Every finding on record at Kerens Care Center

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 medication cart of 4 carts (Med Cart #1) and one medication room refrigerator of one med room refrigerator (Fridge #1) reviewed for pharmacy services. * The facility failed to remove 4 boxes of expired influenza vaccine from Fridge #1 on 6/1/2026.* The facility failed to remove 1 box of discontinued Latanoprost eye drops (used to treat glaucoma - an eye disease that damages the optic nerve) for Resident #26 from Fridge #1 on 4/23/2026.* The facility failed to remove 1 bottle of expired Ondansetron HCL (medication to treat nausea and vomiting) from med cart #1 on 5/5/2026. This failure had the potential for inadequate medication potency and medication unavailability for the therapeutic care for residents.During an observation on 6/9/2026 at 9:28 am of Med Cart #1, a bottle of Ondansetron HCL was noted to read discard after 05/05/26. During an observation on 6/10/2026 at 12:48 pm four boxes of Influenza vaccine were stored in med room fridge #1 with an expiration date of 2026/06 and one bottle of Latanoprost eye drops for Resident #26 was on the fridge shelf. Review of Resident #26 's face sheet dated 6/11/2026 reflected she was an [AGE] year-old female admitted on [DATE] with diagnoses that included: glaucoma (eye disease that damages the optic nerve), cerebrovascular disease (condition that affects the blood vessels and blood supply to the brain), hypertension (high blood pressure), high cholesterol, and dementia (decline in mental abilities). Review of Resident #26's significant change MDS dated [DATE] reflected she had a BIMS of 0 (zero) suggesting severe cognitive impairment. Review of Resident #26 physicians' orders dated 6/11/26 reflected an order for Latanoprost eye drops with a start date of 8/24/2025 and a discontinued date of 4/23/2026. During an interview on 6/9/2026 at 9:28 am, LVN C stated the bottle of Ondansetron HCL showed a discard by date of 5/5/2026. He stated the medication should have been discarded and removed from the med cart. He stated the cart was RN B's and he had just moved the cart down the hall for her and was holding her keys. He stated RN B was responsible for the med cart. During an interview on 6/11/2026 at 1:44 pm, RN B stated the bottle of eye drops for Resident # 26 should not have been in the fridge because they had been discontinued. She stated if there was not an order for the medication, it should have been removed from the fridge and disposed of. She stated having discontinued medications still in the fridge could cause a mix up or a resident could get medication that was no longer ordered. RN B also stated she was unaware there was an expired bottle of Ondansetron HCL on her cart. She stated she tried to check her cart each shift and pull off any discontinued or expired medications but she must have missed this one. During an interview with DON on 6/11/2026 at 9:55 am she stated the influenza vaccine boxes with an expiration date of 2026/6 should not have been in Fridge #1. She stated she thought she had pulled them all and was shocked that they were still in there. She stated the expired Ondansetron HCL medication on med cart #1 should have been pulled. She stated the nurse that worked that cart was terminated the day before. She stated it is the nurse's responsibility that is on the cart to check expiration dates but ultimately it is her (the DON's) responsibility to ensure medications are pulled when expired. She stated the nurses checked their carts day to day, but she tried to do it monthly and the pharmacist came in every other month and checked the carts. She stated a potential negative effect to residents could be that the expired medications may not be effective in providing treatment for their issue. Review of undated facility policy Medication Storage in the Facility reflected: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations orthose of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or withoutsecure closures are immediately removed from stock, disposed of according to the procedures for medicationdestruction, and reordered from the pharmacy, if a current order exits. Review of undated facility policy Expired Medications and Medications with Shortened Expiration Dates reflected: Ensure that all medications in the facility are rotated and / or reviewed on a consistent basis to prevent having expired medications in the facility. Procedure1. The Director of Nursing or other authorized personnel and the Pharmacist Consultant, when appropriate, willdelegate to appropriate personnel the task of ensuring that all medication is rotated appropriately.2. The Director of Nursing or other authorized personnel will delegate to appropriate personnel the task ofensuring that all outdated or expired medications (with the exception of controlled substances, refer tocontrolled substances policy) are removed from the medication cart or other area that medication may bestored in. Depending on individual State rules expired medications may be returned to PharmcareUSA forappropriate destructions refer to each State Board of Pharmacy Rules and Regulations, Resource Conservationand Recovery Act (RCRA) and State Hazardous Materials Regulations.3. All medications will be labeled per State Board of Pharmacy Rules and Regulations that includes specificdirections pertaining to expired or discarded after language.4. In the event that a medication has a shortened expiration date once opened the medication (open-dated) willbe labeled with the date opened and the initials of the nurse. In the event the nurse is unsure if medication hasa shortened expiration date that nurse will contact the Pharmacy to clarify or refer to the manufacturerrecommendations.All OTC medication may be used until manufacturer's expiration date is reached or per the individual StateBoard of Pharmacy and State Health Departments rules and regulations

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 15 residents (Resident #25) reviewed for infection control. RN B failed to perform hand hygiene before administering a breathing treatment to Resident #25 on 6/10/2026. This failure could increase infection control risks causing residents illness, pain, or hospitalization.Findings Include:Review of Resident #25's face sheet dated 6/11/2026 reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses that included: dementia (decline in mental abilities), seizures (abnormal electrical activity in the brain), senile degeneration of the brain (progressive cognitive decline), anxiety disorder, seasonal allergies, shortness of breath and muscle wasting. Review of Resident #25's quarterly MDS dated [DATE] reflected a BIMS of 0 (zero) suggesting severe cognitive impairment. Review of physician orders dated 6/11/2026 for Resident #25 reflected breathing treatments every four hours as needed starting on 6/8/2026. During an observation on 6/10/2026 at 12:28 pm RN B provided a breathing treatment for Resident #25. Once in the resident's room, RN B was observed getting her keys out of her pocket, going back to her medication cart and retrieving medication, locking the cart and then returning to the room. RN B proceeded to pour the medication into the nebulizer housing and complete the breathing treatment for the resident without performing hand hygiene. During an interview with RN B on 6/11/2026 at 1:44 pm she stated she had started doing the breathing treatment for Resident #25 and had done her hand hygiene, but then she needed to go back to her cart for the medication. She stated after she went back to the cart, she forgot to perform hand hygiene again and she should have performed hand hygiene before administering the breathing treatment. She stated that by not performing hand hygiene it could be a contamination issue or infection control issue and it could make a resident sick. During an interview on 6/11/2026 at 9:55 am, DON stated RN B had told her she forgot to do her hand hygiene before giving Resident #25 his breathing treatment. She stated not performing hand hygiene is an infection control issue and they have an at-risk population in the facility. She stated Resident #25 is considered fragile but believed the potential impact to him to be minimal. She stated for other residents that are immuno-compromised this could have been very detrimental, but the impact would depend on the resident. She stated her concern would be spreading disease. She stated they have provided in-services on hand hygiene to the staff, and they can use hand sanitizer unless their hands are visibly soiled, then they must wash their hands. Review of undated facility policy/procedure Aerosolized Hand-Held Nebulizer reflected:Purpose:To provide guidelines for administration of nebulized medication to patients. Policy:A compressor-driven nebulizer will be used (unless piped-in oxygen is available), to administeraerosolized medication as ordered by a physician. Procedure:In order1. Check chart for order and possible contraindications.2. Collect equipment and assemble according to manufacturer's guidelines.3. Enter room, introduce self, check patient ID band and explain procedure to patient.4. Wash hands and observe universal precautions.5. Remove the nebulizer top and measure the prescribed medication and diluents in thenebulizer cup.6. Re-attach the nebulizer top. Review of undated facility policy Infection Control Plan: Overview reflected: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary andcomfortable environment and to help prevent the development and transmission of disease and infection. Infection Control ProgramThe facility will establish an Infection Control Program under which it Investigates, controls, and prevents infections in the facility.

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 5 residents (Resident #2 and Resident #9) reviewed for care plans. The facility failed to include that Resident #2 received an anticoagulant medication on Resident #2's comprehensive care plan. The facility failed to include that Resident #9 had a diagnosis of chronic viral hepatitis on Resident #9's comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met.Findings included:Record review of Resident #2's face sheet dated 06/10/26 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses that included cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain), diabetes (a group of diseases that result in too much sugar in the blood), hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities). Record review of Resident #2's Modified Annual MDS assessment dated [DATE], reflected that Resident #2 had a BIMS score of 03 which reflected the resident was severely cognitively impaired. Resident #2's Modified Annual MDS assessment reflected that the resident required partial/moderate assistance with eating and showering and required substantial/maximal assistance for toileting and personal hygiene. The modified annual MDS reflected Resident #2 was taking an anticoagulant medication. Record review of Resident #2's Physician's Orders, dated 06/10/26, reflected the resident had an order initiated on 05/07/26 for: Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to unspecified sequelae (the long-term aftereffects, complications, or lingering consequences of a previous disease, injury, or medical treatment) of cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain); cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain) due to unspecified occlusion (the act of closing, shutting off, or the state of being blocked) or stenosis (abnormal narrowing of a passage, blood vessel, or tubular structure in the body) of unspecified cerebral artery. Record review of care plan dated 01/31/26 reflected Resident #2 had not been care planned for receiving an anticoagulant medication. In an interview and observation on 06/09/26 at 10:49 AM, Resident #2 stated she was doing fine and staff took good care of her and treated her well. She stated she felt safe at the facility and she had no concerns. Resident #2 had no visible bruising or bleeding. Review of Resident #9's face sheet revealed she was an [AGE] year-old female admitted on [DATE] with diagnoses that included dementia (a decline in mental abilities), chronic viral hepatitis C (liver disease caused by the hepatitis C virus), chronic kidney disease (condition where kidneys are damaged and lose the ability to filter waste and excess fluid from the blood), osteoporosis (decreased bone mass) and heart disease. The face sheet reflected the date of 1/31/2025 when the hepatitis c diagnosis was added to her EMR. Review of Resident #9's significant change MDS assessment dated [DATE], reflected a BIMS of 1 suggesting severe cognitive impairment. Review of the active diagnosis section reflected Resident #9 had a diagnosis of Viral Hepatitis (e.g., Hepatitis A, B, C, D and E.) Review of Resident #9's care plan dated 6/11/2026 reflected the following focus area dated 6/1/2026: The Resident has Hepatitis Date initiated 06/01/2026 Revision 06/10/2026. In an interview on 06/10/26 at 1:48 PM, RN A stated she was aware that Resident #2 received an anticoagulant medication and that the medication should have been care planned. She stated she tried to look at all residents' orders at least once or twice a week to see if there had been any updates so that she could update the care plan. She stated she never received a formal training for how to complete care plan assessments correctly except for when she was in nursing school, but she knew how to do care plans. She stated Resident #2's anticoagulant medication must have slipped by her. She stated if a resident was not care planned properly for taking an anticoagulant, she did not feel as though the resident would have been affected because there was a care plan for an antiplatelet, and it had the same interventions for an anticoagulant and the staff would have known to watch for the same things. In an interview on 06/11/26 at 9:30 AM, the DON stated all of the nursing management were responsible for completing and making changes to the care plans but it was mainly the MDS coordinators responsibility. She stated she believed the MDS coordinator was trained on completing the care plans correctly but she did not know the extent of the training. She stated she would have to look at Resident #2's orders to have known Resident #2 was on an anticoagulant. She stated when a resident received an anticoagulant medication it should have been care planned. She stated if an anticoagulant medication was not care planned it could have caused the staff to not have been monitoring for bruising or bleeding which could have led to harm for the resident. During an interview on 6/11/2026 at 9:55 am DON stated that herself, the MDS nurse or any nurse can update the care plan. She stated information is passed along in morning meetings, care plan meetings or verbally between nurses. She stated she was not aware the care plan for Resident #9 had not been updated until 6/1/2026. During an interview on 6/11/2026 at 11:25 am MDS Nurse stated she did not put in Resident #9's hepatitis diagnosis until 6/1/2026 even though she was admitted with it back in January of 2025. She stated she had been reviewing MDS records and noticed it was missing so she added it. She stated, I wondered how we missed that. She stated she is responsible for updating care plans and that care plans give the staff focus areas for each resident's care. Record review of the undated facility policy titled Comprehensive Care Planning reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but are not limited to resident Kardex records, baseline care plans, and task listings. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record.

Based on interview, and record review, the facility failed to ensure personnel provided basic life support, which included CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to relative physician orders and the Resident's advanced directives for 1 (Resident #1) of 6 residents reviewed for cardio-pulmonary resuscitation. RN A failed to initiate life-saving measures (CPR) when Resident #1, who had a code status of full code was found unresponsive and expired. This failure could place residents at risk of death from not receiving life-saving measures if required. The immediacy began on [DATE] and ended on [DATE]: The noncompliance was identified as PNC. The JT began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. Findings included: Record review of the face sheet, dated [DATE], reflected Resident #1 was admitted on [DATE] with diagnoses of cerebral palsy (disorder that affects a person's movement, posture, and balance), lack of coordination, muscle wasting and atrophy to lower extremity (decreased in muscle tissue size). Record review of admissions progress note, dated [DATE] at 5:20 p.m., reflected Resident # 1 was admitted from the hospital, full Code, with a terminal diagnosis of cerebral palsy and was on hospice. Record review of Resident #1's care plan, dated [DATE], reflected Resident #1 was a full code CPR status, interventions included initial BLS CPR if the resident was without a heartbeat or not breathing. Notify EMS. Record review of Resident #1 Physicians orders, dated [DATE], reflected resident #1 was a full code CPR status. Record review of RN A's written statement (not dated) reflected Resident #1 was found unresponsive with no vital signs and no respiratory effort. This written statement reflected that she contacted hospice and notified the resident's representative of the residents passing. RN A's written statement reflected that she realized she made a serious error in not transporting Resident #1to the hospital for emergency services or initiating CPR. RN A's written statement reflected that she thought it was a condition of hospice admission that residents on hospice were a DNR and she should have double checked to be sure the Resident #1 had a DNR in place. In an interview with RN A on [DATE] at 11:49 am revealed she went into Resident #1's room and found Resident #1 to be unresponsive and her eyes dilated (the body's immediate response to involuntary to the cessation of blood circulation and muscle relaxation, indicating brain stem death). RN A stated she took Resident #1's vital signs with no pulse, no blood pressure and no respiration. RN A revealed she did not provide CPR or transport Resident #1 to the hospital because she thought Resident # 1 was a DNR. She stated she did not check the code status for Resident #1 because she assumed Resident #1 was a DNR because she was on hospice. She stated she notified hospice and Resident #1's representative. Interview with the administrator on [DATE] at 10:15 a.m. revealed Resident #1 was her aunt, and she was the resident's representative listed. She confirmed Resident #1 did not have a DNR on file for and RN A should have performed CPR. She stated she felt it would not have done any good because when RN A found Resident #1, she had already passed. She stated RN A should have attempted e life saving measures because Resident #1 was a full code CPR and RN A did not follow policy. Record review of the facility's CPR policy, undated, reflected CPR was a method of providing systemic circulation by manual chest compression and oxygen by mouth-to mouth breathing or providing air to the lungs via Ambu bag (a devise used in emergencies to help a person breath) to prevent death following cardiac or pulmonary arrest.Record review of the hospice death visit summary, dated [DATE] (no time), reflected the medical director was contacted on [DATE] at 1:25 a.m. by hospice RN and advised Resident #1 was absent of vital signs with dilated and fixed pupils (the body's immediate response to involuntary to the cessation of blood circulation and muscle relaxation, indicating brain stem death). The patient's death was expected. The doctor gave time of death as 1:25 a.m. The facility completed the following interventions prior to surveyor entry on [DATE]: Record review of facility in-service, dated [DATE] (no time), reflected all staff received in-service training on abuse, neglect, resident change of status, pronouncement of death, residents' rights, CPR, self-determination end of life measures, DNR, hospice, and oxygen administration. Interview with DON on [DATE] at 2:19 p.m. revealed that she worked at the facility for six months. She received in-service training at the time of hire and on [DATE] on abuse, neglect, resident change of status, pronouncement of death, residents' rights, CPR, self-determination end of life measures, DNR, hospice, and oxygen administration. She stated she would report abuse or neglect to the administrator. The DON reflected an example of abuse was physical harm of a resident and neglect was not performing proper care for a resident. She stated a resident's code status was found in the EMR and if a resident was found non-responsive, she would check the code status of the resident in the EMR. Interview with LVN A on [DATE] at 2:39 p.m. reflected that she worked at the facility for five years. She received in-service training at the time of hire and on [DATE] on abuse, neglect, resident change of status, pronouncement of death, residents' rights, CPR, self-determination end of life measures, DNR, hospice, and oxygen administration. She stated she would report abuse or neglect to the administrator. She stated an example of neglect was failure to provide care or keep a resident clean. She stated a resident's code status was found on a resident's face sheet in the EMR and if a resident was found non-responsive, she would check the code status of the resident in the EMR. Interview with LVN B on [DATE] at 2:52 p.m. revealed she worked for the facility for one year. She received in-service training at time of hire and on [DATE] on abuse, neglect, resident change of status, pronouncement of death, residents' rights, CPR, self-determination end of life measures, DNR, hospice, and oxygen administration. She stated that an example of neglect did not change a resident's soiled brief. She would report neglect or abuse to the administrator. She states a resident's code status could was in the EMR and if a resident was found non-responsive, she would check the code status of the resident in the EMR. Record review of facility file reflected the facility did a mock code blue (the facility code to signify a medical emergency) for all three shifts (6 a.m.-2 p.m., 2 p.m.-10 p.m., and 10 p.m.-6 a.m.) on [DATE] and then it would be done randomly every week for four weeks.Record review of RN A's personnel file reflected RN A was placed on unpaid investigatory suspension on [DATE]. Record review on [DATE] of the facility time sheet reflected RN A had not worked in the facility since [DATE]. Record review of the facilities code status assessment, dated [DATE], reflected the facility did a full audit of all residents' advanced directive orders, all advanced directive orders for full code and DNR were entered in the facility EMR (electronic medical record) correctly and reviewed all residents' code status were entered into the care plan and matched the physician orders. Record review reflected that the facility did an audit of the code status for all residents deceased in the last 60 days that reflected the code status was followed correctly.The immediacy began on [DATE] and ended on [DATE]: The noncompliance was identified as PNC. The JT began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began.

Based on observation, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans. Resident #1's comprehensive care plan did not reflect Resident #1's mechanical soft texture diet. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: A record review of Resident #1's face sheet dated 04/30/2025, reflected a [AGE] year-old male who was re-admitted to the facility on [DATE]. Resident #1's diagnoses included: unspecified dementia (a condition that causes a decline in thinking, memory, and reasoning abilities), seizures (sudden, temporary disruption of the brain's normal electrical activity, resulting in changes in behavior, movement, feelings, or consciousness.), muscle wasting and atrophy (the muscles are shrinking and losing strength), lack of coordination (having difficulty controlling your movements and making them work together smoothly) and muscle weakness (reduced ability of the body to contract muscle properly, resulting in a lower strength in one or more muscle). A record review of Resident #1's Quarterly MDS assessment, dated 04/10/2025, reflected the resident had a BIMS score of 99, which indicated the BIMS interview was not completed. Resident #1's Quarterly MDS reflected Resident #1 was dependent in the following areas: toileting hygiene, shower/bathe self, and personal hygiene. Resident #1 required substantial/maximal assistance with eating, oral hygiene, and putting on/taking off footwear. Resident #1's Quarterly MDS also reflected he received a mechanically altered diet. A record review of Resident #1's care plan, dated 04/30/2025, reflected Resident #1's care plan did not reflect Resident #1's mechanical soft diet. A record review of Resident #1's physician orders dated 04/30/2025, reflected Resident #1 had a physician order dated 12/08/2023 for regular diet, mechanical soft texture, regular consistency. During an observation on 04/30/2025 at 12:10 pm., Resident #1 was observed eating a mechanical soft diet during lunch in the dining area with the assistance of LVN A. Attempted to interview Resident #1 on 04/30/2025 at 12:10 pm., Resident #1 could not be interviewed due to his severe cognitive impairment. During an interview with LVN A on 04/30/2025 at 12:50pm, LVN A stated that Resident #1 received a mechanical soft diet. LVN A stated Resident #1 has a physician order for his mechanical soft diet. LVN A stated during the dining times she reviews the meal tickets to ensure residents are receiving the correct texture diet. LVN A was not aware that Resident #1's care plan did not reflect his mechanical soft diet. During an interview with the MDS Coordinator on 04/30/2025 at 3:00pm, the MDS Coordinator stated that Resident #1's mechanical soft diet should have been reflected on his care plan. The MDS Coordinator stated she and other department heads were responsible for ensuring that care plans were up to date and accurate. The MDS Coordinator stated if a resident's care plan was not accurate then the resident would not receive the appropriate care needed. During an interview with the ADM on 04/30/2025 at 3:50pm, the ADM stated Resident #1's mechanical soft diet should have been reflected on his care plan. ADM stated it was the MDS Coordinator's responsibility for ensuring care plans have the most accurate information for the resident's care. ADM stated that Resident #1 could have received the wrong texture diet because of his care plan not reflecting his mechanical soft diet. A record review of the facility's Comprehensive Care Planning policy, not dated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following- The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 4 of 4 resident (Resident #13, #14, #24, and #39) and 1 of 1 laundry carts reviewed for infection control. The facility failed to ensure MA B performed proper hand hygiene and sanitize contaminated medication cart and blood pressure equipment when passing medications on Resident #13, #14, #24, and #39. The facility failed to ensure laundry staff handled and stored linens in a manner to ensure cleanliness and protect from dust and soil to prevent cross-contamination and the spread of infections for 1 of 1 laundry carts. This failure could place residents at risk for development of communicable diseases and infections. Findings included: Record review of Resident 13's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of chronic obstructive pulmonary disease (lung disease makes breathing hard), malnutrition, depression, anxiety, and heart disease. Record review of Resident #13's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 07, which indicated the resident's cognitive ability was severely impaired. Record review of Resident 13's Care Plan, reflected a focus area was initiated for Impaired cognitive function/dementia 7/25/2024 with a goal for the resident to be able to communicate basic needs and an intervention to administer medications as ordered. Record review of Resident #14's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of dementia, kidney disease, anemia, abnormal gait, depression, and heart failure. Record review of Resident 14's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 06, which indicated the resident's cognitive ability was severely impaired. Record review of Resident 14's Care Plan, reflected a focus area was initiated for Respiratory Infection on 1/31/25 with a goal for the resident to be free from signs and symptoms of infection. Record review of Resident 's 24 undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of diabetes type 2, depression, anxiety, stroke, falls, and muscle weakness. Record review of Resident 24 's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 02, which indicated the resident's cognitive ability was severely impaired. Record review of Resident #24's Care Plan, reflected a focus area was initiated for a skin cellulitis infection on 4/1/25 with a goal for the resident to be free from complications related to infection. Record review of Resident 39's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of vascular dementia, stroke, anxiety, hypertension (high blood pressure), and cellulitis of lower limb. Record review of Resident 39's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 03, which indicated the resident's cognitive ability was severely impaired. Record review of Resident 39's Care Plan, reflected a focus area was initiated for impaired cognitive function/dementia with a goal for the resident to maintain current level of cognitive function. Observation on 04/08/25 at 01:14 PM to 1:25 PM revealed LS-1 pushing the uncovered laundry cart up and down the North Hall delivering linens to residents' rooms. LS-I then took the cart into the secure unit with the cover still up. Observation on 04/09/25 at 08:45 AM revealed MA B removed a blood pressure cuff from the top of the medication cart and preceded into Resident #24's room to take her blood pressure. MA B touched the resident's arm then returned to work on the medication cart to prepare the medications. She placed the uncleaned blood pressure cuff on top of the cart. After preparing the medications, she returned to the resident, and gave the medications. She then returned to the medication cart to move to the next resident without performing hand hygiene. Observation on 04/09/25 at 08:53 AM revealed MA B removed an uncleaned blood pressure cuff from the top of the medication cart and preceded into Resident #14's room to take her blood pressure. MA B touched the resident's arm then returned to work on the medication cart to prepare the medications. She placed the uncleaned blood pressure cuff on top of the cart. After preparing the medications, she returned to the resident, and gave the medications. She then returned to the medication cart to move to the next resident. She performed hand hygiene here but did not clean the blood pressure cuff or the medication cart top. Observation on 04/09/25 at 09:10 AM revealed MA B removed an uncleaned blood pressure cuff from the top of the medication cart and preceded into Resident #13's room to take his blood pressure. MA B touched the resident's arm then returned to work on the medication cart to prepare the medications. She placed the uncleaned blood pressure cuff on top of the cart. After preparing the medications, she returned to the resident, and gave the medications. She then returned to the medication cart to move to the next resident without performing hand hygiene. Observation on 04/09/25 at 09:23 AM revealed MA B removed a blood pressure cuff from the top of the medication cart and preceded into Resident #39's room to take his blood pressure. MA B touched the resident's arm then returned to work on the medication cart to prepare the medications. She placed the uncleaned blood pressure cuff on top of the cart. After preparing the medications, she returned to the resident, and gave the medications. She then returned to the medication cart to move to the next resident without performing hand hygiene. Observation on 04/09/25 at 10:16 AM to 10:24 AM revealed LS-J pushing the partially uncovered laundry cart up and down the North Hall delivering linens to resident rooms. LS-J then took the cart into the Secure unit and the cover was then lifted completely, leaving the clothes open while she delivered clothes to the rooms. The residents had full access to the clothes and linens on the cart. In an interview on 4/8/25 at 01:50 PM LS-I stated, she worked the laundry area 2 days a week and she stated she kept the cart covered when travelling to the halls, but when she started delivering laundry to the rooms down the hall, she left the cart uncovered because the rooms were close together. She stated, laundry should be covered to protect it from germs and that was done because the residents could get sick if you did not. In an interview on 4/9/25 at 09:23 AM MA B stated, the policy on cleaning equipment between residents was to clean after every 2-3 residents and that was important to prevent the spread of infection and illnesses. She stated the policy on hand hygiene was to clean between each resident to stop the spread of infections. She stated if this was not done residents could get infections and get sick. In an interview on 4/9/25 at 01:50 PM LS-J stated, she normally delivered the laundry with the top down, and she slid it over so she can see what room to go to. She stated the policy was to keep linen carts always covered to prevent cross-contamination that could make residents sick. In an interview on 4/10/25 at 01:32 PM CNA G stated, the policy on hand hygiene between residents was to perform hand hygiene between residents and the policy on cleaning equipment between residents was to clean between residents. She stated it was important to clean hands and equipment for infection control and the negative outcome if that were not done was residents could get an infection or illness. She stated the policy for delivering linens was to keep the cart covered and that was important to keep them clean so residents would not get illnesses. In an interview on 4/10/25 at 01:43 PM LVN H stated, the policy on hand hygiene between residents was to hand sanitize between each resident for 2 times then hand wash the next time and the policy on cleaning equipment between residents was you need to use purple wipes between residents to clean and allow it to sit the appropriate time to dry. She stated it was important to clean hands and equipment because of infection control and the negative outcome if that were not done could be infections or sepsis that could lead to death. She stated the policy for delivering linens was linens were supposed to be always covered and that it was important to keep linens covered during transport because of infection control. She stated, and the negative outcome if that were not done could be infections or sepsis that could lead to death. In an interview on 4/10/2025 at 1:50 PM the ADM stated, the policy on hand hygiene between residents was that staff were required to do hand hygiene always between residents-100% of the time. He stated the policy on cleaning equipment between residents was that it was required 100% of the time. He stated it was important to clean hands and equipment between residents because it could cause infection to spread if not done and could cause death. He stated the policy for delivering linens was to keep them covered during transport for infection control and the negative outcome to residents if linens were not covered could be infections. A record review of the facility policy titled, Fundamentals of Infection control Precautions-Hand Hygiene: Dated 2019 with a last revision date of 3/2024 reflected the following: Hand hygiene continues to be the primary means to prevent the spread infections. Hand Hygiene is required upon and after meeting a resident's intact skin (when taking a blood pressure). Hand Hygiene is required after handling soiled equipment. A record review of the facility policy titled, Linens with a date of 2018 reflected the following: Transport bulk clean linen to resident's rooms in a clean, covered cart. All clean linen will be stored in a secured area. The linen cart will be covered. Per facility, there was no policy specific to sanitizing equipment between residents.

