 2019 included the O2 saturations ranged 95% to 97% and that the resident was receiving oxygen via nasal cannula. A Daily Skilled Nurses Note dated (MONTH) 21, 2019 at 2:46 p.m. included that the resident's respiratory rate was 18, oxygen was in use via nasal cannula at 3 L, and the O2 sat. on room air was 93(%). Review of Daily Skilled Nurses Notes dated (MONTH) 22, 2019, revealed two notes, one note at 3:37 p.m. included that the respiratory rate was 18, the resident was receiving 2 L O2, and the sat. on room air was 97(%). A note at 11:49 p.m. included that the respiratory rate was 18, the resident had shortness of breath on exertion, shortness of breath when lying flat, non-productive cough, oxygen was in use via nasal Cannula at 3 L, and the sat. on room air was 97(%). Review of the clinical record did not reveal any additional documentation that the physician had been notified of the resident's shortness of breath on exertion, when lying flat or a non-productive cough, or that the resident was receiving O2 at 3 L, via nasal cannula. A Daily skilled not dated (MONTH) 23, 2019 at 1:48 p.m. included the respiratory rate was 18, and the resident had shortness of breath on exertion, and was receiving 3 L O2, and the sat. on room air was 93(%). Review of the clinical record did not reveal any additional documentation that the physician had been notified of the resident's shortness of breath on exertion, or that the resident was receiving O2 at 3 L, via nasal cannula. An NP (Nurse Practitioner) note dated (MONTH) 23, 2019 at 2:53 p.m. included statements that the resident denied SOB (Shortness of Breath), there was no current exacerbation of [MEDICAL CONDITION], and the resident had chronic hypoxic [MEDICAL CONDITION], and had been on 4 L of oxygen via nasal cannula at home. Continued review of the NP note dated (MONTH) 23, 2019 did not reveal any additional information that he resident had been receiving oxygen therapy in the facility, or that the resident had been experiencing any shortness of breath or non-productive cough. Review of the physician's orders from (MONTH) 5, 2019, through (MONTH) 23, 2019 did not reveal any physician's orders for the resident to receive oxygen therapy. A Health Status Note dated (MONTH) 23, 2019 at 9:49 p.m. included that the resident had appeared to be more difficult to awaken, and appeared more lethargic. The nurse checked vital signs, and the O2 sat's. were 89% on 3 L of O2 via nasal cannula. The nasal cannula was replaced with a non-rebreather mask, and the sat's improved to 93%. the NP was called and an order was received to send the resident to the hospital for evaluation and treatment of [REDACTED]. The resident was transported via (medical transport) ambulance. Review of the clinical record revealed a notation (flagged in red letters) that an eInteract Transfer form V 4.1 had not been completed for the resident's discharge to the hospital on (MONTH) 23, 2019 at 9:49 p.m. and was overdue. A hospital emergency room report dated (MONTH) 23, 2019 at 9:28 p.m. included that the resident had arrived at the hospital with a complaint from EMS (Emergency Medical Service)that she had been found to have altered level of consciousness, 911 was not called, and when transport EMS picked the resident up from the facility her blood pressure was 70/35, and the facility did not provide any history to the EMS. The report included that upon arrival, the resident was moaning and not speaking, had eyes open but not tracking with her eyes and not following commands to speak. The report included a statement that read The degree at present is severe. A hospital History and Physical Pertinent Report dated (MONTH) 24, 2019 at 3:34 a.m. included that the resident had been intubated in the emergency department, a chest X-Ray had been performed followed by a CT scan which showed the resident had a 15% left lung pneumothorax, and a chest tube was inserted. An interview was conducted on (MONTH) 12, 2019 at 12:05 p.m. with an LPN (Licensed Practical Nurse/staff #132) who stated that if a resident had a change in condition such as a change in mental status and decreased O2 sat's, depending on the resident's condition, she would notify the physician, place the resident on oxygen, with a re-breather mask and call 911. The LPN stated that when a non-rebreather mask is used on a resident, the O2 needed for the non-rebreather mask is 15 [MI] The LPN stated that an oxygen tank must be used because the oxygen tank can deliver 15 L of O2, and an oxygen concentrator cannot deliver 15 [MI] The LPN stated that the facility had a written nursing protocol to provide oxygen and increase the oxygen until the resident's sat's are 90%. The LPN stated she did not know where the facility protocol for oxygen administration was located. The LPN stated that all pertinent medical records are to be sent to the hospital with the resident. An interview was conducted on (MONTH) 16, 2019 at 1:35 p.m. with the Director of Nursing (staff #244) who stated that when there is a medical emergency, the nurse is to call 911, and if the resident's condition is not an emergency, the nurse will call medical transportation (to send the resident to the hospital). However, whether 911 or medical transportation is called depends on the resident's condition. The Director stated that the nurse may not have called 911 because the resident's condition had stabilized. However, the director stated she did not know for sure why the nurse did not call 911 for the resident. The Director stated that the nurse should have completed the eInteract Transfer Form. The Director stated that the nurse should have used 10 L to 15 L of O2 when using a non-rebreather mask and that she was unable to locate the nursing protocol for the use of oxygen mentioned by staff #132 and stated I don't know what she was talking about. An interview was conducted on (MONTH) 16, 2019 at 3:10 p.m. with an RN (Registered Nurse/staff #211) who stated that (on (MONTH) 23, 2019) she had observed that the resident #3 had started having breathing problems while sitting up in a wheelchair. the RN stated that the resident was receiving oxygen from an oxygen tank while sitting in the wheelchair, and that the resident was moved to her bed, and placed a non-rebreather mask at a flow rate of 3 [MI] The RN stated that when the non-breather mask was applied, she removed the resident from the oxygen tank and attached the oxygen tubing to an oxygen concentrator, and the flow rate remained at 3 [MI] The RN stated that the resident's breathing was very diminished with heavy wheezing. The RN stated she notified the physician, and obtained an order to send the resident to the hospital, and she called an ambulance company which arrived 20 minutes later. When asked why an oxygen concentrator was used instead of an oxygen tank which could deliver oxygen at a higher rate, the RN stated that with a non-rebreather mask you can give oxygen at a rate of up to 12 L, and the resident's O2 sat's improved using a concentrator so there was no need for a higher concentration of oxygen. When asked why the nurse did not call 911 to have the resident sent to the hospital emergency department, rather than a medical transport ambulance which took 20 minutes to arrive, the RN stated she had already called the ambulance and that the resident wasn't critical, she was definitely in respiratory distress and had severe wheezing. A policy and procedure titled Transfer or Discharge Emergency, included a statement that emergency transfers or discharges may be necessary to protect the health and/or well being of the resident(s). The policy included that should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, the facility will call 911 and notify the receiving facility that the transfer is being made, prepare a transfer form to send with the resident, assist in obtaining transportation. A policy and procedure titled Pulse Oxymetry (Assessing Oxygen Saturation) included a statement that the purpose of the procedure is to monitor arterial blood oxygen saturation (SaO2) without the use of invasive devices. The policy included to review the physician's orders or facility protocol for pulse oxymetry. A policy and procedure titled Oxygen Administration included a statement that the purpose of the procedure is to provide safe guidelines for oxygen administration. The policy included to verify that there is a physician's order for the procedure, to review the physician's orders or facility protocol for oxygen administration, and to review the resident's care plan to assess for any special needs of the resident. An American Red Cross fact Sheet titled Administering Emergency Oxygen included a stated that emergency oxygen can be given for many breathing and cardiac emergencies. The fact sheet listed instructions for the use of multiple oxygen delivery devices including the non-rebreather mask. The fact sheet included that the non-rebreather mask is a face mask with an attached oxygen reservoir bag and one-way valve between the mask and bag, the victim inhales oxygen from the bag, and exhaled air escapes through valves on the side of the mask. The fact sheet included that the flow rate for the non-rebreather mask is 10-15 LPM (Liters Per Minute) and is suitable for breathing victims only.

Based on clinical record reviews, staff interviews and facility documentation, the facility failed to ensure that the environment for two resident's (#'s 1 and 2) was free from accident hazards. Findings include: -Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment, with an assessment reference date of March 31, 2017, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. This assessment also included that the resident had been assessed to have had daily wandering behaviors, and required supervision with ambulation on and off the unit. Review of resident #1's care plans revealed a plan of care initiated on February 7, 2017, due to the resident being an elopement risk/wanderer. The goal included to maintain the resident's safety. -Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment, with an assessment reference date of June 8, 2017, revealed the resident's cognitive skills for daily decision making were severely impaired. This assessment also included that the resident had short and long term memory problems, and required supervision with ambulation on and off the unit. Review of resident #2's clinical record revealed a care plan regarding the resident's wandering and exit seeking behaviors. The interventions listed included to monitor the resident's location every 15 minutes and to attempt diversional interventions. Review of a facility investigation revealed that on February 6, 2017 at 8 p.m., resident #1 and another cognitively impaired resident (not resident #2) eloped from the Morning Star unit (a secured wandering dementia unit). This report included that at approximately 8 p.m., an alarm went off on the unit and staff were not sure where it was coming from. Staff attempted to turn the alarm off at the control box but were unsuccessful, because they did not know where the alarm was coming from and there was no light on the control box to indicate the location. A second staff member went to the control box and began randomly flipping switches and eventually turned off the alarm. Resident #1 and another resident were found in the front parking lot of the care center. This report also included that both residents had exited from the rear door on the unit and that this door does not have a lighted switch on the alarm panel, as the switch for this door is located on the side of the control panel. Resident #1's elopement risk/wandering care plan was revised on February 22, 2017 and included Scream alarms installed to alert staff of elopement attempts. The care plan did not include interventions to provide any increased supervision or monitoring. Review of another facility investigative report revealed that on June 22, 2017 between 12:40 p.m. and 1 p.m., resident #1 and resident #2 exited the Morning Star unit through a rear exit door, and left the facility unsupervised. Fire Department Reports dated June 22, 2017 revealed that at 1:45 p.m., the fire department was dispatched to an Apparent Death. At 1:47 p.m., they arrived on scene to find resident #1 .face down on the gravel in backyard of a home. Patient .had wandered off . This report also included Patient was mottled, smells of decomposition and had rigor mortises. Patient was not moved or turned over due to obvious death. Further review of resident #1's clinical record revealed a health status note dated June 22, 2017 at 4:34 p.m., which included Resident was seen sitting in day room in chair at 12:40 (p.m.). Continued review of the facility's investigation regarding the elopement of resident #1 and #2 on June 22, 2017, revealed that on June 21, 2017 at about 10 p.m., a staff member had burnt some popcorn in the staff microwave on the Morning Star unit, which set off the fire alarms, causing the doors on the unit to unlock. The fire department responded and met with staff, the main fire control panel on the Morning Star unit was reset, and the doors controlled by the panel were locked and alarmed. Per the report, on June 22, 2017 between 12:40 p.m. and 1 p.m., resident #1 and #2 were noticed to have been missing. The rear exit door of the unit was checked and the door was closed, but was unlocked and the alarm had not sounded, when the door was opened. When the staff could not locate the two resident's, the Police were called. At approximately 1:50 p.m., both residents were located in the backyard of a house. Review of resident #2's clinical record revealed a nurse practitioner note dated June 22, 2017 at 5:18 p.m., which included that the resident had been found outside the facility, denies any complaints and was currently at her baseline. During an interview with the Executive Director (staff #1) conducted on June 23, 2017, she stated that resident #1 had eloped from the secured unit on February 6, 2017. An interview conducted on June 23, 2017 at 9:45 a.m. with a CNA (Certified Nursing Assistant/staff #3), who worked on the unit during the day shift on June 22, 2017. Staff #3 stated on June 22, 2017, both residents had been sitting on the couch waiting for lunch, when another CNA (staff #10) went to get residents #1 and #2, but he could not find them. Staff #3 stated the LPN was informed that the residents were missing. Staff #3 stated that they searched the unit and when they checked the rear door, they noticed it was not locked and the alarm did not sound, when it was opened. An interview was conducted on June 23, 2017 at 10:30 a.m. with a CNA (staff #10), who also had worked the day shift on June 22, 2017. Staff #10 stated that when he was cleaning up after lunch, he could not find resident #1 or #2, so he went to look for them. Staff #10 stated that when he could not find them, he told the nurse (licensed practical nurse/LPN/staff #7). Staff #10 stated that when he went to the rear exit door, he found it unlocked and when it was opened, the alarm did not sound. An interview was conducted on June 23, 2017 at 12:55 p.m., with the LPN (staff #7) who was caring for the residents on June 22, 2017. Staff #7 stated that he saw both residents at 12:40 p.m. and staff noticed that they were missing at 12:50 p.m. Staff #7 stated that they searched the unit and when they were not found, the code for missing resident was called and 911 was called. An interview was conducted on June 23, 2017 at 1:10 p.m. with the LPN (staff #9), who was in charge on the Morning Star unit during the night shift on June 21, 2017, when the popcorn had burned in the microwave. Staff #9 stated that when the alarm sounded the exit gate opened where the resident rooms are located, so she went to monitor the area. Staff #9 stated that the security guard came to the unit to see what was going on and disarmed the alarm. Staff #9 stated a short time later, the fire department and security guard worked on the alarm panel. Staff #9 stated that while security and the fire department were working on the alarm panel, she was caring for a resident who fell , after which she checked the doors to make sure they were closed, but did not check to see if the door was alarmed. Staff #9 further stated that she did not know how to turn the alarm panel off or how to ensure it was working correctly. An interview was conducted on June 26, 2017 at 10:12 a.m. with the security staff member (staff #11) who worked the night shift on June 21, 2017. Staff #11 stated that he heard the alarm and went to the Morning Star unit, and found out it was burnt popcorn and turned off the alarm. Staff #11 stated that when the fire department arrived they checked the alarm panel together and everything was ok, so they left. Staff #11 further stated that he did not know about the switch on the side of the alarm panel for the rear exit door.