Every finding on record at Jacksonville Nursing and Rehab Center

Based on observation, record review, interviews, and a review of facility policies and procedures, the facility failed to ensure that the residents' environment was as free of accident hazards as was possible for one (Resident #108) of 34 residents in the total survey sample. Razors were discovered at Resident #108's bedside. The findings include: On 04/29/25 at 13:52 PM, medication (an oral inhaler) was observed at the bedside of Resident #108. (Photographic evidence obtained). The resident stated, They gave it to me so I can take it when I need it. A review of Resident #108's medical record revealed an admitted [DATE] and diagnoses including unspecified sequelae of other cerebrovascular disease, COPD (chronic obstructive pulmonary disease), nicotine dependence, and anxiety disorder. A review of the Admission MDS (minimum data set) assessment, dated 4/1/25, revealed a BIMS (brief interview for mental status) score of 12 out of 15 possible points, indicating moderate cognitive impairment. The resident required set-up/clean up assistance with eating, substantial/maximal assistance with toileting and transfer tasks, and partial/moderate assistance with bed mobility. A review of the resident's active physician's orders revealed she was receiving the following: - Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 108 (90 Base) mcg/act (micrograms per actuation), 1 inhalation, inhale orally every 6 hours as needed for wheezing/asthma signs/symptoms, and 1 inhalation orally three times a day for COPD/cough for three days (4/10/25) There was no physician's order for self-administration of medications or treatments. A review of the most recent smoking evaluation, dated 3/26/25, revealed that the resident scored 11.0 (unsafe smoker). There was no evidence of an assessment having been completed for self-administration of medications. A review of the active Care Plan revealed the following focus areas: - Resident is at risk for impaired gas exchange/ineffective airway clearance related to COPD, respiratory failure with hypoxia, chronic pulmonary edema, asthma, and lobar PNA (pneumonia). (Date Initiated: 03/24/2025, revised 4/15/25) Goals/interventions in place and appropriate. - Resident is a an unsafe smoker as evidenced by smoking evaluation. (Created 03/26/2025, revised 03/26/2025) Goals/interventions in place and appropriate. - Resident has impaired cognitive function/impaired thought process. (Created 04/01/2025, revised 04/01/2025). Goals/interventions in place and appropriate. The entire care plan was reviewed and there was no evidence of the resident having been care planned for self-administration of medications or treatments. On 05/01/25 at 11:44 AM, an interview was conducted with Certified Nursing Assistant (CNA) A. When she was asked if residents were permitted to give themselves any kind of medication on their own, she replied, No. She was asked if residents were permitted to keep medications in their rooms or in their possession. She stated, No. She was asked what she should do if she observed medications in the resident's room or in their possession. She replied, Go and get my nurse or Unit Manager immediately. On 05/01/25 at 1:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) B. When she was asked what the facility's protocol was for a resident who wanted to self-administer their own medications, she replied, They don't allow them to administer their own medicine. She was asked of there were any residents on her assignment who self-administered medications. She stated, No. She was asked if residents were permitted to give themselves any kind of medication on their own. She stated, No. She was asked if residents were permitted to keep medication in their room or in their possession. She stated, No, like on admission we give medications to the family to take back home so the residents wont have them. She was asked what she should do if she observed medications in the resident's room or in their possession. She stated, I would get it. They might be a little upset with me, but I would get them because its not supposed to be there. Then I would call the family and notify the MD (physician). On 05/01/25 at 2:00 PM, an interview was conducted with CNA C. She was asked if she had observed Resident #108 with her inhaler in her room at the bedside or in her purse. CNA C replied, Yes. She was asked if she had observed Resident #108 using an inhaler on her own, and she replied, No. She was asked if the facility provided any guidance/training/education on how to respond if you observe medications in the resident's room. She stated, No, but I know how to handle that; let the nurse know. She was asked if she had reported the resident having the inhaler in her possession. She stated, No, I have not reported the inhaler to the nurse, but she had to have seen it herself, she could not miss it, it was in there today in plain site. A review of the facility's policy and procedure titled Self-Administration of Medications (SHCRC30004.01B, revised 8/2023), revealed: Purpose: To allow the resident and or legal representative the right to self-administer medication (SAM) when it has been deemed by the interdisciplinary team (IDT) that it is clinically appropriate. A resident may only self-administer medications after the IDT has determined which medications may be self-administered. Document the self-administration of medication on the resident's comprehensive care plan. [NAME] medication administration records to identify individual medicines that are self-administered by each resident.

Based on observation, record review, interviews, and a review of the facility's policies and procedures, the facility failed to provide respiratory care consistent with professional standards of practice for one (Resident #33) of four residents reviewed for oxygen administration. Resident #33 was receiving oxygen without a physician's order. The findings include: On 04/29/25 at 11:13 AM, an interview was attempted with Resident #33. He offered no verbal response to interview questions, and instead covered his head. Oxygen was observed infusing at 3.5 L/min (liters per minute) via nasal cannula (NC). A review of Resident #33's medical record revealed an admitted [DATE] and diagnoses including heart failure, COPD (chronic obstructive pulmonary disease) and acute and chronic respiratory failure with hypoxia. A review of the resident's active physician's orders revealed no orders for oxygen therapy. A review of the Quarterly MDS (minimum data set) assessment, dated 4/16/25, revealed a BIMS (brief interview for mental status) score of 15 out of 15 possible points, indicating intact cognition. The resident was independent with eating. He was dependent on staff for toileting and transfer tasks, and required substantial/maximal assistance with bed mobility. A review of the active Care Plan revealed the following focus areas: - [Resident #33] is at risk for impaired gas exchange related to COPD and chronic respiratory failure. (created 7/20/20, revised 3/10/25). Goal: Resident will have decreased risk of complications related to impaired gas exchange through the review date. Interventions: Oxygen as ordered. Clean concentrator/filters as ordered. Change oxygen tubing as ordered. - [Resident #33] requires assistance with ADLs related to limited mobility and muscle weakness secondary to CHF (congestive heart failure), COPD, AFIB (atrial fibrillation), urine retention, chronic respiratory failure, neuromuscular dysfunction of bladder, depression, obesity, anemia, hypokalemia, dorsalgia, sleep apnea, diabetes mellitus, right foot drop, obstructive/reflux uropathy, ADHD (attention deficit hyperactive disorder), hydrocephalus, and HTN (hypertension). Goals/interventions in place and appropriate. A review of the resident's progress notes revealed a note dated 4/11/2025 at 20:35 (8:35 p.m.) that noted the resident was evaluated by the provider for COPD management. The patient is currently on a complicated pulmonary regimen to consist of Albuterol as needed. The patient remains on intermittent oxygen. Patient does report at times some shortness of breath with exertion. On 05/01/25 at 11:39 AM, an interview was conducted with Certified Nursing Assistant (CNA) A. She was asked if the facility provided any training/education for how to care for a resident who received oxygen therapy. She stated, No, because it's considered medicine so it's taken care of by the nurse. She was asked to describe the care she provided for a resident who was receiving oxygen. She stated, We just make sure that they keep it in their nose and that the tank is full. Anything else, you notify the nurse. For instance, if the tubing looks dirty or clogged or if it's on the floor, or if the tank is empty. She was asked if she had ever been required to change the oxygen flow rate settings. She stated, No. She was asked what she would do if the resident became short of breath. She stated, Notify the nurse or the Unit Manager. On 05/01/25 at 1:42 PM, an interview was conducted with Licensed Practical Nurse (LPN) B. She was asked if the facility provided any training/education for how to care for a resident who received oxygen therapy. She stated, Yes. She was asked to describe the care she provided for for a resident who was receiving oxygen therapy. She stated, We monitor their saturations, provide the breathing medication, and if they have orders for oxygen we make sure the oxygen is set at right level and make sure the room is comfortable. She was asked who was responsible for changing oxygen flow rate settings. She stated, Yes, only the nurse is supposed to change the settings. She was asked what she would do if the resident became short of breath. She stated, First make sure the head is elevated, monitor the oxygen saturations, give the medication, and I may need to increase the oxygen level. When they get stable, I reach out to the medical doctor. She was asked if Resident #33 used oxygen. She stated, Yes, at times. She was asked how often he used it. She stated, I think he uses it on a daily basis but he medicates himself. He takes it on and off. She was asked how she determined the resident's oxygen flow rate. She stated, Whatever the doctor orders. She was asked to access the resident's orders in the EMR (electronic medical record) and confirm how many liters the doctor ordered for Resident #33. She confirmed that the resident did use oxygen daily and did not have an order for it. On 05/01/25 at 3:44 PM, a policy/procedure for oxygen administration was requested. The Regional Nurse Consultant stated, We don't have an oxygen policy. A review of the facility's Procedural Guideline (SHCEDU0001.11M, effective: 1/2023, updated: 6/28/2024) for Physician's Orders revealed: A new order should include: date of order, resident name, identification number, date of birth, physician's/prescriber's name and pertinent ancillary instructions, reason for use, stop order date, as appropriate, and administration parameters, if applicable.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, affecting one (Resident #73) of 103 residents, by failing to eliminate pests from the resident's room. Failure to ensure the necessary housekeeping and maintenance services are provided for residents can increase the risk of disease-causing organisms within the facility. The findings include: On 5/30/23 at 10:28 a.m., Resident #73's room was observed with small roaches crawling on the floor at the doorway entry and on the side of the trash can in the resident's bathroom. (Photographic evidence obtained) A review of the facility's pest control provider's invoices from March 3, 2023 through June 1, 2023, revealed that pests were identified as well as spilled food material on the floors of multiple resident rooms and food debris inside of resident nightstands during their visits. (Copies obtained) A review of the facility's In-House Pest Control Measures from December 2022, through June 2023, revealed no In-House Pest Control Measures were completed in May 2023. On 6/1/23 at 2:00 p.m., the Maintenance Director was asked how the facility maintained an effective pest control program so that the facility remained free of pests. He stated wheelchairs were cleaned and audit logs were completed. In-house pest control of common areas was completed by Maintenance twice weekly. The facility's pest control service sprayed for pests monthly and when needed or when they were called by the facility. Pest complaints were noted in the maintenance log at each nurses' station. A review of the facility's policy and procedure titled Infection Control: Cleaning and Disinfecting of Residents' Rooms (revised 5/2022) revealed: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. Procedure 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled . 7. Personnel should remain alert for evidence of rodent activity (droppings) and report such findings to the environmental services director. Steps in the Procedure, Resident Room Cleaning: . 7. Clean personal use items (e.g., lights, phones, call bells, bedrails, etc) with disinfectant solution at least twice weekly. (Copy obtained).