Based on observations, interviews, and record review the facility failed to provide, based on the comprehensive assessment and care plan, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being in the 1 of 1 memory care units (10 residents) reviewed for activities. The facility did not provide the memory care unit residents with individual or group activities. Findings included: In an observation on 04/09/25 at 9:35 AM in the memory care unit revealed the residents all sitting in the day room with a television on and 1 staff member present with them. Some residents were looking at the television and some were looking around and mumbling to themselves. There was no activity calendar posted in the memory care unit. There was no evidence of activities (puzzles, books, baby dolls, toys, coloring books, pencils, crayons) within the memory care unit. In an observation and interview on 04/09/25 at 2:09 PM with CNA D she stated they did not do activities back there [in the memory care unit], and at the time they were just chilling. The residents were observed to be sitting in the day room talking to themselves and looking around. CNA E was observed to be trying different remote controls to turn on the television, but they did not work. She then got a radio and turned it on for the residents to listen to. In an observation on 04/09/25 at 3:00 PM in the memory care unit revealed all the residents sitting in the day room with 1 staff member present. The television was on, and some residents were watching, and some were looking around and mumbling to themselves. There was no activity schedule posted. In an interview on 04/09/25 at 3:11 PM CNA E stated she had worked at the facility PRN for 2 years, worked 2 days a week, usually 2 or 3 days during the week. She stated activities vary, sometimes they watched the television and/or listened to the radio. She stated the residents liked to walk up and down the hall for exercise and when it was nice outside, they would go outside in the secure courtyard . In an interview on 04/09/2025 at 3:25 PM CNA F stated she did not work in the memory care unit, but she usually went back there to provide breaks to the CNA's when they asked. She stated the residents could have activities back there, but it did not take long for the residents to wander back into the day room. She stated the residents were usually in the day room when she provided breaks so the 1 staff could see all the residents . In an interview on 04/09/2025 at 4:40 PM the AD stated she had been working at the facility for less than 6 months. She had been using the previous AD's activity calendar's and would adjust the activities as needed, but she did not utilize the activity calendar to provide activities to the memory care unit. She stated she did not have an activity log for the memory care unit because she did not do activities with them, but that she was responsible for doing activities with them. She stated the CNA in the memory care unit had recently painted 2 residents nails. The AD inquired with the state surveyor if activities should be done daily in the memory care unit to which the state surveyor recommended, she check with the ADM . In an interview on 04/10/25 at 9:16 AM the ADM stated they did some activities in the memory care unit, but it was not as much as the other population of residents. She stated she did not feel the posted activity calendar in the main area of the facility should apply to the MC unit because some activities were inappropriate for the ability levels of the residents in the MC unit. She stated that due to the state surveyors concerns a group activity was prompted to be done in the memory care unit at 11:00 AM on 4/10/25 . Review of the facility's policy titled SecureCare Activity Program dated last revised January 2023 reflected, The SecureCare Program will provide a robust therapeutic activity program to meet the individual needs of each resident, provide a safe environment that maximizes independence, and provides resident centered care. Therapeutic activity programs will promote a variety of engaging activities geared towards sensory stimulation and skill retention. 1. The Activity Director and Director of Nursing or designee will work in conjunction to develop an organized therapeutic activity program for the SecureCare Program to include community resources and involvement within, as well as outside the health care center. 2. Each resident will have a therapeutic plan of care to meet individual needs and interests, maintain functional ADL skills, and provide social interaction, while protecting the resident from environmental over-stimulation. 3. The Activity Program will include small group activities and individual activities. 4. Programs should take place in mornings, afternoons and evenings that span throughout the entire week.

Based on interviews and observations, the facility failed to provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible for 1 of 1 memory care units (10 total residents) reviewed for homelike environment. The facility failed to provide a homelike environment inside the rooms (by hanging pictures, having decor present, or having color present) for the residents who lived in the memory care unit of the facility. This deficient practice could lead to regression and/or a feeling of institutionalization for the residents. Findings included: In an observation on 4/09/2025 at 09:33 AM in the facility's secured unit revealed a few paintings hung in the hallway as well in the dining room and dayroom. Observations of all 5 rooms (2 residents per room) revealed grey colored walls that were barren of any decorations. No personal or homelike decorations were observed in any of the 5 rooms. Each room contained 2 beds, 2 dressers, televisions, blinds on the window, over-bed lights, a privacy curtain between beds, and in some rooms, a recliner. In a confidential interview on 4/09/25 at 10:15 AM with a residents FM who resided in the facility's secured unit revealed the family of the resident had given the resident a few family pictures to have in the room. This FM did not regularly visit the resident. No pictures were visible in this resident's room. In an interview on 4/09/2025 at 11:30 AM with CNA D she stated she had been working at the facility for a year and a half. When asked about the walls in the resident rooms being bare and not personalized, she stated a lot of the residents exhibited behaviors such as tearing things off the walls. She stated it was just the rules here because some have behaviors and can take the stuff off the wall others cannot have decor in their rooms. She stated they had decor in the dining room and day room because that's where residents gathered and can be watched by the staff. She stated the memory care unit was full; having 2 residents per room for a total of 10 residents and it was hard to watch everybody if they were not in the same location. In a telephone interview on 04/09/25 at 2:54 PM with Resident #36's FM he stated he did not visit the resident often and another FM would be able to provide decor to the resident during that FM's next visit. In an interview on 04/10/25 at 9:16 AM the ADM stated the facility in the past had a decorative team that came and decorated the facility but the residents in the memory care unit took down the pictures that were up. She stated the facility had consistently tried to add more decorations and residents would pull them down. She stated they [facility staff] told family members to bring things to make the resident rooms their home. She stated it was a challenge to keep things in place. She stated a negative outcome to the rooms not feeling homelike could be regression, and she did not want the residents to feel institutionalized. Review of the facility's undated policy titled Resident Rights packet reflected, Safe environment - The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- 1. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. a. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. b. The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. 2. 2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Based on interviews, and record review the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for five of five residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present. Findings included: During an interview on 04/08/2025 at 10:20 am, with the Activity Director revealed the Resident Council meetings were held in the dining room. She stated there was not another area for the residents to meet in private. She stated she would close the doors and place signs on the doors. She stated she would notify staff before the meeting not to come in or out of the dining room until after the resident group meeting. The Activity Director offered to move the Resident Council meeting to a bedroom so it would be private since it was a few residents. During an interview on 04/09/2024 at 09:30am, during a confidential resident group meeting held in a bedroom with five residents revealed their meetings were normally held in the dining room. The residents in attendance of the resident group meeting stated interruptions occurs every- time they had a Resident Council meeting. The residents stated their meetings have never been private. The residents in the meeting stated they could not speak freely because staff would come in. The residents stated the AD would get the staff out during the meeting, but staff continued to interrupt their council meetings. The residents in the meeting stated they would like some place private to meet. During an interview with the ADON on 04/10/2025 at 9:35am revealed she had been trained on resident rights. She said the resident council must have a private place to meet. She said staff were not to be a part of the meeting unless the council invited them. She said the AD was responsible for ensuring the resident council had a private place to meet. She said she had not heard the resident council wanted a more private place to meet. She said if the resident council did not have a private meeting space the residents may not feel comfortable voicing their concerns. During an interview with the AD on 04/010/2025 at 9:37am revealed she had been trained on resident rights. She said the residents were to have a private meeting space for their resident council meeting. She said staff could not be in the meeting without the permission of the resident council. She said she was responsible for ensuring they had a private place to meet. She said she put signs on the dining room door to keep staff out. She said the resident council had not asked for a private place. She said the residents may not feel comfortable saying what they want or would not come to the meetings because it was not private. During an interview with the ADM on 04/10/2025 at 10:12am revealed she had been trained on resident rights. She said the resident council should have a private area to meet, and staff could not attend unless invited. She said she was responsible for ensuring the resident council had a private area to meet. She said if the resident council did not have a private area people could overhear their meeting and try to retaliate. She also said it was a dignity issue. Record Review of the facility's Resident Rights Policy dated 3/09/2022 revealed the residents had the right to be treated with respect and dignity. The resident had the right to privacy. The residents had the right to organize and participate in resident groups in the facility.

Based on observations, interviews, and record review the facility failed to ensure each resident's bedside, toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 3 of 10 residents (Resident #20, Resident #28, and Resident #31) reviewed for the resident call system . The facility failed to provide a working communication system, which was easily at reach, which would allow Resident #20, Resident #28, and Resident #31 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings included: Record review of Resident #20's face sheet dated 04/09/2025 reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included metabolic encephalopathy (brain disease), cellulitis (bacterial infection involving inner layers of the skin), vitamin D deficiency, dry eye, constipation, muscle wasting, abnormalities of gait and mobility, unsteadiness on feet, lack of coordination, reduced mobility, insomnia (difficulty sleeping), glaucoma (eye disease), hypertension (high blood pressure), adult failure to thrive, and history of falling. Record review of Resident #20's Quarterly MDS dated [DATE] reflected Resident #20 had a BIMS score of 03, which indicated severe cognitive impairment. The MDS further reflected Resident #20 needed assistance of two or more helpers for his activities of daily living. Resident #20 required moderate assistance for bed mobility, and transfers, and he used a wheelchair for mobility. Record review of Resident #20's Care Plan, dated 03/07/25, ensure Resident #20's call light was within reach and encourage the resident to use it for assistance as needed. Review of Resident #28's Face Sheet dated 04/09/2025 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #28's diagnoses included dementia (memory, thinking, difficulty), toxic encephalopathy (neurological disorder dur to being exposed to toxic substances), pain due to trauma, muscle wasting, abnormalities of gait and mobility, sexual disorder, delusional disorder (serious mental illness that causes unshakeable false beliefs for at least a month), muscle weakness, unsteadiness on feet, reduced mobility, muscle wasting, lack of coordination, depression, hyperthyroidism (excessive production of thyroid hormones), anxiety (feeling of uneasiness or worry), hyperlipidemia (high cholesterol), seizures, and hypertension (high blood pressure). Record review of Resident #28's Quarterly MDS dated [DATE] reflected Resident #28 had a BIMS score of 06, which indicated severe cognitive impairment. The MDS further reflected Resident #28 required supervision and touching assistance from staff for her activities of daily living, and transfers, and she walked independently. Record review of Resident #28's Care Plan, dated 01/27/25, Ensure/provide a safe environment: Call light in reach, Adequate low glare light, bed in lowest position and wheels locked, Avoid isolation. Review of Resident #31's Face Sheet dated 04/09/2025 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31's diagnoses included encephalitis and encephalomyelitis (inflammation of the brain and the spinal cord), dysphagia (difficulty swallowing), insomnia (difficulty sleeping), calculus of gallbladder (stones in the gallbladder), muscle wasting, unsteadiness on feet, abnormalities of gait and mobility, collapsed vertebra (compression fracture of the spine), nicotine dependency, muscle weakness, nystagmus (involuntary eye movement), hypertension (high blood pressure), and ataxia (impaired balance or coordination due to damage to the brain, nerves or muscles). Record review of Resident #31's Quarterly MDS dated [DATE] reflected Resident #31 had a BIMS score of 07, which indicated severe cognitive impairment. The MDS further reflected Resident #21 required supervision and touching assistance from staff for his activities of daily living, and transfers, and he walked independently. Record review of Resident #31's Care Plan, last revised on 03/01/25, Encourage the resident to use bell to call for assistance. Observation of Resident #31's call light on 04/08/2025 at 11:08am revealed his call light was not within reach of the resident. Resident #31's call light was hanging straight to the floor between the bed and the wall. The resident could not reach the call light. Resident #31 was sitting on the end of his bed in the middle and could not reach the call light if he needed it. Observation of Resident #20's call light on 04/08/2025 at 11:08am revealed his call light was not within Resident #20's reach. Resident #20's call light was on his roommates bedside table. The resident was laying in his bed, and he could not reach the call light if he needed it. Observation of Resident #28's call light on 04/08/2025 at 1:09pm revealed her call light was on the floor approximately 40 feet from the resident. Resident #28 was laying in her bed and could not reach her call light if she needed it. During an interview with Resident #20 on 04/08/2025 at 11:10am revealed he would not answer questions about the call light. During an interview on 04/09/2025 09:33am with Resident #28 revealed her call light was rarely in reach. She said she would have to go underneath her bedside table to get her call light. During an interview on 04/09/2025 09:35am with Resident #31 revealed his call light was always hung straight to the floor. Resident #31 also said he did not use the call light anyway. During an interview with the ADON on 04/10/2025 at 09:312am revealed she had been trained on resident rights. She said the policy was the call light should always be within the resident's reach. She said the call light should be within reach any time the resident was in their room. She said if the call lights were not in the resident's reach the resident would not be able to get the help they needed, and the staff could not tend to them quickly. She also said the resident could fall or worst-case die depending on what was going on with the resident. She said everyone was responsible for ensuring the call light was within reach. She said it was monitored by doing rounds. She said the call light was not in reach because the residents were not in their room a lot and staff may have forgotten to put it back after making the bed. During an interview with LVN B on 04/02/2025 at 1:22pm revealed she had been trained on resident rights. She said the call light was supposed to be where the resident could reach it. She also said that if the resident was paralyzed the call light should be placed on the side that was not paralyzed. She said all staff were responsible for ensuring the call lights were within reach. She said if the call lights were not within the resident's reach the resident could fall or get hurt. She also said the nurses and CNA's were responsible for ensuring the call lights were within the resident's reach. She said the CNA's and nurses monitor the call lights by doing rounds and would put the call light in the resident's reach if it was not in their reach. She said the staff did not pay attention to the call lights and that was why the call lights were not in reach. During an interview with MA B on 04/10/2025 at 10:00am revealed she and staff had been trained on resident rights. She said the call light was supposed to be within the resident's reach. She also said if the resident was in the wheelchair the call light was supposed to be close to the wheelchair. She said the call light needed to be within the residents reach in case of an emergency or in case the residents needed staff. She said the call lights were monitored by the charge nurse and all staff were responsible for ensuring the call lights were within the resident's reach. She said call lights were monitored by walking the halls and checking the call lights. She said she did not know why the call light was not in reach. She said some may have fallen off the residents bed. During an interview with the ADM on 04/10/2025 at 10:16am revealed she and staff had been trained on resident rights. She said the call light was supposed to be within the resident's reach. She also said it was important to have the call light in the resident's reach in case of an emergency. She said if the call lights were not within the resident's reach the resident could die in worst case scenario. She also said management were responsible for ensuring the call lights were within the resident's reach. She said the call lights were monitored by doing rounds. She said she did not know why the call light was not in reach. Policy for dignity and call lights were requested from the ADM on 04/09/2025 at 11:11am, and at 4:17pm. The policy was not received on exit.

Based on observations, interviews, and record review the facility failed to protect and promote an environment that ensured the resident's right to a dignified existence for 2 of 2 residents (Resident #24 and #3) reviewed for resident rights. The facility failed to to address Resident #3's eating restrictions in a dignified manner and protect confidentiality related to incontinence care needs on Resident #24. This failure could place residents at risk for shame and loss of dignity that could negatively impact their quality of life. Findings included: Record review of Resident #3's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of pneumonitis, epilepsy (seizures), stroke, malnutrition, right side muscle weakness related to stroke, dementia, and anxiety. Record review of Resident #3 's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 99, which indicated the resident's cognitive ability could not be determined due to other medical conditions. Record review of Resident #3's Care Plan, reflected a focus area was initiated for depression on 5/16/23 (ongoing) with a goal for the resident to decrease signs and symptoms of depression. Record review of Resident #24's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of diabetes type 2, depression, anxiety, stroke, falls, and muscle weakness. Record review of Resident #24 's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 02, which indicated the resident's cognitive ability was severely impaired. Record review of Resident #24's Care Plan, reflected a focus area was initiated for depression with a goal for the resident to be free from discomfort or adverse reactions from antidepressants. Observation on 04/08/25 at 10:46 AM revealed Resident #24, had a note on her door that opened into the public hallway saying, Please Check Resident 24's (Sign had residents name on it.) Pull-ups are on both legs Thanks. In an interview on 04/09/2025 at 11:50 AM with the ADON when asked by the state surveyor where Resident #3 could be located, she stated he was at the feeder table. There was 1 resident in the presence of the state surveyor and the ADON when this was said. In a follow up interview on 04/09/2025 at 11:58 AM with the ADON when asked why she referred to the table in the dining room as the feeder table she stated she was not supposed to say feeder table; she did not know the correct term for it, and she realized as soon as she said it, she should not have said it. She stated she was aware that was a dignity issue, and she would ask her DON what the correct term was. In a phone interview on 04/10/2025 at 11:15 AM, the Responsible Party for Resident #24 stated she posted the sign. In an interview on 4/10/2025 at 1:32 PM, CNA G stated the policy on maintaining confidentiality regarding resident's incontinence/wearing briefs was to keep all information private and it was important to maintain privacy because it was not anyone else's business. She stated the negative outcome to residents if not done could be embarrassment and it could cause them depression. She stated a sign stating a resident wears a brief might indicate the resident was incontinent and that a sign visible in the hallway was not private. In an interview on 4/10/2025 at 1:43 PM LVN H stated, the policy on maintaining confidentiality regarding resident's incontinence/wearing briefs was they were not supposed to tell anybody. She stated it was important to maintain privacy on incontinence for resident's dignity and privacy and the negative outcome to residents if not maintained could be humiliation and loss of dignity. She stated a sign stating a resident wore a brief would indicate the resident was incontinent and a sign visible in the hallway was not private. In an interview on 4/10/2025 at 1:50 PM the ADM stated, the policy on maintaining confidentiality regarding incontinence/wearing briefs was that the facility was confidential about that information, and it was important to maintain privacy on incontinence because it was a dignity issue for the resident. He stated the negative outcome to residents if not done could be aggressiveness and embarrassment. He stated a sign stating a resident wore a brief would of course indicate the resident was incontinent and a sign visible in the hallway was not private. A record review of the facility undated policy titled, Resident Rights, reflected the following: The resident has a right to a dignified existence. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes quality of life. The facility must protect and promote the rights of the resident.

Based on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #36) of five residents reviewed for ADL care. The facility failed to shave Resident #36's facial hair all along the under side of her chin that was approximately 1 cm in length This deficient practice could place residents at risk of a decline in their sense of well-being and level of satisfaction with life. Findings included: Review of Resident #36's quarterly MDS assessment dated [DATE], reflected an [AGE] year-old-female that was admitted to the facility on [DATE] with diagnoses including high blood pressure, dementia, anxiety, depression, muscle wasting and atrophy, muscle weakness, and unsteadiness of feet. Her BIMS score was a 04, indicating severe cognitive impairment. She required substantial/maximal assistance to maintain personal hygiene. Review of Resident #36's care plan revealed she had an ADL Self Care Performance Deficit with goals to remain clean, dry, and well-groomed and to maintain or improve current level of function in personal hygiene. She had interventions including to assist with personal hygiene was required: hair, shaving, and oral care. Observation and interview on 4/09/25 at 09:36 AM with Resident #36 in her room revealed her sitting in her wheelchair looking at one of the bare walls. The resident had facial hair along her chin that was approximately 1 cm in length. When asked about her chin hair the resident stated it bothered her that it was there, and she wanted it trimmed if the hair was not plucked out 1 by 1. She was unable to recall the last time the facility shaved it for her. In a telephone interview on 04/09/25 at 2:54 PM with Resident #36's FM he stated the resident used to always take care of her shaving needs herself. He did not think there would be any issues with someone helping her out in that area now, she had not shown any combative behaviors. In an interview on 04/09/25 at 3:11 PM with CNA E she stated she had worked at the facility PRN for 2 years, worked 2 days a week, usually 2 or 3 days during the week. She did help with showers, and she had been waiting on razors to be brought back to the memory care unit. She stated some days she had a hard time persuading Resident #36 to get in the shower, but the resident did not regularly refuse or have a history of being combative. She could not recall the last time she shaved Resident #36 . She stated that shaving should be done during the residents' shower time if needed or when asked by the resident. In an interview on 04/10/25 at 9:16 AM the ADM stated typically during showers was when residents would be shaved, but it could be outside of that time as well . The CNA's were responsible for providing showers and ADL care during the residents' assigned shower days. Review of the facility's Shaving, Electric/Safety Razors policy undated reflected: It [shaving] is usually done as a part of daily personal hygiene, although every other day is sufficient for some based on the beard growth. It is done to promote cleanliness and a positive body image.

