Every finding on record at Legacy Nursing at St. Christina

Based on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner. The facility failed to maintain documentation of its ongoing QAPI program. This deficient practice has the potential to affect 131 residents residing in the facility.Review of facility undated policy titled QAPI Policy and Procedure revealed in part. the facility shall develop, implement, and maintain ongoing, facility wide Quality Assurance and Performance (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. Procedure: Develop, Implement, and maintain an ongoing facility wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified concerns. 7. Establish systems and process to maintain documentation relative to the QAPI program, as a basis for demonstrating that there is an effective ongoing program. On 02/24/2026 at 2:45 p.m., the surveyor requested QAPI program information from S1 DON. On 02/24/2026 at 4:00 p.m., a review of the binder provided to the surveyor by S1 DON and S17 Regional revealed a lack of documentation for the facility's QAPI program. In an interview on 02/24/2026 at 4:30 p.m. with S1 DON, S2 ADM, and S17 Regional, it was revealed that the facility was unable to locate its QAPI binder, which contained the facility's documentation and evidence of its ongoing QAPI program. On 02/24/2026 at 5:26 p.m., S17 Regional stated that the facility could not provide evidence of the facility's QAPI program due to the inability to locate the QAPI binder.

Based on record review and interview, the facility failed to provide documentation of the Quality Assurance and Performance Improvement (QAPI) program that addresses the facility's performance improvement activities and projects. The facility failed to provide evidence of the number and frequency of improvement projects conducted. This deficient practice had the potential to affect 131 residents residing in the facility.The facility was unable to present any documented evidence of activities, projects, or the frequency of improvement projects addressing services for the Quality Assurance and Performance Improvement (QAPI) program during the survey. In an interview on 02/24/2026 at 4:30 p.m. with S1 DON, S2 ADM, and S17 Regional, it was revealed that the facility is unable to locate its QAPI binder, which contains the facility's documentation and evidence of its ongoing QAPI program. The facility was unable to provide documentation of its systems and reports on the facility's reporting, investigations, tracking, trending, and monitoring of issues identified in the facility and the QAPI programs' ongoing performance improvement plans.

Based on observation and interview, the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by failing to:1. Ensure all residents seated at the same table were served simultaneously during dining service.2. Ensure Resident #100 was served his meal tray in his room at the same time of his roommate.Total sample size: 56 Findings:1.On 02/22/2026 at 11:51 a.m., Observation of dining room revealed residents seated at the same table were not served at the same time. Three residents were observed seated together at one table. One resident at the table received her meal tray at that time. Following the delivery of that tray, staff were observed serving residents at other tables. On 02/22/2026 at 12:07 p.m., the remaining residents seated at the same table had not yet received their meal trays. On 2/22/2026 at 12:08 p.m., an interview with S14RN/Weekend Supervisor, confirmed that residents seated at the same table should be served meal trays at the same time, but were not. 2.Resident #100Review of Resident #100's medical record revealed an admit date of 04/02/2025 with diagnoses which included: Type 2 Diabetes without Complications, Bipolar Disorder, Hypertension, Hyperlipidemia, Mild Cognitive Impairment, and Muscle Weakness. Review of Resident# 100's quarterly MDS with an ARD of 01/13/2026 revealed Resident #100 had a BIMs score of 15, indicating intact cognition. Resident #100 was independent or required set-up assistance with ADLs. On 02/23/2026 at 8:27 a.m. Resident #100 expressed concerns that his roommate routinely received his breakfast tray approximately one hour before he did. Resident #100 stated he consumed all of his meals in his room. At the time of interview, Resident #100 has not received his breakfast tray. On 02/23/2026 at 8:29 a.m., Interview with S15CNA revealed that two meal carts are delivered to Resident #100's hallway. S15CNA stated the first meal cart arrives at approximately 7:30 a.m. with 12 trays. S15CNA revealed a second meal cart arrives after all residents in the dining room have been served. On 02/23/2026 at 9:15 a.m., Observation revealed Resident #100 still had not received his breakfast tray. Interview with S16CNA revealed that Resident #100's roommate received his breakfast tray with the first meal cart at approximately 7:30 a.m. S16CNA confirmed that Resident #100 had not received his breakfast tray at that time. On 02/23/2026 at 09:23 a.m., an interview with S6DM confirmed that when residents share a room and receive their meals in their room, they should receive their meal trays at the same time. S6DM acknowledged that Resident #100 did not receive his breakfast tray at the same time as his roommate, but should have.

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered plan of care for each resident and ensure that care and services were furnished to attain the resident's highest practicable physical, mental, and psychosocial needs that were identified in the comprehensive assessment for 4 (Resident #10, #32, #80, and #90) of 56 sampled residents by the facility failing to:1. Provide a fall mat as care planned for Resident #90,2. Develop and implement a plan of care related to the activity of daily living (ADL) needs for Resident #32, 3. Provide a splint for a left hand contracture for Resident #80 as care planned.4. Develop and implement a care plan related to Resident #10's nebulizer treatments. Review of facility undated policy titled, Care Planning Policy and Procedure, revealed in part. Purpose: To provide a comprehensive plan of care addressing the resident's needs, strengths, goals, and approaches. Policy: Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches. Resident #90 Review of Resident #90's health record revealed an admission date of 04/07/2025 with diagnoses that included, in part, Chronic Obstructive Pulmonary Disease, Seizures, Severe Major Depressive Disorder, Schizophrenia, and Drug-Induced Subacute Dyskinesia. Review of Resident #90's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/2026, revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of Resident #90's care plan revealed the resident was at risk for falls with interventions that included, in part, a fall mat on the floor next to the bed. Review of facility incident/accident log dated 11/22/2025-2/22/2026 revealed Resident #90 had a witnessed fall 02/20/26 and unwitnessed falls 01/21/2026 and 02/08/2026. On 02/23/2026 at 09:36 a.m., observation revealed Resident #90 sitting on the floor of his room in front of his wheelchair. No fall mat was observed in Resident #90's room at this time. On 02/23/2026 at 11:39 a.m., observation revealed that Resident #90 was on the floor of his room, positioned on his right side. The resident's right arm was positioned under him and observed to have purple discoloration. The resident was observed with one shoe off and pants around his ankles. No fall mat was observed in Resident #90's room at this time. On 02/23/2026 at 1:24 p.m., observation revealed Resident #90 on the floor in his room, positioned on his back next to his bed. No fall mat was observed in Resident #90's room at this time. In an interview on 02/23/2026 at 1:26 p.m. at Resident #90's bedside, S2 ADM confirmed Resident #90 did not have a fall mat in his room as care planned, and should have. Resident #32 Review of Resident #32's health record revealed an admission date of 05/15/2025 with diagnoses that included, in part, Chronic Obstructive Pulmonary Disease, Asthma, Schizoaffective Disorder, Major Depressive Disorder, Impulse Disorder, and Extrapyramidal and Movement Disorder. Review of Resident #32's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/2025, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 7, indicating moderate cognitive impairment. Resident #32 required partial to moderate assistance with bathing/showering, upper-body dressing, lower-body dressing, and transfers. Resident required substantial/maximal assistance with Personal hygiene and putting on and taking off footwear. Review of Resident #32's care plan, with an initiation date of 05/16/2025 and next review date of 02/28/2026, revealed no information related to Resident #32's ADL needs. In an interview on 02/24/2026 at 1:30 p.m., S1 DON stated that all residents' ADL needs should be care-planned. Review of Resident #32's care plan at this time with S1 DON. S1 DON confirmed Resident #32's ADL needs were not care planned, and should have been. Resident #80 Review of Resident #80's EMR (Electronic Medical Record) revealed an initial admission date of 01/29/2025 and diagnoses that included in part, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side, Dysphagia following Cerebral Infarction, Unspecified Mood (Affective) Disorder, Epilepsy, Anxiety, Post Traumatic Stress Disorder, and History of Falling. Review of Resident #80's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/03/2026 indicated Resident #80 was dependent on staff for assistance with eating, mobility, transfers, and personal hygiene. Resident #80 had a BIMS (Brief Interview for Mental Status) score of 13, which indicated intact cognition. Review of Resident #80's Care Plan with an initial date of 02/11/2025 included but is not limited to, Impaired ROM (Range of Motion) requiring splint/brace as evidenced by having difficulty with left hand of active motion and preventing contractures.Wear splint 3 hours a day. Observation on 02/22/2026 at 9:50 a.m. revealed Resident #80 in bed after breakfast. Resident #80 had a left-hand contracture with no splint/brace visible. A brief visual search of resident's furniture and storage shelf did not reveal a splint/brace available for the resident to use. Interview on 02/22/2026 at 9:55 a.m. with Resident #80 revealed that he had not worn a splint/brace on his left hand for a long time and did not know where it was. Interview on 02/23/2026 at 2:45 p.m. with S12 CNA, revealed that she was not aware of a splint/brace available for Resident #80. Observation on 02/23/2026 at 2:47 p.m. of Resident #80's left hand opened by S12 CNA, revealed the inside of his palm was darkened pink with skin that appeared to be pealing and have some surface damage. Interview on 02/24/2026 at 1:30 p.m. with S1 DON confirmed that Resident #80 should have had a splint/brace for his contracted left hand as care-planned but did not. Resident #10 Review of Resident #10's medical record revealed an admit date of 01/24/2025 with diagnoses that included in part.Anemia, Hypertension, Other Specified symptoms and signs involving the Circulatory and Respiratory Systems, and Parkinson's Disease. Review of Resident #10's 02/2026 Physician's Orders revealed in part. Other specified symptoms and signs involving the Circulatory and Respiratory Systems and Personal History of Pneumonia. Review of Resident #10's Physician Orders dated 02/2026 revealed in part.Ipratropium-Albuterol Inhalation Solution (breathing treatment) 0.5-2.5 (3) MG/3ML. 1 application inhale orally every six hours related to Other Specified symptoms and signs involving the Circulatory and Respiratory Systems. Order date 11/24/2025. Review of Resident #10's current Care Plan revealed no documented evidence of a care plan related to Resident #10's nebulizer treatments. Interview on 02/23/2026 with S13 LPN/MDS Nurse confirmed Resident #10 did not have a care plan related to his nebulizer treatments, but he should have.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing: 1. To accurately assess and document the presence of skin tears for Resident #682. To ensure Physician's Orders were implemented for Resident #100. Review of a facility policy titled, Skin/Wound Documentation Policy and Procedure with no review date, read in part.Policy: Skin and wounds will be documented upon admission, readmission, weekly and as needed. Review of Resident #68's medical record revealed an admit date of 12/23/2025 with diagnoses that included in part. Review of Resident #68's medical record revealed an admission date of 12/23/2025 with diagnoses that included in part.Hypertension, Neuroleptic Induced Parkinsonism, Protein-Calorie Malnutrition, and Generalized Anxiety Disorder. Review of Resident #68's admission MDS with an ARD of 12/29/2025 revealed a BIMS sore of 3, which indicated severe cognitive impairment. The MDS revealed Resident #68 needed partial/moderate assistance with toileting and oral hygiene; substantial/maximal assistance with bathing and supervision or touching assistance with eating. Review of Resident #68's Care Plan revealed in part.I have impaired skin integrity with interventions that included in part.watch for changes in my skin status that may indicate worsening of my wound and notify the physician. Watch my skin when providing routine care. Observation on 02/22/2026 at 9:50 a.m. revealed Resident #68 lying in bed with blood on his forehead. Resident #68 observed to have a large band-aide on top of his left hand and uncovered skin tears to bilateral arms. Resident #68 was not verbal at this time. Review of Resident #68's 02/2026 Physician's Orders read in part. Order dated 02/16/2025 by Treatmentm#1: Skin tear: L Hand: Cleanse with wound cleanser, pat dry, apply Triple Antibiotic Ointment, and cover with dry dressing until healed. Treatment #2: Skin tear Left Arm cleanse with wound cleanser, pat dry, apply Triple Antibiotic Ointment and cover with dry dressing until healed. Treatment #3 Left above the eye abrasion, cleanse with wound cleanser, pat dry, apply Triple Antibiotic Ointment and leave open to air daily until healed. Treatment #4 Skin tear; Right Elbow, cleanse with wound cleanser, pat dry, apply Triple Antibiotic Ointment, and cover with dry dressing until healed. Skin tear #5 Left Elbow, cleanse with wound cleanser, pat dry, apply Triple Antibiotic Ointment, and cover with dry dressing until healed. Review of Resident #68's nursing progress notes revealed no documentation of an initial assessment or documentation of skin tears. Interview on 02/23/2026 at 10:08 a.m. with S1 DON revealed she did not know how Resident #68 had gotten skin tears or an abrasion to the forehead. S1 DON stated there was no assessment in the nurse's notes and no incident reports documented on Resident #68. Interview on 02/23/2026 at 10:30 a.m. with S18 LPN/Treatment Nurse revealed she did not know how Resident #68 had gotten skin tears to his arms or an abrasion to the forehead. S18 LPN/Treatment nurse revealed she had did a revision to Resident #68's treatment orders for skin tears and abrasion, but had no knowledge of how he acquired them. Telephone interview on 02/24/2026 at 1:26 p.m. with S14 RN/Weekend Supervisor revealed she had worked on 02/21/20206 and 02/22/2026. S14 RN/Weekend Supervisor stated S19 CNA had reported to her that Resident #68 had walked into a wall, and had a scratch above his eyebrow. S14 RN/Weekend Supervisor stated she had not completed an incident report or documented the incident in Resident #68's medical record. S14 RN/Weekend Supervisor stated about two weeks ago resident had acquired skin tears to his left arm, and she had not documented the incident but should have. Telephone interview on 02/24/2026 at 1:30 p.m. with S19 CNA revealed on 02/22/2026 she had notified S14 RN/Weekend Supervisor that Resident #68 had walked into a wall and had a skin tear to his forehead. Interview on 02/24/2026 at 2:15 p.m. with S1 DON confirmed the following (regarding Resident #68's skin issues): upon any injury the physician and family should be notified, an incident report should be completed and documented in the resident's medical record. Resident #100 Review of Resident #100's medical record revealed an admit date of 04/02/2025 with diagnoses which included: Type 2 Diabetes without Complications, Bipolar Disorder, Hypertension, Hyperlipidemia, Mild Cognitive Impairment, and Muscle Weakness. Review of Resident #100's quarterly MDS with an ARD of 01/13/2026 revealed Resident #100 had a BIMs score of 15, indicating intact cognition. Resident #100 was independent and required set-up assistance with ADLs. On 02/22/2026 at 9:21 a.m., an interview with Resident #100 revealed he had not received several scheduled doses of his prescribed nighttime insulin. Review of Resident #100's Physician Order dated 09/11/2025 read in part.Tresiba FlexTouch Subcutaneous Pen-Injector 100 units/ml – Inject 32 units subcutaneously at bedtime related to Type 2 Diabetes. Review of Resident #100's Medication Administration Record (MAR) for January 2026 through February 2026 revealed Resident #100 did not receive Tresiba on the following dates: 01/12/2026 01/14/2026 01/15/2026 01/19/2026 01/27/2026 01/31/2026 02/11/2026 On 02/24/2026 at 12:46 p.m. Medication Administration Record for Resident #100 reviewed with S1DON. S1DON confirmed that Resident #100's Tresiba was not administered on the identified dates. S1DON confirmed there were no corresponding progress notes documenting a clinical reason the medication was withheld. S1DON confirmed Resident #100 should have received the medication Tresiba as ordered, but did not.

Based on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the menu to ensure the nutritional adequacy of the meal for all 6 residents who received a puree diet.Findings:In an interview during the second kitchen visit on 02/22/2026 at 10:30 a.m., S11 Kitchen Staff revealed the facility had 6 residents being served a puree diet. In an observation on 02/22/2026 at 10:45 a.m., S11 Kitchen Staff failed to puree the roll which was included on the lunch menu. In an interview on 02/23/2026 at 12:15 p.m., S11 Kitchen Staff confirmed that she had not pureed the roll that was included on the menu on 02/22/2026. S11 Kitchen Staff also confirmed she had not been pureeing any bread items when listed on the menu for an unspecified amount of time for all 6 residents who received a puree diet. In an interview on 02/23/2026 at 12:20 p.m., S6 Dietary Manager confirmed S11 Kitchen Staff did not follow the menu on 02/22/2026 by not pureeing the roll but should have.

Based on observation and interview, the facility failed to maintain an effective pest control environment by failing to ensure the facility was free from insects. The deficient practice had the potential to affect all 131 residents who resided in the facility.Findings: Review of the facility's undated policy titled, Pest Control Policy and Procedure read in part.Policy: The facility shall maintain an effective pest control program.Procedure: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During an observation of Resident #8's room on 02/23/2026 at 7:51 a.m., 8:50 a.m., and 9:20 a.m. revealed multiple gnats on a basket of soiled clothes and multiple gnats flying around on top of the basket of clothes. In an interview on 02/23/2026 at 2:05 p.m., S8 NS Adm acknowledged multiple gnats were observed in Resident #8's room in the basket and on top of the soiled clothes and should not have been. In an interview on 02/24/2026 at 6:20 p.m., S5 CES confirmed the above findings.

Number of residents sampled: Number of residents cited: Review of a facility policy titled Advance Directives Policy and Procedure, with no review date read in part.Procedure: 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.Review of Resident #68's medical record revealed an admission date of 12/23/2025 with diagnoses that included in part.Hypertension, Neuroleptic Induced Parkinsonism, Protein-Calorie Malnutrition, and Generalized Anxiety Disorder.Review of Resident #68's medical record on 02/22/2026 at 2:23 p.m. revealed Resident #68's 02/2026 Physician Orders read in part. order dated 01/16/2026-LaPOST-DNR (Do Not Resuscitate). Review of Resident #68's Care Plan with a Target Date of 04/11/2026 revealed in part . I have and advance directive-Full Code with interventions that included in part.I need the nursing staff to have knowledge of my advance directives. I need the social worker to review with me quarterly and as needed for changes in my advance directives.Interview on 02/23/2026 at 11:37 a.m. with S1 DON and S13 LPN/MDS Nurse revealed Resident #68 had a signed physician's order (LaPOST) for DNR and Resident #68's face sheet indicated he was a DNR. Review of Resident #68's care plan at this time with S1 DON and S13 LPN MDS revealed Resident #68 was care planned as a Full Code status. S1 DON and S13 LPN/MDS Nurse confirmed Resident #68's code status on his Care Plan should have been DNR, not Full Code.

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food service safety. The facility failed to ensure that kitchen staff were wearing hair restraints including beard restraints to prevent hair from contacting food. The deficient practice had the potential to affect all of the residents who received meals from the kitchen. There were 131 residents who resided in the facility.Findings:Observation on 02/23/2026 at 12:15 p.m. of the facility's kitchen revealed three male kitchen workers with beards not wearing beard restraints while preparing food, serving food, and washing dishes. Interview on 02/23/2026 at 12:17 p.m. with S6 Dietary Manager revealed that beard restraints are easily available to the male workers with beards. She confirmed that the male kitchen workers with beards should have had beard restraints on but did not.

Number of residents sampled: Number of residents cited: Review of a facility policy titled Oxygen Concentrator Cleaning Policy and Procedure, with no review date read in part.Procedure:Store Oxygen tubing, cannula, and mask in plastic bag when not in use.Oxygen tubing, cannula and mask to be changed weekly and as needed.Review of Resident #10's medical record revealed an admit date of 01/02/2025 with diagnoses which included in part.Anemia, Parkinson's Disease without Dyskinesia, Other Specified symptoms and signs involving the Circulatory and Respiratory Systems and Personal History of Pneumonia.Review of Resident #10's Physician Orders dated 02/2026 revealed in part.Ipratropium-Albuterol Inhalation Solution (breathing treatment) 0.5-2.5 (3) MG/3ML. 1 application inhale orally every six hours related to Other Specified symptoms and signs involving the Circulatory and Respiratory Systems. Order date 11/24/2025.Observation on 02/22/2026 at 1:55 p.m. revealed a nebulizer machine on Resident #10 bedside table. Nebulizer mask was lying on top of the nebulizer machine, uncovered and undated.Interview on 02/22/2026 at 2:00 p.m. with S3 LPN stated Resident #10 received breathing treatments routinely. S3 LPN stated she had given Resident #10 a breathing treatment earlier that day. S3 LPN confirmed Resident #10's nebulizer mask and tubing should have been covered and dated but were not.

Based on interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene by failing to provide assistance with bathing for 1 (Resident #113) of 5 residents reviewed for ADLs. Findings:Review of Resident #113's medical record revealed an admit date of 07/10/2025 with diagnoses which included: Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Atrial Fibrillation, Paranoid Schizophrenia, Major Depressive Disorder, Heart Failure, and Lack of Coordination. Review of Resident #113's Quarterly MDS with an ARD of 01/05/2026 revealed Resident #113 had a BIMs score of 9, indicating moderate cognitive impairment. Resident #113 required partial/moderate assistance with bathing. Review of Resident #113's Care Plan revealed that Resident #113 required staff assistance with ADL care, including bathing. Review of Resident #113's bathing task documentation for the last 30 days revealed Resident #113 received a whirlpool bath on 02/06/2026, 02/17/2026, and 02/19/2026. Documentation reflects a 10-day gap between 02/07/2026 through 02/16/2026 without evidence that bathing services were provided or refused. On 02/22/2026 at 9:37 a.m., interview with Resident #113 revealed he was not consistently receiving his baths as scheduled. On 2/24/2026 at 10:14 a.m., interview with S4CNA revealed that completed baths and refusals are documented in the facility bath log and in the resident's electronic medical record. S4CNA confirmed there was no documentation in the facility bath log indicating Resident #113 received or refused a bath from 02/07/2026 through 02/16/2026 (10 days). On 02/24/2026 at 10:24 a.m., interview with S5CES confirmed there was no documentation in Resident #113's electronic medical record or in the facility bath log indicating Resident #113 received or refused a bath from 02/07/2026 through 02/16/2026. S5CES confirmed that Resident #113 should have received his baths as scheduled, but did not.

Based on record review and interview, the facility failed to ensure the Quality Assessment and Assurance committee met at least quarterly to identify facility issues and coordinate and evaluate performance improvement projects.A review of the facility's Quality Assurance binder revealed that the last documented Quality Assurance (QA) meeting was held on 10/15/2025 for the 2025 3rd quarter (July-September).In an interview on 02/24/2026 at 4:33 p.m., S2 ADM stated that the QAA committee did have a meeting for the 2025 4th quarter, and the documented meeting minutes were located in the QAPI (Quality Assurance and Performance Improvement Program) binder, which the facility cannot locate. S2 ADM stated he had no documented evidence of the QAA committee meeting for the 2025 4th quarter.

Findings:Review of Resident #9's medical record revealed an admit date of 10/25/2025.with diagnoses that included in part.Paraplegia, Chronic Obstructive Pulmonary Disease (COPD), Essential Hypertension, and Neuromuscular Dysfunction of Bladder.Review of the Resident #9's Quarterly MDS with an ARD of 02/03/2026 revealed the following:Section K - Swallowing/Nutritional Status - The resident was on a therapeutic diet. Review of Resident #9's physician orders dated 10/25/2025 revealed an order for NAS (no added salt) diet, Regular texture, Regular-Thin consistency. Double meat, paper tray set up.Review of Resident #9's care plan revealed in part.Intervention: I need my diet served to me as ordered.1.On 02/23/2026 at 1:08 p.m., Interview and Observation of Resident #9's lunch meal ticket revealed diet of NAS, texture regular, fluid thin liquids, with no note for double meat. Observation of Resident #9's lunch tray when first served to the resident revealed he had one piece of fried chicken breast. Resident #9 stated he never gets double portion meat for meals.On 02/23/2026, Interview with S6 DM confirmed Resident #9's diet consisted of double meat, and it wasn't on the meal ticket to be served but should have been.2. Review of Resident #9's Registered Dietician's (RD) notes dated 12/23/2025 revealed recommendations for the following: 1. Add Boost/Ensure twice daily (BID) between meals to provide additional protein/calories for wound healing/weight maintenance. 2. Monitor weight weekly x 4 weeks.Review of Resident #9's RD's notes dated 01/23/2026 revealed a recommendation of the following: 1. Add Boost/Ensure BID between meals to provide additional protein/calories for wound healing/weight maintenance. 2. Monitor weight weekly x 4 weeks.On 02/24/2026, Telephone Interview with S7 RD revealed she provided the facility with her December 2025 and January 2026 recommendations on Resident #9.Review of progress notes revealed there was no documentation of the recommendation being charted as a physician order or being documented in the nurses' notes if not approved.On 02/24/2026 at 3:20 p.m., S1 DON confirmed Resident #9 did not have an order for Boost/Ensure twice a day (BID) but should have.

A review of the facility's undated policy titled, Quality of Care Policy and Procedure, read in part. It is the policy of our company that each resident receives the necessary care to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the resident's comprehensive assessment and plan of care.Resident #1Review of Resident #1's medical record revealed an admission date of 10/06/2022, with diagnoses that included, in part. Chronic Obstructive Pulmonary Disease, Type II Diabetes, and Benign Prostatic Hyperplasia with lower urinary tract symptoms, Obstructive and Reflux Uropathy.Review of Resident #1's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/30/2025 revealed Resident #1 had a BIMS score of 14, which indicated intact cognition. Resident #1 required moderate assistance with showering and bathing.Review of Resident #1's electronic health record's facility task titled, Bathing/Shower Scheduled (Three times weekly) Specify days:(Monday, Wednesday, Friday OR Tuesday, Thursday, Saturday) with a lookback period of 30 days, revealed Resident #1 had 1 documented bath in the past 30 days.Review of handwritten bathing documentation for November 2025 revealed Resident #1 received a bath on 11/15/2025, 11/16/2025, and 11/20/2025. In an interview on 12/08/2025 at 09:00 a.m., Resident #1 revealed he has not had a bath in one week and would like one.Resident #2Review of Resident #2's medical record revealed an admit date of 04/16/2025 with the following diagnoses in part. Chronic Obstructive Pulmonary Disease, Type II Diabetes without complications, and Morbid (Severe) Obesity due to excess calories.Review of Resident #2's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/28/2025 revealed Resident #2 was dependent for showering and bathing, and for all transfers.Review of Resident #2's electronic health record's facility task titled, Bathing/Shower Scheduled (Three times weekly) Specify days:(Monday, Wednesday, Friday OR Tuesday, Thursday, Saturday) with a lookback period of 30 days, revealed Resident #2 had 2 documented bed baths in the past 30 days. Resident #3Review of Resident #3's medical record revealed an admit date of 05/06/2025 with the following diagnoses in part.Cerebral Palsy, Bipolar Disorder Severe with Psychotic Features, Severe Intellectual Disabilities, and Binge Eating Disorder.Review of Resident #3's Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/04/2025 revealed Resident #3 did not have a BIMS score documented. Resident #3's ability to make daily decisions was severely impaired. Resident #3 was dependent on showering/bathing and for all transfers.Review of Resident #3's electronic health record's facility task titled, Bathing/Shower Scheduled (Three times weekly) Specify days:(Monday, Wednesday, Friday OR Tuesday, Thursday, Saturday) with a lookback period of 30 days, revealed Resident #3 had 2 documented baths in the past 30 days.Review of facility handwritten bathing documentation for November 2025 revealed Resident #3 received a bath on 11/17/2025 and 11/21/2025. In an interview on 12/09/2025 at 2:09 p.m., S3DON stated that all bathing charting should be completed in the facility's electronic charting system. Review of facility electronic bathing documentation (last 30 days) for Resident #1, Resident #2, and Resident #3 with the S3DON at this time. S3DON confirmed that there was insufficient documentation to support that the residents were bathed in accordance with their care plans. S3DON confirmed that baths were not provided for Resident #1, #2, and #3 routinely, but should have been. On 12/10/2025 at 08:25 a.m., review of electronic and handwritten bathing documentation for the last 30 days for Residents #1, #2, and #3 with S4CNASupervisor at this time. S4CNASupervisor confirmed that there was insufficient documentation to support that the above residents were bathed in accordance with their care plans. S4CNASupervisor confirmed that the baths were not provided routinely for Resident #1, #2, and #3, but should have been.

Based on record review and interview, the facility failed to ensure that an allegation of verbal abuse was reported immediately, but no later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 3 sampled residents reviewed for abuse. Review of the facility's undated policy titled, Abuse Reporting and Investigation Policy and Procedure, read in part. 2. An Alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance or sight, regardless of age, ability to comprehend, or disability. Examples: Name-calling, cursing, yelling at a patient in anger.Review of Resident #1's medical record revealed an admission date of 10/06/2022, with diagnoses that included, in part. Chronic Obstructive Pulmonary Disease, Type II Diabetes, Benign Prostatic Hyperplasia with lower urinary tract symptoms, Obstructive and Reflux Uropathy.In an interview on 12/08/2025 at 12:07 p.m., S1Administrator revealed that Resident #1 receives counseling services from a third-party company. A staff member from the third-party company visits and provides services to Resident #1 in the facility. In October, S1Administrator revealed he was notified by a supervisor from the third-party company that one of their staff members witnessed an incident between Resident #1 and a facility staff member. S1Administrator requested that the company staff member go to the facility to speak with him about what was witnessed. S1Administrator revealed the situation was investigated, S2SocialWorker made notes on the investigation, and nothing came of the situation. S1Administrator denied being aware of any physical or verbal abuse allegations being involved in the incident.A review of S2SocialWorker facility investigation notes dated 10/17/2025 revealed in part. on 10/17/2025, a staff member from a third-party company went and spoke with 3 facility staff members, including S1Administrator and S2SocialServices, about Resident #1. Third-party staff member said that when she was in the facility Thursday, 10/9/2025, she heard a staff member curse at Resident #1 because he urinated on the floor in front of other residents.In an Interview on 12/08/2025 at 12:55 p.m., S1Administrator revealed he did not feel it was warranted to report based off his findings during the investigation such as the incident not being brought to him for 1 week after the alleged incident and Resident #1 not having any recollection of the incident. S1Administrator confirmed after becoming aware of the incident, he did not report the allegations of verbal abuse in the form of SIMS (Statewide Incident Management System) to the Department of Health.

Based on interview, observation, and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents. This deficient practice resulted in Actual Harm for Resident #2 on 09/21/2025 at 3:30 pm, when Resident #2 was hit by Resident #4 in the face with his left fist. Resident #2 was sent to a local emergency department where he received treatment for a facial contusion. Findings: Review of the facility policy titled Abuse Prevention and Prohibition revealed in part. Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may include resident to resident, staff to resident, or family/visitor to resident. Physical abuse: May include an aggressive act, including inappropriate physical contact that is harmful or likely to cause injury or harm to a resident. Examples include hitting, slapping, pinching, biting, shoving, and kicking. Resident #2 Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses that include in part.Cerebral Infarction due to Embolism of Right Cerebellar Artery; Displaced Fracture of Upper End of Left Humerus; Diabetes; Hemiplegia and Hemiparesis following a Cerebral Infarction affecting Left Dominant Side; and Schizoaffective Disorder. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an ARD of 07/01/2025 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Resident #2 was dependent or required substantial/ maximum assistance with activities of daily living (ADLS). Review of Resident #2's care plan dated 03/05/2025 read in part. On 09/21/2025 I was trying to stop my roommate from leaving the room and physical contact was made. I have bruising noted to the left side of my face and eye orbital. Review of the facility's incident report dated 09/21/2025 at 3:30 p.m. by S2 DON read in part. Resident #2 tried to stop Resident #4 from leaving the room, resulting in a physical altercation. Injuries to Resident #2 included bruising to the left side of Resident #2's face and orbital area. Resident #2 was transferred to a local emergency department for treatment. Review of an Emergency Department record dated 09/21/2025 revealed in part.Resident #2 was sent to the hospital for an evaluation after being assaulted by his roommate. Diagnoses include: Facial Contusion and Physical Assault. Review of a Radiology report dated for 09/21/2025 read in part. Exam: CT Maxillofacial w/o contrastHistory: Assault, nose/ear bleeding, possible facial fracture, face trauma Impression: Mild soft tissue swelling and/or hemorrhage in the subcutaneous fat overlying the left side of the face. Otherwise unremarkable CT scan of the facial bones. Review of Resident #2's 09/2025 Physician Orders revealed a treatment order dated 9/27/2025 to monitor left eye and left side of face daily related to bruising. Observation on 09/29/2025 at 10:40 a.m. revealed Resident #2 had periorbital bruising to the left eye. Interview with Resident #2 at this time revealed he was hit in the eye by another resident. Resident #4 Review of the clinical record for Resident #4 revealed an original admit date of 06/12/2025 with a re-entry date of 09/17/2025 with diagnoses that include in part. Bipolar Disorder; Episodic Manic Severe with Psychotic Features; Anxiety; Depression; Moderate Intellectual Disabilities; Congestive Heart Failure; and Chronic Obstructive Pulmonary Disease. Review of Resident #4's admission MDS with an ARD of 06/24/2025 revealed Resident #4 had a BIMS score of 4, indicating severely impaired cognition. Resident #4 required minimal assistance with ADLs. Review of Resident #4's care plan dated 06/13/2025 read in part. I display behavior related to Impulse Disorder and Moderate Intellectual Disabilities. On 09/21/2025 my roommate was trying to stop me from leaving my room and trying to bite me, so I made contact with roommate. Interview on 09/29/2025 at 11:47 a.m. with Resident #4 revealed that Resident #2 was lying on a mat on the floor, attempting to hit and bite Resident #4's legs. Resident #4 reported that the behavior made him angry, and he struck Resident #2 with his left fist. Resident #4 experienced pain and swelling of the left hand following the altercation and, an x-ray was ordered. Observation of Resident #4's left hand revealed minimal swelling. On 09/29/2025 at 1:18 p.m., a telephone interview with S4 Nurse Practitioner revealed she was notified of the altercation on 09/21/2025 and was informed that Resident #2 sustained facial bruising and bleeding from his nose and left ear. Resident #2 was subsequently sent to the Emergency Department for evaluation and treatment. On 09/29/2025 at 3:51 p.m., an interview with S5 CNA reported that following the incident on 09/21/2025, Resident #4 verbalized to him that he struck Resident #2 in the face because Resident #2 was messing with his legs. On 09/29/2025 at 4:05 p.m., an interview with S6 CNA reported that on 09/21/2025, prior to the physical altercation, Resident #4 threatened Resident #2, stating, If he keeps bothering me, I will blacken his eyes. S6 CNA confirmed she reported these threats immediately to S3 LPN. On 09/29/2025 at 4:30 p.m., an interview with S7 CNA revealed that on 09/21/2025, prior to the physical altercation, Resident #4 threatened Resident #2, stating, I'm going to kill or break his arms if he doesn't stop bothering me. S7 CNA confirmed she reported these threats immediately to S3 LPN. On 09/30/2025 at 8:00 a.m., an interview with S3 LPN revealed that both Resident #2 and Resident #4 exhibited aggressive behaviors. S3 LPN confirmed that Resident #4's threats towards resident #2 were communicated to S2 DON on 09/21/2025. On 09/30/2025 at 11:05 a.m., an interview with S2 DON revealed she was made aware on 09/21/2025 that Resident #4 had made verbal threats of physical harm toward Resident #2. S2 DON stated she went to the residents' room and observed Resident #2 lying on a mat on the floor hollering and cursing, but Resident #4 was not present at that time. S2 DON confirmed the primary care provider or nurse practitioner was not notified after she was made aware of the threats and that no new orders were obtained. On 09/30/2025 at 11:45 a.m., an interview with S1 Administrator revealed he was unaware of any behavioral issues or threats between Resident #2 and Resident #4 prior to the 09/21/2025 altercation and confirmed that S2 DON should have made him aware of the threats, but had not.

Based on interview and record review the facility failed to ensure an allegation of staff to resident sexual abuse and resident to resident physical abuse was reported to the State Survey Agency immediately, but not later than 2 hours after the staff to resident sexual abuse and resident to resident physical abuse was discovered, for 2 (Resident #1 and Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents. Findings:Review of an undated facility policy titled “Abuse Prevention and Prohibition” revealed in part . “An alleged violation of abuse…will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury - to the mandated state agency per reporting criteria within guidelines of notification of an alleged abuse.” Resident #1 Review of Resident #1's medical record revealed an admission date of 04/08/2025, a discharge date of 09/25/2025, with diagnoses that included in part…Intellectual Disabilities, Schizoaffective Disorder; Anxiety Disorder; Major Depressive Disorder, Single episode; Pain; Hypertensive Heart Disease with Heart Failure; and Atrial Fibrillation. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an ARD of 07/15/2025 revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate impaired cognition. Resident #1 was independent with eating and required supervision with toileting and personal hygiene. Interview on 09/26/2025 at 11:50 a.m. with S2 DON revealed that she was notified on 09/22/2025 at approximately 10:00 a.m. that there had been an allegation that Resident #1 was sexually abused at a movie theatre outing by an unnamed facility staff member. S2 DON stated she immediately notified S1 ADM of the allegations of staff-to-resident sexual abuse. In an interview on 09/30/2025 at 11:50 a.m., S1 ADM revealed he did not think the allegation of staff-to-resident sexual abuse involving Resident #1 on 09/22/2025 needed to be reported or opened in the Statewide Incident Management System (SIMS). S1 ADM revealed that this allegation of sexual abuse was not reported. Resident #2 Review of Resident #2's medical record revealed an admission date of 03/05/2025, with diagnoses that included in part…Cerebral Infarction due to Embolism of Right Cerebellar Artery; Displaced Fracture of Upper End of Left Humerus; Diabetes; Hemiplegia and Hemiparesis following a Cerebral Infarction affecting Left Dominant Side; and Schizoaffective Disorder. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an ARD of 07/01/2025 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Resident #2 was dependent or required substantial/ maximum assistance with activities of daily living (ADLS). On 09/30/2025 at 11:05 a.m., an interview with S2 DON revealed she was made aware of the alleged resident to resident abuse involving Resident #2 that occurred on 09/21/2025. S2 DON stated she was responsible for SIMS reporting but required administrative approval before entering an incident, which she did not receive from S1 Administrator. S2 DON confirmed that the alleged abuse was not reported into the SIMS, but should have been. On 09/30/2025 at 11:45 a.m., an interview with S1 Administrator confirmed he was aware of the alleged resident to resident abuse involving Resident #2 on 09/21/2025, but chose not to initiate a SIMS report, due to he felt it was not warranted.

Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice by failing to ensure a residents received a prescribed antibiotic in a timely manner for 1 (#2) of 3 (#1, #2, and #3) sampled residents. Findings:Review of Resident #2's medical record revealed an admit date of 03/10/2025 with diagnoses that included: Other Chronic Osteomyelitis, Left ankle and foot, Cerebral Infarction, Unspecified Hemiplegia and Hemiparesis, Persona; History of Urinary Tract Infection, Unspecified Mood Affective Disorder, Epilepsy, Paranoid Schizophrenia, and Major Depressive Disorder. Review of Resident #2's medical record revealed a progress notes dated 06/23/2025 by the facility Nurse Practitioner read in part. New order noted for urinalysis with culture and sensitivity for dysuria and altered mental status. Review of Resident #2's medical records revealed an unloaded urinalysis dated 06/26/2025 with a hand written note at the bottom that read Cefdinir 300 mg BID. Review of Resident #2's 06/2025 Physician Orders read in part.Order input on 06/27/2025 with a start date of 06/28/2025 at 8:00 a.m. Cefdinir Oral Capsule Give 300 mg by mouth two times a day for UTI for 7 Days. Discontinue date of 06/28/2025. Order input on 06/28/2025 with a start date of 06/28/2025 at 4:00 p.m. Macrobid Oral Capsule 100 MG Give 100 mg by mouth two times a day related to Personal history of UTI for 7 Days. Completed on 07/05/2025. Review of Resident #2's progress noted date 06/28/2025 at 11:22 a.m. read in part. Resident states she is allergic to Cefdinir, it makes me itch. MD notified. No new orders at this time. Review of Resident #2's progress noted date 06/28/2025 at 11:34 a.m. 6/28/2025 11:34 a.m. read in part.New order for Macrobid 100mg by mouth , twice daily for 7 days. Discontinue Cefidinir. This surveyor was unable to reach the nurse that put in the order on for Cefdinir 300mg by mouth twice a day for 7 days on 06/27/2025 during the survey via telephone. An interview on 08/18/2025 at 2:50 p.m., with S1 ADON stated that once a preliminary lab result comes back, the Nurse practitioner is notified for further guidance. S1 ADON stated the lab sends the results to the facility through there Electronic Medical Record (EMR) system immediately after they are resulted. S1 ADON stated the Urinalysis with culture and sensitivity that was collected on 06/26/2025 sent the preliminary report to their EMR on 06/26/2025 at 2:25 p.m. S1 ADON stated an order was put in by staff on 06/27/2025 with a start date of 06/28/2025 at 8:00 a.m. for Cefdinir 300mg, twice daily for 7 days. S1 ADON confirmed Resident #2 should have received the antibiotic medication on 06/26/2025 from the facility emergency kit on the day it was ordered, but had not.

Based on observations, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 (#3) of 3 (#1, #2, and #3) sampled residents. Findings:Review of the Facility's undated policy titled Enteral Feeding Therapy (Tube Feeding) Policy and Procedure read in part.Purpose: to provide liquid nourishment through a tube, inserted into the stomach. Policy: All enteral tube feedings shall have care according to physician orders. Review of Resident #3's medical record revealed and admit date of 09/28/2021 with a readmission date of 07/10/2024 with diagnoses that included: Cerebral Palsy, Aphasia, Mild Protein Calorie Malnutrition, Gastrostomy Status, Dysphagia, Type 2 Diabetes Mellitus, and Bipolar Disorder. Review of Resident #3's admission MDS with an ARD of 07/22/2025 revealed a BIMS of 2, which indicated severely impaired cognition. Review of Resident #3's Care Plan with a review date of 11/02/2025 read in part. I require a PEG tube for adequate nutritional intake related to my dysphagia. Administer my tube feeding as ordered by my physician. Review of Resident #3's current Physician Orders revealed the following, in part: 07/10/2024 -Glucerna 1.5 at 60ml/hr via pump from 7:00 p.m. to 7:00 a.m. 02/28/2025- H20 Flush at 250ml/Q4h via pump from 7:00 p.m. to 7:00 a.m. 09/13/2024-Glucena 1.5 give carton bolus daily at 12:00 p.m. and at 4:00 p.m.; then flush with 100ml of water.07/10/2024- Flush with 100ml of water after bolus feeding. 04/28/2025- PRN-Glucerna 1.5 carton bolus every 24 hours if asks for extra feeding. Observation and interview on 08/18/2025 at 9:38 a.m., accompanied with S2 LPN revealed a bag of peg tube feeding Glucerna dated 08/18/2025 and timed 12:00 a.m. with 1000ml of feeding in the bag and 1000ml of H2O hanging on a feeding pole in Resident #3's bedroom. The peg tube feeding was not connected to Resident #3 and the feeding pump was turned off. S2 LPN stated that she came on shift at 6:00 a.m. today and had not been in Resident #3's room. S2 LPN stated that during her shift Resident #3 gets 2 bolus feedings and receives continuous tube feedings overnight. An interview on 08/18/2025 at 9:53 a.m. with S3 LPN stated she worked on Resident #3's hall last night. S3 LPN stated she went into Resident #3's room between 7:15 p.m. -7:30 p.m. last night but cannot recall if a peg feeding was hanging at the time. S3 LPN stated she gave Resident #3 a bolus feeding at 3:00 a.m. and stated she hung the Glucerna and H2O with tubing on the pole at around 3:00 a.m. S3 LPN confirmed she read the physician orders but may have missed the order for continuous feeding to be administered overnight for Resident #3. S3 LPN denied Resident #3 had refused any feedings. An interview on 08/18/2025 at 3:10 p.m. with S4 DON revealed that Resident #3 should have received the ordered continuous feeding of Glucerna the night of 08/17/2025, but had not.