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Residents #47, #102, and #237) of [NAME]-seven sampled residents. The findings include: 1. On 5/31/2023 at 12:02 p.m., Certified Nursing Assistant (CNA) C was observed in Resident #47's room with the door ajar. From the hallway, the CNA could be seen transferring the resident to bed using a mechanical lift (Hoyer lift) by himself. Upon seeing the surveyor in the hallway, the CNA immediately pulled the privacy curtain preventing further observation. CNA C was then observed exiting Resident #47's room at 12:08 p.m. He was asked about the observation of him transferring the resident using the mechanical lift by himself without assistance and whether this was his routine. He stated it depended upon whether the resident was skilled or not. He stated he had been employed by the facility since 1993, adding that things had changed since that time and he had never left. He stated nursing numbers had gone downhill and Sometimes you have to multi-task and do the best you can with what you have. He was asked if there were any agency staff that could have assisted him. He replied that there were no agency staff in the building so he had to do what he had to do. During an interview with Resident #47 on 6/1/2023 at 11:49 a.m., he was asked how he was transferred by staff. He stated the staff used the Hoyer lift for transfers and that it was usually done with one staff member. During an interview with the Regional Nurse Consultant (RNC) on 6/01/2023 at 3:22 p.m., she stated therapy conducted the staff training for use of the Hoyer lift. She stated there always needed to be two people assisting when transferring a resident via a Hoyer lift, adding that there was not a time one person should be transferring a resident using the Hoyer lift. During an interview on 6/02/2023 at 1:00 p.m. with Director of Rehabilitation (DOR) D, she was asked about the staff training for the use of the Hoyer lift. She stated, We train them to use two persons for the Hoyer. Our company policy is to always have two people present. She was asked to provide a copy of the company policy. She stated, I'm not sure if that's documented anywhere. I know for safety we always require them to have two people present. A review of Resident #47's record revealed that he was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting his right dominant side; cognitive/communication deficit; type 2 diabetes mellitus; acute kidney failure; thoracic aortic aneurysm without rupture; and benign neoplasm of the brain. A review of his physician's orders included a 3/21/2023 order for the resident to Utilize Hoyer lift device for transfers with assist times two. A review of the most recent care plan revealed: FOCUS - Needs assistance with ADLs (activities of daily living) due to anemia from GI (gastrointestinal) bleed and stroke (created 10/24/2022, revised 3/14/2023); GOAL: Resident will maintain current level of function through review date; INTERVENTIONS: Transfers Hoyer lift device for out of bed transfers with assist x 2 (revised 1/12/2023) A review of the Minimum Data Set (MDS) assessment, dated 2/21/2023, revealed Resident #47 was totally dependent on staff for transfers; required extensive assistance with bed mobility, dressing, toilet use and personal hygiene, as well as supervision with locomotion on and off the unit and for eating. A review of the resident's progress notes revealed that Resident #47 was at risk for falls. He had recently sustained falls in the facility on 5/16/2023 and 5/20/2023. 2. On 5/30/2023 at 9:22 a.m., Resident #102 was observed in her room sitting in a Broda chair (tilt-in-space positioning chair) next to her bed. The resident was observed leaning to the left. She was moaning with facial grimacing. She complained of pain from a sore on her buttocks. She stated she needed to get back in bed and had been trying to get back in bed since breakfast. The resident asked for help getting her in bed to relieve the pressure and pain from the sore on her buttocks. The resident was instructed to press her call light for assistance. With assistance, Resident #102 pressed her call light and at 9:26 a.m., a male Certified Nursing Assistance (CNA) responded to the call light. He greeted the resident and asked what she needed. Still moaning in pain, the resident asked to be put back in bed to relieve the pain from the sore on her buttocks. The CNA stated he was not the resident's assigned CNA. He advised the resident that he would find her CNA to help her get back in bed. He then turned off the resident's call light and exited the room. While still on the hallway leading to Resident #102's room, the resident's call light was observed to still be illuminated at 9:31 a.m. A female staff member knocked then entered the resident's room. From the hallway the resident could be heard moaning in pain. The call light was turned light off and the female staff member was seen exiting the resident's room. At 9:32 a.m., the female staff member returned, knocked, and opened the resident's door, partially entering and was overheard telling the resident that her CNA (Employee C) was on his break for 15 minutes and that she would let the nurse know what the resident needed. Again, the resident could be heard moaning with pain. CNA C was observed on the hall at 9:51 a.m. Per the assignment board at the nurses' station, he was assigned to Resident #102's room, however, he still did not go to the room to assist Resident #102. He was observed entering two adjacent rooms in spite of being told Resident #102 needed care. On 6/1/2023 at 11:18 a.m., Resident #102 was observed lying in bed. She denied any pain. She stated she was feeling okay but wanted to be moved over in the bed a little more. She was advised to press her call light for assistance. The resident reached behind her and looked around for the call light which was not in sight. She asked for assistance getting the call light. The call light was in the top drawer of the resident's night stand. (Photographic evidence obtained) The resident asked for the call light so she could call for help. Before the resident could be given the call light, CNA C knocked then entered the resident's room. On 6/2/2023 at 12:00 p.m., Resident #102 was observed lying in bed on her right side/back. She complained of pain. She asked for help turning over to her left side to get her off of the sore on her buttocks in order to relieve the pain. She continued to complain of pain related to the sore on her buttocks. The resident's call light was observed lying on top of her sheets, but not within reach or clipped to the sheet. The resident was asked if she had pressed the call light. She stated she could not get to it. She began to feel around the top of the sheets for it, but she could not reach it. She asked for help clipping the call light to the sheet within her reach. She continued to moan with pain. When she was asked how long she had been in pain, Resident #102 replied that she had been put back in bed after breakfast and had remained in that position on her right side since that time. The resident's call light was pressed for assistance. Upon exiting the resident's room, no nursing staff were observed on the hallway, however, there was one staff member, Housekeeper F, a few rooms away from Resident #102's room. On 6/2/2023 at 12:14 p.m. Housekeeper F was observed entering Resident #102's room. From the hallway she could be heard asking Resident #102 what she needed. Resident #102 was heard asking to be turned because she was in pain. The resident's call light was turned off and Housekeeper F exited the resident's room. Housekeeper F returned to the room she was in previously. She was not observed alerting any nursing staff of Resident #102's needs. She continued entering and exiting other rooms on the hall. Unable to locate nursing staff on the the resident's hallway to ask for assistance, at 12:18 p.m., Resident #102's room was entered again. The resident remained in pain. Her call light was pressed again. At 12:19 p.m., Housekeeper F re-entered the resident's room and turned the light off. She was heard asking the resident what she needed. The resident responded, I already told you. Can't you just move me? As Employee F was preparing to exit the room she acknowledged the surveyor then exited the hall. She was seen going to an adjacent hall. She returned with two CNAs who knocked then entered Resident #102's room, immediately closing the door behind them. During an interview with Licensed Practical Nurse (LPN) B on 6/2/2023 at 1:09 p.m., she stated she was familiar with Resident #102. She stated the resident had a small wound on her buttocks and received pain medication as needed. She stated the resident did not like sitting up in the chair because of the wound. She referred to it as a small wound on the resident's left buttock adding, We try to get her up so she can be out of her room. When asked about the progress of the wound she stated, I don't know if it's healing. I've only worked here three weeks. She was asked about call light response time expectations. She stated, Everybody is responsible for answering the call lights. Every single person. She stated the CNAs should be doing rounds at least every two hours for toileting and repositioning. She further stated she conducted follow-up rounds on the floor and checked the CNAs' charting to verify that they turned and repositioned the residents. She stated the facility's policies were accessible to staff and they could review any policy if they were confused about any subject or requirement. During an interview with the Regional Nurse Consultant (RNC) on 6/2/2023 at 1:27 p.m., she stated the facility did not have a call light response policy. On 6/2/2023 at 1:41 p.m., during an interview with CNA E (identified as one of the CNAs observed entering the room of Resident #102 on 6/2/2023 at 12:19 p.m.), she stated she had been employed with the facility for about 11 months. She further stated she consulted the Kardex (resident-specific, clinical quick reference for nursing staff/CNAs) or the nurse for resident information such as how the resident transferred, their functional status, how long they should be sitting up, etc. CNA E stated she did rounds with the outgoing shift to get report about whether there were any changes with the residents she would be caring for during her shift. She stated residents were supposed to be checked every two hours. When she checked on her residents, she asked if they needed to be changed. She stated if a resident complained of pain, she asked what was wrong. If the resident wanted medication, she reported that to the nurse. If the resident wanted to be repositioned, then she got another staff member to assist her with repositioning the resident. When asked about Resident #102, she stated she was familiar with the resident. She stated the resident had a wound and required repositioning. She stated the resident was alert and was able to express her needs. She can tell you when she's in pain. CNA E also added that the resident will tell you when and how she wants to be repositioned and when it's hurting her and she just let's you know when her bottom is hurting and when she needs to be turned. When asked about call light response time expectations, CNA E stated that it was everyone's responsibility to answer the call lights. She acknowledged assisting Resident #102 earlier. She stated, Even if it's not your patient, you answer it. During an interview with Housekeeper F on 6/2/2023 at 2:44 p.m., she stated she had been employed with the facility for seven years. She acknowledge receiving training on Resident Rights and Abuse and Neglect as well as Call Light Response Times. She stated she was taught to cancel the call light and ask what the resident needed. If it was something she could do, such as getting ice or a snack, then she would do it. If not, she would get the nurse or CNA. She was asked about Resident #102. She stated she was familiar with the resident. She referred to the resident as with it. She was asked about the observations made of her entering and exiting the resident's room. She stated the resident wanted to be turned over because her bottom was hurting. She was asked what happened after the resident requested to be turned over. She stated, I didn't know where her nurse was but her CNA was on break, so I didn't get anyone. So the second time I went to the other end by the 400/500 hall and found the other two CNAs and told them what she needed. I couldn't turn her. We're not allowed to touch them. On 6/2/2023 at 3:08 p.m., Director of Rehabilitation (DOR) D was asked about an assessment for call light use. She stated there wasn't one. She stated if there were concerns that a resident could not use their call light, they'd change it out. She stated she was familiar with Resident #102 and was not aware of any concerns with the resident using her call light. DOR D went to the resident's room. The resident was observed in bed with the call light attached to a towel laid across her midsection not within easy reach. The resident was asked to demonstrate the use of her call light. As the surveyor asked the resident whether she could reach her call light, DOR D unclipped the call light from the towel and handed it to the resident. The resident pressed and successfully illuminated the call light. DOR D was advised of the call light observations throughout the survey. She denied knowledge/observations of any of the concerns stated. She stated she would look into it further and change the call light if needed. On 6/2/2023 at 3:29 p.m., DOR D advised that the call light for Resident #102 had been replaced with an easier to use air bulb style call light. On 6/2/2023 at 3:48 p.m., Resident #102's room was entered. The call light had been replaced and was within reach of the resident. The resident was able to use the new call light. She stated it was so much better. The resident expressed thanks and had no additional concerns at that time. A record review revealed that Resident #102 was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting her left non-dominant side; dysphagia; non-pressure chronic ulcer of the buttock with unspecified severity; type 2 diabetes mellitus without complications; acute respiratory failure with hypoxia; cognitive/communication deficit; need for assistance with personal care, and abnormal posture. Her physician's orders included the following orders dated 1/18/2022: Pain evaluation Q shift (every shift). Norco oral 5-325 mg (milligrams) (narcotic pain medication), 1 tablet by mouth for wound pain 30 minutes prior to wound care, hold for lethargy and give 1 tablet by mouth every 8 hours as needed for moderate to severe pain scale 5-10. Per the 4/10/2023 quarterly Minimum Data Set (MDS) assessment, the resident's Brief Interview for Mental Status (BIMS) score was documented as 15 out of a possible 15 points, indicating intact cognition. There were no moods or behaviors documented. She was totally dependent on staff for all activities of daily living (ADLs). Unhealed pressure ulcers, one or more was checked yes. Moisture associated skin damage was also checked yes. A review of the resident's most recent Care Plan included: FOCUS - [Resident #102] has been noted to yell out due to a diagnosis of stroke. Resident will often yell out as opposed to utilizing the call bell. History of making allegations. GOAL - Resident will demonstrate effective coping skills through the review date (rev 3/20/23). INTERVENTION: Anticipate needs. Resident needs food thirst toileting needs comfort level body positioning pain etc. Evaluate for side effects of medications, medications as ordered, psych evaluation as needed. FOCUS - [Resident #102] is at risk for pain. GOAL: Resident will not have interruption in normal activities due to pain through the review date (rev 3/20/23). INTERVENTION: Analgesics as ordered. Discuss with resident the need to request pain medications before pain becomes severe. Evaluate characteristics of pain location severity on scale of 0-10 and frequency identify existing conditions which may increase pain and/or discomfort. Monitor for probable cause of each pain episode. Monitor for side effects of pain medication. Note any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms or complaints of pain/discomfort. Observe for signs of relief /effectiveness with interventions, utilize non-medication interventions for pain relief. 3. A record review revealed that Resident #237 was admitted to the facility on [DATE], with a re- entry on 10/11/2022, and a discharge on 3/23/2023. Her diagnoses included acute kidney failure, dysphagia - oropharyngeal phase, need for assistance with personal care, adult failure to thrive, and dementia without behaviors. A review of the resident's physician's orders, revealed orders dated 2/9/2023 for a regular diet, mechanical soft texture, nutritional treat with meals, and a house shake four times a day. A review of the Advanced Practice Registered Nurse's (APRN's) note, dated 3/22/2023, read, Resident presented today out of bed in wheelchair at bedside, noted grunting, neck hyper-extended, rhonchi lung sounds, orders given for chest x- ray, nursing reports patient appears to be uncomfortable frequently throughout today. There was no documentation indicating the facility nursing staff notified the physician or APRN about the resident's change in condition prior to the APRN arriving at the facility. A review of the radiology report dated 3/23/2023, revealed left basilar airspace disease and modest left pleural effusion. A Nursing Progress note, dated 3/23/2023, indicated that the resident had a chest x- ray done. It resulted in left basilar airspace disease and modest left pleural effusion. New orders were given for doxycyline hyclate (antibiotic medication), oral tablet 100 milligrams (mg) two times a day for pneumonia (PNA) for 7 days, and oxygen via nasal canula at 2 liters per minute (L/min) as needed. A Change in Condition note, dated 3/23/2023, indicated that the resident was transferred to the emergency room (ER) via Emergency Medical Services (EMS) due to a low oxygen saturation of 89 percent (%) at 2 liters of oxygen. The resident's Care Plan, dated 10/27/2023, indicated the resident had Impaired Gas Exchange/Ineffective Airway Clearance related to Chronic Obstructive Pulmonary Disease (COPD). She also needed assistance with ADLs due to chronic kidney failure, seizures and dementia. The resident's Quarterly Minimum Date Set (MDS) assessment, dated 1/18/2023, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 points, indicating moderate cognitive impairment. She was documented as totally dependent on staff for bed mobility, transfers, toilet use, and required supervision assistance for eating. On 6/2/2023 at 9:11 AM, the Regional Nurse Consultant (RNC) and the Director of Nursing( DON) were interviewed related to Resident #237's change in condition. The RNC stated the resident had a chest x- ray due to a cough and was sent to the ER (emergency room ) due to low blood oxygen saturation. When asked when the change in condition occurred, they both confirmed that there was no documentation about when it occurred, however, the chest x-ray was ordered on 3/22/2023 and obtained on 3/23/2023. They confirmed that there was no documentation on 3/23/2023 during the 7-3 shift about the resident's condition or status of the chest x-ray. The RNC and the DON stated the facility's policy was to contact the physician, family and DON for any changes in a resident's condition. When asked about the turning and repositioning documentation expectations, the DON stated the facility's protocol was to turn and reposition residents every two hours, but staff did not document every time they repositioned a resident. In an interview with Licensed Practical Nurse (LPN) G/Wound Care Nurse on 6/2/2023 at 9:47 a.m., she stated Resident #237 had a small area on her sacrum but it resolved by the time of discharge. She mentioned that the wound healed so quickly that the resident was not seen by the rounding wound care physician. She added that the care plan included turning and repositioning per facility protocol to prevent any new skin breakdown. When asked about the resident's functional status, she stated the resident was totally dependent on staff for all ADLs including bed mobility. She was then asked about the resident's change in condition. She stated she worked on 3/23/2023 on the 3-11 shift. The morning nurse reported the resident's respiratory discomfort and that she was awaiting chest x-ray results. LPN G added that when she checked on the resident, she noted that she had chest congestion. She contacted the radiology department, which provided the x-ray results. The physician was notified of the x-ray results and nursing obtained orders for antibiotics related to infiltration pneumonia, however, the resident's oxygen saturation started dropping before the initiation of the antibiotic. She contacted the physician again and was given orders to transfer the resident to the ER via emergency medical services.