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that one resident's (#209) left foot was adequately assessed and monitored and subsequently was hospitalized with gangrene, and the facility failed to adequately monitor one resident's (#213) lower extremities and subsequently was admitted to the hospital with [REDACTED]. The facility also failed to ensure that two residents (#209 and #54) received [MEDICAL TREATMENT] services per physician orders and that pre and post [MEDICAL TREATMENT] assessments were consistently completed, failed to ensure a snack was provided for one resident (#54) prior to going to [MEDICAL TREATMENT], and failed to ensure that prescribed treatments were administered for two residents (#19 and #85). Findings include: -Resident #209 was admitted to the facility on [DATE], and discharged to the hospital on February 17, 2015. The admitting [DIAGNOSES REDACTED]. Regarding the left foot: Review of the Admission Nursing Data Collection dated February 4, 2015, revealed the resident had no wounds and no foot problems. However, according to the Skin Review Sheet dated February 4, 2015, the resident had redness of the left foot, and that the 3rd and 4th toenails were black. Review of the clinical record revealed there was no documentation that the physician was notified upon admission regarding the condition of the left foot, nor were there any treatment orders. Progress Notes dated February 6, 2015, included this resident had a BIMS (Brief Interview for Mental Status) score of 5; which indicated the resident had severe cognitive impairment. Further review of the clinical record revealed there was no additional assessments that were completed of the resident's left foot from February 5 through February 15. Review of the SBAR (Situation Background Assessment Recommendation) Communication Form dated February 16, 2015, revealed the resident had a change in condition. The documentation included the resident had diabetic wound/gangrene between 4th and 5th toes of the left foot, with redness and swelling, was tender to touch, and between 4th and 5th toes necrotic. A physician's order dated February 16, 2015 included for [MEDICATION NAME] (antibiotic) 900 milligrams (mg) intravenously (IV) every eight hours; first dose now for diabetic wound/ gangrene of foot/toes. Review of the Progress Notes dated February 17, 2015, revealed there were three unsuccessful attempts to start an IV in the resident's right lower arm, and the pharmacy was called for infusion assistance at 4:12 a.m. A physician's order dated February 17, 2015, included to transfer the resident to the hospital for [MEDICAL CONDITION] of the left foot, and gangrene of the 4th and 5th toes and forefoot. There was no clinical record documentation that the resident had a peripheral IV started, prior to being sent to the hospital at 2:55 p.m. on February 17, 2015. Review of the Progress Notes dated February 27, 2015, revealed that the hospital social worker spoke with the facility's social worker and informed her that the resident had osteo[DIAGNOSES REDACTED], which required [MEDICAL CONDITION]. The note further included that the resident was being discharged back to the facility on antibiotics and that the procedure won't be done unless a decision maker for the resident is involved. An interview was conducted on [DATE], with a licensed practical nurse (LPN). The LPN stated that she does not know who does the admission assessments when a resident is newly admitted to the facility. She also stated that skin assessments are done weekly, but not documented anywhere other than on the Treatment Administration Record (TAR). An interview was conducted on [DATE], with the Assistant Director of Nursing (ADON). The ADON stated that the wound nurse became ill in [DATE], and afterwards nursing was responsible for the skin assessments. She also stated that there were problems with the process and things were being missed. An interview was conducted on [DATE], with the resident's physician. The physician stated that this resident's foot wound suddenly appeared on February 16. She stated that the resident was sent to the hospital the next day and was supposed to have his leg amputated due to gangrene, but no family was able available, so the resident was discharged to another facility and eventually became septic and died . Review of the facility's policy on Weekly Skin Checks and Documentation revealed that weekly skin checks should be done and documented including any skin alterations and to notify your unit manager of any new wounds found. Regarding [MEDICAL TREATMENT]: Review of the clinical record revealed the resident had a [MEDICAL TREATMENT] fistula site to the left upper arm. A physician's order was written on February 5, 2015 for [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday. The order also included to check the [MEDICAL TREATMENT] site every shift for bruit, thrill and complications, and to monitor [MEDICAL TREATMENT] site every 30 minutes for four hours post [MEDICAL TREATMENT] and remove pressure dressing after four hours. Review of the care plan for [MEDICAL TREATMENT] dated February 6, 2015, revealed the following interventions: check and change dressing daily at access site and document, encourage resident to go for the scheduled [MEDICAL TREATMENT] appointments, and monitor vital signs as ordered. A Progress Note dated February 12, 2015, included the resident's [MEDICAL TREATMENT] was canceled because of transportation issues, and the physician was notified. Review of the [MEDICAL TREATMENT] documentation revealed that this resident received [MEDICAL TREATMENT] on February 7, and 14, 2015. There was no documented evidence that this resident received the physician ordered [MEDICAL TREATMENT] on February 10 and 12, 2015. Review of the clinical records revealed no documented evidence that pre and post [MEDICAL TREATMENT] assessments were consistently completed on [MEDICAL TREATMENT] days. An interview was conducted with another LPN on [DATE]. The LPN stated that pre and post [MEDICAL TREATMENT] assessments are done on a special form. The LPN stated that the [MEDICAL TREATMENT] site is checked and documented on the TAR, but no documentation is done regarding what the site looks like. She further stated that the scheduler arranges all [MEDICAL TREATMENT] appointments. An interview was conducted with the scheduler on [DATE]. The scheduler stated that she does all of the appointments except for [MEDICAL TREATMENT]. She stated that nursing arranges all [MEDICAL TREATMENT] appointments. An interview was conducted on [DATE], with an LPN. The LPN stated that pre and post [MEDICAL TREATMENT] assessments are done for all [MEDICAL TREATMENT] residents. She stated that admissions arranges all [MEDICAL TREATMENT] transportation at the time of admission into the facility. An interview was conducted with that admissions director on [DATE]. The director stated the he sets up the initial [MEDICAL TREATMENT], but does not know whether transportation actually shows up and does not follow up with nursing regarding [MEDICAL TREATMENT]. An interview was conducted with the DON and the ADON on [DATE]. The DON and the ADON stated that there were problems with transportation to [MEDICAL TREATMENT], but the problems have since been resolved. They stated that admitting sets up the [MEDICAL TREATMENT] and transportation initially, and then nursing is supposed to follow up to ensure the [MEDICAL TREATMENT] occurs. They further stated that nurses should be doing pre and post [MEDICAL TREATMENT] assessments and more thorough documentation. -Resident #54 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Regarding [MEDICAL TREATMENT]: A physician's order was written on [DATE] for [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday. The order also included to check the [MEDICAL TREATMENT] site every shift for bruit, thrill and complications, and monitor [MEDICAL TREATMENT] site every 30 minutes for four hours post [MEDICAL TREATMENT], and remove pressure dressing after four hours. Review of the clinical record revealed there was no documented evidence that [MEDICAL TREATMENT] assessments were completed on [DATE] and 28, 2015. A Nurse's Note dated [DATE] included the resident missed [MEDICAL TREATMENT] because the transportation company did not show up. The note also stated that the transportation company was called several times and told the facility that someone would be there soon, but never came. Further review of the clinical record revealed there was no documented evidence that [MEDICAL TREATMENT] assessments were completed on [DATE], 7, 9, 12, 14, 16, 19, 21, and 23, 2015. An interview was conducted on [DATE], with the DON. The DON stated that when a resident goes to [MEDICAL TREATMENT], a pre assessment is to be completed and upon returning a post [MEDICAL TREATMENT] assessment is to be done and the nurses are to assess the [MEDICAL TREATMENT] site one time and then every shift. An interview was conducted on [DATE], with an LPN. The LPN stated that this resident's [MEDICAL TREATMENT] site is assessed when the resident returns from [MEDICAL TREATMENT] and then every shift. However, the physician's order from [DATE], included to monitor the [MEDICAL TREATMENT] site every 30 minutes for four hours post [MEDICAL TREATMENT]. Review of the facility's policy on [MEDICAL TREATMENT] Services revealed to provide and maintain ongoing assessments of those residents receiving [MEDICAL TREATMENT] in order to ensure optimum benefits from treatment. Regarding not receiving a snack prior to [MEDICAL TREATMENT]: An interview was conducted with resident #54 on [DATE]. The resident stated that he leaves for [MEDICAL TREATMENT] at 5:00 a.m. or earlier. He stated that he does not get a snack to take to [MEDICAL TREATMENT] and had requested a snack several times, but still does not receive one. An interview was conducted with the dietary manager on [DATE]. The dietary manager stated that this resident does not receive a snack from the kitchen to take to [MEDICAL TREATMENT], as she was not informed by nursing that a snack was needed for this resident. Review of the facility's policy on Care of the [MEDICAL TREATMENT] Resident revealed that depending upon each resident's [MEDICAL TREATMENT] schedule, arrangements for having an earlier meal prior to [MEDICAL TREATMENT] appointment and/or providing a snack for the resident to take to the [MEDICAL TREATMENT] appointment should be provided. -Resident #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician summary orders for [DATE] revealed an order to do weekly skin assessment. Review of the admission nursing data collection dated [DATE] revealed that the resident's skin was noted to be warm and dry with scattered bruises to his entire body. Review of the nurse's notes dated [DATE] and [DATE] revealed that there was swelling of the resident's bilateral legs. There was no documentation that the physician was notified. Review of physical therapy and occupational therapy evaluations dated [DATE] both revealed that the resident's skin findings included [MEDICAL CONDITION] to both lower extremities with much more on the right ankle. Further review of the nurse's notes from [DATE] through [DATE] revealed that there was no mention of the status of the resident's swelling of the bilateral lower legs. On [DATE] it was noted in the nurse's notes that the resident has bilateral lower extremity [MEDICAL CONDITION] and a temperature of 101.4 Fahrenheit. Review of the SBAR Communication and Progress note dated [DATE] revealed that the resident presented with his right great toe deep purple in color halfway down his foot with a fluid filled blister to the great toe that measured 0.2 centimeters (cm) x 0.5 cm, was very cool to the touch and with pain of ,[DATE]. Review of the treatment administration record (TAR) for [DATE] revealed that the resident's skin was not assessed weekly as ordered by the physician. Review of the certified nursing assistant (CNA) shower notes for [DATE] revealed that the resident was provided with a shower on [DATE]. There was no documentation of skin findings. Further review of the clinical record revealed that the physician was not notified of the resident's swelling to the bilateral lower extremities until [DATE]. Review of the physician notes dated [DATE] revealed that the resident complained of right great toe pain with deep purple discoloration. It was noted that the resident's right foot was cool to palpation with 1+ [MEDICAL CONDITION], right great toe purple and tender and there was no palpable right pedal pulse. Assessment included vascular occlusion right foot with right great toe compromise and the plan was to send the resident to the emergency room (ER). Review of the physician order dated [DATE] revealed an order to send the resident to closest ER related to vascular compromise to right foot (great toe). Review of the hospital record dated [DATE] revealed that the resident was admitted to the hospital on [DATE] for blue right lower extremity. It was noted in the history of present illness that the resident has a 4 to 5-day onset of right lower extremity swelling and discoloration. Assessment findings of the extremities included significant cyanosis on the right lower extremity, right foot and the dorsal aspect of right foot. It was also noted that the right lower extremity was swollen from the foot to the mid-calf level and the left lower extremity was swollen. An interview with a licensed practical nurse (LPN) was conducted on [DATE] at 8:40 a.m. She stated that the CNA gives resident showers three times a week and when there are changes or findings like bruises, skin tears, [MEDICAL CONDITION], and excoriations, the CNA informs her right away. She said that when the CNA informs her of a skin finding during showers, she conducts an assessment and document the findings in the change of condition notes, skin assessment notes or the nurse's notes and she will notify the physician. She further stated that resident's skin condition is monitored every shift, assessed every week and findings are documented in the nurse's notes. An interview with a CNA was conducted on [DATE] at 8:55 a.m. She stated that she provides shower to residents daily except Sunday. She stated that when there are skin findings like cuts, rash, or [MEDICAL CONDITION], she will notify the nurse right away so that the nurse will do a complete skin assessment. She further stated that she and the nurse together will complete the CNA Weekly Shower Skin Check Form. In an interview with a registered nurse conducted on [DATE] at 9:00 a.m. She stated that when the CNA calls her about a skin finding, she conducts a complete skin assessment right away, documents the finding and inform the physician right away. She further stated that she will sign the completed CNA Weekly Shower Skin Check. However, further review of the closed clinical record revealed that there was no documentation that the resident's skin was assessed by a nurse every shift and/or on a weekly basis nor was there any CNA documentation of skin findings on [DATE] when shower was provided to the resident. In an Interview with medical records staff conducted on [DATE] at 1:10 p.m., she stated that there were no CNA Weekly Shower Skin Check forms for this resident for the duration of the resident's stay in the facility. In an interview with the director of nursing conducted on [DATE] at 11:00 a.m., she stated that the facility do not have a policy on weekly skin assessment nor do they have a policy for resident's with [MEDICAL CONDITION]. She stated that the facility uses the Clinical Guide for [MEDICAL CONDITIONS] for monitoring resident's with [MEDICAL CONDITION]. Review of the facility's Clinical Guide for [MEDICAL CONDITION] revealed that daily requirements included daily documentation and daily [MEDICAL CONDITION] check. It also revealed that CNA documentation and reporting included leg swelling. -Resident #19 was admitted on [DATE], with a [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed no presence of a rash. A physician's order dated [DATE], included for [MEDICATION NAME] cream 5% (also known as [MEDICATION NAME] and used to treat the scabies) to be applied topically from head-to-toe (avoiding the face), leave on for eight hours then wash off. The order continued that the cream was to be reapplied head-to-toe, and left on again for eight hours then washed off. Review of the [DATE] TAR revealed the above Permetherin order, with documentation of the first application. However, there was no documentation