Based on a record review and interview, the facility failed to provide care and services that met professional standards of quality by failing to ensure that a resident's medical record reflected whether Physician's Orders were implemented or refused. The facility failed to document whether wound care was or was not provided for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for skin and pressure ulcers. Review of facility undated policy titled, Skin/Wound Documentation Policy and Procedure, revealed in part. Skin and wounds will be documented upon admission, readmission, weekly, and as needed. The facility shall follow the practitioner's orders for treatment of the pressure ulcer (injury). With each dressing change, or at least weekly, the pressure ulcer (injury) wound shall be assessed and documented. Pressure ulcer (injury) documentation should include, in part.date and time of initial and subsequent treatments. Review of Resident #3's medical record revealed an admit date of 03/10/2025 with the following diagnoses in part. Chronic Osteomyelitis Left Ankle and Foot, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Dysarthria following Cerebral Infarction, Epilepsy, Peripheral Vascular Disease, Presence of Vascular Implants and Grafts, Cellulitis of Left Lower Limb, and history of Venous Thrombus and Embolism. Record Review of Resident #3's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/10/2025 revealed Resident #3 had a BIMS score of 15, which indicated intact cognition. Resident #3 had documented 1 unhealed, unstageable pressure ulcer. Record review of Resident #3's Active Physician Orders read in part. Order Date 07/10/2025- Treatment #1: Stage 4 Left Lateral Foot: Cleanse with wound cleanser, pat dry, apply collagen with silver to wound bed, cover with calcium alginate, cover with dry dressing daily until healed. Record review of Resident #3's care plan with initiation date of 03/13/2025, revealed Resident #3 had an unstageable pressure ulcer to her left lateral foot with interventions that included in part. Provide treatment as ordered by physician. On 07/21/2025 at 2:32 p.m., review of Resident #3's Treatment Administration Record (TAR) revealed no documentation of treatment provided and/or refused for Stage 4 Left Lateral Foot on 07/16/2025 and 07/17/2025. During an interview on 07/22/2025 at 12:57 p.m., with S3LPN and S8RN, Resident #3's 07/2025 TAR was reviewed. S3LPN confirmed Resident #3 did not have any wound care documentation for 07/16/2025 and 07/17/2025, and should have. S3LPN and S8RN confirmed that if Resident #3 had refused care on those dates, refusal should have been documented on Resident #3's TAR and was not.

Based on observations, interviews and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and the resident's person centered plan of care, for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) residents sampled for quality of care. This deficient practice resulted in a delay in treatment of a wound to Resident #3's right elbow, and development of cellulitis of the right elbow that required antibiotic treatment. This failed practice resulted in an actual harm for Resident #3 on 02/26/2025 at 2:26 p.m., when the resident was observed to have a wound to his right elbow, with edema and erythema noted. On 02/21/2025 at 11:38 p.m., Resident #3 sustained a 1cm x 1cm skin tear to the right elbow as a result of a fall, and first aid was administered at that time. Wound care was ordered on 02/23/2025 to clean right elbow scratch with NS, apply Triple Antibiotic Ointment (TAO) and cover with clean dry dressing until healed, monitor for S/S of complications. Resident #3 did not receive the ordered treatment to the right elbow on 02/23/2025 and 02/24/2025, and there was no documentation that wound care was provided on 02/25/2025. S9 NP examined Resident #3 on 02/26/2025 at 2:36 p.m., and diagnosed Resident #3 with Cellulitis of the wound on his right elbow, ordered wound care, and prescribed an oral antibiotic on 02/26/2025 at 2:36 p.m. Findings: Review of Resident #3's medical record revealed an admitted [DATE], with diagnoses that included Hemiplegia following Cerebral Infarction. Review of Resident #3's Quarterly MDS with an ARD of 12/31/2024, revealed a BIMS score of 00, which indicated severe impairment. Resident #3 used a manual wheelchair for mobility. Review of the facility's Incident Log dated 01/28/2025 to 02/26/2025, revealed Resident #3 had an incident with a skin tear noted on 02/21/2025. The location of the skin tear was not noted. Review of the facility's Un-Witnessed Fall Report dated 02/21/2025, revealed, in part .Resident #3 was found on the floor with his wheelchair beside him. Resident #3 had a bruise, and a skin tear to his right elbow that measured 1cm x 1cm. Resident #3 had a hematoma and swelling to the right forearm, and was unable to tell the nurse what happened. Review of Resident #3's Nurse's Note dated 02/21/2025 at 11:30 p.m., revealed, in part .Resident #3 was found on the floor. Resident #3 had a bleeding wound to the right elbow. Review of Resident #3's Physician Orders revealed an order on 02/23/2025 to clean right elbow scratch with NS, apply TAO, and cover with clean dry dressing until healed, monitor for S/S of complications. Review of Resident #3's Treatment Administration Record (TAR) for 02/2025, revealed, in part .wound care to the resident's right elbow was documented as administered on 02/23/2025 and 02/24/2025 by S2 DON. There was no documentation that wound care was provided on 02/25/2025. Interview with S5 ADON on 02/26/2025 at 11:25 a.m., revealed there had not been any wound care of the skin tear to Resident #3's right elbow since the incident occurred on 02/21/2025. Observation of Resident #3 on 02/26/2025 at 11:42 a.m., revealed a wound to Resident #3's right elbow, with edema and erythema noted. Interview with S6 LPN on 02/26/2025 at 11:51 a.m. revealed she was the facility's treatment nurse. S6 LPN confirmed she was not aware of Resident #3's wound to the right elbow, and did not provide any wound care to Resident #3 until 02/26/2025. Interview with S2 DON on 02/26/2025 at 2:07 p.m., revealed she entered the order for Resident #3's wound care on 02/26/2025, with a start date of 02/23/2025. S2 DON stated she signed Resident #3's wound care TAR on 02/23/2025 and 02/24/2025 because I know it was done. S2 DON stated she did provide wound care to Resident #3 on 02/25/2025, but did not sign the TAR. S2 DON stated that did not provide wound care to Resident #3's right elbow on 02/23/2025 and 02/24/2025; however, initialed on those dates because she knew wound care had been provided, and the nurse did not initial. Interview with S9 NP on 02/26/2025 at 2:36 p.m. revealed she had just examined Resident #3, and diagnosed Resident #3 with Cellulitis of the wound on his right elbow, ordered wound care, and prescribed an oral antibiotic. Interview with S7 RN on 02/27/2025 at 10:50 a.m., revealed she was the treatment nurse at the facility on 02/23/2025. S7 RN confirmed she did not provide wound care to Resident #3 on that day. Interview with S8 RN on 02/27/2025 at 10:55 a.m., revealed she was the treatment nurse at the facility on 02/22/2025. S8 RN confirmed she did not provide wound care to Resident #3 on that day. Interview conducted with S2 DON on 02/27/2025 at 12:35 p.m., revealed Resident #3 did not receive wound care on 02/22/2025, 02/23/2025, and 02/24/2025, but should have. S2 DON stated Resident #3 was diagnosed with Cellulitis of the right elbow, and required antibiotic treatment, after not receiving wound care as he should have.

Based on interview, and record review, the facility failed to ensure a resident's right to be free from physical abuse by another resident for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to protect Resident #1 from being punched and kicked by Resident #2 on 09/18/2024, and pushed down on the ground by Resident #2 on 10/04/2024. This failed practice resulted in an actual harm situation for Resident #1 on 09/18/2024 at 3:00 p.m., when a CNA reported Resident #1 was on the floor after wandering into Resident #2's room, and Resident #2 was kicking Resident #1 in the chest and abdominal areas with bare feet; and on 10/04/2024 at approximately 3:50 p.m., when Resident #2 pushed Resident #1 from behind, causing him to fall to the floor face first. Resident #1 was transported to the emergency roiagnom on [DATE], and diagnosed with Laceration of [NAME] Border of Upper Lip, which required 5 Prolene sutures. Findings: Review of the facility's policy Abuse Prevention and Prohibition undated and provided on 10/21/2024, read in part . Each resident has the right to be from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents 3. Physical Abuse may include an aggressive act, including inappropriate physical contact that is harmful, or to cause injury or harm to a resident. b. Examples: hitting, slapping, pinching, biting, shoving; and kicking. Resident #1 Review of Resident #1's medical record revealed an admitted [DATE], with diagnoses that included: Cerebral Infarction, Chronic Kidney Disease, Schizoaffective Disorder, Aneurism of Unspecified Site, Personal History of Traumatic Brain Injury, Major Depressive Disorder, and Anxiety Disorder. Review of Resident #1's Admission MDS with an ARD of 08/26/2024, revealed a BIMS was not conducted as Resident #1 was rarely/never understood, and had moderately impaired cognitive skills for daily decision making. Review of the MDS revealed Resident #1 did not require a mobility device, but required moderate assistance with ambulating 10 feet and 50 feet. Review of Resident #1's Care Plan with a Target date of 11/18/2024, revealed in part . 1. I am at risk for falls r/t unsteady gait and history of falls. 10/04/2024 I had a fall from physical contact with another resident resulting in laceration to lip, sent out of facility to ER. Interventions: Monitor for changes in my condition that may warrant increased supervision/assistance, and notify the physician. 2. I reside in the secure care unit related to wandering behaviors, and difficult redirection. Interventions: Approach me positively and in a calm, accepting manor. Monitor and document my behavior. Provide diversional activities for me. Staff is aware of my wandering/elopement behavior. 3. I have cognitive loss r/t Schizoaffective Disorder, MDD, Anxiety. Interventions: Please approach me from the front in a calm, unhurried manner. Report any changes to my doctor and family. Resident #2 Review of Resident #2's medical record revealed an admitted [DATE], with diagnoses that included: Schizoaffective Disorder Bipolar Type, Anxiety Disorders Unspecified, Extrapyramidal and Movement Disorder, and Drug Induced Subacute Dyskinesia. Review of Resident #2's Quarterly MDS with an ARD of 08/06/2024, revealed a BIMS score of 15, indicating intact cognition. Review of the MDS indicated Resident #2 did not require a mobility device, or supervision with ambulating 10 feet and 50 feet. Review of Resident #2's Care Plan with a Target date of 11/09/2024, revealed in part . 1. Continued Behavior Care Plan. Interventions: Administer behavior medications per physician order. Attempt to redirect me when I become aggressive. Direct me to a quiet place to allow me to calm down. 2. I display physically and verbally aggressive behavior. I have history of pacing/wandering, delusions, and refusal of care. Interventions: Administer my behavior medications as ordered by my physician. Identify causes for my behavior and reduce factors that may provoke me. Place me in area where observation is possible - Secure Unit. 09/18/2024 Resident to Resident Abuse Review of facility investigative notes for Resident #1 and Resident #2 dated 09/18/2024 at 3:00 p.m., read in part . On 09/18/2024, at approximately 3:00 p.m., staff reported that Resident #2 had made physical contact with Resident #1. Investigation by S1 DON, revealed that Resident #1 had wandered into Resident #2's room while both staff members were with other residents. S5 CNA reported that she heard noises coming from Resident #2's room, and upon entering the room, S5 CNA observed Resident #2 making physical contact with Resident #1. Review of a statement by S5 CNA dated 09/18/2024 read in part . I (S5 CNA) was observing other residents at the back of the hall, when I heard Resident #2 yelling get him out my room. I ran to see what was going on, and saw Resident #2 making physical contact towards Resident #1 . Review of investigative notes read in part .Resident #1 was removed from Unit A and placed on another hall while Resident #2 remained on Unit A .On 09/21/2024, Resident #1 continued to require frequent supervision and became difficult to redirect .Resident #1 was placed on 1:1 and then he agreed to go for Inpatient Psychiatric treatment .the facility feels that Resident #1's wandering was the root cause of the incident on 09/18/2024. Review of Resident #1's completed task for increased supervision revealed Q30 minute monitoring was done when he return to the Unit A on 10/01/2024. Review of Resident #1's Nurses' Notes read in part . 10/01/2024 at 5:40 p.m. - Resident #1 returned to the facility. Interview on 10/21/2024 at 2:28 p.m. with S5 CNA revealed Resident #1 went into Resident #2's room on 09/18/2024. S5 CNA reported when she entered, she saw Resident #1 on the floor, and Resident #2 kicking Resident #1's chest/abdominal areas. S5 CNA revealed Resident #2 did not have shoes on. Interview on 10/24/2024 at 2:53 p.m. with S1 DON, revealed on 09/18/2024 at approximately 3:00 p.m., S5 CNA reported she heard a noise coming from Resident #2's room. S5 CNA reported Resident #1 was on the floor, and Resident #2 was kicking him in the side of chest area with bare feet. S1 DON revealed Resident #1 was not injured. S1 DON stated Resident #2, who was lucid and able to say what he did or did not do, admitted to punching and kicking Resident #1 because he was in his room. 10/04/2024 Resident to Resident Abuse Resident #1 Review of Resident #1's Nurses' Notes read in part . 10/04/2024 at 4:26 p.m. - Incident/Behavior Note documented by S2 ADON: Writer was called to unit where resident had gotten pushed by another resident. Resident #1 was on the floor with medium size puddle of blood draining from his left side of upper lip. Resident did not lose LOC as stated by staff that witnessed it, applied pressure to area .called for Resident #1 to be sent for further evaluation. 10/04/2024 at 3:50 p.m. - Incident/Behavior Note documented by S1 DON: Late Entry - Staff reported that Resident #2 pushed Resident #1 from behind without warning. Resident #1 fell to the floor, face first, causing a laceration to his lip. Staff immediately called for assistance. S6 FNP present in facility .assessed resident, provided first aid, and gave orders to send to ER for evaluation. Review of S6 FNP's Progress Note for Resident #1, dated 10/04/2024, revealed in part .complaints of being pushed by another resident, hitting face on floor causing laceration to lip with bleeding. PE: Chronically ill appearing. Upper lip laceration. Neurological Status: AA, Confusion. Superficial injury of head; contusion of lip, initial encounter. Plan: refer to ER for suturing. Review of Resident #1's emergency room Visit Notes dated 10/04/2024, revealed in part . Patient with a complex laceration to his left [NAME] border, with a small arterial bleed. Patient's cognitive disability has made it very difficult to apply pressure and close the wound. Patient was given 10 mg of Valium, 5 mg of Haldol, as well as Benadryl, and then placed in restraints. I (Doctor) was able to close the laceration using 5, 5.0 Prolene sutures. Resident #2 Review of Resident #2's Nurses' Notes read in part . 10/04/24 at 3:52 p.m. Incident/Behavior Note documented by S1 DON: Staff reported that Resident #2 is delusional, stating that he is a doctor, a football player, amongst other various occupations. He was observed making physical contact with another resident. 10/04/2024 at 4:50 p.m. Incident/Behavior Note documented by S1 DON: Late Entry for 4:00 p.m.: Staff reported that Resident #2 pushed Resident #1 from behind without warning. Resident #1 fell to the floor face first, causing a laceration to his lip. Staff immediately called for assistance. Interview on 10/23/2024 at 11:05 a.m. with S3 CNA, revealed on 10/04/2024 around 3:50 p.m., Resident #1 was walking down the hall of Unit A, when Resident #2 immediately came out of Room A and pushed Resident #1 from behind. S3 CNA reported this caused Resident #1 to fall to the floor. S3 CNA stated she rounds on the residents in the unit every 30 minutes. Interview on 10/23/2024 at 11:30 a.m. with S4 LPN revealed on 10/04/2024 approximately 15 minutes after lunch, Resident #2 bee lined it down Unit A, Hall A, and pushed Resident #1 down. S4 LPN reported Resident #1 was frail with an unsteady shuffled gait. S4 LPN reported Resident #1 was bleeding excessively from his mouth. Interview on 10/23/2024 at 2:16 p.m. with S7 CNA revealed they always have 2 CNAs providing care on the Unit A. S7 CNA reported one CNA would monitor the residents walking around and on patio while the other would round on the residents in the rooms. S7 CNA revealed he rounded on the residents every 15 minutes. Interview on 10/23/2024 at 3:18 p.m. with S2 ADON, revealed she was present in the facility on 10/04/2024 when S1 DON got a phone call from a CNA on Unit A, informing S1 DON of an incident occurring between Resident #1 and Resident #2. S2 ADON reported they immediately ran to Unit A, saw Resident #1 on the ground with blood, and Resident #2 was cursing. Interview on 10/23/2024 at 3:34 p.m. with S1 DON, revealed she received a call from S4 LPN notifying her of the incident between Resident #1 and Resident #2. S1 DON reported Resident #2 pushed Resident #1 and he (Resident #1) had blood coming from his mouth.

Based on observation, interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #1), of 3 sampled residents (#1, #2, and #3). The facility failed to ensure Resident #1 was not hit in the face by Resident #2. This failed practice resulted in an Actual Harm situation for Resident #1 on 01/31/2024 at 8:50 p.m. Resident #1 wandered into Resident #2's room, and Resident #2 hit Resident #1 in the face. Resident #1's right eye was red and slightly swollen immediately after the incident. On 02/01/2024 at approximately 8:00 a.m., staff noted Resident #1's eye to have increased swelling and discoloration. Resident #1 was transferred via ambulance to a local emergency roiagnom on [DATE] at 8:30 a.m. Review of a Radiology Report dated 02/01/2024 at 10:00 a.m. revealed Impression: Acute fractures involving the maxillary spine and central maxilla with suspected injury to the root of the left maxillary central incisor and significant soft tissue injury with prominent soft tissue hematoma. Findings: Review of the facility policy titled Abuse Prevention and Prohibition, (date unknown), revealed in part . Each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Procedure: II. Resident abuse may include: 1. resident to resident abuse 2. staff to resident abuse; or 3. family/visitor to resident abuse III. Types of Abuse: 3. Physical Abuse may include an aggressive act, including inappropriate physical contact that is harmful or likely to cause injury or harm to a resident. b. Examples include hitting, slapping, pinching, biting, shoving and kicking. Resident #1 Review of Resident #1's Face Sheet revealed a facility admitted [DATE] to the Secure Unit at approximately 5:30 p.m., due to advanced confusion related to Severe Dementia. Observation of Resident #1 on 02/26/2024 at 8:30 a.m. revealed the area around his right eye was slightly discolored, light blue. Resident #1 was unable to answer any questions regarding his right eye. Interview with S6 CNA on 02/26/2024 at 8:35 a.m. revealed she was assigned to supervise Resident #1. She stated Resident #1 received 1:1 supervision, 24 hours a day, due to wandering. Interview with S1 DON on 02/26/2024 at 12:15 p.m. revealed Resident #1 was admitted to the Secure Unit due to a history of wandering. He required frequent supervision and was independently ambulatory. Review of a Progress Note dated 01/31/2024 at approximately 8:50 p.m., for Resident #1, revealed the following in part . S2 CNA called S3 LPN to the secure unit to report that Resident #1 had wandered into Resident #2's room. Before S2 CNA could reach Resident #1, Resident #2 made physical contact with Resident #1's face. S2 CNA reported she saw Resident #1 heading towards Resident #2's room, and called out to him not to go in there because it was not his room. Resident #1 kept walking towards Resident #2's room. S2 CNA stated Resident #1 had only one foot in Resident #2's room when she made it closer to him. At that time, S2 CNA witnessed Resident #2 use his hand to make contact with Resident #1's face. S2 CNA immediately separated the residents and called S3 LPN to the unit. Review of a Progress Note dated 01/31/2024 at 8:50 p.m., by S3 LPN, revealed the following in part . It was reported by S2 CNA that Resident #1 wandered into Resident #2's room. Resident #2 made physical contact with Resident #1's eye. A head to toe assessment was performed on Resident #1. Resident #1's right eye was swollen and bruised. Review of a Progress Note dated 02/01/2024 at approximately 8:30 a.m., by S1 DON, revealed Resident #1's right eye had an increase in the amount of swelling. S4 FNP was notified and orders were received to send Resident #1 to the ER for evaluation. Resident #1 returned to the facility on [DATE] at approximately 1:50 p.m. Review of ER records revealed Resident #1 was seen on 02/01/2024 for a Maxillary Fracture. Discharge instructions were to follow up with an Oral Maxillofacial surgeon. Additional instructions included Clindamycin (antibiotic) 150 mg three times a day for seven days, and Hydrocodone/Acetaminophen 5/325 mg one tablet every six hours as needed for pain. Review of a Radiology Report dated 02/01/2024 at 10:00 a.m. revealed in part . CT Maxillofacial without IV contrast was completed. Impression: 1. Acute fractures involving the Maxillary spine and central maxilla with suspected injury to the root of the left maxillary central incisor and 2. Significant soft tissue injury with prominent soft tissue hematoma. Interview with S3 LPN on 02/26/2024 at 1:10 p.m., revealed she was called to the Secure Unit on 01/31/2024 by S2 CNA. It was reported to her that Resident #2 hit Resident #1 in the face. S3 LPN stated she assessed Resident #1, and noted his right eye was swollen and discolored. He was ambulating and did not appear to be in any pain. She notified S4 FNP, S1 DON and Resident #1's RP. She started Neuro checks on Resident #1 and placed S5 CNA 1:1 with Resident #1 the remainder of the night. Review of Resident #1's Admit MDS with an ARD of 02/07/2024, revealed a BIMS assessment was not conducted. The MDS revealed Resident #1's cognitive skills for daily decision making were severely impaired. Review of Resident #1's Comprehensive Care Plan with a target completion date of 05/18/2024, revealed in part . An identified problem of wandering - with interventions to monitor the resident 1:1, and notify the NP, DON and RP of any physical aggression towards this resident from another resident. Resident #2 Review of Resident #2's Face Sheet revealed an admitted to the facility of 10/25/2016. Resident #2 was admitted with diagnoses to include in part .Schizoaffective Disorder, Personal history of Traumatic Brain Injury, Anxiety Disorder and Alzheimer's Disease. Review of Resident #2's Quarterly MDS with an ARD of 02/06/2024 revealed a BIMS of 12. Review of Resident #2's care plan, with a target date of 05/20/2024, revealed in part . An identified problem of physical aggression with other residents. Interventions included monitoring on the Secure Care Unit and increased monitoring after any incidents. Review of a Progress Note dated 01/09/2024, at approximately 1:20 p.m., revealed S7 LPN was notified by S8 CNA and S9 CNA that Residents #2 and #R1 were outside in the smoking area. Resident #2 became aggressive towards Resident #R1 due to #R1 accusing Resident #2 of raping his mother. At that time, Resident #2 became angry and made contact with Resident #R1's face before staff could intervene. Review of a Progress Note dated 01/14/2024 at approximately 5:50 p.m., revealed S8 CNA and S9 CNA reported to S10 LPN that Resident #2 was walking up the hallway showing signs of agitation when he was noted to make physical contact with Resident #R2. Resident #R2 had a small opening to his left lower lip. Interview with S6 CNA on 02/26/2024 at 4:15 p.m. revealed Resident #2 had a behavior of physical aggression with other residents that occurred at different times and places without any trigger. Interview with Resident #2 on 02/26/2024 at 8:32 a.m. stated he found resident #1 in his room drinking his coke and he got mad and asked him to leave. When Resident #1 did not leave, he hit him. CNA came in afterward he said.

Based on interview and record review the facility failed to ensure a residents' rights to be free from staff to resident physical abuse, for 1 (Resident #1), of 3 sampled residents (#1, #2, and #3). The facility failed to ensure Resident #1 was not pushed by S5 CNA, while S5 CNA was in the process of intervening during an aggressive act by another resident. This failed practice resulted in an Actual Harm situation for Resident #1 on 12/14/2023 at 4:19 p.m. Resident #1 was pushed by S5 CNA in the dayroom of Hall A, while S5 CNA intervened in an incident that involved Resident #2 and S6 CNA. S5 CNA intervened when Resident #2 grabbed S6 CNA's shirt. S5 CNA pushed Resident #1 during the intervention, and Resident #1 fell and hit his head on a tiled floor. Resident #1 was transferred via ambulance to a local emergency roiagnom on [DATE] at 6:39 p.m. The ER record revealed: Primary Impression: Temporal Bone Fracture. Additional Impressions: Epidural Hemorrhage, Subdural Hemorrhage, and Subarachnoid Hemorrhage. Disposition: Serious. Resident #1 was transferred to another hospital for a higher level of care, and admitted to the Trauma ICU on 12/15/2023. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility policy titled Abuse Prevention and Prohibition revealed in part . Each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Procedure: II. Resident abuse may include: 1. resident to resident abuse 2. staff to resident abuse; or 3. family/visitor to resident abuse III. Types of Abuse: 3. Physical Abuse may include an aggressive act, including inappropriate physical contact that is harmful or likely to cause injury or harm to a resident. b. Examples include hitting, slapping, pinching, biting, shoving and kicking. Review of Resident #1's medical record revealed an original admitted [DATE], and a readmitted [DATE]. Resident #1 was admitted to the Secure Unit on 11/08/2023. Diagnoses included in part .Schizoaffective Disorder, Bipolar Type; Generalized Anxiety Disorder; Depression, Unspecified; Malignant Neoplasm of Bone and Articular Cartilage, Unspecified; and Malignant Neoplasm of Brain, Unspecified. Review of a Quarterly MDS with an ARD of 09/21/2023 revealed Resident #1 was coded to have a BIMS score of 03, which indicated severe cognitive impairment. The MDS revealed Resident #1 exhibited no behaviors, and was independent in all ADLS. Review of a Quarterly MDS with an ARD of 12/29/2023 revealed in part .Resident #1 was coded to have a BIMS score of 03, which indicated severe cognitive impairment. The MDS revealed Resident #1 had no upper and lower ROM impairment; did not require a mobility device; required maximum/substantial assistance for dressing, personal hygiene; partial/moderate assistance for transfers and walking at least 50 feet; and the ability to walk at least 150 feet not attempted due to medical or safety concerns. Review of Resident #1's Comprehensive Care Plan revealed in part . 1. I have diagnosis of Schizophrenia. Goal: I will have decrease in my behavior. Interventions: Admin my medications as ordered by my physician; assist me with some of my ADLs; encourage me to participate in facilities daily activities; Have the pharmacy consultant to review psychotropic medications monthly as needed; Notify my physician of any significant changes. 2. I have an anxiety disorder: Goal: My anxiety will be minimized. Interventions: Administer meds as ordered. Approach me in calm manner Notify MD of any significant changes. Remove me from areas that cause me anxiety. 3. I require a secure unit at this time due to behaviors. I have delusions. Interventions: Monitor my whereabouts every 2 hours or as needed. Review of nursing notes for Resident #1 revealed the following in part . 12/14/2023 at 4:19 - Late Entry Note Text: Correction, documented by S2 DON: Resident on Staff Altercation. 12/14/2023 at 4:19 - documented by S2 DON - Staff reported that they had to intervene to prevent a resident on resident altercation from occurring. In doing so, Resident #1 fell to the ground and obtained a raised area to the top of his head, and was sent to the ER for further evaluation per FNP orders. Head to toe assessment performed. Raised area noted to top of head. B/P 136/82, HR 76, Temp 97.3, RR 18. Resident shook head yes when asked if he had a headache. FNP/RP notified of above. Resident sent to a local hospital's ER for evaluation. Normal confusion noted. Ambulatory and talking to staff at this time. No changes noted in his normal mental status at this time. Neuro-checks are within normal limits. Resident inserted himself in an altercation that did not concern him, and fell as a result of this. 12/14/2023 at 6:39 p.m. - documented by S4 LPN - left in stable condition per stretcher. Resident was talkative and answered appropriately. Neuro Checks WNL at this time. 130/76, 74, 16, 97.4. Review of Emergency Visit Notes dated 12/14/2023 at 7:43 p.m., read as follows in part .Resident #1 was seen by the physician on 12/14/2023 at 7:28 p.m. Review of HPI: Initial Comments revealed in part .patient presented to the emergency room via EMS from NH status post fall. The patient was pushed by a staff member. Nursing Home nurse stated the staff member was trying to control a second aggressive resident, and the patient took that opportunity to attack the staff member. She admits that during that attack the staff member did push the patient away causing him to fall and strike his head. Review of a Radiology Report dated 12/14/2023 at 7:26 p.m. revealed a Head CT Scan without Contrast was done, and revealed in part . Impression: 1. Non-displaced right temporal bone fracture extending into the posterior right frontal lobe with findings most consistent with an epidural hematoma, with volume of approximately 15ml overlying the posterior right frontal lobe in the anterior aspects of the right parietal lobe. 2. Thin subdural hematomas anterior to the inferior medial aspects of both frontal lobes, with mild subarachnoid hemorrhage. Review of ER physician MDM (Medical Decision Making) dated 12/14/2023 read in part . CT Scan was ordered, the nursing staff and techs were able to see a large intracranial hemorrhage. I was called by radiologist - patient with a right temporal bone fracture, associated epidural hematoma 15ml per volume, small bi-frontal subdural hemorrhages as well as some trace subarachnoid hemorrhage. There is no neurosurgery available here at this facility. Transfer initiated, and patient accepted at another hospital. Review of the physician's H&P Notes from the accepting hospital dated 12/15/2023 at 7:48 a.m. read in part . Trauma ICU H&P: Admission Summary. In brief, patient admitted as a trauma transfer following a fall after an altercation with an employee at his assisted living facility. Imaging showed R parietal epidural hematoma, bi-frontal SDH and SAH, and non-displaced R temporal and parietal bone fracture. Active Problems: 1. Epidural hematoma 2. Midline shift of brain due to hematoma 3. SAH (subarachnoid hemorrhage) 4. Subdural hematoma, acute 5. Closed fracture of parietal bone of skull 6. Temporal skull fracture Review of hospital records revealed Resident #1 was discharged back to the nursing home on 12/18/2023. Review of a statement documented by S5 CNA dated 01/19/2023, revealed the following in part . Thursday December 14 about 6:20, I tried to break up Resident #2 and S6 CNA had a hussle. I tried to break up the fight. Resident #1 grabbed me. I pushed him back, I didn't mean to. I was trying to defend myself and help my co-worker. Attempted telephone contact with S5 CNA on 01/12/2024 at 11:49 a.m. revealed the number was not in service. Interview with S6 CNA on 01/11/2024 at 10:30 a.m. revealed the following in part .On 12/14/2023 an altercation occurred on Hall A on the morning shift. S6 CNA stated she and S5 were the CNA staff assigned to Hall A for that shift, and S4 LPN was the nurse on Hall A. She stated Resident #2 was agitated and kept unplugging the television in the dayroom, and she kept trying to redirect him. S6 CNA stated Resident #2 grabbed her shirt during the process of redirecting him. She stated Resident #1 got up and came up to them (she, Resident #2 and S5 CNA), and at some point Resident #1 fell and hit his head. She stated she was unclear what happened. S6 CNA stated the side of Resident #1's head swelled immediately. S6 CNA stated there was no camera in the dayroom of Hall A. Interview with S2 DON on 01/11/2024 at 11:35 a.m. revealed in part .S4 LPN called her to come to Hall A. She stated she and S7 ADON went to Hall A, and when they arrived, everything was quiet. Resident #1 was sitting up in a chair, and S6 CNA was helping him. S2 DON stated S5 CNA said, I was just protecting myself. S2 DON stated S5 CNA said that Resident #1 had his hands around his neck (S5 CNA), and it was a reaction to push him off of him. S2 DON stated she did not witness the incident, and could not verify that Resident #1 had his hand around S5 CNA's neck. S2 DON stated that S5 CNA should not have pushed Resident #1, but added that S5 CNA was defending himself. Interview with S3 Assistant Administrator/CNA Staffing Specialist on 01/12/2024 at 8:40 a.m. revealed S5 CNA worked on Hall A. He stated about 2 months ago, S5 CNA came to him and said he was frustrated and wanted to be moved. S3 Assistant Adm/CNA Staffing Specialist stated he moved S5 CNA to other areas of the nursing home, and did well with the residents in those areas. He stated on 12/14/2023, he asked S5 CNA to work Hall A from 3:00 p.m. to 7:00 p.m. S3 Assistant Administrator/CNA Staffing Specialist stated he did not see any issues with S5 CNA that would have made him aware that there would be issues. S3 Assistant Adm/CNA Staffing Specialist stated in hindsight, he would have taken other actions, and called another CNA who worked Hall A, or worked Hall A himself. Telephone interview with S3 Assistant Administrator/CNA Staffing Specialist on 01/15/2024 at 7:52 a.m. revealed S5 CNA requested to leave Hall A around 2 to 21/2 months ago. He stated S5 CNA was frustrated because he felt closed in, and wanted to go outside the unit and work. He stated S5 CNA never stated he was frustrated with caring for residents with behaviors on Hall A, but that S5 CNA liked to move around. S3 Assistant Administrator/CNA Staffing Specialist stated S5 CNA said he was tired of being closed in, in one spot at a period of time, and that S5 CNA was always a good float CNA. Telephone interview with S4 LPN on 01/18/2024 at 9:00 a.m., revealed she worked 6:00 a.m. to 6:00 p.m. on Hall A on 12/14/2023. She stated on the afternoon of 12/14/2023 while passing medications, she administered medication to Resident #2, and he spit them out, and started throwing things. She stated she was trying to quickly pick the meds off the floor before the other residents could grab and swallow them. During that time, she could hear a commotion going on, and was trying to see what was happening, while picking up the medications at the same time. S4 LPN stated S5 CNA intervened with Resident #2. Resident #2 grabbed S5 CNA's legs and were holding them. While S5 CNA was trying to get free, Resident #1 came up from behind and struck S5 CNA. She stated it was difficult for her to see what was going on. S4 LPN stated S5 CNA pushed Resident #1 trying to protect himself, and Resident #1 fell on his back, and hit his head. S4 LPN stated she examined Resident #1, and noted a hematoma on the posterior portion of Resident #1's head. She stated Resident #1 said he was okay, was able to get up with assistance and sit in a chair. The facility has implemented the following actions to correct the deficient practice: The following is Plan of Correction for incident 12/14/2023 with a completion date of 12/31/2024: Pertaining to the reported incident that occurred on 12/14/2023, the facility has put in place the following tools to ensure residents are being cared for with dignity and respect, and staff feel welcome, safe and supported here at the facility. 1. Inservice regarding abuse and prevention was held 12/14/2023, along with demonstrations of different scenarios regarding aggressive individuals and the correct way to handle the situation. This was presented by S2 RN DON and S1 NFA. 2. Education regarding staff burn/out/handling stress and Handling aggressive Behaviors which included video instruction, printouts, speaker instruction, group discussion as well as post-test performed. During this time, each participant completed each post-test with 80% or higher. Group discussions were performed with each group which included Q/A, as well as past experiences for reference. These sessions started on 12/15/2023 ensuring that the facility's secured unit staff were completed trained first, and then held regularly to capture remaining staff. This is being performed by S1 NFA, S2 RN DON, as well as S3 Assistant Administrator/CNA Supervisor. 3. Safe Surveys for cognitively intact residents have been conducted. This is being performed by the facility's Social Service Worker. This was started on 12/15/2023, and being done weekly. 4. Monitoring tool to assess for staff burn out. This is being performed by S1 NFA, S2 RN DON as well as S3 Assistant Administrator/CNA Supervisor. This was started 12/15/2023. 5. QAPI for Employee Wellness was initiated on 12/15/2023 to monitor for employee burnout/stress to prevent employee burnout, and promote a positive working relationship between management and staff. This plan is being monitored weekly by the facility's QA team. Completion Date: 12/31/2023. Review of the daily monitoring tool revealed the Area of Review - Monitoring Staff Burnout. The tool revealed monitoring was done from 12/15/2023 to 12/31/2023, by S3 Assistant Adm/CNA Staffing Specialist, and no concerns were identified by S3 Assistant Adm/CNA Staffing Specialist. Review of a daily monitoring tool with Area of Review - Monitoring Staff Burnout, completed by S2 DON and S1 ADM from 01/01/2024 to 01/11/2024, revealed S2 DON and S1 ADM documented no concerns. Review of the QAPI completed by S1 Adm with start date of 12/15/2023 revealed: Name of Project - Employee Wellness/Burnout Problem Identified - Employee Wellness/Burnout. Due to client diagnosis regarding cognitive status, employees are more prone to burnout. Root Cause: Employee Burnout due to client demand/need for care. Corrective Action: Education, Support, and Post Testing. Background leading up to the need for this project: Staff reports feelings of burnout/frustration. Goal for project: Ongoing positive relationship b/w management and staff in effort to provide support and education to all staff. Material Resources required for the project: Video training, handouts, return demonstration, flyers, discussions. Project Follow-Up: 12/22/2023, 12/29/2023 and 01/05/2024. The follow-up minutes revealed no report or concerns of staff burnout.

Based on interview and record review, the facility failed to ensure the physician was immediately notified when there was a significant change in a resident's physical health, for 1 (#1) of 3 sampled residents (#1, #2 and #3). This failed practice resulted in an actual harm situation for Resident #1 on 12/22/2023 at approximately 8:45 a.m., when Resident #1 was observed by S8 CNA to have difficulty walking, and was unable to feed himself. S4 LPN was notified; however, S4 LPN did not notify Resident #1's physician. At 2:00 p.m., S8 CNA reported Resident #1's condition to S1 Administrator. Resident #1 was sent to the hospital, and underwent a left Frontoparietal Epidural Hematoma Evacuation on 12/23/2023. Findings: Review of Resident #1's medical record revealed an original admitted [DATE], and a readmitted [DATE]. Diagnoses included in part . Traumatic Subdural Hemorrhage without Loss of Consciousness, Sequela - 12/26/2023; Schizoaffective Disorder, Bipolar Type; Generalized Anxiety Disorder; and Malignant Neoplasm of Brain, Unspecified. Review of a Quarterly MDS with an ARD of 09/21/2023 revealed Resident #1 was coded to have a BIMS score of 03, which indicated severe cognitive impairment. The MDS revealed Resident #1 was independent in all ADLS. Review of a Quarterly MDS with an ARD of 12/29/2023 revealed in part .Resident #1 was coded to have a BIMS score of 03, which indicated severe cognitive impairment. The MDS revealed Resident #1 had no upper and lower ROM impairment; did not require a mobility device; required maximum/substantial assistance for dressing, personal hygiene; partial/moderate assistance for transfers and walking at least 50 feet; and the ability to walk at least 150 feet not attempted due to medical or safety concerns. Review of Resident #1's medical record revealed the resident had sustained a fall at the nursing facility on 12/14/2023, and had the following diagnoses: Epidural hematoma, Midline shift of brain due to hematoma, SAH (subarachnoid hemorrhage), Subdural hematoma, acute, Closed fracture of parietal bone of skull, and Temporal skull fracture. The medical record revealed Resident #1 was hospitalized from 12/14/2023 to 12/18/2023, and did not require surgical intervention at that time. Resident #1 was transferred back to the nursing facility on 12/18/2023. Review of Resident #1's Comprehensive Care Plan with an ARD of 12/29/2023 revealed in part . 1. I have diagnosis of Schizophrenia. Goal: I will have decrease in my behavior. Interventions: Admin my medications as ordered by my physician; assist me with some of my ADLs; encourage me to participate in facilities daily activities; Have the pharmacy consultant to review psychotropic medications monthly as needed; Notify my physician of any significant changes. 2. I have an anxiety disorder: Goal: My anxiety will be minimized. Interventions: Administer meds as ordered. Approach me in calm manner Notify MD of any significant changes. Remove me from areas that cause me anxiety. 3. I require a secure unit at this time due to behaviors. I have delusions. Interventions: Monitor my whereabouts every 2 hours or as needed. Review of Resident #1's Nurses' Notes, read as follows in part . 12/18/2023 at 5:09 p.m. - Nursing Assessment Progress Note. Resident returned from the hospital via ambulance service. Subarachnoid Hemorrhage, Trauma, Epidural Hematoma, Blunt Trauma, Fall, initial encounter, and Closed Fracture of Parietal Bone, initial encounter. Talkative and greeted everyone .ambulated with a steady gait to smoke .speech clear .denies any pain or discomfort at present. documented by S4 LPN. 12/19/2023 at 7:32 p.m. - Resident awake and quiet in bed. Able to make needs and wants known. Ambulates ad lib. Documented by S10 LPN. 12/22/2923 at 8:51 a.m. - Resident sitting outside smoking cigarettes .Resident ambulates with assistance, and requires assistance with meals and ambulation. Resident has change of condition for last 2 days. Resident #1 needed help to walk, and get in and out of bed for the last 2 days. The physician ordered the resident sent to the hospital for evaluation of change in condition. Documented by S4 LPN. 12/22/2023 at 3:00 p.m. - Resident sitting outside. Ambulance service arrived, and resident transferred to hospital at 3:06 p.m. Documented by S4 LPN. Review of a MD Progress Note dated 12/22/2023 at 11:15 a.m. revealed in part . HPI: Patient with recent admission to a medical center noted to have right parietal epidural hematoma, bifrontal subarachnoid hemorrhages, anterior subdural hematoma, nondisplaced right parietal and temporal skull fractures. Returned to facility and was able to ambulate, now noted to have bilateral lower extremity weakness. Patient is nonverbal on my evaluation. Plan: Patient with change in neurological exam, and now weakness in bilateral lower extremities that he is unable to ambulate, with recent episode of subarachnoid hemorrhage. Will transfer patient to ER for further evaluation and treatment, and recommend further evaluation, and repeat CT of the head to reevaluate subarachnoid and subdural hemorrhages. Review of an ER note dated 12/22/2023 at 3:52 p.m., revealed in part .patient sent from his special needs nursing home for evaluation of altered mental status. Apparently had a fall with a significant head injury 1 week ago. admitted in another city for traumatic epidural hematoma and subarachnoid hemorrhage. According to that hospital's documentation, he did not require surgical intervention. He was observed for several days and ultimately discharged back to the NH 2 days ago. An ambulance was called today because the nurse reported he did not seem like himself since he got back from the hospital. They reported that he is less cooperative, and is not walking around the nursing home the way he used to. There is no report of any new fall or trauma of any kind. There is no report of any known sick symptoms including fever, cough, shortness of breath, abdominal pain, nausea, vomiting, or diarrhea. Inpression: 1. Multifocal intrancranial as described above. 2. Nondisplaced right parietal skull fracture with underlying 1.9 cm thick extra-axial convex hemorrhage consistent with epidural hemorrhage. 3. Small bilateral frontal mixed subdural and epidural hemorrhage with left frontal lobe edema. 4. Right temporal lobe edema/contusion with minimal subarachnoid hemorrhage. 5. 3 mm of midline shift to the left. Review of an Operative Procedure Report dated 12/23/2023 revealed the following: Preoperative and postoperative Diagnoses: Left Frontoparietal epidural hematoma with mass effect. Procedure performed: Left frontoparietal craniotomy with epidural hematoma evacuation. Interview with S8 CNA on 01/17/2024 at 3:35 p.m., revealed she was the CNA for the unit, and worked 12/18/2023 through 12/22/2023 from 7:00 a.m. to 7:00 p.m. She stated she was on duty the day Resident #1 returned from the hospital (12/18/2023). She stated Resident #1 needed limited assistance with ambulation, and was incontinent, which was not the case prior to his hospitalization . She stated she reported to S10 LPN, who assessed the resident. S8 CNA stated on the remaining days, 12/19/2023 to 12/21/2023, if there were any issues, she reported to the nurse and followed protocol. S8 CNA stated Resident #1 got worse on 12/22/2023 around 8:45 a.m., and she reported to S4 LPN that Resident #1 had to be fed and could hardly walk. She stated S4 LPN assessed Resident #1, and said she was going to report it to S2 DON. S8 CNA stated at some point during the shift, S6 CNA who was on duty also, reported the change in Resident #1 to S4 LPN, because nothing had been done. S8 CNA stated she left the unit at 2:00 p.m., and reported Resident #1's condition to S1 Administrator, who immediately took action, and Resident #1 was sent to the hospital. Interview with S10 LPN on 01/17/2024 at 3:45 p.m. revealed she worked on the unit from 6:00 a.m. to 6:00 p.m. on 12/20/2023 and 12/21/2023. S10 LPN stated Resident #1 tolerated his medications, and continued to ambulate to smoke. She stated Resident #1 was able to ambulate without assistance, but after he returned from the hospital on 12/28/2023, she had instructed him to use the hand rails, and to walk slowly. S10 LPN stated she was notified of different things, with Resident #1, by S8 CNA, and she assessed the resident. S10 LPN stated she could not state exactly what those things were. She stated when she clocked out on 12/21/2023 at 6:00 p.m., Resident #1 was not in trouble, and she felt as if nothing was wrong, and his condition was stable. Interview with S11 LPN on 01/18/2024 at 6:20 a.m. revealed she worked 6:00 p.m. to 6:00 a.m. on 12/20/2023. She stated Resident #1 was in bed when she arrived, and was in bed all night. She stated she gave him his medicine without incident, and did not notice anything unusual regarding changes in his condition. Interview with S12 LPN on 01/18/2024 at 6:45 a.m. revealed she worked from 6:00 p.m. to 6:00 a.m. She stated on the night of 12/21/2023, Resident #1 stayed in bed all night. She stated she had no issues, and according to the CNAs, there were no issues with Resident #1. Telephone interview with S4 LPN on 01/18/2024 at 9:00 a.m., revealed she was the receiving nurse when Resident #1 returned from the hospital on 12/18/2023, and that he required assistance with walking. She stated on the morning of 12/22/2023, S8 CNA told her that Resident #1's condition had worsened. She stated she informed S8 CNA that she would immediately tell S2 DON. S4 LPN confirmed that she didn't inform S2 DON of the situation with Resident #1, and that S1 Administrator was informed later that day. She stated the physician was making rounds that day, and was asked to see Resident #1 after S1 Administrator was informed. S4 LPN stated S2 DON and the physician went to the unit to assess Resident #1, and the physician ordered that Resident #1 be sent to the ER. Interview with S2 DON on 01/18/2024 at 10:30 a.m. revealed Resident #1 returned to the facility on [DATE]. She stated because she was off on that day, she saw Resident #1 the following day, and he was very pleasant, which was not his norm. She stated she observed him walking; however, he walked slowly, did not need assistance, and continued to ambulate to smoke without assistance. She stated no one told her Resident #1 required extra assistance when walking. S2 DON stated CNAs are supposed to report to their nurse if there are issues with their residents, and the nurse should then call the doctor, and let her (DON) know what's going on. S2 DON stated she and the physician were rounding on 12/22/2023 on another hall, when S1 Administrator asked her to come to the unit. She stated S1 Administrator stated Resident #1 had not been eating and had to be fed, and staff had to hold him up and walk with him. S2 DON stated the physician asked if that was the resident with the head injury, and she replied yes. She stated the physician said immediately to send the resident out. Interview with S1 Administrator on 01/18/2024 at 11:30 a.m., revealed around 2:15 p.m. on 12/22/2023, S8 CNA told her to come see something. She stated Resident #1 was sitting outside the back exit door, talking off. S1 Administrator stated S8 CNA stated Resident #1 was unable to feed himself today, and unable to walk, and she informed S2 DON and the physician.