Based on observations, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 7 of 18 residents (Resident #5, #8, #9, #10, #11, #12, #14) reviewed for medications and pharmaceutical services, in that: The facility failed to ensure narcotic audits were properly conducted on or about [DATE], through [DATE], per the facility's policies and procedures, resulting in unaccounted for, misplaced, and/or misappropriated medications, including (2) tablets of Lorazepam 1mg, (1) tablet of Tylenol #3 (Codeine), (2) tablets of Lorazepam .5mg, (1) tablet of Phenobarbital 60mg, and (1) tablet of Amoxicillin 500mg. The facility failed to ensure medications, including controlled substances, were administered to Resident #5 and Resident #9 on [DATE], at 1800 (6:00 PM), as ordered or scheduled, resulting in the delayed administration of necessary medications. LVN A failed to follow the facility's Medication Administration Procedures policy on [DATE], in that LVN A withdrew and prepared scheduled medications, including narcotics, for Resident #8, #10, and #11, in anticipation of their future administration, but failed to administer the medications or properly dispose of thee medications. LVN A also failed to sign residents' narcotic count sheets after removing the medications, thus creating discrepancies in the count for those medications. LVN A failed to completely and accurately document the administration of Resident #14's Fentanyl 12mcg Transdermal Patch in that LVN A signed the medication out on the resident's narcotic sheet prior to 10:55AM on [DATE] but post-dated the administration for [DATE] at 12:00 PM. LVN A did not withdraw the patch from the prescription box, administer or apply the medication, but documented a reduction in the count by 1 when 2 patches remained, causing a discrepancy in the count. These failures placed the residents at risk of not receiving the intended therapeutic benefits of their medications or care needed to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #5's face sheet on [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses that include, but are not limited to Unspecified Dementia (dementia that is not specified by a doctor; a group of symptoms that affects memory, thinking, and interferes with daily life), Unspecified Glaucoma (an eye condition that damages the optic nerve), Schizoaffective Disorder, Bipolar Type (a form of mental illness that has the features of both schizophrenia and a mood disorder), Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness, loss of interest and changes in sleep and appetite), and anxiety disorder (a condition characterized by overwhelming worry or fear). Review of Resident #5's Quarterly MDS assessment dated [DATE], revealed a BIMS summary score of 12, indicating moderate cognitive impairment. Review of Resident #5's Physician's Orders dated February 26, 2025, reflected she was prescribed Lorazepam Tablet .5mg, Give 1 tablet by mouth at bedtime related to ANXIETY DISORDER, UNSPECIFIED. The start date on this medication was [DATE]. Review of Resident #8's face sheet on [DATE] reflected a [AGE] year-old male admitted to the facility originally on [DATE], with a most recent readmitted [DATE]. His diagnoses include, but are not limited to Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris (a buildup of fats, cholesterol, and other substances in and on the artery walls), Infection and Inflammation Reaction Due to Other Cardiac and Vascular Devices, Implants and Grafts, Sequela (a complication or condition that follows a prior illness or disease), Methicillin Resistant Staphylococcus Aureus Infection (MRSA; a type of bacteria that is resistant to several antibiotics), Cellulitis of Left Upper Limb (a bacterial infection of the skin and the tissue beneath the skin), Bipolar Disorder (chronic mood disorder that causes extreme shifts in mood, energy levels and behavior), and Unspecified Psychosis (a mental health condition characterized by a disconnection from reality). Review of Resident #8's Quarterly MDS assessment dated [DATE], revealed a BIMS summary score of 7, indicating severe cognitive impairment. Review of Resident #8's Physician's Orders dated February 26, 2025, reflected he was prescribed Clindamycin HCl Capsule 300 MG, to be given as 1 capsule by mouth three times a day related to Cellulitis of the left upper limb. The start date of the medication was [DATE]. The end date of the medication was [DATE]. Review of Resident #9's face sheet on [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included, but are not limited to Eencephalopathy (any disease or disorder that affects the brain, leading to changes in thinking, behavior and overall brain function), Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness, loss of interest, and changes in sleep and appetite), and Anxiety Disorder (a condition characterized by overwhelming worry or fear). Review of Resident #9's Quarterly MDS assessment dated [DATE], revealed a BIMS summary score of 5, indicating severe cognitive impairment. Review of Resident #9's Physician's Orders dated 1/ ,d+[DATE], reflected he was prescribed Lorazepam .5 MG Tab, 1 tablet to be given by mouth every night at bedtime. The start date of this medication was [DATE]. Review of Resident #10's face sheet on [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that include, but are not limited to Dementia (a group of symptoms affecting memory, thinking and social abilities), Poly osteoarthritis (osteoarthritis that affects five or more joints simultaneously), chronic pain, Psychotic Disorder with delusions (a mental health condition where a person has unshakable beliefs that are untrue), Anxiety Disorder ((a condition characterized by overwhelming worry or fear), and homicidal ideations (thoughts about homicide). Review of Resident #10's Quarterly MDS assessment dated [DATE], revealed a BIMS summary score of 3, indicating severe cognitive impairment. Review of Resident #10's Physician's Orders on [DATE] reflected she was prescribed Lorazepam 1 MG Tablet, 1 tablet to be given two times a day for agitation/anxiety, with a start date of [DATE], and Tylenol with Codeine #3 ,d+[DATE] mg Tablet (Acetaminophen-Codeine), t tablet to be given by mouth to times a day for pain related to poly osteoarthritis. Review of Resident #11's face sheet on [DATE] reflected a [AGE] year-old female admitted to the facility originally on [DATE] and readmitted to the facility most recently on [DATE]. Resident #11's diagnoses include Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), limitation of activities due to disability, Parkinson's Disease (a movement disorder that affects the nervous system and causes tremor and stiffness), Post Traumatic Stress Disorder (a mental condition caused by a traumatic event), Bipolar Disorder (a chronic mood disorder that causes extreme shifts in mood, energy levels, and behavior), Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness, loss of interest and changes in sleep and appetite),, and chronic pain. Review of Resident #11's Quarterly MDS assessment dated [DATE], revealed a BIMS summary score of 10, indicating moderate cognitive impairment. Review of Resident #11's Physician's Orders on [DATE], reflected she was prescribed Phenobarbital Oral Tablet 60 MG, 1 tablet to be given by mouth two times a day related to seizures (other). The start date of this medication was [DATE]. Review of Resident #12's face sheet on [DATE] revealed a [AGE] year-old female admitted to the facility originally on [DATE] and readmitted to the facility on [DATE]. Resident #12's diagnoses include Schizoaffective Disorder (a mental health condition that combines schizophrenia and mood disorder symptoms), Depressive Type, Non Traumatic Ischemic Infarction of Muscle, Right Thigh (severely blocked blood flow), Hypothyroidism (underactive thyroid), Altered Mental Status, and Cognitive Communication Deficit. with no formal diagnoses listed. Review of Resident #12's Quarterly MDS assessment dated [DATE], revealed a BIMS summary score of 2, indicating severe cognitive impairment. Review of Resident #12's Physician's Orders on [DATE], reflected she was prescribed amoxicillin related to a tooth abscess. The order indicated Amoxicillin Tab 500 MG, 1 tablet to be given by mouth three times a daily for 7 days. The start date of this medication was [DATE]. Review of Resident #14's face sheet on [DATE] revealed an [AGE] year-old male admitted the to facility on [DATE]. Resident #14's diagnoses include Malignant Neoplasm of Prostate (prostate cancer), Anemia (a blood condition characterized by not having enough healthy red blood cells or hemoglobin to carry to the body's tissues), Gout (a form of arthritis characterized by sudden and severe attacks of pain, swelling, redness and tenderness), and Restlessness and Agitation. Review of Resident #14's Physician's Orders on [DATE], reflected he was prescribed Fentanyl Transdermal Patch 72 Hour 12 MCG/HR, which was to be applied as 1 patch transdermal every 72 hours related to Malignant Neoplasm of Prostate and remove per schedule, The start date of this medication was [DATE]. Review of the initial Facility Reported Incident report submitted by ADM on [DATE] at 10:59AM via the web, revealed the date/time of the reported drug diversion incident to be [DATE] at 8:00PM. In the report it stated that the medication aide (MA A) was believed to be responsible for the reported drug diversion. The report stated the medication aide had already been suspended for an unrelated incident when the facility discovered the drug diversion and the Director of Nursing (DON) took over the medication pass at the time of MA A's suspension. Review of a supplemental report submitted by ADM on [DATE] at 11:59 AM, indicated none of the involved residents missed any doses of their medications, and none suffered any adverse effects. It also indicated a police report was filed. The following medications were reported to be missing: LORAZEPAM 1MG belonging to Resident #19, a Benzodiazepine. LORAZEPAM 1MG belonging to Resident #10, a Benzodiazepine. TYLENOL #3 belonging to Resident #10, a combination of acetaminophen and Codeine, an Opiate. PHENOBARBITAL 60MG belonging to Resident #11, a Barbiturate. LORAZEPAM .5MG belonging to Resident #5, a Benzodiazepine. LORAZEPAM .5MG belonging to Resident #9, a Benzodiazepine. AMOXICILLIN 500MG belonging to Resident #12, an antibiotic. Review of the Provider Investigation Report submitted by the facility to HHS on [DATE] , revealed a reported incident of drug diversion which occurred on [DATE] at 6:30 PM at the facility. Resident #9, who is described as an interviewable resident with the capacity to make informed decisions, was listed as one of the residents involved in the incident. The report states that Resident #9 confirmed he was not given any medications on the evening of [DATE]. Resident #5 was also listed as an involved resident. Resident #5 was described as an interviewable resident without the capacity to make informed decisions whose diagnosis is unspecified dementia (a group of symptoms affecting memory, thinking and social abilities). Resident #5 also denied receiving her scheduled medication(s) on the evening of [DATE]. In total, 6 residents were found to have medications missing or unaccounted for. All residents were assessed, and no signs or symptoms of distress were noted. The residents reportedly didn't exhibit behaviors abnormal from their baseline. The medication cart was audited, and no other discrepancies were discovered. Facility staff believed MA A was responsible for the missing medication in that MA A was instigated and engaged in unprofessional verbal disagreements with other staff members on the day of the incident which led to the facility's DON returning to the facility to diffuse the situation and to suspend MA A pending investigation into an unrelated incident. Reportedly MA A refused to write a statement regarding the unrelated incident and refused to count the medication cart with the DON. MA A went home and DON took over med pass and assumed responsibility for the medication cart. MA A was ultimately terminated as the report stated that MA A admitted that she had made the errors by mistake, according to the facility (ADM). The responsible parties for the 6 residents involved were notified, the police were notified, and a report was made. The Medical Director was notified. The pharmacy was notified. The physician and pharmacy recommended no further treatment. Medication Carts were audited to ensure that no more medications were missing. All staff were in-serviced on Drug Diversion and Abuse, Neglect and Medication Administration. The DON was to have conducted random med cart audits, as well as follow along on random med passes. Safe surveys were conducted, which indicated no negative findings or confirmation of abuse or neglect. Review of Investigation Statement written by DM on [DATE] stated that DM observed MA A in the dining room at suppertime and there seemed to be an argument going on. Review of Investigation Statement written by NB on [DATE] at 5:30PM stated that she observed MA A engaged in an argument with other staff members while other staff were feeding residents. Review of Investigation Statement written by LVN A on [DATE], from 5:45PM-6:00 PM, stated while LVN A was sitting at a dining room table, feeding a resident, when MA A came over and began talking about how tired she was and how she had worked 20 days straight. LVN A made the comment that she was tired of hearing MA A complain, which caused MA A to become upset and begin arguing loudly with other staff in front of resident. Review of Investigation Statement written by LVN A on [DATE] at 2200 (10:00 PM), in which it is which stated that she passed medications on the unit at approximately 2000(8PM). DON and LVN A counted narcotics at approximately ,d+[DATE] (9:15 PM-9:30 PM) on [DATE] when they noticed a discrepancy in the count on both carts. Review of Investigation Statement written by MA A on [DATE] (date deduced from information contained within the statement), stated MA A was in the dining room passing trays and she just started screaming at the employees for no reason. MA A stated that she refused to write a statement on the night of the incidentlast nite because she couldn't think. She ends the statement by writing, I do apologize on my behalf. MA A makes no admission to any conduct related to the missing medications. Review of the 12 panel Drug Test Results Record for DON showed that DON submitted to a urinalysis drug test on [DATE] at 1030PM. The results were interpreted by DON at 10:35PM and confirmed by LVN A at 10:55PM. The results were negative. The substances tested for were Phencyclidine (PCP), Methylenedioxymethamphetamine (MDMA), Amphetamines, Methadone, Barbiturate, Buprenorphine (Opiate), Oxycodone (Opioid Analgesic), Methamphetamine, Benzodiazepine, Opiates, Marijuana and Cocaine. Review of the 12 panel Drug Test Results Record for LVN A showed that LVN A submitted to a urinalysis drug test on [DATE] at 10:50PM, which was received by DON. The results were interpreted by DON at 10:55PM. The results were negative. The substances tested for were Phencyclidine (PCP), Methylenedioxymethamphetamine (MDMA), Amphetamines, Methadone, Barbiturate, Buprenorphine (Opiate), Oxycodone (Opioid Analgesic), Methamphetamine, Benzodiazepine, Opiates, Marijuana and Cocaine. Review of the 12 panel Drug Test Results Record for MA A showed that MA A submitted to a urinalysis drug test on [DATE] at 11:35AM, which was received by DON. The results were interpreted by DON at 11:45AM. The results were negative. The substances tested for were Phencyclidine (PCP), Methylenedioxymethamphetamine (MDMA), Amphetamines, Methadone, Barbiturate, Buprenorphine (Opiate), Oxycodone (Opioid Analgesic), Methamphetamine, Benzodiazepine, Opiates, Marijuana and Cocaine. Review of the police report #,d+[DATE] filed by the facility on [DATE] with KPD revealed that a police officer was dispatched to the facility on [DATE] at 12:13PM in reference to a theft of narcotics. The officer met with DON who stated that MA A accidentally wrote the wrong date on several of the [patients] medicine logs. DON stated that instead of writing [DATE], MA A wrote [DATE] when she gave the [patients] their medicine on the previous day (Friday, [DATE]). DON said she was the one who caught the mistake, and that MA A is an elderly lady who just made a mistake but didn't take anything. DON stated that MA A had been drug tested and DON and LVN A counted the medicine and found that nothing was missing at all. DON stated that it was simply a mistake of MA A writing the wrong date. DON told the officer that she just needed to file a report in order to document the incident for the state. The officer cleared the scene at 12:38PM. Review of the facility's in-service records from [DATE] through [DATE] reflected facility staff were in-serviced on procedures regarding Medication Administration (specifically not to pre-pull medications), Abuse and Neglect, Medications to be Given as Ordered, Code of Conduct, and Drug Diversion. The in-service training attendance rosters for [DATE] do not indicate the time in which they were presented to staff, but MA A's signature was contained on each including Drug Diversion and Medication Administration. Review of the Controlled Drug Monitoring Record (audit) dated [DATE] through [DATE] stated, Does all count sheets on all med carts match remaining medication supply? Each date is separated into columns and in each column a date is recorded and the say of the week, as well as an option to circle Yes or No. If a No response is chosen instructions are given to describe and note corrective action. On each of the days listed all count sheets matched the remaining medication supply. Review of the Employee Disciplinary Report signed by MA A, DON, and ADM on [DATE], showed MA A was placed on investigatory suspension pending an investigation into resident rights due to MA A yelling in front of residents. Review of Employee Disciplinary Report signed by MA A, DON, and ADM on [DATE], stated it was discovered on [DATE], following MA A's suspension for raising her voice at other staff in front of residents, that there were medications missing from the medication cart. As a result, MA A was terminated. Review of the statement written by DON regarding the incident involving MA A. The statement is typed and not dated, but dated but stated in part that DON returned to the facility due to argument between several employees, including MA A. MA A refused to provide a statement and said she was going home instead. DON then took over the medication cart from MA A, who reportedly refused to count with DON at that time. Following her assumption of the medication cart, DON said she spoke with the hospice nurse and a resident's wife family member regarding hospice services and care, which she stated took some time. DON stated that she gave 2 residents their medications when the residents came to the desk asking for their nighttime medications. DON said that she and LVN A then counted the narcotics on the cart and did not notice any discrepancies at that time. DON said while giving scheduled narcotics to a resident at around 9:15 PM/9:30 PM, she noticed that the previous signed out medication was for [DATE]. Upon closer inspection of all of the narcotic count sheets, DON states she realized that there were multiple residents with medications signed out for [DATE] & [DATE] as given. DON states she immediately notified ADM. Review of Resident #5's Individual Patient's Controlled Substance Record reflected Resident #5 was prescribed 15 Lorazepam .5MG Tab on [DATE], with an order to give one tablet by mouth every night at bedtime. The administration documentation shows MA A documented the administration of 1 tablet on [DATE] at 2000 (8PM), and 1 tablet on [DATE] at 2000 (8PM). Review of Resident #9's Individual Patient's Controlled Substance Record reflected Resident #9 was prescribed 30 Lorazepam .5MG Tab on [DATE], with an order to give 1 tablet by mouth every night at bedtime. The administration documentation shows that MA A documented the administration of 1 tablet on [DATE] at 2000 (8PM), and 1 tablet on [DATE] at 2000 (8PM). Review of Resident #10's Individual Patient's Controlled Substance Record reflected Resident #10 was prescribed 30 Lorazepam 1mg tablets on [DATE], with administration directions to give 1 tab by mouth twice a day. The administration documentation shows MA A documented the administration of 1 tablet on [DATE] at 2000 (8PM) leaving 12 tablets remaining. LVN A documented the administration of 1 tablet on [DATE] at 800 AM leaving 11 tablets remaining. MA A documents the administration of 1 tablet on [DATE] at 2000 (8PM) leaving 10 tablets remaining, and 1 tablet on [DATE] at 2000 (8PM); leaving 9 tablets remaining. Review of Resident #10's Individual Patient's Controlled Substance Record reflected Resident #10 was prescribed 30 Tylenol #3 tablets on [DATE], with administration directions to give 1 tablet by mouth twice a day. The administration documentation shows LVN A documented the administration of 1 tablet on [DATE] at 800 AM leaving 11 tablets remaining. The administration documentation shows that MA A documented the administration of 1 tablet on [DATE] at 2000 (8PM) leaving 10 tablets remaining, and the administration of 1 tablet on [DATE] with no time indicated leaving 9 tablets remaining. Review of Resident #11's Individual Patient's Controlled Substance Record reflected Resident #11 was prescribed 60MG of Phenobarb on [DATE], with an order to give 1 tablet by mouth twice daily. The administration documentation shows MA A documented the administration of 1 tablet on [DATE] at 2000 (8PM) leaving 10 tablets remaining. But following this administration documentation, the administration of 1 tablet on [DATE] at 2000 (8PM) by DON leaving 9 tablets remaining. Review of Resident #12's Individual Patient's Antibiotic Usage Record reflected Resident #12 was prescribed 21 Amoxicillin 500MG Tab on [DATE], with an order to take one tablet by mouth three times daily for 7 days. On [DATE], MA A documented the administration of one tablet given at 1800 (6:00 PM), which left 2 tablets remaining. DON made a handwritten note on the usage record that states, This was the med card on [DATE]. ,d+[DATE] charting was completed as given on [DATE]. In an interview with ADM on [DATE] at 8:40AM. ADM stated it's her belief that MA A was responsible for the missing medications on [DATE]. ADM stated that she doesn't believe MA A purposefully or intentionally misappropriated the missing medications. ADM stated that MA A had not been acting like herself that day and it's possible MA A was suffering from some sort of cognitive decline. ADM stated that MA A was arguing with staff and DON went to the facility to investigate. ADM said MA A's husband and son had to get her out of her car upon arriving home that evening. ADM said MA A did not remember driving home the next day. ADM stated that MA A was administered a drug test the next morning and the results were negative. ADM stated it is believed that MA A pre-dated her medication administrations. ADM said according to what was documented, the count was right, but further investigation revealed 7 pills were missing. The ADM stated that MA A worked the 2PM-10PM shift as a medication aide and had been employed with the facility since [DATE]. This was MA A's first incident. In an interview with DON on [DATE] at 8:40AM, DON stated that it was reported to her that MA A was arguing with staff and causing a disruption in front of the residents. Since DON lived practically next door to the facility, DON reported that she immediately presented to the facility to investigate. DON said MA A refused to write a statement or count the med cart with her and just wanted to go home. DON stated that she assumed responsibility for the medication cart without counting the medications on the cart to ensure all were accounted for. When the discrepancies were discovered, DON called MA A at 11:00PM on [DATE] to inquire about the missing medications. DON was unable to reach MA A. DON said MA A expressed to her prior to this event that she thought she was dying. No further details or explanation were provided by MA A or DON. In an interview with LVN A on [DATE], at 10:15AM, LVN A stated that she has been employed with this facility for 2 years. LVN A stated that medication aides typically administer medications from 2PM-10PM, but she switched shifts on this day. Observation of medication administration by LVN A on [DATE] at 10:15AM revealed 10 medications administered with 13 opportunities for error. LVN A administered all medications with no errors observed. The medications administered were Calcium 600+D, Cranberry, Fish Oil, Folic Acid, Guanfacine, Multi-Vitamin, Omeprazole, Risperidone, Sodium Chloride, and Vitamin D. Observation of medication cart audit with LVN A and review of the medication cards on the North Hall Treatment Cart on [DATE] at 10:34AM revealed 3 individual medication cups, labeled with Resident #8, #10, and #11's last names on the outside of each cup. The cups were stacked on top of each other and LVN A pushed the cups toward the back of the cart to conceal the medications. The cups contained 1 Clindamycin Cap 300MG belonging to Resident #8, 1 Lorazepam 1mg tablet, 1 Acetaminophen-Codeine #3 tablet belonging to Resident #10, 1 Phenobarbital Tab 60MG, and 1 Hydrocodone/APAP Tab ,d+[DATE]MG belonging to Resident #11. Observation and review of Resident #8's Individual Patient's Antibiotic Usage Record on [DATE] at 10:39AM revealed no documentation of the administration of 1 Clindamycin Cap 300MG on [DATE] by LVN A. Observation and review of Resident #10's Controlled Substance Record on [DATE] at 10:39AM revealed no documentation of Lorazepam 1mg tab on [DATE]. Observation and review of Resident #11's Individual Patient's Controlled Substance Record on [DATE] at 10:40AM revealed no documentation of the administration of 1 Hydrocodone/APAP Tab ,d+[DATE]MG on [DATE] by LVN A. Observation and review of the Med Cart Controlled Drugs-Audit Record for February 2025 on [DATE] at 10:49AM showed LVN A signed the audit record on [DATE] at 6AM which indicated the narcotic count was correct when she accepted the cart and assumed her shift. LVN A signed the audit record on [DATE] at 2PM which indicated the narcotic count was correct when she and accepted the cart from herself. LVN A signed the audit record on [DATE] at 10PM which indicated the count was correct. Observation and review of the Med Cart Controlled Drugs-Audit Record for February 2025 on [DATE] at 10:49AM showed LVN A failed to audit the Med Cart Controlled Drugs before she assumed her shift at 6AM in that LVN A failed to sign the audit record. LVN A was also observed to have signed the audit record during the medication cart audit in an effort to conceal her lack of documentation, however, LVN A signed the audit record incorrectly as the nurse going off duty at 2PM and then again on duty at 10PM. Observation of treatment cart audit for North Hall with LVN C conducted on [DATE] at 10:51AM revealed no discrepancies. Observation of treatment cart audit for East Hall with LVN B conducted on [DATE] at approximately 10:53AM revealed no discrepancies. Observation of med cart audit with LVN A on [DATE] at 10:55AM revealed 2 Fentanyl Transdermal Patches contained in the prescription box belonging to Resident #14. Observation and review of Resident #14's Controlled Substance Administration Record on [DATE] at 10:55AM revealed LVN A documented the administration of 1 Fentanyl 12MCG/HR Patch on [DATE] at 12PM, leaving 1 remaining. In an interview with LVN A on [DATE] at 10:55AM, she admitted she documented the administration of a Fentanyl Patch for Resident #14 on the Medication Administration Record but did not actually administer the medication or sign out the medication. She stated documenting the administration of medications before they are actually given is a bad habit. LVN A stated Resident #14 was a hospice patient who was sleeping hard. She did not want to disturb him. LVN A said she should have documented that she was unable to administer the medication and that she would re-check the resident in 30 minutes. The negative outcome that could have resulted was inaccurate documentation and unaccounted for medications. LVN A stated that she had been in-serviced on this topic some in the past 3 months, In an interview with LVN A on [DATE] at approximately 11AM, she admitted that she had pre-poured the 3 cups of medication found and acknowledged the cups contained narcotics. LVN A said that she has been in-serviced on this issue. She said she is never to pre-pour medications. LVN A stated she believed doing it this way saved tome and was more efficient. She said she recognized now this is why the facility is in the situation it's in. LVN A also admitted that the missing signature on the med cart log was Her's. Observations and/or interviews were conducted on [DATE] from 12:52PM until 1:39PM, of Resident #5, #8, #9, #10, #11, #12, #14, and #19. Of those residents that were able to be interviewed, none expressed complaints or issues. All believed they received all medications and treatments as ordered. All expressed satisfaction with their treatment by staff at the facility and denied being subjected to any form of abuse or neglect. Observations of those residents unable to be interviewed revealed no concerns for the residents, their environment, or their state of being. No residents were observed to be in distress or unhappy. Review of Employee Disciplinary Report dated [DATE] stated LVN A was placed on investigatory suspension pending investigation into allegations of medication error. Review of 1:1 In-service Record on Medication Administration Procedure with LVN A on [DATE] stated, Under no circumstance are we to ever preset meds. When you pop a narcotic or any other medication that requires counting you must sign out for that medication right after you pop the medication. Review of statement written by LVN A on [DATE], indicated an admission by LVN A to pre-filling 3 residents' 11:00AM meds. LVN A stated she did this to save time. She stated that she had been in-serviced many times about setting up meds. LVN A also admitted that she did not sign the narcotic sheets as she was punching out each med. She stated she waits until she is done with med pass to sign the narcotic sheets. Review of LVN A's personnel file on [DATE], at 3:51PM revealed as of [DATE] LVN A holds a current LVN license with no restrictions. LVN A was also a CNA whose certification expired on [DATE] and who was not listed in the Employee Misconduct Registry. LVN A's personnel file included an In-Service Training dated [DATE] on the topic: No setting up medications prior to giving them. The in-service showed to be a 1:1 in-service in that LVN A was the only employee in attendance with DON, ADON, and ADM listed as the instructors. LVN A's personnel file showed

Based on interview, and record review the facility failed to ensure medical records were complete and accurate in accordance with accepted professional standards and practices when the facility to maintain a correct medical record for 1of 1 resident (resident #2) reviewed for diet orders. Evidence supports the resident medical record was not accurate. The facility failed to ensure Resident #2 had an accurate medical record when the physician signed an incorrect diet order for a pureed diet that the resident wasn't getting and did not need. This failure could place residents at risk of getting insufficient nutrition with the wrong diet order which could have diminished her physical and psychosocial well-being. Findings include: Review of Resident #2's undated face sheet reflected that she was a [AGE] year-old female admitted with diagnoses of Malnutrition, Encephalopathy, Chronic Ulcer of Right Calf, Chronic Kidney Disease, Dementia and Anemia. Review of 7/29/24 of Resident #2's Quarterly MDS reflected her BIMS score was 99, which indicates they could not fully evaluate her cognitive abilities. Review of resident #2's 7/5/24 Care Plan reflected she was on a pureed texture diet order with a goal to maintain weight and proper nutrition. The care plan also reflected in the Activities of Daily Living section that on 5/31/24 an intervention was initiated that she required one staff assisting her for eating. Review of Resident #2's orders reflected a diet order on 6/8/24 of a Regular Diet, Pureed Texture, Regular Consistency. The order was signed by PCP on 6/10/24. In an interview on 7/30/24 at 12:20 pm, the LVN stated that on 7/27/24 resident #2 ate whole pieces of shrimp that her family had brought to her. She stated that she thought the resident was on a regular soft diet and that she had never seen the resident eat a pureed diet. In an interview on 7/30/24 at 12:55 with the DS, she stated that resident #2 has received a Regular diet with regular texture (not pureed) for the whole time she has been at the facility. She further stated that she thinks the pureed diet order was an error and that the resident can also feed herself without assistance. In an interview on 7/30/24 at 1:15 pm with PCP regarding the Regular pureed diet order signed on 6/10/24 by PCP, he stated that he was not familiar with the patient as he has so many patients, he can't remember them all. He was not sure if he had seen the resident. He referred surveyor to speak to his Nurse Practitioner. In an interview on 7/30/24 at 1:48 pm the NP stated, the pureed diet was not a diet she would have ordered and that it must have come from when the resident was in the hospital. She further stated that she had seen the resident eating and the correct order for this resident would have been a regular diet with regular texture (not pureed). She also stated the resident was able to feed herself without assistance. In an interview on 7/30/24 at 2:12 pm with the CNA, she stated on 7/27/24 at 3:00 pm resident #2 was eating rice with bite size shrimp. She further stated that she had never seen the resident eat anything, but regular texture diet and she had no problem feeding herself. In an interview on 7/30/24 at 2:30 pm with the ADM she stated, the policy was to serve the diet as ordered by the physician. She also stated that now she was aware that Resident #2 had a Regular pureed diet ordered but was getting a Regular diet with regular texture instead. The ADM stated the negative outcome to an incorrect diet can be as severe as death. In an interview on 7/30/24 at 2:59 pm with the DON she stated, the policy was to serve the diet as ordered and to check the food against the diet order. She further stated that she knew Resident #2 had a pureed diet order but didn't know until now that she wasn't getting that diet. She stated the negative outcome to an incorrect diet can be choking and aspiration (food going into the lungs). In an interview on 7/30/24 at 3:10 pm with the ADON he stated, the policy on serving the diet was that the food should be checked and verified when passing the food to the residents. He stated that he knew resident #2 had a pureed diet ordered but he was not sure what was served to her. He stated the negative outcome to an incorrect diet can be aspiration (food going into the lungs). Record Review of the facility policy titled, Diet Orders/Diet Manual and dated 2012, reflect The Physician will prescribe diets in accordance with the approved Diet Manual and a written order must appear on the medical record before the resident can be served.

Based on interview, and record review the facility failed to implement a policy that is in accordance with the State Medicaid Plan to allow a resident to return to his previous room upon discharge from the hospital for 1 of 1 resident reviewed for discharges. The facility failed to ensure Resident #1 received the services required when they failed to allow Resident #1 to return to the facility after his hospitalization and they failed to appropriately notify the resident, his representative, and the LTC Ombudsman of the discharge. This failure placed residents at risk of an extended, unnecessary hospitalization and a traumatic psychosocial adjustment to a new facility. Findings include: Record review of Resident #1's undated face sheet, reflected he was an [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of Alzheimer's, Urinary Tract Infection, Muscle Weakness, Bipolar (mental illness), and Restlessness and Agitation. He was discharged to the hospital on 6/23/24 to be evaluated for urinary tract infection and behavior. Record review of Resident #1's Quarterly MDS reflected a BIMS score of 4, which indicated the resident's cognition was severely impaired. Record review of Resident #1's Care Plan, reflected a Focus area was initiated for potential for delirium or an acute confusion episode on 12/18/23. In an interview on 7/29/24 at 11:05 a.m., the ADM stated, Resident #1 was not at the facility because he went to the hospital. The ADM stated that she discussed with his family member that it would be best if he did not come back to the facility because she did not want a pattern of abuse from resident to resident. The resident had been aggressive twice with other residents. The ADM stated, the facility would have taken him back; however, his family member understood and found another place. In a telephone interview on 7/29/24 at 3:54 p.m. Resident #1's family member stated, she was told by the ADM that Resident #1 could not return to the facility from the hospital, due to his aggressiveness. She also stated the discharge planner at the local hospital was also told that the facility would not allow the resident to return. In a telephone interview on 7/29/24 at 4:03 p.m. with the local hospital discharge planner stated there were multiple notes documented at the hospital stating that the emergency room , the family member and the case managers were told that the resident could not return to the nursing facility. She agreed to provide the notes to the state. In an interview on 7/30/24 at 12:01 pm DON stated, 'We told the daughter we would lie to place the resident elsewhere, but we would take him back. There is no paperwork (discharge or bed release) because daughter agreed to find him another place. In an interview with OM the business office manager on 7/30/24 at 1:00 pm, she stated there is no discharge paperwork for Resident #1. A record review of the hospital documentation on Resident #1, reflected that the facility refused to allow Resident 1 to return to the facility from the hospital: Note on 6/24/24 9:11 a.m. emergency room nurse reflected, Called the nursing home to update on plan of care - talked to Assistant Director of Nurses, Director of Nurses, and Administrator (ADM) and explained situation, The ADM said the pt has had two offenses for aggression and cannot return to facility. Informed that we would have to explore placement at another NH. Note on 6/24/24 10:19 a.m. by resident's doctor reflected, Nursing home reported that they could not take care of him anymore and refused to take him back. Patient is intermittently confused. Patient aggressive with staff at nursing home and was refused back there. Left in our ER. Note on 6/24/24 1:50 p.m. Discharge Planner's notes reflected, Resident's family member is aware that the facility has stated Resident #1 cannot return the facility he came from. Note on 6/24/24 2:13 p.m. Case Manager's notes reflected, Received call from another local nursing home; they are able to accept patient and report he can come today Resident was discharge to an alternate facility on 6/25/24 (2-days hospitalization ). A record review of the facility policy named, Nursing Facility Resident Rights dated November 2021 reflects on page 3 of 4, residents have the right to receive a 30-day written notice sent to them, their legally authorized representative or a family member for transfers or discharges.

Based on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident (resident #2) reviewed for care plans. The facility failed to ensure Resident #2 had a care plan to reflect the accurate diet she was on. Resident #2 was care planned for pureed textured diet when she was receiving regular diet. This failure could place residents at risk of getting insufficient nutrition with the wrong diet order which could have diminished her physical and psychosocial well-being. Findings include: Review of Resident #2's undated face sheet reflected that she was a [AGE] year-old female admitted with diagnoses of Malnutrition, Encephalopathy, Chronic Ulcer of Right Calf, Chronic Kidney Disease, Dementia and Anemia. Review of 7/29/24 of Resident #2's Quarterly MDS reflected her BIMS score was 99, which indicates they could not fully evaluate her cognitive abilities. Review of resident #2's 7/5/24 Care Plan reflected she was on a pureed texture diet order with a goal to maintain weight and proper nutrition. The care plan also reflected in the Activities of Daily Living section that on 5/31/24 an intervention was initiated that she required one staff assisting her for eating. Review of Resident #2's orders reflected a diet order on 6/8/24 of a Regular Diet, Pureed Texture, Regular Consistency. The order was signed by PCP on 6/10/24. In an interview on 7/30/24 at 12:20 pm, the LVN stated that on 7/27/24 resident #2 ate whole pieces of shrimp that her family had brought to her. She stated that she thought the resident was on a regular soft diet and that she had never seen the resident eat a pureed diet. In an interview on 7/30/24 at 12:55 with the DS, she stated that resident #2 has received a Regular diet with regular texture (not pureed) for the whole time she has been at the facility. She further stated that she thinks the pureed diet order was an error and that the resident can also feed herself without assistance. In an interview on 7/30/24 at 1:15 pm with PCP regarding the Regular pureed diet order signed on 6/10/24 by PCP, he stated that he was not familiar with the patient as he has so many patients, he can't remember them all. He was not sure if he had seen the resident. He referred surveyor to speak to his Nurse Practitioner. In an interview on 7/30/24 at 1:48 pm the NP stated, the pureed diet was not a diet she would have ordered and that it must have come from when the resident was in the hospital. She further stated that she had seen the resident eating and the correct order for this resident would have been a regular diet with regular texture (not pureed). She also stated the resident was able to feed herself without assistance. In an interview on 7/30/24 at 2:12 pm with the CNA, she stated on 7/27/24 at 3:00 pm resident #2 was eating rice with bite size shrimp. She further stated that she had never seen the resident eat anything, but regular texture diet and she had no problem feeding herself. In an interview on 7/30/24 at 2:30 pm with the ADM she stated, the policy was to serve the diet as ordered by the physician. She also stated that now she was aware that Resident #2 had a Regular pureed diet ordered but was getting a Regular diet with regular texture instead. The ADM stated the negative outcome to an incorrect diet can be as severe as death. In an interview on 7/30/24 at 2:59 pm with the DON she stated, the policy was to serve the diet as ordered and to check the food against the diet order. She further stated that she knew Resident #2 had a pureed diet order but didn't know until now that she wasn't getting that diet. She stated the negative outcome to an incorrect diet can be choking and aspiration (food going into the lungs). In an interview on 7/30/24 at 3:10 pm with the ADON he stated, the policy on serving the diet was that the food should be checked and verified when passing the food to the residents. He stated that he knew resident #2 had a pureed diet ordered but he was not sure what was served to her. He stated the negative outcome to an incorrect diet can be aspiration (food going into the lungs). Record Review of the facility policy titled, Diet Orders/Diet Manual and dated 2012, reflect The Physician will prescribe diets in accordance with the approved Diet Manual and a written order must appear on the medical record before the resident can be served.