in the clinical record that the second dose was applied. A dermatology order dated [DATE], reflected [MEDICATION NAME] 5% topical cream to be applied from the neck down, and washed off ten hours later and repeated in one week. A telephone order dated [DATE], documented to continue the [MEDICATION NAME] cream 5% one week after the first treatment and leave on for ten hours. However, review of the [DATE] TAR revealed that the cream was not applied until [DATE]. A physician's order dated [DATE], included for [MEDICATION NAME] 5% cream to be applied from the neck to the toes before sleep, and then washed off ,[DATE] hours later. The treatment was to be repeated on [DATE]. Review of the [DATE] TAR, revealed that the first dose of [MEDICATION NAME] was administered on [DATE]. However, there was no documentation in the clinical record that the second dose of the medication was applied on [DATE]. Interviews were conducted with the DON on [DATE] and [DATE]. After review of the clinical record, the DON could not explain why the cream was not applied as ordered. Review of the facility policy on Non Aerosol Communicable disease-Scabies dated as revised on [DATE], revealed I. RISK A. Scabies are usually spread by prolonged skin to skin contact with a person who has scabies; persons who have had such contact should be evaluated by a physician and treated if necessary. An addendum to this policy dated [DATE], reflected Notify MD/NP/Medical Director and obtain order for each resident on involved unit. [MEDICATION NAME] cream 5%, to be applied to skin from neck to toes, leave on ,[DATE]- hours then shower/bath. Repeat in 7 days if rash present. -Resident #85 was originally admitted on [DATE], and discharged on [DATE], to the hospital due to respiratory distress. The resident was readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident expired on [DATE], [MEDICAL CONDITION] pneumonia. The hospital discharge summary dated [DATE], included that the resident had scabies present on admission. Per the documentation, a dermatology consultation was provided, and it was determined that the rash was consistent with a scabies infection and a treatment of [REDACTED]. The admission orders [REDACTED]. Apply topically to the resident's back and front from head to toes. Leave on for eight to ten hours and then wash off and repeat in seven days. However, a review of the [DATE] MAR (Medication Administration Record) revealed that the Permethrim cream had not been applied from admission through discharge on [DATE], when the resident expired. In addition, the [DATE] MAR also included no documented evidence that the Ivermectin had been administered on [DATE], as physician ordered. An interview was conducted on [DATE], with the DON who stated that physician orders were supposed to be implemented and that the evidence that the order had been implemented was licensed staff's initials on the MAR. According to the DON, if the MAR did not include the licensed staff's initials, then the medication/treatment was not administered. Following a review of the closed clinical record, the DON agreed that the MAR did not include documented evidence that the physician's orders had been implemented. A facility policy titled, Medication Pass Policy included to record the medication given on the residents MAR immediately after administration. After you have finished assisting with medication, it is very important that you immediately write in the MAR and record your initials in the appropriate box.

Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure that nursing care and services were provided to help prevent the development of pressure sores for two resident's (#s 19 and 30), and failed to ensure one resident (#209) with an unstageable pressure sore had wound care orders upon admission and that thorough wound assessments were completed. The sample size was five. Findings include: -Resident #19 was admitted on [DATE], with a [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE], revealed the resident had no pressure ulcers and was on a turning/repositioning program. An ADL (activities of daily living) self-deficit care plan related to [MEDICAL CONDITION] dated November 12, 2014 included the resident was totally dependent on one to two staff for repositioning and turning in bed, which was to be done every two hours and as necessary. A nursing entry dated November 12, 2014 at 2:56 a.m., revealed turned and repositioned q (every) 2 hrs (hours) r/t (related to) dx (diagnosis) of [MEDICAL CONDITION] A nursing entry on November 14 and November 20, 2014, documented that the resident was being repositioned every two hours. Review of the admission MDS (Minimum Data Set) assessment dated [DATE], revealed the resident was at risk for pressure ulcers and had no unhealed pressure ulcers. As part of the treatments, pressure relieving devices to the chair and bed were documented as in place. The care area for pressure ulcers triggered and was to be addressed in a care plan. However, the clinical record did not reflect that a pressure ulcer care plan had been developed at this time. CNA (Certified Nursing Assistant) Care Tracker documentation for the month of December 2014, reflected a Turn and Reposition section in which to document Y (yes) that the resident was turned/repositioned. However, the documentation only included that the resident was turned from December 8 through 16. Also, the frequency was not included. A monthly summary dated December 16, 2014 documented the resident's skin was intact and that preventative measures included frequent repositioning and a wheelchair cushion. Review of the ADL care plan dated December 22, revealed the resident required two staff members for turning/repositioning in bed every two hours and as necessary. Further review of the clinical record did not reveal any consistent documentation that the resident had been turned every 2 hrs in December 2014. Review of an SBAR (Situation Background Assessment Recommendation) form dated January 7, 2015, revealed the resident had a 2 cm (centimeter) x 3 cm shearing area to the resident's left ischium. There was no further description of the wound. The note also included Resident unable to reposition self effectively. Encouraged to call for help with repositioning. A physician's order dated January 7, 2015 included for Exuderm (a [MEDICATION NAME] dressing) to the left lower buttock to be changed every three days until healed. A care plan for actual skin impairment was developed on January 7, 2015 and included the shearing to the resident's left ischium due to fragile skin. Interventions included the following: follow facility protocols for treatment and monitor/document location, size and treatment, and to report failure to heal and signs and symptoms of infection, or maceration to the physician. The interventions did not include for any pressure relieving devices to the bed or chair, as mentioned in the admission MDS assessment and the December 16 monthly nursing summary. Review of a form titled Weekly Wound Rounds Tracking Sheet revealed measurements for week 3 (3.1 cm x 3.2 cm) and week 4 (3.0 cm x 3.0 cm), however, the assessments were undated regarding the actual day the wound was assessed, but were among other entries which had a date of January 13, 2015. The wound bed was described to be pink without odor or drainage. The wound location and type was noted to be other and the wound was not staged. A monthly summary dated January 14, 2015, documented non-intact skin with preventative measures that included reposition frequently and a wheelchair cushion. Based on the January 2015 TAR (treatment administration record), the resident received the wound treatment as ordered. Further review of the clinical record revealed that the Exuderm treatment was discontinued on January 22, 2015 and replaced with a treatment order for silver alginate and a foam adhesive to the left buttock every other day. The January 2015 TAR reflected that the new treatment was completed as ordered. A physician's order dated February 2, 2015 included for a low air loss mattress for wound management. A skin impairment care plan dated February 2, 2015 included for the low air loss mattress. A NP (Nurse Practitioner) progress note dated February 6, included that a low air loss mattress was planned to avoid further pressure to the coccyx (the order for the low air loss mattress was written on February 2). A Quarterly Nursing Data Collection dated February 9, also documented that a preventative device was in place for the wheelchair. Review of a monthly summary dated February 14, continued to reflect non-intact skin, and measures in place included reposition frequently and a wheelchair cushion. Continued review of the clinical record revealed that the left ischium pressure ulcer was last measured in week 3 and 4 of January 2015, per the Weekly Wound Rounds Tracking Sheet (which was undated regarding the actual day the wound was assessed). The last assessment in January included the pressure ulcer measured 3 x 3 cm and the wound bed was pink, without odor or drainage. The pressure ulcer was not assessed again until February 20. According to a physician's wound care note dated February 20, 2015, the resident presented with a left buttock wound and had a current treatment of [REDACTED]. The wound bed was documented to have 80% slough and 20% granulation tissue without eschar, tunneling, and undermining. The wound was noted to have a small amount of exudate, with intact edges and no odor. The plan included for a treatment change, frequent turning, low air loss mattress, and a ROHO cushion to the chair. A physician's order dated February 20, 2015 documented to discontinue the silver alginate treatment to the left buttock area and start Dakins (an antiseptic solution) soaked gauze to the wound daily. However, there was no order for the ROHO cushion, as noted in the physician wound care note. According to the February 2015 TAR, the treatment to the left buttocks was not provided on February 25, 26, and 27, nor was there any documentation as to why the treatments were not done. A physician wound care note dated February 27, 2015 documented the wound had decreased in size to 2.0 x 2.0 x 1 cm. The wound had 80% granulation tissue and 20% slough, without undermining, tunneling, or odor. The wound edges were noted to be intact with a small amount of exudate. The plan was to continue with the treatment and frequent turning. The note further revealed that the facility was still waiting to receive the ROHO cushion and low air loss mattress. Review of a nursing entry dated March 2, 2015 at 12:23 p.m., revealed that the order for the low air loss mattress was refaxed to a DME (durable medical equipment) company. A form titled Wound Weekly Observation Tool dated March 6, 2015 documented the resident had an open area which started as shearing to the left ischium and that the resident's special bed was ordered, but was still pending delivery. A nursing entry dated March 13, 2015 at 11:55 a.m., included the buttocks wound measured approximately 3.0 x 3.0 x 1.6 cm. There was no other description of the wound. A review of the March 2015 TAR revealed that the Dakins treatment was not administered on March 13 and 14, and no reason was documented as to why it was not done. Review of the Weekly Wound Rounds Tracking sheet dated on March 19, 2015 revealed that measurements for week 3 and 4 were 2.0 x 2.4 x 1.0 cm, and the wound had granulation tissue, without odor. Further review of the clinical record revealed no documentation that the resident was turned/repositioned every 2 hrs and as needed, nor was there documentation if the resident received the low air loss mattress and the ROHO cushion in March 2015. The Weekly Wound Rounds Tracking sheet dated April 8, 2015 reflected weekly measurements designated as week 1 through 4 (the specific dates as to when the measurements were obtained were not documented). In comparing the weekly measurements, the wound was noted to have increased in size from 2.2 x 2.4 (week 1, no documented depth) to 3 x 2.8 x 5.0 cm on week 4. The wound color was described as green/gray/black slough with serosanguineous drainage and foul odor. The wound was also noted to now have tunneling at 11 o'clock, which measured 5.0 cm deep and had another area of tunneling at 9 o'clock, which measured 4.8 cm. Furthermore, the decline of the wound from week 1 to week 4 was unable to be determined, as the weekly tracking sheet did not reflect the description of the wound on a weekly basis. There was no documentation in the clinical record regarding when the tunneling to the resident's wound first occurred, nor documentation that the physician was notified. There was also no documentation from April 8 to April 20, 2015, which reflected that the resident was turned/repositioned every two hours, nor the status of the resident's low air loss mattress and ROHO cushion. In addition, there were no further physician visits by the wound care doctor since February 27. Review of the April 2015 TAR revealed that the resident did not receive wound treatments on April 12 and on 17. A physician order dated April 21, 2015 now included for a wound doctor consult. A physician's order dated April 22, 2015 documented to discontinue the current Dakins treatment once the wound vac arrived. The wound vac orders included to pack with foam and run at 125 mmHg (millimeters of mercury) continuously and change three times weekly. A physician order dated April 23, 2015 included for two cultures of the resident's wound to be done. Review of the wound physician consult note dated April 24, revealed that the resident's wound had more tunneling, drainage and odor. A culture was taken and the medical plan included to hold the wound vac and for Dakins soaked gauze. In addition, the note reflected to upgrade the resident to a low air loss alternating pressure mattress. Review of a physician's order dated April 24, 2015 included for [MEDICATION NAME] (antibiotic)100 mg (milligrams) twice daily for 14 days. Additional physician orders dated April 24, included for a ROHO cushion to the wheelchair, Clinton bed, and daily application of Dakins soaked gauze with [MEDICATION NAME] to the wound. Review of the April 2015 TAR revealed the resident did not receive treatments to the wound on April 23, and 24, nor was there documentation as to why they were not done. In addition, there was no further mention in the clinical record of the resident being turned/repositioned every two hours. Review of a wound culture report dated April 26, 2015 revealed the presence of [DIAGNOSES REDACTED], E. coli (Escherichia coli), and ESBL (extended spectrum beta-lactamase). A physician's order dated April 26, 2015 documented to discontinue the [MEDICATION NAME] and to start [MEDICATION NAME] (antibiotic) intramuscularly for seven days. A weekly wound assessment dated [DATE] documented the buttocks pressure ulcer measured 3.4 x 2.0 x 2.5 cm, with tunneling located at 11-12 o'clock (5.8 cm) and 9 o'clock (3.2 cm). The wound bed was described to be 50% red and 50% slough, with brown serous drainage and no odor. A physician's order dated May 8, 2015, included for a change in treatment as follows: apply Kerlix soaked gauze in Dakins solution and pack the resident's wound for 20 minutes and then remove, and then apply a black foam, and wound vac at 125 mmHg continuously. The treatment was to be changed every Monday, Wednesday, and Friday. Review of the May 2015 TAR revealed the resident received the treatments as ordered. A wound care note dated May 15, included that the resident remains on his Clinton mattress and is turned frequently. Interviews were conducted with two LPNs (Licensed Practical Nurse) who were wound care nurses and the DON (Director of Nursing) on May 20 and 21, 2015. The DON and wound care nurses explained that a Braden scale assessment would be completed on admission, but the DON later explained that they were no longer being done, and that all residents admitted were considered at risk for skin breakdown. The wound care nurses explained that residents admitted with a pressure ulcer or who developed a pressure ulcer are assessed by the nurse to include the description of the wound bed, measurements, and initiation of treatment and a care plan, but the nurses were not to stage a pressure wound. The wound care nurses stated that they assess the wounds when developed and upon admission and ensure that appropriate treatments are in place and conduct weekly assessments of the wound. They stated that the weekly assessments should include measurements and description of the wound bed, but the staging of the wound was typically based on the wound care physician's weekly assessment. They also stated any