Based on observation, interview, and record review the facility failed to ensure residents' rights to be free from resident to resident physical abuse. The facility failed to ensure 1 (Resident #18) of 4 (Resident #18, Resident #313, Resident #314, and Resident #363) sampled residents for abuse were not physically abused. This deficient practice resulted in an Actual Harm for Resident #18 that began on 06/18/2023 at 9:40 p.m. when Resident #363 threw the arm of his wheelchair at Resident #18 striking him on the left side of the face. Resident #18 received first-aid treatment in the facility for a laceration to the left face and was sent to a local ED where Resident #18 received three sutures to the left face laceration. Resident #18 continued to complain of pain to the left eye and was referred to ophthalmology on 07/13/2023, when it was determined Resident #18 would require eye surgery. Review of discharge instructions from the ophthalmologist revealed that Resident # 18 underwent a lens removal on 08/08/2023, an intraocular lens replacement on 10/31/2023, and required surgery to repair a retinal detachment of the left eye on 11/14/2023. Findings: Review of the facility policy titled Abuse Prevention and Prohibition revealed in part . Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Resident abuse may include: 1. resident to resident abuse 2. staff to resident abuse; or 3. family/visitor to resident abuse Physical Abuse may include an aggressive act, including inappropriate physical contact that is harmful or likely to cause injury or harm to a resident. #18 Review of the clinical record revealed Resident #18 admitted to the facility on [DATE], with diagnoses that included COPD, Type II DM, Essential HTN, GERD, Hypokalemia, Primary Open Angle Glaucoma, Bipolar disorder, Human Immunodeficiency Disorder, Major Depressive Disorder, Chronic Atrial Fibrillation, and Atrial Flutter. Review of Resident #18's Quarterly MDS with an ARD of 10/09/2023 revealed Resident #18 had a BIMS of 14, indicating no cognitive impairment, required supervision for bed mobility, transfers, eating and toilet use and had no impairment in functional range of motion to the upper and lower extremities. Mobility device noted as cane or crutch. Review of Resident #18's CPOC revealed Resident #18 was at risk for bleeding due to anticoagulant therapy and had impaired vision related to a diagnosis of Glaucoma. Resident #18 was not care planned for aggressive verbal or physical behaviors towards others. #363 Review of the Resident #363's clinical record revealed an admitted [DATE] with diagnoses that included Aphasia, Cerebral edema, Human Immunodeficiency Disorder, Persistent Mood Disorder, Toxoplasmosis, Unspecified Dementia, unspecified severity, with other behavioral disturbance, Hyperlipidemia, Essential Hypertension, Unspecified Glaucoma, Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side. Record review revealed Resident #363 discharged from the facility to the community on 07/20/2023. Review of Resident #363's Quarterly MDS with an ARD of 07/07/2023 revealed Resident #363 had a BIMS of 15, indicating no cognitive impairment, required the extensive assistance of 2 or more persons for bed mobility, transfers, dressing, toileting and personal hygiene. Resident #363 also had range of motion limitations to the upper and lower extremity on one side and utilized a wheelchair for mobility. Review of Resident #363's CPOC revealed in part The resident has behavior problems threatens to throw himself on the floor at risk for injury. Resident has a history of verbal behavior as evidenced by being verbally abusive, verbally inappropriate to staff and peers, calling staff derogatory names and demanding staff use 2 briefs on him at night despite education on the risk associated with extra brief use. Demanding to be cared for first despite refusing to get up when staff first attempted to provide care for resident, not easily redirected. 05/28/2023-I was observed drinking vodka on facility grounds, when counseled on policy violation I became verbally aggressive 06/19/2023-I made contact with a resident Review of a facility incident reported documented by S4 LPN revealed that on 06/18/2023 at 9:40 p.m. staff overheard Resident #18 tell Resident #363 not to go outside of the facility. Resident #363 became angry and threw his wheelchair arm at Resident #18's face. Resident #18's eye was noted to be moderately bleeding. Pressure held until bleeding stopped. Resident #363 ordered to be sent to ED (Emergency Department) to be evaluated for PEC (Physician's Emergency Certificate). Review of resident statements regarding the incident revealed Resident #363 refused to give details of incident and began using vulgar language. Resident #18 stated that he told Resident #363 he could not go outside to smoke in the non designated smoking area. As resident #18 was telling Resident #363 not to go, Resident #363 took the arm of his wheelchair and threw it at Resident #18 and hit him in the left eye. Interview on 11/13/2023 at 1:47 p.m. with Resident #18 revealed another resident got mad and pulled the arm rest off a wheelchair and threw it across the room, striking him in the left eye. Resident #18 stated he was sent out to the emergency room and has since had a procedure done on his eye because of the incident. Review of an emergency department record with a service date of 06/18/2023 revealed Resident #18 presented to the emergency department for evaluation of a laceration to the face. An irregular, 1.5 cm laceration was noted over patient's left zygoma. Laceration extends through dermis, but does not appear to extend into deeper tissues. Bleeding controlled at time of initial examination. No visible foreign body noted. Wound closed with 3 sutures of 5-0 monocryl using simple uninterrupted technique. Telephone interview on 11/15/2023 at 11:58 a.m. with S4 LPN revealed she was the nurse on duty on 06/18/2023 and assigned to Resident #18 and Resident #363. S4 LPN stated approximately 30 minutes before the incident she saw both residents playing cards in the side dayroom. S4 LPN stated another nurse came and got her from down the hall and told her #363 had hit #18 with a piece of his wheelchair. S4 LPN stated she believed #363 was trying to go out the side door to smoke and was redirected by Resident #18, which made him mad. S4 LPN stated #363 was very rude to staff, often caused issues, and had frequent outburst with staff and other residents. S4 LPN stated the residents were separated, the DON and police were called and Resident #18 was sent to the ER. S4 LPN stated Resident #363 was taken to his room by staff until they could get him sent out to be PEC'd. Telephone interview on 11/15/2023 at 12:24 p.m. with S13 LPN revealed on 06/18/2023 she and S14 LPN were walking into the side dayroom just as #363 threw a piece of his wheelchair at #18. S13 LPN stated Resident #18 was standing when she entered the dayroom and appeared to be telling #363 that he had to wait to go out and smoke. S13 LPN stated she was aware #363 had occasional outbursts of screaming and cursing at staff and residents but did not remember him hitting or throwing things. S13 LPN stated after the incident Resident #18 was assessed in the dayroom and Resident #363 taken to his room by staff. S13 LPN stated both residents were sent out to the hospital. Attempted telephone interview with S14 LPN on 11/15/2023 was unsuccessful. Review of a physician consultation report dated 07/13/2023 revealed Resident #18 was seen by an ophthalmologist with findings that included a dislocated intraocular lens. Recommendations were for the resident to return to the clinic on 07/31/2023 and for the resident to have surgery on the left eye on 08/08/2023. Review of the record revealed Resident #18's surgery was delayed because the resident required cardiac clearance and anticoagulants placed on hold pre-operatively. Cardiac clearance was received on 07/26/2023. On 08/08/2023, Resident #18 underwent a Vitrectomy for removal of a lens implant in the left eye, and subsequently had follow up appointments on 08/09/2023 and 08/30/2023. A follow up cardiology appointment was completed on 09/11/2023, and on 10/31/2023, an intraocular lens was inserted in Resident #18's left eye. A case request for a retinal detachment was made after the 10/31/2023 surgical procedure. On 11/14/2023, the resident underwent repair of a retinal detachment of the left eye. Review of discharge instructions dated 11/14/2023 revealed in part . retinal detachment of left eye. Past and present procedures 11/14/2023, Vitrectomy, PARS [NAME] approach-Left eye. Post-op appointment 11/15/2023 at 9:45 a.m. Observation on 11/15/2023 at 2:50 p.m. revealed Resident #18 in the facility dining area conversing with other residents. An eye shield was noted covering Resident #18's left eye and the resident had a neck roll pillow in place. Resident #18 stated his eye pain just wouldn't go away after the incident, so the nurse made him an appointment with the eye doctor. Interview on 11/15/2023 at 9:17 a.m. and 3:37 p.m. with S2 DON revealed Resident #18 complained of pain and vision changes in his left eye and was sent to an ophthalmologist who determined something was torn in the eye. S2 DON confirmed Resident #18's eye surgeries and appointments were a result of the 06/18/2023 wheelchair incident.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and in accordance with person-centered care plans by failing to: 1. Ensure two staff were available, as per care plan, to transfer Resident #6 from the floor back to his mattress. As a result, Resident #6 lay on the cold, tiled floor for an extended period of time; 2. Ensure Resident #24 did not pocket and spit out medications administered to him as ordered; 3. Ensure staff provided supervision/assistance of one person, as per care plan, for Resident #4 when he verbalized the need to use the restroom. As a result, Resident #4 urinated on himself; 4. Ensure Resident #19, who was unable to communicate easily with staff, was not fully exposed in full view of other residents across the room during incontinent care; and 5. Ensure residents and staff had access to a call system in the event emergent or non-emergent help/assistance was needed (Residents #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23 and #24). This failed practice resulted in an Immediate Jeopardy situation for residents #4, #6, #19 and #24. On 01/08/2023 at approximately 10:00 a.m., residents who resided on Hall C, a locked, secure unit, were relocated from Hall C to Hall D, in order to utilize Hall C as a COVID-19 unit. On the 7:00 a.m. and 7:00 p.m. shift on 01/10/2023, with one staff in Hall D, Resident #6 who required two plus persons physical assistance for transfer, was observed on 01/10/2023 at 9:35 a.m. lying on the cold tiled floor, with his head under the bed next to him, wearing only a pull up. Resident #6's was not transferred from that position on the floor to the mattress until 9:40 a.m., when another staff arrived to assist in the transfer. On 01/10/2023 at 9:50 a.m., three pills were noted on the floor next to Resident #24's bed. S4 LPN confirmed the medications (that included his cancer pill), were for Resident #24, and that he did not ensure Resident #24 swallowed all of his medications during the medication pass. On 01/10/2023 at 9:30 a.m., the back of Resident #4's pants were saturated with urine. Resident #4 required supervision with toileting, and had requested to go to the bathroom, and was denied by staff, resulting in Resident #4 urinating on himself. Resident #4 was not changed until 11:30 a.m. Observation on 01/10/2023 at 11:15 a.m. revealed Resident #15 was upset and stated you have to go to the bathroom to do your business, not in here, don't do that in here! S7 CNA was observed providing incontinent care for Resident #19 (who could not communicate easily) in full view of Resident #15 and other residents who were directly across the room. The Immediate Jeopardy continued for the remaining residents (#7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #23) on Hall D. S1 Administrator was notified of the Immediate Jeopardy situation involving residents #4 and #s 6-24 on 01/11/2023 at 5:50 p.m. The Immediate Jeopardy was removed on 01/12/2023 at 4:45 p.m. when the facility submitted an acceptable Plan of Removal, and the surveyors determined through observation, interview and record review that the Plan of Removal was implemented. The plan of removal included: On 01/11/2023 - all residents were assessed for any signs of physical or psychological distress. The DON added another nurse aide to the dining room area for a total of 3 nurse aides assigned to the residents located in the temporary living space in the dining room. The DON in-serviced the staffing coordinator on additional staff being added to the unit on 01/11/2023. In the event a nurse aide calls in, adjustments will be made the DON to ensure that 3 staff are assigned. On 01/11/2023 - The maintenance director added plastic bags to each resident's tray table that included whistles to alert staff. Additionally, the nurses were provided with cell phone, and short-range radios to summon help in an emergent/non-emergent situation. The staff was educated on the use of phone, numbers provided and the use of walkie talkie. The staff gave satisfactory return demonstrations for walkie talkies and emergency. On 01/11/2023 - The DON completed in-service with all nurses assigned to the temporary living space/dining room regarding medication administration: ensuring the resident consumes medications. All nurses were in-serviced on medication administration to ensure residents consume the medication on 01/11/2023. Any staff member not present will be in-serviced by administrative staff before the start of their next shift. On 01/11/2023- Resident #24 was assessed and showed no physical or psychological distress related to not consuming his medication. On 01/11/2023 - The DON/designee started the in-service with all staff on privacy and dignity. Resident #4 was assessed on 01/11/2023 and no problems with dignity were found. Resident #19 was assessed on 01/11/2023 and no problems with privacy were noted. Resident #6 was sent out to the hospital on 01/11/2023. At the time of discharge, no problems with dignity were noted. On 01/11/2023 - Maintenance/Housekeeping Supervisor hung additional privacy curtains to ensure residents dignity and privacy. Additional bedside commodes were added to ensure residents had access to toileting. On 01/12/2023 - All staff were in-serviced regarding privacy/dignity and communication. Nurses were in-serviced on medication administration. Any staff member that was not in-serviced will not be permitted to work until in-servicing has been completed by administrative staff. On 01/12/2023 - All policies and procedures on medication administration, communication and privacy/dignity were reviewed and no changes were made. On 01/12/2023 - Re-education was started with staff on communication procedures by the ADON and will be completed on 01/12/2023. On 01/12/2023 - any staff not re-educated will not work until they have been re-educated by administrative staff. Monitoring: All monitoring began on 01/11/2023. The DON/designee will monitor medication passes 3 times a week for 4 weeks to ensure medications are consumed by the residents. The Administrator/designee will monitor communication procedures, privacy/dignity procedures 5 days a week for 4 weeks to ensure procedures are being followed per policy. Administrator and DON will ensure that there are 3 staff members on the unit during daily rounds. The Immediate Jeopardy continued for the remaining 16 resident who were relocated and housed in Hall D. Findings: Resident #6 Review of Resident #6's medical record revealed and admitted [DATE]. Diagnoses included: Schizoaffective Disorder, Bipolar, Major Depressive Disorder with Psychotic symptoms, Generalized Anxiety and Traumatic Brain Dysfunction. Review of Resident #6's MDS with an ARD of 12/05/2022, revealed a BIMS of 2 (severely cognitively impaired). Resident #6 required extensive two person physical assistance for bed mobility, transfers, dressing, person hygiene, bathing, and toilet use; and extensive one person assistance for eating. Review of Resident #6's Care Plan with a target date of 03/23/2023 revealed a problem of limited physical mobility related to contractures of both hands. Requires max/total assistance from staff with ADLs. At risk for falls related to impaired cognition. Observation on 01/10/2023 at 9:35 a.m. revealed Resident #6 was lying on the tiled floor wearing only a pull up. Resident #6's head was noted to be under the bed of the resident next to him. Interview with S7 CNA at that time revealed Resident #6 removes his clothing, and moves himself off his mattress (which was on the floor) and onto the floor all the time. S7 CNA stated he did not know how long Resident #6 had been on the floor in that position. Observation on 01/10/2023 at 9:40 a.m. revealed S7 CNA and S8 CNA transferred Resident #6 from the floor onto his mattress which was on the floor. Resident #24 Review of Resident #24's medical record revealed an admitted [DATE]. Diagnoses included: Schizophrenia, Muscle Weakness, Lack of Coordination, Chronic Lymphocytic Leukemia of B Cell type not having achieved remission and MRSA. Review of Resident #24's Plan of Care with a completion date of 01/04/2023 revealed in part . 1. I have Schizophrenia and had an episode of physical behavioral symptoms as evidence by packing up my roommate's clothes as well as mine. Interventions included: analyze times of day, places, circumstances, triggers and what de-escalate behavior and document; Communication - provide physical and verbal cues to alleviate anxiety, give positive feedback; resides on male unit. 2. At risk for falls dues to abnormalities of gait/mobility and lack of coordination. Interventions included: Keep call light in reach, encourage resident to voice needs as well as seek/await staff assist for transfers, ensure resident wears appropriate, well-fitting footwear to minimize risk of slipping, and keep environment clear of unnecessary objects. Observation on 01/10/2023 at 9:50 a.m. revealed three pills were noted on the floor next to resident #24's bed. Interview with S7 CNA at that time confirmed the three pills were on the floor, and that Resident #24 received medications that morning from S4 LPN. Interview with S4 LPN on 01/10/2023 at 9:57 a.m. confirmed the three pills on the floor were some of the pills he administered to Resident #24 that morning. S4 LPN pointed to one of the medications on the floor and stated that's his cancer pill right there. S4 LPN confirmed he normally does check Resident #24's mouth for pill pocketing, but stated this morning I guess I didn't do a very good job. S4 LPN was unable to determine what the 2 other pills were. Resident #4 Review of Resident #4's medical record revealed Resident #4 was admitted on [DATE]. Diagnoses included: Dementia with behavioral disturbance, Schizophrenia, Major Depressive Disorder and Post- Traumatic Stress Disorder. Review of Resident #4's Quarterly MDS with an ARD of 12/02/2022 revealed a BIMS of 99 (unable to complete interview). Review of Resident #4's Functional Status revealed Resident #4 required supervision with oversight for bed mobility, transfers, eating and toilet use; and limited one person physical assistance for dressing, person hygiene and bathing. Resident #4 had no ROM impairment for upper and lower extremities. Review of Resident #4's Care Plan with a target date of 03/23/2023 revealed an ADL self-care performance deficit related to Dementia and Behavior. Resident #4 sometimes refuses care. Resident has episodes of socially inappropriate behaviors- can be aggressive at times. Resident wanders and is disoriented to place. Observation on 01/10/2023 at 9:30 a.m. revealed the back of Resident #4's pants was visibly wet, and it appeared he soiled himself with urine. Observation on 01/10/2023 at 11:20 a.m. revealed Resident #4 was wearing the same soiled pants he was observed wearing that morning at 9:30 a.m. The visibly wet area on the back of his pants was larger than was observed at 9:30 a.m. Staff was observed to assist him with changing his clothing at 11:30 a.m. Resident #19 Review of Resident #19's medical record revealed an admitted [DATE]. Diagnoses included: Dementia - Severe with Psychotic Disturbance, Depression and Mild Cognitive Impairment. Review of Resident #19's Admission MDS with as ARD of 01/12/0223 revealed the Admission MDS assessment was still in progress/not completed. Review of Resident #19's Baseline Care Plan as of admission to the facility revealed in part .Resident #19 cannot communicate easily with staff. Functional status documented in the Care Plan revealed: No set-up or physical help needed for bed mobility, transfer; set-up help only for eating, personal hygiene and toilet use; and 1 person physical assistance for dressing and bathing. Observation of Resident #19 on 01/10/2023 at 9:30 a.m. revealed Resident #19 was lying uncovered in bed, in a urine soaked incontinent brief. Observation on 01/10/2023 at 11:15 a.m. revealed Resident #15 speaking with another resident. Resident #15 appeared upset as he stated you have to go to the bathroom to do your business, not in here, don't do that in here! At that same time, S7 CNA was observed providing incontinent care for Resident #19. Full visual privacy for Resident #19 was not provided during care, and Resident #19 was exposed in full view of other residents across the room including Resident #15. Resident #15 stated I don't want to see all of that! Resident #8 Observation on 01/10/2023 at 10:00 a.m. revealed resident #8, who had diagnoses that included Schizoaffective Disorder, Bipolar Type and Anxiety, and required one person physical assistance for toilet use, and extensive one person assistance for personal hygiene, was observed wearing paper scrubs and a diaper. Feces was observed on Resident #8's buttocks above his diaper, and on his bed sheets. Interview with S7 CNA at that time revealed he started his shift at 7:00 a.m. that morning, and was working alone until S8 CNA arrived at 9:30 a.m. S7 CNA confirmed Resident #8 was soiled with feces and needed to be cleaned; however, he stated he did not have a chance to provide incontinent care to any of the residents as of yet since he was working alone. Resident #16 Review of Resident #16's Plan of Care with a completion date of 12/23/2022 revealed in part . 1. I have limited physical mobility due to disease process, weakness. Interventions included: Provide supportive care, assistance with mobility as needed. 2. I have occasional urinary incontinence. Interventions included: notify nurse if incontinent during activities, clean peri-area with each incontinent episode. Observation on 01/10/2023 at 11:30 a.m. revealed S8 CNA was the only staff present in the dining room. Resident #16 voiced his need to use the restroom to S8 CNA. S8 CNA redirected the resident to his bed and instructed him to lay down and rest. S8 CNA told Resident #16 he could not take him to the restroom at that time as he was the only staff on the unit. After Resident #16's request to use the restroom was denied, Resident #16 was noted to have visibly wet pants. Resident #21 Review of Resident #21's Quarterly MDS dated [DATE] revealed a BIMS of 8 (moderately impaired cognitively). Interview with Resident #21 on 01/10/2023 at 10:05 a.m. revealed he stated, you can't even use the restroom in here, there's no privacy at all. The following observations of Hall D on 01/10/2023 at 9:30 a.m. revealed: 1. There were no sinks, no bathrooms and no call system in the dining room. 2. Residents were observed in their beds or wandering around the dining room. 3. There were numerous dirty cups on the floor, soiled linens on the floor, food particles, urine, feces and other debris scattered over the floor. 4. Several residents requested water and staff acknowledged the requests; however, the residents were not given water. There was no water pitcher observed in the area, or a means for the residents to obtain water. 5. There were no bedside tables. Staff stated residents had to eat meals in their beds. 6. Residents' clean clothing were in garbage bags piled on the floor. 7. Residents' beds were unmade, and sheets were thin and dirty with food particles and feces. 8. Several residents were wearing clothes that did not match and/or did not fit properly, and were walking around barefoot on the tiled floor. 9. Several urinals were half full of urine and hanging on the ends of residents' beds. Observation of Hall D on 01/10/2023 at 9:45 a.m. revealed thirteen cloth privacy curtains were observed in between several of the residents' beds. There were 22 beds in the dining room. The privacy curtains extended only in between the beds, and did not provide full visual privacy as they did not enclose the foot of the beds. Observation on 01/10/2023 at 9:45 a.m. revealed there were 6 full urinals noted on the floor of Hall D, and no bathroom facilities were available in that area. Interview with S7 CNA on 01/10/2023 at 9:47 a.m. revealed they did not have a call system for Hall D, and if they needed help, one of the staff would have to leave the area to get assistance, or they could use their cell phone to call the nurse. Interview with S1 Administrator and S2 DON on 01/10/2023 at 10:06 a.m. revealed Hall D was converted into the male locked, secure unit on 01/08/2023. S1 Administrator and S2 DON confirmed there were not enough privacy curtains to provide full visual privacy for all residents. S1 Administrator and S2 DON confirmed the area had no call system available for residents/staff to call for assistance. Interview with S4 LPN on 01/11/2023 10:04 a.m. revealed he was normally assigned to residents on Hall D and on Hall C, and was the nurse for the residents located in Hall D. S4 LPN stated he goes to Hall D to pass medications either at 8:00 a.m. or 9:00 a.m., depending on which hall he starts with his medications pass. S4 LPN stated the staff in Hall D could call him on his personal cell phone if they needed him. S4 LPN stated staff in Hall D would have to use their personal cell phones, as there was no facility phone in Hall D. If a staff did not have a phone, they would have to leave Hall D to find the nurse. Immediately after interview, S4 LPN followed surveyors into Hall D and asked S8 CNA do you have my cell phone number? Surveyors observed S4 LPN write his cell number on a piece of paper on a table in Hall D. Interview with S8 CNA at that time revealed he did not previously have S4 LPN's cell number. Interview with S12 CNA on 01/11/2023 at 10:25 a.m. revealed if she needed assistance from the nurse, she would use her personal cell phone to call room a, and tell them she needed a nurse. Interview with S5 CNA on 01/11/2023 at 2:05 p.m. revealed he worked the night shifts (7:00 p.m. to 7:00 a.m.) on 01/09/2023 and 01/10/2023. S5 CNA confirmed there was no call system available in Hall D. Interview with S1 Administrator and S2 DON on 01/11/2023 at 4:30 p.m. revealed both stated the residents who were residing in Hall D were not in the ideal situation. S1 Administrator and S2 DON stated when they initially moved residents onto Hall D, there was not enough curtains to provide full visual privacy for each resident. S1 Administrator and S2 DON stated there was no available call system set up for staff in Hall D to reach the nurse in the case of emergent or non-emergent situations. S1 Administrator and S2 DON stated they had whistles for the residents to use if they needed assistance; however, no whistles were observed on Hall D.

Based on observation, record review and interview, the facility failed to provide sufficient nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted each resident's rights, physical, mental and psychosocial well-being as determined by resident assessments and individual plans of care. The facility failed to ensure there was sufficient staff to provide supervision and care and services for 20 Residents who resided on a locked, secure unit, and had psychiatric and/or behavioral diagnoses: #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23 and #24. This failed practice resulted in an Immediate Jeopardy situation for residents #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23 and #24 which began on 01/08/2023 at approximately 10:00 a.m., when the residents who resided on Hall C were transferred to Hall D, in order to utilize Hall C as a COVID-19 unit. The facility staffed Hall D with 2 CNAs per shift (7:00 a.m. - 7:00 p.m. and 7:00 p.m. - 7:00 a.m.). Interview of the S2 DON revealed she attempted to staff Hall D with 3 CNAs; however, she was unable to, due to call-ins and no shows. There were periods of time during each shift when one CNA was left alone (shower times, restroom times and smoke breaks). Observations on 01/10/2023 at 9:30 a.m revealed there were residents who were incontinent of urine and feces and required incontinent care along with a change of clothing. Several residents were observed requesting assistance to go to the restroom. S7 CNA stated his shift started at 7:00 a.m. that morning, and he was working alone until S8 CNA arrived at 9:30 a.m. S7 CNA stated he did not have a chance to provide incontinent care to any of the residents as of yet since he was working alone. S1 Administrator was notified of the Immediate Jeopardy situation on 01/12/2023 at 7:00 p.m. The Immediate Jeopardy was removed on 01/13/2023 at 3:53 p.m. when the facility submitted an acceptable Plan of Removal, and the surveyors determined through observation, interview and record review that the Plan of Removal was implemented. The plan of removal included: 01/11/2023 - The 20 residents that were temporarily moved to the dining room due to a COVID-19 outbreak were assessed and showed no physical or psychological signs of distress. No issues with privacy or dignity found. 01/11/2023 - The Director of Nursing added another nurse aide to the dining room area for a total of 3 nurse aides assigned to the residents located in the temporary living space in the dining room. The director of nursing in-serviced the staffing coordinator on additional staff being added to the unit on 01/11/2023. In the event, a nurse aide calls in, adjustments will be made by the Director of Nursing to ensure that 3 staff are assigned. Agency staff can be utilized by the facility in the event that there are call-ins or additional staffing is needed. 01/11/2023 - The maintenance director added plastic bags to each resident tray table that includes whistles to alert staff. Additionally, the nurses were provided with cell phones, and short-range radio (walkie/talkie) to summon help in an emergent/nonemergent situations. The staff was educated on the use of phone, numbers provided, and use of walkie talkie. The staff gave satisfactory return demonstrations for walkie talkies and emergency. 01/11/2023 - The Director of Nursing completed in-service with all nurses assigned to the temporary living space/dining room regarding medication administration: ensuring the resident consumes the medications. All nurses were in-serviced on medication administration to ensure residents consume the medication on 01/11/2023. Any staff member not present will be in-serviced by administrative staff before the start of their next shift. 01/11/2023 - Resident #24 was assessed and showed no physical or psychological distress related to not consuming his medication. 01/11/2023 - The Director of Nursing/designee started the in serviced with all staff on privacy and dignity. Resident #4 was assessed on 01/11/2023 and no problems with dignity were found. Resident #19 was assessed on 01/11/2023 and no problems with privacy were found. Resident #6 was sent out to the hospital on 01/11/2023. At the time of discharge to the hospital, there were no problems with dignity found. 01/11/2023 - The Maintenance/Housekeeping supervisor hung additional privacy curtains to ensure residents' dignity and privacy. 01/11/2023 - The Director of Housekeeping supplied additional bedside commodes to ensure residents have access for toileting. Area is partitioned off and is not near food. 01/11/2023 - Steam table for dining room is located inside the kitchen and is not being utilized for meal service during the temporary relocation period. 01/11/2023 - Administrative staff completed facility-wide assessment. No concerns related to staffing identified. No concerns related to privacy or dignity found. 01/12/2023 - All in-services have been completed with all staff for privacy/dignity, communication, nurses on medication administration. Any staff member that has not been in serviced will not be permitted to work until in- servicing has been completed by administrative staff. 01/12/2023 - Policies and procedures on medication administration, communication, and dignity/privacy were reviewed- no changes were made. 01/12/2023 - Re- education was started with staff on communication procedures by the ADON and will be completed 01/12/2023. Any staff not re-educated will not work until they have been re in serviced by administrative staff. All in-services were completed on 01/12/2023. 01/12/2023 - Corporate representative EVP in-serviced Administrator and DON on F835; definition of citation, guidance and procedures, as well as corrective action plans for F725, F835, and F684. Facility relocation plan Facility infection control nurse, administrator, and corporate representative reviewed facility relocation plan, co-horting warm and hot residents and quarantining to their rooms vs. designating a unit. Facility reviewed staffing plan for COVID-19. COVID positive residents will have designated staff that will only care for residents in said rooms. Signs will be hung on doors for all hot and warm rooms to alert staff to the resident's status. PPE carts will be placed outside doors for proper donning and doffing as it relates to infection control. DHH Epidemiologist is in agreement with the above plan. Pending contingencies: Resident permission to relocate/consolidate COVID negative residents in rooms together to open up room availability to create warm rooms and COVID positive rooms until quarantine timeframes are completed. Residents currently temporarily relocated to the dining room will be tested and pending results, will be relocated back to the secure male unit. Once all residents are relocated out of the dining room, the entire residing space will be terminally clean. E-mist machine will be utilized to disinfect all areas of the facility that are presently occupied. 01/13/2023 - All residents of the facility tested negative for COVID-19. Staff will initiate room moves of the 20 residents currently in the dining room back to the secured male unit after terminal cleaning has been completed of all areas of relocation. Monitoring All monitoring began on 01/11/2023. The DON/designee will monitor medication passes 3 times a week for 4 weeks to ensure medications are consumed by the residents. The Administrator/designee will monitor communication procedures, privacy/dignity procedures 5 days a week for 4 weeks to ensure procedures are being followed per policy. Administrator and DON will ensure that there are 3 staff members on the unit during daily rounds. The likelihood of serious harm or injury to any resident no longer exists as of 01/13/2023 at 3:53 p.m. Findings: Review of residents' medical records who resided on Hall D revealed the following: Resident #4 Resident #4 had an admitted [DATE]. Diagnoses included: Dementia with behavioral disturbance, Schizophrenia, Major Depressive Disorder and Post- Traumatic Stress Disorder. Review of Resident #4's Quarterly MDS with an ARD of 12/02/2022 revealed a BIMS of 99 (unable to complete interview). Review of Resident #4's Functional Status revealed Resident #4 required supervision with oversight for bed mobility, transfers, eating and toilet use; and limited one person physical assistance for dressing, person hygiene and bathing. Resident #4 had no ROM impairment for upper and lower extremities. Review of Resident #4's Care Plan with a target date of 03/23/2023 revealed an ADL self-care performance deficit related to Dementia and Behavior. Resident #4 sometimes refuses care. Resident has episodes of socially inappropriate behaviors- can be aggressive at times. Resident wanders and is disoriented to place. Observation on 01/10/2023 at 9:30 a.m. revealed Resident #4 was wandering about the unit, and the back of his pants was visibly wet. It appeared he soiled himself. Observation on 01/10/2023 at 11:20 a.m. revealed Resident #4 was wearing the same soiled pants he was observed wearing that morning at 9:30 a.m. The visibly wet area on the back of his pants was larger than was observed at 9:30 a.m. Staff was observed to assist him with changing his clothing at 11:30 a.m. Resident #6 admitted [DATE]. Diagnoses included: Schizoaffective Disorder, Bipolar, Major Depressive Disorder with Psychotic symptoms, Generalized Anxiety and Traumatic Brain Dysfunction. Review of Resident #6's MDS with an ARD of 12/05/2022, revealed a BIMS of 2 (severely cognitively impaired). Resident #6 required extensive two person physical assistance for bed mobility, transfers, dressing, person hygiene, bathing, and toilet use; and extensive one person assistance for eating. Review of Resident #6's Care Plan with a target date of 03/23/2023 revealed a problem of limited physical mobility related to contractures of both hands. Requires max/total assistance from staff with ADLs. At risk for falls related to impaired cognition. Observation on 01/10/2023 at 9:35 a.m. revealed Resident #6 was lying on the tiled floor wearing only a pull up. Resident #6's head was noted to be under the bed of the resident next to him. Interview with S7 CNA at that time revealed Resident #6 removes his clothing, and moves himself off his mattress (which was on the floor) and onto the floor all the time. S7 CNA stated he did not know how long Resident #6 had been on the floor in that position. Interview with S7 CNA at that time stated he was working by himself until S8 CNA arrived at 9:35 a.m. and was able to assist with transferring Resident #6 back to his mattress. Observation on 01/10/2023 at 9:40 a.m. revealed S7 CNA and S8 CNA transferred Resident #6 from the floor onto his mattress which was on the floor. Resident #7 admitted [DATE]. Diagnoses included: Schizophrenia and Schizoaffective Disorder, and Bipolar Type. Review of Resident #7's Admission MDS with an ARD of 11/08/2022 revealed a BIMS of 00 (severely cognitively impaired). Resident #7 required limited one person physical assistance for dressing, personal hygiene and bathing; and supervision/oversight for bed mobility, transfer, walking in room/corridor, and locomotion on/off unit. Resident #8 admitted [DATE]. Diagnoses included: Schizoaffective Disorder, Bipolar Type and Anxiety. Review of Resident #8's MDS Quarterly with ARD of 10/14/2022, revealed a BIMS of 9 (moderately cognitively impaired). Resident #8 required limited one person physical assistance for bed mobility, dressing and toilet use; extensive one person physical assistance for personal hygiene and bathing; supervision of one person for transfers; and supervision with set-up help for walk in room and corridor, locomotion on and off the unit, and eating. No ROM impairments for upper and lower extremities. Review of Resident #8's Plan of Care with a target date of 12/23/2022 revealed the following identified problems: ADL self-care deficit related to muscle wasting, Encephalopathy, difficulty walking, abnormality of gait, lack of coordination and history of falls. Identified problem of Schizophrenia with impaired cognitive functioning, impaired decision making, altercations with other residents, and physical aggression towards other residents. Observation on 01/10/2023 at 10:00 a.m. revealed Resident #8 was observed wearing paper scrubs and a diaper. Feces was observed on Resident #8's buttocks above his diaper, and on his bed sheets. Interview with S7 CNA at that time revealed he started his shift at 7:00 a.m. that morning, and was working alone until S8 CNA arrived at 9:30 a.m. S7 CNA confirmed Resident #8 was soiled with feces and needed to be cleaned; however, he stated he did not have a chance to provide incontinent care to any of the residents as of yet since he was working alone. Resident #9 admitted [DATE]. Diagnoses included: Schizoaffective Disorder - Bipolar Type. Review of Resident #9's Quarterly MDS with an ARD of 10/06/2022 revealed a BIMS of 3 (severely cognitively impaired). Resident #9 required supervision with set-up help for bed mobility, transfers, walk in room and corridor, locomotion on and off unit and toilet use; limited one person physical assistance for dressing and personal hygiene; and total dependence of one person for bathing. Resident #10 admitted [DATE]. Diagnoses included: Neuro-syphilis, Vascular Dementia, Severe with other Behavioral Disturbance, Schizoaffective Disorder and Major Depressive Disorder. Review of Resident #10's Quarterly MDS with an ARD of 11/03/2022 revealed a BIMS score of 00 (severely cognitively impaired). Resident #10 required supervision with no set-up help for bed mobility, toileting, walk in room and corridor, and locomotion on and off unit; supervision with set-up help for transfers, dressing, eating, and personal hygiene; and limited assistance/set-up help for bathing. Resident #10 had no upper and lower ROM limitations. Resident #11 admitted [DATE]. Diagnoses included: Major Depressive Disorder, Schizoaffective Disorder- Bipolar Type, Dementia, Psychotic Disorder with Delusions and Schizophrenia. Review of Resident #11's Quarterly MDS with ARD of 10/31/2022 revealed a BIMS of 01 (severely cognitively impaired). Resident #11 required limited one person physical assistance for bed mobility, walk in room and corridor, locomotion on and off unit, toilet use and bathing; supervision of one person for transfers; and extensive one person physical assistance for dressing, eating and personal hygiene. Resident #11 did not have upper and lower ROM impairment. Resident #12 admitted [DATE]. Diagnoses included: Schizoaffective Disorder, Alzheimer's, Paranoid Schizophrenia, Anxiety and Dementia with Behavioral Disturbance. Review of Resident #12's Annual MDS with ARD of 12/06/2022 revealed a BIMS of 99 (severely cognitively impaired). Resident #12 required one person physical assist with toileting, bathing and hygiene. All other ADLs required set up help only. Resident #13 - admitted [DATE]. Diagnoses included: Bipolar Disorder, Schizophrenia and History of mental and behavioral disorders. Review of Resident #13's MDS with an ARD of 10/14/2022 revealed a BIMS of 9 (moderately cognitively impaired). Resident #13 required one person physical assist with bathing and hygiene. All other ADLs required supervision with set up help only. Resident #14 admitted [DATE]. Diagnoses included: Dementia with Behavioral Disturbance, Anxiety Disorder and Bipolar Disorder. Review of Resident #14's MDS with an ARD of 12/09/2022 revealed a BIMS score of 00 (severely cognitively impaired). Resident #14 was independent with ADLs. Review of Resident #14's Care plan with target completion date of 01/11/2023 revealed little or no activity involvement related to Psychosis, Wernickle Disorder, Agitation and cursing. Resident believes he was killed and lives in another world. Resident #15 admitted [DATE]. Diagnoses included: Vascular Dementia - Severe with Behavioral Disturbance and Anxiety Disorder. Review of Resident #15's Quarterly MDS dated [DATE] revealed a BIMS of 99 (unable to complete interview). Functional status revealed Resident #15 required one person physical assistance for transfers, locomotion on and off unit, dressing, toilet use, personal hygiene and bathing; supervision of one person for bed mobility, and supervision with set-up help for eating. Resident #15 had no upper and lower ROM impairment. Review of Resident #15's Care Plan with a goal date of 02/12/2023 revealed a problem of ADL self-care performance deficit related to Dementia and Impaired balance- requires assistance from one staff with ADLs. Resident was identified as being at risk for falls related to impaired balance - history of falls. On 08/22/2022 - attempted to ambulate without assistance and fell . 08/23/2022 - fell while trying to get supper tray. Resident #16 Resident #16 - admitted to the facility on [DATE]. Diagnoses included: Vascular Dementia with Behavioral Disturbance, Impulse Disorder, Schizophrenia, Mild Intellectual Disability and Generalized Anxiety Disorder. Review of Resident #16's Quarterly MDS with an ARD of 09/30/2022 revealed a BIMS of 03 (severely impaired cognitively), and requires supervision and set-up help for bed mobility, transfers, dressing, eating, and toilet use; limited one person assistance for personal hygiene and bathing. ROM - impairment on one side for upper extremities, and no impairment for lower extremities. Review of Resident #16's Plan of Care with a completion date of 12/23/2022 revealed in part . 1. I have limited physical mobility due to disease process, weakness. Interventions included: Provide supportive care, assistance with mobility as needed. 2. I have occasional urinary incontinence. Interventions included: notify nurse if incontinent during activities, clean peri-area with each incontinent episode. Observation on 01/10/2023 at 11:30 a.m. revealed S8 CNA was the only staff present on Hall D. Resident #16 voiced his need to use the restroom to S8 CNA. S8 CNA redirected the resident to his bed and instructed him to lay down and rest. S8 CNA told Resident #16 he could not take him to the restroom at that time, as he was the only staff on Hall D. After Resident #16's request to use the restroom was denied, Resident #16 was noted to have visibly wet pants. Resident #17 admitted [DATE]. Diagnoses included: Impulse Disorder, Anxiety Disorder, Schizophrenia, Schizoaffective Disorder, Bipolar Disorder and Alzheimer's Disease. Review of Resident #17's Annual MDS dated [DATE] revealed a BIMS of 12 (cognitively intact), and indicated Resident #17 was Independent with ADLs. Resident #18 admitted [DATE]. Diagnoses included: Impulse Disorder, Paranoid Schizophrenia, Vascular Dementia with Behavioral Disturbance, Major Depressive Disorder-Recurrent and Severe with Psychotic Symptoms and Bipolar Disorder. Review of Resident #18's Annual MDS dated [DATE] revealed a BIMS of 15 (cognitively intact). Resident #18 required supervision with set-up help for all ADLs. Observation of Resident #18 on 01/10/2023 at 11:10 a.m. revealed Resident #18 walking around with a urinal full of urine in his hand. Resident #18 asked where the trash can was so he could empty it. S7 CNA took the urinal from Resident #18 and walked out of the unit. S8 CNA was left on the unit alone when S7 CNA left to empty the urinal. Resident #19 admitted on [DATE]. Diagnoses included: Dementia - Severe with Psychotic Disturbance, Depression and Mild Cognitive Impairment. Review of Resident #19's Admission MDS with as ARD of 01/12/0223 revealed the Admission MDS assessment was still in progress/not completed. Review of Resident #19's Baseline Care Plan as of admission to the facility revealed in part .Resident #19 cannot communicate easily with staff. Functional status documented in the Care Plan revealed: No set-up or physical help needed for bed mobility, transfer; set-up help only for eating, personal hygiene and toilet use; and 1 person physical assistance for dressing and bathing. Observation on 01/10/2023 at 9:30 a.m. revealed Resident #19 was lying uncovered in bed, with a urine soaked incontinent brief. Resident #20 admitted [DATE]. Diagnoses included: Vascular Dementia with Behavior Disturbance- Severe, Generalized Anxiety Disorder and Schizophrenia. Review of Resident #20's Annual MDS dated [DATE] revealed a BIMS of 15 (cognitively intact). Resident #20 required supervision with set-up help for bed mobility, transfers, walk in room and corridor, locomotion on and off unit, dressing, eating and toilet use; and one person assistance for personal hygiene and bathing. Resident #21 admitted [DATE]. Diagnoses included: Dementia and Major Depressive Disorder. Review of Resident #21's Quarterly MDS dated [DATE] revealed a BIMS of 8 (moderately impaired cognitively). Resident #21 required limited one person assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing; and supervision with set-up for locomotion on and off unit and eating. Resident #22 admitted [DATE]. Diagnoses included: Bipolar Disorder, Dementia, Mood Disturbance and Anxiety. Review of Resident #22's Quarterly MDS dated [DATE] revealed a BIMS of 6 (severe cognitive impairment). Resident #22's functional status for ADLS included: supervision with set up help for bed mobility, transfers, toileting, personal hygiene, bathing eating, walk in room and corridor, and locomotion on and off unit; and assistance of one person for dressing. Resident #23 admitted [DATE]. Diagnoses included: Schizophrenia and Anxiety Disorder. Review of Resident #23's Medicare 5 day MDS dated [DATE] revealed a BIMS of 8 (moderate cognitive impairment). Resident #23 required supervision with one person assistance for bed mobility; extensive one person physical assistance for transfers, dressing, toilet use and personal hygiene; total dependence and one person physical assistance for bathing; supervision with set-up help for locomotion of and off unit; and independent for eating. Resident #24 readmitted on [DATE]. Diagnoses included: Schizophrenia, Muscle Weakness, Lack of Coordination, Chronic Lymphocytic Leukemia of B Cell type not having achieved remission and MRSA. Review of Resident #24's Admission MDS with as ARD of 01/12/0223 revealed the Admission MDS assessment was still in progress/not completed. Review of Resident #24's Plan of Care with a completion date of 01/04/2023 revealed in part . 1. I have Schizophrenia and had an episode of physical behavioral symptoms as evidence by packing up my roommate's clothes as well as mine. Interventions included: analyze times of day, places, circumstances, triggers and what de-escalate behavior and document; Communication - provide physical and verbal cues to alleviate anxiety, give positive feedback; resides on male unit. 2. At risk for falls dues to abnormalities of gait/mobility and lack of coordination. Interventions included: Keep call light in reach, encourage resident to voice needs as well as seek/await staff assist for transfers, ensure resident wears appropriate, well-fitting footwear to minimize risk of slipping, and keep environment clear of unnecessary objects. Observation on 01/10/2023 at 9:30 a.m. revealed Hall D had been converted into a locked unit for male residents. Surveyors observed 21 male residents, and 22 beds in the area. S7 CNA was the only CNA present on the unit at that time. However, S8 an agency CNA, arrived to the unit immediately after the surveyors. The following was observed: 9:30 a.m.: 1. There were no sinks, no bathrooms and no call system in the dining room. 2. Residents were observed in their beds or wandering around the dining room. 3. There were numerous dirty cups on the floor, soiled linens on the floor, food particles, urine, feces and other debris scattered over the floor. 4. Several residents requested water and staff acknowledged the requests; however, the residents were not given water. There was no water pitcher observed in the area, or a means for the residents to obtain water. 5. There were no bedside tables. Staff stated residents had to eat meals in their beds. 6. Residents' clean clothing was in garbage bags piled on the floor. 7. Residents' beds were unmade, and sheets were thin and dirty with food particles and feces. 8. Several residents were wearing clothes that did not match and/or did not fit properly, and were walking around barefoot on the tiled floor. 9. Several urinals were half full of urine and hanging on the ends of residents' beds. 9:45 a.m. - There were 6 full urinals noted on the floor of the dining room, and no bathroom facilities were available in that area. Interview with S7 CNA on 01/10/2023 at 9:47 a.m. revealed residents had to be escorted by staff to Hall B to use the restroom and/or for baths, leaving one CNA on the unit with the remaining residents. S7 CNA stated they did not have a call system in the dining room, and if they needed help, one of the staff would have to leave the area to get assistance, or they could use their cell phone to call the nurse. Interview with S1 Administrator and S2 DON on 01/10/2023 at 10:06 a.m. revealed Hall D was converted into the male locked, secure unit on 01/08/2023. S1 Administrator and S2 DON confirmed the area had no call system available for residents/staff to call for assistance. Observation on 01/10/2023 11:00 a.m. revealed S8 CNA was escorting 2 residents out of the Hall D to go to the restroom on Hall B. Upon surveyors entering Hall D, there was no CNA or any other staff present with the residents in Hall D. The door to an outside exit was observed to be open, and S7 CNA was observed seated outside on a stool smoking along with 4 other residents. When S7 CNA was questioned whether he was monitoring the smoking residents and the residents in Hall D, he said yes, and stood in the doorway of Hall D/outside exit to the smoking area to observe both areas. Interview with S1 Administrator and S2 DON on 01/10/23 at 2:00 p.m. revealed they schedule two CNAs on the day shift (7:00 a.m. - 7:00 p.m.) and two on the night shift (7:00 p.m. - 7:00 a.m.). S2 DON stated she attempted to schedule three staff per shift; however, it was not working out due to call-ins from staff. Observation on 01/11/2023 at 8:35 a.m. revealed S8 CNA was the only CNA present with the residents on Hall D. The second CNA assigned to Hall D (S12 CNA), was observed outside monitoring the residents who were smoking. Interview with S4 LPN on 01/11/2023 10:04 a.m. revealed he was normally assigned to residents on Hall C and D, and was the nurse for the residents located on Hall D. S4 LPN stated he goes to Hall D to pass medications either at 8:00 a.m. or 9:00 a.m. depending on which hall he starts with his medications pass. S4 LPN stated the staff on Hall D could call him on his personal cell phone if they needed him. S4 LPN stated staff on Hall D would have to use their personal cell phones, as there was no facility phone on Hall D. If a staff did not have a phone, they would have to leave Hall D to find the nurse. Immediately after interview, S4 LPN followed surveyors into Hall D and asked S8 CNA do you have my cell phone number? Surveyors observed S4 LPN write his cell number on a piece of paper on a table in Hall D. Interview with S8 CNA at that time revealed he did not previously have S4 LPN's cell number. Observation on 01/11/2023 at 10:20 a.m. revealed S8 CNA was on Hall D alone, while S12 CNA was outside supervising residents who were smoking. S8 CNA stated if he needed the nurse for assistance, he would have to leave Hall D to get the nurse. Interview with S12 CNA on 01/11/2023 at 10:25 a.m. revealed if she needed assistance from the nurse, she would use her personal cell phone to call room a, and tell them she needed a nurse. Observation and interview of S8 CNA on 01/11/2023 at 11:10 a.m. revealed S8 CNA was the only staff present with residents on Hall D. S8 CNA stated that S12 CNA was with some of the residents who went to the canteen. S8 CNA stated if one staff has to leave Hall D for any reason, the other CNA is left alone. The facility only assigns two CNAs to Hall D, and does not send additional staff if one CNA has to leave Hall D for any reason. S8 CNA stated the staff assigned to Hall D have requested to Administration, that extra staff come to assist at these times, but S8 CNA stated Administration hasn't wanted to do anything about all of this until you guys got here. Interview with S6 CNA on 01/11/2023 at 2:00 p.m. revealed he worked on Hall D on 01/08/2023 from 7:00 p.m. - 7:00 a.m. S6 CNA stated there were only two CNAs working that shift, and the nurse was only on Hall D to administer medications. S6 CNA stated if one of the residents needed to use the bathroom, one staff would have to take them, leaving only one staff on Hall D. S6 CNA stated if they needed a nurse or other assistance for Hall D, one of the two staff would have to leave the area to get help since there was no call system available. Interview with S5 CNA on 01/11/2023 at 2:05 p.m. revealed he worked the night shifts (7:00 p.m. to 7:00 a.m.) on 01/09/2023 and 01/10/2023. S5 CNA confirmed there were only two staff assigned to the Hall D both nights. S5 CNA confirmed there was no call system available on Hall D, and if a resident needed to use the restroom, one of the staff would have to escort them to the restroom, leaving one staff on Hall D. S5 CNA stated on the night of 01/10/2023, Resident #6 did not look right, so he had to leave hall D and go and get the nurse to assess Resident #6. Interview with S1 Administrator and S2 DON on 01/11/2023 at 4:30 p.m. revealed both stated the residents who were residing on Hall D were not in the ideal situation. S1 Administrator and S2 DON stated there was no available call system set up for staff in the area to reach the nurse in the case of emergent or non-emergent situations. S1 Administrator and S2 DON stated they had whistles for the residents to use if they needed assistance; however, no whistles were observed on the unit.