Based on observations, interviews and record reviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #7) of seven residents reviewed for quality of care. The facility failed to ensure Resident #7 was transferred using a gait belt on [DATE] that resulted in a 10th rib fracture and pneumothorax This failure could place residents at risk of accidents and injuries. The findings included: Record Review of progress notes dated [DATE] revealed, Resident #7 was transferred with one staff assistance without a gait belt from her bed to her wheelchair by CNA A. Student nurse aide reported resident had no complaints of discomfort during transfer. Resident was taken to dining room for breakfast and during breakfast she complained of pain to left shoulder/arm and generalized chest. NP was notified and ordered x-ray to chest, left arm and left shoulder. Observed 2 staff transfer with Hoyer lift on [DATE] @ 11:00 am. No issues noted with transfer procedure. Observed 1 staff transfer using gait belt on [DATE] @ 11:33 am. No issues noted with transfer procedure. Record review of report on Resident #7 from All-Stat dated [DATE] reflected x-ray of left forearm study was within normal limits. Report of left shoulder x-ray reflected no acute injuries or complications associated with the existing shoulder arthroplasty. Report of x-ray to ribs, bilateral, with posteroanterior chest, 4 views revealed suspicious fracture of the posterior aspect of the right 10th rib following trauma. Clinical correlation and further imaging, if symptomatic are recommended for confirmation and management. Small right lower lobe pneumothorax, likely related to trauma. Close monitoring or further evaluation may be necessary depending on the clinical presentation and symptoms. Linear atelectasis in the basal segment of the left lower lobe, possibly due to minor lung compression or reduced air entry. Clinical evaluation for underlying causes or contributary factors is suggested. Record Review of progress notes dated [DATE] revealed, after receipt of x-ray report of right-side 10th rib fracture and small pneumothorax resident was transported to ER then via air lift to Parkland Hospital due to local hospitals being on divert, for further evaluation. Frontal chest radiograph revealed: 1. The eighth right rib is not completely visualized. Cannot rule out a fracture at this location. Recommend correlation with point tenderness. In addition, patient positioning makes evaluation of the lower right ribs difficult. Recommend dedicated right rib radiographs if there is continuing clinical concern. 2. No obvious pneumothorax. 3. Bronchial wall thickening and interstitial prominence, nonspecific, but can be seen with pulmonary edema, reactive airway disease, or viral infection. Component of chronic interstitial disease cannot be excluded. 4. Left basilar atelectasis. Blunting of the left costophrenic angle may be due to trace effusion or pleural scar. No additional recommendations. Xray of right ribs on [DATE] revealed Suspected subtle nondisplaced fracture of the posterior right 11th rib. Suggest correlation with area of tenderness. The attending physician note stated, upon arrival patient is pleasant and denying medical complaints aside from mild cough which she states she has had for several weeks. Of note patient is a poor historian with baseline dementia, EMS reports that she is in a wheelchair however she reports she is ambulatory. Patient does not recall any trauma to the chest or any part of her body. Musculoskeletal General: no swelling; Cervical back: normal range of motion; Comments: No obvious point tenderness to the thoracic chest, no skin changes. Resident was also diagnosed with a urinary tract infection. ER report stated, Upon assessment pt noted to have nonproductive cough. Pt endorsing pain with deep inhalations during assessment RLL noted to be diminished. Pt currently denies CP, abd pain, NVD, neuro concerns. Resident was transferred from Parkland back to facility on [DATE] at 12:33 am. Record review of Resident #7's facility face sheet dated [DATE] indicated Resident #7 was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #7 had a BIMS of 03 indicating severely impaired cognition. MDS indicated Resident #7 was dependent on chair/bed-to-chair transfers. It did not indicate how many staff required for transfers. It stated, Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. Review of Quarterly MDS for Resident#7 dated [DATE] revealed the resident was dependent with 1- or 2-person transfer. Record review of the comprehensive care plan initiated [DATE] with revision of transfers on [DATE] indicated Resident #7 was at risk for falls and required assist of two staff with Hoyer lift transfers. Review of Care Plan on Resident #7 dated [DATE] and revised on [DATE] reflected resident is at risk for falls with interventions for one staff to assist with transfers. Review of records dated [DATE] for Resident #7 indicated head to toe assessment was completed on all sixteen residents that require transfer assist and care plans of each of those residents reflected transfer status. Review of Inservice records dated [DATE] reflected training provided to all staff regarding abuse and neglect; how to use Kardex; and Moving a Resident, Bed to Chair/Chair to Bed Transfers, Gait Belt Transfers. Review of personnel record reflected disciplinary action for CNA A for improper transfer was initiated on [DATE]. Staff suspension removed following one on one inservice on proper transfers/using gait belt, using Kardex correctly and abuse & neglect dated [DATE] Record review of the CNA Proficiency Audit dated [DATE] indicated CNA A was observed and was competent on transfers. Record review of therapy records for Resident #7 indicated no therapy evaluation for accuracy of transfer assistance was completed due to rural area of facility not physical therapy available. Record review of weekly audits to focus on s/s of staff performing duties in a neglectful manner, interview staff about observing transferring without gait belt, interview residents about staff using gait belt with transfers, and observe 10 ADL's were completed from [DATE] through [DATE]. Record review of MAR for Resident #7 dated [DATE] through [DATE] reflected resident had Tylenol with Codeine #3, ,d+[DATE]mg one tablet by mouth scheduled twice daily. She was also ordered Tylenol with Codeine #3 on [DATE], one tablet by mouth every 8 hours as needed for pain for 14 days. Do not exceed 2600 mg in 24 hours. No as needed pain medications were given from [DATE] through [DATE]. Record review of injury nurses notes on Resident #7 dated [DATE] through [DATE] indicated resident was assessed each shift for ADL decline, pain and change in condition requiring physician notification due to fracture and no changes had occurred. During an interview on [DATE] at 1:05 pm, CNA A said she was a student nurse aide and she transferred Resident #7 as a one person assist. She said she was trained on the use of a gait belt for transfers but did not have one available at that time. She said she should not have had the resident hug her around the neck and pull her to a standing position by the waist of her pants. She reported the resident never hollered, showed discomfort or anything at that time. She said she should have placed a gait belt around the resident to transfer properly. During an interview on [DATE] at 2:58 pm, the DON said it was facility's policy to use a gait belt for transfers. She said the nursing administration was responsible to ensure training was completed for all staff regarding proper transfer techniques. She said all staff were trained on hire, annually, with any incident or change in status on transfers. She said she was responsible for competency checks for the nurses and aides. She said that CNA A was trained on proper transfer technique using a gait belt and Resident #7 required a one person assist with a gait belt for all transfers at that time. She reported the care plan was updated on [DATE] to reflect that Resident #7's transfer status changed and required two staff and Hoyer lift for transfers. She said that each resident had a care plan regarding their transfer status and the aides were aware of each resident's transfer needs. She said if a resident were not properly transferred it could result in injury. She said she expected all staff to transfer residents properly according to policy. Interview with Resident #7 on [DATE] at 3:30 pm. She was pleasant and said she was doing ok. She said that no one in the facility had ever hurt or mistreated her and she felt safe. When asked how the food was, she was confused. When asked if the cooks were good, she said, No he died , and I don't cook. She said she goes to the church for lunch, and she feels ok. Resident requested help to straighten her legs and wanted to go to dinner. Interview with NP on [DATE] at 3:40 pm who reported resident has history of upper respiratory infections with cough. She reported she suspects the fractures that were noted on x-rays were more likely to be caused due to coughing rather than due to the transfer from bed to wheelchair but cannot be certain. Record review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed dated 2003 indicated, .Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable .

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 2 residents (Resident #5) and 1 of 2 staff (CNA A) reviewed for incontinent care as indicated by: The facility failed to ensure CNA A washed or sanitized her hands while going from a dirty to clean surface when performing incontinent care on Resident #5. This deficient practice placed residents at risk for cross contamination and the spread of infection. Findings included: Record Review of Resident #5's face sheet dated 02/28/24 reflected Resident #5 was an [AGE] year-old female with an admitted [DATE]. Resident #5's diagnoses included dementia (disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease), cerebrovascular disease (a variety of medical conditions that affects the blood vessels of the brain and the cerebral circulation, anxiety (an emotion characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), and hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated). Record Review of the most recent quarterly MDS assessment dated [DATE] reflected Resident #5 had a BIMS score of 99 indicating Resident #5 was cognitively impaired and not able to complete the interview successfully. MDS reflected resident was always incontinent of bladder and frequently incontinent of bowel. Record review of Residents # 5's care plan dated 08/16/23 reflected resident had bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Incontinent care at least q2h and apply moisture barrier after each episode. Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Monitor/document/report to MD PRN possible medical causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. Record review of Residents # 5's care plan dated 08/16/23 reflected resident had bowel incontinence. Goal: The resident will not have any complications r/t bowel incontinence. Interventions: Apply barrier cream after every incontinent episode. Check resident every two hours and assist with toileting as needed. Provide peri care after each incontinent episode. Report any skin change to the nurse immediately. In an interview on 02/26/24 at 11:23 AM with Resident #5, she stated she was doing fine, and staff treated her well and were really good. She stated staff took good care of her and she got her showers and medications like she was supposed to. She stated staff checked on her frequently and they always helped her when she needed it. In an observation on 02/27/24 at 09:35 AM of incontinent care that was performed by CNA A and CNA B for Resident #5, CNA A did not properly sanitize her hands in between a dirty and clean surface. CNAs A and B washed their hands, applied their gloves, and began incontinent care for Resident #5. CNA B was assisting Resident #5 with turning while CNA A cleaned Resident #5's front side and then back side. CNA A removed and discarded Resident #5's brief. CNA A then placed a clean brief on Resident #5 without washing or sanitizing her hands or doffing or changing gloves in between. In an interview on 02/27/24 at 10:45 AM with CNAs A and B, CNA A stated she did not wash or sanitize her hands when going from a dirty to clean surface when Resident #5's brief was changed. They stated they had been trained on incontinent care and infection control but had not been told specifically to wash or sanitize hands during brief change when going from a dirty to clean surface. They stated they were aware they should wash their hands when going from a dirty to clean surface but did not think of the incontinent care that way. They stated if they did not wash or sanitize their hands when going from a dirty to clean surface, it could cause cross contamination and a risk of transferring infection. In an interview on 02/28/24 at 09:01 AM with the ADM, she stated it was the facility's policy for staff to wash or sanitize their hands when going from a dirty to clean surface. She stated hand hygiene should have been performed during incontinent care after any resident was cleaned and any dirty linens or brief was removed. She stated staff had been in-serviced on infection control and hand washing. She stated if staff did not wash or sanitize their hands when going from a dirty to clean surface, it could cause the spread of infection. In an interview on 02/28/24 10:17 AM with the DON, she stated it was the facility's policy for staff to wash or sanitize hands when going from a dirty to clean surface. She stated hand washing or sanitizing hands should have been performed during incontinent care after cleaning a resident and discarding dirty linens or brief's and before applying clean briefs or linens. She stated staff had been in-serviced on infection control and hand hygiene. She stated if hand hygiene or sanitizing was not performed during incontinent care or when going from a dirty to clean surface, it could cause an infection. Record Review of the facility policy titled Section - Personal Care - Perineal Care dated as created 04/25/22 and effective 05/11/22, provided by the ADM, revealed the following: An incontinent resident of urine and/or bowel should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible; It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations. Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Procedure content: Start - 10) Perform hand hygiene, 11) [NAME] gloves and all other PPE per standard precautions, 17) Gently perform perineal care, wiping from clean, urethral area, to dirty rectal area, to avoid contaminating the urethral area - CLEAN TO DIRTY!, 24) Doff gloves and PPE, 25) Perform hand hygiene, 26) Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and brief(s), . Record review of the undated facility policy titled Hand Hygiene, provided by the ADM, revealed the following: You may use alcohol based hand cleaner or soap/water for the following: Before and after assisting resident with personal care (e.g., oral care, bathing); Upon and after coming in contact with a resident's intact skin; After contact with a resident's mucous membranes and body fluids or excretions; After handling soiled or used linens, dressings, bedpans, catheters and urinals; After removing gloves or aprons.

Based on observation, interviews, and record review the facility failed to store, distribute, and serve food in accordance with professional standards for one of one kitchen, in that: The facility failed to: A.) Label, date, and store food properly in Refrigerator A, Refrigerator B, Refrigerator C and Refrigerator D. B.) Monitor the temperature of and PH of the dish washer regularly. These failures could place residents who were served from the kitchen at risk for foodborne illnesses and health complications. Findings included: A.) Observation on 09/19/2021 at 9:42 AM of Refrigerator A revealed a large plastic zipped bag containing four cut blocks of cheese without a label or date. Observation on 09/19/2021 at 9:43 AM of Refrigerator B revealed a large plastic zipped bag containing five corn bread rolls with a label but no date on the label. Observation on 09/19/2021 at 9:44 AM of Refrigerator C revealed two medium sized plastic containers with jelly inside of each with no label or date. Observation on 09/19/2021 at 9:45 AM of Refrigerator D revealed six (name brand) dairy drink containers with only five containers having received dates written on the containers. During an interview on 09/19/2021 at 9:50 AM with the DM, she said all items in the refrigerator should be dated and labeled. Review of the facility's Food Receiving and Storage Policy, revised December 2012, reflected the following: Policy Statement: Food must be covered when stored, with a date label identifying what is in the container. B.) Observation on 9/19/21 at 9:45 AM, revealed the temperature and PH log for the dishwasher had not been filled out from 9/11/21 - 9/18/21. During an observation and interview on 9/19/21 at 11:00 AM with the DM, she acknowledged the temperature and PH logs for the dishwasher and stated it appeared her staff had not been testing the temperature or PH while she had been gone. She stated the temperature and PH were to be tested three times a day to ensure dishes were getting appropriately cleaned. Observation on 9/19/21 at 4:22 PM revealed the temperature and PH level log for the dish machine had been already filled out for 9/20/21. Review of the facility's Temperature/Chemical Log Policy, revised December 2012, reflected the following: DSM will be the person responsible for making sure the Temperature/Chemical Log is completed daily.

Based on observation, record review and interview the facility failed to ensure the daily nursing staffing was posted as required for three of three days (9/19/21, 9/20/21, and 9/21/21) reviewed for nurse staffing information, in that: The facility did not post the total number and the actual hours worked by licensed and unlicensed nursing staff on 9/19/21, 9/20/21, and 9/21/21. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census. Findings included: Observation of postings in the facility on 9/19/2021 at 10:09 AM, revealed no posting of daily nurse staffing information. Observation of postings in the facility on 9/20/2021 at 2:22 PM, revealed no posting of daily nurse staffing information. Observation of postings in the facility on 9/21/2021 at 11:14 AM, revealed no posting of daily nurse staffing information. During an observation and interview on 9/20/21 at 2:45 PM with the DON, she stated they kept their nurse staffing information sheet in a binder at the nurse's station. She opened the binder to reveal their nursing staffing information. She stated that was just how they had always done it. During an interview on 9/21/21 at 12:15 PM with the ADM and RDO, the RDO stated her expectations were that the daily nurse staffing information was posted in a visible spot where it could be seen by families, visitors, and residents. She stated she was unaware it was not posted and was stored in a binder instead. Review of the facility's undated Mandatory Posting check-off sheet reflected Daily Staffing by shift of Licensed and Unlicensed Nursing Staff should be posted.

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of eight residents reviewed for falls. The facility failed to supervise Resident #1, who was paralyzed from the waist down, while he was showering in the shower room. The resident fell when the shower chair slid from under him, which resulted in two fractures in his left leg. This failure had the potential to affect the 18 residents residing in the facility who may use the shower room allowing them to potentially harm themselves. Findings included: Review of Resident #1 face sheet on [DATE] reflected Resident is a [AGE] year old male who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Resident is his own responsible party. The Minimum Data Set (MDS) assessment conducted on [DATE] reflected the resident was cognitively aware. He required the limited physical assistance of one person with dressing and he was totally dependent on staff for bathing. Mobility device used was a wheelchair. Resident #1 was paralyzed from the waist down. Review of Resident's fall event report created by LVN C on [DATE] at 6:48 PM reflected the resident slid down in the shower on [DATE] at 5:50 PM. Review of Resident's Progress Report for the month of [DATE] reflected that Resident #1's fall was not documented Progress Report for [DATE] reflected that on [DATE] the resident complained of swelling in his left knee and lower left leg. He stated he felt something move inside when he moved his leg. The NP was notified and an X-ray was ordered. The X-ray results reflected fractures of his tibia (biggest bone in lower leg that bears weight) and fibula (smaller of the two bones between the knee and ankle). The NP, ADMIN, and DON were notified. An order was received to send Resident #1 to the local ER for evaluation and treatment of [REDACTED]. Review of Resident #1's hospital radiology report dated [DATE] reflected bone broken into pieces of the upper tibia and fibula and arthritis of the knee joint and soft tissue swelling. Observation on [DATE] at 10:00 AM revealed Resident #1 lying in bed watching television. Resident #1 revealed that two to three weeks ago he fell in the shower room. He stated the incident occurred around dinner time after he stopped a HA in the hallway and told her he wanted to take a shower. He said she unlocked the door and he went in unassisted. Resident #1 revealed he transferred himself from his wheelchair to the shower chair. When he bent down to retrieve a towel from the floor, the shower chair slid from under him causing him to fall on his left side. He stated he was too far away from the call light string to get help; therefore he started screaming until an aide (unknown name) came in. He said that shortly after, LVN C and another aide came in the room. Resident #1 revealed the aides steadied the shower chair and he transferred himself from the floor to the shower chair. He stated he was asked if he hit his head and he stated that he did not. He was informed that the blood observed was from his toe. Interview with Resident # 1 on [DATE] at 12:00 PM revealed when he was first admitted to the facility on e of the aides would supervise him while he was in the shower, but that when she started working on the memory care unit, no one would go in with him. He stated that when a staff member was in the shower room with him, they would wrap the call bell string around a pole so that it was reachable. He also revealed the staff would also ensure the shower chair was in good working condition and was locked, and watch him transfer from his wheelchair to the shower chair before they stepped out. Resident stated that he guess he just forgot to put the brakes on that day. Interview with Resident #1 on [DATE] at 5:33 PM Resident revealed they increased his pain medication while he was in the hospital and told him that they were going to put a splint on his leg. Resident stated that when he came back to the facility he was told he could not shower alone anymore. Resident #1 revealed he went to the doctor yesterday, he was informed that they were going to allow his leg to heal deformed due to him being paralyzed. An interview with HA E on [DATE] at 2:26 PM revealed Resident #1 approached her on the [DATE] around 4:30 or 5:00 PM and told her that he wanted to take a shower. She stated he asked if she would unlock the door. HA E revealed she let the resident in the shower room and told him she would get an aide to assist him. She said he told her No, I shower by myself. HA E stated that a little while later she heard screaming from the shower room and when she entered, she found the resident on the floor. HA E revealed she exited the shower room and went to get LVN B and CNA F. She stated she and CNA F entered the shower room and the resident asked them to hold the chair while he transferred himself from the floor to the chair. HA E stated then LVN B came in A telephone interview with CNA F on [DATE] at 3:21 PM revealed she was the only aide on the floor when the fall happened. She stated that she went and got the nurse. Then she and another aide went back into the shower room, where they stabilized the shower chair while Resident #1 transferred himself from the floor to the chair and continued his shower after he was assessed by the nurse. CNA F revealed the resident had always showered alone. An interview with RA D on [DATE] at 2:12 PM revealed while she was on lunch break on [DATE], she was informed that Resident #1 fell and was on the floor of the shower room. RA D revealed went to the shower room where she found other staff (LVN C, CNA F, and HA E) in the shower room with the resident. She stated Resident #1 was already back in the shower chair when she arrived. The resident did not complain of pain, but his toe was bleeding. RA D revealed the resident stayed in the shower room for about two hours after the incident. RA D revealed she saw Resident #1 the next week when she was passing meds and she asked him if he was getting out of bed and he said he would. A telephone interview with LVN C on [DATE] at 3:58 PM revealed on [DATE] she clocked in about 15 minutes before her shift began. She stated she was at the nurse's station with LVN B when an aide (unknown name) told them that a resident had fallen in the shower. LVN C stated she asked why he was in the shower by himself at that time of day and on a Sunday. She revealed she entered the shower and Resident #1 was on his bottom on the shower floor. She stated she asked him if he hit his head and he responded no. She stated she looked him over and saw that blood was coming from his toe. LVN C revealed Resident #1 transferred himself into the shower chair and wanted to continue his shower. She stated that later that night she treated his toe. She stated Resident #1 never complained of pain that night or the following weekend when she was on duty. She stated his leg never looked swollen to her. When asked what happened after a resident fell , LVN C revealed a fall observation sheet was completed and the fall was documented. She stated if the resident hit their head, neuro checks were conducted. When asked who assessed Resident # 1 after the fall, LVN C responded I guess I verbally assess him. A telephone interview with LVN B on [DATE] at 3:06 PM revealed she was working on [DATE] and revealed that five minutes before her shift ended an aide came to the nurse's station and informed her and LVN C that a resident fell in the shower room. LVN B revealed LVN C and the aide went into the shower room and she remained at the nurse's station where she was charting. She stated when she finished charting, she stuck her head in the shower room to see if she was needed and LVN C told her no. LVN B stated when she came in on [DATE] Resident #1 told her that when he used his hands to move his leg he could feel something moving around. LVN B stated she informed the DON and x-rays were ordered. She revealed it was discovered Resident #1 had fractures in his left knee. LVN B stated the resident never complained of pain to her. She stated that he had a lot of pain and is on significant pain medication. She also stated he did not complain of swelling to her before that Friday. An interview was conducted with DON on [DATE] at 11:05 PM revealed she did not find out Resident #1 fell in the shower for a couple of days after the incident occurred. She revealed it was brought to her attention by HA E. The DON revealed the nurse who found him failed to report and assess him properly. The DON stated she should have been more meticulous in conducting rounds and talking to resident to ensure that they were being properly cared for. An interview was conducted with Admin on [DATE] at 11:15 AM, revealed that he was informed this past Sunday [DATE] that LVN B felt bones moving in Resident #1's knee and the DON ordered X-ray and that is was when they found out the resident had fractures. The Admin stated the resident fell in the shower on [DATE] and he and the DON were made aware of the fall the next day. The Admin revealed after a fall, an assessment should have been conducted. He stated it was the responsibility of the DON and himself to ensure the event report had been documented and proper procedure was followed. The Admin revealed everyone dropped the ball regarding follow up to ensure a report was taken. An interview was conducted with PT G on [DATE] at 1:26 PM revealed he had worked with Resident #1 for about three weeks and revealed he complained of being in pain, but always said the pain was from the gunshot wound he suffered. The PT revealed that resident did not tell him he fell or was having pain in his knee until [DATE]. An interview was conducted with DON on [DATE] at 3:21 PM and 4:20 PM and revealed she looked in the system and she did not see anywhere that follow up care was given to the resident to ensure he was okay. She stated the facility would ensure that the Resident #1 did not shower alone. When asked if Resident #1 was care planned to take showers without assistance, since his initial MDS assessment reflected he was totally dependent on staff for bathing, the DON revealed she did not see that in his chart. She confirmed that a fall assessment was not conducted nor did anyone follow through with the facility's fall policy, An interview with the DON on [DATE] at 6:22 PM revealed she has found that a lot of the resident's MDS assessment information was not correct and stated that in [DATE] they fired the person who was doing them due to poor work performance. She stated that when the MDS nurse was informed she deleted every care plan she did and medical records. The DON revealed Resident #1 had always showered himself without assistance since he was admitted because he was very independent. Review of the facility's fall assessment policy reflected its purpose was to assess the resident's risk factors related to falls and implement interventions appropriate to prevent injuries. The facility will do a falls risk assessment upon resident ' s admission, readmission, quarterly, and/or when there is a significant change of condition, this form will be kept in the clinical record (assessments section) and will be discussed at each care plan meeting. Facility documentation will reflect all attempts made by the facility to assess and reduce the risk of falling for the resident. If resident has a total score of 10 or greater, the resident should be considered high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. The facilities Abuse Prevention policy (not dated) reflected each resident had a right to be free from abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility developed and implemented a plan containing the seven required components to include identification, reporting, and investigation of allegations of abuse/neglect. The census of 56 was obtained from LVN A during the entrance conference on [DATE] at 9:15 AM.

Based on interviews and record reviews the facility failed to implement its written policy and procedures which prohibits neglect for one (Resident #1) of eight residents reviewed for neglect. LVN C and LVN B (Charge Nurses) failed to follow facility fall policy and DADS self-reporting regulation regarding Resident #1 after they were notified that he had fallen in the shower. This failure resulted in Resident #1 not being properly assessed for 12 days and having two fractures in his left knee go untreated. The resident fell when the shower chair slid from under him, which resulted in two fractures in his left leg. This failure had the potential to affect the 18 residents residing in the facility who may use the shower room allowing them to potentially harm themselves. Findings included: The facilities Abuse Prevention policy (not dated) reflected each resident had a right to be free from abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility developed and implemented a plan containing the seven required components to include identification, reporting, and investigation of allegations of abuse/neglect. Review of Resident #1 face sheet on [DATE] reflected Resident is a [AGE] year old male who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Resident is his own responsible party. The Minimum Data Set (MDS) assessment conducted on [DATE] reflected the resident was cognitively aware. He required the limited physical assistance of one person with dressing and he was totally dependent on staff for bathing. Mobility device used was a wheelchair. Resident #1 was paralyzed from the waist down. Review of Resident's fall event report created by LVN C on [DATE] at 6:48 PM reflected the resident slid down in the shower on [DATE] at 5:50 PM. Review of Resident's Progress Report for the month of [DATE] reflected that Resident #1's fall was not documented Progress Report for [DATE] reflected that on [DATE] the resident complained of swelling in his left knee and lower left leg. He stated he felt something move inside when he moved his leg. The NP was notified and an X-ray was ordered. The X-ray results reflected fractures of his tibia (biggest bone in lower leg that bears weight) and fibula (smaller of the two bones between the knee and ankle). The NP, ADMIN, and DON were notified. An order was received to send Resident #1 to the local ER for evaluation and treatment of [REDACTED]. Review of Resident #1's hospital radiology report dated [DATE] reflected bone broken into pieces of the upper tibia and fibula and arthritis of the knee joint and soft tissue swelling. Observation on [DATE] at 10:00 AM revealed Resident #1 lying in bed watching television. Resident #1 revealed that two to three weeks ago he fell in the shower room. He stated the incident occurred around dinner time after he stopped a HA in the hallway and told her he wanted to take a shower. He said she unlocked the door and he went in unassisted. Resident #1 revealed he transferred himself from his wheelchair to the shower chair. When he bent down to retrieve a towel from the floor, the shower chair slid from under him causing him to fall on his left side. He stated he was too far away from the call light string to get help; therefore he started screaming until an aide (unknown name) came in. He said that shortly after, LVN C and another aide came in the room. Resident #1 revealed the aides steadied the shower chair and he transferred himself from the floor to the shower chair. He stated he was asked if he hit his head and he stated that he did not. He was informed that the blood observed was from his toe. Interview with Resident # 1 on [DATE] at 12:00 PM revealed when he was first admitted to the facility on e of the aides would supervise him while he was in the shower, but that when she started working on the memory care unit, no one would go in with him. He stated that when a staff member was in the shower room with him, they would wrap the call bell string around a pole so that it was reachable. He also revealed the staff would also ensure the shower chair was in good working condition and was locked, and watch him transfer from his wheelchair to the shower chair before they stepped out. Resident stated that he guess he just forgot to put the brakes on that day. Interview with Resident #1 on [DATE] at 5:33 PM Resident revealed they increased his pain medication while he was in the hospital and told him that they were going to put a splint on his leg. Resident stated that when he came back to the facility he was told he could not shower alone anymore. Resident #1 revealed he went to the doctor yesterday, he was informed that they were going to allow his leg to heal deformed due to him being paralyzed. An interview with HA E on [DATE] at 2:26 PM revealed Resident #1 approached her on the [DATE] around 4:30 or 5:00 PM and told her that he wanted to take a shower. She stated he asked if she would unlock the door. HA E revealed she let the resident in the shower room and told him she would get an aide to assist him. She said he told her No, I shower by myself. HA E stated that a little while later she heard screaming from the shower room and when she entered, she found the resident on the floor. HA E revealed she exited the shower room and went to get LVN B and CNA F. She stated she and CNA F entered the shower room and the resident asked them to hold the chair while he transferred himself from the floor to the chair. HA E stated then LVN B came in A telephone interview with CNA F on [DATE] at 3:21 PM revealed she was the only aide on the floor when the fall happened. She stated that she went and got the nurse. Then she and another aide went back into the shower room, where they stabilized the shower chair while Resident #1 transferred himself from the floor to the chair and continued his shower after he was assessed by the nurse. CNA F revealed the resident had always showered alone. An interview with RA D on [DATE] at 2:12 PM revealed while she was on lunch break on [DATE], she was informed that Resident #1 fell and was on the floor of the shower room. RA D revealed went to the shower room where she found other staff (LVN C, CNA F, and HA E) in the shower room with the resident. She stated Resident #1 was already back in the shower chair when she arrived. The resident did not complain of pain, but his toe was bleeding. RA D revealed the resident stayed in the shower room for about two hours after the incident. RA D revealed she saw Resident #1 the next week when she was passing meds and she asked him if he was getting out of bed and he said he would. A telephone interview with LVN C on [DATE] at 3:58 PM revealed on [DATE] she clocked in about 15 minutes before her shift began. She stated she was at the nurse's station with LVN B when an aide (unknown name) told them that a resident had fallen in the shower. LVN C stated she asked why he was in the shower by himself at that time of day and on a Sunday. She revealed she entered the shower and Resident #1 was on his bottom on the shower floor. She stated she asked him if he hit his head and he responded no. She stated she looked him over and saw that blood was coming from his toe. LVN C revealed Resident #1 transferred himself into the shower chair and wanted to continue his shower. She stated that later that night she treated his toe. She stated Resident #1 never complained of pain that night or the following weekend when she was on duty. She stated his leg never looked swollen to her. When asked what happened after a resident fell , LVN C revealed a fall observation sheet was completed and the fall was documented. She stated if the resident hit their head, neuro checks were conducted. When asked who assessed Resident # 1 after the fall, LVN C responded I guess I verbally assess him. A telephone interview with LVN B on [DATE] at 3:06 PM revealed she was working on [DATE] and revealed that five minutes before her shift ended an aide came to the nurse's station and informed her and LVN C that a resident fell in the shower room. LVN B revealed LVN C and the aide went into the shower room and she remained at the nurse's station where she was charting. She stated when she finished charting, she stuck her head in the shower room to see if she was needed and LVN C told her no. LVN B stated when she came in on [DATE] Resident #1 told her that when he used his hands to move his leg he could feel something moving around. LVN B stated she informed the DON and x-rays were ordered. She revealed it was discovered Resident #1 had fractures in his left knee. LVN B stated the resident never complained of pain to her. She stated that he had a lot of pain and is on significant pain medication. She also stated he did not complain of swelling to her before that Friday. An interview was conducted with DON on [DATE] at 11:05 PM revealed she did not find out Resident #1 fell in the shower for a couple of days after the incident occurred. She revealed it was brought to her attention by HA E. The DON revealed the nurse who found him failed to report and assess him properly. The DON stated she should have been more meticulous in conducting rounds and talking to resident to ensure that they were being properly cared for. An interview was conducted with Admin on [DATE] at 11:15 AM, revealed that he was informed this past Sunday [DATE] that LVN B felt bones moving in Resident #1's knee and the DON ordered X-ray and that is was when they found out the resident had fractures. The Admin stated the resident fell in the shower on [DATE] and he and the DON were made aware of the fall the next day. The Admin revealed after a fall, an assessment should have been conducted. He stated it was the responsibility of the DON and himself to ensure the event report had been documented and proper procedure was followed. The Admin revealed everyone dropped the ball regarding follow up to ensure a report was taken. An interview was conducted with PT G on [DATE] at 1:26 PM revealed he had worked with Resident #1 for about three weeks and revealed he complained of being in pain, but always said the pain was from the gunshot wound he suffered. The PT revealed that resident did not tell him he fell or was having pain in his knee until [DATE]. An interview was conducted with DON on [DATE] at 3:21 PM and 4:20 PM and revealed she looked in the system and she did not see anywhere that follow up care was given to the resident to ensure he was okay. She stated the facility would ensure that the Resident #1 did not shower alone. When asked if Resident #1 was care planned to take showers without assistance, since his initial MDS assessment reflected he was totally dependent on staff for bathing, the DON revealed she did not see that in his chart. She confirmed that a fall assessment was not conducted nor did anyone follow through with the facility's fall policy, An interview with the DON on [DATE] at 6:22 PM revealed she has found that a lot of the resident's MDS assessment information was not correct and stated that in [DATE] they fired the person who was doing them due to poor work performance. She stated that when the MDS nurse was informed she deleted every care plan she did and medical records. The DON revealed Resident #1 had always showered himself without assistance since he was admitted because he was very independent. Review of the facility's fall assessment policy reflected its purpose was to assess the resident's risk factors related to falls and implement interventions appropriate to prevent injuries. The facility will do a falls risk assessment upon resident ' s admission, readmission, quarterly, and/or when there is a significant change of condition, this form will be kept in the clinical record (assessments section) and will be discussed at each care plan meeting. Facility documentation will reflect all attempts made by the facility to assess and reduce the risk of falling for the resident. If resident has a total score of 10 or greater, the resident should be considered high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. The census of 56 was obtained from LVN A during the entrance conference on [DATE] at 9:15 AM.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (Resident #1) of eight reviewed for pain. 1. LVN B and LVN C failed to physically assess Resident #1, who was paralyzed from the waist down, after he fell on his left side in shower room on 08/28/2016. On 09/09/2016, Resident #1 complained of pain and swelling to his left knee and it was discovered he had fractures of his left tibia and fibula. This failure could affect all 25 residents by placing them at risk for delayed care and intervention, unrelieved pain, and a decreased quality of life. Findings included: Review of Resident # 1 facesheet on 09/14/2016 reflected Resident was a [AGE] year old male who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Resident is his own responsible party. The Minimum Data Set (MDS) conducted on 06/07/2016 reflected the Resident is cognitively aware. He required the limited physical assistance of a one person with dressing and he was totally dependent on staff for bathing. Mobility device used was a wheelchair. Resident was paralyzed from the waist down. An interview with DON on 09/14/2016 at 6:22 PM revealed she found that a lot of the resident's MDS assessment information was not correct and stated that in July 2016 they fired the person who was doing them due to poor work performance. She stated that when MDS nurse was informed she deleted every care plan she did and medical records. The DON revealed Resident #1 had always showered himself without assistance since he was admitted because he was very independent. Review of Resident #1's care plan does not reflect that he has had any falls or was care planned to take showers unassisted. There were no pain assessments documented for Resident. Review of Resident #1 Medication Administration History Report for 08/01/2016 until 09/14/2016 reflected Resident received the following routine pain medications, [MEDICATION NAME] 1 mg crushed every 8 hours, [MEDICATION NAME] 10 mg. four times a day, [MEDICATION NAME] 72 hours once a day every 3 days, and [MEDICATION NAME] 10-325 mg crushed every 6 hours. Review of Resident #1 PRN Medication Administration History Report for 08/28/2016 until 09/27/2016 reflected Resident received 500 mg. of [MEDICATION NAME] on 09/12/2016 for left wrist pain and rated it somewhat effective. Review of Resident #1's fall event report created by LVN C on 09/10/2016 at 6:48 PM reflected resident slid down in shower on 08/28/2016 at 5:50 PM. Review of Resident 1's Progress Report for the month of August 2016 reflected that Resident's #1 fall was not documented. Progress report for September 2016 reflected that on 09/09/2016 the resident complained of swelling in left knee and lower left leg. He stated he felt something move inside when he moved his leg. NP was notified and X-ray was ordered. The X-ray results reflected fractures of the Resident's tibia (biggest bone in lower leg that bears weight) and fibula (smaller of the two bones between the knee and ankle) . The NP, Admin, and DON were notified. An order was received to send Resident #1 to the local ER for evaluation and treatment of [REDACTED]. Review of Resident #1's hospital radiology report dated 09/09/2016 reflected bone broken into pieces of the upper tibia and fibula. There is arthritis of the knee joint and there was soft tissue swelling. Observation/Interview on 09/14/2016 at 10:00 AM revealed Resident # 1 lying in bed watching television. Resident revealed that two to three weeks ago he fell in the shower room. He stated the incident occurred around dinner time after; he stopped a HA in the hallway and told her he wanted to take a shower. He said she unlocked the door and he went in unassisted. Resident # 1 revealed he transferred himself from his wheelchair to the shower chair. When he bent down to retrieve a towel from the floor, the shower chair slid from under him causing him to fall on his left side. Resident #1 revealed he continued showering taking his braids down and washing his hair unassisted after there fall for an additional two to three hours. He stated the staff checked on him periodically. Interview with Resident # 1 on 09/14/2016 at 5:33 PM revealed that from the time of the fall until now was in constant pain that was described as throbbing with the tune of his heart beat. The resident stated he told several of the nurses and aides (names unknown) of his pain and swelling of his leg, including PT G, who told him his swelling was probably from fluid. Resident revealed he was already on routine pain medication due to being shot years ago, which left him paralyzed. He stated that after the fall the medication only eased the pain some but it did not take it away. He also revealed that he took a sleep aid and after the fall it would take him longer to fall asleep and he would wake up sooner than normal due to the pain. He state the pain was so bad that he was having dreams that his legs were being dragged. Resident revealed his pain intensified a lot after the fall and he would be in his room sweating from the pain even though it was cold in the room . He stated he was in constant pain all day long and when he was still he would rate the pain at a 5 and when he moved it would shoot up to a 10. Resident #1 stated from the time he fell until the time he went to the hospital he did not shower because he was in pain. Resident #1 stated that on average he took 3 showers a month due to his chronic pain. He stated that he was moving his left leg with his hands, when he felt bones moving around and told LVN B, who ordered the X-rays and asked if his leg had been hurting since the fall, which he told her it had. Resident #1 revealed it was then that he learned he had two fractures and was sent out to the hospital where he stayed several hours. He stated they increased his pain medication while he was in the hospital and told him that they were going to put a splint on his leg. An interview with RA D on 09/14/2016 at 2:12 PM revealed while she was on lunch break on 08/28/16, she was informed that Resident #1 fell and was on the floor of the shower room. RA D revealed she went to the shower room where she found other staff (LVN C, CNA F, and HA E) in the shower room with the resident. She stated Resident #1 was already back in the shower chair when she arrived. The resident did not complain of pain, but his toe was bleeding. RA D revealed the resident stayed in the shower room for about two hours after the incident. RA D revealed she saw Resident #1 the next week when she was passing meds and she asked him if he was getting out of bed and he said he would. She stated the resident never complained of pain to her. A telephone interview with LVN B on 09/15/2016 at 3:06 PM revealed she was working on 08/28/2016 and revealed that five minutes before her shift ended an aide came to the nurse's station and informed her and LVN C that a resident fell in the shower room. LVN B revealed LVN C and the aide went into the shower room and she remained at the nurse's station where she was charting. She stated when she finished charting, she stuck her head in the shower room to see if she was needed and LVN C told her no. LVN B stated when she came in on 09/09/2016 Resident #1 told her that when he used his hands to move his leg he could feel something moving around. She stated that he had a lot of pain and was on significant pain medication. She also stated he did not complain of swelling to her before that Friday. An interview was conducted with DON on 09/14/2016 at 11:05 PM revealed did not find out Resident #1 fell in the shower for a couple of days after the incident occurred. She revealed it was brought to her attention by a HA. The DON revealed the nurse who found him failed to report and assess him properly. The DON stated she should have been more meticulous in conducting rounds and talking to resident to ensure that they were being properly cared for. The DON denied knowledge that the resident was in pain. An interview with the DON on 09/14/2016 at 3:21 PM and 4:20 PM and revealed she looked in the system and did not see anywhere that follow up care was given to the resident to ensure he was okay. The census of 56 was obtained from LVN A during the entrance conference on 09/14/2016 at 9:15 AM