Based on observations, interviews, and record reviews, the facility failed to ensure that two (Residents #57 and #85) of two residents reviewed for limited range of motion, from a total of 37 residents in the sample, received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. The findings include: 1. On 5/31/23 at 11:29 AM, Resident #57 was observed in bed. His right upper extremity was contracted to his chest. When the resident was asked if he was able to extend his arm, he held it with the left hand as he tried to stretch it, then shook his head no. He was then asked if he was attending any therapy and again he shook his head no. He stated he had a splint but staff were not consistent with applying it. On 5/31/23 at 3:00 PM, the resident was observed in bed with no splint on his right upper extremity (RUE). On 6/01/23 at 10:05 AM, the resident was observed in bed with no splint on his RUE. On 6/02/23 at 10:30 AM, the resident was observed in bed with no splint on his RUE. He stated staff had just completed providing his morning care. A review of the medical record revealed that Resident #57 was admitted to the facility on [DATE]. his diagnoses included cerebrovascular disease, aphasia and muscle spasms. A review of the resident's physician's orders, dated 1/9/23, indicated that the resident was to participate in the Restorative Nursing Program (RNP) for orthotic management and upper extremity range of motion (ROM) seven times a week as tolerated. Notify rehab of any adverse reaction for pain. Another order, dated 1/30/23, indicated that Resident #57 was to utilize a right upper extremity (RUE) comfy elbow extension and RUE [NAME] air T-hand splint up to six hours per day as tolerated. Monitor skin integrity throughout to ensure no adverse reaction and doff splint immediately and notify rehab if noticed. (Photographic evidence obtained) A review of the care plan, updated on 5/31/23, revealed that the resident was at Risk for Symptoms/Complications related to History of Contracture (RUE). This places him at risk for pain. Interventions included to provide adaptive equipment/splints as tolerated to assist with mobility. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/17/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. He required extensive assistance with bed mobility, transfers and toilet use. He was totally dependent on staff for eating. The MDS did not indicate that the resident was on a restorative program. 2. On 5/30/23 at 1:37 PM, Resident #85 stated she had left-sided weakness and was getting occupational therapy (OT) until last Thursday, 5/25. She added that she was being splinted and was not sure whether she should continue being splinted since therapy stopped. She added that she would like to continue having it as it helped with the pain caused during movement. The resident's splint was observed in her drawer. (Photographic evidence obtained) A review of the medical record revealed that the resident was admitted to the facility on [DATE] with an admitting diagnosis noted as sequelae of unspecified cerebrovascular. A review of her physician's order, dated 2/14/23, revealed the following: Resident may participate in RNP 7 times a week for 15 weeks for contracture management. Resident to utilize Left [NAME] air T-hand orthotic for contracture management. A review of the Care Plan, revised on 5/31/23, revealed that the resident required assistance with activities of daily living (ADLs) and fluctuated from requiring extensive to total assistance/total care except for eating, which she required supervision for due to a diagnosis of stroke. Her ability to perform ADLs varied over the course of the day. Interventions included utilizing a Left [NAME] Air hand orthotic for contracture management. (Photographic copy obtained) A review of the Quarterly MDS assessment, dated 5/12/23, revealed that the resident had a BIMS score of 13, indicating intact cognition. She was assessed to be totally dependent for bed mobility, transfers, toilet use and needed supervision with eating. The resident was not documented to be receiving Restorative Therapy. A review of the Occupational Therapy (OT) notes dated 5/25/23, revealed that the resident had been discharged from OT when her highest practicable level was achieved. The notes further indicated that the resident was placed back on the RNP for passive ROM and splint placement. In an interview with Certified Nursing Assistant (CNA) I on 6/2/23 at 1:08 PM, she stated she had been employed by the facility for three years. She further stated Resident #85 required total care assistance. She confirmed that the resident was contracted and she had seen her with a splint at one time and therapy was placing the splint. She added that the resident was no longer on therapy and nursing staff should be applying the splint. She added that therapy normally taught staff how to apply the splints. A joint interview with the Director of Rehabilitation (DOR) and Licensed Practical Nurse (LPN) H/Restorative Nurse was conducted on 6/2/23 at 1:47 PM. The DOR stated residents were screened quarterly for functional status. If issues were noted, residents were further evaluated for skilled therapy or restorative nursing. She stated residents who were getting discharged from the skilled therapy case load and who remained in the facility, were normally discharged to restorative nursing from therapy. The DOR said, Normally, the frequency for Restorative is 5-7 days a week as tolerated, depending on what is going on. Restorative aides and/or nursing staff are provided with education with return demonstration as to what kind of services the residents need during discharge from skilled therapy. When asked about Residents #57 and #85's contractures, the DOR stated both residents were on the Restorative Nursing case load for splinting. The DOR stated Resident #85 completed skilled rehab on 5/25/23 and was placed back on the RNP. Both the DOR and LPN H accompanied the surveyor to the resident's room and confirmed that the splint was not on the resident. The resident pointed out that the splint was in the closet. The Infection Control Nurse/Restorative Nurse obtained the splint behind a stack of clothes in the closet. LPN H added that sometimes residents were uncomfortable with splints and they were taken off or staff took them off during care. When asked about how the resident tolerated the splints, she stated the staff were expected to document when they were applied and when they were removed. She could not provide documentation for the Restorative Nursing Program. During an interview with the Regional Nurse Consultant (RNC) on 6/2/23 at 4:45 PM, she confirmed that the facility had no documentation on it's Restorative Nursing Program. She added that the facility had identified that the RNP had stopped and had initiated a performance improvement program (PIP) in April 2023. When asked for the audits, she stated, There was no audit, only an in-service was conducted to initiate the program. I learned during the survey that it was not initiated.

Based on observation, interview, and record review, the facility failed to ensure that a resident who required respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (Resident #2) of six residents receiving respiratory treatment, from a total of 37 residents in the sample. The findings include: During an interview with Resident #2 on 5/30/2023 at 2:19 p.m., she advised that she stopped breathing when she slept. She stated Licensed Practical Nurse (LPN) A/Unit Manager was supposed to have ordered her a CPAP device two months ago but it still hadn't arrived. A review of Resident #2's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included heart failure; type 1 diabetes; ischemic cardiomyopathy; hemiplegia/hemiparesis; obstructive sleep apnea; atherosclerotic heart disease of native coronary artery; COPD; pulmonary hypertension; and presence of automatic cardiac defibrillator. A review of the Care Plan revealed the following: FOCUS - Impaired Gas Exchange/Ineffective Airway Clearance related to a diagnosis OSA history of bronchitis (rev 5/23/22) GOAL - Resident will be free of sign/symptoms of respiratory infections through the review date. INTERVENTIONS - BiPAP at 25/20 cm (centimeters) H20 (water) on room air with humidification. BiPAP to be worn during hours of sleep (4/12/22); Monitor for sign/symptoms of respiratory distress; respirations, pulse oximetry, increased heart rate; restlessness, diaphoresis, headaches; lethargy; confusion; atelectasis; hemotysis; cough; pleuritic pain; accessory muscle usage; skin color; vital signs as ordered. Per the Quarterly Minimum Data Set (MDS) assessment, dated 3/23/23, the resident's Brief Interview for Mental Status (BIMS) score was 15/15, indicating intact cognition. There were no moods or behaviors documented. She required supervision with locomotion on/off unit and eating; total dependence with toileting, and extensive assistance with transfers, bed mobility and dressing. A review of the resident's physician's order dated 5/11/23, revealed: BiPAP @ 25/20 cm H20 on room air with humidification to be worn during hours of sleep; Monitor mobile cardiac monitor with it in place on chest, may secure with chest; Please apply supplemental O2 QHS (oxygen at bedtime daily) at 2L (2 liters per minute) for sleep apnea. Will continue until CPAP {*clerical error} has been fixed. During an interview on 6/1/2023 at 1:51 p.m. with LPN B, she was asked to clarify whether the resident was ordered a CPAP or BiPAP device. She replied, I don't know. She stated she had only been employed with the facility for three weeks, and although she was familiar with the resident, she did not have knowledge of this information. She deferred to LPN A. At this time, a person exited from a door behind a desk at the nurses' station. She advised the surveyor this was LPN A. The surveyor made an introduction and explained what was needed. An interview was conducted on 6/1/2023 at 1:53 p.m. with LPN A, who stated she had been employed with the facility for approximately 19 months. She was asked about Resident #2 and the equipment. She stated at times the resident was noncompliant with the CPAP. She stated the resident would mess with it and lost the cord. She further stated she called the company and they were sending a new cord to the facility. She was asked to clarify whether the resident had been ordered a CPAP or BiPAP device. She could not clarify this and stated she would have to look into it. She also could not confirm how long it had been since the cord had been ordered and the resident had been without use of the device. She also could not provide any documentation such as a workorder, invoice etc. for the equipment repair/part ordered. During an interview on 6/1/2023 at 5:07 p.m. with the Regional Nurse Consultant (RNC), she confirmed the equipment was a BiPAP device. She stated they were in communication with the supplier in an attempt to get the equipment sent overnight to the facility. On 6/2/2023 at 9:33 a.m., the RNC advised that the BiPAP cord had been received and delivered to the resident overnight. During an interview on 6/2/2023 at 4:08 p.m. with LPN A, she confirmed the device was a BiPAP and that it had been received. She stated the resident said she was getting an error message that air was leaking from it. She stated she called the supplier and they said the settings were too high and they needed to verify the setting. She stated she was able to confirm the correct setting and they were still working on other possible fixes. She stated she was working with the nurse on the other shift as well to see whether they could get the right fit for the resident, as she had two masks for the device. Again, she was asked how long the issue had been going on. She stated since approximately 5/11/2023. On 6/2/2023 at 4:33 p.m., LPN A advised that she had spoken to the provider and it was determined that there was a crack in the water reservoir of the device which would cause the seal not to seal properly. She was asked to provide correspondence from the onset of the issue on 5/11/23 to current date. She stated there wasn't anything that she could provide as proof that the facility had been making attempts to have the equipment repaired. There are no record of the repair calls to the supplier or a technician with the supplier or the facility, nor were there any work orders or invoices. There were no receipts, payment coupons, or sell slips provided. She stated the phone representative at the supplier stated she could see where she had called in the past, however she could not provide any documentation of this. She again stated there was no documentation to confirm anything had been done to make repairs to the equipment prior to the survey team entering the building.