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to obtain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The facility failed to ensure residents received treatment and care in accordance with professional standards of practice and in accordance with person-centered care plans, and failed to have an effective system in place to ensure there was sufficient staffing to meet the safety and care needs for 20 residents who had psychiatric and behavioral diagnoses (#4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23 and #24). This failed practice resulted in an Immediate Jeopardy situation for residents #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23 and #24 which began on 01/08/2023 at approximately 10:00 a.m., when the residents who resided on Hall C were transferred to Hall D, in order to utilize Hall C as a COVID-19 unit. The facility staffed Hall D with 2 CNAs per shift (7:00 a.m. - 7:00 p.m. and 7:00 p.m. - 7:00 a.m.). Interview of the S2 DON revealed she attempted to staff Hall D with 3 CNAs; however, she was unable to, due to call-ins and no shows. There were periods of time during each shift when one CNA was left alone (shower times, restroom times and smoke breaks). Observations on 01/10/2023 at 9:30 a.m revealed there were residents who were incontinent of urine and feces and required incontinent care along with a change of clothing. Several residents were observed requesting assistance to go to the restroom. S7 CNA stated his shift started at 7:00 a.m. that morning, and he was working alone until S8 CNA arrived at 9:30 a.m. S7 CNA stated he did not have a chance to provide incontinent care to any of the residents as of yet since he was working alone. S1 Administrator was notified of the Immediate Jeopardy situation involving residents #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23 and #24 on 01/12/2023 at 7:00 p.m. The Immediate Jeopardy was removed on 01/13/2023 at 3:53 p.m. when the facility submitted an acceptable Plan of Removal, and the surveyors determined through observation, interview and record review that the Plan of Removal was implemented. The Plan of Removal included: 01/11/2023 - The 20 residents that were temporarily moved to the dining room due to a covid outbreak were assessed and showed no physical or psychological signs of distress. No issues with privacy or dignity found. 01/11/2023 - The Director of Nursing added another nurse aide to the dining room area for a total of 3 nurse aides assigned to the residents located in the temporary living space in the dining room. The director of nursing in-serviced the staffing coordinator on additional staff being added to the unit on 01/11/2023 - In the event, a nurse aide calls in, adjustments will be made by the Director of Nursing to ensure that 3 staff are assigned. 01/11/2023 - The maintenance director added plastic bags to each resident tray table that includes whistles to alert staff. Additionally, the nurses were provided with cell phones, and short-range radio (walkie/talkie) to summon help in an emergent/non-emergent situations. The staff was educated on the use of phone, numbers provided, and use of walkie talkie. The staff gave satisfactory return demonstrations for walkie talkies and emergency. 01/11/2023 - The Director of Nursing completed in-service with all nurses assigned to the temporary living space/dining room regarding medication administration: ensuring the resident consumes the medications. All nurses were in-serviced on medication administration to ensure residents consume the medication on 01/11/2023. Any staff member not present will be in-serviced by administrative staff before the start of their next shift. 01/11/2023 - Resident #24 was assessed and showed no physical or psychological distress related to not consuming his medication. 01/11/2023 - The Director of Nursing/designee started the in-service with all staff on privacy and dignity. Resident #4 was assessed on 01/11/2023 and no problems with dignity were found. Resident #19 was assessed on 01/11/2023 and no problems with privacy were found. Resident #6 was sent out to the hospital on 01/11/2023. At the time of discharge to the hospital, there were no problems with dignity found. 01/11/2023 - The Maintenance/Housekeeping supervisor hung additional privacy curtains to ensure residents' dignity and privacy. 01/11/2023 - The Director of Housekeeping supplied additional bedside commodes to ensure residents have access for toileting. Area is partitioned off and is not near food. 01/11/2023 - Steam table for dining room is located inside the kitchen and is not being utilized for meal service during the temporary relocation period. 01/11/2023 - Administrative staff conducted a facility-wide assessment of all residents. No concerns related to privacy or dignity, as well as no concerns related to staffing. 01/12/2023 - All in-services have been completed with all staff for privacy/dignity, communication, nurses on medication administration. Any staff member that has not been in-serviced will not be permitted to work until in-servicing has been completed by administrative staff. 01/12/2023 - Policies and procedures on medication administration, communication, and dignity/privacy were reviewed- no changes were made. 01/12/2023 - Re-education was started with staff on communication procedures by the ADON and will be completed 01/12/2023. Any staff not re-educated will not work until they have been re-educated by administrative staff. All in-services were completed on 01/12/2023. 01/12/2023 - Corporate representative EVP in-serviced Administrator and DON on F835; definition of citation, guidance and procedures, as well as corrective action plans for F725, F835, and F684. Facility relocation plan Facility Infection Control Nurse, Administrator, and Corporate Representative reviewed facility relocation plan, co-horting warm and hot residents, quarantining to their rooms vs. designating a unit. Facility reviewed staffing plan for COVID-19. COVID positive residents will have designated staff that will only care for residents in said rooms. Signs will be hung on doors for all hot and warm rooms to alert staff to the resident's status. PPE carts will be placed outside doors for proper donning and doffing as it relates to infection control. DHH Epidemiologist is in agreement with the above plan. Pending contingencies: Resident permission to relocate/consolidate COVID negative residents in rooms together to open up room availability to create warm rooms and COVID positive rooms until quarantine timeframes are completed. Residents currently/temporarily relocated to the dining room will be tested and pending results, will be relocated back to the secure male unit. Once all residents are relocated out of the dining room, the entire residing space will be terminally cleaned. E-mist machine will be utilized to disinfect all areas of the facility that are presently occupied. 01/13/2023 - All residents of the facility tested negative for COVID-19. Staff will initiate room moves of the 20 residents currently in the dining room back to the secured male unit after terminal cleaning has been completed of all areas of relocation. Monitoring All monitoring began on 01/11/2023. The DON/designee will monitor medication passes 3 times a week for 4 weeks to ensure medications are consumed by the residents. The Administrator/designee will monitor communication procedures, privacy/dignity procedures 5 days a week for 4 weeks to ensure procedures are being followed per policy. Ad-Hoc QAPI initiated on 01/11/2023. Administrator/DON will address situation daily during stand-up meeting to ensure that the plan in place is remaining effective and to adjust the plan in action as needed to accommodate for changes that occur. Administrator and DON will ensure that there are 3 staff members on the unit during daily rounds. The likelihood of serious harm or injury to any resident no longer exists as of 01/13/2023 at 3:53p.m. Corporate representative will conduct monthly visits and review of clinical systems/environment and resident rounds, to ensure compliance with privacy and dignity. Cross refer to F684 Cross refer to F725 Findings: Observation on 01/10/2023 at 9:30 a.m. revealed Hall D had been converted into the men's locked Dementia unit. There were 20 residents on Hall D at that time and one CNA (S7 CNA). At the same time surveyors entered the unit, S8 CNA arrived to start his shift. Interview with S7 CNA revealed residents were moved from Hall C to Hall D over the weekend due to an outbreak of COVID-19 positive residents in the building. Hall C was currently being used as the facility's COVID-19 unit. Interview with S1 Administrator and S2 DON on 01/10/2023 at 10:06 a.m. revealed Hall D was converted into the male locked, secure unit on 01/08/2023. S1 Administrator and S2 DON confirmed there were not enough privacy curtains to provide full visual privacy for all residents. S1 Administrator and S2 DON confirmed the area had no call system available for residents/staff to call for assistance. Interview with S1 Administrator and S2 DON on 01/10/23 at 2:00 p.m. revealed they schedule two CNAs on the day shift (7:00 a.m. - 7:00 p.m.), and two CNAs on the night shift (7:00 p.m. - 7:00 a.m.). S2 DON stated she attempted to schedule three staff per shift; however, it was not working out due to call-ins and no shows from staff. Interview with S1 Administrator and S2 DON on 01/11/2023 at 4:30 p.m. revealed both stated the residents who were residing in Hall D were not in the ideal situation. S1 Administrator and S2 DON stated when they initially moved residents onto Hall D, there was not enough curtains to provide full visual privacy for each resident. S1 Administrator and S2 DON stated there was no available call system set up for staff in Hall D to reach the nurse in the case of emergent or non-emergent situations. S1 Administrator and S2 DON stated they had whistles for the residents to use if they needed assistance; however, no whistles were observed on Hall D. Interview with S1 Administrator and S2 DON on 01/12/2023 at 3:00 p.m. revealed the Administration did have a plan for moving the residents from Hall C to Hall D due to COVID-19 positive residents in the building. S1 Administrator and S2 DON stated they initiated their plan on 01/08/2023 and were in the process of continuing to implement and revise the plan as needed.

Based on interview and record review, the facility failed to ensure residents are free of any significant medication errors. The facility failed to ensure a Licensed Practical Nurse administered the correct medications to a resident, for 1 (#3) of 5 (#1, #2, #3, #4 and #5) sampled residents. Findings: This failed practice resulted in an actual harm situation for Resident #3 on 10/27/2022, when S3 LPN administered another resident's medication (R1) to Resident #3 during the morning medication pass, which included: Amlodipine (an antihypertensive) 5 mg po 8:00 a.m.; Aspirin (an anticoagulant) 81 mg po 8:00 a.m.; Lexapro (an antidepressant) 10 mg po 8:00 a.m.; Gabapentin (an anticonvulsant) 300 mg po 8:00 a.m.; Lortadine (an antihistamine) 10 mg po 8:00 a.m.; and Protonix (for GERD symptoms) 20 mg po 8:00 a.m. Resident #3 was transferred to the emergency room , and administered Narcan IV by EMS personnel while in route to the hospital. Review of the ER record revealed a Primary Impression of Respiratory Failure, and a Secondary Impression of Hypoxia, Medication Error. Resident #3 was subsequently admitted to the ICU with diagnoses that included Acute Hypercapnic Respiratory Failure - Medication Induced, and Accidental Medication Overdose. Review of the facility's policy titled Administering Oral Medications revealed in part . Purpose - the purpose of this procedure is to provide guidelines for the safe administration of oral medication. Preparation - 1. Verify that there is a physician's medication order for this procedure. Steps in the Procedure - 10. Confirm the identity of the resident. Review of Resident #3's Admission Record revealed he was admitted to the facility on [DATE]. Diagnoses included: Non-traumatic Intracerebral Hemorrhage in Brain Stem, Essential (Primary) Hypertension, Acute Respiratory Failure with Hypoxia, Headache - Unspecified, Hereditary and Idiopathic Neuropathy, unspecified; Anxiety Unspecified; Muscle Weakness (Generalized); and Major Depressive Disorder, Recurrent Unspecified. Review of Resident #3's Quarterly MDS with an ARD of 10/28/2022 revealed the following: Cognitive Status: BIMS - 14 (cognitively intact). Functional Status: Required extensive 2+ persons physical assistance for Bed Mobility and Transfers; extensive one person physical assistance for Dressing and Personal Hygiene; Supervision with Set-up Help only for Eating; Limited one person physical assistance for Toilet Use; Total Dependence with one person physical assistance for Bathing; ROM - impairment on one side for upper and lower extremities, and wheelchair as mobility device. Review of Resident #3's Comprehensive Plan of Care revealed in part . A problem of: I have episodes of verbal or physical behavioral symptoms as evidenced by yelling inappropriately at staff due to he wants staff to place seat belt restraint on him. Staff explains facility is restraint free. 10/24/2022 - I am having visual and auditory hallucinations. Review of Resident #3's Physician Orders for 10/2022 included orders for Valium (a Benzodiazepine/tranquilizer used for anxiety/depression) 5 mg - 1 tablet po one time a day related to anxiety disorder; and Valium 5 mg - give 2 tabs po at hs related to anxiety disorder. Review of Resident #3's 10/2022 MAR revealed in part . Valium 5 mg 1 tablet po one time a day related to anxiety disorder, was scheduled to be given at 8:00 a.m., with a start date of 10/22/2022. The MAR revealed Resident #3 received an 8:00 a.m. dose of Valium on 10/27/2022. Review of a Medication Error Report revealed the following in part . Resident - Resident #3 Date and time of error - 10/27/2022 at 10:45 a.m. Description of Error: Amlodipine (an antihypertensive) 5 mg po 8:00 a.m.; Aspirin (an anticoagulant) 81 mg po 8:00 a.m.; Lexapro (an antidepressant) 10 mg po 8:00 a.m.; Gabapentin (an anticonvulsant) 300 mg po 8:00 a.m.; Lortadine (an antihistamine) 10 mg po 8:00 a.m.; and Protonix (for GERD symptoms) 20 mg po 8:00 a.m. Outcome of Resident - Resident stable, V/S WNL, denies any pain or discomfort. Part II - Type of Error - Wrong Resident. Person making error - S3 LPN Review of R1's MAR for 10/2022 revealed the following medications were prescribed to be given at 8:00 a.m.: Amlodipine Besylate tablets 5 mg - give 1 tablet by mouth 1 time a day; Aspirin Tablet Chewable 81 mg - give 1 tablet by mouth 1 time a day; Lexapro tablet 10 mg - give 1 tablet by mouth 1 time a day; Invega tablet extended release 24 hour 3 mg - give 1 tablet by mouth 1 time a day; Loratadine tablet 10 mg - give 1 tablet by mouth 1 time a day; Metoprolol Succinate ER 24 hour 25 mg - give 1 tablet by mouth 1 time a day; Protonix tablet delayed release 20 mg - give 1 tablet by mouth 1 time a day. Review of Resident #3's Nurse Progress Notes dated 10/27/2022 at 11:15 a.m. revealed in part .Patient was assessed with no signs and symptoms of pain or distress noted. B/P - 144/97, Pulse - 96, Respiration - 19, Temperature - 97.9, O2 Sat - 98%. Notified NP. New orders to send patient to ED for evaluation. Left in stable condition with no signs or symptoms of distress. The Nurse Progress Notes revealed Resident #3 remained hospitalized until 12/06/2022, at which time he was discharged to another Nursing Facility. Review of a Prehospital Care Report Summary for Resident #3 dated 10/27/2022 and completed by EMS Personnel revealed: Chief Complaint: Drug Overdose. Provider Impression: Alt. Level Conscious Head to Toe Assessment: 12:01:47 p.m. revealed: Left and Right Eyes Pinpoint 12:05:59 p.m. Respirations - 12. Treatments/Medications: 12:02:47 p.m. - Oxygen 15 LPM via Non-rebreather Mask 12:09 47 p.m. - Naloxone 2 mg IV Narrative History Text: Assessment - Patient normally has decreased Gcs. Patient not responding his normal per staff. Patient oxygen was below normal limits on room air. Oxygen increased when placed on nonrebreather. Patient pupils were pinpoint. Treatment - IV placed. Narcan administered IV Review of ED HPI notes revealed a service date of 10/27/2022 at 12:29 p.m. The note revealed in part Patient is a [AGE] year old male past history of respiratory failure, intracranial hemorrhage, some anoxic brain injury presents from NH after he reportedly received another patient's medications. EMS reports hypoxic male with pinpoint pupils, 70% on room air. They gave him 2 mg of Narcan IV. Transferred him on a non-rebreather. MEDS taken at NH: Aspirin, Klonopin (a Benzodiazepine/tranquilizer), Valium (a Benzodiazepine/tranquilizer), Lexapro (an antidepressant), Gabapentin (an anticonvulsant), Amlodipine (an antihypertensive), Loratadine (an antihistamine), Metoprolol (an antihypertensive), Oxycarbonate (an anticonvulsant). No dosing provided. Presentation: Hypoxia Stated Complaint: OD Wrong Meds Review of Systems: Neurological: Positive Lethargy Clinical Impression: Primary Impression: Respiratory Failure Secondary Impression: Hypoxia, Medication Error Review of HPI dated 10/27/2022 at 5:59 p.m. revealed patient arrived in ED lethargic. Workup in the ED revealed hypercapnia which was initially treated with NIV (Narcan IV), but given the worsening in his pCO2, patient was intubated and placed on ventilator support. Review of the Free Text DX A&P notes for the Prehospital Care Report Summary revealed in part . admitted to the ICU for: 1. Acute hypercapnic respiratory failure - medication induced 3. Accidental Medication Overdose. Interview with S1 RN/DON on 12/13/2022 at 10:02 a.m. revealed on 10/27/2022, S3 LPN and S1 ADON came to her and stated that S3 LPN had given Resident #3 the wrong medication. S1 RN/DON stated in the middle of medication pass, Resident #3 approached S3 LPN yelling at her and demeaning her, and saying that he wanted his medication. S3 LPN stopped what she was doing and pulled up what she thought was Resident #3's meds on her med cart, poured them and administered them to him. When Resident #3 took the medications, S3 LPN realized she had given Resident #3 the medication for R1. The NP was notified and ordered that Resident #3 be sent to the ER. S3 LPN immediately assessed Resident #3's cognition and vital signs. S1 RN/DON stated it was about 45 minutes from the time the medication error occurred to Resident #3 actually leaving the facility with EMS. S1 RN/DON stated Resident #3 was alert and oriented to person, place and time when he left. Later that day the facility received a call from the ER that informed them that Resident #3 was having difficulty breathing, that EMS had administered Narcan IV to the resident while in route to the ER, and the resident had aspirated and vomited. Interview with S3 LPN on 12/13/2022 at 10:15 a.m. revealed the following: S3 LPN stated she was in the middle of her morning med pass on 10/27/2022 when Resident #3 started yelling at her about his medications. S3 LPN stated she was a new nurse, and Resident #3's behavior made her very nervous, so she decided to stop and give Resident #3 his medications. S3 LPN stated the error was that both MARS (Resident #3 and R1) were pulled up side by side. S3 LPN stated she looked at R1's meds instead of Resident #3's, and gave R1's meds to Resident #3. S3 LPN stated she immediately took the resident's VS and called the NP. The NP told her to call EMS and send Resident #3 to the ER. S3 LPN stated Resident #3 remained alert and followed directions with no change to his mental status from the time she gave the meds to the time he left the facility. Interview with Resident #3's physician on 12/14/2022 at 10:35 a.m. revealed Resident #3 was his patient while at the nursing home, and during his admission to the hospital on 10/27/2022. The physician stated that he remembered that Resident #3 received another patient's medications, which in his opinion caused his transfer to the hospital. The physician asked the surveyor what medications the resident received, and surveyor read the list of medications to the physician from the Hospital's HPI - General Illness Report dated 10/27/2022. The list included Aspirin, Klonopin, Valium, Lexapro, Gabapentin, Amlodipine, Loratadine, Metoprolol, and Oxycarbonte. The physician stated that the combination of the Benzos and Opioids definitely caused his transfer to the hospital, but the problems he had after the transfer was a result of his illnesses. The surveyor asked the physician if he knew anything about the resident receiving Narcan IV while in the ambulance in route to the hospital, and he stated that he did not. Interview with S2 ADON on 12/14/2022 at 11:50 a.m. revealed on 10/27/2022, S3 LPN came to her and told her that she had given Resident #3 R1's medication during the morning medication pass. S2 ADON stated she and S3 LPN immediately went to S1 RN/DON and reported the incident. S2 ADON stated S1 RN/DON took charge of the situation after that time.

Based on interview and record review the facility failed to ensure 1 (#5) of 5 (#1, #2, #3, #4, #5) sampled residents was free from staff to resident physical abuse. This failed practice resulted in an actual harm situation for Resident #5 on 03/04/2022 at 2:30 p.m., when S3 CNA punched Resident #5 in the face multiple times, after Resident #5 hit S3 CNA in the back of her head. Resident #5 was transported to the emergency roiagnom on [DATE], and diagnosed with fractures of the left mandibular condyle, nasal bone, and nasal ridge. Findings: Review of the facility's policy titled Abuse Prevention Program revealed in part . Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Review of Resident #5's clinical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Quarterly MDS with an ARD of 03/02/2022 revealed a BIMS of 8 (indicating moderate cognitive impairment). The MDS revealed Resident #5 did not exhibit any behavioral symptoms during the assessment period. Further review of the MDS revealed the resident required extensive assistance with personal hygiene; limited assistance with dressing; and supervision with bed mobility, transfer, walk in room/corridor, locomotion on/off unit, eating, and toilet use. The MDS revealed Resident #5 had no upper and lower extremity ROM impairments. Review of Resident #5's Care Plan with a Target Date of 05/31/2022 revealed a problem of Resident has impaired cognitive function/dementia or impaired thought processes related to Presenile Dementia, [CONDITION(S)], impaired decision making, [CONDITION(S)] Disorder, Depression, history of suicidal thoughts, altercations with other residents. Interventions included: cue, reorient, and supervise as needed. Further review of Resident #5's Care Plan revealed Resident #5 had an altercation with staff member, ER visit, and Fractures to left mandibular condyle, nasal bone/ridge on 03/04/2022, with interventions to monitor bruising/swelling left eye daily until resolved and monitor steri-strips to nose until healed. Date initiated 03/04/2022. Review of the facility's Incident Report dated 03/04/2022 revealed in part . Resident: Resident #5 Incident Location: Dining Room Notes: Small laceration to bridge of nose, bleeding noted, deviated septum and swelling to nose, and swelling and bruising noted to nose. The Notes further revealed Resident #5 was immediately assessed by Administrator, DON, and Treatment Nurse. Orders obtained to send resident to ER for further evaluation. Witnesses confirmed that this resident did hit S3 CNA, and did knock her wig off her head. But S3 CNA had time to turn around, pick up her wig, put it back on her head, then started punching this resident in the face until he fell down. S3 CNA had every opportunity to walk away. Review of the nurses' notes for Resident #5 documented by an LPN revealed in part .03/04/2022 at 2:45 p.m., Resident #5 assisted by staff to this nurse. Resident #5 was in previous altercation. Resident #5 noted to have laceration to bridge of nose, and bruising and swelling of left eye. Deviation noted to nose. This nurse cleansed Resident #5's laceration to [NAME] of nose, applied steri-strips. FNP notified. New order noted to send out to ER for evaluation. Review of Resident #5's hospital records revealed in part . CT scan of Maxillofacial without contrast was done on 03/04/2022 at 6:00 p.m. IMPRESSION: Fracture of the Mandibular Condyle on the left, and fractured nasal bone and nasal ridge. Interview on 04/12/2022 at 3:00 p.m. with S7 CNA revealed she was present at the birthday party on 03/04/2022, and witnessed the altercation between S3 CNA and Resident #5. S7 CNA stated Resident #5 did not want another resident (#R1) to sit by him, and S3 CNA put a chair next to Resident #5 so #R1 could sit down. S7 CNA stated Resident #5 became agitated, and was cursing and arguing with S3 CNA. When S3 CNA turned to walk away, Resident #5 swatted the back of her hair. S7 CNA stated S3 CNA turned around and hit Resident #5 in the face multiple times, and he was trying to hit back when he fell down on the floor. S7 CNA stated she along with other staff helped Resident #5 up, and called for nurses to assess Resident #5 due to his nose bleed. Observation and interview with Resident #5 on 04/14/2022 9:20 a.m. revealed he was alert and oriented to person, place and time, and was lying in bed. Resident #5 was observed to be clean and well groomed. Interview with Resident #5 revealed his right eye was hurting him, and reported that it has been bothering him since the brawl in the dining room. Resident #5 stated he told the nurses daily about his right eye discomfort, and they have been putting eye drops in for him. Resident #5 stated the eye drops do not really help, but that he did not report that to the nurses. Resident #5 stated had no pain to his mouth or nose, and that he felt safe in the facility, and has had no issues since the incident in the dining room. Interview with S2DON on 04/14/2022 at 9:36 a.m. revealed S3 CNA was terminated and escorted out of the facility by 2 deputies immediately after the incident on 03/04/2022. Interview on 04/14/2022 at 10:57 a.m. with S8 LPN revealed he was Resident #5's nurse on the day of the altercation, but did not witness it. He stated Resident #5's face was busted, and he had swelling to his eyes. Interview on 04/14/2022 at 1:50 p.m. with S2 DON revealed staff education on abuse is done on hire and through in-services throughout the year. S2 DON reported an in-service was done regarding abuse shortly after the incident occurred on 03/04/2022. Review of the facility's In-service Training Record dated 03/04/2022 revealed only 25 of the 85 facility employees had signed the in-service. S2 DON further stated that monitoring for staff to resident abuse was not initiated after the incident on 03/04/2022, and was not currently being done. Interview on 04/14/2022 at 1:52 p.m. with S1 ADM revealed after the incident on 03/04/2022, the social services department conducted a questionnaire titled Safe Survey that was specific for interviewable residents regarding how safe they felt in the facility. Review of the information provided dated 03/04/ 2 and 03/05/2022, revealed the SSD interviewed the 10 cognitive residents who attended the birthday party on 03/04/2022. S1 ADM stated she was unsure if there was documentation regarding non-interviewable residents. Review of documentation given to the surveyor revealed there was no evidence that the remaining 43 cognitive residents who had a BIMS of 12 or greater were interviewed regarding the Safe Survey. There was also no evidence that the 73 residents who had a BIMS of less than 12 were interviewed or monitored to ensure staff to resident abuse did not occur. Interview on 04/14/2022 at 2:12 p.m. with S5 RAD revealed on 03/04/2022, S3 CNA was in the dining room with #R1. S5 RAD stated that Resident #5 was in the back of the dining room by himself, and #R1 wanted to sit with him and he told her she could not sit there. S5 RAD stated she wanted to diffuse the situation, so she asked #R1 if she wanted to find another seat, and #R1 was fine with that. S5 RAD stated S3 CNA worsened the situation by stating that #R1 could sit wherever she wanted, and put a chair next to Resident #5 and told #R1 she could sit there. S5 RAD stated Resident #5 then stood up and folded his arms and said what are you going to do about it, S3 CNA was right next to him at the time. S5 RAD stated S3 CNA had her hand up saying you need to get him out of here, and when S3 CNA turned around in the other direction, Resident #5 flipped the back of her hair. S5 RAD stated Resident #5 did not actually hit her. S5 RAD stated S3 CNA then turned around and starting punching Resident #5 repetitively. S5 RAD stated Resident #5 was attempting to fight back, but could not and he fell to the floor. S5 RAD stated S3 CNA was still punching Resident #5 when he was on the floor. S5 RAD stated she froze and a CNA who was in the dining room broke up the fight. S5 RAD stated Resident #5's nose was bleeding. S5 RAD said she called the front office and the DON and Administrator came and escorted S3 CNA out of the dining room. Interview on 04/14/2022 at 2:45 p.m. with S2 DON confirmed all staff did not receive the in-service training on abuse dated 03/04/2022, and she should have ensured all staff were in-serviced. S2 DON confirmed that only the residents present at the party received the Safe Survey. Interview on 04/18/2022 at 8:12 a.m. with S2 DON revealed she had no further documentation for post incident actions on the abuse that occurred 03/04/2022. Interview on 04/18/2022 at 9:15 a.m. with #R1 revealed she did not remember going to a birthday party in the dining room. Interview on 04/18/2022 at 9:18 a.m. with S6 CNA revealed the altercation started with Resident #5 not wanting #R1 to sit by him. S6 CNA stated S3 CNA said anyone could sit anywhere and walked away. S6 CNA stated as S3 CNA was walking away, Resident #5 went behind her and slapped her on the side of her face. S6 CNA stated S3 CNA turned around and starting punching Resident #5 repeatedly. S6 CNA stated Resident #5 slumped over on the table. S6 CNA reported S3 CNA threw one or two more punches at him, then the fight was broken up. S6 CNA stated she was on the other side of the room, and it all happened so fast that when she walked across the room, the fight was already broken up. S6 CNA further stated Resident #5 was bleeding from the nose, and both of his eyes were swollen. S6 CNA stated the Administrator, DON, ADON, and the Marketer ran to the dining room and escorted S3 CNA to the office. Interview on 04/19/2022 at 12:20 p.m. with S3 CNA revealed she was asked if any of her residents wanted to go to the birthday party that was being held in the dining room. S3 CNA stated one of her female residents (#R1) wanted to go, so she took the resident to the dining room. S3 CNA stated when they arrived, 2 CNAs and the Activity Director were there with several other residents, and were eating cake and ice cream. S3 CNA stated the only chair available for #R1 to sit in was located at a table at the back of the dining room, next to Resident #5. S3 CNA stated #R1 sat in the chair and Resident #5 yelled she couldn't sit there because he didn't want her to, and #R1 got up from the table shouting he's hurting me. S3 CNA reported she asked Resident #5 why #R1 couldn't sit there and he stated he didn't want her to, then he kicked the chair away from the table several times. S3 CNA said she put the chair back to the table and told Resident #5 that #R1 could sit there if she wanted. S3 CNA said Resident #5 started cursing, she turned to walk away and he hit her in the back of her head causing her wig to fall off. S3 CNA stated she does not remember what happened, and does not remember hitting or punching Resident #5. S3 CNA stated it was as if she blanked out. S3 CNA stated she saw a scratch near Resident #5's nose, and assumed it was from a ring that was on her finger. S3 CNA stated she has worked as a CNA since 2017, and is well aware that she is not to hit or abuse a resident in any way. She reported she had worked at the facility for 5 months and never received abuse training. S3 CNA acknowledged that there was a statement about abuse in the employee handbook; however, she has never been trained by the facility. Review of the Police Report dated 03/04/2022 at 3:04 p.m. revealed S3 CNA was arrested at the nursing home and charged with Simple Battery on the Infirmed. Review of S3 CNA's Personnel Record revealed she was terminated by the facility on 03/04/2022 for staff to resident abuse.