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #1) of eight residents reviewed for accidents. The facility failed to supervise Resident #1, who was paralyzed from the waist down, while he was showering in the shower room. The resident fell when the shower chair slid from under him, which resulted in two fractures in his left leg. This failure had the potential to affect the 25 residents residing in the facility who may use the shower room allowing them to potentially harm themselves. Findings included: Review of Resident #1 face sheet on [DATE] reflected Resident is a [AGE] year old male who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Resident is his own responsible party. The Minimum Data Set (MDS) assessment conducted on [DATE] reflected the resident was cognitively aware. He required the limited physical assistance of one person with dressing and he was totally dependent on staff for bathing. Mobility device used was a wheelchair. Resident #1 was paralyzed from the waist down. Review of Resident's fall event report created by LVN C on [DATE] at 6:48 PM reflected the resident slid down in the shower on [DATE] at 5:50 PM. Review of Resident's Progress Report for the month of [DATE] reflected that Resident #1's fall was not documented Progress Report for [DATE] reflected that on [DATE] the resident complained of swelling in his left knee and lower left leg. He stated he felt something move inside when he moved his leg. The NP was notified and an X-ray was ordered. The X-ray results reflected fractures of his tibia (biggest bone in lower leg that bears weight) and fibula (smaller of the two bones between the knee and ankle). The NP, ADMIN, and DON were notified. An order was received to send Resident #1 to the local ER for evaluation and treatment of [REDACTED]. Review of Resident #1's hospital radiology report dated [DATE] reflected bone broken into pieces of the upper tibia and fibula and arthritis of the knee joint and soft tissue swelling. Observation on [DATE] at 10:00 AM revealed Resident #1 lying in bed watching television. Resident #1 revealed that two to three weeks ago he fell in the shower room. He stated the incident occurred around dinner time after he stopped a HA in the hallway and told her he wanted to take a shower. He said she unlocked the door and he went in unassisted. Resident #1 revealed he transferred himself from his wheelchair to the shower chair. When he bent down to retrieve a towel from the floor, the shower chair slid from under him causing him to fall on his left side. He stated he was too far away from the call light string to get help; therefore he started screaming until an aide (unknown name) came in. He said that shortly after, LVN C and another aide came in the room. Resident #1 revealed the aides steadied the shower chair and he transferred himself from the floor to the shower chair. He stated he was asked if he hit his head and he stated that he did not. He was informed that the blood observed was from his toe. Interview with Resident # 1 on [DATE] at 12:00 PM revealed when he was first admitted to the facility on e of the aides would supervise him while he was in the shower, but that when she started working on the memory care unit, no one would go in with him. He stated that when a staff member was in the shower room with him, they would wrap the call bell string around a pole so that it was reachable. He also revealed the staff would also ensure the shower chair was in good working condition and was locked, and watch him transfer from his wheelchair to the shower chair before they stepped out. Resident stated that he guess he just forgot to put the brakes on that day. Interview with Resident #1 on [DATE] at 5:33 PM Resident revealed they increased his pain medication while he was in the hospital and told him that they were going to put a splint on his leg. Resident stated that when he came back to the facility he was told he could not shower alone anymore. Resident #1 revealed he went to the doctor yesterday, he was informed that they were going to allow his leg to heal deformed due to him being paralyzed. An interview with HA E on [DATE] at 2:26 PM revealed Resident #1 approached her on the [DATE] around 4:30 or 5:00 PM and told her that he wanted to take a shower. She stated he asked if she would unlock the door. HA E revealed she let the resident in the shower room and told him she would get an aide to assist him. She said he told her No, I shower by myself. HA E stated that a little while later she heard screaming from the shower room and when she entered, she found the resident on the floor. HA E revealed she exited the shower room and went to get LVN B and CNA F. She stated she and CNA F entered the shower room and the resident asked them to hold the chair while he transferred himself from the floor to the chair. HA E stated then LVN B came in A telephone interview with CNA F on [DATE] at 3:21 PM revealed she was the only aide on the floor when the fall happened. She stated that she went and got the nurse. Then she and another aide went back into the shower room, where they stabilized the shower chair while Resident #1 transferred himself from the floor to the chair and continued his shower after he was assessed by the nurse. CNA F revealed the resident had always showered alone. An interview with RA D on [DATE] at 2:12 PM revealed while she was on lunch break on [DATE], she was informed that Resident #1 fell and was on the floor of the shower room. RA D revealed went to the shower room where she found other staff (LVN C, CNA F, and HA E) in the shower room with the resident. She stated Resident #1 was already back in the shower chair when she arrived. The resident did not complain of pain, but his toe was bleeding. RA D revealed the resident stayed in the shower room for about two hours after the incident. RA D revealed she saw Resident #1 the next week when she was passing meds and she asked him if he was getting out of bed and he said he would. A telephone interview with LVN C on [DATE] at 3:58 PM revealed on [DATE] she clocked in about 15 minutes before her shift began. She stated she was at the nurse's station with LVN B when an aide (unknown name) told them that a resident had fallen in the shower. LVN C stated she asked why he was in the shower by himself at that time of day and on a Sunday. She revealed she entered the shower and Resident #1 was on his bottom on the shower floor. She stated she asked him if he hit his head and he responded no. She stated she looked him over and saw that blood was coming from his toe. LVN C revealed Resident #1 transferred himself into the shower chair and wanted to continue his shower. She stated that later that night she treated his toe. She stated Resident #1 never complained of pain that night or the following weekend when she was on duty. She stated his leg never looked swollen to her. When asked what happened after a resident fell , LVN C revealed a fall observation sheet was completed and the fall was documented. She stated if the resident hit their head, neuro checks were conducted. When asked who assessed Resident # 1 after the fall, LVN C responded I guess I verbally assess him. A telephone interview with LVN B on [DATE] at 3:06 PM revealed she was working on [DATE] and revealed that five minutes before her shift ended an aide came to the nurse's station and informed her and LVN C that a resident fell in the shower room. LVN B revealed LVN C and the aide went into the shower room and she remained at the nurse's station where she was charting. She stated when she finished charting, she stuck her head in the shower room to see if she was needed and LVN C told her no. LVN B stated when she came in on [DATE] Resident #1 told her that when he used his hands to move his leg he could feel something moving around. LVN B stated she informed the DON and x-rays were ordered. She revealed it was discovered Resident #1 had fractures in his left knee. LVN B stated the resident never complained of pain to her. She stated that he had a lot of pain and is on significant pain medication. She also stated he did not complain of swelling to her before that Friday. An interview was conducted with DON on [DATE] at 11:05 PM revealed she did not find out Resident #1 fell in the shower for a couple of days after the incident occurred. She revealed it was brought to her attention by HA E. The DON revealed the nurse who found him failed to report and assess him properly. The DON stated she should have been more meticulous in conducting rounds and talking to resident to ensure that they were being properly cared for. An interview was conducted with Admin on [DATE] at 11:15 AM, revealed that he was informed this past Sunday [DATE] that LVN B felt bones moving in Resident #1's knee and the DON ordered X-ray and that is was when they found out the resident had fractures. The Admin stated the resident fell in the shower on [DATE] and he and the DON were made aware of the fall the next day. The Admin revealed after a fall, an assessment should have been conducted. He stated it was the responsibility of the DON and himself to ensure the event report had been documented and proper procedure was followed. The Admin revealed everyone dropped the ball regarding follow up to ensure a report was taken. An interview was conducted with PT G on [DATE] at 1:26 PM revealed he had worked with Resident #1 for about three weeks and revealed he complained of being in pain, but always said the pain was from the gunshot wound he suffered. The PT revealed that resident did not tell him he fell or was having pain in his knee until [DATE]. An interview was conducted with DON on [DATE] at 3:21 PM and 4:20 PM and revealed she looked in the system and she did not see anywhere that follow up care was given to the resident to ensure he was okay. She stated the facility would ensure that the Resident #1 did not shower alone. When asked if Resident #1 was care planned to take showers without assistance, since his initial MDS assessment reflected he was totally dependent on staff for bathing, the DON revealed she did not see that in his chart. She confirmed that a fall assessment was not conducted nor did anyone follow through with the facility's fall policy, An interview with the DON on [DATE] at 6:22 PM revealed she has found that a lot of the resident's MDS assessment information was not correct and stated that in [DATE] they fired the person who was doing them due to poor work performance. She stated that when the MDS nurse was informed she deleted every care plan she did and medical records. The DON revealed Resident #1 had always showered himself without assistance since he was admitted because he was very independent. Review of the facility's fall assessment policy reflected its purpose was to assess the resident's risk factors related to falls and implement interventions appropriate to prevent injuries. The facility will do a falls risk assessment upon resident ' s admission, readmission, quarterly, and/or when there is a significant change of condition, this form will be kept in the clinical record (assessments section) and will be discussed at each care plan meeting. Facility documentation will reflect all attempts made by the facility to assess and reduce the risk of falling for the resident. If resident has a total score of 10 or greater, the resident should be considered high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. The facilities Abuse Prevention policy (not dated) reflected each resident had a right to be free from abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility developed and implemented a plan containing the seven required components to include identification, reporting, and investigation of allegations of abuse/neglect. The census of 56 was obtained from LVN A during the entrance conference on [DATE] at 9:15 AM.