current or new interventions implemented would be included in the resident's pressure ulcer care plan. During interviews with the DON on May 21, 2015, the DON stated after review of the resident's clinical record that she could not locate any other weekly assessments for the resident's wound. On May 27, 2015 at 11:22 a.m., the resident was interviewed regarding a turning schedule prior to receiving the Clinitron mattress and stated that staff did not turn him every two hours and that he was not on a turning schedule. The resident explained that he needs to call staff to turn him. During interviews with the DON on May 27, 2015, after review of the resident's clinical records, the DON stated that she could not find any documentation that treatments were provided on the missing days in February, March, and April 2015. In addition, the DON stated that the low air loss mattress was not received until March 2015 and was unable to explain why there was a delay. -Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A History and Physical dated November 5, 2014 documented .He is paraplegic.he has a stage four ulcer on his left lower thigh, a left heel wound, and a right dorsal foot wound. A physician's order dated November 5, 2014 included Foot: Apply waffle boot to protect and float both heels. If extra padding is needed then loosely wrap Kerlix roll gauze dressing across the foot and lower leg before applying the waffle boot. A physician's order dated November 27, 2014 documented to float heels while out of bed. However, according to the clinical record, there was no documentation that the waffle boots had been applied in November or December 2014 and no evidence that the resident's heels had been floated when out of bed, in December 2014. A care plan dated January 14, 2015, identified that the resident had limited physical mobility related to neurological deficits, contractures, [MEDICAL CONDITION], multiple wounds, and had bilateral foot drop on admission. The goal included that the resident will remain free of complications related to immobility which included contractures and skin-breakdown, through the next review. The interventions included to monitor, document and report any signs of skin breakdown. Further review of the care plan revealed the physician's orders to float the resident's heels while out of bed and to apply the waffle boots were not included. Continued review of the clinical record revealed there was no documentation that the waffle boots had been applied, nor that the resident's heels had been floated while out of bed from January through April 6, 2015. There was also no physician's order to discontinue the floating of the heels or the waffle boots. A SBAR (situation, background, assessment, recommendation) Communication Form dated April 7, 2015, now documented that an open wound was observed on the resident's right heel. A Wound/Skin assessment dated [DATE] revealed that the open wound to the right heel was a deep tissue injury, which measured 3.5 centimeters (cm) by 2.0 cm, with no depth. The wound had scant serous sanguineous drainage and was red in color. A physician's order dated April 7, 2015 documented to Cleanse right heel with [MEDICATION NAME], apply [MEDICATION NAME] and cover with adhesive foam dressing. Change daily and as needed until healed. An interview was conducted with the ADON (Assistant Director of Nursing) on May 20, 2015. The ADON stated that the physician's order to float the resident's heels did not get documented on the resident's care plan for the CNA's (certified nursing assistants) to implement. The ADON stated that she was unable to provide documented evidence of what interventions were in place to prevent the development of the deep tissue injury to the resident's right heel. An interview was conducted with the DON (Director of Nursing) on May 21, 2015. The DON stated that she was now going to implement a task in the computer for the CNA's to document when a resident's heels are floated. -Resident #209 was admitted to the facility on [DATE], and discharged to the hospital on February 17, 2015. The admitting [DIAGNOSES REDACTED]. Review of the Skin Review Sheet dated February 4, 2015, revealed that the resident had a scratch to the upper right thigh, but no documented evidence of a pressure ulcer at the time of admission. Review of the Admission Nursing Data Collection assessment dated [DATE], revealed that the resident had no wounds. However, review of the Weekly Wound Meeting Flow Sheet dated February 5, 2015, revealed that the resident had an unstageable/eschar pressure ulcer of the left ischium that measured 2.5 cm. by 1.0 cm. No further description of the wound was noted. Review of the closed clinical record revealed that no physician orders for wound treatment were obtained upon admission for the pressure ulcer. Review of the pressure ulcer care plan dated February 6, 2015 revealed to follow facility policies/protocols for the treatment of [REDACTED]. Review of the SBAR form dated February 7, 2015, revealed that the resident had an open area that measured 1.5 centimeters (cm) by 2.3 cm with a depth of less than 0.1 cm. A physician's order was obtained on February 7, 2015, to cleanse the pressure ulcer with wound cleanser, pat dry, and cover with [MEDICATION NAME]. The order did not include how often the treatment should be provided. Review of the TAR revealed that wound care was not provided from February 13 through 17, 2015. Review of the Weekly Wound Meeting Flow Sheet revealed that the left ischium pressure ulcer measured 1.0 cm by 1.0 cm for the second week of care. Further review of the closed clinical record revealed there was no documentation of any description of the wound bed. An interview was conducted with the DON on May 21, 2015. The DON stated that this resident had an unstageable pressure ulcer on his left ischium at the time of admission. She also stated that she does not know why no orders were received until after the resident had been in the facility for three days. Review of the facility policy on Assessing the Resident with a Pressure Ulcer dated as revised on November 2014 revealed that Pressure ulcers should be uniformly described to facilitate communication among associates and ensure adequate monitoring of the progress toward healing.To monitor progress or deterioration of the ulcer, the clinician must accurately measure the length, width and depth of the ulcer and describe the sinus tracts, tunneling undermining, necrotic tissue, exudate and presence or absence of granulation tissue and epithelization.To determine adequacy of the treatment plan, it is essential to monitor pressure ulcers at consistent intervals, Assessment and documentation should be carried out at least weekly, unless there is evidence of deterioration, in which case both the patient and the patient's overall management must be reassessed immediately. Further review of this policy revealed that A pressure ulcer with adequate intervention and vascular supply should show evidence of healing in 2 weeks. Sub-optimal healing may be attributed to inadequacies of the treatment plan or failure to adhere to the treatment plan. Review of a facility policy regarding Evaluation of Potential Pressure ulcers, revised on November 2014 revealed that residents will have an assessment of their skin condition to assess for any abnormal condition.If the resident is admitted with a pressure ulcer, a completed description of the ulcer is written in the nursing history, including size, anatomical location, state of development, drainage, odor, color, tissue involvement, treatment in process and treatment orders.If the resident has no treatment orders for the pressure ulcer or wound, the physician is immediately contacted for orders.The physician's order should include specific site to treat, cleaning solution, primary dressing, secondary dressing, and frequency of dressing change. The policy also included that VI. All bed-bound residents and residents who are at risk to develop pressure ulcers are placed on a turning and repositioning schedule.VII. Each resident who is not mobile is repositioned or turned, depending on their condition, at least once every two hours by the resident assistant responsible for the resident's direct care.IX. Chair bound residents are repositioned and also assisted in exercising.

Based on clinical record review, facility documentation, staff interviews, and review of facility policy and procedures, the facility failed to ensure that services provided met professional standards of quality, by failing to ensure CPR was initiated and that 911 was called for one resident (#208). Findings include: Resident #208 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a form titled Advance Directive Acknowledgement, which documented the resident was a full code. This form was dated [DATE]. According to the Record of Admission form, the resident was listed under code status as a "full code." Review of the facility's investigative documentation included that resident #208 was assessed as stable at 2:30 a.m. on [DATE]. The resident was re-assessed at 3:30 a.m., which showed no change in the residents' condition and showed no signs of respiratory distress. At 5:05 a.m., the LPN entered the residents' room to find the resident nonresponsive and lacking a pulse. At that point, the LPN called the unit manager. The unit manager arrived some ,[DATE] minutes later, as she was in another building and was told by the LPN that the resident had expired. Further documentation included that CPR was not initiated and 911 was not called. During an interview on [DATE] at 12:45 p.m., the LPN providing care to the resident that night stated that she did not think to call 911 or start CPR. She said that she called the manager who was in another building so it took her 10 or so minutes for her to get there. She stated that when the Unit Manager arrived the manager told her to go about her night and she would handle the paperwork. She also stated that during the prior shift they were attempting to switch the residents' code status to DNR, but were unable to accomplish it prior to shift change that night and that it was to be completed the next day. During an interview with the RN unit manager on [DATE] at 1:00 p.m., she stated that she did tell the LPN she would help with the paperwork. She stated that she did not think about calling 911 or starting CPR, as it looked like the resident had already passed. She stated that she was unaware of the initiation to change the code status until after the event with the resident took place. During an interview with the Assistant Director of Nursing on [DATE] at 9:50 a.m., she stated that if a resident was nonresponsive and pulseless, the next steps would include calling 911 and initiating CPR. Review of the facility's CPR policy included that "CPR is initiated when there is a recognized cardiac and/or [MEDICAL CONDITION] arrest. "

Based on clinical record review, staff interviews, review of facility documentation, and review of facility policy, the facility failed to ensure adequate supervision was provided for one resident (#3) which resulted in a suicide attempt. Findings include: Resident #3 was originally admitted to the facility October 2, 2009, and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Clinical record review revealed care plans for resident #3 originally dated September 18, 2010, that addressed problems that included an alteration in mood and behavior related to a [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed physician admission orders [REDACTED]. Review of the resident's clinical record revealed a skilled nursing sign out/check in policy that was signed by the resident on November 7, 2010. It stated that the resident was to notify a Registered Nurse (RN) if she would be leaving the facility and were required to sign out and sign back in upon return. Despite the physician's order [REDACTED]. Review of a quarterly skilled nursing assessment dated [DATE], included that the resident did not have a history of leaving the facility without needed supervision as well as did not have a history of leaving the facility without informing staff. Review of nurses notes included an entry dated January 6, 2012, that the resident had been out of the facility during the night and upon return " smelled like alcohol and assumed that patient would have possibly been consuming alcohol. " No documentation was included as to what interventions were implemented to ensure this or any other harmful situations related to resident #3 would not reasonably occur. The most recent care plan updates were documented as completed on February 27, 2012. Included in the risk of injury careplan was an intervention to identify high-risk situations and help the resident to avoid them. No documentation was included regarding the date of this intervention to determine if it was in place prior to the February 27, 2012. There were no care plans related to elopement risk for resident #3 located in the clinical record. On February 13, 2012, resident #3 was found outside the facility, at a strip mall down the street. While at the strip mall, the resident attempted suicide by cutting her leg with a knife. A 911 call was placed notifying the local police department and emergency medical systems. The resident was then transferred to a local hospital. An interview was conducted with the Director of Nursing (DON) on May 7, 12 at 1:10 p.m. The DON stated that a resident must have a doctor ' s order to be able to leave the facility. She also stated that when a resident did leave, they must notify an RN, sign in and out of the log book, and notify the staff upon the resident's return. The DON stated that the resident was free to wander the facility, which the resident did frequently, but was not allowed to leave the premises. She stated on February 13, 2012 that the resident eloped from the facility and did not have permission to leave. An interview was conducted with the Executive director, DON and regional nurse specialist on May 7, 2012 at 3:10 p.m. The regional nurse specialist stated he was at the facility the day of the attempted suicide and that the resident eloped from the facility and had never eloped before. He stated that on February 12, 2012, the resident's boyfriend had broken up with her and that she had also received a 30 day facility discharge notice related to the resident's smoking non-compliance. He stated that the resident had been reprimanded numerous times for smoking in non-smoking areas. An interview was conducted with a Licensed Practical Nurse (LPN) on May 8, 2012 at 03:00 p.m. She stated that the resident would frequently leave the facility premises and often times without signing out or notifying staff. An interview was conducted with the facility ' s case manager on May 8, 2012 at 03:10 p.m. She stated that the resident would often leave the facility to go to the pharmacy, to eat lunch at a local restaurant or be seen across the street. An interview was conducted on May 8, 2012 at 03:15 p.m. with the facilities clinical regional RN. He stated that since there was documentation that the resident signed in and out of the facility numerous times and was not allowed to, that "the facility has to own up to it". An interview was conducted with the DON on May 8, 2012 at 03:20 p.m. and she stated that the resident was very aware that she was not allowed to leave facility. The DON was unable to explain all of the residents signatures in the sign in and out log books for 2010 and 2011 and stated then "I guess we own it". The facility policy entitled " skilled nursing sign out and check in policy " states that a three step process must be observed. This includes notifying the nurse the day before the expected day away from the community, signing out and checking in by signing in the log book, and notifying the nurse upon arrival. It also states that if the above process is not followed that the facility must assume that the resident is not in a safe situation and that the local law enforcement agency would be contacted. During a re-certification survey dated December 8, 2011, the facility was found to not be in compliance with certain regulations, including F323 (42 CFR 483.25(h) (1) and (2) Accidents and Supervision.) During a follow-up survey dated February 2, 2012, the facility was found to be in continued non-compliance with F323. Since the facility was in an active plan of correction at the time of the incident on February 13, 2012, had identified resident #3 as a resident who would no longer able to be cared for by the facility, and had provided the resident with a 30 day notice, this incident related to lack of supervision is being cited as past non-compliance.