Based on observation, interviews, medical record review and facility policy and procedure review, the facility failed to ensure medications were properly labeled for ten (Residents #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) of sixteen residents sampled. This placed the resident at risk for a medication administration error related to unsafe medication administration. The findings include: During a tour of the facility on 4/13/2022 at 8:46 AM, Employee A, Licensed Practical Nurse (LPN) was observed with multiple empty medication cups labeled with room numbers. When interviewed about this, she stated, This makes it easier for me to pass medications to the residents. When asked how this made the medication pass easier. She opened the medication cart drawer revealing 10 medications cups. Each medication cup had only room numbers (101A, 102B, 103B, 104B, 106A, 106B, 109A, 109B, 110B and 111A) written on them with multiple tablets of various shapes, colors, and sizes. Employee A, LPN acknowledged she had pre-poured the 10 medication cups. She confirmed, she was not supposed to do this; however, it was how she was trained to do the medication pass. She explained that she always used the pre-poured method when administering medication even though, she knew it was not allowed. (Photographic evidence obtained) During an interview with the Director of Nursing (DON) on 4/13/2022 at 10:02 AM, she acknowledged Employee A, LPN was utilizing an outdated medication pass procedure and she should not have pre-poured any medications. A review of the facility census and medical records was conducted and revealed that Resident #7 was admitted to room [ROOM NUMBER]A, Resident #8 was admitted to room [ROOM NUMBER]A, Resident #9 was admitted to room [ROOM NUMBER]B, Resident #10 was admitted to room [ROOM NUMBER]B, Resident #11 was admitted to room [ROOM NUMBER]A, Resident #12 was admitted to room [ROOM NUMBER]B, Resident #13 was admitted to 104B, Resident #14 was admitted to room [ROOM NUMBER]B, Resident #15 was admitted to room [ROOM NUMBER]A, and Resident #16 was admitted to room [ROOM NUMBER]B. (Copy obtained) A review of the facility's policy and procedure titled, Med Pass with Medication Cart (Revised: 04/24/2017) read: Procedure: 11. Prepare medication. a. Remove the resident's medication from the appropriate bin or drawer. Read the medication order(s) and compare with the prescription label(s). b. Check the expiration date of the medication to be given. Pour the prescribed dosage(s) from the container and place in a souffle' cup or calibrated liquid measure cup. c. Read the medication order(s) and again compare with the prescription label(s) to be sure you have the correct dose medication and dose. Line 15. Repeat steps 1-15 for each resident scheduled to receive medication during the pass. (Copy obtained) A review of the Relias Learning, computer based online training course titled, Medication Administration: Avoiding Common Errors which each nurse takes revealed, There is never a circumstance in which medications should be pre-poured. Medications should be drawn up just prior to administration and, if refused, disposed of properly. (Copy obtained)

Based on interviews and record review, the facility failed to provide care and treatment in accordance with professional standards of practice, by delaying hospitalization for one (Resident #51) of two residents reviewed for hospitalization s from a total sample of 40 residents. The findings include: A review of Resident #51's medical record revealed an admitted [DATE] and a readmitted [DATE]. Her primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change assessment dated [DATE] revealed resident's cognition was moderately impaired, and she required limited to extensive assistance with activities of daily living. A nursing progress note dated 7/18/21 at 2:24 AM indicated Resident #51 was observed lying on her back next to her bed. An abrasion was noted above the right eye. The resident stated she slipped and fell . She denied pain at the time of the assessment. A post fall review dated 7/18/21 indicated the fall occurred at 2:10 AM. The resident was ambulating unassisted. A review of Resident #51's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 7/18/21 at 1:27 PM indicated Resident #51 was to have a stat x-ray of the right knee and right femur due to pain. An x-ray result dated 7/18/21 at 9:03 PM indicated a minimally displaced obliquely oriented acute intertrochanteric fracture. The examination date for Resident #51 was on 7/18/21 at 8:15 PM. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 7/18/21 at 11:52 PM indicated Resident #51 was diagnosed with a right femur fracture. The physician was notified, and order was obtained for transfer to the emergency room for evaluation. A nursing progress note dated 7/19/21 at 2:00 AM indicated ambulance service arrived and resident was taken to the emergency room . An attempt to interview the nurse that transferred the resident to the hospital was made. However, the nurse was no longer employed at the facility. A review of Resident #51's hospital history and physical dated 7/19/21 indicated she presented to the emergency department with right leg pain following an unwitnessed fall around 5 AM. The note read, She was apparently ambulatory for a few hours after the fall but then reported she was having too much pain to be able to walk. She had imaging done and was found to have a right femur fracture. On 9/23/21 at 10:01 AM, an interview was conducted with the Employee B, Licensed Practical Nurse (LPN)/Unit Manager (UM). She explained that she was out of the building conducting a mock survey at another facility. The UM stated, she wasn't sure why the resident's transfer to the hospital was delayed. On 9/23/21 at 12:40 PM, an interview was conducted with the Regional Nurse Consultant (RNC). When she was asked about the lapse of time between the second x-ray being ordered and Resident #51's subsequent transfer to the hospital, she stated, she wasn't sure why the delay had occurred.

Based on interviews and record review, the facility failed to implement interventions to address a resident's acute pain related to a fracture after sustaining a fall for one (Resident #51) of two residents reviewed for pain management from a total sample of 40 residents. The findings include: A review of Resident #51's medical record revealed an admitted [DATE] and a readmitted [DATE]. Her primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change assessment dated [DATE] revealed resident's cognition was moderately impaired, and she required limited to extensive assistance with activities of daily living. A nursing progress note dated 7/18/21 at 2:24 AM indicated Resident #51 was observed lying on her back next to her bed. An abrasion was noted above the right eye. The resident stated she slipped and fell . She denied pain at the time of the assessment. A post fall review dated 7/18/21 indicated the fall occurred at 2:10 AM. The resident was ambulating unassisted. A review of Resident #51's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 7/18/21 at 1:27 PM indicated Resident #51 was to have a stat x-ray of the right knee and right femur due to pain. An x-ray result dated 7/18/21 at 9:03 PM indicated a minimally displaced obliquely oriented acute intertrochanteric fracture. The examination date for Resident #51 was on 7/18/21 at 8:15 PM. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 7/18/21 at 11:52 PM indicated Resident #51 was diagnosed with a right femur fracture. The physician was notified, and order was obtained for transfer to the emergency room for evaluation. A nursing progress note dated 7/19/21 at 2:00 AM indicated ambulance service arrived and resident was taken to the emergency room . A review of Resident #51's hospital history and physical dated 7/19/21 indicated she presented to the emergency department with right leg pain following an unwitnessed fall around 5 AM. The note read, She was apparently ambulatory for a few hours after the fall but then reported she was having too much pain to be able to walk. She had imaging done and was found to have a right femur fracture. A review of Resident #51's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had no other orders for analgesics prior to the fall and no ordered analgesics until after returning from the hospital. A review of the medication administration records (MAR) for July 2021 revealed pain evaluation results of 0 on each shift prior to the resident transferring to the hospital. A review of the comprehensive care plan for Resident #51 dated 4/15/21 revealed a focus area for pain. Interventions included analgesics as ordered, evaluate characteristics of pain: location, severity on a scale of 10, and frequency, identify existing conditions that may increase pain or discomfort, observe for signs of relief/effectiveness with interventions. On 9/22/21 at 2:16 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She explained that she had worked at the facility for approximately nine years and that she was familiar with Resident #51. Regarding the fall on 7/18/2021, the nurse explained that the fall occurred on night shift and that she reported to work the following morning. She explained that as the day shift CNA was assisting the resident to stand, the resident complained of pain. The CNA notified the nurse and the nurse went in to assess the the resident. The resident pointed to her knee. The nurse explained that she notified the physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse then reviewed the medical record and asked Employee B, LPN/Unit Manager to review the record. The UM stated, she didn't see anything on the 18th or 19th. On 9/22/21 at 3:13 PM, Employee A, LPN confirmed, she did not give Resident #51 anything for pain. Initially, she stated, I didn't give her anything. The doctor didn't tell me to give her anything. But, she had a [MEDICATION(S)] patch on her back. When asked to confirm whether the resident's acute pain was discussed with the physician, the nurse didn't answer the question but stated, I don't know, I don't remember. On 9/23/21 at 10:01 AM, an interview was conducted with the UM. She explained that she was out of the building conducting a mock survey at another facility when the resident fell . The UM reviewed the resident's record and confirmed that the record contained no documentation of interventions to treat the resident's pain. On 9/23/21 at 12:40 PM, an interview was conducted with the Regional Nurse Consultant (RNC). She explained that the facility conducted an investigation for Resident #51's fall on 7/18/21. The RNC stated, she had spoken with the nurse about the fall after it was brought to her attention during the survey and that the nurse told her she obtained an x-ray order because the resident was grimacing while walking. The RNC acknowledged that, after reviewing the record and speaking with Employee A, LPN the resident received her routinely scheduled [MEDICATION(S)] patches but no other analgesics were adminsitered to treat the acute pain. A review of the facility's pain management policy titled Pain Evaluation directed staff to assess the resident's pain characteristics, contact the physician for orders, and include interventions in the resident's comprehensive plan of care.

Based on observations, interviews and record review the facility failed to ensure that the residents' environment remained free of accident hazards for one of forty-four residents sampled (Resident #88). The findings include: During multiple tours of the facility on 10/14/2019 and 10/15/2019 four blue razors were observed on the top of the nightstand next to the bed in Resident #88's room. The razors were in plain view from the door leading to the 100 hall, and were accessible to passers-by. (Photographic evidence obtained) During an interview on 10/16/2019 at 3:18 pm with Employee C, Licensed Practical Nurse (LPN), she stated that residents are not allowed to keep items such as razors in their rooms. The nurses and Certified Nursing Assistants (CNA) are responsible for monitoring the resident safety. Additionally, even if the family brings items such as razors, it must be removed from the resident's room when the family leaves the facility. During an interview on 10/17/2019 at 2:26 pm with Employee H, LPN Unit Manager, she confirmed that staff should not be leaving sharp items such as razors in resident rooms. During an interview on 10/17/2019 at 3:02 pm with Employee I, Regional Nurse Consultant, she confirmed that sharp items such as razors should not be left in resident rooms. She stated that the nurses and CNAs are to remove the items once they have completed care. The facility's admissions packet was reviewed, including Policies and Rules Governing Resident Conduct and Behavior. The safety and security responsibilities state that residents must secure permission from the facility for the use of personal property and electronic devices e.g. laptops, cell phones, razors, recorders. Review of the facility's policy on Residents Personal Property revealed that sharp objects are prohibited in the rooms of the residents.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections by not cleaning the pill crushers (2 out of 6) observed, not cleaning a glucometer per policy and procedure, and not washing hands before administering medications. The findings include: 1. A pill crusher was observed on 10/17/19 at 1:27 PM on a medication cart for the 200 hall. The pill crusher had caked-on brown debris on the outside and inside of the crusher. Employee C, Licensed Practical Nurse (LPN) confirmed the pill crusher was not clean. She reported it is cleaned weekly. (photographic evidence was obtained) An observation of a pill crusher was observed on a medication cart for the 300 hall with Employee D, Registered Nurse (RN). The pill crusher had caked-on brown debris on the outside and inside. Employee D confirmed the pill crusher was not clean, and reported she wipes the outside daily. (photographic evidence obtained) An interview was conducted with the Director of Nurses (DON) at 2:30 PM on 10/17/19 . She reported the medication carts are audited weekly and pill crushers are cleaned weekly. The DON confirmed there were some pill crushers that were not clean. 2. An observation was conducted of medication administration with Employee B, Registered Nurse (RN) at 4:19 PM on 10/15/19 for a resident in 416-B. Employee B took her glucometer, and supplies to check a blood glucose. After obtaining the blood glucose reading, the RN obtained a bleach wipe, cleaned the glucometer for 30 seconds, wiped all areas, and wrapped it in tissue at 4:28 PM. The DON intervened and reported the nurse was in orientation and her trainer should have been with her. The employee was immediately removed to be in-serviced on cleaning glucometers. Employee F, RN, re-cleaned the glucometer and applied a bleach wipe for 3 minutes with the DON coaching. The RN let the glucometer stay wet for 3 minutes and then let it air dry. The DON stated the glucometer should be cleaned with a bleach wipe for 3 minutes and/or wrapped in a bleach wipe for 3 minutes after wiping thoroughly. A review of the MicroKill bleach wipes Guidelines for Cleaning and Disinfecting Blood Glucose Meter noted after cleaning the blood glucose meter with a wipe, to disinfect the meter before and after each use by disinfecting the meter with a germicidal wipe, by cleaning for 3 minutes or wrapping with wipe for 3 minutes, and allow to air dry. 3. An observation was conducted of medication administration with Employee A, Licensed Practical Nurse (LPN) at 9:14 AM on 10/15/19. Employee A reviewed the Medication Administration Record, [REDACTED]. Employee A entered room [ROOM NUMBER]-A, applied gloves and administered eye drops, one drop to both eyes. Employee A removed gloves, and used sanitizer after leaving the room to clean hands. Employee A was asked about washing hands before administering eye drops, and she confirmed she should have. An interview was conducted with the Director of Nurses (DON) at 10:40 AM on 10/15/19. The DON reported Employee A informed her she did not wash her hands before administering eye drops, and brought the policy for eye drops . The DON stated the LPN should have washed her hands before administering the eye drops and applying gloves. The Policy and Procedure for eye drops, revised on 4/25/17, was reviewed, and it noted under procedure 5. -- wash hands and put on gloves.