Based on observation, interview, and record review, it was determined the facility failed to implement policies, and procedures that prohibit neglect for one (Resident #2) of six residents reviewed for behaviors. The facility staff was aware Resident #2 was verbally abusive with physical outbursts. The facility staff did not implement new interventions to try and prevent his outbursts, which placed him at risk for injury from other residents. Resident #2 was threatening Resident #5 on 07/13/14 and Resident #5 struck Resident #2 in the head with a four foot long florescent light bulb. Resident #2 was transported to the emergency room for a laceration to the head. It was determined a Past Immediate Jeopardy existed from 06/13/14 through 07/29/14. While the IJ was lowered on 07/29/14, the facility remained out of compliance at a severity level of "no actual harm, but the potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern," due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 38 residents, including Resident #2, who were at risk for improper management of behaviors resulting in physical injury. Findings included: Resident #2's Resident Admission Record, dated 01/22/14, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE]. [DIAGNOSES REDACTED]. Resident #2's MDS assessment, dated 07/14/14, reflected a Brief Mental Status (BIMS) score of 12, which indicated he comprehended most conversations. The MDS assessment reflected Resident #2 usually understood, had difficulty focusing attention, which came and went and continuously had disorganized and incoherent thinking. Resident #2 had verbal behavioral symptoms directed towards others including, threatening others, screaming at others, and cursing at others that occurred four to six days out of the week. The MDS assessment reflected no physical behavioral symptoms were directed toward others. Review of Resident #2's "Comprehensive Care Plan," dated 01/21/14 and updated on 03/23/14, revealed the problem as "verbal outburst." The plan of care did not address verbal/physical outbursts or goals related. Interventions were: 1) Observe for early signs of unacceptable behaviors. 2) Provide a calm environment 3) Maintain the safety of all residents and staff 5) Notify MD and family of inappropriate behaviors 7) "Monitor for continued behavior patters, Note time of day, activity, duration, that pattern concentrated at...." Review of physician's orders [REDACTED].#2 was receiving: 1) [MEDICATION NAME] (antianxiety) 10 milligrams (mg) three times a day. 2) [MEDICATION NAME] XR ( antidepressant/antianxiety) 150 mg once a day. 3) [MEDICATION NAME] (impulse control) 120 mg once a day. 4) [MEDICATION NAME] ([MEDICAL CONDITION]) 5 mg twice a day. 5) [MEDICATION NAME] ([MEDICAL CONDITION]) 100 mg every night. 6) [MEDICATION NAME] ([MEDICAL CONDITION]) 100 mg every 12 hours if needed. 7) [MEDICATION NAME]([MEDICAL CONDITION]) 10 mg every night as needed. Review of Resident #2's Nurse's Notes, dated 06/13/14, revealed Resident #2 was involved in a physical altercation with another resident. Review of the facility's "Incident/Accident Report," dated 06/13/14, revealed Resident #2 cursed another resident, and the other resident got mad and kicked Resident #2. Then Resident #2 punched the other resident in the arm and both residents started kicking each other. The recommendation/intervention was to refer to Social Services. The report did not indicate if one or both residents were to be referred to Social Services. Review of an unsolicited document, received via facsimile on 08/13/14 at 11:02 p.m. from the Administrator, regarding the incident on 06/13/14, revealed, "We concluded that was highly unlikely (the resident kicked Resident #2) due to her (resident) physical limitations, and Resident #2 was not noted as aggressor verbally or physically." Review of Resident #2's "Social Progress Notes," dated 06/16/14, revealed Resident #2 was observed kicking at another resident. The SWA attempted to speak with Resident #2. However, the resident was unable to recall the details of the incident, but according to the note was "quick" to begin cursing about the incident. The SWA redirected Resident #2 encouraging him to use positive communication and to not resort to kicking or other forms of physical means. Review of Resident #2's "Psychologist's Progress Notes," dated 06/17/14, revealed his "...mood is stable and he has no complaints about other people. He is getting out of his room and I give him a lot of praise for that." Review of Resident #2's "Psychologist's Progress Notes," dated 06/24/14, revealed "(Resident #2) was feeling quite well...overall, staff says he is doing quite well...I gave him a lot of praise for how well he is doing...." Review of Resident #2's Nurse's Notes, dated 06/25/14, revealed he reported he was sitting out on the front porch, and was hit in the head by another resident because Resident #2 called the other resident a "son of a [***] ...." The notes reflected another resident, who was on the porch at the time, told the nurse Resident #2 hit the other resident and the other resident did not hit Resident #2 at all. The facility's "Incident/ Accident Report, 06/25/14, revealed the recommendation/intervention was to refer to Social Services. The report did not reflect if one or both residents should be referred to Social Services. Review of an unsolicited document, received via facsimile on 08/13/14 at 11:02 p.m. from the Administrator, revealed there were "no witnesses...And (Resident #2) noted as being verbally aggressive per his own statement, not the physical aggressor, no witness...." Review of Resident #2's "Social Progress Notes," dated 06/26/14, revealed he called another resident a "son of a [***] " and in turn the other resident slapped Resident #2 in the head. "...SWA spoke with resident concerning incident. Note: Due to medical [DIAGNOSES REDACTED]. SWA exited conversation (with) resident acknowledging willingness to comply...." Review of Resident #2's June 2014 Behavior Flow sheet revealed he had behaviors 24 out of the 30 days of the month. The 24 days Resident #2 exhibited verbal/physical behaviors with sudden angry outbursts. Interventions included assessing of pain, redirection, discussing behavior with resident, quiet time, reduce noise/distractions, re-orientation to current situation, and to leave alone; and re-approach all of the interventions were documented as not being effective. Review of Resident #2's July 2014 physician's orders [REDACTED]. Review of Resident #2's Nurse's Notes, dated 07/06/14, revealed he became agitated, and RN B spoke with him about his agitation and how he would have to eat his meal in his room, if he could not calm down. The notes reflected Resident #2 entered the dining room cussing and threatening to hit RN B with his "fist ready to swing...(Resident #2) continued to cuss and hit (RN B) on her left arm. (RN B) called 911...." An interview on 08/11/14 at 1:20 p.m. with RN B revealed Resident #2 would walk and cuss and was very aggressive. The other residents would complain all the time about Resident #2, indicating they did not like Resident #2 cussing all the time and acting like he was "tough," like he was going to hurt somebody. RN B stated the residents said "someday we will show him who the boss is." RN B revealed Resident #2 had been hit and also had hit other residents, he had been kicked, slapped and Resident #2 would kick and slap, too. RN B revealed she called the police because Resident #2 hit her on the arm, and he was very threatening. RN B stated she was afraid he was going to hurt her or one of the other residents. RN B revealed she could not get him to calm down, but when the police came, he calmed down some. RN B stated he was very impulsive, and staff never were sure how he was going to react. The surveyor asked what she was supposed to do to assist Resident #2 with his behaviors. RN B replied, "Well the Administrator told everybody in an in-service (Resident #2) only had 'half a brain' and the staff just needed to learn that was how (Resident #2) was." An interview on 08/02/14 at 2:20 p.m. with the DON revealed this type of report (employee incident report) was a different type as it was staff involved and she would have to get that from the ADM. At the time of the surveyors' exit on 08/13/14 from the facility, no report had been provided for the 911 incident. Review of Resident #2's "Psychologist Progress Notes," dated 07/08/14, revealed, "... Behavior with others has been good and I gave him praise for how well he is doing...." Review of Resident #2's Nurse's Notes, dated 07/09/14, revealed he was verbally inappropriate with another resident in the lobby area, and he was medicated. Review of Resident #2's July 2014 "PRN Medications Sheets" revealed no as needed medications were administered on 07/09/14. Review of Resident #2's Nurse's Notes, dated 07/10/14, revealed the staff noticed Resident #2 walking down the north hallway and entering Resident #5's room and removing some of the other resident's sodas. When staff approached Resident #2, he began to cuss at the staff. The notes reflected the staff attempted to redirect the resident, after having to physically remove the drinks from his hands, which was not effective. Review of the "Social Work Referral," dated 07/11/14, revealed Resident #2 entered Resident #5's room, "getting (Resident #5's) sodas, and redirection was not effective...." The SWA spoke with Resident #2 concerning entering another resident's room and taking drinks. The importance of respecting others privacy was discussed with Resident #2. (Note): Resident #2 suffers from a [MEDICAL CONDITION] and refuses constant redirection from staff, as the SWA has "them" (administration) aware of the factor. Review of Resident #2's Nurse's Notes, dated 07/11/14, revealed he had a verbal altercation at the breakfast meal and had to be redirected. Further review of the note revealed Resident #2 would curse the staff out as he was re-directed. Review of Resident #2 Nurse's Note, dated 07/13/14, revealed he was cursing Resident #5 in the dining area during meal service. Resident #5 picked up a four foot long fluorescent bulb and struck Resident #2 on the left side of his head causing a 1.2 centimeter laceration. Resident #2 was transferred to the emergency room for evaluation and treatment. Upon return from the emergency room , RN B had to go outside and stop Resident #2 from starting a fight with Resident #5. An interview with RN B on 08/11/14 at 1:20 p.m. revealed when asked if she worked on 07/13/14, the day Resident #2 was struck by the florescent light bulb, she replied yes. She stated she was the nurse who assessed him and sent him to the emergency room . RN B said it was really a "mess and I was shocked this had happened." RN B said when Resident #2 came back from the hospital, he went outside and she had gone outside because the resident was trying to start a fight. RN B said she faxed all her paperwork to the Administrator, but was told to just keep monitoring him, "so that was what I did." Review of Resident #2's, Care Plan, dated 07/14/14, following the incident, provided by the Administrator at the time of exit on 08/13/14 revealed the problem as "Escalated behavior." The Care Plan reflected, "...Dignity will be maintained of resident and others without noted behavior in next 90 days...1. Use non-violent physical approach. 2. Remove other residents and all unnecessary staff from immediate area. 3. Immediately say "NO" and step back to 3 feet from the resident. 4. Allow resident time to cool down. 5. Attempt to redirect resident to a safe area. 6. Explain all procedures in terms that the resident understands and repeat as necessary until that understanding is achieved. 7. Keep environment free of all hazards. 8. In the event of an episode, a 1:1 monitoring will be implemented immediately. 9. Check for comfort and offer support as needed. 10. Anticipate behavior and re-direct when close proximity to others that might invoke aggression...." Review of the facility's "Incident/Accident Investigation Follow-up," dated 07/13/14, revealed at 11:45 a.m. Resident #5 hit Resident #2 with a light bulb. Resident #2 was sent to the hospital for evaluation and treatment of [REDACTED]. The Investigation Follow-up did not reflect any recommendations/interventions to prevent further occurrences. Review of the facility's Provider Investigation Report, dated 07/13/14, revealed in the section, Investigation Summary, Resident #2 was cursing Resident #5 in the dining room, and Resident #2 began to threaten Resident #5. Resident #5 grabbed a Florescent Bulb and hit Resident #2 on the side of the head. The report reflected the residents were separated, and there were no more issues. Resident #5 voiced regret for hitting Resident #2. The section, Provider Action Taken Post-Investigation, reflected to refer to Social Services (no indication which residents were referred), refer for follow-up with Psychologist, the Maintenance Supervisor was written up for not getting the bulb put away after the contractors left it out, every 15 minutes monitoring for Resident #2 and Resident #5, with no other incidents, and had an all staff in-service on watching for any inappropriate items being left out/safety monitoring. An interview on 08/11/14 at 3:14 p.m. with CNA D revealed she did not see Resident #2 get hit by the light bulb, but she heard all the commotion. CNA D said she had been in the dining room about 10 minutes earlier and Resident #2 was walking around Resident #5's table cussing, yelling, and "shooting (Resident #5) the finger." CNA D revealed Resident #2 has this type of behavior all the time. She stated he walked around "shooting the finger" at other residents and cussing saying "[***] you." When asked about Resident #5's behaviors, CNA D replied Resident #5 was a quiet man, never had been aggressive, and was a very pleasant person. On 08/12/14 at 6:00 p.m., Resident #3 and Resident #17 stated they had been in the dining room during the incident between Resident #2 and Resident #5 on 07/13/14. They stated Resident #2 was cursing at and drawing his hand back as if he was going to hit Resident #5. An interview on 08/11/14 at 3:30 p.m. with LVN G revealed Resident #2 always cussed and Resident #5 just hit him. LVN G indicated Resident #5 just got tired of listening to him. When asked about Resident #5's behaviors, LVN G replied Resident #5 was a quiet man, and she never really had any problems with him. An interview on 08/11/14 at 3:15 p.m. with CNA F revealed she worked double weekends and had been employed one year. CNA F said Resident #2 was always cussing the other residents and the staff, and she did not understand why something had not been done about Resident #2. CNA F said, "You see what happened to him, he got hit in the head with that light bulb." Surveyor queried CNA F concerning Resident #5's behaviors. CNA F replied, "I have never had any problems with aggression with Resident #5." An interview with MA H on 08/13/14 at 12:45 p.m. revealed she was in the main dining room during the incident involving Resident #2 and Resident #5 on 07/13/14. MA H stated she had been assisting another resident to eat and she was not facing the direction of the incident to see what occurred. According to MA H, she heard Resident #2 cursing as was usual for the resident. Resident #5 was cursing back in response to Resident #2. MA H was queried about whether she had intervened during the verbal exchange between the two residents. MA H stated she was unable to recall what she had said, but she had probably instructed Resident #2 to "let's use kind words," as she often did. During this interview, MA H stated she was usually able to redirect Resident #2, but had not received any specific training at the facility related to dealing with Resident #2's behaviors An interview on 08/13/14 at 3:20 p.m. with the ADM regarding Resident #2's behavior revealed she was aware the resident had several resident-to-resident altercations prior to the incident with Resident #5 on 07/13/14. However, she was not aware nursing staff had contacted 911 on 07/06/14 due to Resident #2 behaving aggressively both verbally/physically and hitting a staff member. The Administrator stated if she had known she would have "done something sooner" to address Resident #2's behaviors. According to the ADM, Resident #2 was not physically aggressive "99 percent of the time." She further stated aggressive behaviors were addressed in the resident's care plan and interventions included redirection. She revealed she did not feel staff had become complacent, but more of an acceptance of the resident's behaviors as "that's who they are." The ADM stated she felt staff had "just gotten used to" Resident #2's behaviors, "as we all do" with residents with psychiatric diagnoses. The ADM further stated training and teaching related to dealing with behavioral issues had been provided to staff. Review of the facility's in-service training report, "Physical & Psychological Changes," revealed on 06/10/14 an in-service for all staff was conducted by a guest speaker, from a psychiatric hospital, regarding "Behaviors." Handouts were provided to the staff. One undated handout reflected, "General Guidelines Evaluate and treat treatable conditions (e.g. (for example), pain, urinary tract infection) Prevent new occurrences Educate patient, family, and staff Identify and reduce causative factors Provide periods of reduced stimuli." The undated handout, Behavioral Interventions, reflected, "Reinforcement of alternative behaviors Positive reinforcement Redirection Active Listening Simplify tasks - reduce steps." The undated handout, Possible Non-medication Interventions, reflected, "Behavior Verbal Anger/Abusive Language Possible Interventions Distract & redirect; Try to determine the 'real' reason for the outburst...." Another undated handout, Possible Non-medication Interventions reflected, "Behavior...Aggression (hitting, yelling, verbal abuse, etc.) Possible Interventions...Remove resident from situation, allow space to pace if possible, decrease stimuli, use articles of comfort, utilize crisis intervention techniques." Review of Resident #2 "Psychologist's Progress Notes," dated 07/15/14, revealed he had an altercation with another resident who hit him. The other resident apparently got tired of Resident #2 sticking his middle finger up at him and cursing, so he hit Resident #2. The notes reflected, "I talked to (Resident #2) about not giving the 'finger' to people and being careful about what he says to other people." Resident #2's Social Progress Notes did not reflect an entry regarding his altercation on 07/15/14 with Resident #5. Review of Resident #2's "Social Services Quarterly Assessment," dated 07/21/14, revealed he had no new issues this quarter. The assessment reflected, "Resident #2 is aware of self only, able to makes simple decisions only, is verbally abuse and at times is physically abusive. (Resident #2) requires constant redirection... (Psychological) services offered as needed/upon request...." Review of an unsolicited document faxed on 08/13/14 at 11:02 p.m. revealed "(Resident #2) did not have any physical aggression. (Resident #2) not physical aggressor." Review of Resident #2's Nurse's Notes, dated 07/21/14, revealed he was hit by another resident in the mouth for calling the resident a "[***] ." Review of the facility's "Incident/Accident report," dated 07/21/14, revealed Resident #2 was slapped in the mouth by another resident for calling her a "[***] ." Resident #2 had an abrasion to his lip. Further review revealed a Nurse's Note, dated 07/22/14, provided by the facility with the "Incident/Accident," which reflected the female resident reported to the ADON that Resident #2 grabbed her arm and called her a "[***] " and she slapped Resident #2 in the face to get him to let go of her. The "Incident/Accident Investigation Follow-up," dated 07/21/14, reflected the recommendation/intervention was to refer to Social Services. Review of the unsolicited document faxed on 08/13/14 at 11:02 p.m. revealed this was the first incident Resident #2 was the physical aggressor resulting in a minor injury for Resident #2. An interview with the SWA on 08/25/14 at 3:48 p.m. revealed she assisted with the Social Progress Notes, but the Social Worker came in every other Saturday and read them and signed off on the documentation. SWA said if the Social Worker could not come, then the ADM, who was a Social Worker would review her notes and sign them. When asked about Resident #2 and her visits with him, SWA replied the ADM and the DON would tell her to just go and talk to Resident #2 when he got upset and redirect or encourage him because there was not much they could do for him because of his "[MEDICAL CONDITION]." The SWA stated she always tried and gave Resident #2 positive encouragement every time she saw him, but it never seemed to last long. The SWA revealed sometimes they (Administrative Staff) got together and discussed certain situations and she would have an opinion, but she never made a decision. She stated the decisions were always made by the DON or the ADM. The SWA revealed, "I just did what I was told to do." Interview on 08/26/14 at 3:26 p.m. with the facility's SW revealed she did come to the facility and review and sign the the Social Progress Notes completed by the SWA every other Saturday. The SW stated she was aware of Resident #2's verbal aggression, but had trusted the facility ADM to make the decision what to do. The SW said since the ADM was a Social Worker, and was around the resident regularly, she felt it was better served if they decided what to do with Resident #2. She revealed she trusted that to be the right decision. When asked what she would have done if she were the full time SW in the facility, the SW replied she would have immediately discharged the resident to a Psychiatric Behavior Unit for an evaluation and possible alternate placement. An interview on 08/12/14 at 3:30 p.m. with RN C revealed she had not worked at the facility for a long time, but she had a psychiatric nursing background. RN C said Resident #2 had been re-directed by her when he had become aggressive. RN C said Resident #2 had the potential to be "explosive." An interview on 08/13/14 at 9:30 a.m. with the DON revealed Resident #2 was verbally abusive. When asked what she had done to assist Resident #2 with his "verbally abusive behavior," the DON replied, "(Resident #2) has always been that way." Interview on 08/26/14 at 11:50 a.m. with the Psychologist revealed he was not aware Resident #2 had been having verbal aggression, with outbursts. The Psychologist said if the facility had made him aware he would have recommended Resident #2 be evaluated for a Psychiatric admission or have the primary care physician review his medications. Review of the facility's "Incident/Accident Report," dated 07/28/14, revealed at 8:00 a.m. Resident #2 walked up to another resident in the sitting room and "punched" the other resident in the chest. The recommendation/intervention was to refer to Social Services. Review of the "Behavior Detailed Entry Report" dated June and July 2014 revealed documentation by the CNAs concerning Resident #2's behaviors. Resident #2's behaviors at times included, refusing activities of daily living care (ADLs), refusing to eat, yelling, cursing, threatening staff and other residents, and wandering. An interview on 08/12/14 at 2:45 p.m. with CNA D revealed Resident #2 could be very "rough" to handle at times. She stated the ADM told the staff they just had to re-direct him, but "honey that does not work and he (Resident #2) could be very scary sometimes." CNA D said there had been a couple of times where she had really thought about just walking up to the Nurse's Station and calling the police, but she was afraid that she would lose her job. CNA D revealed she would just try and keep the other residents from hurting Resident #2, or Resident #2 from hurting one of the other residents. When asked if she had been in-serviced regarding how to manage residents with behaviors, she replied yes, over and over again, but they were not resident specific. The staff was told they just had to accept them the way they were, like Resident #2 only had "Half a brain, like that is supposed to help us understand him and keep him and others safe." CNA D revealed then the ADM would just "give us a hand-out, and go to talking about a bunch of other stuff." Review of Resident #2's Nurse's Notes, dated 07/29/14 revealed he was transferred to the "Hospital" for evaluation and treatment on 07/29/14 at 11:00 a.m. Review of Resident #2's psychiatric hospital's History and Physical, dated 07/29/14 (when he was admitted ), revealed, "(Resident #2) was assessed with [REDACTED].#2) is paranoid and suspicious of other residents at the nursing home...(Resident #2) poses significant danger to self and others." The "History of Present Illness" reflected, "(Resident #2) was very paranoid and suspicious, (Resident #2) reported to the physician at the hospital that he thinks the other residents are making fun of him and calling him names. (Resident #2) said he hit another resident without provocation, because the other resident called him a 'mother[***] ,' when (Resident #2) was asked why he did not reported (sic) this, (Resident #2) said I do not report, I take action, if he hits me, I will kill him." Further review of the History and Physical revealed during the assessment: "Resident was very restless, unable to stay still, pacing and fidgeting, (Resident #2) was unable to concentrate and not able to follow directions, and has mood swings with outburst...The goal for treatment is to stabilize his mood, eliminate the [MEDICAL CONDITION], and reduce the agitation and aggressive behaviors...to include medications and psychotherapy." Interview on 08/26/14 at 12:55 p.m. with the facility's Registered Nurse Practitioner (RNP) revealed the facility called her for everything and if she had some dates she would prove the facility had contacted her concerning Resident #2's behaviors. When asked what she did when the facility contacted her concerning Resident #2's behaviors/verbal aggression, she replied, "I would have not done anything, I would not have changed any of his medications, because I know it would have done no good. Resident #2 only has (half a brain) surely you (surveyor) can understand that. " The RNP said, "He has had surgery similar to a Lobotomy, leaving him with half a brain to use." If I gave him more medication it would just be considered a chemical restraint by the "state." Resident #2's psychiatric hospital discharge Physician order [REDACTED].); [MEDICATION NAME] 75 mg every morning (Note: The June and July 2014 physician's orders [REDACTED].) [MEDICATION NAME] and [MEDICATION NAME] were not reordered. Observation during initial tour on 08/11/14 at 9:40 a.m. revealed Resident #2 sitting up on the side of his bed in his room. The resident smiled at the surveyor and said good morning. CNA A was in Resident #2's room, making the bed and said he was incontinent of bowel and bladder, and had recently been in the hospital concerning his behaviors. CNA A thought he had hit another resident, but before that he had been hit by another resident with a light bulb in the dining room during a meal service. The surveyor queried how this happened and CNA A said Resident #2 could be verbally abusive and some of the other residents did not like being cussed at all the time, but since he had been in the hospital he was better. CNA A said she was not working on that day when the incident occurred. CNA A stated it was a weekend, and there was a different set of employees, but she had known about it because she asked why Resident #2's head was cut when she came back to work, that following Monday. Resident #2 was still upset about the incident and was "acting out." The surveyor asked what she meant by "acting out," and CNA A said he was cussing a lot and at times would fight staff and act like he was going to hit staff or another resident. CNA A said Resident #2 had been like that for a while, even before he got hit by the light bulb. The surveyor queried CNA A what the staff was told to do to assist Resident #2 with his behaviors, CNA A replied just to redirect him, but that did not work, most of the time. CNA A revealed, "It was nice to have a Resident not fight me now. I sure hope this lasts for a while." An interview with the SWA on 08/12/13 at 11:10 a.m. revealed she just received on 08/12/14, the yellow carbon section of the Incident/Accident Report related to Resident #5 hitting Resident #2 with a fluorescent light bulb on 07/13/14. The SWA further stated she had plans to educate Residents #2 and #5 on appropriate communication. However, she had not provided the residents with any education or intervened yet. The Surveyor had requested from the DON on 08/12/14 for the July 2014 and August 2014 Behavior Flow Sheets, but they were not provided. Review of Resident #2's Nurse's Notes, dated 08/20/14, revealed he was in a verbal altercation with another resident, who hit him in his upper arm. The notes reflected the nurse assessed both residents, reported the incident to the RNP, ADM, and the DON. No new orders were given. Resident #2's Nurse's Notes, dated 08/21/14 reflected he was transferred to a new facility. Review of Resident #2's "physician progress notes [REDACTED]. Any attempt to prevent outbursts would result in over sedation and chemical restraint...." On 08/11/14 at 9:45 a.m., the ADM stated she was responsible for monitoring the facility's A/N/M prevention program. Review of the facility's undated A/N/M p/p, Resident Behavior & (and) Facility Practices Policy, provided on 08/11/14 as the current p/p, revealed the following: "...Each resident has the right to be free from abuse... Residents will not be subjected to abuse by anyone, including, but not limited to...other residents...Each resident has the right to be free from mistreatment, neglect...This includes the facility's identification of residents' whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis...Therefore, the facility has developed operational policies and procedures for...protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment...The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences...Protection: It is the up most importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that

Based on observation, interview, and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #2) of six residents reviewed for behaviors. The facility staff was aware Resident #2 was verbally abusive with physical outbursts. The facility staff did not implement new interventions to try and prevent his outbursts, which placed him at risk for injury from other residents. Resident #2 was threatening Resident #5 on 07/13/14 and Resident #5 struck Resident #2 in the head with a four foot long florescent light bulb. Resident #2 was transported to the emergency room for a laceration to the head. A Past Immediate Jeopardy was identified. The IJ existed from 06/13/14 through 07/29/14. While the IJ was lowered on 07/29/14, the facility remained out of compliance at a severity level of "no actual harm, but the potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern," due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 38 residents, including Resident #2, who were at risk for improper management of behaviors resulting in physical injury. Findings included: Review of the facility's undated A/N/M p/p, Resident Behavior & (and) Facility Practices Policy, provided on 08/11/14 as the current p/p, revealed the following: "...Each resident has the right to be free from abuse... Residents will not be subjected to abuse by anyone, including, but not limited to...other residents...Each resident has the right to be free from mistreatment, neglect...This includes the facility's identification of residents' whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis...Therefore, the facility has developed operational policies and procedures for...protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment...The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences...Protection: It is the up most importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm...In the area of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. If the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility, as determined by the attending physician, then the resident will be immediately discharged ...If a threat does not exist then an appropriate assessment will be done and the behavior will be care planned to meet this resident's needs and protect others...." On 08/11/14 at 9:45 a.m., the ADM stated she was responsible for monitoring the facility's A/N/M prevention program. Resident #2's Resident Admission Record, dated 01/22/14, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE]. [DIAGNOSES REDACTED]. Resident #2's MDS assessment, dated 07/14/14, reflected a Brief Mental Status (BIMS) score of 12, which indicated he comprehended most conversations. The MDS assessment reflected Resident #2 usually understood, had difficulty focusing attention, which came and went and continuously had disorganized and incoherent thinking. Resident #2 had verbal behavioral symptoms directed towards others including, threatening others, screaming at others, and cursing at others that occurred four to six days out of the week. The MDS assessment reflected no physical behavioral symptoms were directed toward others. Review of Resident #2's "Comprehensive Care Plan," dated 01/21/14 and updated on 03/23/14, revealed the problem as "verbal outburst." The plan of care did not address verbal/physical outbursts or goals related. Interventions were: 1) Observe for early signs of unacceptable behaviors. 2) Provide a calm environment 3) Maintain the safety of all residents and staff 5) Notify MD and family of inappropriate behaviors 7) "Monitor for continued behavior patters, Note time of day, activity, duration, that pattern concentrated at...." Review of physician's orders [REDACTED].#2 was receiving: 1) [MEDICATION NAME] (antianxiety) 10 milligrams (mg) three times a day. 2) [MEDICATION NAME] XR ( antidepressant/antianxiety) 150 mg once a day. 3) [MEDICATION NAME] (impulse control) 120 mg once a day. 4) [MEDICATION NAME] ([MEDICAL CONDITION]) 5 mg twice a day. 5) [MEDICATION NAME] ([MEDICAL CONDITION]) 100 mg every night. 6) [MEDICATION NAME] ([MEDICAL CONDITION]) 100 mg every 12 hours if needed. 7) [MEDICATION NAME]([MEDICAL CONDITION]) 10 mg every night as needed. Review of Resident #2's Nurse's Notes, dated 06/13/14, revealed Resident #2 was involved in a physical altercation with another resident. Review of the facility's "Incident/Accident Report," dated 06/13/14, revealed Resident #2 cursed another resident, and the other resident got mad and kicked Resident #2. Then Resident #2 punched the other resident in the arm and both residents started kicking each other. The recommendation/intervention was to refer to Social Services. The report did not indicate if one or both residents were to be referred to Social Services. Review of an unsolicited document, received via facsimile on 08/13/14 at 11:02 p.m. from the Administrator, regarding the incident on 06/13/14, revealed, "We concluded that was highly unlikely (the resident kicked Resident #2) due to her (resident) physical limitations, and Resident #2 was not noted as aggressor verbally or physically." Review of Resident #2's "Social Progress Notes," dated 06/16/14, revealed Resident #2 was observed kicking at another resident. The SWA attempted to speak with Resident #2. However, the resident was unable to recall the details of the incident, but according to the note was "quick" to begin cursing about the incident. The SWA redirected Resident #2 encouraging him to use positive communication and to not resort to kicking or other forms of physical means. Review of Resident #2's "Psychologist's Progress Notes," dated 06/17/14, revealed his "...mood is stable and he has no complaints about other people. He is getting out of his room and I give him a lot of praise for that." Review of Resident #2's "Psychologist's Progress Notes," dated 06/24/14, revealed "(Resident #2) was feeling quite well...overall, staff says he is doing quite well...I gave him a lot of praise for how well he is doing...." Review of Resident #2's Nurse's Notes, dated 06/25/14, revealed he reported he was sitting out on the front porch, and was hit in the head by another resident because Resident #2 called the other resident a "son of a [***] ...." The notes reflected another resident, who was on the porch at the time, told the nurse Resident #2 hit the other resident and the other resident did not hit Resident #2 at all. The facility's "Incident/ Accident Report, 06/25/14, revealed the recommendation/intervention was to refer to Social Services. The report did not reflect if one or both residents should be referred to Social Services. Review of an unsolicited document, received via facsimile on 08/13/14 at 11:02 p.m. from the Administrator, revealed there were "no witnesses...And (Resident #2) noted as being verbally aggressive per his own statement, not the physical aggressor, no witness...." Review of Resident #2's "Social Progress Notes," dated 06/26/14, revealed he called another resident a "son of a [***] " and in turn the other resident slapped Resident #2 in the head. "...SWA spoke with resident concerning incident. Note: Due to medical [DIAGNOSES REDACTED]. SWA exited conversation (with) resident acknowledging willingness to comply...." Review of Resident #2's June 2014 Behavior Flow sheet revealed he had behaviors 24 out of the 30 days of the month. The 24 days Resident #2 exhibited verbal/physical behaviors with sudden angry outbursts. Interventions included assessing of pain, redirection, discussing behavior with resident, quiet time, reduce noise/distractions, re-orientation to current situation, and to leave alone; and re-approach all of the interventions were documented as not being effective. Review of Resident #2's July 2014 physician's orders [REDACTED]. Review of Resident #2's Nurse's Notes, dated 07/06/14, revealed he became agitated, and RN B spoke with him about his agitation and how he would have to eat his meal in his room, if he could not calm down. The notes reflected Resident #2 entered the dining room cussing and threatening to hit RN B with his "fist ready to swing...(Resident #2) continued to cuss and hit (RN B) on her left arm. (RN B) called 911...." An interview on 08/11/14 at 1:20 p.m. with RN B revealed Resident #2 would walk and cuss and was very aggressive. The other residents would complain all the time about Resident #2, indicating they did not like Resident #2 cussing all the time and acting like he was "tough," like he was going to hurt somebody. RN B stated the residents said "someday we will show him who the boss is." RN B revealed Resident #2 had been hit and also had hit other residents, he had been kicked, slapped and Resident #2 would kick and slap, too. RN B revealed she called the police because Resident #2 hit her on the arm, and he was very threatening. RN B stated she was afraid he was going to hurt her or one of the other residents. RN B revealed she could not get him to calm down, but when the police came, he calmed down some. RN B stated he was very impulsive, and staff never were sure how he was going to react. The surveyor asked what she was supposed to do to assist Resident #2 with his behaviors. RN B replied, "Well the Administrator told everybody in an in-service (Resident #2) only had 'half a brain' and the staff just needed to learn that was how (Resident #2) was." An interview on 08/02/14 at 2:20 p.m. with the DON revealed this type of report (employee incident report) was a different type as it was staff involved and she would have to get that from the ADM. At the time of the surveyors' exit on 08/13/14 from the facility, no report had been provided for the 911 incident. Review of Resident #2's "Psychologist Progress Notes," dated 07/08/14, revealed, "... Behavior with others has been good and I gave him praise for how well he is doing...." Review of Resident #2's Nurse's Notes, dated 07/09/14, revealed he was verbally inappropriate with another resident in the lobby area, and he was medicated. Review of Resident #2's July 2014 "PRN Medications Sheets" revealed no as needed medications were administered on 07/09/14. Review of Resident #2's Nurse's Notes, dated 07/10/14, revealed the staff noticed Resident #2 walking down the north hallway and entering Resident #5's room and removing some of the other resident's sodas. When staff approached Resident #2, he began to cuss at the staff. The notes reflected the staff attempted to redirect the resident, after having to physically remove the drinks from his hands, which was not effective. Review of the "Social Work Referral," dated 07/11/14, revealed Resident #2 entered Resident #5's room, "getting (Resident #5's) sodas, and redirection was not effective...." The SWA spoke with Resident #2 concerning entering another resident's room and taking drinks. The importance of respecting others privacy was discussed with Resident #2. (Note): Resident #2 suffers from a [MEDICAL CONDITION] and refuses constant redirection from staff, as the SWA has "them" (administration) aware of the factor. Review of Resident #2's Nurse's Notes, dated 07/11/14, revealed he had a verbal altercation at the breakfast meal and had to be redirected. Further review of the note revealed Resident #2 would curse the staff out as he was re-directed. Review of Resident #2 Nurse's Note, dated 07/13/14, revealed he was cursing Resident #5 in the dining area during meal service. Resident #5 picked up a four foot long fluorescent bulb and struck Resident #2 on the left side of his head causing a 1.2 centimeter laceration. Resident #2 was transferred to the emergency room for evaluation and treatment. Upon return from the emergency room , RN B had to go outside and stop Resident #2 from starting a fight with Resident #5. An interview with RN B on 08/11/14 at 1:20 p.m. revealed when asked if she worked on 07/13/14, the day Resident #2 was struck by the florescent light bulb, she replied yes. She stated she was the nurse who assessed him and sent him to the emergency room . RN B said it was really a "mess and I was shocked this had happened." RN B said when Resident #2 came back from the hospital, he went outside and she had gone outside because the resident was trying to start a fight. RN B said she faxed all her paperwork to the Administrator, but was told to just keep monitoring him, "so that was what I did." Review of Resident #2's, Care Plan, dated 07/14/14, following the incident, provided by the Administrator at the time of exit on 08/13/14 revealed the problem as "Escalated behavior." The Care Plan reflected, "...Dignity will be maintained of resident and others without noted behavior in next 90 days...1. Use non-violent physical approach. 2. Remove other residents and all unnecessary staff from immediate area. 3. Immediately say "NO" and step back to 3 feet from the resident. 4. Allow resident time to cool down. 5. Attempt to redirect resident to a safe area. 6. Explain all procedures in terms that the resident understands and repeat as necessary until that understanding is achieved. 7. Keep environment free of all hazards. 8. In the event of an episode, a 1:1 monitoring will be implemented immediately. 9. Check for comfort and offer support as needed. 10. Anticipate behavior and re-direct when close proximity to others that might invoke aggression...." Review of the facility's "Incident/Accident Investigation Follow-up," dated 07/13/14, revealed at 11:45 a.m. Resident #5 hit Resident #2 with a light bulb. Resident #2 was sent to the hospital for evaluation and treatment of [REDACTED]. The Investigation Follow-up did not reflect any recommendations/interventions to prevent further occurrences. Review of the facility's Provider Investigation Report, dated 07/13/14, revealed in the section, Investigation Summary, Resident #2 was cursing Resident #5 in the dining room, and Resident #2 began to threaten Resident #5. Resident #5 grabbed a Florescent Bulb and hit Resident #2 on the side of the head. The report reflected the residents were separated, and there were no more issues. Resident #5 voiced regret for hitting Resident #2. The section, Provider Action Taken Post-Investigation, reflected to refer to Social Services (no indication which residents were referred), refer for follow-up with Psychologist, the Maintenance Supervisor was written up for not getting the bulb put away after the contractors left it out, every 15 minutes monitoring for Resident #2 and Resident #5, with no other incidents, and had an all staff in-service on watching for any inappropriate items being left out/safety monitoring. An interview on 08/11/14 at 3:14 p.m. with CNA D revealed she did not see Resident #2 get hit by the light bulb, but she heard all the commotion. CNA D said she had been in the dining room about 10 minutes earlier and Resident #2 was walking around Resident #5's table cussing, yelling, and "shooting (Resident #5) the finger." CNA D revealed Resident #2 has this type of behavior all the time. She stated he walked around "shooting the finger" at other residents and cussing saying "[***] you." When asked about Resident #5's behaviors, CNA D replied Resident #5 was a quiet man, never had been aggressive, and was a very pleasant person. On 08/12/14 at 6:00 p.m., Resident #3 and Resident #17 stated they had been in the dining room during the incident between Resident #2 and Resident #5 on 07/13/14. They stated Resident #2 was cursing at and drawing his hand back as if he was going to hit Resident #5. An interview on 08/11/14 at 3:30 p.m. with LVN G revealed Resident #2 always cussed and Resident #5 just hit him. LVN G indicated Resident #5 just got tired of listening to him. When asked about Resident #5's behaviors, LVN G replied Resident #5 was a quiet man, and she never really had any problems with him. An interview on 08/11/14 at 3:15 p.m. with CNA F revealed she worked double weekends and had been employed one year. CNA F said Resident #2 was always cussing the other residents and the staff, and she did not understand why something had not been done about Resident #2. CNA F said, "You see what happened to him, he got hit in the head with that light bulb." Surveyor queried CNA F concerning Resident #5's behaviors. CNA F replied, "I have never had any problems with aggression with Resident #5." An interview with MA H on 08/13/14 at 12:45 p.m. revealed she was in the main dining room during the incident involving Resident #2 and Resident #5 on 07/13/14. MA H stated she had been assisting another resident to eat and she was not facing the direction of the incident to see what occurred. According to MA H, she heard Resident #2 cursing as was usual for the resident. Resident #5 was cursing back in response to Resident #2. MA H was queried about whether she had intervened during the verbal exchange between the two residents. MA H stated she was unable to recall what she had said, but she had probably instructed Resident #2 to "let's use kind words," as she often did. During this interview, MA H stated she was usually able to redirect Resident #2, but had not received any specific training at the facility related to dealing with Resident #2's behaviors An interview on 08/13/14 at 3:20 p.m. with the ADM regarding Resident #2's behavior revealed she was aware the resident had several resident-to-resident altercations prior to the incident with Resident #5 on 07/13/14. However, she was not aware nursing staff had contacted 911 on 07/06/14 due to Resident #2 behaving aggressively both verbally/physically and hitting a staff member. The Administrator stated if she had known she would have "done something sooner" to address Resident #2's behaviors. According to the ADM, Resident #2 was not physically aggressive "99 percent of the time." She further stated aggressive behaviors were addressed in the resident's care plan and interventions included redirection. She revealed she did not feel staff had become complacent, but more of an acceptance of the resident's behaviors as "that's who they are." The ADM stated she felt staff had "just gotten used to" Resident #2's behaviors, "as we all do" with residents with psychiatric diagnoses. The ADM further stated training and teaching related to dealing with behavioral issues had been provided to staff. Review of the facility's in-service training report, "Physical & Psychological Changes," revealed on 06/10/14 an in-service for all staff was conducted by a guest speaker, from a psychiatric hospital, regarding "Behaviors." Handouts were provided to the staff. One undated handout reflected, "General Guidelines Evaluate and treat treatable conditions (e.g. (for example), pain, urinary tract infection) Prevent new occurrences Educate patient, family, and staff Identify and reduce causative factors Provide periods of reduced stimuli." The undated handout, Behavioral Interventions, reflected, "Reinforcement of alternative behaviors Positive reinforcement Redirection Active Listening Simplify tasks - reduce steps." The undated handout, Possible Non-medication Interventions, reflected, "Behavior Verbal Anger/Abusive Language Possible Interventions Distract & redirect; Try to determine the 'real' reason for the outburst...." Another undated handout, Possible Non-medication Interventions reflected, "Behavior...Aggression (hitting, yelling, verbal abuse, etc.) Possible Interventions...Remove resident from situation, allow space to pace if possible, decrease stimuli, use articles of comfort, utilize crisis intervention techniques." Review of Resident #2 "Psychologist's Progress Notes," dated 07/15/14, revealed he had an altercation with another resident who hit him. The other resident apparently got tired of Resident #2 sticking his middle finger up at him and cursing, so he hit Resident #2. The notes reflected, "I talked to (Resident #2) about not giving the 'finger' to people and being careful about what he says to other people." Resident #2's Social Progress Notes did not reflect an entry regarding his altercation on 07/15/14 with Resident #5. Review of Resident #2's "Social Services Quarterly Assessment," dated 07/21/14, revealed he had no new issues this quarter. The assessment reflected, "Resident #2 is aware of self only, able to makes simple decisions only, is verbally abuse and at times is physically abusive. (Resident #2) requires constant redirection... (Psychological) services offered as needed/upon request...." Review of an unsolicited document faxed on 08/13/14 at 11:02 p.m. revealed "(Resident #2) did not have any physical aggression. (Resident #2) not physical aggressor." Review of Resident #2's Nurse's Notes, dated 07/21/14, revealed he was hit by another resident in the mouth for calling the resident a "[***] ." Review of the facility's "Incident/Accident report," dated 07/21/14, revealed Resident #2 was slapped in the mouth by another resident for calling her a "[***] ." Resident #2 had an abrasion to his lip. Further review revealed a Nurse's Note, dated 07/22/14, provided by the facility with the "Incident/Accident," which reflected the female resident reported to the ADON that Resident #2 grabbed her arm and called her a "[***] " and she slapped Resident #2 in the face to get him to let go of her. The "Incident/Accident Investigation Follow-up," dated 07/21/14, reflected the recommendation/intervention was to refer to Social Services. Review of the unsolicited document faxed on 08/13/14 at 11:02 p.m. revealed this was the first incident Resident #2 was the physical aggressor resulting in a minor injury for Resident #2. An interview with the SWA on 08/25/14 at 3:48 p.m. revealed she assisted with the Social Progress Notes, but the Social Worker came in every other Saturday and read them and signed off on the documentation. SWA said if the Social Worker could not come, then the ADM, who was a Social Worker would review her notes and sign them. When asked about Resident #2 and her visits with him, SWA replied the ADM and the DON would tell her to just go and talk to Resident #2 when he got upset and redirect or encourage him because there was not much they could do for him because of his "[MEDICAL CONDITION]." The SWA stated she always tried and gave Resident #2 positive encouragement every time she saw him, but it never seemed to last long. The SWA revealed sometimes they (Administrative Staff) got together and discussed certain situations and she would have an opinion, but she never made a decision. She stated the decisions were always made by the DON or the ADM. The SWA revealed, "I just did what I was told to do." Interview on 08/26/14 at 3:26 p.m. with the facility's SW revealed she did come to the facility and review and sign the the Social Progress Notes completed by the SWA every other Saturday. The SW stated she was aware of Resident #2's verbal aggression, but had trusted the facility ADM to make the decision what to do. The SW said since the ADM was a Social Worker, and was around the resident regularly, she felt it was better served if they decided what to do with Resident #2. She revealed she trusted that to be the right decision. When asked what she would have done if she were the full time SW in the facility, the SW replied she would have immediately discharged the resident to a Psychiatric Behavior Unit for an evaluation and possible alternate placement. An interview on 08/12/14 at 3:30 p.m. with RN C revealed she had not worked at the facility for a long time, but she had a psychiatric nursing background. RN C said Resident #2 had been re-directed by her when he had become aggressive. RN C said Resident #2 had the potential to be "explosive." An interview on 08/13/14 at 9:30 a.m. with the DON revealed Resident #2 was verbally abusive. When asked what she had done to assist Resident #2 with his "verbally abusive behavior," the DON replied, "(Resident #2) has always been that way." Interview on 08/26/14 at 11:50 a.m. with the Psychologist revealed he was not aware Resident #2 had been having verbal aggression, with outbursts. The Psychologist said if the facility had made him aware he would have recommended Resident #2 be evaluated for a Psychiatric admission or have the primary care physician review his medications. Review of the facility's "Incident/Accident Report," dated 07/28/14, revealed at 8:00 a.m. Resident #2 walked up to another resident in the sitting room and "punched" the other resident in the chest. The recommendation/intervention was to refer to Social Services. Review of the "Behavior Detailed Entry Report" dated June and July 2014 revealed documentation by the CNAs concerning Resident #2's behaviors. Resident #2's behaviors at times included, refusing activities of daily living care (ADLs), refusing to eat, yelling, cursing, threatening staff and other residents, and wandering. An interview on 08/12/14 at 2:45 p.m. with CNA D revealed Resident #2 could be very "rough" to handle at times. She stated the ADM told the staff they just had to re-direct him, but "honey that does not work and he (Resident #2) could be very scary sometimes." CNA D said there had been a couple of times where she had really thought about just walking up to the Nurse's Station and calling the police, but she was afraid that she would lose her job. CNA D revealed she would just try and keep the other residents from hurting Resident #2, or Resident #2 from hurting one of the other residents. When asked if she had been in-serviced regarding how to manage residents with behaviors, she replied yes, over and over again, but they were not resident specific. The staff was told they just had to accept them the way they were, like Resident #2 only had "Half a brain, like that is supposed to help us understand him and keep him and others safe." CNA D revealed then the ADM would just "give us a hand-out, and go to talking about a bunch of other stuff." Review of Resident #2's Nurse's Notes, dated 07/29/14 revealed he was transferred to the "Hospital" for evaluation and treatment on 07/29/14 at 11:00 a.m. Review of Resident #2's psychiatric hospital's History and Physical, dated 07/29/14 (when he was admitted ), revealed, "(Resident #2) was assessed with [REDACTED].#2) is paranoid and suspicious of other residents at the nursing home...(Resident #2) poses significant danger to self and others." The "History of Present Illness" reflected, "(Resident #2) was very paranoid and suspicious, (Resident #2) reported to the physician at the hospital that he thinks the other residents are making fun of him and calling him names. (Resident #2) said he hit another resident without provocation, because the other resident called him a 'mother[***] ,' when (Resident #2) was asked why he did not reported (sic) this, (Resident #2) said I do not report, I take action, if he hits me, I will kill him." Further review of the History and Physical revealed during the assessment: "Resident was very restless, unable to stay still, pacing and fidgeting, (Resident #2) was unable to concentrate and not able to follow directions, and has mood swings with outburst...The goal for treatment is to stabilize his mood, eliminate the [MEDICAL CONDITION], and reduce the agitation and aggressive behaviors...to include medications and psychotherapy." Interview on 08/26/14 at 12:55 p.m. with the facility's Registered Nurse Practitioner (RNP) revealed the facility called her for everything and if she had some dates she would prove the facility had contacted her concerning Resident #2's behaviors. When asked what she did when the facility contacted her concerning Resident #2's behaviors/verbal aggression, she replied, "I would have not done anything, I would not have changed any of his medications, because I know it would have done no good. Resident #2 only has (half a brain) surely you (surveyor) can understand that. " The RNP said, "He has had surgery similar to a Lobotomy, leaving him with half a brain to use." If I gave him more medication it would just be considered a chemical restraint by the "state." Resident #2's psychiatric hospital discharge Physician order [REDACTED].); [MEDICATION NAME] 75 mg every morning (Note: The June and July 2014 physician's orders [REDACTED].) [MEDICATION NAME] and [MEDICATION NAME] were not reordered. Observation during initial tour on 08/11/14 at 9:40 a.m. revealed Resident #2 sitting up on the side of his bed in his room. The resident smiled at the surveyor and said good morning. CNA A was in Resident #2's room, making the bed and said he was incontinent of bowel and bladder, and had recently been in the hospital concerning his behaviors. CNA A thought he had hit another resident, but before that he had been hit by another resident with a light bulb in the dining room during a meal service. The surveyor queried how this happened and CNA A said Resident #2 could be verbally abusive and some of the other residents did not like being cussed at all the time, but since he had been in the hospital he was better. CNA A said she was not working on that day when the incident occurred. CNA A stated it was a weekend, and there was a different set of employees, but she had known about it because she asked why Resident #2's head was cut when she came back to work, that following Monday. Resident #2 was still upset about the incident and was "acting out." The surveyor asked what she meant by "acting out," and CNA A said he was cussing a lot and at times would fight staff and act like he was going to hit staff or another resident. CNA A said Resident #2 had been like that for a while, even before he got hit by the light bulb. The surveyor queried CNA A what the staff was told to do to assist Resident #2 with his behaviors, CNA A replied just to redirect him, but that did not work, most of the time. CNA A revealed, "It was nice to have a Resident not fight me now. I sure hope this lasts for a while." An interview with the SWA on 08/12/13 at 11:10 a.m. revealed she just received on 08/12/14, the yellow carbon section of the Incident/Accident Report related to Resident #5 hitting Resident #2 with a fluorescent light bulb on 07/13/14. The SWA further stated she had plans to educate Residents #2 and #5 on appropriate communication. However, she had not provided the residents with any education or intervened yet. The Surveyor had requested from the DON on 08/12/14 for the July 2014 and August 2014 Behavior Flow Sheets, but they were not provided. Review of Resident #2's Nurse's Notes, dated 08/20/14, revealed he was