Based on observations of current facility practice, clinical record reviews, resident interviews, staff interviews, review of facility documentation, and review of facilty policies and procedures, the facility failed to provide supervision for one resident (#177) with a known history of hypersexuality to prevent the resident from being revictimized by one resident (#227). The facility also failed to supervise and monitor one resident (#289) during a hypoglycemic event which increased the potential for a fall, failed to assess and supervise one resident (#205) who smoked, failed to supervise one resident (#290) with documented unsafe behaviors, failed to supervise multiple residents for the safe administration of medications, and failed to ensure chemical cleaning agents were properly secured. The facility failed to prevent medications, for three residents (#s 194, 207, 285), had been found unattended on the residents' overbed tables. Findings include: -Resident #227 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a Monthly Nursing Summary dated September 4, 2011, which documented "Occasionally socially inappropriate." -Resident #177 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a psychiatric consultation dated November 9, 2011, in the resident's clinical record documented "The concerns were as follows: (1) (Resident's name) hypersexuality and relations with male residents, (2) is (resident's name) able to give consent for sexual interactions? and (3) is (facility) an appropriate placement for (resident's name)...Dr...also expressed concerns that (resident's name) placement at (facility) is not an appropriate placement. She feels that returning (resident's name) to the behavior unit at...would be more appropriate. (Resident's name) has a history of inappropriate sexual interactions and unhealthy relationships. The availability of older men at (facility) allows for (resident's name) revictimization of herself. This is an unsafe environment for her...Recommendations: Capacity evaluation to determine if (resident's name) is psychologically able to consent to sex. Consultation with case manager regarding placement and concerns of treatment team." There was no documentation in the resident's clinical record that a capacity evaluation was done or whether an alternative placement was discussed. Nurse's Notes dated November 12, 2011, documented "Resident has male visitor and able to voice needs." Another psychiatric consultation dated November 15, 2011, in resident #177's clinical record documented "...She is upset that the physician assistant talked to me about her sexual relationship with her boyfriend. (Resident's name) is also upset for staff becoming involved when she had her hand on her boyfriend's knee. Staff has discouraged PDA (public display of affection) however they have said that (resident's name) is allowed to have her boyfriend in her room...Expressed concern about (resident's behaviors). Stated that the goal is for her to continue with stability. Expressed additional concern that the stability may not be able to be maintained with (resident's name) engaging in sexual behaviors." There was no documentation in the resident's clinical record that a care plan was developed to address the resident's hypersexuality. Nurse's Notes dated November 22, 2011, documented "Writer walks in room and resident begins to state that she cannot sleep, writer asks her why, resident stated 'you just don't know about my sexual history.' Writer assured resident that she doesn't have to tell her about her sex life, resident informed that it is inappropriate for me to talk about sex with her." A review of a Witness Statement dated November 22, 2011 documented "While doing medication pass was passing by room...and patient...called me in her room. I went in patient was visibly upset and crying she instructed me to sit down she needed to tell me something important...told me she no longer wanted the relationship with...She said that for about a week he has been going in her room and fingering her while she has been asleep and it wakes her up. She said that the other day he "f-----" her with his cane and also stuck Vaseline and lotion up in her vagina. She was crying and said I know at first I wanted this but after he did this to me with his cane and fingering me while I'm asleep I want him to stay away from me. She said she tried breaking up a week ago but he cried and wouldn't let her. She said she can't be around him he makes her feel horrible. I went to administrator and informed him immediately." There was no documentation in the resident's clinical record that supervision was provided to resident #177 to prevent revictimization. A further review of the resident's clinical record revealed Social Service Progress Notes dated November 22, 2011, which documented, "Spoke with (resident's name) about relationship with (resident #227). Relations became more involved with objects used because (resident #227) can not perform sexually. (Resident's name) stated that all acts were consentual (sic) between them. Therapist visited her and she realized that she was questioning relationship was making her uncomfortable." A summary dated November 23, 2011, of the Witness Statement dated November 22, 2011, documented "Resident was found in her room...visibly upset and crying...(Resident #177) informed...she no longer wanted a relationship with resident (#227)...(Resident #177) and (Resident #227) are on the same unit in different rooms...(Resident #177) requested (resident #227) be moved off the unit. (Resident #227) has refused to be moved...(Resident #177) was moved off the unit...There is no sexual misconduct by (resident #227). This was a consensual relationship." However, a review of resident #177's clinical record revealed Nurse's Notes dated November 23, 2011, which documented "Room change not done. Unable to move bed." Despite this nurses note, no evidence was revealed that a plan for increased supervision was implemented since resident #177 and #227 rooms were adjacent to one another. The resident's clinical record revealed Skilled Nursing Complexity of Care dated November 30, 2011, which documented "Resident complained of increased anxiety and anger with mother and male friend." Nurse's Notes dated November 30, 2011, documented "Resident to dinner with male friend." The resident's clinical record revealed a Skilled Nursing Complexity of Care form dated December 1, 2011, which documented "STD (sexually transmitted disease) labs drawn." Nurse's Notes dated December 1, 2011, documented "...Crying on and off expressing feelings of shame and sadness." Social Service Progress Notes dated December 2, 2011 documented "Resident attended a gynecologist appointment and revealed her relationship with a peer at Immanuel Campus of Care. Resident assured us that all acts again were consentual (sic). Officer...was called in to investigate the relationship for possible sexual abuse." The resident's clinical record revealed a Change of Condition 72 Hour Alert Charting dated December 2, 2011, documented "Dr. office notified facility regarding an incident that happened between this resident and other resident in facility." A review of the resident's clinical record revealed a physician's orders [REDACTED]." A review of the resident's clinical record revealed the resident was moved to a different room on a different unit on December 2, 2011. A review of the resident's clinical record revealed a Witness Statement dated December 2, 2011, which documented "Resident also stated that everything that happened she consented to except for the perfume bottle that he inserted rectally. Resident did admit that she was afraid to say no to other resident. She also explained that other resident would come into room at night when she was sleeping and finger her. Administrator asked patient if she had notified anyone in our facility of incident and resident stated 'I don't remember who I told.' Resident also stated that she didn't think it would go this far." An interview was conducted with resident #177 on December 5, 2011. The resident stated that she had many sexual issues in her past. The resident stated that resident #227 inserted a perfume bottle into her rectum, fingered her while she was asleep, and inserted his cane into her vagina. The resident stated that resident #227 removed a tobacco pouch from his mouth, inserted it into her vagina, and back into his mouth again. The resident stated that resident #227 asked her to get on a bed pan and he stated to her "let me finger you while you pee." The resident further stated that she is embarrassed about her relationship with resident #227 and has stayed in her room since the police came to the facility on [DATE]. The resident stated that her mother was mad at her over the situation. An interview was conducted with the social worker (staff member #6) on December 5, 2011. The social worker stated that she became aware of the relationship between residents #'s 177 and 277 the week of November 21, 2011. The social worker stated that resident #177 told her she was uncomfortable with the relationship. The social worker stated that she doubted that resident #227 had inserted a perfume bottle into resident #177's rectum. The social worker stated that resident #177 was never moved into a different room on November 23, 2011. The social worker stated that she thought the residents would have been monitored and resident #177 moved to a different room, but it didn't happen, The social worker stated that she knew that resident #177 was uncomfortable with the relationship. The social worker stated that resident #177 told her that resident #277 inserted a cane into her vagina. The social worker then stated that she did not know if resident #177 knew the difference between a good relationship and a bad relationship and on November 24, 2011 "everything came to a head." During the interview with the social worker on December 5, 2011, she stated that she reviewed the psychiatric consultations dated November 5 and 19, 2011 on November 22, 2011 and reviewed them with a supervisor. The social worker stated that the resident is her own person and she did not give consent to be moved. An interview was conducted with the social services assistant (staff member #7) on December 5, 2011. The social services assistant stated that we did nothing to prevent this from happening. The social services assistant further stated that she "absolutely" thought something should have been done to prevent the situation. The social services assistant stated that resident #177's placement was inappropriate for this facility. The social services assistant stated that the unit that the residents were on was one of the most isolated and least supervised because the doors were always closed because they open to the outdoors. An interview was conducted with an LPN (licensed practical nurse, staff member #3) on December 6, 2011. The LPN stated that resident #177 told her that she did a lot of sexual things with resident #227, that she allowed him to use a cane and a perfume bottle. The LPN stated that she "absolutely" thought the relationship between the two residents was inappropriate and that she reported it immediately to the administrator on November 22, 2011. An interview was conducted with the DON (director of nursing, staff member #5) on December 6, 2011. The DON stated that the relationship between the two residents was consensual. An interview was conducted with the administrator (staff member #4) on December 6, 2011. Although the Witness Statement dated November 22, 2011, was given to the administrator, the administrator stated that he was unaware that objects were inserted into resident #177's vagina and rectum as he could not recall all the details. An interview was conducted with resident #227 on December 7, 2011. The resident stated that he was involved in a relationship with resident #177 and it was sexual. The resident stated that they "tried" it one time on the bed and one thing led to another. A review of an untitled facility policy documented "...will identify, correct and intervene in situations in which abuse...is more likely to occur. This includes the analysis of...Features of the physical environment that may make abuse...more likely to occur, such as secluded areas in the community...The supervision of staff to identify inappropriate behaviors." -Resident #290 was admitted to the facility December 18, 2009. Clinical record review revealed a history and physical dated December 21, 2009, included that resident #290 had [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated [DATE], included that the resident had signs of delirium including inattention and disorganized thinking. Further documented was the assessment section related to the resident's mood that included the resident was assessed by facility staff to be short-tempered and easily annoyed. In addition, on one to three days during the assessment period the resident was documented to have rejected evaluation or care necessary to achieve the resident's goals for health and well-being. A review of the resident's Care Area Assessment Summary and Documentation Notes dated December 17, 2010, included that both cognitive loss/dementia and behavioral symptoms were care planned. Both the cognitive loss and behavioral symptoms documentation notes included that the resident frequently refused his medications. A review of resident #290's care plan dated December 22, 2010, for noncompliance with treatment plans related to medication therapy included that the physician would be notified regarding non-compliance, that social services would meet with the resident and discuss concerns, and that the physician would educate the resident on risk of non-compliance with taking medications. A review of resident #290's care plan dated December 22, 2010, for high risk of inappropriate behavior secondary to dementia, aggressive and combative behavior, resistance to care and paranoia, included to medicate as ordered, redirect resident when behaviors manifests, notify physician of increase or change in behavior as well as several other non-pharmacological interventions. Review of nurse's notes dated December 9 through 13, 2010, revealed the resident was frequently non-compliant with taking medications and that the physician had been notified. On December 13 and 14, the resident was now documented to be verbally aggressive to staff. On December 15, 2010, nurse's notes included a psychiatric evaluation was ordered related to the resident continuously refusing medication. On December 16, 2010, nurse's notes included that the resident became increasingly agitated related to administration of medications. On December 19, 2010, nurses notes included that resident #290 was now verbally aggressive toward the CNAs when they provided care to resident #290's roommate. Also documented was that the resident's disruptive behavior continued for approximately 30 minutes. However, clinical record review revealed no evidence that the resident's care plan had been updated regarding any safety concerns towards the resident's roommate, or that the physician had been notified related to the resident's escalating behavior. Nurse's notes dated December 20, 2010, included that resident #290 was now banging on the wall with his cane and threatened CNAs and nurse when coming in room. Also documented was that the resident was "very difficult to approach, swinging cane at staff." On December 22, 2010, the resident continued to be combative and was now "swinging metal grabber at staff." Again, no care plan updates were