Based on observations, record reviews and interviews, the facility failed to ensure an effective Infection Prevention and Control Program, including the establishment and implementation of measures to prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 20 residents who currently reside in the facility that are COVID-19 or refused testing. An Immediate Jeopardy situation was identified by the survey team on 11/2/2020 when they observed that there were systemic failures in the facility's Infection Prevention and Control Program. The facility did not ensure compliance of all staff for the proper use and disposal of PPE. The facility allowed residents that tested positive for COVID-19 to remain cohorted in rooms with residents that tested negative for COVID-19. The facility failed to ensure employees with lab confirmed positive COVID-19 results followed the facility's COVID-19 Return to Work Criteria for employees with confirmed or suspected COVID-19. The Administrator was notified of the Immediate Jeopardy on 11/04/2020 at 3:47 p.m. The Immediate Jeopardy was removed on 11/6/2020 at 4:25 p.m. when the facility submitted the following Immediate Jeopardy Plan of Removal which included: #1 - Facility has removed the storage bin 11/02/2020 where clean PPE was being stored and has replaced with three (3) four drawer storage containers and put two bins outside for disposal of bio-hazard material and also one for storage of contaminated re-usable PPE (gowns). The facility has dedicated a unit for lab result confirmed COVID-19 negative residents. Staff have been in- serviced on the proper use and disposal of PPE between midnight and midnight (due to various shifts within facility) between the dates 11/04/2020 and will complete on 11/05/2020. All staff that has signs or symptoms or a confirmed lab result of positive COVID-19, then the staff member will be removed from the work schedule and will not be allowed to return to work following the CDC guidelines for healthcare staff with positive COVID-19 results. The DON, ADON, infection control nurse or designee will in-service the staff once a week starting on 11/04/2020 on the proper use (donning and doffing of gowns, proper mask wearing, face shields/goggles and disposal of PPE ongoing until the DON/ADON/Infection Control nurse or designee believes full competency of staff has been achieved. The donning, doffing, and disposing of PPE by staff will be monitored by the Infection Control nurse and/or designee weekly for the first two weeks, then every other week for one month until COVID is eradicated from the facility. Retraining will be required should noncompliance by noted by staff. Monitoring will be reviewed by QAPI at the regular meeting. The DON, ADON, Administrator and Infection Control Nurse, as well as other management in the facility, will monitor all staff throughout the shifts to ensure staff is using PPE properly and will direct any staff that are not properly using PPE to do so immediately. These monitors will keep a log of these checks each time the check is completed. The log will include the time of the monitoring and what was witnessed. This will aid the DON, ADON and Infection Control nurse or Designee about future in-service needs on the use of PPE. The facility will complete a daily burn rate of all PPE and log this burn rate daily to ensure shortage of PPE is avoided within the facility. The facility currently has enough PPE to last until 11/13/2020 and has reached out to all vendors and other sources to ensure enough supplies are ordered to prevent the facility from experiencing a shortage of PPE during the outbreak. The facility will monitor the supply of PPE by using the following: On 11/6/2020, this facility will begin to implement a log book that will capture the following items regarding PPE and the ordering of PPE. 1. What PPE was ordered (gloves, masks, gowns, etc.) 2. Where these items were ordered from 3. Estimate time of arrival 4. If any item was back ordered 5. The name of the vendor item was ordered 6. Phone number of vendor(s) 7. Total count of PPE ordered, and amount received. This logbook will be kept updated and left with the Administrator and/or designee and readily available upon request. The facility is currently ordering PPE from McKesson and the corporate representative is, Michael Kennedy-601-918-1207. If supplies are not available through this contact, the facility reaches out to numerous sources for supplies and this will be logged in the above mentioned logbook. There are only 3 items that can be disinfected and reused. 1) the face shield or protective eyewear and 2) the heavy, material gowns the facility currently has. The gowns should be placed in a Bio-Hazard barrel and laundered at the facility at the current temperature and instruction that is provided by the CDC. All other items will be discarded upon exiting the building. 3) the N-95 mask can be disinfected and reused up to five (5) days in a shortage crisis. The facility is currently discouraging any staff from using a disinfected mask for more than three (3) days before proper disposal of mask. If any item was back ordered, the facility will keep the order with this vendor but continue to search for alternate suppliers with in stock PPE for immediate order and delivery. The facility is currently ordering PPE from _______ (vendor's name) and ________(vendor's representative). If supplies are not available through this contact, the facility reaches out to numerous sources for supplies and this will be logged in the above-mentioned logbook. #2 - The facility does weekly Covid-19 testing for both residents and staff. The facility tests all prior Covid-19 positive residents and staff when symptomatic or after 90 days (three months) after testing positive per current CDC guidelines. The facility has dedicated a unit for lab result confirmed COVID-19 negative residents. All COVID-19 negative residents have been moved to this unit on 11/02/2020 and will remain on this unit until the facility is COVID-19 free for 14 consecutive days. Staff have been in-serviced on the proper use and disposal of PPE. This will help reduce the spread of COVID-19 within the facility. Residents that have been lab confirmed COVID-19 negative, and refused to relocate to the clean unit, are monitored twice a shift for signs and symptoms of COVID-19. If signs and symptoms are noted by the nursing staff, the residents are immediately placed in isolation until a PCR test has confirmed a negative result. Facility will use POC tests as a measure to aid in identifying positive residents and staff but will ensure that a lab-based PCR test is performed as soon as possible to confirm or deny the results of the POC test results. All residents and staff that exhibit signs and symptoms of COVID-19 will be treated as being positive until a lab-based test can be completed and test results are received. The nursing staff is educated on the signs and symptoms of Covid-19 and stays current on all updates as released from the CDC. The facility has the nursing staff monitoring all residents for signs and symptoms twice per shift, which equates to 6 times in a 24-hour period. The facility has begun in-servicing CNAs on 11/6/2020 and will continue in-servicing all CNA staff ongoing concerning reportable signs and symptoms of Covid-19 to the nursing staff immediately. #3 - The Facility will dedicate staff to the non-covid unit that will work with Covid-19 negative residents only. The dedicated staff will not work other areas of the building until the outbreak is eradicated from the facility. The deficient practice continues at a scope and severity of potential for more than minimal harm for 20 residents who currently reside in the facility that are COVID-19 negative and/or refused testing. Findings: PPE Review of the facility's [MEDICAL CONDITION]/COVID-19 Policy revealed in part . Training and Education: #5 - CDC LTC Webinar Series - have all staff watch and sign an in-service after completing the following CDC Webinar series: PPE Lessons. Observations upon arrival to the facility on [DATE] at 12:30 p.m. revealed S18 Ward Clerk exited the building not wearing a disposable gown, mask and face shield to screen the surveyors for signs and symptoms of COVID-19. She then opened the storage bin at the front entrance, obtained gowns and face shields and issued to surveyors. Interview on 11/02/2020 at 12:55 p.m. with S9 Activity staff revealed she wore the same gown all day and went in and out of residents' rooms without changing. She stated she was instructed to do so by administration due to PPE shortages. Observation on 11/2/2020 at 1:00 p.m. revealed S24 CNA exited the nursing home wearing a disposable gown and facemask. She went to her car, removed the gown and rolled it up, and placed it along with the facemask in the trunk of her vehicle. Interview with S24 CNA at that time revealed she was instructed by administration to keep the used disposable gown in the trunk of her car to reuse the next shift she worked. She stated they were instructed to do this because there was a shortage of gowns. Observation and interview with S8 OT on 11/02/2020 at 1:22 p.m. revealed she was wearing a cloth gown while going to her vehicle. She stated she was instructed by administration to take it home, wash it, and wear it the next time she reported to work. She stated she was never instructed to leave the gown in the facility to be washed. S8 OT continued to her vehicle and placed the gown in a plastic bag in her trunk. Interview on 11/02/2020 at 1:25 p.m. with S2 VP of Clinical Ops and S3 Infection Control Nurse revealed they had instructed all staff to not put PPE in personal vehicles, and disposable gowns were not to be reused. Observation on 11/02/2020 at 2:25 p.m. revealed approximately nineteen staff exited the facility. Four were observed to go and get in their vehicles with their disposable PPE on, six removed their PPE at their vehicles and put it in the trunks of their vehicles, four removed their PPE and placed it in a large barrel that was located on the outside of the entrance door on the left, and five employees were observed to go into a bin that was located on the outside of the entrance door on the right that contained clean PPE. Those five employees got a zip lock bag out with their names on it, removed their disposable PPE, placed the PPE in the bag and then back into the bin that contained the clean PPE. Interview with S25 CNA on 11/2/2020 at 2:45 p.m. revealed that administration had instructed them to take the disposable gowns off and put them in a zip lock bag and place them in the bin which contained clean and used PPE for reuse the next shift they worked. Observation on 11/02/2020 at 2:49 p.m. revealed S16 CNA walking through the facility with her face mask below her nose. Interview of S16 CNA at that time confirmed she was not wearing her facemask correctly. Observation of S26 CNA on 11/02/2020 at 2:50 p.m. revealed she had taken her disposable gown off and put it in a bag. S26 CNA stated at that time that she was taking it home with her, and that she would use it again when she came back to work. She revealed administration had instructed them to do so because of a shortage of PPE. Observation on 11/02/2020 at 3:00 p.m. revealed four staff members exited the facility and went to their vehicles with their disposable gowns in place. Two of the four removed their gowns and threw them in the back seat of their vehicles. The other two employees did not remove their gowns and drove away. Observation on 11/02/2020 at 3:10 p.m. of the bin that was located on the outside of the facility's entrance revealed the bin contained the following: clean unused PPE in unsealed zip lock bags, twenty zip lock bags with disposable gowns rolled up in them with no indication whether they were clean or contaminated. There were some zip lock bags that were not closed and some were open with the used disposable gowns hanging out of them. There were also several used disposable gowns that were rolled up and placed in the bin uncontained, along with dirty face shields, and open boxes of gloves. Interview on 11/02/2020 at 3:12 p.m. with S1 VP of Adm Ops and S2 VP of Clinical Ops confirmed the above findings. Observation of the 200 hall on 11/02/2020 at 3:15 p.m., revealed 4 of 6 to the residents' rooms were open. There were 3 barrels and a linen cart against the wall mid-way down the hall. There was no PPE observed that was available for staff's use. Residents were observed rolling in their wheelchairs in and out of their rooms with no mask on, and no intervention from staff to use their mask. Observation of the 300 Hall on 11/02/2020 at 3:20 p.m. revealed an over bed table that had an unused gown on top of the table. Observation of the 400 Hall on 11/02/2020 at 3:25 p.m. revealed R2 was observed sitting outside the door of her room and was not wearing a mask. There were other residents walking up and down the 400 Hall at this time and were not wearing mask. R2 revealed she had just gotten out of the hospital yesterday with [MEDICAL CONDITION]. There were no staff observed on the 400 Hall at that time. Interview on 11/02/2020 at 3:37 p.m. with S21 CNA revealed she wore the same gown all day, and at the end of her shift she placed the gown in a storage bag and put it in the bin on the front porch of the facility to reuse the next time she worked. She stated she had just received her face shield today and prior to today she had no eye protection. Observation on 11/02/2020 at 3:45 p.m. of the pavilion area of the facility revealed S1 VP of Adm Ops talking to a group of staff without a face mask in place. Social distancing was not being practiced. Interview at 11/02/2020 at 3:50 p.m. with S4 RN revealed that she had been instructed by administration to place PPE in a bag, take home and reuse due to shortages of PPE. Interview on 11/02/2020 at 4:46 p.m. with S3 Infection Control Nurse revealed the burn rate for PPE for the facility was 150 gowns/day. COHORTING Review of the facility's [MEDICAL CONDITION]/COVID-19 Policy revealed in part . Corona Mode of Transmission - All staff receives task or job specific training on prevention of transmission of infectious agents including COVID-19 during orientation. COVID-19 CONTROL: #17. Residents who refuse testing must not be co-horted with other residents who have tested positive for COVID-19 or other residents who have tested negative for COVID-19. To avoid transmission within Long Term Care Facilities, facilities should use separate staffing teams for COVID-19 positive resident to the best of their ability: #3. Long Term Care Facilities should separate patients and residents who have COVID-19 from patients and residents who do not, or have an unknown status. Do not place resident(s) with unknown status on COVID-19 units or with a resident with a positive COVID-19 test result. Interview on 11/02/2020 at 12:45 p.m. with S1 VP of Adm Ops and S2 VP of Clinical Ops revealed there were 10 residents in the facility who were to come off the COVID-19 positive unit today, and that they were having problems with moving the residents around. The facility's Medical Director had instructed them to shelter in place to avoid further problems. S2 VP of Clinical Ops stated that the whole building was now a COVID-19 positive unit. Interview on 11/02/2020 at 1:20 p.m. with S2 VP of Clinical Ops revealed the facility's Medical Director instructed them to make the whole facility a COVID-19 positive building and treat all residents as if they were positive. She stated that as of 10/22/2020 the entire facility became a COVID unit and everyone was treated as if they were positive, even if they were negative. She further stated that there were COVID-19 positive residents in the same room as COVID-19 negative residents. Interview on 11/02/2020 at 1:25 p.m. with S1 VP of Adm Ops, S2 VP of Clinical Ops and S3 Infection Control Nurse confirmed there were COVID-19 positive residents who were housed in the same rooms with residents who tested negative for COVID-19, or had not been tested for COVID-19 due to refusal. S2 VP of Clinical Ops stated that the facility did not have a policy regarding co-horting of COVID-19 positive and COVID-19 negative residents. Review of the facility's census with resident names and room numbers, and a list of COVID-19 negative residents which were provided by the facility on 11/02/2020 revealed the following: 1. R1 who refused testing shared room a with R2 who tested positive for COVID-19 on 10/27/2020, and R3 and R4 who tested positive for COVID-19 on 10/20/2020. 2. R5 who tested negative for COVID-19 shared room b with R6 who tested positive for COVID-19 on 10/13/2020. 3. R7 who tested negative for COVID-19 shared room c with R8 who tested positive for COVID-19 on 10/20/2020. 4. R9 who tested negative for COVID-19 shared room d with R10 who refused testing, and with R11 and R12 who tested positive for COVID-19 on 10/13/2020. 5. R13 who tested negative for COVID-19 shared room e with R14, R15 and R16 who tested positive for COVID-19 on 10/13/2020. 6. R17 who refused testing for COVID-19 shared room f with R8 who tested positive for COVID-19 on 10/22/2020 and R19 who tested negative to COVID-19. 7. R20 who tested negative for COVID-19 shared room g with R21 who tested positive for COVID-19 on 10/22/2020. 8. R23 who tested negative for COVID-19 shared room h with R24 who tested positive for COVID-19 on 10/19/2020. 9. R25 who tested negative for COVID-19 shared room i with R26 and R28 who tested positive for COVID-19 on 10/13/2020 and with R27 who tested positive for COVID-19 on 10/19/2020. Interview with S3 Infection Control Nurse on 11/02/2020 at 2:30 p.m. confirmed the above. Interview on 11/02/2020 at 3:30 p.m. with S5 LPN revealed she worked on the hall j and unit k in the facility. She confirmed she was caring for residents who were COVID-19 positive and negative. Interview at 11/02/2020 at 3:37 p.m. with S21 CNA revealed she worked on unit k, and was not aware of the residents' COVID -19 status because she was not given report on which residents were COVID-19 positive or negative on her unit. Interview on 11/02/2020 at 3:55 p.m. with S2 VP of Clinical Ops revealed that the facility had nothing in place at this time to protect COVID-19 negative residents from becoming infected with COVID-19. STAFFING Review of the facility's COVID-19 Return to Work Criteria for an employee with Confirmed or Suspected Covid-19 revealed in part 1. Test based Strategy: Resolution of fever with the use of fever reducing medications and, improvement of respiratory symptoms (i.e. cough, shortness of breath) and negative results of a FDA Emergency Use Authorized Molecular Assay for COVID-19 from at least 2 consecutive nasopharyngeal swab specimens collected greater than or equal to 24 hours (total of two negative specimens). If Test Based Strategy cannot be used, the Non-test-based strategy may be used for determining when an employee may return to work in healthcare settings: 2. Non-test based strategy: Exclude from work until at least 1 day (24 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (3.g., cough, shortness of breath); and at least 10 days have passed since symptoms first appeared. Employees with laboratory-confirmed COVID-19 who have not had any symptoms should be excluded from work until 10 days have passed since the date of their first positive COVID-19 diagnostic test assuming they have not subsequently developed symptoms since their positive test. Review of the Daily Log Sheets for screening of staff for COVID-19 revealed the staff were to document if they were having any signs and symptoms of COVID-19 and what their temps were prior to entering the facility. Further review of the Daily Log Sheets from 10/14/2020 to 11/4/2020 revealed the following staff signed in and worked although there was documentation that they had signs and symptoms of COVID-19: 10/22/2020 - S22 CNA 10/28/2020 - S23 Dietary 11/03/2020 - S6 LPN 11/04/2020 - S6 LPN. Interview on 11/09/2020 at 11:36 a.m. with S2 VP of Clinical Ops confirmed S22 CNA worked 2:09 p.m. to 9:26 p.m. on 10/22/2020, S23 Dietary worked 7:03 a.m. to 7:09 p.m. on 10/28/2020, S6 LPN worked 11/03/2020 and 11/04/2020; however, she could not confirm S6 LPN's hours. Interview with S2 VP of Clinical Ops on 11/02/2020 at 1:25 p.m. revealed the completion of the facility's Daily Log Sheets for COVID-19 symptoms by staff was done on an honor system due to staff shortage. She confirmed there was no one monitoring these sheets at the sign-in station when staff signed into work, and that there was no facility system for monitoring the sign-in-sheets. Interview on 11/02/2020 at 3:50 p.m. with S4 RN revealed that she had developed symptoms of COVID-19 on 10/18/2020, was tested on [DATE], and received her results on 10/22/2020. She stated she had symptoms on 10/29/2020 and 10/30/2020 of nausea, vomiting and diarrhea. She stated today was her first day back and she told administration that she did not feel well and continued with symptoms. She stated she was instructed that she had to return to work today. Review of facility documenation of staff who tested positive results and staff return to work revealed the following: S10 CNA tested positive on 10/19/2020, and was cleared to return to work on 10/29/2020. However, S10 CNA worked on 10/22/2020, 10/26/2020 and 10/27/2020. S12 CNA tested positive on 10/19/2020, and was cleared to return to work on 10/29/2020. However, S12 CNA worked on 10/22/2020 and 10/27/2020. S13 CNA tested positive on 10/19/2020 and was cleared to return to work on 10/29/2020. However, S13 CNA worked on 10/23/2020, 10/24/2020, 10/25/2020, 10/26/2020, 10/27/2020 and 10/28/2020. S6 LPN tested positive on 10/26/2020 and worked from 10/26/2020 through 10/30/2020, and on 11/01/2020 and 11/02/2020. Review of an email received at 9:12 a.m. on 11/09/2020 from S2 VP Clinical Ops confirmed that the above staff had tested COVID-19 positive and returned to work prior to 10 days. These staff members were not designated staff and worked with all residents in the facility.

Based on record review, observation and interview, the facility failed to ensure adequate supervision to prevent accidents and to ensure the resident environment remains as free of accident hazards as possible for 1 (#3) of 5 sample residents (#1, #2, #3, #4 and #5), by allowing an untrained PCA to provide ADL care to a cognitively impaired resident who was totally dependent upon staff assistance for bathing. This failed practice resulted in an Immediate Jeopardy on 2/9/2019 at 11:56 a.m. for Resident #3 when two staff members observed an untrained personal care attendant (PCA) accompany Resident #3 to the shower room without any trained staff assistance. The untrained PCA remained in the shower with Resident #3 from 11:56 a.m. to 12:16 p.m. Upon exiting the shower room at 12:17 p.m., the resident was observed to have redness to his face, chest area, neck, back and inner thighs and peeling skin from his neck, chest and back. The resident was transferred to a local hospital emergency room and was found to have sustained 1st, 2nd and 3rd degree scald burns. Later on 2/9/2019, the resident was air lifted to a hospital Burn Unit where his admitting [DIAGNOSES REDACTED]. The Administrator was notified of the Immediate Jeopardy on 2/15/19 at 4:50 p.m. The facility submitted an acceptable plan of removal on 2/15/19 at 6:57 p.m. The plan of IJ removal included the following: 1. IJ Removal Plan 2/15/19 at 6:05 p.m. 2. Root Cause Analysis: The root cause of the problem was identified by interviewing staff and watching camera footage. 3. Necessary Changes: a. Procedures were changed to include PCA approved task list and a competency test that must be passed prior to working beginning on 2/15/19 at 6:00 p.m. 4. Training: a. Persons: Staff to be educated include PCAs CNAs, nurses and department heads. b. Objective: The staff will be educated on properly supervising resident care with focus on residents not receiving care by staff that are not licensed to do so. c. Content: Immediately following incident on 2/9/19 staff was in-serviced on PCAs not doing patient care and skills that requires a CNA. On 2/14/19 DON met individually with PCAs and reviewed approved list of duties. See attachment 2. d. Post Test: All PCAs prior to working beginning 6pm on 2/15/19 will have to take a competency test and must make 100%. See attachment 1. 5. Supervision and Employee Performance Evaluation: a. Who will supervise: Persons that will be supervising resident care, PCAs and CNAs are CNA supervisor, nurses, ADON and DON. b. Who will be supervised: PCAs and CNAs. c. When will supervision occur: Supervision of care will be performed on an ongoing basis with documented supervision daily for 30 days, 2 x week for 30 days and weekly thereafter. See attachment 3. d. What are expected behaviors: It is expected that all staff members will only provide care for which they are licensed to perform. PCAs will only perform duties on the PCA approved Duty Task List. 6. Scheduled and Recorded Evaluation: a. Who will evaluate: QA committed will evaluate effectiveness of plan to determine if changes need to be made. It is expected that only staff members licensed to provide care will do so. b. Who will be evaluated: Plan will be evaluated on an ongoing basis in QA morning department head meeting Monday through Friday x 90 days then Quarterly QA. PCAs will also be evaluated according to supervision schedule. CNAs also. c. Expected Behaviors: It is expected that all resident will receive care only by staff licensed to do so. d. When will evaluations occur: Plan will be evaluated on an ongoing basis in QA morning department head meeting x 90 days then Quarterly QA. The deficit practiced continued at a potential for harm for 48 residents who required the assistance of one or two staff for bathing, and 57 residents who were dependent upon staff for bathing (a total of 105 residents). Findings: Review of resident #3's clinical record revealed he was admitted to the nursing facility on 8/28/18 with [DIAGNOSES REDACTED]. Review of the resident's 01/2019 Physician order [REDACTED]. Review of the resident's Quarterly MDS with an ARD of 12/5/18 revealed a BIMS of 99 (unable to complete interview). The resident's Functional Status was coded as follows: Supervision with one person physical assistance for transfer; supervision with set-up help only for walk in room and corridor, locomotion on and off the unit, and eating; limited physical assistance of one person for bed mobility and dressing; extensive assistance of one person for toilet use and personal hygiene; and total dependence with one person physical assistance for bathing. Review of the resident's Comprehensive Plan of Care revealed a problem of ADL Self Care Deficit r/t/aggressive behavior, episodes of verbal or physical behavioral symptoms, elopement, risk/wanderer, and impaired cognitive function/impaired thought process, with a target date 3/5/19. Interventions: Resident requires assistance with bathing/showering. Review of resident #3's Progress Note dated 2/9/19 at 12:53 p.m. read that the resident had a shower using liquid soap - after shower noted resident with redness/blisters to face, skin peeling to chest area/bil arms. NP informed, new order noted to send to the ED for treatment - unable to get v/s - family informed - called ED and informed of transfer - DON informed - will inform on-coming nurse. Review of an Emergency Provider Report revealed an initial Greet Date/Time of 2/9/19 at 1:06 p.m. The report revealed the following: Chief Complaint: Scald burn caused by shower. The Re-Evaluation & MDM Notes revealed the following: On arrival patient is in severe amount of pain and high anxiety, and on stat bedside eval. He has injuries consistent with a scalding burn, on a pour over pattern. Face was affected the most, with full coverage of 2nd and 3rd degree burns; full neck anterior and posterior with severe 2nd degree burns; anterior chest with full coverage 1st and 2nd [MEDICAL CONDITION] extension down his abdomen in a tapering pattern (skipping a band across his lower abdomen at flexion point) to then include penis and scrotum, but sparing his buttocks; his shoulders are burned with extension to posterior neck and upper torso in a shawl-type pattern; left palm was covered with blistering burn (right palm not affected) with small area of left volar arm with 1st degree burns. Determined to be approximately 28% body surface area. Review of the Emergency Patient Record dated 2/9/19 at 1:32 p.m. and documented by an ED RN revealed a Rapid Initial Assessment that read: Subjective Assessment: Patient from the nursing home, sitter states he was in the shower unattended and they thought it was an allergic reaction to the shampoo, but he uses it everyday. The Objective Assessment revealed yelling incomprehensibly, second [MEDICAL CONDITION] entire face, shoulder, anterior torso, half of back, pubic area, and inner portion of thighs bilaterally. Blistering and skin sloughing. Pain Intensity: 10, and Vital Signs Comment: Crying. Further review of the Emergency Patient Record revealed at 4:30 p.m., the ambulance service arrived for transport. Patient has wet to dry dressings on body and is covered in [MEDICATION NAME] Cream. Further review of the Emergency Provider Report revealed the nursing home was called at 1:17 p.m. to alert to potentially scalding hot water. Approximately 1 hour later temp had still not been checked (told maintenance was in route). Approximately 3:47 p.m. the ED was advised by nursing home staff that the hot water was set to 96 degrees Fahrenheit. Review of a HPI dated 2/9/19 at 8:39 p.m. (physician at hospital Burn Unit) revealed the following Active Problems: Burn (any degree) involving 10-19% of body surface; Type 2 Diabetes Mellitus with complication, without long-term current use of Insulin (HCC); Second degree burn of face and head, initial encounter; second degree burn of chest wall, initial encounter; second degree burn of abdomen, initial encounter; second degree burn of right thigh, initial encounter; other [MEDICAL CONDITION] (HCC); and Early onset Alzheimer's Dementia. Observation during an initial tour of the facility on 2/13/19 at 10:30 a.m. revealed there was 1 bathroom with a shower on the 200, 400 and 500 halls, and a bathroom with a shower immediately before entering the Secure Unit (near room [ROOM NUMBER]). There was also one working shower on the Secure Unit (near room [ROOM NUMBER]). Interview of S13 PCA on 2/13/19 at 11:23 a.m. revealed she worked on the Secure Unit with S7 CNA and S24 PCA from 6:00 a.m. to 2:00 p.m. on 2/9/19. She stated that she was in the dayroom with residents when she heard screaming, which was not an abnormal occurrence; however, the screaming did not stop. She stated that the first thing she saw was resident #3 on the floor in the shower, and heard S7 CNA asking what happened. She stated that S24 PCA stated that he did not know. S13 PCA said that the resident's skin was peeling, S7 CNA went to get the S4 LPN, and the resident kept saying I'm burning, I'm burning. S13 PCA further stated regarding her job duties as a PCA, was that she sat and watch the residents, like babysitting, and that she called the CNA if there was a problem. Interview of S 14 PCA on 2/13/19 at 11:40 a.m. revealed that he worked on the unit, assisted CNAs, and kept an eye on the residents. He stated he helped with transfers and passed cigarettes, and did not bathe, shower or change the residents. Interview of S8 CNA on 2/13/19 at 11:55 a.m. revealed she has worked at the facility for almost a year and worked on the Secure Unit. She stated that PCAs are there to observe only, and are not to provide care to the residents. However, review of a facility investigation statement of the 2/9/19 incident given by S8 CNA at 1:10 p.m. (no date) revealed that PCAs helped her changed the residents, and sometimes the PCAs bathed the residents. Interview of S1 Administrator on 2/13/19 at 12:04 p.m. revealed that S2 DON notified him on 2/9/19 at 1:37 p.m. of the incident. He stated that he arrived to the facility at 5:00 p.m. on that day because he was out of town, and was told that the resident had a chemical burn. He said that he had a video of the hallway and doorway, but no video of the shower room. He stated that the CNA Supervisor was not on the unit, but the CNA present (S7 CNA) knew that the PCA was not to provide resident care. The S1 Administrator further stated that S24 PCA's employment had been terminated. Interview of S6 Maintenance Supervisor on 2/13/19 at 12:27 p.m. revealed he was instructed by S1 Administrator to go to work and check temperatures for the next 8 hours after the incident, and that he arrived at the facility at 3:00 p.m. S6 Maintenance stated that he checked water temps every morning between 7:00 a.m. and 8:00 a.m. in every bathroom before use. He stated that he was informed by a CNA on 2/8/19 that the water temperature in the shower outside of room [ROOM NUMBER] (on the unit), was not hot enough. Review of the Hot Water Temperature Log dated 2/9/19 at 3:15 p.m. revealed a temperature of 113.6 degrees F in the shower near room [ROOM NUMBER] (taken immediately after S6 Maintenance Supervisor arrived at the facility). Interview of S7 CNA on 2/13/19 at 12:44 p.m. revealed the following: S7 CNA stated that it was meal time on 2/9/19 and S4 LPN said that she smelled BM. Resident #3 had finished eating lunch and walked into the hallway. She stated that she stayed in the dining room, then walked into the hall down by the shower after she finished cleaning the dining room. She stated that S24 PCA was standing in the shower room door and resident #3 was in a squatting position on the floor. S7 CNA said the resident's body was wet and his face and private parts were red. S13 PCA came over and she (S7 CNA) walked to another room to get a diaper and sent S24 PCA to get the nurse. S7 CNA further stated that PCA's aren't supposed to touch the residents, and that she had no idea that S24 PCA was giving the resident a shower. Interview of S2 DON on 2/13/19 at 3:15 p.m. revealed she received a call from S4 LPN on 2/9/19 at 12:51 p.m. stating that staff had used a different soap on resident #3, and the resident had received chemical burns. At 1:30 p.m., S4 LPN called back and stated that the ER called back and stated that it was not a chemical burn because the soap was tested and the PH was 6, less than water, and it was impossible to cause a burn. She stated the ER had them shut down bathing. She said that she called the S1 Administrator, and he instructed to get water temperatures. Temperatures were checked after S6 Maintenance Supervisor arrived to the facility. S2 DON stated that PCAs are to monitor the residents who required one to one supervision and reside outside the Secure Unit, and residents who have a potential to wonder or leave the facility. Review of the Job Summary for PCAs revealed the Job Summary was entitled 1-1 Tech. Review of the Responsibilities included: #12 - assist other staff members as needed throughout the shift, and #14 - performs other tasks as assigned. There was no documentation in the Job Summary that specified detailed responsibilities/duties/tasks of a PCA. Further interview of the S2 DON on 2/13/19 at 3:15 p.m. revealed that the 1:1 Job Summary is the same Job description that the facility used for PCAS. She stated that PCAs can assist such as handing them something, assist if residents were fighting, but they were not to provide care to the residents. She further stated that PCAs are provided an in-service on what they can and cannot do, and that she had no knowledge of S24 PCA providing showers prior to the event on 2/9/19. S2 DON confirmed that there was no documentation that indicated what the specific job duties of a PCA were. Surveyor review of the Video Surveillance in the S1 Administrator's office on 2/14/19 at 10:00 a.m. with the S1 Administrator and Corporate Personnel present, and again on 2/15/19 with S1 Administrator present revealed the following on 2/9/19: 11:56:46 - S24 PCA entered the dining room. The resident entered his room located at the end hall 100. S4 LPN was at her medication cart facing the dining room. 11:55:56 - S24 PCA leaves the dining room, passes S4 LPN in the hall at the medication cart and enters the resident's room at 11:56:04. 11:56:27 - S4 LPN began pushing her medication cart down hall 100 toward the resident's room. 11:56:30 - Resident #3 came out of his room with S24 PCA walking behind him. S24 PCA was carrying clothing. S4 LPN was rolling her medication cart towards the resident and S24 PCA. 11:56:34 - S4 LPN stopped her medication cart to navigate around a floor dryer located on the right side of the hall. The resident and S24 PCA were walking towards the medication cart on S4 LPN's left. 11:56:42 - S24 PCA and resident #3 continued walking towards S4 LPN, who had stopped her cart due to the cord to the floor dryer impeding her progress. 11:56:47 - S24 PCA was noted assisting resident #3 into the hallway where the shower was located, and stopped to kick the floor dryer cord out of the way. S4 LPN then continued down the hall. S7 CNA came out of the dining room and looked towards S24 PCA and resident #3 who were still in the hall. 11:56:51 - S24 PCA and resident #3 were no longer visible on the video. S4 LPN was at the medication cart. 11:57:46 - S24 PCA walked from the shower area onto hall 100, and immediately turned and went back to the shower area. 11:58:14 - S4 LPN went into the small hall area the shower (where S24 PCA and resident #3 were) was located on. 11:58:20 - S24 PCA walked into the hallway of hall 100, looked into the dining room, then went back to the shower area. 11:58:32 - S4 LPN walked out of the small hall area where the shower was located onto hall 100. 12:15:01 - S4 LPN left the Secure Unit with medication cart, S7 CNA went to a room, got a diaper and went to the shower room. S13 PCA standing at shower hall entrance, then went back to a resident in a wheelchair on hallway 100. 12:16:51 - Resident #3 ambulated from the shower room towards his room unassisted. S7 CNA walking next to him. 12:17:05 - The resident walked unassisted to the doorway of his room. S7 CNA and S24 PCA walked behind him. 12:17:32 - S7 CNA put a diaper on resident #3 in the hallway 100. 12:20 - S24 PCA left the Secure Unit. 12:20:41 - S24 PCA and S4 LPN entered Secure Unit. Interview of S5 CNA Supervisor on 2/15/19 at 9:15 a.m. revealed the following: She was the 1st line supervisor for PCAs. She stated that if she available, she will give those applying for the position of CNA and/or PCA a tour of the facility during the application process so that they can see what they are coming back to. She stated during orientation, she informs the PCAs what they can and cannot do, verbal instruction - no written documentation given to them. She stated that PCAs cannot bathe or do vital signs. Interview of S21 Office Manager, and surveyor review of time sheets with S21 Office Manager on 2/15/19 at 10:50 a.m. revealed S24 PCA was not at work on 8/10/18 and 9/20/18 to attend the in-services. S21 Office Manager stated and confirmed that there was no time sheet for S24 PCA on either of those days. S1 Administrator was present in the room during the interview of S21 Office Manager, review of time sheets, and confirmation that S24 PCA was not present at the in-services dated above although his name was written on the in-service sign-in sheets. Interview of S9 CNA on 2/15/19 at 9:35 a.m. revealed he rode in the ambulance with resident #3 to the hospital on [DATE]. S9 CNA stated that when he arrived on the unit, the resident was on the stretcher with his shirt off. He stated the resident had redness to his face, chest and inner thighs, and was screaming. Interview of S3 weekend RN on 2/15/19 at 11:42 a.m. revealed that on 2/9/19, S4 LPN asked her to come to the unit. When she arrived resident #3 was lying on his bed. His face was red and skin was peeling on his neck, chest and back. She stated that she knew it was a burn, but was unsure if it was a chemical or water burn. She stated that she left the unit to get the paperwork ready to send the resident out, and asked the[NAME] Clerk to call the ambulance. She stated that she got the soap that was used on the resident to send with the EMT to the hospital. She further stated that she had not heard anything about how the incident occurred. Review of the facility investigation statement of the 2/9/19 incident given by S24 PCA and dated 2/9/19 (no time), revealed the resident had a bowel movement on himself. The statement read as follows; As I attempted to bathe him, he was fighting me during the shower. The resident usually used Irish Spring bar soap. The soap was not available so he was bathed with the facility's liquid soap (Medline Soothe and Cool Cleanse). He complained about being cold and soon after I noticed his skin beginning peel redden. I immediately notified the nurse who came and saw the patient. After that patient was sent out to emergency. The surveyor was unable to interview the week-end CNA Supervisor who was on duty the day and time the incident occurred, because she was on sick leave. The surveyor was unable to interview S24 PCA.

Based on interview and record review revealed the facility failed to be administrated in a manner that enables it to use it resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 1 (#3) of 5 sampled residents (#1, #2, #3, #4, and #5). The facility failed to: 1. supervise and monitor all staff providing care to residents; 2. ensure untrained staff were not allowed to assist in residents care; and 3. ensure a system was in place to ensure training and competency of PCAs prior to permitting them to assist residents. This failed practice resulted in an Immediate Jeopardy on 2/9/2019 at 11:56 a.m. for Resident #3 when two staff members observed an untrained personal care attendant (PCA) accompany Resident #3 to the shower room without any trained staff assistance. The untrained PCA remained in the shower with Resident #3 from 11:56 a.m. to 12:16 p.m. Upon exiting the shower room at 12:17 p.m., the resident was observed to have redness to his face, chest area, neck, back and inner thighs and peeling skin from his neck, chest and back. The resident was transferred to a local hospital emergency room and was found to have sustained 1st, 2nd and 3rd degree scald burns. Later on 2/9/2019, the resident was air lifted to a hospital Burn Unit where his admitting [DIAGNOSES REDACTED]. The Administrator was notified of the Immediate Jeopardy on 2/15/19 at 4:50 p.m. The facility submitted an acceptable plan of removal on 2/15/19 at 6:57 p.m. The plan of IJ removal included the following: 1. IJ Removal Plan 2/15/19 at 6:05 p.m. 2. Root Cause Analysis: The root cause of the problem was identified by interviewing staff and watching camera footage. 3. Necessary Changes: a. Procedures were changed to include PCA approved task list and a competency test that must be passed prior to working beginning on 2/15/19 at 6:00 p.m. 4. Training: a. Persons: Staff to be educated include PCAs CNAs, nurses and department heads. b. Objective: The staff will be educated on properly supervising resident care with focus on residents not receiving care by staff that are not licensed to do so. c. Content: Immediately following incident on 2/9/19 staff was in-serviced on PCAs not doing patient care and skills that requires a CNA. On 2/14/19 DON met individually with PCAs and reviewed approved list of duties. See attachment 2. d. Post Test: All PCAs prior to working beginning 6pm on 2/15/19 will have to take a competency test and must make 100%. See attachment 1. 5. Supervision and Employee Performance Evaluation: a. Who will supervise: Persons that will be supervising resident care, PCAs and CNAs are CNA supervisor, nurses, ADON and DON. b. Who will be supervised: PCAs and CNAs. c. When will supervision occur: Supervision of care will be performed on an ongoing basis with documented supervision daily for 30 days, 2 x week for 30 days and weekly thereafter. See attachment 3. d. What are expected behaviors: It is expected that all staff members will only provide care for which they are licensed to perform. PCAs will only perform duties on the PCA approved Duty Task List. 6. Scheduled and Recorded Evaluation: a. Who will evaluate: QA committed will evaluate effectiveness of plan to determine if changes need to be made. It is expected that only staff members licensed to provide care will do so. b. Who will be evaluated: Plan will be evaluated on an ongoing basis in QA morning department head meeting Monday through Friday x 90 days then Quarterly QA. PCAs will also be evaluated according to supervision schedule. CNAs also. c. Expected Behaviors: It is expected that all resident will receive care only by staff licensed to do so. d. When will evaluations occur: Plan will be evaluated on an ongoing basis in QA morning department head meeting x 90 days then Quarterly QA. The deficit practiced continued at a potential for harm for 48 residents who required the assistance of one or two staff for bathing, and 57 residents who were dependent upon staff for bathing (a total of 105 residents). Findings: Cross Refer to F689. Review of an Employee Listing given to the surveyor on 2/14/19 at 11:48 a.m. revealed there were a total of 27 PCAs employed by the facility. Review of the Job Summary for PCAs revealed the Job Summary was entitled 1-1 Tech. Review of the Responsibilities included: #12 - assist other staff members as needed throughout the shift, and #14 - performs other tasks as assigned. There was no documentation in the Job Summary that specified detailed responsibilities/duties/tasks of a PCA. Interview of S1 Administrator on 2/13/19 at 12:04 p.m. revealed that S2 DON notified him on 2/9/19 at 1:37 p.m. of the incident. He stated that he arrived to the facility at 5:00 p.m. on that day because he was out of town, and was told that the resident had a chemical burn. He said that he had a video of the hallway and doorway, but no video of the shower room. He stated that the CNA Supervisor was not on the unit, but the CNA present (S7 CNA) knew that the PCA was not to provide resident care. The S1 Administrator further stated that S24 PCA's employment had been terminated. Interview of the S2 DON on 2/13/19 at 3:15 p.m. revealed that the 1:1 Job Summary is the same Job description that the facility used for PCAS. She stated that PCAs can assist such as handing them something, assist if residents were fighting, but they were not to provide care to the residents. She further stated that PCAs are provided an in-service on what they can and cannot do, and that she had no knowledge of S24 PCA providing showers prior to the event on 2/9/19. The S2 DON confirmed that there was no documentation that indicated what the specific job duties of a PCA were.

Based on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents. This failed practice resulted in an actual harm when resident #2 on 7/4/18, who was care planned to be non-weight bearing and required the use of a mechanical lift for transfers, was manually transferred from a Geri-chair to the bed by S5 and S6 (CNAs). During an interview resident #2 said while the two CNAs were transferring him, he was dropped to the floor with his left leg becoming wedged under the bed. With the resident's left leg still wedged under the bed, the two CNAs manually picked the resident up and continued placing the resident into the bed. On 7/5/18 during the 10:00 p.m. to 6:00 a.m. shift (no time given), the resident's left leg was discovered to be swollen. After an X-Ray was performed, the resident was transferred to the hospital where he was diagnosed with [REDACTED]. Findings: Observation of the resident on 8/6/18 at 10:15 a.m. revealed a large man sitting up in a Geri chair in the day room interacting with the other residents. Further observation revealed he had a plaster cast to his left lower leg. Review of the resident's EHR revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Anxiety disorder, Essential Hypertension, Gout, Type 2 Diabetes Mellitus with Diabetic [MEDICAL CONDITIONS] and [MEDICAL CONDITION] following Cerebral Vascular Disease affecting the right dominant side. Review of a Radiology Report for resident #2 dated 7/5/18 revealed a history of pain and swelling. The Impression was as follows: Acute spiral [MEDICAL CONDITION] third of the tibia with mild displacement. Review of the 7/5/18 facility investigation revealed the resident sustained [REDACTED]. Review of the resident's Quarterly MDS dated [DATE] revealed the resident was coded to have a BIMS summary score of 8 (Moderate Cognitive Impairment), and determined by the facility to be totally dependent with two or more persons physical assistance for transfers between surfaces including to or from the bed, chair, wheelchair, and standing position. The resident was assessed to be unsteady and only able to stabilize with staff assistance for surface to surface transfers (transfer between bed and chair or wheelchair). Review of physician's orders [REDACTED]. Review of the resident's Comprehensive Plan of Care with a goal date of 9/22/18 included the following problems: 1. Limited physical mobility related to [MEDICAL CONDITION] of the right dominant side. Interventions included: to assist with all transfers, mechanical lift with all transfers with two staff members, and Geri-chair for positioning. The goal of this plan was the resident would experience no further decline in physical mobility. 2. Alteration in comfort due to [MEDICAL CONDITION], gout, history of neuropathic pain, and fracture (7/5/18). Interventions included: administer medications as ordered, assess for pain relief after medications and treatments, and notify physician if medications or treatments were ineffective. The goal of this plan was that the resident will appear calm and relaxed with signs or symptoms of unresolved pain/discomfort. Interview of S4 CNA Supervisor on 8/6/18 at 2:20 p.m. revealed the facility has two mechanical lifts and both were located on one of the halls. She revealed a mechanical lift has always been available and functioned properly. She further revealed the CNAs on duty who were assigned to the resident on the evening shift of 7/4/18 were agency CNAs. She stated when the facility used agency CNAs, they are in-serviced on everything they need to know to care for the residents prior to their shift. She confirmed the CNAs were aware of the mechanical lift and that the resident required transfers to be done with the use of the lift. Interview of resident #2 on 8/6/18 at 2:30 p.m. revealed his injury occurred on (MONTH) 4, (YEAR). He stated that on the evening of (MONTH) 4, (YEAR), he was in his Geri-chair and was being transferred to bed for the night. He stated two CNAs were helping him to bed and they did not use the lift. He stated he was dropped on the floor and his foot became wedged under the bed. He stated one of the CNAs picked him up and threw him in the bed. He stated he felt pain in his left leg at that time. Interview of S3 LPN on 8/6/18 at 2:45 p.m. revealed the following: He stated he was assigned to Hall (a) on the 2:00 p.m. to 10:00 p.m. shift on the evening of 7/4/18, and the 10:00 p.m. to 6:00 a.m. shift the night of 7/4/18 into 7/5/18. He stated that there were two CNAs, S5 and S6 who worked for a local nurse staffing agency, and S7, CNA who was the CNA for the resident's room. He stated that S13 CNA who was scheduled to work 10:00 p.m. to 6:00 a.m. on 7/4/18, came in early, and that S13 CNA told him that resident #2 complained that his leg was hurting (no time given). He stated that when he entered the resident's room the resident told him that his leg was hurting. He stated that he did not look at the resident's leg under the covers because it was usual for the resident to state his leg hurt. He further stated that resident #2 has a [DIAGNOSES REDACTED].#2 said that he had been dropped on the floor on the prior evening. The resident reported that he had been dropped by S5 CNA, who had attempted to put the resident in bed by herself. The resident further reported that when S5 CNA attempted to pick him up, his left leg went under the bed. S3 LPN further stated that when he pulled the covers back and checked resident #2's left leg, and the resident's left leg was observed to be swollen. S3 LPN said that he asked S2 RN Treatment Nurse to look at the resident's left leg. When S2 RN Treatment Nurse looked at the resident's left leg, she stated that the leg appeared to be broken. S3 LPN further stated that during the night, at 3:00 a.m., S10 CNA informed him that the resident had been complaining of pain to the left leg; however, when he went to bring the resident something for pain, the resident had gone to sleep. S3 LPN stated he was not sure of the time that S13 CNA informed him of the resident's complaint of pain to the left leg. Further interview with S4 CNA Supervisor on 8/7/18 at 8:25 a.m. revealed the facility does not keep a training log or skills checklist for agency staff. She revealed when agency staff are new to the facility, they are assigned to work 1:1 with residents that require constant supervision. After the agency staff is more familiar with the facility, they are rotated throughout that facility. Interview of S1 DON on 8/7/18 at 9:30 a.m. revealed the facility does not keep a copy of the training records for agency staff. She stated the contract agency provides the facility with a skills checklist. Review of the checklist revealed it did not include transferring residents using a mechanical lift. She stated that Point Click Care provided information regarding each resident's plan of care so that all facility and agency staff would be informed on the most up to date resident information to provide appropriate care. She stated all CNAs are expected to check point click care for special instructions regarding resident care. Interview of S9 LPN on 8/7/18 at 9:50 a.m. revealed she worked for a nurse staffing agency. She revealed she has been working primarily at the facility recently. She confirmed she was very familiar with the resident, and was on duty the morning of (MONTH) 5, (YEAR) (6:00 a.m. to 2:30 p.m.). She stated the resident complained of pain to his leg and that assessment revealed the leg was red and swollen. She further stated the resident was transferred to the hospital that morning for evaluation and treatment. S9 LPN confirmed that resident #2 had not informed her of any complaints of pain to his leg prior to his injury on 7/4/18. Interview of S10 CNA on 8/7/18 at 11:20 a.m. revealed she was assigned on the night shift (10:00 p.m. to 6:00 a.m.) of 7/4/18 to sit one-on-one with another resident who resided in the same room as resident #2. She stated that resident #2 was very uncomfortable that night and complained of pain throughout the night. She stated that she thought the nurse on duty was giving resident #2 pain medications throughout the night. Interview of S11 CNA on 8/7/18 at 11:20 a.m. revealed the mechanical lift has always been available for resident transfers. Telephone interview of S5 CNA on 8/7/18 at 11:30 a.m. revealed she was employed by a nurse staffing agency. She confirmed she was working the evening shift on 7/4/18 and her assignment included the care of resident #2. She stated she and another CNA transferred the resident from his Geri-chair to his bed. She stated they did not use a mechanical lift because the electronic lift was broken, and the mechanical lift would not safely lift the resident due to his weight. She stated she had attempted to use the mechanical lift on a prior occasion to transfer the resident and she felt like the transfer was unsafe. She further stated she informed a nurse that she would not use the mechanical lift to transfer the resident, but she could not confirm who that nurse was. She stated she was at the resident's head and shoulders during the resident transfer on the evening of 7/4/2018. She stated she cannot remember where the other CNA was positioned during the transfer, and did not admit to dropping resident #2 during the transfer. Telephone interview with S12 CNA on 8/7/18 at 2:00 p.m. revealed she worked at the facility on the day shift (6:00 a.m. to 2:00 p.m. on 7/3/18. She stated she was assigned to provide care to resident #2 on that day. She stated the mechanical lift was working properly and that she and another CNA used the mechanical lift to transfer the resident. She stated the resident did not complain of pain, and his leg was not red or swollen on 7/3/18 on the 6:00 a.m. to 2:00 p.m. shift. Review of the User instruction manual for the Medline Hydraulic Patient Lift revealed the maximum weight capacity is 400 pounds. Resident #2's weight on 6/8/18 was 266 pounds, and on 7/6/18 resident #2's weight was 273. Interview of S1 DON on 8/7/18 at 12:40 p.m. confirmed the mechanical lift was available to use on 7/4/18 for the transfer of residents. She stated the CNAs were instructed through Point Click Care to use the lift for all transfers. She stated the CNAs should have used the lift to transfer the resident on 7/4/18. She stated she had never been informed by any staff that the mechanical lift was unsafe. She stated the CNAs reported they did not use the lift to transfer the resident when the incident occurred. After several attempts, this surveyor was unable to contact the CNA supervisor who worked the 2:00 p.m. to 10:00 p.m. shift on 7/4/18. Efforts to contact S6 and S7 CNAs via telephone were unsuccessful.