Based on clinical record review, facility policy and procedure review and staff interviews, the facility failed to protect residents from neglect for one (Resident #1) of three residents sampled for freedom from abuse, neglect, and exploitation, of 115 residents who were a full code status. Resident #1 had an advance directive that did not include withholding cardiopulmonary resuscitation (CPR). The facility neglected to provide CPR in a timely manner after finding Resident #1 unresponsive. The facility failed to immediately determine Resident #1's resuscitation code, and failed to call 911 per the facility policy and procedure for CPR. The resident expired. Failure to provide timely CPR removes the resident's opportunity for successful resuscitation. The Nursing Home Administrator was notified of past noncompliance immediate jeopardy on [DATE]. The immediate jeopardy was removed effective [DATE]. The plan of action was developed on [DATE] with the formal staff training completed on [DATE]. The facility correction date of the deficient practice was [DATE]. The findings include: On [DATE] at 5:30 a.m., Employee A, Registered Nurse (RN), completed a nursing note. She documented Resident #1 as: non-verbal, generalized skin warm to touch, bilateral finger tips cool to touch, eyes closed, blood sugar 155, no respiratory distress noted. Resident assessed for radial and apical pulses, and breathing pattern, HOB (head of bed) up, O2 @ 2 L (oxygen at 2 liters per minute) in place, O2 sat 96% (oxygen blood saturation at 96%), wound vac (vacuum) checked and in place. Chart checked for code status and contacts to be notified. On [DATE] at 5:49 a.m., Employee A completed a nursing note: Emergency Contacts #1 and #2 called. No answer. Message left. On [DATE] a late nursing note entry was made at 2:08 p.m.: 7:15 a.m., Employee A, RN, informing expiration of Resident #1. At 7:30 a.m., Employee C, Licensed Practical Nurse (LPN) arrived, was called by Employee A, RN, and went into resident room, assessed, CPR started. Medical Director has been notified. A review of records revealed a call was made to 911 at 7:30 a.m., and emergency medical services arrived as nurses were doing CPR. They took over and rescue pronounced the resident at 7:37 a.m., then left the building. A review of Resident #1's Social Services Admission Evaluation, dated [DATE], revealed that his Brief Interview for Mental Status (BIMS) score was 9 out of a possible 15 points, indicating moderate impairment. He required total assistance for all activities of daily living except eating. He used a wheelchair for mobility. A review of written statements by the staff, dated [DATE], revealed that at 11:00 p.m. on [DATE], Employee B, Certified Nursing Assistant (CNA), stated she observed the resident asleep and snoring. At 1:00 a.m. on [DATE], she checked the resident for incontinence, and he was still asleep and snoring. At 3:00 a.m. on [DATE], she checked the resident again for incontinence. He was dry and still sleeping. At 5:30 a.m., she checked the resident for incontinence and very little urine was noted. At that time, she noticed that he was not breathing and notified Employee A, RN. A review of a written statement by Employee A, RN, on [DATE], revealed that Employee B, CNA, reported to her that the resident had expired. Employee A went to the resident's room, completed an assessment, no vital signs, resident was warm to the touch. The tips of his fingers were blue. Did not feel any pulse at the time of assessment. Check for code status. Check the chart for family member to notify of resident's status. Employee A was not sure the resident was breathing, as the chest was not rising up/down. No heart rate. A review of a written statement by Employee C, LPN, on [DATE] revealed, Came in at 7:25 a.m. put personal items up. When a CNA informed me Resident #1 had passed. I asked if he was coded, CNA said no; I went into resident's room to assess resident immediately ran to the nurse of this resident and asked if code had been called, she said no, I then immediately went to desk and called a Code Blue over intercom system 2 North Wing. ,[DATE] nurses were at the desk and immediately brought the crash cart to the room, I then called 911, then went to resident's room to assist with the code, CPR was in progress. I then went to the door to let rescue in. Rescue entered the room and took over. Rescue pronounced resident and left the building. I then immediately called the Director of Nursing and family. A closed record review conducted for Resident #1 found he was admitted to the facility on [DATE] for rehabilitation post-hospitalization [MEDICAL CONDITION] (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body ' s response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). He was a [AGE] year-old male with the following Diagnoses: [REDACTED]. [MEDICAL CONDITION] happens when the capillaries, or tiny blood vessels, surrounding the air sacs can't properly exchange carbon [MEDICATION NAME] for oxygen.) with [MEDICAL CONDITION] (deficiency in the amount of oxygen reaching the tissues), [DIAGNOSES REDACTED] ([MEDICAL CONDITION] is the most common form of arrhythmia (irregular heartbeat), which is a condition where a person experiences heart rhythm problems. [DIAGNOSES REDACTED] occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days), Acute kidney failure (an abrupt decline in renal function, clinically manifesting as a reversible acute increase in nitrogen waste products over the course of hours to weeks), Acidosis (an excessively acid condition of the body fluids or tissues), [MEDICAL CONDITION] (inflammation of connective tissue under the skin) of the right axilla (armpit) and chronic pai[DIAGNOSES REDACTED]. A physician's orders [REDACTED]. There was no DNR (do not resuscitate) paperwork in his record. According to the facility's investigation of the event, the facility called the Florida abuse hotline, and the report was not accepted. The DON documented that she notified the resident's representative, law enforcement, and the Florida State Abuse Registry on [DATE]. An interview was conducted with Employee C, LPN/North Wing Desk Nurse on [DATE] at 9:24 a.m. She confirmed her written statement was accurate, and stated she entered the facility and a CNA informed her that Resident #1 had expired. She stated she knew he was a full code, and asked if he was coded. The CNA replied no. She went into the resident's room to assess him, then immediately ran his assigned nurse (Employee A, RN) and asked if a code had been called. She replied no. Employee C immediately went to the nursing desk and called a code blue over the intercom system. Two North Wing day shift nurses were at the desk, and immediately brought the crash cart to the room. Employee C then called 911 and went to the room to assist with the code. CPR was in progress. She went to the door to let rescue in. Rescue entered the resident's room and took over. Rescue pronounced the resident and left the building. Employee C immediately called the Director of Nursing and the resident's family. She stated Employee A did not give any reason why she didn't start CPR. When asked if she felt the nurse was negligent for not doing CPR on a resident with a Full Code status, she replied, Yes, I do. A phone interview was conducted with Employee B, CNA, on [DATE] at 8:38 a.m. She stated when she went into Resident #1's room at approximately 5:30 a.m., she checked him for incontinence. There was very little urine and she noticed he was not breathing. She then went out to the hallway to get a nurse. She couldn't find one, so she sent a text to her nurse (Employee A) at approximately 5:31 a.m., and said Resident #1 had passed away. Employee B stated the resident's color had changed and he was not breathing. I worked for Hospice for 8 years and I know that look. She received a return text from the nurse at 5:31 a.m., which said she was using the restroom and would be right there. Employee B stated she went to look for another nurse and during that time see saw a nurse going into room [ROOM NUMBER]. About the same time, a call light in room [ROOM NUMBER] came on and the CNA went to assist that resident. The CNA stated she saw the nurse exit Resident #1's room and told her that the resident had passed away and she had called the family. When asked if the nurse performed CPR, she didn't know, because she wasn't in the room. When asked if she had CPR certification, she replied no, it was not required at this facility. When asked what she should do if she finds a resident unresponsive, she replied, we were told to go find a nurse, because the nurse is the only one who can call Code Blue. When asked if she felt the nurse was negligent in caring for Resident #1, she replied No, she told me the resident had passed away and she called the family. A phone interview was conducted with Employee A, RN, on [DATE] at 11:58 a.m. She stated she had been a nurse for [AGE] years; six years as an LPN and about five years as an RN. She started working for a second time at the facility on [DATE] as an RN. She previously worked at the facility in (YEAR) as an LPN. When asked about what happened the morning of [DATE] with Resident #1, she stated she was told by Employee B that the resident had passed, so she went into the room and assessed him. He wasn't breathing and had expired. She then said she made a phone call to his family to let them know he had expired. When the manager came in at 7:30 a.m. or so that morning, she called a code and 911 was called. When asked if she pronounced the resident dead, she replied no. When asked if she started CPR, she replied no. When asked if Resident #1 was a full code and whether she should have started CPR, she replied yes. When asked who should pronounce a resident has expired, she said it depended on the situation, but usually the doctor or emergency medical personnel. When asked if she called 911, she said no. When asked if she should have called or had someone call 911, she said yes. When asked if she followed the facility's Code Status and CPR policy, she replied no. An interview was conducted with the DON on [DATE] at 10:00 a.m. She confirmed that Employee A did not call 911 when she should have. She confirmed that Employee A left Resident #1, did not follow the facility policy for CPR and did not perform CPR, though she should have, because the resident was a full code. When asked if Employee A was negligent in her actions, the DON replied, Yes, she was. An interview was conducted with the Administrator on [DATE] at 11:00 a.m. He stated he was notified by the DON about the incident at approximately 7:45 a.m. on [DATE]. He further stated that following his notification he talked to Employees A, B and C, and had them give written statements regarding the event that occurred on [DATE]. He also stated that when he talked with Employee A, she didn't give him a reason explaining why she didn't perform CPR, and she couldn't explain why she didn't get help. The Administrator stated that Employee A failed to follow the facility's CPR policy and call 911. When asked if Employee A was negligent in her actions by leaving the resident in the room and not performing CPR for a full code resident, he replied, Yes, she was. He added, We suspended her following the incident on [DATE] and as a result of our investigation, we have terminated her employment, and reported her to the Board of Nursing. A review of the facility's policy and procedure for CPR - Cardiopulmonary Resuscitation, with a revised date of [DATE] revealed: Policy: Cardiopulmonary Resuscitation (CPR) is initiated to support the ventilation and circulation function until: aid arrives, and the resident is placed on advanced life support systems; he/she is stimulated to function on his/her own; and/or he/she is pronounced dead. 1. Cardiopulmonary resuscitation is initiated on all residents except those with a No Code or Do Not Resuscitate order and/or State approved documentation. 2. Cardiopulmonary resuscitation is performed only by individuals certified in CPR. 3. Licensed nurses are to be certified in CPR and must be re-certified in accordance with certifying agency. Procedure: 1. In the case of cardiac and/or [MEDICAL CONDITION] arrest, Code status is verified and if resident is a Full code then CPR is initialed. 2. Using the paging system and call the code. 3. CPR is continued until life support systems are available, or it may be discontinued if: [NAME] The resident responds B. EMS arrives and takes over 4. Contact the physician and family 5. Document details of occurrence in the clinical record A review of the facility's Abuse and Neglect Prohibition policy and procedure, with a revised date of [DATE] revealed: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, exploitation, and misappropriation of property. On page two of five under Fundamental Information - Definitions: Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. On [DATE] at 11:30 a.m., Employee D, LPN, stated she worked full-time. She had completed multiple CPR drills and she was CPR certified. She also stated the facility had monthly mock CPR drills, and she had participated in a many of them. Training included all the steps taken when performing CPR, and she appropriately recited those steps. On [DATE] at 12:00 p.m., Employee E, CNA, stated she was a full-time employee. When asked what should be done if a resident was discovered unresponsive and not breathing, she was able to recite the appropriate steps to take according to the facility's policy and procedure for initiation of CPR. On [DATE] at 12:15 p.m., an interview was conducted with the Administrator, DON, Corporate Nurse/Senior Regional Clinical Director, and Vice President (VP) of Operations concerning their viewpoints about whether this situation should be considered neglect. They all stated yes. The VP of operations then stated, We reported it to the Abuse Hotline, did the AHCA Day 1 report, notified the Sheriff's Office, suspended the employee pending investigation, terminated the employee on [DATE] and reported her to the Board of Nursing. When reviewing the timeline which showed Employee A, RN, checking the resident at approximately 5:30 am (no CPR started) and Employee C, LPN, calling a Code Blue at approximately 7:30 a.m., all in attendance stated they felt Employee A was neglectful in her actions. In addition, regarding how the facility monitored the staff's care and services to prevent neglect from occurring prior to this event, the VP of Operations stated that the facility had several in-services related to abuse and neglect (training is required at a minimum during orientation and annually). In addition, she added that monthly Code Status drills were conducted monthly. On [DATE] at 12:30 p.m., the DON explained that an audit was completed for every resident in the facility to ensure that their DNR/code status was documented clearly in their clinical records. The daily order list would be updated each day and put on each crash cart. The facility also initiated daily CPR drills each day for seven (7) days post-incident, beginning on [DATE] day shift, to ensure all staff participated. Afterward, CPR drills would be conducted weekly for 30 days and then monthly. The crash carts were checked to ensure all potentially needed supplies were available and all CPR certification cards were reviewed on [DATE]. She stated the facility had been conducting CPR drills randomly each month prior to this incident, which was confirmed through a review of the records. During an interview with the Social Services Director (SSD) on [DATE] at 1:38 p.m., she stated in-service training was provided to staff by Staff Development, the Director of Nursing, the Assistant Director of Nursing and the Unit Managers beginning on ,[DATE] day shift and completed by [DATE], which included information about resident abuse/neglect and staff burn out. She stated that department heads were made aware promptly if there was a concern about an employee's stress level. Staff were taught to make their supervisors aware immediately if they were concerned about abuse/neglect. On [DATE] at 2:00 p.m., an interview was conducted with the facility's Medical Director. He stated he was informed of the incident on [DATE], as he had received a call from the DON early that morning. He stated that he participated in the ad hoc QAPI meeting via telephone, and participated in the plan to do training of all staff regarding advance directives/CPR/Code Blue. When asked if the nurse should have started CPR on Resident #1, he replied, Yes, the resident was a full code and she should have followed facility policy. The Director of Nursing and Unit Manager were made aware of Resident #1's death by 7:30 a.m. on [DATE]. The Administrator was made aware of Resident #1's death at 7:45 a.m. on [DATE] and initiated an investigation on [DATE] by suspending Employee A and assigning another nurse to take over Employee A's assignment. Facility-wide training on CPR, activation of EMS (emergency medical services) and changes in condition for all staff was initiated on [DATE] and completed by [DATE]. Staff involved were interviewed. Between ,[DATE] and [DATE], an audit was completed of all residents' clinical records to ensure that their DNR or Full Code status was clearly documented, as well as an audit of all deaths within the last six months to identify any additional educational needs. The administrator initiated random code simulations every shift daily for all nursing staff for seven (7) days. These were completed as verified through a review of the records from ,[DATE] through the exit on ,[DATE] (14 total). A code simulation was observed on [DATE] at 4:40 p.m. These simulations were to continue weekly for 30 days, then monthly thereafter, following the first seven days post-event. The Administrator developed a plan for the Quality and Assurance Assessment (QA&A) committee to track the progress of the corrective action plan monthly until resolved. An audit was completed on [DATE] of all nursing staff to ensure that there would be a CPR certified staff member on all shifts. The administrator terminated Employee A and reported her to the State Nursing Board.