located in the clinical record regarding potential safety concerns surrounding resident #290 towards his roommate, removal of dangerous objects, removal of the roommate, or more frequent monitoring, or that the physician had been notified related to the resident's continuing escalated behavior. A change of condition charting dated January 13, 2011, included that resident #290 had refused his vital signs and threatened staff with metal grabber. Also documented was that the resident's roommate, resident #142 reported resident #290 hit him on his right arm with the metal grabber. Clinical record review for resident #142 included that that on January 13, 2011, the resident now had a bruise of four by three centimeters, and that the resident was moved to another area. Review of facility investigative documentation included a CNA who worked on the unit and stated that on January 13, 2011, resident #290 was observed to try to hit resident #142 in the head and his body using his cane. Further review included that resident #142 now had a bruise to his right arm that measured four by three centimeters. In an interview conducted December 7, 2011, licensed staff stated that interventions related to a resident who begins exhibiting behaviors and agitation depended on the resident's baseline. In response to a specific question about the behaviors escalating to a point of concern of safety, licensed staff stated that they could increase supervision, do an emergency psych consult, or call the police in the case of an assault. -Review of facility documentation dated March 3, 2011, related to a potential verbal abuse investigation, included written statements from CNAs and a nursing supervisor that medications for three residents (#s 194, 207, 285) had been found unattended on the residents' overbed tables. Nurses notes for resident #194 included that on August 29, 2011, at 5:30 a.m., a nurse documented that she had given the resident her medications including the narcotic pain medication oxycodone with water, but that at 5:45 a.m. the resident told a CNA she had dropped all her pills on the floor. Further documented was that the CNA crawled under the bed to locate all the pills including the narcotics. Also documented was that "resident instructed we will have to watch her swallow meds due to this situation." Observations during the survey included that on November 28, 29, and 30, 2011, on the Pleasant Cove and Garden Cove units, both treatment carts with ointments on top and unlocked and unattended medication carts were observed. A total of four incidents were observed. In an interview conducted on November 30, 2011, at 8:30 a.m., regarding the treatment cart with ointments on top, licensed staff stated sometimes the CNAs need to get a band aid for a resident. Staff further stated it should be locked and she could just give the keys to the CNAs. In an interview conducted December 2, 2011, licensed staff who cared for resident #194 stated that she had become employed with the facility recently, but that she did not have any residents that could self administer their medications. Staff also stated that she did not recall the section in the chart that would assess the ability of a resident to administer their own medications to have been completed since all residents were administered their medications by the nurse. Review of facility policy "Department Safety Rules: Nursing Department Safety Rules" included "m. Treatment carts are to be locked when not in use or out of view. medicine cabinets and carts are to be locked at all times when not being used." and "n. Medications/treatment solutions should be kept locked." -Resident #289 was admitted to the facility February 23, 2011, with [DIAGNOSES REDACTED]. Review of the closed clinical record included admission nursing data collection, dated the day of admission, with information related to the resident's behavioral symptoms, history of falls/accidents, risk factors for falls, and physical limitations. The form was for data collection only, and was not set up as a tool that could be individually scored, so the resident's fall risk was not assessed. A discharge MDS assessment coded the resident with no falls prior to admission, and one fall without injury, while at the facility. An interim care plan, dated the same day, included a fall care plan with the goal stated: resident would remain free from injury related to falls, and approaches included physical and occupational therapy referrals, call light within reach, and to check the resident every one to two hours. Further review of the closed clinical record included a change of condition/72 hour Alert charting form, dated February 27, 2011. This form was initiated due to the resident's fingerstick glucose result of 68 milligrams per deciliter. The first entry, timed at 4:00 p.m. described the glucose result, and food/drink given to the resident, the second entry, at 4:10, documented the fingerstick glucose result, when rechecked, had risen to 78, and that the resident's physician was notified. The final entry, timed 6:00 p.m., included that the resident was stable, and that nursing would continue to monitor the resident. There were no additional entries regarding the resident's condition for the rest of the evening. There were no entries for the entire night shift, no documented evidence that the resident was monitored as per the physician's orders [REDACTED]. An additional change of condition/72 hour alert charting form was initiated on February 28, 2011, and was timed 5:00 a.m. Only the initial assessment portion of the form was completed, and documented that the nurse entered the room for medication pass, and found the resident sitting on the floor beside the bed. Per the nurse, the resident stated that he thought he could stand, but his feet slipped out from underneath him. The note ended that the resident was uninjured, had not hit his head, that he could move all four extremities, and that he was assisted back to bed. There was no additional documentation on this form. The next entry, five hours later, was located on a daily skilled nurses notes, timed at 10:00 a.m., and included that the resident was non responsive to sternal rub, with decreased oxygen saturation, and blood pressure of 78/42, and that the physician was notified. The resident was transported to the emergency room . There was no documentation of the resident's condition from 5:00 a.m. until he was sent to the emergency room at 10:00 a.m. During an interview conducted on December 1, 2011 at 11:00 a.m., the DON stated that the incident report that was to be completed post fall could not be found, and theorized that, since the staff member responsible for entering data from incident reports into the computer was no longer employed, that maybe he had taken them. The DON stated that they have been unable to find some incident reports this staff member was working on. She also acknowledged that there was no documentation of resident assessments, evidence of monitoring, or other pertinent resident information from 6:00 p.m. on February 27, until 5:00 a.m. February 28. The facility policy for change of condition/72 hour alert charting was provided verbally, as evidenced by several staff nurses stating that when the change of condition form was initiated, then every shift was required to document the resident's condition, for 72 hours, after the change of condition/incident occurred. -Resident #205 was admitted to the facility March 8, 2010, with [DIAGNOSES REDACTED]. A smoking assessment, dated July 29, 2010 was located. This form documented that the resident had been determined to be a safe smoker. Review of the clinical record included monthly nursing summaries, the first dated May 8, 2011, included that the resident smoked in unauthorized areas. On June 23, June 30, and July 4, 2011, on a form entitled Skilled nursing weekly acuity assessment, staff documents that the resident was hostile at times when told not to smoke outside on the bridge. On July 7, 2011, the monthly nursing summary stated that the resident cusses at staff when he can't smoke on the bridge. A care plan, initiated July 15, 2011, was reviewed. The problem was stated: Resident used tobacco as evidenced by resident smoking independently in designated area. The goal identified that the resident would not have injury related to tobacco use through the next review, with interventions for resident education on health benefits of quitting tobacco use, and resident education on safety precautions related to tobacco use. There was no evidence that the care plan had been updated to reflect the resident's refusals to smoke in the designated area only, or any other interventions considered besides education. The clinical record also included nursing notes that documented multiple instances of the resident smoking in non-designated areas (as described above), with the resident's response often a profanity, or refusal to put out the cigarette. These notes begin in October 2011. On November 28, 2011, between 5:30 and 6:00 p.m., the resident was observed to be smoking on the second floor of the facility, on a bridge connecting two of the facility buildings. He was less than 20 feet from an open door to another resident's room. A staff member was asked if this resident was allowed to smoke here; the staff stated "He can smoke". On December 1, 2011, at 2:45 p.m., the resident was again observed smoking on the same bridge; he was only five feet away from a door. An interview was conducted immediately with a facility staff member, who stated that resident #205 had been told "many times" not to smoke on the bridge, and had done it many times before. During an interview conducted December 2, 2011 at 11:00 a.m., the unit manager stated that smoking assessments were completed upon admission, and then quarterly. He did not know why resident #205 had only one assessment done in the year and a half that he had been living there. Nurse's notes documented that on December 3, 2011, at 10:00 a.m., resident #205 was observed smoking in a non-designated area, on the second floor bridge. The nurse documented that he/she requested the resident put the cigarette out, which the resident refused. The unit manager was notified, who also attempted to "re-enforce safety." There was no additional documentation on that day. On December 5, 2011, the facility provided a list of "independent" and "supervised" smokers. Resident #205 was on the independent smokers list. During an interview conducted December 7, 2011 at 11:00 a.m. the unit manager stated that the resident had been an unsafe smoker for some time, that when he was caught smoking on the bridge the staff would counsel him, and tell him to go downstairs, and then they would try to confiscate his cigarettes and lighter. He stated that when they can take the cigarettes and lighter away, it is not very long before he has cigarettes and a lighter again. He stated that he suspected that there were other residents who buy extra cigarettes and lighters, and give/sell to resident #205. He stated that they do not know exactly who these residents were, but that they have not initiated any actions to specifically identify those residents, and follow-up. He stated that nursing did their best, but stated the responsibility was now with the administration and the social worker. He stated that sometimes the resident would light a cigarette while on the bridge, then call to the nurses so that they can see him smoke there, because the resident wants to be "kicked out" of the nursing home. He also stated that supervised smokers were not supposed to keep their cigarettes and lighters with them; they were to be kept by Activities department in a box. He stated that resident #205 refused to give up his cigarettes and lighter. He also stated that the resident's designation as a supervised smoker would not make any difference to the resident, since they were unable to make him comply with the rules. The facility was unable to provide policies regarding smokers or smoking assessments. -An observation was conducted on November 29, 2011 at 9:33 AM. The Janitorial closet door located on the Golden Heights Unit had a missing door knob, which prevented the closet from being securely closed. The Janitorial/Hazard/Materials closet contained two cleaning carts. Also identified in the closet was a product identified as H2 Orange (Envirox Concentrate 118). An interview was conducted on November 29, 2011 at 9:40 AM with a housekeeper. The housekeeper did not know how long the door knob was missing. A review was conducted of the Material Safety Data Sheet documented that "...Cleaning with H2 Orange, Section 3-Hazard Identification, Skin: May cause skin irritation, dry skin or stinging sensation, Eyes: may cause eye irritation, Ingestion: May cause stomach upset or nausea. Product is mildly toxic..." A review was conducted of the facility's documentation. The documentation stated to "...Keep janitor closets and storage closets locked to prevent residents coming in contact with hazardous chemicals... "

Based on clinical record reviews, observations, resident and staff interviews, and review of facility policies, the facility failed to implement policies and procedures to ensure that accurate smoking assessments were completed, and that those residents, who met the criteria of an unsafe smoker, were consistently supervised when smoking and that their smoking materials were secured. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on February 1, 2012, for six residents (#s 21, 14, 16, 17, 22, and 13). The sample size was six of seven. Findings include: Based on concerns for the resident's immediate safety, the condition of IJ was identified on February 1, 2012 at 4:50 p.m. The facility provided a plan of correction to the team at 7:45 p.m. The immediacy of the condition was lifted, but not abated at 8:30 p.m. On February 2, 2012, at 9:15 a.m., the facility provided the second updated plan of correction for review. Further documentation was provided of the Smoking policy In-Service to be implemented. A Resident Council meeting was held to informed all facility residents of the new smoking policy on February 2, 2012. Photo resident information books were implemented. The facility was informed that the IJ placed the facility in SQC and extended survey was conducted. Based on the third plan of correction date February 2, 2012 at 10:45 a.m., and verification of the facility's implementation of their plan of correction, the condition of IJ was abated on February 2, 2012 at 11:15 a.m. -Resident #16 was readmitted on [DATE], with [DIAGNOSES REDACTED]. During a random observation conducted on February 1, 2012 at 4:00 p.m., the resident was observed seated in his wheelchair, outside smoking by an exit door, which was not a designated smoking area, and without a smoking apron on and without supervision. An interview was conducted at this time with the resident, who identified himself, and stated that he had a cigarette behind his ear and that he had asked another resident (un-named) to light the cigarette for him. Following this interview, a facility staff person was observed to walk pass the resident and not escort or inform him of the designated smoking areas. At the same time, another staff person was observed to escort the resident to the designated smoking patio. An interview was immediately conducted with that staff person. She stated that although she was off duty, it was still her responsibility to ensure that the resident smoked at the designated smoking area. She also stated that the resident had recently had cigarettes and a lighter removed from him and that he was not always compliant with the facility's smoking rules. Following this observation, the resident's clinical record was reviewed. The clinical record included a smoking assessment dated [DATE]. The smoking assessment included 16 questions to be answered to determine if a resident was a safe smoker. The assessment included the following instructions: "If all of the answers on the assessment are True, the resident is determined to be a safe smoker. If any of the answers on the assessment are False, the resident is determined to be an unsafe smoker and may not have smoking privileges." The smoking assessment included documentation that two of the 16 questions included in the assessment were answered false. The two false questions and answers were as follows: -Resident does not have any upper extremity limitations: False -Resident does not have any lower extremity limitations that would not allow the resident to access the designated smoking area independently or use the emergency water supply: False However, despite the two false responses and the smoking assessment instructions, the resident was assessed to be a safe smoker. Although the resident did not met the criteria for a safe smoker, a smoking care plan (dated December 20, 2011) included conflicting documentation that the resident was an independent smoker. A continued review of the clinical record revealed a Change of Condition/72 Hour Alert Charting entry dated January 11, 2012. The documentation included that the resident had been observed smoking in a non-designated smoking area and that a smoking assessment had been completed and that the resident was now a supervised smoker. A nursing note entry dated January 13, 2012, included documentation that the resident continued to go out on the patio to smoke, however the documentation did not include that he was supervised while smoking. The documentation also included that the resident stated that he understood the rules but that he could not follow them. Another nursing note entry dated January 14, 2012, included documentation that the resident was on the balcony (not a designated smoking area) and that he had flicked his cigarette off the balcony, while people were underneath the balcony. Per the documentation, the resident had been reminded repeatedly not to smoke on the balcony and to go downstairs to the designated smoking area. Although the above actions were observed by staff, there was no evidence staff took action to ensure the resident was supervised to provide safe smoking. As reflected in the most recent smoking assessment the resident required supervised smoking. -Resident #14 was readmitted on [DATE], with [DIAGNOSES REDACTED]. During a random observation conducted on February 1, 2012 at 10:45 a.m., the resident was observed seated in his wheelchair, outside on the smoking patio. At this time, the resident was observed to be handed a lit cigarette from another resident, which he proceeded to smoke. The resident did not have a smoking apron on and facility staff were not observed to be supervising the resident. Before the resident finished smoking the cigarette, a facility staff person was observed to come to the smoking patio, remove a smoking apron from the back pocket on the resident's wheelchair, and put it on the resident. At this time, another staff person was observed to escort other residents to the smoking patio. An interview was conducted at this time with the staff person, who stated that residents were being escorted to the smoking patio for the supervised smoking period. At this time, she identified resident #14 and stated that sometimes the resident required supervision when smoking. She also stated that the licensed staff determine when the resident required supervised smoking and that at this time, she had not been directed to supervise this resident while he smoked. Following this observation the clinical record was reviewed. A review of the clinical record revealed a smoking assessment dated [DATE]. According to the documentation, four of the 16 questions were answered as false. The four false questions and answers included the following: -Resident does not have any decreased level of activity such as sluggishness, staring into space, moving very slowly: False -Resident is able to move from a seated position: False -Resident does not have any lower extremity limitations that would not allow the resident to access the designated smoking area independently or use the emergency water supply: False -Resident can light and smoke a cigarette or other smoking device while demonstrating a safe technique for putting out the matches or lighter and disposing of ash: False Therefore, according to the smoking assessment guidelines and the assessment, the resident was not a safe smoker. A continued review of the clinical record revealed conflicting information regarding the resident's smoking status. A care plan titled, Deficient Diversional Activity, included documentation that the resident was an independent smoker. However, another care plan to address the use of tobacco, included that the resident was identified for the supervised smoking program. In addition, a further review of the clinical record revealed three nursing note entries dated November 20, 23, and December 13, 2011, that included that the resident had been observed smoking in non-designated smoking areas. Per the documentation, the resident was observed smoking in an elevator, and twice inside the facility at different locations. The resident's problematic smoking history included the following: -The entry dated November 20, 2011, included that following the incident of smoking on the elevator, the resident was advised of the smoking policy, counseled and that a message was left for the social service department. -According to the November 23, 2011, entry, the incident of smoking in a hallway was reported to the licensed staff on duty and the Nurse Practitioner. The documentation also included that the resident would now be a supervised smoker. However, the smoking assessment dated [DATE], had already determined that the resident was not a safe smoker. -The last entry dated December 13, 2011, included that the resident was reminded that he was a supervised smoker, and of the designated smoking areas. However, the entry also included that at this time, the resident's cigarettes and lighter were brought to the nurse's station. A further review of the clinical record revealed another nursing note entry dated February 1, 2012 at 11:30 a.m., that included that the activity staff person had reported to the licensed staff that the resident had been observed smoking independently and that a lighter and cigarettes had been taken from the resident. However, this nursing note entry was 45 minutes after the resident was first observed smoking unsupervised on the smoking patio. -Resident #21 was readmitted on [DATE], with [DIAGNOSES REDACTED]. During a random observation conducted on February 2, 2012 at 6:55 a.m., following the identification of IJ and SQC in the area of smoking on February 1, 2012, this resident was observed seated in his wheelchair in the front parking lot of the facility (not a designated smoking area), smoking without facility staff present. At this time, facility staff were notified of the observation. The staff person identified the resident and stated that he was to be supervised while smoking and that he did not always follow the rules. A review of the resident's clinical record revealed two smoking assessments, dated October 31, and December 29, 2011. According to the assessment documentation, three of the 16 questions were answered false. The questions and answers were as follows: -Resident able to move from a seated position: False -Resident does not have any lower extremity limitations: False -Resident does not have any lower extremity limitations that would not allow the resident to access the designated smoking area independently or use the emergency water supply: False According to the smoking assessment instruction guidelines, the resident was not a safe smoker. A continued review of the clinical record, again, revealed conflicting documentation regarding the resident's smoking status. According to a tobacco use care plan, the resident was identified to be an unsupervised smoker, despite the smoking assessment criteria for a safe smoker. Interviews were conducted on February 1, and 2, 2012, with administrative staff, who stated that some residents who required supervised smoking, were not always compliant with the facility's smoking policy. They stated that some residents go to the store and purchase their cigarettes or have them brought into the facility. However, they also stated that when a resident was assessed to not be a safe smoker, their smoking material was to be kept by facility staff and given to the resident by the facility staff, at the assigned supervised smoking periods. At this time, administrative staff acknowledged the discrepancies between the smoking assessment instructions and criteria used to determine if a resident was a safe smoker and the actual identification of those same residents as a supervised smoker. In addition, the corporate nursing consultant stated that not accepting residents who smoke or implementing discharge notices to those residents who habitually do not comply with the facility's smoking policy, would have a great financial impact on the facility. He stated, "We serve the under-served." -Resident #22 was originally admitted on [DATE], and readmitted on [DATE]. [DIAGNOSES REDACTED]. According to a current smoking assessment dated [DATE], there were 16 areas in which the resident was to be assessed to determine if he was a safe smoker. The instructions were to note "True or False" to the individual statements and if the resident had one "False" response he would be considered to be an unsafe smoker. Although the smoking assessment documented a "False" response to one area the resident was assessed to be a safe smoker, which reflected an inconsistency in the determination. The assessment included a statement that the resident was able to understand that smoking materials could only be used in the designated smoking areas. During the course of the follow up survey it was observed that there were two designated areas for smoking. On February 2, 2012 at 6:55 a.m., the resident and one other resident were observed to be smoking in the area of the front door of the facility and without staff present. At this time, facility staff were notified of the observation. A staff person identified the resident and stated that this resident was an independent smoker, however, she also stated that this resident was not to be smoking in the front of the building. She further stated that this resident knew that this was not a designated smoking area but that he was not always compliant. -Resident #13 was originally admitted on [DATE], and readmitted on [DATE]. The resident was assessed to be alert and oriented and able to make needs known. A continued review of the clinical record revealed multiple notations that the resident was at times non-compliant with the smoking policy. A nursing note entry dated November 27, 2011, documented the resident had been seen lighting Kleenex on fire while in the smoking area. When asked by the staff to give them his lighter he refused. He was then educated on unsafe smoking behaviors. A current smoking assessment dated [DATE], and one day after the above described incident, documented the resident was assessed to be a safe smoker. An additional statement documented the resident was able to communicate that he understood that smoking materials could not be shared with any other resident. On February 1, 2012 at 10:45 a.m. resident #13 was observed to be smoking in the designated smoking area. Resident #13 was observed to remove a lit cigarette from his mouth and hand it to resident #14, who then took it and continued to smoke the cigarette. An interview was conducted with the resident on February 1, 2012. He stated he could smoke independently and could keep his cigarettes and lighter. When asked if he ever shared his cigarettes with other residents he stated, "Yes, but no more. A couple of days ago I got into big trouble because I gave a cigarette to a resident who was not supposed to smoke by himself. The staff told me I was in big trouble and if it happened again I would lose my smoking privileges." The resident was then asked if he had given a resident a cigarette earlier this morning. He stated, "Maybe, to tell you the truth maybe it was this morning. Yes, could be." Interviews were conducted with licensed and administrative staff on February 1 and 2, 2012. The staff stated the resident had a long standing history of non-compliant behaviors related to smoking. Staff could not recall when or what the specific incident may have been that the resident referred to of getting into "Big trouble." The staff stated it was a serious problem that resident #13 would give his cigarettes to other residents, particularly those residents who required supervision to ensure safe smoking. -Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the noncompliance care plan date January 2012, documented that the resident had been noncompliant with the facility smoking policy. Review of the previous smoking assessment dated [DATE], revealed the following: The smoking assessment included documentation that three of the 16 questions included in the assessment were answered false. The three false questions and answers were as follows: -Resident is able to move from a seated position: False -Resident does not have any upper extremity limitations: False -Resident does not have any lower extremity limitations that would not allow the resident to access the designated smoking area independently or use the emergency water supply: False Review of the resident's smoking assessment dated [DATE], documented a false for question "the resident does not have any upper extremity limitations (shoulder elbow, wrist, and hand)" next to the false answer was a note "fingers right hand stiff", the back of the assessment The assessment included the following instructions: "If all of the answers on the assessment are True, the resident is determined to be a safe smoker. If any of the answers on the assessment are False, the resident is determined to be an unsafe smoker and may not have smoking privileges." Further review of the assessment had the resident checked to be a safe smoker. On January 26, 2012 the social services notes documented the resident's mood was gruff at times, did not like to be told what to do, and currently goes out to smoke on his own. During an interview on February 1, 2012 at 7:10 p.m., the resident stated he has given smoking materials to his peers, but he was not supposed to give anyone his smoking materials. A facility policy titled, Smoking Policy, included, "It is the policy of...to provide residents with an environment that allows them to exercise their rights by smoking in a specific area when they are capable of doing so independently." The policy also included, "...Smoking will be permitted in designated areas only...A care plan will be implemented...Residents who are assessed as requiring supervision, are only permitted to smoke at assigned times, when supervision is provided by an employee who is assigned to this responsibility...Residents who are assessed as needing supervision must ware smoking aprons while smoking...Smoking materials is kept under lock and key and stored in the activity department..."