Based on interview and record review the facility failed to implement their policy and protect resident #1 from being hit, shoved, pushed down and scratched by R1, R2, R3, R4, R5, R6, R7, R8, and R9, and prevent resident to resident altercations (#1). The facility failed to: 1. implement their policy and protect resident #1 from being either hit in the face or head, shoved, pushed down and scratched by either R1, R2, R3, R4, R5, R6, R7, R8, R9; 2. intervene and protect resident #1 whose behavior and medical condition put her at increased risk for resident to resident altercations; 3. put measures in place to prevent resident #1 from provoking other residents as a result of her wandering, agitation, restlessness, and tendency to "nurse" and pray for other residents (resident #1 was a retired Registered Nurse). Resident #1 nurses' notes reflected the resident was at risk of altercations with other residents due to either she wandered in and out of resident rooms, touched other residents or attempted to give other residents assistance. The resident was at risk of physical altercations with other residents 11 times from April 15, 2014 through April 30, 2014; 19 times from May 4, 2014 through May 28, 2014; 3 times from June 21, 2014 through June 28, 2014; and 5 times July 5, through July 15, 2014. There was documentation of Resident #1 behavior resulting in a physical altercation from other residents on 4/30/14, 5/4/14, 5/16/14, 5/24/14, 5/25/14, 5/27/14 twice, 6/21/14, 6/22/14, 6/23/14, 7/5/14 twice, and 7/16/14. An Immediate Jeopardy situation began on 4/30/14 when resident #1 was hit on the left side of her head by another resident, and ended on 5/29/14 when resident #1 was transferred to an inpatient behavioral health center. The Immediate Jeopardy began again on 6/20/14 when resident #1 was readmitted to the nursing facility, and ended when resident #1 was placed on one to one supervision on 7/16/14. The Administrator was notified of the Immediate Jeopardy on 7/31/14 at 5:05 p.m. The Immediate Jeopardy was removed as of 7/16/14 when the facility placed resident #1 on one on one staff supervision. The survey sample size was 6 (#1, #2, #3, #4, #5, and #6). According to the Resident Census and Condition Report dated 7/30/14, 126 of the facility's 133 residents were diagnosed with [REDACTED]. Findings: Review of the facility policy "Abuse Prevention and Investigation" reflected the residents have the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of property. Residents will not be subjected to abuse by anyone. The facility defined resident abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, This included the deprivation of goods or serivces that are necessary to attain or maintain physical, mental and psychosocial well-being. Physical abuse includes hitting, slapping, pinching and kicking. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Facility staff will identify, and intervene for residents whose behavior or medical condition puts them at increased risk for abuse. If a resident's behavior history or medical condition puts them at risk for abuse, interventions will be developed through the care planning process, such as: care for residents unable to communicate or dependent upon caregivers for nutrition, hydration, repositioning or other activities of daily living; staff monitoring for aggressive residents and medical intervention and/or psychosocial intervention when needed; training, oversight, and support for direct caregivers who are caring for residents with behavior problems that may cause increased frustation for staff. The facility will monitor for and identify the incidents and/or patterns (trends) of incidents, as well as specifc resident signs, symptoms, and outcomes that may indicate the need for further investigation. Any report, grievance or complaint that indicates resident abuse or the potential for resident abuse will be reported to the Administrator and investigated as needed in order to protect all residents. Resident to resident incidents and injuries will be reviewed carefully and while a finding of resident abuse may not be appropriate or a formal investigation deemed necessary due to the absence of legal intent, the facility has the resposibility to intervene on behalf and protect any resident who is adversely affected by the behavior or actions of another resident. Any area of the building that is secluded, or has a particular resident population, or has other characteristics that might increase the possibility of resident abuse occuring will be identified and staff will intervene appropriately in order to help ensure residents are protected. Review of resident #1's clinical record reflected she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS (ARD date of 4/9/14) reflected the resident had a Cognitive BIMS Score of 2 and had episodes of rejecting care. The Admission MDS reflected Active [DIAGNOSES REDACTED]. Further review reflected the resident was mobile with the assistive device of a wheelchair and walker on the Admission MDS. Review of the Quarterly MDS Assessment (ARD date 7/2/14) reflected the resident was discharged to a psychialtric hospital on [DATE] and readmitted to the facility on [DATE] from the Psychiatric Hospital. The Quarterly MDS Assessment reflected the resident's Cognitive BIMS Score was 1, with behaviors of inattention and disorganized thinking. The staff assessment of mood reflected the resident had trouble falling asleep, staying asleep or sleeping too much; poor appetite or eating to much; trouble concentrating on things such as reading the newspaper or watching TV; moving so slowly that other people noticed, or being fidgety or restless, and other behavioral symptoms of rummaging, disrobing in public, and pacing. Review of the facility's Initial Social Service assessment dated [DATE] reflected the resident had signs of [MEDICAL CONDITION] with the behaviors of inattention, disorganized thinking, and psychomotor [MEDICAL CONDITION] that were continously present. Review of the facility's Social Service assessment dated [DATE] and documented by the S3 ADON, reflected the resident had signs of [MEDICAL CONDITION] with behaviors of inattention, diorganized thinking and altered level of consciousness that was continously present. Further review reflected the resident had a memory problem, moderately impaired cognitive skills for daily decision making, made poor decisions, and cues/supervision were required. S3 ADON documented the resident believed she still worked as a nurse, had ideas about what she should be doing, but got distracted easily and had "no safety awareness". Review of the Social Service assessment dated [DATE] and documented by the S3 ADON reflected the resident had delusions, thought she was a minister, and had gone around praying and baptizing the other residents. Review of the Behavioral Hospital Psychiatric Evaluation dated 5/30/14 reflected the resident had psychomotor agitation, was constantly wandering, had impaired attention and concentration and non-sensical thought process, had severe poverty of thought content, impaired recent and remote memory, and gravely impaired insight and judgment. Further review of the evaluation reflected the treatment plan included crisis intervention, evaluation, new medication, provide a safe and structured environment, and prevention of injury to others. Review of the "Elopement Risk Assessment" dated 7/2/14 reflected the resident wandered aimlessly, wandered around the facility daily, and was ambulatory without difficulty. The assessment reflected the resident was at risk for elopement. The above risk assessment reflected staff interventions of frequent monitoring (q 1 hour), utilization of a check in / check out log, key pad egress doors for entry and exit. The summary/conclusion recommendation was placed on q hour 1 census for elopement due to wandering, and reflected the resident had not attempted to elope. Review of resident #1's nurses' notes reflected the resident either wandered in and out of resident rooms, had to be re-directed often, touched other residents or attempted to give other residents assistance on the following dates and times: 4/15/15 at 10:46 a.m., 4/15/14 at 5:31 p.m., 4/16/14 at 2:06 p.m., 4/16/14 at 7:19 p.m., 4/20/14 at 8:00 p.m., 4/22/14 at 8:54 p.m., 4/23/14 at 4:39 p.m. 4/27/14 at 1:25 a.m., 4/27/14 at 8:21 a.m., 4/28/14 at 8:31 a.m., 4/30/14 at 10:26 a.m., 5/4/14 at 4:37 p.m., 5/5/14 at 10:10 a.m., 5/5/14 at 8:57 p.m., 5/7/14 at 10:15 a.m., 5/8/14 at 10:19 a.m., 5/9/14 at 5:31 a.m., 5/12/14 at 10:21 a.m., 5/14/14 at 2:46 p.m., 5/15/14 at 10:11 a.m., 5/17/14 4:42 a.m., 5/18/14 at 1:07 a.m., 5/20/14 at 3:50 a.m., 5/22/14 at 4:31 a.m., 5/23/14 at 2:46 a.m., 5/24/14 at 12:09 p.m., 5/25/14 at 9:37 p.m., 5/27/14 at 5:51 a.m., 5/27/14 at 9:08 p.m., 5/28/14 at 3:20 a.m., 6/21/14 at 10:28 a.m., 6/22/14 at 10:14 a.m., 6/28/14 at 6:30 p.m., 7/5/14 at 2:26 a.m., 7/7/14 at 10:29 a.m., 7/8/14 at 10:36 a.m., 7/10/14 at 10:45 a.m., and 7/15/14 at 1:31 p.m. . Further review of the nurse's note reflected the following: 4/22/14 at 9:31 a.m. reflected the resident was a retired nurse who thought she was still working and was there to supervise the nurse as she did treatments. 4/30/14 at 2:23 p.m. reflected the resident had improvement in mobility and ambulated around the building with poor safety awareness; was verbal but very confused and "had constant talk with little relevance to reality"; resident liked to pray and baptize people; constantly wandered around facility, in and out of resident rooms; had walked up to a resident, touched his face and the other resident was upset by being touched and hit the resident in the face during the "lookback period"; and the resident often picked up things that did not belong to her which upset the other residents because their things went missing. 5/7/14 at 3:57 p.m. reflected the resident was ambulating with an increased steady gait; wandered all over the facility; went into other resident rooms; liked to pray for people and would go up to people and put her hands on them to pray and "can cause problems because other residents do not like to be touched"; resident undressed herself in public; resident was hard to re-direct; and continued to have poor safety awareness. 5/22/14 at 4:31 a.m. reflected the resident had been restless; up and down wandering in hallway; re-directed by staff several times; CNA at bedside to provide close supervision because resident goes in and out other resident rooms and gets into bed with them and tries to awaken them; and resident was confused and unaware of actions. 5/26/14 at 1:37 p.m. reflected the S1 Administrator, S2 DON and S3 ADON had a meeting with the resident's RP (son) and his wife to discuss concerns related to the resident's safety at the facility. The documentation reflected S3 ADON explained to the family the resident was touching things all over the facility and had tried to clean and help the residents, but was unaware of the situation, and was unable to comprehend when other residents wanted to be left alone. The documentation reflected the resident continually touched and talked to other residents, and the other residents would get angry because she was in their personal space (many were Paranoid [MEDICAL CONDITION]), and they would try to hurt her; they were threatened by her touching them and would strike out to get her to stop. Further review reflected the family was informed the resident had continued to bother a resident by touching him and he had hit her twice. S1 Administrator and S2 DON discussed with the RP that the resident could get seriously injured if she had a conflict with one of their younger strong patients and they were concerned due to her age and fragility that she may become seriously injured. The documentation reflected S2 DON explained to the family they could not provide one on one care for the resident to keep her safe, and S3 ADON asked the family if they were able to find an Alzheimer's Unit for the resident, would family be willing to place her in a Alzheimer's Unit where the other residents would have similar illness and likely to be older (less combative) than some of their residents. Further review of the documentation reflected the family agreed to allow placement for resident #1 in Alzheimer/Dementia Unit if available, and S3 ADON documented she would contact the family with information as she looked for placement. 7/5/14 2:26 a.m. reflected the resident was up and wandering up and down the hallway; in and out of other resident's rooms; re-directed per staff constantly; due to confusion and disorientation resident unable to understand what she is doing or to follow the directions the staff provided; resident fidgeting with anything she touches; speech random; resident believes she is helping; it often agitates other residents and causes her to be at risk of adverse reactions from other residents. 7/10/14 at 10:45 a.m. reflected the resident continued to wander in and out of others' rooms, touching others in the face and feet; re-directed often with no effect and seated with unit secretary to keep occupied. Review of the Log of Incidents for the resident prepared by the S2DON and the POC reflected the resident was involved in an incident with other resident on the following dates and times: 4/30/14 at 1:31 p.m. resident was punched by #R1's fist to the left side of the resident's head. Documentation reflected the resident complained of the left side of her head hurting, and #R1 reported the resident had stepped on her foot. 5/4/14 at 10:36 p.m. reflected the resident was in the day room and had touched #R2 in the face until he became aggitated and pushed her to the floor. The care plan reflected the resident was re-directed and placed on 1:1 for a short period of time. 5/16/14 at 3:15 p.m. reflected the resident was attempting to push #R3's wheelchair when #R3 became agitated and hit the resident on the right side of her neck and scratched the resident. S17 RN Treatment Nurse documented on the Wound Assessment Report that resident #1 sustained an abrasion to the right temple 4.0 cms in length and 0.5 cms in width. The note reflected there were multiple abrasions to the right temple area, and a scratch to the front of the resident's neck 0.5 cm by 0.5 cm. The resident was to be closely monitored, psych NP did med review, and [MEDICATION NAME] due to continously pulling on residents trying to help. 5/24/14 at 9:50 a.m. reflected documentation on the "72 Hour Follow-Up" assessment that the resident had tried to assist #R3, who became angry and scratched the resident on the face with skin tear injury noted. The resident was removed from the room. 5/25/14 at 8:46 a.m. reflected resident to resident contact in the dayroom with #R4. The care plan reflected on 5/25/14 resident was ambulating in the hall when another resident hit her in the back for no apparent reason, no injuries noted. 5/26/14 at 11:16 a.m. reflected documentation of injuries per S17 RN Treatment Nurse. The resident had 3 new scratches to her face, however there were 4 scratches documented, 1 on the right side of her nose, 1 on the bridge by right cheek, 1 on the right cheek and 1 scratch on right side of neck. The 5/26/14 "Wound Assessment Report" documented by S18 RN Treatment Nurse reflected the assessment of injuries was: 1) a scratch that measured 5.0 cms by 0.5 cms to the front and right side of the resident's neck; 2) a scratch that measured 1 cm by 0.2 cm to right cheek; 3) a scratch that measured 1 cm by 0.2 cm located on the right cheek distal to wound #2; 4) and a scratch that measured 0.8 cm by 0.3 cm located on the right cheek, just right of the resident's nose. The care plan reflected on 5/26/14 D/C [MEDICATION NAME] 75 mg po QD; 5/26/14 [MEDICATION NAME] 50 mg po QD for sadness. 5/27/14 at 10:15 a.m. reflected the nurse was informed by the ward clerk that she had witnessed the resident punched in the right eye and scratched on the right side of the face by #R3 "again" and had multiple scratches and a swollen right lower eyelid. The care plan dated 5/27/14 reflected both residents counseled, resident #1 placed seated by the ward clerk until agitation resolved, behavior meeting with other resident, psych NP did med review with no changes. 5/27/14 at 7:00 p.m. reflected the resident was in #R5's room and attempted to help #R5 while he was in bed. #R5 scratched the resident over the left side of her face. Staff removed the resident from the room and counseled both residents. The care plan reflected on 5/27/14 altercation with another resident, she was in his room "attempting to help" him while he was in bed and resident scratched her over the left side of her face. Resident removed from the room and treatment started, counseled both residents, psych NP did med review. 5/29/14 the clinical record reflected resident #1 was PEC'd to a Behavioral Hospital for treatment and evaluation for behavior. Further review of the resident's clinical record reflected the resident was readmitted to the facility on [DATE]. Orders included Trazadone to 100 mg po Q HS, Ziprasidone HCL 20 mg 1 po BID with food, and DC [MEDICATION NAME]. 6/21/14 at 12:21 p.m. the nurses' note reflected a CNA witnessed the resident get hit in the face by #R6 on side 2 dayroom. The care plan dated 6/21/14 reflected to re-direct the resident away from other residents when you see her touching residents. 6/22/14 at 6:55 p.m. reflected #R11 brought the resident to the nurse and reported to the nurse the resident was outside at the pavilion when she was hit in the head by #R7 for no apparent reason. A superficial scratch was noted between her eyes. The care plan reflected neuro checks within normal limits at present, small superficial scratch between her eyes. 6/23/14 at 10:00 a.m. reflected a CNA reported to the nurse that #R3 had slapped the resident, knocked her glasses off of her face, and resident complained of pain, face red, small skin tear noted on the right cheek. The care plan dated 6/23/14 reflected psych NP did med review with no changes on both residents, and the aggressor removed from the area. 7/1/14 at 5:46 a.m. reflected documentation the resident had been resting quietly in her bed all night with no distress and no wandering noted; however, on walking rounds the resident was found disrobed from the waist down in #R10's bed who was also disrobed from the waist down. Resident #1 re-directed, and S1 Administrator notified. The care plan dated 7/2/14 reflected [MEDICATION NAME] 0.5 mg give 1 tablet po bid. 7/5/14 at 1:03 p.m. reflected #R8 from side 2 pushed the resident down to the floor and caused her to hit her head. No injury noted. Neuro checks initiated. The care plan dated 7/5/14 reflected the resident was removed from the area. 7/5/14 at 7:22 p.m. reflected while the resident was in the dining hall seated at a table, the resident touched #R9 on the arm and #R9 started hitting the resident in the head, and pulled out a large clump of the resident's hair. The residents were separated and counseled, and resident #1 was assessed to have a lump on the back of her head on the left side. The care plan dated 7/5/14 reflected neurochecks started. 7/16/14 at 5:30 p.m. reflected the resident was brought into the dining room by a CNA, and the CNA and S14 CNA Supervisor informed the nurse that the resident was in resident #2 and #3's room (male residents) naked, and that the resident complained of pain to the right side of chest. The note reflected the S2 DON and MD were notified with new orders for CXR obtained. The care plan dated 7/16/14 reflected the resident was found lying in a male resident's bed naked, and complained of pain to right side of chest area. Resident #1 was placed on 1:1 supervision; 7/16/14 [MEDICATION NAME] 0.5 mg tablet po bid [DIAGNOSES REDACTED]. Review of the Departmental Notes dated 7/17/14 at 12:10 p.m. reflected documentation by S1 Administrator. S1 Administrator documented he returned to the facility on [DATE] around 8:00 p.m. after notification and that residents #2 and #3 each claimed the other roommate had sex with resident #1. The S1 Administrator notified the local sheriff's department of the incident. Documentation reflected the resident was placed on 1 to 1 supervision for her protection. Interview on 7/30/14 at 9:45 a.m. with S1 Administrator revealed the resident was found unclothed (except for her shirt) in another resident's room with 2 male residents (#2 and #3), around 5:00 p.m. on 7/16/14 by staff when a CNA entered the room to deliver a supper tray. Interview of S1 Administrator revealed the staff member found the resident polishing the furniture in resident #2 and #3's room (with her pants). S1 Administrator stated resident #2 and #3 were in the room at the time and were fully dressed. S2 Administrator stated resident #1 was not a cognitive resident and was not able to tell them what happened, and resident #2 and #3 had a Psychiatric [DIAGNOSES REDACTED]. Interview on 7/30/14 at 9:45 a.m. with S1 Administrator revealed the facility had conducted 3 investigations related to abuse for the month of July, 2014. Interview with S1 revealed the facility had 1 investigation for resident #1 for the month of July, 2014, and stated it was dated 7/16/14. Further interview of S1 Administrator at the above time revealed he was notified of the incident on 7/16/14, and came to the facility to begin the investigation that evening. S1 Administrator stated he interviewed the 2 male residents (#2 and #3) were found in the room and their initial statements reflected they had sex with the resident, and then later told police they were not able to physically have sex with the resident. S1 Administrator stated the Sheriff's Deputy was notified and came to the facility to conduct an investigation the evening of the occurrence on 7/16/14, and determined that a crime had not taken place. S1 Administrator stated he reviewed the facility surveillance tape for the hallway with the Sheriff's Deputy and observed the resident walk into resident #2 and #3's room at 4:46 p.m. on her own initiative. Further interview with S1 Administrator revealed they were able to identify the following timelines for the incident that occurred on 7/16/14: 4:37 p.m. resident #3 entered room, 4:43 p.m. resident #2 entered room, 4:46 p.m. resident #1 entered room; 5:03 p.m. resident #3 left room; 5:17 p.m. resident #3 re-entered the room; 5:18 p.m. the CNA entered the room; and 5:19 resident #1 was brought out of the room by the CNA. Further interview at the above time with S1 Administrator revealed they had tried to keep a close eye on the resident because she had behaviors, and wanted to help others. The staff would walk with her, redirect her and tried to involve her in other activities. S1 Administrator stated that prior to the incident on 7/16/14 they had started trying to find the resident another home because she did not fit in at the facility. S1 Administrator stated the resident was placed on 1 on 1 supervision the evening of 7/16/14 (and remained on 1 on 1 until she was transferred to another facility). The S1 Administrator stated that all staff were inserviced the following day. S1 Administrator stated that they could tell on camera that several staff were in the hallway during the incident. Interview on 7/30/14 at 2:15 p.m. with S22 LPN revealed she had worked the evening shift of 7/16/14 on the 500 Hall and had been notified of the above incident. S22 LPN stated she was not aware resident #1 was on the 500 Hall on the evening of 7/16/14, and further stated staff tried to keep an eye on her, but you can't keep up with them all the time. Interview on 7/30/14 at 2:30 p.m. with S23 LPN revealed she routinely worked the day shift with resident #1 and confirmed the resident was confused, could not understand, walked all over the facility, would not stay in 1 place, was in and out of other resident's rooms, and bothered other resident's belongings. S23 LPN stated the other residents could not understand the resident's behavior. Further interview of S23 LPN revealed the resident was a nurse once and wanted to be helpful. S23 LPN confirmed the resident had fallen on 7/15/14 onto her right side and had bruises on her right side after the fall. Telephone interview on 7/30/14 at 2:48 p.m. with S21 CNA revealed she had worked on the 100 Hall with resident #1 on the 2-10 p.m. shift on 7/16/14. S21 CNA stated the resident was hard to keep an eye on because she did not sit still, would go from room to room, was fidgety, and it was hard to keep an eye on 1 person when there was something else that needed to be done. S21 CNA stated the staff could not keep up with her. Further interview of S21 CNA revealed she was getting residents up to go to the dining room for supper on the 100 Hall on 7/16/14, and had last seen the resident between 4:00 and 4:30 p.m. between the 100 Hall and Day Room. Further interview of S21 CNA revealed she noticed the resident held her hand between her legs that evening after the incident and stated the behavior was unusual for the resident. Interview on 7/30/14 at 2:55 p.m. with S14 CNA Supervisor revealed she had been informed on 7/16/14, that resident #1 had been found in another resident's room with no clothes on. S14 CNA Supervisor stated she was on duty the evening of 7/16/14, had observed the resident, did not see any signs of injury, but noticed the resident held her hand between her legs after the incident, and had not observed that behavior from this resident in the past. Interview on 7/30/14 at 3:08 p.m. with S20 LPN confirmed he had worked the 2-10 p.m. shift on 7/16/14, and had been notified by the Hall Monitor that resident#1 had been found nude in a man's room. S20 LPN stated he notified the S2 DON and S1 Administrator. S20 LPN stated he checked / assessed her in her room that evening, and noted some bruising to her right side and right arm that he had not noticed earlier, and noted the resident complained of pain on the right side of her rib cage. S20 LPN stated the resident had recently fallen onto her right side. S20 LPN stated that he notified the S3 ADON (who was still present at the facility), notified the resident's MD, and received an order for [REDACTED]. S20 LPN stated the resident had behaviors and that she would go up to other residents and try to help them and had been scratched by other residents. S20 LPN stated the resident had wandered into someone else's bed to go to sleep, a couple of times and staff had found her and notified them to get her. Interview on 7/30/14 at approximately 3:15 p.m. with S3 ADON confirmed they (S1 Administrator, S2 DON and S3 ADON) had a meeting with the family on 5/26/14 to review the resident's care and risk of injury at the facility, and the fact the resident had already been involved in several resident to resident altercations. Further interview of S3 ADON confirmed they had discussed the inability of the facility to provide one on one staff supervision with the RP (son), and the plan to attempt to find placement for the resident at another facility. Interview on 7/30/14 at 3:30 p.m. with S19 CNA confirmed she had worked the 2-10 p.m. shift on 7/16/14 and had found the resident in resident #2 and #3's room when she went into the room with supper trays. S19 CNA stated she was assigned as Hall Monitor for the supper meal and as Hall Monitor was assigned to pass the hall trays and answer the call lights for all halls during the supper meal service. S19 CNA stated that resident #2 and #3 preferred to eat in their room. She stated that when she went to deliver their meal trays the door to the room was closed, and when she opened it she found resident #1 in their room on the side of the room of resident #2, undressed form the waist down, wiping down the dresser. S19 CNA stated she re-directed the resident to the Women's Bathroom and dressed her, did not see any signs of injury, and stated the resident did not complain or appear to be in pain. S19 CNA stated she brought the resident to the Dining Room and reported the incident to S14 CNA Supervisor and to S20 LPN. Interview on 7/31/14 at 10:45 a.m. with S3 ADON revealed she had assessed resident #1 (in the resident's bed) after the incident on 7/16/14, and stated the resident looked like she was in pain; however, she did not see any evidence of new injuries. Further interview of S3 ADON revealed the S1 Administrator was notified and came to the facility to begin the investigation and the resident was placed on one to one monitoring at that time. Interview on 7/31/14 at 10:45 a.m. with S3 ADON confirmed the resident had been identified with behaviors that put her at risk for injury, and had been involved in multiple resident to resident altercations. The S3 ADON reviewed the approaches that were care planned for the resident and confirmed the interventions that were used were documented in the care plan and the nurses' notes, and included q 1 hour monitoring, short periods of one on one staff supervision, transfer to a Behavioral Hospital, medication review by MD and Psych NP, medication changes, close observation, counseling, re-direction and behavioral meetings. Further interview with S3 ADON revealed the S3 ADON stated "she could not be watched all the time".

Based on interview and record review the facility failed to use the results of the resident's assessments to develop and revise the resident's care plan with individualized approaches related to the resident's [DIAGNOSES REDACTED].#1). The facility failed to: 1. Develop individualized approaches that addressed behaviors that were disruptive, intrusive, and precipitated a negative response from other residents; 2. Identify the problem of Disturbed Thought Processes with measureable, objective goals specific to the resident's needs. Resident #1 nurses' notes reflected the resident was at risk of altercations with other residents due to either she wandered in and out of resident rooms, touched other residents or attempted to give other residents assistance. The resident was at risk of physical altercations from other residents 11 times from April 15, 2014 through April 30, 2014; 19 times from May 4, 2014 through May 28, 2014; 3 times from June 21, 2014 through June 28, 2014; and 5 times July 5, through July 15, 2014. There was documentation of Resident #1's behavior resulting in a physical altercation from other residents on 4/30/14, 5/4/14, 5/16/14, 5/24/14, 5/25/14, 5/27/14 twice, 6/21/14, 6/22/14, 6/23/14, 7/5/14 twice, and 7/16/14. An Immediate Jeopardy situation began on 4/30/14 when resident #1 was hit on the left side of her head by another resident, and ended on 5/29/14 when resident #1 was transferred to an inpatient behavioral health center. The Immediate Jeopardy began again on 6/20/14 when resident #1 was readmitted to the nursing facility, and ended when resident #1 was placed on one to one supervision on 7/16/14. The Administrator was notified of the Immediate Jeopardy on 7/31/14 at 5:05 p.m. The Immediate Jeopardy was removed as of 7/16/14 when the facility placed resident #1 on one on one staff supervision. The survey sample size was 6 (#1, #2, #3, #4, #5, and #6). According to the Resident Census and Condition Report dated 7/30/14, 126 of the facility's 133 residents were diagnosed with [REDACTED]. Findings: Review of resident #1's clinical record reflected she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS (ARD date of 4/9/14) reflected the resident had a Cognitive BIMS Score of 2 and had episodes of rejecting care. The Admission MDS reflected Active [DIAGNOSES REDACTED]. Further review reflected the resident was mobile with the assistive device of a wheelchair and walker on the Admission MDS. Review of the Quarterly MDS Assessment (ARD date 7/2/14) reflected the resident was discharged to a psychialtric hospital on [DATE] and readmitted to the facility on [DATE] from the Psychiatric Hospital. The Quarterly MDS Assessment reflected the resident's Cognitive BIMS Score was 1, with behaviors of inattention and disorganized thinking. The staff assessment of mood reflected the resident had trouble falling asleep, staying asleep or sleeping too much; poor appetite or eating to much; trouble concentrating on things such as reading the newspaper or watching TV; moving so slowly that other people noticed, or being fidgety or restless, and other behavioral symptoms of rummaging, disrobing in public, and pacing. Review of the facility's Initial Social Service assessment dated [DATE] reflected the resident had signs of [MEDICAL CONDITION] with the behaviors of inattention, disorganized thinking, and psychomotor [MEDICAL CONDITION] that were continously present. Review of the facility's Social Service assessment dated [DATE] and documented by the S3 ADON, reflected the resident had signs of [MEDICAL CONDITION] with behaviors of inattention, diorganized thinking and altered level of consciousness that was continously present. Further review reflected the resident had a memory problem, moderately impaired cognitive skills for daily decision making, made poor decisions, and cues/supervision were required. S3 ADON documented the resident believed she still worked as a nurse, had ideas about what she should be doing, but got distracted easily and had "no safety awareness". Review of the nurses' note dated 4/10/14 at 9:06 a.m. reflected the resident wandered into other resident rooms, and on 4/14/14 at 3:35 p.m. reflected she propelled herself at a fast pace in and out of other resident's rooms, and required frequent counseling and redirection. Review of the nurses' note dated 4/16/14 reflected the resident was mobile per wc and went around the building wandering in and out of rooms, and rummaged through anything she could reach. Review of the nurses' note dated 4/20/14 at 8:00 p.m. reflected the resident wandered into other resident's rooms, touched their feet, and required redirection. Review of the nurses' note dated 4/30/14 at 1:31 p.m. reflected a housekeeper heard and saw resident #1 get punched on the left side of her head by #R1, and #R1 reported the resident had stepped on her foot. Review of the nurses' note dated 4/30/14 at 2:23 p.m. reflected the resident was very confused, liked to pray and baptize people, constantly wandered in and out of other resident's rooms, picked up things that did not belong to her, and had upset other residents. Further review reflected resident #1 had gone up to another resident, started touching his face, and the resident had hit her in the face, during the prior lookback period. Review of the Care Plan reflected the problem of Disturbed Thought Process R/T STM/LTM Deficits, Dementia, [MEDICAL CONDITIONS], and Depression, and reflected the following incidents: 4/15/14 - Increased aggitation and restlessness; 4/30/14 - Altercation with another resident; 5/4/14 - Incident with another resident; 5/16/14 - Altercation with another resident; 5/24/14 - Altercation with resident; 6/21/14 - Altercation; 6/22/14 - Altercation; 6/23/14 - Altercation; 7/5/14 - Altercation X2; 7/16/14 - Naked in a male's room. Review of the goal for the above problem (goal date of 10/19/14) reflected: resident #1 will have less behaviors by 10/19/14. Review of the approaches for the above problem reflected: Use resident's name often; introduce self at each encounter; discuss with family history of behavioral changes; counceling as needed for noncomplaince or inappropriate behavior; speak directly to resident; be patient and firm; reward appropriate responses with smiles, nod of head, and verbal praise; Further review of the approaches reflected: 4/2/14 - [MEDICATION NAME] XR 28 mg capsule po HS, [MEDICATION NAME] 4.6 mg/24 hr patch QD, [MEDICATION NAME] 15 mg tablet po Q hs, [MEDICATION NAME] Hcl 5 mg tablet po TID, 4/2/14 Trazadone 50 mg tablet po Q HS; 4/15/14 - Changed 4/2/14 [MEDICATION NAME] 50 mg po Q HS; 4/15/14 - [MEDICATION NAME] 0.25 mg tablet po Q 8 hrs prn anxiety; 4/17/14 - Elopement (census) checks nursing Q 1 hour checks; 4/30/14 another resident said resident #1 stepped on her toes, so the other resident hit resident #1 on the left side of her head, no bruising, redness noted, skin intact, VS within normal limits, neuro checks remain in progress; 5/4/14 resident #1 was in day room when she started putting her hands in another residents face, touching him, he became agitated and pushed her down, resident #1 redirected and placed on one to one for a short period of time; 5/16/14 changed 4/2/14 [MEDICATION NAME] 0.25 mg tablet po QD at 12N; 5/16/14 resident #1 was hit by another resident while she tried to push him in his wheelchair, 5/16/14 monitor resident #1 closely; psych NP did med review and increased [MEDICATION NAME] due to resident continously pulling on residents trying to help them; 5/24/14 resident #1 tried to help another resident and he became mad and scratched her multiple times to the right side of her face, neck and under her left eye, resident #1 was removed from the room; 5/25/14 resident #1 ambulated in the hall and another resident hit her in the back for no apparent reason, no injuries noted; 5/26/14 D/C [MEDICATION NAME] 75 mg po QD, 5/26/14 [MEDICATION NAME] 50 mg po QD for sadness; 5/27/14 had altercation with another resident, she was in his room and attempted to help him while he was in bed, and the other resident scratched her over the left side of her face, resident #1 removed from the room and treatment started, counseled both residents, psych NP did med review; 5/27/14 resident #1 was hit in right eye and scratched on right side of face by another resident, both residents counseled, resident #1 placed seated by ward clerk until aggitation resolved, behavior meeting with other resident, psych NP did med review with no changes; 5/29/14 PEC'd to Red River Behavioral Hospital in Bossier City for treatment and evaluation for behavior; 6/20/14 readmit to facility, increase Trazadone to 100 mg po Q HS, Ziprasidone HCL 20 mg 1 po BID with food, DC [MEDICATION NAME], DC [MEDICATION NAME], and DC [MEDICATION NAME]; 6/21/14 redirect resident #1 away from other residents when see her touching residents; 6/21/14 resident #1 was hit in face by another resident, no injuries noted, residents seperated, couseled and assessed; 6/22/14 resident #1 out on pavilion when another female resident hit her on top of the head for no apparent reason, neuro checks within normal limits at present, small superficial scratch between her eyes; 6/23/14 psych NP did med review with no changes on both residents and the aggressor removed form the area; 7/2/14 [MEDICATION NAME] 0.5 mg give 1 tablet po bid; 7/5/14 pushed down by another resident, caused her to hit the back of her head, no lumps, bumps, bruises, neurochecks initiated, resident removed form the area; 7/5/14 while in dining room the resident touched another resident and the other resident began hitting resident and pulled her hair, lump to backside of head, non-tender, resident removed from area, neurochecks started; 7/16/14 resident was found lying in a male resident's bed naked, co of pain to right side of chest area, resident placed on one to one staff supervision; 7/16/14 [MEDICATION NAME] 0.5 mg tablet po bid [DIAGNOSES REDACTED]. 7/22/14 [MEDICATION NAME] 0.5 mg po bid; 7/24/14 hold [MEDICATION NAME] until available. Review of resident #1's nurses' notes reflected the resident either wandered in and out of resident rooms, had to be re-directed often, touched other residents or attempted to give other residents assistance on the following dates and times: 4/15/15 at 10:46 a.m., 4/15/14 at 5:31 p.m., 4/16/14 at 2:06 p.m., 4/16/14 at 7:19 p.m., 4/20/14 at 8:00 p.m., 4/22/14 at 8:54 p.m., 4/23/14 at 4:39 p.m. 4/27/14 at 1:25 a.m., 4/27/14 at 8:21 a.m., 4/28/14 at 8:31 a.m., 4/30/14 at 10:26 a.m., 5/4/14 at 4:37 p.m., 5/5/14 at 10:10 a.m., 5/5/14 at 8:57 p.m., 5/7/14 at 10:15 a.m., 5/8/14 at 10:19 a.m., 5/9/14 at 5:31 a.m., 5/12/14 at 10:21 a.m., 5/14/14 at 2:46 p.m., 5/15/14 at 10:11 a.m., 5/17/14 4:42 a.m., 5/18/14 at 1:07 a.m., 5/20/14 at 3:50 a.m., 5/22/14 at 4:31 a.m., 5/23/14 at 2:46 a.m., 5/24/14 at 12:09 p.m., 5/25/14 at 9:37 p.m., 5/27/14 at 5:51 a.m., 5/27/14 at 9:08 p.m., 5/28/14 at 3:20 a.m., 6/21/14 at 10:28 a.m., 6/22/14 at 10:14 a.m., 6/28/14 at 6:30 p.m., 7/5/14 at 2:26 a.m., 7/7/14 at 10:29 a.m., 7/8/14 at 10:36 a.m., 7/10/14 at 10:45 a.m., and 7/15/14 at 1:31 p.m. Review of the Log of Incidents for the resident prepared by the S2DON and the POC reflected the resident was involved in an incident with other resident on the following dates and times: 4/30/14 at 1:31 p.m. resident was punched by #R1's fist to the left side of the resident's head. Documentation reflected the resident complained of the left side of her head hurting, and #R1 reported the resident had stepped on her foot. 5/4/14 at 10:36 p.m. reflected the resident was in the day room and had touched #R2 in the face until he became aggitated and pushed her to the floor. The care plan reflected the resident was re-directed and placed on 1:1 for a short period of time. 5/16/14 at 3:15 p.m. reflected the resident was attempting to push #R3's wheelchair when #R3 became agitated and hit the resident on the right side of her neck and scratched the resident. S17 RN Treatment Nurse documented on the Wound Assessment Report that resident #1 sustained an abrasion to the right temple 4.0 cms in length and 0.5 cms in width. The note reflected there were multiple abrasions to the right temple area, and a scratch to the front of the resident's neck 0.5 cm by 0.5 cm. The resident was to be closely monitored, psych NP did med review, and [MEDICATION NAME] due to continously pulling on residents trying to help. 5/24/14 at 9:50 a.m. reflected documentation on the "72 Hour Follow-Up" assessment that the resident had tried to assist #R3, who became angry and scratched the resident on the face with skin tear injury noted. The resident was removed from the room. 5/25/14 at 8:46 a.m. reflected resident to resident contact in the dayroom with #R4. The care plan reflected on 5/25/14 resident was ambulating in the hall when another resident hit her in the back for no apparent reason, no injuries noted. 5/26/14 at 11:16 a.m. reflected documentation of injuries per S17 RN Treatment Nurse. The resident had 3 new scratches to her face, however there were 4 scratches documented, 1 on the right side of her nose, 1 on the bridge by right cheek, 1 on the right cheek and 1 scratch on right side of neck. The 5/26/14 "Wound Assessment Report" documented by S18 RN Treatment Nurse reflected the assessment of injuries was: 1) a scratch that measured 5.0 cms by 0.5 cms to the front and right side of the resident's neck; 2) a scratch that measured 1 cm by 0.2 cm to right cheek; 3) a scratch that measured 1 cm by 0.2 cm located on the right cheek distal to wound #2; 4) and a scratch that measured 0.8 cm by 0.3 cm located on the right cheek, just right of the resident's nose. The care plan reflected on 5/26/14 D/C [MEDICATION NAME] 75 mg po QD; 5/26/14 [MEDICATION NAME] 50 mg po QD for sadness. 5/27/14 at 10:15 a.m. reflected the nurse was informed by the ward clerk that she had witnessed the resident punched in the right eye and scratched on the right side of the face by #R3 "again" and had multiple scratches and a swollen right lower eyelid. The care plan dated 5/27/14 reflected both residents counseled, resident #1 placed seated by the ward clerk until agitation resolved, behavior meeting with other resident, psych NP did med review with no changes. 5/27/14 at 7:00 p.m. reflected the resident was in #R5's room and attempted to help #R5 while he was in bed. #R5 scratched the resident over the left side of her face. Staff removed the resident from the room and counseled both residents. The care plan reflected on 5/27/14 altercation with another resident, she was in his room "attempting to help" him while he was in bed and resident scratched her over the left side of her face. Resident removed from the room and treatment started, counseled both residents, psych NP did med review. 5/29/14 the clinical record reflected resident #1 was PEC'd to a Behavioral Hospital for treatment and evaluation for behavior. Further review of the resident's clinical record reflected the resident was readmitted to the facility on [DATE]. Orders included Trazadone to 100 mg po Q HS, Ziprasidone HCL 20 mg 1 po BID with food, and DC [MEDICATION NAME]. 6/21/14 at 12:21 p.m. the nurses' note reflected a CNA witnessed the resident get hit in the face by #R6 on side 2 dayroom. The care plan dated 6/21/14 reflected to re-direct the resident away from other residents when you see her touching residents. 6/22/14 at 6:55 p.m. reflected #R11 brought the resident to the nurse and reported to the nurse the resident was outside at the pavilion when she was hit in the head by #R7 for no apparent reason. A superficial scratch was noted between her eyes. The care plan reflected neuro checks within normal limits at present, small superficial scratch between her eyes. 6/23/14 at 10:00 a.m. reflected a CNA reported to the nurse that #R3 had slapped the resident, knocked her glasses off of her face, and resident complained of pain, face red, small skin tear noted on the right cheek. The care plan dated 6/23/14 reflected psych NP did med review with no changes on both residents, and the aggressor removed from the area. 7/1/14 at 5:46 a.m. reflected documentation the resident had been resting quietly in her bed all night with no distress and no wandering noted; however, on walking rounds the resident was found disrobed from the waist down in #R10's bed who was also disrobed from the waist down. Resident #1 re-directed, and S1 Administrator notified. The care plan dated 7/2/14 reflected [MEDICATION NAME] 0.5 mg give 1 tablet po bid. 7/5/14 at 1:03 p.m. reflected #R8 from side 2 pushed the resident down to the floor and caused her to hit her head. No injury noted. Neuro checks initiated. The care plan dated 7/5/14 reflected the resident was removed from the area. 7/5/14 at 7:22 p.m. reflected while the resident was in the dining hall seated at a table, the resident touched #R9 on the arm and #R9 started hitting the resident in the head, and pulled out a large clump of the resident's hair. The residents were separated and counseled, and resident #1 was assessed to have a lump on the back of her head on the left side. The care plan dated 7/5/14 reflected neurochecks started. 7/16/14 at 5:30 p.m. reflected the resident was brought into the dining room by a CNA, and the CNA and S14 CNA Supervisor informed the nurse that the resident was in resident #2 and #3's room (male residents) naked, and that the resident complained of pain to the right side of chest. The note reflected the S2 DON and MD were notified with new orders for CXR obtained. The care plan dated 7/16/14 reflected the resident was found lying in a male resident's bed naked, and complained of pain to right side of chest area. Resident #1 was placed on 1:1 supervision; 7/16/14 [MEDICATION NAME] 0.5 mg tablet po bid [DIAGNOSES REDACTED]. Review of the Departmental Notes dated 7/17/14 at 12:10 p.m. reflected documentation by S1 Administrator. S1 Administrator documented he returned to the facility on [DATE] around 8:00 p.m. after notification and that residents #2 and #3 each claimed the other roommate had sex with resident #1. The S1 Administrator notified the local sheriff's department of the incident. Documentation reflected the resident was placed on 1 to 1 supervision for her protection. Interview on 7/30/14 at 9:45 a.m. with S1 Administrator revealed the resident was found unclothed (except for her shirt) in another resident's room with 2 male residents (#2 and #3), around 5:00 p.m. on 7/16/14 by staff when a CNA entered the room to deliver a supper tray. Interview of S1 Administrator revealed the staff member found the resident polishing the furniture in resident #2 and #3's room (with her pants). S1 Administrator stated resident #2 and #3 were in the room at the time and were fully dressed. S2 Administrator stated resident #1 was not a cognitive resident and was not able to tell them what happened, and resident #2 and #3 had a Psychiatric [DIAGNOSES REDACTED]. Interview on 7/30/14 at 9:45 a.m. with S1 Administrator revealed the facility had conducted 3 investigations related to abuse for the month of July, 2014. Interview with S1 revealed the facility had 1 investigation for resident #1 for the month of July, 2014, and stated it was dated 7/16/14. Further interview of S1 Administrator at the above time revealed he was notified of the incident on 7/16/14, and came to the facility to begin the investigation that evening. S1 Administrator stated he interviewed the 2 male residents (#2 and #3) were found in the room and their initial statements reflected they had sex with the resident, and then later told police they were not able to physically have sex with the resident. S1 Administrator stated the Sheriff's Deputy was notified and came to the facility to conduct an investigation the evening of the occurrence on 7/16/14, and determined that a crime had not taken place. S1 Administrator stated he reviewed the facility surveillance tape for the hallway with the Sheriff's Deputy and observed the resident walk into resident #2 and #3's room at 4:46 p.m. on her own initiative. Further interview with S1 Administrator revealed they were able to identify the following timelines for the incident that occurred on 7/16/14: 4:37 p.m. resident #3 entered room, 4:43 p.m. resident #2 entered room, 4:46 p.m. resident #1 entered room; 5:03 p.m. resident #3 left room; 5:17 p.m. resident #3 re-entered the room; 5:18 p.m. the CNA entered the room; and 5:19 resident #1 was brought out of the room by the CNA. Further interview at the above time with S1 Administrator revealed they had tried to keep a close eye on the resident because she had behaviors, and wanted to help others. The staff would walk with her, redirect her and tried to involve her in other activities. S1 Administrator stated that prior to the incident on 7/16/14 they had started trying to find the resident another home because she did not fit in at the facility. S1 Administrator stated the resident was placed on 1 on 1 supervision the evening of 7/16/14 (and remained on 1 on 1 until she was transferred to another facility). The S1 Administrator stated that all staff were inserviced the following day. S1 Administrator stated that they could tell on camera that several staff were in the hallway during the incident. Interview on 7/30/14 at 11:00 a.m. with S1 Administrator revealed the facility had done a QA related to resident #1 after the incident of 7/16/14, and as a result had conducted an inservice related to abuse and neglect. However, further interview with S1 Adminstrator revealed the facility did not have any additional documentation of monitoring related to the QA for resident #1. Additionally, the comprehensive plan of care did not reflect individualized effective approaches to address the resident's specific problematic behaviors. Interview on 7/30/14 at 2:15 p.m. with S22 LPN revealed she had worked the evening shift of 7/16/14 on the 500 Hall and had been notified of the above incident. S22 LPN stated she was not aware resident #1 was on the 500 Hall on the evening of 7/16/14, and further stated staff tried to keep an eye on her, but you can't keep up with them all the time. Interview on 7/30/14 at 2:30 p.m. with S23 LPN revealed she routinely worked the day shift with resident #1 and confirmed the resident was confused, could not understand, walked all over the facility, would not stay in 1 place, was in and out of other resident's rooms, and bothered other resident's belongings. S23 LPN stated the other residents could not understand the resident's behavior. Further interview of S23 LPN revealed the resident was a nurse once and wanted to be helpful. S23 LPN confirmed the resident had fallen on 7/15/14 onto her right side and had bruises on her right side after the fall. Telephone interview on 7/30/14 at 2:48 p.m. with S21 CNA revealed she had worked on the 100 Hall with resident #1 on the 2-10 p.m. shift on 7/16/14. S21 CNA stated the resident was hard to keep an eye on because she did not sit still, would go from room to room, was fidgety, and it was hard to keep an eye on 1 person when there was something else that needed to be done. S21 CNA stated the staff could not keep up with her. Further interview of S21 CNA revealed she was getting residents up to go to the dining room for supper on the 100 Hall on 7/16/14, and had last seen the resident between 4:00 and 4:30 p.m. between the 100 Hall and Day Room. Further interview of S21 CNA revealed she noticed the resident held her hand between her legs that evening after the incident and stated the behavior was unusual for the resident. Interview on 7/30/14 at 2:55 p.m. with S14 CNA Supervisor revealed she had been informed on 7/16/14, that resident #1 had been found in another resident's room with no clothes on. S14 CNA Supervisor stated she was on duty the evening of 7/16/14, had observed the resident, did not see any signs of injury, but noticed the resident held her hand between her legs after the incident, and had not observed that behavior from this resident in the past. Interview on 7/30/14 at 3:08 p.m. with S20 LPN confirmed he had worked the 2-10 p.m. shift on 7/16/14, and had been notified by the Hall Monitor that resident#1 had been found nude in a man's room. S20 LPN stated he notified the S2 DON and S1 Administrator. S20 LPN stated he checked / assessed her in her room that evening, and noted some bruising to her right side and right arm that he had not noticed earlier, and noted the resident complained of pain on the right side of her rib cage. S20 LPN stated the resident had recently fallen onto her right side. S20 LPN stated that he notified the S3 ADON (who was still present at the facility), notified the resident's MD, and received an order for [REDACTED]. S20 LPN stated the resident had behaviors and that she would go up to other residents and try to help them and had been scratched by other residents. S20 LPN stated the resident had wandered into someone else's bed to go to sleep, a couple of times and staff had found her and notified them to get her. Interview on 7/30/14 at approximately 3:15 p.m. with S3 ADON confirmed they (S1 Administrator, S2 DON and S3 ADON) had a meeting with the family on 5/26/14 to review the resident's care and risk of injury at the facility, and the fact the resident had already been involved in several resident to resident altercations. Further interview of S3 ADON confirmed they had discussed the inability of the facility to provide one on one staff supervision with the RP (son), and the plan to attempt to find placement for the resident at another facility. Interview on 7/30/14 at 3:30 p.m. with S19 CNA confirmed she had worked the 2-10 p.m. shift on 7/16/14 and had found the resident in resident #2 and #3's room when she went into the room with supper trays. S19 CNA stated she was assigned as Hall Monitor for the supper meal and as Hall Monitor was assigned to pass the hall trays and answer the call lights for all halls during the supper meal service. S19 CNA stated that resident #2 and #3 preferred to eat in their room. She stated that when she went to deliver their meal trays the door to the room was closed, and when she opened it she found resident #1 in their room on the side of the room of resident #2, undressed form the waist down, wiping down the dresser. S19 CNA stated she re-directed the resident to the Women's Bathroom and dressed her, did not see any signs of injury, and stated the resident did not complain or appear to be in pain. S19 CNA stated she brought the resident to the Dining Room and reported the incident to S14 CNA Supervisor and to S20 LPN. Interview on 7/31/14 at 10:45 a.m. with S3 ADON revealed she had assessed resident #1 (in the resident's bed) after the incident on 7/16/14, and stated the resident looked like she was in pain; however, she did not see any evidence of new injuries. Further interview of S3 ADON revealed the S1 Administrator was notified and came to the facility to begin the investigation and the resident was placed on one to one monitoring at that time. Interview on 7/31/14 at 10:45 a.m. with S3 ADON confirmed the resident had been identified with behaviors that put her at risk for injury, and had been involved in multiple resident to resident altercations. The S3 ADON reviewed the approaches that were care planned for the resident and confirmed the interventions that were used were documented in the care plan and the nurses' notes, and included q 1 hour monitoring, short periods of one on one staff supervision, transfer to a Behavioral Hospital, medication review by MD and Psych NP, medication changes, close observation, counseling, re-direction and behavioral meetings. Further interview with S3 ADON revealed the S3 ADON stated "she could not be watched all the time".