Based on observations, record review, staff interviews, and policy and procedure review, the facility failed to administer tube feedings as ordered for one (Resident #53) of three sampled residents out of 11 residents receiving tube feedings in the facility. Failure to administer tube feedings per the physicians' orders places these residents at risk for malnutrition and weight loss. The findings include: On 6/27/18 at 11:13 AM, Resident #53 was observed lying in bed. The head of the bed was elevated 30 degrees. A bottle of [MEDICATION NAME] 1.5 was hanging on the IV (intravenous) pole next to the bed. There were 750 milliliters (ml) remaining in the bottle. A full bottle contained approximately 1000 ml. The pump was not running. The label on the bottle read (Resident #53) (Room), date 6/27/18, start at 6:00 AM at a rate of 85 ml /hour (hr). (Photographic evidence obtained) On 6/28/18 at 9:22 AM, Resident #53 was observed lying in bed. The head of the bed was elevated 30 degrees. A bottle of [MEDICATION NAME] 1.5 was hanging on the IV pole next to the bed. The gastrostomy tube ([DEVICE]) was infusing [MEDICATION NAME] 1.5 at 85 ml/hr. When asked whether he felt nauseous or had been vomiting, the resident indicated that he had not. He spoke after a pause. He coughed several times. His roommate stated, He does that all the time. Resident #53 was observed again at 10:07 AM on 6/28/18. The [DEVICE] was no longer infusing. The [MEDICATION NAME] bottle was observed to be a 1500 ml bottle when full. There was 1300 ml of food product remaining in the bottle. The label stated that the bottle was hung at 6:00 AM. (Photographic evidence obtained) During an interview on 6/27/18 at 11:26 AM with Employee B, Licensed Practical Nurse (LPN), who was assigned to Resident #53, she stated that the resident received tube feedings from 2:00 PM until 10:00AM. It was a continuous feeding. A record review for Resident #53 revealed physician orders, dated 8/29/17, which read: [MEDICATION NAME] 1.5 at 85 cc/hr. x 20 hours two times a day. The time the feeding was to be turned on was 2:00 PM, and the time it was to be turned off was 10:00 AM. (Photocopy obtained) A review of the Medication Administration Record [REDACTED]. That block was left blank. (Photocopy obtained) A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was assessed as requiring tube feedings. His height was 67 inches (5 feet, 7 inches) and his weight was 144 pounds (lbs.). The MDS assessment dated [DATE], revealed that the resident was assessed as receiving tube feedings. His weight was recorded as 142 lbs. A review of the care plan revealed that the most recent review date was documented as 5/1/18, and the focus area read: Resident has a [DEVICE]. Goal: (Resident #53)'s [DEVICE] will remain patent. One intervention read: Provide tube feeding and water flushes as ordered. Another focus area read: Potential for alteration in nutritional status related to gastrostomy tube use. Interventions read: Administer formula via tube as ordered. Monitor for coughing. Registered dietician evaluation as needed. Weigh as ordered, monitor. (Photocopy obtained) During an interview with Employee C, Unit Manager on 6/28/18 at 2:40 PM, she was asked if the bottle hung at 6:00 AM continued at 2:00 PM if it was not empty. She confirmed that it was started at 2:00 PM, and a new bottle was hung every 24 hours. The Unit Manager then went to the resident's room to check the date and time on the label and the amount of product remaining. She calculated the rate of infusion based on the physician's orders [REDACTED]. That amount equaled 340 ml. She confirmed that only 200 ml had infused from the bottle currently hanging. She reviewed the photographic evidence of the bottle of [MEDICATION NAME] hanging at 11:13 AM on 6/27/18, and confirmed that the bottle had only 750 ml remaining in it and at a rate of 85 ml/hr. it would have infused by approximately 11:30 PM on 6/27/18 to 12:00 AM on 6/28/18. She could not determine whether the resident received a tube feeding continuously from 11:30 PM on 6/27/18 until 6:00 AM on 6/28/18. She left the interview to go to the Director of Nursing's (DON's) office. During an interview with the DON on 6/28/18 at 2:50 PM, she stated, I was here in the room when the night nurse hung this bottle, and she infused some of the food product into the trash can. I was here early this morning to check the dates on the tube feedings throughout the building. She confirmed the bottle was hung at 6:00 AM as was documented on the label of the bottle. She could not confirm that the resident received enteral nutrition from approximately 11:30 PM on 6/27/18 until 6:00 AM on 6/28/18. She could not explain why only 200 ml had been used from the bottle that was hung at 6:00 AM on 6/28/18. She confirmed she understood that the resident should have received 340 ml of food product from 6:00 AM until 10:00 AM. During a telephone interview with Employee E, LPN, on 6/28/18 at 4:21 PM, she confirmed she was the night shift nurse the previous night for Resident #53, and that she hung the bottle of [MEDICATION NAME] at 6:00 AM on 6/28/2018. It was the usual time she hung it. It could be off by a few minutes, but usually within just a few minutes. She wrote the time on the label, then went to hang it and started the feeding. Her shift ended at 7:00 AM. A review of the facility's policy and procedure for Guidelines for Enteral Nutrition revealed: 6. The nurse, registered dietitian, dietary manager, and social worker collaborate with the physician to develop a plan of care for the resident. 7. The nurse obtains a physician's orders [REDACTED]. Feeding tube orders include the following information: The rate and/or timing of administration; Total volume to be given per 24-hour period; Total calories provided per 24-hour period. 8. The nurse checks gastrostomy tube placement periodically during continuous feeding. 9. The nurse administers the enteral feeding regimen according to formula, system type, and method of delivery ordered by the physician. 15. The resident is evaluated for tolerance to the enteral feeding regimen each shift. Intolerance may be manifested by: aspiration. (Photocopy obtained)

Based on record reviews and interviews, the facility failed to post, as required, the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The findings include: A review of the daily staffing sheet, dated 6/28/18, which was posted on a clipboard by the Director of Nursing's (DON's) office, revealed the categories of staff, and the scheduled hours, but not the actual hours worked. This sheet dated 6/28/18 was the only sheet on the clipboard. The Director of Nursing called Employee A (Staffing Coordinator), and she brought a staffing sheet dated 6/27/18 to the DON's office which included the scheduled hours, but not the actual hours worked for each category of licensed and unlicensed nursing staff. An interview was conducted with Employee A on 6/28/18 at 1:30 PM. She stated that she took the sheet down at the end of each day, and then placed the sheet in a drawer with the staffing calculations for each day. She did not post the sheet with the actual hours on the clipboard by the Director of Nursing's office. During an interview with the Director of Nursing and the Regional Nurse Consultant on 6/28/18 at 1:35 PM, they stated that they did not know the actual hours had to be posted daily.

Based on staff and resident interviews and record review, the facility failed to provide notice of a new roommate to 2 of 23 sampled residents before the roommate's arrival to the room (Residents #173 and #178). The findings include: An interview with the Social Services Director on 4/27/2017 at 9:57 AM, revealed that Resident #173 had a new roommate, who moved into room [ROOM NUMBER] A on 4/10/17. After reviewing the resident's records and progress notes, the Social Services Director confirmed that she was unable to find any progress notes or documentation showing Resident #173 was notified prior to receiving a new roommate. Further interview with the Social Services Director on 4/27/2017 at 10:04 AM, revealed that Resident #178 had a new roommate, who moved into room [ROOM NUMBER] B on 2/13/17. After reviewing the resident's records and progress notes, the Social Services Director confirmed that she could not find any progress notes or documentation showing Resident #178 was notified prior to receiving a new roommate. When the Social Services Director was asked what the facility's policy was for documenting a roommate change, she replied, The notice of change in roommate assignment may be made orally or in writing, and then documented in the resident's progress notes. When asked again if Resident #173 or Resident #178 had any documentation in their progress notes showing they had been notified of a roommate change, she replied, No, there are no progress notes for either resident. During an interview on 4/27/2017 at 10:48 AM, Resident #173, who was alert and oriented was asked if he had a room change or roommate change in the last nine months, and he replied, Yes. When asked if he had a roommate change, he replied, Yes. When asked if the facility notified him of the roommate change, he replied, No. During an interview on 04/27/2017 at 10:57 AM, Resident #178, who was alert and oriented, was asked if he had a room change or roommate change in the last nine months. He replied, Yes. When asked if he had a roommate change, he replied, Yes. When asked if the facility notified him of the roommate change, he replied, No. The facility policy titled 'Room and Roommate Assignment Change' stated under Procedure #2: Prior to making a room change or roommate assignment, all parties involved (residents and their representatives) will be provided with a 48-hour advance notice of such changes whenever possible. Procedure #4: Receiving a new roommate: The notice of a change in roommate assignment for a resident receiving a new roommate may be made orally and in writing, and then must be documented in the resident's medical record, in the progress notes.