Based on clinical record review, hospital record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that three residents (#s 286, 36, and 281) were adequately monitored and assessed to prevent dehydration. The sample size was eight. Findings include: -Resident #286 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was admitted with a new pacemaker. Clinical record review revealed the following physician orders: "April 21, 2011, urinalysis, culture and sensitivity to be obtained on April 23, 2011." A review of the care area assessment documentation notes dated April 22, 2011, revealed that hydration had not been triggered in the assessment. A review of the resident's laboratory results revealed the following: April 23, 2011, blood urea nitrogen (BUN) level was 26 milligrams per deciliter (mg/dL), with the normal range indicated to be 8-25. The creatinine level was 2.86 mg/dL, with the normal range indicated to be 0.60-1.50. Further review of the physician orders [REDACTED]. On April 25, 2011, laboratory results indicated the BUN had risen to 31 and the creatinine level was now 2.17. However, on April 25, 2011, a previous laboratory order was repeated as "urinalysis, culture and sensitivity, may straight cath if needed to obtain". The order was rewritten the same day, April 25, 2011, as "urinalysis, culture and sensitivity in A.M., missed on April 23, 2011". Despite three separate orders, the urinalysis and culture and sensitivity results were not contained in the clinical record. A review of the resident's plan of care dated April 27, 2011, revealed that dehydration was addressed with the following interventions: to assess contributing factors, administer medication per physician orders, honor fluid preferences, encourage fluids throughout the day, monitor labs and offer water with meals. The care plan documented that the resident's propensity for dehydration was related to his medical [DIAGNOSES REDACTED]. However, clinical record review revealed the resident was never documented to have had an order for [REDACTED]. Review of nursing notes dated April 28, 2011, included the resident's mental status as alert and anxious; cardiac: regular rhythm; loose stools, skin: normal. A dietary order dated April 28, 2011, included the following: "give large portions at breakfast weight loss six pounds in one week". On April 29, 2011, nursing notes included mental status: alert, anxious, restlessness, cardiac: [MEDICAL CONDITION] skin was documented as clammy, no loose stools. Given [MEDICATION NAME] for anxiety. On April 29, 2011, the resident's laboratory results continued to deteriorate with the BUN now 41 and the creatinine level now 4.0. Despite the rising levels of the BUN which can be an indication of dehydration even with residents whom are diabetic, the clinical record lacked documentation that this was addressed by nursing. In addition, the care plan regarding hydration had not been updated after the repeated abnormal laboratory test levels. On April 30, 2011, nursing notes included mental status oriented to place and time, skin was clammy. Also on April 30, 2011, the resident was documented to have had an extra large loose bowel movement. On May 2, 2011, nursing notes revealed the following: mental status: no change, cardiac: new pacemaker, skin:normal. given [MEDICATION NAME] for anxiety. A continuing review of nursing notes revealed the following assessments: May 3, 2011, mental status: no change, cardiac: regular rhythm, skin:normal, given [MEDICATION NAME] for anxiety On May 3, 2011, the resident had a large loose stool. May 4, 2011, mental status: no change, cardiac: no change; constipated, skin: normal, given [MEDICATION NAME] for anxiety. May 6, 2011, mental status: no change; cardiac: [MEDICAL CONDITION] constipated, skin: clammy at times, given [MEDICATION NAME] for anxiety. Also documented in the clinical record was that from May 4 through 6, 2011, the resident continued to have "extra large loose stools." "Loose stools" continued to be documented until May 9, 2011. Despite this, a review of the Medication Administration Record [REDACTED]. Review of physician's orders [REDACTED]. A review of the lab results revealed no evidence that a test for the [MEDICAL CONDITION] toxin had been obtained. A review of the documentation of meal intake report revealed the following: May 7, 2011, the resident refused breakfast, lunch and ate 75 percent of dinner. On May 8, 2011, the resident ate 25 percent of breakfast, no documentation for lunch and ate 75 percent of his dinner. On May 9, 2011, the resident ate 25 percent of his breakfast, refused lunch and dinner was not documented. Despite his poor intake the clinical record lacked documentation that at any time liquids were encouraged or that liquid consumption alone was documented. Further review of the physician orders [REDACTED]. On May 10, 2011, the dietician wrote an order to "Give 4 ounces of resource three times a day, severe weight loss 19 pounds in two weeks". Despite these orders there was no documented evidence that nursing offered alternatives when meals were refused or poorly consumed or the reason for lack of appetite. Despite the ongoing loose stools, depressed meal intake percentages, and physician's orders [REDACTED]. Nursing notes dated May 10, 2011, revealed that at "1200 nurse practitioner to see patient. Patient noted to have very elevated creatinine level based on recent blood work, Patient not on [MEDICAL TREATMENT]...patient sent to hospital for treatment and evaluation related to lab levels." A review of the resident's discharge summary dated May 10, 2011, revealed the following documentation; "patient has declined functionally, medically, very lethargic, hallucinating, refusing to get out of bed. Nurse practitioner/physician aware." A review of the hospital emergency records dated May 10, 2011, revealed the following: Blood pressure at 1:10 PM, systolic blood pressure 66 mmHg, diastolic blood pressure 36 mmHg (66/36). At 2:24 PM, blood pressure was: systolic blood pressure 100 mmHg, diastolic blood pressure 56 mmHg (100/56). Doctors notes: "Patient required aggressive fluid resuscitation with several boluses of intravenous fluids total of two liters of fluid, with some improvement of [MEDICAL CONDITION]. Patient presented with severe hypovolemia and had severe [MEDICAL CONDITION] on emergency room arrival with systolic blood pressure down to 60's, require two large bore intravenous given normal saline wide open with frequent reassessments. Patient mental status improved and blood pressure improved with aggressive hydration, will admit to the intensive care unit (ICU). Patient may need [MEDICAL TREATMENT] if creatinine level not improved...Will hold on pressors at this time as his lactic acid is normal and suspect he is still volume depleted, high potential for cardiovascular instability. Lab results dated May 10, 2011 at 12:30 PM revealed creatinine was 7.4 (normal range 0.60-1.40) and BUN was 75 (normal range 8-25)." An interview conducted on December 2, 2011, with the director of nursing (DON) revealed that she believed that the resident had [MEDICAL CONDITIONS] which attributed to his dehydration. The DON further stated that the resident's was monitored with meal intakes. -Resident #36 was admitted to the facility most recently on July 1, 2011, with an original admitted [DATE]. His [DIAGNOSES REDACTED]. The resident did not require [MEDICAL TREATMENT]. Review of dietary progress note dated March 26, 2011, revealed the resident was no longer able to feed himself. The resident's care plan was reviewed for the month of June 2011. There was a problem listed as potential for dehydration related to cognitive impairment and that the resident was dependent upon the staff for hydration needs. The goals listed on the care plan were that the resident would not exhibit signs or symptoms of dehydration as evidenced by moist mucous membranes and stable vital signs. The interventions were listed as honoring the resident's fluid preferences, to encourage fluids throughout the day, monitor labs as ordered and offer water with all meals. Laboratory tests were ordered on June 6, 2011, and revealed the resident's renal function was decreased with a urea nitrogen (BUN) of 36 (normal range is 8-25) and a normal creatinine. The lab values were noted on June 17, 2011, with no new orders. Review of the monthly nursing summary dated June 11, 2011, revealed that the resident was dependent for eating, dressing, bed mobility, transfers and locomotion. Review of the medical record revealed a discrepancy in the resident's weight. Weight tracking form for June 2011 reported that the resident weighed 180.6 pounds. The CNA intake and output (I & O) chart detailed reports that the resident's weight was 169 pounds. Review of the physician's orders [REDACTED]. Further review revealed an order to take blood pressure before monitoring\anti-hypertensive medications were given. It further ordered the nursing to encourage the patient to drink at least eight to ten glasses of water throughout the day. Review of the Medication Administration Record [REDACTED]. Review of the resident's vital sign flow sheet revealed his last recorded morning blood pressure prior to being hospitalized was on June 19, 2011 at 138/88. Review of dietary recommendations dated June 15, 2011, for the resident revealed the resident required 2640 cubic centimeters (cc) of fluid a day which was approximately 11 cups of fluid per day. Review of the CNA documentation for the month of June 2011 revealed the resident's oral intake of food and fluids began to decline on June 24, 2011, with an intake of 75 percent of his breakfast, refusal of lunch and 75 percent of his dinner. He was recorded to have consumed 1080 cc of fluid which was equivalent to four and a half cups of fluid. Further review of CNA documentation revealed that on June 25, 2011, the resident drank four cups of fluid and consumed 100 percent of his breakfast and 25 percent of his lunch and dinner. Review of CNA documentation on June 26, 2011, documented that the resident consumed four cups of fluid and 100 percent of his breakfast 25 percent of his lunch, and 50 percent of his dinner. On June 27, 2011, the CNA's documented that the resident consumed 25 percent of his breakfast and lunch and drank two cups of fluid. However there was no documentation that the resident's physician was notified after three and a half days of a decrease in the resident's consumption of food and fluids. Review of nursing notes dated June 27, 2011 at 4:00 p.m. documented that the CNA reported that resident #36 was not responding to speech or shaking. The nurse assessed the resident and he was non-responsive. The nurses notes documented that the nurse practitioner was notified and she ordered a urinalysis, a chest x-ray a basic metabolic panel and a complete blood count. No record of these lab values were evident in the resident's medical record. The note further stated that the family of the resident was notified (there was no indication of time) and when the family arrived they asked that the resident be transferred to the hospital. The nurse practitioner was called and orders were obtained to transport the resident to the hospital. The ambulance drivers documented the resident's blood pressure at 80/62 and started two large bore peripheral IV's and IV fluids in route to the hospital. Review of the emergency room documentation revealed the resident arrived 7:28 p.m. with a blood pressure of 60/40. An indwelling urinary catheter was inserted at 7:40 p.m. Blood work was ordered at 8:00 p.m. and revealed the resident's BUN was 103 (normal range 8 to 25). The creatinine was 3.8 (normal 0.6 to 1.5). Further review revealed a doctor's note dated June 27, 2011, which stated that the patient was "...emergently infused multiple normal saline boluses to achieve hemodynamic stability. Emergently given [MEDICATION NAME] and [MEDICATION NAME] for urinary tract infection and low grade fever/leukocytosis. Will admit to intensive care unit (ICU) for low blood pressures in the 90's. Continue IV fluid for resuscitation. High risk for progression to septic shock..." It further stated that "Interventions in the emergency room were absolutely necessary to prevent serious deterioration in clinical status and possibly irreversibly poor outcome." Blood work was again completed on June 28, 2011 at 1:10 a.m. which revealed the resident's renal labs were beginning to improve with the IV hydration. The BUN was 95 and the creatinine was 2.91. The resident was transferred from the emergency room to the ICU at 2:37 a.m. on June 28, 2011. Review of a physician progress notes [REDACTED]. Another fluid bolus was given and normal saline was also started at 100 ml/hr. A renal consult was called. Blood work was ordered and the patient's BUN had decreased to 93 and creatinine was 2.71. Review of the physician progress notes [REDACTED]. "Patient is hypotensive again. Blood pressure was 71/36. The registered nurse (RN) notes that with every fluid bolus that the patient got the blood pressure improved significantly "...The lungs remain clear per RN...Will order another fluid bolus..." Review of the patient's history and physical dated June 28, 2011 at 7:40 a.m. stated that on arrival the patient had systolic blood pressure in the 60's to 70's but that it responded well to the IV fluid. It further stated that the current blood pressure was 108/46 after 2.5 liters of normal saline. The history and physical also reported a history of [MEDICAL CONDITION] with [MEDICATION NAME] in 2007 that was between 1.6 to 1.9. The nephrology consultation took place on June 28, 2011 at 11:00 a.m. The report stated that the patient was in the intensive care unit and very sick in septic shock and acute [MEDICAL CONDITION]. The patient was critically ill. The nephrology consultation physical examination noted that the resident's blood blood pressure was 82/43 and his mucous membranes were "very dry". Review of the hospital's recorded I&O on June 28, 2011, revealed the resident had an intake of 4225 ml and an output of 350 ml during his first 24 hours at the hospital. Plan stated [MEDICAL CONDITION] needs saline, continue bolus. Patient was making urine. Review of the physician progress notes [REDACTED]. The patient's total intake in the hospital was recorded as 12,335 ml and a total output of 6,450 ml. The hospital discharge reported the hospital course was that the patient came in with urosepsis, had some [MEDICAL CONDITION] that resolved and dehydration. Hospital [DIAGNOSES REDACTED]. An interview was conducted with a CNA on the resident's hall on December 1, 2011 at 8:20 a.m. She reported that they would offer the resident drinks every one to two hours. She stated they tried to get him to drink but sometimes he was combative and would not cooperate. An interview was conducted with a licensed practical nurse (LPN) on December 1, 2011 at 8:25 a.m. on the resident's hall. She stated that they encouraged fluids for the resident every one to two hours. She further stated that he was often sleeping or combative and they were unable to get him to drink but that they do try to push fluids. -Resident #281 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. Review of the resident's daily I & O report, from December 17, 2010 to January 5, 2011, documented the intake of the resident would range from [PHONE NUMBER] cubic centimeters (cc) per 24 hour period. Despite the resident's poor intake the clinical record lacked documentation that liquids were encouraged for the resident. A review of the resident's nutrition data collection dated December 19, 2010, stated that resident consumed 1375 calories and 57 percent of her meals. Review of the resident's care plan dated December 28, 2010, identified dehydration as a problem. The goals included that the resident would remain free of signs and symptoms of dehydration. The interventions of the care plan documented to encourage fluids throughout the day and monitor labs as ordered. Review of resident's meal intake detail report documented that the resident either refused meals or left 25 percent or more of her meals. There was no documented evidence that the CNAs reported to the nurses of resident's poor fluid intake. A review of daily skilled nurses' notes documented the following assessments: December 28, 2010, mental status alert. December 29, 2010, mental status alert, cardiovascular regular rhythm, skin color normal. December 30, 2010, mental status alert. December 31, 2010, mental status alert. January 1, 2011, mental status alert to self, forgetful/confused, cardiovascular regular rhythm, skin color normal, set up meals. January 2, 2011, mental status alert, forgetful/confused, cardiovascular regular rhythm, skin color normal, set up for meals. January 3, 2011, resident alert, able to make needs known. January 4, 2011, mental status alert. January 5, 2011, resident sent to hospital. An interview was conducted on December 5, 2011 at 9:15 AM with a CNA. The CNA stated that she would set up tray for resident, open a milk carton, and then remove the lids from the juices on tray. The CNA stated she would then document the resident's fluid intake in the care tracker. An interview was conducted on December 05, 2011 with a licensed nurse at 9:30 AM. The licensed staff member stated that a resident with poor fluid intake would be reported to the nurse. The nurse would than make a notation in the resident's chart. The licensed nurse also stated that the CNAs would record the resident's fluid intake in the care tracker. An interview was conducted with the registered dietician on December 8, 2011, at 8:00 AM. The dietician stated that the resident's fluid intake was determined by their caloric intake, unless there was a physician's orders [REDACTED]. Review of the facilities policy for hydration protocol stated "Policy: It is the policy... to ensure that residents are offered adequate amounts of liquids and documentation is complete and accurate for the resident's consumption of liquids. Procedure 1. All residents will be offered 500 cc of fluid for each meal to total 1500 cc per day (24 hour period). all resident preferences for fluids will be honored. 3. All resident will be offered additional fluids during the med pass and at least one glass of fluids of choice. 4. CNA's are responsible for documenting hydration in the Care Tracker System..."

Based on clinical record review, observation, resident and staff interviews, and review of facility policy and procedure, the facility failed to ensure one resident's (#1) daily fluid restriction was monitored and documented. The sample size was one of three residents (# 1). Findings include: -Resident #1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the physicians orders dated January 17, 2012, revealed the resident was on a fluid restriction of 1500 centimeters (cc) per 24 hours. Review of the dietary assessment dated [DATE] revealed that the resident calculated fluid requirement was 1538 cc. No other assessments were available. At the bottom of this assessment was a note that stated the previous assessments were missing from the chart. A review of care tracker for intake and output for residents by shift, located in the computer, included cc entries for each day and meal, that indicated the fluid amounts that the resident had consumed during breakfast, lunch and dinner since admission. These amounts were not totaled at the end of each day. The information was missing documentation on nine days. The totals per shift were calculated and on nine days the resident was documented as having less than 1000 cc for the day. An interview was conducted with the licensed practical nurse (LPN) on January 31, 2012. The staff stated that the nursing pull the Intake and output up and review the document on line. She further stated that the totals are not recorded anywhere. The nurses just look at it once a shift. Review of the facility policy for intake and output; revealed that staff were to provide an accurate record of the fluid intake and measure the amount of fluid consumed in a 24 hour period. This information was to be documented on the Intake and Output worksheet and on the care tracker.