Based on observation, interview, and record review, it was determined the facility failed to ensure the environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent resident-to-resident altercations for one (Resident #2) of six residents reviewed for abuse/neglect. 1. The facility staff was aware Resident #2 was verbally abusive with physical outbursts. The facility staff did not implement new interventions to try and prevent his outbursts, which placed him at risk for injury from other residents. Resident #2 was threatening Resident #5 on 07/13/14 and Resident #5 struck Resident #2 in the head with a four foot long florescent light bulb. Resident #2 was transported to the emergency room for a laceration to the head. It was determined a Past Immediate Jeopardy existed from 06/13/14 through 07/29/14. While the IJ was lowered on 07/29/14, the facility remained out of compliance at a severity level of "no actual harm, but the potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern," due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 38 residents, including Resident #2, who were at risk for improper management of behaviors resulting in physical injury. 2. The facility to failed to properly store four-foot long fluorescent light bulbs, which were stored in a corner in the facility's main dining room. Resident #5 hit Resident #2 with one of the light bulbs causing a laceration to the side of Resident #2's head. Resident #2 was transferred to the emergency room where he received treatment to close the laceration. Failure to properly store equipment away from resident accessible areas caused Resident #2 to sustain a laceration injury. This failure had the potential to affect all 27 residents with Dementia by placing them at risk for injuries and/or causing injuries to others. Findings included: 1. Resident #2's Resident Admission Record, dated 01/22/14, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE]. [DIAGNOSES REDACTED]. Resident #2's MDS assessment, dated 07/14/14, reflected a Brief Mental Status (BIMS) score of 12, which indicated he comprehended most conversations. The MDS assessment reflected Resident #2 usually understood, had difficulty focusing attention, which came and went and continuously had disorganized and incoherent thinking. Resident #2 had verbal behavioral symptoms directed towards others including, threatening others, screaming at others, and cursing at others that occurred four to six days out of the week. The MDS assessment reflected no physical behavioral symptoms were directed toward others. Review of Resident #2's "Comprehensive Care Plan," dated 01/21/14 and updated on 03/23/14, revealed the problem as "verbal outburst." The plan of care did not address verbal/physical outbursts or goals related. Interventions were: 1) Observe for early signs of unacceptable behaviors. 2) Provide a calm environment 3) Maintain the safety of all residents and staff 5) Notify MD and family of inappropriate behaviors 7) "Monitor for continued behavior patters, Note time of day, activity, duration, that pattern concentrated at...." Review of physician's orders [REDACTED].#2 was receiving: 1) Buspirone (antianxiety) 10 milligrams (mg) three times a day. 2) Effexor XR ( antidepressant/antianxiety) 150 mg once a day. 3) Medroxyprogesterone (impulse control) 120 mg once a day. 4) Olanzapine (Schizophrenia) 5 mg twice a day. 5) Seroquel (Schizophrenia) 100 mg every night. 6) Seroquel (Schizophrenia) 100 mg every 12 hours if needed. 7) Ambien (Insomnia) 10 mg every night as needed. Review of Resident #2's Nurse's Notes, dated 06/13/14, revealed Resident #2 was involved in a physical altercation with another resident. Review of the facility's "Incident/Accident Report," dated 06/13/14, revealed Resident #2 cursed another resident, and the other resident got mad and kicked Resident #2. Then Resident #2 punched the other resident in the arm and both residents started kicking each other. The recommendation/intervention was to refer to Social Services. The report did not indicate if one or both residents were to be referred to Social Services. Review of an unsolicited document, received via facsimile on 08/13/14 at 11:02 p.m. from the Administrator, regarding the incident on 06/13/14, revealed, "We concluded that was highly unlikely (the resident kicked Resident #2) due to her (resident) physical limitations, and Resident #2 was not noted as aggressor verbally or physically." Review of Resident #2's "Social Progress Notes," dated 06/16/14, revealed Resident #2 was observed kicking at another resident. The SWA attempted to speak with Resident #2. However, the resident was unable to recall the details of the incident, but according to the note was "quick" to begin cursing about the incident. The SWA redirected Resident #2 encouraging him to use positive communication and to not resort to kicking or other forms of physical means. Review of Resident #2's "Psychologist's Progress Notes," dated 06/17/14, revealed his "...mood is stable and he has no complaints about other people. He is getting out of his room and I give him a lot of praise for that." Review of Resident #2's "Psychologist's Progress Notes," dated 06/24/14, revealed "(Resident #2) was feeling quite well...overall, staff says he is doing quite well...I gave him a lot of praise for how well he is doing...." Review of Resident #2's Nurse's Notes, dated 06/25/14, revealed he reported he was sitting out on the front porch, and was hit in the head by another resident because Resident #2 called the other resident a "son of a [***] ...." The notes reflected another resident, who was on the porch at the time, told the nurse Resident #2 hit the other resident and the other resident did not hit Resident #2 at all. The facility's "Incident/ Accident Report, 06/25/14, revealed the recommendation/intervention was to refer to Social Services. The report did not reflect if one or both residents should be referred to Social Services. Review of an unsolicited document, received via facsimile on 08/13/14 at 11:02 p.m. from the Administrator, revealed there were "no witnesses...And (Resident #2) noted as being verbally aggressive per his own statement, not the physical aggressor, no witness...." Review of Resident #2's "Social Progress Notes," dated 06/26/14, revealed he called another resident a "son of a [***] " and in turn the other resident slapped Resident #2 in the head. "...SWA spoke with resident concerning incident. Note: Due to medical [DIAGNOSES REDACTED]. SWA exited conversation (with) resident acknowledging willingness to comply...." Review of Resident #2's June 2014 Behavior Flow sheet revealed he had behaviors 24 out of the 30 days of the month. The 24 days Resident #2 exhibited verbal/physical behaviors with sudden angry outbursts. Interventions included assessing of pain, redirection, discussing behavior with resident, quiet time, reduce noise/distractions, re-orientation to current situation, and to leave alone; and re-approach all of the interventions were documented as not being effective. Review of Resident #2's July 2014 physician's orders [REDACTED]. Review of Resident #2's Nurse's Notes, dated 07/06/14, revealed he became agitated, and RN B spoke with him about his agitation and how he would have to eat his meal in his room, if he could not calm down. The notes reflected Resident #2 entered the dining room cussing and threatening to hit RN B with his "fist ready to swing...(Resident #2) continued to cuss and hit (RN B) on her left arm. (RN B) called 911...." An interview on 08/11/14 at 1:20 p.m. with RN B revealed Resident #2 would walk and cuss and was very aggressive. The other residents would complain all the time about Resident #2, indicating they did not like Resident #2 cussing all the time and acting like he was "tough," like he was going to hurt somebody. RN B stated the residents said "someday we will show him who the boss is." RN B revealed Resident #2 had been hit and also had hit other residents, he had been kicked, slapped and Resident #2 would kick and slap, too. RN B revealed she called the police because Resident #2 hit her on the arm, and he was very threatening. RN B stated she was afraid he was going to hurt her or one of the other residents. RN B revealed she could not get him to calm down, but when the police came, he calmed down some. RN B stated he was very impulsive, and staff never were sure how he was going to react. The surveyor asked what she was supposed to do to assist Resident #2 with his behaviors. RN B replied, "Well the Administrator told everybody in an in-service (Resident #2) only had 'half a brain' and the staff just needed to learn that was how (Resident #2) was." An interview on 08/02/14 at 2:20 p.m. with the DON revealed this type of report (employee incident report) was a different type as it was staff involved and she would have to get that from the ADM. At the time of the surveyors' exit on 08/13/14 from the facility, no report had been provided for the 911 incident. Review of Resident #2's "Psychologist Progress Notes," dated 07/08/14, revealed, "... Behavior with others has been good and I gave him praise for how well he is doing...." Review of Resident #2's Nurse's Notes, dated 07/09/14, revealed he was verbally inappropriate with another resident in the lobby area, and he was medicated. Review of Resident #2's July 2014 "PRN Medications Sheets" revealed no as needed medications were administered on 07/09/14. Review of Resident #2's Nurse's Notes, dated 07/10/14, revealed the staff noticed Resident #2 walking down the north hallway and entering Resident #5's room and removing some of the other resident's sodas. When staff approached Resident #2, he began to cuss at the staff. The notes reflected the staff attempted to redirect the resident, after having to physically remove the drinks from his hands, which was not effective. Review of the "Social Work Referral," dated 07/11/14, revealed Resident #2 entered Resident #5's room, "getting (Resident #5's) sodas, and redirection was not effective...." The SWA spoke with Resident #2 concerning entering another resident's room and taking drinks. The importance of respecting others privacy was discussed with Resident #2. (Note): Resident #2 suffers from a brain injury and refuses constant redirection from staff, as the SWA has "them" (administration) aware of the factor. Review of Resident #2's Nurse's Notes, dated 07/11/14, revealed he had a verbal altercation at the breakfast meal and had to be redirected. Further review of the note revealed Resident #2 would curse the staff out as he was re-directed. Review of Resident #2 Nurse's Note, dated 07/13/14, revealed he was cursing Resident #5 in the dining area during meal service. Resident #5 picked up a four foot long fluorescent bulb and struck Resident #2 on the left side of his head causing a 1.2 centimeter laceration. Resident #2 was transferred to the emergency room for evaluation and treatment. Upon return from the emergency room , RN B had to go outside and stop Resident #2 from starting a fight with Resident #5. An interview with RN B on 08/11/14 at 1:20 p.m. revealed when asked if she worked on 07/13/14, the day Resident #2 was struck by the florescent light bulb, she replied yes. She stated she was the nurse who assessed him and sent him to the emergency room . RN B said it was really a "mess and I was shocked this had happened." RN B said when Resident #2 came back from the hospital, he went outside and she had gone outside because the resident was trying to start a fight. RN B said she faxed all her paperwork to the Administrator, but was told to just keep monitoring him, "so that was what I did." Review of Resident #2's, Care Plan, dated 07/14/14, following the incident, provided by the Administrator at the time of exit on 08/13/14 revealed the problem as "Escalated behavior." The Care Plan reflected, "...Dignity will be maintained of resident and others without noted behavior in next 90 days...1. Use non-violent physical approach. 2. Remove other residents and all unnecessary staff from immediate area. 3. Immediately say "NO" and step back to 3 feet from the resident. 4. Allow resident time to cool down. 5. Attempt to redirect resident to a safe area. 6. Explain all procedures in terms that the resident understands and repeat as necessary until that understanding is achieved. 7. Keep environment free of all hazards. 8. In the event of an episode, a 1:1 monitoring will be implemented immediately. 9. Check for comfort and offer support as needed. 10. Anticipate behavior and re-direct when close proximity to others that might invoke aggression...." Review of the facility's "Incident/Accident Investigation Follow-up," dated 07/13/14, revealed at 11:45 a.m. Resident #5 hit Resident #2 with a light bulb. Resident #2 was sent to the hospital for evaluation and treatment of [REDACTED]. The Investigation Follow-up did not reflect any recommendations/interventions to prevent further occurrences. Review of the facility's Provider Investigation Report, dated 07/13/14, revealed in the section, Investigation Summary, Resident #2 was cursing Resident #5 in the dining room, and Resident #2 began to threaten Resident #5. Resident #5 grabbed a Florescent Bulb and hit Resident #2 on the side of the head. The report reflected the residents were separated, and there were no more issues. Resident #5 voiced regret for hitting Resident #2. The section, Provider Action Taken Post-Investigation, reflected to refer to Social Services (no indication which residents were referred), refer for follow-up with Psychologist, the Maintenance Supervisor was written up for not getting the bulb put away after the contractors left it out, every 15 minutes monitoring for Resident #2 and Resident #5, with no other incidents, and had an all staff in-service on watching for any inappropriate items being left out/safety monitoring. An interview on 08/11/14 at 3:14 p.m. with CNA D revealed she did not see Resident #2 get hit by the light bulb, but she heard all the commotion. CNA D said she had been in the dining room about 10 minutes earlier and Resident #2 was walking around Resident #5's table cussing, yelling, and "shooting (Resident #5) the finger." CNA D revealed Resident #2 has this type of behavior all the time. She stated he walked around "shooting the finger" at other residents and cussing saying "[***] you." When asked about Resident #5's behaviors, CNA D replied Resident #5 was a quiet man, never had been aggressive, and was a very pleasant person. On 08/12/14 at 6:00 p.m., Resident #3 and Resident #17 stated they had been in the dining room during the incident between Resident #2 and Resident #5 on 07/13/14. They stated Resident #2 was cursing at and drawing his hand back as if he was going to hit Resident #5. An interview on 08/11/14 at 3:30 p.m. with LVN G revealed Resident #2 always cussed and Resident #5 just hit him. LVN G indicated Resident #5 just got tired of listening to him. When asked about Resident #5's behaviors, LVN G replied Resident #5 was a quiet man, and she never really had any problems with him. An interview on 08/11/14 at 3:15 p.m. with CNA F revealed she worked double weekends and had been employed one year. CNA F said Resident #2 was always cussing the other residents and the staff, and she did not understand why something had not been done about Resident #2. CNA F said, "You see what happened to him, he got hit in the head with that light bulb." Surveyor queried CNA F concerning Resident #5's behaviors. CNA F replied, "I have never had any problems with aggression with Resident #5." An interview with MA H on 08/13/14 at 12:45 p.m. revealed she was in the main dining room during the incident involving Resident #2 and Resident #5 on 07/13/14. MA H stated she had been assisting another resident to eat and she was not facing the direction of the incident to see what occurred. According to MA H, she heard Resident #2 cursing as was usual for the resident. Resident #5 was cursing back in response to Resident #2. MA H was queried about whether she had intervened during the verbal exchange between the two residents. MA H stated she was unable to recall what she had said, but she had probably instructed Resident #2 to "let's use kind words," as she often did. During this interview, MA H stated she was usually able to redirect Resident #2, but had not received any specific training at the facility related to dealing with Resident #2's behaviors An interview on 08/13/14 at 3:20 p.m. with the ADM regarding Resident #2's behavior revealed she was aware the resident had several resident-to-resident altercations prior to the incident with Resident #5 on 07/13/14. However, she was not aware nursing staff had contacted 911 on 07/06/14 due to Resident #2 behaving aggressively both verbally/physically and hitting a staff member. The Administrator stated if she had known she would have "done something sooner" to address Resident #2's behaviors. According to the ADM, Resident #2 was not physically aggressive "99 percent of the time." She further stated aggressive behaviors were addressed in the resident's care plan and interventions included redirection. She revealed she did not feel staff had become complacent, but more of an acceptance of the resident's behaviors as "that's who they are." The ADM stated she felt staff had "just gotten used to" Resident #2's behaviors, "as we all do" with residents with psychiatric diagnoses. The ADM further stated training and teaching related to dealing with behavioral issues had been provided to staff. Review of the facility's in-service training report, "Physical & Psychological Changes," revealed on 06/10/14 an in-service for all staff was conducted by a guest speaker, from a psychiatric hospital, regarding "Behaviors." Handouts were provided to the staff. One undated handout reflected, "General Guidelines Evaluate and treat treatable conditions (e.g. (for example), pain, urinary tract infection) Prevent new occurrences Educate patient, family, and staff Identify and reduce causative factors Provide periods of reduced stimuli." The undated handout, Behavioral Interventions, reflected, "Reinforcement of alternative behaviors Positive reinforcement Redirection Active Listening Simplify tasks - reduce steps." The undated handout, Possible Non-medication Interventions, reflected, "Behavior Verbal Anger/Abusive Language Possible Interventions Distract & redirect; Try to determine the 'real' reason for the outburst...." Another undated handout, Possible Non-medication Interventions reflected, "Behavior...Aggression (hitting, yelling, verbal abuse, etc.) Possible Interventions...Remove resident from situation, allow space to pace if possible, decrease stimuli, use articles of comfort, utilize crisis intervention techniques." Review of Resident #2 "Psychologist's Progress Notes," dated 07/15/14, revealed he had an altercation with another resident who hit him. The other resident apparently got tired of Resident #2 sticking his middle finger up at him and cursing, so he hit Resident #2. The notes reflected, "I talked to (Resident #2) about not giving the 'finger' to people and being careful about what he says to other people." Resident #2's Social Progress Notes did not reflect an entry regarding his altercation on 07/15/14 with Resident #5. Review of Resident #2's "Social Services Quarterly Assessment," dated 07/21/14, revealed he had no new issues this quarter. The assessment reflected, "Resident #2 is aware of self only, able to makes simple decisions only, is verbally abuse and at times is physically abusive. (Resident #2) requires constant redirection... (Psychological) services offered as needed/upon request...." Review of an unsolicited document faxed on 08/13/14 at 11:02 p.m. revealed "(Resident #2) did not have any physical aggression. (Resident #2) not physical aggressor." Review of Resident #2's Nurse's Notes, dated 07/21/14, revealed he was hit by another resident in the mouth for calling the resident a "[***] ." Review of the facility's "Incident/Accident report," dated 07/21/14, revealed Resident #2 was slapped in the mouth by another resident for calling her a "[***] ." Resident #2 had an abrasion to his lip. Further review revealed a Nurse's Note, dated 07/22/14, provided by the facility with the "Incident/Accident," which reflected the female resident reported to the ADON that Resident #2 grabbed her arm and called her a "[***] " and she slapped Resident #2 in the face to get him to let go of her. The "Incident/Accident Investigation Follow-up," dated 07/21/14, reflected the recommendation/intervention was to refer to Social Services. Review of the unsolicited document faxed on 08/13/14 at 11:02 p.m. revealed this was the first incident Resident #2 was the physical aggressor resulting in a minor injury for Resident #2. An interview with the SWA on 08/25/14 at 3:48 p.m. revealed she assisted with the Social Progress Notes, but the Social Worker came in every other Saturday and read them and signed off on the documentation. SWA said if the Social Worker could not come, then the ADM, who was a Social Worker would review her notes and sign them. When asked about Resident #2 and her visits with him, SWA replied the ADM and the DON would tell her to just go and talk to Resident #2 when he got upset and redirect or encourage him because there was not much they could do for him because of his "brain dysfunction." The SWA stated she always tried and gave Resident #2 positive encouragement every time she saw him, but it never seemed to last long. The SWA revealed sometimes they (Administrative Staff) got together and discussed certain situations and she would have an opinion, but she never made a decision. She stated the decisions were always made by the DON or the ADM. The SWA revealed, "I just did what I was told to do." Interview on 08/26/14 at 3:26 p.m. with the facility's SW revealed she did come to the facility and review and sign the the Social Progress Notes completed by the SWA every other Saturday. The SW stated she was aware of Resident #2's verbal aggression, but had trusted the facility ADM to make the decision what to do. The SW said since the ADM was a Social Worker, and was around the resident regularly, she felt it was better served if they decided what to do with Resident #2. She revealed she trusted that to be the right decision. When asked what she would have done if she were the full time SW in the facility, the SW replied she would have immediately discharged the resident to a Psychiatric Behavior Unit for an evaluation and possible alternate placement. An interview on 08/12/14 at 3:30 p.m. with RN C revealed she had not worked at the facility for a long time, but she had a psychiatric nursing background. RN C said Resident #2 had been re-directed by her when he had become aggressive. RN C said Resident #2 had the potential to be "explosive." An interview on 08/13/14 at 9:30 a.m. with the DON revealed Resident #2 was verbally abusive. When asked what she had done to assist Resident #2 with his "verbally abusive behavior," the DON replied, "(Resident #2) has always been that way." Interview on 08/26/14 at 11:50 a.m. with the Psychologist revealed he was not aware Resident #2 had been having verbal aggression, with outbursts. The Psychologist said if the facility had made him aware he would have recommended Resident #2 be evaluated for a Psychiatric admission or have the primary care physician review his medications. Review of the facility's "Incident/Accident Report," dated 07/28/14, revealed at 8:00 a.m. Resident #2 walked up to another resident in the sitting room and "punched" the other resident in the chest. The recommendation/intervention was to refer to Social Services. Review of the "Behavior Detailed Entry Report" dated June and July 2014 revealed documentation by the CNAs concerning Resident #2's behaviors. Resident #2's behaviors at times included, refusing activities of daily living care (ADLs), refusing to eat, yelling, cursing, threatening staff and other residents, and wandering. An interview on 08/12/14 at 2:45 p.m. with CNA D revealed Resident #2 could be very "rough" to handle at times. She stated the ADM told the staff they just had to re-direct him, but "honey that does not work and he (Resident #2) could be very scary sometimes." CNA D said there had been a couple of times where she had really thought about just walking up to the Nurse's Station and calling the police, but she was afraid that she would lose her job. CNA D revealed she would just try and keep the other residents from hurting Resident #2, or Resident #2 from hurting one of the other residents. When asked if she had been in-serviced regarding how to manage residents with behaviors, she replied yes, over and over again, but they were not resident specific. The staff was told they just had to accept them the way they were, like Resident #2 only had "Half a brain, like that is supposed to help us understand him and keep him and others safe." CNA D revealed then the ADM would just "give us a hand-out, and go to talking about a bunch of other stuff." Review of Resident #2's Nurse's Notes, dated 07/29/14 revealed he was transferred to the "Hospital" for evaluation and treatment on 07/29/14 at 11:00 a.m. Review of Resident #2's psychiatric hospital's History and Physical, dated 07/29/14 (when he was admitted ), revealed, "(Resident #2) was assessed with [REDACTED].#2) is paranoid and suspicious of other residents at the nursing home...(Resident #2) poses significant danger to self and others." The "History of Present Illness" reflected, "(Resident #2) was very paranoid and suspicious, (Resident #2) reported to the physician at the hospital that he thinks the other residents are making fun of him and calling him names. (Resident #2) said he hit another resident without provocation, because the other resident called him a 'mother[***] ,' when (Resident #2) was asked why he did not reported (sic) this, (Resident #2) said I do not report, I take action, if he hits me, I will kill him." Further review of the History and Physical revealed during the assessment: "Resident was very restless, unable to stay still, pacing and fidgeting, (Resident #2) was unable to concentrate and not able to follow directions, and has mood swings with outburst...The goal for treatment is to stabilize his mood, eliminate the psychosis, and reduce the agitation and aggressive behaviors...to include medications and psychotherapy." Interview on 08/26/14 at 12:55 p.m. with the facility's Registered Nurse Practitioner (RNP) revealed the facility called her for everything and if she had some dates she would prove the facility had contacted her concerning Resident #2's behaviors. When asked what she did when the facility contacted her concerning Resident #2's behaviors/verbal aggression, she replied, "I would have not done anything, I would not have changed any of his medications, because I know it would have done no good. Resident #2 only has (half a brain) surely you (surveyor) can understand that. " The RNP said, "He has had surgery similar to a Lobotomy, leaving him with half a brain to use." If I gave him more medication it would just be considered a chemical restraint by the "state." Resident #2's psychiatric hospital discharge Physician order [REDACTED].); Effexor 75 mg every morning (Note: The June and July 2014 physician's orders [REDACTED].) Buspirone and Olanzapine were not reordered. Observation during initial tour on 08/11/14 at 9:40 a.m. revealed Resident #2 sitting up on the side of his bed in his room. The resident smiled at the surveyor and said good morning. CNA A was in Resident #2's room, making the bed and said he was incontinent of bowel and bladder, and had recently been in the hospital concerning his behaviors. CNA A thought he had hit another resident, but before that he had been hit by another resident with a light bulb in the dining room during a meal service. The surveyor queried how this happened and CNA A said Resident #2 could be verbally abusive and some of the other residents did not like being cussed at all the time, but since he had been in the hospital he was better. CNA A said she was not working on that day when the incident occurred. CNA A stated it was a weekend, and there was a different set of employees, but she had known about it because she asked why Resident #2's head was cut when she came back to work, that following Monday. Resident #2 was still upset about the incident and was "acting out." The surveyor asked what she meant by "acting out," and CNA A said he was cussing a lot and at times would fight staff and act like he was going to hit staff or another resident. CNA A said Resident #2 had been like that for a while, even before he got hit by the light bulb. The surveyor queried CNA A what the staff was told to do to assist Resident #2 with his behaviors, CNA A replied just to redirect him, but that did not work, most of the time. CNA A revealed, "It was nice to have a Resident not fight me now. I sure hope this lasts for a while." An interview with the SWA on 08/12/13 at 11:10 a.m. revealed she just received on 08/12/14, the yellow carbon section of the Incident/Accident Report related to Resident #5 hitting Resident #2 with a fluorescent light bulb on 07/13/14. The SWA further stated she had plans to educate Residents #2 and #5 on appropriate communication. However, she had not provided the residents with any education or intervened yet. The Surveyor had requested from the DON on 08/12/14 for the July 2014 and August 2014 Behavior Flow Sheets, but they were not provided. Review of Resident #2's Nurse's Notes, dated 08/20/14, revealed he was in a verbal altercation with another resident, who hit him in his upper arm. The notes reflected the nurse assessed both residents, reported the incident to the RNP, ADM, and the DON. No new orders were given. Resident #2's Nurse's Notes, dated 08/21/14 reflected he was transferred to a new facility. Review of Resident #2's "physician progress notes [REDACTED]. Any attempt to prevent outbursts would result in over sedation and chemical restraint...." On 08/12/14 at 3:15 p.m., the DON stated the facility did not have any p/p addressing resident-to-resident incidents. She stated the facility completed an incident report and followed the State guidelines for reporting incidents. Interview on 08/27/14 at 12:24 p.m. with the DON revealed prior to hiring employees, she made sure the employee was a person who knew how to take care of residents with behaviors. She stated she monitored the staff on a daily basis, so she could determine if the staff needed further training. The DON said the "Behavior Plan" (not facility policy) they had in place was to separate the residents, monitor, refer, and treat, if an incident occurred. Th