Based on observations, record reviews, and staff interviews, the facility failed to maintain the clinical records within acceptable standards and practices affecting all residents who were ordered wound treatments (40 residents in total). The findings include: During an observation on 4/26/17 at 9:10 a.m. of a dressing change for Resident #28, there was no treatment book or computer found on the treatment cart to review treatment prior to administration. Prior to observing the wound, the Wound Care Nurse (WCN) was asked where the location of the wound was and what treatment was ordered. She said the wound was on the lower back. The treatment ordered included cleanse wound with wound care cleanser, apply skin prep to peri-wound, and apply Idosorb gel and border dressing every other day. The WCN prepared the supplies and changed the dressing. When the WCN returned to the treatment cart, she was asked how she knew what treatment to administer since there was no treatment book or computer to use as reference. She stated she reviewed all orders in the morning and also she did treatments Monday - Friday. When asked when did she document the treatments, she stated when she finished all dressing changes. When asked why there was no treatment book or computer to review orders and document upon completion, she stated there was no computer for the treatment carts. She was asked how did she document changes in the wounds, she stated she wrote them on sheet and then documented all the information when she went to the computer at the nursing station. An interview was conducted on 4/27/17 at 11:45 a.m. with the Director of Nursing (DON) and Regional Clinical Director (RCD). When asked why there was no treatment book or computer on the treatment carts, the RCD said she did not know why, but it had been the practice at the facility. She stated that both she and the DON were new. She stated the facility would order computers for the facility today. A copy of the facility's policy was requested regarding documentation of treatments/medications. Review of the policy revealed to verify medication label, the nurse is responsible to read and follow instructions and initial the record after administering to the resident.

Based on record reviews and interviews, the facility failed to ensure that residents received, and the facility provided the necessary care and services to attain or maintain the highest practicable well-being consistent with the residents' comprehensive assessment and plan of care by failing to obtain and provide required anti-[MEDICAL CONDITION] medication or lCD4 lab tests for one resident (Resident #1) of 4 sampled residents, and by putting the resident at risk for physical decline. The findings Include: Resident #1 was [MEDICAL CONDITION](Human Immune Deficiency Virus) positive individual who was prescribed and required the [MEDICAL CONDITION] medication Triumeq tab 600-50-300 mg (milligrams)(Abacavir, Dolutegravir-Lamivud), one tablet by mouth one time a day for management of [MEDICAL CONDITION]. Anti-[MEDICAL CONDITION] drugs like this one need to be taken as prescribed to prevent the development of drug resistance, to keep the [MEDICAL CONDITION] load (amount of virus) in the person's body low, and to keep their immune system intact. Resident #1 was admitted to the facility on [DATE], and the physician ordered a start for this medication on 1/14/2017 (photographic evidence obtained). Review of the Medication Administration Record [REDACTED]. The resident was also ordered a CD4 test on 1/17/2017. Review of the lab work revealed there were no results indicating that the ordered CD4 test was completed. CD4 lab tests measure the number of infection fighting cells there are in a person's immune system. Review of progress notes showed two notes (1/15/2017 and 1/16/2017) stating the medication was on order from the pharmacy (photographic evidence obtained). Review of pharmacy communication to the facility showed that two faxes of their Urgent Non-Covered Medication forms with requests for response were sent to the facility. The first, according to a fax stamp, was sent on 1/16/2017 at 13:06 PM, and the second on 1/16/2017 at 4:10 PM (Photographic evidence obtained). A facility non-coverage form is one that explains the facility cost of the medication, and asks the facility whether they want to switch to a less expensive drug, or whether they will pay for the listed drug. There was no indication that the facility responded to either of these requests. Review of the facility's Medication Pass Guidelines, SHCR .01, stated in part Medications are administered in accordance with the written orders of the physician, and new medications start/ new medication orders begin timely on the same day ordered, unless the next dose would be normally given the next day. (photographic evidence obtained) During an interview with the director of nursing (DON) on 2/9/2017 at 3:47 PM, this surveyor asked why Resident #1 did not receive her anti-[MEDICAL CONDITION] medication, what the facility's normal process was in obtaining special medications, and what the facility did in relation to Resident #1's medication order. The DON stated that Resident #1 was admitted on a Friday afternoon. She said she thought the resident arrived after the evening drug run from the pharmacy, which provided two daily drug runs; one around 8:00 AM, and one around 3:00 PM. The DON went on to say she returned to work on the following Monday, 1/16/2017, and was told by her nurses that the medication was not available from the pharmacy. The DON stated no one told her of any additional cost related to the medication, or non-coverage forms at that time. When the DON was asked why there was no response to the pharmacy's faxed Non-Coverage forms, she stated that she never saw the forms; she only saw those forms when the surveyor requested them from the pharmacy. Then she stated that her name was put at the top of those forms but she never saw them. When she was asked whether the physician was notified that this medication had not been received by the resident, she replied that she thought the physician wrote a new hold order. She was asked to provide the hold order for review, but it was not produced during the survey. This surveyor was unable to locate a hold order in the clinical record. The DON was asked whether she had called the pharmacy regarding the medication's availability once her nursing staff informed her that the medication was not available. She replied, No. She was asked whether a 5-day wait for the medication was considered timely and appropriate, and she replied No, but that was why she tried to get the resident home on 1/18 to get her own supply of the medication. During a telephone interview with the pharmacy (chief pharmacist and billing department) on 2/9/2017 at 1:49 PM, they stated the drug was available. The pharmacy was willing to fill the prescription for Resident #1(Triumeq), but thought the cost of the medication was high. They stated Resident #1 was under managed care, and they first received an order for [REDACTED]. This was communicated via fax to the facility twice on Sunday, 1/16/17. The pharmacy received a discontinuation order for the medication on 1/18/2017. During an interview with the medical director on 2/10/2017 at 11:32 AM, he was asked how important was it for a person to receive prescribed anti-[MEDICAL CONDITION] medication. He stated it was very important, but that the resident's acuity was also a factor to consider. When asked why the anti-[MEDICAL CONDITION] medication was used, the medical director stated they were used to boost the person's immunity. When asked whether he was aware that Resident #1 had not received her medication in five (5) days, he replied that he was not the attending physician, and did not know if the attending physician had been informed on the number of days the resident had gone without the medication. When asked about possible consequences of not receiving the anti-[MEDICAL CONDITION] medication, he stated the resident could have a decline, fever, their [MEDICAL CONDITION] load could increase, and their CD4 could drop.

Based on record review and interview, the facility failed to provide routine drugs to meet the needs of its residents for 1 of 4 residents sampled (Resident #1). Not receiving prescribed medications in a timely manner can result in an unnecessary decline in health, complications in a resident's health status, pain and mental anguish. The findings include: Resident #1 was an HIV (Human Immune Deficiency Virus) positive individual who was prescribed and required the antiviral medication Triumeq tab 600-50-300 mg (milligrams)(Abacavir, Dolutegravir-Lamivud), one tablet by mouth one time a day for management of her HIV. Anti-viral drugs like this one need to be taken as prescribed to prevent the development of drug resistance, to keep the viral load (amount of virus) in the person's body low, and to keep their immune system intact. Resident #1 was admitted to the facility on [DATE], and the physician ordered a start for this medication on 1/14/2017 (photographic evidence obtained). Review of the Medication Administration Record [REDACTED]. The resident was also ordered a CD4 test on 1/17/2017. Review of the lab work revealed there were no results indicating that the ordered CD4 test was completed. CD4 lab tests measure the number of infection fighting cells there are in a person's immune system. Review of progress notes showed two notes (1/15/2017 and 1/16/2017) stating the medication was on order from the pharmacy (photographic evidence obtained). Review of pharmacy communication to the facility showed that two faxes of their Urgent Non-Covered Medication forms with requests for response were sent to the facility. The first, according to a fax stamp, was sent on 1/16/2017 at 13:06 PM, and the second on 1/16/2017 at 4:10 PM (Photographic evidence obtained). A facility non-coverage form is one that explains the facility cost of the medication, and asks the facility whether they want to switch to a less expensive drug, or whether they will pay for the listed drug. There was no indication that the facility responded to either of these requests. Review of the facility's Medication Pass Guidelines, SHCR .01, stated in part Medications are administered in accordance with the written orders of the physician, and new medications start/ new medication orders begin timely on the same day ordered, unless the next dose would be normally given the next day. (photographic evidence obtained) During an interview with the director of nursing (DON) on 2/9/2017 at 3:47 PM, this surveyor asked why Resident #1 did not receive her anti-viral medication, what the facility's normal process was in obtaining special medications, and what the facility did in relation to Resident #1's medication order. The DON stated that Resident #1 was admitted on a Friday afternoon. She said she thought the resident arrived after the evening drug run from the pharmacy, which provided two daily drug runs; one around 8:00 AM, and one around 3:00 PM. The DON went on to say she returned to work on the following Monday, 1/16/2017, and was told by her nurses that the medication was not available from the pharmacy. The DON stated no one told her of any additional cost related to the medication, or non-coverage forms at that time. When the DON was asked why there was no response to the pharmacy's faxed Non-Coverage forms, she stated that she never saw the forms; she only saw those forms when the surveyor requested them from the pharmacy. Then she stated that her name was put at the top of those forms but she never saw them. When she was asked whether the physician was notified that this medication had not been received by the resident, she replied that she thought the physician wrote a new hold order. She was asked to provide the hold order for review, but it was not produced during the survey. This surveyor was unable to locate a hold order in the clinical record. The DON was asked whether she had called the pharmacy regarding the medication's availability once her nursing staff informed her that the medication was not available. She replied, No. She was asked whether a 5-day wait for the medication was considered timely and appropriate, and she replied No, but that was why she tried to get the resident home on 1/18 to get her own supply of the medication. During a telephone interview with the pharmacy (chief pharmacist and billing department) on 2/9/2017 at 1:49 PM, they stated the drug was available. The pharmacy was willing to fill the prescription for Resident #1(Triumeq), but thought the cost of the medication was high. They stated Resident #1 was under managed care, and they first received an order for [REDACTED]. This was communicated via fax to the facility twice on Sunday, 1/16/17. The pharmacy received a discontinuation order for the medication on 1/18/2017. During an interview with the medical director on 2/10/2017 at 11:32 AM, he was asked how important was it for a person to receive prescribed anti-viral medication. He stated it was very important, but that the resident's acuity was also a factor to consider. When asked why the anti-viral medication was used, the medical director stated they were used to boost the person's immunity. When asked whether he was aware that Resident #1 had not received her medication in five (5) days, he replied that he was not the attending physician, and did not know if the attending physician had been informed on the number of days the resident had gone without the medication. When asked about possible consequences of not receiving the anti-viral medication, he stated the resident could have a decline, fever, their viral load could increase, and their CD4 could drop.