Based on interview and record review the facility failed to ensure resident #1 attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The facility failed to: 1. implement their policy and protect resident #1 from being either hit in the face or head, shoved, pushed down and scratched by either R1, R2, R3, R4, R5, R6, R7, R8, R9; 2. develop individualized care plan approaches for resident #1 that addressed behaviors that were disruptive, intrusive, and precipitated a negative response from other residents, and monitor the effectiveness of the care plan approaches; 3. identify the specifics of the problematic behavior, and develope measureable and objective goals to ensure the resident's well-being; 4. provide adequate supervision to prevent resident #1 from being either hit in the face or head, shoved, pushed down and scratched by either #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9 or any other resident who resided at the facility. Resident #1 nurses' notes reflected the resident was at risk of altercations with other residents due to either she wandered in and out of resident rooms, touched other residents or attempted to give other residents assistance. The resident was at risk of physical altercations from other residents 11 times from April 15, 2014 through April 30, 2014; 19 times from May 4, 2014 through May 28, 2014; 3 times from June 21, 2014 through June 28, 2014; and 5 times July 5, through July 15, 2014. There was documentation of Resident #1 behavior resulting in a physical altercation from other residents on 4/30/14, 5/4/14, 5/16/14, 5/24/14, 5/25/14, 5/27/14 twice, 6/21/14, 6/22/14, 6/23/14, 7/5/14 twice, and 7/16/14. An Immediate Jeopardy situation began on 4/30/14 when resident #1 was hit on the left side of her head by another resident, and ended on 5/29/14 when resident #1 was transferred to an inpatient behavioral health center. The Immediate Jeopardy began again on 6/20/14 when resident #1 was readmitted to the nursing facility , and ended when resident #1 was placed on one to one supervision on 7/16/14. The Administrator was notified of the Immediate Jeopardy on 7/31/14 at 5:05 p.m. The Immediate Jeopardy was removed as of 7/16/14 when the facility placed resident #1 on one on one staff supervision. The survey sample was 6 (#1, #2, #3, #4, #5, and #6). According to the Resident Census and Condition Report dated 7/30/14, 126 of the facility's 133 residents were diagnosed with [REDACTED]. Findings: Review of the facility policy "Abuse Prevention and Investigation" reflected the residents have the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of property. Residents will not be subjected to abuse by anyone. The facility defined resident abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, This included the deprivation of goods or serivces that are necessary to attain or maintain physical, mental and psychosocial well-being. Physical abuse includes hitting, slapping, pinching and kicking. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Facility staff will identify, and intervene for residents whose behavior or medical condition puts them at increased risk for abuse. If a resident's behavior history or medical condition puts them at risk for abuse, interventions will be developed through the care planning process, such as: care for residents unable to communicate or dependent upon caregivers for nutrition, hydration, repositioning or other activities of daily living; staff monitoring for aggressive residents and medical intervention and/or psychosocial intervention when needed; training, oversight, and support for direct caregivers who are caring for residents with behavior problems that may cause increased frustation for staff. The facility will monitor for and identify the incidents and/or patterns (trends) of incidents, as well as specifc resident signs, symptoms, and outcomes that may indicate the need for further investigation. Any report, grievance or complaint that indicates resident abuse or the potential for resident abuse will be reported to the Administrator and investigated as needed in order to protect all residents. Resident to resident incidents and injuries will be reviewed carefully and while a finding of resident abuse may not be appropriate or a formal investigation deemed necessary due to the absence of legal intent, the facility has the resposibility to intervene on behalf and protect any resident who is adversely affected by the behavior or actions of another resident. Any area of the building that is secluded, or has a particular resident population, or has other characteristics that might increase the possibility of resident abuse occuring will be identified and staff will intervene appropriately in order to help ensure residents are protected. Review of resident #1's clinical record reflected she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS (ARD date of 4/9/14) reflected the resident had a Cognitive BIMS Score of 2 and had episodes of rejecting care. The Admission MDS reflected Active [DIAGNOSES REDACTED]. Further review reflected the resident was mobile with the assistive device of a wheelchair and walker on the Admission MDS. Review of the Quarterly MDS Assessment (ARD date 7/2/14) reflected the resident was discharged to a psychialtric hospital on [DATE] and readmitted to the facility on [DATE] from the Psychiatric Hospital. The Quarterly MDS Assessment reflected the resident's Cognitive BIMS Score was 1, with behaviors of inattention and disorganized thinking. The staff assessment of mood reflected the resident had trouble falling asleep, staying asleep or sleeping too much; poor appetite or eating to much; trouble concentrating on things such as reading the newspaper or watching TV; moving so slowly that other people noticed, or being fidgety or restless, and other behavioral symptoms of rummaging, disrobing in public, and pacing. Review of the facility's Initial Social Service assessment dated [DATE] reflected the resident had signs of [MEDICAL CONDITION] with the behaviors of inattention, disorganized thinking, and psychomotor [MEDICAL CONDITION] that were continously present. Review of the facility's Social Service assessment dated [DATE] and documented by the S3 ADON, reflected the resident had signs of [MEDICAL CONDITION] with behaviors of inattention, diorganized thinking and altered level of consciousness that was continously present. Further review reflected the resident had a memory problem, moderately impaired cognitive skills for daily decision making, made poor decisions, and cues/supervision were required. S3 ADON documented the resident believed she still worked as a nurse, had ideas about what she should be doing, but got distracted easily and had "no safety awareness". Review of a nurse's note dated 4/2/14 at 11:37 a.m. reflected the nurse telephone the resident's son and inform him of her arrival to the facility. The nurse further documented the son stated "she don't sleep, she's up all night & laughed". Review of the nurses' note dated 4/10/14 at 9:06 a.m. reflected the resident wandered into other resident rooms, and on 4/14/14 at 3:35 p.m. reflected she propelled herself at a fast pace in and out of other resident's rooms, and required frequent counseling and redirection. Review of the nurses' note dated 4/16/14 reflected the resident was mobile per wc and went around the building wandering in and out of rooms, and rummaged through anything she could reach. Review of the nurses' note dated 4/20/14 at 8:00 p.m. reflected the resident wandered into other resident's rooms, touched their feet, and required redirection. Review of the nurses' note dated 4/30/14 at 1:31 p.m. reflected a housekeeper heard and saw resident #1 get punched on the left side of her head by #R1, and #R1 reported the resident had stepped on her foot. Review of the nurses' note dated 4/30/14 at 2:23 p.m. reflected the resident was very confused, liked to pray and baptize people, constantly wandered in and out of other resident's rooms, picked up things that did not belong to her, and had upset other residents. Further review reflected resident #1 had gone up to another resident, started touching his face, and the resident had hit her in the face, during the prior lookback period. Review of the Care Plan reflected the problem of Disturbed Thought Process R/T STM/LTM Deficits, Dementia, [MEDICAL CONDITIONS], and Depression; 4/15/14 Increased aggitation and restlessness; 4/30/14 Altercation with another resident; 5/4/14 Incident with another resident; 5/16/14 Altercation with another resident; 5/24/14 Altercation with resident; 6/21/14 Altercation; 6/22/14 Altercation; 6/23/14 Altercation; 7/5/14 Altercation X2; 7/16/14 Naked in a male's room. Review of the goal for the above problem (goal date of 10/19/14) reflected: resident #1 will have less behaviors by 10/19/14. Review of the approaches for the above problem reflected: use resident's name often, introduce self at each encounter; discuss with family history of behavioral changes; counceling as needed for noncomplaince or inappropriate behavior; speak directly to resident; be patient and firm; reward appropriate responses with smiles, nod of head, and verbal praise; 4/2/14 [MEDICATION NAME] XR 28 mg capsule po HS, [MEDICATION NAME] 4.6 mg/24 hr patch QD, [MEDICATION NAME] 15 mg tablet po Q hs, [MEDICATION NAME] Hcl 5 mg tablet po TID, 4/2/14 Trazadone 50 mg tablet po Q HS; 4/15/14 changed 4/2/14 [MEDICATION NAME] 50 mg po Q HS; 4/15/14 [MEDICATION NAME] 0.25 mg tablet po Q 8 hrs prn anxiety; 4/17/14 Elopement (census) checks nursing Q 1 hour checks; 4/30/14 another resident said resident stepped on her toes, so the other resident hit resident on the left side of her head, no bruising, redness noted, skin intact, VS within normal limits, neuro checks remain in progress; 5/4/14 resident was in day room when she started putting her hands in another residents face, touching him, he became agitated and pushed her down, resident redirected and placed on one to one for a short period of time; 5/16/14 changed 4/2/14 [MEDICATION NAME] 0.25 mg tablet po QD at 12N; 5/16/14 resident was hit by another resident while she tried to push him in his wheelchair, 5/16/14 monitor resident closely; psych NP did med review and increased [MEDICATION NAME] due to resident continously pulling on residents trying to help them; 5/25/14 resident ambulated in the hall and another resident hit her in the back for no apparent reason, no injuries noted; 5/24/14 resident tried to help another resident and he became mad and scratched her multiple times to the right side of her face, neck and under her left eye, resident was removed from the room; 5/26/14 D/C [MEDICATION NAME] 75 mg po QD, 5/26/14 [MEDICATION NAME] 50 mg po QD for sadness; 5/27/14 had altercation with another resident, she was in his room and attempted to help him while he was in bed, and resident scratched her over the left side of her face, resident removed from the room and treatment started, counseled both residents, psych NP did med review; 5/27/14 hit in right eye and scratched on right side of face by another resident, both residents counseled, resident placed seated by ward clerk until aggitation resolved, behavior meeting with other resident, psych NP did med review with no changes; 5/29/14 PEC'd to Red River Behavioral Hospital in Bossier City for treatmetn and evaluation for behavior; 6/20/14 readmit to facility, increase Trazadone to 100 mg po Q HS, Ziprasidone HCL 20 mg 1 po BID with food, DC [MEDICATION NAME], DC [MEDICATION NAME], DC [MEDICATION NAME]; 6/21/14 redirect resident away from other residents when see her touching residents; 6/21/14 hit in face by another resident, no injuries noted, residents seperated, couseled and assessed; 6/22/14 resident out on pavillion when another female resident hit her on top of the head for no apparent reason, neuro checks within normal limits at present, small superficial scratch between her eyes; 6/23/14 psych NP did med review with no changes on both residents and the aggressor removed form the area; 7/2/14 [MEDICATION NAME] 0.5 mg give 1 tablet po bid; 7/5/14 pushed down by another resident, caused her to hit the back of her head, no lumps, bumps, bruises, neurochecks initiated, resident removed form the area; 7/5/14 while in dining room the resident touched another resident and the other resident began hitting resident and pulled her hair, lump to backside of head, non-tender, resident removed from area, neurochecks started; 7/16/14 resident was found lying in a male resident's bed naked, co of pain to right side of chest area, resident placed on one to one staff supervision; 7/16/14 [MEDICATION NAME] 0.5 mg tablet po bid [DIAGNOSES REDACTED]. 7/22/14 [MEDICATION NAME] 0.5 mg po bid; 7/24/14 hold [MEDICATION NAME] until available. Review of resident #1's nurses' notes reflected the resident either wandered in and out of resident rooms, had to be re-directed often, touched other residents or attempted to give other residents assistance on the following dates and times: 4/15/15 at 10:46 a.m., 4/15/14 at 5:31 p.m., 4/16/14 at 2:06 p.m., 4/16/14 at 7:19 p.m., 4/20/14 at 8:00 p.m., 4/22/14 at 8:54 p.m., 4/23/14 at 4:39 p.m. 4/27/14 at 1:25 a.m., 4/27/14 at 8:21 a.m., 4/28/14 at 8:31 a.m., 4/30/14 at 10:26 a.m., 5/4/14 at 4:37 p.m., 5/5/14 at 10:10 a.m., 5/5/14 at 8:57 p.m., 5/7/14 at 10:15 a.m., 5/8/14 at 10:19 a.m., 5/9/14 at 5:31 a.m., 5/12/14 at 10:21 a.m., 5/14/14 at 2:46 p.m., 5/15/14 at 10:11 a.m., 5/17/14 4:42 a.m., 5/18/14 at 1:07 a.m., 5/20/14 at 3:50 a.m., 5/22/14 at 4:31 a.m., 5/23/14 at 2:46 a.m., 5/24/14 at 12:09 p.m., 5/25/14 at 9:37 p.m., 5/27/14 at 5:51 a.m., 5/27/14 at 9:08 p.m., 5/28/14 at 3:20 a.m., 6/21/14 at 10:28 a.m., 6/22/14 at 10:14 a.m., 6/28/14 at 6:30 p.m., 7/5/14 at 2:26 a.m., 7/7/14 at 10:29 a.m., 7/8/14 at 10:36 a.m., 7/10/14 at 10:45 a.m., and 7/15/14 at 1:31 p.m. Review of the Log of Incidents for the resident prepared by the S2DON and the POC reflected the resident was involved in an incident with other resident on the following dates and times: 4/30/14 at 1:31 p.m. resident was punched by #R1's fist to the left side of the resident's head. Documentation reflected the resident complained of the left side of her head hurting, and #R1 reported the resident had stepped on her foot. 5/4/14 at 10:36 p.m. reflected the resident was in the day room and had touched #R2 in the face until he became aggitated and pushed her to the floor. The care plan reflected the resident was re-directed and placed on 1:1 for a short period of time. 5/16/14 at 3:15 p.m. reflected the resident was attempting to push #R3's wheelchair when #R3 became agitated and hit the resident on the right side of her neck and scratched the resident. S17 RN Treatment Nurse documented on the Wound Assessment Report that resident #1 sustained an abrasion to the right temple 4.0 cms in length and 0.5 cms in width. The note reflected there were multiple abrasions to the right temple area, and a scratch to the front of the resident's neck 0.5 cm by 0.5 cm. The resident was to be closely monitored, psych NP did med review, and [MEDICATION NAME] due to continously pulling on residents trying to help. 5/24/14 at 9:50 a.m. reflected documentation on the "72 Hour Follow-Up" assessment that the resident had tried to assist #R3, who became angry and scratched the resident on the face with skin tear injury noted. The resident was removed from the room. 5/25/14 at 8:46 a.m. reflected resident to resident contact in the dayroom with #R4. The care plan reflected on 5/25/14 resident was ambulating in the hall when another resident hit her in the back for no apparent reason, no injuries noted. 5/26/14 at 11:16 a.m. reflected documentation of injuries per S17 RN Treatment Nurse. The resident had 3 new scratches to her face, however there were 4 scratches documented, 1 on the right side of her nose, 1 on the bridge by right cheek, 1 on the right cheek and 1 scratch on right side of neck. The 5/26/14 "Wound Assessment Report" documented by S18 RN Treatment Nurse reflected the assessment of injuries was: 1) a scratch that measured 5.0 cms by 0.5 cms to the front and right side of the resident's neck; 2) a scratch that measured 1 cm by 0.2 cm to right cheek; 3) a scratch that measured 1 cm by 0.2 cm located on the right cheek distal to wound #2; 4) and a scratch that measured 0.8 cm by 0.3 cm located on the right cheek, just right of the resident's nose. The care plan reflected on 5/26/14 D/C [MEDICATION NAME] 75 mg po QD; 5/26/14 [MEDICATION NAME] 50 mg po QD for sadness. 5/27/14 at 10:15 a.m. reflected the nurse was informed by the ward clerk that she had witnessed the resident punched in the right eye and scratched on the right side of the face by #R3 "again" and had multiple scratches and a swollen right lower eyelid. The care plan dated 5/27/14 reflected both residents counseled, resident #1 placed seated by the ward clerk until agitation resolved, behavior meeting with other resident, psych NP did med review with no changes. 5/27/14 at 7:00 p.m. reflected the resident was in #R5's room and attempted to help #R5 while he was in bed. #R5 scratched the resident over the left side of her face. Staff removed the resident from the room and counseled both residents. The care plan reflected on 5/27/14 altercation with another resident, she was in his room "attempting to help" him while he was in bed and resident scratched her over the left side of her face. Resident removed from the room and treatment started, counseled both residents, psych NP did med review. 5/29/14 the clinical record reflected resident #1 was PEC'd to a Behavioral Hospital for treatment and evaluation for behavior. Further review of the resident's clinical record reflected the resident was readmitted to the facility on [DATE]. Orders included Trazadone to 100 mg po Q HS, Ziprasidone HCL 20 mg 1 po BID with food, and DC [MEDICATION NAME]. 6/21/14 at 12:21 p.m. the nurses' note reflected a CNA witnessed the resident get hit in the face by #R6 on side 2 dayroom. The care plan dated 6/21/14 reflected to re-direct the resident away from other residents when you see her touching residents. 6/22/14 at 6:55 p.m. reflected #R11 brought the resident to the nurse and reported to the nurse the resident was outside at the pavilion when she was hit in the head by #R7 for no apparent reason. A superficial scratch was noted between her eyes. The care plan reflected neuro checks within normal limits at present, small superficial scratch between her eyes. 6/23/14 at 10:00 a.m. reflected a CNA reported to the nurse that #R3 had slapped the resident, knocked her glasses off of her face, and resident complained of pain, face red, small skin tear noted on the right cheek. The care plan dated 6/23/14 reflected psych NP did med review with no changes on both residents, and the aggressor removed from the area. 7/1/14 at 5:46 a.m. reflected documentation the resident had been resting quietly in her bed all night with no distress and no wandering noted; however, on walking rounds the resident was found disrobed from the waist down in #R10's bed who was also disrobed from the waist down. Resident #1 re-directed, and S1 Administrator notified. The care plan dated 7/2/14 reflected [MEDICATION NAME] 0.5 mg give 1 tablet po bid. 7/5/14 at 1:03 p.m. reflected #R8 from side 2 pushed the resident down to the floor and caused her to hit her head. No injury noted. Neuro checks initiated. The care plan dated 7/5/14 reflected the resident was removed from the area. 7/5/14 at 7:22 p.m. reflected while the resident was in the dining hall seated at a table, the resident touched #R9 on the arm and #R9 started hitting the resident in the head, and pulled out a large clump of the resident's hair. The residents were separated and counseled, and resident #1 was assessed to have a lump on the back of her head on the left side. The care plan dated 7/5/14 reflected neurochecks started. 7/16/14 at 5:30 p.m. reflected the resident was brought into the dining room by a CNA, and the CNA and S14 CNA Supervisor informed the nurse that the resident was in resident #2 and #3's room (male residents) naked, and that the resident complained of pain to the right side of chest. The note reflected the S2 DON and MD were notified with new orders for CXR obtained. The care plan dated 7/16/14 reflected the resident was found lying in a male resident's bed naked, and complained of pain to right side of chest area. Resident #1 was placed on 1:1 supervision; 7/16/14 [MEDICATION NAME] 0.5 mg tablet po bid [DIAGNOSES REDACTED]. Review of the Departmental Notes dated 7/17/14 at 12:10 p.m. reflected documentation by S1 Administrator. S1 Administrator documented he returned to the facility on [DATE] around 8:00 p.m. after notification and that residents #2 and #3 each claimed the other roommate had sex with resident #1. The S1 Administrator notified the local sheriff's department of the incident. Documentation reflected the resident was placed on 1 to 1 supervision for her protection. Interview on 7/30/14 at 9:45 a.m. with S1 Administrator revealed the resident was found unclothed (except for her shirt) in another resident's room with 2 male residents (#2 and #3), around 5:00 p.m. on 7/16/14 by staff when a CNA entered the room to deliver a supper tray. Interview of S1 Administrator revealed the staff member found the resident polishing the furniture in resident #2 and #3's room (with her pants). S1 Administrator stated resident #2 and #3 were in the room at the time and were fully dressed. S2 Administrator stated resident #1 was not a cognitive resident and was not able to tell them what happened, and resident #2 and #3 had a Psychiatric [DIAGNOSES REDACTED]. Interview on 7/30/14 at 9:45 a.m. with S1 Administrator revealed the facility had conducted 3 investigations related to abuse for the month of July, 2014. Interview with S1 revealed the facility had 1 investigation for resident #1 for the month of July, 2014, and stated it was dated 7/16/14. Further interview of S1 Administrator at the above time revealed he was notified of the incident on 7/16/14, and came to the facility to begin the investigation that evening. S1 Administrator stated he interviewed the 2 male residents (#2 and #3) were found in the room and their initial statements reflected they had sex with the resident, and then later told police they were not able to physically have sex with the resident. S1 Administrator stated the Sheriff's Deputy was notified and came to the facility to conduct an investigation the evening of the occurrence on 7/16/14, and determined that a crime had not taken place. S1 Administrator stated he reviewed the facility surveillance tape for the hallway with the Sheriff's Deputy and observed the resident walk into resident #2 and #3's room at 4:46 p.m. on her own initiative. Further interview with S1 Administrator revealed they were able to identify the following timelines for the incident that occurred on 7/16/14: 4:37 p.m. resident #3 entered room, 4:43 p.m. resident #2 entered room, 4:46 p.m. resident #1 entered room; 5:03 p.m. resident #3 left room; 5:17 p.m. resident #3 re-entered the room; 5:18 p.m. the CNA entered the room; and 5:19 resident #1 was brought out of the room by the CNA. Further interview at the above time with S1 Administrator revealed they had tried to keep a close eye on the resident because she had behaviors, and wanted to help others. The staff would walk with her, redirect her and tried to involve her in other activities. S1 Administrator stated that prior to the incident on 7/16/14 they had started trying to find the resident another home because she did not fit in at the facility. S1 Administrator stated the resident was placed on 1 on 1 supervision the evening of 7/16/14 (and remained on one on one until she was transferred to another facility). The S1 Administrator stated that all staff were inserviced the following day. S1 Administrator stated that they could tell on camera that several staff were in the hallway during the incident. Interview on 7/30/14 at 11:00 a.m. with S1 Administrator revealed the facility had done a QA related to resident #1 after the incident of 7/16/14, and as a result had conducted an inservice related to abuse and neglect. However, further interview with S1 Adminstrator revealed the facility did not have any additional documentation of monitoring related to the QA for resident #1. Additionally, the comprehensive plan of care did not reflect individualized effective approaches to address the resident's specific problematic behaviors. Interview on 7/30/14 at 2:15 p.m. with S22 LPN revealed she had worked the evening shift of 7/16/14 on the 500 Hall and had been notified of the above incident. S22 LPN stated she was not aware resident #1 was on the 500 Hall on the evening of 7/16/14, and further stated staff tried to keep an eye on her, but you can't keep up with them all the time. Interview on 7/30/14 at 2:30 p.m. with S23 LPN revealed she routinely worked the day shift with resident #1 and confirmed the resident was confused, could not understand, walked all over the facility, would not stay in 1 place, was in and out of other resident's rooms, and bothered other resident's belongings. S23 LPN stated the other residents could not understand the resident's behavior. Further interview of S23 LPN revealed the resident was a nurse once and wanted to be helpful. S23 LPN confirmed the resident had fallen on 7/15/14 onto her right side and had bruises on her right side after the fall. Telephone interview on 7/30/14 at 2:48 p.m. with S21 CNA revealed she had worked on the 100 Hall with resident #1 on the 2-10 p.m. shift on 7/16/14. S21 CNA stated the resident was hard to keep an eye on because she did not sit still, would go from room to room, was fidgety, and it was hard to keep an eye on 1 person when there was something else that needed to be done. S21 CNA stated the staff could not keep up with her. Further interview of S21 CNA revealed she was getting residents up to go to the dining room for supper on the 100 Hall on 7/16/14, and had last seen the resident between 4:00 and 4:30 p.m. between the 100 Hall and Day Room. Further interview of S21 CNA revealed she noticed the resident held her hand between her legs that evening after the incident and stated the behavior was unusual for the resident. Interview on 7/30/14 at 2:55 p.m. with S14 CNA Supervisor revealed she had been informed on 7/16/14, that resident #1 had been found in another resident's room with no clothes on. S14 CNA Supervisor stated she was on duty the evening of 7/16/14, had observed the resident, did not see any signs of injury, but noticed the resident held her hand between her legs after the incident, and had not observed that behavior from this resident in the past. Interview on 7/30/14 at 3:08 p.m. with S20 LPN confirmed he had worked the 2-10 p.m. shift on 7/16/14, and had been notified by the Hall Monitor that resident#1 had been found nude in a man's room. S20 LPN stated he notified the S2 DON and S1 Administrator. S20 LPN stated he checked / assessed her in her room that evening, and noted some bruising to her right side and right arm that he had not noticed earlier, and noted the resident complained of pain on the right side of her rib cage. S20 LPN stated the resident had recently fallen onto her right side. S20 LPN stated that he notified the S3 ADON (who was still present at the facility), notified the resident's MD, and received an order for [REDACTED]. S20 LPN stated the resident had behaviors and that she would go up to other residents and try to help them and had been scratched by other residents. S20 LPN stated the resident had wandered into someone else's bed to go to sleep, a couple of times and staff had found her and notified them to get her. Interview on 7/30/14 at approximately 3:15 p.m. with S3 ADON confirmed they (S1 Administrator, S2 DON and S3 ADON) had a meeting with the family on 5/26/14 to review the resident's care and risk of injury at the facility, and the fact the resident had already been involved in several resident to resident altercations. Further interview of S3 ADON confirmed they had discussed the inability of the facility to provide one on one staff supervision with the RP (son), and the plan to attempt to find placement for the resident at another facility. Interview on 7/30/14 at 3:30 p.m. with S19 CNA confirmed she had worked the 2-10 p.m. shift on 7/16/14 and had found the resident in resident #2 and #3's room when she went into the room with supper trays. S19 CNA stated she was assigned as Hall Monitor for the supper meal and as Hall Monitor was assigned to pass the hall trays and answer the call lights for all halls during the supper meal service. S19 CNA stated that resident #2 and #3 preferred to eat in their room. She stated that when she went to deliver their meal trays the door to the room was closed, and when she opened it she found resident #1 in their room on the side of the room of resident #2, undressed form the waist down, wiping down the dresser. S19 CNA stated she re-directed the resident to the Women's Bathroom and dressed her, did not see any signs of injury, and stated the resident did not complain or appear to be in pain. S19 CNA stated she brought the resident to the Dining Room and reported the incident to S14 CNA Supervisor and to S20 LPN. Interview on 7/31/14 at 10:45 a.m. with S3 ADON revealed she had assessed resident #1 (in the resident's bed) after the incident on 7/16/14, and stated the resident looked like she was in pain; however, she did not see any evidence of new injuries. Further interview of S3 ADON revealed the S1 Administrator was notified and came to the facility to begin the investigation and the resident was placed on one to one monitoring at that time. Interview on 7/31/14 at 10:45 a.m. with S3 ADON confirmed the resident had been identified with behaviors that put her at risk for injury, and had been involved in multiple resident to resident altercations. The S3 ADON reviewed the approaches that were care planned for the resident and confirmed the interventions that were used were documented in the care plan and the nurses' notes, and included q 1 hour monitoring, short periods of one on one staff supervision, transfer to a Behavioral Hospital, medication review by MD and Psych NP, medication changes, close observation, counseling, re-direction and behavioral meetings. Further interview with S3 ADON revealed the S3 ADON stated "she could not be watched all the time".

Based on interview and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (#1). The facility's administration failed to: 1. prevent resident #1 from being either being hit in the face or head, shoved, pushed down and scratched by either #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9. 2. intervene and protect resident #1 whose behaviors and medical condition put her at increased risk for physical alterations; 3. provide adequate supervision to prevent resident #1 from being either hit in the face or head, shoved, pushed down and scratched by either #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8 and #R9; 4. put measures in place to adequately supervise and prevent resident #1 from provoking other residents as a result of her behaviors of wandering, agitation, restlessness and tendency to "nurse" other residents (resident #1 was a retired Registered Nurse). The survey sample size was 6 (#1, #2, #3, #4, #5, and #6), and the total census was 133. Resident #1 nurses' notes reflected the resident was at risk of altercations with other residents due to either she wandered in and out of resident rooms, touched other residents or attempted to give other residents assistance. The resident was at risk of physical altercations from other residents 11 times from April 15, 2014 through April 30, 2014; 19 times from May 4, 2014 through May 28, 2014; 3 times from June 21, 2014 through June 28, 2014; and 5 times July 5, through July 15, 2014. There was documentation of Resident #1 behavior resulting in a physical altercation from other residents on 4/30/14, 5/4/14, 5/16/14, 5/24/14, 5/25/14, 5/27/14 twice, 6/21/14, 6/22/14, 6/23/14, 7/5/14 twice, and 7/16/14. An Immediate Jeopardy situation began on 4/30/14 when resident #1 was hit on the left side of her head by another resident, and ended on 5/29/14 when resident #1 was transferred to an inpatient behavioral health center. The Immediate Jeopardy began again on 6/20/14 when resident #1 was readmitted to the nursing facility, and ended when resident #1 was placed on one to one supervision on 7/16/14. The Administrator was notified of the Immediate Jeopardy on 7/31/14 at 5:05 p.m. The Immediate Jeopardy was removed as of 7/16/14 when the facility placed resident #1 on one on one staff supervision. According to the Resident Census and Condition Report dated 7/30/14, 126 of the facility's 133 residents were diagnosed with [REDACTED]. Findings: 1. Cross reference findings at tag F226 2. Cross reference findings at tag F279 3. Cross reference findings at tag F309 4. Cross reference findings at tag F323 Interview on 7/30/14 at 9:45 a.m. with S1 Administrator revealed the facility had conducted 3 investigations related to abuse for the month of July, 2014. Interview with S1 revealed the facility had 1 investigation for resident #1 for the month of July, 2014, and stated it was dated 7/16/14. Review of the nurses' notes reflected S3 ADON documented: 4/30/14 at 2:23 p.m. - the resident had improvement in mobility and ambulated around the building with poor safety awareness, was verbal but very confused and "had constant talk with little relevance to reality", resident liked to pray and baptize people, constantly wandered around facility, in and out of resident rooms, had walked up to a resident, touched his face and the other resident was upset by being touched and hit the resident in the face during the "lookback period", and the resident often picked up things that did not belong to her which upset the other residents because their things went missing; 5/7/14 at 3:57 p.m. - the resident ambulated with an increased steady gait, wandered all over the facility, went into other resident rooms, liked to pray for people and would go up to people and put her hands on them to pray, and "can cause problems because other residents do not like to be touched", resident undressed herself in public, resident was hard to re-direct, and continued to have poor safety awareness; 5/26/14 at 1:37 p.m. - the S1 Administrator, S2 DON and S3 ADON had conducted a meeting with the resident's RP (son) and his wife to discuss concerns related to the resident's safety at the facility. The documentation reflected S3 ADON explained to the family the resident was touching things all over the facility and had tried to clean and help the residents, but "was unaware of the situation", and was unable to comprehend when other residents wanted to be left alone. The documentation reflected the resident continually touched and talked to other residents, and the other residents would get angry because she was in their personal space (many were Paranoid [MEDICAL CONDITION]), and they would try to hurt her, they were threatened by her touching them and would strike out to get her to stop. Further review reflected the family was informed the resident had continued to bother a resident by touching him and he had hit her twice. S1 Administrator and S2 DON discussed with the RP that the resident could get seriously injured if she had a conflict with one of their younger strong patients and they were concerned due to her age and fragility that she may become seriously injured. The documentation reflected S2 DON explained to the family they could not provide one on one care for the resident to keep her safe, and S3 ADON asked the family if they were able to find an Alzheimer's Unit for the resident, would family be willing to place her in a Alzheimer's Unit where the other residents would have similar illness and likely to be older (less combative) than some of their residents. Further review of the documentation reflected the family agreed to allow placement for resident #1 in Alzheimer/Dementia Unit if available, and S3 ADON documented she would contact the family with information as she looked for placement Review of the nurses' notes reflected: 5/22/14 at 4:31 a.m. - the resident was restless and had been up and down wandering in the hallway, re-directed by staff several times, CNA at bedside to provide close supervision because the resident goes in and out other resident rooms and gets into bed with them and tries to awaken them, and resident was confused and unaware of actions. Interview on 7/30/14 at approximately 3:15 p.m. with S3 ADON confirmed they (S1 Administrator, S2 DON and S3 ADON) had a meeting with the family on 5/26/14 to review the resident's care and risk of injury at the facility, and the fact the resident had already been involved in several resident to resident altercations. Further interview of S3 ADON confirmed they had informed the family the facility was not able to provide one on one staff supervision for the resident, and questioned the family about attempting to find placement for the resident at another facility. Interview on 7/31/14 at 10:45 a.m. with S3 ADON confirmed the resident had been identified with behaviors that put her at risk for injury, and had been involved in multiple resident to resident altercations. The S3 ADON reviewed the approaches that were care planned for the resident and confirmed the interventions that were used were documented in the care plan and the nurses' notes, and included q 1 hour monitoring, short periods of one on one staff supervision, transfer to a Behavioral Hospital, medication review by MD and Psych NP, medication changes, close observation, counseling, re-direction and behavioral meetings. Further interview with S3 ADON revealed the S3 ADON stated "she could not be watched all the time". Interview on 7/30/14 at 9:45 a.m. of S1 Administrator revealed he was notified by phone (on 7/16/14) that resident #1 was found unclothed except for shirt in a male resident's room when the CNA took the meal tray into the room. S1 Administrator stated he came to the facility to investigate the report, and interviewed the 2 male residents (#2 and #3) that were in the room with the resident. He stated resident #2 and #3 initially stated they had sex with the resident, and then later told the police they were not able to physically have sex with the resident. S1 Administrator stated the Sheriff's Deputy was notified and came to the facility to conduct an investigation the evening of 7/16/14, and determined that a crime had not taken place. S1 Administrator stated he reviewed the facility surveillance tape for the hallway with the Sheriff's Deputy and observed the resident walk into resident #2 and #3's room at 4:46 p.m. on her own initiative. S1 Administrator revealed they had tried to keep a close eye on the resident because she had behaviors, that included wanting to help others, and that staff would walk with her, redirect her and tried to involve her in other activities. S1 Administrator stated that prior to the incident on 7/16/14 they had talked to the family about the resident, and had started trying to find the resident another home because she did not fit in at the facility. S1 Administrator stated the resident was placed on one on one supervision the evening of 7/16/14 (and remained on one on one until she was transferred to another facility). The S1 Administrator stated that all staff were inserviced the following day. S1 Administrator stated they could tell on camera that several staff were in the hallway during the incident. Interview on 7/30/14 at 11:00 a.m. with S1 Administrator revealed the facility had done a QA related to resident #1 after the incident of 7/16/14, and as a result had conducted an inservice related to abuse and neglect. However, further interview with S1 Adminstrator revealed the facility did not have any additional documentation of monitoring related to the QA for resident #1. Additionally, the comprehensive plan of care did not reflect individualized effective approaches to address the resident's specific problematic behaviors.