Based on observation, interview, and record review, it was determined the Administrator and DON failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one (Resident #2) of six residents reviewed for behaviors. The ADM failed to implement the facility's Abuse and Neglect policy. The ADM failed to monitor the DON to ensure she carried out her responsibilities to ensure Resident #2's needs were being met by the nursing staff. The ADM, DON, and staff were aware Resident #2 was verbally abusive and had physical outbursts, but failed to implement interventions to prevent the verbal abuse and physical outburst. Resident #2 was verbally abusive to Resident #5 and Resident #5 struck Resident #2 in the head with four foot fluorescent bulb. Resident #2 sustained a small laceration and was transported to the emergency room . A Past Immediate Jeopardy was identified. The IJ existed from 06/13/14 through 07/29/14. While the IJ was lowered on 07/29/14, the facility remained out of compliance at a severity level of "no actual harm, but the potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern," due to the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the 38 residents, including Resident #2, who were at risk for improper management of behaviors resulting in physical injury. Findings included: The ADM's Job Description, signed by the ADM on 10/17/13, reflected, "ESSENTIAL POSITION FUNCTIONS: 1) ...Monitors each departments' activities, communicates policies, evaluates performance, provides feedback and assists, coaches, and disciplines as needed. 2) Conducts regular rounds to monitor operations of all departments...and to ensure resident needs are being addressed... 5) Maintains a working knowledge and ensures compliance with all governmental regulations. 6) Ensures understanding of and compliance with all rules regarding residents' rights... 12) Supervises, conducts and participates in department and facility education activities and staff meetings...." On 08/11/14 at 9:45 a.m., the ADM stated she was responsible for monitoring the facility's A/N/M prevention program. Review of the facility's undated A/N/M p/p, Resident Behavior & (and) Facility Practices Policy, provided on 08/11/14 as the current p/p, revealed the following: "...Each resident has the right to be free from abuse... Residents will not be subjected to abuse by anyone, including, but not limited to...other residents...Each resident has the right to be free from mistreatment, neglect...This includes the facility's identification of residents' whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis...Therefore, the facility has developed operational policies and procedures for...protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment...The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences...Protection: It is the up most importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm...In the area of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. If the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility, as determined by the attending physician, then the resident will be immediately discharged ...If a threat does not exist then an appropriate assessment will be done and the behavior will be care planned to meet this resident's needs and protect others...." Resident #2's Resident Admission Record, dated 01/22/14, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE]. [DIAGNOSES REDACTED]. Resident #2's MDS assessment, dated 07/14/14, reflected a Brief Mental Status (BIMS) score of 12, which indicated he comprehended most conversations. The MDS assessment reflected Resident #2 usually understood, had difficulty focusing attention, which came and went and continuously had disorganized and incoherent thinking. Resident #2 had verbal behavioral symptoms directed towards others including, threatening others, screaming at others, and cursing at others that occurred four to six days out of the week. The MDS assessment reflected no physical behavioral symptoms were directed toward others. Review of Resident #2's "Comprehensive Care Plan," dated 01/21/14 and updated on 03/23/14, revealed the problem as "verbal outburst." The plan of care did not address verbal/physical outbursts or goals related. Interventions were: 1) Observe for early signs of unacceptable behaviors. 2) Provide a calm environment 3) Maintain the safety of all residents and staff 5) Notify MD and family of inappropriate behaviors 7) "Monitor for continued behavior patters, Note time of day, activity, duration, that pattern concentrated at...." Review of physician's orders [REDACTED].#2 was receiving: 1) [MEDICATION NAME] (antianxiety) 10 milligrams (mg) three times a day. 2) [MEDICATION NAME] XR ( antidepressant/antianxiety) 150 mg once a day. 3) [MEDICATION NAME] (impulse control) 120 mg once a day. 4) [MEDICATION NAME] ([MEDICAL CONDITION]) 5 mg twice a day. 5) [MEDICATION NAME] ([MEDICAL CONDITION]) 100 mg every night. 6) [MEDICATION NAME] ([MEDICAL CONDITION]) 100 mg every 12 hours if needed. 7) [MEDICATION NAME]([MEDICAL CONDITION]) 10 mg every night as needed. Review of Resident #2's Nurse's Notes, dated 06/13/14, revealed Resident #2 was involved in a physical altercation with another resident. Review of the facility's "Incident/Accident Report," dated 06/13/14, revealed Resident #2 cursed another resident, and the other resident got mad and kicked Resident #2. Then Resident #2 punched the other resident in the arm and both residents started kicking each other. The recommendation/intervention was to refer to Social Services. The report did not indicate if one or both residents were to be referred to Social Services. Review of an unsolicited document, received via facsimile on 08/13/14 at 11:02 p.m. from the Administrator, regarding the incident on 06/13/14, revealed, "We concluded that was highly unlikely (the resident kicked Resident #2) due to her (resident) physical limitations, and Resident #2 was not noted as aggressor verbally or physically." Review of Resident #2's "Social Progress Notes," dated 06/16/14, revealed Resident #2 was observed kicking at another resident. The SWA attempted to speak with Resident #2. However, the resident was unable to recall the details of the incident, but according to the note was "quick" to begin cursing about the incident. The SWA redirected Resident #2 encouraging him to use positive communication and to not resort to kicking or other forms of physical means. Review of Resident #2's "Psychologist's Progress Notes," dated 06/17/14, revealed his "...mood is stable and he has no complaints about other people. He is getting out of his room and I give him a lot of praise for that." Review of Resident #2's "Psychologist's Progress Notes," dated 06/24/14, revealed "(Resident #2) was feeling quite well...overall, staff says he is doing quite well...I gave him a lot of praise for how well he is doing...." Review of Resident #2's Nurse's Notes, dated 06/25/14, revealed he reported he was sitting out on the front porch, and was hit in the head by another resident because Resident #2 called the other resident a "son of a [***] ...." The notes reflected another resident, who was on the porch at the time, told the nurse Resident #2 hit the other resident and the other resident did not hit Resident #2 at all. The facility's "Incident/ Accident Report, 06/25/14, revealed the recommendation/intervention was to refer to Social Services. The report did not reflect if one or both residents should be referred to Social Services. Review of an unsolicited document, received via facsimile on 08/13/14 at 11:02 p.m. from the Administrator, revealed there were "no witnesses...And (Resident #2) noted as being verbally aggressive per his own statement, not the physical aggressor, no witness...." Review of Resident #2's "Social Progress Notes," dated 06/26/14, revealed he called another resident a "son of a [***] " and in turn the other resident slapped Resident #2 in the head. "...SWA spoke with resident concerning incident. Note: Due to medical [DIAGNOSES REDACTED]. SWA exited conversation (with) resident acknowledging willingness to comply...." Review of Resident #2's June 2014 Behavior Flow sheet revealed he had behaviors 24 out of the 30 days of the month. The 24 days Resident #2 exhibited verbal/physical behaviors with sudden angry outbursts. Interventions included assessing of pain, redirection, discussing behavior with resident, quiet time, reduce noise/distractions, re-orientation to current situation, and to leave alone; and re-approach all of the interventions were documented as not being effective. Review of Resident #2's July 2014 physician's orders [REDACTED]. Review of Resident #2's Nurse's Notes, dated 07/06/14, revealed he became agitated, and RN B spoke with him about his agitation and how he would have to eat his meal in his room, if he could not calm down. The notes reflected Resident #2 entered the dining room cussing and threatening to hit RN B with his "fist ready to swing...(Resident #2) continued to cuss and hit (RN B) on her left arm. (RN B) called 911...." An interview on 08/11/14 at 1:20 p.m. with RN B revealed Resident #2 would walk and cuss and was very aggressive. The other residents would complain all the time about Resident #2, indicating they did not like Resident #2 cussing all the time and acting like he was "tough," like he was going to hurt somebody. RN B stated the residents said "someday we will show him who the boss is." RN B revealed Resident #2 had been hit and also had hit other residents, he had been kicked, slapped and Resident #2 would kick and slap, too. RN B revealed she called the police because Resident #2 hit her on the arm, and he was very threatening. RN B stated she was afraid he was going to hurt her or one of the other residents. RN B revealed she could not get him to calm down, but when the police came, he calmed down some. RN B stated he was very impulsive, and staff never were sure how he was going to react. The surveyor asked what she was supposed to do to assist Resident #2 with his behaviors. RN B replied, "Well the Administrator told everybody in an in-service (Resident #2) only had 'half a brain' and the staff just needed to learn that was how (Resident #2) was." An interview on 08/02/14 at 2:20 p.m. with the DON revealed this type of report (employee incident report) was a different type as it was staff involved and she would have to get that from the ADM. At the time of the surveyors' exit on 08/13/14 from the facility, no report had been provided for the 911 incident. Review of Resident #2's "Psychologist Progress Notes," dated 07/08/14, revealed, "... Behavior with others has been good and I gave him praise for how well he is doing...." Review of Resident #2's Nurse's Notes, dated 07/09/14, revealed he was verbally inappropriate with another resident in the lobby area, and he was medicated. Review of Resident #2's July 2014 "PRN Medications Sheets" revealed no as needed medications were administered on 07/09/14. Review of Resident #2's Nurse's Notes, dated 07/10/14, revealed the staff noticed Resident #2 walking down the north hallway and entering Resident #5's room and removing some of the other resident's sodas. When staff approached Resident #2, he began to cuss at the staff. The notes reflected the staff attempted to redirect the resident, after having to physically remove the drinks from his hands, which was not effective. Review of the "Social Work Referral," dated 07/11/14, revealed Resident #2 entered Resident #5's room, "getting (Resident #5's) sodas, and redirection was not effective...." The SWA spoke with Resident #2 concerning entering another resident's room and taking drinks. The importance of respecting others privacy was discussed with Resident #2. (Note): Resident #2 suffers from a [MEDICAL CONDITION] and refuses constant redirection from staff, as the SWA has "them" (administration) aware of the factor. Review of Resident #2's Nurse's Notes, dated 07/11/14, revealed he had a verbal altercation at the breakfast meal and had to be redirected. Further review of the note revealed Resident #2 would curse the staff out as he was re-directed. Review of Resident #2 Nurse's Note, dated 07/13/14, revealed he was cursing Resident #5 in the dining area during meal service. Resident #5 picked up a four foot long fluorescent bulb and struck Resident #2 on the left side of his head causing a 1.2 centimeter laceration. Resident #2 was transferred to the emergency room for evaluation and treatment. Upon return from the emergency room , RN B had to go outside and stop Resident #2 from starting a fight with Resident #5. An interview with RN B on 08/11/14 at 1:20 p.m. revealed when asked if she worked on 07/13/14, the day Resident #2 was struck by the florescent light bulb, she replied yes. She stated she was the nurse who assessed him and sent him to the emergency room . RN B said it was really a "mess and I was shocked this had happened." RN B said when Resident #2 came back from the hospital, he went outside and she had gone outside because the resident was trying to start a fight. RN B said she faxed all her paperwork to the Administrator, but was told to just keep monitoring him, "so that was what I did." Review of Resident #2's, Care Plan, dated 07/14/14, following the incident, provided by the Administrator at the time of exit on 08/13/14 revealed the problem as "Escalated behavior." The Care Plan reflected, "...Dignity will be maintained of resident and others without noted behavior in next 90 days...1. Use non-violent physical approach. 2. Remove other residents and all unnecessary staff from immediate area. 3. Immediately say "NO" and step back to 3 feet from the resident. 4. Allow resident time to cool down. 5. Attempt to redirect resident to a safe area. 6. Explain all procedures in terms that the resident understands and repeat as necessary until that understanding is achieved. 7. Keep environment free of all hazards. 8. In the event of an episode, a 1:1 monitoring will be implemented immediately. 9. Check for comfort and offer support as needed. 10. Anticipate behavior and re-direct when close proximity to others that might invoke aggression...." Review of the facility's "Incident/Accident Investigation Follow-up," dated 07/13/14, revealed at 11:45 a.m. Resident #5 hit Resident #2 with a light bulb. Resident #2 was sent to the hospital for evaluation and treatment of [REDACTED]. The Investigation Follow-up did not reflect any recommendations/interventions to prevent further occurrences. Review of the facility's Provider Investigation Report, dated 07/13/14, revealed in the section, Investigation Summary, Resident #2 was cursing Resident #5 in the dining room, and Resident #2 began to threaten Resident #5. Resident #5 grabbed a Florescent Bulb and hit Resident #2 on the side of the head. The report reflected the residents were separated, and there were no more issues. Resident #5 voiced regret for hitting Resident #2. The section, Provider Action Taken Post-Investigation, reflected to refer to Social Services (no indication which residents were referred), refer for follow-up with Psychologist, the Maintenance Supervisor was written up for not getting the bulb put away after the contractors left it out, every 15 minutes monitoring for Resident #2 and Resident #5, with no other incidents, and had an all staff in-service on watching for any inappropriate items being left out/safety monitoring. An interview on 08/11/14 at 3:14 p.m. with CNA D revealed she did not see Resident #2 get hit by the light bulb, but she heard all the commotion. CNA D said she had been in the dining room about 10 minutes earlier and Resident #2 was walking around Resident #5's table cussing, yelling, and "shooting (Resident #5) the finger." CNA D revealed Resident #2 has this type of behavior all the time. She stated he walked around "shooting the finger" at other residents and cussing saying "[***] you." When asked about Resident #5's behaviors, CNA D replied Resident #5 was a quiet man, never had been aggressive, and was a very pleasant person. On 08/12/14 at 6:00 p.m., Resident #3 and Resident #17 stated they had been in the dining room during the incident between Resident #2 and Resident #5 on 07/13/14. They stated Resident #2 was cursing at and drawing his hand back as if he was going to hit Resident #5. An interview on 08/11/14 at 3:30 p.m. with LVN G revealed Resident #2 always cussed and Resident #5 just hit him. LVN G indicated Resident #5 just got tired of listening to him. When asked about Resident #5's behaviors, LVN G replied Resident #5 was a quiet man, and she never really had any problems with him. An interview on 08/11/14 at 3:15 p.m. with CNA F revealed she worked double weekends and had been employed one year. CNA F said Resident #2 was always cussing the other residents and the staff, and she did not understand why something had not been done about Resident #2. CNA F said, "You see what happened to him, he got hit in the head with that light bulb." Surveyor queried CNA F concerning Resident #5's behaviors. CNA F replied, "I have never had any problems with aggression with Resident #5." An interview with MA H on 08/13/14 at 12:45 p.m. revealed she was in the main dining room during the incident involving Resident #2 and Resident #5 on 07/13/14. MA H stated she had been assisting another resident to eat and she was not facing the direction of the incident to see what occurred. According to MA H, she heard Resident #2 cursing as was usual for the resident. Resident #5 was cursing back in response to Resident #2. MA H was queried about whether she had intervened during the verbal exchange between the two residents. MA H stated she was unable to recall what she had said, but she had probably instructed Resident #2 to "let's use kind words," as she often did. During this interview, MA H stated she was usually able to redirect Resident #2, but had not received any specific training at the facility related to dealing with Resident #2's behaviors An interview on 08/13/14 at 3:20 p.m. with the ADM regarding Resident #2's behavior revealed she was aware the resident had several resident-to-resident altercations prior to the incident with Resident #5 on 07/13/14. However, she was not aware nursing staff had contacted 911 on 07/06/14 due to Resident #2 behaving aggressively both verbally/physically and hitting a staff member. The Administrator stated if she had known she would have "done something sooner" to address Resident #2's behaviors. According to the ADM, Resident #2 was not physically aggressive "99 percent of the time." She further stated aggressive behaviors were addressed in the resident's care plan and interventions included redirection. She revealed she did not feel staff had become complacent, but more of an acceptance of the resident's behaviors as "that's who they are." The ADM stated she felt staff had "just gotten used to" Resident #2's behaviors, "as we all do" with residents with psychiatric diagnoses. The ADM further stated training and teaching related to dealing with behavioral issues had been provided to staff. An Abuse and Neglect In-Service was conducted on 01/24/14. The in-service included the types of abuse, the definition of neglect, reporting abuse and identified the Abuse Coordinator as the Administrator. An In-Service conducted on 02/10/14 included verbal and mental abuse. A sign-in sheet, dated 02/10/14, reflected 39 signatures of staff. The facility's Pay Day Meeting on 04/25/14 included information regarding resident-to-resident altercations and the resident, who instigated or who hurt the other resident, would be placed on one-to-one supervision. The sign-in sheet, dated 04/25/14, reflected CNAs, a medical records staff member, MAs, the ADON and the DON attended the meeting. Twenty names were on the sign-in sheet. Review of the facility's in-service training report, "Physical & Psychological Changes," revealed on 06/10/14 an in-service for all staff was conducted by a guest speaker, from a psychiatric hospital, regarding "Behaviors." Handouts were provided to the staff. One undated handout reflected, "General Guidelines Evaluate and treat treatable conditions (e.g. (for example), pain, urinary tract infection) Prevent new occurrences Educate patient, family, and staff Identify and reduce causative factors Provide periods of reduced stimuli." The undated handout, Behavioral Interventions, reflected, "Reinforcement of alternative behaviors Positive reinforcement Redirection Active Listening Simplify tasks - reduce steps." The undated handout, Possible Non-medication Interventions, reflected, "Behavior Verbal Anger/Abusive Language Possible Interventions Distract & redirect; Try to determine the 'real' reason for the outburst...." Another undated handout, Possible Non-medication Interventions reflected, "Behavior...Aggression (hitting, yelling, verbal abuse, etc.) Possible Interventions...Remove resident from situation, allow space to pace if possible, decrease stimuli, use articles of comfort, utilize crisis intervention techniques." The In-Service Sign-In Sheet, dated 06/10/14, reflected 38 employees attended the in-service including CNAs, LVNs, Housekeepers, laundry staff, RNs, medication aides, business office staff, and kitchen staff. Review of Resident #2 "Psychologist's Progress Notes," dated 07/15/14, revealed he had an altercation with another resident who hit him. The other resident apparently got tired of Resident #2 sticking his middle finger up at him and cursing, so he hit Resident #2. The notes reflected, "I talked to (Resident #2) about not giving the 'finger' to people and being careful about what he says to other people." Resident #2's Social Progress Notes did not reflect an entry regarding his altercation on 07/15/14 with Resident #5. Review of Resident #2's "Social Services Quarterly Assessment," dated 07/21/14, revealed he had no new issues this quarter. The assessment reflected, "Resident #2 is aware of self only, able to makes simple decisions only, is verbally abuse and at times is physically abusive. (Resident #2) requires constant redirection... (Psychological) services offered as needed/upon request...." Review of an unsolicited document faxed on 08/13/14 at 11:02 p.m. revealed "(Resident #2) did not have any physical aggression. (Resident #2) not physical aggressor." Review of Resident #2's Nurse's Notes, dated 07/21/14, revealed he was hit by another resident in the mouth for calling the resident a "[***] ." Review of the facility's "Incident/Accident report," dated 07/21/14, revealed Resident #2 was slapped in the mouth by another resident for calling her a "[***] ." Resident #2 had an abrasion to his lip. Further review revealed a Nurse's Note, dated 07/22/14, provided by the facility with the "Incident/Accident," which reflected the female resident reported to the ADON that Resident #2 grabbed her arm and called her a "[***] " and she slapped Resident #2 in the face to get him to let go of her. The "Incident/Accident Investigation Follow-up," dated 07/21/14, reflected the recommendation/intervention was to refer to Social Services. Review of the unsolicited document faxed on 08/13/14 at 11:02 p.m. revealed this was the first incident Resident #2 was the physical aggressor resulting in a minor injury for Resident #2. An interview with the SWA on 08/25/14 at 3:48 p.m. revealed she assisted with the Social Progress Notes, but the Social Worker came in every other Saturday and read them and signed off on the documentation. SWA said if the Social Worker could not come, then the ADM, who was a Social Worker would review her notes and sign them. When asked about Resident #2 and her visits with him, SWA replied the ADM and the DON would tell her to just go and talk to Resident #2 when he got upset and redirect or encourage him because there was not much they could do for him because of his "[MEDICAL CONDITION]." The SWA stated she always tried and gave Resident #2 positive encouragement every time she saw him, but it never seemed to last long. The SWA revealed sometimes they (Administrative Staff) got together and discussed certain situations and she would have an opinion, but she never made a decision. She stated the decisions were always made by the DON or the ADM. The SWA revealed, "I just did what I was told to do." Interview on 08/26/14 at 3:26 p.m. with the facility's SW revealed she did come to the facility and review and sign the the Social Progress Notes completed by the SWA every other Saturday. The SW stated she was aware of Resident #2's verbal aggression, but had trusted the facility ADM to make the decision what to do. The SW said since the ADM was a Social Worker, and was around the resident regularly, she felt it was better served if they decided what to do with Resident #2. She revealed she trusted that to be the right decision. When asked what she would have done if she were the full time SW in the facility, the SW replied she would have immediately discharged the resident to a Psychiatric Behavior Unit for an evaluation and possible alternate placement. An interview on 08/12/14 at 3:30 p.m. with RN C revealed she had not worked at the facility for a long time, but she had a psychiatric nursing background. RN C said Resident #2 had been re-directed by her when he had become aggressive. RN C said Resident #2 had the potential to be "explosive." An interview on 08/13/14 at 9:30 a.m. with the DON revealed Resident #2 was verbally abusive. When asked what she had done to assist Resident #2 with his "verbally abusive behavior," the DON replied, "(Resident #2) has always been that way." Interview on 08/26/14 at 11:50 a.m. with the Psychologist revealed he was not aware Resident #2 had been having verbal aggression, with outbursts. The Psychologist said if the facility had made him aware he would have recommended Resident #2 be evaluated for a Psychiatric admission or have the primary care physician review his medications. Review of the facility's "Incident/Accident Report," dated 07/28/14, revealed at 8:00 a.m. Resident #2 walked up to another resident in the sitting room and "punched" the other resident in the chest. The recommendation/intervention was to refer to Social Services. Review of the "Behavior Detailed Entry Report" dated June and July 2014 revealed documentation by the CNAs concerning Resident #2's behaviors. Resident #2's behaviors at times included, refusing activities of daily living care (ADLs), refusing to eat, yelling, cursing, threatening staff and other residents, and wandering. An interview on 08/12/14 at 2:45 p.m. with CNA D revealed Resident #2 could be very "rough" to handle at times. She stated the ADM told the staff they just had to re-direct him, but "honey that does not work and he (Resident #2) could be very scary sometimes." CNA D said there had been a couple of times where she had really thought about just walking up to the Nurse's Station and calling the police, but she was afraid that she would lose her job. CNA D revealed she would just try and keep the other residents from hurting Resident #2, or Resident #2 from hurting one of the other residents. When asked if she had been in-serviced regarding how to manage residents with behaviors, she replied yes, over and over again, but they were not resident specific. The staff was told they just had to accept them the way they were, like Resident #2 only had "Half a brain, like that is supposed to help us understand him and keep him and others safe." CNA D revealed then the ADM would just "give us a hand-out, and go to talking about a bunch of other stuff." Review of Resident #2's Nurse's Notes, dated 07/29/14 revealed he was transferred to the "Hospital" for evaluation and treatment on 07/29/14 at 11:00 a.m. Review of Resident #2's psychiatric hospital's History and Physical, dated 07/29/14 (when he was admitted ), revealed, "(Resident #2) was assessed with [REDACTED].#2) is paranoid and suspicious of other residents at the nursing home...(Resident #2) poses significant danger to self and others." The "History of Present Illness" reflected, "(Resident #2) was very paranoid and suspicious, (Resident #2) reported to the physician at the hospital that he thinks the other residents are making fun of him and calling him names. (Resident #2) said he hit another resident without provocation, because the other resident called him a 'mother[***] ,' when (Resident #2) was asked why he did not reported (sic) this, (Resident #2) said I do not report, I take action, if he hits me, I will kill him." Further review of the History and Physical revealed during the assessment: "Resident was very restless, unable to stay still, pacing and fidgeting, (Resident #2) was unable to concentrate and not able to follow directions, and has mood swings with outburst...The goal for treatment is to stabilize his mood, eliminate the [MEDICAL CONDITION], and reduce the agitation and aggressive behaviors...to include medications and psychotherapy." Interview on 08/26/14 at 12:55 p.m. with the facility's Registered Nurse Practitioner (RNP) revealed the facility called her for everything and if she had some dates she would prove the facility had contacted her concerning Resident #2's behaviors. When asked what she did when the facility contacted her concerning Resident #2's behaviors/verbal aggression, she replied, "I would have not done anything, I would not have changed any of his medications, because I know it would have done no good. Resident #2 only has (half a brain) surely you (surveyor) can understand that. " The RNP said, "He has had surgery similar to a Lobotomy, leaving him with half a brain to use." If I gave him more medication it would just be considered a chemical restraint by the "state." Resident #2's psychiatric hospital discharge Physician order [REDACTED].); [MEDICATION NAME] 75 mg every morning (Note: The June and July 2014 physician's orders [REDACTED].) [MEDICATION NAME] and [MEDICATION NAME] were not reordered. Observation during initial tour on 08/11/14 at 9:40 a.m. revealed Resident #2 sitting up on the side of his bed in his room. The resident smiled at the surveyor and said good morning. CNA A was in Resident #2's room, making the bed and said he was incontinent of bowel and bladder, and h