Based on record reviews, observations, and interviews, the facility failed to ensure that 1 out of 3 sampled residents (Resident #1) was free from abuse. Residents #1 and #3 reported continual wandering by Resident #2. Interviews and record reviews revealed Resident #2 had a history of [REDACTED]. The findings include: Interview was conducted with Staff G at 11:25 am on 4/14/2016. Staff G stated that Resident #2 went into Resident #1's room. Staff G stated that Resident #1 complained to her a few days ago about Resident #2 going into her room. Interview was conducted with Staff B at 12:12 pm on 4/14/2016. Staff B stated that on 4/2/2016, Resident #1 reported that Resident #2 came into her room, ate her snacks, and touched her breast. Staff B stated that Resident #2 was placed on one to one supervision pending a psychiatric consult. Staff B stated that on 4/10/2016, Resident #1 reported that Resident #2 came into her room and she hit him with her reacher. Staff B stated that Resident #2 was not placed on one to one supervision because he was not the perpetrator. Staff B stated that Resident #1 was placed on one to one supervision. She stated that even though Resident #2 was accused of wandering into Resident #1's room, he was not the one who did the hitting. Staff B stated that Resident #2 has wandered into other residents' rooms. She stated that she found him on the inside of Rooms #700 and #701, as well as the doorways of Rooms #703 and #705. Interview was conducted with Staff A at 12:39 pm on 4/14/2016. Staff A stated that when she came into work on 4/10/2016, Resident #1 came to her with a broken reacher. Staff A stated that Resident #1 told her that Resident #2 came into her room near her and she hit him with the reacher and broke it. Interview was conducted with Resident #1 at 3:50 pm on 4/14/2016. Resident #1 stated that Resident #2 comes into her room all the time and comes near her bed. She stated that he was last in her room yesterday (4/13/2016). She stated that he has touched her in the past and tried to get in the bed with her. She stated that he also ate her food. Resident #1 stated that she told the Social Worker and several other staff members, and they said nothing. Resident #1 stated that her daughter told her to beat Resident #2 if he tries to feel on her. She stated that the 4/10/2016 incident happened when Resident #2 came into her room near her and tried to do something. She stated that she hit him with her reacher. She stated that staff was aware of the resident coming into her room. She stated that her roommate (Resident #3) sometimes has to yell to tell Resident #2 to get out of their room. Interview was conducted with Resident #3 at 3:42 pm on 4/14/2016. Resident #3 stated that Resident #2 comes into her room daily. She stated that Resident #2 walks toward the back of the room. She stated that he paces up and down the floor, goes by the window, and by Bed B. She stated that she has told several staff members and sometimes she yells and tells him to get out. She stated that staff working in that area knew about the resident constantly coming into her room. Observation of the residents' room showed that Resident #1 was located in the bed next to the window and Resident #3 was located in the bed next to the door. Interview was conducted Staff F, Social Services Director, at 3:00 pm on 4/14/2016. Staff F stated that on 4/2/2016, Resident #1 reported that Resident #2 came into her room and touched her. Staff F stated that an investigation was completed and the facility could not substantiate that it happened. On 4/10/2016, Resident #1 reported to Staff A that Resident #2 came into her room again, and she hit him with her reacher and broke it. Staff F stated the facility was still in their five-day investigation window, and the investigation for the 4/10/2016 incident will not be completed until 4/15/2016. Staff F stated that the facility was trying to find Resident #2 a placement at another facility because of his behaviors. Staff F stated that Resident #2 was currently not on one to one supervision, and he was not placed on one to one supervision when the 4/10/2016 incident occurred because he was not the perpetrator. Interview was conducted with Staff D at 3:30 pm on 4/14/2016. Staff D stated that Resident #2 occasionally goes into other residents' rooms. Staff D stated that she has to redirect him out of other residents' rooms. Interview was conducted with Staff C at 4:05 pm on 4/14/2016. Staff C stated that Resident #2 last went into Residents #1 and #3's room the day before yesterday (4/12/2016). She stated that Resident #2 went to the back of the room near the window, and she had to redirect him out of the room. Staff C stated that she has seen Resident #2 in Residents #1 and #3's room and other residents' rooms. She stated that Resident #2 goes into other residents' rooms because he thinks it is his room. Staff C stated that Residents #1 and #3 have reported to her that Resident #2 comes into their room. Interview was conducted with Staff E, DON, at 4:30 pm on 4/14/2016. Staff E stated that they were trying to relocate Resident #2 because he wanders. Staff E stated that staff members should redirect Resident #2 when he wanders into other residents' rooms. Staff E stated that the facility had a lot of incidents in which residents walk into other residents' rooms. She stated that the facility cannot put every resident on one to one supervision. Staff E stated that the facility was trying to find alternative placement for Resident #2. She stated that Resident #2 was currently not on one to one supervision. Review of Resident #2's care plan showed that Resident #2 was placed on one to one supervision pending a psychiatry consult visit for the incident occurring on 4/2/2016. There was no documentation to show that Resident #1 was placed on one to one supervision for the 4/2/2016 incident. Review of Resident #1's care plan showed that Resident #1 was placed on one to one supervision for the the incident occurring on 4/10/2016. There was no documentation to show that Resident #2 was placed on one to one supervision for the 4/10/2016 incident. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], showed her Brief Interview for Mental Status (BIMS) score as being a 13. Review of Resident #2's care plan showed that on 4/2/2016, a female resident accused Resident #2 of entering her room last night. The female resident stated that Resident #2 ate her snacks, and began to fondle her around the chest area. The female resident told him to get out of her room, he turned around and walked out, leaving his walker in her room. Resident #2 stated that he did not remember doing that. On 4/10/2016, a female resident reported to the nurse that Resident #2 wandered into her room and she hit him with a reacher and it broke. Resident #2 denied anyone hitting him with a reacher. Additional record review revealed that on 8/18/2015, Resident #2 approached another female resident and kissed her and asked her for sex. The care plan indicated that Resident #2 had a history of [REDACTED]. No previous behaviors were noted toward another resident. On 8/31/2015, Resident #2 was wheeling self in the hallway and passed a female resident and asked her where his room was, and the female resident stated, Oh hell, you can see. Resident #2 hit the female resident in the upper arm twice. On 9/5/2015, after returning from a smoking break, Resident #2 stopped in the 600 hallway area and pulled down his pants, exposing himself to staff and other residents. On 9/20/2015, a resident to resident altercation occurred earlier during the day and another resident reported to the charge nurse that she was slapped in the face by Resident #2. On 9/24/2015, Resident #2 allegedly hit a female resident in the chest. The female resident wandered into Resident #2's room. The care plan also showed that Resident #2 had potential to demonstrate sexual verbal behaviors to staff and residents due to his [DIAGNOSES REDACTED]. Evidence photos obtained.

Based on record reviews, observations, and interviews, the facility failed to ensure that 2 out of 3 sampled residents (Residents #1 and #3) received adequate supervision to prevent accidents due to documented behaviors by Resident #2. The findings include: Interview was conducted with Staff G at 11:25 am on 4/14/2016. Staff G stated that Resident #2 went into Resident #1's room. Staff G stated that Resident #1 complained to her a few days ago about Resident #2 going into her room. Interview was conducted with Staff B at 12:12 pm on 4/14/2016. Staff B stated that on 4/2/2016, Resident #1 reported that Resident #2 came into her room, ate her snacks, and touched her breast. Staff B stated that Resident #2 was placed on one to one supervision pending a psychiatric consult. Staff B stated that on 4/10/2016, Resident #1 reported that Resident #2 came into her room and she hit him with her reacher. Staff B stated that Resident #2 was not placed on one to one supervision because he was not the perpetrator. Staff B stated that Resident #1 was placed on one to one supervision. She stated that even though Resident #2 was accused of wandering into Resident #1's room, he was not the one who did the hitting. Staff B stated that Resident #2 has wandered into other residents' rooms. She stated that she found him on the inside of Rooms #700 and #701, as well as the doorways of Rooms #703 and #705. Interview was conducted with Staff A at 12:39 pm on 4/14/2016. Staff A stated that when she came into work on 4/10/2016, Resident #1 came to her with a broken reacher. Staff A stated that Resident #1 told her that Resident #2 came into her room near her and she hit him with the reacher and broke it. Interview was conducted with Resident #1 at 3:50 pm on 4/14/2016. Resident #1 stated that Resident #2 comes into her room all the time and comes near her bed. She stated that he was last in her room yesterday (4/13/2016). She stated that he has touched her in the past and tried to get in the bed with her. She stated that he also ate her food. Resident #1 stated that she told the Social Worker and several other staff members, and they said nothing. Resident #1 stated that her daughter told her to beat Resident #2 if he tries to feel on her. She stated that the 4/10/2016 incident happened when Resident #2 came into her room near her and tried to do something. She stated that she hit him with her reacher. She stated that staff was aware of the resident coming into her room. She stated that her roommate (Resident #3) sometimes has to yell to tell Resident #2 to get out of their room. Interview was conducted with Resident #3 at 3:42 pm on 4/14/2016. Resident #3 stated that Resident #2 comes into her room daily. She stated that Resident #2 walks toward the back of the room. She stated that he paces up and down the floor, goes by the window, and by Bed B. She stated that she has told several staff members and sometimes she yells and tells him to get out. She stated that staff working in that area knew about the resident constantly coming into her room. Observation of the residents' room showed that Resident #1 was located in the bed next to the window and Resident #3 was located in the bed next to the door. Interview was conducted Staff F, Social Services Director, at 3:00 pm on 4/14/2016. Staff F stated that on 4/2/2016, Resident #1 reported that Resident #2 came into her room and touched her. Staff F stated that an investigation was completed and the facility could not substantiate that it happened. On 4/10/2016, Resident #1 reported to Staff A that Resident #2 came into her room again, and she hit him with her reacher and broke it. Staff F stated the facility was still in their five-day investigation window, and the investigation for the 4/10/2016 incident will not be completed until 4/15/2016. Staff F stated that the facility was trying to find Resident #2 a placement at another facility because of his behaviors. Staff F stated that Resident #2 was currently not on one to one supervision, and he was not placed on one to one supervision when the 4/10/2016 incident occurred because he was not the perpetrator. Interview was conducted with Staff D at 3:30 pm on 4/14/2016. Staff D stated that Resident #2 occasionally goes into other residents' rooms. Staff D stated that she has to redirect him out of other residents' rooms. Interview was conducted with Staff C at 4:05 pm on 4/14/2016. Staff C stated that Resident #2 last went into Residents #1 and #3's room the day before yesterday (4/12/2016). She stated that Resident #2 went to the back of the room near the window, and she had to redirect him out of the room. Staff C stated that she has seen Resident #2 in Residents #1 and #3's room and other residents' rooms. She stated that Resident #2 goes into other residents' rooms because he thinks it is his room. Staff C stated that Residents #1 and #3 have reported to her that Resident #2 comes into their room. Interview was conducted with Staff E, DON, at 4:30 pm on 4/14/2016. Staff E stated that they were trying to relocate Resident #2 because he wanders. Staff E stated that staff members should redirect Resident #2 when he wanders into other residents' rooms. Staff E stated that the facility had a lot of incidents in which residents walk into other residents' rooms. She stated that the facility cannot put every resident on one to one supervision. Staff E stated that the facility was trying to find alternative placement for Resident #2. She stated that Resident #2 was currently not on one to one supervision. Review of Resident #2's care plan showed that Resident #2 was placed on one to one supervision pending a psychiatry consult visit for the incident occurring on 4/2/2016. There was no documentation to show that Resident #1 was placed on one to one supervision for the 4/2/2016 incident. Review of Resident #1's care plan showed that Resident #1 was placed on one to one supervision for the the incident occurring on 4/10/2016. There was no documentation to show that Resident #2 was placed on one to one supervision for the 4/10/2016 incident. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], showed her Brief Interview for Mental Status (BIMS) score as being a 13. Review of Resident #2's care plan showed that on 4/2/2016, a female resident accused Resident #2 of entering her room last night. The female resident stated that Resident #2 ate her snacks, and began to fondle her around the chest area. The female resident told him to get out of her room, he turned around and walked out, leaving his walker in her room. Resident #2 stated that he did not remember doing that. On 4/10/2016, a female resident reported to the nurse that Resident #2 wandered into her room and she hit him with a reacher and it broke. Resident #2 denied anyone hitting him with a reacher. Additional record review revealed that on 8/18/2015, Resident #2 approached another female resident and kissed her and asked her for sex. The care plan indicated that Resident #2 had a history of [REDACTED]. No previous behaviors were noted toward another resident. On 8/31/2015, Resident #2 was wheeling self in the hallway and passed a female resident and asked her where his room was, and the female resident stated, Oh hell, you can see. Resident #2 hit the female resident in the upper arm twice. On 9/5/2015, after returning from a smoking break, Resident #2 stopped in the 600 hallway area and pulled down his pants, exposing himself to staff and other residents. On 9/20/2015, a resident to resident altercation occurred earlier during the day and another resident reported to the charge nurse that she was slapped in the face by Resident #2. On 9/24/2015, Resident #2 allegedly hit a female resident in the chest. The female resident wandered into Resident #2's room. The care plan also showed that Resident #2 had potential to demonstrate sexual verbal behaviors to staff and residents due to his [DIAGNOSES REDACTED]. Evidence photos obtained.