Based on interview and record review the facility failed to ensure a resident received adequate supervision consistent with the resident's needs, to prevent a resident who was diagnosed with [REDACTED].#1). The facility failed to: 1. provide adequate supervision to prevent resident #1 from being either hit in the face or head, shoved, pushed down and scratched by either #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9; 2. intervene and protect resident #1 whose behaviors and medical condition put her at increased risk for physical altercations; 3. put measures in place to adequately supervise and prevent resident #1 from provoking other residents as a result of her behaviors of wandering, agitation, restlessness and tendency to "nurse" and "minister" to other residents. Resident #1 nurses' notes reflected the resident was at risk of altercations with other residents due to either she wandered in and out of resident rooms, touched other residents or attempted to give other residents assistance. The resident was at risk of physical altercations from other residents 11 times from April 15, 2014 through April 30, 2014; 19 times from May 4, 2014 through May 28, 2014; 3 times from June 21, 2014 through June 28, 2014; and 5 times July 5, through July 15, 2014. There was documentation of Resident #1 behavior resulting in a physical altercation from other residents on 4/30/14, 5/4/14, 5/16/14, 5/24/14, 5/25/14, 5/27/14 twice, 6/21/14, 6/22/14, 6/23/14, 7/5/14 twice, and 7/16/14. An Immediate Jeopardy situation began on 4/30/14 when resident #1 was hit on the left side of her head by another resident, and ended on 5/29/14 when resident #1 was transferred to an inpatient behavioral health center. The Immediate Jeopardy began again on 6/20/14 when resident #1 was readmitted to the nursing facility, and ended when resident #1 was placed on one to one supervision on 7/16/14. The Administrator was notified of the Immediate Jeopardy on 7/31/14 at 5:05 p.m. The Immediate Jeopardy was removed as of 7/16/14 when the facility placed resident #1 on one on one staff supervision. The survey sample size was 6 (#1, #2, #3, #4, #5, and #6). According to the Resident Census and Condition Report dated 7/30/14, 126 of the facility's 133 residents were diagnosed with [REDACTED]. Findings: Review of resident #1's clinical record reflected she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS (ARD date of 4/9/14) reflected the resident had a Cognitive BIMS Score of 2 and had episodes of rejecting care. The Admission MDS reflected Active [DIAGNOSES REDACTED]. Further review reflected the resident was mobile with the assistive device of a wheelchair and walker on the Admission MDS. Review of the Quarterly MDS Assessment (ARD date 7/2/14) reflected the resident was discharged to a psychialtric hospital on [DATE] and readmitted to the facility on [DATE] from the Psychiatric Hospital. The Quarterly MDS Assessment reflected the resident's Cognitive BIMS Score was 1, with behaviors of inattention and disorganized thinking. The staff assessment of mood reflected the resident had trouble falling asleep, staying asleep or sleeping too much; poor appetite or eating to much; trouble concentrating on things such as reading the newspaper or watching TV; moving so slowly that other people noticed, or being fidgety or restless, and other behavioral symptoms of rummaging, disrobing in public, and pacing. Review of the facility's Initial Social Service assessment dated [DATE] reflected the resident had signs of delirium with the behaviors of inattention, disorganized thinking, and psychomotor retardation that were continously present. Review of the facility's Social Service assessment dated [DATE] and documented by the S3 ADON, reflected the resident had signs of delirium with behaviors of inattention, diorganized thinking and altered level of consciousness that was continously present. Further review reflected the resident had a memory problem, moderately impaired cognitive skills for daily decision making, made poor decisions, and cues/supervision were required. S3 ADON documented the resident believed she still worked as a nurse, had ideas about what she should be doing, but got distracted easily and had "no safety awareness". Review of the Social Service assessment dated [DATE] and documented by the S3 ADON reflected the resident had delusions, thought she was a minister, and had gone around praying and baptizing the other residents. Review of the Behavioral Hospital Psychiatric Evaluation dated 5/30/14 reflected the resident had psychomotor agitation, was constantly wandering, had impaired attention and concentration and non-sensical thought process, had severe poverty of thought content, impaired recent and remote memory, and gravely impaired insight and judgement. Further review of the evaluation reflected the treatment plan included crisis intervention, evaluation, new medication, provide a safe and structured enviorment, and prevention of injury to others. Review of the "Elopement Risk Assessment" dated 7/2/14 reflected the resident wandered aimlessly, wandered around the facility daily, and was ambulatory without difficulty. The assessment reflected the resident was at risk for elopement. The above risk assessment reflected staff interventions of frequent monitoring (q 1 hour), utilization of a check in / check out log, key pad egress doors for entry and exit. The summary/conclusion recommendation was placed on q hour 1 census for elopement due to wandering, and reflected the resident had not attempted to elope. Review of resident #1's nurses' notes reflected the resident either wandered in and out of resident rooms, had to be re-directed often, touched other residents or attempted to give other residents assistance on the following dates and times: 4/15/15 at 10:46 a.m., 4/15/14 at 5:31 p.m., 4/16/14 at 2:06 p.m., 4/16/14 at 7:19 p.m., 4/20/14 at 8:00 p.m., 4/22/14 at 8:54 p.m., 4/23/14 at 4:39 p.m. 4/27/14 at 1:25 a.m., 4/27/14 at 8:21 a.m., 4/28/14 at 8:31 a.m., 4/30/14 at 10:26 a.m., 5/4/14 at 4:37 p.m., 5/5/14 at 10:10 a.m., 5/5/14 at 8:57 p.m., 5/7/14 at 10:15 a.m., 5/8/14 at 10:19 a.m., 5/9/14 at 5:31 a.m., 5/12/14 at 10:21 a.m., 5/14/14 at 2:46 p.m., 5/15/14 at 10:11 a.m., 5/17/14 4:42 a.m., 5/18/14 at 1:07 a.m., 5/20/14 at 3:50 a.m., 5/22/14 at 4:31 a.m., 5/23/14 at 2:46 a.m., 5/24/14 at 12:09 p.m., 5/25/14 at 9:37 p.m., 5/27/14 at 5:51 a.m., 5/27/14 at 9:08 p.m., 5/28/14 at 3:20 a.m., 6/21/14 at 10:28 a.m., 6/22/14 at 10:14 a.m., 6/28/14 at 6:30 p.m., 7/5/14 at 2:26 a.m., 7/7/14 at 10:29 a.m., 7/8/14 at 10:36 a.m., 7/10/14 at 10:45 a.m., and 7/15/14 at 1:31 p.m. . Further review of the nurse's note reflected the following: 4/22/14 at 9:31 a.m. reflected the resident was a retired nurse who thought she was still working and was there to supervise the nurse as she did treatments. 4/30/14 at 2:23 p.m. reflected the resident had improvement in mobility and ambulated around the building with poor safety awareness; was verbal but very confused and "had constant talk with little relevance to reality"; resident liked to pray and baptize people; constantly wandered around facility, in and out of resident rooms; had walked up to a resident, touched his face and the other resident was upset by being touched and hit the resident in the face during the "lookback period"; and the resident often picked up things that did not belong to her which upset the other residents because their things went missing. 5/7/14 at 3:57 p.m. reflected the resident was ambulating with an increased steady gait; wandered all over the facility; went into other resident rooms; liked to pray for people and would go up to people and put her hands on them to pray and "can cause problems because other residents do not like to be touched"; resident undressed herself in public; resident was hard to re-direct; and continued to have poor safety awareness. 5/22/14 at 4:31 a.m. reflected the resident had been restless; up and down wandering in hallway; re-directed by staff several times; CNA at bedside to provide close supervision because resident goes in and out other resident rooms and gets into bed with them and tries to awaken them; and resident was confused and unaware of actions. 5/26/14 at 1:37 p.m. reflected the S1 Administrator, S2 DON and S3 ADON had a meeting with the resident's RP (son) and his wife to discuss concerns related to the resident's safety at the facility. The documentation reflected S3 ADON explained to the family the resident was touching things all over the facility and had tried to clean and help the residents, but was unaware of the situation, and was unable to comprehend when other residents wanted to be left alone. The documentation reflected the resident continually touched and talked to other residents, and the other residents would get angry because she was in their personal space (many were Paranoid Schizophrenics), and they would try to hurt her; they were threatened by her touching them and would strike out to get her to stop. Further review reflected the family was informed the resident had continued to bother a resident by touching him and he had hit her twice. S1 Administrator and S2 DON discussed with the RP that the resident could get seriously injured if she had a conflict with one of their younger strong patients and they were concerned due to her age and fragility that she may become seriously injured. The documentation reflected S2 DON explained to the family they could not provide one on one care for the resident to keep her safe, and S3 ADON asked the family if they were able to find an Alzheimer's Unit for the resident, would family be willing to place her in a Alzheimer's Unit where the other residents would have similar illness and likely to be older (less combative) than some of their residents. Further review of the documentation reflected the family agreed to allow placement for resident #1 in Alzheimer/Dementia Unit if available, and S3 ADON documented she would contact the family with information as she looked for placement. 7/5/14 2:26 a.m. reflected the resident was up and wandering up and down the hallway; in and out of other resident's rooms; re-directed per staff constantly; due to confusion and disorientation resident unable to understand what she is doing or to follow the directions the staff provided; resident fidgeting with anything she touches; speech random; resident believes she is helping; it often agitates other residents and causes her to be at risk of adverse reactions from other residents. 7/10/14 at 10:45 a.m. reflected the resident continued to wander in and out of others' rooms, touching others in the face and feet; re-directed often with no effect and seated with unit secretary to keep occupied. Review of the Log of Incidents for the resident prepared by the S2DON and the POC reflected the resident was involved in an incident with other resident on the following dates and times: 4/30/14 at 1:31 p.m. resident was punched by #R1's fist to the left side of the resident's head. Documentation reflected the resident complained of the left side of her head hurting, and #R1 reported the resident had stepped on her foot. 5/4/14 at 10:36 p.m. reflected the resident was in the day room and had touched #R2 in the face until he became aggitated and pushed her to the floor. The care plan reflected the resident was re-directed and placed on 1:1 for a short period of time. 5/16/14 at 3:15 p.m. reflected the resident was attempting to push #R3's wheelchair when #R3 became agitated and hit the resident on the right side of her neck and scratched the resident. S17 RN Treatment Nurse documented on the Wound Assessment Report that resident #1 sustained an abrasion to the right temple 4.0 cms in length and 0.5 cms in width. The note reflected there were multiple abrasions to the right temple area, and a scratch to the front of the resident's neck 0.5 cm by 0.5 cm. The resident was to be closely monitored, psych NP did med review, and Xanax due to continously pulling on residents trying to help. 5/24/14 at 9:50 a.m. reflected documentation on the "72 Hour Follow-Up" assessment that the resident had tried to assist #R3, who became angry and scratched the resident on the face with skin tear injury noted. The resident was removed from the room. 5/25/14 at 8:46 a.m. reflected resident to resident contact in the dayroom with #R4. The care plan reflected on 5/25/14 resident was ambulating in the hall when another resident hit her in the back for no apparent reason, no injuries noted. 5/26/14 at 11:16 a.m. reflected documentation of injuries per S17 RN Treatment Nurse. The resident had 3 new scratches to her face, however there were 4 scratches documented, 1 on the right side of her nose, 1 on the bridge by right cheek, 1 on the right cheek and 1 scratch on right side of neck. The 5/26/14 "Wound Assessment Report" documented by S18 RN Treatment Nurse reflected the assessment of injuries was: 1) a scratch that measured 5.0 cms by 0.5 cms to the front and right side of the resident's neck; 2) a scratch that measured 1 cm by 0.2 cm to right cheek; 3) a scratch that measured 1 cm by 0.2 cm located on the right cheek distal to wound #2; 4) and a scratch that measured 0.8 cm by 0.3 cm located on the right cheek, just right of the resident's nose. The care plan reflected on 5/26/14 D/C Zoloft 75 mg po QD; 5/26/14 Zoloft 50 mg po QD for sadness. 5/27/14 at 10:15 a.m. reflected the nurse was informed by the ward clerk that she had witnessed the resident punched in the right eye and scratched on the right side of the face by #R3 "again" and had multiple scratches and a swollen right lower eyelid. The care plan dated 5/27/14 reflected both residents counseled, resident #1 placed seated by the ward clerk until agitation resolved, behavior meeting with other resident, psych NP did med review with no changes. 5/27/14 at 7:00 p.m. reflected the resident was in #R5's room and attempted to help #R5 while he was in bed. #R5 scratched the resident over the left side of her face. Staff removed the resident from the room and counseled both residents. The care plan reflected on 5/27/14 altercation with another resident, she was in his room "attempting to help" him while he was in bed and resident scratched her over the left side of her face. Resident removed from the room and treatment started, counseled both residents, psych NP did med review. 5/29/14 the clinical record reflected resident #1 was PEC'd to a Behavioral Hospital for treatment and evaluation for behavior. Further review of the resident's clinical record reflected the resident was readmitted to the facility on [DATE]. Orders included Trazadone to 100 mg po Q HS, Ziprasidone HCL 20 mg 1 po BID with food, and DC Remeron, Xanax, Buspirone. 6/21/14 at 12:21 p.m. the nurses' note reflected a CNA witnessed the resident get hit in the face by #R6 on side 2 dayroom. The care plan dated 6/21/14 reflected to re-direct the resident away from other residents when you see her touching residents. 6/22/14 at 6:55 p.m. reflected #R11 brought the resident to the nurse and reported to the nurse the resident was outside at the pavilion when she was hit in the head by #R7 for no apparent reason. A superficial scratch was noted between her eyes. The care plan reflected neuro checks within normal limits at present, small superficial scratch between her eyes. 6/23/14 at 10:00 a.m. reflected a CNA reported to the nurse that #R3 had slapped the resident, knocked her glasses off of her face, and resident complained of pain, face red, small skin tear noted on the right cheek. The care plan dated 6/23/14 reflected psych NP did med review with no changes on both residents, and the aggressor removed from the area. 7/1/14 at 5:46 a.m. reflected documentation the resident had been resting quietly in her bed all night with no distress and no wandering noted; however, on walking rounds the resident was found disrobed from the waist down in #R10's bed who was also disrobed from the waist down. Resident #1 re-directed, and S1 Administrator notified. The care plan dated 7/2/14 reflected Xanax 0.5 mg give 1 tablet po bid. 7/5/14 at 1:03 p.m. reflected #R8 from side 2 pushed the resident down to the floor and caused her to hit her head. No injury noted. Neuro checks initiated. The care plan dated 7/5/14 reflected the resident was removed from the area. 7/5/14 at 7:22 p.m. reflected while the resident was in the dining hall seated at a table, the resident touched #R9 on the arm and #R9 started hitting the resident in the head, and pulled out a large clump of the resident's hair. The residents were separated and counseled, and resident #1 was assessed to have a lump on the back of her head on the left side. The care plan dated 7/5/14 reflected neurochecks started. 7/16/14 at 5:30 p.m. reflected the resident was brought into the dining room by a CNA, and the CNA and S14 CNA Supervisor informed the nurse that the resident was in resident #2 and #3's room (male residents) naked, and that the resident complained of pain to the right side of chest. The note reflected the S2 DON and MD were notified with new orders for CXR obtained. The care plan dated 7/16/14 reflected the resident was found lying in a male resident's bed naked, and complained of pain to right side of chest area. Resident #1 was placed on 1:1 supervision; 7/16/14 Xanax 0.5 mg tablet po bid [DIAGNOSES REDACTED]. Review of the Departmental Notes dated 7/17/14 at 12:10 p.m. reflected documentation by S1 Administrator. S1 Administrator documented he returned to the facility on [DATE] around 8:00 p.m. after notification and that residents #2 and #3 each claimed the other roommate had sex with resident #1. The S1 Administrator notified the local sheriff's department of the incident. Documentation reflected the resident was placed on 1 to 1 supervision for her protection. Interview on 7/30/14 at 9:45 a.m. with S1 Administrator revealed the resident was found unclothed (except for her shirt) in another resident's room with 2 male residents (#2 and #3), around 5:00 p.m. on 7/16/14 by staff when a CNA entered the room to deliver a supper tray. Interview of S1 Administrator revealed the staff member found the resident polishing the furniture in resident #2 and #3's room (with her pants). S1 Administrator stated resident #2 and #3 were in the room at the time and were fully dressed. S2 Administrator stated resident #1 was not a cognitive resident and was not able to tell them what happened, and resident #2 and #3 had a Psychiatric [DIAGNOSES REDACTED]. Interview on 7/30/14 at 9:45 a.m. with S1 Administrator revealed the facility had conducted 3 investigations related to abuse for the month of July, 2014. Interview with S1 revealed the facility had 1 investigation for resident #1 for the month of July, 2014, and stated it was dated 7/16/14. Further interview of S1 Administrator at the above time revealed he was notified of the incident on 7/16/14, and came to the facility to begin the investigation that evening. S1 Administrator stated he interviewed the 2 male residents (#2 and #3) were found in the room and their initial statements reflected they had sex with the resident, and then later told police they were not able to physically have sex with the resident. S1 Administrator stated the Sheriff's Deputy was notified and came to the facility to conduct an investigation the evening of the occurrence on 7/16/14, and determined that a crime had not taken place. S1 Administrator stated he reviewed the facility surveillance tape for the hallway with the Sheriff's Deputy and observed the resident walk into resident #2 and #3's room at 4:46 p.m. on her own initiative. Further interview with S1 Administrator revealed they were able to identify the following timelines for the incident that occurred on 7/16/14: 4:37 p.m. resident #3 entered room, 4:43 p.m. resident #2 entered room, 4:46 p.m. resident #1 entered room; 5:03 p.m. resident #3 left room; 5:17 p.m. resident #3 re-entered the room; 5:18 p.m. the CNA entered the room; and 5:19 resident #1 was brought out of the room by the CNA. Further interview at the above time with S1 Administrator revealed they had tried to keep a close eye on the resident because she had behaviors, and wanted to help others. The staff would walk with her, redirect her and tried to involve her in other activities. S1 Administrator stated that prior to the incident on 7/16/14 they had started trying to find the resident another home because she did not fit in at the facility. S1 Administrator stated the resident was placed on 1 on 1 supervision the evening of 7/16/14 (and remained on 1 on 1 until she was transferred to another facility). The S1 Administrator stated that all staff were inserviced the following day. S1 Administrator stated that they could tell on camera that several staff were in the hallway during the incident. Interview on 7/30/14 at 11:00 a.m. with S1 Administrator revealed the facility had done a QA related to resident #1 after the incident of 7/16/14, and as a result had conducted an inservice related to abuse and neglect. However, further interview with S1 Adminstrator revealed the facility did not have any additional documentation of monitoring related to the QA for resident #1. Additionally, the comprehensive plan of care did not reflect individualized effective approaches to address the resident's specific problematic behaviors. Interview on 7/30/14 at 2:15 p.m. with S22 LPN revealed she had worked the evening shift of 7/16/14 on the 500 Hall and had been notified of the above incident. S22 LPN stated she was not aware resident #1 was on the 500 Hall on the evening of 7/16/14, and further stated staff tried to keep an eye on her, but you can't keep up with them all the time. Interview on 7/30/14 at 2:30 p.m. with S23 LPN revealed she routinely worked the day shift with resident #1 and confirmed the resident was confused, could not understand, walked all over the facility, would not stay in 1 place, was in and out of other resident's rooms, and bothered other resident's belongings. S23 LPN stated the other residents could not understand the resident's behavior. Further interview of S23 LPN revealed the resident was a nurse once and wanted to be helpful. S23 LPN confirmed the resident had fallen on 7/15/14 onto her right side and had bruises on her right side after the fall. Telephone interview on 7/30/14 at 2:48 p.m. with S21 CNA revealed she had worked on the 100 Hall with resident #1 on the 2-10 p.m. shift on 7/16/14. S21 CNA stated the resident was hard to keep an eye on because she did not sit still, would go from room to room, was fidgety, and it was hard to keep an eye on 1 person when there was something else that needed to be done. S21 CNA stated the staff could not keep up with her. Further interview of S21 CNA revealed she was getting residents up to go to the dining room for supper on the 100 Hall on 7/16/14, and had last seen the resident between 4:00 and 4:30 p.m. between the 100 Hall and Day Room. Further interview of S21 CNA revealed she noticed the resident held her hand between her legs that evening after the incident and stated the behavior was unusual for the resident. Interview on 7/30/14 at 2:55 p.m. with S14 CNA Supervisor revealed she had been informed on 7/16/14, that resident #1 had been found in another resident's room with no clothes on. S14 CNA Supervisor stated she was on duty the evening of 7/16/14, had observed the resident, did not see any signs of injury, but noticed the resident held her hand between her legs after the incident, and had not observed that behavior from this resident in the past. Interview on 7/30/14 at 3:08 p.m. with S20 LPN confirmed he had worked the 2-10 p.m. shift on 7/16/14, and had been notified by the Hall Monitor that resident#1 had been found nude in a man's room. S20 LPN stated he notified the S2 DON and S1 Administrator. S20 LPN stated he checked / assessed her in her room that evening, and noted some bruising to her right side and right arm that he had not noticed earlier, and noted the resident complained of pain on the right side of her rib cage. S20 LPN stated the resident had recently fallen onto her right side. S20 LPN stated that he notified the S3 ADON (who was still present at the facility), notified the resident's MD, and received an order for [REDACTED]. S20 LPN stated staff tried to keep up with her because they knew she wandered and were able to keep up with her most of the time. S20 LPN stated the resident had behaviors and that she would go up to other residents and try to help them and had been scratched by other residents. S20 LPN stated the resident had wandered into someone else's bed to go to sleep, a couple of times and staff had found her and notified them to get her. Interview on 7/30/14 at approximately 3:15 p.m. with S3 ADON confirmed they (S1 Administrator, S2 DON and S3 ADON) had a meeting with the family on 5/26/14 to review the resident's care and risk of injury at the facility, and the fact the resident had already been involved in several resident to resident altercations. Further interview of S3 ADON confirmed they had discussed the inability of the facility to provide one on one staff supervision with the RP (son), and the plan to attempt to find placement for the resident at another facility. Interview on 7/30/14 at 3:30 p.m. with S19 CNA confirmed she had worked the 2-10 p.m. shift on 7/16/14 and had found the resident in resident #2 and #3's room when she went into the room with supper trays. S19 CNA stated she was assigned as Hall Monitor for the supper meal and as Hall Monitor was assigned to pass the hall trays and answer the call lights for all halls during the supper meal service. S19 CNA stated that resident #2 and #3 preferred to eat in their room. She stated that when she went to deliver their meal trays the door to the room was closed, and when she opened it she found resident #1 in their room on the side of the room of resident #2, undressed form the waist down, wiping down the dresser. S19 CNA stated she re-directed the resident to the Women's Bathroom and dressed her, did not see any signs of injury, and stated the resident did not complain or appear to be in pain. S19 CNA stated she brought the resident to the Dining Room and reported the incident to S14 CNA Supervisor and to S20 LPN. Interview on 7/31/14 at 10:45 a.m. with S3 ADON revealed she had assessed resident #1 (in the resident's bed) after the incident on 7/16/14, and stated the resident looked like she was in pain; however, she did not see any evidence of new injuries. Further interview of S3 ADON revealed the S1 Administrator was notified and came to the facility to begin the investigation and the resident was placed on one to one monitoring at that time. Interview on 7/31/14 at 10:45 a.m. with S3 ADON confirmed the resident had been identified with behaviors that put her at risk for injury, and had been involved in multiple resident to resident altercations. The S3 ADON reviewed the approaches that were care planned for the resident and confirmed the interventions that were used were documented in the care plan and the nurses' notes, and included q 1 hour monitoring, short periods of one on one staff supervision, transfer to a Behavioral Hospital, medication review by MD and Psych NP, medication changes, close observation, counseling, re-direction and behavioral meetings. Further interview with S3 ADON revealed the S3 ADON stated "she could not be watched all the time".

Based on interview and record review the facility failed to ensure a resident attained or maintained his highest practicable physical well-being, by failing to timely consult with the resident's physician when he developed greenish drainage from stasis ulcers on his legs for 1 of 5 sampled residents (#3) who received wound care. The facility had a total census of 132 residents, with 28 resident's receiving wound care according to the Resident Census and Condition of Resident's form. The facility failed to: 1. Immediately consult with the resident's physician on 06/01/11 when a Stasis Ulcer to the resident's right lower extremity worsened. The Treatment Nurse observed during assessment of the resident on 06/01/11, that the Stasis Ulcer to the resident's right lower extremity's drainage changed from clear to green, and developed 3+ to 4+ [MEDICAL CONDITION].. 2. Follow the facility's policy and procedure entitled Skin Program, Pressure Ulcers & Other Wounds, that stated that the responsible party would be notified if any evidence of deterioration of wounds. 3. Develop alternative care plan approaches for assessment and treatment of [REDACTED]. 4. Notify the resident's physician and responsible party when there was a significant change in the resident's physical status. Resident #3 was admitted to the nursing facility on 01/24/11. The admission assessment was completed by the Treatment Nurse on 01/24/11, and reflected the resident had a left lower extremity Stasis Ulcer, and right lower extremity fluid filled blisters. Record review and interview of staff revealed the areas to the resident's legs would sometimes "weep" clear fluid; however, the legs were mostly "dry, scaly and cracking". Documentation in the Treatment Notes on 05/10/11 reflected both of the resident's legs were swollen. The physician was contacted and an order was received for an Unna Boot every 3 days until healed. Treatment was performed as ordered for the month of 05/11 with no worsening in the wound documented until 06/01/11. The resident began refusing wound care on 06/06/11. Review of the Treatment Notes dated 05/10/11 at 10:20 a.m. revealed his bilateral lower legs were swollen. The physician was contacted, and the facility obtained an order on 05/10/11 to wrap the left and right lower extremities with an Unna Boot (Calazimine wrap with Coband) every 3 days until healed. Review of the Treatment Administration Record reflected the resident did not refused wound care during the month of 5/11. According to the Resident Wound Documentation sheet dated 06/01/11, the right lower extremity was draining greenish drainage. MD notification on the form reflected that the physician was made aware that the resident refused dressing changes; however, there was no documentation that reflected the physician was notified of the significant change in the resident's wound status (greenish drainage). Resident Wound Documentation notes dated 06/01/11, 06/08/11, and 06/15/11; Treatment Notes dated 06/16/11, 06/24/11, 06/27/11 and 06/30/11; and Weekly Body Audits dated 06/23/11, 06/30/11 and 07/07/11, reflected the resident had green drainage from either the right, left, or both lower leg Stasis Ulcers. According to the Resident Wound Documentation for 06/01/11, 06/08/11 and 06/15/11, the physician was made aware of the resident's refusal of dressing changes. There was no documentation in the above dated notes or in the resident's clinical record to reflect the physician was informed of the wounds' worsening. The resident was taken to the whirlpool after being coaxed to bathe on 07/12/11. Review of the resident's Nurses Notes for 6/11 reflected that the resident refused to be bath and had to be coaxed by certain CNAs to bathe. Interview of the Administrator and DON on 07/18/11 at 9:30 a.m., and review of the resident's nurses' notes dated 07/12/11 at 2:00 p.m., reflected they were called to the whirlpool room by the CNA assisting the resident to bathe.. This interview revealed they observed green drainage seeping from cracks in the anterior portion of the resident's legs (from just under the knee to the ankle), and maggots crawling out of the cracked areas of the resident's legs. The physician was notified of a significant change in the resident's wound status at that time. According to the facility's policy and procedure entitled Skin Program, Pressure Ulcers & Other Wounds, the physician would be notified if any evidence of deterioration is noted. Telephone interview of the resident's physician on 07/19/11 at 9:32 revealed that he was aware that the resident refused treatment to the Stasis Ulcers; however, he was not aware of the dramatic change in the resident's wound until last week ( the week of 07/10/11 to 07/16/11). He further stated that he was not aware that the resident's Stasis Ulcers had developed green drainage in 06/11. Findings: Immediately Consult Resident Physician Review of the Accumulative [DIAGNOSES REDACTED]. Review of the nursing Admission/Readmission assessment dated [DATE] reflected the resident was admitted with a left lower extremity stasis ulcer and right lower extremity fluid filled blisters. Review of the Quarterly MDS dated [DATE] reflected the resident was independent with transfers, needed supervision for ambulation and eating, and required limited assistance of 1 person for dressing, hygiene and bathing. The MDS further reflected the resident had no ROM limitations. Review of the Treatment Notes dated 05/10/11 at 10:20 a.m. revealed his bilateral lower legs were swollen. The physician was contacted, and the facility obtained an order on 05/10/11 to wrap the left and right lower extremities with an Unna Boot (Calazimine wrap with Coband) every 3 days until healed. Review of the Treatment Administration Record reflected there were no missing entries for Unna Boots during the month of 5/11. Review of the Resident Wound Documentation sheet dated 06/01/11 for resident #3 reflected the resident developed a Stasis Ulcer to the right lower extremity. The documentation sheet further reflected there was greenish drainage noted from the leg. Under the section for MD notification on the form, documentation reflected that the physician was made aware that the resident refused dressing changes; however, there was no documentation on the sheet or in the resident's clinical record that reflected the responsible party was notified of the significant change in the resident's wound status (greenish drainage). Further review of the above sheet reflected it was signed by S1 DON and S6 Treatment Nurse. Review of the Wound Documentation Sheet dated 06/01/11 for resident #3 reflected the resident had a Stasis Ulcer to the right lower extremity. The documentation sheet further reflected there was greenish drainage noted from the leg. Under the section MD notification on the form reflected that the physician was made aware that the resident refused dressing changes; however, there was no documentation that reflected the physician was notified of the significant change in the resident's wound status (greenish drainage). Further review of the above sheet reflected it was signed by S1 DON and S6 Treatment Nurse. Review of the Wound Documentation sheet dated 06/8/11 reflected there was a moderate amount of green and bloody drainage noted to the left lower extremity with 4 plus [MEDICAL CONDITION] . The note further reflected that the physician was notified and made aware that the resident refused his dressing change; however, there was no documentation to reflect the physician was notified of the green/bloody drainage. The note was signed by the S1 DON and S6 Treatment Nurse. Review of the Wound Documentation sheet dated 06/15/11 reflected there was a moderate amount of green drainage noted. Further documentation under MD orders reflected the physician was "made aware". Further review of the documentation reflected that it was signed by S1 DON and S6 Treatment Nurse. Review of the Treatment Notes dated 06/16, 06/24, 06/27 and 06/30/11 reflected the resident had green drainage from his lower extremities Stasis Ulcers; however, there was no documentation to reflect the physician was notified. Review of the physician's orders [REDACTED]. Again, there was no documentation to reflect that the physician was aware of the resident's green drainage from his lower extremities. Review of a physician progress notes [REDACTED]. The documentation reflected the resident was diagnosed with [REDACTED]. The above dated physician progress notes [REDACTED]. Review of Weekly Body Audit Reports for the month of 06/11 reflected that on 06/23/11 and 06/30/11, the resident's lower extremities were swollen, and greenish drainage was noted. Further documentation reflected under a section titled "current prevention measures effective" yes was checked. Review of the nurses' notes for 06/11 reflected there was no documentation regarding the resident's bilateral lower leg Stasis Ulcers. Review of a nurse's note dated 06/29/11 at 9:30 a.m. reflected the resident was seen by the physician with a new order for [MEDICATION NAME] (for [MEDICAL CONDITION]). There was no documentation regarding greenish drainage from the resident's lower extremities. . Review of a nurse's note dated 07/6/11 at 9:30 a.m. reflected the resident was seen by the Physician with no new orders noted. Review of a physician progress notes [REDACTED]. Review of a Weekly Body audit dated 07/7/11 reflected the resident's skin was warm and dry, bilateral extremities swollen, 4 plus [MEDICAL CONDITION], greenish discharge noted. the Weekly Body Audit further reflected under section title "current prevention measures effective" Yes, was checked. Review of a Treatment Note dated 07/6 /11 at 2:50 p.m. reflected the resident refused treatment, drainage was noted to bilateral lower extremities and 3 plus [MEDICAL CONDITION] noted. No further assessment of the drainage was documented at that time. Review of a nurse's note dated 07/12/11 at 2:00 p.m. reflected resident #3 was observed to have severe bilateral leg [MEDICAL CONDITION] with small cracks in the skin on both legs. Both legs were observed to have thick dry skin, and maggots were observed in the cracks of skin. The resident was given a bath and his legs scrubbed until all thick dry skin was removed. The note further reflected the physician was notified. Review of a nurse's note dated 07/12/11 at 2:45 p.m. reflected the physician was notified that the wound bed was clean and free of thick dry skin on both legs. No further maggots were observed, the cracks in the skin were observed to be pink. Review of a Physician order [REDACTED]. Further orders dated 07/12/11 at 3:00 p.m. reflected cleanse right and left legs with [MEDICATION NAME], cover with foam dressing, and wrap with Kerlix every day and prn. Review of a nurse's note dated 07/18/11 at 10:00 a.m. reflected received final report of right and left leg wound culture and sensitivity report , noted Staph Aureus and Beta- Hemolytiz Strep on wound. New orders noted for Bactrim DS 1 po BID times 10 days and screen for inpatient wound clinic. Interview on 07/18/2011 at 12:45 p.m. with S2 DON revealed that the physician visited the facility on Wednesdays. She stated that she assisted the physician when he visited the facility on 06/15/11. S2 DON stated that the physician saw the resident's legs and neither she nor the physician saw any drainage at that time. She also stated that she did not know the resident was having green drainage. Further Interview on 07/18/2011 at 12:45 p.m. with S2 DON revealed that she had been the DON for three weeks. She stated she signed the Resident Wound Documentation sheet for resident #3 for the Month of 06/11 and 07/11. S2 DON stated that documentation regarding the resident having green drainage was not on the sheet at the time she signed it. She further stated that she signed the Wound Documentation Sheet before S6 Treatment Nurse completed the form. She stated that she was signing for the staging and the measurement of the resident's ; however, resident #3 did not have an ulcer. S2 DON stated that her signature was on the form before the treatment nurse wrote her findings, and she did not go back and read what the treatment nurse wrote. Interview on 07/19/11 at 10:10 a.m. with S3 ADON revealed that she was the DON until three weeks ago. She said that she never knew that the resident had green drainage from his lower legs. She further stated the treatment nurse never told her. S3 ADON stated that S2 DON was the ADON at that time and she was assessing and staging wounds until 3 weeks ago. S3 ADON stated she did not monitor the treatment nurse and she assumed that the treatment nurse would notify her if there was a change in the resident wound stasis because she had notified her in the past. Further Interview on 07/19/11 at 8:45 a. am. with S3 ADON revealed that she assisted the physician on his visit at the facility on 07/6/11; however, she was not aware that the resident was had green drainage from his lower legs. Interview on 07/19/11 at 12:25 p.m. with S6 Treatment Nurse confirmed that she was the treatment nurse at this facility. She stated that she had been performing treatment on the resident since he was admitted in January 2011. She stated the resident's treatment changed in 05/11 when she noticed the resident's legs were [MEDICAL CONDITION]. The physician ordered Unna boots. She stated on 06/01/11, she noticed that the resident's drainage changed to bloody greenish drainage. She stated that she told the S2 DON who was the ADON at that time. She also informed S2 DON that the resident was refusing his treatments. S6 Treatment Nurse stated that she informed the Physician by talking to him on the phone or faxing him. She stated that she documented on the "Weekly Sheet" which had a picture of the body on it. S6 Treatment Nurse stated S2 DON told her to stop documenting on the "Weekly Sheets" because resident #3 had been diagnosed with [REDACTED]. S6 Treatment Nurse stated that she informed S7 Administrator about the resident's legs. Interview on 07/19/11 at 10:33 a.m. with S8 CNA revealed that S9 CNA/ transportation asked her to bathe the resident since she was his aide that day. She stated that the resident agreed to take a bath. She stated the skin on the resident's legs were extra dry and cracked, and there was nothing crawling on his legs prior to putting him in the water. While the resident was scrubbing his legs in the whirlpool, the dry skin began to fall off and she saw maggots crawling out of his legs. S8 CNA state at that point she called for assistance. Interview with S7 Administrator on 07/18/11 at 9:30 a.m. revealed that she was called to the whirlpool room by S8 CNA on 07/12/11. She stated that when she got there, she called S2 DON to the whirlpool because of what she saw. She stated that there were maggots coming out of the resident's legs. Interview with S2 DON on 07/18/11 at 9:30 a.m. revealed that when she arrived to the whirlpool, the resident was in the whirlpool and she saw green drainage seeping from the cracks in the anterior portions of the resident's legs (from just under the knee to the ankle). She stated that maggots were crawling out of the cracked areas on the legs. She stated that they contacted the doctor who told them to clean it up the best they could and call him back. She stated that once the resident's legs were cleaned, she contacted the physician again. The physician ordered cultures of the areas and antibiotics. S7 Administrator and S2 DON stated that the resident was non-compliant with care. S2 DON stated that he was suppose to wear an Unna Boot to his legs; however, he refused to have it applied. S2 DON stated that the resident had a history of [REDACTED]. Interview with S2 DON on 07/18/11 at 9:30 a.m. with S1 Corporate Nurse revealed she received a call from S2 DON informing her that resident #3 had maggots crawling out of the wounds from his lower legs. S1 Corporate Nurse stated she consulted with the Advance Medical Technology consultant who was a Nurse specialist and Corporate Consultant on wounds. She stated the AMT suggested that they clean the wound with [MEDICATION NAME] and wrap the leg. Interview on 07/18/2011 at 12:45 p.m. with S2 DON revealed that she called S1 Corporate Nurse, on Tuesday, 07/12/11, afternoon when she saw the resident in the whirlpool and maggots were crawling out of both lower legs. S1 DON stated another physician, who was on call for the primary physician, was called and he ordered not to send the resident to the hospital, clean the legs with Dakins Solution or [MEDICATION NAME] Solution and to apply 4 X 4 gauze. S2 DON stated she noticed the resident did have cracks in his skin that were leaking at that time. She stated they scrubbed the resident's lower legs until all the scabs were off and there were no further maggots seen. Telephone interview of the resident's primary physician on 07/19/11 at 9:32 a.m. revealed that he was told in 06/11 that the resident had started refusing treatments. He said that the resident had [MEDICAL CONDITIONS] and therefore the wound was going to get infected. The Unna Boot was to protect the wound from the environment. He was not aware that there was a dramatic change in the wound until the week of 07/10/11. He stated he was not aware that the resident developed green drainage in 06/11. Review of the facility's policy on Skin Program, Pressure Ulcers and Other Wounds reflected under the physician would be notified if any evidence of deterioration was noted, the wound becomes infected, or if wound was not healing within 2 weeks. Review of employee termination report dated 07/15/11 for S6 Treatment Nurse reflected she was terminated because she did not follow company policies. the report reflected S6 Treatment Nurse did not notify the physician of patient change in condition which could have resulted in actual harm. Review and Revised the care Plan Review of the nursing Admission/Readmission assessment dated [DATE] reflected the resident was admitted with a left lower extremity stasis ulcer and right lower extremity fluid filled blisters. Review of a Treatment Note for the resident dated 05/10/11 at 10:20 a.m. reflected the resident's bilateral lower legs were swollen. The physician was contacted, and an order was received on 05/10/11 to wrap left and right lower extremities with an Unna Boot (Calazmine wrap with Coband) every 3 days until healed. Review of Treatment Administration Record for 05/11 reflected the resident received the above documented treatment every 3 days as ordered by the physician. Review of the Resident Wound Documentation sheet dated 06/01/11, 06/08/11 and 06/15/11 reflected the resident refused dressing changes and/or he took the dressings off after the treatment was done. Documentation also reflected that both legs were draining green drainage. Documentation on 06/08/11 reflected the left lower extremity was draining greenish/bloody drainage, and documentation on 06/15/11 reflected the right lower extremity was draining a moderate amount of drainage, and the left lower extremity was draining greenish drainage. Review of the 06/11 Weekly Body Audits dated 06/02/11, 06/16/11 and 06/23/11 reflected resident #3 refused dressing changes to his bilateral lower extremities. The Weekly Body Audits dated 06/23/11 and 06/30/11 further reflected the presence of green drainage. Review of the Treatment Administration Record for 06/11 reflected the resident refused treatment on 06/06/11, 06/09/11, 06/18/11, 06/21/11, 06/24/11, 06/27/11 and 06/30/11. Review of Treatment Notes for 06/11 reflected the resident refused treatment times 3 attempts by the treatment nurse on 06/06/11, 06/09/11, 06/18/11, 06/21/11, 06/24/11, 06/27/11 and 06/30/11. Documentation also reflected that on 06/19/11, the resident refused his treatment and removed the wraps because it made him sweaty. The above documentation during the month of 06/11 reflected the resident refused wound care 14 of 30 days. Review of the 07/11 Treatment Administration Record reflected resident #3 refused treatments on 07/03/11, 07/06/11, 07/09/11, and 07/12/11. Interview of S6 Treatment Nurse on 07/19/11 at 12:25 p.m. revealed she was the treatment nurse at the facility. She stated that she performed treatments to resident #3 since his admission to the facility in 01/11. She stated the resident's treatment changed in 05/11 after she observed the resident's legs were [MEDICAL CONDITION]. The physician ordered an Unna Boot (Calazmine wrap with Coband) every 3 days until healed. She also stated that resident #3 would refuse wound care and/or sometimes he would take the dressing off after the treatment was done. She stated that she would sometimes get another nurse to go with her to provide the resident's wound care when he would refused the wound care treatments. Interview of S4 Treatment Nurse on 07/18/11 at 9:25 a.m. revealed that she was the part time Treatment Nurse and worked with resident #3 when the full time Treatment Nurse was off. The S4 Treatment Nurse stated resident #3 refused wound care and dressings to his legs. Review of resident #3's Comprehensive Plan of Care reflected a problem of Potential for Further Tissue Breakdown due to Decreased Mobility and [MEDICAL CONDITION] to Bilateral Legs, with a problem onset date of 05/10/11. Further review of the above plan of care reflected that on 06/10/11, the resident refused Unna Boots, and when he did allow the Unna Boots to be applied, he removed them. Approaches included: encourage to elevate lower extremities, and monitor for signs and symptoms of infection, increased drainage, odor, size of ulcers, temperature, increased redness and complaints of pain to the site. There were no approaches documented that reflected alternatives to ensure the resident received wound care as ordered once he refused the care. Further review of the plan of care dated 06/14/11, reflected the physician assessed the resident's [MEDICAL CONDITION]. The care plan reflected there were no additional physician orders [REDACTED]. Additionally, there were no approaches that included alternative of care once the resident refused wound care. Review of the nurses' notes for 07/11 reflected that on 07/12/11 at 2:00 p.m., the S2 DON documented that she was called to the whirlpool room on the 500 hall. According to the nurse's note, the resident (#3) who had been refusing baths and was not compliant with treatments to legs, was observed to be in the whirlpool with a CNA bathing him. The note reflected the resident was observed to have severe bilateral leg [MEDICAL CONDITION] with small cracks in the skin on both legs. The note reflected that both legs were observed to have thick dry skin, and maggots were observed in cracks of skin. The resident was given a bath and legs were scrubbed until all thick dry skin was removed. The note further reflected the physician was notified. Interview of S8 CNA on 07/19/11 at 10:33 a.m. revealed that S9 CNA/ transportation asked her to bathe the resident since she was his aide that day, and she had coaxed the resident to get a bath. She stated the skin on the resident's legs were extra dry and cracked, and there was nothing crawling on his legs prior to putting him in the water. She stated that while the resident was scrubbing his legs in the whirlpool, the dry skin began to fall off, and she saw a lot of maggots crawling out of his legs. S8 CNA state at that point she called for assistance. Interview of S7 Administrator on 07/18/11 at 9:30 a.m. revealed that she was called to the whirlpool room by S8 CNA on 07/12/11. She stated that when she got there, she called S2 DON to the whirlpool because of what she saw. She stated that there were maggots coming out of the resident's legs. Interview with S2 DON on 07/18/11 at 9:30 a.m. revealed that when she arrived to the whirlpool, the resident was in the whirlpool and she saw green drainage seeping from the cracks on the anterior portions of the resident's legs (from just under the knee to the ankle). She stated that maggots were crawling out of the cracked areas on the legs. She stated that they contacted the doctor who told them to clean it up the best they could and call him back. She stated that once the resident's legs were cleaned, she contacted the physician again. The physician ordered cultures of the areas and antibiotics. S7 Administrator and S2 DON stated that the resident was non-compliant with care. S2 DON stated that he was suppose to wear an Unna Boot to his legs; however, he refused to have it applied. S2 DON stated that the resident had a history of [REDACTED]. Interview of S2 and S1 Corporate Nurse on 07/19/11 at 11:46 a.m. revealed that treatments for resident #3 should have been offered at different times by other nurses other than the treatment nurse, when resident #3 refused his treatment by S6 Treatment Nurse. The S2 DON stated that nurses should have tried other alternatives such as scheduling the resident's wound care at different times of the day. S2 DON confirmed that the physician ordered the treatment once a day but the treatment could have been offered on other shifts by other nurses that the resident responded to. Review of the facility's Skin Program, Pressure Ulcer and Other Wounds policy reflected under Care and Care Planning for At -Risk Residents section, #9: the interdisciplinary team would develop a care plan listing the resident's risk factors, expected outcomes, and interventions to prevent the development of skin breakdown or to help heal existing wounds. Family or Responsible Party Notification Review of the nursing Admission/Readmission assessment dated [DATE] reflected the resident was admitted with a left lower extremity stasis ulcer and right lower extremity fluid filled blisters. Review of resident #3's Treatment Notes dated 05/10/11 at 10:20 a.m. revealed the resident's bilateral lower legs were swollen. The physician was contacted, and wound care orders were obtained. There was no documentation to reflect the resident's responsible party was notified of the above. Review of the Resident Wound Documentation sheet dated 06/01/11 for resident #3 reflected the resident developed a Stasis Ulcer to the right lower extremity. The documentation sheet further reflected there was greenish drainage noted from the leg. Under the section for MD notification on the form, documentation reflected that the resident's responsible party was made aware that the resident refused dressing changes; however, there was no documentation on the sheet or in the resident's clinical record that reflected the responsible party was notified of the significant change in the resident's wound status (greenish drainage). Further review of the above sheet reflected it was signed by S1 DON and S6 Treatment Nurse. Review of the Resident Wound Documentation sheet for resident #3 dated 06/08/11 reflected there was a moderate amount of green and bloody drainage noted to the left lower extremities with 4+ [MEDICAL CONDITION]. The note further reflected that the responsible party was notified of the resident's refusal of dressing change; however, there was no documentation on the sheet or in the resident's clinical record to reflect the responsible party was notified of the green/bloody drainage. The note was signed by the S1 DON and S 6 Treatment Nurse. Review of the Resident Wound Documentation sheet for resident #3 and dated 06/15/11, reflected there was a moderate amount of green drainage noted to the right lower extremity. Further review of the sheet reflected that the resident's responsible party was made aware that the resident took the dressing off after the treatment was done. There was no documentation on the sheet or in the resident's clinical record that reflected the responsible party was notified of the change in the status of the resident's right lower leg, and that the resident removed the dressings after wound care was completed. Review of the following documentation reflected the resident had green drainage and/or [MEDICAL CONDITION] of his bilateral lower extremities: 1. Treatment Notes dated 06/16/11, 06/24/11, 06/27/11, and 07/06/11. 2. Weekly Body Audits dated 06/23/11, 06/30/11 and 07/07/11. There was no documentation on the above documents that reflected the resident's responsible party was notified. Review of the nurses' notes for 06/11 reflected there was no documentation to reflect the resident's responsible party was notified that the resident had green drainage and/or [MEDICAL CONDITION] of his bilateral lower extremities. Review of resident 3#'s Face Sheet there was no responsible party listed. Interview of S2 DON on 7/18/11 at 3:00 p.m. revealed that resident #3 was homeless and had no next of kin. She further stated because resident #3 was homeless, the Administrator was considered to be his responsible party, and she would be the person to be notified for any change in the resident's condition. Interview of the S7 Administrator on 7/18/11 at 3:15 p.m. revealed she was the resident's responsible party. She stated that she was aware the resident was refusing treatment, but was not aware he had green drainage draining from his wounds. Review of the facility's policy on Skin Program, Pressure Ulcers and Other Wounds, reflected that the resident's responsible party will be kept informed and notified of any significant change in wound status.